Donn Colby

Application of Respondent Driven Sampling to Collect Baseline Data on FSWs and MSM for HIV Risk Reduction Interventions in Two Urban Centres in Papua New Guinea

The need to obtain unbiased information among hard–to-reach and hidden populations for behavioural and biological surveillance, epidemiological studies, and intervention program evaluations has led researchers to search for a suitable sampling method. One method that has been tested among IDU and MSM recently is respondent-driven sampling (RDS). We used RDS to conduct a behavioural survey among FSWs and MSM in two urban centres in Papua New Guinea (PNG). In this paper we present the lessons learned implementing RDS in a developing country setting. We also present comparisons of RDSAT-adjusted versus unadjusted crude estimates of some key socio-demographic indicators as well as comparisons between the estimates from RDS and a hypothetical time–location sample (TLS). Overall, the use of RDS among the MSM and FSWs in PNG had numerous advantages in terms of collecting a required sample size in a short time period, minimizing costs and maximising security for staff and respondents. Although there were a few problems these were easily remedied and we would recommend RDS for other similar studies in PNG and other developing countries.

A Qualitative Study of Stigma and Discrimination against People Living with HIV in Ho Chi Minh City, Vietnam

Stigma and discrimination against people living with HIV/AIDS (PLHIV) are a pressing problem in Vietnam, in particular because of propaganda associating HIV with the “social evils” of sex work and drug use. There is little understanding of the causes and sequelae of stigma and discrimination against PLHIV in Vietnam. Fifty-three PLHIV participated in focus group discussions in Ho Chi Minh City. Nearly all participants experienced some form of stigma and discrimination. Causes included exaggerated fears of HIV infection, misperceptions about HIV transmission, and negative representations of PLHIV in the media. Participants faced problems getting a job, perceived unfair treatment in the workplace and experienced discrimination in the healthcare setting. Both discrimination and support were reported in the family environment. There is a need to enforce laws against discrimination and provide education to decrease stigma against PLHIV in Vietnam. Recent public campaigns encouraging compassion toward PLHIV and less discrimination from healthcare providers who work with PLHIV have been encouraging.

HIV-related risk behaviors among female sex workers in Ho Chi Minh City, Vietnam.

This study quantitatively and qualitatively described HIV risk behaviors among Vietnamese female sex workers (FSWs) who work at three distinct venues in Ho Chi Minh City: street, massage parlors, and bars/clubs. Although 35% of the participants had never been tested for HIV, 18% of street and 7% of bar/club FSWs reported being positive. Almost all massage parlor FSWs had never used a condom for oral sex. Inconsistent condom use for vaginal sex with customers was more prevalent among bar/club FSWs (85%) than massage parlor (72%) and street FSWs (68%). Many participants reported difficulties in negotiating condom use with customers because of economic pressure, maintaining relationships, and lack of bargaining power. Bar/club FSWs revealed a difficult situation where drinking is part of their work. Thirty percent of street FSWs had injected drugs and reported addiction to heroin in relation to their helpless condition as FSWs. Street FSWs had the lowest levels of self-esteem and norms toward practicing safe sex and the highest levels of economic pressure. This study recommends future HIV prevention programs for FSWs in Vietnam that target their specific risk behaviors and work environments.

Field Evaluation of a Prototype Paper-Based Point-of-Care Fingerstick Transaminase Test

Monitoring for drug-induced liver injury (DILI) via serial transaminase measurements in patients on potentially hepatotoxic medications (e.g., for HIV and tuberculosis) is routine in resource-rich nations, but often unavailable in resource-limited settings. Towards enabling universal access to affordable point-of-care (POC) screening for DILI, we have performed the first field evaluation of a paper-based, microfluidic fingerstick test for rapid, semi-quantitative, visual measurement of blood alanine aminotransferase (ALT). Our objectives were to assess operational feasibility, inter-operator variability, lot variability, device failure rate, and accuracy, to inform device modification for further field testing. The paper-based ALT test was performed at POC on fingerstick samples from 600 outpatients receiving HIV treatment in Vietnam. Results, read independently by two clinic nurses, were compared with gold-standard automated (Roche Cobas) results from venipuncture samples obtained in parallel. Two device lots were used sequentially. We demonstrated high inter-operator agreement, with 96.3% (95% C.I., 94.3–97.7%) agreement in placing visual results into clinically-defined “bins” (<3x, 3–5x, and >5x upper limit of normal), >90% agreement in validity determination, and intraclass correlation coefficient of 0.89 (95% C.I., 0.87–0.91). Lot variability was observed in % invalids due to hemolysis (21.1% for Lot 1, 1.6% for Lot 2) and correlated with lots of incorporated plasma separation membranes. Invalid rates <1% were observed for all other device controls. Overall bin placement accuracy for the two readers was 84% (84.3%/83.6%). Our findings of extremely high inter-operator agreement for visual reading–obtained in a target clinical environment, as performed by local practitioners–indicate that the device operation and reading process is feasible and reproducible. Bin placement accuracy and lot-to-lot variability data identified specific targets for device optimization and material quality control. This is the first field study performed with a patterned paper-based microfluidic device and opens the door to development of similar assays for other important analytes.

