Sri Lanka
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Sri Lanka continues to have very low HIV prevalence. In low prevalence settings, the focus of HIV prevention programs should be the most-at-risk populations (MARPs). Data on HIV prevalence amongst MARPs in Sri Lanka is limited, with the exception of female sex workers. Prevalence amongst the latter is also low. However, data collected in the first Behavioral Surveillance Survey (BSS) of October 2006 through March 2007, indicate relatively high levels of risk behavior amongst MARPs. If these groups are not adequately addressed, Sri Lanka will be vulnerable to an increase in HIV infections. Sri Lanka has a narrowing window of opportunity to forestall the spread of HIV among high-risk groups.
State of the Epidemic
UNAIDS estimates that about 3,800 Sri Lankans were living with HIV at the end of 2007, yielding prevalence of less than 0.1 percent. As of December 2007, 957 reported cases of HIV in the country (an increase of 71 cases reported since June 2007) out of which 177 have died. Sixty percent of reported HIV cases are males, and more than half are from Colombo. Under reporting of cases is mainly due to low knowledge about how HIV is spread, and barriers to seeking services due to stigma and discrimination. Most transmission is sexual, four percent is perinatal transmission, and only one percent through blood transfusion. Only one case of HIV acquisition through injecting drug use has been reported. The ratio of HIV-positive men to women in Sri Lanka is 1.4 to 1. The proportion of women infected with HIV has been rising, from 21 percent (1987-1991) to 42 percent (2007), in part because of increased testing of women over the last few years.
Risk Factors and Vulnerability
Despite the low HIV prevalence, the presence of important risk factors in Sri Lanka suggests it may not be maintained if action is not taken. The key risk factors are:
Low Condom Use: The recent BSS noted condom use among most-at-risk groups is generally low (except amongst some subgroups of female sex workers when engaging in commercial sex). Men who have sex with men also have low condom use, as do drug users (although very few inject drugs).
Commercial Sex: Estimates of the number of female sex workers in Sri Lanka vary from 5,000 to 50,000 although the more likely number is around 30,000. In addition, there are networks of men who have sex with men who have multiple partners including paying clients and women. Preliminary findings from the 2006 BSS suggest that STIs and HIV among female sex workers are relatively low, as they see few clients per day and have relatively high condom use. However, while reported symptoms of STIs were low, only about one-third knew women could be asymptomatic. And, knowledge about how HIV is transmitted was low. Women and children engaged in sex work are considered most vulnerable to HIV infection because they often lack the ability or power to negotiate condom use with clients or to seek STI treatment. They are often "hidden," making it a challenge for HIV prevention services to reach them.
Sexually Transmitted Infections: Every year estimates of detected STI cases in Sri Lanka vary from about 60,000 to 200,000, of which only 10 to 15 percent are reported by government clinics. STIs facilitate the spread of HIV infection and serve as indicators for low condom use and other high-risk sexual behaviors.
High Mobility: Migration within Sri Lanka and emigration to the Middle East and neighboring countries is necessary for the economic survival of many rural and urban households.Thousands of women and men live away from their families as migrants abroad and as workers in Sri Lankan Free Trade Zones. An estimated 1.2 million Sri Lankans work in the Middle East and 79 percent of unskilled migrants are women. Removal from traditional social structures is believed to foster unsafe sexual practices, such as having multiple sexual partners and engaging in casual and commercial sex, as well as to increase vulnerability of women and girls to sexual abuse. Very few, however, have tested positive.
Injecting Drug Users (IDUs): Current estimates of opiate users range from 30,000 to 240,000 out of which only 2 percent inject. However, an increase in drug injection could spark an epidemic. The BSS found that both knowledge about HIV transmission and that condom use were low among drug users. In addition, drug users often experience difficulty accessing information and services for both HIV prevention and treatment.
Low Levels of Knowledge about how HIV is Transmitted: Knowledge about HIV transmission was low amongst the populations surveyed in the BSS. This increases the potential for HIV to spread as the groups surveyed are the populations engaging in riskier behavior.
High Levels of Stigma associated with PLWA: The survey also indicated high levels of stigma towards PLWA amongst all groups. Stigma and discrimination discourage PLWA and others who fear they may be infected from seeking health care or from being tested. Moreover, they result in poor quality of care by health care workers.
National Response to HIV and AIDS
Government: In 1992, the Government of Sri Lanka initiated HIV prevention and control efforts through the National STD and AIDS Control Program (NSACP) of the Ministry of Health under the Director General of Health Services. In addition, the National Blood Transfusion Services (NBTS) and the National Programme for Tuberculosis and Chest Diseases (NPTCCD) strengthened their responses to reduce transmission and prevent further spread of HIV. These services are provided in collaboration with eight Provincial Directors of Health Services and the respective District staff. The NSACP in collaboration with the Provinces undertook HIV prevention activities (e.g. a mass media communications strategy to improve knowledge and awareness of HIV) and provides care and treatment to people living with HIV. In addition, Sri Lanka has a well established sero surveillance system and second generation surveillance (behavioral) among vulnerable groups was conducted in 2006. A Management Information System is being established linking all STI clinics in the country to the central NSACP based on a M&E Framework for HIV.
The NSACP improved STI services by refurbishing STI clinics, providing equipment, and facilitating HIV prevention work conducted through contracted NGOs and through the Government Provincial and District Health authorities to reach vulnerable groups. The NSACP also engaged 12 line Ministries including National Institute of Education, Ministry of Labour, Foreign Employment Bureau, Vocational Training Authority, Ministry of Fisheries, National Child Protection Authority, National Youth Services Council, Army, Navy, Air Force and the Police. This work includes advocacy, improving HIV prevention awareness and knowledge of facilities available, encouraging condom use amongst the armed services and introducing VCT services.
The program has helped to ensure blood safety by increasing the voluntary blood donation rates, upgrading blood banks, and increasing transfusion screening for HIV. In addition, the NBTS has initiated a Communication Program through mass media to increase voluntary blood donation and raise the level of awareness and knowledge of HIV/AIDS among the general population.
In addition to these primary prevention efforts initiated by the NSACP through the National HIV Prevention Project, the NSACP established Care and Treatment resources needed to make antiretroviral therapy (ART) available to the HIV positive patients who need treatment. As of April 2008, the NSACP Central STD Clinic followed up 423 patients (just over half of those currently infected), of whom 113 receive ART.
Non-governmental Organizations (NGOs): Work of both local and international NGOs in the area of HIV prevention in Sri Lanka has been limited. NGO work remains largely uncoordinated, and its program coverage of high-risk populations is estimated to be less than 10 percent. Efforts are being undertaken to improve NGO collaboration and coordination with the government. Key actions needed are to increase the capacities of NGOs to work with vulnerable groups and of the government to systematically contract and fund NGOs.
Issues and Challenges: Priority Areas
Increase efforts to reach MARPs. Sri Lanka continues to have very low HIV prevalence. In a low prevalence context like Sri Lanka, programs must focus a large share of their efforts on prevention activities for the most at risk populations, if an epidemic is to be averted. Most efforts to date have focused on the general population amongst whom transmission is low. Prevalence data on MARPs is also limited, but data collected through the BSS indicate these groups do engage in risky behavior and thus need to be reached. Coverage of key populations (female sex workers, men who have sex with men) with targeted prevention programs need to be prioritized.
Stigma and discrimination must be reduced. Stigmatization and discrimination discourage demand for counseling, testing and treatment. Reducing the stigma associated with HIV and AIDS in Sri Lanka will require greater involvement of civil society organizations, businesses, the entertainment industry, religious leaders, and the medical community. As respected opinion leaders, they can play an effective role in reducing harassment of groups promoting positive attitudes towards people with HIV and AIDS and creating an enabling environment for prevention efforts. Training police to reduce harassment of vulnerable groups and engage HIV-positive groups are central to these efforts.
The Health Ministry cannot do it alone. Most at risk groups are not likely to seek MOH services, therefore the Ministry needs to partner with NGOs, some line ministries such as armed forces and prisons department, private sector and civil society organizations, such as trade unions to reach the at risk populations. Although these organizations and institutions are better placed to mobilize and provide services to at-risk groups, their capacity needs strengthening.
Shift focus from inputs to outcomes. Monitoring and evaluation, including surveillance systems, need to be improved, particularly in collecting data, using data for policy and program management decisions, and disseminating it. Strengthened surveillance will be vital to detect potential changes in HIV prevalence and risk practices. Reliable data on coverage and the impact of interventions on behavioral and biological outcomes is critical for mounting an effective nationwide response.
World Bank Response
From 1998 to 2002, the World Bank provided about US$1 million of support each year to Sri Lanka’s HIV/STD program through the Health Services Project, adding to the financial and technical assistance being provided by other multilateral and bilateral agencies, such as WHO and other UN agencies and the Japan Bank for International Cooperation.
The Government of Sri Lanka requested the World Bank to support strengthening the national program to control HIV/AIDS and STIs and in December 2002, the Bank’s International Development Association (IDA) provided a $12.6 million grant to help finance the National HIV/AIDS Prevention Project. The Bank’s support focused on improving prevention efforts for highly vulnerable subpopulations and the general population; enhancing surveillance and monitoring and evaluation systems; reducing stigma and discrimination against people living with HIV and groups at highest risk; and addressing the synergy between tuberculosis and HIV. The Project closed in June 2008.
Last updated: 2008-07-29
Thursday, October 16, 2008
HIV/AIDS IN SAARC COUNTRIES....
Pakistan
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Pakistan still has a window of opportunity to act decisively to prevent the spread of HIV. Although the estimated HIV burden is still low—around 0.1 percent of the adult population – the country is facing a concentrated epidemic among injecting drug users with HIV prevalence above 5 percent among IDUs in three of the four provinces. Given linkages between IDUs and other high risk populations including male and female sex workers, Pakistan needs to scale up targeted intervention urgently to prevent rapid increase in HIV among vulnerable groups.
State of the Epidemic
According to UNAIDS estimates, about 96,000 people were living with HIV in Pakistan at the end of 2007. Officially reported cases are, however, much lower. As in many countries, underreporting is due mainly to the social stigma attached to HIV, limited surveillance and voluntary counseling and testing systems, and the lack of knowledge among the general population and health practitioners.
Although overall HIV prevalence is low in Pakistan, there is growing evidence of local concentrated epidemics among IDUs in major cities across the country. The combination of high levels of risk behavior and limited knowledge about HIV among injecting drug users and sex workers could lead to the rapid spread of HIV.
Risk Factors
There are serious risk factors that put Pakistan in danger of facing a rapid spread of HIV if immediate and vigorous action is not taken:
Concentrated Epidemic among Injecting Drug Users: The number of drug dependent people in Pakistan is estimated to be about 500,000, of whom an estimated 100,000 inject drugs. In 2006, HIV prevalence rates among IDUs ranged between 10 to 50 percent across Quetta, Faisalabad, Hyderabad, Karachi and Sargodha. The majority of these IDUs were either married or sexually active. The common risk factor for the majority of infected drug users was that they used non-sterile injecting equipment and awareness of HIV transmission routes was relatively low. Safe injection practices are more prevalent in cities such as Lahore and Peshawar where targeted interventions have been in place over a longer period.
HIV among Male Sex Workers and Transgenders: Surveillance data for 2006 point to a local concentrated epidemic among MSWs and Hijras in Larkana and Karachi in the Sindh province while prevalence elsewhere is still below 5 percent. Behavioral surveillance data for 2006 indicates very low levels of condom use among MSWs and transgenders across all cities surveyed. One in four of the male sex workers said they also bought or sold sex to women. Such high-risk behavior must be addressed in order to limit the further spread of HIV in and beyond those sexual networks.
Unsafe Practices among Female Sex Workers: Commercial sex is prevalent in major cities and on truck routes. Behavioral and mapping studies in three large cities found a sex worker population of 100,000 with limited understanding of safe sexual practices. Condom use is still low during commercial sex encounters although consistent condom use is more prevalent in Karachi and Lahore where targeted interventions were initiated in 2004. Furthermore, sex workers often lack the power to negotiate safe sex or seek treatment for STIs. High levels of sexually transmitted infections indicate widespread sexual risk-taking.
Inadequate Blood Transfusion Screening and High Level of Professional Donors: It is estimated that 40 percent of the 1.5 million annual blood transfusions in Pakistan are not screened for HIV. About 20 percent of the blood transfused comes from professional donors.
Large Numbers of Migrants and Refugees: Large numbers of workers leave their villages to seek work in larger cities, in the armed forces, or on industrial sites. A significant number (around four million) are employed overseas. Away from their homes for extended periods of time, they may be at increased risk for exposure to HIV.
Unsafe Medical Injection Practices: Pakistan has a high rate of medical injections - around 4.5 per capita per year. Studies indicate that 94 percent of injections are administered with used injection equipment. Use of unsterilized needles at medical facilities is also widespread. According to WHO estimates, unsafe injections account for 62 percent of Hepatitis B, 84 percent of Hepatitis C, and 3 percent of new HIV cases.
Low Levels of Literacy and Education: Efforts to increase awareness about HIV among the general population are hampered by low literacy levels and cultural influences. In 2006 female literacy was estimated at 42 percent.
Vulnerability Due to Social and Economic Disadvantages: Restrictions on women's and girls’ mobility limits access to information and preventive and support services. Young people are vulnerable to influence by peers, unemployment frustrations, and the availability of drugs. In addition, some groups of young men are especially vulnerable due to the sexual services they provide, notably in the transport sector. Both men and women from impoverished households may be forced into the sex industry for income.
National Response to HIV/AIDS
Government: Pakistan’s Federal Ministry of Health initiated a National AIDS Prevention and Control Program (NACP) in 1987. In its early stages, the program was focused on diagnosis of cases that came to hospitals, but progressively began to shift toward a community focus. Its objectives are the prevention of HIV transmission, safe blood transfusions, reduction of STI transmission, establishment of surveillance, training of health staff, research and behavioral studies, and development of program management. The NACP has been included as part of the government's general health program, with support from various external donors.
As the government has indicated, more needs to be done. For example, focus on reducing the exposure of high-risk groups is urgently required as is increasing the service coverage of key populations (injecting drug users, female sex workers, men who have sex with men, and prison inmates). Other priority areas that require attention include improving access to quality treatment and care, strengthening the monitoring and evaluation system, continued advocacy with policy makers and other influential groups and effective coordination with key agencies including police, jail authorities, and the Ministry of Law and of Narcotics Control. In early 2001, the Government of Pakistan, through a broad consultative process, developed a national HIV/AIDS Strategic Framework that set out the strategies and priorities for effective control of the epidemic. The government has finalized costed action plans for the next phase of the federal and provincial Programs covering the period from 2009-2013.
