BACKGROUND: A recent infection testing algorithm (RITA) incorporating case surveillance (CS) with the rapid test for recent HIV infection (RTRI) was integrated into HIV testing services in Thailand as a small-scale pilot project in October 2020. OBJECTIVE: We aimed to describe the lessons learned and initial outcomes obtained after the establishment of the nationwide recent HIV infection surveillance project from April through August 2022. METHODS: We conducted desk reviews, developed a surveillance protocol and manual, selected sites, trained staff, implemented surveillance, and analyzed outcomes. Remnant blood specimens of consenting newly diagnosed individuals were tested using the Asanté HIV-1 Rapid Recency Assay. The duration of HIV infection was classified as RTRI-recent or RTRI-long-term. Individuals testing RTRI-recent with CD4 counts <200 cells/mm3 or those having opportunistic infections were classified as RITA-CS-long-term. Individuals testing RTRI-recent with CD4 counts >200 cells/mm3, no opportunistic infections, and not on antiretroviral treatment were classified as RITA-CS-recent. RESULTS: Two hundred and one hospitals in 14 high-burden HIV provinces participated in the surveillance. Of these, 69 reported ≥1 HIV diagnosis during the surveillance period. Of 1053 newly diagnosed cases, 64 (6.1%) were classified as RITA-CS-recent. On multivariate analysis, self-reporting as transgender women (adjusted odds ratio [AOR] 7.41, 95% CI 1.59-34.53) and men who have sex with men (AOR 2.59, 95% CI 1.02-6.56) compared to heterosexual men, and students compared to office workers or employers (AOR 3.76, 95% CI 1.25-11.35) were associated with RITA-CS-recent infection. The proper selection of surveillance sites, utilizing existing surveillance tools and systems, and conducting frequent follow-up and supervision visits were the most commonly cited lessons learned to inform the next surveillance phase. CONCLUSIONS: Recent HIV infection surveillance can provide an understanding of current epidemiologic trends to inform HIV prevention interventions to interrupt ongoing or recent HIV transmission. The key success factors of the HIV recent infection surveillance in Thailand include a thorough review of the existing HIV testing service delivery system, a streamlined workflow, strong laboratory and health services, and regular communication between sites and the Provincial Health Offices.

BACKGROUND: Respondent-driven sampling (RDS) is the current standard for sampling key populations at risk for HIV infections but is usually limited to local implementation in single towns or cities. Web-based sampling eliminates this spatial constraint but often relies on self-selected convenience samples. We piloted a web-based RDS survey with biomarker collection among men who have sex with men (MSM) in Thailand. OBJECTIVE: This study aimed to evaluate and demonstrate the feasibility of implementing a web-based RDS survey as a routine surveillance system in Thailand. The goal was to enhance surveillance efforts targeting hard-to-reach populations in the country. METHODS: We developed a website to fully function like a conventional RDS survey office, including coupon verification, eligibility screening, consenting, interviewing (self-administered), peer recruitment training, coupon issuance, compensation, and recruitment tracking. All functions were automated; data managers monitored recruitment, data collection, and payment and could be contacted by recruits as needed. Eligible participants were male, older than 15 years, resided in Thailand, and had anal sex with a man in the past 6 months. Recruits who resided in Bangkok were additionally invited to physically attend a participating health clinic of their choice for an HIV-related blood draw. Data were weighted to account for the complex sampling design. RESULTS: The survey was implemented from February to June 2022; seeds (21 at start, 14 added later) were identified mostly through targeted web-based banner ads; coupon uptake was 45.1%. Of 2578 candidate recruits screened for eligibility, 2151 (83.4%) were eligible and 2142 (83.1%) enrolled. Almost all (2067/2578, 80.2%) completed the questionnaire; however, 318 survey records were removed from analysis as fraudulent enrollments. The final sample size was 1749, the maximum number of waves achieved was 191, and sampling covered all 6 geographic regions and 75 of 77 (97.4%) provinces; convergence was reached for several salient variables. The mean age was 20.5 (SD 4.0) years, and most (69.8%) had never tested for HIV before, with fear of stigma as the biggest reason (97.1%) for not having tested. Most (76.9%) had visited gay-focused physical venues several times a week. A condom was used in 97.6% of the last sex acts, 11.0% had purchased sex from other men (past 12 mo), 4.5% had sold sex to men (past 12 mo), and 95.3% had 3+ male sex partners (last 3 mo). No participant in Bangkok presented for a blood draw. CONCLUSIONS: We successfully conducted a web-based RDS survey among MSM in Thailand, covering nearly the entire country, although, as in physical RDS surveys, sampling was dominated by younger MSM. The survey also failed to collect biomarkers in Bangkok. Public health interventions should aim at increasing testing and addressing (the perception of) stigma.

