New Lancet Paper Examines Scale-Up of #HIV Services for Bangkok #MSM

Friday, June 5, 2015

A paper in Lancet HIV on scaling up HIV testing and linkage to care among MSM in Bangkok grabbed the attention of the HIV and global health communities after it was published at the end of March. The study, funded by the World Bank and the Australian National Health and Medical Research Council, used HIV surveillance and service capacity data to model the costs of scaling up HIV services in Bangkok to achieve universal ART coverage. From the abstract:
An additional $55·3 million investment would link an extra 46 700 (30 300–63 200) MSM to HIV testing and 12 600 (8800–16 600) to ART, achieving universal ART coverage of this population by 2022. This increased investment is achievable within present infrastructure capacity. Consequently, an estimated 5100 (3600–6700) HIV-related deaths and 3700 (2600–4900) new infections could be averted in MSM by 2022, corresponding to a 53% reduction in deaths and a 35% reduction in infections from 2012 levels. The expansion would cost an estimated $10 809 (9071–13 274) for each HIV-related death, $14 783 (12 389–17 960) per new infection averted, and $351 (290–424) per disability-adjusted life-year averted.
While I do not usually take an interest in cost forecasting studies (though I probably should), the study struck me because it pointed out how little Thailand spends on HIV prevention in MSM, despite the fact that they have a relatively high share of the HIV risk burden - and it is growing:
Although intervention programmes have effectively targeted female sex workers and people who inject drugs, the Thai national response to HIV in MSM has been largely neglected and, consequently, HIV prevalence in MSM was 20–30% in 2011, and has been increasing. Transmission by unprotected anal intercourse in MSM accounts for about 60% of 43 040 new HIV infections predicted in Thailand from 2012 to 2016...Despite this prediction, investment in prevention for MSM accounted for only 1·3% of the total budget in the 10th National HIV Plan.
I suspect that a large part of that is the relative political unpalatability of interventions targeting MSM - while it is easy to get stakeholder and donors to pitch in to "save" sex workers (e.g., through anti-trafficking initiatives), many are hesitant to get behind programs that reduce risk to MSM. However, MSM are consistently one of the groups at highest risk for contracting HIV - particularly in light of the heavy stigma they face for both their sexual orientation and (for positives) their HIV status.

Indeed, the study notes that "[i]f stigma and discrimination barriers can be reduced such that available infrastructure is used, then capacity is available to service all need." The infrastructure is already there! It is stigma and discrimination that present barriers to those at high risk from accessing services:
More importantly, because of persistent social stigma, MSM are often afraid of being seen by peers and discriminated against by health-care workers when receiving HIV tests. Stigma and discrimination are the most important barriers to the scale-up of services for MSM. Inconvenient operating hours of testing sites, concerns about confi dentiality, and non-friendliness of medical personnel are characteristic of the barriers to HIV testing.
Thailand certainly has a long way to go to service its populations at high risk for HIV, but it is certainly not unique in its challenges. Studies like this that provide a kind of "funding roadmap" are certainly helpful and encouraging. The one thing I was disappointed to see in the limitations section was the fact that the study did not distinguish between MSM who identify as men and transgender individuals (rather, it grouped them all together) - hopefully this can be an area of further research.

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