Transactional sex, HIV and health among young cisgender men and transgender women who have sex with men in Thailand

Evaluating machine learning algorithms for predicting HIV status among young Thai men who have sex with men

OBJECTIVE

This study aimed to develop machine learning (ML) models to predict HIV status and assessed the factors associated with HIV infection among young men who have sex with men (MSM) under the Universal Health Coverage (UHC) programme in Thailand.

METHODS

Young MSM aged 15-24 years who underwent HIV testing through the UHC programme from 2015 to 2022 were included. Data were divided into training (70%) and testing (30%) sets, with the Synthetic Minority Oversampling Technique (SMOTE) applied to address data set imbalance. ML models, including logistic regression, k-nearest neighbour (KNN), random forest, extreme gradient boosting (XGB) and AdaBoost, were used to predict HIV infection.

RESULTS

Among 146 813 young MSM, 11% were diagnosed with HIV. While KNN initially outperformed other ML models, the sensitivity of all models using the original data set was low due to imbalanced data. After applying SMOTE, the XGB model showed the best performance with an accuracy of 0.72, sensitivity of 0.73, specificity of 0.72 and the area under the curve of 0.72. The top predictors of HIV infection were the year of HIV testing (68%), age (55%) and targeted HIV testing (54%).

DISCUSSION

This study demonstrates the potential of ML models, particularly XGB, in predicting HIV infection among young MSM in Thailand under the UHC programme. The application of SMOTE improved model sensitivity, addressing data imbalance and enhancing predictive accuracy.

CONCLUSIONS

ML models have the potential to enhance HIV risk assessment and inform targeted prevention strategies for high-risk populations.

The Situated Vulnerabilities and Resiliencies Framework: a call for integrated strategies to address global HIV inequities for transgender, non-binary, and gender diverse populations

Transgender, non-binary, and gender diverse (trans) populations are burdened by the risk of HIV acquisition. Achieving global UNAIDS 95-95-95 targets by 2030 among trans populations requires conceptual frameworks to understand HIV epidemic drivers and optimise effective strategies to curb HIV inequities in trans populations. The Situated Vulnerabilities and Resiliencies Framework describes and explains HIV inequities in these populations. The HIV epidemic among trans populations is situated in multilevel biopsychosocial contexts, and these populations are made vulnerable to HIV through fundamental causes and conditions that render them at risk for risk. Key considerations include pathways that are linked to sex and gender, all-population and trans-specific exposures, developmental context, syndemic dynamics, and intersectionality. The framework highlights the need to deploy integrated strategies and interventions that are neutral to HIV status and grounded in health and human rights, work with trans communities, and use strengths-based approaches leveraging situated resiliencies (ie, salutogenic factors such as collective agency and trans kinships) to reduce pervasive stigma and advance HIV equity in trans populations.

Seroprevalence and associated factors of HIV, syphilis, hepatitis B, and hepatitis C infections among sex workers in Chiangmai, Thailand during easing of COVID-19 lockdown measures

During the COVID-19 pandemic, sex workers (SW) were one of the vulnerable groups affected by lockdown measures. COVID-19 had also disrupted HIV/Sexually transmitted infection (STI) testing and treatment services for sex workers due to numerous restrictions in specialist medical care. This study aims to assess the seroprevalence of HIV, syphilis, HBV, and HCV and associated factors among SW as COVID-19 restrictions were lifted. The SW aged over 18 years residing in Chiangmai, Thailand, were recruited between March and December 2022. An interview-based questionnaire was administered. Blood was collected for HIV, syphilis, HBV, and HCV serological testing. Logistic regression models were used to examine factors associated with these serological markers. Of 264 SW recruited, 52.3% were male. The median age was 31 years. Male sex workers (MSW) had higher seroprevalence of HIV (13% vs. 4.8%), syphilis (23.9% vs. 6.4%) and HCV (6.5% vs. 2.4%). Female sex workers (FSW) had higher seroprevalence of HBsAg (9.5% vs. 4.4%). A high proportion were unaware of their HIV/STI infection. MSW reporting receptive anal sex were more likely to be HIV and Treponema Ab positive. MSW reporting drug injection history were more likely to be HCV Ab positive. FSW reporting younger age at first sex were more likely to be HIV Ab positive. In conclusion, SW remains particularly affected by HIV/STIs. Despite the lockdown, HIV/STIs continued to spread, highlighting the need to provide access to HIV/STIs testing, prevention, and treatment services for this population, particularly young men.

