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HIV testing and willingness to get HIV testing at a peer-run drop-in centre for people who inject drugs… Ti, Lianping; Hayashi, Kanna; Kaplan, Karyn; Suwannawong, Paisan; Fu, Eric; Wood, Evan; Kerr, Thomas Mar 13, 2012

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RESEARCH ARTICLE Open AccessHIV testing and willingness to get HIV testing ata peer-run drop-in centre for people who injectdrugs in Bangkok, ThailandLianping Ti1,2, Kanna Hayashi2,3, Karyn Kaplan4, Paisan Suwannawong4, Eric Fu2, Evan Wood2,5 andThomas Kerr2,5,6*AbstractBackground: Regular HIV testing among people who inject drugs is an essential component of HIV preventionand treatment efforts. We explored HIV testing behaviour among a community-recruited sample of injection drugusers (IDU) in Bangkok, Thailand.Methods: Data collected through the Mitsampan Community Research Project were used to examine correlates ofHIV testing behaviour among IDU and to explore reasons for not being tested. Multivariate logistic regression wasused to examine factors associated with willingness to access HIV testing at the drug-user-run Mitsampan HarmReduction Centre (MSHRC).Results: Among the 244 IDU who participated in this study, 186 (76.2%) reported receiving HIV testing in theprevious six months. Enrolment in voluntary drug treatment (odds ratio [OR] = 2.34; 95% confidence interval [CI]:1.18 - 4.63) and the tenofovir trial (OR = 44.81; 95%CI: 13.44 - 149.45) were positively associated with having beentested, whereas MSHRC use (OR = 1.78; 95%CI: 0.96 - 3.29) was marginally associated with having been tested.56.9% of those who had not been tested reported in engaging in HIV risk behaviour in the past six months. 181(74.2%) participants were willing to be tested at the MSHRC if testing were offered there. In multivariate analyses,willingness to get HIV testing at the MSHRC was positively associated with ever having been to the MSHRC(adjusted odds ratio [AOR] = 2.42; 95%CI: 1.21 - 4.85) and, among females, being enrolled in voluntary drugtreatment services (AOR = 9.38; 95%CI: 1.14 - 76.98).Conclusions: More than three-quarters of IDU received HIV testing in the previous six months. However, HIV riskbehaviour was common among those who had not been tested. Additionally, 74.2% of participants were willing toreceive HIV testing at the MSHRC. These findings provide evidence for ongoing HIV prevention education, as wellpotential benefits of incorporating HIV testing for IDU within peer-led harm reduction programs.Keywords: HIV testing, Injection drug use, Thailand, Peer-based interventionsBackgroundThe HIV/AIDS epidemic remains a global challenge,with an estimated 33.3 million people living with HIVglobally [1]. In many settings, the fastest growing epi-demics of HIV are occurring among people who injectdrugs [2-4]. Currently, major public health efforts areunderway to scale-up HIV testing [5], as HIV testingleads to early diagnosis, and knowledge of HIV-serosta-tus may minimize HIV transmission by reducing riskybehaviour [6]. Further, testing can help increase accessto treatment for injection drug users (IDU) and therebyreduce HIV-related morbidity and mortality, while alsobolstering prevention efforts by reducing HIV-I RNA toundetectable levels in infected individuals [7].Although there is much evidence to support efforts toincrease the accessibility of HIV testing among IDU,there are many factors that mitigate the likelihood thatIDU will get tested. Barriers such as the fear of an HIV-* Correspondence: uhritk@cfenet.ubc.ca2British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,Vancouver, CanadaFull list of author information is available at the end of the articleTi et al. BMC Public Health 2012, 12:189http://www.biomedcentral.com/1471-2458/12/189© 2012 Ti et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.positive test result, HIV-related stigma, and the