Health Seeking Practices of People Living with HIV and AIDS (PLHIV) in Bangladesh: A Sociological Analysis

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Health Seeking Practices of People Living with HIV and AIDS (PLHIV) in Bangladesh: A Sociological Analysis

Chapter One


1.1 Statement of the Problem

Acquired Immune Deficiency Syndrome (AIDS), caused by the Human Immune Deficiency Virus (HIV), is the most devastating epidemic of today and has spread relentlessly around the globe smashing all the development initiatives organized by the states. Bangladesh, being one of the world’s high densely populated countries and being surrounded by the HIV infected countries, is highly susceptible to HIV transmission. At present the estimated number of PLHIV worldwide is 33.3 million and approximately 2.6 million people were newly infected only in 2009 (UNAIDS/WHO, 2010). The total number of people living with the virus in 2009 was almost more than 20% higher than the number in 2000, and the prevalence was threefold higher than in 1990 (UNAIDS/WHO, 2010). In South and South-east Asia, an estimated 4.1 million people were living with HIV, including 270,000 people who were newly infected and approximately 260,000 people who died from AIDS related diseases in 2009 (UNAIDS/WHO, 2010). Until December 2009, in Bangladesh, 2088 people were identified as HIV infected and among them 850 developed AIDS, and number of AIDS related death throughout the year was 241. Only in 2009 the number of newly HIV infected people in Bangladesh was 343 (NASP, 2010).

People Living with HIV and AIDS (PLHIV) need a variety of health care and social support. Because of their vulnerability to opportunistic infections and their progressive disease, infected people may have a decreased income or become unemployed due to their inability to work during periods of illness. The situation becomes more aggravated when PLHIV find that they or their family members are denied in getting access to appropriate health care, housing, education, and other community services because of their HIV/AIDS status. These discriminatory practices compound the adverse impact of an HIV/AIDS diagnosis, especially as it results in the social isolation of those in need and exclusion from care and community support (UNAIDS/WHO, 2010; Khosla, 2009).

In Bangladesh the needs of PLHIV are not addressed in an integrated and comprehensive manner. Health seeking practices of PLHIV are determined by the availability and accessibility of treatment facilities. Unlike some conventional sources of seeking health care, many of the PLHIV regard NGO and Govt. clinics as inevitable sources of getting health services and HIV testing facilities. The given health services may remain a great discrepancy in between NGO clinics and Govt. clinics. Even though different organizations are working in this area, PLHIV are not getting the required treatment, care, legal, psychological, emotional and socio-economic support from both the family and from society, even from the state. In Bangladesh, much emphasis is given on treatment facilities, but not on other support services, which are as important as treatment, to prolong healthy living of PLHIV and prevent further spread of the infection.

1.2 Setting the Context: Bangladesh

Bangladesh is a land of immense beauty and potential situated in South Asia bordering India, Myanmar and the Bay of Bengal. It is largely a flat deltaic country formed by the confluence of great river systems of the Padma (Ganges), the Brahmaputra and the Meghna. Bangladesh is geographically vulnerable to HIV and AIDS and it has many epidemiological and social factors that could produce devastating epidemic risk factors such as high prevalence of HIV in the neighboring countries, less awareness of HIV infection, existence of large commercial sex industry and Man sex with Man (MSM), sex with multiple clients and mushrooming growth of Injecting Drug Users (IDUs) (Amanullah and Habib, 2002) extreme poverty, illiteracy, ignorance, malnutrition, unemployment, slum housing, family fragility, physical and sexual abuse, high prevalence of STDs, very mobile population, human trafficking into prostitution, stigmatization, conservative social attitudes, migrant workers, low popularity of condoms in an iconoclastic way (Amanullah, 2002).The specific reasons which might be responsible for spreading HIV in Bangladesh are geographical location (NASP, 2007); mushrooming growth of beauty parlor and private sex establishments (Begum, 2007); rapidly growing private universities (BAPS, 2007); construction workers (The Daily Star, 22 March, 2005); private clinic or laboratories (BAPS, 2007).

Whereas HIV/AIDS is one of the most significant health and development problems facing the world today and nobody is beyond its reach, the treatment seeking patterns remain more conventional in both rural and urban settings of Bangladesh regarding HIV/AIDS. Several socio-economic factors play a pivotal role in receiving treatment and care for HIV/AIDS in Bangladesh. The indicators attached to culture and prevalence of HIV/AIDS motivates the infected people to seek care and service from different sources of availability of medicine. People in Bangladesh are sometimes seen to practice self-medication until they feel a severe attack of that particular disease. Despite technological and communicational advances in treatment and care the nature of service as to HIV is still more centralized and urbanized in Bangladesh. Whereas a certain segment of the population remains under poverty line it is quite difficult for many of the PLHIV to come to district (an administrative unit of Bangladesh) area let alone the Dhaka, the capital city of Bangladesh. Since all kind of possible mechanisms of contracting HIV are closely intertwined with the socio-demographic and socio-economic characters of Bangladesh, the researcher has chosen the site as its research location.

1.2.1 Bangladesh: Geographical Proximity to HIV Epidemic

Bangladesh is located in the Asian HIV epicenter (Amanullah, 2002; 2006) and the country traditionally shares a popular crossroad of South- Asian migration/frequent mobility. Lots of sources of illegal entrance and exit tantalize the current status of export-import trade keeping a severe threat to national economy and risk practices. The country has an area of 147,570 square kilometers bordered on the west, north and east by a 2,400 kilometers land frontier with India and, in the southeast, by a short land and water frontier (193 kilometers) with Myanmar (Mitra et al, 1997; 1)

Poverty and prostitution are the prime causes of heterosexual transmission of HIV in many countries of Asia (Podhisitia et al, 1994; Gillies, Tolley and Wolstenholm, 1996; Prybilski and Alto, 1999; Thomas and Bandypadhyay, 1999: WHO, 2001a, 2001b). These socio-economic barriers have tremendously influenced the sex industry of Bangladesh from the nineteenth century (Khan and Arefeen, 1989; Blanchett, 1996; Amanullah, 1997) amplifying the health risks in this multi-territorial country (Quoted in Amanullah, 2002).

