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Background: The Thai Ministry of Public Health (MoPH) considers HIV self-testing (HIVST) a complementary approach to increase access to and uptake of HIV testing especially among men who have sex [...]

OBJECTIVE: The aim of this study is to evaluate the use and acceptability of Carraguard among men and women enrolled as couples in a microbicide trial. MATERIALS AND METHODS: Focus groups were conducted with participants in a 6-month randomized, placebo-controlled trial that enrolled sexually active, low-risk couples in Thailand. Participants were blinded as to which gel they had received at the time of the discussions. RESULTS: Most men and women liked the gel and found it acceptable. The majority of men and women thought that using the gel increased sexual pleasure, although participants disagreed about whether using the gel increased sexual frequency. Drawbacks of gel use included that it was too wet or messy, and nearly all respondents thought that the applicator was too hard. Most men and women questioned the utility of using the gel among married couples since gel use was tied to perception of HIV/STI risk. However, those who perceived themselves to be at risk expressed interest in using the product as an alternative to condoms. Many women were particularly interested in a product that also had contraceptive properties. Gel use also raised issues of trust and fidelity among couples and questions about men's ability to detect women's use of the product. CONCLUSION: Men and women in this study found the gel acceptable and thought that it should be made available if it is found to be safe and effective. Strategies for marketing a potential microbicide product must take the target population into consideration. For married couples, key considerations may be partner dynamics and trust issues, whereas messages focusing on sexual pleasure or disease prevention may resonate more strongly with sex workers or other populations. [ABSTRACT FROM AUTHOR]

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

HIV-infected pregnant women have been the focus of considerable research related to biomedical issues of mother-to-child transmission worldwide. However, there have been few reports on the psychological well-being of new mothers with HIV, either in developed or developing countries. As part of a perinatal HIV transmission and family impact study in Bangkok, predictors of psychological scales were evaluated from interview data (N = 129) collected 18-24 months postpartum. Standardised questionnaires were used to assess depressive symptoms and HIV-related worry. Depressive symptomatology and HIV-related worry were common amongst these women. Multivariate logistic regression analysis identified several factors that predicted these psychological outcomes. High depression scores were associated with women who were no longer in a relationship with their partner (odds ratio (OR) 5.72, confidence interval (CI) 2.18-14.97) and who used venting coping strategies (OR 2.15, CI 1.44-3.21). Higher levels of HIV-related worry were associated with women whose babies were HIV-infected (OR 3.51, CI 1.28-10.69), who had not disclosed their HIV status to others (OR 3.05, CI 1.29-7.24) and who reported that their HIV-infection was something about which their family would be ashamed (OR 3.44, CI 1.34-9.77). Based on the current findings, intervention strategies we propose are psychological interventions which address disclosure issues, feelings of shame and coping strategies as well as financial assistance for single mothers. Interventions that require few resources such as group counselling or support merit special consideration. [ABSTRACT FROM AUTHOR]

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

The HIV epidemic in Thailand is concentrated in key populations, with the highest rates in men who have sex with men (MSM) and transgender women (TG). Previous studies of HIV incidence in these groups have been limited mostly to Bangkok. We measured HIV incidence in MSM and TG in four provinces and evaluated factors associated with incident infections to inform public health prevention efforts. An analysis was conducted using data collected during a prospective observational cohort study during April 2015-May 2018 in outpatient clinics in five hospitals across four provinces in Thailand. MSM and TG aged ≥18 years, who were not known to be HIV-infected, and who reported anal intercourse with a male or TG without a condom in the past six months were enrolled. Participants were followed-up every 6 months for 18 months with questionnaires and HIV testing. A total of 40 HIV seroconversions occurred during follow-up, resulting in an HIV incidence of 3.5 per 100 person-years (95% CI 2.5, 4.8). Multivariate analyses indicated that identifying as gay (adjusted hazard ratio [AHR] 4.9; 95% CI 1.7-14.2), having receptive anal sex in the past six months (AHR 3.6; 95% CI 1.4-9.5), using alcohol (AHR 3.3; 95% CI 1.3-8.3), and taking alkyl nitrites (AHR 4.4; 95% CI 1.7-11.2) in the past six months were all independently associated with HIV infection. Overall this study found a lower HIV incidence in the highest risk population in Thailand compared with similar studies in Bangkok. Accelerated prevention efforts are needed to make the goal of 'zero new infections' possible in Thailand.

