Thailand's response to the HIV epidemic: yesterday, today, and tomorrow

Development of automated HIV case reporting system using national electronic medical record in Thailand

Background

An electronic medical record (EMR) has the potential to improve completeness and reporting of notifiable diseases. We developed and assessed the validity of an HIV case detection algorithm and deployed the final algorithm in a national automated HIV case reporting system in Thailand.

Methods

The HIV case detection algorithms leveraged a combination of standard laboratory codes, prescriptions and International Classification of Diseases, 10th Revision diagnostic codes to identify potential cases. The initial algorithm was applied to the national EMR from 2014 to June 2020 to identify HIV-infected subjects to build the national HIV case reporting system (Epidemiological Intelligence Information System (EIIS)). A subset of potential positives identified by the initial algorithm were then validated and reviewed by infectious disease specialists. This review identified that a proportion of the false positives were due to pre-exposure prophylaxis/postexposure prophylaxis (PrEP/PEP) antiretrovirals, and so the algorithm was refined into a ‘Final Algorithm’ to address this.

Results

Positive predictive value of identifying HIV cases was 90% overall for the initial algorithm. Individuals misclassified as HIV-positive were HIV-negative patients with incorrect diagnostic codes, prescription records for PrEP, PEP and hepatitis B treatment. Additional revision to the algorithm included triple drug regimen to avoid further misclassification. The final HIV case detection algorithm was applied to national EMR between 2014 and 2020 with 449 088 HIV-infected subjects identified from 1496 hospitals. EIIS was designed by applying the final algorithm to automated extract HIV cases from the national EMR, analysing them and then transmitting the results to the Ministry of Public Health.

Conclusions

EMR data can complement traditional provider-based and laboratory-based disease reports. An automated algorithm incorporating laboratory, diagnosis codes and prescriptions have the potential to improve completeness and timeliness of HIV reporting, leading to the implementation of a national HIV case reporting system.

Risky injection practices and HCV awareness in Chiang Mai Province, Thailand: a respondent-driven sampling study of people who inject drugs

Background

People who inject drugs (PWID) are the most exposed to hepatitis C virus (HCV). In Thailand, drug use is highly criminalized, and harm reduction services are scarce. This study estimates risky injection practices and assesses the proportion of HCV awareness and screening in the PWID population in Northern Thailand.

Methods

We used respondent-driven sampling (RDS) to recruit PWID in Chiang Mai Province. Social and behavioural data were collected through face-to-face interviews at an addiction treatment facility. Weighted population estimates were calculated to limit biases related to the non-random sampling method. Univariate and multivariate analyses were performed to study factors associated with HCV awareness and screening.

Results

One hundred seventy-one PWID were recruited between April 2016 and January 2017. Median age was 33 (Interquartile range: 26–40) years, 12.2% were women, and 49.4% belonged to a minority ethnic group. Among participants, 76.8% injected heroin, 20.7% methadone, and 20.7% methamphetamine. We estimate that 22.1% [95% CI: 15.7–28.6] of the population had shared needles in the last 6 months and that 32.0% [95% CI: 23.6–40.4] had shared injection material. Only 26.6% [95% CI: 17.6–35.6] had heard of HCV. Factors independently associated with knowledge of HCV included belonging to a harm reduction organization (adjusted odds ratio (aOR) = 5.5 [95% CI: 2.0–15.3]) and voluntary participation in a drug rehabilitation programme (aOR = 4.3 [95% CI: 1.3–13.9]), while Lahu ethnicity was negatively associated (aOR = 0.3 [95% CI: 0.1–0.9]). We estimate that 5% of the PWID population were screened for HCV; the only factor independently associated with being screened was membership of a harm reduction organization (aOR = 5.7 [95% CI: 1.6–19.9]).

Conclusion

Our study reveals that the PWID population is poorly informed and rarely screened for HCV, despite widespread risky injection practices. A public health approach aimed at reducing the incidence of HCV should target the PWID population and combine harm reduction measures with information and destigmatization campaigns. Civil society organizations working with PWID are a major asset for the success of such an approach, based on their current positive interventions promoting awareness of and screening for HCV.

