Determinants of Behavior Change Intention Among Heterosexual Thai Males Diagnosed with Sexually Transmitted Diseases

Abstract

This study sought to identify factors associated with intention to change sexual practices among heterosexual Thai males diagnosed with sexually transmitted infections (STIs). STI clinic patients (n = 247) reported their sexual behaviors and condom use during the previous 3 months. STI and HIV knowledge, motivation to change sexual practices, and behavioral skills were assessed. Then, self-reported behavior change intention, including consistent condom use, reducing number of sexual partners, not using drugs and alcohol when having sex, and refusal of condomless sex, was examined. Consistent condom use in the past 3 months by Thai males diagnosed with STIs was low across all types of sexual partners (lover 17.2%, casual partner 24%, and sex worker 71.4%). Risk reduction self-efficacy (p < 0.001), perceived benefits from condom use (p < 0.001), perceived barriers to condom use (p < 0.001), perceived risk for HIV (p < 0.05), and STI and HIV knowledge (p < 0.05) were significantly correlated with behavior change intention. Significant predictors of behavior change intention were risk reduction self-efficacy (p < 0.001), perceived benefits of condom use (p = 0.016), and perceived risk for HIV (p = 0.033). They explained 36% of behavior change intention variance. Intervention aimed at enhancing motivation and behavioral skills to adopt preventive behaviors should be developed to prevent recurrent STIs, including HIV infection, among heterosexual Thai males diagnosed with STIs.

Introduction

Globally, it is estimated that annually there are 357 million new cases of the following four sexually transmitted infections (STIs) among people aged 15–49 years: Chlamydia trachomatis (131 million), gonorrhea (78 million), syphilis (6 million), and Trichomonas vaginalis (142 million).¹ The prevalence of these STIs varies by region and gender. These epidemics have a deep impact on the health and lives of children, adolescents, and adults worldwide. STIs impose a substantial strain on the budgets of both households and national health systems in middle- and low-income countries, including Thailand, and have an adverse effect on the overall well-being of individuals.¹

During the past 10 years, the rate of STIs among Thais has been increasing. The national morbidity rate of STIs from all 77 provinces of Thailand in 2005, 2010, and 2014 was 24.78, 40.87, and 54.76 per 100,000 population.² Gonorrhea and syphilis were the most common. In 2015, the national morbidity rate for gonorrhea and syphilis was 13.14 and 5.06 per 100,000 population.³ The prevalence of STIs appears relatively high among Thai adolescents and young adults. The proportions of cases by age group for gonorrhea and syphilis were 15–24 years (57.89% and 33.25%), 25–34 years (19.95% and 26.88%), and 35 years and older (9.10% and 14.87%).³ The incidence of STIs disproportionately affected Thai males with the ratio of 1:0.21 for gonorrhea and 1:0.46 for syphilis.³ From the empirical data, it is sound to conclude that Thai males experience STIs more frequently than women. This low- and middle-income context (LMIC) high-risk group is not only susceptible to recurrent STIs but also at greater risk for HIV infection because of increased biological susceptibility caused by tissue injury as a result of STIs.^4,5 As evident, the mode of HIV transmission in Thailand is mainly through condomless sexual intercourse (84%).⁶

Sexual behaviors associated with recurrent STIs among adolescents and adults included condomless sex, nonmonogamy, and rapid partner turnover.⁷ They are at elevated risk for recurrent STIs, including HIV infection, if they continue to practice the same sexual behaviors. Therefore, to prevent the recurrence of STIs and HIV infection and transmission to partners, heterosexual Thai males diagnosed with STIs must change their sexual practices. To change sexual practices, it is necessary to examine behavior change intention and its predictors because intention is the most proximate predictor of behavior.⁸ Finally, effective safer sex intervention specifically addressing predictors of behavioral change intention can be developed for this LMIC population.

