Understanding the Barriers of HIV Testing Services for Men Who Have Sex With Men and Transgender Women in Bangladesh: A Qualitative Study

Abstract

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.

Keywords

MSM transgender women HIV testing services Bangladesh

Introduction

Although global estimates have depicted overall downward trends in new HIV infections over the last decade,¹ infections are emerging among specific key populations at risk of HIV (KPs) in several countries worldwide. According to recent UNAIDS estimates, men who have sex with men (MSM) and transgender people represented 23% and 2% of the new HIV infections worldwide, respectively.¹ In addition, MSM and transgender women were 27 and 49 times more likely to acquire HIV than their counterparts in the general populations, respectively.² In Asia and the Pacific, specifically, MSM account for 44% of HIV infections as of 2019 and transgender people carried 7% of the regional burden.¹ Moreover, special studies evinced high HIV prevalence among these populations in many countries, such as Indonesia, Malaysia, China, and Thailand.^3–6

Sustainable Development Goal (SDG) 3.3 strives for the elimination of HIV, AIDS, and other neglected tropical diseases by 2030.⁷ The global UNAIDS 90-90-90 target is a crucial vehicle to facilitate the achievement of this target. This specific goal called for 90% of people living with HIV to know their HIV status, 90% of these people to receive antiretroviral therapy and 90% of antiretroviral therapy recipients to become virally suppressed.⁸ To fulfill this goal, the uptake of HIV testing services (HTS) needed to be prioritized because of the role it plays as a critical entry point in HIV care, support, and treatment. Early HIV testing and instantaneous linkages to care, support, and treatment are crucial for preventing HIV infection and increasing life longevity.⁹ Conversely, late or no testing could continue to aggravate the HIV epidemic.¹⁰

In Asia and the Pacific, 75% of the total number of estimated people living with HIV know their HIV status, 80% of them are receiving antiretroviral therapy and 55% of them are virally suppressed, as of 2019,¹ therefore, they are seemingly going to miss the UNAIDS target. Some countries, such as Singapore, Nepal, and Cambodia showed exemplary performances by achieving up to 80% HTS coverage. Whereas, some other countries will most likely miss the targets by the end of the year, including Afghanistan, Pakistan, and Bangladesh, which showed that less than half of the KPs knew their HIV status.¹ Specifically, as of 2019, in Bangladesh, case detection rate was 52.7%, antiretroviral therapy coverage was 65.4% and viral suppression rate was 84.6% among recipients of viral load testing.¹¹

Bangladesh faces a disproportionate HIV burden among KPs, including MSM and transgender women (locally known as hijra).¹² Despite an overall low HIV prevalence in Bangladesh, KPs constitute over half of the newly infected cases in 2019, where MSM and hijra cumulatively account for 4% of the new cases.¹¹

In Bangladesh, there is an estimated total of 131,472 MSM and 10,199 transgender women, of whom 21.2% and 40.6%, respectively, are covered by HIV prevention interventions supported by the Global Fund and implemented by two non-government organizations (NGOs), i.e., Bandhu Social Welfare Society and Light House through the management of International Centre for Diarrhoeal Disease Research, Bangladesh since 2009.¹³ These HIV prevention interventions also provide both provider and client-initiated HTS for MSM and hijra through facility-based and community-based testing services through 53 service delivery centers known as Drop-in centers in 36 districts in Bangladesh, of which eight centers are based in Dhaka. Within these facilities, outreach staff (hereinafter referred to as peer educators) reach out to an assigned list of MSM and hijra at the cruising sites and motivate them to uptake HTS and other services through behavior change communication sessions. MSM and hijra either come to the facility for HTS on their own accord or through referral by the peer educators. The trained medical assistant, who has paraprofessional training, is responsible for administering HTS following the WHO-recommended standard procedures (i.e., pre-test information, consent, HIV testing and post-test counseling) while maintaining privacy and confidentiality. As per the national HIV testing algorithm of Bangladesh, the WHO-recommended HIV rapid testing approach¹³ is followed, where whole blood is collected by pricking the finger and three rapid tests are performed. In addition, community-based HTS is available at convenient community settings (i.e., residences of hijra guru or influential MSM). If the clients are tested HIV positive, they are immediately linked with the antiretroviral therapy centers through accompanied referral.

In addition, five government hospitals started providing anti-retroviral therapy for HIV positive people since October 2017. Alongside anti-retroviral therapy, these antiretroviral therapy centers launched HTS for all population groups (i.e. general populations and KPs together). As of 2020, there are 28 antiretroviral therapy and HTS centers in public hospitals in 23 districts of Bangladesh. HIV positive MSM and hijra are being referred for antiretroviral therapy by the peer navigators working at the NGOs. Historically, HIV prevention services are being provided by the NGOs/Community-based Organizations (CBOs) to all categories of KPs including MSM and hijra. As part of these services, HTS are also being provided by the NGOs and the MSM and hijra community feel comfortable seeking services from the NGO operated Drop-in Centers as their first line of care.¹⁴

Despite Bangladesh’s early response to the HIV epidemic, HTS uptake remains low. Overall, at the end of 2018, it was found that 39% of MSM and hijra knew their HIV status which is well below the UNAIDS target.² Considering that Bangladesh and some other countries in Asia and the Pacific will most likely not achieve the UNAIDS target by the end of the year, attention needs to be devoted to improving the coverage and uptake of HTS in these countries. To optimize the HTS component of the UNAIDS target, it is vital to undertake certain research initiatives to pinpoint the barriers of HTS uptake.

A growing body of literature explored the underlying challenges of HTS uptake such as anticipatory fear of stigmatization and discrimination, low risk perception, negative experiences with healthcare providers, and the dread associated with finding out their HIV positive status.^15–17 However, there remains scant information about the programmatic design and implementation weaknesses of the HTS modality, as well as social and cultural conventions which may hinder the uptake of HTS. In addition, there remains a paucity of detailed and multifaceted analyses about the circumstances and underlying contexts influencing the uptake of HTS, particularly using theoretical constructs. However, such a targeted theoretical analysis is essential for pinpointing the areas that need to be addressed in order to redesign the HTS modality accordingly to achieve the relevant global goal. Consequently, this would help address the unique complexities of these highly marginalized and vulnerable populations.

Such a focused research initiative of this nature is warranted to bridge the gap in achieving the UNAIDS and SDG targets, particularly among MSM and transgender women. As we are approaching the end of 2020, the critical endpoint of the target, the barriers of HTS need to be appraised so that we gain a deeper understanding of why the 90-90-90 targets were missed in Bangladesh and several other countries with similar socio-epidemiological contexts. In addition, findings of such a research initiative could potentially lay the foundation for facilitating the achievement of the relevant SDG target, so that HIV and AIDS can be eliminated by 2030. MSM and transgender women in many countries are part of an environment interlaced with overarching structural issues in several cultural contexts; therefore, they are exposed to various vulnerabilities in terms of HIV and AIDS. In Bangladesh, in particular, prohibitory laws and cultural conventions have posed challenges for MSM and hijra. Specifically, according to the Bangladesh Penal Code 377,¹⁸ any act of male-to-male sex is prohibited and criminalized by law. Moreover, although hijra have been legally recognized as a third gender,¹⁹ literature in Bangladesh showed that they were still subjected to discrimination and humiliating situations because of their inability to conform to heteronormative and cis-gender ideals.^20,21According to our knowledge, there is no such study that has conducted such an investigation of the barriers of HTS uptake in Bangladesh. A focused research initiative, which aligns with the visions of the aforementioned targets, about the underlying contexts hampering HTS uptake could generate insights which could be applied to diverse contexts, especially in settings where HTS uptake and coverage are low. This article aimed to address the following research questions: 1) What are the individual, interpersonal, programmatic, community, and structural barriers of HTS uptake among MSM and hijra? 2) How are these barriers affecting the fulfillment of the 90-90-90 target? In this context, this article aimed to understand the barriers of HTS uptake among MSM and hijra in Bangladesh.

