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Aung T.,Population Services International Myanmar | McFarland W.,University of California at San Francisco | Paw E.,Population Services International Myanmar | Hetherington J.,Population Services International Myanmar
AIDS and Behavior | Year: 2013

To estimate risk behavior and HIV program reach among men who have sex with men (MSM) in Myanmar, we conducted cross-sectional surveys in four cities (Yangon, Mandalay, Pathein, Monywa) using respondent-driven sampling (RDS). Prevention response indicators across the cities ranged from 56 to 70 % testing for HIV and receiving results last year, 89-100 % identifying ways of preventing transmission, 50-95 % rejecting misconceptions about HIV, and 82-94 % using a condom at last anal sex. MSM in smaller cities had similar or higher use of programs compared those in larger cities. MSM classified as Ah Chawk Ma (broadly feminine gender presentation) reported having more sex partners, less consistent condom use, and more frequent history of sexually transmitted infections compared to those described as Tha Ngwe (broadly masculine gender presentation). Our behavioral survey data help advocate for appropriate services and form a baseline to gauge future impact of the HIV response for this marginalized population. © 2013 Springer Science+Business Media, LLC.


Khin H.S.S.,Population Services International Myanmar | Aung T.,Population Services International Myanmar | White C.,Bill and Melinda Gates Foundation
Malaria Journal | Year: 2016

Background: In 2012 the Artemisinin Monotherapy Therapy Replacement (AMTR) project was implemented in Eastern Myanmar to increase access to subsidized, quality-assured artemisinin combination therapy (ACT) and to remove oral artemisinin monotherapy (AMT) from the private sector. The aim of this paper is to examine changes over time in the private sector anti-malarial landscape and to illustrate the value of complementary interventions in the context of a national ACT subsidy. Methods: Three rounds of cross-sectional malaria medicine outlet surveys were conducted, in 2012, 2013 and 2014. Project intervention areas were selected from the Myanmar Artemisinin Resistance Containment (MARC) area. Provider detailing was implemented in these selected areas. Comparison areas were selected outside of this catchment area, from townships in close proximity to the MARC framework. Within each domain, multi-staged sampling was used to select areas for the survey. Outlets with the potential to sell or distribute anti-malarials in the private sector were screened for eligibility. Results: The total number of outlets approached for an interview was as follows in the intervention and comparison areas, respectively: 2012, N = 2046 and 1612; 2013, N = 1636 and 1884; 2014, N = 2939 and 2941. The percentage of pharmacies, general retailers and mobile providers (classed as 'priority outlets') with oral AMT in stock on the day of the survey decreased over time in the intervention areas (2012 = 68 %; 2013 = 48 %; 2014 = 10 %). Conversely, quality-assured ACT availability increased among these outlets (2012 = 4 %; 2013 = 62 %; 2014 = 79 %). Relative oral AMT market share among priority outlets also decreased over time (2012 = 44 %; 2013 = 18 %; 2014 = 14 %), while market share of quality-assured ACT increased (2012 = 3 %; 2013 = 59 %; 2014 = 51 %). Among priority outlets in the comparison area, similar trends were observed, though changes over time were less substantial compared to the intervention area. Other outlet types (community health workers and health facilities) performed relatively well over time though modest improvements were also observed. Conclusion: The findings point to the successful design and implementation of a strategy to rapidly remove oral AMT from pharmacies, general retailers and mobile providers and to replace its use with quality-assured ACT. The evidence also highlights the importance of supporting interventions in the context of a high-level subsidy. © 2016 Khin et al.


Aung T.,Population Services International Myanmar | Thein S.T.,Population Services International Myanmar | McFarland W.,University of California at San Francisco
AIDS and Behavior | Year: 2015

Serosorting (i.e., choosing partners of the same HIV serostatus to reduce the risk of transmission with unprotected sex) and other forms of seroadaptation (i.e., engaging in diverse behaviors according to a hierarchy of risk by type of sex and partner serostatus) are phenomena widely described for men who have sex with men (MSM) in the developed world. We assessed seroadaptive behaviors among MSM surveyed in Yangon, Myanmar in 2013–2014. Among HIV-negative MSM, 43.1 % engaged in some form seroadaptation including serosorting (21.8 %), using condoms with potentially serodiscordant anal sex (19.3 %), and seropositioning (1.7 %). Among HIV-positive MSM, 3.5 % engaged in serosorting, 36.0 % in using condoms with potentially serodiscordant anal sex, 7.0 % in seropositioning, and 46.5 % in any form of seroadaptation. For HIV-negative and HIV-positive MSM, seroadaptation was more common than consistent condom use (38.0 and 26.7 %, respectively). MSM in Myanmar are engaging in seroadaptive behaviors in magnitude and ways similar to MSM in industrialized countries. © 2015 Springer Science+Business Media New York


