Encountering HIV/AIDS

Those who are working in the HIV/AIDS sector clearly understand that fighting stigma is perhaps the most difficult challenge. For example the DS report referred to in Md. Asadullah Khan's recent piece ("AIDS Crisis Looming") mentioned the suspected women workers in the nearby shrimp factory -- what is the purpose of publishing such information? This is poor judgment because it ignores their rights based on assumed information. Furthermore, it stigmatizes all those women who are working there. Yes, in a sense it is a "wake up call" -- a wake up call to prevent such demonization.

Many of us can remember the incident of Mr. H. A. Initially a daily newspaper published a story alleging him to be HIV positive, just because he was returning from abroad and suffering from a disease yet to be diagnosed. At that particular time a team was conducting a study close to that region. I was a part of that team led by Prof. Dr. Nazrul Islam collecting specimens from certain high risk groups. We visited him and collected his blood and it was found to be negative. While we were in his home, we saw his situation, the human costs, and sufferings of such reporting.

As Mr. Khan mentioned: "[M]oreover, the virus has either spread or is likely to spread from the returnees carrying this insidious infection because they were not tested on their arrival. Most people in the country and the government prefer to ignore it. So when the first AIDS case surfaced in the country in 1989 -- the carrier being a returnee from abroad . . ."

Actually it is difficult to justify mandatory HIV testing of the migrant workers or any other group because there are ethical and human rights issues. Mandatory HIV testing is like a modern morality test. Even under most the appropriate conditions, one percent result will be "false positive." Those who will be in that group of people who falsely test positive, will suffer the inescapable consequences and besides a significant proportion will be tested false negative due to the "window period." That is why there is sufficient scientific justification that HIV testing therefore should be voluntary and must be preceded and followed by counseling.

Among other pressing health issues in our country, AIDS is getting its fare share of attention. Bangladesh is among one of those countries that actually responded to AIDS very early in the epidemic. With national and international collaboration, Bangladesh is fighting this epidemic on all fronts. In 1985, the Bangladesh government started its anti-AIDS program by forming Bangladesh AIDS Control and Prevention Program. Now the program is under the National AIDS/STD Program under Ministry of Health and Family Welfare. Nation AIDS Policy was developed in 1996. There are numerous national and international NGOs here working among different target groups for a long time.

Both serological and behavioral surveillance among risk groups for HIV started very early and the prevalence is constantly monitored. Several rounds of surveillance are completed. Although the latest data suggest the prevalence of HIV is still low, but behavioral risk factors are ubiquitous

Risk factors
Although many people in Bangladesh now have heard the word "AIDS," a significantly high portion of Bangladeshis still need to know how it is transmitted. There are better informed groups, particularly the high-risk groups in certain areas of Bangladesh, due to intensive campaign by many groups

Bangladesh has a large commercial sex industry (unofficial estimate is about 100,000 with half a million customer per day) in different forms. A diverse group of clients buy sex from them -- only a few use condoms. Several studies also documented that there is also sex trade involving men who have sex with men in Bangladesh and the use of condom is very low. Many men who are buying sex either from female or male sex workers are also married, thus their wives are also exposed to the risk.

There are about 25,000 injection drug users in Bangladesh. Needle sharing is very common. In one recent study by ICDDRB, the team found high prevalence of HIV (8 per cent) among certain areas which amounts to a concentrated epidemic. Evidence from the world suggests the most successful public health approach to prevent HIV among them is the harm reduction strategy. CARE Bangladesh within this strategy started their needle exchange program, which is successful in reducing needle sharing in certain parts.

But access of intravenous drug users to such facilities is still limited. A survey in various cities has shown that half to three-quarters of male injectors paid for sex and close to one in ten bought sex from men or transvestites; less than 25 per cent used a condom the last time they paid for sex.

The way forward
We must focus on our young people. The HIV/AIDS epidemic has always been an epidemic of the youth. Half of the global population now is under the age of 25 years and the fate of this epidemic critically depends on the actions of the young people. UNAIDS estimated that fifty percent of all new adult HIV infections, about 6,000 infections per day, to be among the age group of 15 to 24 years.

Young people are uniquely vulnerable to HIV due to multitudes of diverse and interrelated factors that are ubiquitous. Although still a low prevalence country, but behavioral patterns and extensive risk factors that facilitate the rapid spread of the infection are widespread, making Bangladesh highly vulnerable to an HIV/AIDS epidemic. The factors that put the youths in the centre of HIV risk and vulnerability include

risky adolescent behaviour associated with experimentation and curiosity, lack of information, education, and supportive services, gender disparity, sexual coercion, injection drug use, cultural and social norms, discrimination, and poverty. Evidence from the success stories suggest that by educating, empowering, and encouraging safer behavior choices among young people, it is possible to turn the tide of the epidemic.

Discussion about sex is taboo in

our closed society. The most difficult issue is adolescent reproductive health as Dr. Ismat Bhuiya of Population Council Dhaka wrote that although strong family structure shaped the lives of many adolescent in Bangladesh, but it fails to respond to adolescents' needs for reproductive health information. Bangladesh government has included adolescent health and management and prevention/control of STIs and HIV/AIDS as a component of Essential Service Package (ESP) under its Health and Population Sector Strategy (HPSS). But translating these policies into practices is a different issue as we have to overcome many structural and systemic barriers. So we have a long way to go, but it must be within very short period of time, as opportunity is running out fast.

There are several studies already published about the sexual behaviour among the married and unmarried adolescent girls and boys, both in urban and rural settings. Many NGOs are now acting on that information. Some NGOs, notably BRAC has a program on sex education. Many NGOs already developed culturally appropriate IEC material regarding the issues for their campaign. As many experts suggests, it is less difficult to provide information, but knowing is not enough, it is necessary to provide skills to act on the information.

Dr. Kazi Mahboob Hassan is conducting research in harm reduction at the School of Population Health, University of Melbourne.