Adherence to 14-day radical cure for Plasmodium vivax malaria in Papua, Indonesia: a mixed-methods study.

BACKGROUND: Reducing the risk of recurrent Plasmodium vivax malaria is critical for malaria control and elimination. Primaquine (PQ) is the only widely available drug against P. vivax dormant liver stages, but is recommended as a 14-day regimen, which can undermine adherence to a complete course of treatment. METHODS: This is a mixed-methods study to assess socio-cultural factors influencing adherence to a 14-day PQ regimen in a 3-arm, treatment effectiveness trial in Papua, Indonesia. The qualitative strand, consisting of interviews and participant observation was triangulated with a quantitative strand in which trial participants were surveyed using a questionnaire. RESULTS: Trial participants differentiated between two types of malaria: tersiana and tropika, equivalent to P. vivax and Plasmodium falciparum infection, respectively. The perceived severity of both types was similar with 44.0% (267/607) perceiving tersiana vs. 45.1% (274/607) perceiving tropika as more severe. There was no perceived differentiation whether malaria episodes were due to a new infection or relapse; and 71.3% (433/607) acknowledged the possibility of recurrence. Participants were familiar with malaria symptoms and delaying health facility visit by 1-2 days was perceived to increase the likelihood of a positive test. Prior to health facility visits, symptoms were treated with leftover drugs kept at home (40.4%; 245/607) or bought over the counter (17.0%; 103/607). Malaria was considered to be cured with 'blue drugs' (referring to dihydroartemisinin-piperaquine). Conversely, 'brown drugs,' referring to PQ, were not considered malaria medication and instead were perceived as supplements. Adherence to malaria treatment was 71.2% (131/184), in the supervised arm, 56.9% (91/160) in the unsupervised arm and 62.4% (164/263) in the control arm; p = 0.019. Adherence was 47.5% (47/99) among highland Papuans, 51.7% (76/147) among lowland Papuans, and 72.9% (263/361) among non-Papuans; p < 0.001. CONCLUSION: Adherence to malaria treatment was a socio-culturally embedded process during which patients (re-)evaluated the characteristics of the medicines in relation to the course of the illness, their past experiences with illness, and the perceived benefits of the treatment. Structural barriers that hinder the process of patient adherence are crucial to consider in the development and rollout of effective malaria treatment policies.

Facilitators and barriers to status disclosure and partner testing of women living with HIV in Indonesia: a mixed methods study.

This mixed-methods study investigated HIV status disclosure and partner testing of women living with HIV (WLWH) in a concentrated epidemic setting in Bandung, Indonesia. The qualitative exploratory strand used theoretical sampling to carry out semi-structured interviews with 47 HIV-infected women with varying anti-retroviral therapy status. The quantitative strand included 122 female patients receiving HIV care at a referral clinic. HIV diagnosis made women reassess their sexual partnerships. Some lost their partner due to death or divorce. Women with a longstanding HIV infection often formed new partnerships. They disclosed their status to new partners without assistance from health providers; the type and stability of the partnership influenced decision to disclose. Fear of rejection prevented initial disclosure prior to bringing the new partners to a health provider. Disclosure did not always result in partner testing because of low risk-awareness or denial of the partner. Despite a similar proportion of status disclosure to partner (92.8%), only 53.7% of new partners of WLWH were tested in contrast to 89.7% of partners tested among WLWH who stayed with the same partner. In antenatal care, where same-day testing was often done for pregnant couples, more partners were tested. Overall, consistent condom use was low and HIV status forced WLWH who continued sex work to work at settings where condom use was not enforced. WLWH face barriers to HIV status disclosure and partner testing and would benefit from partnership counselling. Guidelines for partner notification and testing should include specific strategies for women with longstanding HIV infection.

"No good man will ever want me". How structural social inequality increases women's vulnerability to HIV transmission: a qualitative study from Bandung, Indonesia.

Understanding the pathways that expose women to HIV transmission are vital in improving HIV prevention, especially among a "hidden" group of women without pre-established known risk for HIV. We investigated the pathways which place certain women at greater risk for HIV in a qualitative exploratory study with theoretical sampling using an emergent theory study design in an urban setting in Indonesia. We conducted semi-structured interviews with 47 HIV-infected women, one focus group discussion with five young women who occassionally engage in sex work, participant observation at six sex work venues and two midwife clinics, and 11 informal interviews with midwives, nurses, and obstetricians. Our research found that many women not characterized as belonging to a "high-risk group" or "key population" were nevertheless at increased risk for HIV. A history of sexual abuse, premarital sex, divorce, or involvement in sex work, often precipitated by poverty coupled with discriminatory public health policies further heightened women's exposure to HIV. While reaching at-risk populations is a key strategy in HIV prevention, a novel and more tailored approach is needed to reach more hidden categories of women with less apparent risk behavior yet considerable risk for HIV infection.

Are there differences in HIV retention in care between female and male patients in Indonesia? A multi-state analysis of a retrospective cohort study.

