Legalising Key Population Led Health Services In Thailand Is A Gamechanger
Key populations are groups of people who are disproportionately affected by HIV (which may include men who have sex with men, transgender women and sex workers, among others).
Dr Praphan Phanuphak is a distinguished Professor Emeritus of the Faculty of Medicine, Chulalongkorn University in Bangkok, Thailand. In February 1985, Professor Praphan diagnosed Thailand's first three cases of HIV/AIDS and has been involved in clinical care as well as in HIV prevention and treatment research since then.
Together with late Professors Joep Lange and David Cooper, Prof Praphan co-founded HIV-NAT (the HIV Netherlands, Australia, Thailand Research Collaboration), Asia's first HIV clinical trials centre in Bangkok in 1996. Prof Praphan served as the Director of the Thai Red Cross AIDS Research Centre for 31 years (1989-2020) and is currently the Senior Research and Policy Advocacy Advisor of the Institute of HIV Research and Innovation (IHRI) in Bangkok as well as the Advisor of HIV-NAT.
Dr Phanuphak was speaking with CNS (Citizen News Service) around 10th Asia Pacific AIDS and Co-Infections Conference (APACC 2025), 2nd Asia Pacific Conference on Point-of-Care Diagnostics for Infectious Diseases (POC 2025) and 13th International AIDS Society Conference on HIV Science (IAS 2025).
When people lead, change happens
Sterling examples of high impact key population or community-led health service deliver models come from Thailand. HIV key populations continue to play a major role in delivering Pre-Exposure Prophylaxis (PrEP for HIV prevention) to those who are at a heightened risk of HIV acquisition. Thailand has the largest PrEP rollout in Asia Pacific region, 80% of people using PrEP in Thailand receive it from a clinic led and staffed by members of the community that it serves.
Key population led health services mean that community thinks, demands and does the work and manages the programmes, for the benefit of their own community members (and the country). This model has proven to help accelerate community-led responses towards ending AIDS with government's support, said Dr Praphan Phanuphak.
"Therefore, it is a collaborative effort with equal responsibility and equal importance [between key populations or communities and the government]. One has to respect the other. It is not that the NGOs are snatching the work or the territory of the government," he said.
"Key population led health services (KPLHS) is a bottom-up approach in providing healthcare. It speaks to the needs and willingness of the community which will increase the value of the effort as compared to some thing being given to them passively (top-down approach). It fills the gaps that government cannot do and it is acceptable by the community they serve," emphasised Dr Praphan Phanuphak.
However, there could be some misunderstanding from the government side in some instances. For example, some may opine that 'government is getting blamed for not doing enough good work because of which NGOs are trying to compete with them'. Truth is that KPLHS or community-led models are only helping complement government's work.
"One has to show the evidence that KPLHS (key population led health services) can actually provide quality services to the populations that conventional healthcare providers cannot. Key population led health services will lead to ending AIDS and other sustainable health goals beyond HIV, such as mental health and NCDs, i.e., KPLHS is in accordance with government policy," said Dr Phanuphak.
He added: "KPLHS or key population or community led health services is one arm of the holistic healthcare approach. They need to collaborate with the main stream public healthcare systems. Once the government accepts these facts, legal and financial supports will follow. However, key population led health services may be more expensive than conventional healthcare since the personnels and office facilities are not provided by the government. Therefore, they need enough financial support to ensure sustainability of the programme."
95-95-95 HIV targets for 2025
Dr Praphan firmly believes that the 95-95-95 HIV goals can be achieved. We have science-based tools to deliver on these goals, he said.
95-95-95 goals refer to ensuring 95% of people living with HIV know their HIV positive status, 95% of them are receiving lifesaving antiretroviral therapy, and 95% of those on treatment are virally suppressed. According to the World Health Organization (WHO), there is ZERO RISK of any further HIV transmission from a person living with HIV whose viral load remains undetectable. That is why it is referred to as Undetectable Equals Untransmittable or #UequalsU.
Dr Praphan Phanuphak stresses upon "finding people with HIV early in all sub-groups of the population." He calls for focussing on HIV key populations as well as general population too. "General population is the group currently being left behind since we have rightly focussed on key populations now - but if we are to end AIDS by 2030, we need to reach out to everyone. Each individual - from general population or key population - should have at least one HIV test in their life - earlier the better (and repeat test as appropriate)," he said.
"Pre-Exposure Prophylaxis (PrEP) can prevent up to 99.9% HIV acquisition": Dr Praphan Phanuphak
Pre-Exposure Prophylaxis (PrEP) is a medicine taken by those without HIV to reduce the risk of getting infected with the virus. "PrEP can prevent up to 99.9% of HIV acquisition. One needs to scale up access to PrEP widely and rapidly. Once HIV cannot spread further and individual-at-risk cannot acquire new HIV infection with PrEP use, AIDS can be ended," said Dr Praphan Phanuphak. Treatment is also prevention because when people with HIV are on treatment and their viral load is undetectable, then there is zero risk of any further HIV transmission.
Thailand government rolls out PrEP under its universal health coverage since 2019 onwards. A majority of PrEP is being provided through key population led health services in Thailand.
