OBJECTIVE:To describe the incidence and clearance rates of anal high-grade squamous intraepithelial lesions (HSIL) among MSM and transgender women who initiated immediate antiretroviral therapy during acute HIV acquisition. DESIGN:A prospective cohort study of MSM and transgender women diagnosed with acute HIV acquisition in Bangkok, Thailand. METHODS:Participants who were enrolled from May 2017 to June 2020 underwent anal human papillomavirus (HPV) genotyping, high-resolution anoscopy, and anal biopsies as indicated, at baseline and 6-monthly follow-up visits. RESULTS:Among 89 MSM and 4 transgender women (median age 26 years), the anal HSIL incidence rate was 22.7 per 100 person-years over 180.9 person-years, while the clearance rate was 119.4 per 100 person-years over 32.7 person-years. After adjusting for age, smoking, and baseline CD4 + cell count, incident anal HSIL was greater in those with persistent HPV 16 [adjusted hazards ratio (aHR) 14.98, 95% confidence interval (CI) 1.73-129.48], nonpersistent HPV 16 (aHR 15.12, 95% CI 1.84-124.50), persistent non-16 cancer-associated HPV types (aHR 17.90, 95% CI 2.34-136.74), and nonpersistent non-16 cancer-associated HPV types (aHR 10.65, 95% CI 1.34-84.93) compared to participants with consistently negative cancer-associated HPV. Persistent (aHR 0.17, 95% CI 0.04-0.66) and nonpersistent HPV 16 (aHR 0.22, 95% CI 0.05-0.98) were associated with lower HSIL clearance likelihood. CONCLUSION:Among predominantly young participants initiating antiretroviral therapy during acute HIV acquisition, anal HSIL showed high incidence yet markedly high clearance rates. Anal HPV 16 infection increased risk of incident anal HSIL and decreased lesion clearance. HPV vaccination and HSIL screening/treatment should be implemented despite rapid antiretroviral therapy initiation.

Anal cancer-associated human papillomavirus (caHPV) infection is the leading cause of anal cancer. This study describes human papillomavirus (HPV) progression among participants with acute HIV acquisition. Cisgender men and transgender women initiating antiretroviral therapy during acute HIV acquisition (Fiebig 1–5) underwent anal HPV testing at a sexual health clinic in Bangkok from May 2017 to June 2020. Demographic, sexual history, and laboratory data were collected at HIV diagnosis. Two-state Markov models were created to estimate probabilities and durations of HPV 16, 18/45, other caHPV, and any caHPV. Multivariate analyses were performed by adjusting for age and baseline CD4 count. A total of 94 participants (median age 26 years) were enrolled. Among 92 participants with valid baseline HPV results, 15.2

INTRODUCTION:Men who have sex with men (MSM), especially those living with HIV, are at an increased risk of anal cancer. The prevalence and incidence of its precursor, anal high-grade squamous intraepithelial lesions (HSILs), among MSM who started antiretroviral therapy during acute HIV acquisition are yet to be explored. METHODS:Participants in an acute HIV acquisition cohort in Bangkok, Thailand, who agreed to take part in this study, were enrolled. All participants were diagnosed and started antiretroviral therapy during acute HIV acquisition. Human papillomavirus (HPV) genotyping and high-resolution anoscopy, followed by anal biopsy as indicated, were done at baseline and 6-monthly visits. RESULTS:A total of 89 MSM and four transgender women were included in the analyses. Median age at enrolment was 26 years. Baseline prevalence of histologic anal HSIL was 11.8%. With a total of 147.0 person-years of follow-up, the incidence of initial histologic anal HSIL was 19.7 per 100 person-years. Factors associated with incident anal HSIL were anal HPV 16 (adjusted hazards ratio [aHR] 4.33, 95% CI 1.03-18.18), anal HPV 18/45 (aHR 6.82, 95% CI 1.57-29.51), other anal high-risk HPV (aHR 4.23, 95% CI 1.27-14.14), syphilis infection (aHR 4.67, 95% CI 1.10-19.90) and CD4 count <350 cells/mm3 (aHR 3.09, 95% CI 1.28-7.48). CONCLUSIONS:With antiretroviral therapy initiation during acute HIV acquisition, we found the prevalence of anal HSIL among cisgender men and transgender women who have sex with men to be similar to those without HIV. Subsequent anal HSIL incidence, although lower than that of those with chronic HIV acquisition, was still higher than that of those without HIV. Screening for and management of anal HSIL should be a crucial part of long-term HIV care for all MSM.

