“It Makes Me Want to Come Back Here”: Silom Community Clinic’s Approach to HTC Among MSM in Thailand
High rates of HIV infection among men who have sex with men (MSM) in the Asia-Pacific region are a concern. Many MSM living with HIV remain unaware of their status and are often diagnosed in late stages of the disease. In 2005, the Silom Community Clinic was established in Bangkok to promote HIV testing and counseling while conducting high-quality HIV prevention research among MSM, including transgender populations. The clinic provides supportive, confidential, non-judgmental, and client-centered HIV rapid testing and counseling for MSM.
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"It Makes Me Want to Come Back Here"
by Scott Berry, Maria Claudia Escobar, and Heather Pitorak
Silom Community Clinic's Approach to HIV Testing and Counseling Among Men Who Have Sex with Men in Bangkok, Thailand
At 4 p.m., in Bangkok's red-light and gay district along Silom Road, the heat and bustle of rush hour is intense. Thousands of business-suited commuters head home on foot, weaving their way through makeshift street stalls being erected for the night market. At the same time, gay sex clubs, dance bars, cafes, and restaurants are opening for business—their lights flicker on like eyes opening after a long day's sleep—and their staff sweep the sidewalks and set up outdoor tables in preparation for the long night ahead.
A few steps away, the Silom Community Clinic (SCC) is also opening its doors. Housed in a quiet, private space at Bangkok Christian Hospital, SCC provides HIV and sexually transmitted infection (STI) services to men who have sex with men (MSM), including transgender persons. A welcome retreat from the chaos of Silom Road, yet easily accessible to its MSM clients, SCC has served hundreds of MSM since it opened in 2005. Silom Community Clinic's MSM-friendly services, clinical culture, and its proximity to a neighborhood where many MSM gather has created a loyal and growing clientele among this vulnerable and often stigmatized population.
In 2005, the Thailand Ministry of Public Health–U.S. Centers for Disease Control and Prevention Collaboration (TUC) established SCC at the Bangkok Christian Hospital as a research site for recruitment and implementation of HIV clinical and behavioral studies, as well as for an HIV testing and counseling program, referred to as voluntary counseling and testing (VCT) in Thailand. Silom Community Clinic has since evolved into a successful model for VCT service provision for MSM and receives U.S. Government funds that are administered through the TUC partnership. Elements of SCC's approach to providing VCT services to MSM may be effective in similar settings in Thailand and across the region (U.S. Centers for Disease Control and Prevention 2009).
Disclaimer: The authors' views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
HIV and Men Who Have Sex with Men in Asia and Thailand: Epidemiologic Context
HIV infection among MSM in the Asia-Pacific region is currently a disquieting public health issue (U.S. Agency for International Development [USAID] 2009). MSM in Asia are 19 times more likely than the general population to be living with HIV (Baral et al. 2007), yet the proportion of MSM reached with HIV prevention, treatment, care, and support services remains extremely low (AIDSTAR-One n.d.). In Bangkok and many mega-cities across Asia, MSM already account for more than half of all new cases of HIV (Bangkok Metropolitan Authority 2011). Unless effective HIV prevention strategies are implemented, the Commission on AIDS in Asia predicts that by 2020 approximately half (46 percent) of all new HIV infections in Asia will be among MSM, an increase of 13 percent from 2008 (Commission on AIDS in Asia 2008).
Although Thailand has a well-regarded national HIV program, many people living with HIV, including MSM, are unaware of their HIV status and are thus often diagnosed in advanced stages of the disease (United Nations General Assembly Special Session Thailand 2010). With high HIV incidence—especially among young MSM—Thailand needs to increase the numbers who know their HIV status, interrupt the transmission of HIV and other STIs, and reduce morbidity and mortality of HIV within this population.
Barriers for Men Who Have Sex with Men in Seeking HIV Testing
The term "men who have sex with men" encompasses the full range of men who engage in sex with other men, regardless of how they characterize their sexual orientation. MSM encompasses men who identify as gay and bisexual, as well as those who identify as heterosexual but who have sex with other men in addition to sex with women. In Thailand, MSM includes men who identify as kathoey, a Thai word that has traditionally described male-to-female transgender people and transvestites and, to a decreasing extent, gay and other MSM (Jackson and Sullivan 1999; Thaczuk 2007).
