amfAR, The Foundation for AIDS Research

PERSPECTIVES: What are the greatest barriers to scale-up of PrEP for HIV prevention in the Asia-Pacific region?

(Clockwise, from top left) Dr. Stephane Wen-Wei Ku, Dr. Adeeba Kamarulzaman, Mr. Chris Lagman, Ms. Surang Janyam 
(Clockwise, from top left) Dr. Stephane Wen-Wei Ku, Dr. Adeeba Kamarulzaman, Mr. Chris Lagman, Ms. Surang Janyam

Pre-exposure prophylaxis (PrEP) is increasingly recommended for preventing HIV in high-risk individuals. In the Asia-Pacific, as in much of the world, a large proportion of those who could benefit from PrEP are members of key populations (including men who have sex with men, people who use drugs, and sex workers). But PrEP remains severely underused in the region. To explore why and what could be done to increase uptake of PrEP, TREAT Asia asked four regional experts for their ideas.

Dr. Stephane Wen-Wei Ku is an infectious diseases physician and HIV/STD specialist at the Taipei City Hospital Renai Branch in Taiwan, and a TREAT Asia Network investigator supporting the Taipei Veterans General Hospital site. He is also on the Taiwan AIDS Society’s writing committee for their national PrEP guidelines and conducts PrEP-related research in Taiwan.

In Taiwan, our Centers for Disease Control implemented the first government-led PrEP demonstration project in 2016. But by the end of 2017, only 3% of men who have sex with men (MSM) in Taiwan were taking PrEP, according to a large online survey performed on a social network application for gay men. Major reasons why the survey participants were unwilling to use PrEP included: a) the high cost of PrEP in Taiwan, where PrEP is not reimbursed under our national health insurance scheme and generic TDF/FTC has not yet become commercially available; b) the limited access to PrEP services, which are usually only found in clinics run by HIV specialists in medical centers in metropolitan areas; and c) those most in need of PrEP, including MSM and other key population groups, do not have adequate awareness about PrEP, especially among the younger generation. These barriers are not limited to Taiwan and are common across Asia.

While policymakers and PrEP providers need to improve local infrastructure to scale up PrEP, in many Asian countries, stigma against HIV and LGBT communities still makes open, practical discussions about sexual well-being impossible. Stigma also presents a barrier to adopting novel HIV prevention tools. It is imperative to create a friendly, safe, and trustworthy environment for potential PrEP users from often-marginalized populations if we are determined to make PrEP truly available and accessible in Asia. 

(Left to right): Dr. Stephane Wen-Wei Ku, Taipei Veterans General Hospital; Ms. Boondarika Petersen, TREAT Asia; Dr. Yu-Jiun Chan, Taipei Veterans General Hospital, National Yang-Ming University

Professor Adeeba Kamarulzaman is the Dean of Medicine of the University of Malaya, the president-elect of the International AIDS Society, a founding investigator of the TREAT Asia network, and an expert and advocate around drug use, harm reduction, and HIV in the Asia-Pacific.

Pre-exposure prophylaxis has emerged as a powerful tool for HIV prevention. Recent evidence from Australia showing that a rapid, targeted roll-out of PrEP in New South Wales led to a 25% decline in new HIV diagnoses in just one year among men who have sex with men (MSM) is very welcome news.1 This study is representative of the majority of PrEP studies and national programs to date in focusing on PrEP’s use for the prevention of sexual transmission of HIV, particularly among MSM.

But the use of PrEP in people who use drugs (PWUD) is almost absent, in spite of the findings of the 2013 Bangkok Tenofovir Study showing that PrEP reduces HIV incidence by almost half among injecting drug users. Some clinicians have raised concerns about potentially low adherence rates among PWUD, which could lead to reduced effectiveness of PrEP and drug resistance. There are also concerns that PrEP could lead to an increase in high-risk behaviors because of a diminished perception of HIV risk. However, opportunities for implementation of PrEP for PWUD exist in the setting of substance use treatment programs, where daily attendance for methadone treatment provides the potential for directly observed therapy. Delivery of PrEP for PWUD could also be explored in needle and syringe programs.

