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Sexualized substance use or "chemsex" may contribute to the HIV epidemic among men who have sex with men (MSM) in Thailand. Specific patterns of chemsex use may be associated with different HIV/STI transmission risks. We examined typologies and correlates of sexualized substance use among a sample of high-risk MSM (n = 532) who had attended a private sex party or circuit party in the past three years using latent class analysis. Multinomial regression was used to adjust for variables associated with the 3-class latent class model. We identified a 3-class model as the best fitting model, which included: (1) "negligible sexualized substance users" (36.7%), who had never engaged in chemsex in the past six months; (2) "sexualized substance users" (13.9%), who had a high level of sexualized alcohol use and a wide range of other substances before or during sex in the past six months; and (3) "exclusive chemsex users" (49.4%), who predominantly used crystal methamphetamine, amyl nitrite, and erectile dysfunctional drugs before or during sex in the past six months. Compared to negligible sexualized substance users, exclusive chemsex users were more likely to be HIV-positive, more likely to have six or more sexual partners in the past six months, less likely to have condom use at last anal intercourse, and more likely to have provided sex work. Relative to negligible sexualized substance users, sexualized substance users reported more frequent online sex-seeking behaviors. These subgroups of Thai MSM have unique substance use patterns and HIV-related risk profiles, underscoring the importance of targeted HIV prevention strategies. [ABSTRACT FROM AUTHOR]

Young MSM (YMSM), aged 15–24, account for nearly half of new HIV infections in Thailand. Pre-exposure prophylaxis (PrEP) is an effective prevention medicine for populations at substantial HIV risk, yet YMSM frequently have suboptimal uptake of and adherence to PrEP. We conducted 35 in-depth interviews with YMSM to explore barriers and facilitators of both PrEP initiation and adherence. Interviews also elicited the perceptions and experiences of healthcare providers (HCPs) working with YMSM at three clinics in Bangkok. Primary barriers to PrEP initiation were limited accessibility, insufficient knowledge, and efficacy concerns; HCPs identified no-to-low self-perception of HIV risk, pre-existing health problems, fears of side effects, and living in distant provinces as barriers to PrEP initiation. YMSM primarily reported PrEP information and self-perceptions of elevated HIV risk as facilitators to PrEP initiation. Additionally, forgetfulness and low HIV risk awareness were common barriers to PrEP adherence. Reminders were a prominent facilitator of PrEP adherence alongside disclosure to close relationships, the routinization of regimens, and convenient facilities. HCPs regarded counseling as the leading facilitator of PrEP adherence. By understanding the barriers/facilitators of PrEP use, the current study seeks to help develop evidence-informed PrEP intervention programs among YMSM while considering cultural sensitivity. [ABSTRACT FROM AUTHOR]

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Male HIV serodiscordant couples have diverse relationship agreements regarding sex outside the relationship. We examined the relationship agreements as described by 343 male HIV-negative partners in HIV serodiscordant relationships in Australia, Brazil and Thailand participating in a multi-year cohort study. At baseline, 125 (34.1%) HIV-negative partners reported no agreement, 115 (33.5%) had a monogamous agreement, and 103 (37.9%) had an open agreement allowing sex outside the relationship. Relationship agreements were largely stable over time, with 76% of HIV-negative men reporting the same agreement across follow up, while changes were predominantly towards having an open agreement. Behaviour largely matched relationship agreements, and the predictors of breaking an agreement by having condomless anal intercourse (CLAI) with an outside partner were CLAI within the relationship (OR = 3.17, 95%CI: 1.64–6.14, p < 0.001) and PrEP use in the last three months (OR = 3.42, 95%CI: 1.48–7.92, p = 0.004). When considering HIV transmission risk for HIV-negative men in serodiscordant relationships, greater focus needs to be placed on sex that is occurring outside the relationship and the agreements that facilitate this. [ABSTRACT FROM AUTHOR]

From May 2015 to June 2018, we conducted a PrEP demonstration project at two hospitals and four community-led clinics in Bangkok and Pattaya. HIV-negative, MSM and TGW aged ≥18 years old, reporting sex without a condom, were offered daily PrEP. Participants received HIV testing and completed a computer-based questionnaire at enrollment, 6 and 12 months. We collected self-reported PrEP adherence at months 1, 3, 6, 9, and 12. We used logistic regression to determine factors associated with the decision to take PrEP and calculated HIV incidence among baseline HIV-negative participants. Of 803 participants enrolled, 349 (43.5%) started PrEP. Participants were more likely to start PrEP if they were sex workers, had moderate or high self-perceived risk of HIV, or a high PrEP-knowledge score. Participants used PrEP for a median of 6.1 months. Reported condom use increased and the number of sex partners decreased during follow-up regardless of PrEP use. Six participants not-taking PrEP acquired HIV (HIV incidence 2.2 per 100 person-years), and five taking PrEP acquired HIV (HIV incidence 2.1 per 100 person-years). All five reported taking <4 pills the weeks before study visits. [ABSTRACT FROM AUTHOR]

