Protocol for the Adolescent Menstrual Experiences and Health Cohort (AMEHC) Study in Khulna, Bangladesh: A Prospective cohort to quantify the influence of menstrual health on adolescent girls' health and education outcomes.

BACKGROUND: Menstrual health is essential for gender equity and the well-being of women and girls. Qualitative research has described the burden of poor menstrual health on health and education; however, these impacts have not been quantified, curtailing investment. The Adolescent Menstrual Experiences and Health Cohort (AMEHC) Study aims to describe menstrual health and its trajectories across adolescence, and quantify the relationships between menstrual health and girls' health and education in Khulna, Bangladesh. METHODS AND ANALYSIS: AMEHC is a prospective longitudinal cohort of 2016 adolescent girls recruited at the commencement of class 6 (secondary school, mean age=12) across 101 schools selected through a proportional random sampling approach. Each year, the cohort will be asked to complete a survey capturing (1) girls' menstrual health and experiences, (2) support for menstrual health, and (3) health and education outcomes. Survey questions were refined through qualitative research, cognitive interviews and pilot survey in the year preceding the cohort. Girls' guardians will be surveyed at baseline and wave 2 to capture their perspectives and household demographics. Annual assessments will capture schools' water, sanitation and hygiene, and support for menstruation and collect data on participants' education, including school attendance and performance (in maths, literacy). Cohort enrolment and baseline survey commenced in February 2023. Follow-up waves are scheduled for 2024, 2025 and 2026, with plans for extension. A nested subcohort will follow 406 post-menarche girls at 2-month intervals throughout 2023 (May, August, October) to describe changes across menstrual periods. This protocol outlines a priori hypotheses regarding the impacts of menstrual health to be tested through the cohort. ETHICS AND DISSEMINATION: AMEHC has ethical approval from the Alfred Hospital Ethics Committee (369/22) and BRAC James P Grant School of Public Health Institutional Review Board (IRB-06 July 22-024). Study materials and outputs will be available open access through peer-reviewed publication and study web pages.

Cost-effectiveness of a decentralized, community-based "one-stop-shop" hepatitis C testing and treatment program in Yangon, Myanmar.

Background and Aim: The availability of direct-acting antiviral (DAA) treatment and point-of-care diagnostic testing has made hepatitis C (HCV) elimination possible even in low- and middle-income countries (LMICs); however, testing and treatment costs remain a barrier. We estimated the cost and cost-effectiveness of a decentralized community-based HCV testing and treatment program (CT2) in Myanmar. Methods: Primary cost data included the costs of DAAs, investigations, medical supplies and other consumables, staff salaries, equipment, and overheads. A deterministic cohort-based Markov model was used to estimate the average cost of care, the overall quality-adjusted life years (QALYs) gained, and the incremental cost-effectiveness ratio (ICER) of providing testing and DAA treatment compared with a modeled counterfactual scenario of no testing and no treatment. Results: From 30 January to 30 September 2019, 633 patients were enrolled, of whom 535 were HCV RNA-positive, 489 were treatment eligible, and 488 were treated. Lifetime discounted costs and QALYs of the cohort in the counterfactual no testing and no treatment scenario were estimated to be USD61790 (57 898-66 898) and 6309 (5682-6363) respectively, compared with USD123 248 (122 432-124 101) and 6518 (5894-6671) with the CT2 model of care, giving an ICER of USD294 (192-340) per QALY gained. This "one-stop-shop" model of care has a 90% likelihood of being cost-effective if benchmarked against a willingness to pay of US$300, which is 20% of Myanmar's GDP per capita (2020). Conclusions: The CT2 model of HCV care is cost-effective in Myanmar and should be expanded to meet the National Hepatitis Control Program's 2030 target, alongside increasing the affordability and accessibility of services.

Stigma Associated with Alcohol and Other Drug Use Among People from Migrant and Ethnic Minority Groups: Results from a Systematic Review of Qualitative Studies.

Stigma reduces access to alcohol and other drug (AOD) support. This systematic review explored perceptions and experiences of stigma associated with AOD use among migrant and ethnic minority groups. Qualitative studies published in English were identified using six databases. Two reviewers screened and critically appraised articles using the Joanna Briggs Institute Critical Appraisal Checklist for qualitative studies. Data were synthesised using best fit framework synthesis. Twenty-three studies were included. Stigma drivers and facilitators included stereotypes, socio-cultural norms, legal responses and precarious lived experiences. Stigma intersected with gender, citizenship, race and ethnicity and manifested though shame, exclusion, secondary stigma and discrimination in treatment. Outcomes and impacts included avoidance of services, emotional distress, isolation and loneliness. This review identified similar stigma experiences to other populations, however outcomes were complicated by precarious lived experiences and multiple stigmatised identities. Multi-level interventions are required to reduce AOD-related stigma for migrant and ethnic minority groups.

Feasibility of decentralised, task-shifted hepatitis C testing and treatment services in urban Myanmar: implications for scale-up.

