Are we ready for a sustainable approach? A qualitative study of the readiness of the public health system to provide STI services to the key populations at risk of HIV in Bangladesh

INTRODUCTION

In Bangladesh, sexually transmitted infection (STI) services are available for all populations in public health facilities. However, STI services for key populations (KPs) at risk of HIV need specifically designed approaches that are predominantly administered to KPs through donor-supported service centers operated by non-government organizations (NGOs) and community-based organisations (CBOs). However, the steady decline in donor funding warrants a sustainable transition of STI services for the KPs into public health facilities. This article aimed to explore the service availability and readiness of public health facilities to provide STI services for the KPs.

METHODS

This qualitative study explored the service availability and readiness of public health facilities in three districts of Bangladesh by adapting the Service Availability and Readiness Assessment tool. We conducted 34 in-depth interviews,11 focus group discussions with KPs, and 29 key-informant interviews with healthcare providers, researchers, programme implementers and policy planners, in addition to series of direct observations at the public healthcare facilities. Data were analysed through thematic analysis, and categorised in relation to the WHO building blocks.

RESULTS

This study revealed that the public health system was generally not ready to serve the KPs' needs in terms of providing them with quality STI services. The 'service delivery' component, which is the most crucial facet of the public health system, was not ready to provide STI services to KPs. Findings also indicated that health workforce availability was limited in the primary and secondary healthcare layers but adequate in the tertiary layer, but needed to be oriented on providing culturally sensitised treatment. Counseling, an essential component of STI services, was neither ready nor available. However, health information systems and a few other components were partially ready, although this warrants systematic approaches to address these challenges.

CONCLUSION

The findings show that public health facilities are yet to be fully ready to render STI services to KPs, especially in terms of service delivery and human and health resources. Therefore, it is not only integral to mobilize communities towards the uptake of public health services, but health systems need to be prepared to cater to their needs.

Can oral sex be performed safely among men who have sex with men (MSM) and transgender women in Bangladesh? Challenges, complexities and the way forward

Introduction

There is currently ample research and intervention initiatives addressing anal sex and sexually transmitted infections (STIs) among gender and sexually diverse people (i.e., men who have sex with men (MSM) and transgender women). However, oral sex and oral STIs are not prioritized to the same extent, despite their concerning implications. This article aimed to delineate the underlying contexts of unprotected oral sex and the management challenges of oral STIs.

Methodology

This qualitative study constituted 30 in-depth interviews, 14 focus group discussions, and 10 key-informant interviews with gender and sexually diverse people, service providers of HIV interventions and sexuality researchers. Thematic analysis conventions were applied.

Results

Findings revealed various contexts of unprotected oral sex. In particular, we found a discordance between pleasure and protected sex where participants believed the two phenomena were mutually exclusive, therefore they did not want to compromise their pleasure by using condoms. Moreover, their low awareness, risk perception, and unchallenged misconceptions about the harms of unprotected oral sex fueled their hesitancy to use condoms during oral sex. Compared to anal sex and STIs, oral sex and STIs were less prioritized in the current HIV intervention modalities, where healthcare providers lacked adequate knowledge and training about oral sex and oral STIs, as well as their complexities.

Conclusions

In Bangladesh and several other settings, oral sex is considered a taboo, thus imbuing silence about this issue and its complexities. In this context, it is integral to eradicate the taboos and silence surrounding oral sex and oral STIs in order to strengthen the overall STI management strategy. Therefore, HIV/STI prevention programs and mainstream healthcare facilities need to underscore oral STI interventions, otherwise this issue would remain under-prioritized.

Understanding the Barriers of HIV Testing Services for Men Who Have Sex With Men and Transgender Women in Bangladesh: A Qualitative Study

Coverage of HIV testing services (HTS) is generally low among men who have sex with men (MSM) and transgender women (hijra) in Bangladesh, thus impeding the national goal of attaining the 90-90-90 target. In this context, this article delineates HTS uptake barriers among these populations. This qualitative study entailed 30 in-depth interviews, six focus groups and seven key-informant interviews with purposively selected MSM and hijra, alongside service providers. Participants cited individual and interpersonal barriers such as low risk perception and misconceptions about HIV testing, programmatic barriers such as knowledge gaps among peer service providers, as well as community and structural barriers such as the criminalization and stigmatization of male-to-male sex. Considering these contexts, it is essential for stakeholders to improve the HTS modality using multipronged approaches to address the multifaceted barriers of HTS uptake.

Developing and testing community-based tuberculosis (TB) screening intervention to increase TB referral, case detection and knowledge among sexual minority people in urban Bangladesh: a mixed-method study protocol

INTRODUCTION

Although Bangladesh is a country of generalised tuberculosis (TB) epidemic, the HIV prevalence is low among general populations, and 3.9% among key populations. Despite the high possibility of HIV-TB coinfection, scientifically tested approaches for increasing TB case detection among sexual minority people are yet to be developed and implemented in Bangladesh. Such approaches could foster service delivery linkages between communities and the government health system. Findings of this experimental research are likely to provide new insights for programme managers and policy planners for adopting a similar approach in order to enhance TB referral, thus ultimately increasing TB case detections and reducing the likelihood of TB-related mortalities and morbidities, irrespective of HIV status.