Examining the Sociocultural Context of HIV-related Risk Behaviors Among Kathoey (Male-to-female Transgender Women) Sex Workers in Bangkok, Thailand

Kathoey (male-to-female transgender) sex workers (KSW) in Thailand are at high risk for sexually transmitted infections; however, few qualitative studies have been conducted to understand the sociocultural context of engaging in HIV risk behaviors. A total of 24 participants were purposively sampled in Bangkok based on KSW work venues and substance use. Results revealed the importance of participants' understanding of the self in relation to establishing economic independence through sex work, which could then be used to re-establish support from family, who often have not accepted a son's gender transition. Participants linked being kathoey to a belief in fate but did not view engagement in sex work in the same way. Different sex work venues exposed KSW to different risky situations. HIV prevention programs for kathoey must address the importance of economic security and its relation to social support and gender transition within a cultural- and work-environment-specific framework.

HIV pre-exposure prophylaxis and health and community systems in the Global South: Thailand case study

INTRODUCTION

Pre-exposure prophylaxis (PrEP) is recommended by the World Health Organization as an effective method of HIV prevention for individuals at risk for infection. In this paper, we describe the unique role that Thailand has played in the global effort to combat the HIV epidemic, including its role in proving the efficacy of PrEP, and discuss the opportunities and challenges of implementing PrEP in a middle-income country.

DISCUSSION

Thailand was one of the first countries in the world to successfully reverse a generalized HIV epidemic. Despite this early success, HIV prevalence has remained high among people who inject drugs and has surged among men who have sex with men (MSM) and transgender women (TGW). Two pivotal trials that showed that the use of oral antiretroviral medication as PrEP can reduce HIV transmission were conducted partially or entirely at Thai sites. Demonstration projects of PrEP, as well as clinical trials of alternative PrEP regimens, began or will begin in 2014-2015 in Thailand and will provide additional data and experience on how to best implement PrEP for high-risk individuals in the community. Financing of drug costs, the need for routine laboratory monitoring and lack of awareness about PrEP among at-risk groups all present challenges to the wider implementation of PrEP for HIV prevention in Thailand.

CONCLUSIONS

Although significant challenges to wider use remain, PrEP holds promise as a safe and highly effective method to be used as part of a combined HIV prevention strategy for MSM and TGW in Thailand.

High proportion of HIV serodiscordance among HIV-affected married couples in northern Vietnam

INTRODUCTION

Little is known about the state of HIV transmission among married couples in Vietnam. This study aims to clarify HIV serostatus in this group and elucidate risk factors for intra-marital HIV transmission.

METHODS

In 2012, we enrolled a group of HIV-positive married men registered at the HIV outpatient clinic of a referral hospital in northern Vietnam, along with their wives. Sociodemographic, behavioural and clinical data were collected from men and wives. HIV serodiscordant couples were followed until March 2014 to determine seroconversion rate. A phylogenetic analysis was performed based on env V3 sequence to detail cluster formation among men.

RESULTS

Of the 163 HIV-positive men enrolled in the study, 101 (62.0%) had wives testing HIV-negative. Half of men reported injecting drug use (IDU) as a likely transmission route. Couples reported a high incidence of unprotected sexual intercourse prior to diagnosis; the median (inter quartile range) was 4 (4-8) times per month. Only 17 couples (10.4%) reported using condoms during at least half these instances. Multivariable analysis revealed IDU history among men was independently associated with HIV-negative wives (adjusted OR 0.31; 95% CI 0.10-0.95, p=0.041). Phylogenetic analysis of 80 samples indicated CRF01_AE. Of these, 69 (86.3%) clustered with IDU-associated viruses from Vietnam. No HIV seroconversion was identified during a follow-up of 61 serodiscordant couples, with 126.5 person-years of observation during which HIV-infected men were on antiretroviral drug therapy (ART).

CONCLUSION

High HIV serodiscordance was observed among HIV-affected married couples in northern Vietnam. A large number of at-risk wives therefore remain HIV-negative and can be protected with measures including proper use of ART if couples are made aware of the serodiscordance through screening.

Community health nurses' HIV health promotion and education programmes: a qualitative study

BACKGROUND

Globally, nurses practice in many settings with people with human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), taking an increasing share of the professional burden of care and helping to reduce morbidity and mortality. International literature is sparse about Thai community nurses providing primary healthcare programmes for people with HIV.

