1. Master of Public Health
Project Report
Department
of
Public Health
Effectiveness of Community-Based Outreach programs in reducing the
risks for HIV/AIDS transmission among Intravenous Drug User in a low
prevalence country, Bangladesh.
A Research Protocol
Dr. Raushan Akhter
Student 145400
This thesis is presented as part of the requirement for the award of the degree of Master of Public
Health of the University of Melbourne.
November, 2003

2. TABLE OF CONTENTS
1. Introduction …………………………………………………………….......... 3
2. Background of HIV/AIDS in Bangladesh…………………………………… 4
3. Surveillance data and Prevalence of IDUs in Bangladesh…………………. 5
4. Current situation of drug taking practices and risk factors……………….. 6
5. Interventions to reduce HIV among IDUs…………………………………… 7
6. Prevention programs among (IDUs) in Bangladesh………………………… 8
7. Barriers to reduce the risk behaviours among the IDUs……………………. 8
8. Aims and Objectives…………………………………………………………… 10
9. Goal……………………………………………………………………………. 10
10. Significance of this project……………………………………………………. 10
12. Materials and Methods………………………………………………………… 12
13. Protocol.………………………………………………………………………… 18
14. Ethical issues……………………………………………………………………. 21
15. Discussion……………………………………………………………………….. 21
16. Acknowledgments………………………………………………………………. 23
17. References……………………………………………………………………….. 24
 Flow Chart ……… ………………………………………………………… 19
 Table 1…………………………………………………………………….... 21

3. Introduction
The purpose of this project is to design a research protocol that will increase the knowledge level and reduce the
risky behaviours in order to prevent HIV and STD transmission among the high risk group population, the IDUs
in Bangladesh.
Background
Drug injecting is a global phenomenon, with huge significance for the health and social condition of drug
injectors and the communities in which they live. In 1992, the injection of illicit drugs had been reported from
over 80 countries (Stimson, 1993) and by 1995; reports of injecting had been received from 121 countries
(Stimson, 1996). Injecting drugs has existed in developed countries for many years, and may be found in many
sectors of the population. The more recent diffusion of injecting is occurring in the developing world. In many
developing countries injecting has already permeated a range of social groups in rural and in urban areas, among
slum dwellers and among hill tribes. Following this pathway, injecting is now spreading in countries that are
mostly poor in Asia and that are either in drug producing areas or along drug transit routes. As a result, Asia has
explosive rates of HIV/AIDS among the injecting drug users. The concentration and distribution of this injecting
reflects the social and cultural composition of the country, the groups in which injecting was first introduced and
the stage of diffusion of the practice (Stimson, et al. 1995).
Like many other developing countries, Bangladesh is under the same umbrella of the threat of a future
epidemic of HIV/AIDS. Recently, Bangladesh’s AIDS policy recognized that drug users must be active partners
in the fight against AIDS. Therefore, noting the efficiency of HIV transmission via shared needles, the policy
states: “Prevention of HIV is however possible if---drug users or community organizations are involved in
prevention…. [and] means of behaviour change (access to needles, syringes, bleach, condoms, etc.) are made
accessible, [and] options are offered to the IDUs as to how they will make a change in behaviour rather than a
single approach.” [Government of Bangladesh, “National policy on HIV/AIDS and STD Related Issues,” p-65,
2003]. As a result, programs and methods of reducing or preventing drug injecting risk behaviours needs to be
designed.
Country profile of Bangladesh
Bangladesh is the ninth most populous country in the world having 140.4 million people and 980.8
persons living per sq. km (UNAIDS, 2001). An estimated 70 million Bangladeshi live in absolute poverty.
Despite rapid gains in health status since independence in 1971, the primary health care sector is still very weak.
In this country, still 67 percent of rural children suffer from chronic malnutrition and less than 40 percent of the
population has access to modern primary health services beyond immunization and family planning [Family
Health International (FHI), 1997]. Moreover, only 25 percent of pregnant women receive antenatal care, and

4. someone with formal training attends 14 percent of births only. The maternal mortality of Bangladesh’s is 440
deaths per 1000, which is among the highest in the world (Pisani, 2002).
HIV/AIDS and Bangladesh
Bangladesh is at a critical moment in the course of its AIDS epidemic. The official government figures
suggest that the epidemic is not widespread. A total of 157 HIV positive cases have been reported in which the
male population predominates. So far, 17 HIV infected persons developed AIDS of which 11 have died
(Bangladesh Development Gateway, 2003). Whereas, The Joint United Nations Programme on HIV/AIDS
(UNAIDS) estimated that there are 13,000 HIV-positive people in the country and that HIV prevalence in the
population is less than a tenth of one percent (Human Rights Watch, 2003).
The information on HIV prevalence in Bangladesh is limited and data available is sporadic. Therefore, it
is not known exactly how many people are infected, but it is true that HIV is being detected among the population
especially among vulnerable groups. So far only scant data are available to provide accurate definitions of the
distributions or to quantify the prevalence of several risk behaviours and factors in Bangladesh. However, several
factors, mainly related to the country’s poor socio-economic background are influencing the epidemic (UNAIDS,
UNICEF and WHO, 2002). The factors making the Bangladesh situation particularly vulnerable to a devastating
epidemic are:
a) Low level of HIV/AIDS awareness:
Awareness of HIV/AIDS in the Bangladeshi population remains quite low. One recent survey found that
“Only 19 percent of ever-married women and 33 percent of currently married men had heard of AIDS” (The
Daily Star, 2003). As of July 2003 there was virtually no sex education in Bangladeshi schools. Recently, the
government announced a plan to begin offering sex education in public schools for the first time in 2004 (Agence
France- Presse, 2002).
b) High transit zone and high migration:
Bangladesh is surrounded by parts of India with high HIV prevalence –West Bengal to the west and
Northern India to the east and also a neighbor to the epidemics of Southeast Asia. Myanmar, formerly known as
Bhutan is estimated to have over 850,000 people infected. Again, there is a great deal of migration across
Bangladesh’s borders. Every year, it is estimated that about 74,000 Bangladeshi go abroad without their family
(Rahman, 1999). It is believed that non-marital sex is common during this period.
c) High incidence of premarital and extramarital sex:
The incidence of premarital sex is quite widespread in Bangladesh. The incidence is more in the lower
socio-economic class than in the higher. In addition, most of the long distance truck drivers go for sex with the
commercial sex workers even twice a month while they spend time away from their families. In one survey, 30%
of male clients at an STI clinic were found had sex with unmarried girls (World Bank and WHO, 2001).

