A scoping review of HIV testing among men who have sex with men (MSM) and transgender women (TGW) in Thailand "SCK. F#K. Test. Repeat"

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**"SCK. F#K. Test. Repeat"**

A scoping review of HIV testing among men who have sex with men (MSM) and

transgender women (TGW) in Thailand

Ronaldo Valuz Reyes Candidate number 2080

Project Thesis Credits: 20

Institute of Health and Society Faculty of Medicine

January 22, 2021

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“Whenever AIDS has won, stigma, shame, distrust, discrimination and apathy was on its side.

Every time AIDS has been defeated, it has been because of trust, openness, dialogue between individuals and communities, family support, human solidarity, and the human perseverance

to find new paths and solutions”(1)

- Michel Sidibé

Former Executive Director (2009-2019) Joint United Nations Program on HIV/AIDS

This project thesis is dedicated to all HIV positive MSMs and TGW,

who live their lives to its fullest potentials by putting on their best, bravest faces every day.

It is also dedicated to those who still suffer, despite the advancements in the field of HIV/AIDS research that the world has witnessed in recent years.

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Abstract

Over the past two decades, Human Immunodeficiency Virus (HIV) has spread rapidly among gay men, transgender women and male sex workers in Thailand, reaching epidemic levels. This study used a scoping review approach to create an overview of the existing literature about HIV testing among men who have sex with men (MSM) and transgender women (TGW) in Thailand.

A total of 50 articles and conference abstracts, including a book chapter, were included in this review. The reviewed publications were predominantly drawing on quantitative studies and relatively recent, with all but one article published after 2010. The majority had their focus on the MSM population located in Bangkok, while only a few concentrated solely on the transgender population and on areas outside of the capital city. Thematic analysis revealed six main topics resonating through the majority of the collated material, namely (1) factors influencing HIV testing uptake, (2) prevalence of HIV testing, (3) prevalence of HIV, (4) changes in risk behaviors related to HIV testing, (5) Repeat HIV testing and Loss-to-follow-up and (6) strategies to increase the uptake of HIV testing. Several articles reported on the proportion of subjects who had ever tested for HIV, which varied between 30% and 81%. The prevalence of HIV infection also varied between studies, from 2.8% to 27%, depending on group, location and year. Undergoing an HIV test was shown that it increased the interest in getting tested for HIV regularly in the future, and it was shown to have an association with reduced HIV-risk behaviors. Thirteen strategies currently being implemented in the country to increase the uptake of HIV testing among MSM and TGW were enumerated, and these strategies were tailored to address the factors that influenced HIV testing uptake among this population. These factors were among the six main subtopics that emerged in the thematic analysis. Current programs such as the establishment of community-based MSM and TGW- friendly testing centers, enhanced peer mobilization approach, testing centers and mobile clinics at MSM hotspots, and mobilizing key-population members in providing HIV testing and counseling reflected integration of social science principles in the development of programs intended to increase the uptake of HIV testing. This scoping review confirmed that the existing literature on this field of interest, when organized and presented systematically, offers a detailed description of the aspects of HIV testing among these two unique high-risk populations in Thailand.

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List of acronyms

ACASI Audio-computer-assisted self-interview

AIMSS Asian Internet MSM Sex Survey

aOR Adjusted odds ratio

APCOM Asia Pacific Coalition on Male Sexual Health

aRR Adjusted relative risk

ART Antiretroviral treatments

ASEAN Association of Southeast Asian Nations

CBO Community based organization

CINAHL-EBSCO Cumulative Index to Nursing and Allied Health Literature - Elton B. Stephens Company

CVCT Couple’s voluntary HIV counseling and testing

EHR Electronic health record

eHTC Electronic HIV testing and counselling

EPM Enhanced peer mobilization

FSW Female sex worker

GAHT Gender-affirming hormone treatment

HIV Human Immunodeficiency Virus

HTC/HCT HIV testing and counselling

IMSEAR Index Medicus for South-East Asia Region

IQR Interquartile range

JBI Joanna Briggs Institute

KP Key population

KPLHS Key population-led health services

KSW Kathoey sex workers

LGBT Lesbian/gay/bisexual/transsexual

LTFU Loss to follow-up

MOPH Ministry of Public Health

MSM Men who have sex with men

MSW Male sex worker

MT Medical Technologist

MTSW Male and transgender sex workers

NAAT Nucleic acid amplification test

NAP National AIDS Program

OR Odds ratio

O2O Online-to-Offline

PCC Population, concept and context

PCP Pneumocystis carinii pneumonia

PDA Palm personal digital assistant

PEP Postexposure profylaxis

PLoS Public Library of Science

PLWH People living with HIV

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PrEP Preexposure profylaxis

PRISMA Preferred Reporting Items for Systematic Reviews and Meta- Analyses

PWID People who inject drugs

RC Risk concordance

RD Risk discordance

RDT Rapid diagnostic test

SCC Silom Community Clinic

STD Sexually transmitted diseases

TGW Transgender women

TLS Time-location sampling

TRCARC Thai Red Cross AIDS Research Center

UAI Unprotected anal intercourse

UK United Kingdom

UNAIDS United Nations Program on HIV/AIDS

USA United States of America

USAID United States Agency for International Development

USD US Dollar

VCCT Voluntary confidential counseling and testing VCT Voluntary counseling and testing