Sex between men has not been criminalized in Thailand, yet it is not fully accepted (Jackson 1999). Although Thailand is more accepting of homosexuality than other countries in the Asia-Pacific region, many policymakers and health care workers view homosexuality as "inappropriate" or "misdirected" (Joint United Nations Programme on HIV/AIDS 2010, 2). The absence of an enabling environment that encourages individuals to disclose sexual preferences and behaviors to others may deter them from accessing the health service system. MSM of low socioeconomic status or who are less educated may feel that they are powerless to advocate for themselves or navigate the health system (USAID 2009). In particular, young MSM may not feel empowered to practice health-seeking behaviors, which is a serious public health issue in Bangkok because of the high HIV incidence within this population (van Griensven et al. 2010).
The Silom Community Clinic Approach
Silom Community Clinic strives to provide a supportive, confidential, non-judgmental approach in all aspects of service delivery. By offering a range of free services (see Box 1), the clinic also aims to increase and retain the number of MSM accessing VCT. Another SCC objective is to recruit MSM clients to participate in HIV prevalence and incidence surveillance and monitoring of sexual behavior.
A committed clinic team, including a small reception staff and five nurses, delivers clinical and support services on-site. A case manager facilitates an informal referral system for newly diagnosed HIV-positive clients by maintaining relationships with a range of public and private hospitals and clinics. A moderator facilitates a weekly support group for HIV-positive clients. In this referral model, the case manager provides antiretroviral treatment education and either accompanies the clients to the referral appointment or calls the client to ensure follow-up for appointments. This helps to ensure clients reach the service needed, as the private and public health system can be fragmented. The case manager also sustains referral partnerships by attending a quarterly HIV clinical network meeting with public and private practitioners, government officials, and HIV community staff. Meeting participants discuss the barriers to access and referrals, and collectively propose solutions to referral difficulties.
Other features make SCC's MSM-friendly service delivery approach distinctive. For instance, the clinic's late hours—between 4 p.m. and 10 p.m., Tuesdays through Saturdays, with no appointment required—attract MSM clients who may not be able to attend the clinic during standard hours. The clinic gives new clients a membership card, which preserves confidentiality and facilitates an easy return process for services. One-stop services are provided in private rooms, which also assures clients of confidentiality. Finally, because the clinic's clients have mobile phones, the clinic team successfully uses text messaging to remind clients of follow-up appointments, syphilis testing, and CD4 monitoring. Follow-up appointments are facilitated at the clinic. One week prior to the appointment, the staff sends text message reminders to the client. If clients do not return for follow-up, a team member calls the client directly to arrange a new appointment.
BOX 1. SILOM COMMUNITY CLINIC SERVICES
- Rapid anonymous HIV testing and counseling (including couples VCT)
- Acute HIV testing
- Rapid syphilis testing
- On-site laboratory
- Point-of-care HIV testing and delivery of same-day results
- Syndromic STI evaluation and management for VCT clients
- Hepatitis B vaccination for those eligible
- CD4 count testing
- Tuberculosis screening for infection and disease, and referral to care as needed
- Treatment referrals and referral support into public or private health care system.
With a laboratory on-site, SCC uses anonymous rapid HIV testing technology to provide same-day test results after the initial pre-test counseling session, which assesses the risk profile of the client and provides information on HIV and STIs. Clients who test HIV-positive have blood drawn for initial CD4 testing directly after post-test counseling. Clients return in one week for the CD4 result when referrals for services within the public health system, including tuberculosis screening X-ray, are given. Couples counseling and testing is also available upon request. After testing, clients receive 30 minutes of post-test counseling regardless of the test result to help preserve confidentiality and prevent stigma or easy identification of clients who test positive. This process does not affect the responsiveness of services (e.g., counselor availability). Clients attend VCT without an appointment and report efficient service with minimal wait times. The clinic also offers viral load testing to determine the HIV status of individuals who have symptoms of acute HIV infection, which occurs two to four weeks after infection with HIV.
The supportive atmosphere extends beyond MSM clients to include staff, as well. Growth and development are encouraged, and the SCC staff participates in supervision, discussions, and professional development. Staff is encouraged to learn about areas relevant to MSM as well as technical aspects of HIV and STIs. They also attend HIV conferences and training workshops on relevant subjects.