Engagement with Peer Health Educators Is Associated with Willingness to Use Pre-Exposure Prophylaxis Among Male Sex Workers in Ho Chi Minh City, Vietnam

Men who have sex with men (MSM), including male sex workers (MSW), in Vietnam are at high risk for HIV transmission and acquisition, due to specific psychosocial and contextual factors including stigma and discrimination.1,2 MSW are particularly vulnerable due to the local legal environment, power dynamics (i.e., dependence on sex for livelihood), and individual-level risk.3 However, despite increasing HIV prevalence,4 few HIV prevention interventions have been specifically developed for this population. Identification of HIV prevention strategies that are tailored to the needs of MSW are urgently needed. The iPrEx trial demonstrated the efficacy of taking daily oral pre-exposure prophylaxis (PrEP) to reduce HIV transmission among MSM.5 To date, little research has specifically considered the acceptability of PrEP among MSW in Vietnam. PrEP may be a particularly useful intervention for MSW as it is a user-controlled intervention. Peer educators (PE) are valuable sources of HIV prevention information for MSW in Vietnam,6 and may have a role to play in the development and administration of PrEP interventions. We assessed factors associated with access to PE and the association between contact with a PE and willingness to take PrEP as a potential strategy for implementation of PrEP interventions. In 2010, a behavioral and psychosocial survey was undertaken with 300 MSW in Ho Chi Minh City (HCMC), Vietnam, which assessed past experience with HIV prevention activities and interest in PrEP. The survey was developed following an initial qualitative phase.6 Detailed methods have been described previously.7 Briefly, participants were recruited by PE from a Vietnamese NGO working with MSM, using venue-based sampling stratified on where participants met clients (i.e., street, brothel). Eligible participants were at least 15 years of age, biologically male, Vietnamese citizens who reported exchanging sex for money or goods at least once in the previous month. The survey was anonymous, and participants gave verbal informed consent after receiving information about the study from one of the research staff. Study procedures were approved by the Institutional Review Boards at Beth Israel Deaconess Medical Center and the Ho Chi Minh City Provincial AIDS Committee. The survey contained items pertaining to past participation in HIV prevention programs including if they had received HIV prevention materials (i.e., condoms, personal lubricant, or informational brochures), knowledge of HIV testing and counseling services, HIV/STI testing history, and contact with PE in the previous 12 months. Questions pertaining to willingness to participate in future HIV prevention interventions were adapted from prior studies by our group8 and asked if they would take a daily pill if it would protect against HIV and how likely they were to take the pill if it had side effects. Demographic and behavioral factors were also assessed. Descriptive statistics were calculated for responses regarding past HIV prevention activities and willingness to take PrEP. Logistic regression models were used to analyze the association between demographic and behavioral factors and (1) past contact with a PE; and (2) being at least “somewhat likely” to take a daily pill for HIV prevention if it had side effects. A multivariable model for each outcome was built using backwards elimination starting with all potential covariates, with a p value cutoff of 0.2 to determine the final variables to retain in the model. An alpha level of 0.05 was considered significant. Stata 12.0 (StataCorp, College Station, TX) was used for all analyses. Of 300 participants in the original study, 281 (93.7%) were HIV-uninfected and included in these analyses.9 Table 1 lists the proportion of participants who indicated previous participation in HIV prevention activities and interest in PrEP. More than 2/3 of participants had previous contact with a PE. Most (95.4%) participants indicated that they would take PrEP, although substantially fewer indicated they would take PrEP given side effects (56.7%). Table 1. Proportion of Participants Who Have Participated or Would Participate in HIV Prevention Interventions (N=281) Table 2 displays bivariate and multivariable models assessing factors associated with (1) contact with a PE in the previous year, and (2) being at least “somewhat likely” to take PrEP if it had side effects. MSW who reported previous contact with a PE (AOR 2.28, 95% CI 1.25–4.14) indicated increased willingness to use PrEP. In a multivariable model, older age (AOR 1.09, 95% CI 1.01–1.16) was associated with increased contacts with PE, and identifying as bong lâ (effeminate, AOR 0.29, 95% CI 0.11–0.75), or trai thăng (“straight boy”, AOR 0.43, 95% CI 0.23–0.80) versus bong kin (masculine) was associated with decreased contact with PE. Table 2. Bivariate and Multivariable Logistic Regression Models Assessing Factors Associated with Contact with Peer Educator in Last 12 Months and Willingness to Take Pre-Exposure Prophylaxis (PrEP) If It Involved Side Effects Participants who had previous contact with a PE more frequently indicated that they would take PrEP than those who had not. As PrEP becomes available for MSM in Vietnam, PE will likely play a large role in recruiting and educating participants about the efficacy of PrEP, adherence, and safer sex practices, and counseling related to stigma, side effects, and local resources. Training PE may increase the acceptability of PrEP for Vietnamese MSM, and their role in the expansion of PrEP services in Vietnam should be carefully considered. Given the high penetrance of PE in this population, leveraging this existing infrastructure may improve the feasibility and success of future HIV prevention interventions such as PrEP. Strategies to increase access to PE among key subpopulations are important to improve the scope and quality of programs based on this model. In this study, older men were more likely to have been reached by PE in the past year. This could reflect differences in social networks,10 and they are likely to have had more opportunities to be reached by peers, compared to younger men who have recently “come out.” Younger participants are a particularly vulnerable group, and future work should consider how to engage them in HIV prevention services.11 Participants identifying as bong lộ or trai thăng versus bong kin less frequently indicated engagement with PE. While bong lộ are more visible than other MSM identities in Vietnam,12 due to this visibility, they may also be more susceptible to stigma and therefore less likely to be willing to engage in peer education services in public settings. Similarly, trai thăng may not want to be seen in public or be less willing to engage in peer education since they identify as “straight”.12 Investments should be made to identify strategies to facilitate engagement with PE by bong lộ or trai thăng. This study has several potential limitations. Data collection relied on self-report, which could result in under- or over-reporting of sensitive behaviors. Questionnaires were administered by interviewers, which could result in social desirability bias. Finally, questions regarding side effects related to PrEP did not specify the specific side effects may be, or how severe they could be. More in-depth questions could elucidate which side effects would be barriers to taking PrEP among this population. PE may have the ability to access vulnerable hidden populations that are not reached by mainstream HIV prevention messages, which could maximize uptake of interventions such as PrEP. The results of this study indicate that integrating PE into future PrEP interventions may be an effective way to engage MSW in PrEP. The development of interventions that reach MSW and ensuring they are aware of choices and strategies for HIV prevention will be an important component of a comprehensive HIV prevention strategy in for MSW in Vietnam.