resultingimpacts on relationships with family and public authori-ties are among the reasons why IDU do not get testedfor HIV [8,9]. In Thailand, where the prevalence of HIVamong IDU is as high as 50% [10], an excessive focuson drug law enforcement has likely contributed to thesuboptimal coverage of HIV prevention, treatment andcare among this population [11,12]. For example, somepublic hospitals reportedly collect and share informationconcerning patients’ drug use behaviour with police inThailand [11]. This compromising of patient confidenti-ality prevents many IDU from wanting to use govern-ment testing services, especially given that, in order toqualify for a free HIV test at public testing clinics, IDUmust declare their risk behaviour (P. Sririrund, personalcommunication, April 30, 2011). In addition, if IDUwere to get HIV testing at private clinics, there wouldbe the burden of the cost of an HIV test imposed uponthem. Collectively, these barriers could potentiallyundermine access to HIV testing among this population.Recent studies have found that uptake of HIV testingamong IDU in parts of Asia is as low as 20% annually[13].Several studies have shown that peer-based interven-tions for drug users can often extend the reach andeffectiveness of conventional public health programs[14,15], especially in settings where drug use is heavilypenalized, as in Thailand [16]. There has been increas-ing interest in novel, low-threshold methods of HIVtesting, including peer-based testing [17,18]. However,there are currently no peer-based models of HIV testingin Thailand, and concerns have been expressed regard-ing the inadequate voluntary counselling and HIV test-ing services offered to IDU in this setting [11]. Giventhat knowledge of HIV-positive serostatus can reducethe health burden associated with HIV/AIDS amongIDU, and HIV testing and counselling continue to besupported by international health organizations globally[19,20], the lack of these services in Thailand hasprompted calls for increased voluntary counselling, test-ing and information services across the country [11].According to the Reference Group to the UnitedNations on HIV and Injecting Drug Use, there are anestimated 160,000 IDU living in Thailand [2], of whomthe majority are male and between the ages of 30-40years [16,21]. While there exists some evidence indicat-ing why individuals engaging in illicit drug use have lowuptake of HIV testing services [21], little is known aboutthe factors that influence HIV testing among IDU inThailand. Therefore, we sought to investigate the preva-lence and correlates of HIV testing behaviour among acommunity-recruited sample of IDU in Bangkok, Thai-land. As well, given the growing interest in low-thresh-old and peer-based HIV testing programs, we alsosought to assess willingness to get tested for HIV at adrug-user-run drop-in centre in Bangkok.MethodsThe Mitsampan Community Research Project (MSCRP)is a collaborative research project involving the Mitsam-pan Harm Reduction Centre (Bangkok, Thailand), theThai AIDS Treatment Action Group (Bangkok, Thai-land), Chulalongkorn University (Bangkok, Thailand)and the British Columbia Centre for Excellence in HIV/AIDS (Vancouver, Canada). During June and July of2009, the research partners undertook a cross-sectionalstudy involving 317 community-recruited IDU. Potentialparticipants were recruited through peer-based outreachefforts and word of mouth. Study participants were theninvited to attend the MSHRC to participate in the study.All participants provided informed consent and com-pleted an interviewer-administered questionnaire elicit-ing information about demographic characteristics, druguse, HIV risk behaviour, criminal justice system expo-sure, and experiences with health care. All participantswere given 350 baht (approximately US$11) upon com-pletion of the questionnaire. The study has beenapproved by the research ethics boards of the