Correction: Viraemic-time predicts mortality among people living with HIV on second-line antiretroviral treatment in Myanmar: A retrospective cohort study.

[This corrects the article DOI: 10.1371/journal.pone.0271910.].

Can social support mediate stigma and perceived stress in people live with human immunodeficiency virus?

Stigma has heavily impacted People Living with HIV (PLWH). Limited studies report on how social support affects HIV-related stigma and perceived stress, especially in Myanmar. During first seven months of 2020, a random sample of 248 eligible PLWH were contacted from a private, closed Facebook group with more than 18,000 Myanmar people, where 90% of the members were PLWH. Variables collected included demographics data, perceived stress, social support, and HIV stigma. After controlling for the effects of demographic variables, the path from HIV stigma to perceived stress (direct effect ß = 0.40) and though the mediation of social support was significant (indirect effect ß = 0.014). However, the mediating effect of social support was non-significant between HIV stigma and perceived stress. This exploratory study shows that social support did not have the expected effect of decreasing perceived stress in PLWH in Myanmar. Interventions to reduce HIV stigma to decrease perceived stress should consider other strategies, e.g., spirituality-based practice, to reduce perceived stress in Myanmar PLWH.

The feasibility and acceptability of integrating hepatitis C and HIV diagnostic testing on centralized molecular laboratory platforms in Myanmar.

BACKGROUND: In Myanmar, 1.3 million people have been exposed to hepatitis C (HCV). However, public sector access to viral load (VL) testing for HCV diagnosis remains limited; ten near-point-of-care (POC) devices are available nationally. Myanmar's National Health Laboratory (NHL) has surplus capacity on centralized molecular testing platforms used for HIV diagnostics, presenting an opportunity for integrating HCV testing to expand overall testing capacity. This pilot assessed the operational feasibility and acceptability of HCV/HIV integrated testing implemented with a comprehensive package of supportive interventions. METHODS: HCV VL samples were collected prospectively from consenting participants at five treatment clinics and tested at Myanmar's NHL (October 2019-February 2020) on the Abbott m2000. To optimize integration, laboratory human resources were bolstered, staff trainings were offered, and existing laboratory equipment was serviced/repaired as needed. Diagnostics data during the intervention period were compared against HIV diagnostics data in the seven months prior. We conducted three time and motion analyses at the laboratory and semi-structured interviews with laboratory staff to assess time needs and program acceptability. RESULTS: 715 HCV samples were processed during the intervention period with an average test processing time of 18 days (IQR: 8-28). Despite adding HCV testing, average monthly test volumes were 2,331 for HIV VL and 232 for early infant diagnosis (EID), comparable to the pre-intervention period. Processing times were 7 days for HIV VL and 17 days for EID, also comparable to the pre-intervention period. HCV test error rate was 4.3%. Platforms utilization increased from 18.4% to 24.6%. All staff interviewed were supportive of HCV and HIV diagnostics integration; suggestions were made for broader implementation and expansion. CONCLUSIONS: With a package of supportive interventions, integration of HCV and HIV diagnostics on a centralized platform was operationally feasible, did not adversely impact HIV testing, and was acceptable to laboratory staff. In Myanmar, integrated HCV VL diagnostic testing on centralized platforms may be an important addition to existing near-POC testing in expanding national testing capacity for HCV elimination.

Advanced HIV disease and associated attrition after re-engagement in HIV care in Myanmar from 2003 to 2019: a retrospective cohort study.

