The Associations of Perceived Social Support with Key HIV Risk and Protective Factors Among Young Males Who Have Sex with Males in Bangkok and Chiang Mai, Thailand.

This study used respondent-driven sampling to explore the effects of social support on HIV risk and protective factors among young males who have sex with males (YMSM) in Bangkok (N = 273) and Chiang Mai (N = 243), Thailand. It compared different measures of social support, including living situation, the proportion of family and friends to whom the respondent had disclosed their same-sex attraction, and scores on the multi-dimensional scale of perceived social support as predictors of two outcomes of interest-coerced first sex and HIV knowledge. Social support from family played a mediating role in both outcomes among YMSM in Bangkok but not those from Chiang Mai. Though social support from friends was also studied, it was less strongly associated with the outcomes of interest. The findings support interventions designed to leverage social support networks to increase HIV knowledge and decrease coerced first sex among YMSM. At the same time, they demonstrate that there is not a single risk or demographic profile encompassing all YMSM. Successful programs and policies will need to consider the specific attributes and social environment of YMSM in particular locations in order to effectively address HIV risks.

Recent HIV Testing Among Young Men Who Have Sex with Men in Bangkok and Chiang Mai: HIV Testing and Prevention Strategies Must Be Enhanced in Thailand.

HIV infection among men who have sex with men, particularly in Thai urban settings and among younger cohorts, is escalating. HIV testing and counseling (HTC) are important for prevention and obtaining treatment and care. We examine data from a 2013 survey of males, 15-24 years, reporting past-year sex with a male and living in Bangkok or Chiang Mai. Almost three quarters of young MSM (YMSM) in Bangkok and only 27 % in Chiang Mai had an HIV test in the previous year. Associations for HIV testing varied between cities, although having employment increased the odds of HIV testing for both cities. In Bangkok, family knowledge of same sex attraction and talking to parents/guardians about HIV/AIDS had higher odds of HIV testing. Expanded HTC coverage is needed for YMSM in Chiang Mai. All health centers providing HTC, including those targeting MSM, need to address the specific needs of younger cohorts.

HIVQUAL-T: monitoring and improving HIV clinical care in Thailand, 2002-08.

OBJECTIVE: We report experience of HIVQUAL-T implementation in Thailand. DESIGN: Program evaluation. SETTING: Twelve government hospital clinics. PARTICIPANTS: People living with HIV/AIDS (PLHAs) aged ≥15 years with two or more visits to the hospitals during 2002-08. INTERVENTION: HIVQUAL-T is a process for HIV care performance measurement (PM) and quality improvement (QI). The program includes PM using a sample of eligible cases and establishment of a locally led QI infrastructure and process. PM indicators are based on Thai national HIV care guidelines. QI projects address needs identified through PM; regional workshops facilitate peer learning. Annual benchmarking with repeat measurement is used to monitor progress. MAIN OUTCOME MEASURE: Percentages of eligible cases receiving various HIV services. RESULTS: Across 12 participating hospitals, HIV care caseloads were 4855 in 2002 and 13 887 in 2008. On average, 10-15% of cases were included in the PM sample. Percentages of eligible cases receiving CD4 testing in 2002 and 2008, respectively, were 24 and 99% (P< 0.001); for ARV treatment, 100 and 90% (P= 0.74); for Pneumocystis jiroveci pneumonia prophylaxis, 94 and 93% (P= 0.95); for Papanicolau smear, 0 and 67% (P< 0.001); for syphilis screening, 0 and 94% (P< 0.001); and for tuberculosis screening, 24 and 99% (P< 0.01). PM results contributed to local QI projects and national policy changes. CONCLUSIONS: Hospitals participating in HIVQUAL-T significantly increased their performance in several fundamental areas of HIV care linked to health outcomes for PLHA. This model of PM-QI has improved clinical care and implementation of HIV guidelines in hospital-based clinics in Thailand.

Implementing services for Early Infant Diagnosis (EID) of HIV: a comparative descriptive analysis of national programs in four countries.

