Table of Contents. Evidence of Increasing HIV in Bangladesh 5. Epidemiological studies indicate HIV is increasing 5

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2 Amala Reddy, Robert Kelly, and Tim Brown A 2 (Analysis and Advocacy) Project Family Health International Bangladesh Country Office Dhaka, Bangladesh June 27

3 Table of Contents Evidence of Increasing HIV in Bangladesh 5 Epidemiological studies indicate HIV is increasing 5 Behavioral studies show considerable HIV risk exists 7 HIV Risk from Injection Drug Use 8 HIV Risk from Commercial Sex 7 HIV Risk from Male-to-Male Sex 11 Casual Sex Risks 12 Exploring HIV Spread in the Future 13 The Asian Epidemic Model 13 Applying the Asian Epidemic Model to Bangladesh 14 The AEM Dhaka Baseline Scenario 15 Key messages for prevention programs from the AEM Dhaka Baseline Scenario 21 Impact of IDU Interventions 21 Impact of Sex Work Interventions 22 Impact of MSM Interventions 23 Lessons from the AEM Dhaka Baseline Scenario 24 Future Steps 24 Bibliography 25

4 List of Figures Figure 1: Passive HIV case reports are steadily increasing 5 Figure 2: More men are infected with HIV, but the number of women is increasing 5 Figure 3: National Surveillance detects a HIV epidemic among IDU in Central City A 6 Figure 4: In some regions the majority of IDU still borrow needles, and they have sexual risk as well 7 Figure 5: High proportions of some men buy sex from women, and some from men 8 Figure 6: Female, Male, and Hijra Sex Workers have many clients and less than 1 in 5 used condoms consistently last week 9 Figure 7: Low proportions of males use condoms for commercial sex, and hardly ever consistently 1 Figure 8: High proportions of MSM surveyed report anal sex, but it is largely unprotected by condom use 11 Figure 9: Casual sex is not as common as commercial sex, and men's condom use is about the same for both (Behavioral Surveillance 22, Male Sexual Health Survey) 12 Figure 1: Behavioral risk for HIV in Asia is concentrated in certain sub-populations 13 Figure 11: The epidemic starts with explosive growth of HIV among IDU reaching high prevalence in just a few years 15 Figure 12: The explosive growth of HIV prevalence in IDU will 'seed' the sex work epidemic, because IDU interact with other vulnerable sub-populations 16 Figure 13: HIV prevalence in MSM and MSW grows to very high levels 17 Figure 14: HIV prevalence in low-risk women reaches more than 1% about 1 years after the rise in HIV among IDU 18 Figure 15: New infections show various populations influence the epidemic over time 19 Figure 16: Proportion of new infections shows the relative influence of different populations as the epidemic progresses clearly 19 Figure 17: Five years after the IDU epidemic is apparent, there will be about 5, cumulative HIV infections, and 2, new infections 2 Figure 18: Promoting injection risk reduction can delay or stop the growth of HIV among IDUs 21 Figure 19: Delaying the IDU epidemic will slow but will NOT avert the sex work epidemic 21 Figure 2: Raising condom use by sex workers and clients can control the spread of HIV - the impact is more when combined with a reduction in clients 22 Figure 21: HIV among MSM can be lowered by increasing condom use and greatly reducing commercial sex 23 Figure 22: The AEM Dhaka Baseline Scenario 23

5 List of Acronyms A² Analysis and Advocacy AEM Asian Epidemic Model AIDS Acquired Immune Deficiency Syndrome BAP Bangladesh AIDS Program BBSW Brothel-based female sex workers BSS Behavioral Surveillance Survey comm commercial Con condom epi epidemic FHI Family Health International FSW Female Sex Workers GOB Government of Bangladesh HAPP HIV/AIDS Prevention Project HBSW Hotel-based female sex workers HIV Human Immunodeficiency Virus HSS HIV Sentinel Surveillance ICDDR,B International Center for Diarrhoeal Disease Research, Bangladesh IDU Injection Drug Users IMPACT Implementing AIDS Prevention and Care Project lo-risk low-risk MAP Monitoring the AIDS Pandemic Network MOHFW Ministry of Health and Family Welfare MSM Men who have Sex with Men MSW Male Sex Workers NASP National AIDS and STD Programme Natl National NGO(s) Non-Government Organization(s) PLHA People Living With HIV/AIDS ptnrs partners red reduce RTI Reproductive Tract Infection SBSW Street-based female sex workers STI/STD Sexually Transmitted Infection/Disease SW Sex Worker USAID United States Agency for International Development

