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 JANUARY 1 – MARCH 31, 2019

April 30, 2019

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 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

Narrative I: Executive Summary During Fiscal Year 2019 Quarter 2 (FY19 Q2), 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).

Graph 1: LINKAGES Thailand Cascade for Total KPs (Not Disaggregated)

During this reporting period, LINKAGES reached a total of 11,640 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:

• 7,836 MSM; 876 MSW; 1,119 TG; 1,530 FSW; and 279 TGSW. This total includes 6,452 KPs reached as the result of community-based interactions, while an additional 5,188 were walk-in clients at LINKAGES-supported community health centers. Combined Q1 and Q2 performance accounts for 57% of the annual KP_PREV target. • 528 MSM, 14 MSW, 18 TG, 22 TGSW, and 12 FSW accessed PrEP for the first time. Combined totals for Q1and Q2 represent 49% of the PrEP_NEW target for FY19. • 9,145 MSM; 451 MSW; 957 TG; 251 TGSW; 1,997 FSW; and 177 people who inject drugs (PWID) received HIV testing, along with 9,575 non-KP males; and 9,441 non-KP females. Total HIV testing uptake over Q1 and Q2 represents 149% of the FY19 annual HTS_TST target.

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• Among the above HIV testing clients, 531 MSM, 25 MSW, 50 TG, 11 TGSW and 16 FSW tested HIV-positive, along with 270 non-KP males, and 155 non-KP females. The overall case-finding rate was 3%. Case finding for FY19 to this point accounts for 78% of the FY19 HTS_TST_POS target. • 430 MSM, 3 MSWs, 45 TG, 3 TGSW, 4 FSWs, and 3 PWID initiated anti-retroviral therapy (ART) treatment this quarter, along with 314 non-KP males, and 194 non-KP females. Cumulative treatment initiation since the beginning of FY19 accounts for 69% of the total annual TX_NEW target. • 20,366 clients who were active on ART in Q2 have received at least 1 viral load test in the past 12 months. The overall rate of viral load suppression among those patients who received a VL test (TX_PLVS) was 97% (19,673/20,366).

Key population-specific HIV cascades are presented for two population groups for which LINKAGES Thailand has performance targets, MSM/MSW and TG/TGSW. As the first graph shows, progress towards yearly targets for MSM/MSW is above or near the quarter 2 expected level (50%) for reach (49%), HIV testing (54%), HIV case finding (46%), and PrEP (49%) but somewhat below this expected level for ART initiation (39%).

In terms of HIV cascade performance, LINKAGES achieved an 88% reach-to-test ratio for MSM/MSW for quarters 1-2, 6.0% HIV case finding, and 84% ART initiation among MSM/MSW who were HIV-positive. It is important to note that these calculations are approximate since they do not represent a cohort followed over time but rather comparisons of cross-sectional totals in each category.

Graph 2: LINKAGES Thailand Cascade for MSM/MSW

For TG/TGSW (see below), progress towards yearly targets was at or above expected levels for reach (78%) and HIV testing (51%). The remaining HIV cascade areas were below expected levels – HIV case finding (38%), ART initiation (29%), and PrEP (43%) – and will need performance improvement over the next two quarters.

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In terms of cascade performance for quarters 1-2, LINKAGES achieved a 62% reach-to-test ratio, 5% HIV case finding, and 76% of PLHIV initiating ART. The same considerations noted above regarding caution in interpreting this data apply to these figures as well.

Graph 3: LINKAGES Thailand Cascade for TG/TGSW

Specific programmatic achievements during this reporting period include the following: • LINKAGES Thailand is on track to meet or exceed all key service delivery targets for FY19; including targets for PrEP uptake which have underperformed but which saw a major increase in FY19 Q2 as partners redoubled their PrEP promotional efforts. • A new Rainbow Sky Association of Thailand (RSAT) Community Health Center was formally launched in Chonburi, and several other such centers (Mplus Chiang Mai, Mplus Chiang Rai, RSAT Hat Yai) took significant steps toward formal registration that will make it easier for them to receive reimbursement from the National Health Security Office (NHSO) for HIV services delivered to members of key populations. • In part as the result of LINKAGES research and advocacy, the Thai Ministry of Public Health revised their regulations to allow for HIV self-testing (though implementation of this strategy will be delayed by the need for formal registration of approved self-test kits by the Thai FDA). • LINKAGES launched new information and communication technology (ICT) tools: an online risk assessment platform tied to the Test Me Now online-to-offline test reservation system, and a series of online dashboards to allow implementing partners to track and respond to client feedback in real time. • LINKAGES and partner agencies were highlighted as knowledge and technical leaders at numerous regional forums, including the 21st Annual Bangkok International Symposium on HIV Medicine and regional workshops on PrEP implementation and de- medicalization and on trans-competent healthcare. Additionally, 17 abstracts were prepared and submitted and 13 were accepted for presentation at the 10th IAS Conference on HIV Science, to be held next quarter.

Specific challenges in this reporting period: • While LINKAGES remains on track to meet expected service delivery targets for FY19, performance on the part of key-population led health service (KPLHS) sites declined

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across indicators and for numerous partners and sites. One key reason for declines in testing and case-finding may be that actual HIV incidence is in decline. This is suggested by the preliminary findings of an HIV consensus group supported by LINKAGES which worked in FY19 Q2 to summarize existing surveillance, research, and programmatic data to determine the current state of the HIV epidemic among MSM and TG in Bangkok. In order to achieve case-finding targets, LINKAGES partners will need to rely increasingly on targeted recruitment and testing approaches, to monitor data closely, and to be prepared to shift program approaches in real-time to respond to emerging “clusters” of infection. For this reason, LINKAGES and Thai Red Cross AIDS Research Centre (TRCARC) are working to strengthen online recruitment, to roll out index testing methodologies, and to work with partners on weekly data reviews with a focus on case- finding. • Despite an emerging consensus that the epidemic may be in decline among key populations, some groups (e.g. trans women and trans sex workers especially) remain at elevated risk but are underserved by the current response. This is especially the case in Pattaya, where ongoing technical weakness and management issues make continued support for the Sisters Foundation unsustainable at this time. LINKAGES will transfer funding in Pattaya to Sex Workers in Group (SWING) and expand this organization’s scope of work to include TG/TGSW populations, though we remain open to future collaboration with Sisters should their situation substantively change. • The other key challenge for LINKAGES and implementing partners in Q2 has been managing delays in reimbursements from the national government for community- based service delivery. The delays in signing of contracts with the NHSO have contributed directly to staff reduction and subsequently lower levels of outreach coverage (for some partners as it was initially planned that NHSO funding will be programmed for outreach activities as the Program Incentive Funds (PIF) funding for FY 19 declined which is in alignment with the Thai Government transition plan).

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Narrative II: Achievements and key challenges encountered during the reporting period by thematic area:

A. HIV prevention and linkage to HIV testing and counseling services

In FY19 Q2, LINKAGES Thailand implementing partners continued to provide HIV prevention and referral services through one-on-one outreach and HIV prevention education, small group activities and online/social media activities. Through this combination of HIV prevention activities, a total of 11,640 KPs1 were reached in Q2. Total KP_PREV performance during this reporting period reflects a 35% decrease compared to the FY19 Q1 performance of 18,006. Implementing partners have changed their outreach activities to organize fewer large events that attract large number of people, e.g. beauty contest events, and focused instead on one-to- one outreach activities, small group and promotion through online and social media channels. LINKAGES IPs achieved 57% of the FY19 annual KP_PREV target (29,646/51,756), which puts the project well on track to achieve the expected level of coverage before the end of the fiscal year.

Among clients counted under the KP_PREV indicator, 6,452 (55%) were reached as the result of community-based interactions, while an additional 5,188 (45%) were walk-in clients at LINKAGES-supported community health centers (CHCs) who received the full package of prevention services and were reported under the KP_PREV indicator with the consent of USAID. Fully 65% (3,355/5,188) of all walk-in clients were reported from the Thai Red Cross (TRC) Anonymous Clinic, which is to be expected given that this facility supports no outreach workers on its own. MSM accounted for most walk-in clients (87%) followed by TG (6%), FSW (3%), MSW (3%) and TGSW accounted only 2% of walk-in clients. This is at least in part explained by the fact that TRC-Tangerine, which had the largest number of TG/TGSW walk-in clients during the previous quarter, shifted focus to outreach activities and the number of TG/TGSW clients reached by online outreach activities increased 96% (from 213 in Q1 to 418).

Among KP_PREV clients, 11,138 were referred to HIV testing services (96%), while 154 (1%) self-reported already being HIV-positive and an additional 348 (3%) declined referral to testing services. Known-positive clients were primarily MSM who walked in to CHCs to access services including CD4 screening and HIV care and support. Refusal of referral to HIV testing among walk-in clients was very rare and almost exclusively among TG clients at the Tangerine community health center (23% of all 132 walk-in TG clients at that site); these were individuals seeking to access hormone testing at Tangerine who declined an HIV test but the refusal rate was improved compare to the previous quarter (32% in FY19Q1) due to the modified counseling procedure on motivating clients to get tested.

Among outreach clients, the overall rate of refusal for referral was 5%; however, TGSW and TG declined referral at much high rates (30% and 23%, respectively). While test refusal among TG clients was previously a concern at RSAT Ubon Ratchathani, the situation there appears greatly improved during this reporting period due to partners having a clearer definition of what is meant by “declined”.

1 7,836 MSM (67%), 876 MSW (8%), 1,119 TG (10%), 1,530 FSW (13%) and 279 TGSW (2%).

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Graph 4: LINKAGES Thailand Reach by Quarter (FY15 Q2-FY19 Q2)

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Despite improvements in Ubon Ratchathani, however, in Q2 more than 60% of all TGSW clients at Sisters declined referral to testing (likely to be the result of lower-quality outreach as well as the inconvenient location of the community health center), while refusals were high for outreach clients at Tangerine (46%) and RSAT Pathumthani (71%) as well.

Despite overall low and decreasing rates of refusal of referral2 to HIV testing, ongoing higher- than-average rates particularly among TG and TGSW mean that LINKAGES will continue to monitor more closely the quality of outreach interventions for these populations, and at community health centers will ensure that the provision of hormone services at CHCs continues to serve as an incentive to testing uptake rather than a distraction.

Pre-exposure Prophylaxis (PrEP) During FY19 Q2, LINKAGES partners supported a total of 594 KPs3 to receive PrEP for the first time under a combination of the TRC PrEP-15 service, the COPE4YMSM study,4 and the Princess PrEP project. The number of new PrEP acceptors this reporting period represents a 25% increase from the previous quarter (594 versus 476), as well as 49% of the PrEP_NEW target for FY19 (1,070/2,170). Note that Princess PrEP numbers also include clients who elected to enroll in TRCARC’s new on-demand PrEP service (n=75)5 currently available at RSAT Bangkok, SWING Bangkok, and Mplus Chiang Mai.

