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Reaching out and reaching up - developing a low cost drug treatment system in Cambodia
Axel Klein, Vonthanak Saphonn, Savanna Reid
Harm Reduction Journal , 2012, DOI: 10.1186/1477-7517-9-11
Abstract: The prevailing policy consensus in Cambodia is that drug misuse was unknown until the mid 1990s, an unintended consequence of the country opening its borders to travellers and trade in 1993 after decades of war and isolation. Since then there has been a sharp rise in drug seizures and arrests and the availability of amphetamine type stimulants, opium, cannabis and prescription medicine [1,2].By 1996 the country had been identified as a drug trafficking transit route [3] and by 2001 local drug consumption was being reported [4]. Patterns of use were changing, as they had done earlier in Vietnam, with a shift from opium to heroin, and the rising popularity of amphetamines [5,6]. In 1995, the government formed an inter-ministerial agency, the Secretariat of the National Authority for Combating Drugs (NACD) and solicited support from the international community. The UNODC quickly established itself as one of the key partner agencies, together with WHO, UNAIDS and bilateral agencies [7]. It solicited donor funding to support the NACD financially, assisted the government with the drafting of drug control legislation, and clean-up operations following the discovery of a clandestine laboratory.The need for drug treatment was recognised in early 2000, and led to the formation of an illicit drug-related HIV and AIDS working group (DHAWG) by the NACD and the National Aids Authority (NAA). Without a coherent strategy, problem users and their family were relying on the services of Buddhist monasteries, with a long tradition of taking in troubled young men including drug users, and the patchy service provision by a handful of NGOs like Friends International, the Khmer HIV/AIDS Alliance (KHANA), Khmer Youth Association and Cambodia Network of Positive People. Too often the effectiveness of these service providers was hampered by a lack of critical understanding of substance use, behaviour change or harm reduction [8,9].Many medical practitioners at the time had reservations about
Sustained high prevalence of sexually transmitted infections among female sex workers in Cambodia: high turnover seriously challenges the 100% condom use programme
Heng Sopheab, Guy Morineau, Joyce J Neal, Vonthanak Saphonn, Knut Fylkesnes
BMC Infectious Diseases , 2008, DOI: 10.1186/1471-2334-8-167
Abstract: From March-May, 1079 FSWs from eight provinces consented to participate, provided specimens for syphilis, chlamydia, and gonorrhoea testing, and were interviewed. Univariate and multivariate logistic regression analysis was used to determine factors associated with STIs. STI prevalence was compared with data from the 1996 and 2001 STI surveys.Most FSWs were young (55% aged 15–24) and new to sex work (60% had worked 12 ≤ months). Consistent condom use with clients was reported by 80% of FSWs, but only 38% of FSWs always used condoms with sweethearts or casual partners. Being new to sex work was the only factor significantly associated with "any STI" (OR = 2.1). Prevalence of syphiliwas 2.3%; chlamydia, 14.4%; gonorrhoea, 13.0%; and any STI, 24.4%. Prevalence of each STI in 2005 was significantly lower than in 1996, but essentially the same as prevalence observed in 2001.New FSWs were found to have substantially higher prevalence than those with longer experience. The percent of FSWs who used condoms consistently was high with clients but remained low with non-paying sex partners. Because of the high turnover of FSWs, the prevention needs of new FSWs should be ascertained and addressed. Despite 100% CUP implementation, the prevalence of STIs among FSWs was the same in 2005 as it was in 2001. Limited coverage and weak implementation capacity of the programme along with questionable quality of the STI services are likely to have contributed to the sustained high prevalence. The programme should be carefully reviewed in terms of intensity, quality and coverage.Sexually transmitted infections (STIs) remain major causes of reproductive morbidity and mortality in developing countries; and their high prevalence facilitate HIV transmission [1]. STIs are usually concentrated in core groups such as female sex workers (FSWs) characterized by a high number of partners and poor healthcare seeking behavior [2]. The prevalence of gonorrhoea and/or chlamydia among FSWs was about 20%
The Linked Response: Lessons Emerging from Integration of HIV and Reproductive Health Services in Cambodia
Joanna White,Thérèse Delvaux,Chhorvann Chhea,Sarun Saramony,Vichea Ouk,Vonthanak Saphonn
AIDS Research and Treatment , 2013, DOI: 10.1155/2013/504792
