HIV/AIDS in Thailand: Current HIV/AIDS in Thailand: Current Situation, Successes and Remaining Situation, Successes and Remaining
ChallengesChallenges
Sombat Thanprasertsuk, M.D., M.P.H.Sombat Thanprasertsuk, M.D., M.P.H.Director, Bureau of AIDS, TB & STIsDirector, Bureau of AIDS, TB & STIsDepartment of Disease Control, MoPHDepartment of Disease Control, MoPH
22 April 200422 April 2004
Outline of PresentationOutline of Presentation
Local situation of HIV/AIDSLocal situation of HIV/AIDS Selected InterventionsSelected Interventions
• Condom 100 % ProgramCondom 100 % Program• Educational Campaign and Condom PromotionEducational Campaign and Condom Promotion• Prevention of Mother to Child TransmissionPrevention of Mother to Child Transmission• Acess to Antiretroviral TreatmentAcess to Antiretroviral Treatment• Community InvolvementCommunity Involvement• TB/HIVTB/HIV
Lessons learnedLessons learned
0
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50
60
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HIV Prevalence among Injecting Drug Users at Treatment Clinics, Thailand 1989-2003
Source : Sentinel Serosurveillance, Bureau of Epidemiology, MoPHRemark - : Switching from bi annually (June and December) to an
nually in June since 1995
%
Year
3.12
9.3
15.2
23.0
28.0 27.6 28.226.1
21.1
1618
16
12.2711.76
23.85
17.8
0
4.075
5.96.66.78.26
10.187.7
4.5
4.3
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30Ju
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Direct Indirect Mixed
HIV Sero-prevalence among Direct and Indirect Sex Workers in HIV Sero-prevalence among Direct and Indirect Sex Workers in Thailand, 1989- June 2003Thailand, 1989- June 2003
Source : Sentinel Serosurveillance, Bureau of Epidemiology, MoPH
%
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
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HIV Prevalence Among Pregnant Women, Male Conscripts, Donated
Blood:Thailand -19892003
%
Month/Year
Pregnant women
Donated blood
Conscripts (age 21)
Source: Sentinel Serosurveillance, Bureau of Epidemiology, Ministry of Public Health.Remark: Switching from bi-annually (June and December) to annually in June since 1995 Conscript data in November of each year since 1995 were not shown here
Projection of HIV Infection in ThailandProjection of HIV Infection in Thailand
0
200
400
600
800
1000
1200
1400
1985 1990 1995 2000 2005 2010 2015 2020
tho
usa
nd
s o
f HIV
infe
ctio
ns
Living w/HIV and AIDS Cumulative HIV New HIV
Projected Annual New AIDS Cases
0
10000
20000
30000
40000
50000
60000
1985 1990 1995 2000 2005 2010 2015 2020
Table 1Table 1 Estimated Cumulative Numbers of HIV/AIDS Estimated Cumulative Numbers of HIV/AIDS in the year 2004in the year 2004
HIV infections (adults and children) 1,074,155Deaths (adults and children) 501,600 PWHA 572,500 New HIV infections in 2004 19,500 New AIDS cases in 2004 49,500
Source: 1 Thai Working Groups on HIV/AIDS Projection 2000
Distribution of reported AIDS cases by year of diagnosis in Thailand, September 1984-December 2003
Numbers
Sources: Bureau of Epidemiology, MOPH, Thailand
0
5000
10000
15000
20000
25000
30000
1984-1994
1995 1996 1997 1998 1999 2000 2001 2002 2003
AIDS
The regions comparative of AIDS cases distribute by yearThe regions comparative of AIDS cases distribute by year(Data as of December 31, 2003)(Data as of December 31, 2003)
Number of AIDS cas es : 1 0 0 ,0 0 0
Pop.
