The aim of this study was to examine trends in HIV and related risk behaviours in drug users in Bangladesh, the effects of prevention and harm reduction initiatives that have already been undertaken and to highlight immediate needs. Journal publications, conference abstracts and proceedings were collected and reviewed. As there were relatively few published papers, the grey literature was also reviewed. Experts involved in the development and evaluation of current programmes or policy were contacted for official reports, policy documents or unpublished materials. The trends in injecting and sexual risk behaviours were tabulated. Periodic behavioural and serosurveillance on recognised sentinel groups shows clearly that HIV prevalence among injecting drug users has been increasing steadily. In the capital city, the HIV prevalence among injecting drug users is close to the level of a concentrated epidemic (4.9%). While harm reduction strategies have brought a scope of reduction of injecting-related risk behaviours, the persistent high rates of needle sharing and high prevalence of sexual risk behaviours remains alarming. Non-injecting drug users have maintained a low prevalence of HIV but their high-risk sexual behaviours and transformation into injecting drug users with time are of concern. There are substantial gaps between current needs and the ongoing prevention and harm reduction activities. There is a pressing need for a comprehensive harm reduction programme and review of any policies and laws which may impede this.