What was the problem?
In September 2015, the World Health Organization (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, in the absence of pre-exposure prophylaxis (PrEP), as an incidence of HIV infection that is >3%. Offering PrEP in regions with 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 transgender women (TGW) is 19% and 14%, respectively. As part of the efforts to scale-up HIV testing services (HTS) and prevention interventions, along with proactive referrals to antiretroviral treatment (ART), PrEP for HIV prevention was formally made available in late 2015. However, there were no data on the acceptability to guide targeting and roll-out. Since PrEP is a relatively new prevention intervention in PEPFAR countries, PEPFAR’s partners will need technical assistance to scale best practices with fidelity and to ensure that implementation addresses the diversity of target populations across varied settings.
What is the solution?
Two PrEP pilot studies were successfully implemented in Thailand. One of these studies was the U.S. Centers for Disease Control and Prevention (CDC) Key Population Implementation Study (KPIS) and another was conducted by the U.S. Agency for International Development (USAID) implementing partner, LINKAGES. The CDC-supported study implemented a “Test, Treat, and Prevent HIV Program” at five hospitals in four provinces to increase HIV testing, to help HIV- positive clients begin ART, and to increase access to PrEP among HIV-negative clients. The primary objective for the PrEP component of the pilot was to determine if HIV-negative men who have sex with men (MSM) and transgender women (TGW) would choose to take PrEP as a preventative measure. The team documented factors associated with PrEP acceptance, including: attitudes towards PrEP, PrEP knowledge, and the type of treatment venue (facility or community-based). Given the mobility of key populations, the KPIS study used a tailored methodology to enroll Thai MSM and TGW who reported anal intercourse without using a condom in the previous six months (this tailored approach included a respondent-driven, sampling-based, peer-driven recruitment intervention. HIV-positive patients were systematically offered ART, while HIV-negative patients were offered PrEP.
The USAID/LINKAGES program supported the availability of PrEP across a community-based network of nine KP-led community health centers in four provinces, a 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, which is known as the “Princess PrEP” Program. PrEP was advertised through outreach workers, community events, MSM mobile-phone based applications (apps), and websites frequented by MSM and TGW in Thailand. Furthermore, in order to understand characteristics of PrEP uptake during the initial period of introduction, a cohort of PrEP 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 original KPIS study, 531 tested HIV-negative. Of these 531, 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 KPIS PrEP pilot successfully initiated one-third of the eligible participants onto PrEP, there was variance across the different sites, which needs to be explored further. The LINKAGES sub-study reported that 37% of their participants initiated PrEP.
As shown in the above graph, 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 increase occurring within the past year. Also illustrated is the increase of PrEP use at a variety of sites. The Pulse Clinic, Princess PrEP, and PrEP-30 account for the highest number of users.
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. Demographically, the majority of PrEP users are male, 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 PrEP as part of a combination prevention package of services for MSM and TWG. Community-based PrEP services can extend access and empower MSM and TGW to use PrEP as a 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 is indicated.
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 from April 2015 to October 2016. HIV-positive patients were systematically offered ART, while HIV-negative patients were offered PrEP. An analysis to compare those who were recruited through the peer-driven recruitment intervention (PDI) vs “walk-in on their own” is still needed. In addition, a higher demand for PrEP’s increased marketing, as a prevention strategy, could possibly improve uptake. The key elements of success for the KPIS study were:
offering PrEP systematically and analyzing early vs. late vs. non-PrEP adopters;
multiple streams for enrollment (PDI and walk-in); and
demand creation for PrEP (which needs to increase further).
For the USAID LINKAGES sub-study, the PEPFAR Asia Regional Program examined characteristics of HIV-negative participants at four community-based organizations (CBOs) in Bangkok and Pattaya and at two hospitals in Bangkok and Pathumthani. Participants in the Test and Treat implementation 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 from the hospital settings accepted 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, and 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 manner.
