Young People and HIV/AIDS Young People at the Centre of HIV/AIDS Epidemic Young people aged between 10 and 24 years account for one third of the total population of Bangladesh, or approximately 38 million1. Although Bangladesh is a conservative society, studies have revealed that young people irrespective of marital status engage in unprotected sexual encounters that are high risk for exposure to HIV2. They are not always aware of the risks and dangers posed by unsafe sexual activity and other risk behaviours like injecting drugs and are ill informed and unprepared to protect themselves (Table 1). With this as background, young people have been identified as one of the more vulnerable groups in Bangladesh with regard to HIV/AIDS. In Bangladesh, the prevalence rate for HIV among adults is well below 1%3. However, the sixth round of serological surveillance (2005) shows that there is almost a concentrated epidemic among injecting drug users (IDUs) with HIV rates in central Bangladesh having risen from 1.4% to 4.9% since 1999, and to as high as 8.9% in some neighbouring areas. There are several factors that make Bangladesh vulnerable to an HIV epidemic. The country is geographically situated in close proximity to India and Myanmar, which have a high HIV prevalence, and Nepal which has a concentrated HIV epidemic among IDUs. Open borders, sex industry, links between highrisk groups and bridging populations, labour migration, gender inequities, poverty, low literacy levels, gaps in healthcare delivery and low levels of HIV/AIDS awareness have also been identified as important factors in the spread of HIV infection. The first case of AIDS in Bangladesh was detected in 1989. Since then a total of 658 cases of HIV/AIDS have been confirmed and reported till the end of December 2005. The estimated number of people living with HIV/ AIDS was around 7 500 as on December 20044.
Table 1: Selected data on young people from the 4th Round of National HIV Behavioural Surveillance (2002) Behaviour Bought sex from female in the past month Sought STI treatment at formal facilities Bought sex from male/hijra in the past month Condom use at last commercial sex with female Injected drug in past year *among students of colleges and universities who live in dormitories
Percent 18.2%* 50.5% 2.7%
35.3% 0.4%
Source: 4th Round of National & Behavioural Surveillance Survey (2002), Government of Bangladesh.
Young People Are Vulnerable to HIV & STIs A national baseline HIV/AIDS survey among young people aged 15-24 years established that the STI disease burden was high among them . Approximately 25% of males and 21% of females in the surveyed population reported symptoms of sexually transmitted infections (STIs). 5
STIs have significant implications for the vulnerability of young people to HIV. High levels of STIs among them expose the high levels of unprotected sex, which puts them at risk of contracting HIV. The probability of contracting HIV significantly increases in the presence of STIs.
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The survey revealed that unmarried males who had a history of sexual exposure had a higher prevalence of STI symptoms in the past one year compared to those who were not sexually active (26% and 14% respectively). Similarly, of all married males those who had a history of sexual exposure before marriage and a history of extramarital sex had higher prevalence of STI symptoms (28% as compared to 14%) (Figure 1).
of the male and female youth surveyed actually perceived the risk of STI and HIV infection (Figure 2).
Figure 2: STI knowledge & risk perception among youth 70 60 50 58.6 59.3
Percent
Figure 1: Reported STI symptoms in past one year among male youth (15-24 years) 30
40 31.5 31.9
30 20 10 0
Percent reporting STI symptoms
26
28
25 20 15 10 5 0 Unmarried male Married male Unmarried male not sexually active, married male no extramarital sex Unmarried male sexually active, married male having extramarital sex 14 14
3.7
2.1
2.2 1.1
STI transmission knowledge
Male
Female
Source : Baseline HIV/AIDS Survey among Youth in Bangladesh, ICDDR, B: Centre for Health and Population Research; Associates for Community and Population Research (ACPR); Population Council, Bangladesh, August 2005
Source : Baseline HIV/AIDS Survey among Youth in Bangladesh, ICDDR, B: Centre for Health and Population Research; Associates for Community and Population Research (ACPR); Population Council, Bangladesh, August 2005
Young men and women do not perceive themselves to be at risk of acquiring STI/HIV due to lack of awareness and rampant misconception regarding the transmission and prevention of STIs. Lack of knowledge on STI symptoms and consequent delays in care-seeking behaviour increases their risk towards HIV.
