A cluster randomized trial of community mobilization to reduce methamphetamine use and HIV risk among youth in Thailand: Design, implementation and results.

BACKGROUND: Use of methamphetamines (MA) and other stimulants have consistently been associated with HIV/STI risk globally. We evaluated a community mobilization intervention (Connect to Protect, C2P®) to prevent MA use among youth and reduce HIV risk behaviors through community structural changes. DESIGN: A community-randomized trial in northern Thailand with matched districts randomized to C2P intervention or a standard voluntary counseling and testing (VCT) control. Intervention districts formed stakeholders' coalitions to plan tailored local prevention programs. Two independent random household samples of youth aged 14-24 were surveyed in 2009 and 2012. Lifetime and recent MA use was modeled with multilevel logistic regression. RESULTS: Intervention initiatives included family-strengthening programs, school-based programs and opening a community drug treatment center. Control communities applied the government-led "war on drugs" approach in addition to youth and family programs. Baseline (N = 1077) and follow-up (N = 1225) samples included 47.5% females and 21.7% aged ≤16. Lifetime MA use in intervention districts reduced from 13.4% to 11.7% compared to reduction from 16.2% to 10.4% in the control districts (non-significant). In models, lifetime MA use was associated with: time (aOR = 0.6, 95%CI: 0.38-0.83), females (aOR = 0.2, 95%CI: 0.15-0.29), increasing age (aOR = 2.4, 95%CI: 1.40-4.20, ages 16-19; aOR = 3.5, 95%CI: 2.00-6.12, ages ≥20), and not being full-time students (aOR = 5.3, 95%CI: 3.77-7.37). Recent MA use showed similar results. Additionally, lifetime MA use was significantly associated with alcohol use, risky sexual behaviors and elevated depressive symptoms. CONCLUSIONS: Delay in developing and implementing specific prevention programs in the intervention districts slowed diffusion of the effect into the communities. Secular trends with contentious civil unrest and active drug-enforcement efforts in the control communities also contributed to the null intervention effect. Longer time and intensified efforts stressing a public health approach are needed to demonstrate the effectiveness of community mobilization in reducing substance use and HIV risk in this rural Thai community.

Methamphetamine use is associated with high levels of depressive symptoms in adolescents and young adults in Rural Chiang Mai Province, Thailand.

BACKGROUND: High levels of depressive symptoms often occur among individuals that use or that are dependent on methamphetamine (MA). Thailand is currently experiencing an epidemic of MA use among youth. Understanding the nature of the relationship between depressive symptoms and MA use and identifying those most at risk can further understanding of prevention and treatment options for youth who use MA and present with depressive symptoms. METHODS: In 2011, we conducted a cross sectional epidemiologic study that examined associations between MA use and high levels of depressive symptoms among adolescents and young adults aged 14-29 living in Chiang Mai province, Thailand. A combination of cluster and systematic sampling was conducted to obtain a study sample of participants actively recruited in Chiang Mai province. Depressive symptoms were measured using a Thai translation of the Centers for Epidemiologic Studies Depression scale (CES-D). The independent variables measured reported lifetime and recent MA use within the past 3 months. Multivariate logistic regression models were used to assess associations between MA use and high levels of depressive symptoms. RESULTS: Approximately 19% (n = 394) of the sample reported ever having consumed MA and 31% (n = 124) of lifetime users reported recent MA use within the past 3 months. Recent MA use was associated with high levels of depressive symptoms (aPOR recent use: 2.60, 95% CI: 1.20, 5.63). CONCLUSIONS: This is one of the first studies to examine the association between MA use and high levels of depressive symptoms in a general Thai population. The odds of having high levels of depressive symptoms was significantly greater among recent MA users compared to non-users. These findings support the need for policies, programs and interventions to prevent and treat depressive symptoms presenting among MA using Thai adolescents and young adults in rural Chiang Mai province, Thailand to aid in cessation of MA use. Furthermore, additional research is needed to investigate treatment options for adolescents and young adults in Thailand that use MA and present with high levels of depressive symptoms.

Risk factors and algorithms for chlamydial and gonococcal cervical infections in women attending family planning clinics in Thailand.

AIM: To identify risk factors associated with and evaluate algorithms for predicting Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) cervical infections in women attending family planning clinics in Thailand. METHODS: Eligible women were recruited from family planning clinics from all regions in Thailand. The women were followed at 3-month intervals for 15-24 months. At each visit, the women were interviewed for interval sexually transmitted infection (STI) history in the past 3 months, recent sexual behavior, and contraceptive use. Pelvic examinations were performed and endocervical specimens were collected to test for CT and NG using polymerase chain reaction. RESULTS: Factors associated with incident CT/NG cervical infections in multivariate analyses included region of country other than the north, age

Incidence of HIV and sexually transmitted infections and risk factors for acquisition among young methamphetamine users in northern Thailand.

