Evidence of an explosive epidemic of HIV infection in a cohort of men who have sex with men in Thailand

"We are not gays… don't tell me those things": engaging 'hidden' men who have sex with men and transgender women in HIV prevention in Myanmar

Background

In Myanmar, HIV is concentrated among key populations, yet less than half of the estimated 250,000 men who have sex with men (MSM) and transgender women (TW) report recent HIV testing. As many as 50% of MSM and TW may conceal their same-sex preferences and behaviors, yet little is known about the barriers faced by those who are locally regarded as ‘hidden’ – that is, MSM who do not disclose same-sex preferences and/or identify as gay. This study explored specific barriers to accessing HIV testing and other prevention services among ‘hidden’ MSM to inform appropriate models of service delivery.

Methods

In-depth interviews with MSM (n = 12) and TW (n = 13) and focus group discussions (FGD) with MSM and TW community members, leaders and key informants (n = 35) were undertaken in Yangon during June – September 2015. Participants were recruited by word-of-mouth by trained peer data collectors. Responses to questions from semi-structured guides were transcribed and coded using Atlas Ti. Codes were based on key domains in the guides and applied to transcripts to identify and analyze emerging themes.

Results

Fear of stigma and discrimination and the need to meet gender expectations were key reasons for non-disclosure of same-sex preferences and behaviors; this typically manifested as avoidance of other MSM and settings in which sexual identity might be implicated. These concerns influenced preference and interaction with HIV services, with many avoiding MSM-specific services or eschewing HIV testing services entirely. The difficulties of engaging hidden MSM in HIV prevention was strongly corroborated by service providers.

Conclusion

Hidden MSM face multiple barriers to HIV testing and prevention. Strategies cognizant of concerns for anonymity and privacy, such as One-Stop Shop services and online-based health promotion, can discretely provide services appropriate for hidden MSM. Enhanced capacity of peer-service providers and mainstream health staff to identify and respond to the psychosocial challenges reported by hidden MSM in this study may further encourage service engagement. Overarching strategies to strengthen the enabling environment, such as legal reform and LGBTI community mobilisation, can lessen stigma and discrimination and increase hidden MSM’s comfort and willingness to discuss same-sex behavior and access appropriate services.

Why we need pre-exposure prophylaxis: incident HIV and syphilis among men, and transgender women, who have sex with men, Bangkok, Thailand, 2005-2015

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.

Repeat HIV testing among HIV-uninfected men who have sex with men attending Silom Community Clinic, Bangkok, 2011 - 2014

Since 2010, the Thailand Ministry of Public Health has recommended that men who have sex with men (MSM) have an HIV test at least two times a year. We calculated the proportion of, and factors associated with, testing adherence among the HIV-uninfected MSM clients attending Silom Community Clinic @TropMed. We defined testing adherence as repeating at least one HIV test within six months of an initial HIV-negative test, and used log-binomial regression to test for associated factors. We included 1927 clients during 2011–2014; 362 (19%) were adherent with an increased trend (p < 0.01), from 16% to 24%. Clients aged 18–24 years and those having a history of HIV testing were more likely to adhere (aRR: 1.3, 95% CI: 1.1–1.6; and aRR: 1.3, 95% CI: 1.0–1.5, respectively). One-fifth adhered to the recommendation; older clients or naïve testees were less likely to adhere. We need to impress on clients the importance of repeat HIV testing.

Molecular epidemiology of a primarily MSM acute HIV-1 cohort in Bangkok, Thailand and connections within networks of transmission in Asia

INTRODUCTION

Thailand plays a substantial role in global HIV-1 transmission of CRF01_AE. Worldwide, men who have sex with men (MSM) are at elevated risk for HIV-1 infection. Hence, understanding HIV-1 diversity in a primarily Thai MSM cohort with acute infection, and its connections to the broader HIV-1 transmission network in Asia is crucial for research and development of HIV-1 vaccines, treatment and cure.

METHODS

Subtypes and diversity of infecting viruses from individuals sampled from 2009 to 2015 within the RV254/SEARCH 010 cohort were assessed by multiregion hybridization assay (MHAbce), multiregion subtype-specific PCR assay (MSSPbce) and full-length single-genome sequencing (SGS). Phylogenetic analysis was performed by maximum likelihood. Pairwise genetic distances of envelope gp160 sequences obtained from the cohort and from Asia (Los Alamos National Laboratory HIV Database) were calculated to identify potential transmission networks.

RESULTS

MHAbce/MSSPbce results identified 81.6% CRF01_AE infecting strains in RV254. CRF01_AE/B recombinants and subtype B were found at 7.3% and 2.8% respectively. Western subtype B strains outnumbered Thai B' strains. Phylogenetic analysis revealed one C, one CRF01_AE/CRF02_AG recombinant and one CRF01_AE/B/C recombinant. Asian network analysis identified one hundred and twenty-three clusters, including five clusters of RV254 participants. None of the RV254 sequences clustered with non-RV254 sequences. The largest international cluster involved 15 CRF01_AE strains from China and Vietnam. The remaining clusters were mostly intracountry connections, of which 31.7% included Thai nodes and 43.1% included Chinese nodes.

CONCLUSION

While the majority of strains in Thailand are CRF01_AE and subtype B, emergence of unique recombinant forms (URFs) are found in a moderate fraction of new HIV-1 infections. Approaches to vaccine design and immunotherapeutics will need to monitor and consider the expanding proportion of recombinants and the increasing genetic diversity in the region. Identified HIV-1 transmission networks indicate ongoing spread of HIV-1 among MSM. As HIV-1 epidemics continue to expand in other Asian countries, transmission network analyses can inform strategies for prevention, intervention, treatment and cure.

Selling and buying sex in the city: men who have sex with men in the Bangkok men who have sex with men Cohort Study

We describe participants in the Bangkok Men who have sex with men Cohort Study (BMCS) who sold or bought sex. Men who have sex with men (MSM) and transgender women aged ≥18 years had HIV testing and behavioral data collected at enrollment and every four months. We evaluated report of receiving money or goods for sex (selling sex) or giving money or goods for sex (buying sex) at enrollment using logistic regression models; we also describe sex work over time, and HIV and syphilis incidence among those who report sex work. At enrollment, 511 (29.3%) of 1744 participants reported buying or selling sex. Factors associated with selling sex were young age, lower education, living alone or living with a friend, being unemployed, higher HIV knowledge, binge drinking and club drug use, a higher number of casual male partners, meeting sex partners at specific venues, having a foreign sex partner, and being HSV-1 seropositive. MSM aged 18-21 years who sold sex had an HIV incidence of 11.1 per 100 person-years (95% CI: 6.7-17.4). Almost one-third of participants from BMCS reported sex work at enrollment. Young men who sold sex had high HIV incidence and HIV prevention interventions are needed for this at-risk population in Bangkok, Thailand.

Transmission dynamics among participants initiating antiretroviral therapy upon diagnosis of early acute HIV-1 infection in Thailand

OBJECTIVE

To assess transmission characteristics in a predominantly MSM cohort initiating antiretroviral therapy (ART) immediately following diagnosis of acute HIV-1infection (AHI).

METHODS

A longitudinal study (2009-2017) was performed in participants with AHI (n = 439) attending a single clinic in Bangkok. Plasma samples obtained prior to ART were used to obtain HIV-1 pol sequences and combined with clinical and epidemiologic data to assess transmission dynamics (cluster formation and size) using phylogenetic analysis. Clusters were estimated using maximum likelihood, genetic distance of 1.5% and visual inspection. The potential transmitter(s) in a cluster was determined using time to viral suppression and interview data.

RESULTS

The cohort was predominantly MSM (93%) and infected with HIV-1 CRF01_AE (87%). Medians (ranges) for age and viral load prior to ART were 26 (18-70) years and 5.9 (2.5-8.2) log10 HIV-1 RNA copies/ml. Median time from history of HIV-1 exposure to diagnosis was 19 (3-61) days. Viral suppression was observed in 388 of 412 (94%) participants at a median time of 12 weeks following ART. Twenty-six clusters with median cluster size of 2 (2-5) representing 62 of 439 (14%) participants were observed. Younger age was associated with cluster formation: median 28 versus 30 years for unique infections (P = 0.01). A potential transmitter was identified in 11 of 26 (42%) clusters.

CONCLUSION

Despite high rates of viral suppression following diagnosis and treatment of AHI within a cohort of young Thai MSM, HIV-1 transmission continued, reflecting the need to expand awareness and treatment access to the entire MSM population.