AIM

This study aimed to describe background, experiences and strategies of community nurses regarding their design and delivery of programmes for people living with HIV and AIDS in Chiang Mai Province, Thailand.

DESIGN

This study used a qualitative mixed-methods study employing a qualitative survey and in-depth interviews.

METHODS

Twenty community health nurses from 18 small community hospitals completed a survey comprising demographic data and 13 open-ended questions. Four of them later engaged in in-depth interviews using the same questions. Survey, interview data and field notes were analysed using interpretive content analysis.

FINDINGS

Four themes and six sub-themes portrayed participants' rich experiences and knowledge of HIV health promotion and education; challenges of daily work, discrimination and ethical issues; success through programme diversity comprising promotion of community volunteerism, networking and relationships; and holistic connections with Thai cultural traditions and Buddhism.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Findings help to recognize the diversity, uniqueness and contributions of Thai community nurses regarding culturally appropriate health promotion and education programmes for people living with HIV and AIDS. Findings inform nurses and health officials in and outside of the country to complement innovation in future HIV health promotion and education programmes.

LIMITATIONS

Our sample came from one province of Thailand. Findings might not be reflective of nurses elsewhere.

IMPLICATIONS FOR HEALTH AND NURSING POLICY

Three decades of collective experience in providing holistic and multifaceted HIV and AIDS nursing care, education and health promotion by community health nurses have the potential to effect new and existing policies and protocols on HIV community care in Thailand, but more research is required for this.

Biomedical HIV prevention research and epidemic control in Thailand: two sides of the same coin

For a country with a moderate adult HIV prevalence of just over 1% in 2012, Thailand is widely perceived as having made some extraordinary contributions to the global management of the HIV/AIDS pandemic. It has been promoted as a model of effective HIV control and applauded for its leadership in providing access to antiretroviral treatment. Thailand has also received international recognition for its contribution to biomedical HIV prevention research, which is generally perceived as exceptional. In this paper, Thailand's global role model function as an example of effective HIV/AIDS control and high-quality biomedical HIV prevention research is re-evaluated against the background of currently available data and more recent insights. The results indicate that Thailand's initial response in raising the level of the political significance of HIV/AIDS was indeed extraordinary, which probably prevented a much larger epidemic from occurring. However, this response transpired in unusual extraconstitutional circumstances and its effectiveness declined once the country returned to political normalcy. Available data confirm the country's more than exceptional contribution to biomedical HIV prevention research. Thailand has made a huge contribution to the global management and control of the HIV/AIDS pandemic.

Assessing the effects of HIV/AIDS and TB disease control programmes on health systems in low- and middle-income countries of Southeast Asia: a semi-systematic review of the literature

OBJECTIVE

To systematically review the literature on if and how HIV/AIDS and TB programmes have impacted on general healthcare systems in Association of Southeast Asian Nations (ASEAN) countries.

METHODS

Medline, Embase, Global Health and CINHAL were searched for English language literature published between 1st January 2003 and 31st March 2011. Papers included had to focus on: HIV and/or TB control programmes; the low- and-middle-income ASEAN countries; and factors related to any health systems functions. The effects were examined along six system functions: Stewardship and Governance; Financing; Planning; Service Delivery; Monitoring and Evaluation; and Demand Generation. A comprehensive thematic analytical tool aligned with the above six health systems functions was developed to support data extraction and analysis.

FINDINGS

88 papers met the inclusion criteria. Most programme effects highlighted were related with health service delivery. The other five health system functions were seldom scrutinized, and each covered by less than a quarter of papers. Overall 69% of effects highlighted were positive effects whereas 31% were negative.

CONCLUSION

There was a paucity of robust evidence. Effects on health systems were rarely a focus of research protocols but more often a minor component in the Results/Discussion sections. Particular attention should be paid by Global Health Initiatives to the negative effects that emerged from this study, such as the development of parallel systems, specific incentives not available to the general health systems, and lack of integration of services with private healthcare providers.