Aung T.,Population Services International Myanmar | Wei C.,University of California at San Francisco | McFarland W.,University of California at San Francisco | Aung Y.K.,Population Services International Myanmar | Khin H.S.S.,Population Services International Myanmar
PLoS ONE | Year: 2016

Background Myanmar has the highest burden of malaria in the Greater Mekong. However, there is limited information on ownership and use of insecticide-treated nets (ITNs) in areas of Myanmar most severely affected by malaria. We describe ownership and use of ITNs among people in the malaria-endemic eastern parts of Myanmar and factors associated with ITN use. Methods A cross-sectional household survey using a multi-stage cluster design was conducted in malaria-endemic townships in eastern Myanmar during the high malaria season of August to September, 2014. An effective ITN was defined as 1) a long-lasting insecticide-treated net obtained within the past three years, or 2) any net treated with insecticide within the past year. Results In 4,679 households, the average number of ITNs per household was higher in rural compared to urban areas (0.6 vs. 0.4, p <0.001) as well as the proportionof households owning at least one ITN (27.3% vs. 15.5%, p<0.001). The proportion of households in which all members slept under an ITN was also higher in rural compared to urban areas (15.3% vs 6.9%, p<0.001). In multivariate analysis, rural households (adjusted odds ratio [aOR] 1.78, 95% CI: 1.43-2.21, p<0.001), households in which respondents knew malaria is transmitted by mosquitoes (aOR 1.35, 95% CI: 1.10-1.65, p = 0.004), and in which respondents knew malaria can be prevented by ITN use (aOR 1.86, 95% CI: 1.28-2.70, p<0.001) were more likely to have all members sleep under an ITN. Compared to the lowest socio-economic quintile, households in the richest quintile were less likely to have all members sleep under an ITN (aOR 0.47; 95% CI: 0.33-0.66, p<0.001). Households in which the main income earner was a skilled worker or a businessman were less likely to have all members sleep under an ITN (aOR, 0.70, 95% CI: 0.52-0.96, p<0.025) compared to those headed by farmers or fishermen. Households in which all children slept under an ITN were more likely to be in rural areas (aOR 1.58, 95% CI: 1.19-2.09, p = 0.002) and have a household head who knew malaria can be prevented by ITN use (aOR 2.13, 95% CI: 1.30-3.50, p = 0.003). Children were less likely to have slept under an ITN in houses headed by skilled workers or businessmen (aOR 0.50, 95% CI: 0.33-0.75, p = 0.001) or unskilled workers (aOR 0.66, 95% CI: 0.49-0.89, p = 0.006) compared to households with farmers or fishermen. Higher socio-economic level was associated with lower ITN use by children (aOR 0.56, 95% CI: 0.36-0.88, p = 0.012, highest vs. lowest quintile). Conclusions The study found ownership of ITNs was low in Myanmar in comparison to the goal of one for every two household members. Use of ITNs was low even when present. Findings are of concern given the study areas were part of enhanced efforts to reduce artemisinin-resistant malaria. Nonetheless, groups vulnerable to malaria such as individuals in rural settings, lower socio-economic households, and workers in high mosquito exposure jobs, had higher rates of ITN ownership. Malaria knowledge was linked to effective ITN use suggesting that distribution campaigns should be complemented by behavior change communications. © 2016 Aung et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Chen I.T.,University of California at San Francisco | Aung T.,Population Services International Myanmar | Thant H.N.N.,Population Services International Myanmar | Sudhinaraset M.,University of California at San Francisco | Kahn J.G.,University of California at San Francisco
Malaria Journal | Year: 2015

