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Introduction: The national response in Bangladesh was initiated with establishment of a National AIDS Committee (NAC), and Technical and Co-ordination Committees at central level and committees at various peripheral levels in 1985. A number of activities have been implemented by the NAC, the Ministry of Health and Family Welfare (MOHFW) as well as by the office of the Director General Health Services (DGHS). Adoption of a National Policy in cabinet is a milestone in the way of an effective response. A well-established NGO network carries out various HIV/AIDS related prevention and care interventions. However, in spite of a substantial amount of work already done, the level of response needs to be further strengthened. The Government expression of commitment to AIDS prevention has to be translated into action at the ground level.

National strategic plan: The National Strategic Plan formulated by the government provides a framework for a national response to AIDS and defines Bangladesh's strategies and priorities for HIV/AIDS and STDs prevention and care for five years (1997-2002) in line with National Policy. It is worth mentioning here that Bangladesh is one of the very few countries that have a very well defined state policy document on HIV/AIDS and STD related issues. The strategic plan, which is periodically updated according to changed circumstances, builds on the works already done and emphasizes a multi-sectoral response to the AIDS problem to include enhancing the involvement of various ministries, NGOs, the private sector and the community, and outlines programme management aspects including monitoring and evaluation. This strategic plan also provides a guide for further planning and for the development of sector-specific work plans. The strategy in its projection identified the need for resource allocation and provided systematic guideline for the purpose. The broad strategies and interventions were planned taking into consideration the present epidemiological situation and the likely future scenario. The priority strategies, therefore, include:

• Establishing and keeping a National AIDS Programme management team effective at central, district and upazila levels;

• Preventing transmission of HIV through expansion of interventions targeted among individuals with high risk behaviours including sex workers and their clients, injecting drug users, transport workers, etc;

• Strengthening STD case management to include syndromic management approach; increasing availability, accessibility and use of quality condoms; promoting responsible sexual behaviour of young people both in and out of school; information, education and communication (IEC) activities targeted at policy makers and the general population; enabling legislation and the use of the media, and above all creating an enabling environment for people in general and for those afflicted in specific that would include making information and care available to them;

• Improving a safe blood supply through promoting voluntary blood donation and discouraging professional blood donation;

• Rational use of blood/blood products and a thorough screening of donated blood for HIV and other pathogens;

• Provision of counselling and other support including expansion of voluntary testing facilities targeted at pregnant women or women contemplating pregnancy, and breast feeding mothers;

• Provision of care and support systems including counselling services; implementing activities to include legal amendments to counter the discrimination against people living with HIV/AIDS and vulnerable groups, towards improving community acceptance;

• Establishing HIV/AIDS and STD surveillance to determine present and future magnitude of the problem and to monitor HIV/AIDS and STD programmatic interventions and their effects;

• Strengthening capacity for diagnosis of HIV/AIDS/STDs;

• Mobilizing and supporting various government, private and non-government sectors.

Specific response: Government response to address the epidemic is detailed below:

• As mentioned earlier, national AIDS Committee (NAC) was formed in October 1985, with representation from different stakeholders. The NAC is defined as an advisory body with responsibility for major policy issues and strategies; co-operation and co-ordination of various sectors including NGOs; and supervision of implementation of the programme and mobilization of resources. A Technical Committee (TC) was also formed with experts from relevant fields to provide in-depth scientific, medical and technical advice to the NAC and the National AIDS/STD Programme (NA/SP). By the end of 1990, a Co-ordination Committee (CC) came into being, constituted by key functionaries from institutions already engaged in HIV/AIDS related activities. Responsibilities were assigned to each member of the committee as part of a programme building effort.

• In 1987, government decided to start AIDS prevention activities with the technical and financial assistance of WHO Global Programme on AIDS (GPA). In 1988, planned prevention activities began under a 'Short Term Plan' (STP) which focused on determining HIV/AIDS prevalence, and in developing prevention and control measures, particularly in the health sector. During 1989, a 3-year 'Medium Term Plan' (MTP) was formulated and during the 90's, prevention activities were carried out with WHO support in areas of surveillance, laboratory diagnoses, and strengthening technical, financial, health education, and management capabilities.

• Since 1996, UNDP has been supporting interventions in the country. The Joint United Nations Programme on HIV/AIDS became operational in 1996 to work with Government, NGOs, the private sector, and donors to support the national response to HIV/AIDS.

• The HPSP proposes restructuring of some components of the Health and Family Welfare wings towards unified service delivery. These factors need to be considered in formulating an effective management structure to deliver the health-related aspects of the NA/SP.

• The management structure of National AIDS/STD Programme has been outlined in the policy document. Programme activities are to be carried out by three main functionaries, i.e., the NAC, acting as an advisory body assisted by its Technical Committee, the Ministry of Health and Family Welfare (MOHFW) as the co-coordinating body and the Directorate of Health Services and other ministries, directorates and agencies as the implementing bodies.

• The Technical Committee (TC) continually reviews the programme to reflect the needs as they arise. Important contributions of the TC include assisting the NAC to formulate programme frame-works, guiding programme personnel in the design, development and monitoring/reporting of their activities, and review research protocols to be funded by the government. Programme management itself acts to maintain functional links effectively between the tripartite coalition.

