Acceptability of Pre-Exposure Prophylaxis among MSM and TG in Northern Thailand

1. Acceptability of Pre-Exposure Prophylaxis among MSM and TG in Northern Thailand Daniel Yang, MD Candidate* Fogarty International Clinical Research Scholar Research Institute for Health Sciences Institute (CMU) Johns Hopkins Bloomberg School of Public Health International AIDS ConferenceWashington D.C July 24, 2012 *On behalf of C. Chariyalertsak, A. Wongthanee, S. Kawichai, K. Yotruean, T.E.Guadamuz, V. Suwanvanichkij, C. Beyrer, S. Chariyalertsak

2. Chiang Mai, Thailand

3. Background • HIV incidence and prevalence high among MSM and TG in Chiang Mai, Thailand • Oral PrEP is an HIV prevention approach that involves the regular use of antiretrovirals (ARVs) by people who are HIV-negative. • iPrEx trial: demonstrated 44% overall efficacy of daily oral tenofovir/emtricitabine for preventing HIV in MSM/TG participants

4. Purpose • Investigate the prevalence of PrEP awareness post-iPrEX • Determine PrEP acceptability and demographic/behavioral correlates for acceptability • Separate analysis for MSM and TG

5. Methods • Jan. to Feb. 2012, 238 participants completed a self-administered survey on handheld computers • Collaboration with Chiang Mai Province Public Health Office • Eligibility Criteria: • Male sex at birth • Age ≥ 18 years old • Self-reported HIV un-infected or of unknown status • Anal or oral sex with a man in the last 6 months

6. Methods • Recruitment: Venue-day-time sampling (VDTS) • Entertainment venues - bars, discos, saunas, and massage parlors • Educational venues - universities and vocational schools. *Photos taken in Chiang Mai during iPrEX recruitment.

7. Primary Outcome • For this survey, we define PrEP as the daily use of antiretroviral tablets ‘before’ sex by HIV-negative individuals to reduce their risk of infection with HIV. • If PrEP was 50% effective in preventing HIV infection, how likely are you to use PrEP as an HIV prevention method? 1 – very unlikely 2 – somewhat unlikely 3 – somewhat likely 4 – very likely = accept PrEP

8. Results • 326 individuals completed the screening questionnaire at 17 venues • 131 MSM and 107 TG were eligible and completed the survey (73% of total screened) • Mean age 23.7 (MSM); 21.8 (TG) • Prior awareness of PrEP - 66% of both MSM and TG – (NS) • PrEP acceptability - 41% (MSM) and 37%(TG) – (NS)

9. MSM vs. TG *Bold, p<0.05

10. Results • Correlates of PrEP Acceptability (MSM) • Lifetime history of STIs – 21% • aOR4.58, p<0.01) • Previous HIV testing – 57% • (aOR 2.30, p=0.046) • Regularly planned sex, defined as having made intentional arrangements to have sex – 22% • aOR3.37, p=0.01 • Infrequent sex, once per month or less – 45% • aOR3.00, p<0.01

11. Results • Correlates of PrEP Acceptability (TG) • Having private insurance – 12% • aOR5.01, P=0.02 • Prior awareness of PrEP – 66% • aOR3.30, P=0.02

12. Discussion • Prior awareness of PrEP over 60% - higher than previous surveys which ranged from 16% to 25%. • Chiang Mai was a site of the iPrEX trial • PrEP acceptability moderate at around 40% - lower than previous surveys which ranged from 44-74%. • Lower efficacy (50%)  Lower acceptability

13. Discussion • Correlates of PrEP Acceptability (MSM) • Lifetime History of STIs and Previous HIV Testing • Greater familiarity with health care professionals (promising for PrEP roll-out) • Expanded voluntary HIV counseling and testing (VCT) may improve uptake of PrEP • Infrequent Sex and Planned Sex • Intermittent PrEP may well suited for this population

14. Discussion • Correlates of PrEP Acceptability (TG) • PrEP Awareness • Increasing awareness of PrEP with educational campaigns may also improve uptake. • Among TG, high prevalence of concern regarding treatment interactions between PrEP and other medicines (e.g. female hormones) • Private insurance • Cost is a significant barrier to PrEP acceptability • Financial support needed to subsidize or cover the costs of PrEP. • Limitations: VDTS selection bias, social desirability bias, intent-to use PrEP may not reflect actual behaviors.

15. Conclusion • MSM and TG are distinct populations • Maximizing future PrEP uptake in Northern Thailand: • Educational campaigns to increase awareness • Expanded HIV VCT services to MSM and TG • Financial subsidies to reduce the cost of PrEP

16. Acknowledgements • Mentorship • RIHES: Dr. Suwat Chariyalertsak • JHU: Dr. Chris Beyrer • Fellowship Support • Fogarty International Clinical Research Scholars Program, Fogarty International Center, FICRS-F Support Center at Vanderbilt University • Daniel Yang was supported by the National Institutes of Health Office of the Director, Fogarty International Center, Office of AIDS Research, National Cancer Center, National Eye Institute, National Heart, Blood, and Lung Institute, National Institute of Dental and Craniofacial Research, National Institute On Drug Abuse, National Institute of Mental Health, National Institute of Allergy and Infectious Diseases, and National Institutes of Health Office of Women’s Health and Research through the Fogarty International Clinical Research Scholars and Fellows Program at Vanderbilt University (R24 TW007988) and the American Relief and Recovery Act.

17. Thank you!! *Special Thanks to Dr. SuwatChariyalertsak, Dr. VoravitSuwanvanichkij, Dr. SurindaKawichai, Peter Lange, KhunAntikaWongthanee, KhunPongpunSaokhieo, Dr. Chris Beyrer, Dr. Thomas Guadamuz, KhunChonlisaChariyalertsak and the Chiang Mai Province Public Health Office.

18. Definition of PrEP • Oral pre-exposure prophylaxis is an HIV prevention tool that involves use of medicines to treat HIV called antiretroviralsby people who are HIV-negative. • For this survey, we define PrEP as the daily use of antiretroviral tablets ‘before’ sex by HIV-negative individuals to reduce their risk of infection with HIV.

19. Primary Outcomes • If PrEP was 50% effective in preventing HIV infection, how likely are you to use PrEP as an HIV prevention method? 1– very unlikely 2–somewhat unlikely 3 – somewhat likely 4– very likely • Have you heard of PrEP for HIV prevention before this survey? 1– yes 2 – no