Article

Journal of the International

Association of Providers of AIDS Care
Feasibility of HIV Universal Voluntary 1-10
ª The Author(s) 2014
Reprints and permission:
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DOI: 10.1177/2325957414531622
General Practice Clinic jiapac.sagepub.com

Thana Khawcharoenporn, MD, MSc1,2, Anucha Apisarnthanarak, MD1,2,

Krongtip Chunloy, RN, MPH2, and Kimberly Smith, MD, MPH3,4

Abstract
An HIV transmission prevention program incorporating universal voluntary counseling and testing (UVCT) was conducted in a
general practice (GP) clinic of a Thai hospital. Of the 494 participating patients, 356 (72%) accepted HIV-UVCT. Independent
factors associated with HIV-UVCT acceptance included participating in the program after office hours (4-8 PM; P < .001), living
with domestic partner with no marriage (P ¼ .01), and having primary school education or less (P ¼ .02). The main reasons for
declining HIV-UVCT were time constraint (38%) and perceiving self as no risk (35%). Among the 356 patients undergoing
HIV-UVCT, having moderate to high HIV risk (P < .001) and male sex (P ¼ .01) were independently associated with low HIV risk
perception. By HIV-UVCT, the rate of new HIV infection was 4 (1.1%) of 356 patients. Of these 4 newly diagnosed HIV-infected
patients, 3 (75%) were homosexual men. The findings suggest feasibility of HIV-UVCT in our GP clinic and factors to be consid-
ered for improving the program.

Keywords
feasibility, HIV, universal voluntary counseling and testing, general practice, Thailand

Introduction advantages of early HIV detection, including early engagement

HIV infection and AIDS have been major public health prob-
lems in Thailand. Among Thai adults aged 15 to 49 years, the
prevalence of HIV infection was estimated to be 1.2%, and in
2011, 9700 individuals were newly diagnosed with HIV infec-
tion (15 per 100 000 persons).1 The Ministry of Public Health
of Thailand reported that the rates of new HIV infection were
31.9% among injection drug users, 3.2% among commercial
sex workers, and 1.9% among male attendees of sexually trans-
mitted infection (STI) clinics, while the rate among general
Thai population was 0.2% in 2011.2 The annual rates of new
HIV infection have not declined dramatically despite efforts
and several campaigns to prevent HIV transmission in the
country.1 One of the possible reasons is thought to be the un-
awareness of HIV status among asymptomatic infected individ-
uals who engage in risk behaviors and fuel the ongoing HIV
transmission in the communities.3
HIV universal testing has been recommended by the Centers
for Disease Control and Prevention (CDC) of the United States
since 2006 to increase the awareness of HIV status in the U.S.
communities.4 The recommendations state that universal HIV
testing should be offered to everyone aged 13 to 64 years who
present to health care facilities regardless of their complaining
and presenting symptoms or HIV risks in areas where HIV pre-
valence is 0.1% or more. The universal HIV testing provides
of the infected patients into care to prevent subsequent immu-
nosuppression and HIV-related morbidity and mortality and
increase in awareness of HIV status, which results in actions
to prevent HIV transmission.3-6 In addition, assessment of risk
perception and targeted education to improve risk perception
and reduce risk behaviors can be incorporated into this HIV
testing program.1
In Thailand, HIV infection screening and diagnosis are usu-
ally done by a standard blood test for HIV antibody. All Thai
people are allowed to have this test performed free of charge
every 6 months as a part of a campaign conducted by the Min-
istry of Public Health to reduce new HIV infection and trans-
mission. Pretest and posttest counseling and written consent
1
Division of Infectious Diseases, Faculty of Medicine, Thammasat University,
Pathumthani, Thailand
2
HIV/AIDS Care Unit of Thammasat University Hospital, Pathumthani, Thailand
3
Section of Infectious Diseases, Rush University Medical Center, Chicago,
IL, USA
4
The Ruth M. Rothstein CORE Center, Chicago, IL, USA
Corresponding Author:
Thana Khawcharoenporn, Division of Infectious Diseases, Faculty of Medicine,
Thammasat University, Pathumthani, Thailand.
Email: thanak30@yahoo.com

