In Thailand, telehealth moves PrEP out of the HIV clinic

A KP lay provider from the Rainbow Sky Association of Thailand provides HIV testing at a gay sauna in Bangkok. People testing negative are offered PrEP.

During a pandemic, a differentiated service approach delivers PrEP to more of those who need it.

In many parts of the world today, the most common place to find oral pre-exposure prophylaxis (PrEP) is at an HIV clinic, where PrEP medications are prescribed by an HIV specialist doctor or nurse. In Thailand, however, lay providers — health workers without formal medical certifications — offer PrEP at community clinics nationwide, thanks to training from the Bangkok-based Institute for HIV Research and Innovation (IHRI).

“The demand for lay provider PrEP came directly from the community,” says Nittaya Phanuphak, executive director of IHRI. “Once people understand that HIV testing is the gateway to receiving PrEP, they want to be tested. Our community partners asked for training so they can offer these services quickly, without making their clients visit a hospital or wait a long time to schedule an appointment with a specialist.”

The program works because while antiretroviral therapy to treat HIV can be complicated – with many potential regimens to choose from depending on the needs of each individual – administering PrEP to prevent HIV is generally straightforward. After conducting an HIV test, the lay provider sends the results to a certified health professional using an online chat app. The certified provider then reviews the results and, if PrEP is indicated, authorizes the lay provider to give the client their first month’s supply on the spot.

More than 10,000 people across Thailand are now receiving PrEP through lay providers, many of whom are themselves members of key populations at particular risk for HIV, such as men who have sex with men and transgender women.

Telehealth, via online chat between providers, was always essential to this model. COVID-19 lockdowns and disruptions drove even greater expansion of telehealth, which lay providers often now use to communicate with clients as well as with certified providers.

“Clients could no longer visit their usual community clinic because of lockdowns, or because they may have lost their jobs and moved from Bangkok to their hometowns, for example,” says Phanuphak. “So instead of an in-person visit, we allow clients to do an online consult with their lay provider. The provider will ask them to go to a local clinic for testing, and then if a certified provider confirms that PrEP is still appropriate, the lay provider will courier the medications directly to them.”

Even in non-pandemic times, these telehealth tools can make it much easier for people to initiate and stay on PrEP. For those most vulnerable to HIV – particularly key populations already facing stigma and discrimination due to their age, gender identity or occupation – the ease and privacy offered by telehealth and courier delivery can be lifesaving.

Telehealth is not right for everyone, Phanuphak acknowledges. Some clients need in-person counseling and support to adhere to a PrEP regimen. Others don’t have smartphones or internet access.

“This is why we need differentiated delivery of services,” Phanuphak says. “No single approach is right for every client. We need to listen to and follow the lead of key populations and affected communities to understand and effectively address their needs.”

IHRI is now applying the differentiated service delivery approach and other lessons learned from the fight against HIV to tackle COVID-19. Working directly with leaders in communities most affected by the pandemic, they are teaching lay providers how to screen for COVID-19 and link those who test positive to community-based care that addresses stigma, discrimination, mental health, and other health issues affecting people with COVID-19 and their families.

“In Thailand, as in most parts of the world, the healthcare workers dealing with COVID-19 are also those who have been dealing with HIV,” says Phanuphak. “We know from experience that we can’t succeed when certain groups are left behind. We know how urgent it is to form a community-led response. I’ve been a part of webinars where people want to talk about what the HIV field can learn from COVID-19 – but we should really talk about what COVID-19 can learn from HIV.”

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A KP lay provider from the Rainbow Sky Association of Thailand provides HIV testing at a gay sauna in Bangkok. People testing negative are offered PrEP.

A driver from Mplus Chiang Mai delivers PrEP via moped.

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Advocate for increased investment in community health workers, including lay providers that provide PrEP-related services, who need to be compensated for their work and who need access to COVID-19 vaccines, PPE, and ongoing support and training.

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Read about IHRI’s work to increase the availability, acceptability and scalability of PrEP in Thailand through differentiated services.

Explore other lessons learned from the global rollout of oral PrEP

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