Graph 5: PrEP_New Reach (FY16 Q1-FY19 Q2)

In this quarter, almost all organizations improved new PrEP uptake. RSAT Ubon Ratchathani saw the largest increase in PrEP uptake in this quarter (167% increase) but among a small number of clients. Mplus Chiang Rai saw a 118% increase, RSAT Bangkok a 96% increase, and SWING BKK a 39% increase. After PrEP underperformance over the past several quarters, during this reporting period partners intensified individual risk assessments and promoted PrEP

2 Note that, as per MER indicators, “refusing referral” here relates only to whether clients agreed to accept referral to testing during an interaction with IP staff. It does not indicate whether or not clients who accepted referral actually arrived at a community health center for testing. MER indicators track cross-sectional service delivery – they do not track clients longitudinally across services. 3 528 MSM, 14 MSW, 18 TG, 22 TGSW, 12 FSW 4 Which uses LINKAGES staff, facilities and resources to enroll clients and distribute PrEP. 5 75 on-demand PrEP clients were previously daily PrEP clients who elected to switch to the new protocol; as these clients were existing PrEP users prior to enrolling in on-demand PrEP, they are not included in PrEP_NEW reporting.

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 7 to every eligible client during the counselling process and through online interventions such as Facebook LIVE broadcasts and online advertisements. The new PrEP research projects mentioned above also helped to drive additional demand.

The exceptions were Mplus Chiang Mai and Caremat, which reported 14% and 15% decreases, respectively. Although the number of PrEP uptakes has declined, Mplus reached their PrEP targets for the year and are committed to continue and expand PrEP recruitment in the province. Due to delays in NHSO fund transfer, Mplus had decided to introduced co-payment for lab testing for PrEP but later learned that this has negative implications for PrEP uptake for their clients, many of whom are university students. This issued has immediately been addressed by LINKAGES allowing full reimbursement of lab cost.

There are additionally ongoing questions regarding the targeting of PrEP promotion. PrEP users under the Princess PrEP program have tended overwhelmingly to be MSM in their 20s and 30s, while PrEP use has been lowest among precisely those sub-populations (like sex workers and adolescents) who would benefit most from additional prevention options. This trend continued during this reporting period.

Graph 6: PrEP_New Uptake by Age and KP (FY19 Q2)

However, when compared with PrEP uptake in FY19 Q1, every age group experienced growth in this reporting period excepting KPs aged 25-29 and 40-49, where PrEP uptake decreased 1% and 29% respectively. The most significant increase was among KPs aged 15 - 19 (100%) that came from Facebook advertisement and theYouth PrEP project – RSAT BKK has strategically planned to offer PrEP to all cases, including clients aged between 15-19 years old, during counselling and risk assessment session and PrEP referral from Youth PrEP project (or other ongoing PrEP projects – Cope4Young) participants and Social Network Strategy (SNS) for PrEP referral at RSAT Bangkok. LINKAGES will work closely with other partners to use this pattern for promote PrEP among KP adolescents because the incidence data from Thailand indicates high risk of infection in KP adolescents.

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Table 1: PrEP_New by Age Age PrEP_New 15-19 20-24 25-29 30-34 35-39 40-49 50+ Total FY18 Q1 18 107 175 138 104 91 43 676 FY18 Q2 27 133 170 112 62 41 10 555 FY18 Q3 66 115 147 93 61 43 9 534 FY18 Q4 56 122 158 80 57 57 18 548 FY19 Q1 9 90 147 104 68 41 17 476 FY19 Q2 18 122 146 143 73 45 18 594 Comparing 100% 36% -1% 38% 7% -29% 6% 25% FY19_Q1/Q2

Data on PrEP uptake will inform the design of a new PrEP promotional campaign, currently underway (see below) and will additionally be taken into account as LINKAGES works with partners to introduce an index testing model among HIV-positive clients (see Narrative II, Section B – HIV Counseling and Testing).

Graph 7: PrEP Follow-up Rate (FY19 Q2)

Finally, there remain questions about PrEP retention. Of 3,857 existing PrEP clients with follow- up visits scheduled for FY19 Q2, only 2,328 PrEP users came for follow-up (60%). While below optimal, this represents an improvement over the follow up rate reported in the previous quarterly (38.6%) Follow-up rates are shown above, disaggregated by follow-up visit month.

Owing to relatively low retention rates, the overall PrEP_CURR achievement for this reporting period is 2,328.6 LINKAGES and TRCARC are continuing to develop mobile health interventions to improve PrEP retention and adherence as well as adjusted PrEP data collection forms which will help us to better understand barriers and challenges to PrEP retention. While the final forms are expected to roll out by June 2019, during this reporting period a draft version was piloted to start gathering insights. From one month of data collection, we have seen that 70% of potential PrEP clients did not want to start PrEP because they did not perceive themselves to

6 2,077 MSM; 67 MSM; 71 TG; 95 TGSW; 18 FSW

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 9 be at risk for HIV, despite being at high risk based on self-reported behaviors. One strategy to address this may be the risk assessment tools being developed by LINKAGES and TRCARC; another strategy to tackle this problem is enhance community based organization (CBO) staff counseling skills to be able to better address this risk misperception, which will be addressed in a refresher training to be conducted in Q3 in collaboration with the USAID Community Partnership Project. Risk perception will also be a major focus of the refreshed PrEP promotional campaign currently under development (see below).

Other, less-common reasons for declining PrEP included that 17% did not want to take pills as they feared PrEP related stigma, 16% were still in the window period and were asked to return for HIV testing after the window period had passed, and a remaining 7% cited traveling issues and being unable to go the CBO regularly as required.

Activities for Online Reach and Recruitment During this reporting period, LINKAGES partners have continued to engage with key populations through online channels beyond face-to-face (F2F) outreach. In Q2, LINKAGES partners reported a total of 770,912 online engagements under the ON_CLICK_NEW indicator. Overall online interactions decreased by 70 % (770,912 versus 2,558,756) this quarter; this reduction is primarily the result of contract review and approval with Asia Pacific Coalition on Men’s Health (APCOM), during which time numerous outstanding online activities (e.g. Facebook/Google paid advertising and advertising materials promoted via dating apps) were not implemented. Thus, almost of the online engagements during this reporting period are the result of organic posts from the LINKAGES partners’ official pages (99%). An additional 1% of online interactions results from online influencers managed by LINKAGES IPs. In addition to ON_CLICK engagements, LINKAGES partners reported direct one-to-one online engagement with 5 clients that did not meet the minimum requirements to be reported under the KP_PREV indicator.

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Graph 8: On_Click_New (FY19 Q2)

Image 1: Online promotional materials by Tangerine Clinic Despite the significant overall drop in ON_CLICK engagements this quarter, almost every LINKAGES partner (excepting APCOM) increased their online outreach performance (mainly via their official Facebook pages). Tangerine Clinic, for example, increased their online engagements by 326% compared to the previous quarter (14,572 versus 4,474 engagements) by increasing their online presence, producing additional TG-related content for online dissemination, and further collaborating with TG social media influencers via Facebook Live broadcasts (see Subsection G, below). SWING Bangkok has also started to work in online health promotion and engage with the audience through their official Facebook page; in Q2, SWING worked with their communications staff member from Pattaya to assist the Bangkok office develop their strategy for online engagement. Online-to-Offline Conversion LINKAGES continues to use the TestMeNow “online-to-offline” (O2O) platform, which is currently integrated into all LINKAGES-supported online promotional content, used by online outreach workers and social media influencers when referring individuals to testing, and is

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 11 being used by staff at 15 clinics across 6 project sites7 to track client testing appointments. In FY19 Q2 there were 922 HIV testing reservations made via TestMeNow, which was an 11% decrease from the previous reporting period attributable to the above-described delay in APCOM online promotions activities. A total of 509 clients who made reservations arrived and were confirmed by clinic staff, for a 56% “arrival rate” (compared to 40% in Q1). O2O clients who received HIV testing linked to eCascade data records (n=286) were overwhelmingly MSM (84%) and 66% of the total clients were below the age of 30. Most O2O clients in FY19 Q2 had a previous history of HIV testing (83% versus 17%). The overall case-finding rate (among clients for whom linked eCascade results are available) was 8% (24/286); while the case-finding rate continues to decrease as for all LINKAGES-supported testing modalities, O2O continues to outperform many other approaches to recruiting testing clients when it comes to case-finding rates: CBS 2.4%, walk-in 4.8%, PM 3.1% SNS 10.5%. Graph 9: Online to Offline Trends (FY17 Q4-FY19 Q2)

When disaggregated by mode of O2O recruitment, the data in this quarter highlight a new trend in successful online recruitment compared to previous quarters where APCOM accounted for most successful online engagement via their marketing and promotion activities via YouTube, Facebook and various dating applications. Without those promotions being implemented this quarter, Q2 data show that online outreach via LINKAGES partners has increased its performance and brought 38 tested clients into the project with 8% of HIV case finding, while online influencers had the highest HIV case-finding rate (27%).

7 Bangkok, Chiang Mai, Pattaya, Hat Yai, Ubon Ratchathani, Chiang Rai

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Table 2: Breakdown of Online to Online Recruitment by Approach (FY19 Q2)

While the reduced number of overall engagements and testing reservations, as well as overall reduced case-finding, may be attributable to the delay in planned activities under APCOM’s testBKK campaign (and particularly to the suspension of paid advertisements via online dating apps that have historically showed high case-finding), performance this quarter indicates that, when motivated, other LINKAGES IPs can also contribute significantly to O2O testing and case- finding. LINKAGES expects to see O2O performance improve significantly in Q3, with continued positive performance from community-based IPs and the relaunching of paid promotional advertisements under the testBKK banner. Despite not implementing large- scale of online engagement activities in Q2, APCOM did promote LINKAGES’s new online tool “Risk Assessment”, which allows users to assess their level of HIV risk and received tailored behavior change messages (including referral to testing services) via an anonymous survey linked to the Test Me Now platform. Only 98 individuals completed the risk assessment in Q2; however, the platform was only launched midway through the quarter and has not yet been widely promoted – this number is expected to increase significantly. Among those who completed the assessment, the majority (56%) self- reported as MSM, and 41% had never previously received an HIV test. Unfortunately, only two individuals who completed the assessment subsequently made a testing reservation via Test Me Now, and neither are recorded as having arrived for their appointment. The relatively high proportion of HTC-naïve individuals who completed the survey supports that APCOM continues to reach high-priority populations via their online activities; however, behavioral change strategies need to be strengthened to encourage more of these individuals to access services. LINKAGES and APCOM will provide a more complete breakdown of risk assessment findings in Q3, when there is expected to be a larger body of clients using this tool. We will also continue to work with APCOM, TRCARC and the Thai Ministry of Public Health (MoPH) on strategies to reduce the barriers to HIV testing for online clients, including potentially by introducing on option for online clients to order a self-test kit, as demonstrated successfully under LINKAGES’ recently-completed oral fluid implementation science research. Refreshing Approaches to Behavior Change Communications LINKAGES continues to revise the U=U (“Undetectable = Untransmittable”) campaign with Commetive Productions, which will include 2 videos featuring real HIV-positive individuals openly sharing their identities and educating audiences about the benefits of early treatment and achieving an undetectable status. The two videos will be broadcasted and promoted via our implementing partners’ online channels to promote and recruit the audiences for HIV testing and treatment. Early versions of campaign materials did not include a clear, strong and

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 13 consistent call to action; LINKAGES has worked with Commetive to revise the materials to address this weakness. The U=U campaign is expected to launch in Q3. TRCARC is continuing to develop a TG-focused “PrEP in the City” campaign; simultaneously, LINKAGES is working with Bangkok-based social change agency Love, Frankie to produce an MSM-focused PrEP campaign. In Q2, Love, Frankie conducted several focus group discussions with members of the target audience to better understand pre-existing knowledge and attitudes regarding PrEP among this audience and shared previously developed PrEP promotional materials to test which approaches had more relevance. Interestingly, of the various pre-existing promotional materials shared, the approach that resonated best with target audiences was that featured in a non-professional video developed under the LINKAGES “Ready, PrEP, Go” crowdsourcing competition. While test audiences noted that this video featured lower-quality production values and was not as well-edited or professional as other materials, they found it spoke more realistically to them as a target audience and, by reminding them of their risk, was more likely to motivate MSM to consider using PrEP. As a result of this formative research, Love, Frankie is moving to expand upon the creative concept under the Ready, PrEP, Go video by focusing on realistic storytelling with the dual goals of increasing target audiences’ perception of their own risks, and also establishing PrEP use among young MSM as an emerging norm. The video will be presented under the concept of “With PrEP, you can have fun without fear” with the tagline “Live your life freely, let PrEP protect you.” LINKAGES expects to launch this video, and refreshed PrEP promotional materials for IPs, in Q3. B. HIV testing and counseling

In FY19 Q2, HIV counseling and testing services supported under the LINKAGES Thailand project provided HTS for 31,994 clients8 of whom 41% (12,978) were self-reported KPs and the remaining 59% were reported as members of the general population. This represents a 6% increase in overall HIV testing compared with the previous reporting period; as of the end of Q2, LINKAGES Thailand has achieved 149% of our annual HIV testing target (62,011/41,697).

