Building the evidence base for stigma and discrimination-reduction programming in Thailand: development of tools to measure healthcare stigma and discrimination.

BACKGROUND: HIV-related stigma and discrimination (S&D) are recognized as key impediments to controlling the HIV epidemic. S&D are particularly detrimental within health care settings because people who are at risk of HIV and people living with HIV (PLHIV) must seek services from health care facilities. Standardized tools and monitoring systems are needed to inform S&D reduction efforts, measure progress, and monitor trends. This article describes the processes followed to adapt and refine a standardized global health facility staff S&D questionnaire for the context of Thailand and develop a similar questionnaire measuring health facility stigma experienced by PLHIV. Both questionnaires are currently being used for the routine monitoring of HIV-related S&D in the Thai healthcare system. METHODS: The questionnaires were adapted through a series of consultative meetings, pre-testing, and revision. The revised questionnaires then underwent field testing, and the data and field experiences were analyzed. RESULTS: Two brief questionnaires were finalized and are now being used by the Department of Disease Control to collect national routine data for monitoring health facility S&D: 1) a health facility staff questionnaire that collects data on key drivers of S&D in health facilities (i.e., fear of HIV infection, attitudes toward PLHIV and key populations, and health facility policy and environment) and observed enacted stigma and 2) a brief PLHIV questionnaire that captures data on experienced discriminatory practices at health care facilities. CONCLUSIONS: This effort provides an example of how a country can adapt global S&D measurement tools to a local context for use in national routine monitoring. Such data helps to strengthen the national response to HIV through the provision of evidence to shape S&D-reduction programming.

Underrecognition and Undertreatment for Peripheral Arterial Disease in Diabetic Patients in Thailand.

Objective: Although several guidelines emphasized the importance of atherosclerotic risk factor management in peripheral arterial disease (PAD) in diabetic patients to reduce the cardiovascular mortality, authors do not know to what extent physicians follow these guidelines. Material and Method: Between May 2014 and August 2014, consecutive eligible outpatients, aged ≥45 years with established DM, were invited to be involved in this study. History, physical exam and laboratory test were reviewed. Ankle brachial index ≤0.9 was considered PAD. Then patients were evaluated the percentage of risk factor control according to American Heart Association (AHA) criteria. The good control was defined that patients have adequate risk factor control between 3-5 factors. Results: 2,247 diabetic patients were recruited for the study. 286 patients out of 2,247 were diagnosed PAD (12.7%). 236 PAD patients (82.5%) did not have any symptom of intermittent claudication, rest pain, gangrene or ulcer. According to AHA criteria, the percentage of adequate control in low density lipoprotein, HbA1C and systolic blood pressure in PAD patients was 18.9, 30.1 and 33.2% respectively. 49.8% in PAD patients had met our good risk factor control criteria. Conclusion: Most PAD in diabetic patients was asymptomatic. The atherosclerotic risk factor control was poor in this group.

Experiences and challenges of pre-exposure prophylaxis initiation and retention among high-risk populations: qualitative insights among service providers in Thailand.

Objectives: Pre-exposure prophylaxis (PrEP) has been an essential element of the national combination prevention package and included in the Universal Health Coverage (UHC) of Thailand since 2019. As a part of the national monitoring and evaluation framework, this qualitative study aims to describe experiences and barriers concerning PrEP initiation and retention among service providers from both hospital and Key Population Led Health Service (KPLHS) settings under the country's UHC roll-out. Methods: Between September and October 2020, ten focus group discussions with PrEP service providers from both hospitals and KPLHS across Thailand were conducted of which there were six hospitals, one health service center, three KPLHS. All interviews were recorded and transcribed verbatim to identify providers' experiences, attitudes, and perceived barriers regarding PrEP service delivery in Thailand. Results: Among the 35 PrEP service providers, most of them reported positive attitudes toward PrEP and believed that it is an effective tool for HIV prevention. Men who have sex with men were perceived to be the easiest group to reach while PrEP uptake remains a challenge in other key populations. Integration of a PrEP clinic with other HIV services at hospitals made most healthcare providers unable to adopt an active approach in recruiting new clients like at KPLHS settings. Challenges in delivering PrEP services included lack of public awareness, high workload, limited benefit package coverage, structural and human resources. Conclusion: Additional services to address different health needs should be considered to increase PrEP uptake among harder-to-reach populations. Novel approaches to PrEP service integration and close collaboration between hospitals and KPLHS would be essential in optimizing PrEP uptake and retention. Support regarding raising awareness, expanding service coverage and access, improving facilities and workforce, and providers' capacities are crucial for the success of the national PrEP programme.