As evident, adolescents who have had STIs are at higher risk for recurrent STIs.^7,9 About half of adolescents younger than 15 years develop a second infection with Chlamydia trachomatis 1–6 years after initial Chlamydial infection.¹⁰ Inconsistent condom use during casual sex among Thai males puts them at greater risk for recurrent STIs, including HIV infection. At Bangrak hospital, a special hospital exclusively providing care for STI patients, the rate of HIV infection among males has increased from 1.11% in 2010 to 4.2% in 2014.¹¹ The most effective prevention strategies against HIV and other STIs is male latex condoms when used consistently with lubricant and pre-exposure prophylaxis.^12
–14

As recommended by the Centers for Disease Control and Prevention STD Treatment Guidelines, when used consistently and correctly, male latex condoms are effective in preventing sexual transmission of HIV and STIs by decreasing lower genital tract infections.^13,14 In addition, consistent and correct use of latex condoms also reduces the risk for genital herpes, syphilis, and chancroid when the infected area is covered.¹⁴ To fight against HIV after the outbreak of HIV infection among female sex workers and their clients in 1989, the Thai government launched a 100% condom use program nationwide.^15,16 Since condom use was initially linked to commercial sex in Thailand and sexual activity of Thai men has mostly shifted from sex workers to steady partners, this change may bring about a low rate of condom use.^17
–19 In Thailand, condoms can be easily accessed from healthcare facilities and from convenience stores. As found by a national behavioral surveillance survey conducted in 16,164 vocational students, only 27.1% of male students reported consistent condom use in the past year with their steady partners, and 67% reported using condoms at last coitus.¹⁹

A lower rate of condom use is found among female students, only 19.3% reported that their steady partners used condoms consistently in the past year and 59.3% during last coitus.¹⁹ A higher rate of condom use is reported among transgender individuals (TGs), 52.3% of them identified themselves as inconsistent condom users (not always).²⁰ Among men who have sex with men (MSM), 62.9% of them reported consistent condom use with their partners.²¹

One theoretical model that has widely been used to predict STI/HIV risk behavior is the Information–Motivation–Behavioral Skills (IMB) model of HIV preventive behavior. The IMB model states that HIV prevention information, motivation, and behavioral skills are the fundamental determinants of HIV preventive behavior.²² This model has been extensively tested in various populations from different cultures, including Thais, over 20 years.^18,23 HIV prevention information contains facts about how HIV is transmitted and prevented and HIV prevention heuristics. Motivation refers to the inner efforts to change sexual behaviors. Motivational constructs have been operationalized in multiple dimensions, including beliefs, attitudes, perceptions, moods, feelings, and drive states related to specific actions.²⁴ In a high-risk population, multiple markers of motivation have been used in predicting their STI/HIV sexual behavior change.²⁵ The behavioral skills component is defined as the level of confidence individuals have in their ability to perform HIV-preventive behaviors. To our knowledge, no theory-based study has examined behavioral change intention, including consistent condom use, reducing number of sexual partners, not using drugs and alcohol when having sex, and refusal of condomless sex among heterosexual Thai males diagnosed with STIs. Since male condoms are a male-controlled prevention strategy and there can be inequitable gender norms that reduce women's power to enforce male condom use, effective interventions targeted at LMIC heterosexual Thai males must be developed. The aims of this study were to (1) examine relationships between empirically optimal markers derived from the IMB model and behavioral change intention, and (2) to identify predictors of behavioral change intention among heterosexual Thai adolescents and adults diagnosed with STIs.