To reach its goal of ending AIDS by 2030, Thailand has adopted antiretroviral treatment as prevention and HIV pre-exposure prophylaxis for men who have sex with men (MSM) and transgender women (TGW) as its core HIV control strategy. However, in the absence of reliable epidemiologic indicators, the impact of these policies on the course of the HIV epidemic in these groups remains unknown. To help answer this question, we formulated an HIV epidemic consensus initiative for Bangkok, Thailand, to analyze epidemiologic and program data and reach agreement between experts and stakeholders on the evolving state of the HIV epidemic among MSM and TGW. A customized Delphi process was used to consult and consolidate viewpoints of experts and stakeholders. Experts presented and discussed HIV prevalence and incidence data from recent and ongoing studies among MSM and TGW in Bangkok (2014 to 2018) during a meeting with stakeholders representing government, donors, and civil society. Agreement about the course of the HIV epidemic among MSM and TGW was attained by voting consensus. Based on presented data, meeting participants agreed that HIV prevalence and incidence had decreased among Bangkok MSM from 2014 to 2018. Despite these declines, HIV prevalence and incidence were found to remain high. This was particularly the case among younger MSM. Participants agreed that there was no evidence for a decrease in HIV prevalence and incidence among Bangkok TGW. Introduction of antiretroviral treatment as prevention and HIV pre-exposure prophylaxis may have contributed to these declines. However, HIV prevalence and incidence remained high, and no signs of a decrease were reported among Bangkok TGW. At the current rate of new HIV infections in MSM and TGW, Thailand will not reach its goal of ending AIDS by 2030. This HIV consensus initiative may serve as a model for building agreement and advocacy on epidemiologic and program data and their implications for a large metropolitan city. [ABSTRACT FROM AUTHOR]

The use of undetectable viral load (VL) to negotiate condomless anal intercourse (CLAI) in HIV serodiscordant male relationships has become more common as more data regarding the effectiveness of antiretroviral treatments for the prevention of HIV transmission has been described. We examined viral load agreements (VLAs) for condomless sex in the presence of an undetectable VL in 343 HIV serodiscordant male couples in Australia, Brazil and Thailand. Factors associated with having a VLA included having agreements for the HIV-positive partner to report his VL result (p < 0.001), agreeing that VL affects agreements about sexual practice (p < 0.001), the HIV-negative partner's perception of his partner's undetectable VL (p < 0.001), the couple's belief in the efficacy of undetectable VL in preventing HIV transmission (p < 0.001), and the couple engaging in CLAI with each other (p < 0.001). Over time, these agreements became more common although 49.3% of couples in the sample never had a viral load agreement. As these agreements become more common, further education is required to support male couples in using them safely. [ABSTRACT FROM AUTHOR]

Background: Suboptimal uptake of HIV testing remains a primary bottleneck to HIV prevention and treatment for men who have sex with men (MSM) and transgender women (TGW) in Thailand. The World Health Organization has recommended HIV self-testing (HIVST) as an additional strategic HIV service. However, HIVST has not been fully endorsed and implemented in many countries in Southeast Asia. The aim of this study was to assess the uptake of oral fluid-based HIVST in MSM and TGW populations in Thailand. Methods: During 2017 and 2018, we conducted a cross-sectional study using convenience sampling to enroll 2,524 participants from three major urban areas. Participants were recruited during outreach and online activities and were offered unassisted or assisted HIVST, or referral to HIV testing services. A descriptive analysis was performed for summarizing data. Results: A total of 2,502 participants (1,422 MSM and 1,082 TGW) were included in the analysis with about one-third (36.1%) of them being first-time testers. Among all participants enrolled in the study, a total of 2,486 participants (99.3%) selected HIVST versus referral to HIV testing services. Of those who selected HIVST, 2,095 (84.3%) opted for assisted HIVST while the rest opted for unassisted HIVST: 1,148 of 1,411 MSM (81.4%) and 947 of 1,075 TGW (88.1%) selected assisted HIVST. While no serious adverse events were reported during the study, we found that among 179 participants who needed a confirmatory test and were referred to HIV testing services, 108 (60.3.4%) accessed these later services. Conclusions: This study demonstrated a high uptake of oral fluid-based HIVST among MSM and TGW populations in Thailand and that HIVST could be scaled up through the national epidemic control program. However, a better understanding of HIV testing-seeking behavior and innovative follow-up solutions are needed to improve and monitor linkages to services for people who undertake HIVST. [ABSTRACT FROM AUTHOR]