Transactional sex and its associated factors among gay, bisexual and other men who have sex with men in Nepal

Background Transactional sex, which involves the exchange of sex for money, goods or other items of value, has been associated with adverse health outcomes, such as HIV and other sexually transmitted infections, mental health challenges, and substance use. Although transactional sex has been extensively studied globally among cisgender and transgender women, there is a lack of comprehensive understanding regarding its prevalence and correlates among gay, bisexual and other men who have sex with men (GBMSM), particularly in Nepal. Thus, this study aimed to examine the prevalence of transactional sex and its associated factors among GBMSM in Nepal. Methods A cross-sectional survey was conducted among GBMSM in Kathmandu Valley, Nepal, between October and December 2022 (N =250). We collected information on participants' sociodemographic characteristics, sexual and other behavioural characteristics, and their engagement in transactional sex. Bivariate and multivariate logistic regression analyses were performed to determine the factors associated with transactional sex. Results The average age of participants was 27.5years (s.d. 8.9). Overall, 16.4% reported engaging in transactional sex within the past 6months. Participants with more financial dependants (aOR: 1.2, 95% CI: 1.0-1.5) and those who had experienced police detention (aOR: 4.8, 95% CI: 1.1-19.6) were more likely to engage in transactional sex. In contrast, GBMSM who reported engaging in condomless sex were less likely to engage in transactional sex (aOR: 0.02, 95% CI: 0.06-0.1). Conclusions The study findings underscore a noteworthy prevalence of transactional sex and associated socioeconomic and behavioural factors among GBMSM in Nepal. These results underscore the need for targeted interventions addressing both economic vulnerabilities and legal interactions to reduce transactional sex and its associated risks in this high-risk group.

Patterns of Chemsex Substance Use and Its Association with HIV Transmission Risk Among Men Who Have Sex with Men in Thailand: A Latent Class Analysis

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

Perceived Feasibility and Acceptability of HIV Prevention Research With Daily Oral PrEP Among Young Transgender Women (YTGW) Who Sell or Trade Sex in Bangkok and Pattaya, Thailand

Young transgender women (YTGW) who sell or trade sex have among the highest HIV incidence rates in Thailand. Using qualitative methods, we assessed perceived acceptability, feasibility, and optimal design of a combination HIV prevention intervention including PrEP for YTGW. Key informant interviews were conducted during July 2016-July 2018 with 21 YTGW, aged 18-26 years, who sold sex and resided in Bangkok or Pattaya, Thailand. Grounded theory and content analysis were used for data analysis. Most YTGW interviewed reported high interest in HIV prevention research and believed participation in it supported sexual health. However, participants perceived HIV studies as complicated and time-consuming. Regarding PrEP, participants suggested more PrEP options beyond daily oral PrEP and expressed concerns related to perceived side effects of PrEP, including interaction with gender-affirming hormone therapy. Improving PrEP knowledge, being able to self-assess HIV risk, and reducing HIV/PrEP stigma could increase interest in research and PrEP uptake among YTGW.

Barriers and facilitators to pre-exposure prophylaxis (PrEP) uptake and adherence among men who have sex with men (MSM) in Thailand: a qualitative study

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

High PrEP uptake, adherence, persistence and effectiveness outcomes among young Thai men and transgender women who sell sex in Bangkok and Pattaya, Thailand: findings from the open-label combination HIV prevention effectiveness (COPE) study

Background

Daily oral pre-exposure prophylaxis (PrEP) is effective in preventing HIV infection, but no study has evaluated combination prevention interventions with PrEP for transgender women (TGW) and men who have sex with men (MSM) who sell sex.

Methods

The Combination Prevention Effectiveness (COPE) study was a community-based, non-randomized implementation study in Bangkok and Pattaya, Thailand. Participants were HIV-negative MSM and TGW aged 18-26 years who reported exchanging sex with men in the prior 12 months and who met 2014 U.S. Public Health Service PrEP eligibility criteria. The intervention included quarterly HIV testing, semiannual testing for sexually transmitted infections, provision of condoms with lubricant, and the opportunity to initiate or end daily oral PrEP use at any time during study participation. Participants taking PrEP received monthly adherence counseling and short message service reminders. The primary outcome was HIV incidence rate ratio (IRR) on PrEP vs. not on PrEP. Secondary outcomes were PrEP initiation, PrEP use at 12 months, and PrEP adherence.

Findings

From October 2017 to August 2019, 846 participants were enrolled: 531 (62.8%) immediately initiated PrEP; 104 (12.3%) subsequently initiated PrEP, and 211 (24.9%) never initiated PrEP. Among those initiating PrEP within 30 days of enrollment; 85.9% were on PrEP at the 12-months. When taking PrEP, participants reported adherent PrEP use at 94.2% of quarterly assessments. Ten HIV seroconversions occurred without PrEP use (incidence rate [IR] = 3.42 per 100 person-years [PY]; 95% CI = 1.64-6.30), while zero cases occurred with PrEP use (IR = 0.0 per 100PY; 95% CI = 0.0-0.62), with IRR = 0.0 (95% CI = 0.0-0.22; p < 0.001).

Interpretation

Young Thai MSM and TGW who exchange sex can have high PrEP uptake, persistence and adherence, and low HIV incidence when offered in supportive community-based settings.

Funding

U.S. National Institute of Allergy and Infectious Diseases; Centers for Disease Control and Prevention.