What was the problem?
In September 2015, WHO recommended, “…oral pre-exposure prophylaxis as an additional prevention choice for people at substantial risk of HIV infection as part of combination HIV prevention approaches.” WHO defines substantial risk of HIV infection as incidence of HIV infection, in the absence of PrEP, that is >3% HIV incidence. Offering PrEP at such incidence could potentially make it a cost-saving or cost-effective intervention. In Thailand, the estimated national HIV prevalence among men who have sex with men (MSM) and TGW transgender women (TGW) is at 19% and 14%, respectively. As part of efforts to scale up HIV testing services (HTS) and prevention interventions, coupled with proactive referrals to nationally-supported antiretroviral treatment (ART), pre-exposure prophylaxis (PrEP) for HIV prevention was formally made available in late 2015, but there were no data on acceptability to guide targeting and roll-out. Since PrEP is a relatively new prevention intervention to PEPFAR countries, PEPFAR partners will need technical assistance with scaling best practices with fidelity and ensuring that implementation addresses the diversity of target populations in different settings.
What is the solution?
Two PrEP pilot studies have been successfully implemented in Thailand: the Centers for Disease Control and Prevention (CDC) Key Population Implementation Study (KPIS) and another conducted by U.S. Agency for International Development (USAID) LINKAGES. The CDC-supported study implemented a Test, Treat, and Prevent HIV Program at five hospitals in four provinces to increase HIV testing, help those who test positive begin ART, and increase access to PrEP. The primary objective for the PrEP component of the pilot was to determine if HIV-uninfected men who have sex with men (MSM) and transgender women (TGW) would choose to take PrEP. The team documented factors associated with PrEP acceptance, including: attitudes towards PrEP, PrEP knowledge, and type of treatment venue (facility or community based). This KPIS study included a respondent-driven sampling-based peer-driven recruitment intervention (PDI) to enroll Thai MSM and transgender women who reported anal intercourse without using a condom in the previous six months. HIV-positive patients were systematically offered ART, while HIV-negative patients were offered PrEP.
The USAID/LINKAGES program supported the availability of PrEP through a community-based network of nine KP-led community health centers in four provinces, an MSM-owned and operated private clinic, and a well-known and long-established HIV testing center operated by the Thai Red Cross. Through a unique collaboration arranged by the Thai Red Cross, free PrEP was made available at LINKAGES-supported sites through support from Her Royal Highness Soamsawali, a member of the Thai Royal Family, and is known as the “Princess PrEP” Program. PrEP was advertised through outreach workers, community events, MSM mobile-phone based applications, and websites frequented by MSM and TGW in Thailand. Furthermore, in order to understand characteristics of uptake during this initial period of PrEP introduction, a cohort of users was established as part of a multi-year KPIS Test and Start Study.
What was the impact?
Of the 1,880 people enrolled in the KPIS, 531 tested HIV-negative; of these, 167 (31%) started PrEP, with those reporting sex with an HIV-infected partner (p=0.003), receptive anal intercourse (p=0.02), or receiving PrEP information from a hospital (p<0.0001) being more likely to start PrEP than those without these behaviors or characteristics. While the CDC KPIS PrEP pilot successfully initiated one-third of the eligible participants onto PrEP, there were differences across the different sites that need to be further explored. The LINKAGES sub-study reported that 37% of their participants initiated PrEP.
PrEP use in Thailand increased from only a few individuals in June 2015 to almost 3,500 in June 2017, with a majority of that scale-up occurring in the past year. The graph below illustrates the increase of PrEP use at a number of sites. The Pulse Clinic, Princess PrEP, and PrEP-30 account for the highest numbers.
The PEPFAR Asia Regional Team, which supports programs in Thailand, reported initiating 1,877 new clients on PrEP in fiscal year 2017, greatly exceeding the annual target. The majority of PrEP users are males, with 76% aged 25-49; 15% aged 20-24; and 2% aged 15-19.
These strong results, coupled with PEPFAR country team success in achievement towards programmatic targets, support the scale up of offering PrEP as part of a combination prevention package of services for MSM and TWG. Community-led PrEP services can extend PrEP access and empower MSM and TGW to use PrEP as part of a comprehensive HIV prevention package. PrEP may be a viable prevention strategy among MSM and TGW especially for those who do not perceive themselves to be at risk but who actually are; thus, the need for improved marketing, education, and behavior risk screening.
