High prevalence of vaccine-preventable anal human papillomavirus infections is associated with HIV infection among gay, bisexual, and men who have sex with men in Nairobi, Kenya.

BACKGROUND: Human papillomavirus (HPV) infection is associated with anal cancers and is more prevalent in gay, bisexual, and men who have sex with men (gbMSM), partly due to their vulnerability to HIV infection. Baseline HPV genotype distributions and risk factors can inform the design of next-generation HPV vaccines to prevent anal cancer. METHODS: A cross-sectional study was conducted among gbMSM receiving care at a HIV/STI clinic in Nairobi, Kenya. Anal swabs were genotyped using a Luminex microsphere array. Multiple logistic regression methods were used to identify risk factors for four HPV outcomes (any HPV, any HR-HPV, and 4- and 9-valent vaccine-preventable HPVs). RESULTS: Among 115 gbMSM, 51 (44.3%) were HIV-infected. Overall HPV prevalence was 51.3%; 84.3% among gbMSM living with HIV and 24.6% among gbMSM without HIV (p < 0.001). One-third (32.2%) had HR-HPV and the most prevalent vaccine-preventable HR-HPV genotypes were 16, 35, 45, and 58. HPV-18 was uncommon (n = 2). The 9-valent Gardasil vaccine would have prevented 61.0% of HPV types observed in this population. In multivariate analyses, HIV status was the only significant risk factor for any HPV (adjusted odds ratio [aOR]:23.0, 95% confidence interval [95% CI]: 7.3-86.0, p < 0.001) and for HR-HPV (aOR: 8.9, 95% CI: 2.8-36.0, p < 0.001). Similar findings were obtained for vaccine-preventable HPVs. Being married to a woman significantly increased the odds of having HR-HPV infections (aOR: 8.1, 95% CI: 1.6-52.0, p = 0.016). CONCLUSIONS: GbMSM living with HIV in Kenya are at higher risk of anal HPV infections including genotypes that are preventable with available vaccines. Our findings support the need for a targeted HPV vaccination campaign in this population.

Association of Health Insurance and Documentation with Stigma and Social Support Among Myanmar Migrants with Tuberculosis Before and During Thailand's Policy on Border Closure Due to COVID-19: a Cross-Sectional Study.

OBJECTIVE: The objective of this study was to assess the effect of health insurance and documentation status on tuberculosis (TB)-related stigma and social support before and during Thailand's policy on border closure. METHODS: A cross-sectional study was conducted in two TB clinics in Mae Sot district, a border area of Thailand. Myanmar migrants with new TB were interviewed before (between September 2019 and March 2020) and during Thailand's policy (between April 2020 and January 2021). We used multiple linear regression models to assess the association of health insurance and documentation status with stigma and social support before and during the policy on border closure. RESULTS: Of 229 migrants diagnosed new TB recruited, 117 and 112 were interviewed before and during Thailand's policy on border closure. The relationship of stigma with health insurance and documentation status was modified by the policy. Migrants with health insurance reported significantly lower stigma during the policy compared to those without health insurance, whereas documented migrants had lower stigma before the policy compared to undocumented migrants. No significant association of health insurance and documentation status with social support was observed. Ethnicity, perceived TB severity and education level were also independently associated with TB-related stigma. CONCLUSION: The relationships between health insurance, documentation status and TB-related stigma were modified by Thailand's policy on border closure among Myanmar migrants with TB in a border area of Myanmar and Thailand. Promotion of health insurance and well-planned documentation for migrants should be more discussed and strengthened among stakeholders and policymakers.

Operational research capacity building through the Structured Operational Research Training Initiative (SORT-IT) in China: implementation, outcomes and challenges.