BACKGROUND: The burden of advanced HIV disease (AHD) and predictors of outcomes among people living with HIV (PLHIV) re-engaging in care are not well known. METHODS: We conducted a retrospective cohort study of PLHIV who re-engaged in care after being lost to follow-up (LFU), from 2003 to 2019, in Myanmar. We calculated the incidence rates of attrition after re-engagement and performed Cox regression to identify risk factors for attrition. RESULTS: Of 44 131 PLHIV who started antiretroviral treatment, 12 338 (28.0%) were LFU at least once: 7608 (61.6%) re-engaged in care, 4672 (61.4%) with AHD at re-engagement. The death and LFU rates were 2.21-fold (95% CI 1.82 to 2.67) and 1.46-fold (95% CI 1.33 to 1.61) higher among patients who re-engaged with AHD (p>0.001). Death in patients who re-engaged with AHD was associated with male sex (adjusted HR [aHR] 2.63; 95% CI 1.31 to 5.26; p=0.006), TB coinfection (aHR 2.26; 95% CI 1.23 to 4.14; p=0.008) and sex work (aHR 7.49, 95% CI 2.29 to 22.52; p<0.001). History of intravenous drug use was identified as a predictor of being LFU. CONCLUSIONS: Re-engagement in HIV care in Myanmar is frequent and those who re-engage carry a high burden of AHD. As AHD at re-engagement is associated with higher attrition rates, implementation of differentiated interventions that enable earlier linkage to care and prompt identification and management of AHD in this population is necessary.

Psychometric Evaluation of a Myanmar Version of the Perceived Stress Scale for People Living with HIV/AIDS.

Background and Purpose: Reliable instruments for the measurement of perceived stress in people living with HIV (PLHIV) are crucial. However, there is no Myanmar version of such an instrument. Methods: We adapted the 35-item Perceived Stress Scale for People Living with HIV/AIDS (PSSHIV) into a Myanmar version (PSSHIV-M), and 150 PLHIV completed the survey. Results: The 31-item PSSHIV-M with a five-factor structure has a Cronbach's alpha of .85 to .95. Construct validity was demonstrated for the instrument, and the findings of Rasch analysis also suggest evidence of reliability and validity. Conclusions: The psychometric properties of the 31-item PSSHIV-M with a five-factor structure support its efficacy in ascertaining how HIV perceived stress affects Myanmar PLHIV. It could also facilitate the development of stress management interventions for that population.

Viraemic-time predicts mortality among people living with HIV on second-line antiretroviral treatment in Myanmar: A retrospective cohort study.

INTRODUCTION: Despite HIV viral load (VL) monitoring being serial, most studies use a cross-sectional design to evaluate the virological status of a cohort. The objective of our study was to use a simplified approach to calculate viraemic-time: the proportion of follow-up time with unsuppressed VL above the limit of detection. We estimated risk factors for higher viraemic-time and whether viraemic-time predicted mortality in a second-line antiretroviral treatment (ART) cohort in Myanmar. METHODS: We conducted a retrospective cohort analysis of people living with HIV (PLHIV) who received second-line ART for a period >6 months and who had at least two HIV VL test results between 01 January 2014 and 30 April 2018. Fractional logistic regression assessed risk factors for having higher viraemic-time and Cox proportional hazards regression assessed the association between viraemic-time and mortality. Kaplan-Meier curves were plotted to illustrate survival probability for different viraemic-time categories. RESULTS: Among 1,352 participants, 815 (60.3%) never experienced viraemia, and 172 (12.7%), 214 (15.8%), and 80 (5.9%) participants were viraemic <20%, 20-49%, and 50-79% of their total follow-up time, respectively. Few (71; 5.3%) participants were ≥80% of their total follow-up time viraemic. The odds for having higher viraemic-time were higher among people with a history of injecting drug use (aOR 2.01, 95% CI 1.30-3.10, p = 0.002), sex workers (aOR 2.10, 95% CI 1.11-4.00, p = 0.02) and patients treated with lopinavir/ritonavir (vs. atazanavir; aOR 1.53, 95% CI 1.12-2.10, p = 0.008). Viraemic-time was strongly associated with mortality hazard among those with 50-79% and ≥80% viraemic-time (aHR 2.92, 95% CI 1.21-7.10, p = 0.02 and aHR 2.71, 95% CI 1.22-6.01, p = 0.01). This association was not observed in those with viraemic-time <50%. CONCLUSIONS: Key populations were at risk for having a higher viraemic-time on second-line ART. Viraemic-time predicts clinical outcomes. Differentiated services should target subgroups at risk for a higher viraemic-time to control both HIV transmission and mortality.

The Mediating Effects of Mindfulness on Perceived Stress From HIV Stigma in People Living With HIV in Myanmar: A Cross-sectional Study.

