Heather-Marie Schmidt

BMedSc (Hon), MPH, PhD

Dr. Schmidt serves as the Regional Advisor on HIV Testing, Prevention, and Key Populations for the Joint United Nations Programme on HIV/AIDS (UNAIDS) Asia-Pacific Regional Office and the World Health Organization (WHO) Global HIV, Hepatitis, and Sexually Transmitted Infections Program. She is dedicated to developing global guidelines for PrEP (Pre-Exposure Prophylaxis) and PEP (Post-Exposure Prophylaxis) and providing technical assistance to countries, organizations, and communities in the Asia-Pacific region to support the implementation and promotion of PrEP.

At the APACC 2023 conference, Dr. Schmidt delivered an insightful presentation on “WHO Long-Acting Guidelines in Asia” and further shared her perspectives in an on-site interview with us, discussing WHO’s recommendations for long-acting PrEP, the challenges faced in implementing WHO’s long-acting PrEP guidelines in Asia, and the efforts needed in Asia to achieve the 2030 goal of ending the HIV epidemic.

Infectious Disease Frontier: How does WHO recommend PrEP schemes, especially long-acting PrEP?

Dr. Schmidt: WHO has recommended PrEP for over a decade. In 2012, WHO first recommended oral PrEP containing tenofovir disoproxil fumarate (TDF) for specific high-risk populations, such as serodiscordant couples, men who have sex with men (MSM), and transgender women (TGW). Subsequently, in 2014, WHO expanded its recommendation to include all susceptible populations. In 2021, WHO recommended a second PrEP product and the first long-acting PrEP product, dapivirine vaginal ring. Just last year, in 2022, WHO recommended a third PrEP product, the long-acting injectable cabotegravir. WHO advises the use of PrEP for high-risk populations as part of HIV prevention. Importantly, PrEP is a crucial component of a comprehensive approach to HIV prevention.

Infectious Disease Frontier: What challenges does Asia face in implementing WHO’s long-acting PrEP guidelines, given the significant regional differences?

Dr. Schmidt: Firstly, I believe that WHO guidelines are generally adaptable and not overly prescriptive. While there are substantial differences between Asia and other regions (Africa, Europe, the Americas), WHO guidelines often apply across multiple countries and scenarios. Asia’s situations vary in terms of HIV diagnosis and treatment, stigma and discrimination (and legal issues related to HIV/LGBTI populations), and attitudes towards promoting PrEP. But what I want to emphasize is that the principles of HIV prevention advocated by WHO remain feasible, such as the requirement for HIV testing, especially when discussing the introduction of long-acting cabotegravir into national programs. Regardless of national programs for HIV prevention, the pre-testing requirements set by WHO are consistent. On other fronts, service delivery can take various approaches. There is flexibility in the use of a range of service options, service packages, and how services are provided, and these are principles applicable across all regions. Asia has been relatively successful in this regard. So, we have some very good service delivery options in Asia, with some countries leading the world.

Secondly, I want to mention the choice of availability. WHO is ensuring options to protect against HIV infection. Similarly, these principles apply to different countries to provide a range of choices.

Infectious Disease Frontier: With not much time left until 2030 to end the AIDS epidemic, what efforts do you think are needed globally and in the Asia region?

Dr. Schmidt: Asia still has a long way to go, with just a few years left until 2030. From 2011 to 2021, the number of newly diagnosed HIV infections decreased by only 21%. This is not enough, not fast enough, and we cannot confidently say that we are on track to end the HIV epidemic as a public health threat by 2030. We need to do some things collectively within the Asia-Pacific region and within individual countries to truly accelerate our progress and change the course of the HIV epidemic. Now, I can talk about all of this, but I want to emphasize four particular priorities.

First is strengthening prevention. This relates not only to PrEP but to all types of HIV prevention, including post-exposure prophylaxis. We need to increase opportunities to access PrEP. We need to enhance PrEP availability. But we also need to increase funding absorption and availability. We need to increase access to PEP (post-exposure prophylaxis). We need to boost prevention awareness. If we really want to scale prevention to everyone who could benefit from it, prevention also needs domestic funding.

For me, the second key priority is HIV testing. Everyone should be able to know their HIV status. This means we need innovation in HIV testing. In some places, it’s not true innovation because community-based testing has been around for a long time. But in many countries, it’s a new concept, with testing highly restricted to specific locations. We especially need to make HIV self-testing more easily accessible. I think this not only helps people get services and want to get services, but it also helps provide services.

The third priority is how to eliminate stigma, discrimination, and criminalization. If we still have ongoing and widespread stigma and discrimination, and if we continue to criminalize many high-risk populations or people living with HIV, then we can hardly accelerate prevention, testing, and treatment. These are important priorities that need to be woven into all the work we’re doing.

The fourth priority is differentiated service delivery. This is across prevention, testing, and treatment—ensuring services are client-centered and can be provided where and how a person wants to use them. If you make healthy choices easy choices, life becomes a lot easier. If we are really serious about changing the course of the HIV epidemic, or about scaling prevention, testing, and expanding treatment, differentiated service delivery choices are what we need to do because they have been proven effective. We have good examples in our region, and if we don’t innovate what we’re doing, we might still be having this conversation in 2030 (about not reaching the goal of ending the HIV epidemic).