Methods

Participants and setting

This study was conducted among heterosexual Thai adolescents and adults attending General Male Clinic at Bangrak hospital, STIs Cluster, Department of Disease Control, Ministry of Public Health during the period from November 2015 to April 2016. The study was approved by the Research Ethics Review Committee for Research Involving Human Research Participants, Health Science Group, Chulalongkorn University (COA. No. 214/2015). At the registration desk, a screening form was used by trained health personnel. Only those who identified themselves as heterosexual (having sex with women only) were eligible for the General Male Clinic. Other sexual orientations (TG, MSM, MSW, Bisexual) received services from a Male Health Clinic. A convenience sampling was applied to recruit potential subjects. Of 682 patients screened, 378 were eligible, 268 enrolled (70.8%), and 247 had completed data. They were recruited if (1) they were diagnosed with gonorrhea, syphilis, or nongonococcal urethritis for the first time, (2) did not know their HIV status, and (3) were not allergic to latex condoms.

Multiple regression power analysis was conducted to determine a sample size using PASS 11 (Power Analysis and Sample Size). To detect an effect size (R) of 0.3 attributed to six independent variables using an F-test with a significance level of 0.05, a sample size of 183 is required to achieve 90% power.

Following verbal consent, participants completed a set of questionnaires, which included demographic data, sexual activities in the past 3 months, and a set of questionnaires on information, motivation, behavioral skills, and intention to change behavior in the next 3 months.

Measures

Sexual behaviors

Participants were asked the following: “In the past 3 months, who did you have sexual intercourse with?” The answers were lover/steady partner, casual partner, sex worker, and woman who paid you money. The number of each type of sexual partner was then determined. Participants were classified as “Having multiple sex partners” if having sexual partners >1. The frequency of using condoms with each type of sexual partner was then asked with 4-point-rating scale ranging from every time to never.

Information

STI and HIV knowledge

A 14-item knowledge scale was adapted.¹⁷ The original scale has 28 items, 18 for HIV and 10 for STIs. In this study, only 14 items were selected, 10 for HIV and 4 for STIs. Of these 14 items, 3 measuring HIV and 3 measuring STIs were modified according to the experts’ recommendations. Examples of the HIV knowledge items were as follows: “People can get HIV by having condomless sex with someone,” “HIV attacks the body's immune system so that it cannot fight off infections,” and “Persons who have STIs are at greater chance for HIV infection.” Response options were yes, no, or don't know which was coded as incorrect. The total score was computed by summing the scores for two areas of knowledge, providing a sum ranging from 0 to 14. Higher scores indicated higher knowledge of STIs and HIV. Its content validity index (CVI) was evaluated by three experts who have experience in HIV and STIs (one obstetrician and two nursing professors). It was found to be 0.93 with KR-20 = 0.86.

Motivation

Four measures were used to assess motivation to change sexual behavior.

Perceived risk

Perceived risk for HIV was assessed by asking the following: “Based on your sexual practices over the past 3 months, how much do you think you have been at risk for being infected with HIV?” Response options ranged from 1 (No Risk at All) to 4 (Great Deal at Risk).²⁵

Self-rated motivation

Current motivation to practice safer sex behaviors was assessed using a single item: “How would you describe your motivation to become safer?” Response options ranged from 1 (Not at All Strong) to 4 (Extremely Strong).²⁵ Single-item measures may yield low reliability but face validity is high.

Benefits from condom use

Perceived benefits from condom use were measured with 12 items adapted from previous study.¹⁷ The original version contained 24 items, only 12 items necessary for assessing the benefits of using condoms were selected according to the recommendations of the content experts. This questionnaire included statement such as “A benefit to using male condoms is that they reduce the risk of getting STIs.” Response options ranged from 1 (Strongly Disagree) to 4 (Strongly Agree). The total score ranged from 12 to 60 with higher scores indicating higher perceived benefits from condom use. Its CVI by three experts was 1.00 with α = 0.89.

Barriers to condom use

Perceived barriers to condom use were assessed with a 10-item tool adapted from a previous study.¹⁷ The original version had 15 items. Ten items that assessed the barriers to using condoms were selected according to the recommendations of the content experts. The scale contained statements such as “A bad part of condoms is that they reduce sensation.” Each item was scored on a 4-point Likert-type scale ranging from 1 (Strongly Disagree) to 4 (Strongly Agree). The composite scores ranged from 10 to 40 with higher scores indicating greater perceived barriers. Its CVI by three experts was 0.90 with α = 0.88.

