thailand quarterly and annual progress report july …

LINKAGES Thailand Quarterly Report (July 1 to September 30, 2018) 1

Linkages Across the Continuum of HIV Services for Key Populations Affected by HIV Project (LINKAGES)

Cooperative Agreement No. AID-OAA-A-14-00045

THAILAND QUARTERLY AND ANNUAL PROGRESS

REPORT

JULY 1 – SEPTEMBER 30, 2018

OCTOBER 31, 2018


Acronyms & Abbreviations

AIDS Acquired Immune Deficiency Syndrome amfAR American Foundation for AIDS Research APCOM Asia-Pacific Coalition on Male Sexual Health ART Antiretroviral Therapy ARV Antiretroviral BATS Bureau of AIDS, TB and STIs BKK Bangkok BMA Bangkok Metropolitan Administration CBO Community-based Organization CBS Community-based Supporter CD4 Cluster of Differentiation 4 CDC Centers for Disease Control CHC Community Health Center CHW Community Health Worker CPI Consumer Price Index CREC Central Research Ethics Committee CST Care, Support and Treatment C&C Counseling & Care, Support and Treatment DDC Department of Disease Control DIC Drop-in Center DQA Data Quality Audit DSD Direct Service Delivery DSD Differentiated Service Delivery EA Expenditure Analysis EPM Enhanced Peer Mobilization/Mobilizer Model F2F Face-to-Face FDA Food and Drug Administration FSW Female Sex Worker HCP Health Care Provider HITAP Health Intervention and Technology Assessment Program HIV Human Immunodeficiency Virus HIVST HIV Self-testing HTC HIV Testing & Counseling IAS International AIDS Society ICT Information and Communication Technology IP Implementing Partner IRB Institutional Review Board KP Key Population KPLHS Key Population-led Health Services M&E Monitoring & Evaluation MOU Memorandum of Understanding MoPH Ministry of Public Health MSM Men who have Sex with Men MSW Male Sex Worker NAP National AIDS Program NGO Non-governmental Organization NHSO National Health Security Office O2O Online-to-Offline OF Oral Fluid OI Opportunistic infection


PATH Program for Appropriate Technology in Health PCM Provincial Coordinating Mechanism PEP Post-exposure prophylaxis PEPFAR President’s Emergency Plan for AIDS Relief PHO Provincial Health Office PHSC Protection of Human Subjects Committee POC Point-of-Care PPAT Planned Parenthood Association of Thailand PR-DDC MoPH Principal Recipient Administrative Office Department of Disease Control PrEP Pre-exposure Prophylaxis PTY Pattaya PWID People Who Inject Drugs QA/QI Quality Assessment/Quality Improvement RDMA Regional Development Mission Asia RFA Request for Applications RNA Ribonucleic Acid RNR Risk Network Referral RRTTPR Reach-Recruit-Test-Treat-Prevent-Retain RSAT Rainbow Sky Association of Thailand RTCM Real-time Cascade Monitoring RTF Raks Thai Foundation SBCC Social and Behavior Change Communications SDART Same-day ART SESH Social Entrepreneurship for Spreading Health SIMS Site Improvement through Monitoring System SMS Short Message Service SOP Standard Operating Procedure STI Sexually-transmitted Infection SWING Service Workers in Group TA Technical Assistance TB Tuberculosis TG Transgender TGM Transgender Man TGSW Transgender Sex Worker TGW Transgender Woman TRCARC Thai Red Cross AIDS Research Center USAID United States Agency for International Development VPR Voluntary Partner Referral WHO World Health Organization


Narrative I: Executive Summary

During Fiscal Year 2018 Quarter 4 (FY18 Q4), LINKAGES Thailand continued to work in close collaboration with existing local implementing partners (IPs) and expanded its support to other health care facilities to strengthen combination HIV prevention, care and treatment interventions among members of key populations (KPs), including men who have sex with men (MSM), male sex workers (MSWs), transgender women (TGs), transgender sex workers (TGSWs), and female sex workers (FSWs). Figure 1. Achievements by quarter, FY18

During this reporting period, LINKAGES reached a total of 21,825 KPs with HIV prevention education and commodities. Below is a full breakdown of HIV prevention, care and treatment services including Direct Service Delivery (DSD) and Technical Assistance (TA) combined:

• 15,406 MSM; 1,643 MSW; 1,990 TG; 575 TGSW; and 2,211 FSW were reached with HIV prevention interventions. The combined number of clients counted under KP_PREV this quarter includes 16,343 KPs reached as the result of community-based interactions, while an additional 5,482 were walk-in clients. Total Q1-Q4 achievements for FY18 total 65,676 clients reached with prevention interventions, reflecting 59% of the annual KP_PREV target.

• 466 MSM, 8 MSW, 40 TG, 29 TGSW, and 5 FSW initiated PrEP for the first time, or approximately 4% of the eligible client population testing negative at a community-based clinic. Total PrEP uptake over the course of FY18 was 2,313 individuals, or 138% of the annual PrEP_NEW target.


• 11,218 MSM; 827 MSW; 1,380 TG; 276 TGSW; 89 PWID; 2,088 FSW; 5,433 non-KP males; and 6,257 non-KP females received HIV testing and learned their test results. Combined FY18 Q1-4 achievements were 70,817 individuals, or 91% of the annual HTS_TST target.

• Of the above, 752 MSM, 37 MSW, 65 TG, 21 TGSW, 2 PWID, 15 FSW, 193 non-KP males, and 109 non-KP females tested HIV positive. The overall case-finding rate for Q4 was 4%. Across FY18 Q1-4, 4,380 individuals were newly tested HIV-positive (6%), reflecting 51% of the HTS_TST_POS target.

• 717 MSM; 21 MSW; 64 TG; 13 TGSW; 10 PWID; and 14 FSW, as well as 382 non-KP males and 265 non-KP females started ART during this reporting period. In total, LINKAGES Thailand supported 4,139 HIV-positive individuals to initiate ART over the course of FY18, reflecting 48% of the annual TX_NEW target. In total, there were 24,195 currents receiving treatment as of the end of FY18, reflecting 239% of the TX_CURR target.

• Of all FY17 ART clients being actively tracked in FY18, 73% (n=638) were alive and on ART as of the end of this reporting period. Additionally, 17,241 clients received a viral load test, and 98% had VL<1,000 copies/ml.

Specific programmatic achievements during this reporting period include the following:

• LINKAGES partners exceeded FY18 targets for PrEP service delivery and patients on ART and performed acceptable on their HIV testing targets (though case-finding remained low). While KP_PREV performance was below expectation, it nonetheless represents an 85% increase over the previous quarter.

• Treatment uptake increased 98% over the previous quarter and, while FY18 totals failed to meet the annual target, LINKAGES partners over the course of FY18 increased considerably the percentage of HIV-positive clients who initiated ART, while reducing the time between diagnosis and ART initiation for several partners.

• The LINKAGES key population-led health services (KPLHS) model additionally outperformed the formal healthcare sector in terms of identifying positive clients earlier in the course of their infection, as measured by median CD4 count at baseline.

• More than 70% of all clients on ART as of the end of FY18 had received a viral load test, and among those clients, 98% had achieved viral load suppression.

Specific challenges in this reporting period:

• Case-finding rates declined over the course of FY18, and fewer-than-anticipated numbers of new HIV-positive clients are the key factor behind underperformance on treatment uptake indicators. Specific testing models (sauna-based testing, online recruitment, oral fluid testing) have demonstrated higher case-finding rates, but these models have been unable to deliver testing uptake at scale. It is possible that the expected number of undiagnosed positive individuals in some settings has been overestimated, resulting in unrealistic target setting around case finding. LINKAGES will investigate this possibility with an HIV cascade assessment to be conducted in Bangkok in FY19.

• While LINKAGES accounts for a large percentage of PrEP uptake in Thailand, the number of new PrEP clients has plateaued and represents far fewer than the number of clients needed to achieve epidemic impact. PrEP uptake has also been lower in some sub-populations that, based on self-reported risk and seroprevalence, would be more likely to benefit from PrEP, including sex workers and adolescents. In Q4, LINKAGES worked to develop a refreshed promotional approach for PrEP that will be implemented in FY19.

• HIV prevention, testing and treatment service delivery remains a key challenge in Pattaya generally, but with Sisters specifically. TGSW consistently show the highest case-finding rates of all KPs served under the LINKAGES project and 57% of all TGSW reached for the entire project in FY18 came from Sisters. However, more than 2/3 of TGSW reached by Sisters declined referral to HIV testing, and when clients were tested positive, they had the


lowest median CD4 count at baseline and one of the longest median wait times for ART initiation. While this is partially the result of systemic challenges with treatment delivery in Pattaya, it is notable that Sisters counseling, care and support staff have among the lowest quality assurance scores of any LINKAGES Thailand sites, when assessed by independent observers. Sisters also shows low rates of ART retention at 12 months, though rates of viral load suppression are high for those clients who initiated ART and received a VL test. TGSW in Pattaya are too critical of a population for epidemic control to allow poor-quality services for this population to continue; however, TGSW also cannot be left without necessary services for an extended period while service quality is improved.


Narrative II: Achievements and key challenges encountered during the reporting period by thematic area:

A. HIV prevention and linkage to HIV Testing & Counseling services (HTC)

In FY18-Q4, LINKAGES Thailand implementing partners continued to provide HIV prevention and referral services through one-on-one outreach and HIV prevention education, small group activities and online/social media activities. Through this combination of HIV prevention activities, a total of 21,825 KPs were reached in Q4 - 15,406 MSM (71%), 1,643 MSW (8%), 1,990 TG (9%), 575 TGSW (3%), and 2,211 FSW (10%). Total KP_PREV performance during this reporting period reflects an 85% increase compared to the Q3 performance of 11,808. Among clients counted under the KP_PREV indicator, 16,343 (75%) were reached as the result of community-based interactions, while an additional 5,482 (25%) were walk-in clients at LINKAGES-supported community health centers (CHCs) who received the full package of prevention services and were reported under the KP_PREV indicator with the consent of USAID. Fully 82% of all walk-in clients were reported from the TRC Anonymous Clinic, which is to be expected given that this facility supports no outreach workers on its own. MSM accounted for most walk-in clients (96%) followed by TG (2%), TGSW (1%) and MSW (<1%). FSWs accounted for only 0.22% of walk-in clients, a fact likely explained by the facts that LINKAGES partners do not currently operate any CHCs that target this key population. Among KP_PREV clients, 18,964 were referred to HIV testing services (87%), while 164 (1%) self-reported already being HIV-positive and an additional 2,697 (12%) declined referral to testing services. Known-positive clients were primarily MSM who walked in to CHCs to access services including CD4 screening and HIV care and support. No walk-in clients declined HIV testing, which is unsurprising given that they voluntarily walked in to a testing center. It is, however, notable that while MSM made up the greater proportion of those outreach clients declining referral to testing, TGSW declined testing referral at a much higher rate than any other key population (63%, 328/522). Particularly given that case-finding rates have historically been higher among this population than among other groups, the high rates of testing refusal among TGSWs suggest an urgent need to monitor more closely the quality of outreach interventions for this population and/or to investigate more appropriate coverage models. In total, LINKAGES implementing partners reached 65,676 unique clients with HIV prevention interventions in FY18. While this total represents a 7% coverage increase over the previous fiscal year, it accounts for only 59% of the FY18 annual KP_PREV target. Most project sites achieved (or exceeded) their prevention targets for FY18 – the shortfall is chiefly attributable to the performance of RSAT in metropolitan Bangkok (44% of target) and Chonburi (65% of target), though SWING Bangkok also achieved only 65% of their KP_PREV target. A key cause of this underperformance was the shift in focus on LINKAGES Thailand partners toward improving testing uptake (see Narrative II, Subsection B, below); additionally, LINKAGES has shifted emphasis toward models of online outreach and recruitment that are more in keeping with the shifting behavioral patterns of our target populations. These activities are captured under a new custom indicator, discussed below; however, most of these activities do not meet the current PEPFAR definition for KP_PREV as defined in the MER Indicator Reference Guide Version 2.3, released September 2018.


