1. “Getting to Zero: Thailand’s Experience with E-MTCT” Petchsri Sirinirund Advisor on HIV/AIDS Policy and Programme Department of Disease Control, Thailand Validating the Elimination of Mother-to-Child Transmission has been Achieved: What is the Global Criteria and Current Regional and Country Status? Satellite session sponsored by UNICEF and WHO, 21 July 2014 The 20 th International AIDS Conference, Melbourne

2. Presentation Overview E-MTCT - component of the national plan to end AIDS Progress towards E-MTCT in Thailand Estimation of MTCT rates Thailand’s approach to E-MTCT

3. "Ending AIDS” Certain number of new HIV infections per year <1,000 cases (90% reduction) Mother to child transmission is virtually eliminated All PLHIV receive ART at early stage for their quality of life as well as prevention of transmission to partners AIDS is accepted by society as a chronic medical condition Target 2016Achieved 2013 Number of infants born to HIV+ mothers infected perinatally 70117

4. PROGRESS TOWARD E-MTCT

5. 2000 2002 2004 2006 2008 2010 2012 2013 National PMTCT policy -Short course AZT (34 wks) -VCT -Formula feeding (12 mos) -HIV testing for infants born to HIV+mother -New PMTCT policy (AZT (28wks) +SD NVP) -CD4 antepartum and every 6 mos -Care for partners and family -HAART for mother (CD4<200,symptoms) during ANC -Tail regimen (AZT+3TC) -DNA PCR for infant diagnosis -Formula feeding (18 months) HAART for all HIV-infected pregnant women and couples counseling National PMTCT Policy in Thailand Option A Option B CD4<350 Option B and B+ for subpopulations B+ for CD4<500 serodiscordant couples, coinfection of TB, HBV, HCV Prepared by Rangsima Lolekha, TUC, 2013

6. Mother: ARV prophylaxis coverage HIV testing coverage in women giving birth Thailand PMTCT Program Coverage 2013 Estimated 804,484 deliveries Nearly all Thai pregnant women attending ANC (93.7% for non Thai) HIV prevalence among pregnant women =0.7% Source: 2014 Thailand AIDS Response Report (Department of Health: PHIMS) Newborn: ARV prophylaxis coverage Updated from slide prepared by Rangsima Lolekha, TUC, 2013

7. Indicators20122013 % of infants born to HIV+ mothers receiving a virological test within 2 months of birth 77.272.9 Estimated MTCT rates (%)2.72.3 Estimated MTCT rates (%) - (non Thai)NA4.8 % of pediatric HIV cases on ART70.875.5 Key Indicators

8. ESTIMATION OF MTCT RATES

9. Estimation of MTCT rates 1.Calculate number of HIV+ve mothers from percentages got from program reports – ANC rates – HIV+ve rates among ANC / non ANC 2.Calculate percentages of HIV+ve mothers receiving ARV from percentages got from program reports – No ARV, each regimen 3.Multiply calculated percentages of HIV+ve mothers not receiving and receiving ARV with MTCT rate got from the survey

10. ARV regimen MTCT ratesn/N overall HAART 1.4 %12/848 Dual ARV 5.5 %3/55 Mono ARV 3.8 %20/526 Unspecified regimen / partial ARV 5.7 %22/385 No ARV (from prior study Perinatal study) 12.0 % 2733 women with HIV were reviewed 1779 (63%) infants had HIV outcomes (Yr 2008-2011)

11. ARV regimen weighted Coverage in 2013 MTCT rate (reviewed data from program record) Estimated rates No ARV/only formula feed 0.1%12. 0 %0.0% Partial prophylaxis 10.6%5.7%0.6% Dual ARV 5.6%5.5%0.3% Triple ARV prophylaxis 18.9%1.4%0.3% Triple ARV treatment 64.8%1.4%0.9% 100.0% 2.10%

12. To improve the validity of the calculation of MTCT rates Real time monitoring – Only for HIV+ve pregnant women – Pilot test on using LINE application – Develop specific application Monitored by hospitals and the Department of Health Using as an alert system

13. THAILAND’S APPROACH TO E-MTCT

14. Key interventions for ending AIDS 1.Extend combination prevention (BCC and HTC) to cover 90% of key populations 2.Treat all PLHIV early at any CD4 level (Option B+ for PMTCT) 3.Support ARV adherence 4.Adapt data management towards strengthened case management and retention of individuals in care 5.Normalize HIV

15. Elimination of MTCT – Global criteria Impact indicators 1.≤ 50 new pediatric HIV cases per 100,000 live births and (Thailand ≤ 400 cases ) 2.< 2% MTCT rate Process indicators (2 out of 3) 1.≥ 95% ANC coverage at least 1 visit 2.≥ 95% HIV testing of pregnant women 3.≥ 90% ART coverage of HIV - positive pregnant women

16. E-MTCT in National Operational Plan to end AIDS, 2015-2019 Encourage and support provinces to achieve respective E-MTCT targets – Data by province Data by hospitals in each province Thai and non Thai Active case management of exposed and infected infants – ANC through testing for babies and ART initiation for positive children

17. Sub-national targets IndicatorsBaseline 2013 20152016201720182019 1. # of provinces with ≥ 5% MTCT of HIV 1086432 2. # of provinces with < 95% ANC coverage 654333 3. # of provinces with <95% coverage of pregnant women who know their HIV status TBD3

18. IndicatorsBaseline 2013 20152016201720182019 4. # of provinces with < 90% HAART coverage among HIV+ pregnant women 4535251553 5. # of provinces with < 80% of infants with HIV test within 2 months of birth 69604530155 6. # of provinces with <95% of infants born to HIV+ women receive ARVs 13108642 Sub-national targets - 2

19. Challenges for EMTCT Late ANC, particularly for known HIV+ cases Late ART initiation for HIV+ infants Limited insurance for Non-Thai families Strategic information (separate databases, under reported services, particularly from university and private hospitals)

20. Thank you Hospitals and provincial health offices Department of Health: Bureau of Health Promotion Thailand MOPH-US CDC Collaboration (TUC) Department of Disease Control: National AIDS Management Center UNICEF