Linkages Across the Continuum of HIV Services for Key Populations Affected by HIV Project (LINKAGES) Cooperative Agreement No. AID-OAA-A-14-00045

THAILAND QUARTERLY PROGRESS REPORT APRIL 1 – JUNE 30, 2018

JULY 31, 2018

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 1

Acronyms & Abbreviations

AIDS Acquired Immune Deficiency Syndrome amfAR American Foundation for AIDS Research APCOM Asia-Pacific Coalition on Male Sexual Health ART Antiretroviral Therapy ARV Antiretroviral BATS Bureau of AIDS, TB and STIs BKK Bangkok BMA Bangkok Metropolitan Administration CBO Community-based Organization CBS Community-based Supporter CD4 Cluster of Differentiation 4 CDC Centers for Disease Control CHC Community Health Center CHW Community Health Worker CPI Consumer Price Index CREC Central Research Ethics Committee CST Care, Support and Treatment C&C Counseling & Care, Support and Treatment DDC Department of Disease Control DIC Drop-in Center DQA Data Quality Audit DSD Direct Service Delivery DSD Differentiated Service Delivery EA Expenditure Analysis EPM Enhanced Peer Mobilization/Mobilizer Model F2F Face-to-Face FDA Food and Drug Administration FSW Female Sex Worker HCP Health Care Provider HITAP Health Intervention and Technology Assessment Program HIV Human Immunodeficiency Virus HIVST HIV Self-testing HTC HIV Testing & Counseling IAS International AIDS Society ICT Information and Communication Technology IP Implementing Partner IRB Institutional Review Board KP Key Population KPLHS Key Population-led Health Services M&E Monitoring & Evaluation MOU Memorandum of Understanding MoPH Ministry of Public Health MSM Men who have Sex with Men MSW Male Sex Worker NAP National AIDS Program NGO Non-governmental Organization NHSO National Health Security Office O2O Online-to-Offline OF Oral Fluid

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 2 OI Opportunistic infection PATH Program for Appropriate Technology in Health PCM Provincial Coordinating Mechanism PEP Post-exposure prophylaxis PEPFAR President’s Emergency Plan for AIDS Relief PHO Provincial Health Office PHSC Protection of Human Subjects Committee POC Point-of-Care PPAT Planned Parenthood Association of Thailand PR-DDC MoPH Principal Recipient Administrative Office Department of Disease Control PrEP Pre-exposure Prophylaxis PTY Pattaya PWID People Who Inject Drugs QA/QI Quality Assessment/Quality Improvement RDMA Regional Development Mission Asia RFA Request for Applications RNA Ribonucleic Acid RNR Risk Network Referral RRTTPR Reach-Recruit-Test-Treat-Prevent-Retain RSAT Rainbow Sky Association of Thailand RTCM Real-time Cascade Monitoring RTF Raks Thai Foundation SBCC Social and Behavior Change Communications SDART Same-day ART SESH Social Entrepreneurship for Spreading Health SIMS Site Improvement through Monitoring System SMS Short Message Service SOP Standard Operating Procedure STI Sexually-transmitted Infection SWING Service Workers in Group TA Technical Assistance TB Tuberculosis TG Transgender TGM Transgender Man TGSW Transgender Sex Worker TGW Transgender Woman TRCARC Thai Red Cross AIDS Research Center USAID United States Agency for International Development VPR Voluntary Partner Referral WHO World Health Organization

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 3 Narrative I: Executive Summary During FY18 Quarter 3 (FY18-Q3), LINKAGES Thailand continued to work in close collaboration with existing local implementing partners (IPs) and expanded its support to other health care facilities to strengthen combination HIV prevention, care and treatment interventions among members of key populations (KPs), including men who have sex with men (MSM), male sex workers (MSWs), transgender women (TGs), transgender sex workers (TGSWs), and female sex workers (FSWs).

Figure 1. Achievements by quarter, FY18

* PrEP percentage shows proportion of annual target achieved

During this reporting period, LINKAGES reached a total of 12,025 KPs with HIV prevention education and commodities. Below is a full breakdown of HIV prevention, care and treatment services including Direct Service Delivery (DSD) and Technical Assistance (TA) combined: ● 7,385 MSM; 1,214 MSW; 1,353 TGs; 357 TGSWs; and 1,716 FSWs were reached with HIV prevention interventions. The combined number of clients counted under KP_PREV this quarter includes 11,017 reached through outreach activities and 1,008 who received a full package of HIV prevention services as walk-in clients. Combined Q1-Q3 achievements reflect 40% of expected FY18 achievement for the KP_PREV indicator. ● 460 MSM, 6 MSWs, 34 TGs, 27 TGSWs and 7 FSWs were initiated on PrEP. During FY18 Q1- Q3, 1,765 KPs initiated PrEP, accounting for 105% of the FY18 PrEP_NEW target. ● 9,196 MSM; 515 MSWs; 1,006 TGs; 200 TGSWs, 1,754 FSWs and 77 PWID were provided HIV testing and received their results, along with 509 non-KP males and 649 non-KP females. Combined FY18 Q1-Q3 achievements account for 56% of the FY18 HTC_TST target. ● Of the above, 749 MSM, 26 MSWs, 71 TGs, 22 TGSWs, 11 FSWs and 8 PWID tested HIV- positive, along with 80 non-KP men and 42 non-KP women. The overall case-finding rate was

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 4 7.3% and the newly-identified positive cases in Q1-Q3 account for 37% of the total FY18 HTS_TST_POS target. ● 606 MSM, 28 MSWs, 50 TGs, 10 TGSWs, 8 PWID and 2 FSWs were newly initiated on ART, along with 231 non-KP men and 116 non-KP women. As of the end of FY18-Q3, there were 3,017 MSM; 318 MSWs; 273 TGs; 40 TGSWs; 51 FSWs and 59 PWID clients actively receiving ART, as well as 6,268 non-KP men and 5,796 non-KP women. FY18 Q1-Q3 treatment achievements account for 31% and 156% of the TX_NEW and TX_CURR targets respectively, though the TX_CURR indicator is not cumulative and the final achievement will be counted only against the total number of clients on treatment as of the end of FY18 Q4.

Specific programmatic achievements during this reporting period include the following: ● LINKAGES partners attained their highest level of HIV-diagnosed clients initiating ART compared to previous quarters. This was attained through increased implementation of SDART and improved peer navigation services to hospitals. Despite this achievement, LINKAGES has only reached 31% of its FY18 target of 8,626 individuals initiating ART. ● LINKAGES Thailand partners have already exceeded FY18 targets for service delivery under PrEP_NEW. ● LINKAGES online-to-offline strategy continues to generate increased HIV testing, and this strategy is now being replicated in India, Nepal, and Vietnam.

Specific challenges in this reporting period: ● LINKAGES partners together reported an overall decrease in reach, HIV testing, HIV case finding, and PrEP compared to previous quarters. Although MPlus and Sisters reported higher reach achievements this quarter compared to the previous quarter, all other partners had lower reach which had a domino effect on decreased performance on HIV testing and case finding. This was due to a variety of issues, including lower service uptake during Songkran and staffing issues in numerous agencies. ● Reductions in PrEP uptake from 2018 Q2 signal that more intensive communication interventions on the benefits of PrEP are needed to stimulate increased demand. These are planned to begin in 2018 Q4. ● The Pulse Clinic data review continued during this quarter. Any changes to FY18 results necessitated by this data review will be reflected in the Q4 report.

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 5 Narrative II: Achievements and key challenges encountered during the reporting period by thematic area:

A. HIV prevention and linkage to HIV Testing & Counseling services (HTC)

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 6

In FY18-Q3, LINKAGES Thailand implementing partners continued to provide HIV prevention and referral services through one-on-one outreach, small group activities and online/social media activities. During this reporting period, all implementing sites experienced a declined reach coverage except Sisters, which experienced a 104% increase in number of KPs reached. (Note that numbers in the main body of this report refer to service delivery as per PEPFAR-defined MER indicators. For a full discussion of cohort performance across the cascade of HIV services, see the discussion of eCascade performance included as Appendix 1 of this report). Through the combination of the HIV prevention activities, a total of 12,025 KPs were reached in Q3, including 11,0171 reached through various outreach activities and 1,008 who walked in at LINKAGES-supported community health centers and received the full package of HIV prevention services. Total KP_PREV performance in FY18 Q3 which was equivalent to a 12% decrease against Q2.

Sisters’ outreach program improved significantly this quarter due to the expansion of activities in Sattahip and Laemchabang districts and online outreach channels, such as Facebook, under the direction of a new outreach supervisor and the new outreach team. In addition, Sisters maximized previous efforts on existing service strategies for hormone services and through a network of key transgender opinion leaders.

The sharpest decrease in outreach performance was seen at Caremat where the number of KPs reached dropped by 56% over the last quarter as they re-strategized and shifted activities to focus on their Test-and-Treat study, which drew outreach staff members away from outreach activities. The overall number of KPs reached by SWING also dropped, by 23%, as SWING Bangkok faced significant challenges in providing outreach activities in venue settings when several bars and pubs in the Surawong area were forced to close down by the new land owner.

In addition, the overall number of venue-based sex workers reached dropped as more male sex workers shifted to working through non-venue-based and online channels. SWING Bangkok and Pattaya were both affected by this change, as reflected in low outreach performance during this reporting period. SWING is now adapting their outreach activities and re-strategizing plans to reach more online and non-venue-based sex workers.

For Rainbow Sky Association of Thailand (RSAT), the overall number of KPs reached also dropped, by 4.5%, with the sharpest decreases of 41% at RSAT Ubon Ratchathani and 47% at RSAT Pathum Thani. RSAT Ubon Ratchathani was understaffed due to the resignation of two experienced staff and turnaround time as newly recruited staff were being trained on outreach. RSAT Pathum Thani showed a significant decrease in outreach performance in Q3, consistent with last year’s figures; RSAT has traditionally planned a heavier schedule of outreach activities in Q2 because they know that coverage will decrease in Q3 due to Songkran and university holidays. Tangerine Clinic, despite reaching 164 individuals through one-on-one online outreach discussions did not report KP_PREV for this period due to a misunderstanding regarding the requirements that must be fulfilled to claim service delivery achievements toward this indicator. LINKAGES has addressed this misunderstanding with them and KP_PREV achievements will be reported in Q4.