BACKGROUND: There is a significant increase in survival for HIV-infected children who have early access to diagnosis and treatment. The goal of this multi-country review was to examine when and where HIV-exposed infants and children are being diagnosed, and whether the EID service is being maximally utilized to improve health outcomes for HIV-exposed children. METHODS: In four countries across Africa and Asia existing documents and data were reviewed and key informant interviews were conducted. EID testing data was gathered from the central testing laboratories and was then complemented by health facility level data extraction which took place using a standardized and validated questionnaire RESULTS: In the four countries reviewed from 2006 to 2009 EID sample volumes rose dramatically to an average of >100 samples per quarter in Cambodia and Senegal, >7,000 samples per quarter in Uganda, and >2,000 samples per quarter in Namibia. Geographic coverage of sites also rapidly expanded to 525 sites in Uganda, 205 in Namibia, 48 in Senegal, and 26 in Cambodia in 2009. However, only a small proportion of testing was done at lower-level health facilities: in Uganda Health Center IIs and IIIs comprised 47% of the EID collection sites, but only 11% of the total tests, and in Namibia 15% of EID sites collected >93% of all samples. In all countries except for Namibia, more than 50% of the EID testing was done after 2 months of age. Few sites had robust referral mechanisms between EID and ART. In a sub-sample of children, we noted significant attrition of infants along the continuum of care post testing. Only 22% (Senegal), 37% (Uganda), and 38% (Cambodia) of infants testing positive by PCR were subsequently initiated onto treatment. In Namibia, which had almost universal EID coverage, more than 70% of PCR-positive infants initiated ART in 2008. CONCLUSIONS: While EID testing has expanded dramatically, a large proportion of PCR- positive infants are initiated on treatment. As EID services continue to scale-up, more programmatic attention and support is needed to retain HIV-exposed infants in care and ensure that those testing positive initiate treatment in a timely manner. Namibia's experience demonstrates that it is feasible for a rural, low-income country to achieve high national coverage of infant testing and treatment.

Uptake of early infant diagnosis in Thailand's national program for preventing mother-to-child HIV transmission and linkage to care, 2008-2011.

INTRODUCTION: Early infant diagnosis (EID) has been a component of Thailand's prevention of mother-to-child HIV transmission (PMTCT) programme since 2007. This study assessed the uptake, EID coverage, proportion of HIV-exposed infants receiving a definitive HIV diagnosis, mother-to-child transmission (MTCT) rates and linkage to HIV care and treatment. METHODS: Infant polymerase chain reaction (PCR) testing data from the National AIDS Program database were analyzed. EID coverage was calculated as the percentage of number of HIV-exposed infants receiving ≥ 1 HIV PCR test divided by the number of HIV-exposed infants estimated from HIV prevalence and live-birth registry data. Definitive HIV diagnosis was defined as having two concordant PCR results. MTCT rates were calculated based on infants tested with PCR and applied as a best-case scenario, and a sensitivity analysis was used to adjust these rates in average and worst scenarios. We defined linkage to HIV care as infants with at least one PCR-positive test who were registered with Thailand's National AIDS Program. Chi-squared tests for linear trend were used to analyze changes in programme coverage. RESULTS: For 2008 to 2011, the average EID coverage rate increased from 54 to 76% (p < 0.001), with 65% coverage (13,761/21,099) overall. The number of hospitals submitting EID samples increased from 458 to 645, and the percentage of community hospitals submitting samples increased from 75 to 78% (p = 0.044). A definitive HIV diagnosis was made for 10,854 (79%) infants during this period. The adjusted MTCT rates had significantly decreasing trends in all scenarios. Overall, an estimated 53% (429/804) of HIV-infected infants were identified through the EID programme, and 80% (341/429) of infants testing positive were linked to care. The overall rate of antiretroviral treatment (ART) initiation within one year of age was 37% (157/429), with an increasing trend from 28 to 52% (p < 0.001). CONCLUSIONS: EID coverage increased and MTCT rates decreased during 2008 to 2011; however, about half of HIV-infected infants still did not receive EID. Most HIV-infected infants were linked to care but less than half initiated ART within one year of age. Active follow-up of HIV-exposed infants to increase early detection of HIV infection and early initiation of ART should be more widely implemented.

