Health Seeking Practices of People Living with HIV and AIDS

Health Seeking Practices of People Living with HIV and AIDS (PLHIV) in Bangladesh: A Sociological Analysis Chapter One Introduction 1.1 Statement of the Problem Acquired Immune Deficiency Syndrome (AIDS), caused by the Human Immune Deficiency Virus (HIV), is the most devastating epidemic of today and has spread relentlessly around the globe smashing all the development initiatives organized by the states. Bangladesh, being one of the world’s high densely populated countries and being surrounded by the HIV infected countries, is highly susceptible to HIV transmission. At present the estimated number of PLHIV worldwide is 33.3 million and approximately 2.6 million people were newly infected only in 2009 (UNAIDS/WHO, 2010). The total number of people living with the virus in 2009 was almost more than 20% higher than the number in 2000, and the prevalence was threefold higher than in 1990 (UNAIDS/WHO, 2010). In South and South-east Asia, an estimated 4.1 million people were living with HIV, including 270,000 people who were newly infected and approximately 260,000 people who died from AIDS related diseases in 2009 (UNAIDS/WHO, 2010). Until December 2009, in Bangladesh, 2088 people were identified as HIV infected and among them 850 developed AIDS, and number of AIDS related death throughout the year was 241. Only in 2009 the number of newly HIV infected people in Bangladesh was 343 (NASP, 2010).

People Living with HIV and AIDS (PLHIV) need a variety of health care and social support.

Because of their vulnerability to opportunistic infections and their progressive disease, infected people may have a decreased income or become unemployed due to their inability to work during periods of illness. The situation becomes more aggravated when PLHIV find that they or their family members are denied in getting access to appropriate health care, housing, education, and other community services because of their HIV/AIDS status. These discriminatory practices compound the adverse impact of an HIV/AIDS diagnosis, especially as it results in the social isolation of those in need and exclusion from care and community support (UNAIDS/WHO, 2010; Khosla, 2009).

In Bangladesh the needs of PLHIV are not addressed in an integrated and comprehensive manner. Health seeking practices of PLHIV are determined by the availability and accessibility of treatment facilities. Unlike some conventional sources of seeking health care, many of the PLHIV regard NGO and Govt. clinics as inevitable sources of getting health services and HIV testing facilities. The given health services may remain a great discrepancy in between NGO clinics and Govt. clinics. Even though different organizations are working in this area, PLHIV are not getting the required treatment, care, legal, psychological, emotional and socio-economic support from both the family and from society, even from the state. In Bangladesh, much emphasis is given on treatment facilities, but not on other support services, which are as

important as treatment, to prolong healthy living of PLHIV and prevent further spread of the infection.

1.2 Setting the Context: Bangladesh Bangladesh is a land of immense beauty and potential situated in South Asia bordering India, Myanmar and the Bay of Bengal. It is largely a flat deltaic country formed by the confluence of great river systems of the Padma (Ganges), the Brahmaputra and the Meghna. Bangladesh is geographically vulnerable to HIV and AIDS and it has many epidemiological and social factors that could produce devastating epidemic risk factors such as high prevalence of HIV in the neighboring countries, less awareness of HIV infection, existence of large commercial sex industry and Man sex with Man (MSM), sex with multiple clients and mushrooming growth of Injecting Drug Users (IDUs) (Amanullah and Habib, 2002) extreme poverty, illiteracy, ignorance, malnutrition, unemployment, slum housing, family fragility, physical and sexual abuse, high prevalence of STDs, very mobile population, human trafficking into prostitution, stigmatization, conservative social attitudes, migrant workers, low popularity of condoms in an iconoclastic way (Amanullah, 2002).The specific reasons which might be responsible for spreading HIV in Bangladesh are geographical location (NASP, 2007); mushrooming growth of beauty parlor and private sex establishments (Begum, 2007); rapidly growing private universities (BAPS, 2007); construction workers (The Daily Star, 22 March, 2005); private clinic or laboratories (BAPS, 2007).

Whereas HIV/AIDS is one of the most significant health and development problems facing the world today and nobody is beyond its reach, the treatment seeking patterns remain more conventional in both rural and urban settings of Bangladesh regarding HIV/AIDS. Several socioeconomic factors play a pivotal role in receiving treatment and care for HIV/AIDS in Bangladesh. The indicators attached to culture and prevalence of HIV/AIDS motivates the infected people to seek care and service from different sources of availability of medicine.

People in Bangladesh are sometimes seen to practice self-medication until they feel a severe attack of that particular disease. Despite technological and communicational advances in treatment and care the nature of service as to HIV is still more centralized and urbanized in Bangladesh. Whereas a certain segment of the population remains under poverty line it is quite difficult for many of the PLHIV to come to district (an administrative unit of Bangladesh) area let alone the Dhaka, the capital city of Bangladesh. Since all kind of possible mechanisms of contracting HIV are closely intertwined with the socio-demographic and socio-economic characters of Bangladesh, the researcher has chosen the site as its research location.

1.2.1 Bangladesh: Geographical Proximity to HIV Epidemic Bangladesh is located in the Asian HIV epicenter (Amanullah, 2002; 2006) and the country traditionally shares a popular crossroad of South- Asian migration/frequent mobility. Lots of sources of illegal entrance and exit tantalize the current status of export-import trade keeping a severe threat to national economy and risk practices. The country has an area of 147,570 square kilometers bordered on the west, north and east by a 2,400 kilometers land frontier with India

and, in the southeast, by a short land and water frontier (193 kilometers) with Myanmar (Mitra et al, 1997; 1) Poverty and prostitution are the prime causes of heterosexual transmission of HIV in many countries of Asia (Podhisitia et al, 1994; Gillies, Tolley and Wolstenholm, 1996; Prybilski and Alto, 1999; Thomas and Bandypadhyay, 1999: WHO, 2001a, 2001b). These socio-economic barriers have tremendously influenced the sex industry of Bangladesh from the nineteenth century (Khan and Arefeen, 1989; Blanchett, 1996; Amanullah, 1997) amplifying the health risks in this multi-territorial country (Quoted in Amanullah, 2002).

1.3 Objectives of the Study The major objective of the study is to explore the health seeking practices of PLHIV in Bangladesh. The Specific Objectives of the study are To examine the relationship between socioeconomic determinants of PLHIV and their health seeking practices To explore the existing gaps between NGO clinics/service centers and Govt. clinics in terms of services ensuring accessibility to HIV treatment and care.

To measure the level of knowledge of the People Living with HIV and AIDS (PLHIV) as to HIV and AIDS and STDs To explore the relationship between socio-demographic and socio-economic status of the respondents as well as perceived barriers to HIV treatment and care.

To identify the patterns of social stigma and superstition in comparison with the present status of the victims in society.

To locate whether PLHIV have accessibility to the sources of information and mass media.

To observe whether victims have opportunities to HIV and AIDS prevention program in the context of media exposure.

1.4 Research Questions Is there any relationship between socioeconomic determinants of PLHIV and their health seeking practices?

Has there any gap between NGO clinics/service centers and Govt. clinics in terms of services ensuring accessibility to HIV treatment and care?

What is the level of knowledge of People Living with HIV/AIDS (PLHIV) as to HIV and AIDS and STDs? Has there any relationship between socio-demographic and socio-economic status of the respondents as well as perceived barriers to HIV treatment and care?

What are the patterns of social stigma and superstition in comparison with the present status of the victims in society?

Has there any opportunity of PLHIV to the sources of information and mass media?

Has there any accessibility of the victims to HIV and AIDS prevention program in the context of media exposure?

1.5 Hypothesis

People Living with HIV and AIDS (PLHIV) mostly come from lower strata of the society.

Health seeking practices are mostly promoted by socioeconomic backgrounds of the PLHIV. 1.6 Rationale of the Study The study is about to explore the health seeking practices of PLHIV. The PLHIV require a wide range of services including care, treatment and support, depending on the progression and stage of their HIV infection. Prior to perceive the fact of HIV positive the infected people take medicine and counseling from the nearest drug store and very often go to traditional healers and unqualified practitioners (Ahmad, 2005). Many studies have concentrated that PLHIV are satisfied with treatment and care from NGO clinics and to some extent from government hospitals. Organizational guidelines of organizations providing services to PLHIV may differ greatly between the different organizations, which are supported by the government and other donor agencies. In Bangladesh PLHIV may encounter social discrimination which creates serious problem in obtaining the requisite service and support (Skinner, et al., 2004).

In Bangladesh the HIV prevalence rate is low till today, but it is alarming and acting as a fatal silence (Amanullah, 2006) to destroy the potential human resources of Bangladesh. The geographical location is an unexpected for Bangladesh whereas excessive intention of migration has tantalized and accelerated the vulnerability of women and children. The high rates of crossmigration, unprotected cross border, lack of knowledge are responsible in this regard. In a study it is found that students are the third client group to the commercial sex workers (Amanullah and Choudhury, 2005; 2006; Rahman, 2007). Since the PLHIV cannot comprehend let alone trace the signs and symptoms of this deadly virus they may rush to the local drugstore for first aid. If they feel somewhat cured taking medicines and antiseptic from different sources e.g. traditional healer, homeopathic and Para-professional practitioners (Ahmed, 2005) they may not wish to take extra precautionary measures for this disease. Addressing HIV /AIDS the proper diagnosis and medical treatment are not available in the remote regions of the country. People Living with HIV and AIDS (PLHIV) often may come to Dhaka for treatment and care. But socioeconomic barriers sometimes may make them more vulnerable and susceptible to receiving proper treatment and counseling. The study focuses to explore how a variety of factors play role in directing the health seeking practices of PLHIV in Bangladesh. In order to conceptualize and measure the nature and status of HIV related services the researcher has kept in mind the contradictory patterns of service of NGO clinics and Govt. clinics. So the importance of this systematic study is more rational in this geographically vulnerable situation.

1.7 Scope of the Study The study has been conducted on the different areas of Dhaka, the capital city of Bangladesh.

The People Living with HIV and AIDS (PLHIV) have been interviewed for collecting primary data. HIV/AIDS related health service and practice of the concerned respondents were explored using both qualitative and quantitative data. For this some hypothesis are formulated reviewing literature and deducing from few theoretical frameworks. The study attempts to explore a variety of factors influencing the health seeking practices of PLHIV with a view to measuring the nature and status of services derived from different sources. At the time the level of knowledge of

concerned respondents is measured in order to get a comprehensive idea of perceived susceptibility and perceived severity on HIV/AIDS. So far as I know this study is first in its nature in Bangladesh. The findings of this study would be helpful not only to academicians but to the policy planners and development workers.

1.8 Limitations Since the study depends on respondent’s self reports, it may not be free from unintentional or intentional response biases or deliberate concealment. Being a more sensitive issue, People Living with HIV and AIDS (PLHIV) can keep aloof from giving any information which is more requisite and meaningful to glorify the status of the study. Besides, because of the survey’s nature and the extensive techniques taken by interviewers to ensure privacy and confidentiality, it is unlikely that respondents provided expected answers as to the complexity and severity of this lethal disease. For the sake of achieving the maximum respondents the researcher had to curtail the particular units of research area which could make any biasness in treating the desired sample size statistically representative.

With limited finance and time constraints the researcher had to curtail many programs of the present study. The multipluralistic data collection methods magnified the reliability of the overall findings. Findings are indicative and can be confidently applied for future decision making processes.

Chapter Two REVIEW OF LITERATURE Migration, unsafe sexual intercourse, needle sharing etc. are mostly liable for the massive worldwide transmission of HIV and AIDS. However, lack of adequate knowledge about AIDS and sex education has further aggravated the present epidemic. Although much development in care and increase of funds for HIV infection has been made, HIV and AIDS induced morbidity and mortality is quite high in the developing world (Ivers et al., 2009). Feminization of HIV and AIDS discloses several other facts. Violence against women associated with sexual harassment is a major factor for the spread of HIV (Koenig, Michael et al., 2004: 157). Often women especially teenage girls in developing countries do not want to expose their sexual illness for fear and shame. Also, patriarchal social system ignores women’s opinion and decision making even in cases like marriage and to conceive. Whatever be in the developed world; AIDS patients often face serious discrimination and stigma regarding treatment, normal life- living and even they are socially excluded in almost all third world countries like Ghana, India, and mostly in countries of Sub-Saharan Africa. However, the provision of treatment in those countries is not adequate and often HIV infected people lead a boring and captive life.

Bangladesh, being a developing country, still has a low prevalence rate of HIV transmission. The population groups considered to be most-at-risk include: female sex workers, male sex workers, MSM, transgender, IDUs and heroin smokers (Amanullah, 2002; 2005; 2006; Habib and

Amanullah, 2002; Azim et al., 2009; ICDDRB 2010). Other than that, lack of knowledge about family planning, misconceptions about the disease, illiteracy about STIs contribute to the spread of HIV in Bangladesh. Whatever the degree of severity of AIDS may be, people should be conscious and practice healthy and safe sexual relation (Kippax, 1993; Patton, 1996; Dowsett, 1993) and religious dogma about sexual life can also play a prime role in checking the transmission of AIDS by protecting extra-marital and unsafe sex.

2.1 HIV and AIDS: Global Context During 2009, some 2.6 million people became infected with HIV, including an estimated 370,000 children (UNAIDS/WHO, 2010). Most of these children are babies born to women with HIV, who acquire the virus during pregnancy, labor or delivery, or through breast milk. The year 2009 also saw 1.8 million deaths from AIDS related causes. The number of deaths probably peaked around 2004, and due to the expansion of antiretroviral therapy, declined by 19 percent between 2004 and 2009. Around half of people who acquire HIV become infected before they turn 25, and AIDS is the second most common cause of death among 20-24 year olds (UNAIDS/WHO, 2010).

AIDS is the indomitable monster that causes innumerous people to accept premature death throughout the world. All parts of the world are not equally affected by HIV. Sub-Saharan Africa has been massively devastated by the HIV/AIDS epidemic. The picture is especially bleak for the adolescent aged between 15 - 19 years. In some of the worst affected countries in southern Africa adolescent are greatly affected due to sexual abuse (UNAIDS/WHO, 2010). HIV has already caused an estimated 1.8 million deaths worldwide and has generated profound demographic changes in the most heavily affected countries (UNAIDS/WHO, 2010). Due to the devastating impact the pandemic has flourished throughout the world at an alarming rate making the disadvantaged and minority groups of population vulnerable to many health risks.

With around 68 percent of all people living with HIV residing in sub-Saharan Africa, the region carries the greatest burden of the epidemic. Epidemics in Asia have remained relatively stable and are still largely concentrated among high-risk groups. Conversely, the number of people living HIV in Eastern Europe and Central Asia with has almost tripled since 2000.

Table 2.1: HIV and AIDS: Global Scenario by Region, 2009 Region

Adults & children Adults & Adult living with children prevalence HIV/AIDS newly infected * (%)

Sub-Saharan Africa North Africa and Middle East South and South-East Asia East Asia Oceania Central and South America

22.5 million 460,000 4.1 million 770,000 57,000 1.4 million

1.8 million 75,000 270,000 82,000 4,500 92,000

5.0 0.2 0.3 <0.1 0.3 0.5

AIDSrelated deaths in adults & children 1.3 million 24,000 260,000 36,000 1,400 58,000

Caribbean 240,000 17,000 Eastern Europe and Central 1.4 million 130,000 Asia North America 1.5 million 70,000 Western and Central Europe 820,000 31,000 Global Total 33.3 million 2.6 million Source: Report on Global HIV/AIDS Epidemic, UNAIDS/WHO, 2010 * Proportion of adults aged 15-49 who are living with HIV/AIDS

1.0 0.8

12,000 76,000

0.5 0.2 0.8

26,000 8,500 1.8 million

The number of people living with HIV rose from around 8 million in 1990 to 33 million by the end of 2009 (Fig: 2.1). The overall growth of the epidemic has stabilized in recent years. The annual number of new HIV infections has steadily declined and due to the significant increase in people receiving antiretroviral therapy, the number of AIDS-related deaths has also declined.

Fig 2.1: Global number of people living with HIV, by year.

Source: Report on Global HIV/AIDS Epidemic, UNAIDS/WHO, 2010 Table 2.2: Global HIV and AIDS Estimates, (End of 2009) Global HIV/AIDS Epidemic in 2009 People living with HIV/AIDS

Estimate (in million) 33.3

Range (in million) 31.4-35.3

Adults living with HIV/AIDS

30.8

29.2-32.6

Women living with HIV/AIDS

15.9

14.8-17.2

Children living with HIV/AIDS

2.5

1.6-3.4

People newly infected with HIV

2.6

2.3-2.8

Adults newly infected with HIV

2.2

2.0-2.4

AIDS deaths Orphans (0-17) due to AIDS

1.8 16.6

1.6-2.1 14.4-18.8

Source: Report on Global HIV/AIDS Epidemic, UNAIDS/WHO, 2010 In the early to mid-1980s, while other parts of the world were beginning to deal with HIV and AIDS serious epidemics, Asia remained relatively unaffected. By the early 1990s, however, AIDS epidemics had emerged in several Asian countries and by the end of the decade; HIV was spreading rapidly in many areas of the continent.

Today, around 4.87 million people are living with HIV in South, East and South-east Asia (UNAIDS/WHO, 2010). Although national HIV prevalence rates in Asia appear to be relatively low, the populations of some Asian countries are so vast that these low percentages actually represent very large numbers of people living with HIV. In India for example, an estimated 0.1% of adults aged 15-49 are living with HIV, which seems low when compared to prevalence rates in some parts of sub-Saharan Africa. However, with a population of around one billion, this actually equates to 2.3 million adults living with HIV in India. (UNAIDS/WHO, 2010).

Table 2.3: HIV and AIDS: Asia India China Thailand Vietnam Indonesia Myanmar Pakistan Cambodia Malaysia Nepal

23,10,000 7,40,000 5,30,000 2,80,000 3,14,000 2,40,000 96,000 75,000 80,000 64,000

(Source: UNAIDS/WHO, 2010) While the epidemics in Cambodia, Myanmar and Thailand all showed declines in HIV prevalence, those in Indonesia and Vietnam are growing (UNAIDS/WHO, 2010). As estimated 33.3 million people were living with HIV in 2009, including the 2.6 million people who became newly infected in the past year and 1.8 million died from AIDS related illness in 2009 (UNAIDS/WHO, 2010).

2.2 HIV and AIDS: Bangladesh Perspective HIV prevalence in Bangladesh is low (â&#x20AC;š 1%) among the general population, even within the vulnerable population it continued to be low other than certain sections of injecting drug users.

Experts predicted several possible reasons for this: high levels of circumcision among men, until

recently relatively low levels of injecting drug use, and relatively low risk behavior in the society. There is consensus, however that are sick factors for the spread of HIV in Bangladesh: formal and informal commercial sex trade, low level of condom use, increasing injecting drug use, and rising prevalence levels among injecting drug users. Over the period of 1999-2008, HIV prevalence in central Dhaka showed rapid increase of HIV prevalence. The Serological surveillance shows that the rate of HIV has crossed the concentrated epidemic among IDUs. Rates in central Bangladesh rose from 1.4 percent to 7 percent since 1999, up to as high as 11% in one neighborhood of Dhaka (GOB, 2008; Amanullah, 2006; Khan, 2008).

The epidemic in Bangladesh seems to follow a typical pattern for Asian epidemics. The Asian epidemic model describes how in countries with sizeable IDU and MSM populations, the epidemic kicks off, often very rapidly, among injecting drug users. At the same time HIV is introduced in overlapping sexual networks of female and male sex workers and men who have sex with men. Subsequently HIV spreads through bridging populations to the general population.

Sexual networks largely determine the ultimate epidemic level, especially the proportion of men buying sex (NASP, 2008; Amanullah and Choudhury, 2005, 2007) Figure 2.2 Key indicators associated with HIV/AIDS in Bangladesh.

Displaced population

Unprotected sex

Unsafe blood transfusion

Migration

Injecting Drug Users (IDUs) Commercial Sex Workers (CSWs)

Poverty

Unhygienic surgery Malnutrition

HIV/AIDS Low risk perception

Tuberculosis Male Sex to Male

Geographical location

Sexually Transmitted Disease (STDs)

War and conflict Limitless entrance and exit through territorial area

HIV in Bangladesh remains at relatively low levels in most at-risk population groups, with the exception of injecting drug users (IDUs) where prevalence continues to grow. Although overall HIV prevalence remains under 0.1 percent among the general population in Bangladesh, there are risk factors that could fuel the spread of HIV among high-risk groups. Prompt and vigorous

action is needed to strengthen the quality and coverage of HIV prevention programs, particularly amongst IDUs (World Bank, 2009).

Table 2.4: HIV and AIDS: Bangladesh Scenario, 2009 Cases (Marked)

Total

HIV (identified) AIDS AIDS death Newly infected Total estimated

2088 850 241 343 7500

(Source: NASP, 2010, UNAIDS/WHO, 2010) 2.3 Globalization, MDGs and HIV/AIDS Prevention The sixth prime goal of MDGs is to reduce and combat HIV transmission throughout the world.

AIDS epidemic report (UNAIDS/WHO, 2010) shows that HIV transmission has been decreased and the past trend of HIV spreading is altered (Summit on the MDGs, 2010). Globalization affects all facets of human life, including health and well being. The HIV/AIDS epidemic has highlighted the global nature of human health and welfare and globalization has given rise to a trend toward finding common solutions to global health challenges. Numerous international funds have been set up in recent times to address global health challenges such as HIV. However, despite increasingly large amounts of funding for health initiatives being made available to poorer regions of the world, HIV infection rates and prevalence continue to increase worldwide. As a result, the AIDS epidemic is expanding and intensifying globally. Worst affected are undoubtedly the poorer regions of the world as combinations of poverty, disease, famine, political and economic instability and weak health infrastructure exacerbate the severe and far-reaching impacts of the epidemic (Caldwell and Pieris, 1999). Various global initiatives and collaborations are addressing the global HIV/AIDS challenge. For example, the United Nations Millennium Development Declaration, signed in 2000 by 189 nations, encompasses eight Millennium Development Goals (MDGs), three of which are health related: reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria and other diseases, by 2015 (Travis, 2001).

In her statement, Helen Clark (2009) depicts those laws facilitating targeting prevention services to the excluded and most risk prone parts of society, including MSM and drug users, contributed to bring HIV out of the dark. She mentioned that making laws for sex workers to use condoms and avoidance of punitive legal environment has led to the decline of health risks for sex workers and clients alike. She insists that Global HIV Commission should focus on: Laws and practices which in effect criminalize people living with HIV and vulnerable to HIV; Laws and practices which mitigate or sustain the violence and discrimination as experienced by women; and Laws and practices which facilitate or impede HIV-related treatment access (UNDP 2010).