5. d) Inadequate HIV/AIDS diagnostic facilities:
Unfortunately HIV testing facilities are rarely available in health clinics. Where there are facilities,
however are not usually accompanied by counseling.
e) Low condom use:
Many people still believe that condoms are only family planning device (Rahman, 1999).
f) Others:
Bangladesh also has a high rate of poverty, systemic gender inequality, and an inadequate health care
system, all of which have been seen in many settings to be contributing factors to the rapid spread of HIV
(Chowdhury, et al. 2003).
The combined influence of all of these behavioural and biological factors leads to a non-random and
discriminating spread of HIV in various sub-populations and the population as a whole. Therefore, if
Bangladesh’s campaign against AIDS is to succeed, an effective strategy addressing these high risk groups needs
to be implemented for prevention, before it is too late.
Surveillance data and Prevalence of IDUs in the country
The first national sentinel surveillance (1998-1999) revealed an overall HIV prevalence among the high
risk behaviour practicing sample population to be 0.4% and in second surveillance (1999-2000) it was 0.2%
among 400 sample size (Government of the People’s Republic of Bangladesh, 2000):. However, the sample
size of the two surveys were different and new categories of high risk population were included as sample in the
second survey. Whereas, the rate of injecting drug users (IDUs) was 25 and 20 per 1000 populations in the first
and in the second survey respectively. The study also found that 13% of the street based female sex workers had
injected themselves with drugs, although none of those had been tested positive for HIV (UNAIDS, UNICEF and
WHO, 2002)
Available data from Client Monitoring System of Department of Narcotic Control and other research
report showed that prevalence of injecting drug use (IDUs) is on the increase in many parts of the country. HIV
prevalence remains low in most high risk groups tested but is raising among Intravenous Drug Users (IDUs) and
brothel sex workers. Most injecting drug users in Bangladesh share needles. There are estimated 25000 IDUs
mainly in Dhaka, Rajshahi, and other towns including border areas. A considerable proportion of IDUs are clients
of sex workers and many IDUs are married, putting their family members at a higher risk of disease transmission.
Further, prevalence of STDs is quite high among drug users in general (Bangladesh Development Gateway,
2003). The highest prevalence of HIV/AIDS detected was 2.5% among 400 IDUs coming to detoxification
clinics, but could be higher in out-of treatment IDUs (UNAIDS, 2000). This year, the fourth sentinel surveillance
report showed four percent (4%) HIV prevalence among the injecting drug users in central Bangladesh, which
was disclosed at a press conference by the health ministry officials (The Daily Star, 2003).

6. However, surveillance findings nevertheless concluded that high level of behavioural risk factors for the
acquisition of HIV infection are very much existence at least among the sampled population. Moreover, it is
specifically clear from the surveillance that some groups of people who practice high risk sexual behaviour have a
large number of sexual partners averaging between 12 and 40 per year (Bangladesh Development Gateway,
2003).
Current situation of drug taking practices and risk factors in Bangladesh
The injecting of drugs is believed to have commenced in 1990 in Bangladesh and while the most popular
routes for taking drugs is reported as ingestion or inhalation, injecting does appear to be gaining popularity
(Hassan and Ahmed, 1999) and data recorded in treatment centers report an increase in the rate of injecting from
6% in 1993 to 17% in 1995 in a sample of 402 IDUs (Ray, 1998). In 1996, a Rapid Situation Assessment (RSA)
survey conducted in three major cities (Dhaka, Rajshahi, Chittagong) among 1750 participants reported that other
most commonly used drugs were cannabis, cough syrup (codeine based), sedatives and heroin, where as for those
surveyed in treatment centers the most commonly used drugs were heroin, codeine, cough syrup, buprenorphine,
cannabis and sedatives (Ray, 1998).
Further, the behavioural surveillance study of 1998-99 showed that for those who injected, the drug of
choice was buprenorphine which was frequently mixed in a cocktail of substances including diazepam,
promethazine hydrochloride and chlorpheniramine. Moreover in the northern part of the country, drug use,
including injecting, has been reported it is also common in several areas of the capital, Dhaka. One study showed
that heroin was used by only 2% of participants (n = 450), and was usually dissolved in lemon juice before
injecting (Hossain, 2000).
In 2000, a study in Dhaka reported the average number of injections per day was two in IDUs and the
sites were; 26% into the vein, 56% into muscle and the rest 18% used both the vein and the muscle (Mallick and
Gomes, 2000). Another earlier study reported that 59% always injected into the vein (Jenkins and Rahman, 1999).
Addas are shooting galleries, where most IDUs gather to inject, and where the drugs and the professional
injector can be found. It has been suggested that the professional injectors are able to maintain business through a
good supply of drugs, connections to wholesalers and by providing the injecting services. In 1999, in Rajshahi an
estimated 50 adda injectors and 94 addas were operating in the city. These facilities are often located in disused
buildings and lane ways but some also operate in hotel rooms (Hossain, 2000). In another study it was reported
up to 90 persons a day used a single adda injector, often for multiple injections (Jenkins and Rahman, 1999).
Further studies in the late 1990s reported widespread sharing of needles among all IDUs (60%-90%) and
the professional injectors did not sterilize their needles and syringes (Hossain, 2000). More over, it has been
observed that a needle is only changed when it becomes blunt and glass syringes are rarely changed or discarded
(Hossain, 2000). New needles add an extra expense that few poor IDUs can not afford, thus explaining the
reasons for the wide spread sharing (Jenkins, 1999). In addition, some people have been known to use syringes
rejected by hospitals [Society for Health Education, Agronomy and Self Sufficiency (SHEAS), 1996]. Though

7. there are regulations in place requiring a prescription to buy such equipment, this is often ignored. However,
cleaning of needles by those who shared their needles is rarely adequate. Methods include; using cotton or paper
or using distilled water to clean the needle (Mallick and Gomes, 2000). Some IDUs even use saliva to clean their
needles with the belief that this might destroy any poisons found in the blood (SHEAS, 1996).
Interventions to reduce HIV among IDUs
Specific behaviours associated with drug use that are risk factors for HIV transmission include shared use
of drug injection equipment and unprotected vaginal or anal sex with multiple sexual partners. For this reason,
interventions that can reduce the prevalence of these practices are critical components of a comprehensive AIDS
prevention policy. Therefore, different countries require different polices and prevention efforts which seem to be
most effective in changing behaviour among the IDUs.
Effective risk reduction programs for IDUs implemented in both developed and developing countries include:
A) Educational programs
B) Drug abuse treatment programs
C) Needle exchange programs (NEPs)
D) Community outreach programs
E) Over-the-counter syringe sale
F) Bleach distribution programs for needle cleaning, and
G) HIV counseling and testing
Injecting drug users can and do change their drug use behaviours under certain circumstances. However,
research indicates that while injecting drug users change their needle-sharing and cleaning practices, HIV
prevention efforts have not been successful in the realm of sexual behaviour, particularly with regard to condom
use (Riehman, 1996). Thus safer sex practices need to be incorporated with these methods. Further, it has also
been recognized that education and information alone may not cause a reduction in risky bahaviour among IDUs
(Riehman, 1996). Whereas, education combined with group interactions and exercises seems to be more effective
(McCoy and inciardi 1995; Jemmott, et al. 1992). In addition, there is a growing consensus that effective
prevention programs should include the promotion of treatment for reducing drug use, providing the means for
safer injection, and promoting safer sex (Riehman, 1996).
Therefore, it is clearly understood that for an effective prevention approach, comprehensive action would
be the best successful approach for preventing the spread of HIV, other blood-borne infections, and STDs in drug-using
populations. However, this approach might be difficult to implement and make it sustainable in a
developing country like Bangladesh, where health care facilities are poor; literacy rates are low and most
importantly where resources are not enough.

