Prevention Of Hiv In Bangladesh

Dr. K.K Ezazul Haque, UNFPA
Today's roundtable is part of our continuous advocacy in relation to HIV and SRH (Sexual and Reproductive Health). There is a key theme in the title: policy strategic plan and integration between human health and HIV. A question might be raised that why are we embarking on this issue?  First, if we can integrate SRH and HIV, it will ensure the financial sustainability of the programme in relation to SRH and HIV. Secondly, integration will increase the coverage of the programme in terms of geographic and per capita coverage. It will improve quality of services and reduce stigma discriminations in relation to HIV and SRH. These are the main purposes of integration of SRH and HIV. Let me give some examples of possible integration of HIV and SRH:
1.     Transmission from mother to child is one of the ways of HIV transmission. If we consider maternal health and do integration of maternal health and HIV, there would be less risk of HIV transmission from mother to child. For example, if a mother is found HIV positive, she would be counseled for ARV and special services to reduce the risk of transmission. That is one justification for integration of HIV and maternal health.
2.     Second example is of dual protection. Condom is used as a dual protection method:  family planning and prevention of HTI and HIV. If we consider our programme area in relation to family planning and HIV, my understanding and experience say that these two programs are being implemented in a vertical fashion.  HIV programme and family planning programme are doing the same condom promotion programme but in an incoherent manner. If we can integrate the HIV with the reproductive health, the large number of field workers of family planning programme can easily disseminate the little message about HIV in a short period of time to a large group of population.
3.     If we can integrate the migration issue with the HIV, this can also reduce the risk of transmission as the person can take extra precaution during his stay outside the country.
4.     The fourth is very common but not much talked about: the child marriage issue in relation to HIV. In a child marriage, the girl does not have any negotiation skill with her sexual partner. This can also increase the risk of transmission. We need to think how the child marriage issue can be related to HIV to prevent further transmission.
5.     Fifth one is gender based violence and violence in general. For instance, gender discrimination and gender inequality actually disempower female counter part and she does not have any negotiation power over sex. If there is social and economical empowerment, the female counterpart will have a definite say for safe sex practice.
These are the justifications why we have invited you. We want to have your insights regarding why we need such integration of HIV with the reproductive health. Please allow me to read the Toto Policy statement regarding this issue:
1.     To device a national program,
2.     To prevent and contain the spread of HIV infection as a part of Bangladesh's health system,
3.     To involve all the government sectors and relevant government/non-government organizations to the fullest extent possible in planning, implementation of such program in conformity with global strategy.
So, we have a strong justification why we need integration of HIV and SRH.
Integration of HIV and SRH is very much related to our National AIDS STD Programme (NASP) which is endorsed by the Ministry of Health and Family Welfare. In the third objective it says, “To strengthen the coordination mechanism and management capacity at different levels to ensure an effective multi-sector HIV response”.
In the strategies and plans of the same document, it says that the multi-sector engagement of the HIV epidemic is very complex. It is felt across the society involving individuals, families, sectors and institutions. It, therefore, goes beyond the domain of the heath sectors and an effective response to it must be multi-sectoral. So, if I again refer back to the title, we have a very strong ground and documented justification in relation to policy document and strategic plan. It clearly asks for integration of HIV and reproductive health program. Despite clear policy guidance and our commitment, we are still doing the HIV and reproductive health programmes in a discrete fashion.
It is also important to integrate our funds for HIV and SRH. If a donor only funds for HIV then it is really difficult for the implementing agency to go beyond the donor's mandate. So our donors have to be aware of the issue of integration. Without administrative and financial integration support, implementation of integrated programmes cannot be successful.
Though we have large fund being provided for HIV, still there are gaps. To fill the gaps, we can integrate the services of the other sectors. For example, we can integrate health, education, gender, population and so on. I agree, this is a low prevalent country and unlike Africa and the other high prevalent countries, the integration is not so important. But we need to integrate HIV and SRH to continue the low prevalence effectively. And the integration programme should be mainstreamed.

