1. Thailand experience in implementing collaborative HIV/TB activities Anupong Chitwarakorn, MD Ministry of Public Health, Thailand TB/HIV Satellite symposium at Mexico Conference August 3, 2008

2. Sexual 83.9% IVDU 4.6% Blood products 0.03% MTCT 3.9% Unidentified 7.5% Mode of Transmission in Thailand from reported AIDS cases (as of May 2008) 332,178 patients Population with 63.4 millions (2007) One of 22 high TB burden countries. An estimated 90,000 all TB patients An estimated 556,848 PHA in 2008 (cumulative 1.1 million) 100% coverage (MOPH facility) of DOTS implementation since 2003 100% coverage (MOPH facility) of DOTS implementation since 2003 0.9% of HIV infection in pregnant women (2007) ART services are accessible down to district level under health security assurance fund, social security fund HIV/TB situation in Thailand

3. Progress of TB/HIV implementation 2003 => Piloting TB/HIV activities in Thailand USA CDC Collaboration sites 2004 => Developing a national guideline for TB/HIV collaborative activities 2004 => Appointing the national TB/HIV committee 2005 => Piloting TB/HIV activities in small scale 2005 => Revising recording and reporting forms to include HIV status 2006 => Implementing TB/HIV activities countrywide

4. Monitoring TB/HIV indicators Activities HIV testing in TB patients CD4 testing in HIV/TB pt. ART in HIV/TB pt. ICF 2006 75%(52) 90% 50%(32) 80% 2007 80%(68) 90% 55%(32) 85% 2008 85% 90% 60% 90% 2009 >90% 90% >60% >90% ICF=Intensified tuberculosis case finding

5. Monitoring and evaluation Note: Part I includes patients registered six to nine months earlier

6. Outcomes of TB/HIV activities Activities HIV testing HIV positive CPT* ARV ** ICF 2006 52% (26,552/51,412) 27% (7,141/26,552) 64% (4,551/7,141) 32% (2,260/7,141) 36,138 2007 68% (37,774/55,190) 20% ( 7,615/37,774) 67% (5,080/7,615) 32% (2,456/7,615) 23,593 *Criteria of Cotrimoxazole preventive therapy = CD4<200; **Criteria = CD4<250

7. Major Achievements Developing guidelines for TB/HIV collaborative activities, PITC, ART for TB/HIV patients. Incorporating TB/HIV monitoring indicators into routine TB register. Implementing a new TB/HIV report with 90% reporting districts. Increasing HIV testing from 52% in 2006 to 68% in 2007. High coverage of ICF (?%)

8. PITC models Model 1 2 3 4 5 TB clinic HIV clinic TB clinic HIV clinic HIV Neg TB clinic HIV clinic TB clinic HIV clinic HIV pos HIV clinic TB clinic HIV clinic Post-test Pre-test PITC = Provider initiated HIV testing & counseling

9. Details of provision for TB/HIV services in one region, 2007 Details of TB/HIV services Number (%) -Place to perform PITC TB clinic TB clinic HIV clinic HIV clinic Unknown Unknown 109 (100) 106 (97) 1 (1) 2 (2) -Staff providing TB and HIV care Same person Same person Different person/ same section Different person/ same section Different person/ different section Different person/ different section Unknown Unknown 109 (100) 27 (25) 43 (39) 38 (35) 1 (1)

10. Details of provision for TB/HIV services in one region, 2007 (con’t) Details of TB/HIV services Number (%) -TB/HIV team Established Established Not established Not established 109 (100) 91 (83) 18 (17) -Staff providing PITC TB staff TB staff HIV staff HIV staff Both Both None None Unknown Unknown 109 (100) 57 (52) 17 (16) 31 (28) 1 (1) 3 (3)

11. Major Challenges Lacking joint planning and evaluation between TB and HIV programs at all levels. Supervising TB/HIV activities by TB program staff Lacking PHA registration to collect data to decrease burden of TB in PHA. Integrating TB infection control into routine practice Introducing TB/HIV activities into hospitals outside Ministry of Public Health

12. Major Challenges Low uptake of ART in TB/HIV patients Implementation of IPT Integrating TB infection control into routine practice Information system; TB and HIV services have been integrated into general health services => TB and HIV data are currently reported to NHSO not NTP or NAP Weak linkage of NTP and NAP

13. Technical and financial assistance Thailand MOPH-US. CDC Collab operations for designing pilot projects, helping with policy developing, developing training materials and conducting training, and writing up projects. World Health Organization for financial assistance for pilot projects and external evaluation GFATM for initiative for TB/HIV services