Bangladesh is a low HIV prevalence country with several well-documented at-risk groups, the most prominent of which is brothel-based sex workers and injecting drug users. Although prevalence rate is remaining low in the country, it is surrounded by nations with much higher prevalence rates and with its own at-risk population. Bangladesh has been identified as one of the five countries where HIV/Aids infections are rising in the Asia-Pacific region, it was revealed at the 8th International Congress on HIV/AIDS in Asia and the Pacific held in Colombo, on August 19-23, 2007. The outbreak of HIV in neighbouring countries, cross borders and steady rise of STIs make Bangladesh a high-risk zone for HIV/AIDS prevalence.
Today's low level of HIV infection in our country does not guarantee low prevalence tomorrow. Experience teaches us that early epidemics do not show their magnitude at the beginning. This is good news that our government, donors, and large numbers of NGOs have begun serious investment in both research and prevention interventions. But it also requires efforts of care and support for the people living with HIV/AIDS. It is difficult to capture such a large range of activities with one or just a few indicators. However, a set of well-established health care indicators may help to identify general strengths and weaknesses of health systems. The scale of the HIV/AIDS epidemic has exceeded all expectations since its identification in 1981. As the spread of HIV has been greater than predicted, its severe impact on social, capital, population structure and economic growth has been apprehended.
High risk factors
Behavioral risk factors for HIV/AIDS in Bangladesh are in a danger situation. Besides that there are potential bio-medical risk factors including: (i) an unregulated blood supply system in which blood used in transfusions is not screened for HIV and is donated primarily by professional donors; (ii) unsterile injections in non-formal and formal health-care settings; and (iii) a high prevalence in high-risk groups of other sexually transmitted diseases, which may function as co-factors for HIV transmission, particularly if chronically untreated. Bangladesh behavioral surveillance survey (BSS) reports on several high-risk factors: (a) large number of men buying sex than in other countries in Asia, (b) low levels of knowledge about HIV/AIDS, (c) low perception of personal risk among vulnerable populations, and (d) low condom use rates among sex workers.
Knowledge and behaviour
Information on knowledge and on the level and intensity of risk behaviours related to HIV/AIDS is essential in identifying populations at most risk for HIV infection and in better understanding the dynamics of the epidemic.The indicators on knowledge and misconceptions are an important prerequisite for prevention programmes to focus on increasing people's knowledge about sexual transmission, and, to overcome the misconceptions that act as a disincentive to behaviour change. Indicators on sexual behaviour and the promotion of safer sexual behavior are at the core of HIV/AIDS programmes, particularly with young people who are embarking on their sexual lives, and who are more amenable to behavioral change than adults. Overall denial and apparent confusion about their own risk of acquiring an HIV infection increased among brothel sex workers, with a rise in the "don't know" response from about 25% to 40%. It is not likely that knowledge percentage was scant, it is far more likely that increased insecurity regarding the future maintenance of their residences and livelihoods diminished their capacity to insist on condom use.
STD/STI situation
The predominant mode of transmission of both HIV and other STD/STIs is sexual intercourse. Measures for preventing sexual transmission of HIV and STIs are the same, as are the target audiences for interventions. In addition, strong evidence supports several biological mechanisms through which STIs facilitate HIV transmission by increasing both HIV infectiousness and HIV susceptibility in Bangladesh. In the 2004-05, the Sentinel Surveillance mentioned that syphilis rates were high among hijras (20%) and varied from 6 percent to 16 percent among brothel based female sex workers. A declining trend of syphilis was however observed at many of the city brothels.
Epidemiological situation
The first case of HIV infection was detected in Bangladesh in 1989; by the end of December 2006 the official number of reported cases of HIV was 874 with 240 cases of AIDS of which 109 had died. Bangladesh as a nation has a low prevalence of HIV but risk behaviours are sufficient enough for continued HIV transmission among groups at higher risk and to its general population. Bangladesh has an established second generation HIV surveillance system. This system consists of a sero-surveillance component (implemented by ICDDR,B for the Government of Bangladesh, using World Bank/DFID funding) and a behavioral surveillance component (executed by Family Health International, funded by USAID). The data indicate that HIV prevalence rates among the most vulnerable population groups and some bridging population groups (mainly male clients of sex workers) have remained at <1% with the highest prevalence in injecting drug users with an average of 4.9 percent. But WHO/UNAIDS estimates that there are more than 13,000 HIV/AIDS cases in Bangladesh. According to the report - 2004 of UNICEF, there are 310 children under 14 now live with HIV and almost 2000 children lost their parents due to HIV/AIDS in the country.
Criminalisation of HIV transmission
Several countries have recently introduced laws to criminalise HIV transmission, or exposing another person to the virus. A number of jurisdictions have used general laws against serious bodily harm in cases where someone is accused of knowingly transmitting HIV or willingly exposing others to HIV transmission. Subject of controversy, these measures are sparking debate and concern among policymakers, legal and public health professionals, international organisations and civil society, on whether criminal law is applicable in such cases and if such application is accomplishing or damaging public health goals such as universal access to HIV prevention, treatment, care and support. Addressing these issues, UNAIDS brought together a range of stakeholders in Geneva for a three-day international consultation (31 Oct - 2 Nov 2007) to discuss the apparent trend of criminalisation of HIV transmission in the context of national responses.
Conclusion
Responding to HIV/AIDS on a scale commensurate with the epidemic is a global imperative, and the tools for an effective response are inevitable. Detection and treatment of individuals with STIs is an important part of an HIV control strategy. Clinical services offering STI care are an important access point for people at high risk for both STIs and HIV. Identifying people with STIs allows for not only the benefit of treating the STI, but for prevention education, HIV testing, identifying HIV-infected persons in need of care, and partner notification for STIs or HIV infection. Nothing less than a sustained social mobilisation is necessary to combat one of the most serious crises facing the world community today. As the chair of the Technical Committee of the National AIDS Committee said, a poor country Bangladesh has to opt for preventive measures rather than depend on costly drugs or future vaccines.
Nicholas Biswas is a Researcher and NGO Activist.