ABSTRACT: HIV is a highly stigmatized and stressful condition for people with HIV (PWH). As a country heavily influenced by religion, especially Buddhism, we explore how the perceived stress from HIV stigma interacts with the mediator of mindfulness on PWH in Myanmar. From January to July 2020, a sample of 248 eligible PWH was recruited by quasi-random sampling methods from a private Facebook group in Myanmar. Data on demographics, HIV stigma, mindfulness, and perceived stress were collected. The bias-corrected percentile bootstrap method was used to test multiple mediation analyses. The path from perceived HIV stigma to perceived stress (direct effect ß = 0.16) and the mediating effect of mindfulness on that stress were significant (indirect effect accounts for 45.15% of total effect). The findings indicate that interventions enhancing mindfulness-based practice should be considered to reduce HIV stigma and, therefore, lower perceived stress among PWH in Myanmar.

Factors affecting health-related quality of life of HIV-infected key population in Myanmar.

This cross-sectional study examined factors affecting Health-related Quality of Life (HRQoL) among 273 HIV-infected key populations. This included, men who have sex with men (MSM), people, who inject drugs (PWID), and sex workers (SW), who were currently receiving antiretroviral therapy (ART) in Myanmar. Participants were recruited from four non-government clinics in four main cities. Overall HRQoL score derived from the WHOQOL-HIV BREF questionnaire was 86.08 ± 10.78. The lowest score was found in the environment domain (13.64 ± 2.06), while the highest score was found in the spirituality domain (15.54 ± 3.04). According to the multiple logistic regression analysis, participants, reported having an adequate income (OR = 3.32, P = 0.006), regularly taking meditation (OR = 3.79, P = 0.009), living in Tachileik (OR = 15.43, P = 0.011), and reported having no symptoms during previous 2 weeks (OR = 14.50, P < 0.001), were more likely to have good HRQoL level. In contrast, patients receiving ART < 1 year (OR = 0.163, P = 0.028) reported having low ART adherence (OR = 0.17, P = 0.018) and reported anticipated stigma (OR = 0.23, P < 0.001) and internalized stigma (OR = 0.29, P = 0.006) were less likely to have good HRQoL level.

Adaptation and Validation of the Cognitive and Affective Mindfulness Scale-Revised (CAMS-R) in People Living with HIV in Myanmar.

Objectives: Valid and reliable instruments for the measurement of mindfulness are crucial for people living with HIV. However, there was no Myanmar version of such an instrument. Methods: We adapted the English version of the 12-item Cognitive and Affective Mindfulness Scale-Revised (CAMS-R) based on standard cross-cultural procedures. By randomly sampling methods, a sample of 248 eligible people living with HIV was contacted from a closed Myanmar Facebook group; 159 PLHIV completed the initial 12-item version of the adapted survey. Results: Three items were removed due to low item-to-total correlations of the corrected item-total correlation as well as having infit and outfit mean squares outside the range of 0.6 to 1.4. After deleting the 3 items, the three-factor structure was confirmed by confirmatory factor analysis, which indicated good model fit. The resultant 9-item CAMS-R in Myanmar (CAMS-R-M-2) achieved good internal reliability (Cronbach's α of 0.75 to 0.87, and the corrected item-total correlation ranged from 0.44 to 0.81). Construct validity of the scale was demonstrated by significant association with self-reported HIV stigma and social support levels (r = 0.63, and - 0.53). In Rasch analysis, the infit and outfit mean squares for each item ranged from 0.49 to 1.24, and the person reliability was 2.17 and the separation index was 0.83. Conclusions: The 9-item CAMS-R-M-2 with a three-factor structure has good reliability and validity. Higher total scores and subscale score reflected greater mindfulness qualities in people living with HIV in Myanmar.

Optimizing HIV Services for Key Populations in Public-Sector Clinics in Myanmar.