Universityof British Columbia and Chulalongkorn University.For the present analyses, we restricted the study sam-ple to individuals who were HIV-negative or ofunknown HIV serostatus. As a first step, we comparedIDU who had and had not been tested for HIV in thepast six months using the Pearson c2 test and Fisher’sexact test (when one or more cells contained values lessthan or equal to five). Among the participants who hadnot been tested for HIV in the past six months, weexamined the prevalence of ongoing HIV risk behaviourand asked them to indicate reasons why they had notbeen tested. Second, we compared IDU who were andwere not willing to get free HIV testing at MSHRC,again using the Pearson c2 test and Fisher’s exact test(when one or more cells contained values less than orequal to five). The “willingness to get free HIV testingat MSHRC” variable referred to whether participantswould get tested at least once at the peer-run drop-incentre. Specifically, we asked: “If the MSHRC offeredfree HIV testing with pre- and post-counselling (includ-ing referrals to clinics/hospitals), would you take thetest?” We then built a multivariate logistic regressionmodel to identify independent predictors of willingnessto get free HIV testing at MSHRC by including all vari-ables that were associated with the outcome at the p ≤0.10 level in bivariate analyses.Variables considered in both initial bivariate analysesincluded: gender, median age, relationship status (mar-ried/common law, regular partner vs. separated, dating,single), education level (≥ secondary school vs.Ti et al. BMC Public Health 2012, 12:189http://www.biomedcentral.com/1471-2458/12/189Page 2 of 9< secondary school), heroin injection in the past sixmonths (> once per week vs. ≤ once per week), midazo-lam injection in the past six months (> once per weekvs. ≤ once per week), methamphetamine injection in thepast six months (> once per week vs. ≤ once per week),lent or borrowed syringes to/from others in the past sixmonths (yes vs. no), enrolled in voluntary drug treat-ment in the past six months (yes vs. no), had unpro-tected sex in the past six months (yes vs. no),incarceration in the past six months (yes vs. no), report-ing barriers to accessing health services (any barriers vs.no barriers), and having ever been to MSHRC (yes vs.no). Our barriers to testing variable included the follow-ing: limited hours of operation, long wait times, didn’tknow where to go, jail, detention, prison, no identifica-tion, identification registered somewhere else, nomoney, was treated poorly by healthcare professionals,fear of sharing information of drug using status with thepolice and/or narcotics control board, difficulty keepingappointments, transportation, and others. Additionally,because Bangkok was a site of the tenofovir trial (a pre-exposure prophylaxis trial) that included IDU, beingenrolled in the tenofovir trial (yes vs. no) was also con-sidered in the first bivariate analyses focused on HIVtesting behaviour in the past six months. All p-valueswere two-sided.ResultsIn total, 244 individuals who were HIV-negative or ofunknown HIV serostatus were included in the study,including 77 (31.6%) females. The median age of theparticipants at the time of interview was 37 years (range:20 - 72 years). In total, 186 (76.2%) participants reportedthat they had been tested for HIV in the past sixmonths. As indicated in Table 1, results show that beingenrolled in voluntary drug treatment in the past sixmonths (odds ratio [OR] = 2.34; 95% confidence interval[CI]: 1.18 - 4.63) and being in the tenofovir trial (OR =44.81; 95% CI: 13.44 - 149.45) were positively associatedwith having been tested for HIV. As well, having beento MSHRC (OR = 1.78; 95%CI: 0.96 - 3.29) was margin-ally associated with having been tested for HIV.Although the odds ratio for the incarceration variablecould not be calculated because one cell contained azero, there was a trend towards