CSIRO PUBLISHING
Sexual Health, 2015, 12, 263–268 http://dx.doi.org/10.1071/SH14107
‘Drug users stick together’: HIV testing in peer-based drop-in centres among people who inject drugs in Thailand Lianping Ti A,B, Kanna Hayashi A, Sattara Hattirat C, Paisan Suwannawong C, Karyn Kaplan C and Thomas Kerr A,D,E A
British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. B School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada. C Thai AIDS Treatment Action Group, 18/89 Vipawadee Road, Soi 40 Chatuchak, Bangkok, 10900, Thailand. D Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, BC, V5Z 1M9, Canada. E Corresponding author. Email: [email protected]
Abstract. Introduction: Although there is a well recognised need for novel approaches to HIV testing, particularly for marginalised populations at high risk for HIV infection, there remains a dearth of information on the acceptability of peer-based HIV testing among people who inject drugs (PWID). Methods: Between July 2011 and June 2012, 22 in-depth interviews were conducted with PWID participating in the Mitsampan Community Research Project in Bangkok, Thailand. Semi-structured interviews explored willingness to access rapid HIV testing delivered by a healthcare professional or a trained peer within peer-based drop-in centres. Audio-recorded interviews were transcribed verbatim and a thematic analysis was conducted. Results: All participants indicated interest in accessing rapid HIV testing by a healthcare professional at peer-based drop-in centres due to the advantage of receiving immediate results. Experiencing stigma and discrimination by healthcare workers and wanting to avoid administrative barriers in hospitals were also reported as reasons for why PWID preferred HIV testing in peer-based settings. Peer support and shared lived experiences were repeatedly mentioned as benefits of peer-based testing. However, some concerns regarding peer-delivered testing were expressed and included a fear of peers’ violating confidentiality and concerns regarding peers’ qualifications for conducting an HIV test. Conclusion: Many PWID in this study sample noted the value of a peer-based approach to receiving testing and indicated their willingness to access rapid HIV testing in peer-based drop-in centres. The findings from this study highlight the potential for novel peer-based methods to complement existing HIV services in an effort to improve access to testing among this population. Additional keywords: community-based research, injection drug use. Received 11 June 2014, accepted 21 December 2014, published online 2 March 2015
Introduction In many low- and middle-income countries, injection drug use continues to be a major driver of the HIV epidemic. For example, in Vietnam and Nepal, estimates of HIV prevalence among people who inject drugs (PWID) are reported to be 66% and 53%, respectively.1 In Thailand, although HIV prevalence among PWID appears to be declining in recent years, it remains high at 16% in 2012.2 This is in contrast to the drastic decline in HIV prevalence among other high-risk groups in Thailand, including sex workers and blood donors.2 Routine HIV testing is an essential component of the HIV cascade of care and can lead to the early identification of undiagnosed HIV infection. There is also an opportunity for HIV testing to link PWID to HIV treatment and care.3,4 Journal compilation Ó CSIRO 2015
Moreover, some studies have documented a decrease in HIV risk behaviour as a result of knowledge of HIV serostatus among this population.5 As such, international health organisations, including the World Health Organization, are strongly recommending the scale-up of voluntary HIV testing and counselling services (VCT) for PWID.6 Despite the attempt to scale-up HIV programs in many settings, it is noteworthy that among the PWID population, the successful management of HIV infection is complicated by various individual, social and structural factors that often undermine optimal outcomes of VCT interventions.7,8 In Thailand, the continued reliance on repressive law enforcement to control drug trafficking and use have displaced many PWID away from HIV and healthcare www.publish.csiro.au/journals/sh
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services, and has been associated with high rates of healthcare avoidance, including avoidance of HIV testing.9,10 This is despite the commitment made by Thailand’s 2002 Narcotic Addict Rehabilitation Act B.E. 2545 that reclassified people who use illicit drugs as ‘patients’ and not ‘criminals’.11 Indeed, a recent study undertaken in Bangkok, Thailand demonstrated that PWID who had ever been in compulsory drug detention were significantly more likely to avoid accessing healthcare services.12 Furthermore, stigmatising attitudes of healthcare workers against PWID persist,13 and may cause PWID to avoid accessing traditional healthcare services (e.g. hospitals), including those that provide VCT services. Peer-based models of care, such as peer education and outreach services that exist in community-based settings, have shown success in engaging with hard-to-reach PWID.14–16 However, to our knowledge, peer-delivered HIV testing services have never been implemented among PWID populations in low- and middle-income settings. In many countries, the delivery of an HIV test is only permitted by a healthcare professional (e.g. nurse or physician) in hospitals or clinics. Encouragingly, two recent quantitative studies conducted in Thailand found that a substantial portion of community-recruited PWID were willing to access rapid HIV testing delivered by a healthcare professional or a trained peer in peer-based drop-in centres, if it were available, highlighting the potential of such peer-based testing services to complement existing HIV testing programs that serve this population.17,18 Although as a limitation of these quantitative studies, the reasons why PWID were willing to access peer-based HIV testing are unknown. Therefore, the objective of the present study was to conduct an in-depth qualitative analysis to explore PWID’s willingness to access rapid HIV testing delivered by a healthcare professional or a peer within peerbased drop-in centres in Bangkok, Thailand. Methods The Mitsampan Community Research Project (MSCRP) is a collaborative research effort involving the Mitsampan Harm Reduction Center (MSHRC; a drug user-run drop-in centre in Bangkok, Thailand), the Thai AIDS Treatment Action Group (Bangkok, Thailand), Chulalongkorn University (Bangkok, Thailand) and the British Columbia Centre for Excellence in HIV/AIDS/University of British Columbia (Vancouver, Canada). Between July 2011 and June 2012, the research partners undertook a qualitative research study involving 48 community-recruited PWID. The present study was conducted as part of a larger qualitative study that sought to explore PWIDs’ experiences with policing, compulsory drug detention centres and access to HIV testing and care. Participants were purposively recruited from the concurrent quantitative arm of the MSCRP,19 as well as through peerbased outreach efforts and word-of-mouth, and were invited to attend the MSHRC or Ozone House (another peer-based drop-in centre in Bangkok) in order to participate in the study. Adults residing in Bangkok or in adjacent provinces who had injected drug(s) in the past 6 months were eligible for participation, and through purposive sampling methods, efforts were made to attain balance in age, gender and HIV serostatus. Oral informed consent was obtained before the interview.
