A Web-Based, Respondent-Driven Sampling Survey Among Men Who Have Sex With Men (Kai Noi): Description of Methods and Characteristics.

BACKGROUND: Thailand's HIV epidemic is heavily concentrated among men who have sex with men (MSM), and surveillance efforts are mostly based on case surveillance and local biobehavioral surveys. OBJECTIVE: We piloted Kai Noi, a web-based respondent-driven sampling (RDS) survey among MSM. METHODS: We developed an application coded in PHP that facilitated all procedures and events typically used in an RDS office for use on the web, including e-coupon validation, eligibility screening, consent, interview, peer recruitment, e-coupon issuance, and compensation. All procedures were automated and e-coupon ID numbers were randomly generated. Participants' phone numbers were the principal means to detect and prevent duplicate enrollment. Sampling took place across Thailand; residents of Bangkok were also invited to attend 1 of 10 clinics for an HIV-related blood draw with additional compensation. RESULTS: Sampling took place from February to June 2022; seeds (21 at the start, 14 added later) were identified through banner ads, micromessaging, and in online chat rooms. Sampling reached all 6 regions and almost all provinces. Fraudulent (duplicate) enrollment using "borrowed" phone numbers was identified and led to the detection and invalidation of 318 survey records. A further 106 participants did not pass an attention filter question (asking recruits to select a specific categorical response) and were excluded from data analysis, leading to a final data set of 1643 valid participants. Only one record showed signs of straightlining (identical adjacent responses). None of the Bangkok respondents presented for a blood draw. CONCLUSIONS: We successfully developed an application to implement web-based RDS among MSM across Thailand. Measures to minimize, detect, and eliminate fraudulent survey enrollment are imperative in web-based surveys offering compensation. Efforts to improve biomarker uptake are needed to fully tap the potential of web-based sampling and data collection.

Elimination of Mother-to-Child Transmission of HIV - Thailand.

Thailand experienced a generalized human immunodeficiency virus (HIV) epidemic during the 1990s. HIV prevalence among pregnant women was 2.0% and the mother-to-child transmission (MTCT) rate was >20% (1-3). In June 2016, Thailand became the first country in Asia to validate the elimination of MTCT by meeting World Health Organization (WHO) targets. Because Thailand's experience implementing a successful prevention of MTCT program might be instructive for other countries, Thailand's prevention of MTCT interventions, outcomes, factors that contributed to success, and challenges that remain were reviewed. Thailand's national prevention of MTCT program has evolved with prevention science from national implementation of short course zidovudine (AZT) in 2000 to lifelong highly active antiretroviral therapy regardless of CD4 count (WHO option B+) in 2014 (1). By 2015, HIV prevalence among pregnant women had decreased to 0.6% and the MTCT rate to 1.9% (the elimination of MTCT target is <2% for nonbreastfeeding populations) (4). A strong public health infrastructure, committed political leadership, government funding, engagement of multiple partners, and a robust monitoring system allowed Thailand to achieve this important public health milestone.

Uptake of early infant diagnosis in Thailand's national program for preventing mother-to-child HIV transmission and linkage to care, 2008-2011.

INTRODUCTION: Early infant diagnosis (EID) has been a component of Thailand's prevention of mother-to-child HIV transmission (PMTCT) programme since 2007. This study assessed the uptake, EID coverage, proportion of HIV-exposed infants receiving a definitive HIV diagnosis, mother-to-child transmission (MTCT) rates and linkage to HIV care and treatment. METHODS: Infant polymerase chain reaction (PCR) testing data from the National AIDS Program database were analyzed. EID coverage was calculated as the percentage of number of HIV-exposed infants receiving ≥ 1 HIV PCR test divided by the number of HIV-exposed infants estimated from HIV prevalence and live-birth registry data. Definitive HIV diagnosis was defined as having two concordant PCR results. MTCT rates were calculated based on infants tested with PCR and applied as a best-case scenario, and a sensitivity analysis was used to adjust these rates in average and worst scenarios. We defined linkage to HIV care as infants with at least one PCR-positive test who were registered with Thailand's National AIDS Program. Chi-squared tests for linear trend were used to analyze changes in programme coverage. RESULTS: For 2008 to 2011, the average EID coverage rate increased from 54 to 76% (p < 0.001), with 65% coverage (13,761/21,099) overall. The number of hospitals submitting EID samples increased from 458 to 645, and the percentage of community hospitals submitting samples increased from 75 to 78% (p = 0.044). A definitive HIV diagnosis was made for 10,854 (79%) infants during this period. The adjusted MTCT rates had significantly decreasing trends in all scenarios. Overall, an estimated 53% (429/804) of HIV-infected infants were identified through the EID programme, and 80% (341/429) of infants testing positive were linked to care. The overall rate of antiretroviral treatment (ART) initiation within one year of age was 37% (157/429), with an increasing trend from 28 to 52% (p < 0.001). CONCLUSIONS: EID coverage increased and MTCT rates decreased during 2008 to 2011; however, about half of HIV-infected infants still did not receive EID. Most HIV-infected infants were linked to care but less than half initiated ART within one year of age. Active follow-up of HIV-exposed infants to increase early detection of HIV infection and early initiation of ART should be more widely implemented.