VDT Venue-day-time

VDTS Venue-Day-Time sampling

WHO World Health Organization

WOS Web of Science

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Introduction

The Human Immunodeficiency Virus (HIV), a virus that attacks CD4 cells in the human body to make copies of itself, has remained a serious pandemic in the past four decades of human existence. Although this disease is believed to have its origins from Kinshasa in the Democratic Republic of Congo from as early as the1920s (2), it officially dawned in 1981 by way of an unexpected lung infection called Pneumocystis carinii pneumonia (PCP) among five young, previously healthy homosexual men in Los Angeles, California, USA (3). Since then, the disease has infected 75 million people worldwide and claimed 32.7 million lives. Presently, there are 38 million people living with HIV (PLWH) with 1.7 million new infections recorded in 2019 alone (4).

Together with commercial sex workers and people who inject drugs (PWID), men who have sex with men (MSM) and transgender women (TGW) are among the key populations at higher risk of HIV infection (5). As key affected populations, they are more vulnerable to HIV infection because they are marginalized in the society, making them fearful of accessing HIV services (6). They are frequently subjected to punitive and discriminatory laws and policies that affect their mental health and social behavior which in turn compromise their access to HIV and other health services (7). Aside from these reasons, there are biological, behavioral, and cultural factors which put MSM 26 times more at risk of being infected with HIV than the general population, while the risk is 13 times higher for transgender people (8). In the Joint United Nations Program on HIV/AIDS (UNAIDS) Global AIDS Update Report in 2018 (9), it was noted that “Gay men and other men who have sex with men accounted for an estimated 57% of new HIV infections in western and central Europe and North America, an estimated 41% of new infections in Latin America, more than 25% of new HIV infections in Asia and the Pacific and the Caribbean, about 20% of new infections in eastern Europe and central Asia and the Middle East and North Africa, and an estimated 12% of new infections in western and central Africa” (page 28).

The Asia and the Pacific region ranks second (next to East and Southern Africa) with the largest number of PLWH, and Thailand accounts for 9% of the region’s total population of PLWH (10). Thailand, sometimes called “the gay capital of Asia”, has been recently marketed as a

“pink” destination attracting tourists with its haven of lesbian/gay/bisexual/transsexual (LGBT)-friendly culture, gay go-go bars, gender confirmation surgical clinics and

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2 entertainment venues featuring TGW (locally known as “kathoey” or “ladyboys”). The estimated Thai MSM population in 2019 was 527,900, and the HIV prevalence among this population was 12% in the same year (11). In Bangkok, one in every three MSM were estimated to be HIV positive (12). An explosive epidemic of HIV infection among MSM and TGW during the past two decades in the country’s capital was documented in an article by van Griensven et.al, where HIV prevalence increased from 17.3% in 2003 to 30.8% in 2007 (12). On the other hand, the country’s estimated TGW population is 62,800 with an HIV prevalence of 11% (11).

Despite being internationally credited for successfully reversing the epidemic of HIV transmission within the heterosexual population in late 1990s and early 2000s (12), the Royal Thai Government is in no way near the same accomplishment when it comes to combating HIV among TGW and MSM population, and 44% of new adult infections in 2019 were attributed from these two high-risk populations (10).

In line with Thailand’s continuing commitment to UNAIDS’ goal of ending AIDS by 2030, the country has laid concrete action plans and list of priorities that includes universal access to HIV counseling and testing (HTC, also called voluntary counseling and testing or VCT) (10). HTC is practically the first step in linking seropositive people to treatment and care. It allows timely linkage to treatment and care, and thus reducing morbidity and mortality and further disease transmission. Even though resources for HIV testing are available for free in Thailand, a large proportion of MSM and TGW still do not get tested for HIV. HIV testing and HIV status awareness among MSM and TGW remains suboptimal in Thailand (13). Modelling shows that Thailand’s goal to end AIDS by 2030 is attainable only if HIV testing coverage among key populations is increased to 90% (14). Presently, this is at 43% and 42% for MSM and TGW respectively (11).

To name a few, there are published scoping reviews from countries such as Brazil, China, Malaysia and the United States of America that focus on HIV incidence and risk factors for HIV infections, HIV epidemiology and responses among MSM and TGW, patient preferences for HIV self-testing services and sexual transmission related HIV research (15-18). Similar scoping reviews about HIV testing and/or related topics among MSM and TGW in Thailand is yet to be done.

The objective of this study is to conduct a scoping review in order to provide an overview on what existing literature states about the different aspects of HIV testing among MSM and TGW in Thailand. In addition, this review also aims to identify gaps in the existing body of literature that needs to be explored in future studies.

