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.