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POSSIBLE AIDS EPIDEMIC IN BANGLADESH:

BREAKING THE SILENCE OF COMPLICENCY

Bangladesh is one of the most densely populated


countries in the world. The relatively young age
structure of the population indicates continued
rapid population growth in the future.

In 1992, Bangladesh had around 22 million married


women of reproductive age; by the year 2001, this
number was projected to rise to 31 million.
Instead of a positive demographic transition over
last two decades, the country is still in a vicious
cycle of population expansion and poverty, and this
continues to be a tremendous burden on the nation
(Amanullah, 2002).

Various national studies, including Bangladesh


Demographic and Health Survey (BDHS), indicate
that more than 90 percent of ever-married women
living in rural areas are covered by FP workers,
however, adolescents/younger women are less
likely to have been visited, and the status of

primary health services in rural areas is still very


poor.
Neonatal tetanus, birth-related complications,
diarrheal disease, tuberculosis, STDs and other
Reproductive Tract Infections (RTIs) continue to be
the major killers of the Bangladeshi infants,
children and adults.

Bangladesh is also affected with high levels of


bacterial, viral, mycotic and parasitic disease
which are the major causes of morbidity and
mortality.

These infectious diseases could be the prime


mover for a vicious cycle of HIV epidemic
(Amanullah, 2002).

HIV-related wider risk factors

*Vulnerability of women and children: Trafficking,


forced prostitution/labor, rape of detainees in

police or other official custody, vigilantism


(humiliating, whipping) and discrimination against
women/female children are serious problems in
Bangladesh.

The government has acceded to the U.N.


Protocols, and enacted laws specifically prohibiting
certain forms of discrimination against women.

But enforcement of these protocols is rare and a


large number of child SWs are still working in
countrys brothels/streets in the presence of police.
Because of widespread poverty, about 6.3 million
Bangladeshi children are not only deprived of the
basic rights of life, but are also compelled to work
in hazardous environments at a very young age,
often as child-laborers, sex workers, beggars, etc.

This frequently results in conditions that resemble


servitude and many suffer physical abuse by their
masters. Specially, Bangladeshi young girls face
double burdens, discriminations, and prejudices of
society in the early stages of their lives.

In the above situation adolescent girls and women


do not have the knowledge and means to prevent
HIV infection (Amanullah, 2002).

HIV/AIDS from global and Bangladesh perspective

According to UNAIDS/WHO estimation, nearly 65


million people have been infected with HIV to date.
Of them, more than 30 million have already died of
AIDS.
More than 35 million adults and children were living
with HIV/AIDS throughout the world by the end of
2010.
Of them, nearly 95 percent were living in the
developing world.
In the course of the year 2010, about 3 million
people were newly infected, which included
370,000 children aged <15.

Only in 2010, more than 18 lac people died of


AIDS, which included 2,600,000 children. The ratio
of infection is now almost equal between men and
women.

Compared to men, women were more susceptible


to the infection accounting for more than 50
percent of adult deaths in 2009 and 2010.
According to UNAIDS, In sub -Saharan Africa, 57
percent of adults with HIV are women, and young
women aged 15 to 24 are more than three times as
likely to be infected as young men.

Despite this alarming trend, women know less than


men about how HIV/AIDS is transmitted and how to
prevent infection, and what little they do know is
often rendered useless by the discrimination and
violence they face.

The epidemic is receding in industrializedcountries


and spreading faster than feared in developing
countries like India, China, Myanmar and
Cambodia.

Although HIV/AIDS is spreading in all regions of the


world, some poor countries in the regions of subSaharan Africa and Asia have been experiencing an
explosive outbreak of the epidemic in the recent
past.

UNAIDS/WHO data show that many African


countries have started experiencing the adverse
socioeconomic, demographic and cultural
consequences of the epidemic.
Recently the epicenter of the epidemic has
changed its direction towards South and Southeast
Asia and the new infections continue to occur
among IDUs, CSWs and their clients, migrant
workers, and women (Amanullah, 2002).