Risk factors for delayed entrance into care after diagnosis among patients with late-stage HIV disease in southern Vietnam.

Background We surveyed HIV patients with late-stage disease in southern Vietnam to determine if barriers to access and service quality resulted in late HIV testing and delays from initial diagnosis to entry into HIV care. Methodology 196 adult patients at public HIV clinics with CD4 counts less than 250 cells/mm3 completed a standardized questionnaire. We used multivariate analysis to determine risk factors for delayed entry into care, defined as >3 months time from diagnosis to registration. Results Common reasons for delayed testing were feeling healthy (71%), fear of stigma and discrimination in the community (43%), time conflicts with work or school (31%), did not want to know if infected (30%), and fear of lack of confidentiality (27%). Forty-five percent of participants delayed entry into care with a median CD4 count of 65 cells/mm3. The most common reasons for delayed entry were feeling healthy (51%), fear of stigma and discrimination in the community (41%), time conflicts with work or school (33%), and fear of lack of confidentiality (26%). Independent predictors for delayed entry were feeling healthy (aOR 3.7, 95% CI 1.5–9.1), first positive HIV test at other site (aOR 2.9, CI 1.2–7.1), history of injection drug use (IDU) (aOR 2.9, 95% CI 1.1–7.9), work/school conflicts (aOR 4.3, 95% CI 1.7–10.8), prior registration at another clinic (aOR 77.4, 95% CI 8.6–697), detention or imprisonment (aOR 10.3, 95% CI 1.8–58.2), and perceived distance to clinic (aOR 3.7, 95% CI 1.0–13.7). Conclusion Delayed entry into HIV care in Vietnam is common and poses a significant challenge to preventing AIDS and opportunistic infections, decreasing mortality, and reducing HIV transmission. Improved linkages between testing and care are needed, particularly for patients who feel healthy, as well as incarcerated and drug-using populations who may face structural and social barriers to accessing care.