Thailand's HIV/AIDS program after weaning-off the global fund's support

Background Although the number of smokers has declined in the last decade, smoking is still a major health problem among youngsters and adolescents. For this reason, there is a need for effective smoking prevention programmes targeting primary school children. A web-based computer-tailored feedback programme may be an effective intervention to stimulate youngsters not to start smoking, and increase their knowledge about the adverse effects of smoking and their attitudes and self-efficacy regarding non-smoking. Methods & Design This paper describes the development and evaluation protocol of a web-based out-of-school smoking prevention programme for primary school children (age 10-13 years) entitled 'Fun without Smokes'. It is a transformation of a postal mailed intervention to a web-based intervention. Besides this transformation the effects of prompts will be examined. This web-based intervention will be evaluated in a 2-year cluster randomised controlled trial (c-RCT) with three study arms. An intervention and intervention + prompt condition will be evaluated for effects on smoking behaviour, compared with a no information control condition. Information about pupils' smoking status and other factors related to smoking will be obtained using a web-based questionnaire. After completing the questionnaire pupils in both intervention conditions will receive three computer-tailored feedback letters in their personal e-mail box. Attitudes, social influences and self-efficacy expectations will be the content of these personalised feedback letters. Pupils in the intervention + prompt condition will - in addition to the personalised feedback letters - receive e-mail and SMS messages prompting them to revisit the 'Fun without Smokes' website. The main outcome measures will be ever smoking and the utilisation of the 'Fun without Smokes' website. Measurements will be carried out at baseline, 12 months and 24 months of follow-up. Discussion The present study protocol describes the purpose, intervention design and study protocol of 'Fun without Smokes'. Expectations are that pupils receiving tailored advice will be less likely to smoke after 24 months in contrast to pupils in the control condition. Furthermore, tailored feedback letters and prompting is expected to be more effective than providing tailored feedback letters only. Trial Registration Dutch Trial Register NTR3116

Sex tourist risk behaviour--an on-site survey among Swedish men buying sex in Thailand

BACKGROUND

Thailand is not only a popular destination for Swedish tourists, it is also the foreign country where the largest numbers of Swedish males contract HIV. This study investigated sexual risk-behaviour of Swedish men who have sex with commercial sex workers (CSW) in Thailand.

METHOD

Eligible men were approached on location in red-light districts of Pattaya and Bangkok with a self-administered multiple-choice questionnaire in December 2010. The data collected was analysed using SPSS version 18 generating cross-tabs, independent sample t-test, univariate and multivariate logistic regression.

RESULTS

In total, 158 questionnaires were included in the analyses. The results indicated that 63% of the study sample had lifetime experience of sexual intercourse with CSWs, while 48% of the respondents indicated that they were likely to pay for sex during their present trip. 71% of the lifetime sex-buyers reported consistent use of condoms in the past. Out of the men that were planning to have sex with a CSW in the near future, 80% reported that they would use condoms consistently. While most of these men always use, and plan on always using a condom when having sex with a CSW, some do so inconsistently or not at all. The study found that those reporting inconsistent condom use when engaging in sexual intercourse with Thai CSWs assessed the risk of becoming infected with HIV to be significantly lower than those who used condoms consistently (p < 0.005).

CONCLUSIONS

Inconsistent condom use by Swedish male tourists to Thailand when having sex with CSWs puts them at risk of contracting HIV and other STIs, and seems to be associated with a lower assessment of the risk of becoming infected with HIV.

Social and cultural contexts of HIV risk behaviors among Thai female sex workers in Bangkok, Thailand

