It's time to brace for the worst

Prevalence of HIV/AIDS in the country is low. Still, the deadly disease can spread at a frightening pace; therefore, there is no reason to feel safe, writes Dr Nizam U. Ahmed

AIDS (acquired immunodeficiency syndrome) was first recognised in 1981 when the Centres for Disease Control and Prevention in Atlanta reported unusual clusters of Kaposi's sarcoma and Pneumocystis carinii pneumonia among homosexual male populations in Los Angeles and San Francisco and among injecting drug users in New York City. Within the next four years, human immunodeficiency virus (HIV), the virus that causes AIDS, was recognised and surveillance systems for HIV infection and AIDS cases began to emerge.

Currently there are 33.6 million people living with HIV/AIDS world-wide, a figure which represents infection among one in every 100 adults between the ages of 15 and 49 years. At the end of 1999, 12.8 million people had died of HIV infection. Over two million died in 1999 alone. An estimated 5.8 million new infections occurred in 1999, is corresponding to 16,000 new infections each day. Over 95 per cent of these new infections occurred in the developing countries, 1600 are in children under 15 years of age, About 14,000 are aged between 15 and 49 years, of whom over 40 per cent are women and over 50 per cent are in 15-24 age group.

Asia and the HIV Epidemic 

Just over one in every five HIV/AIDS cases can be found in South and Southeast Asia. While this pales in comparison to the current epidemic in sub-Saharan Africa, the epidemic in Asia is on the rise. It is expected that one in every four cases will occur in this region by the end of the year 2000. The epidemic in South and Southeast Asia began in the late 1980s, and being a newer epidemic than those in North America and Africa, monitoring systems are still inadequate. An estimated six to 10 million people in this region are currently living with HIV/AIDS, correlating with an adult prevalence of 0.69 per cent, equal to that of North America and much lower than the eight per cent prevalence of sub-Saharan Africa. HIV/AIDS claimed lives of 250,000 people of South and Southeast Asia in 1997, and 220,000 children have been orphaned in this region since the epidemic began. Approximately 1.3 million new infections occurred in South and Southeast Asia in 1997 alone. Although levels of infection and routes of transmission differ greatly within the region, the main mode of transmission is heterosexual contact. Approximately 30 per cent of HIV positive persons in the region are female.

Situation of HIV/AIDS in India

The current HIV/AIDS epidemic in India is representative of the increasing epidemic in South Asia and is reminiscent of the early pattern in Africa, where a sharp increase in prevalence among high risk groups was followed by transmission to the general population. An estimated 5-7 million people in India are living with HIV, making it the country with the largest number of HIV-infected people in the world. Ninety per cent of these cases occur among people aged 15-45 years of age, most of whom are from socio-economically disadvantaged groups. The male to female infection ratio is five to one, with female cases occurring mainly among commercial sex workers (CSW). One study conducted among CSW in India found a rise in HIV prevalence from 1.6 per cent in 1986, to 18 per cent in 1995 and 51 per cent in 1996. A similar study among STD clinic attendees and injecting drug users found a 1.4 to 40 per cent increase among the attendees and a zero to 70 per cent increase among drug users. HIV rates among drug users in Manipur were as high as 73 per cent in 1996-97. Other important vehicles of spread include bridge populations such as long-distance truck drivers and migrant labourers. One study of truck drivers in Madras found a rise in seroprevalence among the study population from 1.5 per cent in 1995 to 6.2 per cent in 1996. Unfortunately, the high-risk groups and bridge populations are not the only communities affected by HIV in India. Prevalence among these groups has reached such a high level that transmission is now rapidly occurring in the general population. An indication of this spread is the infection rate among women attending antenatal care centres. A 1996 study among pregnant women in Mumbai found an infection rate of 2.4 per cent, while a similar study in Maharashtra found that 3.5 per cent of pregnant teens were HIV positive. With such high rates of infection now being seen among all populations, India alone is expected to account for one eighth of the world's HIV infections by the year 2000.

Situation of HIV/AIDS in Bangladesh

The first case of HIV in Bangladesh was reported in 1989, and the first case of AIDS followed in 1990. The number of people living with HIV reported in November 1999 is 126, 83 per cent (104) of them are male. The rest 22 female, out of which 46 per cent (10) are housewives infected by their husbands, followed by five commercial sex workers of whom three are below the age of 16 years. Most of the HIV-infected males are emigrant workers sent back home upon diagnosis. Majority of PLHA in Bangladesh resides in three divisions - Sylhet and Dhaka followed by Chittagong. More than 50 per cent of the infected individuals in the Bangladesh are below 35. The number of AIDS cases is 12, and 10 person already died, the most common cause of death were tuberculosis (5) while others being candidial infection (2), malaria (1), diarrhoea (1), enchephalitis (1).

