Introduction

Human immunodeficiency virus (HIV) infection is still considered to be an alarming public health burden in low-and lower-middle income countries (LMIC). Indeed, it is ranked as the 17^th leading cause of death in South Asia [1, 2]. Despite the decreasing prevalence of HIV across the past decade, the associated disease burden is still alarming in some LMIC[1–3]. Bangladesh has witnessed a 10% increase in the incidence of HIV infections across the past decade[4]. This increase is especially prominent among one of the key populations (KPs) that is at risk for HIV infection. For example, the results from the last serological surveillance of 2016 that was conducted among people who inject drugs (PWID) in the city of Dhaka showed that 22% of the sampled male PWID and 5% of the sampled females who inject drugs(FWID) were HIV positive [5]. The HIV epidemic was particularly centered in one specific neighborhood in Dhaka city, where 27.3% of the sampled male PWID were HIV positive [5]. Therefore, there is a risk that HIV infection may transcend KPs and eventually be transmitted to the general population [6].

HIV prevention interventions that targeted KPs that are at risk for HIV, including female sex workers (FSW), men who have sex with men (MSM), transgender women (known as hijra in South Asia), and PWID, were introduced in the early 1990s. These interventions adopt a community-based and peer-led approach, whereby all the activities are operated through static service delivery points that are known as drop-in centers (DICs); prevention services are provided through these DICs [7–9]. This approach raises awareness about safer sex, condom and lubricant, and the perils of needle-syringe exchange (to PWID) through outreach activities that are offered during sex trades and at drug-taking and social gathering spots where KPs typically congregate during particular times. In addition, sexually transmitted infection (STI) management, counseling, HIV testing services (HTS), and recreational activities are provided through DICs, where all the services are provided free of cost [9–11]. The Joint United Nations Programme on HIV/AIDS (UNAIDS) considers the DIC-based approach to be the “best practice.” However, in the absence of support from donors, this approach utilizes limited resources to combat the epidemic [12–14]. Moreover, the DIC-based approach, which is funded by donors and operated by non-governmental organizations (NGOs), has emerged as structures that are parallel to national health systems, thereby leading to inefficiencies in many countries [15–17].

Sustainable service delivery through DICs is one of the major challenges in the national HIV response due to donor dependency. Hence, “sustainable strategies must be built into project design and implementation to enable HIV efforts to continue long after donor-supported projects are completed” [18]. To build resilient and sustainable health systems, several countries have opted for an integrated model to explore the possibility of safeguarding the national HIV response in the absence of donations. Some of these approaches include stigma-reducing initiatives for MSM in Kenya and the Avahan intervention in India, which has successfully transitioned into a phased program in government healthcare facilities [18–22].

Several factors, such as stigma, discrimination, and criminalization deter access to healthcare. Beyrer et al. (1999) claimed that “for people who sell sex (SW) or inject drugs (IDU) and for men who have sex with men (MSM), stigma, discrimination, and criminalization can limit access to care, inhibit service uptake, and reduce the disclosure of risks” [23]. Similarly, in Bangladesh, KPs are less willing to uptake healthcare facilities because the aforementioned factors have a more pronounced effect on them due to their identities or behaviors, which are prohibited by the law. For example, same-sex sexual behaviors and illicit drug use are criminalized by the Bangladesh Penal Code (Section 377) and the Narcotics Control Act (1990), respectively. In addition, several laws in Bangladesh criminalize sex work (e.g., Human Trafficking (Deterrence and Suppression) Act 2012; Section 373, Penal Code, 1860)[24, 25]. Several studies that have been conducted in Bangladesh have shown that public healthcare facilities are not ready to serve the needs of KPs in culturally sensitive ways [26–28]. These studies have underscored the following barriers that deter KPs from uptaking healthcare services: fear of HIV infection among physicians who work at public healthcare facilities, limited access to healthcare services among hijra, and the reluctance of KPs to disclose their sexual behaviors to physicians. Specifically, Ullah et al. (2011) found that physicians’ anticipatory fear of being infected with HIV fueled their discriminatory behaviors toward HIV-positive patients, thereby making the latter group unwilling to publicly seek treatment [26]. Moreover, Khan et al. (2009) noted that hijra in Bangladesh do not have access to healthcare facilities due to their stigmatized identities: “If hijra suffered from anal STIs, they could not disclose it to doctors. Not only for STIs, because of holding stigmatized hijra identity, they had no access to health facilities. They reported hiding their identity while visiting doctors whether in government or private sectors” [28]. Alam (2015) has also observed that stigma and discrimination hinder MSM’s access to public healthcare services in Bangladesh [27]. Moreover, Frances and Aboud (2010) also corroborated the implications of conservative religious and cultural norms with regard to the willingness of community gatekeepers to participate in HIV prevention interventions [29]. These findings underscore the role that several sociocultural and legal factors play in hindering KPs’ access to STI services that are provided by public healthcare facilities.