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Semi-structured in-depth interviews were conducted based on an interview guide, where we were interested in two specific research topics: (i) willingness to access rapid HIV testing by a healthcare professional (i.e. a nurse or physician) in peer-based drop-in centres; and (ii) willingness to access peer-delivered rapid HIV testing in peer-based drop-in centres (i.e. HIV testing services delivered by a trained former or active drug user). Interviews were conducted by two Thai interviewers (including the study’s third author, SH) who received extensive training by the study’s second and last authors (KH and TK). Of note, participants were asked to comment on their willingness to access rapid HIV testing by a healthcare professional or a peer in peer-based drop-in centres from a hypothetical perspective given that these services do not currently exist in the Thai context. To avoid confusion with the traditional method of HIV testing, which requires blood drawn from the cubital fossa, the interviewers explained to participants the step-by-step procedures of a rapid HIV test and emphasised that this type of test only requires a finger prick and the results would be available immediately. The interviewers also reassured the participants that the peers delivering the HIV test would have completed rigorous training before they were able to administer an HIV test. For the present study, we included HIV-positive, HIV-negative PWID and PWID who have never received HIV testing because we wanted to explore diverse experiences and perceptions with regard to HIV testing, and although HIV-positive individuals no longer need to be tested routinely, we believed that these individuals would contribute meaningful narratives based on their past testing experiences. Throughout the data collection process, the research team had ongoing discussions regarding the content of the data as well as the focus and direction of subsequent interviews. Data collection continued until data reached a point of saturation (new participants’ narratives kept repeating the same points). Interviews were audio-recorded and lasted between 40 and 90 min. Upon completion of the interview, participants received a stipend of 450 Thai Baht (approximately US$15). The study was approved by the research ethics boards at Chulalongkorn University and the University of British Columbia. All interviews were transcribed verbatim in Thai and translated to English. These transcripts were reviewed a second time for accuracy by the bilingual interviewers who had developed familiarity with terms used among local PWID. Furthermore, a native English-speaking proofreader fluent in Thai also verified the transcripts that were translated into English for grammatical accuracy by comparing the English transcripts with the Thai transcripts and audio files. Our analysis focussed on PWID’s willingness to access rapid HIV testing by a healthcare professional in a peer-based drop-in centre, as well as their willingness to utilise a peerdelivered model of HIV testing. Interview transcripts were imported into MaxQDA 11 (VERBI GmbH, Berlin, Germany) qualitative analysis software to assist with data management and analysis. The coding framework employed made use of a priori codes derived from the topics used to structure the interview guide, as well as emergent codes based on the content of the interviews. After reviewing the interview data,
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text segments related to each individual code were compiled and categorised, and memos were created to summarise the content and themes related to particular codes. Throughout the analyses, we continued to apply our coding framework in order to refine and expand code categories, and explore instances of negative evidence. Results Sample characteristics In total, 22 individuals who participated in the study reported on their willingness to be tested by a healthcare professional or peer in peer-based settings, including 10 (45.5%) women. The median age was 37.5 years (interquartile range: 33.0–43.5 years). Table 1 summarises the participants’ demographic characteristics, as well as their drug use patterns. Several themes related to willingness to access rapid HIV testing by a healthcare professional or a peer within peer-based drop-in centres were identified. First, we categorised our findings into two analytic categories that included the potential advantages and challenges of both types of services if they were to be implemented in the Thai context. Furthermore, we categorised subthemes that emerged during the coding process within these two broader analytic categories. Under the ‘advantages’ theme, we included the following subthemes: (i) peer support in peer-based HIV testing; (ii) faster results and anonymity with rapid HIV testing in peer-based settings; and (iii) avoiding stigma and discrimination within healthcare settings. Under the ‘challenges’ theme, the following subthemes were included: (i) issues of confidentiality; and (ii) issues of competency and active drug use. By using a technique recommended by Sandelowski (2001) to address the issue of verbal counting in qualitative research,20 we operationally defined ‘many’ and ‘common’ as something reported by half or more of the participants and ‘some and ‘several’ as something reported by less than one-third of the participants. Of note, inferences of generalisability from these terms are discouraged. Advantages of rapid HIV testing in peer-based settings Peer support in peer-based HIV testing Many participants reported they were willing to access HIV testing services within peer-based settings, and noted that they would prefer receiving a HIV test by a healthcare Table 1. Sample characteristics (n = 22) Characteristic Female gender Age (median, interquartile range) Self-reported HIV seropositivity Drugs most frequently injectedA: Midazolam Heroin Methamphetamine Crystal methamphetamine Methadone A
n (%) 10 (45.5) 37.5 (33.0–43.5) 8 (36.4) 15 13 7 5 4
(68.2) (59.1) (31.8) (22.7) (18.2)
Refers to the 6 months before interview. Percentages add up to greater than 100% because multiple answers were allowed.
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professional in peer-based drop-in centres over receiving services in hospital settings. One of the main reasons mentioned was that they were able to have continuous peer support throughout the HIV testing process. ‘You see these people [peers] every day, they’re like family to you. . .’ (Participant #6, male, age 36 years, HIV-positive) ‘. . .Drug users stick together. Decent people won’t want to hang out with us. Nobody wants to hang out with us!. . . Most of the time the positive [drug users] hang out together, checking up on each other’s health and blood count to make sure we’re okay.’ (Participant #6, male, age 36 years, HIVpositive) While all participants expressed interest in accessing rapid HIV testing by a healthcare professional in peer-based settings, some of the participants were also willing to be tested by a peer. ‘Actually, it [peer-delivered testing] makes me feel more comfortable than going to see the doctor. They were users before. They speak my language.’ (Participant #21, male, age 47 years, HIV-negative) Faster results with rapid HIV testing in peer-based settings All participants in the study indicated interest in accessing rapid HIV testing delivered by a healthcare professional at peer-based drop-in centres because there was a perceived advantage to receiving immediate results with minimal administrative hassles. On average, participants reported that it takes 1–2 weeks for hospitals or clinics to inform them of their HIV test results. Encouragingly, of the three participants who have never had a HIV test, all reported they were more willing to access testing services in a peer-based setting compared with hospital settings, given that results would be obtained faster in peer-based settings. ‘It takes a long time to go to the hospital. It takes time to get the test and to wait for the result! We have to wait for queue slips too. . . I don’t want to wait in the queue either. I have to wake up early in order to get the service at noon or afternoon. It’s so boring. I am a user. I want to go use.’ (Participant #10, female, age 33 years, HIV-negative) Anonymity with rapid HIV testing in peer-based settings Anonymity was an important feature of willingness to receive an HIV test at peer-based drop-in centres. The fear that government hospitals collect and store personal identifying information for later use was concerning for one participant. ‘Friends would trust this place [Ozone House] more. They will think it’s faster [to conduct HIV testing] here. Hospital means waiting. You have to make an appointment, fill out a patient
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record, and everything will be on record, filed away somewhere. Here [Ozone House] we have records but we destroy them later on. We don’t keep it like the government.’ (Participant #7, female, age 32 years, HIV-positive) Avoiding stigma and discrimination within healthcare settings When asked why participants were willing to access rapid HIV testing in peer-based settings, many individuals reported past experiences of stigma and discrimination by healthcare workers as their reason. ‘On the day I was receiving my test result, I fought with them [nurses at a hospital]. They didn’t counsel me at all or tell me what to expect if I happened to be HIV positive. All they said was, “you should know better”. They didn’t care about my rights.’ (Participant #16, female, age 37 years, HIV-positive) ‘I feel like compared with other patients, the way they [healthcare workers] talk to you is different, definitely less polite.’ (Participant #21, male, age 47 years, HIV-negative) In addition to the direct stigma and discrimination experienced in hospitals, participants also commonly reported fear of future stigma and discrimination within these settings. Specifically, they were afraid and uncertain as to whether physicians and other healthcare workers would treat them differently than patients who did not use drugs. ‘Because I’m a drug user, I’m not sure whether or not the doctor will be disgusted. Maybe the doctor won’t be disgusted, but maybe the healthcare workers you have to see before meeting the doctor will be.’ (Participant #21, male, age 47 years, HIV-negative) Disadvantages to rapid HIV testing in peer-based settings Issues of confidentiality Many participants were less enthusiastic about rapid HIV testing delivered by a peer than a healthcare professional. It was a common concern that peers would violate their confidentiality and share their serostatus with other people, including other drug users. ‘I don’t trust them [peers] that much. . . I am afraid that they won’t be able to keep my secret.’ (Participant #8, female, age 32 years, HIVpositive) Issues of competency and active drug use There were also fears as to peers’ qualifications for conducting an HIV test and whether these qualifications were held to the same standards as medical professionals. This is despite efforts to assure participants throughout the interview
