Waking up to Reality
Recent surveys reveal that the number of injecting drug users (IDUs) in Bangladesh is rising. What is more frightening is that many of them are HIV positive. Indiscriminate needle sharing and unprotected sex among the IDUs pose a high risk of the virus spreading into the general population. As the World AIDS Day approaches on December1 SWM takes a look at the threat of an epidemic in Bangladesh in the context of inadequate state interventions and the efforts of a few organisations to introduce sustainable methods to rehabilitate IDUs and contain the spread
of the virus.
MoniIruzzaAman a farmer from Elaipur village in Rupsha upazila and his wife were in for the greatest shock of their lives when they took their sick son to Khulna Shishu Hospital. Blood tests revealed that the infant was HIV positive. This prompted the doctors to get blood samples from the other family members. All of them - the father, mother and two other children were tested positive for HIV. A physician who knows the family, suspects that the mother may have been infected with the virus when she received six bags of blood 11 years ago during the complicated delivery of her first child.
This frightening tale gives a glimpse of the gravity of the problem. First, of the complete lack of awareness about HIV (Human Immunodeficiency Virus) and AIDS (Acquired Immune Deficiency Syndrome) and secondly that we have no idea about how fast and how widely it is spreading. While sexual intercourse is the most obvious way for the virus to be transmitted from one person to the other, needle sharing between drug users has been found to be the most common cause for the spread of the virus.
Last year, a survey detected a near HIV epidemic among injecting drug users (IDUs) in a pocket of central Bangladesh. The fifth round of HIV surveillance by the Centre for Health and Population Research of the ICDDR,B (International Centre for Diarrhoeal Disease Research, Bangladesh) reports, "The HIV epidemic in Bangladesh, from an epidemiological perspective, is evolving rapidly. While still a low prevalence country for overall HIV rates, a small pocket of IDUs under second generation surveillance, has shown an HIV prevalence increase from 1.4% to 4% to 8.9% (in one locality) in the past three years." The prevalence rate is what health experts consider a concentrated epidemic in a particular social section. It also means there is too high a risk of the epidemic fanning out for the society to remain complacent about.
But, Bangladesh continues to remain indifferent to the frightening report. Since the first case detected in 1989, only 465 cases of HIV infection were officially reported until December 2004. Of the infected, 87 have developed AIDS and 44 have died. On the other hand, even back in 2002, UNAIDS estimated that some 13,000 adults and children were HIV positive in the country, which by now should have increased at least three-fold, considering the upward trend detected in the ICDDR,B survey. Explaining the chasm between the government and the UN estimates, National AIDS/STD Program (NAP) states, "Significant underreporting of cases occurs because of the country's limited voluntary testing and counseling capacity. The social stigma attached to the disease is a further impediment."
When we consider the five unfortunate members of the farmer family, this is even more relevant. Many IDUs sell their blood to get money to buy drugs, increasing the risk of spreading the virus. As the NAP says, "Bangladesh relies on professional blood-sellers to meet most of the transfusion needs of its people" Referring to the jump of HIV prevalence among a section of IDUs from 1.4 percent to 8.9 percent over just three years time, NAP observes the virus can spread rapidly within the group, then through their sexual partners, many of them sexual workers and their clients into the general population.
There are lessons for us to learn from what happened in Vietnam and Nepal as a consequence of reluctance of the authorities to intervene quickly in similar situations. According to a November 2001 NAP document, "No drug injectors in the northern Vietnam city of Haipong were infected with HIV just two years ago. Now, HIV prevalence in this group has risen above 60 percent. Since new data confirm that drug injectors in Bangladesh share needles even more frequently than they do in Vietnam, similar rises are inevitable here at some point in the future, unless needle sharing falls drastically."
Even at that time, in 2001, when the third round of sero and behavioural surveillance on HIV infection found its prevalence among IDUs to be 1.7 percent, brothel-based sex workers 0.3 to 0.5 percent and floating sex workers 0.5 percent, NAP cautioned, "The information now available should set alarm bells ringing for Bangladesh."
Now, at the end of 2005, the alarm bells should be clamouring even louder. The latest Behavioural Surveillance Survey (BSS) data indicates an increase in risk behaviour such as sharing of needles and a decline in condom use in sexual encounters between IDUs and female sex workers. Around 70 percent of the IDUs routinely share needles. The BSS data also indicates that the IDU population is well integrated into the surrounding urban community, socially and sexually, thus raising a grave concern about the spread of HIV infection.
The fifth BSS shows a large proportion of the IDUs to have commercial and non-commercial female sex partners and condom use is infrequent. A significant number of IDUs - 4.3-6.7 percent - has also sold blood over the last year. Moreover, IDUs travel from other cities to the capital to inject drugs, increasing the chance of spreading the virus.
