Publications by authors named "Thomas E Guadamuz"

57 Publications

Bridging the serodivide: attitudes of PrEP users towards sex partners living with HIV.

AIDS Care 2021 Jul 19:1-4. Epub 2021 Jul 19.

Department of Work & Social Psychology, Maastricht University, Maastricht, the Netherlands.

The introduction of biomedical HIV prevention methods, such as pre-exposure prophylaxis (PrEP), holds the potential to overcome the serodivide. We investigated the attitudes of PrEP users towards having sex with partners living with HIV. PrEP users in the Netherlands were recruited online and completed three questionnaires over a period of six months. We investigated changes over time in feelings of fear of HIV, comfort, and attitudes towards condom use when having sex with men living with HIV (MLHIV). A majority of PrEP users in our sample (up to 71.6%) had sex with MLHIV. Feeling comfortable to have sex with MLHIV did not change over time, but was already at a high level at T1. Most importantly, feeling safe not to use condoms with HIV-positive partners significantly increased, and did so in a rather short period of time after the onset of PrEP use (3-6 months). Taken together, the findings suggest that that PrEP may contribute to decreasing the serodivide between MSM rather quickly after the onset of PrEP use.
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http://dx.doi.org/10.1080/09540121.2021.1954588DOI Listing
July 2021

Quality of Sex Life and Perceived Sexual Pleasure of PrEP Users in the Netherlands.

J Sex Res 2021 Jun 15:1-6. Epub 2021 Jun 15.

Department of Work & Social Psychology, Maastricht University.

Next to its benefits for HIV prevention, PrEP may have psychosocial benefits relating to improved quality of sex life. The aim of the current study was to investigate the onset of changes in the quality of sex life and sexual pleasure of PrEP users in the first months of commencing PrEP use. Moreover, we investigated what factors were related to the quality of sex life of PrEP users. We recruited 145 participants via the Dutch PrEP-advocacy website PrEPnu.nl, and they received follow-up questionnaires after three and six months. We found that PrEP users reported an increase in the quality of their sex life, which was related to reduced fear of HIV since they started using PrEP but not to decreased condom use. PrEP users were more interested in experimenting with sex practices, but they did not always feel more desirable as a sex partner because of PrEP use. Health-care providers and health promotion campaigns could emphasize the positive effects of PrEP on the quality of sex life, in addition to the HIV-preventive effects of PrEP, to decrease PrEP stigma and increase PrEP uptake.
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http://dx.doi.org/10.1080/00224499.2021.1931653DOI Listing
June 2021

"Kids these days pretend to be grownups" (dekkaedaet): sexual control and negotiation among young Thai female students.

BMC Public Health 2021 05 1;21(1):839. Epub 2021 May 1.

Center of Excellence in Research on Gender, Sexuality and Health and Department of Society and Health, Faculty of Social Sciences and Humanities, Mahidol University, 999 Putthamonthon 4 Road Salaya, Nakhon Pathom, Thailand.

Background: Young Thai women are growing up amidst conflicting influences of globalization and traditional Thai culture. They experience confusion about which aspects of their sexuality they can express and must hide. This study examined forms of sexual control and sexual negotiation among young Thai women in secondary and vocational schools.

Methods: Semi-structured interviews and focus group discussions were conducted among 13-to 18-year-old female students attending secondary and vocational schools in six regions of Thailand. Additional semi-structured interviews were conducted with instructors of sex education, school administrators, and parents of students. NVIVO 10 was used to manage, code and assist with data analysis.

Results: Socio-cultural control on young women's sexualities was found from members of their families, schools, communities, and other students. Young women expressing their sexualities openly through verbal expressions, clothing, and behaviors were deemed negatively and stigmatized as dekkaedaet or "kids pretending to be grownups" as it is believed that they are too young and too immature to be responsible for their own decisions on their bodies and sexuality. This dominant discourse subsequently stigmatize and embarrass sexually active women. However, some young women try to negotiate and create options, by utilizing strategies that ensure secrecy.

Conclusion: Comprehensive sexuality education is needed and should be based on the respect for human dignity and sexual and reproductive rights.
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http://dx.doi.org/10.1186/s12889-021-10789-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8088650PMC
May 2021

Correlates of newly diagnosed HIV infection among cisgender women sex workers and transgender women sex workers in Greater Kuala Lumpur, Malaysia.

Int J STD AIDS 2021 Jun 22;32(7):609-619. Epub 2021 Mar 22.

Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, 12228Yale University School of Medicine, New Haven, CT, USA.

Globally, cisgender women sex workers (CWSWs) and transgender women sex workers (TWSWs) experience increased vulnerabilities to HIV infection. Unfortunately, there is limited data on the drivers of HIV infection in these two understudied populations, particularly in Southeast Asia. To better understand factors associated with HIV infection, we evaluated correlates of newly diagnosed HIV infection in these two populations in Greater Kuala Lumpur, Malaysia. A total of 469 women (CWSW: = 283; TWSW: = 186) were included in this study. Most participants who tested HIV+ were unaware of their infection (59.6%; = 34/57). Separate binary and multivariable logistic regressions were conducted to identify correlates of newly diagnosed HIV in CWSWs and TWSWs. Among CWSWs, (aOR = 5.66; = 0.007) and lifetime use of ecstasy/MDMA (aOR = 5.34; = 0.03) were associated with newly diagnosed HIV, while condomless vaginal sex with clients was associated with lower likelihood of HIV infection (aOR = 0.98; = 0.01). Among TWSWs, being single (aOR = 6.76; = 0.03), using mobile application to solicit clients (aOR = 25.33; = 0.006), and having infection (aOR = 88.22, = 0.02) were associated with newly diagnosed HIV. Expansion of HIV/sexually transmitted infection screening is needed to increase detection of HIV and linkage to care for sex workers. Interventions to reduce HIV infection among CWSWs and TWSWs should be tailored to these populations' unique vulnerabilities.
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http://dx.doi.org/10.1177/0956462420970417DOI Listing
June 2021

Slow Uptake of PrEP: Behavioral Predictors and the Influence of Price on PrEP Uptake Among MSM with a High Interest in PrEP.