Although a shift from the DIC-based approach is essential to ensure sustainable STI service delivery, it is equally important to understand the willingness of the KPs to uptake the services that are provided by public healthcare facilities. However, little is known about the willingness of the KPs to uptake these services, thereby resulting in a knowledge gap. In Bangladesh, no formal research study has been conducted till date to explore the willingness of the KP communities to uptake the STI services that are provided by public healthcare facilities [29].

This study aimed to understand and explore the willingness of KPs to uptake the STI services that are provided by public healthcare facilities. Thus, the following research question was proposed: are KP communities willing to uptake the STI services that are provided by public healthcare facilities?

Theoretical framework

Materials and methods

Data collection and analysis

We conducted 34 in-depth interviews (IDIs) with KPs (Table 1). The participants for the IDIs and focus group discussions (FGDs) were purposively sampled in accordance with the maximum variation sampling procedure in order to facilitate the exploration of the diverse issues that are related to the study objectives (e.g., KPs that receive and do not receive HIV prevention interventions). In addition, we conducted 9 key informant interviews (KIIs) and 11 FGDs with KPs, community leaders, and the leaders of community-based organizations (CBOs). For the KIIs, we used the purposeful sampling strategy that entailed a combination of intensity sampling and critical case sampling. The research participants were selected with the assistance of peer educators (PEs) of DICs and research guides who belonged to the KP communities. PEs are individuals from KP communities who conduct behavior change communication sessions to share STI prevention messages with KP communities, provide them with condoms and lubricants or needle/syringes (for PWID), and refer them to DICs to receive STI services. On the other hand, research guides are community representatives who either visit DICs or are acquainted with PEs and have access to KP communities. We conducted the interviews in locations that were convenient to the research participants (e.g., DICs, homes of the KP community members, spots where the KP communities congregated).

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Table 1. Socio-demographic status of the 34 KPs participating in the in-depth interviews.

https://doi.org/10.1371/journal.pone.0221637.t001

Data were collected using semi-structured guidelines that have been developed based on the findings of studies that were conducted among these communities and existing community willingness models [29, 49, 50]. The semi-structured guidelines included questions such as the following: “Did you visit a public healthcare facility for the treatment of STI? What was the reason for visiting the public healthcare facility? What was your experience there? What challenges did you face while visiting those facilities? Why do you think you had faced those challenges? Was there any positive experience in those public health facilities? What were those? Based on your experience, how your positive experiences can be utilized to receive STI services from public healthcare facilities? What is your opinion about the feasibility of STI services provided from public healthcare facilities for KPs?”

The sample inclusion criteria were as follows: (1) KP community members (e.g., MSM, hijra, PWID, FSW) who are18 years of age or older and (2) those who provided informed written or verbal consent for participation in the study. Participants who were unwilling to provide written consent provided verbal informed consent, which was recorded using a digital recorder. The study did not include any minors (i.e., < 18 years of age). Participation in this study was entirely on a voluntary basis, and a consent form that was approved by the Research Review Committee and Ethical Review Committee of International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) was read to the research participants before conducting the interviews or FGDs.

Digital recorders were used to record the interviews and FGDs. However, in some cases, the informants were uncomfortable about being recorded; in such cases, we made handwritten notes. The hand notes were elucidated at the earliest possible time, particularly before conducting the next interview. During FGD sessions, in addition to digital recordings of the proceedings, one of the team members was assigned to prepare handwritten notes. After each IDI, KII, and FGD, the transcripts were prepared by listening to the recordings line-by-line and incorporating field notes when necessary.