Estimating recent HIV incidence among young men who have sex with men: Reinvigorating, validating and implementing Osmond's algorithm for behavioral imputation

HIV incidence information is essential for epidemic monitoring and evaluating preventive interventions. However, reliable HIV incidence data is difficult to obtain, especially among marginalized populations, such as young men who have sex with men (YMSM). Here we evaluate the reliability of an alternative HIV incidence assessment method, behavioral imputation, as compared to serologically estimated HIV incidence. Recent HIV incidence among YMSM (aged 18 to 21 and 18 to 24 years) enrolled in a cohort study in Bangkok from 2006 to 2014 was estimated using two mid-point methods for seroconversion: 1) between age of first anal intercourse and first HIV-positive test (without previous HIV-negative test) (behavioral imputation) and 2) between the date of last negative and first positive HIV test (serological estimation). Serologically estimated HIV incidence was taken as the "gold standard" to evaluate between-method agreement. At baseline, 314 YMSM age 18 to 21 years accumulated 674 person-years (PY) of follow-up since first anal intercourse. Considering that 50 men had prevalent HIV infection, the behaviorally imputed HIV incidence was 7.4 per 100 PY. Of the remaining 264 HIV-negative men, 54 seroconverted for HIV infection during the study, accumulating 724 PY of follow-up and a serologically estimated HIV incidence of 7.5 per 100 PY. At baseline, 712 YMSM age 18 to 24 years (including 18 to 21-year-old men analyzed above) accumulated 2143 PY of follow-up since first anal intercourse. Considering that 151 men had prevalent HIV infection, the behaviorally imputed HIV incidence was 7.0 per 100 PY. Of the remaining 561 HIV-negative men, 125 seroconverted for HIV infection during the study, accumulating 1700 PY of follow-up and a serologically estimated HIV incidence of 7.4 per 100 PY. Behavioral imputation and serological estimation are in good agreement when estimating recent HIV incidence in YMSM.

Heavy Alcohol Use Among Migrant and Non-Migrant Male Sex Workers in Thailand: A Neglected HIV/STI Vulnerability

BACKGROUND

There is scarce research on male sex workers in the context of alcohol use. While heavy alcohol use has been established as a risk factor for HIV and STI infections among men who have sex with men (MSM), men who engage in sex work with other men, particularly from the Global South, have not been included in these studies. Moreover, studies among male sex workers in Asia often do not explore migration contexts of these men.

OBJECTIVES

The objective of this exploratory study is to examine the prevalence and correlates of heavy alcohol use among migrant and non-migrant male sex workers in Bangkok and Pattaya, Central Thailand.

METHODS

Between August and October 2015, 18-24 year-old migrant and non-migrant male sex workers (n = 212) were recruited from various male sex work-identified venues (bars, clubs, massage parlors, and go-go bars) to take an interviewer-administered cross-sectional survey in Bangkok and Pattaya, Thailand. Measures were adapted from previous studies in similar populations and included structured questions across four domains, including demographic characteristics, alcohol use, stimulant use, and sexual behaviors. Multivariable logistic regression assessed the independent associations between heavy alcohol use (heavy versus not heavy) and demographic characteristics, stimulant use and sexual behavior.

RESULTS

Heavy alcohol use was prevalent among one-third of participants. Heavy alcohol use was positively associated with male sex workers who were non-migrant and Thai, currently using stimulants, having 15 or more male clients in the past month and having first consumed alcohol at age 15 years or younger.

CONCLUSIONS

Current HIV prevention efforts should consider subpopulations of MSM, including male sex workers and migrants, as well as other risk behaviors like alcohol, as important contexts for HIV and STI risks.

Acceptability of Peer-Delivered HIV Testing and Counselling Among Men Who Have Sex with Men (MSM) and Transgender Women (TW) in Myanmar

Men who have sex with men (MSM) and transgender women (TW) are a priority population for HIV prevention in Myanmar but report sub-optimal HIV testing frequency. Previous studies have shown that peer involvement in HIV testing can normalize stigmatized sexualities and reduce barriers to testing. We explored the acceptability of peer-delivered HIV testing among 425 undiagnosed MSM and TW in Yangon and Mandalay. An overwhelming majority of participants (86%) reported being 'comfortable/very comfortable' with peer-delivered HIV testing. Logistic regression identified reporting sexual identity as Apone [adjusted odds ratio (aOR) 3.8; 95% CI 1.2-11.7], recent HIV testing (aOR 3.1; 95% CI 1.4-6.5), reporting a high likelihood of HIV acquisition (aOR 3.6; 95% CI 1.7-7.6), and reporting ≥ 5 casual partners in the past 3 months (aOR 0.2; 95% CI 0.1-0.6) as associated with peer-delivered HIV testing acceptability. Given ongoing HIV vulnerability among MSM and TW in Myanmar, peer-delivered testing may offer prevention benefits by increasing testing rates and identifying undiagnosed infection earlier.

Association between HIV genotype, viral load and disease progression in a cohort of Thai men who have sex with men with estimated dates of HIV infection

BACKGROUND

Differences between HIV genotypes may affect HIV disease progression. We examined infecting HIV genotypes and their association with disease progression in a cohort of men who have sex with men with incident HIV infection in Bangkok, Thailand.

METHODS

We characterized the viral genotype of 189 new HIV infections among MSM identified between 2006-2014 using hybridization and sequencing. Plasma viral load (PVL) was determined by PCR, and CD4+ T-cell counts were measured by flow cytometry. We used Generalized Estimating Equations to examine factors associated with changes in CD4+ T-cell counts. Factors associated with immunologic failure were analyzed using Cox proportional hazard models.

RESULTS

Among 189 MSM, 84% were infected with CRF01_AE, 11% with recombinant B/CRF01_AE and 5% with subtype B. CD4+ T-cell decline rates were 68, 65, and 46 cells/μL/year for CRF01_AE, recombinants, and subtype B, respectively, and were not significantly different between HIV subtypes. CD4+ T-cell decline rate was significantly associated with baseline PVL and CD4+ T-cell counts (p <0.001). Progression to immunologic failure was associated with baseline CD4+ T-cell ≤ 500 cells/μL (AHR 1.97; 95% CI 1.14-3.40, p = 0.015) and PVL > 50,000 copies/ml (AHR 2.03; 1.14-3.63, p = 0.017). There was no difference in time to immunologic failure between HIV subtypes.

CONCLUSION

Among HIV-infected Thai MSM, low baseline CD4+ T-cell and high PVL are associated with rapid progression. In this cohort, no significant difference in CD4+ T-cell decline rate or time to immunologic failure was seen between CRF01_AE and other infecting HIV subtypes.

Implementation of a Test, Treat, and Prevent HIV program among men who have sex with men and transgender women in Thailand, 2015-2016

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.

Young Men Who Have Sex with Men at High Risk for HIV, Bangkok MSM Cohort Study, Thailand 2006-2014

High HIV incidence has been reported in young men who have sex with men (YMSM) in North America and Western Europe, but there are limited data from Southeast Asia suggesting MSM may be the driver of the HIV epidemic in this region. We described HIV incidence and risk factors among 494 YMSM enrolled in a cohort study in Bangkok, Thailand. The HIV incidence was 7.4 per 100 person-years. In multivariable analysis, reporting use of an erectile dysfunction drug in combination with club drugs, having receptive or both insertive and receptive anal intercourse with men, having hepatitis A infection, having rectal Chlamydia trachomatis, having hepatitis B infection prior to HIV seroconversion, and reporting not always using condoms with male steady partners were significantly associated with HIV incidence in YMSM. Reduction in new HIV infections in YMSM are critical to reach targets set by Thailand and the region.

Understanding willingness to use oral pre-exposure prophylaxis for HIV prevention among men who have sex with men in China

Background

Oral pre-exposure prophylaxis (PrEP) is recommended as an additional prevention choice for men who have sex with men (MSM) at substantial risk of HIV. The aim of this study was to evaluate the extent, and reasons, for MSM’s willingness to use oral PrEP in Wuhan and Shanghai, China.

Methods

Between May and December 2015, a cross-sectional survey was conducted among 487 MSM recruited through snowball sampling in physical locations frequented by MSM and through social media applications. Exploratory factor analysis was used to group reasons for being willing or not willing to use PrEP. Chi-square tests were used to explore bivariate associations between groupings of reasons for being willing or unwilling to use PrEP, and key sociodemographic and sexual-behavioral characteristics of MSM.