BACKGROUND: Southeast Asia is experiencing an epidemic of methamphetamine use, a drug associated with risky sexual behaviors, putting a large segment of the population at increased risk for sexually transmitted infections (STIs) and HIV and in need of prevention efforts. Incidence estimates of STIs are rare in Southeast Asia, especially among newer risk groups. STUDY DESIGN: We enrolled methamphetamine users aged 18 to 25 years in a 12-month randomized behavioral intervention trial in Chiang Mai, Thailand in 2005. Behavioral questionnaires were administered at visits every 3 months, and biologic specimens were collected at baseline and 12 months to test for common STIs (chlamydia, gonorrhea, HSV-2, and HIV). Poisson regression with robust variance was used to determine risk factors for incident STIs. RESULTS: Overall, 12.7% of 519 participants acquired at least 1 STI. Chlamydia was the most common (10.6%), followed by HSV-2 (4.0%), gonorrhea (2.9%), and HIV (0.6%). Risk factors for both men and women included self-reported incarceration and having a casual sex partner during follow-up, and having a prevalent STI at baseline. Additionally, among women, having 2 or more heterosexual partners, and among men, having a greater frequency of drunkenness were risk factors for STI acquisition. CONCLUSIONS: Although HIV incidence is low in this population, incidence of other STIs is high compared with previous studies of young Thai adults. Risk factors for acquisition emphasize the need for new prevention strategies targeted toward current populations at risk.

Patterns of risky behaviors associated with methamphetamine use among young Thai adults: a latent class analysis.

PURPOSE: Methamphetamine (MA) is the leading illicit drug in Thailand among youth and young adults. Sexual risk behaviors are associated with methamphetamine use, but few data are available on the daily context of methamphetamine use. We developed an inductive behavioral typology that young Thais engage in while using methamphetamine. METHODS: We conducted a cross-sectional study in Chiang Mai, Thailand, in 2005-2006 among 1,162 street-recruited methamphetamine smokers 18-25 years of age. Data collected included sociodemographic characteristics, sexual behaviors, and drug use patterns. Latent class analysis was used to describe patterns of activities in which participants reported engaging directly after using MA. Logistic regression was used to examine univariate correlates of class membership, separately by gender. RESULTS: Participants were 75% male with a median age of 19 years. More than half of participants reported frequent alcohol use (>or=4 days/week) and half of the sample reported smoking MA >or=2 days/ week. Three classes of activities emerged for male participants (n = 863): "work" (job related); "high-risk behaviors" (motorcycle riding, fighting, sex); and "combined" (all activities). Two classes emerged for the women (n = 299): "work" (housework) and "high-risk behaviors." "High-risk behaviors" and "combined" (men only) classes were associated with more frequent alcohol and methamphetamine use compared with the "work" class. CONCLUSIONS: Our study found a distinct typology of behaviors associated with substance abuse among young adults in Thailand. Behavioral typologies allow a better understanding of the nuances of "risky" behaviors and might prove useful in targeting interventions.

Patterns of methamphetamine use and symptoms of depression among young adults in northern Thailand.

INTRODUCTION: Depression often co-occurs with amphetamine type stimulant use and can negatively impact drug treatment outcomes. Understanding the temporal relationship between depressive symptoms and methamphetamine use can further inform both treatment and mental health options. METHODS: Methamphetamine users aged 18-25 years were enrolled in a 12-month randomized behavioral trial in Thailand. Questionnaires were administered every 3 months and included information on substance use and depressive symptoms. Pattern of methamphetamine use during follow-up was characterized into four groups: early cessation, late cessation, relapse and persistent use. Multinomial logistic regression was used to determine the impact of baseline depressive symptoms (CES-D score and % > or =22) on patterns of methamphetamine use during follow-up. Linear and logistic regression was used to determine the impact of patterns of methamphetamine use on depressive symptoms at the end of the trial. RESULTS: No association was found between baseline depressive symptoms and subsequent patterns of methamphetamine use. A significant relationship was found between patterns of methamphetamine use and ensuing depressive symptoms, with those achieving cessation experiencing lower levels of depressive symptoms. DISCUSSION: Many symptoms of depression may resolve with cessation or reduction in methamphetamine use. Clinical and community-based efforts that facilitate drug users' attempts to stop using drugs should be supported as they may contribute to positive cessation outcomes and help to improve overall mental health.

