Increasing Access to Antiretroviral Therapy (ART) for Key Populations
APCOM in partnership with PEPFAR/USAID/EpiC held a webinar on 10 July 2023, 14:00 – 15:30 ICT. Participants from community-led organizations, key populations, and networks from the Asia and Pacific region joined to learn about the latest information on ART, and to strategise on the community-led advocacy and action to increase access to quality ART.
The benefits of ART can be fully realized only if people living with HIV are diagnosed and successfully linked to care. This will require targeted efforts and removing barriers especially amongst key populations, as most of Asia and the Pacific’s epidemics occur amongst sex workers and their clients, men who have sex with men, transgender persons, and injection drug users.
However, despite scale-up in treatment coverage, and the overall decline in HIV infections, the Asia Pacific region still lags behind the global average (treatment coverage for Asia and the Pacific is 66% in 2021 whilst the global average is 75%). A key priority for many countries is to ensure that people who have been diagnosed are also on treatment – and looking at how to address this gap. We also have to ensure that in countries and in certain key populations where there are trends in increase of HIV infections, is to ensure we are better at targeting and providing the services.
“The first time I accessed ARV was because I was a teenager and joined a peer support group with an intermedical foundation in Jakarta. At that time, I saw a few of my peers who were afraid of taking medication and stopped taking medication for several reasons, this made them sick and eventually died. This really broke my heart and made me want to be a treatment role model for those who just found out about their HIV status.”Davi Ardiansyah, Young PLHIV Officer, APN+, Jakarta, Indonesia
Davi, in his opening statement, reminded us not to leave young key populations and young people living with HIV behind. He gave his personal experience of being a young person living with HIV on treatment for more than 10 years. He stressed that access to HIV treatment is a fundamental component of the right to health. He recalled fear and difficulties in accessing information on HIV treatment as a teenager. He was then involved with a local Foundation and peer support group in Jakarta that helped him access treatment. The group then engaged in an active social media campaign, provided story-telling of younger men living with HIV in Jakarta, and established a safe house for young people living with HIV who experienced stigma and discrimination. This really helped to dispel fear about accessing HIV treatment, and that there is support available through their peers that went through similar situations.
“Initial preparedness counseling is very essential before beginning ART. While we make an effort for early rapid same day initiation, we should not lose the focus on preparedness counseling. Differentiated model of Service delivery needs to be adopted for key population to increase access to ART and retention in care”Dr B. B. Rewari, Regional Advisor (HHS), WHO South-East Asia Regional Office, Delhi, India
Dr. B. B. Rewari gave a presentation on What do the WHO guidelines say about ART recommendations and implementation? He mentioned having this webinar designed on ART to increase access to key populations is good. 3.7 million people live with HIV in the Southeast Asia region. 25 percent are unaware of their HIV status. People with HIV status are different in typologies and contexts. HIV data for key populations is not fully available in most countries, and access to key populations is also limited. This webinar offers the opportunity to discuss the barriers and ways forward. This presentation is to educate participants on the fundamentals of ART and the most recent WHO recommendations on ART. Recognize the various methods for key populations, and people living with HIV. And that there is more awareness of the resources available to migrant, prisoner, and mobile populations and anticipate future ART choices.
Renata Ram, the UNAIDS Country Director for the Pacific gave a context of HIV in the Pacific, which we often do not hear about.
The HIV epidemic profile shows that the numbers are quite low, but that’s because of the low population. The Pacific is generally a low HIV prevalence country; however, data from the Pacific must be viewed with a lot of caution because testing is quite low and most of the data is focused on women attending antenatal services and in populations accessing voluntary testing, and most of these are very opportunistic. The Pacific island countries have a key population-driven, concentrated HIV epidemic, and it’s mainly concentrated in men who have sex with men, sex workers, transgender women, and young people. The Pacific island countries suffer a high burden of sexually transmitted infections, but the prevalence and incidence of STIs in individual countries over time are not well known. It is important to note that the Pacific has a very large, uncontrolled STI epidemic. Under the previous Regional and HIV/STI funding, there used to be a comprehensive control program, but in 2014, this fell away.