A draft national AIDS policy and HIV and AIDS Law (both recommending the formation of a National AIDS Council) have been prepared by the National AIDS Control Programme and will be presented to the national cabinet and parliament. Approval of the policy and law would be an important step towards the multisectoral dimension of the national response.
Non-Governmental Organizations (NGOs): At least 54 NGOs are involved in HIV/AIDS public awareness and in the care and support of persons living with HIV/AIDS. These NGOs also work on education and prevention interventions targeting sex workers, truck drivers, and other high-risk groups. NGOs serve as members of the Provincial HIV/AIDS Consortium, which has been set up in all four of Pakistan’s provinces to coordinate HIV/AIDS prevention and control activities. Although NGOs are active in HIV/AIDS prevention activities, it is believed that they are reaching less than fifteen percent of the vulnerable population.
Donors: There is a Theme Group and a Technical Working Group on HIV/AIDS to coordinate the response of United Nations Agencies and to provide assistance to the government in the strategic development of activities. The theme group includes UNAIDS, WHO, UNICEF, UNFPA, UNDP, UNDCP, UNESCO, ILO, the World Bank, national and provincial program managers, and representatives of nongovernmental organizations.
Issues and Challenges: Priority Areas
Vulnerable and High-risk Groups
Expand knowledge, access, and coverage of vulnerable populations—particularly in large cities—to a package of high impact services, through combined efforts of the government and NGOs.
Implement harm-reduction initiatives for IDUs and safe sex practices for sex workers.
Make effective and affordable STD services available for high-risk groups and the general population.
General Awareness and Behavioral Change
Undertake behavioral change communications with the following behavioral objectives: (i) use of condoms with non-regular sexual partners; (ii) use of STI treatment services when symptoms are present and knowledge of the link between STIs and HIV; (iii) use of sterile syringes for all injections; (iv) reduction in the number of injections received; (v) voluntary blood donation (particularly among the age group 18 to 30); (vi) use of blood for transfusion only if it has been screened for HIV; and (vii) display of tolerant and caring behaviors towards people living with HIV and members of vulnerable populations.
Increase interventions among youth, police, soldiers, and migrant laborers.
Blood and Blood Product Safety
· Ensure mandatory screening of blood and blood products in the public and private sectors for all major blood-borne infections.
Conduct education campaigns to promote voluntary blood donation.
Develop Quality Assurance Systems for public and private blood banks to ensure that all blood is properly screened for HIV and Hepatitis B.
Surveillance and Research
Strengthen and expand the surveillance and monitoring system.
Implement a second-generation HIV surveillance that tracks sero-prevalence and changes in HIV-related behaviors, including the spread of STIs and HIV, sexual attitudes and behaviors, and healthcare-seeking behaviors related to STIs.
Building Management Capacity
Continue to build management capacity within provincial programs and local NGOs to ensure evidence-based program implementation.
Identify gaps in existing programs and continue phased expansion of interventions.
World Bank Response
The World Bank is the largest financer of HIV/AIDS programs in Pakistan. It assisted the government’s HIV/AIDS efforts through funding the second Social Action Program (1998-2003). In addition, the World Bank is working with the government and other development partners (CIDA, DFID, USAID, UN agencies) to support the government’s program through the HIV/AIDS Prevention Project. The Bank is providing US$37.1 million, 75 percent of which is a no-interest credit and 25 percent of which is grant money. The project is supporting HIV prevention services to most at risk groups, mass media campaigns aimed at raising awareness and reducing stigma, promoting safe blood transfusion and building management and institutional capacity.
The implementation of targeted intervention has made encouraging progress with expanding coverage of an injecting drug users program in Punjab; implementation of service delivery packages for male and female sex workers in Sindh, Punjab and NWFP; jail inmates in Sindh and truckers nationwide. The data from three rounds of surveillance indicate that HIV prevention services are making a difference as reflected in a reduction in risk behaviors most notably among injecting drug users. At the same time the current coverage of these interventions is limited covering barely 15-20 percent of the most at risk groups of injecting drug users and sex workers. The most important issue relates to mobilizing resources and capacity for scaling up services to the high risk populations. Significant challenges also relate to building capacity of the federal and provincial programs and of the implementing NGOs.
The Bank is committed to supporting the Government’s Program over the next phase focusing particularly on increasing service coverage of most at risk groups in all major urban centers, improving access and quality of treatment and care and strengthening the monitoring and evaluation system.
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Pakistan still has a window of opportunity to act decisively to prevent the spread of HIV. Although the estimated HIV burden is still low—around 0.1 percent of the adult population – the country is facing a concentrated epidemic among injecting drug users with HIV prevalence above 5 percent among IDUs in three of the four provinces. Given linkages between IDUs and other high risk populations including male and female sex workers, Pakistan needs to scale up targeted intervention urgently to prevent rapid increase in HIV among vulnerable groups.
State of the Epidemic
According to UNAIDS estimates, about 96,000 people were living with HIV in Pakistan at the end of 2007. Officially reported cases are, however, much lower. As in many countries, underreporting is due mainly to the social stigma attached to HIV, limited surveillance and voluntary counseling and testing systems, and the lack of knowledge among the general population and health practitioners.
Although overall HIV prevalence is low in Pakistan, there is growing evidence of local concentrated epidemics among IDUs in major cities across the country. The combination of high levels of risk behavior and limited knowledge about HIV among injecting drug users and sex workers could lead to the rapid spread of HIV.
Risk Factors
There are serious risk factors that put Pakistan in danger of facing a rapid spread of HIV if immediate and vigorous action is not taken:
Concentrated Epidemic among Injecting Drug Users: The number of drug dependent people in Pakistan is estimated to be about 500,000, of whom an estimated 100,000 inject drugs. In 2006, HIV prevalence rates among IDUs ranged between 10 to 50 percent across Quetta, Faisalabad, Hyderabad, Karachi and Sargodha. The majority of these IDUs were either married or sexually active. The common risk factor for the majority of infected drug users was that they used non-sterile injecting equipment and awareness of HIV transmission routes was relatively low. Safe injection practices are more prevalent in cities such as Lahore and Peshawar where targeted interventions have been in place over a longer period.
HIV among Male Sex Workers and Transgenders: Surveillance data for 2006 point to a local concentrated epidemic among MSWs and Hijras in Larkana and Karachi in the Sindh province while prevalence elsewhere is still below 5 percent. Behavioral surveillance data for 2006 indicates very low levels of condom use among MSWs and transgenders across all cities surveyed. One in four of the male sex workers said they also bought or sold sex to women. Such high-risk behavior must be addressed in order to limit the further spread of HIV in and beyond those sexual networks.
Unsafe Practices among Female Sex Workers: Commercial sex is prevalent in major cities and on truck routes. Behavioral and mapping studies in three large cities found a sex worker population of 100,000 with limited understanding of safe sexual practices. Condom use is still low during commercial sex encounters although consistent condom use is more prevalent in Karachi and Lahore where targeted interventions were initiated in 2004. Furthermore, sex workers often lack the power to negotiate safe sex or seek treatment for STIs. High levels of sexually transmitted infections indicate widespread sexual risk-taking.
Inadequate Blood Transfusion Screening and High Level of Professional Donors: It is estimated that 40 percent of the 1.5 million annual blood transfusions in Pakistan are not screened for HIV. About 20 percent of the blood transfused comes from professional donors.
Large Numbers of Migrants and Refugees: Large numbers of workers leave their villages to seek work in larger cities, in the armed forces, or on industrial sites. A significant number (around four million) are employed overseas. Away from their homes for extended periods of time, they may be at increased risk for exposure to HIV.
Unsafe Medical Injection Practices: Pakistan has a high rate of medical injections - around 4.5 per capita per year. Studies indicate that 94 percent of injections are administered with used injection equipment. Use of unsterilized needles at medical facilities is also widespread. According to WHO estimates, unsafe injections account for 62 percent of Hepatitis B, 84 percent of Hepatitis C, and 3 percent of new HIV cases.
Low Levels of Literacy and Education: Efforts to increase awareness about HIV among the general population are hampered by low literacy levels and cultural influences. In 2006 female literacy was estimated at 42 percent.
Vulnerability Due to Social and Economic Disadvantages: Restrictions on women's and girls’ mobility limits access to information and preventive and support services. Young people are vulnerable to influence by peers, unemployment frustrations, and the availability of drugs. In addition, some groups of young men are especially vulnerable due to the sexual services they provide, notably in the transport sector. Both men and women from impoverished households may be forced into the sex industry for income.
National Response to HIV/AIDS
Government: Pakistan’s Federal Ministry of Health initiated a National AIDS Prevention and Control Program (NACP) in 1987. In its early stages, the program was focused on diagnosis of cases that came to hospitals, but progressively began to shift toward a community focus. Its objectives are the prevention of HIV transmission, safe blood transfusions, reduction of STI transmission, establishment of surveillance, training of health staff, research and behavioral studies, and development of program management. The NACP has been included as part of the government's general health program, with support from various external donors.
As the government has indicated, more needs to be done. For example, focus on reducing the exposure of high-risk groups is urgently required as is increasing the service coverage of key populations (injecting drug users, female sex workers, men who have sex with men, and prison inmates). Other priority areas that require attention include improving access to quality treatment and care, strengthening the monitoring and evaluation system, continued advocacy with policy makers and other influential groups and effective coordination with key agencies including police, jail authorities, and the Ministry of Law and of Narcotics Control. In early 2001, the Government of Pakistan, through a broad consultative process, developed a national HIV/AIDS Strategic Framework that set out the strategies and priorities for effective control of the epidemic. The government has finalized costed action plans for the next phase of the federal and provincial Programs covering the period from 2009-2013.
A draft national AIDS policy and HIV and AIDS Law (both recommending the formation of a National AIDS Council) have been prepared by the National AIDS Control Programme and will be presented to the national cabinet and parliament. Approval of the policy and law would be an important step towards the multisectoral dimension of the national response.
Non-Governmental Organizations (NGOs): At least 54 NGOs are involved in HIV/AIDS public awareness and in the care and support of persons living with HIV/AIDS. These NGOs also work on education and prevention interventions targeting sex workers, truck drivers, and other high-risk groups. NGOs serve as members of the Provincial HIV/AIDS Consortium, which has been set up in all four of Pakistan’s provinces to coordinate HIV/AIDS prevention and control activities. Although NGOs are active in HIV/AIDS prevention activities, it is believed that they are reaching less than fifteen percent of the vulnerable population.
Donors: There is a Theme Group and a Technical Working Group on HIV/AIDS to coordinate the response of United Nations Agencies and to provide assistance to the government in the strategic development of activities. The theme group includes UNAIDS, WHO, UNICEF, UNFPA, UNDP, UNDCP, UNESCO, ILO, the World Bank, national and provincial program managers, and representatives of nongovernmental organizations.
Issues and Challenges: Priority Areas
Vulnerable and High-risk Groups
Expand knowledge, access, and coverage of vulnerable populations—particularly in large cities—to a package of high impact services, through combined efforts of the government and NGOs.
Implement harm-reduction initiatives for IDUs and safe sex practices for sex workers.
Make effective and affordable STD services available for high-risk groups and the general population.
General Awareness and Behavioral Change
Undertake behavioral change communications with the following behavioral objectives: (i) use of condoms with non-regular sexual partners; (ii) use of STI treatment services when symptoms are present and knowledge of the link between STIs and HIV; (iii) use of sterile syringes for all injections; (iv) reduction in the number of injections received; (v) voluntary blood donation (particularly among the age group 18 to 30); (vi) use of blood for transfusion only if it has been screened for HIV; and (vii) display of tolerant and caring behaviors towards people living with HIV and members of vulnerable populations.
Increase interventions among youth, police, soldiers, and migrant laborers.
Blood and Blood Product Safety
· Ensure mandatory screening of blood and blood products in the public and private sectors for all major blood-borne infections.
Conduct education campaigns to promote voluntary blood donation.
Develop Quality Assurance Systems for public and private blood banks to ensure that all blood is properly screened for HIV and Hepatitis B.
Surveillance and Research
Strengthen and expand the surveillance and monitoring system.
Implement a second-generation HIV surveillance that tracks sero-prevalence and changes in HIV-related behaviors, including the spread of STIs and HIV, sexual attitudes and behaviors, and healthcare-seeking behaviors related to STIs.
Building Management Capacity
Continue to build management capacity within provincial programs and local NGOs to ensure evidence-based program implementation.
Identify gaps in existing programs and continue phased expansion of interventions.
World Bank Response
The World Bank is the largest financer of HIV/AIDS programs in Pakistan. It assisted the government’s HIV/AIDS efforts through funding the second Social Action Program (1998-2003). In addition, the World Bank is working with the government and other development partners (CIDA, DFID, USAID, UN agencies) to support the government’s program through the HIV/AIDS Prevention Project. The Bank is providing US$37.1 million, 75 percent of which is a no-interest credit and 25 percent of which is grant money. The project is supporting HIV prevention services to most at risk groups, mass media campaigns aimed at raising awareness and reducing stigma, promoting safe blood transfusion and building management and institutional capacity.
The implementation of targeted intervention has made encouraging progress with expanding coverage of an injecting drug users program in Punjab; implementation of service delivery packages for male and female sex workers in Sindh, Punjab and NWFP; jail inmates in Sindh and truckers nationwide. The data from three rounds of surveillance indicate that HIV prevention services are making a difference as reflected in a reduction in risk behaviors most notably among injecting drug users. At the same time the current coverage of these interventions is limited covering barely 15-20 percent of the most at risk groups of injecting drug users and sex workers. The most important issue relates to mobilizing resources and capacity for scaling up services to the high risk populations. Significant challenges also relate to building capacity of the federal and provincial programs and of the implementing NGOs.
The Bank is committed to supporting the Government’s Program over the next phase focusing particularly on increasing service coverage of most at risk groups in all major urban centers, improving access and quality of treatment and care and strengthening the monitoring and evaluation system.
HIV/AIDS IN SAARC COUNTRIES....