The Social Ecological Model for Analyzing the Multifaceted Barriers of HIV Testing

The social ecological model is a theoretical construct that analyzes personal and socio-structural factors which drive individuals’ behaviors. This model has been applied in a wide range of HIV-related literature to examine how a nexus of factors influence individuals’ health-related behaviors, such as seeking healthcare from public hospitals, participating in vaccine trials, etc.^20,22 Yet, according to the authors’ knowledge, there remains a paucity of literature that applied this model to critically analyze the circumstances constructing HIV testing uptake behaviors. Because of its ability to explain the “complex associations between social and structural factors, individual practices, the physical environment, and health,” ²³ this framework would serve as an integral tool for contextualizing the MSM and hijra’s HTS uptake behaviors in relation to the abovementioned factors. As reflected by previous literature in Bangladesh and the South Asian region, MSM and hijra are exposed to a unique set of adversities and complexities such as gender-based discrimination and stigmatization, homophobia, and criminalization of male-to-male sex.^21,24,25 Other literature also suggested that these barriers affect their scope to uptake HTS and government as well as UN bodies have called for the prioritization of ensuring maximum testing coverage, particularly for KPs. Therefore, such a theoretical analysis could help foster a contextualized understanding of the multilayered barriers of HTS uptake.

Methods

Study Design

An exploratory qualitative study was conducted to explore the multilayered barriers influencing HTS uptake among MSM and hijra in Bangladesh, applying the social ecological model. To be eligible to participate in the study, the participants needed to be aged between 18-60 years old, provide their verbal consent to participate, and the MSM and hijra needed to have been enrolled in the HIV prevention interventions (detailed in subsequent sections). Exclusion criteria included MSM and hijra who did not belong to the specified age group and those who were not enrolled in the HIV prevention intervention operated by NGOs.

This qualitative study consisted of 30 in-depth interviews with a diverse group of MSM and hijra. To supplement and triangulate in-depth interview data, six focus groups were also conducted, including two with MSM (including male sex workers), two with hijra and two with service providers of the Drop-in Centers. Each focus group was homogenous and consisted of six to nine members. In addition, we conducted seven key-informant interviews with CBO leaders, hijra gurus (leaders of hijra communities), and experienced program managers of NGOs with long-term involvement in HIV interventions.

The elements of the social ecological model were used to guide the development of the interview and focus group guides. In this context, the semi-structured, open-ended guides covered issues such as socio-demographic characteristics, individual, interpersonal, programmatic, community and structural challenges of HIV testing service uptake, lived experiences of HTS and recommendations to improve the HTS approach. It is worth noting that separate guides were used for in-depth interviews, focus groups and key-informant interviews.

Study Population and Sample

The target population consisted of 2582 MSM (including male sex workers) and 466 hijra who were enrolled in four static service delivery points known as Drop-in Centers in Dhaka, Bangladesh which were operated by an implementing partner (i.e. Bandhu Social Welfare Society) of the Global Fund Project. The Drop-in Centers are often the first line of care for MSM and hijra and comprise of services such as: management of sexually transmitted infections, antiretroviral therapy for HIV positive patients, general health services, counseling, group education sessions, referrals/linkages to the nearest hospitals for complicated health conditions, and rest and recreational facilities. Moreover, outreach services are also available for the MSM and hijra which include the distribution of condoms, lubricants, behavior change communication materials, etc.²⁶

Specifically, the study participants included panthi MSM, kothi MSM and hijra. According to the literature, kothi MSM are men who self-identify as part of a socio-sexual community with collective norms. During community gatherings and quests to entice transactional sex clients, they wear feminine dresses and apply makeup.^24,27 On the other hand, panthi self-identify as men but pursue relationships with kothi. Hijra are transgender women who do not conform to male or female gender roles although they encompass characteristics of either or both gender.^21,24

This study employed a specific type of purposive sampling technique, known as maximum variation sampling. Through this sampling approach, the researchers aimed to recruit study samples that were diverse in terms of age, sexual orientation, gender, marital status, occupation, etc. In addition, the researchers expected that this approach would help to identify the commonalities and differences across a variety of socio-demographic characteristics.²⁸ To recruit the participants, the researchers initially sought assistance from the service providers of the Drop-in Center and hijra gurus, since both groups were well-networked with the MSM and hijra communities. Before conducting the study, the researchers set the sample size to approximately 25 for in-depth interviews and 30 for all focus groups combined, along with five for key-informant interviews, based on their objective to allocate 2-3 participants per socio-demographic category as per the conventions of maximum variation sampling. Since the research team has extensively worked with these populations, the intended sample size was also estimated based on their previous research projects with MSM and hijra. The actual sample size was 77 (i.e. 30 in-depth interviews, 40 for all focus groups and seven for the key-informant interviews), which was determined based on the data gaps that emerged from the field, as well as points of data saturation.

Study Settings

Participants were given the freedom to choose interview venues and they mostly chose DIC premises, secluded areas in parks and other places that they perceived safe and conducive to confidential conversations. These settings helped facilitate expression of sentiments on sensitive issues, thus enhancing the authenticity of the data. Each in-depth interview lasted approximately 60-90 minutes, the focus groups spanned around 60-75 minutes, on average, and the key-informant interviews occurred approximately 40-60 minutes. The interview time durations were variable based on the nature of the discussion. Data collection period lasted for approximately three months, until points of redundancy and data saturation were reached. Although there were no provisions for financial incentives, travel allowances and light refreshments were provided to each study participant.

Data Collection

This research was approved by the Ethical Review Committee from the Institutional Review Board of International Centre for Diarrhoeal Diseases Research, Bangladesh. The research team encompassed sociologists, anthropologists, physicians and public health experts who were well-acquainted with qualitative data collection techniques, as well as issues relating to HIV and AIDS. They were also sensitized to work with MSM, hijra and other KPs after working with them for over a decade. Nevertheless, after the research team members were recruited, the first author and senior members of the team conducted a two-week long training about qualitative interview techniques, HIV testing modalities, the HIV and AIDS situation in Bangladesh, and the complexities of MSM and hijra.

The first, second, third, and senior authors, along with the trained non-author research team members, conducted with interviews and focus groups. Before conducting the interview, they received verbal consents from the study participants after they explained the study objectives, benefits and risks to them. Each participant was ensured that the contents of their conversation would remain confidential, their identifying information would not be disclosed and their interview data will be securely stored. Non-verbal communications, expressions, and interactions in focus groups were also documented in field notes alongside interview data. Each interview and focus group was audio-recorded using a digital tape recorder and transcribed line-by-line by a trained researcher, on the same day of the interview. All of the interviews were conducted in standard Bengali and data were not translated during any stage of the study as all research team members and authors were proficient in Bengali.

Data Analysis

The data collection and analysis processes were ongoing simultaneously. After each interviewing day, the author and non-author researchers convened in peer debriefing sessions, where they exchanged their interpretations of the findings and concerns about the emerging field situation, where appropriate. Furthermore, the research team incorporated essential issues into the interview guidelines that were not considered beforehand but were considered important. Amidst these sessions, researchers identified themes that emerged from the interview transcripts and field notes. They applied collaborative coding techniques to identify key themes and sub-themes, and their contexts and meanings. In this approach, the first author, senior author and three other authors coded and exchanged multiple interpretations and analyses of the phenomena being studied, while applying the social ecological model.^29,30 A codebook was used for the data analysis process. The codebook was developed in line with the social ecological model and consisted of the individual, interpersonal, programmatic, community, and structural barriers of the uptake of HTS. Additional efforts were also invested to explore, analyze, and present atypical data as findings.