Online Outreach and Recruitment For online outreach and recruitment, LINKAGES and its IPs continued to explore activities to improve coverage of target populations that preferred less of a face-to-face (F2F) outreach strategy. Facebook Live is a major tool for partners Tangerine and Mplus who use this strategy to enhance access hidden populations; during this reporting period, for instance, Mplus reported that while conducting special events to attract attention from KPs, they successfully recruited 50% of the

1 Outreach total includes 1,414 KP clients who were offered but declined referral to HIV testing services, and 18 clients who self-reported being HIV positive. The remaining 9,585 clients were provided referral to testing.

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 7 participants at a pool party and 70% of participants at the Ram Wong Event from Facebook Live. Sisters Foundation also marked their first instance using Facebook Live by recruiting 33 KP_PREV, 9% of whom came and got tested at the health center afterward. SWING Bangkok also referred 16% of all people tested during the Trasher Bangkok event through Facebook Live and social media promotion.

FHI 360 is now working with LINKAGES Partners to expand and strengthen the use of Facebook Live to link clients to “offline” for HIV testing through online booking. The targeted partners are RSAT Hat Yai, Ubon Ratchathani, Chonburi and Bangkok, as well as SWING Pattaya.

LINKAGES also continues to collaborate with volunteer online recruiters who use the Res99 online- to-offline (O2O) system to drive contacts to HIV testing services. The O2O tool was initially launched only within the Bangkok area, but now the system can make reservations for nine clinics or health facilities in three sites: Bangkok, Chiang Mai and Pattaya. In addition, O2O trainings have been provided to partners in Chiang Rai, Ubon Ratchathani and Hat Yai, where we expect launch by Q4 of 2018. In the recent reporting period, staff at LINKAGES-supported health centers have also done a better job at recording when O2O clients arrive at the clinic, improving the quality of O2O data.

LINKAGES Thailand pioneered this use of “URL tokens” to measure the effectiveness of online outreach, and now other HIV programs in the region have installed and augmented the application, adjusting aspects to fit their own contexts. India launched yes4me.net on May 15, and Nepal will launch merosathi.net this quarter, with a version by USAID SHIFT in Vietnam following next.

As of the writing of this report, O2O clients have created 2,702 reservations, 1,488 of which saw clients successfully arrive for reservations. A “successful” referral rate of 55% is a marked improvement over the roughly 1/3 of outreach clients who accept referral to an HIV testing center and actually follow through on that referral.

In Q3 specifically, the number of reservations in the O2O system increased by 25% over Q2, from 640 reservations to 798, while actual testing increased by 18% and testing yield among the 181 clients for whom we have testing yield data went from 6% in Q2 to 15% in Q3. Across the board, testing uptake among clients who make testing reservations has declined, however, and this may represent lower effectiveness of online communications by outreach workers and social media influencers. It may also speak to the need to introduce strengthened behavior change tools and messaging, such as the HIV risk assessment tool that remains under development by TRC. The great majority of clients recruited by the O2O system and successfully tested (93%) were MSM, with an average age of 28 years (range 16-53), and 84% reported having never previously received an HIV test. The largest numbers of reservations were for RSAT Bangkok, TRC Anonymous Clinic and SWING Bangkok in that order. As shown in Table 1, figures related to the testing results of clients that arrive through the reservation system are based on the 181 clients for which clinic staff correctly linked the reservation record with the resulting eCascade record. LINKAGES continues to face challenges motivating partner agencies to link O2O reservations with eCascade data collection, and in Q3 there was no eCascade record for 56% of all tested O2O clients. LINKAGES has attempted to increase partner diligence by creating an automated report of reservations to be linked, with scannable QR codes, to ease the linking of these O2O records to eCascade records. Online advertising, both paid and organic, continues to account for the largest percentage of reservations and testing follow-through (44% and 40% respectively), followed by outreach workers

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 8 and social media influencers. Direct referral, or clients who go directly to the O2O reservation system without being redirected from another site, accounts for roughly 11% of reservations and 9% of tests. Roughly 2% of all reservations and tests were made directly by implementing partner staff on behalf of clients who wished to make an appointment. As noted above, overall testing yield in Q3 was 15%, and 68% of clients tested positive are already enrolled on ART. Among O2O clients who tested negative this quarter, 16% accessed PrEP. HIV case finding was high among clients referred via online advertisement (16%) and among “direct referral” clients (16%), although these rates were achieved among small numbers of clients. Surprisingly, the highest testing yield (18%, n=12) was among online clients recruited via outreach workers – who previously had contributed no new HIV-positive clients via online recruitment. These new HIV- positive cases were almost exclusively recruited by RSAT BKK online outreach workers, and further investigation is necessary to understand where these clients were recruited and how RSAT was able to target such high-risk individuals. LINKAGES also worked to launch a Facebook “micro-targeting” campaign aimed at reaching hidden populations who do not identify as MSM online. In Q3, LINKAGES observed and shortlisted Facebook Fan pages which are believed based on their content to have significant numbers of KP followers. Targeting parameters have been set based on focus group discussions conducted in FY18 Q1-2, and draft advertisements have been created – the microtargeting activity will be launched in early FY18- Q4.

Table 1. Outcomes of Online Outreach and Test Promotion via Res99, July 2017-June 2018 Reservations Arrived Clients Results Available Positive On ART On PrEP LOP 2,595 1,433 (55%) 577 59 (10%) 40 (68%) 58 (11%) FY18 Q3 798 394 (49%) 181 27 (15%) 20 (74%) 25 (16%) FY18 Q2 640 335 (52%) 179 11 (6%) 8 (73%) 21 (13%)

Outreach 181 111 (61%) 65 12 (18%) 10 (83%) 7 (13%) Influencer 158 84 (53%) 46 4 (9%) 4 (100%) 7 (17%) Advertising 355 156 (44%) 45 7 (16%) 4 (57%) 8 (21%) Direct Referral 88 36 (41%) 19 3 (16%) 1 (33%) 3 (19%) Office 16 7 (44%) 6 1 (17%) 1 (100%) 0 (0%)

Pre-exposure Prophylaxis (PrEP) LINKAGES partners continued to promote PrEP under the Princess PrEP Project. In this quarter, a total of 534 KPs (460 MSM, 6 MSW, 34 TG, 27 TGSW, 7 FSW) received PrEP for the first time, which brings the total number of people receiving PrEP_NEW to 1,765 persons, or 105% of the annual PrEP_NEW target. However, new PrEP acceptors have decreased from the previous quarter, with 534 individuals initiating PrEP compared to 554 in Q2 (See below graph). This suggests that communications interventions are needed to stimulate further PrEP demand among MSM and TG.

PrEP performance at SWING Bangkok has gradually increased in each quarter. In this quarter, 106 individuals started PrEP, of whom 98% were general MSM. This is also true for SWING Pattaya, where higher numbers of general MSM received PrEP.

Promotion through online outreach activities seems to be one of the factors why LINKAGES IP, SWING, is attracting more general MSM to start PrEP, and this has contributed to SWING exceeding its annual PrEP_NEW target by 55% in this quarter.

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 9 PrEP_NEW (Q1 FY16-Q3 FY18) 600 554 534

500 469

400 366

300

190 185 200 159 145 107 88 100 35

0 Q1 FY16Q2 FY16Q3 FY16Q4 FY16Q1 FY17Q2 FY17Q3 FY17Q4 FY17Q1 FY18Q2 FY18Q3 FY18 RSAT ALL SWING ALL TRC ALL Sisters Caremat Mplus Total

To accelerate PrEP scale-up, LINKAGES in FY18 has worked with Social Entrepreneurship to Spur Health (SESH), a Chinese organization founded by crowdsourcing experts together with the University of North Carolina, to launch the Ready-PrEP-Go crowdsourcing contest (https://www.facebook.com/ReadyPrEPGoTH/) to generate new and innovative PrEP messages and communication products targeting young, high-risk MSM and TG. During Q3, LINKAGES developed and distributed several promotional videos and posters, worked with social influencers to raise awareness about Ready-PrEP-Go, conducted in-person events at seven universities and displayed sign-up materials across 24 different faculties to encourage participation.

As of the writing of this report, the Ready-PrEP-Go campaign has reached more than 100,000 individuals, 25,414 of them during the crowd judging period from June 1 to June 20. The Ready-PrEP- Go Facebook Page has 468 fans, the vast majority of whom are Thai individuals based in LINKAGES- supported project sites – while Facebook does not provide public information on the sexual preferences or behaviors of users, 56% of Ready-PrEP-Go fans were males, and 72% were between the ages of 18 and 24.

Through Ready-PrEP-Go, LINKAGES received 16 entries - 5 videos and 11 images. All 11 images and 4 of the videos moved on to crowd judging,2 where the materials were organized via the Ready-PrEP- Go Facebook Page and members of the public were encouraged to “vote” on their preferred materials by Liking or Sharing them with members of their social networks. Crowdsourced materials have been viewed more than 10,000 times since the page was launched, and during the crowd judging period specifically there were 5,600 views and 9,085 unique engagements with crowdsourced materials. We calculate an engagement rate with Ready-PrEP-Go of 98% during the crowd judging period, as compared with a typical Facebook engagement rate with a promotional campaign of 2-4%. The extraordinarily high engagement rate with Ready-PrEP-Go materials is in part a result of the small number of Ready-PrEP-Go “fans”; however, the high ratio of engagements to fans indicates that the crowd judging strategy was successful at fueling high organic (i.e. unpaid) reach and engagement from a small but active core of fans. It is additionally encouraging that more than 99% of sentiments expressed through audience engagements were positive, and included numerous PrEP-related questions - “What is PrEP?” and “Where can I buy PrEP?’’ – to which our team were able to reply directly with reliable information regarding PrEP and general sexual health and testing. An analysis of Google Search Trends in Thailand during the contest period reveals there

2 One video was disqualified for failing to meet the minimum standards as specified in the contest rules.

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 10 was additionally an increase in the number of Google searches for the most-used Thai terms for PrEP3 compared to the period immediately before the contest, suggesting that contest activities may have contributed to increased online interest in this HIV prevention strategy.

