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A HISTORIOGRAPHY OF PRE-EXPOSURE PROPHYLAXIS (PREP) IN THAILAND

I. Abstract

The purpose of this research is to provide a history of the development and application

of Pre-Exposure Prophylaxis (PrEP) in Thailand. PrEP is a relatively new form of treatment

for HIV recommended for individuals who are not yet infected but are highly at risk. This is

done by studying the works of various authors who studied its implementation in different

countries Thailand, in particular. This can be used as an opportunity by the government

and different Philippine institutions to implement PrEP as a legitimate treatment to inhibit

the spread of HIV in the country.

II. Introduction

Human Immunodeficiency Virus (HIV) is an immunovirus that is mainly transmitted

through sexual intercourse and exposure to infected blood. It weakens the body by

attacking the immune system, specifically the CD4 cells (T cells), which help the immune

system fight off infections. If left untreated, HIV reduces the number of CD4 cells (T cells) in

the body, making the person more likely to get infections or infection-related cancers. Over

time, HIV can destroy so many of these cells that the body cant fight off infections and

disease. These opportunistic infections or cancers take advantage of a very weak immune

system and signal that the person has AIDS, the last state of HIV infection.1 The origin of

1"What Is HIV-AIDS?" Accessed December 4, 2016. https://www.aids.gov/hiv-aids-basics/hiv-aids-


101/what-is-hiv-aids/.
the virus is still unknown but scientists believe that Simian Immunodeficiency Virus (SIV)

from the chimpanzees of Central Africa may have hopped species and mutated into HIV.2

The most advanced stage of HIV is acquired immunodeficiency syndrome (AIDS);

during this stage, the patients immune system is badly damaged to the point that they have

completely exposed themselves to opportunistic infections. An individual is said to have

developed AIDS when their CD4 cells fall below 200 cells per cubic millimeter of blood (as

opposed to the 500 to 1,600 cells per cubic millimeter of normal healthy non-infected

people. The development of at least one opportunistic disease, regardless of CD4 count, can

also be considered as a start to AIDS. Although there are treatments, the patients life

expectancy drops considerably once diagnosed with AIDS.3

With around 36.7 million people infected worldwide, HIV still remains a pressing issue

up to this day. 4% of the total people living with this disease are children who contracted

the disease from their parents by childbirth, pregnancy, or breastfeeding.4 A cure is yet to

be found for HIV but various measures and treatments are being used in order to inhibit

the development of the virus, lengthen the life of the victim, reduce the chances

transmission, and prevent various opportunistic diseases. The most widespread form of

treatment is antiretroviral therapy (ART) wherein the patient undergoes a medicinal

2 "Where Did HIV Com From?" Accessed December 4, 2016. http://www.theaidsinstitute.org/node/259.


3 "What Is HIV-AIDS?" Accessed December 4, 2016. https://www.aids.gov/hiv-aids-basics/hiv-aids-
101/what-is-hiv-aids/.
4 "HIV-AIDS Global Statistics." Accessed December 3, 2016. https://www.aids.gov/hiv-aids-basics/hiv-aids-

101/global-statistics/.
regimen where they take a variety of anti-HIV medicine in combination such as

neviraphine, zidovudine, and lamivudine.5

Second only to sub-Saharan Africa, Asia has the highest HIV prevalence rate in the

world. 6 Thailand in Southeast Asia has become a hotspot for HIV, accounting for

approximately 9% of HIV cases in Asia7; it had faced a generalized HIV epidemic, with

national HIV prevalence peaking at 4.0% among male army recruits in 1993 and 2.6%

among pregnant women attending antenatal clinics in 1995. 8 However, thanks to

institutions that reacted quickly to the growing public concern, the Thai government was

able to reverse the epidemic through a program that revolves around 100% condom use

during commercial sex.9 By 2013, HIV prevalence among adults in the country have

dropped to 1.1%, this decline can be attributed to early intervention programs such as the

aforementioned condom-use policy and the encouragement of the Thai government to use

other preventative measures such as pills.10 Thailand also became the very first country in

