Background National notifiable diseases surveillance system (NNDSS) data in developing countries is usually incomplete, yet the total number of fatal cases reported is commonly used for national priority setting. Melioidosis, an infectious disease caused by Burkholderia pseudomallei, is largely underrecognized by policy makers due to the underreporting of fatal cases via the NNDSS. Methods Collaborating with the Epidemiology Division (ED), Ministry of Public Health (MoPH), we conducted a retrospective study to determine incidence and mortality of melioidosis cases already identified by clinical microbiology laboratories nationwide. A case of melioidosis was defined as a patient with any clinical specimen culture positive for B. pseudomallei. Routinely available microbiology and hospital databases of secondary-care and tertiary-care hospitals, the national death registry, and NNDSS data were obtained for analysis. Results A total of 7,126 culture-confirmed melioidosis patients were identified from 2012 to 2015 in 60 hospitals countrywide. The total number of cases diagnosed in Northeast, Central, South, East, North, and West Thailand were 5,475, 536, 374, 364, 358 and 19 cases, respectively. Overall 30-day mortality was 39% (2,805/7,126). Only 126 (4%) of deaths were reported to the NNDSS. Age, presentation with bacteremia and pneumonia, prevalence of diabetes, and 30-day mortality were different by geographical regions (all p values<0.001). ED, MoPH has agreed to include the findings of our study in the next annual report of the NNDSS. Conclusions Melioidosis is an important cause of death in Thailand nationwide, and its clinical epidemiology may be different by region. In developing countries, NNDSS data can be supplemented by integrating information from readily available routine datasets.

HIV prevalence remains high in men who have sex with men (MSM) in Bangkok. Even though resources for HIV testing and treatment are available for all, a large proportion of MSM still do not get HIV tested. We studied high risk MSM who are unaware of their HIV status to help maximize effectiveness of our resources. Convenience sampling was conducted among MSM who came for HIV testing at the Thai Red Cross Anonymous Clinic and two popular drop-in centers in Bangkok. Inclusion criteria were MSM aged >18 years, have not been tested positive for HIV, who reported ≥1 of the following in the previous 6 months: condomless sex with a male, being a sex worker, or having a sexual transmitted infection diagnosis. Audio-Computer-Assisted Self-Interview was used to assess psychosocial profile, sexual risks, and HIV testing patterns prior to being informed of their HIV positive status. Among 499 high-risk MSM enrolled, the median age was 24.8 years and 112 (22 %) tested HIV-positive. Among the HIV-positive participants, 92 % self-identified as gay (versus bisexual), 39 % attained a bachelors degree or higher, 65 % had monthly income 10,000-29,999 baht ($280-830 USD), 10 % had vaginal or anal sex with a woman in the past 12 months, 39 % had condomless receptive sex with men and 21 % went to Lat Phrao to find a sexual partner. Compared to HIV negative MSM, HIV-positive MSM had less HIV testing: 31 % had ever been tested for HIV, 12 % had been tested in the past 6 months; but were more likely to guess correctly their positive status (31 %). Regarding psychosocial variables among HIV-positive MSM, 7 % had regular methamphetamine use in the past 3 months, 10 % had >2 sources of discrimination, and 8 % had >2 sources of discrimination due to being MSM. In multivariable model, age<30 year old, self-identified as gay, had monthly income <50,000 baht ($1400 USD), had anal sex with men in past 12 months, had >2 sources of discrimination because of being MSM, did not get HIV test in past 6 months, and guess of positive HIV were significantly associated with HIV positive status. Young MSM with lower socioeconomic status (SES) should be prioritized for innovative approaches to promoting awareness and uptake of HIV testing. Societal stigmatization of MSM should be addressed as a potential barrier to uptake of voluntary HIV testing. Resilience factors among these marginalized MSM who still test frequently and remain HIV-negative despite residing in a context with community viral loads and discrimination should also be studied in order to curb the HIV epidemic in Bangkok.

Background Early antiretroviral therapy (ART) restricts the size of the HIV reservoir in infants. However, whether antiretroviral (ARV) prophylaxis given to exposed vertically infected children exerts similar effects remains unknown. Methods We measured total and integrated HIV DNA, as well as the frequency of CD4 T-cells producing multiply-spliced RNA (msRNA) after stimulation (inducible reservoir) in vertically-infected Thai infants. Eighty-five infants were followed longitudinally for up to three years. We compared the size of the reservoir in children who received continuous prophylactic ARV since birth versus those who never received or discontinued prophylaxis before initiating ART. We used samples from a cross-sectional cohort of 37 Thai children who had initiated ART within 6 months of life to validate our findings. Results Before ART, levels of HIV DNA and the frequencies of cells producing msRNA were significantly lower in infants who received continuous prophylactic ARV since birth compared to those in whom prophylactic ARV was discontinued or never initiated (p&lt;0.020 and p&lt;0.001, respectively). Upon ART initiation, total and integrated HIV DNA levels decayed significantly in both groups (&lt;0.01 in all cases). Interestingly, the initial differences in the frequencies of infected cells persisted during three years on ART. The beneficial effect of prophylaxis on the size of the HIV reservoir was confirmed in the cross-sectional study. Importantly, no differences were observed between children who discontinued prophylactic ARV before starting ART and those who delayed ART initiation without receiving prior prophylaxis. Conclusions Neonatal prophylactic ARV with direct transition to ART durably limits the size of the HIV reservoir.

There are few studies comparing proportion, frequency, mortality and mortality rate of antimicrobial-resistant (AMR) bacterial infections between tertiary-care hospitals (TCHs) and secondary-care hospitals (SCHs) in low and middle-income countries (LMICs) to inform infection control strategies. We evaluated bloodstream infections (BSIs) from 2012 to 2015 in 15 TCHs and 34 SCHs in Thailand. There were differences in the proportions (%) of BSI caused by AMR strains for some pathogens between TCHs and SCHs. Of 19,110 patients with AMR BSI, 6,491 (34.0%) died. Among patients with AMR BSI, there were no or minimal differences in mortality proportion for all AMR pathogens between TCHs and SCHs. However, the frequency and mortality rates of AMR BSI were considerably higher in TCHs for most pathogens. For example, the mortality rate of hospital-origin carbapenem-resistant Acinetobacter baumannii BSI in TCHs was two and a half times higher than that in SCHs (8.4 vs. 3.6 per 100,000 patient-days at risk, mortality rate ratio 2.51; 95% confidence interval 1.44 to 4.37, p=0.0012). Targets of and resources for antimicrobial stewardship and infection control programs in LMICs may need to be tailored based on hospital type and size, as burden of AMR infections could differ by hospital setting.