As recommended by qualitative experts, decision trails were maintained in order to ascertain consistency and accuracy in the implementation of the codes.^29,31 Inter-coder reliability was also assessed by quantifying the number of coder agreements in proportion to the total number of coder interactions.²⁹ In instances where inter-coder disagreements could not be resolved, the coders consulted the Principal Investigator where the consensus was eventually reached. Incongruity within and between key themes and sub-themes were alleviated through peer debriefing meetings, which nurtured inter-subjective interpretations and the modification of data collection tools.³²To ascertain scientific rigor i.e., credibility, transferability, dependability, and conformability,³³ various techniques were applied. For example, we applied various data collection techniques, deployed multiple researchers, relied on several data sources of data, and used different analytical lenses and approaches to triangulate the data. Furthermore, to verify and check the correctness of the data and interpretative findings from the emic perspectives of the study participants, they were invited to the researchers’ office where the researchers internally disseminated their findings to them and asked for feedback. Participants’ feedback was incorporated after a thorough discussion.

Results

In this study, the underlying barriers to HTS uptake among MSM and hijra were explored and analyzed in relation to the social ecological model (as depicted in the black, grey and white colors in Figure 1). The model implicates that these barriers were rooted not only within the participants’ individual and interpersonal challenges but also within the gaps of the HTS modality in the HIV intervention program in which they were enrolled. These findings also showed that many of their HTS uptake challenges are attributed to the structural issues embedded within their local contexts. As per the characteristics of the social ecological model, these barriers have not necessarily impacted HTS uptake in isolation, rather they were intertwined and aggregately influenced the uptake of HTS.

Figure 1.

The Barriers of HTS Uptake as Depicted by the Social Ecological Model.

Socio-Demographic Characteristics of the Participants

The in-depth interview, focus group and key-informant interview participants (N=77) emerged from a variety of socio-demographic backgrounds (Table 1). In-depth interviews were conducted on 14 kothi, 9 panthi and 7 hijra. Almost half of the participants were on the younger side, where 46.6% of them were aged between 18-25 years old. The majority (80%) were unmarried, whereas five participants were married and one was divorced. The majority of the participants were either illiterate or educated up to the primary level (collectively 56.7% of the participants). In terms of the focus groups, 30% of the participants were non-community member men, whereas 27.5% and 12.5% of them were kothi and panthi MSM, respectively. 32.5% of the focus group participants were hijra. The majority (62.5%) of the participants are unmarried. In terms of occupational status, MSM and hijra in-depth interview and focus group participants primarily partook in service jobs, sex work, and traditional hijra work (badhai). On the other hand, most of the key-informants were service providers by occupation. Most of the key-informants were non-community males, although there were also some MSM, transgender and female key-informants.

Table 1.

Socio-Demographic Features of the Participants.

Characteristics	In-depth interview n = 30 (%)	Focus group discussion n = 40 (%)	Key informant interview n = 7 (%)
Age group
18–25	14 (46.6)	15 (37.5)	0
26–35	10 (33.4)	18 (45)	2 (28.6)
36–60	6 (20)	7 (17.5)	5 (71.4)
Gender
Male (Non-Community)		12 (30)	3 (42.8)
MSW(Kothi)	14(46.6)	11(27.5)	1(14.3)
MSM(Panthi)	7 (23.3	5 (12.5)	0
Transgender women	9 (30)	13 (32.5)	2 (28.6)
Female	0	0	1(14.3)
Marital status
Married	5(16.7)	15 (37.5)	6 (85.7)
Unmarried	24(80)	25 (62.5)	1(14.3)
Divorced	1 (3.3)		0
Years of schooling
No schooling	5(16.7)	3 (7.5)	0
1–5	12(40)	15 (37.5)	0
6–10	8(26.6)	12 (30	3 (42.8)
11–15	4(13.3)	10 (25)	4 (57.2)
Occupation
Unemployed	2(6.7)	3 (7.5)	0
Service	5(16.7)	16 (40)	6 (85.7)
Small business	2(6.7)	4 (10)	0
Student	3 (10)	2 (5)	0
Sex worker	11(36.7)	10 (25)	0
Traditional hijra work (Badhai)	4 (13.3)	5 (12)	1(14.3)

Individual and Interpersonal Barriers Influencing Uptake of HTS

The MSM and hijra faced some intrapersonal and interpersonal challenges which hindered their uptake of HTS. It is also worth mentioning, however, that these barriers are not isolated entities and can be influenced by macro-level barriers, particularly at the programmatic and structural layers. In Figure 1, this layer is depicted in white.

Low Perceived Risk of HIV Leading to Low Perceived Importance of HTS

Participants, specifically male sex workers and hijra participants, alluded to having a low perceived risk of HIV, adamantly asserting that they would not be HIV-positive since they have had practiced unprotected sex with multiple partners both in transactional and non-transactional sexual encounter without experiencing negative health ramifications. Their low risk perception instilled a false sense of confidence that they are invincible from any infection. Therefore, they assumed that they would not be vulnerable to HIV; hence they did not deem it necessary to seek testing services.

Preconceived Notions and Misconceptions About HTS

Moreover, some MSM and hijra participants possessed a multitude of misconceptions. For example, some kothi misconstrued that peer educators forcibly castrated them or indoctrinated them into the hijra sub-culture, under the pretense of performing HTS. A hijra CBO leader recalled that she heard such anecdotes in India, thus instilling suspicion and fear among MSM and non-castrated hijra in Bangladesh. A peer educator mentioned:

“When we invite some kothi for HTS, a group of them refuses to come. They think that we are lying to them about taking a blood test and we might inject hormones and convert them into hijra instead. Therefore, they do not want to participate” (Peer educator, 25 years, focus group).

Likewise, some panthi participants feared that the HTS providers would inject feminizing hormones into them in an effort to transform them into kothi. Therefore, despite persistent efforts of peer educators to promote the benefits of HTS, this group of MSM often refused to take up on this offer.

The Emotional Connections to Romantic Partners as Deterrents to HTS Uptake

As the MSM and hijra sub-cultures embody unique belief systems, the decisions of these participants are often overruled by these beliefs, which consequently influenced their attitudes towards HTS uptake. For example, a CBO leader explained that most kothi and hijra have steady romantic partners known as parik, with whom they share a long-term emotionally intimate connection. Therefore, the participants were unwilling to partake in any activity that they perceived would compromise the sanctity of their relationship with their parik, including HTS. The CBO leader also explained that most kothi and hijra are fearful of undergoing HTS, anticipating that they would be disconnected from their parik and, hence, their coveted support system, if identified as HIV-positive. This anticipatory fear fueled their reluctance to uptake HTS. As one of the kothi participants stated:

“I do not think I need HIV testing because I use condoms with all my sex partners except my parik. I do not use condoms with him because I love him more than life and I consider him like my husband. If I use condoms with him, he might become suspicious of me. Then, I will lose him and I cannot bear that” (Male sex worker, 25 years, in-depth interview).

In addition, some participants attributed their low perceived HIV vulnerability to consistent condom use during transactional sex, despite commonly practicing unprotected sex with their male romantic partners (pariks) and spouses. In turn, this diminished their will to get tested, thus incurring deleterious consequences. A kothi participant stated, “I do not think I need HIV testing because I use condoms with all my sex partners except my parik” (Male sex worker, 21 years, in-depth interview).

Fear of Needle Pricking as a Deterrent for HTS

Due to limited education and awareness about HIV, some MSM and hijra possessed limited knowledge of the benefits of seeking healthcare, including HTS. On the contrary, they felt daunted about undergoing clinical tests, which superseded their perceived benefits of taking these tests. Some of the participants expressed their fear of blood tests and being pricked by needles. A kothi participant expressed:

“I have never given blood or been tested for HIV because I get scared at the thought of my finger being pricked. I am scared that I will lose consciousness if the needle is inserted into my finger and blood comes out of my body” (Kothi, 19 years, in-depth interview).