Results

Overall, 71.3% of respondents were willing to use PrEP. The most commonly reported reasons for being willing to use PrEP were preventing HIV infection (91.6%), taking responsibility for own sexual health (72.6%) and protecting family members from harm (59.4%). The main reasons for being unwilling to use PrEP were being worried about side effects (72.9%), the necessity of taking PrEP for long periods of time (54.3%) and cost (40.4%). Individual characteristics that influenced the type of reasons given for being willing or unwilling to use PrEP included being married to a woman, having a regular sex partner, rates of condom use with regular and casual sex partners, and the number of casual sex partners.

Conclusion

The introduction of PrEP in China could benefit from promotion campaigns that emphasize its role in preventing HIV infection, in taking responsibility for own sexual health, and in protecting family members from potential harm. To reduce uptake barriers, it will be essential to provide accurate information to potential PrEP users about the mild and short-term nature of side effects, and the possibility of taking PrEP only during particular periods of life when the risk of HIV exposure might be highest.

Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

OBJECTIVES

Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP.

METHODS

We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article).

RESULTS

Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%).

CONCLUSIONS

This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

The finding of casual sex partners on the internet, methamphetamine use for sexual pleasure, and incidence of HIV infection among men who have sex with men in Bangkok, Thailand: an observational cohort study

BACKGROUND

The finding of casual sex partners on the internet and methamphetamine use have been described as risk factors for HIV infection in men who have sex with men (MSM). However, the interplay between these factors has not been studied prospectively in one design. This study aims to determine the associations between finding casual sex partners on the internet and incident methamphetamine use and HIV infection.

METHODS

In this observational cohort study of Thai MSM, we recruited Bangkok residents aged 18 years or older with a history of penetrative male-to-male sex in the past 6 months. Baseline and follow-up visits were done at a dedicated study clinic in central Bangkok. Men were tested for HIV infection at every study visit and for sexually transmitted infections at baseline. Baseline demographics and HIV risk behaviour information were collected at every visit by audio computer-assisted self-interview. We used a descriptive model using bivariate odds ratios to elucidate the order of risk factors in the causal pathway to HIV incidence and methamphetamine use. We used Cox proportional hazard regression analysis to evaluate covariates for incident methamphetamine use and HIV infection.

FINDINGS

From April 6, 2006, to Dec 31, 2010, 1977 men were screened and 1764 were found eligible. 1744 men were enrolled, of whom 1372 tested negative for HIV and were followed up until March 20, 2012. Per 100 person-years of follow-up, incidence of methamphetamine use was 3·8 (128 events in 3371 person-years) and incidence of HIV infection was 6·0 (212 events in 3554 person-years). In our descriptive model, methamphetamine use, anal sex, and various other behaviours cluster together but their effect on HIV incidence was mediated by the occurrence of ulcerative sexually transmitted infections. Dual risk factors for both incident methamphetamine use and HIV infection were younger age and finding casual sex partners on the internet. Having ever received money for sex was predictive for incident methamphetamine use; living alone or with a housemate, recent anal sex, and ulcerative sexually transmitted infections at baseline were predictive for incident HIV infection.

INTERPRETATION

In MSM in Bangkok, casual sex partner recruitment on the internet, methamphetamine use, and sexually transmitted infections have important roles in sustaining the HIV epidemic. Virtual HIV prevention education, drug use harm reduction, and biomedical HIV prevention methods, such as pre-exposure prophylaxis, could help to reduce or revert the HIV epidemic among MSM in Bangkok.

FUNDING

US Centers for Disease Control and Prevention and the Johns Hopkins Fogarty AIDS International Training and Research Program.

The Associations of Perceived Social Support with Key HIV Risk and Protective Factors Among Young Males Who Have Sex with Males in Bangkok and Chiang Mai, Thailand

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.

Playing and Never Testing: Human Immunodeficiency Virus and Sexually Transmitted Infection Testing Among App-Using MSM in Southeast Asia

Little is known about mobile application (app)-based behavior of men who have sex with men (MSM) in Thailand. A cross-sectional online assessment of app users in Bangkok found that more than a quarter have never tested for human immunodeficiency virus (HIV) and 1 in 3 never tested for sexually transmitted infections (STI). STI testing patterns and HIV testing frequency were highly associated with each other in multinomial logistic regression. In the midst of an escalating epidemic where HIV incidence among MSM is highest in Asia, apps can serve to engage those least likely to be reached by traditional methods of recruitment and outreach in Thailand.

Ice parties among young men who have sex with men in Thailand: Pleasures, secrecy and risks

BACKGROUND

Crystal methamphetamine (ice) has become the substance of choice among young men who have sex with men (YMSM) in urban Thailand. Yet, there is scarce data on this phenomenon, partly due to the difficulty in accessing men who will disclose and openly discuss the social contexts, meanings and risks surrounding ice practice. We present an ethnography of ice parties, critically discussing the in-depth social meanings of ice; the sexual socialities and the secrecy surrounding its use; the transactions between older and younger men; and the role of the Internet and mobile technology.

METHODS

Forty repeated narrative interviews (life stories), ten focus group discussions, as well as systematic online and offline observations were conducted over a three-year period. Purposive sampling was used to recruit study participants in a variety of online and offline spaces and through working closely with local Thai community-based organizations serving MSM. To be eligible, participants had to be between 18 and 29 years, able to converse in Thai, had used ice, and had anal sex with another man in the past 6 months. We also strived for sample variability with respects to socio-demographic characteristics (e.g., age, educational attainment and living situation). Data analysis was conducted in Thai by two researchers using the constant comparative method based on grounded theory.

RESULTS

On surface, participants described ice parties as exclusive, in trend, luxurious, fun and pleasurable-a kind of modern camaraderie among beautiful men. In reality, however, this group phenomenon was a social hierarchy containing several important players with relational power to one another, to the ice itself and to the physical space where ice was being consumed. These players included ice suppliers, party hosts, party guests and "icetenders." The paper also discusses the sociality of secrecy that surrounds ice parties as well as the power relations between older relatively rich men who provide ice and the younger men who crave for the chemical, pointing to the risks associated with engagement at ice parties, including instances of rape, violence and unsafe sex. For some participants, ice use was part of their "everyday life," or even believed to be a "rites of passage." For others, it involved sexual silence in cases where they were forced to have (unprotected) sex with certain persons or engage in high-risk activities against their will.

CONCLUSIONS

Ice parties, where high-risk practices were common, power and agency quickly became relational and negotiable. This paper illuminated the secret sociality of ice so that public health efforts will be better equipped with understanding and reaching out to young men who may be at heightened risk for HIV, STI, violence and other health concerns. Ice parties can, for example, be seen as opportunities for harm-reduction strategies whereby young men are not judged for the activities they engage, but are instead respected and approached in a contextualized, non-judgmental way. Finally, icetenders and party hosts may be individuals where public health practitioners can target and include in the development of novel harm-reduction programs.

Structural barriers to HIV prevention among men who have sex with men (MSM) in Vietnam: Diversity, stigma, and healthcare access

Men who have sex with men (MSM) in Vietnam experience disproportionate rates of HIV infection. To advance understanding of how structural barriers may shape their engagement with HIV prevention services, we draw on 32 in-depth interviews and four focus groups (n = 31) conducted with MSM in Hanoi between October 2015- March 2016. Three primary factors emerged: (1) Diversity, both in relation to identity and income; Vietnamese MSM described themselves as segregated into Bóng kín (hidden, often heterosexually-identified MSM) and Bóng lộ (‘out,’ transgender, or effeminate MSM). Lower-income, ‘hidden’ MSM from rural areas were reluctant to access MSM-targeted services; (2) Stigma: MSM reported being stigmatized by the healthcare system, family, and other MSM; and (3) Healthcare access: this was limited due to economic barriers and lack of MSM-friendly services. Our research suggests the need for multiple strategies to reach diverse types of MSM as well as to address barriers in access to health services such as stigma and costs. While a great deal has been written about the diversity of MSM in relation to gender performance and sexual identities, our research points to the substantial structural-level barriers that must be addressed in order to achieve meaningful and effective HIV prevention for MSM worldwide.

The management of methamphetamine use in sexual settings among men who have sex with men in Malaysia

BACKGROUND

The intentional use of illicit drugs for sexual purposes (also known as 'chemsex') is well known within the MSM communities in Malaysia although research in this population is scarce primarily because both drug use and homosexuality are illegal and stigmatised in Malaysia.

METHODS

From April to December 2014, interviews were conducted with twenty men (age range 21-43) living in Greater Kuala Lumpur who had sexual intercourse with other men in the past 6 months and who used illicit drugs at least monthly in the past 3 months. Fourteen men were recruited via gay social networking smartphone applications or websites while six were referred by the participants. Data were analsed using thematic analytic approach.

