HIV/AIDS in Thailand: Current Situation, Successes and Remaining Challenges Sombat Thanprasertsuk, M.D., M.P.H. Director, Bureau of AIDS, TB & STIs Department of Disease Control, MoPH 22 April 2004

Outline of Presentation Local situation of HIV/AIDS Selected Interventions Condom 100 % Program Educational Campaign and Condom Promotion Prevention of Mother to Child Transmission Acess to Antiretroviral Treatment Community Involvement TB/HIV Lessons learned

HIV Prevalence among Injecting Drug Users at Treatment Clinics, Thailand 1989-2003 % Year Source: Sentinel Serosurveillance, Bureau of Epidemiology, MoPH Remark: Switching from bi-annually (June and December) to annually in June since 1995

HIV Sero-prevalence among Direct and Indirect Sex Workers in Thailand, 1989- June 2003 % Source: Sentinel Serosurveillance, Bureau of Epidemiology, MoPH

HIV Prevalence Among Pregnant Women, Male Conscripts, Donated Blood:Thailand 1989-2003 % Conscripts (age 21) Pregnant women Donated blood 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 Month/Year

Projection of HIV Infection in Thailand

Projected Annual New AIDS Cases

Table 1 Estimated Cumulative Numbers of HIV/AIDS in the year 2004  HIV infections (adults and children) 1,074,155 Deaths (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

The regions comparative of AIDS cases distribute by year (Data as of December 31, 2003) Number of AIDS cases : 100,000 Pop. Sources: Bureau of Epidemiology, Department of Disease Control

Risk Factor of AIDS Cases, Thailand 1984-2003 Source: Bureau of Epidemiology, MoPH, Thailand data as of March 31, 2003

Distribution of AIDS cases by five opportunistic infections in Thailand, (Data as of September 1984-December 2003) 3.2% 4.6% 14.8% 18.6% 25.5% Sources: Bureau of Epidemiology, Department of Disease Control

100% Condom Program

100% Condom Program in Sex Establishment Cooperation between authorities and sex establishments’ owners or managers Availability and accessibility of quality condoms Availability of STI care, appropriate staff with experienced in outreached program, friendly Monitoring and evaluation : STI infection rate, condom use at last sex.

Number of STD cases and condom use rate among male & CSW (1984-2000) Condom use in CSWs and clients Percent condom use thousands -100 - -75 - 50 male Sex worker

100% Condom Use among commercial sex worker during 1997-2002 Source: Sentinel Serosurveillance, Bureau of Epidemiology, MoPH

Educational Campaign and Condom Promotion among General Public

National behaviour surveillance survey 2000-2002 Shift in sexual partner selection, among men, from sex worker to casual partners (friends, girlfriends, etc.) Survey among youth aged 15-25 show high level of knowledge toward HIV (72% of youth) but 68% indicated that carrying condom is uncomfortable 100% condom use didn’t reach general population and youth, factory workers and mobile population groups

Condom social marketing Extend condom use beyond CSW Reduce social stigma for condom use and carry. Increase accessibility Promote Condom Vending Machine Quality assurance of condom both pre- and post-marketing surveillance.

Condom Vending Machine

Prevention of Mother to Child Transmission

Development of Thailand’s National Policy on PMTCT Prevention Works: Development of Thailand’s National Policy on PMTCT 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 Because PMTCT programs are central to other efforts, I’d like to spend a few minutes discussing a successful example: Thailand. In the last decade, Thailand developed and implemented a national PMTCT program that can serve as a model for others.

Thailand 's PMTCT programme VCT, ZDV prophylaxis, infant formula replacement feeding In 2002; 559,702 pregnant women received ANC 96.7 % of pregnant women participated in VCT 1.15 % found to be HIV+ 80 % of HIV + mothers received ZDV (AZT) 95 % of infants born to HIV+ mothers received ZDV Reduce risk from 30 % to 8 %, preventing 2,500- 3000 infant infections each year, PMTCT+ cover care of HIV+ mother’s family

Prevent Mother to Child Transmission Antiretroviral during pregnancy and labour Milk for children born with HIV +ve women Decrease infection rate from 30% to < 3%%

Number of Pediatric AIDS in Thailand 1988 - 2001 Total = 8868 cases Year

Access to Antiretroviral Treatment

The 3 by 5 Initiative "Lack of access to antiretroviral therapy (ART) is a global health emergency… To deliver antiretroviral treatment to the millions who need it, we must change the way we think and change the way we act.” LEE Jong-wook, Director-General, World Health Organization

