1

Countdown To Zero ,Elimination of MTCT in Thailand

Sarawut boonsuk MD,MPHChief of Maternal and child Group

Department of Health Focal point PMTCT program , DOH,Thailand

2

HIV/AIDS Epidemic in Thailand

• People living with HIV/AIDS* 494,861 PLHA• HIV prevalence among adults ≥ 15 years* 0.9%• Number of health facilities provided ART** 943 facilities (96% governmental hospitals)

• Number of PLHA receiving ART 2011** 225,272 PLHA (97% adults, 3% children)• ART coverage for those needing ART (CD4<350)** 65% • Number of PLHA newly initiated on ART 2011** 35,618 PLHA• Number of PLHA death due to HIV* 27,234 PLHA

Source: * The Asian Epidemic Model (AEM) Projections for HIV/AIDS in Thailand 2005-2025 ** UNGASS report 2011

3

0.0 0.0

0.7 0.71.0 1.0

1.4 1.51.8

1.6

2.3

1.8 1.7 1.51.7

1.5 1.4 1.41.2 1.1

0.9 0.9 0.8 0.7 0.7 0.7 0.6 0.6

0

1

2

3

4

5

6 SentinelPHIMS-ANCPHIMS-No ANC

Sources: serosentinel surveillance, BoEPHIMS, Department of Health

%

HIV Prevalence in Pregnant Women by ANC Status

1989-2011

20012002

20032004

20052006

20072008

20092010

20112012

20132014

20152016

20172018

20192020

0

5,000

10,000

15,000

20,000

25,000

Extramarital

Female from Husband

Male from wife

Female sex worker

Male from sex worker

Male sex with male

Injection Drug User

By 2020 with current interventions

Estimated Number of New HIV Infections per YearAdults ≥ 15 y, classified by Sub-population, Thailand, 2001-2020

Source: 2009 AIDS Epidemic Projection and Estimation Modeling (AEM)

11.9%

48.6%

5.5%

2.4%

6.3%

20.5%

4.8%

Male sex with male

Female from husband

Male from wife Injection Drug User

Male from sex worker

Extramarital Sex worker0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

17,484

9,811

3,8034,472

3,449

2,681

1,343

Estimated number of new adult HIV infections by mode of transmission, 2012-2016 (N = 43,043)

Total new HIV infection among couple = 13,614 (31.6%)

(40.6%)

(22.8%)

(8.8%)(10.4%)

(8%)(6.2%)

(3.1%)

6

National PMTCT M&E system

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

MTCT-CARE in all provinces- Partner HIV testing - CD4 post partum- Care for mother and family (OI prophylaxis, ARV)

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 q 6 mos

-HAART for mother (CD4<200,symptoms) during ANC -Tail regimen (AZT+3TC) - DNA PCR for infant diagnosis

HAART for all HIV-infected pregnant women and couples counseling

Thai National PMTCT Policy Evolution

PHIMS “Perinatal HIV inventory monitoring system” (76 provinces)

PHOMS “Perinatal HIV outcome monitoring system” (4 provinces (2001), 14 provinces (2004)

NAP “National AIDS Program”

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Thailand’s National Supported PMTCT Program

HIV counseling and testing (HCT)• Routine voluntary HCT for all pregnant women (opt out)

• Individual counseling• Group counseling• Couples counseling

Laboratory testing for HIV-infected pregnant women• Routine blood testing for pregnant women (CBC, Blood group,

HBsAg, VDRL, Anti-HIV)• CD4 test at 14 wks GA and q 6 monthsTriple ARVs (LPV/r-based HAART) for all HIV-infected pregnant

women, AZT or triple ARVs for HIV-exposed babiesEID at 1-2 and 4-6 months of age

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Uptake of HIV Testing and Syphilis Testing among Pregnant Women, Thailand

Oct 11-Sep 12 (n = 416,626)

PHIMS, Thailand DOH

90 93 99.2 99.2 96.5

19 16

0102030405060708090

100

Syphilis testing Syphilistreatment in

women

HIV testing inpregnantwomen

HIV testing(ANC)

HIV testing (noANC)

pretest couplecounseling

posttest couplecounseling

%

VDRL+: 0.06%Confirm SY: 0.05%

HIV+0.64

HIV+ 0.59%

HIV+: 3.12%

Partner HIV status at delivery: 129,490 (31%) HIV+: 0.83%

9

Percentage of HIV+women receiving ART/PMTCT

Prophylaxis (Oct 11-Aug 12) (N=4,615)

0102030405060708090

100

HAART for lifelong

treatment

Triple ARV prophylaxis

AZT+SD NVP No ARV

Receiving CD4 84%

%

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EID Coverage among HIV-Exposed InfantsChi square for linear trend p <0.001