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Methods

The research area pertaining to HIV testing is both broad and heterogenous. Studies and reviews conducted about HIV testing, specifically in the MSM and TGW populations in Thailand, have had different foci. To name a few, topics range from implementation of different testing strategies to online platforms of HIV testing, HIV-related stigma in the context of HIV testing, motivating and deterring factors for voluntary HIV testing and mobilization of lay key- population community members in HIV testing drives. In addition, available publications draw on studies that have variable study designs and methodologies, which makes conducting a systematic literature review about this topic unideal. If one is to review this broad topic, a synthesized, summarized and easy to understand manner of presentation is necessary, and it is because of these reasons that scoping review, as a method of examining the extensive topic of HIV testing among MSM and TGW in Thailand, was chosen. Since scoping reviews allow the rapid examination of the extent, range and nature of research activity about a broad topic without describing research findings in detail (19), it is an effective method of mapping available evidence that would otherwise be difficult to synthesize considering the range of material that is available. By systematically presenting what is available, we will also be able to see what is lacking, and thus identify gaps in the existing body of literature that needs to be explored in future studies.

Definitions of scoping reviews are rare (19). This type of literature review is a way of mapping the range, extent and nature of available research on a topic, providing a summary of existing evidence and determining if a full systematic review is warranted (19, 20). It differs from a systematic review in the sense that it provides a broader landscape of the body of knowledge on a topic, whereas systematic reviews provide a more precise picture of a particular subject and have greater rigour (20). The main goal of scoping reviews however, is not to assess the quality of the evidence (20). To present all the available research on the topic, scoping reviews entails searching for, and reviewing different types of articles and reports, which may include, but are not limited to: all accessible relevant literature and research; opinion pieces; reference list; and grey literature (20, 21).

The method that was used in this scoping review was based on the model proposed by Arksey and O’Malley in 2005 for conducting a scoping review (19). The model consists of a methodological framework that involves the following stages:

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4 1. Stage 1: Identifying the research question

2. Stage 2: Identifying relevant studies 3. Stage 3: Study selection

4. Stage 4: Charting the data

5. Stage 5: Collating, summarizing and reporting the results

This model for conducting a scoping review also includes a sixth and optional stage,

“consultation exercise”, which involves insights from representatives from national voluntary bodies, practitioners from local organizations and key informant carers. Due to limited resources and time constraints, this optional stage was not done in this review.

The steps undertaken under each stage were as follows:

Stage 1: Identifying the research question

The topic of HIV testing among MSM and TGW has long fascinated the author, and he thought that a project thesis about this topic would be both interesting and valuable. On October 2018, he presented this idea to his project thesis adviser, Kåre Moen, who is a medical doctor and social anthropologist, and a professor of community medicine and global health known for his work and research on HIV among gender and sexuality diverse populations. After searching the internet for available literature, the author found out that there are numerous papers and articles written about HIV testing among MSM and TGW in Thailand, but a summarized presentation of these publications had yet to be done, which he consequently pointed out to his adviser. A few brainstorming sessions took place in 2019, and on January 2020, the research objectives and questions were formulated, and the project outline was submitted to, and later approved by, the Institute of Health and Society, Faculty of Medicine, University of Oslo.

The purpose of this scoping review is to create an overview of HIV testing among MSM and TGW in Thailand through mapping the existing literature. It aims to answer the main research question: What is the current knowledge about HIV testing among MSM and/or TGW in Thailand?

This research question was formulated in the hope that by answering it, it would offer the following:

• Knowledge about the existing methods and strategies implemented in Thailand to increase the uptake of HIV testing among members of the MSM and TGW population

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• Idea about the prevalence and uptake of HIV testing among these two high-risk populations

• Overview of the most common factors that influence the decision to get tested for HIV

• Insights on topics for future research based on reflection upon research gaps in existing literature

Formulation of the abovementioned research question and objective was based on PCC (Population, Concept and Context) elements developed by Joanna Briggs Institute (JBI) which they published in 2015 as a part of their Methodology for JBI scoping reviews (22). The population (P) in this scoping review are MSM and TGW, the concept (C) is HIV testing, while the context (C) is Thailand. This PCC also guided inclusion and exclusion criteria, which will be explained in detail later.

HIV testing as a research topic is both broad and non-specific. A broad research topic was chosen to maintain a wide approach in order to generate breadth of coverage, reducing the likelihood of missing relevant articles (19).

In addition to the main research question, three sub questions were also formulated, as these questions also delve into the attributes of the context, population and context. Through these specific questions, discussions can be stimulated and insights are to be generated, giving the readers a wider perspective of the topic HIV testing. These sub questions were:

1. What role has the involvement of the gay and transgender communities played in HIV testing campaigns in Thailand?

2. What is known about the relevance of stigma for the uptake of HIV testing in Thailand?

3. What is known about the effect of knowing one’s HIV status on the HIV risk behaviors and attitudes towards HIV testing of men who have sex with men and transgender women in Thailand?

Stage 2: Identifying Relevant Studies

A comprehensive search through different literature search engines was completed to collect related journals, articles and publications. The initial search was conducted on January 14, 2020 on eight electronic databases: PubMed, Scopus, Index Medicus for South-East Asia Region

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6 (IMSEAR), MEDLINE (Ovid), Web of Science (WOS), Global Health, Cumulative Index to Nursing and Allied Health Literature - Elton B. Stephens Company (CINAHL-EBSCO) and Public Library of Science (PLoS). These databases were specifically selected because of their comprehensiveness and potential to cover as many medical journals as possible. They were also recommended by the university librarian because they were updated and they provided a broad coverage of many topics within medicine and allied health sciences.

