Stigma in health facilities: why it matters and how we can change it.

Stigma in health facilities undermines diagnosis, treatment, and successful health outcomes. Addressing stigma is fundamental to delivering quality healthcare and achieving optimal health. This correspondence article seeks to assess how developments over the past 5 years have contributed to the state of programmatic knowledge-both approaches and methods-regarding interventions to reduce stigma in health facilities, and explores the potential to concurrently address multiple health condition stigmas. It is supported by findings from a systematic review of published articles indexed in PubMed, Psychinfo and Web of Science, and in the United States Agency for International Development's Development Experience Clearinghouse, which was conducted in February 2018 and restricted to the past 5 years. Forty-two studies met inclusion criteria and provided insight on interventions to reduce HIV, mental illness, or substance abuse stigma. Multiple common approaches to address stigma in health facilities emerged, which were implemented in a variety of ways. The literature search identified key gaps including a dearth of stigma reduction interventions in health facilities that focus on tuberculosis, diabetes, leprosy, or cancer; target multiple cadres of staff or multiple ecological levels; leverage interactive technology; or address stigma experienced by health workers. Preliminary results from ongoing innovative responses to these gaps are also described.The current evidence base of stigma reduction in health facilities provides a solid foundation to develop and implement interventions. However, gaps exist and merit further work. Future investment in health facility stigma reduction should prioritize the involvement of clients living with the stigmatized condition or behavior and health workers living with stigmatized conditions and should address both individual and structural level stigma.

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

This study used respondent-driven sampling to explore the effects of social support on HIV risk and protective factors among young males who have sex with males (YMSM) in Bangkok (N = 273) and Chiang Mai (N = 243), Thailand. It compared different measures of social support, including living situation, the proportion of family and friends to whom the respondent had disclosed their same-sex attraction, and scores on the multi-dimensional scale of perceived social support as predictors of two outcomes of interest-coerced first sex and HIV knowledge. Social support from family played a mediating role in both outcomes among YMSM in Bangkok but not those from Chiang Mai. Though social support from friends was also studied, it was less strongly associated with the outcomes of interest. The findings support interventions designed to leverage social support networks to increase HIV knowledge and decrease coerced first sex among YMSM. At the same time, they demonstrate that there is not a single risk or demographic profile encompassing all YMSM. Successful programs and policies will need to consider the specific attributes and social environment of YMSM in particular locations in order to effectively address HIV risks.

Effects of Radiation Therapy on Immunological and Virological Status in HIV-Infected Cancer Patients in Thailand: A Multicenter Prospective Study.

BACKGROUND: Radiation therapy (RT) is the core part of cancer multidisciplinary management which causes myelosuppression. The current standard or RT among HIV-positive cancer patients who are immuno-compromised does not differ from that of HIV-negative ones. OBJECTIVE: To determine the effects of radiation therapy on immunological and virological status among HIV-infected cancer patients. MATERIAL AND METHOD: A prospective observational study was conducted of HIV-infected cancer patients who received definitive RT in seven hospitals in Thailand. Blood samples were taken to determine immune status using CD4%, and virological status was identified using plasma HIV-RNA viral load (HIV-VL) assay: at baseline before RT at the last week of RT completion; and at the 6-month follow-up visit. Additional CD4% test was performed at the 3-month follow-up visit. RESULTS: Ninety HIV-infected cancer patients from seven hospitals in Thailand were included in the analysis. The median age was 40 years old (range 19-61). Seventy-six patients (84.4%) were female and 65 (72.2%) were cases of invasive cervical cancers. Eighty-seven percent of patients had been receiving antiretroviral treatment (ART) before RT The mean CD4% at baseline, RT completion, 3-month and 6-month follow-up visits, were 18.7%, 20.1%, 16.8% and 17.1%, respectively. The proportion of CD4% reduction in the non-ART group was higher than that of the ART group throughout the period, particularly at the 3-month follow-up visit (100% vs. 29.7%, p = 0.0004). Six cases had a HIV-VL increase of more than 10 times (1-log10) at completion of RT: 3 of these were non-ART and 3 were ART-uncontrolled viral suppression. CONCLUSION: RT had a suppressive effect on immunological status in HIV-infected cancer patients, particularly in the subacute period among those who were not on ART HIV-disease progression was observed during radiation treatment in HIV-infected cancer patients without ART and those with ART-uncontrolled viral suppression.

