Evaluation of a pre-exposure prophylaxis programme for men who have sex with men and transgender women in Thailand: learning through the HIV prevention cascade lens.

INTRODUCTION: Men who have sex with men (MSM) and transgender women (TGW) are two key populations (KPs) in Thailand at high risk for HIV. Uptake and scale-up of pre-exposure prophylaxis (PrEP) among them has been slow. We used data from Princess PrEP, Thailand's largest KP-led PrEP programme, to operationalize PrEP service cascades. We identified gaps and pointed out where additional data are needed to inform a larger HIV prevention cascade. METHODS: Numbers of people tested for HIV, tested HIV negative, eligible for PrEP (defined as any of the following in the past three months: condomless sex with partners of unknown/uncertain HIV status or antiretroviral treatment or viral load status, multiple partners, engaging in sex work, sexually transmitted infections, injecting drugs, using amphetamine-type stimulants, or repeated use of post-exposure prophylaxis), offered PrEP and accepted PrEP during January to November 2019 were retrieved from Princess PrEP database to inform PrEP service cascades for MSM and TGW. Reasons for not accepting PrEP were documented. RESULTS: Of 6287 MSM who received HIV testing in Princess PrEP, 92.3% were HIV negative and 70.2% of them were eligible for PrEP. PrEP was offered to 94.7% of those eligible and 48.0% of those offered accepted it. Among 900 TGW who had HIV testing, 95.3% tested HIV negative and 64.8% of them met PrEP eligibility criteria. Of these, 95.0% were offered PrEP and 43.9% of them accepted it. Among MSM and TGW who met PrEP eligibility criteria, no or low-HIV-risk perception was the most common reason provided (46.7% of 2007 MSM and 41.9% of 296 TGW) for not accepting PrEP. CONCLUSIONS: PrEP service cascades from the Princess PrEP programme identified no or low-risk perception as key barrier to PrEP acceptance among MSM and TGW who met PrEP eligibility criteria. More implementation research studies are needed to explore PrEP motivation and access in larger communities outside of clinical services. This is to identify gaps and strategies to address them within motivation, access and effective use domains of the HIV prevention cascade.

Linkages to HIV confirmatory testing and antiretroviral therapy after online, supervised, HIV self-testing among Thai men who have sex with men and transgender women.

INTRODUCTION: Online, supervised, HIV self-testing has potential to reach men who have sex with men (MSM) and transgender women (TGW) who never tested before and who had high HIV-positive yield. We studied linkages to HIV confirmatory test and antiretroviral therapy (ART) initiation among Thai MSM and TGW who chose online and/or offline platforms for HIV testing and factors associated with unsuccessful linkages. METHODS: MSM and TGW were enrolled from Bangkok Metropolitan Region and Pattaya during December 2015 to June 2017 and followed for 12 months. Participants could choose between: 1) offline HIV counselling and testing (Offline group), 2) online pre-test counselling and offline HIV testing (Mixed group) and 3) online counselling and online, supervised, HIV self-testing (Online group). Sociodemographic data, risk behaviour and social network use characteristics were collected by self-administered questionnaires. Linkages to HIV confirmatory testing and/or ART initiation were collected from participants who tested reactive/positive at baseline and during study follow-up. Modified Poisson regression models identified covariates for poor retention and unsuccessful ART initiation. RESULTS: Of 465 MSM and 99 TGW, 200 self-selected the Offline group, 156 the Mixed group and 208 the Online group. The Online group demonstrated highest HIV prevalence (15.0% vs. 13.0% vs. 3.4%) and high HIV incidence (5.1 vs. 8.3 vs. 3.2 per 100 person-years), compared to the Offline and Mixed groups. Among 60 baseline HIV positive and 18 seroconversion participants, successful ART initiation in the Online group (52.8%) was lower than the Offline (84.8%) and Mixed groups (77.8%). Factors associated with unsuccessful ART initiation included choosing to be in the Online group (aRR 3.94, 95% CI 1.07 to 14.52), <17 years old at first sex (aRR 3.02, 95% CI 1.15 to 7.92), amphetamine-type stimulants use in the past six months (aRR 3.6, 95% CI 1.22 to 10.64) and no/single sex partner (aRR 3.84, 95%CI 1.36 to 10.83) in the past six months. CONCLUSIONS: Online, supervised, HIV self-testing allowed more MSM and TGW to know their HIV status. However, linkages to confirmatory test and ART initiation once tested HIV-reactive are key challenges. Alternative options to bring HIV test confirmation, prevention and ART services to these individuals after HIV self-testing are needed.

What would you choose: Online or Offline or Mixed services? Feasibility of online HIV counselling and testing among Thai men who have sex with men and transgender women and factors associated with service uptake.

INTRODUCTION: HIV testing coverage remains low among men who have sex with men (MSM) and transgender women (TGW). We studied characteristics of Thai MSM and TGW who chose online and/or offline platforms for HIV counselling and testing and the feasibility of integrating online technologies and HIV self-testing to create service options. METHODS: From December 2015 to June 2017, MSM and TGW enrolled from Bangkok Metropolitan Region and Pattaya could choose between: offline HIV counselling and testing (Offline group), online pre-test counselling and offline HIV testing (Mixed group), and online counselling and online, supervised, HIV self-testing (Online group). Sociodemographic data, risk behaviour and social network use characteristics were collected by self-administered questionnaires. Logistic regression models identified covariates for service preferences. RESULTS: Of 472 MSM and 99 TGW enrolled, 202 self-selected the Offline group, 158 preferred the Mixed group, and 211 chose the Online group. The Online group had the highest proportion of first-time testers (47.3% vs. 42.4% vs. 18.1%, p < 0.001) and reported highest HIV prevalence (15.9% vs. 13.0% vs. 3.4%, p = 0.001) as compared to Offline and Mixed groups, respectively. Having tested for HIV twice or more (OR 2.57, 95% CI 1.03 to 6.41, p = 0.04) increased the likelihood to choose online pre-test counselling. Being TGW (OR 6.66, 95% CI 2.91 to 15.25, p < 0.001) and using social media from four to eight hours (OR 2.82, 95% CI 1.48 to 5.37, p = 0.002) or >8 hours (OR 2.33, 95% CI 1.05 to 5.16, p = 0.04) increased selection of online, supervised, HIV self-testing. Providers primarily used smartphones (79.2%) and laptops (37.5%) to deliver online services. Self-testing strip image sharpness and colour quality were rated "good" to "excellent" by all providers. Most participants (95.1%) agreed that online supervision and HIV self-testing guidance offered were satisfactory and well delivered. CONCLUSIONS: Online HIV services among MSM and TGW are feasible in Thailand and have the potential to engage high proportions of first-time testers and those with high HIV prevalence. When designing public health interventions, integrating varied levels of online HIV services are vital to engage specific sections of MSM and TGW populations in HIV services. CLINICAL TRIAL NUMBER: NCT03203265.