Sri lanka joshh volume 2, December 2016 by Publications of Sri Lanka College of Sexual Health and HIV Medicine

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Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH) Volume 2, 2016

Contents Editorial................................................................................................................................................... ii Leading article Towards Ending AIDS in Sri Lanka ........................................................................................................... 4 Papers Management of patients with sexually transmitted infections by general practitioners in the district of Gampaha............................................................................................................................................. 9 Knowledge, Attitudes and Behaviours related to Sexually Transmitted Infections and HIV/AIDS among factory workers in Seethawaka Export Processing Zone, Avissawella, Sri Lanka ..................... 14 Response to ART among adult PLHIV: a prospective study at HIV clinic Colombo............................... 20 Time taken to escort men who have sex with men (MSM) for HIV testing in the peer group interventions in Sri Lanka...................................................................................................................... 27 Hyperbilirubinemia during atazanavir treatment in people living with HIV (PLHIV), SriLanka. ........... 35 Management of sexually transmitted infections (STI)-associated syndromes by part-time general practitioners (GP) in Puttalam district. ................................................................................................. 40 Case reports Gonococcal Tysonitis............................................................................................................................. 47 Diagnostic dilemma in managing relapsing episodes of Cryptococcal meningitis in HIV infected patient; a case report............................................................................................................................ 49 Author Guidelines ................................................................................................................................ 55

Official publication of Sri Lanka College of Sexual Health and HIV Medicine

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Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH) is the official Journal of; Sri Lanka College of Sexual Health and HIV Medicine, No 29, De Saram Place, Colombo 10, Sri Lanka. Tel: +94 (071) 0900003 Email: srilanka.coshh@gmail.com

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Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Editorial Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH) Sri Lanka Journal of Sexual Health and HIV Medicine is the official journal of Sri Lanka College of Sexual Health and HIV Medicine (Sri Lanka CoSHH) which is formerly known as Sri Lanka College of Venereologists.

Editorial Board Editor-in-chief Dr Ariyaratne Manathunge MBBS, MSc, MD, FSLCV

Acquisition editor Dr Jayadarie Ranatunga MBBS, PgDip Ven, MD

Assistant editors Dr Nalaka Abeygunasekara MBBS, PgDip Ven, MD Dr. Ajith Karawita MBBS, PgDip Ven, MD

Editorial board members Dr Lucian Jayasuriya MBBS, DTPH, FCMA FSLCV, FCGP Dr Lilani Rajapakse MBBS, MSc, MD, FSLCV

Secretary Dr Buddhika Perera MBBS, PgDip Ven, MD

The leading article of this volume is on “Towards ending AIDS in Sri Lanka”. This is the summary of the Presidential Address given by the author at the inauguration of the 21st Annual Scientific Sessions of the college in 2016. Undoubtedly, “Ending AIDS” is one of the most talked about subjects during 2016. The goal set by UNAIDS by 2020, is to diagnose 90 percent of people living with HIV; provide antiretroviral drugs to 90 percent of that population; and ensure that 90 percent of patients receiving treatment have a suppressed viral load, making it hard for infection to be transmitted. The long-term global goal is to end AIDS by 2030. According to the joint publication of National STD/AIDS Control Programme and Sri Lanka Medical Association, titled “Towards ending AIDS in Sri Lanka; a road map”, Sri Lanka has taken a proactive stance of ending AIDS by 2025, five years earlier than the global goal. To achieve this ambitious target testing and treatment must go to hard-to-reach populations, especially the poorest of the poor in the country, men who have sex with men, drug users, sex workers, beach boys and other marginalized people. The war against AIDS cannot truly be won without the progress towards elimination of poverty and inequality. The other main challenge to ending the epidemic is the stigma that is associated with the disease. These are the real challenges confronting those involved in providing prevention, treatment and care services for people infected and affected by HIV/AIDS. Ariyaratne Manathunge Editor-in-chief (http://www.who.int/reproductivehealth/topics/sexual_health/i ssues/en/)

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

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Leading article __________________________________________________________________________________

Presidential address 2016

understand the level of the progression of HIV disease.

Towards Ending AIDS in Sri Lanka

Natural history of HIV mainly consists of asymptomatic illness followed by period of opportunistic infections and opportunistic malignancies. After many revisions and updates, WHO has recommended clinical stage-based approach for the evaluation of clinical disease in HIV.

Dr Ajith Karawita Presidential address at the inaugural session of the Sri Lanka College of Sexual Health and HIV Medicine (Sri Lanka CoSHH), 13-15 October 2016, Kingsbury, Colombo.

HIV acquisition followed by a viral fever like illness called seroconversion illness. Then there is a long latency about 8-12 years called clinical stage I which is followed by symptomatic diseases of clinical stage II, III, and IV as depicted in the slide

Chief Gust Dr Palitha Mahipala Guest of honour Dr David Barlow Distinguished invitees from abroad Past presidents Fellows of the college Members of the council of the Sri Lanka College of Sexual health and HIV Medicine Members of the college My teachers, friends, ladies and gentlemen, The theme of the 21st Annual Scientific Sessions and today’s my keynote address is on “Towards ending AIDS in Sri Lanka” My presentation include Introduction Global scenario in ending AIDS HIV epidemic in Sri Lanka Ending AIDS in Sri Lanka

Clinical stage I is generally the asymptomatic stage, clinical stage II and III are pre-AIDS illnesses. If a patient is having stage IV illnesses, he or she is categorized as having AIDS.

1. Introduction

Fortunately in HIV, those with clinical stage II, III and IV illnesses can be reversed by adequate suppression of viraemia. Therefore, antiretrovirals and management of opportunistic diseases can keep infected persons at stage I increasing the life expectancy and quality of life till complete cure is available.

As you know, the Human Immunodeficiency Virus (HIV) damages the smooth functioning of your immune system leading to immune deficiency and dysregulation. HIV targets important cells in the immune system. The central immune defect is the infection of CD4+ lymphocytes leading to the destruction and depletion of cells with increase in HIV viraemia and emergence of opportunistic diseases.

Therefore, you can end or stop the progression of the disease, to its advanced stage called AIDS. In other words, you can end AIDS theoretically and scientifically by own immunity supported by antiretroviral drugs.

Clinical presentations, CD4+ lymphocyte count and HIV viral load are the main parameters to

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Leading article __________________________________________________________________________________ However, the problem is that, whether we could deliver this science to our community, scale enough to end AIDS in human population. Therefore, we need to put lots of effort for programme and implementation science more and more to reach every person concerned.

Globally HIV new infections per year reached its peak in 1997, at 3·3 million new infections (95% uncertainty interval [UI] 3·1–3·4 million). Annual HIV new infections declined fast from 1997 to 2005. However, it stayed relatively constant at about 2.6 million per year (range 2·5–2·8 million) since 2005.

The United Nations Political Declaration on ending AIDS done on 8th June 2016 sets world on the fast track to end the epidemic by 2030. Countries have agreed, to a historic and urgent agenda to accelerate efforts towards ending the AIDS epidemic by 2030. The ambitious 90-90-90 triple target is the treatment target towards ending AIDS.

It urges to detect 90% from the invisible infected people in the geographical area concerned and treat 90% of identified, followed by adequate suppression of HIV viraemia among 90% of those on treatment. As mentioned in the Global Burden of Diseases Study 2015, published in Lancet, the number of people living with HIV/AIDS has been steadily increasing and reached 38·8 million (95% UI 37·6–40·4 million) in 2015.

But, triple-90 has no emphasis on behavioural determinants of HIV infection and generation of new infections. Its slogan is to detect and treat. It is a treatment target to help in ending AIDS. Therefore, our prevention programmes across all populations including key populations and other measures need to be kept tight while trying to achieve triple-90.

At the same time, HIV/AIDS mortality has been declining at a steady pace, from a peak of 1·8 million deaths (95% UI 1·7–1·9 million) in 2005, to 1·2 million deaths (1·1–1·3 million) in 2015.

2. Global scenario in ending AIDS Now, we will see how the global scenario in ending AIDS

Scale-up of ART and prevention of mother-tochild transmission has been one of the greatest successes of global health in the past two decades.

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Leading article __________________________________________________________________________________ According to the study, of the 195 countries included in the study, 102 experienced an increase in the annual number of new HIV infections between 2005 and 2015. The study recorded a substantial heterogeneity in the levels and trends of HIV/AIDS across countries. Although many countries have experienced decreases in HIV/AIDS mortality and in annual new infections, other countries have had slowdowns or increases in rates of change in annual new infections.

increase in annual HIV case rate as reported to the National STD/AIDS Control Programme. As of end second quarter 2016, 2,436 cumulative number of cases reported in Sri Lanka. During the last three years annual case rate was around 230. However, five years back in 2010 it was 121. Currently, it is estimated that about 4,100 people are living with HIV and every year < 500 new infections are being added and about <100 number of estimated AIDS deaths occur. Adult HIV prevalence is < 0.1%

The bitter truth is that no country has yet achieved the 90-90-90 target.

No province or district is exempted of HIV. However, analysis of new cases reported in 2015 showed that most of them were reported in the districts of Colombo, Gampha, Puttalam, and Kurunegala. New case rate per 100,000 populations in Colombo, Gampaha and Puttlem districts was 2.6, 2.3 and 1.8 respectively. Further, new case rate for Vavuniya, Kegalle, Kurunegala and Anuradhapura were 1.7, 1.4, 1.2 and 1 respectively

Globally only 41% of people living with HIV are receiving antiretroviral therapy (ART), and coverage of treatment remains low in many healthcare settings. After three decades of interventions against HIV, still over 2 million new HIV infections occur annually. Whether we like it or not, it shows a failure; a failure by all stakeholders. What do you think? Can we end AIDS by 2030, globally? Is it Possible? Plausible? Or a distant prospect?

Analysis of main mode of transmission in each year from 2003 to 2015 shows that the main mode of transmission is heterosexual and the heterosexual epidemic is more prominent. However, there is gradual increase in the proportion of homosexual transmissions over the last years. Perinatal transmission ranges from 2-8% during the period. No cases have been reported due to blood and blood product transfusions.

I know, predicting uncertainties are difficult, especially when you do not have knowledge on potential predictors. I think, ending AIDS globally is a distant prospect, unless all countries intensify their efforts.

Distribution of HIV cases by the age shows that majority of cases are reported in the age group of 25-49 years. It is important to note that about 32 cases are reported in the age group of 15-24 years which is used as the proxy value for new HIV infections.

3. HIV epidemic overview in Sri Lanka As you all know Sri Lanka is an Island country, with a population of about 21 million living in a land area of approximately 65,000 square kilometres. It is a multilingual, multiethnic and multilingual country.

Sero-positivity rate of different sub populations gives an overall picture of the HIV situation in the country. Testing different population groups in non-probability samples in various settings is shown in the table. The sero-positivity as you see, ranges from 0.003%-0.24.

In Sri Lanka, first case of HIV reported in 1987 and since then there has been a gradual

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Leading article __________________________________________________________________________________ However, in recently concluded integrated biological and behavioural survey 2014/15 (IBBS), different subpopulations tested in probability samples and the sero-prevalence among Female Sex Workers was 0.81%, MSM 0.88% However, FSWs and MSM prevalence in the districts of Colombo and Galle is 1% while injecting drug users and beach boys prevalence was 0%.

More robust data need to be fed for realistic estimation and projections to see whether we are working with close number to the actual invisible number. Widespread testing for case detection is a must and need to take necessary steps to mainstream HIV testing to all possible entry points in health or non-health sectors. Key populations coverage is a priority but need to make it available freely beyond KPs for case detections.

Condoms as a prevention (CasP) tool has been socialized among high risk groups to some acceptable level, according to the IBBS survey. Ninety three percent (93%) of female sex workers had used condoms with their last client. Condom use among MSM was 58% and the same figure for beach boys. Among people who inject drugs it was 68%. According to the IBBS, condom use has reached to 60% or beyond but issue is that whether the coverage of these populations is enough because of its hidden nature of the behaviour.

It is very important to link all diagnosed people with HIV to HIV care services through follow up and support services. Networking and active case finding is one of the cost effective and easiest way to detect positive cases. Creation of enabling environment by removing or mitigating barriers for access for testing and care through legal and policy reforms and strengthening right based approaches.

4. Ending AIDS in Sri Lanka Sri Lanka should follow the 90-90-90 triple target to end AIDS by 2030 or even before 2030, or if possible need to go beyond 90%.

Making structural changes in healthcare delivery, scale up Sexual Health services and ART centres to every corner of the country adhering to the principles of Universal Health Coverage (UHC).

Out of the triple-90, the first 90 is the most difficult target in Sri Lanka, we need to identify 90% of infected people in the entire population, which is an invisible population.

Enabling environment at healthcare systems need to be established by reducing HIV stigma and discrimination ensuring confidentiality and making culturally competent workforce.

Estimate says, about 4100 people living with HIV at any given point. However, we could link to services nearly about 1000 PLHIV, that is about 25% of the estimate.

The second and third 90% or latter double-90% is mainly related to the treatment and care services. To reach this double 90%, most important factor is to retain PLHIV in care.

Therefore, about 3000 people are living with HIV, but missing faces in our treatment services.

Achieving first 90%, that is to detect 90% of people living with HIV from the invisible real number need attentions to the following.

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Leading article __________________________________________________________________________________ Favourable legal and policy environment need to be in place to strengthen right to health and non-hesitant access to treatment and care.

HIV clinicians and care service can play a major role in achieving the latter double-90%. I think Sri Lanka can achieve the latter double 90% quickly with the adaptation of â&#x20AC;&#x153;test and treatâ&#x20AC;? policy and free and accessibility of Viral Load testing, HIV resistance testing and availability of treatment options.

Further, enabling social environment for PLHIV need to be created by removing or mitigating social barriers such as stigma and discrimination, marginalization, homophobia, transphobia, lack of acceptance of sexual diversity, denial attitudes of the society for sex and sexuality.

Ending AIDS in Sri Lanka is not easy unless we intensify all our efforts. Therefore, all we need is to work towards ending AIDS in Sri Lanka before 2030 without making it a distant prospect.

The supportive family environment is also important for PLHIV to retain in treatment and care.

There is no way of stepping back; we need to move forward and intensify prevention efforts. We need to scale up treatment and care services. We need to invest money for innovations. Finally most importantly make all possible efforts to deliver the evidence of science to our community.

We have paid less attention about personality issues and mental health which can reduce the retention in care such as anxiety, depression, non-concerned health behaviour, self stigma, religious fatalism, and personal attitudes towards treatment.

Finally, I would like to recommend the ministry of health and the National STD/AIDS Control Programme, Sri Lanka to form a National steering committee and identify plan of action to make the ending AIDS a reality, which is possible.

Enabling environment at healthcare systems need to be strengthened by training of staff to be culturally competent and sensitive. Low level of defaulter tracing and emphasis on partner servicers common due to conflicts of rights, but new strategies need to be implemented ensuring the rights of people.

Thank you Acknowledgement

Viral load testing need to be made available at an accessible and affordable distance.

Treatment adherence strengthened.

need

Deviations for CAMs (complementary and alternative medicines) is another issue.

Dr Ariyaratne Manathunge, and the staff of the strategic information management unit of the National STD/AIDS Control Programme for generating important information Dr Sisira Liyanage, Director, National STD/AIDS Control Programme Office bearers and the Council of the college of Venerologists Dr Sriyakanthi Beneragama for HIV and IBBS data

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Management of patients with sexually transmitted infections by general practitioners in the district of Gampaha Jayakody W.C.J.K.1, Pathmeswaran A.2, Wickramasuriya C.D.3

Abstract Introduction: In Sri Lanka, care for sexually transmitted infections (STIs) is given by both public and private sectors. Though there is an organized system for provision of care in government STD clinics, system available for the same purpose in private sector has not been studied. Objective: To describe the knowledge and practices related to the management of patients presenting with symptoms and signs of sexually transmitted infections (STD Syndromes) among general practitioners in the District of Gampaha. Method: A descriptive cross sectional study was carried out among 200 general practitioners. Data were collected by using a self-administered structured questionnaire in English language and analyzed using SPSS 16. Results: Majority of the study population were male (76%) with MBBS qualifications (97%) and involved in part time general practice (92.5%). Significant number (21% ) of GPs have not heard the term syndromic management of STDs. Almost three quarter (74%) of GPs did not use any guideline for the management for STIs. Only a minority of GPs has prescribed the recommended antibiotic combination for patients presenting with urethral discharge (10%), vaginal discharge (16%), non vesicular genital ulcers (3.5%) and vesicular genital ulcers (35%). Majority (55.5%) of GPs have done condom promotion. Counselling on STI prevention was done only by about half (48%) of the GPs. Conclusions: Most GPs were not aware of the syndromic management of STDs. Diagnostic tests that have been carried out were not appropriate to the symptoms and recommended treatment was not prescribed for most of the syndromes. They were unfamiliar with the STI management guidelines. Key words: STIs-Sexually Transmitted infections, GPs- General practitioners Authors: corresponding author; 1 Dr. W. C. J. K. Jayakody, MBBS, PgD Ven, MD; Consultant Venereologist, Teaching Hospital, Kurunegala, Email: wcjksovis@gmail.com 2 Prof.A. Pathmeswaran, MBBS, MSc, MD (Com.Med); Department of Public Health, Faculty of Medicine, University of Kelaniya, Ragama. 3Dr. C. D. Wickramasuriya, MBBS, Msc, MD (Com.Med) Dip.GUM (Lon); National STD/AIDS Control Programme, Colombo. Acknowledgement: Members of college of general practitioners and independent medical practitioners, all the Consultant Venereologists of National HIV/AIDS Control Programme Originality: This is an original work not published anywhere, presented at 21 st Annual Scientific Sessions of Sri Lanka College of Sexual Health and HIV Medicine 2016. Conflict of interest: No conflict of interest Submitted: 14.12.2016, Accepted: 28.12.2016

groups who are the main work force of a country. Complications of infection, stigma and discrimination attached to them, facilitation of the transmission and acquisition of HIV infection are major sequelae of STIs, if not detected and properly treated early1. Emergence of high levels of antibiotic

Full article Introduction Sexually transmitted infections are of major public health importance as they predominantly affect sexually active age

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Papers __________________________________________________________________________________ resistance to some STIs has also been reported owing to inappropriate use of antibiotics2. The assessment of practices and knowledge of GPs in contributing to the control and spread of STIs by early diagnosis and recommended treatment is very important. General practitioners are an important segment of primary care providers in Sri Lanka. They provide comprehensive medical care and preventive care to patients and their families. They provide continuity of care and act as an advisor to patient and their families in all health related matters3. They play a valuable role in the management of sexually transmitted infections (STIs) too. In Sri Lanka, any doctor who has gained full registration with the Sri Lanka medical council is eligible to start a general practice. One does not need postgraduate qualification or specific training to start a general practice4. They engage in full time or part time practice. Patients are free to select the doctor or the hospital as they wish. There is no strict referral procedure from primary care to secondary and tertiary care5. It is estimated that 60-85% of patients with STIs seek treatment in the private sector6,7. Although a significant proportion of patients with STIs are seen and treated by GPs, so far, no studies had been done on the GPs knowledge or their practices related to the care given for STIs in Sri Lanka. Studies done in other countries have shown that GPs lack the correct knowledge on STIs. As it is observed that a significant proportion of patients with STIs attend private sector, the services provided by GPs in the overall care should be assessed in order to provide a quality assured service. Most of the time, GPs manage patients with STIs clinically without going for the investigations due to money availability and time constraints. Syndromic management is a suitable option under this circumstance. Therefore, the assessment of correct knowledge on syndromic approach of STDs is beneficial for improvement of care rendered by them. This study was carried out to describe the knowledge and practices related to the management of patients presenting with

symptoms and signs of sexually transmitted infections (STD Syndromes) among general practitioners in the District of Gampaha and to identify the gaps. Method The study was carried out in Gampaha district in Western province. Gampaha is identified as a district rich with both public and private sector health care institutions. Study population was the general practitioners who have had MBBS, RMP qualifications or any other foreign qualification and registered at the SLMC and engaged in providing medical care for a fee. Two hundred GPs were assessed through pretested, self-administered questionnaire in English language. Sample size was calculated by using 95% confidence level and 5% confidence limit. As there was no database or register for GPs for Gampaha district, a sampling frame was prepared using several available resources. There were 493 GPs in the list. GP centers were plotted on a geographical map of Gampaha district. The regions where there were more than seven GP centers were identified from the map. For logistical reasons, data collection was restricted to these areas. Total of 200 GPs who were willing to participate in the study were visited and given the questionnaires. Epi data software was used for data entry. Data were processed and analyzed using SPSS 16. Ethical clearance was obtained from the ethical clearance committee, Faculty of Medicine, University of Kelaniya, Sri Lanka. Results Majority of the study population was male (76%) and part time practitioners (92.5%) with less than 10 years of experience in general practice (62%). (Table 1). Fifty four percent of the study population was in the age range of 36-45years with a median age of 42 years. It is significant that one fifth of GPs were seeing over 40 patients per day. Almost all the GPs were MBBS degree holders (97%).