Real-World Effectiveness of COVID-19 Vaccines against Severe Outcomes during the Period of Omicron Predominance in Thailand: A Test-Negative Nationwide Case-Control Study.

Due to the widespread Omicron variant of SARS-CoV-2 in Thailand, the effectiveness of COVID-19 vaccines has become a major issue. The primary objective of this study is to examine the real-world effectiveness of COVID-19 vaccines based on secondary data acquired under normal circumstances in a real-world setting, to protect against treatment with invasive ventilation of pneumonia during January to April 2022, a period when Omicron was predominant. We conducted a nationwide test-negative case-control study. The case and control were matched with a ratio of 1:4 in terms of age, date of specimen collection, and hospital collection specimen and the odds ratio was calculated using conditional logistic regression. Overall, there was neither a distinction between mix-and-match regimens and homologous mRNA regimens against severe symptoms, nor was there a decline of the protective effect over the study period. The third and fourth dose boosters with ChAdOx1 nCoV-19 or mRNA vaccines provided high levels of protection against severe outcomes, approximately 87% to 100%, whereas two doses provided a moderate degree (70%). Thus, this study concludes that current national vaccine strategies provide favourable protective benefits against the Omicron variant. All Thais should receive at least two doses, while high-risk or vulnerable groups should be administered at least three doses.

A focused multi-state model to estimate the pediatric and adolescent HIV epidemic in Thailand, 2005-2025.

BACKGROUND: We estimated the magnitude of the HIV epidemic among children and youth living with HIV (CYHIV) aged 0-25 years in Thailand, projecting forward from 2005 to 2025, and identified underreported input parameters that influence epidemic projections, in order to inform future public health and research priorities. METHODS: We developed a focused multi-state transition model incorporating perinatally-acquired HIV and non-perinatally-acquired HIV, stratified by population, including men who have sex with men (MSM), female sex workers (FSW), people who inject drugs (PWID), and the remainder of the population ("other"). We populated the model with published and programmatic data from the Thai national AIDS program when available. We projected the period from 2005-2025 and compared model results to programmatic data and projections from other models. In a scenario analysis, we projected the potential impact of pre-exposure prophylaxis (PrEP) for MSM from 2018-2025. RESULTS: The initial 2005 cohort was comprised of 66,900 CYHIV; 8% CYHIV were <5 years, 21% were 5-14 years, and 71% were 15-25 years of age. By 2020, 94% were projected to be >15 years and infections among MSM constituted 83% of all new HIV infections. The numbers of CYHIV decreased over time, projected to reach 30,760 by 2020 (-54%) and 22,640 by 2025 (-66%). The proportion of all CYHIV aged 0-25 who were diagnosed and on ART increased from 37 to 60% over the 2005-2025 period. Projections were sensitive to variations in assumptions about initial HIV prevalence and incidence among MSM, PWID, and "other" youth. CONCLUSIONS: More data on incidence rates among sexual and gender minority youth and PWID are needed to characterize the role of specific exposures and key populations in the adolescent HIV epidemic. More accurate estimates will project shifts in population and inform more targeted interventions to prevent and care for Thai CYHIV.

Increased Work Experience Associated with Less Stigmatizing Attitudes towards People Living with HIV among Thai Healthcare Personnel.