6 Evidence of Increasing HIV in Bangladesh Bangladesh has remained at low HIV prevalence, although experts have been predicting that an HIV epidemic is expected based on the prevailing risk factors. This report examines the evidence for this prediction, and describes modeling efforts to assess the future of HIV if the current behavioral patterns remain the same. Epidemiological studies indicate HIV is increasing The epidemiological data indicates that HIV infection is on the rise. Passive case reports of HIV and AIDS have been steadily increasing, especially in recent years, as shown in Figure 1. Some of this may be due to the increase in HIV testing centers. Figure 1: Passive HIV case reports are steadily increasing 1 Reported HIV and AIDS Cases (1989 to 26) Reported Cases Year New HIV+ Cases New AIDS Cases Deaths due to AIDS Total HIV+ Cases There are almost four times more men (76%) than women (21%) among the reported HIV cases up to 25. Data on the modes of infection of diagnosed cases are not disseminated. Although the number of men infected relative to women is still high, the number of women is gradually increasing, indicating that some heterosexual spread is occurring (Figure 2). Figure 2: More men are infected with HIV, but the number of women is increasing # Male or Female Infections Gender Distribution of New HIV Reported Cases Year Males Females Gender Unknown Ratio Males:Females Ratio of males to females The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk 5

7 The annually conducted National HIV Serological Surveillance (HSS) has found an increasing trend in HIV among injection drug users (IDU) in Central Bangladesh (Figure 3). In the seventh round of surveillance (25-26) an average prevalence of 7% HIV was detected among injectors in Central City A, which is a concentrated epidemic. Figure 3: National Surveillance detects a HIV epidemic among IDU in Central City A 8 HIV prevalence among Injection Drug Users sampled from Needle Exchange Programmes in Central Bangladesh (Source: National HIV Sentinel Surveillance) % HIV North-West R A J S H A H I I N D I A Central D H A K A S Y L H E T North-East Year of Surveillance Central-A I N D I A South-West K H U L N A B A R I S A L South C H I T T A G O N G I N D I A South-East MYANMAR The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk Khulna Chittagong Sylhet Dhaka Rajshahi Barisal W N E 1 S 1 Miles The HSS also indicates HIV infection may be spreading among injectors beyond Central City A. For the first time in the sixth round HSS, HIV was detected among IDU in two other cities, Southeast D (2%) and Northwest F1 (.6%), and by the seventh round in HIV was at more than 1% prevalence in these two cities, as well as in Central E (1.1%, 1.8%, and 1% HIV respectively). Besides IDU, the HSS monitors infection among various other groups known to be vulnerable to HIV because of their behavior: female (FSW) and male sex workers (MSW), transgender sex workers (Hijras), men who have sex with men (MSM), various occupational cohorts of men at risk such as truckers (TR), rickshaw-pullers (RP), launch workers, regular partners of FSW, and male STI patients. Generally HIV prevalence has been less than 1% in all these groups, although cases of HIV infection have been detected in different groups every year- mostly in the Central Division (66% of the 56 total HIV-positives up to 25, with about half in Central City A). But in the last two rounds of surveillance, the second highest HIV infection rates were recorded among casual female sex workers surveyed in Northwest K1 (2% in 23-24, and 1.7% in 24-25, with small numbers sampled). Among hotel-based sex workers as well, a prevalence of 1.5% HIV was found in Southeast A in the surveillance. 6

