The Bangladesh Focus on Data and Targeted Interventions. 20 years of HIV in Bangladesh Experiences and Way Forward

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1 The Bangladesh Focus on Data and Targeted Interventions 20 years of HIV in Bangladesh Experiences and Way Forward South Asia Regional Knowledge Forum New Delhi, India March 15, 2010

2 SOURCES OF INFORMATION SURVEILLANCE DATA RESEARCH DATA OTHER SURVEY DATA MOST AT RISK POPULATIONS GENERAL POPULATION OVERALL SCENARIO SERVICES IDUs FEMALE SEX WORKERS MSM INCLUDING MALE SEX WORKERS HIJRAS OTHER GROUPS MIGRANTS INDIGENOUS POPULATIONS

3 HIV TARGETTED INTERVENTIONS IN BANGLADESH LANDMARK EVENTS /96/ st PLHIV FSW in Tangail Street FSW in Dhaka IDU in Dhaka MSM in Dhaka HIV sero & behavioural surveillance started Scaling up in all groups except MSM thru HAPP BAP initiated with MSM, Hijra Scaling up in all groups except MSM thru GF Rnd 6 MSM added in HAPP HATI replac ed HAPP Surve illance not done HATI interrupt ed HATI restarted in FSW and clients Surveillance reviewed Further scaling up in all groups thru GF RCC of Rnd 2 expected?hati?surveill ance

4 WHERE HAS HIV BEEN FOUND IN BANGLADESH? INJECTING DRUG USERS (IDUs) - mainly in Dhaka FEMALE SEX WORKERS starting to emerge in border towns INTERNATIONAL RETURNEE MIGRANT WORKERS service data

5 HIV PREVALENCE IN DRUG USERS 6508 drug users sampled from 28 areas HIV found in six cities only HIV is localized in one area of Dhaka where it is rising gradually % IDU-Dhaka IDU-Chandpur IDU-Ishwardi Combined male-khulna IDU-Narayanganj IDU-Teknaf Heroin smokers-dhaka Combined female-dhaka, N.ganj and Tongi Dhaka (Male) Dhaka A1 Dhaka A2 Source: HIV surveillance, Round VIII,2007 (unpublished)

6 Female sex workers National estimate of FSW: 90,000 Brothel: Hotel and residence ,000 Street : ,000 Areas for sampling FSW PANCHAGAR Prevalence of HIV among FSW THAKURGAON NILPHAMARI KURIGRAM RANGPUR DINAJPUR GAIBANDHA JAIPURHAT SHERPUR NAOGAON CHAPAI NAWABGANG BOGRA Asam SUNAMGANJ SYLHET NETROKONA MYMENSINGH RAJSHAHI MOULVIBAZAR NATOR SIRAJGANJ KISHOREGANJ HABIGANJ TANGAIL GAZIPUR PABNA KUSHTIA DHAKA NARSINGDI MEHERPUR RAJBARI MANIKGANJ NARAYANGANJ Tripura CHUADANGA JHENAIDAH MAGURA FARIDPUR MUNSHIGANG COMILLA CHANDPU SHARIYATPUR JESSORE NARAIL R GOPALGANJ FENI BARISAL LAKSMIPUR RANGAMATI KHULNA NOAKHALI JHALAKATI PIROJPUR BAGERHAT BHOLA PATUAKHALI BORGUNA Bay of Bengal BANDARBAN Source: HIV surveillance, Round VIII,2007 (unpublished)

7 Cross border mobility of casual female sex workers from border areas Variables Crossed the border to India or Myanmar, % Sold sex while in the neighbouring country, % Teknaf N=246 Hili N=150 Burimari N= Source: HIV surveillance, Round VIII,2007 (unpublished)

8 Migration and HIV Data from People Living with HIV in Bangladesh (N=740) Heterosexual transmission = 76.3%

9 HOW HAS BANGLADESH CONTINUED TO REMAIN AT LOW PREVALENCE? 1. Interventions started early 2. Circumcision

10 Foss et al, Addiction UNAIDS Best Practice documents: 1. Street FSW in Dhaka 2. Brothel FSW in Tangail 3. MSM

11 HCV prevalence and incidence in male IDU from Dhaka Round II Round III Round V Round VII Round VIII Source: HIV surveillance, Round VIII,2007 (unpublished) Source: Azim et al, IDU cohort study unpublished)

12 Active syphilis in female sex workers over the rounds of surveillance % Source: HIV surveillance, Round VIII, 2007 (unpublished) Round I Round II Round III Round IV Round V Round VI Round VII Round VIII Street, Dhaka Street, Ctg Street, Khulna Hotel, Dhaka Hotel, Ctg Hotel, Sylhet Casual, Chandpur Casual Teknaf Casual, Hili Casual, Burimari Casual, Barisal Street, Dhaka: p<0.001, Casual, Barisal p=0.049; Casual,Teknaf p=0.037 Involvement with an HIV NGO programme had a protective effect Chittagong street sex workers and hotels in Dhaka

