Innovative Clinical Models

in HIV Prevention and Care

Nittaya Phanuphak, MD, PhD

Thai Red Cross AIDS Research Centre, Bangkok, Thailand

The HIV cascade model

Opportunities for PrEP

Opportunities

for TasP

• Community-based organizations are most suitable to “reach, recruit, test, treat/PrEP and retain" the risk individuals

• Online platform has high potential to enhance the cascade

REC

RU

IT Conventional outreach methods

Online outreach

Online-to-offline platform

TEST Same-day HIV

testing

Community-based/led testing sites

Facility-based testing sites

Self-testing

TREA

T/P

REV

ENT Linkage to ART

service

Community-led ART/PrEP sites

Facility-based ART sites

RET

AIN Retention

support for both HIV-positive and HIV-negative clients

Online adherence and retention support for ART and PrEP clients

• Half of new HIV infections in Thailand occur among MSM but current HIV testing coverage among Thai MSM is less than 30%

• 60-65% of MSM returned for repeated HIV testing within a year

Data from IBBS, Thai Red Cross Anonymous Clinic and Silom Community Clinic

Recruit – Test – Treat & Prevention – Retain

83% 74% 75%

diagnosed on treatment virally suppressed

THAILAND 2014

Community-led Test & Treat and PrEP service delivery model

CHIANG MAI

CAREMAT/MPLUS

Type of clients: MSM and TG

BANGKOK

Rainbow Sky Association of

Thailand (RSAT)

Type of clients: MSM and TG

Service Workers IN Group

(SWING)

Type of clients: MSWs

SONGKHLA (HAT YAI)

RSAT

Type of clients: MSM and TG

CHONBURI (PATTAYA)

SISTERS

Type of clients: TG/TG sex workers

SWING

Type of clients: MSWs

Service delivery capacity strengthening for TEST-TREAT-RETAIN

Didactic, hands-on, performance log

Finger prick blood collection, HIV testing, syphilis testing, POC CD4

STI counseling/sampling from anus, neovagina, oro-pharynx

TB screening and prevention

Ongoing coaching, QA/QI and case discussions

Service delivery capacity strengthening for TEST-PrEP-RETAIN

Didactic training on use of ARVs for HIV prevention, with lots of Q&A

Community forum to create awareness, demand and support from MSM

and TG communities

Ongoing coaching, QA/QI and case discussions

Expansion to “Princess PrEP” program: free community-led PrEP service

Updated Community-based Test and Treat Study“Total” Enrollment, by Partner, as of April 28, 2016

CBOsEnrolled

ParticipantsHIV-

NegativeInconclus

iveHIV-Positive

Seroconversion

Exclusion**%Consent for

ARTStart ART

SWING BKK6 May 2015

254 221 0 33 (13%) 1 6 100% 22 (79%)

RSAT BKK22 May 2015

462 328 0 130 (28%) 4 8 99% 107 (85%)

SISTERS26 June 2015

258 226 0 31 (12%) 1 7 100% 19(70%)

CAREMAT1 July 2015

557 490 1* 61(11%) 1 12 100% 40 (82%)

SWING PTY16 July 2015

147 109 0 36 (25%) 1 2 94% 27 (82%)

RSAT HDY5 Nov 2015

110 100 0 10 (9%) 0 0 100% 10 (100%)

Total 1,788 1,474 1 301 (17%) 8 35 99% 225 (81%)

*In follow-up process for repeat testing **Age <18 years or known HIV-positive status

79% successfully started ART

Median days to start ART 15 days (IQR 9-22)

5% within 2 weeks of diagnosis

16% didn’t start ART after 2 weeks of diagnosis

End of March 2016

Community-based Test & Treat Cascade, by Population (May – Dec 2015)

CD4 COUNT AT DIAGNOSIS N = 172

<350 76 (44%)

350-500 48 (28%)

>500 48 (28%)

Median (IQR) 373 (280-507)