Risk and vulnerability in the Asia-Pacific region

Overall, as of the end of 2010, an estimated 5 to 7


million adults andchildren have become infected
with HIV in South and Southeast Asia.

Most of these infections occurred in a few large


countries (particularly in certain pockets) of
thisregion. In this region, as available behavioural
and epidemiological data suggest, an increased
vulnerability and rapid outbreak of the epidemic in
near future is inevitable.

It is feared that the explosive sex trade,


widespread use of illicit drugs, increasing rates of
STDs, abject poverty, illiteracy, patriarchy and
large scale populationmovements have already
made this region a fertile ground for rapid
expansion of HIV epidemic (Amanullah, 2002).

Unprotected sex with female SWs and sharing


needles and syringes are two major factors in
severe transmission of HIV/STDs in Thailand,
Cambodia, Myanmar, China and India.

In these states, a significant proportion of SWs and


IDUs are already infected with HIV and the rates
vary from <1percent to >40percent in some
settings.

It is widely believed that the increasing sex trade in


this region has resulted from significant sociopolitical and economic changes and unrest.
Therefore, the nature and profile of SWs vary
enormously within and between countries. There
are male and female SWs, who work fulltime, parttime or seasonally in variety of settings such as in
registered/organised and unorganised brothels,
residences, bars, massage parlors, streets or
hotels.

Bangladesh: geographical proximity to HIV


epicentres

Unfortunately Bangladesh is in the Asian HIV


epicentre and the country traditionally shares a
popular crossroad of South-Asian
migration/frequent mobility.

The country has an area of 147,570 square


kilometres bordered on the west, north and east by
a 2,400 kilometres land frontier with India and, in
the southeast, by a short land and water frontier
(193 kilometres) with Myanmar.

After Thailand, the HIV epidemic is currently


expanding in India, Cambodia, China and Myanmar.
According to a recent nationwide surveillance, HIV
cases were found to be concentrated in central
areas and some border districts of Bangladesh.
Like India and Pakistan, the prevalence of HIV is
largely concentrated in some central urban,
seaports and border areas in Bangladesh.
Since the discovery of the first case in 1986, the
pandemic has exploded in India and according to
UNAIDS/WHO and other authentic estimates, this
poor country has the largest number of HIV
infections in the world approximately 5 to 9
million. In India, 2000 people are being infected
newly with HIV every day.

An estimated 50,000 Sex Workers (SWs) have been


playing the dominant role in the heterosexual
transmission of HIV only in Mumbai.

In Myanmar, HIV infection among sex workers


increased from 4 percent in 1992 to more than 20
percent during 1996-2004. This country currently
has more than 2.4 to 5 million HIV infected people.
With about 1.5 percent to 2 percent prevalence
rate and rapidly growing epidemic in the region,
Cambodia and Myanmar are the highest infected
areas in South and Southeast Asia (Amanullah,
2002).
Poverty, prostitution and HIV in Bangladesh

Poverty and prostitution are the prime causes of


heterosexual transmission of HIV in many countries
of Asia. Not only in Asia, HIV has spread in many
European, Pacific, African, and north-American
countries where people belonged to stigmatized
ethnic communities, were of lower socioeconomic
status, or faced volatile political/regional conflicts.

Studies from the above regions testified that


structural factors exacerbated the vulnerabilities of
those people. The current experience of India,
Nepal, Vietnam, Myanmar, Cambodia, Laos, China
and Thailand also confirms the fact that HIV is a
disease of poverty and dislocation (Amanullah,
2002).

Explaining the situation of African, North American


and other regional contexts, HIV social researchers
already established the importance of a sociocultural perspective on the pandemic.

In this context, the transformation of thinking


about the pandemic and behavior change has
already moved from the narrow notion of individual
cognition to questions of greater socio-cultural and
other societal vulnerabilities (Amanullah, 2002).