FINDINGS

The average duration of illicit drug use was 6.4 years (range 1-21) and all participants were using methamphetamine ("ice" or crystal meth) with frequency of use ranged from daily to once a month. Participants came from diverse ethnic, economic, and occupational backgrounds. Most participants used an inhalation apparatus ("bong") to consume methamphetamine and injection was rare in the sample. The primary motivation of methamphetamine use was to increase sexual capacity, heighten sexual pleasure and enhance sexual exploration and adventurism. Socializing with friends ("chilling"), and increased energy for work were secondary motivations. Participants emphasized the need to control the use of methamphetamine and some have established rules to control the amount and duration of use and a minority of men have maintained condom use during anal sex while under the influence of methamphetamine. Participants who professed to be in control of their drug use characterized themselves as functional users regardless of the health and social consequences from continuing use. Overall, participants perceived themselves differently from the traditional opioid users and reported limited access to sexual health and substance use treatment services.

CONCLUSION

There is a need to increase access to HIV prevention services such as PrEP and PEP, professional support, and substance abuse treatment for drug-using MSM. A more open and friendly environment towards drug-using MSM may help them access and engage with the health services.

Analysis of False-Negative Human Immunodeficiency Virus Rapid Tests Performed on Oral Fluid in 3 International Clinical Research Studies

Background.

The OraQuick Advance Rapid HIV-1/2 Test is a point-of-care test capable of detecting human immunodeficiency virus (HIV)-specific antibodies in blood and oral fluid. To understand test performance and factors contributing to false-negative results in longitudinal studies, we examined results of participants enrolled in the Botswana TDF/FTC Oral HIV Prophylaxis Trial, the Bangkok Tenofovir Study, and the Bangkok MSM Cohort Study, 3 separate clinical studies of high-risk, HIV-negative persons conducted in Botswana and Thailand.

Methods.

In a retrospective observational analysis, we compared oral fluid OraQuick (OFOQ) results among participants becoming HIV infected to results obtained retrospectively using enzyme immunoassay and nucleic acid amplification tests on stored specimens. We categorized negative OFOQ results as true-negative or false-negative relative to nucleic acid amplification test and/or enzyme immunoassay, and determined the delay in OFOQ conversion relative to the estimated time of infection. We used log-binomial regression and generalized estimating equations to examine the association between false-negative results and participant, clinical, and testing-site factors.

Results.

Two-hundred thirty-three false-negative OFOQ results occurred in 80 of 287 seroconverting individuals. Estimated OFOQ conversion delay ranged from 14.5 to 547.5 (median, 98.5) days. Delayed OFOQ conversion was associated with clinical site and test operator (P < .05), preexposure prophylaxis (P = .01), low plasma viral load (P < .02), and time to kit expiration (P < .01). Participant age, sex, and HIV subtype were not associated with false-negative results. Long OFOQ conversion delay time was associated with antiretroviral exposure and low plasma viral load.

Conclusions.

Failure of OFOQ to detect HIV-1 infection was frequent and multifactorial in origin. In longitudinal trials, negative oral fluid results should be confirmed via testing of blood samples.

High risk exposure to HIV among sexually active individuals who tested negative on rapid HIV Tests in the Tshwane District of South Africa-The importance of behavioural prevention measures

OBJECTIVE

To assess the prevalence of HIV risk behaviour among sexually active HIV sero-negative individuals in the Tshwane district of South Africa (SA).

METHODS

Demographic and HIV risk behaviour data were collected on a questionnaire from participants of a cross-sectional study that screened for early HIV infection using pooled nucleic acid amplification testing (NAAT). The study enrolled individuals who tested negative on rapid HIV tests performed at five HIV counseling and testing (HCT) clinics, which included four antenatal clinics and one general HCT clinic.

RESULTS

The study enrolled 9547 predominantly black participants (96.6%) with a median age of 27 years (interquartile range [IQR]: 23-31). There were 1661 non-pregnant and 7886 pregnant participants largely enrolled from the general and antenatal HCT clinics, respectively. NAAT detected HIV infection in 61 participants (0.6%; 95% confidence interval [CI]: 0.4-0.8) in the whole study. A high proportion of study participants, 62.8% and 63.0%, were unaware of their partner's HIV status; and also had high prevalence, 88.5% and 99.5%, of recent unprotected sex in the general and pregnant population, respectively. Consistent use of condoms was associated with protection against HIV infection in the general population. Trends of higher odds for HIV infection were observed with most demographic and HIV risk factors at univariate analysis, however, multivariate analysis did not show statistical significance for almost all these factors. A significantly lower risk of HIV infection was observed in circumcised men (p <0.001).

CONCLUSIONS

These data show that a large segment of sexually active people in the Tshwane district of SA have high risk exposure to HIV. The detection of newly diagnosed HIV infections in all study clinics reflects a wide distribution of individuals who are capable of sustaining HIV transmission in the setting where HIV risk behaviour is highly prevalent. A questionnaire that captures HIV risk behaviour would be useful during HIV counselling and testing to ensure that there is a systematic way of identifying HIV risk factors and that counselling is optimised for each individual. HIV risk behaviour surveillance could be used to inform relevant HIV prevention interventions that could be implemented at a community or population level.

Risk Behaviors Among Young Men Who Have Sex With Men in Bangkok: A Qualitative Study to Understand and Contextualize High HIV Incidence

The Bangkok Men Who Have Sex With Men (MSM) Cohort Study has shown high HIV incidence (8-12/100 person-years) among 18-21-year-old MSM. These data led to a further study using qualitative methods among young (18-24 years old) MSM in order to understand the factors driving the HIV epidemic among YMSM. We conducted eight focus group discussions and 10 key informant interviews among YMSM in Bangkok, Thailand. Sociodemographic and behavioral data were collected using a questionnaire. We audio-recorded, transcribed, and analyzed qualitative and questionnaire data using computer software. The categories relating to risk behavior were (1) the use of social networks for seeking sexual partners and the marketing promotions of MSM entertainment venues, (2) social influence by peers and older MSM, (3) easy access to high parties and group sex, (4) easy access to club drugs, (5) conceptions related to HIV risk, and (6) sexual preferences of YMSM. Increased HIV testing, same-sex education, and YMSM-specific HIV prevention efforts are urgently needed for YMSM in Bangkok.

Poppers use and Sexual Partner Concurrency Increase the HIV Incidence of MSM: a 24-month Prospective Cohort Survey in Shenyang, China

The use of poppers is highly prevalent in MSM, but little is known about the association between their use and HIV incidence in China. A prospective cohort study was conducted from 2011 to 2013 in MSM in Shenyang. 475(79.6%) of eligible HIV-negative MSM participated in this prospective survey and near one fourth MSM (23.4%) ever used poppers. About one-third of the participants had condomless anal intercourse, half had multiple sexual partners and 10.5% were syphilis positive. The HIV incidence densities were15.5 (95% CI:9.4-23.4)/100 PY[person-years]) and 4.6 (95% CI:2.9-7.0)/100 PY in poppers-users and non-poppers-users, respectively. Predictors of HIV seroconversion included poppers-using-behavior, having had more than two male partners, practicing group sex, unprotected anal intercourse(UAI) with male partners, and baseline syphilis positivity (all P < 0.05). In conclusion, the use of poppers, high-risk-sexual behaviors and syphilis infection significantly increase the HIV incidence among Shenyang MSM. It is essential for policy makers to add poppers to the official controlled illicit drug list to reduce HIV transmission among the MSM community. A comprehensive strategy should also be implemented to control both their high-risk-sexual behaviors and risk of syphilis infection, since these may represent novel ways to prevent new HIV infections in these MSM.

Screening for Chlamydia trachomatis and Neisseria gonorrhoeae infection among asymptomatic men who have sex with men in Bangkok, Thailand

We report positivity rates of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infection at each anatomic site among asymptomatic men who have sex with men (MSM). We calculated the number needed to screen (NNS) to detect CT and NG infection at each anatomic site. From 2006 to 2010, we enrolled Thai MSM, age ≥ 18 years into the Bangkok MSM Cohort Study. Participants underwent physical examination and had rectal, urethral, and pharyngeal screening for CT and NG infection using nucleic acid amplification tests (NAATs). Of 1744 enrollees, 1696 (97.2%) had no symptoms of CT and NG infection. The positivity rates of CT and NG infection at any site were 14.3% (rectum, urethra, pharynx) and 6.4% (rectum, urethra), respectively. The NNS to detect rectal CT and rectal NG infections was 10 and 16, respectively (p < 0.05). For urethral infection, the NNS of CT was lower than the NNS of NG (22, 121: p < 0.05). The lowest NNS found for rectal CT infection was in HIV-infected MSM (6, 5-8). Asymptomatic CT and NG infection were common among MSM in Bangkok, Thailand and frequently detected in the rectum. In setting where screening in all specimens using NAAT is not feasible, rectal screening should be a priority.

