Online HIV self-testing in Thailand struggles to link trans women and gay men to treatment
Trans women and men who have sex with men who opt for online supervised HIV-self testing are more likely to test positive but are less likely to seek treatment than those testing offline.
Researchers recruited 465 HIV-negative men who have sex with men and around 100 transgender women from Bangkok and Pattaya between 2015 and 2017 then followed them for 12 months.
Participants were offered either real-world HIV testing and counselling, a mix of online pre-test counselling and real-world testing, or online counselling and finger-prick HIV-self testing, assisted by online support. Around 150 chose the mixed option and roughly 200 chose the offline-only and online-only options. Testing was conducted on enrolment, after six months and at the end of the study.
The median age of participants was 26. In the past six months, 68% had more than one sex partner, 77% reported using condoms inconsistently, 6% had used amphetamine‐type stimulants and 18% had engaged in group sex.
HIV prevalence was found to be highest among the online, self-testing group (15%, compared to 13% in the offline group and 3.4% in the mixed group). However, only half (53%) of those who had a reactive self-test began antiretroviral treatment (ART), compared to around 85% of those testing positive through real-world testing and counselling and 78% diagnosed through the mixed approach.
A total of 60 people tested HIV positive or had a reactive result in their first test and 18 became HIV positive during the study. Three quarters (75%) of those who tested reactive through HIV self‐testing subsequently accessed HIV confirmatory testing, which was conducted in a community setting, all of whom were confirmed to have HIV.
HIV‐positive participants in all groups received support and were encouraged to visit their preferred hospitals to begin treatment. Those who tested positive for HIV were contacted by study staff two weeks after testing positive then after one, three and six months. Those with a reactive self-test were contacted after three days, one week and a fortnight, then every two to four weeks.
Overall, ART was successfully initiated by 78% of HIV-positive participants – which is higher level than the national average of 70%. An analysis was also conducted to identify specific factors associated with not starting ART. These included having first had sex under the age of 17, using amphetamine‐type stimulants and having no or only one sexual partner sex in the past six months.
Participants who chose to receive online HIV self‐testing were more likely to cite the fear of meeting people they may know as a barrier to testing for HIV than those who chose offline testing. They were also more likely to experience discrimination from family members than those who opted for offline testing. The lower up-take of ART among this group is therefore likely to be linked to the need to visit conventional HIV treatment facilities.
This suggests that providing ART in a non‐conventional setting, such as a community-based organisation staffed by transgender women or men who have sex with men, who are more likely to be non‐judgemental and familiar with the lifestyles and needs of those receiving services, will be crucial to supporting HIV self‐testing as it continues to be rolled out in Thailand and beyond.