AIDS Behav 2021 Aug 21;25(8):2382-2390. Epub 2021 Feb 21.

Department of Work & Social Psychology, Faculty of Psychology and Neuroscience, Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands.

Despite the improved availability and affordability of PrEP in the Netherlands, PrEP uptake is low among men who have sex with men (MSM). To optimize uptake, it is important to identify facilitators and barriers of PrEP use. During our study period, the price of PrEP dropped significantly after generic PrEP was introduced. We investigated whether the price drop predicts PrEP uptake, alongside behavioral and demographic characteristics. Participants (N = 349) were recruited online and completed three questionnaires over a period of 6 months, between February 2017 and March 2019. After 6 months, 159 (45.6%) participants were using PrEP. PrEP uptake was greater among MSM who ever had postexposure prophylaxis (PEP) treatment, among MSM with a better perceived financial situation, and when the price of PrEP dropped. MSM in a tighter perceived financial situation may use PrEP more when it would be free or fully reimbursed.
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http://dx.doi.org/10.1007/s10461-021-03200-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8222036PMC
August 2021

Socio-Sexual Experiences and Access to Healthcare Among Informal PrEP Users in the Netherlands.

AIDS Behav 2021 Apr 16;25(4):1236-1246. Epub 2020 Nov 16.

Department of Work & Social Psychology, Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands.

The aim of this qualitative study was to explore the experiences of informal PrEP users regarding access to PrEP and PrEP-related healthcare, community responses, sexual behavior and well-being. We interviewed 30 men who have sex with men (MSM) in semi-structured online interviews between March and August 2018. Interviews were analyzed using interpretive description. Informal PrEP users were well informed about the use of PrEP, but sometimes did not make use of renal testing. Participants reported a lack of PrEP knowledge among healthcare providers, which limited their access to PrEP and put them at risk, as they received incorrect information. Although some participants reported negative reactions from potential sex partners, most received positive reactions and were sometimes seen as more desirable sex partners. PrEP healthcare services should not only be accessible to formal PrEP users, but also to PrEP users who procure PrEP informally.
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http://dx.doi.org/10.1007/s10461-020-03085-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7973587PMC
April 2021

Willingness to Use HIV Self-Testing and Associated Factors Among Transgender Women in Malaysia.

Transgend Health 2020 2;5(3):182-190. Epub 2020 Sep 2.

Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.

While global research on the implementation of HIV self-testing (HIVST) has increased exponentially, few studies have assessed information on HIVST uptake factors (i.e., willingness, preferences) in transgender women (TW) and none in the Malaysian context. We therefore sought to assess willingness to use HIVST among this understudied key population. A cross-sectional survey was conducted among 361 HIV-negative Malaysian TW in 2017. Participants were recruited using flyers, announcements through social media, and direct referral from staff members of the community-based organizations serving the TW communities. Multivariable logistic regression was used to identify correlates of willingness to use HIVST. Nearly half of the participants (47.6%) reported that they would be willing to use HIVST. Multivariable analysis showed that willingness to use HIVST was positively associated with having experienced sexual assault in childhood (adjusted odds ratio [aOR]=3.239, <0.001), having ever used mobile phone or apps to find sex work clients (aOR=1.677, =0.040), and having engaged in condomless sex in the past 6 months (aOR=1.886, =0.018). In contrast, living in Kuala Lumpur (aOR=0.559, =0.032), having higher number of sex work clients per day (aOR=0.927, =0.004), and current depressive symptoms (aOR=0.576, =0.026) were negatively associated with willingness to use HIVST. Findings in this study suggest that TW in our sample were moderately willing to use HIVST. Especially important here is the increased interest in HIVST among TW who are at higher risk for HIV infection. Overall, our findings underscore the need for additional research on how to most effectively implement HIVST for key populations, including TW, such that uptake and retention in regular HIV screening is sustained.
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http://dx.doi.org/10.1089/trgh.2019.0085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7480722PMC
September 2020

Willingness to Use HIV Self-Testing With Online Supervision Among App-Using Young Men Who Have Sex With Men in Bangkok.

Sex Transm Dis 2021 03;48(3):e41-e44

Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands.

Abstract: An online assessment among social media-using young men who have sex with men found that 87% were willing to use HIV self-testing with online supervision. Correlates included never tested, having higher numbers of sexual partners, and seeking partners online. HIV self-testing with online supervision may be appropriate for young men who have sex with men who have high risks and may not access venue-based settings.
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http://dx.doi.org/10.1097/OLQ.0000000000001271DOI Listing
March 2021

Social violence among Thai gender role conforming and non-conforming secondary school students: Types, prevalence and correlates.

PLoS One 2020 14;15(8):e0237707. Epub 2020 Aug 14.