8 Behavioral studies show considerable HIV risk exists National Behavioral Surveillance Survey (BSS) and other studies have found that some of the highest behavioral risk in Asia exists in Bangladesh among IDU, FSW and their clients, and MSM. Some of the noteworthy risk behaviors with respect to HIV infection are outlined in the sections that follow. HIV Risk from Injection Drug Use The highest concentrations of drug injectors are found in the Central A and Northwest regions. The majority of IDU surveyed in BSS5 (23-24) borrowed used needles in the previous week, which is a highly efficient means for HIV spread (Figure 4). The exception is Northwest A (21% borrowed needles) where HIV prevention efforts have been very effective. In Central A and Northwest B borrowing had increased since the previous BSS. Figure 4: In some regions the majority of IDU still borrow needles, and they have sexual risk as well % Reported Key Injecting and Sexual Risk Behaviors of Injection Drug Users, Behavioral Surveillance Survey Borrowed needles last week Sex w/fsw last year Condom use w/fsw last time CentralA SoutheastD NorthwestA NorthwestB Consistent condoms w/fsw last year About 3 to 4% of the IDU surveyed bought sex from FSW in the previous year, with only about 1% always using condoms. In Central A while this represented a decrease in commercial sex since the previous BSS, there was also a decrease in condom use at last sex. The danger in the drug situation is that injectors are not always isolated socially; many of them are connected through injecting and sexual behaviors to other at-risk and low-risk populations. Hence, HIV can certainly spread from IDU to other groups. The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk 7

9 HIV Risk from Commercial Sex The results of a recent nationally-representative Male Reproductive Health Survey (MRHS) indicate that on average one in ten men aged 18 to 49 years visited FSW (9.9%) in the last year (ICDDRB, 26). The majority of men in some occupations believed to result in higher risk who were surveyed by BSS4 (22) bought sex from FSW. Around 15% of these men also had anal sex with a male sex worker in the previous month. If these men get infected with HIV, they can transmit it to their wives, who may not themselves have sexually risky behavior, and through them to future children. Lower proportions of male students aged years and living in college/university dormitories visited female sex workers (18%), and a very small percent had sex with a male sex worker. compares the groups surveyed in BSS4, since students were only surveyed that year. In BSS5 (23-24) there was a significant decline to 5% of rickshaw-pullers in Central A visiting FSW and 7% visiting MSW, but the other heterosexual male groups showed no significant changes. Among the MSM who were surveyed by BSS4 at cruising sites, more than 8% had bought sex from male sex workers in the previous month, while about a third had also had commercial sex with women. Figure 5: High proportions of some men buy sex from women, and some from men The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk % Reported Males visiting Female and Male Sex Workers last month, Behavioral surveillance (22) Sex w/fsw last month Sex w/msw last month Males Natl last yr Students CentralA RP CentralA RP SoutheastA TR CentralA MSM CentralA MSM Northeast A 84 8

10 Sex workers negotiate with clients at different venues: in brothels, in hotels, on the streets, and from residences. Regardless of venue or gender, all the sex workers surveyed by the BSS entertain high numbers of clients every week. Hotel-based FSW have the highest client numbers reported anywhere in Asia. Figure 6 shows the behavioral risk indicators for commercial sex workers from the BSS4 (22) and BSS5 (23-24). The average clients per week did decline significantly among FSW working on the streets and in hotels in Central A, and among MSW in Southeast A, but more than doubled among Hijra sex workers. Figure 6A: Female, Male, and Hijra Sex Workers have many clients and less than 1 in 5 used condoms consistently last week % Reported Clients and Condom use of Female and Male Sex Workers, 4rth Behavioral Surveillance Survey (22) Mean clients per week Condom use last sex w/clients Consistent condom use w/clients last week BBSW National SBSW Central A SBSW Southeast A SBSW Southwest A HBSW Central A HBSW Southeast A MSW Central A MSW Southeast A Hijra Central A Figure 6B: Female, Male, and Hijra Sex Workers have many clients and less than 1 in 5 used condoms consistently last week % Reported Clients and Condom use of Female and Male Sex Workers, 5th Behavioral Surveillance Survey (23-24) Mean clients per week Condom use last sex w/clients Consistent condom use w/clients last week BBSW National SBSW Dhaka SBSW Southeast A SBSW Southwest A HBSW Dhaka HBSW Southeast A MSW Central-A MSW Southeast-A Hijra Central A The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk 9

