title: HIV care in Yangon, Myanmar; successes, challenges and implications for policy.
abstract: BACKGROUND
  Approximately 0.8% of adults aged 18-49 in Myanmar are seropositive for Human Immunodeficiency Virus (HIV). Identifying the demographic, epidemiological and clinical characteristics of people living with HIV (PLHIV) is essential to inform optimal management strategies in this resource-limited country.
  
  
  METHODS
  To create a "snapshot" of the PLHIV seeking anti-retroviral therapy (ART) in Myanmar, data were collected from the registration cards of all patients who had been prescribed ART at two large referral hospitals in Yangon, prior to March 18, 2016.
  
  
  CONCLUSIONS
  Anti-retroviral therapy had been prescribed to 2643 patients at the two hospitals. The patients' median [interquartile range (IQR)] age was 37 (31-44) years; 1494 (57%) were male. At registration, injecting drug use was reported in 22 (0.8%), male-to-male sexual contact in eleven (0.4%) and female sex work in eleven (0.4%), suggesting that patients under-report these risk behaviours, that health care workers are uncomfortable enquiring about them or that the two hospitals are under-servicing these populations. All three explanations appear likely. Most patients were symptomatic at registration with 2027 (77%) presenting with WHO stage 3 or 4 disease. In the 2442 patients with a CD4+ T cell count recorded at registration, the median (IQR) count was 169 (59-328) cells/mm3. After a median (IQR) duration of 359 (185-540) days of ART, 151 (5.7%) patients had died, 111 (4.2%) patients had been lost to follow-up, while 2381 were alive on ART. Tuberculosis (TB) co-infection was common: 1083 (41%) were already on anti-TB treatment at registration, while a further 41 (1.7%) required anti-TB treatment during follow-up. Only 21 (0.8%) patients were prescribed isoniazid prophylaxis therapy (IPT); one of these was lost to follow-up, but none of the remaining 20 patients died or required anti-TB treatment during a median (IQR) follow-up of 275 (235-293) days.
  
  
  CONCLUSIONS
  People living with HIV in Yangon, Myanmar are generally presenting late in their disease course, increasing their risk of death, disease and transmitting the virus. A centralised model of ART prescription struggles to deliver care to the key affected populations. TB co-infection is very common in Myanmar, but despite the proven efficacy of IPT, it is frequently not prescribed.
authors.affiliation: Department of Medicine, University of Medicine 2, Yangon, Myanmar.
authors.forename: Ne Myo
authors.initials: NM
authors.lastname: Aung
authors.affiliation: Department of Medicine, University of Medicine 2, Yangon, Myanmar.|Menzies School of Health Research, Darwin, Australia.|The Kirby Institute, Sydney, Australia.
authors.forename: Josh
authors.initials: J
authors.lastname: Hanson
authors.affiliation: Department of Medical Care, Ministry of Health, Nay Pyi Taw, Myanmar.
authors.forename: Tint Tint
authors.initials: TT
authors.lastname: Kyi
authors.affiliation: Insein General Hospital, Yangon, Myanmar.
authors.forename: Zaw Win
authors.initials: ZW
authors.lastname: Htet
authors.affiliation: The Kirby Institute, Sydney, Australia.
authors.forename: David A
authors.initials: DA
authors.lastname: Cooper
authors.affiliation: The Kirby Institute, Sydney, Australia.|University of Adelaide, Adelaide, Australia.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Boyd
authors.affiliation: Department of Medicine, University of Medicine 2, Yangon, Myanmar.
authors.forename: Mar Mar
authors.initials: MM
authors.lastname: Kyi
authors.affiliation: Department of Medicine, University of Medicine 2, Yangon, Myanmar.
authors.forename: Htin Aung
authors.initials: HA
authors.lastname: Saw
mesh_terms: D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D000995:Antitubercular Agents / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D015496:CD4-Positive T-Lymphocytes / Q000276:immunology; D060085:Coinfection / Q000188:drug therapy / Q000821:virology; D005260:Female; D006678:HIV / Q000302:isolation & purification*; D015658:HIV Infections / Q000453:epidemiology / Q000276:immunology / Q000628:therapy* / Q000635:transmission; D006801:Humans; D007538:Isoniazid / Q000627:therapeutic use; D059012:Lost to Follow-Up; D008297:Male; D008875:Middle Aged; D002052:Myanmar / Q000453:epidemiology; D012307:Risk Factors; D011477:Sex Work; D012725:Sexual Behavior; D019966:Substance-Related Disorders / Q000821:virology; D014376:Tuberculosis / Q000188:drug therapy / Q000821:virology
chemical_list: D000995:Antitubercular Agents; D007538:Isoniazid
keywords: Anti-retroviral therapy; HIV; Isoniazid prophylaxis therapy; Key affected populations; Myanmar; Resource limited settings; Tuberculosis