Unite Health Systems With Community-led Health Services To Deliver On UHC
Despite mounting evidence of how key population or community-led health services have bridged the gap between public health system and those unreached, we are yet to optimally integrate community-led health service delivery model into public health system effectively, said Dr Nittaya Phanuphak.
Dr Nittaya Phanuphak is the Executive Director of Institute for HIV Research and Innovation (IHRI), Governing Council member of International AIDS Society (IAS), and Convener of 2nd Asia Pacific Conference on Point-of-Care Diagnostics for Infectious Diseases.
Sterling examples of high impact key population or community-led health service deliver models come from the land of smiles – Thailand. HIV key populations continue to play a major role in delivering Pre-Exposure Prophylaxis (PrEP for HIV prevention) to those who are at a heightened risk of HIV acquisition. Thailand has the largest PrEP rollout in Asia Pacific region, 80% of people using PrEP in Thailand receive it from a clinic led and staffed by members of the community that it serves. Key populations are groups of people who are disproportionately affected by HIV (which includes gay men and other men who have sex with men, transgender women and sex workers).
'On the ground, despite successes, we have faced challenges too over the last decade in our efforts to integrate community-led health service delivery model into the national public health system in Thailand. Key population lay providers are still the main providers and carers who are initiating and maintaining key population clients in PrEP services,' said Dr Phanuphak.
Over two years ago, Thai government changed regulations which adversely impacted the community-led health services. For example, due to these regulatory changes by the government, PrEP medications were not allowed to be stocked at the clinics run by key populations. Key population service providers were only allowed to give PrEP if it was prescribed by government doctors (and not NGO doctors).
'These regulations are still there but, on the ground, we are upholding our core values of delivering health services in a people-centred way. Many public hospitals work closely with key population led clinics since more than a decade now. These hospitals have seen the impact of key population led health services at the provincial level. They too feel that the best way forward is to continue and maintain the original flow of having client come to the key population led clinics, get tested for HIV by lay providers, and then have the PrEP prescription made through TeleHealth by a government doctor. PrEP can be given out to the client within an hour of entering the clinic,' said Dr Phanuphak.
Funding cuts have made community-led services even more vital
Trump's decisions have snapped funding majorly to a range of health-related projects in the Global South. Dr Nittaya opines that with limited resources it becomes even more critical to ensure we are serving those most in need and most likely to be left behind.
'We need to continue integrating key population led health services into country's healthcare system and make sure that key population led clinics are receiving their reimbursements from the government in a fair way. We also need to ensure that the cadres of lay providers are recognised and endorsed at the country level,' said Dr Nittaya Phanuphak.
Community-led services are not just limited to HIV
'Key population or community-led health services is not only limited to HIV services. It can also be expanded to services for sexually transmitted infections (STIs), mental health, harm reduction, among others. This would be a real game changer for public health in Thailand,' said Dr Phanuphak.
Other countries in southeast Asian and western pacific region such as the Philippines, Viet Nam, Myanmar, and Laos, are also following Thailand-model by adapting community-led health services in their own unique in-country contexts and realities.
Communities and countries need to learn from each other too, says Dr Nittaya Phanuphak. 'We learn from the Philippines that there are members of key populations within the healthcare providers including medical professionals. In Viet Nam, we are seeing a good role of private sector in developing key population led clinics – many of which are social enterprise models too.'
End delays in translating scientific breakthroughs into public health impact
Among the biggest breakthrough scientific announcements in 2024 was lenacapavir - a medicine (twice yearly injections) that showed 100% protection against HIV among women who took part in the study. The study called PURPOSE-1 had cisgender women as participants and lenacapavir demonstrated 100% efficacy in preventing HIV infection. PURPOSE-2 study enrolled a more diverse population of cisgender men, transgender men, transgender women and non-binary individuals who have sex with partners assigned male at birth. PURPOSE-2 study results showed that twice-yearly lenacapavir cut HIV incidence by 96%.
Dr Nittaya Phanuphak shares her disappointment because when the HIV prevention medicine lenacapavir was announced last year, she was rightly hoping for a rapid rollout to protect many more people from HIV acquisition. But it has not happened so far.
"Despite the progress over the last 2-3 decades in HIV response, we still had 1.3 million people who were newly diagnosed with HIV in 2023 worldwide. Around a quarter of these new infections occurred in Asia Pacific region. We have HIV prevention tools in our region but pace at which these are being rolled out is not acceptable. No one needs to get newly infected with HIV because we have the science-based tools to prevent the transmission. For example, PrEP rollout is barely 2% of the target rollout for 2025 (target was to ensure that at least 8.2 million people have used PrEP at least once in a year by end of 2025). This is a huge gap," she said.
Unless all science-based new and old HIV prevention tools would not be offered to people to choose from, we would not be able to protect everyone from the virus.
"When research and development of these new health technologies have taken place in our countries in the Global South so that we can have enough scientific evidence for approvals from US FDA or European Medicine Agency, then why cannot people of our own countries access these approved products?" asks Dr Phanuphak. "This is not fair."
Deploying health technologies developed by the Global South equitably at the point-of-need
Dr Phanuphak calls for uniting our community power in the Global South and leverage upon our regional purchasing power to negotiate lowest possible prices for quality assured screening and diagnostic tools and generic medicines - especially those developed in the Global South. She also underlines the importance of taking services for multiple diseases and health conditions to the communities in people-centred and rights-based manner.
She says that when a health technology is approved by the regulators, it should be developed and made accessible to the people in the Global South without any delay. Not doing so, is not acceptable.
1st Asia Pacific Conference on Point-of-Care Diagnostics for Infectious Diseases was held in Australia. Dr Phanuphak was among those who worked hard to bring the 2nd POC 2025 to Thailand which will be held during 19-21 June 2025 with her being its convener.