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2 Journal of the International Association of Providers of AIDS Care
forms are mandatory for the HIV testing in accordance with
Thai laws. Generally, population groups at high risk for HIV
infection include men who have sex with men, commercial sex
workers, injection drug users, and attendees of STI clinics7 and
are targets for this HIV universal voluntary counseling and test-
ing (HIV-UVCT) in Thailand. However, there has not been any
official recommendation about how to implement the HIV-
UVCT in settings with populations at lower HIV risk, such
as general outpatient clinics or emergency departments. We
conducted this study to evaluate the feasibility of the in-
house HIV transmission prevention program that incorporates
HIV-UVCT among patients visiting a general practice (GP)
clinic in Thailand.
Methods
Study Population, Setting, and Design
An HIV transmission prevention program incorporating HIV-
UVCT was conducted in a GP clinic of Thammasat University
Hospital (TUH) in Pathumthani, Thailand, during the period
from June 1, 2012, to July 31, 2012. The GP clinic provides pri-
mary care services to adult patients (age 15 years) in
Pathumthani and the nearby provinces. The HIV transmission
prevention program was initiated by the HIV care team of TUH,
which consists of 3 infectious disease physicians, 2 HIV nurses,
2 nonphysician medical assistants, and 2 HIV-infected volun-
teers, to promote HIV transmission prevention and provide rel-
evant education for patients visiting GP clinic. The program
was set up specifically and not included in the regular patient
care at the GP clinic. Due to the limited resources and staff of
the GP clinic to do HIV-UVCT, the HIV care team worked on
the program independently of the GP clinic staff and as an extra
service. This study was a prospective study conducted among
GP clinic patients who participated in this HIV transmission pre-
vention program and was approved by the Faculty of Medicine,
Thammasat University Ethics Committee.
Study Procedures
The HIV transmission prevention program was conducted in
the GP clinic from 8:00 AM to 8:00 PM on all weekdays through-
out the 2-month period. Patients waiting to see doctors were
approached and asked to participate in the program that con-
sisted of a brief HIV knowledge assessment questionnaire, free
HIV-UVCT offering, and education provided by the HIV care
team personnel in verbal sessions and brochures. All partici-
pants provided written informed consent before participating
in the study. The brief questionnaire asked the participants to
answer whether the 12 different statements about HIV trans-
mission were true or false. The participants’ answers were used
to guide what education topics should be provided for each
individual. Data including demographics, reasons for visiting
the GP clinic, and reasons for accepting or declining HIV-
UVCT were collected in the brief questionnaire. Among the
participants who accepted HIV-UVCT, the pretest counseling
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was done by the HIV counselors of the HIV care team, and the
counseling form was used to collect data about demographics,
HIV test history, HIV acquisition risks and behaviors, safe sex
practices, and HIV risk perception before the participants
underwent HIV testing. The questions in the counseling form
were adapted and modified from the validated survey form
used to assess HIV acquisition risks and behaviors and HIV risk
perception in previous studies.8,9 During the counseling pro-
cess, if the participants reported that they were HIV infected,
they were excluded from HIV testing. Primary and secondary
telephone numbers of each participant were collected for sub-
sequent HIV testing result notification. The participants were
also informed the contact number to ask for the test results. The
identification code that was known only between the partici-
pant and the HIV counselor was given to each participant for
future confidential contact about the test results.
Study Definitions
Participants self-identified their sexual orientation and HIV
risk perception during the counseling. To identify their own
HIV risks, the participants answered ‘‘No risk at all,’’ ‘‘A little
risk (low risk),’’ ‘‘More than a little (moderate risk),’’ and ‘‘A
lot of risk (high risk)’’ to the HIV counselors. The investigators
of this study subsequently evaluated the participants’ risk as
‘‘low risk,’’ ‘‘moderate risk,’’ and ‘‘high risk’’ based on the pre-
specified risk characteristics and behaviors reported in the
counseling form and according to previous studies’ criteria.8,9
This risk categorization tool was validated in the previous stud-
ies for use in differentiating participants with different levels of
risk behavior.8,9 Participants who were categorized as moder-
ate or high risk but perceived their risks as no or low risk were
classified as having low HIV risk perception.
HIV Testing and Result Notification
The HIV counselors obtained the participants’ consent for HIV
testing in written documentation. Participants’ blood was col-
lected at the GP clinic and was sent to the TUH serology
laboratory. HIV testing was initially performed using ARCHI-
TECT HIV Ag/Ab Combo (Abbott, Germany), which is a che-
miluminescent microparticle immunoassay. If the HIV
antibody was detected by this test, it was then confirmed by the
other 2 HIV antibody detection assays, Determine HIV-1/2
(Alere Medical, Japan), which is an immunochromatographic
test, and SERODIA HIV-1/2 (FUJIREBIO, Japan), which is
a passive particle agglutination test. If all 3 assays indicated
a positive result, the test result would be reported as HIV pos-
itive. Generally, it takes about 24 to 72 hours before the official
result comes out. Notification of the test results was done via
telephone. The HIV counselors called all participants to inform
the negative results. However, if the test result was positive,
they would inform the participants via telephone to come to
TUH for posttest counseling and result notification, in accor-
