11 July 2024

Despite the ambitious goal of freeing Thailand from HIV/Aids by 2030, the authorities have suddenly rationed the distribution of so-called before and after pills that keep infection at bay.

“If you want to stop Aids from spreading, you must make preventive tools and resources easily available to people,” said Surang Janyam, founder of the medical nonprofit Swing Thailand. “Why would you ever limit people’s access to these pills?”

Like the Rainbow Association of Thailand and Anonymous Clinic, Swing Thailand runs private clinics that actively distribute pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) medicines for free with state support.

PrEP pills can prevent HIV infection if taken continuously some seven days ahead of risky sex, or every day if necessary.

The PEP regimen, meanwhile, must start within 72 hours after exposure to risky sex to prevent HIV cells from replicating and infecting the person.

The National Health Security Office (NHSO), which manages the universal healthcare scheme, has made PrEP and PEP pills available to its beneficiaries since 2021.

Last year, it expanded free provision of the pills to anybody who needed them, whatever health scheme they belong to.

There are three key healthcare schemes in Thailand. The largest is the universal healthcare scheme, which covers some 48 million people. The others are social security, which covers some 10 million employees and registered freelancers, and the medical coverage scheme for civil servants and their family members.

The benefits of PrEP and PEP have led many clinics and hospitals to actively prescribe them to people who may be worried about their risky sexual behavior. These pills have been dispensed for free under state support over the past year.

However, that policy faltered when Public Health Minister Anutin Charnvirakul in December postponed the disbursement of 5.14 billion baht for disease prevention and health promotion for people not covered by the universal healthcare scheme.

Reportedly recommended by his legal advisers, Anutin’s move is believed to be rooted in legal technicalities. Under Thai law, the universal healthcare scheme is granted a budget for disease prevention and health promotion, but the other two health schemes only have government funding for treatment.

Since PrEP and PEP prevent rather than treat disease, they are not technically covered under budget for the other two schemes.

Also, the Department of Health Service Support has introduced a new rule that PrEP and PEP should only be prescribed by state-run medical facilities. In other words, clinics run by civic organizations like Swing Thailand are no longer able to prescribe these drugs on their own.

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Risk of backfiring

Surang warned that using strict legal interpretations to govern dispensation of HIV/Aids medication could backfire and damage Thailand’s efforts to combat the disease. She pointed out that the budget required to provide PrEP or PEP is far lower than the cost of antiretroviral drugs that people living with HIV may require for the rest of their lives.

“Also, without easy access to PrEP or PEP, new HIV infections will rise,” she warned.

Currently, about 500,000 Thais are living with HIV. Every year, almost 6,000 people test positive for the virus.

Amid growing public awareness of HIV/Aids, along with more sources for its prevention, authorities have set a goal of limiting the number of new infections per year to 1,000 by 2030.

However, this goal appears under threat now that the government has curbed access to PrEP and PEP.

One gay man interviewed by Thai PBS World said he felt uncomfortable at the thought of visiting a state hospital to get a prescription for either PrEP or PEP.

“Yes I’m covered by the universal healthcare scheme, but how can I take a day off work to go to the hospital I’m registered at to get a prescription?” he asked, speaking on condition of anonymity.

He said that these new rules have made access to such life-saving drugs so complicated that he feels like the government does not want to protect the public anymore.

“From my experience, doctors working in state hospitals are not friendly towards the LGBTQ+ community. When I asked to be prescribed PrEP, I was asked if I was promiscuous,” he said.

He explained that he requires the drug because it gives him additional safety. He added that even though he practices safe sex with the use of condoms, he is still anxious about the risk of a condom failing.

Nimit Tien-udom, adviser to the director of the Aids Access Foundation, said people who rely on PrEP need to take the drug daily for at least a month and any disruption can raise the risk of HIV cells replicating and spreading.

Surang also warned that if people ordered these drugs online, they risked missing days in the strict daily regimen, which could lead to them developing resistance to the medication.

“If that happens, it will become even tougher to prevent HIV/Aids,” she said.

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What’s the government’s solution?

The Public Health Ministry held a meeting with civic organizations earlier this month to address problems related to the distribution of PrEP/PEP.

After the meeting, clinics run by Swing Thailand and the Rainbow Sky Association were paired up with a state hospital in Bangkok to allow them to distribute PrEP/PEP via prescriptions. The ministry has also promised to resolve the funding issue soon.

Though Swing Thailand welcomes the move, Surang said the PrEP given to her clinics came from a global fund. As far as she knows, the global fund has only granted Thailand 10,000 bottles. Her clinics in Bangkok alone have handed out 1,600 bottles of PrEP so far this month, she said.

“So I worry about what will happen in the long term,” Surang said.

Chumrong Phengnongyang, a deputy director of Swing Thailand who advocates for the rights of sex workers, said the ministry should realize that clinics run by civic organizations are actually part of the country’s healthcare sector.

“It should officially recognize and support us,” she said.

Dr Opas Karnkawinpong, the Public Health Ministry’s permanent secretary, has vowed his ministry will ensure people’s access to the necessary drugs is not affected.

“We will meet people’s need for PrEP/PEP no matter whether they are covered by the universal healthcare scheme or not. We will try to resolve this issue with the NHSO,” he said.

By Thai PBS World