2009年-世界发展银行全球_20_Years_of_HIV_in_Bangladesh___Experiences_and_Way_Forward_201页_3mb

20 Years of HIV in Bangladesh: Experiences and Way Forward

Core Content

This document provides a comprehensive overview of the HIV epidemic in Bangladesh over the past 20 years, focusing on risk groups, barriers to prevention, structural factors, and the national response. It is a joint publication by the World Bank and UNAIDS, highlighting the progress made and the challenges that remain.

Main Authors

• Tasnim Azim (ICDDR,B)
• Sharful Islam Khan (ICDDR,B)
• Quamrun Nahar (ICDDR,B)
• Masud Reza (ICDDR,B)
• Nazmul Alam (ICDDR,B)
• Rumana Saifi (ICDDR,B)
• M. Shah Alam (ICDDR,B)
• Ezazul Islam Chowdhury (ICDDR,B)
• Elizabeth Oliveras (ICDDR,B)

Key Findings and Main Points

HIV Prevalence in Bangladesh

• HIV prevalence in the general population remains low, at less than 0.1%.
• Among high-risk groups:
  • Female sex workers (FSWs): prevalence below 1% in most areas, but up to 2.7% in a border town.
  • Male sex workers (MSWs): prevalence below 1%.
  • Male who have sex with males (MSM): prevalence below 1%.
  • Transgendered people (Hijra): prevalence less than 1%, but high rates of active syphilis.
  • Injecting drug users (IDUs): prevalence up to 7% in one Dhaka neighborhood, with overall 1.2% in 2007.

Risk Groups and Vulnerabilities

• Female Sex Workers (FSWs):

  • Estimated at 90,000, with part-time or "casual" sex workers being even more difficult to estimate.
  • Shift from brothels to less regulated venues (hotels, streets, private homes).
  • High client turnover and low condom use, especially in hotel-based FSWs.
  • High rates of STI symptoms and active syphilis.

• Male Sex Workers (MSWs):

  • A subset of MSM, with some engaging in drug injection.
  • 5% of MSWs in Chittagong reported injecting drugs in the last year.
  • High STI symptoms and low condom use.

• Male who have sex with males (MSM):

  • Heterogeneous group, many hide their sexual behavior and reject the term MSM.
  • Estimated at 40,000–150,000, likely underestimated.
  • Low HIV prevalence but high rates of STI symptoms and multiple sex partners.
  • High network connectivity, which could accelerate HIV spread if it emerges.

• Transgendered People (Hijra):

  • Highly marginalized and stigmatized, facing social exclusion from an early age.
  • High rates of abuse, including physical, verbal, and sexual.
  • Many are forced into sex work due to lack of traditional income sources.
  • High client turnover and low condom use, with active syphilis rates rising since 2004–05.

• Injecting Drug Users (IDUs):

  • Concentrated in Dhaka, with the largest number estimated between 20,000–40,000.
  • HIV prevalence increased in Dhaka, reaching 7% in 2007/08 in one neighborhood.
  • HCV prevalence is high among IDUs, with concerns over unsafe injection practices.
  • Homeless IDUs are more than five times as likely to be HIV positive compared to those with fixed addresses.

• Overlapping Risk Groups:

  • Female drug users often engage in sex work and have low condom use.
  • Some MSWs also inject drugs, increasing their vulnerability.
  • Genetic analysis shows distinct HIV strains among different risk groups, indicating separate transmission routes.

Barriers to Condom Use

• Determinants of Unsafe Sex:

  • Stigma, lack of knowledge, and social norms discourage condom use.
  • Clients of sex workers often have low condom use, especially with new partners.
  • Drug users are more likely to engage in unsafe sex due to drug-related behavior and limited access to prevention services.

• Condom Use Among Different Groups:

  • Consistent condom use among FSWs ranges from 14% to 42% depending on location.
  • Among MSM, condom use is very low, with rates as low as 14%.
  • HIV prevalence among IDUs is linked to unsafe injection practices and sharing of needles.

Structural Factors Affecting HIV Interventions

• Macro Level Factors:

  • Political commitment and early establishment of the National AIDS Committee (NAC) in 1985.
  • The role of the Government of Bangladesh (GoB) in policy formulation and resource mobilization.

• Intermediate Level Factors:

  • Limited access to prevention services among high-risk groups.
  • Inadequate integration of services for MARPs and general population.
  • Insufficient understanding of how to target migrant populations effectively.

National HIV Response

• National AIDS Committee (NAC):

  • Established in 1985, with the President as Chief Patron.
  • Supervises HIV/AIDS programs, formulates policies, and mobilizes resources.

• National AIDS/STD Program (NASP):

  • Operates under the Ministry of Health and Family Welfare (MOHFW).
  • Oversees and coordinates HIV/AIDS prevention and control.
  • Implements the National HIV/AIDS Strategy and national policies.

• Interventions:

  • Needle/syringe programs (NSP) and opioid substitution therapy (OST) have been implemented.
  • Behavioral surveillance surveys (BSS) and rapid situation and response assessments (RSRA) have provided critical data.
  • NGO-led interventions have been effective in some areas, but coverage remains uneven.

• Challenges:

  • Inconsistent condom use and low knowledge of HIV transmission.
  • Inadequate prevention services for MARPs.
  • Lack of systematic data on spousal transmission and couples at risk.
  • Insufficient focus on migrant populations and their role in HIV spread.

Recommendations

• Develop context-specific interventions for high-risk groups.
• Strengthen prevention services for MARPs, including IDUs, FSWs, MSM, and Hijra.
• Increase condom use and promote safer sexual practices.
• Address structural and social barriers to HIV prevention.
• Improve data collection and monitoring, especially among migrant populations.
• Enhance partner notification systems and STI management.
• Promote life skills education (LSE) and behavior change communication (BCC) among youth.

Key Information

• Surveillance System: In place since 1998, with eight serological and five behavioral surveys providing critical data.
• HIV Transmission Routes: Unprotected sex, sharing of needles, and group sex.
• Migration: A key factor in HIV transmission, with international migrant workers potentially bringing HIV into the country.
• Prevention Services: NSP, OST, and NGO-led programs have been implemented, but coverage and effectiveness vary.
• Youth and STIs: 28% of unmarried males reported non-marital sex, with 28% of them having last sex with a sex worker. 28% of young people who had sex reported STI symptoms, but only a quarter sought care.

Conclusion

Bangladesh has maintained low HIV prevalence through early and sustained interventions targeting most-at-risk populations (MARPs). However, challenges such as stigma, limited access to prevention services, and inadequate attention to migrant populations persist. The document emphasizes the need for more targeted and context-specific interventions, improved data collection, and enhanced partner notification systems to effectively manage and control the HIV epidemic in the country.