Phurpa Lhamo | Punakha

Beginning early next year, some Bhutanese can run their own tests for HIV (human immunodeficiency virus) when the health ministry pilots the HIV self-testing (HIVST) kit and introduce the community-led HIV testing.

This is to reduce the detection gap in the country and to ensure privacy to the individuals.

According to World Health Organisation (WHO), 77 countries have adopted the HIV self-testing policies.

A protocol highlighting the procedures and steps of conducting the tests and follow-up on patients, among other directives is being developed.

Sample size, training of health officials and area of the pilot project would be determined according to the protocol.

The HIVST kits (testing through oral swaps) would be procured through the World Health Organisation (WHO) and the Global Fund support.

For the community-led HIV testing, members of Lhak-Sam and self-help groups such as Rainbow Bhutan and Red Purse are expected to receive training to conduct the HIV tests.

These initiatives were discussed at the two-day national consultation in strengthening HIV and AIDS advocacy programme themed ‘Bridging the gap through leaving no one behind,’ held in Punakha. Lhak-Sam conducted the consultation meeting.

The meeting with participants from private sectors, government agencies, CSOs, monastic and religious institutions and media ended yesterday in Punakha.

Bhutan has an estimated 1,300 people living with HIV (PLHIV). Of that, only 721 (374 male and 347 female) have been diagnosed. This means that around 44.5 percent of the total PLHIV isn’t detected.

Bhutan’s 90-100-90  target

The detection gap further hampers Bhutan’s commitment to achieving the 90-100-90 goal by 2023 and ending the HIV epidemic by 2030.

The goal targets to ensure that 90 percent of the total HIV-infected persons know their status; 100 percent of those diagnosed with HIV/AIDS are put on treatment; and 90 percent of PLHIV on treatment to achieve viral load suppression.

Of the three targets, Bhutan has achieved its target to ensure that 90 percent of PLHIV on treatment to achieve viral load suppression.

Of Bhutan’s 721 diagnosed HIV/AIDS cases, 545 are living cases. Of the total living cases, 525 are on ART (antiretroviral treatment).

Bhutan has achieved 95 percent of putting all PLHIV persons on ART.

Detection gap of 44.5 percent in Bhutan remains a concern among the stakeholders working towards ending HIV.

In Bhutan, of the total 1,300 estimate persons, nearly 580 PLHIV are not detected.

Lhak-Sam’s executive director, Wangda Dorji said that with an individual having the potential to infect around five individuals unknowingly in a year, the total undetected cases could infect nearly 3,000 individuals a year.

He added that today an approximate 320,000 people have not come forward for voluntary testing and counselling. “So, the question arises, where are we going wrong in terms of bridging the gap between the service seeker and the service provider.”

Eliminating mother-child HIV transmission

The country is also gearing towards declaring the elimination of mother-child HIV transmission. Today, with 5.5 percent, mother to child transmission is the second highest mode of transmission of HIV.

With 93.6 percent of the cases, the sexual route remains the main mode of transmission of HIV.

Speaking at the meeting, Department of Public Health Program Manager Lekey Khandu said that the introduction of voluntary counselling and testing (VCT) in all hospitals in 2006 was targeted towards pregnant mothers.

In 2013, the VCT was further extended to the Basic Health Units (BHUs) to ensure that all pregnant mothers have access to HIV testing facilities.

The aim was toward triple elimination—transmission of HIV, congenital syphilis and hepatitis B from pregnant mothers to the child.

Lekey Khandu said that mother to child transmission of HIV had been eliminated, but the ministry today required evidence to show the achievement.

The HIV scenario 

On average 44 HIV cases are detected every year in Bhutan. Until June 2020, 34 HIV-positive cases were reported.

With 60 cases, 2019 recorded the maximum number of cases in Bhutan. Of the 721 cases in the country, 374 male and 347 female.

Lekey Khandu said that unlike in other countries where female dominated the cases, there was no gender disparity in the number of HIV cases in Bhutan.

“Estimated new infections and people living with HIV are gradually showing signs of decline. We are at the stabilising stage but we need to put in more effort to decrease this curve,” he said.

A majority of PLHIV are between the age group of 20 and 49.

Lekey Khandu said that a certain number of cases were also among people above 50. “We are trying to analyse why cases for 50 plus are increasing annually. In our society because of the relaxed sexual norms, the prevalence of intergenerational sex,  and transitional sex might be the reason. The younger group of female is infected and older age men are infected.”

Bhutan saw an increase in HIV detection rate in 2006.

Lekey Khandu attributed this to the introduction of two health information and service centres (HISC) in 2005 in Thimphu and Phuentsholing. The centres targeted sex workers and drug users.

Based on the effectiveness of HISC, two more such centres were opened in Gelephu and Samdrupjongkhar in 2010 targeting men having sex with men and the LGBT community.

Contact tracing provides largely to the detection HIV positive person. Until 2019 since detection began in 1993, 29 percent of cases detected were through contact tracing. At 24 percent, medical screening also provided largely to diagnosis of HIV.

Way forward

Apart from community-led testing and the HIVST, the ministry is also working towards providing comprehensive key population preventive services. This service package would include a range of services including mental health and counselling.

Lekey Khandu said that the mobile vans to conduct HIV tests had proven beneficial to the people and health workers and that the services would be enhanced.

The HIV testing services have also been introduced in out-patient department (OPD), in-patient department (IPD) and emergency wards.

Unlike in the past, health workers would now initiate HIV tests depending on a person’s willingness.

Because contact tracing has proven beneficial in Bhutan, the ministry will develop protocols to further strengthen it. The protocol would provide guidelines on the time frame of conducting contact tracing, which today is conducted by health workers on their own willingness and concern.

Advocacy, condom promotion, and the treat-all policy, where all patient diagnosed with HIV are put on ART are other measures to fight HIV in Bhutan.

Discrimination and stigmatisation of PLHIV, and lost to follow-up cases of PLHIV are some of the major challenges in fighting HIV.