High levels of viral repression, malnutrition and second-line ART use in adolescents living with HIV: a mixed methods study from Myanmar.
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SUBMITTER: Murray J
PROVIDER: S-EPMC7085147 | biostudies-literature | 2020 Mar
REPOSITORIES: biostudies-literature
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High levels of viral repression, malnutrition and second-line ART use in adolescents living with HIV: a mixed methods study from Myanmar.
Murray Jillian J Whitehouse Katherine K Ousley Janet J Bermudez Elkin E Soe Theint Thida TT Hilbig Adelene A Soe Kyi Pyar KP Mon Phyu Ei PE Tun Kyaw Tint KT Ei Win Le Shwe Sin WLSS Cyr Joanne J Deglise Carole C Ciglenecki Iza I
BMC infectious diseases 20200320 1
<h4>Background</h4>Adolescents living with HIV/AIDS (ALHIV) are a particularly vulnerable but often overlooked group in the HIV response despite additional disease management challenges.<h4>Methods</h4>All ALHIV (10-19 years), on ART for ≥6 months, presenting to care at a Médecins Sans Frontières (MSF) clinic in Myanmar from January-April 2016 were eligible for the quantitative study component (clinical history, medical examination, laboratory investigation). A subset of these respondents were i ...[more]
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Project description:BackgroundThe number of people living with HIV on antiretroviral treatment (ART) in Myanmar has been increasing rapidly in recent years. This study aimed to estimate rates of virological failure on first-line ART and switching to second-line ART due to treatment failure at the Integrated HIV Care program (IHC).MethodsRoutinely collected data of all adolescent and adult patients living with HIV who were initiated on first-line ART at IHC between 2005 and 2015 were retrospectively analyzed. The cumulative hazard of virological failure on first-line ART and switching to second-line ART were estimated. Crude and adjusted hazard ratios were calculated using the Cox regression model to identify risk factors associated with the two outcomes.ResultsOf 23,248 adults and adolescents, 7,888 (34%) were tested for HIV viral load. The incidence rate of virological failure among those tested was 3.2 per 100 person-years follow-up and the rate of switching to second-line ART among all patients was 1.4 per 100 person-years follow-up. Factors associated with virological failure included: being adolescent; being lost to follow-up at least once; having WHO stage 3 and 4 at ART initiation; and having taken first-line ART elsewhere before coming to IHC. Of the 1032 patients who met virological failure criteria, 762 (74%) switched to second-line ART.ConclusionsWe found high rates of virological failure among one third of patients in the cohort who were tested for viral load. Of those failing virologically on first-line ART, about one quarter were not switched to second-line ART. Routine viral load monitoring, especially for those identified as having a higher risk of treatment failure, should be considered in this setting to detect all patients failing on first-line ART. Strategies also need to be put in place to prevent treatment failure and to treat more of those patients who are actually failing.
| S-EPMC5300167 | biostudies-literature
Project description:BackgroundMalnutrition (specifically undernutrition) in older, community-dwelling adults reduces well-being and predisposes to disease. Implementation of screen-and-treat policies could help to systematically detect and treat at-risk and malnourished patients. We aimed to identify barriers and facilitators to implementing malnutrition screen and treat policies in primary/community care, which barriers have been addressed and which facilitators have been successfully incorporated in existing interventions.MethodA data-base search was conducted using MEDLINE, Embase, PsycINFO, DARE, CINAHL, Cochrane Central and Cochrane Database of Systematic Reviews from 2012 to June 2016 to identify relevant qualitative and quantitative literature from primary/community care. Studies were included if participants were older, community-dwelling adults (65+) or healthcare professionals who would screen and treat such patients. Barriers and facilitators were extracted and mapped onto intervention features to determine whether these had addressed barriers.ResultsOf a total of 2182 studies identified, 21 were included (6 qualitative, 12 quantitative and 3 mixed; 14 studies targeting patients and 7 targeting healthcare professionals). Facilitators addressing a wide range of barriers were identified, yet few interventions addressed psychosocial barriers to screen-and-treat policies for patients, such as loneliness and reluctance to be screened, or healthcare professionals' reservations about prescribing oral nutritional supplements.ConclusionThe studies reviewed identified several barriers and facilitators and addressed some of these in intervention design, although a prominent gap appeared to be psychosocial barriers. No single included study addressed all barriers or made use of all facilitators, although this appears to be possible. Interventions aiming to implement screen-and-treat approaches to malnutrition in primary care should consider barriers that both patients and healthcare professionals may face.Review registrationsPROSPERO: CRD42017071398 . The review protocol was registered retrospectively.