The present study focuses on establishing the quality assurance of laboratories for recent infections (RTRI) in Thailand. We developed a cold-chain independent method, using fully characterized plasma obtained from the Thai Red Cross Society, and prepared as dried tube specimens (DTS). Twenty microliters of HIV-seronegative, recent, and long-term infected samples were aliquoted into individual tubes and dried at room temperature, 20-30 degrees Celsius, in a biosafety cabinet overnight to ensure optimal preservation. The DTS external quality control and external quality assessment were tested for homogeneity and stability following the ISO/Guide 35 guidelines. The DTS panels were distributed to 48 sites (FY 2022) and 27 sites (FY 2023) across 14 and 9 provinces, respectively, in Thailand. The results from participating laboratories were collected and evaluated for performance. The results were scored, and acceptable performance criteria were defined as the proportion of panels correctly tested, which was set at 100%. The satisfactory performance ranged from 96% to 100% and was not significantly different among the 13 health regions. The developed and implemented DTS panels can be used to monitor the quality of RTRI testing in Thailand.

BACKGROUND: Thailand's HIV epidemic is heavily concentrated among men who have sex with men (MSM), and surveillance efforts are mostly based on case surveillance and local biobehavioral surveys. OBJECTIVE: We piloted Kai Noi, a web-based respondent-driven sampling (RDS) survey among MSM. METHODS: We developed an application coded in PHP that facilitated all procedures and events typically used in an RDS office for use on the web, including e-coupon validation, eligibility screening, consent, interview, peer recruitment, e-coupon issuance, and compensation. All procedures were automated and e-coupon ID numbers were randomly generated. Participants' phone numbers were the principal means to detect and prevent duplicate enrollment. Sampling took place across Thailand; residents of Bangkok were also invited to attend 1 of 10 clinics for an HIV-related blood draw with additional compensation. RESULTS: Sampling took place from February to June 2022; seeds (21 at the start, 14 added later) were identified through banner ads, micromessaging, and in online chat rooms. Sampling reached all 6 regions and almost all provinces. Fraudulent (duplicate) enrollment using "borrowed" phone numbers was identified and led to the detection and invalidation of 318 survey records. A further 106 participants did not pass an attention filter question (asking recruits to select a specific categorical response) and were excluded from data analysis, leading to a final data set of 1643 valid participants. Only one record showed signs of straightlining (identical adjacent responses). None of the Bangkok respondents presented for a blood draw. CONCLUSIONS: We successfully developed an application to implement web-based RDS among MSM across Thailand. Measures to minimize, detect, and eliminate fraudulent survey enrollment are imperative in web-based surveys offering compensation. Efforts to improve biomarker uptake are needed to fully tap the potential of web-based sampling and data collection.