Outcomes of a Comprehensive Youth Program for HIV-infected Adolescents in Thailand.

We developed an intervention program for HIV-infected Thai adolescents with two group sessions and two individual sessions, focusing on four strategies: health knowledge, coping skills, sexual risk reduction, and life goals. An audio computer-assisted self-interview (ACASI) was administered to assess knowledge, attitudes, and practices (KAP) regarding antiretroviral therapy management, reproductive health, and HIV-associated risk behavior. The program was implemented in two HIV clinics; 165 (84%) adolescents (intervention group) participated in the program; 32 (16%) completed the ACASI without participating in the group or individual sessions (nonintervention group). The median age was 14 years, and 56% were female. Baseline KAP scores of the intervention and nonintervention groups were similar. Two months after the intervention, knowledge and attitude scores increased (p < .01) in the intervention group, and the increase was sustained at 6 months. KAP scores did not change from baseline in the nonintervention group at 6 or 12 months after enrollment.

Knowledge, attitudes, and practices regarding antiretroviral management, reproductive health, sexually transmitted infections, and sexual risk behavior among perinatally HIV-infected youth in Thailand.

More than 30% of perinatally HIV-infected children in Thailand are 12 years and older. As these youth become sexually active, there is a risk that they will transmit HIV to their partners. Data on the knowledge, attitudes, and practices (KAP) of HIV-infected youth in Thailand are limited. Therefore, we assessed the KAP of perinatally HIV-infected youth and youth reporting sexual risk behaviors receiving care at two tertiary care hospitals in Bangkok, Thailand and living in an orphanage in Lopburi, Thailand. From October 2010 to July 2011, 197 HIV-infected youth completed an audio computer-assisted self-interview to assess their KAP regarding antiretroviral (ARV) management, reproductive health, sexual risk behaviors, and sexually transmitted infections (STIs). A majority of youth in this study correctly answered questions about HIV transmission and prevention and the importance of taking ARVs regularly. More than half of the youth in this study demonstrated a lack of family planning, reproductive health, and STI knowledge. Girls had more appropriate attitudes toward safe sex and risk behaviors than boys. Although only 5% of the youth reported that they had engaged in sexual intercourse, about a third reported sexual risk behaviors (e.g., having or kissing boy/girlfriend or consuming an alcoholic beverage). We found low condom use and other family planning practices, increasing the risk of HIV and/or STI transmission to sexual partners. Additional resources are needed to improve reproductive health knowledge and reduce risk behavior among HIV-infected youth in Thailand.

Assessment of a couples HIV counseling and testing program for pregnant women and their partners in antenatal care (ANC) in 7 provinces, Thailand.

BACKGROUND: Couples HIV testing and counseling (CHTC) at antenatal care (ANC) settings allows pregnant women to learn the HIV status of themselves and their partners. Couples can make decisions together to prevent HIV transmission. In Thailand, men were tested at ANC settings only if their pregnant partners were HIV positive. A CHTC program based in ANC settings was developed and implemented at 16 pilot hospitals in 7 provinces during 2009-2010. METHODS: Cross-sectional data were collected using standard data collection forms from all pregnant women and accompanying partners who presented at first ANC visit at 16 hospitals. CHTC data for women and partners were analyzed to determine service uptake and HIV test results among couples. In-depth interviews were conducted among hospital staff of participating hospitals during field supervision visits to assess feasibility and acceptability of CHTC services. RESULTS: During October 2009-April 2010, 4,524 women initiating ANC were enrolled. Of these, 2,435 (54%) women came for ANC alone; 2,089 (46%) came with partners. Among men presenting with partners, 2,003 (96%) received couples counseling. Of these, 1,723 (86%) men and all pregnant women accepted HIV testing. Among 1,723 couples testing for HIV, 1,604 (93%) returned for test results. Of these, 1,567 (98%) were concordant negative, 6 (0.4%) were concordant positive and 17 (1%) were HIV discordant (7 male+/female- and 10 male-/female+). Nine of ten (90%) executive hospital staff reported high acceptability of CHTC services. CONCLUSIONS: CHTC implemented in ANC settings helps identify more HIV-positive men whose partners were negative than previous practice, with high acceptability among hospital staff.

