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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
Successful start of a preparatory HIV cohort study among men who have sex with men (MSM) in Bangkok, Thailand: preliminary baseline, follow-up and HIV
incidence data
Presented by Wipas Wimonsate
Thailand MOPH – U.S. CDC Collaboration, Nonthaburi, Thailand
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
• HIV-1 prevalence among MSM in Bangkok increased from 17.3% in 2003 to 30.7% in 2007
• MSM in Bangkok are an important population for HIV prevention activities and treatment and care services
• Cohort development among MSM in Bangkok may help to evaluate biomedical interventions (prophylaxis, vaccines)
• However, we have no information on HIV-1 incidence, STI prevalence, follow-up rates, and risk factors for HIV infection
Background
30.728.3
17.3
0
5
10
15
20
25
30
35
2003 2005 2007
Year
% H
IV in
fect
ed
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
Study design
• Longitudinal cohort study
• 3 years follow up at 4 monthly intervals
• Oral fluid HIV testing, ACASI questionnaire and risk reduction counseling at every visit
• STI evaluation at baseline
• Blood draw at month 0, 12, 24 and 36 for storage and future testing
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
• Inclusion criteria for eligibility are:
– Thai national
– Male at birth
– Resident of Bangkok or periphery
– At least 18 years of age
– Have had oral or anal sex with another man in the preceding six months
– Availability and commitment for at least 36 months of follow-up
– Willing to provide written informed consent
Study population
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
Expected and actual number of participants, HIV positivesand HIV seroconvertors
during year 1, year 2, and year 3 of the study
ExpectYear 1
ActualYear 1
ExpectYear 2
ActualYear 2
ExpectYear 3
ActualYear 3
Total 1,354 1,292 - - - -
HIV-1 negative 1,114 1,002 - - - -
HIV-1 positive (baseline) 240 290 - - - -
HIV-1 seroconversion 32 34 30 20* 28 …*
* the study is currently in year 2
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
Study locationSilom Community Clinic, 3rd Floor Bangkok Christian Hospital, Silom, Bangkok, Thailand
Bangkok
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
Recruitment of study participants• Existing VCT clients • Onsite recruitment• Community Based Organization • Website (www.silomclinic.in.th)
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
Statistical methods
• Risk factors for HIV infection at baseline– Logistic regression analysis
• HIV incidence– Incidence density calculation
(# of HIV seroconversions / total number of person
years of follow up during interval)– Kaplan-Meier analysis
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul
Number of study participants and visitsApril 2006 – July 2008
2006 2007
Visits 7698(average 45/day)
Participants 1292
2008
Enrollmentcompleted
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
Demographic characteristics at baseline April 2006 – January 2008
N=1292n (%)
Age group (years) : mean 26.8, range 18-56
18-2122-29
30+
238702352
(19)(54)(27)
Education levelVocational/University 781 (60)
Employment statusEmployed 981 (76)
BirthplaceBorn outside Bangkok 831 (64)
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
HIV, HBV, HAV, HCV, HSV-1, HSV-2, TP, rectal CT and rectal NG prevalence at baseline
April 2006 – January 2008
1
57
20
4
96
23
44
27
0
10
20
30
40
50
60
HBV* HAV
% infected
SyphilisHIV HCV CT NGHSV-1 HSV-2 * excluding those positive for Anti-HBs alone and those negative for all markers (HBsAg, Anti-HBc, and Anti-HBs)
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
Risk factors for prevalent HIV infection at baseline April 2006 – January 2008
MultivariateOR (95% CI) P
Age group (years)18-2122-29
30+
1.001.772.32
(1.09-2.87)(1.33-4.09)
0.0220.003
Education levelHigh school or lowerVoc/Tech/University+
1.721.00
(1.23-2.39) 0.001
Employment statusUnemployedEmployed
1.001.70 (1.12-2.57) 0.012
Inhaled nitrates (poppers) (past 4m)NoYes
1.002.29 (1.47-3.58) 0.000
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
OR (95% CI) P
Usual anal sex position Insertive only Practice receptive
Never had anal sex
1.001.71 -
(1.22-2.41) -
0.002
Ever had HIV testNeverEver
1.601.00
(1.16-2.20) 0.004
Worry about getting HIV in the futureAlways to oftenRegularly to never
1.961.00
(1.43-2.68) 0.000
HSV-2YesNo
3.891.00
(2.79-5.43) 0.000