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Category 26-35 36-45 46-55 56-65 66-75 >76 Male Female MBBS+ PG MBBS RMP Other < 10 11 – 20 21 -30 > 31 Not mentioned

Sex Professional qualifications

Duration of practice in years

laboratory investigations for urethral discharge and vaginal discharge, respectively. Most of the time, they have carried out UFR, urine culture, VDRL, FBC and FBS for patients with STI symptoms. Only a minority of GPs has prescribed the recommended antibiotic combination for patients presenting with urethral discharge (10%), vaginal discharge (16%), non vesicular genital ulcers (3.5%) and vesicular genital ulcers (35%). Condom promotion was mentioned by 80% of GPs while 55.5% of GPs said they always promoted condom. Less than half of GPs (47.5%) always counseled on STI prevention and 22% of them never did it. Sixty five percent said they refer patients to government STD clinics for further care.

Freq (%) 26 (13.0) 108 (54.0) 52 (26.0) 9 (4.5) 3 (1.5) 2 (1.0) 152 (76.0) 48 (24.0) 63 (31.5) 131 (65.5) 1 (0.5) 5 (2.5) 124 (62.0) 56 (28.0) 13 (06.5) 6 (03.0)

Discussion Syndromic management represents a simple, feasible treatment strategy for resource-poor settings. The immediate treatment avoids further transmission and complications that can occur as a result of loss to follow-up. Additionally, it minimizes the cost of laboratory testing and potentially avoids false negatives or positives that might come from poor laboratory settings and differences in sensitivity and specificity1. Because of these advantages, syndromic approach is a very useful method to adopt in the private sector where there are no laboratory facilities at hand.

1 (0.5)

Significant number (21%) of GPs have not heard the terminology of syndromic management of STDs. Out of the GPs who had heard about syndromic management, the knowledge on correct etiology for each syndrome was poor. Almost three quarter (74%) of GPs did not use any guideline for the management for STIs and 15% did not know that there is a guideline for STI management in Sri Lanka.

Fig 1: Management of STD patients by GPs

In the present study, a significant proportion had insufficient knowledge on syndromic management or the terminology of syndromic management of STDs. After three decades of the introduction of syndromic approach by WHO, quite a few Sri Lankan GPs knew about it. Similar findings have been obtained in Pakistan where 82% of private and public sector health care providers were not aware of the terminology of “syndromic management of STDs”8 .

80 70

60 50 40 30 20 10

0 Sexual history taking

Always

Genital examination

Sometimes

Laboratory investigations

Rarely

Never

Although a significant number of GPs (73.5%) were always keen to take sexual history, less than half of the GPs had always done genital examination (47%). Laboratory investigations were done by only 72% of GPs. (Fig. 1) Of them, 52% and 42% have not done relevant

Their knowledge on common etiology of main syndromes was also poor. Main etiology of urethral discharge and genital ulcer syndromes according to syndromic guideline

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Papers __________________________________________________________________________________ were mentioned by 17% and 8.5% of GPs respectively .The study clearly showed the knowledge gap with respect to etiology of syndromes. This finding is not limited to Sri Lanka alone. Health care providers in other resource poor settings were also not aware on the correct etiology of the STI syndromes9,10 .Only 44% of Pakistan doctors have mentioned the correct etiology for urethral discharge and cervical discharge9. Though guidelines are developed, management of STIs are not done accordingly by most of the GPs. Mere availability of a guideline does not reflect effective management of STIs because clinicians may not adhere to the standard guidelines due to lack of training or unawareness. In the present study almost three quarter of GPs (74%) did not use any guideline to manage STIs and 15% of GPs did not know about it . Even though the local guideline was published about 10 years prior to the current study, only a few GPs (3.5%) have used it . It is obvious that syndromic approach is not popular among current generation of GPs in Sri Lanka.

most favorite tests for STI diagnosis were UFR, Urine culture and VDRL. The similar finding was identified in the previous study done in UK. Majority of GPs (54%) have done the urinalysis and mid stream urine for culture in patients with dysuria and urethral discharge in that study11. Fifty four percent of GPs in this study have also done UFR for patients presenting with urethral discharge. These results made the conclusion that GPs were not aware about the correct diagnosis test based on the etiology of STD syndromes. Majority of the GPs (81%) have ordered tests from private labs and a significant number of GPs (43%) have referred patients to government STD clinics for investigation and further management. Recommended treatment according to National guideline for three main syndromes were mentioned by a few GPs. Over treatment, under treatment and incorrect treatment was common for all three syndromes. Almost equal number of GPs has used doxycycline (35%) which is recommended for chlamydia and ciprofloxacin (33%) which has already been abandoned due to resistance to gonorrhoea. The immediate treatment for men with urethral discharge was tetracycline, ciprofloxacin and amoxicillin in UK11. Majority (51.5%) of GPs had prescribed metronidazole for patients with vaginal discharge. Forty four percent of GPs used acyclovir for management of vesicular genital ulcers however a few GPs (5%) prescribed benzathine penicillin for the treatment for non vesicular genital ulcers. All these findings indicate that under treatment and inappropriate therapy is common among GPs. Addressing the preventive strategies during STI case management further enhance the comprehensive care. According to National syndromic guideline, STI prevention includes educate and counsel on STIs, promote and provide condoms and contact tracing and partner treatment. This study shows 89% of GPs have mentioned that they have discussed about partner treatment with the patient. Most of the GPs (41%) asked the patient to inform the contact to attend clinic and over

Sexual history taking is one of the key components in STI management. Majority of GPs (73.5%) had always taken sexual history once a patient presented with STI symptoms in the present study. However detailed sexual risk assessment with respect to sexual preferences and practices were obtained by 52% and 48% of GPs respectively. Anyhow, GPsâ&#x20AC;&#x2122; interests to examine the patients were less compared to history taking. Only less than half of the GPs always examined the patients complaining of STI symptoms. This may be due to lack of privacy in some GP settings to carry out proper genital examination or they were in rush with patient load. Almost one quarter of GPs (25%) made for etiological diagnosis and most of the time others have not requested the investigations. It is obvious that they practiced a somewhat similar method to syndromic management even though they did not know the terminology. However their testing was not appropriate to identify the etiology. Unnecessary testing was very common. Their

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Papers __________________________________________________________________________________ one third of GPs (35.6%) asked patient to bring the contact . However their way of tracing partners was vague and there was no proper system to check whether the partner has turned up for the treatment. The same method has been followed by some Pakistan GPs too. Thirty three doctors (41%) encouraged STD patients to inform their partners about risk to them and 28 (35%) asked the patient to bring in their partners9. It is interesting that almost equal percentages have found in both studies. Even in government settings, the level of contact tracing is not at an acceptable level in Sri Lanka. There are many factors that may be contributing to this. Social and cultural factors play a major role in this.

practitioners should be educated on syndromic management to provide better STI services to the patient. User friendly information booklet on STIs should be distributed to GPs to follow during their consultations. Steps should be taken to update STI knowledge and guidelines for GPs in private sector. References 1.

World Health Organization. Integrating STI/RTI Care for Reproductive Health Sexually Transmitted and Other Reproductive Tract Infections: A Guide to Essential Practice. Geneva: WHO; 2005. Report No.: ISBN 92 4 159265 6. 2. Iyalomhe GBS, Iyalomhe SI, Eholor R. Antibiotic prescription and resistance: A contemporary literature review. International Journal of Medicine and Medical Sciences. 2011 December; 3(14): p. 376-380. 3. De Silva N. Lecture notes in family medicine. 2nd ed. Sri Lanka: Sarvodaya Vishva Lekha; 2006. 4. Ramanayake R P. Historical Evolution and Present Status of Family Medicine in Sri Lanka. J Family Medicine Primary Care, India. 2013 April-June; 2(2): p. 131-134. 5. Ramanayake R P, Perera D P, De Silva A H, Sumanasekara R D. Patient held medical record: solution to fragmented health care in Sri Lanka. The health. 2013 Apr; 3. 6. World Health Organization. Involving Private Medical Practitioners in TB and STD Control, Report of Informal Consultation. New Delhi: WHO; 2001. 7. Independent Medical Practitioners Association. Epidemiology of STI and History taking in STI. 1st ed. Colombo: IMPA; 2005. 8. Mohsin S, Magnus U, Shakila Z, Cecilia S. Knowledge, attitude and practices regarding HIV/AIDS and STDs among health care providers in Lahore,Pakistan. JAyub Med Coll Abbottabad. 2009 Apr; 21. 9. Khandwalla H, Luby S, Rahman S. Knowledge, attitudes, andpractices regarding sexually transmitted infections among generalpractitioners and medical specialists in Karachi, Pakistan. SexTransm Infect. 2000; 76: p. 383-385. 10. Stokes T, Bhaduri S, Schober P, Shukla R. GPs' management of genital Chlamydia: a survey of reported practice. Family Practice an International Journel. 1997 August; 14(6): p. 455-60. 11. Ainsworth J, Weaver T, Murphy S, Renton A. General practitioners' immediate management of men presenting with urethral symptoms. Genitourinary Medicine. 1996 September; 72: p. 427-430. 12. Mallikarachchi M K, Liyanage R, De Silva A H. Health care seeking behaviour among Central STD clinic attendees. In College of Venereologists; 2008; Colombo.

Majority of GPs in the present study have promoted the condoms and counseled their patient on STI prevention. Approximately two third of GPs have always (62%) referred to further care whereas half that number (33%) has sometimes referred to government STD clinics. Approximately two third of GPs have referred their patients with STDs to government STD clinics. This result support the findings from the study done in NSACP that out of symptomatic STI patients, 44% had taken treatment from private doctors before coming to the STD clinics12 .Our GPs were more likely to refer for further care when compared to Indian study where only one fourth of HCPs (26.03%) had referred their patient to specialists. Conclusion Most GPs were not aware of the syndromic management of STDs. Therefore they lacked in depth knowledge on syndromes and the steps of management in a setting where investigation facilities are not available. Diagnostic tests that have been carried out were not appropriate to the symptoms and recommended treatment was not prescribed for most of the syndromes. Most of them have tried to prevent further transmission and future acquisition of STIs for the index patient. They were unfamiliar with the STI management guidelines. Therefore, general

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Knowledge, Attitudes and Behaviours related to Sexually Transmitted Infections and HIV/AIDS among factory workers in Seethawaka Export Processing Zone, Avissawella, Sri Lanka Rajapakshe R.W.K.M.D.1, Weerasinghe G.2

Abstract Introduction: Factory workers in Export Processing Zones (EPZs) have been identified as a group with vulnerable behaviour for acquiring Sexually Transmitted Infections (STIs) including HIV due to many social and environmental risk factors. This study was done to assess the knowledge, attitudes and behaviours related to STI and HIV/AIDS among male and female factory workers in Seethawaka EPZ. Method: A descriptive cross sectional study was carried out among 430 factory workers in Seethawaka EPZ, using self-administered questionnaire. Statistical analysis was done using SPSS 16.0. Results: Majority (85%) had satisfactory level of knowledge on HIV. Age (p= 0.0001), education level (p=0.031) and working category (p= 0.0001) were significantly associated with knowledge. Only 7.6% tested for HIV though 83.2% knew about testing. Knowledge on STIs was fairly good (>75%) except for awareness on asymptomatic nature of STIs (24.4%). Many (56.7%) showed poor level of attitudes towards people living with HIV (PLHIV). Education level (P=0.0001), working category (p=0.003) and HIV related knowledge (P=0.0001) had a significant association with attitudes. Sex with non-regular partners (NRP) during the past 12 months was reported by 36.2% males and 27.4% females but only 64% of men and 48.4% women had used a condom with their last NRP. Male to male sex was prevalent in 14.6% of males and only 30% of them had used condoms at last anal sex. Conclusions: Knowledge of factory workers on HIV and STIs was satisfactory but there were some areas those need further strengthening which would improve workersâ&#x20AC;&#x2122; attitudes towards PLHIV. Furthermore, behaviour change communication and condom promotion programmes are highly recommended to promote safe sex. Key words: HIV, STI, Export processing zones, Seethawaka Authors: corresponding author; 1Dr R.W.K.M.D. Rajapakshe, MBBS. PgDip Ven, MD; Acting Consultant Venereologist, STD Clinic, Kegalle . Email; manjuladil75@gmail.com 2Dr G. Weerasinghe, MD (USSR), MSc, MD (Com.Med), FRCP (Edin); Consultant Venereologist, National STD/AIDS Control Programme, Sri Lanka Acknowledgement: Prof. S. Sivayogan, Head of the Department of Community Medicine, Faculty of Medicine, University of Sri Jayewardenepura , Mr Athula Jayasinghe, Director (Zone) â&#x20AC;&#x201C;SEPZ, All the participants of study at Seethawaka EPZ, Conflict of interest: No conflict of interest Funding: No funding support for this study Originality: This is an original work not published anywhere, presented at 21 st Annual Scientific Sessions of Sri Lanka College of Sexual Health and HIV Medicine 2016. Submitted: 19.11.2016, Accepted: 28.11.2016

because of their harmful effects on individuals as well as society. STIs account for a major public health burden in Sri Lanka too. Young sexually active people from age 15-49 years comprise major proportion of STI clinic attendees (1). HIV prevalence is low in Sri

Full article Introduction Sexually transmitted infections (STIs) and HIV are considered as major health problem

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Papers __________________________________________________________________________________ Lanka (<0.1%) over the years, yet there had been steady .increase in the new diagnosis of HIV over .the last years (1). Since HIV commonly .infects people who are in their productive ages, it has a huge socioeconomic .impact that threatens economy in many countries (2). Certain behaviours like having unprotected sex with an unknown partner and having multiple .sexual partners are known to create, enhance, and perpetuate the risk of acquiring STIs /HIV. In addition some people become vulnerable for the STI/HIV due to factors like the lack of .knowledge and .skills necessary to protect themselves, factors relating to the quality and .coverage of .services and societal factors such as social and .cultural norms, practices and beliefs. Rapid expansion of Export Processing Zones (EPZs) throughout the world is seen as a prominent feature of globalization. As a result of introduction of open economy to Sri Lanka, EPZ were also established in Sri Lanka and currently there are 12 EPZ locations administered by Board of Investment (BOI) of Sri Lanka (3). Factory workers in these zones have been identified as a social stratum and an occupational group with vulnerable behaviour for acquiring STIs and HIV due to many social and environmental risk factors. These include weakening of parental control due to separation from family and traditional cultural background, reinforcement of high risk behaviour by peer groups and lack of access to accurate information. Thus, their knowledge on STIs and HIV transmission and methods of prevention is crucial to avoid them getting these infections. The results .of the first round BSS (4) in Sri Lanka done in 2006-2007 identified surprisingly poor knowledge about STI/HIV despite higher level of education among factory workers. Furthermore misunderstandings about the modes of transmission of STI/HIV, extremely stigmatizing attitudes towards PLHIV and unsafe sexual practices with low condom use also had been identified. There was no recent study done to assess new trends in those

areas of knowledge, attitude and behaviours. Therefore this study was carried out to assess the knowledge, attitudes and behaviours related to STI and HIV/AIDS among male and female factory workers in Seethawaka EPZ which is one of the largest processing zones in Sri Lanka. Method A descriptive cross sectional study was done among male and female factory workers working at Seethawaka EPZ who fulfilled the inclusion criteria. The study was carried out from 01/06/2013 to 31/07/2013. Probability proportionate to size (PPS) sampling method was used in the study to minimize the probability of getting large number of sample from large scale enterprises and to include individuals from factories of all scales in the study. After selection of 20 clusters in 12 factories, required sample size of 440 was selected by systematic sampling. Out of 440, 430 who did not meet the exclusion criteria and gave consent participated in the study. Well-structured self-administered questionnaire in Sinhala and Tamil languages was used as the study instrument. Questionnaire included the questions on HIV/STI related knowledge, attitude towards PLHIV and sexual behaviours. Principal Investigator (PI) or Research Assistant (RA) doctors were available at the site for any clarifications. Data were analyzed using a personal computer by the PI. SPSS.16 software was used for analysis. Results The study sample was predominantly young age, ranging from 17 to 45 years. Mean age was 26.87(20.8 -32.9) years. The greater proportion was female (58.8%). More than 85.4% of this group were educated up to Ordinary Level (O/L) or above. Majority (63.5%) were skilled workers while 18.6% were still on training. Around 51% were single, while 39.1% were married. Considerable percentage (5.8%) was living together with a sexual partner.

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missing values (N=7), 2 missing values (N = 3), 3 missing values (N = 4) Denominator – factory workers who heard about HIV/AIDS About 83.4% knew that HIV transmission risk can be reduced by having sex with single uninfected partner. Only 60.6 % knew that they could protect themselves from HIV by consistent use of a condom. Mosquito bites were identified incorrectly as mode of HIV transmission by 19.7% of workers while 14% and 9.5% thought that it can be contracted through sharing food or clothes respectively. There was a statistically significant association of knowledge on HIV with age (p= 0.0001), level of education (p=0.031) and working category (p= 0.0001).