Key populations, ie, female sex workers, men who have sex with men, transgender people, people who inject drugs, and people in prisons and other closed settings, experience stigma, discrimination, and structural barriers when accessing HIV prevention and care. Public health facilities in Myanmar became increasingly involved in HIV service delivery, leading to an urgent need for healthcare workers to provide client-centred, key population-friendly services. Between July 2017-June 2018, the Myanmar Ministry of Health and Sports and National AIDS Programme collaborated with ICAP at Columbia University and the US Centers for Disease Control and Prevention to implement a quasi-experimental, multicomponent intervention including healthcare worker sensitization training with pre- and post- knowledge assessments, healthcare worker and client satisfaction surveys, and structural changes. We observed modest improvements among healthcare workers (n = 50) in knowledge assessments. Classification of clients into key population groups increased and fewer clients were classified as low risk. Key population clients reported favourable perceptions of the quality and confidentiality of care through self-administered surveys. Our findings suggest public health facilities can deliver HIV services that are valued by key population clients.

Adaptation and validation of a culturally adapted HIV stigma scale in Myanmar.

BACKGROUND: HIV stigma is a common barrier to HIV prevention, testing, and treatment adherence, especially for low- and middle-income countries such as Myanmar. However, there was no validated Myanmar version of a stigma scale. Therefore, we adapted the English version of the 40-item Berger's HIV stigma scale and the 7-item Indian HIV stigma scale into a 47-item Myanmar HIV stigma scale and then evaluated the scale's psychometric properties. METHOD: From January 2020 to May 2020, using random sampling methods, 216 eligible Myanmar people living with HIV/AIDS (PLWHA) were contacted from a closed Facebook group that included more than 10,000 PLWHA. A sample of 156 Myanmar PLWHA completed the online self-reported survey. RESULTS: A six-factor structure for the scale was determined through exploratory factor analysis, explaining 68.23% of the total variance. After deleting 12 items, the 35-item HIV stigma scale achieved Cronbach 's α of 0.72 to 0.95. Construct validity of the scale was demonstrated by significant association with self-reported depression and social support levels (r = 0.60, and - 0.77, p < 0.01). In Rasch analysis, the scale achieved person reliability of 3.40 and 1.53 and a separation index of 0.92 and 0.70. The infit and outfit mean squares for each item ranged from 0.68 to 1.40. No differential item functioning across gender or educational level was found. CONCLUSIONS: The psychometric properties of the 35-item Myanmar version of the HIV stigma scale support it as a measure of stigma among PLWHA in Myanmar. This instrument could help healthcare providers to better understand how stigma operates in PLWHA and to develop tailored stigma-reduction interventions in Myanmar.

Translation, Adaption, and Psychometric Testing of the Myanmar Version of the Medical Outcomes Study Social Support Survey for People Living With HIV/AIDS.

Introduction: Valid and reliable instruments are crucial for measuring perceived social support among people living with HIV (PLHIV). We aimed to investigate the psychometric properties of the English version of the 19-item Medical Outcomes Study Social Support Survey (MOS-SSS) adapted for PLHIV in Myanmar. Methods: Based on a standard cross-cultural procedure, we adapted the MOS-SSS and formed a Myanmar version of the scale (MOS-SSS-M), and then tested its validity and reliability. A sample of 250 eligible PLHIV was collected from a closed Facebook group that included more than 10,000 Myanmars, most of whom were PLHIV. Results: The MOS-SSS-M achieved a Cronbach's α of 0.82-0.95. Confirmatory factor analysis revealed an acceptable fit index for the four-factor structure. Construct validity was demonstrated by significant association with self-reported HIV stigma and stress levels, and further confirmed by the findings of Rasch analysis. Conclusion: The MOS-SSS-M with a four-factor structure can be used to measure the level and categories of perceived social support among PLHIV in Myanmar.

Predictors of virological failure among people living with HIV receiving first line antiretroviral treatment in Myanmar: retrospective cohort analysis.