1.3 Objectives of the Study

The major objective of the study is to explore the health seeking practices of PLHIV in Bangladesh. The Specific Objectives of the study are

To examine the relationship between socioeconomic determinants of PLHIV and their health seeking practices

To explore the existing gaps between NGO clinics/service centers and Govt. clinics in terms of services ensuring accessibility to HIV treatment and care.

To measure the level of knowledge of the People Living with HIV and AIDS (PLHIV) as to HIV and AIDS and STDs

To explore the relationship between socio-demographic and socio-economic status of the respondents as well as perceived barriers to HIV treatment and care.

To identify the patterns of social stigma and superstition in comparison with the present status of the victims in society.

To locate whether PLHIV have accessibility to the sources of information and mass media.

To observe whether victims have opportunities to HIV and AIDS prevention program in the context of media exposure.

1.4 Research Questions

Is there any relationship between socioeconomic determinants of PLHIV and their health seeking practices?

Has there any gap between NGO clinics/service centers and Govt. clinics in terms of services ensuring accessibility to HIV treatment and care?

What is the level of knowledge of People Living with HIV/AIDS (PLHIV) as to HIV and AIDS and STDs?

Has there any relationship between socio-demographic and socio-economic status of the respondents as well as perceived barriers to HIV treatment and care?

What are the patterns of social stigma and superstition in comparison with the present status of the victims in society?

Has there any opportunity of PLHIV to the sources of information and mass media?

Has there any accessibility of the victims to HIV and AIDS prevention program in the context of media exposure?

1.5 Hypothesis

People Living with HIV and AIDS (PLHIV) mostly come from lower strata of the society.

Health seeking practices are mostly promoted by socioeconomic backgrounds of the PLHIV.

1.6 Rationale of the Study

The study is about to explore the health seeking practices of PLHIV. The PLHIV require a wide range of services including care, treatment and support, depending on the progression and stage of their HIV infection. Prior to perceive the fact of HIV positive the infected people take medicine and counseling from the nearest drug store and very often go to traditional healers and unqualified practitioners (Ahmad, 2005). Many studies have concentrated that PLHIV are satisfied with treatment and care from NGO clinics and to some extent from government hospitals. Organizational guidelines of organizations providing services to PLHIV may differ greatly between the different organizations, which are supported by the government and other donor agencies. In Bangladesh PLHIV may encounter social discrimination which creates serious problem in obtaining the requisite service and support (Skinner, et al., 2004).

In Bangladesh the HIV prevalence rate is low till today, but it is alarming and acting as a fatal silence (Amanullah, 2006) to destroy the potential human resources of Bangladesh. The geographical location is an unexpected for Bangladesh whereas excessive intention of migration has tantalized and accelerated the vulnerability of women and children. The high rates of cross-migration, unprotected cross border, lack of knowledge are responsible in this regard. In a study it is found that students are the third client group to the commercial sex workers (Amanullah and Choudhury, 2005; 2006; Rahman, 2007). Since the PLHIV cannot comprehend let alone trace the signs and symptoms of this deadly virus they may rush to the local drugstore for first aid. If they feel somewhat cured taking medicines and antiseptic from different sources e.g. traditional healer, homeopathic and Para-professional practitioners (Ahmed, 2005) they may not wish to take extra precautionary measures for this disease. Addressing HIV /AIDS the proper diagnosis and medical treatment are not available in the remote regions of the country. People Living with HIV and AIDS (PLHIV) often may come to Dhaka for treatment and care. But socioeconomic barriers sometimes may make them more vulnerable and susceptible to receiving proper treatment and counseling. The study focuses to explore how a variety of factors play role in directing the health seeking practices of PLHIV in Bangladesh. In order to conceptualize and measure the nature and status of HIV related services the researcher has kept in mind the contradictory patterns of service of NGO clinics and Govt. clinics. So the importance of this systematic study is more rational in this geographically vulnerable situation.

1.7 Scope of the Study

The study has been conducted on the different areas of Dhaka, the capital city of Bangladesh. The People Living with HIV and AIDS (PLHIV) have been interviewed for collecting primary data. HIV/AIDS related health service and practice of the concerned respondents were explored using both qualitative and quantitative data. For this some hypothesis are formulated reviewing literature and deducing from few theoretical frameworks. The study attempts to explore a variety of factors influencing the health seeking practices of PLHIV with a view to measuring the nature and status of services derived from different sources. At the time the level of knowledge of concerned respondents is measured in order to get a comprehensive idea of perceived susceptibility and perceived severity on HIV/AIDS. So far as I know this study is first in its nature in Bangladesh. The findings of this study would be helpful not only to academicians but to the policy planners and development workers.

1.8 Limitations

Since the study depends on respondent’s self reports, it may not be free from unintentional or intentional response biases or deliberate concealment. Being a more sensitive issue, People Living with HIV and AIDS (PLHIV) can keep aloof from giving any information which is more requisite and meaningful to glorify the status of the study. Besides, because of the survey’s nature and the extensive techniques taken by interviewers to ensure privacy and confidentiality, it is unlikely that respondents provided expected answers as to the complexity and severity of this lethal disease. For the sake of achieving the maximum respondents the researcher had to curtail the particular units of research area which could make any biasness in treating the desired sample size statistically representative.

With limited finance and time constraints the researcher had to curtail many programs of the present study. The multipluralistic data collection methods magnified the reliability of the overall findings. Findings are indicative and can be confidently applied for future decision making processes.