Knowledge about HIV/STI About 98% of study sample had heard of HIV/AIDS from a wide range of sources. Their knowledge on all modes of transmission of HIV was satisfactory (above 79%) except for transmission through breast milk (59.4%) (Table1). Table 1: Frequency distribution of knowledge on different modes of HIV transmission (n=423) Knowledge on Frequency Percentage transmission (N) (%) mode Can HIV be transmitted from an infected person to their uninfected partner during unprotected sexual intercourse? Yes 347 83.4 No 33 8 Don’t know 36 8.6 Total 4161 100 Can a person get HIV from a transfusion of HIV infected blood/blood products? Yes 373 88.8 No 11 2.6 Don’t know 36 8.6 Total 4202 100 Can a person get HIV by getting injections with a needle that was already used by a person who is infected with HIV? Yes 364 86.9 No 16 3.8 Don’t know 39 9.3 Total 4193 100 Can a pregnant woman infected with HIV transmit the virus to her unborn child? Yes 334 79.6 No 30 7.1 Don’t know 56 13.3 Total 4202 100 Can HIV infected mother transmit HIV to baby by breast feeding? Yes 249 59.4 No 72 17.2 Don’t know 98 23.4 Total 4193 100

Testing for HIV was very low (7.6%) despite their good knowledge on availability of testing facilities (83.2%) in Sri Lanka. Knowledge on STI transmission was fairly good (>75%) except for transmission through non penetrative genital contact (14.8%). Asymptomatic nature of STI was also not known by many (24.4%). There was a statistically significant association of knowledge on STI with age (p= 0.0001), level of education (p=0.013) and working category (p= 0.0001).Strikingly low number (2%) who had STI symptoms visited the government Sexually Transmitted Disease (STD) clinics. Attitudes towards others with HIV/AIDS The study identified existence of stigmatizing attitudes towards PLHIV. About 68% of respondents were neither willing work with a staff member who is HIV positive nor do they like to care for a sick HIV infected relative. More than 75% of respondents were not willing to live in the same house with a person infected with HIV. Only 58% would like to share a meal with a person with HIV. About 72% felt that PLHIV should not have equal rights as other people while 64.7% agreed that they should not be allowed to do jobs. The highest level of negative attitude was towards the sexual and reproductive rights of

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Papers __________________________________________________________________________________ PLHIV as nearly 84% said that they should not be allowed to marry and have children. Level of education (P=0.0001), working category (p=0.003) and level of HIV related knowledge ((P=0.0001) had a statistically significant association with their attitudes towards PLHIV.

Factory workers knowledge on transmission modes of HIV were at satisfactory level except for transmission through breast milk. Though the National BSS (4) demonstrated similar pattern the knowledge, level in BSS were higher than the current study. Their knowledge of condom as a protective measure for HIV was not that satisfactory (60.6 %).

Behaviours related to HIV/AIDS and STI Out of workers who were sexually active during previous 12 months, 36% males and 27.4% females had vaginal sex with nonregular partner (NRP). Sixty four percent of males used condoms with NRPs while 48.4% females did so with their NRPs at last sex. A considerable number of males (13%) engaged in sex with commercial partners (CP) in previous year and 83% of them used condoms with CPs at last sex. Only 2 females were engaged in commercial sex during previous 12 months and both used condoms with clients when they last sell sex.

The present study confirmed that misconceptions on HIV transmission now exists to a lesser extent; as majority disagreed with common misconceptions related to HIV transmission. Despite the good knowledge on testing facilities (83.2%) only a minority (7.6%) had done a test for HIV and received results in the previous year. Not knowing where to go for testing may have contributed to this. Very few workers (17.5%) were aware of the availability of drugs to treat HIV. Lack of knowledge on availability of effective medication for HIV in the country may also have act as hindrance to testing.

Around 27.1% male factory workers who ever had sex reported having anal sex with another man ever in their life while 14.6% of them had this behaviour during previous 12 month. Only 30% reported using condoms when they last had anal sex with a man.

Level of knowledge was high among workers aged 25 and more compared to workers who were less than 25 years, suggesting knowledge increases with increasing age. Poor level of knowledge was less seen among more educated group. Skilled workers had a significantly higher knowledge.

A statistically significant association found between unsafe sex and civil status (p<0.0001) and persons at living arrangement (p<0.0001) where workers who were single showing more unsafe sex and who were living with regular partners showing more safe sex. There was no significant association between workers knowledge on HIV and their unsafe sexual behaviour.

Overall knowledge on STI transmission was fairly good. Similar to results in HIV, there was a statistically significant association of knowledge on STI with age (p= 0.0001), level of education (p=0.013) and working category (p= 0.0001). It was noted in the study that strikingly low number (2%) visited the government STD clinic or STD specialist for treatment of STI related symptoms. Non availability of STD service in a nearby hospital may have influenced this.

Discussion The study identified factory workers employed in EPZ as young group with satisfactory level of education. It revealed that considerable percentage (5.8%) of workers was cohabiting with a sexual partner without being married.

It was evident from the present study that attitudes of people in Sri Lanka towards PLHIV are still not at an acceptable level. Favourable

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Papers __________________________________________________________________________________ attitudes associated with level of education (p=0.013) and level of HIV related knowledge ((P=0.0001). This necessitates the importance of further increasing the knowledge among this group to reduce their negative attitudes towards PLHIV.

achievements, people engage in high risk behaviour. An interesting finding was that there was no statistically significant association between workers knowledge on HIV and their unsafe behaviour even though it has a significant association with attitude. This clearly demonstrate that correct knowledge can improve the negative attitudes but mere increase in knowledge canâ&#x20AC;&#x2122;t improve safe behaviour as it depends on many factors other than knowledge. This further challenges us on the traditional awareness programmes those targeted only in increasing knowledge. The important and urgent need of new strategies and methods to increase safe sexual behaviour among youth is highlighted from the study.

Considerable number of sexually active workers had sex with heterosexual NRPs and condom use with them was not satisfactory. In contrast they used condoms more when engaged in commercial sex. This emphasizes the further need of educating the workers on risk of getting HIV/STI through NRPs in future awareness programmes. Considerable number had unsafe male to male sex which was much higher than the findings in first round BSS among factory workers. Such dramatic rise in this behaviour within few years is likely to reflect the increasing trends in homosexual behaviour among men. There are factories in the EPZ which only have male workers. Unavailability of females in the working place may also be contributing to the increase trend of this behaviour. This issue needs to be addressed in the future interventions for the workers and condoms should be promoted for homosexual activities stressing the high risk of HIV transmission through anal sex.

Conclusions and Recommendations The study identified satisfactory knowledge of factory workers on HIV and STIs but there were some areas those need further strengthening. Thus the study recommends strengthening the HIV/STI awareness programmes catering specially on correct transmission modes, symptomatology, condom as a main preventive method, availability of testing centres and effective treatment for HIV. Improving knowledge would have a positive effect on workersâ&#x20AC;&#x2122; attitudes towards PLHIV.

Majority (83.4%) of workers identified unprotected sex as a mode of HIV transmission and even higher percentage (94.6%) recognized it as a mode of transmitting STIs; still there was a considerable gap found between the knowledge and practices.

Very low attendance to STI clinics was also found in the study .Therefore another timely step would be to establish a STD clinic in the nearby Base Hospital, where workers can be benefitted both on preventive and treatment aspects.

Workers who were single had more unsafe sex while who were living with regular partners showed the highest safe sex which was statistically significant. Interestingly no significant association of unsafe sex was observed with age, level of education and working category even though those variables had significant association with their knowledge on HIV. This reflects that irrespective of the gender, age or educational

High level of heterosexual as well as homosexual unprotected sex was noticed in the study. Therefore the study highly recommends changing the traditional methods of awareness to more focussed methods of behaviour change communication (BCC) strategies highlighting the gap found in

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ knowledge and behaviour in the study. Implementation of condom promotion programme ensuring availability of condoms with confidential supply is also recommended. References 1.

National STD/AIDS Control Programme. Annual Report 2015. Colombo: National STD/AIDS Control Programme, Ministry of Health, Sri Lanka; 2016 UNAIDS.Report on the global AIDS epidemic. Geneva: 2008. Available from:http://www. Unaids .org/en/KnowledgeCentre/HIVData/GlobalReport/2 008/2008_Global_report.asp [Accessed 10th August 2009] BOI Sri Lanka.Setting up in Sri Lanka.Available from: http://www.boi.lk/2013/freetradezones industrial parks. asp. [Accessed 08th March 2013] Rawstorne P, Worth H.Sri Lanka Behavioural Surveillance Survey: First Round Survey Results 2006-2007. Colombo:National STD/AIDS Control Programme, Ministry of Healthcare and Nutrition, Sri Lanka.2007.

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Response to ART among adult PLHIV: a prospective study at HIV clinic Colombo Rajapaksa L .I.1, Herath N2., Aryaratne K. A. M.1, Weerasinghe G.1

Abstract Introduction: Sri Lanka has initiated ART programme in 2004. By the end of 2014 a total of 825 patients were receiving care services with 481 at the HIV clinic, Colombo. Based on WHO consolidated guidelines on ART published in 2013 the ART guideline was updated in 2014. It was decided to determine the response to ART among PLHIV managed according to the new guideline. The objective of the study was to determine the response to ART among adult PLHIV attending HIV clinic, NSACP. Methods: A clinic based prospective study was carried out at the main STD/HIV clinic in Colombo to assess the clinical and laboratory response to ART. All adult PLHIV who were started on ART from 1st November 2014 to 31st October 2015 were included in the study and were followed up till end October 2016. Data was collected using interviewer administered questionnaire by trained medical officers. Laboratory data and other relevant information were extracted from patient records. Ethical clearance was obtained. Results: A total of 95 patients were started ART at the HIV clinic, Colombo during this period. Majority (74%) were males with median age of 38 years. Among PLHIV 35.1% males and 24% of females were in WHO stage 3 or 4 at the time of presentation. TB was the commonest OI (10%) followed by PCP (9%). ART was started due to CD4 count< 500 cells/Âľl (77%), key populations (6%) and for PMTCT (5%). ART regimen had to be substituted in 7%. Adherence was satisfactory in females (88%) and males (89%). Most of the patients were on TDF+FTC+EFV regimen (67%) and this group experienced least side effects. Quality of life improved in 95%. CD4 count increased while viral load was <1000 copies/ml among 96% of those who had satisfactory adherence (n=76). Conclusion: Most patients had satisfactory adherence and clinical, immunological and virological response was satisfactory. Poor adherence need to be further analyzed. Fixed dose combination TDF+FTC+EFV was the preferred first line regimen and was well tolerated by PLHIV. Key words: ART, PLHIV, viral load, response, fixed dose combination Authors: corresponding author; 1 Dr L. I. Rajapaksa, MBBS, MSc, MD (Com.Med); Consultant Venereologists, National STD/AIDS Control Programme, Ministry of Health, Sri Lanka. Email: lilanirajapaksa2@gmail.com 2 Dr N. Herath, MBBS, PgDip Ven, MD; Acting Venereologists, National STD/AIDS Control Programme, Ministry of Health, Sri Lanka 3 K. A. M. Aryaratne, MBBS, MSc, MD (Com.Med), Consultant Venereologists, National STD/AIDS Control Programme, Ministry of Health, Sri Lanka 4 G Weerasinghe, MD (USSR), MSc, MD (Com.Med), FRCP (Edin); Consultant Venereologists, National STD/AIDS Control Programme, Ministry of Health, Sri Lanka Acknowledgement: The authors would like to acknowledge the staff of the HIV clinic, Colombo. We express our gratitude to all participants who consented to take part in the study. Originality: This is an original work not published anywhere Conflict of interest: No conflict of interest Funding â&#x20AC;&#x201C; Self funded Submitted: 10.12.2016, Accepted: 28.12.2016

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ Treatment guidelines for HIV infection are age-specific. Guidelines for adults and adolescents are compiled by the National STD AIDS Control Programme (NSACP) and latest edition is in 2014.

Full article Introduction By the end of 2015, 2309 new HIV infections have been reported to National STD/AIDS Control Programme with a HIV seropositivity rate of 0.02%. (1) According to the data available, adult prevalence remains less than 0.1% and the estimated number infected in the community is 4200. (2)

Justification Sri Lanka has initiated ART programme in 2004 and since then has managed many PLHIV with satisfactory results. The first guideline on HIV care was printed in 1998 followed by the ART guideline in 2004.(5,6) This was recently updated in 2014 based on the global consolidated guideline of WHO. It is important to have a clear understanding on the use of guideline in the management of PLHIV and also to assess the clinical and laboratory response to ART. For this we should look at the PLHIV population identified, eligibility criteria for initiation of ART, side effects, adherence issues and response to ART including weight gain, improvement of clinical presentation, CD4 levels and viral load levels. Clinical response will be assessed according to the WHO staging, performance scale and presence of opportunistic infections. WHO definitions for clinical, immunological and virological failure will be considered.

PLHIV are managed according to the national ART guidelines including appropriate treatment, contact tracing and regular follow up. Services for PLHIV are offered ranging from counselling and basic care to provision of ART services. (3) The decision on starting ART depends on the stage of the disease, CD4 levels, viral load, presence of any concomitant opportunistic infections, pregnant women and key populations. The goal of treatment is to maintain satisfactory immune system to prevent the occurrence of opportunistic infections. In Sri Lanka the CD4 level considered for eligibility for ART was <200 cells/µl from 2004. In the year 2011 this was changed to <350 cells/µl. The 2013 WHO consolidated guideline gives the cut off point as <500 cells/µl with priority for <350 cells/µl.(3) Antiretroviral therapy (ART) is the principal method for preventing decline of immunity. According to the 2013 WHO guideline prophylaxis for specific opportunistic infections was indicated when CD4 count is <200 cells/µl. (4)

Clinical failure in adults - New or recurrent clinical event (other than IRIS) indicating WHO stage 4 condition after 6 months of effective treatment Immunological failure - CD4 counts falls to the baseline or below, persistent CD4 levels below 100cells/mm3 or CD4 count drop by 50% or more from peak value

Successful long-term ART results in a gradual recovery of CD4 cell numbers and an improvement of immune response. Viral load is expected to decline within 5-6 months to undetectable levels indicating the response to ART. In addition to virologic response and reduced risk of opportunistic infection, there is evidence to suggest that non-AIDS-defining illnesses, particularly in psychiatric and renal disease, may also be reduced when on ART. (4)

Virological failure - Plasma viral load above 1000 copies/ml based on two consecutive viral load measurements after 3 months of treatment (4) We designed a prospective study to achieve the following objectives:

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ Objectives

CD4 count <500 cells/Âľl WHO stage 3 or 4 Pregnancy Key population Sero-discordant couples

General objective To determine the response to ART of adult PLHIV attending HIV clinic, NSACP

Exclusion criteria Specific objectives The following categories were excluded from the sample: paediatric patients with HIV, pregnant women with HIV and those who cannot give information regarding partners such as mentally subnormal people. PLHIV who had got registered during this period but had previous exposure to ART also were excluded.

To determine the sociodemographic characteristics of PLHIV on ART attending HIV Clinic, Colombo. To determine the eligibility criteria to start ART To describe the response to ART based on clinical as well as laboratory data To describe the effect of side effects and adherence issues in ART services. To determine the occurrence of drug resistance and treatment failure

Study instrument Data were collected by using an interviewer administered questionnaire which include questions on socio demographic characteristics, details about side effects and adherence issues. Emphasis was placed on clinical improvements following initiation of ART. Diagnosis of past opportunistic infections were based on the diagnosis cards issued during inward management and current infections were evaluated by a consultant physician. Details on the diagnosis of mild to moderate conditions which were managed as outpatients, eligibility criteria for ART and laboratory data were obtained through case records maintained at the HIV clinic.

Methods It was a clinic based descriptive study. Study setting Study was conducted in the HIV clinic, Colombo for two-year period from 1st November 2014 till 31st October 2016. HIV clinic, Colombo is the main HIV clinic of the country which had been in existence since HIV care services started in Sri Lanka. The principal investigator and other investigators are permanent staff members having experience in the setting for more than three years.

Method of data collection Data were collected by investigators who are practicing medical officers at the HIV clinic. As experienced medical officers having more than one year experience at the HIV clinic the investigators were able to obtain necessary information using correct techniques. They were given a 2-day training before conducting the study.

Sample size Study population was adult PLHIV eligible for ART services at the HIV clinic, Colombo. All PLHIV who become eligible for ART from 1st November 2014 to 31st October 2015 during were included in the sample. (5) According to the ART guideline developed in 2014 for Sri Lanka the eligibility criteria to start ART in 2014 and 2015 included the following;

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ Collection of data

Permission and ethical clearance:

Interview method was used to obtain information as this method also offers opportunity of counselling PLHIV as well. (7) There were 95 PLHIV who became eligible according to the criteria considered in the study.

Ethical clearance was obtained from the Ethical clearance committee of the National Hospital Sri Lanka. Permission to conduct the study was obtained from the Director, National STD AIDS Control Programme, Sri Lanka. Interviewer administered questionnaire did not include personal identification details to maintain anonymity and confidentiality. Further medical officers who have satisfactory training at the STD clinic and having more than one year experience in providing services were used as interviewers.

Each eligible PLHIV started on ART was included in the study sample. They were informed in detail the purpose of the study. A friendly atmosphere was developed before starting the interview. These people were interviewed while taking the history or when they were waiting for laboratory results. Only one person was interviewed in a clinic room at a time. After getting the informed consent questions were introduced. All the responses were entered by the interviewers according to the previously defined way. After the completion of the questionnaire the respondents were counseled on ART services.

Results Among the PLHIV who started ART in the period 75.8% were males and median age of PLHIV was 38 years. Median age for males was 38.9 years and for females this was 38.6 years. Most of the PLHIV had education up to OL or above and more females (72%) were in this group than males (68.4%). More males (38.0%) were single than females (28.5%). Close to half of PLHIV (54.3%) were married and living together with marital partner. Among males 53.5% were married while among females it was 57.1%. Monthly family income was less than Rs. 20,000 for most of the PLHIV (77.0%). More females belonged to this category (91.6%) than males (71.4%).

The sample was followed up till end October 2016 thereby end of the period all in the sample had completed period of one year or more after starting ART. Medical officers went through case records and previous diagnosis cards of each patient and filled the check list. Some cases which had issues in diagnosis were discussed with the consultant physician and final diagnosis was reached. Diagnosis of past opportunistic infections were extracted from diagnosis cards issued during inward management and current infections were evaluated by a consultant physician. Details on the diagnosis of mild to moderate conditions which were managed as outpatients, eligibility criteria for ART and laboratory data were obtained through case records maintained at the HIV clinic.

Among PLHIV 29% was identified in the late stage with symptoms including two PLHIV referred following diagnosis of TB. Five females were diagnosed through ANC screening. More PLHIV were in stage 1 and 2 at the time of diagnosis (67.4%) while 35.7% males and 22.7% females were in WHO stage 3 or 4. There were more males in stage 3 and 4 than females. However, this difference was not significant. (P>0.05) At the time of initiating ART significantly higher percentage of males (31.4%) were ill in performance B or C stage than females (18.2%).

