Background No data are available on the feasibility of pre-exposure prophylaxis (PrEP) delivered by trained key population (KP) community health workers. Herein we report data from the KP-led Princess PrEP program serving men who have sex with men (MSM) and transgender women (TGW) in Thailand. Methods: From January 2016 to December 2017, trained MSM and TGW community health workers delivered same-day PrEP service in community health centres, allowing clients to receive one PrEP bottle to start on the day of HIV-negative testing. Visits were scheduled at Months 1 and 3, and every 3 months thereafter. Uptake, retention and adherence to PrEP services and changes in risk behaviours over time are reported. Results: Of 1467 MSM and 230 TGW who started PrEP, 44.1% had had condomless sex in the past 3 months. At Months 1, 3, 6, 9 and 12, retention was 74.2%, 64.0%, 56.2%, 46.7% and 43.9% respectively (lower in TGW than MSM at all visits; P<0.001), with adherence to at least four PrEP pills per week self-reported by 97.4%, 96.8%, 96.5%, 97.5% and 99.5% of respondents respectively (no difference between MSM and TGW). Logistic regression analysis identified age >25 years, being MSM and having at least a Bachelors degree significantly increased retention. Condomless sex did not change over the 12-month period (from 47.2% to 45.2%; P=0.20). New syphilis was diagnosed in 4.9% and 3.0% of PrEP clients at Months 6 and 12 (cf. 7.0% at baseline; P=0.007). Among PrEP adherers and non-adherers, there were one and six HIV cases of seroconversion respectively, which resulted in corresponding HIV incidence rates (95% confidence interval) of 0.27 (0.04–1.90) and 1.36 (0.61–3.02) per 100 person-years. Conclusion: Our KP-led PrEP program successfully delivered PrEP to MSM and TGW. Innovative retention supports are needed, especially for TGW and those who are young or with lower education levels. To scale-up and sustain KP-led PrEP programs, strong endorsement from international and national guidelines is necessary.

Introduction Low uptake of HIV testing and services, including pre‐exposure prophylaxis (PrEP), in Thai men who have sex with men (MSM) and transgender women (TGW) may be due to the inaccuracy in self‐risk assessment. This study investigated the discordance between self‐perceived HIV risk and actual risk. Methods Data were obtained between May 2015 and October 2016 from MSM and TGW enrolled in key population‐led Test and Treat study in six community health centres in Thailand. Eligible participants were at least 18 years old, Thai national, had sex with men, had unprotected sex with a man in the past six months or had at least three male sex partners in the past six months, and were not known to be HIV positive. Baseline demographic behavioural characteristics questionnaires, including self‐perceived HIV risk, were self‐administered. Participants received HIV/STI (syphilis/gonorrhoea/chlamydia) testing at baseline. Participants who self‐perceived to have low risk, but engaged in HIV‐susceptible practices were categorized as having risk discordance (RD). Regression was conducted to assess factors associated with RD among MSM and TGW separately. Results Of the 882 MSM and 406 TGW participants who perceived themselves as having low HIV risk, over 80% reported at least one of the following: tested HIV positive, engaged in condomless sex, tested positive for a sexually transmitted infection sexually transmitted infection (STI; or used amphetamine‐type stimulants. Logistic regression found that living with a male partner (p = 0.005), having never tested for HIV (p = 0.045), and living in Bangkok (p = 0.01) and Chiang Mai (p < 0.001) were associated with increased risk discordance among MSM. Living with a male partner (p = 0.002), being less than 17 years old at sexual debut (p = 0.001), and having a low knowledge score about HIV transmission (p < 0.001) were associated with increased risk discordance among TGW. However, for TGW, being a sex worker decreased the chance of risk discordance (p = 0.034). Conclusions Future HIV prevention messages need to fill in the gap between self‐perceived risk and actual risk in order to help HIV‐vulnerable populations understand their risk better and proactively seek HIV prevention services.