The trained members of the research team (including the research guides) conducted repeated observations at the public healthcare facilities. They sought to observe events such as the presence of KPs at the public healthcare facilities, behaviors of the hospital staff toward KPs, interactions between KPs and those who are involved in service delivery, and the reaction of the other patients in the presence of KPs. In order to observe these phenomena carefully and systematically, we developed and utilized semi-structured guidelines for observations. Similar semi-structured guidelines were used for interviews and FGDs. The semi-structured guidelines ensured that the researchers observed events consistently without limiting the events that were under observation. The team observed events with an open mind to accommodate issues that were perceived to be pertinent to the research objectives. The observation was an ongoing process, and it was conducted alongside other qualitative data collection methods. The research team members who were involved in observation prepared detailed write-ups based on their detailed observational notes on a regular basis and shared these notes with the other team members. The observational notes included objective-specific descriptions and subjective interpretations of their observations.

We undertook data collection and analysis concurrently because they are not only an ongoing and reflexive processes but they also facilitate the identification of data saturation [51, 52]. The data were thematically and contextually analyzed using a line-by-line manual data analysis procedure. The data were coded into themes and subthemes. We developed a structural coding method by designing a joint or collaborative coding framework in lieu of the solo coding framework [53]. During primary analysis, we identified emerging themes and subthemes, and further analyzed their contexts and meanings. We also identified gaps in the data and issues that had not been previously covered. Atypical data were not overlooked. Instead, they were further explored, analyzed, and presented as findings. As has been suggested by many qualitative researchers, the researchers of the present study the maintained field diaries to document detailed field-level observations and interpretative findings, which were analyzed in a manner that was similar to what was followed for interview transcripts [54–57]. The research team interpreted and exchanged findings during peer-debriefing meetings. This nurtured inter-subjective interpretations and facilitated the modification of data collection tools [51]. A range of strategies was utilized to ensure scientific rigor (i.e., validity and reliability), primarily by means of triangulation (i.e., relying on more than one data source, method, investigator, and analytic approach)[58].

We used the “Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist” to report the findings (S1 Table) [59]. In addition, we did not attempt to generalize the findings to a wider population. Instead, we obtained a systematic and in-depth understanding of the research question. Since the existence of multiple realities lie at the core of qualitative research, we investigated these realities by searching for disconfirming evidences. We only incorporated findings when they “survived serious attempts to falsify it” [58, 60]. We have strengthened the validity and reliability of the findings and minimized internal bias by providing “thick descriptions” (i.e., explicit and detailed descriptions) of the research process and findings [58, 61].

This study was approved by the Research Review and Ethical Review Committees of icddr,b.

Results

Based on the thematic and contextual analysis of the findings, three types of “willingness” emerged during ongoing data analysis: (1) complete willingness, (2) reluctance or moderate willingness, and (3) resistance or complete unwillingness. These three types of willingness are illustrated in the diagram that is presented in Fig 1.

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Fig 1. SEM framework on community willingness.

https://doi.org/10.1371/journal.pone.0221637.g001

Lack of privacy

To receive necessary treatment, KPs must disclose their histories. However, to circumvent situations in which fellow patients may scrutinize or mock their behaviors, they prefer to access a more secluded environment where their privacy is more likely to be maintained. Several KPs unfavorably compared the degree of privacy in public healthcare facilities to their respective DICs. They opined that they preferred the latter because they could easily disclose their details to the HCP within a closed-door setting. On the other hand, in public healthcare facilities, the doors were observed to be constantly open, and the patient queues overflowed to such an extent that other patients could hear the conversations that were exchanged between the physician and patient. One of hijra who participated in this study described her experience in the following manner:

For me, it is not possible to express my sexual problems in front of several people. Since the door is open, other patients can hear my private information. Often, people I know stand there. On the other hand, we do not face such problem in DIC as the doctor (referring to the Medical Assistant) provides services in a closed-door room, where we can express everything. I cannot imagine such services in the government hospital.