11 Of significant HIV risk is the fact that most commercial sex is unprotected by condoms. Less than 4% of the sex workers surveyed in BSS4 and 5 reported using a condom at last sex. Except for a significant increase in the percent of street-based sex workers in Central A consistently using condoms, there were no particular improvements in condom use by other FSW groups. Condom use by MSW in Southeast A did improve significantly by BSS5, so that greater proportions of MSW surveyed reported using condoms than FSW or Hijras. Still only 15 to 2% of MSW reported always using a condom in the previous week, and the proportion of FSW and Hijras that consistently used condoms was extremely low. In the MRHS, 4% of the men who had sex with FSW in the previous year used condoms (Figure 7), which corroborates the reports from sex workers. About a third of the students surveyed by BSS used condoms for commercial sex encounters with FSW; however, only around 2% of the occupational groups of men surveyed did so, and there was a significant decreasing trend observed from BSS4 to BSS5 in last time condom use. Only around 1% of these men used condoms for anal sex with MSW. Figure 7: Low proportions of males use condoms for commercial sex, and hardly ever consistently The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk % Reported Condom use at last sex with Female and Male Sex Workers, Behavioral surveillance (22) Condom use w/fsw last time Consistent condoms w/fsw last month Condom use w/msw last time 12 5 Consistent condoms w/msw last month Males Natl Students CentralA RP CentralA RP SoutheastA TR CentralA MSM CentralA MSM Northeast A More MSM in Central A used condoms when they had anal sex with MSW than the other groups of men surveyed. In the Northeast the proportion of MSM using condoms for commercial sex was in the same range as the other male groups. 1

12 HIV Risk from Male-to-Male Sex The majority of MSM located at cruising sites in Central A for the BSS4 reported anal sex with non-commercial and commercial male partners in the previous month. In Northeast A almost half the MSM had non-commercial partners, and as in Central A over 8% had visited male sex workers (Figure 8). According to the MRHS at the national level 2% of men had sex with other men in the last year. There are large differences in BSS4 and BSS5 in how many MSM had sex with different types of partners. Since these are the only comparable rounds of survey, it is difficult to know if the values represent real changes or are due to underlying biases. Less MSM in Central A were buying sex from MSW in BSS5, but more were having sex with other types of partners (MSM, and non-commercial and commercial females). The opposite was true among MSM in Northeast A in BSS5 - there were significant declines in sex with all partners, except for an increase in sex with MSW. Figure 8: High proportions of MSM surveyed report anal sex, but it is largely unprotected by condom use % Reported Sexual Risk Behaviors of Men who have Sex with Men, Behavioral Surveillance Survey (22) Sex w/noncomm. male last month Condom use at last sex w/noncomm. male Sex w/msw last month Condom use at last sex w/msw Adults Natl MSM CentralA MSM Northeast A Condom use reported in male-to-male sex was very low considering the high risk of HIV transmission during anal sex. However, there was a significant increasing trend found in BSS5 in last time condom use of MSM with male partners and FSW. As shown in Figures 5 and 7 about a third of the MSM surveyed also bought sex from women with very low condom use. Many were married as well (47%). Therefore, with their multiple partnerships and low condom use, these men can potentially spread HIV infection among the different at-risk groups and to low-risk women. The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk 11

13 Casual Sex Risks Sex with non-commercial, non-marital partners is less commonly reported by men in surveys than commercial sex, as shown in Figure 9. The condom use reported for casual sex was slightly less than for commercial sex. Figure 9: Casual sex is not as common as commercial sex, and men's condom use is about the same for both (Behavioral Surveillance 22, Male Sexual Health Survey) 1 Casual Sex (Non-comm, non-spousal) reported by Males 75 % Reported Casual sex w/female last month Condom use last casual sex w/female Adults Natl Students CentralA RP CentralA RP SoutheastA TR CentralA The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk 12

