Science and community in the response to HIV, STIs and co-infections in Asia and the Pacific: Panel Discussion on PrEP & STIs Prioritization of expanding the free access to testing and treatment of HIV, STI, Hep C and other coinfections 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 www.iasociety.org
Access: to what services (testing, treatment or prevention or all)? If resource is not a problem, it is costeffective 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 www.iasociety.org
Community participation in each step of Reach- Recruit-Test-Treat-Prevent-Retain cascade KEY POPULATION-LED HEALTH SERVICES COMMUNITY-BASED HEALTH SERVICES COMMUNITY OUTREACH AND RECRUITMENT COMMUNITY OUTREACH REACH Online or offline, to provide HIV education, promotional materials, condoms, lubricant, needles and syringes REACH RECRUIT Refer to HIV testing service, with referral letters, coupons, tickets and/or clinic registration support REACH RECRUIT TEST By 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 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, needsbased, demand-driven, and client-centered. 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. 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 Source: FrontLines, March/April 2016, Dressed to Test: Empowered Communities Take HIV Services to the Streets
Key Population-Led Test & Treat and PrEP services CHIANG MAI CAREMAT/MPLUS Type of clients: MSM and TG CHONBURI (PATTAYA) SISTERS Type of clients: TG/TG sex workers SWING Type of clients: MSWs BANGKOK RSAT Type of clients: MSM and TG 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 CBOs HOSPITALS CBOs HOSPITALS
Early diagnosis and early initiation of ART can be achieved through KPLHS model Median CD4 count 366 cells/mm 3 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 Successfully engage at-risk individuals with high incidence of HIV PrEP TARGETS 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)
Key Population-Led Same-Day PrEP Services Risk assessment and PrEP counseling process HIV testing Start ART immediately Behavioral questionnaire Willing to take PrEP Not willing to take PrEP Routine appointment (at least 6-monthly HIV testing) More details on PrEP CrCL <60 ml/min Provide a bottle of PrEP to start Discontinue PrEP Continue PrEP Referral to renal doctor, consider re-screening for PrEP, and at least 6-monthly HIV testing Blood collection for creatinine and HBV antigen testing CrCl >60 ml/min Month 1, month 3 and quarterly follow up
Thailand s PrEP programs Jul 2011 HPTN 052 96% prevention efficacy with immediate ART Oct 2014 National Guidelines recommended ART regardless of CD4 count and PrEP Mar 2016 PrEP at SCC Jan 2016 @Trop Med Princess PrEP (KPLHS model) Oct 2018 Free PrEP for high-risk MSM/TG Nov 2010 iprex showed 44% prevention efficacy among MSM with daily TDF/FTC Dec 2012 The 1 st Test & Treat project in MSM and TGW in 4 provinces Dec 2014 May 2015 PrEP-30 at Community-Led TRCARC and Facility- Based Test & Treat projects, along with PrEP substudy in MSM and TGW Jan 2016 PrEP@Piman Jan 2017 PrEP2Start
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 3500 3000 Cumulative number of PrEP users PrEP2Start 2500 2000 1500 Princess PrEP 1000 500 PrEP-30 0 Dec 2014 Jun 2015 Dec 2015 Jun 2016 Dec 2016 Jun 2017 PrEP-30 PrEP substudy Princess PrEP PrEP@Piman PrEP at SCC@TropMed Pulse Clinic MOPH PrEP2Start
Key Population-Led Health Services (KPLHS)