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.

Establishing a surveillance system on sexual and reproductive health and rights (SRHR) of key populations (KPs) at risk of compromised outcome of SRHR- A protocol for a mixed-method study.

BACKGROUND: Key populations (KPs) who are at risk of compromised situation of sexual and reproductive health and rights in Bangladesh constitute including males having sex with males, male sex workers, transgender women (locally known as hijra) and female sex workers. Globally, these key populations experience various sexual and reproductive health and rights burdens and unmet needs for ailments such as sexually transmitted infections including Neisseria Gonorrhoea, Chlamydia Trachomatis and human papillomavirus. Most key population focused interventions around the world, including Bangladesh, primarily address human immune deficiency virus and sexually transmitted infections-related concerns and provide syndromic management of sexually transmitted infections, other sexual and reproductive health and rights issues are remained overlooked that creates a lack of information in the related areas. There is currently no systematic research in Bangladesh that can produce representative data on sexual and reproductive health and rights among key populations, investigates their sexual and reproductive health and rights needs, how their needs evolve, and investigate underlying factors of sexual and reproductive health and rights issues that is crucial for informing more sexual and reproductive health and rights-friendly interventions for key populations. Keeping all these issues in mind, we are proposing to establish a sexual and reproductive health and rights surveillance system for key populations in Bangladesh. METHOD: The sexual and reproductive health and rights surveillance system will be established in Dhaka for males having sex with males, male sex workers and transgender women, and the other in Jashore for female sex workers. The duration will be for 3 years and data will be collected twice, in year one and year two adopting a mixed method repeated cross-sectional design. All key populations 15 years and above will be sampled. Behavioural data will be collected adopting a face-to-face technique and then biological samples will be collected. Those who will be found positive for human papillomavirus, will be referred to a government hospital for treatment. Free treatment will be provided to those who will be found positive for other sexually transmitted infections. In total, 2,240 key populations will be sampled. Written assent/consent will be taken from everyone. Data will be entered by Epi-Info and analysed by Stata. Report will be produced in every year. DISCUSSION: This surveillance system will be the first of its kind to systematically assess the situation of sexual and reproductive health and rights among selected key populations in Bangladesh. It is expected that this study will provide insights needed for improving the existing sexual and reproductive health and rights intervention modalities for these vulnerable and marginalized key populations.

Community based peer-led TB screening intervention: an innovative approach to increase TB knowledge, presumptive case identification, and referral among sexual minority people in urban Bangladesh.

INTRODUCTION: One of the contributors to tuberculosis (TB) burden among vulnerable populations, such as sexual minority people, is the delay in case finding and notification. Given their socially excluded, hard-to-reach nature, community-led approaches need to be introduced to facilitate their screening of TB symptoms and their subsequent referral to TB healthcare providers. This article aimed to explore the existing challenges surrounding TB screening and referral, and the implementation facilitators and barriers of the proposed community-based TB screening model for sexual minority people in Dhaka, Bangladesh. METHODS: This study followed the quasi-experimental design using mixed methods (i.e., qualitative and quantitative) approach. The study participants who were also a part of the community-led TB screening model included sexual minority people enrolled in HIV prevention interventions. In addition to quantitative inquiry, in-depth interviews were conducted on sexual minority people, focus group discussions were also conducted on them and HIV prevention service providers, and key-informant interviews were conducted on service providers, programmatic experts and TB researchers. Data were analyzed using content, contextual and thematic approaches. RESULTS: The 'Six Steps in Quality Intervention Development' framework was used to guide the development of the community-based TB screening model. In Step 1 (identifying the problem), findings revealed low rates of TB screening among sexual minority people enrolled in the HIV prevention intervention. In Step 2 (identifying contextual factors for change), various individual, and programmatic factors were identified, which included low knowledge, low-risk perception, prioritization of HIV services over TB, and stigma and discrimination towards these populations. In Step 3 (deciding change mechanism), community-based screening approaches were applied, thus leading to Step 4 (delivery of change mechanism) which designed a community-based approach leveraging the peer educators of the HIV intervention. Step 5 (testing intervention) identified some barriers and ways forward for refining the intervention, such as home-based screening and use of social media. Step 6 (collecting evidence of effectiveness) revealed that the main strength was its ability to engage peer educators. CONCLUSION: This study indicates that a community-based peer-led TB screening approach could enhance TB screening, presumptive TB case finding and referral among these populations. Therefore, this study recommends that this approach should be incorporated to complement the existing TB program.

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.

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.

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.

People who inject drugs in Bangladesh - The untold burden!