14 Exploring HIV Spread in the Future One way to look at what the impact of HIV is likely to be in Bangladesh is through the use of computer modeling packages to make projections of the number of HIV infections and AIDS cases to be expected. The A 2 (Analysis and Advocacy) Project in Bangladesh, supported by Family Health International IMPACT and BAP funding, has applied the Asian Epidemic Model (AEM) developed by Tim Brown and Wiwat Peerapatanapokin at East-West Center to assess the likely pattern of HIV spread. The Asian Epidemic Model The AEM is a deterministic process model developed specifically to replicate the dominant patterns of HIV transmission in Asian countries, where the primary driving forces of HIV epidemics are sex work and sharing of needles by injection drug users. As shown in Figure 1, behavioral risk for HIV infection tends to be concentrated in populations such as IDU, FSW and their clients, and MSM (including MSW). They play an important role in fuelling the epidemic, and then HIV is transmitted from them to their lower risk non-commercial female sexual partners, including spouses, and ultimately to their children. The AEM has been used successfully in Thailand and Cambodia to make accurate projections of the course of those HIV epidemics. Figure 1: Behavioral risk for HIV in Asia is concentrated in certain sub-populations FSW Clients MSM Low or no risk males Low or no risk females IDUs Newborns In the model HIV is introduced into the key at-risk populations, and the numbers of infected and uninfected people in each that result from the frequency of unprotected sexual or needle-sharing acts are calculated, using standard epidemiological equations for transmission of HIV, given the prevalence in the different groups. The AEM inputs are entered in an Excel worksheet user interface on a yearly basis starting from 198, and mainly include three types of data on each key population: 1) Population sizes and demographic details, 2) Epidemiological and biological information, including STI prevalence, and 3) Risk behavior indicators such as condom use, needle sharing, etc., and also the duration and frequency of risk behaviors. The AEM is a semi-empirical model. A projection is made of the number of HIV-infections in each at-risk subpopulation based on the data inputs, and the predicted curve is then "fit" to the actual HIV prevalence over time (an input) by adjusting the transmission frequencies and cofactors until the two curves are comparable. Transmission frequencies are in this way set at country (or region-specific) values Factors that increase or decrease HIV infection such as sexually transmitted infections and male circumcision are entered separately as cofactors. The major outputs of the AEM include HIV prevalence, new and cumulative HIV infections, AIDS cases, and deaths. Any of these variables may be extracted for the population as a whole by age, or by at-risk population. The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk 13

15 Applying the Asian Epidemic Model to Bangladesh The main difficulties applying the AEM in Bangladesh are: There are no extensive HIV trends available for the at-risk groups, as there is not a widespread HIV epidemic yet. Hence, the transmission parameters that produce the AEM-projected HIV curves cannot be tuned to fit the local situation. AEM has extensive information needs and many data gaps were found. The data in Bangladesh is mainly from a few sentinel surveillance sites; hence nationally representative indicators on HIV, STI, or risk behaviors of vulnerable groups are not easily derivable. To overcome the problems encountered: A "Scenario-building" approach was taken, i.e., a Baseline Scenario projection was made of what is likely to happen if current risk behaviors stay the same as measured now, with no behavior changes. Transmission parameters were selected based on the scientific literature and experience from other countries. The AEM was applied to Dhaka City only rather than the whole country. This seemed useful because based on the data synthesis the earliest outbreaks of HIV are likely in the capital Dhaka; and from the national size estimates, the highest concentrations of the vulnerable groups live in Dhaka. There is also more behavioral data available from the BSSs and other studies. Sensitivity analyses were done for uncertain inputs, i.e., they were varied across a reasonable range and the impact on projections was determined. The AEM links behavior with the progress of HIV infection. With accurate data inputs it can tell us the past history of an epidemic, and evaluate the long term effects of behavior changes on HIV prevalence. The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk 14

16 The AEM Dhaka Baseline Scenario To generate an AEM projection for the Dhaka City Corporation area, all the available HIV-related data was compiled and synthesized to extract the required inputs. If the observed trend in behavior from surveys was questionable or inconsistent, generally values representing less behavioral risk were used as inputs. What follows is a picture of what is likely to happen if HIV is introduced in Dhaka City, given the risk behaviors outlined below. Figure 11: The epidemic starts with explosive growth of HIV among IDU reaching high prevalence in just a few years 1 8 % HIV among IDU Years About 3 years after HIV is introduced in Year the prevalence among IDU starts to grow explosively as shown in Figure 11, reaching 3% in Year 5, and stabilizing just above 7% about 1 years later. This is completely consistent with trends in HIV infection observed in IDU populations around Asia, and is possible considering that: IDU inject 2.5 times a day on average 76% borrow needles over the week 75% of IDU are in high risk networks (25% 'never shared' in the last week) IDU who borrow needles share 5% of their injections The plateau level is determined by factors such as the levels of needle-sharing, the pattern of the networks, and the turnover in the IDU population. The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk 15

