Elsevier

Social Science & Medicine

Volume 48, Issue 8, April 1999, Pages 1103-1116
Social Science & Medicine

Sexual regimes and sexual networking: the risk of an HIV/AIDS epidemic in Bangladesh

https://doi.org/10.1016/S0277-9536(98)00417-1Get rights and content

Abstract

Bangladesh adjoins the Asian region with the severest AIDS epidemic and has common borders with two of the most affected areas, the Indian Hill States and northern Burma. There has been disagreement about the danger to Bangladesh, one view citing the likelihood of transmission from neighbouring infected populations and the other claiming that the country's predominantly Muslim culture protects it. This paper reports on a 1995–1997 research project. Preliminary research was carried out in Dhaka in 1995–1996 which suggested that the poor squatter areas might well sustain an epidemic. The experience also showed that more accurate measures of sexual networking could be obtained from males than females. The 1997 field research reported here investigated 983 males, 52% single and 48% married in Chittagong city and two more rural areas of Chittagong Division in southeast Bangladesh. It was found that around half of all males and probably a somewhat lower proportion of females, experience premarital sexual relations, with males having a lower level of extramarital than premarital relations. The factor heightening Bangladesh's risk of an epidemic is that one-quarter of single males and a significant but lower level of married males have had relations with prostitutes. This is one explanation for quite high levels of STDs in Bangladesh. The factors restricting the chances of a major national epidemic are the small number of premarital sexual episodes per person and the low level of intravenous drug use.

Introduction

By the end of 1996 the world estimates for the AIDS epidemic were over six million dead and a further 23 million seropositive and nearly all certain of death (UNAIDS, 1996). Of those living persons infected with the disease 62% were in sub-Saharan Africa, but the majority of the rest were in South and Southeast Asia. There were over five million infected persons in this region, most in northern Thailand, northern Burma, the small hill states of northeast India and in southern Yunnan in China, all within a few hundred kilometres of the `Golden Triangle'. Bangladesh is little further away and shares a common border with the Indian hill states and Burma.

There has accordingly been controversy about the likelihood of an AIDS epidemic in Bangladesh and the need to undertake widespread testing for HIV and to mount a major campaign to alert the population. Those in favour of these measures argue that acutely infected areas are close to Bangladesh and that there is a movement of people from outside the country into the two major cities, Dhaka and Chittagong. There are also movements across the country's western border to and from Calcutta. This includes those working in commercial sex, because the larger urban areas of Bangladesh have significant red light areas and Calcutta has major areas; the movement is facilitated by Bangladesh and West Bengal speaking the same language, Bengali. Those against what they regard as precipitate action argue that the Muslim religion's opposition to sexual relations outside marriage limits such relationships, especially in the case of women, and so reduces the chance of an AIDS epidemic being sustainable. They also argue that there are no communities of significant size of intravenous drug users or homosexuals.

Accordingly a joint research program of the MCH-FP Extension Project (Rural) of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) and the Health Transition Centre, Australian National University was funded to investigate the situation. The program concentrated on the population outside Dhaka, partly because this was the mandate of the MCH-FP Extension Project (Rural) and partly because 93% of the country's population lives outside Bangladesh's major city. However, political disturbances in early 1996 confined work to the city. This had the advantage of allowing a longer time than had been originally planned for training, pilot testing and revision of the research instruments. It also provided comparative information on the city population, confirming deductions from sexually transmitted disease (STD) studies that some of the poor, mostly male rural–urban migrants living in the city's extensive squatter settlements, unmarried or unaccompanied by wives, engaged in sufficient commercial sex to make at least a limited AIDS epidemic among this population a possibility (Sharma et al., 1997, p. 28).

The main fieldwork of the project was thus delayed until 1997 and occupied the first quarter of the year. It was carried out in Chittagong City with its 2.5 million inhabitants and in a string of smaller towns and adjacent rural areas stretching over 150 km north–south through that city either side of the Dhaka-Chittagong and Arakan highways. The area to the north of Chittagong was more commercialized and reputedly less traditional, both in culture and religion, than the area to the south, although the whole eastern part of Bangladesh is held to be unusually religious. The methodology was that of anthropological demography (cf. Caldwell et al., 1988a, Caldwell et al., 1988b; Caldwell et al., 1994). The most important conclusion of the 1996 work and one that has been confirmed in other research (cf. Maloney et al., 1981, p. 68; Aziz and Maloney, 1985, p. 99), is that the pressure on women not to engage in sex outside marriage is so great that it is impossible to obtain truthful reports from them on sexual activity. This fear of testifying about such activity is an accurate evaluation of the situation, for women's lives can easily be destroyed by the suspicion that they have been guilty of premarital or extramarital sex. Amin and Hossain (1995)have chronicled recent cases of punishments, including death and at a minimum social ostracism, ordered by village religious or shalish trials of women found guilty of zina (adultery/fornication). Although they emphasize that ``shalish have no jurisdiction to hold trials for zina, which is not a criminal offence under Bangladeshi law'' (Amin and Hossain, 1995, pp. 1341–1342), it is clear that the village authorities, who invoke the shariat (the family law in the Koran), believe they are following a higher authority than secular law. Amin and Hossain (1995)substantiate, by chronicling a succession of cases, that men have little to fear from their sexual activities outside marriage either in the form of shalish trials or public ostracism. Indeed they may earn a kind of respect from some of their male friends (Aziz and Maloney, 1985, p. 99). Nevertheless, the 1996 research revealed that even men were unlikely to give truthful accounts of their sexual activities when they thought their parents, wives, children or neighbours might overhear.