8. Prevention programs among Intravenous Drug Users (IDUs) in Bangladesh
In Bangladesh, the injecting drug user intervention is based on a harm reduction strategy to reduce the
spread of HIV and to minimize the negative health effects of drug injecting. Around 3,200 injecting drug users
(IDUs) are reached every day through this program. It has two major components:
a) Drop in centers:
There are seven Drop in Centers (DIC) only in the capital, Dhaka City. These are considered to be safe
places for the IDUs where they can come to socialize, take rest for sometime, seek referral services to drug
treatment, receive treatment for abscess, STDs, and other ailments. Community detoxification camps are
organized for those IDUs who want to get out of the drug habit (Begg, 1999).
b) Outreach services:
Twenty-six trained Peer Outreach Workers (POW) have been recruited for this task, who are current
injecting drug users. They work in addas, where IDUs gather. They train and educate IDUs about safer
practices and distribute condoms along with information on HIV/STD (Begg, 1999).
Barriers to reduce the risk behaviours among the IDUs in Bangladesh
Absence of sex education at home and in institutions
In Bangladesh, the educational curriculum does not have sex education for children or for adolescents.
Though the present curriculum of science in higher secondary level contains several reproductive health
componants, the information is incomplete, disordered and not in detail. For the youth, sex education is not
offered in government or out-of-school education programs. The prevailing socio-cultural norms inhibit the
disclosure of information about the sexual activities of adolescents, thus preventing obtaining accurate
information on their reproductive health [Shohojogi-AIDS (Bangladesh), 2002] As a consequence, of six million
adolescent students in approximately 14,000 secondary schools, 3.5 million male students are ignorant about
education on sex (Alochona Magazine, 2003). In Bangladesh, previously sex education has been geared toward
high risk groups, such as CSWs and drug users, because many projects are funded by foreign donors as part of
more general reproductive health programs. The result is that the general population sees sexual problems as
being a concern only those who engage in inappropriate sexual behaviour.
On the other hand, the adults in Bangladeshi society in general are reluctant to give sex education because
they feel this will increase the possibility of sexual activity, promiscuity and early pregnancy. According to the
parents, sex education might compromise the family honour by providing youth with information that will lead to
dangerous social consequences for girls. Through arranged marriages or an economic transaction via marriage the
parents try to control the sexuality of youth (Alochona magazine, 2003). Moreover, public health workers,
teachers or parents, who have the most contact with youth and who often can act as sex educators, are not well

9. trained. They often adopt a moralistic and didactic tone. This alienation of the larger society is one of the root
causes for the failure to initiate and institute sex education in the country.
Abuse against injection drug users (IDUs)
There are records of several cases that the injecting drug users (IDUs) are beaten and extorted by the police
and by mastans (committing robbery by force) in the country. Human Rights Watch gathered several reports of
police extortion of injection drug users. Further, Human Rights Watch was also told of several arrests of outreach
workers. Moreover, the police arrests are sometimes accompanied by violence. If the drug user refuses or fails to
produce the bribe that police demanded, they are tortured inhumanly while in police custody, and then transferred
to jail. (Human Rights Watch, 2003).
As a result, the injection drug user breeds fear rather than collaboration; they become further alienated from
figures of authority and from society in general, and it become more difficult for them to be participants or
beneficiaries of AIDS prevention and care programs.
Weakness of law enforcement system
The policy makers are sympathetic and supportive to needle exchange programmes which is (to be
believed) an important tool in the nation’s HIV prevention strategy. Even if they might appear to have
controversy at this stage, needle exchange is legitimate to implement. The policy goes further to recognize that
“there is overwhelming evidence of the high effectiveness of needle exchange programmes” [Government of
Bangladesh, “National policy on HIV/AIDS and STD Related Issues,” p-65), 2003]. However, strict
paraphernalia laws are restricting procurement of syringes and needles without prescription, or misuse of the law
(suspected people are arrested for carrying injecting equipment) increases the risk of sharing needles and therefore
of transmitting HIV. Police harassment is still going on, where high risk groups are suffering from beatings,
robbery of money and drugs, and reselling of drugs to drug users at higher prices by the law enforcement
department. Even death was caused due to excessive beating by the police force (Advocacy Guide for HIV
Prevention among IDUs, 2002). As a consequence, police are at the forefront of Bangladeshi public debate, and
there is an emergence for the reformation of the law enforcement system. Otherwise, the IDUs could not be traced
or contacted to make a change or reduce their risky behavioural practice. This would result in an increase in the
risk of sharing needles, rise of HIV transmission and ultimately the fight against HIV/AIDS in Bangladesh would
be undermined.
Scarce resources
There are major resource problems in Bangladesh, especially an acute lack of medical and public health
resources. In developed countries, the ability to extend a harm-reduction approach from the national level has
been helped by having relatively well developed social welfare systems and an educated population accessible
through a range of media (Stimson, et al. 1995). Whereas any long term intervention program for drugs or HIV
infection in Bangladesh is faced by problems of access to populations, with limited media coverage, poor
transport and communications, and most importantly fund shortages and low educational levels. As like other
developing countries, the per capita income and GDP are also low.

10. The health care system in the country is generally characterized by poor allocation of resources for service
development, lack of qualified personnel and poorly developed information gathering systems. The cost of
introducing some of the harm reduction measures that have been used in rich countries, for example: free syringes
and free treatment including substitute prescribing, cannot be borne in this country where urgent priority is for
other health problems (e.g. malaria, malnutrition, tuberculosis, dengue fever, arsenic toxicity) as well as non-health
sector ones (e.g. education, housing, sanitation, natural disaster and so on). However, in respect to different
social, bahavioural, cultural and political factors which mediate the spread of injecting drug use, we need to
introduce a cost-effective and sustainable harm minimization technology to combat the HIV/AIDS epidemic
before it is too late.
Aims and Objectives
Primary:
 To design a community-based outreach HIV intervention trial in two locations of two district town in
Bangladesh.
 To increase knowledge of HIV prevention practices
 To reduce HIV- related drug and sex risk behaviour
Long term outcomes not addressed in this protocol
 To reduce the risk of HIV/AIDS in the individual and in the community
 To reduce transmission of STDs, and to provide STD referral (& management)
 To enhance and strengthen the community, which will rely on outreach programs and a peer leader
approach to service delivery.
 To promote an accessible, acceptable, cost-effective and sustainable strategy to reduce the risk behaviours
among the Intravenous Drug Users (IDUs).
 To reduce drug-use related morbidity and mortality.
Goal:
 The overall goal of this project is to design a protocol to improve knowledge and to reduce the risks for
HIV, and other blood-borne infections, and STDs in drug-using populations.
Significance of this project
Health and social consequences
High-risk practices are inevitably connected with serious health consequences. In South-East Asia the
prevalence of HIV-1 among IDUs in many sites reached 40% within one year of it first being identified (Stimson,
1994). The injecting behaviours are so risky that, for example in Myanmar, many injectors become infected with

