HIV/AIDS epidemic and its existing situation in Bangladesh is not very well understood, but it is true that HIV is being detected among our population especially among vulnerable cohorts. Repeated rounds of surveillance revealed that the rate of seropositivity is highest among injecting drug users (IDUs) and the findings also confirmed the presence of high level of behavioural risk factors for the acquisition of HIV infection. The behaviour having highest risk among drug abusing population is sharing of needles. When the sentinel survei-llances showed the above findings, a number of studies on knowledge, attitude, behaviour and practice (KABP) showed that there is a very low knowledge on HIV/AIDS among different population groups especially about the relationship between drug use and transmission of HIV.

There are other reasons for drug abusing population to remain a potential source of HIV transmission. Institute based information reveals a high rate of sexually transmitted diseases (STDs) among drug abusing population, and sexual promiscuity is quite common among them. Many IDUs are married, and practice of unsafe sex increases the risk of heterosexual transmission among married couple and thereby increases the vulnerability of mother to child transmission at the same time. It has been found that drug abuse including injecting drug use is reasonably present among low-fee sex workers. The prevalence is also high among professional blood donors, another high-risk population for HIV transmission. There is attitudinal commonality among the drug abusing population and population vulnerable to HIV infection.

As mentioned earlier and as of time today, the level of HIV in this country has been low and appears to have been increased quite slowly over the past few years. At this moment, it is little difficult to predict how much more and how rapidly such an increase would take place. Only continuous and repeated surveillance will be able to provide us the right kind of information and it may only be assumed that Bangladesh is in the pre-epidemic stage for HIV. If an epidemic erupts, it will assumably erupt first among low-fee sex workers with the highest average turnover of customers, and injecting drug users. The low-fee brothel based sex workers have the possibility of getting infected by male partners who regularly frequent towns and ports along the Bangladesh border with high prevalent countries. Injecting drug use is also more prevalent in the areas having common border with neighbouring countries. Some of the bordering areas of India like Manipur have a very high rate of HIV infection among drug injectors.

Many special contextual features including widespread poverty, unequal access to health services, often-subordinate status of women, and low literacy and education contribute equally and simultaneously to the propagation of both these two epidemics. In addition, there is a visible dearth of a multi-sectoral response, and policy level support and commitment for empowerment of vulnerable groups to negotiate on the issues like stigma and discrimination. Moreover, research, especially operational research, which is essential for effective implementation of any programme particularly those related to preventive actions in the field of drug abuse and HIV/AIDS is very limited in this country.

The above mentioned factors indicate that the present drug abuse and HIV situation could evolve rapidly into an impending and escalating epidemic with serious health and socio-economic consequences. If so happens, there would be necessity for major adjustments within individuals and their families, the health system, the community and the society as a whole. Otherwise one may apprehend an overburdened health care system both in terms of human and financial resources, disintegration of family structures, problems relating to increased poverty, increased number of orphans and abandoned children, and shortage of manpower in agriculture, industry and other sectors. It may thus be said that it is time for an immediate action. We cannot miss this window of opportunities for a preventive action. Therefore, the country needs to take prompt initiatives and reinforce existing responses to prevent those two inseparable problems. This may be accomplished by adopting and/or adjusting time bound national policies, developing a long-term strategy, initiating multi-sectoral programme implementation, increasing partnership with NGOs and other community organisations, developing regular surveillance system, prioritising targeted intervention, ensuring participation of vulnerable and affected population in preventive action, initiating safe behaviouaral practice campaign, attracting donor support and resource mobilisation, and making some major breakthrough in the field of information dissemination.

All the above initiatives need a comprehensive, holistic and integrated national response. Similarly, a well-established goal directed GO-NGO network to carry out the function of prevention, care and intervention would become obligatory to supplement the national response. However, it must be mentioned here that a substantial amount of work has already been done, and the level of response needs to be further strengthened. The policy level commitment has to be translated into action at the ground level.

