Implementation of a Test, Treat, and Prevent HIV program among men who have sex with men and transgender women in Thailand, 2015-2016

<div><p>Introduction</p><p>Antiretroviral therapy reduces the risk of serious illness among people living with HIV and can prevent HIV transmission. We implemented a Test, Treat, and Prevent HIV Program among men who have sex with men (MSM) and transgender women at five hospitals in four provinces of Thailand to increase HIV testing, help those who test positive start antiretroviral therapy, and increase access to pre-exposure prophylaxis (PrEP).</p><p>Methods</p><p>We implemented rapid HIV testing and trained staff on immediate antiretroviral initiation at the five hospitals and offered PrEP at two hospitals. We recruited MSM and transgender women who walked-in to clinics and used a peer-driven intervention to expand recruitment. We used logistic regression to determine factors associated with prevalent HIV infection and the decision to start antiretroviral therapy and PrEP.</p><p>Results</p><p>During 2015 and 2016, 1880 people enrolled. Participants recruited by peers were younger (p<0.0001), less likely to be HIV-infected (p<0.0001), and those infected had higher CD4 counts (p = 0.04) than participants who walked-in to the clinics. Overall, 16% were HIV-positive: 18% of MSM and 9% of transgender women; 86% started antiretroviral therapy and 46% of eligible participants started PrEP. A higher proportion of participants at hospitals with one-stop HIV services started antiretroviral therapy than other hospitals. Participants who started PrEP were more likely to report sex with an HIV-infected partner (p = 0.002), receptive anal intercourse (p = 0.02), and receiving PrEP information from a hospital (p<0.0001).</p><p>Conclusions</p><p>We implemented a Test, Treat, and Prevent HIV Program offering rapid HIV testing and immediate access to antiretroviral therapy and PrEP. Peer-driven recruitment reached people at high risk of HIV and people early in HIV illness, providing an opportunity to promote HIV prevention services including PrEP and early antiretroviral therapy. Sites with one-stop HIV services had a higher uptake of antiretroviral therapy and PrEP.</p></div

Study Schema for the NNRTI Response Study—Zambia, Kenya, Thailand (2005–2008).

<p>Among the 779 women who completed 24 wk follow-up on NNRTI-based ART (excluding the three women who were temporarily off therapy), self-reported adherence over the five visits by week 24 was greater than 95% for 440 (95%) of 461 NVP-unexposed women and 300 (94%) of 318 NVP-exposed women (<i>p</i> = 0.5). Among the 724 women who completed 48 weeks on NNRTI-based ART, self-reported adherence over the two visits at weeks 36 and 48 was greater than 95% for 419 (97%) of 433 NVP-unexposed women and 280 (96%) of 291 NVP-exposed women (<i>p</i> = 0.7). f/u, follow-up; LTFU, lost to follow-up.</p

Relationship between exposure interval and treatment failure at 48 weeks in the NNRTI Response Study—Zambia, Kenya, Thailand (2005–2008).

a<p>Adjusted ORs controlling for country, CD4 cell count, viral load, WHO stage, age, hemoglobin, and body mass index (all as categorical variables as in <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000233#pmed-1000233-t001" target="_blank">table 1</a>). See <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000233#s3" target="_blank">methods</a> for definition of primary analysis.</p>b<p>Adjusted ORs controlling for country, CD4 cell count, viral load, WHO stage, and age (all as categorical variables as in <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000233#pmed-1000233-t001" target="_blank">table 1</a>) – hemoglobin and body-mass index were not retained in the final model.</p>c<p>Adjusted ORs controlling for country, CD4 cell count, viral load, WHO stage, and age (all as categorical variables as in <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000233#pmed-1000233-t001" target="_blank">table 1</a>) - hemoglobin and body-mass index were not retained in the final model. A separate multivariate model that included self-reported adherence did not alter the adjusted ORs in any appreciable way. See <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000233#s3" target="_blank">methods</a> for definition of on-treatment analysis.</p><p>Ref, reference group.</p

Factors associated with treatment failure in the primary analysis in the NNRTI Response Study—Zambia, Kenya, Thailand (2005–2008).

<p>See <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000233#s3" target="_blank">Methods</a> for definition of primary analysis.</p>a<p>Adjusted ORs controlling for country, CD4 cell count, viral load, WHO stage, age, hemoglobin, and body mass index (all as categorical variables as in <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000233#pmed-1000233-t001" target="_blank">Table 1</a>. Twenty-one observations are not included, owing to missing baseline results for either viral load or hemoglobin.</p><p>Ref, referent group.</p

Knowledge and attitudes of test, treat, and prevent HIV program participants about HIV infection, antiretrovirals, and pre-exposure prophylaxis, Thailand, 2015–2016.

<p>Knowledge and attitudes of test, treat, and prevent HIV program participants about HIV infection, antiretrovirals, and pre-exposure prophylaxis, Thailand, 2015–2016.</p

Baseline characteristics of participants enrolled in the NNRTI Response Study—Zambia, Kenya, Thailand (2005–2008).

<p>*<i>p</i>-Value<0.05, compared to Zambia by Wilcoxon rank-sum test.</p

Results of logistic regression analysis evaluating characteristics of participants in the test, treat, and prevent HIV program with prevalent HIV infection who chose to start antiretroviral therapy (ART), Thailand, 2015–2016.

<p>Results of logistic regression analysis evaluating characteristics of participants in the test, treat, and prevent HIV program with prevalent HIV infection who chose to start antiretroviral therapy (ART), Thailand, 2015–2016.</p

Baseline characteristics of participants in the test, treat, and prevent HIV program, Thailand, 2015–2016.

<p>Baseline characteristics of participants in the test, treat, and prevent HIV program, Thailand, 2015–2016.</p

Baseline characteristics of participants enrolled by prior exposure to single-dose nevirapine in the NNRTI Response Study—Zambia, Kenya, Thailand (2005–2008).

<p>*<i>p</i>-Value<0.05, compared to unexposed by Wilcoxon rank-sum test.</p

Results of logistic regression analysis to evaluate characteristics of participants in the test, treat, and prevent HIV program associated with prevalent HIV infection, Thailand, 2015–2016.

<p>Results of logistic regression analysis to evaluate characteristics of participants in the test, treat, and prevent HIV program associated with prevalent HIV infection, Thailand, 2015–2016.</p