BACKGROUND: Chinese Center for Disease Control and Prevention (China CDC) introduced the Structured Operational Research Training Initiative (SORT IT) into China to build a special capacity and equip public health professionals with an effective tool to support developing countries in strengthening their operational research. The paper aims to investigate and analyze the implementation, outcomes and challenges of the first cycle of SORT IT in China. MAIN TEXT: As a result of the successful implementation, SORT IT China, Cycle 1 has demonstrated fruitful outputs as exemplified by the 18-month follow-up to the post-training initiatives of the twelve participants, who all achieved the four milestones required by SORT IT. Eleven of twelve (92%) manuscripts generated that focused on the prevention and control of malaria, influenza, HIV/AIDS, hepatitis B, schistosomiasis, tuberculosis and Japanese encephalitis were published by peer-reviewed international journals with the impact factor ranging from 2.6 to 4.8. The most up-to-date citation count on February 19, 2021 was 53 times out of which 31 times were cited by Science Citation Index papers with 94.827 impact factor in total. Six senior professionals from China CDC also facilitated the whole SORT IT training scheme as co-mentors under the guidance of SORT IT mentors. The twelve participants who gained familiarity with the SORT IT courses and training principles are likely become potential mentors for future SORT IT, but they as the non-first language speakers/users of English also faced the challenge in thoroughly understanding the modules delivered in English and writing English academically to draft the manuscripts. CONCLUSION: The outcomes from the first cycle of SORT IT in China have led to studies contributing to narrowing the knowledge gap among numerous public health challenges nationally and internationally. It is believed the researchers who participated will continue to apply the skills learned within their domain and help build the training capacity for future operational research courses both in China and in developing countries with similar needs.

Changes in health-related quality of life and the associated factors among Myanmar migrants with tuberculosis: a cohort study.

BACKGROUND: Migrants are known to be predominantly poor population which are predisposing to social and health problems, particularly infectious diseases including tuberculosis (TB). TB itself and effect of treatment may further result in substantial morbidity and lowering the quality of life. This study aimed to assess the changes in health-related quality of life (HRQOL) within six months of anti-TB treatment initiation, and the associated factors in Myanmar migrants under anti-TB treatment within this border area. METHODS: This was a prospective cohort study of adult Myanmar migrants with new TB who were within two months of treatment initiation in two TB clinics in Mae Sot, a Thai-Myanmar border area between September 2019 and July 2020. Eight individual domain scores of the HRQOL and Physical and Mental Component Summary (PCS and MCS) scores measured by SF-36 were calculated at month-2 (T1) as baseline, and at the month-4 (T2) and month-6 follow-up visits (T3). Generalized estimation equation models were used to assess the longitudinal changes in PCS and MCS scores of HRQOL. RESULTS: Of the 155 patients recruited, 93 (60.0%) and 65 (69.9%) completed the month-4 and month-6 follow-ups, respectively. Both the PCS (+ 6.1) and MCS (+ 6.3) scores significantly improved between T1 and T3, with the lowest scores being general health, with the least improvement in social function (+ 1.5) compared with the other domains. Migrants with ethnic origin of Burmese or other were associated with higher PCS and MCS. Those living with family and having higher numbers of initial TB symptoms were associated with lower PCS and MCS scores. Those diagnosed during routine medical checkup were positively associated with PCS scores, whereas patients diagnosed during active case findings were negatively associated with MCS scores. Patients who received residential TB care had higher PCS scores than those with OPD-based TB care. CONCLUSIONS: Continuous improvement in quality of life was found among Myanmar migrants with TB during treatment but their quality of life is still low. Patients with low mental health, especially in the social domain, requires further attention. Active screening policy and supportive strategies during treatment are essential to TB migrants.

Coverage of tuberculosis and diabetes mellitus screening among household contacts of tuberculosis patients: a household-based cross-sectional survey from Southern Thailand.

BACKGROUND: The comorbid presence of tuberculosis and diabetes mellitus has become an increasingly important public health threat to the prevention and control of both diseases. Thus, household contact investigation may serve a dual purpose of screening for both tuberculosis and diabetes mellitus among household contacts. We therefore aimed to evaluate the coverage of screening for tuberculosis and diabetes mellitus among household contacts of tuberculosis index cases and to determine predictors of tuberculosis screening. METHODS: A household-based survey was conducted in February 2019 in Muang district of Phatthalung Province, Thailand where 95 index tuberculosis patients were newly diagnosed with pulmonary or pleural tuberculosis between October 2017 and September 2018. Household contacts of the index patients were interviewed using a structured questionnaire to ascertain their past-year history of tuberculosis screening and, if appropriate, diabetes mellitus screening. For children, the household head or an adult household member was interviewed as a proxy. Coverage of tuberculosis screening at the household level was regarded as households having all contacts screened for tuberculosis. Logistic regression and mixed-effects logistic regression models were used to determine predictors of tuberculosis screening at the household and individual levels, respectively, with the strengths of association presented as adjusted odds ratios (AOR) and 95% confidence intervals (CI). RESULTS: Of 61 responding households (64%), complete coverage of tuberculosis screening at the household level was 34.4% and among the 174 household contacts was 46.6%. About 20% of contacts did not receive any recommendation for tuberculosis screening. Households were more likely to have all members screened for tuberculosis if they were advised to be screened by a healthcare professional rather than someone else. At the individual level, contacts aged ≥35 years (AOR: 30.6, 95% CI: 2.0-466.0), being an employee (AOR: 0.1, 95% CI: 0.0-0.8) and those who had lived more than 5 years in the same household (AOR: 0.1, 95% CI: 0.0-0.8) were independent predictors for tuberculosis screening. Coverage of diabetes mellitus screening was 80.6% with lack of awareness being the main reason for not being screened. CONCLUSIONS: Compared to diabetes screening, the coverage of tuberculosis screening was low. A better strategy to improve coverage of tuberculosis contact screening is needed.

