HIVQUAL-T: monitoring and improving HIV clinical care in Thailand, 2002-08.

OBJECTIVE: We report experience of HIVQUAL-T implementation in Thailand. DESIGN: Program evaluation. SETTING: Twelve government hospital clinics. PARTICIPANTS: People living with HIV/AIDS (PLHAs) aged ≥15 years with two or more visits to the hospitals during 2002-08. INTERVENTION: HIVQUAL-T is a process for HIV care performance measurement (PM) and quality improvement (QI). The program includes PM using a sample of eligible cases and establishment of a locally led QI infrastructure and process. PM indicators are based on Thai national HIV care guidelines. QI projects address needs identified through PM; regional workshops facilitate peer learning. Annual benchmarking with repeat measurement is used to monitor progress. MAIN OUTCOME MEASURE: Percentages of eligible cases receiving various HIV services. RESULTS: Across 12 participating hospitals, HIV care caseloads were 4855 in 2002 and 13 887 in 2008. On average, 10-15% of cases were included in the PM sample. Percentages of eligible cases receiving CD4 testing in 2002 and 2008, respectively, were 24 and 99% (P< 0.001); for ARV treatment, 100 and 90% (P= 0.74); for Pneumocystis jiroveci pneumonia prophylaxis, 94 and 93% (P= 0.95); for Papanicolau smear, 0 and 67% (P< 0.001); for syphilis screening, 0 and 94% (P< 0.001); and for tuberculosis screening, 24 and 99% (P< 0.01). PM results contributed to local QI projects and national policy changes. CONCLUSIONS: Hospitals participating in HIVQUAL-T significantly increased their performance in several fundamental areas of HIV care linked to health outcomes for PLHA. This model of PM-QI has improved clinical care and implementation of HIV guidelines in hospital-based clinics in Thailand.

Prevalence of hepatitis B, tetanus, hepatitis A, human immunodeficiency virus and feasibility of vaccine delivery among injecting drug users in Bangkok, Thailand, 2003-2005.

OBJECTIVES: To estimate the prevalence of hepatitis B virus (HBV), tetanus, hepatitis A virus (HAV) and human immunodeficiency virus (HIV) in injecting drug users (IDUs), risk factors associated with infection and the feasibility of HBV vaccine delivery in HBV seronegatives. METHODS: Cross-sectional seroprevalence survey of 1535 IDUs recruited from 17 Bangkok Metropolitan Administration (BMA) methadone clinics and HBV vaccination of seronegatives. RESULTS: Prevalence of antibody to HBV, tetanus, HAV and HIV was 87.8%, 68.1%, 60.2% and 35.9%, respectively. Prevalence of HBV and HAV increased with increasing age; prevalence of tetanus decreased with increasing age. Being HIV seropositive was related inversely to income and being tetanus seronegative. Of the 189 HBV seronegative IDUs, 81.0% completed the vaccine series. IDUs with HIV had a 6.5-fold odds of vaccine non-response. CONCLUSIONS: These data underscore the need for, and feasibility of, vaccine delivery in this population and support targeting efforts at high-risk age groups.

A randomized, placebo-controlled trial to assess the safety and acceptability of use of carraguard vaginal gel by heterosexual couples in Thailand.

OBJECTIVES: To determine the safety and acceptability of use of Carraguard, a carrageenan-derived candidate microbicide gel, during sexual intercourse in women and men. STUDY DESIGN: We conducted a 6-month randomized, placebo-controlled trial among sexually active, couples at relatively lower risk for HIV infection in northern Thailand. METHODS: Women inserted 1 applicator of study gel vaginally every time the couple had sex. Safety was assessed by symptom report and genital examination of both partners and by changes in vaginal flora. Acceptability was assessed by participant interview. RESULTS: Overall, 55 couples were randomized, 28 to Carraguard use and 27 to the methyl-cellulose placebo gel group. Retention and study gel use were similarly high in both study groups; use of gel without condoms was reported in more than 95% of vaginal sex acts. The 2 study groups were similar in the proportions of women and men with symptoms or with genital findings without epithelial disruption, of men with findings with epithelial disruption, and of women with abnormal genital flora, whereas more women in the placebo group had findings with epithelial disruption. Women and men in both groups reported that the gel and applicator were acceptable. CONCLUSIONS: Carraguard can safely be used an average of 2 to 3 times per week during sex and is acceptable to Thai women and men.