11. HIV-1 within the first few weeks of starting to inject (Stimson, et al. 1995). HIV prevalence at this high rate is
sustained by the interaction between high-risk sharing behaviours, the high prevalence rate, and the many new
cases of infection that are at a highly infectious stage of HIV disease. Further, in Yunnan, high rates of sexual
transmission of HIV have been reported from injectors to their wives. In Southeast Asia, the epidemic spread to
high prevalence in Myanmar, Manipur and Yunnan occurred within three years of the outbreak in Thailand
(Stimson, 1994).
However, the social, cultural and legal environment of HIV among the IDUs is generally marked by
stigma, prejudice and a judgmental attitude, especially with regard to sexual behaviour. Moreover, the injection
drug users, who are already stigmatized by the society, often experience heightened degrees of discrimination as
compared to others living with the virus. Among them, homelessness, unemployment, low socioeconomic status
and high mortality are the adverse social consequences related to drug use. The linkage between injection drug
use, HIV and social stigma in the public imagination is so strong , that HIV has come to be understood as a ‘social
evil’ in this country. Therefore, in order to combat the HIV-related social stigma experienced by IDUs, it will be
important to find ways to de-link the disease, and those affected by it from the moral opprobrium associated with
the use of illicit drugs (Deany, 2000).
Unique setting for counseling and training through peer education
Community-based outreach workers are on the front-line in the local community, and they know where,
when, and how to contact even the most difficult-to-reach drug users in their neighborhoods. As a trusted and
recognized source of information, an outreach worker can help drug users understand their personal risks for HIV
and other blood-borne diseases and identify the preventive steps they need to take. As a peer, the outreach worker
can encourage drug users to stop or reduce using injecting drugs and enter drug abuse treatment (Needle, et al.
2003).
Moreover, they can provide referrals to drug users for drug-abuse treatment, for testing and counseling for
HIV/AIDS and other infectious diseases, and other community health, prevention, and social programs [National
Institute of Drug Abuse (NIDA), 1999]. Most importantly, outreach workers are a vital link to networking for
educational and risk-reduction information on HIV/AIDS, HBV, HCV, and other STDs, and disseminating and
distributing information and materials for behavioral change, including the HIV/AIDS risk-reduction hierarchy,
bleach kits to disinfect injection equipment, condoms for safer sex, and instructions for proper condom use and
disposal.
Effective strategy for behavioural change
Community-level interventions may be an important way to effect behavioural change on a broad scale.
NIH-supported researchers have investigated the impact of community-level approaches both in the United States
and abroad. More than 15 years of research on HIV/AIDS prevention with IDUs, crack cocaine users, and many
of their sex partners has shown that community-based outreach is effective for all types of drug-using risk groups,
in a range of local settings. Cumulative research from a 23-site study that followed 18,144 drug users (13,164
IDUs and 4,980 non-injecting crack users) reports that three to six months after participating in the intervention,

12. 72 percent of the IDUs either stopped injecting drugs or reduced their frequency of injection. Of those who
continued to inject, nearly 60 percent either stopped or reduced reusing or sharing their syringes. Twenty-six
percent of the crack cocaine users, including 8,184 IDUs who also used crack and 4,980 non-injecting crack users,
had stopped using crack cocaine at follow-up. Moreover, 25 percent of the 18,144 drug users who participated in
the study had entered drug abuse treatment at follow-up, many for the first time (NIDA, 1999).
Cost-effective intervention
Cost-effectiveness studies have reported that, community based outreach programs are a low-cost
intervention approach that permit ongoing contact with drug users and multiple opportunities to reinforce the HIV
risk reduction message. Sustained, well-designed strategies using a community-based model for HIV prevention
can lead to substantial reductions in health-care and social costs associated with the treatment and care of people
with HIV/AIDS and other infectious disease (CDC, 1993). Further, community-based outreach interventions
could help avert future medical costs associated with the care and treatment of HIV/AIDS (Pinkerton, 2000). In
addition, research has shown that the three complementary approaches that make up comprehensive HIV
prevention for drug users: community-based outreach, drug abuse treatment, and access to sterile syringe
programs are cost-effective.
The community-based outreach model is most cost-effective when its strategies are implemented among
the high-risk groups early in the epidemic, when the prevalence is low and using this model the greater number of
potential new infections in the populations can be averted (Des Jarlais, et al. 1995).
Materials and Methods
This study would be conducted in two district towns of Bangladesh. This intervention trial is developed
based on the review of different published articles on Intervention Studies on Intravenous Drug Users (IDUs)
implemented in various developed, developing and transitional countries. These cover the extent, nature and
strategies of preventions along with reducing the risk behaviours of HIV infection among IDUs. Reports on
national HIV surveillance, behavioural and sero-surveillance survey on STD and AIDS conducted by NGOs and
the Government of Bangladesh from the period of 1998 to 2002 were reviewed.
Subject recruitment
The primary means of recruitment would be from the government hospital register (containing all
demographic data, drug history, medical history, work history as well as family and other contacts) as most drug
users are serviced by government health care facilities. If sufficient sample size would not be available, then the
secondary method of recruitment would be through professional social workers who are familiar with the current
users hidden in the community. Study respondents would be opiate-addicted IDUs, injecting drugs at least once
during the previous week or month, 18 years of age or older, male or female and from any racial/ethnic
community would be the inclusion criteria for this study. The only basis for exclusion would be participants who

13. are enrolled in any other drug intervention program would not be considered for this study to minimize any
confounding or bias.
Sample group
The sample for the study will be obtained using targeting sampling procedures similar to those used in the
U.S. National Institute on Drug Abuse-funded evaluations of street outreach. Targeted sampling is a method
whereby representative samples of hidden populations such as IDUs are recruited in a systematic fashion (David,
et al. 2002), using this method a general survey will be done in the local community to identify homeless persons
who are illicit drug users not in treatment, and persons who are interested to receive confidential HIV counseling
and testing by giving their signature and informed consent and administering all relevant information about
demographics, HIV-risk behaviours and testing history, illicit drug use, and socio-sexual connections. It is
expected that respondents would be predominantly male, as prevalence of female IDUs users is still low to date.
Study location
Rajshahi Metropolitan City and Pabna Metropolitan City are the two districts which would be selected
for this study, because these are the narcotics smuggling routes in Bangladesh, which have attracted the drug-dealers
since 1980. At baseline, there would be no significance differences between the participants of the two
sites on demographic data like age, caste, marital status, and educational status. The general populations of these
two districts are mostly homeless or slum dwellers having low or no education, low income, and most importantly
are unemployed. Rapid urbanization, illiteracy and poor socio-economic conditions are the main features which
contribute to this risky bahavioural practice. Further, easy availability and cheap price increases wide spread use
of drugs among these groups in this region in comparison to other districts of the country.
Outreach team
The research team will consist of ex-drug users (identified from the renowned local community leaders,
who are familiar with the drug users and their milieu), professional social workers, and indigenous residents of
the selected communities. This team will recruit the IDUs and conduct program interventions. The hospital
registers containing the details of intravenous drug users (IDUs) would be contacted in each district in the six
months preceding the beginning the of study recruitment. Using these records, the outreach team will identify the
location and social organization of drug users (IDU population) to identify the appropriate respondents in each
district. IDUs that express interest in this study, and found to be eligible will be enrolled.
Enrollment & consent procedure
Eligible interested participants will be invited to attend a briefing session on the study, presented by a
staff member of the outreach team. Each participant will be given an opportunity to know anything about the
study, and then requested to sign the consent form. The baseline and follow-up questionnaires will include some
assessment used to characterize respondents ‘risk status’ (low vs. high). Respondents will be judged to be at low
risk, if during the previous seven days they did not used a syringe that someone else had just used without first
cleaning it with bleach or, if they did use a nonsterilized syringe, and they did so only with a regular sexual
partner who they believed to be HIV negative. Conversely, respondents would be judged to be high risk if they

