AIDS and Behavior

, Volume 16, Issue 3, pp 618–625

HIV Risk Behavior Among HIV-Infected Men Who have Sex with Men in Bangkok, Thailand

Authors

  • Pachara Sirivongrangson
    • Sexually Transmitted Infection Cluster, Bureau of AIDS/TB/STIs, Department of Disease ControlMinistry of Public Health (MOPH)
    • Global AIDS ProgramThailand MOPH-U.S. CDC Collaboration
  • Angkana Charoenwatanachokchai
    • Sexually Transmitted Infection Cluster, Bureau of AIDS/TB/STIs, Department of Disease ControlMinistry of Public Health (MOPH)
  • Umaporn Siangphoe
    • Global AIDS ProgramThailand MOPH-U.S. CDC Collaboration
  • Kimberley K. Fox
    • Global AIDS ProgramThailand MOPH-U.S. CDC Collaboration
    • Global AIDS ProgramCDC
  • Naiyana Jirarojwattana
    • Sexually Transmitted Infection Cluster, Bureau of AIDS/TB/STIs, Department of Disease ControlMinistry of Public Health (MOPH)
  • Liesbeth Bollen
    • Global AIDS ProgramThailand MOPH-U.S. CDC Collaboration
  • Naruemon Yenyarsan
    • Sexually Transmitted Infection Cluster, Bureau of AIDS/TB/STIs, Department of Disease ControlMinistry of Public Health (MOPH)
  • Somchai Lokpichat
    • Sexually Transmitted Infection Cluster, Bureau of AIDS/TB/STIs, Department of Disease ControlMinistry of Public Health (MOPH)
  • Orapin Suksripanich
    • Global AIDS ProgramThailand MOPH-U.S. CDC Collaboration
  • Michelle McConnell
    • Global AIDS ProgramThailand MOPH-U.S. CDC Collaboration
    • Global AIDS ProgramCDC
Original Paper

DOI: 10.1007/s10461-011-9884-3

Cite this article as:
Sirivongrangson, P., Lolekha, R., Charoenwatanachokchai, A. et al. AIDS Behav (2012) 16: 618. doi:10.1007/s10461-011-9884-3

Abstract

We assessed prevalence of sexually transmitted infection (STIs), sexual risk behaviors, and factors associated with risk behaviors among HIV-infected MSM attending a public STI clinic serving MSM in Bangkok, Thailand. Between October 2005–October 2007, 154 HIV-infected MSM attending the clinic were interviewed about sexual risk behaviors and evaluated for STIs. Patients were examined for genital ulcers and had serologic testing for syphilis and PCR testing for chlamydia and gonorrhea. Results showed that sexual intercourse in the last 3 months was reported by 131 men. Of these, 32% reported anal sex without a condom. STIs were diagnosed in 41%. Factors associated with having sex without a condom were having a steady male partner, having a female partner and awareness of HIV status <1 month. Sexual risk behaviors and STIs were common among HIV-infected MSM in this study. This highlights the need for increased HIV prevention strategies for HIV-infected MSM.

Keywords

HIVMSMRisk behaviorsSTI

Introduction

HIV prevalence among men who have sex with men (MSM) in Bangkok, Thailand increased from 17 to 31% between 2003 and 2007 [13]. Mathematical models of HIV in Thailand estimate that about 25% of new infections in 2008 were from MSM [4].

In Thailand, there are few clinics that specifically target sexually transmitted infection (STI) and HIV services to MSM. However, in some HIV clinics in Thailand, MSM constitute as many as 25% of HIV-infected male clients [5]. MSM with HIV or STI clinical symptoms typically access STI clinics, anonymous VCT clinics or general outpatient clinics for STI screening, STI treatment, and HIV counseling and testing. Some sex establishments in Thailand require male sex workers to get regular clinical and laboratory screening for HIV and STI at STI clinics [6]. If the men test HIV positive, they are referred to an HIV clinic. Some STI clinics, VCT clinics, and outpatient clinics provide CD4 count testing, opportunistic infection prophylaxis, risk reduction counseling, or counseling on HIV disclosure to partner before referring patients to HIV clinics.