“Currently everything is facilitated by the governments of each country, usually at the community level. It’s more advocacy for some level of prevention. However, there is a large need for communities to step up in this space of service delivery and also for peer support for people living with HIV. The testing uptake in most of the countries is very low. So even the reality of HIV cases is not a true picture with what we’re reporting. If countries have a high STI rate the HIV numbers are not adding up and detection, even at a later stage is poor. So it is highly possible that people may pass away from age-related deaths without knowing that they were you know diagnosed with HIV”Renata Ram, UNAIDS Country Director for the Pacific, Suva, Fiji
Some of the recommendations that Renata mentioned are; regional drug procurements with strengthening of in-country stock management and supply chain, decentralize ARV dispensing and monitoring, implement loss mitigation strategies, and increase donor support for Community-led interventions. As currently, everything is facilitated by the governments of each country, usually at the community level, through advocacy or some level of prevention. However, there is a large need for communities to step up in this phase of service delivery and also pull in peer support for PLHIV. The testing update for most of these countries is very low and does not reflect the reported data from these countries. It is highly possible that people may pass away from age-related causes of death without knowing that they will be diagnosed with HIV.
Country examples of Community-led interventions for ART access
Danvic from The LoveYourself, community-based organization from the Philippines presented their work on ART access using HIV self-testing, in the context of the Philippines is experiencing a fast and furious epidemic in terms of diagnosing 50 cases per day, and what The LoveYourself has done to provide ways on how to engage key populations and how they can be retained and access ARV via our testing approach.
“When people access an HIV service, this only serves the practical need but HIV is a highly stigmatized disease that has personal needs. These personal needs address the intersectionalities that are attached to the disease itself attached to HIV in itself. These personal needs address mostly psychosocial problems that are attached to the disease and directly affects the lives of our clients”Danvic Rosadino, Head of Programs and Innovations, LoveYourself, Manila, Philippines
The LoveYourself in 2023 have provided around 20,000 HIV self-tests in the country. This was offered entirely virtually via Facebook Messenger because it is the most popular social media platform in the Philippines. In this service, they employed digital innovations in order to help clients with risk assessment, the delivery of the kits, and instructions on how to get and report the results. And if they are non-reactive, they will be automatically enrolled in PrEP by offering PrEP through this mechanism as well.
For the reactive self-test cases, what is important is that if they report to us their results, and immediately there will be a volunteer that will be helping them to provide coaching and motivation. And so, we must first address their personal needs before we can address the practical needs in terms of accessing treatment. Personal needs mean understanding resources that may stop them from accessing the ART treatment. It is important to understand the results and set goals within themselves, so it will not be a barrier for them to access ART. Answering questions that they have prior to starting ART or prior to treatment with ART. And set the goal for them that links to confirmatory testing and same-day enrollment in ART.
Danvic shared that what they have done in their services is that they also offer physical and enhanced service delivery components, for example same-day ART, CD4 count, and TB testing. These mechanisms help with a seamless experience from the service user from online to the physical service that they are getting once they have an option to be linked to confirmatory testing.
“We actually have a really good relationship with the hospitals, so we started a pilot project together with IHRI to show the government the data that community-based organization can also provide ART service for HIV cases”Chamrong Phaengnongyang, Deputy Director, SWING, Bangkok, Thailand
In Thailand, Chamrong, Deputy Director of the SWING organization shared their experience through their key population-led health services (KPLHS) for sex workers.
He highlighted a pilot project in collaboration with IHRI to advocate to the government so that same-day ART treatment can be provided by community-based organizations. The advantages of same-day ART through community-based organisations include:
- Reducing the workload of hospital staff and the overcrowding of patients at ARV clinics in public hospitals, and CBOs may check the client’s preparedness before beginning
- CBOs can give suitable support in terms of mental and emotional concerns to clients with ARV therapy
- Clients can begin ARV the same day (immediately)
- After initiating ARV, CBOs can give post-care services
- The treatment service is provided at no cost.
This model is to help ensure task sharing as the constraints of ART availability in the past were that the ARV clinics at public hospitals were usually only open one or two days a week, and there was also a very long waiting period with a large number of clients at the ARV clinics at public hospitals. Furthermore, the public hospitals to which some customers must travel for ARV are rather far away. Patients who test positive in public hospitals must return to their home province to receive ARV therapy from facilities there.