Background: The emergence of artemisinin-resistant Plasmodium falciparum parasites in Southeast Asia threatens global malaria control efforts. One strategy to counter this problem is a subsidy of malaria rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT) within the informal private sector, where the majority of malaria care in Myanmar is provided. A study in Myanmar evaluated the effectiveness of financial incentives vs information, education and counselling (IEC) in driving the proper use of subsidized malaria RDTs among informal private providers. This cost-effectiveness analysis compares intervention options. Methods: A decision tree was constructed in a spreadsheet to estimate the incremental cost-effectiveness ratios (ICERs) among four strategies: no intervention, simple subsidy, subsidy with financial incentives, and subsidy with IEC. Model inputs included programmatic costs (in dollars), malaria epidemiology and observed study outcomes. Data sources included expenditure records, study data and scientific literature. Model outcomes included the proportion of properly and improperly treated individuals with and without P. falciparum malaria, and associated disability-adjusted life years (DALYs). Results are reported as ICERs in US dollars per DALY averted. One-way sensitivity analysis assessed how outcomes depend on uncertainty in inputs. Results: ICERs from the least to most expensive intervention are: $1,169/DALY averted for simple subsidy vs no intervention, $185/DALY averted for subsidy with financial incentives vs simple subsidy, and $200/DALY averted for a subsidy with IEC vs subsidy with financial incentives. Due to decreasing ICERs, each strategy was also compared to no intervention. The subsidy with IEC was the most favourable, costing $639/DALY averted compared with no intervention. One-way sensitivity analysis shows that ICERs are most affected by programme costs, RDT uptake, treatment-seeking behaviour, and the prevalence and virulence of non-malarial fevers. In conclusion, private provider subsidies with IEC or a combination of IEC and financial incentives may be a good investment for malaria control. © 2015 Chen et al.; licensee BioMed Central.


Lwin M.M.,Population Services International Myanmar | Sudhinaraset M.,University of California at San Francisco | San A.K.,Population Services International Myanmar | Aung T.,Population Services International Myanmar
Malaria Journal | Year: 2014

Background: Since 2008 the Sun Primary Health (SPH) franchise programme has networked and branded community health workers in rural Myanmar to provide high quality malaria information and treatment. The purpose of this paper is to compare the malaria knowledge level and health practices of individuals in SPH intervention areas to individuals without SPH intervention. Methods. This study uses data from a cross-sectional household survey of 1,040 individuals living in eight rural townships to compare the knowledge level of individuals in SPH intervention areas to individuals without SPH intervention. Results: This study found that the presence of a SPH provider in the community is associated with increased malaria knowledge and higher likelihood of going to trained providers for fevers. Furthermore, the study found a dose-response, where the longer the duration of the programme in a community, the greater the community knowledge level. Conclusion: The study suggests that community health workers might have significant impact on malaria-related mortality and morbidity in rural Myanmar. © 2014 Lwin et al.; licensee BioMed Central Ltd.


Aung T.,Population Services International Myanmar | Lwin M.M.,Population Services International Myanmar | Sudhinaraset M.,University of California at San Francisco | Wei C.,University of California at San Francisco
Malaria Journal | Year: 2016

Background: The World Health Organization (WHO) recognizes Myanmar as having the highest burden of malaria in the Greater Mekong Sub-region (GMS). Early diagnosis and proper treatment are critical in containing malaria. The objective of this study was to assess determinants of seeking treatment for fever from trained providers across rural and urban areas in Eastern Myanmar. Methods: A cross-sectional survey was conducted during the high malaria seasons in the eastern part Myanmar between August and September 2014. Multi-staged cluster sampling was used to sample households. A series of questions related to treatment-seeking for fever were asked. Bivariate and multivariate logistic regressions were conducted to identify independent correlates of seeking treatment for fever from trained providers. Results: The analysis was restricted to 637 participants who reported either themselves or their family members having had fever 2 weeks prior to the interview. In the multivariate analysis, rural residents were less likely to have sought treatment from trained providers (AOR = 0.60, 95 % CI 0.42-0.88; p = 0.01) while residents who had fever patients between the ages of 5 and 14 years (AOR = 1.60, 95 % CI 0.90-2.53; p = 0.05); and those who knew that sleeping under bed nets can prevent malaria (AOR = 2.08, 95 % CI 1.00-4.30; p = 0.05); were borderline more likely to have sought treatment. Conclusion: This study suggests that rural populations need improved access to trained providers. Additionally, future programmes should focus on increasing knowledge around malaria prevention and treatment. © 2016 The Author(s).