Behavioral skills

Risk reduction self-efficacy

Self-efficacy for engaging in safer sex behaviors was assessed by a 10-item measure adapted from previous study.²⁵ The original version had 12 items and 7 items related to heterosexual situations were selected. Three items asking about multiple sexual partners, drug and alcohol use, and condom slippage and breakage were added to the scale. The scale asked questions such as “How confident are you that you would be sure you had condoms with you?” and “How confident are you that you could reduce the number of sexual partners?” A 4-point Likert-type scale ranging from 1 (Very Unsure) to 4 (Very Sure) was used. The total score ranged from 10 to 40 with higher scores indicating higher self-efficacy in performing risk reduction behaviors. Its CVI by three experts was 0.90 with α = 0.90.

Prevention behaviors

Behavior change intention

Intention to change sexual practices and adopt preventive behaviors was assessed by a 10-item scale.²⁵ It asked the likelihood that participants would engage in specific safer sex activities such as keeping condoms nearby, using condoms consistently, reducing the number of sexual partners, not using drugs and alcohol when having sex, and refusal of condomless sex over the next 3 months. Responses were made on a 4-point Likert-type measure ranging from 1 (Very Unlikely) to 4 (Very Likely). The total score ranged from 10 to 40 with higher scores representing greater intentions. Its CVI by three experts was 1.00 with α = 0.91.

Data analyses

Data were analyzed using SPSS v17.0 (Statistical Package for the Social Sciences, Chicago, IL). Exploratory data analysis was conducted to appraise data accuracy. Mean, standard deviation, and percentage were calculated to describe sociodemographic data and sexual behaviors.

Bivariate correlations were examined using Pearson product-moment correlation. Stepwise multiple regression was then performed to identify significant predictors of behavior change intention. Higher order effect and interactions among independent variables were assessed; none was significantly associated with behavior change intention. As p-values were two tailed, p < 0.05 was considered statistically significant.

Results

Sample characteristics

Participant characteristics and sexual behaviors are displayed in Table 1. The mean age of heterosexual Thai males was 35 years with an age range of 13–59 years. Most of them were single (52.6%). They were mostly laborers (42.5%) who finished secondary school (30%). Regarding their sexual behaviors, almost all reported having vaginal sex, only 0.3% indicated that they had both vaginal and anal sex. A quarter of them identified themselves as having multiple sexual partners. Different types of partners were related to frequency of condom use. Almost half of heterosexual Thai males (41.9%) admitted that they never used condoms with their lovers/steady partners. The rate of noncondom users was lower among heterosexual Thai males when having sex with casual partners (24%). Since sex workers may be perceived as more likely to be infected with STIs, including HIV, consistent condom use with this type of partner by Thai males was quite high (71.4%). Consistent with the national report, the majority of the participants in this study were diagnosed with gonorrhea (85.8%).

Table 1.

Sociodemographic Data, Sexual Behaviors, and Diagnosis of Participants (N = 247)

Variables	n (%)
Age
Mean ± SD	35.18 ± 11.9
Minimum, maximum	13–59
Marital status
Married	90 (36.4)
Single	130 (52.6)
Divorced/widowed	27 (11.0)
Occupation
Student	30 (12.1)
Laborer	83 (33.7)
Government officer	41 (16.6)
Employee	66 (26.7)
Other	27 (10.9)
Education level
Primary school	22 (8.9)
Secondary school	105 (42.5)
Vocational school	46 (18.6)
Bachelor degree and above	74 (30.0)
Income (Baht/month)
<5000	24 (9.7)
5001–10,000	56 (22.7)
10,001–15,000	56 (22.7)
15,001–20,000	39 (15.8)
20,001–25,000	32 (12.9)
>25,000	40 (16.2)
Multiple sex partners
Yes	63 (25.5)
No	184 (74.5)
Condom use with lover/steady partner (n = 186)
Always	32 (17.2)
Most of the time	32 (17.2)
Sometimes	44 (23.7)
Never	78 (41.9)
Condom use with casual partner (n = 125)
Always	30 (24.0)
Most of the time	33 (26.4)
Sometimes	32 (25.6)
Never	30 (24.0)
Condom use with commercial sex workers (n = 42)
Always	30 (71.4)
Most of the time	6 (14.3)
Sometimes	0 (0.0)
Never	6 (14.3)
Diagnosis
Gonorrhea	212 (85.8)
Syphilis	14 (5.7)
Nongonococcal urethritis	21 (8.5)

