1. Methamphetamine Use Prior to Sex and the Risk Factors Associated with HIV Prevalence Among Men Who Have Sex With Men (MSM) in Thailand,
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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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,

8. 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.

9. 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.

10. 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)

11. Demographics of study population
HIV Positive (n=372)
Total (N=1,744) P
Prevalence (%)
Age category (years)
0.14
79 (21.2)
452 (25.9)
17.5
145 (39.0)
629 (36.1)
23.1
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

12. 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

13. 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 ( )
0.02*
Methamphetamine use prior to sex
1.00
1.16 ( )
0.54
Hepatitis B surface antigen (HBsAg) 
Negative
Positive
1.84 ( )
0.01*
Anal warts (by clinical examination)
4.65 ( )
<0.01*
Anti-HSV positivity
anti-HSV-1
1.25 ( )
0.19
anti-HSV-2
2.64 ( )
anti-HSV-1 and 2
4.23 ( )
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

14. Multivariate Analyses Of Factors Associated With HIV Prevalence Among MSM In Bangkok
AOR (95% CI) P
Age at first sex (years)γ
0.94 ( )
<0.01*
Usual anal sex role
Insertive only 1
Receptive only
1.73 ( )
0.05*
Dual role taking
1.77 ( )
0.01*
Forced to have sex against will
Never
Ever
1.63 ( )
Treponema Pallidum (TP)
Non-reactive
Reactive
1.91 ( )
0.02*
Park sex seeking No
Yes
1.67 ( )
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

15. 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

16. 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.

17. 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)

18. Acknowledgements Funding supports
The Thai Ministry of Science and Technology
The Hopkins Fogarty AIDS International Training and Research Program (AITRP) (Grant Number:D43TW )
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: D43TW )
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.