UCLA

Decentralization of HIV testing and the cascade of HIV treatment for mothers and infants in Myanmar

by

San Hone

Doctor of Philosophy in Epidemiology

University of California, Los Angeles, 2017

Professor Roger Detels, Chair

Background: Joining hands with the global community, Myanmar has committed to move towards the elimination of mother to child transmission of HIV. The 1.5-decade Prevention of Mother to Child Transmission of HIV (PMCT) program in Myanmar introduced point-of-care testing in 2013 for all Antenatal Care (ANC) attendees as an approach towards community based interventions. This study assessed progress along the cascade of PMCT services and also the challenges faced by service providers during the initial phase of implementing the new intervention.

Methods: A serial cross sectional study was employed to assess progress of HIV testing uptake from 2013 to 2015 in 228 townships. The progress for urban and rural health center groups was assessed in a sample of 23 townships where the decentralized testing activity was initiated in 2013. A cohort study was used to assess the factors associated with compliance to prescribed medication among pregnant women living with HIV and their HIV exposed infants.

Results: During the study period, the median HIV testing coverage among ANC attendees increased from 20 to 90%, increasing proportions being tested at their first ANC visit and receiving their results on the same day. Travel times and costs, and heavy workloads of primary care providers were identified as obstacles for ANC attendees to receive all essential services in a single ANC visit. Structural gaps such as inadequate logistic supplies and limited availability of services for diagnosis and treatment of HIV exposed infants at primary care level were also identified as challenges that hindered the progress of program implementation. Fear of stigma and discrimination remain as major challenges for successful implementation of the PMCT program in Myanmar.

Conclusions: Urgent remedial action is required to improve logistical delivery of supplies to health care centres, and to identify and establish proper linkage for early diagnosis and treatment of HIV-exposed infants. There is also a need to recruit and train local volunteers as alternative health care cadres. Continuous mentoring from supervisors and quality control measures for HIV testing should be implemented. The program should identify appropriate strategies for addressing stigma and discrimination against pregnant women and their families living with HIV.

Key words: Elimination of mother to child transmission of HIV; Prevention of mother to child transmission of HIV; community based intervention; decentralized HIV testing; primary care providers