Chapter Two


Migration, unsafe sexual intercourse, needle sharing etc. are mostly liable for the massive worldwide transmission of HIV and AIDS. However, lack of adequate knowledge about AIDS and sex education has further aggravated the present epidemic. Although much development in care and increase of funds for HIV infection has been made, HIV and AIDS induced morbidity and mortality is quite high in the developing world (Ivers et al., 2009). Feminization of HIV and AIDS discloses several other facts. Violence against women associated with sexual harassment is a major factor for the spread of HIV (Koenig, Michael et al., 2004: 157). Often women especially teenage girls in developing countries do not want to expose their sexual illness for fear and shame. Also, patriarchal social system ignores women’s opinion and decision making even in cases like marriage and to conceive. Whatever be in the developed world; AIDS patients often face serious discrimination and stigma regarding treatment, normal life- living and even they are socially excluded in almost all third world countries like Ghana, India, and mostly in countries of Sub-Saharan Africa. However, the provision of treatment in those countries is not adequate and often HIV infected people lead a boring and captive life.

Bangladesh, being a developing country, still has a low prevalence rate of HIV transmission. The population groups considered to be most-at-risk include: female sex workers, male sex workers, MSM, transgender, IDUs and heroin smokers (Amanullah, 2002; 2005; 2006; Habib and Amanullah, 2002; Azim et al., 2009; ICDDRB 2010). Other than that, lack of knowledge about family planning, misconceptions about the disease, illiteracy about STIs contribute to the spread of HIV in Bangladesh. Whatever the degree of severity of AIDS may be, people should be conscious and practice healthy and safe sexual relation (Kippax, 1993; Patton, 1996; Dowsett, 1993) and religious dogma about sexual life can also play a prime role in checking the transmission of AIDS by protecting extra-marital and unsafe sex.

2.1 HIV and AIDS: Global Context

During 2009, some 2.6 million people became infected with HIV, including an estimated 370,000 children (UNAIDS/WHO, 2010). Most of these children are babies born to women with HIV, who acquire the virus during pregnancy, labor or delivery, or through breast milk. The year 2009 also saw 1.8 million deaths from AIDS related causes. The number of deaths probably peaked around 2004, and due to the expansion of antiretroviral therapy, declined by 19 percent between 2004 and 2009. Around half of people who acquire HIV become infected before they turn 25, and AIDS is the second most common cause of death among 20-24 year olds (UNAIDS/WHO, 2010).

AIDS is the indomitable monster that causes innumerous people to accept premature death throughout the world. All parts of the world are not equally affected by HIV. Sub-Saharan Africa has been massively devastated by the HIV/AIDS epidemic. The picture is especially bleak for the adolescent aged between 15 – 19 years. In some of the worst affected countries in southern Africa adolescent are greatly affected due to sexual abuse (UNAIDS/WHO, 2010). HIV has already caused an estimated 1.8 million deaths worldwide and has generated profound demographic changes in the most heavily affected countries (UNAIDS/WHO, 2010). Due to the devastating impact the pandemic has flourished throughout the world at an alarming rate making the disadvantaged and minority groups of population vulnerable to many health risks.

With around 68 percent of all people living with HIV residing in sub-Saharan Africa, the region carries the greatest burden of the epidemic. Epidemics in Asia have remained relatively stable and are still largely concentrated among high-risk groups. Conversely, the number of people living HIV in Eastern Europe and Central Asia with has almost tripled since 2000.

Table 2.1: HIV and AIDS: Global Scenario by Region, 2009

Region Adults & children

living with HIV/AIDS

Adults & children

newly infected

Adult prevalence*


AIDS-related deaths in

adults & children

Sub-Saharan Africa 22.5 million 1.8 million 5.0 1.3 million
North Africa and Middle East 460,000 75,000 0.2 24,000
South and South-East Asia 4.1 million 270,000 0.3 260,000
East Asia 770,000 82,000 <0.1 36,000
Oceania 57,000 4,500 0.3 1,400
Central and South America 1.4 million 92,000 0.5 58,000
Caribbean 240,000 17,000 1.0 12,000
Eastern Europe and Central Asia 1.4 million 130,000 0.8 76,000
North America 1.5 million 70,000 0.5 26,000
Western and Central Europe 820,000 31,000 0.2 8,500
Global Total 33.3 million 2.6 million 0.8 1.8 million

Source: Report on Global HIV/AIDS Epidemic, UNAIDS/WHO, 2010

* Proportion of adults aged 15-49 who are living with HIV/AIDS

The number of people living with HIV rose from around 8 million in 1990 to 33 million by the end of 2009 (Fig: 2.1). The overall growth of the epidemic has stabilized in recent years. The annual number of new HIV infections has steadily declined and due to the significant increase in people receiving antiretroviral therapy, the number of AIDS-related deaths has also declined.

Fig 2.1: Global number of people living with HIV, by year.

Source: Report on Global HIV/AIDS Epidemic, UNAIDS/WHO, 2010

Table 2.2: Global HIV and AIDS Estimates, (End of 2009)

Global HIV/AIDS Epidemic in 2009 Estimate

(in million)


(in million)

People living with HIV/AIDS 33.3 31.4-35.3
Adults living with HIV/AIDS 30.8 29.2-32.6
Women living with HIV/AIDS 15.9 14.8-17.2
Children living with HIV/AIDS 2.5 1.6-3.4
People newly infected with HIV 2.6 2.3-2.8
Adults newly infected with HIV 2.2 2.0-2.4
AIDS deaths 1.8 1.6-2.1
Orphans (0-17) due to AIDS 16.6 14.4-18.8

Source: Report on Global HIV/AIDS Epidemic, UNAIDS/WHO, 2010

In the early to mid-1980s, while other parts of the world were beginning to deal with HIV and AIDS serious epidemics, Asia remained relatively unaffected. By the early 1990s, however, AIDS epidemics had emerged in several Asian countries and by the end of the decade; HIV was spreading rapidly in many areas of the continent.