Department of Society and Health, Faculty of Social Sciences and Humanities, Mahidol University, Nakhon Pathom, Thailand.

Background: Gender role non-conforming behaviors are a significant risk factor for school-related violence. The objective of this study is to describe the types, prevalence and correlates of social violence among Thai secondary school students, with a focus on gender role non-conformity.

Methods: This article uses secondary data from a national study of 2070 secondary school students aged 13-20 years representing Bangkok and all four regions of Thailand. Students were asked about their gender/sexual identity, self-perception of their masculinity or femininity, and experiences of social violence. Correlates of social violence were examined using multivariable logistic regression models.

Results: Prevalence of social violence victimization was high (57%). Most students considered themselves to be as masculine or as feminine as other members of their sex (82.6%), while 9.1% thought that they were less masculine/less feminine, and 8.3% thought they were more masculine/more feminine. Students who considered themselves less masculine or less feminine than others of their sex (AOR = 1.59, 95% CI: 1.13, 2.25) were more likely to experience social violence, compared to students who considered themselves equally masculine/feminine. Students who self-identified as lesbian, gay, bisexual or transgender (LGBT) (AOR = 1.37, 95% CI: 1.01, 1.86) were also more likely to experience social violence, compared to students who did not identify as LGBT. However, students who considered themselves more masculine or feminine than other students of their sex (AOR = 0.62, 95% CI: 0.44, 0.88) were less likely to experience social violence.

Discussion: Students who identified as LGBT, or considered themselves to be less masculine or less feminine than other students of their sex, had higher odds of social violence victimization. Anti-bullying campaigns need to emphasize that perpetrating social violence is not tolerated, and gender-based violence needs to be included in comprehensive sexuality education curricula.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0237707PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428170PMC
October 2020

Peer victimisation and depression among gender conforming and non-conforming Thai adolescents.

Cult Health Sex 2020 07 13;22(7):808-821. Epub 2020 May 13.

Center of Excellence in Research on Gender, Sexuality and Health, Faculty of Social Sciences and Humanities, Mahidol University, Nakhon Pathom, Thailand.

Like most low- and middle-income countries, Thailand is facing an increasing burden of depressive disorders among adolescents, but research and services for them are largely neglected. This study explored the association between types of peer victimisation, gender non-conformity, health risk behaviours, and depressive symptoms among Thai students aged 13-18 years. Overall, prevalence of depressive symptoms was 14.7% (95% CI: 12.6-15.6), 12.2% (95% CI: 9.5-13.9) among male students and 16.5% (95% CI: 13.8-18.0) among female students. Among both sexes, social and sexual victimisation in the past month were strongly associated with depressive symptoms in the past week. Gender non-conforming female adolescents, as well as male and female adolescents who had experienced sexual and social victimisation, had a high burden of depressive symptoms. Mental health professionals and educators working with young people in Thailand should consider assessment for clinically significant depressive disorders.
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http://dx.doi.org/10.1080/13691058.2020.1737235DOI Listing
July 2020

Association of co-occurring psychosocial health conditions and HIV infection among MSM in Malaysia: Implication of a syndemic effect.

Int J STD AIDS 2020 05 16;31(6):568-578. Epub 2020 Apr 16.

Faculty of Medicine, Centre of Excellence for Research in AIDS, University of Malaya, Kuala Lumpur, Malaysia.

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http://dx.doi.org/10.1177/0956462420913444DOI Listing
May 2020

Association of co-occurring psychosocial health conditions and HIV infection among MSM in Malaysia: Implication of a syndemic effect.

Int J STD AIDS 2020 05 16;31(6):568-578. Epub 2020 Apr 16.

Faculty of Medicine, Centre of Excellence for Research in AIDS, University of Malaya, Kuala Lumpur, Malaysia.

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http://dx.doi.org/10.1177/0956462420913444DOI Listing
May 2020

Revisiting the 'Thai gay paradise': Negative attitudes toward same-sex relations despite sexuality education among Thai LGBT students.

Glob Public Health 2020 03 29;15(3):414-423. Epub 2019 Oct 29.

Center of Excellence in Research on Gender, Sexuality, and Health, Faculty of Social Sciences and Humanities, Mahidol University, Nakhon Pathom, Thailand.

School settings are volatile and often violent for LGBT teens who are first coming to terms with their sexuality. We explored the attitudes of LGBT students in Thai secondary schools towards homosexuality. Students aged 12-19 years were surveyed in 393 public institutions providing secondary-school education in six regions of Thailand, selected by a multistage cluster sampling. Among 1088 LGBT-identified students, 378 (35%) reported negative attitudes toward homosexuality. Factors associated with homonegative attitudes in a multivariable logistic regression analysis were identifying as a transgender (Adjusted Odds Ratio [aOR] 2.5, 95% CI 1.5-4.1), having low academic performance (GPA scores of 2-3 [aOR 2.6, 95% CI 1.7-4.1] or less than 2 [aOR 2.1, 95% CI 1.5-2.]), and attending sexuality education classes covering topics such as bullying LGBT students (aOR 1.9, 95% CI 1.2-3.1) and safe homosexual practices (aOR 2.1, 95% CI 1.7-4.1). Sexuality education in its current form in Thai public schools may not be effective in reducing homonegative attitudes of LGBT-identified students. A more comprehensive sexuality education emphasising gender and rights along with strategies addressing social disparities due to sexual orientation is needed to enable Thai LGBT teens to accept their sexuality without shame and self-disrespect.
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http://dx.doi.org/10.1080/17441692.2019.1684541DOI Listing
March 2020

Illicit Drug Use and Social Victimization among Thai Sexual and Gender Minority Adolescents.