COUNTRY PROFILE:Maldives
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State of the Epidemic | Risk Factors| National Response to HIV/AIDS | Issues and Challenges: Priority Areas | World Bank Response
The Maldives took action against HIV/AIDS before the first domestic case was reported in 1987 and, as a result, has so far kept the threat to a minimum. With few resources currently required for treatment, the Maldives has the opportunity to focus on better understanding risk factors, such as sexual practices and drug use and accessibility to health services, and translating this knowledge into improved action in the ongoing HIV/AIDS program.
State of the Epidemic
As of mid-2004, 14 people had tested positive for HIV, and 10 people had died of AIDS. The number of people in the Maldives living with HIV or AIDS is less than 200, according to UNAIDS estimates. The major mode of HIV transmission in the country appears to be heterosexual sex.
Risk Factors and Vulnerability
Mobility: Many Maldivian citizens go abroad for education and work and are away from their families for long periods of time. More information is needed on the risk behaviors that these citizens may engage in while they are away from the support of their families.
Sexual Practices: High rates of divorce and remarriage in the Maldives create exposure to large sexual networks capable of transmitting HIV and other STIs. Since symptoms of HIV infection often do not appear for many years, people who are unaware that they are infected may infect their serial spouses and casual sex partners.
Drug Use: A 2003 UNDP rapid situation assessment of drug abuse in the Maldives revealed that drug abuse is on the increase in the country and is initiated at a very young age. Opioids, primarily brown sugar, hashish oil, and other cannabinoids, are the most frequently seized and most frequently abused drugs. In the outer atolls, reports of use of cologne, inhalants, and alcohol are also common. A significant number of users are also involved in selling drugs to support their habit and have been involved with the law enforcement agencies through imprisonment, banishment, or house arrest. Drug use is a risk factor for HIV infection for two reasons: drug users who are unable to afford their daily doses may resort to selling sex to earn money, and injecting drug users may share contaminated needles (although injecting is not currently the main mode of taking drugs in the Maldives).
Dispersed Population: Maldivians inhabit 200 of the 1,200 islands that make up their country. This dispersed population creates barriers to educating people on HIV/AIDS, distributing condoms, and treating people for STIs that increase transmission of HIV. A UN study in 2000 revealed that in the smaller islands, 55% of the population had no radio, and 86% had no television in the home. Many small islands have no bookstore, and access to newspapers is irregular.
Tourism Employment: The Maldivian tourist economy employs about 5,000 immigrant workers, mainly from India and Sri Lanka. These workers, far from their support systems, families, and usual sexual partners, are vulnerable to participating in high-risk behaviors such as sex without a condom and sex with commercial sex workers. More research is needed to better understand the risk behaviors of immigrant workers and to tailor existing HIV/AIDS programs to their needs without introducing stigma against foreigners.
External Tourism: In 2004, about 600,000 tourists visited the Maldives, almost double the entire population of the Maldives. Although sex tourism is not present in the Maldives, the great influx of people from all over the world represents a potential route of introduction of HIV and high-risk behaviors such as injecting drug use and unsafe sex.
National Response to HIV/AIDS
Government: The Maldives started its AIDS Control Program in 1987, four years before the first domestic HIV case was reported. The Program is coordinated by the National AIDS Council, a multisectoral body with representatives from various ministries and NGOs. Activities include public education, peer education, awareness creation workshops, blood-product screening, and care of HIV/AIDS patients. Condoms are widely accessible on main islands, and nearly 99% of all households are aware of HIV/AIDS. The government carries out a high level of screening, including mandatory screening of all its citizens when they return from an overseas stay of more than a year.
Nongovernmental Organizations (NGOs): UNDP reports that there are few NGOs in the Maldives. Those that are active have provided educational services such as weekly radio programs, peer education, and seminars.
Donors: WHO and UNFPA have provided funding and technical assistance for HIV/AIDS awareness and prevention programs. The Government of Italy, through UNDP, is funding a drug abuse-prevention program. The UN Theme Group on HIV/AIDS carried out a situational analysis of HIV/AIDS in the Maldives in order to increase the multisectoral response.
Issues and Challenges: Priority Areas
Maintain Multisectoral Commitment. The challenge for the Maldives will be to avoid the complacency that can often follow early success. The Maldives will need to maintain and further strengthen its multisectoral commitment to HIV/AIDS prevention, expanding it, for example, to include the tourism and shipping industries. Only by continuing to involve all sectors will activities sufficiently reach smaller islands.
Increased Research. More research is needed to better understand risk factors such as drug use, serial monogamy, and the pattern of male-to-male sex. Once more is known about these behaviors, increasingly effective prevention programs can be developed.
“Travel Safe.” The Maldives can help its citizens, tourists, and immigrant workers design personal plans to keep themselves safe from HIV and other STIs while away from their homes. The process of preparing a personal safety plan helps make the abstract concepts of the HIV/AIDS epidemic more concrete and of personal significance. These plans can help avoid the threats to physical and mental health that result from being away from support systems for long periods of time.
Decrease Crosscutting Vulnerabilities. Vulnerable groups, such as poor people and women, have less access to health services. Tackling this broader problem will help the Maldives improve its overall health status as well as keep the number of HIV/AIDS cases in check.
World Bank Response
The Government of Maldives has not requested funding or technical assistance for HIV from the World Bank.
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State of the Epidemic | Risk Factors| National Response to HIV/AIDS | Issues and Challenges: Priority Areas | World Bank Response
The Maldives took action against HIV/AIDS before the first domestic case was reported in 1987 and, as a result, has so far kept the threat to a minimum. With few resources currently required for treatment, the Maldives has the opportunity to focus on better understanding risk factors, such as sexual practices and drug use and accessibility to health services, and translating this knowledge into improved action in the ongoing HIV/AIDS program.
State of the Epidemic
As of mid-2004, 14 people had tested positive for HIV, and 10 people had died of AIDS. The number of people in the Maldives living with HIV or AIDS is less than 200, according to UNAIDS estimates. The major mode of HIV transmission in the country appears to be heterosexual sex.
Risk Factors and Vulnerability
Mobility: Many Maldivian citizens go abroad for education and work and are away from their families for long periods of time. More information is needed on the risk behaviors that these citizens may engage in while they are away from the support of their families.
Sexual Practices: High rates of divorce and remarriage in the Maldives create exposure to large sexual networks capable of transmitting HIV and other STIs. Since symptoms of HIV infection often do not appear for many years, people who are unaware that they are infected may infect their serial spouses and casual sex partners.
Drug Use: A 2003 UNDP rapid situation assessment of drug abuse in the Maldives revealed that drug abuse is on the increase in the country and is initiated at a very young age. Opioids, primarily brown sugar, hashish oil, and other cannabinoids, are the most frequently seized and most frequently abused drugs. In the outer atolls, reports of use of cologne, inhalants, and alcohol are also common. A significant number of users are also involved in selling drugs to support their habit and have been involved with the law enforcement agencies through imprisonment, banishment, or house arrest. Drug use is a risk factor for HIV infection for two reasons: drug users who are unable to afford their daily doses may resort to selling sex to earn money, and injecting drug users may share contaminated needles (although injecting is not currently the main mode of taking drugs in the Maldives).
Dispersed Population: Maldivians inhabit 200 of the 1,200 islands that make up their country. This dispersed population creates barriers to educating people on HIV/AIDS, distributing condoms, and treating people for STIs that increase transmission of HIV. A UN study in 2000 revealed that in the smaller islands, 55% of the population had no radio, and 86% had no television in the home. Many small islands have no bookstore, and access to newspapers is irregular.
Tourism Employment: The Maldivian tourist economy employs about 5,000 immigrant workers, mainly from India and Sri Lanka. These workers, far from their support systems, families, and usual sexual partners, are vulnerable to participating in high-risk behaviors such as sex without a condom and sex with commercial sex workers. More research is needed to better understand the risk behaviors of immigrant workers and to tailor existing HIV/AIDS programs to their needs without introducing stigma against foreigners.
External Tourism: In 2004, about 600,000 tourists visited the Maldives, almost double the entire population of the Maldives. Although sex tourism is not present in the Maldives, the great influx of people from all over the world represents a potential route of introduction of HIV and high-risk behaviors such as injecting drug use and unsafe sex.
National Response to HIV/AIDS
Government: The Maldives started its AIDS Control Program in 1987, four years before the first domestic HIV case was reported. The Program is coordinated by the National AIDS Council, a multisectoral body with representatives from various ministries and NGOs. Activities include public education, peer education, awareness creation workshops, blood-product screening, and care of HIV/AIDS patients. Condoms are widely accessible on main islands, and nearly 99% of all households are aware of HIV/AIDS. The government carries out a high level of screening, including mandatory screening of all its citizens when they return from an overseas stay of more than a year.
Nongovernmental Organizations (NGOs): UNDP reports that there are few NGOs in the Maldives. Those that are active have provided educational services such as weekly radio programs, peer education, and seminars.
Donors: WHO and UNFPA have provided funding and technical assistance for HIV/AIDS awareness and prevention programs. The Government of Italy, through UNDP, is funding a drug abuse-prevention program. The UN Theme Group on HIV/AIDS carried out a situational analysis of HIV/AIDS in the Maldives in order to increase the multisectoral response.
Issues and Challenges: Priority Areas
Maintain Multisectoral Commitment. The challenge for the Maldives will be to avoid the complacency that can often follow early success. The Maldives will need to maintain and further strengthen its multisectoral commitment to HIV/AIDS prevention, expanding it, for example, to include the tourism and shipping industries. Only by continuing to involve all sectors will activities sufficiently reach smaller islands.
Increased Research. More research is needed to better understand risk factors such as drug use, serial monogamy, and the pattern of male-to-male sex. Once more is known about these behaviors, increasingly effective prevention programs can be developed.
“Travel Safe.” The Maldives can help its citizens, tourists, and immigrant workers design personal plans to keep themselves safe from HIV and other STIs while away from their homes. The process of preparing a personal safety plan helps make the abstract concepts of the HIV/AIDS epidemic more concrete and of personal significance. These plans can help avoid the threats to physical and mental health that result from being away from support systems for long periods of time.
Decrease Crosscutting Vulnerabilities. Vulnerable groups, such as poor people and women, have less access to health services. Tackling this broader problem will help the Maldives improve its overall health status as well as keep the number of HIV/AIDS cases in check.
World Bank Response
The Government of Maldives has not requested funding or technical assistance for HIV from the World Bank.
HIV/AIDS IN SAARC COUNTRIES....
COUNTRY PROFILE:India
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State of the Epidemic | Risk Factors | National Response to HIV/AIDS | Issues and Challenges: Priority Areas | World Bank Response
State of the Epidemic
The Government of India estimates that in 2006, about 2.45 million Indians were living with HIV (1.75 - 3.15 million) with an adult prevalence rate of 0.41%. India’s highly heterogeneous epidemic is largely concentrated in six states — in the industrialized south and west, and in the north-eastern tip. On average, HIV prevalence in those states is 4–5 times higher than in the other Indian states. HIV prevalence is highest in the Mumbai-Karnataka corridor, the Nagpur area of Maharashtra, the Nammakkal district of Tamil Nadu, coastal Andhra Pradesh, and parts of Manipur and Nagaland.
The Indian epidemic continues to be concentrated in populations with high risk behavior characterized by unprotected paid sex, anal sex, and injecting drug use with contaminated injecting equipment. Several high risk groups have high HIV prevalence, and sexual networks are wide and inter-digitating. According to India’s National AIDS Control Organization (NACO), the bulk of HIV infections in India occur during unprotected heterosexual intercourse. Consequently, and as the epidemic has matured, women account for a growing proportion of people living with HIV (38 percent in 2005), especially in rural areas. The low rate of multiple partner concurrent sexual relationships among the wider community seem to have, so far, protected the larger body of people with 99 percent of the adult Indian population being HIV negative. However, although overall prevalence remains low, even relatively minor increases in HIV infection rates in a country of more than one billion people could translate into large numbers of people becoming infected.
Recent data suggests there are signs of a decline in HIV prevalence among sex workers in areas where focused interventions have been implemented, particularly in the southern states although overall prevalence levels among this group continues to be high. Data also indicate that there is a slow decrease in HIV prevalence among the general population in southern states. Although more analysis is required, this probably means that the number of people becoming newly infected with HIV is decreasing. This decrease is more perceptible in states such as Tamil Nadu where the intensity of HIV prevention efforts has been high.
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Risk Factors
Several factors put India in danger of experiencing rapid spread of HIV if effective prevention and control measures are not scaled up throughout the country. These risk factors include:
Unsafe Sex and Low Condom Use: In India, sexual transmission is responsible for 84 percent of reported HIV cases and HIV prevalence is high among sex workers (both male and female) and their clients. In Mumbai and Pune, for example, 54 percent and 49 percent of sex workers, respectively, were found to be HIV-positive (NACO, 2005). A large proportion of women with HIV appear to have acquired the virus from regular partners who were infected during paid sex. HIV prevention efforts targeted at sex workers are being implemented in India. However, the context of sex work is complex and enforcement of outdated laws often act as a barrier against effective HIV prevention and treatment efforts. Indeed, condom use is limited especially when commercial encounters take place in ‘risky’ locations with low police tolerance for this activity. In addition, interventions tend to primarily target brothel-based sex workers, who represent a minority of sex workers. HIV information and awareness among sex workers appears to be low, especially among those working in the streets. Some prevention programs run by sex workers’ cooperatives —in Sonagachi, Kolkata, for example—have encouraged safe paid sex practices and have been associated with lower HIV prevalence (Kumar, 1998; Jana et al., 1998).
Men Who Have Sex with Men (MSM): Relatively little is known about the role of sex between men in India’s HIV epidemic, but the few studies that have examined this subject have found that a significant proportion of men in India do have sex with other men. In two states where data have been collected, HIV prevalence of 6.8 percent and 9.6 percent were found among MSM in Chennai and Mumbai, respectively (NACO, 2004). More recently, HIV prevalence of 12 percent was found among MSM seeking voluntary counseling and testing services in Mumbai, and 18 percent prevalence was found at 10 clinics in Andhra Pradesh. In some areas, a substantial proportion of MSM also sell sex. Poor knowledge of HIV has been found in groups of MSM. The extent and effectiveness of India’s efforts to increase safe sex practices between MSM (and their other sex partners) will play a significant role in determining the scale and development of India’s HIV epidemic.
