Thai testing campaign suggests how local cultures can influence testing behaviour

A campaign to encourage Thai gay men and other men who have sex with men (MSM) to test at least once a year for HIV has had modest success, a study presented at the Eighth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2015) in July in Vancouver reveals, with repeat testing rates increasing slightly over the study period.

However, rates of re-testing are, at about 25% within a year, far below the 90% recommended by the Thai Ministry of Public Health (MOPH).

One of the most intriguing aspects of this study is that testing was far more likely around men’s birthdays and during festival periods. While there has been no qualitative work to ask why, researchers suggested that Thai Buddhist ideas about performing 'good deeds' on birthdays could be capitalised on to increase testing rates.

The study

The Silom Community Clinic is the largest HIV clinic for MSM in Thailand, and since its foundation in 2005 has served nearly 10,000 clients who have averaged four visits each.

Glossary

hepatitis A virus (HAV)

The hepatitis A virus is transmitted through contaminated food and water, as well as human faeces. It can be passed on during sex, particularly rimming (oral-anal contact). Symptoms usually last less than two months, although they continue in some people for up to six months. Drug treatment is not needed. A vaccine is available to prevent hepatitis A.

 

pathogenesis

The origin and step-by-step development of disease.

qualitative

Qualitative research is used to explore and understand people’s beliefs, experiences, attitudes or behaviours. It asks questions about how and why. Qualitative research might ask questions about why people find it hard to use HIV prevention methods. It wouldn’t ask how many people use them or collect data in the form of numbers. Qualitative research methods include interviews, focus groups and participant observation.

retention in care

A patient’s regular and ongoing engagement with medical care at a health care facility. 

syphilis

A sexually transmitted infection caused by the bacterium Treponema pallidum. Transmission can occur by direct contact with a syphilis sore during vaginal, anal, or oral sex. Sores may be found around the penis, vagina, or anus, or in the rectum, on the lips, or in the mouth, but syphilis is often asymptomatic. It can spread from an infected mother to her unborn baby.

When clients come for HIV tests, they receive pre- and post-test counselling and risk reduction advice, which also includes a recommendation to come back for another test within twelve months or if they have symptoms suggesting a sexually transmitted infection (STI) – syphilis, hepatitis A and hepatitis B tests are always done and STI screening is performed if there are symptoms.

For the purposes of this study only men who had a record of clinic attendance lasting longer than a year and whose first clinic visits took place between the beginning of 2006 and the end of 2013 (with follow-up to October 2014 for repeat visits) were counted.

This amounted to 4597 men. A third of them were under 25 at their initial visit and most (88%) were Thai nationals. There was in fact quite good retention at the clinic with half of the men attending for at least a four-year period.

However only 44% (2016 men) actually had more than one HIV test at the clinic (some may have had tests at other clinics), and only 23% (1036 men) had even one test that was less than twelve months after a preceding test. The median interval between HIV tests was 17 months.

During the study period the proportion of men who re-tested within a year after their first test, increased from 20.4% of those who first tested during 2006 to 2010 to 25.1% whose first test was between 2011 and 2013. There was a 50% increase in the likelihood of testing within a year (including men who tested more than twice) after October 2010; this may be to do with the MOPH making its recommendation of six- to 12-monthly testing for MSM around this time.

Men under 25 were 20% more likely to re-test within a year and not surprisingly anyone who tested because they had a confirmed STI was 3.7 times (270%) more likely to re-test within a year.

The strongest correlations for re-testing were unexpected, however. Clinic clients who re-tested were 4.5 times more likely to do so during the month of their birthday. And they were 6.1 times more likely to re-test during the months of February, March and May. In the latter case, the researchers see this as being linked with three major public festivals/holidays: the ‘western’ New Year in January, the Chinese New Year and Valentine’s Day in February, and the Thai New Year and water festival (Songkhran) in April.

Comments and conclusions

Aidsmap.com asked study presenter Timothy Holtz from the US Centers for Disease Control (CDC) who are supporting the study along with the MOPH, why there was such a strong correlation of testing with birthdays and festivals.

He said: “Our answers are only hypotheses…but regarding birth month, per our common understanding of cultural practices in Thailand, Thai citizens like to perform ‘good works’ or a ‘good deed’ on the occasion of their birthday. This is apparently quite common at Buddhist temples, and there is commercial involvement in trying to get Thais to do a small deed or good works that day. Getting tested to make sure that they are free of HIV could be one of the good deeds they consider.

“As for festivals, this may be related to knowledge or fear of HIV exposure during ‘party events’ over the holidays. This is concordant with Tuesdays, the first day the clinic is open after a weekend, being the busiest weekday for tests.”

Festivals are certainly risky times in Thailand: they are associated with drinking, and road deaths double during the Thai New Year period. The clinic does not currently send out re-test reminders but clearly reminders could be timed to coincide with the times clients are most minded to test.

Previous studies have found very high HIV prevalence and incidence in gay men, including young men, especially in Bangkok. Repeat testing does seem to help to prevent HIV. A separate poster presented at the conference, by the same researchers but featuring just the 2209 men who received more than one HIV test between October 2005 and August 2014, found that the chances of remaining uninfected by HIV increased by 80% for each additional HIV test performed and by 130% if the test was performed within a year.

It is not the testing that does this of course; the presumption is that STI treatment plus the regular risk-reduction counselling helps clients avoid HIV, although the causation could run the other way: those more likely to test frequently may also be better at avoiding HIV.

References

Wimonsate W et al (presenter Holtz TH.) Repeat HIV voluntary counseling and testing within one year among men who have sex with men, Bangkok, Thailand 2006-2013. Eighth IAS Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2015), Vancouver. Oral presentation no TUAC0302. 2015.

See presentation slides here.

Wimonsate W et al. Increased counseling and testing visits are associated with remaining HIV uninfected. Eighth IAS Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2015), Vancouver. Poster presentation no MOPED714. 2015.

See poster here.