Subst Use Misuse 2019 18;54(13):2198-2206. Epub 2019 Jul 18.

HIV Prevention and Health Promotion Unit, UNESCO , Bangkok , Thailand.

We examined the prevalence of lifetime illicit drug use and social victimization, and their association, among sexual and gender minority (SGM) and non-SGM Thai adolescents. In 2013, we conducted a school-based national survey among students grades 7-12 (aged 13-20 years) from 15 secondary schools ( = 2,070) around Thailand. We classified adolescents with same-sex attraction, sexual or gender non-conforming identities as SGM. Generalized estimating equations were used to estimate the odds of illicit drug use by SGM and non-SGM status. Prevalence of lifetime illicit drug use was significantly higher among SGM adolescents than non-SGM adolescents (10.3 vs. 5.3%), but did not differ between those with same-sex attraction and SGM identity (10.3 vs. 10.8%). Among non-SGM adolescents, general social victimization, sexual experience and any school truancy were associated with lifetime illicit drug use (OR = 2.59, 95% CI: 1.53, 4.38; OR = 6.59, 95% CI: 4.90, 8.86; and OR = 4.93, 95% CI: 3.13, 7.75, respectively). Among SGM adolescents, SGM-based social victimization, depressive symptomology and suicidal ideation were associated with lifetime illicit drug use (OR = 3.17, 95% CI: 2.03, 4.95; OR = 5.03, 95% CI: 2.32, 10.90; and OR = 5.03, 95% CI: 2.76, 9.16, respectively). SGM adolescents have higher burden of illicit drug use. Moreover, illicit drug use among SGM adolescents is indicative of depressive symptomology and suicidal ideation. Tailored and comprehensive programs are needed to reduce the gap in burden of illicit drug use between SGM and non-SGM adolescents.
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http://dx.doi.org/10.1080/10826084.2019.1638936DOI Listing
May 2020

Comprehensive sexuality education in Thailand? A nationwide assessment of sexuality education implementation in Thai public secondary schools.

Sex Health 2019 06;16(3):263-273

Center of Excellence in Research on Gender, Sexuality and Health, Faculty of Social Sciences and Humanities, Mahidol University, 999 Putthamonthon 4 Road Salaya, Nakhon Pathom 73170, Thailand; and Department of Society and Health, Faculty of Social Sciences and Humanities, Mahidol University, 999 Putthamonthon 4 Road Salaya, Nakhon Pathom 73170, Thailand; and Corresponding author. Email:

Background The purpose of this nationwide study was to assess implementation of comprehensive sexuality education (CSE) in Thai public secondary schools, with a view to reveal its strengths and weaknesses.

Methods: This was a mixed-methods study using a cross-sectional survey of 8837 students and 692 teachers at 398 public secondary schools, selected by multistage cluster sampling from six regions of Thailand, along with participatory focus group discussions with 150 students, and semi-structured in-depth interviews with 30 students and 70 teachers.

Results: Sexuality education was provided in most schools, but its implementation was incomprehensive and inconsistent across different types of schools. Topics covered were broad, but emphasis was primarily on biology and negative consequences of sex, in particular preventing adolescent pregnancy. Topics related to human rights, gender equality, and sexual and gender diversity were not addressed sufficiently. Pedagogy was found to be heavily lecture-based, while class environment was not comfortable for many students.

Conclusion: Gaps recognised in this study reflect the challenges of providing sexuality education in school settings where society's political and sociocultural norms are imposed and traditional pedagogical ways have remained dominant. Strategies are needed to address implementation shortcomings to make sexuality education more comprehensive in Thailand.
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http://dx.doi.org/10.1071/SH18121DOI Listing
June 2019

Ice parties among young men who have sex with men in Thailand: Pleasures, secrecy and risks.

Int J Drug Policy 2018 05 23;55:249-255. Epub 2018 Apr 23.

Department of Society and Health, Faculty of Social Sciences and Humanities, Mahidol University, Nakorn Pathom, Thailand; Center for Health Policy Studies, Faculty of Social Sciences and Humanities, Mahidol University, Nakorn Pathom, Thailand.

Background: Crystal methamphetamine (ice) has become the substance of choice among young men who have sex with men (YMSM) in urban Thailand. Yet, there is scarce data on this phenomenon, partly due to the difficulty in accessing men who will disclose and openly discuss the social contexts, meanings and risks surrounding ice practice. We present an ethnography of ice parties, critically discussing the in-depth social meanings of ice; the sexual socialities and the secrecy surrounding its use; the transactions between older and younger men; and the role of the Internet and mobile technology.

Methods: Forty repeated narrative interviews (life stories), ten focus group discussions, as well as systematic online and offline observations were conducted over a three-year period. Purposive sampling was used to recruit study participants in a variety of online and offline spaces and through working closely with local Thai community-based organizations serving MSM. To be eligible, participants had to be between 18 and 29 years, able to converse in Thai, had used ice, and had anal sex with another man in the past 6 months. We also strived for sample variability with respects to socio-demographic characteristics (e.g., age, educational attainment and living situation). Data analysis was conducted in Thai by two researchers using the constant comparative method based on grounded theory.