Studies have reported a high prevalence of STIs and sexual risk behavior among MSM [7, 8]. However, limited data on sexual risk behaviors and STI prevalence among HIV-infected Thai MSM are available to guide HIV prevention efforts and STI screening practices. Prevention efforts and STI screening guidelines for HIV-infected MSM are critical to reduce the risk of further HIV and STI transmission [2]. In this paper, we assessed prevalence of STIs, sexual risk behaviors, and factors associated with risk behaviors and STIs among HIV-infected MSM attending a public STI clinic serving MSM in Bangkok, Thailand.

Methods

All HIV-infected MSM attending a public STI clinic in Bangkok were assessed by clinic staff for STI signs and symptoms, sexual risk behaviors, and partner HIV status. MSM attended the clinic for evaluation of STI symptoms or follow-up after STI treatment, for HIV counseling and testing, or for periodic HIV and STI screening as required by sex establishment employers. HIV-infected MSM included those testing positive prior to or on the day of assessment. Demographic, behavioral, and clinical data were recorded in a standardized format in the patient record. Data from patient visits between October 2005 and October 2007 were abstracted for analysis.

Behavioral data were collected through face-to-face interview with a male counselor or nurse. A steady partnership was defined as a sexual relationship lasting at least 2 months with an emotional bond between partners, a casual partnership was defined as a sexual relationship without an emotional bond, and a commercial partnership was defined as a sexual relationship with the exchange of money or goods. STI-related symptoms were defined as urethral or anal discharge, genital or anal pain or lesions, or dysuria.

All consenting men had a genital exam regardless of whether they reported STI-related symptoms. STI-related examination findings were defined as genital or anal ulcer, rectal erythema, yellow or green urethral or anal discharge, and swollen testes. STI treatment was provided according to national guidelines [9] and free of charge, along with condoms. Risk reduction and HIV disclosure counseling were provided as part of routine HIV/STI care. Current Thai guidelines [10] for care of HIV-infected persons recommend taking a history of STI symptoms at each visit, syphilis serology screening at the initial visit, and gram stain and culture from urethral or anal discharge if present. Counseling on sexual risk reduction, disclosure, and adherence is provided for all patients as appropriate in the clinic. HIV-infected MSM were invited to bring their partners to the clinic for free HIV testing. All HIV-infected persons were provided with free CD4 testing and referred to a hospital for opportunistic infection prophylaxis and antiretroviral treatment if eligible according to Thai national guidelines (HIV-infected persons with CD4-cell count <200 cells/mm3 or clinical AIDS are eligible for antiretroviral treatment and Pneumocystis jiroveci pneumonia prophylaxis; CD4-cell count <100 cells/mm3 are eligible for prophylaxis of cryptococcosis) [11]. Condoms and lubricants were offered free of charge to all patients.

Laboratory Evaluation

Two urethral specimens were collected for all consenting men. One was examined with gram stain and cultured for Neisseria gonorrhoeae. The other was tested by Amplicor polymerase chain reaction (PCR) analysis (Roche Diagnostic Systems, Basel, Switzerland) for the detection of Chlamydia trachomatis and N. gonorrhoeae. Rectal specimens were collected for culture of N. gonorrhoeae on selective media. Serum samples were tested for syphilis using the Rapid Plasma Reagin (RPR) card test (Newmarket Laboratories Ltd, Kentford, UK) for screening and the Treponema pallidum haemagglutination assay (TPHA; Fujirebio Inc., Tokyo, Japan) for confirmation. Persons were considered to have an STI if they had clinician-confirmed genital ulcers, positive test results indicating gonorrhea or chlamydial infection, or a reactive RPR confirmed by TPHA.

HIV infection status was confirmed by Murex HIV1-2 ELISA (Murex Biotech Ltd, Dartford, UK), if it was not previously documented. CD4-cell count test results were obtained from patient history or from HIV clinic referral letters.

Data Analysis

Data were analyzed and statistical tests performed using Statistical Package for Social Sciences for Windows, version 12 software (SPSS Inc., Chicago, IL, US). Chi-squared tests were used to test for differences in proportions unless any cell was <5, in which case Fisher’s exact test was used. An α of 0.05 was used for significance. Logistic regression was used to calculate odds ratios (OR) with 95% confidence intervals (CI). Multivariate modeling was carried out using multiple logistic regression with the final choice of model including risk factors with p < 0.2 in bivariate analysis. Factors that were highly correlated with other factors in the model were examined to identify the best factor to include in the final multivariate model.