8 9,145 MSM; 451 MSW; 957 TG; 251 TGSW; 1,997 FSW; 177 PWID; 9,575 non-KP males; 9,441 non-KP females

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Graph 10: LINKAGES Thailand HIV Testing Performance by Quarter

Increases in overall HIV testing should be interpreted with care – KPLHS sites receiving direct LINKAGES funding and technical assistance accounted for 38% (12,018/31,994) of all reportable HIV testing uptake during this period and increased only 1% over the previous quarter. At the site level, numerous KPLHS partners saw significant decreases in testing uptake, including RSAT Hat Yai, RSAT Chonburi, Sisters, and Caremat. One key reason for this decline is that Sisters and Caremat had unusually high performance on HIV testing in FY19 Q1 (among lower-risk client populations) as they were pushed to achieve NHSO service delivery targets before the end of the calendar year – performance this quarter is more in line with historical averages, though Caremat showed improved case-findings when they focused on higher-risk subpopulations rather than broach-based HIV testing uptake. RSAT also noted that budget restrictions from NHSO funds transfer delays and organizational restructuring led to limited activities, particularly limited mobile testing which contributes significantly to testing uptake in Hat Yai and Chonburi.

The majority of reported HIV testing uptake (62%, 19,976/31,994) came from a network of 104 public and private-sector healthcare facilities (HCFs) that have received PEPFAR-funded technical assistance and which serve both walk-in clients and individuals referred by LINKAGES implementing partners. Service delivery via this network of HTS providers increased 10% over the previous quarter.

It is notable that 46% of all referral to testing came from RSAT Chonburi, which completed renovations in January 2019 and formally opened their community health center the third week of February. RSAT reports that many testing clients continue to access services via healthcare facility referral due to the limited opening hours at the RSAT Chonburi community health center (Friday-Sunday). This site does not currently have a full-time medical technologist; for the time being, Chonburi Hospital has agreed to provide a part-time technologist to the health center to conduct testing, LINKAGES will be working with RSAT to reconsider appropriate staff and operating hours to ensure value for the PEPFAR investment in

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 15 developing this community space for KPLHS service delivery. In the longer term, RSAT Chonburi is taking steps to register with the Provincial Health Office as a Medical Technologist Clinic, after which they can prepare an application for laboratory accreditation – which, process is expected to be completed by the end of FY20 Q1.

Graph 11: LINKAGES Thailand HTC and Case Finding by IP

*Data include testing and case-finding as a result of referrals not included in PEPFAR reporting totals Of the 31,994 clients tested under PEPFAR support during Q2, 1,058 clients were newly identified as HIV-positive,9 for an overall case-finding rate of 3%. The breakdown of case- finding by key population was 531 MSM, 25 MSW, 50 TG, 11 TGSW, 16 FSW, 270 non-KP males, and 155 non-KP females. While LINKAGES partners identified 15% fewer new HIV cases in this reporting period than in the previous period, and while this case-finding rate represents a continued decline in HIV case finding, LINKAGES Thailand has still achieved 78% of our FY19 case-finding target (1,058/2,944) and is well on-track to achieve our expected case-finding target for this year.

As can be seen above, case-finding rates were almost uniformly low across LINKAGES KPLHS sites, including even the TRC Anonymous Clinic, which traditionally has shown notably higher levels of case finding in comparison to other testing sites. During this reporting period, the key exceptions were the RSAT expansion sites in Samut Prakan (10% case-finding) and Chonburi (12%). RSAT reports that these higher case-finding rates are related almost exclusively to use of the Social Network Strategy (SNS) and to online recruitment and referral, both of which have been associated with higher case-finding rates among smaller numbers of clients. As discussed above, RSAT Chonburi both operates a community health center-based testing service and refers clients for healthcare facility-based testing; in this case, case-finding at the community health center was 8% (5/60) while among referral clients was 15%. While community-based testing at this site outperformed other CHCs in terms of case-finding, those who elected referral to a third-party service provider appear to represent an even higher-risk group. This raises the possibility that additional high-risk individuals may have been lost at this site due to unsuccessful referral to HCF-based testing.

9 475 DSD, 619 TA-SDI

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 16

Overall case-finding rates disaggregated by population (inclusive of linked testing results not counted toward PEPFAR indicators) are below:

Table 3: Overall Case Finding Rates by KP Populations Total Testing Total Positives Case Finding MSM 9303 558 6% MSW 451 25 6% TG 979 53 5% TGSW 251 11 4% FSW 1997 16 1% PWID 177 0 0% non-KP males 9575 270 3% non-KP females 9441 155 2% Total 32173 1124 3% KP Total 13158 663 5%

Case-finding rates continue to be higher for self-reported KPs than among members of the general population, but lower than anticipated for high-risk populations. Case-finding rates among KPs testing through HCFs are notably higher than at KPLHS sites (14% versus 4%), likely because HCF walk-in testing is skewed towards individuals who are already sick. Case-finding has previously been higher among TG and TGSW than seen during this reporting period, driven by declines in the number of cases identified at Sisters (-36%) and Tangerine (-4%). LINKAGES is performing below expectation with regards to case-finding for these populations, and we will work with Tangerine to reinvigorate online promotions for trans women. However, given this is the fourth consecutive quarter of declining case-finding performance at Sisters, and given the ongoing management and quality-control challenges with that implementing partner, LINKAGES plans to transition away from direct support for Sisters. We will expand the scope of work for SWING Pattaya to include TG and TGSW in that site.

HIV Testing Service Delivery Models

Among KPLHS sites in FY19 Q2, 72% (8,666/12,018) were provided through community health center testing facilities, with a 5% case-finding rate. A further 26% (3,118/12,018) were tested via mobile testing services in community settings with a 1% case-finding rate – partners repeatedly stress mobile testing as their major approach for increasing HTC uptake, but mobile testing accounts for a smaller proportion of overall testing in Q2 than it did in Q1, with fewer new cases identified. FSW account for 39% of mobile testing with a case-finding rate of <1% - consistent with overall low case-finding among this target population - however, even among other KPs, the case-finding rate for mobile testing is lower than that achieved through community health center testing. The case-finding rate for sauna-based testing was 5%, but this model accounts for less than 1% of overall KPLHS service delivery. It is possible that the programmatic introduction of oral fluid self-testing (see below) will significantly alter the uptake of mobile testing services; the current, blood-based mobile testing model does not contribute significantly to case-finding targets, nor is it linked to facility-based PrEP provision for HIV-negative clients. LINKAGES will work with partners to reconsider the expenditure of time and resources around these activities.

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 17

Graph 12: HIV Testing Breakdown of KPLHS vs HCF

As noted above, a significant proportion of HIV testing under the LINKAGES project comes not from community-based KPLHS partners, but from a network of 104 healthcare facilities that have received PEPFAR-funded technical assistance relating to HIV counseling and testing for KPs. During this reporting period, 19,976 individuals received HIV testing from these partners (63% of the total testing figure for Q2). Self-reported members of key populations accounted for only 6% of HCF-based testing clients, though the case-finding rate among HCF-based KP clients was 14% (163/1189), indicating a high-risk pool of clients who are a priority for both rapid ART initiation and index testing for epidemic control.

Graph 13: LINAKGES Thailand Provincial Level HTC and Case Finding by HCFs

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 18

When disaggregated by province, HCFs in Songkhla province account for proportionally more of testing uptake, but with a low case-finding rate. HCFs in Pathumthani and Samut Prakan, conversely, account for a very small percentage of testing but with extremely high case-finding rates. It may follow that, as metropolitan Bangkok is documented to have a higher HIV prevalence than other areas of the country, hospitals in and around the city correspondingly find higher numbers of cases. However, LINKAGES Thailand currently does not have access to testing and/or case-finding data from hospitals in Bangkok proper to allow for a more complete comparison.

KPLHS contributions, in comparison, accounted for only 37% (11,789/31,993) of all HIV testing in Q2, but 91% of all testing uptake among self-reported KP individuals under the LINKAGES project (11,789/12,978), 45% of total case-finding (475/1,058) and 74% of all case-finding among self-reported KPs (470/633). These sites remain critical to closing the “gap” in HIV testing uptake for key populations.

The key point is that both community- and healthcare facility-based testing models are necessary to provide a comprehensive response for KPs. While LINKAGES continues to work with partners to increase uptake of community-based testing and early case identification (see oral fluid screening, below), we are also seeking to standardize and expand technical assistance to healthcare facilities through the introduction of critical services like index testing for KPs and through working with provincial health offices to improve HCF-based data reporting and analysis. Index Testing and Risk Network Referral

Beginning in FY19, PEPFAR has placed considerable emphasis on index testing as a strategy for increasing case-finding through HIV testing services while reducing “over testing”. In response to this priority, LINKAGES is working to rollout a KP-specific index testing model for implementing partners that will integrate traditional Voluntary Partner Referral (VPR) with a new approach known as Risk Network Referral (RNR).

During this reporting period, 40 newly diagnosed HIV-positive clients were offered index testing services by LINKAGES IPs. This represents only 4% of all newly diagnosed PLHIV (40/1,058). However, LINKAGES is not yet working to introduce index testing at PEPFAR- supported HCFs; 8% (40/475) of all newly diagnosed clients at KPLHS sites were offered index testing, which is still far below the necessary level. A total of 9 HIV-positive clients accepted index testing and identified 10 contacts for referral to testing. Of these, 8 were tested with 1 new HIV-positive case identified. In addition, 143 walk-in clients self-reported they were seeking testing because one of their sexual partners had tested HIV-positive; of those, 9 tested positive. Therefore, LINKAGES Thailand total HIV testing achievement for this reporting period is 151 index contacts tested and 10 new cases identified (7% case finding).