But Clark (2009) astonishingly remarks that many countries still use the law to punish behavior associated with HIV transmission. She further added that HIV response has used new programs to reduce the price of HIV medicines and increase access to HIV related treatment. Voluntary Counseling and Testing (VCT) and Mother-to-Child Transmission (MTCT) have recently become a major focus of HIV control programs in developing countries (Dabis et al, 2000; De Cock et al, 2000). Experts (Marcelo 2007; Joseph 2008) suggests that the present HIV crisis can only be made pacified effectively with its relation with poverty and neoliberal globalization is addressed by broad, effective, and long term policy responses.

2.4 Mobility of the Population and HIV Transmission An increasingly mobile global population exacerbates the risk of HIV transmission. The increasing volume of international travel contributes to the spread of sexually transmitted infections, including HIV. Refugee populations arising from areas of conflict, estimated by the United Nations High Commission for Refugees to number 97 million worldwide (UNHCR, 2004) are at higher risk, as are internal migrants within countries, who oscillate between rural and urban milieu. According to the International Labor Organization, at the beginning of the 21st century, 120 million workers worldwide were migrants (ILO, 2OO2). Migration plays a significant role in the economic and cultural life of Burkina Faso, a factor that was shown to play a critical role in the spread of HIV from the very beginning of the epidemic (Dawson, 1988; UNAIDS/WHO, 2010). Similar picture is observed in Bangladesh, a South-East Asian developing country. More or less 250,000 people are said to migrate abroad in search of job (UNDP 2008). Very often and frequently these migrant people get infected with HIV for risk practice and transmit it after return to home (Amanullah, 2002).

In the contemporary literature on AIDS migration is seen as a generator of contracting HIV transmission (Tatum and Schoech, 1992). And the prevalence rate varies from city to city, place to place and across community. In many cases the unavailability of residence causes irresponse to HIV related treatment services (Montoya, et al 1998). The present literatures on HIV/AIDS reports that demographic and income eligibility often forces people to migrate from rural to urban areas and most of those migrated people engage in risk practices in many of the third world countries and even in developed countries like USA (Cohn, Klein, Mohr, Horst, and Weber, 1994).

2.5 HIV and AIDS Epidemic: Affected and Displaced Population Hundreds of millions of people worldwide are currently affected by armed conflict, both directly and indirectly. By the end of 2002, there were approximately 40 million displaced people globally: 15 million refugees (UNHCR, 2003a; UNRWA, 2003) and 25 million IDPs (Global IDP Project, 2003). The complex relationship between HIV/AIDS and conflict is still not documented and sometimes remains hidden. Many recent publications have asserted that conflict is directly associated an increase in HIV/AIDS transmission (Hooper, 1999; McGinn et al, 2001; UN Institute of Peace; Save the Children, 2002). One paper claimed that women are six times more likely to contract HIV in a refugee camp than in the general population outside of the camp

(Gardiner, 2001). Sub-Saharan Africa is disproportionately affected by the HIV/AIDS epidemic, epidemic and conflict. The epidemiology of HIV/AIDS during conflict is complicated, but the vulnerability of conflict-affected and forced-migrant populations (Khaw et al, 2000; Hankins et al, 2002; International Rescue Committee, 2002; Save the Children, 2002; Smith, 200) has been shown to be associated with the breakdown in social structures, lack of income and basic needs, sexual violence and abuse as well as increased use of drug.

There was a dramatic increase in the incidence of conflict and complex emergencies in the last half century. Manuel et al. (2010) further posits that Bosnia, Haiti and Liberia have undergone through protracted conflicts, and hostilities continue in Eastern DRC. The prevalence of HIV among people aged 15-49 in Bosnia, DRC, Haiti and Liberia in 2007 was estimated to be 0.1 percent, 1.5 percent, 2.2 percent, and 1.7 percent respectively. The fact is that displaced and sexually abused women conspicuously fail to get benefit from post-conflict HIV and other health interventions. In Haiti and DRC, displaced women have been living in extreme fear that they or their daughters may get infected with HIV. They stated also that having been raped, knowing someone who had been raped or fearing rape has now become a prime psychological impediment to return to their families and communities of their origin (Manuel et al., 2010).

Many countries have been seemingly overwhelmed by the speed and its impact on forced migrants (Kenny et al., 2010) and other mobile populations. Evidence-based experience, good assessment and a readiness to adapt programs to local realities has been the key to tackling HIV in Asia. For example, in Malaysia there are about 70,000 refugees from Myanmar. At the end of 2009, there were 124 refugees receiving ART supported by the Ministry of Health and UNHCR (Burton et al., 2010). A different notion often depicts the same criteria that conflict, displacement, food insecurity and poverty make the affected populations more prone to HIV transmission. There is a misconception that refugeesâ&#x20AC;&#x2122; HIV rates are always higher than those in their host countries; in fact, evidence suggests that the opposite is more likely, but it is always context specific (Spiegel, 2004) 2.6 HIV and AIDS: A Discrepancy between Urban and Rural Settings Poverty creates conditions ripe for HIV transmission. Economic growth has caused rapid urbanization in India, with large urban slum populations composed of migrants, manual laborers (UNDP, 2000). Currently 260 million people in India (26 percent of the population) live under the poverty line (Government of India, Economic Survey, 2000-2001). Low income, untreated STDs and sex trade increase the risk of HIV transmission, whereas the infections cause mucosal ulceration with an easy entry for HIV. India has a very high rate of STDs; the current estimates are about 6 percent to 9 percent of the population, with more than new infections per year. A sample of randomly selected households in Tamil Nadu found that that 2.1 percent of the adult population living in the countryside had HIV infection compared with 0.07 percent of the urban population. Agricultural output, the cornerstone of production in agrarian economies, is decreasing as a result of increased mortality in the workforce, resulting in what has been termed "new-variant famine". Studies predict that in the ten most severely affected African countries, the agricultural workforce will decline by 10â&#x20AC;&#x201C;26 percent by 2020 (ILO, 2002).

2.7 Knowledge, Attitudes and Practices about HIV and AIDS among PLHIV

In most cases, inadequate sexual knowledge associated with AIDS and a deficit of protective and treatment materials lead to the rise of practices and attitudes like – refusal to admit HIV infected persons in public hospitals, boycotting AIDS care professionals and thinking the treatment of HIV –infected persons as a wastage of resources in third world countries like Nigeria (Nigeria Federal Ministry of Health 2001). In some poor neighborhoods, African-American folk beliefs depict AIDS to ‘toilets’, ‘filth’, ‘touching’, ‘kissing’, and ‘mosquitoes’. There are even misbeliefs that HIV-infected persons could be cured if they have massive sex with virgin girls.

Like the treatment of other serious diseases many AIDS patients take the healing procedure of alternative, traditional and religious healers. Ingstad describes traditional Botswanian healers like- ngaka ya diatola(‘doctor of the bones’), ngaka ya dishotswa (‘doctor of herbs’), and profiti (a prophet of the African Churches). In this way, in several contexts, the cultural representation of AIDS can be a mix of medical and indigenous belief (Helman 1999: 340-356).

As to Parker, transmission and prevention of AIDS differs between developed and developing nations (Helman, 1999: 340-356). He further exemplifies it by citing the case of the USA and Western Europe and Brazil. As a result of this, strategies made for one country or region may not be totally appropriate for another. This is important that AIDS is intimately linked with sexual behaviors; this intimate area of human relationship is many times challenging to study and research. Problems also arise since average bisexual and homosexual men live within their families.

Female sex workers in third world countries are the worst victims of HIV- infection. In most cases, economic dependence and poverty are the prime causes of prostitution. Due to poor family background most prostitutes are illiterate or do not have the minimal sex education. So, they do not understand the necessity of using condoms and often they are forced by their clients not to use condoms at the time of sexual intercourse (AIDS Education and Prevention, 10 (4), 303-316, 1998). Moreover, structural factors also affect the transmission of HIV- infection among sex workers (Kinnel, 1991; Simon et al., 1993). Proper and adequate knowledge of HIV/AIDS has become the central topic of discussion today. In Bangladesh, a difference is seen regarding the knowledge about HIV/AIDS between rural and urban areas. Print and media campaign have a positive influence on proper knowledge of HIV transmission and prevention.

2.8 Risk Perception and HIV/AIDS Epidemic At present, in its third decade, HIV/AIDS has become one the most dangerous pandemics in modern history. The risk of AIDS is controlled and motivated by a wide number of factors. As to Stefan (2002), the risk of AIDS can be apprehended in three particular ways: a. risk as a ‘danger of modernization’, b. risk as a ‘neologism of insurance’, and c. risk as a ‘bio-political technology’ – at play in recent attempts to frame HIV/AIDS as a threat to international security.

In his famous book ‘Risk Society’, (1992) conceptualizes ‘risk’ as “a systematic way of dealing with hazards and insecurities induced and introduced by modernization itself” (Beck 1992: 21).

Beck’s distinction between ‘natural’ and ‘artificial’ hazards insists that in the age of AIDS we must confess that we are still subject to hazards originating in nature. AIDS as a disease of modernity, as mentioned before, is intimately linked to – a. modernization policies promoted by international organizations; b. the modernization of transport infrastructures enabling the

movement of goods and people across long distances; and c. to technologically complex processes for extracting mineral and biomedical resource.

The AIDS pandemic is rooted in variegated and complex ways with the neo-liberal development models used to accelerate rapid economic modernization. In many developing countries, AIDS crises require a degree of public expenditure to address it and its provision may clash with internal and external financial pressures. The projected million of people being infected with AIDS since the pandemic began, with a few exceptions, infected by one of the three modes of transmission: sexual, parental, and mother to child. Cases of infection through oral sex have been found but transmission of this type is perceived to be less risky than penile-vaginal or penile-anal sex.

Women aged between 15-49 are the most vulnerable and helpless group to be affected by HIVinfection. Because their male partners often are bisexuals and homosexuals and they maintain sexual relationships with their life-partners. The case of female sex workers cannot also be left omitted. Most of the time these women due to lack of sex and AIDS education do not use condoms and even conceive without testing AIDS. As a result, they themselves and their partners and also their newborn child/ children is/are infected with HIV (Zenilman et al. 1995; Ward et al.

1993; and Farmer et al. 1993).

Bangladeshâ&#x20AC;&#x2122;s 8th round of Serological Surveillance (2007) showed that HIV prevalence among all high-risk groups remained below 1 percent with the exception of injecting durg users. Among injecting drug users, prevalence was less than 2 percent in all sites except Dhaka. In Dhaka, prevalence rose from 1.7 percent in 1999 to 7 percent in 2006 marking the first concentrated epidemic among any high-risk group in Bangladesh (World Bank, 2009).

2.9 Women and Childrenâ&#x20AC;&#x2122;s Vulnerability to HIV and AIDS The entire physical, mental and social wellbeing of an individual in all matters relating to the sexual and reproduction should be the utmost concern of government and all stake holders in population since women are the producer of human offspring and the future of a nation is subject to their sound sexual and reproductive health. But in most cases women and children are the worst sufferer in terms of HIV- transmission. UN program on HIV/AIDS in 2009 projected that out of the 30.8 million adults were living with AIDS all over the world, 50 percent of them were women (UNAIDS/WHO, 2010). Data shows that 98 percent of these women live in the developing world (UNAIDS/UNFPA/UNIFEM, 2010). According to 2010 AIDS epidemic report updated by UNAIDS, up to 2009 of the total 33.3 million HIV infected, 15.9 million are women and 2.5 children are also the highly potential group to be infected by HIV (UNAIDS/WHO, 2010).

2.10 Socio-cultural Drawbacks of PLHIV and Treatment Seeking Patterns Health seeking behavior refers to those things that humans do to prevent diseases and to detect diseases in asymptomatic stages. In developing countries there are fewer opportunities for testing and treatment of AIDS and most often in these countries cultural practices play a significant role to the transmission of HIV.

In Africa, as to Daniel (2006) factors influencing sexual transmission of HIV include: a. promiscuity, with a high prevalence of sexually transmitted diseases; b. sexual practices associated with increased risk of HIV-transmission; c. cultural practices associated with increased virus transmission. Daniel (2006) argues, at present promiscuity is the most significant cultural factor liable for HIV-transmission in Africa. Female circumcision; such as infibulations, excision and sunna circumcision are found in Africa as cultural practices that make the female population more susceptible to HIV-infection . Sharing of unsterilized needles contributes as a factor for HIV-transmission in Africa. In parts of Africa, there is a general belief that Western medicine can provide explanation or cure for certain diseases (Kofi et al 1997:244).

Condom use in India was insignificant while 74 percent reported sex with female sex workers and 15 percent of male IDUs also reported having sex with men (Panda et al., 1998) which vehemently affects the rate of infecting with HIV/AIDS. Health counseling is a new concept in India. Patients here are much less proactive in seeking health care than in developed countries. In the context of HIV-test counseling, the process of building a risk inventory involves discussing the sexual life style of the client. This falls into the realm of taboo. Worse, high risk behavior is viewed as morally wrong; hence few visit the Voluntary Counseling and Testing (VCT) centers (Solomon et al., 2002) An emerging cadre of ‘para-professionals’ as main provider of formal allopathic care to the disadvantaged populations (Ahmad, 2005) was observed, in addition to the predominance of self-care in Bangladesh. Household poverty was instrumental in shaping health seeking behavior.

The probability to access to any type of healthcare, and professional allopathic care (MBBS) was found to be greater for men than for women. In third world countries like Bangladesh, there are very limited treatment and support provision for PLHIV. Most of the HIV-infected people cannot carry on required facilities of testing HIV. Since these tests are expensive and their scope is limited, a few NGOs solely carry on this responsibility. There are more or less 12000 HIVinfected people in Bangladesh (WHO 2009). But as data provided by the National AIDS/STD Program, only 452 AIDS patients are regularly given anti-retroviral therapy (ART). And still there is no provision of CD-4 test equipment outside Dhaka (Prothom Alo, 2010).

2.11 Social Stigma and Misconceptions: Discriminatory Attitudes towards PLHIV Stigma and discrimination play significant roles in the development and maintenance of the HIV epidemic. Especially the situation is dangerous in many third world countries like South Africa, Sub-Saharan African countries and South Asian countries like Bangladesh. In a developing country like Bangladesh, the high risk practicing groups like commercial sex workers, IDUs, MSM, transgender population (hijra) - are socially excluded (Khosla, 2009) . Matter of tremendous attention is that their deep-rooted causes of observed risky behaviors are not addressed and their treatment in complicated by different social and cultural barriers. In Bangladesh, generally social norms accord females comparatively lower status than males.

Transgender populations such as the ‘hijras’ are often threatened by local hoodlums and even face verbal and physical abuse. Moreover, behavior of MSM is not conceptualized as Western homosexuality. MSM also experience social discrimination and legal persecution. Often is the case of being HIV infected considered as socially-deviant behavior; i.e. as extra-marital and premarital sex. The female sex workers are worst suffering risk practicing population in Bangladesh

(Amanullah, 2002). Here they are deprived of their human and health rights and still sex work before marriage is considered socially immoral and deviant work. Also the CSWs are subject to harassment from hoodlums, law enforcing authorities, and brothel-owners alike. And all these factors pave the way of the spread of more HIV-transmission making the anti-AIDS programs (Khosla, 2009).

The same picture of Bangladesh has taken a severe and particularly a horrendous form in the apartheid system (Parker, et al. 2001). Sabatier (1988) states that discrimination against AIDS patients is perpetrated against communities that are thought to be more affected by HIV in terms of skin color, gender, sexual orientation, type of work, i.e. prostitution and geography. Among the world countries, South Africa has the largest number of incidents of stigma. Recently, the situation has been of stigma and discrimination has been so severe and dangerous that recently former UN Secretary General Kofi Annan made a combined call to end racism and discrimination against PLHIV (Skinner, 2004).

2.12 HIV/AIDS Control Program and Public Response in Bangladesh In an attempt to avert generalized epidemics The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) has granted Bangladesh 265+ million US$ (till Round 8) to fight all three diseases (AIDS, TB and Malaria). A recent GFATM grant (Round 6) of US$ 40 million to promote prevention activities through high risk interventions for the MARP and the especially vulnerable young people is also being managed by Save the Children. To limit the spread of HIV among the vulnerable young people and Most at Risk Populations, Bangladesh has received 59.7 million US$ under two separate grants, Round-2 and Round-6, from the Global Fund (UNAIDS/WHO, 2005).

Through the collaborative efforts of Save the Children USA, the implementing NGOs and the Government of Bangladesh tremendous progress has been made, achieving 85 percent of the planned activities in the first two years and GFATM appreciated it and announced the project as a best practice in partnership model internationally. Since 2004, Save the Children has carried out critical activities including setting up an MIS database through data collection and monitoring and evaluation, conducting baseline research on key target groups, producing and disseminating behavioral change communication and advocacy materials, conducting capacity building with providers on Youth Friendly Health Services based on approved National Standards, and most notably integrating an HIV/AIDS education curriculum into the formal education system from grades 6 to 12. (GOB, UNAIDS/WHO 2005, UNDP, 2006) The goal of HATI is to 'reduce the spread of HIV and the impact of AIDS for the high-risk groups as well as the general population of Bangladesh by undertaking targeted interventions among the high-risk groups'. HAPP (HIV/AIDS Prevention Project) came to an end in December 31, 2007 and the financing of HIV activities moved into HNPSP. As the selection and launching of MSA of HNPSP getting delayed, for managing Targeted Intervention beyond December 2008, it was decided that the current set up would continue till December 2008 for avoiding interruptions. UNICEF has set its own outcomes the project as to reduce risk of HIV transmission among the most at Risk Population (MARP) and keep the HIV prevalence below the level of concentrated epidemic among them (CPAP outcomes) and the purpose as 'to increase capacity of NGOs to respond to HIV epidemic' with the specific expected outputs (GOB, UNAIDS/WHO 2005, UNDP, 2006)

Several effective programs undertaken by both government and NOG initiatives are at work in Bangladesh. The National AIDS/STD Program has set in place guidelines on key issues including testing, care, blood safety, sexually transmitted infections, and prevention among youth, women, migrant populations, and sex workers (Wikipedia, 2010). In 2004, a six-year National Strategic Plan (2004–2010) was approved. The country’s HIV policies and strategies are based on other successful programs in Bangladesh and include participation from schools, as well as religious and community organizations (NASP, 2010) From 2000–2005, USAID's IMPACT Project had been implemented in Bangladesh. From then until October 2009, USAID's Bangladesh AIDS Program (BAP) had been managed working with 21 local organizations and NGOs on 23 projects to provide a strong, coherent approach to outreach among the most vulnerable. Now BAP is scaling up and integrating HIV prevention efforts and provision of clinical services. Drop-in centers—branded as Modhumita—provide health services for vulnerable populations in strategic HIV and AIDS "hotspots." (BAP, 2010).

Chapter Three THEORETICAL FRAMEWORK

3.1 Health Belief Model (HBM) As a psychological theory, the stages of the Health Belief Model (HBM) massively attract the individual without assessing the role that structural and environmental issues may have on a person’s ability to enact behavior change. The Health Belief Model (HBM) is one of the most widely used conceptual frameworks for understanding health behavior. In the 1950s the U.S. public health service flourished the model in order to explain people’s participation in health screenings (Rosenstock, 1966). The HBM aims to predict whether individuals choose to engage in a healthy action in order to prevent the chances of diseases or the health threats posed by inappropriate or unhealthy practices. According to HBM, there are two main types of beliefs that influence people to take appropriate preventive action. These include beliefs related to readiness to take action and beliefs related to modifying factors that facilitate or inhibit action. The variables that are used to measure readiness to take action are perceived susceptibility to the illness or any health threats and the perceived severity of the illness. perceived benefits (i, e. the perceived advantages of taking action) and perceived barriers (i.e. the perceived costs or constraints of the specific action) are the main modifying variables (Rosenstock, 1990; Norman and Brain, 2005). According to the HBM when individuals are faced with a potential threat to their health they consider their susceptibility to, and the severity of the health threat.

According to HBM once an individual perceives a threat to his/her health and is simultaneously cues to action, and his/her perceived benefits outweigh his/her perceived threats then the individual is most likely to undertake the recommended preventive health action. For instances when applied to parents’ immunization behavior, the HBM suggests that simply having knowledge and awareness about infectious diseases will not necessarily result in increased visits to a hospital for vaccinations. Instead, the model specifies four related elements that must be present for knowledge about disease to be translated into preventive action.

Figure 3.1: A schematic outline of the Health Belief Model proposed by Rosenstock (1990) Socio-demographic factors (education, age, sex, race, ethnicity)

Expectations Perceived benefits to action Perceived barriers to action Perceived self- efficacy to perform action

Cues to Action Media Personal influence

Threats Perceived susceptibility(or, acceptance of the diagnosis) Perceived severity of ill-health condition

Behavior to reduce threats based on expectations

This is a more psychological model applied to explore and examine a variety of health behaviors in diverse populations. With the advent of HIV/AIDS, this model has been used to gain a better understanding of sexual risk behaviors (Rosenstock et al, 1994). The HBM is based on the understanding that a person will take a health-related action (i.e., use condoms) if that person: feels that a negative health condition (i.e., HIV) can be avoided, has a positive expectation that by taking a recommended action, he/she will avoid a negative health condition (i.e., using condoms will be effective at preventing HIV), and believes that he/she can successfully take a recommended health action (i.e., he/she can use condoms comfortably and with confidence).

The Health Belief Model is a framework for motivating people to take positive health actions that uses the desire to avoid a negative health consequence as the prime motivation. For example, HIV is a negative health consequence, and the desire to avoid HIV can be used to motivate sexually active people into practicing safe sex. Similarly, the perceived threat of a heart attack can be used to motivate a person with high blood pressure into exercising more often.

A great limitation following with the HBM is lack of consistency in applying and testing of the model. For example, identifying and measuring the concept of cues to action has been problematic. Cues can be diverse in nature, may occur in a transient manner, and an individual may or may not consciously remember events that elicit action. In specific studies, the nature and importance of cues is more difficult to evaluate because research participants are questioned about behaviors performed in the past. The socio-structural variables attached and crucial in

shaping and influencing personal behavior like sexual risk practice, excessive alcoholism, immunization behavior, dieting (Matsuda, 2002; Amanullah, 2004, 2009; Uddin, 2009) are massively overlooked in formulating this model. This is supposed to negate all socio-cultural factors like race, ethnicity, myths and after all discriminatory attitude and brand itself as a unilinear model.

3.1.1 Knowledge, Attitude, Practice (KAP) Model The knowledge, Attitude and Practice (KAP) Model was popular in developing countries to study human behavior during 1950s to 1960s. To protect human risk behavior, psychologists used this first. The UCSF AIDS Health Project 1998 stated that, in HIV/STD prevention as in other areas of health and behavior, the knowledge, the attitude-behavior (KAP) or knowledge attitude-practice continues is often referred to. In other words, the main argument of KAP model is that human behavior is influenced by ascribed knowledge which can change the attitude. As a result the practice may be changed. This can be shown in the following way: Knowledge

Attitude

Practice

Where, Knowledge= the capacity to acquire and use information, a mixture of comprehension, experience, discernment and skill.

Attitude= the inclinations to reject in a certain pre-dispositions or to organize opinions into coherent and interrelated structures.