• Under the leadership of the Secretary, MOHFW, the AIDS Information and Awareness Campaign Committee (AI&ACC), comprising of representatives from several ministries, WHO, donor agencies, media and NGOs, have conducted many activities since its inception. Several IEC materials have been produced and distributed by this committee. Other activities have included social mobilization meetings, exhibitions and seminars in cities, towns and villages. Many media activities have focused on contexts in which people get involved in high-risk behaviours, as well as the public at large. However, means to redress religious and cultural sentiments, while still dispensing accurate information on means of transmission and methods for protection, need to be considered. Recent surveys indicate that literate and non-literate populations alike are generally mis- or uninformed about AIDS and are not empowered with sufficient information to protect themselves.

• The availability of a quality condom at an affordable price is an essential component of any HIV/AIDS and STD control programme. At present, GOB provides 37% of condoms while the remaining 63% comes from the Social Marketing Company (SMC) funded by the USAID and the European Union. SMC has recently introduced a new brand with a clear message to link its use to prevent STDs and AIDS. A market has been established for this brand. The STD message should also be considered for all other condoms. For the first time SMC has also been allowed by the government to use TV for promoting condom for HIV. Condoms are also distributed free by many NGOs.

• In March 1997, a protocol for a safe blood transfusion service was submitted to the MOHFW by the Blood Transfusion Technical Sub-Committee of the NAC. At present, a few laboratories have started to provide facilities to test for HIV in the country. Most are in the private sector. However, pre-, post- and follow-up counselling has yet to become an essential part of the process. As HIV/AIDS awareness increases, a rise in the demand for HIV testing is likely. To meet this demand, health facilities that offer voluntary counselling and testing would be required. As it stands now, MOHFW has embarked on establishing 97 blood transfusion centres in the country up to district level, some of which will in the private sector. These centres will screen blood for HIV, trepenoma, malaria, HBsAg and HCV.

• NGOs have set up a STD/AIDS Network. It is broadly recognized that NGOs, given their potential for flexibility and interactive relations with community members, have much to offer towards prevention and behaviour change activities. Relevant to STD/HIV/AIDS, close collaboration between government and NGOs is currently being addressed. NGOs are being invited to support the MOHFW with delivery of the Essential Services Package (ESP); interventions for community behavioural change; training and providing standard guidelines for the programme. NGOs have been carrying out the major part of HIV/AIDS prevention activities nation-wide. From IEC and targeted interventions, to policy formulation, NGOs have been instrumental at all levels. Indeed, without NGO participation, Bangladesh would undoubtedly have been much further behind than it is at present. Furthermore, there is a network of media people (AIDS and Health Writers Group) and an AIDS and Legal Issues group (ALACAA). A successful consensus workshop was held (November 1995) to agree on the relative roles for GOB and NGOs towards HIV/AIDS prevention and control. In essence, NGOs have been given full support to complement GOB efforts and to take on activities that are beyond government's scope.

• There are specific issues that AIDS brings to women. The disadvantaged and marginalized status of women in Bangladesh deprives them of access to information and intervention programmes on AIDS as well as, most importantly, negotiating power in matters of sexuality. In response, a Women Wing (WW) of the NAC was set up to raise and plan for such issues within the NAC and the programme. In the NGO sector, women are taking part in programmes addressing the wider socio-developmental issues of women as well as providing information and behaviour change support to women. NGOs are also making a start to promote male responsibility in matters of sexuality and family planning. The role of the man as a dominant partner in sexual decision-making is often forgotten, perhaps because of the perceived difficulties. However, this is an area that obviously requires focused attention if a NAP is to be successful.

1. National Policy: The National Policy on HIV/AIDS/STD related issues has been approved by the cabinet in 1997.

2. National Strategy: A comprehensive five-year National Strategy (1997 – 2002) has been prepared and adopted in National AIDS Committee (NAC) for effective implementation of HIV/AIDS interventions.

3. National HIV-AIDS Behaviour Change Communication Strategy: Development of the National HIV-AIDS Behaviour Change Communication Strategic Implementation Plan for Bangladesh has been completed. The document has been approved National AIDS committee.

4. National Mapping: The task of Geographical Information System (GIS) on Brothel in Bangladesh has been completed and preparations are ongoing to have national GIS mapping to determine the vulnerability, and availability of interventions and service facilities.

5. Generation of Database: Process to conduct a national vulnerability study in persuasion of creating a national database has been initiated. Process for a KAPB survey has also been initiated.

6. Sentinel Surveillance: Two sentinel surveillance on HIV/AIDS and syphilis (1998 – 19999 and 1999 – 2000) have been completed and findings were disseminated. Third sero- and behavioural surveillance is nearing completion.

7. Multi-sectoral involvement: Effective interaction with different ministries to develop their respective plan of action to support the National AIDS Programme has been initiated.

8. Formation of local committees: Structure and terms of reference of AIDS Committees at district and upazila levels in order to support and maintain liaison with National Committee regarding different relevant activities were reviewed and revised, and finally submitted to the government after affirmation of Technical Committee (TC) of NAC.