Injecting Drug Use (IDU): Injecting drug use is the main risk factor for HIV infection in the north-east (especially in the states of Manipur, Mizoram and Nagaland), and features increasingly in the epidemics of major cities elsewhere, including in Chennai, Mumbai and New Delhi (MAP, 2005; NACO, 2005). Using shared injecting drug equipment is the main risk factor for HIV infection in the north-east, and features increasingly in the epidemics of cities in other states. Products injected include legal pharmaceuticals (e.g. buprenorphine, pentazocine and diazepam), in addition to heroin. Current interventions targeting IDU tend to be inconsistent, and too small and infrequent to yield demonstrable results. Harm reduction programs need to be extended and expanded as a matter of urgency in those parts of India with serious drug injecting-related HIV epidemics.
Migration and Mobility: Migration for work takes people away from the social environment of their families and community. This can lead to an increased likelihood to engage in risky behavior. Concerted efforts are needed to address the vulnerabilities of the large migrant population. Furthermore, a high proportion of female sex workers in India are mobile. The mobility of sex workers is likely a major factor contributing to HIV transmission by connecting high-risk sexual networks.
Low Status of Women: Infection rates have been on the increase among women and infants in some states as the epidemic spreads through bridging population groups. As in many other countries, unequal power relations and the low status of women, as expressed by limited access to human, financial, and economic assets, weakens the ability of women to protect themselves and negotiate safer sex both within and outside of marriage, thereby increasing their vulnerability.
Widespread Stigma: Stigma towards people living with HIV is widespread. The misconception that AIDS only affects men who have sex with men, sex workers, and injecting drug users strengthens and perpetuates existing discrimination. The most affected groups, often marginalized, have little or no access to legal protection of their basic human rights. Addressing the issue of human rights violations and creating an enabling environment that increases knowledge and encourages behavior change are thus extremely important to the fight against AIDS.
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National Response to HIV/AIDS
Government: Shortly after reporting the first AIDS case in 1986, the Government of India established a National AIDS Control Program (NACP) which was managed by a small unit within the Ministry of Health and Family Welfare. The program’s principal activity was then limited to monitoring HIV infection rates among risk populations in select urban areas.
In 1991, the scope of NACP was expanded to focus on blood safety, prevention among high-risk populations, raising awareness in the general population, and improving surveillance. A semi-autonomous body, the National AIDS Control Organization (NACO), was established under the Ministry of Health and Family Welfare to implement this program. This “first phase” of the National AIDS Control Program lasted from 1992 -1999. It focused on initiating a national commitment, increasing awareness and addressing blood safety. It achieved some of its objectives, notably increased awareness. Professional blood donations were banned by law. Screening of donated blood became almost universal by the end of this phase. However, performance across states remained variable. By 1999, the program had also established a decentralized mechanism to facilitate effective state-level responses, although substantial variation continued to exist in the level of commitment and capacity among states. Whereas states such as Tamil Nadu, Andhra Pradesh, and Manipur demonstrated a strong response and high level of political commitment, many other states, such as Bihar and Uttar Pradesh, have yet to reach these levels.
The second phase of the NACP began in 1999 and ended in March 2006. Under this phase, India continued to expand the program at the state level. Greater emphasis was placed on targeted interventions for high-risk groups, preventive interventions among the general population, and involvement of NGOs and other sectors and line departments, such as education, transport and police. Capacity and accountability at the state level continues to be a major issue and has required sustained support. Interventions need to be scaled up to cover a higher percentage of the population, and monitoring and evaluation need further strengthening. In order to induce a sense of urgency, the classification of states has focused on the vulnerability of states, with states being classified as high and moderate prevalence (on the basis of HIV prevalence among high risk and general population groups) and high and moderate vulnerability (on the basis of demographic characteristics of the population).
While the government’s response has been scaled up markedly over the last decade, major challenges remain in raising the overall effectiveness of state-level programs, expanding the participation of other sectors, and increasing safe behavior and reducing stigma associated with HIV-positive people among the population.
Preparations for the third phase of the NACP included a comprehensive consultative process including state specific and nationwide consultations with Indian national stakeholders such as PLWHA networks, local and international NGOs, experts and practitioners of HIV control initiatives, as well as international development partners. The transition from NACP I, to NACP 2 and now NACP 3 is one of a gradually more comprehensive response. While for NACP I the main focus was on safe blood and general prevention, NACP 2 established the State AIDS Control Societies and started working with NGOs. Now with NACP 3, Government will build further on these partnerships with civil society organizations but also work towards greater active involvement of the target groups themselves in the program. There will be greater integration of the medical response to the epidemic e.g. through provision of ART, STI services, and treatment of opportunistic infections through the National Rural Health Mission. The surveillance system of the NACP was also greatly improved over the course of the first and second phase and will be further enhanced under the third phase.
Non-Governmental and Community Based Organizations (NGOs & CBOs): There are numerous NGOs and CBOs working on HIV/AIDS issues in India at the local, state, and national levels. Projects include targeted interventions with high risk groups; direct care of people living with HIV; general awareness campaigns; and care for children orphaned by AIDS. Funding for non-government and community-based groups comes from a variety of sources: the federal or state governments of India, international donors, and local contributions.
Donors: India receives technical assistance and funding from a variety of UN partners and bilateral donors. Bilateral donors such as USAID, CIDA, and DFID have been involved since the early 1990s at the state level in a number of states. USAID has committed more than US$70 million since 1992, CIDA US$11 million, and DFID close to US$200 million. The number of major financers and the amount of funding available has increased significantly in the last year. Since 2004, the Bill and Melinda Gates Foundation has pledged US$200 million, and the Global Fund has approved US$54 million for HIV/AIDS for projects in rounds two, three and four. DFID (GBP 107 million) is providing pooled financing together with the Bank (US$ 250 million) in overall support to India’s HIV/AIDS program NACP 3. Other donors include the Clinton Foundation, various UN agencies, DANIDA, SIDA, and the European Union.
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Issues and Challenges: Priority Areas
Limited Capacity: There are institutional constraints, both structural and managerial, to scale up at the national and state levels. It is critical that these factors be addressed as the program expands its response to the epidemic. NACO will need to change in its role and responsibilities to provide the leadership and direction for a stronger multi-sector response for the next phase in India’s fight against HIV/AIDS; while the states will need to provide implementation capacity to put a robust program into place. The capacity to mount a strong program is weakest in some of the poorest and most populated states with significant vulnerability to the epidemic. There is a need for tailored capacity-building activities and attention to performance-based financing approaches. In addition, the program also experiences high turnover of state level project directors, resulting in limited continuity and variability in performance across states.
Donor Coordination: There are over 32 large donor agencies working with NACO in different states and on different programs apart from many more who support NGOs in states. Each donor comes with its own mandate and requirements, as well as areas of focus. The transaction cost to the government as a result of attending to the various demands of the donors is huge. There is a need for better coordinating mechanisms among the donors and clear leadership by the Government to reduce the transaction costs.
Use of Data for Decision Making: There remains a need for greater use of data for decision making, including program data and epidemiological data. A lot of data that is being generated is not adequately used for managing the program or informing policies and priorities. Results-based management and linking incentives to the use of data should be explored.
Stigma and Discrimination: Stigma and discrimination against people living with HIV/AIDS and those considered to be at high risk remain entrenched. Stigma and denial undermine efforts to increase the coverage of effective interventions among high risk groups such as men having sex with men, sex workers and injecting drug users. Harassment by police and ostracism by family and community drives the epidemic underground and decreases the reach and effectiveness of prevention efforts. Though there is significant increase in awareness due to efforts by the government, there is much room for improvement.
Low Awareness in Rural Areas: The results from the 2005 BBC World Service Trust KAP survey (17 states, 22,800 respondants) showed 89 percent of the urban population and 82 percent of the rural population had heard of HIV/AIDS. However, sentinel site behavioral surveillance (2001) showed that although there was high basic awareness levels (82.4 percent in males and 70 percent in females), rural women demonstrated very low rates of awareness in Bihar (21.5 percent), Gujarat (25 percent), and Uttar Pradesh (27.6 percent). New approaches need to be tried to reach rural communities with information about HIV/AIDS, safe sex and how to prevent and treat HIV and AIDS.
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World Bank Response
In 1991, the Government of India and the World Bank expanded their collaboration on infectious disease control programs and by 1992 the first National AIDS Control Project was launched with a World Bank credit of US$84 million. The project helped the government to broaden prevention efforts and to establish institutions and procedures necessary to curb the spread of HIV. Building upon lessons learned from the first project, India requested World Bank financing for a follow-on project. With a World Bank credit of US$191 million, the Second National HIV/AIDS Control Project was started. The use of State AIDS Societies to speed the distribution of funds at the state level helped increase the pace of implementation. Most recently, the Bank worked closely with the Government of India and other donors on the preparation of the third National HIV/AIDS Control Project (US$250 million) which was signed in July, 2007. NACP 3 will focus on coordinating all donor and NGO activities within the scope of the country’s program on AIDS control - in consonance with the Three Ones. It proposes higher coverage of groups with high risk behavior (NACP 2 covered 10-60% of groups with high risk behavior, NACP 3 envisages to cover 80% of the high risk groups). NACP 3 also clearly differentiates activities that must be delivered through general health services and places responsibility on those relevant government health programs. It will also further support CBOs to deliver about half of all interventions targeting high risk groups.
The Bank has undertaken analytical work to strengthen the national response, including an analysis of the full array of costs and consequences likely to result from several plausible government policy options regarding funding for anti-retroviral therapy (ART). The Bank has also carried out sector work on the economic consequences of the HIV/AIDS epidemic on India. In April, 2007, the Bank, together with UNODC, AusAID and SIDA, sponsored an inter-country consultation on preventing HIV among injecting drug users. In July 2007, “Case Studies from India: Corporate Responses to HIV/AIDS” was released. This report presents case studies on how businesses can gain from supporting interventions aimed at preventing HIV both at the workplace and in local communities—and from taking early decisive action.
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State of the Epidemic | Risk Factors | National Response to HIV/AIDS | Issues and Challenges: Priority Areas | World Bank Response
State of the Epidemic
The Government of India estimates that in 2006, about 2.45 million Indians were living with HIV (1.75 - 3.15 million) with an adult prevalence rate of 0.41%. India’s highly heterogeneous epidemic is largely concentrated in six states — in the industrialized south and west, and in the north-eastern tip. On average, HIV prevalence in those states is 4–5 times higher than in the other Indian states. HIV prevalence is highest in the Mumbai-Karnataka corridor, the Nagpur area of Maharashtra, the Nammakkal district of Tamil Nadu, coastal Andhra Pradesh, and parts of Manipur and Nagaland.
The Indian epidemic continues to be concentrated in populations with high risk behavior characterized by unprotected paid sex, anal sex, and injecting drug use with contaminated injecting equipment. Several high risk groups have high HIV prevalence, and sexual networks are wide and inter-digitating. According to India’s National AIDS Control Organization (NACO), the bulk of HIV infections in India occur during unprotected heterosexual intercourse. Consequently, and as the epidemic has matured, women account for a growing proportion of people living with HIV (38 percent in 2005), especially in rural areas. The low rate of multiple partner concurrent sexual relationships among the wider community seem to have, so far, protected the larger body of people with 99 percent of the adult Indian population being HIV negative. However, although overall prevalence remains low, even relatively minor increases in HIV infection rates in a country of more than one billion people could translate into large numbers of people becoming infected.
Recent data suggests there are signs of a decline in HIV prevalence among sex workers in areas where focused interventions have been implemented, particularly in the southern states although overall prevalence levels among this group continues to be high. Data also indicate that there is a slow decrease in HIV prevalence among the general population in southern states. Although more analysis is required, this probably means that the number of people becoming newly infected with HIV is decreasing. This decrease is more perceptible in states such as Tamil Nadu where the intensity of HIV prevention efforts has been high.
back to top
--------------------------------------------------------------------------------
Risk Factors
Several factors put India in danger of experiencing rapid spread of HIV if effective prevention and control measures are not scaled up throughout the country. These risk factors include:
Unsafe Sex and Low Condom Use: In India, sexual transmission is responsible for 84 percent of reported HIV cases and HIV prevalence is high among sex workers (both male and female) and their clients. In Mumbai and Pune, for example, 54 percent and 49 percent of sex workers, respectively, were found to be HIV-positive (NACO, 2005). A large proportion of women with HIV appear to have acquired the virus from regular partners who were infected during paid sex. HIV prevention efforts targeted at sex workers are being implemented in India. However, the context of sex work is complex and enforcement of outdated laws often act as a barrier against effective HIV prevention and treatment efforts. Indeed, condom use is limited especially when commercial encounters take place in ‘risky’ locations with low police tolerance for this activity. In addition, interventions tend to primarily target brothel-based sex workers, who represent a minority of sex workers. HIV information and awareness among sex workers appears to be low, especially among those working in the streets. Some prevention programs run by sex workers’ cooperatives —in Sonagachi, Kolkata, for example—have encouraged safe paid sex practices and have been associated with lower HIV prevalence (Kumar, 1998; Jana et al., 1998).
Men Who Have Sex with Men (MSM): Relatively little is known about the role of sex between men in India’s HIV epidemic, but the few studies that have examined this subject have found that a significant proportion of men in India do have sex with other men. In two states where data have been collected, HIV prevalence of 6.8 percent and 9.6 percent were found among MSM in Chennai and Mumbai, respectively (NACO, 2004). More recently, HIV prevalence of 12 percent was found among MSM seeking voluntary counseling and testing services in Mumbai, and 18 percent prevalence was found at 10 clinics in Andhra Pradesh. In some areas, a substantial proportion of MSM also sell sex. Poor knowledge of HIV has been found in groups of MSM. The extent and effectiveness of India’s efforts to increase safe sex practices between MSM (and their other sex partners) will play a significant role in determining the scale and development of India’s HIV epidemic.
Injecting Drug Use (IDU): Injecting drug use is the main risk factor for HIV infection in the north-east (especially in the states of Manipur, Mizoram and Nagaland), and features increasingly in the epidemics of major cities elsewhere, including in Chennai, Mumbai and New Delhi (MAP, 2005; NACO, 2005). Using shared injecting drug equipment is the main risk factor for HIV infection in the north-east, and features increasingly in the epidemics of cities in other states. Products injected include legal pharmaceuticals (e.g. buprenorphine, pentazocine and diazepam), in addition to heroin. Current interventions targeting IDU tend to be inconsistent, and too small and infrequent to yield demonstrable results. Harm reduction programs need to be extended and expanded as a matter of urgency in those parts of India with serious drug injecting-related HIV epidemics.
