Treatment as prevention: Will it work in Thailand?

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1 Treatment as prevention: Will it work in Thailand? Tanarak Plipat Department of Disease Control, Ministry of Public Health Thailand MoPH US CDC Collaboration

2 Treatment as prevention Thailand: country background PMTCT Expanding the ARV program PrEP

4 Thailand: Country background Indicators Estimate Total Population (million) 67 Sex ratio (male:1 female) 0.97 Percent of population urbanized 31 Per capita income (US$) 9,600 Number of live births 765,000 Crude death rate 6.2 Maternal mortality rate (per 100,000 life births) 10.8 Male life expectancy at birth 70 Female life expectancy at birth 77 Infant mortality rate (per 1,000 live births) 4.2 Under five mortality rate (per 1,000 live births) 9

5 Thailand health system Policy Development Technical Financing Agencies Health care Provider

6 Health Providers 25 regional hospitals 69 general hospitals 741 community hospitals > 9,700 health centers 112 other government hospitals 319 private hospitals

7 PMTCT 1994 PACTG VCT & Formula feeding

8 PMTCT 1994 PACTG VCT & Formula ZVD donation feeding program

9 PMTCT Short course study PACTG 076 results & Pilot study results VCT & Formula ZVD donation feeding program

10 PMTCT Short course study PACTG 076 results & Pilot study results VCT & Formula ZVD donation Single drug feeding program PMTCT

11 PMTCT Short course study PACTG 076 results & Pilot study results VCT & Formula ZVD donation Single drug AZT+NVP feeding program PMTCT

12 PMTCT Short course study PACTG 076 results & Pilot study results VCT & Formula ZVD donation Single drug AZT+NVP feeding program PMTCT 2010 Triple drug PMTCT

13 2010 PMTCT regimen AZT + 3TC + LPV/r CD4 350 start the ARV immediately CD4 > 350 start the ARV at 14 weeks If no ANC, Intrapartum: 300 mg ZDV and 200 mg SD NVP at the onset of labor and 300 mg ZDV every 3 hours thereafter ARV to infant: AZT + 3TC + NVP

14 Percentage of pregnant women who received HIV testing and percentage of HIV positive pregnant women who received ARV, Thailand Percents Women received HIV testing HIV positive women received ART

15 Trends in perinatal transmission rate, Thailand Percent

16 PMTCT: reasons for success A strong infrastructure of antenatal care program that has a high coverage A network of HIV VCT program The program has been gradually developed and upgraded. Budget impact Workload

17 Raising the CD4 threshold: Is it possible in Thailand?

18 Progress of Thai ART program 300,000 Number 78% 250, , , ,000 50, Source: HIV/AIDS fund, NHSO

19 AIDS Expenditure (2009) Total health expenditure ~383 B.Baht Total AIDS expenditure ~7.2 B.Baht (1.9%) 76.1% of Total AIDS expenditure are for Care and treatment (5.5 B. Baht).

20 Major Financing Agencies for Care & Treatment Universal Coverage funded (UC or NHSO) Social Security Office (SSS) Civil Servant Medical Benefit Scheme (CSMBS) International funding agencies 1.3% of the care & treatment expenditure

21 Current treatment guidelines CD4 < 200 or incident of AIDS Regimen: d4t+3tc+nvp Drug cost per year: 15,000 Baht (NHSO) MOPH has recommended to raise the CD4 threshold up to 350

22 Estimated impact of the new guideline (Start ART when CD4<350/µl) Percents

23 What is happening now? Policy & Technical we should start treatment earlier (CD4<350) Finance we should focus our attention to the patient who need it most (CD4<200) If we are doing a good job on the patient who need it most, then we can talk the program expansion. Health care provider we are treating as much as we can within the budget that we ve got.

24 HIV-VCT & CD4 testing HIV-VCT & CD4 testing are free. Last year, 320,000 people received HIV-VCT services (exclude HIV-VCT for PMTCT). Among MSM in 2010, 29% had ever been tested for HIV. Among FSW in 2010, 43% had ever been tested for HIV. 36% of the registered HIV infected persons were tested for CD4 level.

25 Reasons for receiving ART late Stigma and discrimination Knowledge and attitude toward ART Accessibility & workload improvement

26 Workload In the outpatient unit of the public hospital, patients may have to spend more than 3 hours at the hospital but they have a chance to see the doctor for 4 minutes.

27 HIV-Drug resistance 6% of AIDS patients received 2 nd line ART. On average, 2 nd line drug is 3.5 times more expensive than the 1 st line drug. Switching rate was 1-2% per year

28 Abdominal dialysis program: What is expensive for Thai? The cost of hemodialysis is 400,000 Baht per year. Renal replacement therapy was included into UC scheme in In 2011, 3.2 B.Baht (2.5%) of the UC budget (129 B.Baht in 2011) are for the RRT. When fully scale up, the RRT could consume more than 12% of the UC budget.

29 Equity Budget impact: Is it possible? When fully scale up, the program may require more than twice the budget it uses today. Workload: Need to scale up HIV-VCT capacity Stigma and discrimination issue Knowledge and attitude toward ART

30 Pre-exposure Prophylaxis May be needed for the SW No system/infrastructure available to provide the services How will the PrEP program compete with the treatment program on the limited resources?

31 Acknowledgement Dr.Sorakit Pakeecheep - NHSO Dr.Peeramon Ningsanon - NHSO Dr.Petchsri Sirinirund Departement of Disease Control, Ministry of Public Health Dr.Viroj Tangcharoensathien - IHPP

National AIDS Spending Assessment Report Thai Working Group on National AIDS Spending Assessment Reporting date: July 12, 2012

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