Oped: Asia and the Pacific's PrEP Landscape

When it comes to describing the extent of Asia’s HIV epidemic among MSM, the numbers say it all. MSM HIV infection rates are above 6% in Myanmar, Vietnam, China, Indonesia, Malaysia, and Thailand, reaching close to 14% in Mongolia. Several cities in the region, including Ho Chi Minh, Jakarta, and Kuala Lumpur are already at 15%. In Bangkok, almost one in three MSM is HIV-positive. On top of this, consistent condom use remains low, with less than half of MSM in most major Asian cities using condoms consistently - a rate that is far too low to have an impact on reducing HIV transmission among MSM.

 

In this context, PrEP offers a much-needed circuit breaker, especially if Asia is to meet the UNAIDS fast-track targets. Efforts to scale up the use of PrEP in Asia have steadily advanced, with some countries moving more rapidly than others. Several countries, for example, have initiated grass-roots education efforts through advertising, social media and community engagement events. These education efforts share up-to-date research, provide information about the availability of PrEP, and in some cases offer peer support and assistance to community members to help them overcome barriers to access and find ways to obtain PrEP when it is not available or affordable locally.

Localized trials and pilot programs are also being used to create an evidence base in Asia for the efficacy of PrEP. These projects involve PrEP being supplied for a set period of time to a monitored group of participants at high risk of HIV transmission.  “The results from these trials will be crucial in forming the evidence base necessary to scale up the provision of PrEP to the national level within countries where pilot projects have been successfully implemented,” says Midnight Poonkasetwattana, executive director of APCOM, a community-based organization that works on HIV prevention among men who have sex with men in the Asia-Pacific region. “Additionally, this knowledge will be made available throughout the region to help other countries move forward with the implementation of their own pilots and scale-up.”

Getting PrEP on the radar and making an evidence base for rolling it out is only part of the puzzle for HIV advocates in Asia. Getting PrEP included as an HIV prevention tool in the National HIV Strategies of individual countries needs to become a crucial part of Asia’s prep for PrEP. “Without relevant policy frameworks in place, national insurance agencies and pharmaceutical regulatory bodies won’t approve PrEP as prevention, severely limiting its availability and potential impact,” says Midnight. Action to address these kinds of policy and regulatory issues has already commenced in several countries, although most cite the outcomes of local pilot projects as a precursor to any significant progress in this area.

“Advocates from across Asia have highlighted the importance of continuing to provide up-to-date information about the efficacy, safety and cost-effectiveness of PrEP to educate those who inform policy and make decisions about health spending,” says Midnight. The latter of these is crucial because the cost of scaling up access to PrEP is one of the biggest barriers for all countries in the region. “Given the pressure on national health budgets across Asia, innovative and multifaceted funding models will need to be developed with the community as part of the health system. However, there are some countries with Global Fund, USAID, and/or PEPFAR funding where the inclusion of PrEP can already happen. This will provide the necessary data for the effectiveness of PrEP in other local contexts, and hopefully once the long-term cost benefits become evident, investment in PrEP will flow across the region,” says Midnight.

In the meantime, international travel for PrEP within the region has become increasingly common. Pharmacies have also begun to ship PrEP to individuals in countries where it is not yet available. These suggest that information and awareness about PrEP may be outpacing increases in access. Cost and the ability to travel, however, are still creating unequal geographies of access. There is still much work to be done in making PrEP ubiquitously available as part of a comprehensive prevention toolkit.

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