| S-EPMC6631945 | biostudies-literature
Project description:ObjectivesAdherence clubs (AC) offer patient-centred access to antiretroviral therapy (ART) while reducing the burden on health facilities. AC were implemented in a health centre in Mozambique specialising in patients with a history of HIV treatment failure. We explored the impact of AC on retention in care and VL suppression of these patients.MethodsWe performed a retrospective analysis of patients enrolled in AC receiving second- or third-line ART. The Kaplan-Meier estimates were used to analyse retention in care in health facility, retention in AC and viral load (VL) suppression (VL < 1000 copies/mL). Predictors of attrition and VL rebound (VL ≥ 1000 copies/mL) were assessed using multivariable proportional hazards regression.ResultsThe analysed cohort contained 699 patients, median age 40 years [IQR: 35-47], 428 (61%) female and 97% second-line ART. Overall, 9 (1.3%) patients died, and 10 (1.4%) were lost to follow-up. Retention in care at months 12 and 24 was 98.9% (95% CI: 98.2-99.7) and 96.4% (95% CI: 94.6-98.2), respectively. Concurrently, 85.8% (95% CI: 83.1-88.2) and 80.9% (95% CI: 77.8-84.1) of patients maintained VL suppression. No association between predictors and all-cause attrition or VL rebound was detected. Among 90 patients attending AC and simultaneously having VL rebound, 64 (71.1%) achieved VL resuppression, 10 (11.1%) did not resuppress, and 14 (15.6%) had no subsequent VL result.ConclusionImplementation of AC in Mozambique was successful and demonstrated that patients with a history of HIV treatment failure can be successfully retained in care and have high VL suppression rate when enrolled in AC. Expansion of the AC model in Mozambique could improve overall retention in care and VL suppression while reducing workload in health facilities.
| S-EPMC7756444 | biostudies-literature
Project description:There are limited data from resource-limited settings on antiretroviral resistance mutations that develop in patients failing second-line PI ART.We performed a cross-sectional virological assessment of adults on second-line ART for ?6 months between November 2006 and December 2011, followed by a prospective follow-up over 2 years of patients with virological failure (VF) at the Hospital for Tropical Diseases, Vietnam. VF was defined as HIV RNA concentrations ?1000 copies/mL. Resistance mutations were identified by population sequencing of the pol gene and interpreted using the 2014 IAS-USA mutation list and the Stanford algorithm. Logistic regression modelling was performed to identify predictors of VF.Two hundred and thirty-one patients were enrolled in the study. The median age was 32 years; 81.0% were male, 95.7% were on a lopinavir/ritonavir-containing regimen and 22 (9.5%) patients had VF. Of the patients with VF, 14 (64%) carried at least one major protease mutation [median: 2 (IQR: 1-3)]; 13 (59%) had multiple protease mutations conferring intermediate- to high-level resistance to lopinavir/ritonavir. Mutations conferring cross-resistance to etravirine, rilpivirine, tipranavir and darunavir were identified in 55%, 55%, 45% and 27% of patients, respectively. Higher viral load, adherence <95% and previous indinavir use were independent predictors of VF. The 2 year outcomes of the patients maintained on lopinavir/ritonavir included: death, 7 (35%); worsening virological/immunological control, 6 (30%); and virological re-suppression, 5 (25%). Two patients were switched to raltegravir and darunavir/ritonavir with good HIV control.High-prevalence PI resistance was associated with previous indinavir exposure. Darunavir plus an integrase inhibitor and lamivudine might be a promising third-line regimen in Vietnam.
