Arunrat Tangmunkongvorakul

Facilitators and barriers to medication adherence in an HIV prevention study among men who have sex with men in the iPrEx study in Chiang Mai, Thailand

In 2008, the Pre-exposure Prophylaxis Initiative (iPrEx) study expanded to include men who have sex with men (MSM) in Chiang Mai, Thailand. In full, 114 participants from Chiang Mai joined this international double-blinded trial of daily FTC-TDF (Truvada®) or placebo as a pre-exposure prophylaxis (PrEP) HIV prevention strategy. To better understand the characteristics of iPrEx participants specifically from this underserved population in Thailand, and gain insights into their experiences of trying to take a daily tablet as part of this blinded PrEP trial, we conducted a qualitative study. In 2010, 32 MSM iPrEx participants provided in-depth interviews and an additional 14 joined focus group discussions. Results of the qualitative analyzes suggested that participants held generally positive attitudes toward the iPrEx study and study medication and related this to high rates of adherence to the daily regimen. Participants also reflected on the provision of quality health care as part of participation in the trial, as well as support from clinical research staff, family and friends as helpful in supporting high rates of study medication adherence. Discourse concerning challenges to adherence included medication taking behavior, which was contextualized by lifestyle, living arrangement, social life, social stigma in terms of being mistakenly identified as HIV positive or unintentional disclosure of sexual identity to family and friends, and relationship conflicts with partners. The results provide broader perspectives of participant experiences of the study medication and daily adherence in the larger contexts of the MSM community, close relationships, and the study climate, and can be leveraged in constructing PrEP adherence support approaches within these communities.

Gender double standards in young people attending sexual health services in Northern Thailand

Concern about the sexual and reproductive health of young people has been mounting recently in Thailand. Unequal gender relations have a considerable influence on the lives of young people, especially young women, yet few studies have explored the ways in which they have impacted on provision of sexual health care. Drawing upon data from a qualitative study in Northern Thailand, this paper explores the views and experiences of young people in seeking health care, highlighting the kinds of gender double standards and power imbalances that may pose obstacles to their use of sexual and reproductive health services. Findings reveal the vulnerability of sexually active young women in seeking support and care from partners, parents, and service providers. Those who experience adverse outcomes of sexual activity, such as unwanted pregnancy or infection, report facing indifference, victim blaming, or the threat of abandonment by their partners. Because of their fear of disclosure to their parents and communities, of their sexual activity, they opt for clandestine and unsafe abortion and seek the counsel of peers and drugstores rather than parents and providers. At the service provider level, young women report facing threatening and judgemental attitudes, indifferent counselling, and possible violation of confidentiality. This is in marked contrast to the treatment of young men, who generally meet with a more sympathetic and accepting response.

Sexual perceptions and practices of young people in Northern Thailand.

This study draws together survey and qualitative data on sexual practices among more than 1750 young Northern Thai people aged 17–20 years. The survey data indicate that sexually active young people frequently engage in, or are subjected to, risk-taking behaviours that may expose them to sexually transmitted infections and unwanted pregnancies. These include having multiple sexual partners and quite frequent partner turnover. High percentages also engage in unprotected sexual intercourse with various types of sexual partner (steady, casual and paid), and young women especially had often experienced sexual coercion. Qualitative data revealed a mixture of perceptions and practices affecting sexual intercourse among the young, such as having unplanned sex, engaging in sexual relations to display love or cement committed relationships, and having serial relationships, both monogamous and non-monogamous. We conclude that condom use should be a central focus of activities aimed at preventing adverse sexual health outcomes, but that new intervention approaches to encourage use of other contraceptives are also needed. Changes in sexual norms among young people also need to be acknowledged and accepted by older Thai generations in order for programmes and interventions to combat negative sexual and reproductive health consequences to be more effective.

