National ART Program - NAP

Utilization of NAP Monitoring data for Policy Decision “Treatment as Prevention”

Sorakij Bhakeecheep, MDDirector

National Health Security Office, Region 1THAILAND.

Contents

• Brief overview ART program Thailand• National patient monitoring system - NAP• Utilization of NAP monitoring data for policy

decision “Treatment as Prevention”

ART Program in Thailand

1997-98 2000 01 02 03 04 05 06 07 11

ARV research(mono/dual)

National Access to ARV Treatment for PLHIV (NAPHA)(Pilot program under GF and MoPH research fund)

PMTCT researches

National Health Security Act(Health promotion, Prevention,

Cure and Rehabilitation)

12 13

PMTCT National Program

14

ART at CD4<350

Advocate TasP (Any CD4)

Universal Access to ART

ART at CD4<200

ART Coverage among Persons Living with HIVNumber of PLHA Receiving ART (2001-2013)

20012002

20032004

20052006

20072008

20092010

20112012

20132014

20152016

20172018

20192020

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

PLHA-CD4 > 500

62,330

137,090

76,371

PLHA-CD4 ≤ 500

Source: AIDS Epidemic Model (AEM), NHSO – NAP, SSO, CSMBS, GF, and Thai GPO

PLHA-≤ 350246,049

•Area graph shows estimated persons living with HIV by CD4 levels•Linear graph shows number of currently PWHA retain in the cohort•The coverage is 80% according to CD4<350

80% Coverage of ART need(CD4<350)

National AIDS Program Monitoring System(NAP)

- Implemented in April 2007- Designed for supporting patient care, fund

administration and program monitoring- Web application architecture- Centralized user management system- Individual data collecting with transaction oriented

(medications, lab, etc)- National ID encryption to avoid data duplication

Overview of NAP System Architecture

Health Service Providers National Health Security Office

VCT facilities

HIV clinics

Laboratories

Procurement & Logistics

Link to Birth-Death Registration from ministry of interior

AIDS experts

Internet Data Processing

NAP Database

Internet

Fund Administration

Program Monitoring

Policy decision & planningPatient monitoring and

quality improvement

Concept of Using Data to Inform Policy

Information base

Policy AnalysisPolicy Decision

Resource Preparation

Knowledge base

Input Process Output

Evidence Based of Treatment as Prevention: Clinical vs. Public Health Aspect

• Currently, there is insufficient evidence and/or favorable risk-benefit profile to support initiating ART at CD4 >500 or regardless of CD4 …. (Clinical aspect)(Reference: WHO Consolidated Guidelines on The Use of ARV Drugs for Treating and Preventing HIV Infection : p. 93)

• Observation from HTPN 052 :- PWHA receiving ART with suppressed viral load would reduce risk of HIV transmission to their partners (Prevention aspect)

• In conclusion, the benefits of starting ART at CD4 >500 is not for who’s taking ARV drugs, but for their partners (Public Health Benefit)

What should be considered in addition to efficacy and benefit of

an intervention?

1. Cost-effectiveness (Return of investment)2. Negative impacts (Retention &

Adherence)3. Resources availability (Man, Money)4. Feasibility & Sustainability5. Prioritization6. Equity and ethics

How can BIG Data answer these questions ?

PWHA Cascade

Source: AIDS Epidemic Model (AEM), NHSO, SSO, CSMBS, GF, and Thai GPO

Status Reported number

HIV+ currently alive (Estimated) 459,509 (100%)

HIV+ currently access to treatment 246,049 (54%)

HIV+ not accessed to treatment (if treat for all) 213,460 (46%)

HIV+ never registered to National registry 133,781 (63%)

HIV+ ever registered to National registry 79,679 (37%)

Lost of follow up during pre-ART (CD4 > 350) 37,292 (47%)

Lost of follow up during receiving ART 42,387 (53%)

• Only 54% of PWHA can access to ART• 46% cannot access to ART • Among who cannot access to ART, 37% have been registered but lost during follow up

• 47% - loss during pre-ART• 53% - loss during receiving ART

Proportion of CD4 at Diagnosis and ART Initiation(2008-2013)

CD4 at newly HIV+ diagnosis CD4 at ART Initiation

• Nearly half of new HIV+ had very low CD4 (less than 100) at the time of diagnosis and ART initiation• These findings demonstrated late access to HIV care services, thus reflecting the performance of HCT program

Performance of HCT Program need to be improved

98 94101 98 97

109 84 75 88 97 97

111 Median

CD4

Children Adults

331,357381,717 286,214 227,451 175,813 155,221

23,510 (6%)

