1. HIV/STD Research Program Thailand MOPH – US CDC Collaboration Bangkok, Thailand IAS 2015 July 21, 2015: TUAC0302 HIV/STD Research Program Division of HIV/AIDS Prevention Wipas Wimonsate, Sarika Pattanasin, Anuwat Sriporn, Pikunchai Luechai, Kesinee Satumay, Narongritt Tippanonth, Nutthawoot Promda, Timothy H. Holtz, Anupong Chitwarakorn, Eileen F. Dunne Repeat HIV Voluntary Counseling and Testing Within One Year Among Men Who Have Sex With Men, Bangkok, Thailand 2006-2013

2. Background  Current Thailand Ministry of Public Health (MOPH) Guidelines state that men who have sex with men (MSM) should repeat HIV testing every 6-12 months  2014-2016 Thailand National AIDS Strategy  Silom Community Clinic @TropMed, Bangkok  Started in 2005  Large MSM-friendly clinic in Thailand; 10,000+ clients  State of the art voluntary counseling and testing (VCT)  Anonymous or confidential testing

3. HIV VCT at SCC @TropMed At each VCT visit:  pretest and posttest counseling  risk behavior reduction counseling  packages of condom and sexual lubricant  testing for immunity to hepatitis A and B viral infection and evaluation/treatment for syphilis infection  symptomatic screening and treatment for other STIs: gonococcal and nongonococcal infections; genital ulcers; and warts

4. HIV VCT at SCC @TropMed For first-time testers who are HIV negative:  recommend to repeat VCT every 6-12 months  recommend to repeat HIV testing whenever suspect has symptoms of STI  provide treatment to those diagnosed with STI; and recommend to repeat VCT in the next 3-6 months

5. Objective of this Analysis  Describe the proportion and trends of repeat HIV VCT within 12 months  Describe factors associated with repeat HIV VCT among HIV-negative MSM attending Silom Community Clinic @TropMed

6. Methods: MSM Study Population  Initial VCT visit with HIV test occurred between 2006–2013 with follow-up period through October 2014  Visited the clinic for more than 12 months  Baseline HIV-negative result  Annually: the number and proportion of first-time testers who had another VCT visit within the next 12 months  Tester #1 had first VCT visit in 2006 and had another VCT visit in 2007. Tester #1 was counted in the numerator of year 2006 over the total number of first-time testers in year 2006

7. Methods: Statistical Analysis  Binomial distribution to calculate 95% Confidence Interval  Chi-square test for trend to test changes in the proportion of repeat testing within 12 months by calendar year of entry  Multivariate logistic regression analysis to determine the factors associated with repeat testing within 12 months  Basic demographic information (age, nationality, birthplace, and current residency) collected at time of first visit and time variables of all visits, in addition to STI test results

8. Results: Study Population Characteristics As of October 2014 Total included4,597 (100%) Age 25 years old and above3,080(67%) Thai nationality3,999(87%) Lived in Greater Bangkok Metro Area4,045(88%) Had visited clinic for >4 years2,161(47%) Had subsequent tests(2,016) 44% (MD = 2, Range 1-26) Median (MD) of interval between tests17 months (Range 1d – 96m) Had subsequent tests within 12 months1,036(23%)

9. Proportion of Repeat HIV Testers Within 12 Months p < 0.01 (chi-square test for trend)

10. MV LR: Factors Associated with Repeat HIV Testing within 12 Months Characteristics Adjusted Odd Ratio95% Confidence Interval Age <25 years old1.2(1.0 – 1.3) Lived in Bangkok or surroundings 1.2(0.9 – 1.5) Joined clinic after Oct 2010 1.5(1.3 – 1.8) Repeated VCT during one’s own birth month 4.5(3.1 – 6.5) Repeated VCT during peak visit months* 6.1(5.0 – 7.5) Diagnosed with any STI3.7(2.8 – 5.0) * Those months after Thai holiday periods (Conventional New Year in January, Valentine’s Day and Chinese New Year in February, and Thai New Year/Songkran in April): namely February; March; and May

11. Limitations  In a VCT clinic service, minimum of risk factors are recorded  MSM who presented themselves or were referred to the clinic service might not be representative of MSM in Bangkok and Thailand  The effects of HIV stigmatization as well as testing- related trauma were also not evaluated as barrier to repeat testing

12. Limitations Cont’d  The quality of and client’s preference on HIV counseling and testing methods, content and aspect of the counseling session as well as clinic facility and location were not evaluated for motivation to repeat testing  The effect of 2010 MOPH policy of HIV testing two times per year was not assessed as motivation to repeat testing  Clients might repeat the test at other clinics at their convenience, leading to underreported proportion at our clinic

13. Summary  Between 2006–2013 the proportion of men who repeated VCT significantly increased  Roughly one-fifth of MSM repeated VCT within 12 months (short of the 2016 goal of 90% set by MOPH)  MSM age <25 years old or diagnosed with STI may have known of their higher risk thus more likely to repeat VCT sooner

14. Interpretation  During 2005–2011, Bangkok had several prolonged events of political unrest and major flooding. These might have impeded the ability of people who joined the clinic before October 2010 to repeat their VCT within next 12 months  The 2010 MOPH policy of HIV testing two times per year, released in October 2010, might have influenced the higher proportion of repeat VCT among people who joined the clinic after October 2010

15. Recommendations  Counseling messages to emphasize repeating VCT according to Thailand MOPH recommendations should be strengthened and systematic strategies to retain testers should be implemented  Based on the correlation with one’s own birthday and peak visit months, staff should consider using these times as reminders for routine VCT

16. Acknowledgments  We thank the co-authors, staff at the Silom Community Clinic @TropMed, outreach workers as well as the VCT clients  Disclaimer The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the U.S. Centers for Disease Control and Prevention and the Thailand Ministry of Public Health  Contact information Please e-mail Wipas Wimonsate at hpx2@cdc.gov