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Collection Highlights

Self restoration of People Living with HIV AIDS in China

1st Edition Rongting Hou

Children and Young People Living with HIV AIDS A Cross

Cultural Perspective 1st Edition Pranee Liamputtong (Eds.)

Development, Sexual Cultural Practices and HIV/AIDS in

Africa Samantha Page

HIV AIDS Treatment in Resource Poor Countries Public

Health Challenges 1st Edition Max Essex
Teaching AIDS The Cultural Politics of HIV Disease in
India Dilip K. Das

Landscapes of Activism Civil Society and HIV and AIDS Care

in Northern Mozambique 1st Edition Joel Christian Reed

Thinking Differently about HIV AIDS Contributions from

Critical Social Science 1st Edition Eric Mykhalovskiy
(Editor)

Understanding Prevention for HIV Positive Gay Men

Innovative Approaches in Addressing the AIDS Epidemic 1st
Edition Leo Wilton (Eds.)

Climatic Hazards in Coastal Bangladesh Non Structural and

Structural Solutions 1st Edition Bimal Paul
Global Perspectives on Health Geography

Alak Paul

HIV / AIDS
in Bangladesh
Stigmatized People, Policy and Place
Global Perspectives on Health Geography

Series editor
Valorie Crooks, Department of Geography, Simon Fraser University, Burnaby, BC, Canada
Global Perspectives on Health Geography showcases cutting-edge health geography
research that addresses pressing, contemporary aspects of the health-place interface.
The bi-directional influence between health and place has been acknowledged for
centuries, and understanding traditional and contemporary aspects of this connection
is at the core of the discipline of health geography. Health geographers, for example,
have: shown the complex ways in which places influence and directly impact our
health; documented how and why we seek specific spaces to improve our wellbeing;
and revealed how policies and practices across multiple scales affect health care
delivery and receipt.
The series publishes a comprehensive portfolio of monographs and edited volumes
that document the latest research in this important discipline. Proposals are accepted
across a broad and ever-developing swath of topics as diverse as the discipline of
health geography itself, including transnational health mobilities, experiential
accounts of health and wellbeing, global-local health policies and practices,
mHealth, environmental health (in)equity, theoretical approaches, and emerging
spatial technologies as they relate to health and health services. Volumes in this
series draw forth new methods, ways of thinking, and approaches to examining
spatial and place-based aspects of health and health care across scales. They also
weave together connections between health geography and other health and social
science disciplines, and in doing so highlight the importance of spatial thinking.
Dr. Valorie Crooks (Simon Fraser University, [email protected]) is the Series Editor of
Global Perspectives on Health Geography. An author/editor questionnaire and book
proposal form can be obtained from Publishing Editor Zachary Romano (zachary.
[email protected]).

More information about this series at http://www.springer.com/series/15801

Alak Paul

HIV/AIDS in Bangladesh
Stigmatized People, Policy and Place
Alak Paul
Department of Geography and Environmental Studies
University of Chittagong
Chittagong, Bangladesh

ISSN 2522-8005     ISSN 2522-8013 (electronic)

Global Perspectives on Health Geography
ISBN 978-3-030-57649-3    ISBN 978-3-030-57650-9 (eBook)
https://doi.org/10.1007/978-3-030-57650-9

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2020
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
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The publisher, the authors, and the editors are safe to assume that the advice and information in this book
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To
Emeritus Professor Peter J Atkins,
Durham University, UK
(Dr Peter Atkins has been supporting
Bangladeshi Geographers as a true friend
for the last three decades)
Foreword

The Department of Geography at Durham University has welcomed many

Bangladeshi research students over the last 50 years. Returning home most have
taken up leadership positions in the university sector and their contributions to aca-
demic research and to applied research through consultancy have been notable.
Examples of important recent books by Durham alumni in Bangladesh include
the monumental National Atlas of Bangladesh (Asiatic Society of Bangladesh
2017) jointly edited by Nurul Islam Nazem; Manzurul Hassan’s Arsenic in
Groundwater: Poisoning and Risk Assessment (CRC Press 2018); Nahid Rezwana’s
Disasters, Gender and Access to Healthcare: Women in Coastal Bangladesh
(Routledge 2018); and Geography in Bangladesh: Concepts, Methods and
Applications (Routledge 2019) edited by Sheikh Tawhidul Islam and Alak Paul.
Alak Paul is an expert in public health from the social and environmental per-
spectives with many publications in international journals. The present monograph
is highly significant. I wrote in May 2020 at the peak of the pandemic of COVID-19,
when all other news has disappeared from the media. It is timely that Alak’s book
reminds us that the HIV/AIDS pandemic has not gone away. It remains a threat
despite falling from the headlines in recent years. His methodology of intensive
qualitative fieldwork is impressive because it shows the human tragedies behind the
infection. Reading the testimonies of some of his interviewees is harrowing and also
moving, particularly because they were so surprised that anyone should take an
interest in their plight. This type of work reminds us that medical epidemiology can-
not give us a full picture of disease; we need to understand the social context of
transmission in order to fashion appropriate policy responses.
Following Professor Paul’s example will be a challenge for researchers who,
these days, are required to produce quick results. Rather, this book is a reminder that
fieldwork is often time-consuming and that the best scholarship requires commit-
ment, determination and alertness to the human scale of the issues under
consideration.