Today, around 4.87 million people are living with HIV in South, East and South-east Asia (UNAIDS/WHO, 2010). Although national HIV prevalence rates in Asia appear to be relatively low, the populations of some Asian countries are so vast that these low percentages actually represent very large numbers of people living with HIV. In India for example, an estimated 0.1% of adults aged 15-49 are living with HIV, which seems low when compared to prevalence rates in some parts of sub-Saharan Africa. However, with a population of around one billion, this actually equates to 2.3 million adults living with HIV in India. (UNAIDS/WHO, 2010).

Table 2.3: HIV and AIDS: Asia

India 23,10,000
China 7,40,000
Thailand 5,30,000
Vietnam 2,80,000
Indonesia 3,14,000
Myanmar 2,40,000
Pakistan 96,000
Cambodia 75,000
Malaysia 80,000
Nepal 64,000

(Source: UNAIDS/WHO, 2010)

While the epidemics in Cambodia, Myanmar and Thailand all showed declines in HIV prevalence, those in Indonesia and Vietnam are growing (UNAIDS/WHO, 2010). As estimated 33.3 million people were living with HIV in 2009, including the 2.6 million people who became newly infected in the past year and 1.8 million died from AIDS related illness in 2009 (UNAIDS/WHO, 2010).

2.2 HIV and AIDS: Bangladesh Perspective

HIV prevalence in Bangladesh is low (‹ 1%) among the general population, even within the vulnerable population it continued to be low other than certain sections of injecting drug users. Experts predicted several possible reasons for this: high levels of circumcision among men, until recently relatively low levels of injecting drug use, and relatively low risk behavior in the society. There is consensus, however that are sick factors for the spread of HIV in Bangladesh: formal and informal commercial sex trade, low level of condom use, increasing injecting drug use, and rising prevalence levels among injecting drug users. Over the period of 1999-2008, HIV prevalence in central Dhaka showed rapid increase of HIV prevalence. The Serological surveillance shows that the rate of HIV has crossed the concentrated epidemic among IDUs. Rates in central Bangladesh rose from 1.4 percent to 7 percent since 1999, up to as high as 11% in one neighborhood of Dhaka (GOB, 2008; Amanullah, 2006; Khan, 2008).

The epidemic in Bangladesh seems to follow a typical pattern for Asian epidemics. The Asian epidemic model describes how in countries with sizeable IDU and MSM populations, the epidemic kicks off, often very rapidly, among injecting drug users. At the same time HIV is introduced in overlapping sexual networks of female and male sex workers and men who have sex with men. Subsequently HIV spreads through bridging populations to the general population. Sexual networks largely determine the ultimate epidemic level, especially the proportion of men buying sex (NASP, 2008; Amanullah and Choudhury, 2005, 2007)

Figure 2.2 Key indicators associated with HIV/AIDS in Bangladesh.

Unprotected sex

IV in Bangladesh remains at relatively low levels in most at-risk population groups, with the exception of injecting drug users (IDUs) where prevalence continues to grow. Although overall HIV prevalence remains under 0.1 percent among the general population in Bangladesh, there are risk factors that could fuel the spread of HIV among high-risk groups. Prompt and vigorous action is needed to strengthen the quality and coverage of HIV prevention programs, particularly amongst IDUs (World Bank, 2009).

Table 2.4: HIV and AIDS: Bangladesh Scenario, 2009

Cases (Marked) Total
HIV (identified) 2088
AIDS 850
AIDS death 241
Newly infected 343
Total estimated 7500

(Source: NASP, 2010, UNAIDS/WHO, 2010)

2.3 Globalization, MDGs and HIV/AIDS Prevention

The sixth prime goal of MDGs is to reduce and combat HIV transmission throughout the world. AIDS epidemic report (UNAIDS/WHO, 2010) shows that HIV transmission has been decreased and the past trend of HIV spreading is altered (Summit on the MDGs, 2010). Globalization affects all facets of human life, including health and well being. The HIV/AIDS epidemic has highlighted the global nature of human health and welfare and globalization has given rise to a trend toward finding common solutions to global health challenges. Numerous international funds have been set up in recent times to address global health challenges such as HIV.

However, despite increasingly large amounts of funding for health initiatives being made available to poorer regions of the world, HIV infection rates and prevalence continue to increase worldwide. As a result, the AIDS epidemic is expanding and intensifying globally. Worst affected are undoubtedly the poorer regions of the world as combinations of poverty, disease, famine, political and economic instability and weak health infrastructure exacerbate the severe and far-reaching impacts of the epidemic(Caldwell and Pieris, 1999). Various global initiatives and collaborations are addressing the global HIV/AIDS challenge. For example, the United Nations Millennium Development Declaration, signed in 2000 by 189 nations, encompasses eight Millennium Development Goals (MDGs), three of which are health related: reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria and other diseases, by 2015 (Travis, 2001).

In her statement, Helen Clark (2009) depicts those laws facilitating targeting prevention services to the excluded and most risk prone parts of society, including MSM and drug users, contributed to bring HIV out of the dark. She mentioned that making laws for sex workers to use condoms and avoidance of punitive legal environment has led to the decline of health risks for sex workers and clients alike. She insists that Global HIV Commission should focus on:

Laws and practices which in effect criminalize people living with HIV and vulnerable to HIV;

Laws and practices which mitigate or sustain the violence and discrimination as experienced by women; and

Laws and practices which facilitate or impede HIV-related treatment access (UNDP 2010).

But Clark (2009) astonishingly remarks that many countries still use the law to punish behavior associated with HIV transmission. She further added that HIV response has used new programs to reduce the price of HIV medicines and increase access to HIV related treatment. Voluntary Counseling and Testing (VCT) and Mother-to-Child Transmission (MTCT) have recently become a major focus of HIV control programs in developing countries (Dabis et al, 2000; De Cock et al, 2000). Experts (Marcelo 2007; Joseph 2008) suggests that the present HIV crisis can only be made pacified effectively with its relation with poverty and neoliberal globalization is addressed by broad, effective, and long term policy responses.