The U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the largest bilateral funder of human immunodeficiency virus (HIV) prevention and control programs worldwide, currently supports implementation of preexposure prophylaxis (PrEP) to reduce HIV incidence among persons at substantial risk for infection, including female sex workers, men who have sex with men (MSM), and transgender women (hereafter referred to as key populations). Recent estimates suggest that 54% of all global new HIV infections in 2018 occurred among key populations and their sexual partners (1). In 2016, PEPFAR began tracking initiation of PrEP by key populations and other groups at high risk (2). The implementation and scale-up of PrEP programs across 35 PEPFAR-supported country or regional programs* was assessed by determining the number of programs reporting any new PrEP clients during each quarter from October 2016 to September 2018. As of September 2018, only 15 (43%) PEPFAR-supported country or regional programs had implemented PrEP programs; however, client volume increased by 3,351% over the assessment period in 15 country or regional programs. Scale-up of PrEP among general population clients (5,255%) was nearly three times that of key population clients (1,880%). Among key populations, the largest increase (3,518%) occurred among MSM. Factors that helped drive the success of these PrEP early adopter programs included initiation of national, regional, and multilateral stakeholder meetings; engagement of ministries of health and community advocates; revision of HIV treatment guidelines to include PrEP; training for HIV service providers; and establishment of drug procurement policies. These best practices can help facilitate PrEP implementation, particularly among key populations, in other country or regional programs to reduce global incidence of HIV infection., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

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

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., Competing Interests: The authors have declared that no competing interests exist.

Introduction: In 2014, the Government of Thailand recommended pre-exposure prophylaxis (PrEP) as an additional HIV prevention programme within Thailand's National Guidelines on HIV/AIDS Treatment Prevention. However, to date implementation and uptake of PrEP programmes have been limited, and evidence on the costs and the epidemiological and economic impact is not available., Methods: We estimated the costs associated with PrEP provision among men having sex with men (MSM) participating in a facility-based, prospective observational cohort study: the Test, Treat and Prevent HIV Programme in Thailand. We created a suite of scenarios to estimate the cost-effectiveness of PrEP and sensitivity of the results to the model input parameters, including PrEP programme effectiveness, PrEP uptake among high-risk and low-risk MSM, baseline and future antiretroviral therapy (ART) coverage, condom use, unit cost of delivering PrEP, and the discount rate., Results: Drug costs accounted for 82.5% of the total cost of providing PrEP, followed by lab testing (8.2%) and personnel costs (7.8%). The estimated costs of providing the PrEP package in accordance with the national recommendation ranges from US$223 to US$311 per person per year. Based on our modelling results, we estimate that PrEP would be cost-effective when provided to either high-risk or all MSM. However, we found that the programme would be approximately 32% more cost-effective if offered to high-risk MSM than it would be if offered to all MSM, with an incremental cost-effectiveness ratio of US$4,836 per disability-adjusted life years (DALY) averted and US$7,089 per DALY averted respectively. Cost-effectiveness acceptability curves demonstrate that 80% of scenarios would be cost-effective when PrEP is provided solely to higher-risk MSM., Conclusion: We provide the first estimates on cost and cost-effectiveness of PrEP in the Asia-Pacific region, and offer insights on how to deliver PrEP in combination with ART. While the high drug cost poses a budgeting challenge, incorporating PrEP delivery into an existing ART programme could be a cost-effective strategy to prevent HIV infections among MSM in Thailand., (© 2018 The Authors. Journal of the International AIDS Society published by John Wiley & sons Ltd on behalf of the International AIDS Society.)

