Thailand’s government has stopped the country’s leading pre-exposure prophylaxis (PrEP) services from operating, jeopardising an approach that has attracted international attention and is at the heart of Asia’s largest PrEP programme.
Around 80% of people using PrEP in Thailand receive it from a clinic led and staffed by members of the community that it serves. But under new rules, only government doctors can prescribe PrEP and community services cannot dispense it. Another rule change stops PrEP being issued to people excluded from the country’s main health insurance system.
Most of the services affected are ‘key-population led services’. Key populations are groups of people who are disproportionately affected by HIV – in Thailand, men who have sex with men, transgender women and sex workers. The clinics are run by community members and have meaningfully engaged the wider community to create services that respond to their needs.
“Even though we have trained community providers, technicians, and years of experience in PrEP provision, we are not allowed to provide PrEP or even stock it in our clinic,” Surang Janyam, director of the SWING Foundation, told aidmap.
The two key policy changes came just two weeks after key population-led services were showcased by the Thai government at UNAIDS’ Programme Coordinating Board, which it hosted and chaired in Chiang Mai in mid-December 2022. Delegates visited the MPLUS Foundation, the leading PrEP provider for men who have sex with men, male sex workers and transgender women in northern Thailand.
Then, on 23 December, the Ministry of Public Health’s Department of Health Service Support issued guidelines which state that from 1 January 2023, only government doctors can prescribe PrEP, only government pharmacists can dispense PrEP, and key population-led clinics will not be able to keep PrEP medications in stock. The same rules hold true for post-exposure prophylaxis (PEP).
Following that, on 28 December, the National Health Security Office (chaired by the Minister for Public Health who is also the Deputy Prime Minister) revoked payments for disease prevention and health promotion, including HIV prevention services, for those who are not covered by the country’s Universal Coverage Scheme (UCS) . This is an insurance programme providing free access to a comprehensive health benefits package for most Thai citizens, funded through taxation by the National Health Security Office.
When UCS began covering PrEP three years ago, it boosted uptake of the HIV prevention medication and also reduced reliance on donor funding, but coverage is now denied to many who have started PrEP.
The motives for the policy changes are unclear. Some cite concerns about the legality of using National Health Security Office funds to cover services for people who are not insured under UCS. Similarly, the first decision may be due to a new interpretation of existing legislation about how health services are provided.
Perhaps the medical establishment is pushing back against grassroots services run by non-clinicians from such stigmatised groups as men who have sex with men, sex workers and transgender people? Or with general elections coming up, are politics and economic worries taking a toll on PrEP services in Thailand?
Key population-led clinics cannot prescribe or stock PrEP
The government’s first decision prevents key population-led clinics from prescribing and stocking PrEP (and PEP). These clinics have been popular because they offer a “one stop service” in a supportive, stigma-free environment.
In Bangkok (home to around 70% of Thailand’s PrEP users), sex workers have received PrEP at the clinic run by the Service Workers in Groups (SWING) Foundation, while many men who have sex with men and transgender women have attended the Rainbow Sky Association of Thailand. Both clinics have received technical support from the Institute of HIV Research and Innovation (IHRI).
“Rolling out of PrEP has been made possible in Thailand mainly because of the people from the key populations who work as lay service providers,” Dr Nittaya Phanuphak, Executive Director of IHRI told aidsmap.
She believes the services are successful because they are designed, established, and co-delivered by people from the community. Given the widespread stigma in government health facilities, members of key populations often prefer to use a service staffed by peers who they know will understand their lives.
“Medical doctors or pharmacists or other healthcare professionals do not have to be physically present within the clinic premises, because well-trained key population lay providers use tele-consultation or tele-medicine with them and are supervised remotely,” Dr Nittaya continued.
However, at these clinics, the doctors prescribing PrEP are employed by IHRI, which is a non-governmental organisation. This is no longer possible following the government’s decision.
Dr Nittaya says that government hospitals could have been central to the rollout of PrEP from the beginning, but the numerous hospitals they approached were not willing to play the role that IHRI plays.
“I honestly do not want to play this role because I know the importance of getting these services integrated into Bangkok’s healthcare system,” Dr Nittaya continues. “But it has not been very successful so far. Building trust between healthcare providers and community-led organisations takes time.”
There was more success in northern Thailand. Key population-led organisations like MPLUS Foundation and CAREMAT have worked with the government-run clinics or hospitals. But even they have been impacted by the new policies.