Asia to eliminate HIV transmission from mothers to children:

Thailand became one of the first countries in the world in which pregnant women

living with HIV had access to free antiretroviral therapy. Untreated, women living with HIV

have up to a 45% chance of transmitting the virus to their children during pregnancy,

5 HIV Treatment in the Philippines. Accessed December 3, 2016. http://hivtestkit.ph/hiv-treatment-in-the-


philippines/.
6 "HIV AND AIDS IN THAILAND." AVERT. July 22, 2016. Accessed December 3, 2016.

http://www.avert.org/professionals/hiv-around-world/asia-pacific/thailand.
7 Ibid.
8 Colby, Donn, Kriengkrai Srithanaviboonchai, Suphak Vanichseni, Sumet Ongwandee, Nittaya Phanuphak,

Michael Martin, Kachit Choopanya, Suwat Chariyalertsak, and Frits Van Griensven. "HIV Pre-exposure
Prophylaxis and Health and Community Systems in the Global South: Thailand Case Study." Journal of the
International AIDS Society 18, no. 4 (Suppl 3). doi:10.7448/ias.18.4.19953.
9 Ibid.
10 HIV AND AIDS IN THAILAND." AVERT. July 22, 2016. Accessed December 3, 2016.

http://www.avert.org/professionals/hiv-around-world/asia-pacific/thailand.
delivery or breastfeeding. However, the risk drops dramatically if HIV treatment is given to

both mother and child.11

The HIV epidemic among MSM [men who have sex with men] in Thailand continues

unabated with high incidence and prevalence. Similar to experiences elsewhere, past and

current HIV prevention programming has had limited efficiency or success in decreasing

the transmission of HIV in this population.12

In the Philippines, the very first case of HIV infection was in 1984 and since then a total

of 32,647 cases have been reported. Most of the cases were asymptomatic and infection

peaked in 1991.13 While boasting some of the lowest HIV infection rates in the world, the

Philippines remains to be one of the seven countries to have the fastest growing number of

cases with a 25% increase over the span of 2001 to 2009.14 Various organizations such as

the UNICEF are implementing HIV and AIDS programs in cooperation of local government

units (LGUs) in priority areas in the country in order to sustain the fight against the spread

of the infection.15

Pre-exposure prophylaxis

11 "THAILAND IS THE FIRST COUNTRY IN ASIA TO ACHIEVE ELIMINATION OF HIV TRANSMISSION AND
SYPHILIS FROM MOTHERS TO THEIR CHILDREN," UNAIDS, October 27, 2016, , accessed December 4, 2016,
http://www.unaids.org/en/resources/presscentre/featurestories/2016/october/20161027_thailand
12 Colby, Donn, Kriengkrai Srithanaviboonchai, Suphak Vanichseni, Sumet Ongwandee, Nittaya Phanuphak,

Michael Martin, Kachit Choopanya, Suwat Chariyalertsak, and Frits Van Griensven. "HIV Pre-exposure
Prophylaxis and Health and Community Systems in the Global South: Thailand Case Study." Journal of the
International AIDS Society 18, no. 4 (Suppl 3). doi:10.7448/ias.18.4.19953.
13 HIV-AIDS Department of Health Epidemiology Bureau March 2016 March 2016. Accessed December 2,

2016. http://www.doh.gov.ph/sites/default/files/statistics/EB_HIV_Mar-AIDSreg2016.pdf.
14 "HIV and AIDS in the Philippines." Accessed December 4, 2016.

https://www.unicef.org/philippines/hivaids.html.
15 Ibid.
Pre-exposure prophylaxis (PrEP) is a relatively new form of treatment of HIV that was

only recently approved by the Food and Drug Administration (FDA) on July 16, 201216; it

reduces the chances that the user can contract HIV. Daily usage of PrEP significantly

reduces the risk of its user from becoming infected by interfering with the virus ability to

replicate once exposed.17 Daily PrEP reduces the risk of getting HIV from sex by more than

90%. Among people who inject drugs, it reduces the risk by more than 70%.18 It is

important to clarify that PrEP is not a treatment nor a cure for HIV but rather a

preventative pill. It is recommended especially to people who are HIV negative but are

highly at risk. The only drug recommended for PrEP is Gilead Sciences Truvada a

combination of tenofovir and emtricitabine.

