Psychosocial factors, such as depression, are associated with an increased risk of HIV acquisition in Thailand and other settings (Guadamuz et al., 2014; Sun et al., 2020), particularly among youth (Coker et al., 2010; van Griensven et al., 2004). Homophobia, stigma, and discrimination negatively impact psychosocial health among gay and bisexual men (Centers for Disease Control and Prevention [CDC], 2016). The burden of depression is considerably higher in men who have sex with men (MSM).

One study in Thailand and Brazil reported that depressive symptoms were common in both MSM (40%) and transgender women (TGW) who have sex with men (51%) (Poteat et al., 2020). Another study reported that higher numbers of psychosocial health conditions were associated with a history of forced sex, social isolation, suicidal thoughts or actions, “club” drug (i.e., ecstasy, ketamine, methamphetamine, and Gamma-hydroxybutyrate) use, alcohol intoxication, and selling sex among MSM and TGW in Bangkok, Thailand (Guadamuz et al., 2014). A study of adolescents in northern Thailand reported that a significantly higher proportion of males identifying as homosexual or bisexual had signs of depression compared to heterosexual males, (MSM: 30.8%; heterosexual: 13.6%; p < 0.001) (van Griensven et al., 2004). Additionally, TGW experience depression at higher rates than the general population (Hoffman, 2014). Among sexual minority adolescent males, depression and other psychosocial issues are associated with engaging in risk-taking behaviours, such as having sex without a condom, which increases the likelihood of acquiring HIV (Liu et al., 2020; Perry et al., 2019). A study among persons with diagnosed HIV infection in South Africa found that depression is a significant barrier to ART initiation (Truong et al., 2021) and another study found mental health screening around the time of HIV testing may improve linkage to care (Truong et al., 2021).

Characterizing the psychosocial health of youth at risk for HIV is important for providing tailored support for optimal HIV prevention to this population (Miltz et al., 2019). However, only a limited number of studies have been conducted in Southeast Asia. To assess the importance of integrating mental health screening and services with HIV prevention, we evaluated behavioural and psychosocial factors, including depressive symptoms, among young MSM and TGW screened for a cohort study in Thailand.

Adolescents and young men aged 15–29 years who were male sex at birth and identified as male, female, or questioning their sexual identity, were a resident of Bangkok or neighbouring provinces (Pathum Thani, Nonthaburi, Samut Prakarn, and Nakhon Pathom) or Nakhon Sawan province, and reported sexual interest in or having had oral or anal sex with another man during the past six months were invited to the study at three sites in Thailand: Silom Community Clinic (SCC, a non-governmental setting with a provider-client service delivery model) and Bangrak Hospital (BH) in Bangkok (a governmental setting with a provider-client service delivery model); and Rainbow Clinic (RC, a governmental setting with peer-driven community outreach) in Nakhon Sawan which is, approximately 243 km north of Bangkok.

A two-step enrollment process was performed during August 2017–July 2018. In the first step, interested persons who provided informed consent answered demographic, and behavioural questions about the preceding 3 months including questions about having experienced depression using computer-assisted self-interview (CASI). They underwent rapid HIV antibody testing (Alere Determine^™, Abbott, Inc., Japan). HIV-reactive test results were confirmed by two alternative rapid HIV antibody tests (SD-Bioline^™, Standard Diagnostics, Inc., Korea, and One Step Anti-HIV (1&2) ^™, InTec Product Inc., P.R. China), in accordance with Thai national HIV testing algorithm. If all three rapid tests were reactive, the person was provided with these results and given post-test counselling, and if HIV-positive, the person was actively linked to HIV care and treatment according to Thai national guidelines. If the rapid tests were inconclusive, an HIV nucleic acid amplification test (NAAT) was performed on a second sample taken after the initial blood draw on the same day to test for acute HIV.

