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 AND ANNUAL PROGRESS REPORT JULY 1 – SEPTEMBER 30, 2018 OCTOBER 31, 2018 LINKAGES Thailand Quarterly Report (July 1 to September 30, 2018) 1 Acronyms & Abbreviations AIDS Acquired Immune Deficiency Syndrome amfAR American Foundation for AIDS Research APCOM Asia-Pacific Coalition on Male Sexual Health ART Antiretroviral Therapy ARV Antiretroviral BATS Bureau of AIDS, TB and STIs BKK Bangkok BMA Bangkok Metropolitan Administration CBO Community-based Organization CBS Community-based Supporter CD4 Cluster of Differentiation 4 CDC Centers for Disease Control CHC Community Health Center CHW Community Health Worker CPI Consumer Price Index CREC Central Research Ethics Committee CST Care, Support and Treatment C&C Counseling & Care, Support and Treatment DDC Department of Disease Control DIC Drop-in Center DQA Data Quality Audit DSD Direct Service Delivery DSD Differentiated Service Delivery EA Expenditure Analysis EPM Enhanced Peer Mobilization/Mobilizer Model F2F Face-to-Face FDA Food and Drug Administration FSW Female Sex Worker HCP Health Care Provider HITAP Health Intervention and Technology Assessment Program HIV Human Immunodeficiency Virus HIVST HIV Self-testing HTC HIV Testing & Counseling IAS International AIDS Society ICT Information and Communication Technology IP Implementing Partner IRB Institutional Review Board KP Key Population KPLHS Key Population-led Health Services M&E Monitoring & Evaluation MOU Memorandum of Understanding MoPH Ministry of Public Health MSM Men who have Sex with Men MSW Male Sex Worker NAP National AIDS Program NGO Non-governmental Organization NHSO National Health Security Office O2O Online-to-Offline OF Oral Fluid OI Opportunistic infection LINKAGES Thailand Quarterly Report (July 1 to September 30, 2018) 2 PATH Program for Appropriate Technology in Health PCM Provincial Coordinating Mechanism PEP Post-exposure prophylaxis PEPFAR President’s Emergency Plan for AIDS Relief PHO Provincial Health Office PHSC Protection of Human Subjects Committee POC Point-of-Care PPAT Planned Parenthood Association of Thailand PR-DDC MoPH Principal Recipient Administrative Office Department of Disease Control PrEP Pre-exposure Prophylaxis PTY Pattaya PWID People Who Inject Drugs QA/QI Quality Assessment/Quality Improvement RDMA Regional Development Mission Asia RFA Request for Applications RNA Ribonucleic Acid RNR Risk Network Referral RRTTPR Reach-Recruit-Test-Treat-Prevent-Retain RSAT Rainbow Sky Association of Thailand RTCM Real-time Cascade Monitoring RTF Raks Thai Foundation SBCC Social and Behavior Change Communications SDART Same-day ART SESH Social Entrepreneurship for Spreading Health SIMS Site Improvement through Monitoring System SMS Short Message Service SOP Standard Operating Procedure STI Sexually-transmitted Infection SWING Service Workers in Group TA Technical Assistance TB Tuberculosis TG Transgender TGM Transgender Man TGSW Transgender Sex Worker TGW Transgender Woman TRCARC Thai Red Cross AIDS Research Center USAID United States Agency for International Development VPR Voluntary Partner Referral WHO World Health Organization LINKAGES Thailand Quarterly Report (July 1 to September 30, 2018) 3 Narrative I: Executive Summary During Fiscal Year 2018 Quarter 4 (FY18 Q4), LINKAGES Thailand continued to work in close collaboration with existing local implementing partners (IPs) and expanded its support to other health care facilities to strengthen combination HIV prevention, care and treatment interventions among members of key populations (KPs), including men who have sex with men (MSM), male sex workers (MSWs), transgender women (TGs), transgender sex workers (TGSWs), and female sex workers (FSWs). Figure 1. Achievements by quarter, FY18 During this reporting period, LINKAGES reached a total of 21,825 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: • 15,406 MSM; 1,643 MSW; 1,990 TG; 575 TGSW; and 2,211 FSW were reached with HIV prevention interventions. The combined number of clients counted under KP_PREV this quarter includes 16,343 KPs reached as the result of community-based interactions, while an additional 5,482 were walk-in clients. Total Q1-Q4 achievements for FY18 total 65,676 clients reached with prevention interventions, reflecting 59% of the annual KP_PREV target. • 466 MSM, 8 MSW, 40 TG, 29 TGSW, and 5 FSW initiated PrEP for the first time, or approximately 4% of the eligible client population testing negative at a community-based clinic. Total PrEP uptake over the course of FY18 was 2,313 individuals, or 138% of the annual PrEP_NEW target. LINKAGES Thailand Quarterly Report (July 1 to