Results: On surface, participants described ice parties as exclusive, in trend, luxurious, fun and pleasurable-a kind of modern camaraderie among beautiful men. In reality, however, this group phenomenon was a social hierarchy containing several important players with relational power to one another, to the ice itself and to the physical space where ice was being consumed. These players included ice suppliers, party hosts, party guests and "icetenders." The paper also discusses the sociality of secrecy that surrounds ice parties as well as the power relations between older relatively rich men who provide ice and the younger men who crave for the chemical, pointing to the risks associated with engagement at ice parties, including instances of rape, violence and unsafe sex. For some participants, ice use was part of their "everyday life," or even believed to be a "rites of passage." For others, it involved sexual silence in cases where they were forced to have (unprotected) sex with certain persons or engage in high-risk activities against their will.

Conclusions: Ice parties, where high-risk practices were common, power and agency quickly became relational and negotiable. This paper illuminated the secret sociality of ice so that public health efforts will be better equipped with understanding and reaching out to young men who may be at heightened risk for HIV, STI, violence and other health concerns. Ice parties can, for example, be seen as opportunities for harm-reduction strategies whereby young men are not judged for the activities they engage, but are instead respected and approached in a contextualized, non-judgmental way. Finally, icetenders and party hosts may be individuals where public health practitioners can target and include in the development of novel harm-reduction programs.
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http://dx.doi.org/10.1016/j.drugpo.2018.04.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5970987PMC
May 2018

Heavy Alcohol Use Among Migrant and Non-Migrant Male Sex Workers in Thailand: A Neglected HIV/STI Vulnerability.

Subst Use Misuse 2018 09 20;53(11):1907-1914. Epub 2018 Feb 20.

c Meyers College of Nursing, New York University , New York , NY , USA.

Background: There is scarce research on male sex workers in the context of alcohol use. While heavy alcohol use has been established as a risk factor for HIV and STI infections among men who have sex with men (MSM), men who engage in sex work with other men, particularly from the Global South, have not been included in these studies. Moreover, studies among male sex workers in Asia often do not explore migration contexts of these men.

Objectives: The objective of this exploratory study is to examine the prevalence and correlates of heavy alcohol use among migrant and non-migrant male sex workers in Bangkok and Pattaya, Central Thailand.

Methods: Between August and October 2015, 18-24 year-old migrant and non-migrant male sex workers (n = 212) were recruited from various male sex work-identified venues (bars, clubs, massage parlors, and go-go bars) to take an interviewer-administered cross-sectional survey in Bangkok and Pattaya, Thailand. Measures were adapted from previous studies in similar populations and included structured questions across four domains, including demographic characteristics, alcohol use, stimulant use, and sexual behaviors. Multivariable logistic regression assessed the independent associations between heavy alcohol use (heavy versus not heavy) and demographic characteristics, stimulant use and sexual behavior.

Results: Heavy alcohol use was prevalent among one-third of participants. Heavy alcohol use was positively associated with male sex workers who were non-migrant and Thai, currently using stimulants, having 15 or more male clients in the past month and having first consumed alcohol at age 15 years or younger.

Conclusions: Current HIV prevention efforts should consider subpopulations of MSM, including male sex workers and migrants, as well as other risk behaviors like alcohol, as important contexts for HIV and STI risks.
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http://dx.doi.org/10.1080/10826084.2018.1436564DOI Listing
September 2018

Challenges and emerging opportunities for the HIV prevention, treatment and care cascade in men who have sex with men in Asia Pacific.

Sex Transm Infect 2017 08 20;93(5):356-362. Epub 2017 Jul 20.

HIV, Hepatitis and STI Unit, Regional Office for the Western Pacific, World Health Organization, Manila, Philippines.

In Asia Pacific, most countries have expanded HIV treatment guidelines to include all those with HIV infection and adopted antiretroviral treatment for prevention (TFP) as a blanket strategy for HIV control. Although the overall epidemic development associated with this focus is positive, the HIV epidemic in men who have sex with men (MSM) is continuing unperturbed without any signs of decline or reversal. This raises doubt about whether TFP as a blanket HIV prevention policy is the right approach. This paper reviews currently available biomedical HIV prevention strategies, national HIV prevention policies and guidelines from selected countries and published data on the HIV cascade in MSM. No evidence for efficacy of TFP in protecting MSM from HIV infection was found. The rationale for this approach is based on assumptions about biological plausibility and external validity of latency-based efficacy found in heterosexual couples. This is different from the route and timing of HIV transmission in MSM. New HIV infections in MSM principally occur in chains of acutely HIV-infected highly sexually active young men, in whom acquisition and transmission are correlated in space and time. By the time TFP renders its effects, most new HIV infections in MSM will have already occurred. On a global level, less than 6% of all reports regarding the HIV care cascade from 1990 to 2016 included MSM, and only 2.3% concerned MSM in low/middle-income countries. Only one report originated from Asia Pacific. Generally, HIV cascade data in MSM show a sobering picture of TFP in engaging and retaining MSM along the continuum. Widening the cascade with a preventive extension, including pre-exposure prophylaxis, the first proven efficacious and only biomedical HIV prevention strategy in MSM, will be instrumental in achieving HIV epidemic control in this group.
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http://dx.doi.org/10.1136/sextrans-2016-052669DOI Listing
August 2017

Playing and Never Testing: Human Immunodeficiency Virus and Sexually Transmitted Infection Testing Among App-Using MSM in Southeast Asia.