HIV-related stigma in health facilities has been suggested as a primary target for HIV-related stigma reduction. The objective of this study was to describe negative attitudes among Thai healthcare personnel (HCP) toward PLHIV. This nationwide probability sampled survey was conducted in 2019 in 12 provinces in Thailand and Bangkok, the capital. Participants were considered to have stigmatizing attitudes toward PLHIV if they had a stigmatizing view in response to at least one of the four questions. Eighty-two percent of the 3056 respondents had at least one stigmatizing attitude. Younger HCP, ages < 30 (AOR = 1.60; 95%CI: 1.18-2.18) and 30-39 (AOR = 1.60; 95%CI: 1.21-2.12) were more likely to have stigmatizing attitudes towards PLHIV compared to those aged 50 and older. Being support staff, support-clinical (AOR = 1.89; 95%CI: 1.44-2.49) and support-nonclinical (AOR = 1.71; 95%CI: 1.24-2.36) as opposed to professional staff also increased the likelihood of having stigmatizing attitudes. Stigma was also more likely to be present in HCPs who did not work at HIV-focused clinics (AOR = 1.97; 95%CI: 1.57-2.48). HCP who had more work experience, especially related to PLHIV care, were less likely to have stigmatizing attitudes. These personnel could be good peer educators or role models for a stigma reduction campaign within their healthcare facilities.

Integration and scale-up of efforts to measure and reduce HIV-related stigma: the experience of Thailand.

OBJECTIVE(S): To share Thailand's journey to develop and implement a national response to measure and tackle HIV-related stigma and discrimination and key implementation lessons learned. DESIGN: A national response to stigma and discrimination including policy, measurement, and interventions. Intervention activities began in health facilities because of their key role in achieving health outcomes. METHODS: Three building blocks were implemented: policy and its translation into a roadmap for action; measurement development and routinization to inform intervention design and track progress; and intervention development and implementation. RESULTS: Thailand has successfully integrated a response to stigma and discrimination into its national HIV response. Stigma and discrimination-reduction was included as a key strategic goal for the first time in the 2014-2016 National AIDS Strategic Plan. A costed national stigma and discrimination-reduction roadmap incorporated into the operational plan provided clear strategic direction on how to move forward. The development of HIV-related stigma and discrimination measures and their incorporation into the national HIV monitoring and evaluation framework has led to routine data collection to monitor stigma and discrimination in health facilities, key populations, and the general population. Development and successful piloting of a health facility stigma-reduction package - the 3 × 4 approach - has led to national scale-up of the approach through a modified approach. Thailand continues to evolve and innovate the program, including developing new activities to tackle stigma and discrimination beyond the health system. CONCLUSION: Thailand's experience demonstrates the key elements needed to make addressing stigma and discrimination a priority in the national HIV response.

Recent declines in HIV infections at Silom Community Clinic Bangkok, Thailand corresponding to HIV prevention scale up: An open cohort assessment 2005-2018.

OBJECTIVES: We assessed HIV-1 infection among men who have sex with men (MSM) attending Silom Community Clinic (SCC) in Bangkok, Thailand from 2005 to 2018. Since 2014, Thailand increased implementation of HIV prevention strategies including pre-exposure prophylaxis and Treatment as Prevention. METHODS: MSM attending SCC were tested for HIV using rapid tests. We assessed trends in HIV prevalence, incidence and compared incidence before and after 2014. RESULTS: From 2005 to 2018, 14,034 clients attended SCC for HIV testing. The HIV prevalence increased from 19.2% in 2005-2006 to 34-0% in 2010, remained stable until 2016 and decreased to 17.2% in 2018 (p<0.0001). The HIV incidence was 4.1 per 100 person-years (PY), with an inverted U-shape trend and a peak in 2009 (p<0.0001). Incidence among young MSM aged 13-21 years remained high at 10.0 per 100 PY. Among those aged 22-29 years, lower incidence was found from Q 3 2016, with a relative risk reduction of 46.2% (p<0.001); and a similar reduction among those aged ≥30 years from Q4 2014, corresponding to scale up of HIV prevention strategies. CONCLUSION: We found a decline in HIV infection among Thai MSM. However, incidence remained high among young MSM.

HIV/AIDS care and treatment in three provinces in northern Thailand before the national scale-up of highly-active antiretroviral therapy.