a positive associationbetween having been incarcerated in the past six monthsand having been tested for HIV. Of the 58 participantswho were not tested for HIV, 41 responded to the ques-tion: “Why haven’t you taken an HIV test?” Of these, 27(65.9%) stated that they believed they were HIV-nega-tive. However, 33 (56.9%) participants who did not getan HIV test engaged in at least one of the followingrisky behaviours in the past six months: syringeborrowing, syringe lending, or unprotected vaginal oranal intercourse.In total, 181 (74.2%) participants responded that theywere willing to get tested at the MSHRC. As shown inTable 2, factors positively associated with a willingnessto be tested for HIV at the MSHRC included beingenrolled in voluntary drug treatment in the past sixmonths (OR = 1.94; 95%CI: 1.02 - 3.68), reporting a bar-rier to accessing health services (OR = 1.99; 95%CI: 1.05- 3.77), and having been to the MSHRC (OR = 3.17;95%CI: 1.68 - 6.01). There was also a marginally signifi-cant association between willingness to get tested at theMSHRC and having lent or borrowed syringes to/fromothers in the past six months (OR = 2.36; 95%CI: 0.94 -5.90). Additionally, female sex was negatively associatedwith willingness to be tested for HIV at the MSHRC(OR = 0.46; 95%CI: 0.26 - 0.84).Table 3 presents the results of multivariate analyses offactors associated with willingness to get HIV testing atthe MSHRC. As indicated here, having been to theMSHRC (adjusted odds ratio [AOR] = 2.42; 95%CI: 1.21- 4.85) remained positively associated with willingness toget HIV testing at the peer-run drop-in centre. An ana-lysis of interactions was then conducted between genderand enrolment in voluntary drug treatment in the pastsix months. A positive association between willingnessto be tested at the MSHRC and being enrolled in volun-tary drug treatment was found for females (AOR = 9.38;95%CI: 1.14 - 76.98), while a marginal positive associa-tion between willingness to get tested for HIV at theMSHRC and non-enrolment in voluntary drug treat-ment was found for males (AOR = 2.07; 95%CI: 0.98 -4.39).DiscussionIn the present study, we found that HIV testing wascommon among Thai IDU, with 76.2% reporting thatthey had been tested in the past six months. Havingbeen enrolled in voluntary drug treatment and beingenrolled in the tenofovir trial was positively associatedwith having been tested for HIV, while having been tothe MSHRC was marginally associated. Among thosewho had not been tested for HIV in the past sixmonths, approximately 56% had recently engaged insome form of HIV risk behaviour. We also found thatalmost three-quarters of the sample (74.2%) expressedwillingness to get tested for HIV at the drug-user-runMSHRC. In a multivariate analysis, having been toMSHRC was independently and positively associatedwith willingness to get tested at MSHRC. Enrolment involuntary drug treatment was also associated with will-ingness to get tested at the MSHRC, although this rela-tionship interacted with gender, with women inTi et al. BMC Public Health 2012, 12:189http://www.biomedcentral.com/1471-2458/12/189Page 3 of 9Table 1 Bivariate analyses of factors associated with being tested for HIV in the past six months among IDU inBangkok, Thailand (n = 244)Tested for HIV in past six months n (%)Characteristic Yes186 (76.2%)No58 (23.8%)Odds Ratio(95% CI) p - valueGenderFemale 54 (29.0) 23 (39.7) 0.62 (0.34 - 1.15) 0.13Male 132 (71.0) 35 (60.3)Median age≥ 37 years old 96 (51.6) 24 (41.4) 1.51 (0.83 - 2.74) 0.17< 37 years old 90 (48.4) 34 (58.6)Relationship statusMarried/common law, regular partner 100 (53.8) 33 (56.9) 0.88 (0.49 - 1.60) 0.68Separated, dating, single 86 (46.2) 25 (43.1)Education level≥ secondary education 66 (35.5) 23 (39.7) 0.84 (0.46 - 1.53) 0.56< secondary education 120 (64.5) 35 (60.3)Heroin injection*> once per week 54 (29.0) 17 (29.3) 0.99 (0.52 - 1.89) 0.97≤ once per week 132 (71.0) 41 (70.7)Midazolam injection*> once per week 114 (61.3) 32 (55.2) 1.29 (0.71 - 2.33) 0.41≤ once per week 72 (38.7) 26 (44.8)Methamphetamine injection*> once per week 71 (38.2) 18 (31.0) 1.37 (0.73 - 2.58) 0.32≤ once per week 115 (61.8) 40 (69.0)Lent or borrowed syringes to/from others*Yes 33 (17.7) 9 (15.5) 1.17 (0.53 - 2.62) 0.70No 153 (82.3) 49 (84.5)Enrolled in voluntary drug treatment*Yes 75 (40.3) 13 (22.4) 2.34 (1.18 - 4.63) 0.01No 111 (59.7) 45 (77.6)Had unprotected sex*Yes 87 (46.8) 29 (50.0) 0.88 (0.49 - 1.59) 0.67No 99 (53.2) 29 (50.0)Incarceration*Yes 11 (5.9) 0 (0.0) – 0.07No 175 (94.1) 58 (100.0)Reporting barriers to accessing health servicesAny barriers 68 (36.6) 21 (36.2) 1.02 (0.55 - 1.87) 0.96No barriers 118 (63.4) 37 (63.8)Ever been to MSHRCYes 90 (48.4) 20 (34.5) 1.78 (0.96 - 3.29) 0.06No 96 (51.6) 38 (65.5)In tenofovir trialYes 132 (71.0) 3 (5.2) 44.81 (13.44 - 149.45) < 0.01No 54 (29.0) 55 (94.8)* Activities in the previous six monthsIDU Injecting drug usersMSHRC Mitsampan Harm Reduction CentreCI Confidence IntervalTi et al. BMC Public Health 2012, 12:189http://www.biomedcentral.com/1471-2458/12/189Page 4 of 9Table 2 Bivariate analyses of factors associated with willingness to get free HIV testing at the MSHRC among IDU inBangkok, Thailand (n = 244)HIV testing at MSHRCn (%)Characteristic Yes181 (74.2%)No63 (25.8%)Odds Ratio(95% CI) p - valueGenderFemale 49 (27.1) 28 (44.4) 0.46 (0.26 - 0.84) 0.01Male 132 (72.9) 35 (55.6)Median age≥ 37 years old 92 (50.8) 28 (44.4) 1.29 (0.73 - 2.30) 0.38< 37 years old 89 (49.2) 35 (55.6)Relationship statusMarried/common law,regular partner103 (56.9) 30 (47.6) 1.45 (0.82 - 2.58) 0.20Separated, dating, single 78 (43.1) 33 (52.4)Education level≥ secondary education 68 (37.6) 21 (33.3) 1.20 (0.66 - 2.20) 0.55< secondary education 113 (62.4) 42 (66.7)Heroin injection*> once per week 56 (30.9) 15 (23.8) 1.43 (0.74 - 2.77) 0.28≤ once per week 125 (69.1) 48 (76.2)Midazolam injection*> once per week 113 (62.4) 33 (52.4) 1.51 (0.85 - 2.69) 0.16≤ once per week 68 (37.6) 30 (47.6)Methamphetamine injection*> once per week 70 (38.7) 19 (30.2) 1.46 (0.79 - 2.70) 0.23≤ once per week 111 (61.3) 44 (69.8)Lent or borrowed syringes to/from others*Yes 36 (19.9) 6 (9.5) 2.36 (0.94 - 5.90) 0.06No 145 (80.1) 57 (90.5)Enrolled in voluntary drug treatment*Yes 72 (39.8) 16 (25.4) 1.94 (1.02 - 3.68) 0.04No 109 (60.22) 47 (74.6)Had unprotected sex*Yes 86 (47.5) 30 (47.6) 1.00 (0.56 - 1.77) 0.99No 95 (52.5) 33 (52.4)Incarceration*Yes 10 (5.5) 1 (1.6) 3.63 (0.45 - 28.91) 0.30No 171 (94.5) 62 (98.4)Reporting barriers to accessing health servicesAny barriers 73 (40.3) 16 (25.4) 1.99 (1.05 - 3.77) 0.03No barriers 108 (59.7) 47 (74.6)Ever been to MSHRCYes 94 (51.9) 16 (25.8) 3.17 (1.68 - 6.01) < 0.01No 87 (48.1) 47 (74.6)* Activities in the previous six monthsIDU Injecting drug usersMSHRC Mitsampan Harm Reduction CentreCI Confidence IntervalTi et al. BMC Public Health 2012, 12:189http://www.biomedcentral.com/1471-2458/12/189Page 5 of 9treatment being the more willing to get tested at theMSHRC.We found that just over three-quarters (76.2%) of oursample of IDU had previously been tested for HIV inthe past six months. Our findings are consistent withprevious studies demonstrating fairly high levels of HIVtesting in other middle-income settings contending withhigh rates of HIV infection among IDU, includingAndhra Pradesh, India (89%) [22] and St. Petersburg,Russia (76%) [23]. However, our findings are inconsis-tent with previous studies that show low uptake of HIVtesting among IDU in Asia [13]. That said, it is unclearwhether the high rate of testing observed here is par-tially a reflection of the existence of the tenofovir trial,as 55% of participants had enrolled in this study.Although HIV testing appears to be quite commonamong IDU in Bangkok, there were still a number ofactive drug-using participants who had not been testedin the past six months. Among the