Dr. Halidah Khandaker, Executive Director, Confidential Approach to AIDS Prevention (CAAP)
In 1995/96, AIDS Committee developed a strategy. There was an indication for integration of HIV/AIDS with STD (Sexually Transmitted Diseases) prevention. Although there was no mention of MCH (Maternal and Child Health), STD was one of the features.  The strategy had four objectives:
1.     Prevention of transmission of HIV;
2.     Reduce the impact of HIV infection;
3.     Prevention of STD;
4.     Management of STD.
I do not know how it was separated again and why it did not work. From the observation, age and experience with many departments of obstetric gynecology, STD and HIV infection I can say integration has many good sides, especially for women. Because, if a woman gets chance to get all the services from one place, for her it becomes beneficial to come and take the services. As you know, women are always neglected and they hardly get any chance to come to hospital or come to take other services, except during delivery or pregnancy. About that also I am very doubtful because most of the deliveries are being done at home than in the center. So, in that case, when a woman gets chance to have MCH services, she can get the services of STD also. And if she can also get the services of detection for HIV also, then she can get three or four services from one place. That will reduce her husband's burden to bring her to the hospital repeatedly. It will also reduce the cost of healthcare.
As HIV and STD spread almost by the same method of sexual transmission, the prevention is also the same. For instance, a woman can ask her husband to use condom to have less children. So, then she will have good health and will have a reduced chance of getting HIV infection from her husband or vice versa. Condom promotion can help this. This is not only beneficial for women, but for men also, because they are the ones who will be providing the sustenance for their wives and children.
I want to urge our authorities to integrate HIV especially with MCH. Because when a woman cannot get the chance to detect if she is positive or negative, she can come to the MCH centre. She will have some blood test and during that time she can have the HIV test also. So, that becomes very easy for her to get to know the status. And when she knows the status, she can get the chance of having the condom; have fewer children and less infection.
She may not be infected at all, or the child may not be infected at all. You can make conditions like “I have told you before.” And the other thing is that it is man's responsibility to spare or reduce the chance of infection, i.e. by using condom. So HIV should be integrated with family planning also. And my idea is to integrate  the three services: HIV, STD and Family Planning. Only one condom can save many lives. So, why will men be reluctant?
I am not a feminist. I am a mother, a wife and I love my husband and my children. I love my family and I wanted to be a house-wife which I do love. Still, this is true that men have to realize. I may not ask my husband whether he is having affair with other lady but I should have the courage to speak it out some other way. If the husband becomes responsible then I will tell him that, “I do not care how many women you are having affairs with; but when you have affairs with me then please use the condom.” I think, the men here would agree with me.

Clockwise from top left: Dr. K K Ezazul Haque, Dr. Halidah Khandaker, ABM Kamrul Hasan, Dr.Ishrat Jahan, Dr. Abdul Waheed, Leo Kenny, M A Siddiqui, Cdre (Rtd.) Nurul Amin Chowdhury, Shashish Shami Kamal, Dr. Muhammad Munir Hussain, Dr. Samir Kumar Howlader, Ali Reza, Dr. Tajuddin Oyeware, Saleh Ahmed.

Dr. K.K Ezazul Haque
There is some confusion about the integration issue. One clinic is doing the STI (sexually transmitted infections) services and they are also providing the HIV services. They say that they are doing integration. We are not here to discuss that issue actually; we are saying the integration in relation to the mainstream and linkage.
Since we do not have policy, strategic, management, administrative and financial support for the integration programme from the centre level, it will be very sporadic and it will have minimal impact. That is why we are urging again that we need government support not only from the MOHFW but also from all other relevant ministries.
If we consider maternal health, we do not need to implement the integration issue in all the maternal health clinics in the same way. What is required is that we have to select the area, the population group and who are at risk – then only we can specifically counsel them in a maternal health setting and find the risk of transmission from their body to the coming child. That is the main purpose.

ABM Kamrul Hasan, Programme Coordinator, UNODC
We have a policy document on HIV AIDS, which was officially endorsed perhaps 20 years back in 1997. The journey started in around 1994/95. At that time most of the Asian countries did not have any policy regarding HIV/AIDS. Later on, we prepared the strategic document -- National HIV AIDS Strategy. In terms of policy and strategy, it was fantastic. The country was in a very good position. After 20 years, we have to re-think whether we should go back again to the policy, whether we should update, whether we should revise the policy or not. That is very important because the situation has changed in a multifarious way. We should be at per with the change.
At that time our focus was just to combat HIV. We did not realise its relation with other health issues. If you go through the policy, it will say everywhere that, the other reproductive health issue was not considered very much.  For example,we  only focused upon the injecting drug users, but not about other injecting forms and other drugs. We did not address how the young generation was induced with the illicit drugs and what is the relation between reproductive health and HIV. That time these issues were not discussed nor addressed. After 20 years it is very important to look back again to that policy.
When we talk about integration we have to consider the issue of human resource for health. Who are the main implementers of our health programmes? Each and every union has a union FWC (Family Welfare Center). In most unions we have the union sub centre. In Upazila, we have Upazila Health Centre. They are the main providers of reproductive health services. We have to integrate our HIV /AIDS programme with these mainstream providers of health and family planning services.
We have also facilitated community health service. If we go back to the policy and strategy, we must consider broader perspective rather than only focusing on HIV or STI. For example, child-marriage, adolescent-pregnancy, illicit drugs taken by young generation are really pertinent issues related to reproductive health, which make individuals vulnerable to HIV/STI. HIV or STI infection is the outcome of many issues. All we need to do is to address all the pertinent issues so that we can cut the HIV infection or STI occurrences. It is our goal. We should provide more adolescent friendly health services because they often think that they don't require any healthcare.
Our SRH and family planning programmes are very much focused on married couple. There is a large section of unmarried man and women who also need SRH and family planning services.
We have to incorporate some life skill programmes in our SRH and HIV policies. It is important for the young and adolescents.