Migration and Mobility: Migration for work takes people away from the social environment of their families and community. This can lead to an increased likelihood to engage in risky behavior. Concerted efforts are needed to address the vulnerabilities of the large migrant population. Furthermore, a high proportion of female sex workers in India are mobile. The mobility of sex workers is likely a major factor contributing to HIV transmission by connecting high-risk sexual networks.
Low Status of Women: Infection rates have been on the increase among women and infants in some states as the epidemic spreads through bridging population groups. As in many other countries, unequal power relations and the low status of women, as expressed by limited access to human, financial, and economic assets, weakens the ability of women to protect themselves and negotiate safer sex both within and outside of marriage, thereby increasing their vulnerability.
Widespread Stigma: Stigma towards people living with HIV is widespread. The misconception that AIDS only affects men who have sex with men, sex workers, and injecting drug users strengthens and perpetuates existing discrimination. The most affected groups, often marginalized, have little or no access to legal protection of their basic human rights. Addressing the issue of human rights violations and creating an enabling environment that increases knowledge and encourages behavior change are thus extremely important to the fight against AIDS.
back to top
--------------------------------------------------------------------------------
National Response to HIV/AIDS
Government: Shortly after reporting the first AIDS case in 1986, the Government of India established a National AIDS Control Program (NACP) which was managed by a small unit within the Ministry of Health and Family Welfare. The program’s principal activity was then limited to monitoring HIV infection rates among risk populations in select urban areas.
In 1991, the scope of NACP was expanded to focus on blood safety, prevention among high-risk populations, raising awareness in the general population, and improving surveillance. A semi-autonomous body, the National AIDS Control Organization (NACO), was established under the Ministry of Health and Family Welfare to implement this program. This “first phase” of the National AIDS Control Program lasted from 1992 -1999. It focused on initiating a national commitment, increasing awareness and addressing blood safety. It achieved some of its objectives, notably increased awareness. Professional blood donations were banned by law. Screening of donated blood became almost universal by the end of this phase. However, performance across states remained variable. By 1999, the program had also established a decentralized mechanism to facilitate effective state-level responses, although substantial variation continued to exist in the level of commitment and capacity among states. Whereas states such as Tamil Nadu, Andhra Pradesh, and Manipur demonstrated a strong response and high level of political commitment, many other states, such as Bihar and Uttar Pradesh, have yet to reach these levels.
The second phase of the NACP began in 1999 and ended in March 2006. Under this phase, India continued to expand the program at the state level. Greater emphasis was placed on targeted interventions for high-risk groups, preventive interventions among the general population, and involvement of NGOs and other sectors and line departments, such as education, transport and police. Capacity and accountability at the state level continues to be a major issue and has required sustained support. Interventions need to be scaled up to cover a higher percentage of the population, and monitoring and evaluation need further strengthening. In order to induce a sense of urgency, the classification of states has focused on the vulnerability of states, with states being classified as high and moderate prevalence (on the basis of HIV prevalence among high risk and general population groups) and high and moderate vulnerability (on the basis of demographic characteristics of the population).
While the government’s response has been scaled up markedly over the last decade, major challenges remain in raising the overall effectiveness of state-level programs, expanding the participation of other sectors, and increasing safe behavior and reducing stigma associated with HIV-positive people among the population.
Preparations for the third phase of the NACP included a comprehensive consultative process including state specific and nationwide consultations with Indian national stakeholders such as PLWHA networks, local and international NGOs, experts and practitioners of HIV control initiatives, as well as international development partners. The transition from NACP I, to NACP 2 and now NACP 3 is one of a gradually more comprehensive response. While for NACP I the main focus was on safe blood and general prevention, NACP 2 established the State AIDS Control Societies and started working with NGOs. Now with NACP 3, Government will build further on these partnerships with civil society organizations but also work towards greater active involvement of the target groups themselves in the program. There will be greater integration of the medical response to the epidemic e.g. through provision of ART, STI services, and treatment of opportunistic infections through the National Rural Health Mission. The surveillance system of the NACP was also greatly improved over the course of the first and second phase and will be further enhanced under the third phase.
Non-Governmental and Community Based Organizations (NGOs & CBOs): There are numerous NGOs and CBOs working on HIV/AIDS issues in India at the local, state, and national levels. Projects include targeted interventions with high risk groups; direct care of people living with HIV; general awareness campaigns; and care for children orphaned by AIDS. Funding for non-government and community-based groups comes from a variety of sources: the federal or state governments of India, international donors, and local contributions.
Donors: India receives technical assistance and funding from a variety of UN partners and bilateral donors. Bilateral donors such as USAID, CIDA, and DFID have been involved since the early 1990s at the state level in a number of states. USAID has committed more than US$70 million since 1992, CIDA US$11 million, and DFID close to US$200 million. The number of major financers and the amount of funding available has increased significantly in the last year. Since 2004, the Bill and Melinda Gates Foundation has pledged US$200 million, and the Global Fund has approved US$54 million for HIV/AIDS for projects in rounds two, three and four. DFID (GBP 107 million) is providing pooled financing together with the Bank (US$ 250 million) in overall support to India’s HIV/AIDS program NACP 3. Other donors include the Clinton Foundation, various UN agencies, DANIDA, SIDA, and the European Union.
back to top
--------------------------------------------------------------------------------
Issues and Challenges: Priority Areas
Limited Capacity: There are institutional constraints, both structural and managerial, to scale up at the national and state levels. It is critical that these factors be addressed as the program expands its response to the epidemic. NACO will need to change in its role and responsibilities to provide the leadership and direction for a stronger multi-sector response for the next phase in India’s fight against HIV/AIDS; while the states will need to provide implementation capacity to put a robust program into place. The capacity to mount a strong program is weakest in some of the poorest and most populated states with significant vulnerability to the epidemic. There is a need for tailored capacity-building activities and attention to performance-based financing approaches. In addition, the program also experiences high turnover of state level project directors, resulting in limited continuity and variability in performance across states.
Donor Coordination: There are over 32 large donor agencies working with NACO in different states and on different programs apart from many more who support NGOs in states. Each donor comes with its own mandate and requirements, as well as areas of focus. The transaction cost to the government as a result of attending to the various demands of the donors is huge. There is a need for better coordinating mechanisms among the donors and clear leadership by the Government to reduce the transaction costs.
Use of Data for Decision Making: There remains a need for greater use of data for decision making, including program data and epidemiological data. A lot of data that is being generated is not adequately used for managing the program or informing policies and priorities. Results-based management and linking incentives to the use of data should be explored.
Stigma and Discrimination: Stigma and discrimination against people living with HIV/AIDS and those considered to be at high risk remain entrenched. Stigma and denial undermine efforts to increase the coverage of effective interventions among high risk groups such as men having sex with men, sex workers and injecting drug users. Harassment by police and ostracism by family and community drives the epidemic underground and decreases the reach and effectiveness of prevention efforts. Though there is significant increase in awareness due to efforts by the government, there is much room for improvement.
Low Awareness in Rural Areas: The results from the 2005 BBC World Service Trust KAP survey (17 states, 22,800 respondants) showed 89 percent of the urban population and 82 percent of the rural population had heard of HIV/AIDS. However, sentinel site behavioral surveillance (2001) showed that although there was high basic awareness levels (82.4 percent in males and 70 percent in females), rural women demonstrated very low rates of awareness in Bihar (21.5 percent), Gujarat (25 percent), and Uttar Pradesh (27.6 percent). New approaches need to be tried to reach rural communities with information about HIV/AIDS, safe sex and how to prevent and treat HIV and AIDS.
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World Bank Response
In 1991, the Government of India and the World Bank expanded their collaboration on infectious disease control programs and by 1992 the first National AIDS Control Project was launched with a World Bank credit of US$84 million. The project helped the government to broaden prevention efforts and to establish institutions and procedures necessary to curb the spread of HIV. Building upon lessons learned from the first project, India requested World Bank financing for a follow-on project. With a World Bank credit of US$191 million, the Second National HIV/AIDS Control Project was started. The use of State AIDS Societies to speed the distribution of funds at the state level helped increase the pace of implementation. Most recently, the Bank worked closely with the Government of India and other donors on the preparation of the third National HIV/AIDS Control Project (US$250 million) which was signed in July, 2007. NACP 3 will focus on coordinating all donor and NGO activities within the scope of the country’s program on AIDS control - in consonance with the Three Ones. It proposes higher coverage of groups with high risk behavior (NACP 2 covered 10-60% of groups with high risk behavior, NACP 3 envisages to cover 80% of the high risk groups). NACP 3 also clearly differentiates activities that must be delivered through general health services and places responsibility on those relevant government health programs. It will also further support CBOs to deliver about half of all interventions targeting high risk groups.
The Bank has undertaken analytical work to strengthen the national response, including an analysis of the full array of costs and consequences likely to result from several plausible government policy options regarding funding for anti-retroviral therapy (ART). The Bank has also carried out sector work on the economic consequences of the HIV/AIDS epidemic on India. In April, 2007, the Bank, together with UNODC, AusAID and SIDA, sponsored an inter-country consultation on preventing HIV among injecting drug users. In July 2007, “Case Studies from India: Corporate Responses to HIV/AIDS” was released. This report presents case studies on how businesses can gain from supporting interventions aimed at preventing HIV both at the workplace and in local communities—and from taking early decisive action.
HIV/AIDS IN SAARC COUNTRIES....
COUNTRY PROFILE:Bhutan
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The Himalayan Kingdom of Bhutan, though isolated geographically, is not impervious to HIV. Increasing cross-border migration and international travel, combined with behavioral risk factors, mean Bhutan could face increases in HIV infections. With HIV prevalence currently very low, there is still time to stop its spread.
State of the Epidemic
To date, 144 HIV cases have been officially reported among Bhutan’s population of about 700,000. UNAIDS estimates that about 500 people could have been living with HIV or AIDS at the end of 2005, which would amount to a prevalence of less than 0.01 percent of the population. Most reported cases were likely infected 5 to 8 years ago and thus do not present a current picture of the state of the epidemic. Sentinel surveillance data for 2007 confirm HIV prevalence remains well below one percent in the general population, and the armed forces. Data on most-at-risk groups are not representative and thus prevalence among those most likely to experience a rise in HIV prevalence are not available.
Among the cases reported to date, positive cases have been confirmed among sex workers, prison inmates and armed forces, but not amongst STI and TB patients. Mode of transmission is primarily sexual. Half of all infected are male and two-thirds are between 20 and 49 years of age. People living with HIV in Bhutan come from diverse occupational backgrounds and districts. They include farmers, housewives (half identified through contact tracing), armed forces, and female sex workers.
Risk Factors
Despite Bhutan’s low HIV prevalence, the presence of several risk factors suggest HIV could spread if not adequately addressed:
Prevalence of Sexually Transmitted Infections (STIs): STIs facilitate the spread of HIV infection. Although the exact magnitude of STIs in the country is not known, gonorrhea, the most common, has an estimated annual incidence of about 2 percent among the adult population. Syphilis, on the other hand, for which all blood donors and pregnant women are screened, shows a slightly lower rate. Data on STI symptoms, the recent General Population Survey (GPS 2006) found about 5-6 percent of men and 8 percent of women had had a STI symptom. STI symptoms are highest amongst urban men. Knowledge about STI symptoms was low, particularly among women, and few, if any, knew that STIs could be asymptomatic in women. The same survey found only 73 percent of those surveyed knew condoms could prevent STIs. The STI data are consistent with low HIV prevalence.
Spread of Commercial Sex Work: While the border town of Phuntsholing, with its thriving commercial sex, remains a high transmission zone, sex work is perceived to be spreading to other border towns, and some interior districts of Thimphu, Paro, Trongsa, and Mongar. Much of sex work in the interior districts is informal and therefore more difficult to identify. Furthermore, frequent police raids in the border areas force sex work underground.
Risk of Substance Abuse: Substance abuse is associated with a higher risk of HIV infection as it can lower inhibitions and increase sexual risk-taking behavior. Although there are no studies on substance abuse in Bhutan, alcohol consumption in the country is extensive, and there are indications of the growing use of amphetamines, and other drugs among young people. Nevertheless, heroin and injecting drug use are currently minimal in Bhutan, unlike in neighboring Nepal, northeastern India, and southern China.
Less Rigid Sexual Norms: Sexual norms for both men and women are perceived to be less stringent in Bhutan than in other South Asian countries. The GPS of 2006 noted multiple concurrent relationships are not uncommon. One-fifth of all married people have engaged in extramarital sex in the last year, and 14 percent of unmarried people had sex in the last year. Rates are considerably higher among urban males (43 percent had extramarital sex in the last year, and 42 percent of urban single men had premarital sex in the last year). Although their partners are generally girlfriends and acquaintances, 15 percent of men having sex with non-regular partner frequent sex workers. While overall this is a small number (4-5 percent of all men), casual attitudes towards sex by this small sexually active subgroup of the population and their links to risk groups could eventually lead to small, truncated epidemics. On the other hand, the Bhutanese Government’s open discussion of sexual health issues, unlike in other countries of the region, is a positive factor.
Gender and Rural/Urban Disparities: Awareness about HIV is about 99 percent. Knowledge about how HIV is transmitted and how it can be prevented is less universal, although highest on knowledge about the preventive effects of condom use. Knowledge is higher in urban areas than rural areas, and higher among men than women. Condom use is also higher in urban areas, and higher among men. Condom use with extramarital sex partners is high (76 percent in urban areas, 64 percent rural areas, 84 percent for urban males but only 44 percent for urban females). Condom use in premarital sex is also high, at 73 percent in both rural and urban areas. Women’s limited ability to negotiate condom use and their more limited knowledge puts them at greater risk.
Invisibility of Most-at-Risk Populations in Bhutan: Little is known about how HIV is spreading in Bhutan. In most countries, HIV has spread from most-at-risk populations (MARPs), including sex workers, injecting drug users and men who have sex with men, yet to date there is little information on the behavior of these groups in Bhutan. Reaching them has proven difficult as the limited privacy that results from the closeness of social networks leads many to hide “unacceptable” behaviors more than in larger and more fluid societies.