(71%)(82%)

(43%)(56%)

(38%)

Cascade Accessing and Retention to Care-ART, (2007 – 2013), NAP Monitoring System, NHSO

Data source: NAP Database , National Health Security Office

Effectiveness of ART Program (2012)

Data source: National Health Security Office

No ART Alive Retained to care

CD4<350 or OI

0

20,000

40,000

60,000

80,000

100,000 88,761

57,658

18,01710,287

0

100,000

200,000

300,000

237,510214,016

185,726

131,093

Total Registration to care and treatment services = 326,271

Pre-ART

Retention rate87%

Retention rate31%

Receiving ART

• In pre-ART, loss to follow up occurs 3 times higher than ART group• A number of PWA who are eligible for ART didn’t receive treatment• In ART group, 70% of who retained to ART has viral load suppression

Quality of care in ART program need to be improved

70%

Using Projecting Model to Forecast ART Service Demands

Data input from NAP is required in order to calculate

service demand from Projecting Model

Estimated number of PLHA receiving ART 2014-2019

2013

2014 (BL)

2015

2016

2019

Number of PWHA receiving ART -Baseline (CD4 < 350)

171,028

182,217

192,188

201,116

222,505(22%)

-Any CD4 + Current HCT

171,028

182,688

198,238

210,117

236,997(30%)

-Any CD4 + 25% increasing HCT

171,028

182,688

198,650

211,968

249,932(37%)

-Any CD4 + 50% increasing HCT

171,028

182,688

198,986

213,488

260,643(43%)

-Any CD4 +100% increasing HCT

171,028

182,688

199,660

216,528

282,064(54%)

Increased # PWHA receiving ART compare to baseline scenario of the same year-Any CD4 + Current HCT - 470 6,050 9,001

14,492 (7%)

-Any CD4 + 25% increasing HCT - 470 6,462

10,852

27,427 (12%)

-Any CD4 + 50% increasing HCT - 470 6,798

12,372

38,138 (17%)

-Any CD4 + 100% increasing HCT - 470 7,472

15,412

59,559 (27%)

ART Service Demand Forecasting (UHC Schemes only)

Within next 5 years (2019), work load will increase ~20 – 50 %

ART Budget Forecasting (2015-2019)

Scenario

2015 2016 2017 2018 2019

Additional budget needed

(drugs+lab)

Total program

budget rising from 2014

-Any CD4 + Current HCT

2.1 3.2 3.8 4.4 5.1 18.6 32.8

-Any CD4 + 25% increasing HCT

2.3 3.8 5.6 7.6 9.7 29 43.2

-Any CD4 + 50% increasing HCT

2.4 4.4 7.3 10.3 13.4 37.8 52

-Any CD4 + 100% increasing HCT

2.6 5.4 10.4 15.6 21 55 69.2

ART Unit Cost (Drugs + Lab) = 352 USD/pt/yr, not include cost of HCT, capacity building, operation)

Unit = million USD

Additional budget needed from baseline scenario

•In the next 5 years, additional budget need for drugs and lab would be 18 – 55 mUSD•To end AIDS in the next 10 years, Thailand would spend totally of 400 mUSD in addition to baseline scenario

National Health Security Office 17

CD4 < 350 CD4 350-500 CD4 > 500 Total

# Estimated PWHIV 308,379 74,760 76,371 459,510

Known HIV status (Above water) 246,049 8,971 6,109 261,129

HIV status unknown (Under water) 62,330 65,789 70,262 198,381(43%)

% coverage 80% 12% 8% 57%

CD4 < 350CD4 = 350-500

CD4 > 500

Known HIV status

HIV statusunknown

Issue on Equity and Priority

1 3 5

4 62

• 43% of PWHIV do not know their HIV status. One-third of which urgently need ART (<350). Barriers stop them from accessing to health services.• Initiating ART at any CD4 just only benefit for people who are already accessed to services, but DO NOT solve the existing barriers in the inaccessible group.

In resources limited setting, who should we considered a PRIORITY ?

Conclusion• TasP could reduce new HIV infection and has showed some

potential in ending AIDS

• To implement this intervention, some critical issues should be seriously considered

• Health infra-structure strengthening (including human resources) for:– Extensive HCT scaling up esp. MARPs

– Effective quality improvement to increase early access and retention to ART

• Long term budget availability including domestic and external resources

Acknowledgement

• National Health Security Office (NHSO)• Thailand MoPH-US CDC Collaboration (TUC)• Bureau of AIDS, TB and STIs, MoPH• All ART centers under UHC network