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My parents don't want to talk about HIV and AIDS
Mar 11, 2006

Dear Dr.Bobby, I am 15 years old and I have a great fear of diseases, mainly HIV/AIDS. One day when I was going to the doctor, I asked my parents a simple question, "What if I have AIDS?" After hearing my question, my mother told me not to talk about it and my father said that HIV only happens in dirty places and to dirty people. I felt horribly offended by this even if I didn't have this virus in me. I told them that there were many people in this world that got infected accidentally and some were even born with it but my parents didn't want to listen to me and didn't want me to get tested. My parents are very strict and religious and doesn't believe in sex before marriage and they swear that there's no one our country (Bangladesh) who are infected and it's only in western countries and in Africa. How can I explain to them that HIV is everywhere?

Response from Dr. Frascino

Hello,

Your mother told you not to talk about it and your father said that HIV only happens in dirty places and to dirty people?!!?? It always amazes me that 25 years into this global pandemic and with over 40,000,000 people infected worldwide, attitudes like those of your parents are still so prevalent. Enlightening your parents on this topic will not be easy, but I would encourage you to continue trying. How about doing a school project on HIV/AIDS in Bangladesh? That way you could talk about HIV/AIDS with teachers and classmates and show your parents your report. I'll reprint below a "Health Profile" on Bangladesh that discusses HIV/AIDS. Other information is readily available on the Internet.

Fear of diseases generally stems from lack of understanding. Learning more about HIV/AIDS what it is, how it is (and is not) transmitted, how to prevent it and how to treat it will decrease your fears and hopefully allow you to educate not only your parents, but your friends as well.

Good luck.

Dr. Bob

HEALTH PROFILE: Bangladesh HIV/AIDS CONTINUES>

Estimated Number of Adults and Children Living with HIV/AIDS (end 2004, based on new Government of Bangladesh estimates) 7,500 (low-high estimates 70019,000)

Total population (end 2003) 149,664,000

Adult HIV prevalence (end 2003) < 0.2%

HIV-1 Seroprevalence in Urban Areas Population most at risk (sex workers and clients, individuals with sexually transmitted infections, or other persons with known risk factors) 2%

Population least at risk (pregnant women, blood donors, or other persons with no known risk factors)

Source: HIV/AIDS Surveillance Data Base; Ministry of Health and Family Welfare, Government of Bangladesh, 2005; UNAIDS April 2005

U.S. Agency for International Development

www.usaid.gov

With an estimated prevalence of less than 1%, Bangladesh is considered a low HIV-prevalence country. Nonetheless, it may be gradually heading toward an epidemic unless drastic measures are taken. With a population of nearly 150 million, an increase of just 1% in the rate of infection among the adult population in Bangladesh would mean more than a million additional HIV/AIDS cases. The first person with HIV/AIDS was reported in 1989, and since 1994, prevalence has risen steadily. According to a 2004 United Nations study, the number of HIV infections in Bangladesh has tripled over the last six years, with increasing prevalence among most-at-risk populations: commercial sex workers, men who have sex with men (MSM), migrant workers, and injecting drug users (IDUs). National survey data indicate that HIV infection among IDUs jumped from 1.8% in 2001 to more than 4% by 2004. In one Dhaka "hotspot," the prevalence has jumped to 9%. Designing effective HIV/AIDS prevention programs will require better understanding of the knowledge, attitudes, behaviors, and practices among these vulnerable populations.

Other factors contributing to Bangladesh's HIV/AIDS vulnerability include cross-border interaction with the high-prevalence areas in Burma and North East India, low condom use (24%); and a general lack of knowledge about HIV/AIDS, sexual disease transmission, and risky behaviors.

Heterosexual contact among commercial sex workers is a major mode of HIV transmission, and the level of unprotected sex is high (40%). Programs established to address HIV/AIDS transmission and other health issues of sex workers are thus far inadequate. Police brutality against sex workers, including MSM, further compounds the problem by traumatizing the very populations health workers need to reach, driving them out of reach of HIV-prevention services. Earnings from Bangladeshi migrant work (including commercial sex work in India) are a vital contribution to the national incomeabout 30% of national savings. HIV/AIDS awareness among migrant workers is low, based on their limited access to information. HIV testing is mandatory as part of the standard hiring procedure for documented migrant workers (which may explain the higher HIV incidence among migrant workers versus that of the general population). Many Bangladeshis work within the informal migrant sector, however. Reaching these mobile populations when focusing HIV/AIDS messages in Bangladesh is crucial to stemming the epidemic.

The most-at-risk population of IDUs often faces homelessness, unemployment, and incarceration, further compounding their risk of HIV/AIDs. IDUs also participate in needle-sharing, as well as the illegal sale of blood, thus potentially tainting the national blood supply.

Knowledge of HIV is high among sex workers and their clients but extremely low among the general population. A recent survey showed only 20% of married women and 33% of married men had heard of HIV/AIDS. Within Bangladesh's relatively conservative, predominantly Muslim population, there is little discussion of HIV/AIDS. As outlined in its 20022007 strategy, USAID support aims to help avert a serious epidemic in Bangladesh by keeping HIV prevalence among the most seriously at-risk populations under 5%.