Background: Thailand's long-standing HIV sero-sentinel surveillance system for people who inject drugs (PWID) is confined to those in methadone-based drug treatment clinics and representative data are scarce, especially outside of Bangkok., Methods: We conducted probability-based respondent-driven sampling (RDS) surveys in Bangkok (n=738) and Chiang Mai (n=309) to increase understanding of local HIV epidemics and to better inform the planning of evidence-based interventions., Results: PWID had different epidemiological profiles in these two cities. Overall HIV prevalence was higher in Bangkok (23.6% vs. 10.9%, p<0.001) but PWID in Bangkok are older and appear to have long-standing HIV infections. In Chiang Mai, HIV infections appear to be more recently acquired and PWID were younger and had higher levels of recent injecting and sexual risk behaviors with lower levels of intervention exposure. Methamphetamine was the predominant drug injected in both sites and polydrug use was common although levels and patterns of the specific drugs injected varied significantly between the sites. In multivariate analysis, recent midazolam injection was significantly associated with HIV infection in Chiang Mai (adjusted odds ratio=8.1; 95% confidence interval: 1.2-54.5) whereas in Bangkok HIV status was not associated with recent risk behaviors as infections had likely been acquired in the past., Conclusion: PWID epidemics in Thailand are heterogeneous and driven by local factors. There is a need to customize intervention strategies for PWID in different settings and to integrate population-based survey methods such as RDS into routine surveillance to monitor the national response., (Published by Elsevier Ireland Ltd.)

Background: Estimating the sizes of populations at highest risk for HIV is essential for developing and monitoring effective HIV prevention and treatment programs. We provide several country examples of how service multiplier methods have been used in respondent-driven sampling surveys and provide guidance on how to maximize this method's use., Methods: Population size estimates were conducted in 4 countries (Mauritius- intravenous drug users [IDU] and female sex workers [FSW]; Papua New Guinea-FSW and men who have sex with men [MSM]; Thailand-IDU; United States-IDU) using adjusted proportions of population members reporting attending a service, project or study listed in a respondent-driven sampling survey, and the estimated total number of population members who visited one of the listed services, projects, or studies collected from the providers., Results: The median population size estimates were 8866 for IDU and 667 for FSW in Mauritius. Median point estimates for FSW were 4190 in Port Moresby and 8712 in Goroka, Papua New Guinea, and 2,126 for MSM in Port Moresby and 4200 for IDU in Bangkok, Thailand. Median estimates for IDU were 1050 in Chiang Mai, Thailand, and 15,789 in 2005 and 15,554 in 2009 in San Francisco., Conclusion: Our estimates for almost all groups in each country fall within the range of other regional and national estimates, indicating that the service multiplier method, assuming all assumptions are met, can produce informative estimates. We suggest using multiple multipliers whenever possible, garnering program data from the widest possible range of services, projects, and studies. A median of several estimates is likely more robust to potential biases than a single estimate.

The aim of this study is to estimate HIV prevalence and assess sexual behaviors in a high-risk and difficult-to-reach population of clients of female sex workers (FSWs). A modified variation of respondent-driven sampling was conducted among FSWs in Bangkok, where FSWs recruited 3 FSW peers, 1 client, and 1 nonpaying partner. After informed consent was obtained, participants completed a questionnaire, were HIV-tested, and were asked to return for results. Analyses were weighted to control for the design of the survey. Among 540 FSWs, 188 (35%) recruited 1 client, and 88 (16%) recruited 1 nonpaying partner. Clients' median age was 38 years. HIV prevalence was 20% and was associated with younger age at first sexual experience [relative risk (RR) = 3.10, 95% confidence interval (CI) 1.16-8.24] and condom use during last sexual encounter with regular partner (RR = 3.97, 95% CI 1.09-14.61). Median age of nonpaying partners was 34 years, and HIV prevalence was 15.1%. There were 56 discordant FSW-client pairs and 14 discordant FSW-nonpaying partner pairs. Condom use was relatively high among discordant FSW-client pairs (90.1%) compared to discordant FSW-nonpaying partner pairs (18.7%). Results suggest that sexual partners of FSWs have a high HIV prevalence and can be a bridge for HIV transmission to other populations. Findings also highlight the importance of initiating surveillance and targeted programs for FSW partners, and demonstrate a recruitment method for hard-to-reach populations.