2.4 Mobility of the Population and HIV Transmission

An increasingly mobile global population exacerbates the risk of HIV transmission. The increasing volume of international travel contributes to the spread of sexually transmitted infections, including HIV. Refugee populations arising from areas of conflict, estimated by the United Nations High Commission for Refugees to number 97 million worldwide (UNHCR, 2004) are at higher risk, as are internal migrants within countries, who oscillate between rural and urban milieu. According to the International Labor Organization, at the beginning of the 21st century, 120 million workers worldwide were migrants (ILO, 2OO2).Migration plays a significant role in the economic and cultural life of Burkina Faso, a factor that was shown to play a critical role in the spread of HIV from the very beginning of the epidemic (Dawson, 1988; UNAIDS/WHO, 2010). Similar picture is observed in Bangladesh, a South-East Asian developing country. More or less 250,000 people are said to migrate abroad in search of job (UNDP 2008). Very often and frequently these migrant people get infected with HIV for risk practice and transmit it after return to home (Amanullah, 2002).

In the contemporary literature on AIDS migration is seen as a generator of contracting HIV transmission (Tatum and Schoech, 1992). And the prevalence rate varies from city to city, place to place and across community. In many cases the unavailability of residence causes irresponse to HIV related treatment services (Montoya, et al 1998). The present literatures on HIV/AIDS reports that demographic and income eligibility often forces people to migrate from rural to urban areas and most of those migrated people engage in risk practices in many of the third world countries and even in developed countries like USA (Cohn, Klein, Mohr, Horst, and Weber, 1994).

2.5 HIV and AIDS Epidemic: Affected and Displaced Population

Hundreds of millions of people worldwide are currently affected by armed conflict, both directly and indirectly. By the end of 2002, there were approximately 40 million displaced people globally: 15 million refugees (UNHCR, 2003a; UNRWA, 2003) and 25 million IDPs (Global IDP Project, 2003). The complex relationship between HIV/AIDS and conflict is still not documented and sometimes remains hidden. Many recent publications have asserted that conflict is directly associated an increase in HIV/AIDS transmission (Hooper, 1999; McGinn et al, 2001; UN Institute of Peace; Save the Children, 2002). One paper claimed that women are six times more likely to contract HIV in a refugee camp than in the general population outside of the camp (Gardiner, 2001). Sub-Saharan Africa is disproportionately affected by the HIV/AIDS epidemic, epidemic and conflict. The epidemiology of HIV/AIDS during conflict is complicated, but the vulnerability of conflict-affected and forced-migrant populations (Khaw et al, 2000; Hankins et al, 2002; International Rescue Committee, 2002; Save the Children, 2002; Smith, 200) has been shown to be associated with the breakdown in social structures, lack of income and basic needs, sexual violence and abuse as well as increased use of drug.

There was a dramatic increase in the incidence of conflict and complex emergencies in the last half century. Manuel et al. (2010) further posits that Bosnia, Haiti and Liberia have undergone through protracted conflicts, and hostilities continue in Eastern DRC. The prevalence of HIV among people aged 15-49 in Bosnia, DRC, Haiti and Liberia in 2007 was estimated to be 0.1 percent, 1.5 percent, 2.2 percent, and 1.7 percent respectively. The fact is that displaced and sexually abused women conspicuously fail to get benefit from post-conflict HIV and other health interventions. In Haiti and DRC, displaced women have been living in extreme fear that they or their daughters may get infected with HIV. They stated also that having been raped, knowing someone who had been raped or fearing rape has now become a prime psychological impediment to return to their families and communities of their origin (Manuel et al., 2010).

Many countries have been seemingly overwhelmed by the speed and its impact on forced migrants (Kenny et al., 2010) and other mobile populations. Evidence-based experience, good assessment and a readiness to adapt programs to local realities has been the key to tackling HIV in Asia. For example, in Malaysia there are about 70,000 refugees from Myanmar. At the end of 2009, there were 124 refugees receiving ART supported by the Ministry of Health and UNHCR (Burton et al., 2010). A different notion often depicts the same criteria that conflict, displacement, food insecurity and poverty make the affected populations more prone to HIV transmission. There is a misconception that refugees’ HIV rates are always higher than those in their host countries; in fact, evidence suggests that the opposite is more likely, but it is always context specific (Spiegel, 2004)

2.6 HIV and AIDS: A Discrepancy between Urban and Rural Settings

Poverty creates conditions ripe for HIV transmission. Economic growth has caused rapid urbanization in India, with large urban slum populations composed of migrants, manual laborers (UNDP, 2000). Currently 260 million people in India (26 percent of the population) live under the poverty line (Government of India, Economic Survey, 2000-2001). Low income, untreated STDs and sex trade increase the risk of HIV transmission, whereas the infections cause mucosal ulceration with an easy entry for HIV. India has a very high rate of STDs; the current estimates are about 6 percent to 9 percent of the population, with more than new infections per year. A sample of randomly selected households in Tamil Nadu found that that 2.1 percent of the adult population living in the countryside had HIV infection compared with 0.07 percent of the urban population. Agricultural output, the cornerstone of production in agrarian economies, is decreasing as a result of increased mortality in the workforce, resulting in what has been termed “new-variant famine”. Studies predict that in the ten most severely affected African countries, the agricultural workforce will decline by 10–26 percent by 2020 (ILO, 2002).