Dr. K.K Ezazul Haque
MDG and ICPD policy documents are very relevant to this linkage issue. I want to quote from the ICPD document: "information, education and counseling for responsible sexual behaviour and effective transmission of sexually transmitted diseases including HIV should become integral component to all SRH services". We are a signatory to the ICPD Programme of Action. So we are obliged to formulate and implement programmes in an integrated way.
Dr. Ishrat Jahan, Programme Manager, Adolescent and Reproductive Health, DGFP
DGFP can do a lot in terms of providing integrated services. We have large number of field level workers. We can employ them in integrated services.
In our country women only come to hospital when it is an urgent issue. From the gender perspective it can be said that sometimes they are not allowed to come. When they come to our service centres we screen them and make them aware about HIV issues.
I have doubts about the quality of knowledge of our service providers on HIV. So training for the field workers on HIV is urgently needed.
DGFP provide some SRH services to adolescents. In different districts we conduct awareness campaign on this issue.  We are also talking about preventing child marriage and adolescent pregnancy. We need to add some information about HIV and high risk behaviour with SRH. Now we are reviewing our adolescent reproductive health strategy. We have already finalized reproductive health action plan. We will disseminate the action plan soon. In the new action plan we have committed to do more about adolescent reproductive health.
In our reproductive health programs we should include the HIV issue. In our family planning centres we should have some diagnosis facility for women who are at risk, for example women who have husbands living abroad or addicted or open to high risk behaviour. It is important because there is a risk of vertical transmission of HIV from mother to child.
My next point is safe blood transfusion. In delivery section,when any emergency situation arises we need lot of blood.That's why it is very important to screen blood properly in delivery centres. Otherwise it can cause HIV infection to both mother and child.
We have to promote only condom. We have to inform people about the dual use of condom: family planning and prevent HIV and STD.
We should focus more on men. If they are aware then it becomes easy for his spouse to maintain a safe sexual and reproductive health. So men should be incorporated in our campaign.

Dr. Abdul Waheed, Line Director, NASP
How human resource for health and HIV prevention should be linked is an important question. In our national strategy it is clearly explained. But we are not implementing it. So we have to think how to implement it.
We are doing different things in different ways. For example, DGFP and DGHS are doing things according to their own plans. But there should be a linkage at some point. That point should be at the service level.

Leo Kenny, Country Director, UNAIDS
It is widely recognized that we can get better results by avoiding parallel health system. It needs to be done not only in terms of SRH and HIV but also in range of services such as TB, MCH etc. In this age countries can not afford not to do it because it means efficient use of resources is not being made. By 2015, we should achieve the desired progress in linkage issue.
Improvement of linkage between HIV and sexual reproductive health is very important. If a country does not make enough progress it is because of the following reasons: your analysis of the service delivery is flawed; you are not doing enough to ensure  linkage between the service systems to promote maternal health and health of children; weak health systems and lack of an entry point to address sexual and gender based violence; you are not doing enough to ensure linkage among MDG 3,4,5 and 6.
We are not harnessing the opportunity of using the HIV entry point to address the MCH issues, we need to harmonize the funding of HIV and SRH; we are not strengthening capacity of our service providers to link between SRH and HIV.
There are also some legal barriers to this integration effort. That happens to key population like transgender, sex workers, people injecting drugs, men having sex with men and adolescent population who do not have access to health services.
We must do more to address stigma and discrimination, including removal of punitive laws and policies that block access to services of those people who are most at risk.

Dr. K.K Ezazul Haque
I want to quote some lines from the 2010 ANGUS Report: "Response to HIV in Bangladesh is provided through multiple funders and multiple implementers. Lack of smooth coordination among player is a major hindrance to providing quality services. In Bangladesh multiple ministries need to be involved to ensure key services. This is not carried out effectively. Roles and responsibilities of designated focul points in 16 ministries need to be clarified and reactivated." This is very important. We have 16 HIV focal points in 16 ministries. If we can activate the integration process will be smoother.