dance with Thai laws. A total of 3 calls (1 week apart) were
attempted to notify the participants of their results, and
Khawcharoenporn et al
additional 3-week duration was allowed after that for the parti-
cipants to call back before contact failure was considered. Only
the participants who could identify the identification codes cor-
rectly were informed of the negative result or were requested to
come to TUH. Among participants with negative HIV testing,
further HIV transmission prevention strategies were recom-
mended over the phone along with posttest counseling, while
HIV-infected participants were inquired about the plans for
their HIV continuity care in regard to medical coverage and
chosen health care facilities to establish care. HIV transmission
prevention and health maintenance strategies were recom-
mended at the end of the posttest counseling.
Data Analyses
All statistical analyses were performed using SPSS version
15.0 (SPSS, Chicago, Illinois). Categorical variables were
compared using Pearson w2 or Fisher exact test as appropriate.
Continuous variables were compared using Mann-Whitney U
test. All P values were 2 tailed; P values less than .05 were con-
sidered statistically significant. Variables that were present at a
significance level of P < .20 in univariate analysis or had prior
significance for HIV testing acceptance (age, sex, level of edu-
cation, and marital status),10,11 HIV positivity (age, sexual
orientation, and risk behaviors),7,12 and low HIV risk percep-
tion (age, sex, sexual orientation, and education)13-15 were
entered into logistic regression models. These variables were
subsequently removed from the models in backward stepwise
fashion if their P values were >.05 until the final model had
reached. Adjusted odds ratios and 95% confidence intervals
were determined for risk factors associated with HIV testing
acceptance, HIV positivity, and low HIV risk perception.
Results
Characteristic of the Study Participants
A total of 821 patients attending the GP clinic were
approached, of which 494 (60%) patients participated in the
HIV transmission prevention program. The median age was
34 years (range 15-68 years). Three hundred seven (62%)
patients participated in the program during office hours
(8 AM-4 PM), and 260 (53%) were male. Most of the participants
were company workers (36%), government officers (18%), and
merchants (16%); 44% were single, and 56% had secondary
school education or less. The main reason for visiting the GP
clinic was regular visit for health problems, such as diabetes,
hypertension, and hyperlipidemia (67%), followed by health
checkup (29%; Table 1).
Reasons and Characteristics Associated with Declining or
Accepting HIV-UVCT
A total of 138 (28%) patients participated in the HIV knowl-
edge assessment questionnaire and education session but
declined to undergo HIV-UVCT. Of these 138 participants,
60 (44%) did not provide the reason for HIV-UVCT declining.
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3
The 3 most common reasons provided by the remaining 78 par-
ticipants were time constraint (30 [38%]), perceiving self as no
risk for HIV infection (27 [35%]), and having HIV test with
negative result within a year (14 [18%]). Other reasons
included being afraid of pain or of needles (5%), being healthy
(3%), and being afraid of having a positive HIV test result
(1%). When comparing between participants who accepted and
declined HIV-UVCT (Table 1), the declining participants were
more likely to participate in the program during office hours, be
a merchant, have a college or a bachelor degree education, have
higher monthly household income, and present to the GP clinic
for regular visit for health problems and health checkup.
Among the 356 HIV-UVCT accepting participants, the reasons
for undergoing testing included desire to know HIV infection
status (321 [90%]), suspect of having HIV infection (11
[3%]), preparing for marriage and pregnancy (10 (3%)], inter-
est in free test (8 [2%]), following friends who want to be tested
(4 [1%]), and recent high-risk exposure (2 [0.6%]). By multi-
variable logistic regression analysis (Table 2), characteristics
independently associated with HIV-UVCT acceptance included
participating in program during nonoffice hours (P < .001), liv-
ing with a domestic partner without marriage (P ¼ .01), and hav-
ing primary school education or less (P ¼ .02).
Characteristics and HIV Risks among Participants
Undergoing HIV Test
Of the 356 participants undergoing HIV-UVCT, 254 (71%)
were self-willing to be tested, while 102 (29%) were advised
by accompanying friends or family members before they
decided to get tested, 118 (33%) had prior HIV test, all of
which had negative results and 344 (97%) were heterosexual.
The majority of the 356 participants reported having vaginal
sex (299 [84%]) while having oral sex and anal sex were
reported in 78 (22%) and 44 (12%), respectively. The reported
rates of consistent condom use were all low with each type of
sex (13% with vaginal sex, 9% with oral sex, and 5% with anal
sex). Other reported risks for HIV acquisition included having
tattoo or piercing (24%), having STIs within the past year
(3%), having sexual partner who exchanged sex for money
or drugs within the past 30 days (1%), injection drug use
(0.3%), and having sexual partner who had STIs within the
past year (0.3%). Based on the risk categorization tool, 80
(23%) participants had moderate to high HIV risk. Of these
356 participants, 345 (97%) were reachable for HIV result
notification within the median time of 5 days (range 1-36
days), while 11 (3%) had contact failure. Among the 11 par-
ticipants with contact failure, the median age was 29 years
(range 15-67 years), 6 (55%) were male, 6 (55%) were mar-
ried, 7 (64%) had secondary school education or less, 8
(73%) participated in the program during nonoffice hours,
11 (100%) came to the GP clinic for health checkup, 1 (9%)
had prior HIV test, 11 (100%) were heterosexual, 3 (27%)
were categorized into HIV high-risk group, and 1 (9%) had
low perception of HIV risk.
4 Journal of the International Association of Providers of AIDS Care