2.7 Knowledge, Attitudes and Practices about HIV and AIDS among PLHIV

In most cases, inadequate sexual knowledge associated with AIDS and a deficit of protective and treatment materials lead to the rise of practices and attitudes like – refusal to admit HIV infected persons in public hospitals, boycotting AIDS care professionals and thinking the treatment of HIV –infected persons as a wastage of resources in third world countries like Nigeria (Nigeria Federal Ministry of Health 2001). In some poor neighborhoods, African-American folk beliefs depict AIDS to ‘toilets’, ‘filth’, ‘touching’, ‘kissing’, and ‘mosquitoes’. There are even misbeliefs that HIV-infected persons could be cured if they have massive sex with virgin girls. Like the treatment of other serious diseases many AIDS patients take the healing procedure of alternative, traditional and religious healers. Ingstad describes traditional Botswanian healers like- ngaka ya diatola(‘doctor of the bones’), ngaka ya dishotswa (‘doctor of herbs’), and profiti (a prophet of the African Churches). In this way, in several contexts, the cultural representation of AIDS can be a mix of medical and indigenous belief (Helman 1999: 340-356).

As to Parker, transmission and prevention of AIDS differs between developed and developing nations (Helman, 1999: 340-356). He further exemplifies it by citing the case of the USA and Western Europe and Brazil. As a result of this, strategies made for one country or region may not be totally appropriate for another. This is important that AIDS is intimately linked with sexual behaviors; this intimate area of human relationship is many times challenging to study and research. Problems also arise since average bisexual and homosexual men live within their families.

Female sex workers in third world countries are the worst victims of HIV- infection. In most cases, economic dependence and poverty are the prime causes of prostitution. Due to poor family background most prostitutes are illiterate or do not have the minimal sex education. So, they do not understand the necessity of using condoms and often they are forced by their clients not to use condoms at the time of sexual intercourse (AIDS Education and Prevention, 10 (4), 303-316, 1998). Moreover, structural factors also affect the transmission of HIV- infection among sex workers (Kinnel, 1991; Simon et al., 1993). Proper and adequate knowledge of HIV/AIDS has become the central topic of discussion today. In Bangladesh, a difference is seen regarding the knowledge about HIV/AIDS between rural and urban areas. Print and media campaign have a positive influence on proper knowledge of HIV transmission and prevention.

2.8 Risk Perception and HIV/AIDS Epidemic

At present, in its third decade, HIV/AIDS has become one the most dangerous pandemics in modern history. The risk of AIDS is controlled and motivated by a wide number of factors. As to Stefan (2002), the risk of AIDS can be apprehended in three particular ways: a. risk as a ‘danger of modernization’, b. risk as a ‘neologism of insurance’, and c. risk as a ‘bio-political technology’ – at play in recent attempts to frame HIV/AIDS as a threat to international security.

In his famous book ‘Risk Society’, (1992) conceptualizes ‘risk’ as “a systematic way of dealing with hazards and insecurities induced and introduced by modernization itself” (Beck 1992: 21). Beck’s distinction between ‘natural’ and ‘artificial’ hazards insists that in the age of AIDS we must confess that we are still subject to hazards originating in nature. AIDS as a disease of modernity, as mentioned before, is intimately linked to – a. modernization policies promoted by international organizations; b. the modernization of transport infrastructures enabling the movement of goods and people across long distances; and c. to technologically complex processes for extracting mineral and biomedical resource.

The AIDS pandemic is rooted in variegated and complex ways with the neo-liberal development models used to accelerate rapid economic modernization. In many developing countries, AIDS crises require a degree of public expenditure to address it and its provision may clash with internal and external financial pressures. The projected million of people being infected with AIDS since the pandemic began, with a few exceptions, infected by one of the three modes of transmission: sexual, parental, and mother to child. Cases of infection through oral sex have been found but transmission of this type is perceived to be less risky than penile-vaginal or penile-anal sex.

Women aged between 15-49 are the most vulnerable and helpless group to be affected by HIV-infection. Because their male partners often are bisexuals and homosexuals and they maintain sexual relationships with their life-partners. The case of female sex workers cannot also be left omitted. Most of the time these women due to lack of sex and AIDS education do not use condoms and even conceive without testing AIDS. As a result, they themselves and their partners and also their newborn child/ children is/are infected with HIV (Zenilman et al. 1995; Ward et al. 1993; and Farmer et al. 1993).

Bangladesh’s 8th round of Serological Surveillance (2007) showed that HIV prevalence among all high-risk groups remained below 1 percent with the exception of injecting durg users. Among injecting drug users, prevalence was less than 2 percent in all sites except Dhaka. In Dhaka, prevalence rose from 1.7 percent in 1999 to 7 percent in 2006 marking the first concentrated epidemic among any high-risk group in Bangladesh (World Bank, 2009).

2.9 Women and Children’s Vulnerability to HIV and AIDS

The entire physical, mental and social wellbeing of an individual in all matters relating to the sexual and reproduction should be the utmost concern of government and all stake holders in population since women are the producer of human offspring and the future of a nation is subject to their sound sexual and reproductive health. But in most cases women and children are the worst sufferer in terms of HIV- transmission. UN program on HIV/AIDS in 2009 projected that out of the 30.8 million adults were living with AIDS all over the world, 50 percent of them were women (UNAIDS/WHO, 2010). Data shows that 98 percent of these women live in the developing world (UNAIDS/UNFPA/UNIFEM, 2010). According to 2010 AIDS epidemic report updated by UNAIDS, up to 2009 of the total 33.3 million HIV infected, 15.9 million are women and 2.5 children are also the highly potential group to be infected by HIV (UNAIDS/WHO, 2010).

2.10 Socio-cultural Drawbacks of PLHIV and Treatment Seeking Patterns

Health seeking behavior refers to those things that humans do to prevent diseases and to detect diseases in asymptomatic stages. In developing countries there are fewer opportunities for testing and treatment of AIDS and most often in these countries cultural practices play a significant role to the transmission of HIV.

In Africa, as to Daniel (2006) factors influencing sexual transmission of HIV include: a. promiscuity, with a high prevalence of sexually transmitted diseases; b. sexual practices associated with increased risk of HIV-transmission; c. cultural practices associated with increased virus transmission. Daniel (2006) argues, at present promiscuity is the most significant cultural factor liable for HIV-transmission in Africa. Female circumcision; such as infibulations, excision and sunna circumcision are found in Africa as cultural practices that make the female population more susceptible to HIV-infection . Sharing of unsterilized needles contributes as a factor for HIV-transmission in Africa. In parts of Africa, there is a general belief that Western medicine can provide explanation or cure for certain diseases (Kofi et al 1997:244).

