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

%
60

50

40

30

20

10

0 Year
D e c -8 9

D e c -9 0

D e c -9 1

D e c -9 2

D e c -9 3
J u n -9 1

D e c -9 4

J u n -0 0
J u n -8 9

J u n -9 0

J u n -9 2

J u n -9 3

J u n -9 4

J u n -9 5

J u n -9 6

J u n -9 7

J u n -9 8

J u n -9 9

J u n -0 1

J u n -0 2

J u n -0 3
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

%
30
28.0 27.6 28.2
26.1
25
23.0
21.1
20
17.8 18
15.2 16 16
15
10.1 12.27
11.76
10 7.7 8 8.26
9.3 6.7 6.6 5.9
4.3 5
5 4.07
3.12 4.5 3.85
2
0 0
J un-8 9

J un-9 1

J un-9 2

J un-9 3

J un-9 4

J un-9 5

J un-9 6

J un-9 7

J un-9 8

J un-0 0

J un-0 2
J un-9 0

J un-9 9

J un-0 1

J un-0 3
Direct Indirect Mixed

Source: Sentinel Serosurveillance, Bureau of Epidemiology, MoPH

 HIV Prevalence Among Pregnant Women, Male Conscripts, Donate
% d Blood:Thailand 1989-2003
4.5

3.5 Conscripts (age 21)

3

2.5

2 Pregnant women
1.5

1
Donated blood
0.5

0
มิ .ย.-89

ธ.ค.-89

มิ .ย.-91

ธ.ค.-91

ธ.ค.-92

มิ .ย.-93

ธ.ค.-94

มิ .ย.-95

มิ .ย.-96

มิ .ย.-97

มิ .ย.-99

มิ .ย.-00

Jun-01

Jun-02

มิ .ย.-03
มิ .ย.-90

ธ.ค.-90

มิ .ย.-92

ธ.ค.-93

มิ .ย.-94

ธ.ค.-95

มิ .ย.-98
Source: Sentinel Serosurveillance, Bureau of Epidemiology, Ministry of Public Health. Month/Year
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
 Projection of HIV Infection in Thailand
1400
1200
thousands of HIV infections

1000
800
600
400
200
0
1985 1990 1995 2000 2005 2010 2015 2020

Living w/HIV and AIDS Cumulative HIV New HIV

Projected Annual New AIDS Cases

60000

50000

40000

30000

20000

10000

0
1985 1990 1995 2000 2005 2010 2015 2020
 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

30000 AIDS

25000
20000
15000
10000
5000
0
1984- 1995 1996 1997 1998 1999 2000 2001 2002 2003
1994
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.

90
Country
80
70 Center
60 North
50 North-Eastern
40 South
30
20
10
0
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Sources: Bureau of Epidemiology, Department of Disease Control

 Risk Factor of AIDS Cases, Thailand 1984-2003

Vertical
IVDU transmission
Unknown 4.7% 4.4%
7.1%

Blood receipt
0.03%

Sexual transmission
83.7%

Source: Bureau of Epidemiology, MoPH, Thailand

data as of March 31, 2003
Distribution of AIDS cases by five opportunistic infections in Th
ailand,
(Data as of September 1984-December 2003)

Pneumonia Recurrent
3.2%
Candidiasis
4.6%
Cryptococcosis 14.8%
Pneumocystis Carinii
Pneumonia
18.6%
Mycobacterium 25.5%
Tuberculosis

0 20000 40000 60000 80000

Sources: Bureau of Epidemiology, Department of Disease Control

100% Condom Program
 100% Condom Program in Sex Establishment

 Cooperation between authorities and sex establishment

s’ owners or managers
 Availability and accessibility of quality condoms
 Availability of STI care, appropriate staff with experie
nced in outreached program, friendly
 Monitoring and evaluation : STI infection rate, condo
m use at last sex.
 Number
Number of
of STD
STD cases
cases and
and condom
condom use
use rate
rate
among
among male
male&&CSW
CSW(1984-2000)
(1984-2000)
Condom use in CSWs and clients

Percent condom use

thousands
300 -100
male
-
200 -75
Sex worker
-

100 - 50

0
1984 1986 1988 1990 1992 1994 1996 1998 20000
100% Condom Use among commercial sex
worker during 1997-2002
100
% Direct
98 Indirect
96

94

92
90
88
86

84
82
1997 1998 1999 2000 2001 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- a
nd post-marketing surveillance.
Condom Vending Machine
Prevention of Mother to
Child Transmission
 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
 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

1400
1282
1216
1200 1154
1055
1000
870 889
800 755
600 572
460
400 371
200
134
19 71
0
88-90 91 92 93 94 95 96 97 98 99 00 01 02
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 an
d change the way we act.”
LEE Jong-wook, Director-General, World Health Or
ganization
 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

Research Data Drug stock Lab Monitoring

International
and development management network Evaluation
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
• 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 com
munities and Border area
 Access to care and Services - Str
engthening services and Advoca
cy
 Antiretroviral access
 PMTCT
 Treatment of Opportunistic Infe
ction
 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 en
hanced
 National responses with strong political and financial
commitment is required
 New focused preventive intervention for youth, mobile p
opulation and vulnerable groups need to be addressed an
d 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 res
earch and monitoring
Thank you