Khin H.S.S.,Population Services International Myanmar | Chen I.,University of California at San Francisco | White C.,Population Services International Myanmar | Sudhinaraset M.,University of California at San Francisco | And 4 more authors.
Malaria Journal | Year: 2015

Background: Global malaria control efforts are threatened by the spread and emergence of artemisinin-resistant Plasmodium falciparum parasites. In 2012, the widespread sale of partial courses of artemisinin-based monotherapy was suspected to take place in the highly accessed, weakly regulated private sector in Myanmar, posing potentially major threats to drug resistance. This study investigated the presence of artemisinin-based monotherapies in the Myanmar private sector, particularly as partial courses of therapy, to inform the targeting of future interventions to stop artemisinin resistance. Methods: A large cross-sectional survey comprised of a screening questionnaire was conducted across 26 townships in Myanmar between March and May, 2012. For outlets that stocked anti-malarials at the time of survey, a stock audit was conducted, and for outlets that stocked anti-malarials within 3 months of the survey, a provider survey was conducted. Results: A total of 3,658 outlets were screened, 83% were retailers (pharmacies, itinerant drug vendors and general retailers) and 17% were healthcare providers (private facilities and health workers). Of the 3,658 outlets screened, 1,359 outlets (32%) stocked at least one anti-malarial at the time of study. Oral artemisinin-based monotherapy comprised of 33% of self-reported anti-malarials dispensing volumes found. The vast majority of artemisinin-based monotherapy was sold by retailers, where 63% confirmed that they sold partial courses of therapy by cutting blister packets. Very few retailers (5%) had malaria rapid diagnostic tests available, and quality-assured artemisinin-based combination therapy was virtually nonexistent among retailers. Conclusion: Informal private pharmacies, itinerant drug vendors and general retailers should be targeted for interventions to improve malaria treatment practices in Myanmar, particularly those that threaten the emergence and spread of artemisinin resistance. © 2015 Khin et al.


Thein S.T.,Population Services International Myanmar | Aung T.,Population Services International Myanmar | McFarland W.,Center for Public Health Research | McFarland W.,University of California at San Francisco
AIDS and Behavior | Year: 2015

While it is known that HIV prevalence is higher among key affected populations, such as female sex workers (FSW), the sizes of these populations are difficult to estimate. This study aimed to estimate the numbers of FSW in the two largest cities of Myanmar using multiple data-driven methods. A total of 778 FSW (450 in Yangon, 328 in Mandalay) were recruited though time-location sampling during November and December 2013. Five multiplier methods and a modified wisdom of the crowds method were applied within the surveys to calculate the number of FSW in each city. The median of the methods estimated a population size of FSW in Yangon at 4992 (acceptable upper and lower bounds: 4482–5753) and 3315 (2992–3368) in Mandalay. These estimates translate to a population prevalence of FSW among adult women (age 18–49 years) of 0.35 % (0.32–0.40 %) in Yangon and 0.77 % (0.69–0.84 %) in Mandalay. © 2015, Springer Science+Business Media New York.


O'Connell K.,Population Services International | Hom M.,Population Services International Myanmar | Aung T.,Population Services International Myanmar | Theuss M.,Population Services International Myanmar | Huntington D.,World Health Organization
PLoS ONE | Year: 2011

Background: Quality is central to understanding provider motivations to join and remain within a social franchising network. Quality also appears as a key issue from the client's perspective, and may influence why a client chooses to use a franchised provider over another type of provider. The dynamic relationships between providers of social franchising clinics and clients who use these services have not been thoroughly investigated in the context of Myanmar, which has an established social franchising network. This study examines client motivations to use a Sun Quality Health network provider and provider motivations to join and remain in the Sun Quality Health network. Taken together, these two aims provide an opportunity to explore the symbiotic relationship between client satisfaction and provider incentives to increase the utilization of reproductive health care services. Methods and Findings: Results from a series of focus group discussions with clients of reproductive health services and franchised providers shows that women chose health services provided by franchised private sector general practitioners because of its perceived higher quality, associated with the availability of effective, affordable, drugs. A key finding of the study is associated with providers. Provider focus group discussions indicate that a principle determinate for joining and remaining in the Sun Quality Health Network was serving the poor. © 2011 O'Connell et al.

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