While passing by the Dhaka Medical College Hospital (DMCH) one cannot miss seeing a number of people looking like they have just come out of hell. Their skin ashen, with ill-health, they wear tattered dirty rags and sit around in scattered groups, sharing a syringe or two to get their daily 'fix'. A particularly dangerous practice of the IDUs is called 'shooting gallery', says Iqbal Faruk, a director of Crea, a pioneering rehabilitation service provider to drug addicts in Bangladesh. "In fear of getting caught red--handed by the police, they share a large syringe to inject drugs very quickly. This practice is particularly widespread in Rajshahi and also in some pockets of Dhaka," he elaborates.
Another alarming aspect is the very high prevalence of Hepatitis C (HCV) among the IDUs, which the NAP puts at 83 percent. NAP says, "This is comparable to levels in countries that are experiencing a concentrated and growing HIV epidemic." Hepatitis C causes damage to the liver and can lead to fatal diseases such as liver cirrhosis and liver cancer. The hepatitis C virus can be contracted through transmission of infected blood or body fluids by transfusions, needleshaving, sexual intercourse or from an infected mother to her baby.
The fifth sero survey also reveals that about 8 percent of heroin addicts often switch to injectable drugs as an alternative. Thus they too should be counted among those who share needles in shooting drugs.
Barely two months old, Modhu, a baby boy, lives in a rehabilitation centre for drug addicts at Lalbagh in Old Dhaka. He is actually lucky to be alive. His mother, an intravenous drug user resorted to prostitution to sustain her habit and was admitted at the centre in an advanced stage of pregnancy. If she were not here, Modhu might not have seen the light of life at all or might have ended up forsaken on a footpath. His mother certainly could not have borne the costs of a caesarean or the subsequent complications of a premature baby. She was also in no state to take care of a child, being preoccupied with how to get her next fix.
Modhu was born in the small hours of October 2. "His mother had been in labour since the previous evening," says Lavlu, Crea-Modhumita rehab centre-in-charge. "We took her first to Azimpur maternity centre. But when the hospital staff learnt about her drug addiction and her occuptaion, they refused to admit her. The same thing happened when we went to Bangladesh Medical College and Hospital. At last we managed to get her admitted to Ibne Sina Hospital."
"The amniotic sac was ruptured, and it was a pre-mature delivery at only seven and a half months of pregnancy. The birth weight was low, too only 1.9 kg," pitches in Dr. Baquirul Islam Khan, who left his prestigious job as programme manager of Grameen Kalyan to manage the Crea-FHI HIV Prevention Project. "So, we had to go for a caesarean section and keep the child in an incubator for several days. Then he caught bronchopneumonia and we had to transfer him to Shishu Hospital," he adds.
When the woman returned to the rehab centre with the baby, the 30 plus inmates including 11 women and the 25 staff members felt a sudden shift in the environment. Two months into its launching, the centre seems more like a home than a detention camp. They decided to name the boy Modhu and if any girl-child is born here in future to name her Mita.
Modhu-Mita has become the brand name of a range of HIV/AIDS prevention services such as the needle exchange programme, drop-in and crisis support centres for drug addicts, medical facilities for sex workers etc. These services are provided under the IMPACT project of Family Health International (FHI). IMPACT works with government and non-governmental organisations (NGOs) at the community level to strengthen the care and support systems, to prevent HIV transmission and to promote behavioural change among the high-risk groups.
The fifth Behavioural Surveillance Survey found virtually no change in the behavioural patterns of the most high-risk groups between 1997 and 2004. This has shaken up all the agents associated with HIV/AIDS, prevention and control. The FHI and its partners including the government, CARE, Marie Stopes and USAID have realised the urgency of a new and more comprehensive approach to combat the menace.
Formerly most of the government, NGO-run and private sector clinical facilities used to offer short-term, usually 14-day, detoxification services to drug addicts including the IDUs, leaving out a crucial follow up rehabilitation. Detoxified patients, without having psychological therapy, social and financial rehabilitation, and counselling, went back to their addiction, particularly those who had lost their means of livelihood. Considering the new findings, IMPACT early this year, decided to launch a completely free and comprehensive package of physical, social and financial rehabilitation for the drug addicts. This initiative offered for the first time an opportunity for the dirt-poor addicts to return to the social mainstream.
IMPACT has contracted three renowned organisations Apon, Crea and Ahsania Mission working with the rehabilitation of drug addicts, to provide this service in Dhaka, which is the most high-risk zone in terms of an HIV epidemic. Preference is given to the destitute, IDUs and women. The government, too, is going to expand its 40-bed central treatment centre for drug addicts to a 250-bed one, of which 100 beds will be for patients seeking detoxification and 150 beds for rehabilitation. Of the three IMPACT partners working with the Modhumita brand, Apon will launch a rehab centre exclusively for female drug addicts and Ahsania Mission for males only. They are in the process of setting up the centres.
Crea has already opened its centre at Lalbagh that tends to both male and female patients. The patients are referred by CARE drop-in centres but can also seek treatment voluntarily, by themselves, Crea Executive Director Tarun Kanti Gayen, a psychologist working for around two decades in this field.