Em. Professor of Geography, University of Durham  Peter J. Atkins

Durham, UK

vii
Acknowledgements

Though updated, this book is mainly based on the author’s PhD thesis. The author
extends his deepest gratitude to his PhD mentors (Professor Dr Peter J. Atkins and
Dr Christine E. Dunn) in the Department of Geography, Durham University, UK
who stimulated his interest in marginalized groups and guided his every step of the
way and opened eyes to contemporary concepts and theories in health geography.
Their unhesitating support, careful reading and comments in the early drafts, advice,
and critique have enabled him to clarify his qualitative data, sharpen his ideas and
develop the organization of his thesis. Special thanks are due to Professor Dr
Jonathan Rigg of Bristol University and Dr. Marcus Power of Durham University,
UK for their valuable comments and suggestions in combining theoretical aspects
and ‘real data’. The author also shows his best gratitude to Valorie Crooks, series
editor of Global Perspectives on Health Geography of the Springer Nature and the
entire editorial team for comments and guidance throughout this ‘transformation’.
The author would like to show his thanks to Mary Shepherd (Johns Hopkins
University), Dr. K. Sarker (India), Dr. Mahbubur Rahman (Japan), Dr. Matiur
Rahman (ICDDR,B)) and Dr. Tapan K. Nath (Malaysia) for their assistance during
the PhD research. He is grateful to Professor Dr. Md. Shahidul Islam of Dhaka
University; Professor K. Maudood Elahi of Stamford University, Dhaka; Dr. Sk.
Tawhidul Islam and Ms. Nandini Sanyal of Jahangirnagar University, Dhaka; Dr
Dwaipayan Sikdar of Chittagong University; and Simon McConway, John and
Pauline Owen of Durham for their every help both in Durham and Bangladesh. He
would like to express his sincere thanks to the authority of Chittagong University
(CU), Bangladesh for allowing him study leave for PhD and all members of the
teaching staff of the Department of Geography, CU.
His special gratitude to the ‘marginalized’ community of Bangladesh particu-
larly sex workers, drug users and people living with HIV (PLWH) who gave him
enough time unexpectedly and shared their sufferings without hesitation, which
actually helped him to make this book today. They not only allowed him to tell their
unspoken life story for this research but also thought him a friend and well-wisher.
The author is only hoping that those who read this book will understand their suf-
ferings and hardships through the interpretations of their lives which he has come to

ix
x Acknowledgements

understand. Here, his special thanks go to many NGOs, GOB officials and local
people in Jessore and Khulna who acted as his local guides to make the ‘bridge of
friendship’ with the respondents. His thanks go to Mr. Solzar Rahman, Mr. Nitish
C. Mandol and Ms. Farzana Kabir for their involvement to facilitate his accommo-
dation and research assistants. His thanks are also due to his research assistants
(Md. Atiqur Rahman, Bishnu Mallick, Sanatan Kumar, Arjun Mondal, Indrojit
Kumar, Anjan Das, Mamun Al Hasan, Syamol and Ashfak Mahmud) for the way
they have worked with him in the course of this study.
He is very grateful to Overseas Research Students Awards Scheme (ORSAS),
UK and Department of Geography in Durham University for financial support dur-
ing the PhD research. He is also grateful to Geography Alumni Association, Ustinov
Travel Award, Durham University; Sidney Perry Foundation, UK; and Charles
Wallace Bangladesh Trust, UK for their financial support for PhD fieldwork and for
completion of the research. Finally, the author extends his indebtedness to all his
family members for inspirations, especially his life partner Sumana Podder and two
boys, Anirudho and Arindom.
Overview

Acquired immune deficiency syndrome (AIDS) is one of the most complex health
and socio-economic problems today, leading to many adverse impacts on individu-
als, communities and societies. It has become increasingly concentrated among
marginalized populations in the developing countries like Bangladesh, a poor coun-
try in South Asia. Bangladesh is a predominantly Muslim country, where it might be
thought the human immunodeficiency virus (HIV) is unlikely to be a problem
because of traditional and conservative mores. But the results of different surveil-
lance rounds have shown Bangladesh to be at risk of an HIV epidemic. There are
many vulnerability factors such as geographical location, trans-border mobility,
poverty, stigma and discrimination that favour the spread or transmission of HIV/
AIDS. Most studies in Bangladesh on HIV are medical in approach and generally
ignore the socio-economic, cultural or geographic linkages of HIV. Much research
has been carried out on sexuality, sexually transmitted diseases (STDs), drug use
and awareness related to HIV infection, but a few investigations have contributed to
understanding the ‘lifeworlds’ of vulnerable people, and the stigma of marginalized
communities. In addition, a few research projects have attempted to see the role of
place and mobility in relation to HIV risk in Bangladesh. These research gaps have
left planners poorly equipped to design and implement HIV prevention strategies.
The present book seeks to bridge this gap in understanding health risk behaviour in
relation to prejudice, place and policy by exploring the issues of vulnerable and
marginal people’s lives which put them at risk of infection and also their coping
strategies and how these are played out. The aim is also to gain an understanding of
the perceptions of local civil society, people and policy planners in explaining the
vulnerability of people to HIV and proposing mitigation measures.
This book uses a qualitative approach as a methodological research strategy, rec-
ognizing that policy, people and places make a difference. In other words, the
researcher has tried to explore the issue from a socio-geographic point of view along
with health and policy planning in his field work in Jessore, Khulna and Dhaka. The
location of both Jessore and Khulna has ‘geographical value’ as they have ports,
brothels, opium dens, large transport terminals and slums. This research has been
carried out on three social groups: First, the researcher worked with people

xi
xii Overview

v­ ulnerable and marginalized to HIV infection (i.e. sex workers, drug users, people
living with HIV (PLWH) and transport workers including Indian truckers). Second,
he talked with local elites or people in civil society (i.e. journalists, NGO personnel
and local government officials). Finally, he worked with key personnel and policy
planners, i.e. high Bangladesh Government (GOB) and Non-Governmental
Organization (NGO) officials in Dhaka. Regarding the sampling frame, besides the
NGO beneficiaries, he managed this challenging work by developing contact with
marginalized people through ‘snowball’ sampling. Despite its topic being a sensi-
tive issue, this research did not negatively impinge on his respondents from any
ethical or moral point of view. To fulfil the research objectives, the work is fully
based on qualitative methods for data collection (i.e. in-depth interviews, focus
group discussions, participant observation and naturalistic observation) and data
analysis (i.e. grounded theory). The researcher used flexible conversational tech-
niques for questioning the participants in convenient places.
The evolving HIV/AIDS pandemic has shown a consistent pattern through which
marginalization, discrimination, stigmatization, and, more generally, a lack of
respect for human rights and dignity of individuals and groups heighten their vul-
nerability. In particular, due to this social, economic and legal context, sex workers
and drug users are subjected to harassment which can increase their ‘everyday’
vulnerability to sexually transmitted diseases and make them ‘victims’ to violence.
Most PLWH participants felt a loss of self-image and self-esteem, uncertain and
unpredictable future and distressing emotions. Discrimination against them has also
been increasing. The qualitative information in this research demonstrates the real
health risk to HIV/AIDS of the vulnerable people through their ‘lifeworlds’. This
research also managed to highlight or distinguish the geographically significant
places, like port areas of Bangladesh in relation to STD/HIV/AIDS. It makes a rela-
tionship between geographic space and health risk, particularly with drug users and
sex workers, through ‘risk bridging’. Apart from women-trafficking and Indian
truckers, this research has also found much evidence that many vulnerable people
including sex workers, drug users and transport workers are at health risk due to
their high mobility and the role of risky and non-risky places. A transparent and
accountable mechanism is needed to ensure stronger coordination of activities on
HIV and to ensure that commitments to HIV prevention and control are effectively
translated into action. The government must formulate and implement programmes
to reduce stigma and discrimination so that people living with HIV, and particularly
members of vulnerable groups, can access services for prevention, care and support.
It is expected that this research will ultimately lead to a better understanding of the
social and geographical context of HIV/AIDS and provide a better foundation for
health planning. In addition, this research develops a methodology of investigation
for the study of a complex health and social environment in Bangladesh.
Regarding the arrangement of the book, a review of existing the HIV risk and
vulnerability factors, descriptions of HIV literatures in Bangladesh and research
gap, and detailed methods will be elaborated in the first chapter. Chapter 2 will look
at the everyday geography of marginalized people’s daily rituals, physical discom-
fort, sorrows and anger, dreams and frustrations which fuel their vulnerability.
Overview xiii