National Response to HIV and AIDS
Government: The Royal Government of Bhutan acted early to initiate HIV prevention activities in the country. In 1988, five years before the first HIV infection was detected in the country, the Royal Government established a National HIV/AIDS and STD Control Program (NACP). The program is managed by the Ministry of Health.
Bhutan has demonstrated a strong political commitment to preventing and controlling the spread of HIV. Her Majesty Queen Ashi Sangay Choden Wangchuk is the UNFPA Goodwill Ambassador and an outspoken advocate of reproductive health, including HIV prevention. Furthermore, the government’s Ninth Five-Year Plan has identified HIV/AIDS and STI prevention and control as one of the most important programs for addressing emerging health issues and promoting better health for women and adolescents in Bhutan.
The national program, which has been financed substantially by donors, has focused on carrying out studies and monitoring specific populations, screening blood to ensure blood safety, integrating management of STIs into primary health care, improving treatment of STIs, and setting up voluntary counseling and testing at the National Referral Hospital and two independent facilities in Thimphu and Phuntsholing. It has also worked closely with line ministries and district governments to address HIV and AIDS multisectorally, training health personnel, and producing information, education, and communications materials.
The program requires stronger intervention in other areas that are most effective in a low-prevalence setting: providing prevention services to and empowering those who are most at risk of contracting HIV (MARPs); reducing stigma and discrimination; and improving the information base for better monitoring and evaluation as well as policy and planning decisions.
Non-Governmental Organizations (NGOs): Although local NGOs are nonexistent, Bhutan has civil society organizations such as religious bodies and youth groups which have an important role to play in HIV prevention and care.
Issues and Challenges: Priority Areas
The usual approaches to reach MARPs are difficult to mount in Bhutan: In a low prevalence setting, a concentrated epidemic will only be averted if MARPs are adequately reached. In most countries these interventions are implemented by NGOs and Community Based Organizations (CBOs). However, there are practically no NGOs in Bhutan and CBOs lack the necessary experience and none have worked on HIV. Even bringing PLWA to work together is difficult given the lack of privacy and stigma. NACP needs to encourage and train CBOs to work with MARPs and gradually scale up interventions. A well designed communications program can assist in reducing stigma. Given the less rigid attitudes towards sex, NACP also needs to target “hot spots” to increase condom use.
Human and physical constraints: Bhutan has a serious shortage of manpower at all levels and available staff is overstretched. Skills in some areas are lacking and the necessary t echnical expertise is often not available in-country. The rugged terrain and distances that need to be traveled to reach much of the country imply higher costs and greater difficulties to provide the necessary supervision and support. Better coordination and more targeted use of resources can improve program performance given limited human resources. This implies a strengthening of the information base on risk behavior and epidemic trends, as well as data to monitor the response. District level capacity needs to be strengthened.
World Bank Response
In June 2002, the World Bank, in collaboration with the Royal Government of Bhutan, carried out a rapid situational assessment, as a basis for discussions on possible support for the Government’s efforts to combat HIV and AIDS. In June 2004, the Bank approved an IDA grant of US$5.8 million for the HIV/AIDS and STI Prevention Project. The project seeks to scale up the Government’s efforts to contain the epidemic and reduce the incidence and prevalence of STIs. Specifically, it seeks to:
Expand HIV and STI prevention interventions, especially for most-at-risk populations.
Initiate care and treatment for people living with HIV and AIDS (PLWHA).
Improve STI prevention and treatment.
Improve human resources through long-term and short-term training and country exchanges, particularly in the area of public health and laboratory science.
Improve blood safety.
Improve management and technical capacity of Dzongkhags, line ministries, and civil society organizations to undertake HIV/AIDS prevention.
Strengthen surveillance, monitoring and evaluation, and information systems for better decision making on policies and programs, and expand the information base.
Engage community-based organizations, NGOs, local governments, and multi-sectoral agencies at the district level in expanding and accelerating HIV/AIDS interventions among populations.
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The Himalayan Kingdom of Bhutan, though isolated geographically, is not impervious to HIV. Increasing cross-border migration and international travel, combined with behavioral risk factors, mean Bhutan could face increases in HIV infections. With HIV prevalence currently very low, there is still time to stop its spread.
State of the Epidemic
To date, 144 HIV cases have been officially reported among Bhutan’s population of about 700,000. UNAIDS estimates that about 500 people could have been living with HIV or AIDS at the end of 2005, which would amount to a prevalence of less than 0.01 percent of the population. Most reported cases were likely infected 5 to 8 years ago and thus do not present a current picture of the state of the epidemic. Sentinel surveillance data for 2007 confirm HIV prevalence remains well below one percent in the general population, and the armed forces. Data on most-at-risk groups are not representative and thus prevalence among those most likely to experience a rise in HIV prevalence are not available.
Among the cases reported to date, positive cases have been confirmed among sex workers, prison inmates and armed forces, but not amongst STI and TB patients. Mode of transmission is primarily sexual. Half of all infected are male and two-thirds are between 20 and 49 years of age. People living with HIV in Bhutan come from diverse occupational backgrounds and districts. They include farmers, housewives (half identified through contact tracing), armed forces, and female sex workers.
Risk Factors
Despite Bhutan’s low HIV prevalence, the presence of several risk factors suggest HIV could spread if not adequately addressed:
Prevalence of Sexually Transmitted Infections (STIs): STIs facilitate the spread of HIV infection. Although the exact magnitude of STIs in the country is not known, gonorrhea, the most common, has an estimated annual incidence of about 2 percent among the adult population. Syphilis, on the other hand, for which all blood donors and pregnant women are screened, shows a slightly lower rate. Data on STI symptoms, the recent General Population Survey (GPS 2006) found about 5-6 percent of men and 8 percent of women had had a STI symptom. STI symptoms are highest amongst urban men. Knowledge about STI symptoms was low, particularly among women, and few, if any, knew that STIs could be asymptomatic in women. The same survey found only 73 percent of those surveyed knew condoms could prevent STIs. The STI data are consistent with low HIV prevalence.
Spread of Commercial Sex Work: While the border town of Phuntsholing, with its thriving commercial sex, remains a high transmission zone, sex work is perceived to be spreading to other border towns, and some interior districts of Thimphu, Paro, Trongsa, and Mongar. Much of sex work in the interior districts is informal and therefore more difficult to identify. Furthermore, frequent police raids in the border areas force sex work underground.
Risk of Substance Abuse: Substance abuse is associated with a higher risk of HIV infection as it can lower inhibitions and increase sexual risk-taking behavior. Although there are no studies on substance abuse in Bhutan, alcohol consumption in the country is extensive, and there are indications of the growing use of amphetamines, and other drugs among young people. Nevertheless, heroin and injecting drug use are currently minimal in Bhutan, unlike in neighboring Nepal, northeastern India, and southern China.
Less Rigid Sexual Norms: Sexual norms for both men and women are perceived to be less stringent in Bhutan than in other South Asian countries. The GPS of 2006 noted multiple concurrent relationships are not uncommon. One-fifth of all married people have engaged in extramarital sex in the last year, and 14 percent of unmarried people had sex in the last year. Rates are considerably higher among urban males (43 percent had extramarital sex in the last year, and 42 percent of urban single men had premarital sex in the last year). Although their partners are generally girlfriends and acquaintances, 15 percent of men having sex with non-regular partner frequent sex workers. While overall this is a small number (4-5 percent of all men), casual attitudes towards sex by this small sexually active subgroup of the population and their links to risk groups could eventually lead to small, truncated epidemics. On the other hand, the Bhutanese Government’s open discussion of sexual health issues, unlike in other countries of the region, is a positive factor.
Gender and Rural/Urban Disparities: Awareness about HIV is about 99 percent. Knowledge about how HIV is transmitted and how it can be prevented is less universal, although highest on knowledge about the preventive effects of condom use. Knowledge is higher in urban areas than rural areas, and higher among men than women. Condom use is also higher in urban areas, and higher among men. Condom use with extramarital sex partners is high (76 percent in urban areas, 64 percent rural areas, 84 percent for urban males but only 44 percent for urban females). Condom use in premarital sex is also high, at 73 percent in both rural and urban areas. Women’s limited ability to negotiate condom use and their more limited knowledge puts them at greater risk.
Invisibility of Most-at-Risk Populations in Bhutan: Little is known about how HIV is spreading in Bhutan. In most countries, HIV has spread from most-at-risk populations (MARPs), including sex workers, injecting drug users and men who have sex with men, yet to date there is little information on the behavior of these groups in Bhutan. Reaching them has proven difficult as the limited privacy that results from the closeness of social networks leads many to hide “unacceptable” behaviors more than in larger and more fluid societies.
National Response to HIV and AIDS
Government: The Royal Government of Bhutan acted early to initiate HIV prevention activities in the country. In 1988, five years before the first HIV infection was detected in the country, the Royal Government established a National HIV/AIDS and STD Control Program (NACP). The program is managed by the Ministry of Health.
Bhutan has demonstrated a strong political commitment to preventing and controlling the spread of HIV. Her Majesty Queen Ashi Sangay Choden Wangchuk is the UNFPA Goodwill Ambassador and an outspoken advocate of reproductive health, including HIV prevention. Furthermore, the government’s Ninth Five-Year Plan has identified HIV/AIDS and STI prevention and control as one of the most important programs for addressing emerging health issues and promoting better health for women and adolescents in Bhutan.
The national program, which has been financed substantially by donors, has focused on carrying out studies and monitoring specific populations, screening blood to ensure blood safety, integrating management of STIs into primary health care, improving treatment of STIs, and setting up voluntary counseling and testing at the National Referral Hospital and two independent facilities in Thimphu and Phuntsholing. It has also worked closely with line ministries and district governments to address HIV and AIDS multisectorally, training health personnel, and producing information, education, and communications materials.
The program requires stronger intervention in other areas that are most effective in a low-prevalence setting: providing prevention services to and empowering those who are most at risk of contracting HIV (MARPs); reducing stigma and discrimination; and improving the information base for better monitoring and evaluation as well as policy and planning decisions.
Non-Governmental Organizations (NGOs): Although local NGOs are nonexistent, Bhutan has civil society organizations such as religious bodies and youth groups which have an important role to play in HIV prevention and care.
Issues and Challenges: Priority Areas
The usual approaches to reach MARPs are difficult to mount in Bhutan: In a low prevalence setting, a concentrated epidemic will only be averted if MARPs are adequately reached. In most countries these interventions are implemented by NGOs and Community Based Organizations (CBOs). However, there are practically no NGOs in Bhutan and CBOs lack the necessary experience and none have worked on HIV. Even bringing PLWA to work together is difficult given the lack of privacy and stigma. NACP needs to encourage and train CBOs to work with MARPs and gradually scale up interventions. A well designed communications program can assist in reducing stigma. Given the less rigid attitudes towards sex, NACP also needs to target “hot spots” to increase condom use.
Human and physical constraints: Bhutan has a serious shortage of manpower at all levels and available staff is overstretched. Skills in some areas are lacking and the necessary t echnical expertise is often not available in-country. The rugged terrain and distances that need to be traveled to reach much of the country imply higher costs and greater difficulties to provide the necessary supervision and support. Better coordination and more targeted use of resources can improve program performance given limited human resources. This implies a strengthening of the information base on risk behavior and epidemic trends, as well as data to monitor the response. District level capacity needs to be strengthened.
World Bank Response
In June 2002, the World Bank, in collaboration with the Royal Government of Bhutan, carried out a rapid situational assessment, as a basis for discussions on possible support for the Government’s efforts to combat HIV and AIDS. In June 2004, the Bank approved an IDA grant of US$5.8 million for the HIV/AIDS and STI Prevention Project. The project seeks to scale up the Government’s efforts to contain the epidemic and reduce the incidence and prevalence of STIs. Specifically, it seeks to:
Expand HIV and STI prevention interventions, especially for most-at-risk populations.
Initiate care and treatment for people living with HIV and AIDS (PLWHA).
Improve STI prevention and treatment.
Improve human resources through long-term and short-term training and country exchanges, particularly in the area of public health and laboratory science.
Improve blood safety.
Improve management and technical capacity of Dzongkhags, line ministries, and civil society organizations to undertake HIV/AIDS prevention.
Strengthen surveillance, monitoring and evaluation, and information systems for better decision making on policies and programs, and expand the information base.
Engage community-based organizations, NGOs, local governments, and multi-sectoral agencies at the district level in expanding and accelerating HIV/AIDS interventions among populations.
COUNTRY PROFILE:Bangladesh
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HIV in Bangladesh remains at relatively low levels in most at risk population groups, with the exception of injecting drug users (IDUs) where prevalence continues to grow. UNAIDS estimates that about 12,000 Bangladeshis were living with HIV at the end of 2007. Although overall HIV prevalence remains under 0.1 percent among the general population in Bangladesh, there are risk factors that could fuel the spread of HIV among high-risk groups. Prompt and vigorous action is needed to strengthen the quality and coverage of HIV prevention programs, particularly amongst IDUs.
State of the Epidemic
Bangladesh’s seventh round of serological surveillance (2006) showed that HIV prevalence among all high risk groups remained below 1 percent with the exception of injecting drug users. Among injecting drug users, prevalence was less than 2 percent in all sites except Dhaka. In Dhaka, prevalence rose from 1.7 percent in 1999 to 7 percent in 2006 marking the first concentrated epidemic among any high risk group in Bangladesh.
Risk Factors
Bangladesh is vulnerable to an expanded HIV epidemic due to the prevalence of behavior patterns and risk factors that facilitate the rapid spread of HIV. Risk factors include:
Large Commercial Sex Industry: There are over 105,000 male and female sex workers in Bangladesh. Brothel-based female sex workers reportedly see around 18 clients per week, while street-based and hotel-based workers see an average of 17 and 44 clients per week respectively.
Condom Use: 6th round BSS (2006-2007) data indicate significant improvement in condom use during last sex with new client particularly among brothel and street based workers. Condom use was 70 percent for brothel workers and ranged between 51 to 81 percent among street workers. However, condom use was low among hotel based sex workers in Dhaka and Chittagong at 40 and 36 percent respectively. Hotel based workers are especially vulnerable to HIV as they have the largest number of clients. Consistent condom use and with regular clients is lower for all sub-groups.
