High acceptability of HIV self-testing in a randomized trial among transgender women and men who have sex with men, Myanmar.

HIV self-testing (HIVST) shows promise to improve HIV diagnosis among those seeking privacy and anonymity in HIV testing. This may include sexual and gender diverse populations, who experience disproportionately high burdens of stigma and HIV globally. To inform potential scale-up of HIVST in Myanmar, we implemented a community-led, mixed-methods randomized trial in Yangon. Adult trans-feminine individuals and cisgender men who have sex with men were recruited via respondent-driven sampling. Participants (N = 577) completed a baseline survey and were randomized to community-based HIV testing services (HTS) or HIVST. One-third of participants reported lifetime HIV testing. Over half (59.4%) returned for a second study visit to report their test result and test acceptability, which was lower among HTS-assigned participants compared to those assigned to HIVST (55.6% vs. 63.1%; p = 0.096). Participants reported that both HIVST and HTS were easy to access, test, and interpret/understand the results of their HIV test. Ninety percent of HTS-assigned participants indicated they would test regularly if they could access HIVST. Qualitative participants (N = 20) described that the convenience and privacy afforded by HIVST may increase the availability and coverage of testing. Taken together, these results suggest HIVST is an acceptable, low-barrier complement to community-based HTS for key populations in Myanmar.

"We are not gays don't tell me those things": engaging 'hidden' men who have sex with men and transgender women in HIV prevention in Myanmar.

BACKGROUND: In Myanmar, HIV is concentrated among key populations, yet less than half of the estimated 250,000 men who have sex with men (MSM) and transgender women (TW) report recent HIV testing. As many as 50% of MSM and TW may conceal their same-sex preferences and behaviors, yet little is known about the barriers faced by those who are locally regarded as 'hidden' - that is, MSM who do not disclose same-sex preferences and/or identify as gay. This study explored specific barriers to accessing HIV testing and other prevention services among 'hidden' MSM to inform appropriate models of service delivery. METHODS: In-depth interviews with MSM (n = 12) and TW (n = 13) and focus group discussions (FGD) with MSM and TW community members, leaders and key informants (n = 35) were undertaken in Yangon during June - September 2015. Participants were recruited by word-of-mouth by trained peer data collectors. Responses to questions from semi-structured guides were transcribed and coded using Atlas Ti. Codes were based on key domains in the guides and applied to transcripts to identify and analyze emerging themes. RESULTS: Fear of stigma and discrimination and the need to meet gender expectations were key reasons for non-disclosure of same-sex preferences and behaviors; this typically manifested as avoidance of other MSM and settings in which sexual identity might be implicated. These concerns influenced preference and interaction with HIV services, with many avoiding MSM-specific services or eschewing HIV testing services entirely. The difficulties of engaging hidden MSM in HIV prevention was strongly corroborated by service providers. CONCLUSION: Hidden MSM face multiple barriers to HIV testing and prevention. Strategies cognizant of concerns for anonymity and privacy, such as One-Stop Shop services and online-based health promotion, can discretely provide services appropriate for hidden MSM. Enhanced capacity of peer-service providers and mainstream health staff to identify and respond to the psychosocial challenges reported by hidden MSM in this study may further encourage service engagement. Overarching strategies to strengthen the enabling environment, such as legal reform and LGBTI community mobilisation, can lessen stigma and discrimination and increase hidden MSM's comfort and willingness to discuss same-sex behavior and access appropriate services.

New HIV testing technologies in the context of a concentrated epidemic and evolving HIV prevention: qualitative research on HIV self-testing among men who have sex with men and transgender women in Yangon, Myanmar.

INTRODUCTION: Global effort to increase early diagnosis and engagement in HIV care emphasize the importance of developing novel approaches to reaching those missed by traditional methods. Such needs are particularly great for men who have sex with men (MSM), transgender women (TW), and other populations who face stigma. Myanmar's HIV epidemic is concentrated among key populations and the revised National Strategy aims to reduce late diagnosis and barriers to care to curb HIV incidence among these groups. HIV self-testing (HIVST) may be one method to improve testing and diagnosis among key populations, by placing HIV testing and disclosure within the individual's control. METHODS: Formative, qualitative research including in-depth interviews with adult MSM (N = 12) and TW (N = 13) and focus group discussions with MSM, TW, and community key informants (N = 35) were conducted in June-September 2015 in Yangon, Myanmar. To inform a subsequent HIV care continuum intervention, including HIVST, participants' opinions and perceptions about HIVST were elicited. RESULTS: The confidentiality and privacy of HIVST, particularly as it related to disclosure of HIV status and sexual behaviour, was widely recognized among participants. These major advantages were further supported by the opportunity to avoid stigma, convenience of self-testing (reduced need for transportation and time to go to clinics), and the availability of a pain-free testing option. Participants weighed these benefits against perceived disadvantages of HIVST, the majority of which centred on the perception that HIVST does not include counselling. Participants were concerned that potential lack of counselling would result in poor mental health outcomes, inadequate linkage to HIV care and surveillance, and reductions in disclosure of HIV status. Participants did not view these disadvantages as an impediment, but provided suggestions for future implementation of HIVST in Myanmar. CONCLUSION: MSM and TW are optimistic about the confidentiality and privacy afforded by HIVST but wanted HIV counselling and linkage to appropriate services. The domestic reprioritization of HIV and opening of the country to international support has substantially increased the availability of HIV treatment and provides new opportunities, like HIVST, to potentially improve the HIV response for key populations who are at risk for HIV acquisition.