14. used a syringe which was not cleaned with bleach and shared with someone other than a regular sexual partner or
with a regular sexual partner whose HIV status was either positive or unknown. Baseline data collected by the
questionnaire would be recorded immediately in a computer. After obtaining informed consent, interviewers will
take blood samples for HIV antibody testing using ELISA methods and confirmed by Western blotting. In the
meanwhile, participants will be assured about the maintenance of confidentiality of their risk assessment and
antibody testing. Further, extensive tracking information would be gathered to assist the outreach team and
interviewers in contacting IDUs for follow-up interviews. It can be mentioned here that concentration of this
study will be more towards the ‘high risk’ group participants as it will be expected that number of ‘low risk’
subjects will not be available or inadequate.
Community-based outreach group intervention trial
The principal elements of this outreach intervention trial are:
a) Providing AIDS education, raising awareness about drugs, HIV/AIDS and STD and their transmission in
general, HIV prevention activities
b) Basic risk reduction activities involving group training and counseling/face-to face communication
c) Delivering bleaching powder and
d) Distributing condoms
The educational session will be strengthened by providing a video or slide presentation demonstrating correct use
of bleach and condom and also supported by educational promotional literature for literate clients. Outreach
workers will also refer drug users to other available services in the community.
In this outreach model, clients would be provided at least three sessions in face-to face settings:
Session 1- raising awareness about drugs, HIV and other blood-borne disease transmission, correct techniques for
needle decontamination with bleach, and condom use.
Session 2- reinforcing the components of the first session and assisting clients in identifying their own specific
risk behaviours and understanding the strategies to reduce their HIV, STD and blood-borne risks.
Session 3- providing information about existing services and advising on social and medical problems.
Since clients need to be transferred to a different location for the testing, there might be a chance for loss of
subjects to this service.
Control group participations
A control group of current IDUs will be recruited in Pabna Metropolitan City, at which no outreach
services will be available; a sample of IDUs will complete the baseline assessment. A similar strategy would be
adapted for the recruitment procedure. After one year, the individuals would be followed-up to review the
progress. The purpose for this follow-up visit is for two reasons. Firstly, this will encourage the participants to be
in touch with the program as they will receive some money as intensives, and some materials (bleach and

15. condom) free of cost. Secondly, refresher training will be provided to strengthen or reinforce their basic
knowledge level and help them to change their risky behavioural practice.
Reasons for selection of these interventions in this trial
AIDS education
Since unprotected sex and risky injecting behaviour are the driving forces behind most HIV epidemics,
therefore, knowledge about AIDS/AIDS, the behaviours that spread it and the ways it can be avoided, are
important prerequisites for prevention of unsafe sex and injecting behavioural practices. Further, data has shown
that 60% of drug users in this country are unaware about AIDS and the mode of its transmission (Govt. of
Bangladesh, and UNAIDS, 2000). At present, Life Skills-Based Education (LSBE) is being adopted as a means to
empower young people in challenging situations. As LSBE enhances the quality of content by addressing issues
relevant to the lives of learners and is often applied to pertinent health and social issues which are not traditionally
included in the academic curriculum and which demand the adoption of positive behaviours by young people
(e.g., health, human rights, gender equality, peace). Therefore, one of the key defenses against the spread and
impact of HIV/AIDS is to ensure access to free and compulsory primary education of good quality and learning to
prevent and cope with HIV/AIDS among the high risk groups. Because, HIV/AIDS prevention programs that
have balanced with knowledge, attitudes and skills related to HIV transmission have proven more effective in
actually challenging behaviour than those that have focused on information alone. Further, skills-based programs
have proven more effective in delaying the age of first sexual intercourse, and increasing safe sex behaviours
among sexually active youth (e.g., increasing use of condoms, reducing of sexual partners) [WHO, 1999].
Training and counseling
These approaches can help IDUs to make an informed decision to reduce harmful behaviours by
understanding their risks for HIV, other blood-borne disease and identifying the preventive steps they need to
take. Counseling will help people to understand better and deal with problems, communicate better with whom
they are emotionally involved, improve and reinforce motivation to change behaviour and help people to learn
and deal with fear and anxiety. It can provide support at time of crisis, give protection from drug use and help
them cope with the consequences of an HIV infection by giving emotional support and referring them to relevant
services at individual level (Young people, HIV/AIDS, and substance use in Asia, 2002). It is means of ensuring
that information on AIDS is correct and consistent, and of assessing lifestyles, personal expectations, and
willingness and capacity to change behaviour. Analysis among the IDUs in Hong Kong, found a rising awareness
of risk factors and declining risk behaviour, when the IDUs were trained as interviewers and peer counselors to
educate injectors about harm reduction techniques. Similarly, Bangkok has also experienced some success in risk
reduction among IDUs after instituting AIDS education, training and counseling programs through community
outreach (Riehman, 1996).

16. Condom promotion
Condoms will be made easily accessible at a low price or sometimes free to the clients through a social
marketing approach in this setting. Their availability and affordability price to the target group will be ensured
whenever there is demand. In this context, different mass medias will be encouraged to stimulate people
addressing the potential users by motivating people to adopt condom use and sustain it for safer sex practice. In
the meanwhile, correct use of condoms will be taught through a life skilled-based training approach.
Use of Bleach
Bleach has long been recognized as an effective technique for sterilizing injecting equipment and it is
clearly an intervention to be used when injection drug users have no safer alternatives (Preventing HIV
transmission, 2003). This strategy is particularly appropriate in Bangladesh, where needles are in short supply and
bleach is a relatively inexpensive item compared to sterile needles. One important benefit to increasing
availability of bleach is that it can be used by the general population. This in turn could make provision to
injecting drug uses more acceptable in the eyes of government, the public and the funding agencies. With this
view, bleach distribution programs in San Francisco revealed that the IDUs who used bleach increased from 3
percent to 76 percent (Riehman, 1996). Similarly, in a program instituted in Churachandpur, Manipur, India found
knowledge of bleach as a disinfectant rose from 3 to 99 percent in one year, intention to use bleach increased from
2 percent to 79 percent, and actual use of bleach increased from 31 percent to 72 percent after one year (Riehman,
1996). Therefore, for Bangladesh where sterile needles are inaccessible and difficult to obtain for injecting drug
users (for economic, legal, and political reasons), bleach distribution needs to be considered as an active viable
and effective alternative.
Barriers / Constrains to implement other effective strategies
Needle Exchange Programs (NEPs)
In Bangladesh, there is not an adequate supply of sterile needles for hospital use. This makes it difficult to
argue government should fund for provision of sterile needles to a marginalized group such as IDUs. Moreover,
the government of Bangladesh is mostly dependent on donor contributions to implement other important health
problems; e.g, arsenic toxicity, tuberculosis, malnutrition, infectious diseases, etc. In these circumstances, it
would be difficult, and not feasible to spend an additional amount in this field. In addition, a range of negative
views about needle exchange programs would be expressed by various groups, including fundamentalists, law
enforcement officials, pharmacists, and drug treatment providers. Specific community concerns range from fears
that such programs would worsen already severe drug abuse problems and elevate existing high levels of crime to
concerns that such programs would promote immoral activities (Preventing HIV transmission, 2003). Further,
there are some negative outcomes that might result from NEPs which include an increase in improperly discarded
needles, an increase in drug injectors, or more importantly the perception that the government condones drug use