At the end of the crowd judging period, we calculated the overall votes by adding up the numbers of ‘Likes’ and ‘Shares’. Five of the Images and three of the videos with the highest number of votes moved to the next round of expert judging. The expert judging panel consisted of healthcare professionals, communications, marketing professors, community-based organization (CBO) workers who work directly with young TG and MSM, and FHI 360 staff. Entries were scored based on four main criteria: content, creativity, technique and effectiveness. As a result, the top three images and three videos were selected to be finalists. Judges also selected two of the top videos and the top image for further development.

LINKAGES then pre-tested the 2 videos and 1 image with 55 members of key populations (20 MSM, 35 TG) in Bangkok and Chiang Mai, ages 19-27, 75% of whom had not previously been exposed to the Ready-PrEP-Go contest. In general, participants described the materials of easy to understand, designed for members of key populations, attention-getting and believable, though the video products performed better than the static image, and there was a clear preference for one video. The results of this pre-test will be used as input for further development of the products. Designers of the finalists’ products will work directly with a professional marketing company to polish their work by using comments provided by judges as well as comments collected from our key population (55 young MSM and TG). A new campaign launch to promote these materials to the key population is expected to be developed by the end of August.

B. HIV Testing & Counseling (HTC)

In FY18-Q3, LINKAGES implementing partners and partner hospitals successfully provided HIV testing services to, and shared results with, 13,906 (13,653 DSD, 253 TA) clients, 12,748 of whom were KPs. As in FY18-Q2, LINKAGES continued to support provision of HTC services for clients who could not be identified as members of a key population, accounting for 8% (n=1,158) of all service delivery reported under the HTS_TST indicator this quarter. The majority of non-KP clients (82%) received HIV testing services at the extended network of service delivery hospitals, which continued to receive ongoing technical assistance from LINKAGES.

In total, LINKAGES Thailand at the end of this reporting period has achieved 56% of the annual HTS_TST target, and testing for FY18-Q3 represents an 11% decline compared to the previous reporting period. This decline occurred despite the addition of 19 new healthcare facilities reporting testing figures based on technical assistance provided by LINKAGES. In total, non-DSD healthcare facilities receiving LINKAGES TA accounted for 17% of all HIV testing reported during Q3 (and 25% of all case finding); the actual decline in HTS service delivery among community partners during this reporting period was 13%.

3 Searches for “ยยยยยยย” (PrEP medicine in Thai) doubled during the contest period, while searches for “ยยPrEP” (half Thai half English) increased from approximately 1100 to 1900 when compared to the period immediately before the Ready-PrEP-Go campaign.

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 11 Figure 3. HTC performance, by quarter, FY15-Q2 to FY18-Q3

The largest decreases in testing uptake were seen at Mplus, Caremat and SWING Pattaya. Caremat testing significantly decreased because LINKAGES reduced their staff size and scope of activities to focus on capacity building and completion of research goals under the Test and Treat Cohort Study. A significant proportion of the testing target for Caremat was shifted to Mplus in Chiang Mai, which despite decreases in testing this quarter have already achieved 96% of their annual target through a combination of online advertisement on Facebook and Gay apps and online safe-sex counselling, as well as mobile HIV testing at major festivals, events and KPs hotspots. Mplus Chiang Rai did see a significant decrease in testing (53%) but they plan to introduce additional mobile testing events in Q4 to make up the difference. SWING Pattaya, while also reporting a decrease in testing uptake, has already exceeded their testing target for FY18.

In short, difficulties achieving the HTS_TST indicator are not chiefly attributable to sites which underperformed in FY18 Q3 compared to previous quarters; the chief difficulty is underperformance in metropolitan Bangkok with regards to LINKAGES IPs in those sites failing to achieve expected targets as well as the relatively large number of unassigned targets in those sites. LINKAGES is working to expand collaborations with private providers and engagement with health centers under the BMA to provide service for KPs in wider areas.

Tangerine Clinic has continued to increase its HIV testing performance by utilizing its online recruitment and networking platforms through online community influencers. In this reporting period, 399 transgender women (TGW) and 33 transgender men (TGM) received HIV testing and counselling; 53% of these TG clients were reached online through Tangerine Clinic’s Facebook page, and of those 52 (23%) were first-time HIV testers.

In this reporting period, SWING Bangkok provided HIV testing services to 1,688 individuals, including 766 FSWs and, in total, has by the end of the quarter achieved 50% of their annual target for FSWs and 91% of their annual target for MSM/TG. SWING Bangkok is planning to revise their existing strategy to better reach FSWs on social media and chat platforms and to recruit more peer leaders to help identify potential venues for mobile testing.

With regards to HIV case finding, a total of 1,009 individuals were confirmed HIV-positive during this reporting period (7.3%), which accounts for 37% of the annual target for HTS-TST_POS. Case finding rates by KP group are as follows:

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 12 ● 9,196 MSM with a case finding rate of 8.1% ● 515 MSWs with a case finding rate of 5% ● 1,006 TGs with a case finding rate of 7.1% ● 200 TGSWs with a case finding rate of 11%, ● 1,754 FSWs with a case finding rate of <1% ● 77 PWIDs with a case finding rate of 10.4% ● 509 non-KP males with a case finding rate of 15.7% ● 649 non-KP females with a case finding rate of 6.5%

An HIV case-finding rate of 15.7% among non-KP males would suggest this group represents a high- risk population (potentially non-self-identified KPs); however, this number should be interpreted with caution as some non-LINKAGES healthcare facilities may have systematically underreported on members of the general population who tested HIV negative, skewing the case-finding rate for these groups unrealistically high.

Encouragingly, HIV testing uptake among TG and TGSW clients in FY18-Q3 showed a 32% increase over the previous quarter, and the case finding rate among these tested clients was 8%. These increases were probably the result of social interventions and TG online influencers, as it was reported that 53% of those seeking services were reached through the Tangerine Facebook page, and of those, 23% were first-time HIV testers. Tangerine has made integration of hormone monitoring services a major focus of their online promotional efforts, and during this quarter the Tangerine team provided technical assistance to Sisters, Caremat, RSAT and SWING on gender- affirmative hormone level monitoring services, providing hormone monitoring support to a total of 250 TGW. Of those, 249 received HIV testing and 14 were tested HIV-positive; HIV case finding rate was at 6%.

In collaboration with LINKAGES Thailand, Tangerine also successfully partnered with the Bangkok Metropolitan Administration (BMA) to organize a training on PrEP scale-up and hormone level monitoring among transgender women, attended by 130 BMA health staff.

Figure 4. HTC Uptake and yield, by partner, FY18-Q3

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 13 Overall HIV case finding among LINKAGES implementing partners remains virtually unchanged from the previous quarter. The Thai Red Cross Anonymous Clinic continued to be the largest HIV testing service provider for KPs and continued to achieve the highest case finding in terms of both proportion (10%) and absolute number of new HIV-positive cases identified (418).

Following declines in performance on HIV testing and HIV case finding in the last quarter, LINKAGES technical and program staff worked with partners to re-strategize their outreach and testing approaches. A significant improvement in HIV case finding can be seen at RSAT Ubon Ratchathani and Chonburi, where HIV case finding increased from 8% to 12% and 3% to 14% respectively, whereas the overall RSAT case finding rate was at 6%.

HIV Testing Service Delivery Models As in previous quarters, facility-based HIV testing accounted for 77.6% of all HIV testing uptake (among KP clients only) during this reporting period, with an 8.1% case-finding rate, while 21.9% were attributable to non-sauna based mobile testing, with a 2.8% case-finding rate. Mobile testing, as noted above, has been a major vehicle by which partners have increased testing uptake: however, in FY18-Q3 mobile testing numbers among KPs decreased 44.4% from the previous quarter, while facility-based testing decreased by only 1.2%. Mobile testing activities also are not contributing significantly to increased case finding rates. It is worth noting here that FSWs account for 46% of all mobile testing uptake and 73.2% of all FSW testing is accomplished via mobile services; reported HIV seroprevalence is much lower among FSWs compared with other key populations, as borne out by notably lower case finding among FSWS than among the MSM/TG population under the LINKAGES project, at 0.5% versus 4.8%.

Sauna-based testing, while implemented on a limited scale, has in previous quarters contributed significantly higher rates of HIV case-finding. However, among the 75 KP clients who received a sauna-based test during this reporting period, only 7 new positive cases were detected (9.13%). Previous data analysis suggested saturation at existing sauna-based testing sites; new cases detected this quarter were the result of a new sauna testing site added to the project.

LINKAGES Thailand has also been recruiting new testing clients using a clinic-based recruitment model called Social Network Strategy (SNS) through RSAT Bangkok and RSAT Songkhla. During this reporting period, 71 clients were referred for testing via SNS at these two sites and 10 of them were found to be HIV-positive (14%)m a case-finding rate higher than the average case detection from EPM in those centers (RSAT Bangkok: 8% and Songkhla: 9.2%). These two centers also tracked recruitment using a total of 9 HIV-positive peer mobilizers, who referred 20 clients to testing with a 10% case-finding rate.