HIV communication between husbands and wives: effects on husband HIV testing in northern Thailand.

In northern Thailand, where substantial male-to-female transmission of HIV has occurred in stable partnerships, the relationships between counseling, communication, and HIV-preventive behaviors in married couples have not been well studied. In a study of HIV incidence among women in northern Thailand, each participant was advised to learn her husband's HIV-infection status and was asked to bring him for an interview at the final 12-month follow-up visit. Of the 337 men interviewed, 58% reported having ever had an HIV test. More men reported testing following their wives' enrollment: 12% in the year prior to enrollment vs 22% during the 1-year study (p < 0.001). In the univariate analysis, men's HIV testing during the 6 months before being interviewed was associated with communication about HIV testing with their wife and extra marital sex with non-FSW while married. Testing following their wife's request was the most common reason reported. Agreement between husband's and wife's reports was poor for most issues, such as whether HIV-related communication had occurred, but agreement as to whether the husband had ever been tested for HIV was relatively high (kappa = 0.62). However, in the logistic regression analysis, only sex with non-FSW while married remained associated with HIV testing (p = 0.02). The results suggest a relationship between counseling, communication, and husband HIV testing. Better communication by couples may result in more effective use of HIV testing, which is already prevalent in this population, to prevent HIV transmission.

Screening HIV-infected women for cervical cancer in Thailand: findings from a demonstration project.

OBJECTIVES: Although cervical cancer is an AIDS-defining illness, few HIV-infected women are routinely screened for cervical cancer in Thailand. We screened HIV-infected women for cervical cancer as a component of HIV care and assessed high-risk human papillomavirus (HPV) and cervical cancer prevalence. METHODS: From July 2003 through February 2004, HIV-infected women attending either an infectious disease clinic or a sexually transmitted infection (STI) clinic in Bangkok were tested for high-risk HPV types by Hybrid Capture 2 and screened for cervical cancer by Pap test; those with abnormal cervical cytology were referred for diagnosis and treatment. RESULTS: Two hundred ten HIV-infected women at an infectious disease clinic (n = 150) and an STI clinic (n = 60) received cervical cancer screening. The high-risk HPV prevalence was 38.6% and the prevalence of abnormal cervical cytology was 20.4%. Abnormal cervical cytology and high-risk HPV detection were associated (P < 0.001). We received pathology reports for 23 (53.5%) of 43 women, including all those with a Pap test showing high-grade squamous intraepithelial lesions; the cervical cancer prevalence was 1.9% (4 of 210; 95% confidence interval, 0.5-4.8%). CONCLUSION: The estimated prevalence of high-risk HPV and cervical cancer among HIV-infected women in Thailand was high. This emphasizes the need to integrate cervical cancer screening into HIV care.

Safety and acceptability of the candidate microbicide Carraguard in Thai Women: findings from a Phase II Clinical Trial.

OBJECTIVE: To determine the safety and acceptability of vaginal application of Carraguard, a carrageenan-derived candidate microbicide gel. DESIGN: A randomized, placebo-controlled, triple-blinded clinical trial was conducted in Chiang Rai, northern Thailand. METHODS: Women were asked to insert one applicator of study gel vaginally at least three times per week (with or without sex) and to use gel with condoms every time they had sex. Safety was assessed by visual inspection of the vagina and cervix, changes in vaginal flora and self-reported symptoms at day 14, month 1 and then monthly for up to 1 year. Acceptability was assessed through reported use of the gel, return of used and unused applicators, and quarterly interviews. RESULTS: One hundred sixty-five women were randomized: 83 to Carraguard and 82 to the placebo (methylcellulose gel) group. Study gel use was similarly high in both groups throughout the trial with an average of four applicators per week. Carraguard use was not associated with abnormal genital clinical findings, abnormal vaginal flora, Pap smear abnormalities or other abnormal clinical signs or symptoms. Adverse events were mostly mild, not attributed to gel use, and similarly distributed between groups. Participants in both groups reported high acceptability. CONCLUSIONS: Carraguard can safely be used an average of four times per week with or without sex and is acceptable to Thai women. A Phase III efficacy trial of Carraguard is warranted and is currently ongoing in South Africa.