Men who have sex with men (MSM) in Western urban areas have seen substantive decreases in new diagnoses of HIV infection. This paper explores whether such declines are present among MSM and transgender women (TGW) in Southeast Asia and discusses implications for HIV policies and programming. A scoping review was conducted of scientific publications and selected documents regarding the spread of HIV infection among MSM and TGW in major urban centres of the Association of Southeast Asian Nations (ASEAN) region. Continued high HIV prevalence and incidence among MSM are found in integrated behavioural and biological surveillance (IBBS) and research studies. HIV prevalence among MSM under IBBS decreased only in Bangkok from 28.6% in 2014 to 10.3% in 2018, whereas it was increasing in Kuala Lumpur, Ho Chi Minh City, Vientiane, and Phnom Penh. HIV/AIDS case reports regarding new HIV infection diagnoses among MSM have started to decrease in Singapore since 2011 and have been plateauing in Metropolitan Manila since 2017. Where data were available, it was found that HIV prevalence among TGW was high and if IBBS was conducted, it was increasing. HIV prevalence among TGW under IBBS in Jakarta had risen to 34.0% (2015) and 14.0% (2019) in Phnom Penh. These findings suggest that most ASEAN member states have so far failed to effectively implement and scale-up scientifically proven biomedical HIV prevention measures and counter stigma and discrimination that impedes access to appropriate HIV prevention and treatment services for MSM and TGW. [ABSTRACT FROM AUTHOR]

• Decline in HIV infection in Bangkok, Thailand among men who have sex with men (MSM). • HIV incidence remains high in young MSM in Bangkok, Thailand. • HIV decline associated with increases in HIV prevention and treatment implementation in Bangkok, Thailand, including HIV pre-exposure prophylaxis (PrEP) and Treatment as Prevention (TasP). • First report of HIV incidence declines associated with increasing PrEP and TasP implementation in a Low or Middle Income (LMI) country. We assessed HIV-1 infection among men who have sex with men (MSM) attending Silom Community Clinic (SCC) in Bangkok, Thailand from 2005 to 2018. Since 2014, Thailand increased implementation of HIV prevention strategies including pre-exposure prophylaxis and Treatment as Prevention. MSM attending SCC were tested for HIV using rapid tests. We assessed trends in HIV prevalence, incidence and compared incidence before and after 2014. From 2005 to 2018, 14,034 clients attended SCC for HIV testing. The HIV prevalence increased from 19.2% in 2005–2006 to 34–0% in 2010, remained stable until 2016 and decreased to 17.2% in 2018 (p < 0.0001). The HIV incidence was 4.1 per 100 person-years (PY), with an inverted U-shape trend and a peak in 2009 (p < 0.0001). Incidence among young MSM aged 13–21 years remained high at 10.0 per 100 PY. Among those aged 22–29 years, lower incidence was found from Q 3 2016, with a relative risk reduction of 46.2% (p < 0.001); and a similar reduction among those aged ≥30 years from Q4 2014, corresponding to scale up of HIV prevention strategies. We found a decline in HIV infection among Thai MSM. However, incidence remained high among young MSM. [ABSTRACT FROM AUTHOR]

Background The HIV Prevention Trials Network (HPTN) 067/Alternative Dosing to Augment PrEP Pill Taking (ADAPT) Study evaluated the feasibility of daily and nondaily human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) regimens among high-risk populations, including men who have sex with men (MSM) and transgender women, in Bangkok, Thailand and Harlem, New York. We used a mathematical model to predict the efficacy and effectiveness of different dosing regimens. Methods An individual-based mathematical model was used to simulate annual HIV incidence among MSM cohorts. PrEP efficacy for covered sex acts, as defined in the HPTN 067/ADAPT protocol, was estimated using subgroup efficacy estimates from the preexposure prophylaxis initiative (iPrEx) trial. Effectiveness was estimated by comparison of the HIV incidence with and without PrEP use. Results We estimated that PrEP was highly protective (85%–96% efficacy across regimens and sites) for fully covered acts. PrEP was more protective for partially covered acts in Bangkok (71%–88% efficacy) than in Harlem (62%–81% efficacy). Our model projects 80%, 62%, and 68% effectiveness of daily, time-driven, and event-driven PrEP for MSM in Harlem compared with 90%, 85%, and 79% for MSM in Bangkok. Halving the efficacy for partially covered acts decreases effectiveness by 8–9 percentage points in Harlem and by 5–9 percentage points in Bangkok across regimens. Conclusions Our analysis suggests that PrEP was more effective among MSM in Thailand than in the United States as a result of more fully covered sex acts and more pills taken around partially covered acts. Overall, nondaily PrEP was less effective than daily PrEP, especially in the United States where the sex act coverage associated with daily use was substantially higher. [ABSTRACT FROM AUTHOR]