To spread word about its services, SCC develops partnerships within the MSM community. In 2005, the TUC partnered with the Rainbow Sky Association of Thailand, a lesbian, gay, bisexual, and transgender organization, to establish the national MSM Community Advisory Board and to promote SCC's services and the Bangkok MSM Cohort Study(2) to MSM across the city. The TUC employs an outreach coordinator based at Rainbow Sky who works with an outreach team at bars, saunas, parks, clubs, and other public places. Rainbow Sky also promotes the clinic's services through its own community-based projects, including peer groups, health peer education camps, telephone information helpline, and condom distribution.
In the coming years, the Bangkok MSM Cohort Study will be downsized and replaced by advanced studies, e.g., clinical trials of rectal microbicides and dosage and adherence studies of pre and post exposure chemoprophylaxis. Findings from recent HIV prevention research found that HIV transmission can be reduced by treating uninfected, high-risk MSM with a daily dose of antiretroviral drugs (Grant et al. 2010). In another study, serodiscordant heterosexual couples who were treated with early antiretroviral therapy produced a relative reduction of HIV transmission by 89 percent (Cohen et al. 2011). Consequently, SCC will develop demonstration projects to implement pre-exposure prophylaxis for the prevention of HIV infection among high risk, drug-using, and young MSM. SCC will also develop culturally-specific "test and link" and "test and treat" models, in an effort to identify HIV discordant MSM couples, where the HIV infected partner will be treated early to demonstrate the possibility of preventing HIV transmission between partners.
The ultimate goal of SCC has remained the same throughout its existence: to build infrastructure to conduct HIV prevention research, serve as a model for services for MSM, and to be integrated in the government prevention package for MSM. The clinic is seeking to become part of Thailand's public health system so that MSM-friendly services may be scaled up, and to serve as a model that can be adapted by other programs to strengthen Thailand's HIV response targeting MSM.
Key Results: Increases in Clients Tested and High Return Rates
Silom Community Clinic's design and delivery of clinical services have helped improve HIV testing uptake among MSM. Since the clinic's inception, MSM attending the clinic have increased fourfold, with client numbers rising from 207 in 2005 to 864 in 2010 (see Figure 1). The clinic has also seen a steady increase in the number of MSM returning for VCT, a reported return rate of 60.5 percent since SCC's establishment. Those enrolled in studies frequently return several times per year for HIV and STI health screening. The total number of visits by clients increased from 416 in 2005 to 3,158 in 2010. Since SCC initiated services, almost 100 percent of clients have received test results during post-test counseling. The clinic is reaching high-risk clients as HIV prevalence among clients at first visit is 28 percent.
What Works Well
Silom Community Clinic possesses distinctive features that contribute to effective outreach to and retention of MSM.
Non-judgmental, client-centered, supportive, and engaged service providers
The staff consistently displays an accepting and supportive attitude toward MSM, their lifestyles, and their relationships. The majority of the current staff was part of the original team when SCC was created. Staff participated in the evolution of service delivery that was recursively tested and adapted and helped shape what is now the client-centered approach used at SCC. MSM clients interviewed at the clinic emphasized that the staff's supportive approach is one of the most effective aspects of the clinic's service delivery. One client, Somchai, said, "Without this [acceptance], it's totally impossible [for me to attend a service]." The clinic staff's acceptance of MSM and willingness to discuss personal and sexual aspects of MSM clients' lives contribute to creating a welcoming atmosphere, which encourages MSM clients to return for services. To further narrow the gap between provider and client, clinical team members wear street clothing instead of nursing uniforms, which MSM notice and appreciate.
Support services for providers to prevent burnout
The clinic's management team provides ongoing support to the clinical staff which the staff consider highly valuable. Staff regularly participate in one-on-one supervision, team discussions, and debriefing sessions. The staff participate in an education and development program that supports ongoing training on such topics as MSM lifestyles and behaviors, clinical HIV issues, and HIV and STI diagnosis, treatment, and counseling. The clinic's supportive management approach effectively prevents staff burnout, contributes to high-quality service delivery, and helps clinical staff maintain their sensitive and supportive attitudes toward their MSM clients.