NATIONAL RESPONSE

The nation's HIV/AIDS prevention program was established in 1985 under the aegis of the National AIDS Committee chaired by the Minister of Health and Family Welfare. The National AIDS and STD Program is the government body charged with coordinating policy and programs in the country. A national policy on HIV/AIDS and sexually transmitted diseases was then formulated to ensure oversight of HIV/AIDS prevention and control efforts, to coordinate an overall national response, and to provide technical and operational support as well as behavior change strategies. A new National Strategic Plan (20042010) has just been approved. These national HIV policies and strategies are based on Bangladesh's successful family planning programs and now include participation from schools as well as religious and community organizations. The government also works with the World Bank on the $20 million HIV/AIDS Prevention Project aimed at preventing HIV from gaining a larger foothold within high-risk populations and at limiting its spread into the general population. Primary objectives include the rapid scale-up of successful nongovernmental organization (NGO) programs that focus on high-risk populations to raise awareness and expand advocacy among the general population, policymakers, and vulnerable populations; and to strengthen government capacity to respond to HIV/AIDS in blood safety, project management, and surveillance. Bangladesh maintains a well-established second-generation surveillance system, including a sero-surveillance component implemented by the International Centre for Diarrhoeal Disease Research/Bangladesh (ICDDR/B), using funding from the World Bank and United Kingdom Department for International Development; and a behavioral surveillance component, implemented by Family Health International (FHI) and funded by the United States Agency for International Development (USAID).

In addition to voicing support of AIDS awareness at the highest level, including a speech by the Minister of Health at the 2001 United Nations General Assembly Special Session on HIV/AIDS, the government advocates and implements various HIV education efforts, with a recent focus on journalists and schoolchildren. In 2003, a national youth policy was established on reproductive health, including HIV awareness. Starting in 2006, students in 21,000 secondary and upper-secondary schools will be taught about HIV/AIDS issues. The program will introduce a "life skills" curriculum, including a chapter on HIV/AIDS drafted with assistance from the United Nations Children Fund.

USAID SUPPORT

As outlined in its 20022007 strategy, USAID support aims to help avert a serious epidemic by keeping HIV prevalence among the most seriously at-risk populations under 5%. Assistance focuses on prevention and dissemination of educational programs about high-risk behaviors and includes:

Improving sexually transmitted infection (STI) services for high-risk populations

Enhancing NGO technical capabilities in HIV prevention

Promoting condom use through social marketing and NGOs working with high-risk populations

Initiating counseling, testing, and care for people infected with HIV

Strengthening sero- and behavioral surveillance

Conducting research on new approaches and strategies

Building on its National Integrated Health and Population Program (NIPHP) begun in 1997, USAID helps to expand the range, quality, and use of clinical health services (especially by the poor); strengthen the institutional capabilities of recipient NGOs; and influence government policy to increase the role of the private sector in health service provision. It also supports information gathering on national disease status and funds the triennial Bangladesh Demographic and Health Surveys.

USAID-supported activities include behavior change communication, capacity building, condom social marketing, counseling and testing, policy work, research, STI testing and treatment, and surveillance. In 2004, USAID continued to expand assistance for HIV/AIDS prevention, focusing on reducing harmful behaviors among at-risk populations via peer education, STI treatment, and condom promotion. Achievements include:

9.8% increase in condom sales by the USAID-supported Social Marketing Company (SMC)

Technical assistance for government procurement of 446 million condoms (for both SMC and the public sector)

Launch of a contraceptive security strategy to improve government management of future contraceptive needs

Promotion of behavior change and risk reduction among high-risk populations

To stem the spread of HIV among adolescents, who constitute 25% of the population, USAID also conducts mass media campaigns, including a weekly radio program and a television series, and disseminates toolkits, videos, facilitator guides, and comic books.

Behavior change communication

With support from USAID, the Implementing AIDS Prevention and Control Activities (IMPACT) project, which FHI implements, has created peer education programs for HIV/STI prevention focusing on high-risk groups in Bangladesh. With active involvement of partner NGOs and peer educators, and based on audience formative analysis, pretest, and field experience, FHI has developed peer education training packages specific to different target groups and people with HIV. The training packages are meant to train the peer educators, site workers, outreach workers and local project staff in: the basics of HIV, AIDS, and STIs; responsible behavior to eliminate and reduce risks; how to be an effective peer educator; and gender and sexuality. FHI trainers have directly conducted over 2,000 training events and have trained a total of 46 trainers, 639 peer educators, 605 hotel site workers, and 291 project staff from 23 NGOs. Besides supporting FHI-supported implementing agencies, the communications and training unit also extended its technical support to other agencies in terms of training curriculum development and providing training of trainers. A total of 63 external agencies participated, including 37 NGOs under the United Nations Children's Fund HIV/AIDS Prevention Project and four NGOs under the United Nations Population Fund, along with World Vision, CARE Bangladesh, SMC, Bangladesh Youth First, and others.