Abstract: 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. 1. Introduction Over the last decade, the importance of linking sexual and reproductive health and HIV policies, systems, and services has been increasingly recognized. Several studies have shown how such linkages might be beneficial for both HIV and reproductive health (RH) programmes [1, 2]. More specifically, efforts have been deployed to integrate HIV testing, care, and, more recently, treatment within antenatal and delivery care services as a strategy to prevent mother-to-child transmission of HIV (PMTCT; [3]). A systematic review concluded that limited, nongeneralizable evidence supports the effectiveness of integrated PMTCT programmes versus non- or partially integrated services [4]. Limited evidence also suggests that PMTCT integration may improve the overall quality of antenatal (ANC) and delivery care services and female attendance at ANC services [4–9], although causal relationships are hard to ascribe [10]. Conversely, however, some commentators have noted that the integration of PMTCT might decrease quality of care and have potential negative
Evaluation of the impact of the voucher and accreditation approach on improving reproductive behaviors and status in Cambodia
Benjamin Bellows, Charlotte Warren, Saphonn Vonthanak, Chhea Chhorvann, Hean Sokhom, Chean Men, Ashish Bajracharya, Ubaidur Rob, Tung Rathavy
BMC Public Health , 2011, DOI: 10.1186/1471-2458-11-667
Abstract: Population Council, funded by the Bill and Melinda Gates Foundation, intends to generate evidence around the "voucher and accreditation" approaches to improving the reproductive health of low-income women in Cambodia. The study comprises of four populations: facilities, providers, women of reproductive age using facilities, and women and men who have been pregnant and/or used family planning within the previous 12 months. The study will be carried out in a sample of 20 health facilities that are accredited to provide maternal and newborn health and family planning services to women holding vouchers from operational districts in three provinces: Kampong Thom, Kampot and Prey Veng and a matched sample of non-accredited facilities in three other provinces. Health facility assessments will be conducted at baseline and endline to track temporal changes in quality-of-care, client out-of-pocket costs, and utilization. Facility inventories, structured observations, and client exit interviews will be used to collect comparable data across facilities. Health providers will also be interviewed and observed providing care. A population survey of about 3000 respondents will also be conducted in areas where vouchers are distributed and similar non-voucher locations.A quasi-experimental study will investigate the impact of the voucher approach on improving reproductive health behaviors, reproductive health status and reducing inequities at the population level and assess effects on access, equity and quality of care at the facility level. If the voucher scheme in Cambodia is found effective, it may help other countries adopt this approach for improving utilization and access to reproductive health and family planning services.Stagnating indicators for several reproductive and child health conditions in many countries of Africa and Asia are a major concern for national governments and development partners striving to achieve the Millennium Development Goals (MDGs). Universally, the
Little Evidence of Subclinical Avian Influenza Virus Infections among Rural Villagers in Cambodia
Gregory C. Gray, Whitney S. Krueger, Channimol Chum, Shannon D. Putnam, Thomas F. Wierzba, Gary L. Heil, Benjamin D. Anderson, Chadwick Y. Yasuda, Maya Williams, Matthew R. Kasper, Vonthanak Saphonn, Patrick J. Blair
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0097097
Abstract: In 2008, 800 adults living within rural Kampong Cham Province, Cambodia were enrolled in a prospective cohort study of zoonotic influenza transmission. After enrollment, participants were contacted weekly for 24 months to identify acute influenza-like illnesses (ILI). Follow-up sera were collected at 12 and 24 months. A transmission substudy was also conducted among the family contacts of cohort members reporting ILI who were influenza A positive. Samples were assessed using serological or molecular techniques looking for evidence of infection with human and avian influenza viruses. Over 24 months, 438 ILI investigations among 284 cohort members were conducted. One cohort member was hospitalized with a H5N1 highly pathogenic avian influenza (HPAI) virus infection and withdrew from the study. Ninety-seven ILI cases (22.1%) were identified as influenza A virus infections by real-time RT-PCR; none yielded evidence for AIV. During the 2 years of follow-up, 21 participants (3.0%) had detectable antibody titers (≥1:10) against the studied AIVs: 1 against an avian-like A/Migratory duck/Hong Kong/MPS180/2003(H4N6), 3 against an avian-like A/Teal/Hong Kong/w312/97(H6N1), 9 (3 of which had detectible antibody titers at both 12- and 24-month follow-up) against an avian-like A/Hong Kong/1073/1999(H9N2), 6 (1 detected at both 12- and 24-month follow-up) against an avian-like A/Duck/Memphis/546/74(H11N9), and 2 against an avian-like A/Duck/Alberta/60/76(H12N5). With the exception of the one hospitalized cohort member with H5N1 infection, no other symptomatic avian influenza infections were detected among the cohort. Serological evidence for subclinical infections was sparse with only one subject showing a 4-fold rise in microneutralization titer over time against AvH12N5. In summary, despite conducting this closely monitored cohort study in a region enzootic for H5N1 HPAI, we were unable to detect subclinical avian influenza infections, suggesting either that these infections are rare or that our assays are insensitive at detecting them.