Ethics Approval

This study was approved by the Thai Ministry of Public Health and the US Centers for Disease Control and Prevention as program evaluation, not requiring review by an institutional review board.

Results

From October 2005 through October 2007, 154 HIV-infected MSM attended the STI clinic and underwent assessment and testing for STIs. The median age was 28 years, and the median time since learning HIV status was 2 months (Table 1). Among 145 HIV-infected MSM with data for time since learning HIV status, 54 cases had been aware of HIV status for <1 month on the day of data collection, including ten cases that were diagnosed with HIV infection on the day of data collection. Characteristics of HIV-infected MSM who had been diagnosed <1 month are compared to those diagnosed 1 month or more before data collection in Table 2. Of those with 1 month or more since HIV diagnosis, 25% (23/91) were on ART and median duration of ART was 32 months. No HIV-infected MSM diagnosed <1 month had received ART. The overall median CD4 cell count was 328 cells/mm3. Thirty percent (46/153) had a CD4 count <200 cells/mm3, but only 20% (9/46) of these were receiving antiretroviral treatment (ART). All ART eligible patients were referred for HIV treatment and care.
Table 1

Characteristics of HIV-infected men who have sex with men (MSM) attending a public sexually transmitted infection (STI) clinic in Bangkok, Thailand, 2005–2007

Characteristics

N = 154 cases

General

 

Age, years

28 (17–65)

Months since HIV diagnosis, Median (range)

2 (0–306)

Years of education, Median (range)

12 (0–19)

Behavioral

n/N (%)

Oral/anal/vaginal sexual intercourse in last 3 months

131/154 (85)

 Steady male partner in the last 3 months

79/131 (60)

  Disclosed HIV to steady male partner

28/78 (36)

  Know HIV status of steady male partner

28/74 (38)

  Male steady partner tested for HIV

25/65 (39)

   Partner HIV negative

15/23 (65)

 Casual male sex partner in the last 3 months

69/131 (53)

 Female sex partner in the last 3 months

19/131 (15)

 Bought sex in last 3 months

11/131 (8)

 Sold sex in last 3 months

27/111 (24)

 Oral sex without condom (any in last 3 months)

102/120 (85)

 Anal sex without condom (any in last 3 months)

36/112 (32)

 Vaginal sex without condom (any in last 3 months)

7/15 (47)

Clinical: HIV

 

Median CD4 cell count, cell/mm3 (range)

328 (6–1203)

 CD4-cell count <200 cells/mm3

46/153 (30)

Current ARV treatment, n/N (%)

25/153 (16)

 Median duration of ARV treatment, months (range)

32 (9–46)

Clinical: sexually transmitted infection (STI)

n/N (%)

STI-related symptoms

39/154 (25)

STI-related findings

39/154 (25)

Clinician-confirmed genital ulcer

16/154 (10)

Chlamydial infection

15/146 (10)

Gonorrhea

20/152 (13)

 Urethral

17/146 (12)

 Rectal

6/141 (4)

Reactive syphilis serology

31/148 (21)

 RPR titer ≥1: 8

14/148 (10)

Any STI-positive result

63/154 (41)

Numbers may vary due to missing data

ARV antiretroviral; RPR rapid plasma reagin

aAny STI-positive result included reactive syphilis serology or a positive test result indicating chlamydia, gonorrhea

Table 2

Characteristics of new and old cases of HIV-infected men who have sex with men (MSM) attending a public sexually transmitted infection (STI) clinic in Bangkok, Thailand, 2005–2007

Characteristics

Old casesa

N = 91

New casesb

N = 54

P value

General

   

Age, years

28

27

0.73

Months since HIV diagnosis, Median (range)

10 (1–306)

0.3 (0–0.9)

<0.001

Years of education, Median (range)

12 (9–16)

12 (9–16)

0.59

Behavioral

n/N (%)

  

Oral/anal/vaginal sexual intercourse in last 3 months

74/91 (81)

48/54 (89)

0.23

 Steady male partner in the last 3 months

48/74 (65)

26/48 (54)

0.24

  Disclosed HIV to steady male partner

19/43 (44)

9/26 (35)

0.43

  Know HIV status of steady male partner

20/44 (46)