The university librarian also assisted in designing the search strategies. A string of controlled vocabulary and keyword searching was used. To standardize the results, the same keywords were used in all of the eight electronic databases. The search query keywords consisted different terms and synonyms for HIV infection and HIV testing, the target key-populations and their abbreviations and different popular geographic areas in Thailand, all of which were considered to be central and related to the topic. Refer to Table 1 for the actual search strategy used in PubMed, as an example. There were no timeframe or study design filters applied to the searches, nor were there any language limitation specified.

TABLE 1| Sample search strategy used in PubMed Search strategy (Title/Abstract)

#1 HIV (306,472)

#2 Human Immunodeficiency Virus (86,266)

#3 AIDS (147,710)

#4 Acquired Immune Deficiency Syndrome (5,907)

#5 OR / #1, #2, #3, #4, #5 (397,676)

#6 test (1,429,029)

#7 testing (530,037)

#8 screening (509,297)

#9 screen (123,883)

#10 detection (855,762)

#11 detect (362,773)

#12 OR / #6, #7, #8, #9, #10, #11 (3,164,801)

#13 MSM (9,808)

#14 men who have sex with men (10,913)

#15 LGBT (1,410)

#16 TGW (237)

#17 transgender women (920)

#18 gay (10,823)

#19 bisexual (8,384)

#20 homosexual (9,357)

#21 transgender (5,362)

#22 OR / #13, #14, #15, #16, #17, #18, #19, #20, #21 (35,886)

#23 Thailand (79,710)

#24 Thai (13,958)

#25 Bangkok (3,654)

#26 Chiang Mai (1,327)

#27 Pattaya (27)

#28 Phuket (179)

#29 OR / #23, #24, #25, #26, #27, #28 (81,796)

#30 AND / #5, #12, #22, #29 (147)

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Stage 3: Study Selection

In this scoping review, the study selection process involved three phases. The first phase focused on eliminating duplicate publications. To do this, the citation files (.RIS) of all the search results from the eight electronic databases were imported into the reference management program EndNote version X9.2. In this program, all the articles, conference abstracts and publications that were identified in framework stage 2 were alphabetically listed, which made it easier to scan the list for duplicates. A manual comparison of citation details and abstracts of the articles with the same title and/or author was done.

The initial examination of the unique, non-duplicated publications indicated that the search strategy had picked up many irrelevant studies. Thus, there was a need to exclude studies that did not address the objective and/or the research questions. This led to the second phase of the study selection. As suggested by Arksey and O’Malley in 2005 (19, 20), a set of inclusion and exclusion criteria were established to determine the relevance of each citation/record to the topic. These criteria were formulated post hoc, as the author became increasingly familiar with the literature and topic. Each title, with its corresponding abstract, were reviewed based on the inclusion and exclusion criteria. The articles were then divided into three groups: articles to be excluded, articles to be included, and those with undetermined relevance. In the case of the third group, the author had to acquire and read the full text articles to establish their relevance.

Inclusion criteria

The inclusion criteria were in line with the PCC (Population, Concept, Context) elements developed by Joanna Briggs Institute (22). Therefore, all studies to be included should:

• Include Thai MSM and/or TGW as their target population, or one of their target populations

• Delve into the topic of HIV testing

• Have been conducted in Thailand.

In addition, these studies or topics were also included given that they also meet all the aforementioned inclusion criteria:

• Studies about HIV testing conducted in Asia or Southeast Asia, where Thai MSM and/or TGW were included as one of the target populations.

• HIV testing as part of Preexposure profylaxis (PrEP) and/or Postexposure profylaxis (PEP)

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• Studies that focused on factors or risk behaviors that may influence the uptake of HIV testing

• Epidemiologic profiling of MSM and/or TGW who participate in HIV testing Exclusion criteria

The exclusion criteria were also in line with the PCC elements. Excluded studies were those that:

• Did not include Thai MSM and/or TGW as (one of the) specified target population(s).

• Had the general Thai population as subjects.

• Did not focus on HIV testing

• Was not conducted in Thailand.

Studies with the following main topics without a component that focused on HIV testing, were excluded:

• HIV vaccine

• HIV and other sexually transmitted diseases (STDs)

• HIV-related infections and diseases

• HIV testing of stored blood samples in blood banks

• Antiretroviral treatments (ART) for HIV

• PrEP and/or PEP

• Intravenous drug use and HIV

• Molecular epidemiology of HIV subtypes

• Knowledge on HIV prevention

• Condom use

• Risk factors for HIV transmission

The third phase of the study selection process also involved screening and reviewing the full text of those in the “undetermined relevance” group. This was done because at this stage, the abstracts alone cannot be relied upon as representative of the entire article, especially for those whose eligibility to be included in the study was in question. This screening approach was important because titles and abstracts alone did not reflect some points and claims that were relevant to the topic. All the articles that were assessed to be relevant after the third phase of the study selection process were taken further into stage 4.