BACKGROUND:Age-specific data on anal, and corresponding cervical, human papillomavirus (HPV) infection are needed to inform female anal cancer prevention. METHODS:We centrally reanalyzed individual-level data from 26 studies reporting HPV prevalence in paired anal and cervical samples by human immunodeficiency virus (HIV) status and age. For women with HIV (WWH) with anal high-grade squamous intraepithelial lesions or worse (HSIL+), we also investigated concurrent cervical cytopathology. RESULTS:In HIV-negative women, HPV16 prevalence decreased significantly with age, both at anus (4.3% at 15-24 years to 1.0% at ≥55 years; ptrend = 0.0026) and cervix (7.4% to 1.7%; ptrend < 0.0001). In WWH, HPV16 prevalence decreased with age at cervix (18.3% to 7.2%; ptrend = 0.0035) but not anus (11.5% to 13.9%; ptrend = 0.5412). Given anal HPV16 positivity, concurrent cervical HPV16 positivity also decreased with age, both in HIV-negative women (ptrend = 0.0005) and WWH (ptrend = 0.0166). Among 48 WWH with HPV16-positive anal HSIL+, 27 (56%) were cervical high-risk HPV-positive, including 8 with cervical HPV16, and 5 were cervical HSIL+. CONCLUSIONS:Age-specific shifts in HPV16 prevalence from cervix to anus suggest that HPV infections in the anus persist longer, or occur later in life, than in the cervix, particularly in WWH. This is an important consideration when assessing the utility of cervical screening results to stratify anal cancer risk.

Objectives First, to describe the antiretroviral therapy (ART) delivery models available in Thailand to understand differentiated service delivery for further service system optimization and expansion of best practices; second, to determine the client characteristics associated with model uptake.Methods Across-sectional assessment using secondary data was conducted to describe ART models implemented as routine services at four public hospitals in three major provinces with a high-HIV burden in Thailand. From April to October 2020, ART clients were screened consecutively according to the inclusion criteria: Thai, aged = 18 years, and on ART for = 6 months. HIV treatment models were categorised based on the service type, location, provider, and frequency. Logistic regression was used to identify the associated factors.Results Seven individual ART delivery models were identified: four were facility-based and three were out-of-facility. No group models were identified. Of 3,366 records of ART clients reviewed, 3,213 (95.5%) met the study criteria and received ART through the following models: conventional (32.6%), nurse-led clinical consultation (10.0%), fast-track refill (29.0%), after-hours clinic (10.6%), pharmacist-led pickup center (3.6%), key population-led community-based organisation (2.7%), and mailing (11.5%). Age, population, duration on ART, and viral load were associated with the uptake of certain alternative service models when compared to the conventional model.Conclusions Among the variety of ART delivery approaches available in Thailand, facility-based models remain the most prevalent. Future work should investigate the role of client preference and choice in choosing service models and service utilisation patterns over time, and assess the acceptability and effectiveness of these models