Access to HIV/AIDS Medical Care in Thailand Treatment of common opportunistic infections as TB, PCP, cryptococcal meningitis etc. Monotherapy (AZT) 1992- 1995 Dual therapy (AZT+ddI and AZT+ ddC) 1995 - 1996 HIV Clinical Research Network (dual and triple ARV) 1997-2000 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 Lab network Data management Monitoring Evaluation Research and development Drug stock management International Collaboration

ART Team Hospital: Physician, nurse, lab technician, Pharmacist, counselor, social worker NGO, PWHA group Experts from medical universities Provincial Health Offices Regional Offices of Disease Prevention and Control Regional Health Centers Ministry of Public Health: BATS, DOH, DOMS, DOMH

Inclusion criteria for ART (Adult) AIDS Symptomatic with CD4 ≤ 250 cell/mm3 Asymptomatic with CD4 < 200 cell/mm3

Criteria (Children): Clinical & Immunological All children with age < 12 months Children aged > 12 months with Clinical staging B, C or CD4 < 20%

Antiretroviral Regimens in National Access to ARV Program for PHA, 2002-2003 D4T, 3TC, Nevirapine AZT, 3TC, Nevirapine D4T, 3TC, Efavirenz AZT, 3TC, Efavirenz D4T, 3TC, Boosted PI AZT, 3TC, Boosted PI (Indinavir+ritonavir)

Expand Access to ARV Plan, Thailand 2001 Target - 3,000 individuals, 109 hospitals 2002 Target - 13,000 individuals, 430 hospitals 2003 Target - 23,000 individuals, 630 hospitals 2004 Target - 50,000 individuals, All hospitals

Sources of Resources for Antiretroviral Therapy in 2004 Government Budget : National Access to Antiretroviral Program for PHA [ NAPHA ] [cover 40,000 cases] ATC, PATC, PMTCT plus Co-payment system Patients participating in clinical studies Global Fund [cover 10,000 cases] Patients pay out of their own pockets Health Insurance Scheme Social Security Civil Servant Health Benefit

Community involvement

Community capacity building Awareness of community to HIV/AIDS Capacity building for local authorities : Tumbon (sub-district) administrative organisation, Health volunteer, Religious leader etc. Collaboration with NGOs and various local agencies in HIV/AIDS Strengthening groups of People with HIV/AIDS

TB/HIV Program

TB/HIV Policy TB/HIV/STI programme TB/HIV ongoing activities national functional TB/HIV coordinating committee, TB/HIV ongoing activities Strengthen core activities -TB: DOTS -HIV: prevention and care -STI: syndromic approach

Collaborative TB/HIV activities A. Establish the mechanism for collaboration A.1. TB/HIV coordinating bodies A.2. HIV surveillance among TB patient A.3. TB/HIV planning A.4. TB/HIV monitoring and evaluation B. To decrease the burden of TB in PLWHA B.1. Intensified TB case finding B.2. Isoniazid preventive therapy B.3. TB infection control in care and congregate settings C. To decrease the burden of HIV in TB patients C.1. HIV testing and counselling C.2. HIV preventive methods C.3. Cotrimoxazole preventive therapy C.4. HIV/AIDS care and support C.5. Antiretroviral therapy to TB patients. WHO STP, TB/HIV; ICP 001

Focused Intervention for 2004 Condom and Social Marketing Youth Health program Casual sex & safe sex Public Education Counseling (VCT) Targeted group education Special approach program for Mobile pop., Vulnerable communities and Border area Access to care and Services - Strengthening services and Advocacy Antiretroviral access PMTCT Treatment of Opportunistic Infection HIV-TB Integrated strategy Community involvement CCC (Family medicine) Social Services for People affected by AIDS

Lessons learned (1) HIV/AIDS burden is high and still raging, a major health threat to the country. National strategic plan and implementation need to be enhanced National responses with strong political and financial commitment is required New focused preventive intervention for youth, mobile population and vulnerable groups need to be addressed and rapidly implemented

Lessons learned (2) - Challenges on ARV Program - Long term social services and supports for families affected by AIDS are required - Partnerships, collaboration and involvment from all sectors of society - key to progress, sustainability, and effective responses - Monitoring and Evaluation - crucial component, including Epidemiological, social, and behavioral research and monitoring

Thank you