The basic rehab process takes six months, followed by support services, said Gayen. Of the six months, 14 days are for detoxification, then three months for various rehab therapies and training, and the rest are for day-care services, followed by after-care. Again, the detox service is available in three categories: in-house, home and community detoxification. The last two categories are particularly novel. Home detoxification is most suitable for certain categories of addicts such as women, elderly people and service-holders, to whom taking admission to a rehab centre poses the risk of getting stigmatised by society. However, in home detox, the family members of the patient have to be intensely involved in caring for the patient. The patients also are required to go through the rest of the programme at the centre, with leave to stay at home only overnight.
In community detoxification, on the other hand, the entire community becomes involved by providing the accommodation for a detox camp, volunteer staff, etc. The Crea-Modhumita has already carried out a community detox programme at Hazaribagh in the city, says Dr. Khan. The October 14-27 programme held at the local community centre started with 24 patients. The local city corporation ward commissioner, Mujibur Rahman, played a key role in arranging the venue, while a local youth club came up with the volunteer staff. Of the initial 24 patients, one had to be transferred to the DMCH as his condition became medically critical and one was expelled for violent behaviour. The remaining 22 successfully completed the course.
Gayen says the community detoxification method has proved to be highly successful and sustainable in India, particularly in the southern states. It is because, after detoxification, the patients are helped to get a job and more importantly are treated with compassion and understanding by community members. Thus it also helps eradicate the stigma and segregation attached to drug addiction. This approach, Gayen noted, has the potential to revolutionise the drug addiction and HIV scenarios in Bangladesh, where the government, NGO and private-sector interventions are either too meagre or too ineffectual to make any real difference.
Elaborating on the difference between the previously available interventions and that of Crea-Modhumita, Dr Khan says, "They did not link other essential psycho-social services for relapse prevention, for changing behavioural pattern and mindset, and for increasing self-efficacy with detoxification, which we are doing. After admission to the centre, we screen the patients for sexually transmitted infection (STI) and provide abscess management, bio-safety, counselling to the patients and their family members, as well as vocational training."
At present, patients get in-house training in block printing, tailoring, embroidery and carpentry. Dr Khan says the range of training area will be widened gradually. Those who already have some kind of vocational skills will be referred to higher training institutes. "We will get the patients graduating the course to form self-help groups and are trying to get funds to provide them with micro-credit to set up small businesses or enterprises so that they can survive financially. We are also considering launching a sort of recovery home for the women who have no shelter or family or have lost it to drug addiction, to help them stay clean," Khan adds.
As of end-October, 38 patients including 11 women joined the Modhumita course, says Tuheen, a staff member of the centre, against the target of treating 475 in-house patients a year. Half of them, he says, are IDUs. The identity of patients who know they are HIV positive as well as those who are found so in tests are kept strictly confidential. They are completely free to decide whether to get treatment and/or counselling or not. The HIV/AIDS services are provided by Jagori of the ICDDR,B while Marie Stopes helps treat the STI cases.
Mariam (not her real name) a patient, says that she has not been taunted or harassed by the male-in-mates of the centre. She was referred to this centre by a CARE drop-in centre in September. After the 14-day detoxification, she went home for a day and relapsed when she heard her husband had married again. For two days she lived her former life of addiction, but then realised her mistake and returned to the centre to start recovering once again.
Mariam was introduced to drugs at a very young age. "I was married at the age of 17. My husband used to drink, smoke ganja and take other stuff. We lived in City Palli. I started to smoke pot with him. After two/three years I began to drink Phensidyl and then started taking heroin." To feed her addiction, she started to steal from her mother and relatives' homes. Every day, she needed at least 300 taka and sometimes spent up to 1,000 taka on drugs. Eventually, she fell into prostitution and injecting drugs with others in the profession.
Mariam has a nine-year-old boy who does not live with her. Only her mother may give her shelter now on the condition that she stays off addiction and returns to normal life. "I want to be good again, so that nobody can blame me anymore. Then I will bring my son to me." She is learning embroidery and tailoring, and hopes to make a living from it someday.
Under the IMPACT-Modhumita drive, Apon, Crea and Ahsania Mission together aim at rehabilitating at least 3,000 drug addicts in three years from now. But, considering the huge number of drug addicts _ around 4600000 in the country according to FHI estimates (including some 25 to 30 thousand IDUs) _ 3,000 is just a drop in the bucket. The intervention appears even more inadequate as a recent baseline survey by CARE in 20 districts reports the tendency of drug injecting to be rising rather than falling.
The government must acknowledge the extent of the threat of the spread of HIV. While the prevalence is higher among marginal groups such as IDUs and sex workers; it is from these groups that the virus will reach the general populace because of lack of knowledge about the risks of needle-sharing, unprotected sex and transfusion of untested blood. Along with state interventions, communities must take responsibility to educate its members about HIV and take care of them when they are sick.
(R) thedailystar.net 2005