Thailand may have been recognized as a true leader in Asia and the Pacific Region for its progress in rapid PrEP service rollout among those at high risk, but the demand for PrEP is plateauing. The gap between those who are eligible for PrEP and those who actually receive PrEP services still remains vast. There is an urgent need for the demedicalization of PrEP in order for it to be accessible to those in need.
IHRI has been a significant player in PrEP, partaking in extensive differentiated approaches to increase availability, acceptability and scalability of PrEP in Thailand.
The Princess PrEP Project is a demonstration project initiated by the Thai Red Cross AIDS Research Centre (TRCARC) in collaboration with LINKAGES Thailand Project (managed by FHI 360), the Thailand Ministry of Public Health and the Thai Government Pharmaceutical Organization. The project receives funding support from the Thai Red Cross Princess Soamsawali HIV Prevention Fund and the United States Agency for International Development under the United States President’s Emergency Plan for AIDS Relief.
The Princess PrEP Project provides free PrEP services in 6 high HIV prevalence provinces for members of key populations including men who have sex with men, transgender women, female sex workers and people who inject drugs.
Same-day HIV testing and PrEP services are provided by trained community health workers (CHWs), themselves members of the key populations they serve, working for four community-based organizations that collectively operate 8 community health centers: Rainbow Sky Association of Thailand (RSAT) in Bangkok, Ubon Ratchathani and Songkhla; Service Workers in Group Foundation (SWING) in Bangkok and Chonburi; Caremat in Chiang Mai; and Mplus in Chiang Mai and Chiang Rai. IHRI provides continuous capacity building to ensure that CHWs can provide HIV services in accordance with national standards.
The three-year project, starting in January 2016, was set up to celebrate the auspicious occasion of Her Royal Highness Princess Suddhanarinatha’s 60th birthday. Its aim is to generate evidence to support the Thai government in issuing a concrete policy to de-medicalize PrEP by allowing trained CHWs who are members of key populations to provide PrEP to individuals who are at risk of HIV infection. This key population-led PrEP services have contributed to almost half of all Thai PrEP users. Thailand, subsequently, has included PrEP service into the country’s Universal Health Coverage in October 2019, becoming the first country in Asia to scale up PrEP service at large. More affordable PrEP is expected to increase its uptake in order to meet the national target, which it is still far behind.
Ramautarsing RA, Meksena R, Sungsing T, Chinbunchorn T, Sangprasert T, Fungfoosri O, Meekrua D, Sumalu S, Pasansai T, Bunainso W, Wongsri T, Mainoy N, Colby D, Avery M, Mills S, Vannakit R, Phanuphak P, Phanuphak N. Evaluation of a pre-exposure prophylaxis programme for men who have sex with men and transgender women in Thailand: learning through the HIV prevention cascade lens. J Int AIDS Soc 2020; 23 Suppl 3: e25540.
Phanuphak N, Sungsing T, Jantarapakde J, et al. Princess PrEP program: the first key population-led model to deliver pre-exposure prophylaxis to key populations by key populations in Thailand. Sex Health. 2018; 15(6): 542-55.
IHRI is among one of the three clinical sites in Thailand to participate in this large-scale clinical trial, referred to as ‘HPTN 083’, funded by the National Institutes of Health in the United States. If the long-acting injectable drug cabotegravir is found to be safe and effective, it may be easier for some people to adhere to than current daily PrEP. In May 2018, IHRI won the Best Community Engagement Award for its active engagement of the MSM and TGW communities, as well as for the social campaign that generated interested in HPTN 083.
In July 2020, researchers from the HPTN announced that the HPTN 083 clinical trial showed that a pre-exposure prophylaxis (PrEP) regimen containing long-acting cabotegravir (CAB LA) injected once every 8 weeks was superior to daily oral tenofovir/emtricitabine (TDF/FTC) for HIV prevention among cisgender men and transgender women who have sex with men. The results were reported at the 23rd International AIDS Conference (AIDS 2020: Virtual).
Overall, HPTN 083 enrolled 4,570 cisgender men and transgender women who have sex with men at research sites in Argentina, Brazil, Peru, South Africa, Thailand, the U.S., and Vietnam. Two-thirds of study participants were under 30 years of age, and 12% were transgender women. Half of the participants in the United States identified as Black or African American.
A total of 52 HIV infections occurred during follow-up, with 13 infections in the CAB arm (incidence rate 0.41%) and 39 infections in the TDF/FTC arm (incidence rate 1.22%). The hazard ratio in the CAB versus TDF/FTC arms was 0.34 (95% CI 0.18-0.62), corresponding to a 66% reduction in incident HIV infections in study participants given CAB compared to TDF/FTC. These results meet the statistical criteria for superiority of the regimen containing CAB compared to TDF/FTC in the HPTN 083 study population. The consistent adherence to TDF/FTC throughout the study and low incidence rate in both arms of the study clearly demonstrates both agents were effective at preventing HIV acquisition.
In response to the high HIV incidence and the low coverage of PrEP service among young MSM and TGW aged below 20, IHRI aims to expand the coverage of PrEP services to these groups, who are disproportionately affected by HIV. To this aim, STANDUP-TEEN was developed to explore the role of HIV self-testing (HIVST) in accelerating PrEP uptake and to improve retention in PrEP care among young MSM and TGW, aged 15-19. STANDUP-TEEN is a study that aims to expand HIVST and PrEP services to 600 young MSM and TGW in 4 provinces (Bangkok, Chonburi, Songkla and Chiang Mai). To strengthen the study, IHRI, in collaboration with Mahidol University, conducted a qualitative study to assess feasibility and perception of HIVST among the groups who are on PrEP. To scale up HIVST and PrEP among these targeted groups, the study will use innovative approaches including development of PrEP and HIVST delivery, and virtual visits.