Sources: Bureau of Epidemiology, Department of Disease Control
0102030405060708090
198919901991199219931994199519961997199819992000200120022003
Country
Center
North
North-Eastern
South
Risk Factor of AIDS Cases, Thailand 1984-2003
Sexual transmission83.7%
Blood receipt0.03%
Unknown7.1%
IVDU4.7%
Vertical transmission
4.4%
Source: Bureau of Epidemiology, MoPH, Thailand
data as of March 31, 2003
Distribution of AIDS cases by five opportunistic infections in ThDistribution of AIDS cases by five opportunistic infections in Thailand, ailand,
(Data as of September 1984-December 2003)(Data as of September 1984-December 2003)
0 20000 40000 60000 80000
Pneumonia Recurrent
Candidiasis
Cryptococcosis
Pneumocystis CariniiPneumonia
MycobacteriumTuberculosis
3.2
%14.8%
4.6
%
2
5 .5%
186.%
Sources: Bureau of Epidemiology, Department of Disease Control
100% Condom Program100% Condom Program
100% 100% CCondomondom PProgram in rogram in SeSex x EEstablishmentstablishment100% 100% CCondomondom PProgram in rogram in SeSex x EEstablishmentstablishment
Cooperation between authorities and sex establishmentCooperation between authorities and sex establishments’ owners or managerss’ owners or managers
Availability and accessibility of quality condomsAvailability and accessibility of quality condoms Availability of STI care, appropriate staff with experieAvailability of STI care, appropriate staff with experie
nced in outreached program, friendlynced in outreached program, friendly Monitoring and evaluation : STI infection rate, condoMonitoring and evaluation : STI infection rate, condo
m use at last sex.m use at last sex.
Cooperation between authorities and sex establishmentCooperation between authorities and sex establishments’ owners or managerss’ owners or managers
Availability and accessibility of quality condomsAvailability and accessibility of quality condoms Availability of STI care, appropriate staff with experieAvailability of STI care, appropriate staff with experie
nced in outreached program, friendlynced in outreached program, friendly Monitoring and evaluation : STI infection rate, condoMonitoring and evaluation : STI infection rate, condo
m use at last sex.m use at last sex.
Number of STD cases and condom use rateNumber of STD cases and condom use rateamong male & CSW (1984-2000)among male & CSW (1984-2000)
Number of STD cases and condom use rateNumber of STD cases and condom use rateamong male & CSW (1984-2000)among male & CSW (1984-2000)
0
100
200
300
1984 1986 1988 1990 1992 1994 1996 1998 2000
male
Sex worker
Percent condom usethousands
Condom use in CSWs and clients
-100
-
-75
-
- 50
0
100% Condom Use among commercial sex 100% Condom Use among commercial sex worker during 1997-2002worker during 1997-2002
82
84
86
88
90
92
94
96
98
100
1997 1998 1999 2000 2001 2002
Direct
Indirect %
Source : Sentinel Serosurveillance, Bureau of Epidemiology, MoPH
Educational Campaign and Educational Campaign and Condom Promotion among Condom Promotion among
General PublicGeneral Public
National behaviourNational behaviour ssurveillance surveillance surveyurvey 2000-20022000-2002
Shift in sexual partner selection, among men, from Shift in sexual partner selection, among men, from sex worker to casual partners (friends, girlfriends, sex worker to casual partners (friends, girlfriends, etc.) etc.)
Survey among youth aged 15-25 show high level Survey among youth aged 15-25 show high level of knowledge toward HIV (72% of youth) but of knowledge toward HIV (72% of youth) but 68% indicated that carrying condom is 68% indicated that carrying condom is uncomfortableuncomfortable
100% condom use didn’t reach general population 100% condom use didn’t reach general population and youth, factory workers and mobile population and youth, factory workers and mobile population groupsgroups
Condom social marketingCondom social marketingCondom social marketingCondom social marketing
• Extend condom use beyond CSW Extend condom use beyond CSW• Reduce social stigma for condom use and Reduce social stigma for condom use and
carry.carry.• Increase accessibilit Increase accessibility y • Promote Condom Vending MachinePromote Condom Vending Machine• - Quality assurance of condom both pre an - Quality assurance of condom both pre an
- d post marketing surveillance. - d post marketing surveillance.
