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

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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

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4.3

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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

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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

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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