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Stage 4: Charting the Data

The main purpose of charting the results in a scoping review is to provide readers with a logical and descriptive summary of the results (22). To have a clear and systematic presentation of the included articles, they were charted in a table with the following headings: author(s), title and type of publication, publication year, objectives, study population, research method, data collection and key findings of relevance for HIV testing. Findings and conclusions that were of great significance in relation to the objectives of this review were noted in the chart. By doing so, the author was able to summarize and make comparisons of the studies across different research designs, study populations and data collection strategies, and this highlighted not only studies whose findings supported each other, but also those that have some contradictory findings. This chart is presented in table 2 in the results chapter of this review.

Stage 5: Collating, Summarizing and Reporting the Results

Synthesis of the studies included characterization of the material and a thematic (or content) analysis of it:

Characterization of the material

After all the articles had been charted, the author summarized the general characteristics of the collated publications in order to generate an overview of their publication years, the locations where the studies had been conducted, whether or not full texts were available, the length of publications (number of pages), relation to other studies, sample sizes, characteristics of the populations studied, the main topics covered and whether or not study limitation(s) had been explicitly stated. This work was done with the assistance of Microsoft^® Excel^® 2016. Totals were tallied and percentages were calculated based on different nominal data.

Thematic analysis

For the thematic analysis, the program NVivo^® 12 was used. Theme analysis pertains to the process of identifying themes assumed to be important to the research topic while describing the phenomenon being studied and reviewed at the same time (23). In this approach, pattern recognition was conducted within the pool of data, resulting in emerging themes that became the basis for analysis (24). Relevant sentences, phrases and paragraphs in each of the articles were coded and similarly coded portions of the texts thereafter grouped together. A set of temporary or provisionary codes were used throughout this process while the final set of codes

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10 were formulated post hoc. Organizing the studies and literature thematically was challenging and time-consuming process because of the great diversity among them.

The presentation and summary of the material included in this scoping review did not focus on the “weight” of evidence of the quality of the research papers because according to Arksey and O'Malley, a scoping study is not about assessing the quality of evidence and is not used to determine if a particular study provide robust or generalizable findings (19). Results of stage 5 is presented in both tabular and narrative forms.

Results

This review focused on describing the landscape of available literature on the topic of HIV testing among MSM and TGW in Thailand. The results of this scoping study were divided into four sections: the selection process, chart presentation (also known as the stage 4), characterization of the material and thematic analysis. The last two sections are products of the work done under stage 5.

The selection process

The eight electronic databases were searched with the keywords listed in Table 1. The initial search yielded 735 potentially relevant publications which were broken down as follows:

PubMed n=147, Scopus n=191, IMSEAR n=0, MEDLINE (Ovid) n=55, WOS n=190, Global Health n=78, CINAHL-EBSCO n=72 and PLoS n=2. 147 stated English as the language in which the article was written in, while the other 586 citations had no specified language. Of these 735 potentially relevant publications, 402 were duplicates and thus eliminated from the list. The remaining 333 articles were analyzed based on their title and abstract. 242 articles were excluded based on the inclusion/exclusion criteria, while a total of 45 articles met the eligibility criteria and were included in this study. However, the remaining 46 articles had undetermined relevance based on their titles and abstracts, so full text of these articles had to be obtained and reviewed to determine their eligibility to be included in the final pool of publications in this scoping review. Five articles from this group were eventually determined to be relevant, while the other 41 articles were excluded. The final material consisted of 50 articles and conference

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abstracts written in English. The author was able to obtain 43 full text articles. The remaining 7 publications were abstracts presented at different conferences, congresses or symposia, and full text of these studies were not available. Despite this, these abstracts were included in this scoping review because of the relevance of the information they presented in relation to the objectives of this review.

The flow of the articles from the identification process, through the screening process and to the final inclusion phase is represented in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart in Figure 1.

FIGURE 1| PRISMA flowchart of identification of relevant studies and study selection process

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Chart presentation

Charting the publications included in this scoping review was an important part of this study because it gave an overview of all the articles, which made it easier to draw connections and conclusions from the publications collected. The results of the work done in stage 4 is found in table 2 which is presented on the next page. For reference, it should be noted that many of the studies included in this scoping review did not have HIV testing as their main topic. Therefore, what has been described in the key findings column may not always align with or specifically answer the objectives stated in the objective(s) column. Only key findings related to HIV testing were included in the chart.

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TABLE 2 | Summary of included literature relevant to HIV testing av MSM and/or TGW in Thailand

Author(s) Title and type of Publication

Publication Year

Objective(s) Study population

Research method

Data collection

Key findings of relevance for HIV testing Remarks 1 Anand et al.(25) Journal

Innovative strategies using communications technologies to engage gay men and other men who have sex with men into early HIV testing and treatment in Thailand

2015 To evaluate the effectiveness of the online-to-offline platform of Adam’s Love website in linking MSM to HTC services.