Method of data analysis Data was analysed by the investigator using SPSS package.

principal

Among PLHIV 69.6% did not have any OI during the previous year and there was no Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ difference between males (70%) and females (68%). The common opportunistic infections were TB (10.1%), PCP pneumonia (9.1%) and oral candidiasis (5.1%).

relation to adherence there was no marked difference among males (11%) and females (12.5%). There was no association of adherence with educational status of PLHIV or marital status. However, those who had monthly income >Rs. 20,000 showed adherence more than those who earned less. Among those who were on TDF+FTC+EFV adherence was unsatisfactory in 12.6% while this was 20% among PLHIV on TDF+FTC+LPV/r.

Table 1: Eligibility criteria for initiation of ART Male Eligibility criteria for ART No. % WHO stage 2 2.9 CD4 count 57 81.4 Sero-discordant

Pregnancy

Female No. 2

Total

% No. 9.1

% 4.3

15 68.2 72 78.2

5.7

4.5

5.4

0.0

4 18.2

4.3

2.9

0.0

2.2

MARP

7.1

0.0

5.4

Total

100

Side effects Of the sample, 68.4% did not experience any side effects due to ART. There was no difference in males (69.1%) and females (65.0%). The common side effects reported were vomiting and nausea (11.5%) and skin rash (5.2%). These were mostly seen in the first 3 weeks after starting ART. Significant side effects were few which included jaundice (1.1%), anaemia (3.2%) and drowsiness (1.1%). 76.9% of PLHIV who were started on TDF+FTC+EFV did not show any side effects while this was 70% among PLHIV on AZT+3TC+EFV. Among those on TDF+FTC+LPV/r 54.5% were free of side effects. All 3 PLHIV who were on AZT+3TC+LPV/r experienced significant side effects. As expected PLHIV who developed anaemia were on AZT based regimens. Drowsiness, headache and fatigue were experienced by PLHIV who were on EFV based regimens. Skin rash, nausea and vomiting was seen among PLHIV who were on TDF+FTC+EFV.

22 100 92 100.0

(Missing â&#x20AC;&#x201C; 3)

Most patients were started on ART due to low CD4 count less than 500 cells/ Âľl. Five males started ART as they were continuing risk behaviours as MARPs. Pregnant women and PLHIV in serodiscordant relationships were others who started ART. Three PLHIV who were diagnosed in late stage of infection died soon after diagnosis before starting ART. The preferred first line regimen with fixed combination dose TDF+FTC+EFV was used for 66.3% of PLHIV. Fixed dose combination was the most used ARV regimen in all four WHO clinical stages. This included 70.8% males and 66.6% females. Another 11.6% of PLHIV were started on AZT+3TC+EFV. There were 12.6% on PI based regimens as first line ARV regimen. PI had to be considered in some instead of EFV due to neurological issues, depression, pregnancy and late stage presentations etc.

Only six PLHIV showed significant side effects to substitute first line ARV regimen. This included 2 patients on AZT+3TC+LPV/r and 2 PLHIV on TDF+FTC+LPV/r. Those on fixed dose combination TDF+FTC+EFV only 2 (3%) had to substitute ARV regimen due to side effects.

At the end of October 2016 there were 6 deaths reported in the sample and six were lost to follow up. Four PLHIV who died were in stage 4 at the time of starting ART.

When death and lost to follow up was excluded 94.5% showed improvement of quality of life while on ART. Five PLHIV including, four on TDF+FTC+EFV (6.1%) and one on TDF+FTC+LPV/r (10%) did not report

In the sample, only 1% had highly unsatisfactory adherence. However, another 9.5% showed unsatisfactory adherence. In

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ improvement of quality of life following initiation of ART. This included one PLHIV who was in WHO stage 4 at the start of ART and four PLHIV who were in stage 1 and 2. Mean weight increased from 53.3 kg at the time of initiating ART to 55.6 kg after starting ART. Median CD4 count at the time of starting ART was 276.7 cells/µl and the range was 2774 cells/µl. This increased to 530.8 cells/µl after treatment. With range 23 – 932 cells/µl. PLHIV in CD4 level less than 200 cells/µl decreased markedly from 34.7% to 3.2% while PLHIV with more than 500 cells/µl increased from 10.2% to 66.3% after starting ART.

Discussion The main objective of the study was to determine the response to ART of adult PLHIV attending the main HIV clinic, Colombo. All adult PLHIV who started ART during the study period (n=95) were recruited for the study. Small sample size was a limitation. The instrument which was used to collect data was an interviewer administered pre-coded structured questionnaire given in the Annexures. Representing the country literacy level 98% had some form of schooling. However, it was noted that females had more education than males. Close to three fourths of the PLHIV had monthly income <Rs.20,000. The percentage of females receiving family income < Rs. 20,000 was higher than males.

By the end November 2016, there were six deaths reported in the group. Six PLHIV were lost to follow up while three were transferred out to other clinics.

More males were in late stage than females at the time of diagnosis. This may be due to low perception of risk. As seen elsewhere TB and PCP were the commonest OI among PLHIV. In addition to low CD4 counts and symptoms other causes such as serodiscordant relationship, pregnancy and key populations practicing risk behaviours too were considered as eligibility criteria for ART according to the guidelines. With ART close to 90% showed improved quality of life. There were deaths among PLHIV diagnosed late in the disease with low CD4 counts. Early diagnosis would have prevented these deaths. According to the WHO recommendations most PLHIV were started on first line ART regimen with TDF+FTC+EFV. Side effects were not uncommon however, only six PLHIV had to substitute first line regimen due to toxicity. Serious toxicity which required substitution was lowest in the group on fixed dose combination TDF+FTC+EFV.

By the end November 2016, out of 80 PLHIV who were tested for viral load 91.3% had viral load <1000 copies/ml with 85% with viral load <34 copies/ml. Out of 7 who had >1000 viral load four had poor adherence. Three PLHIV showed treatment failure while on ART and they had low CD4 counts before starting ART. Among PLHIV who continued ART with satisfactory adherence 96.1% showed reduced viral load less than 1000 copies/ml. Table 2: Change in viral load after ART for more than one year Viral load level <34 34 - <1000 >1000 Total

No. of PLHIV 68 5 7 80

Percent (%) 85.0 6.3 8.7 100.0

Satisfactory viral load reduction response was closely associated to the adherence level. Those who showed poor adherence had high viral loads at the end of one year period. There was no relationship between side effects experienced and the level of adherence.

As expected with ART there was marked improvement of quality of life in 94.5% of PLHIV. After initiation of ART performance improved and mean weight increased. Median CD4 count increased from 276.7 cells/µl to 530.8 cells/ µl. There was significant reduction in viral load with 91.3% of the sample showing viral load <1000

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ copies/ml. Weight gain and performance scale improvement too indicate the positive response to ART. Those who showed high viral loads were either having unsatisfactory adherence or were defaulters. One year later there were six deaths mainly among late presenters who had low CD4 counts at the start. Though adherence is considered as a major challenge, in this study a high level of adherence was observed in most patients.

regimen and was well tolerated by PLHIV in the present study. References 1. 2. 3.

A major limitation of the study was the small number of patients who participated. Being a low prevalence country annual case detection is between 200-225. Out of them the numbers becoming eligible for ART is further reduced.

The study can conclude that significant immunological improvement and virological suppression is possible if satisfactory adherence is observed. As seen in other countries fixed dose combination TDF+FTC+EFV was the preferred first line

National STD/AIDS Control Programme. Ministry of Health, Annual Report 2015. Colombo; 2016 National STD/AIDS Control Programme. Ministry of Health, Sri Lanka country estimates HIV; 2015 National STD/AIDS Control Programme. Ministry of Health, The guidelines on use of antiretroviral drugs. Colombo: NSACP. (2014). WHO. Consolidated guidelines on the use of ART. Geneva: WHO. 2013. National STD/AIDS Control Programme. Ministry of Health, Guidelines for use of ART. Colombo: NSACP. 2004 National STD/AIDS Control Programme. Ministry of Health, Management of HIV infection. Colombo: NSACP. 1998 Fisher Andrew James R Foreit. Designing HIV AIDS intervention studies. Population Council. 8. WHO.The use of antiretroviral drugs for treating and preventing HIV infection WHO Geneva, second edition. 2016

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Time taken to escort men who have sex with men (MSM) for HIV testing in the peer group interventions in Sri Lanka M. Suchira Suranga1, D. A. Karawita2, S.M.A.S. Bandara3, R. M. D. K. Rajakaruna4

Abstract Introduction: Sri Lanka has completed a phase of an HIV prevention project (from 2013 to 2015) for men who have sex with men (MSM) under the support of Global Fund. The intervention was to deliver an HIV prevention package (HPP) to MSM which included provision of six services (1. STI knowledge, 2. HIV knowledge, 3. MSM tailored leaflets, 4. Condom/dildo demonstration, 5. Provision of condoms, and 6. Clinic escort). MSM who received all 1, 2, 3, 4 and 5 services in the HPP are defined as “reached”. The final step is to escort the reached (who received initial 5 services) MSM to an STD clinic, and ones they are escorted they are defined as “escorted”. This HPP was delivered to MSM through peer educators (PE) scattered in four high populous districts in the country. Each PE has regular contact with another 6-15 peers forming a peer group (PG). However, in this model, a significant number of MSM does not take the escorting step (step 6). Therefore, the purpose of this paper is to analyze the time taken to escort and other associated factors for an MSM to be escorted to an STD clinic. Method: All the MSM peers (699 MSM) registered in 2013 and retained during the project till the end of December 2015 have been filtered out from the web-based monitoring and evaluation information management system (MEIMS) for analysis. Time-to escort analysis with Kaplan–Meier was performed to find out median escort time. Hypothesis testing for equality of survival distribution (Kaplan–Meier curve) was conducted to determine the differences in probabilities of first clinic escort for different socio-economic and demographic characteristics. Results: Estimated median time-to escort was 17 months (SD = 0.867). Escorting is less likely with non-youth MSM (>25 years), educated MSM (> GCE O/L), rural MSM, Nachchi MSM (effeminate males), high frequent receptive MSM (>7/week) and high duration MSM (>10 years). Galle and Gampaha districts shows high performance in escorting compared to other districts Conclusions: More vulnerable and high risk segments of MSM population are less likely to be escorted for HIV testing in the current programme design. Current intervention need to strengthen with more focus strategies to address this programmatic gap. In addition, performance of PEs, field supervisors and coordinators has been observed to be a major factor in improving escort rate. Key words: Men who have sex with Men (MSM), HIV, time taken to escort, Escorts, Peer Education, Survival Analysis Authors: corresponding author: 1 Mr Suchira Suranga, M.Phil, M.Sc., B.Sc (sp) Hons, Deputy Director, Monitoring and Evaluation, The Family Planning Association of Sri Lanka. Email: suchirasuranga@gmail.com, suranga@fpasrilanka.org 2 Dr Ajith Karawita, MBBS, PGD Ven, MD, MSLCV; Consultant Venereologist, Teaching Hospital, Anuradhapura 3 Mr. Amal Bandara, M. Sc. (Reading), PGD in Development Studies, B.Sc (Nutrition), Monitoring and Evaluation Officer (Global Fund Project), The Family Planning Association of Sri Lanka 4Mr. Duminda Rajakaruna, MA (Sociology), BA (sp) Hons (Economics), Assistant Director, Monitoring and Evaluation, The Family Planning Association of Sri Lanka Acknowledgement: Family Planning Association of Sri Lanka, Heart to Heart Lanka, Saviya Development Foundation, Dr. Ariyaratne Manathunge, Consultant Venereologist, National STD/AIDS Control Programme of Sri Lanka Originality: This is an original work not published anywhere Conflict of interest: No conflict of interest Funding: Global Fund round 09 HIV prevention programme Submitted: 09.11.2016, Accepted: 10.12.2016

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ prevalence estimation carried out in the integrated biological and behavioural survey (IBBS) showed that HIV prevalence among FSW and MSM were 0.8% and 0.9% respectively while among DU and BB the HIV prevalence was 0%.

Full article Introduction Sri Lanka is an Island country of about 65,610 km2 located near the southern tip of India. Sri Lanka currently experience a low-level of HIV epidemic based on the fact that HIV prevalence has not consistently exceeded 5% in any of the high risk groups (HRGs) such as female sex workers (FSW), men who have sex with men (MSM), beach boys (BB) and people who inject drugs (PWID). (1) However, as of end 2015, a cumulative total of 2308 HIV positive persons have been reported to the National STD/AIDS Control Programme (NSACP), Ministry of Health, Sri Lanka. (2) During 2015, total of 235 HIV cases reported to the NSACP and it was the highest number reported in a year. In general, an estimate of 10.5 new infections occurs per week while, only about 4.5 new cases reported to the NSACP per week. (2)

Peer group approach Sri Lanka has completed a phase of HIV prevention project from 2013 to 2015 (36 months) under the support of the Global Fund. The Family Planning Association of Sri Lanka (FPASL) as the non-governmental principal recipient of the GFATM grant carried out interventions targeting men who have sex with men (MSM). The main intervention is through peer group model (Fig 01). In this model, identified MSM peer educators (identified persons with knowledge and leadership qualities within peer networks) were trained and a monthly allowance was given to maintain a regular contact with another 6-15 peers forming a peer group (PG). These peer educators (PEs) were employed in different locations and overall supervision was carried out by full-time salaried field supervisors and district coordinators.

During the last five years (2011-2015) relative proportion of heterosexual transmission of HIV reduced from 74% (2011) to 54% (2015) while proportion of male-to-male transmission increased from 20% (2011) to 41% (2016). Mother to child transmission remained between 3-7% over the last 5 years. Injecting drug use as a mode of transmission reported in less than 2.5% of cases. However, transmission through, blood and blood products have not been identified as a method of transmission since 2000. (2)

Fig 01: Peer Group P â&#x20AC;&#x201C; Peer (6-15 in number) MSM PEâ&#x20AC;&#x201C; Men who have sex with men peer educator

Peer educators are supposed to deliver an HIV prevention package (HPP) to MSM in their peer group. HIV prevention package (HPP) includes the provision of 6 components listed in the Box 1.

National Stretegic Plan (NSP) of Sri Lanka has identified different HRGs for HIV prevention interventions such as Female sex workers (FSW), men who have sex with men (MSM), beach boys (A group of men who associate with tourists as guides or animators, and provide entertainment including sexual services, majority of them are bisexuals), clients of sex workers and drug users (DU) as most-at-risk populations (MARPs). (3) The mapping and size estimation study carried out in 2013 showed that estimate of 14,132 female sex workers, 7,551 MSM, 1314 BBs, and 17,459 DU in the country. (4) HIV

Box 1: HIV prevention package (HPP) 1. Provision of STI knowledge 2. Provision of HIV knowledge 3. Provision of MSM tailored leaflets 4. Condom/dildo demonstration 5. Provision of condoms and 6. Escorting of peers to STD clinic for HIV testing.

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ Under this project, HPP was delivered through 248 MSM peer educators to their peer groups covering a population of 3,638 MSM.

Baseline data was collected at the registration of an MSM to peer groups using an interviewer administered registration form. The subsequent follow up data on the status of the delivery of components of the HPP including the escort status to an STD clinic for HIV testing were monthly recorded by PE on the Peer Calendar and sent to the community based organization (CBO) under which PEs were employed. Furthermore, re-checking of peer calendars and on site data verifications were carried out by the M&E staff to improve data quality. The M&E staff of the CBO feeds data to the web-based monitoring and evaluation information management system (MEIMS) maintained at the Family Planning Association of Sri Lanka (FPA)

Peers are referred as “Reached” if the first five services are delivered (reached peers). Once the reached peers (who received all 1-5 services in the HPP) are escorted to an STD clinic they are referred as “Escorted” (escorted peers). (5) Although escorting of MSM to the government STD clinic for HIV testing and counselling is one of the important aspects of the HIV prevention package, percentage of MSM escorted remained 23% to 39% during the past three years (2013-2015). Table 01 describe the number and percentage of MSM escorted from 2013 to 2015 against number of MSM reached with HPP (6).

This MEIMS maintains peer cohort from the time of peer registration with follow up data during the project period using a unique identifier called client reference number or client ID (From 2013 to end 2015). (5)

Table 1: Number and percentage of MSM reached vs. escorted from 2013 to 2015.

Year

Number of MSM Reached with HPP

Number of MSM escorted to STD Clinics

Percenta ge of MSM escorted

2013

2127

496

23%

2014

2980

969

33%

2015

3638

1416

39%

Time-to-event analysis was performed using Kaplan–Meier curves and estimates. Total of 699 MSM peers registered during the accrual period of the project (2013). Peer registration was considered as the “start of the serial time” and event was the escort step of the HIV prevention package (6th step). Total of 699 serial times were analyzed using KaplanMeier estimator (KM estimator) at the end of the project period to find out median escort time with 95% confidence interval. In this study, inverse KM curve (one minus survival function) was used to understand the escorting pattern of the MSM cohort. So, the X axis of the curve represent the “time to first escort” in number of months from initiation of the project and Y axis represent “proportion of MSM escorted at least one time” to STD clinics for HIV testing. The oneminus survival function is referred to as the “time-to-escort function” hereafter in this paper. An important advantage of the Kaplan–Meier curve is that the method can take into account some types of “censored data” (7). In this study, censored data represent the MSM who couldn’t escort at

Source: - Annual Progress Report of the Primary Recipient 2 (PR2) - Global Fund HIV prevention Project (Round 09 Grant - Phase 2

The purpose of this paper is to analyze the factors affecting the median time-to-escort “time taken to escort” to an STD clinic. This study analyse the escorting pattern of the first year cohort (2013) who retained in the project till the end of follow-up (end December 2015)

Methodology A cohort of MSM registered in the first year (2013) and who retained in the project till the end of December 2015 (end of follow-up) was taken for the analysis. Total of 699 MSM peers registered in the first year and retained till the end of follow-up.

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ least one time by end of the project (December, 2015). Further, hypothesis testing (Mantel-Cox test, Generalized Wilcoxon test and Tarone-Ware test) was conducted to determine the differences in probabilities of first escort for different socio-economic and demographic characteristics. One minus survival functions (Time-to-escort functions) of different sub samples of MSM (considering socio-economic and demographic characteristics) were compared and graphically illustrated.

Time-to-escort analysis Out of the 699 serial times, 499 MSM peers (71.4%) had completed the event of interest (escort step) at least one time by the end of the project period (secular time). The remaining MSM (28.6%) who have not been escorted at least one time were presented as â&#x20AC;&#x153;Censoredâ&#x20AC;? in KM curves. Estimated median time-to-escort was 17 months (SD = 0.867 months). In other words, as an estimate, only 50% of the MSM peers have been escorted to the STD clinics during the first 17 months (95% CI = 15.3-18.7 months) of the project.