INTRODUCTION: Human Immunodeficiency Virus (HIV) prevalence among young gender-diverse (a wide range of gender identities for people whose gender identity is different from the sex that they were assigned at birth) individuals is high but testing coverage among this key population remains low. We aim to evaluate strategies for outreach, HIV testing, and linkage to proper management in young men-who-have-had-sex-with-men (MSM, homosexual male) and transgender women (TGW) in Bangkok, Thailand. METHODS: The "YM2M outreach program" consisted of two strategies: 1) online platforms (OP) and 2) physical outreach activities (POA). Participant questionnaires were completed on a voluntary basis during outreach activities during 2018-2021. Demographic and behavioral characteristics were assessed for association with HIV positivity. RESULTS: A total of 3,972 homosexual male and TGW participated in the YM2M program: 2,973 by OP and 999 by POA. Of 2,230 participants who reported gender identity, 603/1,392 (43.3%) of OP and 252/985 (25.6%) of POA were gender diverse. Of 631 (21.2%) participants in OP and 970 (97.1%) in POA who underwent testing, 286 (45.3%) in OP and 41 (4.2%) in POA were HIV-positive. The venue reporting highest HIV yield was the Mor-Lam (11.5%). Among those with an HIV-positive test, 175 (61.2%) from OP and 23 (51.1%) from POA were successfully linked to HIV care. The independent factors associated with HIV positive in OP were being youth (adjusted odd ratio (aOR), 0.37; 95%CI 0.16-0.81; P = 0.01) and suspected or confirmed STI (aOR 15.39; 95%CI 7.17-33.03, P<0.01); while those in in POA at Mor-Lam were being gender diverse (aOR, 8.43; 95%CI 1.94-36.62; P<0.01) and reactive syphilis test (aOR, 5.40;95%CI 2.45-11.88; P<0.01). Linkage to pre-exposure prophylaxis (PrEP) among HIV-negative participants was low, 4.9% and 2.6% in OP and POA participants, respectively. CONCLUSIONS: While uptake of HIV testing was higher in POA while OP was more effective in identifying undiagnosed people living with HIV/AIDS and linking them to care. Neither strategy was considered effective in linkage to PrEP.

Gay, bisexual, and other men who have sex with men (GBMSM) are disproportionately affected by mental health problems and human immunodeficiency virus (HIV). Health navigation has the potential to improve both HIV and mental health outcomes; however, few studies have measured the impact of navigation on mental health among people living with HIV. We analyzed longitudinal data from a sociobehavioral survey and navigation monitoring system with GBMSM living with HIV in Guatemala (n = 346) that participated in a 12-month differentiated care intervention. We examined relationships between navigation characteristics (frequency, duration, mode of interactions, and level of emotional, instrumental, and informational navigation support) and anxiety and depression using fixed-effects regression. We also examined if these relationships were moderated by baseline social support. We found that as navigation interactions increased, anxiety significantly improved [B = -0.03, standard error (SE) = 0.01 p = 0.05]. Participants who received high levels of informational navigator support also experienced a significant improvement in anxiety compared with those receiving low levels of informational support (B = -0.81, SE = 0.40, p = 0.04). Unexpectedly, we found that as the proportion of in-person navigation interactions increased, anxiety worsened (B = 1.12, SE = 0.54, p = 0.04). No aspects of navigation were significantly associated with depression and baseline social support did not moderate the relationship between navigation and anxiety and depression. To improve the mental health of key populations affected by HIV, health navigation programs should prioritize frequent interaction and informational navigation support for clients with anxiety while considering other strategies that specifically target reducing depressive symptoms, including other cost-effective modalities, such as mobile apps.

Globally, gay, bisexual, and other men who have sex with men (GBMSM) are disproportionately affected by HIV, but few interventions address mental health and HIV outcomes among GBMSM living with HIV. The purpose of this study was to pilot a multicomponent intervention, integrating emotional well-being (EW) and health navigation for GBMSM living with HIV in Guatemala City. We implemented a 12-month intervention, including a four-session EW component and a health navigation component among newly diagnosed and reengaged GBMSM with HIV (n = 112). We conducted socio-behavioral surveys at baseline and endline to measure patient characteristics and HIV, and mental health outcomes as well as viral load testing. We documented participation in EW sessions and used a smartphone application to track navigation mode, frequency, and content. Using first-difference estimation modeling, we assessed associations between participation in EW and navigation and mental health (depression and anxiety symptoms) and HIV outcomes (HIV treatment adherence, viral suppression). Acceptability was high for EW (86%) and navigation (99%). During the intervention, viral suppression increased significantly and anxiety and depression decreased significantly. Participation in EW sessions and greater navigation frequency and duration were associated with being suppressed, whereas higher emotional navigator support was associated with being unsuppressed. Participation in EW sessions was associated with reduced anxiety. Findings suggest that multicomponent interventions integrating individual counseling and navigation may promote EW and sustained viral suppression. Future intervention research is needed to confirm whether HIV and mental health outcomes are attributable to the intervention and to assess mechanisms of influence.

