Washington D.C., USA, July 2012www.aids2012.org Acceptability of Pre-Exposure Prophylaxis among MSM and TG in Northern Thailand Daniel Yang, MD Candidate* Fogarty International Clinical Research Scholar Research Institute for Health Sciences Institute (CMU) Johns Hopkins Bloomberg School of Public Health International AIDS Conference Washington D.C July 24, 2012 *On behalf of C. Chariyalertsak, A. Wongthanee, S. Kawichai, K. Yotruean, T.E. Guadamuz, V. Suwanvanichkij, C. Beyrer, S. Chariyalertsak

Washington D.C., USA, July 2012www.aids2012.org Chiang Mai, Thailand

Washington D.C., USA, July 2012www.aids2012.org Background –HIV incidence and prevalence high among MSM and TG in Chiang Mai, Thailand –Oral PrEP is an HIV prevention approach that involves the regular use of antiretrovirals (ARVs) by people who are HIV-negative. –iPrEx trial: demonstrated 44% overall efficacy of daily oral tenofovir/emtricitabine for preventing HIV in MSM/TG participants

Washington D.C., USA, July 2012www.aids2012.org Purpose –Investigate the prevalence of PrEP awareness post-iPrEX –Determine PrEP acceptability and demographic/behavioral correlates for acceptability Separate analysis for MSM and TG

Washington D.C., USA, July 2012www.aids2012.org Methods –Jan. to Feb. 2012, 238 participants completed a self- administered survey on handheld computers –Collaboration with Chiang Mai Province Public Health Office –Eligibility Criteria: Male sex at birth Age ≥ 18 years old Self-reported HIV un-infected or of unknown status Anal or oral sex with a man in the last 6 months

Washington D.C., USA, July 2012www.aids2012.org Methods Recruitment: Venue-day-time sampling (VDTS) –Entertainment venues - bars, discos, saunas, and massage parlors –Educational venues - universities and vocational schools. *Photos taken in Chiang Mai during iPrEX recruitment.

Washington D.C., USA, July 2012www.aids2012.org Primary Outcome For this survey, we define PrEP as the daily use of antiretroviral tablets ‘before’ sex by HIV-negative individuals to reduce their risk of infection with HIV. If PrEP was 50% effective in preventing HIV infection, how likely are you to use PrEP as an HIV prevention method? 1 – very unlikely 2 – somewhat unlikely 3 – somewhat likely 4 – very likely = accept PrEP

Washington D.C., USA, July 2012www.aids2012.org Results 326 individuals completed the screening questionnaire at 17 venues 131 MSM and 107 TG were eligible and completed the survey (73% of total screened) Mean age 23.7 (MSM); 21.8 (TG) Prior awareness of PrEP - 66% of both MSM and TG – (NS) PrEP acceptability - 41% (MSM) and 37% (TG) – (NS)

Washington D.C., USA, July 2012www.aids2012.org MSM vs. TG % of MSM% of TGp-value Age < Private Insurance2012<0.001 Receptive Anal Sex2474<0.001 Received Payment for Sex Current Hormone Use 645<0.001 Previous STI Previous HIV testing Infrequent Sex Planned Sex *Bold, p<0.05

Washington D.C., USA, July 2012www.aids2012.org Results Correlates of PrEP Acceptability (MSM) –Lifetime history of STIs – 21% aOR 4.58, p<0.01) –Previous HIV testing – 57% (aOR 2.30, p=0.046) –Regularly planned sex, defined as having made intentional arrangements to have sex – 22% aOR 3.37, p=0.01 –Infrequent sex, once per month or less – 45% aOR 3.00, p<0.01

Washington D.C., USA, July 2012www.aids2012.org Results Correlates of PrEP Acceptability (TG) –Having private insurance – 12% aOR 5.01, P=0.02 –Prior awareness of PrEP – 66% aOR 3.30, P=0.02

Washington D.C., USA, July 2012www.aids2012.org Discussion –Prior awareness of PrEP over 60% - higher than previous surveys which ranged from 16% to 25%. Chiang Mai was a site of the iPrEX trial –PrEP acceptability moderate at around 40% - lower than previous surveys which ranged from 44-74%. Lower efficacy (50%)  Lower acceptability

Washington D.C., USA, July 2012www.aids2012.org Discussion Correlates of PrEP Acceptability (MSM) –Lifetime History of STIs and Previous HIV Testing Greater familiarity with health care professionals (promising for PrEP roll-out) Expanded voluntary HIV counseling and testing (VCT) may improve uptake of PrEP –Infrequent Sex and Planned Sex Intermittent PrEP may well suited for this population

Washington D.C., USA, July 2012www.aids2012.org Discussion Correlates of PrEP Acceptability (TG) –PrEP Awareness Increasing awareness of PrEP with educational campaigns may also improve uptake. Among TG, high prevalence of concern regarding treatment interactions between PrEP and other medicines (e.g. female hormones) –Private insurance Cost is a significant barrier to PrEP acceptability Financial support needed to subsidize or cover the costs of PrEP. Limitations: VDTS selection bias, social desirability bias, intent-to use PrEP may not reflect actual behaviors.

Washington D.C., USA, July 2012www.aids2012.org Conclusion MSM and TG are distinct populations Maximizing future PrEP uptake in Northern Thailand: –Educational campaigns to increase awareness –Expanded HIV VCT services to MSM and TG –Financial subsidies to reduce the cost of PrEP

Washington D.C., USA, July 2012www.aids2012.org Acknowledgements Mentorship –RIHES: Dr. Suwat Chariyalertsak –JHU: Dr. Chris Beyrer Fellowship Support –Fogarty International Clinical Research Scholars Program, Fogarty International Center, FICRS-F Support Center at Vanderbilt University –Daniel Yang was supported by the National Institutes of Health Office of the Director, Fogarty International Center, Office of AIDS Research, National Cancer Center, National Eye Institute, National Heart, Blood, and Lung Institute, National Institute of Dental and Craniofacial Research, National Institute On Drug Abuse, National Institute of Mental Health, National Institute of Allergy and Infectious Diseases, and National Institutes of Health Office of Women’s Health and Research through the Fogarty International Clinical Research Scholars and Fellows Program at Vanderbilt University (R24 TW007988) and the American Relief and Recovery Act.

Washington D.C., USA, July 2012www.aids2012.org Thank you!! *Special Thanks to Dr. Suwat Chariyalertsak, Dr. Voravit Suwanvanichkij, Dr. Surinda Kawichai, Peter Lange, Khun Antika Wongthanee, Khun Pongpun Saokhieo, Dr. Chris Beyrer, Dr. Thomas Guadamuz, Khun Chonlisa Chariyalertsak and the Chiang Mai Province Public Health Office.

Washington D.C., USA, July 2012www.aids2012.org Definition of PrEP Oral pre-exposure prophylaxis is an HIV prevention tool that involves use of medicines to treat HIV called antiretrovirals by people who are HIV-negative. For this survey, we define PrEP as the daily use of antiretroviral tablets ‘before’ sex by HIV- negative individuals to reduce their risk of infection with HIV.

Washington D.C., USA, July 2012www.aids2012.org Primary Outcomes If PrEP was 50% effective in preventing HIV infection, how likely are you to use PrEP as an HIV prevention method? 1 – very unlikely 2 – somewhat unlikely 3 – somewhat likely 4 – very likely Have you heard of PrEP for HIV prevention before this survey? 1 – yes 2 – no