1181 MSM recruited online via Adam’s love website

Quantitative Descriptive, based on primary data

Survey, Social media analytics, Adam’s Love website, HIV testing at partner clinics

The article described the experiences related to a Thai website, and how it can potentially be utilized in scaling up HTC services. www.adamslove.org, was created by the Thai Red Cross AIDS Research Center (TRCARC) in 2011 and has engaged many online MSM users to take part in their online services like comprehensive HIV information and message boards, promotion of HTC, referral to testing centers, and many other services. The website has contributed to a 25% increase in the total number of MSM that went to the TRCARC for an HIV test in 2012. Analysis of the online behavioral survey revealed that majority of the MSM recruited online to HTC were young (between 14-25 years old) and are not open with their gender identity

(closeted/discreet). Social media analytics showed that HIV information videos with male celebrities and gay personalities, as well as non-financial incentives has increased the participation of MSM into HTC services. The website’s ‘online-to- offline’ recruitment model can scale up recruitment to HTC among MSM.

Data are more likely biased towards gay men and other MSM, as the study recruited only a small proportion of transgender individuals (1.6%) into HTC services.

2 Anand et al.(26) Journal

Implementation of an online HIV prevention and treatment cascade in Thai men who have sex with men and transgender women

2017 To analyze participant

characteristics based on their preference of HTC delivery model in Adam’s Love electronic health record system (EHR), and

186 MSM and TGW

Survey, EHR system in Adam’s Love website

This article presented the web browser- based EHR system which was added to the Adam’s Love website in 2015. It had three models of linking its users to HIV testing and counseling. Statistical analysis of the results showed that the traditional HTC model (both pretest counseling and HIV testing at the clinic) appealed to those who identified themselves as gay, while those

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Publication Year

Research method

Data collection

Key findings of relevance for HIV testing Remarks using Adam's Love

Electronic Health Record system

to identify which model is the most feasible based on usage and revisits to the EHR.

that identified themselves as bisexual, are young (median age 25 years) and those with high-risk sexual behaviors were more likely to prefer either the hybrid model (online pretest counseling, HIV testing in the clinic), or the electronic HTC (eHTC) model (Online pretest counseling and online supervised HIV testing). Based on the usage and revisits to the EHR, that the hybrid model was argued for as “possibly the is the most feasible, acceptable and engaging model” (page 21) among the three models.

3 Anand, et al.

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Journal

A novel Online-to- Offline (O2O) model for preexposure prophylaxis and HIV testing scale up

2017 To conduct a pilot test of Adam’s Love Online-to-Offline (O2O) model and to evaluate its effect on the uptake of HIV testing.

425 MSM and TGW who received eCounseling and e-tickets from Adam’s Love website

QR code tracking and online metrics, online questionnaires , Adam’s Love website

This article presented the pilot study conducted to measure HIV testing uptake done via the O2O model of Adam’s Love website. 76,5% of those who received online counseling and received e-tickets actually checked-in at an offline HIV testing site, with the majority preferring Thai Red Cross anonymous clinic over community-based HIV testing centers. The difference in the preferred HIV testing site was mainly because of confidentiality concerns and fear of being stigmatized.

Median time between receiving an e-ticket and checking in at the testing center (Interquartile range, IQR) was 3 days.

Because of satisfactory high HIV test uptake and short IQR, the pilot study proved that the O2O model is highly effective in linking online at-risk MSM and TGW to HIV testing services.

The study also evaluated PrEP uptake among subjects that tested negative for HIV.

4 Budkaew, et. al (27)

Journal

Factors associated with the decision to have HIV antibody testing among Thai

2015 To assess the factors related to the decision to undergo an HIV testing among Thai MSM during the previous

100 MSM attending Chatapadung STD clinic in Khon Kaen Hospital

Mixed quantitative and qualitative methods, Descriptive,

Self- administered questionnaires , Interview

In this article, statistical analysis identified that being >24 years old, a history of having an STD, and having a positive attitude about HIV testing were all significantly associated with a previous HIV test. During the interview, the participants revealed their

This article focused on MSM.

No TGW participation was specified.

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Publication year

Research method

Data collection

Key findings of relevance for HIV testing Remarks men who have sex

with men

12 months based on

primary data

motivations for getting an HIV test, which included their desire to know their HIV status, as well as compliance to their employer-mandated HIV test requirement.

Furthermore, the most common reasons for not getting an HIV test among interview participants without previous HIV testing experience were fear of the results should it turn positive, perception of having no risk for getting HIV, and their perception of HIV testing as a time-consuming procedure. In order to enhance the uptake of HIV testing, it should be made simple, inexpensive, quick, anonymous, and it should focus on young MSM (< 24 years old) as well as those with poor attitudes toward HIV testing

5 Chariyalertsak et al. (28)

Journal

HIV incidence, risk factors, and motivation for biomedical intervention among gay, bisexual men, and transgender persons in Northern Thailand

2011 To describe the characteristics of MSM and TGW that attended an HIV testing and pre- screening for the iPrex pre-exposure chemoprophylaxis trial and to assess their interest to participate in future HIV prevention trials

551 MSM and TGW clients who presented for HIV testing at the Prevention of Infection in Man (PIMAN) center in Chiang Mai, Thailand

Questionnaire, Serum testing for HIV antibodies using Determine HIV-1/2 (Abbott), ELISA as confirmatory test for positive sera.

In Chiang Mai, PIMAN center is the only MSM and TGW HTC center. Among the participants, 55.9% had a history of previous HTC, more common among MSM than TGW (60,2% vs 43,6% respectively).