OBJECTIVES: To assess the feasibility considerations for a decentralised, one-stop-shop model of care implemented in Yangon, Myanmar. SETTING: Two primary care level clinics in urban Yangon, Myanmar. DESIGN: This is a feasibility study of a highly effective care model. Using Intervention Complexity Framework by Gericke et al, we collated and analysed programmatic data and evaluation data to outline key project implementation requirements and experiences. PARTICIPANTS: Programmatic data were collected from clinical records, GeneXpert device test and maintenance reports, national guidelines, product and device instructions and site monitoring visit reports. Healthcare providers involved in delivering care model contributed interview data. RESULTS: The main feasibility considerations are appropriate storage for test kits and treatments (in response to temperature and humidity requirements), installation of a continuous stable electricity supply for the GeneXpert device, air-conditioning for the laboratory room hosting GeneXpert, access to a laboratory for pretreatment assessments and clear referral pathways for specialist consultation when required. Lessons from our project implementation experiences included the extensive time requirements for patient education, the importance of regular error monitoring and stock storage reviews and that flexible appointment scheduling and robust reminder system likely contributed to high retention in care. CONCLUSIONS: Detailed documentation and dissemination of feasibility requirements and implementation considerations is vital to assist others to successfully implement a similar model of care elsewhere. We provide 10 recommendations for successful implementation. TRIAL REGISTRATION NUMBER: The trial was registered at ClinicalTrials.gov NCT03939013 on May 6, 2019. This manuscript presents post-results data on feasibility.

Hepatitis C elimination in Myanmar: Modelling the impact, cost, cost-effectiveness and economic benefits.

BACKGROUND: Myanmar has set national hepatitis C (HCV) targets to achieve 50% of people diagnosed and 50% treated by 2030. The WHO has additional targets of reducing incidence by 80% and mortality by 65% by 2030. We aimed to estimate the impact, cost, cost-effectiveness and net economic benefit of achieving these targets. METHODS: Mathematical models of HCV transmission, disease progression and the care cascade were calibrated to 15 administrative regions of Myanmar. Cost data were collected from a community testing and treatment program in Yangon. Three scenarios were projected for 2020-2030: (1) baseline (current levels of testing/treatment); and testing/treatment scaled up sufficiently to reach (2) the national strategy targets; and (3) the WHO targets. FINDINGS: Without treatment scale-up, 333,000 new HCV infections and 97,000 HCV-related deaths were estimated to occur in Myanmar 2020-2030, with HCV costing a total $100 million in direct costs (testing, treatment, disease management) and $10.4 billion in lost productivity. In the model, treating 55,000 people each year was sufficient to reach the national strategy targets and prevented a cumulative 40,000 new infections (12%) and 25,000 HCV-related deaths (25%) 2020-2030. This was estimated to cost a total $189 million in direct costs ($243 per DALY averted compared to no treatment scale-up), but only $9.8 billion in lost productivity, making it cost-saving from a societal perspective by 2024 with an estimated net economic benefit of $553 million by 2030. Reaching the WHO targets required further treatment scale-up and additional direct costs but resulted in greater longer-term benefits. INTERPRETATION: Current levels of HCV testing and treatment in Myanmar are insufficient to reach the national strategy targets. Scaling up HCV testing and treatment in Myanmar to reach the national strategy targets is estimated to generate significant health and economic benefits. FUNDING: Gilead Sciences.

Matching action to need: an analysis of Global Burden of Disease 2017 and population health data to focus adolescent health policy and actions in Myanmar.

Background: Myanmar is a country undergoing rapid transitions in health. Its national strategic policy for young people's health is being revised but there is a paucity of population data to inform local priorities and needs. Objective: In this paper we describe a comprehensive profile of adolescent health in Myanmar to focus policy and health actions. Methods: We used available primary data, and modelled estimates from the GBD 2017, to describe health outcomes (mortality and morbidity), health risks and determinants for adolescents in Myanmar between 1990-2017. A governance group of key stakeholders guided the framing of the study, interpretation of findings, and recommendations. Results: Overall health has improved for adolescents in Myanmar since 1990, however adolescent mortality remains high, particularly so for older adolescent males; all-cause mortality rate for 10-24 years was 70 per 100,000 for females and 149 per 100,000 for males (16,095 adolescent deaths in 2017). Overall, the dominant health problems were injuries for males and non-communicable disease for females in a context of ongoing burden of communicable and nutritional diseases for both sexes, and reproductive health needs for females. Health risks relating to undernutrition (thinness and anaemia) remain prevalent, with other health risks (overweight, binge alcohol use, and substance use) relatively low by global and regional standards but increasing. Gains have been made in social determinants such as adolescent fertility and modern contraception use; however, advances have been more limited in secondary education completion and engagement in employment and post education training. Conclusions: These results highlight the need to focus current efforts on addressing disease and mortality experienced by adolescents in Myanmar, with a specific focus on injury, mental health and non-communicable disease.