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.

Sexually transmitted infection services as a component of HIV care: findings of a demonstration project among HIV-infected women in Thailand.

OBJECTIVES: As Thailand scales up its antiretroviral treatment program, the role of sexually transmitted infection (STI) services to prevent HIV transmission has not been addressed. We provided STI services for HIV-infected women as a component of HIV care and assessed STI prevalence and risk behaviors. METHODS: HIV-infected women attending an infectious disease clinic and an STI clinic in Bangkok were screened for the presence of genital ulcers by visual inspection, for gonorrhea and chlamydial infection by polymerase chain reaction, for trichomoniasis by wet mount, and for syphilis by serology. Women were asked about sexual risk behavior and use of antiretroviral treatment. Risk-reduction counseling, condoms, and STI treatment were provided. RESULTS: Two-hundred ten HIV-infected women at an infectious disease clinic (n = 150) and an STI clinic (n = 60) received STI services from July 2003 through February 2004. The prevalence for any STI was 8.0% at the infectious disease clinic and 30.0% at the STI clinic (P < 0.01). Of the 116 (55.2%) sexually active women, 42 (36.2%) reported sex without a condom during the last 3 months. Women receiving antiretroviral treatment reported condom use during last sex more often compared with those not receiving antiretroviral treatment (82.2% vs. 58.8%; P = 0.03). CONCLUSION: STIs and sexual risk behavior were common among these HIV-infected women, and STI services for HIV-infected persons have been expanded to more clinics in Thailand. Further analysis of HIV transmission risk is necessary for developing a national strategy for prevention of HIV transmission among HIV-infected persons.

Sexual coercion among adolescents in northern Thailand: prevalence and associated factors.

Sexual coercion was assessed in a cross-sectional survey of drug use and sexual behavior in vocational school students from Chiang Rai, Thailand (n = 1725; ages 15-21), using audio-computer assisted self-interview. Sexual coercion was reported by 6.5% of males and 21% of females. Mean age at first occurrence was 16 years (range 8-20) among males and 17 years (range 5-21) among females. Most perpetrators were male (52% among males; 98% among females) and known by the participants. Among females, associated factors were history of pregnancy, selling sex, marijuana use, perceived risk of STD, two or more lifetime sexual partners, and living away from family. Among males, associated factors were homo- or bisexual self-identification, parents living together, and ulcerative STD history.

Rapid whole-blood finger-stick test for HIV antibody: performance and acceptability among women in northern Thailand.

Although use of rapid HIV antibody tests of finger-stick blood specimens could expand voluntary counseling and testing in areas where fear of venipuncture and delays in learning test results are barriers, there is little information on performance and acceptability of these tests in Asia. We used the Hema. Strip HIV-1/2 test (Saliva Diagnostic Systems, Vancouver, WA) in a prospective cohort study of HIV seroincidence among women in northern Thailand from 1998 to 1999. Nurses obtained whole-blood specimens by finger-stick testing and provided test results and counseling at each visit. Acceptability of the rapid test was assessed at the first 6-month follow-up visit. HIV-1 seroprevalence among the 804 women screened at enrollment was 3.1%. Positive rapid test results from 25 women were confirmed by enzyme immunoassay and Western blot analysis using serum obtained by venipuncture. Of the 741 women who returned for follow-up, 56% preferred specimen collection by finger-stick testing to venipuncture, 80% preferred immediate rather than delayed test results, 79% preferred the rapid test method to typical testing methods, and 97% were satisfied with the test method used. Results from this study demonstrate the utility and acceptability of the rapid finger-stick test for HIV antibody among women in northern Thailand.

Risk factors for sexually transmitted diseases in northern Thai adolescents: an audio-computer-assisted self-interview with noninvasive specimen collection.