9. NGO Inventory: An inventory (electronic version) on NGOs working in the field HIV/AIDS/STD prevention and control has been completed and a user-friendly text transformation of the inventory has been done for general use.

10. NGO selection modalities and selection criteria: NGO selection modalities and selection criteria have been developed as a guiding document for GO-NGO collaboration modality, NGO selection process and funding mechanism.

11. Partnership with NGOs: 24 NGOs have been selected and funded for behaviour change support intervention activities. Monitoring tools and MIS are also in place to ensure a better quality of intervention.

12. Capacity building of NGOs: Training of NGOs on different components of programme implementations is one of the major initiatives of the National Programme.

13. Capacity building at management level: Training on Programme Management in the field of HIV/AIDS and also syndromic management of STDs are undertaken as regular events. The National Programme regularly supports the attendance of government officials, academicians and NGOs in different scientific events, training programmes, study tours, workshops and conferences.

14. Research support: Research proposals have been contracted out to Institute of Epidemiology, Disease Control and Research (IEDCR) to study the qualitative aspect of condom promotion and antibiotic sensitivity in gonococcal infection.

15. Support to professional organizations: An intervention initiative was contracted out to Bangladesh Medical Association (BMA) to orient its member physicians on HIV/AIDS and STD issues.

16. Capacity building at field level: Divisional training workshops in six divisional towns for upazila level health and family welfare managers were organized to orient and train the participants on HIV/AIDS/STD issues. Similarly, upazila level workshops to orient and train upazila health and family welfare workers were organized in all the upazilas of the country. Around 55,000 health and family welfare workers were oriented and trained on basic issues of HIV/AIDS and STDs in those training workshops.

17. Collaborative efforts with other ministries for capacity building: Process is underway to organize orientation programmes for 1,000,00 law enforcers under Ministry of Home Affairs on HIV/AIDS and STD issues. Preparation of an educational module for the purpose has been completed. Similar collaborative initiatives have been taken with Ministry of Education for orientation of teachers, and with Ministry of Youth and Sports, Ministry of Women’s Affairs, Ministry of Religious Affairs and Ministry of Local Government, Rural Development and Cooperative to incorporate the HIV/AIDS issues in their respective training curriculum. Separate curriculums are under preparation for individual ministries. Advocacy programme has also been initiated with Ministry of Labour and Manpower.

18. Support to other service organizations: Financial and technical support has been provided Bangladesh Red Crescent Society (BDRCS) to have orientation programmes for their volunteers. Training of Trainers (ToT) was done for BDRCS officials and first phase of implementation of training programme has already been completed. The National Programme has developed educational and instructional materials for the purpose.

19. Community orientation: Workshop on HIV/AIDS/STD with (1) City Corporation/Municipalities Ward Commissioners/Members, (2) Head of NGOs, (3) Head of the teaching institutes (4) Religious leaders including Imams of different mosques in City Corporation and Municipalities and (5) Local elites and opinion leaders in different districts and municipal areas are being held.

20. Development of educational and instructional materials: Educational and instructional materials were prepared for orientation of senior health personnel at division, district and upazila level on HIV/AIDS and STD issues. Similarly, educational materials for different opinion leaders, social elites and professional groups in different municipal areas have also been prepared.

21. General awareness programmes: Billboards with HIV/AIDS messages have been erected in division, district and upazila towns. TV spots have been developed and broadcasted on regular basis in both public and private TV channels to supplement the messages used in the Billboards. Messages have also been disseminated through print media. Messages are prepared and are being painted on double-decker buses after an agreement has been reached with Ministry of Communication for the purpose.

22. Community participation initiatives: Initiative has been taken to organize a nationwide cycle rally with the ultimate purpose of forming community youth forum. Piloting workshops to field test this awareness generation effort have been completed. The event will be organized very soon.

23. Legal, ethical and human rights issues: Review of legal, ethical and human rights issues related to HIV/AIDS in Bangladesh to understand existing situation and identify future necessity have been completed. Further elaboration of the work done is underway.

24. Support to people living with HIV and AIDS (PLWHA): Measures are underway to facilitate forming a network of people living with HIH/AIDS and to support them for their capacity building, and to provide a supportive and enabling environment for them.

25. World AIDS Day observation: The National AIDS/STD Programme has been organizing the World AIDS Day every year since its inception. Last year it was organized in a befitting manner. The attraction of the day included a grand people’s rally, exhibition of intervention programmes, discussion meetings and cultural events. Different government organizations, development partners and NGOs took part in the different activities of the day.

26. Multi sectotral approach in combating HIV/AIDS

    a. Curriculum development for Imam & Muajjins training on HIV/AIDS with Ministry of Religious Affairs.

    b. Curriculum development for Police Personnel training on HIV/AIDS with Ministry of Home Affairs.

    c. Curriculum development for Youths training on HIV/AIDS with Ministry of Youth & Sports.

    d. Publication of Commemorative poster stamp on World AIDS Day.

    e. Initiation of Joint efforts with Federation Labour Unions in Awareness Raising for prevention of AIDS with Directorate of Labour, Ministry of Labour and Manpower.