Factors associated with lifetime HIV testing among women in four Southeast Asian countries: Evidence from the demographic and health surveys.

BACKGROUND: Southeast Asian countries have been trying to increase HIV testing coverage of women since awareness of HIV status is essential to eliminate mother-to-child transmission of HIV. This study determined factors related to lifetime HIV testing uptake among women aged 15-49 years in four Southeast Asian countries: Myanmar, Cambodia, the Philippines and Timor-Leste. METHODS: This study used cross-sectional data from the 2015-16 Myanmar Demographic and Health Survey (DHS), the 2014 Cambodia DHS, the 2017 Philippines National DHS and the 2016 Timor-Leste DHS. We conducted multivariable logistic regression analyses to identify factors associated with lifetime HIV testing among women aged 15-49 years who completed the surveys in each country and ran a fixed effects logistic regression model using pooled data. RESULTS: The proportions of lifetime HIV testing uptake among women aged 15-49 years were 42.1% in Cambodia, 19.5% in Myanmar, 4.6% in the Philippines, and 3.7% in Timor-Leste. Marital status, age, education, and wealth were significantly associated with lifetime HIV testing uptake among women in all four countries. Other factors (e.g., comprehensive knowledge of HIV, rural/urban residence, positive attitudes towards negotiation for safer sex) were also significant determinants of HIV testing uptake among women in some of these countries. CONCLUSIONS: A multi-sectoral collaboration of related sectors and organizations is necessary to increase access to HIV testing and HIV knowledge of women to overcome the barriers to HIV testing. It is critical to make HIV testing services available and accessible to women, especially in rural areas.

Economic burden on people living with HIV who attend self-help groups in Yangon, Myanmar.

This study aims to determine economic burden or cost of human immunodeficiency virus (HIV) and its consequences from patient perspective and to examine factors influencing the cost. This is a prevalence-based cost-of-illness (COI) study. A cross-sectional survey was carried out in Yangon, Myanmar during March and April 2018. Face-to-face structured interview was conducted among 264 people living with HIV (PLHIV) who were members of the selected four self-help groups (SHGs) that provided HIV peer support. Micro-costing approach was adopted for the cost calculation. Direct medical cost, direct non-medical cost and indirect cost were considered. Cost of HIV per patient in the year 2017 was estimated at 228.2 international dollar (Int$). Direct medical cost was only small portion of the total cost (5.6%). Indirect cost or cost of time loss was the largest contributor among the cost components, accounted for 61.2% of the total cost. First year of the antiretroviral therapy (ART) initiation and second line drug regimen have positive effect on the costs. HIV resulted in substantial economic burden for the patients. Effective interventions aim at reducing the economic burden on patients by providing compensation on transportation cost and providing job opportunity are essential. Further researchers examining cost from provider and societal perspectives are warranted to provide complete picture of the economic burden of HIV in Myanmar.

HIV Testing among General Population with Sexually Transmitted Infection: Findings from Myanmar Demographic and Health Survey (2015-16).

BACKGROUND: Human Immunodeficiency Virus (HIV) testing and counseling is recommended for people with Sexually Transmitted Infections (STIs). In Myanmar, HIV testing and its predictors among those with STI in general population is unknown. METHODS: This is a cross-sectional study using secondary data from Myanmar demographic and health survey 2015-16. We included all women and men aged 15-49 years that reported having STI in the past 12 months. Self-reported HIV testing and its predictors were assessed (using modified Poisson regression with robust variance estimates). We have provided weighted estimates as the analyses were weighted for the multistage sampling design. RESULTS: Of 998 self-reported STIs, 96 [9.6%, 95% confidence interval (CI): 7.5, 12.1] had been tested for HIV in the past 12 months. Respondents who were residing in hilly regions [adjusted prevalence ratio (aPR): 2.28, 95% CI: 1.29, 4.04] were more likely to have taken the HIV test. However, people in the poorest quintile (aPR: 0.34, 95% CI: 0.12, 0.96) and those who were staying at the current residence for more than 12 months (aPR: 0.45, 95% CI: 0.25, 0.79) were less likely to have taken HIV test. CONCLUSION: There is a necessity to promote HIV literacy and HIV testing among those with STI with focus on the poorest populations.

HIV Care Cascade among Prisoners of the Mandalay Central Prison in Myanmar: 2011-2018.