The Parasol Protocol: An Implementation Science Study of HIV Continuum of Care Interventions for Gay Men and Transgender Women in Burma/Myanmar.

BACKGROUND: Efforts to improve HIV diagnosis and antiretroviral therapy (ART) initiation among people living with HIV and reduce onward transmission of HIV rely on innovative interventions along multiple steps of the HIV care continuum. These innovative methods are particularly important for key populations, including men who have sex with men (MSM) and transgender women (TW). The HIV epidemic in Myanmar is concentrated among key populations, and national efforts now focus on reducing stigma and improving engagement of MSM and TW in HIV prevention and care. OBJECTIVE: This study aims to test the use of several innovations to address losses in the HIV care continuum: (1) use of respondent-driven sampling (RDS) to reach and engage MSM and TW in HIV testing, (2) HIV self-testing (HIVST) to increase HIV testing uptake and aid early diagnosis of infection, (3) community-based CD4 point-of-care (POC) technology to rapidly stage HIV disease for those who are HIV infected, and (4) peer navigation support to increase successful health system navigation for HIV-infected MSM and TW in need of ART or HIV engagement in care. METHODS: To assess the effect of HIVST, we will implement a randomized trial in which MSM and TW adults in the greater Yangon metropolitan area who are HIV uninfected will be recruited via RDS (N=366). Participants will complete a baseline socio-behavioral survey and will be randomized to standard, voluntary counseling and testing (VCT) or to HIVST. Biologic specimens will be collected during this baseline visit for confirmatory testing using dried blood spots. Participants will be asked to return to the study office to complete a second study visit in which they will report their HIV test result and answer questions on the acceptability of the assigned testing method. Aim 1 participants with confirmed HIV infection and who are not engaged in care (N=49) will be offered direct enrollment into Aims 2 and 3, which include immediate CD4 POC and the option for peer navigation, respectively. Aims 2 and 3 participants will be prospectively followed for 12 months with data collection including interviewer-administered sociobehavioral survey, CD4 POC, and viral load testing occurring biannually. Participants who accept peer navigation will be compared to those who decline peer navigation. Analyses will estimate the impact of CD4 POC on engagement in care and the impact of peer navigation on ART adherence and viral load. RESULTS: Formative qualitative research was conducted in June and September 2015 and led to further refinement of recruitment methods, HIVST instructions and counseling, and peer navigation methods. Aim 1 recruitment began in November 2015 with subsequent enrollment into Aims 2 and 3 and is currently ongoing. CONCLUSIONS: These innovative interventions may resolve gaps in the HIV care continuum among MSM and TW and future implementation may aid in curbing the HIV epidemic among MSM and TW in Myanmar.

Retention and mortality outcomes from a community-supported public-private HIV treatment programme in Myanmar.

INTRODUCTION: There is a growing interest in the potential contribution the private sector can make towards increasing access to antiretroviral therapy (ART) in low- and middle-income settings. This article describes a public-private partnership that was developed to expand HIV care capacity in Yangon, Myanmar. The partnership was between private sector general practitioners (GPs) and a community-based non-governmental organization (International HIV/AIDS Alliance). METHODS: Retrospective analysis of 2119 patient records dating from March 2009 to April 2015 was conducted. Outcomes assessed were immunological response, loss to follow-up, all-cause mortality, and alive and retained in care. Follow-up time was calculated from the date of registration to the date of death, loss to follow-up, transfer out, or if still alive and known to be in care, until April 2015. Cox proportional hazards model was used to identify predictors of loss to follow-up and mortality. Kaplan-Meier survival analysis was used to estimate survival function of being alive and retained in care. RESULTS: The median number of patients for each of the 16 GPs was 42 (interquartile range (IQR): 25-227), and the median follow-up period was 13 months. The median patient age was 35 years (IQR: 30-41); 56.6% were men, 62 and 11.8% were in WHO Stage III and Stage IV at registration, respectively; median CD4 count at registration was 177 cells/mm3; and 90.7% were on ART in April 2015. The median CD4 count at registration increased from 122 cells/mm3 in 2009 to 194 cells/mm3 in 2014. Among patients on ART, CD4 counts increased from a median of 187 cells/mm3 at registration to 436 cells/mm3 at 36 months. The median time to initiation of ART among eligible patients was 29 days, with 93.8% of eligible patients being initiated on ART within 90 days. Overall, 3.3% patients were lost to follow-up, 4.2% transferred out to other health facilities, and 8.3% died during the follow-up period. Crude mortality rate was 48.6/1000 person-years; 42% (n=74) of deaths occurred during the pre-ART period and 39.8% (n=70) occurred during the first six months of ART. Of those who died during the pre-ART period, 94.5% were eligible for ART. In multivariate regression, baseline CD4 count and ART status were independent predictors of mortality, whereas ART status, younger age and patient volumes per provider were predictors of loss to follow-up. Probability of being alive and retained in care at six months was 96.8% among those on ART, 38.5% among pre-ART but eligible patients, and 20.0% among ART-ineligible patients. CONCLUSIONS: Effectively supported private sector GPs successfully administered and monitored ART in Myanmar, suggesting that community-supported private sector partnerships can contribute to expansion of HIV treatment and care capacity. To further improve patient outcomes, early testing and initiation of ART, combined with close clinical monitoring and support during the initial periods of enrolling in treatment and care, are required.