Introduction Status Neutral Approach - Nittaya Phanuphak - Academic Medical Education

Introduction

Status Neutral Approach
Nittaya Phanuphak
Institute of HIV Research and Innovation,
Thailand

Status-Neutral Approach
to HIV
Nittaya Phanuphak, MD, PhD
Institute of HIV Research and Innovation (IHRI)

Falling short of
UNAIDS 90-90-90
Testing & Treatment
targets by 2020

“81-82-88 = 59%”

                      UNAIDS. Prevailing against Pandemics by Putting People at the Centre. World AIDS Day Report 2020.

Major gaps towards
HIV prevention
coverage targets

“770,000 –
775,000 PrEP
users globally”

                     UNAIDS. Prevailing against Pandemics by Putting People at the Centre. World AIDS Day Report 2020.
                                                                  AVAC. PrEP W atch Global PrEP Tracker, October 2020.

Percentage change
of HIV incidence
among KPs, global,
2010-2019

“+25% in MSM
and +5% in
transgender
people”

                     UNAIDS. Prevailing against Pandemics by Putting People at the Centre. World AIDS Day Report 2020.

Phanuphak N, et al. Curr HIV/AIDS Report 2020. https://doi.org/10.1007/s11904-020-00516-z

Same-day ART initiation through CBO-hospital
partnership

    USAID LINKAGES project and IAS DSD, November 2020.

Same-Day PrEP:
close collaboration between CBOs and hospitals

2020ThailandNational Guidelines on HIV/AIDSTreatment and Prevention
Ramautarsing RA, et al. J IntAIDSSoc 2020; 23Suppl 3: e25540.
Phanuphak N, et al. Sex Health 2018; 15(6): 542-55.

Same-day ART
                                           initiation

                                                                            Jul 17 – Sep 20

   Bangkok sites                                        Non-Bangkok sites
USAID LINKAGES project,September 2020.

• U=U stigma is “sexual stigma”

         • With U=U:
            ▪ Condoms are not required to prevent HIV
U=U           transmission

Stigma
            ▪ Concerns about sexual risk compensation

         • Lack of knowledge and disbelief (despite
           robust evidence showing zero risk)

         • Stigmatizing attitudes towards PLHIV
           stereotypes related to sexual
           irresponsibility, as well as intersectional
           stigma related to sexual minority and/or
           gender non-conforming individuals

                  Calabrese SK and Mayer KH. JIAS 2020; 23:e25559. Rodger AJ, et al. JAMA 2016; 316: 171–81.
                  Bav inton B, et al. Lancet HIV 2018; 5: e438–47. Rodger AJ, et al. Lancet 2019; 393: 2428-38.

Overcoming U=U stigma
• Establish universal U=U patient education in normative
  guidelines dictating clinical practice
• Incorporate U=U into clinical education for all HIV service
  providers
• Facilitate patient–provider conversations about U = U with
  concrete tools
• Broaden public awareness through public
  health messaging

 Calabrese SK and Mayer KH. JIAS 2020; 23:e25559. https://www.preventionaccess.org/

PrEP uptake in Thailand and Vietnam, by service
       delivery model

NAP, Princess PrEP, prepthai.net, May 2020.

• Association to HIV and its socially
           discrediting behaviors

         • PrEP stigma is also “sexual stigma”

PrEP        ▪ Conscious or unconscious discomfort with
              the idea of sexual expression unfettered by
              the threat of HIV infection
Stigma   • Before PrEP:
            ▪ Limiting sexual activity/partner and
              consistent condom use are two behavioral
              restraint measures for HIV prevention

         • With PrEP:
            • More effective in HIV prevention, but is seen
              as a less honorable prevention measure

                  Golub S. Curr HIV/AIDS Rep. 2018 April ; 15(2): 190–197. doi:10.1007/s11904-018-0385-0.

Key Population-Led
Health Services (KPLHS):
designed and co-delivered by KPs   • A defined set of HIV-related health
                                     services, focusing on specific key
                                     populations

                                   • Services are identified by the
                                     community itself and are, therefore,
                                     needs-based, demand-driven, and
                                     client-centered

                                   • Delivered by trained and qualified
                                     lay providers, who are often
                                     members of the key populations

                                                Vannakit R, et al. JIAS 2020; 23(6):e25535.
                                                USAID LINKAGES project and USAID Community Partnership project

•   The first PrEP campaign for TGW in Asia,
    designed and produced by TGW

•   Highlight gain framing massages, rather than
    risk reduction messages, around PrEP use

“PrEP can be taken together with hormone.
You can simply just take them together
every day!”

Danz
Tangerine Clinic Counselor

“Do you want to take PrEP today so
you won’t have to worry about your
HIV test results every time you come
in for testing?”

Tum
Tangerine Clinic Nurse

Conclusions
• Status-Neutral approach to HIV can change the paradigm of HIV
  programs, emphasizing equally both treatment and prevention to
  end HIV epidemic.

• Stigma related to U=U and PrEP can affect uptake and retention in
  HIV testing, ART and PrEP services.

• Innovative approaches to overcome stigma must be urgently
  explored through implementation science to generate data from
  various context to feed into the development of guidelines/policies.

Acknowledgements