Background Over 50% of HIV infections in Thailand annually occur among men who have sex with men (MSM) and transgender women who use online applications to meet their sexual partners. We conducted a cross-sectional study assessing undetectable=untransmittable (U=U) understanding, pre-exposure prophylaxis (PrEP) awareness, sexual behaviours and factors associated with HIV knowledge among users of Hornet in Thailand. Methods From November 2019 to January 2020, a survey was conducted using convenience sampling on Hornet in Thailand. HIV literacy was assessed via 22 questions, and multivariable linear regression was performed. Results 960 responses were assessed; median age was 34 years, the majority were MSM (80.4%), Thai (83.8%), had at least bachelor's degree (74.9%). Regarding the risk profiles, 39.1% reported inconsistent condom use, 15.0% used amphetamine-type stimulants, 56.9% had not taken PrEP in the last six months and 20.5% never had an HIV test. Only 22.8% thought that U=U was completely accurate. Lower HIV knowledge was associated with being from Africa (beta -8.13, 95% CI -14.39 to -1.87), age of 25 years or younger (beta -2.6, 95% CI -4.37 to -0.82), education less than bachelor's degree (beta -2.58, 95% CI -3.98 to -1.19), having more than one sexual partners (beta -2.41, 95% CI -4.13 to -0.69), paying three or more people to have intercourse (beta -2.5, 95% CI -4.26 to -0.74), not knowing one's HIV status (beta -3.56, 95% CI -5.45 to -1.68) and not answering about previous PrEP use (beta -4.11, 95% CI -7.86 to -0.36). Higher HIV knowledge was associated with being from Europe (beta 2.54, 95% CI 0.46 to 4.61), the Americas (beta 3.37, 95% CI 0.44 to 6.30) and previous PrEP use (beta 2.37, 95% CI 0.94 to 3.81). Conclusion Among Hornet users in Thailand, the U=U message was unclear, and PrEP use was suboptimal. Large HIV knowledge gaps and high-risk behaviours were concerning. Educational campaigns in online spaces are needed to promote awareness and HIV prevention strategies.

Routine testing for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in people with heightened risk is lacking in Thailand. This study aimed to assess the performance of the Cepheid Xpert CT/NG assay, conducted by key population (KP) lay providers, for CT and NG detection on single-site and pooled specimens from the pharynx, rectum, and urine. Between August and October 2019, 188 men who have sex with men and 11 transgender women were enrolled. Participants collected urine specimens while trained KP lay providers obtained pharyngeal and rectal swabs. Compared to single-site testing with the Abbott RealTime CT/NG assay by medical technologists, the Xpert assay missed one pharyngeal NG infection out of 199 single-site specimens, giving a 93.3% sensitivity for pharyngeal NG and one missed pharyngeal NG infection out of fifty pooled specimens, giving an 88.9% sensitivity for pharyngeal NG. There was no discrepancy between the two assays for CT detection. The Cohen's Kappa coefficient of pooled specimen testing by the Xpert was 0.93 for NG and 1 for CT when compared to single-site testing by Abbott. Implementing pooled specimen testing by KP lay providers can be a cost-saving strategy to enhance the uptake of CT/NG services for populations facing increased risk.

IntroductionIn Thailand, where the HIV epidemic is concentrated among key populations (KPs), particularly men who have sex with men (MSM) and transgender women (TGW), an HIV service delivery model tailored to KPs was piloted. This study evaluated the acceptability and retention of clients who accepted and declined the KP-led HIV treatment service. MethodsA retrospective cohort study was conducted using secondary data from three community-based organizations (CBOs) and three hospitals in Thailand. KP lay providers were trained to lead HIV treatment service in which MSM and TGW living with HIV received counselling and a 3-month antiretroviral therapy (ART) supply at CBOs. Thai MSM and TGW who were at least 18 years, on ART for at least 6-12 months, without co-morbidities/co-infections, and virally suppressed were eligible and offered the service. Those who declined received ART via other service models offered by the hospitals and served as a comparison group. ResultsOf 220 clients screened between February 2019 and February 2020, 72% (159/220) were eligible of which 146 were MSM and 13 were TGW. Overall, 45% (72/159) accepted the KP-led service. Of those who declined, 98% (85/87) preferred to see the physician at the hospital. After 12 months of follow-up, among those accepted, 57% were in care at the CBO, 32% were referred back to and in care in other service models offered by the hospital, 10% were successfully transferred out to other hospital and 1% were lost to follow-up (LTFU); among those declined, 92% were in care in any service models offered by the hospital, 5% were successfully transferred out to other hospital, 2% were LTFU and 1% died (p-value<0.001). ConclusionsDespite moderate acceptability and retention in care at the CBO among the clients accepting the KP-led service, almost all clients were engaged in care overall. Multiple service models that meet the preferences and needs of KPs living with HIV should be available to optimize engagement in care.

