::: Star Weekend Magazine :::

Cover Story

An Epidemic Waiting to Happen

Bangladesh's HIV/AIDS epidemic is still classified as low level with only 13,000 people living with HIV/AIDS. But experts working on the issue say the country is on the brink of a nationwide AIDS crisis.

NAIMUL HAQ

Many experts point out that ten years ago India had almost the same low level status but it now has an uncontrollable epidemic of HIV/AIDS. The Indian government was initially in denial regarding the fact that India could have so many people living with HIV/AIDS.

In Bangladesh's case several factors, mainly related to the country's poor socio-economic background, make it an easy target for an epidemic. These include high rates of sexually transmitted diseases (STI) among the commercial sex workers, low use of condom, low level of awareness on prevention of sexually transmitted disease among the commercial sex workers (CSW), low level of awareness among the intravenous drug users (IDUs) about transmission of HIV virus through needle sharing and also low awareness about HIV transmission among adolescents, the group most vulnerable.

Social barriers represent another problem in Bangladesh. Due to religious and cultural taboos people especially in schools, social meetings and public gatherings are shy about talking about the risks of unprotected sex.

Mohammad Ali, a school teacher in a village of Cox's Bazar district says, "I did not want to believe HIV infection could reach our community but since it is hidden and can spread through anyone who is positive we have to be cautious. I think it is time for religious leaders to come forward in preventing the spread of HIV it."

A local NGO recently trained Ali on awareness of HIV/AIDS and he has been holding small gatherings in his courtyard to talk about HIV/AIDS. Likewise, many other religious leaders in the community have started similar courtyard talks to make people aware about HIV/AIDS.

"People used to feel shy about talking about things like using condom. But as elderly people have started talking about it no one seems to feel shy about it anymore," says Ali's fellow teacher Mazed Khorram.

Drug users using needles, however, are the most susceptible group. Not only can they contract the HIV virus through sharing needles, these individuals often go to sex workers which increase the risk of the virus spreading. The latest data available from the sero-surveillance report shows that about four per cent of the IDUs have HIV infection and it is set to increase or may even reach epidemic proportion among them, experts point out.

Initially, the rate of infection among the IDUs in central Bangladesh was 1.7 per cent which has now jumped to four per cent and reaching close to the 'concentrated epidemic' mark of five percent among the IDUs.

Major General A S M Motiur Rahman speaking to the Star Weekend Magazine says, "Bangladesh is still lucky to be low prevalence with high risk behaviour. In other high risk groups like commercial sex workers, truckers and professional blood donors the prevalence of HIV infection is less than one per cent."

Maj. General Rahman, who is the Chairman of the National AIDS Technical Committee, however, said that considering the high risk behaviour there is no reason to believe that the country is safe from an outburst of HIV infection.

Surveys of commercial sex workers also shows that although these women have every intention of using condom and understand the risk of not protecting themselves, in most cases it was found that their clients refused to use condoms.

Rehana, (not real name) a sex worker from a city suburb says, "Most of my clients do not enjoy sex with a condom. Since they are buying sex it is they who rule the business 'either forget condom or forget the sex' my clients say."

Although they need to be counseled before sex, the majority of the CSWs do not have time or place for counselling and so they continue to engage in unprotected sex.

Surveys show that IDUs do not bother to buy a second syringe to push drugs. A single needle has multiple users. "I cannot afford to buy another syringe. If I had enough money I would buy another ampoule of pethedine to enjoy," said Mahbub, (not his real name) living in a residential dormitory of Dhaka University.

The most frightening thing about the spread of HIV infection is that about 80 per cent blood donors are 'professional' donors and evidence shows that little less than one per cent of them have HIV infection and the trend shows that the percentage is rising.

During emergencies the so-called blood banks, which are largely unregistered or have no formal affiliation with the government, sell blood for Tk 500 to as high as Tk 1000 a bag of 500 ml to patients needing surgery. Most such commercial blood comes without any screening. Many donors are intravenous drug users who sell blood to buy drugs.

About three years ago, the blood banks managed by the Bangladesh Red Crescent Society started screening all bags of blood from voluntary donations for four diseases including STI and HIV infection. The authority maintains that until now they have had no blood that has tested positive for HIV virus but sources inside the laboratory says the infection rate is well below 0.001 per cent.

The national blood transfusion programme, which has now over one hundred-blood preservation and collection centres across the country in various district hospitals and medical colleges, unofficially says that screening for HIV infection shows about 0.02 per cent prevalence.

All these factors put together eerily resemble high HIV prevalence countries in Africa such as South Africa, Kenya, Nigeria, Mozambique and Zambia.

"The fact remains that the Bangladesh government still believes that HIV infection is low but what about the general population?" asks an expert.

Many countries require people to get mandatory testing for HIV infection before travelling but those returning from countries with high HIV prevalence have no arrangement for voluntary couselling which is most urgently required in the present scenario. There is evidence of high rates of HIV transmissions to wives from their husbands after their return from mostly Middle Eastern countries.

