Bangladesh

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State of the Epidemic| Risk Factors| National Response to HIV/AIDS| Issues and Challenges: Priority Areas| World Bank Response

HIV in Bangladesh remains at relatively low levels in most at risk population groups, with the exception of injecting drug users (IDUs) where prevalence continues to grow. Although national HIV prevalence remains under 1 percent among the general population in Bangladesh, there are risk factors that could fuel the spread of HIV among high-risk groups. Prompt and vigorous action is needed to strengthen the quality and coverage of HIV prevention programs, particularly amongst IDUs.

State of the Epidemic

UNAIDS estimated that approximately 11,000 Bangladeshis could have been living with HIV at the end of 2005. Bangladesh’s sixth round of sentinel surveillance (2004-2005) showed an overall prevalence of 0.6%. The sixth round was carried out in five groups: injecting drug users (IDUs), female sex workers (FSW), men who have sex with men (MSM), male sex workers (MSW) and bridge population groups (mobile men including rickshaw drivers, truckers and dockworkers). While overall HIV prevalence is still low, prevalence is higher in risk groups such as sex workers, injecting drug users and men who have sex with men.

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Risk Factors

Bangladesh is vulnerable to an expanded HIV epidemic due to the prevalence of behavior patterns and risk factors that facilitate the rapid spread of HIV. Risk factors include:

• Large Commercial Sex Industry: There are over 105,000 male and female sex workers in Bangladesh. Brothel-based female sex workers reportedly see around 18 clients per week, while street-based and hotel-based workers see an average of 17 and 44 clients per week respectively.
• Low Levels of Condom Use:  5^th round BSS (2003-2004) data indicate that between 24 percent (street based) – 40 percent (brothel based) of sex workers reported using a condom with their most recent (during past one week) clients. The rate of condom use is even lower with regular clients. MSW showed the highest rate of condom use (44 percent), and transgenders showed the lowest rate of condom use (15.6 percent).
• Sexually Transmitted Infections: Syphilis rates have shown marginal decline over recent years. However recent surveillance data shows 44 percent of female IDUs are also sex workers and have a higher prevalence of syphilis (9.2 percent prevalence compared with 2.9 percent of male IDUs). The high rates of syphilis and other STIs confirm the low level of condom use and the presence of other risky sexual behaviors that facilitate the spread of the HIV.
• Needle-sharing among Injecting Drug Users: The six round sentinel surveillance data show that there is a concentrated epidemic among IDUs in one neighborhood of Dhaka with an HIV prevalence of 7.1 percent. This level of infection among IDUs poses a significant risk as the infection can spread rapidly – and is spreading – within the group, then through their sexual partners and their clients into the general population. Data found that 44 percent of female IDUs are also sex workers and had a higher prevalence of syphilis, indicating they need to be urgently targeted as they have a high potential to spread HIV (none in the sample were found to have HIV although 82 percent had shared needles). Another concern is the significant number of IDUs who sell their blood professionally. Bangladesh continues to rely on professional blood-sellers to meet part of the transfusion needs of its people.  
• Lack of Knowledge: Data on knowledge and behavior indicates that only 17 percent of the most-at-risk populations have correct knowledge about prevention and misconceptions on HIV/AIDS. Furthermore, a 2005 population-based survey among adolescents and young people (15-24 years) indicated that only one out of three males in urban and one out of four in rural areas had correct knowledge of HIV and AIDS. Among the general population, data indicate that 59 percent of ever-married women and 42 percent of men of age 15-54 could not mention a single way to avoid contracting HIV. 
• High level of stigma associated with people living with HIV.
• People engaged in high risk behaviors often have limited access to health care.

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National Response to HIV/AIDS

Government: In late 1996, the Directorate of Health Services in the Ministry of Health and Family Welfare outlined a National Policy on HIV/AIDS. A high-level National AIDS Committee (NAC) was formed, with a Technical Advisory Committee, and a National AIDS/STD Program (NASP) unit in the ministry. The NAC includes representatives from key ministries, NGOs and a few parliamentarians. Action has been taken to develop a multi-sector response to HIV/AIDS. Strategic action plans for the National AIDS/STD Program set forth fundamental principles, with specific guidelines on a range of HIV issues including testing, care, blood safety, prevention among youth, women, migrant workers, sex workers, and STIs. While earlier commitment was limited and implementation of HIV control activities was slow, Bangladesh has strengthened its programs to improve its response. The 2005 Poverty Reduction Strategy Paper of the Government highlighted HIV/AIDS in the health section. The Government of Bangladesh also prepared the National Strategic Plan for HIV/AIDS for the period 2004-2010 under the guidance of NAC and with the involvement and support of different stakeholders. Efforts to mainstream HIV/AIDS in public sectors outside the Ministry of Health and Family Welfare were initiated through designation and training of focal points on HIV/AIDS in 16 government ministries.

Non-Governmental Organizations (NGOs): More than 380 NGOs and AIDS Service Organizations have been implementing programs/projects in different parts of the country. These initiatives focused on prevention of sexual transmission among high-risk groups involving mostly female sex workers, MSM, IDUs, Rickshaw pullers and truckers. NGOs are often in a better position than the public sector to reach high-risk groups, such as sex workers and their clients and injecting drug users. Building the capacity of NGOs, especially the small ones, and combining their reach with the resources and strategic programs of the government is an effective way to change behavior in high-risk groups and prevent the spread of the virus to the general public.

Donors: The British Department for International Development (DfID), USAID, Sida and GTZ are financing a number of HIV/AIDS control activities in Bangladesh. These include a social marketing program; peer education and condom promotion activities; information, education, and communication efforts; STI treatment; surveillance and operational research; and capacity building for NGOs. Three UN agencies are assisting the Government in the implementation of some project components: UNICEF is managing the NGO service delivery component, WHO is managing the blood safety activities, and UNFPA is managing the capacity building component. A Global Fund grant for $40 million (Round 6) to promote prevention of HIV among adolescents and young people brings together Government and Save the Children, USA and is being implemented through NGOs. The FHI/USAID supported project ($13 million, 2005-2008) is also focusing on selected interventions for some high-risk groups including expansion of VCT services.

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Issues and Challenges: Priority Areas

Vigorous action is required to prevent further spread of HIV in Bangladesh. Key tasks include:

• Scale up behavioral change activities and health promotion interventions for high-risk behaviors and vulnerable groups, particularly IDUs and sex workers.
• Expand advocacy and awareness among the general population through multi-sectoral agencies.
• Promote the social acceptability of condom use and ensure adequate supply and access.
• Reduce discrimination against those infected with HIV, or groups engaging in high-risk behaviors, through appropriate advocacy, policies, and related measures.
• Strengthen the Government’s capacity for program implementation, management, and monitoring of program activities.
• Promote NGO capacity for program planning, implementation, and supervision of interventions.   
• Strengthen mechanisms for collaboration and coordination within and between government, the non-governmental sector, development partners, and other stakeholders.

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World Bank Response

The World Bank supports the Government's two-pronged strategy: First, increasing advocacy, prevention, and treatment of HIV/AIDS within the Government's existing health programs, and second, scaling up interventions among high risk groups.

In 2000, the Bank approved a credit of USD 26 million for the HIV/AIDS Prevention Project (HAPP 2000-2007) which supports the scaling up of interventions among groups at high risk in a rapid and focused manner while strengthening overall program management. DFID provides an additional USD 4.46 million for HAPP. Over the next year HAPP interventions will be progressively integrated into the Government of Bangladesh and Multi-Donor supported Health, Nutrition and Population Sector Program, while the HIV/AIDS Prevention Project will close.

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