(Hijra, 32 years old, IDI, Chapai Nawabganj)

Since multiple physicians occupy a room and concurrently interact with other patients, it is difficult for patients to freely divulge personal information. KPs fear that other patients may mock them or spread rumors about them to other people in the area. Therefore, they lie about their condition to physicians. When compared to the other KP communities, this sentiment is more amplified among MSWs because of their perceived fear of being reported to law enforcement agencies. In this regard, one of the MSWs from Chapai Nawabganj made the following observation:

When I entered the doctor’s room, I found several people besides the doctor, such as medical representatives, intern medical assistants, etc. Often, the patient queue overflows to the doctor’s room as the door is always open. Disclosing private matters in front of several people is difficult. I finally went in to get my anal problem treated. But I could not express my problem clearly because I was feeling embarrassed and due to shyness. Therefore, I said that I had back pain. At DIC, it is not a problem to share anything as the door of the doctor’s room always remains closed while treating patients.

(MSW, 35 years old, IDI, Chapai Nawabganj)

Discussion

Most KPs were either “reluctant” or “resistant” to seek STI services that were provided by public healthcare facilities. None of the KPs were avidly willing to uptake STI services that were provided by public healthcare facilities. In all the three districts, some MSM, FSWs, and hijra felt uncomfortable about disclosing their sexual practices and professions to their physicians due to fear of identity disclosure, anticipated stigma, and adverse legal consequences. Similarly, previous studies that have been conducted by Khan et al. (2009) and Chakrapani et al. (2011) have examined kothi’s qualms about being reported to the authorities as well as demeaning behaviors such as a lack of privacy and refusal of treatment that some kothi have been subjected to [28, 62]. Khan et al. (2009) also reported that hijra were hesitant to disclose their health issues and encountered “abusive behaviors” in healthcare settings [28]. A few other studies have also reported that MSM and transgender women face similar struggles when they avail STI and HIV-testing services, which render them resistant to the uptake of HIV-testing services [63–66]. MSM and MSWs, particularly kothi, fear being reported to the legal authorities due to the criminalization of same-sex sexual behaviors in Bangladesh. However, our study findings reveal that hijra also face this problem not only due to their sexual behaviors but also due to the lack of understanding about their gender identities on the part of HCPs and other HRH.

Similarly, FSWs reported that they were abused in many ways and that they were given unsolicited advice and shamed for their professional choices and practices. Similarly, Wahed et al.’s (2017) study also noted that unfriendly behavior on the part of HCPs is a barrier that precludes FSWs from availing sexual health services [67]. Similarly, a Nepal-based study also identified a lack of privacy, judgmental attitudes of service providers, and discrimination as deterrents that impede the utilization of sexual health services among FSWs [68]. However, our study also evinced that FSWs faced sexual harassment in public healthcare facilities; this finding is a novel contribution to the existing literature.

A few SFSW were willing and are at complete willingness state to visit healthcare facilities. The findings of our study can be contrasted against the findings of a few other studies that have been conducted in other countries, where all categories of FSWs reported that their primary concerns about visiting public healthcare facilities were attributable to the lack of privacy and fear of being identified as sex workers [10, 62, 63]. Nonetheless, this finding is similar to Logie et al.’s (2010) observations that highlighted structural issues such as privacy being a major concern among MSM and transgender women in Jamaica [65]. However, our study findings suggest that the fear of being identified as a sex worker is more prominent among SFSWs than other FSWs. Indeed, due to their “unusual attire and unpolished appearance and mannerisms,” it is easier for HCPs and other HRH to identify them as sex workers. On the other hand, residence-based female sex workers (RFSW) in Bangladesh were found to typically embody a more “refined outward appearance.” Therefore, they may be able to easily blend in with other female patients. Nevertheless, FSWs who belong to both these categories were anxious about attending public healthcare facilities. They also dreaded the possibility that someone else might find out about their profession (i.e., sex workers) and consequently treat them in an unpleasant manner.

PWID generally had low self-esteem because they were denied STI services at public healthcare facilities, called derogatory names, and/or antagonized for their shabby physical appearance. This propagated a vicious cycle that resulted in a refusal to seek treatment. Their low self-esteem, perceived discrimination, and the fear of being antagonized by HCPs have also been documented in previous studies that were conducted in developing and developed countries [69–72]. Specifically, perceived discrimination hinders KPs’ unwillingness to seek STI services from public healthcare facilities. A few other previous studies have also indicated a potential link between perceived discrimination and poor health outcomes [73–77].