Introduction: Men who have sex with men (MSM) and transgender women (TGW) are two key populations (KPs) in Thailand at high risk for HIV. Uptake and scale‐up of pre‐exposure prophylaxis (PrEP) among them has been slow. We used data from Princess PrEP, Thailand's largest KP‐led PrEP programme, to operationalize PrEP service cascades. We identified gaps and pointed out where additional data are needed to inform a larger HIV prevention cascade. Methods: Numbers of people tested for HIV, tested HIV negative, eligible for PrEP (defined as any of the following in the past three months: condomless sex with partners of unknown/uncertain HIV status or antiretroviral treatment or viral load status, multiple partners, engaging in sex work, sexually transmitted infections, injecting drugs, using amphetamine‐type stimulants, or repeated use of post‐exposure prophylaxis), offered PrEP and accepted PrEP during January to November 2019 were retrieved from Princess PrEP database to inform PrEP service cascades for MSM and TGW. Reasons for not accepting PrEP were documented. Results: Of 6287 MSM who received HIV testing in Princess PrEP, 92.3% were HIV negative and 70.2% of them were eligible for PrEP. PrEP was offered to 94.7% of those eligible and 48.0% of those offered accepted it. Among 900 TGW who had HIV testing, 95.3% tested HIV negative and 64.8% of them met PrEP eligibility criteria. Of these, 95.0% were offered PrEP and 43.9% of them accepted it. Among MSM and TGW who met PrEP eligibility criteria, no or low‐HIV‐risk perception was the most common reason provided (46.7% of 2007 MSM and 41.9% of 296 TGW) for not accepting PrEP. Conclusions: PrEP service cascades from the Princess PrEP programme identified no or low‐risk perception as key barrier to PrEP acceptance among MSM and TGW who met PrEP eligibility criteria. More implementation research studies are needed to explore PrEP motivation and access in larger communities outside of clinical services. This is to identify gaps and strategies to address them within motivation, access and effective use domains of the HIV prevention cascade. [ABSTRACT FROM AUTHOR]

In Thailand, pre-exposure prophylaxis (PrEP) is recommended for human immunodeficiency virus (HIV) prevention among at-risk men who have sex with men (MSM). We modeled the impact of PrEP and condom use as independent and combined interventions on the estimated number of HIV infections among a hypothetical population of 10,000 MSM in Bangkok, Thailand. Our model demonstrated a 92% (95% confidence interval 89.7, 94.2) reduction in HIV infections among Thai MSM who took daily PrEP and self-reported using condoms correctly and consistently (100% condom use). Increased use of PrEP and condoms likely would have a substantial impact on the HIV epidemic in Thailand. [ABSTRACT FROM AUTHOR]

The HPTN 067/ADAPT Study evaluated the feasibility, acceptability, patterns of adherence and coverage for three randomly assigned oral FTC/TDF pre-exposure prophylaxis (PrEP) dosing regimens to prevent HIV infection. Using qualitative methods, we explored facilitators and barriers among a subset of men who have sex with men (MSM) participants in Bangkok, Thailand. Between August 2013 and March 2014, 32 HPTN 067/ADAPT participants joined in 6 focus group discussions, and 6 attended key informant interviews. Facilitators of PrEP adherence included use of strategies to have PrEP available when needed, simplicity in regimen requirements with recognition that more complex regimens may take some time to master, ability to plan for sex, receipt of social and technology support, ability to use a PrEP regimen that best matches to one's own patterns of sex, and experiences with PrEP as a part of health and well-being. Challenges to PrEP adherence included perceptions of no or low HIV risk, difficulties following regimens when intoxicated, concerns about side effects, experience of HIV stigma, and affordability of PrEP outside of study context influencing uptake and use in the community. Preferences for regimens varied, suggesting that multiple PrEP effective regimen options should be available to fit those with different needs. [ABSTRACT FROM AUTHOR]

This pilot study examined the feasibility and acceptability of the HIV/AIDS self-management education program-Thai (HASMEP-T) for HIV-positive Thai men who have sex with men (MSM). HASMEP-T is a group-based adaptation of the evidence-based intervention, HASMEP. Participants were 40 Thai MSM living with HIV aged 18 years or older, recruited from an HIV clinic housed in a hospital in Thailand. Results support the feasibility of recruitment, screening, eligibility, and retention methods. The majority of the participants reported that the intervention was acceptable and met their initial expectations. Furthermore, all recruited participants in the intervention group (n = 20) completed HASMEP-T. Overall, intervention group participants demonstrated significant increases in all aspects of HIV self-management (p <.05), as well as improvement in quality of life in the psychological domain (p <.05). Our findings provide preliminary support for the large-scale, randomized-controlled trial of the efficacy of HASMEPT to promote self-management behaviors among HIV-positive Thai MSM. [ABSTRACT FROM AUTHOR]

The global trend in HIV incidence overall is declining; however, there is a plateau in new HIV infection among men who have sex with men (MSM) and transgender women (TGW) despite extensive investment in HIV prevention targeting these populations. Many studies usually conflate these two groups together, which may overlook many disparate characteristics unique to each population, impeding the efficacy of HIV interventions. To better understand the vulnerable diversity that may put these individuals at risk of HIV infection, we conducted qualitative analysis among Thai MSM and TGW, aiming to identify sexual pattern themes of MSM and TGW in Bangkok in order to better understand their distinctive sexual life context. Convenient and purposive samplings were used to recruit Thai MSM and TGW aged ≥ 18 years old and living in Bangkok, Thailand, for focused group discussions and one-on-one in-depth interviews, respectively. Total of 12 MSM and 13 TGW participated in focused group discussions, which were conducted separately for MSM and TGW. Additionally, 5 MSM and 5 TGW were involved in one-on-one in-depth interviews. Thematic analyses were performed separately for MSM and TGW. The results show that MSM and TGW have distinct and diverse sexual patterns, and within the identified themes: partnering, partner finding, protection, and enhancing sexual pleasure (only for MSM). Participants reported having varying sexual experiences. Recognizing the difference and diversity in partnering and sexual practice of MSM and TGW is crucial in order to develop tailored interventions that suit the vulnerability of the key populations in Thailand. [ABSTRACT FROM AUTHOR]