Knowledge on STI transmission, prevention and symptoms among young people was found to be very low. Most youths did not perceive the risk for HIV as they had little or no knowledge of the fact that STI increases the vulnerability towards HIV. Less than 5%
Many Young People Are Especially at High Risk Girls and young women Girls and young women are more susceptible to STI/ HIV infection than men due to biological and other factors such as the need to receive blood transfusion more often on account of anaemia or complications at child birth. Low social status of women in Bangladesh and other contextual features including widespread poverty, low literacy and educational levels and limited skill training and employment opportunities place girls and young women in particular at a high risk of infection. Women are also more at risk from violence, trafficking and coercive sex or from the economic vulnerability that forces them into sex work. Their economic situation also compromises their ability to negotiate protection or leave risky relationships. Early marriage further deprives women of a chance of acquiring more autonomy, access to information and negotiating power in matters of sexuality. The mean age of marriage of girls in Bangladesh is 16.9 years. While 48% of 15-19 year-old girls are married, about 60% of them become mothers before the age of 196. Married women are also at a growing risk of HIV and STIs due to the risky behaviour of their spouses who may visit sex workers or engage in IDU practice. In fact, a higher prevalence of STI was observed in married women in comparison with unmarried women5.
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Perceived risk of HIV
Perceived risk of STI
STI prevention knowledge
Young sex workers Young sex workers have been identified as the most at risk population for HIV/AIDS. Sex workers in Bangladesh report the highest number of partners per week in Asia (18 to 44) and their partners have the lowest figures for use of condoms in any Asian country7. The porous borders of Bangladesh have also led to increased and unabated trafficking of young adults and children to the neighbouring countries of India and Myanmar where HIV/AIDS is already widespread. Studies within Bangladesh revealed sexual abuse of child domestic workers and adolescents on the street, sexual exploitation through trafficking of adolescents for sex work both internally and to other countries and the transition into sex work of children growing up in brothels. Sexual exploitation was also found to exist within the garment industry which employs nearly 400 000 girls. Findings from the 5th round of HIV surveillance in Bangladesh (2003-2004) showed low HIV prevalence rates in female sex workers (less than 1%) but high rates of active syphilis (9.7%-12%) among them 8. The northwestern border areas had the highest prevalence of HIV (2%) among female sex workers. The findings also revealed that hotel-based sex workers were younger and had the highest number of clients while consistent use of condoms remained low across all ages.
years. Most MSM sold sex to 7-8 clients every night and 40% of them were unfamiliar with condoms. STI complications were common while the overall use of condoms was very low. About 57% of MSMs were married while some of them offered their sexual services to women too9. MSM are a heterogeneous population group including many who are identified as heterosexual in orientation. While this factor increases their invisibility it also increases manifold the risks associated with HIV/ AIDS.
Injecting drug users (IDUs) The results of the sixth round of serological surveillance showed that in Bangladesh, IDUs in the central city A site have the highest prevalence of HIV (4.9%)10. The survey showed that the HIV epidemic is no longer localized to one neighbourhood but has spread to a wider area. It was during the 5th round of National Serological and Behaviour Surveillance (2003-2004) that for the first time the highest level of HIV infection ever in Bangladesh (4%) was found among IDUs (Figure 3). Sharing of needles and injecting equipment was common among them (27-74.5%).