PURPOSE OF REVIEW:HIV preexposure prophylaxis (PrEP) is a key tool in ending the HIV epidemic. Long-acting cabotegravir (LA- CAB) phase II/III studies revealed promising efficacy in preventing HIV acquisition. Here, we discuss key considerations for implementing LA-CAB in low- and middle-income countries (LMIC).RECENT FINDINGS:PrEP roll out in LMIC is still far from ideal, and contextual factors within LMIC vary widely. Implementation science studies are urgently needed to optimize the implementation of LA-CAB in different settings, consider effective service delivery models, and ensure program sustainability. Preferences and concerns regarding LA-CAB among potential users are unknown but likely specific to local context. Demedicalized and simplified PrEP service delivery increases uptake, and ways to safely and effectively do the same for LA- CAB need to be explored. Although ideally LA-CAB should be an additional choice of HIV prevention method, its cost will be the major determinant in deciding its position as a first line choice or restricted second-line option.SUMMARY:LA-CAB has the potential to enhance PrEP uptake. However, several implementation challenges need to be explored and addressed to ensure it can be accessed and utilized in different settings by those who need it the most.

In Thailand, the HIV epidemic disproportionately affects men who have sex with men and transgender women, who account for more than half of new infections annually [1]. In 2015, the key population-led health services (KPLHS) model was established to address low uptake of HIV services (testing, treatment and prevention) among these populations. KPLHS was designed by community members based on their needs and demands. Lay providers, themselves members of the communities they serve, are trained to deliver HIV and health services in key population-led clinics established and operated by community-based organizations (CBOs) [2]. These services include the provision of HIV counselling and testing, sexually transmitted infections (STI) testing and treatment, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis, and antiretroviral therapy (ART) for maintenance. KPLHS has been responsible for 55% of HIV testing in 2018, and 82% (12,748/15,546) of current PrEP users in 2021 in Thailand who are among key populations. Initially, KPLHS was primarily funded through the US President's Emergency Plan for AIDS Relief and The Global Fund to Fight AIDS, Tuberculosis and Malaria. This was largely because CBOs were excluded from receiving reimbursement for clinical service delivery through the National Health Security Office (NHSO), which funds Thailand's Universal Health Coverage programme. However, in 2016, NHSO began paying CBOs for HIV-related reach and recruit (R&R) activities on a cost-per-head basis through an annual “social contracting” mechanism, totalling US $6 million [3]. Nevertheless, important barriers remained: (1) lack of perceived feasibility, value and contribution of lay providers to the national HIV response among local healthcare providers, national healthcare professional councils, and Ministry of Public Health (MOPH) and NHSO leaderships, (2) limitation of reimbursement to R&R-related services and (3) the need to reapply for the contract every year. Development of training modules and administrative systems by IHRI, to facilitate certification of lay providers in HIV counselling, sample collection and conducting point-of-care tests for HIV and STI, and dispensing HIV-related medications as prescribed by doctors (e.g. PrEP). Development of a manual for quality standards for HIV service delivery, including key compentencies for lay providers, by IHRI in collaboration with The Department of Disease Control, MOPH and the Thailand MOPH—U.S. CDC Collaboration, to ensure the quality of services provided can be formally assessed and assured. Identification of champions from among CBO leadership, to facilitate partnership with IHRI and reciprocal learning. Establishment of a coalition for collaboration and joint advocacy efforts, including IHRI, CBO leadership, UNAIDS and LINKAGES Thailand. Organization of a series of high-level policy and advocacy dialogues with MOPH, central and regional NHSO offices, hospitals and provincial health offices, to raise awareness and generate support for task shifting to lay providers. Presentation of scientific findings from KPLHS and its impact on the national HIV response, and conduct and facilitate site visits for policy makers to demonstrate the effectiveness and feasibility of the model, to assist with policy decisions. In 2018, NHSO initiated an indirect reimbursement scheme for HIV testing and PrEP services conducted by certified lay providers, through which CBOs were paid via public hospitals. This scheme allowed more financial contributions to KPLHS, but faced key challenges: lack of acceptance of, and confidence among local public hospital leadership in the quality of services delivered by lay providers, resulting in difficulty partnering with them, and complications in reaching financial agreements. As a result of our ongoing advocacy and demonstration of successful