Table 1. Characteristics of the Study Participants.a

Characteristics All (N ¼ 494) Accepted UVCT (N ¼ 356) Declined UVCT (N ¼ 138) Pb

Hours of the program participation .001*

Office hours (8 AM-4 PM) 307 (62) 189 (53) 118 (86)
Nonoffice hours (4 PM-8 PM) 187 (38) 167 (47) 20 (15)
Sex .78
Male 260 (53) 186 (52) 74 (54)
Female 234 (47) 170 (48) 64 (46)
Age in years, median (range) 34 (15-68) 34 (15-68) 33 (15-67) .31
Occupation .005*
Company worker 179 (36) 136 (38) 43 (31)
Government officer 89 (18) 61 (17) 28 (20)
Merchant 78 (16) 46 (13) 32 (23)
Student 74 (15) 52 (15) 22 (16)
Housewife 37 (8) 33 (9) 4 (3)
Monk 16 (3) 16 (5) 0 (0)
Farmer 4 (1) 2 (1) 2 (1)
Retired 2 (0.4) 1 (0.3) 1 (1)
Unemployed 15 (3) 9 (3) 6 (4)
Marital status .04*
Single 216 (44) 148 (42) 68 (49)
Married 206 (42) 145 (41) 61 (44)
Living with domestic partner 42 (9) 36 (10) 6 (4)
Divorced 22 (5) 19 (5) 3 (2)
Widowed 8 (2) 8 (2) 0 (0)
Highest education .001*
Primary school or less 138 (28) 115 (32) 23 (17)
Secondary school 137 (28) 100 (28) 37 (27)
College or bachelor’s degree 196 (40) 126 (35) 70 (51)
More than bachelor’s degree 23 (5) 15 (4) 8 (6)
Religion .08
Buddhism 475 (96) 344 (97) 131 (95)
Islam 11 (2) 7 (2) 1 (1)
Christian 8 (2) 5 (1) 6 (4)
Monthly household income in US$, median (range) 667 (40-16 667) 667 (83-16 667) 900 (40-50 000) <.001*
Reasons for visiting the general practice clinic .001*
Regular visit for health problems 329 (67) 232 (65) 97 (70)
Health checkup 141 (29) 100 (28) 41 (30)
Noninfectious diseases medical complaints 20 (4) 20 (6) 0 (0)
Suspected of having an infectionc 4 (1) 4 (1) 0 (0)

Abbreviatons: UVCT, universal voluntary counseling and testing.

a
Data are in numbers (%) unless otherwise indicated.
b
Comparison between participants accepted and declined universal voluntary counseling and testing (UVCT).
c
Any kind of infections including HIV infection.
*significant P values (<0.05).

Characteristics Associated with HIV Positivity
Among the 356 participants undergoing HIV test, 4 (1.1%)
were HIV positive. The diagnosis of HIV infection was new for
these 4 participants. Of these, 4 (100%) of the newly HIV diag-
nosed participants were male, 3 (75%) were homosexual;
potential route of HIV acquisition included sexual contact 3
(75%) and tattooing and piercing 2 (50%; 1 person can have
multiple potential routes of acquisition). Three (75%) had mod-
erate to high HIV risk and 2 (50%) had low-risk perception. All
of the 4 HIV-infected participants were contacted and informed
the result within the median time of 7 days (range 3-14 days).
Comparing between HIV-positive and HIV-negative partici-
pants (Table 3), HIV-positive participants were more likely
to be homosexual, have anal and oral sex, have moderate to
high HIV risk, and be uncertain about HIV risks in sexual part-
ner. By multivariable logistic regression analysis, characteris-
tics independently associated with HIV positivity were being
homosexual men (P < .001; Table 2).
HIV Risk Perception and Characteristics Associated with
Low Risk Perception
Among the 356 participants undergoing HIV-UVCT, 36 (10%)
had low HIV risk perception. Comparing between participants
with low risk perception (having moderate or high risk for HIV
but perceiving self as no or low risk) and correct risk perception,

