Methamphetamine Use Prior to Sex and the Risk Factors Associated with HIV Prevalence Among Men Who Have Sex With Men (MSM) in Thailand, 2006-2010 Good morning chair, co-chair, ladies and gentlemen I am Major Phunlerd Piyaraj, from Parasitology Department of Phramongkutklao College of Medicine My presentation today is entitled “Methamphetamine Use Prior to Sex and the Risk Factors Associated with HIV Prevalence Among Men Who Have Sex with Men (MSM) in Thailand” Phunlerd Piyaraj1,2, Frits van Griensven2, Chris Beyrer3, Supaporn Chaikummao2, Kenrad E. Nelson3 Parasitology Department of Phramongkutklao College of Medicine, Bangkok, Thailand1 , Thailand Ministry of Public Health - U.S. CDC Collaboration (TUC), Nontaburi, Thailand 2,Johns Hopkins Bloomblerg School of Public Health, MD, USA3

Disproportionate burden of HIV infection between MSM and general population Let’s me talk briefly about the background and rationale of this study. There was the evidence of disproportionate high HIV prevalence and incidence in populations of MSM in Thailand and Globally. For instance, this figure shows data from The Lancet and the UNAIDs, Which reported on the global HIV prevalence in MSM population (as shown in the orange bars) compared with each regional adult (as shown in the shorter red bars) in 2012 Source: Chris Beyrer, Global epidemiology of HIV infection in men who have sex with men, The Lancet, 2012 and Global report: UNAIDS report on the global AIDS epidemic 2012

Upward Trends of Substance Use among MSM in Bangkok, Thailand Prevalence (%) IN Thailand, and several other Asian countries, drug use during sex by MSM has not been specially addressed in HIV prevention efforts, Even though its increased prevalence has been established as in this slide shows the upward trends among MSM in Bangkok in 2003 to 2007 ATS: Amphethamine Type Substance, Source: van Griensven F et al. 2009

Methamphetamine use and HIV Risk Behaviors *Sex partners *Have sex with IDU *History of STD *Exchange sex for money *Consistent condom use A growing body of research supports the relationship between methamphetamine use by MSM and increase in behaviors that can put the user at risk for HIV infection. The example of these risky behaviors are include: having had multiple sex partners, having sexual encounter with injection drug users, had history of sexually transmitted diseases, ever had exchange sex for money and also practice less use of condom

Methamphetamine prior to sex Inhibition Sexual desire HIV infection Multiple sex partners Interfere ability and desire to practice safe sex Prolong intercourse The slide shows the link between Methamphetamine use and HIV-related risk behaviors and HIV infection Since Methamphetamine use prior to sex may decrease inhibition and increase sexual desire then may interfere The ability and desire to practice safe sex, prolong sexual intercourse, increasing libido and also greater number of sex partners

Rationale Does the Methamphetamine Use Prior to Sex Common in Thailand? Does the Methamphetamine Use to Enhance Sex Facilitate Greater HIV Risk Taking among MSM in Thailand? Previous studies suggest that increased of this emerging high-risk behavior may play an important role in the explosive epidemic of HIV infection among these men However, its dependent contribution to directly increasing risk of HIV infection is unclear It is important to determine whether using methamphetamine to enhance sex is common in Thai-MSM and Dose the methamphetamine use to enhance sex facilitates greater HIV risk taking among MSM in Thailand? However, no study in Thailand has been conducted to investigate the contribution of being under the influence of drugs during sex on, in particular methamphetamine, as emerging risk factors for HIV prevalence

Thai MSM: Meth use prior to sex and HIV infection Aim 1: To examine the prevalence of self-reported using methamphetamine prior to sex among Thai MSM Study Design Objectives Aim 2: To investigate the risk factors associated with HIV prevalence including methamphetamine prior to sex Thai MSM: Meth use prior to sex and HIV infection Cross-Sectional Study Study Design 1,744 MSM Men, aged 18 years or older Thai nationality, resident of Bangkok Anal sex in the preceding 6 months However, no study in Thailand has been conducted to investigate the contribution of being under the influence of drugs during sex on, in particular methamphetamine, as emerging risk factors for HIV prevalence To fulfilled this gaps of knowledge, a cross-sectional study was conducted among MSM in Bangkok The objectives of this study were including: To examine the prevalence of self-reported using methamphetamine to enhance sex among Thai MSM To investigate the risk factors associated with HIV prevalence including methamphetamine prior to sex The eligibility criteria for participating in the study were including men who resided in the Bangkok metropolitan area or peripheral provinces Thai nationals, reported penetrative oral or anal sex with another man in the preceding six months and were at least 18 years of age All participants were enrolled at a dedicated male sexual health clinic in central Bangkok in 2006 to 2010 (Silom Community Clinic, BCH, Silom Road, Bangkok, supported by TUC). Study Population Location and Time Bangkok, 2006 - 2010

