Lessons learned and experiences from 30 years of antiretroviral therapy in Thailand
Posted on July 16, 2015
Dr. Praphan Phanuphak in The 5th HIV-NAT Mini Symposium
So much has changed over the years! Dr Praphan Phanuphak, the director of HIV-NAT, Thai Red Cross AIDS Research Centre, was the first doctor in Thailand to encounter and treat HIV patients. He talks about how to change policies for the treatment of HIV in Thailand and betterment of the lives of HIV-infected people.
Three Decades Leading the Charge Against AIDS in Thailand
TREAT Asia Report Interview: Dr. Praphan Phanuphak
Thirty years ago, Dr. Praphan Phanuphak diagnosed the first three cases of HIV in Thailand. In 1989, he co-founded the Thai Red Cross AIDS Research Centre (TRC-ARC), and currently serves as its director. Dr. Phanuphak and TRC-ARC have helped set the agenda for the HIV response in the Asia-Pacific and conducted some of the region’s—and world’s—most groundbreaking AIDS research. In 2001, Dr. Phanuphak helped found the TREAT Asia Network. He is also a professor of medicine at Chulalongkorn University and a member of the World Health Organization (WHO) Strategy and Policy Committee on HIV and the UNAIDS Scientific Advisory Committee.
TREAT Asia Report: Could you tell us about the creation of the Thai Red Cross AIDS Research Centre (TRC-ARC) and the impact the program has had on the response to HIV in Thailand and across the Asia-Pacific?
Dame Elizabeth Taylor, amfAR founding international chairman, and Dr. Phanuphak meet patients living with HIV in Bangkok in 1989.
Dr. Praphan Phanuphak: In 1989, the Thai Red Cross Society was already heavily involved in responding to HIV through its hospitals and national blood bank, so the executive board established TRC-ARC to coordinate all of its HIV-related activities, including those of its volunteers.
In the early days of HIV, Thai law required that hospitals and clinics report the names of individuals who tested positive to the Ministry of Public Health, and the names were occasionally leaked to the public. This often resulted in patients losing their jobs or access to education, as well as being stigmatized by neighbors and friends. And this made people very afraid of HIV testing. In order to get rid of this fear, TRC-ARC made a special request to the government to set up a ‘no-name’ HIV counseling and testing facility, meaning that TRC-ARC could not report the names of its patients.
On July 4, 1991, we established the Thai Red Cross Anonymous Clinic. It was Asia’s first anonymous clinic, and the public response was so huge it caused the government to lift the reporting law. Soon many more anonymous clinics were established throughout the country, but the Anonymous Clinic remains Thailand’s largest voluntary counseling and testing (VCT) center. The clinic performs more than 25,000 HIV tests a year and helps identify thousands of HIV-infected individuals annually, referring them to treatment and care centers. And many individuals diagnosed at the Anonymous Clinic participate in the clinical trials undertaken by TRC-ARC.
Over the last 26 years, TRC-ARC has been involved in HIV care and prevention services, research, and advocacy. The services we provide may only directly benefit the clients who come to the center, but our research and pilot treatment and prevention program models have generated interest worldwide, resulting in changes in HIV-related medical practice and policy in Thailand and throughout the world.
Dr. Phanuphak discusses working with amfAR CEO Kevin Robert Frost to found the TREAT Asia Network and the impact the Network has since had across the Asia-Pacific region.
TA Report: The Thai research community, civil society, and government have been leaders in the region in the fight against AIDS. How have you and your colleagues been able to achieve so much?
Dr. Phanuphak: First, the academics and researchers working in the HIV field in the early days saw the need and committed to providing antiretroviral therapy (ART) to HIV-infected people, including pregnant women to prevent mother-to-child transmission (PMTCT) of HIV. Once we were committed, we then had to find ways to get the treatment. Many patients could not afford ART, so we worked with non-governmental organizations (NGOs) and patient groups to convince the government to provide it.
While waiting for the government to take action, we sought to collaborate on clinical trials with researchers in the West or pharmaceutical companies so we could gain scientific information about HIV while also ensuring the participating patients had access to free ART. This is how HIV-NAT (The HIV Netherlands Australia Thailand Research Collaboration), Asia’s first HIV clinical trials center, was formed in 1996. We also solicited public donations for patient care. For example, TRC-ARC was able get support from Her Royal Highness Princess Soamsawali to set up a donation fund for PMTCT many years before the Thai government started its national PMTCT program.
TA Report: Currently, men who have sex with men (MSM) account for 41% of new HIV infections in Thailand, and in Bangkok, HIV prevalence among MSM is 25%—much higher than among other populations in the country. How do you hope the TRC-ARC’s innovative research into a community-based ‘test and treat’ model that focuses on MSM and transgender individuals will impact this high rate?
