Access to ARV : Non Rational ... Approach to Inappropriate Treatment Institute of Health Research Chulalongkorn University This is a part of the project aims to study information needs among PHA for decision making about ARV treatments This presentation is a part of the project aims to study information needs, among people living with HIV/AIDS (or PHA) for decision making about antiretroviral treatment. The project has been performed by Drug Dependence Research Center, Institute of Health Research, Chulalongkorn University.

HIV/AIDS : The Leading Health Threat Deaths (x1000) DALYs (x1000) The first case of acquired immunodeficiency syndrome was identified in 1981. Since then, about three million people died from HIV/AIDS and the toll of disease burden reached to forty million. Now, HIV/AIDS has become the leading causes of mortality and morbidity among working aged people especially in resource poor countries. (The World Health Report 2003)

HIV/AIDS : The Leading Health Threat In Thailand, The first AIDS case was identified in September 1984. In May 1985, The Ministry of Public Health declared HIV infection as a priority communicable disease. And the first wave of rapid epidemic spread of HIV infection actually started in the beginning of 1988. The intravenous drug user population was the first group to suffer from the nationwide rapid spread of HIV infection. The prevalence rose from less than one percent (1%) up to more than thirty percent (30%) within 8 months. Female prostitute was the second population whose HIV prevalence was increasing. Then, the majority of the HIV infection in Thailand is through heterosexual transmission. For twenty years after HIV attacked Thailand, over half a million Thai people have HIV/AIDS and we will have about fifty thousand new AIDS case per year. (The Thai Working Group on HIV/AIDS Projection. “Projections for HIV/AIDS in Thailand : 2000-2020” March 2001)

ARV : Treatment To Fight AIDS Coverage of adults with antiretroviral therapy (WHO, 2002) Asia-Pacific (43,000/1,000,000) Eastern Mediterranean (3,000/9,000) Europe (7,000/80,000) The strategies to fight HIV/AIDS include prevention from HIV infection, treatment of the disease and care of the patient. Antiretroviral drug is strategic treatment. Azidothymidine or AZT was the first ARV approved for use in USA in 1987. The effective ARV as HAART was developed by 1995. Nowadays, there are more than twenty FDA-approved antiretroviral drugs. But only 5% of people living with HIV/AIDS who need treatment can access to ARV. The coverage of ARV in Africa is only 1% and in South-East Asia is only 4%. Americas (196,000/370,000) Africa (50,000/4,100,0000

ARV : Treatment To Fight AIDS Hard to access to ARV leads to the low percentage coverage. World Health Organization set the goal to fill the coverage gap. WHO aims to provide ARV for three million people living with HIV/AIDS in developing countries by the year of two thousand and five. The strategy include scaling up access to treatment, increasing drug procurement volumes and decreasing drug price for low-income countries. Worldwide : WHO backs “3 by 5” target of ARV treatment for 3 million people by 2005

Thailand : Access To ARV Assessment of South-East Asia for providing antiretroviral treatment indicates that Thailand has good preparedness for scaling-up treatment with ARV. National policy of Thailand includes the plan for antiretroviral treatment, the guideline and training of ARV management. Ministry of Public Health subsidized ARV for ten thousand PHA last year and aims to supply ARV for fifty thousand PHA by the fiscal year of two thousand and four which is the W-H-O goal “3 by 5” target for Thailand.

Thailand : Access To ARV The Government Pharmaceutical Organization (GPO) of Thailand can produce generic ARV, both NRTI and NNRTI, single and fixed dose combination. The most popular regimen is GPOvir, the one pill of stavudine (d4T), lamivudine (3TC) and nevirapine (NVP).

Thailand PHA: Access to ARV Subsidized (Free/Co-payment) National Program – ATC/NAPHA Clinical trial – International/ National/ Medical School Projects 30 Baht Health Insurance Program Non-Subsidized Hospitals– Governmental/Private/ Medical School Now, Thailand has National Access to Antiretroviral Program for People Living with HIV/AIDS or NAPHA. This national program is a step forward from Access to Care or ATC launched by the year two thousand. Fifty thousand PHA, naive or experienced cases, will receive ARV from this national program for free or co-payment. The other sources of ARV treatment include participating in many clinical trials, or PHA can pay for ARV at many hospitals under physician investigation and ARV prescription. In addition, PHA can pay only thirty bahts for GPOvir under health insurance program. PHA can purchase ARV at many medical sectors with prescription

Health Self Help Groups for HIV/AIDS PHA in Thailand is not alone. There are about 600 health self help groups for HIV/AIDS over the country. About 50% are non-governmental organization. Thirty percent are in Bangkok. PHA share their knowledge, experiences of illness and treatment, both modern and traditional among each other. Some groups coordinate their activities with medical sectors and subsidized some basic health examination and opportunistic prophylactic treatment.

PHA - Access to ARV I would like to present some informations from key informant about PHA attitude in access to ARV. The clinical trials or even ATC program have a limit of time. PHA network help each other to find ARV subsidized projects to sustain the treatment.

Cheap drug as GPOvir is popular mean of choice for PHA own pocket.

PHA - Access to ARV National guideline set the time to start ARV at when CD4 below two hundred for asymptomatics. But some PHA have the attitude that start ARV when healthy is benefit especially if they get drug for free.

PHA - Access to ARV To get free drug, PHA may falsify their history of illness or treatment in order to meet the project inclusion criteria. During each project gap, they adjust regimen dosages by themselves to prolong drug supply. ARV sharing or trading among PHA commonly occurs.

PHA - Access to ARV Some PHA sold expensive drug, for example, efavirenz they got for free and used nevirapine which was cheaper instead. Abroad cheap drug was also the choice. PHA network set the broker to buy lots of efavirenz from China or India and could retail to peer at cheap price. PHA knew the places where they could get drug for free or cheaper.

PHA Non-Rational Access to ARV Their own way to improve access to ARV leads to non-rational approach such as falsify information, starting drug early and disconnected drug use. All of these affect to inappropriate treatment.

PHA Non-Rational Access to ARV Prevention Development of ARV manufacture and distribution management may solve the problem of hard to access to ARV. But non-rational access to ARV also needs concern. Individual ability to improve access to ARV increases the risk of non-rational drug use Enough supply of cheap and effective regimen is not enough. Capacity building for knowledge-based decision-making of PHA by education about drug pro’s and con’s and drug adherence should be accelerated. Management of ARV treatment among projects, programs and private sectors should be systematic monitoring and control

Thank you Khob-Khun-Ka

Thailand : Access To ARV National Program from Access To Care (ATC) to National Access to Antiretroviral Programs for PHA (NAPHA) Free of charge / co-payment naive / experienced PHA

Thailand : NAPHA for Adult Inclusion criteria AIDS defining illness symptomatic with CD4 < 250 cells/cu.mm. asymptomatic with CD4 < 200 cells/cu.mm. Exclusion criteria AIDS defining TB asymptomatic with CD4 > 200 cells/cu.mm. ARV experienced with defined regimen sensitivity non compliance for monitoring and treatment