Sexually Transmitted Infections: Syphilis rates fell among brothel and street based sex workers in Dhaka and among IDUs in Dhaka and Rajshahi between 2004 and 2006. Syphilis rates, however, have remained unchanged for hotel based sex workers, male sex workers and street based workers in Chittagong indicating the presence of other risky sexual behaviors that facilitate the spread of the HIV.
Needle-sharing among Injecting Drug Users: The seventh round of serological surveillance data show that there is a concentrated epidemic among IDUs in one neighborhood of Dhaka with an HIV prevalence of 10.4 percent. This level of infection among IDUs poses a significant risk as the infection can spread rapidly – and is spreading – within the group, then through their sexual partners and their clients into the general population. The BSS data for 2006-2007 indicate the persistence of unsafe injecting practices among IDUs and the majority still share needles and syringes. Another concern is the significant number of IDUs who sell their blood professionally. Bangladesh continues to rely on professional blood-sellers to meet part of the transfusion needs of its people.
Lack of Knowledge: Data on knowledge and behavior indicates that only 17 percent of the most-at-risk populations have correct knowledge about prevention and misconceptions on HIV/AIDS. Furthermore, a 2005 population-based survey among adolescents and young people (15-24 years) indicated that only one out of three males in urban and one out of four in rural areas had correct knowledge of HIV and AIDS. Among the general population, data indicate that 59 percent of ever-married women and 42 percent of men of age 15-54 could not mention a single way to avoid contracting HIV.
High level of stigma associated with people living with HIV.
People engaged in high risk behaviors often have limited access to health care.
National Response to HIV/AIDS
Government: In late 1996, the Directorate of Health Services in the Ministry of Health and Family Welfare outlined a National Policy on HIV/AIDS. A high-level National AIDS Committee (NAC) was formed, with a Technical Advisory Committee, and a National AIDS/STD Program (NASP) unit in the ministry. The NAC includes representatives from key ministries, NGOs and a few parliamentarians. Action has been taken to develop a multi-sector response to HIV/AIDS. Strategic action plans for the National AIDS/STD Program set forth fundamental principles, with specific guidelines on a range of HIV issues including testing, care, blood safety, prevention among youth, women, migrant workers, sex workers, and STIs. While earlier commitment was limited and implementation of HIV control activities was slow, Bangladesh has strengthened its programs to improve its response. The 2005 Poverty Reduction Strategy Paper of the Government highlighted HIV/AIDS in the health section. The Government of Bangladesh also prepared the National Strategic Plan for HIV/AIDS for the period 2004-2010 under the guidance of NAC and with the involvement and support of different stakeholders. Efforts to mainstream HIV/AIDS in public sectors outside the Ministry of Health and Family Welfare were initiated through designation and training of focal points on HIV/AIDS in 16 government ministries.
Non-Governmental Organizations (NGOs): More than 380 NGOs and AIDS Service Organizations have been implementing programs/projects in different parts of the country. These initiatives focused on prevention of sexual transmission among high-risk groups involving mostly female sex workers, MSM, IDUs, rickshaw pullers and truckers. NGOs are often in a better position than the public sector to reach high-risk groups, such as sex workers and their clients and injecting drug users. Building the capacity of NGOs, especially the small ones, and combining their reach with the resources and strategic programs of the government is an effective way to change behavior in high-risk groups and prevent the spread of the virus to the general public.
Donors: A Global Fund grant for $40 million (Round 6) to promote prevention of HIV among adolescents and young people brings together Government and Save the Children, USA and is being implemented through NGOs. The FHI/USAID supported project ($13 million, 2005-2008) is also focusing on selected interventions for some high-risk groups including expansion of VCT services.
Issues and Challenges: Priority Areas
Vigorous action is required to prevent further spread of HIV in Bangladesh. Key tasks include:
Scale up behavioral change activities and health promotion interventions for high-risk behaviors and vulnerable groups, particularly IDUs and sex workers.
Expand advocacy and awareness among the general population through multi-sectoral agencies.
Promote the social acceptability of condom use and ensure adequate supply and access.
Reduce discrimination against those infected with HIV, or groups engaging in high-risk behaviors, through appropriate advocacy, policies, and related measures.
Strengthen the Government’s capacity for program implementation, management, and monitoring of program activities.
Promote NGO capacity for program planning, implementation, and supervision of interventions.
Strengthen mechanisms for collaboration and coordination within and between government, the non-governmental sector, development partners, and other stakeholders.
World Bank Response
The World Bank supports the Government's two-pronged strategy: First, increasing advocacy, prevention, and treatment of HIV/AIDS within the Government's existing health programs, and second, scaling up interventions among high risk groups.
The HIV/AIDS Prevention Project (HAPP 2000-2007) jointly financed by the Bank and DfID provided $27 million of assistance to support the scaling up of interventions among groups at high risk in a rapid and focused manner while strengthening overall program management. Three UN agencies assisted the Government in the implementation of key project components: UNICEF managed the NGO service delivery component, WHO managed the blood safety activities, and UNFPA managed the capacity building component. With the closure of the project, HIV interventions are being integarated into the Government of Bangladesh and Multi-Donor supported Health, Nutrition and Population Sector Program.
Last updated: 2008-07-29
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HIV in Bangladesh remains at relatively low levels in most at risk population groups, with the exception of injecting drug users (IDUs) where prevalence continues to grow. UNAIDS estimates that about 12,000 Bangladeshis were living with HIV at the end of 2007. Although overall HIV prevalence remains under 0.1 percent among the general population in Bangladesh, there are risk factors that could fuel the spread of HIV among high-risk groups. Prompt and vigorous action is needed to strengthen the quality and coverage of HIV prevention programs, particularly amongst IDUs.
State of the Epidemic
Bangladesh’s seventh round of serological surveillance (2006) showed that HIV prevalence among all high risk groups remained below 1 percent with the exception of injecting drug users. Among injecting drug users, prevalence was less than 2 percent in all sites except Dhaka. In Dhaka, prevalence rose from 1.7 percent in 1999 to 7 percent in 2006 marking the first concentrated epidemic among any high risk group in Bangladesh.
Risk Factors
Bangladesh is vulnerable to an expanded HIV epidemic due to the prevalence of behavior patterns and risk factors that facilitate the rapid spread of HIV. Risk factors include:
Large Commercial Sex Industry: There are over 105,000 male and female sex workers in Bangladesh. Brothel-based female sex workers reportedly see around 18 clients per week, while street-based and hotel-based workers see an average of 17 and 44 clients per week respectively.
Condom Use: 6th round BSS (2006-2007) data indicate significant improvement in condom use during last sex with new client particularly among brothel and street based workers. Condom use was 70 percent for brothel workers and ranged between 51 to 81 percent among street workers. However, condom use was low among hotel based sex workers in Dhaka and Chittagong at 40 and 36 percent respectively. Hotel based workers are especially vulnerable to HIV as they have the largest number of clients. Consistent condom use and with regular clients is lower for all sub-groups.
Sexually Transmitted Infections: Syphilis rates fell among brothel and street based sex workers in Dhaka and among IDUs in Dhaka and Rajshahi between 2004 and 2006. Syphilis rates, however, have remained unchanged for hotel based sex workers, male sex workers and street based workers in Chittagong indicating the presence of other risky sexual behaviors that facilitate the spread of the HIV.
Needle-sharing among Injecting Drug Users: The seventh round of serological surveillance data show that there is a concentrated epidemic among IDUs in one neighborhood of Dhaka with an HIV prevalence of 10.4 percent. This level of infection among IDUs poses a significant risk as the infection can spread rapidly – and is spreading – within the group, then through their sexual partners and their clients into the general population. The BSS data for 2006-2007 indicate the persistence of unsafe injecting practices among IDUs and the majority still share needles and syringes. Another concern is the significant number of IDUs who sell their blood professionally. Bangladesh continues to rely on professional blood-sellers to meet part of the transfusion needs of its people.
Lack of Knowledge: Data on knowledge and behavior indicates that only 17 percent of the most-at-risk populations have correct knowledge about prevention and misconceptions on HIV/AIDS. Furthermore, a 2005 population-based survey among adolescents and young people (15-24 years) indicated that only one out of three males in urban and one out of four in rural areas had correct knowledge of HIV and AIDS. Among the general population, data indicate that 59 percent of ever-married women and 42 percent of men of age 15-54 could not mention a single way to avoid contracting HIV.
High level of stigma associated with people living with HIV.
People engaged in high risk behaviors often have limited access to health care.
National Response to HIV/AIDS
Government: In late 1996, the Directorate of Health Services in the Ministry of Health and Family Welfare outlined a National Policy on HIV/AIDS. A high-level National AIDS Committee (NAC) was formed, with a Technical Advisory Committee, and a National AIDS/STD Program (NASP) unit in the ministry. The NAC includes representatives from key ministries, NGOs and a few parliamentarians. Action has been taken to develop a multi-sector response to HIV/AIDS. Strategic action plans for the National AIDS/STD Program set forth fundamental principles, with specific guidelines on a range of HIV issues including testing, care, blood safety, prevention among youth, women, migrant workers, sex workers, and STIs. While earlier commitment was limited and implementation of HIV control activities was slow, Bangladesh has strengthened its programs to improve its response. The 2005 Poverty Reduction Strategy Paper of the Government highlighted HIV/AIDS in the health section. The Government of Bangladesh also prepared the National Strategic Plan for HIV/AIDS for the period 2004-2010 under the guidance of NAC and with the involvement and support of different stakeholders. Efforts to mainstream HIV/AIDS in public sectors outside the Ministry of Health and Family Welfare were initiated through designation and training of focal points on HIV/AIDS in 16 government ministries.
Non-Governmental Organizations (NGOs): More than 380 NGOs and AIDS Service Organizations have been implementing programs/projects in different parts of the country. These initiatives focused on prevention of sexual transmission among high-risk groups involving mostly female sex workers, MSM, IDUs, rickshaw pullers and truckers. NGOs are often in a better position than the public sector to reach high-risk groups, such as sex workers and their clients and injecting drug users. Building the capacity of NGOs, especially the small ones, and combining their reach with the resources and strategic programs of the government is an effective way to change behavior in high-risk groups and prevent the spread of the virus to the general public.
Donors: A Global Fund grant for $40 million (Round 6) to promote prevention of HIV among adolescents and young people brings together Government and Save the Children, USA and is being implemented through NGOs. The FHI/USAID supported project ($13 million, 2005-2008) is also focusing on selected interventions for some high-risk groups including expansion of VCT services.
Issues and Challenges: Priority Areas
Vigorous action is required to prevent further spread of HIV in Bangladesh. Key tasks include:
Scale up behavioral change activities and health promotion interventions for high-risk behaviors and vulnerable groups, particularly IDUs and sex workers.
Expand advocacy and awareness among the general population through multi-sectoral agencies.
Promote the social acceptability of condom use and ensure adequate supply and access.
Reduce discrimination against those infected with HIV, or groups engaging in high-risk behaviors, through appropriate advocacy, policies, and related measures.
Strengthen the Government’s capacity for program implementation, management, and monitoring of program activities.
Promote NGO capacity for program planning, implementation, and supervision of interventions.
Strengthen mechanisms for collaboration and coordination within and between government, the non-governmental sector, development partners, and other stakeholders.
World Bank Response
The World Bank supports the Government's two-pronged strategy: First, increasing advocacy, prevention, and treatment of HIV/AIDS within the Government's existing health programs, and second, scaling up interventions among high risk groups.
The HIV/AIDS Prevention Project (HAPP 2000-2007) jointly financed by the Bank and DfID provided $27 million of assistance to support the scaling up of interventions among groups at high risk in a rapid and focused manner while strengthening overall program management. Three UN agencies assisted the Government in the implementation of key project components: UNICEF managed the NGO service delivery component, WHO managed the blood safety activities, and UNFPA managed the capacity building component. With the closure of the project, HIV interventions are being integarated into the Government of Bangladesh and Multi-Donor supported Health, Nutrition and Population Sector Program.
Last updated: 2008-07-29
HIV/AIDS IN SAARC COUNTRIES....
COUNTRY PROFILE:Afghanistan
Printer Friendly Version (pdf)
State of the Epidemic
Reliable data on HIV prevalence in Afghanistan is sparse. To date, 478 HIV cases have been reported, however, UNAIDS and WHO estimate that there could be between 1,000 and 2,000 Afghans living with HIV. The HIV epidemic is at an early stage in Afghanistan, and is concentrated among high risk groups, mainly injecting drug users (IDUs) and their partners. Afghanistan’s emerging epidemic likely hinges on a combination of injecting drug use and unsafe paid sex. According to a 2006 study, percent of IDUs in Kabul were HIV positive. Almost one third of the IDUs participating in the study said they used contaminated injecting equipment. In addition, large proportions of these (male) drug users also engaged in other high-risk behavior. For example, 32 percent had sex with men or boys, and 69 percent bought sex. Only about half of the IDUs knew that using unclean syringes carries a high risk of HIV transmission or that condoms can prevent infection.
Risk Factors
Knowledge is increasing about the factors that influence the spread of HIV in Afghanistan. Risks and vulnerabilities that play a role and which require further investigation include:
Injecting Drug Use: Afghanistan is the world’s largest producer of opium, which is used to make heroin. A 2005 survey estimated that Afghanistan had almost one million drug users including 200,000 opium users and 19,000 drug injectors of whom 12,000 inject prescription drugs and 7,000 inject heroin. A 2006 survey in Kabul estimated that several categories of drug use had increased by more than 200 percent in 12 months. The intensification of the war on drugs, by reducing the availability of heroin, can cause drug users to turn to injecting drugs as a more cost-effective option. These factors, combined with poverty and the lack of information, can lead to widespread injecting drug use and the sharing of needles. The use of non-sterile injecting equipment can jumpstart an epidemic and lead to rapid increase in HIV prevalence.
Large Numbers of Refugees and Displaced People: Approximately eight million Afghans spent some time living abroad as refugees, in Pakistan (5 million) and Iran (3 million). Today, about one million widows and 1.6 million orphans, four million returnees and 500,000 internally displaced people live in Afghanistan, while almost four million Afghan refugees still live in Pakistan and Iran. These countries have rapidly growing IDU driven HIV epidemics. Although little is known about the HIV risk behaviors of Afghan refugees and displaced people, such groups generally have little access to information about HIV. They are also at risk due to isolation from their families and lack of means to support themselves.
High Levels of Illiteracy: Illiteracy presents a barrier to HIV awareness and prevention. The literacy rate in the general population is very low (36 percent) and lowest among women (13 percent) with little awareness about HIV and AIDS and almost no condom use.