Experiences from the pilot implementation of the Package of Essential Non-communicable Disease Interventions (PEN) in Myanmar, 2017-18: A mixed methods study.

BACKGROUND AND OBJECTIVES: Myanmar adopted the World Health Organization (WHO) Package for Essential Non-Communicable Disease Interventions (PEN) in 20 pilot townships in 2017. This study was conducted to assess the implementation of PEN, its effectiveness and understand the facilitators and barriers in its implementation. METHODS: Mixed methods design involving a quantitative component (retrospective study analysing both aggregate and individual patient data from PEN project records; cross-sectional facility survey using a structured checklist) and a descriptive qualitative component. RESULTS: A total of 152,446 individuals were screened between May 2017-December 2018 comprising of current smokers (17.5%), tobacco chewers (26.3%), Body Mass Index ≥25 kg/m2 (30.6%), raised blood pressure i.e. ≥ 140/90 mmHg (35.2%) and raised blood sugar i.e. Random Blood Sugar >200 mg/dl, Fasting Blood Sugar >126 mg/dl (17.1%). Nearly 14.8% of those screened had Cardiovascular Disease (CVD) risk score ≥20%, 34.6% had CVD risk not recorded. Of 663 patients registered with diabetes and/or hypertension in 05 townships, 27 (4.1%) patients made three follow-up visits after the baseline visit, of whom, CVD risk assessment, systolic blood pressure and blood sugar measurement was done in all visits in 89.0%, 100.0% and 78.0% of cases respectively. Health facility assessment showed 64% of the sanctioned posts were filled; 90% of those appointed been trained in PEN; key essential medicines for PEN were available in half of the facilities surveyed. Confidence of the health care staff in managing common NCD and perceived benefits of the project were some of the strengths. CONCLUSION: High loss to follow up, poor recording of CVD risk score, lack of essential medicines and equipments were the key challenges identified that need to be addressed before further expansion of PEN project to other townships.

Utilization of insecticide-treated bed nets and care-seeking for fever and its associated socio-demographic and geographical factors among under-five children in different regions: evidence from the Myanmar Demographic and Health Survey, 2015-2016.

BACKGROUND: Malaria is one of the top-five contributors to under-5 deaths in Myanmar. Use of insecticide-treated nets (ITN) and receiving early appropriate care in case of fever are the core interventions to prevent malaria and its complications and thereby deaths. This study aimed to assess among the under-five children, (a) utilization of ITNs and its associated factors, (b) care-seeking behaviour among their caregivers and its associated factors and uptake of malaria testing among those with fever in the last 2 weeks. METHODS: This was a cross sectional study using secondary analysis of Myanmar Demographic and Health Survey (MDHS) conducted in 2015-2016. Multivariable logistic regression was used to explore the factors associated with non-utilization of ITNs and not seeking care for fever. Effect sizes have been presented using odds ratios with 95% confidence intervals. Data analysis was done using svyset command in STATA to account for the multi-stage sampling design of the survey. RESULTS: Of 4597 alive under-five children, 80.5% did not sleep under an ITN last night. The factors significantly associated with non-utilization of ITNs were residing in malaria elimination regions (aOR = 2.0, 1.3-3.2), urban residence (aOR = 1.8, 1.2-2.9), staying in delta region (aOR = 8.7, 4.7-12.2), hilly region (aOR = 3.0, 2.0-4.6, and having highest wealth quintile (aOR = 1.8, 1.1-3.0). Around 16% had fever in the last 2 weeks, of whom 66.7% sought care for fever and 3% got tested for malaria. Nearly half (50.9%) of the caregivers sought care from a government health facility, followed by private hospital/doctor (27.8%), shop (8.0%), village health worker (4.4%) and pharmacy (3.1%). The factors associated with not seeking care for fever were residing in specific geographical locations (hilly, delta and central plains compared to coastal region) and having lowest wealth quintile (aOR = 2.3, 1.1-5.7). CONCLUSIONS: This study highlighted that ownership and utilization of ITNs was very poor among under-5children. Care-seeking behaviour of the caregivers of under-5 children in case of fever was dismal with two-thirds not seeking care. The programme should seriously consider addressing these barriers if Myanmar is to achieve zero malaria deaths by 2030.