We describe incident human immunodeficiency virus (HIV) and syphilis trends in men who have sex with men (MSM) and transgender women (TGW) presenting for HIV voluntary counseling and testing (VCT) services and sexually transmitted infection (STI) management at the Silom Community Clinic, Bangkok, Thailand. Clients underwent rapid HIV testing and syphilis rapid plasma reagin (RPR) testing. For incidence analysis, we included clients with >1 follow-up visit. Initial negative HIV with subsequent positive HIV defined incident HIV infection; incident syphilis infection was defined as negative RPR followed by positive RPR (titer ≥1:8) and confirmatory anti- Treponema pallidum antibodies. Calculation of incidence using Poisson regression assumed a uniform probability distribution throughout the seroconversion interval. From 15 September 2005 to 31 December 2015, we tested 10,158 clients for HIV and 10,324 for syphilis. Overall, 7109 clients tested HIV-seronegative and contributed 7157 person-years (PY). Three-hundred forty-seven incident HIV infections resulted in an incidence rate of 4.8 per 100 PY (95% confidence interval [CI] 4.4-5.4). We found an inverted U-shape trend of HIV incidence over time with a peak of 6.4 per 100 PY in quarter 2/2011 ( p < 0.01) (Poisson with RCS function, p = 0.001). Overall, 8713 clients tested seronegative for syphilis and contributed 8623 PY. The incidence of syphilis infection was 4.4 per 100 PY (95% CI 3.9-4.8). Despite an apparent decline in HIV incidence among MSM and TGW attending VCT services, syphilis incidence rose and remained high. Evaluating temporal trends of HIV and syphilis incidence provides an opportunity to evaluate epidemic trajectories and target limited program funding. We recommend focused HIV and STI prevention interventions for MSM in Bangkok. [ABSTRACT FROM AUTHOR]

HIV testing among men who have sex with men (MSM) and transgender (TG) women remains low in Thailand. The HIV prevention program (PREV) to increase HIV testing and link those who tested HIV-positive to care provided trainings to peer educators to conduct target mapping, identify high risk MSM and TG women through outreach education and offer them rapid HIV testing. Trained hospital staff provided HIV testing and counseling with same-day results at hospitals and mobile clinics and referred HIV-positive participants for care and treatment. We used a standardized HIV pre-test counseling form to collect participant characteristics and analyzed HIV test results using Poisson regression and Wilcoxon rank sum trend tests to determine trends over time. We calculated HIV incidence using data from participants who initially tested HIV-negative and tested at least one more time during the program. Confidence intervals for HIV incidence rates were calculated using the Exact Poisson method. From September 2011 through August 2016, 5,629 participants had an HIV test; their median age was 24 years, 1,923 (34%) tested at mobile clinics, 5,609 (99.6%) received their test result, and 1,193 (21%) tested HIV positive. The number of people testing increased from 458 in 2012 to 1,832 in 2016 (p < 0.001). Participants testing at mobile clinics were younger (p < 0.001) and more likely to be testing for the first time (p < 0.001) than those tested at hospitals. Of 1,193 HIV-positive participants, 756 (63%) had CD4 testing. Among 925 participants who returned for HIV testing, HIV incidence was 6.2 per 100 person-years. Incidence was highest among people 20-24 years old (10.9 per 100 person-years). HIV testing among MSM and TG women increased during the PREV program. HIV incidence remains alarmingly high especially among young participants. There is an urgent need to expand HIV prevention services to MSM and TG women in Thailand. [ABSTRACT FROM AUTHOR]