17. ((Islam, et al. 1999).Therefore, the high levels of concern about potential negative effects of needle exchange
programs would prohibit their use in the socio-cultural context of Bangladesh, despite the evidence supporting
them.
Needle sales over the counter
There is no national policy to prescribe and dispense injection equipment in Bangladesh, because, the
government does not view drug addiction as a high priority issue. Rather it is seen as a self-created problem.
Thus, due to this lack of supportive policy environment, the risk for disease transmission among the intravenous
drug users is partly the result of restricted access to sterile injection equipment. These legal or policy barriers to
availability or use of equipment compels sharing and reuse of syringes among the drug users. On the other hand,
physicians treating patients who use injection drugs do not consider protecting their patients from blood-borne
diseases by prescribing sterile injection equipment when appropriate, which in turn is due to absence of policy
responses for consideration towards the IDUs. Today, medical evidence has established that providing safe
injection equipment to injection drug users, although not a panacea, prevents HIV and other blood-borne
infections and does not increase drug abuse (Burris, et al. 2000). This evidence compels a reassessment of the
legality of providing injection equipment by prescription and selling them by pharmacists in this country.
Whereas, in an analysis of the legality of prescribing and dispensing syringes through the health care system, it
was found that both prescribing and dispensing sterile injection equipment are legal in many states (Burris, et al.
2000). Therefore, as long as there are legal barriers to access sterile injection equipment, the reduction of safer
injection practices among the IDUs would be far behind.
Drug treatment
Increasing access to drug treatment is a frequently recommended approach to slowing the spread of HIV
in IDUs. Whereas in Bangladesh, detoxification and rehabilitation programs are scarce, and only few drug users
have the resources to attend them. Again, recidivism is high for those receiving treatment, as occurs in most
counties of the world. A study in 1998-99 revealed that 99% of the participants who had made attempts to stop
drug use had failed to do so (Hossain, 2000). Moreover, the traditional approach to treating drug users is in the
psychiatric units of hospitals, which suffers from shortage of beds resulting a few being able to receive proper
treatment. Other problems include physicians being discouraged from offering their services to treatment centers
because they can lose their seniority if they are not properly released by the Ministry of Health and placed under
the Department of Narcotic Control (Hossain and Ahmed, 1999). Therefore, though studies have consistently
shown that participation in methadone maintenance treatment is associated with lower rates of drug injections, but
to date low priority is given from the policy planner and health directorate of Bangladesh to this intervention
approach.

18. Outcomes
From this study I will expect the following outcomes:
There would be significant improvement in knowledge, and in drug-related and sex related risk behaviour
following their participation in an outreach-based HIV risk reduction intervention trial after thirty-six months
follow-up among the intravenous drug users (IDUs) comparison to control group participation.
a) Awareness would be raised about drugs, HIV/AIDS and other STDs transmission and prevention activities
among the intervention groups.
b) Significant reduction in drug injection, multi-person reuse of syringes and needles, and other injection
materials (cotton, saliva, distilled water).
c) Improvement in use of injection equipment by cleaning with bleach,
d) Improvement of safer sex practices by using condoms.
Outcome measurement
Baseline assessment would be performed for both the groups, and data would be collected on socio-demographic
information, knowledge of HIV/AIDS and STD, and their prevention, and HIV-related risk
behaviours, both injecting and sexual. The baseline and follow-up interviews would be conducted by trained
researchers using a brief standard questionnaire and the outreach interventions in the outreach locations
(Rajshahi City Corporation). The intake period would be from June to August, 2004 and the follow-up would be
done three (3) consecutive times once in a year during the 36 month study period. Following the basic training
and counseling, then each participant would be asked to return for follow-up visits after one (1) year for refresher
training. On each of the visit participants will be interviewed using the same standard questionnaire, would
provide blood sample for serological tests, and receive face-to face HIV/AIDS and STD risk reduction health
education and counseling. They will also receive Taka 500/ ($US 8.62) for their travel cost and food allowances.
Further, bleach for cleaning injection equipment and condoms will be distributed for safer sex practices. After 36
months, follow-up data would be collected on knowledge on HIV and STD, drug and sex risk behaviour and
behavioural change, where the outcome would be measured on knowledge, HIV-related drug risk and sexual risk
behaviour.
Knowledge of HIV/AIDS and STD would be measured by completing a structured questionnaire format
consisting of basic concepts on HIV/AIDS and STD, and its risk behavioural practice. A structured questionnaire
would be developed for the training of the participants on basic concepts of HIV/AIDS, STD and other blood-borne
diseases. At follow-up, the comparison with the baseline would be categorized as improved with number
and percentage of participants and not improved or similar with number and percentage of participants.
Frequency of injection, would be evaluated grading from one to five times per week, one to twice daily, or
more times daily; a change in the frequency of injection at follow-up compared with the baseline would be
indexed as increase, and no change.

19. Sharing of needles and injection, would be assessed as no sharing, sharing less than once in a week, sharing
more than twice in a week, and sharing very often; a change in the frequency of sharing at follow-up would be
recorded as increased, and no change.
Similarly, use of bleach would be evaluated as always use, occasional use and no use. A change in the
behaviour to disinfect needles by using bleach at follow-up would be indexed as increased, and no change.
Sexual risk behaviour
Data of sexual risk behaviour would be collected on- numbers of sex partners, history of commercial sex, and
practicing safer sex by using condoms. Sexual risk behaviour at follow-up would be measured for the period
between baseline and follow-up interventions. Observation would be made for correct techniques for needle
decontamination with bleach and condom use.
Flow chart: Community Intervention Trial
Government hospital register Professional social worker
Potential IDUs
Inclusion:
Male, 18+ years & above, drug using in the last
week or month
Intervention (n = 260)
Education, training &counseling, bleach
delivering & condom distribution
1st year follow-up
2nd year follow-up
Assessment (3rd year)
Outcome: (n=181,including 30% drop out)
Knowledge improved - 40% to 65%
Reduction in risk behaviour - 28% to 48%
Exclusion: Female &children
Control ( n =260)
No outreach services
1st year follow-up
2nd year follow-up
Assessment (3rd year)
Outcome : ( n=181, including 30% drop out)
Knowledge improved - 40% to 45%
Reduction in risk behaviour- 28% to 33%

20. Sample size
I wish to hypothesis that the proportion with sufficient knowledge level on HIV/AIDS among the subjects will
increase from 40% (Govt. of Bangladesh and UNAIDS, 2000) to 65% after 3 years of program implementation,
then the resulting sample size becomes n = 90 in each group. Whereas, the HIV related risk behaviour would
increase from 28% ((Govt. of Bangladesh and UNAIDS, 2000) to 43%. During this three years, I presume that
the knowledge level and risky behaviours in the control group will improve by 5%. While, the government may
initiate programs for the IDUs at the national level. As a result, the total increase among the intervention group
becomes 48% and the control group becomes 33%. Therefore, the sample size is needed n = 181 in each group
and considering a 30% drop out by the completion of the project, and having a power effect 80%, the total sample
size needed n = 260 in each group.
Statistical Analysis
Calculation will be done by comparing pretest and post test questionnaires finding the proportion with sufficient
knowledge or risky behaviours in the intervention group with that of the control group. Relative Risk (RR) and p-value
will also be calculated. Again, as I will be assessing the intervention program, I will be analyzing
as intention-to-treat rather than per protocol.
Results:
Participants will be recruited using targeting sampling procedure from districts, Rajshahi Metropolitan
City and Pabna Metropolitan City who will be predominantly male. Because, it is expected that outreach would
not be able to identify female drug users as it is common knowledge that the prevalence of opiate use among
women in Bangladesh is still disproportionately small. Different data from serosurveillance reports of Bangladesh
also indicated that a negligible number of female IDUs were identified in their surveys. Hence, it is expected that
only male IDUs subjects will be recruited for this study.
At baseline, there should be no significance differences between the participants from outreach and control
locations on demographic data like age, marital status and educational level. Comparisons would be made
between the two groups for knowledge level, and HIV-related drug and sex risk behaviour. After 36 months,
follow-up data will be collected for 181 IDUs from outreach locations and 181 IDUs from control locations.
Comparison will be done between baseline data to third year follow-up data. This comparison will reveal whether
the participants from the outreach locations have statistically significant level of improved knowledge, and this
might lead them consequently to be engaged in significant protective behaviour and practiced injecting risk
reduction behaviour. Beside the knowledge level, we will test for statistically significance differences in the four
areas of HIV-related risk behaviours-(1) frequency of injection, (2) Sharing of injection and needles (3)Use of
bleach, and (4) Use of condom.