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that rapid HIV testing procedures only require a finger prick and the peer would be fully trained before performing a test. Nevertheless, participants commonly reported that they would feel more assured if a physician or nurse delivered the HIV test. ‘They [peers] can’t be as good as doctors. And they are not doctors! I wouldn’t waste time getting tested with them! I would rather go to the doctor and have a clear result.’ (Participant #10, female, age 33 years, HIV-negative) ‘They [peers] are not reliable. They have no degree. What did they study? It’s sensitive dealing with this kind of stuff [HIV].’ (Participant #18, male, age 52 years, HIVnegative) Additionally, concerns over peers being high while delivering an HIV test was also reported as another reason for the unwillingness of many participants’ to be tested by their peers. ‘I don’t feel assured with them [peers]. I can’t be sure if they’re 100% sober. For those [peers] handing out the needles, I don’t want them testing me. They’re drug users and they work as volunteers. But they still do drugs. They’re not 100% reliable.’ (Participant #18, male, age 52 years, HIV-negative) Discussion The present study explored Thai PWID’s willingness to access rapid HIV testing by a healthcare professional or a peer within peer-based settings. We found that all participants in our study noted the value of peer-based approaches to HIV testing and all expressed willingness to receive an HIV test delivered by a healthcare professional within a peer-run drop-in centre. Participants reported that professionally delivered rapid HIV testing within peer-run drop-in centres would: (i) allow them the opportunity to find support among their peers regardless of the results; (ii) provide faster results with minimal administrative hassles compared with hospital settings; and (iii) help them avoid the stigma and discrimination experienced within some hospital settings. In contrast, there was less enthusiasm for peerdelivered rapid HIV testing and many reported fear of peers violating confidentiality of test results and peers’ qualifications for conducting an HIV test to the same standards as medical professionals as some of the main reasons for not wanting to receive an HIV test delivered by a peer. However, despite these concerns, several participants were still willing to be tested by peers. The fact that all participants reported willingness to access rapid HIV testing by a healthcare professional within peer-run drop-in centres suggests that peer-based approaches for PWID should not be limited to HIV prevention education, harm reduction and outreach services, as they have historically been;21 in fact, there appears to be an important benefit for peer-based HIV testing to complement traditional HIV services within this community. Indeed, there may be a role for rapid peer-based HIV testing approaches coupled with immediate post-test counselling and prevention strategies within a
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combination prevention framework to minimise HIV transmission among this population. The present study showed that PWID seek support from their peers, which suggests peers can play a role in increasing coverage of HIV testing among this population. These findings are in line with two recent quantitative studies conducted by our group, which demonstrate that Thai PWID who have ever been to a peer-run drop-in centre were more likely to be willing to access rapid HIV testing in a peer-based setting17 as well as peer-delivered HIV testing.18 Given the growing body of evidence that suggest the added value in providing peer-based HIV services among other populations,22–24 in addition to numerous reports by various United Nations organisations supporting peer-based approaches for HIV prevention, treatment and care for PWID,6,25 the Thai government and other non- and inter-governmental funding agencies should consider incorporating routine HIV testing services within already established peer-run centres. Our findings shed light on some structural, administrative and time-related obstacles that may be contributing to poor and inconsistent HIV testing uptake among Thai PWID. Due to long wait times and delays in receiving test results in hospital settings, participants reported they would rather access rapid HIV testing in peer-based drop-in centres. With immediate results from rapid HIV testing, time-related barriers will be minimised and may in fact increase the likelihood of PWID accessing HIV testing services on a regular basis. Furthermore, there were concerns regarding the collection and confidential maintenance of personal information in hospital settings. This is consistent with reports indicating that some hospitals collect and share information concerning patients’ drug use behaviour with police in Thailand.9 Given that little is known about this topic, further research investigating such experiences among PWID and police should be conducted. The PWID population in Thailand continues to experience stigma and discrimination within healthcare settings and, as a result, many individuals have been deterred from accessing healthcare services, including routine HIV testing.13,26 Not surprisingly, participants in the present study reported stigma and discrimination in hospitals as one of the main reasons why they would prefer to access rapid HIV testing within peer-based settings if they existed. Indeed, a large body of evidence has suggested peer-based methods as a key component of HIV services to address persistent stigma and discrimination against this population.27,28 While all participants were willing to access rapid HIV testing services delivered by a healthcare professional within peer-based settings, there were mixed responses regarding their willingness to access HIV testing delivered by their peers. This is despite the interviewers’ efforts to emphasise that rapid HIV testing by trained peers is a less invasive procedure than traditional testing methods usually undertaken by healthcare professionals. Some participants felt their peers may not be adequately trained to competently deliver a HIV test. Instead, they insisted they would feel much more comfortable if it were provided by a nurse or a physician. Others noted the fear that peers would breach confidentiality and they would be further stigmatised within their community. The internal and external HIV-related stigma that PWID experience is concerning, and efforts to minimise this by reducing the stigma associated with
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HIV disease and illicit drug use through educating the community, the public, and healthcare professionals on these issues may be beneficial. Indeed, we have previously shown that peer-delivered testing may be a valuable tool in reaching more vulnerable subgroups of PWID, including those with a history of incarceration.18 Therefore, it may still be important to consider peer-delivered HIV testing alongside testing services delivered by a healthcare professional in a peerbased setting to improve HIV testing coverage among this population. Given that approaches to minimising barriers associated with peer-delivered rapid HIV testing were not discussed, future qualitative research should seek to explore this further. This study has several limitations that should be taken into account. First, although efforts were made to attain a balance in gender and age among the participants, we could not meaningfully reach subpopulations of PWID who also belonged to other vulnerable populations, including transgendered persons and sex workers, who may have different viewpoints on their willingness to receive rapid HIV testing delivered by a healthcare professional or a peer within peer-run drop-in centres. Second, we included participants regardless of their HIV status and therefore, participants of HIV-positive serostatus who would no longer need routine HIV testing were eligible for this study. Nevertheless, we felt that HIV-positive individuals would contribute meaningful narratives based on their past testing experiences. Finally, while the description of the peer-delivered testing intervention provided to those interviewed included a statement regarding training for peers who deliver HIV tests, the interviewers did not specifically discuss the step-by-step process of how the training and qualification would be achieved. Future research should consider adding this type of description, as it may influence willingness to be tested by peers given the concerns expressed in this study regarding competence. All PWID in our sample noted the value of a peer-based approach to receiving HIV services and indicated their willingness to access rapid HIV testing delivered by a healthcare professional within peer-based drop-in centres. In contrast, there were mixed feelings regarding their interest in peer-delivered rapid HIV testing. Nevertheless, given the overall enthusiasm for a peer-based approach to HIV testing, our findings highlight the potential for these novel methods to complement existing HIV services in an effort to improve access to testing among PWID in Thailand. Conflicts of interests None declared. Acknowledgements We would particularly like to thank the staff and volunteers at the Mitsampan Harm Reduction Center, Thai AIDS Treatment Action Group and OZone House for their support, and Dr Niyada Kiatying-Angsulee of the Social Research Institute, Chulalongkorn University, for her assistance with developing this project. We also thank Tricia Collingham, Deborah Graham and Peter Vann for their research and administrative assistance, and Prempreeda Pramoj Na Ayutthaya, Arphatsaporn Chaimongkon, Sabrina K. Gyorvary, Orntima Kularb and Somkiat Meetham for their assistance with data collection.