The initial response at the national level to bring in the two very vicious problems under the same umbrella should be to develop a National Integrated Policy providing a framework for a well outlined integrated national response defining country's strategies and priorities for a time-limited duration. It is worth mentioning here that Bangladesh is one of the very few countries that have a very well defined state policy document on HIV/AIDS and STD related issues. The integrated strategic plan should have provision for updating periodically according to changed circumstances, built on the works already done and should emphasise a multi-sectoral response to the problems. It would include the involvement of various ministries, NGOs, the private sector and the community, and would outline programme management aspects including monitoring and evaluation. This strategic plan should also provide a guide for further planning and for the development of sector-specific work plans. The strategy in its projection should identify the need for resource allocation and provide syste-matic guideline for resource distribution. It should have specific scheme for mobilizing resources to support various government, private and non-government sector initiatives.

The broad strategy in its development should take into consideration the present epidemiological situation and the likely future scenario. The priority strategies, therefore, should primarily include provisions for interventions targeted at vulnerable and high-risk population, increased availability and accessibility of services, and creation of an enabling environment for people in general and for those afflicted by the problems in particular. The latter should also include enactment of legislation to counter discrimination against drug abusing population, people living with HIV/AIDS and other vulnerable groups, and initiatives towards improving community acceptance. The strategy should also have scope for augmenting existing surveillance systems to determine present and future magnitude of the problem.

Once a comprehensive policy is adopted and a strategy is developed, what is needed is a holistic National Intervention Plan and an integrated plan of action with wider participation of different stakeholders. The work plan should include, among others, scheduled plan of activities, expected output with situation specific assumptions, and activity specific estimated budget. In case of intervention programmes for marginalised and hard to reach population, the programmes need more frequent review for taking stock of the programme accomplishments, and identify gaps and necessities. It would also aid in redesigning the whole programme or a part of it specially because both drug abuse and HIV/AID are ever changing phenomenons taking different dimensions at different times. Another mandatory element in programme implementation is integrated team building exercise involving all management, technical and support services. There is also a considerable need for capacity building specifically for NGOs both in programme implementation and programme management. It is all the more necessary because motivation and skill are two very important components for implementation of any programme and drug abuse and HIV/AIDS together have certain uniqueness in their profile as a problem and needs necessary motivation and skill to work for them.

Review of programme implementation strategies in different countries, both developing and developed, reveals certain issues that may need priority consideration. In order to implement interventions for specific population, especially in a low prevalent situation, targeted intervention is the method of choice for effective carrying out of interventions. In order to have a priority based targeted intervention, it is essential to have intensive consultation and interaction within the government, NGO sectors and donor communities to identify the vulnerabilities, develop scientific database, and select and implement appropriate interventions. It must be ensured that the relevant stakeholders involved in long-term planning are aware of the probable social and economic im-pacts of the issues, and role of targeted intervention in their mitigation.

Although NGOs have established a strong and sustainable partnership with the government for initiating many intervention programmes, there are evidences that there is very limited involvement of local government authorities and other relevant organisations in overall management of drug abuse and HIV/AIDS intervention programmes. It is therefore recommended that local level project steering committees should be formed, and kept alive and fully functional. Lack of coordination in programme implementation may leave the possibility of duplication of programmes and may become a hindrance to cost saving. To avoid such situations, it needs a tripartite coordination between government, other donor agencies and implementing organisations. Therefore, provisions for regular meetings between involved parties to share information and experiences with the purpose of strengthening the coordination between different bodies should be ensured on priority basis.

In conclusion it may be said that there are many potential areas for success in national response for drug abuse control and HIV/AIDS prevention. Considering the nature and uniqueness of both the problems and their preponderance to spread among the high-risk behaviour practicing population, population specific comprehensive and holistic intervention programmes twining the two issues targeted at particular high-risk population would have more sustainable effect from prevention perspective. Capacity building, motivational activities, and availability and accessibility to high quality client friendly services would increase the possibility of sustenance of the programmes. A changed perception of the community in general about the issues under consideration and their long-term consequences would provide more favourable environment for implementation of programmes at particular vulnerable geographical locations.

Dr. Syed Kamaluddin Ahmed is a mental health professional.