These studies demonstrated that PrEP is an appropriate prevention strategy for MSM and TGW and that it 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, receive prevention messaging, and potentially initiate PrEP (or in the case of HIV-positive test results, 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 scope of reach through PDI, but also by word of mouth in KP communities. Increased community awareness may increase walk-in clients, in addition to those referred directly through the PDI model. Importantly, PrEP as a prevention intervention lends attention to the full HIV cascade, rather than focusing primarily on treatment for HIV-positive clients.
Scaling Up PrEP Implementation
Lessons learned from KPIS on PrEP provision at facilities 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 (TA) 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, high estimated numbers of MSM and TGW, and the largest combined numbers of KPs in Thailand. The following factors contributed to the success of the PrEP pilot study intervention:
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; the Thai Red Cross; civil society organizations, and other development partners for the implementation and evaluation of relevant activities. The committee was highly engaged and met quarterly, both of which were critical to programmatic success. The PEPFAR Team and Technical Steering Committee developed and implemented the KPIS study. This collaboration was pivotal to the success of the community- and facility-based PrEP projects. This close collaboration and engagement with key stakeholders and implementing partners will need to continue for a cost-effective PrEP scale- up.
Attention to challenges for target populations: MSM and TGW face significant stigma and discrimination. Thus, it was critical for staff to be well-trained and for the clinical setting, including both community sites and facilities, 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 individuals who accessed resources.
Demand creation/market/education: Time and resources invested in informing the target populations about PrEP contributed to those who initiated on PrEP.
As with all new interventions, adequate resources must be devoted to the 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 peer networks and site staff members.
Promotion messages about the benefits of early HIV testing and treatment were provided through the “Buddy Station” web portal, community events, and the “Test BKK” campaign. The “Buddy Station” website served as a hub for uploading informational materials on early “Test and Treat” and PrEP. The site’s main objective was to promote HIV testing and provide HIV education in an entertaining and accessible manner. Activities were conducted to promote the website. From April to October 2014, 22,000 users visited the website. The “Test BKK” campaign targets MSM who are high-risk, but are not typically reached through traditional peer-outreach approaches.
Systems to Incentivize HIV Case-Finding
Innovative efforts by Population Services International (PSI) to incentivize case-finding and implement payment schemes for the HIV treatment cascade have been implemented. A partnership was formed with a magazine that is popular among MSM to disseminate key messages on the benefits of and locations to access HIV testing services (HTS). This partnership included the use of private sector gift vouchers 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
The success of PrEP implementation has been greatly impacted by engaging KPs and community stakeholders. The PEPFAR Asia Regional team has meaningfully engaged with communities and developed collaborative relationships with KP and civil society organizations. 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 coherence with the national program, the same assessment guideline was used for the four MSM clinics where the CDC and MOPH provided TA. Community-based providers have received training to meet quality standards for HTS at the site level. Additional advances in program quality improvement 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).
Creation of an enabling environment for service uptake: Trainings to minimize stigma and discrimination and to acknowledge the specific health needs of MSM and TGW now exist for HIV healthcare providers.
CDC KPIS Study Costing Analysis
A standard-method, itemized cost analysis was applied to derive the total programmatic financial and unit costs. Retrospective data for 12 months was collected for PrEP analysis. The analysis assumed the continued employment of the same facility staff, and an equivalent cadre (with the same pay scale) was assumed for the project staff as well. Key findings included:
cost per person, per year (PPPY) for PrEP is less than cost PPPY for ART (it is 12% to 31% less, depending on the price of the PrEP regimen used);
overall, drugs were the key cost driver for PrEP (~83% of the cost);
PDI drove down the cost of the intervention;
volume drives down the cost per person reached; and
pay scales for staff may vary, depending on their level of involvement.
A costing analysis for USAID LINKAGES study will be performed in FY2017 and 2018.
Revised by the PEPFAR Solutions Team, May 2018