1. Prevention with Positives: view from health provider Sakchai Chaiyamahapurk* Supasit Pannarunothai** Office of Disease Control and Prevention 9 th Phitsanulok* PhD. Student, Health System and Policy* Faculty of Medicine, Naresuan University**

2. การประชุมเชิงปฏิบัติการ Prevention with Positives เชียงใหม่ สคร 8, 9, 10 (1 กย 51) เชียงใหม่ สคร 8, 9, 10 (1 กย 51) ขอนแก่น สคร 5, 6, 7 ขอนแก่น สคร 5, 6, 7 เพชรบุรี สคร 3, 4 เพชรบุรี สคร 3, 4 กรุงเทพ สคร 1, 2 กรุงเทพ สคร 1, 2 สงขลา สคร 11, 12(28 ตค 51) สงขลา สคร 11, 12(28 ตค 51)

3. Outline Rationale for Prevention with Positives Rationale for Prevention with Positives Objective and methodology of this survey study Objective and methodology of this survey study Results Results Ethical dilemma Ethical dilemma Discussion Discussion

4. Prevention with Positives or Positives prevention Prevention with Positives or Positives prevention Health promotion in People with HIV and AIDS aim to prevent of STI and HIV re-infection and decrease transmission to sexual partner

5. New HIV Infections in Thailand by Risk Group Per Year (East West Center)

6. Prevention with positive in Thailand Universal access of ART under universal coverage scheme make HIV a chronic treatable disease. Universal access of ART under universal coverage scheme make HIV a chronic treatable disease. Estimated 500000 PWHA who are alive and Estimated 500000 PWHA who are alive and now 180000 are treated with ART now 180000 are treated with ART Increase proportion of HIV who get infected from regular partner compared with casual and commercial sex. Increase proportion of HIV who get infected from regular partner compared with casual and commercial sex. Implementation of Prevention with Positive program were done by Bureau of AIDS, Department of Disease Control, Thai MOPH with 5 workshops during Aug- Oct 2008 for HCW around the country. Implementation of Prevention with Positive program were done by Bureau of AIDS, Department of Disease Control, Thai MOPH with 5 workshops during Aug- Oct 2008 for HCW around the country.

7. Implementation of 6 Strategies for prevention with positive during clinical visit in Thailand MOPH hospital(2008) Risk reduction (condom, number of partners) Risk reduction (condom, number of partners) STI screening and treatment STI screening and treatment Disclosure to sexual partner Disclosure to sexual partner HIV testing for partner HIV testing for partner ARV adherence ARV adherence Prevention of unwanted pregnancy and PMPCT Prevention of unwanted pregnancy and PMPCT

8. Objectives To know attitude of health provider regarding to Prevention with positives To know attitude of health provider regarding to Prevention with positives To survey current practice of health provider To survey current practice of health provider To estimate sexual practice of HIV patients according to the view of health providers To estimate sexual practice of HIV patients according to the view of health providers To view the opinion of health provider regarding to the intervention at the societal level such as law on Prevention with Positive To view the opinion of health provider regarding to the intervention at the societal level such as law on Prevention with Positive

9. Methodology Cross-sectional study Cross-sectional study Anonymous, self administered questionnaire Anonymous, self administered questionnaire Population – health care providers attending 4 workshops for Prevention with positive around the country during August-October 2008 Population – health care providers attending 4 workshops for Prevention with positive around the country during August-October 2008 Questionnaire with Likert scale answer 5 point: Questionnaire with Likert scale answer 5 point: 1. Strongly agree 2. Agree (1,2 grouped as Agree) 1. Strongly agree 2. Agree (1,2 grouped as Agree) 3. Unsure 4. Disagree 5. Strongly disagree 3. Unsure 4. Disagree 5. Strongly disagree

10. Result of the study Characteristics Total respondent: 560, 74% were nurse Total respondent: 560, 74% were nurse Work in HIV clinics, OPD, ANC. Work in HIV clinics, OPD, ANC. Regional hospital 3%, Provincial 10%, Community 87% Regional hospital 3%, Provincial 10%, Community 87% Median working experience 5 years(1-15) Median working experience 5 years(1-15)

11. Attitude on Positive prevention 97% agreed they had duty to prevent HIV transmission. 97% agreed they had duty to prevent HIV transmission. 83% are comfortable to talk about sex with patient. 83% are comfortable to talk about sex with patient. Less than half(44%) had time for counseling. Less than half(44%) had time for counseling.