LINKAGES is working to integrate lessons learned under the SNS model into a wider Index Testing approach consistent with PEPFAR’s global focus on increased case finding though index testing and partner notification. During FY18-Q3, key LINKAGES and TRCARC staff attended a regional Index Testing workshop in Bangkok hosted by the Global LINKAGES Project and LINKAGES Thailand. This workshop aimed to understand the Index Testing model and how to build on the existing EPM approach as well as clinic-based recruitment of HIV-positive peer mobilizers. LINKAGES Thailand staff are finalizing an online training package on a KP-specific index testing model (Risk Network Testing) that will be rolled out to all partners and shared with LINKAGES projects regionally.

HIV Self Testing Implementation Science Regarding the HIV self-testing operations research, the study team met with the Public Health Office (PHO) in Chonburi and Chiang Mai during Q3 to obtain permission to implement the second phase of the oral fluid studies in both provinces. The team discussed the preliminary findings of Phase 1 and

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 14 explained the new procedures for Phase 2. Ethical clearance from the Institutional Review Board (IRB) of Chulalongkorn University was obtained on March 6, 2018 and the letter of approval was immediately shared with both PHOs. PHO Chonburi issued the permission letter on April 5 and PHO Chiang Mai on May 2.

In April 2018, the study team organized a workshop in Bangkok for 20 participants to discuss experiences and strategies for recruitment and enrolling participants through social media. As most of the participants who were enrolled through social media during Phase 1 opted for HIVST versus peer-mediated testing, the study team wanted to encourage the study staff to recruit participants through social media during Phase 2 of the study. SWING BKK and Mplus also had an opportunity during this workshop to share their experiences and tips for successfully recruiting participants through social media.

In mid-April, the study team held trainings for staff of the five research sites, RSAT, SWING BKK, Mplus, SISTERS and SWING Pattaya. The dates were April 19-21 in Bangkok for 30 participants; May2-4 in Chiang Mai for 19 participants and May 9-11 in Pattaya for 23 participants. These trainings aimed to review the key procedures for recruitment, enrollment, screening and follow-up of participants enrolled in the study.

After receiving their letter of approval from Chulalongkorn IRB, the study team then submitted the application package to the Thai FDA to obtain a waiver for importing the HIVST kits, with the FDA granting approval on June 5, 2018. The test kits passed quality control by the FHI 360 senior laboratory specialist before delivery to research sites together with other study documents and essential materials. The site-specific study activation notice was sent to the five research sites on June 21, and enrollment of participants in Phase 2 began immediately. As of July 25, 2018, the number of enrolled cases are showed in the below Table.

Table 2. Number of participants enrolled in Phase 2 of the of study, June 21 to July 25, 2018 Peer mediated Self-Testing Total/Site RSAT_BKK 51 13 64 SWING_BKK 11 11 22 MPLUS_CNX 0 3 3 SISTER_PTY 1 4 5 SWING_PTY 19 29 48 Total /Option 82 60 142

Site monitoring visits were conducted in each research site immediately after the enrollment of participants for Phase 2. During each visit, the participant binders pending from phase one and from those newly enrolled in phase two were reviewed and the OF team identified and discussed the issues with the research site teams, making corrections accordingly in participant binders and in the LINKAGES Thailand database used for the study.

LINKAGES Thailand then shared with the Bureau of AIDS, TB and STIs (BATS) the preliminary key findings of Phase 1 and discussed the content of the letter to the Thai-FDA for justifying needed changes in MoPH regulations for supporting HIVST in Thailand. This letter, and attendant documentation, were submitted to Thai FDA in May 2018, and Thai FDA then set up a committee to review the letter, although no meeting has been organized yet.

However, the BATS team is planning to approach the Vice Minister of Public Health during the bi- annual review of the National Guidelines on HIV/AIDS, planned for July 2018, to advocate HIVST to the Thai FDA committee. The BATS team is also planning to ask the Deputy Director of the

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 15 Department of Disease Control to hold a formal meeting with Thai FDA to discuss next steps for moving forward HIVST in Thailand.

The MoPH Principal Recipient Administrative Office (PR-DDC) is planning to use the oral fluid-based self-testing for this year in their Global Fund-supported program in Thailand. PR-DDC has requested BATS to provide guidance for the development of the oral fluid-based self-testing guidelines, and BATS has approached the US CDC Thailand-U.S. CDC Collaboration (TUC) team for technical assistance on the guidelines for the lab component only. When that draft is finalized, they will conduct a meeting to review the guidelines and LINKAGES Thailand may participate in this review.

Capacity Building for HIV Testing Services In capacity building for KP-led counseling and testing services, during Q3 LINKAGES Thailand, led by TRCARC, continued to implement an HIV clinical service quality improvement process for counselors and CST staff through on-the-job training for six new community health centers in Chiang Rai, Ubon Ratchathani, Pathum Thani, Samut Prakan, Nonthaburi and Chonburi provinces. This aimed to strengthen basic counseling skills on encouraging clients to stay HIV-negative and to initiate ART in a timely manner, and to reduce stigma & discrimination and related social concerns regarding HIV serostatus.

In June of this quarter, FHI 360 collaborated with TRCARC and the USAID Community Partnership on the workshop “Standardization to Foster Counseling, Care & Support and Treatment QA/QI Measures” for provincial-level staff in counseling, care & support, and treatment quality assurance. People who attended are members of provincial advisory committee who will act as a network body focusing on assessing counseling and CST services in KPLHS. The workshop aimed to standardize counseling and CST measures so that all members understand the method used and can perform assessments at the same standards for all nine provinces.

The committee members are health care professionals from key stakeholders including the provincial health office (PHO), Office of Prevention and Disease Control (OPDC), National Health Security Office (NHSO) and key referral health care facilities as shown below: ● 3 health care professionals from NHSO region 13-BKK and region 12-Songkla ● 6 health care professionals from Patumthani, Samut Prakan, Chiang Rai, and Ubon PHOs ● 1 health care professional from BMA ● 5 health care professionals from OPDC region 12-SK, region 10-Ubon, region 6 Chonburi, region 1-Chiang Mai, and the Urban Institute for Disease Prevention and Control-Nonthaburi ● 23 health care professionals from 22 key referral hospitals ● 13 clinic managers from KPLHS partners ● 6 staff from TRCARC & UCP

The duties of these committee members will be to assess the quality of counseling and CST services under the KPLHS model in FY18-Q4 and provide feedback and suggestions to improve the quality of HIV/AIDS-related healthcare service delivery. LINKAGES will support QI in all KPLHS sites as suggested by the committee. QA/QI committees are now functional in five provinces. Committee members have already helped in sharing resources among KPLHS and local health care organizations. To promote sustainability, these committees will be the link to KPLHS pools of potential networks/partners, building partnerships with local stakeholders to support KP-led health services and mobilizing local support on HIV/AIDS activities.

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 16 C. Treatment (provision of ART, linkage to ART and/or progress on ART uptake)

Figure 5. Aggregate treatment, by quarter, FY15-Q2 to FY18-Q3

During Q3, LINKAGES IPs supported ART initiation for 1,051 HIV-positive clients, including 606 MSM; 28 MSW; 50 TG; 10 TGSW; 8 PWID; and 2 FSW, as well as 231 non-KP males and 116 non-KP females. This represents a 14% increase in new ART clients as compared with the previous quarter; however, new ART clients as of the end of FY18 Q3 account for only 31% of the total TX_NEW target for FY18, primarily because HIV case finding continues to be lower than expected.

The “rate” of treatment initiation expressed as a ratio of clients initiating ART over clients tested positive increased from 79% to 104%; however, this figure must be interpreted with care as clients initiating ART in FY18 Q3 are a combination of newly diagnosed clients, clients diagnosed during previous reporting periods, and those who were diagnosed outside the LINKAGES project (including “non-KP clients”) but who received ART services through hospitals benefiting from PEPFAR- supported technical assistance with regards to HIV care and treatment.

Reporting of ART initiation figures from hospitals is critical for achievement of LINKAGES service delivery targets as, under the Thai government’s social benefits programs most HIV-positive clients initiate free ART services through these healthcare facilities. To increase HIV testing and ART uptake, and to enhance the quality of KP-friendly care and treatment, during this reporting period LINKAGES cooperated with PHOs in Chiang Rai, Ubon Ratchathani, Pathum Thani and Nonthaburi and added more healthcare facilities to collect, report, and analyze HTC and ART data. As a result, 14 facilities from Chiang Rai, 10 from Ubon Ratchathani, 8 from Pathum Thani, 1 from Bangkok and 1 from Nonthaburi have agreed to become part of provincial networks, accept TA from LINKAGES, and report on HTC- and ART-related services.

In total, LINKAGES over the course of FY18 has provided technical assistance on HTC and HIV CST to 133 health care facilities in nine provinces; in FY18-Q3 these facilities accounted for 47% of all

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 17 TX_NEW reporting. However, as of this reporting period there were still no ART cases being reported to LINKAGES by Bangkok-based healthcare facilities, despite Bangkok having the highest burden of HIV-positive cases and the largest number of facilities where individuals could seek ART. We will be providing (previously scheduled but delayed) technical assistance in Bangkok during Q4 and have consulted with BMA on the potential to export data from the national AIDS treatment management system – it is anticipated that in Q4 we will be able to extract data to reflect PEPFAR-supported ART service delivery at Bangkok-area hospitals.

Figure 6. Treatment cascade, by partner, FY18-Q3

During this quarter, rates of successful referrals for ART initiation were highest in Chiang Mai, and the Tangerine Clinic also demonstrated high linkage to treatment. ART treatment initiation has improved markedly in Bangkok with the initiation of same-day ART (see below) at the TRC Anonymous Clinic, and referrals for SDART have significantly impacted ART initiation at RSAT BKK and SWING BKK compared to previous quarters.

One of the key challenges of the LINKAGES Thailand project has been to link those tested HIV- positive to ART and help them maintain adherence. LINKAGES has been promoting SDART since July 2017 to answer to this challenge, and the model aims for HIV- positive individuals to start ART within the day or no later than 72 hours after HIV diagnosis. During this reporting period, in collaboration with TRCARC, LINKAGES supported SDART in Bangkok at the Thai Red Cross Anonymous Clinic - through referral from RSAT and SWING BKK - and was in negotiations to launch the model in five additional provinces.