13 WHAT ARE THE SOURCES OF RISK? Continued high risk behaviours Structural factors that prevent adoption of safe behaviours Not taking into consideration diversity of MARPs Interruption of service delivery and essential supplies such as condoms

14 Lending/borrowing needles/syringes in the last week: BSS % Source: BSS

15 Risk behaviours, STI and active syphilis % Brothels Dhaka street Ctg street Khulna street Dhaka hotel Ctg hotel Sylhet hotel >20 clients/week consistent ocndom use with new clients consistent ocndom use with regular clients STI symptoms in last yr Active syphilis Source: BSS and HIV surveillance, Round VIII,2007 (unpublished)

16 WHAT ARE THE SOURCES OF RISK? Continued high risk behaviours Structural factors that prevent adoption of safe behaviours Not taking into consideration diversity of MARPs Interruption of service delivery and essential supplies such as condoms

17 IDUs: ADDAS IN RAJSHAHI AND CHAPAINAWABGANJ Injectors often gathered in groups in one house within a locality and such a gathering was called an adda NSP in these cities had been organised such that needles/syringes were provided to adda owners and they would then give those to the injectors when they came for their drugs During BSS of , drives by law enforcement agencies to destroy these addas were ongoing. An adda owner said that the owners were being targeted by the police and one owner had already been arrested Because of this the addas had become irregular, IDUs were scattered and outreach workers were having difficulty in locating the IDUs Source: BSS

18 Power structure: Sex trade setting SOURCE: ICDDR,B, NASP, SAVE THE CHILDREN, USA, UNDER GFATM ROUND 6

19 INSIGHTS FROM QUALITATIVE STUDIES INTO BARRIERS TO CONDOM USE In hotels, a client s transaction takes place with the hotel management and not directly with the sex worker. The client pays a fixed amount for a single sex act which is handed over to the hotel boy before entering the room where he is allowed 10 to 15 minutes with the sex worker. If the agreed time is exceeded, the hotel boy knocks on the door to ensure that the client does not enter into a direct negotiation with the sex worker for multiple sex acts. In such situations, the sex workers may also be harassed by the hotel management. Therefore, as condoms delay ejaculation, sex workers sometimes discourage clients from using condoms. SOURCE: ICDDR,B, NASP, SAVE THE CHILDREN, USA, UNDER GFATM ROUND 6

20 WHAT ARE THE SOURCES OF RISK? Continued high risk behaviours Structural factors that prevent adoption of safe behaviours Not taking into consideration diversity of MARPs Interruption of service delivery and essential supplies such as condoms

21 Various patterns of Residence FSW Issues Permanent Semi-permanent Temporary Period of stay in residence Status of the RFSW Extent of exploitation Decision making capacity Stays in a residence for longer period (months to years) Usually owned by the power structure More exploited and are often victims of violence Most have little decision making power Stays in a residence for a shorter (days/weeks) Not owned but dependent on the power structure Less exploited Have more decision making power Stays in a residence for a brief time of the day Neither owned nor dependent Less exploited Have more decision making power Mobility Limited Mobile Highly mobile Challenges in Reachable if residence reaching is accessed Reachable if the residence is accessed but adherence is difficult due to mobility Very difficult to reach due to high mobility SOURCE: ICDDR,B, NASP, SAVE THE CHILDREN, USA, UNDER GFATM ROUND 6

22 WHAT ARE THE SOURCES OF RISK? Continued high risk behaviours Structural factors that prevent adoption of safe behaviours Not taking into consideration diversity of MARPs Interruption of service delivery and essential supplies such as condoms

23 Participated in any NGO intervention programme in the last year Female sex workers MSM, male sex workers and Hijra % * * % * * * 58.2 * * 20.4 * * p<0.05 for trend

24 RECOMMENDATIONS ON THE WAY FORWARD a. GENERAL RECOMMENDATIONS b. SPECIFIC RECOMMENDATIONS 1. Continuing and scaling up HIV prevention programmes 2. Understanding the local context 3. Enhancing capacity at all levels 4. Advocacy at all levels 5. Regular evaluation of ongoing programmes 6. Collection of strategic information through surveillance, surveys, research and developing a national database

25 ACKNOWLEDGEMENT ICDDR,B TEAM: Tasnim Azim Sharful Islam Khan Quamrun Nahar Masud Reza Najmul Alam Rumana Saifi M. Shah Alam Ezazul Islam Chowdhury Elizabeth Oliveras OTHERS: M. Omar Rahman, IUB Shah Ehsan Habib, DU Mohammed Enamul Hoque WORLD BANK AND UNAIDS