The rates of both HIV and HCV are exploding among the People Who Inject Drugs (PWID) subpopulation in the People's Republic of Bangladesh. 5,586 HIV confirmed cases have been reported since the first case of HIV was identified in 1989, of which, 865 new cases (15.5%) have been reported in the year 2017 alone. Among the new cases, 330 (38.2%) were from PWID population. The HCV prevalence is also high in Dhaka, with 40% of the PWID with unknown HIV status and 60.7% co-infected with HIV. The predominant HIV-1 strains circulating in the population are subtype C (41.4%) followed by CRF07 BC (24.2%), CRF01 AE (9.1), A1 (6.6%), and B (2.5%). HCV subtypes 3a and 3b are the most prevalent circulating strains (88.5%) among PWID. Harm reduction interventions particularly Needle Syringe Program (NSP) for PWID have been operating in Bangladesh since 1998. Opioid Substitution Therapy (OST) commenced in 2010 but only covers 2.9% of the total estimated PWID population in the country. A preliminary assessment of the needle/syringe sharing networks of HIV positive PWID was made in order to determine the HIV status among needle/syringe sharing partners. From a network of 36 HIV positive PWID seeds, 96 needle/syringe sharing partners were identified, of which 10 were HIV positive. Characterization of the nature of transmission within PWID networks is required in order to develop clinical services aimed at this vulnerable subpopulation and to halt the epidemic.

Effects of In-country and Cross-Border Mobility on Condom Use Among Transgender Women (hijras) in Bangladesh: A Cross-Sectional Study.

In Bangladesh transgender women (hijras) are thought to be highly mobile that may be an impediment to condom use. This cross-sectional study was conducted to determine the extent of mobility of hijras, in-country and cross-border, and whether mobility affects condom use in anal intercourse. Hijras ≥15 years of age, receiving services from the Global Fund supported HIV prevention program were enrolled. A behavioral questionnaire was administered and blood was tested for antibodies to HIV and syphilis. Of 889 hijras sampled, 41.3 % never traveled, 26.4 % traveled in-country and 32.3 % crossed the border in the last year. HIV and active syphilis was at 0.8 and 1.8 % respectively. Among hijras who crossed the border condom use was less likely in last anal intercourse (AOR 0.68; 95 % CI 0.48-0.96), and consistently with new (AOR 0.59; 95 % CI 0.34-1.01) and regular clients (AOR 0.45; 95 % CI 0.27-0.76) in the last week. This study concludes that in Bangladesh hijras are highly mobile and cross-border mobility negatively affects condom use.

Health-related quality of life in old age: a comparison between rural areas in Bangladesh and Vietnam.

This study compares health-related quality of life (HRQoL) and its determinants among older people (≥60 years) in rural Bangladesh and Vietnam. Cross-sectional studies among older people were conducted in Bangladesh (n = 1031) and Vietnam (n = 870). Data on HRQoL were collected using an instrument that includes 24 items distributed into 6 dimensions. Older people in Vietnam reported more favorable HRQoL outcomes than those in Bangladesh, reporting better HRQoL on physical, psychological, social, and financial dimensions. Hierarchical linear regression analyses show that advanced age, being a woman, belonging to a poor household, and reporting poor health were significantly associated with lower HRQoL scores in both Bangladesh and Vietnam. In Bangladesh, being illiterate was additionally associated with lower HRQoL scores. The results of this explorative study underline the importance of a cross-cultural understanding of HRQoL of older people and the influence of the socioecological context.

Impact of health education on health-related quality of life among elderly persons: results from a community-based intervention study in rural Bangladesh.

UNLABELLED: This study examines the change in health-related quality of life (HRQoL) among (> or =60 years) elderly persons as a result of health education intervention. A community-based intervention study was performed in eight randomly selected villages ( INTERVENTION: n = 4; CONTROL: n = 4) in rural Bangladesh. A total of 1135 elderly persons was selected for this study. The analyses include 839 participants ( INTERVENTION: n = 425; CONTROL: n = 414) who participated in both baseline and post-intervention surveys. Participants in the intervention area were further stratified into compliant (n = 315) and non-compliant (n = 110) groups based on the reported compliance to the intervention activities. The intervention includes, for example, physical activity, advice on healthy food intake and other aspects of management. To create an enabling environment, social awareness was provided by means of information about the contribution of and challenges faced by elderly persons at home and the community, including information about elderly persons' health and health care. The intervention activities were provided to the elderly persons, caregivers, household members and community people for 15 months. The HRQoL was assessed using a multi-dimensional generic instrument designed for elderly persons. Multivariate analyses revealed that in the non-compliant group the probabilities of increased scores were less likely in overall HRQoL (OR 0.52, 95% CI 0.32-0.82). Among the CONTROL group, increased scores were less likely in the physical (OR 73, 95% CI 0.54-0.99), social (OR 0.37, 95% CI 0.27-0.50), spiritual (OR 0.60, 95% CI 0.34-0.94), environment (OR 0.36, 95% CI 0.26-0.49) dimensions and overall HRQoL (OR 0.44, 95% CI 0.32-0.59) (adjusted for age, sex, literacy, marital status and economic status). This study concludes that provision of community-based health education intervention might be a potential public health initiative to enhance the HRQoL in old age.