Practice= the application of rule and knowledge that leads to action. According to the sociologists, it is not easy to change sexual behavior.

They stated that the particular behavior of clients promote the sex workers to risk behavior. The sociologists argued that the Commercial Sex Workers (CSW) cannot practice on ascribed knowledge. Though they have positive attitude towards knowledge they cannot practice to survive. The sociologists identified these factors for these risk practice. These are survival, male domination, economic stability, cultural variation, religion, education, environment and remoteness of diseases. The sociologists believe that KAP model can be effective in developing countries if it is reshaped by the cultural construction. They argued that practice is originated through culture and it is related to individualâ&#x20AC;&#x2122;s own belief, socialization process, rituals, religion etc.

3.2 The Theory of Reasoned Action (TRA)

The TRA model focuses on a framework used for linking a number of mediating variables in response to risk behavior. This theory mainly provides a rigorous construct that links individual beliefs, attitudes, intentions, and behavior (Fishbein et al. 1994). Essentially the behavioral and normative beliefs- referred to as cognitive structures influence individual attitudes and subjective norms respectively. On the contrary attitudes and norms shape a person’s intention to perform a behavior. Critically the TRA model adapts a linear process in which changes in an individual’s behavioral and normative beliefs will ultimately affect the individual’s behavior. The best predictor of behavior is intention. Intention is the cognitive representation of a person's readiness to perform a given behavior, and it is considered to be the immediate antecedent of behavior.

This intention is determined by three things: their attitude toward the specific behavior, their subjective norms and their perceived behavioral control. The theory of planned behavior holds that only specific attitudes toward the behavior in question can be expected to predict that behavior. Attitudes toward the behavior are conceptualized as the individual’s positive or negative feelings about performing a behavior. It is appropriated through an assessment of one’s beliefs regarding the consequences. Normative beliefs are a combination of a person’s beliefs regarding other people’s views of a behavior and the person’s willingness to conform to those views. Finally, perceived behavioral control influences intentions. Perceived behavioral control refers to people's perceptions of their ability to perform a given behavior. These predictors lead to intention. A general rule, the more favorable the attitude and the subjective norm, and the greater the perceived control the stronger should the person’s intention to perform the behavior in question.

Figure 3.2: The Theory of Reasoned Action (Ajen and Fishbein, 1994)

The person’s beliefs that the behavior leads to certain outcomes and his/her evaluations of the outcomes.

Attitude toward the behaviour

Relative importance of attitudinal and normative considerations The person’s beliefs that the specific individual or groups think he/she should or should not perform behaviour and his/her motivation to comply with the specific references

Intention

Behaviourr r

Subjective norms

Using the Theory of Reasoned Action (TRA) the study has explained and predicted a variety of human behaviors. Based on the premise that humans are rational and that the behaviors being explored are under volitional control, the theory provides a construct that links individual beliefs, attitudes, intensions, and behaviour. This theory asserts that the extent of behaviour change can be viewed as a function of a person’s perception of what his/her peers’ attitude is towards performing the task. The identification of community norms as an incentive or hindrance to change is an important factor, especially in low perceived/high actual risk environments, and highlights the need to work closely with community exceptions (Fishbein et al.1994).

3.3 AIDS Risk Reduction Model (ARRM) Introduced in 1900 the AIDS Risk Reduction Model (ARRM) encompasses a scholastic framework for explaining and predicting the behavior change efforts of individuals in association with the sexual transmission of HIV/AIDS. The three stage model, AARM incorporates several variables from other behavior change theories, including the Health Belief Model, efficacy theory, emotional influences and interpersonal processes. The stages as well as the hypothesized factors that influence the successful completion of each stage (Catania, Kegeles and Coates, 1990) are hereby attached.

Firstly: Recognition and labeling of one’s behavior as high risk Hypothesized influences

knowledge of sexual activities associated with HIV transmission; believing that one is personally susceptible to contacting HIV; believing that having AIDS is an undesirable; Social norms and networking.

Secondly: Making a commitment to reduce high-risk sexual contacts and to increase low-risk activities Hypothesized influences cost and benefits; enjoyment(e.g., will the changes affect my enjoyment of sex); response efficacy; self-efficacy; Knowledge of the health utility and enjoyability of a sexual practice, as well as social factors (group norms and social support), are believed to influence an individual’s cost and benefit and self efficacy beliefs.

Thirdly: Taking action Hypothesized influences social networking and problem-solving choices (self-help, informal and formal help); prior experiences with problems and solutions; level of self-esteem; resource requirements of acquiring help; ability to communicate verbally with sexual partner; Sexual partner’s beliefs and behaviors.

There are also some other internal and external factors (Catania et al, 1990) that may motivate individual movement across stages. For instance, aversive emotional states (e.g. high level of distress over HIV/AIDS or alcohol and drug that blunt emotional states) may facilitate or hinder the labeling of one’s behavior. It is to focus those external motivators, such as public campaigns, an image of a person dying from AIDS, or informal support groups, may also cause people to examine and potentially change their sexual activities. The domain of individual’s behaviour and attitudes should be tagged as high risk in order to avoid the contract of HIV. The findings of my study show that risk perception of the PLHIV is mainly dominated by socio-cultural factors on a broader sense. Awareness and networking play a pivotal role in determining the conscious mind of an individual towards high risk perception. The theory of Catania is highly intertwined with my research findings expressing a unilinear relationship.

3.4 Power Relations: A Nexus between Discourse and Sexuality Power every now and then determines the ability of dominant class who want to exercise their will over the subordinate class taking the opportunity of their many shortcomings and backdrops.

Foucault at first attacks the conventional notion of power and asserts that power is something which is performed, something more like a strategy than a possession (Foucault, 1978).

Power must be analyzed as something which circulates, or as something which only functions in the form of chain. Power is employed and exercised through a network like organization.

Individuals are the vehicles of power, not its points of application (Foucault, 1980:98). Power is

regarded as a chain or net, which is a system of relations spread throughout the society (Mills, 2007:35). Individuals should not be seen as the recipients of power, but as the place where power is enacted and resisted. Thus his theorizing of power forces us to reconceptualize not only power itself but also the role that individuals play in power relations whether they are simply subjected to oppression or whether they actively play role in the form of their relations with others and with institutions (Mills, 2007:35).

Rather than a top down model of power relations which examines the way the state or institutions oppress people he is concerned to develop a bottom up model where the body is one of sites where power is enacted and resisted (Mills, 2007: 82). Foucault attempts to describe the interactions and the individual without assuming that one of them is primary in the relation. The focus in Foucault’s work seems the individual is not to be conceived of as a sort of elementary nucleus…on which power comes to fasten …in fact it is already one of the prime effects of power that certain bodies, certain gestures, certain discourses, certain desires, come to be identified and constituted as individuals (Foucault, 1980:98). Thus, rather than seeing individuals as stable entities, he analyses the discursive processes through which bodies are constituted. He also shows that the notion of liberation through sexuality is an illusion as “where there is desire the power relation is already present: an illusion, then to denounce this relation for a repression exerted after the event; but vanity as well to go questing after a desire that is beyond the reach of power (Foucault,1978:15).

In a disciplinary scheme Foucault also talks about the way that women’s bodies and sexualities are shaped by social pressures (Mills, 2007:93). Women’s bodies, particularly middle-class women’s bodies have been the subject of a vast array of different practices and discursive regimes. Foucault (1975) describes the disciplinary structures which were put in place in prisons and armies in the nineteenth century in order to ensure the smooth running of these institutions; people within the institutions were forced to obey commands and perform even mundane actions according to a rigid set of rules which were internalized to such an extent that they began to seem part of the individual’s personality. Capitalist production has colonialized a great number of techniques from such institutions, and others, in its construction of the work, ensuring that notions such as punctuality, self-discipline and precision are internalized by workers as desirable qualities (Mills, 2007:93).

3.5 Sociological and Cultural Approaches to Risk Perceptions The two dominant traditions of socio-cultural risk research which started to dominate the field in the early 1910s were the cultural approach of Douglas and Wildavsky (1982) and the Risk Society approach of Ulrich Beck (1992). In their seminal work Risk and Culture, Douglas and Wildavsky (1982) view risk perception from the functionalist perspective as primarily a sociocultural phenomenon affected by social organization and values that guide behavior and affect judgments about what is to be considered “dangerous” (Oliver-Smith, 1996).

Douglas and Wildavsky developed cultural theory on a grid/group pattern and maintain that it has an important role to play in the determination of risk perception. They argued that risks are socially constructed as each culture and each set of shared values and supporting social institutions are biased toward highlighting certain risks and downplaying others (Douglas and Wildavsky, 1982). The rigorous analysis of risk perception and behavior must involve elements from the psychological approaches, as well as from the anthropological approaches. Mary

Douglas and her colleagues pioneered the ‘grid-group’ cultural theory that challenged the standardized psychological approach to risk perception. The central theme of cultural theory is that “human attitudes towards risk perception are not homogenous but very systematical according to cultural biases” (Royal Society, 1992:112). The way people perceive and act upon the world is the cornerstone of cultural theory. The basis of cultural theory is grid group typology. On pursuance of Douglas, variation in social participation can be adequately accounted by the dynamics between two dimensions group and grid.

The group itself is defined in terms of the claims it makes over its constituent members, the boundary it draws around them, the rights it confers on them to use its name and other protections, and levies and constraints it applies. Group is one obvious environmental setting, but we seem unable to conceive of the individual’s environment if it is not a group of some kind (Douglas, 1978:8). In a single statement, group refers to whether an individual is member of bonded social units and how absorbing the group’s activities are on the individual. The other dimension of grid-group theory is grid.

The term grid suggests the cross-hatch of the rules to which individuals are subject to in course of their interaction. As a dimension it shows a progressive change in the mode of control. At the strong end, there are visible rules about space and time related to social roles; at the other end, near zero, the formal classifications fade, and finally vanish. At the strong end of grid, individuals do not, as such freely transact with one another. An explicit set of institutionalized classifications keep them apart and regulate their interactions, restricting their options (Douglas, 1978:8). With a concise explanation grid indicates to what a degree a social context is regulative and restrictive in regard to individual’s behavior.

Having the dynamics of group involvement and the subsequent relationship between group and grid, researchers were able to identify four major groups in modern society that relate to risk analysis. The four common groups or patterns of social relations: hierarchy, egalitarianism, individualism and fatalism (Douglas and Wildabsky et al, 1982), what societies choose to call risky is largely determined by social and cultural factors, no nature (Royal Society, 1992:112) The way theory has been flourished and set in my research is that risk practices are a great concern for enhancing health related complexities. Risk perception tremendously varies from person to person, society to society in this new knowledge based and technically well-equipped postmodern society. The nature and content of risk has turned into a new form and affably attached the changing practices in this global cultural setting. People are not well aware of the high risk practices in our social setting. Even if they perceive the ramification of risk activities, they do not carry out any precautionary measure for upgrading and alleviating the affectivity of that. IDUs, female sex workers, commercial blood users, foreign return migrant workers are high risk population to contacting HIV in our country. Risk should be regarded as a catalyst between perceived susceptibility and perceived severity of the people, though it is socio-culturally wellshaped model affecting the psychometric notions of the victims (Royal Society, 1992) The study relates Beck’s (1992) risk society to conform about risk practices mostly dominated by socio-cultural factors. Risk practice as to HIV/AIDS is a great concern for the forthcoming days of Bangladesh. It goes without saying that risk practices are mainly determined by socio-cultural factors in the context of Bangladesh.

3.5.1 Risk Society and the Mass Media

Risk society is a social theory which describes the production and management of risks in modern society. Beck basically focused on the role of mass media in revealing risks and describing the competing scientific and political interests in their management. Ulrich Beck has placed ideas of ‘risk society’ on the intellectual map; his social theory of late modern society and its endemic production of potentially catastrophic risks has attracted (Cottle,1998:5), considerably academic interest in Europe and beyond. Dispersed across his writings is a view of the mass media which is theoretically positioned as playing a crucial role in process of risk revelation, the social contestation that surrounds scientific knowledge of risks, and also processes of social challenge to ‘risk society’. He is also surely right to signal the important positions occupied and performed by the mass media within the field of risk communications (Cottle, 1998:5).

The term ‘risk society’ is not intended to imply an increase of risk in society, but rather a society that is organized in response to risks. It is a society increasingly preoccupied with the future (and also with safety), which generates the notion of risks (Giddens, 1999: 3). While human beings have always have been subjected to a level of risk, modern society is exposed to a particular type of risk that is the result of modernization process itself, altering social organization. Modern risks are mainly the product of human activity (Beck, 1992).

Beck’s view of ‘risk society’ is essentially catastrophic; we are living on the ‘volcano of civilization’ in which exceptional conditions threaten to become the norm it is as if Chernobyl, or perhaps a worst-case scenario of bovine spongiform encephalopathy (BSE) in the UK, exemplifies his understanding of ‘risk society’. Catastrophes that touch the vital nerves of society in a context of highly bureaucratic safety and welfare around the sensationalist greed of the mass media, threaten markets, make sales prospects unpredictable, devalue capital and set streams of voters in motion. Thus the evening news ultimately exceeds even the fantasies of counter cultural dissent; daily newspaper reading becomes an exercise in technology critique (Beck, 1992a: 116) Beck also presents us with television ontology, developing a view of the constitutive role played by the television in everyday life, and how this relates to wider environmental concerns.

Television is thought to position us as individuated viewers, consuming standardized, increasingly globalized, programming while nonetheless opening up new vistas for private contemplation—a formulation in many respects redolent of William’s earlier ‘mobile privatization’ (Williams, 1974: 26). Through the media we lead a kind of spatial and temporal double life. We are at one and the same time here and somewhere else. These sorts of emerging life situations seem to display an individual and institutional schizophrenia in their ‘bilocality’ (Beck, 1992b:132-3) His television of ‘bilocality’ presents both an opportunity and a danger: though exposed to the possibility of ‘long distance morality’, individuals may become apathetic in response to excessive media demands placed upon them (Tester, 1994:1995). Though the increasingly individualized society lends itself to single-issue politics and movements, the media is thought capable of performing a steering role in relation to these.

Identifying the mass media as an important domain for the social construction and social definition of , as well as the social challenge to , ‘risk society’, his ideas resonate with the interests of mass communication researchers pursuing the social and discursive processes involved in the social construction and representation of social problems(Cottle, 1998:25).

Though highly promising, on closer inspection Beck’s ideas on the media appear to have corporate an ontological and /epistemological slippage that renders his understanding of the actual social processes involved in relation to the representation of risks indistinct. Ideas of

cultural symbolism, and the role of culture more generally, in mediating risks remain underdeveloped and the differentiated nature of the news media and the contingent nature of their appeals were found to have been overlooked (Cottle, 1998).

3.6 Labeling Theory: Social Organization and the Individual Labeling Theory refers to the idea that individuals become deviant when two things occur: (a) a deviant label is applied to them (e.g., loner, punk) and (b) they adopt the label by exhibiting the behaviors, actions, and attitudes associated with it. This approach to deviance recognizes its cultural relativity and is aware that deviance can result from power imbalances. But it takes the idea of deviance further by illustrating how a deviant identity develops through the application and adoption of labels. Labeling theory argues that people become deviant as a result of people forcing that identity upon them and then adopting the identity. Labels are understood to be the names associated with identities or role-sets in society. Examples of more innocuous labels might include father or lover. Deviant labels refer to identities that are known for falling outside of cultural norms, like loner or punk (Goffman, 1963).

There are two additional ideas related to the labeling theory approach to understanding deviance.

First, once a deviant identity is adopted, it is often the case that the past behaviors of the now deviant individual are re-interpreted in light of the new identity. The process of re-casting one's past actions in light of a current identity is referred to as retrospective labeling.

Another important element of labeling theory involves the idea of stigma. Stigma is a quality, behavior, or reputation applied to discredit someone and at the same time makes the individual psychologically stratified from others in an unexpected way. Stigma is conceptualized as the phenomenon whereby an individual with an attribute is deeply discredited by his/her society and rejected as a result of the attribute (Goffman, 1963). This is a process by which the reaction of others spoils normal identity of a person. Goffman emphasizes the fact that the stigma relationship is one between an individual and a social setting with a given set of expectations; thus, everyone at different times will play both roles of stigmatized and stigmatizer (or, as he puts it, "normal"). He addressed the three different types of potential social stigma. These are physical deformities, perceived abnormalities or blemishes of character (such as addiction, mental disorder, or imprisonment) and tribally allocated stigmas related to another’s race, nation or religion (Cockerham, 2000).

The dramatic expansion which drew Goffman’s attention is that an individual has a both a personal and social identity, and that the central feature of the stigmatized individual’s situation in life is the search for acceptance by so-called ‘normals’. He stated that there are three stages in the learning of stigmatized person. Stage one is learning the ‘normal’ point of view and he or she disqualified for according to it. Stage two is learning to cope with the way others treat the kind of person he or she is supposed to be. Stage three is learning to cover an abnormality and pretend to be like everyone else in the group. For example, an illiterate person may try to ‘ pass’ as literate by pretending to read the newspaper, or a mentally distressed person may a special effort to behave in ways which others find acceptable.

This is to state that stigmatization involves dehumanization, threat, aversion and sometimes the depersonalization of others into stereotypic caricatures from the perspective of the stigmatizer.

Goffman gives the example of blacks being stigmatized among whites, and whites being stigmatized among blacks. Stigmatizing others can serve several functions for an individual, including self-esteem enhancement, control enhancement, and anxiety buffering, through

"downward-comparison-" comparing oneself to less fortunate others can increase one's own subjective sense of well-being and therefore boost one's self-esteem (Heatherton, et al., 2000).

This can be asserted that stigma refers to the situation of the individual who is disqualified from full social acceptance because of some mark of infamy or disgrace or a label that is often difficult to hide or disguise (Goffman, 1963).

On pursuance of the study, PLHIV belong to a new domain of identity crisis when they perceive the matter that they are already infected with HIV. Soon after disclosing the issue of affecting with HIV, the victims follow changes in the attitudes of others which make them separated and deviant from the normal way of living and social setting. In accordance with the Gofmanâ&#x20AC;&#x2122;s labeling theory, PLHIV try to cope with the surrounding ambience and attitudes of others in a scholastic way. In spite of having limited participations in all social activities, they have to bear up lots of social burdens and comments in an unconscious mind. At a stage PLHIV find them isolated and disappointed in terms of living status in society (Goffman, 1963).

Some interactionists regard human behavior as the product of what people decide is going on around them. They are there most interested not in events and their apparent causes, but in the meaning or interpretation that individuals pace upon events. For example perception of health risks such as HIV/AIDS related complexities and susceptibility to health risks are culturally shaped, regionally contextualized. The outstanding character many studies pick up remains that survivability is the big question for the population at risk, risk perception and safe health promoting behavior are likely to be less important for them. Female sex workers, commercial sex workers and injecting drug users are high risk population (Amanullah, 2002) in the contemporary society. Survivability is the main and crucial concern for existing them.

Women are enthusiastically assumed to be the focus of attention in this male dominated patriarchal society. Whereas women and children are more susceptible to HIV in Bangladesh because of over-migration to overseas and unprotected sexual intercourse, the situation is still getting worse and affecting the base of society tremendously. The vulnerability of women becomes more manifest after infecting with HIV, if they belong to husbandâ&#x20AC;&#x2122;s family and share anything of this health related complexities. People from husbandâ&#x20AC;&#x2122;s family do not treat them well and very often claims to the bearer of HIV. Because of the patriarchal and dominant attitudes, the treatment seeking patterns as to HIV varies from person to person. Testing facilities and medical services are not ensured ever and anon because of social bindings and personal unawareness.

Frankly speaking women feel embarrassed situation and mortification for focusing themselves in this debated social setting due to many internal factors. The society determines one sort of label for these disadvantaged women in a literal sense. A silence oppression and stigmatization derived from family haunt the way of living of PLHIV, especially women.

The stigmatized are ostracized, devalued, rejected, scorned and shunned in our society. They experience discrimination, insults, and attacks and are even murdered. Those who perceive themselves to be members of a stigmatized group, whether it is obvious to those around them or not, often experience psychological distress and many view themselves contemptuously different (Heatherton, et al., 2000). Although the experience of being stigmatized may take a toll on selfesteem, academic achievement, and other outcomes, many people with stigmatized attributes have high self-esteem, perform at high levels, are happy and appear to be quite resilient to their negative experiences (Heatherton, et al., 2000).

The study gives equal emphasis on the severity of discriminatory attitudes towards PLHIV, along with explaining the health seeking practices of the victims. Considering the health related risk

factors and treatment practices, this research is supposed to focus the nature and character of vulnerability and distresses of stigmatized population in this society.

Chapter Four METHODOLOGY To achieve objectives of the current study both quantitative and qualitative techniques of data collection were applied. In order to supplement quantitative data qualitative data has been incorporated. Case studies were conducted for collecting qualitative data from People Living with HIV/AIDS (PLHIV). Collecting data through survey has been accomplished for exploring the health seeking practices and the existing gaps between NGO clinics/service centers and Government clinics in terms of services to achieve a holistic view of the respondents.

4.1 Selection of the Research Area Dhaka, the capital city of Bangladesh has been chosen as the research area for collecting data.

The researcher has identified some selective NGO clinics working on the treatment and care of People Living with HIV/AIDS (PLHIV) in Dhaka city to get an overall scenario of the health seeking practices of the victims. The study has been conducted in both NGO clinics and DIC in Dhaka city because People Living with HIV/AIDS (PLHIV) from different regions of the remote areas of Bangladesh come here to receive treatment and service.

4.2 Data Collection Methods To carry out the survey a semi-structured and self-employed interview schedule has been used for compiling data in keeping with the objectives of the study. As a part of the comprehensive study, some case studies have also been conducted. These case studies provided in-depth information as to the health seeking practices of PLHIV determined by socioeconomic factors and the exiting differences of health services between NGO clinics and Govt. clinics.

The decision of using both qualitative and quantitative methods of data collection was because of their appropriateness for examining different facets of the phenomenon under study, for triangulation of the data, and for adding breadth and depth to the examination of the issues studied. These purposes are consistent with the suggestions made by Green et.al. (1989) and Patton (1990) about the use of both quantitative and qualitative methods of research in a singular study. Such pluralism in methodology or triangulation, we argue, is not aimed merely at validation but at deepening and widening oneâ&#x20AC;&#x2122;s understanding about the phenomenon being studied (WHO, 1997; Amanullah, 2002).

4.3 Sampling Procedure As part of non probability procedure data were collected purposively from the victims who were available during the special treatment and counseling day. The People Living with HIV/AIDS (PLHIV) are the population of my research work. Being a highly sensitive and confidential issue

the researcher has been able to reach 100 respondents who are actively HIV positive, for conducting survey. As part of collecting qualitative information the study adopts twenty cases of the victims. The process which had been adopted for collecting data was snowball sampling process. Because of organizational confidentiality and pressure it was challenging for the researcher to gather accurate information about PLHIV. With organizational and individual assistance the researcher could manage the situation and collect information which again reminds the application of snowball sampling.

