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This study describes rates and correlates of disease progression and survival among 194 female sex workers in northern Thailand who were infected with human immunodeficiency virus type 1 (HIV-1; 96% with subtype E). The median rate of CD4 T lymphocyte decline (3.9 cells/microL/month), median time from infection to <200 CD4 T lymphocytes/microL (6.9 years), and time to 25% mortality (6.0 years) were similar to those found in studies performed in Western countries before highly active antiretroviral therapy was available to populations infected with HIV-1 subtype B. Mortality rates among women with >100,000 HIV-1 RNA copies/mL were 15.4 times higher (95% confidence interval, 5.2-45.2) than among women with <10,000 copies. Initial CD4 T lymphocyte counts and serum virus load were independently strong predictors of survival. These results can help in assessing the effects of the epidemic in Thailand and in determining the prognoses for individual patients. [ABSTRACT FROM AUTHOR]

This paper examines factors that may place female Thai adolescents and young adults at risk for HIV, sexually transmitted diseases (STDs), and unintended pregnancies. A total of 832 female vocational students participated in a cross-sectional audio-computer-assisted self-interview (ACASI) survey after providing informed consent. The questionnaire covered: sociodemographic characteristics; knowledge, attitudes, and beliefs related to HIV and STDs; contraceptive practices; sexual experiences and behaviors; and drug use. Oral fluid was tested for HIV antibodies and urine was tested for illicit drugs and for the presence of gonococcal or chlamydial nucleic acids. A total of 359 women (43.1%) reported sexual intercourse history, with an average age at first sex of 17.6 years, and a 2.6 mean number of lifetime sex partners. Twenty-one percent of the entire sample reported coerced sexual contact or intercourse. Among those with sexual intercourse experience, 27.3% (n=98) had been pregnant and the majority of their most recent pregnancies were terminated. Three tested positive for HIV antibodies. Sexually active young Thai women report behaviors or experiences that may expose them to HIV/STD infection and unintended pregnancy in the future. These include unprotected intercourse, sexual coercion, low levels of contraceptive use, and drug and alcohol use. Culturally appropriate interventions that increase their awareness of and ability to respond to these sexual health risks are needed. [ABSTRACT FROM AUTHOR]

Context: Thailand has undergone dramatic social changes in the last two decades, yet little is known about factors related to sexual initiation among adolescents., Methods: A survey using the audio computer-assisted self-interviewing method was conducted to assess social and demographic characteristics, substance use, sexual behavior, and knowledge of HIV and STIs among 1,725 vocational school students aged 15-21 living in northern Thailand. Gender differences for these factors were evaluated using chi-square and Mann-Whitney U tests. Multivariate survival analysis using Cox proportional hazards models assessed associations between these variables and sexual initiation for each gender., Results: Males initiated sexual intercourse at an earlier age than females (median ages of 17 and 18, respectively). At any given age, sexual initiation was associated with having a nonagricultural background and using alcohol or methamphetamine (adjusted rate ratios, 1.3-2.9). For males, initiation was also associated with having parents who did not live together, having a friend as a confidant, tobacco use, high perceived risk for HIV and high STI knowledge (1.3-1.7). For females, other factors associated with earlier initiation were younger age at interview, living away from family, lacking a family member as a confidant, high perceived risk for STIs and ever having smoked marijuana (1.3-2.4)., Conclusions: Interventions to ameliorate the adverse consequences of early sexual initiation need to address social influences such as parents and peer groups. Programs should identify and target high-risk subgroups, such as those who are sexually experienced at an early age and those engaged in patterns of generalized risk-taking.

Palmtop-assisted self-interviewing (PASI) may provide a cheaper and more mobile alternative to audio-computer-assisted self-interviewing (ACASI) for collecting sensitive behavioral data. To evaluate PASI, in late 2002 the authors enrolled 1,283 Thai students aged 15-21 years in a randomized trial. Data collection used PASI, ACASI, self-administered questionnaire, and face-to-face interview in combination with drug-use urine testing. By use of reported levels of behaviors and agreement between self-reports of smoking and urine test results, PASI and ACASI (alpha = 0.05) were compared for noninferiority, and PASI and interview were compared for superiority (alpha = 0.05). Noninferiority of PASI was demonstrated by use of self-reports of the most sensitive areas of sexual behavior (e.g., oral sex, sexual intercourse, commercial sex, history of genital ulcers, pregnancy), as well as self-reports of less sensitive behaviors (e.g., alcohol use, dietary behaviors, symptoms of depression). Data generally showed noninferiority of PASI, ACASI, and self-administered questionnaires when compared with each other and superiority of PASI, ACASI, and self-administered questionnaires when compared with interviews. PASI agreements between self-reports of tobacco smoking and presence of nicotine metabolites in urine were noninferior to ACASI and superior to interviews. The establishment of PASI noninferiority and superiority using behavioral and biologic measures suggests that PASI is a scientifically acceptable alternative for collecting sensitive behavioral data.