| S-EPMC4743698 | biostudies-literature
Project description:OBJECTIVE:To examine consumers' perceptions of their food environments, their food consumption patterns and preferences, and to better understand the attributes of foods that are available within food environments in Myanmar. DESIGN:An exploratory mixed-methods study using a combination of focus group discussions, market and consumer surveys. SETTING:Four study settings in Myanmar were included: an upper-income township of Yangon; a lower-income township of Yangon; a middle-income township in the southern Myanmar town of Dawei; and a lower-income village in the country's dry zone of Magway.ParticipantsThirty-two women participated in the focus groups discussions, twenty market surveys were conducted and 362 consumers (both men and women) completed food consumption surveys. RESULTS:Focus group participants indicated that the availability of a diverse range of foods had increased over time, while the quality of foods had decreased. Health was seen primarily through the lens of food safety and there was an overall lack of knowledge about which foods were more or less healthy. Consumers preferred fruits, vegetables and red meat compared with highly processed snack foods/beverages. Although consumers reported low intakes of highly processed snack foods, Burmese street food was consumed in high quantities. The market surveys suggested that fresh, minimally processed and highly processed foods were available at all markets across the study settings. CONCLUSIONS:Consumers are exposed to a variety of foods, of varying quality, within their food environments in Myanmar. Interventions aimed at increasing consumer knowledge regarding healthy diets and improving food safety are needed.
| S-EPMC6536824 | biostudies-other
Project description:There is no published evidence on contact investigation among multidrug-resistant tuberculosis (MDR-TB) patients from Myanmar. We describe the cascade of contact investigation conducted in 27 townships of Myanmar from January 2018 to June 2019 and its implementation challenges. This was a mixed-methods study involving quantitative (cohort analysis of programme data) and qualitative components (thematic analysis of interviews of 8 contacts and 13 health care providers). There were 556 MDR-TB patients and 1908 contacts, of whom 1134 (59%) reached the health centres for screening (chest radiography and symptoms). Of the latter, 344 (30%) had presumptive TB and of them, 186 (54%) were investigated (sputum microscopy or Xpert MTB/RIF®). A total of 27 TB patients were diagnosed (six bacteriologically-confirmed including five with rifampicin resistance). The key reasons for not reaching township TB centres included lack of knowledge and lack of risk perception owing to wrong beliefs among contacts, financial constraints related to loss of wages and transportation charges, and inconvenient clinic hours. The reasons for not being investigated included inability to produce sputum, health care providers being unaware of or not agreeing to the investigation protocol, fixed clinic days and times, and charges for investigation. The National Tuberculosis Programme needs to note these findings and take necessary action.
| S-EPMC7157597 | biostudies-literature
Project description: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.
| S-EPMC6924823 | biostudies-literature
Project description:IntroductionSecond opinion programmes aim to support the patients' decision-making process and to avoid treatments that are unnecessary from a medical perspective. The German second opinion directive, introduced in December 2018, constitutes a new legal framework in statutory health insurance for seeking second opinions for elective procedures and so far includes tonsillectomy, tonsillotomy, hysterectomy and shoulder arthroscopy. The directive mandates physicians who recommend one of the above-mentioned surgeries to inform their patients of their legal right to visit a certified second opinion provider. Since second opinion programmes are a fairly recent phenomenon in Germany, no comprehensive data are yet available on the degree of implementation, users, potential barriers and their effectiveness. We aim to examine the characteristics and the use of second opinion programmes as well as the needs and wishes from the perspective of (potential) users in Germany, with focus on the decision-making process, the patient-physician relationship and the motivation to seek a second opinion, as well as the role of health literacy.Methods and analysisSix substudies will include the following stakeholders: (1 and 2) patients with one of the four surgery-indications covered by the directive, (3) patients who electively sought an online-based second opinion, (4) patients with oncological diseases, (5) the general population and (6) medical specialists. A mixed-methods approach will be used, including questionnaires, interviews and focus groups. The data will be evaluated using quantitative descriptive analysis and qualitative content analysis. The integration of the results will take place in the form of a triangulation protocol.Ethics and disseminationThe study protocol was approved by the Ethics Committee of the Brandenburg Medical School. The findings will be published in peer-reviewed journals and presented at scientific conferences.
