Major challenges in health care for people living with HIV in Bangladesh

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METHODS
REFERENCES
Major challenges in health care for people living with HIV in Bangladesh
Arunthia Zaidi Urmi1, Irona Khandaker2, Chandra Nath Roy2, M. Shah Alam1, Samina Choudhury3, Fadia
Sultana3, Habiba Akhter4, Tasnim Azim1
1. International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh.
Tohoku University, Japan. 3. Save The Children USA, Dhaka, Bangladesh. 4. Ashar Alo Society (AAS), Dhaka, Bangladesh. 2.
As of December 2009 in Bangladesh, a total of 1745
cumulative HIV cases has been reported. (National
AIDS/STD Programme [NASP] , 2009)
Estimated number of People Living with HIV (PLHIV) in
Bangladesh is around 7500 (Govt. of Bangladesh, 2008)
In Bangladesh, the first Highly Active Antiretroviral
Therapy (HAART) became available in 2003 (Tabassum
et.al, 2003).
Antiretroviral (ARV) treatment was provided to less
than 15 percent of the estimated number of PLHIV at the
end of 2007. (Govt. of Bangladesh, 2008).
Only five non-government organizations (NGOs) are
providing treatment, care and support services to the
PLHIV in Bangladesh . (Govt. of Bangladesh, 2008).
No study has documented the extent of access to
health care for PLHIV in Bangladesh.
Providing effective healthcare services to all PLHIV is
essential, but in order to do so an understanding of the
gaps and barriers is required.
The study was designed to :
 assess health service needs of PLHIV.
 identify the perceptions of PLHIV and service
providers regarding available health services.
 assess the barriers to providing effective healthcare
services to PLHIV.
Emerging Themes
BACKGROUND
OBJECTIVES
Design - Qualitative study using focus group
discussions (FGDs).
Setting - 13 FGDs were conducted in six
divisional cities of Bangladesh during March – April
2008.
Participants - 49 PLHIV, 53 service providers.
Recruitment - Purposive sampling;
PLHIV groups included adult HIV positive, receiving
services from existing care and support NGOs,
both male and female, both under ART and not
eligible for ART, and the ones that were willing to
participate. The PLHIV were selected by the NGOs.
Service provider groups included those who had
any experience in providing services to PLHIV. They
were selected by the investigators on the basis of
their availability and willingness to participate.
Data collection - Two FGD guidelines were
prepared and finalized through a consultative
workshop. Discussions were recorded on
audiotapes, transcribed verbatim and then
compared with the hand written notes.
Data analysis - All transcripts were thematically
analyzed and shared with the other investigators.
Ethics - Written consents were taken from all
participants. All FGD notes, audio tapes and
transcripts were kept in locked cabinet.
RESULTS
Acknowledgement
All participants of FGDs, Ashar Alo Society (AAS), Mukto Akash Bangladesh (MAB), Confidential
Approach for AIDS Prevention (CAAP), and HIV/AIDS and STD Alliance, Bangladesh (HASAB)
Arunthia Zaidi Urmi, ICDDR,B, Dhaka, Bangladesh.
Email: arunthia@icddrb.org, arunthia@gmail.com
The study was funded by Save the Children USA, the management agency for GFATM round six under
National AIDS/STD Program (NASP) and administered by ICDDR,B.
For further information
, little support from government facilities,
QUOTES FROM PLHIV PARTICIPANTS
The services for PLHIV have been very ad hoc.
Decentralization of health services for PLHIV and
expansion of services in rural areas is essential.
Provision of free ARVs and local production of
ARV should be taken into consideration.
Government should play a coordination role to
stop duplication of services by NGOs.
NGOs should consider employment of PLHIV and
look for alternative sources of income for PLHIV.
Competition among NGOs stems from need of
funds; strategic planning for need based support
should be done and seek funds accordingly.
Training on stigma and discrimination should be
provided to the staff of NGOs and service providers.
DISCUSSION
Limited
access to
health care
Barriers to
participate
in health
care
Gaps in
health care
Service
providers’
dissatisfaction
with the health
services
Stigma and
discrimination
Unemployment
Disclosure
of HIV
status
Satisfaction
regarding
available
health services
Access
through
referral
linkages is
limited to few
organizations
Transport costs
and hazards to
access health
services located
in main cities
Health care
services for
PLHIV are
extremely
limited and
centralized in
Dhaka
Insufficient
medicine
supplies
Unmotivated
and untrained
staff in health
facilities
Duplication of
services and lack
of coordination
among NGOs
leads to
competition
amongst
themselves for
PLHIV
limited funds and
interruption in the
funding for NGOs
result in inability
to provide regular
services to PLHIV
Unfriendly
attitude and
behavior of
some health
care staffs
Most PLHIV were
external migrants
and lost job after
diagnosis, they can
not afford major
expenses related to
health care
At least some
services are
available such
as VCT and
some ARV and
OIs medicine
Faced by service
providers:
difficulty in
renting space for
office, other
people’s
suspicion about
their HIV status
Faced by
PLHIV:
Derogatory
remarks,
anger,
gossip
Job transfer,
perceived
political
affiliation, not
enough
incentive and
recognition
Disclosure
has had some
negative
effects,
especially in
health care
settings
Gaps in health care:
“The NGOs do not have all the medicine that are needed for us, if doctor
prescribes four medicines, sometimes we have to buy three of them,
is it possible for us?”
Barriers to participate in health care:
“When there is a project there is support, when there is no project
there is no support. Do we become HIV negative then?”
“If we go to organization X, they say we are getting medicine from
organization Y, and if we go to Y they say we are getting from X. This
way we are deprived from every organization. …What should we do?”
“They [health care staffs] provide service but they don’t do it with love,
previously they used to care; now they don’t do it with affection. See, if
you give me medicine, but do not monitor whether I am taking it or
throwing it, all you care about is that you are supposed to give the
medicine and you have given this”.
Unemployment:
“We are only few and there are many NGOs working in the HIV field in
Bangladesh, if each NGO employs one HIV positive person, all of us
would have survived.”
Disclosure of HIV status:
“The NGO provided me (financial support for) a shop….and for the shop
they made a video recording, they had the AIDS bags (the bag had
statements about AIDS) with them; the community people were
suspicious because of that and said I must have AIDS otherwise why
should they are carrying AIDS bags and why are they recording me?”
Satisfaction regarding available health services:
“They [organizations] have picked us up from the streets and are
providing services. They are doing things for us that even our family
and relatives don’t do for us.”
“Counselling was very useful; it helped to reduce my mental pressure,
refreshed my mind, and provided me courage.”
 National AIDS/STD Programme (NASP) (2009). World AIDS day 2009 souvenir.
 Govt. Of Bangladesh(2008). UNGASS country progress report, Bangladesh. Reporting
period: 2006-2007. National AIDS/STD Programme, Ministry of Health and Family Welfare.
 Tabassum S, Hassan KM, Mamun KZ, Islam MN; IAS Conference on HIV Pathogenesis and
Treatment (2nd : 2003 : Paris, France). THE HIV/AIDS SCENARIO IN BANGLADESH: A LOW
PREVALENCE, HIGH-RISK COUNTRY. Antivir Ther. 2003; 8 (Suppl.1): abstract no. 1137.
Little
support
from
government
facilities
CONCLUSION
The barriers identified are at different levels – policy,
community and service providers. Better coordination
between different agencies may overcome some of
these barriers.