The treatment is considered as a breakthrough by many researchers and have been

helpful in keeping HIV cases down especially in Asia where condom use remains

inconsistent. Thailand in particular has been a site for daily oral trials and demonstrations

especially in men who have sex with men (MSM), transgender women (TGW), and people

who inject drugs (PWID).1920

TRCAC [Thai Red Cross Anonymous Clinic] started its PrEP project at the end of 2014.

Users are charged US$ 1 a day for their supply of pills, along with the recommended

16 "FDA approves first drug for reducing the risk of sexually acquired HIV infection" (Press release). Food and
Drug Administration. Accessed December 1, 2016.
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm312210.htm
17 "What Is PrEP?" What Is PrEP. Accessed December 3, 2016. http://www.whatisprep.org/.
18 "PrEP 101." Accessed December 3, 2016. http://www.cdc.gov/hiv/pdf/library/factsheets/prep101-

consumer-info.pdf.
19 Research/Demonstration Projects. Accessed December 2, 2016. http://www.prepwatch.org/thailand/
20 Colby, Donn, Kriengkrai Srithanaviboonchai, Suphak Vanichseni, Sumet Ongwandee, Nittaya Phanuphak,

Michael Martin, Kachit Choopanya, Suwat Chariyalertsak, and Frits Van Griensven. "HIV Pre-exposure
Prophylaxis and Health and Community Systems in the Global South: Thailand Case Study." Journal of the
International AIDS Society 18, no. 4 (Suppl 3). doi:10.7448/ias.18.4.19953.
counselling and health evaluations. PrEP is only for people who are HIV-negative, so users

undergo an initial HIV test and a check for other sexually transmitted infections as well as

tests to measure how the liver and kidneys are functioning. After the first month, users

repeat the evaluation and then return for testing every three months.21

In the Philippines, there is a low awareness of PrEP as a treatment for HIV as shown by

surveys on potential users.22 However, non-governmental organizations (NGOs) such as

LoveYourself are introducing PrEP to the community:

LoveYourself is starting a pilot project for PrEP, including regular check-ups, risk

reduction and adherence counselling, in two of its clinics in Manila, Philippines, in

November.23

Significance of the Study

Pre-exposure prophylaxis (PrEP), over the short period of time it has been on the

market, has been proven in practice to be an effective counter-measure against HIV.

Despite having currently relatively low infection rates in the country, the rising number of

reported cases is alarming and should be given a more proactive response by the

community. The proper implementation of PrEP is a good first step to alleviating a brand

new epidemic in Asia. As established in the previous chapter, few people within the country

are aware of PrEP as a treatment for HIV; to study the history of its development and

adoption in Thailand may prove to be beneficial to finding out how the Philippine

21 COUNTRIES IN ASIA START TO ROLL OUT PREP. November 2, 2016. Accessed December 4, 2016.
http://www.unaids.org/en/resources/presscentre/featurestories/2016/november/20161102_asia.
22 Ibid.
23 Ibid.
government and/or various NGOs can better implement and market PrEP as a viable anti-

HIV treatment.

III. Related Literature


Studies conducted on the implementation of PrEP in Thailand
Thailand has been the site of studies and trial projects of daily oral PrEP in men who

have sex with men (MSM), transgender (TG) women, women and people who inject drugs.

