Some of the factors that contribute to the spread of HIV in Bhutan are clearly related to development; they include:

• Bhutan borders India and is located near Nepal, where HIV/AIDS already is an urgent problem
• more business people and civil servants are travelling outside the country as Bhutan opens up to global society
• increasing rural-to-urban migration
• sex work is on the increase
• low awareness of the implications of unsafe sex
• high STI-incidence among certain groups and in certain parts of the country
• sexual relations are less restricted compared with other countries in the region
• in general, safe sex matters are not discussed at inter-personal level

Bhutan's National HIV/STI Control Programme started in 1988 and adopted a multi-sectoral initiative involving all sections of society. The programme is integrated into the decentralised national health system and focuses on HIV prevention. Its activities include condom promotion and free distribution in urban and rural areas through hospitals, basic health units, health workers and private outlets. This has resulted in a higher number of condoms being distributed and used. HIV prevention and awareness activities, counselling and monitoring of the health status of most of the 60 commercial sex workers (including both nationals and non-nationals) active in the Phuentsholing border area are another aspect of the HIV/AIDS programme.

In Phuentsholing, a multi-sectoral task force works with commercial sex workers to halt the spread of HIV. Regular STI-treatment campaigns are undertaken, targeting the general population and specific target groups such as sex workers. Currently, activities include promoting HIV/AIDS awareness among the school youth. Information about reproductive health and HIV/AIDS has recently been introduced into the high school curriculum. Community leaders are also becoming involved in awareness programmes in rural areas.

Her Majesty Queen Ashi Sangay Choden Wangchuck, in her capacity as a UNFPA Goodwill Ambassador, regularly visits different parts of the country to discuss reproductive health issues and HIV/AIDS with women, youth and leaders. Her Majesty plays and instrumental role in creating HIV/AIDS awareness in the country. The commitment on the part of the royal family and government is an unusual and positive factor in the region's response to the HIV/AIDS epidemic. In addition, the Assembly of People's Representatives recently urged government to step up activities to minimise the impact of HIV/AIDS.

The relatively egalitarian gender relations in Bhutanese society are another positive factor. Women's position is strong, particularly at household level, and their negotiating power in sexual matters is relatively good. As Bhutanese attitudes to sex are relatively liberal, HIV prevention programmes are pragmatic and realistic; e.g., condoms are distributed to everyone, including to unmarried people and adolescents.

Serious bottlenecks for effective implementation of the HIV/AIDS programme exist as well, however. Bhutan is heavily dependent on donor funding and may find itself short of funds when it steps up HIV/AIDS activities. Data to support implementation of programmes are available only to a limited extent. Implementation of HIV/AIDS programmes at the community level is often hampered by problems of accessibility.

What about the future? With high STI rates and the process of opening up to the rest of the world, it is realistic to expect that the HIV rate will increase. At the moment, interventions focus mainly on sex workers. Better scrutiny of who are the most vulnerable groups could enhance the effectiveness of interventions. The increasing numbers of HIV-infected persons will require more resources for counselling. Finally, the country should prepare for the time when the health care system and people at home will have to care for people suffering from AIDS. Other issues such as confidentiality and rights of people with HIV/AIDS also deserve attention. Bhutan could build on experiences and lessons learned in neighbouring countries and adapt them to the local situation.