Development of a diagnosis disclosure model for perinatally HIV-infected children in Thailand.

While disclosure of HIV status to perinatally HIV-infected children has become an increasingly important clinical issue, specific disclosure guidelines are lacking. We developed a pediatric HIV diagnosis disclosure model to support caretakers. All HIV-infected children greater than 7-years-old at two participating hospitals in Bangkok, Thailand, and their caretakers, were offered disclosure according to the 4-step protocol: (1) screening; (2) readiness assessment; (3) disclosure; and (4) follow-up. Disclosure occurred after agreement of both providers and caretakers. Among 438 children who were screened, 398 (89%) were eligible. Readiness assessment was completed for 353 (91%) of eligible children and 216 (61%) were determined ready. Disclosure was done for 186 children. The mean age at eligibility screening was 10.5 years (range: 6.8-15.8 years); the mean age at disclosure was 11.7 years (range: 7.6-17.7 years). The mean duration between eligibility screening and disclosure was 15.2 months. There were no significant negative behavioral or emotional outcomes reported in children following disclosure. This HIV diagnosis disclosure model was feasible to implement and had no negative outcomes. As the time for preparation process was over 1 year for most cases, the disclosure process can be initiated as early as age 7 to allow enough time for disclosure to be completed by the age of adolescence.

Compliance with and outcomes of CD4-based national guidelines for prevention of mother-to-child transmission of HIV for Thailand, 2006-2007.

The 2006 Thailand national prevention of mother-to-child transmission of HIV (PMTCT) guidelines recommended antiretroviral (ARV) regimen use during antenatal care (ANC) be based on CD4 results: highly active antiretroviral therapy (HAART) should be used for a CD4 < 200 cells/mm(3) and zidovudine/single-dose nevirapine should be used for a CD4 count > or = 200 cell/mm(3). We evaluated compliance with and outcomes of these guidelines. We conducted a retrospective chart review of HIV-infected women and their infants born during October 2006 - December 2007 at 27 hospitals in 11 provinces of Thailand. The infant HIV-infection status was determined using laboratory test results and death reports. Mother-infant pairs were classified as fully, partially, or non-compliant with PMTCT guidelines based on CD4 testing history and ARV received. Factors associated with compliance were analyzed using univariate and multivariate generalized estimating equations (GEE). Among 875 mother-infant pairs reviewed, 387 mothers (44%) had ANC CD4 testing done, of whom 75 (19%) had a CD4 count < 200 cells/mm(3). Proportions of pairs fully, partially and non-compliant with guidelines were 38, 34 and 28%, respectively. A definitive infant HIV-infection status was determined in 578 infants (66%). The overall mother-to-child transmission (MTCT) rate was 5.1% [95% confidence interval (95%(CI): 3.8-6.9] and the MTCT rates for the fully, partially and non-compliant groups were 1.2% (95% CI: 0.4-3.3), 6.0% (95% CI: 3.7-9.5) and 9.5% (95% CI: 6.2-14.0; p<0.001). Factors associated with compliance were: have ANC, awareness of the mothers' HIV status before delivery, and having first ANC prior to 24 weeks gestation. Compliance with the 2006 national PMTCT guidelines was low, and the MTCT rates were high among non- and partially compliant mother-infant pairs. The simplified PMTCT guidellines introduced in 2010, might increase compliance with and improve outcomes for Thailand's PMTCT program.

Successful clinical outcomes following decentralization of tertiary paediatric HIV care to a community-based paediatric antiretroviral treatment network, Chiangrai, Thailand, 2002 to 2008.

INTRODUCTION: Most paediatric antiretroviral treatments (ARTs) in Thailand are limited to tertiary care hospitals. To decentralize paediatric HIV treatment and care, Chiangrai Prachanukroh Hospital (CRH) strengthened a provincial paediatric HIV care network by training community hospital (CH) care teams to receive referrals of children for community follow-up. In this study, we assessed factors associated with death and clinical outcomes of HIV-infected children who received care at CRH and CHs after implementation of a community-based paediatric HIV care network. METHODS: Clinical records were abstracted for all children who initiated ART at CRH. Paired Wilcoxon signed rank tests were used to assess CD4% and virological change among all children. Cox proportional hazard models were used to assess factors associated with death. Treatment outcomes (CD4%, viral load (VL) and weight-for-age Z-score (WAZ)) were compared between CRH and CH children who met the criteria for analysis. RESULTS: Between February 2002 and April 2008, 423 HIV-infected children initiated ART and 410 included in the cohort analysis. Median follow-up for the cohort was 28 months (interquartile range (IQR)=12 to 42); 169 (41%) children were referred for follow-up at CH. As of 31 March 2008, 42 (10%) children had died. Baseline WAZ (< -2 (p=0.001)) and baseline CD4% (<5% (p=0.015)) were independently associated with death. At 48 months, 86% of ART-naïve children in follow-up had VL<400 copies/ml. For sub-group analysis, 133 children at CRH and 154 at CHs were included for comparison. Median baseline WAZ was lower in CH children than in CRH children (p=0.001); in both groups, WAZ, CD4% and VL improved after ART with no difference in rate of WAZ and CD4% gain (p=0.421 and 0.207, respectively). CONCLUSIONS: Children at CHs had more severe immunological suppression and low WAZ at baseline. Community- and tertiary care-based paediatric ART follow-ups result in equally beneficial outcomes with the strengthening of a provincial referral network between tertiary and community care. Nutrition interventions may benefit children in community-based HIV treatment and care.