The HIV prevalence was 12,9% among the study population. Univariate and

multivariate logistic regression identified that the population of MSM and TGW seeking HIV testing are young (below 24 years old), well-educated and markedly at- risk for HIV infection due to their risky sexual behaviors (e.g. condomless anal sex). During the 20-month period this study was conducted, only 11,4% of the visiting clients had more than 1 VCT at the clinic.

Due to a small subset of participants that returned for another HIV test, the authors suggested that prospective data from a less selected population of MSM and TGW were required for better estimation of the incidence of HIV in this population in this region.

Only 25,4% of the study population were TGW.

The study also discussed the motivation of the study population for Biomedical HIV prevention trials.

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16

Publication year

Research method

Data collection

Key findings of relevance for HIV testing Remarks 6 Chariyalertsak

et al. (29)

Book chapter Implementing biomedical HIV prevention advances in Thailand.

2014 To present a picture of HIV situation in Thailand reflecting on its past and present experiences in combating the HIV epidemic, achievements and barriers in their HIV prevention

strategies. This book chapter also presented the lessons learned from the challenges and controversies in Thailand’s HIV prevention strategies.

Not applicable Knowledge synthesis, Descriptive, based on secondary data

Data and information from different articles, journals, public documents, policies and statistical records

Successful interventions against HIV that Thailand has implemented in the past years dealt and addressed only the needs of easy- to-reach target populations. This explains why Thailand still has low HIV testing coverage among the members of the MSM population, a hard-to-reach risk group. New strategies aimed at increasing VCT coverage among key affected populations, such as rapid and routine testing, mobile testing and a drive to normalize HIV testing by promoting National HIV testing days, were mentioned in this chapter. Opinions and information coming from the members of the MSM and TGW populations should be considered before any implementation strategy is designed and adopted.

7 Guadamuz et.al (13)

Journal

Young, Online and in the Dark: Scaling Up HIV Testing among MSM in ASEAN

2015 To identify the characteristics of MSM who never test themselves for HIV, their reasons for not doing so, and to find out other barriers to HIV testing

4,310 MSM from the 10 member countries of the

Association of Southeast Asian Nations (ASEAN). Of these, 697 participants were from Thailand.

Analyzed data from Asian Internet MSM Sex Survey (AIMSS)

Of the 697 Thai MSM who participated in the online survey, 21.4% have never tested for HIV. Practice of unprotected anal sex, self-perceived low risk for HIV infection, being heterosexual or bisexual, and fear of getting a positive HIV test result were characteristics of MSM in this region that were positively correlated to having never tested for HIV. Other reasons negatively correlated to getting tested for HIV were concerns about the cost of testing and eventual treatment, fear of needles and lack of knowledge about where to get tested.

Rapid scale up in HIV testing among MSM in Thailand should be implemented as a part of the country’s law on universal access to anti-retroviral treatment. The use of geo-spatial apps and social media as a creative way in raising acceptability of regular HIV testing among MSM was suggested in this article.

Data came from countries that are members of the ASEAN.

Independent correlates of never testing for HIV was not analyzed per country.

Therefore, the characteristics mentioned were not country- specific. No participants from the TGW population were mentioned in the article.

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Publication year

Research method

Data collection

Key findings of relevance for HIV testing Remarks 8 Hiransuthikul,

et al. (30)

Journal Changes in risk behaviors among Thai men who have sex with men and transgender women enrolled in the test and treat cohort

2019 To determine the changes in risk behaviors during a 24-month study period among 3 groups of MSM and TGW participating in a teat-and-treat cohort

689 MSM and TGW enrolled in a Test and Treat Demonstratio n Project; of which are 115 HIV positive, 50

seroconverters and 524 HIV negatives

Quantitative Experimen- tal based on primary data

HIV testing at baseline and every 6 months thereafter.

Online self- administered questionnaire

A significant reduction in risk behaviors was observed among HIV positive participants (HIV positive at enrollment to the program), which strengthened the evidence that health education given through the test-and-treat program helped HIV positive individuals into avoiding risky behaviors. In contrast, seroconverters (initially HIV negative but became HIV positive during the study period), who had a higher risk behavior level at baseline compared to the other groups, continued to practice high-risk behaviors even after being infected with HIV, and despite health education provided during HIV testing sessions. The HIV negative group (participants who remained HIV negative throughout the study period) had the lowest baseline risk behavior levels among the three groups, and it remained low throughout the study. This group however, had a constant trend of having multiple sexual partners combined with increased condom use.

Free condoms, health education and risk reduction counseling were provided to participants every HTC session done every 6 months.

Changes in risk behaviors were measured based on 5 risk behaviors: STI during follow-ups, multiple sexual partners in the past month, UAI, self-perception of risk, use of amphetamine in the past month.

9 Janamnuaysook et. al (31)

Poster discussion abstract

Integrating gender- affirming hormone treatment (GAHT) into HIV services facilitates access to HIV testing, syphilis testing, PrEP, and other sexual health services among transgender women in Thailand

2019 To explore the effects of integrating GAHT into HIV services for TGW in Thailand

1886 TGW who attended the Tangerine Community Health Center

Not specified GAHT integration to HIV services resulted in higher access to HIV testing services among TGW. Combination of these two services at one place is beneficial since TGW not accessing GAHT were found to be more susceptible to HIV infection.