In this article, applying the SEM framework, we attempted to explore the willingness of the KPs to visit public healthcare facilities and the underlying reasons for different categories of willingness. Within the framework of SEM, our findings highlight the unwillingness of the individual KPs to seek STI treatment from public healthcare facilities, and their difficult interactions with a stigmatizing, discriminatory and incompetent healthcare system. Structural factors, such as the all-encompassing stigma and discrimination the KPs face in healthcare settings (e.g., primary, secondary and tertiary levels) also hamper their willingness to visit the public healthcare facilities. Punitive laws against same-sex relationships and sex work, as well a lack of institutional guidelines on which queue hijra can choose to stand in the outpatient department contribute to KP’s decision on not wanting to come back again.

In essence, our observations resonate with past findings in that KPs in Bangladesh exhibit a general lack of willingness to visit public healthcare facilities in order to avail STI services. However, none of the studies that have been conducted in LMICs have reported that KP communities undergo pleasant and hassle-free experiences when they visit hospitals. Nevertheless, our findings suggest that not all of their experiences at public healthcare facilities negatively impact their willingness to uptake STI services. Hence, efforts to enhance the willingness of KPs to avail STI services at public healthcare facilities must aim to both enhance the positive aspects and mitigate the negative aspects of their encounters with HCPs and other HRH.

Conclusion

In this article, we used the SEM theoretical framework, which entails individual behaviors as well as structural factors (e.g., experiences of KPs when they visit public healthcare facilities, hidden nature of KPs, stigma) to contend that KPs’ willingness to uptake STI services that are provided by public healthcare facilities does not depend solely on individual or community experiences. Instead, it is linked to a nexus between sociostructural factors and health inequalities. KPs’ willingness to uptake STI services predominantly can be conceptualized as a continuum that ranges from “resistant” to “completely willing” (Fig 2). Resistance toward the uptake of STI services that are provided by public healthcare facilities was mainly exemplified by a substantial proportion of the participants who were completely unwilling to visit public healthcare facilities due to their firsthand adverse experiences with the unsympathetic and often antagonistic healthcare providers. On the other hand, very few participants appeared to be situated at the “completely unwilling” end of the spectrum based on their positive firsthand experiences and anecdotal reports from peers. However, since this is a continuum, some participants belonged to neither extreme. Nevertheless, they were considered to be “resistant” because they were hesitant to uptake services unless certain conditions were fulfilled.

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Fig 2. Continuum of community willingness.

https://doi.org/10.1371/journal.pone.0221637.g002

The entire spectrum of community willingness primarily relies on the preparedness of the public healthcare system to administer STI treatments. It is also important to note that this spectrum is dynamic. This indicates that KPs can vacillate between feeling “resistant” and “completely unwilling” depending on their own and peers’ experiences. For instance, it is possible for “reluctant” participants to gradually start feeling “completely unwilling” or “resistant” depending on the nature of the experiences that they are subjected to when they revisit public healthcare facilities.

All the KPs expressed a willingness to revisit public healthcare facilities if (a) the HCPs and other HRH are sensitized about the culture and practices of KP communities, (b) efforts are made to protect their privacy, and (c) changes in discriminatory behavior and stigmatizing attitudes toward KPs are ensured. In order to achieve this, training programs must be conducted at public healthcare facilities, and the health system as a whole must be strengthened. Policy and practice-related changes that aim to enhance confidentiality and reduce discrimination in public healthcare facilities are also vital. The findings also underscore the need for interventions that address sexual identity-related stigma in public healthcare settings in order to augment KPs’ willingness to visit these facilities. The findings also revealed that KPs are unlikely to seek STI services that are provided by public healthcare facilities if structural factors (e.g., stigmatizing, discriminatory, and the incompetent healthcare system; punitive laws against same-sex sexual behaviors and sex work) and all-encompassing stigma remain unaddressed.

Additionally, community mobilization must be promoted by empowering and involving influential members of the KP community (e.g., CBO leaders, hijra guru). As posited by Thurman et al. (2000), “Communities are always changing, adapting [and] growing. They are ready for different things at different times” [44]. Hence, depending on the changes that occur in the KP community, the public healthcare system must be resilient and prepared to evolve in order to address the emerging needs of KPs by adopting a public-private partnership approach.

Supporting information

Acknowledgments

This research protocol was funded by The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund). icddr,b acknowledges with gratitude the commitment of The Global Fund to its research efforts. icddr,b is also grateful to the Governments of Bangladesh, Canada, Sweden and the UK for providing core/unrestricted support.