Because of this fear, the participants were wary of seeking HTS, thus making them reluctant to visit the Drop-in Center for testing services.

Anticipatory Fear of the Negative Ways That HTS May Affect Their Wellbeing

MSM and hijra participants who occasionally practiced unprotected sex explained that knowing their HIV status would lessen their morale and emotional wellbeing. Moreover, since they previously heard that there is no curative pathway for HIV, they reported contemplating suicide if they were to find out they were HIV positive. Therefore, they refrained from HTS, thus perpetuating the “ignorance is bliss” mentality. As one of the male sex worker participants reported:

“I do not know my HIV status and have no other diseases so I consider myself okay. It feels satisfying in a way. However, if I get diagnosed as HIV positive, then I cannot imagine what severe mental (emotional) reaction I might have. So I might as well not get tested” (Male sex worker, 21 years, in-depth interview).

Since HIV is generally stigmatized in their immediate communities as well as their societies and country, they did not want to carry on the label of being HIV-positive. In this context, they believed that knowing their HIV status would demoralize them to the extent of ruining their mental health.

Programmatic Barriers Within the HIV Prevention Interventions

The participants also experienced some challenges which are linked to the implementation of the program where they received HIV prevention services. Although HTS is widely available for MSM and hijra, some barriers were found to constrict their’ ability to uptake HTS, as delineated in this section. This layer is illustrated in grey in Figure 1.

Inadequate Skill of Peer Educator to Disseminate Accurate Information About HTS

Participants opined that peer educators did not possess adequate knowledge about the fundamental principles of HTS uptake, thus compromising their ability to successfully motivate participants to uptake HTS. According to participants, peer educators often disseminated partial information about the testing procedure, estimated testing duration, the HIV window period, etc., thus failing to highlight the importance of HTS. MSM participants reported that some peer educators would make empty promises to incentivize them to uptake HTS. For example, they were promised that HTS could screen all of their infections. Consequently, the participants expressed annoyance at the peer educators and were unable to internalize the messages the per educators conveyed. According to an MSM participant:

“Some peer educators do not know enough information about the benefits of HTS. Instead, they just say that if we go with them, we will get free blood tests and medicines for all of our health problems. They also told us that the test would only last 10-15 minutes, even though that is incorrect. So, when we see the discrepancy between the promise and reality, we become annoyed and frustrated. This situation discourages MSM from taking HTS” (MSM, 36 years, focus group).

Therefore, because of the knowledge and skill gaps among the peer educators and, to some extent, other service providers, MSM and hijra participants felt misled, thus further fueling their feelings of annoyance and frustration about HIV testing.

Rigid Testing Schedule as a Barrier of HTS Uptake

According to the extant schedule, HTS is typically offered from 9 am to 5 pm on weekdays, with no alternative sessions available on weekends or after-hours. This engenders discordances in schedules for MSM and hijra who are enrolled in educational institutions or involved with jobs. In light of this issue, participants opined that without launching regular HTS sessions beyond the existing schedule (such as on weekends or after 5pm on weekdays), it would be difficult to uptake HTS. An MSM student stated:

“We only get time on weekends, since we have classes on weekdays. However, HTS is not available during weekends. Therefore, we would have to skip classes if we want to get HTS, although that is not feasible. Therefore, people like us are unable to uptake HTS” (MSM, 18 years, in-depth interview).

However, the DIC staff participants questioned the feasibility and sustainability of this approach. They opined that, considering the extant staff structure, it would be challenging to operate additional shifts unless the staff received overtime allowance or compensatory leave.

Dropout of Peer Educators and Lack of Viable Backup Options

Findings indicated that peer educators are mostly recruited from the local community because of their network and pre-existing rapport with the MSM and hijra. However, the peer educators often drop out because of job transfers, migration etc. Since a functional peer volunteer option is rare in the existing intervention, recruitment and deployment of peer educators are time-consuming processes. In turn, this disrupts the smooth administration of HTS, because it not only results in loss of connections between the peer educators and their assigned communities, but it also stunts the development of a rapport between the new peer educators and their communities. As one of the staff participants mentioned:

“Peer educators are dropping out for several reasons that are unavoidable. Deploying a new qualified peer educator becomes time-consuming and challenging because of the unavailability of an active peer volunteer pool. Often, existing peer educators are not interested in creating an effective peer volunteer pool from their cruising sites. Instead, they perceive peer volunteers as their competitors. This whole situation compromises the performance of HTS” (Drop-in Center manager, 34 years, focus group).

Because of these circumstances, it has become increasingly difficult and time-consuming for the peer educators to situate their MSM and hijra beneficiaries, thus slowing down the process of properly motivating them to uptake HTS.

Unmet Expectations of Extensive Testing Packages in Drop-In Centers

For majority of the MSM and hijra participants, the Drop-in Center was considered the first line of care and support for various health ailments. Therefore, they also held high expectations that the facility would accommodate provisions for diagnostic testing services besides HIV, such as syphilis, gonorrhea, hepatitis B and C, etc. They also expected this would be free of cost due to their limited financial capacity. However, due to budgetary constraints, the Drop-in Center could not incorporate these testing provisions. In this context, given their busy schedules and financial constraints, the participants did not deem it worthwhile to visit the Drop-in Center merely for HIV testing, unless they could get other health conditions tested for free as well. As one of the male sex workers opined:

“Many of us suffer from different STI problems which need to be conformed through testing, I think more of our community members would have been encouraged to uptake HIV test if they heard that you also provide the testing facilities for STIs like syphilis, gonorrhea and Hepatitis” (Male sex worker, 25 years, focus group).

Considering their personal circumstances and their high expectations of the Drop-in Centers in terms of being able to address their healthcare needs, they did not perceive it to be worth it to visit the Drop-in Center merely for HTS.

Community and Structural Barriers

The black layer of Figure 1 has depicted that in addition to the individual and interpersonal challenges and the programmatic challenges, there are also some challenges of HTS uptake attributed to community and structural barriers. Some of these barriers included the cultural conventions, ensuring livelihood, the criminalization of same-sex activities, poverty, unpredictable mobility of these communities and institutional barriers. It is worth noting that there is limited scope to tackle these community and structural barriers through individual level efforts. Findings highlighted the following key community and structural barriers.

Cultural Rules and Regulations of Hijra and Implications on HTS Uptake

The hijra sub-culture of Bangladesh mandates that disciples (chelas) of the guru participate in traditional occupations (collectively referred to as hijragiri) such as collecting money from local people and markets (bazar tola), and blessing newborns and newly married couples (badhai). Gurus strictly obligate their chelas to exclusively dedicate their daytime to hijragiri. Thus, this limits their scope to perform other activities, including HTS, because gurus opined that this time could have been utilized on hijragiri. Furthermore, chelas could not partake in activities without their gurus’ consent otherwise they would inflict a punitive fine (don). Therefore, this posed challenges for Drop-in Center staff to bring chelas for HTS. According to a hijra participant:

“We live in a guru’s residence (dera). Since she is like our mother who looks after us, it is impossible for us to disobey her, regardless of the reason. We know you cannot be liable for us if we face problems in our personal and community life” (Hijra, 35 years, in-depth interview).

Moreover, some gurus consider sex work disrespectful to traditional hijra conventions, since hijra are often characterized as asexual in the context of their community. Therefore, many chelas feared that their gurus would suspect them to be a sex worker if diagnosed as HIV positive, thus dissuading them from HTS. Therefore, because of these cultural complications, the circumstances were often not conducive to the uptake of HTS for hijra.