Materials and Methods Demographic and behavioral data were collected by audio-computer-assisted self-interview Men were tested for STI/HIV infection Logistic regression analysis was used to investigate the risk factors associated with HIV prevalence Demographic and behavioral data were collected using audio computer assisted self-interview (ACASI). The questionnaires obtained demographic characteristics, sexual and drug use behavior, previous HIV testing as well as data regarding HIV knowledge, attitudes about risk relevant behaviors and prevention practices. Pre-test and post-test counseling for HIV and other sexually transmission infections (STI) were provided by well-trained study nurses. The study nurses also explained the study objectives and procedures as well as obtained written informed consent from all participants. The subjects were informed that their identification would be confidential. Adjusted Odds ratios (OR) and 95% confidence intervals (CI) for risk factors of HIV seroprevalence among these men were estimated by multivariate logistic regression.

Human Subjects The ethical review committee for research in human subjects of the Thailand Ministry of Public Health (FWA#1953) An institutional review board of the US Centers for Disease Control and Prevention (FWA#1413) The protocol of this study was reviewed and approved by the ethical committee from The Thai-MOPH and the US-Centers for disease control and prevention.

Results April, 2006 to November, 2010 1,744 1,764 Eligible 1,977 Enrolled 1,764 Eligible 1,977 Screened Let’s move on the results this study: During April 2006 to November 2010, total of 1,977 men were screened, of those only 1,764 men were eligible for this study and the final of 1,744 men were enrolled into the study. The study found that the proportion of self-reported Methamphetamine use to enhance sex was 11.3% (195/1,744). And we also found that the overall HIV prevalence at baseline was 21.3% (374/1,744). Methamphetamine use = 11.3% (195/1,744) The overall HIV prevalence = 21.3% (372/1,744)

Demographics of study population   HIV Positive (n=372) Total (N=1,744) P Prevalence (%) Age category (years) 0.14 18 - 22 79 (21.2) 452 (25.9) 17.5 23 - 27 145 (39.0) 629 (36.1) 23.1 28 - 32 78 (21.0) 350 (20.1) 22.3 >32 70 (18.8) 313 (17.9) 22.4 Employment status <0.01* Unemployed 26 (7.0) 78 (4.5) 33.3 Employed 239 (64.2) 1036 (59.4) Student 37 (9.9) 321 (18.4) 11.5 Employed and Student 309 (17.7) 22.7 Education Level Primary or less 56 (15.1) 186 (10.7) 30.1 Secondary 113 (30.4) 496 (28.4) 22.8 Vocational 302 (17.3) 26.2 University or higher 124 (33.3) 760 (43.6) 16.3 Male circumcision (clinical examination) 0.79 No 335 (90.1) 1564 (89.7) 21.4 Yes 180 (10.3) 20.6

Prevalent of substance use among MSM in Bangkok, Thailand, 2006-2010 The most common substance use among these were including: Poppers or nitrate inhalation was reported by 23% of these men. follow by using the sedative about 20%, Viagra, methamphetamine and marijuana use about 14% about 9% reported using ecstacy and 6% using other drugs

Self-Reported Methamphetamine Use Prior to Sex was Not Multivariate Analyses Of Factors Associated With HIV Prevalence Among MSM In Bangkok AOR (95% CI) P Nitrate inhalation No 1 Yes 1.68 (1.08-2.60) 0.02* Methamphetamine use prior to sex 1.00 1.16 (0.72-1.86) 0.54 Hepatitis B surface antigen (HBsAg)  Negative Positive 1.84 (1.16-2.94) 0.01* Anal warts (by clinical examination) 4.65 (2.77-7.81) <0.01* Anti-HSV positivity anti-HSV-1 1.25 (0.89-1.76) 0.19 anti-HSV-2 2.64 (1.67-4.18) anti-HSV-1 and 2 4.23 (2.69-6.65) Self-Reported Methamphetamine Use Prior to Sex was Not Associated With HIV Prevalence This slide shows the multivariate logistic regression analysis for risk factors associated with HIV prevalence among MSM in Thailand After adjusting for the potential confounders, several independent risk factors for prevalent HIV infection were: Use of nitrate inhalation Baseline seropositivity for hepatitis B surface antigen, HSV-1 infection and co-infection with HSV-1 and 2 clinically appearance of anal warts However, using methamphetamine were not statistically significantly associated with HIV infection prevalence at baseline. Note: AOR; Adjusted Odds Ratio, 95% CI; 95% Confidence interval, P; P-value, *;p<0.05