Increasing commercial sex working in Bangladesh

The sex industry has been well established in


Bangladesh since the nineteenth century. The
urban and semi-urban brothels are organised and
controlled by formal/informal functionaries such as
vested local influential, rabbles, police and
madams/managers.
These established brothels are evidence of a large
customer base among the general population.
Women who join brothels/streets come from most
disadvantaged sections of the society and are
predominantly the products of abject poverty.

A considerable number of impoverished


housewives, destitute widows and students are
assumed to have been involved with part-time
commercial sex working recently (Amanullah,
2002).

Prostitution is not an illegal or punishable offence


in Bangladesh and therefore, there is no law in the
country to prevent a girl becoming a sex worker.

However, article 18(2) of the Constitution states,


the State shall adopt effective measures to
prevent prostitution and gambling.

The outcome of this paradoxical situation is that


the government often violates SWs human rights
or their rights of profession by destructive ways.

Although the prime target of the act is to prevent


child and forced prostitution, there is no
implementation of the act in these respects.

Currently, a large number of child sex workers are


assumed to be working in many
organised/unorganised brothels of the country
under enforced conditions.

The state appears in the role of oppressor rather


than protector of the rights of occupation and
livelihood.

An estimated 150,000 SWs are currently working in


Bangladesh. Several studies show that the floating
SWs are largely available in the capital and other
major cities in Bangladesh.

The most frequent visitors to brothel, street and


house-based SWs are businessmen, students,
transport workers, security personnel and foreign
tourists.
In 1997, some researchers estimated that at least
10,000 child prostitutes were working in Dhaka City
alone (Amanullah, 2002).
In recent years, the academicians have conducted
several studies on Bangladeshi commercial sex
workers. These studies are largely based on brothel
based SWs, descriptive in nature, and seriously
lacking in theoretical orientation. Because of the
rapid spread of HIV in the region, NGO researchers
have recently started focusing on the health and
other risk behaviors of both institutionalized and
floating sex workers, and some of them tried to
correlate their findings with existing socio-cultural
factors.

A few of them attempted to show the structural


barriers and contextual/institutionalized risk
factors surrounding the brothels and sex working
communities as a whole. Although most of these
recent researchers designed their studies by
combining survey and anthropological techniques,
none was found relating their findings to existing
psychosocial model/theories of behavior change
(Amanullah, 2002).

Though people generally believe sexual intercourse


with SWs to be wrong, the above review indicates
that a large number of commercial sex workers
operate in Bangladesh. Important findings of these
studies include: relatively high frequency of foreign
tourists and migrant workers, extremely low level
of condom use, lack of proper knowledge and
misconceptions about prevention/cure of
STDs/HIV/AIDS, present or past history of STDs,
extremely low literacy/educational levels, societal
violence, clients pressure for non-use of condoms
and the history of drug use among SWs.

Together, these factors may hasten the incidence


of HIV infection among SWs and their clients in
near future.
Scholars from all over the world have been
predicting since the early 1990s that the future
spread of epidemic in any country will correlate
closely with the current and future prevalence of
STDs, injecting drug using, poverty, culturally
constructed risk-behaviours, socioeconomic
conditions, political/regional conflicts, race and
ethnicity, and emerging sex business.

Bangladesh clearly qualifies in terms of all


conditions stated above. The following section will
try to reveal the truth (Amanullah, 2002).
Current status of HIV/AIDS in Bangladesh

Although many South and Southeast Asian


countries started documenting their HIV epidemic
in the late 1980s, due to scarcity of authentic
data, it was difficult to assess the burden of HIV
epidemic precisely for Bangladesh.

Ten years ago, WHO estimated that Bangladesh


belonged to pattern III countries for HIV/AIDS
epidemic, meaning the infection had not reached
one adult per 1000 in the country.