Acute HIV infection detection and immediate treatment estimated to reduce transmission by 89% among men who have sex with men in Bangkok

Introduction: Antiretroviral treatment (ART) reduces HIV transmission. Despite increased ART coverage, incidence remains high among men who have sex with men (MSM) in many places. Acute HIV infection (AHI) is characterized by high viral replication and increased infectiousness. We estimated the feasible reduction in transmission by targeting MSM with AHI for early ART.

Methods: We recruited a cohort of 88 MSM with AHI in Bangkok, Thailand, who initiated ART immediately. A risk calculator based on viral load and reported behaviour, calibrated to Thai epidemiological data, was applied to estimate the number of onwards transmissions. This was compared with the expected number without early interventions.

Results: Forty of the MSM were in 4th-generation AHI stages 1 and 2 (4thG stage 1, HIV nucleic acid testing (NAT)+/4thG immunoassay (IA)-/3rdG IA–; 4thG stage 2, NAT+/4thG IA+/3rdG IA–) while 48 tested positive on third-generation IA but had negative or indeterminate western blot (4thG stage 3). Mean plasma HIV RNA was 5.62 log¹⁰ copies/ml. Any condomless sex in the four months preceding the study was reported by 83.7%, but decreased to 21.2% by 24 weeks on ART. After ART, 48/88 (54.6%) attained HIV RNA <50 copies/ml by week 8, increasing to 78/87 (89.7%), and 64/66 (97%) at weeks 24 and 48, respectively. The estimated number of onwards transmissions in the first year of infection would have been 27.3 (95% credible interval: 21.7–35.3) with no intervention, 8.3 (6.4–11.2) with post-diagnosis behaviour change only, 5.9 (4.4–7.9) with viral load reduction only and 3.1 (2.4–4.3) with both. The latter was associated with an 88.7% (83.8–91.1%) reduction in transmission.

Conclusions: Disproportionate HIV transmission occurs during AHI. Diagnosis of AHI with early ART initiation can substantially reduce onwards transmission.

Subtypes and Risk Behaviors Among Incident HIV Cases in the Bangkok Men Who Have Sex with Men Cohort Study, Thailand, 2006-2014

HIV-1 incidence and prevalence remain high among men who have sex with men (MSM), and transgender women (TGW), in Thailand. To examine the link between epidemiologic factors and HIV-1 subtype transmission among Thai MSM, we compared covariates of infection with HIV CRF01_AE and other HIV strains among participants in the Bangkok MSM Cohort Study (BMCS). The BMCS was an observational cohort study of Thai MSM and TGW with up to 60 months of follow-up at 4 monthly intervals. Participants underwent HIV/sexually transmitted infections testing and provided behavioral data at each visit. Infecting viral strain was characterized by gene sequencing and/or multiregion hybridization assay. We correlated behavioral/clinical variables with infecting strain using Cox proportional hazards. Among a total of 1372 HIV seronegative enrolled participants with 4,192 person-years of follow-up, we identified 215 seroconverters between April 2006 and December 2014, with 177 infected with CRF01_AE and 38 with non-CRF01_AE subtype. Age 18-21 years (adjusted hazard ratio [AHR] 2.2, 95% confidence interval [CI]: 1.4-3.5), age 22-29 (AHR 1.6, 95% CI: 1.1-2.3), living alone (AHR 1.5, 95% CI: 1.1-2.1), drug use (AHR 2.2, 95% CI: 1.4-3.5), intermittent condom use (AHR 1.7, 95% CI: 1.3-2.3), any receptive anal intercourse (AHR 1.7, 95% CI: 1.2-2.4), group sex (AHR 1.5, 95% CI: 1.1-2.2), anti-herpes simplex virus type 1 (AHR 1.5, 95% CI: 1.1-2.1), and Treponema pallidum antibody positivity (AHR 2.5, 95% CI: 1.4-4.4) were associated with CRF01_AE infection. Age 18-21 years (AHR 5.1, 95% CI: 1.6-16.5), age 22-29 (AHR 3.6, 95% CI: 1.3-10.4), drug use (AHR 3.1, 95% CI: 1.3-7.5), group sex (AHR 2.4, 95% CI: 1.1-5.0), and hepatitis B virus surface antigen (AHR 3.6, 95% CI: 1.3-10.2) were associated with non-CRF01_AE infection. We observed several significant biological and behavioral correlates of infection with CRF01_AE and other HIV strains among Thai MSM. Divergence in correlates by strain may indicate differences in HIV transmission epidemiology between CRF01_AE and other strains. These differences could reflect founder effects, transmission within networks distinguished by specific risk factors, and possibly biological differences between HIV strains.

Adaptation of the HIV/AIDS Self-Management Education Program for Men Who Have Sex With Men in Thailand: An Application of the ADAPT-ITT Framework

This formative research aimed to describe the use of the ADAPT-ITT framework to modify the HASMEP for use with HIV-positive Thai men who have sex with men (MSM). We selected, adapted, and tested the acceptability and feasibility of the HASMEP intervention for delivery in an HIV clinic in Thailand. We chose to base our adaptation on the HASMEP that was initially developed in South Africa. The ADAPT-ITT framework was used to guide the study. Our adaptation was informed by qualitative data collected during focus groups from 48 participants (40 HIV-positive Thai MSM and 8 health care providers) and online surveys of Thai MSM. Findings of focus groups indicate that the HASMEP is feasible and acceptable when administered to the participants. The result of this work is an adapted HASMEP intervention and training materials. This study provides a strong foundation for further research on HIV/AIDS self-management in HIV-positive MSM.

Effect of HSV-2 infection on subsequent HIV acquisition: an updated systematic review and meta-analysis

Background

HIV and herpes simplex virus type 2 (HSV-2) infections cause a substantial global disease burden and are epidemiologically correlated. Two previous systematic reviews of the association between HSV-2 and HIV found evidence that HSV-2 infection increases the risk of HIV acquisition, but these reviews are now more than a decade old.

Methods

For this systematic review and meta-analysis, we searched PubMed, MEDLINE, and Embase (from Jan 1, 2003, to May 25, 2017) to identify studies investigating the risk of HIV acquisition after exposure to HSV-2 infection, either at baseline (prevalent HSV-2 infection) or during follow-up (incident HSV-2 infection). Studies were included if they were a cohort study, controlled trial, or case-control study (including case-control studies nested within a cohort study or clinical trial); if they assessed the effect of pre-existing HSV-2 infection on HIV acquisition; and if they determined the HSV-2 infection status of study participants with a type-specific assay. We calculated pooled random-effect estimates of the association between prevalent or incident HSV-2 infection and HIV seroconversion. We also extended previous investigations through detailed meta-regression and subgroup analyses. In particular, we investigated the effect of sex and risk group (general population vs higher-risk populations) on the relative risk (RR) of HIV acquisition after prevalent or incident HSV-2 infection. Higher-risk populations included female sex workers and their clients, men who have sex with men, serodiscordant couples, and attendees of sexually transmitted infection clinics.

Findings

We identified 57 longitudinal studies exploring the association between HSV-2 and HIV. HIV acquisition was almost tripled in the presence of prevalent HSV-2 infection among general populations (adjusted RR 2·7, 95% CI 2·2–3·4; number of estimates [N_e]=22) and was roughly doubled among higher-risk populations (1·7, 1·4–2·1; N_e=25). Incident HSV-2 infection in general populations was associated with the highest risk of acquisition of HIV (4·7, 2·2–10·1; N_e=6). Adjustment for confounders at the study level was often incomplete but did not significantly affect the results. We found moderate heterogeneity across study estimates, which was explained by risk group, world region, and HSV-2 exposure type (prevalent vs incident).

Interpretation

We found evidence that HSV-2 infection increases the risk of HIV acquisition. This finding has important implications for management of individuals diagnosed with HSV-2 infection, particularly for those who are newly infected. Interventions targeting HSV-2, such as new HSV vaccines, have the potential for additional benefit against HIV, which could be particularly powerful in regions with a high incidence of co-infection.

Funding

World Health Organization.