Marginalized people’s stigma, identity, rights and sufferings caused by discrimina-

tion will be explored in the third chapter. Chapter 4 will investigate the risk behav-
iours of vulnerable people and their level of knowledge about health risks along
with different risk-minimizing techniques. Chapter 5 will examine the role of
‘place’ in channelling potential risk and the importance of geographical location in
determining the hidden disaster of HIV in Bangladesh. Chapter 6 will discuss issues
related to HIV prevention including addressing marginalization and stigmatization
issues. A summary of the geographies of HIV/AIDS in Bangladesh will be dis-
cussed in Chap. 7 from the context of stigmatized people, policy and place.
Abbreviations

AIDS Acquired immune deficiency syndrome

ART Antiretroviral therapy
BDR Bangladesh Rifles
BSF Border security force
BSS Behavioural surveillance survey
CSW Commercial sex worker
DFID Department for International Development
DU Drug user
FGD Focus group discussion
GOB Government of Bangladesh
HAPP HIV/AIDS Prevention Project
HBV Hepatitis B virus
HCV Hepatitis C virus
HIV Human immunodeficiency virus
HNPSP Health Nutrition Population Sector Programme
ICDDR, B International Centre for Diarrhoeal Disease Research, Bangladesh
IDH Infectious Diseases Hospital
IVDU Intravenous drug user
KABP Knowledge, attitudes, beliefs and practices
MR Menstrual regulation
MSM Males sex with males
NASP National AIDS/STD Programme
NGO Non-Governmental Organization
OI Opportunistic infection
PBD Professional blood donor
PLWH People living with HIV/AIDS
STDSexually transmitted disease
STISexually transmitted infection
Taka1 taka= 0.012 US $
UBINIG Unnayan Bikalper Nitinirdharoni Gobeshona
UNAIDSJoint United Nations Programme on HIV/AIDS

xv
xvi Abbreviations

UNFPA United Nations Population Fund

USAID United States Agency for International Development
VCT Voluntary counselling and testing
WHO World Health Organization
Contents

1 HIV/AIDS in Bangladesh and Present Research������������������������������������   1

1.1 Introduction����������������������������������������������������������������������������������������   1
1.2 Risk and Vulnerability Factors for HIV/AIDS in Bangladesh������������   2
1.3 Research on HIV/AIDS in Bangladesh and Present
Endeavour ������������������������������������������������������������������������������������������   8
1.4 Ethical Approach of the Research������������������������������������������������������ 11
1.5 Approach to Study Area Selection������������������������������������������������������ 13
1.6 Methods���������������������������������������������������������������������������������������������� 13
1.7 Concluding Remarks�������������������������������������������������������������������������� 19
References���������������������������������������������������������������������������������������������������� 19
2 ‘Lifeworlds’ of Marginalized People�������������������������������������������������������� 27
2.1 Introduction���������������������������������������������������������������������������������������� 27
2.2 Female Sex Workers’ Everyday Life and Rituals ������������������������������ 29
2.3 Drug User’s Daily Vulnerability �������������������������������������������������������� 38
2.4 Sorrows and Anger of PLWH ������������������������������������������������������������ 46
2.5 Everyday Life and HIV Vulnerability������������������������������������������������ 50
References���������������������������������������������������������������������������������������������������� 51
3 Stigmatized People and Societal Prejudice���������������������������������������������� 57
3.1 Introduction���������������������������������������������������������������������������������������� 57
3.2 Sex Workers’ ‘Bad’ Identity �������������������������������������������������������������� 59
3.3 Stigmatized Drug Addiction �������������������������������������������������������������� 64
3.4 Discrimination Towards PLWH���������������������������������������������������������� 69
3.5 Identity, Stigma and HIV Danger ������������������������������������������������������ 74
References���������������������������������������������������������������������������������������������������� 75
4 HIV Risk Behaviour, Consciousness and ‘Risk Coping’������������������������ 79
4.1 Introduction���������������������������������������������������������������������������������������� 79
4.2 Risk Behaviours of Vulnerable People ���������������������������������������������� 81
4.3 HIV Knowledge and Consciousness�������������������������������������������������� 88