Figure 3: Significant rise in HIV prevalence in IDUs between Round II & Round V of serological surveillance 5 HIV in IDUs 4
Prevalence percent
4 3 2
Young men who have sex with men (MSM) Men who have sex with men (MSM) is a largely invisible group in Bangladesh due to the stigma associated with male to male sexual relationships and the corresponding high value attached to the normative image of heterosexual men. However, MSM population has been included in all rounds of serosurveillance conducted in Bangladesh and the HIV prevalence was found to be less than 1%. There is growing evidence of MSM exploratory behaviour among boys in Bangladesh though no national-level data on young MSM is available. A need assessment study for prevention of HIV/AIDS/ STIs among MSM in the age group of 21-30 years in Dhaka revealed that the mean age of their first sexual encounter with other males was mostly between 10-12
1 0
1.4
Round II (1999-2000)
Round V (2003-2004)
Source: HIV in Bangladesh: The Present Scenario, National AIDS/STD Programme, DGHS, MOHFW, Bangladesh, Dhaka, November 2004.
There is the great risk of HIV spreading from IDUs to the bridging population since the former are not an isolated group: they are mobile, sexually active and married and less than 15% of them use condoms consistently4. Some of the IDUs also sell blood to buy illicit drugs. Given the prevalent risky behaviours in IDUs, HIV can move rapidly as evidenced in other countries. 3
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Why Young People Are More Vulnerable Early initiation of sexual activity There is increasing evidence of a significant proportion of young people being initiated early into sexual activity. A national survey on young people aged 1524 years reported that 48% of rural and 45% of urban males had their first sexual experience between ages 15-17 years5. Figure 4 on the age at first experience of premarital sex shows that 31% of rural and 38% of urban males had sex before they turned 20 and about one-sixth had sex for the first time before the age of 15 years. Twenty-six percent reported having sex with commercial sex workers with urban youth reporting higher exposure in this regard than their rural counterparts. Age group 15-17 11 2 23 2 35 2
Figure 5: Prevalence of premarital sex among youth
18-20
21-24 0
10 Male
20
30 Female
40
Percent Source : Baseline HIV/AIDS Survey among Youth in Bangladesh, ICDDR, B: Centre for Health and Population Research ; Associates for Community and Population Research (ACPR); Population Council, Bangladesh, August 2005
Figure 4: Age at first premarital sex among male youth 21-24 4 3 31 38 48
that they had always used condom during sex and only 35% spoke of condom use in their last premarital sexual encounter (Figure 6).
Age group
18-20 15-17 < 15 0 17 12
Figure 6 : Condom use in premarital sex by youth 45
70 60 50 58
Percent
20
40
60
Percent Rural Male Urban Male
40 30 20 10 0 Never Always Ever 24 12
35
Source : Baseline HIV/AIDS Survey among Youth in Bangladesh, ICDDR, B: Centre for Health and Population Research ; Associates for Community and Population Research (ACPR); Population Council, Bangladesh, August 2005
In the survey the reported prevalence of premarital sexual activity among females was very low (2%) (Figure 5). But the reported data on premarital sex by males were suggestive of a higher prevalence of the same among females. The most common reported partner in premarital sex was the girlfriend (58%), followed by sex worker (26%). The prevalence of extramarital sex in married males was about 7% with 57% of them reporting commercial sex workers as the main sexual partner outside of marriage. According to the same survey condom was not used in more than half of all premarital sexual experiences. About 22% of unmarried males had premarital sex and 58% of them never used a condom. Only 24% reported
Last time
Condom Use Youth (15-24 years)
Source : Baseline HIV/AIDS Survey among Youth in Bangladesh, ICDDR, B: Centre for Health and Population Research; Associates for Community and Population Research (ACPR); Population Council, Bangladesh, August 2005
Young people lack information and skills A national survey among the youth conducted in 2005 showed that 93% of males and 85% of females were aware of HIV/AIDS5. Awareness was found to be higher among urban youth. The main sources of information on HIV/AIDS were TV followed by radio, peer group and print media. The two most common routes of transmission of HIV reported by both urban
