A country report 2014
Gender Assessment of the National HIV Response in Bangladesh
National AIDS/STD Programme
Ministry of Health and Family Welfare
Road 130, House 11/B,
Gulshan-1, Dhaka-1212, Bangladesh
UNAIDS Bangladesh
IDB Bhaban (8th floor), E/8-A RokeyaSharani
Sher-e-Bangla Nagar, Dhaka-1207, Bangladesh
Foreword
It is a great pleasure to disseminate the report of Gender Assessment of National HIV Response gaining a full understanding of the existing gender-related policy and programmatic gaps in Bangladesh. The report describes the status of the HIV epidemic through the lens of gender differences, deeper understanding of the factors affecting equitable access to needed HIV services by key populations at higher risk including women and girls and identifies critical gaps and opportunities to make HIV response more gender transformative.
This assessment is crucial in strengthening gender issues in the National Strategic Plan (NSP) through midterm review and a key opportunity to strengthen gender and reference including indicators and measurement to the HLM goal and Global Fund New Funding Model. It also supports to achieve UNDAF targets especially on gender equality and women’s advancement in Bangladesh by providing (baseline) information against (globally) required indicators.
We believe that the report will provide critical insights into the gender transformative HIV response in Bangladesh. Under the leadership of the National AIDS/STD Programme, it will assist policy makers and experts to address identified gaps and recommendations to strengthen gender related policy and programmatic interventions.
Dr. Husain Sarwar Khan Leo Kenny
Line Director Country Director
National AIDS/STD Programme (NASP) UNAIDS Bangladesh
Acknowledgement
We gratefully acknowledge the collaboration of National AIDS/STD Programme, UN agencies including UNFPA and UN Women in Bangladesh, NGOs and Community based organizations for generously offering their valuable time, expert advice and information and made this assessment possible.
We are grateful for the contributions made by the following Gender Assessment Core Team Members for their active engagement and contribution throughout the assessment process including co-facilitating and acting as resource persons during validation workshop and supporting to formulate recommendations and the next steps.
- Mahbuba Begum, Deputy Program Manager, Program Management, National AIDS/STD Programme (NASP);
- Dr Abul Hossain, Project Director, Multisectoral Program on Violence against Women, Ministry of Women and Children Affairs (MoWCA);
- Mahtabul Hakim, Program Coordinator, UN Women;
- GorkeyGourab, Manager, M&E, icddr’b;
- HabibaAkther, President, Network of PLHIV;
- ShamimaPervin, Senior Program Officer-Gender, UNFPA;
- Md Abu Taher, Team Leader, Emphasis Project, HIV Program, CARE Bangladesh;
- Shale Ahmed, Executive Director, BandhuSocial Welfare Society;
- Dr Lima Rahman, Program Director, HIV/AIDS Sector, Save the Children
This assessment would not have been possible without the technical support from International consultant, Smriti Aryal and National consultant, S.M Naheeaan who coordinated and led the entire assessment process, facilitated the validation workshop, drafted the recommendations,prepared and finalized this assessment report.
Abbreviation
AIDS Acquired Immune-Deficiency Syndrome
ARV Anti-Retroviral
ART Anti-Retroviral Treatment
BCC Behavior Change Communication
BDHS Bangladesh Demographic Health Survey
BSS Behavioral Surveillance Survey
BSWS Bandhu Social Welfare Society
CSO Civil Society Organization
FSW Female Sex Worker
GBV Gender Based Violence
GFATM Global Fund to fight AIDS, Tuberculosis and Malaria
GIPA Greater Involvement of People Living with AIDS
GOB Government of Bangladesh
HIV Human Immunodeficiency Virus
icddr’b International Centre for Diarrheal Diseases Research, Bangladesh
KP Key Population
LGBT Lesbian Gay Bisexual and Transgender
MARP Most at Risk Population
MDG Millennium Development Goal
M&E Monitoring and Evaluation
MOHFW Ministry of Health & Family Welfare
MOWCA Ministry of Women & Children Affairs
MSM Men who have Sex with Men
MSW Male Sex Worker
NASP National AIDS/STD Programme
NGO Non-Governmental Organization
NOP+ Network of PLHIV
NSP National Strategic Plan
PPTCT Prevention of Parent-to-Child Transmission
PLHIV People Living with HIV
PWID People Who Inject Drugs
PWUD People Who Use Drugs
SGBV Sexual and Gender Based Violence
SHG Self Help Group
SRH Sexual Reproductive Health
STD Sexually Transmitted Disease
STI Sexually Transmitted Infection
SW Sex Worker
TG Transgender
UNFPA United Nations Population Fund
