How to Curb the HIV/AIDS Prevalence in Bangladesh?

HIV/AIDS epidemic represents an emerging health threat for the whole World. HIV/AIDS occurrence rate In Bangladesh is still below 1percent but eventually is becoming a threat for the nation. However, the absence of sufficient research on HIV in the Bangladesh context motivates this secondary research. The present study discusses the strength, weaknesses, and interventions taken to combat HIV in Bangladesh. Also, it presents the key challenges that can potentially hinder progress in combating HIV. Finding demonstrates that the massive treatment gap is the core concern coupled with a crucial population such as injecting drug users (IDU), transgender is making the situation even worst. In addition, the Rohingya crisis is causing a sharp surge in HIV/Infection. This research aims to provide policymakers with information and suggestions based on existing studies and HIV/AIDS prevention planning.


Introduction
Acquired immunodeficiency syndrome (AIDS) is a transmittable ailment caused by the human immunodeficiency virus (HIV). HIV destroys the human immune system and develops AIDS, which results in loss of life. The global occurrence of HIV is about 37 million in which, around 2 million are newly infected in 2017. The massive killer AIDS-associated diseases ended 940,000 lifestyles in 2017, and globally, 21.7 million patients were getting access to antiretroviral therapy. The total number of HIV infections has been declined in the Asia-Pacific region by 31% for the last 14 years (Koirala, 2017). AIDS-related fatality also has fallen in the ASIA Pacific region; in 2016, AIDS-related death was recorded 170,000; however, the fatality rate dropped by 70,000 compared to the year 2010. UNAIDS (2018) report says that PLHIV in Asia and the pacific is 5.2 million, where 2.8 million patients have access to ART (antiretroviral therapy). Despite that, 1.7 mullions AIDS-related death occurred in this region (Avert, 2018). Bangladesh is considered a low incidence country (0.1%), still in inclined condition to an HIV epidemic (Das, 2017). Nevertheless, the first patient detected with the HIV epidemic was in 1989. Since then, the number of HIV patients started increasing. In addition, there are around 1495 HIV/AIDS incidents that have been recorded in Bangladesh (UNAIDS, 2008). Moreover, in 2015 number of HIV patients was 4,143, which was three (3) times higher than the year 2008. Despite that fact, in 2017, 1700 new HIV contamination and 1,100 deaths were recorded in Bangladesh due to AIDS. ART coverage in the country is less than 20% (Das, 2017), as shown in bellow Figure 1. PLHIV is 13,00 0, where only 2,470 patients are on ART.  (Rezwan et al., 2016) Ahasan, Hossain, & Reza, (2018) To assess the status of Antiretroviral Therapy (ART) in Bangladesh Urge for (a) substantial investment in facility improvement and continuance, (b) addressing focus groups such as migrants, children with HIV properly, (c) look for the effective measure to overcome legal and social barriers. Sarma et al. (2017) To assess the HIV/AIDS-related knowledge, attitudes, and behaviors among students Curriculum upgrading regarding self-risk perception, scaling up a training program, a nationwide pre-post study assessing knowledge level. Yaya (2016) To unearth the influential factors of HIV knowledge in Bangladesh.
Significant investment. Despite being aware of HIV, people have too little understanding of how it transmits; thus, substantial financial and logistic investment is needed in increasing awareness. Urmi et al. (2015) To identify risk factors for HIV positivity a mong returning migrants workers Migrant workers group and intervention are required, and their spouse needs specific focus as they noticeably contribute to increasing the number of HIV infection in the country. Khan et al. (2019) Assessing the HIV status among IDUs Treatment and health services for IDUs are required. Also, information on HIV occurrence, protective measures, mental health, an empirical study is lacking that needs improvement. Hsan et al. (2019) Assessing the HIV status among Rohingya refugees Extensive behavioral change programs, allied preventive measures, such as social protection, preventing drug use, restricting forced prostitution, and empowering health professionals prioritizing HIV prevention Are suggested. Haque et al. (2018) To assess the awareness level among married women regarding HIV Mass media, schools, religious entities, workplaces can be utilized for the awareness campaign. A resilient social movement to prevent HIV/AIDS is a must. Mahmood (2020) To examine the impact of violence in increasing vulnerability towards HIV among Bangladeshi women.
Urge for policy development for women's safety against violence. Counseling and sexual education facility development is encouraged. Islam, Minichiello, & Scott (2019).
To understand the concept of resilience among the people living with HIV.
Self-help groups, culturally appropriate interventions to assist the HIV infected parents and their children Sheikh, Uddin, & Khan (2017) to assess the knowledge level and understanding of pattern, factors linked to HIV/AIDS among Bangladeshi women.
Recommends effective awareness program via mess media, family education (women and her partner). Faruk, Begum & Rana, (2017) To understand the level and trends towards the HIV/AIDS epidemic and awareness in Bangladesh.
The government initiated awareness programs, intervention strategies are required. Sahani, Islam & Biswas, (2017) To understand the significance of HIV infection implying mathematical modeling technique The low prevalence rate is increasing, which is a matter of apprehension. Nahar et al. (2017) To assess the knowledge level of sociodemographic factors and their impact among IDUs.
Practical strategies for harm reduction, education, knowledge increasing about HIV/AIDS among IDUs are needed. Afroz et al. (2020) To comprehensively study the challenges faced by children affected or infected by HIV/AIDS (CABA) because of parents' HIV/AIDS status.
Ensuring educational facilities for CABA by increasing government support (i.e., financial, educational, treatment, skill-developing for generating income) is necessary to thrive. Rahman et al. (2018) To determine the frequency of malnutrition and HIV, categorize the allied factors Educating adolescence, cost-effective infrastructure development, strategy reform, capacity-building for HIV prevalence is suggested. Also, social media, training health professionals for better treatment, and teachers for increasing awareness among the youth population have been recommended.  Identifying diverse risk factors among HIV patients A counseling facility regarding high-risk behavior is necessary. Geibel et al. (2017) Evaluation of a training program for health professionals Interventions to reduce stigma among health professionals through participatory training programs are recommended. Rashid (2017) To assess the knowledge level, influential factors associated with HIV among adolescents students.

