Dr M A Momen
orld AIDS Day 2000 brought Bangladesh both good and bad news. Good news is that reliance on public sector statistics of very low prevalence of HIV positive case and dependence on a good piece of national policy paper on HIV and AIDS allows one to heave a sigh of relief. The country has so far officially registered 17 AIDS patients with 11 of them already dead. The official count of HIV positive population does not exceed two hundred. With 36.6 million global seropositive population including those with symptomatic at the beginning of the new millennium, 5.6 million new infections and 16.3 million AIDS death in the past the Bangladesh share does not appear significant and disturbing. The satisfactory HIV/AIDS status for Bangladesh allows one to be complacent. Bad news is that these statistics are hardly believable and that to the surprise of even the gloom mongers HIV infections have tremendous multiplication effect.
Good news is that religion prohibits premarital sex and promiscuity and Bangladesh people are said to be mostly religious. Bad news is that Bangladesh is infested with people characterized by high-risk behaviour and whatever their religions are they do not care to know what is written in the scriptures when the engage themselves in casual or adventurous sexual activities. Knowledge of HIV/AIDS is very minimal among Bangladesh population of all age groups. Good news is that lack of knowledge may provide a sense of satisfaction and bad new is that lack of knowledge may allow the continuation of risky sexual behaviour and promote the risk-embracing culture leading to the rise in the number of HIV infections.
Months ago, while meeting the press, Bangladesh Representative of World Health Organization for Bangladesh praised the country's achievement in the health and population sector. He hailed Bangladesh efforts in eradicating polio and malaria. This said success in eradication of malaria has again been questioned with the re-emergence of malaria and increasing number of malaria deaths for the last three consecutive years. Risk of malaria has also widened its grasp. The Representative brushed aside the public sector statistics of HIV positive population suggesting that the country had at least 20000 HIV cases and expressed his concern that Bangladesh was sitting on time bomb and that it was only a question of time to witness the explosion. Bangladesh does not have any broad-based survey on HIV/AIDS population. All estimates are simply conjectural. Bangladesh does not know the extent of HIV prevalence. The more concerned ones find even the WHO estimate to be a conservative one. With AIDS threatening at the frontiers of Bangladesh health for all by 2000 remains a wild dream.
In Asia the problem is compounded by massive ignorance of HIV status of the population. In Africa nine out of ten HIV infected people do not know what they are carrying with them. With low level of effective literacy (parrot speaking of a few letters and putting on signatures do not make literate) and serious lack of sexual education and a very low level of AIDS campaign it is natural that Bangladesh may remain one of the least concerned nations. The UNICEF publication 'State of the World 2000' shows that the overwhelming share of male and female adolescents in Bangladesh have no knowledge of AIDS and safe sex.
Low prevalence of HIV infections gave many Sub-Saharan African countries a sense of complacence. The countries paid highly for being incapable of measuring the magnitude of looming danger to be inflicted upon their population by HIV/AIDS. When more pressing issues of coping with poverty and malnutrition, and primary health care are yet to be tackled, one finds it not so justifiable to ask for a larger slice of pie from the health budget to combat a disease that has not manifested in a scale. Many Sub-Saharan countries had a similar situation of low prevalence and high complacence that punished these countries severely and continues to inflict punishment. HIV/AIDS decimated too many lives and claimed too much of development achieved over the years.
Despite enjoying a low prevalence Bangladesh provides a very high-risk situation in question of HIV infection multiplication and sudden spread of the disease. Geographically Bangladesh is located at the gateway of South Asia. Countries having high prevalence of HIV infections, unfortunately, surround this gateway. India is reported have five million HIV positive cases, the highest count for any country in the world and Myanmar has, according to a recent WHO estimate another 700,000 HIV positive population. Bangladesh also enjoys a close proximity with Thailand that was once known to the hotbed of HIV in Asia. Despite all out public and private sector efforts to contain the multiplication of infection the number of HIV positive population reached one million in Thailand.
Cross-border communication and relationship, both legal and illegal with India is cause of major concern. The alarming rise of prostitution at the frontiers, trafficking of Bangladesh girls, risky sexual behaviour of the trans-border truckers, helpers, smugglers, drug abusers and border security personnel add to the risk. In the Indian state of Manipur, one of the seven sisters states and located not to too far from Bangladesh had a very low prevalence of HIV, but within a span only four years it has overwhelmed the state. The transmission chains of the deadly virus, poverty, illiteracy, lack of access to health facilities and denial of women's power in the negotiation of sex with their male counterparts make the situation worse.
There is no stopping of infiltration of Myanmar refugees to Bangladesh. Marriage between the Rohinga refugees and those living in the hilly frontier districts and in Cox's Bazar is not uncommon. With Myanmar, ranking number one in terms of HIV prevalence as percentage of total population in Asia (the two others to follow Myanmar are Thailand and Cambodia), there are reasons to suspect that some of the refugees may be the carriers of the deadly virus of AIDS and that they might already have transmitted the infection to some local people.
Some of the already detected AIDS patients carried the virus as overseas workers. Each year there is a movement of around 100,000 job seekers to different foreign countries; some located in high-risk zones. In absence of an appropriate screening system it is difficult to ascertain how many of them return home with HIV infection to contribute to the chain of transmission.
Among the high-risk group of population commercial sex workers (CSWs) and injecting drug users (IDUs) are riskier. Although there is no comprehensive census on the number of CSWs and frequency of their entertainment of customers, Professor Nazrul Islam estimates that the number should be around one hundred thousands. CSWs generally offer unprotected and as such unsafe sex to their customers. Studies have found higher prevalence of HIV among the injecting drug users in Bangladesh. In neighbouring Myanmar, IDUs are the most significant carriers of HIV. Again due to resource constraints and poor management clinical intervention in both public and private sector is minimal.
A very high prevalence of sexually transmitted diseases (STDs) among CSWs and also among housewives is a cause of concern as being prone to STDs enhances the vulnerability to HIV infections. Prevalence of STDs in Bangladesh is very high. Health awareness is poor among Bangladesh population. Many monogamous couples are not even aware that one of the partners or both are suffering from one or other sexually transmitted disease/s. Whether one likes it or not the fact remains that premarital and extramarital sexual practices are in abundance in Bangladesh. Although the UNAIDS Chief Peter Piot assures that Bangladesh situation is not as grim as in some other Islamic countries he focuses on the fact that the country remains highly vulnerable being surrounded by high prevalent neighbours.
Women in general enjoy low status in Bangladesh and they are hardly allowed to think that sex is pleasant and mutually exclusive an exercise and they can seldom bargain on sex and safety. Talking sex is unacceptable and it entails with it an idea of committing sin. Sexual and reproductive health education is next to nil in all tiers of learning. Both male and female adolescents generally learn the wrong thing about sex from wrong people. Stigmas associated with sex and sexual diseases and misconceptions promote risk-embracing behaviour in sexuality. Over and above, poverty closes for the majority of the population doors of health service delivery system. The government with the support of AIDS-concerned donors has floated a 54 million US dollar programme to combat HIV/AIDS. A warning may not be irrelevant that big budgets are ineffective and sometimes harmful when they are spent on unwise and capricious projects. Finally, it would be healthy and money-wise for the planners to spent less on touring abroad, arranging symposiums in posh hotels, and purchasing luxury vehicles for officials and consultants. Bangladesh has over the years painfully experienced criminal squandering of national exchequer and donors' money in the name of public welfare.
Source: The Bangladesh Observer, 4 February 2001