Eliminate legal and structural barriers
Dr Praphan calls for eliminating all legal and structural barriers including stigma and discrimination that block access to existing HIV and other health and social support services - especially for HIV key populations.
He not only calls for strong and sustained national political commitment which is essential to end AIDS by 2030 but also for accountability of political leaders if we fail to deliver on the promise to end AIDS by 2030. He acknowledges that USA President Trump's current policy decisions have severed research funding and development financing for a range of programmes including HIV in the Global South. "This could pose to be a big obstacle for ending AIDS in many developing countries," said Dr Phanuphak.
Lot of progress towards ending AIDS but challenges remain
Thailand has seen alarmingly high HIV rates in certain sub-national areas or key populations in late 1980s and early 1990s. But a strong community-led response to prevent HIV has turned the tide since then and brought down HIV rates significantly. Thailand today champions a HIV response which parallels only a few other nations in the Global South. And Thailand is on track to deliver on HIV goals for 2025 too.
"100% condom use campaign to prevent HIV infection from commercial sex was a game changer. Establishment of HIV-NAT (the HIV Netherlands Australia Thailand Research Collaboration), the first HIV clinical trials centre in Asia to provide free up-to-date HIV treatment through clinical trials in 1996, was another major step forward," said Dr Praphan Phanuphak.
Helping children born to HIV positive parents are HIV free
When world's first therapy was rolled out in the rich nations in 1994 to reduce the risk of vertical transmission of HIV (from mother to child), Thailand soon began its rollout two years later (1996 onwards). Zidovudine was the first available antiretroviral agent for reducing mother-to-child HIV transmission in 1994.
"Princess Soamsawali prevention of mother to child transmission of HIV (PMTCT) project was another gamechanger to provide up-to-date PMTCT drugs to all pregnant women in Thailand, free of charge, from 1996 to 2010," said Dr Praphan Phanuphak. Thailand government took over and provided science-based triple antiretroviral therapy from 2010 to all HIV infected pregnant women so that no child is born of HIV. In 2016, Thailand became the first country in Asian region to eliminate mother to child transmission of HIV as well as syphilis.
Another gamechanger which helped Thailand progress towards ending AIDS is generic manufacturing of lifesaving antiretroviral medicines from 2006 onwards. Thailand is a leading manufacturer of generic medicines in the region and also procures lifesaving medicines from other nations including India.
Test and treat policy was rolled out in Thailand, a year before the WHO recommendation came in
A year before the WHO recommendation came for "Test and Treat" policy, Thailand had begun its rollout.
WHO "Test and Treat" policy meant that anyone diagnosed with HIV, regardless of their CD4 count or stage of infection, should be offered and immediately linked to lifesaving antiretroviral therapy. Strong scientific evidence showed that this approach maximises the benefits of early treatment for individual health and to prevent further transmission of the virus.
What could have gone better in HIV response
Dr Praphan Phanuphak reflects and shares that although "Test and Treat" and PrEP was rolled out by Thailand but it has not been implemented to its full scale. To some extent, it lacks a sense of urgency, and frequent changes of policy makers also impacted the rollout.
Flashback to 1980s: When first HIV cases were diagnosed in Thailand by Dr Praphan Phanuphak
"I was accidentally involved in HIV/AIDS arena. I am not an infectious disease doctor, but an allergist and clinical immunologist trained in USA. The first patient, an American gay man living in Thailand, was referred to me at King Chulalongkorn Hospital in October 1984 to investigate the cause of his recurrent muco-cutaneous infection. Immunologic investigations revealed that his T-helper cell numbers and T-cell functions were moderately low, but no diagnosis was made. In February 1985 the patient was admitted into the hospital with confirmed diagnosis of Pneumocystis carinii pneumonia (PCP) and his T-cell numbers and functions were further deteriorated. With the diagnosis of PCP and severe T-cell defect, AIDS was diagnosed at that time," shared Dr Praphan Phanuphak.
He added: "During the same month, a Thai male sex worker was referred to Chulalongkorn Hospital because of multi-organ cryptococcal infection. His T-cell numbers and T-cell functions were also severely impaired. AIDS was diagnosed in this second patient since he had sexual contact with a foreign man who had sex with men. The girlfriend of this patient was asymptomatic but had generalised lymphadenopathy, Her T-cell numbers and functions were moderately impaired. This patient was counted as the third case. Sera collected from these 3 patients were tested for HIV in May 1985 when the anti-HIV test kit was available in Thailand. All were HIV-positive. These are the first 3 HIV/AIDS cases diagnosed in Thailand, all in February 1985. With the availability of anti-HIV test in Thailand, more and more patients were diagnosed. This accidentally drove me deeper and deeper into the HIV field, coupled with the fact that there were not very many infectious disease doctors in the early days who were willing to see HIV patients."
Dr Phanuphak's lifetime contribution and continuing guidance to shaping HIV responses in Thailand and worldwide is commendable. We hope community-led responses would steer the global AIDS response towards getting on track to end AIDS by 2030.
