A decades-long effort to promote condom use and regular HIV testing in Asia has been falling short in many countries, as evidenced in high infection rates among pockets of high-risk people, in particular men who have sex with men (MSM) and sex workers.
Consequently, the development in recent years of pre-exposure prophylaxis (PrEP) medicines for HIV prevention would seem like good news. It is, although there continues to be heated debate among policymakers and healthcare providers about issues ranging from ethics and side effects to resource allocation and access. As well, some fear that risky behaviour will rise if people believe they will be protected in advance.
Experts agree that PrEP is one of the best available prevention tools in regions such as Asia where HIV remains endemic among specific population groups. However, risk assessments and comprehensive understanding about the drug still pose major concerns.
"PrEP has been under study for many years in clinical trials. The result is that it works well with extremely limited side effects and the risks of drug resistance and behaviour compensation are very low," said Annette Sohn, director of Therapeutics Research, Education, and Aids Training in Asia (Treat Asia).
The World Health Organization (WHO) recommends those with "substantial risks" to consider using the prophylaxis as part of their HIV prevention regime; however, the concern is that general public cannot usually assess their own risks.
"Now we are talking about PrEP in the real world," said Dr Sohn."People don't think about risk behaviour in terms of percentages or formal guidelines. We need governments and healthcare providers to help them understand what 'substantial risk' means."
People who take the pills, she said, were entitled to understand what it means for them and how to use the medication effectively.
"Doctors should be able to assess the behaviours of their patients and see if PrEP would be appropriate for them," added Kiat Ruxrungtham, a professor in the Allergy and Clinical Immunology Division of the Faculty of Medicine at Chulalongkorn University, and deputy director of HIV Netherlands, Australia, Thailand (HIV-NAT).
While some have argued that supporting the use of prophylaxis implies approval of high-risk behaviours and would reduce condom use, Dr Kiat said there was no ideal solution to containing the spread of HIV.
"It could be seen as a double-edged sword, but with or without PrEP, we know that people will still be engaging in unsafe sex. If the preventive medicine is available, why should we be against it?" he said.
Dr Nittaya Phanuphak, chief of the prevention department with the Thai Red Cross Aids Research Centre, added that the side effects of PrEP were so small that they were far outweighed by the benefits; consequently, the public should acknowledge PrEP as part of a prevention programme.
"In the span of a person's life, there could a period when the risk of contacting HIV may be higher than at other times. That is when PrEP fills this gap," she added. "Therefore, it should be made available to the general public as quickly and broadly as possible."
Beena Kuttiparambil, chief of HIV/Aids (Adolescent Development) with Unicef, added that PrEP shouldn't be seen as a morning-after pill or a simple solution. There are a lot of issues and one needs to undergo testing beforehand with counseling support.
"There has to be a good understanding of what he or she is getting into and knowing that this is not a life-long option but for a certain period, not just a case of taking PrEP so that you can keep living the way you want," she added.
Experts agreed that assessing one's own risk is extremely difficult and more has to be done to encourage people to have regular HIV tests. Many people have never been tested, either because they believe they are not at risk, or are simply afraid to find out.
"We have to make sure that we are not shaming them that they have done something wrong. They should be able to take responsibility for their own health," added Dr Sohn.
"Not everybody wants to use a condom every time. A condom is a very obvious sign of trying to prevent sexually transmitted disease or HIV whereas a PrEP pill can be taken without knowledge of the partner. That puts the prevention tool in the hand of the individual. It doesn't have to be a negotiation with your partner."
Nittaya Phanuphak, chief of the prevention department with the Thai Red Cross Aids Research Centre, displays tablets of Tenofovir, an HIV prophylaxis that the Thai Food and Drug Administration approved in 2013.
IMPROVING ACCESS
In Thailand, MSM and transgenders account for nearly half of all new HIV infections annually, according to Dr Nittaya.
Statistics from the International Aids Society (IAS) show that infection among MSM is very high in cities in Asia, with levels between 13% and 32% found in many cities in China, India, Myanmar and Vietnam.
More than 15% of MSM in Vietnam and 8% in Indonesia have HIV. Fewer than 5% are infected in Bangladesh, the Philippines and Malaysia, it noted.
In Bangkok, infection levels among MSM were as high as 25% in 2009.
The major factors contributing to the rapid spread among MSM in large cities include the lack of knowledge about the disease and ways of protection, and the easily availability of sex partners, especially nowadays through online dating applications.
"We have been promoting condom use for over 30 years. The prevalence of this epidemic shows us that this method alone no longer works for MSM," said Midnight Poonkasetwattana, executive director of the Asia-Pacific Coalition on Male Sexual Health (Apcom).
Thai society is still very regressive when it comes to sex education, he added. People still won't admit that teenagers are already experimenting with sex. Comprehensive sex education, including recognition of gender and sexual diversity, has to be included in school textbooks so that the younger generation are not afraid to seek sexual health services.
While some blame the spread of HIV on social media and hook-up apps, Mr Midnight said the reality is we cannot stop the use of new technologies and more people will continue to use the apps. Consequently, we need to adapting HIV prevention strategies to fit in with the times.
"PrEP is now available as an additional prevention tool to condoms and lubricants, but it is still very limited for clinical research. There needs to be more effort from the government to promote the use of the medicine and make it publicly accessible among MSM," he said.
Chris Beyrer, director of the Johns Hopkins Fogarty Aids International Training and Research Program, said in an earlier interview that the "frightening truth" was that in many parts of the world, we simply do not know how bad the epidemic among MSM groups may be.
"Transmission among MSM is still not tracked in most countries, resulting in a significant research gap. More research is urgently needed to inform more effective HIV prevention efforts," he said.
Dr Sohn added that in order to make PrEP more widely available across the region, the price needs to come down further. The one medication approved for use in Thailand costs 40 baht per tablet. One approach is to increase demand and encourage bulk purchases.
"There is no question that this will cost the government more money. Making the investment today will save more money tomorrow," she said.
Dr Kiat added that in order to end the Aids epidemic by 2030, the priority now should be on prevention and encouraging treatment. The faster a cure can be found, the fewer people will become infected. Stopping one person from getting the virus means saving the lives of three or five in the future, he added.