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 19

Graph 14: LINKAGES Thailand Index Testing by Partner

LINKAGES acknowledges that these figures are far below the contribution PEPFAR envisions index testing making to overall program performance; however, this model has only recently been introduced to partners and not all pieces are as yet in place for full rollout. As can be seen above, in Q2 only 6 KPLHS sites implemented any form of index testing (though case finding under this model was significantly higher than baseline at SWING Pattaya, Caremat, and Tangerine Clinic). The single largest LINKAGES implementing partner by client volume (TRC Anonymous Clinic) is not yet implementing index testing; nor are any of the hospitals in the wider network of PEPFAR-supported HCFs. Standardized training and data collection tools will be rolled out to these sites beginning in Q3.

LINKAGES is also working with TRCARC to finalize Thai-language standard operating protocols for Risk Network Referral and has completed modification to the online Test Me Now platform to allow for virtual partner referral via cellphone, email and/or internet-based messaging platforms. The overarching model, shown above, will Image 2: Integrated HIV index testing model for key populations include both positive and negative clients (to minimize the risk of further stigmatizing PLHIV), will allow recruitment of both sexual partners and high-risk members of one’s social network (based on increased case-finding among KP social networks as demonstrated by other LINKAGES countries, and will provide a range of referral options: provider and peer-driven Quarterly Progress Update (January 1- March 31, 2019) – Thailand 20 referral approaches, client-initiated HIV self-testing, and the introduction of anonymous digital referral. Training of KPLHS sites to implement this integrated model will be conducted in May 2019 and will be rolled out to participating HCFs in June. The integration of oral fluid self- testing may be delayed as the Thai government is still finalizing implementation guidelines for the newly released self-testing policy (see Subsection F – Innovative HIV Prevention Research, below).

Gender-Affirming Care for TG Clients In the second quarter of FY19, the TRCARC-supported team from the Tangerine Clinic continued to provide technical assistance on gender-affirmative hormone level monitoring to seven community health centers.10 During this reporting period, 183 TGW received hormone level monitoring services; of those, 173 TGW (94.5%) also received HIV testing, including 6 clients from RSAT Hat Yai who were first-time testers. Six new HIV-positive cases were identified for an overall case-finding rate of 3.5%. Additionally, 171 hormone monitoring clients received syphilis testing (6 reactive) and 15 (or 9% of those with a negative test result) received PrEP, 13 of whom were first-time PrEP clients. The Tangerine team conducted technical assistance site visits to SWING Pattaya and BKK and new staff at RSAT BKK and Hat Yai, during which they provided refresher sessions on data collection as well as HIV and health services for transgender women. During the visit, staff also conducted data validation exercises for the hormone level monitoring service. Site visits identified that the LINKAGES FY19 budget was a key concern for many IPs, as each CBO has set their own quota for hormone testing based on their budget, and most CBOs have seen a demand that is bigger than their quotas. As clients very often can’t pay, the CBOs have to turn away the clients, which in turn has resulted in lower numbers of clients accessing these services. Some of the action plans include increasing reach through online channels and promoting hormone level monitoring services through the strongly established TGW network in each province. SWING Bangkok also plans to incorporate hormone services into their mobile clinic once every quarter to increase testing uptake. Finally, during this reporting period, the Reproductive Health Association of Cambodia (RHAC) visited Tangerine Community Health Clinic to learn from Tangerine about how to integrate gender-affirmative hormone services for transgender people into HIV programming.

Integrated Syphilis Screening for HIV Testing Clients Since FY14, all KPLHS clients who receive an HIV test through a community health center have been supported to receive a TPHA serological screening test for syphilis. In FY19, LINKAGES started to systematically collect data on STI screening, diagnosis and treatment. During this reporting period, LINKAGES-supported sites provided syphilis screening for 7,862 clients, a 9% increase over syphilis screening conducted in the previous quarter. Despite this increase, only 65% (7,862/12,018) of all KPLHS testing clients received a syphilis test. This screening gap exists partially because screening is not offered for clients with a history of syphilis infection as the existing community-based screening algorithm cannot distinguish between active and historical syphilis infection. To address this gap, LINKAGES will support introduction of a simple rapid plasma reagin (RPR_ test which can be conducted by lab technicians at KPLHS sites and which will be able to identify active infection as well as monitor treatment success.

10 Mplus Chiang Mai and Chiang Rai, Caremat, RSAT BKK and Hat Yai, and SWING BKK and Pattaya

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 21

Of the 7,862 clients who did receive a syphilis test, 523 were reactive (7%). This is an increase over the 5% reactivity rate in FY19 Q1. Only 43% (225/523) of reactive clients received a confirmatory test, and 83% (187/225) of those tested were confirmed with active syphilis infection. Almost all clients with active syphilis (183/187, 98%) were confirmed to have received treatment.

Graph 15: LINKAGES Thailand STI Cascade by Partner

The outlier with regards to syphilis screening is the TRC Anonymous Clinic, which reported a 31% reactivity rate among clients who were screened for infection. TRCARC were unable to access information from the Anonymous Clinic on syphilis confirmation and treatment in time for submission of this report; however, LINKAGES will report complete data on the syphilis cascade for all partners by the end of the next reporting period.

Quality Assurance (QA) and Quality Improvement (QI) for HIV Testing and Counseling Services

During this reporting period, LINKAGES continued to support and analyze the results of the LINK automated client feedback system to standardize measure of client satisfaction across LINKAGES implementing partners. Between January and March, 1,146 clients provided responses11 with most of the responses coming from RSAT Bangkok.

11 854 MSM; 111 TGW; 32 MSW; 20 TG-SW; 80 FSW; 2 TGM; 19 Non-KP males and 28 Non-KP females

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 22

Graph 16: Number of LINK Responses by IP

Clients reached by outreach workers (n=238) were generally very satisfied (69%) or satisfied (27%). Among HIV testing clients, 333 reported receiving services at KPLHS facilities and 80 received a community-based mobile test. More clients reported being very satisfied at KPLHS sites (68%) than at mobile clinics (62%); however, a minority of clients from SWING BKK, RSAT BKK and RSAT expansion sites in metropolitan BKK reported being unsatisfied (1%) and very unsatisfied (2%) with the registration and laboratory officers. Additionally, 7% of clients from mobile clinic raised issue regarding concerns about confidentiality, rushed service from staff, and some staff lacking knowledge and skills. Clients also had the option of providing written feedback via the web survey – the most commonly cited complaints were regarding clinic working hours, waiting times and friendly services.

Overall client feedback regarding KPLHS services was positive; where specific concerns were identified via client feedback, LINKAGES is communicating these results with partners and will follow-up to ensure that issues are addressed. During this reporting period, LINKAGES also created web-based dashboards at the site level, so that implementing partners can directly access and monitor their own client feedback data. Review of these data will be integrated into weekly and monthly project performance meetings with IP staff (see Subsection E, below).

In addition to monitoring service quality, LINKAGES continued to work in Q2 to proactively improve quality. Quality improvement activities in this reporting period were based on the results of quality assessments conducted in FY18, and focused on RSAT sites, SWING Bangkok and Mplus Chiang Rai. LINKAGES Thailand staff worked with implementing partners to develop and update counseling and care support treatment SOPs with particular emphasis on managing TB screening and referral, transfer of health rights and continuous client follow-up, disclosure support, and the introduction of index testing procedures. RSAT in particular presented challenges following their numerous staffing changes at the end of FY18 – LINKAGES worked closely with new RSAT staff to jointly write counseling and care and support SOPs, so that new clinic workers would become better familiarized with counseling standards; referral system flows; key information on HIV, TB, STIs, and ART; and protocols for violence response and positive retention. LINKAGES and RSAT BKK senior staff also supervised dry runs of new TB and STI management flows for counselor and care and support staff. Quarterly Progress Update (January 1- March 31, 2019) – Thailand 23

Following this work, LINKAGES and the implementing partners identified a provincial-level supervisor to observe counseling and care and support activities and provide ongoing coaching and skills building. The identification of these supervisors closes a gap recognized by the QAQI committees, which noted that LINKAGES and TRCARC cannot always be present to monitor service delivery, and more regular support might be necessary. Provincial-level supervision will begin in different sites at different times between April-June 2019, and the provincial-level counselor will observe local counselors at least semiannually, with findings and feedback incorporated into quality improvement activities conducted by the IPs themselves as well as by LINKAGES.

In addition to technical assistance for counseling and supportive services, during this reporting period TRC Anonymous Clinic staff conducted laboratory QA/QI at RSAT Hat Yai. The assessment results were satisfactory, but some improvement was needed in the laboratory document control, especially internal audit reports and KPIs. In addition, the capacity of staff responsible for safety should be strengthened to ensure the safety management in the site. Ongoing QI will be provided through technical staff at FHI 360. The laboratory QA/QI plan for the remaining sites was developed and will be conducted among all 7 CBOs in 4 provinces (Bangkok, Chiang Mai, Chonburi and Chiang Rai) in the next reporting period.

Finally, LINKAGES worked with TRC to further standardize the overlapping approaches to quality assurance and quality improvement being supported under PEPFAR/USAID funding in Thailand. In March 2019, LINKAGES staff and TRCARC arranged a meeting with the USAID Community Partnership project to better integrate and coordinate quality assurance and quality improvement for HTC services. The graphic below shows the key sources of information for QA/QI and breaks down the areas of responsibility.

Figure 1: Clinic Quality Assessment Mapping Chart

Staff quality Clinic quality

SIMS assessment by USAID

LINK Survey by FHI360

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 24

As can be seen, clinic quality is assessed through a combination of USAID SIMS visits and the LINK survey conducted by LINKAGES (see below), while UCP is responsible for introducing staff quality standards through training and certification, enforced through standard operating procedure and monitored through regular in-depth client surveys and provincial level QAQI committees. Quality improvements are carried out through provincial level supervision by local counselors, coaching by senior staff of the implementing partners as well as FHI 360 and TRCARC, and through refresher courses and e-learning activities conducted by UCP. As has been described above, components of this QAQI model are already being put into practice.

C. Treatment (provision of ART, linkage to ART and/or progress on ART uptake)

During this reporting period, LINKAGES Thailand supported initiation on ART for 996 HIV- positive clients,12 including 430 MSM, 3 MSWs, 45 TG, 3 TGSW, 4 FSWs, 3 PWID, 314 non-KP males, and 194 non-KP females. This represents a 4% decrease in new ART initiations over the previous reporting period – itself explained by the reduction in the number of new positive clients identified in Q2 – but LINKAGES has nevertheless achieved 69% (2,034/2,942) of the anticipated TX_NEW target for FY19.

An additional 221 KPLHS clients were confirmed by LINKAGES partners as having initiated ART at facilities not currently supported by PEPFAR, and who therefore could not be counted toward achievement of PEPFAR indicators under current MER definitions. Total ART uptake as a ratio of newly initiated ART patients to newly diagnosed PLHIV for Q2 is 112% (1,217/1,088) though it is acknowledged that this ratio may overstate the actual proportion of ART uptake, since some TX_NEW clients in Q2 will have been diagnosed in previous quarters, while some clients newly diagnosed in Q2 will initiated treatment in subsequent quarters. Additionally, because LINKAGES Thailand reporting includes service delivery figures for both KPLHS sites and HCFs, and because clients move from facility to facility based on personal mobility and health rights eligibility, it cannot be assumed that all ART clients will have tested positive under LINKAGES support. The proportion cited above is a best-case scenario based on cross-sectional data.