Introduction: Antiretroviral therapy reduces the risk of serious illness among people living with HIV and can prevent HIV transmission. We implemented a Test, Treat, and Prevent HIV Program among men who have sex with men (MSM) and transgender women at five hospitals in four provinces of Thailand to increase HIV testing, help those who test positive start antiretroviral therapy, and increase access to pre-exposure prophylaxis (PrEP). Methods: We implemented rapid HIV testing and trained staff on immediate antiretroviral initiation at the five hospitals and offered PrEP at two hospitals. We recruited MSM and transgender women who walked-in to clinics and used a peer-driven intervention to expand recruitment. We used logistic regression to determine factors associated with prevalent HIV infection and the decision to start antiretroviral therapy and PrEP. Results: During 2015 and 2016, 1880 people enrolled. Participants recruited by peers were younger (p<0.0001), less likely to be HIV-infected (p<0.0001), and those infected had higher CD4 counts (p = 0.04) than participants who walked-in to the clinics. Overall, 16% were HIV-positive: 18% of MSM and 9% of transgender women; 86% started antiretroviral therapy and 46% of eligible participants started PrEP. A higher proportion of participants at hospitals with one-stop HIV services started antiretroviral therapy than other hospitals. Participants who started PrEP were more likely to report sex with an HIV-infected partner (p = 0.002), receptive anal intercourse (p = 0.02), and receiving PrEP information from a hospital (p<0.0001). Conclusions: We implemented a Test, Treat, and Prevent HIV Program offering rapid HIV testing and immediate access to antiretroviral therapy and PrEP. Peer-driven recruitment reached people at high risk of HIV and people early in HIV illness, providing an opportunity to promote HIV prevention services including PrEP and early antiretroviral therapy. Sites with one-stop HIV services had a higher uptake of antiretroviral therapy and PrEP. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: In 2014, the Government of Thailand recommended pre‐exposure prophylaxis (PrEP) as an additional HIV prevention programme within Thailand's National Guidelines on HIV/AIDS Treatment Prevention. However, to date implementation and uptake of PrEP programmes have been limited, and evidence on the costs and the epidemiological and economic impact is not available. Methods: We estimated the costs associated with PrEP provision among men having sex with men (MSM) participating in a facility‐based, prospective observational cohort study: the Test, Treat and Prevent HIV Programme in Thailand. We created a suite of scenarios to estimate the cost‐effectiveness of PrEP and sensitivity of the results to the model input parameters, including PrEP programme effectiveness, PrEP uptake among high‐risk and low‐risk MSM, baseline and future antiretroviral therapy (ART) coverage, condom use, unit cost of delivering PrEP, and the discount rate. Results: Drug costs accounted for 82.5% of the total cost of providing PrEP, followed by lab testing (8.2%) and personnel costs (7.8%). The estimated costs of providing the PrEP package in accordance with the national recommendation ranges from US$223 to US$311 per person per year. Based on our modelling results, we estimate that PrEP would be cost‐effective when provided to either high‐risk or all MSM. However, we found that the programme would be approximately 32% more cost‐effective if offered to high‐risk MSM than it would be if offered to all MSM, with an incremental cost‐effectiveness ratio of US$4,836 per disability‐adjusted life years (DALY) averted and US$7,089 per DALY averted respectively. Cost‐effectiveness acceptability curves demonstrate that 80% of scenarios would be cost‐effective when PrEP is provided solely to higher‐risk MSM. Conclusion: We provide the first estimates on cost and cost‐effectiveness of PrEP in the Asia‐Pacific region, and offer insights on how to deliver PrEP in combination with ART. While the high drug cost poses a budgeting challenge, incorporating PrEP delivery into an existing ART programme could be a cost‐effective strategy to prevent HIV infections among MSM in Thailand. [ABSTRACT FROM AUTHOR]

This study used respondent-driven sampling to explore the effects of social support on HIV risk and protective factors among young males who have sex with males (YMSM) in Bangkok (N = 273) and Chiang Mai (N = 243), Thailand. It compared different measures of social support, including living situation, the proportion of family and friends to whom the respondent had disclosed their same-sex attraction, and scores on the multi-dimensional scale of perceived social support as predictors of two outcomes of interest—coerced first sex and HIV knowledge. Social support from family played a mediating role in both outcomes among YMSM in Bangkok but not those from Chiang Mai. Though social support from friends was also studied, it was less strongly associated with the outcomes of interest. The findings support interventions designed to leverage social support networks to increase HIV knowledge and decrease coerced first sex among YMSM. At the same time, they demonstrate that there is not a single risk or demographic profile encompassing all YMSM. Successful programs and policies will need to consider the specific attributes and social environment of YMSM in particular locations in order to effectively address HIV risks. [ABSTRACT FROM AUTHOR]

Although HIV prevalence remains high among Bangkok's MSM early HIV testing as an entry point to ART has not been successfully implemented among in this population. Men who present late for initial HIV testing are a particular concern in the context of the Bangkok HIV epidemic, in that if long-term positives have had condomless sex during the time that they remained untreated they are likely to have been efficient transmitters of infection, to say nothing of the implications for their own health. A sequential sample of MSM who tested HIV positive, and CD4 counts, was taken at the Thai Red Cross Anonymous Clinic and two drop-in centers in Bangkok. Inclusion criteria were MSM aged >18 years, having not tested HIV positive earlier, 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 (STI) diagnosis. Analysis was conducted by distinguishing between three groups of CD4 counts: <200, 200-500, >500 cells/μ to identify the social and behavioral characteristics of the men who presented late for HIV testing. Median CD4 was 325 cells/μ(n = 95). MSM with initial CD4< 200 cells/μ were significantly more likely to report problematic alcohol use. They were also more likely to report receptive anal sex and more likely to be engaged in sex work. MSM with CD4< 200 cells/μ were less likely to report recent HIV testing. Main barriers to HIV testing included being afraid of finding out that they were HIV positive and concerns about efficacy and side effects of HIV treatment. HIV stigma and concerns about treatment are still widespread and are potential barriers to HIV care among MSM in Bangkok. These barriers may work to keep men from finding out their positive HIV status in a timely manner. Thai MSM need to be made aware of the current availability of friendly HIV testing and ART services, and public health programs need to work to change their perceptions regarding ART itself. These same types of strategies might also work to destigmatize HIV and MSM within Thai society as a whole. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Rectal microbicides (RMs) may offer substantial benefits in expanding HIV prevention options for key populations. From April to August 2013, we conducted Tablet-Assisted Survey Interviewing, including a discrete choice experiment, with participants recruited from gay entertainment venues and community-based organizations in Chiang Mai and Pattaya, Thailand. Among 408 participants, 74.5 % were young men who have sex with men, 25.5 % transgender women, with mean age = 24.3 years. One-third (35.5 %) had ≤9th grade education; 63.4 % engaged in sex work. Overall, 83.4 % reported they would definitely use a RM, with more than 2-fold higher odds of choice of a RM with 99 versus 50 % efficacy, and significantly higher odds of choosing gel versus suppository, intermittent versus daily dosing, and prescription versus over-the-counter. Sex workers were significantly more likely to use a RM immediately upon availability, with greater tolerance for moderate efficacy and daily dosing. Engaging key populations in assessing RM preferences may support biomedical research and evidence-informed interventions to optimize the effectiveness of RMs in HIV prevention. [ABSTRACT FROM AUTHOR]