NIMH Project Accept (HPTN 043) HIV/AIDS community mobilization (CM) to promote mobile HIV voluntary counseling and testing (MVCT) in rural communities in Northern Thailand: modifications by experience.

Project Accept is a RCT designed to test the efficacy of community mobilization (CM), mobile voluntary counseling and testing (MVCT), and post-test support services (PTSS) in reducing HIV incidence in three African countries and Thailand. The intervention started in rural areas, northern Thailand in January 2006. CM initially included door-to-door visits during the daytime, small group discussions and joining organized meetings and followed by MVCT. In February 2007, CM strategy using HIV/AIDS "edutainment" (education and entertainment) during evening hours was introduced. After edutainment was initiated, the number of participants increased substantially. VCT uptake increased from 18 to 28 persons/day on average (t test; t = 7.87 P < 0.0001). Edutainment especially motivated younger people, as the median age of VCT clients decreased from 38 to 35 years old (median test; z = 6.74, P < 0.0001). Providing free MVCT in community settings along with edutainment during evening hours increased VCT uptake and was particularly attractive to younger adults.

Health diplomacy and the adaptation of global health interventions to local needs in sub-Saharan Africa and Thailand: evaluating findings from Project Accept (HPTN 043).

BACKGROUND: Study-based global health interventions, especially those that are conducted on an international or multi-site basis, frequently require site-specific adaptations in order to (1) respond to socio-cultural differences in risk determinants, (2) to make interventions more relevant to target population needs, and (3) in recognition of 'global health diplomacy' issues. We report on the adaptations development, approval and implementation process from the Project Accept voluntary counseling and testing, community mobilization and post-test support services intervention. METHODS: We reviewed all relevant documentation collected during the study intervention period (e.g. monthly progress reports; bi-annual steering committee presentations) and conducted a series of semi-structured interviews with project directors and between 12 and 23 field staff at each study site in South Africa, Zimbabwe, Thailand and Tanzania during 2009. Respondents were asked to describe (1) the adaptations development and approval process and (2) the most successful site-specific adaptations from the perspective of facilitating intervention implementation. RESULTS: Across sites, proposed adaptations were identified by field staff and submitted to project directors for review on a formally planned basis. The cross-site intervention sub-committee then ensured fidelity to the study protocol before approval. Successfully-implemented adaptations included: intervention delivery adaptations (e.g. development of tailored counseling messages for immigrant labour groups in South Africa) political, environmental and infrastructural adaptations (e.g. use of local community centers as VCT venues in Zimbabwe); religious adaptations (e.g. dividing clients by gender in Muslim areas of Tanzania); economic adaptations (e.g. co-provision of income generating skills classes in Zimbabwe); epidemiological adaptations (e.g. provision of 'youth-friendly' services in South Africa, Zimbabwe and Tanzania), and social adaptations (e.g. modification of terminology to local dialects in Thailand: and adjustment of service delivery schedules to suit seasonal and daily work schedules across sites). CONCLUSIONS: Adaptation selection, development and approval during multi-site global health research studies should be a planned process that maintains fidelity to the study protocol. The successful implementation of appropriate site-specific adaptations may have important implications for intervention implementation, from both a service uptake and a global health diplomacy perspective.

PrEP stigma among current and non-current PrEP users in Thailand: A comparison between hospital and key population-led health service settings.