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Khawcharoenporn et al
Table 2. Multivariable Logistic Regression Analysis for Factors
Associated with HIV-UVCT Acceptance, HIV-Positive Test Result,
and Low HIV Risk Perception among the Study Participants.
Adjusted odds ratio
(95% confidence
Factors interval)
HIV UVCT acceptance
Program participation during 5.47 (3.23-9.25)
nonoffice hours
Living with domestic partner 3.19 (1.28-7.97)
Primary school education or less 1.86 (1.10-3.16)
HIV-positive test result
Being homosexual men 112.32 (9.31-355.63)
Having high actual HIV risk 3.64 (0.16-82.71)
Having low HIV risk perception 1.95 (0.10-39.02)
Low HIV risk perception
Having moderate to high HIV risk 227.76 (32.21-576.48) <.001
Male sex 2.74 (1.23-6.08) .01
Being homosexual men 3.77 (0.85-16.75) .08
Abbreviation: UVCT, universal voluntary counseling and testing.
participants with low risk perception were more likely to be men,
younger, homosexual or bisexual, uncertain about HIV risks in
sexual partners and have STIs within the past year (Table 4).
By multivariable logistic regression analysis, having moderate
to high HIV risk and male sex were independently associated
with low HIV risk perception (Table 2).
Discussion
Our study demonstrates feasible implementation of HIV-
UVCT that was incorporated into an HIV transmission preven-
tion program in a GP clinic of a Thai university hospital with
the high rate of acceptance (72%). Given that the program was
conducted by the hospital’s HIV care team and utilized its
laboratory resource and the HIV antibody tests were totally
supported by the Ministry of Public Health of Thailand, the
extra cost incurred from the program was modest.
Health care provider-initiated HIV-UVCT has been recom-
mended in the 2006 CDC guidelines to increase access to HIV
testing.4 However, several barriers including insufficient time,
burdensome consent process, lack of knowledge/training, lack
of patient acceptance, pretest counseling requirements, com-
peting priorities, and inadequate reimbursement limit effective-
ness of this testing approach.16 Setting up the extra HIV
transmission prevention program like ours in a GP clinic has
some advantages over the HIV-UVCT offering by GP physi-
cians. First, the program provides specific knowledge-guided
education along with detailed HIV risk assessment and coun-
seling. This type of education could shorten the time used for
pretest counseling for about 10 minutes and made the counsel-
ing more efficient. Second, HIV care staff in the program has
more dedicated time to talk, discuss, and educate the partici-
pants about HIV-UVCT and prevention strategies compared
to a GP physician. Finally, the active approach of the program
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5
can potentially increase the likelihood of program participation
and HIV-UVCT acceptance as evident in our study.
Notification of the HIV test result is critical for further coun-
seling and engaging new HIV-infected individuals into care.4
However, previous studies demonstrated that 10% to 55% of
P individuals at risk for HIV infection did not return for HIV
results after the standard HIV testing.17,18 HIV rapid testing
that uses blood-based tests with or without oral fluid-based test
<.001
has thus become an ideal strategy that can inform the result
.01 within about an hour.19 A randomized study from the United
.02 States revealed that a significant higher proportion of the par-
ticipants receiving HIV rapid tests were informed about their
<.001 status than were those receiving standard HIV tests (95% ver-
.42 sus 43%).20 HIV rapid testing was shown to be associated with
.66
high rate (97%) of linkage to care and successful virological
suppression within the median time of 8 months after HIV
diagnosis in another study.21 Based on a model of HIV trans-
mission, increased HIV testing will modestly reduce HIV inci-
dence among gay men in Australia and would be acceptable if
HIV testing becomes convenient.22 Nonetheless, there have not
been randomized trials comparing between rapid and standard
HIV tests in regard to linkage to care, treatment outcomes, and
HIV transmission reduction. Two studies have shown that the
incidences of posttest risk behaviors among participants under-
going both types of test were not different.23,24 In addition, cost
and availability may limit utility of the rapid tests in resource-
constrained settings. We demonstrated that use of the standard
conventional blood-based tests in this study was associated
with high rate of acceptance (72%). The rates of result notifica-
tion were 97% for all participants and 100% for HIV-infected
participants. The difference in the rates of result notification
in our study and the previous study was due to the use of HIV
counselor-initiated confidential telephone contact in our study
compared to having the participants calling in for follow-up
appointments to be notified of the results in another study.20
Altogether, HIV rapid testing provides some benefits over the
standard testing and is recommended for use. However, in set-
tings where the rapid testing is not available, the standard test-
ing can be used.
In a general outpatient setting, common reasons for declin-
ing HIV-UVCT include having a previous/recent HIV test, per-
ceiving oneself as no risk for HIV, and unwillingness to know
the status.20,25 Our results concurred with these findings but
also identified time constraint as the most common reported
reason. In addition, we found that participation in the program
during nonoffice hours was independently associated with
HIV-UVCT acceptance. These results suggest that operating
time of the program in relation to availability of the participants
is an important factor to be considered to improve the HIV-
UVCT program. Participants who had recent HIV testing or
declined HIV testing should be informed about the benefits
of regular testing when risks are present and frequency of test-
ing they can receive based on the national policies and medical
coverage. During the HIV-UVCT offering, assessment of risk
perception could help identify additional participants who
should receive HIV-UVCT. It should be noted that only a few
6 Journal of the International Association of Providers of AIDS Care