Homo- or bisexual (HB) adolescents may have greater and different health risks than the population of heterosexual adolescents. We assessed sexual orientation and health risk behaviors in 1,725 consenting 15- to 21-year-old vocational school students in northern Thailand. Data were collected using audio-computer-assisted self-interviewing. Nine percent of males and 11.2% of females identified themselves as homo- or bisexual. HB males had an earlier mean age at sexual debut (14.7 years) and a higher mean number of lifetime sexual partners (7.9) than did heterosexual males (16.8 years and 5.8 partners, respectively). HB males (25.9%) and females (32.2%) were sexually coerced more often than were heterosexual males (4.6%) and females (19.6%). Drug use was reported significantly more frequently by HB females and significantly less frequently by HB males than by their heterosexual counterparts. HB males showed more signs of social isolation and depression than did heterosexual males. We conclude that HB adolescents in northern Thailand are at greater and different health risks than are their heterosexual counterparts. Differential health education messages for HB and heterosexual youth are warranted.

The objective of this study was to assess the prevalence of not wearing a helmet (unprotected) while riding a motorcycle and associated risk behaviors among adolescents and young adults in Northern Thailand. Participants were 1725 students, aged 15-21 years, from 3 vocational schools in Chiang Rai Province; 51.8% were male. Participants completed a classroom-based computer-assisted self-interview (ACASI). Of men 72.7% and of women 64.4% reported unprotected motorcycle riding 3 times or more in the past week. Logistic regression analysis showed the variables independently associated with unprotected riding to be history of ever riding after having had 3 or more alcoholic drinks (odds ratio (OR) = 2.21, 95% confidence interval (CI) = 1.76-2.21), attending technical school (OR = 2.09, 95% Cl = 1.55-2.83), living with the family (OR = 1.38, 95% CI = 1.10-1.73), and having ever had a traffic accident (OR = 1.20, 95% CI = 1.12-1.29). Being of hill tribe ethnicity (vs Thai lowlander) was associated with protected riding (OR = 0.42, 95% CI = 0.20-0.90). Adolescents and young adults in Chiang Rai are at high risk for riding a motorcycle without a helmet buckled on the head. Public education in combination with enforcement of compulsory helmet use while riding a motorcycle is recommended.

Setting: A provincial referral hospital in northern Thailand, where a cross-sectional study during 1995-1996 reported on the occupational risk of Mycobacterium tuberculosis transmission., Objective: To describe the effectiveness of prevention strategies for nosocomial tuberculosis (TB)., Design: A prospective study among health care workers (HCW) including annual tuberculin skin test (TST) screening and active TB surveillance. Following a comprehensive risk assessment, preventive interventions were implemented targeting HCWs, hospitalised patients, and the hospital environment., Results: The number of pulmonary TB cases diagnosed increased steadily from 102 in 1990 to 356 in 1999. The TST conversion rate was 9.3 (95% CI 3.3-15) per 100 person-years (py) in 1995-1997, but declined steadily to 2.2 (95% CI 0.0-5.1) in 1999. HCWs first screened within 12 months of employment had higher TST conversion rates (adjusted RR = 9.5, 95% CI 1.8-49.5) compared to those employed for longer than 12 months. The annual rate of active TB per 100 000 HCWs was 536 in 1995-1999., Conclusion: These HCWs were exposed to active TB patients and were at risk for M. tuberculosis infection, particularly during their first 12 months of employment. Implementation of nosocomial TB control measures in 1996 was followed by declining TST conversion rates, despite increasing exposure to active TB patients.

Setting: A provincial referral hospital in northern Thailand, where a cross-sectional study from 1995-1996 reported on the occupational risk of Mycobacterium tuberculosis transmission., Objective: To assess the impact of acid-fast bacilli sputum smear-positive results notification to improve tuberculosis (TB) services by documenting the location of sputum collection, completing the TB register immediately, and minimising delays between hospital admission and treatment initiation., Design: The cohort of smear-positive TB patients identified through laboratory microscopy record reviews from 1994-1999. Time from admission to hospital, laboratory diagnosis of TB, registration for treatment, and initiation of therapy were determined during the implementation of enhancing the laboratory results notification system., Results: The number of unregistered TB patients fell from 44 cases in 1994 to none in 1999. The time elapsed from admission to treatment initiation decreased from a mean of 5.6 days in 1997 (n = 162) to 3.1 days in 1999 (n = 136) (P < 0.001). This decrease was attributed to a reduction in time between laboratory diagnosis and treatment from 2.7 days in 1997 to 0.6 days in 1999 (P < 0.001)., Conclusion: Prompt identification, isolation and treatment of TB patients occurred through an enhanced laboratory notification system. Such systems are inexpensive, improve TB care services and may reduce nosocomial transmission of M. tuberculosis.