Though many NGOs are working on HIV/AIDS in Dhaka city, the researcher chose two renowned NGOs called Asar Alo Society and Mukto Akash as well as one DIC due to strict constraints and formalities. Recognizing himself as an academician the researcher had to cross and accomplish a comprehensive process of submitting letters signed by supervisor in a condition of not disclosing any information of their clients. The study covers 70, 15 and 15 PLHIV respectively from Asar Alo Society, Mukto Akash as well as DIC. 4.4 Construction of the Interview Schedule For conducting survey, a semi-structured interview schedule was developed. The interview schedule included six parts containing the information: Socio-demographic characteristics Socio-economic determinants (e.g. rank of occupational status, category of income, level of education etc.)

Knowledge on HIV/AIDS and its association STDs and STIs Mobility of the population Exposure to mass media Risk communication an risk perception Attitudes towards susceptibility and severity of the disease/illness Treatment seeking patterns and sources Health services received from health centers Attitudes towards HIV/AIDS related stigma and superstition Response to HIV/AIDS related public control program 4.5 Pre-testing and Finalization of Survey Instrument The pre-testing was conducted among small group from the sample population in order to make an experiment of the effectiveness of research instruments. The researcher designed the draft interview schedule and also completed pre-testing. Based on pre-test results the translation, consistency and integrity of the interview schedule were verified. Researcher then finalized the schedule and showed it to the supervisor for final approval. After final approval of the supervisor the Bengali interview schedule was printed and later it translated into in English. During pre-testing of the survey instruments, the following issues were considered: The probing techniques The language necessary to address specific occupational and risk behavior issues The sequence of the questions The technique/method/option for documenting responses Providing appropriate skips in the interview schedule

The instrument of the case study was based on a detailed checklist that evolves all possible items needed. A well organized checklist and a field diary were used for the qualitative part of this research.

4.6 Non- availability of Respondents The researcher attempts to reach the target groups and accomplish interview schedule with great sincerity. If the sample respondent was not available at the time interview, at least three or four revisits were undertaken to interview the sample respondents. There were lots of cases of nonresponse from respondents including cases of timing problem, personal excuses and feeling embarrassed. In this condition, the interviewer selected alternative respondents from the study area so that the overall sample size was covered. Therefore, the overall rate of non-response in this study is zero.

4.7 Data Collection Instruments Administering questionnaire survey requires a literate target population. Besides it every now and then becomes problematic because participants may more likely to stop answering mid-way through the survey. Non-response rate is also high in questionnaire survey. Thus considering the drawbacks of using questionnaire, semi-structured interview schedule was used for conducting survey. In order to collect data this study solely depended on survey. Moreover in line with the study design qualitative data was also gathered to achieve the desired goal. Following UNAIDS/WHO guideline, a checklist was constructed containing questions related to the topic of this research for conducting case studies (UNAIDS/WHO, 1997).

4.8 Administering the Survey The field work for the present study was conducted for a period of three months from July, 2010 to September, 2010. The researcher administered the survey to respondents according to the sampling plan discussed above. Considering the sensitivity of the information, required special attention was given to minimize the reluctance of the respondents to talk about their perception, behavior and practices as to HIV and AIDS. There were four interviewers responsible for data collection from the target NGOs. All of them were graduate level students and had the experience of conducting survey-interview and case studies. Besides, they were trained on the data collection mechanism, the art of data collection and data collection instruments (e.g. interview schedule, checklist for case study).

The researcher needed the organizational permission from the concerned health centers in administering the research. In order to make up the formal procedure two letters with a sample of interview schedule and a checklist for survey and case study respectively were submitted to the concerned authority. On pursuance of the consent of concerned authority, the interviewers got themselves permitted for collecting data on some strict restrictions and conditions as to the information gathered from People Living with HIV and AIDS (PLHIV). Before approaching the sample respondents, the interviewers informed them about the purpose of this study, topics under study and the need for collecting data.

4.9 Computerization and Management of Data Data collected through the survey were processed using SPSS windows program (version 11.5).

Quantitative data processing involved the following steps: • • • • • • • • • • • • • •

Interview schedule registration and editing Edit verification Listing of open-ended responses and classifications Coding and code transfer Verification of coding and code transfer Development of data entry structure (variable view) Data entry and entry verification Entering data as per interview schedule structure in SPSS 11.5 version Verifying the logic and accuracy of the data as per filled up interview schedule Keeping and maintaining data backups Tabulating as per objective and requirement in quantum (an upgraded version of SPSS), also tabulating data in SPSS 11.5 version Development of analysis plan Program development as per the analysis plan Program running and report generation

4.10 Analysis of Data In the present study data collected from field were edited to look for a missing or error codified to entry into the computer and grouped in terms of variables the Statistical Package for the Social Sciences (SPSS) was used to analyze the data (version 11.5). As statistical techniques frequency distribution and percentage were used for data analysis. Due to limitation of time higher level statistical analysis is not conducted.

4.11 Operationalization and Measurement of the Relevant Variables Rigour and validity are at the core of doing research and are intimately related to the researcher’s need to measure phenomenon (Blalock, 1985). Measurement, in turn, is intimately related to two processes: conceptualisation and operationalisation. Conceptualization is the process of taking a construct or concept and refining it by giving it a conceptual or theoretical definition. This is done under the guidance of the theoretical framework, perspective or approach the researcher is committed to.

The process of operationalisation makes the bridge to data analysis. Operationalisation is taking a conceptual definition and making it more precise by linking it to one or more specific, concrete indicators or operational definitions.

Demographic Profile: Demographic profile of the respondents have been measured by the certain criteria (1) Gender of the respondents (2) Age of the respondents (3) Marital status of the respondents (4) Religion Socio-economic Status: The Socio-economic status of the respondents has been measured by the following certain criteria (1) Total member of the family (2) Educational and occupational background of the respondents (3) Monthly average income of the household Exposure to Media: Exposure to media of the respondents was measured using certain information on (1) Listening to radio and (2) Watching television with a structured format of Yes/No response categories.

Timing of Exposure to Media: A five point relative scale has been set to measure the timing of exposure to radio and television. Scale coded responses as 1= Morning, 2= Noon, 3= Afternoon, 4= Night, 5= other time Exposure to Sources of HIV/AIDS Information: Exposure to sources of HIV/AIDS information was measured using certain sources of information such as (a) Radio, (b) Television, (c) Newspapers, (d) Magazines, (e) Festoons, (f) Banners, (g) Meeting, and (h) Seminar Awareness about HIV/AIDS: Awareness about HIV/AIDS of the respondents was measured by using a structured format of Yes/No response categories on knowledge about HIV/AIDS, statement regarding HIV/AIDS, perception on the spread and prevention of HIV/AIDS. Perceived Susceptibility to HIV/AIDS: Perceived susceptibility towards HIV/AIDS has been incorporated in the research in order to collect information on perception to be infected by HIV/AIDS, perception about causes to infect.

Perceived Benefits to Treatment Facilities: Perceived benefits to treatment facilities have been installed in the research in order to measure the availability of treatment and counseling in both NGO clinics and Govt. clinics. Respondents experience was measured by using a structured format of Yes/No response categories on different services provided by the authority.

Knowledge about High Risk Population: High risk population typically involves that group of population who are more susceptible to HIV/AIDS. Respondentâ&#x20AC;&#x2122;s knowledge of high risk population derived from different sources is measured by asking respondents few items.

Approaches toward Health Seeking Practices: Health seeking practice refers to the source from which People Living with HIV receive treatment and care. Respondents were asked as to practices with an opportunity of multiple responses like (1) NGO clinic, (2) Private clinic, (3) Govt. hospital, (4) Traditional healer, (5) Homeopathy, and (6) Other 4.12 Qualitative Study: Case Studies Researchers who use a naturalistic approach to investigate peopleâ&#x20AC;&#x2122;s feelings and beliefs, or ways of life, find qualitative data in a variety of sources and are interested in appreciating the meanings attached to them (Walsh, 2001:7). Qualitative data derived from case studies assisted the researcher to get a thorough analysis of the respondents feeling, attitudes and practices as to the knowledge, treatment and counseling of HIV. Organizational and administrative cooperation also became helpful for getting an inner concept of the vulnerability of the victims.

The case study is not a specific technique; it is a way of organizing social data so as to preserve the unitary character of the social object being studied (Goode and Hatt, 1952:331). Few case studies were conducted on the subjects selected purposively apart from the random samples survey. Twenty cases were studied comprehensively with collecting data using in-depth

interview technique. While conducting survey researcher observed the interesting but poignant cases to be selected for the case study subjects. Results of the case studies added the vivid picture of the facts being studied.

4.13 Validity and Reliability The use of multiple methods of data collection and analysis allows the researcher to get benefit from the advantages of each method. Moreover the quality of data largely depends on the interviewerâ&#x20AC;&#x2122;s skill and in wider sense on the overall nature of the study and its subjects. The study design also made it possible to triangulate (Patton, 1990) the qualitative findings with the findings from quantitative part. In order to ensure the richness, originality and authenticity, the qualitative findings were transcribed verbatim, which ultimately allowed the researcher to organize the data manually using long field notes.

Validity basically refers to the issue of whether the collected data is a true picture of what is being studied. The threats to validity are numerous and not always controllable or even perceptible. The complex nature of the social phenomenon is the starting point of those threats.

Moreover an attempt was made to ensure internal validity-a preliminary consideration that provides the researcher to deal with problems of validity. By internal validity it is commonly understood the need to use the most appropriate design for what you are studying (Blalock, 1985). What the researcher has done is to design the study to ensure internal validity, expecting that the consistency between the patterns observed in the data and the explanatory arguments proposed will be a clear test for that.

Reliability has to do with the consistency of findings and, in that sense, is directly related to procedures of data handling and analysis. If a method of collecting evidence is reliable, it means Variables that anybody else Socio-economic using this method, or the same person using it another time, would come up with the same findings (McNeill, 1990). Along the process of analyzing data, reliability was a Occupation constant concern and all Income efforts were made to guarantee reliability of findings. The researcher also highlights the ethics in data handling and analysis, an issue that becomes even more relevant in studies that involve a high Statusdegree of personal proximity to the topic of research or the case being analyzed, and that evolve with a high degree of openness in the explanatory arguments.

Several national and international studies followed theses techniques (Habib, Amanullah, 2002; NGO Clinic Panda, 1998; Azim, 2008) Psychological Characteristics

Perceived Susceptibility

4.14 Conceptual Framework HIV/AIDS

Perceived Severity

Figure 4.1: Conceptual framework of the study Perceived Benefits

Health Seeking Practices

Private Clinic Govt. Clinic Traditional healer

Perceived Barriers

Homeopathy Others Socio-demographic Variables

Enabling Factors

Sex

Availability

Age

Accessibility

Marital status

Acceptability

4.15. Ethical Consideration Social researchers must consider the right of the subjects involved in any study (Baker, 1999).

Following UNAIDS/WHO guide lines, the present study maintained ethical principles in dealing with PLHIV. The details of the ethical considerations are stated below.

Confidentiality: The respondents were informed clearly that the information they provided during the interview would be kept strictly confidential. Only the respondents and the researcher would have access to the interview schedule and other study instruments. The interview schedule and other study instruments would then be destroyed upon completion of the data analysis and cross-tabulation.

Privacy: Furthermore, privacy during the survey was safeguarded. The survey was held under conditions where in the respondent felt most comfortable in responding openly. Also their identity was not linked to the study at any point of time or stages of the study. It was the respondentsâ&#x20AC;&#x2122; discretion to participate in the survey. The study registered oral consent from all respondents. Any form of coercion of the study subjects was strictly avoided in either getting their consent on interview.

Chapter Five RESULTS OF THE STUDY

5.1 Socio-Demographic Profile of the People Living with HIV and AIDS (PLHIV) In the study 100 PLHIV ranging from age 17 to 58 were interviewed. Of them 67 percent was male and 33 percent was female. The number of male respondents seems to be higher because of their direct participation in risk practices more than the female ones. The feasibility and accessibility to treatment and care is much higher among male than female the ratio discloses the scenario. The highest number of PLHIV belongs to the intervals 30-35 and 35-40, ranging from 19 and 21 respectively. The figure indicates that people in this stage are mainly engaged in working life. The major concern is male person which covers the 30 percent of PLHIV of the concerned years. Mobility of working people (50 percent) could be identified as the single major cause of getting affected with HIV virus because people at this age become more engaged in risk practices. On the contrary 11 percent female of PLHIV belongs to less than 25 year which indicates a vulnerable stage of women. Early marriage and poverty could be regarded as the influencing variables for increasing the rate of victims in the beginning of life. The average age of the respondents was 35.9 years with a standard deviation of 7.30.

A large number of the PLHIV (62 percent) remains married in the study which is another important socio-demographic factor. The outstanding character of marital status was separated life (16 percent) of the PLHIV, the concern goes 9 percent of the respondents who are widowed having lost their husband in an immature age. Around 60 percent of the PLHIV hails from village area who are uncompromisingly concerned with working facilities in foreign coutries and

urban areas of the respective living place. Of the PLHIV 26 percent of the respodents assert them as city dwellers who are at most risk in terms of health related hazard. Only 15 percent of the PLHIV admiteed the fact of living in Upazilla area of the country. An astounding majority of the PLHIV (92.0 percent) was Muslim and rest of them was Hndu. This figure is also congruent with the national statistics of Bangladseh. The majority of the population of bangladesh (about 88 percent) is Muslim (BBS, 2007).

Table 5.1: Distribution of the PLHIV by Socio-Demographic Characteristics Characteristics Male Female Total (%) Age (in years) (%) (%) < 25 25 to 30 30 to 35 35 to 40 40 to 45 45+ Marital Status Single Married Separated Widowed Deserted Place of Living City Upazilla Village Religion Islam Hindu N=100

2 9 15 15 11 15

11 8 4 6 4 0

13.0 17.0 19.0 21.0 15.0 15.0

11 45 10 1 0

1 17 6 8 1

12.0 62.0 16.0 9.0 1.0

15 12 40

11 3 19

26.0 15.0 59.0

61 6 67

31 92.0 2 8.0 33 100.0 (Source : Field Work, 2010)

Figure 5.1: The distribution of the PLHIV by sex

5.2 Socio-Economic Criteria of the People Living with HIV and AIDS (PLHIV) The study found that a majority of the PLHIV (25 percent) got themselves engaged in hosehold chores who are simply women. A considerable number of PLHA (16 percent) was identified as unemployed whereas 20 percent of the PLHIV found themselves in various professions. Of the PLHIV 13 percent were counted as migrant workes and service holders respectively in the study. Few respondents (11 percent) were attached to farming though it is an agricultural country. Income is an important factor more enthusiastically connected to the socio-economic status of the people. A large number of PLHIV (69 percent) shows themselves that their monthly income is less than 5000 (BDT). Only 19 percent of the respondents admitted that their income range was 5000-1000 (BDT). The rest of respondents disclosed the fact of having more than 10,000 (BDT). In fact, around 4 percent of the PLHIV confessed that they had an earning source of more than 20,000 (BDT). The average monthly income of the family of respondents was 5650 BDT which disclosed the fact that most of respondents had got HIV infected as a result of migration for earning livelihood, frustration and therefore being engaged in risk practices.

Education a dominant character of the lifestyles and status, affects many aspects of life including demographic and health behavior. Many studies show that peop;le with formal education have strong influences on health behavior, attitudes and practices. School attendence among PLHIV was moderately high with more than 70 percent. A certain number of respondents (39 percent) had only primary level schooling. With a view to getting higher education, 29 percent of the PLHIV had participated in secondary school level and only 7 percent of the whole respondents completed tirtiary level education.

Table 5.2: Distribution of the PLHIV by Socio-Economic Characteristics Characteristics Employment Status Migrant worker Housewife Farmer Service holder Retired Unemployed Other Total

Male (%) 12 0 11 9 2 14 19 67

Female (%) 1 25 0 4 0 2 1 33

Total (%) 13.0 25.0 11.0 13.0 2.0 16.0 20.0 100.0

Income (BDT) <5000 5000 to 10000 10000 to 15000 15000 to 20000 20000 +

41 16 4 3 3

28 3 0 1 1

69.0 19.0 4.0 4.0 4.0

Total

67

33

100.0

Education (Level) Illiterate Primary Secondary Tertiary Total

12 31 18 6 67

13 8 11 1 33

25.0 39.0 29.0 7.0 100.0

(Source : Field Work, 2010)

Table 5.3 shows that more than 50 percent of the PLHIV belongs to a family of 1-4 members, very often called a nuclear family in the socio-economic model of Bangladesh. But 49 percent claimed them as part of an extended family where the number of family members was more than four. More than 80 percent of the respondents were satiated with the living status they feel in their family. Approximately 45 percent stated that they had problem for food. Though 80 percent of the PLHIV had more than three times meal, the level of nutritious food was comparatively low for many of them. The unemployment problem, because of foreign-return and social constraints had thwarted the level of earning for many PLHIV in the family.

Table 5.3: PLHIV by Family Composition and Living Status Category

Male (%)

Female (%)

Total (%)

1-4 5-8 9-15

32 28 7

19 14 0

51.00 42.00 7.00

Satisfaction Satisfactory living Problem for Food

54 28

28 16

82.0 44.0

1 13 42 11

1 5 19 8

2.0 18.0 61.0 19.0 100.0

Number of Family Members

Meal in a day 1 time 2 times 3 times more Total

(Source : Field Work, 2010) 5.3 Awareness of HIV Transmission and Risk Groups

Table 5.5 shows that 95 percent of the PLHIV reported that unprotected sex and sharing of infected needles /syringes might transmit HIV among human body. Male respondents were more likely aware of the transmission of HIV than female oneâ&#x20AC;&#x2122;s. Unprotected sex with female SWs and sharing of infected needles and syringes are two major factors in severe transmission of HIV/STDs (Behave et al,1995; Cohen, 1998; UNAIDS/WHO, 2001d; WHO, 2001b, 2001c) in Thailand, Combodia, China, Myanmar and India. As the AIDS pandemic continues to divastate South-Asia, no nation from this region can consider itself free. This is widely believed that the increasing sex trade in this region has resulted from soci-political and economic changes and unrest.Moreover, 90 percent of the PLHIV believed that blood transfusion and mother to child transmission were the major reasons for spreading this virus. Sex with infected people was regarded as the route of HIV transmission by 85 percent of the respondents. More than 60 percent PLHIV supported that sex with CSWs and male to male sex might augment the routes of HIV transmission. Womenâ&#x20AC;&#x2122;s response was negotiably low than male. Only 12 percent respondents conceptualized that sexual fluids might cause HIV transmission. In this case, female respondents were more likely to respose than female ones. Few respondents (4 percent) supported that mosquito/insect bites and saliva could affect human body by transmitting HIV. Table 5.4: Awareness on the Routes of Transmission of HIV* Risk Practices

Male (%) 66.32

Female (%) 33.68

Total (%) 95

Sharing of infected 66.32 needles/syringes Sex with HIV infected 64.71 person Blood transfusion 65.56

33.68

95

35.29

85

34.44

90

Mother to transmission Sex with CSWs

child 66.67

33.33

90

66.67

33.33

69

Male to Male sex

68.85

31.15

61

Mosquito/insect bites

50.00

50.00

4

Saliva

75.00

25.00

4

Sexual fluids

41.67

58.33

12

Unprotected sex

* Multiple Responses

(Source : Field Work, 2010)

The symptoms of infecting with HIV may not be conspicuous at the genesis of becoming ill with this disease. Many preliminary signs might be regarded as the prime causes of infecting with this virus. Table 5.6 shows that 90 percent of the PLHIV confirmed about recurrent fever as an important symptom of HIV. Men were more likely to response than women. Diarrhoea and decreased appetite was also marked as a sign by more than 80 percent respondents. The signs and symptoms which were given moderate emphasis were coughing and shortness of breath, weight loss and extreme fatigue as well as nausea, abdominal cramps, and vomiting covering 70 percent, 77 percent and 68 percent of the PLHIV. Severe headaches, difficult or painful swallowing, white spots or unusual blemishes in the mouth, menstrual irregularities (for women) and seizures and lack of coordination were identified as the variables of signifying HIV by 56 percent, 53 percent, 48 percent, 24 percent and 14 percent of the PLHIV. At every case men were more enthusiastic to response than women. The exceptional event was menstrual irregularities (for women) where womenâ&#x20AC;&#x2122;s response was 95.83 percent comparing with male (4.13 percent).

Table 5.5: Signs and Symptoms of People Living with HIV/AIDS (PLHIV)* Signs and Symptoms of People Living with HIV/AIDS (PLHIV) Seizures and lack of -coordination Difficult or painful swallowing Diarrhea & decreased appetite Recurrent fever

Male (%)

Female (%)

Total (%)

9

5

14

32

21

53

58

25

83

59

31

90

Nausea, abdominal 45 cramps, and vomiting Weight loss and extreme 49 fatigue Severe headaches 36

23

68

28

77

20

56

White spots or unusual 30 blemishes in the mouth Menstrual irregularities 1 (for women)

18

48

23

24

* Multiple Responses

(Source : Field Work, 2010)

The newly infected people with HIV was estimated as 2.7 million in 2008 (UNAIDS/WHO, 2009) and the global scenario of infecting women and children under 15 years had touched an unexpected level knocking the door of Bangladesh. Table 5.6 summarizes that more than 90 percent of PLHIV identified IDUs as the most risk group to HIV epidemiology. Male

respondents were more likely to female. The child of affected pregnant mother, commercial sex workers and female sex workers were extensively reported by PLHIV to be most risk groups such as 77 percent, 76 percent and 75 percent respectively. Womenâ&#x20AC;&#x2122;s response was quite low than men in many respects. Around 56 percent of PLHIV gave consent to commercial blood users who were nearly about to risk. Whereas 44 percent of PLHIV was on behalf of individual with multiple sexual partners, another 22 percent and 2 percent of the PLHIV gave approach to internal migrant workers and others respectively who were regarded as most risk.

Table 5.6: Most Risk Groups to Contract HIV* Risk Groups

Male (%) Individual with multiple 70.45 sexual partners Female sex workers 68.00

Female (%) 29.55

Total (%) 44

32.00

75

Commercial sex workers

68.42

31.58

76

Injecting Drug Users (IDUs) Commercial blood users

68.48

31.52

92

67.86

32.14

56

Child of affected 61.04 pregnant mother Internal migrant workers 71.43

38.96

77

28.57

21

Others

50.00

2

* Multiple Responses

50.00

(Source : Field Work, 2010)

5.3.1 Level of Knowledge on HIV and AIDS by PLHIV The study explores the level of knowledge of the respondents as to HIV/AIDS using a scale of knowledge-measurement. Table 5.17 picks up the level of knowledge of the PLHIV, an output of mathmatical explanation derievd from table 5.18. The level of moderate knowledge has been dominated by 57 percent of the PLHIV while 37 percent of respondents reach at higher stage of knowledge as to HIV/AIDS. Only 6 percent of the respondents were identified as low level of knowledge.