BACKGROUND: Human immunodeficiency virus drug resistance (HIVDR) can negatively impact the effectiveness of antiretroviral therapy (ART). We aimed to estimate the prevalence of pretreatment HIVDR (PDR) among ART initiators and the prevalence of viral load (VL) suppression and acquired HIVDR among individuals receiving ART for 12 ± 3 months (ADR12) and ≥48 months (ADR48) in El Salvador. METHODS: Nationally representative cross-sectional PDR, ADR12 and ADR48 surveys were conducted among adults with HIV from October 2018 to August 2019, following World Health Organization-recommended methods. Demographic and clinic data and blood specimens were collected. RESULTS: Two hundred sixty participants were enrolled in the PDR survey, 230 in ADR12 and 425 in ADR48. Twenty-seven percent (95% confidence interval [CI], 17.1%-39.9%) of ART initiators had PDR to efavirenz or nevirapine. The prevalence of VL suppression was 88.8% (95% CI, 83.1%-92.8%) in ADR12 and 80.5% (95% CI, 76.6%-84.0%) in ADR48 surveys. Among people with HIV receiving a first-line nonnucleoside reverse transcriptase inhibitor (NNRTI)-based ART regimens and with unsuppressed VL, the prevalence of ADR to efavirenz or nevirapine was 72.0% (95% CI, 32.3%-93.3%) and 95.0% (68.5%-99.4%) in the ADR12 and ADR28 surveys, respectively. ADR12 to boosted protease inhibitors (PI/r) or integrase strand transfer inhibitors (INSTIs) was not observed. ADR48 was 1.3% (95% CI, 0.2%-9.6%) and 2.1% (0.3%-13.7%), respectively. CONCLUSIONS: Programmatic improvements in ART delivery are urgently needed in El Salvador to address the high levels of resistance to efavirenz or nevirapine among ART initiators and the low VL suppression prevalence among individuals on treatment.

Background: An electronic medical record (EMR) has the potential to improve completeness and reporting of notifiable diseases. We developed and assessed the validity of an HIV case detection algorithm and deployed the final algorithm in a national automated HIV case reporting system in Thailand. Method(s): The HIV case detection algorithms leveraged a combination of standard laboratory codes, prescriptions and International Classification of Diseases, 10th Revision diagnostic codes to identify potential cases. The initial algorithm was applied to the national EMR from 2014 to June 2020 to identify HIV-infected subjects to build the national HIV case reporting system (Epidemiological Intelligence Information System (EIIS)). A subset of potential positives identified by the initial algorithm were then validated and reviewed by infectious disease specialists. This review identified that a proportion of the false positives were due to pre-exposure prophylaxis/postexposure prophylaxis (PrEP/PEP) antiretrovirals, and so the algorithm was refined into a 'Final Algorithm' to address this. Result(s): Positive predictive value of identifying HIV cases was 90% overall for the initial algorithm. Individuals misclassified as HIV-positive were HIV-negative patients with incorrect diagnostic codes, prescription records for PrEP, PEP and hepatitis B treatment. Additional revision to the algorithm included triple drug regimen to avoid further misclassification. The final HIV case detection algorithm was applied to national EMR between 2014 and 2020 with 449 088 HIV-infected subjects identified from 1496 hospitals. EIIS was designed by applying the final algorithm to automated extract HIV cases from the national EMR, analysing them and then transmitting the results to the Ministry of Public Health. Conclusion(s): EMR data can complement traditional provider-based and laboratory-based disease reports. An automated algorithm incorporating laboratory, diagnosis codes and prescriptions have the potential to improve completeness and timeliness of HIV reporting, leading to the implementation of a national HIV case reporting system. Copyright 2022 Author(s) (or their employer(s)).

Mental health problems, including anxiety and depression, are a common comorbidity among gay, bisexual and other men who have sex with men (GBMSM) living with HIV. Informed by social support theory, health navigation is a strengths-based intervention that has been demonstrated to improve HIV care outcomes. The purpose of this study was to explore how health navigation influences the mental health of GBMSM living with HIV. We analyzed longitudinal qualitative in-depth interviews conducted with GBMSM (n = 29) in a 12-month multi-component intervention to improve HIV care outcomes, including health navigation. We used narrative and thematic analytic approaches to identify salient themes, including if and how themes changed over time. Participants described that navigator support helped them maintain good mental health, prevent crises and respond to crises. Navigator support included providing motivational messaging, facilitating participants' control over their health and improving access to care, which aided with supporting mental health. Navigators also responded to acute crises by providing guidance for those newly diagnosed with HIV and support for those experiencing critical life events. Participants emphasized the importance of feeling heard and valued by their navigators and gaining hope for the future as key to their wellbeing. In conclusion, health navigation may be an effective intervention for promoting mental health among GBMSM living with HIV. Additional research is needed to examine mediating pathways between navigation and mental health, including informational support, or if navigator support moderates the relationship between stressors and mental health outcomes for GBMSM.

