Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.
Even with effective prevention and treatment measures, HIV continues to require urgent action in the Asia-Pacific region to identify those living with HIV and those at high risk of acquiring HIV, and improve their linkage to HIV testing and medical care.
To facilitate this effort, an expert panel was formed that included HIV care providers and researchers, community organisation leaders, and patient advocates in China, Hong Kong Special Administrative Region, Singapore, South Korea, Taiwan and Thailand.
The panel identified four critical focus areas to end HIV as a public health threat in the region: (1) stigma and discrimination; (2) HIV prevention; (3) HIV testing, diagnosis and treatment; and (4) quality of life of people living with HIV.
This commentary summarises the challenges surrounding these focus areas and provides recommendations to improve the HIV care continuum in the Asia-Pacific region, as well as examples of previously successful interventions.
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.
Cross-cutting recommendation 1: strengthen key population-led health services and community-led efforts
Supporting the development and sustainability of key population-led health services and scaling up of community-led services can overcome a range of challenges across the HIV care continuum.6 This requires policymaking and resourcing. For example, in Thailand, the police can cite possession of condoms as evidence used to criminalise sex work, which discourages condom use and increases risk of HIV.9 One programme that addressed this challenge was implemented by a local non-government organisation that provided the Service Workers in Group Foundation (SWING) Internship, which aimed to help local police understand issues faced by sex workers. Police gained a better understanding of sex workers’ issues, promoted condom use, conducted outreach events, and taught English and Thai at SWING’s drop-in centre. Unfortunately, recent policy changes in Thailand have restricted community-led organisations like SWING from directly providing HIV prevention services, including condoms and PrEP.10
Cross-cutting recommendation 2: standardise routine health data related to prevention, testing and treatment
Standardising the collection of routine health data around HIV prevention, testing and treatment among people living with HIV and key populations would help identify data gaps and guide improvements in HIV care delivery.6 An accurate assessment of the achievement rate of the 95-95-95 goals requires standardised data collection and analyses, particularly for health and quality of life indicators, while ensuring anonymity.
Cross-cutting recommendation 3: improve awareness and implementation of U=U
Public endorsement by policymakers and government officials of U=U is necessary to drive awareness and acceptance and reduce stigma and discrimination among healthcare providers and society in general.6 Stakeholders should work together to ensure the availability of HIV viral load testing to allow for establishment of HIV undetectability to support U=U discussions between people living with HIV and their providers. These conversations should take place in safe spaces with newly diagnosed individuals, as well as people living with established HIV, to encourage ART adherence and improve quality of life. One example of this type of public endorsement comes from the Taiwan Lourdes Association and Persons with HIV/AIDS Rights Advocacy Association of Taiwan, who partnered to produce a short educational film, featuring three people living with HIV who shared how U=U and viral suppression through ART had given them a second chance at life. Additionally, the film advocates and inspires people living with HIV to achieve viral suppression, adhere to treatment, and look after their physical and mental health (https://www.youtube.com/watch?v=3aPvnaM0kWM).
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.
Data availability statement
There are no data in this work.
Patient consent for publication
The HIV Care Continuum & Beyond Initiative was funded by ViiV Healthcare in partnership with the APCOM Foundation, the Institute of HIV Research and Innovation (IHRI), TREAT Asia/amfAR-the Foundation for AIDS Research, Lourdes Association, Taiwan Love and Hope Association, and Love4One. Members of the HIV Care Continuum & Beyond steering committee are Nittaya Phanuphak, Midnight Poonkasetwattana, Weiping Cai, Andrew Chidgey, Jun Yong Choi, Sen-Chieh Hsu, Hsi-Hsun Lin, Kwang Seo Park, Annette H Sohn, Zhifeng Wang, Chen Seong Wong and Benjamin Young. Partners and endorsers of the HIV Care Continuum & Beyond Initiative are the APCOM Foundation, the Institute of HIV Research and Innovation (IHRI), Treat Asia/amfAR, Lourdes Association, Taiwan Love and Hope Association, Love4One, Taiwan AIDS Foundation, Beijing Love Without Borders and HEART. Editorial assistance was provided under the direction of the authors by Jeffrey Stumpf, Jenny Johnson and Jennifer Rossi, MedThink SciCom, and funded by ViiV Healthcare.
Handling editor Seye Abimbola
Collaborators HIV Care Continuum & Beyond Committee.
Contributors MP and NP contributed to the conception and design of this work. JYC contributed to the drafting of the manuscript. All authors contributed to the acquisition, analysis and interpretation of the data, critically revising the manuscript for important intellectual content, and approved this manuscript for publication.
Funding This work was funded by ViiV Healthcare.
Disclaimer The sponsor had a role in the writing of the report; the decision to submit the paper for publication was made by the authors.
Competing interests NP has received grants and/or honoraria from ViiV Healthcare, Gilead Sciences, USAID, TREATAsia/amfAR, US National Institutes of Health, IAPAC, Virology Education and International AIDS Society, which were paid to her institution, and has participated in WHO Guidelines development groups. JYC and MP have no conflicts of interest to disclose.
Provenance and peer review Not commissioned; externally peer reviewed.