12. Attitude on Positive prevention 74% confident in knowledge and skill 74% confident in knowledge and skill 21% felt that counseling was not effective for prevention of transmission 21% felt that counseling was not effective for prevention of transmission 33% feel expert such as psychologist, counselor are more proper for preventive counselling 33% feel expert such as psychologist, counselor are more proper for preventive counselling

13. Frequent practice of Positive prevention in clinical setting 75% talked about condom use 75% talked about condom use 65% asked whether patient was sexually active 65% asked whether patient was sexually active 65% talked about disclosure 65% talked about disclosure

14. Estimation of sexual practice Among the Positives Among the Positives :view from health care provider

15. Highest voted abstinence rate = 0-10%

16. Highest voted unsafe sex rate 21-40%

17. Highest voted partner disclosure rate 41-60%

18. Confidentiality and Disclosure to third party More than half(59%) considered public health benefit more than individual patient benefit More than half(59%) considered public health benefit more than individual patient benefit 78% believed that counseling could solve disclosure problems. 78% believed that counseling could solve disclosure problems. 7% did notify directly or indirectly to patients’ partners when patients did not disclose their HIV status to partners by themselves. 7% did notify directly or indirectly to patients’ partners when patients did not disclose their HIV status to partners by themselves. Most reasons for notifying: preventing of HIV transmission and rights of their partners to be informed. Most reasons for notifying: preventing of HIV transmission and rights of their partners to be informed. Most reasons for not notifying : patient’s rights, fear of adverse effect on patients. Most reasons for not notifying : patient’s rights, fear of adverse effect on patients.

19. law enforces PWHA disclose to regular partner75% law enforces PWHA disclose to regular partner 75% In case patients deny to disclose and partners have risk of getting infection, HCW should have protected right to inform partner 47% In case patients deny to disclose and partners have risk of getting infection, HCW should have protected right to inform partner 47% law enforces PWHA disclose to sexual partner 70% law enforces PWHA disclose to sexual partner 70%

20. Discussion HCWs see Prevention with Positives as priority, barriers are such as limitation of time and skill of personnel. HCWs see Prevention with Positives as priority, barriers are such as limitation of time and skill of personnel. Condom promotion is the most sexual health promotion intervention in clinical setting. Condom promotion is the most sexual health promotion intervention in clinical setting. Prevention among HIV patients is needed as low abstinence rate, significant unsafe sex and nondisclosure from view of providers. Prevention among HIV patients is needed as low abstinence rate, significant unsafe sex and nondisclosure from view of providers. Demand for disclosure is clear. Ethical dilemma on disclosure remains unresolved, with conflicts between right Demand for disclosure is clear. Ethical dilemma on disclosure remains unresolved, with conflicts between right (privacy of patients) and right to be informed of their partners. (privacy of patients) and right to be informed of their partners.

21. Strategy for Positive prevention (International HIV/AIDS alliance) Individually focused health education and support Ensuring access, scaling up and improving service delivery Community mobilisation Advocacy and policy change

22. Ethical dilemma facing HCW Confidentiality VS VS Duty to warn Duty to warn

23. Disclosure and notification UNAIDS :http://data.unaids.org/pub/BaseDocument2008/20080731_jc1513_policy_ criminalization_en.pdf ttp://data.unaids.org/pub/BaseDocumentttp://data.unaids.org/pub/BaseDocument Some countries enact legal obligation to disclose HIV status to partner or HCW Some countries enact legal obligation to disclose HIV status to partner or HCW UNAIDS does not support due to right to privacy of health status, stigma, discrimination and violence UNAIDS does not support due to right to privacy of health status, stigma, discrimination and violence All people have the ethical obligation not to harm others Empower HIV-positive people to practice safer sex and/or voluntarily disclose Empower HIV-positive people to practice safer sex and/or voluntarily disclose

