METHODS REFERENCES Major challenges in health care for people living with HIV in Bangladesh Arunthia Zaidi Urmi 1 , Irona Khandaker 2 , Chandra Nath Roy 2 , M. Shah Alam 1 , Samina Choudhury 3 , Fadia Sultana 3 , Habiba Akhter 4 , Tasnim Azim 1 1. International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh. 2. Tohoku University, Japan. 3. Save The Children USA, Dhaka, Bangladesh. 4. Ashar Alo Society (AAS), Dhaka, Bangladesh. 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.