Prioritization of Sustaining Livelihood Over HTS

Many kothi and hijra participants generated income through part-time jobs, small business and/or sex work. They reported that their earnings could not sufficiently finance their living expenditures. Therefore, some of them reported struggling for their livelihood. Because of their impoverished backgrounds, they typically received little to no education. Hence, this fostered their indifference to actively seeking health services, including HTS. Moreover, in other cases, some kothi and hijra were so invested in attaining money that there was no scope to accommodate other activities in their schedules, including HTS. A key-informant mentioned:

“Many MSM and hijra live from hand to mouth due to poverty and lack of education. Some cannot sell sex due to their unattractive appearance. They cannot even earn through other means due to the lack of access to mainstream jobs. Therefore, they are struggling for their lives. Therefore, they are indifferent to their health needs and checkups, including HTS. There is a saying in Bengali, “everything is fine if you are not starving (pet thik to shob thik).” Nothing is okay for a starving person, no matter how much effort you invest in motivating them” (CBO leader, 38 years, key-informant interview).

In addition, even if they are willing to uptake HTS, they cited the long distance from their homes or spots to the DIC as an inconvenience. They perceived that the time invested in commuting to the DIC and undergoing HTS could have been spent on contributing to their livelihood.

The Implications of the Criminalization of Male-to-Male Sex on Their Ability to Uptake HTS

Findings revealed that MSM and hijra often refrained from staying in the cruising spots out of apprehension of being accosted by the law enforcement agencies. They are especially vulnerable to violence, harassment and arbitrary arrests due to punitive laws against male-to-male sex and repressed sexual rights among both MSM and hijra. Therefore, MSM and hijra reported feeling constrained from expressing their sexual identities, and consistently feared harassment from law enforcement agencies. Participants reported that law enforcement agencies became increasingly stringent, thus accosting participants who would linger at the cruising spots. Moreover, many hoodlums (mastans) leveraged opportunities to rape or extort them. Therefore, MSM and hijra were less willing to linger at the spots, thus making it difficult for the peer educators to reach them for HTS. A male sex worker participant explained that:

“When we cannot safely stay at cruising spots, how do you expect us to meet peer educators and get tested for HIV? Police and hoodlums (mastans) harass us continuously ––- they rape, beat, arrest us and demand money. We need to save ourselves first, then we can think about HTS” (Male sex worker, 40 years, focus group).

Considering the criminalization of same-sex activity, the MSM constantly lived in fear and apprehension, thus compelling them to resort to alternatives for seeking clients, such as virtual platforms. In turn, this affected their presence at the spots, thus compromising outreach activities by the peer educators.

Fear of Stigma and Discrimination

The felt and enacted stigma associated with practicing male-to-male sex was also a perceived barrier to seeking healthcare, including the uptake of HTS. MSM experienced stigma due to their “so-called immoral sexual behavior” (MSM, 23 years old, in-depth interview) whereas hijra were subjected to stigma due to their non-conforming gender identities. Therefore, they feared that if they were identified as HIV positive, their HIV status would potentially exacerbate their stigma, marginalization and social exclusion among their families and surrounding communities. A kothi participant expressed that:

“My family members call me effeminate man (maigga pola) and bully me often because of my feminine characteristics and male-to-male sex practices. If I find out I am HIV-positive, they would eventually know my HIV status. The aftermath would be devastating, and my life would be in danger” (Kothi, 25 years, in-depth interview).

On the other hand, male sex worker participants anticipated another consequential dimension compared to their non-sex worker counterparts. Due to the nature of their tightly-linked networks, they feared that information about their HIV positive status would circulate throughout their network. As a result, this was perceived to hinder their influx of sex work clients due to the clients’ fear of contracting HIV. According to a participant:

“HIV and AIDS create serious panic in our society, and we heard many people becoming isolated and ostracized from family, society, and jobs just because they were diagnosed as HIV-positive. Therefore, we are worried that would have to face the same destiny if we were diagnosed as HIV positive. Therefore, we prefer avoiding HTS” (Male sex worker, 39 years, in-depth interview).

These two instances highlighted that the stigma surrounding HIV has not only permeated through the general societies but also the immediate MSM and hijra communities. Therefore, the participants opted for not knowing their status rather than being subjected to enacted and felt stigma.

“He Escaped Quickly Without Notice”: Where Guilt, Shame, and Indifference Converge

Some young and married MSM, particularly who originate from religious families, felt guilt and shame due their non-normative sexual behaviors. These sentiments eventually engendered low self-esteem, demoralization, and compromised emotional welfare, along with the notion that they “have deviated from a socially acceptable lifestyle” (MSM, 23 years, focus group). Therefore, they felt indifferent to the threat of HIV and, hence, HTS. Sometimes, peer educators brought them for HTS, yet they ultimately absconded after the pre-test information session, in order to circumvent the revelation of potentially devastating results. According to a staff participant:

“When I was providing pre-test information to an MSM for HTS, he seemed a bit upset. I tried to provide adequate moral support, reassuring him not to worry about testing. However, when the pre-test information sharing session was finished, he quickly escaped without notice” (Medical assistant, 22 years, focus group).

Because many of these participants were already shamed and stigmatized due to their unique mannerisms and practices, they lacked the morale to potentially face the reality of their HIV-positive status.

Unpredictable Mobility of MSM and Hijra

MSM and hijra generate income through sex trade, dance shows, dramatic performances, badhai, and attending arbitrations for solving intra-community clashes among hijra, which entails traveling to other cities, districts, sub-districts, and countries, most of which are spontaneous voyages. Hence, on some occasions, it became difficult for peer educator to reach out to them and ensure their presence for HTS sessions. One of the peer educators explained:

“There were situations where we invited them for HTS one week in advance and they agreed to take HTS, but on the scheduled day, they become unavailable. After trying to trace them, we find out that they went to another district or city for sex trade or hijragiri” (Peer educator, 26 years, focus group).

Therefore, it was difficult for the peer educators to trace the MSM and hijra, especially the latter, because their cultural conventions stipulated that they move to various settings to perform certain tasks.

Rapid Urbanization and Technological Advancements

Many male sex workers would formerly come to unoccupied spaces (i.e. parks, playgrounds, etc.) to seek clients for sex work. However, due to rapid urbanization, these spaces have suddenly become inhabited by residential and commercial buildings, thus transforming these venues into “dead spots”. Meanwhile, due to technological advancements, a portion of relatively young and educated male sex workers reported connecting with and locating potential clients through technological platforms, such as mobile phone and social media. In fact, nowadays, many of these participants have resorted to covertly contacting their clients and engaging in sex work through online platforms. Due to these challenges, these participants did not come to the spots, thus circumscribing the programmatic scope of HTS coverage.

Institutional Level Barriers at Public Healthcare Facilities

As same-sex behaviors are criminal offences in Bangladesh, MSM and hijra are often subjected to internalized stigma and discrimination in public healthcare facilities. Moreover, some kothi and hijra participants experienced hostile and judgemental attitudes from healthcare providers while seeking services for other ailments such as STIs, thus discouraging them from HTS. As a result, they felt safe and comfortable visiting the Drop-in Centers instead for services. They did not deem the public healthcare facilities as a conducive and adequately sensitized environment to cater to their healthcare needs. Moreover, since public healthcare facilities are open for all populations including KPs; they did not perceive the hospitals to be community-friendly and understanding of their culture and needs. They are also apprehensive that their informational confidentiality would be breached because of the possibility of running into people they may know from their vicinity. Inconvenient service hours (i.e. 9 AM to 2 PM), long waiting times, lack of provider-initiated testing at government hospitals also served as barriers to the uptake of HTS. Furthermore, many participants were not aware that HTS was available in the government hospitals due to the paucity of demand generation activities, such as peer-led outreach services.