Shobha Shukla – CNS (Citizen News Service)
(Shobha Shukla is the award-winning founding Managing Editor and Executive Director of CNS (Citizen News Service) and is a feminist, health and development justice advocate. She is a former senior Physics faculty of prestigious Loreto Convent College and current Coordinator of Asia Pacific Regional Media Alliance for Health and Development (APCAT Media) and Chairperson of Global AMR Media Alliance (GAMA received AMR One Health Emerging Leaders and Outstanding Talents Award 2024). She also coordinates SHE & Rights initiative (Sexual health with equity & rights)
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Government of India is investing in raising awareness such as via painted messages on public transport buses. A youth shared his user experience of 1097: he preferred to speak in Bengali language on 1097 tollfree helpline but after 3 unsuccessful attempts, gave up. Dr Chinmoyee promised to take this feedback to appropriate review meetings. Dr Chinmoyee Das of the NACO encouraged young people to reach out to official complaints officer appointed in every institution. If there is not an officer like this, then report to state AIDS control societies, she said. Be the messenger to help #endAIDS Dr Chinmoyee Das appealed to all young people to be the messenger to help spread and amplify correct messages around HIV combination prevention, HIV voluntary counselling and testing, 1097 tollfree helpline, HIV/AIDS Act, 2017 (to end stigma and discrimination), among others issues. We also must ensure that confidentiality of young people with HIV is protected all through the care continuum, she said. NACO's Dr Chinmoyee Das complemented NCPI Plus for making treatment literacy workshops successful 'and for being the messenger.' She confirmed that now onwards, for those (young or old) stable on lifesaving antiretroviral therapy, multi-months dispensing (instead of a month's supply) should be a reality. This should be happening across India. Dr Chinmoyee Das of NACO addressed the issue faced by orphans with HIV that as they can live in care centres till age of 18. She agreed the support should be extended to 5-7 more years – but this is currently being discussed as NACP-6 is getting shaped. 'There are state-specific schemes for livelihood, education, social welfare, etc, as well as through National Health Mission, so those must be fully utilised too,' she said. Greater involvement of youth in decision-making 'National Coalition of People living with HIV in India (NCPI Plus) is going to consider in its next board meeting if leadership of 'Youth Lead Voices' can be represented on NCPI Plus board,' confirmed Manoj Pardeshi, co-founder of NCPI Plus, TAAL Pharmacy and Network of Maharashtra People living with HIV or NMP Plus. 'I have witnessed Youth Lead Voices (YLD) to grow from 440 young people with HIV (on a WhatsApp group) a year back, to over 1860 young people with HIV across the country' said Sumita Taneja, EpiC, Country Representative at FHI 360 India. 'Over 800 of them are from priority states.' 'It gives me hope to see that HIV related public health messaging and communications done by Plan India and NACO is more youth-friendly and designed, conceptualised and implemented in a way which is more likely to resonate with the targeted young people,' said Simran Sheikh of Plan India. Simran is a noted human rights crusader since several years. No child should be born with HIV In Asia Pacific region, there are 120,000 children (aged between 0-14 years) who are living with HIV. Indonesia comprises 26% of the regional total of new HIV infections among children, followed by India (23%) and Papua New Guinea (8%). All 3 infections of HIV, syphilis and hepatitis-B, can be transmitted from women to their newborns during pregnancy and childbirth. In addition, HIV can be transmitted during breastfeeding too. Despite knowing how to prevent vertical transmission (from mother to the baby) of HIV, syphilis and hepatitis-B infections, we are failing with every child who is born with either of these preventable infections. We have the science-backed tools to ensure that all children are born free of these three infections. Failing to deploy them with utmost effectiveness is highly unacceptable. Let us all remind ourselves that medicines like zidovudine was first used in rich nations over 30 years ago (in 1994) to reduce HIV risk of the unborn child of HIV positive parent(s). Today we have far more effective treatment regimens available to ensure children are born free of HIV - and both mother and the child live healthy and normal lives. "Indian government's programme (prevention of mother to child transmission of HIV) has been running since 2003. I think it is high time that no child should be born with HIV," rightly said Dr Asha Hegde, Director South Asia, Family Health, Advisory Director Communicable and Non-Communicable Diseases at PATH. She added that we need to do more for children and young people between 10-18 years age group too. Dr Asha Hegde shared a positive example from Churachandpur, Manipur, India where there is a safe space co-created with local partners for young people. "We have built the agency of the younger population," she said while complementing Youth Voices Lead too - which resonates with the spirit driving the safe space project in Churachandpur. "Now we are slowly providing and offering services for HIV voluntary counselling and testing, refills of lifesaving antiretroviral therapy, opioid substitution therapy or harm reduction services, among others." Latest UNAIDS 2025 data shows that key populations have higher HIV risk. Four of every five (79%) new infections in Asia Pacific region were among key populations and their partners. Criminalisation and marginalisation deepen their vulnerability, making it harder to reach them with services. Let us hope that National Youth Conclave 3.0 results in stronger and urgent person-centred actions to prevent new HIV infections as well as for better programmes to provide treatment, care and support with rights and dignity to all those in need. Shobha Shukla, Bobby Ramakant – CNS (Citizen News Service)
