Community-based model for the delivery of antiretroviral therapy in Cambodia: a quasi-experimental study protocol.

BACKGROUND: Multi-month dispensing (MMD) is the mainstay mechanism for clinically stable people living with HIV in Cambodia to refill antiretroviral therapy (ART) every 3-6 months. However, less frequent ART dispensing through the community-based ART delivery (CAD) model could further reduce the clients' and health facilities' burden. While community-based services have been recognized as an integral component of HIV response in Cambodia, their role and effectiveness in ART delivery have yet to be systematically assessed. This study aims to evaluate the CAD model's effectiveness on the continuum of care and treatment outcomes for stable people living with HIV in Cambodia. METHODS: We will conduct this quasi-experimental study in 20 ART clinics across the capital city and nine provinces between May 2021 and April 2023. Study sites were purposively selected based on the availability of implementing partners, the number of people living with HIV each clinic serves, and the accessibility of the clinics. In the intervention arm, approximately 2000 stable people living with HIV will receive ART and services from the CAD model. Another 2000 stable people living with HIV in the control arm will receive MMD-a standard care model for stable people living with HIV. The primary outcomes will be retention in care, viral load suppression, and adherence to ART. The secondary endpoints will include health providers' work burden, the model's cost-effectiveness, quality of life, mental health, social support, stigma, and discrimination. We will compare the outcome indicators within each arm at baseline, midline, and endline using descriptive and inferential statistics. We will evaluate the differences between the intervention and control arms using the difference-in-differences method. We will perform economic evaluations to determine if the intervention is cost-effective. DISCUSSION: This study will build the evidence base for future implementation and scale-up of CAD model in Cambodia and other similar settings. Furthermore, it will strengthen engagements with community stakeholders and further improve community mobilization, a vital pillar of the Cambodian HIV response. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04766710 . Registered 23 February 2021, Version 1.

Challenges and outcomes of implementing a national syphilis follow-up system for the elimination of congenital syphilis in Cambodia: a mixed-methods study.

OBJECTIVES: We aimed to describe the challenges and outcomes of implementing a national syphilis follow-up system to improve syphilis management in maternal and child health (MCH) services in Cambodia. DESIGN: Operational study; quantitative cohort data and cross sectional qualitative data. SETTING: Public health facilities at national level and in four provinces with high syphilis prevalence in Cambodia. PARTICIPANTS: Pregnant women screened for syphilis; MCH health care providers and managers. METHODS: We conducted an operational research using syphilis screening and treatment data collected from a national follow-up system (cohort data) and reported in the health management information system (HMIS) between 2019 and 2020. We also conducted indepth interviews with 16 pregnant women and focus group discussions with 37 healthcare providers and managers. Descriptive statistics and thematic content analysis were used. OUTCOME MEASURES: Syphilis testing and treatment results and perceptions regarding these services. RESULTS: A total of 470 pregnant women who tested positive in rapid syphilis testing were recorded in the national syphilis follow-up system in 2019-2020. Of these, 71% (332 of 470) received a rapid plasma reagin (RPR) test and 95% (n=315) tested positive; 78% (246 of 315) received any syphilis treatment and only 28% (88 of 315) were treated adequately with benzathine penicillin G (BPG). Data from four provinces with high syphilis prevalence (more closely monitored) showed higher testing and treatment rates than at the national level. HMIS aggregated data reported a higher number of pregnant women screened and treated for syphilis than the follow-up system during the same period. Barriers to syphilis testing and treatment included late antenatal care, long distance to RPR testing and treatment, partners' lack of support to reach the health facility, BPG stockout and poor adherence to oral treatment in the absence of BPG. Providers and managers reported a lack of communication across services, insufficient skills to treat infants and absence of clear guidance regarding the revised follow-up system. Study findings contributed to changes in operating procedures nationwide to facilitate access to syphilis testing and adequate treatment and a systematic follow-up of pregnant women and exposed infants. CONCLUSIONS: Study results contributed to informing improvements to syphilis management in MCH services in Cambodia.

Unhygienic stool-disposal practices among mothers of children under five in Cambodia: Evidence from a demographic and health survey.

BACKGROUND: Unhygienic disposal of children's stools affects children's health in terms of their susceptibility to many diseases. However, there are no existing studies into the impact of unhygienic stool disposal in Cambodia. Therefore, this study aimed to identify factors associated with the unhygienic disposal of children's stools among children under the age of five in Cambodia. METHODS: An analytical cross-sectional study was conducted using data from the Cambodia Demographic and Health Survey (CDHS) 2014. A multivariable binary logistic regression was conducted using Stata to analyze factors associated with the unhygienic disposal of children's stools. RESULTS: Overall, the prevalence of practicing unhygienic disposal of children's stools was 29.27% (95%CI: 27.51%- 31.09%). Factors statistically associated with this practice were: living in the Central Plain, Plateau and Mountains, Coastal and Sea regions (AOR = 1.65; 95% CI: 1.33-2.04), (AOR = 2.53; 95% CI: 1.98-3.24) and (AOR = 4.16; 95% CI: 3.15-5.48) respectively, poor household wealth (AOR = 1.58; 95% CI: 1.31-1.91), the mother having no education (AOR = 1.45; 95% CI: 1.14-1.85), a high number of children aged under five (AOR = 1.11; 95% CI: 1.03-1.20), being in the "other" religious category (AOR = 1.77; 95% CI: 1.25-2.51), living in a household with unimproved toilet facilities (AOR = 1.22; 95% CI: 1.11-1.34), living in a household with inadequate hygiene (AOR = 1.33; 95% CI: 1.12-1.59), and the household not being visited by a family planning worker in the last year (AOR = 1.45; 95% CI: 1.19-1.77). However, an increase in the child's age by even a month had significant negative associations with unhygienic practice (AOR = 0.65; 95% CI: 0.60-0.70), even when controlling for other covariates. CONCLUSION: Almost one third of the mothers do not practice hygienic disposal of children's stools in Cambodia. Unhygienic practices were more prevalent in certain regions, and were also associated with low wealth, lack of education, an increase in the number of children under five in the household, religion, lack of sanitation and access to healthcare professionals. Conversely, the child's age was found to be positively associated with the hygienic disposal of children's stools.