2008 2009 2010 2011 TotalNumber of live births** 797,356 787,739 766,370 796,104 3,147,569HIV prevalence in pregnant women# 0.74% 0.69% 0.63% 0.63% 0.72%Estimated number of HIV-infected pregnant women 5,900 5,435 4,828 4,936 22,573

** Data from Ministry of Interior, # Data from national PMTCT monitoring system, Department of Health, MOPH

*2008 2009 2010 20110%

20%

40%

60%

80%

100%

3183 3447 3370 3602

HIV Exposed Infants Received EID

Received EID Not received EID

63% 70% 73%

53%

NAP Database June2012

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Mother-to-Child HIV Transmission Rate 2008-2012, PCR Testing Results & Weighted Average Estimation

2008 2009 2010 2011 20120.00.51.01.52.02.53.03.54.04.55.0

3.83.2 3.2

2.42.1

4.6

3.93.4

3.12.8

%MTCT rate in PCR tested infants %MTCT rate by wiegthed average

HAART for All(Boosted PI-based HAART 70-80%)

12

Continuum of Care in HIV-infected Infants

2007 2008 2009 2010 2011

81

118108 104

81

44

92 9478

3732

65 63 57

35

Number of infant positive at first PCR Total infant received CD4 count testTotal infant initiated ART

Mean age (days) at first CD4 517 429 379 269 176 Mean age (days) at ART 535 425 398 268 156

NAP database: 30 Jun 2012

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Thailand – Major Challenges

• ~800,000 deliveries per year with 2% no ANC• 5,000 deliveries with HIV-positive/year

– 10% no ANC– 25% first ANC visit > 28 wks GA– 15% received less than optimum ARV (not HAART)– About half CD4 < 350 cells/cu.mm

• 20-25% of HIV exposed infants did not receive EID• < 30% of HIV-infected infants received ART within 1 year of

age

Department of Health, Thailand

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Sterilizing cure: lessons learned

Modified from the slide collection of Prof. Sharon Lewin. Hutter et al., N Engl J Med, 2009; 360:692; Allers et al., Blood. 2010 117(10):2791; Yukl et al., Int Workshop on HIV and Hepatitis Resistance, Sitges, June 2012

102

103

104

105

106

107

HIV

-1 R

NA

(cop

y/m

L)

cART cART

AML diagnosis

2nd BMTfor relapse

AML

BMTdonor cells

without CCR5

2007 2008 2012

GI tract biopsy

CSF

Brain biopsy

2009

GI tract biopsy

No RNA/DNA

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The Mississippi Baby: Functional Cure of HIV

31 hours 3 days 10 days 20 days 30 days0

5000

10000

15000

20000

25000

30 hours HIV DNA+

AZT/3TC/NVP started at 31 hours

AZT/3TC/LPV/r from day 7

Persaud D, 2013 CROI, Abstract 48LB

HIV

RNA Loss to follow up

and stop ART at age 18 months

HIV RNA 19,812 copies/ml

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Almost no HIV virus detected•HIV RNA < 50 copies/ml•No replication competent virus•Very low HIV DNA level•HIV RNA detected at 1 copy/ml

No HIV-specific immunity•Non-reactive HIV EIA•Non-reactive Western Blot•No HIV-specific CD8 response

At 24 months of age

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Goal for Elimination Mother-to-Child HIV Transmission, in Thailand by 2015

1. 50% reduction in number of new pediatric HIV infection

2. 50% reduction of AIDS mortality rate among HIV+

mothers and babies

50% reduction of AIDS mortality in

children

-Promote early infant diagnosis-Early access to Rx and care-Improve quality of pediatric HIV treatment, promote ARV adherence and reduce complication

Reduction of new HIV infection among women

15-45 years for 2/3 of estimated number

Reduction of unmet family planning

need to zero

Reduce MTCT rate to < 2%

95% of HIV+mothers and family refer to treatment and care

Prong 1 target

Prong 2target

Prong 3target

Prong4target

sarawut boonsuk DOH,MOPH 2012

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Thailand’s Program for eMTCT and Pediatric HIV Cure( New GL)

• ANC 100% anywhere, any scheme (to eliminate barrier to ANC access and promote high quality of ANC and PMTCT)

• Promote couple HIV counseling and testing • Revised PMTCT guidelines (2013)

– Change CD4 criteria from <350 to <500 cu.mm (for continuing ART after delivery)

– ART for serodiscordance couples– PCR at 1,2 and 4 months for high risk for MTCT infants– Start ART as soon as possible for HIV-infected infants < 1 yr of

age– Triple ARVs for high risk of MTCT infants at birth and

discontinue if PCR result was negative

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Thailand’s Program for eMTCT and Pediatric HIV Cure

• Launch Active Case Management for eMTCT and Pediatric HIV Cure in FY14– Actively manage HIV-infected pregnant women to receive