UNAIDS Joint United Nations Programme on HIV/AIDS
UNICEF United Nations Children’s Fund
UN Women United Nations Entity for Gender Equality and the Empowerment of Women
VCT Voluntary Counseling and Testing
YKAP Young Key Affected Population
Table of Contents
Acknowledgement...... 2
Abbreviation...... 3
Introduction...... 7
Gender Assessment Tool...... 8
Process of Gender Assessment in Bangladesh...... 9
Gender Assessment Core Team...... 10
Validation Workshop...... 10
The Status of the Current HIV Epidemic...... 10
Main Issues from Stage 2 in the GAT Tool...... 12
HIV Awareness and Condom Use...... 12
High Risk Behavior and Early Sexual Debut…………………………………………………………………………………………13
Status of Women and Girls...... 14
Sexual and Gender based Violence...... 16
Stigma and Discrimination...... 17
Main Discussion Points from Stage 3 GAT Tool...... 18
Policies, Strategies and Structures...... 19
HIV Response Focusing on Priority Population...... 21
Laws, policies and practices affecting HIV response...... 22
Summary of Key Issues, Gaps and Challenges for Gender Transformative HIV Response...... 25
Recommended Policy and Program Interventions...... 27
Agreed Actions as Next Steps...... 29
Annex 1 TOR: THE CORE TEAM SUPPORTING THE UNDERTAKING OF GENDER ASSESSMENTS OF NATIONAL HIV RESPONSES IN BANGLADESH 30
Annex 2 List of Core Team Members Supporting the Undertaking of Gender Assessments of National HIV Response in Bangladesh 33
Annex 3 Validation Workshop of the Gender Assessment of National HIV Response in Bangladesh...35
Introduction
Nearly 30 years into the HIV epidemic, persistent gender inequality and human rights violations continue to hamper progress and threaten the gains that have been made in HIV prevention and treatment response globally.[1] In Bangladesh, although HIV prevalence continues to be low (<0.1%) among general population, it is significant among key population groups such as people who use drugs (PWUD), sex workers (SW), transgender persons (TG) and Men who have sex with Men (MSM).[2]More than 37% of newly identified HIV cases in 2013were among women and transgender.[3]74%of the newly reported HIV caseswere among general married population.[4]Persistent gender inequalities, widespread discrimination, injustice and other factorssuch as high levels of violence against women and girls and transgender populations not only undermine the efforts in curbing HIV epidemic but continue to impact on country’s overall efforts in achieving Millennium Development Goals (MDGs).
Gender inequalities, gender-based violence (GBV) and harmful gender norms promote unsafe sex and reduce access to HIV and sexual and reproductive health services for women, men and transgender persons. In particular,
GBV including the threat or fear of violence makes women and girls, sex workers, men who have sex with men and transgender people more vulnerable to HIV.[5]
Norms of masculinity (including homophobia) can encourage high risk sexual behavior by men and make their partners more vulnerable.
Norms of femininity can prevent women (especially young women) from accessing HIV information and services.[6]
Lack of education, social norms and positioning, and economic insecurity limits decision-making power, mobility and access to information and services.
Health seeking behavior is influenced by gender and, stigma and discrimination.
Therefore, HIV services must be sensitive to sexual and reproductive health and gender needs and rights of women, men, transgender persons in all their diversity, in particular those living with HIV and key populations at higher risk of HIV.[7]
The UNAIDS Agenda for Women, Girls, Gender Equality and HIV[8] andstrategy “Getting to Zero”[9] commits to advancing gender equality for an effective HIV response, calling for gender-transformative HIV responses in which gender equality and human rights are at the center of the AIDS response.
Building on achievements of a multi partner initiative (involving 11 Ministries and 9 UN agencies) towards achieving MDG 3, which is Promote Gender Equality and Empower Women, the National AIDS/STD Programme together with UNAIDS agreed to undertake a comprehensive Gender Assessment of the current HIV epidemic and the response. The assessment was strategically aligned with theongoing Mid Term Review of the 3rdNational Strategic Plan (NSP) on AIDSand was undertaken during the period of September to December 2013.The main objectives of the Gender Assessment were to:
Assess the status of the HIV epidemic through the lens of gender,and gain a deeper understanding of the factors affecting equitable access to HIV services by key populations at higher risk including women and girls.