In the second step, HIV-negative persons were invited to participate in a 12-month longitudinal Young MSM cohort study (YMSM study) (Figure 1), which included regular clinical visits at three-month intervals. SCC offered daily oral HIV pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate/emtricitabine to all cohort participants at its site; BH and RC (supported by the Ministry of Public Health) did not offer PrEP since this was not standard of care at these clinical sites during the study period. Cohort participants underwent a physical examination at baseline. Every 3 months, they completed a CASI to collect psychosocial and behavioural data, and were tested for HIV. In addition, participants initiating PrEP completed a CASI to collect data on PrEP use during the prior seven days and one month.

We defined adolescents as persons aged <18 years. The presence of depressive symptoms was defined as responding “Yes” to both of the following questions: “Have you ever felt very sad, very depressed, excessively tired, or excessively stressed in the past one month?”; and “Does this affect your daily life?” Bullying was defined as reporting feeling one or more of the following: neglected; ignored; or bullied, disrespected, or looked down on in any school, healthcare, family, or community setting.

Acceptance of gender identity and sexual orientation was defined as responding “Yes” to the following questions: “Do you have at least one member in your family who knows and accepts who you are as [your gender identity (male/TGW/Not sure)] and [sexually attractive to (man/woman/TGW/Not sure)]?” All questions were reviewed and approved by representatives of the young Thai MSM and TGW community. PrEP adherence among participants in the longitudinal cohort who took PrEP was defined as a self-report of taking at least four doses of daily oral PrEP during the preceding seven days and skipping <5 days of daily oral PrEP during the preceding one month.

More than one-tenth of youth at risk of HIV who screened for a longitudinal cohort study in Bangkok and Nakhon Sawan province had depressive symptoms and about one out of twenty had HIV. During the follow-up period, no HIV acquisition was found at the site able to offer PrEP.

The HIV prevalence in our cohort is consistent with the HIV prevalence of 9.1% (95% CI: 5.8, 12.5) detected in sentinel surveillance of Bangkok MSM and TGW aged 15–22 years in 2018 (van Griensven et al., 2022). The study design allowed us to assess not only baseline HIV prevalence among screened youth, but also the incidence of HIV in adolescent and young adult cohort participants. HIV incidence among the cohort participants who did not have access to PrEP services was high. In a previous study that enrolled MSM and TGW who sell sex aged 18–26 years in Bangkok and Pattaya, Thailand, HIV incidence among participants not on PrEP was 3.4 per 100 person-years (95% CI: 1.6, 6.3) (Weir et al., 2023).

A substantial proportion (12.6%) of adolescent and young MSM and TGW being screened for inclusion in the cohort reported depressive symptoms. The assessment of associations between depressive symptoms and various sociodemographic, clinical, and other factors found multifactorial associations. These associated factors included attending a private school. Notably, most of the participants with depressive symptoms attended a private school, of whom the majority were not living with family. Depressive symptoms may be related to social isolation (i.e., being away from family and community) rather than the type (private vs public) of educational facility. This explanation is supported by other studies, such as a study among Brazilian adolescents that found that a distant relationship with parents and feelings of loneliness were associated with mental health challenges (Escobar et al., 2020) and depression (Stickley et al., 2016).

In our analysis, the association between depressive symptoms and having a partner with HIV may be related to the anxiety and stress associated with risk-taking behaviour. A study conducted among MSM with and without HIV in England (Miltz et al., 2021) found a high prevalence (13.3%) of depressive symptoms among MSM without HIV who reported having sex without a condom. In our results, the majority (69%) of screened persons with depressive symptoms had a sexual partner living with HIV or whose HIV status was unknown and reported at least one episode of anal sex without a condom in the past 3 months (90.9%).

Among the persons screened, those who learned about the study from friends were also less likely to have depressive symptoms, suggesting that supportive friendships are important for psychosocial health in these youth. Although most study participants reported at screening that they had at least one friend accepting of their gender identity and sexual orientation, we did not assess peer connectedness and depressive symptoms. Especially among teenagers (aged 10–19 years), adolescent friendships are important in the development of sexual behaviour and gender identity (Kornienko et al., 2016). The Youth Risk Behavior Survey, United States, 2021 demonstrated that adolescents who relied on their peers for support had positive health outcomes, including reductions in emotional distress, symptoms of poor mental health, and suicidal ideation. Lack of friends and school support were associated with self-report of poor mental health among students who identified as heterosexual, bisexual, or who questioned their gender, but not among students who identified as lesbian or gay (Wilkins et al., 2023).