Bivariate analysis

In bivariate analysis, five independent variables were statistically significantly associated with behavior change intention, including risk reduction self-efficacy, perceived benefits from condom use, perceived barriers to condom use, perceived risk for HIV, and STI and HIV knowledge (Table 1). Only self-rated motivation was not related to behavior change intention. However, a bivariate relationship does not always portray the actual association between two variables in a multivariate model. Based on theoretical consideration, self-rated motivation was entered in a stepwise multiple regression model.

Predictors of behavior change intention

Independent variables derived from the IMB model were all entered into the regression model. Multivariate outliers of all predictors were examined. Some cases demonstrated high values of studentized deleted residuals, Mahalanobis distance, and leverage statistic. Nevertheless, no df-batas were greater than the critical value of |(df-batas)|>2. In addition, none of these outliers was considered as influential cases on regression coefficients (range of D_i = 0–0.05). A conditioning index of >30 and at least two variance proportions were bigger than 0.50 for a given root number indicated multicollinearity; none was found in this study. A histogram and a Q-Q plot demonstrated that the residuals of regression analysis were normally distributed.

To determine the best-fitting model, the F-test was used, which indicated the statistical significance of the overall model. The final model of behavior change intention consisted of risk reduction self-efficacy, perceived benefits of condom use, and perceived risk for HIV (Table 3). The full predictive model explained 36% (adjusted R ² = 0.36) of the variance in changing sexual behaviors and adopting preventive behaviors. Based on beta weight (β) of each predictor in the final model, risk reduction self-efficacy was the strongest predictor of behavior change intention (β = 0.47) followed by perceived benefits from using condoms (β = 0.19) and perceived risk for HIV (β = 0.15). Prediction equation for behavior change intention among Thai males can be obtained as follows: \documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} \begin{align*}{\rm {Behavior \ change \ intention}} \ = \ & 11.56 + 0.41 \{\rm Self-efficacy} \\ & {+ \ 0.17 \ {\rm Benefits }} \\ & {+ \ 0.66} \ {\rm Risk} + \varepsilon \end{align*} \end{document}

As indicated in the final model, heterosexual Thai males diagnosed with STIs were more likely to change their sexual behaviors and adopt preventive behaviors if they felt confident in their ability to do so, believed in the benefits of using condoms, and perceived that they were at greater risk for HIV.

Discussion

Sexual practices related to recurrent STIs among heterosexual Thai males found in this study included condomless sex especially with lovers/steady partners; 41.9% of them indicated that they never used condoms with this type of partner. Nonmonogamy and rapid partner turn over were other sexual practices found in this study; a quarter of participants reported that during the past 3 months they had multiple partners. Interestingly, 74.5% of these Thai males, even though they claimed that they were monogamous, were infected with STIs. This could indicate that their female sexual partners had multiple partners. A low rate of condom use, especially with their lovers/steady partners, may, in part, be due to the fact that condom use had historically been linked to intercourse with sex workers.¹⁶ In addition, many Thai people use condoms for the purpose of pregnancy prevention rather than to prevent STIs/HIV. Among this population, since their lovers/steady partners used other types of contraceptive methods, condom use was not necessary in this situation. The low rate of condom use was consistent with previous studies reported in Thailand.^17
–19