Objectives: To examine the association between HIV infection and tuberculosis (TB) and the proportion of TB attributable to HIV in Chiang Rai province, northern Thailand, in response to a rapidly changing incidence of HIV infection., Methods: Case-control study covering the period 1990 to 1998. Cases were all new TB patients seen at Chiang Rai Hospital. Controls were antenatal clinic attendees, delivery patients, surgical patients, blood donors, and military conscripts. Odds ratios (ORs) were calculated by year, age group, and sex, using each control group separately. The population attributable fraction was calculated by year., Results: During the study period, the number of new TB cases in Chiang Rai Hospital increased more than threefold. The ORs increased over time compared with all control groups for both sexes but did not vary consistently with age. The proportion of TB cases attributable to HIV rose to 72.0% in male patients and 65.8% in female patients by 1998., Conclusions: The HIV epidemic has a profound and prolonged impact on TB burden. Despite the marked reduction in HIV incidence already seen in Chiang Rai, the HIV prevalence among TB cases and the proportion of cases attributable to HIV continue to rise.

Condom use and its psychosocial correlates were investigated in a sample of 1,725 male and female vocational students (aged 15-21 years) in northern Thailand. Consistent condom use was relatively infrequent with all partner types (8.0% with recent steady partners, 28.5% with casual partners, and 30.7% with commercial sex partners), and only 24.3% reported condom use at first sex. These findings suggest that condom use, even with commercial partners, is not becoming widely established in the younger generation of Thai youths. Condom use with commercial partners was far below goals established by Thailand's 100% Condom Campaign, which was particularly significant for a population in Thailand's HIV epicenter. Consistent condom use with a steady partner was significantly related to condom use during first sex, which suggests the importance of establishing a "condom habit." Consistent condom use with casual partners was related to never having been pregnant (self or partner). Having used condoms at first sex also was associated with never having been pregnant (self or partner), as well as with a number of background social and psychological factors. Intentions to use condom were highly related to peer norms. Results suggest the importance of addressing peer norms concerning condom use, as well as the role of condoms in effective birth control.

Setting: Chiang Rai, the northernmost province of Thailand., Objective: To evaluate the occupational risk for tuberculous infection of health care workers (HCWs) and the utility of tuberculin skin test (TST) in a developing country setting., Design: A cross-sectional TST survey, including a risk assessment questionnaire, of Chiang Rai Hospital HCWs., Results: Of 911 HCWs tested, 623 (68%) had indurations of > or = 10 mm and 322 (35%) indurations of > or = 15 mm. Factors most predictive for TST positivity, using either cut-off, were employment > 1 year, frequent direct patient contact, and male sex. Moreover, having a bacillus Calmette-Guérin (BCG) scar was predictive of a > or = 10 mm, but not a > or = 15 mm, reaction., Conclusions: Chiang Rai Hospital HCWs had an increased risk for Mycobacterium tuberculosis infection, which was significantly associated with occupational exposure. Where BCG coverage is high, a TST cut-off of > or = 15 mm may correlate better with M. tuberculosis infection than does a cut-off of > or = 10 mm. Effective, affordable infection control measures are needed for health care facilities in developing countries such as Thailand, where HCWs may be at increased risk for M. tuberculosis infection from occupational exposures.

Objectives: To determine the incidence of HIV-1 infection, temporal trends in incidence, and risk factors for seroconversion in a cohort of female commercial sex workers (CSW) in upper northern Thailand, the region of Thailand with the highest rates of HIV-1 infection., Methods: CSW were enrolled from 1991 through 1994 and evaluated prospectively with interviews, physical examination, testing for sexually transmitted diseases (STD), and serologic testing for HIV-1 infection., Results: The incidence of HIV-1 seroconversion in the first year of follow-up was 20.3 per 100 person-years among 126 brothel-based CSW and 0.7 per 100 person-years among 159 other CSW who worked in other venues such as bars or massage parlors. Incidence remained elevated among brothel-based CSW who were enrolled later in the study compared with those who enrolled earlier. Through 1996, 30 women seroconverted. In a multivariable proportional hazards model, seroconversion was significantly associated (P < 0.05) with brothel-based sex work (adjusted risk ratio, 7.3) and Chlamydia trachomatis cervical infection (adjusted risk ratio, 3.3)., Conclusion: Despite national HIV control efforts and declining rates of infection among young men in Thailand, brothel-based CSW may continue to be at high risk for HIV-1 infection. Additional efforts are needed to provide alternative economic choices for young women, to ensure universal condom use during commercial sex, and to develop new prevention technologies.