12 222 DSD, 774 TA-SDI

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Graph 17: LINKAGES Thailand Aggregate Treatment Uptake by Quarter (FY15 Q2-FY19 Q2)

When ART uptake is disaggregated by site, partner performance varied widely this quarter. Among those sites where ART uptake within the same fiscal quarter is lowest,13 42% of those clients not initiated on ART before the end of the reporting period either already started treatment after the cutoff date for this report or have been verified in the process of transferring health rights or medical records so that treatment will begin within Q3. An additional 33% were either uncontactable or proactively requested that LINKAGES partner staff not contact them. Among the remaining clients who did not start treatment, 12% reported they were “unready” for ART, and 12% were relocating out of the project coverage area (including 4 non-Thai clients) and declined to be linked to locally available treatment services. Finally, 1 client reported being declined ART by their healthcare provider because their CD4 count was considered too high, contravening Thailand’s national test and treat policy. While the relatively low rates of ART initiation appear at least in part the result of clients on process but not yet initiating treatment (which is an argument for greater rollout of same day ART (SDART)) these findings additionally support the need for continued messaging on the importance and benefits of early treatment initiation, particularly as part of a client-centered “treat and test” approach to HIV post-test counseling and index testing.

13 Caremat, Mplus CM, SWING PTY, RSAT CB, RSAT PT, RSAT NB

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 26

Graph 18: LINAKGES Thailand Treatment Cascade by Site

Update on Same-Day ART During this reporting period, 523 clients tested HIV-positive at the TRCAC (53.3% were newly diagnosed; 46.7% were re-engaged). Of clients who tested positive, 29.6% were from the general population, 61.4% were MSM, 5.2% were TGW, and 3.8% were adolescents (defined as being 19 years old or younger). There is a drastic increase in HIV diagnoses among the general population clients: in Q1, 30.3% of new HIV diagnoses were among the general population, compared to 66.5% in this quarter.

Of these 523 clients, 438 were logistically eligible for SDART services. Of those who were eligible, 90.4% accepted to enter SDART services. When stratified by population, 86.8% of general population clients accepted SDART compared with 86.3% of MSM, 93% of TGW, and 95% of adolescents. The median (IQR) CD4 count at diagnosis was 345 (198-428) cells/mm3; the median (IQR) time from care engagement to ART initiation was 1 (1-8) days.

Between July 2017 to March 2019, 1,843 clients who initiated ART had been on treatment for 6 months. Of these, only 59.6% had been tested for viral load, and 99.5% (n=989) among these were virally suppressed. When compared to other populations, adolescents had the lowest viral suppression rate (85.7%; 66/77).

In addition to TRCAC, SDART has now been replicated in 9 hospitals across 5 provinces.14 Since scale-up of this model began, 746 clients have tested HIV positive in those hospitals, 674

14 Chiang Rai, Chiang Mai, Ubon Ratchathani, Chonburi, and Songkhla

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 27

(90.3%) agreed to receive SDART services, and 564 of those (83.7%) initiated ART.15 Of these, 494 (87.6%) did not have clinical concerns and initiated ART within a median (IQR) of 0 (0-8) days from care engagement; 70 (12.4%) had clinical concerns and initiated ART within a median (IQR) of 18 (12-26) days after care engagement.

While treatment initiation was relatively fast among clients with no pre-existing clinical concerns, in total only 46.6% of all clients started ART on the same day of care engagement, with a median (IQR) duration of 16 (5-33) days for the remaining 53.4%. Hospitals with same- day ART initiation rates of less than 50% included Queen Savang Vadhana Hospital in Chonburi, Chiang Rai Prachanukroh Hospital in Chiang Rai, and Sunpasitthiprasong Hospital in Ubon Ratchathani. LINKAGES and TRCARC are working to better understand the reasons for treatment delays, including conducting site visits and arranging a hospital-level SDART meeting, which will be organized in May 2019 and led by Nakornping Hospital, one of the top performing hospitals.

Of 564 clients who received SDART, 221 had reached at least month 6. Of these, only 26.2% (58/221) were tested for viral load and 84.5% (49/58) were virally suppressed. Together with viral load testing rates from Bangkok-based Same-Day ART clients, this suggests that viral load monitoring is a serious issue in Thailand and could have negative implication to helping the country control the HIV epidemic (see Subsection D, below).

Bangkok has the lowest ART coverage when compared to other cities in Thailand, and thus SDART expansion is the main priority for the program. In addition to inviting Bangkok hospitals to participate in the hospital-level ART meeting mentioned above, TRCARC is also planning on hosting a Bangkok-specific Same-Day ART consultation meeting, in which hospitals in Bangkok, are invited to discuss plans to implement Same-Day ART. This meeting will take place in June 2019.

Technical Assistance and Capacity Building for Treatment, Care and Support During this reporting period, LINKAGES staff conducted a 2019 review of updated HIV and HIV treatment information for 143 health care professionals representing 102 healthcare facilities across Chiang Rai, Chonburi, and greater Bangkok. Participants included 18 doctors, 13 pharmacists, 74 nurses and 15 public health officers/medical technologists. An additional 23 care and support officers from LINKAGES IPs joined the trainings to gain more knowledge on treatment and care for HIV in key population groups to support clients effectively. This training topic was identified as a key area of interest for staff at HCFs working with the LINKAGES project through a TA needs assessment conducted at the end of FY18.

In addition to the TA trainings workshop, LINKAGES also conducted workshops with healthcare facilities to review project data and address needed improvements in KP data collection and analysis with 127 referral network hospitals. These meetings focused on identifying KPs’ gender identity, conducting accurate data entry, and using data to advocate with healthcare facility management to reduce gaps in HIV and ART services. The most commonly identified issues discussed during these workshops were:

15 Seventy-two clients did not agree to receive SDART, for reasons including wanting to start ART at registered hospital (n=11), not wanting ART (n=3), died (n=3), anxiety (n=9), being treated for OI(s) (n=17), and unspecified reason (n=29). Among those 674 who accepted the service, 110 (16.3%) could not initiate ART, due to referrals related to opportunistic infections (n=55), personal reasons such as anxiety, or not feeling ready (n=3), referrals to registered hospitals (n=8), or unspecified (n=44).

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 28

• PHOs have insufficient HIV-related data to advocate with provincial-level policymakers; • HIV-positive clients diagnosed in a hospital setting had significantly lower median CD4 counts at baseline compared with clients diagnosed in the community (165 to 318 cell/ml compared 235 to 690 cell/ml) and hospital-based clients are being diagnosed when they have already begun to experience signs and symptoms of disease; • HCF data demonstrated the concerningly large proportions of hospital patients diagnosed positive had still not initiated ART by the end of the current fiscal year: Samut Prakan 42%, Patumthani 41%, and Nonthaburi 27%. Additionally, among those diagnosed at a hospital who did initiate ART, median time to treatment initiation was more than 16 days in Samutprakarn and 26 days in Patumthani. • Viral suppression among hospital clients looks extremely good around 95%; however, as many as 10% of HCF clients who are eligible for VL testing do not receive it. In some localities – Patumthani and Samut Prakan - the percentage of those virally suppressed would have fallen around to around 86-87% if those patients eligible for testing but not tested had been included in the data.

Finally, during FY19 Q2 LINKAGES staff continued to conduct regular site visits to follow-up the clinic management, clinic flows, care & support practices, and treatment referral systems to ensure that CBO staff adhere to HIV related standards guidelines and the KPLHS SOP. During this reporting period, 8 KPLHS counselors and care and support staff received on the job training and coaching visits from FHI teams. Areas identified as needing addition support were: • STIs knowledge, flow of syphilis testing and standard practice • TB flow and dry run fast track system that designate in SOPs • Couple counseling for index testing • CST database and client record systems • Monitoring CST performance

To begin addressing these issues, CST staff from SWING Bangkok, SWING Pattaya, RSAT BKK, RSAT Patumthani, RSAT Nonthaburi, RSAT Samut Prakan, RSAT Chonburi and Sisters attended the HIV update training described immediately above. FHI 360, TRCARC, and UCP will work to collaboratively support all IPs to be able to provide STI/HIV care that meets the minimum standards of practice.

D. Retention and care and support services

As of the end of FY19 Q2, 36,13116 HIV-positive clients were actively receiving ART services under PEPFAR support, either directly through LINKAGES IPs under a differentiated services delivery (DSD) model (n=224) or through a network of 117 public and private-sector hospitals that have received LINKAGES and TRCARC support for treatment provision and adherence (n=35,907) and which reported TX_CURR numbers during this reporting period. This represents 547% (36,131/6,611) of the anticipated TX_CURR target for FY19; however, TX_CURR is not cumulative across quarters so the final achievement toward this indicator will be dependent on the number of clients actively receiving ART at the end of FY19 Q4.

16 3,366 MSM; 36 MSW; 273 TG; 9 TGSW; 75 FSW; 136 PWID; 16,275 non-KP males; 15,961 non-KP females

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 29

As previously, performance on the TX_CURR indicator is largely because LINKAGES has worked to provide technical assistance and successfully build relationships with key ART service providers across our nine provinces. This explains the high proportion of “non-KP” TX_CURR clients. Non-LINKAGES healthcare facilities are much less likely to ask or record information on the KP status of 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.

In addition, a total of 20,366 clients who were active on ART in Q2 have received at least 1 viral load test in the past 12 months (103% of those eligible for VL testing). The overall rate of viral load suppression among those patients who received a VL test (TX_PLVS) was 97% (19,673/20,366). It should however be noted that viral load testing performance varied significantly between HCFs and KPLHS sites – while 109% (19,647/18,082) of eligible HCF patients received a viral load test, only 45% (719/1,591) of KPLHS patients did so. VL suppression rates among those tested were high for both KPLHS and HCF patients (99% and 97%, respectively).

Graph 19: LINKAGES Thailand Viral Load Suppression by Site

As can be seen above, viral load suppression is high among KPLHS clients who received a test across all sites; however, only three KPLHS sites achieved testing uptake rates above 50%: RSAT BKK at 156%; Tangerine Clinic at 75%; and Mplus Chiang Mai at 57%. VL testing uptake rates are almost uniformly low, which is also consistent with findings under the TRCARC SDART activity, though LINKAGES is working with IPs to strengthen messaging around viral load testing, which will be further promoted as part of an upcoming “U=U” campaign (see Subsection A, above). LINKAGES had further intended to improve VL testing uptake using GeneXpert Point-of-Care testing in community settings; however, that activity is currently on- hold due to budgetary constraints (see Subsection F, below).

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 30

Retention in Care and Loss to Follow-Up Reporting on loss to follow-up among ART patients under LINKAGES Thailand is complicated by the fact that many patients who receive HIV treatment supported through PEPFAR technical assistance are served via public-sector hospitals that do not have mechanisms in place for reporting aggregate data on longitudinal patient tracking, and where such data are available, they are not covered by existing data sharing agreements between LINKAGES and these hospitals. LINKAGES and USAID are engaged in ongoing negotiations with the Ministry of Public Health to gain access to national patient-tracking data in order to more fully characterize retention among ART patients; in the meantime, the data presented here are for those clients tested HIV positive at KPLHS sites under the LINKAGES project, and subsequently monitored by community-based care and treatment staff.