Prevalence of HIV in Bangladesh is still low according to the First National Sentinel Surveillance for HIV and Syphilis 1997-98, which was conducted by ICDDR,B in collaboration with the government. The results have also shown that HIV is also present in considerable number among high risk groups of the people surveyed, such as CSW 0.6 per cent, intravenous drug users (IDUs) 2.5 per cent, STD patients 0.1 per cent. Men having sex with men 0.2 per cent and overall prevalence among these selected groups was 0.4 per cent. Prevalence of Syphilis is high particularly among sex workers (60-70 per cent) both brothel-based and floating. Although overall prevalence of HIV is low but it is present in considerable numbers among IDUs (2.5 per cent). HIV is also present in brothel-based sex workers. Relatively high HIV prevalence among IDUs (2.5 per cent) suggests that Bangladesh is at the beginning of an HIV epidemic, which has the potential of spreading rapidly.

The estimated number of HIV-infected people is 21,000 according to WHO and UNAIDS (1992). The number of reported cases in males greatly outweighs the number of reported cases in females. For example, of the 29 cases detected in 1996, 23 were male and 6 were female. Of the 17 infected women in the BAPCP data file, 10 are housewives and two are SWs. Of the 68 males in this same data pool, 30 are migrant labourers, two truck drivers and 29 categorised as of 'occupation unknown'. For a graphic representation of the growing epidemic in Bangladesh, see Figure 2.

Although the HIV/AIDS epidemic is currently nascent or not fully understood in Bangladesh, this country exhibits several risk factors, which could facilitate rapid spread of HIV within its borders. One major problem is a common porous border with India and Myanmar, both of which are currently experiencing HIV epidemics. Bangladesh's risk factors also include premarital sex among approximately 50 per cent of youth, 74,000 migrant workers who leave their homes for long periods of time each year, approximately 225,000 truck drivers and their assistants, 50 per cent of whom have sex with non-regular partners on their journeys. Besides, blood transfusion is a major risk factor. Some 200,000 units of blood are required per year of which almost 80 per cent are drawn from professional blood donors. Among them 20 per cent of professional blood donors are from IDUs who share needles (up to 97 per cent), and over 100,000 CSW, many of whom have a history of STD. One study among CSW in Bangladesh found that 95 per cent had contracted genital herpes and 60 per cent had syphilis. Such diseases not only facilitate transmission of HIV but also indicate presence of risky sexual behaviours such as sex without a condom. If the prevalence of HIV infection in Bangladesh can be limited to less than five per cent in high-risk groups such as CSW, then an epidemic among the general population can be averted. However, control of the epidemic in these groups requires immediate action by government and NGOs in establishing appropriate targeted interventions and STD treatment services for national response in Bangladesh.

Another aspects of risk generating factor are the borders with India and Myanmar. In these two countries HIV/AIDS had already spread in frightening proportions. So considering this situation the conditions of Bangladesh seems to be rather vulnerable because movements of people to and from these two countries exist both legally and illegally. The situation in these countries is more serious than Bangladesh. Any time the situation here could be like that. It has been found that 0.6 per cent of commercial sex workers are HIV-positive in Bangladesh, but there is nothing to feel happy about because when the number was zero there was no multiplication and now when we got a figure no matter how small it may be, it will multiply and the speed of that is very rapid. For example, in 1988 in Thailand one per cent of intravenous drug users were HIV-positive and in 1989 that figure reached 39 per cent. Here in Bangladesh in 1998 we found the figure in the same population as 2.5 per cent, but this figure may have increased many times in 1999. In Myanmar, in 1988 the percentage among drug users was zero, but in 1991 it reached 71 per cent. In India, in 1986 only one per cent of commercial sex workers were positive, in 1995 the figure rose to 18 per cent and in 1996 to 51 per cent. So it is evident from these figures of HIV-positive Indian commercial sex workers as to how fast HIV/AIDS can spread. For that reason we must be cautious about our neighbouring countries. The percentage of HIV-positive people is relatively high in the Indian State of Manipur. But these Monipuris enter our country without any hindrance, without any passport or visa. For that reason we should take special care of that region.

HIV/AIDS is the area of communicable disease control, and arguably of health and human development, where Health Population Sector Program (HPSP) of government needs to demonstrate its ability to act quickly, effectively, and wisely in dealing with high priority. There is still time to avert a catastrophic epidemic. HIV could at any time increase exponentially among and within groups of injecting drug users, commercial sex workers, and their contacts. We are running out of time.