Initiation of antiretroviral therapy or antiretroviral prophylaxis in pregnant women living with HIV registered in five townships of Mandalay, Myanmar: A cross sectional study.

BACKGROUND: A series of interventions are required to prevent mother to child transmission (PMTCT) of Human Immunodeficiency Virus (HIV) starting from HIV testing of pregnant women, initiating antiretroviral therapy (ART) or antiretroviral prophylaxis to HIV-positive pregnant women to providing HIV prophylaxis to newborn babies. Gaps in each step can significantly affect the effectiveness of PMTCT interventions. We aimed to determine the gap in initiation of ART/antiretroviral prophylaxis for pregnant women living with HIV, delay in initiation of ART/antiretroviral prophylaxis and factors associated with the delay. METHODS: This is a cross sectional study using routinely collected programme data from five health facilities providing PMTCT services located at Township Health Departments (THD) of Mandalay, Myanmar. RESULTS: There were 363 pregnant women living with HIV enrolled between January 2012 and December 2017. Sixty (16%) women were excluded from the study due to missing data on dates of HIV diagnosis. Of 303 (84%) women included in the study, 89/303 (29%) and 214/303 (71%) were diagnosed with HIV before and during current pregnancy respectively. Among 214 women, 180 (84%) women were started on ART by the censor date (31st March 2018). Among those who started ART, 109 (61%) women had a delay of starting ART > 2 weeks from diagnosis. Women residing in township 4 had a significantly higher risk of delay in initiation of ART/antiretroviral prophylaxis compared to women residing in township 1 [adjusted prevalence ratio 4.2 (95% confidence interval 1.2-14.8]. CONCLUSIONS: We found that one in four women living with HIV knew their HIV status before current pregnancy. Although the rate of ART/antiretroviral prophylaxis initiation was high among pregnant women living with HIV, there was a delay. Early initiation of ART/antiretroviral prophylaxis among newly HIV diagnosed pregnant women needs to be strengthened.

Outcomes of Community-Based Systematic Screening of Household Contacts of Patients with Multidrug-Resistant Tuberculosis in Myanmar.

Screening of household contacts of patients with multidrug-resistant tuberculosis (MDR-TB) is a crucial active TB case-finding intervention. Before 2016, this intervention had not been implemented in Myanmar, a country with a high MDR-TB burden. In 2016, a community-based screening of household contacts of MDR-TB patients using a systematic TB-screening algorithm (symptom screening and chest radiography followed by sputum smear microscopy and Xpert-MTB/RIF assays) was implemented in 33 townships in Myanmar. We assessed the implementation of this intervention, how well the screening algorithm was followed, and the yield of active TB. Data collected between April 2016 and March 2017 were analyzed using logistic and log-binomial regression. Of 620 household contacts of 210 MDR-TB patients enrolled for screening, 620 (100%) underwent TB symptom screening and 505 (81%) underwent chest radiography. Of 240 (39%) symptomatic household contacts, 71 (30%) were not further screened according to the algorithm. Children aged <15 years were less likely to follow the algorithm. Twenty-four contacts were diagnosed with active TB, including two rifampicin- resistant cases (yield of active TB = 3.9%, 95% CI: 2.3%-6.5%). The highest yield was found among children aged <5 years (10.0%, 95% CI: 3.6%-24.7%). Household contact screening should be strengthened, continued, and scaled up for all MDR-TB patients in Myanmar.

Monitoring and evaluation of intervals from onset of fever to diagnosis before "1-3-7" approach in malaria elimination: a retrospective study in Shanxi Province, China from 2013 to 2018.