In Thailand, two of the studies that have been conducted to show the efficacy of PrEP in

reducing HIV acquisition include the Bangkok Tenofovir Study (BTS) and the iPrEX Study.

The Bangkok Tenofovir Study24 assessed the use of a once-daily antiretroviral pill

containing tenofovir disoproxil fumarate as PrEP for reducing the rate of HIV infection

among men and women who inject drugs. The Bangkok Ministry of Public Health and

Bangkok Metropolitan Administration collaborated in order for the project to be

materialized. Gilead Sciences donated study medications for the project. The study aimed

to determine if PrEP with the in-take of daily oral tenofovir would lower the risk of people

who inject drugs to acquire HIV infection. The participants of the study consisted of 2,413

HIV-uninfected men and women who reported to have been injecting drugs during the

previous year. The study was conducted in drug treatment clinics in Bangkok. 20 percent of

the population under study were female with 489 and 80 percent were male with 1, 924.

The age of the respondents ranged from 20 to 60 years old. People with hepatitis B

24Choopanya, Kachit, Michael Martin, Pravan Suntharasamai, Udomsak Sangkum, Philip A Mock, Manoj
Leethochawalit, and Sithisat Chiamwongpaet et al. 2016. "Antiretroviral Prophylaxis For HIV Infection In
Injecting Drug Users In Bangkok, Thailand (The Bangkok Tenofovir Study): A Randomised, Double-Blind,
Placebo-Controlled Phase 3 Trial". http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-
6736(13)61127-7.pdf.
infection, women who were pregnant, and people infected with HIV were excluded from

the study. The participants were divided into two groups, one being assigned to TDF daily,

while the other was assigned to take a placebo daily. The pills that were distributed looked

identical therefore the participants were not aware of what pill they were taking. All of the

participants were counseled on the use of other preventive methods, including safer

injection drug behavior and provision of condoms. Financial incentives and Directly

Observed Therapy (DOT) were also offered and ninety percent of the respondents took

DOT. The results of the study showed that a total of 50 people became infected, 17 from the

TDF group and 33 people from the placebo group, resulting in a 49 percent reduction in the

risk of acquiring HIV infection among those who have been taking tenofovir. A separate

analysis was conducted among the TDF group and the results showed that the level of

protection increased to 74 percent.

The iPrEX (Initiativa Profilaxis Pre-Exposicin) study commenced in 2007 and

results were rendered in November 2010. Just like the BTS, the iPrEX study also aimed to

assess the efficacy of taking Truvada (emtricitabine/tenofovir disoproxil fumarate) to

lower the rate of HIV acquisition. The participants were divided into two groups, one group

consisting of 1,251 people was assigned to take Truvada on a daily basis, while the other

group consisting of 1,248 people was assigned to take placebo. The pills that were

distributed also looked identical, therefore the participants were not aware of what pill

they were taking. Counseling and HIV and STD testing were also provided. The study

participants consisted of 2,499 HIV-negative men and transgender women who have sex

with men at 11 sites in Brazil, Ecuador, Peru, South Africa, Thailand and US. The

participants were interviewed on sexual activity, condom use, and risk of HIV. Tests were
conducted to confirm HIV status. They were given 30-day supplies of pills and were

required to attend monthly adherence interviews and HIV testing. The average age of the

participants was 27 and they were assessed for 21 months. The results of the study showed

that 131 participants were infected, with 48 from the Truvada group and 83 people from

the placebo group. The rate of new infection was lowered by 42% through the intake of

Truvada. This includes those who took their pills daily as well as anyone who took them

less often.