| S-EPMC7878127 | biostudies-literature
Project description:OBJECTIVES:Tenofovir (TDF) is increasingly used in second-line antiretroviral treatment (ART) in sub-Saharan Africa. We compared outcomes of second-line ART containing and not containing TDF in cohort studies from Zambia and the Republic of South Africa (RSA). METHODS:Patients aged 16 years and older starting protease-inhibitor-based second-line ART in Zambia (1 cohort) and RSA (5 cohorts) were included. We compared mortality, immunological failure (all cohorts), and virological failure (RSA only) between patients receiving and not receiving TDF. Competing risk models and Cox models adjusted for age, sex, CD4 count, time on first-line ART, and calendar year were used to analyze mortality and treatment failure, respectively. Hazard ratios (HRs) were combined in fixed-effects meta-analysis. FINDINGS:1687 patients from Zambia and 1556 patients from RSA, including 1350 (80.0%) and 206 (13.2%) patients starting TDF, were followed over 4471 person-years. Patients on TDF were more likely to have started second-line ART in recent years and had slightly higher baseline CD4 counts than patients not on TDF. Overall, 127 patients died, 532 were lost to follow-up, and 240 patients developed immunological failure. In RSA, 94 patients had virologic failure. Combined HRs comparing TDF with other regimens were 0.60 (95% confidence interval [CI]: 0.41 to 0.87) for immunologic failure and 0.63 (0.38-1.05) for mortality. The HR for virologic failure in RSA was 0.28 (0.09-0.90). CONCLUSIONS:In this observational study, patients on TDF-containing second-line ART were less likely to develop treatment failure than patients on other regimens. TDF seems to be an effective component of second-line ART in southern Africa.
| S-EPMC3432418 | biostudies-literature
Project description:BACKGROUND:Research in health communication frequently views it as an information dissemination strategy, thus neglecting the intricacies involved in communicating a sensitive topic such as menstruation. The social patterning in menstrual communication, a taboo in India, and its consequent health-effects on adolescents are under-studied. METHODS:We studied the social determinants of menstrual communication influencing menstrual- health through semi-structured interviews of 21 boys and girls each, 12 key-respondent interviews, followed by a cross-sectional survey of 1421 adolescents from Nashik district, India. We thematically analysed the qualitative data and fit multivariable logistic regression to model risk ratios. FINDINGS:We found social disparities in adolescents' experiences of communication taboo regarding menstruation. While boys curbed their curiosity about the topic, girls too faced resistance to their experience-sharing and treatment-seeking for menstrual illnesses. The inequality in menstruation-related communication was evident as more boys than girls faced avoidance to their questions [IRR at 95%CI: 2.75 (2.04, 3.71)]], and fewer tribal than rural girls were communicated severe taboos (OR at 95% CI: 0.18 (0.09, 0.36))]. Girls who had been communicated severe (versus no/mild) taboos reported greater stress about menstrual staining (IRR at 95% CI: 1.31 (1.10, 1.57)], emphasizing the health consequences of such communication inequalities. CONCLUSIONS:Our study highlights the need to address gender and setting-specific communication experiences of adolescents in India, a patriarchal society. The inequality in communication needs attention as it creates unequal patterns in Indian adolescents' menstrual health and experiences, which may manifest as inequities in reproductive health-related outcomes even in their adult-lives.
| S-EPMC6797238 | biostudies-literature