793

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Figure 2. LINKAGES Thailand Reach by Quarter, FY15 Q2-FY18 Q4

RSAT SWING Mplus Caremat Sisters The Poz TRC - Tangerine TRC - Anonymous


Explanation of increase in prevention coverage in FY18 Q4 Despite overall lower-than-anticipated performance on the KP_PREV indicator for FY18, during this reporting period, almost all LINKAGES Thailand implementing sites improved their KP_PREV coverage. Some of the sharpest increases came from FY18 expansion sites, including RSAT Nonthaburi which saw a 400% coverage increase (98 in Q3 to 490 in Q4), and Mplus Chiang Rai which increased 254% (505 to 1,789). SWING Bangkok also reported a 146% coverage increase among MSM/TG populations (706 to 1,734). Across sites, increases are primarily attributable to expansion of activities (including mobile testing) to new sites and innovative new activities including special online events organized with the Blue’d dating application (SWING Bangkok) and a ‘Peer HIV Education Camp’ to reach young MSM and generate networks of peer mobilizers (RSAT Ubon Ratchathani). Some partners also noted that the resumption of oral fluid HIV testing services helped them to attract clients (see Narrative II, Subsection B, for more details on this activity). Activities for Online Reach and Recruitment As described above, MSM and TG are increasingly more likely meet online to socialize, meet partners, and consume content (including health information). This well-documented trend is partially responsible for lower-than-anticipated prevention coverage using face-to-face outreach models. LINKAGES Thailand has been working with partners to expand service promotion and access to HIV prevention and treatment information for online audiences via a variety of online channels: Table 1. LINKAGES Thailand-support Online Recruitment Models and Platforms

General Population KP-Specific

Websites (one-way, static communication)

• TRC Anonymous Clinic

• BMA Website (forthcoming)

• TestBKK

• Adam’s Love (previously)

Messaging/Chatting Platforms (two-way controlled communication)

• Line

• CamFrog

• WeChat

• Aza

• Beetalk

• Blue’d

• Grindr

• Hornet

Social Media (multi-directional, broadcast communication)

• Instagram

• YouTube

• Twitter

• Facebook

• Partner Facebook Pages

• Specific Facebook Groups

• Specific campaigns (i.e. Ready-PrEP-Go)

• Targeted advertisement

With LINKAGES support, implementing partners increasingly are using these media not only to disseminate information, but to engage clients and refer them to services (O2O). While a small subset of these individuals may be captured under the existing KP_PREV indicator (for instance, if they walk in to a community health center), most of this effort is not captured under the current PEPFAR monitoring and evaluation framework. With this quarterly report, LINKAGES Thailand is therefore trialing two new custom indicators1 to narratively reflect the investment in online strategies:

• ON_VIEW - number of people who potentially “view” HIV prevention information (test, referral, risk assessment, PrEP PEP, STIs, etc.) via online channels, reflective of the total potential reach of online content.

1 While these indicators are new to LINKAGES Thailand, they were initially developed for use by LINKAGES programs in the Eastern Caribbean and were approved for use in narrative reporting by the LINKAGES global technical team and USAID technical backstops for that region.


• ON_CLICK – number of discrete engagements with content via online channels, including Likes, Shares, Comments, Messages, Subscriptions, and Reservations, reflective of the intensity of online engagement.

Throughout FY18, the total ON_VIEW figure for all LINKAGES partners and online/social media platforms was a potential audience of 1,881,020. Facebook accounts for the majority of this figure (1,723,291), followed by website views (139,920, mostly from TestBKK). During the same period, ON_CLICK for all LINKAGES Partners was 314,289. Most of these engagements were clicks from content shared by APCOM on Facebook to either the Test Me Now O2O platform or the TestBKK website (151,457 click-throughs in total). In total, 16.7% of the ON_VIEW audience actually engaged in content via the ON_CLICK metric.2 In the next Fiscal year, LINKAGES Thailand and our partners will use granular social media metrics to better plan social media and online engagement strategies. Specific online reach and recruitment activities in FY18 Q4 included targeted Facebook Live sessions and online “television shows” – for instance, Mplus developed a series of regularly scheduled Facebook broadcasts that integrate health messaging with entertaining content for MSM/TG in the Chiang Mai area:

• แอ๊วผู ้(Flirting with Guys; which targets MSM/TG who love watching good looking/

influencers),

• เม๊ามอยซอยยกิ (Gossip Show: a talk and variety show for TG), and

• นดัยมิ นดัยิม้ (Gym Time, Smile Time: for MSM who love going to the gym to learn how to work

out, featuring a rotating cast of good-looking local guys). In response to concerns that LINKAGES outreach efforts were not effectively reaching specific sub-groups of MSMs (young men aged 18-20, group sex participants, drug users) LINKAGES Thailand has also been experimenting with so-called “micro-targeted” social media advertising on the Facebook platform to encourage two of these groups to book appointments for HIV testing. Facebook allows advertisers to reach precisely defined groups of users based on a wide variety of individual and network characteristics under the broad headings of demographics, behaviors and – critically - interests, including self-reported interests relating to sex and sexuality media preferences, and pop culture figures. Current practice suggests that these categories can be used to effectively target KPs based on their interests in the LGBT community and same-sex relationships. LINKAGES chose to target young men (aged 18-20) and group sex participants and conducted consumer interviews with members of these audience segments to identify (1) distinguishing interests that would facilitate micro-targeting, and; (2) data on the hopes and aspirations of these groups for use in crafting effective messages for social media advertising. Based on the results of this formative research, LINKAGES Thailand ran short-term, micro-targeted Facebook campaigns:

• A campaign targeting men aged 18-20 in the Bangkok metropolitan area who reported interest in same-sex relationships and LGBT culture resulted in 816 “click throughs” to the Test Me Now O2O appointment booking site, and also allowed us to A/B test different creative approaches and determine that one creative campaign was much cheaper and more effective than the other at attracting users ($0.19 per click for 520 users versus $0.38 per click for 296 users), at a total cost of about $200.

2 As discussed, ON_VIEW and ON_CLICK are not MER indicators and should be interpreted with caution. Because these figures are aggregated across multiple platforms and partners, they cannot be deduplicated (and may also represent overlap with clients reached via traditional outreach). These figures are also likely to reach KPs as well as members of the general population, though LINKAGES is working with partners to be increasingly targeted in our social media approached. Finally, online reach and engagement may include individuals outside the LINKAGES Thailand catchment areas, though the majority of contents are produced in Thai language and, where paid promotional strategies have been employed, targeting filters have been set to users based in Thailand exclusively (based on IP address).


• A test campaign for older (20-34) MSM interested in group sex targeted men between the ages of 21-35 who are interested in Anne Hathaway, Miss Universe or Christina Aguilera—a set of interests identified in our focus groups. This targeting yielded 505 “clicks” to the Test Me Now site at a cost of $0.195/click (total advertising cost $100).

These test campaigns established the viability of reaching specific sub-groups of MSM in Bangkok via more targeted social media advertising; unfortunately, despite the relatively large number of click-throughs to the Test Me Now O2O site, only a single Facebook user made an appointment as a direct result of these ads. We are investigating whether the advertisements provide enough information to Facebook users to attract those who are interested in learning their HIV status, and what additional reinforcement is required to convert an interested audience member into a testing client. Because LINKAGES Thailand and our partners increasingly use Facebook as one of the main tools to reach to our target populations, we arranged a meeting with Facebook Thailand to discuss our activities and the potential for collaboration with our partners. Facebook has a strategic interest in ensuring that Facebook advertisers are successful at reaching their target audiences; the company has accordingly expressed an interest in providing training for LINKAGES Thailand partners, which will be arranged in FY19 Q1. SWING Bangkok also partnered with the Blue’d application to promote and conduct special O2O events to reach online hidden, younger MSM using popular social media influencers on that platform. A single event resulted in 34 new people tested, with a 7% case-finding rate; 100% of those newly diagnosed HIV-positive were successfully linked to treatment.

Finally, APCOM has continued to promote HIV testing and PrEP in Bangkok via the TestBKK brand. During this reporting period, the TestBKK website recorded 65,872 page-views from 43,918 unique viewers, the majority of whom were males between the ages of 25 to 34 years based in Thailand. Across all TestBKK channels, APCOM reported 445 reservations made and 131 tests conducted via the Test Me Now O2O application, which came from the TestBKK web page, as well as from two discrete, targeted ad campaigns run on Facebook and on the Hornet dating application. After analyzing their data, APCOM concluded that Facebook ad campaigns using known and socially influential faces (for instance, stars of the former GayOK web-based drama series) generated the lowest cost per landing page view in comparison to previous ad campaigns that used stock male images. APCOM also concluded that Hornet ad campaign using the the in-app text and image ad format is much more cost-effective in generating traffic to the O2O platform and encouraging reservations in comparison to other ad formats supported on that social media platform. These findings will be used across LINKAGES Thailand partners to improve the performance of online promotional strategies. Online-to-Offline Conversion LINKAGES continues to refine and rollout an O2O platform for HIV appointment booking in order to facilitate access to testing and to evaluate the various models of online recruitment described above. In FY18 Q4, our O2O platform underwent a re-branding effort and is now referred to as Test Me Now – all previous links to this platform under the Res99 “brand” remain operational so that no potential clients will be lost. To date, there have been 3,602 reservations made via the O2O platform, 1,856 of which have resulted in testing uptake (52%).3 However, due to difficulty motivating clinic staff to complete data entry for clients referred via Test Me Now, data on the results of service uptake are available on only

3 It is possible that more clients who made reservations followed through and were tested, but clinic staff failed to record their arrival, resulting in lower reporting of successful referrals.


821 unique clients. Among those, 86 have been newly diagnosed HIV-positive for a case-finding rate of 10% - among those clients, 74% have been confirmed to have started ART. Among the 734 negative clients,4 87 have accessed PrEP (12%).

* Case-finding rates are calculated based on the number of clients for whom partners completed full data entry.