Global progress in PMTCT and paediatric HIV care and treatment in low- and middle-income countries in 2004-2005.

A growing number of countries are moving to scale up interventions for prevention of mother-to-child transmission (PMTCT) of HIV in maternal and child health services. Similarly, many are working to improve access to paediatric HIV treatment. This paper reviews national programme data for 2004-2005 from low- and middle-income countries to track progress in these programmes. The attainment of the UNGASS target of reducing HIV infections by 50% by 2010 necessitates that 80% of all pregnant women accessing antenatal care receive PMTCT services. In 2005, only seven of the 71 countries were on track to meet this target. However PMTCT coverage increased from 7% in 2004 (58 countries) to 11% in 2005 (71 countries). In 2005, 8% of all infants born to HIV positive mothers received antiretroviral prophylaxis for PMTCT, up from 5% in 2004, though only 4% received cotrimoxazole. 11% of HIV positive children in need received antiretroviral treatment in 2005. In 31 countries that had data, 28% of women who received an antiretroviral for PMTCT also reported receiving antiretroviral treatment for their own health. Achieving the UNGASS target is possible but will require substantial investments and commitment to strengthen maternal and child health services, the health workforce and health systems to move from pilot projects to a decentralised, integrated approach.

What strategies to boost production of affordable fixed-dose anti-retroviral drug combinations for children in the developing world?

BACKGROUND: No more than 8% of HIV positive children needing treatment in low- and middle-income countries have access to antiretroviral drugs (ARVs). Children presently account for about 4% of all treated patients, while for equitable access they should make up at least 13%. AIMS: This study explores key issues, implications and interaction dynamics to boost production of easy-to-use and affordable fixed-dose combination (FDC) ARVs for children in the developing world. Potentials for equitable solutions are examined including priority steps and actions, appropriate treatment options and reliable forecasting methods for paediatric ARVs, as well as combination incentives to generic companies against market unattractiveness and enforced intellectual property (IP) rights. Moreover, implementation strategies to enhance the development and production of affordable ARV paediatric formulations and appropriate supply systems to ensure availability are investigated. RESULTS: The current market for FDC paediatric ARVs is already substantial and will only grow with improved and scaled up diagnosis and monitoring of children. This provides an argument for immediate increase of production and development of FDC ARVs for children. These formulations must be low cost and included in the list of Essential Medicines to avoid children continuing to lag behind in access to treatment. Access-oriented, long-term drug policy strategies with the ability to pass muster of governments, the UN system, as well as generic and research-based enterprises are needed to let children gain expanded and sustained access to FDC ARVs. Under the requirements listed above, IP-bound Voluntary License (VL) flexibilities do appear, if coupled with substantial combination incentives to generic firms, as a fitting tool into the needs. Policies must consider enhancing human resource capacity in the area of caregivers and social and health workers aiming to spread correct information and awareness on effectiveness and rationale of FDC ARVs for children. Policies should urge that paediatric ARV treatment programmes entwine with extant interventions on prevention of mother-to-child transmission, as well as with HIV treatment initiatives focused on mothers and household members. Policies, again, should consider centralising functions and pooling resources to help overcome drug supply barriers. WHO's brokering role in VL-based agreements between wealthy and developing country industries, as well as its technical guidance in setting international standards should not be waived while looking for sustained access to optimised ARV treatments for children. Strategies discussed in this paper, while taking unavoidability of marketing and profit rules into account, look closely into the trade and drug policy directions of China and India according to frontier crossing implications of their IP management trends as well as their multi-faceted penetration strategies of both the wealthy and under-served markets the world over.