There are some obstacles when advocating for a community-based same-day ART model with health authorities in Thailand and hospital teams. Testing can be done at community clinics, but ART treatments are not trusted by public hospitals for community clinics to provide. This creates the need for advocacy for working with hospitals because of the low level of trust in the work of the community-based organisations.
Chamrong commented that the study’s findings and suggestions were supposed to demonstrate the feasibility of implementing community-based same-day ART between CBOs and public hospitals. Providing data to the public hospitals was one approach taken by the community-based clinics to convince the public hospitals to accept early care treatment provided by community clinics. He hopes that in the future, they can show the success of their study to the government to prove that we can provide service for same-day ART treatment by community-based organizations.
The role of community-led monitoring (CLM) in improving the quality of ART access
“One of the benefits of implementing CLM is that the communities can monitor and improve the service by themselves, which is better than waiting for the top down approach. So they can do more effective work.”Amphika Poowanasatien, Senior Technical Officer, Care and Treatment, USAID/EpiC Thailand
Amphika Poowanasatien, Senior Technical Officer, Care and Treatment, USAID/EpiC Thailand highlights their CLM activities under the EpiC Thailand project which includes the improvement of the quality of services through CLM data.
The project was established in 2022 in Chiang Mai and Chonburi with one pilot hospital in each area, working with the Provincial Health Office to present the CLM concept, allow CLM activities in the province, and invite key provincial CBOs to join the committee. After the first year of operation, hospital employees, the provincial network, and the key population saw a benefit since clients received better service.
The CLM committee’s role includes coordinating with academic organizations and provincial networks to support CLM activity, representing civil society in public relations, and leading the community to drive policy, implement it, and manage the budget. The province’s CLM operations include establishing the CLM activity and schedule, as well as having a meeting with the committee and stakeholders to explain the objective responsibility, step-off work, and schedule activity. Create the CLM questionnaire, collect and analyze data, and discuss the results and improvement plan with healthcare facilities around the province.
This results in CLM findings and enhancements in 2022. Chonburi’s ART service has seen an improvement. The finding is a long-term ART replenishment service. The hospital and director discussed how to enhance the service, and they agreed to increase the DSD of the ART service to maintain treatment continuity, including the ART Health service. Following our training, we established the function of promoting DST in front of the ARV Clinic so that patients could seek the DSD service and created the Q system to help with the review. These actions shorten the wait time for ART refills and make it easier for patients to receive their drug regimen.
Other benefits of applying for CLM include:
- Community, implementing, monitoring, and upgrading their service by themselves rather than using the top-down method, making people more productive at work.
- There is strong coordination among community health care professionals to handle the problem collectively.
- The organization’s advocacy base to sustain advances in HIV care access.
Throughout the webinar, participants were able to provide interactive inputs from regarding their country-level challenges and recommendations for increasing access to Antiretroviral Therapy (ART) for key populations.
|Welcome & Introductions:· Housekeeping· Overview of the session· Introduction of speakers
|What does the WHO Guideline say about ART recommendations and implementation?
|Q&A Incl. Intro to Jamboard(Interactive inputs from participants re country-level challenges and recommendations)
|Sharing session: ART Access Gaps in the Asia Pacific Region
|Speaker: Renata Ram UNAIDS Country Director UNAIDS Pacific office
|Q&A Incl. Stat/recap of Jamboard
|How to fill gaps: examples from the two countries, Philippines and Thailand.Sharing session: Gaps (10 mins each) Reaching the most vulnerable in a country setting: Simplifying ART access by using HIV self-test (example from a key population perspective) Reaching the most vulnerable in a country setting: community-based ART services for sex workers (example from a PLHIV org)
|Speaker: Love Yourself, Philippines
Speaker: SWING Thailand
|Q&A Incl. Stat/recap of Jamboard
|The role of community-led monitoring (CLM) in improving the quality of ART access Reflections on the situations and moving ahead – PEPFAR ROP/COP
|Amphika Poowanasatien, Senior Technical Officer, Care and Treatment, USAID/EpiC Thailand project
|Thank you to the speakers and Close