6/26 (23)

0.06

  Male steady partner tested for HIV

17/39 (44)

6/22 (27)

0.21

   Partner HIV negative

10/15 (67)

2/6 (33)

1.00

 Casual male sex partner in the last 3 months

36/74 (49)

30/48 (63)

0.13

 Female sex partner in the last 3 months

10/74 (14)

7/48 (15)

0.87

 Bought sex in last 3 months

6/21 (29)

4/13 (31)

0.89

 Sold sex in last 3 months

17/74 (23)

9/48 (19)

0.58

 Oral sex without condom (any in last 3 months)

51/67 (76)

44/45 (98)

0.002

 Anal sex without condom (any in last 3 months)

17/62 (27)

18/43 (42)

0.12

 Vaginal sex without condom (any in last 3 months)

2/7 (29)

3/6 (50)

0.43

Clinical: HIV

   

Median CD4 cell count, cell/mm3

353

311

0.52

 CD4-cell count <200 cells/mm3

25/91 (28)

17/54 (32)

0.61

Current ARV treatment, n/N (%)

23/91 (25)

0/54

<0.001

Clinical: sexually transmitted infection (STI)

n/N (%)

  

STI-related symptoms

22/91 (25)

13/54 (24)

1.000

STI-related findings

22/91 (25)

13/54 (24)

1.000

Clinician-confirmed genital ulcer

8/91 (9)

5/54 (9)

0.92

Chlamydial infection

7/87 (8)

5/51 (10)

0.72

Gonorrhea

16/90 (18)

3/54 (6)

0.04

 Urethral

13/87 (15)

3/51 (6)

0.11

 Rectal

5/85 (6)

0/52

0.19

Reactive syphilis serology

14/88 (16)

17/52 (33)

0.02

 RPR titer ≥1: 8

6/88 (7)

8/52 (15)

0.10

Any STI-positive resultc

34/91 (37)

24/54 (44)

0.40

Numbers may vary due to missing data

ARV antiretroviral; RPR rapid plasma reagin

aOld cases “HIV-infected MSM who were aware of HIV status ≥1 month on the day of data collection”

bNew cases “HIV-infected MSM who were aware of HIV status <1 month on the day of data collection”

cAny STI-positive result included reactive syphilis serology or a positive test result indicating chlamydia, gonorrhea

Sexual intercourse in the last 3 months was reported by 131 (85%) men. Of these, 79 (60%), 69 (53%), and 19 (15%) reported sex with steady male partners, casual male partners, and female partners, respectively. The median number of sexual partners in the last 3 months was 3 (range 1–5). Among HIV-infected MSM who had sexual intercourse in the last 3 months, 13% reported having sex with both male and female partners; almost one-fourth reported having both steady and casual male partners (data not shown), and 8% reported buying sex during the last 3 months (Table 1). Ten of 11 HIV-infected MSM who bought sex reported using condoms with the commercial sex partner (data not shown). Selling sex during the last 3 months was reported by 24% (27/111) of patients who responded (Table 1). Of those who sold sex during the last 3 months, 96% used a condom with their last client (data not shown).

A higher proportion of HIV-infected MSM reported having oral sex without a condom (102/120, 85%) than having anal sex without a condom (36/112, 32%) in the past 3 months (Table 1). HIV-infected MSM who had sex with steady or casual male partners were more likely to report having oral sex without a condom than anal sex without condom (p < 0.01) (data not shown). A higher proportion of HIV-infected MSM who had been aware of their HIV status <1 month reported having oral sex without a condom (44/45, 98%) than did those who had been aware of HIV status for 1 month or more (51/67, 76%) (p value = 0.002) (Table 2).

STIs were found in 41% of men (21% reactive syphilis serology, 13% gonorrhea, 10% chlamydia, and 10% genital ulcer). However, only 25% of HIV-infected MSM in this study reported STI-related symptoms or had STI-related findings (Table 1). A higher proportion of HIV-infected MSM diagnosed for <1 month had a reactive syphilis serology (33%) than did those diagnosed for longer (16%), (p value = 0.02) (Table 2). In contrast, we found a higher overall proportion with gonorrhea among men diagnosed for 1 month or more (18%) than among men diagnosed for a shorter time (6%), (p value = 0.04) (Table 2).

