Dhaka Thursday December 1, 2011

Men's involvement in the context of
HIV prevention in Bangladesh

UNFPA and The Daily Star organised a roundtable on 'Men's involvement in the context of HIV prevention in Bangladesh' on 20 November 2011. We publish a summary of the discussions..

-- Editor

Mahfuz Anam
Editor and Publisher, The Daily Star

We are much better off than many but the fact that we are better off makes us complacent .We are in some sort of unchartered middle ground where, because of social economic, cultural and religious reasons, HIV is not that prevalent as in many other countries. However, that fact of not being prevalent is making us complacent about taking measures which we should. This is exposing us to vulnerabilities which we must seriously guard against. Given our particular culture we are a bit shy talking about sexually transmitted diseases. Sex as a topic never comes in the public domain. I think we have done a clever job of not saying it directly but saying it indirectly and campaigning with innovative languages about the whole threat of sexually transmitted diseases. However taboo covered it is, it has to be brought in the public domain and we will have to face the fact as it is and prevent HIV from spreading. As a media institution we would be happy to collaborate in every way possible.

Arthur Erken, Country Representative, UNFPA
Bangladesh is still a low prevalence HIV country, but we are not immune for a full blown epidemic. And since men and male sexual behavior are the main drivers for the spread of the infection, we need to get much more serious about their role and responsibilities. And we need to target men in their multiple roles in society: as husbands, policy makers, community leaders, law enforcers, but also as drug users, or clients of sex workers. So, we need a holistic approach to address male sexual behaviour. To address male sexual behavior, we have to ensure that we look at their particular needs for sexual and reproductive health information and services. Too often, we see a man as simply a 'target' of interventions, not as a beneficiary of and an active participant in HIV-related programme interventions. Therefore, in the mainstream family planning and reproductive health programme, we should be looking for ways to reach men with sexual and reproductive health, including HIV & AIDS, information and services. The purpose of this dialogue is to look for better ways of involving men in HIV & AIDS programming.

Dr. Khandaker Ezazul Haque , UNFPA
I am going to start with some brief background of HIV situation. Considering the global and national context, HIV/AIDS is not only a health problem, it is a socio-economic problem as well. Since the beginning of infection, a specific group of people commonly known as “Key affected population” previously knows as” Most at Risk Population” bear the brunt of HIV infection. Global epidemiological data says that this transmission of HIV is mostly heterosexual. Though we commonly say, everyone is potentially susceptible, but social circumstances do leave this group particularly vulnerable. In most of the cases this vulnerability is associated with men's unsafe sexual behavior, gender inequity and gender based violence which is further aggravated by associated stigma and discrimination as imposed mostly by men. Considering this context, interventions for HIV prevention, mostly address the women and girls to counter their detrimental role of unsafe sex practice and violence against women.

A study shows that more than 1 in 3 (36.8%) married Bangladeshi men reported physically and/or sexually abusing their wives in the past year. This study shows that Bangladeshi men who perpetrate intimate partner violence represent a greater threat to the sexual health of their wives compared with non]abusive men, based on increased rates of extramarital sexual behaviour and acquisition of STI. So, there is justification to focus on women and girls in HIV prevention.

Moreover, programmes which addresses gender issues for HIV prevention, have an inclination to mainly target women, focusing on 'empowerment discourse' with an objective of social and economical emancipation and achieving decision making power for safe sex practice and prevention of HIV. According to my opinion, men have long been portrayed as 'the problem'; this rarely functioned as an incentive to work for gender equality by engaging directly with them for safe sex practices. This tendency of ignoring the potential of men's involvement is being questioned whether women, who have learnt about their rights in empowerment projects, can exercise these if there has been no male involvement.

HIV prevention programmes aim at empowering women by improving their access to information, skills, services and technologies. This approach, when used alone, has every chance of failure if gender power relation between men and women is not considered in wider societal context and dynamics. The acquired skill and information will not work unless and until we have get support from men for prevention of violence and safe sex practice.

So, I think, in HIV prevention, closer linkages between women's empowerment and male involvement need to be established. To me, this women's empowerment and men's involvement are two side of one coin which supplement and compliment each other. Moreover, I believe like women, men also have sexual and reproductive health need. We should not forget that masculinity attitude and unsafe sex practice also leave men vulnerable to HIV. They have unmet sexual and reproductive health needs, and if these needs are adequately addressed, men's support for women's safe practice will be spontaneously ensured.