xvii
xviii Contents

4.4 Health ‘Risk Coping’ Practices���������������������������������������������������������� 92

4.5 Knowledge, Risk Minimization and Sustaining of HIV Risk������������ 99
References�������������������������������������������������������������������������������������������������� 100
5 Stigmatized Place, Mobility and HIV Risk Channelling���������������������� 105
5.1 Introduction�������������������������������������������������������������������������������������� 105
5.2 Place as a ‘Risky’ and ‘Safe’������������������������������������������������������������ 108
5.3 Mobility and Role of Border Towns ������������������������������������������������ 115
5.4 Hidden HIV Cases in Bangladesh?�������������������������������������������������� 119
5.5 Place, Mobility and HIV ������������������������������������������������������������������ 126
References�������������������������������������������������������������������������������������������������� 127
6 Stigmatized HIV Policy Issues and Local Practice ������������������������������ 133
6.1 Introduction�������������������������������������������������������������������������������������� 133
6.2 Ambiguity of Recognition to Marginalized People�������������������������� 134
6.3 HIV Prevention and Limitations ������������������������������������������������������ 138
6.4 HIV Prevalence, Testing and Awareness������������������������������������������ 142
6.5 Discrimination, Support and Treatment for PLWH�������������������������� 145
6.6 NGO ‘Politics’ and Donor Policy ���������������������������������������������������� 148
6.7 HIV Surveillance and Strategic Planning ���������������������������������������� 153
6.8 Expected Role of Government in HIV Prevention��������������������������� 156
6.9 Concluding Remarks������������������������������������������������������������������������ 159
References�������������������������������������������������������������������������������������������������� 159
7 Summary and Conclusion ���������������������������������������������������������������������� 165
7.1 Introduction�������������������������������������������������������������������������������������� 165
7.2 HIV/AIDS and Challenges for Bangladesh�������������������������������������� 165
7.3 Is HIV/AIDS Only a Health Concern? �������������������������������������������� 169
7.4 Dilemmas in HIV Research in Bangladesh�������������������������������������� 171
7.5 Conclusion���������������������������������������������������������������������������������������� 171

Index������������������������������������������������������������������������������������������������������������������ 173
Chapter 1
HIV/AIDS in Bangladesh and Present
Research

1.1 Introduction

HIV/AIDS is one of the most complex health and socio-economic problems in the
world at present, having adverse impacts on individuals, communities and societies.
Over the last two decades, it has become increasingly concentrated among margin-
alized populations in developing countries like Bangladesh. Apart from behavioural
and bio-medical risk factors, HIV/AIDS has spread fast where there is widespread
stigma and discrimination, along with poverty and illiteracy. In particular, stigma
continues to remain a major barrier to treatment and this in turn enhances vulnera-
bility. According to the World Health Organization (2019), HIV is transmitted
mostly through semen and vaginal fluids during unprotected sex without the use of
condoms. Globally, most cases of sexual transmission involve men and women,
although in some developed countries homosexual activity remains the primary
mode. Beside sexual intercourse, HIV can also be transmitted during drug injection
by the sharing of needles contaminated with infected blood, by the transfusion of
infected blood or blood products and from an infected woman to her baby: before
birth, during birth or just after delivery (WHO, 2019). Many people with HIV do not
know that they are infected and this lack of diagnosis makes it difficult to bring them
under any form of care. Once infected, a person may not have symptoms for many
years but can still transmit the disease to others. The virus multiplies in the body and
eventually destroys the immune system. As a result, tuberculosis and other bacteria
can cause opportunistic infections (OIs), although usually these organisms will not
cause disease in healthy people. The terminal stage of HIV infection, when patients
suffer from OIs, is called AIDS. Approximately 50% of HIV-infected persons will
develop AIDS after 7–10 years of infection. The average survival time for a person
with AIDS may be only 6 months in developing countries and 1–3 years in devel-
oped countries (WHO, 1997). However, with the advent of new antiretroviral ther-
apy, survival has improved dramatically in richer countries. These drugs, which are

© The Editor(s) (if applicable) and The Author(s), under exclusive license to 1
Springer Nature Switzerland AG 2020
A. Paul, HIV/AIDS in Bangladesh, Global Perspectives on Health Geography,
https://doi.org/10.1007/978-3-030-57650-9_1
2 1 HIV/AIDS in Bangladesh and Present Research

very expensive, are unfortunately beyond the reach of most patients in the develop-
ing world. According to the World Disasters Report by International Federation of
Red Cross (IFRC, 2018), HIV/AIDS is the disaster that keeps on killing.
Globally, the HIV/AIDS epidemic constitutes one of the most burning threats
known to humankind. Since the start of the epidemic, more than 35.4 million people
have died from AIDS-related illnesses and 77.3 million people have become infected
with HIV. According to the latest figures published by UNAIDS (2018), an esti-
mated 37.9 million people globally were living with HIV. 1.7 million people became
newly infected with HIV in 2018 and about 1 million people have died from AIDS-­
related illnesses in 2018. About 23.3 million people were accessing antiretroviral
therapy in 2018. More than three quarters of AIDS-related deaths occur in Sub-­
Saharan Africa, and South Africa is the country with the highest prevalence of HIV
in the world. Currently, 66% of the total people with HIV infection are concentrated
in Sub-Saharan Africa, but epidemics elsewhere in the world are growing rapidly.
More than 90% of the PLWH population resides in developing countries (WHO,
2019). Epidemiological studies indicate that, unlike the western world and Africa,
HIV is a relative newcomer to Asia. In South East Asia, it was first identified in
1984 in Thailand. In India, it was first reported in 1986, in Burma in 1987 and in
Bangladesh in 1989 (Paul, 2009). It is estimated that the region had 3.8 million HIV-­
infected persons in 2018 (UNAIDS, 2018). Exploratory sero-surveillance indicates
an epidemic scale of HIV infection in Thailand, India and Burma, especially in
population groups engaged in unprotected heterosexual sexual activities.
Traditionally, CSWs in South Asia have been brothel-based. But, due to rapid socio-­
economic and cultural change, the commercial sex business has undergone signifi-
cant change. CSWs are now available in hotels, restaurants, bars, street corners or
inconspicuous houses in residential areas, massage and beauty parlours. In addition,
intravenous drug use is high in Burma, Nepal and north east India, all of which are
very close neighbours of Bangladesh. In South Asia, the HIV situation in India,
Nepal and Burma is critical, in terms of the number of HIV patients and risk. With
many people living with HIV/AIDS in neighbouring countries, what is the situation
of a Muslim nation, Bangladesh? Although it is a predominantly a culturally conser-
vative Muslim country, there are many social and economic, as well as geographical
factors, fuelling the potential HIV risk in Bangladesh through insecure sexual activ-
ity and drug habits which in theory are ‘visibly’ prohibited.