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Table 2: Knowledge of HIV transmission among youth (15-24 years) Mode of transmission Use of non sterile needles/syringes Receiving HIV/AIDS infected blood Sex with HIV/AIDS infected person Unprotected sex with HIV/AIDS infected person Pregnancy/delivery by a HIV/AIDS infected mother Breast feeding by a HIV/AIDS infected mother Number surveyed Male Percent 37 26 11 10 4 3 5 794 Female Percent 46 32 15 12 10 4 6 195 All Percent 41 29 13 11 7 3 12 729
Source: Baseline HIV/AIDS Survey among Youth in Bangladesh. Conducted by ICDDR, B: Centre for Health and Population Research; Associates for Community and Population Research (ACPR); The Population Council, Bangladesh August 2005
and rural youth were the use of non-sterile needles/ syringes (37% males and 46% females) followed by receipt of HIV-infected blood (26% males and 32% females). Only 10% males and 12% females seemed to be aware that unprotected sex with an HIV-infected person could transmit HIV (Table 2). Only 36% males and 41% females could identify two or more of the six correct routes of HIV transmission. As many as 46% males and 39% females could identify any route of transmission while a third of the young people surveyed did not know of the ways to prevent HIV. More than 70% of the respondents knew the correct answers on items listed in Table 3. However, less than
one third of the youth surveyed possessed correct knowledge on questions regarding anal and oral sex posing a risk factor for transmission of HIV. A majority of youths harboured several grave misconceptions about transmission and prevention of HIV. More than 50% believed that HIV could spread by coughing or sneezing while 63% felt that HIV can be transmitted by sharing food and water (Table 4).
Table 4: Misconceptions regarding HIV transmission and prevention Transmission Cough/sneeze Sharing food/water Sharing bath/pond Prevention Washing after sex prevents HIV/AIDS Using lubricant with condom prevents HIV/AIDS Taking antibiotics prevents HIV/AIDS Taking vaccines prevents HIV/AIDS Sex during menstruation prevents HIV/AIDS 57 73 54 54 64 Percent 52 63 39
Table 3: Correct knowledge about HIV/AIDS Indicators Healthy person may be HIV+ve IDU is a risk factor for HIV/AIDS Can get HIV from blood transfusion Condoms can reduce risk Limiting sex with one partner reduced risk Multiple partners can increase risk Females can have HIV by anal sex with males One can be infected by oral sex Percent 61 72 79 74 73 80 34 31
Source: Baseline HIV/AIDS Sur vey among Youth in Bangladesh, ICDDR, B: Centre for Health and Population Research; Associates for Community and Population Research (ACPR); Population Council, Bangladesh, August 2005
Source: Baseline HIV/AIDS Survey among Youth in Bangladesh. Conducted by ICDDR,B: Centre for Health and Population Research; Associates for Community and Population Research (ACPR); The Population Council, Bangladesh, August 2005
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More than 97% of urban and 95% of rural male and 93% of urban and 85% of rural females reported to have heard about the condom. Awareness was higher among married youth. Knowledge of the condom as a method of contraception was high. However, only 35% male and 18% female youth knew about the dual role of condoms in preventing pregnancy and HIV. The percentage aware of the fact that condom use can prevent STIs was even lower. Despite widespread availability, condom use is low among the youth in Bangladesh. The social stigma associated with the purchase of a condom in public was found to be a major barrier for this. In a survey among youth aged 15-24 years it was found that 50% of male youth and 82% female youth felt that unmarried people should not be allowed the provision of buying a
condom. Approximately 60% and 30% of unmarried youth (both male and female) respectively said they were not confident about buying a condom from a vendor who was known to their family5. There are few avenues for young people in Bangladesh to acquire correct information about sexual health, STIs/HIV and other related issues. Religious, cultural and social norms are not in favour of the issue of sex education in schools. Discussions on these issues within the family or the community are few and far between. Bangladesh is yet to develop policies that specifically address the needs of young people on HIV/AIDS. Existing reproductive health services are generally inaccessible to young people and also do not offer an environment of privacy and confidentiality.