In the year 2010, the country still does not know


the exact number of its HIV positive people.
Analyzing latest surveillance data, some national
and international researchers have suspected that
HIV prevalence is just beginning to increase in
Bangladesh (Amanullah, 2002).
The people in South and Southeast Asia regularly
practice high-risk behaviors, some of which are
traditional and implicit in nature. These disguised
risk behaviors are very much conducive to an
explosive outbreak of HIV. It is now clearly
established that the HIV-1 virus has been spreading
virulently in South and South Asian countries
through sex workers and IDUs.

According to epidemiological sources, all HIV strain


s found in Bangladesh are HIV-1. HIV-2 or any other
clear retro-viral strains have not been detected yet
in the country. Indexed publication on the

epidemiological, behavioral and cultural aspects of


HIV and prostitution has been voluminous for
Thailand, India and some island states of Southeast
Asia.

In contrast, although, recently some international


NGOs have started epidemiological inquires, there
is still a scarcity of publication on behavioral and
cultural construction of HIV/AIDS in Bangladesh.
Various national and international studies observe
that the prime risk factor for HIV invasion in
Bangladesh is heterosexual transmission, to and
from SWs, followed by IDUs and blood transfusion.

The countrys religious rigidity, sociocultural taboo


on sexual discussion/sexuality, and traditional
social structure are seemingly dysfunctional in
preventing a large segment of its population from
practicing unsafe commercial sex, or other implicit
risk-behaviors.

Transmission of HIV through IDUs and heterosexual


contact are believed to be the prime mover of AIDS

epidemic in the South and Southeast Asian


countries.

Since the first diagnosis of AIDS in 1989, up until


now, Bangladesh has officially reported only a few
HIV infections (2088) and AIDS (850) cases.

There is no doubt that these numbers represent an


undercounting. Besides, the available surveillance
stem of the country does not allow researchers to
approximate the HIV-1 seroprevalence in this
country.

National and international experts suspect that the


actual number of infections is much higher.
According to a WHO estimate, about 20,000
Bangladeshi adults and children were infected with
the HIV by the end of 1993, and over 100,000
could have been infected by 1997.

A sentinel surveillance system has not been


established yet in this country to prove or disprove
this estimate and therefore, the experts and policy

makers often depend on guessing, or inappropriate


surveillance, in estimating the number of HIV
infection.

However, the government has recently


acknowledged that about 7,500 people could have
been infected with HIV in Bangladesh.
Furthermore, researchers do not know exactly the
route(s) of entry of HIV infection in Bangladesh. It
is assumed that the frequent mobility of
Bangladeshis to its neighboring India, Myanmar,
Thailand, Middle East, or western countries may be
an important source of entry.

It is also feared that the virus has entered


Bangladesh through foreign tourists/businessmen
who are the regular customers of local/regional sex
industry (Amanullah, 2002).
The explosive outbreak of HIV in certain pockets of
India, Indonesia, Nepal, and Myanmar is believed
to have occurred through heterosexual IDUs.

Now, Bangladesh also qualifies for this trend. In


Bangladesh, although the overall HIV prevalence
rates among population groups most vulnerable to
HIV infection is less than 1 percent (0.3 percent),
the overall HIV prevalence among IDUs is 4
percent.

More importantly, in some pockets in central


Bangladesh the prevalence of HIV among IDUs is
about 9 percent. These IDUs have high rates of
HEP-C prevalence (59percent) and about 21-44
percent of them regularly visit sex workers.

The rate of consistence use of condom among


these IDUs is less than 5 percent, which is seriously
low compared to their counterparts in many Asian
countries. These IDUs should be treated as being
major risk factors for the transmission of HIV/STDs
in Bangladesh (Amanullah, 2002).
The prevalence of HIV, as indicated by the recent
sero-surveillance, among floating SWs is 2 percent
in central Bangladesh. This figure may be very low
compared to

regional neighbors, however, it is a signal that the


country is not immune to the spread of HIV through
sex workers. Another point prevalence study
among STD patients in port city Chittagonj shows
a 0.5 percent and a 4.5 percent of HIV and syphilis
seroprevalence respectively.
In the study, 79 percent of the subjects never used
condoms. The study cautioned that its subjects
were at risk for further spread of HIV because of
their increasing syphilis prevalence and high-risk
sexual practices.