Community-led PrEP Study Enrollment, as of April 28, 2016

RSAT BKK (26 Nov. 2015)

SISTERS PTY (22 Oct. 2015)

SWING BKK (29 Oct. 2015)

Enrollment: 98

Agreed to take PrEP: 59 (60%)

Enrollment: 126

Agreed to take PrEP: 62 (49%)

Enrollment: 45

Agreed to take PrEP: 20 (44%)

SWING PTY (24 Nov. 2015)

Enrollment: 33

Agreed to take PrEP: 23 (70%)

TOTAL ENROLLMENT: 302

(95% of total HIV-neg in T&T)AGREED TO TAKE PREP: 164 (54%)

Princess PrEP Press Release in Bangkok, 16 Februay 2016

Chaired by the MOPH DDC Director General and Prof Praphan Phanuphak

Blessing quote from HRH Princess Soamsawali to support “community-led

PrEP services” was officially handed to CBO leaders

Expand PrEP to 3,000 MSM and TG over 3 years

11 January – 30 April 2016: 267 MSM and TG assessed 256 started PrEP

Use MSM magnetic celebrities

to draw attention towards normalization of HIV and HIV testing

Sep 2011 – Aug 2015

- Visitors: 2.3M (21% repeat visitors), Page views: 10.8M pages

- Edutainment Video Views: 1.4M views

- Webboard / Facebook / E-mail: Average 20 questions/day

- 25% of TRC Anonymous Clinic clients came because of Adam’s Love

- >10,000 referrals to HIV and STI services

Adam’s Love website http://www.adamslove.org/

APCOM’s engagement with MSM via virtual venues

Interactive approaches on MSM

websites

Engagement with social and

sexual networking apps

Coordinated social media-based

campaigns

Princess PrEP program: Adam’s Love Online-to-Offline component

During Jan – April 2016

– 425 booked 325 visited clinics (76%)

– 148 decided to have HIV testing only

– 168 started PrEP

Supported by amfAR GMT Initiative Grant

Online supervised HIV self-testing videos and manual

• Piloting oral fluid rapid testing – Operations research and phased roll-out to partners

• Use of HIV testing in various venues– Outreach

– Mobile services

– Community events

– Home-based

• Concrete linkages to confirmation, treatment and support

Increased use of new diagnostic/screening test that make HIV testing easier

A mobile application carried by community staff to:

• Collect client data• Track and manage cases across the

HIV cascade• Guide staff through complex EPM

processes• “Stay connected” with SMS

messaging• Improve performance over time

eCascade: Mobile app for real-time data collection and referrals tracking

Connecting providers and their clients for better performance and service through eCascade

Peer Mobilizer

• Short-term

with incentives

• No formal

training

• Recruits

clients within

their own

social network

Client

• Responsible

for own

health

• Opportunity

to become

new Peer

Mobilizer

Community-based

Supporter

• Long – term with

salary

• Training/mentoring

• Educates and retains

clients across the

cascade

Expanding reach through social networks

No HIV+’s found by

peer mobilizers

High # of HIV+ found by

peer mobilizer

Super recruiter

White = reachedBlack = HIV tested

Red = HIV+Blue rim = first-time tester

Identifying high-value social networks

Seed: af040224

Nickname: A

CBS: 1010112

Recruited: 29

Testing Rate: 96.5%

Testing Yield: 14.3%

Prioritizing effective peer mobilizers

94% HIV

testing uptake

83% ART

initiation

10% HIV+

yield

Establishing and enhancing community-led HIV service models and online

platform are feasible and needed to achieve national and global targets to end

the HIV epidemic

CBOs are eager and proud to have their capacities built up beyond just being

outreach worker and recruiter for the research projects become

community research sites

Address structural barriers to institutionalize and finance community-led HIV

services and online platform

To enhance (for TG) and extend the community-led model to other key

populations (e.g. youths and PWID)

Conclusions and steps forward

More innovative and exciting models will continue

to arise where commitment and enthusiasm are

shared among stakeholders!