implementation, MOPH issued a decree in 2019, allowing certified lay providers to deliver high-quality services (HIV counselling, sample collection for HIV and STI testing, conducting rapid/point-of-care tests and dispensing ART and PrEP as prescribed by doctors), signifying an important advance in regulatory reform to legalize lay providers to perform these services [6]. Furthermore, NHSO increased investments in local CBOs implementing KPLHS through social contracting for R&R and indirect reimbursement for HIV testing, from US$ 167,000 in 2016 to US$ 914,000 in 2019 [7]. The coalition among IHRI, CBOs and UNAIDS continued to engage in high-level policy discussions engaging national healthcare professional councils, to obtain the endorsement of the KPLHS standards, training modules and certification system by the MOPH. This was the key step to advance direct reimbursement from NHSO to CBOs in order to address the bottleneck previously experienced with indirect reimbursement through public hospitals, and to expand it to other services, such as PrEP. In September 2021, the certification of lay providers and CBOs by MOPH was implemented at the national level. From September 2021 to May 2022, the number of certified lay providers increased from 199 to 263. Eighteen CBOs were certified in 2021 and 32 CBOs have already applied for certification in 2022. MOPH-certified lay providers and CBOs, as described above, completed NHSO's requirement for direct reimbursement and activated its implementation. Although Thailand's MOPH now recognizes IHRI's certification system, lay providers who have previously been certified by IHRI still need to take an additional MOPH examination to achieve national certification. HIV testing and PrEP have not yet been included as part of the national certification and remain reimbursable only through public hospitals. The programme partners continue to be committed to implementing a strategy in order to achieve harmonization of examination requirements and inclusion of HIV testing and PrEP in the certification system to facilitate direct reimbursement of these services. We need to move from community engagement to community leadership in designing KPLHS, demonstrating its feasibility, and facilitating certification and integration in the national healthcare system of KPLHS. They have dedicated themselves to drive KPLHS implementation since its inception, and overcame substantial initial resistance from health authorities. These community leaders are key contributors to policy changes, with powerful voices across negotiating platforms. Through their expertise and contribution, these champions have cemented their roles in policy and advocacy discussions at the national level in Thailand. By demonstrating the increased uptake of HIV testing and PrEP among key populations and conducting ongoing advocacy activities, we have successfully turned yesterday's “not feasible” into today's successful KPLHS programmes. We need to rethink who gets to decide whether a programme is feasible and how this is ultimately defined. Initial international funding can be leveraged to generate data on programme effectiveness, feasibility and impact in order to facilitate high-level policy and advocacy discussions to ensure transitioning to domestic financing and sustainability. Building coalitions with multiple domestic and international stakeholders is essential to defend, negotiate and advocate with transparency, sincerity and persistence, in order to overcome various regulatory and policy barriers. Community leadership in co-delivering services has confronted health professionals who traditionally were placed at the top of a hierarchy. The client-centred design also challenged paternalism where health professionals commonly restrict clients’ capacity to make own informed choice. A beneficial policy climate among coalitions is, therefore, crucial in the process especially in Thailand, where hierarchy and paternalism characterize its healthcare system and can delay the advancement of innovative HIV service delivery models. All authors declare no competing interests related to this work. SP, SJ, TC, PC, PP and NP designed, led and implemented strategies. SP and RAR wrote the first draft. SJ, TC, PC, PP and NP reviewed, revised and provided feedback on the draft. RAR and NP revised the following drafts. NP revised the final draft, which was reviewed and approved by all authors. We are grateful to colleagues at IHRI, Service Workers in Group (SWING), Rainbow Sky Association of Thailand (RSAT), Mplus, Family Health International (FHI) 360, UNAIDS, USAID Regional Development Mission for Asia, Department of Disease Control, MOPH, Thailand MOPH-US CDC Collaboration (TUC), NHSO and UNAIDS for their trust and commitment in the establishment of KPLHS in Thailand. This work was supported by the USAID and US President's Emergency Plan for AIDS Relief (PEPFAR) through the Linkages Across the Continuum of HIV Services for Key Populations cooperative agreement (LINKAGES) and the Meeting Targets and Maintaining Epidemic Control (EpiC) managed by FHI 360 and the USAID Community Partnership (ENGAGE) managed by IHRI.

