4. Rationale for rating of risk to development outcome.

Rating: Moderate

Financial. Apart from HNPSP, several other sources of funds are also available--USAID through FHI, and GFATM (Rounds 2 and 6) through Save the Children, USA. Bangladesh has also been invited by GFATM to participate in Round 7. The total amount of funding for HIV/AIDS prevention, care and support, and treatment, from various sources is now substantial.

Institutional. HIV/AIDS prevention is a very small part of the larger HNPSP, and there is a real danger of it falling between the cracks. The program will soon face the challenge of having to identify the genuine high-risk groups (i.e. IDUs and not heroin smokers), substantially scale up TIs among these groups, as well as develop content for several core components. With the addition of GFATM Round 6 funds, coverage of vulnerable groups is expected to double, thereby increasing the challenges of coordination, stewardship and management. Given the volume of funding flowing into Bangladesh from multiple streams, there is a real danger of duplication and mismanagement, given the lack of both technical and managerial expertise within NASP.

Technical. The very high level of male circumcision in Bangladesh, practiced for religious reasons, makes a generalized epidemic unlikely. However, other risk factors--high levels of commercial sex work, low condom use, pockets of IDUs--do exist, and require a coordinated response. While the technical paradigms in place for TIs are sound, coverage is still an issue of concern. No comprehensive mapping has been done to estimate the denominators for various high risk groups; and it is not possible to tell what proportion of high risk groups are currently being covered, and how much of a scale-up is really required. Surveillance has been well done within the current framework; however, it is confined to areas where TIs are already being implemented, and this methodology will require re-thinking. The ability to guide and manage the revised surveillance system is not available at NASP, and any delays in contracting a competent agency to undertake this activity will seriously undermine the evidence-base for interventions in the country. Components such as the Advocacy and Communication and the Safe Blood program were not well implemented under HAPP, and it is not clear how HNPSP will ensure that they will be better done henceforth.

Social. Bangladesh is a conservative society, and while substantial progress has been made with regard to addressing issues of vulnerability, stigma and discrimination among high risk groups, more widespread IEC and advocacy have not yet been implemented. National level networks of FSWs exist but are not very active, and no coordinated programmatic approach has been developed under HAPP to develop and involve community groups. However, there are strong NGOs on the ground, with the capacity to work closely with the high risk communities with quality interventions.

Political. A detailed review of the Policy Environment was recently undertaken (Towards a coordinated national response for Targeted Interventions in Bangladesh: A brief review and look forward. Tony Bondurant et al; World Bank consultants' report; November 12, 2007), which concluded that "the necessary policy building blocks exist, although implementation is limited in some areas". Major policies have recently been adopted that will provide an enabling environment, if implemented; and GOB has been taking a pragmatic and evidence-based approach to HIV prevention; a good example is the wide implementation of the needle-sharing program for IDUs.