www.iasociety.org Prioritization of expanding the free access to testing and treatment of HIV, STI, Hep C and other co- infections for MSM and other Key Populations, and the role of the community-based health service providers in such expansion (nothing about PrEP) Key words : Access, KP, Community involvement Praphan Phanuphak, MD, PhD The Thai Red Cross AIDS Research Centre Bangkok, Thailand, 17 November 2017 Science and community in the response to HIV, STIs and co-infections in Asia and the Pacific: Panel Discussion on PrEP & STIs
Transcript
www.iasociety.org
Prioritization of expanding the free access to testing and treatment of HIV, STI, Hep C and other co-
infections for MSM and other Key Populations, and the role of the community-based health service providers in such expansion (nothing about PrEP)
Key words: Access, KP, Community involvement
Praphan Phanuphak, MD, PhD
The Thai Red Cross AIDS Research Centre
Bangkok, Thailand, 17 November 2017
Science and community in the response to HIV,
STIs and co-infections in Asia and the Pacific: Panel Discussion on PrEP & STIs
www.iasociety.org
Access: to what services (testing,
treatment or prevention or all)?
• If resource is not a problem, it is cost-effective to have access to both treatment and prevention (PrEP) once you invest in testing.
• If resource is limited, one would invest in treatment, especially in early Rx which also needs early testing.
• Country has to prioritize.
• Certainly, if theses services are free, you will have more access.
www.iasociety.org
Access to which population?
(General population or KP)
• Access to all population is ideal since KP is included.
• Access to all (general population) will minimize stigma and discrimination but it may not be cost-effective as compared to targeting at KPs.
• Message has to address general population but money and effort have to go to KPs.
www.iasociety.org
How to meet the demand?
• Conventional health sector alone will not be able to meet the demand of the scaling up HIV services due to the limited manpower, service time and ability to reach the key populations.
• KP community organizations can help.
• It extends beyond community-based health services into community-led health services, called KP-led health services (KPLHS) based on the guiding principle of need-based and demand-driven
Community participation in each step of Reach-
Recruit-Test-Treat-Prevent-Retain cascade
REACH
RECRUITRefer to HIV testing service, with referral letters, coupons, tickets and/or clinic registration support
REACHOnline or offline, to provide HIV education, promotional materials, condoms, lubricant, needles and syringes
REACH
RECRUIT
TESTBy health care professional team in a mobile clinic setting, along with referral to TREAT and PREVENT, may work with health care professional team to RETAIN
REACH
RECRUIT
TEST by KP lay providers
TREAT ART dispensing according to Differentiated Service Delivery model
PREVENT by PrEP/PEP
RETAIN in TEST, TREAT and PREVENT services
KEY POPULATION-LED HEALTH SERVICES
COMMUNITY-BASED HEALTH SERVICES
COMMUNITY OUTREACH AND RECRUITMENT
COMMUNITY OUTREACH
Dusita Meekrua prepares to conduct a finger-prick test at the SWING drop-in center in Bangkok. “Every time I provide counseling service, I feel like I’m helping someone in my own family,” she says.
Source: FrontLines, March/April 2016, Dressed to Test: Empowered Communities Take HIV Services to the Streets
Key Populations-Led Health Services (KPLHS)
• “KP Community leadership”: services necessary for addressing the HIV epidemic and related health issues are identified by the community itself and are, therefore, needs-based, demand-driven, and client-centered.
• KP-CLHS is not just a service set up by CBOs but a true partnership between CBOs and government/public health facilities.
• Community health workers have their capacity intensively built and strengthened within a short period of time to provide “certain” health services with high quality.
• Counseling, finger-prick blood and oral fluid collection, test and report HIV test results, STI sampling, point-of-care CD4, TB screening
• PrEP and PEP
Key Population-Led Test & Treat and PrEP services
CHIANG MAI
CAREMAT/MPLUS
Type of clients: MSM and TG
BANGKOK
RSAT
Type of clients: MSM and TG
SWING
Type of clients: MSWs
CHONBURI (PATTAYA)
SISTERS
Type of clients: TG/TG sex workers
SWING
Type of clients: MSWs
SONGKHLA (HAT YAI)
RSAT
Type of clients: MSM and TG
KPLHS significantly contributes to national HIV
testing figures among MSM and TGW• More than 7,000 HIV testing and 600 PrEP services are provided to MSM and
TG in Thailand by community health workers in 2016
HOSPITALS
CBOs
CBOs
HOSPITALS
Early diagnosis and early initiation of ART
can be achieved through KPLHS model
• Median CD4 count 366 cells/mm3 at diagnosis
• Median (IQR) time from HIV diagnosis to ART initiation = 15 (8-22) days
• Need close collaboration and mutual trust between CBO testing sites and
referral ART hospitals
Source: TRC Community-Led Test and Treat Study among Thai MSM and TG (Mar 2017)
High risk individuals with high seroconversion
rate can be identified through KPLHS model
Thailand National AIDS Strategy to End AIDS by 2030 (launched in 2016)- Increase domestic funding to CBOs- Community-Led Health Services to be integrated as part of national health service system
Source: TRC Community-Led Test and Treat Study among Thai MSM and TG (Mar 2017)
Successfully engageat-risk individuals withhigh incidence of HIV
PrEP TARGETS
Key Population-Led Same-Day PrEP Services
Behavioral questionnaire
HIV testing
Willing to take PrEP
Not willing to take PrEP
Blood collection for creatinine and HBV
antigen testing
Start ART immediately
Routine appointment
(at least 6-monthly HIV testing)
Risk assessment and PrEP counseling
process
More details on PrEP
Referral to renal doctor, consider re-screening for
PrEP, and at least 6-monthly HIV testing
CrCl >60 mL/min
Continue PrEP
Discontinue PrEP
CrCL <60 mL/min
Month 1, month 3 and quarterly follow
up
Provide a bottle of PrEP to start
Jul 2011HPTN 052
96% prevention efficacy with
immediate ART
Dec 2012 The 1st Test &
Treat project in MSM and TGW in
4 provinces
Oct 2014 National Guidelines recommended ART regardless of CD4 count and PrEP
Nov 2010iPrEX showed
44% prevention efficacy among MSM with daily
TDF/FTC
Dec 2014 PrEP-30 at
TRCARC
May 2015 Community-Led
and Facility-Based Test &
Treat projects, along with PrEP
substudy in MSM and TGW
Jan 2016 Princess PrEP(KPLHS model)
Jan 2016PrEP@Piman
Mar 2016PrEP at SCC@Trop Med
Jan 2017PrEP2Start
Thailand’s PrEP programs
Oct 2018 Free PrEP for
high-risk MSM/TG
Princess PrEP program: Key Population-Led PrEP Service Delivery Model
• Started in January 2016 aiming at providing
PrEP to 1,000 individuals at high risk for HIV
per year, through KPLHS
• More than 1/3 of PrEP users in Thailand have accessed PrEP through the Princess PrEP program
Thailand’s PrEP programs
0
500
1000
1500
2000
2500
3000
3500
Dec 2014 Jun 2015 Dec 2015 Jun 2016 Dec 2016 Jun 2017
