silom community clinic monday, 4 august 2008, 11:00 – 12:30, session room 7 moac0105 successful...

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



• 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



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



• 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



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



Study locationSilom Community Clinic, 3rd Floor Bangkok Christian Hospital, Silom, Bangkok, Thailand

Bangkok



Recruitment of study participants• Existing VCT clients • Onsite recruitment• Community Based Organization • Website (www.silomclinic.in.th)



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



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



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)



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)



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



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



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



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



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)



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



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



Chatuchak

Rattanakosin

SilomSukhumvit

Ramkhumheang

Silom Community Clinic

MSM hot spots in Bangkok, Thailand



• 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



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



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



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



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



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



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)

silom community clinic monday, 4 august 2008, 11:00 – 12:30, session room 7 moac0105 successful...

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