Yes, there is a National AIDS Committee, a National Programme and Strategy, and Plan of Action for HIV/AIDS prevention and control. Necessary as these are, the effective outreach and impact of these formal mechanisms remain doubtful. Public information and education activities remain sporadic; actual impact of present information dissemination on motivation and behavioral change is not evaluated. There still is an air of denial and or complacency around the incidence and prevalence of HIV. Unjustified comfort is placed on culture and tradition as protective forces while it is widely known that sexual transmission of infections is widespread and rising. Thus present reported number of HIV infections and AIDS cases could well be misleading, merely the tip of an iceberg, and certainly is no insurance against the possibility of a future epidemic of HIV and AIDS.

The experience of India, Thailand, Myanmar: that devastating epidemic of sub-Saharan Africa are strong reminders of what a climate of denial, complacency, and lack of preparedness and early action can result in. Learning and taking the cue from countries around Bangladesh, there is a very strong case for intensification of prevention and control activities with all earnestness and energy irrespective of the current reported level of infections: equally strong case for adopting innovative and appropriate strategies that suit the situation of Bangladesh society and people but not making compromise on proven and prevailing facts, a real need to monitor closely not only the inputs provided but more importantly the outcomes of all prevention and control activities. A comprehensive action programme will have many components; some of that list will have relative priority on evidence of their net outcomes and impact rather than on external direction or high visibility. Some of these measures are mentioned below.

HIV infection is preventable by information and education: As there is no vaccine yet, no effective cure either, education and motivation are the main instruments. Information on HIV touches very private and intimate personal matters. To be effective information and education must move dissemination a step further towards belief and motivation. Information must be accurate, consistent, and delivered in ways that does more than passively give information but also make an impact on the receiver and peers; stimulate thoughts on held ideas and eventually change belief and behaviour. Information has to be clear and factually driven, not clouded with compromise. Mention of words such as condom and safe sex is still confined to seminars and are largely avoided in public and classroom communication. Adolescents and young adults are a major segment of population who will soon enter reproductive and sexually active stage of life; this group is also exceptionally vulnerable and benefit most from education and empowerment that correct knowledge only brings. Public education covers a wide range of target groups; that range must not exclude adolescents, young adults and eventually children above 10 years in all schools.

To start with, information and education on HIV need to be included in a school health education programme that covers sexual hygiene and health as education on good grooming, body care and safety. Teaching of reproductive health to the adolescents and young adults is basic life support education irrespective of fear of HIV infection.

Safety first and foremost: Means and methods of protection from accidental infection due to ignorance or risky behaviour can be explained, taught and provided as necessary. This is absolutely indicated as the incidence of sexually transmitted diseases (so called venereal diseases) is already high and the route of HIV infection is also the same. HIV infection could well masquerade within common venereal infections like syphilis and gonorrhea. The prevailing view that only those who work for a living selling sex are at risk is entirely wrong and dangerous; ignorance and negligent practice by a large vulnerable population exposed accidentally or intentionally is suicidal. There can be no excuse for keeping such an attitude where those most in need are denied knowledge; knowledge and information is power, ignorance is not. Condom use should be mandatory.

Protection from HIV and other sexually spread infections are relatively simple and straightforward. Use of condoms may be made far more convenient and free by improving access; machine dispenser of condoms may be placed at as many strategic places as possible, their use monitored and changes made as necessary.

Not by government alone: HIV prevention and control succeeded nowhere when left to government departments and bureaucrats alone. As stated, it is a personal belief and behaviour issue where government functionaries even if designated exclusively are not best trained or equipped to bring about necessary changes. Governments can provide policy direction based on evidence, technical and financial support based on broad strategies, but other partners who have effective outreach and penetration are better positioned to deliver the substance. Therefore, government and external partners are urged to encourage much more extensive and direct involvement of non-governmental organisations in actual delivery of the programme. This may be easier said than done. But all proven experience confirm that close and extensive participation by all civil society organisations particularly those with high credibility at the local level with good track record is crucial element of success. HIV prevention and control is one programme that demands exceptionally total mobilisation of the society, more than it demands mobilisation of government departments and functionaries.

Needed more than fancy publicity: Attractive and expensive publicity attracts attention and some admiration. But does that do the job? Some of the TV publicity on HIV is so arty and so indirect it misses the main message; it often skirts around in vague words that camouflage more than it reveals. Such publicity does arouse extreme fear and anxiety more than it motivates rational response by belief in personal power to act. Huge billboards and hoardings bearing grave and fear provoking messages are of questionable value; messages may be changed to be more educative and less fearful. The same goes for some TV spots that are either so vague or so foggy that miss the object of the message. A clear message can be disseminated in a subtle manner but need also be understood without unnecessary camouflage.