Condom use in India was insignificant while74 percent reported sex with female sex workers and 15 percent of male IDUsalso reported having sex with men (Panda et al., 1998) which vehemently affects the rate of infecting with HIV/AIDS.

Health counseling is a new concept in India. Patients here are much less proactive in seeking health care than in developed countries. In the context of HIV-test counseling, the process of building a risk inventory involves discussing the sexual life style of the client. This falls into the realm of taboo. Worse, high risk behavior is viewed as morally wrong; hence few visit the Voluntary Counseling and Testing (VCT) centers (Solomon et al., 2002)

An emerging cadre of ‘para-professionals’ as main provider of formal allopathic care to the disadvantaged populations (Ahmad, 2005) was observed, in addition to the predominance of self-care in Bangladesh. Household poverty was instrumental in shaping health seeking behavior. The probability to access to any type of healthcare, and professional allopathic care (MBBS) was found to be greater for men than for women. In third world countries like Bangladesh, there are very limited treatment and support provision for PLHIV. Most of the HIV-infected people cannot carry on required facilities of testing HIV. Since these tests are expensive and their scope is limited, a few NGOs solely carry on this responsibility. There are more or less 12000 HIV-infected people in Bangladesh (WHO 2009). But as data provided by the National AIDS/STD Program, only 452 AIDS patients are regularly given anti-retroviral therapy (ART). And still there is no provision of CD-4 test equipment outside Dhaka (Prothom Alo, 2010).

2.11 Social Stigma and Misconceptions: Discriminatory Attitudes towards PLHIV

Stigma and discrimination play significant roles in the development and maintenance of the HIV epidemic. Especially the situation is dangerous in many third world countries like South Africa, Sub-Saharan African countries and South Asian countries like Bangladesh. In a developing country like Bangladesh, the high risk practicing groups like commercial sex workers, IDUs, MSM, transgender population (hijra) – are socially excluded (Khosla, 2009) . Matter of tremendous attention is that their deep-rooted causes of observed risky behaviors are not addressed and their treatment in complicated by different social and cultural barriers. In Bangladesh, generally social norms accord females comparatively lower status than males. Transgender populations such as the ‘hijras’ are often threatened by local hoodlums and even face verbal and physical abuse. Moreover, behavior of MSM is not conceptualized as Western homosexuality. MSM also experience social discrimination and legal persecution. Often is the case of being HIV infected considered as socially-deviant behavior; i.e. as extra-marital and pre-marital sex. The female sex workers are worst suffering risk practicing population in Bangladesh (Amanullah, 2002). Here they are deprived of their human and health rights and still sex work before marriage is considered socially immoral and deviant work. Also the CSWs are subject to harassment from hoodlums, law enforcing authorities, and brothel-owners alike. And all these factors pave the way of the spread of more HIV-transmission making the anti-AIDS programs (Khosla, 2009).

The same picture of Bangladesh has taken a severe and particularly a horrendous form in the apartheid system (Parker, et al. 2001). Sabatier (1988) states that discrimination against AIDS patients is perpetrated against communities that are thought to be more affected by HIV in terms of skin color, gender, sexual orientation, type of work, i.e. prostitution and geography. Among the world countries, South Africa has the largest number of incidents of stigma. Recently, the situation has been of stigma and discrimination has been so severe and dangerous that recently former UN Secretary General Kofi Annan made a combined call to end racism and discrimination against PLHIV (Skinner, 2004).

2.12 HIV/AIDS Control Program and Public Response in Bangladesh

In an attempt to avert generalized epidemics The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) has granted Bangladesh 265+ million US$ (till Round 8) to fight all three diseases (AIDS, TB and Malaria). A recent GFATM grant (Round 6) of US$ 40 million to promote prevention activities through high risk interventions for the MARP and the especially vulnerable young people is also being managed by Save the Children. To limit the spread of HIV among the vulnerable young people and Most at Risk Populations, Bangladesh has received 59.7 million US$ under two separate grants, Round-2 and Round-6, from the Global Fund (UNAIDS/WHO, 2005).

Through the collaborative efforts of Save the Children USA, the implementing NGOs and the Government of Bangladesh tremendous progress has been made, achieving 85 percent of the planned activities in the first two years and GFATM appreciated it and announced the project as a best practice in partnership model internationally. Since 2004, Save the Children has carried out critical activities including setting up an MIS database through data collection and monitoring and evaluation, conducting baseline research on key target groups, producing and disseminating behavioral change communication and advocacy materials, conducting capacity building with providers on Youth Friendly Health Services based on approved National Standards, and most notably integrating an HIV/AIDS education curriculum into the formal education system from grades 6 to 12. (GOB, UNAIDS/WHO 2005, UNDP, 2006)

The goal of HATI isto ‘reduce the spread of HIV and the impact of AIDS for the high-risk groups as well as the general population of Bangladesh by undertaking targeted interventions among the high-risk groups’. HAPP (HIV/AIDS Prevention Project) came to an end in December 31, 2007 and the financing of HIV activities moved into HNPSP. As the selection and launching of MSA of HNPSP getting delayed, for managing Targeted Intervention beyond December 2008, it was decided that the current set up would continue till December 2008 for avoiding interruptions. UNICEF has set its own outcomes the project as to reduce risk of HIV transmission among the most at Risk Population (MARP) and keep the HIV prevalence below the level of concentrated epidemic among them (CPAP outcomes) and the purpose as ‘to increase capacity of NGOs to respond to HIV epidemic’ with the specific expected outputs (GOB, UNAIDS/WHO 2005, UNDP, 2006)

Several effective programs undertaken by both government and NOG initiatives are at work in Bangladesh. The National AIDS/STD Program has set in place guidelines on key issues including testing, care, blood safety, sexually transmitted infections, and prevention among youth, women, migrant populations, and sex workers (Wikipedia, 2010). In 2004, a six-year National Strategic Plan (2004–2010) was approved. The country’s HIV policies and strategies are based on other successful programs in Bangladesh and include participation from schools, as well as religious and community organizations (NASP, 2010)

From 2000–2005, USAID’s IMPACT Project had been implemented in Bangladesh. From then until October 2009, USAID’s Bangladesh AIDS Program (BAP) had been managed working with 21 local organizations and NGOs on 23 projects to provide a strong, coherent approach to outreach among the most vulnerable. Now BAP is scaling up and integrating HIV prevention efforts and provision of clinical services. Drop-in centers—branded as Modhumita—provide health services for vulnerable populations in strategic HIV and AIDS “hotspots.” (BAP, 2010).