BACKGROUND: China's 1-3-7 approach was extensively implemented to monitor the timeframe of case reporting, case investigation and foci response in the malaria elimination. However, activities before diagnosis and reporting (before '1') would counteract the efficiency of 1-3-7 approach but few data have evaluated this issue. This study aims to evaluate the timelines between onset of fever and diagnosis at healthcare facilities in Shanxi Province. METHODS: Routine data were extracted from IDIRMS and NMISM database from 2013 to 2018. Time intervals between onset of fever and healthcare-seeking and between healthcare-seeking and diagnosis were calculated. Each of the documented malaria cases was geo-coded and paired to the county-level layers of polygon. RESULTS: A total of 90 cases were reported in 2013-2018 in Shanxi Province, and 73% of cases reported at provincial health facilities. All malaria cases were imported from Africa (90%) and Southeast Asia (10%) especially around the Chinese Spring Festival (n = 46, 51%). The median days between fever and healthcare-seeking and between healthcare-seeking and diagnosis of malaria were 3 and 2, respectively. CONCLUSIONS: The current "1-3-7" approach is well executed in Shanxi Province, but delays intervals observed in case finding before 1-3-7 approach occurred in all levels of facilities in Shanxi Province, which imply that more efforts are highlighted for timely case finding. Health education should be provided for improving awareness of healthcare-seeking, and various technical training aiming at the physicians should be carried out to improve diagnosis of malaria.

Early Success With Retention in Care Among People Living With HIV at Decentralized ART Satellite Sites in Yangon, Myanmar, 2015-2016.

Introduction: Myanmar is one of the countries in the Asia-Pacific region hit hardest by the HIV epidemic that is concentrated among urban areas and key populations. In 2014, the National AIDS Programme (NAP) launched a new model of decentralized service delivery with the establishment ART satellite sites with care delivered by HIV peer workers. Methods: ART satellite sites are implemented by non-government organizations to service high burden HIV areas and populations that suffer stigma or find access to public sector services difficult. They provide continuity of HIV care from outreach testing, counseling, linkage to care, and retention in care. Anti-retroviral (ART) initiation occurs at health facilities by specialist physicians. We conducted a retrospective cohort study of people living with HIV (PLHIV) who were initiated on ART from 2015 to 2016 at five ART satellite sites in Yangon, Myanmar to assess outcomes and time from enrolment to ART initiation. Results: Of 1,339 PLHIV on ART treatment in 2015-16, 1,157 (89%) were retained, and 5% were lost from care and 5% reported dead, at the end of March 2018. Attrition rates (death and lost-to-follow-up) were found to be significantly associated with a CD4 count ≤ 50 cells/mm3 and having baseline weight ≤ 50 kg. Median time taken from enrolment to ART initiation was 1.9 months (interquartile range: 1.4-2.5). Conclusion: We report high rates of retention in care of PLHIV in a new model of ART satellite sties in Yangon, Myanmar after 3 years of follow-up. The delays identified in time taken from enrolment to ART initiation need to be explored further and addressed. This initial study supports continuation of plans to scale-up ART satellite sites in Myanmar. To optimize outcomes for patients and the program and accelerate progress to reduce HIV transmission and end the HIV epidemic, operational research needs to be embedded within the response.

"If we miss this chance, it's futile later on" - late antenatal booking and its determinants in Bhutan: a mixed-methods study.

BACKGROUND: To achieve the Sustainable Development Goal related to maternal and neonatal outcomes, the World Health Organization advocates for a first antenatal care (ANC) contact before 12 weeks of gestation. In order to guide interventions to achieve early ANC in the lower middle-income setting of Bhutan, we conducted an assessment of the magnitude and determinants of late ANC in this context. METHODS: This was a mixed-methods study with quantitative (cross-sectional study) and qualitative (in-depth interviews with pregnant women and ANC providers) component in a concurrent triangulation design. The quantitative component retrospectively analysed the socio-demographic and clinical characteristics, and the gestational age at booking of women who were provided care for delivery or miscarriages at the three tertiary hospitals in Bhutan from May-August 2018. The qualitative component involved thematic analysis of in-depth interviews with ten women attending ANC visits and four healthcare workers involved in ANC provision. RESULTS: Among 868 women studied, 67% (n = 584) had a late booking (after 12 weeks), and 1% (n = 13) had no booking. Women with only primary education and those residing in rural areas were more likely to have a late first ANC booking. While many women achieved the recommended eight ANC visits, this did not necessarily reflect early booking. Late booking was common among multigravida women. The interviews illustrated a general understanding and recognition of the importance of early ANC. Support from peers, family and co-workers, and male participation in accessing ANC were seen as enablers. The outreach clinics (ORCs) at the primary healthcare level were an important means of reaching the ANC services to women in rural areas where geographical accessibility was a barrier. Specific barriers to early ANC were gender insensitivity in providing care through male health workers, cost/time in ANC visits, and the inability to produce the documents of the father for booking ANC. CONCLUSION: Late ANC booking was common in Bhutan, and appeared to be associated with educational, geographic, socio-cultural and administrative characteristics. A comprehensive information package on ANC needs to be developed for pregnant mothers, and the quality of ANC coverage needs to be measured in terms of early ANC booking.

