Turning the tide of the HIV epidemic in Thailand
It is a morning like any other at the Thai Red Cross AIDS Research Centre, a civil society organization operating under the umbrella of the Thai Red Cross Society. In a building in the heart of Bangkok, nurses, doctors, counsellors and peer educators are busy with their daily work, providing HIV services for the 200 people who attend the Thai Red Cross Anonymous Clinic every day for medical check-ups, HIV tests and HIV prevention services, including condoms and pre-exposure prophylaxis (PrEP).
When he was 35 years old, Praphan Phanuphak―the Director of the centre, which he co-founded in 1989―discovered the first case of HIV in Thailand. “It happened by accident. A patient was referred to me to investigate why he had a recurrent fungal skin infection,” he recalled. “In February 1985, this patient was admitted with pneumocystis pneumonia. During that month, another man was referred to the hospital with generalized cryptococcus infection. Both were diagnosed with HIV. Since then, I have devoted my life to treating people living with HIV and developing solutions to expand access to HIV services in the country.”
Mr Praphan remembers that in the early days of HIV the response in Thailand faced several challenges. At the time, Thai law required hospitals to report the names of people diagnosed with HIV to the Ministry of Public Health, which contributed to increasing stigma and discrimination against people living with HIV. In response, the Thai Red Cross established the Thai Red Cross Anonymous Clinic, Asia’s first anonymous clinic, and advocated with the Thai Government to remove the reporting law. The Anonymous Clinic remains the most renowned centre providing voluntary HIV testing in the country.
“Until the beginning of 2000, antiretroviral medicines were not available through public health facilities in Thailand, and many people living with HIV could not afford to buy them,” said Mr Praphan. He said that in 1996 the Thai Red Cross AIDS Research Centre was the first to provide free antiretroviral medicines as part of its clinical trials through the HIV Netherlands–Australia–Thailand Research Collaboration.
“After years of despair, a time of hope finally came. For that, I want to thank Her Royal Highness Princess Soamsawali, who stood by our side by setting up a fund for the prevention of mother-to-child transmission of HIV in 1996, several years before the Thai Government started its successful prevention programme,” said Mr Praphan.
The AIDS response in Thailand has changed dramatically over the years. In 2006, Thailand integrated its HIV services, including antiretroviral therapy, into its universal health coverage scheme. Since 2014 Thailand has provided antiretroviral therapy for all regardless of their CD4 level. Everyone can access treatment for free, and people living with HIV are offered treatment immediately after diagnosis.
However, many people are starting antiretroviral therapy late. “We have the medicines, but many people are not being diagnosed fast enough,” warned Mr Praphan. Despite tremendous progress, the HIV epidemic is not yet over in Thailand. HIV remains concentrated among key populations: almost 50% of new HIV infections in 2018 were among gay men and other men who have sex with men. Low uptake of HIV testing among key populations is related to the acceptability of services and stigma and discrimination, which hinder access to HIV diagnosis, prevention and care.
“From our experience, helping key populations to reach their peers and bring them to HIV drop-in centres, where they can be tested, is the best way to detect and diagnose people living with HIV early enough,” said Mr Praphan, who successfully advocated to amend Thai law to allow certified lay providers from key populations to provide a number of HIV services.
The Thai Red Cross AIDS Research Centre’s approach focuses on undertaking pilot projects to generate evidence to inform national planners and policymakers. That evidence provides a foundation for national acceptance and the roll-out of innovation on a national scale.
Taking the lead in reaching out to key populations, the centre has been offering PrEP to people at substantial risk of HIV since 2014 through projects such as the Princess PrEP Programme. In October 2019, Thailand introduced PrEP under its universal health coverage benefits package as a pilot phase in efforts to scale up PrEP nationwide.
Mr Praphan believes that policymakers and programme implementers should understand that, “We cannot continue to do business as usual. In Asia and the Pacific, several countries are still either sceptical or conservative in terms of promoting the necessary approaches to change the course of the HIV epidemic.” He thinks that the region cannot achieve the 90–90–90 targets by 2020 at the current pace. “We need to think out of the box and look at what other countries are doing that can be taken as a model. This is how we can move faster on our way towards ending AIDS as a public health threat.”