21. Table 1. Anticipated changes from baseline to follow-up in knowledge level and HIV-related risk behaviours of IDUs from community
outreach (O) and control (C) locations (N= 362)
Variables n Outcome
*
Percent
(%)
No change Percent
(%)
RR and 95%
Confidence
Interval (CI)
P-value
Knowledge of
HIV/AIDS and STD
O =181
C =181
118
81
65
45
63
100
35
55
1.45, (1.20 – 1.77) 0.0001
Risky behaviours:
a) Frequency of
injection
b) Sharing of
needles and
injection
c) Use of bleach
d) Use of condom
O = 181
C =181
87
60
48
33
94
121
52
67 1.45, (1.12 – 1.87) 0.0039
* Number of subjects achieving sufficient level of knowledge or reducing risky behaviours after 36 months.
Ethical issues:
Institutional ethics committee approval will be sought for the undertaking of this project. The ethics committees
from the Ministry of Health and Bangladesh Medical Health and Research Council (BMHRC) will be consulted.
All subjects will be provided with a detailed brief of the project and its aims, including the details of how their
personal information will be handled and maintained. Informed consent will be obtained from all subjects,
including an opt out clause without penalty or adverse treatment during the study period.
Survey Instrument:
The survey instrument is unlikely to cause the subjects any undue stress or be in anyway onerous on the subject’s
time. At the conclusion of the study, once all data has been collated and analyzed, all data in the survey
instruments will be destroyed by the study investigators.
Training and counseling:
This is an educational session which will impart knowledge to raise awareness about drugs, HIV transmission and
their harmful consequences and improving skills on correct techniques for needle decontamination with bleach,
and condom use. Apart from this bearing time consuming, this technique would not cause any undue harm or
damage to the subjects during or after the sessions.
Discussion:
The aim of this community-oriented model is to improve health by changing norms at the community level
through encouraging behavioral changes which will be facilitated by the behaviours and attitudes of peers.

22. Community outreach will provide substantial opportunities to contact and work with the hard-to reach group in
the population (IDUs).
The strengths of this project are many fold. Firstly, it is plausible that the interventions will be responsible
for the observed behavioural change. It is also plausible that reductions in injection risk behaviours led to
reductions in new HIV infections, given that HIV is a blood-borne disease, that drug injection exposes needles
and other injection equipment and paraphernalia to blood, and that blood from contaminated equipment is
conveyed to other users of that equipment. Thus, when IDUs stop or decrease reusing of dirty equipment, it is
logical that HIV transmission will also decrease. Further, an appropriate time sequence is allowed between
intervention and outcome which will strengthen outreach interventions led IDUs to change their behaviours.
Secondly, the program outcome would be achievable as the participants will be randomly assigned having the
same socio-demographic characteristics in two different areas.
Thirdly, the sample size is reasonable with a standard power effect to get the desired outcome.
Finally most importantly, this project will be cheap to implement in respect to Bangladesh’s current economic
situation where minimum resources will be required for the time period. This model can be used in a large scale at
the national level to prevent HIV/AIDS among IDUs.
However, some limitations of this study deserve mention. Although the researchers will try sincerely to
recruit and retain a representative sample of incomplete treated IDUs, attrition from baseline to follow-up might
render the sample less representative. The sample may consist only with the higher risk participants. Secondly,
female participants can not be covered in this study.
Other problems and obstacles may also be faced during the HIV intervention implementation in
Bangladesh. Firstly, the problem of injecting drug use is not yet considered as a priority area for AIDS
intervention in general. As such, the cooperation from different agencies would not be satisfactory to launch this
project. Secondly, current AIDS intervention focuses only on heterosexual transmission and targets commercial
sex workers. Other high risk groups of the population will be left out, who are also equally important for
intervention. Thirdly, there might be a great chance of police harassment when the addicts would be identified in
possession of syringes and needles. As a result, many drug users may stop carrying syringes when they go in
search of drugs. This will compel sharing practices at places outside of IDUs’ houses and in particular at dealer’s
locations. These community resistances to HIV intervention efforts will be attempted to be overcome by the
formation of a community advisory board composed of locally influential opinion leaders, who will exchange
dialogue with the law enforcement personnel to stop harassment to the addicts who possessed personal syringes. It
is expected that this bilateral cooperation will facilitate carrying of personal syringes by IDUs in the community.
However, one important area in which may need to be concentrated upon is that outreach workers might
be pressured to assist with the medical problems of IDUs where there is no supportive service or treatment
facilities for IDUs at the community level. Therefore, strengthening primary medical care for the IDUs is an
emerging concern. In addition, there is an urgent need to improve and expand HIV testing and treatment facilities
within the community.

23. Acknowledgments
I thank Dr. Mark Jenkins, Senior Lecturer of Epidemiology and Biostatistics Unit and Centre for genetic
Epidemiology, Department of Public Health for his continuous guidance’s and assistance to prepare this protocol.
I am also thankful to Professor Nick Crofts, Director, and The Centre for Harm Reduction and Deputy Director,
The Burnet Institute, for his resourceful materials and reference list which helped me to a great extent to develop
this project. Finally, I thank Dr. Catherine Bennett, Lecturer of epidemiology and Biostatistics Unit, for her
valuable feedback.

24. References: [1]
Advocacy Guide for HIV prevention among IDUs, 2002.
http://www.rararchives.org/adv/AnnexA.pdf. (retrieved on 02.09.03)
Agence France- Presse, (2002): Bangladesh schools to have sex education from 2004.
Wysiwyg://72http://www.aegis.com/news/afp/2002/AF0212C9.html. (accessed on 20.07.03)
Ahmed, N. U (1999): HIV/AIDS situation in Bangladesh (edited) Shohojogi – AIDS Forum provided by the
Foundation du Present.
http://hivnet.ch:800/asia/bangladesh (accessed on 06.08.03)
Alochona Magazine, February 2003 issue: Breaking the silence; Pros and Cons of Introducing Sex Education in
Bangladesh.
Wysiwyg://103/http://magazine.alochona………...magazine2003/February/theme/theme1.asp. (Retrieved on
10.09.03)
Bangladesh Development Gateway, 2003: HIV/AIDS in Bangladesh, Current Situation.
http://www.bangladeshgateway.org/sdnp/health/aids/current-situation.html. (accessed on 31.08.03)
Begg, M (1999): Injecting drug users Intervention, SHAKTI Project, CARE Bangladesh. Activity report March
1998 to June 1999, CARE Dhaka, Bangladesh.
Burris, S. JD; Lurie, P; Abrahamson, D. JD; Rich, JD (2000): Physician Prescribing of Sterile Injection
Equipment To prevent HIV Infection: Time for Action. vol- 133, Issue – 3, p: 218 -226.
Centers for Disease Control and Prevention (CDC), (1993): Center for Substance Abuse treatment (SAMHSA),
NIDA Prevention Bulletin. U.S. department of health and Human Services, Public Health Service.
Chowdhury, M.R ; Islam, N ; Rasul, G (1996): Meeting the challenges of HIV/AIDS in Bangladesh. Bangladesh
AIDS Prevention & Control Programs Dhaka, Bangladesh.
David, R. G; Richard, B; Kim, A; James, K; Daniel, P; Joseph, G (2000): Two–to-Six fold decreased Odds of
HIV Risk Behaviours Associated with of Syringe Exchange, Journal of Acquired Immune Deficiency Syndrome,
vol- 31(2); Issue- 1st October, 2002. pp. 237 – 242.
Deany, P (2000): HIV and Injecting Drug Use: A New Challenge to Sustainable Human development UNDP,
HIV and development Programme.
Des Jarlais, D.C. H. Hagan, S.R. Friedman, P. Friedmann, D. Goldberg, M. Frischer, et al. 1995. Maintaining low
HIV seroprevalence in populations of injecting drug users. Journal of the American Medical Association.
274(15): 1226-1231.
Family Health International (FHI), [1997]: AIDS Control and Prevention Project, vol.-2, December, p:1-2
Government of Bangladesh, “National policy On HIV/AIDS and STD related Issues,” p-65, Dhaka, 1996.
Centers for Disease Control and Prevention, “Use of Bleach in Prevention of Transmission of HIV in health care
settings.”
Government of Bangladesh, (2000): Report on the Second National Expanded HIV Surveillance, 1999 – 2000.
Government of Bangladesh and UNAIDS.