Among 79 HIV-infected MSM with steady male partners, 36% had disclosed their HIV status and 38% reported their partner had been HIV tested; among these, 65% reported their partner had tested HIV-negative (Table 1). Among the 15 men with known sero-discordant steady male partners, 64% reported using condoms at last sex with that partner, and 36% had disclosed their HIV status to the partner.

Factors Associated with Having Sex Without a Condom

HIV-infected MSM were more likely to have had unprotected vaginal sex with female partners (aOR 6.0, 95% CI 1.4, 26.0) and unprotected anal sex with steady male partners (aOR 12.9, 95% CI 3.5, 47.6) than with other male partner types (Table 3). MSM diagnosed with HIV for <1 month were more likely than those diagnosed for longer to have had sex without a condom (aOR 2.7, 95% CI 1.0–7.1). HIV-infected MSM not receiving ART were more likely than those receiving ART to have had anal or vaginal sex without a condom during the last 3 months (aOR 5.3, 95% CI 1.0, 29.1) (Table 3). Age, education, history of sex work, CD4 count, HIV status of steady male partner, and current STIs were not significantly associated with having anal or vaginal sex without a condom.
Table 3

Factors associated with anal or vaginal sex without a condom during the last 3 months among 131 HIV-infected men who have sex with men (MSM) attending a public sexually transmitted infection (STI) clinic in Bangkok, Thailand, 2005–2007

Factors

Having sex without condom during the last 3 months n = 43/131 (%)

Unadjusted OR (95% CI)

P value

Adjusted OR (95% CI)

P value

Agea (years)

 ≥28 (median)

19/64 (30)

1

 

 

 <28

24/67 (36)

1.3 (0.6–2.8)

0.46

 

Education (in years)a

 ≥12

26/93 (28)

1

 

 

 <12

17/37 (46)

2.2 (1.0–4.8)

0.05

1.7 (0.6–4.5)

0.28

Time since HIV diagnosis (months)

 ≥1

20/74 (27)

1

 

1

 

 <1

20/48 (42)

1.9 (0.9–4.2)

0.09

2.7 (1.0–7.1)

0.05

Partner types

 Female

10/19 (53)

5.6 (1.6–19.5)

0.007

6.0 (1.4–26.0)

0.02

 Steady male only

20/39 (51)

5.6 (1.9–16.4)

0.002

12.9 (3.5–47.6)

<0.001

 Both steady and casual male

6/29 (21)

1.3 (0.4–4.6)

0.68

1.6 (0.4-6.0)

0.53

 Commercial male only

1/9 (11)

0.6 (0.1-8.0)

0.68

0.7 (0.07–7.4)

0.78

 Casual male only

6/36 (17)

1

 

1

1

Sex work

 Current

11/27 (41)

1.6 (0.6–3.7)

0.33

 Never

32/104 (31)

1

   

HIV status of steady male partner

   

 Unknown

23/46 (50)

2.0 (0.5–7.6)

0.31

 Negative

4/16 (25)

0.7 (0.1–3.5)

0.63

 

 Positive

4/12 (33)

1

   

STI-related symptomsb

 Yes

12/35 (34)

1.1 (0.5–2.5)

0.83

 

 No

31/96 (32)

1

 

CD4-cell count (cells/mm3)

 ≥350

21/62 (34)

1.1 (0.5–2.2)

0.85

 <350

22/68 (32)

1

 

 

Receiving ARV treatment

 Yes

3/20 (15)

1

 

1

 

 No

40/110 (36)

3.2 (0.9–11.7)

0.07

5.3 (1.0–29.1)

0.06

Numbers may vary due to missing data

ARV antiretroviral

aAge and education (in years) were dichotomized above and below median values

bSTI-related symptoms were defined as urethral or anal discharge, genital or anal pain or lesions, and dysuria

Factors Associated with an STI

STI prevalence was significantly higher among men who had STI symptoms than among men with no STI symptoms (aOR 3.8, 95% CI 1.3, 11.3). Patients with CD4 counts ≥350 cells/mm3 were more likely to have an STI than patients who had CD4 counts <350 cells/mm3 (aOR 2.9, 95% CI 1.3, 6.2). ART and history of sex work were not significantly associated with an STI (Table 4).
Table 4