Table 5.7 Level of Knowledge on HIV and AIDS by PLHIV Level of Knowledge

Frequency

Percent

Low knowledge Moderate knowledge High knowledge Total

6 57 37 100

6.0 57.0 37.0 100.0

(Source : Field Work, 2010) As part of measuring knowledge, about 97 percent of the PLHIV supported sharing of infected needles/syringes as one of the major reasons for transmitting HIV in Bangladesh. Moreover 96 percent of the respondents confirmed that unsafe blood transfusion might accelerate HIV transmission among people. It suggests that people become more concerned about risk practices whenever they get the awareness program. A considerable number of the PLHIV fosters one sort misconception about HIV transmission. Around 10 percent of the respondents believe that HIV can be spread by using someone's personal belongings like a drinking or eating utensil. A majority of the subjects, in a study carried out by CARE-Bangladesh in 1996 had heard about AIDS, but their levels of knowledge were extremely poor and incomplete. Some of them stated that HIV transmits through food, clothing, foreigners (Koreans), and black cats (Sarker, Reza and Durandin, 1996: 38) .It shows that there is still a great limitation of implementing HIV related awareness program. The program targeted HIV /AIDS awareness raising does not function properly always, even though the concerned organizations and health centers are playing a vital role in this sector.

Table 5.8: Awareness of HIV and AIDS Category

Male (%) STD has a positive relation with HIV/AIDS transmission 44 TB has a positive relation with HIV/AIDS transmission 38 A person can get AIDS by kissing someone on the mouth or 12 through coughing and sneezing HIV can be spread by using someone's personal belongings 7 like a drinking or eating utensil People with AIDS usually can be identified by looking at 11 them There is a cure for AIDS 45 Most people who get AIDS usually die from the disease 50 Having sex with someone without a condom is one way of 59 getting it A man with AIDS can give it to a man during anal sex 65 A woman with AIDS can only give it to a man during 64 vaginal sex Receiving blood transfusion with infected blood can give a 66 person AIDS You can get aids by sharing a needle with a drug user who 65

Female (%) 16 18 6

Total (%) 60.0 56.0 18.0

2

9.0

6

17.0

23 29 30

68.0 79.0 89.0

29 30

94.0 94.0

30

96.0

32

97.0

has the disease A person can get aids by tattooing/body 19 18 27.0 piercing/circumcision A pregnant woman who has AIDS can give it to her baby 61 28 89.0 (Source : Field Work, 2010) Around 98 percent of the respondents asserted that practicing safe sex (condom use) was one of the major criteria of combating HIV/AIDS. Several national studies show that the awareness and usefulness of condoms have risen in Bangladesh for last few decades among ever-married women/men (Mitra et al, 2001), adolescents (Mitra, Islam and Amanullah, 1996) and SWs and their clients (Amanullah and Islam, 1996; Jenkins, 1999). 87 percent of the PLHIV confirmed that pure blood transfusion was a major determinant of preventing HIV. Anti-drug, a remedy of combating HIV and AIDS was supported by 64 percent of the respondents. The reported practices were self-medication, keeping single sexual partner, homeopathic treatment and herbal practice claiming 35 percent, 31 percent, 26 percent and 21 percent respectively.

Table 5.9: Awareness of Combating HIV and AIDS by Sex*

Combating HIV/AIDS Practicing safe sex (condom use) Keeping single sexual partner Taking pure blood

Male (%)

Female (%)

Total (%)

67.35

32.65

98

70.97

29.03

31

66.67

33.33

87

Anti-drug

65.63

34.38

64

Self-medication Homeopathic treatment Herbal practice

65.71

34.29

35

61.54

38.46

26

71.43

28.57

21

* Multiple Responses

(Source : Field Work, 2010)

Though the level of knowledge of PLHA is moderately high, but their performance in practice is not satisfactory to promote health seeking behavior. The health seeking practices of the PLHA in Bangladesh are determined by socio-cultural construction of society. The KAP model does not suite to this social structure because the health seeking practices of PLHA are linked to the beliefs, socialization procedure and psychological functions they belong to which is avoided by this model.

5.3.2 Perceived Susceptibility and Perceived Severity of HIV and AIDS More than 70 percent of the respondents believe that they could avoid contracting HIV with the help of preventive action. Men were more likely to avoid contracting HIV than women. Women are not highly exposed to different sources of mass media. Around 90 percent of the male PLHAIV states that they watch television at different times in a day. But 78 percent of the female PLHIV said that they watched television on a regular basis. Every now and then women are kept in the dark in this male dominated patriarchal society due to many socio-cultural impediments.

Table 5.10: Perceived Susceptibility of the PLHIV by Sex Characteristics Avoid contracting HIV

Male N=67 (%) 73.13

Female N=33 (%) 66.66

Total N=100 (%) 71

Diagnosis for HIV treatment

98.51

90.91

96

(Source : Field Work, 2010) Table 5.8 reports that about 96 percent of the PLHIV wished that they needed proper diagnosis for treating HIV. Men were more likely to receive treatment than women. Since the income generating activity is dominated by male, female does not show any more interest in treatment seeking practices. Perceived susceptibility of male as to HIV is higher than female in Bangladesh. A variety of socio-structural and socio-cultural factors are claimed the dropping of womenâ&#x20AC;&#x2122;s response in measuring perceived susceptibility.

Table 5.11: Perceived Severity to HIV Treatment by Sex

Passing days Male without treatment (%) N=67 <1 month 31.34 2-6 months 28.36

Female (%) N=33 48.48 15.15

Total (%) N=100 37 24

6-12 months

11.94

21.21

12

1-2 years

13.43

18.18

15

14.43

6.06

12

2 year+

(Source : Field Work, 2010) Perceived severity to HIV treatment was measured by counting how days PLHIV had passed without treatment soon after being informed of the concerned fact. Table 5.9 focuses that around 40 percent of the PLHIV reported that they had taken HIV treatment before less than one month soon after getting infected with HIV. Female are more likely to receive treatment than male at the beginning period of conforming to HIV. More than 20 percent of the respondents stated that they received HIV treatment from 2 to 6 months. The scenario of treatment taking is different by sex in this case. Male are more interested to response with HIV treatment in comparison with female at the first half the year receiving treatment. Whereas 15 percent of the PLHIV take treatment from 1 to 2 years of life, more than ten percent of the respondents passed more than 2 years in taking treatment. Female are seen to be more concerned and enthusiastic to male in the period of 1 to 2 years of life.

5.3.3 Knowledge of STDs among PLHIV It can be epitomized that the presence of STDs increases the risk of HIV transmission manifold.

Only 68 percent of the PLHIV revealed that they had heard about STDs. On the contrary, 32 percent of the respondents expressed that they had not possessed any idea of the STDs at all.

Figure 5.2: Whether ever heard of any Sexually Transmitted Diseases (STDs) Table 5.10 shows that whether PLHIV have a clear idea about different types of STDs and its relation with HIV in terms of sex. Around 65 percent of the PLHIV confirmed that gonorrhea was a STD while 59 percent of the respondents had knowledge about syphilis. Men were more preferably higher than women in answering about STDs. The percent of percentage of the PLHIV was only 28 who were well aware of the clamedia. Trichomoniasis is one sort of STD which is apparently supported by 15 percent of the respondents. Approximately 5 percent of the PLHIV gave consent about genital sore but the highest number of respondents goes with male respondents which was astounding to some extent.

Table 5.12: Awareness of STDs by Sex*

STDs

Male (%) Syphilis 71.19 Gonorrhea 70.77 Clamedia 78.57 Trichomoniasis 80.00 Genital Sore 100.00 Other 66.67

* Multiple Responses

Female (%) 28.81 29.23 21.43 20.00 0.00 33.33

Total (%) 59 65 28 15 4 3

(Source : Field Work, 2010)

5.4. Exposure to Mass Media and Health Seeking Information Accessibility to knowledge and information as to HIV epedemiology is often chanelled to increase people’s awareness of the health related risk behavior, which may affect their perceptions and behavior. Exposure to risk free practices such as safe sex realtion, pure blood transfusion are essentially requisite for PLHIV. Awareness and counseling program can make them sure of the severity of the disease and the proper channels of receiving treatment. This is obligatory to pick up that exposure to mass media is very important for PLHIV because of their vulnerability and susceptibility to risk practices. The message “Bachte Holley Jante Hobe” is important not only for the PLHIV but also for the general people in order to be conscious of the deadly virus HIV/AIDS and its horrifying ramification. Exposure to electronic and print media was given equally emphasis in order to measure their accessibility to it.

Figure 5.3: Ever encountered massage called “Bachte Holey Jante Hobe” More than 90 percent of the PLHIV received the message called “Bachte Holley Jante Hobe” from satellite channels, banners and meetings. The present study shows that information about HIV prevention could be easily disseminated among general people by arranging awareness program or postering banners. People Living with HIV/AIDS are more exposed to satellite channels (62 percent)

Figure 5.4: Sources of perceiving “Bachte Holley Jante Hobe”

5.4.1 Exposure to Mass Media

In this study exposure to mass media was assessed by asking respondents when they usually listen to radio, watch television. It was also asked them that whether they had accessibility to reading newspaper. Of the PLHIV, 35 percent of respondents listen to radio on a regular basis.

Exposure to radio is higher among female than male respondents. Majority of the respondents (about 15 percent) listen to radio at night while 10 percent of the respondents listen to it other time. Around 90 percent of the PLHIV gave consent about watching television and expressed their positive attitudes toward HIV related national messages. Though the highest number of respondents (35 percent) are exposed to satellite channel, but 27 percent of the respondents expressed that they are frequently used to watching both satellite and BTV. The peak time for watching TV was regarded night claiming to be free from all kinds of works. More than 50 percent of the frequently TV viewers chose night for wacthing TV. Around 20 percent of the PLHIV got themselves esposed to watching TV at other time. Watching TV at morning, noon and afternoon was categorized by respondents at 9 percent, 1 percent and 6 percent respectively.

Women are more likely to watch BTV than male. Moreover around 40 percent male PLHIV got used to watching satellite channel which was comparatively higher than female. Around 40 percent of respondents expressed they were used to reading newspaper. The number male respondents was higher than those of female in reading newspaper.

Table 5.13: PLHIV by their Media Exposure Sources Radio Listening to Radio Morning Noon Afternoon Night Other time N=35 Television Frequently watched TV channel BTV Satellite Channel Both N=88 Watching TV Morning

Male (%) N=67 32.84

Female (%) N=33 39.39

Total % N=100 35.0

2.99 1.49 4.48 13.43 10.45

0.0 9.09 6.06 15.15 9.09

2.0 4.0 5.0 14.0 10.0

88.06

87.88

88.0

23.88 40.30 23.88

30.30 24.24 33.33

26.0 35.0 27.0

10.45

6.06

9.0

Noon Afternoon Night Other time Reading Newspaper N=38

1.49 4.48 50.75 20.90 49.25

0.0 9.09 57.58 15.15 15.15

1.0 6.0 53.0 19.0 38.0

(Source : Field Work, 2010) 5.4.2 Exposure to HIV and AIDS Related Awareness Program More than 90 percent of the PLHIV proclaimed that they had ever hard/watched campaign on HIV/AIDS from the reliable sources of both electronic and print media. Men are more likely to expose to media than women. Almost 60 percent of the PLHIV received information on HIV/AIDS from satellite channels but 52 percent of the respondents supported banners for getting information. Around 46 percent of the respondents got the message on HIV/AIDS from BTV, only 12 percent and 9 percent of the PLHIV heard the message from Bangladesh Betar and FM radio respectively. The other sources of print media such as festoon, daily newspaper and magazine were reached by PLHIV characterizing 44 percent, 20 percent and 6 percent respectively. Men were almost likely to response than women in this media based multiple responses questions.

Table 5.14: Response to HIV and AIDS Control Program* Characteristics

Male (%) N=67 Ever heard/watched 94.03 any campaign on HIV/AIDS Sources information BTV Satellite channel Daily newspaper Magazine FM radio Bangladesh Betar Festoons Banners Others * Multiple Responses

Female (%) N=33 90.91

Total (%) N=100 93

36.36 57.58 15.15 9.09 6.06 15.15 36.36 39.39 3.03

46 58 20 6 9 12 44 52 8

of 50.75 58.21 22.39 4.48 10.45 10.45 47.76 58.21 10.45

(Source : Field Work, 2010)

5.5 Mobility of the Population and HIV Transmission Half of the PLHIV (50 percent) has got an experience of working in abroad as an important part of exporting manpower of the country. More than 65 percent of the male respondents are directly concerned in different activities in abroad as part of earning money and travelling country. The overwhelming character is that around 48 percent of the male respondents had passed more than four years of working life in abroad. Around 10 percent of the PLHIV passed less than one year in abroad while 5 percent of respondents stayed in abroad for nearly three years. Only 3 percent of respondents lived in abroad for three years.

Table 5.15: Mobility of the PLHIV Mobility PLHIV

of

the Male (%) N=67 Worked in Abroad 67.16

Female (%) N=37 13.51

Total (%) N=100 50.0

Duration < 1 year 2 years 3 years 4 years+

8.96 4.48 5.97 47.76

5.41 0 2.70 5.41

8.0 3.0 5.0 34.0

Purpose Tourism Working Treatment

4.48 62.68 2.99

3.03 9.09 3.03

4.0 45.0 3.0

(Source : Field Work, 2010) 5.6 HIV Testing and Immediate Feelings of PLHIV Counseling is a major issue of treatment facilities about health related complexities. However 52 percent of the PLHIV counseled with either health practitioners or others as to HIV prior to testing this. But 48 percent of the respondents did not make any counseling before testing HIV. Men were more likely to counsel about HIV testing than females. This proves that women are more reserved in focusing themselves than men in this male dominated society. Due to sociocultural constraints women very often feel more hesitation in approaching many issues about this sensitive disease. Around 27 percent of the PLHIV offered themselves in testing HIV in less than one month and womenâ&#x20AC;&#x2122;s participation was higher than men in this case. In between 2 to 6 months 24 percent of the respondents made HIV test for the second time but 20 percent of the PLHIV confirmed their test in more than twenty years. Another 13 percent of the respondents tested them within 6-12 months but 16 percent of the respondents took nearly two years of testing that. Perceived severity as to HIV testing of the PLHIV was moderately high. But the

great concern goes against 20 percent of the respondents who take more than two years in testing HIV.

Figure 5.5: Counseling prior to testing HIV Around 55 percent of the male PLHIV were confirmed that they counseled with any practioner or any other but 45 percent of the female PLHIV did not make any counsel. The present data proves that male are more conscious of the severity of any disease than female. But interestingly the level of perception of testing HIV in short time was higher among women than men.

The feelings of PLHIV, soon after hearing HIV testing report were categorized and measured on the basis of multiple responses. 80 percent of the respondents looked depressed when they had confirmed of the fact of being infected with HIV. Men were more likely to response than women. 45 percent of the PLHIV wanted to commit suicide in response to HIV positive report.

Whereas 22 percent of the respondents wished to practice self-medication, another 17 percent wanted to go through herbal medicine. Interestingly 14 percent of the respondents did not show any interest to react with this horrifying news.

Table 5.16 HIV Testing and Immediate Feelings of PLHIV Characteristics

Female (%) N=33 45.00

Total (%) N=100 52

Testing HIV after ever have perceived the virus <1 month 26.87

27.27

27

2-6 months 6-12 months

27.27 21.21

24 13

Counseling before HIV test

Male (%) N=67 55.00

22.39 8.96

1-2 year 2 year+ Total

17.91 23.88

12.12 12.12

16 20 100.0

Immediate feelings of PLHIV* No reaction 71.43 Depressed 66.25 Wanted to commit suicide 62.22 Self-medication 68.18 Herbal medicine 64.71 Others 85.71

28.57 33.75 37.78 31.82 35.29 14.29

14 80 45 22 17 7

* Multiple Responses

(Source : Field Work, 2010)

5.7 Socio-economic and Socio-cultural Obstacles: An Unsolved Threat to HIV Treatment Nearly 70 percent of the PLHIV stated that they have to pay a high transport cost in taking treatment from the different parts of the country. Since HIV treatment and care are more centralized in Bangladesh, people have to come to the city area for proper treatment and counseling. More than 60 percent of the respondents claimed that financial crisis was one of the major obstacles of getting HIV treatment. Men were more likely to response to women. The study found that more than 50 percent of the PLHIV spoke about the unavailability of medicine, while 53 percent claimed the long time procedure as the major reasons for getting HIV treatment and counseling. Around 50 percent of the PLHIV identified distance as one the major barriers of getting HIV care.

Table 5.17: Socio-economic Obstacles of HIV/AIDS Treatment* Obstacles of getting Male HIV/AIDS treatment (%)

Female (%)

Total (%)

Financial crisis Long time procedure Distance Transportation costs Unavailability of medicine Others

66.13 58.49 66.67 70.00 64.81

33.87 41.51 33.33 30.00 35.19

62 53 48 70 54

90.91

9.09

11

* Multiple Responses

(Source : Field Work, 2010)

The emotional attachments of the PLHIV were given emphasis to identify their feelings about this infectious disease. At a holistic sense, Table 5.13 shows that 73 percent of the respondents were suffering from deep sadness, and another 67 percent of the PLHIV were feeling guilty because of being infected with HIV/AIDS. Loss of self-esteem, fear of dying and feeling

embarrassed were counted as 59 percent, 55 percent and 36 percent by the PLHIV as part of expressing emotional distresses. Almost 47 percent of the PLHIV stated that they perceived one sort of negligence and rapidly changed behavior in the attitudes of the others. Men were more likely to response than women in almost every case.

Table 5.18: Emotional Distresses of PLHIV by Sex* Emotional distresses of PLHIV Deep sadness Fear of dying Feeling guilty Feeling embarrassed Loss of self-esteem Perceived change in attitudes of others

Male (%) 67.12 72.73 70.15 72.22 66.10 74.47

* Multiple Responses

Female (%) 32.88 27.27 29.85 27.78 33.90 25.53

Total (%) 73 55 67 36 59 47

(Source : Field Work, 2010)

5.7.1 Social Stigma and Discrimination towards PLHIV Table 5.11 indicates that 30 percent of the respondents had characterized lack of social awareness as an important social barrier in HIV treatment. About 70 percent of the PLHIV were male whereas the rest of the respondents were female. A number of respondents who claimed social stigma, superstitious attitudes and low education as social barriers were characterized as 26 percent, 25 percent and 23 percent respectively. Health providersâ&#x20AC;&#x2122; delay and low risk perception were regarded as the barriers by 19 percent of the PLHIV. Table 5.19: Socio-cultural Barriers in HIV Treatment* Social barriers HIV/AIDS treatment

in

Low risk perception

Male (%) 63.16

Female (%) 36.84

Total (%) 19.0

Social stigma

80.77

19.23

26.0

Low education

60.87

39.13

23.0

Lack of awareness

70.00

30.00

30.0

Superstitious attitudes

76.00

24.00

25.0

Health providersâ&#x20AC;&#x2122; delay

73.68

26.32

19.0

Others

75.00

25.00

4.0

* Multiple Responses

(Source : Field Work, 2010)

5.8 Health Seeking Practices of the PLHIV and Access to Treatment and Care

More than 90 percent of the PLHIV come to NGO clinic for treatment and care. They showed full interest in receiving treatment and support from this organization. The authority of the NGOs treats them as their clients not patients. Counseling program, arranged by NGO clinics was given more emphasis for overcoming the complexity of HIV/AIDS. Men (68.48 percent) were more likely to receive treatment than women (31.52 percent). Around 38 percent of the PLHIV takes treatment from Govt. hospital.

Table 5.20: Sources of Treatment of PLHIV by Sex*

Sources of Treatment

Male (%)N=67

Total(%)N=100

68.48 76.00 57.89

Female(%)N=3 3 31.52 24.00 42.11

NGO clinic Private clinic Govt. hospital Traditional healer

55.55

44.44

18

Homeopathy

57.14

42.86

14

* Multiple Responses

92 25 38

(Source, Field Work, 2010)

Approximately 25 percent of the PLHIV proclaimed that they took treatment and care from private clinics. Around 76 percent of the male PLHIV was enthusiastic in taking treatment and counseling which was higher than female. A number of respondents who took treatment from traditional healer and homeopathy practitioner were characterized as 18 percent and 14 percent respectively.

Table 5.21: Sources of HIV Testing of PLHIV * Sources of HIV Testing NGO clinic

Male (%) N=67 60.98

Female (%) N=33 39.02

Total (%) N=100 41

Govt. clinic Private hospital

61.70 76.92

38.30 23.08

47 26

Foreign clinic

100.00

0.00

5

* Multiple Responses

(Source : Field Work, 2010

Almost 47 percent PLHIV made HIV test in Govt. clinics. 62 percent of the respondents were male where the rest of the respondents were female. NGO clinic, an important source of testing HIV in Bangladesh was determined by 41 percent of the PLHIV. But men were more likely than women in this case like the before. 26 percent of the PLHIV confirmed that they took testing

report from private clinics and only 5 percent found other sources like foreign clinic of making test.

Table 5.14 summarizes that around 90 percent of the PLHIV confirmed that NGO clinic was a major source for supplying medicine and couselling. At the same time only 19 percent of the PLHIV stated that they had taken medicine and counseling from Govt. hospitals for preventing this virus. The sercvices centring HIV for NGO clinics were medical check-up, regular monitoring, home care and extra care covering 88 percent, 85 percent, 74 percent and 73 percent.

But only 10 percent of the respondents stated that they got the respective services from government clinics. This is evident that PLHIV are more likely to receive treatment and services from NGO than Govt. clinics. Around 50 percent of the PLHIV says that they are satiated at the services of nutritional food and pure drinking water from NGOs while only 10 percent of the PLHIV confirmed that they received the same services from Govt. clinics.

Table 5.22: Treatment Facilities in between NGO Clinics and Govt. Clinics*

Treatment Facilities

NGO Clinics

Government Clinics

(%)

(%)

Supplying Medicine

90%

19%

Counseling

92%

19%

Home Care

74%

10%

Bed Facility

60%

10%

Medical Check-up

88%

20%

Nutritious Food

54%

07%

Pure Drinking Water

54%

16%

Money Consuming

67%

08%

Regular monitoring

85%

09%

Extra Care

73%

11%

Hygienic Environment

82%

16%

* Multiple Responses

(Source : Field Work, 2010)

Figure 5.6 The Distribution of the Treatment Facilities in Between NGO Clinics and Govt Clinics The discrepancy between services provided by the government and NGOs has touched an acute level in Bangladesh (Fig 5.6). Government has no direct control over the treatment facilities and preventive programs. Health practitioners of government hospitals do not want to make any operation or treatment of PLHIV because of extra-precautionary measures of not contracting HIV. Different sources of government often assert that no discrimination as to HIV treatment remains in the country. The present study explores multipluralistic but discriminatory patterns of health services of the PLHIV claiming the negligible participation of government in this sector.