September 30, 2018) 4 • 11,218 MSM; 827 MSW; 1,380 TG; 276 TGSW; 89 PWID; 2,088 FSW; 5,433 non-KP males; and 6,257 non-KP females received HIV testing and learned their test results. Combined FY18 Q1-4 achievements were 70,817 individuals, or 91% of the annual HTS_TST target. • Of the above, 752 MSM, 37 MSW, 65 TG, 21 TGSW, 2 PWID, 15 FSW, 193 non-KP males, and 109 non-KP females tested HIV positive. The overall case-finding rate for Q4 was 4%. Across FY18 Q1-4, 4,380 individuals were newly tested HIV-positive (6%), reflecting 51% of the HTS_TST_POS target. • 717 MSM; 21 MSW; 64 TG; 13 TGSW; 10 PWID; and 14 FSW, as well as 382 non-KP males and 265 non-KP females started ART during this reporting period. In total, LINKAGES Thailand supported 4,139 HIV-positive individuals to initiate ART over the course of FY18, reflecting 48% of the annual TX_NEW target. In total, there were 24,195 currents receiving treatment as of the end of FY18, reflecting 239% of the TX_CURR target. • Of all FY17 ART clients being actively tracked in FY18, 73% (n=638) were alive and on ART as of the end of this reporting period. Additionally, 17,241 clients received a viral load test, and 98% had VL<1,000 copies/ml. Specific programmatic achievements during this reporting period include the following: • LINKAGES partners exceeded FY18 targets for PrEP service delivery and patients on ART and performed acceptable on their HIV testing targets (though case-finding remained low). While KP_PREV performance was below expectation, it nonetheless represents an 85% increase over the previous quarter. • Treatment uptake increased 98% over the previous quarter and, while FY18 totals failed to meet the annual target, LINKAGES partners over the course of FY18 increased considerably the percentage of HIV-positive clients who initiated ART, while reducing the time between diagnosis and ART initiation for several partners. • The LINKAGES key population-led health services (KPLHS) model additionally outperformed the formal healthcare sector in terms of identifying positive clients earlier in the course of their infection, as measured by median CD4 count at baseline. • More than 70% of all clients on ART as of the end of FY18 had received a viral load test, and among those clients, 98% had achieved viral load suppression. Specific challenges in this reporting period: • Case-finding rates declined over the course of FY18, and fewer-than-anticipated numbers of new HIV-positive clients are the key factor behind underperformance on treatment uptake indicators. Specific testing models (sauna-based testing, online recruitment, oral fluid testing) have demonstrated higher case-finding rates, but these models have been unable to deliver testing uptake at scale. It is possible that the expected number of undiagnosed positive individuals in some settings has been overestimated, resulting in unrealistic target setting around case finding. LINKAGES will investigate this possibility with an HIV cascade assessment to be conducted in Bangkok in FY19. • While LINKAGES accounts for a large percentage of PrEP uptake in Thailand, the number of new PrEP clients has plateaued and represents far fewer than the number of clients needed to achieve epidemic impact. PrEP uptake has also been lower in some sub-populations that, based on self-reported risk and seroprevalence, would be more likely to benefit from PrEP, including sex workers and adolescents. In Q4, LINKAGES worked to develop a refreshed promotional approach for PrEP that will be implemented in FY19. • HIV prevention, testing and treatment service delivery remains a key challenge in Pattaya generally, but with Sisters specifically. TGSW consistently show the highest case-finding rates of all KPs served under the LINKAGES project and 57% of all TGSW reached for the entire project in FY18 came from Sisters. However, more than 2/3 of TGSW reached by Sisters declined referral to HIV testing, and when clients were tested positive, they had the LINKAGES Thailand Quarterly Report (July 1 to September 30, 2018) 5 lowest median CD4 count at baseline and one of the longest median wait times for ART initiation. While this is partially the result of systemic challenges with treatment delivery in Pattaya, it is notable that Sisters counseling, care and support staff have among the lowest quality assurance scores of any LINKAGES Thailand sites, when assessed by independent observers. Sisters also shows low rates of ART retention at 12 months, though rates of viral load suppression are high for those clients who initiated ART and received a VL test. TGSW in Pattaya are too critical of a population for epidemic