Results

Time-to-escort analysis by district of project implementation

Background Information A total of 699 MSM peers, retained in the service cycle during the project period (20132015), were filtered out for the analysis and sample characteristics are shown in the table 02. Table 2: Distribution of sample characteristics Freq

Perce nt (%)

Cum. Perce nt (%)

District

Colombo Gampaha Kalutara Galle Total Urban Semi urban Rural Total <25yr >25 Total Married Unmarried Living together Divorced Widow Total Up to Grade 08 Up to GCE O/L Up to GCE A/L Above GCE A/L Total <5 yr 5 to 10 10 to 20 > 20 yr Total

247 98 97 257 699 304 184 211 699 335 364 699 125 514 32 17 9 697 98 361 205 32 696 173 252 228 43 696

35% 14% 14% 37% 100% 43% 26% 30% 100% 48% 52% 100% 18% 74% 5% 2% 1% 100% 14% 52% 29% 5% 100% 25% 36% 33% 6% 100%

35% 49% 63% 100%

Location

Age

Marital Status

Level of School Education

Duration in MSM behavior (No of years)

Escorted

Levels

Proportion of MSM

Variable

Figure 1: Time-to-escort functions by districts

43% 70% 100% (Generalized Wilcoxon test P = 0.534, X2 = 2.1920 and TaroneWare test P = 2610, X2 = 4.006).

48% 100%

As shown in the figure 1, the time-to-escort functions of different districts are significantly different, showing a high escort rates in Galle and Gampaha by end of the project (log rank test P=0.033, X2 = 0.050). Although, there is no statistically significant difference in escort rates among four districts in the first half of the project, Kalutara district has performed over other districts during the first half. So, lowest median time to first escort was recorded in Kalutara (13 months) followed by Colombo (16 months), Gampaha (16 months) and Galle (17 months).

18% 92% 96% 99% 100% 14% 66% 95% 100% 25% 61% 94% 100%

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ Time-to-escort analysis by sociodemographic and behavioural factors

with more frequent receptive anal sex (>7 week), long duration MSM (>10 years). Other groups of MSM showed less medium time-to-escort (more likely to escort). They included, generally young MSM (<25 years), Less educated MSM (up to GCE O/L), noneffeminate MSM, urban and semi-urban MSM (Table 3)

Escorting of MSM peers for an STD clinic is depend on many factors. In the secular time period of the study(2013-2015), some MSM showed relatively more median time-toescort. They included, Non-youth MSM (>25 years), educated MSM (> GCE O/L), rural MSM, Nachchi MSM (effeminate males), MSM

Table 3: Distribution of estimated median time-to-escort and hypothesis tests by socio-demographic factors and behavioural factors

Variable

Levels

Sociodemographic factors

Age (years) Youth: < 25 yrs Non-youth: >25 yrs Level of Education

Marital Status

Location of the hot spot MSM Category

Behavioural factors

Frequent of receptive anal sex per week Frequent of insertive anal sex per week Duration of MSM behavior Test for HIV before joining with the program

Youth Non-youth Overall Up to GCE O/L Above GCE O/L Overall Ever Married Other Overall Rural Urban/Semi Overall Nachchi Other MSM Overall Less than 7 7 and above Overall Less than 7 7 and above Overall <10 years >10 years Overall Yes No Overall

Estimated Median timeto-escort (months) 95% Confidence Interval Months Lower bound

Upper bound

16 17 17 16 20

13.096 14.564 15.300 14.412 16.707

18.904 19.436 18.700 17.588 23.293

17 16 17 17 17 16 17 20 16 17 16 22 18 17 13 16 16 17 17 16 22 17

15.180 13.264 14.824 15.280 13.841 13.763 15.300 13.185 14.528 15.330 12.444 19.143 15.348 15.293 10.119 14.394 13.912 13.976 15.180 14.254 16.852 15.180

18.820 18.736 19.176 18.720 20.159 18.237 18.700 26.815 17.472 18.670 19.556 24.857 20.652 18.707 15.881 17.606 18.088 20.024 18.820 17.746 27.148 18.820

Hypothesis tests for equality of time-to-escort Breslow (Generalized Wilcoxon) Early part of the curve

TaroneWare

Log Rank (Mantel-Cox)

Middle part of the curve

Latter part of the curve

X2=3.389 P=0.066

X2=4.194 P=0.041*

X2=5.098 P=0.024*

X2=3.420 P=0.064

X2=3.964 P=0.046*

X2=4.201 P=0.040*

X2= 0.000 P= 0.984

X2=0.012 P= 0.913

X2= 0.060 P= 0.807

X2= 2.666 P= 0.103

X2= 3.424 P= 0.064

X2= 4.580 P=0.032*

X2=1.300 P=0.254

X2=2.227 P=0.136

X2=3.454 P=0.043*

X2=10.513 P=0.001*

X2=9.257 P=0.002*

X2=7.799 P=0.005*

X2=0.350 P=0.554

X2=0.209 P=0.648

X2=0.062 P=0.804

X2=2.159 P=0.142

X2=3.170 P=0.05*

X2=4.419 P=0.036*

X2=1.985 P=0.159

X2=2.480 P=0.115

X2=2.941 P=0.086

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Proportion of MSM Escorted

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Figure 3: Cumulative Escort distributions for high educated and less educated MSM

Proportion of MSM Escorted

Figure 2: Cumulative Escort distributions for youth and non-youth MSM

Figure 4: Cumulative Escort distributions for MSM living in rural and urban area

Figure 5: Cumulative Escort distributions for Nachchi and other MSM

Proportion of MSM Escorted

Pr o p or ti o n of M S M Es co rt e d

Figure 6: Cumulative escort vs duration of MSM behaviour (<10years and â&#x2030;Ľ10 years)

Figure 7: Cumulative Escort distributions by number of receptive anal sex

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ escort is associated with age group of MSM (P=0.008), level of education (P=0.007), urban/rural status

Discussion A previous cross sectional analysis conducted using the sample of MSM found that the clinic (P<0.001), duration of MSM behaviour (P=0.018), experience of an HIV test during previous 12 months (P=0.050), number of receptive anal sex (P=0.050). (8)

insertive MSM (>7/week) probably due to the fact that low frequent insertive MSM are reluctant to disclose the homosexual behaviour at STD clinics. In this analysis, rural MSM were also needed long time-to-escort which may be due to stigma and distance related factors. Overall, these results indicate that MSM with higher risk of HIV take longer time for the first escort and are less likely to be escorted for HIV testing. As shown in the graphical illustrations, and results of the hypothesis testing, this difference is higher and significant in the middle and later part of the project. Apart from the socio-demographic and behavioural factors, pressure imposed on peer educators by the project management to achieve the escort targets may affect on higher rate of escorts of low risk MSM who are easy to escort for HIV testing. This programme quality gap may increase by introducing strategies such as incentivising the peer educators on their performance, by setting unrealistic targets.

In this study, time-to-escort analysis and hypothesis testing for equality of escort functions shows that some groups take long time to be escorted to an STD clinic. Those groups include high frequent receptive MSM (>7/week), MSM who never had an HIV test (before project enrolment), educated MSM and Nachchi MSM (effeminate MSM). Furthermore, Peer educators have taken about 17 months to escort Non-youth MSM, rural MSM, low frequent insertive MSM (<7/week) and MSM with >10 years behaviour. Therefore, different innovative strategies need to be adopted to increase the rate of HIV testing among those who take longer time-to-escort. High frequent receptive MSM (>7/week) and Nachchi MSM (effeminate MSM) are less likely to be escorted by peer educators. Nachchi MSM also includes male sex workers (MSW) and most of them practice receptive anal sex. Receptive anal sex and effeminate nature of Nachchi MSM have self and felt stigma which made them to be escorted less likely.

In addition, it has been observed that district variation of escort rates are also largely depend on the district level implementation (CBO), performance of PE, field supervisors and coordinators who can overcome some of the difficulties found. These lesson learnt needs to be considered in designing and implementing of future HIV prevention interventions for MSM.

MSM who never had an HIV test before the enrolment to the project seems to be still difficult to be escorted for an HIV test may be due to some personal or access related barrier.

Conclusion Escorting of MSM peers to an STD clinic is depending on many factors. The estimated median time-to-escort an MSM peer was 17 months from the start of the project.

Furthermore, non-youth MSM and long duration MSM (>10 years) are also taking relatively long time-to-escort may be due to some experience based personal attitude.

Time-to-escort functions of different districts are significantly different, showing a high escort rates in Galle and Gampaha towards the end of the project, there is no significant

Although it is not statistically significant, low frequent insertive MSM (<7/week) are more difficult to be escorted than high frequent

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ difference in escorts among four districts in the first half of the project. This shows the differences of efficiency of implementation of the project by the staff of the CBOs. Efficiency is significant at the latter part of the project most probably due to the time, target and incentive bound programmatic pressure of the project.

References 1.

Relatively longer time has been taken for peer educators to escort high frequent receptive MSM (22 months) and MSM who never had an HIV test (22 months). A median of about 20 months has been taken to escort educated MSM and Nachchi MSM. Furthermore, it has been taken about 17 months to escort nonyouth MSM, rural MSM, low frequent insertive MSM (<7/week).

Relatively shorter period (13 months) has been taken by peer educator to escort high frequent insertive MSM (>7/week) probably due to their self acceptance of homosexual behaviours and more masculine nature of the behaviour.

Generally, more attention and tailored interventions are necessary to improve escort rates among MSM who needed longer timeto-escort to an STD clinic for HIV testing because they are less likely to be escorted. Current intervention need to be strengthened with more focus strategies to address this programmatic gap. In addition, performances of PEs, field supervisors and coordinators have been observed to be a major factor in improving escort rate.

UNAIDS/WHO. Guidelines for second generation HIV surveillance. World Health Organization. Geneva : s.n., 2000. NSACP/MoH. Annual Report 2015. National STD/AIDS Control Programme, Ministry of Health. Colombo : s.n., 2016. National STD/AIDS Control Programmes. National Strategic Plan 2013-2017. National STD/AIDS Control Programme, Ministry of Health. Colombo : s.n., 2013. National STD/AIDS Control Programme. National size estimation of most-at-risk populations (MARPs) for HIV in Sri Lanka. National STD/AIDS Control Programme, Ministry of Health. Colombo : National STD/AIDS Control Programme, 2013. Family Planning Association of Sri Lanka. Monitoring and Evaluation Plan, Glonal Fund round 9 HIV prevention project (Phase II) . Family Planning Association of Sri Lanka. Colombo : s.n., August 2013. The Family Planning Association of Sri Lanka. Annual Progress Report of the PR2 - Global Fund HIV prevention Project (Round 09 Grant - Phase 2). Colombo : Monitoring and Evaluation Unit - The Family Planning Association of Sri Lanka, 20132015. Nonparametric estimation from incomplete observations. Kaplan, L E and Meier, P. [ed.] John Tukey. 282, 1958, Journal of the American Statistical Association, Vol. 53, pp. 457-481. Factors associated with clinic escorts in peer-led HIV prevention interventions for men who have sex with men (MSM) in Sri Lanka. Suranga, M Suchira, et al. UNAIDS, WHO Working Group. Guideline for second generation HIV surveillance: an update: Know your epidemic. World Health Organization. Geneva : s.n., 2013.

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Hyperbilirubinemia during atazanavir treatment in people living with HIV (PLHIV), Sri Lanka. D.I.Rajapaksha1, A.Azraan2, L.I.Rajapaksa3

Abstract Introduction: Atazanavir (ATV) is an antiretroviral drug of the protease inhibitor class. It is used to treat HIV infection in combination with other HIV medications. Atazanavir was first introduced to National STD/AIDs control programme of Sri Lanka in 2014. Symptomatic hyperbilirubinemia is a common adverse effect associated with atazanavir use. Objective of this study was to see the significance of hyperbilirubinemia with ritonavir boosted atazanavir use among people living with HIV receiving antiretroviral therapy. Method: This was a descriptive cross sectional study carried out among all PLHIV started on retonavir boosted atazanavir based regimens, who were receiving care services at National STD/AIDS control programme, Sri Lanka. Results: Total of 40 PLHIV who had taken atazanavir more than 90 days during the study period (28 months) were analyzed. Cumulative incidence of hyperbilirunemia of grade 2 or above during the study period was 40% (n=16). Almost all PLHIV had isolated indirect hyperbilirubinemia. Conclusions: Significant proportion of patients (40%) developed grade 2 or more indirect hyperbilirubinemia following initiation of atazanavir based therapy and 25% (n=10) improved symptomatically and biochemically during follow up. But in 12.5% (n=5) patients antiretroviral regimen had to be substituted. Key words: Atazanavir, hyperbilirubinemia, substitution, People living with HIV (PLHIV) Authors: corresponding author; 1Dr D.I. Rajapaksha, MBBS, PgDVen, MD Venereology; Senior Registrar, NSACP, Colombo, Sri Lanka. Email: irukamfc@yahoo.com 2Dr A. Azraan, MBBS, PgDVen, MD Venereology; Senior Registrar, NSACP, Colombo, Sri Lanka. 3Dr L. I. Rajapaksa, MBBS, Dip STD, MSc Community Medicine, MD Community Medicine; Consultant Venereologist, NSACP, Colombo, Sri Lanka. Acknowledgement: HIV clinic staff Conflict of interest: No conflict of interest. Funding: No funding support for this study Originality: This is an original work, not published or presented anywhere. Submitted: 29.11.2016, Accepted: 15.12.2016

neucleoside reverse transcriptase inhibitor or an integrase inhibitor as first line

Full article antiretroviral therapy (ART). National guideline of antiretroviral drugs for treating and prevention of HIV infection 2014, Sri Lanka prefer tenofovir (TDF), emtricitabine (FTC) plus efavirenz (EFV) as first line ART regimen. There are instances, where we use protease inhibitor class in first line instead of efavirenz in some patients such as patients

Introduction World Health Organization (WHO) consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection 2016, recommends two nucleoside/ nucleotide reverse transcriptase inhibitors plus a non

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ with psychiatric illness, history of suicidal attempts and who are engaged in shift duties especially night tasks, etc. When first line antiretroviral regimen failed, we prefer second line regimen constitute with a boosted protease inhibitor. In Sri Lanka, protease inhibitor class is also used as a switching drug to people who cannot tolerate non nucleoside reverse transcriptase inhibitor class. Ritonavir boosted atazanavir (ATV/r), lopinavir (LPV/r) and darunavir (DRV/r) are the available options in Sri Lanka. Darunavir is mostly restricted to third line regimens. Following introduction of atazanavir (ATV) in 2014 in Sri Lanka, it is more preferred due to once daily dosing and less likely to cause lipid elevations. Atazanavir is the first protease inhibitor approved for once daily dosing. It is available in 300mg capsule formulation. It was first approved in 2003 from U.S. Food and Drug Administration. It is recommended for treatment naive and treatment experienced HIV patients (1) (2).

Table 1: Severity grading hyperbilirubinemia according to laboratory parameters Toxicity Grade 1 Grade 2 Grade 3 Grade 4

of the

Hyperbilirubinemia >1.0-1.5×ULN >1.6-2.5×ULN >2.6- 5×ULN > 5×ULN

Atazanavir causes an elevation of unconjugated hyperbilirubinemia as a result of UDP glucuronyl transferase 1A1 inhibition. UGT 1A1 is responsible liver enzyme for conjugation of bilirubin to soluble glucuronide (1). This adverse effect appears with initiation of atazanavir. Most frequent symptoms are scleral icterus and yellowish discolouration of skin. This is mostly isolated hyperbilirubinemia and other liver enzymes are not affected. Following introduction of atazanavir to national programme since 2014 we have started atazanavir in combination with other antiretrovirals for 42 people living with HIV. However, little is known about atazanavir induced hyperbilirubinemia among Sri Lankan patients. The objective of the study was to assess significance of hyperbilirubinemia in HIV infected patients started on atazanavir based regimen.

Common side effects of atazanavir include nausea, vomiting, jaundice, abdominal pain, diarrhea, dizziness and flu like illness. Atazanavir associated hyperbilirubinemia is a common adverse effect and it was defined as hyperbilirubinemia developing after initiation of atazanavir therapy in the absence of other causes of hyperbilirubinemia (1). According to WHO consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection 2016, indirect hyperbilirubinemia (clinical jaundice) is a major type of toxicity associated with ritonavir boosted atazanavir (ATV/r) therapy. But this phenomenon is clinically benign but potentially stigmatizing. WHO consolidated guidelines 2016, mentioned to substitute only if adherence is compromised. Hyperbilirubinemia as an ART toxicity was classified in accordance with WHO consolidated guidelines 2016 (2) (Table 1).

Method A descriptive cross sectional study was conducted among all the PLHIV who initiated antiretroviral therapy (ART) with atazanavir (300mg per day) from May 2014 to August 2016 (28 months) and received care services at the Colombo, HIV clinic of the National STD/ AIDS control programme, Sri Lanka. PLHIV who were started on atazanavir based regimen at least 90 days prior to study period were included in the study. Forty (40) study subjects were included in the study. Atazanavir exposure was evaluated from records of all patients. The prescription of antiretroviral with the starting and ending dates were identified through patient’s

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ records. Baseline liver profile tests, hepatitis B surface antigen and hepatitis C antibody screening test, which were carried out prior to initiation of antiretroviral therapy were studied and documented. Liver profiles were followed up at regular intervals of 1 month, 3 months, 6 months and thereafter in every 6 months following initiation of atazanavir. The total bilirubin level recorded at any point during the follow up was taken in to account in deciding the severity grading of toxicity. Data was collected using a data extraction sheet and data was processed and analyzed by using Microsoft excel 2013.

HC Ab Alcohol abuse INAH prophylaxis

They were followed up at monthly intervals and liver profiles repeated at 1 month, 3 months and 6 months after the initiation of antiretroviral therapy. Thereafter, in every 6 months if there were no other indications. Cumulative incidence of hyperbilirunaemia (toxicity grade 2 or above) during the period of 28 months was 40% (n=16) and of them 35% (n=14) were symptomatic with scleral icterus. In all cases hyperbilirubinemia was developed within first 90 days of initiation of therapy.

Table 1: Baseline characteristics

ATV/r started among

ALT

AST

GGT

S.bilirubin HBs Ag

No. 38 1 1 40 21 7

Percent 95% 2.5% 2.5% 100% 52.5% 17.5%

10 1

25% 2.5%

1 40 36 4 40 36 4 40 33 7 40 40 40

2.5% 100% 90% 10% 100% 90% 10% 100% 82.5% 17.5% 100% 100% 100%

100% 32.5% 67.5% 100% 35% 65% 100%

As baseline, alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), gamma glutamyl transferase (GGT) and serum bilirubin levels were measured prior to the initiation of atazanavir/ritonavir based therapy. All the study participants had total bilirubin levels less than upper limit of normal and liver enzyme levels less than twice the upper limit normal (ULN) before starting atazanavir. All the study subjects had been tested for hepatitis B and C coinfections prior to initiation of therapy and none were positive. (Table 1)

In the study population (n=40), majority were males (68%). An overall mean CD4 cell count at the initiation of atazanavir was 481 cells/µl (Mdn=378 cells/µl) and the range was 16 – 960 cells/µl. Distribution of other baseline characteristics is tabulated in table 1.