5.9 Socio-economic Status and Access to Information Table 5.8 which give Chi-square and V values shows that sources of exposing mass media are significantly associated with three important variables, sex, education and occupation. Education is found to be significantly associated with exposure to radio (P<0.05) and newspaper (P< 0.001). It is found that more female are exposed to radio listening and more male are exposed to television watching. Around 40 percent of the respondents read newspaper; this lower rate of exposure to newspaper reading may be affected by the low level of knowledge of PLHIV. Sex has been significantly associated with exposure to newspaper reading (P< 0.01). It is found that more men tend to read newspaper than women. Such type of exposure to newspaper reading may be affected by the level of knowledge and curiosity of knowing the present condition of markets, politics, economy, environment and health sectors etc. Moreover marital status has a coherent relation with newspaper reading (P< 0.05). Income, occupation and place of living do not show any significant relation with different variables of mass media.

Tables 5.23: Summary table of Cramerâ&#x20AC;&#x2122;s V and Chi-square on access to information by

socio-economic variables Sociodemographic Variables sex

Media Exposure Listening to Watching Radio Television χ2=.418, df 1 V=.003

Reading Newspaper χ2=10.914**, df 1,

education

V=.327**

V=.227

V= .461***

Income

V=.170

V=.165

V= .268

Marital status

V=.162

V= .065

V=.324*

occupation

V=.212

V= .165

V=.320

Place of Living

V=.171

V=.225

χ2=.040, df 2,

P= 0.05* P= 0.01** P= 0.001*** 5.10 Socio-demographic Status and Perceived Barriers to HIV Treatment Perceived barriers to HIV treatment are significantly related to most of the socio-demographic and socio-economic Variables the study shows. Table 5.8 shows that income is significantly associated with financial crisis related to perceived barriers to HIV treatment (P= < 0.05). Less income generating people tend to feel financial crisis more than those who are economically solvent. The size of family, education and marital status do not show any significant relation to perceived barriers of HIV treatment.

Tables 5.24: Summary table of Cramer’s V and Chi-square on perceived barriers to HIV treatment by socio-demographic and economic variables Sociodemographic and economic characteristics Age

Perceived barriers to HIV Treatment

Sex

Financial crisis V=.169

Long time Distance procedure V=.359* V=.266

Transportation costs V=.163

Unavailability of medicine V=.232

χ2=.289,df=1 χ2=4.90*,df=1

χ2=.083,df=1 χ2=.444, df=1

χ2=.583, df=1

Education

V=.251

V=.186

V=.177

V=.105

V=.104

Occupation

V=.329

V=.318

V=.213

V=.244

V=.394*

Income

V=.348*

V=.200

V=.242

V=.259

V=.202

Place of V=.006 living Marital status V=.292

Ď&#x2021;2=7.129*,df=2 V=.172

Ď&#x2021;2=4.273, df=2

V=.311**

V=.185

V=.190

V=.217

V=.116

Family members

V=.289

V=.343

V=.336

V=.245

V=.301

P= 0.05* P= 0.01** P= 0.001*** 5.11 Socio-economic Status and Health Seeking Practices Table 6.1 which gives Chi-square and V values shows that sources of HIV testing are significantly associated with three socio-economic variables, education (P< 0.05), income(P< 0.05) and occupation (P< 0.01).

Table 5.25: Summary of Cramerâ&#x20AC;&#x2122;s V and Chi-square on HIV testing derived from different sources by socio-economic variables Socio-economic variables

Sources of HIV testing NGO clinic Govt. clinic

Private clinic

Foreign clinic

Education

V= .092

V= .147

V= .118

V= .328*

Income

V= .211

V= .214

V= .336*

V= .196

Occupation

V= .427**

V= .191

V= .393*

V= .289

P= 0.05* P= 0.01** P= 0.001*** Socio-economic variables emerged as the most common significant determinants of seeking sources of HIV testing. Education has a coherent relation with the treatment facilities of foreign clinics. The more PLHIV educated, the more they concerned about health seeking practices.

Income, another socio-economic variable is significantly related with testing facilities of private clinics. Accessibility to private clinics requires a handsome amount of money because of their quality based services and favorable environment. Majority of the PLHIV showed their interest in receiving treatment from private clinics, let alone Govt. clinics. However it can be stated that occupational status and income are significantly associated with services from private clinics.

NGO clinic, an important source of testing HIV is mainly dominated by people from different occupational statuses. PLHIV from different stages of life take treatment due to availability of medicine and proper testing facilities.

Occupational status of the PLHIV is significantly related to unavailability of medicine (P< 0.05).

People having less income source or even no income at all do not get the requisite medicine and diagnosis to prevent the severity of this disease. Place of living, where PLHIV stay is significantly related to two important variables- long time procedure (P< 0.05) and unavailability

of medicine (P< 0.01), fashioned as perceived barriers. PLHIV from multiple backgrounds do not have equal accessibility to HIV treatment. Since HIV treatment facilities are more centralized, people from different remote regions cannot afford to medicine and testing facilities on a regular basis. Monitoring system is highly overlooked by the health practitioners in many cases.

However the treatment process takes long time in order to prevent this disease. Long time procedure, the important perceived barrier is significantly associated with age and sex status of the PLHIV. Whereas 40 percent of the PLHIV belongs to an interval of 30-40 age group, a vital segment of enjoying life is still rest. They feel the procedure as very time consuming. In spite of having no permanent diagnosis for HIV, both male and female had shown one sort of madness for long term prevention of this disease.

QUALITATIVE FINDINGS: CASE STUDIES This chapter deals with the qualitative findings of the study. Collected data and information have been presented and analyzed as written discussion for the qualitative study.

5.12 Nexus between HIV/AIDS and STDs The Human Immunodeficiency Virus (HIV), a germ that includes not only the transmission of it from person to person through sexual intercourse but also a combination of a series concerns regarding HIV/AIDS. Theoretically this causes a slow but progressive collapse of the immune system, the body's main mechanism for fighting diseases. This severe damage to the immune system is called AIDS. HIV destroys a certain type of blood cells that help the body fight off infections. The difference between HIV & AIDS is extremely conspicuous whereas HIV is the Virus and AIDS is the ramification of the infection of HIV. AIDS and Sexually Transmitted Diseases (STDs) are highly proximate each other. Persons who experience STD might have faced a possible threat of becoming affected with HIV/AIDS. In the study around 60 percent of the PLHIV believe that STD has a positive relation with HIV transmission. Many of the respondents claim that they have experienced STDs and taken medical treatment for this. Mrs. Ayesha Khatun is a twenty seven year who states that she is severely attacked with STDs like gonorrhea. She believes that she has been affected by her husband.

5.13 Risk Practices and HIV Epidemic It is feared that the explosive sex trade, widespread use of illicit drugs, increasing rates of STDs, abject poverty, illiteracy, patriarchy and large scale population movements have already made this region a fertile ground for rapid expansion of HIV epidemic.

Ever since the genesis of teenage period Mr. Ripon leads a separated life in Dhaka city. In spite of having family in Bikrampur in Munsigang he keeps himself very often in Golap Shar Mazar, Dhaka. He does not know about the recent status of his family. Professionally he is a rickshaw puller and takes drugs on a regular basis. He is highly familiar with the items of drug like Heroine, Pathedin, Gaza and Yaba also. At the same time he practices sex with commercial sex workers having no scope of marriage.

A handsome number of the PLHIV who were migrant ensured that they had continuously practiced unsafe sex in abroad. Most of the IDUs share unprotected needles and syringes for taking drug which exacerbates the level of risk.

5.14 Unsafe Sex Practices and HIV/AIDS: A Reality for Migrants Migrant workers account for a significant number of HIV cases in Bangladesh, primarily because they are subjected to mandatory HIV testing. Around 50 percent of the respondents have passed a vital segment of working life in overseas. In 2004, data from the National AIDS/STD (Sexually Transmitted Disease) program showed that 57 (56 percent) of the 102 newly reported cases were among returning migrants (UNDP 2008). Few people travelled neighboring countries like India, Singapore and Malaysia. As part of working in abroad, majority of the victims had stayed in Middle East without some exceptional cases. Being a great source of exporting manpower Bangladesh is massively susceptible to HIV/AIDS epidemic. The study identifies Saudi Arabia as the highest risky region of contracting HIV/AIDS. Many of the respondents expressed outspokenly that they got themselves engaged in sexual intercourse with commercial sex workers without any contraceptive. They did not perceive that they might have touched such a risky and lethal disease in life. Recollecting the reminiscence events of Malaysia Mr. Sarker stated that there was also a dwelling place close to mine where Philippine, Nepalese, Indonesian and Indian working girls lived in and used to getting them engaged in sex trade. He along with his Nepalese friends every now and then went to their house and accomplished sexual intercourse without any contraceptive. There were also some other nice and smart European girls adjacent to that house. By the by they met with that girls and offered themselves in sexual intercourse again.

Many of the respondents had claimed that they practiced an unsafe sex in abroad but did not regard this as a concern for getting HIV. Mr. Hanif, a twenty year young man who comes of a noble family from Ghatla, Noakhali elaborated the point mentioning that due to economic scarcity he could not continue his study anymore and at last left the country in quest of earning livelihoods. He had engaged him in sexual relationship with sex workers more than four times when he was staying in Bahrain. Without any condom he had frequently completed sexual intercourse with a nice Thai girl. In response to a question he states that sexual demand cannot ever be fulfilled using condom. He believed that most of the girls engaged in sex trade hail from Philippine, Thailand and Bangladesh. These girls possessed extra qualities of satisfying sexual demand. By the way he met a nice girl whose native area is Noakhali in Bangladesh.

Many of the respondents admitted that they could not understand that they might be infected with such virus through practicing unsafe sex in foreign countries. Moreover some of the PLHIV claimed and eventually identified different reasons as the prime factors of contracting HIV like blood transfusion, repugnance of health practitioners avoiding unlawful sexual relation. Apart from the family and country the migrant workers get themselves isolated and detached from the

normal setting of life. Prolonged working life of the people in overseas, even though separated from post-marital sexual relationship promotes health related risk practices. The ramification of these risk practices is an open secret issue for the women and children posing severe threat to preventive measures for HIV/AIDS in Bangladesh. Thatâ&#x20AC;&#x2122;s why it can be asserted that migration acts as a fuel and circuit of contracting HIV in Bangladesh.

5.15 HIV and AIDS: Women and Child Vulnerability Women require special attentions in HIV interventions in Bangladesh, given their social, economic and political status. Women belonging to an age group of 15-24 are 8 times more vulnerable to HIV/AIDS than those of any other age (UNAIDS, 2010). Women are more likely to contract HIV/AIDS than men because of a series of factors.

When Mrs. Luna Amin was pregnant at the time of first child bearing, she might have affected with HIV through blood transfusion. During child bearing three bags blood were used in her operation without any test. In 2004 she was identified as a people living with HIV. Her first son was tested and proved to be HIV negative. After five years, she had had her second child but did not receive any blood. Unfortunately her second son was marked as HIV positive because of her already been affected with it.

Majority of women claim that they become affected with HIV/AIDS from the intimate relationship and sexual intercourse of their husbands who have already passed many years of life in abroad in quest of money. Some of the respondents who are at the beginning of their conjugal life, already stopped in a sudden storm do not wish to get themselves married once again. Some of them who are desperate about life but still with family do not show any interest to have child for avoiding the victimization of HIV risk.

Rahima Begum believes that she is obviously affected by her husband. Having a great reproach there is nothing to escape from this. Her husband came to the country every six months other and stayed two months here. As much she can presage that her husband was in an illicit sexual contact with someone in Saudi Arabia. Otherwise it is not possible to get affected with this lethal disease. She is free from any sexually transmitted disease.

Womenâ&#x20AC;&#x2122;s lower social and cultural status also causes them to have less accessibility to education, employment opportunities and health care, including opportunities for HIV tests, counseling and medical care. Whereas women are subjected to early marriage, sexual abuse and violence in intimate and marital relationship, they are pressurized to have sexual relationship without any contraceptive that uplifts again the level of risk and danger.

5.16 Socio-economic Constraints and Cultural Barriers A vital number of migrant workers come back to country after passing some years in abroad with a view to looking for a bridegroom. Due to several economic impediments and lack of social security parents of the nice girls show an enthusiastic attitude over the foreign return boy. They wish to be tension free, at the same time economically solvent to some extent arranging the marriage ceremony of their daughter. Migrant workers have a great demand in the market of

marriage in our country. Educationally less qualified people never think of throwing their immature girls in a risky life and making the migrant worker as a life partner. Majority of the women outspokenly claims that their early marriage with migrant worker is the key factor of this risky life. Whereas women are not secured from socio-cultural perspectives, parents feel hesitation to make them educated sending educational institutions. Social security, educational expenses and conventional ideas are given preference by many parents in this socio-structural model. Thatâ&#x20AC;&#x2122;s why girls who have not crossed the required age of marriage become forced to get them engaged in marriage in this immature period. This promotes in enhancing health related complexities making women and children more vulnerable to HIV epidemiology in Bangladesh.

5.17 Social Discrimination, Stigma and Misconceptions Some of the respondents claim that they follow a change in the attitudes and behaviors of other family members whenever they perceive the matter of being affected with HIV/AIDS. The other members of the family feel one sort of threat of getting closure and touched with the victims in order to avoid any health related complexity. Lack of proper knowledge and consciousness as to HIV/AIDS has also accelerated and intensified the vulnerability of women and children.

Whereas women are treated as the prime source of carrying this lethal virus, they also face at the same time a huge number of pejorative comments from the members of husband family.

Separated life of the victims also raises lots of questions in the mind of general people that make them more pensive. Majority of the victims acknowledge that they are not equally given permission in public dealings as they got used to leading a time in the early hours of life. People generally claim that the only illicit sexual relationship is the prime cause of getting HIV and other diseases approaching the victims in a negative sense.

Mrs. Ayesha Khatun, a twenty seven year married woman hailing from the rustic and territorial area of Benapole in Jessor commented that all the members of her husbandâ&#x20AC;&#x2122;s family are not aware of her victim to this disease. She believes that it is more questionable whether she will be able to find bridegroom for marrying her elder son. She is in fear of becoming outcast and insulted from the society. If this news reaches to people they may not allow them as part of society. Uncertainty of life has made her more pale and sick. Mentally she is passing a heinous life.

Lack of adequate information, the stigma attached to HIV/AIDS, the lack of confidentiality make them different and detached from the rest of society. A handsome number of respondents who are migrants do not wish to disclose the fact of becoming affected with HIV because of receiving a great status and acceptance to the general people of society. Sometimes all other members of the family are kept in the dark as to this deadly disease that also intensifies the vulnerability and severity of risk for women and children. One of the respondents believes that she might have detached not to have a child if she could perceive of living with HIV earlier.

Disappointed at the sudden death of her husband, Ms. Sabrina Akhter states that at the very beginning the members of my husbandâ&#x20AC;&#x2122;s family showed negligence and oppressive attitude to me let alone a threat to life. I am likely to sacrifice all hopes and aspirations. There is no intention of getting myself engaged into marriage.

The notion of stigma and discriminatory approaches very often acts as an exclusive barrier in combating HIV/AIDS. When one of the family members is marked as PLHIV, women become the first to be diagnosed with HIV and may be accused of being the source of it in the family.

Patriarchal social structures, restricted norms and values designed for humiliating women and socially constructed deep rooted ideologies make female PLHIV very often more confused about life worsening the situation in Bangladesh.

5.18 Health Seeking Practices of PLHIV and Access to Health Services in Bangladesh: An Inevitable Challenge for the State A small number of respondents sought treatment, care and advice from traditional healers and public health care facilities. Ms. Luna Amin hailing from Gollamari in Khulna expressed that she had taken treatment and care from village doctors, traditional healer and fakir for the last few years. No one of them could identify his disease properly. She also took homeopathic medicine for the interest of getting cured.

The health service as to HIV/AIDS is mainly dominated and facilitated by NGO clinics in Bangladesh. The NGO clinics, the prime source of ensuring treatment and service offer the opportunity of testing HIV/AIDS on a regular basis. Most of the respondents reported that they are highly satiated at the treatment and counseling of NGO clinics. A handsome number of respondents had received treatment and counseling from different sources when they could not make themselves assure of the affectivity of HIV/AIDS. When her husband felt the illness of being affected with Hepatitis, her husband was forced to come back to the country from Saudi Arabia. As soon as her husband returned to country, he was approached a homeopathic practitioner in Khilgaon area of the capital city of Bangladesh.

Ms. Nahar, a forty year lady who lives in a village under Bancharampur upazilla in Bhramanbaria district states easily but exasperatedly claims not to get any remedy from that treatment. Only 38 percent of the respondents has taken treatment from government hospitals but at the same time showed a negative image in their services. Discrimination shows itself not only in general peopleâ&#x20AC;&#x2122;s attitudes but also it manifests to a great extent in the attitudes of public health practitioners. Mr. Karim a migrant worker from Nuria, Sariatpur expresses his experience.

Doctors in public health centers do not show any interest for touching them let alone mental support and requisite counseling. It seems to me that we are really neglected and helpless in regard to treatment seeking.

This is to assert that victims have a great repugnance on the services of government health practitioners. On the contrary they supported the services of counseling and treatment of NGO clinics and appealed to invent a quality based remedy for preventing this disease. Mr. Sarker, a forty year migrant worker states

that taking medicine such as ARB, vitamin, calcium and neotack tablets from Asar Alo Society; he is still leading a danger free life. He tries to participate in the counseling program arranged

by AAS on a regular basis.

Networking plays a vital role in reaching treatment and care as to HIV/AIDS, some of the respondents emphasized. People from different remote areas are not well aware of the real sources of treatment and care. Mrs. Ayesha Khatun, a twenty seven year married woman hailing from the rustic and territorial area of Benapole in Jessor expressed that she had met a person called Adit Narayan who managed all the things and supports for receiving treatment from an NGO in Dhaka. She along with her husband is still taking treatment, care and support from Asar Alo Society. They feel somehow better taking treatment from here. Different medicines like vitamin, iron tablets and kalbony are offered by the clinic authority. Ceprosine (anti-biotic) is also provided to meet up the demand preventing the severity of illness.

The government has not taken yet sufficient initiatives for ensuring cost-free HIV test and not even for diagnosing the virus in a friendly way. Majority of the respondents claim that they face one sort of insult and discriminatory approaches from the qualified public health practioners in exchange of fair services.

One couple of Jessor was infected with HIV and at the same time concerned with eye-related complexities. The authority of Asar Alo Society wanted formal permission offering letter to National Eye Institute and Hospital with a view to treating the victim, but they completely negated doing any operation of eye (Prothom Alo, 2010).

HIV treatment and care in Bangladesh are completely controlled by the global funding through some selective NGOs; government does not play any direct role with a view to continuing the treatment process. Unless the treatment procedure of HIV/AIDS is connected with the mainstream treatment facilities, this type of discrimination will be continued keeping a prolonged period. The situation might be worse if the proposed funding is stopped suddenly. All concerted efforts regarding the development issues of HIV treatment and cure will turn into failure if government shows any negligence in making HIV treatment connected to mainstream treatment procedure.

5.19 Present Status of Health of PLHIV: Expected Life Expectancy and Prospects More than 90 percent of the respondents receive treatment and care from NGO clinics and remain still hale and hearty. Some of the respondents who were highly affected with STDs are now quite cured taking proper medicine and counseling. Safe sex is now practiced by the victims because they are fully now aware of the issue. Mr. Hanif, a twenty year young man of Ghatla of Noakhali says that using contraceptives I am still doing sexual intercourse with my wife .Though my wife is aware of my being HIV positive, she is still continuing a good relationship with me. A three stage model, the ARRM gives emphasis on response efficacy and emotional influences of PLHIV that reminds that the low risk activities will be encouraged by the changing behavior. A large number of male respondents lead a separated and monotonous life having divorced from

wives and detached from the rest of family members. Few respondents wish to lead a sound life in future if the scientists can ensure the remedy of getting fully rid of this deadly disease.

Mr. Rokon describes his experience saying that I am already divorced and no more interested to get me engaged in marriage once again in life. My only daughter proved as HIV negative is living with me. Ms. Sabrina Akhter a twenty year girl who has already lost her husband asserts that my ex-lover is quite interested to marry me whether I might be affected with HIV/AIDS or any other lethal disease. It seems to me I need to get me engaged in marriage but I do not want to make any harm anyone. This is noticeable that sometimes men are likely to be crazy and respectful to first love of life. Several constraints may exist in the life of beloved person but he is idiosyncratically stubborn to receive her let alone the risk of life. Sometimes it becomes more axioms that love can make a man really blind about life.

Chapter Six DISCUSSION AND CONCLUSION 6.1 Socio-economic Backgrounds of the PLHIV Family structure and availability of sources generating income contribute as a determining correlate for the PLHIV to seek proper and adequate treatment. Also educational status, especially, adequate and proper sex education plays a great role particularly for females to be or not to be affected by HIV infection. The average income and enrollment in education of the respondents shows that the monthly incomes in most families were not adequate to ensure a standard living for the entire family. Although many of the respondents attended primary and secondary level education, only a few of them received education up to tertiary level. In this study, most of them cannot manage an adequate income to support their livelihood and family.

As a consequence many of them began petty business or went abroad as laborers which again magnify the rate of prevalence of HIV in Bangladesh. High risk practices of migrant workers vehemently affect the epidemiological structure of HIV transmission. And this situation aggravated when they maintained sexual relationship both with their life partners and CSWs. Sociologist Beck (1992) defines AIDS as a disease of modernity and poverty and it is shaped and reformed by neoliberal policy of the First World. This malpractice further increases the mother to child HIV transmission of which the mother is totally unaware of. A significant proportion of the male respondents were unemployed and most of them were foreign-returnee. Driven by the frustration and uncertainty of life most of them often try to find cheap entertainment practicing high risk behaviors and thereby increases the prevalence rate.

6.2 Knowledge and Perception of HIV and AIDS and Risks The present study brings out the facts that almost cent percent of the respondents believe that HIV is transmitted from unprotected sex and sharing of infected needles and male respondents were more likely aware of the HIV transmission than were the female respondents. It is also a common knowledge of the respondents that blood transfusion and mother to child transmission

are the key routes for spreading the HIV. Despite the handsome percentage of high and moderate knowledge of HIV, the respondents were affected with HIV. People Living with HIV/AIDS (PLHIV) become more aware of the transmission and prevention of HIV since they receive information on it from different sources.

There is an intimate correlation between transmission of HIV and STDs along with the practices of sharing unsterilized and infected needles. In Bangladesh sexual transmission cases predate all the other risk practicing groups, the number of IDUs is signified massively by majority of the respondents. Other than sexual and needle sharing means unsafe blood transfusion is hold to be the fourth prime area of HIV transmission in Bangladesh. Female and children are more susceptible to HIV transmission and most of the life partners of the male respondents and their children got infected with HIV due to the practices of risk behaviors with the CSWs by their male counterparts.