At the Thai Red Cross Anonymous Clinic, during this reporting period, 372 cases (344 MSM and 28 TGW) met eligibility criteria for SDART and 345 cases (318 MSM and 27 TGW) agreed to SDART initiation. The median (IQR) CD4 count for newly diagnosed KPs was 319 (222-421.5) cells/mm3 while re-engaged cases had a median (IQR) CD4 count of 296 (211-417) cells/mm3. Only 300 cases (276 MSM and 24 TGW) met clinical eligibility criteria and successfully initiated ART with a median (IQR) time from HIV diagnosis to ART initiation of 3 (0-9) days. The majority of those who did not meet clinical eligibility criteria or had a history and/or clinical findings to initiate ART were suspected of having tuberculosis (TB) or cryptococcal meningitis, or other serious opportunistic infections, which required further investigation or treatment before initiating ART.

FHI 360 and TRCARC met with health care providers from 13 hospitals in Chiang Rai, Chiang Mai,

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 18 Ubon Ratchathani, Chonburi and Songkhla to discuss the possibility of implementing SDART in these and other priority provinces. In June, Ubon Ratchathani province accepted and committed to implement SDART. They have now established a rapid treatment referral system and Sunpathiprasong Hospital is now accepting clients and CD4 test results from RSAT Ubon Ratchathani to initiate ART within 72 hours of diagnosis. And as with Nakornping, Hangdong and Sarapee Hospital in Chiang Mai province, Mplus and Caremat can accompany clients with CD4 and other laboratory test results to SDART in those hospitals.

Through LINKAGES, TRCARC will provide technical support to expand and replicate this referral system and SDART initiatives to a wider network of hospitals in Ubon Ratchathani. But the common barriers that hinder full commitment from hospitals to start participating in SDART are lack of available CD4 machines and required frequency of CD4 testing. Many district hospitals also do not have CD4 machines to conduct testing for clients within one day; blood samples are instead sent to provincial hospitals. In addition, it was found that not every provincial hospital conducts CD4 testing on a daily basis but rather on a weekly basis. However, during a meeting with Chiang Rai Prachanukroh Hospital in Chiang Rai, the medical team agreed to accept CD4 results of those newly diagnosed cases referred from Mplus Chiang Rai in order to start ART treatment at the hospital no later than 72 hours after diagnosis. Another factor is that not all hospitals offer HIV or ART clinic services every day, and cases that test positive at IPs on certain days may still need to wait 72 hours or more before they can start ART.

D. Retention and Care in Support Services

As of the end of FY18 Q3, 15,822 HIV-positive clients have been actively receiving ART services. Of those, 3,758 (3,017 MSM; 318 MSW; 273 TG; 40 TGSW; 51 FSW and 59 PWID) KP clients are still on ART, as well as 6,268 non-KP men and 5,796 non-KP women (23.7% KP clients; 76.3% non-KP clients). The reason for the high proportion of TX_CURR clients listed as non-KP is that a significant proportion of TX information is provided by non-LINKAGES healthcare facilities, which as discussed earlier are much less likely to ask or record information on KP status for their clients. Nonetheless these individuals represent a priority population of HIV-positive people who have benefited from PEPFAR-supported improvements to service delivery to increase the quality of their healthcare and decrease the risk of their transmitting infection onward – the decision to include these clients in reporting was discussed with, and approved by, USAID.

The TX_CURR performance of FY18-Q3 represents 162% of the annual TX_CURR target of 10,268 persons; however, TX-CURR is not measured cumulatively and final FY18 achievement against this targeted will be calculated based on the total number of clients actively on treatment as of the end of FY18-Q4.

Over the last three reporting periods, performance on this indicator has increased significantly, especially during Q3. This is because LINKAGES has successfully provided technical assistance to several main hospitals where IPs have sent their HIV-positive clients.

But while the overall performance of this indicator has been on the rise, the progress of each LINKAGES IP toward this indicator needs to improve to ensure that all of their HIV-positive peers continue to receive and adhere to ART. The challenge for IPs is that after clients have received ART and are able to cope with side-effects, the clients no longer want to engage and contact IPs, and some of them sever ties. In response, several IPs have come up with a follow-up plan to maintain engagement with their HIV-positive clients without intruding on clients’ privacy.

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 19 Differentiated Service Delivery Regarding Differentiated Service Delivery (DSD) as part of the community-led Test & Treat cohort study, LINKAGES started integrating DSD for ART into the KPLHS model for MSM and TGW in four priority provinces. Patients who maintain ART adherence for more than one year, have two consecutive undetectable HIV RNA CD4 greater than 200 cells/mm3, have no adverse drug reactions or current illnesses, and have a good understanding of lifelong ART adherence are now eligible to receive ART maintenance from KP community health-workers (KP-CHW) at KPLHS clinics. During this reporting period, 23 (69.7%) out of 33 “stable” clients were reached for follow-up for DSD.

TRCARC has now also been awarded a small grant from the International AIDS Society (IAS) to document the differentiated service delivery model implemented in Thailand with PEPFAR support. On June 11-12, TRCARC organized a two-day workshop in Bangkok with key representatives from implementing partners and key provincial-level stakeholders, including PHOs and referral hospitals, to obtain more in-depth information and achieve consensus on how the DSD model for Thailand has been developed and implemented. The discussion aimed to develop lessons learned and a case study on DSD to be produced at the invitation of IAS and with joint IAS/Linkages funding.

The outcomes from this two-day workshop will be disseminated through IAS and will be used to support broader implementation of differentiated service delivery along the HIV cascade in other settings. The dissemination of our work through IAS will also provide an appropriate platform to allow implementers, policymakers and providers from around the globe, working in different settings and contexts, to understand the background, methodology and experiences of KPLHS, and adapt relevant elements to fit their local situation. The report to local stakeholders will also enable advocacy for sustainable scaling-up of these models to address HIV among KPs in Thailand, and to leverage the development of further documentation of KPLHS through visual media.

Capacity Building for Care, Support and Treatment Regarding counseling and care, support and treatment (CST) for PLHIV this quarter, LINKAGES staff continued visiting new community health centers, examining clinic management, clinic flow, care & support, and treatment referral systems. Thirty-three new KPLHS staff, at Mplus-Chiang Rai (9 staff), RSAT-Ubon Ratchathani (11 staff), Pathum Thani (6 staff), Samut Prakan (3 staff), Nonthaburi 1 staff), and Chonburi (3 staff), received coaching visits to ensure the quality of services meets the counseling and CST standard operating procedures (SOPs). For existing KPLHS staff, LINKAGES teams have been reviewing the practice of clinic procedures, following-up CST performance, including ART initiation, adherence, and viral load suppression results regularly. In addition, eleven clinic staff of Mplus Chiang Rai attended a two-day training on ART, OIs, and STIs treatment conducted by FHI 360.

While strengthening service provision at established KPLHS sites, LINKAGES, TRCARC and the USAID Community Partnership Project have continued working to coordinate start-up activities for new sites at RSAT Ubon Ratchathani, RSAT Chonburi and RSAT Pathum Thani. During this quarter, LINKAGES provided onsite technical assistance at RSAT Ubon Ratchathani in response to SIMS findings to strengthen clinical services from registration, to counselling, testing, and to care and support. FHI 360 staff also delivered a one-day TB integrated HIV training for RSAT Ubon Rachathani and other key health care facility stakeholders in the province. The outcomes of this training were that clinic staff are able to conduct initial assessment among their clients, consider referral of clients with TB symptoms for further diagnosis and treatment and implement appropriate infection control measures in the facility to prevent clients and staff from contracting TB infection. Overall, the clinic now promotes healthy behaviors and hygiene among their staff and clients by implementing basic health practices and TB infection control measures. The follow-on SIMS visits found all serious issues had been rectified.

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 20 LINKAGES also successfully set up a local QA/QI team to provide a quality assessment of each KPLHS site. The role of this team is to assess and identify any services in clinics that require quality improvement while LINKAGES continues to provide technical assistance to both well-established sites and newly set up sites to improve their capacities in providing high-quality services. Through close collaboration with the Chonburi PHO and RSAT, LINKAGES secured a verbal agreement that Chonburi Hospital will provide QA services for RSAT Chonburi and, in Pathum Thani, the PHO supported RSAT and LINKAGES to apply to the Office of Consumer Protection for permission to operate a KPLHS clinic. Community health centers in these two provinces are set to open in Q4.

For technical assistance on strengthening laboratory services, a total of eight community health centers received technical assistance on laboratory quality assurance and quality improvement. LINKAGES carried out periodic laboratory assessments to identify opportunities for improvement at each center. Feedback and technical recommendations were provided to laboratory staff and the FHI 360 laboratory support team took corrective action accordingly. Mplus applied for laboratory accreditation by the Medical Technologist Council, which conducted an audit on April 23, 2018. FHI 360 provided technical support for Mplus to address all observations during the audit.

Additional laboratory assessments were also conducted for the newly-opened RSAT Ubon Ratchathani and results will be used as a baseline for future quality improvement. This round of assessments found a need for full-time medical technologist staff and noted that a majority of required laboratory documentation was not yet available. LINKAGES will conduct QA/QI for clinical services at RSAT Ubon Ratchathani and the local hospital separately, twice per year for each.