Vol. 11, No. 5, 2021, E-ISSN: 2222-6990 © 2021 HRMARS
The overall level of knowledge is low, particularly among females, thus requiring scale-up programs that circulate comprehensive information and knowledge and increase communication among high school students and rural communities.

Government and other Initiatives
The government of Bangladesh (GOB) is working for the HIV/AIDS prevalence and several local and international NGOs science 1989. With the financial support from Global Fund, MOHFW (Ministry of Health and Family Welfare), GOB launched an HIV prevention intervention project named "Prevention of HIV/AIDS among Young People in Bangladesh." Moreover, the project combines AIDS prevention, including awareness increasing information through print and mass media, evidence-based education in the classroom setting, friendly health services, social marketing strategy on the accessibility of condoms, a support program for parents with the help of religious and community leaders. Moreover, the program aims to enhance the level of knowledge and awareness among the young generation. The book chapter has been included in the national textbook from Grade VI to XII (Huda & Ferdous, 2018). Hence, it is expected that each year, around 11 million students will receive adequate knowledge regarding HIV/AIDS under this nationwide project. Teachers, governing body members, institutions have been trained for the sustainability of this curriculum-based intervention. PIACT a non-profit NGO working together with GoB. They are running a teachers training program since 2004 for capacity building among the school teachers who are involved in teaching about HIV/AIDS in a classroom setting. (Sarma et al., 2017). "Nijeke Jano" (Know yourself) is a booklet series on youths' reproductive health information. The intervention initiative was taken in 2002, and regularly it's being updated (ICDDRB, 2019). MoHFW (Ministry of Health and Family Welfare) reviewed the last edition of the booklet in January 2015. MoHFW also conducts workshop for youths'

HIV/AIDS Treatment
GoB is providing HIV/AIDS treatment facilities using the national fund for a limited number of patients, commenced by ICDDR-B for the last 14 years. ART program was first initiated in 2008 with the support of GFATM (NSAP, 2018). GBD is facilitating the ART program since 2012 (NSAP, 2018). NASP of Bangladesh (National AIDS/STD Programme) offers VCT via twelve hospital-based drop-in-centers (DICs). NGOs (Non-governmental organizations) and CBOs (community-based organizations) provide HIV testing facilities to a limited number of key populations (KPs) with support from the GFATM. Sentinel surveillance being provided among PWIDs (Persons Who Inject Drugs), MSM (men who have sex with men) and, FSW (female sex worker) since 2011 (Rezwan et al., 2016). Another NGO called Bandhu Social Welfare Society offers an HIV testing facility for MSM and transgender (TGs) populations. Pediatric HIV treatment also having very insufficient centers and can take care of only two hundred kids to be diagnosed and treated (NSAP, 2018).