Background: Pre-exposure prophylaxis (PrEP) has demonstrated effectiveness in high-risk populations. PrEP service in Thailand became free of charge under the Universal Health Coverage (UHC) in 2021. The National Health Security Office launched a pilot project in 2020 to ensure sustainable service delivery, and the national monitoring and evaluation (M&E) framework was adopted to evaluate early phase implementation. We carried out a cross-sectional survey as part of the M&E process to investigate PrEP stigma among current and non-current PrEP users from both hospital and Key Population Led Health Services (KPLHS) settings in Thailand. Methods: Between August and October 2020, an online cross-sectional survey was conducted. A link for a self-administered questionnaire was distributed to all active PrEP centers and PrEP clients were then recruited by PrEP providers. Descriptive and univariate analysis using Chi-square were applied in the analyses. Attitudes toward PrEP were ranked from the most negative to the most positive. The negative attitude can be interpreted as PrEP stigma. Results: This study included 513 PrEP clients (355 from hospitals and 158 from KPLHS). In both settings, respondents' attitudes toward PrEP were generally positive, but some potential stigma was observed. 31.8% of hospital PrEP clients and 9.5% of KPLHS clients agreed that PrEP users should keep their pills hidden from others. Almost half (44.5%) of hospital clients and 18.4% of KPLHS clients agreed that PrEP users are often viewed negatively by society. More than 20% of hospital clients and 12% of KPLHS agreed that PrEP users frequently experience difficulties when their partner/lover/family find out that he or she is on PrEP. Respondents from the hospitals had slightly higher PrEP stigma than those from KPLHS. Conclusions: According to our findings, at the policy level, the campaign to provide PrEP education to all groups of people should be continued in order to promote a positive view of PrEP and reduce PrEP-related stigma among the general population, which is critical for successful PrEP implementation.

A comparison of attitudes and knowledge of pre-exposure prophylaxis (PrEP) between hospital and Key Population Led Health Service providers: Lessons for Thailand's Universal Health Coverage implementation.

BACKGROUND: HIV Pre-exposure prophylaxis (PrEP) has demonstrated efficacy and effectiveness among high-risk populations. In Thailand, PrEP has been included in the National Guidelines on HIV/AIDS Treatment and Prevention since 2014. As a part of the national monitoring and evaluation framework for Thailand's universal coverage inclusion, this cross-sectional survey was conducted to assess knowledge of, attitudes to and practice (KAP) of PrEP service providers in Thailand. METHODS: We conducted a cross-sectional survey to explore knowledge of, and attitudes towards PrEP among providers from hospital and Key Population Led Health Services (KPLHS) settings. The questionnaire was distributed online in July 2020. Descriptive and univariate analysis using an independent-sample t-test were applied in the analyses. Attitudes were ranked from the most negative (score of 1) to the most positive (score of 5). RESULTS: Overall, there were 196 respondents (158 from hospitals and 38 from KPLHS) in which most hospital providers are female nurse practitioners while half of those from KPLHS report current gender as gay. Most respondents report a high level of PrEP knowledge and support provision in all high-risk groups with residual concern regarding anti-retroviral drugs resistance. Over two-fifths of providers from both settings perceive that PrEP would result in risk compensation and half of KPLHS providers are concerned regarding risk of sexual transmitted infections. Limited PrEP counselling time is a challenge for hospital providers. CONCLUSIONS: Service integration between both settings, more involvement and distribution of KPLHS in reaching key populations would be essential in optimizing PrEP uptake and retention. Continuing support particularly in raising awareness about PrEP among healthcare providers and key populations, facilities and manpower, unlimited quota of patient recruitment and PrEP training to strengthen providers' confidence and knowledge would be essential for successful PrEP implementation.

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.

Acceptability of pre-exposure prophylaxis among men who have sex with men and transgender women in Northern Thailand.

BACKGROUND: Northern Thailand has a high burden HIV epidemic among MSM and TG. Oral pre-exposure prophylaxis (PrEP) with tenofovir-emtricitabine has demonstrated efficacy in preventing HIV among MSM and TG in Chiang Mai, Thailand. Determinants of PrEP acceptability are needed to gauge the potential uptake of this prevention strategy. METHODS: From January to February 2012, 238 MSM and TG participants, who self-reported as HIV-uninfected or of unknown status, completed a self-administered survey on hand-held computers. Participants were recruited by venue-day-time sampling and asked to rate their likelihood of using oral PrEP for HIV prevention with an efficacy of 50%. PrEP acceptability was defined as being "very likely" to use PrEP. Odds ratios and 95% CIs were calculated to identify correlates of acceptability. RESULTS: 131 MSM and 107 TG responded, with mean ages of 23.7 and 21.8, respectively. 24% of MSM engaged primarily in receptive anal sex vs. 74% of TG. 21% of MSM and 44% of TG reported regular medication use. Prior awareness of PrEP was high at 66% among both MSM and TG respondents. 41% of MSM and 37% of TG were "very likely" to use PrEP. Among MSM, factors associated with PrEP acceptability included a prior history of STIs (AOR 4.6; 95%CIs 1.7-12.6), previous HIV testing (AOR 2.4 95%CIs 1.1-5.3), regularly planned sex (AOR 2.8 95%CIs 1.1-7.2), and infrequent sex (AOR 2.9 95%CIs 1.3-6.3). Among TG, factors associated with acceptability included prior awareness of PrEP (AOR 3.3; 95%CIs 1.2-9.0) and having private insurance (AOR 5.0; 95%CIs 1.3-19.0). CONCLUSION: MSM and TG in Northern Thailand are distinct groups in terms of sexual behaviors, patterns of medication use, and correlates of PrEP acceptability. Efforts to maximize PrEP uptake should include expanded HIV testing services and the provision of financial subsidies to reduce the cost of PrEP.

