Phase 1 research

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Preventing HIV/AIDS Among Young People in Bangladesh

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Phase 1 research

The first phase of the Round 2 GFATM project was for two years between 2004 and 2006. Five studies were completed by ICDDR,B and its partners: a baseline survey, three operations research protocols, and a rapid assessment, generating an evidence base to provide strategic direction for HIV programming for young people in Bangladesh.

Baseline HIV/AIDS Survey of 12,000 Youth in Bangladesh 2005

The prevalence of HIV is still low in Bangladesh. The results of the few behavioural studies, including national behavioural surveillance, indicate that risky sexual behaviour is common with low condom use. Youth (aged 10 to 24 years) constitute one-third of the 140 million people in Bangladesh, and although limited information on sexual behaviour and STI prevalence among youth does exist, it is insufficient and does not match the interventions to be implemented under the GFATM ‘Prevention of HIV/AIDS among young people in Bangladesh’ project. A baseline survey was planned to measure knowledge, prevalence of risky sexual behaviours and prevalence of specific STIs among a nationally representative sample of youth in Bangladesh, and to survey theknowledge of parents, guardians, service providers and policy planners about HIV/AIDS, and their attitudes towards effective preventive measures.

A multi-item, structured, sex-matched survey questionnaire was applied to a representative sample of young people (aged 15 to 24 years) selected using data from the Bangladesh Bureau of Statistics. A total of 12,729 youth, 727 parents/guardians, 722 teachers and community/religious leaders, 875 health service providers and 10 policy planners were interviewed. The population of young people was stratified by urban/rural and married/unmarried. Blood samples were collected from a subsample of youth, and males who were aged 18 years and above, out of school and earning money were assessed separately as a potential target group.

Youth Clients of Sex Workers

Adolescents and youth (aged 15 to 24 years) constitute one-third of the total population of Bangladesh (43/129.2 million), and many are sexually active and at risk of contracting STIs and HIV/AIDS. Studies have shown prevalence of sexual risk behaviours, and premarital and extramarital sex is common. There is limited data however on the youth who are involved in risky sexual behaviour: information on sexual behaviour and practices, condom use, STI symptoms and the STI disease burden are essential for designing successful HIV intervention programmes. A study was conducted among young clients who visited hotels in Dhaka city to buy sex from female sex workers (FSWs), to generate knowledge on risk behaviour and practices.

A total of 1013 youth (aged 15 to 24 years) visiting hotels to buy sex were enrolled in the study between September 2005 and February 2006. The study was conducted in 9 hotels (6 hotels with FHI-funded HIV intervention programmes and 3 hotels without such a programme) in Dhaka, Bangladesh, using both qualitative and quantitative methods. Eighty per cent of the sample was from intervention hotels and twenty percent from non-intervention hotels. A sub-sample of 53 young clients was purposively selected for in-depth interviews and 5 young clients and hotel staff were selected for key informant interviews.

Community Readiness for HIV/AIDS Prevention

Given its relatively conservative religious and cultural norms, Bangladeshi society is expected to resist the introduction of HIV/AIDS prevention messages addressing sexual behaviour and the use of condoms. Community groups such as religious leaders, teachers, health professionals, and union parishads have together created a consensus about prescriptive norms of sexuality for youth, including that unmarried youth should not be able to purchase or access condoms and schools should not discuss sexuality. Consequently, health professionals are aware that beginning HIV prevention activities for youth will require a working partnership with these organizations at the community level.

By 2009, the GFATM project in Bangladesh aims for improved commitment and support from policy makers, religious and community leaders, parents and teachers for programmes to prevent young people getting infected with HIV.Strategies that are in varied stages of implementation include mass media awareness campaigns, school health education, youth friendly health services, sensitization of community leaders and condom promotion campaigns. Advocacy with gatekeepers can create an enabling environment for youth to adopt safe behaviour. This study assessed how ready various community organizations and local stakeholders are currently to begin facilitating HIV prevention activities.

Internationally researchers have been examining the role of communities and their influence on the prevention of high-risk youth behaviours. Studies have found that communities can have a profound, positive influence on prevention outcomes, but only if they are ready. The stages of readiness of a community organization to act on behalf of HIV prevention include awareness of the country’s vulnerability, knowledge of transmission and prevention, planning to act, preparation to act, and initiation of activities.

To measure the readiness of various community groups, both members and key informants of these groups were interviewed and rated for their activities at each stage. The questions were designed to elicit information about how each community group was understanding and acting on information about the imminent HIV epidemic as it affected youth in Bangladesh. Included were questions on HIV/AIDS awareness and its spread, the HIV pandemic, the country situation, perception of youth risk-taking behaviour as a problem in the community, ownership of the problem, awareness of prevention methods, organizational responses to HIV, and actual community-based activities, such as a prevention plan, working strategies, action taken, and networks among groups and external relations. Attitudes towards specific preventive strategies, such as mass media messages and condom access for youth, were assessed. Finally, with the help of vignettes and in-depth interviews, youth discussed their own perceptions of community barriers to preventive strategies. It is anticipated that these results will form the foundation for more effective community and public health partnerships and in the end, more effective HIV/AIDS prevention efforts.

Youth Access to Condoms

Around the world youth often do not have access to basicreproductive health (RH) information, or skills in negotiating sexual relationships, nor access to affordable, confidential RH services. They lack proper knowledge about their own and their partners’ sexuality, communicate very little about sex in their relationships, and believe in numerous sexual myths. In Bangladesh, youth represent approximately one-third of the total population, and are at risk of STIs and HIV infection, and unwanted pregnancy because neither schools nor health services address their sexual and reproductive health needs. Some youth are involved in high-risk behaviours, including unsafe sex practices, and consequently suffer from STIs. The high-risk behaviours are more prevalent among working male youth. There is therefore an urgent need to enhance youths’ access to life skills RH education and condom services.

An operations research study was designed to test the feasibility of using peers to improve access to life skills RH education and condom services for male youth in Bangladesh. Youth clubs were identified as an ideal place to reach young males in an organized manner. Three upazilas were selected purposively from Dhaka district and randomly assigned to experimental group I, experimental group II or the control group. From each upazila four youth clubs from four unions were selected randomly. Male club members aged 15 to 24 years were listed, which served as a sampling frame for pre- and post-intervention surveys (May 2005 and February 2006 respectively), as well as for the subsequent interventions. Before implementing the interventions, focus group discussions were conducted among gatekeepers and youth in the experimental clubs to explore ideas about male youth access to RH information and services.

Rapid Assessment of Youth Friendly Health Services

Although the current prevalence of HIV in Bangladesh is low amongst the general population, it is higher amongst certain groups, such as injecting drug users. Bangladesh is on the brink of a generalized epidemic and young people (aged 15-24) are the most vulnerable group in terms of high-risk behaviour and lack of information. Health care facilities can play an important role for young people in promoting sexual health and shaping positive sexual health behaviours. Currently in Bangladesh, there is little health care provision tailored towards the needs of young people, however there is growing recognition that services should be more ‘youth-friendly’.

This formative research assessed young people’s perspectives on existing health care provision and consulted them about key characteristics for youth-friendly health service in Bangladesh. This information will help programme planners to design programmes and evaluation tools that are responsive to the health and psychosocial needs of young people in Bangladesh.