"We must meet the challenge of expanding access to HIV treatment. The government has no arrangements to provide treatment even for opportunistic infection to people living with HIV/AIDS (PLWHA) although we have more that 300 AIDS patients," says a physician of BSMMUH.

Low Prevalence
According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), the first cases of HIV/AIDS, detected in Bangladesh was the late 1980s and early 1990s, were among citizens returning from foreign travel.

The same UN agency reported, 13,000 people in Bangladesh were living with HIV/AIDS at the end of 2001. Between 1989 and 1996, the Institute of Epidemiology, Disease Control, and Research (IEDCR) tested 70,676 people from a variety of occupational groups and found only 82 to be infected. Out of the total 67 were males, many who had lived abroad, and 15 females.

By June 2002, the cumulative total of passively reported HIV cases was 216, according to the Department of Virology of Bangabandhu Sheikh Mujib Medical University (BSMMUH).

The information on HIV prevalence in Bangladesh is limited and available data suggests that the overall prevalence is low even among vulnerable groups.

In view of the gradual infection rate that started in the early 80s, the Bangladesh government formed a National AIDS Committee way back in October 1985 for prevention and control of HIV/ AIDS. By 2003 it has completed a Short term Plan of Action, an interim plan of Action and many other activities related to prevention and control of HIV/AIDS.

The National AIDS Committee, therefore, considered the necessity for a national policy on HIV/AIDS. The Director General of Health Services, accordingly, formed an 11-member "Task Force" with the chairman of the Technical Committee as its convenor.

GLOBAL FACTS ON HIV/AIDS
Worldwide, AIDS kills more than 8,000 people every day or one person every 10 seconds.
HIV accounts for the highest number of deaths by any single infectious agent.
Since the beginning of the epidemic, AIDS has claimed more than 25 million lives; more than 14 million children have lost one or both parents to AIDS.
Every year, an estimated 3 million people die of AIDS of whom 500,000 are children under the age of 15 years.
Nearly 5 million persons (4.2 million adults and 700,000 children) are newly infected with HIV each year; more than 95% of them belong to developing countries.
Almost 50% of newly HIV-infected adults in 2003 were women and 50% were young adults in the 1524 years age group.
Unsafe sex is the predominant mode of transmission of HIV worldwide accounting for 8090% of infections.
There are 40 million persons living with HIV/AIDS, worldwide. Of these, 2.5 million are children less than 15 years of age.
Six million people in developing countries have HIV infections that urgently require antiretroviral treatment to keep them alive and healthy but fewer than 300,000 are being treated.

General Information on HIV/AIDS
What is HIV/AIDS?
HIV is the abbreviation of Human Immuno - deficiency Virus. This virus caused Acquired Immuno Deficiency Syndrome (AIDS). Thus HIV is the name of the virus and AIDS is the name of the disease.
As the name AIDS implies, it is a condition where there is deficiency in the body's natural defence mechanism or the immune system. It is "acquired" because it is not a hereditary condition.
It is important to note that every person who has HIV infection will develop, AIDS over a period of time depending upon the general health and natural defense mechanism of the body.
AIDS is caused by infection with the virus called Human Immunodeficiency Virus (HIV). This virus is passed from one person to another through blood-to-blood and sexual contact. In addition, infected pregnant women can pass HIV to their babies during pregnancy or delivery, as well as through breast-feeding. People with HIV have what is called HIV infection. Most of these people will develop AIDS as a result of their HIV infection.

Basic facts about HIV/AIDS

What body fluids transmit HIV?
These body fluids have been proven to spread HIV:
- blood
- semen
- vaginal fluid
- breast milk
- other body fluids containing blood

These are additional body fluids that may transmit the virus that health care workers may come into contact with:
fluid surrounding the brain and the spinal cord
fluid surrounding bone joints
fluid surrounding an unborn baby

The modes of HIV transmission

HIV is transmitted mostly through semen and vaginal fluids during unprotected sex without the use of condoms. Globally, most cases of sexual transmission involve men and women, although, in some developed countries homosexual activity remains the primary mode.
Besides sexual intercourse, HIV can also be transmitted during drug injection by the sharing of needles contaminated with infected blood; by unsafe transfusion, of infected blood or blood products; and from an infected woman to her baby - before birth, during birth or just after delivery.

How to avoid the virus?
One can avoid HIV infection by abstaining from sex, by having a monogamous sexual relationship with an uninfected partner or by practicing safer sex. Safer sex involves the correct use of a condom during each sexual encounter and also includes non-penetrative sex.

Is oral sex unsafe?
Oral sex does carry some risk of infection because infected fluids can be transmitted through the mouth especially if there are bleeding gums or tiny sores somewhere in the mouth. The same is true if infected sexual fluids from a woman get into the mouth of her partner. But infection from oral sex alone seems to be very rare.

Are women at equal risk of being infected with HIV?
Women are, in fact, more at risk of getting infected because of their increased vulnerability. In addition, their low status within the family and society further heighten their vulnerability to infection. It is therefore most important that every woman has access to information about HIV/AIDS to protect herself.