To reach its goal of ending AIDS by 2030, Thailand has adopted antiretroviral treatment as prevention and HIV pre-exposure prophylaxis for men who have sex with men (MSM) and transgender women (TGW) as its core HIV control strategy. However, in the absence of reliable epidemiologic indicators, the impact of these policies on the course of the HIV epidemic in these groups remains unknown. To help answer this question, we formulated an HIV epidemic consensus initiative for Bangkok, Thailand, to analyze epidemiologic and program data and reach agreement between experts and stakeholders on the evolving state of the HIV epidemic among MSM and TGW. A customized Delphi process was used to consult and consolidate viewpoints of experts and stakeholders. Experts presented and discussed HIV prevalence and incidence data from recent and ongoing studies among MSM and TGW in Bangkok (2014 to 2018) during a meeting with stakeholders representing government, donors, and civil society. Agreement about the course of the HIV epidemic among MSM and TGW was attained by voting consensus. Based on presented data, meeting participants agreed that HIV prevalence and incidence had decreased among Bangkok MSM from 2014 to 2018. Despite these declines, HIV prevalence and incidence were found to remain high. This was particularly the case among younger MSM. Participants agreed that there was no evidence for a decrease in HIV prevalence and incidence among Bangkok TGW. Introduction of antiretroviral treatment as prevention and HIV pre-exposure prophylaxis may have contributed to these declines. However, HIV prevalence and incidence remained high, and no signs of a decrease were reported among Bangkok TGW. At the current rate of new HIV infections in MSM and TGW, Thailand will not reach its goal of ending AIDS by 2030. This HIV consensus initiative may serve as a model for building agreement and advocacy on epidemiologic and program data and their implications for a large metropolitan city.

Abstract Background Viral hepatitis is highly prevalent among people with HIV (PWH) and can lead to chronic liver complications. Thailand started universal hepatitis B vaccination at birth in 1992 and achieved over 95% coverage in 1999. We explored the prevalence of hepatitis B and C viral infections and the associated factors among PWH from same-day antiretroviral therapy (SDART) service at the Thai Red Cross Anonymous Clinic, Bangkok, Thailand. Methods We collected baseline characteristics from PWH enrolled in the SDART service between July 2017 and November 2019. Multivariable logistic regression was performed to determine factors associated with positive hepatitis B surface antigen (HBsAg) and hepatitis C antibody (anti-HCV). Results A total of 4011 newly diagnosed PWH who had HBsAg or anti-HCV results at baseline: 2941 men who have sex with men (MSM; 73.3%), 851 heterosexuals (21.2%), 215 transgender women (TGW; 5.4%), and 4 transgender men (0.1%). Median age was 27 years. Overall seroprevalence of HBsAg and anti-HCV were 6.0 and 4.1%, respectively. Subgroup prevalence were 6.2 and 4.7% among MSM, 4.6 and 2.4% among heterosexuals, and 9.3 and 3.7% among TGW, respectively. Factors associated with HBsAg positivity were being MSM, TGW, born before 1992, CD4 count < 200 cells/mm3, and alanine aminotransferase ≥ 62.5 U/L. Factors associated with anti-HCV positivity were being MSM, age > 30 years, alanine aminotransferase ≥ 62.5 U/L, creatinine clearance < 60 ml/min, and syphilis infection. Conclusions Around 5–10% of newly diagnosed PWH in Bangkok had hepatitis B viral infection after 25 years of universal vaccination. Anti-HCV positivity was found in 4–5% of PWH who were MSM and TGW. As World Health Organization and Thailand national guidelines already support routine screening of hepatitis B and C viral infections in PWH and populations at increased risk of HIV including MSM and TGW, healthcare providers should reinforce this strategy and provide linkage to appropriate prevention and treatment interventions. Catch-up hepatitis B vaccination should be made available under national health coverage.

