Overcoming challenges across the HIV care continuum in the Asia-Pacific region: expert recommendations

Introduction

According to 2021 estimates, the Asia-Pacific region has the second largest population of people living with HIV (6 million).1 More than one-quarter of all new HIV diagnoses in the region occurred in people aged 15–24 years.1 However, only 76% of people living with HIV knew their status, and of these, 86% were being treated with antiretroviral therapy (ART), falling short of the 95-95-95 Joint United Nations Programme on HIV/AIDS (UNAIDS) Fast-Track targets.1–3 Additionally, the United Nations has called for 95% of all people at risk of acquiring HIV to have access to and use effective HIV prevention methods, including pre-exposure prophylaxis (PrEP), by 2025,4 although only 5%–15% of populations at high risk in the Asia-Pacific region are aware of PrEP.5

Thus, there is a need for improvement in all areas of the treatment cascade, particularly with regard to diagnosis and linkage to care. The HIV Care Continuum & Beyond Initiative was established to unite stakeholders through a 12-member steering committee from China, Hong Kong Special Administrative Region, Singapore, South Korea, Taiwan and Thailand to share activities and identify common priorities critical to achieving these global targets.6

Identified focus areas

The following four focus areas were identified by the steering committee: (1) stigma and discrimination; (2) HIV prevention; (3) HIV testing, diagnosis and treatment; and (4) quality of life of people living with HIV.6 Recommendations to address each focus area were also proposed (table 1).

Stigma and discrimination against key populations at the greatest risk of acquiring HIV, including men who have sex with men and transgender communities, prevent people from accessing essential prevention, testing, and treatment services and increase the risk of transmission.6 Removing structural barriers, including decriminalisation, and ending stigma and discrimination, particularly among healthcare professionals in government-owned health and hospital facilities, as well as ensuring legal protections for key populations and people living with HIV, are critical first steps. Additionally, research should include measuring social attitudes to identify ways to improve public education and challenge misconceptions around HIV. Furthermore, according to UNAIDS and additional published analyses, decriminalisation is critical to ending the HIV epidemic because punitive laws (eg, the criminalisation of same-sex sexual relations, transgender people, HIV exposure, non-disclosure and transmission, drug possession and use, and sex work) have been shown to block access to HIV services and increase risk of HIV acquisition.6–8

Across the Asia-Pacific region, HIV transmission has occurred largely through sexual contact, and therefore methods to prevent the sexual transmission of HIV must be part of the efforts to achieve the 95-95-95 goals. Having access to a combination of effective, people-centred HIV prevention options (condoms and lubricants, PrEP, post-exposure prophylaxis, sexually transmitted infection testing and treatment, awareness of undetectable=untransmittable (U=U)) and harm reduction services is crucial for all people at risk of transmitting or acquiring HIV.6 Further research is needed to support the implementation of PrEP. Additionally, community-led educational initiatives must be developed to raise awareness of the effectiveness of and access to PrEP among key populations, particularly young key populations. Greater investment and advocacy for the inclusion of PrEP in national health funding programmes and target setting for scaling up PrEP use should be a priority. Services to deliver PrEP should continue to be provided outside of healthcare settings, including community-led services, and should be simplified, differentiated and digitalised, where appropriate.

The HIV treatment cascade describes the steps in the patient journey leading from testing, through diagnosis, on to treatment, maintenance and viral suppression.6 There are three critical elements in this framework: (1) increasing access to testing, (2) improving provision of care and (3) linking testing to provision of treatment to achieve viral suppression. Having multiple access points for HIV testing is critical to ensuring access and uptake. This can be provided through centre-based testing, community-based testing and self-testing. Ensuring confidentiality when developing HIV services is integral to improving diagnosis and treatment uptake. Same-day ART initiation has been shown to reduce the gap between testing and treatment uptake and should be promoted wherever feasible. To improve treatment outcomes, people living with HIV should have access to optimal, guideline-recommended ART regimens. To achieve this, effective public subsidy schemes, fit-for-purpose regulation and local clinical guidelines, and other factors must be addressed.

In recent years, there have been growing calls for an additional UNAIDS target focused on quality of life, which goes well beyond biomedical factors. There is evidence to suggest that people living with HIV are at an elevated risk of poorer mental health, and this may be attributed to the varying forms of stigma that they face as well as other social factors, such as community estrangement and lack of or weakening social networks as they grow older.6 To this end, the committee recommends conceptualising and monitoring quality of life for people living with HIV and integrating multidisciplinary clinical services across health concerns.

Conclusion

The HIV Care Continuum & Beyond Initiative provided recommendations to remove barriers to HIV care caused by short-sighted and restrictive policies, and to emphasise the important role of community-led responses to spur progress. By prioritising HIV in the public health agenda for the Asia-Pacific region, these recommendations can help create a positive policy environment that reduces stigma and discrimination for all people living with HIV, particularly among key populations, and can reinforce a person-centred continuum of care.