24. http://data.unaids.org/pub/BaseDocument/2008/20080731_jc1513_policy_criminalization_en.pdf Criteria to inform their patients’ sexual partners of the HIV status of their patient. The International Guidelines on HIV/AIDS and Human Rights http://data.unaids.org/pub/BaseDocument/2008/20080731_jc1513_policy_criminalization_en.pdf thoroughly counselled. failed to achieve appropriate behavioural changes. refused to notify or consent to the notification A real risk of HIV transmission. reasonable advance notice. conceale identity of the HIV-positive person from the partner(s) Follow up to ensure support

25. Ethical dilemma facing PWHA Right to confidentiality VS Right to be informed Right to confidentiality VS Right to be informed Do no harm to other VS Right to privacy and avoid stigma and discrimination Do no harm to other VS Right to privacy and avoid stigma and discrimination

26. Criminalization of HIV transmission UNAIDS and UNDP http://data.unaids.org/pub/BaseDocument/2008/20080731_jc1513_policy_criminalization_en.pdf Should be applied only in overt case; knowing their status, intentionally act, does in fact transmit. Should be applied only in overt case; knowing their status, intentionally act, does in fact transmit. could increase stigma and discrimination could increase stigma and discrimination Drive PWHA from treatment and prevention Drive PWHA from treatment and prevention Establishment of fact is difficult Establishment of fact is difficult No evidence of deterring behavior. No evidence of deterring behavior.

27. Thai law related to HIV disclosure National Health Act- personal health information is protected under privacy law except that when other law allows. National Health Act- personal health information is protected under privacy law except that when other law allows. State Information Act- personal medical record cannot be disclosed to others( มาตรา 15) except that disclosure is benefit for benefit or health of others( มาตรา 20). State Information Act- personal medical record cannot be disclosed to others( มาตรา 15) except that disclosure is benefit for benefit or health of others( มาตรา 20). Criminal Code- doctor, nurse have liability if they disclose patient information and cause adverse effect on patient Criminal Code- doctor, nurse have liability if they disclose patient information and cause adverse effect on patient

28. Questions How to resolve disclosure of HIV dilemma How to resolve disclosure of HIV dilemma Which ethical principle dominate. Which ethical principle dominate. Disclosure need law or ethic. Disclosure need law or ethic. What is the best strategy for PwP: individual counseling, community mobilization, social marketing or law and policy. What is the best strategy for PwP: individual counseling, community mobilization, social marketing or law and policy. What is public opinion to this dilemma What is public opinion to this dilemma Status Quo or Proactive policy Status Quo or Proactive policy

29. Proposal for further study Qualitative and quantitative study about public /professional opinion on disclosure issue among vulnerable group and stakeholder Qualitative and quantitative study about public /professional opinion on disclosure issue among vulnerable group and stakeholder Follow up study for change of opinion of HCW in one year after PwP in clinical setting implementation Follow up study for change of opinion of HCW in one year after PwP in clinical setting implementation Experimental study of effectiveness of PwP program is ongoing. Experimental study of effectiveness of PwP program is ongoing.

30. Acknowledgement Bureau of AIDS Bureau of AIDS Dr. Tawesak Nopkesorn, Naresuan university Dr. Tawesak Nopkesorn, Naresuan university Dr. Rangsima Lohlekhla, TUC Thailand Dr. Rangsima Lohlekhla, TUC Thailand Staff of 12 regional DPC office Staff of 12 regional DPC office All health care provider who attend Prevention with Positives workshops. All health care provider who attend Prevention with Positives workshops.

31. Thank you for your attention