Thailand was very early into the epidemic and a peak of
incidence was reached in injecting drug users as early as 1985, to be followed
closely by female sex workers and their clients in the early 1990s. Even as late
as 2000 there were more diagnoses among heterosexual women who were not sex
workers than among gay men.
Now, however, men who have sex with men (MSM) and transgender women (TGW) represent 29% of
new infections and more in urban sites: Donn Colby of the Thai Red Cross (TRC)
said that although MSM and TGW represent only 30% of clients at the HIV and STI
clinic run by TRC, they represent 90% of new HIV diagnoses. HIV prevalence in
high-risk gay men in Bangkok has been over 30% since 2007 and is about 7% in
the national MSM and TGW population.
About 5600 people have accessed
PrEP so far in Thailand, though not all are necessarily current users. PrEP provision in Bangkok
started as early as 2014, through the PrEP-30 scheme at the TRC’s clinics. Here, people could buy Thai-manufactured generic PrEP for
30 Thai baht a day (about US $0.90 or UK £0.70). This was followed in 2015 by a
small implementation research programme offering free PrEP in metropolitan
Bangkok and the tourist hub of Pattaya.
In early 2016 PrEP provision in Thailand at least doubled
when Princess Sirindhorn, the late king’s popular eldest daughter, announced
that she, supported by USAID, was sponsoring a programme to provide free PrEP
to 1000 people a year for the next three years. The "Princess PrEP" scheme
currently supplies PrEP to half the PrEP users in Thailand and has opened
clinics in Thailand’s second- and third-biggest cities, Chiang Mai and Hat Yai.
In this last year of its operation, it is targeting young PrEP seekers in a country
where the majority of new HIV infections are acquired by young and
adolescent MSM and TGW.
The beginning of 2017 marked the introduction of
PrEP by the Thai Public Health Ministry (MOPH), which added
three cities in the poorer north-east of the country and its second tourist
mecca, Phuket. The number of MOPH PrEP prescriptions is currently limited but
is expanding quite rapidly. Some form of free PrEP is now available to MSM,
TGW and serodiscordant couples in 26 of Thailand’s 76 provinces.
Seven community organisations in the three biggest cities
plus Pattaya are included as pilot PrEP providers in a so-called Key
Populations-Led Health Service scheme (KP-LHS). Presenter Ravipa Vannakit from USAID described
these as “learning labs” where community-based organisations provide HIV
testing and self-testing facilities as well as PrEP. Between them the KP-LHS
centres are now providing PrEP to 30% of PrEP users in Thailand –1467 MSM and
The average age of PrEP seekers is 29 in MSM and 26 in TGW but some
centres are reaching younger people: for instance, in the Rainbow Sky Association clinics
in Bangkok and Hat Yai, which provide PrEP for 865 people between them, 46% of
TGW and 31% of MSM are under 24, and 18% of TGW are under 19.
Other than ages, the characteristics of MSM and TGW PrEP
users were similar apart from two big differences: a third of TGW but
only 7% of MSM were or had been sex workers, and only 34% of TGW but 71% of MSM
had a college or university education.
As in some other settings, retention has proven to be an issue.
Nearly half of TGW (46%) and 23% of MSM did not return for their one-month
visit after starting PrEP; after 12 months, only 47% of MSM and 25% of TGW
were still returning for their three-monthly check-ups and refills.
One unexpected finding is that it was presumed that when PrEP
become available for free through the other programmes, demand for 30-baht PrEP
would decrease. This has not happened; the number of new clients per month at
the Thai Red Cross clinics in Bangkok has increased from about 25 in
late 2015 to about 80 a month now, with a cumulative total of about 1850 people
having started PrEP. Donn Colby believes
that a lot of the paying customers are people who might not qualify for the
free PrEP schemes, including heterosexuals and foreigners, but also that the
amount of personal information required at the clinics is less: “Some of our clients may have reasons to value privacy,” he said.