TX_ML is intended to drive improved tracing of patients to ensure patient outcomes are known and that appropriate programmatic action is being taken to locate patients that have missed clinical visits. Since the launch of the LINKAGES project, 6,017 patients under the KPLHS model have initiated ART. Of those, 1,287 (21%) have not been retained by care and support staff.17 The breakdown in patients lost to follow-up is as follows:

• 12 died (<1%) • 5 were transferred out of the LINKAGES coverage area (<1%) • 677 were tracked but partner staff were unable to contact them (53%) • 523 were not actively followed-up during this reporting period (41%) • 70 requested that partner staff not contact them (5%)

Graph 20: LINKAGES Thailand ART Cases with No Clinical Contact by Site

17 Note that failure to retain ART patients should not necessarily be interpreted to mean these individuals are no longer received ART, only that they have not been successfully followed-up by care and support staff to confirm their current treatment status.

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 31

When disaggregated by site, the largest numbers of lost to follow-up clients come from RSAT Bangkok and Mplus Chiang Mai – these sites additionally account for the largest proportion of clients who were not proactively followed-up. This is partially because budget reductions in FY19 have led to staffing shake ups and reductions in the number of care and support staff – with limited human resources, partners have chosen to focus follow-up efforts on newly initiated ART clients or others who were considered more likely to present retention challenges. Despite human resource challenges, LINKAGES acknowledges the critical importance of supporting and documenting retention on treatment for all ART clients, and will work with RSAT and Mplus to ensure that follow-up protocols are strengthened and that the treatment status for all ART clients under their care has been ascertained within this fiscal year.

E. Strategic information and monitoring and evaluation

Following on the FY19 Annual M&E Workshop, which was held during the last reporting period, in Q2 LINKAGES conducted indicator trainings on site for all partner staff in Chiang Mai and Chiang Raito ensure a clear understanding of FY19 indicators and to address any questions or concerns arise from the annual workshop.

LINKAGES also co-conducted Routine Data Quality Assurance (RDQA) with partners’ M&E teams at SWING Pattaya, RSAT Chonburi, RSAT Ubon Ratchathani, and RSAT Songkhla. During these visits, LINKGES staff worked with partners to identify source documents, databases and responsible individuals for ensuring completeness of reporting for each indicator. SWING Pattaya in particular showed significant improvement in data management across different indicators and staff who involved in the data management demonstrated better understanding of indicators and their calculation. RSAT sites had been through major restructuring that affected their work and data flows, especially RSAT Songkhla where data management was being handled by staff who were new to the process and will require further monitoring and capacity building. All findings were debriefed at each site and while most action items were addressed in the course of the RDQAs, some remaining issues will be followed up in Q3.

In addition to working with implementing partners, LINKAGES M&E staff also conducted training sessions on data collection tools and processes for Data Coordinators and other healthcare facility staff at the 2019 HIV and HIV Treatment Meetings hosted by LINKAGES CST team in Chiang Rai, Chonburi, and Bangkok and surrounding provinces.

In terms of national data engagement and advocacy, LINKAGES contributed and participated in various meetings held by the Ministry of Public Health and UNAIDS. These included National Size Estimation, PrEP Size Estimation, RTCM+ Development, and GAM Report.

Toward the end of this quarter, LINKAGES established a committee comprised of technical, M&E/SI, and program staff to create a weekly progress dashboard and a standard operating procedure with implementing partners to review data on a weekly basis, analyze progress toward service delivery targets,18 and plan programmatic improvements where achievements are below expectation. The draft procedure calls for real-time, weekly data to be obtained

18 Weekly data reviews will preliminarily focus on performance on HTS_TST, HTS_TST_POS, TX_NEW, and PrEP_NEW indicators. HTS_INDEX will be added to weekly reviews as this model is rolled out across sites. Treatment retention and VL testing will be examined monthly and quarterly, but will not be a part of the weekly reviews as much of this data comes from healthcare facilities that do not report into eCascade; accessing updated data on a weekly basis is therefore not considered realistic at this time.

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 32 from the eCascade system, which will preliminarily be used by partners to generate simple, Excel-based dashboards though eventually it may be possible to have these dashboard visualizations generated directly in eCascade. Partners will be responsible for accessing data on a weekly basis, creating the required dashboards, and identifying areas for improvement. LINKAGES staff (as well as potentially USAID RDMA representatives) will meet either in person or virtually with partner staff at the site level to discuss the outcomes of weekly data analysis and plan programmatic responses. This process will be launched at all sites by the end of Q3.

Consensus meeting on HIV epidemic among MSM and TG in Bangkok LINKAGES worked with the Bankgok Metropolitan Administration (BMA) and TRC to host a series of HIV consensus meetings with the objective of summarizing existing surveillance, research, and programmatic data to determine the current state of the HIV epidemic among MSM and TG in Bangkok and to identify areas for increased programmatic attention and intervention. This consensus was determined to be particularly useful because a majority of testing sites in Bangkok and nationally are witnessing decreased HIV case finding, and it is not certain if this is due to reduced HIV infections, saturation, or a need for better targeting of undiagnosed HIV cases.

During this quarter, a modified Delphi process was used to reach consensus between experts and stakeholders. The Delphi technique was originally developed as an iterative process of soliciting and consolidating expert opinions for the purpose of reaching consensus about a complex problem. Dr. Frits van Griensven, a LINKAGES consultant and expert in HIV epidemiology, established a literature database of all scientific publications regarding HIV epidemiology and prevention in Bangkok MSM and TGW as a resource to support the Dephi process. In Q3, the consensus group will meet a second and final time to conclude and vote on conclusions based on data presented at the initial meeting.

Digital Tools for Strategic Information The eCascade system – which is comprised of both a smartphone-based mobile data collection system to allow workers to record service data, as well as a real-time dashboard application that calculates and visualizes the resulting data – continues to evolve and grow in use. The number of unique individual clients in the system rose to 126,564, marking a 6.2% gain in new unique individuals reached since the end of Q1. Almost 318,000 forms in total have been filled out for those individuals, at an average of about 2.51 service forms per individual client, a continued gradual rise in forms per client that reflects individuals continuing to engage with our system over time. Our previous quarterly report described the launch of a new dashboard section that automatically calculates MER indicators from eCascade data. This feature arose from an increased frequency of requested data reporting.

During Q2, this need became much clearer as a requirement of weekly data review (described immediately above) was specified. LINKAGES staff immediately initiated further adjustments to the dashboard. Beyond the current ability to retrieve indicators for weekly time periods, the new features will now extract them in a flexible data format, as opposed to merely presenting them in disaggregation grids. This will make it much easy to quickly render stronger analysis and visualization in statistical packages. Allowing LINKAGES and partner staff to visualize these indicators by time, KP, age, and geography will extend higher analysis capabilities to partners, and at the same time allow our teams to determine through experience which visualizations

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 33 are most valuable. Those selections will then be ultimately implemented within the pages of the online dashboard.

LINKAGES staff has continued to meet, engage, and advise the Thai Government MOPH team that is building the RTCM+ system. RTCM+ development has been gradual as the team confronts complexities and decisions about design elements. LINKAGES’ participation has lent not only perspectives on integrating RTCM+ with our own data system, but also M&E-based advisement on the general data structures and methods used in their system’s design.

Online-to-offline approach. LINKAGES Thailand’s TestMeNow reservation app, which tracks the success of online-to-offline (O2O) recruitment methods, continues to increase in functionality. As of the writing of this report, Thailand clients have created 5660 reservations, 2919 of which saw the client successfully arrive for his reservation. This “recorded booking arrival rate” rate of approximately 50% has remained fairly constant over time. The goal of ensuring that clinic staff take the time to ask clients if they had reserved, and mark them arrived, is a key focus in this system’s success. (The technical analysis of O2O data are described in Subsection A, above.)

During this reporting period, LINKAGES completed updates that will allow TestMeNow to also serve as a vehicle to manage index testing client flows. The design allows counselors to offer HIV+ clients the opportunity to choose to become a seed and pass a digital coupon to their sexual or social contacts. The digital coupon to be given to the contacts -- which is a uniquely coded hyperlink -- can be transmitted via chat or any online medium. Alternatively, the seed can elect to have this coupon sent to his contacts anonymously, in which case the CBO will transmit it using an official organizational chat account on the appropriate platform for the recipient. LINKAGES will train partners and clinic staff in the use of this new referral tool in Q3, with a focus on establishing standard procedures to protect client sensitivities and privacy.

LINKAGES also continued discussions with senior management of the dating app Hornet, to seek a way to direct Hornet users to LINKAGES reservation apps when they are due for an HIV test. This has proved to be a complex negotiation, as Hornet states that they prefer a method that would create a large new application infrastructure. LINKAGES aims to both gain these potential additional new referrals while still ensuring that any new infrastructure still gives our apps the existing abilities to track all other outreach methods.

The total of other countries building their O2O approaches on a “clone” of the Thailand O2O app has now risen to five: India, Nepal, Kenya, Sri Lanka, and Cambodia. The latter two have not yet launched. Additional LINKAGES countries are planning to adopt the system in the future.

LINK client feedback system. During this quarter, LINKAGES further refined LINK, a centralized method of collecting client feedback about the quality of the services they received from service delivery partners. LINK is triggered when a client has a new eCascade form filled out for them at the point of outreach or clinic walk-in. After a client has completed the service, they receive an SMS message requesting their feedback, and providing a clickable link. If a client clicks the link, they are taken to a form that asks questions about their satisfaction in a number of dimensions. To current date, the six participating partners have had over 2800 of these online forms completed. This quarter, all implementing partners were provided links to online

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 34 dashboards visualizing results of the clients’ feedback. Findings from regular review of client feedback will be integrated into weekly and monthly performance reviews with partners. (For current outcomes of LINK data analysis, see Subsection B, above.)

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

The following are updates from the implementation science and research projects currently supported by LINKAGES:

Community-led Test and Treat cohort study. This study has been closed since December 2018, as the follow-up for all participants in the Community-led Test and Treat cohort study has been completed, and the data cleaning and entering process is currently underway.

HIV Self Testing Implementation Science. The HIV self-testing study was completed as of the end of the previously reporting period, though LINKAGES continues to work to package and disseminate the results of this study. Aa technical brief as well as potentially a short video documentary will be completed within FY19.

They key outcome of this study has been the sharing of information with the Thai Ministry of Public Health (MoPH) to advocate for the inclusion of HIV self-testing models as part of the national testing policy. In the previous reporting period, the MoPH released a draft notification on HIV self-testing in Thailand – during this quarter, the LINKAGES study team provided substantive comments on the drat notification and key senior TRCARC staff participated in two Thai FDA committee meetings where they also provided technical comments on HIV self- testing, informed by the results of the LINKAGES study. Following this consultative process, the MoPH approved a ministerial notification on legality of HIV self-testing, which was officially announced in Thai Government Gazette on April 9, 2019.