Participants with better adherence to Truvada saw higher rates of protection:

Those who reported taking Truvada >50% of the time, the efficacy was 50%. Those

who reported taking Truvada >90% of the time, the efficacy was 73%. Those with blood

levels of drug equal to 4 days of dosing per week, the efficacy was 96%. Those with

blood levels of drug equal to 7 days of dosing per week, the efficacy was 99%.25

Studies on PrEP efficacy has also been conducted in several African countries such

as Uganda, Kenya, and Botswana. The TDF-2 study commenced in March 2007 and its

results were presented in July 2011. The study also aimed to assess the efficacy of Truvada

in-take in order to prevent HIV infection. Due to low maintenance of the study, it was

stopped early. The participants were divided into two groups, one group of 601 people was

assigned to take Truvada while the other group of 599 people was assigned to a placebo

daily. The participants did not know what pills they were taking. Counseling and HIV

testing were also provided. Pregnancy testing and family planning were also given to

women. The participants consisted of 1,200 HIV-negative heterosexual men and women

25Stockman, J.A. 2012. "Preexposure Chemoprophylaxis For HIV Prevention In Men Who Have Sex With Men".
Yearbook Of Pediatrics 2012: 271-272. doi:10.1016/j.yped.2011.06.019.
aged 18-39 years old from 2 sites in Botswana. 93 percent of the participants were single

and all received monthly tests to confirm HIV status, as well as pregnancy and other tests.

The respondents were observed for 12 months. 14 percent stated to have a sexual partner

within the past month while 81 percent admitted consistent use of condom. The results of

the study showed that 33 participants became infected, 9 from the Truvada group and 24

from the placebo group. Basing from the overall results, Truvada lowered the rate of new

infections by 63 percent. Half of the participants who became infected had no detectable

drug in their blood.26

Another study conducted was the Partners PrEP which started in 2008 and

presented in 2011. The study aimed to assess the safety and efficacy of the intake of

Truvada or Viread to prevent HIV infection. The participants of the study included 4, 758

mixed-status jeterosexual couples from 9 sites in Kenya and Uganda. 38 percent of the men

were HIV-negative while 62 percent of the women were HIV-negative. The couples who

were positive with HIV were in good health but were not acquiring HIV treatment. The

participants were divided into three groups, one group of 1,579 people was assigned to

take Truvada daily, the second group consisting of 1,584 people was assigned to Viread,

and the third group consisting of 1,584 people was assigned to placebo. The pills were also

distributed randomly, with the participants not being aware of what pill they were taking.

Counseling and treatment for STD were provided individually and as couples. The couples

were observed for 2 to 3 years. All of the participants were interviewed on sexual activity,

use of condoms and risk of HIV infection. Partners who were HIV-negative were given 30-

26Thigpen, Michael C., Poloko M. Kebaabetswe, Lynn A. Paxton, Dawn K. Smith, Charles E. Rose, Tebogo M.
Segolodi, and Faith L. Henderson et al. 2012. "Antiretroviral Preexposure Prophylaxis For Heterosexual HIV
Transmission In Botswana". New England Journal Of Medicine 367 (5): 423-434.
doi:10.1056/nejmoa1110711.
day supplies of pills. They were required to attend monthly adherence interviews and

blood testing. The results of the study showed that 82 participants became infected, 13

from the Truvada group, 17 from the Viread group, and 52 from placebo group. Women

were mostly infected. Based from the overall results of the study, Truvada lowered the rate

of new infections by 75% while Viread reduced the rate by 67%. Participants with greater

adherence to Truvada had higher rates of protection.27

PEP, which stands for post-exposure prophylaxis, is another known treatment for

HIV. This treatment involves taking antiretroviral medicines (ART) after being potentially

exposed to HIV to prevent becoming infected. In order to effectively reduce the chances of

acquiring HIV infection, one must take PEP within 72 hours of possible exposure to HIV.

PEP is given to prevent further replication of the virus at the site of exposure, eventually

stopping the infection from becoming permanent.

a. Studies done on the implementation of PrEP in other countries


Although the rate of HIV cases in the Philippines may be low as compared to other

countries, incidences of STDs, multiple partners, and injection drug use with sharing of

needles is increasing which means that an epidemic might occur if necessary preventions

are not implemented thus allowing the spread of the virus to the appropriate risk groups.