Finally, the researchers concluded from their clad


analysis that this strain was more analogous to the
clades seen in India than in Thailand.
Currently there are no scientific
behavioural/epidemiological studies on other types
of Bangladeshi SWs who operate in rented house,
hotels, or boats.
Because of their clandestinity and frequent
mobility, it is very difficult to study these groups
and thus the country does not have a proper
understanding either of the prevalence or
knowledge, attitudes and practices concerning HIV

and condom use for these large segments of the


sex working population (Amanullah, 2002).
Bangladesh has many guarded/unguarded
traditional trade routes as well a common
sociocultural identity with these neighbouring
countries. It is believed that a large number of
people and SWs cross between the borders of each
country every year for business, travel and sex
tours.

A recent Indian study has confirmed that about 12


percent of SWs working in Calcutta brothels are
from Bangladesh.

Therefore, Bangladesh is in grave danger of the


epidemic spreading to it. The factors which led
India to become the worlds most HIV infected
country are very much present in Bangladesh,
although the country has been showing a fatal
silence by depending on its strong religiosity,
social taboos on sex and traditionalism.

The following review of existing literature does not


support the authoritys complacency any more
(Amanullah, 2002).
Non-marital sexual relations
Pre-marital sex: Despite strong religiosity and
sociocultural norms, severalqualitative and
quantitative studies show that promiscuity, illicit
sexual behaviour and multiple sex partners are
common among Bangladeshi youths.

In an anthropological study, eminent ICDDR,B


researchers reported that, 50 percent of their
subjects (young men) had engaged in intercourse
before their marriage, adolescents were not
punished for their premarital sex, and such sexual
activities were related to respondents
socioeconomic status.

About half of the subjects (Bangladeshi males)


admitted having premarital sex in a joint study of
ICDDR,B and the Health Transition Center of
Australian National University.

Furthermore, about 50 percent of


married/unmarried men, who reported having
premarital sex, had visited sex workers.
In a recent study of adolescents, some BRAC
researchers reported that by the age of 16-18
years, 80-90 percent of urban males had sexual
experience compared to 40-60 percent of rural
males. Of the men, who had sex outside of
marriage, 71 percent mentioned SWs as their
sexual partners (Amanullah, 2002).
Extra-marital sex: The practice of extra-marital sex
is also very frequent amongdifferent transport
workers and small professional groups.

In an international study 52 percent of married and


47 percent of unmarried men had had extramarital
coitus mostly with their girl friends, sisters-in-law
and SWs.

In a SMC study on HIV/AIDS, 56 percent truckers


mentioned visiting SWs and other sex partners,
and their averageage of first sex was 20. Among
truckers, 26 percent stated that they had serial
sexwith a common SW, 79 percent were aware of

HIV/AIDS, only 19 percent thought that the


infection could be checked by using condoms, and
a dismal 8 percent thought that they were
susceptible to the disease.

The actual incident of condom use with SWs and


other kin/sex partners was not recalled (Amanullah,
2002).
Sexually Transmitted Diseases (STDs)
It is now well established that the presence of both
ulcerative and non-ulcerative STDs increases the
risk of HIV transmission as much as 3 to 10 folds.
Specifically, various genital ulcers, such as herpes
simplex II or syphilis and trichomonas virginals,
Chlamydia trachoma is and neisseria gonococcal
infections, have been identified as catalyzing
agents in increasing the susceptibility to HIV
infection all over the world.
In the absence of a comprehensive and routine
screening, a scientific STD prevalence is not
available for Bangladeshi population.
Gonorrhea, syphilis, genital herpes and genital
warts are the most prevalent STDs among
Bangladeshi commercial sex workers.