BACKGROUND: Progress toward the global target for 95% virological suppression among those on antiretroviral treatment (ART) is still suboptimal. We describe the viral load (VL) cascade, the incidence of virological failure and associated risk factors among people living with HIV receiving first-line ART in an HIV cohort in Myanmar treated by the Médecins Sans Frontières in collaboration with the Ministry of Health and Sports Myanmar. METHODS: We conducted a retrospective cohort study, including adult patients with at least one HIV viral load test result and having received of at least 6 months' standard first-line ART. The incidence rate of virological failure (HIV viral load ≥ 1000 copies/mL) was calculated. Multivariable Cox's regression was performed to identify risk factors for virological failure. RESULTS: We included 25,260 patients with a median age of 33.1 years (interquartile range, IQR 28.0-39.1) and a median observation time of 5.4 years (IQR 3.7-7.9). Virological failure was documented in 3,579 (14.2%) participants, resulting in an overall incidence rate for failure of 2.5 per 100 person-years of follow-up. Among those who had a follow-up viral load result, 1,258 (57.1%) had confirmed virological failure, of which 836 (66.5%) were switched to second-line treatment. An increased hazard for failure was associated with age ≤ 19 years (adjusted hazard ratio, aHR 1.51; 95% confidence intervals, CI 1.20-1.89; p < 0.001), baseline tuberculosis (aHR 1.39; 95% CI 1.14-1.49; p < 0.001), a history of low-level viremia (aHR 1.60; 95% CI 1.42-1.81; p < 0.001), or a history of loss-to-follow-up (aHR 1.24; 95% CI 1.41-1.52; p = 0.041) and being on the same regimen (aHR 1.37; 95% CI 1.07-1.76; p < 0.001). Cumulative appointment delay was not significantly associated with failure after controlling for covariates. CONCLUSIONS: VL monitoring is an important tool to improve programme outcomes, however limited coverage of VL testing and acting on test results hampers its full potential. In our cohort children and adolescents, PLHIV with history of loss-to-follow-up or those with low-viremia are at the highest risk of virological failure and might require more frequent virological monitoring than is currently recommended.

Antiretroviral therapy (ART) coverage at public and private ART facilities in Myanmar.

Myanmar's continuum of HIV care was surveyed to assess the National AIDS Control Programme's progress; according to its reports, ART coverage was 38% in 2014, 47% in 2015, and 56% in 2016. To evaluate ART coverage and gaps in care, a serial cross-sectional study used the national programme data reported between January 2014 and December 2016, including 228 public and 62 private ART facilities. ART coverage among PLHIV under 15 years old was 89% in 2014, 93% in 2015, and 88% in 2016. Retention in ART care among women was higher than among men, although women were more likely to discontinue care. PLHIV who were enrolled in ART facilities initiated ART at the rates of 60% in 2014, 68% in 2015, and 74% in 2016. Over the 3-year study period, these facilities reported that 2.5-3.7% of PLHIV taking ART had died, and that 3.3-4.8% were lost to follow-up. PLHIV who were tested for viral load were low (2.5-3%). The continuum of HIV care at ART facilities has improved, but more information about attrition and viral suppression are still needed. The reporting system for newly diagnosed PLHIV and facilities for viral load testing need to be strengthened.

Performance and Outcomes of Routine Viral Load Testing in People Living with HIV Newly Initiating ART in the Integrated HIV Care Program in Myanmar between January 2016 and December 2017.

Myanmar has introduced routine viral load (VL) testing for people living with HIV (PLHIV) starting first-line antiretroviral therapy (ART). The first VL test was initially scheduled at 12-months and one year later this changed to 6-months. Using routinely collected secondary data, we assessed program performance of routine VL testing at 12-months and 6-months in PLHIV starting ART in the Integrated HIV-Care Program, Myanmar, from January 2016 to December 2017. There were 7153 PLHIV scheduled for VL testing at 12-months and 1976 scheduled for VL testing at 6-months. Among those eligible for testing, the first VL test was performed in 3476 (51%) of the 12-month cohort and 952 (50%) of the 6-month cohort. In the 12-month cohort, 10% had VL > 1000 copies/mL, 79% had repeat VL tests, 42% had repeat VL > 1000 copies/mL (virologic failure) and 85% were switched to second-line ART. In the 6-month cohort, 11% had VL > 1000 copies/mL, 83% had repeat VL tests, 26% had repeat VL > 1000 copies/mL (virologic failure) and 39% were switched to second-line ART. In conclusion, half of PLHIV initiated on ART had VL testing as scheduled at 12-months or 6-months, but fewer PLHIV in the 6-month cohort were diagnosed with virologic failure and switched to second-line ART. Programmatic implications are discussed.

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.

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.

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.

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.