Discussion

Our study explored barriers impacting HTS uptake and hence, the initiative to fulfill the UNAIDS target by 2020 among MSM and hijra. If Bangladesh is not on track for achieving this goal, it will also be difficult for the country to fulfill SDG 3.3 in the long-run.³⁴ This analysis depicted the perceived barriers to the uptake of HTS. To gravitate closer to achieving the first 90 of the global target, it is crucial to address these barriers.

This study presented the barriers in relation to the social ecological model. Within this framework, the findings of this study depicted the reluctance of some of the MSM and hijra to partake in HTS and the social and structural factors which fueled this reluctance (depicted in Figure 1). As demonstrated by the white, grey, and black layers presented in Figure 1, it is evident that human behavior is influenced by multiple layers, such as the individual, interpersonal, programmatic, community, and structural levels.^30,35,36 Several public health experts suggested that these multifaceted factors shaped their service uptake behaviors.^36–38 To depict the relationship between these factors and the HTS uptake behaviors of the MSM and transgender women, the social ecological model was applied.

At the individual level, the findings of this study identified the low-risk perception of HIV infection among the study participants as a key barrier, which resonate with previous studies among the same populations in other countries.^39–42 Participants claimed that they also possessed misconceptions and limited capacity to understand, internalize, and retain knowledge about HTS, primarily owing to limited education, which also aligned with findings of studies conducted on MSM and transgender women in China and Guatemala.^39,43

Moreover, a study based in Zambia also cited misconceptions about HIV testing and the apprehension of negative consequences of testing as barriers to HTS.⁴² The participants of our study also reported the anticipatory fear of being forcibly feminized using hormone injections under the pretense of HTS, although there is yet to be evidence depicting the same phenomenon in other settings. This study also explored that the excessive fear of needle pricking and blood tests adversely impacted the uptake of HTS. However, a recent qualitative study contrasted this finding, noting that the MSM and hijra participants preferred blood-based tests over the oral fluid-based approach due to accuracy of the former.⁴⁴ After re-examining the findings connected to individual and interpersonal barriers, it is evident that most of them can be tackled through programmatic interventions both locally and in some other similar contexts.

At the programmatic level, some study participants indicated that they were not motivated to uptake HTS due to inadequate HTS skills among peer educators and dissemination of educational information from peer educators. The critical role of peer educators to empower more MSM to uptake HTS was also underpinned in another study conducted in Karnataka, India.⁴⁵ Our study also identified inconvenient testing schedules for students and full-time working populations as another implementation barrier, which was also mirrored in a qualitative study in China.⁴³

The findings also presented some community and structural factors which influenced the willingness of the study participants in Bangladesh. Criminalization of same-sex behavior was as a prominent barrier, which was corroborated by Arreola et al.’s study.⁴⁶ HIV-related stigma, self-perceived stigma, and homophobia among MSM and hijra were also found as deterrents to increasing HTS uptake in previous studies from developing and developed countries, alike.^{16,39,43,47,48} Participants also cited limited education and poverty as barriers to seeking HTS. Likewise, two studies based in Brazil and the USA indicated that participants who never received HTS were also less educated, from poorer families and generated less income.^49,50

The findings of this study reflected that demoralization and poor self-esteem also negatively influenced the uptake of HTS among MSM and hijra, which necessitates further investigation in the cultural context of Bangladesh. Similarly, a recent qualitative study based in Indonesia identified the fear of shame and embarrassment as barriers to HTS uptake.⁴ A quantitative study also highlighted that the anticipatory fear of stigma was significantly associated with information avoidance about HIV status.⁵¹ The intra- and inter-country mobility of hijra posed as a barrier, for which the context was delineated in another study in Bangladesh but there was limited analysis of how it affected health service uptake. Therefore, this study supplements that knowledge gap.⁵² Our findings noted the hierarchical power structure of hijra communities as an obstacle to HTS, which was not elaborated in any other literature since this phenomenon was not explored so far. In addition, rapid urbanization and technological advancement were identified as barriers for the uptake of HTS among some relatively young and educated MSM, which was not known to be explored in previous analyses. Moreover, this study briefly explained that many of the MSM were unable to seek HTS in the public healthcare facilities despite there being available client-initiated provisions, primarily due to the fear of stigma and discrimination. This finding was also mirrored in another qualitative study conducted in Bangladesh by Gourab and colleagues, which showed that MSM and hijra were reluctant or resistant to visit the public healthcare facilities because of antagonizing behaviors from the healthcare providers.²⁰

Implications of the Findings

The findings and the social ecological analysis implicated that HIV prevention interventions not only need to target each layer of barriers but also carefully examine the relationships between each level of barriers. For example, there are many exogenous factors they may not be taking into consideration which could shape individual beliefs and attitudes such as community norms, the need to generate income, or the fear of being stigmatized. Likewise, literature suggested that knowledge-based approaches might not be effective for persuading beneficiaries to uptake healthcare services if their primary concerns are about generating financial stability.³⁸ The analysis of societal stigma as well as the criminalization of male-to-male sex also provided a lens for assessing and understanding the barriers to uptake HTS. Targeted measures can be taken at the structural, organizational, community, and interpersonal levels to increase the coverage of HTS among these specific populations, and eventually to other vulnerable populations. For instance, at the interpersonal level, on the other hand, intimate partners can also be targeted in interventions in the form of family counseling initiatives. On the community level, tailored interventions can be conducted to mitigate the stigmatization of these populations, while engaging CBO leaders and members of the study communities.

At the structural level, strong advocacy events, both on the local and national scales, can be facilitated to sensitize policy and law makers about the importance of optimizing HTS uptake among these populations for containing the HIV burden. The HIV prevention guidelines developed by the WHO and other UN bodies for a range of stakeholders have advised for the enforcement of anti-discriminatory laws. They argued that such initiatives could bolster the uptake of necessary healthcare services amongst these populations, thus improving treatment outcomes and reducing HIV risks and vulnerabilities.⁵³ Research has shown that promising outcomes have been demonstrated in countries such as India and South Africa after decriminalizing homosexuality.^54,55 It is worth noting that Bangladesh embodies Islamic ideals and the general politics is influenced by Islamic political parties, therefore, we noted that political parties in power always remain careful in dealing with sensitive issues such as male to male sex and so on. Therefore, it would be more challenging to inflict decriminalization laws right at the moment.⁵⁶ Nevertheless, the times are changing, and even things that were deemed unacceptable 10 years ago are accepted on national grounds. For instance, recognizing hijra as a third gender exemplifies this notion. Thus, in the future, it may be possible to gradually begin the strategic advocacy for relaxing the punitive measures on male-to-male sex, thus ensuring accessibility to the healthcare facilities for the marginalized populations.^53–55

Study Limitations

A limitation of the study was that the MSM and hijra participants were selected from an HIV prevention intervention; therefore the possibility of selection bias cannot be ignored. Since majority of the MSM and hijra in Bangladesh were out of the HIV prevention intervention coverage, the views and insights of these groups may not be fully reflected. However, to mitigate this bias, this study attempted to use triangulation with other stakeholders such as service providers and other influential people in the study and general community.

Areas for Future Research

Future research might be conducted to explore the pathways to overcome the barriers that were explored in this study, in the form of feasibility or pilot studies on approaches such as oral fluid-based testing and structural interventions. Moreover, future research initiatives could be conducted on the feasibility and acceptability of self-testing approaches as a way of tackling barriers to HTS uptake.