participants whowere not tested for HIV, the majority perceived them-selves to be HIV-negative even though they had engagedin at least one HIV risk behaviour in the past sixmonths. This raises concern that some IDU in Thailandmay be unaware of their HIV risk, indicating a need forintensified and targeted outreach, education and testingefforts to reach these individuals [9,24]. Interestingly,our findings reveal that the type of illicit drugs injected(heroin, midazolam, and methamphetamine) was notassociated with either of our outcome variables, suggest-ing that our findings are uniform across individuals whouse different types of drugs.UNODC recommends community-based, voluntarydrug treatment programs across South East Asia as asubstitute for incarceration and compulsory drug deten-tion centres for IDU [25]. Voluntary drug treatmentprograms, in particular opiate substitution therapy(OST), have been previously associated with a reductionin risky behaviour and HIV infection among IDU in var-ious settings [26-28]. Adding to the benefits of voluntarytreatment, we found that participants who were enrolledin voluntary treatment were significantly more likely toget tested for HIV compared to those who were notenrolled in voluntary treatment. Our findings supportthe recommendation of the United States Centres forDisease Control and Prevention (US CDC) to integrateHIV testing services as part of voluntary drug treatment[29]. However, concerns have been raised about the nat-ure of current HIV testing in voluntary drug treatmentcentres in Thailand, as it has been reported that insome of these centres, HIV testing is mandatory and acondition of receiving services [11]. Given that ourstudy did not differentiate between mandatory andvoluntary HIV testing in voluntary treatment programs,future research should seek to untangle this complexrelationship. Nevertheless, in these settings, replacingthe system of mandatory testing with voluntary HIVtesting in these treatment programs may prove to beeffective in increasing the proportion of IDU in Thai-land who get tested, thereby allowing for early diagnosis,enhanced access to antiretroviral therapy (ART) treat-ment, and targeted education and interventions to con-trol the spread of HIV [6].Table 3 Multivariate logistic regression analyses of factors associated with willingness to get free HIV testing atMSHRC among IDU in Bangkok, Thailand (n = 244)Variable Adjusted Odds Ratio (AOR) 95% Confidence Interval (CI) p - valueLent or borrowed syringes to/from others*(yes vs. no) 1.49 (0.56 - 4.00) 0.43Reporting barriers to accessing health services(yes vs. no) 1.22 (0.59 - 2.51) 0.58Ever been to MSHRC(yes vs. no) 2.42 (1.21 - 4.85) 0.01Gender (not enrolled in voluntary treatment*)(male vs. female) 2.07 (0.98 - 4.39) 0.06Gender (enrolled in voluntary treatment*)(male vs. female) 0.22 (0.03 - 1.85) 0.16Enrolled in voluntary drug treatment* (male)(yes vs. no) 1.01 (0.46 - 2.18) 0.99Enrolled in voluntary drug treatment* (female)(yes vs. no) 9.38 (1.14 - 76.98) 0.04*Activities in the previous six monthsIDU Injection Drug UsersTi et al. BMC Public Health 2012, 12:189http://www.biomedcentral.com/1471-2458/12/189Page 6 of 9In addition to being enrolled in voluntary drug treat-ment, being enrolled in the tenofovir trial was also posi-tively associated with HIV testing among IDU. Thetenofovir trial in Thailand, sponsored by the US CDC,was launched in 2005 in an attempt to examine thesafety and efficacy of this antiretroviral drug. Currently,tenofovir (alone) is being provided to approximately2,400 HIV-negative IDU and 17 drug treatment clinicsacross Bangkok [30]. Results of the US CDC-sponsoredpre-exposure prophylaxis trial in Thailand are to berevealed in early 2012 [31]. The increased odds of HIVtesting among IDU in the tenofovir trial could be attrib-uted to the fact that all participants in the trial receivefree rapid HIV testing on an ongoing basis. Althoughour