Recently, the number of indirect female sex workers (FSWs) who work at bars/clubs and massage parlors is substantially increasing in Thailand; however, there are huge gaps in knowledge about HIV risk behaviors among indirect FSWs. This study aimed to describe and understand HIV risk behaviors among Thai FSWs in Bangkok in relation to sociocultural factors and work environment (e.g., bars/clubs, massage parlors, brothels, and street). Based on venue-based purposive sampling methods, Thai FSWs were recruited for qualitative interviews (n=50) and survey interviews (n=205). Based on mixed methods, the study revealed that HIV risk and substance use behaviors among FSWs significantly differed depending on work venues, although there were no significant differences between work venues on some key risk behaviors (e.g., inconsistent condom use with primary partners and customers; willingness to engage in unsafe sex with customers). A multiple linear regression analysis revealed that FSWs who had used illicit drugs, were young, had low levels of self-esteem, or reported STIs had frequently engaged in unprotected vaginal sex with customers. Also, FSWs who worked at bars/clubs, were young, had higher income, or reported STIs had frequently engaged in sex with customers under the influence of alcohol. Qualitative interviews illustrated FSWs' alcohol and drug use due to their stressful life (e.g., long working hours and a large number of customers) and easy access to alcohol and drugs. FSWs had shown inaccurate knowledge about HIV prevention methods and engaged in risky behaviors, such as washing vagina with water or toothpaste after having had sex with customers. The HIV prevention strategies in Thailand need to be re-structured through implementing evidence-based HIV prevention intervention programs for FSWs, which must address sociocultural factors (e.g., self-esteem) and alcohol and drug use specific to work venues.

Interventions for families affected by HIV

Family-based interventions are efficacious for human immunodeficiency virus (HIV) detection, prevention, and care, but they are not broadly diffused. Understanding intervention adaptation and translation processes can support evidence-based intervention (EBI) diffusion processes. This paper provides a narrative review of a series of EBI for families affected by HIV (FAH) that were adapted across five randomized controlled trials in the US, Thailand, and South Africa over 15 years. The FAH interventions targeted parents living with HIV and their children or caregiver supports. Parents with HIV were primarily mothers infected through sexual transmission. The EBIs for FAH are reviewed with attention to commonalities and variations in risk environments and intervention features. Frameworks for common and robust intervention functions, principles, practice elements, and delivery processes are utilized to highlight commonalities and adaptations for each location, time period, and intervention delivery settings. Health care, housing, food, and financial security vary dramatically in each risk environment. Yet, all FAH face common health, mental health, transmission, and relationship challenges. The EBIs efficaciously addressed these common challenges and were adapted across contexts with fidelity to robust intervention principles, processes, factors, and practices. Intervention adaptation teams have a series of structural decision points: mainstreaming HIV with other local health priorities or not; selecting an optimal delivery site (clinics, homes, community centers); and how to translate intervention protocols to local contexts and cultures. Replication of interventions with fidelity must occur at the level of standardized functions and robust principles, processes, and practices, not manualized protocols. Adopting a continuous quality improvement paradigm will enhance rapid and global diffusion of EBI for FAH.

Benefits of family and social relationships for Thai parents living with HIV

Family and social relationships are important structural supports in Thailand that are likely to influence the health and mental health of persons living with HIV (PLH). Structural equation modeling examined these relationships among 409 PLH in two communities in Thailand. Latent variables were constructed for most outcomes and mediators, with adherence to antiretroviral (ARV) therapy, depression, and disclosure represented by single-item indicators. All models controlled for gender, age, and education. Disclosure was significantly and positively associated with ARV adherence, and to both family functioning and social support. Family functioning and social support were significantly related to the PLH's self-perceptions of health and mental health, as well as being significantly correlated with each other. Better family functioning was significantly associated with better quality of life, better perceived health, fewer symptoms of depression, and greater ARV adherence. Social support was significantly associated with better quality of life and fewer depressive symptoms. These results highlight the important role that an organized and structured family life and social support network can play in encouraging better health outcomes among PLH.

Incarceration experiences among a community-recruited sample of injection drug users in Bangkok, Thailand

Background

Since 2003 Thailand has waged an aggressive "war on drugs" campaign focused on arresting and incarcerating suspected drug users and dealers. However, little is known about incarceration experiences among IDU in the wake of the recent war on drugs. Therefore, we sought to examine incarceration experiences among IDU in Bangkok, Thailand.

Methods

We examined the prevalence of incarceration among community-recruited IDU participating in the Mitsampan Community Research Project. Multivariate logistic regression was used to identify factors associated with a self-reported history of incarceration. We also examined the prevalence of injection drug use and syringe sharing within prisons.