BACKGROUND: Pre-treatment HIV drug resistance (HIVDR) to NNRTIs has consistently increased in low-/middle-income countries during the last decade. OBJECTIVES: To estimate the prevalence of pre-treatment HIVDR and acquired HIVDR among persons living with HIV (PLHIV) on ART for 12+/-3 months (ADR12) and >/=48 months (ADR48) in Honduras. PATIENTS AND METHODS: A nationwide cross-sectional survey with a two-stage cluster sampling was conducted from October 2016 to November 2017. Twenty-two of 54 total ART clinics representing >90% of the national cohort of adults on ART were included. HIVDR was assessed for protease and reverse transcriptase Sanger sequences using the Stanford HIVdb tool. RESULTS: A total of 729 PLHIV were enrolled; 26.3% (95% CI 20.1%-33.5%) ART initiators reported prior exposure to antiretrovirals. Pre-treatment HIVDR prevalence was 26.9% (95% CI 20.2%-34.9%) to any antiretroviral and 25.9% (19.2%-33.9%) to NNRTIs. NNRTI pre-treatment HIVDR was higher in ART initiators with prior exposure to antiretrovirals (P = 0.001). Viral load (VL) suppression rate was 89.7% (85.1%-93.0%) in ADR12 and 67.9% (61.7%-73.6%) in ADR48. ADR12 to any drug among PLHIV with VL >/=1000 copies/mL was 86.1% (48.9%-97.6%); 67.1% (37.4%-87.5%) had HIVDR to both NNRTIs and NRTIs, and 3.8% (0.5%-25.2%) to PIs. ADR48 was 92.0% (86.8%-95.3%) to any drug; 78.1% (66.6%-86.5%) to both NNRTIs and NRTIs, and 7.3% (1.8%-25.1%) to PIs. CONCLUSIONS: The high prevalence of NNRTI pre-treatment HIVDR observed in Honduras warrants consideration of non-NNRTI-based first-line regimens for ART initiation. Programmatic improvements in HIVDR monitoring and adherence support may also be considered.

Health navigation is increasingly being used to support people living with HIV, but timely monitoring of navigation is challenging due to the burden of reporting a high volume of diverse activities. We designed a mobile application (app) for navigators to report their interactions with men who have sex with men living with HIV (n = 374), including: (1) mode of support; (2) content; and (3) duration. We assessed sociodemographic and behavioral characteristics of the study sample and calculated monitoring system indicators. We also conducted qualitative interviews with navigators (n = 7) and used thematic analysis to assess app acceptability and usability. From January 2017 to June 2018, 95.3% of participants interacted with their navigator at least one time and 4281 reports were recorded by nine navigators. The median number of interactions per participant was 10 (range: 1-46). The majority of interactions (71.6%) occurred remotely. Most frequently covered topics included: appointment reminders (36.9%), employment (19.9%), and family (15.5%). Navigators indicated that the system was easy to use, but some did not use it in real time as intended. Timely access to navigator data enabled feedback and continuous training. These data can also facilitate analysis of intensity and content of interactions to improve tailoring and sustainability.