Chapter Three


3.1 Health Belief Model (HBM)

As a psychological theory, the stages of the Health Belief Model(HBM) massively attract the individual without assessing the role that structural and environmental issues may have on a person’s ability to enact behavior change. The Health Belief Model (HBM) is one of the most widely used conceptual frameworks for understanding health behavior. In the 1950s the U.S. public health service flourished the model in order to explain people’s participation in health screenings (Rosenstock, 1966). The HBM aims to predict whether individuals choose to engage in a healthy action in order to prevent the chances of diseases or the health threats posed by inappropriate or unhealthy practices. According to HBM, there are two main types of beliefs that influence people to take appropriate preventive action. These include beliefs related to readiness to take action and beliefs related to modifying factors that facilitate or inhibit action. The variables that are used to measure readiness to take action are perceived susceptibility to the illness or any health threats and the perceived severity of the illness. perceived benefits (i, e. the perceived advantages of taking action) and perceived barriers (i.e. the perceived costs or constraints of the specific action) are the main modifying variables (Rosenstock, 1990; Norman and Brain, 2005). According to the HBM when individuals are faced with a potential threat to their health they consider their susceptibility to, and the severity of the health threat.

According to HBM once an individual perceives a threat to his/her health and is simultaneously cues to action, and his/her perceived benefits outweigh his/her perceived threats then the individual is most likely to undertake the recommended preventive health action. For instances when applied to parents’ immunization behavior, the HBM suggests that simply having knowledge and awareness about infectious diseases will not necessarily result in increased visits to a hospital for vaccinations. Instead, the model specifies four related elements that must be present for knowledge about disease to be translated into preventive action.

Figure 3.1: A schematic outline of the Health Belief Model proposed by Rosenstock (1990)

Socio-demographic factors (education, age, sex, race, ethnicity)


Perceived benefits to action

Perceived barriers to action

Perceived self- efficacy to perform action


Perceived susceptibility(or, acceptance of the diagnosis)

Perceived severity of ill-health condition

Cues to Action


Personal influence

This is a more psychological model applied to explore and examine a variety of health behaviors in diverse populations. With the advent of HIV/AIDS, this model has been used to gain a better understanding of sexual risk behaviors (Rosenstock et al, 1994). The HBM is based on the understanding that a person will take a health-related action (i.e., use condoms) if that person:

feels that a negative health condition (i.e., HIV) can be avoided,

has a positive expectation that by taking a recommended action, he/she will avoid a negative health condition (i.e., using condoms will be effective at preventing HIV), and

believes that he/she can successfully take a recommended health action (i.e., he/she can use condoms comfortably and with confidence).

The Health Belief Model is a framework for motivating people to take positive health actions that uses the desire to avoid a negative health consequence as the prime motivation. For example, HIV is a negative health consequence, and the desire to avoid HIV can be used to motivate sexually active people into practicing safe sex. Similarly, the perceived threat of a heart attack can be used to motivate a person with high blood pressure into exercising more often.

A great limitation following with the HBM is lack of consistency in applying and testing of the model. For example, identifying and measuring the concept of cues to action has been problematic. Cues can be diverse in nature, may occur in a transient manner, and an individual may or may not consciously remember events that elicit action. In specific studies, the nature and importance of cues is more difficult to evaluate because research participants are questioned about behaviors performed in the past. The socio-structural variables attached and crucial in shaping and influencing personal behavior like sexual risk practice, excessive alcoholism, immunization behavior, dieting (Matsuda, 2002; Amanullah, 2004, 2009; Uddin, 2009) are massively overlooked in formulating this model. This is supposed to negate all socio-cultural factors like race, ethnicity, myths and after all discriminatory attitude and brand itself as a unilinear model.

3.1.1 Knowledge, Attitude, Practice (KAP) Model

The knowledge, Attitude and Practice (KAP) Model was popular in developing countries to study human behavior during 1950s to 1960s. To protect human risk behavior, psychologists used this first. The UCSF AIDS Health Project 1998 stated that, in HIV/STD prevention as in other areas of health and behavior, the knowledge, the attitude-behavior (KAP) or knowledge attitude-practice continues is often referred to. In other words, the main argument of KAP model is that human behavior is influenced by ascribed knowledge which can change the attitude. As a result the practice may be changed. This can be shown in the following way:

Knowledge Attitude Practice


Knowledge= the capacity to acquire and use information, a mixture of comprehension, experience, discernment and skill.

Attitude= the inclinations to reject in a certain pre-dispositions or to organize opinions into coherent and interrelated structures.

Practice= the application of rule and knowledge that leads to action. According to the sociologists, it is not easy to change sexual behavior.

They stated that the particular behavior of clients promote the sex workers to risk behavior. The sociologists argued that the Commercial Sex Workers (CSW) cannot practice on ascribed knowledge. Though they have positive attitude towards knowledge they cannot practice to survive. The sociologists identified these factors for these risk practice. These are survival, male domination, economic stability, cultural variation, religion, education, environment and remoteness of diseases. The sociologists believe that KAP model can be effective i