MSM-friendly location and design of services
Silom Community Clinic reports high return rates for follow-up VCT and related services among MSM, who revisit the clinic an average of two to three times per year. In addition to the staff's supportive approach, the clinic's location, situated in an area of Bangkok that many MSM frequent, is integral to its effective service delivery. The clinic is located within a secluded area of the Bangkok Christian Hospital and is integrated into the hospital so that it is not immediately recognizable as either an HIV clinic or as a service provider for MSM. These characteristics encourage MSM to access services. By providing health services after normal working hours, the clinic encourages MSM to attend after work, on weekends, and before or after socializing in the area. In addition, confidentiality and privacy are preserved by issuing anonymous membership cards and providing all services in private clinic rooms. Services are provided by the same nurse in the same room, which adds to the comfort and ease of services experienced by clients. Finally, the text message reminders sent to clients motivates them to return to the clinic for other services.
Rapid HIV testing with same-day results
Rapid HIV testing technology is an effective approach for increasing the number of clients who test for HIV and actually receive their results. The clinic's director suggests that use of rapid HIV testing with same-day results has helped ensure that clients receive their test results in post-test counseling at the clinic (van Griensven 2011).
Generating MSM demand for VCT through community-based organizations
The high return rates suggest SCC has achieved considerable success in designing a program that encourages MSM to seek HIV and other health services. One important factor has been SCC's clinic-community partnerships, which help generate demand for VCT among MSM. The Rainbow Sky outreach coordinator suggested that MSM may encourage each other to attend VCT services, which may be more effective than messages from persons or organizations outside MSM peer networks. Clients who have had positive experiences at SCC become champions of VCT within their own networks. MSM clients bring their sexual partners to HIV testing sites and recommend VCT to their friends.
Referral and linkage to HIV treatment and care services
As a VCT facility focusing on increasing testing uptake among MSM, SCC does not provide antiretroviral treatment for people with HIV or ongoing clinical management. However, through the informal referral system and committed relationships with external services, the clinic strives to provide clients with a continuum of care by educating MSM on antiretroviral and treatment guidelines and referring them to public and private health services, where care and services are often disjointed. Members of coordinating organizations interviewed highlight the effectiveness of professional relationships maintained by the case manager, which facilitates active communication and referral.
While SCC is successfully increasing the number of MSM tested and yielding high return rates, challenges remain in providing a complete and effective range of needed services.
Providing adequate prevention services for young MSM
The SCC caseload reflects the high incidence of HIV among younger MSM: 12 percent are 21 years and younger (van Griensven 2010). These figures correspond with Thailand's HIV epidemic, reflecting an increased risk and burden of HIV on young MSM in Bangkok (van Griensven et al. 2010). While SCC has been effective in reaching MSM with VCT, the clinic needs to have an increased impact on HIV prevention among young MSM. Reaching young MSM in Thailand may be difficult because of concerns about seeking VCT, especially if there are no symptoms of HIV or other illnesses. HIV prevention within this community may require providing additional training to community-based partners to improve the quality of counseling with young MSM about HIV prevention and the need for regular HIV testing as part of a high risk group, and to expand the delivery of VCT services in MSM community settings, such as bars, sex venues, and dance parties.
Preventing loss to follow-up
Silom Community Clinic established an informal referral system, using a case manager to build relationships with external clinics and follow up with clients. Staff members are aware that some HIV-positive MSM clients do not take advantage of their referrals for HIV care and treatment services; staff assume this relates to fear of stigma and discrimination, and fear or shame of disclosing their HIV status to other providers. A key challenge for MSM-focused VCT services is to prevent loss to follow-up and to ensure that health services are sensitive and responsive to MSM living with HIV.
Reaching poor and less-educated MSM
The clinic's MSM cohort is largely composed of middle-class, educated MSM, with the majority holding at least a bachelor's degree. The clinic reports fewer MSM clients with low socioeconomic status and little education. However, other MSM-focused HIV clinics in Bangkok report a greater caseload of MSM clients with low socioeconomic status. The clinic needs to determine how to reach these MSM, which is necessary to increase uptake of VCT and have a greater impact on HIV within the broader MSM community.
Expanding the reach of the SCC model
The clinic's VCT service delivery is an effective MSM-friendly service provision model. However, while the clinic has seen increases in the number of MSM clients, SCC is only reaching a portion of the MSM population, which remains a challenge for the clinic. The clinic aims to determine how to successfully promote its VCT approach to reach a greater number of MSM clients and is working to become integrated into Thailand's public health system.
Create easy access
One of SCC's key successes is its approach to VCT service delivery. Providing service hours that are convenient and conducive to the target group, anonymous client cards, and text message reminders are all elements that facilitate and encourage MSM to access HIV testing. These features help define SCC's service approach and can be used to design similar VCT services for MSM. Because SCC does not provide treatment, it is critically important to ensure that a referral system is in place to bridge the gaps of a health system that can be disjointed.