Prisoners have a higher HIV prevalence and higher rates of attrition from care as compared with the general population. There is no published evidence on this issue from Myanmar. We assessed (1) HIV test uptake, HIV positivity, and enrollment in care among newly admitted prisoners between 2017 and 18 (2) Treatment outcomes among HIV-positive prisoners enrolled in care between 2011 and 18. This was a cohort study involving secondary analysis of program data. Among 26,767 prisoners admitted to the Mandalay Central Prison between 2017 and 2018, 10,421 (39%) were HIV-tested, 547 (5%) were HIV-positive, and 376 (69%) were enrolled in care. Among the 1288 HIV-positive prisoners enrolled in care between 2011 and 2018, 1178 (92%) were started on antiretroviral therapy. A total of 883 (69%) were transferred out (post-release) to other health facilities, and among these, only 369 (42%) reached their destination health facilities. The final outcomes (censored on 30 June 2019) included the following: (i) Alive and in care 495 (38%), (ii) death 138 (11%), (iii) loss to follow-up 596 (46%), and (iv) transferred out after reaching the health facilities 59 (5%). We found major gaps at every step of the HIV care cascade among prisoners, both inside and outside the prison. Future research should focus on understanding the reasons for these gaps and designing appropriate interventions to fill these gaps.

Uptake of routine viral load testing among people living with HIV and its implementation challenges in Yangon region of Myanmar: a mixed-methods study.

OBJECTIVES: In 2017, Myanmar implemented routine viral load (VL) monitoring for assessing the response to antiretroviral therapy (ART) among people living with HIV (PLHIV). The performance of routine VL testing and implementation challenges has not yet assessed. We aimed to determine the uptake of VL testing and factors associated with it among PLHIV initiated on ART during 2017 in ART clinics of Yangon region and to explore the implementation challenges as perceived by the healthcare providers. DESIGN: An explanatory mixed-methods study was conducted. The quantitative component was a cohort study, and the qualitative part was a descriptive study with in-depth interviews. SETTING: Six ART clinics operated by AIDS/sexually transmitted infection teams under the National AIDS Programme. PRIMARY OUTCOME MEASURES: (1) The proportion who underwent VL testing by 30 March 2019 and the proportion with virological suppression (plasma VL <1000 copies/mL); (2) association between patient characteristics and 'not tested' was assessed using log binomial regression and (3) qualitative codes on implementation challenges. RESULTS: Of the 567 PLHIV started on ART, 498 (87.8%) retained in care for more than 6 months and were eligible for VL testing. 288 (57.8%, 95% CI: 53.3% to 62.2%) PLHIV underwent VL testing, of which 263 (91.3%, 95% CI: 87.1% to 94.4%) had virological suppression. PLHIV with WHO clinical stage 4 had significantly higher rates of 'not being tested' for VL. Collection of sample for VL testing only twice a month, difficulties in sample collection and transportation, limited trained workforce, wage loss and out-of-pocket expenditure for patients due to added visits were major implementation challenges. CONCLUSIONS: The VL test uptake was low, with only six out of ten PLHIV tested. The VL testing uptake needs to be improved by strengthening sample collection and transportation, adopting point-of-care VL tests, increasing trained workforce, providing compensation to patients for wage loss and travel costs for additional visits.

Working towards a master patient index and unique identifiers to improve health systems: the example of Myanmar.

In the health systems of many countries, there is neither a requirement to collect a minimum set of demographic information during patient registration nor a standard way of identifying patients. This impedes the provision of integrated, good-quality care for individual patients and, at the system level, prevents generation of the high-quality data necessary for effective management and continuous improvement. Assigning each patient a unique identifier (UID) to create a master patient index (MPI) is therefore essential to ensure data interoperability across all the points of patient care within a health system. Although advances in technology are shifting the boundary between civil registration and personal identification, the additional value of an MPI/UID system lies in the technical and operational capacity to ensure that clinical data are safely and securely managed. Moreover, operationalization of MPI/UID data enables the establishment of an evidence-based, constantly improving "learning health system" with feedback loops that allow measurement, evaluation and visualization of performance over time. The Ministry of Health and Sports of Myanmar is actively engaged in a multistakeholder collaborative process working towards a nationwide MPI/UID system. Demonstration pilots are planned for both online and offline modes of operation for HIV/AIDS, mother and child health (including eliminating mother-to-child transmission of HIV and syphilis) and hospital settings, which are expected to open up the potential for expansion to all health interventions and facilities. With the implementation of the MPI/UID system under way in Myanmar, the Ministry of Health and Sports is laying the foundation to put individuals at the centre of care and deliver a lifelong service for all.

Progress and Challenges of Implementing Decentralized HIV Testing For Prevention of Mother-to-Child Transmission of HIV - Myanmar.