Dr. Phanuphak: The TRC-ARC strongly believes in the concept of ‘treatment as prevention’ [using ART to reduce patients’ HIV viral load to undetectable levels, which greatly reduces the chances of transmission]. But to benefit from treatment as prevention, infected people need to be diagnosed and treated as soon as possible after infection. This is known as ‘test and treat.’
Because MSM and transgender individuals have the largest number of HIV infections in Thailand, we decided to do a feasibility and acceptability study of early testing and treatment in this specific population. The project started in 2012. At the time Thailand’s policy was to start ART once a patient’s CD4 count dropped below 350, but for this study we wanted to initiate treatment much earlier. Therefore, we had to request ART from the Government Pharmaceutical Organization (GPO). In addition, we had to secure funding for screenings, laboratory tests, condoms, and community outreach from many national and international groups, including the National Health Security Office, the Department of Disease Control, the World Health Organization, the Dutch AIDS Fonds, amfAR, and the National Research Council.
Fortunately, the Department of Disease Control was very interested in being a partner in this pilot project to ensure that it could be replicated at government hospitals and scaled up nationally in the future. Then in late 2014, the Thai government began providing ART to anyone with HIV, regardless of CD4 count, in recognition of the effectiveness of treatment as prevention and research showing that the strategy was cost-effective in the long term.
For our first test and treat pilot project, we worked with 800 MSM and transgender individuals. It demonstrated that the model was successful, so a second, larger project was launched in 2015, with support from USAID. This second project is comparing facility-based test and treat programs with community-based, community-led programs. We hope the project will stimulate interest in early HIV testing and treatment among MSM and transgender individuals, which should result in marked reduction of new HIV infections. The model can then be adapted to target other key affected populations in Thailand, as well as the general population, helping to end AIDS in the country.
Dr. Phanuphak and his daughter, Dr. Nittaya Phanuphak, attend an event for Adam’s Love, a Thai Red Cross AIDS Research Centre initiative targeting MSM.
TA Report: The TRC-ARC is also participating in several cure-focused studies. Based on your work to date, how optimistic are you that we will find a cure for HIV that can be feasible in Thailand and other low- and middle-income countries?
Dr. Phanuphak: HIV cure research needs large amounts of resources and expertise. The Thai Red Cross Anonymous Clinic is frequented by hundreds of individuals at high risk of infection every day, which helps us conduct our cure research. We retest all samples that initially test negative with nucleic amplification tests (NAT), which can detect individuals during the earliest phase of infection—known as acute infection. As a result, many patients with acute infection can be identified and treated early, and these patients are the subjects of our cure study.
I am optimistic that at least 20% of the patients who are treated within the first two weeks of infection can achieve a functional cure or remission—i.e., not needing to continue lifelong ART in order to control their virus. Whether this cure strategy is feasible for other low- and middle-income countries is uncertain, but it is not impossible if patients can be diagnosed early enough.
TA Report: What do you think TREAT Asia’s major accomplishments have been since 2001?
Dr. Phanuphak: I was among the first supporters of TREAT Asia. I had known Kevin Frost, amfAR’s CEO, for more than two decades through his work in Thailand, and I knew that he had a good heart and that he was determined to do something about HIV infection in Thailand and Asia, so I knew I had to support his initiative.
And I have not been disappointed. TREAT Asia has done a lot for Thailand and Asia regarding HIV training, research, and advocacy. Even more importantly, it established a network of HIV physicians and scientists throughout Asia. Now we all know each other and can collaborate on research and advocacy under the guidance of Dr. Annette Sohn, the director of TREAT Asia.
And TREAT Asia has many groundbreaking initiatives that other networks in the world don’t have, such as the Anal Neoplasia Study in Asia-Pacific (ANSAP), researching HPV-related anal cancers among MSM living with HIV, and HIV edutainment websites like www.adamslove.org and www.temanteman.org that target specific populations and are known around the world.
TA Report: What critical challenges still remain regarding patient care and HIV research in Thailand and the region?
Dr. Phanuphak: In Thailand, our policy now allows universal access to ART at any CD4 level and two free HIV tests a year for every Thai citizen. However, many patients are still starting ART late, after their disease has progressed and their CD4 count is very low, around 100. Therefore, reaching and diagnosing all infected individuals and getting them on ART is the most important challenge.
For other countries in the region, the priority is establishing policies that expand access to free HIV testing and ART. Most Asian countries are middle-income and can afford the cost. And even though the initial investment may be high, it is a cost-effective intervention in the long run.
Also, countries in the region need to depend more on their own national resources, rather than on international resources like the Global Fund to Fight AIDS, Tuberculosis and Malaria. The research needed most is investigations into the best strategies for implementing early diagnosis and treatment and its cost-effectiveness, as well as studies on the use of pre-exposure prophylaxis (PrEP) as a component in our overall prevention packages. If all of us commit to these goals, we can end AIDS in Asia.