As a result, HIV self-testing is now legal in Thailand; however, companies wishing to sell or distribute self-test kits must register and receive approval from the Thai FDA before their products can be brought to market. OraSure – the manufacturer of the kit used in the LINKAGES study – has already applied to register their oral fluid test kit for use by healthcare professionals. This kit is identical to the self-test kit – the only differences are in terms of packaging and directions. Registration of this test kit for professional use is expected to be completed by June 2019, at which point OraSure indicates they plan to submit for registration of the self-test kit. It is hoped that because the registration of the test kit for professionals is already in process, the self-test kit registration will be faster as the performance of the product may be already approved by the FDA under the registration of the kit for professionals and Thai FDA may just ask to review the packaging and data on accuracy to interpret results by the users.

LINKAGES and TRCARC are currently reviewing the new Thai government regulations to determine the potential scope for HIV self-testing promotion and distribution (i.e. online, through index testing services, via pharmacies and/or community health centers etc.). Additional clarity is required regarding what approaches the government will and will not allow. Nonetheless, this is considered a major step forward in terms of ensuring greater

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 35 accessibility to HIV testing services, and LINKAGES will fully integrate self-testing into our program approaches as soon as a legally registered test kit is available on the market.

STI POC study. The study on the feasibility to integrate the POC testing for sexually transmitted infections (STIs) and HIV viral load into community-based clinics for MSM and TGW in Thailand has been delayed due to expenses in other areas but is currently planned to be launched in October 2019 (assuming sufficient funding). The amended protocol version 1.4 was approved from Chulalongkorn University IRB and IRB at Hat Yai Hospital on February 7 and March 14, respectively. In the meantime, study recruitment materials and STI educational materials received IRB approval on March 5. In order to prepare and ensure smooth implementation of the study, SOPs on STIs specimen collection in validation period and the Manual of Operating Procedure (MOP) under this study were drafted and will be finished by April. In addition, TRCARC has been coordinating with the USAID Community Partnership project on the provision of technical assistance to sites on STIs, treatment and specimen collection. A training of trainers (ToT) was held in December 2018 for representatives from Mplus Chiang Mai, SWING BKK, and RSAT BKK, and ToT participants rolled out training to other CBOs staff in February 2019.

C-FREE. During this reporting period, LINKAGES supported Dreamlopments in the submission of study drug, Myhep All, importation permit from Thai FDA, submission of revised study protocol, C-FREE study meeting, study nurses’ trainings and dry-run preparation.

Dreamlopments’ application to import Myhep All was approved by the Thai FDA in March 2019; a revised study protocol has subsequently been submitted to the Central Research Ethics Committee (CREC) for ethical review and clearance, which approved the protocol with minor comments on the study consent forms for Bangkok and Chana sites. Dreamlopments will amend and re-submit the study consent forms and study protocol for final approvals from CREC IRB, Chulalongkorn IRB, and Protection of Human Subjects Committee (PHSC, FHI 360 IRB) in April 2019 and expects to receive approval from all three IRBs in May 2019.

In terms of site preparation, Dreamlopments conducted a C-FREE study investigator initiation meeting in February 2019 to formally review and discuss the study procedures and preparations for study initiation. Study supplies and equipment, including the GeneXpert system, have been installed at all study sites. LINKAGES supported the study nurses during equipment, study protocol and laboratory procedures trainings sessions and dry-run preparation at each site.

Participants enrolment and site initiation will begin once the C-FREE study receives approval from all three IRBs and the study drug is imported to Thailand. First site initiation is expected to be at the end of May 2019.

STANDUP-TEEN. The STANDUP TEEN study will assess the effects of HIV self-testing on the uptake of and retention in PrEP services among adolescent MSM and TGW (aged between 15- 19), as well as the effect of targeted strategies to promote PrEP adherence. During this reporting period, the process for an IRB agreement between Chulalongkorn University’s IRB and the FHI 360 PHSC was finalized, and necessary amendments to the research protocol and research instruments (such as CRF, PIS, questionnaires and informed consent forms for both online and offline) were completed with the aim to resubmit the amended protocol to

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 36

Chulalongkorn University IRB in April. In addition, SOPs under this study e.g. HIV self-testing kit inventory system, specimen shipment in controlled temperature are being revised based on the first reviewer’s comments and will be finished by April.

Communication materials for study recruitment were submitted to Chulalongkorn University IRB at late January and were received the approval on March 5. HIV self-test instructional materials, including videos demonstrating oral fluid and blood-based testing, were also finalized during this reporting period.

The process for obtaining FDA approval for 3,200 oral-fluid self-testing kits and 1,000 blood- based self-testing kits was also completed, with the shipment of self-testing kits to TRCARC at the end of January and on March 19, respectively. Upon the shipment arrival, the accelerated process for obtaining FDA approval for importation of the second batch of 1,000 blood-based self-testing kits were submitted with the aim to receive more 1,000 self-testing kits shipment in mid-May.

In preparation for the study launch, TRCARC conducted a training on Good Clinical Practice (GCP) and Human Subject Protection (HSP) on March 27 to refresh the knowledge of CBO staff and navigators about conducting clinical research, ensuring the quality and integrity of study data, and ensuring the protection of human subjects participating in research.

Finally, the qualitative component of this research activity, which is being conducted in collaboration with Mahidol University, has received prior ethical approval and data collection among adolescent MSM and TGW, community health workers, health care workers and parents has been completed at 6 KP-led organizations19 in 4 priority provinces at the end of February. iFACT. All 20 HIV-positive participants completed the full intensive PK at week 8, and 19 participants have completed the follow up visit at week 15. However, one was lost to follow up at week 15. TRCARC has started the data analysis and plan to have the abstract ready as a late- breaker abstract for IAS 2019.

G. Knowledge Management and Regional/Global Technical Leadership

During this reporting period, LINKAGES and TRCARC took advantage of the 21st Annual Bangkok International Symposium on HIV Medicine to organize and participate in discussions around key PEPFAR-supported HIV prevention, care and treatment innovations. LINKAGES staff and partners participated in the Symposium and delivered presentations on PrEP and same-day ART, as well as key global technical innovations for optimizing performance across the HIV cascade.

Linkages also supported two key technical meetings on the side lines of the Symposium: Regional Consultation on PrEP Implementation, and the Transgender-Competent Care Workshop.

19 Mplus, Caremat, SWING Pattaya, SWING BKK, RSAT BKK, RSAT Hat Yai

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 37

The regional PrEP consultation brought together 150 people from 14 countries – Australia, Belgium, Cambodia, Hong Kong, India, Indonesia, Malaysia, Myanmar, the Philippines, Singapore, Sri Lanka, Thailand, Vietnam, and USA – to share experiences on PrEP implementation and explored de-medicalization models for KPs such as the nurse-led PrEP, pharmacist-led PrEP and key population-led PrEP. It was agreed that these differentiated models are feasible, cost-efficient and strongly preferred. Other innovative methods to increase PrEP uptake, retention and adherence, such as the tele-mentoring and of self-PrEP were also discussed. This year, the discussion was extended to include people who inject drugs (PWID), the group that was never adequately mentioned in PrEP context. Myanmar will be the first country to integrate PrEP for PWID to its existing malaria outreach program.

The Transgender-Competent Care Workshop was organized by the Thai Red Cross Tangerine Academy for transgender health in partnership with the US-based Fenway Institute, to share up-to-date knowledge on transgender-competent care and existing models that have successfully integrated HIV programming into TG health care services, and to explore the needs for transgender health in the Asia-Pacific Region. Nearly 120 health care providers, nurses and community health workers from around and beyond the Asia-Pacific region participated, including representatives from Australia, Cambodia, Fiji, Germany, Hong Kong, India, Indonesia, Malaysia, Myanmar, Netherlands, Philippines, Singapore, Sri Lanka, Taiwan, Thailand, United Kingdom, United States and Vietnam. Key action points from the workshop included the need to collect more TG-specific data, the need for formalized protocols and guidance on gender-affirming services and hormone use, and the need for mechanisms to share information and provide South-South capacity building in this area, including through setting up regional networks and organizing online training courses and webinars for healthcare providers on transgender-competent health services.

Dissemination reports for both meetings were drafted and submitted for review during this reporting period and will be finalized in Q3.

During this reporting period, LINKAGES staff and partners also submitted numerous abstracts for the 10th International AIDS Society Conference on HIV Science, which will be held in Mexico City in July 2019. Between FHI 360 and TRCARC, a total of 17 abstracts were submitted to IAS 2019, and 13 were accepted (5 oral presentations, 2 poster discussions, and 6 poster exhibitions). 1 additional abstract is pending late-breaker submission due to data analysis that was only conducted in March 2019. The full list of accepted abstracts is presented in Table 4:

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 38

Table 4: LINKAGES Thailand Abstracts Accepted to IAS 2019 Conference # Abstract Title First Author Acceptance Status 1 Drug-drug interactions between the use of feminizing Akarin H. (Pending Late- hormone and antiretroviral drugs among HIV-positive Breaker Thai transgender women. Submission) 2 A pathway to policy commitment for sustainability of Key Panus N. Oral Presentation Population-Led Health Services Model in Thailand 3 Transitioning from international funding to domestic Panus N. Poster Exhibition health financing to support key population-led health services in Thailand: The Songkhla model 4 Engagement of peer navigators in the multidisciplinary Pich Seekaew Poster Exhibition team of providers in the same-day antiretroviral therapy initiation hub model in Bangkok, Thailand 5 Same-day antiretroviral therapy initiation in Thailand: Pich Seekaew Initial results from scale-up in public hospitals in four Oral Presentation provinces in Thailand 6 Different models of same-day antiretroviral therapy Pich Seekaew initiation in Thailand: A first look into the future of scale- Oral Presentation up 7 High acceptability and feasibility of same-day Pich Seekaew Oral Presentation antiretroviral therapy services among HIV-positive adolescents in Bangkok, Thailand 8 Transgender-led same-day antiretroviral therapy services Pich Seekaew Poster Exhibition at the Tangerine Community Health Center in Bangkok, Thailand 9 Transgender-led social media interventions effectively Rena J. Poster Discussion identify transgender woman subpopulations with substantial risk of HIV acquisition and successfully link to HIV prevention, care and treatment services 10 Integrating gender-affirming hormone treatment into HIV Rena J. Poster Discussion services facilitates access to HIV testing, syphilis testing, PrEP, and other sexual health services among transgender women in Thailand 11 Sexually transmitted infections and HIV co-infection in Tanat Chinburnchorn Poster Exhibition Same-Day ART cohort in Bangkok, Thailand: Who are at risk? 12 Is TDF-based regimen suitable for ART initiation without Tanat Chinburnchorn Poster Exhibition the availability of baseline laboratory test results in Same-Day ART service in Thailand? 13 It’s easy and convenient!”: Perceived facilitators and Thomas G. Poster Exhibition barriers for HIV self-testing and PrEP uptake among adolescent men who have sex with men, transgender women, and their parents 14 From “nice-to-have” to “necessary”: increases in Ravipa Vannakit Oral Presentation domestic financing and perceived value of key population-lead HIV services by the Thai government as international donor funding transitions

Finally, in March, Miss International Queen 2019 Jazell Barbie Royale, along with the first runner-up Esmon Kanwara Kaewjin from Thailand and the second runner-up Yaya from China, made a special visit to the Tangerine Clinic to discuss transgender health and human rights for transgender people, on the occasion of the International Transgender Day of Visibility. The event was attended by over 100 people and the media coverage can be found at below links:

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 39

NBT: https://youtu.be/1nsuuiyIUyw TRCARC: https://www.youtube.com/watch?v=vJ8B7Nab5UU CH 7: https://s.ch7.com/333469

H. Costing and financing of KP-LHS

Cost Study. During FY19 Q2, the HITAP study team finished data collection at all sites and have been in the process of data verification with the sites. The teams visited the following sites to complete the data collection process: SWING Bangkok, Mplus, and Ozone and Mae-Ramad Hospital in January 2019; Mfriend Udonthani, RSAT Songkla, and Rak Thai in February 2019; and Samut Prakan Hospital in March 2019.