The German sociologist Ulrich Beckâ&#x20AC;&#x2122;s (1992) notion of risk can be applied to the present risk practices perceived by PLHIV. Beck argued that modern risks are entirely the resultants of unwise and frantical human activity. As to the notion of Beck, electronic media has created a kind of spatial and temporal double life and it plays the role of making the domain for social construction and social definition of risk society, as applied to present crisis left by HIV transmission.

Health belief model conceptualizes that risk perception refers to being susceptible to potential threats, the perception of risk groupsâ&#x20AC;&#x2122; influences health promoting behavior. According to HBM, there are two types of beliefs that influence people to take appropriate preventive action. These include beliefs related to readiness to take action and beliefs related to modifying factors that facilitate or inhibit action. The variables that are used to measure to readiness to action are perceived susceptibility to the illness or any health threats and the perceived severity of the illness. Perceived benefits (i.e. the perceived advantages of taking action) and perceived barriers (i.e. the perceived costs or constraints of the specific action) are the main modifying variables (Rosenstock, 1990; Norman and Brain, 2005; Amanuallh, 2002). The given services from NGO clinics and health related treatment costs such as transport, medical check-up are determined as the mediating variables by many of the PLHIV in relation with seeking health care.

6.3 HIV Control Program and Access to Information The study found that 88 percent of the PLHIV frequently watched TV and only 35 percent of the respondents were exposed to radio. The electronic media predominates over the print media in the present study. Only a considerable number of the respondents read newspaper. This evidence proves that people with secondary and primary education are not highly exposed to reading newspaper. Only 7 percent of the PLHIV received tertiary level education, an important sign of determining the rate of newspaper readers. 93 percent of the respondents have either heard or watched any campaign of HIV/AIDS. 58 percent of the respondents receive the information from satellite channels because it covers the highest percentage of watching television. This analysis proves that exposition to electric media has augmented the level of awareness of PLHIV. A large number of the respondents regard festoons and banners as the important sources for disseminating HIV knowledge.

6.4 Perceived Barriers and HIV Treatment

The socio-economic complications of HIV treatment are determined by socio-economic indicators of PLHIV. Socio-demographic variables keep also a similar effect on the perceived barriers of seeking heath care. Transport cost is regarded as one of the significant variables of perceiving treatment barrier. Financial crisis is indicated as an important barrier by 62 percent of the respondents which is attached to the income of PLHIV. People with less income perceive more barriers in HIV treatment than those have higher income source. Place of living, where PLHIV stay is significantly related to two important variables- long time procedure (P< 0.05) and unavailability of medicine (P< 0.01), fashioned as perceived barriers.

Place of living of PLHIV has a negative correlation in the treatment procedure and testing facilities, very often counted as a great barrier in receiving proper health care. This situation emerges out of the centralization of treatment centers and facilities located only in the large cities. The facility of treatment procedure and testing HIV is not available in remote regions of the country which makes a great impediment in seeking health care for the general PLHIV. Some socio-cultural constraints are determined as important variables of seeking heath care of PLHIV. The emotional attachments of the PLHIV are more important to identify the feelings of people they foster about this infectious disease and its victims. Majority of the respondents claimed that they felt deep sadness and guilt from the onset of infecting with HIV. General People of society never take the fact of infecting with HIV/AIDS easily because of the fear of getting susceptibility to HIV/AIDS. Almost 47 percent of the PLHIV stated that they perceived one sort of negligence and rapidly changed behavior in the attitudes of the others. In treatment process, public health practitioners very often show discriminatory attitudes towards PLHIV. Recently doctors of DMCH have negated point black to make the operation of appendicitis of an HIV infected people (Prothom Alo, 2001). Women who are living with HIV are more vulnerable to treatment seeking practices due to socio-cultural impediments. As to remembering the oppressive attitudes and discriminator behavior of many members of her husband’s family, Ms. Nahar stated that people of husband’s family did not take the issue of infecting with HIV easily.

Inspite of staying her husband in Saudi Arabia already tested and proved to be infected with HIV, many of her husband’s family claimed her for bearing this deadly virus. At the outset of infecting with HIV she did not wish to disclose the fact due to fear of outcast and social stigma.

But her husband informed other members of family very soon which was like a sudden storm in life and made the situation worse she did not expect of what.

Majority of the PLHIV both male and female confessed that they wished not to present them as PLHIV in front of many. The stigma and attitudinal changes immediately become visible when anyone can understand the fact of contacting with HIV. These facts are supported by the cultural theory of Douglas. People Living with HIV very often hide health promoting behavior due to socio-cultural limitations. And this makes many of the PLHIV more vulnerable to treatment seeking and health care let alone ensuring discrimination free life.

Social stigma and superstitious attitudes of PLHIV are regarded as socio-cultural barriers by the considerable number of the respondents. Around 30 percent of the respondents, inspite of having moderate and high level of knowledge, were not aware of the disease at the outset of contracting with it. People Living with HIV/AIDS very often face discriminatory behavior and attitudes in the family, even their life is threatened when they perceive attitudinal changes among others of society. They experience discrimination, insults, and attacks and are even murdered. Those who perceive themselves as to be members of a stigmatized groups, often experience psychological distress many view themselves contemptuously different (Heatherton, et al, 2000). Goffman applied the idea of stigma to understand how to discredit someone and at the same time makes

the individual psychologically alienated from others in an unexpected way. The situation becomes worst when PLHIV perceive themselves as separated from the participation of many things of mainstream society.

6.5 Health Seeking Practices: Dominating Factors A considerable number of the respondents go to NGO clinic for treatment and care. The study shows that 92 percent of the respondents receive allopathic medicine from NGO clinics.

Although there have been pluralism in the types of health care providers sought, bio-medicine (allopathic medicine) remained dominant, as also seen elsewhere (Mizrachi and Shuval 2005, Stevenson, et al, 2003). 38 percent of the PLHIV receives treatment and care from Govt. clinics, which is attached to the services of high academician medical professional. Around 25 percent of the PLHIV sought health care services from private clinics while 18 percent of the respondents went to traditional healers. Only 14 percent of the respondents took homeopathy treatment, a conventional method of treating patients. A decrease in the use of traditional practitioners (Faith healers, Kabiraj/totka,) was noted among the study population which is consistent with the trend seen at the national level as well (Cockroft, et al, 2004). This is unlike the use of traditional medicine in other Asian countries such as Laos, India, Vietnam (Syndara et al 2005, Gogtay et al 2002, Ladinsky et al 1987).

There are 96 VCT (Voluntary Counseling and Testing) centers in Bangladesh, established with an objective of testing HIV (Prothom Alo, 2010). HIV is tested without any cost in these organizations. These centers are controlled by some selective NGOs like Asar Alo Society, Mukto Akash and Confidential Approach to AIDS Prevention etc. Moreover 41 percent of the respondents made their HIV testing in NGO clinics, but about 47 percent of the respondents took the testing facility from Govt. clinics. Only 26 percent of the respondents received treatment from private clinics. This figure conceptualizes that a considerable number of the respondents go to qualified health practitioners in Govt. hospitals for testing HIV on pursuance of the opinion of local health practitioners. Ultimately, PLHIV receive the given services of NGO clinics because of their socio-economic status.

Socio-economic variables emerged as one of the most significant determinants of seeking health care among PLHIV. Education was significantly associated with HIV testing, an important aspect of seeking health care services (P< 0.05). Those with primary or above education (75 percent) are three times more likely to seek health care than those who have no education. There are a number of explanations for why education is an important determinant of seeking health services and treatment seeking practices. Education is likely to influence knowledge and attitudes towards severity of disease and enhance the understanding of getting well treatment (Caldwell, 1981). In this study, the findings of a strong educational effect on the health seeking practices are consistent with findings of other studies (Addai, 2000; Rahman et. al 2008; Ahmed, 2005) Moreover, income and occupational status were also found to be significantly related to health seeking practices of PLHIV. The study specifies that income and occupation have a close relation with the services of private clinics. People who have higher income are more likely to seek treatment and care in private clinics than those who have no or little income. Those who have high occupational background are more likely to seek health care from private clinics than those having no high professional status. People with less income generating activity very often take treatment and care from NGO clinics (P< 0.01). Since the cost free treatment and testing

facilities are only given by NGO clinics. PLHIV from different of life visit this health centers and receive the requisite service and care.

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Annex-1: Case Studies Case One TN-301 Ms. Nahar, a forty year lady lives in a village under Bancharampur upazilla in Bhramanbaria district. Though she is primarily educated, she is a nice housewife in professional life. Due to husband’s immature death she passes a miserable life in the teeth of all oppositions. Lack of income and guidance has trammeled the way of living and eventually created a severe threat to schooling of her only child. She never went to abroad. She is satisfied with members from her husband’s family. They treat her well and cooperate in different family activities. Her husband was staying in Saudi Arabia for six years. When her husband felt the illness of being affected with Hepatitis, her husband was forced to come back to the country. As soon as her husband returned to country, he was approached a homeopathic practitioner in Khilgaon area of the capital city of Bangladesh. Though her husband took remedial measures like requisite medicine, counseling from there but could not get any fruitful result for the mitigation of illness. When every medicine and measure failed to act against him, her husband was counseled to test his blood in any health centre to get accurate information about the disease. When he was tested in Medinova health care centre, he had been signified as a people living with HIV. Nahar believes that she is obviously affected with HIV from continuing sexual intercourse with her husband without contraceptive. She used to continuing sexual intercourse without contraceptives with her husband before his death. All the members of the family called for the test of HIV when her husband had become of being affected with this lethal disease. In 2003 she was marked as HIV positive. Fortunately their only one child was marked as HIV negative in the family. Their child is still keeping well in terms physical and mental aspects. She does not wish to have marriage and child again. In spite of having mental pressures and mortification she wishes to be tension free and sound in the later phases of life with her child. There is the necessity of money in bearing the educational expenses of her child. This is quite impossible to

maintain the cost of family let alone educational expense at the same time. Taking treatment and care from AAS she feels better in life. She states that the NGO authority supplies them with transport cost, medicine and hardly food item.

Case Two TN-303 As a city dweller Mr. Zakir lives at Green road in Danmondi area in Dhaka city. He is forty eight years of old and a migrant worker in profession. His family consists of five members. His monthly income is 25000 BDT and leads a handsome life. He had completed secondary education but could not continue higher education because of the scarcity of money. For the interest of family he was encouraged to go abroad for earning livelihoods. With a view to changing the wheel of luck, he left the country for Saudi Arabia in 1993. As a migrant worker he has been doing service in Saudia Arabia for 17 years. He cannot perceive how he has been affected with this severe disease. To be frank, he admitted the fact of engagement in sexual intercourse in abroad four or five years ago. But he asserts that he has not got himself affected with HIV from that sexual contact. He believes that he might have affected with HIV through blood transfusion from a minor operation in 2007. When health related complexity had reached at a peak stage, no treatment and care acted for him. He was called for blood test and proved as a people living with HIV in 2008. He firstly did not show any interest on the severity of this disease.

He became segregated from any sexual intercourse for the last five years. There is no alternative to death in this disease. When he perceived the matter of being affected with this virus, he took the treatment from NGO clinics. He did not go anywhere else for HIV/AIDS treatment. Low risk perception, fear and social stigmas have endangered the normal way of his living. Family members donâ&#x20AC;&#x2122;t treat him as like as before. In family life wife does not treat him like before.

Hesitation, tension and sufferings have trammeled the spirit of living with family. He had a great lacking but no subtle concept regarding knowledge of HIV & AIDS before attending the counseling program arranged by Asar Alo Society. But their counseling program helped me a lot to have knowledge regarding HIV &AIDS explicitly. There is a common belief in Bangladesh, particularly in rural Bangladesh that, AIDS is a communicable disease that passes on the others when one gets close to victims. Even the family numbers hardly bother to isolate the HIV victims, but the victims get themselves as threatening and burden in family and society. Although it is everyone's basic right to lead a normal life but sometimes depression and discriminatory attitudes shatter the mind.

Case Three TN-304 Mr. Awlad seems to be very industrious and enthusiastic in life. He lives in the Alirtake village of Narayangang. Setting apart from the family this thirty five year young leads a separated life.

There is no family income he comments. He is now completely unemployed. Though he had some savings but his wife played false with him. Needless to say she went away her fatherâ&#x20AC;&#x2122;s house taking all the money, ornaments and valuable things. A handsome amount of money had been deposited in his wifeâ&#x20AC;&#x2122;s account earlier when she was staying in abroad. He is now fully an insolvent person having no charming dream in life.

Passing thirteen years in Saudia Arabia as a migrant worker, Mr. Awlad comes back to the country and gets himself married with a seventeen year nice girl. At a stage he went to Kuwait for earning more money with a view to bringing happiness for family. Soon after coming back to the country after four years he fall a victim to severe illness. He was sure of his being affected with HIV/AIDS in 2005 when the doctors informed the result of blood testing. Hearing the news

he was in a fix what to do. At a time he became more depressed and exasperated about life. He cannot call up the event how he has been affected with lethal disease. He believes that he never did any anti-religious and illicit sexual relations with anyone so far he can assume. His wife and only child also were tested and proved with HIV negative fortunately. His wife along with child and money has already left him and confirmed not to come back in this life. He is highly satiated taking treatment and counseling from NGO clinics. Mr. Awlad believes that he can live more if he takes timely medicine, diagnosis and counseling. In the present situation of life he is again interested to get himself engaged into marriage. The authority of Asar Alo Society NGO clinics has ensured him of the fact of match-making if they get the expected HIV positive bridegroom.

People who are his nearest ones do not treat him well. They try to avoid his participation in any family and social program. When Mr. Awlad becomes present in front of public place people show one sort of insouciance and different outlook to him. This pains him seriously and ultimately reduces self-esteem. Whereas he is not aware of the real source of getting this lethal virus, he wishes to live more. He insisted on inventing inoculation for controlling this disease.

Case Four TN-307 Mr. Samsul Haq, a fifty seven year old person is living with HIV/AIDS since the genesis of 2001. He hails from the remote area of southern part at Kallankalash village of Patuiakhali district. Engaged in farming, his monthly income is about three thousand taka. There are seven members in his family. He stays in family and passes marital life in a happily mood. Infatuated with religion he is an educated person and possessesor of a sound health. As part of working life he had spent over ten years in Saudi Arabia. He was identified as a people with HIV in 2001.He did not perceive the severity of the matter at the outset of blood testing. He had passed nearly six years without treatment. Scarcity of money along with distance gap is to be signified as the major impediments behind this delay of treatment. He has to come to Dhaka from the rustic area of Patuakhali district, the remote part of southern Bengal. This is also more time consuming to take HIV treatment and care from the very local area. He was never victim of STDs any time in life.

He took injection for health related problems when he was staying in foreign country. He claims that he might have affected with this virus from unhygienic series used by foreign medical practitioner. He maintained high secrecy of this disease to his local region. Being a man of religious minded, he says that everyone must have died one day. Thatâ&#x20AC;&#x2122;s why there is no extra tension of living more. Before going to test blood in medical centre he took herbal medicine, injection and counseling from traditional and local health practitioners. He also used few amulets for recovering the severity of illness but did not bring any effective result. Taking treatment and counseling from NGO clinic, he leads a sound life now.

All the members of his family are conscious of this disease and treat him well. In personal life he is now detached from sexual intercourse. There is no intention to go abroad again. Carrying out all the rules and regulations of life he wishes to spend the rest of life in the country. He believes that a systematic and regular treatment can ensure a sound health. As to HIV/AIDS medical facilities should be augmented in local area for the interest of saving valuable money and time he states in a phase of speaking. All the people of society should treat HIV/AIDS positive people like a sound man.

Case Five TN-114

Ever since the genesis of teenage period Mr. Ripon leads a separated life in Dhaka city. In spite of having family in Bikrampur in Munsiganj he keeps himself very often in Golap Shar Mazar, Dhaka. He is twenty eight years old and remains single still in life. He does not know about the recent status of his family. Professionally he is a rickshaw puller and takes drugs on a regular basis. He is highly familiar with the items of drug like Heroine, Pathedrin, Gaza and Yaba also.

He believes that he has become addicted keeping a detached life from family at the beginning of life. He does not wish to go back to his family again in life.

At the same time he practices sex with commercial sex workers having no scope of marriage. A few days ago he got himself engaged in sexual intercourse in a shanty area of the city. But he was caught red handed by the police and sent to Jail. When he was appeared in Court he was given drugs by the police authority to keep mentally balanced. Sometimes he has to pass many days in jail only for the claim of taking lots of drugs and getting engagement in illicit sexual intercourse. He cannot perceive when he has touched with HIV/AIDS disease. He treats himself as person that has no prestige and power in life. Isolated from family he wishes to get himself marry and a sound life. At the same time he also asserts that it is not possible for him to lead a sound life because no one shows interest about him, not even his relatives.

Victimized of this lethal disease he has taken treatment and care from Modhumoti, an NGO in Dhaka city. He often visits the DIC of Mukto Akash and takes medicine and contraceptives on a daily basis. He believes that he might have caught in HIV from the women or injecting drugs. He shares syringes and needles with others who are equally professionals and enthusiastic about drugs. He looks fickle minded person wearing a very dirty and shabby dress. He is very interested and peculiar to watch film in G-Cinema channel arranged by DIC authority. Mr. Ripon believes that people do not treat him well and keep aloof maintaining a certain distance. He is satisfied with the service of this DIC. They provide them with sufficient pure drinking water and counseling. They encourage him to motivate to use condom in sexual relationship.

Case Six TN-308 Mr. Karim, a single man of forty one lives in Nuria, Sariatpur. Inspite of having secondary education he leads an unemployment life at present. Having no income source and family life he tastes a separated life. Sometimes he becomes despair of life. He was brought up in the teeth of lots of economic oppositions. He could not acquire more education because of money. His fatherâ&#x20AC;&#x2122;s monthly income was not sufficient for running the family let alone education. All of these factors mainly encouraged him to migrate in foreign country. Selling some lands he managed the requisite money and got the permission for settling in Malaysia.

When he was staying in Malaysia for the purpose of working he got himself engaged in love with a Malayan nice girl. Unfortunately he had engaged himself with the girl in sexual intercourse without any contraceptive. He wanted to get her marry and became the citizen of Malaysia. But all his hopes and aspirations were ended in smoke because of law related complexities. He could not finally manage her as life partners. The Malayan girl was highly addicted and detached from family. When all attempts proved to be failed to convince the authority of Malaysia, he finally he could not stay more than four years in Malaysia and ran away the country. His life is afflicted with severe economic crises. Mentally he is also more disappointed and unhappy having no job. In family life he is severely neglected and humiliated and sometimes regards life as meaningless. He took treatment from the Holy Family and Jagori at the very beginning of perceiving the illness. He is now taking all kind of services from AAS

health centre and satisfied with it. There are some limitations in this treatment. Nutritious food, pure drinking supply and emergency medical facilities should be developed more than what it is still.

He also took treatment and counseling from Government health clinics but did not show any interest to go there again for service. Doctors are not so friendly to touch and give mental support to them in Government health clinics. Their negligible behavior mainly shocks and torments his mentality. He asserts that discriminatory behavior shows itself not only in general people’s attitude and approach, it also becomes manifest in public health practitioners. He wishes to get himself in any job soon so that he can live a systematic and economic balanced life.

Case Seven TN-327 Mrs. Sabrina Akhter, a young and nice girl aged twenty year passes a crucial time in life having lost husband in this immature age. All hopes and aspirations have been shattered within a single moment. She hails from Trishal, Mymensing. Her family consists of four members. Being very nice her parents wished her to get marry at the early stage of life. Moreover she claims that her parents and nearest relatives persuaded her to engage in marriage. She never imagined that he might be affected and fallen in a threat of danger. She was too little to take any decision about her personal life. She gave equal emphasis the wishes of her parents and all other members of family.

With a view to leading a happier life, Sabrina got herself married with a man working in Kuwait.

As part of working life her husband had spent seven years in abroad. After passing five years of working life in Kuwait, her husband comes back to the country in order to spend some days.

Miss. Sabrina was chosen as the bridegroom by her husband’s family members. Soon after passing some days her husband goes to Kuwait again and comes back to country with illness three years later. Unfortunately, her husband died in 2008.

She believes that her husband was aware of the fact of being affected with HIV but never shared anything. Sabrina asserts that she is inevitably affected by her husband. At the very beginning the members of her husband’s family showed negligence and oppressive attitude to her. She is likely to sacrifice all hopes and aspirations. There is no intention of getting herself into marriage.

She urged me to invent any kind of vaccine of this lethal disease. She wishes to lead a risk free life now. If she becomes cured of this disease; she might have got herself marry in to marriage again. Every other member of her family is not aware of this disease.

Mrs. Sabrina takes care and treatment from NGO clinics. Transport cost, home services etc are given by this NGO clinics. She is highly satisfied at the service of this clinic. She joins their counseling program and becomes aware of the different issues of treatment and care. At family life she leads a simple life. She feels the necessity of being engaged in marriage but thinks not to harm anyone. She is highly tensed about the rest of life whereas her husband is only a history.

Case Study Seven Continued…….

He can hardly manage the living cost. There is more than one offer for getting herself into marriage. Being aware of the case of HIV positive, her boy friend who loves her much from childhood wishes to have her as life partner in life. Her boyfriend is prepared to receive her any time at any place. She is making relationship with her boyfriend. She speaks with him five to six times a day. Her boyfriend asserts that he will not break the promise of getting her in life whatever disease she might have engaged. Though she had negated the issue that she is still maintaining a sexual relationship with her boyfriend, her looking face proved the matter clearly.

Case Eight TN-328 Mr. Reza Choudhury comes of an elegant Muslim family of Cougacha, Jessor. He is thirty five year old and leads a separated life. Actually he has no source of income generating activities but passes an uncompromised struggle of life. There is no one in his family without only daughter.

With a view to visiting he went to Calcutta of India few years ago. When he was staying in India he fell to a victim a severe abdomen pain and headache. On pursuance of doctor’s advice he had to take preliminary treatment but did not get himself cured. At last they counseled him to make an operation for another complexity of the body. The doctors of India successfully finished his operation and suggested the requisite medicine and antidote for the finalization of this disease.

He believes that he might have been affected with HIV from blood transfusion which was provided by the doctors of India.

As part of living in territorial area of Jessor; he often visits India for different purposes. In the country he becomes severely sick and takes treatment from traditional healers and local medical practitioners. When all kinds of treatment prove as futile he was counseled to test blood. At this time he was proved as a people living with HIV. On the spot he flew away Jessor because of the fear of police. He believes that police can shoot him because this people can affect other more easily. He became afraid of the message of becoming affected this deadly disease. So far I have noticed that he is desperate and pensive about life.

Case Study Eight Continued…….

Mr. Reza Choudhury leads a detached life keeping aloof from wife. He along with only daughter is now dependent on the income of his sisters. The woman whom he chooses as life partner has gone away because of having no income source. Lots of sufferings and hesitations have grasped the normal way of life. People do not treat him well. There is no intention to get him engaged again in marriage. He has taken treatment and care from NGO only and expressed satisfaction at their services. He asserts that it takes huge time and money to come to Dhaka for treatment. If any health centre could be established regarding HIV treatment in Upazila Sadar, it would be more benefited for them to receive service. He will be more conscious of the severity of this deadly disease and make people help to get rid of this.