IntroductionMen who have sex with men (MSM) and transgender women (TGW) are two key populations (KPs) in Thailand at high risk for HIV. Uptake and scale‐up of pre‐exposure prophylaxis (PrEP) among them has been slow. We used data from Princess PrEP, Thailand’s largest KP‐led PrEP programme, to operationalize PrEP service cascades. We identified gaps and pointed out where additional data are needed to inform a larger HIV prevention cascade.MethodsNumbers of people tested for HIV, tested HIV negative, eligible for PrEP (defined as any of the following in the past three months: condomless sex with partners of unknown/uncertain HIV status or antiretroviral treatment or viral load status, multiple partners, engaging in sex work, sexually transmitted infections, injecting drugs, using amphetamine‐type stimulants, or repeated use of post‐exposure prophylaxis), offered PrEP and accepted PrEP during January to November 2019 were retrieved from Princess PrEP database to inform PrEP service cascades for MSM and TGW. Reasons for not accepting PrEP were documented.ResultsOf 6287 MSM who received HIV testing in Princess PrEP, 92.3% were HIV negative and 70.2% of them were eligible for PrEP. PrEP was offered to 94.7% of those eligible and 48.0% of those offered accepted it. Among 900 TGW who had HIV testing, 95.3% tested HIV negative and 64.8% of them met PrEP eligibility criteria. Of these, 95.0% were offered PrEP and 43.9% of them accepted it. Among MSM and TGW who met PrEP eligibility criteria, no or low‐HIV‐risk perception was the most common reason provided (46.7% of 2007 MSM and 41.9% of 296 TGW) for not accepting PrEP.ConclusionsPrEP service cascades from the Princess PrEP programme identified no or low‐risk perception as key barrier to PrEP acceptance among MSM and TGW who met PrEP eligibility criteria. More implementation research studies are needed to explore PrEP motivation and access in larger communities outside of clinical services. This is to identify gaps and strategies to address them within motivation, access and effective use domains of the HIV prevention cascade.

Background Suboptimal uptake of HIV testing remains a primary bottleneck to HIV prevention and treatment for men who have sex with men (MSM) and transgender women (TGW) in Thailand. The World Health Organization has recommended HIV self-testing (HIVST) as an additional strategic HIV service. However, HIVST has not been fully endorsed and implemented in many countries in Southeast Asia. The aim of this study was to assess the uptake of oral fluid-based HIVST in MSM and TGW populations in Thailand. Methods During 2017 and 2018, we conducted a cross-sectional study using convenience sampling to enroll 2,524 participants from three major urban areas. Participants were recruited during outreach and online activities and were offered unassisted or assisted HIVST, or referral to HIV testing services. A descriptive analysis was performed for summarizing data. Results A total of 2,502 participants (1,422 MSM and 1,082 TGW) were included in the analysis with about one-third (36.1%) of them being first-time testers. Among all participants enrolled in the study, a total of 2,486 participants (99.3%) selected HIVST versus referral to HIV testing services. Of those who selected HIVST, 2,095 (84.3%) opted for assisted HIVST while the rest opted for unassisted HIVST: 1,148 of 1,411 MSM (81.4%) and 947 of 1,075 TGW (88.1%) selected assisted HIVST. While no serious adverse events were reported during the study, we found that among 179 participants who needed a confirmatory test and were referred to HIV testing services, 108 (60.3.4%) accessed these later services. Conclusions This study demonstrated a high uptake of oral fluid-based HIVST among MSM and TGW populations in Thailand and that HIVST could be scaled up through the national epidemic control program. However, a better understanding of HIV testing-seeking behavior and innovative follow-up solutions are needed to improve and monitor linkages to services for people who undertake HIVST.

BackgroundBased on government estimates from the Asian Epidemic Model, new infections among men who have sex with men (MSM) and transgender women (TGW) in Thailand are forecast to proportionally increase over time. Daily oral Pre-exposure prophylaxis (PrEP) protects against HIV acquisition when used as prescribed. The “Princess PrEP” program is the first key population-led (PrEP) initiative under Thai royal patronage with an aim to scale up countrywide implementation of PrEP.MethodsRetention in and adherence to key population-led HIV PrEP services among HIV-uninfected Thai MSM and TGW was examined in four provinces: Bangkok, Chonburi, Chiang Mai, and Songkhla. HIV, HBsAg, creatinine tests, and self-administered questionnaires were performed during baseline measures. Participants were followed up after month 1, at month 3, then every 3 months. Correlates of nonadherence and loss to follow up at 1 month were assessed using linear regression models.Results37.4% of the participants reported low adherence to services (≤ 3 pills/week or missed clinic schedule at month 1). Factors associated with low adherence included younger age (25 years and under) (adjusted odds ratio (aOR): 1.49, 95% confidence interval (95% CI: 1.01–2.21, p = 0.044), being a TGW (aOR: 2.2, 95% CI: 1.27–3.83, p = 0.005), and whether the participant had not previously accessed services at the clinic (aOR = 1.68, 95% CI: 1.03–2.76, p = 0.04). Additionally, participants in Chonburi (the only TGW site) showed significantly lower adherence than those in the other three provinces (aOR: 2.91, 95% CI: 1.55–5.45, p = 0.001).ConclusionUrgent, innovative interventions for early PrEP adherence support among vulnerable sub-populations such as younger users, TGW, and new clients are needed to maximize prevention strategy in Thailand.Electronic supplementary materialThe online version of this article (10.1186/s12889-019-6645-0) contains supplementary material, which is available to authorized users.