I am confident, that if men have good and supportive attitude towards women, this can facilitate the empowerment process manifold. I am not against the prototype or existing women's empowerment process, but, I thing, if men's support can be ensured, process of women's emancipation will be easier and less time consuming. My urge, we should think on this issue very seriously to harmonize the empowerment process with men's involvement as they are the good and trustworthy partners for their mutual benefit.

Men are argued to have influence on women's sexual behaviour, which implies that working only with women is not enough. Men are therefore should be encouraged to use this power positively, take the first step towards change and take responsibility for and with women.

Bridget Job-Johnson, HIV Specialist, Unicef
We have to look at needs to bring change in the society. We need a major shift in terms of how men are seen vis a vis sexual and reproductive health services.

Dr. Fadia Sultana, Senior Manager, Coordination and Capacity Building, Save the Children
Regarding HIV prevention, Bangladesh has clear priorities, partnership for prevention of HIV with a solid vision for Zero new HIV infections. Zero discrimination. Zero AIDS related deaths where we are committed for. Under the leadership of Ministry of Health and family Welfare and National AIDS STD program Bangladesh stared early responses, addressing most risky behaviors, factoring awareness raising campaigns into behavior change program under GFATM resources have contributed for impact.

We have national strategies, commitment and investment in place in the area of HIV prevention, care and support through national program. The country is awarded three Rounds of GFATM funding support for HIV and AIDS program, Round HIV 2 project focus on the young people who are belongs to 15 to 24 from 2004 to 2009; a large number of them are young male.

The programme went through a systematic baseline survey to understand the knowledge, perception level of the young people and the programme was designed to address gaps in information and service. It targets to institutionalize access to information through life-skill teaching and service utilization to bring the young people under the youth friendly service institutions in the government and private sectors. We usually do not think that young people have high risk behaviour but baseline survey shows that there is very high risk behaviour among the young people and self risk perception was low.

Considering country gap and prevalence, Round 6 HIV project given focus on Most- at-Risk populations particularly drug injecting people and female sex workers and infected and affected people with HIV and “Rolling Continuation Channel (RCC)” stated from 2009 to be continued till 2015.

The strategies include scaling up prevention program among most at risk population particularly IDUs & Female Sex Workers Men sex with men and transgender, scaling up prevention programs among young and vulnerable youth and workplace intervention through Partners.

In Asia most of the women are infected by their partners and in Asia PLHIV rate is about 35 %. So we have to take special care of the partners. In relation to male involvement she said that defining male for addressing through HIV program is key looking at HIV prevention program, male as population having risk behavior like Injecting drug user, client of sex workers who need essential services, on the other hand male as law enforcing agency, parents, religious leaders to involve for creating enabling and supportive environment for increasing service access and utilization.

Data suggests that a significant proportion of new HIV infections within key populations at higher risk In Dhaka city the prevalence has remained stable at 7% among Injecting Drug Users (IDU) which ahs reduced according to recent 9th sero surveillance.

Regarding achievements HIV prevalence remains low which is less than 1%, active syphilis has declined among Injecting Drug Users (IDUs)

* Knowledge has increased considerably among Young people, in endline survey in comparison to baseline at beginning of the project.

* Study shows that condom use has increased among Young People from 40% to over 55% and also among the young clients of hotel based female sex workers from 14.1% to 48.3% which ultimately reduces the risk of HIV transmission

* 556 people living with HIV are in ART treatment that will reach to 600

* HIV is included in the national education curriculum from grades VI-XII and Teachers and SMC members are trained.

* 14,000 IDUs, and 28600 FSWs are reached through 114 Drop in Centres (DICs) in 52 districts under GFATM HIV program.

* Save the Children through three grants of GFATM generated evidence for use for quality improvement and resource mobilization

Regarding general information besides surveillance, BDHS is the only source where we can only see the knowledge level of HIV, but unfortunately we cannot see the practice level like condom usage for prevention of HIV. The rate of using condom among the base line people was really a very low. But in the recent years we can see a tremendous increase of this use which occurred because of knowledge. The school base education curriculum and in text book can be a good media so that the people would get correct information. So that in adulthood or any time in their life cycle they can take the right decision. Regarding male involvement in SRH programmes she requested is to use existing community based infrastructure of the government. Existing family planning and maternal and child health services to be attracted by and facilities to be ready to address SRH needs to support male. The word condom was stigmatized; even it was not mentioned in any media. But now there is ahuge change because of the planned campaign such as “Bachte hole Jante Hobe”. These changes are made possible because of the government leadership and government owned programmes. Government allowed the media and the people to get the right information.