Results

252 IDU were recruited in August 2008; 66 (26.2%) were female and the median age was 36.5 years. In total, 197 (78.2%) participants reported a history of incarceration. In multivariate analyses, reporting a history of incarceration was associated with a history of compulsory drug treatment (adjusted odds ratio [AOR] = 4.93; 95% confidence interval [CI]: 1.95 - 12.48), non-fatal overdose (AOR = 3.69; 95%CI: 1.45 - 9.39), syringe sharing (AOR = 2.20; 95%CI: 1.12 - 4.32), and female gender (AOR = 0.41; 95%CI: 0.20 - 0.82). Among those who reported a history of incarceration, 59 (29.9%) reported injection drug use in prison, and 48 (81.4%) of these individuals reported sharing syringes in prison. Incarceration was not associated with the number of injections performed in the previous week (p = 0.202).

Conclusion

Over three-quarters of the IDU participating in this study reported a history of incarceration, and 30% of these individuals reported injection drug use within prison. Further, an alarmingly high level of syringe sharing within prison was reported, and incarceration was not associated with reductions in drug use. These findings provide further evidence of the need for community diversion strategies, as well as harm reduction programs, in Thai prisons.

Twenty-five years of HIV: lessons for low prevalence scenarios

During the initial quarter century since the discovery of HIV, international response has focused on high prevalence scenarios and concentrated epidemics. Until recently, the theoretical underpinnings of HIV prevention were largely based on these responses-the assumption that inadequate responses to concentrated epidemics within low prevalence populations could rapidly lead to generalized epidemics. The limits of these assumptions for HIV prevention in low prevalence scenarios have become evident. While examples of rapid HIV diffusion in once low prevalence scenarios exist, emergence of generalized epidemics are less likely for much of the world. This paper reviews several key issues and advances in biomedical and behavioural HIV prevention to date and highlights relevance to low prevalence scenarios.

AIDS and the stigma of sexual promiscuity: Thai nurses' risk perceptions of occupational exposure to HIV

This paper examines the culturally shaped meanings of AIDS and perceptions of accidental occupational exposure to HIV among a group of twenty nurses in Bangkok, Thailand. The findings are based on data collected as a part of a larger mixed-methods study that examined how perceptions of risk behaviours (including sexual promiscuity) shape health workers' perceptions of patients living with HIV/AIDS. Nurses' narratives revealed that despite acknowledgement of the low probability of occupational exposure to HIV, the fear of HIV infection remained and was largely driven by the enormity of the anticipated social (rather than the health) consequences of being HIV-positive. The perceived certainty of social ostracism was reinforced by participants' observations of the social rejection experienced by people living with HIV/AIDS both within and outside clinical settings. For female nurses, the dominant social perception that women living with HIV/AIDS were violators of gender norms, and thus 'guilty' victims, was an issue central to their self-identities. Ways of improving care for people living with HIV in the light of the nurses' concerns and future research are discussed.

The 100% Condom Use Program: a demonstration in Wuhan, China

The 100% Condom Use Program (100% CUP) was evaluated in Wuhan, China. The program sought to increase knowledge of STI/HIV transmission, increase condom use rates, and reduce the prevalence of sexually transmitted infections (STIs) among sex workers (commercial sex workers (CSWs)), via condom availability and use policies in entertainment establishments and STI services including education and counseling. Entertainment establishment owners and CSWs participated in educational sessions and multiple community sectors were involved in the program. At baseline, 170 female CSWs were assessed, and 102 CSWs were assessed at the final 21-month follow-up. At 6-month follow-up, 95% of entertainment establishments were in compliance with 100% CUP policies. At 15 months, condoms were readily available in retail outlets, and condom use rates rose by 94.5%. Refractive rates of chlamydia and methodological limitations of the evaluation leave unanswered questions about the effectiveness of the program. Nonetheless, outcomes suggest that the 100% CUP may be a promising approach to HIV prevention in China.

Co-infection with human immunodeficiency virus and tuberculosis in Asia

Asia has the highest numbers of tuberculosis cases (60% of the global total) and has experienced a marked rise in HIV seroprevalence (22% of the global total) in key subpopulations of these highly populous nations. Thus, co-infected patients are a challenge for practitioners and public health workers alike. The U.S.-Japan Cooperative Medical Science Program is spearheading interdisciplinary collaborations in Asia to address the many outstanding research priorities for HIV-tuberculosis co-infection. There is an urgency to this agenda for many reasons, including the frequency with which tuberculosis accounts for the death of HIV-infected persons in Asia, and the continued rise of multiple drug-resistant Mycobacterium tuberculosis. We review briefly the public health situation in Asia, highlighting research questions from US-Japan-Asian partner joint meetings, and cite salient studies to indicate trends and challenges.