In this reporting period, 849 clients made reservations via Test Me Now, which represents a small increase over the previous quarter (7%). RSAT Bangkok alone accounted for 41% of all reservations, followed by the TRC Anonymous Clinic (21%) and SWING Bangkok (16%). While demographic information is only available on the 211 clients for whom partners completed data entry, among those 88% were MSM, the median age was 28 (18-63), and 80% reported having previously received an HIV test. Of concern, only 43% of the 849 reservations made in Q4 resulted in a clinic arrival (n=362). As can be seen in the chart above, O2O reservations have been steadily growing over the last three quarters; however, the number of arrivals has remained more or less constant. This can be attributed to the growing role of asynchronous social media-based advertising in O2O recruitment – this quarter, advertising accounted for 59% of all reservations, but it has been seen that this recruitment model, while achieving wide reach, generates relatively lower commitment to service uptake among those clients who make appointments. A breakdown of O2O recruitment by major channels in Q4, seen below, shows the relative contribution of different forms of online promotion and highlights the missed opportunity to improve testing numbers if more advertising clients can be converted to testing clients. As described above, LINKAGES is working with partners and creative agencies to improve the targeting and quality of online advertisements. Table 2. FY18 Q4 Online-to-Offline Outcomes by Promotional Channel

Reservations Arrivals Arrival Rate Data Available

Tested Negative

Tested Positive

Case Finding

Outreach 214 113 53% 74 62 12 16%

Influencer 57 29 51% 14 14 0 0%

Advertising 499 181 36% 112 100 12 11%

Direct Referral 79 39 49% 11 9 2 18%

4 1 client received an inconclusive result.

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Figure 3. O2O Trends, FY18 Q1-4 (n=3,018)

Reservations Arrivals Case-Finding Rate*


This is also the second quarter in a row that structured online outreach has generated high case-finding rates. All new positive cases were referred by RSAT Bangkok online outreach workers – RSAT reports that they have intensified their online outreach approaches by requiring all outreach workers to spend at least 50% of their working time implementing online approaches. They have also specifically targeted high-risk individuals included Twitter users who broadcast their preferences for drug-associated sexual activity and group sex, and they have used social networking applications like Hornet to target users at hot spots such as saunas at specific days and times. Outreach workers engage these individuals through private messages and promote the Test Me Know website, which has driven the higher case-finding. Strengthening of Strategic Behavior Change Communications In addition to the online reach and promotional activities described above, LINKAGES Thailand continued in FY18 Q4 to work on a number of initiatives to strengthen communications approaches. These included working with TestBKK to begin production of a limited-time, social-media based reality series that will be used to promote HIV prevention and testing themes. During this quarter, APCOM worked to prepare mock scripts and story boards for review, with the intention that the series (linked to the Test Me Now platform) will be ready to launch before the end of the calendar year. LINKAGES also selected three media agencies through an open and competitive bidding process to provide ongoing creative services under a Master Services Agreement contract mechanism:

• Commetive Productions will work with LINKAGES and TRCARC to plan a communications campaign around treatment literacy and early ART initiation, which will be linked to the Undetectable = Untransmittable (U=U) message. To activate this campaign, LINKAGES is engaging with a young, HIV-positive Thai social media influencer who has created an online space for people living with HIV in Thailand. This influencer will is providing community insight into campaign development – the campaign is expected to launch by the end of FY19 Q1.

• Love Frankie will work with LINKAGES to build a social media-based campaign around PrEP promotion, which will build off of the creative concepts sourced through the Ready-PrEP-Go contest and will explicitly target early adopters to encourage members of their personal networks to try PrEP. At the end of this reporting period, LINKAGES was finalizing contractual arrangements with Love Frankie for this activity, with the goal of a campaign being launched before the end of the calendar year.

• Trasher will work with LINKAGES and our community partners to host community mobilization events for the above-described campaigns and will help to disseminate “micro-targeted” Facebook advertising campaigns, such as the ones described above, to their network of followers, and linked to the O2O platform.

In addition to revising communications approaches directly under PEPFAR support, in FY18 Q4 LINKAGES also provided substantial technical assistance to the Bangkok Metropolitan Authority (BMA) to link our O2O platform to their service delivery sites (see Narrative II, Subsection E, for further details) but also to develop their vision for a city-wide web portal to serve as a central hub for HIV-related information and services. FHI 360 together with TRCARC helped BMA to shape the design for this web portal, provided instruction in the use of a creative brief tool to hone their concept and strategy, and suggested the necessity of a city-wide campaign to build and audience and increase traffic to this website. Pre-exposure Prophylaxis (PrEP) During FY18 Q4, LINKAGES partners supported a total of 548 KPs (466 MSM, 8 MSW, 40 TG, 29 TGSW, 5 FSW) to receive PrEP for the first time under the Princess PrEP project. This brings the total


number of people reported under the PrEP_NEW indicator to 2,313 persons, or 138% of the annual PrEP_NEW target. PrEP users under the Princess PrEP program have tended overwhelmingly to be MSM in their 20s and 30s and, based on data from the TRCARC cohort study, report relatively high levels of risky behavior; however, PrEP use has been lowest among precisely those sub-populations (like sex workers and adolescents) who would benefit most from additional prevention options. It is therefore encouraging that, over the course of FY18, the greatest growth in PrEP uptake has been among KPs ages 15-19, who despite accounting for only 6% of total PrEP users in FY18 to date,5 show an average growth in PrEP uptake quarter-to-quarter of 97% (compared to 5% for 20-24-year-olds, and negative growth for all other age groups). Incidence data from Thailand indicate high risk of infection among KP adolescents, so it is heartening to see a focus on promoting PrEP uptake among this sub-population. Despite this, as the graph below show, the number of new PrEP acceptors in FY18 Q4 represents only a 3% increase from the previous quarter (548 versus 534). Additionally, the total number of PrEP users in Thailand is far below the required level of coverage to see epidemic impact – based on the experience in New South Wales, Australia it is currently estimated that Thailand would need to achieve PrEP uptake among a minimum of 20% of key populations (or 200,000 individual PrEP users) to see population-level reductions in new infections. With 5,000 individuals currently on PrEP6 (2.5% of estimated need) this would suggest that communications interventions are badly needed to stimulate further PrEP demand and to focus on highest-risk subpopulations.

Addressing the plateau in PrEP demand in the second half of FY18 will be one of the key focuses of SBCC activities in FY19. Previous demand generation activities focused primarily on raising awareness about PrEP and, thus, were principally effective at mobilizing what Rogers’ Diffusion of Innovations model refers to as innovators – extremely early adopters who are motivated primarily by novelty and have high risk tolerance, but who only make up about 2.5% of any population and

5 Total FY18 Q1-4 breakdown of PrEP users by age is as follows: 15-19 (7%); 20-24 (21%); 25-29 (28%); 30-34 (18%); 35-39 (12%); 40-49 (10%); 50+ (3%) 6 Included those supported under Princess PrEP and those who have accessed PrEP via PrEP implementation research supported by PEPFAR, those accessing hospital-based PrEP under the Thai MoPH, and those utilizing clinic-based fee-for-service PrEP.

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Figure 4. PrEP_NEW (Q1 FY16-Q4 FY18)

RSAT ALL SWING ALL TRC ALL Sisters Caremat Mplus Total


who are typically not trendsetters among the wider population. As described above, LINKAGES will work Love Frankie, a Thailand-based creative agency, to develop a creative campaign for PrEP promotion incorporating successful elements from the “Ready, PrEP, Go!” competition and primarily targeting Early Adopters and Early Majority individuals who, collectively, account for almost 50% of any given population. Specifically, this campaign will seek to identify key opinion leaders within high-risk segments of the target audience who embrace change opportunities and who can speed diffusion of PrEP by sharing successful experiences of adopting PrEP as a prevention strategy and promoting evidence of PrEP effectiveness. B. HIV Testing & Counseling (HTC)

In FY18 Q4, LINKAGES implementing partners and partner hospitals successfully provided HIV testing services to, and shared results with, 27,568 clients,7 15,878 of whom were self-reported KPs (58%).8 As in FY18-Q3, LINKAGES continued to support provision of HTC services for clients who could not be identified as members of a key population, who collectively account for 42% (n=11,690) of all service delivery reported under the HTS_TST indicator this quarter.9 The majority of non-KP clients (91%) received HIV testing services through an extended network of service delivery hospitals, which continued to receive ongoing technical assistance from LINKAGES in FY18. Testing service delivery in FY18 4 represents a 98% increase compared to the previous reporting period; however, this improvement must be interpreted with care. LINKAGES IPs saw a more modest 26% increase when combining direct service delivery with HIV testing referral (from 11,596 in Q3 to 14,601 in Q4). Every site (except for Sisters in Pattaya) saw service delivery increases during this quarter, driven by increased focus on Internet-based service promotion and mobile testing events. In addition, SWING in Bangkok extended their clinic hours responsive to shifting business times at sex work venues, and both SWING and Caremat restructured their outreach and peer mobilization teams to more efficiently target KPs. The reduction in testing uptake at Sisters was expected as this

7 14,157 DSD, 13,411 TA 8 11,218 MSM, 827 MSW, 1,380 TG, 276 TGSW, 89 PWID, 2,088 FSW 9 The justification for counting non-KPs under the HTS_TST indicator is that, anecdotally, many KPs choose to access facility-based healthcare services but do not self-report as KPs, or hospitals do not record and report them as such. This justification is borne out by the fact that hospitals and community-based testing services performed similarly in terms of case-finding, suggesting that their clients represent populations with similar levels of HIV risk.

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Figure 5. LINKAGES Thailand HTC Performance by Quarter, FY15 Q2-FY18 Q4

Reach Test Positive Reach-to-Testing Ratio Case Finding


IP reduced their staff size and scope of activities to focus on capacity building and completion of research goals under the Test and Treat Cohort Study, with responsibility for other service delivery shifted to SWING Pattaya. Most of the dramatic increase in HIV counseling and testing in Q4, however, comes from LINKAGES’ network of facility-based healthcare providers, who reported 2,310 clients tested in Q3 but 12,967 during this reporting period (a 461% increase). This increase does not actually reflect an increase in service uptake, but improvements in data entry at healthcare facilities that have received LINKAGES-supported TA. In Q4, LINKAGES provided training and performance-based financial support for facility-based HIV coordinators as well as six data coordinators sitting in Provincial Health Offices. This support has helped improve healthcare facilities’ recognition of the importance of data collection and analysis, strengthened the PHOs’ access to and analysis of facility-level data, and, as a result, during this reporting period healthcare facilities supported by LINKAGES reported much more comprehensively on their service delivery. In total, LINKAGES Thailand at the end of FY18 reported 70,817 individuals receiving HIV testing services, a 103% increase over FY17 and 91% of the annual HTS_TST target. This represents the largest HTS_TST achievements measured by year, and by quarter, since the project began. We acknowledge that this is in part due to the inclusion of HTC clients who did not self-report being members of a key population; however, when looking at self-reported KP clients alone, LINKAGES partners also reported a 60% increase in testing uptake over FY17. Despite overall good performance toward the HTS_TST target, not all LINKAGES Thailand implementing partners achieved their annual goals for testing uptake – most notably, newly opened expansion sites in Nonthaburi, Chonburi, Samut Prakan, and Pathum Thani struggled to achieve testing targets. The primary explanation for this is that those sites have no community health center capable of providing on-site HTC, and clients must be referred elsewhere for services. Encouragingly, the RSAT expansion site in Ubon Ratchathani performed to expectations, and the newly opened Mplus site in Chiang Rai far exceeded its testing targets. While HIV testing uptake increased markedly across FY18, case-finding rates have declined steadily. In Q4, a total of 1,194 individuals were confirmed HIV-positive.10 Due to the much larger number of individuals tested this represents an 18% increase in case finding, however the case finding rate declined from 7% to 4%. Of all positive cases identified in Q4, 64% (n=769) were detected through community-based implemented partners either administering tests or recruiting and referring to other service centers, while 36% (n=425) came from healthcare facility clients.