Objective: To evaluate extended acceptability of vaginal use of a carrageenan-based candidate microbicide and placebo in northern Thai women., Methods: As part of a randomized, placebo-controlled, triple-blinded clinical trial, women were asked to insert gel with each vaginal sex act and at least three times per week for 1 year. Used applicators were collected monthly; acceptability questions were asked quarterly., Results: One hundred sixty-five women were enrolled (83 microbicide, 82 placebo); 148 (90%) remained in the study for 12 months. Gel use was high, with > or =87% returning at least three used applicators per week at each visit. Although acceptability was generally high, some decline in positive reporting was noted in terms of ease of application, timing of gel insertion, and gel volume over time. Approximately one quarter reported gel use increased her sexual pleasure. Over one quarter reported that gel volume of 5 mL was too much. All women with a steady partner at 12 months reported talking to their partner about using the gel. Only 2 women spontaneously mentioned being able to use a product covertly as one of the most appealing attributes of a potential microbicide., Conclusions: Although women in this study generally reported high acceptability and use, some found 5 mL of gel to be too much. Focusing on enhanced sexual pleasure and lubrication may be beneficial for marketing proven microbicides. Development of products will need to balance lubrication and efficacy with perceptions of too much volume. The ability to use a product covertly was not a high priority in this population.

Background: Since early in Thailand's HIV epidemic, HIV seroprevalence among injection drug users (IDUs) in Bangkok has been around 40%. As Thailand moves to strengthen HIV prevention and care programs for Bangkok IDUs, information on current patterns of drug use and an estimate of the size and composition of the IDU population are essential., Methods: We used respondent-driven sampling (RDS) to recruit Bangkok IDUs who reported injecting in the past 6 months. IDUs were interviewed with a standardized questionnaire. Logistic regression was used to compare IDUs currently or previously in treatment with those never treated. RDS software was used to estimate IDU population size based on the proportion in treatment., Results: Of 963 IDUs recruited, 828 (86%) were men. One hundred and twelve IDUs (12%) reported never having attended a drug treatment clinic. Young age, unemployment, injection of single drug, and never having been HIV tested were significantly associated with never-in-treatment status. The estimated proportion of IDUs in treatment was 0.55 (95% confidence interval, 0.52-0.60). Dividing the known number of IDUs in treatment (1981 IDUs attending Bangkok drug treatment clinics during October 2003 through March 2004) by this proportion, we estimated the number of IDUs in Bangkok during the period of RDS to be 3595 (95% confidence interval, 3296-3810)., Conclusions: Data obtained through RDS, although subject to limitations from co-existing government drug control policies and possible under-recruitment of out-of-treatment IDUs, will be useful in informing policy, strengthening prevention approaches, and improving methods to monitor the HIV epidemic among Thai IDUs.

In northern Thailand, where substantial male-to-female transmission of HIV has occurred in stable partnerships, the relationships between counseling, communication, and HIV-preventive behaviors in married couples have not been well studied. In a study of HIV incidence among women in northern Thailand, each participant was advised to learn her husband's HIV-infection status and was asked to bring him for an interview at the final 12-month follow-up visit. Of the 337 men interviewed, 58% reported having ever had an HIV test. More men reported testing following their wives' enrollment: 12% in the year prior to enrollment vs 22% during the 1-year study (p < 0.001). In the univariate analysis, men's HIV testing during the 6 months before being interviewed was associated with communication about HIV testing with their wife and extra marital sex with non-FSW while married. Testing following their wife's request was the most common reason reported. Agreement between husband's and wife's reports was poor for most issues, such as whether HIV-related communication had occurred, but agreement as to whether the husband had ever been tested for HIV was relatively high (kappa = 0.62). However, in the logistic regression analysis, only sex with non-FSW while married remained associated with HIV testing (p = 0.02). The results suggest a relationship between counseling, communication, and husband HIV testing. Better communication by couples may result in more effective use of HIV testing, which is already prevalent in this population, to prevent HIV transmission.