Our results found that almost one-fifth (16.9%) of the screened persons had been bullied, comparable to the 10.0% (95% CI: 5.5, 14.5) reported from the Thailand national survey in 2013 (Sirirassamee & Sirirassamee, 2015) and a history of being bullied was associated with depressive symptoms. The findings are consistent with reports that bullied adolescents are about twice as likely to have depression as non-bullied adolescents (Ttofi et al., 2016). Furthermore, the survey among high school students in the U.S. found that sexual identity was significantly associated with experiencing bullying, particularly among sexual minority youth (Clayton et al., 2023). Considering the gender identity of the screened persons in the current analysis, bullying may contribute to the occurrence of depressive symptoms. Our analysis found that adolescents and young TGW were particularly vulnerable to bullying. Approximately one-third of the TGW reported experiencing some kind of bullying in the past year, almost three times higher than what screened MSM reported (29.4% and 13.5%, respectively).

We observed that depression is notably prevalent in this population and our findings are consistent with existing literature. This finding is particularly significant given that depression has been linked to an increased risk for HIV among this population. Although our analysis does not directly assess whole-person care (Van Heerden et al., 2023), and client-centred counselling for depression evaluation and management, there is potential merit in these models and integrating a simple depression screening tool such as Patient Health Questionnaire (PHQ-2), which would assist with determining whether a referral for standardized in-depth depression assessment and care with local mental health professionals would be necessary.

Fifteen per cent of the adolescents screened were not aware of the Thai Ministry of Public Health’s recommendation for adolescents to access HIV/STI services without parental permission. That lack of knowledge of this opportunity may have led to a delay in the initiation of HIV testing in at least one participant. This finding emphasizes the importance of ensuring that all youth at risk of HIV are aware of, and follow guidance on, HIV testing and know their rights to access HIV testing, prevention and treatment services.

The reduced HIV incidence among participants enrolled in the longitudinal cohort at the single site offering HIV PrEP access highlights the prevention potential of PrEP, even among groups that may have lower adherence, such as adolescents and young adults. The findings of this study support the importance of HIV prevention services for young and adolescent populations, including HIV testing and PrEP (Thailand-MoPH, 2021).

Our findings are subject to several limitations. The definition of depressive symptoms was not based on standardized mental health tools such as the Thai version Patient Health Questionnaire (PHQ-9) (Lotrakul et al., 2008). However, the use of CASI to collect sensitive information (sexual behaviour, drug use and symptoms of depression) with an easy short questionnaire may increase the sensitivity and validity of the data collected (van Griensven et al., 2001). The YMSM study was not intended to assess depressive symptoms specifically and we could not evaluate any association of depressive symptoms with incident HIV due to the length of the follow-up period in the study. The study population was not representative of all young men who have sex with men and TGW receiving HIV prevention services in Thailand, however, they were geographically diverse and were drawn from a variety of governmental and non-governmental settings with peer-driven community outreach and a provider-client service delivery model. The high rate of loss to follow-up among persons enrolled in the longitudinal cohort at the rural Nakhon Sawan site outside of Bangkok, may create bias in our calculation of HIV incidence. Accessible HIV services that include PrEP may help improve follow-up and service utilization for youth in rural areas such as Nakhon Sawan in the future.

The results of this study highlight the importance of integrating mental health screening and mental health services with HIV testing and prevention for youth at risk of HIV. To ensure good health and well-being, routine evaluations for depression in different clinical and non-clinical settings could help identify vulnerable youth, and create supportive environments with a whole-person care model for HIV prevention and ensure linkage to care.