Overview of HIV/AIDS

New HIV infection (HIV incidence)

Bhutan has a low-level HIV epidemic with an estimated prevalence below 0.3% (UNIADS Spectrum 2020). Compared to other counties in the region, Bhutan’s HIV epidemic started much later, with the first case diagnosed in 1993, and progressed more slowly. Sporadic cases appeared between 1993 and 2000. From 2000 to 2013, the number of new HIV diagnosed cases rose from 9 to 51. Since 2013, there has been a plateau in the number of new HIV diagnoses, fluctuating between 49 and 58 annually (Figure 1).

Case diagnosis

Out of 88,413 HIV tests conducted in 2018 (among 5,37,728 people who are 15 years and above) about 60 HIV cases were diagnosed (Figure 2). As of June 2021, the detected number of cases is 773 (401 males and 372 females) which includes 32 new cases detected within Jan-June 2021 period. The detected cases represent only about 57% of the estimated 1300 people living with HIV (PLHIV) in Bhutan. Out of 773 diagnosed about 581 are currently living with HIV in the country while 556 are on ART resulting in 95.69% coverage. Despite the low prevalence of HIV in Bhutan, the need to intensify HIV Counseling and Testing is being accorded high priority by the Royal Government to bridge the current case detection gap of about 41% of the estimated PLHIV in the country.

By age and mode of diagnosis

About 70% of the reported cases belong to the age group of 25-49 and 14% are between the ages of 15-24 years. While 5% below 15 years of age and 11% above 50 years (Figure 3). This shows that the majority of cases are being reported among the most economically productive and younger age group. The reported cases are being diagnosed through different rout of transmission (Figure 4). For example, the most dominant mode of diagnosis is through Contact Tracing (28%), Voluntary Testing (25%) and Medical Screening (24%) followed by Antenatal Clinics (9%), Mobile testing (8%) and Blood donor (5%) respectively.

Mode of transmission

The majority (96%) of the reported cases have acquired the infection through heterosexual route, followed by MTCT.

Distribution of cases by place of living

The HIV cases are being reported from all across the country with high prevalence in major urban areas like Thimphu, Chukha, Wangdue, Sarpang, Samtse and S/Jongkhar (Figure 5).

A brief history of National HIV and AIDS Response in Bhutan

The response to the epidemic in Bhutan started long before the first HIV case was detected in the country. Taking into account the consequences of the HIV epidemic on personal and national development, the government initiated the National STI and HIV/AIDS Prevention and Control Programme (NACP) in 1988. Five years after the initiation of the NACP, in 1993, a National AIDS Committee (NAC) was established to oversee and coordinate multi-sectoral efforts to ensure a harmonized approach for HIV control and prevention. The NAC was restructured to form the National HIV and AIDS Commission for policy formulation and strategic responses. Planned activities have been implemented over the years to counter the spread of HIV through a Short-Term Plan (STP) with a focus on prevention, capacity building, the establishment of testing facilities and case detection. The STP progressed to a three-year Medium-Term Plan (MTP-I, 1990–1993) with a focus on condom promotion, strengthening of infrastructure, training of health workers, strengthening programme monitoring and evaluation, and preparing the groundwork for HIV care and management. A second Five-Year Plan, MTP-II, was developed in 1995 to include a multi-disciplinary framework to involve various government ministries and the private sectors to prevent the spread of HIV and AIDS in the country with financial assistance from the World Health Organization (WHO) and Danida.

The national response towards the prevention and control of HIV and AIDS received a strong political commitment to preventing HIV and AIDS. On 24th May 2004, the Fourth King, His Majesty Jigme Singye Wangchuck, issued a Royal Decree to encourage HIV prevention and to respect the rights of PLHIV. The following year, in 2005, with the growing rate of infection among the younger generation, the Fifth King, His Majesty the Jigme Khesar Namgyel Wangchuck, proclaimed to the nation, “HIV is no exception. The youth will use their strength of character to reject undesirable activities; their compassion to aid those afflicted and their will to prevent its spread”. Furthermore, the work of Her Majesty, the Queen Mother Ashi Sangay Choden Wangchuck for the prevention of HIV and AIDS in the last two decades is a source of inspiration. Today the Royal decrees serve as a core pillar of the country’s HIV responses and provide the much-needed political support.

BASICS ABOUT HIV & AIDS

What is HIV?

HIV stands for Human Immunodeficiency Virus. As the name suggests, it only causes disease in humans by attacking and destroying the white blood cells of our immune system. The white blood cells in our body are also referred to as T-cells (T-Lymphocytes) and CD4 cells.

The main function of the white blood cells (WBCs) is to help our body fight the infection by attacking any bacteria, virus and germs that invade our body. Therefore, the loss of white blood cells makes our immune system weaker and unable to defend itself from infections. If left untreated, it may take up to 10 or 15 years for the immune system to be severely damaged and can no longer defend itself from infections and diseases. This is an indication of advancing to AIDS. However, the duration of HIV advancing to AIDS depends upon a person’s age and overall health condition.