Conclusion

This study explored various complex barriers affecting HTS uptake among MSM and hijra in Bangladesh. If the appropriate efforts are invested upon involving various stakeholders, it is feasible to specifically address several individual and programmatic barriers within current HIV interventions. Yet, given the legal, socio-cultural and political contexts of Bangladesh, it is integral to enact focused advocacy initiatives to properly address the structural barriers. As we are approaching the end of the quest to fulfill the UNAIDS fast-track target, it is integral to critically evaluate the impediments to achieving the goal, particularly the barriers of HIV testing. In this context, these findings may help the policymakers and program implementers in Bangladesh and other countries with similar socio-cultural contexts to think more critically and holistically about the interventions to increase HTS uptake among MSM and hijra not only to achieve the fast-track target but also lay a strong foundation for fulfilling the respective SDG target by 2030.

Footnotes

Ethical Approval and Consent to Participate

This research obtained ethical approval from the Ethical Review Committee of icddr,b. Prior to each interview, understood and informed consents were attained from the participants.

Data Accessibility Statement

Since the populations that were interviewed in this research were men who have sex with men and transgender women and male-to-male sex is punishable by law, we preserved the confidentiality of their information. In addition, icddr,b has their own data policy therefore sharing data needs to be authorized by the research administration unit of the institution. Apart from that, as per the contractual agreement with the donor, UNAIDS, prior permission will be needed to release the data.

Acknowledgement

We gratefully acknowledge the UNAIDS for providing their funding support for this research project. icddr,b gratefully acknowledges the commitment of Governments of Bangladesh, Canada, Sweden, and the UK for providing their core/unrestricted support.

Authors’ Contributions

MNMK is the first author of this manuscript and was responsible for the overall supervision of data collection and analysis and drafting of the manuscript. GS was involved in overall data collection, supervision and analysis and assisted in the drafting of the manuscript. SDI was involved in the literature review, analysis of data and writing the manuscript. GG supported in data analysis and the development of this manuscript. AKMR reviewed the manuscript and provided valuable suggestions for the overall improvement of the article. SIK is the senior and corresponding author of this manuscript and provided valuable analytical contributions and insights for the improvement of this article.

Declaration of Conflicting Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was carried out by funding from UNAIDS Grant # 00727.

Author Biographies

Mohammad Niaz Morshed Khan, is a senior research Investigator who has been working at the Programme for HIV and AIDS at icddr,b since 2002. Previously, he served as assistant programme manager in the same unit. He has received his MPhil in Social Work From Dhaka University in 2006, followed by an MPH in State University of Bangladesh in 2014 and a Post-graduate Diploma from Lund University, Sweden in 2017. He is currently pursuing a PhD program in the Graduate School of Health Sciences in Hiroshima University, Japan. He has published research about the contexts of drug use among sexual and gender minorities, the willingness of KPs to seek healthcare and other issues pertaining to sexuality, HIV and AIDS.

Golam Sarwar, is an assistant programme manager of icddr,b, as well as the focal person for STIs, HIV testing services and TB co-infection, since 2015. He has previously worked at icddr,b as a Research Investigator since 2009. He completed his Post-graduate Diploma on SRHR from Lund University, Sweden in 2018, his MPH from State University of Bangladesh in 2018, and MBBS in Dhaka Medical College in 2005. He has co-authored publications about the willingness of KPs to uptake public healthcare, and he is leading a project about TB-HIV co-infection among sexual and gender minorities.

Samira Dishti Irfan, MPH, is working as a senior research officer since 2019 and has served as a research officer since 2017. She received her Bachelors in Science degree from University of California, Berkeley in 2015 and her Masters in Public Health from North South University in 2017. Her research interests lie in gender, drug use, and HIV and AIDS. She has authored publications about determinants of tuberculosis, underlying contexts of drug use in sexual and gender minorities and willingness of KPs to uptake healthcare.

Gorkey Gourab, is working as senior programme manager and assistant scientist at Program for HIV and AIDS of icddr,b. Since 2004, he has worked in various roles: manager – M&E, assistant programme manager, senior research fficer, research officer, and program officer. He has completed his MPH from University of Melbourne, Australia in 2015; and Masters in Anthropology from Rajshahi University, Bangladesh in 2004. He has authored publications about willingness of KPs to uptake healthcare, indigenous populations, complexities of KPs, etc. His research interests are male sexuality, gender, HIV and AIDS, qualitative research, and medical anthropology.

A. K. M. Masud Rana, PhD, has been the project coordinator of the Programme for HIV and AIDS of icddr,b since 2013. He previously served as a Researcher in BRAC from 1993. He has completed his PhD in Medical Science from Karolinska Instituttet in 2009. He has published several important research articles in international peer reviewed journals such as AIDS and Behavior, Health Education Research, Health Promotion International, Ageing and Society and Public Health as lead author. His research interests include public health and HIV prevention.

Sharful Islam Khan, the senior author, Dr. Sharful Islam Khan is the head and scientist of the Programme for HIV and AIDS of icddr,b since 2017. In 2004, he attained his PhD from Edith Cowan University, Australia, his MHSS from Mahidol University in 1997 and MBBS from Dhaka Medical College in 1992. His research is focused on sexuality, sexual behaviours, sexual health, qualitative research, STIs, HIV and AIDS. He has authored several publications on these issues, including several publicationsabout underlying reasons for methamphetamine use on sexual and gender minorities.

References

1. UNAIDS. UNAIDS report 2020. Geneva: UNAIDS, 2020.

2. UNAIDS. UNAIDS data report. Geneva: UNAIDS, 2019.

3. Zhou

Wang

Zeng

, et al. Mortality, morbidity, and risk factors in China and its provinces, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2019; 394: 1145–1158.

4. Muccini

Crowell

Kroon

, et al. Leveraging early HIV diagnosis and treatment in Thailand to conduct HIV cure research. AIDS Res Ther 2019; 16: 25.

5. Wulandari

LPL

Ruddick

Guy

, et al. “Self-testing sounds more private, rather than going to the clinic and everybody will find out”: facilitators and barriers regarding HIV testing among men who purchase sex in Bali, Indonesia. PLoS One 2019; 14: e0214987.

6. Chandra

Bazazi

Nahaboo Solim

, et al.

Retention in clinical trials after prison release: results from a clinical trial with incarcerated men with HIV and opioid dependence in Malaysia.

HIV Res Clin Pract 2019; 20: 12–23.

7. UNAIDS. The 2030 agenda for sustainable development. Geneva: UNAIDS, 2015.

8. UNAIDS. An ambitious treatment target to help end the AIDS epidemic. Geneva: UNAIDS, 2014.

9. Campbell

Lippman

Moss

, et al.

Strategies to increase HIV testing among MSM: a synthesis of the literature.

AIDS Behav 2018; 22: 2387–2412.

10.

10. Mukolo

Villegas

Aliyu

, et al.

Predictors of late presentation for HIV diagnosis: a literature review and suggested way forward.

AIDS Behav 2013; 17: 5–30.

11.

11. ASP. World AIDS day. In: Government of the People's Republic of Bangladesh (ed) AIDS/STD programme (ASP) DGoHS MoHaFW. Dhaka: Government of the People's Republic of Bangladesh, 2019.

12.

12. ASP. Behavioural and serological surveillance on males having sex with males, male sex workers and hijra. Technical Report. Dhaka: AIDS/STD Programme (ASP), Directorate General of Health Services, Ministry of Health and Family Welfare, Government of the people's Republic of Bangladesh, 2017.

13.

13. ASP. Mapping study and size estimation of key populations in Bangladesh for HIV programs 2015-2016. Dhaka: National AIDS/STD Control Programme, Ministry of Health and Family Welfare, Government of Bangladesh, 2017.

14.

14. WHO

Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. Geneva: World Health Organization, 2014.

15.

15. Gamarel

Nelson

Stephenson

, et al. Anticipated HIV stigma and delays in regular HIV testing behaviors among sexually-active young gay, bisexual, and other men who have sex with men and transgender women. AIDS Behav 2018; 22: 522–530.

