Asia is large and diverse. HIV/AIDS: Regional and Thailand. The Asian HIV Epidemic. Praphan Phanuphak, M.D., Ph.D.

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1 Asia is large and diverse HIV/AIDS: Regional and Thailand Scenario Praphan Phanuphak, M.D., Ph.D. The Thai Red Cross AIDS Research Centre ASAP-sponsored SBW: ICAAP-11; Nov. 21, 2013 A continent with largest population Diverse geography (South, South-East, East and Central Asia), culture, religion & believes (Buddhism, Hindu, Muslim, Christian, Zen, etc.) Extremely diverse with regard to wealth (low, low-middle, high-middle & high income), infrastructure, HIV prevalence & HIV risk groups, competing national priorities & political commitment Level of wealth does not always reflect a better political commitment or better access to care & treatment The Asian HIV Epidemic Started around , 3-5 years after the Western world Mostly brought in by foreigners or by returned citizens traveling or living abroad or by imported blood products Thus, it was easy in the early day to blame foreigners, forgetting that it could be a domestic problem, an unfortunate lag time for prevention has been wasted. Interestingly, after more than 2 decades of epidemic in Asia, the epidemic in most Asian countries still remains concentrated in risk groups (MSM, IDU, FSW). This is the main barrier for the wider public and political response. Adults and children estimated to be living with HIV 2012 North America [ million] Caribbean [ ] Latin America 1.5 million [1.2 million 1.9 million] Western & Central Europe [ ] Middle East& North Africa [ ] Sub-Saharan Africa 25.0 million [23.5 million 26.6 million] Eastern Europe & Central Asia [1.0 million 1.7 million] East Asia [ million] South & South-East Asia 3.9 million [2.9 million 5.2 million] Oceania [ ] Total: 35.3 million[32.2 million 38.8 million]

2 Regional HIV / AIDS statistics 2012 Sub-Saharan Africa Middle East and North Africa South and South-East Asia East Asia Latin America Caribbean Eastern Europe and Central Asia Western and Central Europe North America Oceania TOTAL Adults and children living with HIV 25.0 million [23.5 million 26.6 million] [ ] 3.9 million [2.9 million 5.2 million] [ million] 1.5 million [1.2 million 1.9 million] [ ] [1.0 million 1.7 million] [ ] [ million] [ ] 35.3 million [ M] Adults and children newly infected with HIV 1.6 million [1.4 million 1.8 million] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] 2100 [ ] 2.3 million [ M] Adult prevalence (15 49) [] 4.7 [ ] 0.1 [ ] 0.3 [ ] <0.1 [< ] 0.4 [ ] 1.0 [ ] 0.7 [ ] 0.2 [ ] 0.5 [ ] 0.2 [ ] 0.8 [ ] Adult & child deaths due to AIDS 1.2 million [1.1 million ] [ ] [ ] [ ] [ ] [ ] [ ] 7600 [ ] [ ] 1200 [< ] 1.6 million [ M] Country HIV prevalence in Asia adult prevalence Number of HIV-infected Thailand ,000 Cambodia ,900 Myanmar ,000 Vietnam ,000 India ,270,000 China ,000 UNGASS Report HIV prevalence among Asian MSM Country (City) HIV prevalence Year Cambodia China Hong Kong Indonesia (Jakarta) Lao PDR Myanmar Philippines (Manila) 0 (N=500) 2006 Singapore Taiwan (Taipei) Thailand (Bangkok) Vietnam Source: van Griensven F et al, Curr Opinion HIV/AIDS 2009; 4: Increasing proportion of new HIV infections from MSM over time The Asian Epidemic Model Projections for HIV/AIDS in Thailand:

3 Transition from risk groups to general population: A lesson from Thailand First Thai patient with AIDS diagnosis returned home from USA in late 1984 and died the same year Thailand first 2 de novocases of AIDS were diagnosed in February 1985 at Chulalongkorn Hospital using clinical, OKT4, OKT4/OKT8 ratio and T cell mitogen (PHA) stimulation : homo/bisexual 1988: Intravenous drug users (IDU) 1989: Female sex workers (FSW) 1990: Clients of FSW (males with STD) 1991: Pregnant women and newborns, i.e., general population From concentrated epidemic to generalized epidemic once the epidemic reaches FSW. HIV Prevention in Asia: What is needed Non-complacency of political leaders in prevention Controversies need to be settled e.g., condom distribution in school, needle exchange, homophobia, etc. Scaling up and normalizing HIV testing More ART coverage: treatment as prevention Higher coverage of PMTCT especially option B or B+ Adequate resources for HIV prevention, not what remains after treatment & care Prevention for marginalized and illegal populations HIV-associated stigma & discrimination needs to be removed HIV testing delivery site: Thai Red Cross Anonymous Clinic During , among 19,525 TRC-AC clients 73 had CD4 count (91 within 1 month, median 3 days) HIV prevalence: overall 13 women 13 MSM 29 Het men 8 Phanuphak N, et al. JAIDS 2011;56: Passive VCT not very successful. Strategies to increase HCT uptake National policy for active VCT with public communication & measures to stop all mandatory testing HIV testing delivery site Hospital-based, clinic-based: convenient, user friendly Mobile clinic, community-based & community-led, home-based HIV counseling and testing techniques Free of charge with same-day (one-hour) test results Individual pre-test counseling and negative post-test counseling be replaced by pre-test information or group counseling Signed informed consent be replaced by verbal consent Task shifting (counselor, lab technician) Ancillary services to attract target population and normalize HIV testing STI, Pap smear (anal & cervical), PICT Link and universal access to treatment and care including CD4