In a serological investigation, researchers noticed


that, of SWs, 57 percent were positive for syphilis,
14 percent had gonorrhea, 20 percent had
Chlamydia, 20 percent had herpes, and 6percent
were carriers of Hepatitis-B virus. All gonorrhoea
cases were associated with syphilis.

Recent national sero-surveillance data by ICDDR,B


show that the prevalence of syphilis among
Bangladeshi SWs is 7 percent.
In a 1993 situational analysis, about 41 percent of
skin/VD out-door patients had genital tract
injection, 14 percent had syphilis, 6 percent had
non-gonococcal urethritis (NGU) infections, 38
percent had some combination of STDs, and the
treatment facilities were non-specific and
insufficient. In another study of 3,000 currently
married village women of reproductive age, 640
(21.9 percent) reported some symptoms of RTIs.

In 1992, Save the Children (USA) studied 980


women over the age of thirteen and 70 men during

a four-day free health clinic conducted in rural


Rangunia, Chittagong.

In the study, 54 percent of the women had a


history of present or past STDs, 61 percent, having
current symptoms of STDs, had an abnormal
vaginal discharge, 5 percent had genital ulcers, 34
percent had lower abdominal tenderness and 4
percent had genital warts.

Because of anal intercourse, some women had anal


warts. Among men, 57 percent had Human
Papilloma Virus (genital warts).

The study warned that in the absence of adequate


testing and treatment facilities, the high incidence
of STDs in such a poor and remote rural community
would provide a fertile ground for explosive and
unchecked outbreak of HIV (Amanullah, 2002).
Usage of condoms
Several national studies show that awareness of
the usefulness of condoms has risen in Bangladesh
for last few decades among ever-married

women/men, adolescents, and SWs and their


clients. However, the most disturbing fact for HIV
program planners is that, of those women and men
who are currently using FP methods, only a
nominal number of women and men stated that
they were using condoms and the practice was
strikingly related to their education and place of
residence.

As indicated by recent BDHS, although the current


use of condoms has risen steadily among women,
the discontinuation of its usage was highest among
all contraceptive methods.

In addition, the consistent use rates of condoms


are largely unknown for them. For various
sociocultural reasons, the FP program planners
have advocated condoms cautiously during their
initial condom intervention, and by now, the issue
is so less important that Bangladeshi FP workers do
not feel confident about discussing/recommending
or promoting condoms to their clients.

The above national scenario confirms that the


condom is not a part of sex culture in Bangladesh
(Amanullah, 2002).
Eminent Australian researchers observed that
although by international standards the recorded
levels of non-marital and commercial sex are not
high in Bangladesh,
however, most of this sexual activity was
reported to be unprotected.

In their study, only about 12 percent of the


subjects reported always using condoms with nonmarital/causal sexual partners.
Their findings are more or less similar to existing
condom use rates reported by available condom
and prostitution studies in Bangladesh (Amanullah,
2002).

Other risk factors

Drug use: In the absence of systematic research,


the extent of drug use, specificallythe prevalence

of Injecting Drug Use (IDU) is not well documented


in Bangladesh.
Some haphazard studies carried out in this field
indicated the presence of huge number of drug
users and wide-scale availability of various
local/imported drugs such as heroin, charas/ganja
(Indian hemp plant), alcohol, morphine, pethidine,
phensidyl, buprenorphine etc.

It is feared that already a high proportion of


inhalers has converted into injectors in Bangladesh
(Amanullah, 2002).

Because of its geographical proximity to other HIV


infected South Asian countries, Bangladesh is
particularly at risk of transmitting HIV through
IDUs.

In 1998, the prevalence of HIV was highest in the


world among the IDUs in Myanmar: 74 percent in
Rangoon, 84 percent in Mandalay and 91 percent
in Myitkyina.

In 1997, the overall sero-positivity rate of IDUs in a


pocket of India, where heroin was the drug of
choice, was 54.56 percent.