How does a mother transmit HIV to her unborn child?
An HIV-infected mother can infect her child in her womb during constant exchange of her blood. The baby is more at risk if the mother has been recently infected or is in a later stage of AIDS. Transmission can also occur at the time of birth when the baby is exposed to the mother's blood and to some extent transmission can occur through breast milk. Transmission from an infected mother to her baby occurs in about 30 per cent of cases.

Is there any risk of infection if one is physically exposed with an HIV infected person?
There are no risks involved. One may share the same telephone with other people in office or work side by side in a crowded factory with other HIV infected persons, even share the same cup of tea, but this will not expose one to the risk of contracting the virus.

Can someone get infected with HIV from mosquito bites?
No. From the start of the HIV epidemic there has been concern about HIV transmission of the virus by biting and bloodsucking insects, such as mosquitoes. However, studies conducted by the Centre for Disease Control and Prevention in Atlanta, USA (CDC) and elsewhere have shown no evidence of HIV transmission through mosquito bites or any other insects even in areas where there are many cases of AIDS and large populations of mosquitoes. Lack of such outbreaks, despite intense efforts to detect them, supports the conclusion that HIV is not transmitted by insects.

It is important to know that:
HIV is not an airborne or food-borne virus, and it does not live long outside the body. HIV can be found in the blood, semen, or vaginal fluid of an infected person.
The three main ways HIV is transmitted:
Through having sex (anal, vaginal, or oral) with someone infected with HIV.
Through sharing needles and syringes with someone who has HIV.
Through exposure (in the case of infants) to HIV before or during birth, or through breast feeding.

How can one tell if he has HIV infection?
The only way to know for sure if one has this virus is by taking a blood test called the "HIV Antibody Test." Some people call it the "HIV Test" or the "AIDS Test," even though this test alone cannot tell if one has AIDS. The HIV test can tell one if she has the virus and can pass it to others in the ways already described.

What are the symptoms of the HIV/AIDS?
A person infected with HIV is not likely to have any symptoms for about three to ten years. This period may be longer if the natural defense mechanism of the body is good. Although a person infected with HIV does not have any symptoms, he/she can spread the infection to others.
The symptoms of AIDS are divided into major and minor symptoms. As per the definition of AIDS given by the World Health Organisation, a person is said to have AIDS if he/she at least two major signs and at least one minor sign and there is no other cause of poor immune mechanism. The term "AIDS related illness" is used when a person has some of the signs and symptoms, has antibodies to HIV in the blood but does not have two major and one minor sign.

Interview

Living With the AIDS virus

NAIMUL HAQ speaks to the executive director of Ashar Alo Habiba Akter about the existing problems of People Living with HIV/AIDS (PLWHA)

"Treatment management for the people living with HIV/AIDS (PLWHA) is a major concern now and unfortunately the state or private sector provides no support in this regard to any PLWHA," Says Habiba Akter, founder executive director of Ashar Alo, an organisation of PLWHA. "Many people are suffering from opportunistic infections who badly require care and support and most importantly hospitalisation but the public or private hospital do not want to treat us," continues Akter.

Akter, who has had wide range of exposure on travelling to various countries to be trained on HIV/AIDS adds, "Nineteen out of a total of 108 members of our organisation died in the last two years. I am sure that if we were able to provide appropriate support to them they could have lived longer. Although we are getting support from organisations like Family Health International, Christian Commission for Development in Bangladesh (CCDB) and Action Aid it is still not enough. We need more support for example to buy anti-retroviral (ARV), to conduct regular testing for CD4 cells and viral load test, both of which are vital for a PLWHA but currently these are being done from our own organisation with great limitations."

"Last December one of our members in Sylhet had to be shifted to the capital for hospitalisation. He had no support for care and treatment but he died on the train on his way to the capital. This is sad that despite knowing about our problems the government has done, until now, nothing to come to our support."

Akter also explained that private medical practitioners do not want to treat PLWHA. So there is not much choice except for referring a sick PLWHA to our designated hospital for treatment. Akter also observed that donors and many private organisations have contributed for many social development activities but they are not interested in supporting PLWHA. "We badly require financial support to help our members to make a healthy living but due to lack of funds we are unable to do that," Akter said.

Ashar Alo, established in 2000, has been actively engaged in counselling on HIV/AIDS especially to family members of PLWHA, medical practitioners, community leaders and PLWHA themselves.

She also talked about discrimination of PLWHA saying that the way awareness raising programmes are being carried out is not enough. Innovative and more attractive programmes are needed to raise awareness about HIV/AIDS and for this the media must come forward. At the same time the programmes must focus on avoiding discriminating PLWHA which is a major problem in Bangladesh.

Ashar Alo plans to expand in Rajshahi and Khulna this year. It already has branches in Sylhet and Chittagong.

Naimul Haq, senior reporter of The Daily Star, has had wide experience on HIV/AIDS attending special training programmes, workshops, and conferences and has been awarded several prestigious fellowships abroad.