1.2  isk and Vulnerability Factors for HIV/AIDS

R
in Bangladesh

Being a third world country, Bangladesh is highly vulnerable to HIV/AIDS, not

only as a medical challenge, but also in terms of its socio-cultural and geographical
context (Paul, 2009). Bangladesh is one of the four countries in the region where the
epidemic continues to increase (UNAIDS, 2012). Though Bangladesh has a low
1.2 Risk and Vulnerability Factors for HIV/AIDS in Bangladesh 3

HIV prevalence (less than 1%) in the general population (NASP, 2014), according
to the National Surveillance of 2015–2016, a concentrated epidemic has been
recorded among the male drug users in a neighbourhood of Dhaka (old Dhaka)
where the prevalence was 27.3%. The prevalence of HIV among sex workers and
other risk groups is less than 1% (NASP, 2016). The first case of HIV in Bangladesh
was detected in 1989 and up until December 2016 the total number of detected
cases was 4721 of whom 799 have died, leaving 3922 known people living with
HIV (NASP, 2016). About one third of detected PLWH are women. Among the 578
new HIV cases reported in 2016, 32.9% were among women, and 5.5% were among
children. However, the majority of infections are likely to remain undetected, and
the total national estimate is about 14,000 PLWH (UNAIDS, 2018).
The country has a range of contextual factors that create and sustain this vulner-
ability. A stereotypical view of the people of Bangladesh is that they are likely to
follow Islamic religious norms meticulously as it is a predominantly Muslim nation.
There is a common misconception, for instance, that STDs, HIV and AIDS are not
health risks for them. But in reality there is evidence that all of the health risk behav-
iours related to HIV (e.g. premarital/extra marital sex, homosexuality, prostitution
and intravenous drug use) are present, contradictory to the norms of the mainstream,
conservative society (see Khan, Hudson-Rodd, Saggers, & Bhuiya, 2005). In addi-
tion, there are also many vulnerability factors (e.g. geographical location, trans-­
border mobility, low HIV/AIDS awareness, poverty and gender inequalities), which
individually and collectively favour the spread or transmission of HIV/AIDS (see
Gibney et al., 1999). Although Bangladesh is considered a low prevalence nation at
present, from the epidemiological point of view, the HIV situation is evolving rap-
idly. Importantly, it is commonly assumed that some significant geographical loca-
tions, particularly the urban and border areas are channels for the ‘transmission’ and
‘importation’ of HIV into the country where CSWs, IDUs and TWs are highly
mobile and sell sex and share needles. As a consequence, there are several key nodes
for the diffusion of the disease across the whole country. In what follows, the exist-
ing risks and vulnerabilities, including behavioural, bio-medical, social and struc-
tural, for HIV infection in Bangladesh are explained.
Sexuality AIDS is overwhelmingly a sexually transmitted disease and sex is sur-
rounded by taboos in nearly all human societies, including Bangladesh. Many
research findings mainly by medical scientists and sociologists indicate that the
incidence of extramarital sex is quite widespread in Bangladesh (Rob & Mutahara,
2000). Prostitution is prohibited, but there are a significant number of female sex
workers, particularly in the urban, border and port areas. Studies have shown that
Bangladeshi society, long considered so conservative, is more footloose and sexu-
ally free than is commonly admitted. Aziz and Maloney (1985) found that 50% of
youths, mostly of the lower socio-economic class, have experienced sex before mar-
riage. Folmer et al. (1992) also found prevalence of premarital sex among their
respondents with 29%of them using condoms. Other researchers such as Islam
(1981) and Maloney et al. (1981) reported similar findings in the significant propor-
tion of their subjects and noted occurrences of induced abortions among unmarried
4 1 HIV/AIDS in Bangladesh and Present Research

girls. According to the World Bank Report (2006), a flourishing commercial sex
industry is an important behavioural risk for HIV in Bangladesh. A few important
academic works on behavioural risks, by Caldwell and Pieris (1999) and Roy,
Anderson, Evans, and Rahman (2010) found evidence which explained many
anomalies regarding social issues on sexuality and also evaluated the prospects of
an AIDS epidemic. They found that levels of premarital and extramarital sex among
men, especially transport workers, are moderate by international standards but
probably higher than the expectation in a socially conservative society. However,
about 8–11% of Bangladeshi men aged 15–49 years (NASP, 2009) buy sex from
female sex workers, occasionally or frequently. Apart from lower class men, recently
it is an open secret that many of the middle-high and high income people frequently
engage in hotel/residence-based extramarital sex in the metropolitan cities (Gazi
et al., 2009).
Deteriorating economic conditions in Bangladesh are leading more and more
Bangladeshi women to the sex trade. They are generally non-literate, divorced or
separated women and may be organized in brothels or may be ‘floating’ (Khan,
1999). Floating sex workers waiting to be picked up is a common nightly scene in
many areas of big cities, including Dhaka and Chittagong. By comparison, MSM
behaviour is largely hidden; it is, however, believed that it is more prevalent than
previously thought (Chan & Khan, 2007; Khan et al., 2005). There is some evidence
of homosexuality among labourers, transport workers and boys. Particularly, rick-
shaw pullers and manual cart pullers have been reported as committing rape on a
certain group of child labourers who sleep in an open part of the market at night
(Choudhury, Arjumand, & Piwoo, 1997).
Illegal Opiate Use Drug trafficking is the distribution of illicit drugs by large-scale
operations, which can, and often do, cross national boundaries, as well as the small-­
scale syndicates that distribute drugs at the local level (Bean, 2002). Afghanistan
accounts for almost 75% of the world’s illicit opium supply (MacDonald &
Mansfield, 2001). Much of the remainder is from the traditional growing region of
the Golden Triangle (Burma, Laos and Thailand). Significant amounts, however, are
grown elsewhere, such as in Iran and Turkey. Bangladesh is considered to be an
important hub of illicit drug smuggling. It is located between the ‘Golden Triangle’
and the ‘Golden Crescent’ opiate-producing zones, and has become an easily acces-
sible market for opiates (GOB, 2002). The problem of drug abuse has reached rec-
ognizably significant proportions today in Bangladesh and it is linked to organized
and petty crime (Muntasir, 2005). In general, most addicts are males. Frustration,
curiosity and peer pressure are the most frequent reasons given for drug addiction.
Illegal opiate use behaviour, which is considered a lifestyle risk factor for HIV, is
prevalent. In addition, a significant number of drug users are extremely marginal-
ized and live on the streets and out of any social structure which puts them in more
vulnerable situations. Repeated rounds of surveillance have revealed that the rate of
sero-positivity is highest among intravenous drug users (IVDUs) and the findings
also confirm the presence of high levels of behavioural risk factors for the acquisi-
tion of HIV infection through needle sharing (Azim et al., 2008; Mondal, Takaku,
1.2 Risk and Vulnerability Factors for HIV/AIDS in Bangladesh 5