How does it work?
For the KPIS study, PrEP was offered at two of the five hospitals in the study. Despite limited marketing of the KPIS study, 1,880 people met eligibility criteria and chose to enroll in the study between April 2015 through October 2016 (1,967 people were assessed for enrollment, 95.6% enrolled in the study). This KPIS study included a respondent-driven, sampling-based, and peer-driven recruitment intervention (PDI) to enroll Thai MSM and TGW who reported anal intercourse without using a condom in the previous six months. HIV-positive patients were systematically offered ART, while HIV-negative patients were offered PrEP. An analysis to compare those who were recruited through the PDI vs “walk-in on their own” needs to be conducted. In addition, demand creation to increase marketing of PrEP as a prevention strategy could possibly improve uptake. The key elements of success for the KPIS study were:
- offering PrEP systematically, analyzing early versus late versus non-PrEP adopters;
- optional models for enrollment (PDI and walk-in); and
- demand creation, which needs to be increased.
For the USAID LINKAGES sub-study, the PEPFAR Asia Regional Program examined characteristics of HIV-negative participants in four community-based organizations (CBOs) in Bangkok and Pattaya, and two hospitals in Bangkok and Pathumthani. Participants in the Test and Treat implementation science study were offered enrollment into a PrEP sub-study. Approximately two thirds of MSM and TGW accessing HIV services in the CBOs and one third in the hospital setttings decided to use PrEP when offered. Key elements of success from the LINKAGES study were:
- availability of both free and low-cost PrEP (approximately $1 per day);
- social media-based information about PrEP, as well as users’ experiences;
- high-level political support from a respected leader; and
- well-established networks of CBOs that informed clients about PrEP and provided eligible clients with PrEP in a timely way.
These studies demonstrated that PrEP is an appropriate prevention strategy for MSM and TGW and that can be implemented in both community- and facility-based settings. Individuals recruited from the peer-driven modality, as well as those who “walked-in” for HIV-testing were receptive to learning about PrEP with a significant number initiating PrEP. Offering PrEP in diverse settings with KP friendly staff will increase the number of MSM and TGW that get tested and receive prevention messages and possibly initiate PrEP, or if HIV-infected get started on treatment.
Findings highlight the need for education through demand creation and marketing, if uptake is to be successful. Creating KP-friendly sites will increase the number of hard to reach MSM and TGW through PDI but also by word of mouth in KP communities; thus, walk-in clients may increase as well as those referred directly through the PDI model. Importantly, PrEP as a prevention intervention lends attention to the full HIV cascade and not only treatment for the infected.
Scaling Up PrEP Implementation
Lessons learned from KPIS on providing PrEP at facility-based sites are being used to inform the scale-up of access to PrEP in nine clinics at pilot PrEP2Start sites across seven provinces, with financial support from the Thai Government and technical assistance from the PEPFAR Asia Regional Program. PrEP scale up is targeting MSM and TGW in priority provinces, which have the largest estimated numbers of PLHIV, largest on estimated numbers of MSM and TGW, and largest combined numbers of KPs in Thailand. Further, access to free PrEP at community sites has been made possible by a generous donation from Her Royal Highness Princess Soamsavali, and some higher income MSM who are willing to pay for low-cost PrEP in a tailored, private-clinic setting. The following factors that contributed to the success of the PrEP innovations
- Inclusion of relevant partners: The PEPFAR Asia Regional Team organized a Technical Steering Committee that provided a forum to ensure collaboration, coordination, and communication between the PEPFAR team; the Royal Thai Government; Thai Red Cross (TRC); civil society organizations, and other development partners in the conduct and evaluation of protocol defined activities. The committee was highly engaged and met quarterly, both of which were critical for programmatic success. The PEPFAR team and Technical Steering Committee, developed and implemented the KPIS studies. This collaboration was pivotal in the success of the community- and facility-based PrEP projects. Close monitoring showed that PrEP was a viable prevention intervention for MSM and TGW. This close collaboration and engagement with key stakeholders and implementing partners will need to continue for PrEP to be scaled up in a cost-effective manner.