Factors associated with detection of sexually transmitted infections (STI) among 154 HIV-infected men who have sex with men (MSM) attending a public sexually transmitted infection (STI) clinic in Bangkok, Thailand, 2005–2007

Factors

STIsa

n = 63/154 (%)

Unadjusted OR (95% CI)

P value

Adjusted OR (95% CI)

P value

Ageb (years)

 ≥28 (median)

32/81 (40)

1

 

 

 <28 

31/73 (43)

1.1 (0.6–2.2)

0.71

Time since HIV diagnosis (months)

 ≥1

34/91 (37)

1

   

 <1

24/54 (44)

1.3 (0.7–2.7)

0.40

  

Education (in years)b

 ≥12

41/107 (38)

1

 

 

 <12

22/46 (48)

1.5 (0.7–3)

0.27

Sex work

 Current

15/27 (56)

2.0 (0.9–4.7)

0.11

1.5 (0.6–3.9)

0.40

 Never

40/104 (39)

1

 

1

 

Unprotected last sex any male partnerd

 Yes

21/48 (44)

1.1 (0.6–2.4)

0.72

 

 No

32/79 (41)

1

 

 

STI-related symptomsc

 Yes

14/24 (58)

2.3 (1.0–5.6)

0.06

3.8 (1.3–11.3)

0.02

 No

49/130 (38)

1

 

1

 

CD4-cell count (cells/mm3)

 ≥350

37/70 (53)

2.6 (1.3–5.1)

0.01

2.9 (1.3–6.2)

0.01

 <350

25/83 (30)

1

 

1

 

Receiving ARV treatment

 Yes

6/25 (24)

0.4 (0.2–1.1)

0.07

0.4 (0.1–1.3)

0.13

 No

56/56 (44)

1

 

1

 

Numbers may vary due to missing data

ARV antiretroviral

aSTI defined as clinician-confirmed genital ulcer or positive test result for chlamydial infection, gonorrhea, or syphilis

bAge and education were dichotomized above and below the median value

cSTI-related symptoms were defined as urethral or anal discharge, genital or anal pain or lesions, and dysuria

dUnprotected last oral, vaginal or anal sex with any male partner

Factors Associated with HIV Disclosure to Steady Partners

In bivariate analysis, age, education, time since HIV diagnosis, antiretroviral therapy, unprotected last sex with male steady partner, and current sex work were not significantly associated with HIV disclosure to steady partners (data not shown).

Discussion

Sexual risk behavior was common in this cohort of HIV-infected MSM attending a public STI clinic in Bangkok. This information is consistent with other reports that found high-risk sexual behavior among MSM of unknown serostatus [3, 12, 13]. Without specific prevention interventions for HIV-infected MSM, transmission may persist and rates of HIV infection among MSM continue to rise, as projected in models of new HIV infections in Thailand [4]. However, reports from the US and Europe have shown decreased sexual risk behavior among MSM following HIV prevention interventions [14, 15], and such effective interventions are urgently needed in Thailand.

Most HIV-infected MSM who bought or sold sex in this study practiced safe sex. Although aimed at female sex workers and their clients, Thailand’s successful 100% condom campaign promoted condom use in commercial sex transactions and may have influenced condom use in male-to-male commercial sex as well [16]. We found that many HIV-positive MSM had multiple sex partners, consistent with previous reports from populations of MSM with unknown HIV serostatus [1214]. HIV-infected MSM with steady male partners and female partners in this study had particularly high rates of anal sex without a condom. This is consistent with previous studies that reported an association between sex without a condom and sex with steady partners [17] and female partners [18]. This finding supports targeting of prevention interventions to HIV-infected MSM with steady male partners and female partners, in addition to those with casual partners.

We report a smaller proportion of people on ART having unprotected last sex as compared to those not on ART, echoing findings from other studies [5, 19]. People receiving ART generally have more frequent HIV clinic visits than those not on ART, and therefore are more likely to be exposed to counseling messages about condom use and other positive self-care messages [5]. Counseling and access to HIV care should be increased for HIV-positive MSM who are not yet eligible for ART.