Sex Transm Dis 2017 07;44(7):406-411

From the *Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, †Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands; ‡Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands; and §Department of Society and Health and the Center for Health Policy Studies, Faculty of Social Sciences and Humanities, Mahidol University, Nakhon Pathom, Thailand.

Little is known about mobile application (app)-based behavior of men who have sex with men (MSM) in Thailand. A cross-sectional online assessment of app users in Bangkok found that more than a quarter have never tested for human immunodeficiency virus (HIV) and 1 in 3 never tested for sexually transmitted infections (STI). STI testing patterns and HIV testing frequency were highly associated with each other in multinomial logistic regression. In the midst of an escalating epidemic where HIV incidence among MSM is highest in Asia, apps can serve to engage those least likely to be reached by traditional methods of recruitment and outreach in Thailand.
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http://dx.doi.org/10.1097/OLQ.0000000000000624DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5470588PMC
July 2017

'Hu Hong' (bad thing): parental perceptions of teenagers' sexuality in urban Vietnam.

BMC Public Health 2017 02 28;17(1):226. Epub 2017 Feb 28.

Department of Society and Health, Faculty of Social Sciences and Humanities, Mahidol University, Nakhon Pathom, Thailand.

Background: Teenagers under 18 years old in Vietnam are considered as minors who usually lack the autonomy to make decisions. They are also sometimes viewed as contributors to social evils including crime, violence and substance use. Moreover, most Vietnamese teenagers have unsafe sex before marriage. The objective of this study is to explore the parental perceptions relating to their teenagers' sexuality, particularly the social and cultural forces, that may hinder access to sexuality information.

Methods: Guided by a Community Advisory Board (CAB), this qualitative study uses four focus group discussions (FGDs) consisting of 12 mothers and 12 fathers, as well as twelve individual in-depth interviews (IDIs) with a diverse sample of parents of teens in Ho Chi Minh City (HCMC), Vietnam. Content and discourse analysis were conducted, based on Foucauldian concepts.

Results: Four themes emerged: 1) Meanings of sexuality and sexuality education, 2) Early sexual intercourse destroys teenagers' future, 3) Teenagers are not hu hong (spoil/bad thing), are innocent and virgin, and 4) Policing and controlling of sexual intercourse among teens. Parents did not view their teenage children as sexual beings; those who are sexual are considered hu hong. Parents believed that teens need to be policed and controlled to prevent them from becoming hu hong, particularly girls. Controlling of sexuality information by parents was therefore common in HCMC, but differed by gender and educational levels of parents. For example, fathers more than mothers were not comfortable teaching their teenage children about sex and sexuality. Parents with higher education police their teenage children's usage of the Internet and social media, while parents with lower education control who can be friends with their teenage children.

Conclusions: Vietnamese parents in general have negative views of sex and sexuality education for their teenage children. Recognizing that many Vietnamese teenagers have unsafe sex before marriage, parents need to change their perceptions and understand the importance of comprehensive sexuality education (CSE), which are included in UNESCO, UNFPA and UNICEF-developed CSE tools.
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http://dx.doi.org/10.1186/s12889-017-4133-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5331690PMC
February 2017

Transgender populations and HIV: unique risks, challenges and opportunities.

J Virus Erad 2016 Apr 1;2(2):87-93. Epub 2016 Apr 1.

Department of Retrovirology, US Army Medical Directorate-Armed Forces Research Institute of the Medical Sciences, Bangkok, Thailand; Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA.

Due to unique social, behavioural, structural and biological issues, transgender (TG) populations, especially TG women, are at high risk for HIV acquisition. This increased risk is multifactorial, due to differing psychosocial risk factors, poorer access to TG-specific healthcare, a higher likelihood of using exogenous hormones or fillers without direct medical supervision, interactions between hormonal therapy and antiretroviral therapy, and direct effects of hormonal therapy on HIV acquisition and immune control. Further research is needed to elucidate these mechanisms of risk and to help design interventions to reduce HIV risk among transgender populations.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4965251PMC
April 2016

Birth Experiences of Immigrant Latina Women in a New Growth Community.

J Racial Ethn Health Disparities 2016 09 29;3(3):466-72. Epub 2015 Aug 29.

Mahidol University, Nakhon Pathom, Thailand.

A woman's birth experience can impact the physical and mental well-being of mothers long after the birth of their child. Little is known about the experiences of Latina women in areas with small, yet growing Latino populations. To understand Latina's perceptions of their childbirth experience and to see how insurance status impacts that experience, we conducted in-depth, semi-structured interviews with a non-proportional quota sampling of ten Latina women, five with and five without health insurance. Most women reported a positive global experience; the birth of a healthy child was the most important factor influencing birth experiences for all of them. Locus of control and support from medical providers and loved ones also shaped experiences. Uninsured women reported lower levels of perceived control and support, which did impact their birthing experience. These differences could be influenced by social status and position. Medical provider, hospital, and policy recommendations are made which could lead to improvements in uninsured Latinas' childbirth experiences.
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http://dx.doi.org/10.1007/s40615-015-0159-yDOI Listing
September 2016

Suboptimal HIV Testing Uptake Among Men Who Engage in Commercial Sex Work with Men in Asia.

LGBT Health 2016 12 16;3(6):465-471. Epub 2016 Mar 16.