Pre-treatment loss to follow-up and treatment delay among bacteriologically-confirmed tuberculosis patients diagnosed in Mandalay Region, Myanmar.

BACKGROUND: Pre-treatment loss to follow-up (PTLFU) among tuberculosis (TB) patients is a global public health problem, because such patients are highly infectious and experience high mortality. There is no published evidence on this issue from Myanmar. OBJECTIVE: To determine PTLFU and treatment delays (> 7 days duration between the date of diagnosis and starting anti-TB treatment) and their associated demographic, clinical, and health system-related factors among bacteriologically confirmed (sputum smear-positive and/or Xpert-positive) TB patients diagnosed in public health facilities of the Mandalay Region between January and June 2017. METHOD: This was a cohort study involving secondary analysis of routine programme data. Every bacteriologically confirmed TB patient in the laboratory register was tracked for at least 3 months in the treatment register. Patients neither found in the treatment register nor referred out for treatment were considered PTLFU. RESULTS: Of the 1365 bacteriologically confirmed patients diagnosed, 1051 (77%) started on anti-TB treatment, 200 (15.6%) were referred for treatment to health facilities outside the study area, and 114 (8.4%, 95% CI 7.0%-9.9%) did not initiate anti-TB treatment (PTLFU). PTLFU was significantly higher in those with TB/HIV co-infected (18%), sputum smear-negative but Xpert MTB-positive patients (31%), and patients diagnosed at a moderate- or high-volume facility (> 50 patients tested form TB during the study period) (~ 10%). Of the 940 patients with dates recorded, 46 (5%) had a treatment delay of more than 7 days. Patients aged 45-64 years had higher risk of treatment delay compared to those aged 15-44 years. About 97% of records did not have a phone number recorded. CONCLUSION: PTLFU and treatment delay were relatively low in the Mandalay Region. While this is reassuring, urgent steps must be taken to address those that are lost, which includes improving documentation of phone numbers to improve 'trackability', instituting proactive measures to trace patients lost in the care pathway, and introducing an indicator in the national tuberculosis programme (NTP) monthly report to monitor and review PTLFU. Patient subgroups with higher PTLFU should receive priority attention.

Internet Addiction among Secondary School Adolescents: A Mixed Methods Study.

INTRODUCTION: Excessive use of internet can lead to "Internet Addiction". A sharp rise in the number of internet users among adolescents in Bhutan have been observed lately which could have potential side-effects on their health. The aim of this study was to find the prevalence of internet addiction and psychological co-morbidities among the secondary school-going adolescents. METHODS: This is a descriptive cross-sectional quan-qual sequential mixed method design with a quantitative component and qualitative component. The study was conducted between 1st May and 30st November 2017 conducted in twelve schools across Bhutan after taking ethical clearance was from Research Ethics Board of Health of Bhutan. Data were doubleentered in EpiData Entry, validated and imported into STATA version 12.0 for analysis. Point estimate at 95% CI was calculated along with frequency and proportion for binary data. RESULTS: Among 721 adolescents from twelve selected schools, prevalence of internet addiction was 248 (34.440%) at , 95% Confidence Interval (31-38%). Out of A total of 586 (81%) preferred smartphone for internet use with 388 (54%) actually using it. Depression and anxietywere the associated psychological co-morbidities seen along with internet addiction. Internet addiction was high among those using internet at home, using smartphone for internet access, social networking and night time internet use were associated with internet addiction. Boredom, stress/anxiety and peer pressure were triggers of internet use. Internet addiction also affected academic performance, social interactions and sleep. CONCLUSIONS: Prevalence of internet addiction among adolescents in Bhutan is high comparing to previous standard data which requires immediate attention.