Background Same-day antiretroviral therapy (SDART) initiation, in which people living with HIV (PLHIV) who are antiretroviral therapy (ART)-naïve, willing, and clinically eligible start ART on the same day of HIV diagnosis, has been implemented in several healthcare facilities in Thailand since 2017. This evidence-based practice has demonstrated increased ART uptake, virologic suppression, and retention in care. However, linkage to care gaps exist in community-based organizations (CBOs) in Bangkok whereby as much as 20% of key populations (KP), mainly men who have sex with men and transgender women, living with HIV were lost to follow-up pre-ART initiation. To increase access to and uptake of ART among these populations, this study proposes that trained KP lay providers should lead community-based ART (CB-SDART) initiation service. This protocol describes the combined use of the Proctor’s implementation outcome framework and the Consolidated Framework for Implementation Research to guide and evaluate the CB-SDART implementation. Methods This study follows the hybrid design type 3: it is an implementation trial that secondarily assesses service and client outcomes by comparative interrupted time series analysis. Five strategies have been formulated to meet three implementation outcomes (i.e., feasibility, fidelity, and sustainability): (1) developing stakeholder relationships by engaging the CBO leaderships, (2) training and educating KP lay providers, (3) adapting and tailoring SDART to CBO-specific context, (4) using evaluative and iterative strategies to assess adherence to standard operating procedures, and (5) developing stakeholder relationships by engaging external stakeholders. Teleconsultation with physicians and ART home delivery will be integrated as another ART initiation option for clients and allow service provision during the COVID-19 pandemic. A mixed-method assessment will be conducted on key stakeholders and PLHIV diagnosed at two implementing CBOs, Rainbow Sky Association of Thailand and Service Workers in Group Foundation, in Bangkok, Thailand. Discussion This implementation research may be the first to provide robust data at the implementation, service, and client levels to inform how to successfully task-shift SDART initiation service to trained KP lay providers and facilitate the expansion of CB-SDART in the future. Trial registration This trial was registered with the Thai Clinical Trial Registry as TCTR20210709004 on July 9, 2021.

Purpose: Feminizing hormone therapy (FHT) is used by many transgender women as a pharmacological method to mitigate gender dysphoria. However, information on hormone concentrations among those who use FHT is lacking. We aimed to determine the proportion of Thai transgender women who were using FHT who had hormone concentrations within target ranges in a real-world clinic setting. Methods: Transgender women who attended Tangerine Clinic in Bangkok, Thailand, reported current use of FHT at clinic entry, and tested for both blood estradiol (E2) and total testosterone (TT) concentrations were included in the analysis. Hormone target concentrations were defined as 100–200 pg/mL for E2 and <50 ng/dL for TT. Results: Of 1534 transgender women included, 2.5% had undergone orchiectomy, and 524 (34.2%) had any hormones within target concentrations. Median (interquartile range) E2 and TT concentrations at baseline were 29 (14.3–45.3) pg/mL and 298.5 (22–646) ng/dL, respectively. Among those who had any hormones within target concentrations, 28 (1.8%), 11 (0.7%), and 485 (31.6%) had both hormones, only E2, and only TT within target concentrations, respectively. Among 1010 (65.8%) transgender women who had neither hormone within target concentrations, 989 (64.5%) and 21 (1.4%) had suboptimal and supraphysiological E2 concentrations, respectively. Among those who came to at least one follow-up visit (n=302), 165 (54.6%) transgender women managed to achieve or maintain either hormone within target concentrations. Conclusion: One-third of Thai transgender women who were using FHT had any hormones within target concentrations at baseline in this real-world setting study. Most transgender women who had neither hormone within target concentrations had suboptimal rather than supraphysiological E2 concentrations. More than half managed to achieve or maintain at least one hormone concentration within target concentrations at follow-up visits, suggesting a positive effect from attending a trans-led, integrated gender-affirming care and sexual health service.

