Thailand’s PrEP Implementation Progress With Exclusive Interview Comments From Professor Andrew Grulich – The Kirby Institute, Sydney

Thailand’s PrEP Implementation Progress With Exclusive Interview Comments From Professor Andrew Grulich – The Kirby Institute, UNSW, Sydney

PrEP implementation was a very hot, challenging topic at the 21^st Bangkok International Symposium on HIV Medicine 2019 organised by HIV-NAT.

The Symposium was held at The Queen Sirikit National Convention Centre, January 16-18^th..

The latter part of this article will include comments from the highly-respected Professor Andrew Grulich of The Kirby Institute, UNSW, Sydney, Australia on his team’s ground-breaking studies and some comparisons with the PrEP implementation in Thailand.

Thailand’s PrEP timeline:

To review the Kingdom’s progress on PrEP implementation here’s a base timeline of progression:

• November 2010: iPrEX showing 44% prevention efficacy among MSM who took the TDF/FTC combination pill on a daily basis.
• July 2011: HPTN 052 showed a 96% prevention efficacy with immediate ART.
• December 2012: Introduction of the “1^st Test & Treat project” for MSM and TGW in 4 provinces.
• October 2014:  National guidelines recommended ART regardless of CD4 count and PrEP.
• December 2014: Introduction of PrEP-30 by TRCARC (Thai Red Cross AIDS Research Centre) which saw availability of treatment costing just 30-baht per day.
• May 2015: The introduction of Community-Led and Facility-Based “Test & Treat” projects along with PrEP sub-study in MSM and TGW.
• January 2016: The Princess PrEP. This was the first key population-led PrEP initiative under Royal patronage and through a generous donation from Her Royal Highness Princess Soamsavali has been a major initiative in the country’s PrEP implementation.
• January 2017: PrEP2 – This government-initiated PrEP scale-up program is led by MOPH/TUC to increase and strengthen PrEP treatment in hospitals and health centres in 7 provinces.

Comparisons:

During the HIV symposium Professor Andrew Grulich, Program Head of the HIV Epidemiology and Prevention Program at The Kirby Institute took time out to respond exclusively to Thailand Medical News on some interesting comments and comparisons between his teams highly effective PrEP implementation program initiatives and those being conducted in Thailand.

For this, we at Thailand Medical News are extremely grateful. We also strongly believe that with continued global cooperation such as that from Professor Grulich that the implementation and expansion of PrEP treatment programs and their associated effectiveness will continue at an ever-increasing rate.

Note: Thailand Medical New’s Question are highlighted in bold with Professor Grulich’s response below each:

1.Based on your experience, what is the one piece of advice you would give in relation to the most effective way to achieve a rap id roll-out of PrEP implementation for Thai communities?

In gay men, PrEP is close to 100% effective if taken daily. It is easy to take – one pill once a day – and is safe. PrEP is a huge advance in HIV prevention, and clinicians should discuss PrEP as an effective interventions in all their gay patients. Community education is required to ensure gay men are aware of PrEP, and seek it out.

2. Our understanding is that currently only 50% of gay Thai men who began PrEP in one scheme were still taking PrEP 1 year later. How does this compare with statistics from your initiatives?

In Australia, over 80% of gay men who start taking PrEP continue to take it for at least one year. PrEP programs need to be inexpensive and highly accessible to encourage those at risk to keep taking it for as long as they are at risk.

3. The average age of Thai MSM PrEP seekers is 29. Could you advise the average age across your established initiatives?

This is a slightly lower age than we see in Australia. However, Thai data do suggest that young gay men are at high risk, and the risk is highest in those aged younger than 25. Targeting men at risk at all ages is important, but targeting men aged less than 25 is particularly important.

4.Based on your program implementation to date what do you believe are the most important steps to be taken in terms of the modelling effect?

To achieve major reductions in new HIV infections at the population level, the most important thing is high-coverage. In my state of New South Wales, we now estimate that over 20% of gay men are now taking PrEP, and most men at high risk are taking PrEP. Once high-coverage is achieved, herd protection will lead to the interruptions of chains of HIV transmission and the reduction of HIV transmission at the population level. Large reductions in HIV can be achieved – in NSW we say a one-third reduction in new HIV infections state-wide within 12 months of recruiting our PrEP cohort. IF implemented quickly and high levels of coverage introduced, decreases in HIV infection within 2 years can be achieved.