The country needs to continue and scale the comprehensive HIV prevention and care, treatment and support programmes for most at risk population and People with HIV and at the same time individual risk factors to be analyzed. Men's have to get proper information from where they usually get services about STI related problems, about self risk. VCT could be an entry point for prevention. We have to expand the VCT programme and standardize services. We need more facilities beside government efforts.
*Based on our experiences and lessons learnt priorities in programming would be continued to focus on most at risk and most vulnerable populations for maximum coverage with evidence-based approaches, strengthening health systems and it's linkages with most at risk population and People living with HIV and AIDS services along with integrated HIV program with SRH, reproductive, maternal and child health. Drop in centers to be linked with existing Government services for Most at Risk population and facilities to be prepared to provide services irrespective to status so that Drug user, sex workers can get friendly services with respect interventions and in increasing condom use among youth clients of sex workers
*There are 13 focal points under key ministries on HIV AIDS. I would like to request activate existing focal points to review their role and incorporate men in HIV programme. At the same time district AIDS committee to be more functional under Directorate General of Health services for local accountability.

Misti McDowell, Country Director, FHI360
We have programmes to reach to the spouse of the female sex workers. That is very important to make them part of the solution. I think without involving men in the HIV programme we cannot get real success.

Dr.Md.Enamul Haque, National Consultant - HIV/AIDS, World Health Organization
It is very important to perform a proper situational analysis before any public health programmatic intervention initiated. Let us analyze strength, weakness, opportunity and threat in existing situation properly before any programmatic intervention. It is not cost effective for a programme to confront an undesired situation that has aroused in absence of proper situational analysis in the beginning.

Any programmatic intervention needs a proper exit strategy in the proposal. It helps in sustainability of programme continuation when donors withdraw their fund. Exit strategy should explicitly mention the time, place and person for proper hand over and it should be explicitly a part of any project proposal to donor. Clear exit strategy ensures better sustainability of any programme in developing countries.

Women suffer more discrimination and stigma in society than man. If a person belongs to marginal society e.g. sex workers, transgender, intravenous drug user etc, problem becomes more acute. When women or members of a marginal society suffers more stigma than man after HIV infection, its not an isolated phenomenon. The root of the problem lies inside the power relationship among men and women in society, financial independence, thus decision making capacity etc. In short, it depends on men's attitude how they see women in any social structure. In the light of this reality, there should be a comprehensive effort involving all sectors (education, women and social welfare, law, media etc; not only public health sector alone !) to make people aware about their due rights, gender issues, changing attitudes, compassion to fellow human beings etc. It's a gradual process and situation is slowly changing to better direction in comparison to the situation prevailed ten years back.

Dr. Nazmul Alam, ICDDRB
We established Man Involvement Forum, it did not work. With the collaboration of FHI we conducted a survey among 9000 men with innovative procedure like using ballot box which gave good results. In Matlab, we did another research focusing on the male only but the programme did not survive due to financial constraints. We need more concentration from our policy makers and higher managements to sustain these projects .The 2008's Asia Commission Report stated that half of the infected are not practicing risk behaviour rather they are infected by their male partners. We could not start male involvement as a holistic project. We should remove these hindrances.

Brother Ronald Drahozard, Executive Director, Apon
In Bangladesh most of the young people who are addicted start taking drugs before the age of 20. They start sexual activity long before becoming adult. So we have to start our work from the young people so that we expect the adult to be using their position, authority and power positively. Another important pocket is the street children. 10% of them are drug users and also HIV positive. There may be 4-5 hundred thousand street children in Bangladesh. This is a very high percentage. If even half of those become street adult then it is horrible. So we have to do something to take them out from the street. We need to help this people so that they can be made skilled in any job and can find a job off the street and are able to live a responsible life.

Md. Gias Uddin, Project Manager, FPAB
Our national programmes for HIV and SRH are very vertical. Some NGOs are working on HIV and some on SRH. But there is no integration among them; the coverage is very poor. The least number of people are getting services and information. On the other hand, some NGOs are addressing the sex workers with condoms and information, but what about their partners. They are out of the service. We are not covering the male people. Similarly, some NGOs are working with the young people but their focus is mainly on SRH not on HIV. If we integrate both the programme we can get better services at minimum cost.

Hasnain Sabih Nayak, International and Culture Editor, TOITOMBOOR
In our country, whatever programme we are implementing in the social or cultural context, it is not able to make much dent. Still there remains a taboo in discussing about sexual diseases. If you take HIV as a medical discussion even that is not possible to be discussed in public other than in selected forums. We should counter such mindset with specific social intervention to change the mind set.

I want to further broaden the topic of street children that it is not only the street children but children in general also. When the children are born you do not know who might be on the street or who might not be. We should focus on the social and cultural transformations during their childhood. When we are making any strategy and policy, we have to think in long term perspective to make it effective.