Case Nine TN- 330 As part of searching livelihood Mr.Sattar, a forty year matured has finished a journey in abroad.

Literally uneducated he was impressed to leave the country because of economic hardships. Now he dwells in his native area Araihazar, in Narayangang. He belongs to a family of five members.

He can hardly support in the income generating activities of his family. Having marriage in Bangladesh Mr. Sattar went to Malaysia and stayed there for six years. When he was staying in abroad, he went to brothel on a regular basis. Motivated by Bangladeshi and Nepalese friends he mainly chose this way and got him engaged in sexual intercourse without any contraceptive. The commercial sex workers engaged in sex trade in Malaysia are mainly Malayan, Nepalese and Philippine. They are so nice having a great sexual appeal that attracted me much to share sex with them.

Though he leads a foreign life in Malaysia he does not confess the matter being affected with HIV from any sexual intercourse or blood transfusion. At the same time he proclaims not to be affected with that. He is well aware of the treatment sources of this disease now. Due to shame

and desperation he became detached from taking treatment when the testing report of blood proved to be HIV positive.

Case Study Nine Continued…….

He is now hale and hearty taking medicine and counseling from Asar Alo Society clinic. All the members of family treat him well. Sometimes he feels mental depression and hesitation.

Economical instability and crises have lowered the standard of living. He has three daughters and wife in personal life. All of them were tested and proved as HIV negative. Family members treat him well. He has taken counseling and treatment from both Government and NGO clinics. He claims that doctors in public clinics do not show their interest in the treatment of HIV. They feel nervous to give people living with HIV proper treatment and service. At present condition he is hale and hearty taking medicine and counseling timely. He wishes more support and friendly approach of the people. A fruitful care and treatment is enthusiastically expected from the government and donor agencies for the better life.

Case Ten TN- 342 Mr. Hanif is a twenty year young man who had completed his primary education in time in Ghatla, Noakhali. Due to economic scarcity he could not continue his study anymore and at last left the country in quest of earning livelihoods. Having marriage a local girl he went abroad. His family consists of four members. Though he served as a migrant worker in Bahrain he leads a life having no employment. In family life he is satisfied living with other members.

Mr. Hanif believes that HIV mainly comes from sexual intercourse with affected woman. The women are mainly liable for spreading this deadly virus. As a migrant worker he has passed over four years in Bahrain. He comes to Bangladesh to visit his beloved wife and other members of family. Soon after spending some days here, he attempts to go in Bahrain for the second time in 2009. When he was called for medical test in Medinaova clinic, he became identified as a HIV positive. He did not get any permission to leave the country then. He is to bound to stay within the country.

Case Study Ten Continued…….

In Bahrain he along with friends sometimes went to hotel and met with commercial sex workers.

He had engaged him in sexual relationship with sex workers more than four times when he was staying in Bahrain. Without any condom he had frequently completed sexual intercourse with a nice Thai girl. In response to a question he states that sexual demand cannot ever be fulfilled using condom. He believes that most of the girls engaged in sex trade hail from Philippine, Thailand and Bangladesh. These girls possess extra qualities of satisfying sexual demand. By the way he met a nice girl whose native area is Noakhali in Bangladesh.

Before going to abroad, Mr. Hanif had got himself engaged in marriage. Using contraceptives he is still doing sexual intercourse with his wife. His wife is aware of his being HIV positive. In family life his wife is pregnant and has two daughters also. He did not make any test all other members of his family not even the pregnant wife. There is no concern about the victimization of the ensuing child. Everything will be determined by the wish of omnipotent Allah. His wife does not show any negligence to him. Safe sex practice is done by them. People in rustic area are not fully aware of the fact because he does not like to disclose it. They treat him well as he was before. Infatuated with foreign life Mr. Hanif is passing a simple and homespun life in the country. He takes medicine, and counseling from AAS every other month. He also joins the counseling program on a regular basis. The transport cost along with other food and drinking

water facilities is provided by the authority. He emphasized that medical facilities should also be promoted and made easier for the general people.

Case Eleven T N- 343 Ms. Luna Amin hails from Gollamari in Khulna. Soon after finishing college education she was got married with a man who leaves the country few days later. There are four members in her family. She is a thirty year housewife and is continuing conjugal life well. She seems too worried but not unhappy. She never visited any foreign country in life. The monthly family income is 5000 BDT which is not sufficient for running family in the present context. Having no income source like the before she has to minimize the way living every moment.

When Ms. Luna Amin was pregnant at the time of first child bearing, she might have affected with HIV through blood transfusion. During child bearing three bags blood were used in her operation without any test. In 2004 she was identified as a people living with HIV. Her first son was tested and proved to be HIV negative. After five years, she had had her second child but did not receive any blood. Unfortunately her second son was marked as HIV positive because of her already been affected with it. If she had perceived the matter of saving her upcoming child from HIV she might have taken treatment counseling with doctors. Though her husband has passed over twenty years in Saudi Arabia, he was identified as HIV negative.

Ms. Luna Amin had taken treatment and care from village doctors, traditional healer and fakir for the last few years. No one of them could identify his disease properly. She also took homeopathic medicine for the interest of getting cured. Unluckily no medicine acted properly on behalf of her. At the eleventh hour she was convinced to take treatment and support from public health practitioners. Therefore she was admitted in Khulna hospital but the prescribed medicine by doctors did not bring any fruitful result. She was shifted to PG hospital in Dhaka. When doctors had failed to identify the disease once and again, they made a test of her blood and ensured of the fact of HIV. They did not inform Luna firstly, but made a test of her other family members.

Case Study Eleven Continuedâ&#x20AC;Śâ&#x20AC;Ś.

When she was informed of the fact of being infected with HIV, she became like mad. She cast aside eating, sleeping and the regular activities of life. All the members of her husbandâ&#x20AC;&#x2122;s family are well aware of the issue and treat her well. Luna Amin believes that her husband is faultless in this case. He claimed that doctors were not conscious of this fatal disease. There is no medicine and antidote for the final cure of this disease. Taking proper counseling and medicine she may lead a danger free life. In spite of having some limitations she participates in the counseling programs on a continual basis organized by AAS. She is satiated at their behavior in terms of treatment and service. At present she uses contraceptives at the time of sexual intercourse with husband. Inspite of having some exasperation her husband treat her same as before. She is now well and satiated living with family.

Case Twelve TN- 345 Mrs. Rahima Begum a twenty seven year hardworking girl resides at Tongi, Gazipur. She has completed secondary education and got married at the very early age of life. Her monthly family income is 10000 BDT. The family consists of five members. Every body of the family treats her

well. They do not show any negligence on her. Her husband had stayed in Saudi Arabia for the last sixteen years. Before three years her husband became ill and went to India for treatment. He was identified as a people living with HIV at a private clinic in India.

Coming back to the country, Mrs. Rahima Begum was tested and proved as HIV positive also.

She could not believe that she could have infected with such an unexpected virus. She became puzzled and began to think about the subsequent impacts guiding future life. Rahima Begum believes that she is obviously affected by her husband. In spite of having a great reproach on her beloved husband, she could not find any solution to get rid of this problem instantly.

Case Study Twelve Continued…….

There is nothing to escape from this disease. Though she knew that there was no cure for this disease, her looking face proved an unquenchable thirst for living more in the earth. Her husband came to the country every six months other and stayed two months here. As much she can presage that her husband was in an illicit sexual contact with someone in Saudi Arabia.

Otherwise it is not possible to get affected with this lethal disease. She is free from any sexually transmitted disease. She looks so much pale and weightless. The fragile physical fitness proves how much struggle she carries on. Everybody of her family cooperates with all other activities as before. In spite of having satisfaction in family life, one sort of mental pain haunts her always.

Mrs. Rahima Begum had visited local health centers many times but did not get any well treatment for preventing this disease. In accordance with the opinion of many elders, he knocked at the different sources and took remedial measures for alleviating the level of affectivity. She even used amulets, took pure water and herbal medicine with a view to getting cured completely.

All the attempts, adopted for preventing this risky virus had been ended in smoke. She did not find any way to get treatment and eventually decided to visit NGO clinic for procuring this problem. She is satiated after getting treatment and care from the concerned health center.

Case Thirteen T N- 349 Mr. Sarker, a forty year industrious man had finished primary education at early age of life.

Unfortunately he could not continue study more because of different socio-economic complexities. He keeps himself in a remote part called Baseil in Tangail district. His family comprises of four members. Professionally he is a migrant worker and has passed a prolonged period in abroad. In spite of having wife and son he is hardly satisfied living in family life. As part of working in foreign country he had stayed in Malaysia for nine years. He has been suffering from severe fever and vomiting for a long period. No medicine and remedy acted for his body.

Case Study Thirteen Continued…….

Finally he was called for a medical test and identified as HIV positive in Malaysia in 2006. He became pale hearing the news but there was nothing to do in that period. There was no treatment of this disease in Malaysia. Getting back to the country he finds out the Asar Alo Society NGO with the help of PG hospital in Dhaka. Though he was affected with STDs earlier, he is now completely free from that. Moreover, his wife and son are tested and proved as HIV negative.

When Mr. Sarker lived in Malaysia he along with his Nepalese friends often stayed in the same house. There was also a cottage type house adjacent to their ones where Philippine, Nepalese, Indonesian and Indian working girls dwelt in and got themselves engaged in sex trade. First of

all he could not understand the matter what happened there. Being aware of the fact, Mr. Sarker along with his Nepalese friends every now and then went to their house and did sexual intercourse without any contraceptive. There were also some other nice and smart European girls close to that house. At a time they met with that girls and offered themselves in sexual intercourse. Though he stayed nine years in Malaysia, he did not go there for the first two or three years of working life in Malaysia. When he began to know about that house he went for satisfying sexual demand every other week. There is no intention to go to Malaysia because of being HIV positive. In marital life he is not so satisfied with wife. He uses contraceptive when he gets him in sexual contact with his wife.

He does not feel real satisfaction in sexual intercourse because of carrying out some restrictive rules and regulations. Wife does not love him as much as before. All other members of family do not like him because of having no role in income generating activities. He took care and medical support only from NGO. He takes medicine such as ARB, vitamin, calcium and neotack tablets and remains still well. He tries to participate to the counseling program of AAS on a regular basis. Satiated at their service the AAS authority manages all transport cost and food for them.

Case Fourteen T N- 351 Mrs. Ruksana Akhter a twenty year nice girl lives in Keranigang, a semi urban area in Dhaka.

Soon after finishing secondary education her parents got her marry with a migrant person. His family consists of six members. Losing husband in this immature age she is facing a hard nut to crack in family life. Having no current family income she depends on her brotherâ&#x20AC;&#x2122;s income for the maintenance of family and leads a miserable life. She thinks that it was totally wrong decision in my life to engage in marriage in that time. If I was an educated woman I could handle all the problems and income generating activities more skillfully.

Her husband was staying in Malaysia for Twelve years. Before marriage he had passed eight years in Malaysia. When her husband was identified as a people living with HIV, she was forced to test HIV and proved to be positive. Fortunately her child was marked as HIV negative. In spite of having no problem from husbandâ&#x20AC;&#x2122;s family she is staying still in her fatherâ&#x20AC;&#x2122;s house. Lots of pains and sufferings haunt her always. Though she is well aware of the matter of being affected with HIV from her husbands, she does not show any interest to make guilty her. At the age of fourteen years she was got married with a Malaysian migrant worker negating her personal choice. As part of social custom she got agreed at getting engaged in marriage. There no further intention to marry anyone in this life. Her husband had taken treatment from traditional healers, private practitioners in City hospital and Sikder medical but did not get any benefit from that.

Psychologically she is now in balanced position.

If he becomes busy with his work he feels better more. He receives vitamin and iron tablets on a regular basis from NGO clinics. She also gets transport cost and food from there. She has not gone anywhere else for receiving treatment and care. Though she is highly satiated at their treatment but expressed an intention to invent any remedy or preventive to combat the situation in time. She has no idea about commercial or woman sex workers. Even he cannot perceive that they are in a risk position in terms of HIV/AIDS and STDs. Because of having no higher knowledge she cannot comprehend the severity of being vulnerable to this disease. Being affected with this lethal disease she is now trying to maintain a religious-centered life.

Case Fifteen TN- 352 Mrs. Ayesha Khatun is a twenty seven year married woman who hails from the rustic territorial area of Benapole in Jessor. Her family comprises of five members and very often leads a confused life. Her husband had passed nearly two years in India and got himself married with a twenty year handsome girl there. Being a person living in territorial area, her husband often goes to India for visiting and very often for working there. Attacked by severe poverty and illness her husband received the help and assistance from relatives staying in India. Some days ago her husband was marked as a people living with HIV/AIDS. Luckily her two sons are tested and proved as HIV negative. Physically her husband is feeble and blind of two eyes.

Her economic problem is more acute and hardly can manage nutritious food and better treatment.

Her husband is totally bereft of doing any job for maintaining the cost of family living. Having great crisis it is quite impossible for them to continue the educational expenses of their elder son.

An uncertain future always haunts her about the upcoming days of life. She has more eagerly appealed for the assistance and support of her family. She is also interested to take loan on a small interest for starting business so that she can support her family.

She and her little child have been suffering from scarcity of food and malnutrition for the last few years. She is severely attacked with STDs like Gonorrhea. She believes that she has been affected by her husband. Counseling with her husband’s little sister she went to a health care in Benapole and made a test of her blood. The result was more horrifying and became puzzled hearing the news of being attacked with HIV. Ayesha had met a person called Adit Narayan who managed all the things and supports for receiving treatment from an NGO in Dhaka. She along with her husband is still taking treatment, care and support from Asar Alo Society. They feel somehow better taking treatment from here. Different medicines like vitamin, iron tablets and kalbony are offered by the clinic authority. Ceprosine (anti-biotic) is also provided to meet up the severity of illness.

Case Study Fifteen Continued…….

All the members of her husband’s family are not aware of her victim to this disease. Ayesha believes that it is more questionable whether she will be able to find bridegroom for her elder son. She is in fear of becoming outcast. If this news reaches to people they may not allow them as part of society. She has already understood the severity of this disease. Uncertainty of life has made her more pale and sick. Mentally she is passing a heinous life. The physical condition is not so well because of the scarcity of income generating activities. Highly tensed about the ensuing days of life she is feeling a grim reality. She took loan one time from Asar Alo Society.

Case Sixteen TN- 354 Mr. Rokon, a twenty seven year young and energetic person leads a separated life. Though he is primarily educated he is a dedicated service holder. His monthly income is 2500 BDT. His family consists of three members. He can hardly run his family with this meager income. He had been passing a happier marital life from the very beginning of twenty first century. Unluckily their conjugal life did not continue because of a sudden storm in life. Mr. Rokon had to make a conclusion of marital life on pursuance of his wife’s sweet will. Now he is mentally pressurized and exasperated about life.

Rokon got himself married with a seventeen year handsome girl in 2001. Soon after passing two years of marital life, he was identified as a people living with HIV. He has a daughter who completed her first day in 2003.When family members of her wife perceived the matter of his being affected with HIV they did not the issue easily. They forced the girl to leave her husband.

At last his wife got her married with another one else offering a divorced letter to Mr. Rokon.

The only daughter is still living with her father’s family. Sometimes his wife visits her girl.

Fortunately his only daughter proved herself as HIV negative.

Case Study Sixteen Continued…….

Making educated his daughter completely he will arrange the program of her marriage. He cannot identify the real source from which he becomes affected with this deadly disease. So far he can assume he might have might have affected from friends.

He is no more interested to get him engaged in marriage. All the members of family treat him well. He is now hale and hearty. He takes treatment and service from Asar Alo Society on a regular basis. Having no employment he leads a miserable life. Economic assistance is more essential for continuing life. Though he is aware of the inevitability of death he fosters the wish of living more. He insisted on our invention of any remedy for keeping safe from this disease.

Case Seventeen T N- 313 Mrs. Salma Begum is a married woman who comes from the Ovyanagar area of Jessor. She has finished her matriculation from the local school and got married with a migrant worker on pursuance of her parents’ advice. Her family consists of five members. Having no scarcity of earning source she leads a complete life without some mental hesitations. Though she wished to be an educated person from early stage of life, she is now fully satiated with compromising life.

Nevertheless she is happy as a successful housewife in family life. His marital life is fantastic and sound.

In 1998 Mrs. Salma had become severely ill and took blood for the sake of operation of her body. Soon after passing the sufferings of that illness she again faces a serious accident in her life. She believes that she might have affected with HIV through blood transfusion. He claims that doctors have a great disinterest in testing blood before operationalizing any patient which has lead her to a severe disease which is not curable. In 2008 she was called for blood test in CMH and unfortunately identified as a people living with HIV. At the early period she took treatment and care from traditional healer for fever and headache but did not get cured.

Case Study Seventeen Continued…….

When her health related complexity deteriorated she had gone to MBBS doctors for better treatment at public hospital Khulna city. Though her husband was staying in Saudi Arabia for sixteen years but proved himself as HIV negative. He does not give her husband any claim for this lethal disease. She asserts that the doctors were not so sincere about the intensity of affectivity of this disease in that period. Because of their ignorance and insouciance they could not perceive the matter seriously. She is still keeping well in terms of health and living. She is taking counseling and medicine from AAS on a regular basis. They also provide transport cost and food on the she comes for attending the counseling program. She is completely satisfied at their services.

Case Eighteen TN- 315 Mr. Mahbubur Rahman who is a sound person of forty two year lives in the village area of Bogra. He belongs to a family of five members having no handsome family income. He is somewhat exasperated about life and incapable of coming health centre timely. This is money consuming and wastage of time. He had been suffering the recurrent fever for the few days in 2007. He went to local doctor and took medicine and counseling on pursuance of the practitioner’s advice. He also had taken herbal medicine from Kabiraj but did not get any benefit for that. When doctors from Bangladesh failed to identify the reasons of his being affected with disease she hit upon a plan to go to India for treatment. When all kinds of treatment ended in smoke in India too he was counseled for blood test and unfortunately proved to be HIV positive in 2007.

Mr. Mahbub never went to abroad before going to India for treatment. He believes that he most probably might have affected with HIV through transfusing untested blood. He was not sincere more clearly in 2002 when he had to do a major operation of her body. No member of his is affected with HIV in family.

Case Study Eighteen Continued…….

Though he was marked as HIV positive in India but never made any claim to health practitioners who counseled to make blood test. Their medical equipment was not hygienic let alone the lukewarm of health practitioners. He believes that he never got himself engaged in any sexual intercourse. He also tries to lead a religious centered life.

He is sound in terms of other health related complexities. He has no STDs and free from skin diseases. He receives the treatment and care from AAS and shows satisfaction at their behavior.

Sometimes he feels the painful scenery of inevitable death. People do not treat him as like as they did in the past. He expects more medical facilities from Bangladesh government to mitigate the problem of HIV/AIDS. We will be happier if you invent any kind of inoculation of this disease with a view to giving a sound body for us. He gave suggestion for enhancing medical facilities for the victims who are vulnerable to this disease.

Case Nineteen T N- 316 As part of earning livelihoods, Mr. Abu Jafor leads a service life in the capital city of Dhaka. At present he resides at College Gate Area, Mohammadpur in Dhaka city. He is a thirty four year young and energetic and handsome person. He hails from Feni and completes his college education before going to abroad. His family consists of eight members. He is still leading a marital life. His monthly in income is more than ten thousand money. For the sake of better living he leaves the country at a stage and migrates to South Africa, a congenial ambience of spreading HIV epidemic.

As a migrant worker Jafor had passed approximately ten valuable years of life in South Africa.

In 2009 he was tested in Africa and marked as HIV positive holder. He believes that he might have been affected with HIV/AIDS through blood transfusion in South Africa. In 2006 he came back to the country and got married with a nice girl.

Case Study Nineteen Continued…….

Fortunately all other members of family are safe now. He did not use any contraceptive in sexual intercourse when he was staying in South Africa. He could not perceive the matter of being affected with this lethal disease more clearly. When he stayed in South Africa he was practicing sexual intercourse. He engaged to contact marriage with an African local girl. As part of sexual satisfaction he also visited with commercial sex workers in different brothels. He does not confess of being guilty and concerned with this horrifying disease because of unlawful sexual intercourse. He mainly claimed the process of being blood transfusion for affecting with HIV. In family life he is still living with his wife and practicing safe sex (condom) in sexual intercourse. There is no intention of having any child because he believes that it might be affected with HIV/AIDS. All members of society treat him in a different way. They show one sort of negligence and humiliation over him. They also feel exasperation and mortification in society because of the victim of Jafor to this disease. People in society treat him as a guilty because of spending time in abroad. Though he was taking treatment from public health practitioners in South Africa, he also received treatment and counseling from Asar Alo Society in Bangladesh. He takes therapy on a regular basis. He seems to be hale and hearty. Taking services like ART or ARB tablets from Asar Alo Society he is keeping himself well. He could understand the fact of becoming engaged with HIV/AIDS after six months of disclosing some traces of illness. In spite of having some economic limitations he leads a happy life taking proper medicine. He wishes to live long making no harm to others.

Case Twenty T N- 310 Mr. Riki, a highly educated person lives in the Sadar area of Narayangang district. He is a thirty year young married man. His family consists of four family members. Physically sound he is a service holder having monthly income around 7000 BDT. He makes himself guilty for the affectivity of this fatal disease called HIV/AIDS. Very recently affected with HIV/AIDS, Riki is a handsome migrant worker in profession. As part of working in abroad he had passed over five years in Saudi Arabia. After crossing two years of foreign life he comes back to country and gets himself engaged in marriage. In 2010 he was called for blood test and identified as a people living with HIV. Unfortunately his wife is tested and marked as HIV positive. He believes that he might have affected from Saudi Arabia. He got used to practicing sexual intercourse with commercial sex workers there. He was not even well informed of being affected with deadly disease. Like all other Bangladeshi friends he every now and then goes the nearby brothel and completes sexual urge.

Family members do not treat him well. They are more exasperated at his illness with the disease.

They sometimes try to avoid him and keep aloof from making any commitment. Having no scope of working facilities in Bangladesh he can not engage in any income generating activities.

His family is passing a crucial time in terms of economic crisis. There is no further intention of going abroad once again in life. He visited many traditional healers, homeopathic practitioners and local doctors for getting treatment and care. But when he perceived the severity of illness, even no medicine acted for him he was called for medical check-up and unfortunately proved as HIV positive. He is continuously taking service from Asar Alo Society. The authority of the AAS also provides transport cost and food on the particular day he comes to join their counseling program.

He believes that it is not requisite to maintain restrictive rules and methods in sexual relationship since they are both already affected. Her wife sometimes expresses her painful sorrows because

of this disease. But Riki tries to motivate her in a different way. He tries to manage the situation more carefully with a view to leading a happy life. He expects that it is quite possible to lead a cherished happy life taking treatment and care maintaining proper channels.