Challenges and emerging opportunities for the HIV prevention, treatment and care cascade in men who have sex with men in Asia Pacific

In Asia Pacific, most countries have expanded HIV treatment guidelines to include all those with HIV infection and adopted antiretroviral treatment for prevention (TFP) as a blanket strategy for HIV control. Although the overall epidemic development associated with this focus is positive, the HIV epidemic in men who have sex with men (MSM) is continuing unperturbed without any signs of decline or reversal. This raises doubt about whether TFP as a blanket HIV prevention policy is the right approach. This paper reviews currently available biomedical HIV prevention strategies, national HIV prevention policies and guidelines from selected countries and published data on the HIV cascade in MSM. No evidence for efficacy of TFP in protecting MSM from HIV infection was found. The rationale for this approach is based on assumptions about biological plausibility and external validity of latency-based efficacy found in heterosexual couples. This is different from the route and timing of HIV transmission in MSM. New HIV infections in MSM principally occur in chains of acutely HIV-infected highly sexually active young men, in whom acquisition and transmission are correlated in space and time. By the time TFP renders its effects, most new HIV infections in MSM will have already occurred. On a global level, less than 6% of all reports regarding the HIV care cascade from 1990 to 2016 included MSM, and only 2.3% concerned MSM in low/middle-income countries. Only one report originated from Asia Pacific. Generally, HIV cascade data in MSM show a sobering picture of TFP in engaging and retaining MSM along the continuum. Widening the cascade with a preventive extension, including pre-exposure prophylaxis, the first proven efficacious and only biomedical HIV prevention strategy in MSM, will be instrumental in achieving HIV epidemic control in this group.

"We Might Get Some Free Beers": Experience and Motivation for Transactional Sex Among Behaviorally Bisexual Men in Vientiane, Laos

People engaging in transactional sex are considered a key population for HIV prevention. Prior quantitative surveys demonstrated that behaviorally bisexual men in Vientiane, Laos commonly transact sex. In 2013, we conducted a qualitative study to explore behaviorally bisexual men's experience, motivations, and perceptions related to transactional sex in Vientiane. Behaviorally bisexual men were recruited from bars, nightclubs, and dormitories for five focus group discussions (FGDs) and 11 in-depth interviews (n = 31). Additionally, young women were recruited from a university, garment factory, and nightclub for four FGDs (n = 22). Transcripts were translated and thematically coded. Bisexual male participants most commonly described being paid for sex by male-to-female transgender people and buying sex from women. Both male and female participants reported that older, single women pay younger men for sex. Negotiation and direction of sexual transactions are influenced by age, attraction, and wealth. Common motivations for selling sex included the need for money to support family or fund school fees, material gain, or physical pleasure. Transactional sex was often opportunistic. Some behaviorally bisexual men reported selling sex in order to pay another more desirable sex partner or to buy gifts for their regular sex partner. Participants perceived high risk associated with intercourse with female sex workers but not with other transactional sex partners. Health interventions are needed to improve knowledge, risk perception, and health behaviors, but must recognize the diversity of transactional sex in Vientiane. Both physical and virtual settings may be appropriate for reaching behaviorally bisexual men and their partners.

Beliefs and Perception About HIV/AIDS, Self-Efficacy, and HIV Sexual Risk Behaviors Among Young Thai Men Who Have Sex With Men

This study examined the relationships of HIV/AIDS beliefs, self-efficacy for AIDS preventive behaviors, perception of HIV as a chronic disease, and HIV risk behaviors among young Thai men who have sex with men. Participants were recruited for a self-administered anonymous survey through Facebook. Logistic regression analysis was used to identify factors associated with each of four HIV risk behavior outcomes. Factors associated with sexual risk behaviors included age (18 and 21 years), having a current regular male partner, self-efficacy for AIDS preventive behaviors (self-efficacy in refusing sexual intercourse, self-efficacy in questioning potential sex partners, and self-efficacy in condom use), AIDS health belief (perceived susceptibility to HIV/AIDS, perceived severity of HIV/AIDS, perceived barriers to condom use, and cues to action for HIV/AIDS prevention), and perception of HIV/AIDS as a chronic disease (perceived HIV sero-status disclosure). Knowledge generated from this study has the potential to inform prevention messages for young Thai MSM.

Brief communication (Original). Challenges of providing treatment and care to men who have sex with men and with HIV/AIDS in Bangkok

Background: Across the Asia-Pacific, men who have sex with men (MSM) constitute a growing proportion of those infected with and at risk for HIV/AIDS, but frequently lack access to treatment-related resources because of stigma and discrimination.

Objective: To identify challenges that a community-based organization (CBO) and its corresponding HIV clinic in Bangkok, Thailand, face in order to facilitate access to HIV-related care and treatment services by HIV-positive MSM.

Methods: Data were collected through focus group discussions, semi-structured interviews, and surveys of staff members and volunteers working at the support facilities from April through May 2011.

Results: A total of 21 staff and volunteers working at the support facilities participated. Participants reported various barriers to use of HIV-related services by MSM including fear of stigmatization because of their infection status, limited clinic/hospital hours, and misunderstanding of risks.

Conclusions: In response to these barriers, CBOs implemented solutions ranging from outreach activities to organization of a men’s health clinic targeting MSM.

Psychosocial and Behavioral Characteristics of High-Risk Men Who Have Sex with Men (MSM) of Unknown HIV Positive Serostatus in Bangkok, Thailand

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.

Differences Between Men Who Have Sex with Men (MSM) with Low CD4 Cell Counts at Their First HIV Test and MSM with Higher CD4 Counts in Bangkok, Thailand

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.

Engagement of Gay Men and Other Men Who Have Sex with Men (MSM) in the Response to HIV: A Critical Step in Achieving an AIDS-Free Generation

Men who have sex with men (MSM) continue to be at elevated risk for HIV acquisition and transmission secondary to biological and behavioral characteristics, social and sexual network characteristics, community environmental factors, and structural factors. HIV incidence rates remain high among MSM in both low- and high-income settings, and in both concentrated and more generalized HIV epidemic settings. While data quality tends to be poorer, the best estimates collectively suggest that MSM have up to 20 times the odds of living with HIV as compared to other reproductive aged adults across low- and middle-income countries. Recent prevention strategies to lower biological HIV transmission and acquisition risks, including the early use of antiretrovirals to decrease infectiousness for those living with HIV, and pre-exposure prophylaxis for those at significant risk of HIV acquisition, have demonstrated the potential to change the trajectory of the HIV epidemics among MSM. However, the coverage and effectiveness of these approaches is limited by structural factors including the punitive legal frameworks and institutional discrimination that contribute to limited uptake, challenges to adherence, and suboptimal health-seeking behaviors among MSM. More intensive efforts will be required to reach MSM who do not currently have access to relevant and effective prevention and treatment services or elect not to access these services given enacted and/or perceived stigma. Respect for human rights, including efforts to aggressively confront and combat the forms of stigma that are preventing us from achieving an AIDS-Free generation, are needed for all people including gay men and other MSM.

Active targeted HIV testing and linkage to care among men who have sex with men attending a gay sauna in Thailand

Existing data on the feasibility of human immunodeficiency virus (HIV) testing and counseling (HTC) and linkage to care among men who have sex with men (MSM) in hotspots are currently limited. A prospective study on active targeted HTC and linkage to care among MSM (≥18 years old) was conducted at a gay sauna in Thailand from November 2013 to October 2015. HIV risks and risk perception were evaluated through an anonymous survey. HIV testing with result notification and care appointment arrangement were provided on-site. Of the 358 participants; median age was 30 years; 206/358(58%) were at high risk for HIV acquisition; 148/358(41%) accepted HTC, all of whom either had prior negative HIV tests [98/148 (66%)] or had not known their HIV status [50/148 (34%)]. The three most common reasons for declining HTC were prior HIV testing within 6 months (48%), not ready (19%) and perceiving self as no risk (11%). Of the 262 moderate- and high-risk participants, 172 (66%) had false perception of low HIV risk which was significantly associated with declining HTC. Among the 148 participants undergoing HTC, 25 (17%) were HIV-infected. Having false perception of low risk (P = 0.004) and age <30 years (P = 0.02) were independently associated with HIV positivity. Only 14 of the 25 HIV-infected participants (56%) could be contacted after the result notification, of whom 12 (86%) had established HIV care and received immediate antiretroviral therapy. The active targeted HTC and facilitating care establishment was feasible among MSM attending the gay sauna but required strategies to improve accuracy of HIV-risk perception and linkage to care.

