The scientific evidence is overwhelming in that we have here [in PrEP] the capacity to interrupt the chain of HIV acquisition and transmission with a tool that is incredibly, highly effective when used properly, and here at amfAR, for thirty years, we’ve tried to be guided by the science. And in this case the science is clear. PrEP works….which isn’t to say it’s the be all and end all, obviously, but as prevention it’s as good as anything we’ve ever seen and, in most cases, better,” shares Kevin Robert Frost, CEO of amfAR, about why the nonprofit organization has been an early and outspoken advocate for PrEP in the U.S., and steadfast supporter of PrEP implementation studies and demonstration projects abroad as well. “But if people don’t access [PrEP] or won’t access it through the channels that you’ve created, what good is it?”
To help answer these implementation questions with complexity, across different cultural and healthcare contexts, amfAR offers its resources and expertise to those in need. For example, amfAR supported a PrEP study (SWING) among female sex workers in Thailand to understand their attitudes toward the prevention option. “We found a very high degree of acceptability in that context, and that is encouraging to us because we are looking for that kind of high level of potential acceptability in order to expand on projects like this one in order to take these [projects] to other settings,” notes Frost.
One of those other settings is the Philippines, one of the first countries in Asia to introduce PrEP, and what the nonprofit organization and its partners seek to learn through a new study is: In terms of PrEP, how best can healthcare providers reach out to men who have sex with men and transgender women who are at risk of acquiring HIV? And then, how best can they deliver PrEP to those who choose it? As we know, when it comes to effective prevention messaging and encouraging engagement along the continuum of HIV care, one size does not fit all.
MSM and transgender women have been selected for the study because, although HIV prevalence in the Philippines overall is low, they comprise populations not only vulnerable to HIV infection but also underserved by larger public-health interventions, particularly in urban areas, and their sexual health has been hampered by social stigma and legal barriers (limited access to condoms and HIV testing and counseling for those under the age of eighteen), which have arguably led to steep increases in rates of infection of late. Across the nation, four out of five people with HIV are MSM. Men who have sex with men, and men who have sex with men and women, account for eighty-five percent of all new HIV infections.
AmfAR has partnered with LoveYourself, a Manila-based LGBT organization, the World Health Organization (WHO) Regional Office for the Western Pacific, and the Research Institute for Tropical Medicine (RITM) at the Philippines Department of Health on a pilot project that seeks to provide concrete answers about best practices when it comes to outreach and implementation among men who have sex with men and transgender women who are at risk of acquiring HIV infection. Frost adds that another important partner is the Philippines government’s Ministry of Health—in the periphery for now, as the project is not being conducted in its clinics, but a vital part of PrEP outreach and roll-out as the project hopes its evidence will inform national PrEP-related policies and guidelines.
A two-year study, Project PrEPPY (PrEP Pilipinas) will enroll 200 MSM and transgender women who are HIV-negative. PrEP, a daily oral antiretroviral regimen, will be offered free at Love Yourself’s two clinics in metro Manila, along with HIV prevention services that will include routine HIV and STI testing, intensive patient education on PrEP, treatment preparedness and adherence support, in addition to peer support. Chris Lagman, Deputy Director of LoveYourself and Rossana Ditangco, MD, head of the AIDS Study Group at the RITM are the co-principal investigators of the study.
Significant declines in rates of infection across Asia have proven that treatment as prevention works, says Frost, “particularly in Southeast Asia where, in countries like Thailand, Cambodia and Malaysia, we’ve seen thirty percent reduction.” Frost attributes the reductions partially to TasP, but points to “comprehensive prevention approaches as well, and a willingness on the parts of governments and ministries of health to be open to being guided by the evidence and not ideology.
“That’s a harder lift in the Philippines because for example, we know that a condoms-in-schools program was recently killed in the Philippines by conservatives. And the conservatives are influenced obviously by the Roman Catholic Church, which plays a very big role in the Philippines. Eighty percent of Filipinos are Catholic.” It becomes harder for NGOs and the government to focus on prevention messaging, especially as, Frost notes, messaging needs to be targeted to youth and it needs to be frank about sex. “And that’s hard to do in countries that do have these very strong ideological movements that influence [messaging].”
Sex-related stigma often prevents individuals from accessing prevention tools, says Frost, even when condoms are given away free in health centers. Preparing for sex is seen as shameful, he continues. Add to that an older generation reluctant to talk about sex and it’s clear that a different tactic is needed to address these challenges. Project PrEPPY hopes to illuminate how a culturally tailored, community-based healthcare setting might work around some of these issues.
In closing, Frost shares, “We are strong advocates for PrEP, but people shouldn’t misunderstand that to mean we’re not also strong advocates for condoms. We are. We still strongly believe that people who can use condoms should use condoms. PrEP does nothing to address all the other sexually transmitted infections that live in the constellation of infections that people can be exposed to. There are plenty of contexts in which people can’t negotiate condoms, and we know what some of those are. In those contexts, PrEP plays an even bigger role. [At the end of the day] we would argue that people have to be responsible for their own health, so everyone has to be responsible for making sure they take care of themselves with whatever means that they can.”
For more information, visit: amfar.org.
Chael Needle is Managing Editor of A&U.