5.In terms of “knowledge of and access to” PrEP, what initiatives introduced in your programs do you believe have been most successful?

We need to build community demand for PrEP. Messages should be simple at clear. The key messages are 1) PrEP works and will stop you getting HIV; 2) PrEP is simple (1 pill once a day) and 3) PrEP is safe. Gay men need to know these facts – around the world gay men have tended to be sceptical about PrEP, but attitudes change once men are educated. This can be through targeted education (eg via dating apps for gay men) but also broad scale (eg train station advertisements; billboards) in areas where gay men live in high concentration.

6.Could you give one final PrEP comment you feel worthy of highlighting?

PrEP is the most exciting development in HIV prevention we have ever had. When combined with increased HIV testing and treatment soon after diagnosis, and with the continued promotion of condom use, we have a chance to drive new HIV infections down. 

Thailand Medical News closing remark:

Thailand Medical News highly commend the sterling work and extremely positive results achieved by Professor Andrew Grulich and his team to date.

We are also confident that such success can only spur on our Thai colleagues working in the PrEP implementation field to greater achievements.

Reference notes:

Some reference material: Taken from the TRCARC (Thai Red Cross AIDS Research Centre) and information gleaned from the 21^st Bangkok International Symposium on HIV Medicine 2019.

Biography of Professor Andrew Grulich:

Andrew is an internationally renowned authority in immune deficiency, infection and cancer; and in the transmission and prevention of HIV and sexually transmissible infections (STIs) in homosexual men. He graduated in Medicine in 1986 (MBBS, Adelaide) and completed a MSc in Epidemiology at the London School of Hygiene (1990) before returning to Australia where he completed a PhD in the epidemiology of HIV-associated cancer at UNSW (1998).  He is a medical epidemiologist and a Public Health Physician (FAFPHM, 1995) and in 2015 was elected as a Fellow of the Australian Academy of Health and Medical Sciences. He has worked in HIV research for more than twenty-five years, and at the Kirby Institute (formerly known as the National Centre in HIV Epidemiology and Clinical Research) since 1995. His current research is mainly in two areas: first, the transmission and prevention of HIV and sexually transmitted infections in homosexual men, with a focus on biomedical and behavioural prevention, and second, the intersection between infection, altered immune function and cancer, particularly as it relates to human papillomavirus-related cancer and focussing on anal cancer. Through his membership of state and federal ministerial advisory committees, he has been centrally involved in the policy response to HIV prevention in Australia.

Research Interests:

Epidemiology and prevention of HIV infection, including behavioural and biomedical prevention. Malignancies associated with HIV infection and other immunodeficient states and infections. Human Papillomavirus infection and anal cancer. Epidemiological methods.

Broad Research Areas:

Cancer, Epidemiology, HIV - AIDS, Infectious Diseases, Immunology

Qualifications:

MB BS Adel, PhD UNSW, MScEpid Lond, DipObst Flin, FAFPHM, DRACOG, FAAHMS

Society Memberships & Professional Activities:

International AIDS Society;Member and past president, Australasian Society for HIV Medicine; member, Australasian Epidemiology Association; International Papillomavirus society; Fellow of the Faculty of Public Health Medicine

Specific Research Keywords:

Acquired Immune Deficiency Syndrome (AIDS), Cancer, Epidemiology, Immunology and Infectious Disease, Infectious disease control

Qualifications 

1998 PhD, University of New South Wales, Sydney, NSW.
1990 MSc (Epid), London School of Hygiene & Tropical Medicine, UK.
1986 MBBS, Adelaide University, South Australia.

Professional

1995 Fellow of the Australian Faculty of Public Health Medicine, Royal Australasian College of Physicians.
1988 Diploma in Obstetrics, Flinders Medical Centre, South Australia.

Grants 

Andrew has held two NHMRC Principal Research Fellowships. In 2012-2017 he was named CI on grants totalling > $31million (>$41million in his career). Of these grants, in 2012-17 he was CIA on grants totalling $7.6million ($10.6million in his career). He has been successful as a CI in obtaining grants from the NHMRC (program, project, partnership schemes), Cancer Councils and Cure Cancer Australia, State and Federal Health Departments, the pharmaceutical industry, and international philanthropic organisations.

Awards 

2015 Fellow of the Australian Academy of Health and Medical Sciences