findings show a positive association between beingenrolled in the tenofovir trial and HIV testing, concernshave been expressed over the fact that the trial sites inThailand failed to provide sterile syringes and needles toIDU participants [32,33]. Efforts to engage and consultwith IDU community groups at an earlier stage of thetrial design process may have helped alleviate these con-cerns and should be considered for future HIV preven-tion trials as a means of ensuring appropriate access toHIV prevention technologies among trial participants.Internationally, peer outreach and peer-run initiativeshave been shown to be successful in extending thereach and effectiveness of conventional public healthprograms, including those focused on preventing andtreating HIV/AIDS among IDU [14,34,35]. Since thelaunch of Thailand’s 2003 “War on Drugs” campaign,the government has continued to rely on repressiveapproaches to drugs, including arbitrary arrests, black-listing, drug planting by police, extrajudicial executionsand other human rights violations of people involvedwith drugs [11,36,37]. In this context, severe stigma anddiscrimination persist against Thai IDU, promptingmany to avoid public health programs [37]. Additionally,problems related to stigmatizing attitudes of health careproviders focused on IDU have been reported amongThai health professionals, including nursing students,which in turn likely adversely affects the willingness ofIDU to access health care [38]. Given these problems,the noted effectiveness of various peer-based methodsfor IDU, and the high willingness to access HIV testingat the MSHRC, peer-based HIV testing interventions forIDU may have high potential for success in this setting.In the present study, having been to the MSHRC pre-viously was significantly and positively associated withwillingness to get HIV testing at the centre. In an earlierstudy conducted on the MSHRC, results showed thatthe main reason IDU did not access the centre was thelack of knowledge of its existence [16]. Therefore, futureefforts should focus on increasing awareness of andimproving access to the MSHRC and other drop-in cen-tres like it. Since the focus of this paper was on willing-ness to get HIV testing at the MSHRC withoutspecifying whether the testing was peer-delivered, futureresearch efforts should seek to determine whether IDUwould be willing to be tested by a peer either in thecontext of a drug-user-run harm reduction program orin other conventional health care settings.Enrolment in voluntary drug treatment was also asso-ciated with willingness to get HIV testing at theMSHRC. As mentioned above, there was an interactioneffect involving enrolment in voluntary treatment andgender, and willingness to get tested at the MSHRC.Among participants who were not enrolled in voluntarytreatment, males were significantly more willing thanfemales to get tested at the MSHRC, although this asso-ciation did not reach conventional significance. Amongfemale IDU, those engaged in treatment were signifi-cantly more willing to get tested at the MSHRC com-pared to those out of treatment. In light of thesefindings, future research should seek to unpack the gen-der dynamics surrounding addiction treatment enrol-ment and HIV testing behaviour within this setting.This study has several limitations. First, because of thecross-sectional nature of the study, there is an inabilityto determine a temporal relationship between exposureand outcome, and therefore causation cannot beinferred. Second, the data collected were self-reportedand may be subject to reporting biases. Socially desirablereporting as well as recall bias may affect reports of bothrisk behaviour and testing behaviour. Third, since thestudy sample was small and not randomly selected, thestudy may not be representative of Thai IDU. As well,our findings may not be generalizable to other popula-tions of IDU. Lastly, because of the small