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References 1 Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA, Wodak A, Panda S, Tyndall M, Toufik A, Mattick RP. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet 2008; 372: 1733–45. doi:10.1016/S0140-6736(08)61311-2 2 Bureau of Epidemiology. HIV total sentinel surveillance. Bangkok: Ministry of Public Health Thailand; 2013. Available online at: http:// www.boe.moph.go.th/report.php?cat=20 [verified 1 May 2014]. 3 Girardi E, Sabin C, Monforte A. Late diagnosis of HIV infection: epidemiological features, consequences and strategies to encourage earlier testing. J Acquir Immune Defic Syndr 2007; 46: S3–8. doi:10.1097/01.qai.0000286597.57066.2b 4 Wood E, Kerr T, Hogg R, Palepu A, Zhang R, Strathdee S, Montaner JSG. Impact of HIV testing on uptake of HIV therapy among antiretroviral naive HIV-infected injection drug users. Drug Alcohol Rev 2006; 25: 451–4. doi:10.1080/09595230600883313 5 Schlumberger M, Desenclos J, Papaevangelou G, Richardson S, Ancelle-Park R. Knowledge of HIV serostatus and preventive behaviour among European injecting drug users: second study. Eur J Epidemiol 1999; 15: 207–15. doi:10.1023/A:1007578402083 6 World Health Organization, United Nations Office Drugs and Crime, Joint United Nations Programme on HIV/AIDS. WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users. Geneva: WHO; 2012. Available online at: http://apps.who.int/iris/ bitstream/10665/77969/1/9789241504379_eng.pdf [verified 1 May 2014]. 7 Downing M, Knight K, Reiss TH, Vernon K, Mulia N, Ferreboeuf M, Carroll A, Vu C. Drug users talk about HIV testing: motivating and deterring factors. AIDS Care 2001; 13: 561–77. doi:10.1080/095401 20120063205 8 Moyer L, Brouwer K, Ramos R, Lozada R, Cruz M, Magis-Rodriguez C, Stratjdee SA. Barriers and missed opportunities to HIV testing among injection drug users in two Mexico–US border cities. Drug Alcohol Rev 2008; 27: 39–45. doi:10.1080/09595230701710845 9 Human Rights Watch, Thai AIDS Treatment Action Group. Deadly denial: barriers to HIV/AIDS treatment for people who use drugs in Thailand. Report No.: 17. Bangkok: Human Rights Watch; 2007. 10 Ti L, Hayashi K, Kaplan K, Suwannawong P, Wood E, Montaner J, Kerr T. HIV test avoidance among people who inject drugs in Thailand. AIDS Behav 2013; 17: 2474–8. doi:10.1007/s10461-0120347-2 11 Pearshouse R. Compulsory drug treatment in Thailand: observations on the Narcotic Addict Rehabilitation Act B.E. 2545 (2002). Toronto, ON: Canadian HIV/AIDS Legal Network; 2009. Available online at: http://www.aidslaw.ca/publications/interfaces/downloadFile.php? ref=1429 [verified 1 May 2014]. 12 Kerr T, Hayashi K, Ti L, Kaplan K, Suwannawong P, Wood E. The impact of compulsory drug detention exposure on the avoidance of healthcare among injection drug users in Thailand. Int J Drug Policy 2013; 25: 171–4. doi:10.1016/j.drugpo.2013.05.017 13 Chan KY, Stoove M, Sringernyuang L, Reidpath D. Stigmatization of AIDS patients: disentangling Thai nursing students’ attitudes towards HIV/AIDS, drug use, and commercial sex. AIDS Behav 2008; 12: 146–57. doi:10.1007/s10461-007-9222-y 14 Broadhead R, Heckathorn D, Anthony D, Madray H, Mills R, Hughes J. Harnessing peer networks as an instrument for AIDS prevention: results from a peer-driven intervention. Public Health Rep 1998; 113: 42–57.