10 723 DSD, 471 TA


Among LINKAGES implementing partners in FY18 Q4, the TRC Anonymous Clinic continued to achieve the highest number of clients tested, cases identified and the highest overall case-finding rate (9%). Despite the reduction in scope of activities at Sisters, this partner also achieved a comparatively high case-finding rate (8%), which is consistent with project data indicating increased HIV risk among the TGSWs who account for most of Sisters’ clients. It is critical that coverage and service delivery for these clients not suffer while LINKAGES staff work to strengthen Sisters’ organizational and technical capacity. Other LINKAGES IPs saw much lower-than-anticipated case-finding rates, despite LINKAGES technical and program staff worked with implementing partners to re-strategize their outreach and testing approaches and partners’ attempts to use program data to emphasize higher-risk subpopulations and higher-yield testing modalities. [We will also be introducing a modified index testing approach (“Treat and Test”) in FY19 to specifically target more intensive recruitment among the social and sexual networks of HIV-positive individuals. Table 3. LINKAGES Thailand Case Finding by Key Population, FY18

FY18 Q4 FY18 Cumulative

Populations Total Testing Case Finding Total Testing Case Finding

MSM 11,218 6.7% 39,260 8.2%

MSW 827 4.5% 3,455 4.8%

TG 1,380 4.7% 4,306 6.4%

TGSW 276 7.6% 1,004 9.0%

FSW 89 0.7% 327 0.7%

PWID 2,073 2.2% 7,313 6.7%

non-KP males 5,433 3.6% 6,779 5.1%

non-KP females 6,257 1.7% 8,373 2.3%

Total 27,553 4.3% 70,817 6.2%

KP Total 15,863 5.6% 55,665 6.9%

Overall, LINKAGES Thailand achieved an average case-finding rate of 6% over the course of FY18, and LINKAGES partners reported 4,380 newly diagnosed HIV-positive individuals, which represents only

3,207 3,219

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Figure 6. LINKAGES Thailand HTC Uptake and Yield by Partner, FY18 Q4

Test Positive Case Finding


51% of the anticipated annual HTS_TST_POS target. While MSM accounted for the largest proportion of testing clients (55%), the highest case-finding rates were found among TGSW (9.0%), who represent only 1.4% of total testing uptake, and as noted elsewhere in this report are much more likely than other clients to decline referral to HIV testing services when reached by project staff. Improving overall case-finding rates will require more effective models for targeting these highest-risk individuals and will require that those models be implemented at scale. HIV Testing Service Delivery Models Facility-based HIV testing11 accounted for 68% (10,731/15,878) of all HIV testing uptake among KP clients during this reporting period, with an 8% (816/10,731) case-finding rate – this represents a lower proportion of overall testing uptake compared with the previous quarter (78%). Mobile testing accounted for 31% of all HTC uptake in Q4 (4,980/15,878) with a 1.5% case-finding rate; this represents a larger proportion of overall testing compared with FY18 Q3, but this figure is difficult to disaggregate. Sauna-based mobile testing achieved a significantly higher case-finding rate (12%) but accounted for less than 1% of overall service delivery. Non-sauna mobile testing (4,915 clients with a 1% case-finding rate) was a combination of mobile testing events and peer-assisted oral fluid testing under the operational research study (see below); however, as of the writing of this report, final data were not available on confirmed case-finding via oral fluid testing and confirmed positive oral fluid test results are reported under facility-based testing rather than mobile due to the need to follow the national, blood-based testing algorithm. The most concrete conclusion that can be drawn at this time is that implementing partners should emphasize sauna-based testing to increase case-finding; however, it is unlikely this model will be implemented at wide scale due to (1) the limited number of venues available and willing to host testing services, and (2) the limited number of clients who can be served during a single sauna-based testing event due to logistic constraints. Finally, online and unassisted self-testing accounted for less than 1% of overall testing uptake and reported no new HIV-positive cases identified; however, as above, oral fluid self-testing with preliminary reactive results must be confirmed with a blood test and are counted under facility-based testing – figures reported to PEPFAR may, in this case, underestimate the potential contribution of oral fluid testing to case-finding, but we await final analysis of the research data to quantify this. HIV Self Testing Implementation Science Since the inception of the Oral Fluid Testing Study Phase 2 in June 2018, a total of 1,517 participants (954 MSM and 563 TG) have been enrolled in the study (as of 19 October 2018) representing 95% the total sample size for Phase 2. It is expected the recruitment will be completed by all research sites by the end of October 2018. The most recently available data are included in this narrative to accurately reflect up-to-date progress on this activity; however, delivery of self-testing kits in the M&E matrix attached to this report reflects only activities within the reporting period as appropriate for PEPFAR indicator reporting.

11 Facility-based HIV testing is defined here to include all testing conducted in a fixed testing venue, whether that be VCT in a community-based health center, through referral, or for KP clients who were tested at a hospital or other formal healthcare facility that received technical assistance under the LINKAGES project.


Table 4. Interim Outcomes of Oral Fluid Screening Operational Research Phase 2

KP

Sample Size

Enrolled %

Achievement Testing

Approach

Enrolled Screened Result

15-17 yrs.

>18 yrs.

15-17 yrs.

>18 yrs.

Negative Positive/ Reactive

Invalid/ Can’t Read

MSM 970 954 98% Peer-Mediated

33 750 33 750 747 34 2

Self-Testing

3 161 2 161 151 12 0

Referral 1 6 1 5 6 0 0

TG 630 563 89% Peer-Mediated

10 480 10 480 460 30 0

Self-Testing

1 65 1 52 52 1 0

Referral 0 7 0 7 6 1 0

A total of 1,273 participants (783 MSM and 490 TG), or 84% of the total participants to date, selected peer-mediated oral fluid testing, while 230 (18%) participants (164 MSM and 66 TG) selected unassisted HIVST. An additional 14 participants (7 MSM and 7 TG) chose to be referred to a community health center for blood-based HIV testing following the national testing algorithm. Peer-mediated screening, as observed during the phase 1, remains the preferred screening option for both MSM and TG populations enrolled in this study. Based on current monitoring data, higher reactivity rates were observed among MSM who opted for unassisted HIVST (7%) compared to those who selected peer-mediated testing (4%). Among the 66 who selected unassisted HIVST, only one (1.5%) participant was screened reactive while out of 490 transgender women who selected peer-mediated screening, 30 (6%) were screened reactive.

As depicted below, most MSM (97%) and TG (96%) who enrolled through face to face channel opted for peer-mediated screening option while for those enrolled through social media channels, the majority of MSM (71%) and TG (60%) participants opted for unassisted HIVST. Among those who selected unassisted HIVST, EMS was the most preferred delivery option for both MSM (71%) and TG (58%) participants. These preliminary findings are consistent with findings of phase one and highlight the need to provide differentiated service delivery options for different KP subpopulations. Figure 7. Service Delivery Preferences, Oral Fluid Screening Operational Research


As data collection is expected to be completed within FY19 Q1, after October the LINKAGES research team will focus on data management and analysis. Dissemination plans have been shared with USAID/RDMA and include dissemination of findings at the community and national levels in Thailand, presentations at selected regional workshops/meetings, submission of abstracts to regional/international conferences; and submission of manuscripts to peer-reviewed journals. Regarding the HIVST policy in Thailand, the Bureau of AIDS, Tuberculosis, and Sexually Transmitted Infections (BATS) in May 2018 submitted a letter and evidence to the Thai Food and Drug Administration (FDA) justifying the urgent need to review MoPH regulations around self-testing. Based on BATS’ request, the Thai-FDA has set up a committee to work on this issue, but no official meetings have been held. On September 25, the Department of Disease Control (represented by the Deputy Director of DDC and the Director of BATS) and Thai FDA (represented by the Director of the Medical Devices Control Division) met to discuss progress toward modifying MoPH regulations; during this meeting, the Thai FDA acknowledged the importance of HIVST as one of the key strategies that could contribute to “Ending AIDS” goal in Thailand. Both parties agreed that the Thai FDA should complete their review of the MoPH regulations by the end of year 2018. To further support the goal of broader rollout of self-testing options, LINKAGES Thailand has been working with BATS, TRCARC, and other stakeholders to prepare an advocacy brief for a national launch during FY19. Specific timing of this event is still being discussed with BATS and, should a policy change be announced in the interim, this brief may become unnecessary. LINKAGES is also preparing a brief documentary-style video to highlight successes under the oral fluid study and to further advocate with policymakers for HIVST in Thailand. Capacity Building for HIV Testing Services During this reporting period, LINKAGES also continued to support quality improvement of KP-led HTC services. Following on the workshop held in the previous quarter to standardize quality assurance and quality improvement (QA/QI) measures for counseling, LINKAGES in July and August worked with TRCARC and the provincial-level QA/QI Committees to conduct onsite quality assessment across 13 partner sites. These assessments were conducted in collaboration with 33 healthcare professionals representing 29 organizations in 9 provinces, who acted as quality assurance evaluators:

• NHSO representations from Bangkok and Songkhla

• Representatives from the offices of Disease Prevention and Control from Chiangmai, Ubon Ratchathani and Songkhla

• PHOs and BMA representatives from Chonburi, Ubon Ratchathani, Nonthaburi, Pathumthani, Samutprakarn and Bangkok

• Staff of 18 hospitals from across all 9 provinces Evaluators assessed the quality of service delivery for 46 staff of LINKAGES implementing partners including HTC counselors and care and support staff. The assessment examined the accuracy and appropriateness of counseling content as well as the service providers’ interpersonal communications skills. KPLHS staff achieved an average score of 76% (SD = 0.1172) and median 77% for counseling content, and an average score of 73% (SD = 0.0957) and median 74% for communication skills.