Correlates of incarceration among young methamphetamine users in Chiang Mai, Thailand.

OBJECTIVES: We examined correlates of incarceration among young methamphetamine users in Chiang Mai, Thailand in 2005 to 2006. METHODS: We conducted a cross-sectional study among 1189 young methamphetamine users. Participants were surveyed about their recent drug use, sexual behaviors, and incarceration. Biological samples were obtained to test for sexually transmitted and viral infections. RESULTS: Twenty-two percent of participants reported ever having been incarcerated. In multivariate analysis, risk behaviors including frequent public drunkenness, starting to use illicit drugs at an early age, involvement in the drug economy, tattooing, injecting drugs, and unprotected sex were correlated with a history of incarceration. HIV, HCV, and herpes simplex virus type 2 (HSV-2) infection were also correlated with incarceration. CONCLUSIONS: Incarcerated methamphetamine users are engaging in behaviors and being exposed to environments that put them at increased risk of infection and harmful practices. Alternatives to incarceration need to be explored for youths.

Sexually transmitted infections and sexual and substance use correlates among young adults in Chiang Mai, Thailand.

BACKGROUND: Data on the prevalence of and associated behavioral risk factors for sexually transmitted infections (STI) in young adults in Asia have not been widely studied. STUDY DESIGN: We conducted a cross-sectional study in Chiang Mai, Thailand in 2005--2006 among 658 sexually active participants aged 18 to 25 years, the majority having a history of recent methamphetamine (MA) use. Data were collected by interview and STI were detected using standard laboratory assays. RESULTS: Overall, 38% of participants had at least one laboratory confirmed STI. Herpes simplex virus and Chlamydia were significantly more common among women, whereas hepatitis B virus was significantly more common among men. Men reported a greater number of sexual partners than women, and condom use at last sex was infrequent. Most participants reported using MA at least weekly, with men more frequent users than women, and more often giving reports of frequent drunkenness and lifetime arrests. Behavioral correlates of prevalent STI were similar to the published literature. In multivariate analysis, women > or =20 years of age, with > or =2 heterosexual partners in the past year and a younger age at sexual debut were significantly more likely to have a prevalent STI. Men > or =20 years of age, with > or =2 heterosexual partners in the past year and who enrolled both sex and drug network members were significantly more likely to have a prevalent STI, whereas men who used a condom at last sex were significantly less likely to have a prevalent STI. Substance abuse was associated with behavioral risks but not with prevalent STI. CONCLUSIONS: Sexual risks and substance abuse are substantially elevated among young Thai MA users, but only sexual risks are associated with prevalent STI.

A qualitative study of sexual behaviours among methamphetamine users in Chiang Mai, Thailand: a typology of risk.

INTRODUCTION AND AIMS: Methamphetamine (MA) has become the leading drug of abuse in northern Thailand over the past several years, particularly among youth. The current qualitative study explores the relationship between sexual behaviours and MA. DESIGN AND METHODS: Between March 2002 and January 2003, 48 in-depth interviews with young MA users aged 15-2 years in Chiang Mai. Interviews were transcribed verbatim in Thai and translated into English. Data were analysed inductively using the constant comparative method common to grounded theory methods. Atlas-ti was used for data management. The current analysis was stratified by gender. RESULTS: Participants were 44% male and the median age was 20 years. At the time of the interviews, 70% were not using MA. A typology of experiences with and feelings about MA's relationship to sexual activity emerged: (1) enhanced libido--individuals who found that MA enhances their sexual experiences (n = 13); (2) decreased libido or no effect--individuals who found that MA detracted from sexual desire (n = 22); and (3) virgins (n = 13). DISCUSSION AND CONCLUSIONS: Participants reported several distinct patterns of relationship between MA and sex. Tailored interventions are needed that address specific patterns of sexual behaviors among youth in order to promote sustainable safer sex behaviours in this population.

Young Thai women who use methamphetamine: intersection of sexual partnerships, drug use, and social networks.