Ohkusa, Sugawara, & Okabe, 2009). Injecting drug use has steadily gained in popu-
larity in Bangladesh (Khan, 2006). A considerable proportion of heroin users shared
a needle/syringe during their last injection. Recent Behavioural Surveillance Survey
(BSS) data indicate that the drug user population is well integrated into the sur-
rounding urban community, socially and sexually, thus raising concerns about the
spread of HIV infection (Islam et al., 2015). However, drug users are also sexually
active with their married or unmarried partners. BSS data also indicate an increase
in risk behaviours such as sharing of injecting equipment and a decline in consistent
condom use in sexual encounters between drug users (including IVDUs and heroin
smokers) and female sex workers. More than half of the heroin users had commer-
cial and non-commercial female sex partners in the last year and those who did had
multiple partners. Condom use, both in the last sex act and consistently in the last
month, was very low with both commercial and non-commercial partners. This
overlapping, as well as multiple relations between more vulnerable and bridging
populations, makes Bangladesh vulnerable to HIV/AIDS.

Awareness of HIV/AIDS Public awareness of HIV/AIDS is an important prereq-

uisite for behavioural change. Many people in Bangladesh have now heard the
words ‘HIV’ and ‘AIDS’ as a result of intensive campaigns by different media and
NGOs (Rahman & Rahman, 2007), but a significant portion still need to know how
it is transmitted and that it can be prevented. The level of awareness among high-­
risk groups, as well as the public generally, is surprisingly low (Yaya, Bishwajit,
Danhoundo, Shah, & Ekholuenetale, 2016). Educated people are better informed
about HIV prevention than the poor but, as Caldwell and Pieris (1999) explain, the
lack of openness with regard to sexual issues means that opportunities for improved
knowledge are limited. Regarding awareness of STDs among married women of
reproductive age, Khan, Rahman, Khanam, Barkat-e-Khuda, and Ashraf (1997)
found that women in rural areas are generally not aware of STDs, although their
knowledge varied with their husband’s occupation, and their own age and level of
education. But Haque, Hossain, Chowdhury, and Uddin (2018) mentioned that a
sizeable portion of married women have an adequate knowledge and awareness
regarding the HIV/AIDS. Bhuiya, Hanifi, Hossain, and Aziz (2000) showed that
awareness of HIV/AIDS among the general population, particularly villagers, is
very low. The total number of non-marital sexual contacts as well as the low knowl-
edge levels/exposure to HIV prevention information and programming suggests that
community-wide awareness campaigns are needed. Epidemiological data, particu-
larly on STIs and related complications among high-risk behaviour groups, is lim-
ited in Bangladesh due to poor recognition of STIs as a major health problem, the
stigma and discrimination associated with STIs and the lack of coordination between
service providers and the research community (Nessa et al., 2005). However, differ-
ent surveys of long-distance truck drivers revealed that most of them had contact
with commercial sex workers (CSWs) about twice a month but that they mostly do
not know about HIV/AIDS.
6 1 HIV/AIDS in Bangladesh and Present Research

Blood Transfusion System Unscreened blood transfusions and commercial blood

donation by professional donors are important bio-medical risk factors for HIV
infection in Bangladesh. Many studies shown that blood transfusion could be a
potential risk in future as blood screening facilities are not good in most hospitals
and blood banks, and there are no effective rules for commercial blood collection,
testing, processing, storage and distribution (i.e. Akhter et al., 2016; Hossain,
Bhuiya, & Streatfield, 1996). The existing blood transfusion system carries a danger
of HIV transmission. Currently, the country needs annually about 300,000–350,000
units of blood, only 20–25% blood comes from voluntary donation. A significant
percentage of (about 30%) blood is collected from professional blood donors
through illegal blood banks (The Independent, 2017). Most professional blood
donors (PBDs) sell their blood to raise money to feed their drug habits, which can
also fuel the danger of HIV transmission. It is suspected that a good number of
PBDs are positive for hepatitis B and syphilis (Alam, Hossain, & Chowdhury,
2015). Recently, some PBDs have been identified as PLWH in a border area of the
country. Moreover, unsterile injections in non-formal and formal health-care set-
tings can be one of the significant potential bio-medical risk factors for HIV infec-
tion in Bangladesh (Gibney, Choudhury, Khawaja, Sarker, & Vermund, 1999). It is
a fact that disposable plastic syringes including needles are resold in shops and
markets, adding greatly to the risk of spread of HIV/AIDS.

Sexually Transmitted Diseases A high prevalence of sexually transmitted dis-

eases (STDs) is a co-factor for HIV transmission among the ‘most at-risk’ groups,
and is associated with bridging to the general public if untreated or ineffectively
treated. Bangladesh has a large commercial ‘sex industry’ in different forms. A
diverse group of clients buy sex and only a few use condoms. Many believe that the
low level of HIV/AIDS in the Muslim dominated society is a result of societal con-
servatism and religious teaching about immoral sex. But there are studies showing
high levels of commercial sex and significant levels of STDs, thus presenting a situ-
ation more complex than the stereotype (Rahman & Rahman, 2007). Research con-
firms that there is a low level of condom use by sex workers (Sarkar, Islam, Durandin,
et al., 1998). These CSWs are mostly non-literate and are organized in brothels or
work casually in the streets (Khan, 1999) but condom use for commercial sex is low
in Asia (only 2%) and the turnover of clients is high (averaging 44 clients a week).
As a result, most CSWs have STDs, including syphilis and gonorrhoea (Rahman,
Alam, Nessa, Hossain, et al., 2000; Nessa et al., 2005). A number of studies
(Hossain, Mani, Sidik, Shahar, & Islam, 2014; Khanam et al., 2017; Sabin, Hawkes,
Rahman, et al., 1997) also indicate the prevalence of STDs and RTI over a long
period in the country. In addition, high rates of STDs also appear to be present
among drug users. The existence of risky behaviour and high levels of sexually
transmitted infections (STIs) among the ‘core groups’ indicates the potential for a
serious HIV/AIDS epidemic in Bangladesh. However, transport workers are not
necessarily regarded as a vulnerable group in terms of national surveillance. They
are considered to be possible ‘bridges’ to the general population, potentially trans-
mitting HIV and STIs to their wives and to the population in general (Knight, 2006).
1.2 Risk and Vulnerability Factors for HIV/AIDS in Bangladesh 7