sample size,there were wide intervals around some of the estimatesreported.ConclusionsIn the present study, we found high rates of HIV testingamong Thai IDU. However, we found that among parti-cipants who were not tested for HIV, a high proportionhad recently engaged in some form of HIV risk beha-viour. We also observed a high rate of willingness to getfree HIV testing at the MSHRC. Willingness to betested was independently associated with having been toMSHRC, and among women, having been enrolled involuntary drug treatment was also associated with will-ingness to be tested at the MSHRC. These findingshighlight the need for ongoing educational effortsrelated to HIV transmission, as well opportunities toexpand harm reduction strategies to include peer-ledHIV testing for IDU in Thailand.Ti et al. BMC Public Health 2012, 12:189http://www.biomedcentral.com/1471-2458/12/189Page 7 of 9AcknowledgementsWe would particularly like to thank the staff and volunteers at theMitsampan Harm Reduction Centre for their support and Dr. NiyadaKiatying-Angsulee of the Social Pharmacy Research Unit, Faculty ofPharmaceutical Sciences, Chulalongkorn University, for her assistance withdeveloping this project. We also thank Daniel Miles Kane, Deborah Graham,Tricia Collingham and Calvin Lai for their assistance with data management,and Prempreeda Pramoj Na Ayutthaya and Puripakorn Pakdirat for theirassistance with data collection. Funding for this study was provided by theMichael Smith Foundation for Health Research. Michael Smith Foundationhad no further role in the study design; in the collection, analysis andinterpretation of data; in the writing of the report; or in the decision tosubmit the paper for publication.Author details1Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada.2British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,Vancouver, Canada. 3Interdisciplinary Studies Program, University of BritishColumbia, Vancouver, Canada. 4Thai AIDS Treatment Action Group, Bangkok,Thailand. 5Department of Medicine, University of British Columbia, St. Paul’sHospital, Vancouver, Canada. 6Urban Health Research Initiative, BC Centre forExcellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6,Canada.Authors’ contributionsLT and TK designed the study. EF conducted the statistical analyses. LTdrafted the manuscript and incorporated all suggestions from all the co-authors. All authors made significant contributions to the conception of theanalyses, interpretation of the data, and drafting of the manuscript. Allauthors read and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Received: 10 November 2011 Accepted: 13 March 2012Published: 13 March 2012References1. Joint United Nations Programme on HIV/AIDS (UNAIDS): Global report:UNAIDS report on the global AIDS epidemic. 2010 [http://www.unaids.org/globalreport/Global_report.htm].2. Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA,Wodak A, Panda S, Tyndall M, Toufik A, Mattick RP: Global epidemiology ofinjecting drug use and HIV among people who inject drugs: asystematic review. Lancet 2008, 372:1733-1745.3. McInnes CW, Druyts E, Harvard SS, Gilbert M, Tyndall MW, Lima VD,Wood E, Montaner J, Hogg RS: HIV/AIDS in Vancouver, British Columbia: agrowing epidemic. Harm Reduct J 2009, 6(5).4. 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Chan KY, Stoove MA, Sringernyuang L, Reidpath DD: Stigmatization ofAIDS patients: disentangling Thai nursing students’ attitudes towardsHIV/AIDS, drug use, and commercial sex. AIDS Behav 2008, 12:146-157.Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/12/189/prepubdoi:10.1186/1471-2458-12-189Cite this article as: Ti et al.: HIV testing and willingness to get HIVtesting at a peer-run drop-in centre for people who inject drugs inBangkok, Thailand. BMC Public Health 2012 12:189.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitTi et al. 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