15 Kerr T, Hayashi K, Fairbairn N, Kaplan K, Suwannawong P, Zhang R, Wood E. Expanding the reach of harm reduction in Thailand: experiences with a drug user-run drop-in centre. Int J Drug Policy 2010; 21: 255–8. doi:10.1016/j.drugpo.2009.08.002 16 Latkin CA, Sherman S, Knowlton A. HIV prevention among drug users: outcome of a network-oriented peer outreach intervention. Health Psychol 2003; 22: 332–39. doi:10.1037/0278-6133.22.4.332 17 Ti L, Hayashi K, Kaplan K, Suwannawong P, Fu E, Wood E, Kerr T. HIV testing and willingness to get HIV testing at a peer-run drop-in centre for people who inject drugs in Bangkok, Thailand. BMC Public Health 2012; 12: 189. doi:10.1186/1471-2458-12-189 18 Ti L, Hayashi K, Kaplan K, Suwannawong P, Wood E, Montaner J, Kerr T. Willingness to access peer-delivered HIV testing and counseling among people who inject drugs in Bangkok, Thailand. J Community Health 2012; 38: 427–33. doi:10.1007/s10900-0129635-z 19 Hayashi K, Fairbairn N, Suwannawong P, Kaplan K, Wood E, Kerr T. Collective empowerment while creating knowledge: a description of a community-based participatory research project with drug users in Bangkok, Thailand. Subst Use Misuse 2012; 47: 502–10. doi:10.3109/ 10826084.2012.644110 20 Sandelowski M. Real qualitative researchers do not count: the use of numbers in qualitative research. Res Nurs Health 2001; 24: 230–40. doi:10.1002/nur.1025 21 The Global Fund To Fight AIDS. Tuberculosis and malaria. Grant portfolio: Thailand; 2012. Available online at: http://portfolio. theglobalfund.org/en/Grant/List/THA [verified 1 May 2014]. 22 Callaghan M, Ford N, Schneider H. A systematic review of taskshifting for HIV treatment and care in Africa. Hum Resour Health 2010; 8: 8. doi:10.1186/1478-4491-8-8 23 Chang LW, Kagaayi J, Nakigozi G, Ssempijja V, Packer AH, Serwadda D, Quinn TC, Gray RH, Bollinger RC, Reynolds SJ. Effect of peer health workers on AIDS care in Rakai, Uganda: a cluster-randomized trial. PLoS ONE 2010; 5: e10923. doi:10.1371/ journal.pone.0010923 24 Kawichai S, Celentano D, Srithanaviboonchai K, Wichajarn M, Pancharoen K, Chariyalertsak C, Visrutaratana S, KhumaloSakutukwa G, Sweat M, Chariyalertsak S; Project Accept Study Team. NIMH Project Accept (HPTN 043) HIV/AIDS community mobilization (CM) to promote mobile HIV voluntary counseling and testing (MVCT) in rural communities in Northern Thailand: modifications by experience. AIDS Behav 2012; 16: 1227–37. doi:10.1007/s10461-011-0099-4 25 World Health Organization (WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations Office on Drugs and Crime (UNODC). Advocacy guide: HIV/AIDS prevention among injecting drug users. Geneva: WHO; 2004. Available online at: http:// www.who.int/hiv/pub/advocacy/en/advocacyguideen.pdf [verified 1 May 2014]. 26 Brener L, Von Hippel W, Kippax S, Preacher K. The role of physician and nurse attitudes in the health care of injecting drug users. Subst Use Misuse 2010; 45: 1007–18. doi:10.3109/10826081003659543 27 Joint United Nations Programme on HIV/AIDS (UNAIDS). The greater involvement of people living with HIV/AIDS (GIPA); 2007. Available online at: data.unaids.org/pub/BriefingNote/2007/ jc1299_policy_brief_gipa.pdf [verified 1 May 2014]. 28 Maher L, Coupland H, Musson R. Scaling up HIV treatment, care and support for injecting drug users in Vietnam. Int J Drug Policy 2007; 18: 296–305. doi:10.1016/j.drugpo.2006.12.006
www.publish.csiro.au/journals/sh
Sexual Health, 2015, 12, 263–268 http://dx.doi.org/10.1071/SH14107
‘Drug users stick together’: HIV testing in peer-based drop-in centres among people who inject drugs in Thailand Lianping Ti A,B, Kanna Hayashi A, Sattara Hattirat C, Paisan Suwannawong C, Karyn Kaplan C and Thomas Kerr A,D,E A
British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. B School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada. C Thai AIDS Treatment Action Group, 18/89 Vipawadee Road, Soi 40 Chatuchak, Bangkok, 10900, Thailand. D Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, BC, V5Z 1M9, Canada. E Corresponding author. Email: [email protected]
Abstract. Introduction: Although there is a well recognised need for novel approaches to HIV testing, particularly for marginalised populations at high risk for HIV infection, there remains a dearth of information on the acceptability of peer-based HIV testing among people who inject drugs (PWID). Methods: Between July 2011 and June 2012, 22 in-depth interviews were conducted with PWID participating in the Mitsampan Community Research Project in Bangkok, Thailand. Semi-structured interviews explored willingness to access rapid HIV testing delivered by a healthcare professional or a trained peer within peer-based drop-in centres. Audio-recorded interviews were transcribed verbatim and a thematic analysis was conducted. Results: All participants indicated interest in accessing rapid HIV testing by a healthcare professional at peer-based drop-in centres due to the advantage of receiving immediate results. Experiencing stigma and discrimination by healthcare workers and wanting to avoid administrative barriers in hospitals were also reported as reasons for why PWID preferred HIV testing in peer-based settings. Peer support and shared lived experiences were repeatedly mentioned as benefits of peer-based testing. However, some concerns regarding peer-delivered testing were expressed and included a fear of peers’ violating confidentiality and concerns regarding peers’ qualifications for conducting an HIV test. Conclusion: Many PWID in this study sample noted the value of a peer-based approach to receiving testing and indicated their willingness to access rapid HIV testing in peer-based drop-in centres. The findings from this study highlight the potential for novel peer-based methods to complement existing HIV services in an effort to improve access to testing among this population. Additional keywords: community-based research, injection drug use. Received 11 June 2014, accepted 21 December 2014, published online 2 March 2015
Introduction In many low- and middle-income countries, injection drug use continues to be a major driver of the HIV epidemic. For example, in Vietnam and Nepal, estimates of HIV prevalence among people who inject drugs (PWID) are reported to be 66% and 53%, respectively.1 In Thailand, although HIV prevalence among PWID appears to be declining in recent years, it remains high at 16% in 2012.2 This is in contrast to the drastic decline in HIV prevalence among other high-risk groups in Thailand, including sex workers and blood donors.2 Routine HIV testing is an essential component of the HIV cascade of care and can lead to the early identification of undiagnosed HIV infection. There is also an opportunity for HIV testing to link PWID to HIV treatment and care.3,4 Journal compilation Ó CSIRO 2015
Moreover, some studies have documented a decrease in HIV risk behaviour as a result of knowledge of HIV serostatus among this population.5 As such, international health organisations, including the World Health Organization, are strongly recommending the scale-up of voluntary HIV testing and counselling services (VCT) for PWID.6 Despite the attempt to scale-up HIV programs in many settings, it is noteworthy that among the PWID population, the successful management of HIV infection is complicated by various individual, social and structural factors that often undermine optimal outcomes of VCT interventions.7,8 In Thailand, the continued reliance on repressive law enforcement to control drug trafficking and use have displaced many PWID away from HIV and healthcare www.publish.csiro.au/journals/sh
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services, and has been associated with high rates of healthcare avoidance, including avoidance of HIV testing.9,10 This is despite the commitment made by Thailand’s 2002 Narcotic Addict Rehabilitation Act B.E. 2545 that reclassified people who use illicit drugs as ‘patients’ and not ‘criminals’.11 Indeed, a recent study undertaken in Bangkok, Thailand demonstrated that PWID who had ever been in compulsory drug detention were significantly more likely to avoid accessing healthcare services.12 Furthermore, stigmatising attitudes of healthcare workers against PWID persist,13 and may cause PWID to avoid accessing traditional healthcare services (e.g. hospitals), including those that provide VCT services. Peer-based models of care, such as peer education and outreach services that exist in community-based settings, have shown success in engaging with hard-to-reach PWID.14–16 However, to our knowledge, peer-delivered HIV testing services have never been implemented among PWID populations in low- and middle-income settings. In many countries, the delivery of an HIV test is only permitted by a healthcare professional (e.g. nurse or physician) in hospitals or clinics. Encouragingly, two recent quantitative studies conducted in Thailand found that a substantial portion of community-recruited PWID were willing to access rapid HIV testing delivered by a healthcare professional or a trained peer in peer-based drop-in centres, if it were available, highlighting the potential of such peer-based testing services to complement existing HIV testing programs that serve this population.17,18 Although as a limitation of these quantitative studies, the reasons why PWID were willing to access peer-based HIV testing are unknown. Therefore, the objective of the present study was to conduct an in-depth qualitative analysis to explore PWID’s willingness to access rapid HIV testing delivered by a healthcare professional or a peer within peerbased drop-in centres in Bangkok, Thailand. Methods The Mitsampan Community Research Project (MSCRP) is a collaborative research effort involving the Mitsampan Harm Reduction Center (MSHRC; a drug user-run drop-in centre in Bangkok, Thailand), the Thai AIDS Treatment Action Group (Bangkok, Thailand), Chulalongkorn University (Bangkok, Thailand) and the British Columbia Centre for Excellence in HIV/AIDS/University of British Columbia (Vancouver, Canada). Between July 2011 and June 2012, the research partners undertook a qualitative research study involving 48 community-recruited PWID. The present study was conducted as part of a larger qualitative study that sought to explore PWIDs’ experiences with policing, compulsory drug detention centres and access to HIV testing and care. Participants were purposively recruited from the concurrent quantitative arm of the MSCRP,19 as well as through peerbased outreach efforts and word-of-mouth, and were invited to attend the MSHRC or Ozone House (another peer-based drop-in centre in Bangkok) in order to participate in the study. Adults residing in Bangkok or in adjacent provinces who had injected drug(s) in the past 6 months were eligible for participation, and through purposive sampling methods, efforts were made to attain balance in age, gender and HIV serostatus. Oral informed consent was obtained before the interview.