Uptake of antiretroviral therapy in HIV-positive women ever enrolled into 'prevention of mother to child transmission' programme, Mandalay, Myanmar-a cohort study.

BACKGROUND: Early initiation and longer duration of anti-retroviral therapy either as prophylaxis (pARV) or lifelong treatment (ART) in HIV-positive pregnant women prior to delivery has a huge impact in reducing mother to child transmission (MTCT) of HIV, maternal morbidity, mortality and increasing retention in care. In this study, we aimed to determine the following in a 'prevention of mother-to-child transmission' (PMTCT) programme in Central Women Hospital, Mandalay, Myanmar: i) uptake of ART and factors associated with the uptake ii) duration of ART/ pARV received by HIV-positive pregnant women prior to delivery, iii) factors associated with ART/ pARV initiation after delivery and iv) factors associated with shorter duration of ART/ pARV (≤ 8 weeks prior to delivery). METHOD: This was a retrospective cohort study using routinely collected data from PMTCT programme. We used multivariable Cox proportional Hazard model or log binomial models to assess the association between socio-demographic and clinical factors with a) uptake of ART/pARV, b) initiation of ART/pARV after delivery, c) shorter (≤8 weeks) duration of ART/PARV prior to delivery. RESULTS: Of the 670 ART naïve HIV-positive women enrolled to PMTCT programme between March 2011 and December 2016, 588 (88%) were initiated on ART/pARV. In adjusted analysis, only pregnancy stage at enrolment was significantly associated with initiation of ART/pARV. Of 585 who had delivered babies on or before the censor date, 522 (89%) were on ART/pARV. Women who lived outside Mandalay were more likely to be initiated on ART after delivery (i.e., delayed ART initiation in those on ART). Among women who were initiated on ART/pARV before delivery (n = 468), only 59% got ART/pARV for > 8 weeks before delivery. Women whose spouses' HIV status was not recorded had 40% higher risk of short duration of ART/pARV. CONCLUSIONS: This study shows high uptake of ART/pARV among those enrolled into the PMTCT programme. However, about one in eight pregnant women did not receive ART before delivery. Among those initiated on ART/pARV before delivery, nearly half of them received ART/pARV for less than 8 weeks prior to delivery. These aspects need to be improved in order to eliminate mother-to-child transmission of HIV.

Catastrophic health expenditure among industrial workers in a large-scale industry in Nepal, 2017: a cross-sectional study.

OBJECTIVES: The study aimed at estimating out-of-pocket (OOP) expenditure, catastrophic health expenditure (CHE) and distress financing due to hospitalisation and outpatient care among industrial workers in Eastern Nepal. METHODS: We conducted a cross-sectional study involving industrial workers employed in a large-scale industry in Eastern Nepal. Those who were hospitalised in the last 1 year or availed outpatient care within the last 30 days were administered a structured questionnaire to estimate the cost of illness. CHE was defined as expenditure more than 20% of annual household income. Distress financing was defined as borrowing money/loan or selling assets to cope with OOP expenditure on health. RESULTS: Of 1824 workers eligible for the study, 1405 (77%) were screened, of which 85 (6%) were hospitalised last year; 223 (16%) attended outpatient department last month. The median (IQR) OOP expenditure from hospitalisation and outpatient care was US$124 (71-282) and US$36 (19-61), respectively. Among those hospitalised, the prevalence of CHE and distress financing was found to be 13% and 42%, respectively, and due to outpatient care was 0.4% and 42%, respectively. Drugs and diagnostics account for a large share of direct costs in both public and private sectors. More than 80% sought hospitalisation and outpatient care in a private sector. CONCLUSION: Industrial workers face significant financial risks due to ill health compared with the general population. Poor utilisation and higher cost of care in public health facilities warrant strengthening of public sector through increased government spending. The labour act 2014 of Nepal should be strictly adhered.

Are death and loss to follow-up still high in people living with HIV on ART after national scale-up and earlier treatment initiation? A large cohort study in government hospital-based setting, Myanmar: 2013-2016.