E. Strategic information and monitoring and evaluation

LINKAGES continued to improve quality of reported data and provide technical support as well as data with an emphasis on data use to implementing partners and health care facilities through the following major activities conducted in Quarter 3: ● Routine Data Quality Assurance (RDQA): In Q3, LINKAGES, along with the M&E staff at each implementing partner, conducted RDQA to ensure good quality and accuracy of the data reported at RSAT Bangkok, RSAT Ubon Ratchathani, RSAT Chonburi, SWING Bangkok, SWING Pattaya and Caremat. ● Data management: Apart from the RDQA, LINKAGES also led discussions on data management, which focused on data collection process, data flow, eCascade, the use of data via dashboards, and identifying gaps at each site in order to improve understanding of staff and strengthen data systems and processes. ● Service dry-run preparation: LINKAGES, in collaboration with TRCARC, provided technical assistance on data collection tools and data systems during the service dry-run preparation period at RSAT-Ubon Ratchathani before the opening of their clinic. ● Data dissemination: Project staff participated in the Provincial Coordinating Mechanism (PCM) Meeting hosted by PHO with LINKAGES support to demonstrate how to use data collection tools and disseminate provincial data to local stakeholders in Ubon Ratchathani.

During this period, growth continued in both the use of the eCascade system as well as its functionality (for a full report on service delivery as tracked by eCascade, see Appendix 1). eCascade consists of both the mobile data application as well as the online dashboard and partner-access data hub. As of the writing of this report, the system has currently registered almost 94,000 individuals entering the cascade either through outreach work or through clinic walk-in. About 209,000 forms have been filled out about these individuals in service contexts from outreach to testing to treatment, at an average of about 2.23 service forms per individual.

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 21 During this quarter, LINKAGES completed the implementation of “Version 3” of the dashboard/data hub application, which was the largest set of new features since the system launched. Seventeen new features in total provided new support for partners, including improved access to data in flexible field sets; new UIC-counting fields in data outputs; and other data tools. Social network views can now graphically visualize KP, condom use and recency of a network’s development. A new “priority outreach report” allows partners to prioritize which past clients are more crucial for targeted follow-up based on risk factors. The app also now imports data generated by the TRC SDART activity, and places it, deduplicated, into cascade visualization, improving the accuracy treatment numbers.

As a result of the extended discussions around the full use of eCascade for M&E purposes between M&E and mobile data staff, LINKAGES staff defined and submitted specifications for the next version of the data hub application (Version 4). This new version will mark an important change: while eCascade View was initially envisioned as a tool to track cascades and understand client flows, this next version will now directly calculate PEPFAR indicators, and apply the required disaggregation by key population, age and service outcome. This will assist in new requests for indicators to be calculated more frequently.

LINKAGES staff continued to liaise with our counterparts at Thailand DDC as well, to ensure that our “API” data connection to submit eCascade data directly into RTCM is again implemented when the department completes its newer version, RTCM+.

F. Innovative HIV prevention research for more effective approaches for HIV epidemic control

The community-led Test & Treat Cohort study extended study period to follow up LTFU clients until the end of June 2018. As a result of coordinated efforts among community partners to follow up on research participants following the workshop on Improving Quality and the Use of Data to Strengthen Key Populations-Led Health Services in April, a total of 175 HIV-negative MSM and TGW (14.7%) among 1,190 cases who missed the last visit in Month 18 were successfully reengaged and returned for last visit follow-up. In addition, of 13 HIV-positive cases who reached their scheduled month 18 (last) visit, 8 HIV-positive MSM and TGW were retained in this cohort study and the follow- up rate was at 61.5%. During this quarter, three studies were developed to address programmatic challenges in HIV prevention research among key populations, including data gaps among TGW and adolescent populations. The progress during this reporting period included the following: ● A feasibility study on integrating point-of-care (POC) for sexually-transmitted infections (STIs) and HIV viral load into community-based clinics for MSM and TGW in Thailand received IRB approval of protocol version 1.3 at Chulalongkorn University in June 2018. This aims at reducing the high burden of STIs among MSM and TGW. The study protocol will subsequently be submitted to Ethics Committee at the Department of Disease Control, provincial ECs and FHI 360’s Protection of Human Subjects Committee (PHSC).

● TRCARC submitted an implementation research protocol on adolescent PrEP to FHI 360 and USAID for technical review in June 2018. The aim of the STANDUP TEEN protocol is to determine the effect of HIV self-testing on the uptake of and retention in pre-exposure prophylaxis service among older adolescent MSM and TGW. In parallel, a study on PrEP adherence, conducted at the Thai Red Cross Anonymous Clinic (TRCAC) with technical collaboration with the Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, through the Collaborative Initiative for Paediatric HIV Education and Research

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 22 (CIPHER) grant, enrolled 29 HIV-negative MSM and TGW (24 MSM and 5 TGW) into the study during this reporting period (7 through TRCAC, 6 from SWING BKK and 16 from RSAT BKK).

● The country’s first full intensive pharmacokinetic (PK) clinical research to determine interaction between the use of feminizing hormone therapy and antiretroviral agents concomitantly among TGW (iFACT) has enrolled 314 out of the total target of 40 participants (77.5% enrolment rate). This research aims to facilitate linkage to PrEP and ART among TGWs. During this reporting period, 20 HIV-negative TGWs completed the last follow-up visit at week 15. For the 11 HIV-positive participants, four (4) completed the last visit at week 15; five (5) completed the full intensive PK at week 8; and another two (2) were in the full intensive PK at week 3 and week 5. In addition, a late-breaker AIDS 2018 abstract submission on iFACT was accepted as a poster discussion to be presented at the AIDS 2018 Press Conference.

Finally, during this reporting period, the C-FREE study protocol received IRB approval from the Central Research Ethics Committee (CREC) in mid-May, but the Thai FDA in May rejected study lead Dreamlopments' request for a permit to import Panovir, a generic combination of sofosbuvir/velpatasvir, made by Incepta (Bangladesh). This halted progress on enrolling study participants, and so Dreamlopments, FHI 360, the Raks Thai Foundation, MoPH and other C-FREE study investigators re-engaged sofosbuvir/velpatasvir patent owner, Gilead Sciences, sending a letter to the Thai FDA to reconsider. Despite the setback, Dreamlopments has been revising the protocol to prepare for the change of the study drug and finalizing the study SOPs. The revised protocol will be submitted to CREC for expedited review, with a final approved version to Research Affairs, Faculty of Medicine, Chulalongkorn University IRBs for expedited approval, and a final approved local IRB version to FHI 360’s PHSC for final approval. There is a site investigator preparation meeting planned for August and enrolment of participants can begin once the C-FREE protocol receives approval from all three IRBs. LINKAGES Thailand continues to support Dreamlopments in engaging with Raks Thai Foundation, The Global Fund and the drug companies in price negotiations. LINKAGES Thailand entered into an agreement with the Foundation for AIDS Rights (FAR), a well- known non-profit organization among HIV networks for PLHIV rights and S&D advocates, to ensure S&D free services under KPLHS by developing COPs and administering standardized, HIV-related S&D operational guidance in each pilot KPLHS. This will broaden health services access by creating an environment that is suitable for the targeted population. During this reporting period, FAR conducted one meeting on May 4, 2018 to orient attendees to S&D comprehensive prevention, care and treatment services for KP clients based on its “3x4” Package. There was also one workshop on May 10-11, 2018 to discuss the content of questionnaires for collecting baseline and endline data on S&D from health care service providers and users. This was attended by representatives of each participating site and was hosted by LINKAGES Thailand implementing partners, SISTERS, SWING Pattaya and RSAT Bangkok.

4 20 HIV-negative and 11 HIV-positive individuals

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 23 G. Knowledge Management and Regional/Global Technical Leadership

The major knowledge management activity this quarter was preparation for the International AIDS Conference in Amsterdam. LINKAGES coordinated and finalized 17 abstracts, including three oral abstract sessions, two poster discussion sessions, and 12 poster exhibitions.

During Q3, LINKAGES also provided tools and trainings to IPs on documenting project activities. During a three-day training, staff from each IPs drop-in center learned how to properly use a DSLR camera to capture the story of their daily work and outreach activities. The course focused particularly on laying the foundation for quality, traceability and history for project documentation.

Applying knowledge management principles and techniques, LINKAGES Thailand also continues to integrate learning across the project implementation and consolidate successful changes in the form of guidance and tools that can be readily spread to new sites. The online training curriculum model was created during this quarter and the first four modules of the training curriculum on the Risk Network Referral model will be completed in FY18-Q4.

H. Costing and financing of KP-LHS

While an in-depth cost analysis is being carried out (see below), LINKAGES continues to utilize PEPFAR expenditure analysis methods (EA) to provide basic cost analysis on community health services for Q3.

Table 3. Cost per unit analyses, FY18-Q3 Management Cost per Caremat Mplus RSAT Sisters SWING/MSMTG SWING/FSW included unit (USD) KP_PREV 27 35 20 20 30 23 HTS_TST 72 62 42 43 20 44 Positive 2,208 1,632 647 880 345 6,972 TX_New* 1,607 962 587 2,263 301 n/a *Calculation method KP_PREV: Expenditures of KP-MSMTG and KP-SW HTS_TST: Expenditures of HTC, Lab, and OBI TX_NEW: Expenditures of CBCTS and FBCTS (Noted that TX-New performance reported under facilities is included as a denominator for the partners). Management costs include: Expenditures on overall program management (PM), strategic information (SI), and health system strengthening (HSS).

The unit cost for KP_PREV is between USD 20 and 35, for HIV testing is USD 20 to 72, for HIV case finding USD 345 to 6,972, and for treatment initiation USD 301 to 2,263. These ranges are similar to the previous quarter, however, there were some notable changes. For example, treatment initiation for FSWs at SWING is not reflected because they had no FSW clients to refer to treatment.

During Q3, the study team moved forward with data collection, and in June 2018 the World Bank and FHI 360 selected the Health Intervention and Technology Assessment Program (HITAP) to carry out data collection for the cost analysis. The study team and the selected data collection team have prepared the proposal and other materials for submission to the IRB, Development of Human Research Protection committee (IHRP) and the Ethical Review Committee for Research on Human Subjects at the Bangkok Medical Service Department.