Background Although key populations (KPs), such as men-who-have-sex-with-men (MSM) are disproportionately affected by HIV, many prevention and treatment services are not easily accessible for KP members. To address the needs of KPs, Thailand established pre-exposure prophylaxis (PrEP) service delivery together with and led by KP members. This study determines the epidemiological impact and cost-effectiveness of key population-led (KP-led) PrEP.Methods We calibrated a compartmental deterministic HIV transmission model to the HIV epidemic among Thai MSM. Besides KP-led PrEP, we included other Thai service delivery models of PrEP (fee-based PrEP, the government PrEP program).Data on consistent PrEP use (5 years daily use, 95% effectiveness for preventing HIV) came from Thai PrEP delivery models. For the period 2015-2032, we ranged the number of PrEP starters (40,000-120,000), effectiveness of PrEP (45%-95%), and proportion of consistent users (10%-50%). The analysis started in 2015 when PrEP was introduced. A cost-effectiveness ratio of <160,000 Baht per quality-adjusted life year (QALY) over 40 years was cost-effective.Findings Without PrEP, 53,800 (interquartile range 48,700-59,700) new HIV infections are expected in 2015-2032. KP-led PrEP was found to have the strongest epidemiological impact of all delivery models averting 58% of infections compared to without PrEP. The epidemiological impact depends on the number of PrEP starters and proportion of consistent use. Although all PrEP service delivery models are cost-effective, KP-led PrEP is most cost-effective with incremental cost-effectiveness ratios of 28,000-37,300 Thai Baht per QALY.Interpretation Our model projects KP-led PrEP having the greatest epidemiological impact and being the most cost-effective service delivery model of PrEP in Thailand.

Background: Increasing number of hepatitis C virus (HCV) infections among HIV positive men whohave sex with men (MSM) as in an acute HIV infection cohort study in Bangkok, reached an incidence of 45/1000 person-years in 2018. Direct-acting antivirals (DAAs), that cure HCV infection and thereby can prevent transmission, are expensive, their reimbursement being presently delayed to the chronic stages of liver fibrosis. The aim of this study was to determine the cost-effectiveness of immediate DAA treatment to reduce HCV transmission among HIV positive MSM in Bangkok. Methods: A deterministic transmission model was calibrated to the HCV epidemic among HIV positive MSM in Bangkok. We compared the current practice of starting DAAs at METAVIR stage F2 rather than at stage F1, or immediately after diagnosis, at stage F0. Cost-effectiveness was examined from a payer's perspective, using a 3% annual discounting rate. Results: Compared to the incidence in 2018, delaying DAA treatment to METAVIR stage F2 or F1, increases HCV incidence in 2030 to 63/1000 person-years and 56/1000 person-years, respectively. Conversely, immediate DAA treatment reduces the incidence to 26/1000 person-years. Compared to initiating treatment at stage F2, immediate treatment is cost saving within seven years and saves $17 million over 40 years. One-way sensitivity analysis showed that lower cost savings were achieved at a higher price of DAA treatment and at less frequent HCV screening. Conclusion: Immediate DAA treatment is cost saving and increases health benefits by reducing HCV incidence among HIV-infected MSM.