INTRODUCTION: A nationally representative HIV drug resistance (HIVDR) survey in Nicaragua was conducted to estimate the prevalence of pretreatment HIVDR (PDR) among antiretroviral therapy (ART) initiators and acquired HIVDR among people living with HIV (PLHIV) who had received ART for 12 +/- 3 months (ADR12) and >/=48 months (ADR48). METHODS: A nationwide cross-sectional survey with a two-stage cluster sampling was conducted from March to November 2016. Nineteen of 45 total ART clinics representing >90% of the national cohort of adults on ART were included. ART initiators were defined as PLHIV initiating or reinitiating first-line ART. HIVDR was assessed for protease, reverse transcriptase and integrase Sanger sequences using the Stanford HIVdb algorithm. Viral load (VL) suppression was defined as <1000 copies/mL. Results were weighted according to the survey design. RESULTS AND DISCUSSION: A total of 638 participants were enrolled (PDR: 171; ADR12: 114; ADR48: 353). The proportion of ART initiators with prior exposure to antiretrovirals (ARVs) was 12.3% (95% CI: 5.8% to 24.3%). PDR prevalence to any drug was 23.4% (95% CI: 14.4% to 35.6%), and 19.3% (95% CI: 12.2% to 29.1%) to non-nucleoside reverse transcriptase inhibitors (NNRTI). NNRTI PDR was higher in ART initiators with previous ARV exposure compared with those with no exposure (76.2% vs. 11.0%, p < 0.001). Protease inhibitors (PI) and integrase strand transfer inhibitors PDR was not observed. VL suppression rate was 77.8% (95% CI: 67.1% to 85.8%) in ADR12 and 70.3% (95% CI: 66.7% to 73.8%) in ADR48. ADR12 prevalence to any drug among PLHIV without VL suppression was 85.1% (95% CI: 66.1% to 94.4%), 82.4% to NNRTI and 70.2% to nucleoside reverse transcriptase inhibitors (NRTI). ADR48 prevalence to any drug among PLHIV without VL suppression was 75.5% (95% CI: 63.5% to 84.5 %), 70.7% to NNRTI, 59.4% to NRTI and 4.6% to PI. CONCLUSIONS: Despite implementation challenges yielding low-precision HIVDR estimates, high rates of NNRTI PDR were observed in Nicaragua, suggesting consideration of non-NNRTI-based first-line regimens for ART initiators. Strengthened HIVDR monitoring, systematic VL testing, and improved ART adherence support are also warranted.

Through 2017, roughly 40 years since HIV/AIDS became a global health crisis, the world has experienced devastating consequences: an estimated 35 million HIV-infected persons have died, 17 million children have been orphaned, and 37 million persons are living with the virus [1,2]. With sustained commitment to address the epidemic, control and virtual elimination of HIV is within reach in some countries. In 2014, the Joint United Nations Programme on HIV/AIDS released ambitious treatment targets to reach HIV epidemic control by 2030, calling for 90% of all persons living with HIV (PLHIV) to be diagnosed, 90% of diagnosed PLHIV to be on HIV treatment, and 90% of treated PLHIV to be virally suppressed by 2020 (90-90-90) [3]. By 2017, 75% of PLHIV knew their HIV status, 79% of these were on treatment, and 81% of these achieved viral suppression [1]. Still millions of PLHIV who require diagnosis and treatment are not yet reached.

We piloted a health navigation strategy to promote timely linkage to care among men who have sex with men (MSM) and transgender women (TW) recently diagnosed with HIV in Guatemala City. We used a mixed-methods approach, integrating quantitative data collected during clinic visits and qualitative data from in-depth interviews, to characterize acceptability of navigation and time to linkage, defined as having the first clinical care visit. Out of 54 participants who enrolled in the pilot (n = 52 MSM; n = 2 TW), 50 (92.6%) accepted navigation and all were linked to care. Median time to linkage was 3 days (Interquartile Range 2-5 days). In qualitative interviews, participants expressed feeling scared and alone following their diagnosis and appreciated the support of a navigator, especially when they did not feel they could access their existing support networks. Future research and evaluation should continue to assess how to best use health navigation to support key populations recently diagnosed with HIV.

Men who have sex with men (MSM) are disproportionately affected by HIV in Guatemala and may benefit from health navigation programs designed to support timely linkage to HIV care. We conducted qualitative in-depth interviews with MSM (n = 19) linked to care within days of their diagnosis with the support of a health navigator. We used narrative analysis and systematic coding to identify themes related to HIV diagnosis and experiences with navigators. Participants experienced strong feelings of fear upon receiving a positive HIV test result. This fear led to social isolation and limited reliance on family and friend networks for support. Health navigators developed strong relationships with participants by providing the emotional support they were lacking and supporting them to overcome their fear and other structural barriers to HIV care, including stigma. Findings support the important role of navigation for MSM in Guatemala and could be transferable to other settings in Latin America.