“We are not able to provide a one stop service and keep the promise of same day PrEP delivery, because we cannot store medicines at the clinic,” said Natthakarn Laohacharoensombat of the MPLUS Foundation.
The key population-led services were designed to simplify access to PrEP – community workers test for HIV, send the result electronically to a doctor who issues a PrEP prescription, and the community worker dispenses the medication, all within an hour of someone walking in. But with the new arrangements, community workers now need to travel to the government hospital to collect medication for patients.
“We are exposing people to be more at risk of HIV by failing to provide them with services in a timely manner,” Natthakarn told us.
They added that although the government has been trying to encourage its hospitals across the country to provide PrEP since 2020, until now only about 100 hospitals have done so and the number of actual PrEP clients is very small.
Thai UCS funds will not cover those not insured under it
The second policy change means that the Thai government will no longer cover the cost of HIV prevention services (including HIV testing, condoms, PrEP and PEP) for those not covered under its Universal Coverage Scheme (UCS).
UCS is the key programme that has enabled Thailand to achieve universal health coverage, providing free healthcare to millions of citizens who previously had to pay out of pocket. By 2011, it covered over 80% of people in Thailand – those who were not already covered by the Social Security Scheme (for those working in the private formal sector, 12% of Thai people) or the Civil Service Medical Benefit Scheme (for public sector workers and their families, 7% of the population). Additionally, there are a few who pay for private health insurance.
However, some people face bureaucratic barriers to accessing care through the UCS – for example, someone who has moved to Bangkok from another province and does not have formal sector employment will not be able to update the residence listed on their official documents, so will be expected to return to their home province for all healthcare. (A situation faced by many transgender women and sex workers, for example). And non-Thai citizens cannot join the scheme, excluding over two million migrant workers from other Asian countries.
The new rules also create problems for those enrolled in the schemes for private and public sector employees – one in five Thai citizens. Only UCS covers prevention and health promotion services, whereas the other schemes only cover treatment costs.
Prior to these decisions, everyone in Thailand could receive HIV prevention services for free from any of the community-led clinics – regardless of which health insurance scheme they were covered by, or if they were not covered at all.
“Every Thai citizen could access free HIV testing twice a year and at any of the hospitals,” said Dr Nittaya Phanuphak. “That is the main reason how we were able to increase the uptake of HIV testing in the country.”
She told aidsmap that around 30% of people accessing free HIV testing, 60% of current active PrEP users of PrEP and half of PEP users are not covered by UCS.
“Key populations face a range of structural barriers in accessing healthcare services including PrEP,” Midnight Poonkasetwattana of APCOM told aidsmap. “That is what makes community-led services so vital to ensure stigma-free accessible and available services for them. Why would any government want to disrupt services that have proven to work so well?”
Pushback by people across the country
A coalition of civil society organisations have submitted a joint letter to the Prime Minister’s Office on 11 January 2023. An online petition, already signed by over 6600 people, is also mounting pressure on Thai government to resolve the crisis.
Civil society is collectively demanding that the Thai government:
- Officially endorses key population-led clinics as part of Thailand’s healthcare facilities.
- Issues guidelines allowing doctors and pharmacists from civil society organisations, private clinics and private hospitals to provide professional support to key population-led PrEP services.
- Issues guidelines allowing PrEP to be stocked at key population-led clinics.
- Approves the use of National Health Security Office funds to cover health promotion and prevention services for all Thai citizens, regardless of health insurance scheme.
Following a meeting between the government, communities and other stakeholders on 18 January, a stopgap arrangement to provide 10,000 doses of PrEP with funding from The Global Fund and PEPFAR has been put in place. But this stock will only be enough for one to two months.
The Thai Ministry of Public Health told aidsmap that they are trying to link the SWING Foundation and the Rainbow Sky Association with the Bang Rak Medical Center – a government facility offering sexual health services in the capital – for supervision and resumption of their services.
“As of now the experience of working with the government hospital is not as smooth as that of working with IHRI,” Surang Janyam of SWING told aidsmap. “This government hospital does not have any experience of PrEP provision.”
As the community clinics are no longer allowed to stock PrEP, either the PrEP user or a staff member needs to go to a government pharmacy to collect the medicine. Clinical information used to be sent electronically, but now staff members need to go to the hospital to input the data. The key-population led clinics are busiest at the weekends, creating a huge backlog on Mondays when government services reopen after the weekend.
“The government has to listen to communities,” Surang says. “We are not trying to compete with the government but are trying to support the government by providing options for people who are unable to access government services”.