Table 3. Characteristics of the 356 Participants Undergoing HIV Universal Voluntary Counseling and Testing Categorized by the Test Result.a

Characteristics All (N ¼ 356) HIV positive (n ¼ 4) HIV negative (n ¼ 352) Pb

Hours of the program participation 1

Office hours (8 AM-4 PM) 189 (53) 2 (50) 187 (53)
Nonoffice hours (4 PM-8 PM) 167 (47) 2 (50) 165 (47)
Sex .12
Male 186 (52) 4 (100) 182 (52)
Female 170 (48) 0 (0) 170 (48)
Age in years, median (range) 34 (15-68) 31 (17-46) 35 (15-68) .41
Occupation .71
Company worker 136 (38) 1 (25) 135 (38)
Government officer 61 (17) 1 (25) 60 (17)
Student 52 (15) 1 (25) 51 (15)
Merchant 46 (13) 0 (0) 46 (13)
Housewife 33 (9) 0 (0) 33 (9)
Monk 16 (5) 1 (25) 15 (4)
Farmer 2 (1) 0 (0) 2 (1)
Retired 1 (0.3) 0 (0) 1 (0.3)
Unemployed 9 (3) 0 (0) 9 (3)
Marital status .22
Single 148 (42) 4 (100) 144 (41)
Married 145 (41) 0 (0) 145 (41)
Living with domestic partner 36 (10) 0 (0) 36 (10)
Divorced 19 (5) 0 (0) 19 (5)
Widowed 8 (2) 0 (0) 8 (2)
Highest education .87
Primary school or less 115 (32) 2 (50) 113 (32)
Secondary school 100 (28) 1 (25) 99 (28)
College or bachelor’s degree 126 (35) 1 (25) 125 (36)
More than bachelor’s degree 15 (4) 0 (0) 15 (4)
Religion .93
Buddhism 344 (97) 4 (100) 340 (97)
Christian 7 (2) 0 (0) 7 (2)
Islam 5 (1) 0 (0) 5 (1)
Monthly household income in US$, median (range) 667 (83-16,667) 1,583 (200-3,333) 667 (83-16,667) .34
Willing to be tested for HIV
Self-willing 254 (71) 3 (75) 251 (71) 1
Being advised by others 102 (29) 1 (25) 101 (29)
Prior HIV test 118 (33) 0 (0) 118 (34) .31
Ever had sexual intercourse 307 (86) 3 (75) 304 (86) .45
Sexual orientation <.001
Heterosexual 344 (97) 1 (25) 343 (97)
Homosexual 9 (2) 3 (25) 6 (2)
Bisexual 3 (1) 0 (0) 3 (1)
Number of different sexual partner within 30 days (median, range) 1 (0-5) 2 (0-3) 1 (0-5) .2
Number of new sexual partner within 30 days (median, range) 0 (0-5) 0 (0-0) 0 (0-5) .51
Having vaginal sex 299 (84) 0 (0) 299 (85) .001
Using condom with vaginal sex consistently 40/299 (13) – 40/299 (13) -
Having anal sex 44 (12) 3 (75) 41 (12) .006
Using condom with anal sex consistently 2/44 (5) 0/3 (0) 2/41 (5) .95
Having oral sex 78 (22) 3 (75) 75 (21) .03
Using condom with oral sex consistently 7/78 (9) 0/3 (0) 7/75 (9) .94
Ever injected drug with needle 1 (0.3) 0 (0) 1 (0.3) 1
Ever had tattoo or piercing 85 (24) 2 (50) 83 (24) .24
Ever exchanged sex for money or drugs 0 (0) 0 (0) 0 (0) 1
Having STIs within the past year
Yes 9 (3) 0 (0) 9 (3) 1
Not sure 30 (8) 1 (25) 29 (8) .3
Sexual partner injected drug with needle within the past 30 days
Yes 0/307 (0) 0/3 (0) 0/304 (0) 1
Not sure 44/307 (14) 3/3 (100) 41/304 (13) .003

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Khawcharoenporn et al 7

Table 3. (continued)