• Extend condom use beyond CSW Extend condom use beyond CSW• Reduce social stigma for condom use and Reduce social stigma for condom use and
carry.carry.• Increase accessibilit Increase accessibility y • Promote Condom Vending MachinePromote Condom Vending Machine• - Quality assurance of condom both pre an - Quality assurance of condom both pre an
- d post marketing surveillance. - d post marketing surveillance.
Condom Vending MachineCondom Vending MachineCondom Vending MachineCondom Vending Machine
Prevention of Mother to Prevention of Mother to Child TransmissionChild Transmission
1994 - Results of ACTG 076: ZDV decreases mother-to-child transmission by 2/3
1996 - MOPH and World Bank re-evaluate ARV use: ZDV in pregnant women is most cost-effective use of ARV
1998 - Bangkok trial shows effectiveness of short-course ZDV
1997-98 MOPH begins pilot programs providing short-course ZDV to pregnant women in Regions 10 and 7
1999 - National PMTCT guidelines reviewed
2000 - Regimen of ZDV for HIV+ women/infants supported nationally
2003 - ZDV + NVP as regimen for PMTCT
Prevention Works:Development of Thailand’s Nation
al Policy on PMTCT
Thailand 's PMTCT programmeThailand 's PMTCT programme VCT, ZDV prophylaxis, infant formula replacement VCT, ZDV prophylaxis, infant formula replacement
feeding feeding
In 2002; 559,702 pregnant women received ANCIn 2002; 559,702 pregnant women received ANC• 96.7 % of pregnant women participated in VCT96.7 % of pregnant women participated in VCT• 1.15 % found to be HIV+1.15 % found to be HIV+• 80 % of HIV + mothers received ZDV (AZT) 80 % of HIV + mothers received ZDV (AZT) • 95 % of infants born to HIV+ mothers received ZDV 95 % of infants born to HIV+ mothers received ZDV
Reduce risk from 30 % to 8 %, preventing 2,500- 3000 Reduce risk from 30 % to 8 %, preventing 2,500- 3000 infant infections each year,infant infections each year,
PMTCT+ cover care of HIV+ mother’s familyPMTCT+ cover care of HIV+ mother’s family
Prevent Mother to Child TransmissionPrevent Mother to Child Transmission
Antiretroviral during pregnancy and Antiretroviral during pregnancy and labourlabour
Milk for children born with HIV +ve Milk for children born with HIV +ve womenwomen
Decrease infection rate Decrease infection rate • from 30% to < 3%%from 30% to < 3%%
Number of Pediatric AIDS in Thailand 1988 - 2001Number of Pediatric AIDS in Thailand 1988 - 2001Number of Pediatric AIDS in Thailand 1988 - 2001Number of Pediatric AIDS in Thailand 1988 - 2001
19 71 134
460
755870
12161282
11541055
889
572
371
0
200
400
600
800
1000
1200
1400
88-90 91 92 93 94 95 96 97 98 99 00 01 02
Year
Total = 8868 cases
Access to Antiretroviral Access to Antiretroviral TreatmentTreatment
The 3 by 5 Initiative The 3 by 5 Initiative
"Lack of access to antiretroviral therapy (ART) is "Lack of access to antiretroviral therapy (ART) is a global health emergency… a global health emergency… To deliver antiretroviral treatment to the millions To deliver antiretroviral treatment to the millions who need it, we must change the way we think anwho need it, we must change the way we think and change the way we act.”d change the way we act.”LEE Jong-wook, Director-General, World Health OrLEE Jong-wook, Director-General, World Health Organizationganization
Access to HIV/AIDS Medical Care Access to HIV/AIDS Medical Care in in ThaiThailandland
Treatment of common opportunistic infections as TB, PCP, cryptococcal meningitis etc.
