1. Community-Led and Online Strategies for Testing, Treatment and PrEP among MSM and Transgender Persons in Thailand
Nittaya Phanuphak, MD, PhD
Thai Red Cross AIDS Research Centre
Better data, better programs: how implementation science is transforming
the HIV response for key populations
KPIS Satellite Symposium
23 July 2017

2. Thailand’s new HIV infections by route of transmission
Est. 29,626
new HIV+
Thailand is a country where around half of new HIV infections each year currently occur in men who have sex with men and transgender women.
Source: AIDS Epidemic Models, 2015, Projection & Estimation Working Group

3. Thailand’s 90-90-90 achievements
80%
72%
79%
= 45.5%
THAILAND 2014
THAILAND 2014
“MSM only” 19% % % = 4.6%
89%
70%
82%
THAILAND 2015
= 51.1%
From 2014 to 2016, Thailand has made good progress in terms of the first 90 target, from 80% to 95%. However, although with more than 70% ART initiation and around 80% viral suppression, the percentage of total PLHIV who have suppressed viral load has not increased much, only from 45% to 54%.
95%
70%
81%
THAILAND 2016
= 53.9%
diagnosed on treatment virally suppressed
Source: Thailand NHSO

4. Community-Led Health Services (CLHS) model for MSM and transgender people
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

5. Community-Led Health Services (CLHS)
“Community leadership”: services necessary for addressing the HIV epidemic and related health issues are identified by the community itself and are, therefore, needs-based, demand-driven, and client-centered.
Dusit 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.
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
“Community leadership”: services necessary for addressing the HIV epidemic and related health issues are identified by the community itself and are, therefore, needs-based, demand-driven, and client-centered.
Services are closely and formally linked to the health sector and follow standards developed in partnership with the MOPH.
CLHS is not just a service set up by CBOs but a true partnership between CBOs and government/public health facilities.
FrontLines, March/April 2016, Dressed to Test: Empowered Communities Take HIV Services to the Streets

6. CLHS 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

7. Highlights from multiple studies and programming in Thailand related to Community-Led Health Services (CLHS)
HIV Test & Start Study (USAID LINKAGES Project with KPIS funds)
To provide evidence on the feasibility of CLHS to enhance early diagnosis of HIV and linkage to ART and PrEP/prevention among MSM and TG at very high-risk for HIV in order to inform programming
HIV oral fluid screening study (USAID LINKAGES Project )
To provide evidence on client acceptability and to inform Thai MOPH policy on self- and lay-testing strategies
Online, supervised, HIV self-testing study (amfAR)
To explore and compare different strategies related to online strategies for HIV testing
Tangerine Community Health Center (USAID LINKAGES Project)
Integrated hormone and sexual health services for transgender persons
PrEP programming in Thailand
PrEP-30 program (self-paid)
PrEP Implementation Research (USAID LINKAGES Project and CDC with KPIS funds)
Princess PrEP (USAID LINKAGES Project)
PrEP2Start (MOPH with CDC technical support)

8. 1860 MSM
329 HIV-positive (18%)
84% Started ART
86% with VL <50 copies/mL at month 6
Early diagnosis and early initiation of ART can be achieved through CLHS model in the “Community-Led Test and Start Study”
786 TG
69 HIV-positive (9%)
87% Started ART
94% with VL <50 copies/mL at month 6
Median CD4 count 366 cells/mm3 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)

9. High risk individuals with high seroconversion rate can be identified through CLHS model in the “Community-Led Test and Start Study”
HIV incidence (by Mar 2017): MSM 6.19 per 100 PY, TG 2.40 per 100 PY
MSW in Pattaya: per 100 PY
TGSW in Pattaya: 4.06 per 100 PY
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)

10. “HIV oral fluid screening operational research” among MSM and TG in Thailand to inform national policy

11. Web-based Instructions for oral fluid HIV Screening - VDO and pictures -

12. Self-selection and HIV yield, as of 7 July 2017
Peer-mediated testing = 87 (73.7%)
 reactive 8%
Preliminary data from LINKAGES Thailand, as of 7 July 2017 not for quotation

13. Adam’s Love: Online platform to enhance HIV testing
Online education
eBooking for HIV testing and PrEP
We all realize that lots of young MSM and TG are connecting online to engage in offline risk. We know we can reach these people online, but we all have been challenged to “convert this online reach into offline testing and other service uptake”.
Adam’s Love is one very successful online communication channel which could reach millions of people over a 4-year period and engage MSM and TG who were reached online to communicate their sexual health concerns with us through online channels where more than 20,000 referrals were already made to HIV and STI services.
Online, supervised, HIV self-testing