Details of the proposal are:

Funding source: USAID, LINKAGES Thailand, FHI 360, UNAIDS, World Bank

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 24 Principal Investigator: Dr. Arthorn Riewpaiboon, Professor and Health Economist, Faculty of Pharmacy, Mahidol University Data Collection Study Lead: Dr. Pattara Leelahavarong, Program Leader and Head of Research Unit, HITAP Data collection and analysis to be performed by: Health Intervention and Technology Assessment Program (HITAP)

Study goals and objectives: To estimate financial and economic unit costs along the RRTTPR cascade for three service delivery models for key population HIV services: (1) hospital-based model, (2) NGOs reach-recruit to hospitals and mobile HIV testing services, and (3) key population-led health services (KPLHS). These models are implemented in the real world as opposed to estimating the cost of normative best practices.

Primary outcomes: Costs are expected to be used by policymakers and implementers to inform allocation of financial resources to KP HIV services in Thailand, particularly to inform the NHSO’s inputs into the 2020 national budget for HIV prevention in Thailand. Estimates of cost will be used for the further evaluation of interventions within KPLHS.

Costing approach: Gross costing methods will be applied using a top-down approach, where the steps along the CoPCT cascade will be treated as cost centers. Both financial costs, which capture the resources paid for to deliver goods and services, and economic costs, which capture opportunity costs and value all resources used to provide services even if they are not paid for, e.g. donated goods or services or volunteer labor, will be estimated. For gross costing, total costs during a one- year timeframe, from October 2016 to September 2017 (FY17), will be determined for each site using financial records on the total expenditure and fixed assets of the site for personnel, recurrent operating costs and building spaces. These records will also be used for the recurrent supplies, consumables and equipment for each step along the cascade. Regarding valuation of equipment, other capital items and building space will use replacement prices. Allocation of total cost of study site to each step along the Cascade will depend on the input (personnel, recurrent supplies, recurrent operating costs, and building spaces and other capital items). The proportion of space used for each step along the cascade will be measured and used for allocation of general building and recurrent operating costs. Personnel, recurrent supplies, consumables and equipment will be allocated to the steps where they are used. In cases for which the allocation is not clear or resources are used in multiple steps, we will develop rules for systematically allocating resources across relevant steps in consultation with site staff. The number of clients in each key population over the total number of clients will be used to estimate KP-specific costs at each step of the cascade. In addition, financial records will be obtained from LINKAGES and USAID to estimate the supportive activities and technical support above the service delivery site that is provided to each site. Estimated costs of each activity will be converted to the local currency unit (Thai baht) values, for base-year 2018 using the consumer price index (CPI).

Data sources: Sources of cost data will be derived from study sites as the main source, both primary data obtained via interviews and secondary data obtained from accounting and financial reports, and hospital databases. Existing, above-site information systems such as LINKAGES monitoring and evaluation routine reports and the eCascade database (for KPLHS), Global Fund monitoring reports (for the three community-based health service sites), as well as Government Health Information System databases, could be used in the validation process for a cross-check. Information will also be gathered from routine electronic systems at each site and this will be supplemented with information from paper records as necessary.

Data analysis plan summary: Quantity of resources used and their unit cost will be presented. Total costs and cost of each component will be estimated for each site and cost center. Average total cost

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 25 and cost of each component of the cascade will be estimated. The costs of cascade outputs will be classified by type of key population. The data will be analyzed in Microsoft Excel, in order to allow for systematic checking and generating of information. Descriptive statistics will be applied where appropriate.

IRB submissions are expected to be approved by the beginning of Q4, and the data collection forms will be reviewed and given feedback by sites accordingly.

Financing. Reimbursements from NHSO to LINKAGES’ partners are highlighted below. All funding is in the process of reimbursement, as all contract targets have been achieved, except for RSAT Bangkok, who “gave” the targets for female and male sex workers back to NHSO and RSAT Ubon Rachathani with no update available for this quarter. Any late reimbursement is due to the closeout process between the NHSO and the LINKAGES partners for this current contract.

New contracts between NHSO and partners are in the process of being finalized. This was facilitated by LINKAGES involvement in negotiations between provincial NHSO offices and partners. For example, TRCARC facilitated the policy dialogue among directors of Hat Yai hospital and National Health Security Office Region 12 to support HIV testing services conducted by RSAT Hat Yai since late April in Q3. On May 31 of this quarter, LINKAGES convened a meeting to finalize a mechanism to support RSAT Hat Yai to receive HIV testing cost from NHSO through Hat Yai hospital. The main result of this meeting was the signing of memorandum of understanding that will allow the reimbursement of HIV testing services between Hat Yai hospital and RSAT Hat Yai. The reimbursement for testing services conducted by RSAT will come from NHSO funding, at THB120, or USD 4, per test. This marked the first formal and concrete recognition and collaboration between KP-LHS and a facility-based health service. The process leading to this success includes:

1. Capacity building of health services by KPs (on finger prick blood collection training, clinic set-up and service quality monitoring). 2. Registration of KPLHS community health centers as medical technologist clinics (still requires oversight by certified medical technologist). 3. Establishment of close collaboration with Provincial Health Offices, Provincial Departments of Disease Control and key hospitals, to ensure continued quality assurance and improvement of KPLHS.

LINKAGES is working to replicate this promising process as one of the options to ensure sustainability of KPLHS in other provinces.

Figure 7. NHSO funding reimbursement from FY18-Q1 to FY18-Q3

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 26

LINKAGES and USAID have also obtained commitment from BATS and NHSO to re-strategize FY19 MSM and TG target coverage under NHSO funding to high-burden provinces (mostly under PIF Provinces). This significant step will result in a concrete transition from international funding for KPLHS operation to in-country funding. With full commitment to ensure success of Thailand’s transition plan, LINKAGES is currently in discussion with NHSO on a technical assistance plan that can be offered to strengthen their grant management and monitoring process, as well as working with KPLHS partners on their FY19 workplan, and budget development as well as identification of technical assistance needed.

Recognizing that financial sustainability is only one of the approaches to ensure KPLHS sustainability, LINKAGES also worked with USAID Community Partnership Project, led by TRCARC and BATS, on the certification of KP service providers, and to draft a ministerial regulation to recognize KPLHS as part of the national health system contributing to ending the HIV/AIDS epidemic in Thailand.

I. Capacity building and technical assistance, including collaboration with Global Fund partners and support to their program implementation

Table 4. Capacity building and technical assistance provided in FY18-Q3 Date Activity/details No. of Male Female Participants participants 2-3 Workshop on lessons 28 22 6 ● 2 staff from Sisters April, learned for the ● 3 staff each from SWING BKK and 2018 promotion of and SWING Pattaya recruitment for the oral ● 6 staff each from RSAT BKK and fluid study in Bangkok Mplus Chiang Mai ● 8 staff from FHI 360 4 UC patient workshop 39 19 20 ● 1 staff from RSAT Nonthaburi April, ● 2 staff each from RSAT Samut 2018 Prakan and Social Security Office ● 3 staff each from RSAT Pathum Thani and NHSO ● 4 staff from RSAT BKK ● 5 staff from SWING BKK ● 5 staff each from FHI 360 and BMA ● 7 staff from TRCARC 19-21 Lessons learned for 51 35 16 ● 1 staff each from RSAT April, the promotion and Nonthaburi, Department of 2018 recruitment for the Employment, Ministry of Public Exploring Uptake of Health and USAID HIV Oral Fluid Testing ● 2 staff each from RSAT Pathum Study - Specific Thani and Consultant Training in Bangkok ● 4 staff rom TRCARC ● 12 staff from FHI 360 ● 13 staff from SWING BKK ● 14 staff from RSAT BKK 2-4 Workshop on HIV Oral 26 20 6 ● 7 staff from FHI 360 May, Fluid Study - Specific ● 19 staff from Sisters 2018 Training in Chiang Mai 9-11 Workshop on HIV Oral 30 25 5 ● 7 staff from FHI 360 May, Fluid Study - Specific ● 9 staff from Sisters 2018 Training in Pattaya ● 14 staff from SWING Pattaya

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 27 Date Activity/details No. of Male Female Participants participants 15-18 Test & Treat: PLHIV 39 26 13 ● 1 staff each from USAID and May, network testing for Consultant 2018 accelerated epidemic ● 3 staff from TRCARC control ● 34 staff from Global FHI 360 30 Photography 31 20 11 ● 1 staff each from USAID, RSAT May - workshop Chonburi, RSAT Nonthaburi, RSAT 1 June Pathum Thani, RSAT Samut Prakan 2018 and RSAT Songkhla ● 2 staff each from RSAT Ubon Ratchathani, Caremat, Mplus Chiang Mai, Mplus Chiang Rai, Sisters, SWING BKK, SWING Pattaya ● 3 staff from RSAT BKK ● 4 staff each from TRCARC and FHI 360 7-8 “Management of 67 24 43 ● 2 staff each from Mplus Chiang June ARVs, STIs and HIV Mai and Facilitator 2018 testing and treatment ● 6 staff from FHI 360 data in MSM/TG ● 10 staff from Mplus Chiang Rai population" in Chiang ● 47 staff from Health Facilities Rai -7 Doctors -19 HIV co-nurses -4 Pharmacists -5 Public Health Officers -12 HIV Peers 13- Safety and Security 17 14 3 ● 1 staff each from RSAT Samut June- meeting Prakan and RSAT Songkhla 18 ● 2 staff each from RSAT BKK, Caremat, Mplus Chiang Mai, Sisters, SWING BKK and SWING Pattaya ● 3 staff from FHI 360 21-22 QA/QI meeting 65 22 43 ● 1 staff each from RSAT BKK, RSAT June Chonburi, RSAT Nonthaburi, RSAT 2018 Pathum Thani, RSAT Samut Prakan, RSAT Songkhla, RSAT Ubon Ratchathani, Caremat, Mplus Chiang Mai, Mplus Chiang Rai, Sisters, SWING BKK and SWING Pattaya ● 7 staff from TRCARC ● 10 staff from FHI 360 ● 36 nurses from PHO, NHSO, OPDC, BMA, and key health care facilities 22- PrEP Uptake 17 12 5 ● 1 staff each from, Blue D, USAID, June- Crowdsourcing TRCARC, Attitude and RSAT BKK 18 Contest ● 4 staff from FHI 360 ● 8 staff from Other organizations 22- Positive Network 10 9 1 ● 1 staff from APCOM June- Brainstorm meeting ● 2 staff each from TRCARC and 18 FHI360 ● 5 staff from Other organizations