Focusing on the Young to Halt the Spread of HIV/AIDS HIV prevalence in Bangladesh is still low with few diagnosed AIDS cases. The priorities for the NASP under the strategic plan (1997-2002) are, therefore, to prevent sexual transmission of HIV and reduce the vulnerability of the population with high-risk behaviours like injecting drug use. The National Strategic Plan for HIV/AIDS (2004-2010) identified ‘Reduce the Vulnerability of Youth’ as one of the subobjectives under Objective 2 for youth, which includes planning and implementation strategies for young people. Immediate priorities include: implementing interventions targeted at individuals with high risk behaviour, strengthening STD clinical management at the community level using syndromic approach; improving accessibility of various population groups to good quality condoms, and safe blood transfusion. In the area of care, priorities would include developing counselling services and taking steps to counter discrimination and stigmatization for people living with HIV/AIDS and towards enhancing their community acceptance. In addition, advocacy to mobilize political commitment, allocate adequate resources and initiate multisectoral response and programme expansion to the district and upazila levels will remain priority areas. The Ministry of Health and Family Welfare of the Government of Bangladesh has launched a programme, Prevention of HIV/AIDS among Youth and Adolescents in Bangladesh, with support from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). The programme aims at preventing HIV infection in young people by providing HIV prevention information through the mass media, life skills, education through youth organizations and clubs and by making health services more youth friendly, reviewing and updating the social marketing strategy for greater accessibility of condoms targeted to young people, and integrating HIV prevention, education and information into the school curriculum. It also aims at enhancing advocacy levels and initiating a sensitization programme targeting parents, religious and community leaders and policy makers and to generate evidence-based data for strategic directions to the intervention-procedures. The HIV/AIDS Prevention Programme (HAPP) focuses interventions for high-risk groups and also targets young people in these groups.
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References : Prevention of HIV/AIDS among young people in Bangladesh: a collaborative project between Ministry of Health & Family Welfare and Save the Children-USA funded by GFATM. Dhaka: Ministry of Health & Family Welfare, 2004. 2. National HIV Serological and Behavioral Surveillance: Bangladesh HIV surveillance - 4th round. Dhaka: CDDR, B: Centre for Health and Population, 2002.(Accessed 30 August 2006: http://202.136.7.26/activity/index.jsp?activityObjectID=2430). 3. AIDS epidemic update: special report on HIV prevention. Geneva: UNAIDS, WHO, 2005. (Accessed 30 August 2006: http://whqlibdoc.who.int/unaids/2005/929173439X_eng.pdf). 4. National strategic plan for HIV/AIDS 2004 -2010. Dhaka: National AIDS/STD Programme; Directorate General of Health services; Ministry of Health and Family Welfare, 2005. 5. Baseline HIV/AIDS survey among youth in Bangladesh. Dhaka, ICDDR, B: Centre for Health and Population Research, Associates for Community and Population Research (ACPR), Population Council, Bangladesh, 2005. 6. Summary of end line survey on adolescent reproductive health. Dhaka: UNFPA, 2005. 7. Pathfinder International. Fact sheet: responding to HIV/AIDS Bangladesh. Dhaka (Access 11 October 2006: http://www.pathfind.org/site/DocServer/ PF.Fact_Sheets.HIV.Banglades.pdf?docID=6282#search=%22Pathfinder%20International%20HIV%2FAIDS% 20Fact%20Sheet%20bangladesh%22). 8. HIV/AIDS in Bangladesh: the present scenario: a summary of key findings from the fifth round of serological and behavior surveillance for HIV in Bangladesh (2003-2004). Dhaka: National AIDS/STD Programme, DGHS, MOHFW, Bangladesh, 2004. 9.. HIV/AIDS/STI intervention among MSM: an experience from ODPUP. Dhaka: HIV/AIDS and STD Alliance Bangladesh, 2003. 10. National HIV serological surveillance, 2004-2005, Bangladesh: sixth round technical report. Dhaka: National AIDS/STD Programme: Directorate General of Health Services; Ministry of Health and Family Welfare, Bangladesh, 2005. 1.
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