The linked response: Lessons emerging from integration of HIV and reproductive health services in Cambodia

A qualitative assessment was made of service provider and user perceptions of the quality of integrated reproductive health services established through a pilot intervention in Cambodia. The intervention aimed to promote pregnant women's HIV testing and general utilization of reproductive health facilities as well as improve the follow-up of HIV-positive women and exposed infants through strengthened referral and operational linkages amongst health facilities/services and community-based support interventions for PLHIV. The study was conducted in one operational district where the intervention was piloted and for comparative purposes in a district where integrated services had yet to be implemented. Service providers in the pilot district reported improved collaboration and coordination of services, more effective referral, and the positive impact of improved proximity of HIV testing through integrated local level facilities. Community-based support teams for PLHIV embraced their expanded role, were valued by families receiving their assistance, and were understood to have had an important role in referral, PMTCT follow-up and countering PLHIV stigmatization; findings which underscore the potential role of community support in integrated service provision. Challenges identified included stigmatization of PLHIV by health staff at district hospital level and a lack of confidence amongst non-specialized health staff when managing deliveries by HIV-positive women, partly due to fear of HIV transmission. © 2013 Joanna White et al

What impact might the economic crisis have on HIV epidemics in Southeast Asia?

Objective: To evaluate the potential impact of the current global economic crisis (GEC) on the spread of HIV. Design: To evaluate the impact of the economic downturn we studied two distinct HIV epidemics in Southeast Asia: the generalized epidemic in Cambodia where incidence is declining and the epidemic in Papua New Guinea (PNG) which is in an expansion phase. Methods: Major HIV-related risk factors that may change due to the GEC were identified and a dynamic mathematical transmission model was developed and used to forecast HIV prevalence, diagnoses, and incidence in Cambodia and PNG over the next 3 years. Results: In Cambodia, the total numbers of HIV diagnoses are not expected to be largely affected. However, an estimated increase of up to 10% in incident cases of HIV, due to potential changes in behavior, may not be observed by the surveillance system. In PNG, HIV incidence and diagnoses could be more affected by the GEC, resulting in respective increases of up to 17% and 11% over the next 3 years. Decreases in VCT and education programs are the factors that may be of greatest concern in both settings. A reduction in the rollout of antiretroviral therapy could increase the number of AIDS-related deaths (by up to 7.5% after 3 years). Conclusions: The GEC is likely to have a modest impact on HIV epidemics. However, there are plausible conditions under which the economic downturns can noticeably influence epidemic trends. This study highlights the high importance of maintaining funding for HIV programs

Positive Virological Outcomes of HIV-Infected Patients on Protease Inhibitor-Based Second-Line Regimen in Cambodia: The ANRS 12276 2PICAM Study

BackgroundAssessment of virological outcomes among HIV-infected patients receiving protease (PR) inhibitor-based second-line regimen are uncommon in Cambodia. The objective of this study is to assess the virological effectiveness of this regimen as well as impact of adherence boosting for patients experiencing virological failure.MethodsThe 2PICAM study (Clinicaltrial: NCT01801618) is a cross-sectional study of HIV-infected adults on PR inhibitor-based second-line regimen since at least 6 months, conducted in 13 representative sites, comprising more than 90% of the target population. Adults with HIV RNA above 250 copies/mL (threshold of the assay) at inclusion received boosted adherence counseling during 3 months followed by HIV RNA control. For confirmed virological failure, genotype resistance test was performed and expert committee used results for therapeutic decision.ResultsAmong the 1,317 adults enrolled, the median duration of second-line regimen was 5 years. At inclusion, 1,182 (89.7%) patients achieved virological success (<250 copies/mL) and 135 (10.3%) experienced a virological failure (>250 copies/mL). In multivariable analysis, factors associated with virological success were: CD4 cell count between 201 and 350/mm3 (OR: 4.66, 95% CI: 2.57–8.47, p < 0.0001) and >350/mm3 (OR: 6.67, 95% CI: 4.02–11.06, p < 0.0001), duration of PI-based regimen >2 years (OR: 1.64, 95% CI: 1.03–2.62, p = 0.037), ATV-containing regimen (0R: 1.65, 95% CI: 1.04–2.63, p = 0.034) and high level of adherence (OR: 2.41, 95% CI: 1.07–5.41, p = 0.033). After adherence counseling, 63 (46.7%) patients were rescued while 72 (53.3%) were not. For the 54 patients with genotype resistance tests available, high or intermediate levels of resistance to lopinavir, atazanavir, and darunavir were reported for 13 (24%), 12 (22.2%), and 2 (3.7%) patients, respectively. Change to an alternative PR inhibitor-based regimen was recommended for 17 patients and to third-line regimen, including integrase inhibitors for 12.ConclusionThis study reports high rate of virological suppression of second-line regimen and importance of adherence boosting prior to deciding any change of ART regimen. Genotype resistance tests appear necessary to guide decisions. Such information was of great importance for National HIV Program to adapt guidelines and program needs for third-line regimen