Significant predictors of behavior change intention were risk reduction self-efficacy, perceived benefits from using condoms, and perceived risk for HIV. These findings partially support the IMB model. They offer limited support for the IBM model as a framework for predicting risk over time in a high-risk population. As proposed in the IMB model of HIV preventive behavior, an individual must be well-informed, motivated, and possess the necessary self-efficacy behavioral skills to initiate AIDS preventive behaviors.²² AIDS prevention information and motivation affect AIDS preventive behaviors through behavioral skills, while information and motivation exert a direct effect. Similar to other empirical tests of the IMB model, this study found that neither STI and HIV knowledge was significantly predictive of intention to change risky behaviors (β = 0.07) nor was it related to risk reduction self-efficacy (r = 0.07). However, their STI and HIV knowledge was moderately high (Mean = 11.31 ± 2.71: range 0–14). A high level of correct STI and HIV knowledge is yet to be linked to safer sex behaviors.^25,26AIDS-related information was only associated with other IMB constructs (perceived benefits from and barriers to condom use), not with behavior change intention. This finding together with the results from other studies on the high-risk population for HIV/AIDS has drawn the same conclusion which suggests that information is an important but insufficient precursor to AIDS preventive behavior.^27
–29

Motivation is essential to adopting behavior change strategies.²⁵ Four markers of motivation (perceived benefits from condom use, perceived barriers to condom use, self-rated motivation, and perceived risk for HIV) were used to predict STI/HIV behavior change intention among heterosexual Thai males. In a high-risk population, multiple markers of motivation have been used in predicting their STI/HIV behavior change.²⁵ Using multiple measures allows researchers to identify more specific motivational factors than a simple face valid measure. Based on the Health Belief Model, perceived risk for a disease, perceived benefits from taking action, and perceived barriers to taking action are critical motivational factors.³⁰ In bivariate analysis, only self-rated motivation was not significantly related to behavior change intention (Table 2). In multivariate analysis, perceived benefits from condom use and perceived risk were significant predictors of behavior change intention (Table 3). STI Thai males who believed in the benefits of using condoms and perceived greater risk for HIV were more likely to change their sexual practices and adopt preventive behaviors. The findings were consistent with other studies.^25,27 However, perceived barriers to condom use failed to be significantly predictive of behavior change intention. In addition, their perception on barriers to condom use found in this study was fairly low (Mean = 21.65 ± 4.79: range, 10–40). This may possibly be due to a nationwide campaign on condom use promotion through mass media by the Ministry of Public Health during the past decade. Exposure to such a campaign might influence Thai males to have positive feelings toward condom use.¹⁷ Nevertheless, a perception of fewer barriers did not inspire them to change their sexual practices and adopt safer sex behaviors. Another index of motivation derived from the IBM model that failed to predict behavior change intention was self-rated motivation. It was captured by a single item asking “How would you describe your motivation to become safer?” Using a single item is not likely to capture the complexity of this construct even though face validity is strong.²⁵ Interestingly, its mean score was 3.58 (±0.83) with a range of 1–4 indicating that most of the subjects in this study were motivated to practice safer sex. A high level of motivation to adopt safer sex might have been a function of the recent diagnosis of gonorrhea, syphilis, or nongonococcal urethritis for the first time. Regardless of the level of their intention to change sexual behaviors, they had greater conscious awareness of their own motivation to change behaviors. The finding is in contrast to other studies.²⁵ Further research is needed to examine more comprehensive models of behavior change intention among heterosexual Thai males currently diagnosed with an STI.

Table 2.