We found lower rates of condom use with oral sex than with anal sex. Although the rate of HIV transmission through oral sex is reported to be very low [20], oral sex can transmit other STIs. MSM should be aware of these risks. The prevalences of gonorrhea, chlamydial infection, and reactive syphilis serology in this report were high. The higher prevalence of STIs among HIV-infected MSM with CD4 counts >350 cells/mm3 compared to those with lower CD4 counts may reflect higher rates of sexual activity among patients who have not yet developed HIV-related symptoms [21].

We report a higher sero-discordance rate among HIV-infected MSM and their steady partners than other studies in Thailand and the US, and we found that known HIV status of partners correlated with disclosure to partners [5, 22]. In other reports, factors associated with HIV disclosure to steady partners [23] were relationship type, perceived partner HIV status, and sexual behaviors. Although we did not detect similar associations, this may be due to the fact that most HIV-infected MSM in this study were only recently diagnosed with HIV and had not received HIV disclosure counseling. While knowledge and disclosure of HIV serostatus could theoretically offer HIV prevention opportunities through sero-sorting, this is a potentially risky strategy as many men, particularly those with acute HIV infection, are not aware of their HIV status [24]. Further research is needed to determine the most appropriate methods for promoting HIV disclosure among MSM partners and increasing the numbers of MSM who know their status.

HIV-infected MSM in this report had riskier behavior than reported by MSM in other studies [14, 25], most likely due to the selection of the study population from an STI clinic. However, this may also be influenced by the fact that about one-third of those in this study had been aware of their HIV status for <1 month at the time of risk behavior data collection.

Strategies are needed to increase HIV testing and counseling for MSM through provision of HIV rapid tests with same day results in MSM-friendly clinic and community settings. As recommended by WHO and UNAIDS [26], promoting provider-initiated HIV testing and counseling for MSM at health facilities and MSM clinics should be a primary approach for increasing knowledge of serostatus and access to treatment and care. CD4 monitoring should be provided to patients at STI clinics and referral linkages between STI and HIV clinics should be strengthened for patients who are antiretroviral treatment eligible.

The high gonorrhea, chlamydial infection, and syphilis prevalences among both symptomatic and asymptomatic HIV-infected MSM supports recommendations by the U.S. Centers for Disease Control and Prevention for universal STI screening for all sexually active MSM [27, 28]. The currently recommended screening package for HIV-infected MSM in Thailand [10] includes syphilis serology at initial visit and gram stain and culture of urethral or anal discharge for symptomatic HIV-infected MSM. The cost of PCR testing for C. trachomatis and N. gonorrhoeae is high and these tests are not routinely available in most settings in Thailand. A cost-effectiveness analysis comparing screening strategies with various criteria, frequencies and testing methods may facilitate refinement of these recommendations.

This study has some limitations. First, we did not address HIV transmission risk through injecting drug use or the influence of alcohol and other drug use behaviors which may lead to higher sexual risk behavior among MSM [29]. Secondly, we did not collect in-depth information on partner-seeking activities and other behaviors closely related to sexual risk, including whether unprotected sex was insertive or receptive. Information on both preventive and risk behaviors would help identify specific prevention messages for this population. Thirdly, our study was conducted in an STI clinic and one-third of patients had been aware of their HIV status for <1 month before the day of data collection. These two factors could lead to higher measurements of STIs and risk behaviors than among HIV-infected MSM in long-term clinical care. Finally, this study analyzed data from routine clinical services, and there were missing data from patients who did not answer some behavior questions and from patients who had no STI symptoms and did not want to be evaluated with STI laboratory tests. Missing data differentially from patients with high or low levels of sexual risk behaviors might have affected the results in this report.

Conclusions

Sexual risk behaviors and STIs were common among HIV-infected MSM in Bangkok. High HIV discordance and low disclosure rates among steady partners highlight the need for additional HIV prevention strategies for MSM. Behavioral risk assessments, behavior change communication, and interventions and materials for MSM that address relationship status and serostatus of partners should be included in HIV and STI programs. Integration and evaluation of prevention interventions in HIV care settings should be broadly implemented, including provision of free condoms, lubricants, and STI screening for all sexually active HIV-infected MSM.

Acknowledgments

For their important contributions to this work, the authors express their gratitude to all health care providers and HIV-infected MSM participating in this project at the public STI clinic in Bangkok (Bangrak Hospital). This work was funded by the Thailand MOPH and the U.S. CDC.

Copyright information

© Springer Science+Business Media, LLC (outside the USA)  2011