BACKGROUND: Myanmar has adopted point-of-care (POC) HIV testing for its prevention of mother-to-child transmission of HIV program, and was initiated in 84 townships in 2013. This study assessed the progress of HIV testing uptake from 2012, one year prior to POC testing, to 2015, and the challenges faced by service providers during the rapid rollout of this testing strategy. METHODS: This serial cross-sectional study included 23 townships randomly selected from the 84 townships. An open-question survey was used to collect information on the challenges faced by service providers. A random effects logistic model was used for assessing the progress of HIV testing uptake among urban and rural health center groups. RESULTS: HIV testing uptake for antenatal care (ANC) attendees increased from 60% to 90% for rural and from 70% to 90% for urban attendees. The proportion of ANC attendees who were tested at their first visit increased from 70% to 80% for rural and from 70% to 90% for urban attendees. In addition, the proportion receiving same-day test results increased from less than 10% to 90% for both groups. Major challenges faced during the initial rollout included low health awareness among pregnant women, fear of stigma and discrimination, long travel times and costs, and increased workloads of providers in rural settings. CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS: The program should consider recruiting local volunteers to help reduce the workloads of service providers. Professional education based on need and continued mentoring and quality control schemes for HIV testing need to be in place. This decentralized strategy would be applicable to other resource-limited countries.

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.

Time to anti-retroviral therapy among people living with HIV enrolled into care in Myanmar: how prepared are we for 'test and treat'?

BACKGROUND: Among people living with HIV (PLHIV) enrolled into care, time to anti-retroviral therapy (ART) has not been studied in Myanmar. To inform progress, we conducted this operational research among treatment-naive PLHIV (≥18 years) enrolled during a period of three years (2014-2016) at Pyin Oo Lwin, Myanmar. OBJECTIVES: To determine (i) the time from HIV diagnosis to ART initiation (time to ART) and associated factors and (ii) the association between time to ART and attrition (loss to follow-up and death) from ART care. METHODS: This was a retrospective cohort study involving a record review of secondary programme data. The PLHIV were followed up to 5 December 2017 for ART initiation and up to 31 March 2018 (date of censoring) for attrition during ART. RESULTS: Of 543 enrolled, 373 (69%) were found to be eligible and initiated on ART. Of 373, 245 (67%) were initiated within 6 weeks of enrolment. The median enrolment delay (from diagnosis) was 4 (IQR: 1, 14) days and median ART initiation delay (from ART eligibility) was 20 (IQR: 13, 36) days. The median time to ART (excluding the time interval in pre-ART care) was 29 (IQR: 18, 55) days and was significantly long in those with prevalent TB and CD4 count ≥ 500/mm3 at enrolment. Among 373, the annual incidence density of attrition was 12.8% (0.95 CI: 10.2, 15.7). Attrition was common in first 100 days. Time to ART (after excluding time interval in pre-ART care) was not significantly associated with attrition. CONCLUSION: The programme appears to be on track to initiate ART as soon as possible in a 'test and treat' scenario (implemented since September 2017) subject to interventions to reduce ART initiation delay.

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.

Factors associated with death and loss to follow-up in children on antiretroviral care in Mingalardon Specialist Hospital, Myanmar, 2006-2016.

BACKGROUND: Myanmar National AIDS programme's priority is to improve the survival of all people living with HIV by providing anti-retroviral therapy (ART) care. More than 7200 children (aged <15 years) have been enrolled into ART care from 2005 to 2016. A previous study showed that ~11% children on ART care had either died or were lost to follow-up by 60 months. Factors associated with death and lost-to follow-up (adverse outcomes) have not been previously studied. OBJECTIVES: To describe the association between demographic and clinical characteristics at enrollment into ART care with adverse outcomes. METHODS: Cohort study using records of children enrolled for ART care at Mingalardon Specialist Hospital (main Paediatric ART center in Myanmar) from 2006-2016. We used multivariable Cox proportional hazards regression models for analysis. RESULTS: 1,159 children were enrolled for ART care and they contributed a total of 1.45 million person-days of follow-up period. 112 (10%) had an adverse outcome during the follow-up time period (55 deaths, 57 lost to follow-up). Enrollment into the ART care through in-patient care department of the hospital, CD4 Cell count <50/mm3, enrollment during changing ART guidelines (different ART eligibility criteria and preferred ART regimen) were independently associated with higher hazards of adverse outcome. Receiving protease inhibitor-based ART regimen at enrollment was independently associated with lower hazards of adverse outcome. Age, sex, residing in urban or rural areas, WHO clinical stage, having TB at the time of enrollment, receiving cotrimoxazole prophylaxis were not statistically associated with adverse outcomes. CONCLUSION: Our analysis reconfirms good survival of children on ART care (including those with TB). The characteristics associated with adverse outcomes (other than CD4 cell count<50) are surrogates of some unmeasured underlying health system/ patient related factors that needs further exploration to improve the survival of children on ART care.

