Coordinating the Fight Against HIV Nationally, Regionally and Globally
Featuring Ying-Ru Lo, M.D.
Dr. Ying-Ru Lo is coordinator of the HIV, Hepatitis and Sexually Transmitted Infections program at the World Health Organization's (WHO) Regional Office for the Western Pacific in Manila, Philippines. Previously, she served as global HIV Prevention coordinator for the HIV/AIDS Department at the WHO headquarters in Geneva, and worked in the organization's national office in Thailand and regional office in New Delhi, India. Originally from Hamburg, Germany, Dr. Lo has also worked as a clinician and public health advisor in Europe and Latin America.
Having worked on national, regional, and global levels at the WHO, you bring a unique perspective to the response to HIV. How do you think the program priorities vary between the levels, and do they align with WHO objectives for ending the HIV epidemic?
My priority has been to translate research into implementation, and I think that's the WHO's key mandate at all the different levels of the organization. For example, at WHO headquarters in Geneva, the main task is to set international norms and standards by reviewing evidence and consulting with experts and then developing and releasing guidelines. At the regional and country levels, we support the implementation of those guidelines and work directly with country governments to adapt their national guidelines to adopt the recommendations.
However, we are becoming increasingly limited in our ability to support the roll-out and evaluation of guidelines in the Asia-Pacific because external donors are phasing out support for the WHO in the region. Our ability to implement the WHO's objectives for ending the epidemic may disappear if we don't have expertise at the regional and country level.
The HIV epidemics in Asia are highly concentrated within key populations, including men who have sex with men (MSM), transgender individuals, sex workers, and people who inject drugs (PWID). How is the WHO Regional Office for the Western Pacific (WPRO) working to encourage governments to prioritize supporting these often marginalized populations?
Our staff have a very close working relationship with the Ministries of Health in their areas, and we can access the highest levels of the ministries and the policy makers and providers that are responsible for public health programs and service delivery. And it's through that constant dialogue that we really advocate sustaining and funding different prevention interventions for these populations.
Plus, our surveillance and program monitoring data are a very powerful tool for advocacy because they show in which locations and populations HIV is found, the size of those populations, and the trend in HIV infection among them. For example, in the Philippines, we are seeing exponential growth of new HIV infections among MSM, and just today we were looking at the data with the Department of Health and discussing why this is happening.
Only a small fraction of MSM are getting tested, and the infection rate is so high that the transmission probability is quite high, meaning existing interventions, like promoting condoms, are not sufficient. You have to ratchet up HIV testing and introduce antiretroviral pre-exposure prophylaxis (PrEP) to prevent HIV acquisition and transmission. And we had this dialogue with them, and now they are very interested in moving in that direction and in finding their own funding. That's one example.
Fear of stigma and discrimination continues to be a key barrier to HIV testing. Are there innovative approaches to reducing stigma and increasing testing that you think should be scaled up?
Yes, that's a big problem. Testing rates are low and not only in this region -- it's a global problem. If you look at the data, about 60-70% of individuals tested globally are women, but the largest number of new HIV infections is among men. So what we are looking to do at the WHO is combine provider-initiated testing with testing done by community peers -- MSM, PWID, and others from community-based organizations.
This model is being used in many different countries across Asia. We are trying to work with community-based organizations so they are confident in the quality of the testing they are providing, and then also to support them in combining HIV testing with screening for other sexually transmitted infections (STIs), like syphilis and hepatitis, because people may not come for an HIV test, but they may want a hepatitis B vaccine or have symptoms of another STI. And we are also working to evaluate the effectiveness of that model.
Another approach is self-testing, which hasn't been evaluated yet, but in Asia there are some projects seeking to do so. And the interest is high, particularly among MSM. There are some concerns about quality, and this is where WHO would be very important, in helping support or establish quality assurance systems for self HIV testing. Another strategy is the introduction of PrEP, which would require a lot of testing and retesting in the community, and probably be a vehicle for increasing uptake of HIV testing among high-risk MSM. And that's where the HIV epidemic is now -- it's among MSM.
But right now, it's just a hypothesis that these interventions will work in an Asian setting. We know too little about what we're doing and how we're doing it, and we need more implementation research.
WPRO is helping to coordinate the first Biregional Expert Consultation on Advancing Implementation Research on HIV/AIDS in Asia, taking place in November in Tokyo. What do you hope to achieve through this consultation?
In Asia, we have an epidemic concentrated among MSM and PWID and other key populations. At the same time, many countries are transitioning to lower-middle-income status and have strong research capacity. So I think the countries in the region are very well positioned to answer questions about why HIV death rates are not decreasing more in key populations and why testing rates and linkage to care are not going up. And these are questions we could answer through implementation research.
At the Tokyo meeting, we are bringing in experts, including colleagues from John Hopkins University and the University of North Carolina, to explain these research methods to representatives from around the region. It's also a very good opportunity to expand research partnerships. The meeting is supported by TREAT Asia, USAID, the U.S. National Institutes of Health, the Japan AIDS Society, and the National Center for Global Health and Medicine in Japan, and attendees are being actively engaged to shape the program and help support this collaborative effort.
WPRO has taken the lead in prioritizing hepatitis B vaccination and treatment for hepatitis B and C through its Regional Action Plan and country-level negotiations. What have been the early outcomes of these efforts and what do you think can realistically be accomplished in terms of access to hepatitis screening, treatment, and care in the next five years?
The burden of hepatitis B and C is highest in this part of the world, but there has been a serious commitment to prevention and immunization. WPRO was the first WHO regional office to set targets for immunization, and the region as a whole has reached the milestone set for 2015, reducing hepatitis B prevalence in children five years of age to less than 2%. And 12 countries have reached the goal for 2017, reducing prevalence to less than 1% in children five years of age.
Our Regional Action Plan, which includes the screening, care, and treatment of people with hepatitis B and hepatitis C, has been endorsed by all 37 of the WHO Western Pacific Member states, and that's a big success. This plan will guide actions in the countries for the next five years. And we have conducted analysis in China, which has high hepatitis prevalence, showing that investing in treatment for hepatitis B and newer treatments for hepatitis C is cheaper than spending the money on suboptimal therapy or not treating hepatitis at all. We are also working on similar data in Mongolia and the Philippines.
These data are an important tool for advocating at the highest level of the government and showing them the "bang for the buck" they can get. I'm very hopeful and very confident that we can make a difference in the next five years -- but the drug prices do have to go down.
The WHO treatment guidelines recently started recommending treatment for all people living with HIV regardless of CD4 count. Why was this the moment for making that recommendation and how and when do you think it will be implemented throughout the region?
Well, I have been an advocate of this for a long time, and I think it's a very powerful intervention to prevent deaths and transmission of HIV. Countries may be worried about the cost of the drugs and sustainability, but I think the treatment guidelines will be implemented throughout the region gradually, country by country. I'm traveling to Shanghai next week to attend the Chinese National HIV/AIDS Conference to have a discussion about this.
But having a guideline that says "treat all" is an easy thing to do. Diagnosing people early will be the critical question. We know 50% of people living with HIV don't know their status, and that in many countries, including upper-middle-income countries like Thailand, the average CD4 count at diagnosis is below 200 [the threshold for an AIDS diagnosis]. So it's important to look at PrEP for prevention, which is also recommended in the same WHO guidelines. And we also have testing guidelines that recommend new modes of getting and increasing access to testing. That's the most difficult thing, early diagnosis -- early, early, early -- and increasing linkages to care once people are diagnosed.
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