SETTING: Myanmar National AIDS Program has had significant scale-up of services and changes in CD4 eligibility criterion for ART initiation from 2013 to 2016. This study assessed early death within 6 months and attrition (death and loss to follow-up, LTFU) after ART initiation and their associated factors. DESIGN: A retrospective cohort study on people living with HIV (PLHIV >15 year of age) enrolled at three specialist hospitals in Yangon from 1st June 2013 to 30th June 2016. Cox regression was used to calculate hazard ratios (HRs) of early death and attrition. RESULTS: Of 11,727 adults enrolled, 11,186 (95%) were initiated on ART, providing 15,964 person-years of follow-up. At baseline, median age was 36 years [IQR: 30-43], 58% were men and median CD4 count was 151 cells/mm3 (IQR: 54-310). There were 733(6%) early deaths, 961(9%) total deaths and 1371 (12%) LTFU during the study period. Independent risk factors for early death were older age (41-50 and ≥51 years) [aHR 1.38, 1.07-1.78 and 1.68, 1.21-2.34], male (1.84, 1.44-2.35), low weight (2.06, 1.64-2.59), bedridden, (3.81, 2.57-5.66) and CD4 count ≤ 50 cells/mm3 (6.83, 2.52-18.57). In addition to above factors, high attrition was associated with an abacavir-based regimen. CONCLUSION: Although there was a low rate of early deaths, patients were being diagnosed late and there was a high attrition rate from specialist hospitals. Concerted effort is required to increase early diagnosis and ART initiation, and strengthen community systems for HIV care to achieve ambitious goal of ending AIDS epidemic by 2030.

Attrition among HIV positive children enrolled under integrated HIV care programme in Myanmar: 12 years cohort analysis.

BACKGROUND: In Myanmar, HIV seropositive children are being enrolled in an integrated HIV care (IHC) Program for HIV treatment and care since 2005. OBJECTIVES: To assess the: (a) attrition (death or loss-to-follow-up) rates among children (aged ≥ 18 months to < 15 years) enrolled into the programme before and after initiation of anti-retroviral therapy (ART) (pre-ART and ART periods); (b) demographic and clinical factors associated with attrition during these two periods. METHODS: Children enrolled in IHC Programme and their status (death, lost to follow-up, regular follow-up or transferred out) was assessed as on 30 June 2017. Attrition rates (per 100 person-years) at pre - ART and ART periods were calculated and the association between demographic and clinical characteristics with attrition was assessed using Cox proportional hazards model. RESULTS: Among 2,736 children enrolled, pre-ART attrition rate was 19 per 100 person-years of follow-up (95% CI: 17-21) and ART attrition rate was 4 per 100 person-years of follow-up (95% CI: 3-4) with higher levels during the initial few months of enrolment. The 36-month retention rates during pre-ART period was 75% (95% CI: 72-78) and during ART period was 87% (95% CI: 86-88). The children 'at enrolment' with relatively lower levels of haemoglobin, immune deficiency, underweight for age, higher WHO clinical stages, presence of hepatitis B infection had higher hazards of attrition in both periods. CONCLUSION: The attrition rates are high particularly among children with relatively poorer clinical, nutritional profiles at enrolment. The study suggests the urgent need for improving adherence counselling especially during the initial few months of enrolment and early ART initiation.

Evaluation of a tuberculosis active case finding project in peri-urban areas, Myanmar: 2014-2016.

OBJECTIVES: We assessed the effect of an active case finding (ACF) project on tuberculosis (TB) case notification and the yields from a household and neigbourhood intervention (screening contacts of historical index TB patients diagnosed >24months ago) and a community intervention (screening attendants of health education sessions/mobile clinics). DESIGN: Cross-sectional analysis of project records, township TB registers and annual TB reports. RESULTS: In the household and neigbourhood intervention, of 56,709 people screened, 1,076 were presumptive TB and 74 patients were treated for active TB with a screening yield of 0.1% and a yield from presumptive cases of 6.9%. In the community intervention, of 162,881 people screened, 4,497 were presumptive TB and 984 were treated for active TB with a screening yield of 0.6% and yield from presumptive cases of 21.9%. Of active TB cases, 94% were new, 89% were pulmonary, 44% were bacteriologically-confirmed and 5% had HIV. Case notification rates per 100,000 in project townships increased from 142 during baseline (2011-2013) to 148 during intervention (2014-2016) periods. CONCLUSIONS: The yield from household and neigbourhood intervention was lower than community intervention. This finding highlights reconsidering the strategy of screening of contacts from historical index cases. Strategies to reach high-risk groups should be explored for future ACF interventions to increase yield of TB.