Prevalence and Determinants of Herpes Simplex Virus Type 2 (HSV-2)/Syphilis Co-Infection and HSV-2 Mono-Infection among Human Immunodeficiency Virus Positive Men Who Have Sex with Men: a Cross-Sectional Study in Northeast China

This study assessed the prevalence and determinants of herpes simplex virus type 2 (HSV-2)/syphilis co-infection and HSV-2 mono-infection in human immunodeficiency virus (HIV)-positive men who have sex with men (MSM) in China. A cross-sectional study was conducted of 545 HIV-positive MSM in Shenyang between February 2009 and October 2014. Participants underwent physical examinations and serological tests for HSV-2 and syphilis. A multinomial logistic regression was used to identify the risk factors associated with HSV-2/syphilis co-infection and HSV-2 mono-infection. The prevalence of HSV-2 mono-infection, syphilis mono-infection, and HSV-2/syphilis co-infection (95% confidence interval) was 48.6% (44.4-52.8%), 34.3% (30.3-38.3%), and 22.9% (19.4-26.5%), respectively. After controlling within HSV-2/syphilis-seropositive cases, regression analysis revealed that the related factors for HSV-2/syphilis co-infection included age (25-50 vs. ≤ 24 years: adjusted odds ratio [aOR], 4.55; > 50 vs. ≤ 24 years: aOR, 43.02), having regular female sexual partner(s) in the past 6 months (aOR, 0.43), and age at first MSM experience (≤ 18 vs. > 18 years: aOR, 2.59) (all P < 0.05). The high prevalence of HSV-2 mono infection and HSV-2/syphilis co-infection in HIV-positive MSM indicates a high secondary HIV transmission risk. A campaign for detection and treatment of HSV-2 and syphilis is urgently required for HIV-positive MSM in China.

Declining trend in transmitted drug resistance detected in a prospective cohort study of acute HIV infection in Bangkok, Thailand

Introduction

As availability of antiretroviral therapy expands in developing countries, the risk for transmission of drug-resistant HIV also increases. Patients with acute HIV infection (AHI) provide an opportunity for real-time monitoring of transmitted drug resistance (TDR). SEARCH 010/RV 254 study is a prospective, longitudinal study of AHI. This analysis was performed to characterize changes in TDR over time in persons enrolled in the AHI cohort.

Methods

Genotype testing for TDR mutations was performed on 229 subjects enrolled from 2009 to 2014.

Results

The cohort was predominantly male (95%) and men who have sex with men (92%). TDR prevalence was 7.0%, declining from 12.5% in 2009–2010 to 4.8% in 2013–2014 (p=0.08). By drug class, resistance prevalence was 3.6% for proteases inhibitors, 2.6% for nucleoside/nucleotide reverse transcriptase inhibitors and 2.2% for non-nucleoside reverse transcriptase inhibitors. The greatest decline in prevalence was seen in the non-nucleoside reverses transcriptase inhibitors, from 9.4% in 2009–2010 to 0.7% in 2013–2014 (p=0.005).

Conclusions

TDR appears to be declining among individuals with AHI in Bangkok and in 2013 to 2014 met the World Health Organization definition for low prevalence. Continued surveillance is necessary to determine if this trend persists.

Sociodemographic Factors, Sexual Behaviors, and Alcohol and Recreational Drug Use Associated with HIV Among Men Who Have Sex with Men in Southern Vietnam

A total of 2768 MSM participated in a survey in southern Vietnam. Univariate and multivariate logistic regression analyses were performed to determine predictors of HIV infection. The prevalence of HIV among MSM was 2.6 %. HIV infection was more likely in MSM who were older, had a religion, had engaged in anal sex with a foreigner in the past 12 months, previously or currently used recreational drugs, perceived themselves as likely or very likely to be infected with HIV, and/or were syphilis seropositive. MSM who had ever married, were exclusively or frequently receptive, sometimes consumed alcohol before sex, and/or frequently used condoms during anal sex in the past 3 months were less likely to be infected with HIV. Recreational drug use is strongly associated with HIV infection among MSM in southern Vietnam. HIV interventions among MSM should incorporate health promotion, condom promotion, harm reduction, sexually transmitted infection treatment, and address risk behaviors.

HIV and Sexual Risk Among Men Who Have Sex With Men and Women in Asia: A Systematic Review and Meta-Analysis

We performed a systematic review to estimate the proportion of men who have sex with men (MSM) in Asia who are bisexual and compare prevalence of HIV and sexual risk between men who have sex with men and women (MSMW) and men who have sex with men only (MSMO). Forty-eight articles based on 55 unique samples were identified from nine countries in Asia. Bisexual behaviour was common among MSM (pooled prevalence 32.8 %). Prevalence of HIV (pooled OR 0.90; 95 % CI 0.77-1.05), recent syphilis infection (pooled OR 0.99; 95 % CI 0.93-1.06) and unprotected anal intercourse (pooled OR 0.80; 95 % CI 0.57-1.11) were similar between MSMW and MSMO, but heterogeneity was high. MSMW had lower odds of reporting a prior HIV test than MSMO (OR 0.82; 95 % CI 0.70-0.95; p = 0.01, I(2) = 0 %). Targeted interventions are needed to increase uptake of HIV testing among MSMW. Increased reporting of disaggregated data in surveillance and research will help improve understanding of risk in MSMW and inform targeted interventions.

Recent HIV Testing Among Young Men Who Have Sex with Men in Bangkok and Chiang Mai: HIV Testing and Prevention Strategies Must Be Enhanced in Thailand

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.

Prevalence of Anal Human Papillomavirus Vaccine Types in the Bangkok Men Who Have Sex With Men Cohort Study

BACKGROUND

The quadrivalent human papillomavirus (qHPV) and 9 valent (nHPV) vaccine are licensed for males to prevent anal HPV-associated dysplasia and cancer caused by HPV types 6, 11, 16, and 18 (qHPV) and additional types 33, 35, 45, 52, and 58 (nHPV), respectively. Both conditions are common in HIV-infected and HIV-uninfected men who have sex with men (MSM). It is not well documented which anal HPV vaccine types are most prevalent in Southeast Asia.

METHODS

A convenience sample of 400 anal swabs were obtained from 200 HIV-infected and 200 HIV-uninfected sexually active Bangkok MSM Cohort Study participants. After swab collection in PreservCyt (Cytyc Corp, Marlborough, MA), the media was stored at -80°C until processing. DNA was extracted, amplified by polymerase chain reaction, denatured, and then hybridized to probes for 37 HPV types and β-globin.

RESULTS

The mean participant age was 25.6 years (range, 18-55 years); the mean CD4 T-cell count was 410 cells/mm in the HIV-infected participants. Among all swab samples, 386 (192 HIV-positive and 194 HIV-negative) had adequate β-globin for HPV genotype testing. Anal HPV type was detected in 44.3% of participants whose samples underwent genotype testing. Both qHPV and nHPV types were more frequently detected in HIV-infected compared with HIV-uninfected (42.2% vs. 23.2% [P < 0.01], 50.0% vs. 24.2% [P < 0.01]), respectively). There were no significant relationships between social behaviors (alcohol use, drug use) or sexual behaviors (number of partners, condom usage, sexual positioning) and anal HPV prevalence.

CONCLUSIONS

The prevalence of anal vaccine HPV types in Thai MSM was similar to that reported in MSM from Western populations and has a similar distribution by HIV status. Targeting young MSM with vaccination could offer protection against HPV vaccine types.

A Group-Based Sexual Risk Reduction Intervention for Men Who Have Sex With Men in Ho Chi Minh City, Vietnam: Feasibility, Acceptability, and Preliminary Efficacy

An emerging HIV epidemic can be seen among men who have sex with men (MSM) in Vietnam. There are currently no evidence-based behavioral sexual risk reduction interventions for MSM in this setting. Between October 2012 and June 2013, 100 high-risk MSM from Ho Chi Minh City were enrolled in an open pilot trial to assess feasibility and acceptability of a group-based, manualized sexual risk reduction intervention, and to preliminarily examine changes in primary and secondary outcomes. Participants completed a behavioral assessment battery and HIV testing at baseline, 3, and 6 months post-baseline. Over 80.0 % of the sample was <25 years old and 77.0 % identified as Bong kin ("hidden," masculine-appearing). Feasibility and acceptability of the program was evidenced by 87.0 % retention for the intervention sessions, 78.0 % completion of the 6 month assessment, and positive responses on evaluation forms and qualitative exit interviews. There was a decline in the number of condomless anal sex acts from baseline (6.32) to 3 month (2.06) and 6 month (2.49) follow-up (p < .0001). These data support the need for further testing of this group-based, behavioral HIV prevention intervention to reduce sexual risk behavior among MSM in Vietnam in a randomized controlled efficacy trial.

