As one drives through the winding mountain roads in Tsirang Dzongkhag, located in the south-central part of Bhutan, the eye catches a sign: 'Let's Stop HIV'. What's interesting about this message is that it has been put up at the entrance of the local higher secondary school. As adolescents come spilling out of their classes at the end of the day, many stop to read the board. In fact, there are similar messages all across Bhutan – in schools, shops, community halls, health centres and even at restaurants and bars.
Living cheek-by-jowl with large neighbours like India and China, where the numbers of those living with HIV/AIDS are not insignificant, Bhutan is a nation at risk. To keep this risk to the minimum and to secure 'Shangri-la' from one of the most stigmatised diseases of modernity, Bhutan set up in 1988 the National AIDS Control Programme – the authority responsible for implementing the HIV/AIDS control and management strategies – that heavily focuses on awareness raising and prevention as its strategy.
The disease is relatively new to Bhutan – the first cases were detected around 1993. But since then on an average about 25-26 cases are detected every year. According to the Ministry of Health, from December 2009 until June 2010, a total of 32 cases have been detected.
Sonam Wangdi, Programme Officer, National STI & HIV/AIDS Control Programme, Department of Public Health, Bhutan, says, “Currently, there are 217 people detected in Bhutan with HIV infection. These include 18 children ranging between 1 to12 years, who have acquired the infection from infected parents (mother to child transmission). Almost 91 per cent of HIV infections are attributed to unsafe heterosexual practice such as low condom use.”
Clearly, while the number of infections may appear to be low, factors like the high rates of Sexually Transmitted Infections (STIs), risky behaviour among the population, and the rapid economic development that has spurred migration, could result in Bhutan having to cope with larger numbers of infections in the future.
For the AIDS Control Programme, therefore, “prevention and getting the basic messages out there to the people” is the golden mantra. Says Wangdi, “The programme took off with a five-year project initiated by the World Bank. We covered all the 20 districts where basic HIV facilities were started. The focus was on building the foundations – awareness and advocacy, initiating testing services in the hospitals, starting drop-in centres, and so on. For technical assistance – developing strategic plans, training modules for counsellors, treatment guidelines – we completely relied on the World Health Organisation (WHO) and UNAIDS. In fact, we still do. They have access to a lot of experts in the field and they help us to link up with them.”
Statistics of the Ministry of Health show that the epidemic doesn't 'favour' any particular group; it cuts across all sections of society and includes everyone from government and corporate employees, to businessmen, farmers, uniformed personnel, religious persons, housewives and sex workers. Even the male-female ratio is equal. The only anomaly is that young people between 15 to 29 years currently account for 50 per cent of the infected population.
“Right now it is this group that we are working with,” says Wangdi. Be it school-going children like the ones in Tsirang or the youngsters who frequent the newly-opened karaoke bars in Thimpu or even the unemployed youth that register with the Ministry of Labour, awareness building for all these groups is being carried out in full swing.
With the grant support of the Global Fund, outreach efforts for young people have gained further strength through the National AIDS Control Programme. “In 2008, we got Round Six of the Global Fund – around 3.5 million dollars. This went into areas that focused on school-going children and those that are out of the formal school system,” he reveals.
Initially, the idea was to include life-skills based HIV education in the school curriculum. “But that could not happen as its timing was not aligned with the time for them to change their curriculum. So there was a change in strategy and we decided to train the teachers instead in life skills on HIV/AIDS. This is an on-going programme,” says Wangdi.
According to Kinley Dorji, Global Fund Coordinator with the Ministry of Health, “We have already trained around 700 teachers in life skills on HIV/AIDS and they in turn teach it to the students.”
For those out of school, the National AIDS Control programme has also stepped into the non-formal education system. Explains Wangdi, “In Bhutan, this form of non-formal basic education is provided in the evenings. And so besides a sizable number of youngsters we also get to spread awareness among two other groups – women and the elderly who come for adult education. We have managed to include HIV education in the non-formal curriculum and it is working very well, especially at the grassroots.”
Interestingly, synergy has also been established with the Bhutan Chamber of Commerce and Industry (BCCI), which gives the programme access to those working in the private hospitality and entertainment establishments. “Not only have we made educational material readily available to them, we have installed condom boxes in the bars as well,” says Dorji. HIV awareness for the out-of-work youth is conducted in cooperation with the Ministry of Labour through pamphlets, leaflets and other IEC material. This targeted approach, focusing on identified risk groups, has shown results. “In terms of awareness/knowledge on HIV among the general population, I think, Bhutan would rank among the highest in the region,” claims Wangdi.
A little creativity has only eased the way. The programme targeting children has a range of fun activities, from sponsored quiz competitions in district schools to encouraging local school children, theatre groups and popular singers, to put up skits and shows spreading the word. 'What is HIV?' 'What happens when HIV infects a person?' 'When a person has AIDS…', 'If ART is not the cure, why is it important for people living with HIV and AIDS?' These are just some of the questions that are asked and answered repeatedly to get the right information across to young minds.
While awareness-building is a major tool for ensuring prevention now, securing the conditions of people living with HIV/AIDS – by ensuring availability of quality drugs and testing machinery, specialised counselling facilities and most importantly helping them in establishing a peer network – is the next step. “We've started some work with them – giving basic training and trying to get them on board with us. This is a very big challenge here in Bhutan especially because they are just a few of them and society is very small and conservative. Confidentiality becomes a big issue; it is difficult for them to come together and even meet each other for that matter,” observes Wangdi.
But efforts at creating networks are continuing and counsellors have been brought into the picture to help make life a little bit easier for those who need to come to terms with their status. The counsellors are few in number, however – there are only 40 specialised counsellors in the country. There is a chief counsellor with the team in Thimphu and district hospitals have a counsellor to deal with the cases in the districts. Each of the drop-in centres in the 20 districts across the country has a male and a female counsellor. Interestingly, an attempt has been made to get around the problem of insufficient number of counsellors, by training all health workers with basic counselling skills.
This small but compassionate army of counsellors has also achieved a major breakthrough by aiding around 15 HIV positive people – mostly based in the Capital – to come together and form an informal peer network where they meet and share their problems. Confident about themselves, the group is now looking to expand their membership for which they are travelling to different parts of the country in pursuit of this agenda. For Bhutan, these are all unprecedented and innovative steps to address an incipient health challenge and Global Fund has helped to make them possible through its financial support.
Bhutanese society, known for its conservatism, is now beginning to face up to the realities of HIV/AIDS. What has helped this is the support that the Palace has extended to the National AIDS Control Programme. The Royal Decree on HIV/AIDS calls for “care and compassion to those infected”. Observes Wangdi, “The biggest strength for our awareness efforts is the Royal Decree on HIV-AIDS issued by the king where he has talked about how all people should join hands and contribute to the cause. At the same time he has forbidden discrimination. Support from that quarter means that people are sure to sit up and listen.”
By arrangement with WFS