Identify critical gaps and opportunities to make HIV response more gender transformative and ensurethat the revision of NSP and costing of strategic and operational plans fully consider gender transformative interventions.
Use assessment findings to strengthen multi-sectorial partnershipand resource mobilization for formulating policies and implementing programsthat address gender inequality, gender based abuse and harmful gender norms and practices that hinder effective response to HIV.
Gender Assessment Tool
The Gender Assessment Tool is a structured set of guidelines and questions that can be used to guide and support the process of analyzing the extent to which national responses to HIV, in both generalized and concentrated epidemics, take into account the critical goal of gender equality.[10]The development of the tool was facilitated by UNAIDS at the global level, by convening an internationalExpert Reference Group comprised of members from various governments, UN agencies and civil society organizations. The Expert Reference Group provided strategic guidance on the development of the tool.[11]
The Tool is a planned, systematic and deliberate set of steps and processes which examine and question the status of the HIV response (plans and actions undertaken by national governments to address HIV) with specific reference to its gender dimensions (the socially constructed roles, behaviors, activities and attributes that a given society considers appropriate for women and men, including key populations).[12]The tool enables a greater understanding on the extent to which a national response recognizes and then acts on recognition of gender inequality as a key determinant of HIV. It also helps to ensure that gender equality is a goal of the national response to HIV.
Gender Assessment process of an HIV response involves the following four stages:
- Preparing for the Gender Assessment of the National Response (STAGE 1)
- Knowing your HIV epidemic and country context from a gender perspective (STAGE 2)
- Knowing your country response from a gender perspective (STAGE 3)
- Using the findings of the Gender Assessment to strengthen the HIV response (STAGE 4)
The tool has been piloted in several countries and is flexible and adaptable to different contexts.
Process of Gender Assessment in Bangladesh
Under the leadership of the National AIDS/STDProgramme, UNAIDS County office in Bangladesh along with UN Women, development partners and civil society undertook a gender assessment of the national HIV response process using UNAIDS Tool. An international consultant and a national consultant were hired by UNAIDS to provide technical support and manage the assessment process including writing of the assessment report.
The methodology for undertaking gender assessment was based on the principles of transparency and inclusivity, with particular care given to facilitate and ensure a meaningful participation of people living with HIV, women in all of their diversity, and key populations at all stages of the assessment process.
Gender Assessment Core Team
The Gender Assessment Core Teamwas formed by the National AIDS/STD Programme and constitutedrepresentatives from National AIDS/STD Programme (NASP), Ministry of Women and Children Affairs (MoWCA), UN Women, UNFPA, icddr’b, CARE Bangladesh (CARE-B), Save The Children, Network of PLHIV (NOP+)and Bandhu Social Welfare Society (BSWS) respectively and secretariat support from the UNAIDS Country Office in Bangladesh (see ANNEX 1 for the ToRs of the core team members and ANNEX 2 for list of members). The main purpose of the core team was to ensure country ownership of the assessment process and provide overall guidance and direction.Under the overall leadership of the National AIDS/STD Programme in Bangladesh, the core team hada responsibility to plan and execute a participatory and transparent assessment process with the support from consultants. They were also responsible for technical oversight and finalization of the key findings and analysis including recommendations.
Validation Workshop
A 3 day validation workshop was organized from 09-11 December, 2013to bring together stakeholders from diverse sectors, including gender and HIV experts to systematically review and validate data pre-populated tooland develop key recommendations including priority interventions for gender transformative HIV response.A total of 44 participants from 23 organizations including from various government institutions, CSOs, NGOs, UN and other partners reviewed, provided feedback and formulated recommendations for future action at this workshop.The specific objectives of the workshop were to:
- Present, review and validate assessment data and analysis done by the consultants and the core team.
- Identify gaps and opportunities for making HIV response more gender transformative.
- Develop a set of recommendations including key interventions to be included in the currently being reviewed 3rdNational Strategic Plan on HIV.
- Agree on next steps for implementation of the recommendations including for integrating intothe Global Fund New Funding Model Concept Note, other sectorial plans and programs.