Intimacy versus Isolation: A Qualitative Study of Sexual Practices among Sexually Active HIV-Infected Patients in HIV Care in Brazil, Thailand, and Zambia

The success of global treatment as prevention (TasP) efforts for individuals living with HIV/AIDS (PLWHA) is dependent on successful implementation, and therefore the appropriate contribution of social and behavioral science to these efforts. Understanding the psychosocial context of condomless sex among PLWHA could shed light on effective points of intervention. HPTN 063 was an observational mixed-methods study of sexually active, in-care PLWHA in Thailand, Zambia, and Brazil as a foundation for integrating secondary HIV prevention into HIV treatment. From 2010–2012, 80 qualitative interviews were conducted with PLWHA receiving HIV care and reported recent sexual risk. Thirty men who have sex with women (MSW) and 30 women who have sex with men (WSM) participated in equal numbers across the sites. Thailand and Brazil also enrolled 20 biologically-born men who have sex with men (MSM). Part of the interview focused on the impact of HIV on sexual practices and relationships. Interviews were recorded, transcribed, translated into English and examined using qualitative descriptive analysis. The mean age was 25 (SD = 3.2). There were numerous similarities in experiences and attitudes between MSM, MSW and WSM across the three settings. Participants had a high degree of HIV transmission risk awareness and practiced some protective sexual behaviors such as reduced sexual activity, increased use of condoms, and external ejaculation. Themes related to risk behavior can be categorized according to struggles for intimacy and fears of isolation, including: fear of infecting a sex partner, guilt about sex, sexual communication difficulty, HIV-stigma, and worry about sexual partnerships. Emphasizing sexual health, intimacy and protective practices as components of nonjudgmental sex-positive secondary HIV prevention interventions is recommended. For in-care PLWHA, this approach has the potential to support TasP. The overlap of themes across groups and countries indicates that similar intervention content may be effective for a range of settings.

Prevalence and Correlates of HIV Testing among Young People Enrolled in Non-Formal Education Centers in Urban Chiang Mai, Thailand: A Cross-Sectional Study.

Background HIV testing is the gateway to HIV prevention, treatment, and care. Despite the established vulnerability of young Thai people to HIV infection, studies examining the prevalence and correlates of HIV testing among the general population of Thai youth are still very limited. This study investigates socio-demographic, behavioral, and psychosocial factors associated with HIV testing among young Thai people enrolled in Non-formal Education Centers (NFEC) in urban Chiang Mai, Northern Thailand. Methods This was a cross-sectional quantitative study conducted among young unmarried Thai youth—between the ages of 15 and 24—who were enrolled in NFEC in urban Chiang Mai. Multiple logistic regressions were used to identify correlates of “ever tested for HIV” among the sexually active participants. Findings Of the 295 sexually active participants, 27.3% reported “ever tested for HIV;” 65.4% “did not consistently use condom;” and 61.7% “had at least 2 lifetime partners.” We found that “self-efficacy” (AOR, 4.92; CI, 1.22–19.73); “perception that it is easy to find a location nearby to test for HIV” (AOR, 4.67; CI, 1.21–18.06); “having at least 2 lifetime sexual partners” (AOR, 2.05; CI, 1.09–3.85); and “ever been pregnant or made someone pregnant” (AOR, 4.06; CI, 2.69–9.15); were associated with increased odds of having ever been tested. On the other hand, “fear of HIV test results” (AOR, 0.21; CI, 0.08–0.57) was associated with lower odds of ever having been tested for HIV. Conclusion The main finding is that a substantially high proportion of Thai youth is engaged in risky sexual behaviors—yet reports low rates of ever having been tested for HIV. This highlights an urgent need to develop appropriate interventions—based on the identified correlates of HIV testing. There is also an urgent need to enhance HIV testing and to promote safer sexual behaviors among young Thai people—particularly those who are out-of-school.

Birth control, pregnancy and abortion among adolescents in Chiang Mai, Thailand

The authors studied more than 1750 young urban Chiang Mai residents regarding pre-marital sex, contraception and reproductive health outcomes. Almost two-thirds of the males had had sexual intercourse, compared to one-third of the females. Withdrawal was the most popular method of birth control followed by condom use. There were more females (30.5 per cent) reporting that they had been pregnant than males (17.5 per cent) reporting that they had caused pregnancies. Two-thirds of the respondents who had experienced or caused pregnancy reported that it ended in abortion. Almost half of those who had experienced abortion had induced it themselves, usually using illegal abortifacients. One-third went to a private clinic or hospital illegally. Self-induced abortions were sometimes associated with complications that were treated with pharmacy medications or severe complications requiring hospital treatment. Adolescents in northern Thailand need improved sexual health services and programmes. To be effective though, attention should also be given to underlying cultural attitudes toward sexuality and young people, especially women.

Coital Experience Among Adolescents in Three Social-Educational Groups in Urban Chiang Mai, Thailand.