Incidence of and temporal relationships between HIV, herpes simplex II virus, and syphilis among men who have sex with men in Bangkok, Thailand: an observational cohort

Background

High HIV incidence has been detected among men who have sex with men (MSM) in Thailand, but the relationship and timing of HIV, herpes simplex virus 2 (HSV-2), and syphilis is unknown. This analysis measures incidence, temporal relationships, and risk factors for HIV, HSV-2, and syphilis among at-risk MSM in the Bangkok MSM Cohort Study.

Methods

Between April 2006 and December 2010, 960 men negative for HIV, HSV-2, and syphilis at entry enrolled and contributed 12–60 months of follow-up data. Behavioral questionnaires were administered at each visit; testing for HIV antibody was performed at each visit, while testing for syphilis and HSV-2 were performed at 12 month intervals. We calculated HIV, HSV-2, and syphilis incidence, assessed risk factors with complementary log-log regression, and among co-infected men, measured temporal relationships between infections with Kaplan-Meier survival analysis and paired t-test.

Results

The total number of infections and incidence density for HIV, HSV-2, and syphilis were 159 infections and 4.7 cases/100 PY (95 % Confidence Interval (CI): 4.0–5.4), 128 infections and 4.5/100 PY (95 % CI: 3.9–5.5), and 65 infections and 1.9/100 PY (95 % CI: 1.5–2.5), respectively. Among men acquiring >1 infection during the cohort period, mean time to HIV and HSV-2 infection was similar (2.5 vs. 2.9 years; p = 0.24), while syphilis occurred significantly later following HIV (4.0 vs. 2.8 years, p < 0.01) or HSV-2 (3.8 vs. 2.8 years, p = 0.04) infection. The strongest independent predictor of any single infection in adjusted analysis was acquisition of another infection; risk of syphilis (Adjusted Hazards Ratio (AHR) = 3.49, 95 % CI: 1.89–6.42) or HIV (AHR = 2.26, 95 % CI: 1.47–3.48) acquisition during the cohort was significantly higher among men with incident HSV-2 infection. No single independent behavioral factor was common to HIV, HSV-2, and syphilis acquisition.

Conclusion

HIV and HSV-2 incidence was high among this Thai MSM cohort. However, acquisition of HIV and co-infection with either HSV-2 or syphilis was low during the time frame men were in the cohort. Evaluation of behavioral risk factors for these infections suggests different risks and possible different networks.

HIV incidence and associated risk factors in men who have sex with men in Mainland China: an updated systematic review and meta-analysis

Background: The national annually reported proportion of men who have sex with men (MSM) among people living with HIV (PLWH) is growing in China. To better inform the public health sector how to improve HIV prevention strategies, it is necessary to understand the current level of HIV incidence and its correlates. Methods: Google Scholar, PubMed, Web of Science and three major Chinese electronic publication databases (http://qikan.cqvip.com/, http://g.wanfangdata.com.cn/, http://www.cnki.net/, respectively) were searched for studies reporting HIV incidence. Comprehensive Meta-Analysis (CMA) 2.0 statistical software (Biostat, Inc. Englewood, NJ, USA) was used to calculate the pooled HIV incidence and perform subgroup-analysis to find correlates for HIV seroconversion in Chinese MSM. Random effects modelling was then conducted. Results: Twenty-five eligible studies were included in this meta-analysis. The calculated pooled HIV incidence was 5.61/100 person years (PY), with an increasing trend over time (3.24/100PY, 5.29/100PY, 5.50/100PY in 2005-2008, 2009-2011, 2012-2014 respectively, χ2 test for trend P = 0.04). Subgroup analyses indicated that age <25 years (rate ratio (RR) = 1.85), junior college education and below (RR = 1.87), having ≥ 2 male sexual partners in past 6 months (RR = 2.50), baseline syphilis infection (RR = 2.99), homosexual orientation (RR = 1.91), preferred bottom/versatile roles in anal sexual intercourse (RR = 2.33), and having unprotected anal intercourse in the past 6 months (RR = 2.16) significantly increased the risk for HIV seroconversion (each P < 0.05). Uncircumcised MSM had a marginal statistically significant higher HIV incidence (RR = 3.35, P = 0.051). Conclusion: HIV incidence is still alarmingly high among Chinese MSM. Stronger HIV intervention strategies should be implemented, in particular targeting young, less educated and syphilis-infected MSM.

Prevalence and Correlates of Chlamydia trachomatis and Neisseria gonorrhoeae by Anatomic Site Among Urban Thai Men Who Have Sex With Men

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infection are prevalent among men who have sex with men (MSM) and may infect multiple anatomic sites. We measured site-specific prevalence and correlates of CT and NG infection among Bangkok MSM Cohort Study participants.

METHODS

In April 2006 to November 2010, 1744 men enrolled in the Bangkok MSM Cohort Study. Participants provided historical information and underwent physical examination. Rectal, urethral, and pharyngeal CT and NG screening were performed by nucleic acid amplification and/or culture. Logistic regression was used to identify correlates of site-specific CT, NG, and coinfection.

RESULTS

Among 1743 participants, 19.2% were infected with CT and/or NG. CT, NG, and CT-NG coinfection were detected in 11.6%, 4.6%, and 2.9%, of participants, respectively. Rectal, urethral, and pharyngeal CT infections were detected in 9.5%, 4.5%, and 3.6% of cases. N. gonorrhoeae was present at these sites in 6.1%, 1.8%, and 0.5% of cases. Most infections were asymptomatic (CT: 95.3%, NG: 83.2%). Rectal CT and NG infections were mutually associated (CT: adjusted odds ratio [AOR], 5.4; 95% confidence interval [CI], 3.4-8.7; NG: AOR, 2.4; 95% CI, 1.1-5.2) and independently associated with HIV infection (CT: AOR, 1.6, 95% CI, 1.0-2.4; NG: AOR, 2.0, 95% CI, 1.3-3.1). Numerous behavioral correlates of infection were observed.

CONCLUSIONS

CT and NG infections are highly prevalent among MSM in Bangkok, most frequently affect the rectum, and are most often asymptomatic. Routine screening of asymptomatic MSM for CT and NG infection should include rectal sampling and focus on men with HIV and a history of other sexually transmitted infections.

Towards 'reflexive epidemiology': Conflation of cisgender male and transgender women sex workers and implications for global understandings of HIV prevalence

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.

Protocol of a cluster randomised stepped-wedge trial of behavioural interventions targeting amphetamine-type stimulant use and sexual risk among female entertainment and sex workers in Cambodia

INTRODUCTION

HIV risk among female entertainment and sex workers (FESW) remains high and use of amphetamine-type stimulants (ATS) significantly increases this risk. We designed a cluster randomised stepped wedge trial (The Cambodia Integrated HIV and Drug Prevention Implementation (CIPI) study) to test sequentially delivered behavioural interventions targeting ATS use.

METHODS AND ANALYSIS

The trial combines a 12-week Conditional Cash Transfer (CCT) intervention with 4 weeks of cognitive-behavioural group aftercare (AC) among FESW who use ATS. The primary goal is to reduce ATS use and unprotected sex among FESW. The CCT+AC intervention is being implemented in 10 provinces where order of delivery was randomised. Outcome assessments (OEs) including biomarkers and self-reported measures of recent sexual and drug use behaviours are conducted prior to implementation, and at three 6-month intervals after completion. Consultation with multiple groups and stakeholders on implementation factors facilitated acceptance and operationalisation of the trial. Statistical power and sample size calculations were based on expected changes in ATS use and unprotected sex at the population level as well as within subjects.

ETHICS AND DISSEMINATION

Ethical approvals were granted by the Cambodia National Ethics Committee; University of New Mexico; University of California, San Francisco; and FHI360. The trial is registered with ClinicalTrials.gov. Dissemination of process indicators during the multiyear trial is carried out through annual in-country Stakeholder Meetings. Provincial 'Close-Out' forums are held at the conclusion of data collection in each province. When analysis is completed, dissemination meetings will be held in Cambodia with stakeholders, including community-based discussion sessions, policy briefs and results published and presented in the HIV prevention scientific journals and conferences.

CONCLUSIONS

CIPI is the first trial of an intervention to reduce ATS use and HIV risk among FESW in Cambodia.

RESULTS

Will inform both CCT+AC implementation in low and middle-income countries and programmes designed to reach FESW.

TRIAL REGISTRATION NUMBER

NCT01835574; Pre-results.