Rectal NGYesNo
2.541.00
(1.45-4.47) 0.001
Multivariate
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
Follow-up ratesamong the HIV negative fraction of the BMCS
(July 2008)
77(202/264)
88(880/1002) 83
(781/940)80
(563/708) 74(335/452)
0
10
20
30
40
50
60
70
80
90
100
4 8 12 16 20
Month follow-up (MFU) visit
Fixed Improves as study progresses
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
5.5(54/985)
2.9(2/69)
6.1(19/311)
4.2(11/263)
7.9(15/190)
5.2(6/116)
0
1
2
3
4
5
6
7
8
9
10
4 8 12 16 20 Total
Month follow-up (MFU) visit
HIV incidence density(54 cases, July 2008)
Mean age at HIV seroconversion: 24 yrsRange 18 – 42 yrs
Per 100 person-yearsFixed Improves as study progresses
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
80
82
84
86
88
90
92
94
96
98
100
0 120 240 360 480 600 720
After 780 days of study, cumulative HIV incidence 9.4%; 90.6% HIV free
Cumulative HIV incidence, Kaplan-Meier method (July 2008)
Pe
rce
nt s
urvi
val
90.6%
Days (4months = 120 days)
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
Conclusions • A preparatory HIV cohort study was successfully started
among MSM in Bangkok
• High HIV and STI prevalence at baseline
• High HIV incidence
• Good follow-up rates
• Risk factors for HIV infection are not different from those
seen elsewhere
• An appropriate population for the evaluation and
implementation of HIV preventive interventions
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
Thank you Co-authors:
Supaporn Chaikummao, Jaray Tongtoyai, Chonticha Kittinunvorakoon, Anuwat Sriporn, Anchalee Varangrat, Pasakorn Akarasewi, Patchara Sirivongrangson, Janet McNicholl, Frits van Griensven
Thailand MOPH – U.S. CDC Collaboration: Warunee Thienkrua, Tareerat Chemnasiri, Patnaree Oungprasertgul, Pechpailin Khlaimanee, Atitaya Sangiamkittikul, Rinda Wongbenchaporn, Waraporn Feangfu, Narongritt Tippanont, Somsak Yafant, Rutt Chuachoowong, Wannee Chonwattana, Michael Martin, Robert Linkins, Michael Malison
Rainbow Sky Association of Thailand:Kamonsate Kenkarnrue, Rapeepan Jommareuang, Danai Linjongrat, Thanachai Chaisewi, Dejchapol Kanlayanamitr
DisclaimerThe data and conclusions presented are those of the authors and do not necessarily represent the views of the US Centers for Disease Control and Prevention
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
Chatuchak
Rattanakosin
SilomSukhumvit
Ramkhumheang
Silom Community Clinic
MSM hot spots in Bangkok, Thailand
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
• Services (free of charge):HIV VCTIf HIV positive: CD4 count, TB evaluation, referral for
ARVHBV testing and vaccinationHAV testingSyndromic STI evaluation
• Development of community relationsCommunity Based Organization (CBO)
Community Advisory Board (M-CAB)
Silom Community Clinic: Tue – Sat, 4 – 10 PM
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
Number of clients and visits to the Silom Community Clinic September 2005 – July 2008 (VCT)
4861
1894
0
1000
2000
3000
4000
5000
6000
Visits
Number
Clients
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
HIV, HBV, HAV and TP prevalence among VCT clients,September 2005 – July 2008 (VCT)
44
33
6
25
0
5
10
15
20
25
30
35
40
45
50
HBV(Anti-HBs+)
HAV
% infected
RPR-TPHIV
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
Current intervention: condom use counseling
% Consistent condom use with all male partners in the past 4 months
43
61 61 64 66 62 65
0
10
20
30
40
50
60
70
80
90
100
Enrol 4 8 12 16 20 24Month follow-up (MFU) visit
Fixed Improves as study progresses
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
Future study: PrEP clinical trial: Truvada
Currently studying the possibility and willingness to
participate in the intermittent Pre and Post exposure
prophylaxis clinical trial of 1,500 MSM participants in the
Bangkok Metropolitan area
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
N=1292n (%)
Sexual identity Homosexual Others
1016276
(79)(21)
Alcohol consumption (4m)Yes 1116 (86)
Used drug (4m)Yes 303 (24)
Sexual characteristics at baseline April 2006 – January 2008
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silomcommunityclinic
Monday, 4 August 2008, 11:00 – 12:30, Session Room 7 MOAC0105
N=1292n (%)
Usual anal position (4m)Insertive onlyPractice receptive
No anal sex
443829
20
(34)(64)(2)
Total # of male partner (4m)0-23+
370922
(29)(71)
Received money or gift for sex (4m)
Yes 256 (20)
Prior HIV test Ever 615 (48)
Worry about getting HIVAlways to often 410 (32)