17 Approximately 2 to 3 years after the IDU epidemic is apparent, HIV prevalence increases rapidly in hotel-based female sex workers and reaches 94% before it starts stabilizing at the end of the projection (Figure 12). The rise in infection in hotel-based FSW is followed soon after by a slower but still rapid rise in prevalence among street-based and other female sex workers to about 85 percent. Figure 12: The explosive growth of HIV prevalence in IDU will `seed' the sex work epidemic, because IDU interact with other vulnerable sub-populations % HIV At-risk populations Dhaka Baseline Scenario Years Size (% years adults) IDU Hotel-based Sex Workers Street-based Sex Workers Client Average duration The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk Clients of sex workers Lit. survey, MRHS Female sex workers Natl. Size Estimate Injecting drug users Natl. Size Estimate Men having sex w/men Lit. survey, MRHS Male sex workers Lit. survey 1% of males >25, 15+ in 26.93% of females 3,25 hotel based, street /residence.4% of males 8, 1% of males approx. 25, in 26.4% of males 1 MSW:25 MSM 7 yrs 7 yrs 8 yrs 8 yrs 2 yrs 6 yrs 16

18 After HIV infection spreads to female sex workers. HIV infection grows steadily over the next 1 years among their clients to more than 35 percent.the behaviors that predict this pattern are: 26% IDU visit FSW 27% IDU use condoms with hotel-based FSW, and 9% use condoms with street-based FSW Hotel-based FSW have at least 5 clients per day and work 4 days per week Street-based FSW have at least 2 clients per day and work 5 days per week Only 25% of hotel-based FSW and 36% street-based FSW used condoms with their last client sex 1% of adult males are clients of sex workers Figure 13: HIV prevalence in MSM and MSW grows to very high levels % HIV Years IDU Street-based Sex Workers MSW Hotel-based Sex Workers Client MSM Despite trying to generate a conservative baseline by using BSS4 data inputs, HIV in MSW reaches almost 9% and MSM is at 64% by the end of the projection, and is still growing (Figure 13). However, these values are not unlikely considering that: 1% of MSM and MSW engaged in anal sex last year On average MSM had anal sex once a week, with 39% using condoms with other MSM 88% MSM visited MSW in a year, with 25% using condoms 47% MSM have regular female partners 28% MSM visited FSW in a year, with 16% using condoms MSW have an average of 9 clients per week, and 25% used condoms with clients 1% MSW have regular female partners 6% MSW visited FSW The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk 17

19 Figure 14: HIV prevalence in low-risk women reaches more than 1% about 1 years after the rise in HIV among IDU % HIV Years Adult male (15+) Adult female (15+) Lo-risk men Lo-risk women By the end of the projection HIV among adult females is estimated to reach about 4%. Prevalence among adult males in Dhaka City surpasses 1 percent about 6 years after IDU prevalence rises, and stabilizes at around 6 percent after 2 years (Figure 14). The behavioral patterns of adult populations that lead to this are: 1% of males are clients of sex workers for at least 7 years, with condom use of less than 4% Husbands and wives have sex on average once a week, with 4% condom use 8% males and 3% females have casual sex, on average 5 times a year, with 11% condom use 9% males are circumcised The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk Transmission probabilities Male-to-Female transmission.2 Male-to-Male transmission.5 Ratio of Male-to-Female over Female-to-Male transmission 3. Transmission per needlestick for IDU.4 Cofactors STD cofactors of 2 for men, 1 for women Circumcision factor 3. 18