4 HIV testing policy at TRC-ARC AIM: Normalize HIV testing Increase the uptake of HIV testing among risk groups and general population Provider-initiated counseling & testing (PICT) Mobile VCT in colleges, saunas Social media: Earlier HIV testing (to prevent spreading) by routine (repeat) testing for those negative Earlier linkage to care (to prevent morbidity) Effective referral to CD4 & ART services Bangkok MSM Test & Treat pilot study The PICT approach of the Thai Red Cross Anonymous Clinic Family planning services Health check up packages Cervical & anal Pap smear HIV Counseling & Testing Special events campaign & outreach activities STD screening & treatment Nutrition services Using Anal Pap and STI service as entry point for HIV testing for MSM Among 1,429 MSM clients in known HIV+ve, 35 known HIV-ve, &13 never tested Previous HIV status STI MSM clients Anal Pap MSM clients HIV-ve Unknown HIV-ve Unknown Acceptance of HIV testing tested +ve for HIV Active VCT using Mobile Health Clinic to reach MSM for early HIV testing MSM-targeted services in saunas and other venues Body muscle and fat mass measurement with brief advice on exercise tips Rapid HIV testing and rapid syphilis testing 178 tested 30 HIV+ (18, 2 acutes), 15 syphilis cases (9) A new mobile clinic to reach MSM in the entertainment venues will be supported by ITRC Using Anal Pap smear as entry point for HIV testing Acute HIV cases 2/178 = 1.1 from mobile clinic 58/38,000 = 0.2 from stand-alone VCT clinics Ms. Wasana Sathienthammawit and Mr. Charnwit Pakam Men s Health Clinic counselor Photos used with permission

5 Adam s Love website TRC MSM Test & Treat feasibility study Recruitment and informed consent process Refuse Sign consent form HIV testing HIV-ve MSM HIV+ve MSM Informed consent process for immediate ART Accept immediate ART or Eligible for ART Standard VCT and ART Semi-annual plus selfschedule HIV testing Refuse immediate ART and not yet eligible for ART Start ART Follow-up every 6 months Evaluate adherence, retention, safety, CD4, HIV-RNA (and partner s HIV status if enrolled) Evaluate retention, CD4, HIVRNA (and partner s HIV status if enrolled) Assess return rate for HIV testing which may be more or less than self-scheduled 17 HIV treatment & care in Asia: Challenges Number of new HIV infections in Thailand Implementing the new WHO Treatment Guidelines How to get patients diagnosed early such as PICT? Cost of earlier treatment & coverage Treat more people with CD4 <350 or to cover people with CD4 <500? Laboratory monitoring (VL, resistance) Coverage of 2nd and 3rd line ART Manpower shortage: Task shifting Short-term care: STD, reproductive health needs Long-term care: HIV and age-related metabolic complications, chronic diseases & malignancies More dependent on national budget Adherence and lost to follow-up Test every one and treat every one (Test & Treat) Baseline scenario VCT 90 in KAPs and treat at any CD4 Source: Wiwat Peerapatphokin: National Consultation on Strategic Use of ARVs, 9-10 August 2012 Research Centre for Health Economics and Evaluation (ReCHEE)

6 of new 30 infections Thailand Getting to Zero of New Infections Focus where of new infections occur Mode of Transmission Casual and Extramarital sex Spousal transmission Injection Drug User Sex worker and clients 43,040 new infections ( ) Male who had sex with male of new infections occur in BKK 65 of new infections projected to occur in 31 provinces Treatment as Prevention Thailand adopts new national policy to test and treat HIV September 27, 2013: Thailand National AIDS Committee finally approved Ending AIDS Strategies as proposed by MOPH. In this 3-year national plan, treatment as prevention and PrEPare among the action steps with plan to start ART at CD4<500 in 2014, Treat all in 2015, and PrEPdemonstration projects in The plan was approved by the Cabinet on October 15, 2013 with allocation of more budget to NHSO. November 1, 2013: The adult treatment guideline committee approved starting ART at any CD4 level. Thailand is the 3 rd country in the world that approves the Test & Treat policy after USA and France! $$Why wealthy Asian countries are not so committed in HIV / AIDS? $$ Low HIV prevalence in their own countries Afraid of non-popular acceptance by their voters if large amount of budget is spent on HIV prevention due to stigma related to sex, condom and drug abuse Non-profitable investment in R&D for HIV prevention (e.g., vaccine) & care (e.g., ARV) Do not believe that economic breakdown in other countries as a result of HIV/AIDS will affect their own economy Refer their responsibility to USA and other Western countries who are harder hit by the epidemic Lack of regional concerted effort and political push Conclusion Asia has the potential to have devastating generalized HIV epidemic like that in Sub-Saharan Africa due to its large population and the presence of all high risk behaviors. Political commitment is essential to reverse the epidemic or to prevent the transformation from concentrated to generalized epidemic. Commitment has to come with their own national resources of which can be enhanced by regional and international collaborations.

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