The Institute of HIV Research and Innovation (IHRI) is a non-profit organisation located in Bangkok, Thailand that implementing HIV and sexual health research and programs. IHRI’s key goals are to provide advanced clinical and implementation research on HIV and other health-related issues, to strengthen the capacity of community health workers and other health care providers to deliver services to key populations, and to foster policy change and advocacy. Over the last 20 years, the success of their evidence-based, person-centred, and community-led approach to key population-led health services (KPLHS) has positioned IHRI as a key player and innovator in infectious disease research and service delivery in Thailand and the Asia-Pacific region.
The strength of their model relies on their core commitment to community leadership, whereby affected communities lead the research and service delivery process, with technical experts and implementers at IHRI playing a supporting and enabling role. This is made possible through a context-specific approach to the capacity building of lay health workers, who work in partnership with other health care professionals to provide services such as HIV testing, pre-exposure prophylaxis (PrEP), and HIV treatment for key populations -- and to produce evidence on the effects of their interventions.
Over their past 20 years of work in the HIV and sexual health field, IHRI has adopted a flexible approach to community-led priority-setting, grounded in strong principles and always informed by local needs. Building on this work, IHRI aims to serve as a learning hub to strengthen the capacity of community health workers and to promote and advocate for evidence-based policy change. As a result of this commitment to knowledge translation, their community-led approach to health service provision for key populations has been endorsed and institutionalised by the Thai government.
Their current flagship project is the Key Population-led Health Services (KPLHS) programme, which they developed and institutionalised. Building on the KPLHS concept, IHRI established the Tangerine Clinics that use an integrated gender-affirming sexual health service approach to effectively bring more than 6,200 transgender women and men into the healthcare system. The Tangerine Clinic model has been expanded to several countries in the Asia-Pacific, including Vietnam, the Philippines, Myanmar, Nepal and India. IHRI works with a broad range of stakeholders, including governments, international non-governmental organisations, and domestic and international civil society organisations.
IHRI’s work is based on core principles of respect, equity, diversity, and sustainability. Their organisational model is centred on community members and clients leading the design and implementation of rights-based, client-centred health services. Through meaningful partnership with communities, they provide differentiated services that are friendly, convenient, and high-quality and that improve people’s quality of life.
As one staff member explained, the organisation doesn’t use the concept of community engagement in their work, focusing rather on community leadership. Because their model is fundamentally based on the leadership of community-based lay service provider, without whom no activities could take place, they do not create a binary between researchers and service providers and community members that need to be resolved through community engagement activities.
In the understanding of senior IHRI staff, the need for community leadership in their work emerged from very concrete and pressing needs of communities themselves, rather than through an explicitly transformative or power shifting intention. In 2014, the leader of a community organisation for key populations approached IHRI’s director to ask if they could conduct HIV testing themselves, rather than having professionals from outside the community coming to test people. In the context of high rates of stigma and discrimination, mistrust of outsiders was a barrier to health care access for many. This encounter created a “perfect storm,” the director recalled, as overworked health care providers in an overburdened health care system were also in need of new ways of working. At the same time, there was a shift in the funding environment during this period towards supporting more community-led projects. An IHRI staff member described this moment as a “game changer” for them as a health care provider, through which they realised that their role should be to service as a “technical assistant provider,” aiming to empower community members to become the direct service providers.
From that initial impulse, IHRI consolidated its community-led “test and treat” model, which eventually involved lay providers offering services along the whole HIV care continuum – from testing to treatment continuity. This allowed IHRI to refine a comprehensive package of services, including clinical and psychosocial services, that could be delivered on the ground through a new infrastructure for community-led services.
This model has proven to be extremely effective and efficient at “filling the gap” in health services for key populations and moving closer to ending HIV in Thailand. Currently, more than 50% of 50% of HIV testing and 80% of PrEP services among key populations in Thailand are provided through their KPLHS programmes. In 2019, the strong evidence they had produced of the success of this programme led to the Thai Ministry of Public Health announcing a policy change to endorse and legalise the provision of HIV services by key population lay providers as part of the national HIV strategy, integrating KPLHS into the Ministry of Public Health to sustain this service delivery model. KPLHS has become not just a service provided by community-based organisations but a true partnership with government and public health facilities. The goal for 2023 is to extend the model to 18 additional regions across the country, ensuring all have access to community-led care.
Across their work, IHRI has been able to demonstrate how community leadership can lead to better, more effective service delivery and to stronger evidence for action. With genuine community leadership of research and programmes, traditional models of community engagement become no longer necessary for transformative practice.
One of IHRI’s main successes rests in their ongoing foregrounding of learning and innovation throughout their work. They continuously adapt and refine their model of service delivery through clinical and implementation research projects, which together form their research platform. Through ensuring that their work is evidence-based and sharing this learning more publicly, they also deepen their relationships with local and national institutions as well as international advisory organisations. This learning approach allows them to expand their impact by serving as a learning hub that translates evidenced-based, innovative knowledge into improvements in health policies and practices.
The sustainability and credibility of their KPLHS model is a testament to the success of their evidence-based approach. This approach, together with the community-led infrastructure and tools they created, has also allowed for the replication of their models in other regions and countries, as well as its adaptation to address other health issues. Their evidence-based model moves beyond integrates the ethical and sometimes instrumental goals of community engagement to offer a strong proof of concept for more meaningful models of community leadership in health research and programming.
While they have managed to build and scale their model sustainably in HIV research and service delivery, they acknowledge that their approach hasn’t yet expanded to address other health issues. IHRI staff also acknowledge that their community-led, person-centred and stigma-free approach still has a long way to go when it comes to clinical research and service delivery outside of the clinics they lead, where stigmatising attitudes from health remain a major barrier to care.
IHRI’s core focus on delivering evidence-based, community-led programs is exciting as it moves beyond traditional modes of community engagement to enable more meaningful partnerships. By focusing on community needs and visions for the programme from the onset, and collaboratively trying and testing solutions until they prove effective, community leadership is integrated into program design and deliver, rather than added as a tick-box exercise or additional set of activities dissociated from programme outcomes.