In 1984, the first case of HIV infection in the Philippines was reported. From January

1984 to March 2016, there has been 32,647 cases of HIV Ab sero-positive reported to the

27Baeten, Jared M., Deborah Donnell, Patrick Ndase, Nelly R. Mugo, James D. Campbell, Jonathan Wangisi, and
Jordan W. Tappero et al. 2012. "Antiretroviral Prophylaxis For HIV Prevention In Heterosexual Men And
Women". New England Journal Of Medicine 367 (5): 399-410. doi:10.1056/nejmoa1108524.
HARP (HIV/AIDS & ART in the Philippines).28 According to HARP, Ninety-one percent

(29,805) of the total reported cases were asymptomatic at the time of reporting. 30,136

were male and 2,500 were female with 28 years old as the median age. Eighty-two percent

or 26,632 of all the 32,647 cases in the Philippines that were diagnosed were reported

from January 2011 to March 2016. Most of these cases were still asymptomatic at the time

of reporting.

During its early years (1984-1990), 133 of 216 cases were female. In 1991, the number

of infected males started to rise in the Philippines. From 2011 to 2016, 96% (25,439) of the

reported 26,632 cases comprised of males. From 2001 to 2005, the cases comprised of

people aged 39-45 years old but starting from 2006 to 2016, the age group with the

prevalent proportion of cases has become younger to 25-34 years old. 29

The Philippine government has faced HIV/AIDS assertively. It responded with urgency,

having considered the experiences of other countries such as Indonesia and Vietnam,

which is now experiencing a high number of HIV/AIDS cases. The enactment of the

Philippine AIDS Prevention and Control Act of 1998 was one of the urgent responses of the

government. The law called for a comprehensive nationwide HIV/AIDS educational

campaign, full protection of human rights and suspected HIV-infected persons, promotion

of safe and universal precautions in practices that carry risks of HIV transmission,

28 "HIV/AIDS & ART REGISTRY OF THE PHILIPPINES MARCH 2016". 2016. Department Of Health.
http://www.doh.gov.ph/sites/default/files/statistics/EB_HIV_Mar-AIDSreg2016.pdf.
29 "HIV/AIDS & ART REGISTRY OF THE PHILIPPINES MARCH 2016". 2016. Department Of Health.

http://www.doh.gov.ph/sites/default/files/statistics/EB_HIV_Mar-AIDSreg2016.pdf.
eradication of conditions that aggravate spread of HIV infection, and recognition of the role

of affected individuals in promotion information about the said virus.30

PrEP has been circulating in the U.S. and other countries for several years now but only

a limited number of Filipinos are aware of the treatment. The PrEP program is being

introduced to the Philippines through the collaboration among of the Department of Health

(DOH), Research Institute for Tropical Medicine (RITM), World Health Organization

(WHO), and Love Yourself (TLY). The PrEP program was started in 2015 and funding from

AMFar has been approved since October. It has been planned that the actual

materialization of the program would happen on January or February of 2017.31

IV. Conclusion
The practical application of PrEP in Thailand has been beneficial to inhibiting the

spread of HIV in the country. Being a relatively new treatment, there are only a handful of

studies that tackle the effects of PrEP but most of them has shown promise. By studying the

success of the application of PrEP in Thailand, we can use this information to further

advance and promote PrEP as a legitimate treatment within the Philippines to halt the

growth of HIV cases in the country.

30 Mateo Jr., Ricardo and Jesus Sarol Jr. 2004. "HIV/AIDS In The Philippines". AIDS Education And Prevention.
http://web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=ca9118f6-32da-4905-aaec-
246373322bac%40sessionmgr120&vid=1&hid=124.
31 "Meet The Organization Introducing Prep To The Philippines". 2016. UNAIDS Asia-Pacific. https://unaids-

ap.org/2016/11/02/meet-the-organization-introducing-prep-to-the-philippines/.