In 2003, Thailand launched a program to place 50,000 persons on highly active antiretroviral therapy (HAART) by the end of 2004, following a series of efforts since the early 1990s to develop comprehensive HIV/AIDS care services. To evaluate existing services and needs in advance of the national HAART scale-up, in 2002 we surveyed 31 hospitals and 389 community health centers in three northern Thai provinces, and interviewed 1,015 HIV-infected patients attending outpatient clinics. All hospitals offered voluntary HIV counseling and testing, 84% provided primary prophylaxis for Pneumocystis carinii pneumonia, 58% for tuberculosis, 39% for cryptococcal meningitis, and 87% had some experience providing antiretroviral therapy. Community health centers provided more limited service coverage. Of patients interviewed, 63% had been diagnosed with symptomatic HIV disease, and of these, 32% reported ever receiving antiretroviral therapy; 51 % of all patients had received a CD4 T-lymphocyte count. Thailand's current national HAART scale-up is being performed in a setting of well-developed hospital-based services introduced over the course of the epidemic.

The impact of Thailand's public health response to the HIV epidemic 1984-2015: understanding the ingredients of success.

INTRODUCTION: Thailand has been heralded as a global leader in HIV prevention and treatment, and its experience with the HIV/AIDS epidemic holds valuable lessons for public health. This paper documents Thailand's response to its HIV epidemic from the late 1980s until today, and analyses its epidemiological impact (incidence and mortality). We discuss the association between the trajectory of HIV incidence and mortality rates over time, and the programmatic investments, policies and interventions that were implemented in the last three decades. METHODS: This is a review paper that draws on published literature, unpublished sources and routine behavioural and serological surveillance data since 1989. It is informed by the modelling of epidemiological impacts using the AIDS Epidemic Model. The AIDS Epidemic Model and Spectrum were used to assess the impact on incidence and mortality. Apart from epidemiological data, National AIDS Spending Assessment and programme data were also used to assess financial investments. RESULTS: Thailand is well on its way to meeting the 90-90-90 targets, the goal that by 2020, 90% of people living with HIV know their HIV status, 90% of people with diagnosed HIV infection receive sustained antiretroviral therapy, and 90% of people receiving antiretroviral therapy (ART) are virally suppressed. In Thailand, 89% of people living with HIV know their status, 72% receive ART and 82% have viral load testing - 99% of whom are suppressed. The public health response to HIV in Thailand has averted 5.7 million infections since 1991. If Thailand had not responded in 1991 to the HIV epidemic, and had there been no prevention and ART provision, the country would have experienced an estimated 158,000-225,000 deaths in the 2001-2006 period. This figure would have risen to 231,000-268,924 in the 2007-2014 period. A total of 196,000 deaths were averted between 2001 and 2014. If ART scale-up had not occurred in 2001, Thailand would have experienced between 50,000 and 55,000 deaths per year in the period 2001-2006, and 31,000-46,000 annual deaths between 2007 and 2014. The main impact in terms of deaths averted is seen from 2004 onwards, reflecting treatment scale up. CONCLUSIONS: Thailand's AIDS response has prevented needless morbidity and mortality due to the HIV epidemic. In the context of Thailand's ageing population, it is faced with the twin challenges of maintaining life-long quality services among HIV patients and sustaining behaviour change to maintain primary prevention gains. Keeping the focus of the policy makers and health administrators on 'Ending the HIV epidemic' will require consistent advocacy, and evidence-based, innovative and efficient approaches.

Acceptance of HIV testing and counseling among unmarried young adults in Northern Thailand.

A cluster randomized trial was used to assess the effect of an active group intervention in promoting utilization of voluntary HIV testing and counseling (HIV-TC). Villagers from 40 clusters were sampled to represent the premarital age population and assigned into two groups, intervention and comparison. The intervention was designed to enhance risk perception and increase knowledge about HIV testing. Interviews were performed before and after the intervention. At baseline, 23% of 398 participants had been tested for HIV at least once and 90% reported testing positive. Most participants perceived that they had no chance of being infected with HIV. Among the intervention group, 71% participated in the intervention activities. The risk ratio of HIV-TC acceptance among the intervention group was 2.92, but the risk difference was only 8.11%. Factors associated with HIV-TC acceptance were ever having had a sexually transmitted disease, being previously married, intention to get tested, and having partici pated in AIDS-related activities.