FY 19 Q2 comprised of the second phase of data collection. The teams visited the following sites to complete the data collection process: SWING Bangkok, Mplus, and Ozone and Mae- Ramad Hospital in January 2019; Mfriend Udonthani, RSAT Songkla, and Rak Thai in February 2019; and Samut Prakan Hospital in March 2019. Dissemination of results is expected to be in late May. NHSO contracts with LINKAGES community partners. The figure below shows the trend of NHSO contracted amounts with LINKAGES partners from FY 2018 to FY 2019. The average increase is approximately 119% over this two-year time period. Two partner agencies (SWING and RSAT) have increased by more than 300% in FY19 compared to FY18 due to increasing targets assigned by NHSO. A few partners show a lower amount of funding due to the adjusted contracted amount per case. For example, in FY18 RSAT Songkhla received 2,300 baht for MSM/TG and 2,800 baht for FSW, whereas in FY19 they received 1,800 for MSM/TG and for sex workers. The decreasing amount per unit also applies to the downward trend at Caremat Chiang Mai. This reduction in the contracted amount per case is due to changes in the compensated service delivery package. Since the launch of the HIV prevention fund, the unit cost per client were inclusive of HIV testing and STI screening service fees which an NHSO contractor is required to pay at a health facility. However, in FY19 the HIV testing and STI service fees will be directly reimbursed to service-providing health facilities registered with NHSO which means the current unit cost only reflects the proportion of the budget for HIV prevention (Reach-Recruit-Referral) and retention activities. For this reason, LINKAGES and TRCARC are redoubling efforts to have KPLHS sites registered as hospital nodes, to remain eligible for reimbursement of testing services.

It should be noted that some of these amounts in FY19 are what NHSO and partners have agreed upon but are still in a process of finalization. The partners who are currently in the finalization process are those sites in Bangkok, and the contracted amounts will be finalized when the contracts are signed. Therefore, these numbers will be updated next quarter.

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 40

Graph 21: NHSO Funding Trends from 2018 to 2019

In order to further integrate the KPLHS model into the current national health system (and subsequently simplify NHSO reimbursement for KPLHS-delivered services), during this reporting period LINKAGES and TRCARC facilitated the signing of a memorandum of understanding (MoU) between Nakornping Hospital and Mplus Chiang Mai. This MoU symbolizes a formal collaboration between the government and the community-based organization, and reflects task sharing and task shifting in order to accelerate the ending AIDS strategy by 2030. Having a formal MoU between the local hospital and CBO was one of the requirements for registration of NHSO node, and Mplus took this opportunity to register as an NHSO node for HIV testing services. Once the registration process is complete, Mplus can reimburse HIV testing services from the NHSO scheme like other hospitals. TRCARC and FHI 360 laboratory staff members will help Mplus Chiang Mai with the preparation to receive an assessment from NHSO region#1 on 2 April 2019. In Songkhla Province, RSAT Hat Yai has also submitted all required documents for node registration with NHSO region #12. RSAT are waiting for the confirmation date to receive an assessment from NHSO region #12 to visit their laboratory, which will most likely happen in May 2019. TRCARC and FHI 360 laboratory staff members will facilitate the preparation for an assessment. I. Capacity building and technical assistance, including collaboration with Global Fund partners and support to their program implementation

Capacity building and technical assistance provided in FY19 Q2 include the following:

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 41

Table 5: Capacity Building Activities Date Activity/details Total no. of Male Female Participants participants 18 January The Management of 55 18 37 • 5 staff from FHI 360 2019 HIV/AIDS in MSM/TG • 10 staff from Mplus Therapy and HIV Testing • 40 staff from Chiang Rai and Treatment Data, Health Facilities Chiang Rai 1-Feb-19 The Management of 53 15 38 • 2 staff from SWING Pattaya HIV/AIDS in MSM/TG • 3 staff each from RSAT Therapy and HIV Testing Chonburi and Sisters and Treatment Data, • 4 staff from FHI 360 Chonburi • 41 staff from Chiang Rai Health Facilities 15-Feb-19 The Management of 69 20 49 • 3 staff from SWING Bangkok HIV/AIDS in MSM/TG • 6 staff from RSAT Bangkok Therapy and HIV Testing • 10 staff from FHI 360 and Treatment Data, • 50 staff from Bangkok and Bangkok and Vicinities vicinities Health Facilities 22-Mar-19 Bangkok HIV Epidemic 17 6 11 • 1 staff each from UNAIDS and Consensus Project Expert USAID Panel Working Group • 2 staff each from Thailand (EPWG) 2nd Preparatory MOPH - U.S. CDC and Bangkok Meeting Metropolitan Administration • 3 staff each from TRCARC and FHI360 • 5 staff from Health Facilities 27-Mar-19 The Data Validation 30 25 5 • 3 staff from FHI360 Meeting for the study sites • 11 staff from SWING Bangkok in Bangkok under the Oral • 16 staff from RSAT Bangkok Fluid Testing Study

In total, 224 individuals were trained during this reporting period, 84 males, 140 females.

Key events, TA and capacity-building activities organized during this quarter included the following: • The Management of HIV/AIDS in MSM/TG Therapy and HIV Testing and Treatment Data • Bangkok HIV Epidemic Consensus Project Expert Panel Working Group (EPWG) 2nd Preparatory Meeting • The Data Validation Meeting for the study sites in Bangkok under the Oral Fluid Testing Study

III. QUARTERLY FINANCIAL SUMMARY Expenditures Total Obligation Obligation this Quarter Expenditures Remaining COP Thailand $ 12,946,092 $ 112,350 $ 12,942,422 $ 3,670 Test and Treat $ 700,000 $ 700,000 $ (0) OHA $ 1,500,000 $ (7,831) $ 1,492,168 $ 7,832 Gamechanger $ 4,949,000 $ - $ 4,949,000 $ - COP16 Gamechanger $ 5,900,000 $ 302,607 $ 5,900,000 $ - COP17 Quarterly Progress Update (January 1- March 31, 2019) – Thailand 42

Gamechanger $ 1,950,000 $ 1,857,776 $ 1,857,776 $ 92,224 COP18 KPIS - Thailand $ 590,000 $ 48,031 $ 349,225 $ 240,775

Table 6: Program level monitoring results not disaggregated by KP Indicators PEPFAR Achievements/Targets (Type: PEPFAR vs. custom) Type of Q2 Year to Annual % target support Date Target achieved KP_PREV: Number of KPs reached with DSD 11,640 29,646 51,756 57% 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 HIV DSD 12,018 23,915 Testing and Counseling (HTC) services for HIV TA_SDI 19,976 38,097 and received their test results (PEPFAR) Total 31,994 62,012 41,697 149% HTS_INDEX: Number of individuals who were DSD 151 154 identified and tested using Index testing TA_SDI 0 0 services and received their results (PEPFAR) Total 151 154 N/A N/A HTS_SELF: Number of individual HIV self-test DSD 0 214 kits distributed (PEPFAR) TA_SDI 0 0 Total 0 214 1,600 13% PrEP_NEW: Number of KPs who received DSD 594 1,070 2,170 49% antiretroviral pre-exposure prophylaxis to prevent HIV infection (PEPFAR) PrEP_CURR: Number of individuals, inclusive of DSD 2,328 2,328 those newly enrolled, that received oral antiretroviral pre-exposure prophylaxis to prevent HIV during the reporting period (PEPFAR) TX_NEW: Number of KPs newly enrolled on DSD 222 505 antiretroviral therapy (ART) (PEPFAR) TA_SDI 774 1,529 Total 996 2,034 2,942 69% TX_CURR**: Number of KPs currently receiving DSD 224 224 antiretroviral therapy (ART) (PEPFAR) TA_SDI 35,907 35,907 Total 36,131 36,131 6,611 547%

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Appendix 1: Performance under eCascade

During FY19 Q2, there were a total of 13,742 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, 6,345 were clinic walk-ins, while 7,397 were outreach clients, of whom 7,093 were referred for HIV testing. 11,289 clients received an HIV test – 82.14% of all clients reached. Testing uptake was higher among walk-in clients (95%) as compared to outreach clients (44% of all outreach clients successfully referred to testing, which while suboptimal is nonetheless a significant increase in testing uptake among outreach clients). The overall case-finding rate among all clients who received an HIV test was 4%.

When client recruitment is broken down more granularly, CBSs reached 5,617 clients and successfully referred 3,685 (66%) to testing services with a 2% case-finding rate. In comparison, PMs recruited 1,063 clients and tested 1,012 (95%) with a 3% 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 (126 recruited, 114 tested) but with significantly higher case finding (11%). Online outreach accounted for 1,080 new clients and, consistent with findings from the O2O system, only 60% of those received an HIV test; however, the case-finding rate was 9%. 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 20% of all case-finding in Q1). However, they account for only 16% of overall project coverage.

Regarding peer mobilizers specifically, there were increase number of active PMs in FY19 Q2 as compared with FY 19 Q1 (81 vs. 59) but PMs were less active – with an average of 13 new clients per active PM in FY19 Q2 versus 23 new clients per PM in FY19 Q1.

The implementing partners who utilized the PM approach the most in terms of absolute number of clients recruited in FY19 Q2 were Mplus (n=302), Caremat (n=177), Swing Bangkok (n=155), Mplus Chiang Rai (n=127), RSAT Phatumthanee (n=124) and the rest was lower than a hundred clients. However, when viewed as a proportion of overall contribution to outreach recruitment, the biggest users of PMs this quarter were Caremat (74% of all outreach recruitment was by PMs), RSAT Phatumthanee (37%) and RSAT Chonburi (30%). Sister, RSAT Hat Yai and Swing Pattaya did not have active PM in this quarter because of staff turnover at RSAT Hat Yai. Both Swing and Sisters in Pattaya have seen lower numbers of active PM since the beginning of the project.

Case-finding rates among PM clients were highest at Swing Pattaya (33%), RSAT Chonburi (15%), RSAT Samutprakarn (7%), and RSAT Pathumthani (6%). However, these rates were achieved among very small numbers of clients tested. RSAT Pathumthani PMs contributed the largest total number of newly diagnosed HIV-positive clients, with a case-finding rate of 6% among 124 PM clients who received HIV tests. Case-finding rates in both Chiang Mai and Chiang Rai were 2%, although this may reflect low background prevalence in those sites.

1,426 clients were registered as enrolled on ART in FY19 Q2. By the end of the quarter, the implementing partner with the lowest percentage of new HIV-positive clients initiating

Quarterly Progress Update (January 1- March 31, 2019) – Thailand 44 treatment was Caremat (19% treatment uptake), which came in part from poor communication with clients regarding the benefits of rapid ART initiation. LINKAGES will keep looking closely on this. All other sites reported more than three-fourths of new HIV-positive clients on treatment.

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.

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