Category TDF+FTC+ATV/r ABC+3TC+ATV/r ZDV+3TC+ATV/r Total Naïve First line substitution second line Second line substitution Third line Total < ULN B/w 1-2 x ULN Total < ULN B/w 1-2 x ULN Total < ULN B/w 1-2 x ULN Total < ULN Negative

40 13 27 40 14 26 40

B/w-Between, ULN-Upper limit of normal, INAHIsoniacid

Results

Category Regimen

Negative Yes No Total Yes No Total

Among those who developed indirect hyperbilirubinemia, none showed elevations of AST, ALT, GGT, ALP more than twice the upper limit of normal. Hyperbilirubinemia due to unconjugated hyperbilirubinemia was seen among all study subjects. During the study period, outcome of interest (total bilirubin level) was measured and recorded against the level of toxicity grades (table 2)

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ Table 2: Distribution by level of toxicity Toxicity No toxicity Grade 1 Grade 2 Grade 3 Grade 4 Total

Bilirubin < ULN >1.0-1.5×ULN >1.6-2.5×ULN >2.6- 5×ULN > 5×ULN

No 20 4 5 6 5 40

was on stage 3 management level of bronchial asthma. Percent 50% 10% 12.5% 15% 12.5% 100%

Discussion Several clinical studies demonstrated atazanavir induced hyperbilirubinemia. CASTLE was a randomized 96 weeks trial which demonstrated clinical significance of hyperbilirubinemia among HIV 1 infected patients treated with ritonavir boosted atazanavir. Overall 44% of patients receiving atazanavir/ritonavir had hyperbilirubinemia (grade 3- 4) at any time during the 96 weeks study. Less than 1% of patients discontinued atazanavir due to hyperbilirubinemia, jaundice or scleral icterus (3). Atazanavir and other determinants of hyperbilirubinemia studied in a cohort of 1150 HIV positive patients of 9 year follow up period in Canada. Cumulative incidence of hyperbilirubinemia of grade 3 and 4 after 1, 5 and 8 years exposure to atazanavir were 30.1%, 73.4% and 83.6%, respectively (4). Findings among PLHIV in Sri Lanka were also supported by CASTLE and atazanavir and other determinants cohort study of 1150 patients in Canada.

Patients with grade 2 toxicity (5 patients) continued with the same regimen, hyperbilirubinemia improved with time. Six patients developed symptomatic grade 3 toxicity with scleral icterus. Among them one patient had ultrasonic evidence of grade 2 fatty liver disease since baseline and she was on long term antidepressants in addition to antiretrovirals. Patient was really worried about icterus and atazanavir discontinued due to cosmetic reasons. Her regimen was substituted with boosted lopinavir and she improved rapidly. Four patients with grade 3 toxicity continued on same regimen with close observation of symptoms and liver functions. They showed gradual reduction of total bilirubin level and regression of symptoms with time. One patient with symptomatic adverse effects lost to follow up. Grade 4 toxicity developed in 5 patients. They had isolated indirect hyperbilirubinemia. Atazanavir was discontinued in 4 patients with grade 4 toxicity.

This study provided information on use of atazanavir among Sri Lankan PLHIV. All the patients started on atazanavir based therapy since 2014 were included in the study. In this group 3 PLHIV had poor adherence and experienced virological failure while another PLHIV defaulted for follow up. Cumulative incidence of hyperbilirubinemia during 28 months period was 40%. Atazanavir associated hyperbilirubinemia was not related with elevations of other liver enzymes, but it led to discontinuation in 5 patients due to cosmetic reasons. However, there were few limitations which need to be mentioned. Firstly, small sample size is a concern. Monitoring of liver functions could be done at more regular intervals, if it was available consistently.

Cosmetic issues were a concern for PLHIV as they had deep scleral icterus. And it was substituted with another protease inhibitor or non nucleoside reverse transcriptase inhibitor due to aesthetic reasons. Following substitution, they improved rapidly where symptoms disappeared and liver biochemistry returned to normal levels. Three (7.5%) patients who were started on atazanavir experienced virological failure due to adherence issues and had to be started on another antiretroviral regimen. It was substituted in one PLHIV to avoid drug interactions with inhalational steroids, as she

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

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Conclusion

References

Significant proportion of study subjects (40%) developed isolated indirect hyperbilirubinemia during the period studied (28 months). However, none showed elevations of liver enzymes more than twice the upper limit normal. Cosmetic issues were a concern among study subjects and led to discontinuation of therapy in 12.5%. As our sample size is small we cannot conclude suitability of atazanavir as a first line therapy. We need to follow up larger cohort of patients to predict about adverse effects and outcome of atazanavir use.

Drug record – atazanavir. United States: National Library of Medicine (https://livertox.nih.gov/Atazanavir/, accessed 25 November 2016). Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection, recommendations for a public health approach. Geneva: World Health Organization; second edition 2016 (http://www.who.int/hiv/pub/arv/arv-2016/en/, accessed 21 November 2016). Molina JM, Andrade-Villanueva J, Echevarria et al; management of antiretroviral naïve HIV 1 infected patients: 96 week efficacy and safety results of the CASTLE study;2010(https://www.ncbi.nlm.nih.gov/pubmed /20032785, accessed on 15 November 2016). Claudie L, Jean-Guy B, Helen T, et al; atazanavir and other determinants of hyperbilirubinemia in a cohort of 1150 HIV – positive patients: Results from 9 years of follow up; 2013 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3 704117, accessed on 18 November 2016).

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Management of sexually transmitted infections (STI)-associated syndromes by part-time general practitioners (GP) in Puttalam district. Wijayasinghe, W.A.H.P1., Ariyaratne Manathunge2, Harshani, S.R.A.P.3

Abstract Introduction: Puttalam district shows higher rate of HIV. Considering the interaction between HIV and STI, management of STI-associated syndromes by GPs was studied. The objective of the study was to describe the management of STI-associated syndromes by GPs in Puttalam district. Method: A descriptive cross-sectional study was done in Puttalam district from 1st February to 30th April 2016 among 114 randomly selected part-time GPs using a self-administered questionnaire. Management of five STI syndromes was compared with national guidelines. Results: Vaginal discharge and lower abdominal pain syndromes were encountered by majority (97%) of GPs. However, vaginal discharge was considered as the syndrome with the highest possibility of an STI by majority (93%) of GPs. Urine full report (94.9%) and VDRL (77.5%) were the commonest investigations ordered by GPs. Only 4.3% of patients with urethral discharge, 4.3% of patients with vaginal discharge, 15 % of patients with genital ulcers, 10.5% of patients with scrotal swelling and 1.7% of patients with genital warts were managed according to the national guidelines. Notably none of the patients with lower abdominal pain syndromes were managed according to the guideline. Management of partners of patients with STI syndromes were done by 50.9% of GPs. Majority of GPs (87%) educated patients on STI prevention. Most of the referrals were to the local STI clinic (74.6%) and most of these referrals were patients with genital warts (89.5%). Conclusions: Large number of GPs is managing patients with STI syndromes. However, standard management of STI syndromes is done by only small number of GPs. Therefore, more educational and training programs on STI management for GPs are recommended. Key words: STIs, Sexually Transmitted infections, GPs, General practitioners Authors: corresponding author; 1 Dr W.A.H.P. Wijayasinghe , MBBS; National STD/AIDS Control Programme, No 29, De Saram Place, Colombo 10, Sri Lanka. Email: hemindawijaya@gmail.com 2Dr Ariyaratne Manathunge , MBBS, MD; Consultant Venereologist, National STD/AIDS Control Programme, No 29, De Saram Place, Colombo 10, Sri Lanka. 3Dr. S.R.A.P. Harshani MBBS, MSc in community medicine; Additional MOH, MOH office, Puttalam, Sri Lanka. Acknowledgements: RDHS â&#x20AC;&#x201C; Puttalam, All heads of institutes of government hospitals in Puttalam district, All medical officers in Puttalam district. Conflict of interest: Authors claim no conflict of interest Funding: No funding support Originality: This was presented as an oral presentation in the 21st Annual scientific sessions of College of Sexual Health and HIV medicine. Submitted: 07.12.2016, Accepted: 28.12.2016

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ men with Chlamydia and 80% of women and 10% of men with gonorrhoea are asymptomatic)5

Full article Introduction Sexually Transmitted Diseases (STD) that are reported to the National STD/AIDS Control Programme are on the rise. According to the annual report of the National STD/AIDS Control Program (NSACP), there have been 19,530 and 22,059 new patients registered in STD clinics in Sri Lanka in 2013 and 2014 respectively. Most common STDs in 2014 in Sri Lanka were Genital herpes, Non Gonococcal Urethritis, Genital Warts, Syphilis, Gonorrhoea and Trichomonaiasis in descending order of prevalence.

Most of these STDs are curable, provided the patients are treated with the appropriate antibiotic or antiviral with the correct dose for recommended duration. If not, they may be partially treated and may transmit the disease to their sexual contacts and may become resistant for commonly used antibiotics as well. It is very important to treat the partners in STIs because if the partner is not treated, the patient will acquire the infection again from the partner in a short time. And it is very important to educate them regarding the protective mechanisms and provide them the necessary psychological and social support. It is also important to follow up them regularly and screen them for other STIs as well. Safe sexual practices are the best methods for prevention. Delaying sexual debut, monogamous partnership, correct and consistent use of condoms and changing from high risk penetrative sex to low risk nonpenetrative sex are among them.

STIs are mostly transmitted via unprotected sexual intercourse but there can be other ways of transmission as well. e.g.: via contaminated needles/ sharp instruments, blood and blood products and mother to child. Unprotected receptive anal sex is the most risky sexual practice but the disease can be transmitted in vaginal or oral sex as well. There are several factors that contribute to transmission of STIs. Among them social factors like lack of knowledge and lack of access to affordable protective mechanisms, cultural and religious reasons, inability to negotiate with the partner for safe sex: biological factors like younger age, female gender, behavioural factors like multiple partners, regular changing of partners, injectable drug use are common contributors. Having one STI makes a person vulnerable to acquire more STIs because the genitalia becomes inflamed and opens up a pathway for infections. Women are at a higher risk than men as their area of genital exposure is larger than men and they usually start sexual life earlier than men.

In Sri Lanka, NSACP is the place where prevention and treatment programs for STIs are being implemented and monitored. There is one central STD clinic in Colombo as well as there are 30 peripheral STD clinics and 23 branch clinics scattered in Sri Lanka to control and treat STIs. According to the publication of World Health Organization in 2007, management of Sexually Transmitted Diseases should not be exclusively done at STI clinics.6 They can be managed by first contact medical officers according to the guidelines for syndromic approach for STI management. NSACP has published guidelines for syndromic approach for STD case management in 2001.7 It includes treatment for current episode, health education on STIs, counselling on safe sexual practices, partner notification and treatment,

Main symptoms in STDs are genital, peri-anal or oral blisters and/or ulcers, discharge from urethra and/or vagina, warts in genitalia or peri-anal region, pain and swelling of testis and lower abdominal pain. But it has been found that most of the patients with STIs are asymptomatic. (70% of women and 50% of

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ condom promotion and follow up or referral to an STI clinic.

district of Puttalam which is located in the North-Western part of the country. It has 48 government western medicine institutes, including: one District General Hospital (DGH), two Base Hospitals (BH), 12 District Hospitals (DH), 33 Preliminary Care Health Units (PMCU) and 16 Medical Officer of Health areas (MOH). There were 386 Doctors working in these health care institutes when the study was carried out.

Justification: Puttalam district is situated in North Western province in Sri Lanka. STD clinic, Chilaw is the main clinic that manages patients with STDs in the Puttalam district. There have been 664 new patients registered in the STD clinics in 2013, of which 363 patients were diagnosed of having one or more STDs and 779 new patients were registered in 2014, of which 406 patients were diagnosed of having one or more STDs.

Doctors who were working in the government hospitals and practising as part-time GPs were considered as the population and there were 203 GPs in the sampling frame. Doctors who were on leave during the study period, specialists in medical profession, and doctors practicing other than western medicine were excluded from the population.

8,9

Total newly registered patients moved up from 11th position in 2013 to 6th position in 2014 in the country in comparison with other districts.8

Simple random sampling (SRS) technique was used to select study units from the sampling frame of 203 GPs. Sample size was calculated using 95% confidence level, assumed proportion as 50% (0.5) and acceptable error as 10% (0.1). Calculated sample size was 96 and a 25% of non-response rate was then added and required sample size came as 120.

The most prevalent presentations to the STD clinic, Puttalam in 2014 were Non Gonococcal Urethritis, Vaginal Candidiasis, Bacterial Vaginosis, Genital Herpes and Syphilis.9 It also showed a significant number of HIV patients in Puttalam district in 2014 with 2.3/100,000 population which became the 3rd highest prevalence within a district in the country. 9

Structured self administered questionnaire was used as the data collection tool. Questionnaire was pre-tested among a group of part-time GPs outside Puttalam district and necessary adjustments were made to the final questionnaire.

Considering these facts and that inadequate management of STDs can lead to increase in transmission of HIV. Therefore, it was decided to carry out a study on syndromic management of STDs by part time general practitioners in Puttalam district.

Data collection was completed during 1st February 2016 to 30th April 2016 by the principal investigator.

Objectives:

Ethical clearance was obtained by Ethics Review Committee, Faculty of Medicine, University of Kelaniya (letter number: FWA 00013225)

To study the management of STI-associated syndromes by part time general practitioners in the district of Puttalam.

Data analysis was done using SPSS version 13 and results were compared with the syndromic management guidelines published by NSACP in 2001.

Methods Descriptive cross sectional study was carried out among part-time GPs practising in the

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ GPs practices on five different STI-associated syndromes (namely urethral discharge, vaginal discharge, genital ulcers, scrotal swelling, pain and tenderness in lower abdomen and genital growths) were observed.

considering STIs as a cause for those STIsyndromes. Table 2: Percentage of GPs who have seen an STI-associated syndrome and who thought an STI as a cause of the syndrome (n=114) STI-associated syndromes

Results

Percent of GPs seen STIsyndromes (n=114)

The study data collection was carried out among 114 randomly selected sample of GPs (response rate 95%)

Vaginal discharge 97% Lower abdominal pain 97% Scrotal swelling 90% Genital ulcers 78% Urethral discharge 76% Genital growths 60% Percentages are not mutually exclusive

Background characteristics Distribution of basic characteristics of the sample is mentioned in the table 1.

Percent of GPs suspected an STI as a cause (n=GPs who have seen the symptom) 94% 93% 89% 87% 56% 46%

Table 1: Sample characteristics of GPs Characteristic Gender Male female Total Place of GH work BH DH PMCU MOH Total Experience <1year as a GP 1-2years 2-5years >5years Total

Number 78 36 114 24 45 27 8 10 114 17 29 16 52 114

Percent 68% 32% 100% 21% 40% 24% 7% 9% 100% 15% 25% 14% 46% 100%

Investigations ordered by GPs for STIassociated syndromes Investigations have been performed by 102/114 GPs. Common investigations ordered by GPs for STI-associated syndromes in the private practice are tabulated in table 3. UFR was the mostly ordered investigation by GPs. Table 3: Investigations performed on patients with given STI syndromes by GPs Category None UFR VDRL Genital swabs FBC ESR Pap smear HIV antibodies Hep B serology

DGH-General Hospital, BH-Base Hospitals, DH-District Hospitals, PMCU-Preliminary Medical Care Units, MOH-Medical Officer of Health.

Experience of STI-associated syndromes Majority of the GPs have seen patients with STI syndromes. Vaginal discharge is the mostly seen STI syndrome and genital growth (genital warts) is the least seen STI syndrome. Majority suspects an STI as a possible cause of the symptom. Considering of a possibility of an STI is highest with the symptom vaginal discharge [n=107(93.8%)] and lowest with scrotal swelling [n=53(46.5%)]. Most important thing is that some GPs are not

Number

Percent 12 93 76 29 9 3 1 1 1

11% 95% 78% 30% 9% 3% 1% 1% 1%

Percentages and numbers are not mutually exclusive

Use of antibiotics syndromes by GPs

for

STI-associated

Most of the GPs would use antibiotics for management of STI syndromes. Antibiotics use by STI-syndrome are tabulated in table 4.

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ They used antibiotics mostly on vaginal discharge and least on genital growths.

and 30 (52.8%) out of them are managing asymptomatic partners as well. Performing investigations on partners was done by 52 GPs (45.6%) and the most commonly used investigation was UFR, as it was with the patients. (Table 6) Table 6: investigations performed on partners by GPs

Table 4: Percentage of GPs who use antibiotics for different STI-syndromes (n=114) STI-associated syndromes Vaginal discharge Lower abdominal pain Scrotal swelling Genital ulcers Urethral discharge Genital growths

Number 110 82 74 71 92 14

Percent 96.5% 83.3% 76.3% 65.8% 81.6% 17.5

Category UFR VDRL Genital swab HIV screening Hep B serology

Percentages and numbers are not mutually exclusive

Common antibiotics used by GPs for different STI-syndromes are tabulated in the table 5 with dose and frequency. It is interesting to notice that some of them have used antibiotics for genital growths whereas 3 GPs (2.6%) have used trichloroacetic acid (TCA) for treatment. Table 5: Use of antibiotics by the STIsyndrome Symptom

Mostly used antibiotic

Vaginal discharge (n=110)

Metronidazole 400mg tds, PO

36%

Urethral discharge (n=92)

Ciprofloxacin 500mg bd, PO

Lower abd. pain (n=82)

Number 42 42 16 03 1

Percent 72 72 27 05 02

Percentages and numbers are not mutually exclusive

Use of antibiotics on partners of patients with STI-syndromes was done by 33 (28.9%) GPs and they were mostly similar to the antibiotics used with patients. (Table 7) Table 7: Most common antibiotics used on partners

Percent.

Symptom of the patient

Mostly used antibiotic

46%

Vaginal discharge (n=9)

Metronidazole 400mg tds, PO

27%

Ciprofloxacin 500mg bd, PO

48%

Urethral discharge (n=6)

Ciprofloxacin 500mg bd, PO

18%

Scrotal swelling (n=74)

Ciprofloxacin 500mg bd, PO

39%

Lower abdominal pain (n=9)

Ciprofloxacin 500mg bd, PO

27%

Genital ulcers (n=71)

Acyclovir 400mg tds, PO

31%

Scrotal swelling (n=5)

Ciprofloxacin 500mg bd, PO

15%

Genital growths (n=14)

Acyclovir 400mg tds, PO

50%

Genital ulcers (n=7)

Acyclovir 400mg tds, PO

21%

Genital growths (n=3)

Acyclovir 400mg tds, PO

Percentages and numbers are not mutually exclusive

Percent. of GPs out of whom used antibiotics

Percentages and numbers are not mutually exclusive

Management of partners of patients with STI-associated syndromes

Health education sessions carried out by GPs for patients with STI-associated syndromes

Managing partners of patients with STIsyndromes was done by 50.9% (n=58) of GPs

Health education is a part of complete management of STI patients and it was done

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ by 99 GPs (87%). Out of that, 73.7% of them advised to stick to a single partner, 71.1% advised on correct and consistent use of condoms and 77.2% advised on importance in follow up.