Ethical issues in the NIMH Collaborative HIV/STD Prevention Trial

OBJECTIVE

To develop decision rules regarding key ethical dimensions in scientific protocols for the National Institute for Mental Health (NIMH) Collaborative HIV/STD Prevention Trial taking place in five countries (China, India, Peru, Russia, and Zimbabwe).

DESIGN

Countries had HIV rates from 27 to 0.1%, the standard of care varied from access to antiretroviral drugs to no availability, and the reporting of sexually transmitted diseases (STD) to government agencies was mandatory in some countries and not in others. These variations presented challenges when developing decision rules that could be uniformly adopted across countries and simultaneously follow the ethical principles of beneficence, respect, and justice.

METHODS

We used several strategies to identify and resolve ethical dilemmas for this international HIV prevention trial. First, we identified key principles, especially those derived for clinical therapeutic, biomedical preventive, or device trials. We convened a 'workgroup on protecting human participants' and charged them with identifying and implementing optimal procedures for ensuring the ethical and equitable treatment of participants and making recommendations to minimize physical, psychological, and social harm to the participants. Each site had a community advisory board, essential in identifying local ethical issues and possible resolutions to them. The NIMH established a data safety and monitoring board with ultimate responsibility for adjudicating ethical dilemmas and decisions. The protocols were deliberated thoroughly by the Trial steering committee, and approved by nine United States and five in-country institutional review boards.

RESULTS

We summarize the decision rules adopted to resolve the ethical dilemmas identified. Especially important were the translation of clinical trials principles for a behavioral intervention trial, strategies for ensuring confidentiality and informed consent, dilemmas relating to partner notification of sexually transmitted infections including HIV, minimizing the risks of social harm, establishing community partnerships, ensuring equity among United States and in-country principal investigators, and building capacity for additional research.

CONCLUSION

We document our processes and decisions, and their underlying rationales, and hope they contribute to the development of further thinking and practice regarding the ethics of social and behavioral HIV and STD prevention trials in resource-poor settings.

Going beyond "ABC" to include "GEM": critical reflections on progress in the HIV/AIDS epidemic

A considerable number of studies have sought to identify what factors accounted for substantial reductions in HIV seroprevalence after several countries deployed "ABC" (abstinence, be faithful, condom use) strategies. After much public discourse and research on ABC success stories, the Joint United Nations Programme on HIV/AIDS 2004 epidemic report indicated that nearly 50% of infected people worldwide were women, up from 35% in 1985. In light of the feminization of HIV/AIDS, we critically assess the limitations of ABC strategies. We provide 3 additional prevention strategies that focus on gender relations, economics, and migration (GEM) and can speak to the new face of the epidemic. Pressing beyond ABC, GEM strategies provide the basis for a stronger central platform from which national efforts against HIV/AIDS can proceed to reduce transmission risks.

Expansion of HIV/AIDS in China: lessons from Yunnan Province

In this article we systematically and critically review the Chinese and English language literature on human immunodeficiency virus (HIV)-related studies in Yunnan Province, Southwestern China. Yunnan Province had the first Chinese HIV outbreak and is still the worst affected area in the nation. Since 1989, HIV infection has extended from injecting drug users into the general population through sexual transmission. Since the economic reform of the 1980s, changed social norms and increased migration have spawned increases in HIV-related risk behaviors such as drug use and commercial sex work. A smaller size of "bridge" populations and lower sexual contact rates between persons in "bridge" and general populations may explain the slower expansion of the HIV epidemic in Yunnan compared to nearby Southeast Asian nations. In 2004, women in antenatal care had a 0.38% HIV prevalence province wide, although >1% infection rates are seen in those counties with high injection drug rates. Patterns of drug trafficking have spread the unusual recombinant HIV subtypes first seen in Yunnan to far-flung regions of China. Increased efforts of Yunnan's HIV control program are correlated with an improved general HIV awareness, but risk behaviors continue at worrisome rates. Future efforts should focus on changing risk behaviors, including harm reduction and condom promotion, especially among the "bridge" groups. The resurgence of commercial sex work in Yunnan, and the high frequency of workers migrating into provinces far from home and family are all sociocultural factors of considerable importance for future HIV and sexually transmitted disease control in China.