She rightly calls for deploying scientifically validated point-of-care health tools closer to the communities to strengthen multiple disease responses, such as for TB, HIV, STIs, vector-borne diseases like malaria or dengue, hepatitis, HPV, among others.
She calls for accelerating innovations in developing more health technologies to serve the most-in-need communities in a rights-based, gender transformative and people-centred manner. "Point-of-care technologies is not only limited to testing for example, but also point-of-care sample collection tools too, so that sample collection not only gets enhanced but also it can be done in a way that it becomes self-care. We should not have to rely on people going to healthcare facilities for sample collection by healthcare providers, but if science-based tools become available, then sample collection can perhaps be done by the clients themselves and sent to the nearest testing centre."
"We cannot talk about new point-of-care technologies without talking about game-changing health financing, policies and political commitment too. At the POC 2025, I hope that we can bring all these aspects together so that we can not only transition in deploying point-of-care health technologies where they are needed most in people-centred manner, but also how can we sustain the implementation," she said.
Integration may not mean the same for everyone
Dr Phanuphak reflects that integration may have different meanings for different people. "A programme manager may think of integrating services together, such as those for TB and HIV. For grant managers it may mean integrating testing platforms, such as those for TB and HIV. We have seen on the ground already that community-led clinics have naturally integrated HIV, hepatitis and STIs services to serve people better. Lay providers have also gone beyond the laboratory integration by integrating mental health, harm reduction, social and legal services."
She calls for reimagining integration in a people-centred way so that we can deliver on WHO Multi-Disease Elimination Approach at the local level and scale up those that have demonstrated impact.
Shobha Shukla – CNS (Citizen News Service)
(Shobha Shukla is the award-winning founding Managing Editor and Executive Director of CNS (Citizen News Service) and is a feminist, health and development justice advocate. She is a former senior Physics faculty of prestigious Loreto Convent College and current Coordinator of Asia Pacific Regional Media Alliance for Health and Development (APCAT Media) and Chairperson of Global AMR Media Alliance (GAMA received AMR One Health Emerging Leaders and Outstanding Talents Award 2024). She also coordinates SHE & Rights initiative (Sexual health with equity & rights). Follow her on Twitter @shobha1shukla or read her writings here www.bit.ly/ShobhaShukla)
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In clinical practice, Dr Gilada's first clinical HIV case was of a German national who was referred to him from Goa Medical College in July 1987. He recollects the first Indian national with HIV who came to his clinic - a former sex worker who had stopped sex work in 1979. She was under his medical care but despite best of efforts, she could not be saved and died of AIDS in JJ Hospital. Her postmortem examination confirmed she had HIV and abdominal TB. This was also the first postmortem examination in India of a person positive for HIV. It was done by Dr DN Lanjewar in 1988. Flashback: When first HIV cases were diagnosed in Thailand "I was accidentally involved in HIV/AIDS arena. I am not an infectious disease doctor, but an allergist and clinical immunologist trained in USA. The first patient, an American gay man living in Thailand, was referred to me at King Chulalongkorn Hospital in October 1984 to investigate the cause of his recurrent muco-cutaneous infection. Immunologic investigations revealed that his T-helper cell numbers and T-cell functions were moderately low, but no diagnosis was made. In February 1985 the patient was admitted into the hospital with confirmed diagnosis of Pneumocystis carinii pneumonia (PCP) and his T-cell numbers and functions were further deteriorated. With the diagnosis of PCP and severe T-cell defect, AIDS was diagnosed at that time," said Dr Praphan Phanuphak, a living legend who helped shape Thailand's HIV response since the first few AIDS cases got diagnosed in the land of smiles in 1985. Dr Praphan Phanuphak is a distinguished Professor Emeritus of the Faculty of Medicine, Chulalongkorn University in Bangkok, Thailand. Together with late Professors Joep Lange and David Cooper, Prof Praphan co-founded HIV-NAT (the HIV Netherlands, Australia, Thailand Research Collaboration), Asia's first HIV clinical trials centre in Bangkok in 1996. 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These are the first 3 HIV/AIDS cases diagnosed in Thailand, all in February 1985. With the increasing availability of HIV test in Thailand, more and more patients were diagnosed. This accidentally drove me deeper and deeper into the HIV field, coupled with the fact that there were not very many infectious disease doctors in the early days who were willing to see HIV patients." Way forward towards ending AIDS Dr Phanuphak's and Dr Gilada's lifetime contribution and continuing guidance to shaping HIV responses is commendable. Governments have promised to end AIDS by 2030. Ending AIDS means that all people living with HIV should have viral load undetectable (so that they can live normal healthy lives and there is zero risk of any infection spread from them as per the WHO). In addition, all people in all their diversities, must have access to full range of science-based HIV combination prevention options in a person-centred and rights-based manner. But global AIDS response is slipping and is off the mark. With recent funding cuts, it becomes even more challenging to ensure that HIV response gets on track to end AIDS. But if we are to deliver on the promises enshrined in SDGs and #HealthForAll, then ending AIDS is clearly a human rights imperative. Shobha Shukla – CNS (Citizen News Service) (Shobha Shukla is the award-winning founding Managing Editor and Executive Director of CNS (Citizen News Service) and is a feminist, health and development justice advocate. She is a former senior Physics faculty of prestigious Loreto Convent College and current Coordinator of Asia Pacific Regional Media Alliance for Health and Development (APCAT Media) and Chairperson of Global AMR Media Alliance (GAMA received AMR One Health Emerging Leaders and Outstanding Talents Award 2024). She also coordinates SHE & Rights initiative (Sexual health with equity & rights). Follow her on Twitter @shobha1shukla or read her writings here