Common problems across sites and partners included a failure to conduct adequate risk and needs assessments when counseling clients, a focus on information giving as opposed to client-centered counseling, and in some cases a failure to assess and/or adequately support clients to access services beyond HIV testing (i.e. tuberculosis, STI etc.). It is notable that scores at expansion sites were consistently lower than at the more established KPLHS providers; this may be expected, but it also points to the need for RSAT to do more to transfer skills from their established service providers to staff at their relatively new community health centers. As part of quality assurance processes, LINKAGES also conducted exit surveys with 474 clients across all sites. Findings were consistent with the QA/QI review: clients were by and large satisfied with pre-counseling; however, 12% of clients reported feeling uncomfortable with counselors at SISTERS, Caremat and MPlus Chiangmai. Clients also requested more support for convincing their partners to test and more emphasis on making a tangible appointment for their next test. LINKAGES plans a number of measures in FY19 to address quality issues, with a focus on those sites that scored 65% or lower on the QA/QI assessment. These include:

• LINKAGES will send new staff to apprentice at local hospitals to practice counseling and CST skills

• Experienced IP staff will provide coaching every quarter (focusing on RSAT expansion sites)

• LINKAGES will continue to provide onsite TA onsite, with a focus on appropriate screening of client risks and needs, motivational strategies for supporting behavior change, support for partner referral and support to access a wider range of services (including mental support and treatment services for HIV-positive clients) Technical assistance that LINKAGES will provide to all partners extract from QAQI result.

In addition to quality assurance for counseling services, in FY18 Q4 LINKAGES also conducted a “Laboratory Safety and Same Day HIV Testing” training course for 25 participants (laboratory technician and medical technologist) representing all LINKAGES laboratories. Training topics included types of safety hazards, an overview of biosafety levels and general safety precautions, and an introduction to laboratory safety practices and safety equipment. LINKAGES lab specialists also attended laboratory audits at SWING Pattaya and Sisters, conducted by an auditor from Banglamung hospital, and at RSAT Hat Yai, conducted by a medical technologist from Hat Yai hospital. Observations during these audits were discussed with our implementing partners and corrective action plans have been put into place to address identified issues was

89%83% 81% 79%

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Figure 8. QA/QI Review of Service Delivery: Results by CBO/Site

Contents Skills


summarized during the close out meeting and the corrective action plans were discussed with both laboratory team. Lab Accreditation certificates are currently in process for SWING Pattaya and Sisters; additionally, Mplus Chiang Mai received their accreditation certification in August based on an audit conducted in FY18 Q3. C. Treatment (provision of ART, linkage to ART and/or progress on ART uptake)

During this reporting period, LINKAGES IPs supported ART initiation for 1,486 HIV-positive clients,12 including 717 MSM; 21 MSW; 64 TG; 13 TGSW; 10 PWID; and 14 FSW, as well as 382 non-KP males and 265 non-KP females. This represents a 41% increase in new ART clients compared with the previous quarter. In total, LINKAGES reported 4,139 HIV-positive clients initiated on ART in FY18, which represents a 115% increase in treatment initiation compared to FY17. Improvements in treatment initiation in FY18 are primarily attributable to the introduction of same-day ART at some sites (see below) as well as to improved referral relationships and data sharing with a network of healthcare facilities across LINKAGES’ nine provinces. In total, LINKAGES over the course of FY18 has provided technical assistance on HTC and HIV care, support and treatment (CST) to 133 health care facilities in nine provinces; as of FY19 Q4, 107 of these hospitals had agreed to share service delivery data with LINKAGES.13 Reporting of ART initiation figures from hospitals

12 313 DSD; 1,173 TA 13 99 healthcare facilities reported TX_NEW data to LINKAGES in FY18 Q3 – in Q4 this increased to 107 facilities despite the loss of one hospital which previously shared data, but which has since changed ownership and new management did not agree to continue sharing information. LINKAGES additionally provided technical assistance on ART for Bangkok-area hospitals in FY18 Q4; however, after receiving that assistance the hospitals declined to share their data.

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Figure 9. LINKAGES Thailand Aggregate Treatment Uptake by Quarter, FY15 Q2-FY18 Q4

Positive TX_NEW % ART Initiation


receiving PEPFAR-supported technical assistance is critical to achieving LINKAGES service delivery targets, because under the Thai government’s social benefits programs most HIV-positive clients initiate free ART services through these healthcare facilities. These healthcare facilities accounted for 61% of TX_NEW reporting for FY18 Q4 and 44% of all TX_NEW reporting for FY18 in total. Despite these achievements, ART treatment initiation under the LINKAGES project in FY18 still accounts for only 48% of the total TX_NEW target. This underperformance reflects lower-than-anticipated HIV case-finding rates across all partners and sites; linkage to ART services among clients who do test positive has improved across the life of the project. During this reporting period, the “rate” of treatment initiation expressed as a ratio of clients initiating ART over clients tested positive increased from 104% to 124%. This figure must however be interpreted with care as clients initiating ART in FY18 Q4 are a combination of newly diagnosed clients, clients diagnosed during previous reporting periods, and those who were diagnosed outside the LINKAGES project (including “non-KP clients”) but who received ART services through hospitals benefiting from PEPFAR-supported technical assistance. A more accurate estimation of life-of-project treatment uptake, measured among a longitudinally tracked cohort of 6,080 HIV-positive clients registered in the LINKAGES Thailand eCascade system, would be 82%, though this calculation does not account for clients who may have accessed treatment in healthcare facilities not collaborating with LINKAGES.

During this quarter, rates of successful referrals for ART initiation by implementing partners were highest in Chiang Mai, and the Tangerine Clinic also demonstrated high linkage to treatment. ART treatment initiation has improved markedly in Bangkok with the initiation of same-day ART (see below) at the TRC Anonymous Clinic. ART uptake at RSAT and SWING in Bangkok, however, have not been significantly impacted by availability of SDART at the Anonymous Clinic. Clients have not been enthusiastic about accessing treatment services at TRC, because they will have to be transitioned to a different provider for long-term treatment support. However, BMA has recently announced a willingness to introduce SDART on a trial basis at several their clinics – because BMA clinics can offer long-term ART support under the national social benefits scheme, it is hoped that this new option will strengthen treatment uptake for other LINKAGES clients in Bangkok.

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Figure 10. LINKAGES Thailand Treatment Cascade by Partner, FY18 Q4

Positive TX_NEW % ART Initiation


Table 5. Median CD4 at Baseline of Implementing Partners (n = 862) and Health Care Facilities (n = 1701), FY 2018

IPs Median CD4 Min Max Provinces Median CD4 Min Max

Mplus CR 568 43 1,469 Chiang Rai 144 4 1,121

Caremat 435 234 617

Mplus CM 428 30 1,098 Chiang Mai 209 2 3,501

RSAT-SPK 424 12 1,354 Samut Prakan 288 3 1,224

RSAT-CBI 407 234 677 Chonburi 319 2 1,372

Swing BKK 393 26 960

Swing PATT 367 48 649

RSAT-NBI 366 5 1,020 Nonthaburi N/A N/A N/A

RSAT-HDY 357 2 1,368 Songkhla 225 2 852

RSAT-BKK 339 5 1,632

RSAT-UBI 309 33 904 Ubon Ratchathani 168 2 970

RSAT-PTI 292 103 609 Patthumthani 250 1 758

Sisters 211 90 241 Note: 1. HCFs data in FY 2018 2. IPs data FY15 Q2-FY18 Q4 retrieved from eCascade on September 30, 2018

In addition to improvements in ART treatment initiation, LINKAGES-supported KPLHS sites in FY18 have also seen higher median CD4 at baseline: median CD4 at baseline for LINKAGES IPs ranged from 211-560 cells/mm3 (n = 862) compared with median CD4 at baseline for healthcare facilities, which ranged from 144-319 cells/mm3 (n = 1701). At KPLHS sites, 82% of clients had CD4 at baseline > 200 cells/ml3, which only 59% clients in health care facilities had CD4 > 200 cells/mm3. This would tend to support the argument that community-based testing sites are indeed identifying HIV-positive individuals earlier in their course of infection, which has important implication for treatment outcomes as well as for the prevention of onward HIV transmission. When examined by partner, median CD4 at baseline was highest in Chiang Rai, and lowest at Sisters, which adds to the growing evidence for the importance of ensuring continuity of care for TGSW in Pattaya. Table 6. Median Days Knowing HIV Serostatus to ART Initiation of Implementing Partners (n = 862) and Health Care Facilities (n = 1701), FY 2018

IPs Median Days Min Max HCFs Median Days Min Max

Mplus CM 10 1 436 Chiang Mai 15 1 137

SWING BKK 14 1 765

RSAT-BKK 21 1 784

RSAT-SPK 21 2 32 Samut Prakan 8 1 103

Mplus CR 22 1 1,907 Chiang Rai 22 1 384

RSAT-HDY 25 3 266 Songkhla 20 1 233

RSAT-NBI 27 6 56 Nonthaburi N/A N/A N/A

RSAT-PTI 27 2 374 Patthumthani 22 1 194

RSAT-UBI 28 1 197 Ubon Ratchathani 22 1 241

SISTERS 35 3 292

RSAT-CBI 35 7 212 Chonburi 18 1 385

SWING PATT 47 4 988

Note: 1. HCFs data in FY 2018 2. IPs data FY15 Q2-FY18 Q4 retrieved from eCascade on September 30, 2018

Finally, the median time to ART initiation for newly diagnosed clients at LINKAGES sites in FY18 ranged from 10 to 47 days. This represents a notable reduction for some sites, including Mplus Chiang Mai (30 days in 2017 reduced to 10 days in 2018) and SWING Bangkok (26 days in 2017 to 14 days in 2018). Median times to ART initiation remain unacceptably long in other sites, including Sisters (35 days), RSAT Chonburi (35 days), and SWING Pattaya (47 days). Time to treatment initiation also generally compares poorly with healthcare facilities; however, in most sites KPLHS clients must first be transferred to a healthcare facility before they can begin ART, which accounts for at least some of the discrepancy. Lengthy treatment initiation times in Pattaya specifically are


also partially the result of access issues at the main ART service providers – this is a known issue and speaks to the importance of offering multiple options for ART service delivery and for rolling out SDART service models more widely. Update on Same-Day ART Despite the improvements described above, timely linkage to ART among HIV-positive MSM and TGW remains a critical challenge. To help close the persistent treatment gap, TRCARC launched SDART in July 2017. During this reporting period, a total of 548 clients (366 MSM and 30 TGW) were diagnosed HIV positive at the TRC Anonymous Clinic: 405 individuals agreed to SDART initiation and 364 cases met clinical eligibility criteria14 and successfully initiated ART. For newly diagnosed patients, the median (IQR) CD4 count was 297 (220.5-434) cells/mm3 while re-engaged patients had a median (IQR) CD4 count of 269 (180-420) cells/mm3. Median (IQR) time from care to ART initiation was 0 (0-0) days. As noted above, TRCARC has also worked with SWING and RSAT in Bangkok to offer a SDART option; however, since FY18 Q2 only 19% of RSAT clients (n=42) and 31% of SWING clients (n=26) initiated ART under this protocol. LINKAGES and TRCARC have provided considerable technical assistance to expand the SDART model further. Since August 2018, 13 hospitals in Chiang Rai, Chiang Mai, Ubon Ratchathani, Chonburi, and Songkhla have begun implementing SDART and collecting data. However, only 5 hospitals15 have completed IRB approvals which allow their data to be collected and analyzed by TRCARC – those data will be discussed in the FY19 Q1 report. We also continue to work with partners and local hospitals to generate support for SDART and to overcome logistic and technical barriers. A critical bottleneck has been that, despite the national Test-and-Start policy, hospitals still require baseline CD4 results before initiating ART, but limited access to CD4 machines and restricted CD4 testing schedules have meant substantial treatment delays in some sites. In Chiang Mai, Mplus and Caremat can now accompany clients with CD4 and other laboratory test results to SDART in at Nakornping, Hangdong, Sarapee, and Chiang Mai hospitals as well as Chiang Rai Prachanuchroh Hospital. LINKAGES and TRCARC will provide technical support to expand and replicate this referral system and SDART initiatives to a wider network of hospitals in Ubon Ratchathani. When the RSAT laboratory receives its Laboratory Accreditation, hospitals have indicated they will accept CD4 test results from RSAT Ubon Ratchathani. However, one outstanding factor is that not all hospitals offer HIV or ART clinic services every day, and cases that test positive at IPs on certain days may still need to wait 72 hours or more before they can start ART.