14. amfAR GMT Initiative “Online Test and Treat Study”
Conventional offline HIV testing at clinics
Online counseling + offline HIV testing
Online counseling + online, supervised HIV self-testing
Funded by amfAR, The Foundation for AIDS Research

15. Integrating Community-Led Health Services with online strategies to increase access and yield of HIV testing
Group A (n=194)
Conventional testing at clinics
Group B1 (n=117)
Online counseling + offline testing
Group B2 (n=145)
Online counseling + online, supervised self-testing
Health Professionals (n=64)
Community Health Workers (n=130)
Health Professionals (n=31)
Community HealthWorkers (n=114)
First-time testers (%)
35.9%
46.2%
15.4%
32.3%
48.2%
HIV prevalence (%)
4.7%
17.7%
1.7%
3.2%
21.1%
1st time testers for Group A : 80/189 (42.3%) ; 1st time testers for Group A-Facility-based: 23/62 (37.1%); 1st time testers for Group A-Community-led: 57/127 (44.9%)
1st time testers for Group B1 : 13/102 (12.8%)
1st time testers for Group B2 : 35/89 (39.3%) ; 1st time testers for Group B2-Facility-based: 8/26 (30.8%); 1st time testers for Group B2-Community-led: 27/63 (42.9%)
Community-led web recruitment  high HIV-positive yield
Preliminary data from TRCARC, as of 30 April 2017
Funded by amfAR, The Foundation for AIDS Research

16. “Tangerine Community Health Center” at TRC Anonymous Clinic: Trans-led, integrated, hormone and sexual health services
600 transwomen and 185 transmen clients, Nov 2015 – Apr 2017
17% post-sexual reassignment surgery among transwomen
90% HIV testing acceptance rate
Hormone services increase return rate (61% vs. 35%, p<0.001) and subsequent HIV testing (35% vs. 19%, p<0.001) and PrEP (12% vs. 6%, p=0.02) services among transwomen, compared to those who did not receive hormone services
Hormone monitoring services, including for those on PrEP or ART, can now be provided by trained trans lay providers at other CBOs in Bangkok, Chonburi and Chiang Mai
With growing need for the country and the government to have transgender-specific data to inform policy, the TRCARC established the Tangerine Clinic last year to provide trans-led, integrated, hormone therapy and sexual health services to both transwomen and transmen.
HIV prevalence among 300 transwomen clients up to now was 9%. 16% had sexual reassignment surgery and a look at subset of transwomen post-surgery revealed that around 80% had neovaginal sex and one fifth carried oncogenic HPV types in the neovagina. None had neovaginal exam after surgery and a few had warts or foreign bodies inside it. Every woman was very satisfied with the exam. Data from the Tangerine Clinic will further inform us on how long-term sexual health care should be provided for these women in Thailand.
The Tangerine team has also recently reached out to TG community-based organizations to strengthen the capacities of TG lay providers to provide hormone monitoring services, in addition to just providing HIV testing and PrEP, to their clients with an aim to enhance adherence and retention of TG PrEP users and TG ART clients in HIV prevention and treatment programs.

17. Thailand’s PrEP programs
PrEP Implementation Research
Facility-based PrEP by MOPH
USAID LINKAGES and CDC KPIS funds
Fee-for-Service PrEP
CDC technical support
Community-Led PrEP (Princess PrEP)
USAID LINKAGES and TRCARC funds

18. Princess PrEP program: Support for community-led PrEP service for MSM and transgender women in Thailand
PrEP is available for free to key populations under the community-led PrEP program using the money from Thai Red Cross HIV Prevention Public Donation Fund. Her Royal Highness Princess Soamsawali who established this public donation fund, which was originally used for PMTCT, has been kind enough to give her blessing quote to our colleagues in 7 drop-in centers to give courage and support to the community-led PrEP program. This program was therefore named the “Princess PrEP program”.
Funded by TRC HIV Prevention Fund, PEPFAR/USAID through LINKAGES, Government Pharmaceutical Organization, Atlanta Thailand

19. Thailand’s PrEP programs
Princess PrEP
PrEP-30
*From Community-based Test and Treat/PrEP and Princess PrEP databases

20. Conclusions and next steps
Community-Led Health Services model is feasible and effective in enhancing uptake of early HIV testing and treatment, as well as PrEP, among at-risk communities
Online strategy is an equally or more important channel to reach, recruit and test at-risk MSM (and transgender women). It is dramatically enhanced in the hands of community health workers.
Community-Led Health Services models and online strategies will be expanded and/or strengthened for other key populations including more transgender women (through integrated hormone and sexual health services) and people who use/inject drugs