16.

16. Logie

Lacombe ‐ Duncan

Brien

, et al. Barriers and facilitators to HIV testing among young men who have sex with men and transgender women in Kingston, Jamaica: a qualitative study. J Int AIDS Soc 2017; 20: 21385.

17.

17. Deblonde

De Koker

Hamers

, et al.

Barriers to HIV testing in Europe: a systematic review.

Eur J Public Health 2010; 20: 422–432.

18.

18. Bangladesh Penal Code 377 (1860). Government of People's Republic of Bangladesh.

19.

19. HRW. "I want to live with my head held high": abuses in Bangladesh's legal recognition of hijras. Dhaka: Human Rights Watch, 2016.

20.

20. Gourab

Khan

MNM

Hasan

, et al. 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. PLoS One 2019; 9-15.

21.

21. Khan

Hussain

Parveen

, et al. Living on the extreme margin: social exclusion of the transgender population (hijra) in Bangladesh. J Health Popul Nutr 2009; 27: 441.

22.

22. Chakrapani

Newman

Shunmugam

, et al.

Social-structural contexts of needle and syringe sharing behaviours of HIV-positive injecting drug users in Manipur, India: a mixed methods investigation.

Harm Reduct J 2011; 8: 9.

23.

Poundstone

Strathdee

Celentano

The social epidemiology of human immunodeficiency virus/acquired immunodeficiency syndrome.

Epidemiol Rev 2004; 26: 22–35.

24.

24. Khan

Khan

MNM

Hasan

AMR

, et al. Understanding the reasons for using methamphetamine by sexual minority people in Dhaka, Bangladesh. Int J Drug Policy 2019; 73: 64–71.

25.

25. Li

Rawat

Rhoton

, et al. Harassment and violence among men who have sex with men (MSM) and hijras after reinstatement of India's "sodomy law". Sex Res Social Policy 2017; 14: 324–330.

26.

26. Gourab

Khan

MNM

Hasan

AMR

27.

27. Khan

Hudson-Rodd

Saggers

, et al.

Men who have sex with men's sexual relations with women in Bangladesh.

Cult Health Sexual 2005; 7: 159–169.

28.

Patton

MQ.

Qualitative research & evaluation methods: integrating theory and practice. Thousand Oaks: Sage Publications, 2014.

29.

Saldaña

The coding manual for qualitative researchers. Thousand Oaks: Sage, 2015.

30.

30. Baral

Logie

Grosso

, et al. Modified social ecological model: a tool to guide the assessment of the risks and risk contexts of HIV epidemics. BMC Public Health 2013; 13: 1–8.

31.

Wicks

The coding manual for qualitative researchers. 3rd ed. Thousand Oaks: Sage, 2015.

32.

Ezzy

Qualitative analysis. London: Routledge, 2013.

33.

33. Lincoln

Guba

YSLEG

Guba

, et al. Naturalistic inquiry. Thousand Oaks: SAGE Publications, 1985.

34.

Kamau

Donoghue

Transforming our world: the 2030 agenda for global action. Final draft of the outcome document for the UN summit to adopt the post-2015, 2015. United Nations.

35.

35. Atujuna

Newman

Wallace

, et al.

Contexts of vulnerability and the acceptability of new biomedical HIV prevention technologies among key populations in South Africa: a qualitative study.

PLoS One 2018; 13: e0191251.

36.

36. Larios

Lozada

Strathdee

, et al.

An exploration of contextual factors that influence HIV risk in female sex workers in Mexico: the social ecological model applied to HIV risk behaviors.

AIDS Care 2009; 21: 1335–1342.

37.

Krieger

The ostrich, the albatross, and public health: an ecosocial perspective–or why an explicit focus on health consequences of discrimination and deprivation is vital for good science and public health practice.

Public Health Rep 2001; 116: 419.

38.

38. Chakrapani

Newman

Singhal

, et al.

Willingness to participate in HIV vaccine trials among men who have sex with men in Chennai and Mumbai, India: a social ecological approach.

PLoS One 2012; 7: e51080.

39.

39. Liu

Sun

Qian

H-Z

, et al. Qualitative assessment of barriers and facilitators of access to HIV testing among men who have sex with men in China. AIDS Patient Care STDs 2015; 29: 481–489.

40.

40. Carvalho

Fuertes

Lucas

, et al. HIV testing among Portuguese men who have sex with men–results from the European MSM Internet Survey (EMIS). HIV Med 2013; 14: 15–18.

41.

41. Barrington

Knudston

Bailey

OAP

, et al.

HIV diagnosis, linkage to care, and retention among men who have sex with men and transgender women in Guatemala City.

J Health Care Poor Underserv 2016; 27: 1745.

42.

42. Qiao

Zhang

, et al.

Facilitators and barriers for HIV-testing in Zambia: a systematic review of multi-level factors.

PLoS One 2018; 13: e0192327.

43.

43. Wei

Yan

Yang

, et al.

Accessing HIV testing and treatment among men who have sex with men in China: a qualitative study.

AIDS Care 2014; 26: 372–378.

44.

44. Frye

Wilton

Hirshfield

, et al. Preferences for HIV test characteristics among young, black men who have sex with men (MSM) and transgender women: implications for consistent HIV testing. PLoS One 2018; 13: e0192936.

45.

45. Beattie

Bhattacharjee

Suresh

, et al. Personal, interpersonal and structural challenges to accessing HIV testing, treatment and care services among female sex workers, men who have sex with men and transgenders in Karnataka state, South India. J Epidemiol Community Health 2012; 66: ii42–ii8.

46.

46. Arreola

Santos

G-M

Beck

, et al. Sexual stigma, criminalization, investment, and access to HIV services among men who have sex with men worldwide. AIDS Behav 2015; 19: 227–234.

47.

47. Lorenc

Marrero-Guillamón

Llewellyn

, et al. HIV testing among men who have sex with men (MSM): systematic review of qualitative evidence. Health Educ Res 2011; 26: 834–846.

48.

48. Levy

Wilton

Phillips

, et al. Understanding structural barriers to accessing HIV testing and prevention services among black men who have sex with men (BMSM) in the United States. AIDS Behav 2014; 18: 972–996.

49.

49. Brito

Kendall

Kerr

, et al. Factors associated with low levels of HIV testing among men who have sex with men (MSM) in Brazil. PLoS One 2015; 10: e0130445.

50.

50. Nelson

Pantalone

Gamarel

, et al.

Correlates of never testing for HIV among sexually active internet-recruited gay, bisexual, and other men who have sex with men in the United States.

AIDS Patient Care STDs 2018; 32: 9–15.

51.

51. Price

Howell

Gesselman

, et al.

Psychological threat avoidance as a barrier to HIV testing in gay/bisexual men.

J Behav Med 2019; 42: 534–544.

52.

52. Rana

AKM

Reza

Alam

, et al.

Effects of in-country and cross-border mobility on condom use among transgender women (HIJRAS) in Bangladesh: a cross-sectional study.

AIDS Behav 2016; 20: 2165–2177.

53.

53. WHO. Guidelines: prevention and treatment of HIV and other sexually transmitted infections for sex workers in low- and middle-income countries. Geneva: World Health Organization, 2012.

54.

Jain

Impact of the decriminalization of homosexuality in Delhi: an empirical study, 2013. Journal of Arkansas, Social Change and Public Service, University of Arkansas, Little Rock.

55.

55. Hagopian

Rao

Katz

, et al.

Anti-homosexual legislation and HIV-related stigma in African nations: what has been the role of PEPFAR?

Glob Health Action 2017; 10: 1306391.

56.

Hossain

Religious politics in the context of male-to-male sex. In: Khan SI (ed). Dhaka, 2020.