In our society we find that if anyone has bi-sexual relation and have HIV infection we disassociate from him thinking he is a victim of his fault. This attitude should be changed.

Bridget Job-Johnson
We are seeing more and more men's involvement in the medical treatments. Now, we find husbands in the hospitals when their wives are delivering babies. The paradigm is shifting. When men go to hospital there is a need to suggest to them to take HIV test.

Rape within marriage is another issue. How is that to be dealt with? In that situation the woman is not able to negotiate about condom use which exposes her to the risk of getting infected.

Before formulating policies we have to learn more about man's different behaviours in different roles. They are father, they are the bread winner and they are community leaders. Do we know whether they talk about these things or want to hear? We need to know what they think.

Dr. Samir Kumar Howlader, IOM
I want to focus on the migrant population. They are highly vulnerable to HIV not because of migration but problems associated with the migration process, when they come back with infection and they spread the infection in their wives or partners. So here again men come to be highlighted to address their needs. So we should not blame the man rather they should be looked at as partners not as a burden. I am in favour of parallel programmes not only for man or woman but comprehensive programmes including both for preventing HIV or sexually transmitted disease.

Safat Hasan, National Youth Forum-UNFPA
We the young generation already know about HIV infection and its prevention. But the problem is that we only know the general concepts, not in depth. We follow the radio, TV, tag lines, advertisements which contain messages on HIV. These are the worst things. We only know but do not care. It seems we are not educated. When we have to face a situation we are blank and get infected. We have to incorporate young people. There are medical centres but we feel shy to go there. Steps should be taken like online centre or hotline so that privacy could be secured. Another problem is that we are not free with our teachers not even our parents. In our academic syllabus our teachers usually do not talk of the HIV chapters. We have to get out of such mind set.

Dr. Md. Abdul Waheed, NASP
In Bangladesh the main reason of HIV transmission is heterosexual behaviour. Though the reported number of HIV victims is comparatively low but still it exists in our society because of low number of condom use, lack of information and increasing injection of drugs. I would like to focus on gender discrimination. In our patriarchal society women are having less power. They cannot even take decision about their health. It is reported that a large number of women in our country are infected by their husband. Different sources say that even sex workers are aware that using condom will save them from HIV, but the male clients refuse to use condom. This is high time for the male to ensure their responsibility not only towards women but also towards their own health, no matter the woman is his wife or a sex worker. It is a good point that our government is working hard to minimize the gender disparity. In Bangladesh men should be more responsible. Increasing the negotiation power of women and providing them universal access to health care regarding reproductive health, can make real change.

Dr. Khandaker Ezazul Haque
Men's involvement issue also needs to address the mainstreaming of HIV and gender issues. It means that we need full time dedicated personnel, sustainable financial commitment, and administrative support at relevant ministries and sectors. Questions might be raised why we need mainstreaming while we are talking about men's involvement in HIV prevention. Answer though not simple, but I believe not complicated; in fact it facilitates active engagement of all stake holders, ensure quality and wider coverage of services. As I mentioned earlier it will also ensure to address both side of the coin, the empowerment process of women and men's involvement.

In terms of targeted intervention for “Key affected population”, I think we should also emphasize on this issue. Anecdotal and research findings depict that sex workers are well aware about the safe sex practice, but due to undue influence and detrimental roles of men and local power structure, they can not negotiate with clients for safe sex practice. In this context, we also need to think seriously on this issue of clients involvement for safe practice during buying sex. In fact men's involvement is not only an issue of Ministry of Health and Family Welfare, but other relevant ministries required to be involved. We need policy advocacy for active engagement of different ministries to coalesce on a single platform on this issue to devise a mechanism and strategy for men's involvement in Bangladesh.

Dr. Hashina Begum, Assistant Representative, UNFPA
We are talking about men, but we need to focus on young boys as well because they will be ultimately the men in near future. So, from now on, we need to inform them about different aspects of HIV and sexual and reproductive health through different comprehensive programmes. I believe, then they will be responsible regarding the HIV/AIDS and SRH when they will reach adult hood.