HIV infection among men who have sex with men, particularly in Thai urban settings and among younger cohorts, is escalating. HIV testing and counseling (HTC) are important for prevention and obtaining treatment and care. We examine data from a 2013 survey of males, 15-24 years, reporting past-year sex with a male and living in Bangkok or Chiang Mai. Almost three quarters of young MSM (YMSM) in Bangkok and only 27 % in Chiang Mai had an HIV test in the previous year. Associations for HIV testing varied between cities, although having employment increased the odds of HIV testing for both cities. In Bangkok, family knowledge of same sex attraction and talking to parents/guardians about HIV/AIDS had higher odds of HIV testing. Expanded HTC coverage is needed for YMSM in Chiang Mai. All health centers providing HTC, including those targeting MSM, need to address the specific needs of younger cohorts. [ABSTRACT FROM AUTHOR]

The HIV epidemic has had a widespread impact on global scientific and cultural discourses related to gender, sexuality, and identity. ‘Male sex workers’ have been identified as a ‘key population’ in the global HIV epidemic; however, there are methodological and conceptual challenges for defining inclusion and exclusion of transgender women within this group. To assess these potential implications, this study employs self-critique and reflection to grapple with the empiric and conceptual implications of shifting understandings of sexuality and gender within the externally re-created etic category of ‘MSM’ and ‘transgender women’ in epidemiologic HIV research. We conducted a sensitivity analysis of our previously published meta-analysis which aimed to identify the scope of peer-reviewed articles assessing HIV prevalence among male sex workers globally between 2004 and 2013. The inclusion of four studies previously excluded due to non-differentiation of cisgender male from transgender women participants (studies from Spain, Thailand, India, and Brazil: 421 total participants) increased the overall estimate of global HIV prevalence among ‘men’ who engage in sex work from 10.5% (95% CI 9.4–11.5%) to 10.8% (95% CI 9.8–11.8%). The combination of social science critique with empiric epidemiologic analysis represents a first step in defining and operationalising ‘reflexive epidemiology’. Grounded in the context of sex work and HIV prevention, this paper highlights the multiplicity of genders and sexualities across a range of social and cultural settings, limitations of existing categories (i.e. ‘MSM’, ‘transgender’), and their global implications for epidemiologic estimates of HIV prevalence. [ABSTRACT FROM AUTHOR]

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Introduction: Pre-exposure prophylaxis (PrEP) is recommended by the World Health Organization as an effective method of HIV prevention for individuals at risk for infection. In this paper, we describe the unique role that Thailand has played in the global effort to combat the HIV epidemic, including its role in proving the efficacy of PrEP, and discuss the opportunities and challenges of implementing PrEP in a middle-income country. Discussion: Thailand was one of the first countries in the world to successfully reverse a generalized HIV epidemic. Despite this early success, HIV prevalence has remained high among people who inject drugs and has surged among men who have sex with men (MSM) and transgender women (TGW). Two pivotal trials that showed that the use of oral antiretroviral medication as PrEP can reduce HIV transmission were conducted partially or entirely at Thai sites. Demonstration projects of PrEP, as well as clinical trials of alternative PrEP regimens, began or will begin in 2014-2015 in Thailand and will provide additional data and experience on how to best implement PrEP for high-risk individuals in the community. Financing of drug costs, the need for routine laboratory monitoring and lack of awareness about PrEP among at-risk groups all present challenges to the wider implementation of PrEP for HIV prevention in Thailand. Conclusions: Although significant challenges to wider use remain, PrEP holds promise as a safe and highly effective method to be used as part of a combined HIV prevention strategy for MSM and TGW in Thailand. [ABSTRACT FROM AUTHOR]