BACKGROUND: Little is known about HIV treatment outcomes in Indonesia, which has one of the most rapidly growing HIV epidemics worldwide. METHODS: We examined possible differences in loss to follow-up (LTFU) and survival between HIV-infected females and males over a 7-year period in an HIV clinic in Bandung, West Java. Data imputation was performed on missing covariates and a multi-state Cox regression was used to investigate the effects of sex and other covariates on patient transitions among four states: (1) clinic enrollment with HIV, (2) initiation/continuation/re-initiation of antiretroviral therapy (ART), (3) LTFU, and (4) death. RESULTS: We followed 3215 patients (33% females), for a total of 8430 person-years. ART was used by 59% of patients at some point. One-year retention was 73% for females and 77% for males (p = 0.06). One-year survival was 98% for both females and males (p = 0.15). Females experienced a higher relative hazard to transition from HIV to LTFU (adjusted hazard ratio 1.21; 95% confidence interval 1.00-1.45), but this decreased after adjustments for clinical variables (aHR 0.94; 95% CI 0.79-1.11). Similarly, a lower relative hazard in females to transition from ART to death (aHR 0.59; 95% CI 0.35-0.99) decreased after adjustments for demographic variables. CONCLUSION: This Indonesian cohort has low ART uptake and poor overall pre- and post-ART retention. Female-male differences in survival and retention were gone after adjusting for clinical and sociodemographic factors such as CD4 count and education level. Efforts should be made to improve retention among patients with lower education.

Maternal and environmental risk for faltered growth in the first 5 years for Tanjungsari children in West Java, Indonesia.

BACKGROUND AND OBJECTIVES: Low birth weight leads to growth faltering, attributable inter alia to malnutrition and maternal health and literacy. Risk for growth faltering in rural children under five is studied. STUDY DESIGN: The Risk Approach Strategy in Tanjungsari, West Java has been analysed for all pregnancies during 1988-1989 and 4,698 singleton infants born between 1 January 1988 and 31 April 1990. Weight and body length/height measurements were repeated over 60 months, and plotted against WHO standards. Weight-for-age and height-forage z-scores were calculated using 2006 WHO growth as reference. The correlation between shortness (so-called stunting) and its presumptive risk factors was determined. A subset underwent DNA analysis for insulin-like growth factor-1 (IGF-1), and insulin receptor substrate-1 (IRS-1) polymorphism. RESULTS: Weight and body length/height follow-ups were followed-up for 3795 infants; 14.2% of the cohort had low birth weight (<2500 g) (LBW) and 85.8% normal birth weight (NBW). LBW infants showed a similar velocity but tended to catch up more slowly (GEE; p<0.001). Relative to WHO references, the differential for stature increased with age, largely offset by reduced weight-for-age so that weight-for-height tracked close to the WHO reference; this contrasts with more divergence internationally. Birth length and weight, along with potable water access were correlated with stunting for children under 2 years. Neither the observed IGF-1, IRS-1 or combined gene polymorphisms were associated with LBW. Conclusions: The prediction by factors operative during pregnancy for early life stature, with some adaptation for LBW infants, endures to 60 months.

Women with HIV in Indonesia: are they bridging a concentrated epidemic to the wider community?

BACKGROUND: Male injecting drug users drove the onset of the HIV epidemic in Indonesia but over time more women have been diagnosed. We examined the relative proportion of female patients in an HIV cohort and characterized their probable transmission route and reproductive profile. DESIGNS: Prospective cohort study in a referral hospital in West Java. METHODS: Interviews with standardized questionnaires, physical and laboratory examinations were done for 2622 individuals enrolled in HIV care between 2007 and 2012. The proportion of women in this cohort was compared with national estimates. The general characteristics of HIV-infected women and men as well as the sexual and reproductive health of HIV-infected women were described. RESULTS: The proportion of female patients enrolled in HIV care increased from 22.2 % in 2007 to 38.3 % in 2012, in line with national estimates. Women were younger than men, fewer reported a history of IDU (16.1 vs. 73.8 %, p < 0.001) and more were tested for HIV because of a positive partner (25.5 vs. 4.0 %, p < 0.001). The majority of women were in their reproductive age, had children, and were not using contraceptives at the time of enrolment. CONCLUSION: HIV-infected women in Indonesia have specific characteristics that differ them from women in the general population. Further research to elucidate the characteristics of women exposed to HIV, their access to testing and care and sexual and reproductive needs can help reduce transmission to women and children in the context of concentrated HIV epidemic in Indonesia.

Pregnancy exposure to atmospheric pollutants and placental weight: an approach relying on a dispersion model.

BACKGROUND: Epidemiologic studies suggest an association between air pollution exposure and foetal growth. The possible underlying biological mechanisms have little been studied in humans, but animal studies suggest an impact of atmospheric pollutants on placental function. OBJECTIVES: Our aim was to investigate the association between exposure to atmospheric pollutants' levels during pregnancy and placental weight, birth weight and the placental to foetal weights ratio (PFR). For comparison purposes, the effects of active smoking on the same measures at birth have also been estimated. METHODS: The study relies on women from Eden mother-child cohort recruited in the middle-sized cities of Poitiers and Nancy (France). Nitrogen dioxide (NO(2)) and particulate matter with diameter <10 µm (PM10) home address levels during pregnancy were assessed using ADMS-Urban dispersion model. We characterized associations of NO(2), PM10 levels and active smoking with placental, birth weights and PFR by distinct linear regression models. RESULTS: Air pollution levels were higher and had greater variability in Nancy (5th-95th centiles, 19.9-27.9 µg/m(3) for PM10) than in Poitiers (5th-95th centiles, 14.3-17.8 µg/m(3)). Associations differed by study area: in Nancy (355 births), air pollution levels were associated with decreased placental weight and PFR, while in Poitiers (446 births), opposite or null associations were observed. Cigarette smoking was not associated with placental weight while it was associated with a decrease in birth weight and an increase in PFR. CONCLUSION: Results regarding air pollution estimated effects were not similar in both study areas and should therefore be taken with caution. The placental weight decrease observed with air pollutants in the more polluted area of Nancy is consistent with a recent epidemiological study. In this area, maternal active smoking and PM10 levels tended to have opposite effects on the PFR, suggesting different mechanisms of action of both pollutants on foetal growth.