Treatment and Policy Gap
HIV incidence among the general population in Bangladesh is still low, and therefore, it has not been taken under critical situations (Rezwan et al., 2016). Despite incriminating in the number of patients on ART (Antiretroviral therapy), the treatment gap is increasing, as shown in Figure 3. The ART response rate was only 1,800 in 2016 increased to 2,500 in 2017 (Hsan et al., 2019).  (Rezwan et al., 2016), even though very few confined facilities are accessible for identifying OIs (opportunistic infections) and coinfections. Moreover, checking for and STI (Sexually Transmitted Infection) offerings inaccessible. As a result, medical resources in Bangladesh are gradually reducing for HIV prevention, testing, and STI offerings.
Moreover, many protective measures were taken to preserve the human right of PLHIV to ensure that confidentiality does not become a barrier toward searching for HIV healthcare facilities (Tran, 2012). HIV testing and counseling facilities are not coupled together to ease the stigma of this life-threatening disease. Stigma linked to HIV creates refraining behavior among couples from taking counseling sessions and HIV testin g.
Moreover, there is no policy for HIV testing or structured HIV prevention program for returning migrants. Lack of structured and dependent HIV anticipation among migrants is a disadvantage of the HIV detection and prevention system (Urmi, Leung & Wilkin son, 2015). Hence, the treatment gap is not the only reason behind HIV prevalence and the massive fatality of AIDS.
The weakness of the healthcare system is threatening for healthcare quality improvement of the general population. HIV checking out is performed in MDR (multidrug-resistant) and remedy failure amongst Tuberculosis (TB) patients. High -risk groups such as PWIDs, MSM, FSW were underneath sentinel surveillance insurance till 2011 (NASP, 2014). Bangladesh is currently relying on external resources for HIV care and facilities as high as 84%, and treatment coverage also remains low (Koirala, 2017). A study from Bangladesh determined that 80% of the nurses and 90% of the physicians behaved discriminatory towards PLHIV. In addition, the insurance policy does not provide coverage for PLHIV in Bangladesh (Koirala, 2017). The government and many NGOs have taken several initiatives; however, the treatment gap could not be reduced. Despite that, regular HIV examination is not available due to the low HIV incidence among the general population (Rezwan et al., 2016) of Bangladesh.

Resource Limitation
Limitation of resources is another drawback for the HIV-related healthcare service. Two HIV viral load testing and eight CD4 T cell are not functioning due to the limited resources in Bangladesh. Moreover, healthcare budget allocation is continually shrinking in Bangladesh. In the last seven economic years, healthcare expenditure budgetary allocation government expenditure for the healthcare sector decreases trend as the funding dropped from 6.2% to 4.3%. Inadequate public spending creating a catastrophic impact on the general population as the OOP (out-of-pocket payment) is approximately 65% (Hassan et al., 2016). The Healthcare sector is heavily dependent on international organizations or development partners. Healthcare Insurance almost doesn't exist in the country. Even though a few NGOs have channeled the medical insurance schemes in recent years, it will take some time to benefit the entire population. In add ition, many NGOs are also closing down due to the lack of human resources and financial support (Rezwan et al., 2016). Hence, the healthcare system in Bangladesh is entirely dependent on its government for financial assistance, service policy, and delivery mechanism determination and set up.
World Health Organization (WHO) has highlighted some challenges in Bangladesh for successful HIV/AIDS running prevention intervention. Although HIV prevalence is currently low, the number of people with HIV infection can be increased. HIV infection can increase among IDU and Bangladesh workers in foreign countries engaged in unsafe sex activities. Despite the minor scale of supporting services regarding treatment and care and ART related to HIV/AIDS positives is available in Bangladesh. Moreover, the Bangladesh government setting is so complicated; to establish VCT services across the country. Quality treatment is required, including ARVs, as demand and need for these services are increasing. Hence, strengthening the government healthcare system in technical expertise is a must for diagnosis and treatment. Bangladesh needs a lot of experts in this field (WHO, 2018).