D. Retention and Care in Support Services As of the end of FY18 Q4, there were 24,195 HIV-positive clients16 actively receiving ART services with LINKAGES support. These include 4,047 KP clients17 (17%), 10,329 non-KP men and 9,819 non-KP women (83% non-KP clients, collectively). This represents 239% of the annual TX_CURR target of 10,144 persons.

14 The majority of those who did not meet clinical eligibility criteria had history and/or clinical findings which made the doctors suspect tuberculosis (TB) or other serious opportunistic infections. 15 Chiang Mai Hospital, Sarapee Hospital, Sanpatong Hospital, Hangdong Hospital and Hat Yai Hospital 16 329 DSD; 23,866 TA 17 3,380 MSM; 180 MSW; 296 TG; 43 TGSW; 79 FSW and 69 PWID


Performance on the TX_CURR target is largely because LINKAGES has worked over the course of FY18 to provide technical assistance and successfully build relationships with key ART service providers across our nine provinces. This also explains the high proportion of “non-KP” TX_CURR clients. Non-LINKAGES healthcare facilities are much less likely to ask or record information on the KP status of their clients. Nonetheless these individuals represent a priority population of HIV-positive people who have benefited from PEPFAR-supported improvements to service delivery to increase the quality of their healthcare and decrease the risk of their transmitting infection onward – the decision to include these clients in reporting was discussed with, and approved by, USAID. Table 7. LINKAGES Thailand Retention on ART Performance, FY18

TX_RET 12 Months (n=877) TX_RET 24 Months (n=698) TX_RET 36 Months (n=365)

No. (%) No. (%) No. (%)

Alive on ART 638 (73%) 398 (57%) 236 (65%)

Lost to Follow-up 232 (26%) 295 (42%) 122 (33%)

Died 3 (<1%) 2 (<1%) 3 (1%)

Stopped ART 4 (<1%) 3 (<1%) 4 (1%)

LINKAGES partners have made significant achievements on the TX_CURR target; however, we acknowledge that this indicator does not track longitudinal retention in treatment services. Based on program data at the end of FY18, at 12 months after initiating ART, 73% of IPs’ clients were still alive on treatment, 26% were lost to follow-up (LTFU), 0.3% had died, and 0.5% had stopped ART. Across the last 36 months, proportion of ART patients who have died or stopped treatment has been at or less than 1%; however, loss to follow-up has increased over time as clients who are stable on ART and capable of managing side effects have little reason to engage on an ongoing basis with LINKAGES implementing partners. Another reason for lower-than-optimal rates of follow up is the lack of appropriate systems to track clients and alert partners to the need for follow-up – LINKAGES has worked with partners to address this issue and protocols/systems developed by Caremat and RSAT are being introduced to additional sites. Finally, Sisters in particular underwent a restructuring in FY18 Q4 during which two care and support staff were let go because of questionable skills – during this transition period, some clients were not followed up appropriately. It should also be noted that the TX_RET numbers cited above are calculated based on a denominator of clients being actively tracked by KPLHS partners. Roughly half of all HIV-positive clients who initiated treatment in FY17 did so through other service providers18 that do not provide active follow-up services over time. As the importance of hospital ART service providers has grown over the course of FY18, and as LINKAGES partners shift began a shift to domestic funding in FY19, we will work with KPLHS IPs, provincial health offices and healthcare facilities to integrate community-based follow-up services into hospital service delivery systems, so that LINKAGES partners can help re-engage with a wider array of LTFU clients and help reengage them in services.

18 TRC Anonymous Clinic, Pulse Clinic, Adam’s Love, hospitals within LINKAGES network of service delivery partners


During this reporting period, 17,372 clients received a viral load test, and 98% (16,949/17,372) achieved a suppressed viral load, defined as VL < 1000 copies/ml, which means these clients adhere well to their ART. As can be seen above, VL suppression was high across all KPLHS partners, though Sisters was noticeably lower than other partners. No VL data are reported for the TRC Anonymous Clinic because Thai MoPH guidelines call for VL testing following 6 months of ART, and the Anonymous Clinic transitions ART clients to a long-term treatment provider before that time. High VL suppression rates notwithstanding, follow-up for viral load testing needs to be strengthened in FY19, since 74% of hospital-based ART clients received a VL test result, compared to only 44% of ART patients being monitored by KPLHS staff under DSD models. Anecdotally, clients have less knowledge and, therefore, less concern about monitoring their viral load, and this topic is often not clearly addressed as part of clinical consultation. Plans to increase VL testing in FY19 include assigning CST staff to follow-up and report on VL test results on a quarterly basis rather than annually, and 2) modifying existing hospital consent forms to allow healthcare facilities to share health information with CST staff to allow more proactive follow-up. This modification to existing consent procedures was recommended by Hat Yai Hospital and had already been implemented at all RSAT sites. Capacity Building for Care, Support and Treatment LINKAGES staff conducted site visits to both existing and new IPS during Q4 to examine clinic management, clinic flow, care & support practices, and treatment referral systems to ensure adherence to established KPLHS standards of practice. Sixty-four KPLHS counselors and CST staff received coaching visits to ensure the quality of services meets the counseling and CST standard operating procedures (further detailed in Narrative II, Subsection B, above). LINKAGES teams also reviewed clinic procedures and CST follow-up activities, including support for ART initiation, adherence, and especially, viral load testing. In addition, LINKAGES supported fifty clinic staff from all IPs to attend a three-day workshop, conducted by the Thailand National AIDS Council, to discuss new information presented at the 2018 International AIDS Conference.

454

91 86

135

19 30

449

90 83

134

17 29

99% 99% 97% 99%

89%97%

0%

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60%

80%

100%

120%

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RSAT SWING Mplus Caremat Sisters TRC -Tangerine

Ind

ivid

ual

s Se

rved

Figure 11. LINKAGES Thailand Viral Load Suppression by Partner in FY18

Total VL VL < 1,000 % VL Suppressed


Site visits in Q4 revealed common issues across all partners – difficulty providing high-quality case management services due to high staff turnover, insufficient client record systems, and CST staff unfamiliar with how to use eCascade as a client retention tracking tool. Additionally, while CST staff followed up with regards to ART initiation and retention, insufficient attention was paid to CD4 and/or VL monitoring or syphilis testing and treatment. In response, 46 staff members (including care and support workers and M&E staff) from RSAT and SWING attended a workshop to prepare CST strategic plans for FY19 – outcomes of this workshop included better understanding of key treatment and retention indicators, the introduction of data-driven practices for monitoring and improving CST outcomes, and the preparation of site-specific FY19 CST plans. At their request, LINKAGES will conduct a second workshop for Mplus Chiang Mai, Chiang Rai and Caremat in November 2018. A bright spot in strengthening of CST services is that Caremat has been working over the course of FY18 to develop a digital application to help them better track and link positive clients to treatment. While this application serves several purposes, starting in Q3, Caremat introduced a Care and Support function for recording, tracking and following up positive clients, alerting CST officers when they have a new client, issuing reminders when a client needs to be followed up for referral etc. This application serves some of the same functions as the LINKAGES eCascade tool, but also incorporates clinical information and functions that were previously housed under TRCARC’s iClinic program. A dashboard helps the Clinic Manager to monitor all clients in real time and prioritize clients who need to be followed up. Caremat believes that the application contributed to their overall performance in FY18, include an 81% linkage to care rate for HIV-positive clients. In the future, Caremat will use the dashboard for monitoring and evaluation, reporting and presenting purposes and as they transition to a private, fee-supported clinic they will use this tool to help calculate service and treatment costs, produce bills and manage financial recording. During this quarter, LINKAGES also provided onsite technical assistance at RSAT Chonburi, SWING Bangkok, and SWING Pattaya in response to SIMS findings to strengthen clinical services from registration, to counselling, testing, and to care and support. FHI 360 staff also delivered a one-day TB integrated HIV training for Mplus Chiang Rai with other key health care facility stakeholders in the province. The outcomes of this training were that clinic staff can conduct initial assessment among their clients, consider referral of clients with TB symptoms for further diagnosis and treatment and implement appropriate infection control measures in the facility In FY19, this type of workshop will be implemented to all RSAT expansion sites, as well as for existing sites that need the TB refresher course for their new staff. LINKAGES, TRCARC and the USAID Community Partnership Project also continued working to coordinate start-up activities for the RSAT Chonburi Community Health Center, which will open on December 1, 2018. LINKAGES also worked with the Chonburi PHO and RSAT to set up a local QA/QI team to provide quality assessment of KPLHS services and secured a verbal agreement that Chonburi Hospital will provide QA services for RSAT Chonburi.