The Status of the Current HIV Epidemic
The overall HIV prevalence in Bangladesh has remained <0.1% since 2000 as per serological surveillances. Since the beginning of the epidemic, the country has registered a total of 3241 cases of HIV infection.[13] However, the estimated number of PLHIV is around 8000. Although HIV prevalence has remained below 1% as per annual case reporting, the rate of new HIV infections are increasing gradually and the trend is rising significantly over the years among key populations.[14]In 2012, about 26% of new infections were among those who were 25 years or less.[15] In 2013, females accounted for 35.9% of new infections.[16]74% of the newly reported HIV cases were among general population who are married.[17]
According to the latest Serological Surveillance (Round 9, 2011),[18]the HIV prevalence among PWUD was 1.1%, Female Sex Workers (0.3%), Hijra (0.7%), MSM and MSW (0%).Although HIV prevalence was below 1% in most groups of female sex workers, in casual sex workers (those who were selling had either one or more main sources of income) from Hilli (a small border town in the northwest part of Bangladesh), HIV prevalence was 1.6% and 3.2% among Hijra.
The Round 9 surveillance[19] tested 7,529 drug users (PWID, heroin smokers and the combined group of PWID and heroin smokers) from 30 different cities in 2011. HIV prevalence wasdetected in five groups with highest rate of 5.3% was reported in Dhaka among male PWID. The other four groups include male PWID from Narayanganj (1.5%) and Satkhira (0.4%); female combined PWID and heroin smokers from Dhaka, Narayanganj, Tongi (1.2%) and Benapole (1%).However, a 2009 study indicated that female PWUD may be at more risk as many sold sex to support their addiction, and depended on their male partners to buy their drugs and then shared injections with them. The study also stated that two-thirds of female drug users were sex workers.[20]
MSM and MSW were tested positive for HIV (0.2% and 0.7% respectively) in 7th surveillance round in 2006.[21] However, in 9th surveillance round, none of the MSM or MSW tested was positive for HIV. But in 2013, a Midline survey was conducted among Global Fund supported interventions in Dhaka where HIV prevalence was found to be 0.7%.[22]Among the transgender community (hijra) however, the HIV prevalence was 1% in two sites (Dhaka –the capital of Bangladesh and Manikganj-a peri-urban site adjacent to Dhaka.
HIV Prevalence RateOverall / Female / Male / <25 Years / _> 25 Years
F / M / F / M
IDU* / 1.1% / 1.1% / 1.2% / 1.3% / 0.9% / 1.1% / 1.3%
Sex Workers* / 0.3% / 0 / 0.2% / 0 / 0.3% / 0
Transgender* / 1.1% / 1.7% / 0.8%
MSM** / 0.7%
*Source:9th Round National HIV Serological Surveillance, 2011.
**HIV Midline Survey among MSM, MSW & TG, icddr’b, 2013 (Unpublished data from Dhaka only)
Main Issues from Stage 2 in the Gender Assessment Tool
This section presents a summary of the main issuesemerging from the review and analysis of existing literature including information included in the pre-populated GAT tool Stage 2.
HIV Awareness and Condom Use
The review of existing data showed key populations, including SWs, PWID, TGs and Young key populations, generally lack understanding about HIV and engage in sexual practices which are not safe. Although many have heard of HIV, only 31% of FSWs, 30% of MSWs, 28% of MSMs and 20% of PWID have a comprehensive knowledge of HIV according to Behavioral Surveillance 2006-2007.[23]Only 13.8% of females and 22.9% of males in the age group of 15-19 years and 13% of females and 22% of males in the age group of 20-24 years correctly identify ways of preventing sexual transmission of HIV and reject major misconceptions as reported in 2012.[24]
Another icddr’b study suggested that only 21.8% of hijra sex workers reported using condoms during last sex in the last week with regular clients.[25] Consistent use of condoms was reported to be even lower – 13.3% reported consistent use of condoms with new clients and 12% with regular clients in the last week.[26]In case of MSM, only 20.9% used condom with non-commercial male/hijra sex partners, 23.7% with commercial male sex partners and 22.6% with female sex workers according to a Behavioral Survey conducted in 2011.[27]In case of MSW, condom use in last anal sex act was reported at 39% with new clients and 24.9% with regular clients.[28]29% condom use in the last sex act was reported with non-commercial male/hijra sex partners.[29]For sex workers, condom use varies with settings and locations. Among street based sex workers: the use of condom during last sex act with new and regular clients was high in Chittagong (76.7%), in Dhaka 43.3%, in Khulna 23.7%.[30]