Key Population Injecting drug users (IDU)
Drug abuse is imperative social trouble growing public fitness problems in Bangladesh. Bangladesh is in an inclined situation due to its geographical alignment. The country is surrounded by 'golden crescent' (Pakistan, Iran, Afghanistan) and 'golden triangle' (Laos, Thailand, Myanmar) known for the drug. Due to geographical vulnerability, drug abuse cases are growing extensively. The risk of getting infected is three times higher among IDUs due to needle sharing than sexual transitions (Nahar et al., 2017). IDUs are the highest contributors of HIV/AIDS and contamination in Bangladesh (Rezwan et al., 2016). Despite that, only a few NGOs are facilitating HIV testing for IDUs since 1998. The HIV treatment and testing uptake rate among IDUs in Bangladesh is only 5% (Rezwan et al., 2016).

Transgender
There is no HIV routine check and check-up available for the 10,000 transgender (TG or Hijra) population. According to the survey report of 4th round behavioral survey report, 0.8% of TGs have HIV infection as they are sexually abused. A community affiliation named "Bandhu Social Welfare Society" has involvement in HIV testing intervention programs amongst TGs, but that's not adequate (BHS, 2017;Rezwan et al., 2016). Transgender (TGs) or hijras aren't inclined to go for remedy. Currently, prevention and HIV testing coverage is 46% and 35%, respectively, as shown in Figure 4.

Rohingya
Rohingya displaced society has been appearing in Bangladesh since the late 1970s. Previously, Rohingya people had been displaced into the country in 1978 and 1991-1992, approximately by 2 to 2.6 million respectively (Mahmood, Wroe & Fuller, 2017). Recent displacement of more than four (4) million Rohingya refugees, Bangladesh has been recognized as World's biggest refugee camp (White, 2017). Bangladesh is a haven for 950,000 Rohingya refugees living in Myanmar-Bordered-Cox's Bazar (ICDDRB, 2017). This population has many health issues that are alarming for the country; HIV/AIDS is a significant concern (Beyrer & Kamarulzaman, 2017). Myanmar has been recognized as the second highest (0.8% of the population) HIV prevalence country in South East Asia. In  (Islam, 2018). GoB and NGOs are endeavoring their best to offer healthcare services to homeless refugees. October 30, 2017, sixty-one HIV-positive Rohingya people were identified. By June 23, 2018, the Health minister mentioned another sixty-three HIV-positive Rohingya patients had been identified. Moreover, at the least eighty-three cases of HIV have been said within the camp to date (Islam, 2018). Approximately a million Rohingya people are residing in the refugee camp in Cox's Bazar, Bangladesh. In March 2019, 319 HIV cases were recorded, and 19 died (Hsan et al., 2019). Despite that, many other Rohingya refugees, especially ladies and girls, have been abused in Myanmar; and have a high chance of having HIV/AIDS infection. ICDDR-B and ASP (AIDS/STD Programme) are working together to run HIV/AIDS Programme (ICDDRB, 2017;Beyrer & Kamarulzaman, 2017).