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Semi-structured in-depth interviews were conducted based on an interview guide, where we were interested in two specific research topics: (i) willingness to access rapid HIV testing by a healthcare professional (i.e. a nurse or physician) in peer-based drop-in centres; and (ii) willingness to access peer-delivered rapid HIV testing in peer-based drop-in centres (i.e. HIV testing services delivered by a trained former or active drug user). Interviews were conducted by two Thai interviewers (including the study’s third author, SH) who received extensive training by the study’s second and last authors (KH and TK). Of note, participants were asked to comment on their willingness to access rapid HIV testing by a healthcare professional or a peer in peer-based drop-in centres from a hypothetical perspective given that these services do not currently exist in the Thai context. To avoid confusion with the traditional method of HIV testing, which requires blood drawn from the cubital fossa, the interviewers explained to participants the step-by-step procedures of a rapid HIV test and emphasised that this type of test only requires a finger prick and the results would be available immediately. The interviewers also reassured the participants that the peers delivering the HIV test would have completed rigorous training before they were able to administer an HIV test. For the present study, we included HIV-positive, HIV-negative PWID and PWID who have never received HIV testing because we wanted to explore diverse experiences and perceptions with regard to HIV testing, and although HIV-positive individuals no longer need to be tested routinely, we believed that these individuals would contribute meaningful narratives based on their past testing experiences. Throughout the data collection process, the research team had ongoing discussions regarding the content of the data as well as the focus and direction of subsequent interviews. Data collection continued until data reached a point of saturation (new participants’ narratives kept repeating the same points). Interviews were audio-recorded and lasted between 40 and 90 min. Upon completion of the interview, participants received a stipend of 450 Thai Baht (approximately US$15). The study was approved by the research ethics boards at Chulalongkorn University and the University of British Columbia. All interviews were transcribed verbatim in Thai and translated to English. These transcripts were reviewed a second time for accuracy by the bilingual interviewers who had developed familiarity with terms used among local PWID. Furthermore, a native English-speaking proofreader fluent in Thai also verified the transcripts that were translated into English for grammatical accuracy by comparing the English transcripts with the Thai transcripts and audio files. Our analysis focussed on PWID’s willingness to access rapid HIV testing by a healthcare professional in a peer-based drop-in centre, as well as their willingness to utilise a peerdelivered model of HIV testing. Interview transcripts were imported into MaxQDA 11 (VERBI GmbH, Berlin, Germany) qualitative analysis software to assist with data management and analysis. The coding framework employed made use of a priori codes derived from the topics used to structure the interview guide, as well as emergent codes based on the content of the interviews. After reviewing the interview data,
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text segments related to each individual code were compiled and categorised, and memos were created to summarise the content and themes related to particular codes. Throughout the analyses, we continued to apply our coding framework in order to refine and expand code categories, and explore instances of negative evidence. Results Sample characteristics In total, 22 individuals who participated in the study reported on their willingness to be tested by a healthcare professional or peer in peer-based settings, including 10 (45.5%) women. The median age was 37.5 years (interquartile range: 33.0–43.5 years). Table 1 summarises the participants’ demographic characteristics, as well as their drug use patterns. Several themes related to willingness to access rapid HIV testing by a healthcare professional or a peer within peer-based drop-in centres were identified. First, we categorised our findings into two analytic categories that included the potential advantages and challenges of both types of services if they were to be implemented in the Thai context. Furthermore, we categorised subthemes that emerged during the coding process within these two broader analytic categories. Under the ‘advantages’ theme, we included the following subthemes: (i) peer support in peer-based HIV testing; (ii) faster results and anonymity with rapid HIV testing in peer-based settings; and (iii) avoiding stigma and discrimination within healthcare settings. Under the ‘challenges’ theme, the following subthemes were included: (i) issues of confidentiality; and (ii) issues of competency and active drug use. By using a technique recommended by Sandelowski (2001) to address the issue of verbal counting in qualitative research,20 we operationally defined ‘many’ and ‘common’ as something reported by half or more of the participants and ‘some and ‘several’ as something reported by less than one-third of the participants. Of note, inferences of generalisability from these terms are discouraged. Advantages of rapid HIV testing in peer-based settings Peer support in peer-based HIV testing Many participants reported they were willing to access HIV testing services within peer-based settings, and noted that they would prefer receiving a HIV test by a healthcare Table 1. Sample characteristics (n = 22) Characteristic Female gender Age (median, interquartile range) Self-reported HIV seropositivity Drugs most frequently injectedA: Midazolam Heroin Methamphetamine Crystal methamphetamine Methadone A
n (%) 10 (45.5) 37.5 (33.0–43.5) 8 (36.4) 15 13 7 5 4
(68.2) (59.1) (31.8) (22.7) (18.2)
Refers to the 6 months before interview. Percentages add up to greater than 100% because multiple answers were allowed.
