According to the UNAIDS report 2002, approximately 13,000 people (including women and children) are carrying HIV infection in Bangladesh and experts opined the situation is below the level of concentrated epidemic (<1%). However, till December 2004, only 465 cases were officially reported. The significant under-reporting of cases is due to social stigma and country's limited voluntary testing and counselling capacity. The sero-surveillance studies have shown an increased HIV prevalence from 1.4% (2002) to 4% (2003) to 8.9% (2004) among injecting drug users (IDU) in central area of Bangladesh indicating rapid evolving of HIV epidemiology in the country.

Why is HIV situation alarming in Bangladesh?
Research on sex industries have identified approximately 200,000 sex workers in Bangladesh who are usually non-literate and whose customers represent all segments of society. Female sex workers have an average of 5-6 clients, the highest number of clients in commercial sex than any other counties in South-East Asia region. Moreover the floating prostitutes are present in large number though the precise distribution and prevalence is still unknown. A number of studies also found that a substantial proportion of young and single textile and garment workers supplement their low wages by occasional prostitution.

The occurrence of premarital and extramarital sexual activities including homosexual activities are also widespread in our country. Around 60% of youth have had sexual experiences before marriage. Extramarital sex exists in rural societies, particularly when husbands are absent for a long time. In addition, Bangladeshis are active in global gay scene. The behavioral surveillance data have shown that 60% of long distant truck drivers have sex with commercial sex workers about twice a month without having any knowledge on HIV/AIDS. The alarming reality is that the majority of men still do not use condom in commercial sex. Research points out about 98% of floating and 96% of hotel based sex workers do not use condom in their sexual encounters. About two-third of rickshaw pullers and truck driers surveyed reported that they never touched a condom in their lives. According to the behavioral surveillance report, Bangladesh is the lowest condom use country in the South-East Asia region.

Sexually transmitted infections (STI) act as a major co-factor of HIV transmission and serve as indicators of low condom use and other high-risk sexual behavior. Studies have shown high rates of STIs in various populations in the country. According to UNDP (2003), sex workers in Dhaka city have had very high rates of syphilis (60%), gonorrhoea (18%) and chlamydia infection (20%). A rural study found that 47% reported symptoms of reproductive tract infections, 56% had laboratory evidence infections, of which 23% were STIs.

The Department of Narcotic Control, Bangladesh and other research report stress that needle sharing continues to be routine among injecting drug users and the number of new injectors are increasing. The report pointed out that contrary to the common belief, injecting drug users are not isolated from the society; they have regular sex partners, they buy sex from women as well as other men, they sell blood, and they move between cities and injects. In another survey, 13% of sex workers reported having injecting drugs. This close interaction and networking can potentially spread the epidemic widely to the general population.

The Bangladesh economy relies on more than 1.5 million migrants mostly from neighboring countries, who spend much of the year away from their families, are known to be at increased risk of contracting HIV.

The BRAC response
BRAC initiated response against HIV/AIDS through conducting several studies on HIV/AIDS awareness in Matlab in late 1990s. Such studies showed a very little proportion of rural people knew about AIDS, and a few proportion of them knew about its transmission and prevention. During 1997-1999, BRAC carried out operation researches on behavior change communication, and identified pre- and extra- marital sexes, sexual abuse, low condom use and high rates of STIs with no/ very little treatment among Matlab population. In response to that, BRAC Research and Evaluation Division developed and tested a low cost, simple and culture sensitive HIV/AIDS awareness education module in Matlab. BRAC piloted the module in Mirzapur and Tangail districts during 1999 to 2001 for scaling-up. Thereafter in 2002, BRAC undertook a 4-year HIV/AIDS prevention programme in 5 divisions of Bangladesh targeting the high-risk and general populations.

BRAC HIV/AIDS education programme
The community based HIV/AIDS education programme was initiated in 2002 that aims to increase HIV/AIDS awareness among community people including adults and adolescents, internal migrants and brothel based commercial sex workers (CSW). The programme targets a total of 7.4 million people from Dhaka, Khulna, Chittagong, Sylhet and Barishal divisions with support from SIDA and government through Unicef as management agency. The programme has four main approaches encompassing the whole cycle of preventing HIV transmission from high-risk to general population through bridging community. The 4-components include, 1) mass awareness of HIV/AIDS in the community including couple education, 2) awareness raising among adolescents in secondary schools as well as in the community, 3) preventing HIV/AIDS among the high-risk populations comprising brothel based commercial sex workers, and 4) preventing HIV among internal migrants. It is noted that groups of stakeholders/ gatekeepers are also trained and sensitized on HIV/AIDS and the programme.

The programme for adults: BRAC provided training to 1,524 programme organisers (PO), and 2,300 community health workers (CHW) and extension workers, who in turn, disseminate information among community people on the basics of HIV/AIDS and on safer sex practices. The CHWs educate community peoples through one-to-one contact while visiting households. They specifically relay the information to married couples. The POs conduct group meetings, identify RTI and STI patients and refer them to the BRAC health centre (BHC) or GOB health facilities. The popular theater on HIV/AIDS conducted in each village act as a reinforcement tool for the awareness raising.

The programme for adolescents: The programme targets both out school and secondary school (class VIII X) adolescent boys and girls in the community. The two trained teachers in each class, one male and one female, are responsible to provide information on the basics of HIV and AIDS to the students. Each student would receive the orientation two-times a year. Personal hygiene and some issues of reproductive and sexual health problems are also a part of discussion. Questions can be asked anonymously through a question box.

Gonokendra pathagar and Kishori pathagar of BRAC education programme is used to reach the community based adolescents through peer education approach. Flip-charts, booklets and videos are used as BCC materials.

The programme for internal migrants: To halt the spread of HIV infection from high-risk to general populations, BRAC addresses the internal migrants like bus and truck drivers and helpers, and industrial workers as they are the potential clients of commercial sex. The program activities encompass awareness raising, condom promotion for safer sex practice and basic curative services for STIs. Peer education is the main employed method.

The programme for commercial sex workers: The programme targets brothel based sex workers with the aim to empower them to reduce risks and vulnerability through enhancing safer sex practices. BRAC initiated the HIV/AIDS awareness programme for the CSWs through group formation of 15-20 members in each. BRAC's trained Shastho Shebikas (SS) and trained volunteers from the group are responsible to educate them on HIV and AIDS and condom promotion for safer sex practices. The empowerment programme includes mobilisation, savings and consumption loan activities to support their livelihood during the lean and crisis period. BRAC frontline workers and volunteers contacted the sex workers through group meetings and one-to-one contacts. Condom demonstrations are conducted by the Shastho Shebikas in order to relay the correct use of condoms. Personal hygiene practices are also being taught. The volunteers also distribute condoms and keep track of how many are being used by the sex workers. Moreover, shasthya shebika provides limited curative services for ten general diseases. The Programme Organisers identify and treat the RTI and STI cases through syndromic management, and if necessary refer the cases to the BRAC health centres, government health facilities and other NGO clinics.

The writer is an official at Research and Evaluation Division of BRAC.