E. Strategic information and monitoring and evaluation

In Quarter 4, LINKAGES completed 10 Routine Data Quality Assurance (RDQA) visits to 10 partners, including RSAT Nonthaburi, RSAT Ubonratchathani, RSAT Songkhla, Caremat, Mplus Chiang Mai, RSAT Pathumthani, Mplus Chiang Rai, Sisters, SWING Pattaya, and RSAT Samut Prakarn, to ensure data accuracy and quality. As a result, LINKAGES was able to identify gaps and discrepancies


between reported data, source documents, and databases, and work in collaboration with partners to address M&E systems improvements. LINKAGES extended the RDQA visits to incorporate refresh training sessions on interpreting and using eCascade dashboards and data entry into them in order to improve staff understanding. Other technical support on data management and flow, data collection and recording, and clarification of indicator definitions were also provided during the visits. During the quarter, LINKAGES met with Caremat to better understand its alternative database system and to determine its potential use with other agencies, given its current advantages in capturing comprehensive HIV cascade services. However, from our current assessment of the application, more functions and enhancements such as barcode scanning and form printing need to be added before it can totally replace existing databases and data collection tools. The quarter saw continued strong usage of the eCascade system, both the mobile data collection application as well as usage of the data hub/dashboards. The number of unique individuals registered, as deduplicated by Thai UIC code, rose from 94,000 to 110,740, a rise of almost 18 percent in the single quarter. During the quarter, LINKAGES completed the next version (4.0) of the dashboard/data hub which added monitoring and evaluation components. The new functions automatically calculate PEPFAR indicators for any timeframe and any partner, and these are disaggregated by client characteristics required by MER guidance. When the current testing of these automated calculations is complete, this function will address the requirements for increasing frequency of indicator calculations reporting. LINKAGES continues to liaise with Thailand government agencies to contribute our data and link our data sets to improve the government’s understanding of the epidemic and its strategic response. During the quarter, we continued to connect with the MOPH teams specifying and constructing the new RTCM+ application, which is proceeding gradually due to repeated adjustments of the functionality specified by the system’s developer. LINKAGES is also in ongoing discussion with teams from Bangkok Metropolitan Administration and TUC, which, during the period of RTCM delay, have requested that eCascade data join the data sources compiled by that team to improve its calculations of KP testing and treatment, which will also contribute to the revised AIDS Zero Portal (AZP). Online-to-offline approach. LINKAGES Thailand’s approach to tracing online-to-offline success continues to grow and develop:

• Our program has continued to supply its “promotional token URL” approach, as well as direct copies of its software application, for use by other country programs, including India, Nepal, and Kenya, as well as others like Indonesia and Vietnam that applied our methods in their own applications.

• After discussion with partners, the Thailand reservation application completed its name change, and is now titled TestMeNow.net. However, note that a key aspect of our system’s design is that the reservation tool effectively changes its branding to match that of any participating promotional partner, which in many cases means that our system’s own name is not a focus for users.

• Discussions with Bangkok Metropolitan Administration (BMA) resulted in a request by BMA to join the TestMeNow reservation system, to serve as a part of its new outreach campaign to school-age youth. The first 3 BMA clinics are now receiving reservations, with more expected to join later.


• The BMA partnership, and the potential for similar future participation, has required LINKAGES to procure a set of new functions for the O2O reservation tool. This is because these new partners do not participate in eCascade, and therefore this type of clinic must supply HIV test results directly into the system in order to obtain case finding data from them.

• This new development procurement, at the same time, is also integrating a package of other functions that were implemented by other countries that were given copies of Thailand’s application, such as India and Nepal. These features include an integrated risk assessment, SMS-sending, and other new functions.

• As of the writing of this report, Thailand clients have created 3662 reservations, 1884 of which saw the client successfully arrive for his reservation.

F. Innovative HIV prevention research for more effective approaches for HIV epidemic

control

The following are updates from the implementation science and research projects currently supported by LINKAGES: Community-led Test and Treat cohort study. The study has been following up the HIV-negative cases until the end of June 2018 while will continue following up the HIV-positive cases through the end of December 2018. As a result, a total of 166 HIV-positive cases were re-scheduled for the end-line visit. During this reporting period, of 159 HIV-positive who reached their scheduled visits within this month, 16 cases presented at CBOs with a retention rate of 10%.

Princess PrEP. This PrEP scale-up project (whose achievement figures have been reported elsewhere in this report) is the country’s first and largest key population-led PrEP program and contains an implementation science component to measure client characteristics, retention, and other data. The project achieved remarkable progress in enrolling 344 PrEP users (277 MSM, 61 TGW and 3 FSW and 3 in serodiscordant relationship). Meanwhile, the program achieved the follow-up rate of 42%. Of 3,105 MSM and TGW who reached their schedule visits within this month, 1,300 PrEP users came for follow-up. The follow-up rate is showed in the figure below by month. To improve and facilitate the retention in PrEP care, as well as adherence, TRCARC and FHI 360 will accelerate an action plan to address this challenge including the development of mobile-health interventions and enhanced communication materials.


On-demand PrEP service provision is currently available at RSAT BKK, SWING BKK and Mplus. To date, there were 38 on-demand PrEP users (RSAT BKK=6, Mplus = 14 and SWING BKK = 18). These included those who switched the regimen from daily PrEP (RSAT BKK=4, Mplus=1 and SWING BKK=13)

STI POC study. The research on the feasibility study to integrate the point-of-care (POC) for sexually transmitted infections (STIs) and HIV viral load into community-based clinics for MSM and TGW in Thailand will be implemented in January 2019. During this quarter, POC machines were purchased to prepare for the study. C_FREE. During this reporting period, LINKAGES supported Dreamlopments in engaging with The Raks Thai Foundation and The Global Fund in selecting a new study drug, including price negotiation with the drug company. The drug selected to replace Panovir, the drug which the Thai FDA had rejected the import request for, is Myhep All, a generic combination of sofosbuvir/velpatasvir, made by Mylan (India). Dreamlopments engaged with the drug company and Thai FDA for process to request to import Myhep All for the C-FREE study and prepared the new dossier to apply for the importation permit for Myhep All. The application will be filed in December 2018 per Thai FDA’s advice and recommendations, and the revised protocol with the new selected drug will be submitted for IRB expedited review and approval.

In collaboration with FHI 360, Dreamlopments finalized laboratory quality standards, including, work flows and procedures, safety reports and monitoring plan. In addition, Dreamlopments sent five study nurses to attend Thai AIDS Society’s 17th HIV/AIDS workshop to update their essential HIV and HCV knowledge and engaged with participating community organizations by sending the study nurses to their sites to observe and provide preliminary preparation for C-FREE study protocol. Enrolment of participants can begin once the C-FREE protocol receives approval from all three IRBs and study drug is imported to Thailand.

STANDUP-TEEN. Implementation research on adolescent PrEP made considerable progress in both two major components on 1) HIV self-testing and PrEP and 2) development of a targeted strategy to promote adherence to PrEP among sexually active adolescent MSM and TGW (aged 15-19 years) . Regarding the development of a research protocol to determine the effect of HIV self- testing on the uptake of and retention in PrEP service among older adolescent MSM and TGW (STANDUP-TEEN), the protocol was submitted to Chulalongkorn University IRB in July 2018 and the response to IRB comments were provided in August 2018. It is expected that the protocol approval will take place in October 2018. The protocol of the qualitative study to assess the feasibility and perception of HIVST among adolescent MSM and TGW who are on PrEP was developed and submitted to Mahidol University, with the expected starting date of the study in November 2018. iFACT. The country’s first clinical research to determine the interaction between the use of feminizing hormone therapy and antiretroviral agents concomitantly among TGW ( iFACT) , aimed at facilitating the linkage to PrEP and ART among TGW, has progressed considerably in terms of enrollment of research participants. Of the total target of 40 participants, 20 HIV-negative and 16 HIV-positive TGW were enrolled, with the enrollment rate at 90%. A draft manuscript for JIAS was developed during the quarter and will be finalized for submission during the first quarter of FY 19. A protocol amendment version to extend the enrolment period to December 31, 2018 was approved by the Chulalongkorn IRB on August 2, 2018.


G. Knowledge Management and Regional/Global Technical Leadership The following activities, publications, and events were launched during this final quarter of 2018:

• A journal article on the Princess PrEP program was published in the journal Sexual Health by LINKAGES and USAID authors: Phanuphak, Nittaya, Thanthip Sungsing, Jureeporn Jantarapakde, Supabhorn Pengnonyang, Deondara Trachunthong, Pravit Mingkwanrungruang, Waraporn Sirisakyot et al. "Princess PrEP program: the first key population-led model to deliver pre-exposure prophylaxis to key populations by key populations in Thailand." Sexual health (2018).

• Launched at the beginning of Q4, the Differentiated HIV Service Delivery report will be further distributed by the International AIDS Society to showcase the components of a differential approach for HIV service delivery in Thailand.

• Manuscripts on 1) discordance between self-perceived and actual risk of HIV infection among MSM and transgender women in Thailand 2) the same-day ART hub at the Thai Red Cross anonymous testing center and 3) preliminary results from the iFACT study were in preparation and review during Quarter 4 for submission to journals during the first quarter of 2019.

• The following papers were presented by LINKAGES and USAID authors at the IAS conference in Amsterdam July 23-27, 2018:

Type of session

Topic

Oral Abstract Session

Key population-led health services (KP-LHS) critical to PrEP introduction among MSM and TG in Thailand

Poster Exhibition

Same-Same but Different: Expanding HIV Testing and PrEP to New MSM Subpopulations through the Private-Sector Pulse Clinic in Thailand

Poster Exhibition

Enhancing HIV testing coverage through peer-driven recruitment models among transgender women in Pattaya

Poster Exhibition

Barriers and Facilitating Factors That Hinder the Antiretroviral Therapy Initiation Among Key Populations Under LINKAGES-Thailand Project

Poster Exhibition

Sustainable laboratories for key population-led HIV services in Thailand: mentoring and twinning lead to government accreditation and financing

Poster Discussion

Session

Increased domestic financing of key population-led health services (KP-LHS): Lessons from Thailand's transition planning and response

Poster Exhibition

Increased HIV case finding rate among MSM and TG in Laos from a community-led HIV oral fluids screening project


Same-Day ART Initiation in HIV/STI Testing Center in Bangkok, Thailand: Initial Results From an Implementation Research

Poster Exhibition

Retention and adherence to PrEP among MSM and transgender women in Thailand's 'Princess PrEP program': the Key Population-Led PrEP Program

Poster Exhibition

High acceptance and satisfaction of differentiated antiretroviral therapy service delivery among men who have sex with men, transgender women and healthcare workers in Thailand


During Q4, preparations for upcoming events were in process. This includes the USAID TICA Connect, World AIDS Day event in collaboration with TRCARC, and Oral Fluid-based Testing Advocacy event, all of which are scheduled to take place in FY quarter 4.

H. Costing and financing of KP-LHS During Quarter 4, the HITAP study team received an IRB approval from the Institute for Development of Human Research Protection (IHRP) to proceed with data collection activities at selected sites. The team initiated the study by providing data collection training to participating partners. Data collection then commenced at all sites under the 3 models to be examined in the study: 1) Model 1 consists of RRTTPR services provided at hospital-based settings 2) Model 2 is RRTTPR services organized such that reach and recruit services are provided by community-based organizations who refer the rest of the cascade to the hospital-based settings, and 3) Model 3 consists of RRTTPR services provided at the community-based organization. The selected sites/organizations are listed as follow: Model 1: 1) Bangkok Public Health Center 28 (BMA) 2) Roi-Et Hospital

Model 2: 1) Ozone Tak, Mae Sot 2) Rak Thai, Samut Prakan 3) Planned Parenthood Association of Thailand (PPAT), Kohn Kaen 4) MFriend, Udontani 5) MReach, Kohn Kaen

Model 3: 1) Rainbow Sky Association of Thailand (RSAT) Bangkok 2) Rainbow Sky Association of Thailand (RSAT) Songkla, Hat Yai 3) Service Worker IN Group Foundation (SWING) Bangkok 4) Service Worker IN Group Foundation (SWING) Chonburi, Pattaya 5) SISTERS Foundation Chonburi, Pattaya 6) Mplus Chiang Mai

Preliminary analysis of the study is expected to be held in FY19, Quarter 1.