M A Siddiqui, Columnist
Education is an important means to disseminate HIV information. Our education curriculum should include comprehensive reproductive health education.
We can talk about SRH in forums but not in our families. We should come out of such stigma.

Dr. Halidah Khandaker
I want to tell our parents to take courage and talk to your children about SRH and HIV issues. When we first went for campaign in schools, the headmaster asked us only to take science students. I had to fight with them to make them understand that the student from Arts background would also be a man or women. So take courage and be careful.
Saleh Ahmed , ED, Bondhu Social Welfare Society
Among the transgender community we only provide condom and STI services. But we are not able provide them other SRH services. So they remain vulnerable. There is also an important issue of access for the transgender community.
Providing SRH services can not be separated from the livelihood issue. Our transgender community has very little access to formal job market. That's why they have to opt for risky professions for earning livelihood. It makes them more vulnerable to HIV/ AIDS.
When we talk about gender-based violence we do not count the transgender. They are also victims of different kind of violence. There should be strong punitive measures in case of violence against transgender and feminine male.
There is a large group of man having sex with man. Most of them start practicing this risky behaviour at the adolescent age. According to our government policy they are considered children and we cannot promote condom among children. But adolescents come to our centres and we are providing them condoms but we cannot register their name. So in policy formulation we have to also consider these issues.

Dr. Tajuddin Oyeware, Chief, HIV/ AIDS , Unicef
Every child has a right to survive. Meaning that when it is born, it has the right to born free of HIV. Within that framework we look at the issue of HIV. We have to explore opportunities that bring about efficiency of investment and effectiveness of intervention. And to do that integration and linkage is central.  If we go about doing parallel programme we will not achieve anything. It will be expensive. There will be lot of duplication and wastages. We do not have any other options than to push hard for integration and linkages. For that we need to do something at policy level. UNICEF unequivocally supports linkages between SRH and HIV.
I want to focus on two important groups: adolescents and pregnant mothers. They are the continuum of cares. At the pre-pregnant period, what does the girl need? She needs good reproductive health and to be free of HIV. She needs HIV counseling and testing. And how do you implement HIV counseling and testing if you do not integrate SRH and HIV counseling? When one visits a SRH expert he or she can ask for HIV testing. Even to prevent the transmission of HIV from the mother to the child, contraceptive is critical .When a mother decides not to be a pregnant, a child cannot be infected. The important topic about which we do not talk much is that when a mother is HIV positive she needs access to family planning method to delay pregnancy or not to be pregnant at all.
When a mother is pregnant, the matter of integration comes again. MCH service providers can easily provide HIV testing and counseling services. It is the best place to do that.
Bangladesh has made massive progress in cutting down the rate of under-five mortality. We have to integrate early infection diagnosis for the infants at the point of neonatal care.
Bangladesh has all the ingredients to do a successful integration but we need to join them together. 2014 is the best time to do that because at that time we will do the midterm review of National HIV/AIDS strategy . At that time, midterm review of the National Health Population Sector Wide Programme will also be held.  So we have a great opportunity to link all these together.

Ali Reza, OIC, UNIC
Awareness requires dissemination of proper information. It leads to understanding. Understanding leads to awareness. Awareness leads to actions. And positive actions lead to change. And this change makes the desired goal of a nation. Since the young generation is the agent of change we have to talk about our youths when we talk about any integration. We have to know the need of reproductive health services of the young population. We mostly focus  upon vulnerable groups. But there are large number of young groups who are out of the counting but equally vulnerable to HIV infection.
We want other daily newspapers to come forward like The Daily Star in holding discussion on HIV issues and make our citizens aware. Among the TV channel only the state run BTV shows HIV related programmes. There are many channels in our country that do everything except showing any programme on  HIV. We urge them to allow some slots for dissemination of HIV information. Mainstream radio channels as well as community radio channels should also join the campaign.
In many cases, educated people, even doctors, are not aware about AIDS infection. I know someone whose wife got infected during delivery of her child. One of her relatives donated her blood during emergency delivery operation. The blood screening system was poor. So she got infected. In many renowned hospitals in the country blood screening is not properly done. We should also emphasise on this issue.
I would urge to observe International AIDS Day in all educational institutions. Our schools should teach students about SRH and HIV. The students will further disseminate the message..