GPs current practice of management was co pared with the national guidelines on the management of STI-associated syndromes. Majority of GPs are not following standard treatment guidelines. However, it seems that acceptable number of GPs educate patients (87%), promote condoms (71%) and discuss about partner management (51%). (Table 10) Table 10: GPs practicing expected management

Referral decisions taken by GPs for STIassociated syndromes GPs mostly referred patients with genital growths (90%). Patients with lower abdominal pain were the least referred syndrome (54%). (Table 8)

Management component

Table 8: referring of patients with STIassociated syndromes for management STI-associated syndromes

Genital growths Genital ulcers Vaginal discharge Urethral discharge Scrotal swelling Lower abd. pain

Number of GPs who referred patients 102 92 74 72 68 62

Use of correct treatm ent

Genital ulcers Scrotal swelling Urethral discharge Vaginal discharge Genital growths Lower abd. pain Health education to patients Condom promotion Partner management

Percent of GPs who referred patients 90% 81% 65% 63% 60% 54%

Discussion

Percentages are not mutually exclusive

Most of the GPs participated in the research were having experience of more than 5 years as a GP and have seen patients with STIassociated syndromes in GP practice. Vaginal discharge is the mostly seen STI syndrome and genital growth (genital warts) is the least seen STI syndrome. Their suspicion on possibility of a patient having an STI with presenting symptoms is highest with the vaginal discharge [n=107(93.8%)] and lowest with scrotal swelling [n=53(46.5%)]. They mostly used UFR as the investigation on patients with STI syndromes. Antibiotic use was for patients with STI syndromes were highest with vaginal discharge and lowest with genital growths whereas use of proper antibiotic with recommended dose and duration for STD syndromes was lower7.

They mostly referred patients with STI syndromes to the local STD clinic for further follow up, and they also referred patients to other specialities as well. (Table 9) Table 9: place of referral Place of referral

Local STD clinic Gynaecology clinic Dermatology clinic Consultant Venereologist Surgical clinic

Number of GPs who referred patients 86 83 55 24

Percent of GPs who referred patients 75% 73% 48% 21%

21%

Percent of GPs practising expected treatment 16% 10.5% 4.4% 4.4% 2.6% 0.0% 87% 71% 51%

Percentages are not mutually exclusive

Comparison of current management practice with the standard management for STIassociated syndromes by GPs

Partner management was done by 51% of GPs, which is not satisfactory and it should be improved. Use of antibiotics on partners was not according to the national guidelines 7.

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Papers __________________________________________________________________________________ Health education to patients and condom promotion were satisfactory (87% and 71% respectively) but need to be further improved.

Conclusions Experience of GPs with patients having STI syndromes was more than 50% for all the given six syndromes. Their level of suspicion on the syndromes was more than 50% except for genital growths. They mostly used UFR as the investigation for patients with STI syndromes. Antibiotics were used for management of all the given STI syndromes and different antibiotics were preferred for different STI syndromes.

5. 6. 7. 8.

Partner management was also done by some GPs and some of them managed asymptomatic partners as well. They used investigations on partners and the most common investigation was UFR. They used antibiotics on partners as well but the number was less than that of patients.

practice in the Netherlands BMJ Open. 2013 Dec 30; 3(12) Lorch R. et.al. (2013) The chlamydia knowledge, awareness and testing practices of Australian general practitioners and practice nurses: survey findings from the Australian chlamydia control effectiveness pilot (ACCEPt).BMC Fam Pract. 2013 Nov 13; 14: 169 Kalwij S. et.al. (2003-2011) Using educational outreach and a financial incentive to increase general practices' contribution to chlamydia screening in South-East London BMC Public Health. 2012 Sep 18; 12:802. Homes K. et.al .Sexually transmitted diseases : 4: 555-595: 607-647 World Health Organisation. (2007)Training modules for syndromic management of STIs: 2nd ed: STD case management work book , National STD/AIDS Control Programme /Sri Lanka. (2011) Annual report 2013, National STD/AIDS Control Programme, Sri Lanka Annual report 2014, National STD/AIDS Control Programme, Sri Lanka

Health education and condom promotion was done at GP practice. Some GPs referred patients with STI syndromes to other healthcare professionals, mostly to local STD clinic. With reference to national guidelines, their use of antibiotics on patients with STI syndromes was poor. Considering all above factors, more educational and training programs on STD management for GPs at primary health care are recommended.

References 1.

Wetten S.et.al (2015) Diagnosis and treatment of chlamydia and gonorrhoea in general practice in England 2000-2011: a population-based study using data from the UK Clinical Practice Research Datalink.BMJ Open. 2015 Apr 22; 5 (5) Trienekens SC. et.al. (2008-2011) Consultations for sexually transmitted infections in the general

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Case Reports __________________________________________________________________________________

Gonococcal Tysonitis K.A.C.R.Wijesekara1, N.Abeygunasekara2

Abstract A 31 year old married male presented with urethral discharge, dysuria and painful lump over the penis. Examination revealed thick, yellowish, offensive urethral discharge and tender, enlarged Tysonâ&#x20AC;&#x2122;s gland. Gram staining of the urethral smear showed intracellular and extracellular Gram negative diplococci, suggesting the diagnosis of gonococcal tysonitis. He responded well to the intramuscular ceftriaxone and oral doxycycline therapy. Key words: Gonococcal tysonitis Authors: corresponding author; 1 Dr K.A.C.R. Wijesekara, MBBS, PgD Ven, Registrar in Venereology, National STD/AIDS Control Programme, No 29, De Saram Place, Colombo 10, Sri Lanka. Email: randimadr@yahoo.com 2 Dr N Abeygunasekara, MBBS, PgD Ven, MD; Consultant Venereologist, Teaching Hospital, Kalubowila, Sri Lanka Conflict of interest: Authors claim no conflicts of interest Funding: Self financing Originality: This is an original work and there have not been any previous publications Submitted: 03.12.2016, Accepted: 15.12.2016

worker. Examination revealed thick, yellowish discharge with offensive odour at the urethral meatus. There was a soft, tender and erythematous lump (0.5cm x 0.5cm) over the coronary sulcus close to the right side of the frenulum (Figure 1). There was no discharge from the enlarged Tysonâ&#x20AC;&#x2122;s gland. Gram staining of the smear taken from the urethral discharge showed intracellular and extracellular Gram negative diplococci. However, gonococcal culture became negative as there was a delay in transporting the sample to the central lab. Serological tests for syphilis and HIV were negative. The patient was treated with intramuscular ceftriaxone 500mg single dose and doxycycline 100mg twice daily for seven days. The patient responded well to treatment and intracellular/ extracellular Gram negative

Full article Introduction Gonorrhoea is a curable STI with profound impact on sexual and reproductive health. Worldwide annual estimation of new gonococcal infection is 78 million (1). In Sri Lanka during the year 2015, about 450 gonorrhoea cases were reported (2). Usually gonorrhoea resolved without complications. Gonococcal Tysonitis is a very rare complication with only a few reported cases in the world. Literature survey did not reveal any reported cases from Sri Lanka. Following is a case of gonococcal tysonitis.

Case history Thirty one year old newly married man attended the STD clinic, Kalubowila complaining of burning pain inside the urethra while passing urine for 1 week, urethral discharge for 5 days and painful lump over the penis for 3 days duration. He had sexual exposures only with marital partner and last sexual exposure was three days back. According to him she was a female sex

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Case Reports __________________________________________________________________________________ diplococci were absent in the repeated urethral smear. Figure 1: Purulent urethral discharge with unilateral Tysonitis

References 1.

Discussion

This patient was having gonococcal urethritis complicated with unilateral Tysonitis. Tysonâ&#x20AC;&#x2122;s glands are modified sebaceous glands, without hair and with ducts lined by columnar epithelium located one on each side of the frenulum and communicate directly with the prepucial sac. Their function is to produce smegma. Gonococcal Tysonitis is a rare entity causing a protruding cystic globoid enlargement either unilaterally or bilaterally. The cystic swelling is tender and filled with pus (3).

4. 5.

6. 7.

World Health Organization. Sexually transmitted and reproductive tract infections. 2016. who.int/reproductivehealth/topics/rtis/en National STD/AIDS Control Programme. Annual report Sri Lanka. 2015. Mc millan, Alexander. Young, Hugh. Ogilvie M, Marie. Scott R G. Clinical practice in sexually transmissible infections. 1st edition. Saunders; 2002. Fiumara.N.J. Gonococcal Tysonitis. British Journal of Venereal Diseases. 1977;53:145. Subramanian S. Gonococcal Urethritis with Bilateral Tysonitis and Periurethral Abscess. Sexually Transmitted Diseases. 1981;8:77. Gaffoor PMA. Gonococcal tysonitis. Postgraduate Medical Journal. 1986;62:869â&#x20AC;&#x201C;70. Bavidge.K.J.N. Gonococcal infection of the penis. British Journal of Venereal Diseases. 1976;52:66. National STD/AIDS Control Programme. Sexually transmitted infections management guideline Sri Lanka. 2009.

The size of the swelling can vary from a large pea to that of a small olive. There is more chance of infection in patients with congenital genital abnormalities and phimosis. Attention should be paid to such patients with gonorrhoea to rule out Tysonitis. Tysonitis presents a distinct and unique clinical picture which is easily diagnosed if there is awareness of the condition. Tysonitis can also be caused by other organisms such as Escherichia coli. Gonococcal urethritis with associated tysonitis is rare. It could be either unilateral as in this patient or bilateral Tysonitis as reported by Fiumara, Subramanian and Abdul Gaffoor in their case reports (4)(5) (6). Bavidge also reported one case of gonococcal tysonitis (7). Tysonitis occur as a local complication of gonorrhoea and it can co-infect with Chlamydia trachomatis in 15-35% of cases (8). Standard treatment includes 500mg single dose of intramuscular ceftriaxone with doxycycline 100mg twice daily for 1 week.

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

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Diagnostic dilemma in managing relapsing episodes of Cryptococcal meningitis in HIV infected patient; a case report Pannala. W.S1, Godakandaarachchi. L.P.P2, Wijewickrama. A3, Ranatunga. J. D4

Abstract HIV associated morbidity and mortality has dramatically been reduced over the past decade with introduction of antiretroviral therapy (ART). However, significant number of undiagnosed patients still present with advanced HIV disease. Cryptococcal meningitis, commonly caused by the fungus Cryptococcus neoformans, is one of the commonest central nervous system opportunistic infection among those who diagnosed during advanced stage of disease. Relapsing episodes of Cryptococcal meningitis is not uncommon following successful treatment. Relapses may occur due to treatment failure or development of paradoxical cryptococcal immune reconstitution inflammatory response (IRIS) following immunological recovery with ART. However, the exact cause of relapse occurring after commencement of ART is indistinguishable from treatment failures and IRIS. Here, we present a case of a patient with HIV who had been treated for Cryptococcal meningitis that subsequently developed two recurrent episodes of Cryptococcal meningitis after initial Cryptococcal treatment, within consecutive two months while on ART. Key words: HIV, ART, Immune Reconstitution Inflammatory Syndrome, IRIS, Paradoxical Cryptococcal IRIS Authors: corresponding author; 1 Dr W.S.Pannala, MBBS, PgD Ven; Registrar, National STD/AIDS Control Programme, No 29, De Saram Place, Colombo 10, Sri Lanka. Email: warunip@yahoo.com 2 Dr L.P.P Godakandaarachchi, MBBS, PgD Ven; Registrar , North Colombo Teaching Hospital, Ragama, Sri Lanka,Email:piyumika8@gmail.com 3Dr.A.Wijewickrama,MBBS, MD, MRCP (UK); consultant physician, National Institute of Infectious Diseases, Angoda, Sri Lanka 4Dr.J.D.Ranatunga,MBBS,PgD Ven,MD; consultant venereologist, North Colombo Teaching Hospital, Ragama, Sri Lanka Acknowledgement: Professorial medical unit, NCTH, Ragama, Sri Lanka, staff of the NIID, Angada and STD clinic, Ragama, Sri Lanka Conflict of interest: Authors claim no conflicts of interest Funding: No funding support for this case report Originality: This is an original work and there have not been any previous publications Submitted: 09.11.2016, Accepted: 20.12.2016

cryptococcal disease are C. neoformans var. grubii, neoformans and gattii. Epidemiological studies have confirmed that primary infections occur during childhood and are usually asymptomatic (1). Infection occurs following inhalation of organism and result in localized disease in the lung. Conditions in which the host immune system is compromised, such as HIV infection, organism disseminates from the lung to other organs, especially to the brain, where it causes the meningoencephalitis (2).

Full article Introduction HIV associated morbidity and mortality has dramatically been reduced over the past with introduction of antiretroviral therapy (ART). However, late presentations of disease still remain to be a problem even in developed world. Cryptococcal meningitis is one of the commonest life threatening central nervous system opportunistic infection among patients with advanced HIV disease. Causative organism, Cryptococcus is encapsulated yeast, ubiquitous in the environment. The organisms most commonly associated with HIV-related

According to the latest CDC recommendations (Centers for Disease Control and Prevention, USA) treatment of cryptococcal meningitis

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Case Reports __________________________________________________________________________________ consists of three phases, Induction therapy, consolidation therapy and maintenance therapy. For induction, Amphotericin B formulations are given intravenously in combination with oral flucytosine. After two weeks of successful induction therapy consolidation therapy is initiated with fluconazole 400mg daily and continued at least 8 weeks. Subsequently fluconazole should be reduced to 200mg daily and continue as chronic maintenance therapy to complete at least one year. High dose flucanazole monotherapy (1200md daily) is inferior to amphotericin B, depending on the early fungicidal activity and can be given alternatively for induction therapy only for those who cannot tolerate amphotericin B.

a diagnosis of exclusion, making it a diagnostic dilemma especially in resource limited settings. Other than several case reports and few retrospective and prospective studies published in other countries, to our knowledge there are no published materials in Sri Lanka in this regard.

However, subgroup of patients will develop relapsing episodes of meningitis after successful initial response. This can either be due to treatment failure or paradoxical cryptococcal IRIS.

28 year old married male presented at North Colombo Teaching Hospital (NCTH), Sri Lanka on first week of May 2016 with a history of intermittent fever and headache associated with loss of appetite and loss of weight for last three months duration. At onset, the fever was low grade. However, during the later part of the illness, he developed high grade fever with chills which needed hospital admission. He was investigated and treated as an outpatient in private sector for several weeks when he admitted to NCTH. Though he complained on and off dry cough, he did not have haemoptysis or significant shortness of breath on exertion. He had left sided moderate headache without photophobia, vomiting or limb weakness. He neither had altered level of conciseness nor the seizures. The patient was investigated at NCTH as a case of pyrexia of unknown origin (PUO) and found to have positive HIV screening test which was confirmed by the Western blot test. His baseline liver and renal functions were within normal limits. He had moderate normochromic normocytic anaemia (Hb9.8g/dl) which was reported as anaemia of chronic disease in blood picture. Pulmonary TB was excluded by negative mantoux test, chest radiograph and three negative sputum samples for Acid-fast Bcilli (AFB). Sputum was also negative for Tuberculosis culture as well as GeneXpert MTB assay. He was negative for

Here, we present a case of a newly diagnosed patient with HIV who had been treated for Cryptococcal meningitis that subsequently developed two recurrent episodes of meningitis after initial treatment response, within consecutive two months while on antiretroviral therapy.

Case history

Treatment failure is defined as “a lack of clinical improvement and continued positive CSF cultures after 2 weeks of appropriate therapy, including management of increased intracranial pressure (ICP) or as a relapse after an initial clinical response, defined as recurrence of symptoms with a positive CSF culture after ≥4 weeks of treatment”(3). Whereas in IRIS patients experiences a clinical deterioration as a consequence of rapid and dysregulated restoration of antigen specific immune responses during the treatment with antiretroviral therapy or ART(4). Although there is no gold standard definition for IRIS, it is generally accepted that certain minimum requirements should be fulfilled to diagnose IRIS. A temporal association between ART initiation and the subsequent worsening of symptoms, evidence of immune restoration with ART and exclusion of possible other pathologies are among them(4). Paradoxical Cryptococcal-IRIS occurs around 6% to 45% patients with HIV associated Cryptococcal meningitis who survive to start ART(5). However, Cryptococcal-IRIS is usually

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Case Reports __________________________________________________________________________________ Hepatitis B surface antigen, Hepatitis C antibody and toxoplasma antibodies. However, cytomegalovirus (CMV) antibody came as positive, but CMV was not detected by DNA PCR. He did not have focal lesions or cerebral oedema on contrast-enhanced computed tomography (CECT) brain.

or vomiting. But the patient continued to have ART and fluconazole without seeking medical advice for the next four weeks. Then he admitted at infectious disease hospital (IDH), Angoda on the first week of August 2016 with one episode of altered consciousness which persisted about 2 hours on previous day. On admission he was on ART and fluconazole 400 mg daily for last six week. He was having moderately severe generalized headache for about last four weeks without fever, vomiting or neurological weakness. He was also having good compliance to both drugs on admission. The patient was conscious, rational and afebrile and had neither features of meningeal irritation nor focal neurological signs at presentation. His respiratory, cardiovascular and abdominal examinations were normal. His renal functions, liver functions and haematological parameters were within normal limits at this admission.

The lumber puncture revealed no CSF pleocytosis, slightly elevated CSF protein (54.6mg/dl) and reduced glucose levels (31mg/dl). C. neoformans was positive in India Ink preparations and cryptococcal cultures along with positive serum and CSF cryptococcal antigens, confirmed the diagnosis. Furthermore, CSF was negative for bacterial cultures, Tuberculosis cultures as well as GeneXpert MTB. His baseline CD4 count was 78 cells/µl and baseline HIV-1 viral load was 920,487 copies/ml. Around third week of admission, the patient was commenced with amphotericin B deoxycholate 0.7mg/kg IV daily for induction phase of the cryptococcal meningitis treatment. However, he was unable to receive treatment for more than 5 days due to rising serum creatinine levels. (from 79 µmol/l to 174 µmol/l). Thereafter, he was treated with oral fluconazole 1,200 mg daily for two weeks (14 days) as the induction phase of treatment. The patient’s serum creatinine was reduced back to normal levels after discontinuation of treatment with amphotericin B deoxycholate. At the completion of 2 weeks of induction therapy fluconazole dose was reduced to 400mg once daily treatment which was planned to be given in next 8 weeks as the consolidation phase of the treatment. After completion of two weeks induction phase, the patient was symptom free. However, microbiological response was not assessed with repeat CSF cultures. Around the third week of cryptococcal meningitis therapy, ART was started with tenofovir, emtricitabine and efavirenz (TDF+FTC+EFV) regimen. The patient well tolerated ART and was asymptomatic thereafter, until completion of two weeks of ART when he again developed moderately severe on and off headache without any fever

The lumber puncture at IDH revealed marked CSF inflammation with a WBC count of 27 cell/µl (100% lymphocytes), 102mg/dl protein. CSF was positive for cryptococcal antigens, whereas CSF India ink stain and cryptococcal culture became negative. High pressure flow of CSF through the needle was observed during the lumber puncture, but the exact CSF pressure was not measured. CSF cultures for bacteria and mycobacteria were also negative and the computed tomography (CT) of the brain did not show any focal lesions. While waiting for culture results, empirical therapy was started with high dose cefotaxime and liposomal amphotericin B 3mg/kg IV daily and ART was continued without interruption. The patient’s headache was fully resolved with this treatment together with serial lumber punctures in first two consecutive days of admission with removal of 20 -30 ml of CSF during each time. He only experienced marginal serum creatinine rise with liposomal amphotericin B, comparing with initial Amphotericin B deoxycholate therapy. During the hospital stay patient did not experience any new symptoms or signs and two weeks of

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Case Reports __________________________________________________________________________________ induction period of liposomal amphotericin B was successfully completed. The patient was discharged on the 20th day, few days after restarting fluconazole 400 mg daily as consolidated phase of cryptococcal therapy and remained asymptomatic while receiving ART and fluconazole until he readmitted after 4 days of discharge with reappearance of headache, severe vomiting and one episode of self limited left sided body weakness. On admission patient was conscious, rational and afebrile but having positive neck stiffness and Kernig’s signs indicating meningeal irritation. But he did not have any focal neurological signs. Noncontrast computed tomography (NCCT) of the brain was normal on admission. CSF revealed 72mg/dl protein, low sugar and 14 cells/µl (100% lymphocytes). CSF was still positive for Cryptococcal antigen and the India ink stain and Cryptococcal culture were negative. During the lumbar puncture procedures (sitting position), high pressure flow of CSF through the needle was observed, but the exact CSF pressure was not measured. Patient’s symptoms were resolved with another two serial lumber on two consecutive days removing 30ml of CSF during each time. The patient was continued with ART and fluconazole 400mg daily.