Competing Health Priorities: Afghanistan has one of the worst maternal mortality rates in the world, with an estimated 15,000 Afghan women dying every year from pregnancy-related causes. One in four children dies before its fifth birthday; more than half the deaths are due to acute respiratory tract infections, diarrhea, and vaccine-preventable diseases. Early attention and response to HIV and AIDS risks getting lost amid the focus on these other urgent health issues.
Low Status of Women: Women in Afghanistan experience one of the lowest social positions in the world. Denied access to education and jobs and often not allowed to leave their homes without a male relative, they lack access to information on how to protect themselves.
Issues and Challenges: Priority Areas
Universal access to health care services for most at risk groups. The Ministry of Public Health is committed to universal access to health services. However, due to stigma, discrimination and other socio-economic factors access to services for most at risk groups is limited.
Gather data for planning and action. Behavioral surveillance data and knowledge, attitude and practice (KAP) surveys are urgently needed to develop a coherent plan which can be translated into effective action. Mapping of high-risk groups such as injecting drug users and sex workers was conducted in 2007 in Kabul, Jalalabad and Mazar, and different HIV prevalence studies have been conducted among IDUs. However, the information about IDUs, MSM and sex workers networks remain limited.
Implement a multi-sector response. Coordination among ministries is crucial to guarantee health services to IDUs, sex workers and prisoners, who are currently facing barriers to access. It is also important to increase HIV awareness, and reduce stigma. It is especially important that, in addition to the health sector, the counter narcotics, transport, justice, interior, religious, women’s affairs and education sectors are involved.
Expansion of primary health care services to remote underserved areas. The primary health care system is the backbone of any HIV/AIDS program. An effective, community-oriented primary health care system will improve reproductive health. This includes providing access to condoms, treating STIs, and increasing public awareness of HIV/AIDS and methods to prevent the spread of HIV. It is critical that the primary health care services be expanded to remote underserved areas
National Response to HIV/AIDS
Government: The Ministry of Public Health has developed a national strategic plan (2006-2010), with goals to maintain low HIV prevalence (less than 0.5 percent) and to reduce the mortality and morbidity associated with HIV and AIDS. This strategic framework has been translated into a program operational plan (POP). Reversing the spread of HIV has also been included as a goal of the Afghanistan National Development Strategy (ANDS)
According to the Afghanistan National HIV/AIDS Strategic Framework, the six objectives are to:
Strengthen strategic information to guide policy formation, program planning and implementation;
Gain political commitment and mobilize resources necessary to implement the national HIV/AIDS/STI strategy;
Ensure development and coordination of a multi-sector HIV/AIDS response and develop institutional capacity of all sectors involved;
Raise public awareness on HIV/AIDS and STI prevention and control, ensure universal access to behavior change communication on HIV, especially targeting vulnerable and at risk groups;
Ensure access to prevention, treatment and care services for high-risk and vulnerable populations;
Strengthen the health sector capacity to implement an essential package of HIV/AIDS prevention, treatment and care services within the framework of Basic Package of Health Services and Essential Package of Hospital Services.
To address the multi-sectoral issues attached to the HIV epidemic, the Afghanistan HIV/AIDS Coordination Committee (HACCA) was established in 2007. The HACCA acts as a policy forum for different ministries, NGOs, and civil society involved in the fight against HIV and AIDS.
An international conference on Opioid Substitution Therapy (OST) was held in Kabul in November 2007 with participation of experts from Afghanistan, Uzbekistan, India, Europe and the United States. This conference was an important step towards the establishment of OST in Afghanistan and a sign of the growing organizational capacity of the National AIDS Control Program.
Non-Governmental Organizations (NGOs): Afghanistan has both international and national NGOs involved in the provision of health services. Eighty percent of existing health facilities are either operated or supported by NGOs. The support of NGOs by the health care system is critical, including drug supplies, supervision, training, and incentives. NGOs play a key role in reaching most at risk and vulnerable groups (injecting drug users and their partners, sex workers and their clients; prisoners and others). Several NGOs are involved in targeted interventions to prevent HIV among high risk groups, though still on a small scale.
Donors: UNICEF (through PMTCT, training, and MSM study), UNFPA (through VCCTs), and WHO (through ART and TB/HIV projects) are supporting Afghanistan’s efforts to combat HIV/AIDS. The total budget of these UN agencies is around $500,000 per year. UNODC is also very active in the country, though primarily focused on demand reduction interventions. The Global Fund to Fight AIDS, Tuberculosis, and Malaria has approved a proposal for US$ 11 million that will finance harm reduction activities in 8 provinces of the country: activities are expected to start in September 2008. Other partners include the Asian Development Bank and USAID. USAID is expected to provide US$ 1 million to explore MSM networks, to support laboratories and to finance the HACCA Secretariat.
World Bank Response
In 2007, the World Bank signed a three year, US$10 million grant with the Government of the Islamic Republic of Afghanistan to enhance the national response to HIV/AIDS through the Afghanistan HIV/AIDS Prevention Project.
The project will provide harm reduction services to at risk groups (IDUs, sex workers, prisoners, and truckers) in different cities (Kabul, Mazar, Jalalabad, Herat). Services will be provided by NGOs selected through a competitive process. The project also aims at strengthening surveillance through integrated biological and behavioral surveys and knowledge, attitudes and practice studies to be conducted among high risk groups by Johns Hopkins University. The project aims to increase awareness of HIV prevention and reduce stigma and discrimination through communications and advocacy activities to be implemented by Constella Futures.
The project is funding capacity building activities to strengthen the National AIDS Control Program in areas such as program management, monitoring and evaluation, communication etc. Funding for multi-sector innovative activities will also be made available to NGOs and ministries other than public health, to enhance the multi-sector response to HIV.
As mentioned above, project activities will be carried out by agencies (national NGOs and international institutions) to be contracted by the National AIDS Control Program. The contracts for HIV surveillance and advocacy and communication were signed in July 2008, while nine other contracts are expected to be signed by August 2008.
Printer Friendly Version (pdf)
State of the Epidemic
Reliable data on HIV prevalence in Afghanistan is sparse. To date, 478 HIV cases have been reported, however, UNAIDS and WHO estimate that there could be between 1,000 and 2,000 Afghans living with HIV. The HIV epidemic is at an early stage in Afghanistan, and is concentrated among high risk groups, mainly injecting drug users (IDUs) and their partners. Afghanistan’s emerging epidemic likely hinges on a combination of injecting drug use and unsafe paid sex. According to a 2006 study, percent of IDUs in Kabul were HIV positive. Almost one third of the IDUs participating in the study said they used contaminated injecting equipment. In addition, large proportions of these (male) drug users also engaged in other high-risk behavior. For example, 32 percent had sex with men or boys, and 69 percent bought sex. Only about half of the IDUs knew that using unclean syringes carries a high risk of HIV transmission or that condoms can prevent infection.
Risk Factors
Knowledge is increasing about the factors that influence the spread of HIV in Afghanistan. Risks and vulnerabilities that play a role and which require further investigation include:
Injecting Drug Use: Afghanistan is the world’s largest producer of opium, which is used to make heroin. A 2005 survey estimated that Afghanistan had almost one million drug users including 200,000 opium users and 19,000 drug injectors of whom 12,000 inject prescription drugs and 7,000 inject heroin. A 2006 survey in Kabul estimated that several categories of drug use had increased by more than 200 percent in 12 months. The intensification of the war on drugs, by reducing the availability of heroin, can cause drug users to turn to injecting drugs as a more cost-effective option. These factors, combined with poverty and the lack of information, can lead to widespread injecting drug use and the sharing of needles. The use of non-sterile injecting equipment can jumpstart an epidemic and lead to rapid increase in HIV prevalence.
Large Numbers of Refugees and Displaced People: Approximately eight million Afghans spent some time living abroad as refugees, in Pakistan (5 million) and Iran (3 million). Today, about one million widows and 1.6 million orphans, four million returnees and 500,000 internally displaced people live in Afghanistan, while almost four million Afghan refugees still live in Pakistan and Iran. These countries have rapidly growing IDU driven HIV epidemics. Although little is known about the HIV risk behaviors of Afghan refugees and displaced people, such groups generally have little access to information about HIV. They are also at risk due to isolation from their families and lack of means to support themselves.
High Levels of Illiteracy: Illiteracy presents a barrier to HIV awareness and prevention. The literacy rate in the general population is very low (36 percent) and lowest among women (13 percent) with little awareness about HIV and AIDS and almost no condom use.
Competing Health Priorities: Afghanistan has one of the worst maternal mortality rates in the world, with an estimated 15,000 Afghan women dying every year from pregnancy-related causes. One in four children dies before its fifth birthday; more than half the deaths are due to acute respiratory tract infections, diarrhea, and vaccine-preventable diseases. Early attention and response to HIV and AIDS risks getting lost amid the focus on these other urgent health issues.
Low Status of Women: Women in Afghanistan experience one of the lowest social positions in the world. Denied access to education and jobs and often not allowed to leave their homes without a male relative, they lack access to information on how to protect themselves.
Issues and Challenges: Priority Areas
Universal access to health care services for most at risk groups. The Ministry of Public Health is committed to universal access to health services. However, due to stigma, discrimination and other socio-economic factors access to services for most at risk groups is limited.
Gather data for planning and action. Behavioral surveillance data and knowledge, attitude and practice (KAP) surveys are urgently needed to develop a coherent plan which can be translated into effective action. Mapping of high-risk groups such as injecting drug users and sex workers was conducted in 2007 in Kabul, Jalalabad and Mazar, and different HIV prevalence studies have been conducted among IDUs. However, the information about IDUs, MSM and sex workers networks remain limited.
Implement a multi-sector response. Coordination among ministries is crucial to guarantee health services to IDUs, sex workers and prisoners, who are currently facing barriers to access. It is also important to increase HIV awareness, and reduce stigma. It is especially important that, in addition to the health sector, the counter narcotics, transport, justice, interior, religious, women’s affairs and education sectors are involved.
Expansion of primary health care services to remote underserved areas. The primary health care system is the backbone of any HIV/AIDS program. An effective, community-oriented primary health care system will improve reproductive health. This includes providing access to condoms, treating STIs, and increasing public awareness of HIV/AIDS and methods to prevent the spread of HIV. It is critical that the primary health care services be expanded to remote underserved areas
National Response to HIV/AIDS
Government: The Ministry of Public Health has developed a national strategic plan (2006-2010), with goals to maintain low HIV prevalence (less than 0.5 percent) and to reduce the mortality and morbidity associated with HIV and AIDS. This strategic framework has been translated into a program operational plan (POP). Reversing the spread of HIV has also been included as a goal of the Afghanistan National Development Strategy (ANDS)
According to the Afghanistan National HIV/AIDS Strategic Framework, the six objectives are to:
Strengthen strategic information to guide policy formation, program planning and implementation;
Gain political commitment and mobilize resources necessary to implement the national HIV/AIDS/STI strategy;
Ensure development and coordination of a multi-sector HIV/AIDS response and develop institutional capacity of all sectors involved;
Raise public awareness on HIV/AIDS and STI prevention and control, ensure universal access to behavior change communication on HIV, especially targeting vulnerable and at risk groups;
Ensure access to prevention, treatment and care services for high-risk and vulnerable populations;
Strengthen the health sector capacity to implement an essential package of HIV/AIDS prevention, treatment and care services within the framework of Basic Package of Health Services and Essential Package of Hospital Services.
To address the multi-sectoral issues attached to the HIV epidemic, the Afghanistan HIV/AIDS Coordination Committee (HACCA) was established in 2007. The HACCA acts as a policy forum for different ministries, NGOs, and civil society involved in the fight against HIV and AIDS.
An international conference on Opioid Substitution Therapy (OST) was held in Kabul in November 2007 with participation of experts from Afghanistan, Uzbekistan, India, Europe and the United States. This conference was an important step towards the establishment of OST in Afghanistan and a sign of the growing organizational capacity of the National AIDS Control Program.
Non-Governmental Organizations (NGOs): Afghanistan has both international and national NGOs involved in the provision of health services. Eighty percent of existing health facilities are either operated or supported by NGOs. The support of NGOs by the health care system is critical, including drug supplies, supervision, training, and incentives. NGOs play a key role in reaching most at risk and vulnerable groups (injecting drug users and their partners, sex workers and their clients; prisoners and others). Several NGOs are involved in targeted interventions to prevent HIV among high risk groups, though still on a small scale.
Donors: UNICEF (through PMTCT, training, and MSM study), UNFPA (through VCCTs), and WHO (through ART and TB/HIV projects) are supporting Afghanistan’s efforts to combat HIV/AIDS. The total budget of these UN agencies is around $500,000 per year. UNODC is also very active in the country, though primarily focused on demand reduction interventions. The Global Fund to Fight AIDS, Tuberculosis, and Malaria has approved a proposal for US$ 11 million that will finance harm reduction activities in 8 provinces of the country: activities are expected to start in September 2008. Other partners include the Asian Development Bank and USAID. USAID is expected to provide US$ 1 million to explore MSM networks, to support laboratories and to finance the HACCA Secretariat.
World Bank Response
In 2007, the World Bank signed a three year, US$10 million grant with the Government of the Islamic Republic of Afghanistan to enhance the national response to HIV/AIDS through the Afghanistan HIV/AIDS Prevention Project.
The project will provide harm reduction services to at risk groups (IDUs, sex workers, prisoners, and truckers) in different cities (Kabul, Mazar, Jalalabad, Herat). Services will be provided by NGOs selected through a competitive process. The project also aims at strengthening surveillance through integrated biological and behavioral surveys and knowledge, attitudes and practice studies to be conducted among high risk groups by Johns Hopkins University. The project aims to increase awareness of HIV prevention and reduce stigma and discrimination through communications and advocacy activities to be implemented by Constella Futures.
The project is funding capacity building activities to strengthen the National AIDS Control Program in areas such as program management, monitoring and evaluation, communication etc. Funding for multi-sector innovative activities will also be made available to NGOs and ministries other than public health, to enhance the multi-sector response to HIV.
As mentioned above, project activities will be carried out by agencies (national NGOs and international institutions) to be contracted by the National AIDS Control Program. The contracts for HIV surveillance and advocacy and communication were signed in July 2008, while nine other contracts are expected to be signed by August 2008.
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