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.

Prevalence of HIV, risk behaviours and vulnerabilities of female sex partners of the HIV positive people who inject drugs (PWID) in Dhaka city, Bangladesh.

BACKGROUND: The HIV epidemic in Bangladesh is largely being driven by people who inject drugs (PWID) and mainly concentrated in Dhaka city. Intregrated biological and behavioural survey (IBBS) data of 2016 showed that a considerable percentage of the HIV positive PWID had unsafe sex with their female sex partners. Prevalence of HIV, risk behaviorus and vulnerabilities among the female sex partners of the PWID still remain unexplored. METHODS: To measure HIV prevalence, risk behaviours (drugs/injection/sexual) and vulnerabilities (treatment of and knowledge of sexually transmitted infections (STIs) and HIV/uptake of the routine HIV testing and HIV prevention services/physical and sexual violence), a quantitative survey was conducted among 227 female sex partners of the HIV positive PWID in Dhaka city in 2019 by adopting a take-all sampling technique. RESULTS: The median age of participants was 34.0 years. Prevalence of HIV was 16.7% (95% CI: 12.4-22.2). Only 6.8% to 18.7% of the participants used condoms consistently with different male sex partners; only 6.8%cto 18.7% during last year. Seventy five percent (95% CI: 69.2-80.8) had no knowledge on STI symptoms. Self-reported symptoms of STIs were reported by 26% (95% CI: 20.7-32.1) and half sought treatment during last year. Nineteen percent (95% CI: 14.7-25.1) had comprehensive knowledge of HIV. As part of the routine HIV prevention services by the PWID drop-in-centres (DICs), 42.7% (95% CI: 36.4-49.3) of the participants were tested for HIV and knew their result within the last year. One-third never received HIV prevention services. During the last one year preceding the survey, 46% (95% CI: 39.3-52.6) reported been beaten and 20.2% (95% CI: 15.3-26.1) been raped. CONCLUSION: It is urgently necessary to consider the high-risk behaviours and vulnerabilities in designing or to strengthen targeted interventions for female sex partners of the HIV positive PWID in Dhaka city to ensure equality in accessing and utilization of services.

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.