Acceptability of Carraguard vaginal microbicide gel among HIV-infected women in Chiang Rai, Thailand.

BACKGROUND: Few studies of microbicide acceptability among HIV-infected women have been done. We assessed Carraguard® vaginal gel acceptability among participants in a randomized, controlled, crossover safety trial in HIV-infected women in Thailand. METHODOLOGY/PRINCIPAL FINDINGS: Participants used each of 3 treatments (Carraguard gel, methylcellulose placebo gel, and no product) for 7 days, were randomized to one of six treatment sequences, and were blinded to the type of gel they received in the two gel-use periods. After both gel-use periods, acceptability was assessed by face-to-face interview. Responses were compared to those of women participating in two previous Carraguard safety studies at the same study site. Sixty women enrolled with a median age of 34 years; 25% were sexually active. Self-reported adherence (98%) and overall satisfaction rating of the gels (87% liked "somewhat" or "very much") were high, and most (77%) considered the volume of gel "just right." For most characteristics, crossover trial participants evaluated the gels more favorably than women in the other two trials, but there were few differences in the desired characteristics of a hypothetical microbicide. Almost half (48%) of crossover trial participants noticed a difference between Carraguard and placebo gels; 33% preferred Carraguard while 12% preferred placebo (p = 0.01). CONCLUSIONS/SIGNIFICANCE: Daily Carraguard vaginal gel use was highly acceptable in this population of HIV-infected women, who assessed the gels more positively than women in two other trials at the site. This may be attributable to higher perceived need for protection among HIV-infected women, as well as to study design differences. This trial was registered in the U.S. National Institutes of Health clinical trials registry under registration number NCT00213044.

HIV transmission rates in Thailand: evidence of HIV prevention and transmission decline.

BACKGROUND: Analysis of HIV transmission rates has provided insight into the impacts of HIV-related prevention programming and policies in the United States by providing timely information beyond incidence or prevalence alone. The purpose of this analysis is to use transmission rates to assess past prevention efforts and explore trends of the epidemic in subpopulations within Thailand. METHODS: Asian Epidemic Model HIV incidence and prevalence were used to calculate transmission rates over time nationally and among high-risk populations. RESULTS: A national HIV/AIDS program implemented in Thailand in the 1990s that targeted sex workers and the general population was correlated with a decrease in new cases despite high prevalence. The turning point of the epidemic was in 1991 when the national transmission rate was 32%. By the late 1990s, the rate dropped to less than 4%. All subpopulations experienced a rate decline; however, sex workers still experienced higher transmission rates. CONCLUSIONS: The declining trend in HIV transmission rates despite ever-growing prevalence indicates prevention success correlated with the national HIV/AIDS program. Data from subgroup analyses provide stronger evidence of prevention success than incidence alone, as this measure demonstrates the effect of efforts and accounts for the burden of disease in the population.

Antiretroviral therapy during tuberculosis treatment and marked reduction in death rate of HIV-infected patients, Thailand.

Antiretroviral therapy (ART) is lifesaving in patients with advanced HIV infection, but the magnitude of benefit in HIV-infected patients receiving tuberculosis (TB) treatment remains uncertain, and population-based data from developing countries are limited. We prospectively collected data about HIV-infected TB patients from February 2003 through January 2004 in Ubon-ratchathani, Thailand. During 12 months, HIV was diagnosed in 329 (14%) of 2,342 patients registered for TB treatment. Of patients with known outcomes, death during TB treatment occurred in 5 (7%) of 71 who received ART and 94 (43%) of 219 who did not. Using multivariate analysis, we found a large reduction in the odds of death for patients receiving ART before or during TB treatment (odds ratio, 0.2; 95% confidence interval, 0.1-0.5), adjusting for CD4 count, smear status, co-trimoxazole use, and treatment facility. ART is associated with a substantial reduction in deaths during TB treatment for HIV-infected TB patients in Thailand.