20 Figure 15 shows how the contribution of the different populations to new infections changes over time. While IDU are critically important in the first five years of the epidemic, by the eighth year clients of FSW dominate. By the tenth year a growing number of new infections start to occur in low-risk women who are the wives of these clients. Figure 15: New infections show various populations influence the epidemic over time 3 New infections in thousands Years IDU Client FSW Lo-risk women MSM MSW Lo-risk men The sizes of the IDU and MSM populations are limited; therefore, the real potential for a substantial HIV epidemic lies in heterosexual populations as shown in Figure 16. According to the national size estimates,.9 percent of women in Dhaka are sex workers, and 1 percent of men are clients of these women (Table 1). Most of these clients are married, or will be in the future, creating significant HIV risk for their wives, which leads to increasing proportions of infected low-risk women as the epidemic progresses (Figure 16). Figure 16: Proportion of new infections shows the relative influence of different populations as the epidemic progresses clearly New infections in thousands 5, 45, 4, 35, 3, 25, 2, 15, 1, 5, Years Client IDU MSW MSM FSW Lo-risk men Lo-risk women The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk 19

21 Figure 17: Five years after the IDU epidemic is apparent, there will be about 5, cumulative HIV infections, and 2, new infections Infections in thousands Year New HIV Cumulative HIV Current HIV About five years after the increase in IDU infections becomes evident, there will be about 5, infections overall in Dhaka City, of which about 2, will be new infections (Figure 17). By the end of the projection there will be an estimated 4, cumulative HIV infections in Dhaka City, which would constitute a huge social and economic burden for Bangladesh. After varying key behavioral risk indicators, the qualitative finding that Dhaka faces a significant HIV epidemic is supported - the epidemic starts 2 years earlier or later and varies from 3 to 1% HIV in adult males. The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk Sensitivity analyses The following inputs were validated by varying across indicated ranges, with the final Dhaka Baseline Scenario inputs in parentheses: Transmission parameters Male STD cofactors: 1, 2 (baseline), 3 Impact of circumcision: 2., 3. (baseline), 4. Impact of fraction circumcised:, 5%, 9% (baseline) Client percentages: 5%, 1% (baseline), 15% Duration of male same-sex behavior: 1, 2 years (baseline), 25 years Higher and lower STI levels HBSW: 15%, 3% (baseline), 6% Impact of IDU sharing networks: 5%, 6%, 75% (baseline), 8%, 9% Fraction of injections shared by those IDU who share: 33%, 5% (baseline), 62%, 75%, 8% 2

22 Key messages for prevention programs from the AEM Dhaka Baseline Scenario AEM policy relevant analyses can be done whereby the effects of changes in transmission modes or behaviors on HIV infection are examined in "Intervention Scenarios" as described below. Impact of IDU Interventions If harm reduction interventions effectively delay the start of the IDU epidemic by 5 years as shown in Figure 18, then adult male prevalence rising to 1% is also delayed until 3 years later (Figure 19). Figure 18: Promoting injection risk reduction can delay or stop the growth of HIV among IDUs 1 8 % HIV among IDU Years IDU Dhaka Baseline Delay IDU 5yrs No IDU epi Figure 19: Delaying the IDU epidemic will slow but will NOT avert the sex work epidemic % HIV among Adult Males Years Males Dhaka Baseline Males Delay IDU 5yrs Males No IDU epi If the IDU epidemic is averted entirely, it will still not stop the HIV increase in adults because of the current level of commercial sex and low condom use, but it will take longer for the adult male epidemic to reach 1% (Figures 18 and 19), and the overall epidemic grows more gradually. The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk 21

23 Impact of Sex Work Interventions Targetted interventions that increase condom use between FSW and clients can greatly reduce the number of adult infections. Increasing condom use to 5% can reduce HIV among adult males to less than half the Dhaka Baseline prevalence (2 percent); but only if condom use reaches 8%, within a relatively short time period, can HIV prevalence be kept below 1% (Figure 2). Figure 2: Raising condom use by sex workers and clients can control the spread of HIV - the impact is more when combined with a reduction in clients 6 % HIV among Adult Males Years Baseline HBSW25,SBSW36 Year1+ HBSW5,SBSW75 Year6+ FSW5 Year6+,FSW8 Year8+ FSW5 Year6+ FSW5 Year6+, Clients half Year8+ FSW5-8 Year8+, Clients half The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk As also shown in Figure 2, there is an additional benefit if increased FSW condom use is combined with a reduction in the number of male clients of FSW. If condom use is raised to 5% and the proportion of all men who visit FSW (clients, IDU, MSM) are also reduced by half, adult male HIV prevalence remains below 1 percent. Increased condom use with client reduction has a dramatic impact on HIV among FSW. If 8% of FSW use condoms along with an overall reduction in the number of clients, HIV prevalence only reaches 5% (data not shown). 22