Objectives: To evaluate the acceptability of candidate microbicide Carraguard among couples participating in a safety trial., Study Design: A 6-month randomized, placebo-controlled trial was conducted in sexually active, low-risk couples in Thailand., Methods: Couples who were monogamous, HIV uninfected, and not regular condom users were enrolled. Acceptability data were collected through structured questionnaires at repeated intervals. At the closing study visit, participants were asked questions about hypothetical product characteristics and future use. Compliance with gel use was assessed by questionnaires, coital diaries, and tracking of used and unused applicators., Results: Among 55 enrolled couples, follow up and adherence with gel use were high and sustained, with 80% of women using gel in over 95% of vaginal sex acts. Because acceptability results from Carraguard and placebo arms were similar, they were combined for this analysis. Overall, 92% of women and 83% of men liked the gel somewhat or very much; 66% of women and 72% of men reported increased sexual pleasure with gel use; and 55% of women and 62% of men reported increased frequency of intercourse. Only 15% of women but 43% of men thought that gel could be used without the man knowing. Although men and women had similar views overall, concordance within couples was low, with no kappa coefficients above 0.31., Conclusion: Carraguard gel use was acceptable to low-risk couples in northern Thailand. Reported associations between gel use and increased sexual pleasure and frequency suggest a potential to market microbicide products for both disease prevention and enhancement of pleasure.

Objective: To determine the safety and acceptability of vaginal application of Carraguard, a carrageenan-derived candidate microbicide gel., Design: A randomized, placebo-controlled, triple-blinded clinical trial was conducted in Chiang Rai, northern Thailand., Methods: Women were asked to insert one applicator of study gel vaginally at least three times per week (with or without sex) and to use gel with condoms every time they had sex. Safety was assessed by visual inspection of the vagina and cervix, changes in vaginal flora and self-reported symptoms at day 14, month 1 and then monthly for up to 1 year. Acceptability was assessed through reported use of the gel, return of used and unused applicators, and quarterly interviews., Results: One hundred sixty-five women were randomized: 83 to Carraguard and 82 to the placebo (methylcellulose gel) group. Study gel use was similarly high in both groups throughout the trial with an average of four applicators per week. Carraguard use was not associated with abnormal genital clinical findings, abnormal vaginal flora, Pap smear abnormalities or other abnormal clinical signs or symptoms. Adverse events were mostly mild, not attributed to gel use, and similarly distributed between groups. Participants in both groups reported high acceptability., Conclusions: Carraguard can safely be used an average of four times per week with or without sex and is acceptable to Thai women. A Phase III efficacy trial of Carraguard is warranted and is currently ongoing in South Africa.

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

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

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

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

Unplanned pregnancy among young people can lead to adverse social, psychological, and health outcomes, particularly when it results in abortion. In 1999, we examined the prevalence of and factors associated with pregnancy and abortion among 1725 consenting vocational school students in northern Thailand. Results from an audio computer-assisted self-interview showed that 48% of the male and 43% of the female students reported ever having had sexual intercourse. Among those who had had intercourse, 27% of the women and 17% of the men said they or their partner had ever been pregnant. Among the last reported pregnancies that resulted in delivery or abortion, 95% were aborted. Age, current contraceptive use, early initiation of sexual intercourse (

To investigate knowledge and perceptions of HIV transmission risk and interest in vaginal microbicides in northern Thailand, we conducted 14 focus group discussions and 80 interviews with men and women in Chiang Rai province. Women were recruited from antenatal or postpartum clinics, and men from various work sites. Participants evinced substantial knowledge about HIV, with two exceptions important for prevention campaigns: (a) confusion about the window period between a new infection and positive HIV-test result and (b) overestimation of the safety of extramarital sex with partners who are not sex workers. Most participants reported no personal HIV risk. Participants described Thai women as generally vulnerable to HIV infection because of the unlikelihood of condom use with their husbands and because women cannot control their husbands' extramarital behavior. Women apparently face particular risk after childbearing; peripartum abstinence averages 6-9 months, during which time some Thai men may have alternative sex partners. Women, and to a lesser degree, men were interested in potential microbicides, although they voiced many thoughtful questions about the products and about efficacy trials.

Sexual coercion was assessed in a cross-sectional survey of drug use and sexual behavior in vocational school students from Chiang Rai, Thailand (n = 1725; ages 15-21), using audio-computer assisted self-interview. Sexual coercion was reported by 6.5% of males and 21% of females. Mean age at first occurrence was 16 years (range 8-20) among males and 17 years (range 5-21) among females. Most perpetrators were male (52% among males; 98% among females) and known by the participants. Among females, associated factors were history of pregnancy, selling sex, marijuana use, perceived risk of STD, two or more lifetime sexual partners, and living away from family. Among males, associated factors were homo- or bisexual self-identification, parents living together, and ulcerative STD history.