Loss to Followup in HIV-Infected Patients from Asia-Pacific Region: Results from TAHOD
Jialun Zhou,Junko Tanuma,Romanee Chaiwarith,Christopher K. C. Lee,Matthew G. Law,Nagalingeswaran Kumarasamy,Praphan Phanuphak,Yi-Ming A. Chen,Sasisopin Kiertiburanakul,Fujie Zhang,Saphonn Vonthanak,Rossana Ditangco,Sanjay Pujari,Jun Yong Choi,Tuti Parwati Merati,Evy Yunihastuti,Patrick C. K. Li,Adeeba Kamarulzaman,Van Kinh Nguyen,Thi Thanh Thuy Pham,Poh Lian Lim
AIDS Research and Treatment , 2012, DOI: 10.1155/2012/375217
Abstract: This study examined characteristics of HIV-infected patients in the TREAT Asia HIV Observational Database who were lost to follow-up (LTFU) from treatment and care. Time from last clinic visit to 31 March 2009 was analysed to determine the interval that best classified LTFU. Patients defined as LTFU were then categorised into permanently LTFU (never returned) and temporary LTFU (re-entered later), and these groups compared. A total of 3626 patients were included (71% male). No clinic visits for 180 days was the best-performing LTFU definition (sensitivity 90.6%, specificity 92.3%). During 7697 person-years of follow-up, 1648 episodes of LFTU were recorded (21.4 per 100-person-years). Patients LFTU were younger ( ), had HIV viral load ≥500?copies/mL or missing ( ), had shorter history of HIV infection ( ), and received no, single- or double-antiretroviral therapy, or a triple-drug regimen containing a protease inhibitor ( ). 48% of patients LTFU never returned. These patients were more likely to have low or missing haemoglobin ( ), missing recent HIV viral load ( ), negative hepatitis C test ( ), and previous temporary LTFU episodes ( ). Our analyses suggest that patients not seen at a clinic for 180 days are at high risk of permanent LTFU, and should be aggressively traced. 1. Introduction Loss to followup (LTFU) in patients receiving antiretroviral therapy can cause serious consequences such as discontinuation of treatment and increased risk of death [1–3]. At a program level, LTFU can make it difficult to evaluate outcomes of treatment and care [4, 5]. In resource-limited settings, where treatment has become rapidly available following the rollout of antiretroviral therapy, LTFU presents even more challenging obstacles that require special consideration and approaches [6, 7]. One of the key questions in patient followup is how to define a patient as LTFU. This has varied in studies conducted in different settings [8–10]. Defining LTFU using a very early threshold, for example, a patient with no clinic visit in the last three months, may result in many patients being considered as LTFU who would return to clinic naturally at a later date. Defining LTFU with a long threshold, for example, one year, may mean delaying too long before any effort is made to track patients potentially at risk of LTFU. The majority of research into LTFU in HIV-infected patients receiving antiretroviral treatment in resource-limited settings has been conducted in the sub-Saharan Africa region [3, 10–13]. A few studies have been conducted among Asian, mostly female, patients
Risk and prognostic significance of tuberculosis in patients from The TREAT Asia HIV Observational Database
Jialun Zhou, Julian Elliott, Patrick CK Li, Poh Lim, Sasisopin Kiertiburanakul, Nagalingeswaran Kumarasamy, Tuti Merati, Sanjay Pujari, Yi-Ming A Chen, Praphan Phanuphak, Saphonn Vonthanak, Thira Sirisanthana, Somnuek Sungkanuparph, Christopher KC Lee, Adeeba Kamarulzaman, Shinichi Oka, Fujie Zhang, Goa Tau, Rossana Ditangco
BMC Infectious Diseases , 2009, DOI: 10.1186/1471-2334-9-46