24 Impact of MSM Interventions Interventions for MSM that stress the risk of unprotected anal sex and communicate the benefits of partner reduction can have a large impact on HIV infections among them. Increasing condom use to 5% with other MSM and for commercial sex resulted in HIV prevalence among MSM (38%, Figure 21) that was roughly two-thirds the Baseline value. Decreasing the proportion of MSM with multiple partners over a five-year period at the same time could lower prevalence to less than 1%. Figure 21: HIV among MSM can be lowered by increasing condom use and greatly reducing commercial sex 1 % HIV among Female Sex Workers Years BL MSM Con5 28+ Con5 28+, red MSM w/commsex & MSWCli Con5 28+, red MSM w/comm sex & ptnrs & MSWCli Con Con5_8 21+, red MSM w/comm sex & ptnrs & MSWCli What is A 2? The A 2 (Analysis and Advocacy) Project is a joint regional project of Family Health International (Bangladesh Country Office and the Asia Regional Program Office), East-West Center, and USAID/Health Policy Initiative Task Order 1 (Constella Futures). A 2 came out of the realization that although countries in Asia have collected a wealth of data on HIV and AIDS over the years, critical analysis of this data has been lacking. As a result, responses in the region are directed in an ad hoc fashion without a clear understanding of where new infections are occurring, the effectiveness and targeting specificity of current prevention and care approaches, or the long term impact of different prevention and care program alternatives. The aim of A 2 is to bridge this gap between knowledge and action and to improve responses by building national capacity to pool existing local epidemiological, behavioral and response data, analyze it with state-of-the-art modeling tools, and determine where responses should be targeted to have the maximal impact and what resources are needed to make a difference. Locally relevant, targeted messages are then produced to move policy makers, program managers, and donors to make the right choices. A 2 is currently underway in 4 Asian countries: Bangladesh, China (Yunnan and Guangxi Provinces), Thailand, and Vietnam. Bangladesh was one of the first countries to initiate A 2 (October 23), and this report describes the outcomes of the first phase. The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk 23

25 Lessons from the AEM Dhaka Baseline Scenario Given the high risk behavior in Dhaka, a large HIV epidemic is expected unless prevention is strengthened. HIV spread will remain focused not "generalized", hence interventions must focus on and prioritize higher risk populations. Delaying the IDU epidemic provides time to get sex work interventions scaled up. Once HIV spread starts it will be rapid given the risk behaviors, therefore programs must be scaled up now, not later Figure 22: The AEM Dhaka Baseline Scenario % HIV Years IDU Hotel-based Sex Workers Street-based Sex Workers Client MSW MSM Adult male (15+) Adult female (15+) Future Steps The Asian Epidemic Model for Dhaka City 26: The Consequences of Current Risk To stave off an HIV epidemic in Bangladesh, the priorities should be to increase the extent of coverage of at-risk groups by quality prevention programs that: Prevent the IDU epidemic in Dhaka from spreading through expanded harm reduction and demand reduction facilities. Stop the Sex Work epidemics from developing by increasing condom use in commercial sex. Stop the MSM epidemic from developing by increasing condom use in anal sex. Make men aware of the benefits of reducing sexual partners. The latest version of AEM is linked with the Futures Group GOALS model which projects HIV intervention expenses based on coverage and cost input data. The next phase of the A 2 Project will be to apply the AEM- GOALS linked model in Bangladesh, which will enable a comprehensive analysis extending from HIV projections to the likely levels of behavior change and cost impacts. The overall modeling results will provide policy makers with a basis on which to develop cost-effective HIV/AIDS interventions, and care and treatment plans. Various data gaps were identified in the process of building the AEM model that should be filled in by further research. In particular there is an urgent need to supplement current HSS and BSS indicators with results from new population studies and more rounds of surveillance. There is a need for better STI surveillance, and STI measures in groups such as FSW, MSM/MSW and the general population. 24

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