BACKGROUND: Previous studies of sexual behavior and sexually transmitted diseases (STDs) in Thai adolescents may have been limited by participation bias and underreporting of stigmatized behaviors. GOAL: The goal was to increase knowledge about risk behaviors and STDs among youths in Thailand. STUDY DESIGN: Students aged 15 to 21 years completed an audio-computer-assisted self-interview. Oral fluid was tested for HIV antibodies and urine was tested for Chlamydia trachomatis and Neisseria gonorrhoeae nucleic acids with polymerase chain reaction. RESULTS: Of 1736 invited students, 1725 (99.4%) agreed to participate. Overall, C trachomatis infection was detected in 49 (2.8%), and there were five cases (0.3%) each of infection with N gonorrhoeae and HIV. Among those who reported sexual intercourse, the prevalence of chlamydial infection was 3.7% among men and 6.1% among women. Logistic regression analysis showed age-adjusted factors associated with chlamydial infection among men to be parents' occupation in agriculture, having sold sex, having a sex partner who had been pregnant, and the number of casual sex partners during lifetime. Among women, age-adjusted factors were parents' occupation in agriculture, number of casual partners during lifetime, having an older sex partner, and perception of higher HIV infection risk. CONCLUSION: These adolescents had high rates of unprotected intercourse and are at risk for STDs. Prevention programs should emphasize use of effective contraceptive methods, including condom use; reducing the number of sex partners (stressing the risk a partner of older age may pose to female adolescents); and reducing engagement in commercial sex.

Prevalence of and risk factors for methamphetamine use in northern Thai youth: results of an audio-computer-assisted self-interviewing survey with urine testing.

AIMS: Data from drug treatment facilities, drug seizures and drug arrests suggest rapidly increasing methamphetamine use by adolescents in Thailand. However, limited quantitative data are available about the prevalence of its use or correlates of use. The purpose of our study was therefore to estimate the prevalence of methamphetamine use and to identify possible risk factors. DESIGN: Cross-sectional survey using anonymous audio-computer-assisted self-interview and urine specimen analysis. SETTING: Chiang Rai Province, Thailand. PARTICIPANTS: 1725 students, 15-21 years of age (893 male and 832 female) attending one of three vocational schools in Chiang Rai Province. FINDINGS: Three hundred and fifty male and 150 female students reported a history of having ever used methamphetamine. In addition, 128 male and 49 female students had positive urine test results, indicating recent methamphetamine use; 27 of these students denied having ever used methamphetamine. According to history, urine test, or both, 41.3% of male students and 19.0% of female students used methamphetamine. In multivariate analysis, methamphetamine use was highly correlated with the use of other substances, sexual activity, peer pressure, positive attitudes toward methamphetamine, and absence of a family confidant. CONCLUSIONS: Methamphetamine use is common among adolescent students in northern Thailand. Demographic, behavioral and psychosocial correlates of methamphetamine use identified in this study may be helpful for the design and implementation of preventive interventions.

Incidence of HIV-1 infection and effects of clinic-based counseling on HIV preventive behaviors among married women in northern Thailand.

To determine the incidence of and risk factors for HIV-1 infection among married women in northern Thailand, we enrolled 779 seronegative women from family planning clinics and a postpartum ward in Chiang Rai, Thailand, from 1998 through 1999. Women were tested for HIV antibodies at 6 and 12 months after enrollment. They received HIV prevention counseling at enrollment and at each follow-up visit. Counseling covered partner communication, partner HIV testing, and condom use by steady partners. Effects of counseling were measured using standardized questionnaires. Follow-up rates were 94% at 6 months and 92% at 12 months. Only 1 woman seroconverted during the follow-up period, yielding an overall HIV incidence of 0.14 per 100 person-years. After receiving counseling, women reported significantly increased communication with husbands concerning HIV risk, HIV testing, and condom use during the first 6 months after enrollment; communication remained high for 6 to 12 months. Women reported a modest increase in HIV testing and consistent condom use by husbands. The risk for HIV transmission to women in steady relationships is low in northern Thailand. Although HIV prevention counseling promoted partner communication, its effects on HIV preventive behaviors were limited.