Correlation Matrix of Factor Related to Behavior Change Intention (N = 247)

	1	2	3	4	5	6	7
1. Risk reduction self-efficacy	1.00
2. Benefits from condom use	0.50^‡	1.00
3. Barriers to condom use	−0.27^†	−0.20^†	1.00
4. Perceived risk	−0.05	0.12	−0.14	1.00
5. STI and HIV knowledge	0.07	0.24^†	−0.16^*	0.08	1.00
6. Self-rated motivation	0.13	0.07	−0.12	0.09	−0.01	1.00
7. Behavior change intention	0.56^‡	0.45^‡	−0.30^‡	0.15^*	0.16^*	0.09	1.00

p < 0.05.

†

p < 0.01.

‡

p < 0.001.

STIs, sexually transmitted infections.

Table 3.

Stepwise Multiple Linear Regression Analysis of Behavior Change Intention (N = 247)

Variables	B	SE	β	t	p
Constant	11.56	2.71		4.27	0.000
Risk reduction self-efficacy	0.41	0.07	0.47	6.04	0.000
Benefits from condom use	0.17	0.71	0.19	2.43	0.016
Perceived risk for HIV	0.66	0.31	0.15	2.16	0.033
R ²	0.37
Adjusted R ²	0.36
F value	27.55				0.000

Risk reduction self-efficacy was used to capture the IMB construct of behavioral skills. It was the strongest predictor of behavior change intention (β = 0.47). Heterosexual Thai males who felt confident in their ability to perform HIV-preventive behaviors had greater intention to change their sexual behaviors and adopt preventive behaviors. The finding supported the behavioral skills construct of IMB model and was consistent with other studies.^{17,25

–29}

In this study, there were some limitations. First, because of using a convenience sample, the results of the study may have limited generalizability to Thai adolescents and adults. Second, this study asked future action in changing sexual behaviors and adopting preventive behaviors; subjects could only speculate as to what their sexual behavior would be in the future. A longitudinal approach is suggested so that actual action in changing sexual behaviors and practicing preventive behaviors could be captured. Third, it relied on self-reported measures of sensitive behaviors, perhaps limiting its reliability.

In conclusion, heterosexual Thai males diagnosed with STIs practiced unsafe sex behaviors, including inconsistent condom use and having multiple sex partners. They ought to change their sexual behaviors to prevent recurrent STIs and HIV infection. This theory-based study provided important information regarding significant determinants of behavior change intention among a Thai high-risk population. Its modifiable predictors consisted of risk reduction self-efficacy, perceived benefits from using condoms, and perceived risk for HIV. Based on empirical data, behavioral intervention aimed at enhancing motivation and behavioral skills to promote safer sex behaviors should be developed. The motivation to change sexual practices by raising the perception of their own risk for HIV as well as the benefits of condom use must be incorporated in such an intervention. In addition, strategies to enhance their confidence in their ability to perform HIV-preventive behaviors should be emphasized. As suggested by the CDC (2015), the prevention and control of STIs are based on five strategies.¹³ The developed intervention will fit under the strategy of accurate risk assessment and education and counseling of persons at risk on ways to avoid STIs through changes in sexual behaviors and use of recommended prevention services. Integrated combination of biomedical, behavioral, and structural interventions is suggested for STI prevention.³¹ The intervention should then be a combination prevention strategies. As recommended by the CDC (2015), another strategy is pre-exposure vaccination of persons at risk for vaccine-preventable STIs.¹³ For heterosexual Thai males, hepatitis B vaccination is recommended for all unvaccinated, uninfected persons being evaluated for STIs. However, the persons have to pay their own and the cost is quite high resulting in a low uptake rate. Pre- and postexposure prophylaxis for HIV is not recommended for Thai patients yet. Regarding male circumcision, it reduces the risk for HIV and some STIs in heterosexual men.²⁸ In Thailand, it is performed for those who have indications and diagnosed by urologists.

Footnotes

Acknowledgments

This study was funded by the Ratchadapisek Somphot Endowment Fund of Chulalongkorn University (RES560530228-HR).

Author Disclosure Statement

No competing financial interests exist.

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