Access to needles and syringes and methadone maintenance therapy among people who inject drugs in Yangon, Myanmar: a qualitative study.

BACKGROUND: Access to sterile needles, syringes and methadone maintenance therapy (MMT) is critical to reduce the prevalence of bloodborne virus infections among people who inject drugs (PWID). We aimed to explore the experiences of PWID with respect to accessing needles/syringes services and MMT in Yangon, Myanmar. METHODS: Burnet Institute implemented a community-based hepatitis C testing and treatment (CT2) program for PWID with on-site needles and syringes distribution. Separate from CT2, MMT was available at two government-run sites in Yangon. We conducted in-depth interviews with 15 PWID who received hepatitis C care in this program. Interviews were transcribed verbatim and translated into English. Thematic data analysis was performed using NVivo12 software. RESULTS: Self-reported changes to needles/syringes sharing behaviour after hepatitis C education in the CT2 program and commencement of treatment were observed. One third of participants reported they became aware of the risks of sharing and reusing needles/syringes, and consequently refrained from sharing after the CT2 program. Inadequate availability of NSPs, cost of needles/syringes, and issues maintaining privacy when accessing needles/syringes emerged as key barriers to accessibility of needles/syringes. Participants described difficulties in accessing free needles/syringes. They were not aware of other free needles/syringes services at the time of the interview. Purchasing needles/syringes from pharmacies had privacy and confidentiality concerns. Structural barriers to accessibility of MMT were identified for both MMT sites in Yangon. Of the two MMT sites in Yangon, participants reported that the Ywarthargyi center had strict eligibility criteria for take-home methadone and transportation issues as it was located in the outskirt of the town. The Thingyangyun center was in a more convenient location, but only offered daily observed doses and had a long waiting time which was burdensome for some employed participants. CONCLUSION: Expansion of free needles/syringes services and adaptations of MMT to consider the needs and individual preferences of PWID will improve their access to these services and would likely reduce injecting related harms.

Outcomes of the CT2 study: A 'one-stop-shop' for community-based hepatitis C testing and treatment in Yangon, Myanmar.

BACKGROUND: With the advent of low-cost generic direct-acting antivirals (DAA), hepatitis C (HCV) elimination is now achievable even in low-/middle-income settings. We assessed the feasibility and effectiveness of a simplified clinical pathway using point-of-care diagnostic testing and non-specialist-led care in a decentralized, community-based setting. METHODS: This feasibility study was conducted at two sites in Yangon, Myanmar: one for people who inject drugs (PWID), and the other for people with liver disease. Participants underwent on-site rapid anti-HCV testing and HCV RNA testing using GeneXpert(R) . General practitioners determined whether participants started DAA therapy immediately or required specialist evaluation. Primary outcome measures were progression through the HCV care cascade, including uptake of RNA testing and treatment, and treatment outcomes. FINDINGS: All 633 participants underwent anti-HCV testing; 606 (96%) were anti-HCV positive and had HCV RNA testing. Of 606 tested, 535 (88%) were RNA positive and had pre-treatment assessments; 30 (6%) completed specialist evaluation. Of 535 RNA positive participants, 489 (91%) were eligible to initiate DAAs, 477 (98%) completed DAA therapy and 421 achieved SVR12 (92%; 421/456). Outcomes were similar by site: PWID site: 91% [146/161], and liver disease site: 93% [275/295]). Compensated cirrhotic patients were treated in the community; they achieved an SVR12 of 83% (19/23). Median time from RNA test to DAA initiation was 3 days (IQR 2-5). CONCLUSIONS: Delivering a simplified, non-specialist-led HCV treatment pathway in a decentralized community setting was feasible in Yangon, Myanmar; retention in care and treatment success rates were very high. This care model could be integral in scaling up HCV services in Myanmar and other low- and middle-income settings.

Patients' access to and acceptance of community-based hepatitis C testing and treatment in Myanmar: A mixed-method study.

Hepatitis C (HCV) infection elimination in low- and middle-income countries requires decentralised HCV services to increase testing and linkage to care. The CT2 Study investigated patients' views of access to and acceptance of two community-based HCV care models in Myanmar using a mixed-methods approach. Point-of-care HCV testing and general practitioner-initiated HCV treatment were provided at two community clinics in Yangon, Myanmar-the Burnet Institute's (BI) clinic focused on people who inject drugs (PWID), and the Myanmar Liver Foundation's (MLF) clinic focused on people with liver-related diseases. Study staff administered quantitative questionnaires to 633 participants receiving anti-HCV antibody testing. Purposive sampling was used to recruit 29 participants receiving direct-acting antiviral treatment for qualitative interviews. Among participants completing quantitative questionnaires, almost all reported the clinic location was convenient (447/463, 97%), waiting time was acceptable (455/463, 98%), and HCV antibody and RNA testing methods were acceptable (617/632, 98% and 592/605, 97% respectively). Nearly all participants were satisfied with their clinic's services (444/463, 96%) and preferred same-day test results (589/632, 93%). BI clinic participants were more confident that they understood HCV antibody and RNA results; MLF clinic participants were more comfortable disclosing their risk behaviour to staff and had slightly higher satisfaction with the overall care, privacy and secure storage of their information. In qualitative interviews, participants reported that flexible appointment scheduling, short wait times and rapid return of results increased the clinic's accessibility. The simplified point-of-care testing and treatment procedures and supportive healthcare providers contributed to participants' acceptance of the HCV care model. This decentralised community-based HCV testing and treatment model was highly accessible and acceptable to CT2 participants. Prioritizing patient-centred care, rapid provision of results, flexible appointments and convenient clinic locations can promote accessible and acceptable services which may in turn help accelerate progress in reaching HCV elimination targets.