Monotherapy (AZT) 1992- 1995
HIV Clinical Research Network (dual and triple ARV) 1997-2000
Dual therapy (AZT+ddI and AZT+ ddC) 1995 - 1996
Access to care (triple ARV and OI prevention and treatment) since 2000
National Access to ARV for PWHA since 2003
National Access to ARV for PWHA
Researchand development
Drug stock
management
MonitoringEvaluation International
Collaboration
Labnetwork
Datamanagement
ART TeamART Team
Hospital: Physician, nurse, lab technician, Hospital: Physician, nurse, lab technician,
Pharmacist, counselor, social workerPharmacist, counselor, social worker NGO, PWHA groupNGO, PWHA group Experts from medical universitiesExperts from medical universities Provincial Health OfficesProvincial Health Offices Regional Offices of Disease Prevention and Regional Offices of Disease Prevention and
ControlControl Regional Health CentersRegional Health Centers Ministry of Public Health: BATS, DOH, DOMS, DOMHMinistry of Public Health: BATS, DOH, DOMS, DOMH
Inclusion criteria for ARTInclusion criteria for ART (Adult)(Adult)
AIDS AIDS
Symptomatic with CD4 ≤ 250 cell/mmSymptomatic with CD4 ≤ 250 cell/mm33
Asymptomatic with CD4 < 200 cell/mmAsymptomatic with CD4 < 200 cell/mm33
All children with age All children with age < < 12 12 momonthsnths
Children agedChildren aged >> 12 months with 12 months with Clinical staging B, CClinical staging B, C
oror CDCD44 < < 2020%%
Criteria (Children): Clinical & ImmunologicalCriteria (Children): Clinical & Immunological
Antiretroviral RegimenAntiretroviral Regimenss in in National Access National Access to ARV Program for PHA, to ARV Program for PHA, 2002-20032002-2003
DD44TT, 3, 3TCTC,, Nevirapine Nevirapine
AZT, 3TC, NevirapineAZT, 3TC, Nevirapine
DD44T, T, 33TC, Efavirenz TC, Efavirenz
AZT, 3TC, EfavirenzAZT, 3TC, Efavirenz
DD44T, T, 33TC, Boosted PI TC, Boosted PI
AZT, 3TC, Boosted PIAZT, 3TC, Boosted PI
(Indinavir+ritonavir)(Indinavir+ritonavir)
20012001 Target - 3,000 individuals, 109 hospitalsTarget - 3,000 individuals, 109 hospitals
20022002 Target - 13,000 individuals, 430 hospitalsTarget - 13,000 individuals, 430 hospitals
20032003 Target - 23,000 individuals, 630 hospitalsTarget - 23,000 individuals, 630 hospitals
20042004 Target - 50,000 individuals, All hospitalsTarget - 50,000 individuals, All hospitals
Expand Access to ARV Plan, ThailandExpand Access to ARV Plan, Thailand
Sources of Sources of Resources for Resources for Antiretroviral Antiretroviral TTherapy herapy in in 20042004
Government Budget : Government Budget : National Access to Antiretroviral National Access to Antiretroviral Program for PHA [ Program for PHA [ NAPHANAPHA ] [cover 40,000 cases] ] [cover 40,000 cases]• ATC, PATC, PMTCT plusATC, PATC, PMTCT plus
• Co-payment system Co-payment system
• Patients pPatients participatarticipating ing in clinical in clinical studiesstudies
Global Fund [cover 10,000 cases]Global Fund [cover 10,000 cases] PPatients pay out of atients pay out of their owntheir own pockets pockets Health Insurance SchemeHealth Insurance Scheme
• Social SecuritySocial Security
• Civil Servant Health BenefitCivil Servant Health Benefit
Community involvementCommunity involvement
Community capacity buildingCommunity capacity building Awareness of community to HIV/AIDSAwareness of community to HIV/AIDS Capacity building for local authorities : Capacity building for local authorities :
• Tumbon (sub-district) administrative organisation, Tumbon (sub-district) administrative organisation, • Health volunteer, Health volunteer, • Religious leader etc.Religious leader etc.