Create an MSM-friendly atmosphere for clients and among staff
Staff members' positive attitudes about working at SCC with MSM are recognized as essential to providing high-quality services. Engendering an MSM-supportive atmosphere among staff is essential to attract and retain MSM clients, and it can be fostered through sensitization training. Increasing staff comfort in working with MSM can be achieved through educational sessions, role-plays, and discussions with MSM peer educators. In addition, small details such as use of "streetwear" rather than laboratory coats by staff can help de-medicalize the environment and foster a friendly, welcoming space.
Build a supportive environment for staff to prevent burnout
Efficient management and encouragement of continuing education and debriefing sessions for staff can help to prevent burnout. Working in HIV service delivery can lead to burnout due to undue stress, negative attitudes about HIV, or poor remuneration. Being aware of and attempting to meet staff needs may help replicate this supportive environment for personnel. Programs that aim to implement SCC's approach should institute policies that reward staff, improve clinical supervision, and increase team-based support and access to ongoing learning and development opportunities.
Use MSM-frequented locations for VCT service delivery
While SCC's location in the larger hospital setting reaches certain populations of MSM, establishing VCT services in communities where other MSM populations, such as young MSM, congregate is essential. Community strategies may be effective in reaching MSM subgroups who are particularly hard to reach, do not frequent services, or are at exceptionally high risk of HIV, including young people. Providing VCT services in alternative locations, outside of conventional health services, and in the community may increase the reach of HIV testing and referral to care and treatment.
Maintain privacy and confidentiality
Silom Community Clinic's service delivery prioritizes clients' privacy and confidentiality by using anonymous testing protocols rather than names. If clients are able to trust a clinic or program, it increases the likelihood that they will return for other services. All VCT services should aim to provide private counseling rooms for consultations, signage or communications products that protect the confidentiality of clients, and, if needed, a private entrance and exit to access the VCT clinic.
Offer HIV rapid testing with same-day results to prevent loss to follow-up
Silom Community Clinic uses HIV rapid testing technology, which ensures that clients receive their results the same day they test. Having the on-site laboratory is also valuable for confirmatory testing. Rapid testing effectively reduces loss to follow-up, because clients do not have to return for results days or weeks following testing. In SCC's case, this has helped lead to high client retention rates. If national governments or Ministry of Health departments do not have an approved or preferred rapid testing algorithm, programmers and policymakers should advocate for rapid HIV testing. This may help to increase the proportion of VCT clients receiving HIV test results in public health clinics or hospitals delivering VCT services. In fact, the model of rapid testing success at SCC was instrumental in moving the Thai policy toward rapid testing for all most-at-risk populations (Wolf 2011). Additionally, VCT sites should proactively identify factors that contribute to loss to follow-up.
Generate demand for VCT services among MSM
Silom Community Clinic successfully built and sustains demand for their services by partnering with MSM-led community-based organizations. Partnering among services and community organizations is effective because peer-based promotion helps build and sustain trust between MSM and clinic services. Partnerships with a community-based MSM organization may be particularly effective in urban areas such as Bangkok that have extensive networks of MSM, multiple locations where MSM meet, and an environment where real or perceived stigma and discrimination can make MSM populations difficult to reach.
Silom Community Clinic is a unique, successful model that reaches MSM and can increase the uptake of HIV testing and counseling. Adapting the SCC approach can assist programs and countries to move forward as they seek to more effectively target the HIV response and reach MSM.
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The authors wish to thank the following people for their guidance, input, and/or review: Vincent Wong, Charlene Brown, Cameron Wolf, and Kai Spratt, U.S. Agency for International Development (USAID)/Washington; ThuVan Dinh, and Panus Rattakitvijun Na Nakorn, USAID Regional Development Mission Asia; and Clif Cortez, United Nations Development Programme Asia-Pacific Regional Centre. The authors wish to thank Professor Frits van Griensven, and the clinic staff, clients, and partners of the clinic for their participation and willingness to share the important experience of the Silom Community Clinic.
Berry, Scott, Maria Claudia Escobar, and Heather Pitorak. 2012. "It Makes Me Want to Come Back Here": Silom Community Clinic's Approach to HIV Testing and Counseling Among Men Who Have Sex with Men in Bangkok, Thailand. Case Study Series. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.