1. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 Successful start of a preparatory HIV cohort study among men who have sex with men (MSM) in Bangkok, Thailand: preliminary baseline, follow-up and HIV incidence data Presented by Wipas Wimonsate Thailand MOPH – U.S. CDC Collaboration, Nonthaburi, Thailand

2. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 HIV-1 prevalence among MSM in Bangkok increased from 17.3% in 2003 to 30.7% in 2007 MSM in Bangkok are an important population for HIV prevention activities and treatment and care services Cohort development among MSM in Bangkok may help to evaluate biomedical interventions (prophylaxis, vaccines) However, we have no information on HIV-1 incidence, STI prevalence, follow-up rates, and risk factors for HIV infection Background % HIV infected

3. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 Study design Longitudinal cohort study 3 years follow up at 4 monthly intervals Oral fluid HIV testing, ACASI questionnaire and risk reduction counseling at every visit STI evaluation at baseline Blood draw at month 0, 12, 24 and 36 for storage and future testing

4. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 Inclusion criteria for eligibility are: –Thai national –Male at birth –Resident of Bangkok or periphery –At least 18 years of age –Have had oral or anal sex with another man in the preceding six months –Availability and commitment for at least 36 months of follow-up –Willing to provide written informed consent Study population

5. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 Expected and actual number of participants, HIV positives and HIV seroconvertors during year 1, year 2, and year 3 of the study Expect Year 1 Actual Year 1 Expect Year 2 Actual Year 2 Expect Year 3 Actual Year 3 Total1,3541,292---- HIV-1 negative1,1141,002---- HIV-1 positive (baseline)240290---- HIV-1 seroconversion 32343020*28…* * the study is currently in year 2

6. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 Study location Silom Community Clinic, 3 rd Floor Bangkok Christian Hospital, Silom, Bangkok, Thailand Bangkok

7. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 Recruitment of study participants Existing VCT clients Onsite recruitment Community Based Organization Website (www.silomclinic.in.th)

8. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 Statistical methods Risk factors for HIV infection at baseline –Logistic regression analysis HIV incidence –Incidence density calculation (# of HIV seroconversions / total number of person years of follow up during interval) –Kaplan-Meier analysis

9. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 Number of study participants and visits April 2006 – July 2008 20062007 Visits 7698 (average 45/day) Participants 1292 2008 Enrollment completed

10. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 Demographic characteristics at baseline April 2006 – January 2008 N=1292 n(%) Age group (years) : mean 26.8, range 18-56 18-21 22-29 30+ 238 702 352 (19) (54) (27) Education level Vocational/University781(60) Employment status Employed981(76) Birthplace Born outside Bangkok831(64)

11. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 HIV, HBV, HAV, HCV, HSV-1, HSV-2, TP, rectal CT and rectal NG prevalence at baseline April 2006 – January 2008 HBV* HAV % infected SyphilisHIVHCVCTNGHSV-1HSV-2 * excluding those positive for Anti-HBs alone and those negative for all markers (HBsAg, Anti-HBc, and Anti-HBs)

12. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 Risk factors for prevalent HIV infection at baseline April 2006 – January 2008 Multivariate OR(95% CI)P Age group (years) 18-21 22-29 30+ 1.00 1.77 2.32 (1.09-2.87) (1.33-4.09) 0.022 0.003 Education level High school or lower Voc/Tech/University+ 1.72 1.00 (1.23-2.39)0.001 Employment status Unemployed Employed 1.00 1.70(1.12-2.57)0.012 Inhaled nitrates (poppers) (past 4m) No Yes 1.00 2.29(1.47-3.58)0.000

13. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 OR(95% CI)P Usual anal sex position Insertive only Practice receptive Never had anal sex 1.00 1.71 - (1.22-2.41) - 0.002 Ever had HIV test Never Ever 1.60 1.00 (1.16-2.20)0.004 Worry about getting HIV in the future Always to often Regularly to never 1.96 1.00 (1.43-2.68)0.000 HSV-2 Yes No 3.89 1.00 (2.79-5.43)0.000 Rectal NG Yes No 2.54 1.00 (1.45-4.47) 0.001 Multivariate

14. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 Follow-up rates among the HIV negative fraction of the BMCS (July 2008) Fixed Improves as study progresses

15. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 HIV incidence density (54 cases, July 2008) Mean age at HIV seroconversion: 24 yrs Range 18 – 42 yrs Per 100 person-years Fixed Improves as study progresses

16. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 After 780 days of study, cumulative HIV incidence 9.4%; 90.6% HIV free Cumulative HIV incidence, Kaplan-Meier method (July 2008) Percent survival 90.6% Days (4months = 120 days)

17. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 Conclusions A preparatory HIV cohort study was successfully started among MSM in Bangkok High HIV and STI prevalence at baseline High HIV incidence Good follow-up rates Risk factors for HIV infection are not different from those seen elsewhere An appropriate population for the evaluation and implementation of HIV preventive interventions

18. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 Thank you Co-authors: Supaporn Chaikummao, Jaray Tongtoyai, Chonticha Kittinunvorakoon, Anuwat Sriporn, Anchalee Varangrat, Pasakorn Akarasewi, Patchara Sirivongrangson, Janet McNicholl, Frits van Griensven Thailand MOPH – U.S. CDC Collaboration: Warunee Thienkrua, Tareerat Chemnasiri, Patnaree Oungprasertgul, Pechpailin Khlaimanee, Atitaya Sangiamkittikul, Rinda Wongbenchaporn, Waraporn Feangfu, Narongritt Tippanont, Somsak Yafant, Rutt Chuachoowong, Wannee Chonwattana, Michael Martin, Robert Linkins, Michael Malison Rainbow Sky Association of Thailand: Kamonsate Kenkarnrue, Rapeepan Jommareuang, Danai Linjongrat, Thanachai Chaisewi, Dejchapol Kanlayanamitr Disclaimer The data and conclusions presented are those of the authors and do not necessarily represent the views of the US Centers for Disease Control and Prevention

19. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 Chatuchak Rattanakosin Silom Sukhumvit Ramkhumheang Silom Community Clinic MSM hot spots in Bangkok, Thailand

20. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 Services (free of charge): HIV VCT If HIV positive: CD4 count, TB evaluation, referral for ARV HBV testing and vaccination HAV testing Syndromic STI evaluation Development of community relations Community Based Organization (CBO) Community Advisory Board (M-CAB) Silom Community Clinic: Tue – Sat, 4 – 10 PM

21. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 Number of clients and visits to the Silom Community Clinic September 2005 – July 2008 (VCT) Visits Number Clients

22. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 HIV, HBV, HAV and TP prevalence among VCT clients, September 2005 – July 2008 (VCT) HBV (Anti-HBs+) HAV % infected RPR-TPHIV

23. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 Current intervention: condom use counseling % Consistent condom use with all male partners in the past 4 months FixedImproves as study progresses

24. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 Future study: PrEP clinical trial: Truvada Currently studying the possibility and willingness to participate in the intermittent Pre and Post exposure prophylaxis clinical trial of 1,500 MSM participants in the Bangkok Metropolitan area

25. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 N=1292 n(%) Sexual identity Homosexual Others 1016 276 (79) (21) Alcohol consumption (4m) Yes1116(86) Used drug (4m) Yes303(24) Sexual characteristics at baseline April 2006 – January 2008

26. silom community clinic Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105 N=1292 n(%) Usual anal position (4m) Insertive only Practice receptive No anal sex 443 829 20 (34) (64) (2) Total # of male partner (4m) 0-2 3+ 370 922 (29) (71) Received money or gift for sex (4m) Yes256(20) Prior HIV test Ever615(48) Worry about getting HIV Always to often410(32)