The Information, Education, Communication/Population Communication Services of Johns Hopkins Bloomberg School of Public Health provides technical assistance through a cooperative agreement for behavior change communications to increase use of services and focus on selected high-impact health behaviors, particularly among adolescents. Under the project, the Bangladesh Center for Communication Programs developed a series of booklets, radio and television spots, and videos to help influence behavior through educational entertainment.

Capacity building

USAID supports capacity-building activities via the DELIVER Project, which helps to improve government capacity to ensure the availability of high-quality contraceptives and essential health products. Activities include technical assistance in the procurement and management of logistics, effective and efficient distribution at all system levels, and human resource development within the health logistics system. USAID's NGO Service Delivery Program supports 41 local NGOs. Program goals include expanding the scope and quality of services, as well as access for the resource-poor, building institutional and financial capacity, and influencing policies to expand the role of NGOs as health care providers in Bangladesh. With USAID support, PRIME (Improving Performance of Primary Providers' Training and Education in Reproductive Health) works to build the capacity of NGO clinical training organizations, enhance on-the-job performance of service providers, and provide limited assistance to the government in support of the public sector training strategy. Additional activities include the development of curricula and a training management information system that encourage training follow-up and monitor quality.

Condom social marketing

The Social Marketing Company, the largest privately managed not-for-profit social marketing organization in the world, markets oral and injectable contraceptives, condoms, and oral rehydration salts nationwide. SMC provides its brands to about 4 of every 10 users of the condom, helping to reduce HIV transmission. In partnership with FHI, over 12 million condoms have been distributed to most-at-risk populations to stem the HIV epidemic.

HIV counseling and testing

Through USAID funding to the FHI/IMPACT project, the first three full-service HIV counseling and testing centers in Bangladesh are open in Dhaka, Chittagong, and Sylhet. This project is run in collaboration with ICDDR/B. People living with HIV/AIDS are then referred to care and support services provided by the Ashar Alo Society, also funded by USAID through FHI/IMPACT.

Strengthening Clinical Contraceptive Services, which works with the government, NGOs, and the private sector to increase the use of long-term clinical contraceptive services, is also supported by USAID population funds. Implemented by EngenderHealth, the project aims to improve knowledge and awareness and increase demand for clinical contraceptive services; improve access to services; and strengthen counseling and improve the quality of services, including HIV-infection prevention. EngenderHealth has provided technical assistance on infection prevention modules to HIV and STI clinical training run by FHI/IMPACT. Activities include local-level planning for better use of facilities and resources, training providers, strengthening behavior-change communication activities, and developing logistic support and management information systems.

Research

USAID funds FHI/IMPACT to conduct extensive research on HIV and STIs in Bangladesh. Epidemiological and contextual analysis, including accurate estimates of the sizes of populations needing services, is an essential part of USAID's response. FHI has developed expertise using routinely collected program monitoring data in conjunction with surveillance data to improve program performance. A Behavioral Surveillance Survey is being undertaken annually. This has helped programmers and policy makers understand the importance of HIV prevention efforts. The male reproductive health survey provides data on males from both urban and rural areas of Bangladesh to estimate the prevalence of known risk factors of HIV infection. This is one of the few general population surveys of its kind in the region and will be valuable information for programming purposes. There is an ongoing study in Dhaka to assess two types of treatment for women at high risk of STIs. The study compares the effectiveness of Periodic Presumptive Therapy against Enhanced Syndromic Management on the incidence of several STIs. The information derived from this study will be crucial for the design and implementation of Periodic Presumptive Therapy against Enhanced Syndromic Management for STI and HIV interventions in Bangladesh.

MEASURE/Evaluation, implemented by the Carolina Population Center at the University of North Carolina with support from USAID, conducts population-based surveys to measure the performance of NIPHP NGOs in providing essential service packages to address various health issues, including communicable disease control. The survey output provides information on a number of indicators within the country's strategic framework.

The Family Health Research Project continues activities begun under the Operations Research Program in 1997; it carries out applied research, results dissemination, and technical assistance, and supports two demographic and epidemiological surveillance sites. The USAID-funded MEASURE/Demographic and Health Survey+ provides information to help measure progress in attaining strategic objectives for population and health.

Sexually transmitted infections

FHI/IMPACT provides technical assistance to improve STI prevention and management, reduce HIV/AIDS-related policy constraints, expand links between prevention and care, and strengthen program monitoring and evaluation. IMPACT has placed special emphasis on quality assurance to address the programmatic, strategic, and clinical factors responsible for the loss to effective treatment of potentially STI/HIV infected persons.

IMPORTANT LINKS AND CONTACTS

USAID/Bangladesh, Madani Avenue, Baridhara, Dhaka 1212, Bangladesh Tel: 880-2-885-5500, Fax: (880-2) 882-3648

Website: http://www.usaid.gov/bd

USAID HIV/AIDS Website, Bangladesh: http://www.usaid.gov/our_work/global_health/aids/Countries/ane/bangladesh.html

Prepared for USAID by Social & Scientific Systems, Inc., under The Synergy Project

For more information, see

http://www.usaid.gov/our_work/global_health/aids



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