Thailand: Retaining people in care key to PrEP adherence

Country-wide implementation of pre-exposure prophylaxis (PrEP) for key affected populations in Thailand is well under way and providing important data about the sub-populations that are struggling to adhere to this important HIV prevention initiative.

PrEP is a course of antiretroviral treatment targeted at HIV-negative individuals at a high-risk of HIV infection. It has proven to be a powerful tool for the HIV response, but it’s effectiveness as an intervention relies on people being able to adhere to treatment as prescribed.

Thailand have introduced several cost-reduced and free PrEP programmes targeted at populations most at risk of HIV in order to reduce new infections in these groups. Some 44.4% of new infections from 2012 to 2016 were among men who have sex with men, transgender women, and male sex workers.

The ‘Princess PrEP’ programme in Thailand – the first initiative under royal patronage led by the target populations themselves – provides free rapid HIV testing and PrEP administered by trained community health workers at seven Thai community organisations in Bangkok, Chonburi, Chiang Mai, and Songkhla provinces. The programme had successful enrolment, but there remain key challenges around care retention and adherence to services. 

A new analysis revealed that 37.4% of men who have sex with men and transgender women had low adherence to PrEP. Low adherence was defined as taking less than three pills a week, or not showing up to an appointment after the first month (loss to follow-up). The sub-populations least likely to be adherent were younger populations under 25, transgender women, and new clients to the Princess PrEP programme. 

An initial 829 participants were enrolled in the programme during the study period, with 564 men who have sex with men and 89 transgender women included in the analysis. HIV, HBsAg, creatinine tests, and self-administered questionnaires were performed at baseline, and were followed up after 1 month, 3 months, and then every 3 months. 

Risk-taking behaviour was relatively high in the group. Just under half (42.3%) of the participants reported not using a condom in the past three months, the median number of partners was 3, while 5.7% used amphetamines and 20.1% had group sex – of these 32.8% inconsistently used condoms and 48.8% used drugs. 

In their discussion, the authors note that efforts should largely be focused on retaining people in care, because 90% of the participants who were categorised as being poorly adherent were actually lost to follow-up. Of the group that did attend an appointment after one month, 94% were categorised as having good adherence. 

Of the sub-populations who struggled with adherence, more research is needed into behavioural interventions that would help support them to remain in care and adhere to PrEP. Crucially, while PrEP is widely implemented in Thailand with a number of demonstration projects, it is not integrated into Thailand’s national healthcare schemes. Recognition of PrEP as a key prevention strategy within the national health service would mean resources could be spent on research to better understand how to effectively deliver interventions to the most vulnerable populations.
 
For example, Young Thai men who have sex with men and transgender women are prolific users of internet and technology. “Data shows that this population strongly prefers online-to-offline healthcare models,” comment the authors. “Adapting existing, efficacious offline healthcare support for online platforms is an initial step towards potentially improving retention and adherence in PrEP programs. This strategy has proven feasible and effective in both reducing barriers towards HIV medication adherence in youth living with HIV and treatment linkage in MSM.”

Given the proven efficacy of PrEP and the burden of HIV risk among trans women and men who have sex with men – they could still benefit from PrEP with appropriate behaviour change interventions. “Next generation of preventative HIV care, [and] increased efforts from civil society and government sectors will be crucial in providing effective prevention.”