What is AIDS?

AIDS stands for Acquired Immunodeficiency Syndrome and is not a virus but a set of symptoms caused by HIV. We called person has developed AIDS when his/her immune system becomes too weak to fight against any infections thus showing some symptoms of illnesses. This is the last stage of HIV infection in our body and if left untreated will ultimately lead to death.

How is HIV transmitted?

We must know that HIV is found in the bodily fluids like blood, semen and pre-seminal fluid, vaginal or anal secretions and breastmilk of someone living with the virus. Therefore, HIV can be transmitted from person to person if infected body fluids come in contact with our blood in the body.

There are four main ways where these fluids can come in contact with each other:

  • Have unprotected sex (vaginal, oral and anal) without using condoms with an HIV infected person. Anal sex possesses a much higher risk of HIV transmission than vaginal sex.
  • Transfusion of HIV infected blood or blood products including organ transplants.
  • Sharing of HIV infected needles, syringes, blades and piercing instruments.
  • HIV infected pregnant mother to her child (during pregnancy, or at the time of delivery or during breastfeeding).
  • HIV can transmit from person to person only if infected body fluids such as (Blood, semen, vaginal or anal secretions and breast milk).

How HIV is not transmitted?

You will not get HIV by…

  • Hugging, shaking and holding hands with a person with HIV
  • Living, sitting, eating and swimming together with HIV infected person.
  • Sharing of utensils, towels and clothes with HIV infected person.
  • Coughing and sneezing because HIV cannot survive in the air.
  • Insect bites such as mosquitoes because it only sucks your blood but does not inject the blood of the last person it bit.

Who is at risk for the acquisition and transmission of HIV?

Overall, we all are equally vulnerable to HIV and other STIs irrespective of our social status, sexual orientation, race, ethnicity, gender, age, and place of living. However, certain sub-population groups are at increased risk of acquiring HIV and other STIs due to the biological (Age and sex) and social determinants (Individual life style, social and community networks, socio-economic, and cultural) which influences the individual risk behaviour.

Like many other countries in the region the key population like Men having Sex with Men (MSM), Transgender (TG) person, Sex Workers, High-Risk Women (HRW) and Injecting Drug Users (IDUs) are considered as high-risk group while taxi drivers, trucker and migrant workers, youths and uniformed personnel are considered as the venerable population.

Why are women particularly young women more vulnerable to HIV infection than men?

There are social, cultural, economic and biological factors that make women and young adolescent girls highly vulnerable to HIV/AIDS.

In many societies including ours, there exists a culture of silence around women and their families, particularly rape and matters of domestic violence. Moreover, being economically dependent, women are more vulnerable to coercion and less likely to be able to negotiate safe sex for fear of violence and rejection.

Women are biologically more vulnerable because the mucus membrane lining the vagina can be easily damaged during forceful sexual intercourse. HIV easily enters the blood through damaged surfaces. The situation is even worse among young girls whose inner lining of the mucus membrane are immature and fragile as compared to adult women.

Patients with STIs are most vulnerable to HIV/AIDS. Almost 50 to 80% of STIs in women have no symptoms or symptoms that cannot be easily recognized. Even if there are symptoms, women tend to bear the pain and discomfort of STIs because they may be reluctant to visit a doctor.

What are the symptoms of HIV/AIDS?

Symptoms of AIDS can include the following:

  • Rapid weight loss.
  • Recurring fever or profuse night sweats.
  • Extreme and unexplained tiredness.
  • Prolonged swelling of the lymph glands in the armpits, groin, or neck.
  • Diarrhea lasts for more than a week.
  • Sores of the mouth, anus, or genitals.
  • Pneumonia.
  • Red, brown, pink, or purplish blotches on or under the skin or inside the mouth, nose, or eyelids.
  • Memory loss, depression, and other neurologic disorders.

What are the prevailing HIV myths and misconceptions?

  • Wearing a double condom gives better protection for HIV and STIs (False).
  • Condom is reusable (False)
  • Condom reduces the pleasure of sex (False)
  • A condom protects from HIV and STIs but not pregnancy and vice versa (False).
  • Condoms do not have any expiry date so they can be used without any doubt (False).
  • It is safe to hair gel, hair oil or face cream to increase the lubrication for pleasurable sex (False).
  • Females using IUD/oral pills or who have undergone tubectomy need not use a condom (False).
  • Vasectomised males do not need condoms (False)
  • A condom can be used for a purpose other than sex (False).

What should we do with the AIDS patient?

Royal Degree (Kasho) for care, support and compassion to people living with HIV was issued since 2004 and it discourages any form of stigma and discrimination against people living with HIV and AIDS.

AIDS patients are treated like any other patient with chronic manageable diseases. They have equal access to all facilities and services like any other individual. We mustn’t stigmatize or discriminate People Living with HIV and other key populations like MSM, TG and Sex Workers including IDUs.