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professional in peer-based drop-in centres over receiving services in hospital settings. One of the main reasons mentioned was that they were able to have continuous peer support throughout the HIV testing process. ‘You see these people [peers] every day, they’re like family to you. . .’ (Participant #6, male, age 36 years, HIV-positive) ‘. . .Drug users stick together. Decent people won’t want to hang out with us. Nobody wants to hang out with us!. . . Most of the time the positive [drug users] hang out together, checking up on each other’s health and blood count to make sure we’re okay.’ (Participant #6, male, age 36 years, HIVpositive) While all participants expressed interest in accessing rapid HIV testing by a healthcare professional in peer-based settings, some of the participants were also willing to be tested by a peer. ‘Actually, it [peer-delivered testing] makes me feel more comfortable than going to see the doctor. They were users before. They speak my language.’ (Participant #21, male, age 47 years, HIV-negative) Faster results with rapid HIV testing in peer-based settings All participants in the study indicated interest in accessing rapid HIV testing delivered by a healthcare professional at peer-based drop-in centres because there was a perceived advantage to receiving immediate results with minimal administrative hassles. On average, participants reported that it takes 1–2 weeks for hospitals or clinics to inform them of their HIV test results. Encouragingly, of the three participants who have never had a HIV test, all reported they were more willing to access testing services in a peer-based setting compared with hospital settings, given that results would be obtained faster in peer-based settings. ‘It takes a long time to go to the hospital. It takes time to get the test and to wait for the result! We have to wait for queue slips too. . . I don’t want to wait in the queue either. I have to wake up early in order to get the service at noon or afternoon. It’s so boring. I am a user. I want to go use.’ (Participant #10, female, age 33 years, HIV-negative) Anonymity with rapid HIV testing in peer-based settings Anonymity was an important feature of willingness to receive an HIV test at peer-based drop-in centres. The fear that government hospitals collect and store personal identifying information for later use was concerning for one participant. ‘Friends would trust this place [Ozone House] more. They will think it’s faster [to conduct HIV testing] here. Hospital means waiting. You have to make an appointment, fill out a patient
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record, and everything will be on record, filed away somewhere. Here [Ozone House] we have records but we destroy them later on. We don’t keep it like the government.’ (Participant #7, female, age 32 years, HIV-positive) Avoiding stigma and discrimination within healthcare settings When asked why participants were willing to access rapid HIV testing in peer-based settings, many individuals reported past experiences of stigma and discrimination by healthcare workers as their reason. ‘On the day I was receiving my test result, I fought with them [nurses at a hospital]. They didn’t counsel me at all or tell me what to expect if I happened to be HIV positive. All they said was, “you should know better”. They didn’t care about my rights.’ (Participant #16, female, age 37 years, HIV-positive) ‘I feel like compared with other patients, the way they [healthcare workers] talk to you is different, definitely less polite.’ (Participant #21, male, age 47 years, HIV-negative) In addition to the direct stigma and discrimination experienced in hospitals, participants also commonly reported fear of future stigma and discrimination within these settings. Specifically, they were afraid and uncertain as to whether physicians and other healthcare workers would treat them differently than patients who did not use drugs. ‘Because I’m a drug user, I’m not sure whether or not the doctor will be disgusted. Maybe the doctor won’t be disgusted, but maybe the healthcare workers you have to see before meeting the doctor will be.’ (Participant #21, male, age 47 years, HIV-negative) Disadvantages to rapid HIV testing in peer-based settings Issues of confidentiality Many participants were less enthusiastic about rapid HIV testing delivered by a peer than a healthcare professional. It was a common concern that peers would violate their confidentiality and share their serostatus with other people, including other drug users. ‘I don’t trust them [peers] that much. . . I am afraid that they won’t be able to keep my secret.’ (Participant #8, female, age 32 years, HIVpositive) Issues of competency and active drug use There were also fears as to peers’ qualifications for conducting an HIV test and whether these qualifications were held to the same standards as medical professionals. This is despite efforts to assure participants throughout the interview
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that rapid HIV testing procedures only require a finger prick and the peer would be fully trained before performing a test. Nevertheless, participants commonly reported that they would feel more assured if a physician or nurse delivered the HIV test. ‘They [peers] can’t be as good as doctors. And they are not doctors! I wouldn’t waste time getting tested with them! I would rather go to the doctor and have a clear result.’ (Participant #10, female, age 33 years, HIV-negative) ‘They [peers] are not reliable. They have no degree. What did they study? It’s sensitive dealing with this kind of stuff [HIV].’ (Participant #18, male, age 52 years, HIVnegative) Additionally, concerns over peers being high while delivering an HIV test was also reported as another reason for the unwillingness of many participants’ to be tested by their peers. ‘I don’t feel assured with them [peers]. I can’t be sure if they’re 100% sober. For those [peers] handing out the needles, I don’t want them testing me. They’re drug users and they work as volunteers. But they still do drugs. They’re not 100% reliable.’ (Participant #18, male, age 52 years, HIV-negative) Discussion The present study explored Thai PWID’s willingness to access rapid HIV testing by a healthcare professional or a peer within peer-based settings. We found that all participants in our study noted the value of peer-based approaches to HIV testing and all expressed willingness to receive an HIV test delivered by a healthcare professional within a peer-run drop-in centre. Participants reported that professionally delivered rapid HIV testing within peer-run drop-in centres would: (i) allow them the opportunity to find support among their peers regardless of the results; (ii) provide faster results with minimal administrative hassles compared with hospital settings; and (iii) help them avoid the stigma and discrimination experienced within some hospital settings. In contrast, there was less enthusiasm for peerdelivered rapid HIV testing and many reported fear of peers violating confidentiality of test results and peers’ qualifications for conducting an HIV test to the same standards as medical professionals as some of the main reasons for not wanting to receive an HIV test delivered by a peer. However, despite these concerns, several participants were still willing to be tested by peers. The fact that all participants reported willingness to access rapid HIV testing by a healthcare professional within peer-run drop-in centres suggests that peer-based approaches for PWID should not be limited to HIV prevention education, harm reduction and outreach services, as they have historically been;21 in fact, there appears to be an important benefit for peer-based HIV testing to complement traditional HIV services within this community. Indeed, there may be a role for rapid peer-based HIV testing approaches coupled with immediate post-test counselling and prevention strategies within a