HIV incidence, risk factors, and motivation for biomedical intervention among gay, bisexual men, and transgender persons in Northern Thailand.

BACKGROUND: HIV prevalence among men who have sex with men (MSM) and transgender (TG) persons is high and increasing in Chiang Mai, northern Thailand. OBJECTIVES: To describe demographic, socioeconomic, sexual behavior and interest in future HIV prevention trials among gay and bisexual MSM and TG presenting for HIV testing (VCT) and pre-screening for the iPrEx pre-exposure chemoprophylaxis trail. METHODS: In 2008-09, MSM/TG participants attending VCT were interviewed and tested for HIV and STI. Univariate and multivariate regression analyses were done to assess associations with HIV infection. RESULTS: A total of 551 MSM clients (56.1% gay, 25.4% TG, and 18.5% bisexual (BS)) were enrolled. The mean age was 23.9 years. HIV prevalence among MSM overall was 12.9% (71/551); 16.5% among gay men, 9.3% among TG, and 6.9% among BS. Consistent use of condom was low, 33.3% in insertive anal sex and 31.9% in receptive anal sex. Interest in participation was high, 86.3% for PrEP, 69.7% for HIV vaccine trials, but 29.9% for circumcision. HIV was independently associated with being gay identified, aOR 2.8, p = 0.037 and with being aged 25-29, aOR 2.7, p = 0.027. Among repeat testers, HIV incidence was 8.2/100 PY, 95% CI, 3.7/100PY to 18.3/100PY. CONCLUSION: HIV risks and rates varied by self-reported sexual orientation and gender identity. HIV was associated with sexual practices, age, and being gay-identified. These are populations are in need of novel prevention strategies and willing to participate in prevention research.

Awareness about antiretroviral treatment, intentions to use condoms, and decisions to have an HIV test among rural Northern Lowland Thai and ethnic minority young adults.

Young adults aged 18 to 32 years were randomly selected from a household probability sample participating in Project Accept in the remote areas of Chiang Mai province in northern Thailand in 2005. Among 2989 respondents, 44.4% had never heard of antiretroviral treatment (ART). Lack of awareness of ART was independently associated with having had no formal education compared with some formal education and being an ethnic minority compared with being Thai. In all, 57% of the respondents who had ever heard of ART stated that if ART were easily available in their communities it would affect their intentions to be tested for HIV, whereas only 36% stated that this would affect their intentions to use condoms. Younger participants were less likely to intend to get an HIV test as compared with older individuals, and ethnic minorities were less likely to report that they would get an HIV test compared with Thai lowlanders. Single individuals and people who lived separately from their spouses were more likely to have the intention to use condoms if ART were available.

Community-based voluntary counseling and testing services in rural communities of Chiang Mai Province, Northern Thailand.

Between September, 2002 to May, 2003, we implemented community-based HIV Voluntary Counseling and Testing (VCT) services in four rural areas of Chiang Mai Province. The services included providing HIV/AIDS education and free mobile VCT using rapid testing with same day results. Overall, 427 villagers came for VCT (testers) and consented to be interviewed. HIV prevalence among testers was 4.9%, range from 1.1 to 8.4% by area. 'It is free' and/or 'convenient' were the most frequently cited factors that motivated them to get tested (72%) from our mobile VCT. Rural residents came for VCT when logistical barriers were removed. HIV prevalence among testers in some areas was high. Without extending HIV prevention efforts to population segments with less access to health care, the HIV problem in Thailand may re-emerge. Convenient and low-cost VCT may prove crucial for containing this HIV epidemic.