It bridges TGW seeking help for hormonal treatment to HIV testing, as well as rapid referral to ART for those who tested positive for HIV.

This abstract is included in the 10^th IAS Conference on HIV Science. Full text was not available online.

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18

Publication year

Research method

Data collection

Key findings of relevance for HIV testing Remarks 10 Janamnuaysook

et. al (32)

Integrated gender affirmative hormone treatment services improve access to and retention in HIV testing, syphilis testing and PrEP service uptake among transgender women in Thailand

2018 To examine the potential role of GAHT-services as a starting point in facilitating uptake of HIV testing and other sexual health services.

972 TGW who attended the Tangerine Community Health Center

Not specified Participants that got GAHT were more likely to revisit HIV testing clinics and they consequently had higher rates of repeat HIV testing (32% vs 25%, p = 0.019).

TGW not availing themselves of the GAHT services had lower income, higher HIV prevalence (13% vs 3%, p<0.001) and a trend towards higher HIV incidence compared to those who used GAHT services. The study concluded that GAHT services should be fully integrated in subsidized HIV and sexual health packages for TGW.

This abstract is included in the 22^nd International AIDS Conference.

Full text was not available online.

11 Jantarapakde et.

al (33)

Online supervised HIV self-testing identified high HIV yield among Thai men who have sex with men and transgender women

2018 To evaluate HIV positive/reactive rates and linkage to ART among MSM and TGW in an online supervised HIV testing study, compared to those who got a clinic- based HIV testing

564 participants, 465 of which are MSM and 99 are TGW.

Self- administered questionnaires HIV testing, supervised online HIV self-testing

Most of the participants preferred Online HTC (online pretest counseling and online supervised testing). Baseline HIV positive result was 14.4% for the online group, while it was 13% in the group that received clinic-based HTC. HIV prevalence was lowest (3.2%) among those that received pretest counseling online and HIV testing at the clinic. A challenge that was pointed out was about how to effectively link those that tests HIV positive at home to clinics for confirmatory tests.

This abstract is included in the 22^nd International AIDS Conference.

Full text was not available online.

12 Johnston et. al (34)

Journal

Recent HIV Testing Among Young Men Who Have Sex with Men in Bangkok and Chiang Mai:

HIV Testing and Prevention Strategies Must Be Enhanced in Thailand

2016 To evaluate associations of HIV testing and sexual risk behaviors among young MSM (YMSM) based on data collected from a behavioral risk survey conducted in Bangkok and Chiang Mai

A total of 510 YMSM (267 from Bangkok, 243 from Chiang Mai)

Surveys and interviewer- administered questionnaires via

respondent- driven sampling

Among YMSM (ages 15-24), the rate HIV testing is 2.75 times higher in Bangkok compared to Chiang Mai. One-quarter of participants in Bangkok and three quarters of YMSM had not undergone HIV testing during the past 12 months. These findings were likely due to the greater availability of testing centers in Bangkok (91 public and private MSM testing centers) as compared to Chiang Mai (1 MSM testing center).

Lower levels of HIV knowledge and the rate of inconsistent condom use was higher among participants in Chiang Mai. Use of.

(25)

Publication year

Research method

Data collection

Key findings of relevance for HIV testing Remarks illegal drugs and alcohol to enhance sex

was reported by 60% of the participants in both cities, a factor found to increase the odds for HIV testing. Reasons for this correlation were unclear. Other factors that were positively and significantly correlated with increased HIV testing in both cities were employment, being open about gender identity and sexual debut ≤ 15. Issues were raised regarding the need for increased awareness on HIV testing centers, as well as promotion of accurate self-assessment of HIV risk. Suggestions included the need to increase youth- and MSM- friendly clinics in Chiang Mai and distribution of self-test kits to address privacy and stigma concerns 13 Khawcharoen-

porn et. al (35)

Journal

Active targeted HIV testing and linkage to care among men who have sex with men attending a gay sauna in Thailand

2017 To evaluate the feasibility of conducting an active targeted HTC and linkage to care among Thai MSM attending a gay sauna

358 MSM attending a gay sauna in Pathumthani, Thailand

HTC (including pre- and posttest counseling), survey, follow-up calls monthly

59% of the participants declined to get tested for HIV at a gay sauna. The remaining 41% underwent HTC, where 17% tested positive for HIV. 56% of those who tested positive for HIV were successfully linked to continuity of care.

Based on the acceptance rate of 41% and detection of HIV in 17% among those who got HTC, active targeted HTC in a gay sauna could be conducted provided that the preparations were sufficient and well- coordinated with the authorities, relevant organizations and the sauna owner.

Unwillingness to participate is mainly due to privacy concerns and time constraints, while factors identified to be associated with declining HTC in a sauna included recent HTC in the last 6 months, age >25, being married, and false perception of low HIV risk. Addressing these factors are needed to overcome obstacles in implementation of HTC among MSM in gay hotspots such as a gay sauna.

A scoping review of HIV testing among men who have sex with men (MSM) and transgender women (TGW) in Thailand "S*CK. F*#K. Test. Repeat"

"S*CK. F*#K. Test. Repeat"