25. [2]
Hassan, K. M (1999): HIV/AIDS status in Bangladesh. Shohojogi – AIDS Forum provided by the Foundation du
Present.
http://hivnet.ch:800/asia/bangladesh (accessed on 06.08.03)
Hossain, M (2000): Injecting drug users, HIV risk behaviours and shooting galleries in Rajshahi, Bangladesh.
Drug and Alcohol review, 19: 413- 417.
Human Rights Watch, (2003): Ravaging the vulnerable, Abuses Against Person at High Risk of HIV infection in
Bangladesh. Sec-IV,
http://www.hrw.org/reports/2003/bangladesh 0803/5.html (accessed on 02. 09.03)
Islam, M. M; Karim, E; Mian, M. A. H; Kristeneen, S; Chowdhury, M. R; Vermund, S. T (1999): an update on
the prevalence of HIV/AIDS in Bangladesh, vol-30, No-2, June,1999.Institute of Epidemiology Disease Control
and Research, Dhaka, Bangladesh.
Jemmott, J.B., L.S. Jemmott and G.T. Fong. 1992. Reductions in HIV risk-associated sexual behaviors among
black male adolescents: effects of an AIDS prevention intervention. American Journal of Public Health. 82:372-
377.
Jenkins, C and Rahman, H (1999): Rapid situational assessment of injecting drug use and HIV risk in Northern
Bangladesh. A paper presented at the 5th International congress on AIDS in the Asia Pacific, 23 – 27 October,
Kualalumpur, Malaysia.
Mallick, P. S and Gomes, J. M (2000): Injecting drug users semi-annual behavioural survey (March – April),
2000. SHAKTI Project, Health and Population Sector, CARE – Bangladesh.
McCoy, C.B. and J. Inciardi.1995. Sex, Drugs, and the Continuing Spread of AIDS. Los Angeles, CA: Roxbury
Publishing Company.
Needle, R. H ; Friedman, B. S; Touze, D. G ; Badrieva, L ; Grund, J-P. C ; Suresh Kumar, M ; Nigro, L ;
Manning, G ; Latkin, C (2003): Prevention of HIV/AIDS Among Injection Drug Users: A review of the Evidence
on the Effectiveness of Community- Based Outreach.
NIDA (National Institute on Drug Abuse), (1999): Principles of HIV Prevention in Drug-using Populations. NIH
Publication No. 99 – 4180, Oct, 1999.
Pinkerton, S; Holtgrave, D; Difranceis, W; Semaan, S; coyle, S. L and Masotti, J (2000): Cost – threshold analysis
of the National AIDS Demonstration Research HIV Prevention Intervention, AIDS 14 (2): 1257 – 1268, 2000.
Pisani, E (2002): Estimating the size of populations at risk for HIV, Issues and Methods. A joint
UNAIDS/IMPACT/FHI, Workshop Report.
Preventing HIV Transmission, (2003): The Role of Sterile Needles and Bleach.
http://www.nap.edu/html/needle/summary.html. (retrieved on 24.09.03).
Rahman, M (1999): Bangladesh and HIV, SEA-AIDS, 5th International Congress on AIDS in Asia and the Pacific
(ICAAP)
http://www.hivnet.ch:800/asia/sea-aids/view/R? 1895 (retrieved on 28.10.03)

26. [3]
Ray, R (1998): South Asia: Drug Demand Reduction Report, UNDP Regional Office for South Asia, New Delhi,
India.
Riehman, K. S (1996): Injecting Drug use and AIDS in Developing Countries: Determinants and Issues for Policy
Consideration. Background paper for the Policy Research Report Confronting AIDS World Bank, Policy
Research Department, October, 1996.
SHEAS (Society for Health, Education, Agronomy and Self Sufficiency), (1996): Community need assessment
for injecting drug users, SHEAS, Bangladesh.
Shohojogi-AIDS (Bangladesh), The Independent, 13 January, (2002): Most adolescents hardly aware of safe sex:
Sex education a must for preventing STD: Experts.
Stimson, G. V, (1993): The global diffusion of injecting drug use; implications for human immunodeficiency
virus infection. Bulletin on Narcotics XLV (1): 3-17
Stimson, G. V (1994): Reconstruction of sub-regional diffusion of HIV infection among injecting drug users in
South East Asia: Implications for early intervention. AIDS 8: 1630-1632.
Stimson, G. V; Adelekan, M; Rhodes, T (1995): The diffusion of drug injecting in developing countries. The
Centre for Research on Drugs and Health Behaviour, University of London.
Stmpson, G V. (1996): Drug injecting and the spread of HIV infection in South east Asia. In Sherr L, Catalan J,
Hedge B, Psycho social aspects of AIDS. Chur: Harwood. I Stimson G V, choopanya Kachit (1996): Global
perspectives on drug injecting. In Stimpson G V, Des Jarlais D C, Ball A, drug Injecting and HIV infection:
Global Dimensions and Local Responses.
The Daily Star, July 30, 2003: HIV/AIDS in Bangladesh
http://archives.healthdev.net/sea-aids/msg00747.html. (accessed on 08.31.03)
UNAIDS, UNICEF, WHO, 2002 Update. Epidemiological Fact Sheet on HIV/AIDS and Sexually transmitted
Infections, Bangladesh.
UNAIDS, (2000): HIV in Bangladesh: AIDS, Poverty, Gender Inequality, Livelihoods and Development.
UNAIDS Epidemiological Fact Sheet-2000.
World Health Organization, (1999): Preventing HIV/AIDS, STI and related Discrimination: An important
Responsibility of Health – Promoting Schools.
World Bank and WHO, Country Brief, 2001.
Young People, HIV/AIDS, Drug and Substance use in Asia, (2002): Revisiting the ‘Hidden epidemic’ A situation
assessment of drug Use in Asia in the context of HIV/AIDS; The Center for Harm Reduction, Burnet Institue,
January 2002.