The rate was just about 4 percent in 1991. In 1991,


the prevalence of HIV was 1 percent among the
IDUs in Kathmundu.

In 2002, the overall sero-positivity rate of IDUs in


Kathmundu was more than 60 percent. Jakarta also
experienced the same trend.

These IDUs are the potential sources of explosive


heterosexual and perinatal transmission of HIV
infection in the region. It is estimated that around
100,000 IDUs are in Bangladesh now.

Most of them share needles/syringes and have not


tested yet for HIV.
Unsafe blood transfusion: About 8090percent of
blood supply in Bangladesh ispurchased, usually
from unscreened professional blood donors (clients
of SWs, drug users, STD patient etc.).

The HIV positivity rate among Phnom Penh blood


donors has risen from 0.1 percent in 1991 to about
10 percent in 1995.
Men who have sex with men (MSM): Unprotected
anal intercourse is one of thedominant routes of
transmitting HIV.
Male to male sex in Bangladesh is
politically, socially, and religiously sensitive and
extremely difficult to address.
Under old British law, incorporated into Bangladesh
Penal Code, these behaviours are illegal in the
country.

Furthermore the Quran and Sharia strictly had


forbidden the practice. In contrast, several studies
show the practice of anal intercourse among SWs
and general populations (Amanullah, 2002).
Researchers recently observed that the
transmission of STDs/HIV is invisible among
Bangladeshi gays because of insufficient anal/oral
testing and denial of such behaviours by the
participating males themselves.

In a Bangladeshi study 81 percent of subjects had


multiple sex partners and were sexually active
between their age of 1318 and the majority had
had sex relationships with women and female SWs.

These men are not interested to test their HIV


status because of personal security, about half of
them do not use condoms, and most importantly,
only 6.3 percent of them stated a consistent use of
condoms (Amanullah, 2002).
Awareness of HIV/AIDS among SWs and clients
The awareness of HIV/AIDS among SWs and their
clienteles is recently reported by some national
and sub-national studies. In a 1996 baseline survey
of HIV/AIDS and Condom Use among six
Bangladeshi brothels, 83 percent of SWs and 74.5
percent of their clients stated that they had heard
of HIV/AIDS.

In the survey, about 90 percent of subjects stated


that AIDS has no cure, while 72 percent86
percent of them stated that AIDS is a fatal
disease.

Despite their increasing awareness, both SWs and


clients expressed considerable misconceptions on
the modes of transmission, ways of protection and
their personal susceptibility to the disease.

For example, only 36 percent of clients and 38


percent of SWs thought that they could get HIV. Of
them, only 6 percent of clients and 13 percent of
SWs thought that they could get the disease
because of non-use of condoms.

Recent HAPP baseline survey also revealed the


same results (Amanullah, 2002).
The major findings of the above baseline survey
were found consistent with thef indings of another
baseline survey carried out in Tangail brothel by
CAREBangladesh in 1996.

A majority of the subjects in that survey had heard


about AIDS, but their levels of knowledge were
extremely poor and incomplete.

Some of them stated that HIV transmits through


food, clothing, foreigners (Koreans), and black cats.
These findings are further consistent with other
studies carried out among brothel and floating
SWs.
Because of NGO interventions, subsequent
Bangladeshi follow-up KAP surveys revealed a
dramatic rise in various rates of the earlier baseline
surveys.

However, despite much improvement, these followup studies reported misunderstanding among SWs
and their clients concerning modes of transmission
and ways of prevention of HIV.

They also revealed disjunctures between


knowledge and practices. These studies further
observed that the SWs were forced to practice risk
behaviours and were less likely to care about risk
information provided by the media or NGO workers
(Amanullah, 2002).

Diffusion of HIV/AIDS information

There is a dearth of indexed data on the extent and


effectiveness of HIV/AIDS related riskcommunication/diffusion channels among
Bangladeshi SWs and their clienteles.
A few studies have been carried out recently to
assess the media habits of SWs and their clients.
In these studies, Radio, television and cinema
appeared as the dominant electronic channels.