With regard to the condom use, we need to talk more about this issue. Our policies and strategies that has been actually initiated very early in Bangladesh, and that could be one of the reasons that still we have a very low prevalence of HIV. But we are still confused about some areas where usage of condom is very low, and we do not know whether our programmes are effective or not . The question demands that if we have a very effective intervention, condom use rate should go up, but on the contrary, still it is actually not going up at a rate as expected. We always talk about the negotiation skill of the Most at risk population, specifically the sex workers, but what is the scenario in the sex trade ? The sex workers now have condom, and can negotiate for safe sex, but man denies to use condom because they are not fully aware of the risk and not changing their attitude and behavior. Experiences from other countries like Senegal or Thailand, we come to know that if we could have a very good targeted intervention involving man, the STI can be reduced and condom use rate could be increased. Also, we need research to know why we are not able to overcome the barriers, and despite of intervention, and why men's involvement is not up to the mark. If we are able to aware the man about the benefit of safe sex practice, their meaningful involvement will be facilitated. The best example is the EPI. If you look at the national immunization day, usually men take leave from the office, and take their babies to the immunization centre.

Another thing is that we need more study on the good practices of man. We also need to look into the monitoring and evaluation regarding what we are doing , and whether that is really effective because with our resources we need to have a very good intervention that really yields the result on HIV /AIDS.

Hasnain Sabih Nayak
I would like to reiterate two things. One is whatever initiative we take we should consider the cultural sensitiveness and long term strategy which will bring about attitudinal change in the mind set of our society. Another thing is that there are pieces or chapters in our curriculum but in most of the schools those chapters are not taught. This is a gap. If we could monitor and act upon that we would be able to overcome the gap.

Dr Shamim Jahan, Technical Director, FHI 360
There are lots of success stories involving men in the HIV programme that need to come out. If we share those success stories among us that will be of great benefit. Another is working with the media .If we involve the media, bringing them within the programme, then it would be a boon.

Dr. Nazmul Alam
One of our studies shows that internal migrants are vulnerable to HIV as they are the increasing client of the sex workers. They should be properly informed about the risk of getting infected. Another thing is sustainability. If we can identify good practices and recommend so that the government programmes can integrate those at a larger scale.

Bridget Job-Johnson
We have to disseminate the messages through social media. The messages need not to be in the brushier but to be in the social media. We need youth friendly services to disseminate the knowledge.

Dr. Khandaker Ezazul Haque
I think fidelity, mutual trust, respectfulness and good understanding are very important on this issue being discussed. Men should be proactive, and play forwarding role for safe sex practice. As, based on socio-cultural and other associated conservative context, women can not raise this issue to their husbands openly, and men should under stand this complexity, and be sensible and reasonable to protect their wives and partners.

Bridget Job-Johnson
Unicef has a research monitoring component. A project was launched looking at girl's empowerment and the project realized that if you do not include boys it is not going anywhere. The project was redefined and included boy and parents, and then it was successful. Government now takes over the programmes for larger period.

Dr.Md.Enamul Haque
We do not have enough data. We need a good survey.

Brig-Gen (Retd.) Shahedul Anam Khan, Editor, Defense and Strategic Affairs, The Daily Star
The question of attitude of men and empowerment of women is correlative. Prevention is a battle for the mind too. It is not enough only to learn but we have to learn how to react to particular situation. And that is where the media can play a vital role. Talking about HIV is a taboo. If we fail to inform general people we would not be able to intervene successfully. There is need for strategic cooperation with media.

Arthur Erken
I would like to sum up our discussion, by highlighting the following points:
First, if you want to address certain aspects of human behavior and try to change human behavior, in this case male sexual behavior, we have to start programme interventions at an early age! If we want an HIV-free society in future, we need to focus our attention on programmes aimed at children, including street children, and young adolescents.

Second, we need consistency in our programmatic interventions and approaches. If you want to change society and social behavior, one has to look at long-term sustained inte4rventions, not just five-year projects. Exercising discipline in pursuing a certain approach is very important.

Third, we are still missing vital data and statistics on sexual behaviour.

Fourth is programme design. We have to make HIV information appealing to men, especially young people. Also, for designing meaningful programme interventions targeting men, we need to know the language that men speak and understand when it comes to sexual behavior, reproductive and sexual health.

Fifth, we cannot deal with HIV prevention effectively without taking into account the power relations in society. Hence, dealing with issues related to gender equality and women's empowerment are vital when addressing the role of men in HIV prevention.

Sixth is stigma. Time has come to break the stigma surrounding HIV & AIDS. Failing to do so will make it very hard for HIV prevention programmes to succeed.

Seventh, migrants (both external and internal) and transportation workers are very important, and to some extent new, target groups to be taken into account I designing HIV prevention programmes.

Finally, we do not find much coverage in the mainstream media when it comes to HIV & AIDS. We have to involve media in our programmes so that people can be better informed about the importance of the issue. Moreover, we have to tap into the new social media outlets to reach people with correct information about HIV prevention.