Discussion Serum cryptococcal antigen is almost always positive in patients with cryptococcal meningitis (3). All patients with a positive serum cryptococcal antigen should undergo further evaluation by lumbar puncture after CT or MRI cerebral scanning(1). A positive CSF cryptococcal antigen, Indian ink stain of CSF, or CSF Cryptococcus culture confirms meningitis(1). Up to 75% patients with cryptococcal meningitis have routine blood cultures positive for Cryptococcal neoformans (3). As our patient had positive serum and CSF cryptococcal antigen together with positive CSF India ink stain and positive CSF cryptococcal culture he fulfilled all the criteria to diagnose HIV associated cryptococcal meningitis during the first presentation at NCTH, Ragama. However, his blood cultures were not positive for Cryptococcal neoformans. Paradoxical Cryptococcal IRIS occurs as worsening or recurring already treated Cryptococcal disease in the same or new anatomical site, despite microbiologic treatment success (6). Other than the commoner CNS manifestations like meningeal disease and cryptococcoma, C-IRIS can present as non-CNS manifestations like fever, eye disease, suppurating soft tissue lesions, hypercalcemia or cavitative and nodular pulmonary disease (6). Reported time to develop paradoxical C-IRIS after ART varies widely with median time ranging from 1 to 10 months (6).

At the beginning of the first relapse, his CD4 count had been increased to 246 cells/ µl from baseline value of 76 cells/ µl and HIV1 viral load was reduced to 49 copies/ml indicating rapid immunological and virological recovery with six weeks of ART. Although the relapses were initially considered as treatment failures, considering negative fungal cultures as well as rapid immunological and virological response to ART, both relapses were assumed to be caused by paradoxical cryptococcal IRIS retrospectively. He received 8 weeks fluconazole 400mg daily as consolidation phase of cryptococcal therapy without interruption and currently fully recovered and in good condition with ART and fluconazole 200mg daily maintenance therapy.

In our case patient was clinically responded during initial two weeks of antifungal therapy and presented with worsening CNS symptoms at six weeks of ART. However, we were not certain about the patient’s initial microbiological treatment success after treatment as we did not perform repeat lumber puncture and CSF cultures following completion of induction phase of therapy. Risk factors for paradoxical-IRIS have been reported as high HIV viral load prior to ART,

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Case Reports __________________________________________________________________________________ earlier initiation of ART after treating the disease, low initial CD4 count and greater CD4 recovery during first 6 months and presence of fungaemia with higher serum cryptococcal antigen titer at pre-ART (6). However, in some prospective cohorts, HIV-1 viral load, time to start ART, and baseline CD4 were not risk factors for C-IRI (6). A paucity of CSF inflammation at the time of initial Cryptococcal meningitis diagnosis has also been associated with subsequent development of IRIS (7).

recommended antifungal medications. But a positive fungal culture after three months of antifungal therapy can be considered as treatment failure and exclude the diagnosis of C-IRIS (9). In our case patient was initially treated sub optimally with fluconazole monotherapy induction and he developed the first relapse at six weeks of ART and fluconazole therapy. Therefore, we were unable to exclude the diagnosis of treatment failure and justified the retreatment of patient with optimal induction therapy.

As our patient was commenced with ART just after completion of two weeks induction therapy despite paucity of CSF inflammation, very high baseline HIV viral load and low baseline CD4 count, favour the diagnosis of paradoxical cryptococcal IRIS.

However, during the second relapse, considering the repeatedly negative Cryptococcal cultures, rapid immunological and virological recovery with ART as well as successful completion of liposomal amphotericin B induction therapy during first relapse, the diagnosis of paradoxical cryptococcal IRIS was quiet certain. Two Serial lumber punctures with removal of 20-30ml of CSF at a time together with ART and fluconazole consolidation therapy alleviated the symptoms of the patient during this relapse.

Although widely available CSF parameters like protein, WBC levels are informative of IRIS risk, particular cut point as an ideal diagnostic threshold has not been identified. But, those with more prominent CSF inflammation like WBC count >25 cells/µl and protein > 50 mg/dl, at the time of cryptococcal diagnosis, infrequently develop IRIS once receiving ART. Therefore, high risk patients may be identifiable prior to ART according to case by case basis (7).

The treatment failure of cryptococcal meningitis may be due to poor adherence to antifungal medications or fluconazole resistance. As primary resistance to fluconazole is uncommon for Cryptococcal neoformans, susceptibility testing is not routinely recommended for initial management of cryptococcosis (3). However, isolates collected during a relapse should be checked for drug susceptibility.

One prospective study done in Uganda found pre-ART increase in serum Th17 and Th2 responses (IL17 and IL4) and lack of pro inflammatory cytokine responses (TNFα, granulocyte colony stimulating factor, vascular endothelial growth factor) predispose individuals to subsequent IRIS (8). After validation these biomarkers might be an objective tool to predict the risk of C-IRIS and guide the timing of ART.

Optimal therapy for patients with treatment failure has not been established. According to CDC recommendations patients who fail to respond fluconazole monotherapy induction should be switched to amphotericin B, with or without flucytosine. “Those initially treated with an amphotericin B formulation should remain on it until a clinical response occurs. Liposomal amphotericin B or amphotericin B lipid complex is better tolerated and has

Meningeal C-IRIS is usually indistinguishable from a relapse at the time of presentation. CSF culture results may help to differentiate the two clinical scenarios. However, negative CSF culture is not an absolute requirement to diagnose C-IRIS due to the variable time taken for CSF sterility after treating with

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Case Reports __________________________________________________________________________________ Guidelines See Appendix 2 for list of members of the BHIVA Guidelines Subcommittee Op. Infection. 2010; 2. Litvintseva AP, Mitchell TG. Population Genetic Analyses Reveal the African Origin and Strain Variation of Cryptococcus neoformans var . grubii. plos Pathog. 2012;8(2):8–11. 3. Centers for Disease Control and Prevention. Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults. 2014;149–60. Available from: https://aidsinfo.nih.gov/contentfiles/lvguidelines/a dult_oi.pdf 4. Sharma SK, Soneja M. HIV & immune reconstitution inflammatory syndrome (IRIS). Indian J Med Res [Internet]. 2011;134(December):866–77. Available from: http://www.pubmedcentral.nih.gov/articlerender.f cgi?artid=3284095&tool=pmcentrez&rendertype=a bstract 5. Longley N, Harrison TS, Jarvis JN. Cryptococcal immune reconstitution inflammatory syndrome. Curr Opin Infect Dis. 2013;26(1):26–34. 6. Haddow LJ, Colebunders R, Meintjes G, Lawn SD, Elliott JH, Easterbrook PJ, et al. Cryptococcal Immune Reconstitution Inflammatory Syndrome in HIV-1–infected individuals: Literature Review and Proposed Clinical Case Definitions. Lancet Infect Dis. 2010;10(11):791–802. 7. Boulware DR, Bonham SC, Meya DB, Wiesner DL, Park GS, Kambugu A, et al. Paucity of initial cerebrospinal fluid inflammation in cryptococcal meningitis is associated with subsequent immune reconstitution inflammatory syndrome. J Infect Dis. 2010;202(6):962–70. 8. Boulware DR, Meya DB, Bergemann TL, Wiesner DL, Rhein J, Musubire A, et al. Clinical features and serum biomarkers in HIV immune reconstitution inflammatory syndrome after cryptococcal meningitis: A prospective cohort study. PLoS Med. 2010;7(12):1–14. 9. Nunnari G, Gussio M, Pinzone MR, Martellotta F, Cosentino S, Cacopardo B, et al. Cryptococcal meningitis in an HIV-1-infected person: Relapses or IRIS? Case report and review of the literature. Eur Rev Med Pharmacol Sci. 2013;17(11):1555–9. 10. Makadzange AT, Ndhlovu CE, Takarinda K, Reid M, Kurangwa M, Gona P, et al. Early versus Delayed Initiation of Antiretroviral Therapy for Concurrent HIV Infection and Cryptococcal Meningitis in Sub‐Saharan Africa. Clin Infect Dis [Internet]. 2010;50(11):1532–8. Available from: http://cid.oxfordjournals.org/lookup/doi/10.1086/ 652652

greater efficacy than deoxycholate formulation in this setting and should be considered when initial treatment with other regimens fails”(3). Timing of ART for cryptococcosis is a therapeutic dilemma due to conflicting data. Most available studies are also underpowered to provide definitive guidance (10). According to the CDC recommendation timing of ART administration should be considered between 2 and 10 weeks after the start of antifungal therapy with the precise starting dates based on individual conditions and local experience. Multisite randomized trial done in Uganda and South Africa showed deferred ART until 5 weeks after the start of amphotericin therapy had improved survival comparing with ART initiated at 1 to 2 weeks. The findings were especially significant, among the patients with a paucity of white cells in CSF (3). Recommended management of Cryptococcal IRIS according to CDC guidelines are to continue both ART and antifungal therapy and reduction of CSF pressure if present. However, several trials have suggested steroids as well as non steroidal anti inflammatory drugs for the treatment of IRIS but none of them are clearly proven. Considering available literature and our experience we also recommend, evaluation of each case should be done carefully and individually in case by case basis, based on available resources and expertise to decide on ART timing, diagnosis and the management of cryptococcal meningitis and its complications.

References 1.

Lane FB, London N. British HIV Association guidelines for the treatment of opportunistic infection in HIV-positive individuals 2010 M Nelson ,D Dockrell , S Edwards on behalf of the BHIVA

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Author information ___________________________________________________________________________ appropriate for journals that distinguish authors from other contributors.

Author Guidelines Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH) is a peer-reviewed biomedical journal published annually following the scientific sessions of the Sri Lanka College of Sexual Health and HIV Medicine.

Authorship credit should be based on, 1) Substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data 2) Drafting the article or revising it critically for important intellectual content; and 3) Final approval of the version to be published.

Section 1: Journal Components (1.1). Leading articles: Leading articles are expert opinions on current topics, usually solicited by the editors. Presidential address of the Sri Lanka College of Venereologists at its annual scientific sessions is usually included in this section of the journal. They do not usually exceed 1500 words and 20 references.

Authors should meet conditions 1, 2, and 3. All other contributors who do not meet criteria for authorship should be listed in an acknowledgements section.

Section 3: Submitting Manuscripts

(1.2). Papers: This includes original research work and reviews concerning the preventive and curative medicine in the field. They should not exceed 2000 words, 5 tables or illustrations, and 20 references.

All submissions should be made with, following 3.1. Covering letter: to the editor-in-chief explaining the originality of the work, and the letter should acknowledge any potential conflict of interest. Should also be included details about the corresponding author (Email is mandatory).

(1.3). Brief Reports: This category includes case reports, reports of drug adverse effects, preliminary reports of continuing studies or trials, new patient management methods, and reports of new techniques and devices. They should not exceed 750 words, 3 tables or illustrations, and 10 references.

3.2. Letter of agreement: is a letter signed by the principal author, corresponding author and coauthors agreeing for the publication (author with google profiles, LinkedIn, e-portfolios, professional WebPages can confirm online). This may be optional in some situations.

(1.4). Points of Views: The Sri Lanka JoSHH also accept essays expressing point of views, presenting hypotheses and controversial issues, clarifying recent advances in the field and historical issues and essays pertaining to laws, policies, ethics, rights and best practices in the field. They should not exceed 2000 words, 5 tables and illustrations, and 20 references.

3.3. Manuscript: Manuscript is the complete document which includes the following two sections. 3.3.1: Title and abstract page (which include) Title: Title with the study design author line: Names as author wishes to appear them in the author line. Abstract: include Introduction, Method, Results, and Conclusions. Word counts for paper-250, Case reportsâ&#x20AC;&#x201C;150 words. Key words: 5-6 MeSH words Author details: Name, professional qualification, affiliation, corresponding authorsâ&#x20AC;&#x2122; email Acknowledgement: Acknowledge other contributors. Conflict of interest: Declare conflict of interests Financial support: Mention about financing, grant no, agency etc.,

(1.5). Miscellaneous: The JoSHH will also consider publication of letters (less than 400 words of text, 3 authors, and 5 references), obituaries (less than 400 words), and contributions to the picture-story series (not more than 250 words of text, 3 authors, 3 references and 2 clear black & white or colour photographs).

Section 2: Authorship The International Committee of Medical Journal Editors (ICMJE) has recommended the following criteria for authorship; these criteria are still

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

Author information ___________________________________________________________________________ cell. Tables should be numbered with Arabic numerals, in the order in which they are cited in the text. A table title should describe concisely the content of the table. Explain all non-standard abbreviations in footnotes, and use the following symbols, in sequence *, †, ‡, §, ¶, **, †† Figures: Figures should be professionally drawn or prepared. Lettering should be uniform in style. Number the figures in the order in which they are cited in the text. Close up photos and photos with magnification should have scale markers on degree of magnification. Submit images in TIFF or JPEG format (minimum resolution 300dpi). The authors will have to incur the cost for colour printing.

Originality of the work: Few account on the originality of the work. 3.3.2. Full article Introduction: Introduction to the subject, study justification, and objective/s Methods: study design, population, sampling technique, sample size, data collections method, tools etc., Results: Results should be clearly arranged according to the title and objectives of the study Discussion: Discuss your findings in relation to local, regional and global context. Conclusions: Round off your overall findings of the research in relation to objectives of the study and provide the new knowledge References: Number the references in the order in which they are first cited in the text (Vancouver style of referencing). Use Arabic numerals within parentheses. Note that the Sri Lanka JoSHH requires the complete name of journal (and not its abbreviation), year, volume. Authors have the responsibility to get permission from the relevant authors to quote citations. Always use primary references

Section 5: Editorial correspondence The manuscript should be submitted online through the following link

http://joshhm.sljol.info/ Subsequent editorial correspondences are done through the manuscript submission and review system of the Sri Lanka Journal of Sexual Health and HIV Medicine and also through email of authors.

Section 4: Formatting guidelines 4.1. General: All parts of manuscript, including tables and figure legends, must be typed using fonts of Calibri. Font size for the text should be 11 points with single line spacing. All illustrations, figures and tables are placed within the text at the appropriate points. Manuscripts should be typed in lowercase with proper rule of capitalization, on white paper A4 (212 × 297 mm).

You can contact the editor-in-chief (EIC) by the following email.

editor.srilanka.coshh@gmail.com Kindly note that abstracts not confirming to the above specifications will be rejected.

4.2. Guideline for the use of units: Use SI units throughout, except for blood pressure and haemoglobin content. Other units may be given in parentheses.

Manuscripts should be submitted with a fee of 1000 LKR as administrative cost as a cheque in favour of Sri Lanka College of Venereologists or send the manuscript with the bank deposit slip to the account name “Sri Lanka College of Venereologists”, account No 1781307, Regent Street, Bank of Ceylon, Colombo 10).

4.3. Guideline for the use of drugs and instruments: Generic names must be used for all drugs. Include the proprietary name only if it is needed for a specific purpose. Instruments may be referred to by proprietary name, giving the name and location of the manufacturer in the text in parentheses.

Work cited: 1.

International Committee of Medical Journal Editors. International Committee of Medical Journal Editors. [Online].; 2013 [cited 2013 April 15. Available from: HYPERLINK “http://www.icmje.org”.

World Association of Medical Editors. World Association of Medical Editors. [Online].; 2013 [cited 2013 May 01. Available from: HYPERLINK

4.4. Guideline for tables and figures Tables: All tables must be typed single-spaced with left horizontal alignment of text/numbers in each

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"http://www.wame.org/ resources/ publication ethics-policies-for-medical-journals".

publication. All accepted articles for publication will be acknowledged to the corresponding author.

Ceylon Medical Journal. Sri Lanka Journals Online. [Online].; 2013 [cited 2013 May 1. Available from: HYPERLINK http://www.sljol.info/index.php/CMJ

The type of peer review process of the Sri Lanka JoSHH There are essentially three stages at which an article can be reviewed:

Peer review process

Before the author submits it to the Journal (Presubmission review) Review by the journal, and Review after it has been published

The editorial board consist of Editor-in-chief, acquisition editor, assistant editors, members and the secretary. Editorial board is elected from the members of the Sri Lanka College of sexual Health and HIV Medicine at its annual general meeting. In addition to the editorial board, there is a panel of reviewers.

Pre-submission review: Sri Lanka JoSHH recommends authors to seek pre-submission reviews from individuals or peer review service providers to improve their articles before they submit to Journal.

Editor-in-chief scrutinizes all the articles submitted by authors for its consistency with the author guidelines, timeliness and originality of the work, importance of the research problem, clarity of writing, methodology, validity of data, scientific strength, and appropriateness for readers of the Journal.

Based on the editor’s, reviewers/referees and author’s preference, Single-blind review, doubleblind review or open review is arranged. Single-blind review: the reviewer knows the author.

Editor-in-chief informs the decision to the respective authors regarding submitted articles.

Double-blind review: Neither the reviewer nor the author knows each other.

Editor-in-chief send selected articles for peer review process and regularly obtain advice on individual manuscripts from reviewers (experts on the manuscript subject area). In addition, opinions are sought from statistical reviewers before publication.

Open review: Both the reviewer and the author knows each other. Post-publication review: finally, once an article is published (online), anyone in the world can review the article – commenting on how good or bad it is.

Editors reserve the right to modify style, shorten articles, make editorial corrections where necessary, and to determine priority and time of

Sri Lanka Journal of Sexual Health and HIV Medicine (Sri Lanka JoSHH), Volume 2, December 2016

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