Dr. K.K Ezazul Haque
UNFPA have recently started a radio ad on HIV in Dhaka FM. It is a 30 seconds slot and  will be aired 60 times in 24 hours for 40 days.

Dr. Samir Kumar Howlader, National Programme Officer, IOM
Linkage at the service level is not possible without linkage at the strategic and policy level. Mostly we do some sporadic work of integration at the field level that in the long run fails to sustain due to lack of proper policies of integration at the national level.
Integration will bear good results if we consider the vulnerability of the migrant workers. They are termed emerging vulnerable population in the third national strategic plan. We did some sporadic work for migrant workers to prevent HIV infection like pre-departure orientation and linkages to service providers after they are back. But we do not have any policy for their spouses. This is an important area of integration. If we integrate SRH with HIV, then the spouses who stay back in the home country can access the SRH services as well as HIV consultation.
Why do we not include unmarried young people? We only work for married couple. We should focus on unmarried young people.
When we talk about multi-ministerial involvement we know that there are 16 ministries that are involved in the committee on HIV and HIV focal points are there. I do not know if Ministry of Expatriate Welfare and Overseas Development is involved there. If they are not involved then nothing can be done successfully for the migrants.

Dr. K.K Ezazul Haque
It is really a challenge to follow up HIV issues of an immigrant from country of origin to country of destination. We have to address the challenge seriously.

Dr. Muhammad Munir Hussain, Project Manager, Plan International Bangladesh
We are overburdened with policies and strategies. I want to emphasise on mainstreaming, both internally and externally. Different ministries have different policies. We have to know if there is something about HIV. Then we have to coordinate those policies with the national HIV policy.
We have incorporated HIV issues in our secondary school curriculum. In 2012, we have also incorporated different SRH issues in the curriculum of secondary school. Now, it is not just about small family.  In the curriculum, we have discussed adolescent reproductive health and family planning issues, in details. But we need to train our school teachers so that they can teach these things in a student-friendly way.

Shashish Shami Kamal, Youth Member, UNFPA Youth Group
To reach the critical youth population we have to involve the youths themselves in our campaign. Then it will be easier to reach young people and create a lasting impact upon them. When I was a member of an anti-smoking group, we undertook an anti-smoking campaign and involved some of the smokers. It worked like a miracle. They motivated others not to smoke and some of them broke the bad habit.
We need more research on men and masculinity. Masculinity is socially constructed. Masculinity breeds some negative ideals that attract young boys. Young people are curious about everything under the sun and get involved in various harmful practices just out of curiosity and manipulated by different patriarchal constructions of manhood. It may be injecting drugs, having multiple partners and so on, which make them vulnerable to HIV and STDs. So we have to work on the idea of masculinity and fight out wrong notions of manhood. We need to understand the young man, his ideas and his curiosity and reach them with information about HIV and SRH in ingenuous ways. The masculinity issue should also be included in the HIV research paradigm.
Another important issue is using ICT in dissemination of information about HIV. We can also make communication channels so that one can get HIV and SRH service related information over phone or via internet without disclosing his or her identity.

Dr. K.K Ezazul Haque
We need to work more on leadership issue to raise the voices of young people. We want to see youth-friendly programs and services .  DGFP has already introduced some adolescent friendly services.

Cdre (Rtd.) Nurul Amin Chowdhury, Programme Advisor, RTM International
Our strategy should be sensitive to our social reality. In village areas, it is still difficult to talk about HIV. We have to reach them in innovative ways and help get rid of the social stigma about HIV. We have to provide HIV related information and SRH services in an integration package so that people can also understand linkage between HIV and SRH and do not shy away from the services.

Dr. Ishrat Jahan
We are not providing contraceptive to unmarried adolescents. But there are large numbers of unmarried adolescents who are involved in sexual activities.  They are high-risk group. We do not even register their names; even there is no column in the register book for unmarried adolescents. This is an important area to work on. To provide them contraceptives we have to change our policy. Our policies are solely focused on married couples. We should change our perception and incorporate unmarried adolescents in our services.

Dr. K.K Ezazul Haque

UNFPA has strong mandate to work on integration of HIV and SRH issues. We are trying our best to do so. We are providing training to service providers to build their capacity on delivering integrated services. We are also providing technical assistance to NASP. UNFPA has closely worked with the government to formulate a communication strategy for integrated services. We have learnt a lot from today's roundtable. We will incorporate your recommendations and work together for creating an effective linkage between HIV and SRH.

UNFPA and The Daily Star jointly organized a roundtable on 'Prevention of HIV in
Bangladesh' recently. Below we publish a summary of the discussions -- Editor