Aims: Data from drug treatment facilities, drug seizures and drug arrests suggest rapidly increasing methamphetamine use by adolescents in Thailand. However, limited quantitative data are available about the prevalence of its use or correlates of use. The purpose of our study was therefore to estimate the prevalence of methamphetamine use and to identify possible risk factors., Design: Cross-sectional survey using anonymous audio-computer-assisted self-interview and urine specimen analysis., Setting: Chiang Rai Province, Thailand., Participants: 1725 students, 15-21 years of age (893 male and 832 female) attending one of three vocational schools in Chiang Rai Province., Findings: Three hundred and fifty male and 150 female students reported a history of having ever used methamphetamine. In addition, 128 male and 49 female students had positive urine test results, indicating recent methamphetamine use; 27 of these students denied having ever used methamphetamine. According to history, urine test, or both, 41.3% of male students and 19.0% of female students used methamphetamine. In multivariate analysis, methamphetamine use was highly correlated with the use of other substances, sexual activity, peer pressure, positive attitudes toward methamphetamine, and absence of a family confidant., Conclusions: Methamphetamine use is common among adolescent students in northern Thailand. Demographic, behavioral and psychosocial correlates of methamphetamine use identified in this study may be helpful for the design and implementation of preventive interventions.

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

To determine the incidence of and risk factors for HIV-1 infection among married women in northern Thailand, we enrolled 779 seronegative women from family planning clinics and a postpartum ward in Chiang Rai, Thailand, from 1998 through 1999. Women were tested for HIV antibodies at 6 and 12 months after enrollment. They received HIV prevention counseling at enrollment and at each follow-up visit. Counseling covered partner communication, partner HIV testing, and condom use by steady partners. Effects of counseling were measured using standardized questionnaires. Follow-up rates were 94% at 6 months and 92% at 12 months. Only 1 woman seroconverted during the follow-up period, yielding an overall HIV incidence of 0.14 per 100 person-years. After receiving counseling, women reported significantly increased communication with husbands concerning HIV risk, HIV testing, and condom use during the first 6 months after enrollment; communication remained high for 6 to 12 months. Women reported a modest increase in HIV testing and consistent condom use by husbands. The risk for HIV transmission to women in steady relationships is low in northern Thailand. Although HIV prevention counseling promoted partner communication, its effects on HIV preventive behaviors were limited.

To assess women's interests and concerns regarding participation in trials of microbicides in Chiang Rai, Thailand, we administered structured questionnaires. Before answering the questionnaire, women attended an educational session on microbicides and clinical trials. Of 370 participants, 82% correctly answered 8 or more of the 11 overall comprehension questions, indicating an adequate knowledge base among the women from which to answer questions about attitudes toward microbicide trials. The most common motivations for participating in a trial were "getting tested for HIV" and "doing something good for women's health." The greatest barrier to participation was women's fear that if they proposed use of a microbicide, their husbands might feel protected and thereby have more sex partners. Overall, 6.2% said they would be "definitely willing to participate," and 66.8% said they wanted to participate but wanted to think about it. Most women previously unacquainted with the concept of microbicides or clinical trial design displayed adequate knowledge of these subjects after the short educational session. If women's initial reactions are validated by actual willingness, surveys could prove valuable for selecting sites for microbicide trials, estimating enrollment rates, and tailoring trials to make them most acceptable to women.