5 Department of Epidemiology and Biostatistics, University of California , San Francisco, San Francisco, California.

Purpose: Men who have sex with men and are sex workers (MSMSW) are disproportionately affected by the growing and emerging HIV epidemic. As sex work and same-sex behavior are heavily stigmatized and often illegal in most Asian countries, HIV research focusing on MSMSW has been limited. The goal of this analysis is to examine HIV testing practices and identify correlates of HIV testing among MSMSW in Asia.

Methods: The Asia Internet MSM Sex Survey, an online cross-sectional survey of 10,861 men who have sex with men (MSM), was conducted in 2010. Data on sociodemographic characteristics, HIV testing behaviors, and sexual behaviors were collected. Five hundred and seventy-four HIV-negative/unknown respondents reported receiving payment for sex with men at least once in the past 6 months and were included in this analysis. Multivariable logistic regression was conducted to identify independent correlates of HIV testing in the past year.

Results: About half (48.6%) of the participants had been tested for HIV at least once within the past year, and 30.5% had never been tested. We also found that MSMSW participants who engaged in risky behaviors were less likely to be tested.

Conclusion: While one might expect a high HIV testing rate among MSMSW due to the risks associated with engaging in sex work, we found that HIV testing uptake is suboptimal among MSMSW in Asia. These results suggest that targeted HIV prevention and testing promotion among MSMSW are needed.
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http://dx.doi.org/10.1089/lgbt.2015.0051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5165677PMC
December 2016

Ethics of Online Assent: Comparing Strategies to Ensure Informed Assent Among Youth.

J Empir Res Hum Res Ethics 2016 02 28;11(1):15-20. Epub 2016 Feb 28.

University of Pittsburgh, PA, USA.

Individuals, including youth, often participate in online research without understanding the characteristics of studies they have agreed to be part of. We assessed the impact of including questions as part of the assent process by randomizing 568 youth to one of three groups: (a) asking youth to only read study information and then indicate their willingness to participate, (b) requiring youth to answer two questions about the study's risks and voluntary nature as part of the assent process, and (c) requiring youth to answer seven questions. Participants in the two- and seven-question groups, compared with the no-question group, were less likely to complete the assent process but, among those who did complete it, were more likely to read and understand study information.
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http://dx.doi.org/10.1177/1556264615624809DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4842165PMC
February 2016

Ethics of Online Assent: Comparing Strategies to Ensure Informed Assent Among Youth.

J Empir Res Hum Res Ethics 2016 02 28;11(1):15-20. Epub 2016 Feb 28.

University of Pittsburgh, PA, USA.

Individuals, including youth, often participate in online research without understanding the characteristics of studies they have agreed to be part of. We assessed the impact of including questions as part of the assent process by randomizing 568 youth to one of three groups: (a) asking youth to only read study information and then indicate their willingness to participate, (b) requiring youth to answer two questions about the study's risks and voluntary nature as part of the assent process, and (c) requiring youth to answer seven questions. Participants in the two- and seven-question groups, compared with the no-question group, were less likely to complete the assent process but, among those who did complete it, were more likely to read and understand study information.
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http://dx.doi.org/10.1177/1556264615624809DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4842165PMC
February 2016

A Male Promotores Network for Latinos: Process Evaluation From a Community-Based Participatory Project.

Health Promot Pract 2016 05 13;17(3):332-42. Epub 2015 Oct 13.

Mahidol University, Nakorn Pathom, Thailand.

Background Lay health advisor (LHA) interventions with Latino men are rare, especially in emerging Latino communities. We present a process evaluation of a male LHA network aiming at connecting Latino men to various kinds of services and to the Latino community. It assesses the feasibility of (1) maintaining a steering coalition; (2) hiring, training, and retaining male LHA; and (3) recruiting and assisting underserved participants. Methods Project management data and LHA debriefings were analyzed qualitatively and compared to a logic model and evaluation table prepared before the project started. Results The community coalition steered the project during its implementation. Eleven men attended the initial LHA training. Two thirds of them reflected the community in educational level. One third did not and required extra mentoring from the other LHA to recruit participants. LHA requested topics for monthly trainings according to their needs in the field, including housing, sexual health, and immigration. LHA enrolled 182 participants. Participants' needs went beyond health issues. Therefore, LHA needed to forge new collaborations with local social service organizations. Conclusions Recruiting male LHA is feasible. LHA and the community coalition can suggest adaptations to fit the local context.
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http://dx.doi.org/10.1177/1524839915609059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4833632PMC
May 2016

Yauk gyar mann yin (Be a man!): masculinity and betel quid chewing among men in Mandalay, Myanmar.

Cult Health Sex 2016 5;18(2):129-43. Epub 2015 Aug 5.

a Center for Health Policy Studies , Mahidol University , Nakhon Pathom , Thailand.

Betel quid chewing is associated with various oral cancers and other health concerns, including reproductive health issues. Nevertheless, the practice is widespread in Myanmar, especially among men. This qualitative study elucidates the gendered aspects of betel quid chewing by examining how it links with masculine ideology among male betel quid chewers in Mandalay, Myanmar. Data were collected through in-depth interviews, focus-group discussions, key-informant interviews and participant observation. The thematic content analysis was guided by Connell's concept of hegemonic masculinity and Butler's notion of gender performativity. The findings indicated that young Mandalay men were drawn to betel quid chewing by the value they gave to satisfying their curiosity, power competition, risk-taking and a display of manliness. Thus, the practice of betel quid chewing, as defined by our participants, was perceived as manly, trendy, stylish and sexually attractive. For adult men, betel quid chewing was a social lubricant that assisted them in talking with clients and co-workers, thus enhancing their economic opportunities with other men. It also helped working-class men to work harder. Betel quid chewing harm-reduction programmes therefore need to be mindful of masculinity issues as well as the economic aspects of betel quid chewing.
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http://dx.doi.org/10.1080/13691058.2015.1055305DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737701PMC
September 2016

Young, Online and in the Dark: Scaling Up HIV Testing among MSM in ASEAN.