Our conclusion was that most men testify fairly readily and apparently with reasonable accuracy on their sexual activities provided that they feel the discussion is confidential and not overheard. This testimony is also the best available on women's sexual activities and can provide an approximate picture of the situation. Given these findings, the 1997 research was focused solely on men.

Section snippets

Issues and evidence

Previous research on Bangladeshi sexual networking and other matters determining the likelihood of an AIDS epidemic is not extensive. That which exists is summarized here, beginning with higher-risk behaviour than heterosexual intercourse.

Research suggests that there is little intravenous drug use even by prostitutes, and that drug use is largely restricted to ganja (hashish or cannabis) (Khan and Arefeen, 1989, p. 115; Chin et al., 1995, p. 2; Hossain et al., 1996, p. 67). The present research

The 1997 research program

The research was carried out in the low-lying, flood-prone alluvial plains of southeast Bangladesh adjacent to the Ganges-Brahmaputra delta, using anthropological and demographic survey techniques. The principal investigators and their assistants were participants for the whole period of the research and continually probed into the matters under investigation with both the respondents and other members of the society: officials, religious leaders, youth groups, medical workers and many others.

Methodology

The Northern and Southern Rural areas were within 50 km of Chittagong city, to its north and southeast, respectively. The Rural areas were chosen because each was adjacent and apparently similar to a surveillance district of the ICDDR,B MCH-FP Extension Project (Rural). These districts provided comparable data both from the surveillance system and because a household sample had been drawn from them by the present investigators to undertake a study of fertility and family planning. Because both

The level of non-marital sexual relations

Table 1 presents responses from both groups of respondents on non-marital sexual relations. For unmarried men these relations are solely premarital, while for married men, as will be seen, they are predominantly so.

The proportion of those now unmarried who will have sex before marriage may rise somewhat further, but it appears that about half of the males in this area experience premarital sexual relations. There is little evidence that this situation has changed greatly over the last

The constraints on non-marital sexual relations

Much of our discussion will concentrate on the major Muslim society, and there will be a primary focus on rural areas. Hindus were found to have somewhat lower (but statistically significant) levels of non-marital sexual behaviour (both non-commercial and commercial relations), probably because their fear of cross-caste relations places lower-caste women beyond reach for at least some of the higher-caste males, and possibly because their religion places less emphasis on the joys of even marital

Commercial sex

Unless condoms are regularly used, the risk of both STD and HIV/AIDS infection rises exponentially with the number of different sexual partners, with the rise being much steeper if the partners are not sequential but parallel. That is why commercial sex practiced without condoms places its female practitioners at high risk and their male clients at considerable risk.

Prostitution is neither rare in Bangladesh, especially in the larger urban areas, nor new. Khan and Arefeen (1997), p. 3) used

Sexually transmitted diseases

The threat of an AIDS epidemic has encouraged testing for other sexually transmitted diseases. Probably the most representative study, at least of urban populations, was that carried out in 1997 of 800 pregnant women either as patients or undergoing regular check-ups at eight medical college hospitals and one clinic throughout the country. Seropositivity levels were 3.0% for syphilis, 5.5% for hepatitis B and 3.4% for hepatitis C (Husain et al., 1997, p. 19). The Chittagong District, where the

HIV/AIDS

In spite of the detection of significant levels of STDs and the evidence that commercial sex was probably the main route of transmission, there is no similar evidence for AIDS. The Government of Bangladesh (1997), p. 10) reported that 79 seropositive persons and ten with symptomatic AIDS had been identified and, among the latter, four had died. Certainly, most seropositive people had not been tested so the true number probably ran into thousands. However, the level was not necessarily very

Conclusion

The level of HIV/AIDS is at present very low in Bangladesh and it is far from certain that a major epidemic will develop. Many Bangladeshis explain this low level in terms of the predominantly Muslim composition of the society and Islam's teaching that sex should be confined to marriage. Yet the situation is more complex than this because there is a surprisingly high level of commercial sex and a not insignificant level of sexually transmitted disease within the country. The object of the

Acknowledgements

This research was funded by the Rockefeller Foundation through its Health Sciences Division. Assistance in the Health Transition Centre, Australian National University, has been provided by Jeff Marck, Wendy Cosford, Pat Goodall, Diane Crosse and Elaine Napper.

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    1

    Previously MCH-FP Extension Project (Rural), International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh.

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    Previously Coordinator, ICDDR,B-ANU Joint Project, ICDDR,B, Dhaka, Bangladesh.

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