HIV in Southeast Asia: Progress, Process, and the Work Ahead

Dr. Razia N. Pendse, Regional Advisor for HIV, sexually transmitted infections, and hepatitis at the South-East Asia Regional Office (SEARO) of the World Health Organization

Dr. Razia N. Pendse has been with the WHO for more than 10 years. Before her current role as regional advisor at SEARO, she worked at the WHO headquarters in Geneva in the Department of Maternal, Newborn, Child and Adolescent Health on prevention of mother-to-child transmission and malaria in pregnancy, and was responsible for managing partnerships across key stakeholders for improving maternal and newborn care. She has also worked at the country level with UNICEF India, and with non-governmental and community-based organizations in Rajasthan, India.

TREAT Asia Report: Currently only half of people living with HIV in the South-East Asia region know their status, and only half of those are being treated. How can testing and treatment rates be improved?

Dr. Pendse: Knowing one’s status is the critical first step. We need a multitude of approaches—like peer-led outreach activities, decentralized approaches including community community-based testing, and home-based testing, either self-testing or assisted by visiting health care workers or trained community health workers/peers who can help identify reactive tests and make referrals for confirmation of diagnosis.

Once the status is known, peer-led or community-led counseling and support can help link patients to care more quickly. This is important to start early for better treatment outcomes and to also have the prevention benefit of early treatment to prevent further transmissions.

Most patients still present late for treatment and only when they have complications, despite guidelines that promote early diagnosis and treatment.

For decentralized testing and treatment to be successful, it is important to have simplified, standardized testing approaches and differentiated service delivery models that allow treatment to be easily initiated and maintained.

TREAT Asia Report: How is the WHO working with country programs to highlight and address how stigma and discrimination in healthcare settings continue to be critical barriers to care for people living with HIV?

Dr. Pendse: In collaboration with the United Nations Development Programme (UNDP) Bangkok Regional hub, the WHO has supported capacity building of health care staff on reducing stigma and discrimination against people with HIV in health care settings, especially for improving access for MSM and transgender people. As part of country support, the WHO works with ministries of health and partners especially UNAIDS to review laws and legislation, as part of the HIV program review and planning for improving access to HIV interventions—particularly for population groups that are marginalized and yet most vulnerable.

Left to right: Dr. Naoko Ishikawa, WHO Western Pacific; Dr. Razia Pendse, WHO South-East Asia; and Dr. Shaffiq Essajee, WHO Geneva; at a meeting for the Thailand Regional Validation on Elimination of Mother-to-Child HIV and Congenital Syphilis, Bangkok, 2016

TREAT Asia Report: While expansion of HIV treatment in the region since 2010 has led to a 47% decrease in new infections, there are still a significant number of AIDS-related deaths, and special concern about the high number of deaths among adolescents and young adults. What should be done to address the late diagnosis and treatment initiation that are at least partly responsible for these deaths?

Dr. Pendse: Expanding testing and ensuring early linkage to care is critical to preventing AIDS-related deaths. Most patients still present late for treatment and only when they have complications, despite guidelines that promote early diagnosis and treatment. Some of this could be due to lack of knowledge, but in large part it is due to stigma—self and societal. Stigma and discrimination in health care settings pose further barriers to access, especially for adolescents.

HIV is treatable and AIDS can be prevented with earlier treatment—this message needs to be driven home. Early diagnosis and treatment not only saves lives but prevents further transmission. HIV is like any other chronic disease that will need life-long treatment—people on treatment need to be supported and cared for.

Adolescents are generally out of the service delivery chain and reaching out to them requires innovative approaches along the entire continuum of prevention, testing, treatment, and care.

Adolescents are generally out of the service delivery chain and reaching out to them requires innovative approaches along the entire continuum of prevention, testing, treatment, and care. Technology can often help reach adolescents and young people. Peer-led interventions and the creation of safe spaces where adolescents can access information and services without fear of stigma, discrimination, and judgmental societal perceptions will go a long way in addressing HIV in these vulnerable population groups.

TREAT Asia Report: Why is access to routine viral load measurements still a problem for most of the region?

Dr. Pendse: The issues are manifold. While global guidelines now recommend viral load as the preferred monitoring tool, translation into practice at the national level takes time; it requires infrastructure, procurement, capacity-building, and other resources for scaling up the new intervention. Financial allocations for national programs are done one or two years in advance and newer interventions can be planned only in the next cycle. The inclusion of newer diagnostics depends on the availability and costs. As CD4 machines were already available or actually being procured when the recommendation to measure viral load was put into place, there has been some disagreement across various sectors in policy making whether to continue with CD4 or move to viral load. Matching supply to the demand is also critical. While civil society advocacy has created demand, supply has not kept pace. Various business models have been tried, including procurement through the Global Fund, public-private partnerships, and innovative financing.

All countries now have recommendations on using viral load for monitoring the treatment response, but scale up still has some way to go. There are still some hoops to jump through in terms of setting up service delivery models—such as transporting samples rather than referring patients, point-of-care VL measurement, hub and spoke models for facilitating diagnostics and service delivery, and reducing turnaround times for getting results.

TREAT Asia Report: How can Thailand’s success in eliminating mother-to-child transmission of HIV be replicated in other countries?

Dr. Pendse: Mother-to-child transmission of HIV was eliminated in Thailand thanks to high-level political commitment. This included integration of prevention of mother-to-child transmission (PMTCT) into the maternal-child health service delivery national stewardship and leadership, domestic resource allocation to provide free PMTCT services at the point of care, monitoring and evaluation and continuous quality improvement. The PMTCT program uses HIV and syphilis testing and treatment outcomes as quality-of-care indicators for maternal-child health, and ensures community engagement for reaching pregnant women of all ethnic groups in all locations, including migrants.

Any country that aspires to having a generation born free from HIV and syphilis needs to work on all of these elements and with the determination and dedication that Thailand has shown.

TREAT Asia Report: Can you give examples of how SEARO works with civil society groups to implement WHO guidelines for HIV diagnosis, treatment, and care for key populations such as men who have sex with men, female sex workers and their clients, transgender individuals, and people who use drugs?

Dr. Pendse: Civil society partners participate in and contribute to discussions in planning, review, and implementation meetings at the regional level. We also do specific activities with our civil society partners; for example, we are working with APCOM on scaling up community-based testing and pre-exposure prophylaxis. Civil society partners are also part of the review missions that we do at the country level. We see civil society networks and organizations as critical partners for scaling up and sustaining the HIV health sector response. Civil Society members were part of the regional validation team that recommended certification of EMTCT of HIV and Syphilis for Thailand

WHO and UNAIDS have worked together for the past four years on expanding HIV testing through community-based and -led approaches. We have documented and shared country examples that have led to pilot projects on community-based approaches for HIV testing.

The respondent is a staff member of the World Health Organization. The respondent alone is responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of the World Health Organization