This article compares coital experience of Chiang Mai 17–20-year-olds who were: (1) out-of-school; (2) studying at vocational schools; and (3) studying at general schools or university. Four-fifths, two-thirds and one-third, respectively, of males in these groups had had intercourse, compared to 53, 62 and 15 per cent of females. The gender difference for general school/university students, but not vocational school students, probably reflects HIV/AIDS refocusing male sexual initiation away from commercial sex workers. Vocational school females may have been disproportionately affected. Loss of virginity was associated, for both sexes, with social-educational background and lifestyle, and was less likely in certain minority ethnic groups. Among males, it was also associated with age and parental marital dissolution, and among females, with independent living and parental disharmony. Within social-educational groups, lifestyle variables dominated, but among general school/university students, parental marital dissolution (for males) and disharmony (for females) were also important, and Chinese ethnicity deterred male sexual experimentation.

Socio-behavioral risk factors among older adults living with HIV in Thailand

Background There has been a global increase in HIV infection in persons 50 years of age and older. This group is at risk for development of chronic illness that may be exacerbated by socio-behavioral risk factors such as smoking, unhealthy alcohol use, and sedentary lifestyle. However, socio-behavioral risk factors in this older HIV infected population are not well described. The current study aims to describe and document factors related to alcohol use, tobacco smoking, and physical exercise in older adults living with HIV (OALHIV). Methods This cross-sectional quantitative study was conducted between August and September 2015, and enrolled HIV-infected participants aged 50 years and older from 12 community hospitals in Chiang Mai Province, Northern Thailand. Results Of the 364 participants recruited in the study, 57.1% were female, and 67.3% were between 50–59 years of age. Respectively, 15.1%, 59.1%, and 18.7% were current smokers, currently engaged in physical exercises, and reported ever drank alcohol in the past year. 22.1% of those who drank alcohol reported experience of heavy episodic drinking. Male gender was one of the strongest predictors of ever drank alcohol in the past year (AOR, 4.66; CI, 2.28–9.49; P<0.001) and of being a current smoker (AOR, 13.41; CI, 7.23–24.87; P<0.001). Lower household income was associated with increased odds of ever drank alcohol in the past year (household income (1 USD = 35 THB) of ≤ 5,000 Baht versus > 20,000 Baht: AOR, 5.34; CI, 1.28–22.25; P = 0.021). Lower educational level was associated with decreased odds of physical exercises (no education versus secondary and higher: AOR, 0.22; CI, 0.08–0.55; P = 0.001). Conclusion Smoking and alcohol use is common among OALHIV, with a substantial proportion not engaging in physical exercises. Interventions for OALHIV should particularly target males and those of lower socio-economic status to deter smoking and alcohol use and to promote physical exercises.

Correction: Socio-behavioral risk factors among older adults living with HIV in Thailand

[This corrects the article DOI: 10.1371/journal.pone.0188088.].

“I Wasn’t in My Right Mind”: Qualitative Findings on the Impact of Alcohol on Condom Use in Patients Living with HIV/AIDS in Brazil, Thailand, and Zambia (HPTN 063)

PurposeThere have been significant biomedical improvements in the treatment and prevention of HIV over the past few decades. However, new transmissions continue to occur. Alcohol use is a known barrier to medication adherence and consistent condom use and therefore may affect treatment as prevention (TasP) efforts. The purpose of this study was to further explore how alcohol is associated with condom use and sexual transmission behavior in three international cities.MethodHIV Prevention Trials Network 063 was an observational mixed-methods study of HIV-infected patients currently in care in Rio de Janeiro, Brazil; Chiang Mai, Thailand; and Lusaka, Zambia. Across these three global cities, 80 qualitative interviews were conducted from 2010 to 2012. From these interviews, quotes related to substance use, almost all of which were alcohol, were analyzed using thematic analysis to identify how the use was related to sexual transmission behaviors.ResultsOverall, the theme that alcohol impairs cognitive abilities emerged from the data and included the following subthemes: expectancies, impaired decision-making, loss of control, and less concern for others. Themes specific to international settings and risk subgroups were also identified.ConclusionOur analysis identified how alcohol influences sexual transmission behavior in HIV patients in three international settings. These findings may provide direction for content development for future secondary prevention interventions to effectively implement TasP internationally.