- Attention to challenges for target populations: MSM and TGW face significant levels of stigma and discriminations. Thus, it was critical for staff to be well-trained and for the clinical setting which included both community and facility sites to be KP-friendly.
- Access to KPs: Inclusion of members of the MSM and TGW communities who can foster trusting relationships through the PDI model increased the number of KP individuals who accessed resources.
- Demand creation/market/education: Time and resources invested in informing the target population of MSM and TGW about PrEP contributed to those who chose to initiate PrEP.
As with all new innovations, adequate resources must be devoted to dissemination of information. That is, marketing and demand creation must occur if “buyers” are to invest in purchasing a new product. The number of new individuals on PrEP progressively increased, quarter-by-quarter, throughout fiscal year 2017 as information disseminated through peers and site-level staff.
Promotion of the benefits of early HIV testing and treatment was provided through the “Buddy Station” web portal, community events, and the “Test BKK” campaign. The “Buddy Station” website served as a hub for uploading demand creation materials and other educational materials, including information on early Test and Treat and PrEP. The site’s main objective was to promote HIV testing and provide HIV edutainment. Activities were conducted to promote the website, including promotional events at areas where MSM congregate in Bangkok and press visits. From April-October 2014, 22,000 users visited the website. The “Test BKK” campaign targets high-risk MSM who are typically not reached through traditional peer-outreach approaches through online sexual networks.
Systems to Incentivize HIV Case-Finding
Innovative efforts to incentivize case-finding and implement schemes to pay for specific contributions to HIV treatment cascade outcomes have been implemented through Population Services International (PSI) sub-partners. A partnership was formed with a magazine that is popular among MSM to disseminate key messages on the benefits of and locations to access HTS. This partnership included the use of gift vouchers from the private sector as complimentary rewards when readers accessed HTS services at community-based organizations. PSI has also deployed innovative approaches to conduct “virtual” outreach to MSM through applications like “Grindr” and “Line.” Efforts to incentivize pharmacists to support an HTS referral network are being explored.
Community and Civil Society Engagement
Success in PrEP implementation has been greatly impacted by engaging KPs and community stakeholders. The PEPFAR Asia Regional team has meaning engaged with communities and developed collaborative relationships with KP and civil society organizations (CSOs). They have utilized the Local Capacity Initiative to: improve technical and organizational capacity of consortium partners; provide effective, cost-efficient, and sustainable TA; and enhance, broaden, and expand local and regional civil society advocacy efforts.
Implementing Quality Standards
CDC has worked with Thai Red Cross MSM clinic and the ministry of public health (MOPH) to develop a set of assessments for MSM-friendly clinics. To ensure complementarity with the national program, the same assessment guideline was used for the four MSM clinics to which the CDC and MOPH provided technical assistance. Community-based providers have received training to meet quality standards with respect to HTS (particularly using finger-prick sample collection) at the site level. Additional advances in improving program quality are listed below.
- Investments in innovative information systems: One national confidential unique identifier code (UIC) scheme now exists, and it is now feasible to follow clients confidentially across a cascade using a combination of UIC (in communities) and national identification (in HTS and ART sites).
- Facilitating an enabling environment for service uptake: Trainings to minimize stigma and discrimination now exist for HIV providers. TRCARC has also been training healthcare providers to supply services that are more relevant to the specific health needs of MSM and TGW.
CDC KPIS Study Costing Analysis
A standard-method, ingredient-based cost analysis was applied to derive the total programmatic financial and unit cost. Retrospective data for 12 months was collected for PrEP analysis. The analysis assumed that the same facility staff would continue to provide services, and an equivalent cadre with the same pay scale as the project staff would take over the activities performed by the project staff. Key findings included:
- cost per person, per year (PPY) for PrEP is less than cost PPY for ART (it is 12% to 31% lower depending on the price of PrEP regimen used);
- overall, drugs were the key cost driver for PrEP (~83% of the cost);
- PDI drove down the cost of intervention;
- volume drives the cost per person reached; and
- pay scale of staff that performed the activities; here senior staff were engaged, whereas costs may be lower if lower grades or different cadres perform the services.
Recommendations for using PDI, task shifting to lower cadre of staff, and improving and expanding demand creation are all at varying degrees of adaptation and will all increase volume. A costing analysis for USAID LINKAGES study will be performed in FY2017 and 2018.