However, these studies have not addressed


whether the SWs and their clients act based on the
risk information they receive from the media and
existing risk-communication channels(Amanullah,
2002).
Despite the low prevalence of HIV, the above
discussion suggests that HIV may spread rapidly in
Bangladesh in near future.

As the AIDS pandemic continues to devastate


South-Asia, no nation from this region can consider
itself immune.
Complacency in Bangladesh would lead to more
rapid and widespread infection. In this country,
already some AIDS patients died of persistent

diarrhoea (possibly due to cryptosporidiosis),


tuberculosis, malaria and encephalitis. Most of the
Bangladeshi AIDS patients now alive are suffering
from tuberculosis.

From the above analysis three conclusions can be


drawn. First, if unchecked in the initial stages, the
assumed low-profile HIV situation of Bangladesh
could evolve rapidly into an escalating epidemic,
like its neighboring India, with tremendous health
and socio-economic burdens(Amanullah, 2002).
Secondly, in Bangladesh, STDs and TB are the
epidemic, not AIDS. Therefore, there is
complacency instilled by the knowledge that the
country has limited numbers of AIDS cases; this
attitude obscures awareness of the leading edge of
the epidemic for a clearly risk-practising society.

This detailed article has provided evidence that the


country cannot afford to sit back and wait for HIV
to spread.
The country needs to be proactive about
prevention (Amanullah, 2002).

Thirdly, given the magnitude of the wider


socioeconomic risk factors and structural barriers
to safe sex practices, the possibility of changing
unsafe sexual practices of adolescents and youths,
adult population, and other stigmatised group by
employing western strategies is questionable
(Amanullah, 2002).

Against this background, the government of


Bangladesh has recognized HIV/AIDS as not just a
health problem but largely as a development issue
inextricably linked to cultural, social and economic
determinants demanding a wide and accelerated
multi-sectoral response.

Recently, the government has approved National


Strategic Plan for HIV/AIDS (NSP) for the period
2004-2010.
In 2004, the government has received a grant from
the Global Fund to fight AIDS, Tuberculosis and
Malaria (GFATM) for the Prevention of HIV/AIDS
among Youths and Adolescents in Bangladesh.

The Ministry of Health and Family Welfare (MOHFW)


has selected Save the Children-USA as the
Management Agency (MA) for the project under the
umbrella of National AIDS/STD Program (NASP).

Out of five packages under the project, PIACT


Bangladesh, a national NGO, has been awarded to
implement the package titled Integrating
HIV/AIDS into Secondary School & College
Curriculum as well as Dissemination of Developed
Materials (Package: GF 903).

The objective of the package is to include HIV/AIDS


information into the curricula of secondary and
higher secondary education and distribution of
advocacy materials to youths.
Under another package (GF: 901), a consortium of
Mattra and PIACT is diffusing HIV/AIDS information
throughout the country using various electronic,
print, folk, and interpersonal channels.

Using culture sensitive ideas and diffusion


techniques, their campaign has already attracted
huge audiences. The other packages of the project

are also working in overcoming the socio-cultural


constraints faced by the HIV program mangers in
earlier times.

As such, this GFATM project is a remarkable step,


advocated by the highest level policy makers of
Bangladesh, which could produce an informed
youth audience throughout the country in near
future and help preventing HIV transmission not
only among the general audiences but also among
the risk-practicing population of the country.

The success achieved in Thailand and many other


African Muslim and Non-Muslim countries such as
Senegal, Zimbabwe and Uganda reveals that,
despite structural and cultural barriers such as
gender inequalities, poverty, illiteracy, stigma and
male dominance, there is still some hope to
increase safe sex practices through culturally
sustainable HIV/AIDS prevention programs, school
and college education, and providing support
services to vulnerable groups, specially riskpracticing women and children (Amanullah, 2002).