Social and Structural Risk Bangladesh has many contextual features, including
widespread poverty, gender inequality, stigma and discrimination, violence, poor
healthcare infrastructure, untrained health care personnel and low levels of literacy
that are relevant to HIV risk and vulnerabilities. Poverty and gender inequalities
have been playing an important role in transmitting the risk among marginalized
people. Poverty is the primary cause of trafficking in the region and traffickers target
their prey in the poverty-stricken rural areas. Due to poverty mainly, human traffick-
ing into prostitution, stigmatization of these women, conservative social attitudes
and huge migration flows (mainly rural to urban) exist (Mahmood, 2007). The HIV/
AIDS epidemic in Asian countries has been strongly influenced by gender inequal-
ity and the frequent practice of men visiting sex workers. Women lack the power to
refuse sexual activities due to a lack of economic empowerment and the cultural
convention that wives are unable to refuse sex with their husband or demand the use
of a condom.
The biggest challenge to an expanded response to HIV/AIDS in Bangladesh is
the government’s limited funding capacity. There are limited care and support pro-
visions for PLWH (NASP, 2004). Regarding health care, many health care person-
nel do not have appropriate training to handle the medical needs of people living
with HIV/AIDS. Social and cultural barriers in risk prevention are formidable.
Stigma and discrimination are problems, and public perceptions of PLWH and
members of vulnerable populations are negative (Panos, 2006). However, HIV/
AIDS policy should not only emphasize medical and technological aspects, but
should also be based on social and economic considerations. Human rights must be
addressed in a comprehensive national policy. In all international declarations and
the national policy on HIV/AIDS, reference is made to the need for a human rights
framework. Human rights here include access to health care, information, confiden-
tiality and gender equity (NASP, 2005).
Geographical Location and Mobility The geographical nature of Bangladesh, in
particular its long borders with India and Myanmar, exacerbates the HIV/AIDS
hazard (Gibney, Choudhury, Khawaja, Sarker, Islam, & Vermund, 1999; Sarkar
et al., 2008). Bangladesh has a significant cross border trade at land ports and move-
ments of population, including high-risk groups between Bangladesh and India.
This trans-border mobility is high for various reasons, i.e., trade, education, reli-
gious exchange, recreation and some illegal activities. It is notable that India is in
the phase of rapidly rising prevalence of HIV, with an estimated 2.1 million cases
(UNAIDS, 2017). Bangladesh has thirty border districts, 28 sharing a border with
India and two with Myanmar. Most of the land frontiers are open with rivers running
across. Bangladeshi trafficking groups have been able to build up powerful bases in
the border districts of India in West Bengal and Assam, to the north and west, and
these are now the favourite transit points for trafficked people (GOB, 2004; IOM,
2004). Population increases, environmental crises and structural adjustments in
Bangladesh have encouraged migration to India. An estimated 2000 Bangladeshis
cross the border every day, including labourers, smugglers and trafficked women
and girls (Knight, 2006). Porous borders with economically poorer Bangladeshis
8 1 HIV/AIDS in Bangladesh and Present Research

(not needing a visa to visit India) aggravate the problem of cross border trafficking
and the country has remained a source of women and children for some consider-
able time. The environmental closeness of Bangladesh to Myanmar, and conse-
quently the Golden Triangle drug trail, has made it a major transit route for drug
smuggling. The HIV epidemic among drug users in Myanmar and its heroin export
routes has led to HIV epidemics in neighbouring countries (Chelala & Beyrer,
1999). Myanmar has been considered a primary contributor to the spread of HIV/
AIDS in this region and 240,000 cases were estimated of HIV infection in Myanmar
by the end of 2018 (UNAIDS, 2018). However, the constant movement is one of the
major reasons for the transmission of HIV particularly among drug users in north-
ern India, Afghanistan, Pakistan and Bangladesh. In addition, there is a high preva-
lence of HIV cases in two of India’s north eastern provinces, Nagaland and Manipur,
which have Myanmar as a neighbour. China is also facing a similar crisis along the
stretches where it shares Myanmar’s north eastern border (UNAIDS, 2006).
However, Bangladesh has a large number of overseas migrant workers who have
gone in search of better job opportunities mainly to countries in the Middle East, or
Malaysia and South East Asian countries (Mercer, Khanam, Gurley, & Azim, 2007).
It is widely suspected that some of them have come back after being infected with
STDs and HIV from these countries. Most of the detected HIV/AIDS cases in
Bangladesh are overseas migrant workers. In addition, there is a great deal of migra-
tion between rural and urban areas within the country (NASP, 2004), and Bangladesh
hosts large communities of Rohingya refugees from Myanmar in the south east part
of the country. The two major seaports also receive many foreign ships’ crews the
year round. Together, these population movements add to the risk of STDs and
HIV/AIDS.

1.3  esearch on HIV/AIDS in Bangladesh and Present

R
Endeavour

In much research, HIV/AIDS continues to be considered as a ‘bio-medical/behav-

ioural level’ problem, but Campbell and Williams (1999) suggest that it should be
seen instead as a ‘Bio-Psycho-Social’ problem. In other words, epidemiological
data alone cannot represent its multiple and complex social dimensions (Mann,
1987). The critical interacting factors of sexual and injecting drug-using cultures,
together with the governmental and societal response to the HIV threat, shape the
geographies of HIV/AIDS in particular settings (Ford, Siregar, Ngatimin, & Maidin,
1997). The HIV epidemic has brought new dimensions of risk to third world coun-
tries like Bangladesh. It has also brought many changes, not only in the health sec-
tor, but also in social and economic issues (NASP, 2016). These changes have
occurred in the everyday lives of the individuals and communities who are highly
vulnerable or affected by the HIV threat. Over the last 25 years, around the world
many geographers, sociologists, anthropologists, psychologists, epidemiologists
1.3 Research on HIV/AIDS in Bangladesh and Present Endeavour 9