Risk factors associated with injection initiation among drug users in Northern Thailand

Background

Circumstances surrounding injection initiation have not been well addressed in many developing country contexts. This study aimed to identify demographic factors, sexual behaviors and drug use characteristics related to injection initiation among drug users in northern Thailand.

Methods

A cross-sectional survey was conducted among 2,231 drug users admitted to the Northern Drug Treatment Center in Mae Rim, Chiang Mai, Thailand, between February 1, 1999 and December 31, 2000. A multiple logistic regression was employed to identify the independent effects from potential risk factors of transition into injection.

Results

After controlling for other covariates, being 20 years of age or older, single, ever receiving education, urban residence, and having a history of smoking or incarceration were significantly associated with higher likelihood of injection initiation. Multiple sex partners and an experience of sex abuse were associated with an increased risk of injection initiation. Comparing to those whose first drug was opium, individuals using heroin as their initiation drug had greater risk of injection initiation; conversely, those taking amphetamine as their first drug had less risk of injection initiation. Age of drug initiation was negatively associated with the risk of injection initiation: the older the age of drug initiation, the less the risk of injection initiation.

Conclusion

Injection initiation was related to several demographic factors, sexual behaviors and drug use characteristics. Understanding these factors will benefit the design of approaches to successfully prevent or delay transition into injection.

Drug Users: A Potentially Important Bridge Population in the Transmission of Sexually Transmitted Diseases, Including AIDS, in China

OBJECTIVE

The objective of this study was to examine risk characteristics among bridge and nonbridge drug users.

STUDY DESIGN

A cross-sectional study was conducted among drug users. Drug users who shared needles and engaged in sex with both high-risk partners and low-risk partners were defined as bridgers.

RESULTS

A total of 312 drug users were recruited, among whom 49.4% (154) were bridgers. Among bridgers, 83.1% injected drugs and 35% shared needles in the past month. Eighty-seven percent (134) of bridgers had one or more commercial sex partners in the past year. Only 3.9% of the bridgers and 4.6% of nonbridgers consistently used condoms with regular sex partners. Fifty-eight percent of bridgers and 46.8% of nonbridgers tested positive for hepatitis C virus, whereas 15.6% of bridgers and 7% of nonbridgers tested positive for syphilis.

CONCLUSIONS

The pervasiveness of bridgers among drug users and their risky sexual behavior underscore their role in the spread of sexually transmitted diseases.

Structural interventions: concepts, challenges and opportunities for research

Structural interventions refer to public health interventions that promote health by altering the structural context within which health is produced and reproduced. They draw on concepts from multiple disciplines, including public health, psychiatry, and psychology, in which attention to interventions is common, and sociology and political economy, where structure is a familiar, if contested, concept. This has meant that even as discussions of structural interventions bring together researchers from various fields, they can get stalled in debates over definitions. In this paper, we seek to move these discussions forward by highlighting a number of critical issues raised by structural interventions, and the subsequent implications of these for research.

HIV infection among female drug users in Northern Thailand

Reports on HIV infection and risk behaviors among female drug users in developing countries, particularly in Asia, are limited. In this study, we investigated HIV prevalence and risk factors for HIV infection among 200 women admitted for 21-day inpatient drug detoxification in Chiang Mai, Thailand. Volunteers completed a face-to-face interview using a structured interview, HIV pre-test counseling, specimen collection for HIV and STD tests, and were provided test results and HIV post-test counseling 1 week later. Two-third of participants (68%) were ethnic minorities with no formal education. Overall, 14 (7%) were HIV positive: 25% among 28 heroin injectors and 4.1% among 172 opium or methamphetamine smokers (p<0.001). History of drug injection and sexual abuse were associated with HIV infection. HIV prevention strategies for drug-using women in Thailand should consider both harm reduction strategies for drug use and promoting safer sex measures in a culturally appropriate context.