Multivariate Analyses Of Factors Associated With HIV Prevalence Among MSM In Bangkok AOR (95% CI) P Age at first sex (years)γ 0.94 (0.91-0.98) <0.01* Usual anal sex role Insertive only 1 Receptive only 1.73 (0.99-3.01) 0.05* Dual role taking 1.77 (1.14-2.75) 0.01* Forced to have sex against will Never Ever 1.63 (1.16-2.29) Treponema Pallidum (TP) Non-reactive Reactive 1.91 (1.10-3.32) 0.02* Park sex seeking No Yes 1.67 (1.10-2.53) Moreover, the independent risk factors associated with HIV prevalence among these men were also including: age at first sex practiced dual role taking of anal intercourse ever had forced sex baseline seropositive for syphilis recruited sex partners from park Note: AOR; Adjusted Odds Ratio, 95% CI; 95% Confidence interval, P; P-value, *;p<0.05

Discussion Exposures Outcome Meth use HIV Prevalence Directly investigate the impact of Methamphetamine use prior to sex on HIV prevalence among MSM after adjusting for sexual behaviors Exposures Outcome Meth use HIV Prevalence UAI Utilizing information provided from the prevalence of HIV study among MSM in Thailand, we were able to directly investigate the impact of Methamphetamine use prior to sex on HIV prevalence among MSM after adjusting for sexual behaviors Findings form these data and those from other projects in the literature were consistent in describing association between methamphetamine use, HIV-related sexual risk behaviors among MSM Drug use STIs Multiple sex partners

Conclusion Behavior of methamphetamine use to enhance sex was common and high prevalence of HIV infection among these men It is underscores the need for innovative and increased efforts to prevent HIV infection in this population For the conclusion: Behavior of methamphetamine use to enhance sex have been recently increasingly popular among Thai-MSM and prevalence of HIV infection are high and increasing among MSM in Bangkok too. We believed that using prospective cohort study possible risk factor was important follow-up to evaluate the impact of these behaviors with the incident of HIV infection among these men was warranted. The overlapping nature of the epidemic of methamphetamine abuse and HIV infection among MSM underscored the need for development of a considered and comprehensive plan for response.

Public Health Significance There is a need for a broad approach in addressing methamphetamine use and risk for infection with HIV and other STDs HIV and STD prevention and treatment programs could be enhanced to include assessment for methamphetamine use With referrals to methamphetamine treatment, primary testing and sexual health promotion For the public health significance There is a need for a broad approach in addressing methamphetamine use and risk for HIV infection and other sexually transmitted diseases. HIV and STDs prevention and treatment programs could be enhanced to include assessment for methamphetamine use With referrals to methamphetamine treatment, primary testing and sexual health promotion In addition, prevention programs may be an important and cost-efficient method for providing health education and risk reduction interventions (such as advocating for MSM to avoid or reduce methamphetamine use)

Acknowledgements Funding supports The Thai Ministry of Science and Technology The Hopkins Fogarty AIDS International Training and Research Program (AITRP) (Grant Number:D43TW000010-25) Phramongkutklao College of Medicine Johns Hopkins Bloomberg School of Public Health Thailand Ministry of Public Health - U.S. CDC Collaboration (TUC) Silom Community Clinic and Staffs Rainbow Sky Community Based Organization All Participants in Bangkok MSM Cohort Study Finally, I would like to acknowledgements The funding supports from The Thai Ministry of Science and Technology The Hopkins Fogarty AIDS International Training and Research Program (AITRP) (Grant Number: D43TW000010-25) Phramongkutklao College of Medicine The collaborating institutes which including Johns Hopkins Bloomberg School of Public Health Thailand Ministry of Public Health - U.S. CDC Collaboration (TUC) Silom Community Clinic and Staffs Rainbow Sky Community Based Organization And the most importantly I would like to thank all Participants in Bangkok MSM Cohort Study Thank you for your attention. Questions and suggestions are welcome.