Collaboration with NGOs and various local Collaboration with NGOs and various local agencies in HIV/AIDS agencies in HIV/AIDS
Strengthening groups of People with HIV/AIDSStrengthening groups of People with HIV/AIDS
TB/HIV ProgramTB/HIV Program
TB/HIV PolicyTB/HIV Policy TB/HIV/STI programmeTB/HIV/STI programme
• national functional TB/HIV coordinating national functional TB/HIV coordinating committee, committee,
TB/HIV ongoing activities TB/HIV ongoing activities Strengthen core activitiesStrengthen core activities
-TB: DOTS-TB: DOTS-HIV: prevention and care-HIV: prevention and care-STI: syndromic approach-STI: syndromic approach
Collaborative TB/HIV activitiesCollaborative TB/HIV activities
A. Establish the mechanism for collaborationA. Establish the mechanism for collaborationA.1. TB/HIV coordinating bodiesA.1. TB/HIV coordinating bodiesA.2. HIV surveillance among TB patientA.2. HIV surveillance among TB patientA.3. TB/HIV planningA.3. TB/HIV planningA.4. TB/HIV monitoring and evaluationA.4. TB/HIV monitoring and evaluation
B. To decrease the burden of TB in PLWHAB. To decrease the burden of TB in PLWHAB.1. Intensified TB case findingB.1. Intensified TB case findingB.2. Isoniazid preventive therapyB.2. Isoniazid preventive therapyB.3. TB infection control in care and congregate settingsB.3. TB infection control in care and congregate settings
C. To decrease the burden of HIV in TB patientsC. To decrease the burden of HIV in TB patientsC.1. HIV testing and counsellingC.1. HIV testing and counsellingC.2. HIV preventive methodsC.2. HIV preventive methodsC.3. Cotrimoxazole preventive therapyC.3. Cotrimoxazole preventive therapyC.4. HIV/AIDS care and supportC.4. HIV/AIDS care and supportC.5. Antiretroviral therapy to TB patients.C.5. Antiretroviral therapy to TB patients.
WHO STP, TB/HIV; ICP 001
Focused Intervention forFocused Intervention for 2004 2004 Condom and Social MarketingCondom and Social Marketing Youth Health programYouth Health program Casual sex & safe sexCasual sex & safe sex Public EducationPublic Education CoCoununseseliling (ng (VCTVCT)) Targeted group educationTargeted group education Special approach program for Special approach program for
Mobile pop., Vulnerable comMobile pop., Vulnerable communities and Border areamunities and Border area
Access to care and Services - StrAccess to care and Services - Strengthening services and Advocaengthening services and Advocacycy
AAntiretroviral access ntiretroviral access PMTCTPMTCT Treatment of Opportunistic InfeTreatment of Opportunistic Infe
ctionction HIV-TB Integrated strategyHIV-TB Integrated strategy CommunitCommunityy involvementinvolvement CCC CCC (Family medicine)(Family medicine) Social Services for People Social Services for People
affected by AIDSaffected by AIDS
Lessons learned (1)Lessons learned (1)
HIV/AIDS HIV/AIDS bburden is high and still raging, a major health urden is high and still raging, a major health threat to the country.threat to the country.
National strategic plan and National strategic plan and iimplementation need to be enmplementation need to be enhancehancedd
National responses with strong political and financial National responses with strong political and financial commitmentcommitment is requiredis required
New New ffocused ocused preventive preventive intervention for youth, mobile pintervention for youth, mobile population and vulnerable groups need to be addressed anopulation and vulnerable groups need to be addressed and rapidly implementedd rapidly implemented
Lessons learned (2)Lessons learned (2)
- Challenges on ARV Program- Challenges on ARV Program- Long term social services and supports for families - Long term social services and supports for families
affected by AIDS are required affected by AIDS are required - - PartnershipsPartnerships, c, collaboration ollaboration and involvment from all and involvment from all
sectors of society sectors of society - key - key to to progressprogress, , sustainabilitsustainability, y, and effective responsesand effective responses
- Monitoring and Evaluation - crucial component- Monitoring and Evaluation - crucial component, , including Eincluding Epidemiological, social, and behavioral respidemiological, social, and behavioral research and monitoring earch and monitoring
Thank youThank you