Annual AIDS day parades are colourful ceremonial occasions before TV camera; how much these contribute to raise public awareness remains open to doubts. Each day is really AIDS day; awareness and action need go hand in hand. If there is anything to be celebrated, it is the good and responsible sexual practice and safety becoming a way of life, when ignorance is replaced by power of knowledge, when personal responsibility to protect the family and community becomes the norm rather than the exception.

Serious behavioral research is suggested, the findings of which need to inform the policy makers and producers of publicity campaign. Anthropological evidence is available and need not invent the wheel afresh. Behavioral research into change of belief and practice is a subtle but major contribution to communication strategy. This merits urgent attention even though impatience and haste may ignore the research agenda. Some civil society groups and voluntary associations enjoying impeccable reputation may be more successful and should therefore be preferentially encouraged and financed under the government programme to give their best practice evidence. .

Prevention more credible when integrated with care: No HIV control strategy will make much headway unless prevention strategy is combined with good compassionate care of those already HIV infected or diseased. AIDS has no radical cure but drugs can prolong lives, care can bring some quality of life and comfort, treatment with compassion can give some dignity to the victims. These are not available at present. Persons with known HIV infection are cursed, ill treated, rejected by family and society, and even by doctors and caregivers. But they need shelter, safety, and care; they need assurance and treatment just as for any other illness. Mere evidence of change of attitudes and practice will give people welcome assurance; it will improve voluntary testing for HIV infection and private counseling without fear or prejudice. Integration with treatment and social care will enhance the credibility and acceptance of the prevention programme itself. To those who are content to accept the status quo, all these seem utopian, easier said than done. But we have to look only just beyond our borders to see how Thailand dealt with the serious problem of stigma and rejection of HIV and AIDS sufferers. Countries and communities within countries have shown examples of how to integrate care and counseling, how to remove rejection and condemnation, how to remove prejudice and include compassion. HIV infection is even less contagious than many other infections that have been cared for in hospitals and homes. It is a matter of education and removing fear and misinformation from minds.

Education will help reassure but some courageous individuals and committed outfits in civil society will help too. Commitment in this case has to extend beyond appearing in TV close ups, into continuous involvement at field and home level.

Practical innovation: Brothels are not illegal in Bangladesh. Though there have been raids and extraditions yet society knows brothels exist and even thrive when subjected to expulsion. Thus, unlike the ostrich hiding its head in the sand, the society has to face facts and devise practical and acceptable change and support new ways of doing things that need to be done. Both the clients and the provider of service are exposed and vulnerable; HIV spreads through the sexual route more than any other. For safety and well being of the workers and clients alike, compulsory testing for sexually spread infection including HIV in particular would have been a good preventive and control strategy. This need not be deferred on any ground. Regular monitoring should be carried out preferably not by the police or any government office but by well-reputed voluntary bodies with known record of working with the discriminated sections of the society.

Individuals need to be outspoken and act with courage. Municipal corporations, as public service bodies, need to act to serve public interest and public convenience, and do so without slightest discrimination or self-assumed prejudice. Being representatives of public, their duty is to serve and accommodate the needs and convenience of all, not few, of those who sent them to those offices. The same goes for all other public representatives, including the parliament. As to the civil society, rather than float with the floatsome of superstition or bask in the lights of posh seminars and conferences, some of them must come out of their self-woven cocoons, and stand ready to be counted.

End notes

Considering the current HIV/AIDS situation in neighboring States of India (with highest number of HIV/AIDS outside Africa), in Nepal, Myanmar, and Thailand, Bangladesh has no room for comfort or complacency with current low incidence and prevalence. Conditions that favour spread of HIV infection exist in Bangladesh; when combined with low public awareness and lack of mobilisation and motivation to fight this menace aggressively, Bangladesh might be sitting on that proverbial time bomb that is ticking away silently but relentlessly. Lessons are to be learnt from sub-Saharan Africa, India and Nepal where initial denial and hesitancy delayed determined response. Culture and tradition might help but unfortunately do not confer much immunity to HIV. While fear of HIV may do some good but fear and stigma without power and will to prevent or care do serious harm. With no effective vaccine in sight, HIV prevention still is a function of change of personal behaviour and beliefs. That is why HIV prevention and control is a societal responsibility, a challenge to be overcome by social movement for action and not by a government health programme alone.

If the people, the parliament, the government, and the international community believe, as they indeed have to, that HIV and AIDS represent a serious security threat to countries and peoples in greatest need of development, does it not make enormous sense to meet the threat of HIV and AIDS by winning the war of prevention and pre-emption? The other day, Kofi Annan, Secretary General of the United Nations, challenged the international community to do enough to tackle the HIV/ AIDS, which he called the (real) weapon of mass destruction. If Bangladesh is perched on a time bomb of HIV waiting to explode (as some believe it is), are we all willing and able to defuse that ticking time bomb?

Dr. Zakir Husain is former Director, Programme WHO South East Region.