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 28

In total, 420 individuals were trained during this reporting period, 248 females, 172 males. Key events, TA and capacity-building activities organized during this quarter included the following: ● A PrEP uptake crowdsourcing contest was organized to share LINKAGES’ plan to introduce the crowdsourcing strategies as a means to promote PrEP uptake to national and provincial stakeholders and to gather advice, recommendations and input on the proposed plan to roll out this activity. ● To strengthen referral networks and promote KP friendly services, LINKAGES strengthened capacity of partners on management of ARVs, STIs, and HIV testing and treatment data in MSM/TG populations and for all health facilities, including CBO staff, to provide up-to date information on HIV treatment, opportunistic infections, STIs and the specific needs of KPs in Chiang Rai. ● Phase 2 of the Oral Fluid Testing Study started this period and CBO staff assigned to this were trained on ethics, research and study procedures including the use of the oral fluid HIV kits and how to interpret the results. Each research site was managed by a trained site investigator affiliated with the CBO. This included: ○ a workshop on lessons learned for the promotion of, and recruitment for, the Oral Fluid Testing Study in Bangkok; ○ lessons learned for the promotion and recruitment for the Exploring Uptake of HIV Oral Fluid Testing Study Specific Training in Bangkok; ○ a workshop on the HIV Oral Fluid Testing Study in Chiang Mail; and ○ a workshop on HIV Oral Fluid Testing in Pattaya. ● The LINKAGES team, which includes CST staff from FHI 360 and TRCARC, organized multi- province QA/QI team meetings to discuss QA/QI tools for counseling and care and support to standardize measures. Provincial QA/QI will be conducted by teams of provincial experts, FHI 360, TRCARC as well as lead CBO staff. ● A Positive Network Brainstorm meeting: During Q3, LINKAGES and TRCARC collaborated with a social media influencer, who was once an RSAT Hat Yai Client and who confidently disclosed his status to the public, to host a first meeting among positive client networks in Bangkok. Several news agencies showed their interest in helping LINKAGES advocate for ART initiation among people who test positive. This included such outlets as The Standard, Attitude Online magazine, and Blued. This closed-group-meeting aimed to understand the barriers for people who test positive to immediately start ART. To design better campaigns to target people who test positive to start ART, and to better target high-risk populations to get tested, this grouping shared experience in demand creation. LINKAGES is now planning a similar meeting among people who are on PrEP in Q4, and will develop campaigns with a creative agency to be selected later. ● Test & Treat PLHIV network testing for accelerated epidemic control: From May 15 to 18, LINKAGES Global conducted a regional workshop on Test & Treat in Bangkok for participants from all over Asia to share experiences about Voluntary Partner Referral (VPR) and Risk Network Referral (RNR).

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 29 III. Quarterly Financial Summary

Funding Expenditures this Total Obligation Obligation Quarter Expenditures Remaining Field Support $ 12,946,092 $ 492,953 $ 12,015,257 $ 930,835 Thailand Field Support $ 700,000 $ - $ 700,000 $ - Thailand Test and Treat Field Support $ 1,500,000 $ 190,051 $ 789,844 $ 710,156 Thailand (OHA) Field Support $ 10,849,000 $ 1,710,407 $ 6,781,000 $ 4,068,000 Thailand (Gamechanger)

Table 5. Program-level monitoring results Indicators PEPFAR Achievements/Targets (Type: PEPFAR vs. custom) Type of Q3 Year to Annual % target support Date Target achieved KP_PREV: Number of KPs reached with DSD 12,025 44,068 110,826 40% individual and/or small group level HIV preventive interventions that are based on evidence and/or meet the minimum standards required (PEPFAR) HTS_TST*: Number of KPs who received DSD 11,343 36,205 HIV Testing and Counseling (HTC) services TA_SDI 2,563 7,044 for HIV and received their test results Total 13,906 43,249 77,578 56% (PEPFAR) HTS_TST_POS: Number of KPs who DSD 734 2,310 received HIV Testing and Counseling TA_SDI 275 876 (HTC) services for HIV and received their Total 1,009 3,186 8,626 37% test results as positive (PEPFAR) PrEP_NEW: Number of KPs who received DSD 534 1,765 antiretroviral pre-exposure prophylaxis TA_SDI 0 0 to prevent HIV infection (PEPFAR) Total 534 1,765 1,680 105% TX_NEW: Number of KPs newly enrolled DSD 323 966 on antiretroviral therapy (ART) (PEPFAR) TA_SDI 728 1,687 Total 1,051 2,653 8,626 31% TX_CURR**: Number of KPs currently DSD 341 N/A receiving antiretroviral therapy (ART) TA_SDI 15,481 N/A (PEPFAR) Total 15,822 N/A 10,144 156%

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 30 Appendix 1: Performance under eCascade

During FY18 Q3, there were a total of 17,288 unique clients registered in eCascade (this figure is not equivalent to KP_PREV, as this number does not distinguish between wholly new clients and those reached in previous quarters of FY18). Of these clients, 4,827 were clinic walk-ins, while 12,461 were outreach clients, of whom 11,539 were referred for HIV testing. 9,624 clients received an HIV test - 55.6% of all clients reached. Testing uptake was higher among walk-in clients (95%) as compared to outreach clients (42.1% of all outreach clients referred to testing). It is notable that a referral rate of 42.1%, while lower than ideal, is still a significant improvement over previously reported referral rates for outreach. The overall case-finding rate among all clients who received an HIV test was 5.4%.

When client recruitment is broken down more granularly, CBSs reached 10,699 clients and successfully referred 3,895 (36%) to testing services with a 4.2% case-finding rate. In comparison, PMs recruited 764 clients and tested 692 (91%) with a 7.7% case-finding rate. Testing yield among walk-ins was 5%. As seen in previous periods, the CHC-based social network strategy delivered relatively few new clients in this period (77 recruited, 76 tested) but with significantly higher case finding (15.8%). Online outreach accounted for 1,404 new clients and, consistent with findings from the O2O system, only 33% of those received an HIV test; however, the case-finding rate was 13%. Innovative strategies piloted under LINKAGES Thailand (peer mobilization, SNS, online-based outreach and recruitment) continue to demonstrate significant success in terms of higher rates of testing uptake and yield (these models combined account for 24% of all case-finding in Q3). However, they account for only 13% of overall project coverage.

Regarding peer mobilizers specifically, there were an almost identical number of active PMs in Q3 as compared with Q2 (88 vs. 87), but in Q2 PMs were much more active – with an average of 11 new clients per active PM in Q2 versus 8 new clients per PM in Q3. The result of this is that PMs recruited significantly more clients in Q2 compared to Q3 (1,063 versus 764) which resulted in significantly fewer testing clients (984 versus 692).

The implementing partners who utilized the PM approach the most in terms of absolute number of clients recruited in FY18 Q3 were Mplus Chiang Mai (n=219), SWING BKK (n=192), and Caremat (n=146). However, when viewed as a proportion of overall contribution to outreach recruitment, the biggest users of PMs this quarter were Caremat (31% of all outreach recruitment was by PMs), Mplus Chiang Mai (14%), and Mplus Chiang Rai (13%). PMs only accounted for 9% of outreach recruitment at SWING BKK. Meanwhile, PMs associated with RSAT BKK only recruited 52 clients in Q3, out of a total of 2,951 outreach clients (2%).

Case-finding rates among PM clients were highest at RSAT Ubon Ratchathani (21%), RSAT Hat Yai (20%) and Sisters (15%). However, these rates were achieved among very small numbers of clients tested. SWING BKK PMs contributed the largest total number of newly diagnosed HIV-positive clients, with a case-finding rate of 12% among 179 PM clients who received HIV tests. Case-finding rates in Chiang Mai and Chiang Rai were 4% and 2% respectively, although this may reflect low background prevalence in those sites. It is also worth noting that a visual analysis of PM recruitment networks in Q3 reveals a number of “clusters” of comparatively high seropositivity that should be a focus of outreach and recruitment activities moving forward.

Out of 487 clients diagnosed as HIV-positive during this quarter, 293 are listed as enrolled on ART for an uptake rate as of the end of Q3 of 60%. This rate is for Q3 only and does not include clients tested positive in previous quarters who initiated treatment during this quarter. Among Q3 clients who

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 31 started ART, the average time from diagnosis to treatment initiation was 10 days (S.D. 13.85 days) but the mode was 0 days thanks to the initiation of SDART at the TRC Anonymous Clinic.5

By the end of the quarter, the implementing partners with the greatest percentage of new HIV- positive clients not yet initiating treatment were Caremat and Sisters (both 86%), RSAT Ubon (63%), SWING Pattaya (61%), and RSAT Hat Yai (57%). All other sites reported at least half of new HIV- positive clients on treatment. The sites with the lowest rate of non-initiation were Mplus Chiang Rai (20%) and TRC (24%). Care and support staff are in the process of following up with the remaining 194 clients tested positive this quarter who have not yet initiated ART.

Calculating a treatment uptake rate is of course highly dependent on time, and particularly among clients diagnosed late in the quarter, ART uptake is likely to improve. Viewed over the life of the project to date, fully 83% of all clients diagnosed HIV-positive under LINKAGES Thailand and registered in eCascade have initiated ART.

5 These figures do not include 3 ART clients with a date of ART initiation listed as earlier than their date of diagnosis, indicating an issue with data entry.

LINKAGES Quarterly Report (April to June 30, 2018) – Thailand 32