A multidimensional approach to measure poverty in rural Bangladesh.

Poverty is increasingly being understood as a multidimensional phenomenon. Other than income-consumption, which has been extensively studied in the past, health, education, shelter, and social involvement are among the most important dimensions of poverty. The present study attempts to develop a simple tool to measure poverty in its multidimensionality where it views poverty as an inadequate fulfillment of basic needs, such as food, clothing, shelter, health, education, and social involvement. The scale score ranges between 72 and 24 and is constructed in such a way that the score increases with increasing level of poverty. Using various techniques, the study evaluates the poverty-measurement tool and provides evidence for its reliability and validity by administering it in various areas of rural Bangladesh. The reliability coefficients, such as test-retest coefficient (0.85) and Cronbach's alpha (0.80) of the tool, were satisfactorily high. Based on the socioeconomic status defined by the participatory rural appraisal (PRA) exercise, the level of poverty identified by the scale was 33% in Chakaria, 26% in Matlab, and 32% in other rural areas of the country. The validity of these results was tested against some traditional methods of identifying the poor, and the association of the scores with that of the traditional indicators, such as ownership of land and occupation, asset index (r=0.72), and the wealth ranking obtained from the PRA exercise, was consistent. A statistically significant inverse relationship of the poverty scores with the socioeconomic status was observed in all cases. The scale also allowed the absolute level of poverty to be measured, and in the present study, the highest percentage of absolute poor was found in terms of health (44.2% in Chakaria, 36.4% in Matlab, and 39.1% in other rural areas), followed by social exclusion (35.7% in Chakaria, 28.5% in Matlab, and 22.3% in other rural areas), clothing (6.2% in Chakaria, 8.3% in Matlab, and 20% in other rural areas), education (14.7% in Chakaria, 8% in Matlab, and 16.8% in other rural areas), food (7.8% in Chakaria, 2.9% in Matlab and 3% in other rural areas), and shelter (0.8% in Chakaria, 1.4% in Matlab, and 3.7% in other rural areas). This instrument will also prove itself invaluable in assessing the individual effects of poverty-alleviation programmes or policies on all these different dimensions.

Social capital and quality of life in old age: results from a cross-sectional study in rural Bangladesh.

The objective of this article is to identify determinants of quality of life (QoL) and investigate their association with individual- and community-level social capital among older people in rural Bangladesh. A cross-sectional study of 1,135 elderly persons (aged >/= 60 years) was conducted in a rural district in Bangladesh. Independent variables included age, sex, education, economic status of the elderly person, and individual- and community-level social capital. Self-rated QoL was the dependent variable. Descriptive analyses were done to show group differences in QoL and logistic regression analyses to identify determinants of QoL. Advanced age, poor household economic status, and low social capital at individual and community levels were significant determinants of poor QoL among the elderly. This population-based study provided empirical evidence that social capital both at individual and community levels was directly associated with the QoL of elderly people in rural Bangladesh.

Measuring perceived health outcomes in non-western culture: does SF-36 have a place?

This study explored the usefulness of a generic health assessment tool SF-36 in measuring perceived health outcomes in a developing-country setting. The adapted Bangla version was administered in 10 villages of Matlab sub-district in Bangladesh during second half of 1999. Respondents included currently-married males and females selected randomly from households stratified according to their association with women-focused development interventions of BRAC. Findings revealed that the respondents from BRAC households perceived their health status marginally better than the poor non-member group in most domains studied, sometimes significantly so, e.g. general and mental health (p < 0.05). The respondents from BRAC reported better 'current health' than their non-member counterparts. The gender difference in assessment of health status was noted among the groups. Age, education, and poverty were important determinants of perceived health status. SF-36 proved to be a useful tool for self-assessment of health status and group comparison when properly modified for cross-cultural adaptation.