Willingness to Use the Internet to Seek Information on HIV Prevention and Care among Men Who Have Sex with Men in Ho Chi Minh City, Vietnam

Background In Vietnam, men who have sex with men (MSM) are highly affected by HIV and need new targeted HIV prevention strategies. Objectives To assess the willingness to use the Internet to seek information on HIV prevention and care and associated factors among MSM in Ho Chi Minh City. Methods A descriptive cross-sectional study was conducted in 2012. Participants were recruited using a convenience sampling method in venues most frequented by MSM and completed a self-administered questionnaire. Logistic regression models were performed to estimate factors associated with the willingness to use the Internet to seek information on HIV prevention and care. Results A total of 358 MSM were approached for the survey and 222 questionnaires (62.0%) were eligible for analyses. Overall, 76.1% of the respondents reported that they were willing to use the Internet to seek information on HIV prevention and care. A number of male partners in last year less than or equal to 3 (Adjusted Odds Ratio: 3.07, 95% Confidence interval: 1.40–6.73), a history of STI screening (4.10, 1.02–16.48) and HIV testing (3.23, 1.20–8.64) and having ever sought a male sexual partner through the Internet (3.56, 1.55–8.18) were significantly positively associated with the willingness to use the Internet to seek information on HIV prevention and care. Conclusion The MSM interviewed in Ho Chi Minh City reported a high willingness to use the Internet to seek information on HIV prevention and care. In a context where new media are increasingly considered as promising options for reaching this HIV risk group, further research should be conducted on developing and testing tailored online tools adapted to the needs of Vietnamese MSM.

A Point-of-Care Paper-based Fingerstick Transaminase Test: Toward Low-cost “Lab-on-a-Chip” Technology for the Developing World

There is currently great need for high-quality, low-cost, point-of-care diagnostics that can benefit patients in resource-limited settings and correspondingly growing interest in the diagnostic utility of microfluidic platforms that are based on paper. We describe the development, early clinical testing, and potential clinical impact of a novel paper-based, multiplexed microfluidic assay designed for rapid, semiquantitative measurement of aspartate aminotransferase and alanine aminotransferase in a fingerstick specimen. This device ultimately holds promise for providing universal access to affordable point-of-care screening for drug-induced liver injury in resource-limited settings and opens the door to development of similar point-of-care clinical assays for other important analytes.

Altered Memory Circulating T Follicular Helper-B Cell Interaction in Early Acute HIV Infection

The RV254 cohort of HIV-infected very early acute (4thG stage 1 and 2) (stage 1/2) and late acute (4thG stage 3) (stage 3) individuals was used to study T helper- B cell responses in acute HIV infection and the impact of early antiretroviral treatment (ART) on T and B cell function. To investigate this, the function of circulating T follicular helper cells (cTfh) from this cohort was examined, and cTfh and memory B cell populations were phenotyped. Impaired cTfh cell function was observed in individuals treated in stage 3 when compared to stage 1/2. The cTfh/B cell cocultures showed lower B cell survival and IgG secretion at stage 3 compared to stage 1/2. This coincided with lower IL-10 and increased RANTES and TNF-α suggesting a role for inflammation in altering cTfh and B cell responses. Elevated plasma viral load in stage 3 was found to correlate with decreased cTfh-mediated B cell IgG production indicating a role for increased viremia in cTfh impairment and dysfunctional humoral response. Phenotypic perturbations were also evident in the mature B cell compartment, most notably a decrease in resting memory B cells in stage 3 compared to stage 1/2, coinciding with higher viremia. Our coculture assay also suggested that intrinsic memory B cell defects could contribute to the impaired response despite at a lower level. Overall, cTfh-mediated B cell responses are significantly altered in stage 3 compared to stage 1/2, coinciding with increased inflammation and a reduction in memory B cells. These data suggest that early ART for acutely HIV infected individuals could prevent immune dysregulation while preserving cTfh function and B cell memory.

HIV pre-exposure prophylaxis and health and community systems in the Global South: Thailand case study

Pre‐exposure prophylaxis (PrEP) is recommended by the World Health Organization as an effective method of HIV prevention for individuals at risk for infection. In this paper, we describe the unique role that Thailand has played in the global effort to combat the HIV epidemic, including its role in proving the efficacy of PrEP, and discuss the opportunities and challenges of implementing PrEP in a middle‐income country.