Characteristics All (N ¼ 356) HIV positive (n ¼ 4) HIV negative (n ¼ 352) Pb

Sexual partner exchanged sex for money or drugs within the past 30 days
Yes 3/307 (1) 0/3 (0) 3/304 (1) 1
Not sure 45/307 (15) 3/3 (100) 42/304 (14) .003
Sexual partner had STIs within the past year
Yes 1/307 (0.3) 0/3 (0) 1/304 (0.3) 1
Not sure 57/307 (19) 3/3 (100) 54/304 (18) .006
Actual HIV risk
No to low risk 276 (77) 1 (25) 275 (78) .04
Moderate to high risk 80 (23) 3 (75) 77 (22)
Low HIV risk perception 36 (10) 2 (50) 34 (10) .05
Abbreviation: STI, sexually transmitted infection.
a
Data are in numbers (%) unless otherwise indicated.
b
Comparison between participants with HIV-positive and HIV-negative test results.

Table 4. Characteristics of the 356 Participants Undergoing HIV Universal Voluntary Counseling and Testing Categorized by their HIV Risk
Perception.a

Low risk perception Correct risk perception

Characteristics All (N ¼ 356) (N ¼ 36) (N ¼ 320) Pb

Hours of the program participation .76

Office hours (8 AM-4 PM) 189 (53) 20 (56) 169 (53)
Nonoffice hours (4 PM-8 PM) 167 (47) 16 (44) 151 (47)
Sex .004
Male 186 (52) 27 (75) 159 (50)
Female 170 (48) 9 (25) 161 (50)
Age in years, median (range) 34 (15-68) 27 (17-61) 35 (15-68) .03
Occupation .14
Company worker 136 (38) 15 (43) 121 (38)
Government officer 61 (17) 4 (11) 57 (18)
Student 52 (15) 6 (17) 46 (14)
Merchant 46 (13) 5 (14) 41 (13)
Housewife 33 (9) 1 (3) 32 (10)
Monk 16 (5) 1 (3) 15 (5)
Farmer 2 (1) 1 (3) 1 (0.3)
Retired 1 (0.3) 0 (0) 1 (0.3)
Unemployed 9 (3) 3 (8) 6 (2)
Marital status .27
Single 148 (42) 20 (56) 128 (40)
Married 145 (41) 13 (36) 132 (41)
Living with domestic partner 36 (10) 1 (3) 35 (11)
Divorced 19 (5) 2 (6) 17 (5)
Widowed 8 (2) 0 (0) 8 (3)
Highest education .14
Primary school or less 115 (32) 16 (44) 99 (31)
Secondary school 100 (28) 6 (17) 94 (29)
College or bachelor’s degree 126 (35) 14 (39) 112 (35)
More than bachelor’s degree 15 (4) 0 (0) 15 (5)
Religion .5
Buddhism 344 (97) 36 (100) 308 (96)
Christian 7 (2) 0 (0) 7 (2)
Islam 5 (1) 0 (0) 5 (2)
Monthly household income in US$, median (range) 667 (83-16,667) 667 (200-6,667) 667 (83-16,667) 1
Willing to be tested for HIV 1
Self-willing 254 (71) 29 (81) 225 (70)
Being advised by other 102 (29) 7 (19) 95 (30)
Prior HIV test 118 (33) 7 (19) 111 (35) .2
Ever had sexual intercourse 307 (86) 36 (100) 271 (85) .008
(continued)

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8 Journal of the International Association of Providers of AIDS Care

Table 4. (continued)

Low risk perception Correct risk perception

Characteristics All (N ¼ 356) (N ¼ 36) (N ¼ 320) Pb

Sexual orientation .004

Heterosexual 344 (97) 31 (86) 313 (98)
Homosexual 9 (2) 3 (8) 6 (2)
Bisexual 3 (1) 2 (6) 1 (0.3)
Number of different sexual partner within 30 days (median, range) 1 (0-5) 1 (0-5) 1 (0-4) .86
Number of new sexual partner within 30 days (median, range) 0 (0-5) 0 (0-5) 0 (0-4) .32
Having vaginal sex 299 (84) 32 (89) 267 (83) .48
Using condom with vaginal sex consistently 40/299 (13) 3/32 (9) 37/267 (14) .59
Having anal sex 44 (12) 5 (14) 39 (12) .77
Using condom with anal sex consistently 2/44 (5) 1/5 (20) 1/39 (3) .22
Having oral sex 78 (22) 10 (28) 68 (21) .37
Using condom with oral sex consistently 7/78 (9) 0/10 (0) 7/68 (10) .59
Ever injected drug with needle 1 (0.3) 1 (3) 0 (0) .1
Ever had tattoo or piercing 85 (24) 8 (22) 77 (24) .81
Ever exchanged sex for money or drugs 0 (0) 0 (0) 0 (0) 1
Having STIs within the past year
Yes 9 (3) 4 (11) 5 (2) .008
Not sure 30 (8) 17 (47) 13 (4) <.001
Sexual partner injected drug with needle within the past 30 days
Yes 0/307 (0) 0 (0) 0/271 (0) 1
Not sure 44/307 (14) 25 (69) 19/271 (7) <.001
Sexual partner exchanged sex for money or drugs within the past 30 days
Yes 3/307 (1) 0 (0) 3/271 (1) 1
Not sure 45/307 (15) 25 (69) 20/271 (7) <.001
Sexual partner had STIs within the past year
Yes 1/307 (0.3) 0 (0) 1/271 (0.3) 1
Not sure 57/307 (19) 29 (81) 28/271 (10) <.001
Actual HIV risk <.001
No to low risk 276 (77) 0 (0) 276 (86)
Moderate to high risk 80 (23) 36 (100) 44 (14)
Abbreviation: STI, sexually transmitted infection.
a
Data are in numbers (%) unless otherwise indicated.
b
Comparison between participants with low and correct HIV risk perception.

