Relevant interventions to tackle the gaps in HIV/HCV prevention and care in key affected populations, Myanmar.

Nearly six million people are living with HIV in the Asia Pacific region. The HIV prevalence among the adult general population is 0.2%. The epidemic is largely concentrated in key affected populations (KAPs); HIV prevalence is 14% in people who inject drugs (PWID), 5 % in men who have sex with men (MSM) including transgender (TG) and 1% in female sex workers (FSW). Inadequate coverage and poor quality of services for KAPs continue to undermine responses to HIV. Without addressing the needs of KAPs, a sustainable HIV response will not be achieved. In Myanmar, HIV prevalence is concentrated in PWID with 19%, in MSM with 8.8% and in FSW with 8%, while in the adult general population it was <1% in 2019. There were an estimated 240,000 people living with HIV, 10,000 new HIV infections and 7,700 AIDS related deaths in 2019. The number of people living with HIV who know their status is unknown. 76% of people living with HIV in Myanmar are on antiretroviral therapy and 72% of them reached HIV viral suppression. However, those data are much lower in KAPs. In PWID, MSM and FSW population, the percentage of HIV-positive people aware of their status are 28%, 31% and 41% respectively. Among them, 14% of PWIDs, 44% of MSM, and 59 % of FSWs received ART but no data are available for HIV viral suppression. Medical Action Myanmar (MAM) is one of the few non-government medical organizations, working in Myanmar on HIV/HCV prevention and treatment for KAPs. MAM has an HIV prevention and treatment program in Yangon suburban area targeting FSW and MSM.MAM introduced HIV viral load testing using GeneXpert since 2016 before its public sector expansion in 2018. In 2020, MAM introduced pre-exposure prophylaxis of HIV infection (PrEP) for the MSM and TG population together with the national program. MAM’s harm reduction program is situated in northern Myanmar where there is a high proportion of PWID. It is set up within the MAM primary health care clinic, supported by an outreach team with peer educators, who are integrated with networks of existing community health workers (CHWs). As part of the integration model, CHWs are being trained for community-based HIV and HCV testing, counseling, referral for treatment and harm reduction activities including needle and syringes distribution and condoms promotion. With my PhD, I will analyze MAM programs to document gaps in HIV prevention, treatment and outcomes and propose targeted interventions to close those gaps. I will describe the full HIV cascade of care among PWIDs in a remote mountainous area and explore predictors for disengagement and viral failure. I will document viral load uptake and describe the viral load cascade after a high viral load in adults, in an area with decentralized viral load testing. I will document uptake of testing and treatment for HCV, and outcomes in HIV-positive PWIDs benefitting from integrated HIV/HCV care. Finally, I will document PrEP uptake and occurrence of HIV-infection among prospectively enrolled MSM and TG in Suburban Yangon.