Globally, PWUD continue to be left behind in the scale-up of antiretroviral and PrEP programs. We have to put in greater efforts to understand why this is so, and it is time that we turn our focus to conducting pilot and demonstration projects to assess the feasibility and efficacy of PrEP roll-out for PWUD in different settings. 

1 Population-level effectiveness of rapid, targeted, high-coverage roll-out of HIV pre-exposure prophylaxis in men who have sex with men: the EPIC-NSW prospective cohort study. Grulich AE, Guy R, Amin J, Jin F, Selvey C, Holden J, Schmidt HA, Zablotska I, Price K, Whittaker B, Chant K, Cooper C, McGill S, Telfer B, Yeung B, Levitt G, Ogilvie EE, Dharan NJ, Hammoud MA, Vaccher S, Watchirs-Smith L, McNulty A, Smith DJ, Allen DM, Baker D, Bloch M, Bopage RI, Brown K, Carr A, Carmody CJ, Collins KL, Finlayson R, Foster R, Jackson EY, Lewis DA, Lusk J, O'Connor CC, Ryder N, Vlahakis E, Read P, Cooper DA; Expanded PrEP Implementation in Communities New South Wales (EPIC-NSW) research group. Lancet HIV. 2018 Oct 17. pii: S2352-3018(18)30215-7.

Chris Lagman is the Senior Director and co-founder of LoveYourself, a non-governmental organization that provides HIV testing, prevention, and clinical support services in the Philippines.

The biggest hindrance in scaling up the use of PrEP for HIV prevention in the Philippines is our people's conservatism, due in large part to a highly religious, predominantly sex-negative culture. Rarely do you find Filipinos talking about sex in an educated way. Sex is a taboo topic and sex education is practically non-existent, so we end up learning about sex through friends and porn. We have not seen success of any sort in the use of condoms for prevention, so one can just imagine how PrEP would fare.

To move forward and wade through this very “viscous” situation, we need industrial-strength political will, efficient processes, and a united community, collaborating with a forward-thinking government. We need to focus our investment of resources where change is less hampered by politics and subject to special interests. This would clearly mean programs led by private groups, non-governmental organizations, and other community-based organizations. We need to truly strengthen the capacity of communities to implement change. Integration of these programs within institutions and sustainability are critical, so partnership with national and local governments should always be part of the equation.

(Left to right): Ms. Surang Janyam, SWING; Ms. Jennifer Sherwood, amfAR Public Policy Office; Dr. Dusita Phuengsamran, Institute for Population and Social Research, Mahidol University; Mr. Chamrong Phaengnongyang, SWING Foundation; Dr. Michele Decker, Johns Hopkins University

Surang Janyam is the Director of the Service Workers in Group Foundation (SWING), supporting HIV prevention and care outreach and programs focused on reaching sex workers and other vulnerable groups in Thailand.

Five years ago, PrEP emerged as a spectacular hope for us in the HIV/AIDS community for its effectiveness in HIV prevention. However, what held us back from adopting it was our limited knowledge and distorted understanding about PrEP. As PrEP involved taking an antiretroviral drug used to treat HIV infection, many of us were disinclined to use it because we identified ourselves as people not at risk for HIV and therefore had no need for PrEP.

At the same time, accessibility was the problem for people who wanted to take PrEP and did not know where they could get it, as it was not widely available and was not free of charge for all. Some people who started taking PrEP had problems with side effects or other complications and opted to stop taking it.

Most importantly, some governments did not think that PrEP was a useful tool to prevent HIV, but instead a harmful practice encouraging promiscuity and "irresponsible behaviors" among its users. For them, it was not reasonable to include PrEP in health insurance programs or offer PrEP as part of government-funded HIV prevention. In the end, not everyone could access PrEP, and this stopped people from seeking it out. The message was and has been that PrEP is not for everyone.

The solutions, therefore, include changing perceptions and attitudes about PrEP at all levels of the community and health programs. Awareness about PrEP needs to be spread, and myths and stigma about HIV and PrEP need to be eliminated. People need to be encouraged to seek out PrEP in order to overcome the confusing messages and incorrect information of the past.