or none of the participants declined HIV-UVCT because of
being afraid of pain or of needles in this study and previous
studies.20,25 This suggests that blood-based tests remain feasi-
ble and acceptable in most settings especially when standard,
non-blood-based and painless tests are not available.
In high-risk population, HIV-UVCT acceptance was
reported to be associated with injection drug use, not having
steady partner, currently having STIs, and history of STIs,
while in the low-risk general outpatient setting, younger age
and low education were significantly associated with HIV-
UVCT acceptance.25,26 Our study results revealed that living
with domestic partner with no marriage and low education
were independent factors associated with HIV-UVCT accep-
tance. These may reflect the participants’ uncertainty about
behaviors and HIV status of their unmarried partners. However,
the reason why less-educated participants were more likely to
accept HIV-UVCT than were well-educated participants was
unclear and requires further studies.
Our findings indicated that being homosexual men was
independently associated with HIV positivity. This corre-
sponds with the reported high incidence of HIV infection in this
population in Thailand.7,27 In our program, assessment of risk
perception was performed during the pretest counseling.
Although only 10% of the participants in this study had low
HIV risk perception, which was significantly less than those
in a high-risk population (84%),8 the group that risk perception
should be assessed was moderate or high-risk men. These par-
ticipants should be informed about their actual risks and edu-
cated on behavior modification and HIV prevention during
the HIV-UVCT. In a GP clinic setting, persons at risk for low
HIV risk perception may be identified through a self-
assessment questionnaire that can be completed while they are
waiting to see a doctor in the clinic. A screening nurse in the
clinic can use the questionnaire to guide further educational
interventions for each individual which are provided by avail-
able health care workers in the clinic or an HIV care team of the
hospital. Studies are needed to determine a campaign that can
effectively establish correct awareness of HIV risk and to cre-
ate skills for self-assessment of HIV risk in the community.
There were limitations in this study. First, risks and risk
behaviors of participants declining HIV-UVCT were not col-
lected in this study and might be different from the accepting

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Khawcharoenporn et al
participants. Second, the results may have limited generaliz-
ability, given that our study population consisted of primarily
heterosexuals with low to moderate income in Thailand.
Finally, the face-to-face interview with the HIV counselors
might impact the disclosure of HIV risks and risk behaviors
of the participants. However, this limitation was minimized
because the pretest counseling was done in a private room and
the HIV counselors were well trained in conversations to make
the participants trust them and open up to tell the truth. In addi-
tion, the counselors expressed their willingness to educate and
support the participants.
In conclusion, implementation of HIV-UVCT as a part of
HIV transmission prevention program in our GP clinic was fea-
sible with high acceptance rate. The strategies used in this
study were able to identify a number of new HIV-infected indi-
viduals among the generally low-risk population. Reasons for
and characteristics associated with accepting or declining
HIV-UVCT should be considered to improve the HIV-UVCT
program. Opening an HIV testing facility during nonoffice
hours and using the knowledge-based education strategy could
potentially attract more individuals accepting HIV testing and
shorten the time spent on the process, respectively. HIV risks
and risk behavior assessment and emphasis on consistent con-
dom use are important and should be incorporated into the
HIV-UCVT program. Health care system strengthening and
policies to make rapid HIV testing and/or point-of-care CD4
testing available along with educational interventions in both
health care and community settings are needed to increase
access to HIV testing and successful linkage to care and treat-
ment. Given the advantages of early HIV diagnosis, future
research is needed to determine appropriate strategies to
implement HIV-UVCT in emergency departments, private
physician offices, and settings outside health care facilities,
such as entertainment venues, colleges, government offices,
company offices, and factories in HIV-endemic resource-
limited countries.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This study
was supported by the Pathumthani Province Public Health Office,
Pathumthani, Thailand.
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