and medical scientists have had an increasing interest in HIV and AIDS and its
related subjects. In Bangladesh, this influence has been very limited. Most of the
research on HIV has been performed by public health scientists and epidemiolo-
gists. Very little academic research on HIV has addressed the socio-economic or
socio-geographic issues of the marginalized and stigmatized communities who are
considered as the ‘risk group’ for HIV infection in Bangladesh.
There is a vast literature on epidemiology and aetiology for the most at-risk
groups. These reports have looked not only at HIV infection but also at STDs and
hepatitis. Firstly, most work (for example, Azim et al., 2000; Bosu, 2013; Hossain,
Akter, Kamal, Mandal, & Aktharuzzaman, 2012; Islam, Hossain, Kamal, & Ahsan,
2003; Mowla & Sattar, 2016; Nessa et al., 2005) has assessed risk through blood
testing. Secondly, much research (for example, Alam et al., 2013; Gibney,
Choudhury, Khawaja, Sarker, Islam, & Vermund, 1999; Haseen et al., 2012; Jenkins,
1999; Kamal, Hassan, & Salikon, 2015; Rahman & Zaman, 2005) has assessed risk
behaviours for HIV prevalence of sex workers and drug users as well as truckers. A
few works (like, Gibney, Choudhury, Khawaja, Sarker, & Vermund, 1999; Mollah
et al., 2004) have also looked at the bio-medical issues of HIV risk in Bangladesh.
These above-mentioned studies have tried to show the potentiality of the future HIV
threat to Bangladesh from the behavioural as well as the bio-medical point of view.
Thirdly, there are a good number of papers (for example, Islam, Mostafa, Bhuiya,
Hawkes, & de Francisco, 2002; Khan et al., 1997; Sarafian, 2012) which have
focused on the assessment of awareness of HIV/AIDS among the different stake-
holders, especially the most at-risk groups for HIV. Finally, all the above categories
of work discuss some relevant preventive efforts in their concluding remarks.
With a dominant bio-medical and epidemiological framework, many studies of
HIV in Bangladesh frequently ignore the explanatory issues regarding the prejudice
against marginalized and vulnerable people, unhealthy places and policy, all of
which can be investigated by utilizing qualitative methodologies (Paul, 2019).
Following Mann (1987), epidemiological data alone cannot represent the multiple
and complex social dimensions of HIV/AIDS. According to him, the pandemic has
been conceptualized as consisting of three separate phases: an epidemic of HIV
infection, an epidemic of AIDS and an epidemic of social, cultural, economic and
political responses to AIDS. The third of these has been the most explosive, charac-
terized by denial, stigma and discrimination. However, a substantial literature sup-
ports the notion that the HIV/AIDS epidemic is determined by a combination of
structural, social/cultural and individual factors (Mac-Phail & Campbell, 2001;
Scambler & Paoli, 2008). The AIDS pandemic is now extremely complex, consist-
ing of a number of smaller and constantly changing epidemics which affect indi-
viduals, communities and nations in a multiplicity of different ways. But in
Bangladesh, many arenas of research in the HIV field have not been covered equally.
It has been found in this review that there has not yet been any in-depth research
concerning the socio-cultural and geographic impacts of the HIV disaster in
Bangladesh. Almost all of the literature shows HIV as an epidemiological problem
rather than investigating it from a social or cultural point of view and still less using
qualitative methods. The present research is an endeavour to fill these gaps. The
10 1 HIV/AIDS in Bangladesh and Present Research

valuable qualitative field data will demonstrate the causes of HIV risk and vulnera-
bility, and the book seeks a better understanding of the nature of the social and
locational context of HIV/AIDS in Bangladesh and will therefore assist with health
care policy planning. Although most epidemiological research (for example, Gazi,
Mercer, et al., 2008; Hosain & Chatterjee, 2005) has hinted at the necessity for
doing intensive study on geographically significant places like the border towns of
Bangladesh, there has not been significant academic research in this area.
Furthermore, there has been no work on PLWH and their ‘lifeworlds’ in conjunction
with HIV policy issues in Bangladesh. Little academic research (see, for example,
Hasan, 2007; Hossain & Kippax, 2011; Human Rights Watch Report, 2003; Sarma
& Oliveras, 2011; Paul, Atkins, & Dunn, 2012; Karim & Mona, 2013) has been car-
ried out from the social, geographical or policy point of view.
The aim of this study is to explore those issues in vulnerable and marginal peo-
ple’s lives which put them at risk of infection and also their adopted coping strate-
gies and how are these played out. In addition, the research aims to gain an
understanding of the perceptions of civil society and policy planners with respect to
vulnerability to HIV and the necessary mitigation measures. Within these general
aims, the study has five main objectives. First, I will detail the ‘lifeworlds’ of mar-
ginalized communities in terms of their everyday practices or customs, along with
their emotions and aspirations. Here, I will consider brothel and non-brothel sex
workers, opiate users and PLWH as marginalized groups because of their negative
status, the hostility of mainstream society and active discrimination by the state.
Their monetary uncertainty and everyday suffering are covered in detail. Their
anger and expectations from society are also discussed which combined play a role
in putting them at health risk. Conducting this research required an extended period
of time to be spent with the marginalized communities to obtain the views about
‘lifeworlds’ through in-depth interviewing, focus group discussion and naturalistic
observation. Second, there is no information on how HIV-affected or HIV-prone
people in Bangladesh live with social hazards. Still less research in Bangladesh has
focused on the way in which these social and psychological factors affect people’s
everyday lives.
This book is devoted to the task of studying the socio-geographical and psycho-
logical aspects of having HIV or living in close proximity to people with HIV. The
investigation of identity ‘crises’ and related consequences due to marginalization
and stigmatization status will be helpful in measuring their potential risk of infec-
tion. Victimization processes will be explored in order to understand the negative
societal attitudes in each study area. Third, in this book, ‘risk’ is discussed in the
light of the implications for understanding how everyday norms influence the ways
in which people perceive risk and act in response to risk. Vulnerable people’s per-
ceptions about their risk behaviours and their impact on health will be of great help
in revealing the real causes of risky behaviour in relation to HIV infection. Vulnerable
people include sex workers, drug users and Bangladeshi and Indian truckers. In
addition, their knowledge or consciousness about health risks, as well as their cop-
ing and adaptive techniques, will uncover their experiences of living with health
risks. Fourth, this book will examine places from different points of view, such as
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