PLoS One 2015 14;10(5):e0126658. Epub 2015 May 14.

Center of Excellence for Research in AIDS, University of Malaya, Kuala Lumpur, Malaysia.

Background: Poor HIV testing uptake by MSM may be attributable to unique challenges that are localized in Southeast Asia.

Objective: To characterize MSM who never tested for HIV, to identify correlates of never testing, and to elucidate the perceived barriers to HIV testing.

Methods: The present study used data from the Asian Internet MSM Sex Survey (AIMSS) and restricted the analysis to 4,310 MSM from the ten member countries of the Association of South East Asian Nations (ASEAN).

Results: Among MSM participants from ASEAN in our sample, 1290 (29.9%) reported having never been tested for HIV, 471 (10.9%) tested for HIV more than 2 years ago, and 2186 (50.7%) reported their last test date was between 6 months and two years ago, with only 363 (8.4%) of these men having been tested in the past 6 months. In multivariable logistic regression, younger MSM (age 15-22 years old [AOR: 4.60, 95% CI: 3.04-6.96]), MSM with lower education (secondary school or lower [AOR: 1.37, 95% CI: 1.03-1.83]), MSM who identify as bisexual or heterosexual (compared to gay-identified) (AOR: 1.94, 95% CI: 1.60-2.35), and MSM who had never used a condom with male partners (AOR: 1.61, 95% CI: 1.32-1.97) had higher odds of never been HIV tested. Main reason for not being tested was a low risk perception of HIV exposure (n = 390, 30.2%).

Conclusion: Current HIV prevention response must not leave MSM "in the dark," but instead meet them where they are by utilizing the Internet creatively through social media and smart phones. As ASEAN Economic Community (AEC) is quickly becoming a reality, so must there be an equally fast and united response to slowing down the HIV epidemics among MSM in ASEAN.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0126658PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4431680PMC
February 2016

Latent class analysis of substance use among men who have sex with men in Malaysia: Findings from the Asian Internet MSM Sex Survey.

Drug Alcohol Depend 2015 Jun 2;151:31-7. Epub 2015 Apr 2.

Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA.

Background: High prevalence of substance use among men who have sex with men (MSM) may drive the HIV epidemic in Malaysia but patterns of substance use among Malaysian MSM have not been examined. Our study investigated specific Malaysian MSM risk groups to determine the association between their substance use and sexual risk behaviors.

Methods: Data from Malaysian respondents (n=1235) in a large, multinational online survey of Asian MSM in 2010 were used to identify latent classes of substance use. Subsequent covariates were included in a joint model to predict class membership.

Results: The 3-class model was identified as the best fitting model, which included: (1) 'negligible substance use' for those reporting none or using any substance sparingly; (2) 'soft substance use' for those using poppers, ecstasy and drinking before sex; and (3) 'amphetamine-type stimulant (ATS) use' for those using stimulants (methamphetamine, ecstasy), erectile dysfunction drugs and recreational drug use before sex. Men in the 'ATS use' category were significantly less likely to not know their HIV status (AOR: 0.30, 95%CI: 0.14,0.66), more likely to have had more than 6 male sex partners (AOR: 4.83, 95% CI: 1.92-12.2), to have group sex (AOR:4.07, 95% CI: 2.31-7.15), to report inconsistent condom use (AOR:2.01, 95% CI: 1.12-3.60), to be HIV-infected (AOR:3.92, 95% CI: 1.63-8.42) and to have had any sexually transmitted infections (AOR:3.92, 95% CI:1.70, 9.08), compared to men in the 'negligible substance use' category.

Conclusions: Our study identified subgroups of Malaysian MSM with distinct substance use patterns and HIV-related risk profiles, which provides implication for targeting HIV prevention in this subpopulation.
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http://dx.doi.org/10.1016/j.drugalcdep.2015.02.040DOI Listing
June 2015

Consent Challenges for Participation of Young Men Who Have Sex With Men (YMSM) in HIV Prevention Research in Thailand.

Ethics Behav 2015 Mar;25(2):180-195

Department of Society and Health, Faculty of Social Sciences and Humanities, Mahidol University, Nakorn Pathom, Thailand ; Center for Health Policy Studies, Faculty of Social Sciences and Humanities, Mahidol University, Nakorn Pathom, Thailand.

Young men who have sex with men (YMSM) under 18 years are often excluded from HIV prevention research in Thailand due to cultural attitudes toward youth sexuality, social stigma, and difficulties obtaining guardian permission. Culturally sensitive focus group discussions conducted with parents and YMSM in Bangkok, Thailand identified barriers and facilitators related to minors' participation in HIV prevention research. Although gender and class differences emerged, mothers and fathers were generally accepting of research to reduce HIV risk, but not in favor of waiver. Youth's positive attitude toward parental permission was tempered by concerns about harms posed by disclosing same-sex attraction through permission forms.
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http://dx.doi.org/10.1080/10508422.2014.949721DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4349333PMC
March 2015
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