METHODS AND ANALYSIS

This operational research will follow a quasi-experimental design, applying both qualitative and quantitative methods, in two drop-in centres in three phases. Phase 1 will encompass baseline data collection and development of a community-based TB screening approach. In phase 2, the newly developed intervention will be implemented, followed by end-line data collection in phase 3. Qualitative data collection will be continued throughout the first and second phases. The baseline and end-line data will be compared both in the intervention and comparison areas to measure the impact of the intervention.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Institutional Review Board of International Centre for Diarrhoeal Disease Research, Bangladesh. The findings will be disseminated through diverse scientific forums including peer-reviewed journals, presentation at conferences and among the policy-makers for policy implication. The study started in January 2019 and will continue until June 2020.

Changes in condom use among males who have sex with males (MSM): Measuring the effect of HIV prevention programme in Dhaka city

Background

A systematic assessment was done to examine the effect of HIV interventions among MSM in Dhaka, Bangladesh. MSM were defined as males having sex with males but did not sell sex in the last year. MSM are hidden, marginalized and stigmatized population groups not only in Bangladesh but also globally. In 2010, HIV interventions for MSM were expanded in 40 districts of Bangladesh through 65 drop-in-centres (DICs) and peer outreach workers.

Methods

Data from two surveys on MSM in Dhaka in 2010 (baseline) and 2013 (midline) were used to analyse the effect of ongoing HIV prevention services. Both surveys used time location sampling to randomly select MSM for risk behaviour interviews. Two outcome variables were considered; condom use in the last anal sex act and consistent condom use during anal sex in the last month. Univariate and multivariate logistic regression methods were used to determine factors associated with condom use.

Results

Condom use significantly increased at the midline than baseline (p<0.001 for both). Multivariate analysis showed that having comprehensive knowledge of HIV and participation in HIV prevention programme were positively associated with both last time and consistent condom use. MSM who had comprehensive knowledge of HIV were 1.9 times (95% CI: 1.3–2.8, p = 0.002) and 2.1 times (95% CI: 1.4–3.2, p<0.001) more likely to use condoms than those who did not have comprehensive knowledge of HIV. The likelihood of using condoms among MSM was more than double at the midline than the baseline (p<0.01 for both). However, odds of condom use was significantly lower among those who perceived themselves to be at risk or were not able to assess their own risk of HIV.

Conclusion

To sustain positive changes in HIV risk behaviours, HIV prevention programmes for MSM need to be continued and strengthened.

The willingness to receive sexually transmitted infection services from public healthcare facilities among key populations at risk for human immunodeficiency virus infection in Bangladesh: A qualitative study

Background

In Bangladesh, community-based and peer-led prevention interventions for human immunodeficiency virus infection are provided to key populations (KPs) by drop-in centers (DICs), which are primarily supported by external donors. This intervention approach was adopted because public healthcare facilities were reportedly insensitive to the needs and culture of KPs, particularly with regard to the provision of sexually transmitted infection (STI) services. Nonetheless, in the absence of external funding, STI services need to be integrated into public healthcare systems.

Methods

A qualitative study was conducted in 2017 to understand the willingness of KPs to uptake the STI services of public healthcare facilities. Data were collected based on 34 in-depth interviews, 11 focus group discussions, and 9 key informant interviews. The social-ecological theoretical framework was used to analyze the data thematically and contextually.

Results

Most participants were either resistant or reluctant to uptake STI services from public healthcare facilities because of their previous firsthand experiences (e.g., disrespectful and judgmental attitudes and behaviors), perceived discrimination, anticipatory fear, and a lack of privacy. Very few participants who had visited these facilities to receive STI services were motivated to revisit them. Nevertheless, they emphasized their comfort in DICs over public healthcare facilities. Thus, it appears that KPs can be situated along a care-seeking continuum (i.e., resistance to complete willingness). Unless policymakers understand the context and reasons that underlie their movement along this continuum, it would be difficult to encourage KPs to access STI services from public healthcare facilities.

Conclusion

KPs’ willingness to uptake the STI services of public healthcare facilities depends not only on individual and community experiences but also on the nexus between socio-structural factors and health inequalities. Community mobilization and training about the needs and culture of KPs for healthcare professionals are essential. Therefore, addressal of a wide range of structural factors is required to motivate KPs into seeking STI services from public healthcare facilities.

Living on the extreme margin: social exclusion of the transgender population (hijra) in Bangladesh

The transgender people (hijra), who claim to be neither male nor female, are socially excluded in Bangladesh. This paper describes social exclusion of hijra [The term is used in this abstract both in singular and plural sense] focusing on the pathway between exclusion and sexual health. In an ethnographic study, 50 in-depth interviews with hijra, 20 key-informant interviews, and 10 focus-group discussions (FGDs), along with extensive field observations, were conducted. The findings revealed that hijra are located at the extreme margin of exclusion having no sociopolitical space where a hijra can lead life of a human being with dignity. Their deprivations are grounded in non-recognition as a separate gendered human being beyond the male-female dichotomy. Being outside this norm has prevented them from positioning themselves in greater society with human potential and security. They are physically, verbally, and sexually abused. Extreme social exclusion diminishes self-esteem and sense of social responsibility. Before safer sex interventions can be effective in a broader scale, hijra need to be recognized as having a space on society's gender continuum. Hijra, as the citizens of Bangladesh and part of society's diversity, have gender, sexual and citizenship rights, that need to be protected.