BACKGROUND: Given high rates of methamphetamine (MA) use among young people in Thailand and evidence of an association between MA and increased sexual risk behaviour, we examined the association between women's recent sexual partnerships, social network characteristics and drug and alcohol use. METHODS: Female participants (n=320) in an HIV behavioural trial among young (18-25 years) MA users in Chiang Mai completed a drug and sexual behaviour survey and social network inventory. Multinomial regression analyses accounting for clustered data examined individual and network characteristics associated with recent sexual partnership category. We compared women with only one male partner in the past year (39%) to those with multiple male partners (37%) and those with only female partners (24%). RESULTS: Differences in levels of drug and alcohol use and social and sexual network characteristics were dependent on recent sexual partnership profiles. The multiple partner group reported an average of five male partners in the past year; 12% reported consistent condom use in the past 30 days. Compared to both groups, women with multiple male partners used MA more frequently, had larger non-sex networks with more MA users, were more likely to have an MA-using sex partner, and received less emotional support from their partners. Women with multiple male partners and only female partners reported more frequent alcohol use. CONCLUSIONS: Policy and intervention efforts targeting drug use and sexual behaviour among young Thai women are drastically needed and may benefit from consideration of the diversity within the population. These data point to the need for targeted prevention approaches that take into account the varying characteristics and social influences of these different groups of women.

Initiation of methamphetamine use among young Thai drug users: a qualitative study.

PURPOSE: Methamphetamine (MA) has become the leading drug of abuse in northern Thailand over the past several years, particularly among youth. The current qualitative study examines factors associated with initiation of MA use. METHODS: Between March 2002 and January 2003, 48 in-depth interviews with young MA users were conducted in advance of a randomized, MA harm reduction, peer outreach intervention trial. The interviews were conducted in the city of Chiang Mai and the surrounding district. Data were inductively analyzed using the constant comparative method common to grounded theory methods. Atlas-ti was used for data management. RESULTS: Participants were 57% male and had a median age of 20 years (range 15-31 years). A culture of MA ubiquity characterized participants' initiation stories. Drug ubiquity encompassed three elements: the extent of MA use within peer networks; the availability of MA; and exposure to MA before initiation. All participants were introduced to MA by people close to them, most often by their friends. Internal reasons for trying MA were curiosity, a way to lose weight or to enhance hard work, and a way to "forget life's problems." With the prevalence of MA use among participants' peers, initiation seemed inevitable. CONCLUSIONS: Initiation was characterized as ubiquitous in terms of peer networks' use and availability. Because of the prevalent norm of MA use, these data indicate that interventions targeting social networks and young Thais before MA initiation are needed.

Associations of substance abuse and sexual risks with self-reported depressive symptoms in young adults in northern Thailand.

Depression among young adults is a significant mental health issue worldwide. Withdrawal from amphetamine and chronic alcohol use is associated with significant increases in depressive symptoms. Young adults with depressive symptoms are more likely to engage in sexual risk behaviors than peers who are not depressed. We investigated the association between substance abuse and sexual risk behaviors with recent depressive symptoms (using the Centers for Epidemiologic Studies Depression Scale [CES-D] scale) in a sample of 1189 young adults aged 18 to 25 years in Chiang Mai, Thailand, who were recruited based on recent methamphetamine use or were sex partners of a methamphetamine user. High reports of depressive symptoms, based on CES-D scores ≥22, were seen in 45% of women and 31% of men (P < 0.0001) and were associated with alcohol problems (Cut down, Annoyed, Guilty, Eye-opener [CAGE] score and frequency of drunkenness) and frequent methamphetamine use in men but not women. For women, higher depressive symptoms were associated with greater numbers of reported sexual partners during the past year where condoms were infrequently used. These results point to the importance of identifying substance abuse among young adults in Thailand and its contribution to depressive symptoms and the importance of recognizing depression as a significant public mental health problem in this population.

Motivations for methamphetamine cessation among young people in northern Thailand.

AIM: To understand factors influencing cessation intentions among young Thai methamphetamine (MA) users, a population with dramatically increasing rates of MA use. DESIGN AND PARTICIPANTS: A total of 48 in-depth interviews conducted between March 2002 and January 2003 with current and recent MA users aged 15-29 years. SETTING: Chiang Mai city and surrounding district, Thailand. MEASUREMENT: Interviews addressed family history, drug use patterns and influences, cessation history, drug treatment experiences and sexual behavior. Data were analyzed inductively using the constant comparative method common to grounded theory methods. Atlas-ti was used for data management. FINDINGS: Cessation intentions were motivated by a range of internal and external influences, including attitudes towards continued MA use shaped by recognition of negative impact on self and others; influence of family, peers, partners and community stigma; perceptions on cessation and drug treatment; and external facilitators and situational barriers, such as extensive peer pressure and drug availability. In most cases, multiple factors operated simultaneously. Some variation according to duration of use and treatment status was observed. CONCLUSIONS: Evidence-based interventions addressing MA use among Thai young people are urgently needed. These data support the continuation of evidence-based drug treatment at levels adequate to address the population need and implementation a multi-faceted approach that aims to enhance identified cessation influences in this population and minimize contextual barriers to cessation.