Discussion
The risk of HIV infection is still high due to numerous factors, specifically the high occurrence of TB, STI, and Hepatitis B+, more than one sex partners, marginalized group, high levels of transactional sex, unsafe blood donor, price excessive, low condom use rate (BHS, 2017). Again, few berries that need immediate attention include (a) vulnerability among injecting drug users (IDUs), (b) lack of voluntary counseling, (c) shortage of healthcare facilities, (d) lack of awareness, (e) gender inequality, (f) overpopulation of FSWs, MSM, (g) social stigma, (h) facilitative prison environment is. Moreover, several degrees of exclusion among high-risk groups is the reason behind the increasing number of HIV infection and AIDS-related death (Khosla, 2009).
Hence, interventions that include mobile VCT (Voluntary Counselling and Testing) centers must be studied and applied to promote HIV testing (Rezwan et al., 2016). Improving the acceptance and attempt level for HIV testing can be achieved through providing friendly service. NASP should have additional concern on developing a sustainable healthcare model to serve HIV patients and high-risk groups. WHO guiding for ART needs to be followed accordingly for full coverage of KPs (Rezwan et al., 2016). The behavioral intervention has to be coupled with HIV testing. CBOs intervention programs along with condom distribution for FSWs need to be scaled up. Measures need to be taken to illuminate confusion and misconception on HIV/AIDS so that people do not get involved in any unstable behavioral misconduct (Rezwan et al., 2018).
Hence, to reduce or eliminate the HIV/AIDS suffering, some interventions are suggested by the researchers. Authorities in Bangladesh must establish public talk about healthcare facilities for HIV/AIDS, as it can be avoided if not cured at the moment. Hence, identifying focus groups that are vulnerable to HIV should be the priority with the exact number of people belongs to that groups of behavior change intervention-engaging in advocacy and focus and counseling applications via multi-sectoral businesses. Projects for flourishing social acceptability of condom use, easing stigma, lowering discrimination have to be prioritized (Rezwan et al., 2018). An adequately designed systematic approach must be taken to deal with HIV/AIDS prevention (Islam, 2018).
People living with HIV need to be treated appropriately in terms of treatment, services, and behavior of the people living in the society. Capacity building for program planning, monitoring the implemented intervention, management process needs to be strengthened both at the national and NGO level. Media-based intervention activities can play a vital role in creating awareness. Traditional media like TV, radio, the newspaper have already been utilized for HIV/AIDS camping. Social media can be a part of such an awareness program. Due to peer effete, youth tends to follow their peers or friend. Peers can be trained to spread awareness among others. Peers have a significant influence on adolescents. The Muslim majority (approximately 90%) can be utilized positi vely by designing programs like religious leaders who teach or talk on HIV/AIDS to the parents for healthy life skill improvement. Producing quality and systematic research is required to get updated and reliable data regarding HIV/AIDS occurrence, prevention, intervention success. A trusted source of information is a prerequisite for appropriate policies and programs to be developed and intervention. Although there is no alternative to increasing the healthcare service facilities but HIV/AIDS is associated with social stigma, level of awareness, poor treatment uptake rate, unwillingness for HIV testing so on and so forth. Therefore, the ministry of health cannot uproot the HIV/AIDS problem all alone. More, NGOs should come forward and extend their help to make Bangladesh a free country of HIV/AIDS disease.
Hence, it's a real challenge for a nation to fight back with such types of diseases that require a combined, integrated activity to be eased. Although, the "Multisector Approach" is appreciated for non-communicable diseases according to WHO (SDG). Although, the "Multisector approach" is favored for non-communicable diseases in step with WHO (SDG). Understanding the nature of the HIV/AIDS incidence, the "Multisector approach" is strongly recommended for HIV/AIDS prevention through HIV/AIDS is a noncommunicable disease. There is no alternative way to end the death toll by implementing the "Multi-sector Approach" for HIV/AIDS prevention. Hence, the study suggests that a total number of fourteen (14) ministries of Bangladesh need an integrative intervention approach that includes; Ministry of Finance, Ministry of Health and Family Welfare, Ministry of Local government and Rural Development and Co-operative, Ministry of Religious Affairs, Ministry of Home Affairs, Ministry of Information, Ministry of Education, Ministry of law, justice, and Parliamentary Affairs, Ministry of Public Administration, Ministry of Primary and Mass Education, Ministry of Planning, Ministry of Social welfare, Ministry of Youth and Sports, Ministry of Women and Children Affairs. Sex education in learning institutions, healthcare awareness among all members of society, legal and ethical practice, proper law enforcement could uproot HIV/AIDS from the country. Therefore, it is expected that this approach will bring visible success compared to the silo method of intervention.

Limitation and Future Research Direction
This paper used only available secondary data available via scholarly databases but government, NGO generated reports could not be assessed. The extreme shortage of secondary data caused a lack of evidence demonstrability in this study. Thus, more rigorous empirical and secondary research is required in this phenomenon. Primary statistical data could not be gathered. Data about high-risk groups are also insufficient. Therefore, this researcher relied heavily on the WHO, The Joint United Nations Programme on HIV/AIDS (UNAIDS) reports for data.

Conclusion
This research contributes to the knowledge as there are limited studies on this particular phenomenon in the Bangladesh context. Also provides information and suggestion for practical implication for policymaking. Thus the study can guide further research in another developing country context. However, there are numerous active NGOs and community-based organizations (CBOs) in Bangladesh. HIV prevention programs are aided mainly by these NGOs and CBOs with external funding. Social ignorance and conceptual gap derived from religious aspects make the situation more critical and vulnerable for the transgender population. Lack of social awareness and acceptance toward HIV patients, shortcoming on understanding, and conceptual gap derived from religious aspects make the situation more critical and vulnerable to the ease of HIV/AIDS (HBS, 2017).