HIV-1 drug resistance before initiation or re-initiation of first-line antiretroviral therapy in low-income and middle-income countries: a systematic review and meta-regression analysis.

BACKGROUND: Pretreatment drug resistance in people initiating or re-initiating antiretroviral therapy (ART) containing non-nucleoside reverse transcriptase inhibitors (NNRTIs) might compromise HIV control in low-income and middle-income countries (LMICs). We aimed to assess the scale of this problem and whether it is associated with the intiation or re-initiation of ART in people who have had previous exposure to antiretroviral drugs. METHODS: This study was a systematic review and meta-regression analysis. We assessed regional prevalence of pretreatment drug resistance and risk of pretreatment drug resistance in people initiating ART who reported previous ART exposure. We systematically screened publications and unpublished datasets for pretreatment drug-resistance data in individuals in LMICs initiating or re-initiating first-line ART from LMICs. We searched for studies in PubMed and Embase and conference abstracts and presentations from the Conference on Retroviruses and Opportunistic Infections, the International AIDS Society Conference, and the International Drug Resistance Workshop for the period Jan 1, 2001, to Dec 31, 2016. To assess the prevalence of drug resistance within a specified region at any specific timepoint, we extracted study level data and pooled prevalence estimates within the region using an empty logistic regression model with a random effect at the study level. We used random effects meta-regression to relate sampling year to prevalence of pretreatment drug resistance within geographical regions. FINDINGS: We identified 358 datasets that contributed data to our analyses, representing 56 044 adults in 63 countries. Prevalence estimates of pretreatment NNRTI resistance in 2016 were 11·0% (7·5-15·9) in southern Africa, 10·1% (5·1-19·4) in eastern Africa, 7·2% (2·9-16·5) in western and central Africa, and 9·4% (6·6-13·2) in Latin America and the Caribbean. There were substantial increases in pretreatment NNRTI resistance per year in all regions. The yearly increases in the odds of pretreatment drug resistance were 23% (95% CI 16-29) in southern Africa, 17% (5-30) in eastern Africa, 17% (6-29) in western and central Africa, 11% (5-18) in Latin America and the Caribbean, and 11% (2-20) in Asia. Estimated increases in the absolute prevalence of pretreatment drug resistance between 2015 and 2016 ranged from 0·3% in Asia to 1·8% in southern Africa. INTERPRETATION: Pretreatment drug resistance is increasing at substantial rate in LMICs, especially in sub-Saharan Africa. In 2016, the prevalence of pretreatment NNRTI resistance was near WHO's 10% threshold for changing first-line ART in southern and eastern Africa and Latin America, underscoring the need for routine national HIV drug-resistance surveillance and review of national policies for first-line ART regimen composition. FUNDING: Bill & Melinda Gates Foundation and World Health Organization.

Evolution of the health sector response to HIV in Myanmar: progress, challenges and the way forward.

Critical building blocks for the response to HIV were made until 2012 despite a series of political, social and financial challenges. A rapid increase of HIV service coverage was observed from 2012 to 2015 through collaborative efforts of government and non-governmental organisations (NGOs). Government facilities, in particular, demonstrated their capacity to expand services for antiretroviral therapy (ART), prevention of mother-to-child transmission (PMTCT) of HIV, tuberculosis and HIV co-infection and methadone-maintenance therapy (MMT). After nearly three decades into the response to HIV, Myanmar has adopted strategies to provide the right interventions to the right people in the right places to maximise impact and cost efficiency. In particular, the country is now using strategic information to classify areas into high-, medium- and low-HIV burden and risk of new infections for geographical prioritisation - as HIV remains concentrated among key population (KP) groups in specific geographical areas. Ways forward include: •Addressing structural barriers for KP to access services, and identifying and targeting KPs at higher risk;•Strengthening the network of public facilities, NGOs and general practitioners and introducing a case management approach to assist KPs and other clients with unknown HIV status, HIV-negative clients and newly diagnosed clients to access the health services across the continuum to increase the number of people testing for HIV and to reduce loss to follow-up in both prevention and treatment;•Increasing the availability of HIV testing and counselling services for KPs, clients of female sex workers (FSW), and other populations at risk, and raising the demand for timely testing including expansion of outreach and client-initiated voluntary counselling and testing (VCT) services;•Monitoring and maximising retention from HIV diagnosis to ART initiation and expanding quality HIV laboratory services, especially viral load;•Prioritising integration of HIV and related services in high-burden areas;•Increasing the proportion of PLHIV receiving testing and treatment at public facilities by improving human resources and increasing public facilities providing these services to ensure sustainability;•Obtaining intelligence and tailoring services in hard-to-reach/under-served areas;•Strengthening planning, monitoring, and coordination capacity especially at regional levels.