Setting: Chiang Rai, the northernmost province of Thailand, where extensive human immunodeficiency virus (HIV) transmission has resulted in a rapid increase in tuberculosis., Objective: To assess the utility of tuberculin and anergy skin testing to identify latent Mycobacterium tuberculosis infection in HIV-infected persons., Design: A cross-sectional study and analysis were conducted to examine reactivity to tuberculin and two control antigens (mumps and candida) in HIV-negative and HIV-positive blood donors and female sex workers., Results: HIV-positive persons had markedly decreased tuberculin reactivity; 14%, 19%, and 40% had an induration of > or = 10 mm, > or = 5 mm, > or = 2 mm, respectively, while 51% of 525 HIV-negative persons had an induration of > or = 10 mm (P < 0.001). Mumps and candida positivity (reactions of > or = 3 mm) were found in 94% and 78% of HIV-negative persons compared with 72% and 61% of HIV-positive persons, respectively (P < 0.001). Although HIV-positive persons had markedly less tuberculin reactivity even at higher CD4+ cell counts (> 400 cells/microL), reactivity to mumps and candida was present in more than half of HIV-positive persons with low CD4+ cell counts (< or = 200 cells/microL). Reaction to control antigens did not predict tuberculin reactivity., Conclusion: In this setting, tuberculin and anergy skin testing have a low predictive value in detecting M. tuberculosis infection in HIV-infected persons, and therefore such testing has a limited role in identifying HIV-infected persons who may benefit from tuberculosis preventive therapy programs.

Objective: To determine the level of and reasons associated with adherence to tuberculosis preventive therapy among asymptomatic HIV-infected individuals in northern Thailand., Design: A prospective cohort study with a 9-month follow-up., Methods: A total of 412 HIV-infected persons were enrolled in a tuberculosis preventive therapy programme in a hospital. A 9-month isoniazid regimen was prescribed. Adherence was determined by pill count. Participants who missed a scheduled appointment for more than a month were interviewed. Five focus group discussion sessions were held among those who successfully completed the therapy., Results: Of the 412 participants, 69.4% (286) completed the 9-month regimen. The adherence rate, defined as the proportion of those who took more than 80% of pills, was 67.5% (n = 278). Sex, source of participants and history of physical symptoms were associated with adherence. A significant portion of defaults took place at the beginning of the therapy. Out-migration, denial of HIV status, and perceived side effects of isoniazid were frequently cited as reasons for non-adherence. For those adhering participants, the acceptance of personal HIV status, concern about children and family, and a good health provider relationship were important reasons motivating adherence. Several reminder systems were developed by the participants., Conclusions: Although a isoniazid preventive therapy programme was shown to be feasible, further adjustments on the selection of participants, enrollment process, and follow-up system based on these findings are necessary to increase the adherence.

Objective: Chiang Rai, the northernmost province of Thailand, has experienced an explosive HIV epidemic since 1989. This study assessed the impact of HIV infection on tuberculosis (TB) in the area., Methods: We analyzed the incidence of reported TB in the province from 1982 through 1993 and TB registry data at Chiang Rai Hospital from 1985 through 1994., Results: Following a steady decline in reported TB from 1982 through 1991, the incidence of TB increased sharply after 1991. TB registry data from Chiang Rai Hospital, which began confidential HIV testing in October 1989, indicated a steady and rapid increase in the number and proportion of HIV-seropositive TB patients from four (1.5% of all TB patients) in 1990 to 207 (45.5%) in 1994 (P < 0.001). Compared with HIV-negative TB patients, HIV-positive TB patients were more likely to be men, aged 20-39 years and have extrapulmonary TB (P < 0.001). Treatment completion rates were similar. Twelve months after beginning TB treatment, HIV-positive TB patients had a mortality rate of 68.6% [95% confidence interval (Cl), 62.7-74.3] compared with 10.0% (95% Cl, 8.3-12.1%) in HIV-negative patients (P < 0.001)., Conclusion: Thailand and other Asian countries where HIV is spreading rapidly must promptly address the dual epidemic of TB and HIV in order to reduce preventable morbidity and mortality.