Abstract: The risk of TB diagnosis after recruitment was assessed in patients with prospective follow-up. TB diagnosis was fitted as a time-dependent variable in assessing overall survival.At baseline, 22% of patients were diagnosed with TB. TB incidence was 1.98 per 100 person-years during follow up, with predictors including younger age, lower recent CD4 count, duration of antiretroviral treatment, and living in high TB burden countries. Among 3279 patients during 6968 person-years, 142 died (2.04 per 100 person-years). Compared to patients with CDC category A or B illness only, mortality was marginally higher in patients with single Non-TB AIDS defining illness (ADI), or TB only (adjusted HR 1.35, p = 0.173) and highest in patients with multiple non-TB AIDS or both TB and other ADI (adjusted HR 2.21, p < 0.001).The risk of TB diagnosis was associated with increasing immunodeficiency and partly reduced by antiretroviral treatment. The prognosis of developing TB appeared to be similar to that following a diagnosis of other non-TB ADI.The use of highly active antiretroviral therapy (HAART) has led to dramatic reductions in morbidity and mortality in HIV patients [1,2]. However, tuberculosis (TB) remains a common opportunistic infections and a major cause of death among patients with HIV, especially in sub-Saharan African and Asian countries [3-5], where there is a high background prevalence of TB [5-7].The risk of TB in HIV-infected patients and the impact of TB diagnosis on disease progression in HIV infected patients have been well described in Africa [3,8-10]. The Asia-Pacific region has a large burden of both tuberculosis [7], with nearly 5 million prevalent cases and over 3 million new cases in 2006, and HIV, with an estimated 5 million people living with HIV and 380,000 new infections occurring in 2007 [11]. It is estimated that 2.5 million people are living with both infections in the region [5]. Despite the importance of these inter-related epidemics in the region, fe
Trends in CD4 counts in HIV-infected patients with HIV viral load monitoring while on combination antiretroviral treatment: results from The TREAT Asia HIV Observational Database
Jialun Zhou, Thira Sirisanthana, Sasisopin Kiertiburanakul, Yi-Ming A Chen, Ning Han, Poh_Lian Lim, Nagalingeswaran Kumarasamy, Jun Choi, Tuti Merati, Evy Yunihastuti, Shinichi Oka, Adeeba Kamarulzaman, Praphan Phanuphak, Christopher KC Lee, Patrick CK Li, Sanjay Pujari, Vanthanak Saphonn, Matthew G Law
BMC Infectious Diseases , 2010, DOI: 10.1186/1471-2334-10-361
Abstract: Treatment-naive HIV-infected patients who started cART with three or more and had three or more CD4 count and HIV VL tests were included. CD4 count slopes were expressed as changes of cells per microliter per year. Predictors of CD4 count slopes from 6 months after initiation were assessed by random-effects linear regression models.A total of 1676 patients (74% male) were included. The median time on cART was 4.2 years (IQR 2.5-5.8 years). In the final model, CD4 count slope was associated with age, concurrent HIV VL and CD4 count, disease stage, hepatitis B or C co-infection, and time since cART initiation. CD4 count continues to increase with HIV VL up to 20 000 copies/mL during 6-12 months after cART initiation. However, the HIV VL has to be controlled below 5 000, 4 000 and 500 copies/mL for the CD4 count slope to remain above 20 cells/microliter per year during 12-18, 18-24, and beyond 24 months after cART initiation.After cART initiation, CD4 counts continued to increase even when the concurrent HIV VL was detectable. However, HIV VL needed to be controlled at a lower level to maintain a positive CD4 count slope when cART continues. The effect on long-term outcomes through the possible development of HIV drug resistance remains uncertain.Studies show that latent infection of CD4 cells provides a mechanism for lifelong persistence of HIV-1, even in patients on effective anti-retroviral therapy [1]. To suppress viral replication so that the VL is below the level of detection with standard assays is thus one of the aims at the start of antiretroviral treatment. Maximal and durable suppression of HIV VL prevents or delays development of drug resistant mutations, preserves CD4 cells, and eventually results in better clinical outcomes. According to the US guidelines, if HIV VL suppression is not achieved, it is necessary to change to a new regimen, a second or third line regimen, with at least two active drugs [2].HIV-infected patients in most developing countries h
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