"It Makes Me Want to Come Back Here": Silom Community Clinic's Approach to HTC Among MSM in Bangkok, Thailand

This case study from the United States Agency for International Development (USAID)'s AIDSTAR-One (AIDS Support and Technical Assistance Resources, Sector 1, Task Order 1) explores communication strategies being undertaken to address disconcerting rates of HIV infection among men who have sex with men (MSM) in Thailand, where "many MSM and other people living with HIV remain unaware of their HIV status and are often diagnosed in late stages of the disease." Specifically, it looks at the work of the Silom Community Clinic (SCC), which was established in Bangkok, Thailand, in 2005 by the Thailand Ministry of Public Health-US Centers for Disease Control and Prevention Collaboration (TUC) to create a model to promote HIV testing and counselling (HTC) while at the same time conducting HIV prevention research among MSM, including transgender populations. The clinic, which is located in an area reportedly popular with MSM and yet integrated into a hospital health care facility and so not immediately recognisable as an MSM- or HIV-related facility, works to provide supportive, confidential, non-judgmental, and client-centred HIV rapid testing and counselling for MSM.

The story of a man, detailed in one text box within the case study, who has attended SCC captures some of the communication strategies and tools that characterise this initiative: "Tan [all names are pseudonyms] felt compelled to test for HIV when his boyfriend told him he was HIV-positive. He searched for HIV testing information online and subscribed to online chat sites where he shared his concerns with HIV-positive MSM. After three months, an online friend sent him a link to an SCC video on YouTube, which convinced Tan to get tested. Aek, one of the VCT [voluntary counselling and testing] nurses at SCC, met Tan at the reception room; Tan noticed Aek was not wearing a uniform, which helped him to relax. After 30 minutes in the post-test counseling session, Tan learned he was HIV-negative and felt relieved. Aek gave Tan the opportunity to talk through his fears about his partner's status and how he could negotiate with his boyfriend and remain HIV-negative. Tan has been attending the clinic for almost one year and receives text messages to attend the clinic for follow-up testing every four months. Tan described the services as 'similar to life coaching...health providers [at the clinic] challenge me to think and change my sexual behavior by doing a self-assessment of my risk behavior.' He has improved his knowledge and skills about safe sex as well as his emotional capacity to manage relationships, including his relationship with his HIV-positive partner."

As highlighted in Tan's story, SCC's client-friendly approach includes features such as: one-stop services, rapid HIV testing and same-day results, an on-site laboratory, operation after-hours and on weekends, anonymous memberships and private counselling rooms, no need for appointments or identification (no questionnaires are used), integration of sexually transmitted infection (STI) screening into VCT services, a non-judgmental attitude and acceptance of MSM, dedicated support services for newly diagnosed MSM, and text message reminders to MSM clients for return visits.

Since the clinic's inception, MSM attending the clinic have increased fourfold, with client numbers rising from 207 in 2005 to 864 in 2010. The clinic has also seen a steady increase in the number of MSM returning for VCT, a reported return rate of 60.5% 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% of clients have received test results during post-test counselling. The clinic is reaching high-risk clients, as HIV prevalence among clients at first visit is 28%.

A core lesson to emerge from this case study is that staff members' positive attitudes about working at SCC with MSM are "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."

Amongst the recommendations offered in the case study: Generate demand for VCT services among MSM. SCC "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."