NHSO collaboration. Reimbursements from NHSO to LINKAGES partners are highlighted below, both first payments and committed contracts for FY 2018. These are significantly higher than in 2017, indicating increasing investments by NHSO in KPLHS.

Poster Exhibition

Low prevalence and incidence of hepatitis C among men who have sex with men and transgender women in a key population-led Test and Treat cohort in Thailand

Poster Exhibition

Service Workers in Group (SWING): Addressing multi-level HIV risks associated with male sex workers through Key Population-Led comprehensive approach in Bangkok and Pattaya

Poster Exhibition

Towards increasing domestic financing for civil society organizations in the HIV response: Accreditation of HIV clinical services provided by key populations


Integrated gender affirmative hormone treatment services improve access to and retention in HIV testing, syphilis testing, and pre-exposure prophylaxis (PrEP) service uptake among transgender women in Thailand

Poster Exhibition

Key population-led health services are increasing access to HIV services among transgender women sex workers in Pattaya, Thailand

Poster Discussion

Session

Online Supervised HIV Self-Testing identified high HIV yield among Thai men who have sex with men and transgender women

Poster Exhibition

GAYOK Bangkok: Increasing PrEP awareness among young gay men in Bangkok with a scripted web series


Figure 13: NHSO Reimbursement for 2018

I. Capacity building and technical assistance, including collaboration with Global Fund partners and support to their program implementation

Capacity building and technical assistance provided in FY18-Q4 Date Activity/details Total no. of

participants Male Female Participants

11 July 2018

Crowdsourcing Recognition Day

31 16 15 • 1 staff each from RSAT BKK, APCOM, Tiffany, SSRUIT, Thammasat University, Commetive Company, Blue D and Seven Republic

• 2 staff from Mplus Chiang Mai, USAID and FADE

• 3 staff from SSRUIC, Chiangmai Team, One five film, and PT

• 5 staff from FHI360

24 August 2018

TB/ HIV Workshop for Mplus Chiang Rai

22 13 9 • 3 staff from FHI360

• 7 staff from Health Facilities

• 12 staff from Mplus Chiang Rai

27 August 2018

The target setting meeting with 13 PIF key provinces in collaboration with BATS and TUC

35 18 17 • 1 staff each from Volunteer, RSAT Pathum Thani, RSAT Samut Prakarn, RSAT Songkhla, Caremat, Mplus Chiang Mai and Mplus Chiang Rai

• 3 staff from SWING BKK

• 4 staff from Health Facilities

• 10 staff from RSAT BKK

• 11 staff from FHI360

17-31 August 2018

Provincial Data Coordinator Training

6 4 2 • 6 Health care Coordinators from Songkhla, Chonburi, Chiang Rai, Ubon, Samut Prakarn and Pathumthani

12 September 2018

LINKAGES Thailand Positive Networking Meeting

16 16 0 • 1 staff each from SWING Pattaya, Nextzy and FHI360

• 2 staff from TRCARC

• 11 Volunteers


In total, 110 individuals were trained during this reporting period, 67 males, 43 females.

Key events, TA and capacity-building activities organized during this quarter included the following:

• Crowdsourcing Recognition Day – LINKAGES sponsored a session whereby participants and winners of the PrEP Crowdsourcing contest were brought together and recognized for their contributions.

• TB/ HIV Workshop for Mplus Chiang Rai - This workshop provided training for outreach workers, clinic staff (registration, Med-tech staff, counselors, CST, and management personnel) on TB knowledge, TB screening, TB prevention (infection control, arranging fast-track service), and developing a TB referral system with health care facilities nearby or based on clients’ health rights.

• The target setting meeting with 13 PIF key provinces in collaboration with BATS and TUC – LINKAGES participated in a meeting where target setting between NHSO, USAID-supported programs (LINKAGES, UCP), and the CDC were discussed and preliminarily finalized.

• Provincial Data Coordinator Training – This training supported provincial data coordinators embedded in Chiang Rai, Ubon, Chonburi, Songkla, Samut prakarn, and Pathumthani provinces to increase their skills in preparing and entering HTC & treatment data to excel sheets and following up with quarterly data submitted to LINKAGES.

III. Quarterly Financial Summary

Funding Obligation

Expenditures this Quarter

Total Expenditures

Obligation Remaining

Field Support Thailand

$ 12,946,092 $ 565,188 $ 12,580,445 $ 365,647

Field Support Thailand Test and Treat

$ 700,000 $ - $ 700,000 $ -

Field Support Thailand (OHA)

$ 1,500,000 $ 413,617 $ 1,203,461 $ 296,539

Field Support Thailand (Gamechanger)

$ 4,949,000 $ (1,832,000) $ 4,949,000 $ -

KPIS - Thailand $ 590,000 $ 47,993 $ 229,194 $ 360,806


Table 5. Program-level monitoring results

Indicators (Type: PEPFAR vs. custom)

PEPFAR Type of support

Achievements/Targets

Q4 Year to Date

Annual Target

% target achieved

KP_PREV: Number of KPs reached with individual and/or small group level HIV preventive interventions that are based on evidence and/or meet the minimum standards required (PEPFAR)

DSD 21,825 65,676 110,826 59%

HTS_TST: Number of KPs who received HIV Testing and Counseling (HTC) services for HIV and received their test results (PEPFAR)

DSD 14,157 50,362

TA_SDI 13,411 20,455

Total 27,568 70,817 77,578 91%

HTS_TST_POS: Number of KPs who received HIV Testing and Counseling (HTC) services for HIV and received their test results as positive (PEPFAR)

DSD 723 3,033

TA_SDI 471 1,347

Total 1,194 4,380 8,626 51%

PrEP_NEW: Number of KPs who received antiretroviral pre-exposure prophylaxis to prevent HIV infection (PEPFAR)

DSD 548 2,313

TA_SDI 0 0

Total 548 2,313 1,680 138%

TX_NEW: Number of KPs newly enrolled on antiretroviral therapy (ART) (PEPFAR)

DSD 313 1,279

TA_SDI 1,173 2,860

Total 1,486 4,139 8,626 48%

TX_CURR: Number of KPs currently receiving antiretroviral therapy (ART) (PEPFAR)

DSD 329 N/A

TA_SDI 23,866 N/A

Total 24,195 N/A 10,144 239%


Appendix 1: Performance under eCascade During FY18 Q4, there were a total of 24,356 unique clients registered in eCascade (this figure is not equivalent to KP_PREV, as this number does not distinguish between wholly new clients and those reached in previous quarters of FY18). Of these clients, 6,107 were clinic walk-ins, while 18,249 were outreach clients, of whom 16,479 were referred for HIV testing. 13,127 clients received an HIV test – 43.5% of all clients reached. Testing uptake was higher among walk-in clients (97.69%) as compared to outreach clients (39.24% of all outreach clients referred to testing). It is notable that a referral rate of 39.24%, while lower than previously reported referral rates for outreach. The overall case-finding rate among all clients who received an HIV test was 4.6%. When client recruitment is broken down more granularly, CBSs reached 15,689 clients and successfully referred 5,663 (35.90%) to testing services with a 3.2% case-finding rate. In comparison, PMs recruited 1,272 clients and tested 1,171 (92%) with a 4.5% case-finding rate. Testing yield among walk-ins was 5.2%. As seen in previous periods, the CHC-based social network strategy delivered relatively few new clients in this period (87 recruited, 84 tested) but with significantly higher case finding (14.3%). Online outreach accounted for 1,617 new clients and, consistent with findings from the O2O system, only 38% of those received an HIV test; however, the case-finding rate was 9.4%. Innovative strategies piloted under LINKAGES Thailand (peer mobilization, SNS, online-based outreach and recruitment) continue to demonstrate significant success in terms of higher rates of testing uptake and yield (these models combined account for 36.37% of all case-finding in Q4). However, they account for only 11.99% of overall project coverage. Regarding peer mobilizers specifically, there were an almost identical number of active PMs in Q4 as compared with Q3 (113 vs. 88) and in Q4 PMs were much more active – with an average of 11 new clients per active PM in Q4 versus 8 new clients per PM in Q3. The result of this is that PMs recruited significantly more clients in Q4 compared to Q3 (1,063 versus 1,276) which resulted in significantly larger testing clients (1,171 versus 692). The implementing partners who utilized the PM approach the most in terms of absolute number of clients recruited in FY18 Q3 were Mplus Chiang Mai (n=349), Mplus Chiang Rai (n=290), Caremat (n=239), SWING BKK (n=200) and the rest was lower than a hundred clients. However, when viewed as a proportion of overall contribution to outreach recruitment, the biggest users of PMs this quarter were Caremat (47% of all outreach recruitment was by PMs), Mplus Chiang Rai (16%) and Mplus Chiang Mai (15%). PMs only accounted for 13% of outreach recruitment at RSAT Chonburi. Meanwhile, PMs associated with SWING BKK only recruited 200 clients in Q4, out of a total of 3,032 outreach clients (7%). Case-finding rates among PM clients were highest at RSAT Hat Yai (40%), RSAT Ubon Ratchathani (25%), SWING Bangkok (11.6%), and RSAT Bangkok (7.1%). However, these rates were achieved among very small numbers of clients tested. SWING BKK PMs contributed the largest total number of newly diagnosed HIV-positive clients, with a case-finding rate of 11.6% among 173 PM clients who received HIV tests. Case-finding rates in Chiang Mai and Chiang Rai were 2.1% and 3.8% respectively, although this may reflect low background prevalence in those sites. Out of 604 clients diagnosed as HIV-positive during this quarter, 1,266 are listed as enrolled on ART for an uptake rate as of the end of Q4 of 110.3%. This rate is for Q4 only and does not include clients tested positive in previous quarters who initiated treatment during this quarter. Among Q4 clients who started ART, the average time from diagnosis to treatment initiation was 10 days (S.D. 13.85 days).


By the end of the quarter, the implementing partners with the greatest percentage of new HIV-positive clients not yet initiating treatment were SWING Pattaya and RSAT Chonburi (both 53%), Mplus Chiang Rai (59%) and Sisters (both 5961%), and RSAT Samutprakarn (60%). All other sites reported more than a quarter at least half of new HIV-positive clients on treatment. The sites with the lowest rate of non-initiation were RSAT Phatumthanee (103%) and Tangerine (84%). Care and support staff are in the process of following up with the remaining 192 clients tested positive this quarter who have not yet initiated ART.

Calculating a treatment uptake rate is of course highly dependent on time, and particularly among clients diagnosed late in the quarter, ART uptake is likely to improve. Viewed over the life of the project to date, fully 83% of all clients diagnosed HIV-positive under LINKAGES Thailand and registered in eCascade have initiated ART.


Appendix 2: PERFOMANCE OVERVIEW FOR FY18 FSW PERFOMANCE OVERVIEW FOR FY18


MSM PERFOMANCE OVERVIEW FOR FY18, COTE D'IVOIRE


TRANS PEOPLE PERFOMANCE OVERVIEW FOR FY18

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