Background: Drug use, unwanted pregnancy, human immunodeficiency virus (HIV) infection, and sexually transmitted diseases are serious health problems among Thai youth. The gravity of these problems demands high-quality data to direct public health policy and prevention programs. Previous studies of stigmatized behaviors have been hampered by participation bias and underreporting. To evaluate sexual behavior, disease, and drug use, we used audio-computer-assisted self-interviewing (ACASI) and noninvasive specimen collection methods. We also evaluated effectiveness of these methods in minimizing participation bias and underreporting., Methods: In late 1999, students aged 15 to 21 years attending 3 vocational schools were invited to participate in a cross-sectional survey. Consenting students completed a classroom-based ACASI interview using a confidential code number system. Oral fluid specimens were tested for HIV antibodies, and urine was tested for chlamydial and gonococcal nucleic acids, methamphetamines, and opiates., Results: Of 1736 invited students, 1725 (99%) agreed to participate. Of these, 48% of the male students and 43% of the female students reported ever having had sexual intercourse. Overall, the mean number of lifetime sexual partners was 4.6 among male participants (median: 2) and 2.8 among female participants (median: 1). Consistent use of condoms with steady partners was reported by 16% of male participants and 11% of female participants who had such partners. Of all male participants, 7% had ever paid for sex, 3% had ever sold sex, and 7% had ever been coerced to have sex. Of all female participants, 3% had ever sold sex and 21% had ever been coerced to have sex. Among women with a history of sexual intercourse, 27% reported at least 1 pregnancy. Of these pregnancies, 83% were terminated. Among those with sexual intercourse experience, the prevalence of HIV infection was 0.5%; of infection with Neisseria gonorrhoeae, 0.4%; and of infection with Chlamydia trachomatis, 5%. Twenty-nine percent of students reported ever having used methamphetamines. Ten percent had a methamphetamine-positive urine test. In the ACASI interview, 16% of these denied ever having used methamphetamines. The prevalence of opiate positive urine tests was low (0.2%)., Conclusion: This study shows that adolescents and young adults in Chiang Rai are at high risk for having unprotected intercourse, being coerced to have sex, unwanted pregnancy, sexually transmitted diseases, and drug use. The high enrollment rate demonstrates the feasibility and acceptability of using ACASI and noninvasive specimen collection methods in a developing country. ACASI use may lead to increased, but not to complete, self-reporting of sensitive behaviors.

To study HIV-1 seroprevalence, risk factors, and preventive behaviors among reproductive-age women in northern Thailand, 804 consenting women who were identified postpartum or who were visiting family planning clinics were interviewed and tested during 1998 to 1999. Almost all women were currently married and had been pregnant more than once. Their median age was 27 years. HIV-1 seroprevalence was 3.1% overall and was higher in women aged between 25 and 29 years (5.9%), having had > or =2 lifetime sex partners (6.5%), or whose current marriage had lasted for < or =1 year (7.0%). No woman reported HIV risk factors other than heterosexual sex. Most (76%) HIV-infected women reported no casual sex partners and, therefore, had likely acquired the infection from their husbands. HIV testing and partner communications were common, but only 2% of couples used condoms consistently in the prior 6 months. Nearly half of these women perceived themselves at no or low risk for HIV infection; these women were less likely to have taken preventive actions. To prevent HIV transmission in stable partnerships in this population, additional efforts are needed to increase HIV testing and condom use, to improve women's negotiation skills, and to develop new methods that do not require partner cooperation such as vaginal microbicides or vaccines.

The objective of this study was to assess changes in the family situation of HIV-infected women who have recently given birth. As part of a prospective perinatal HIV transmission study, interviews were conducted with a subset of HIV-infected women at 18 to 24 months postpartum, and answers were compared with baseline information obtained during pregnancy. Standardized scales were used to assess levels of psychosocial functioning. A convenience sample of 129 HIV-infected women enrolled during pregnancy was interviewed at 18 to 24 months postpartum. At delivery, the women were young (median age, 22 years), primiparous (57%), and asymptomatic (93%). When baseline and follow-up data were compared, more women were living alone (1% versus 6%; p = 0.03), fewer women were living with their partners (98% versus 73%; p < 0.001), and 30% of families had reduced incomes. At follow-up, 10% of partners had died, and more partners than wives had become ill or died (21% versus 4%; p = 0.02). Most children (78%) were living with their mothers, but only 57% of the HIV-infected women were the primary caretakers. Fewer women had disclosed their HIV status to others (e.g., family, friends) than to their partners (34% versus 84%; p < 0.001), largely because of fear of disclosure. The women appeared to have high levels of depression and worry. The women's greatest worries were about their children's health and the family's future. Within 2 years after childbirth, substantial change within the families of HIV-infected women was evident. These were manifest by partner illness or death, family separation, reduced family income, shifting responsibilities for child care, and signs of depression and isolation. Providing family support is a major challenge in Thailand as the perinatal HIV epidemic progresses.