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combination prevention framework to minimise HIV transmission among this population. The present study showed that PWID seek support from their peers, which suggests peers can play a role in increasing coverage of HIV testing among this population. These findings are in line with two recent quantitative studies conducted by our group, which demonstrate that Thai PWID who have ever been to a peer-run drop-in centre were more likely to be willing to access rapid HIV testing in a peer-based setting17 as well as peer-delivered HIV testing.18 Given the growing body of evidence that suggest the added value in providing peer-based HIV services among other populations,22–24 in addition to numerous reports by various United Nations organisations supporting peer-based approaches for HIV prevention, treatment and care for PWID,6,25 the Thai government and other non- and inter-governmental funding agencies should consider incorporating routine HIV testing services within already established peer-run centres. Our findings shed light on some structural, administrative and time-related obstacles that may be contributing to poor and inconsistent HIV testing uptake among Thai PWID. Due to long wait times and delays in receiving test results in hospital settings, participants reported they would rather access rapid HIV testing in peer-based drop-in centres. With immediate results from rapid HIV testing, time-related barriers will be minimised and may in fact increase the likelihood of PWID accessing HIV testing services on a regular basis. Furthermore, there were concerns regarding the collection and confidential maintenance of personal information in hospital settings. This is consistent with reports indicating that some hospitals collect and share information concerning patients’ drug use behaviour with police in Thailand.9 Given that little is known about this topic, further research investigating such experiences among PWID and police should be conducted. The PWID population in Thailand continues to experience stigma and discrimination within healthcare settings and, as a result, many individuals have been deterred from accessing healthcare services, including routine HIV testing.13,26 Not surprisingly, participants in the present study reported stigma and discrimination in hospitals as one of the main reasons why they would prefer to access rapid HIV testing within peer-based settings if they existed. Indeed, a large body of evidence has suggested peer-based methods as a key component of HIV services to address persistent stigma and discrimination against this population.27,28 While all participants were willing to access rapid HIV testing services delivered by a healthcare professional within peer-based settings, there were mixed responses regarding their willingness to access HIV testing delivered by their peers. This is despite the interviewers’ efforts to emphasise that rapid HIV testing by trained peers is a less invasive procedure than traditional testing methods usually undertaken by healthcare professionals. Some participants felt their peers may not be adequately trained to competently deliver a HIV test. Instead, they insisted they would feel much more comfortable if it were provided by a nurse or a physician. Others noted the fear that peers would breach confidentiality and they would be further stigmatised within their community. The internal and external HIV-related stigma that PWID experience is concerning, and efforts to minimise this by reducing the stigma associated with
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HIV disease and illicit drug use through educating the community, the public, and healthcare professionals on these issues may be beneficial. Indeed, we have previously shown that peer-delivered testing may be a valuable tool in reaching more vulnerable subgroups of PWID, including those with a history of incarceration.18 Therefore, it may still be important to consider peer-delivered HIV testing alongside testing services delivered by a healthcare professional in a peerbased setting to improve HIV testing coverage among this population. Given that approaches to minimising barriers associated with peer-delivered rapid HIV testing were not discussed, future qualitative research should seek to explore this further. This study has several limitations that should be taken into account. First, although efforts were made to attain a balance in gender and age among the participants, we could not meaningfully reach subpopulations of PWID who also belonged to other vulnerable populations, including transgendered persons and sex workers, who may have different viewpoints on their willingness to receive rapid HIV testing delivered by a healthcare professional or a peer within peer-run drop-in centres. Second, we included participants regardless of their HIV status and therefore, participants of HIV-positive serostatus who would no longer need routine HIV testing were eligible for this study. Nevertheless, we felt that HIV-positive individuals would contribute meaningful narratives based on their past testing experiences. Finally, while the description of the peer-delivered testing intervention provided to those interviewed included a statement regarding training for peers who deliver HIV tests, the interviewers did not specifically discuss the step-by-step process of how the training and qualification would be achieved. Future research should consider adding this type of description, as it may influence willingness to be tested by peers given the concerns expressed in this study regarding competence. All PWID in our sample noted the value of a peer-based approach to receiving HIV services and indicated their willingness to access rapid HIV testing delivered by a healthcare professional within peer-based drop-in centres. In contrast, there were mixed feelings regarding their interest in peer-delivered rapid HIV testing. Nevertheless, given the overall enthusiasm for a peer-based approach to HIV testing, our findings highlight the potential for these novel methods to complement existing HIV services in an effort to improve access to testing among PWID in Thailand. Conflicts of interests None declared. Acknowledgements We would particularly like to thank the staff and volunteers at the Mitsampan Harm Reduction Center, Thai AIDS Treatment Action Group and OZone House for their support, and Dr Niyada Kiatying-Angsulee of the Social Research Institute, Chulalongkorn University, for her assistance with developing this project. We also thank Tricia Collingham, Deborah Graham and Peter Vann for their research and administrative assistance, and Prempreeda Pramoj Na Ayutthaya, Arphatsaporn Chaimongkon, Sabrina K. Gyorvary, Orntima Kularb and Somkiat Meetham for their assistance with data collection.
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15 Kerr T, Hayashi K, Fairbairn N, Kaplan K, Suwannawong P, Zhang R, Wood E. Expanding the reach of harm reduction in Thailand: experiences with a drug user-run drop-in centre. Int J Drug Policy 2010; 21: 255–8. doi:10.1016/j.drugpo.2009.08.002 16 Latkin CA, Sherman S, Knowlton A. HIV prevention among drug users: outcome of a network-oriented peer outreach intervention. Health Psychol 2003; 22: 332–39. doi:10.1037/0278-6133.22.4.332 17 Ti L, Hayashi K, Kaplan K, Suwannawong P, Fu E, Wood E, Kerr T. HIV testing and willingness to get HIV testing at a peer-run drop-in centre for people who inject drugs in Bangkok, Thailand. BMC Public Health 2012; 12: 189. doi:10.1186/1471-2458-12-189 18 Ti L, Hayashi K, Kaplan K, Suwannawong P, Wood E, Montaner J, Kerr T. Willingness to access peer-delivered HIV testing and counseling among people who inject drugs in Bangkok, Thailand. J Community Health 2012; 38: 427–33. doi:10.1007/s10900-0129635-z 19 Hayashi K, Fairbairn N, Suwannawong P, Kaplan K, Wood E, Kerr T. Collective empowerment while creating knowledge: a description of a community-based participatory research project with drug users in Bangkok, Thailand. Subst Use Misuse 2012; 47: 502–10. doi:10.3109/ 10826084.2012.644110 20 Sandelowski M. Real qualitative researchers do not count: the use of numbers in qualitative research. Res Nurs Health 2001; 24: 230–40. doi:10.1002/nur.1025 21 The Global Fund To Fight AIDS. Tuberculosis and malaria. Grant portfolio: Thailand; 2012. Available online at: http://portfolio. theglobalfund.org/en/Grant/List/THA [verified 1 May 2014]. 22 Callaghan M, Ford N, Schneider H. A systematic review of taskshifting for HIV treatment and care in Africa. Hum Resour Health 2010; 8: 8. doi:10.1186/1478-4491-8-8 23 Chang LW, Kagaayi J, Nakigozi G, Ssempijja V, Packer AH, Serwadda D, Quinn TC, Gray RH, Bollinger RC, Reynolds SJ. Effect of peer health workers on AIDS care in Rakai, Uganda: a cluster-randomized trial. PLoS ONE 2010; 5: e10923. doi:10.1371/ journal.pone.0010923 24 Kawichai S, Celentano D, Srithanaviboonchai K, Wichajarn M, Pancharoen K, Chariyalertsak C, Visrutaratana S, KhumaloSakutukwa G, Sweat M, Chariyalertsak S; Project Accept Study Team. NIMH Project Accept (HPTN 043) HIV/AIDS community mobilization (CM) to promote mobile HIV voluntary counseling and testing (MVCT) in rural communities in Northern Thailand: modifications by experience. AIDS Behav 2012; 16: 1227–37. doi:10.1007/s10461-011-0099-4 25 World Health Organization (WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations Office on Drugs and Crime (UNODC). Advocacy guide: HIV/AIDS prevention among injecting drug users. Geneva: WHO; 2004. Available online at: http:// www.who.int/hiv/pub/advocacy/en/advocacyguideen.pdf [verified 1 May 2014]. 26 Brener L, Von Hippel W, Kippax S, Preacher K. The role of physician and nurse attitudes in the health care of injecting drug users. Subst Use Misuse 2010; 45: 1007–18. doi:10.3109/10826081003659543 27 Joint United Nations Programme on HIV/AIDS (UNAIDS). The greater involvement of people living with HIV/AIDS (GIPA); 2007. Available online at: data.unaids.org/pub/BriefingNote/2007/ jc1299_policy_brief_gipa.pdf [verified 1 May 2014]. 28 Maher L, Coupland H, Musson R. Scaling up HIV treatment, care and support for injecting drug users in Vietnam. Int J Drug Policy 2007; 18: 296–305. doi:10.1016/j.drugpo.2006.12.006
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