1. 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

2. 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

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

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

5. 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

6. Projection of HIV Infection in Thailand

7. Projected Annual New AIDS Cases

8. Table 1 Estimated Cumulative Numbers of HIV/AIDS in the year 2004
 HIV infections (adults and children) ,074,155
Deaths (adults and children) ,600
 PWHA ,500
 New HIV infections in ,500
 New AIDS cases in ,500
Source: 1 Thai Working Groups on HIV/AIDS Projection 2000

9. Distribution of reported AIDS cases by year of diagnosis in Thailand, September 1984-December 2003
Numbers
Sources: Bureau of Epidemiology, MOPH, Thailand

10. 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

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

12. 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

13. 100% Condom Program

14. 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.

15. 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

16. 100% Condom Use among commercial sex worker during 1997-2002
Source: Sentinel Serosurveillance, Bureau of Epidemiology, MoPH

17. Educational Campaign and Condom Promotion among General Public

18. 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 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

19. 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.

20. Condom Vending Machine

21. Prevention of Mother to Child Transmission

22. Development of Thailand’s National Policy on PMTCT
Prevention Works:
Development of Thailand’s National Policy on PMTCT
Results of ACTG 076: ZDV decreases mother-to-child transmission by 2/3
MOPH and World Bank re-evaluate ARV use: ZDV in pregnant women is most cost-effective use of ARV
Bangkok trial shows effectiveness of short-course ZDV
MOPH begins pilot programs providing short-course ZDV to pregnant women in Regions 10 and 7
National PMTCT guidelines reviewed
Regimen of ZDV for HIV+ women/infants supported nationally
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.

23. 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, infant infections each year,
PMTCT+ cover care of HIV+ mother’s family

24. 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%%

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

26. Access to Antiretroviral Treatment

27. 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

28. Access to HIV/AIDS Medical Care in Thailand
Treatment of common opportunistic infections as TB, PCP, cryptococcal meningitis etc.
Monotherapy (AZT)
Dual therapy (AZT+ddI and AZT+ ddC)
HIV Clinical Research Network (dual and triple ARV)
Access to care (triple ARV and OI prevention and treatment) since 2000
National Access to ARV for PWHA since 2003

29. National Access to ARV for PWHA
Lab
network
Data
management
Monitoring
Evaluation
Research
and development
Drug stock
management
International
Collaboration

30. 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

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

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

33. 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)

34. 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

35. 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

36. Community involvement

37. 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

39. TB/HIV Program

40. 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

41. 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

42. 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

43. 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

44. 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

45. Thank you