Background Young men who have sex with men (YMSM) and transgender women (YTGW) are at high risk for HIV acquisition. In attempt to end the HIV epidemic, the comprehensive HIV prevention packages should be offered. However, the PrEP persistent among this population in western studies was low. The acceptability, uptake and persistent among Thai YMSM/YTGW PrEP clients were explored. Methods This is a sub-study of PrEP implementation project in Chiang Mai Thailand which was conducted during December 2015–February 2017. In the main study, PrEP@PIMAN, 105 participants who were 18 years and older, able to read and write in Thai, creatinine clearance ≥60 mL/minute, negative urine protein, and HBs-Ag-negative YMSM/YTGW were enrolled. Twelve months of PrEP along with quarterly visit and comprehensive HIV prevention package were offered. The data were collected through interview and computer-assisted self-interview. Each participant voluntary made their own decision about PrEP uptake. Results Sixty participants (57% of the main study) were youth, aged 16–24 years old. Of those, 82% were gay men and 12% were TGW (self-identified). Mean age was 21 years old and 80% were university/college students. At baseline, median partner in past 3 month was 3 (range 0–52). Approximately one-fourth of the participants reported history of sexually transmitted diseases (STDs) and 8% has positive TPHA at baseline. Majority (72%) initiated PrEP with 70% at the enrollment 2% during the study. PrEP was discontinued in 25% (10/42) due to nonserious side effects, participant preference or lost to follow-up (see Figure 1). The retention rate at 12 month were 70%. PrEP use was not consistent (see Figure 2). Only 30% reported adherence ≥60% (or equivalent to ≥4 pills/ week) throughout the study period. There was no seroconversion during 49 person-year of follow-up with 5 confirmed new STDs (incidence of 10/100 person-year). Conclusion This project demonstrated a good uptake with varying PrEP adherence rate among Thai YMSM and YTGW. The PrEP persistent was persistence could be improved. Further interventions and strategies should be explored to enhance PrEP adherence among this population. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]

Thailand has the highest prevalence of HIV among countries in Asia but has also been a pioneer in HIV prevention and treatment efforts in the region, reducing the incidence of new infections significantly over the last two decades. Building upon this remarkable history, Thailand has set an ambitious goal to stop the AIDS epidemic in the country by 2030. A key component of the strategy to achieve this goal includes scale-up of HIV screening programs to facilitate early HIV diagnosis and investment in mechanisms to support immediate initiation of antiretroviral therapy (ART). Initiation of ART during early or acute HIV infection not only reduces viremia, thereby halting onward transmission of HIV, but also may facilitate HIV remission by reducing the size of the latent HIV reservoir and preserving immune function. In Thailand, many efforts have been made to reduce the time from HIV infection to diagnosis and from diagnosis to treatment, especially among men who have sex with men and transgender women. Successfully identifying and initiating ART in individuals with acute HIV infection has been leveraged to conduct groundbreaking studies of novel strategies to achieve HIV remission, including studies of broadly-neutralizing HIV-specific monoclonal antibodies and candidate therapeutic vaccines. These efforts have mostly been deployed in Bangkok and future efforts should include other urban and more rural areas. Continued progress in HIV prevention, screening, and treatment will position Thailand to substantially limit new infections and may pave the way for an HIV cure. [ABSTRACT FROM AUTHOR]

Introduction: There are few data about the range of strategies used to prevent sexual HIV transmission within gay male serodiscordant couples. We examined HIV prevention strategies used by such couples and compared differences between countries. Methods: Opposites Attract was a cohort study of male serodiscordant couples in Australia, Brazil and Thailand, from May 2014 (Australia) or May 2016 (Brazil/Thailand) to December 2016. At visits, HIV‐positive partners had viral load (VL) tested; HIV‐negative partners reported sexual behaviour and perceptions of their HIV‐positive partner's VL results. Within‐couple acts of condomless anal intercourse (CLAI) were categorized by strategy: condom‐protected, biomedically protected (undetectable VL and/or pre‐exposure prophylaxis [PrEP]), or not protected by either (HIV‐negative partners engaging in insertive CLAI, receptive CLAI with withdrawal, or receptive CLAI with ejaculation). Results: A total of 343 couples were included in this analysis (153 in Australia, 93 in Brazil and 97 in Thailand). Three‐quarters of HIV‐positive partners were consistently virally suppressed (<200 copies/mL) during follow‐up, and HIV‐negative partners had correct perceptions of their partner's VL result for 76.5% of tests. One‐third of HIV‐negative partners used daily PrEP during follow‐up. Over follow‐up, 73.8% of couples had CLAI. HIV‐negative partners reported 31,532 acts of anal intercourse with their HIV‐positive partner. Of these, 46.7% were protected by condoms, 48.6% by a biomedical strategy and 4.7% of acts were not protected by these strategies. Australian couples had fewer condom‐protected acts and a higher proportion of biomedically protected acts than Brazilian and Thai couples. Of the 1473 CLAI acts where the perceived VL was detectable/unknown and were not protected by PrEP (4.7% of all acts), two‐thirds (n = 983) were when the HIV‐negative partner was insertive (strategic positioning). Of the 490 acts when the HIV‐negative partner was receptive, 261 involved withdrawal and 280 involved ejaculation. Thus, <1% of acts were in the highest risk category of receptive CLAI with ejaculation. Conclusions: Couples used condoms, PrEP or perceived undetectable VL for prevention in the majority of anal intercourse acts. Only a very small proportion of events were not protected by these strategies. Variation between countries may reflect differences in access to HIV treatment, education, knowledge and attitudes. [ABSTRACT FROM AUTHOR]