Reduction in mother-to-child transmission of HIV in Thailand, 2001-2003: Results from population-based surveillance in six provinces.

BACKGROUND: In 2000, Thailand implemented a national program to prevent mother-to-child HIV transmission (PMTCT). OBJECTIVE: To describe the effectiveness of the prevention of mother-to-child HIV transmission program in Thailand. DESIGN AND METHODS: A register of HIV-exposed children at birth was created with follow-up of infection status. The register included children born to HIV-infected women between 1 January 2001 and 31 December 2003 at 84 public health hospitals in six provinces of Thailand. The main outcome measure was HIV infection in children. RESULTS: A total of 2200 children born to HIV-infected mothers were registered. Of these mother-infant pairs, 2105 (95.7%) received some antiretroviral prophylaxis, including 1358 (61.7%) who received the complete short-course zidovudine regimen during pregnancy and labor for the mother and after birth for the infant, with or without other antiretrovirals. HIV infection outcome was determined for 1667 (75.8%) children, of whom 158 [9.5%, 95% confidence interval (CI), 8.1-11.0%] were infected. Transmission risk was 6.8% (95% CI 5.2-8.9%) among 761 mother-infant pairs that received the complete zidovudine regimen alone, and 3.9% (95% CI, 2.2-6.6%) among 361 mother-infant pairs that received the complete zidovudine regimen combined with other antiretrovirals, usually nevirapine. The overall transmission risk from this cohort, including all antiretroviral prophylaxis combinations, is estimated to be 10.2%. CONCLUSIONS: The Thai national PMTCT program is effective in reducing mother-to-child transmission risk from the historical risk of 18.9-24.2%. The addition of nevirapine to short-course zidovudine beginning in 2004 may further improve program effectiveness in Thailand.

Preventing mother-to-child HIV transmission: the first year of Thailand's national program.

CONTEXT: Each year in Thailand, about 10,000 children are born at risk for mother-to-child human immunodeficiency virus (HIV) transmission. In 2000, Thailand implemented a national program to prevent mother-to-child HIV transmission. OBJECTIVE: To describe the results of implementation of the program. DESIGN: Monthly collection of summary data from hospitals. SETTING: Public health hospitals (n = 822) in all 12 regions of Thailand, representing 75 provinces, excluding Bangkok. PARTICIPANTS: Women giving birth from October 2000 through September 2001, including HIV-seropositive women and their neonates. MAIN OUTCOME MEASURES: Percentages of women giving birth who were tested for HIV, HIV-seropositive women giving birth who received antenatal prophylactic antiretroviral drugs, and HIV-exposed neonates who received prophylactic antiretroviral drugs and infant formula. RESULTS: Among 573,655 women (range, 27,344-77,806 by region) giving birth, 554,912 (96.7%) received antenatal care (range, 91.9%-98.8% by region). Of 554,912 women giving birth who had antenatal care, 517,488 (93.3%) were tested for HIV (range, 87.7%-99.4% by region) before giving birth; of 18,743 women giving birth who did not have antenatal care, 13,314 (71.0%) were tested for HIV (range, 21.7%-92.9% by region). Of 6646 HIV-seropositive women giving birth, 4659 (70.1%) received prophylactic antiretroviral drugs before delivery (range, 55.3%-81.2% by region). Of 6475 neonates of HIV-seropositive women, 5741 (88.7%) received prophylactic antiretroviral drugs (range, 67.4%-96.9% by region) and 5386 (83.2%) received infant formula (range, 65.3%-100% by region). CONCLUSIONS: Major program components of Thailand's national program for preventing mother-to-child HIV transmission were implemented. Thailand's experience may encourage other developing countries to implement or expand similar national programs.