ARV, identify high risk for MTCT infants– Promote EID and early ART– Promote linkage to care for PCR positive infants

• Confirm HIV-infection status as soon as possible• Start ART immediately to limit HIV reservoir HIV cure

research (partner with research group)

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PCR Labs Network

(14DMSc, 1CMU)BATS Case Manager

(B-CM)

Early ANC, PMTCT

DOH Case Manager

(D-CM)

Regional Case Manager

(R-CM)Hospital Case Manager (H-CM)

Advisory Committee Oversees “Elimination of MTCT & Pediatric HIV Cure”

Active Case Management Network for eMTCT & Ped HIV Cure

EID

- PCR 2 ASAP - Early ART ASAP if PCR2 positive

- Care & Support

New PCR Positive Case

DOH DDC

Ped Cure research

DMSc, NHSO

if PCR positive,

investigate and manage

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1. รอ้ยละของศูนยใ์ห้คำ�ปรกึษ�คณุภ�พ (Psychosocial Clinic) และเชื่อมโยงกับระบบชว่ยเหลือนักเรยีนใน โรงเรยีน เชน่ ย�เสพติด บุหรี ่ เอดส ์OSCC คลินิกวยัรุน่ ฯ ไมน่้อยกว�่ 70 2.รอ้ยละ ของหญิงติดเชื้อได้รบัก�รให้คำ�ปรกึษ�ก�รคมุกำ�เนิด

และคว�มเส่ียงในก�รต้ังท้องชำ้�

Action Plan for Prevent new HIV infections among women of reproductive age and Unwanted pregnancy

Increasing to care in Vulnerable group

วธิกี�รดำ�เนินง�น

*Counseling*condom Free*safetypregnancy *IT/HBSS

- SRR MCHT- YFHS

- Psychosocial Clinic

- OSCC

Service Setting

Integrate PP area base Funding

Process Indicator

Outcome Indicator

1.อัตร�ก�รคลอดในม�รด�อ�ยุ 15-19 ปี ไมเ่กิน 50 ต่อ ประช�กรหญิงอ�ยุ 15-19 ปีพนัคน

2.รอ้ยละก�รต้ังครรภ์ชำ้�ในวยัรุน่ 15-19 ปี รอ้ยละ 10

Impact

Percentage of pregnancy women HIV infected < 0.5

Prevent unwanted pregnancies among women living with HIV/AIDS

22

1. รอ้ยละของหญิงตั้งครรภ์ได้รบัก�รฝ�กครรภ์ครัง้แรกอ�ยุครรภ์น้อยกว�่หรอืเท่�กับ 12 สปัด�ห์ไมน่้อยกว�่ 60

2. รอ้ยละของบรกิ�ร ANC คณุภ�พ ไมน่้อยกว�่ 703. รอ้ยละของห้องคลอดคณุภ�พ ไมน่้อยกว�่ 704.รอ้ยละหญิงตั้งครรภ์ได้รบัตรวจเชื้อ เอสไอวรีอ้ยละ 1005.หญิงต้ังครรภ์ได้รบัก�รให้คำ�ปรกึษ�แบบคู่รอ้ยละ 356.รอ้ยละท�รกท่ีเกิดจ�กแมติ่ดเชื้อได้รบัก�รตรวจPCR ท่ี 1 เดือน

รอ้ยละ 807.รอ้ยละหญิงตั้งครรภ์และเด็กท่ีติดเชื้อ หรอืมคีว�มเส่ียงได้รบัก�ร

ติดต�มเป็นร�ยบุคคล ม�กกว�่รอ้ยละ 80

Action Plan for Prevent HIV transmission from women living with HIV/AIDS to their infants using ARV prophylaxis

ฝ�กท้องไว คลอดปลอดภัย PCR ทันใจ ใสใ่จ ARV

วธิกี�รดำ�เนินง�น

-คัดกรองคว�มเส่ียง /Lab-แก้ไขคว�มเส่ียงโดยเรว็--ARV

- ANC&LR/WCC/DCC

มคีณุภ�พ

- SRR MCHT

ก�รเข�้ถึงบรกิ�รของหญิงต้ังครรภ์

- ฝ�กท้องทุกท่ี ฟรทีกุสทิธิ์

Service Setting

บูรณ�ก�รกองทนุตำ�บล

Process Indicator

Outcome Indicator

1 . รอ้ยละ หญิงตั้งครรภ์ติดเชื้อได้รบัย�ต้�นไวรสัรอ้ยละ1002. รอ้ยละเด็กอ�ยุน้อยกว�่1ปีท่ีติดเชื้อ ได้รบัARV >80%

Impact

Transmission rate < 1 %

New case HIV infection in infant < 50 cases

Risk Management

หญิงตั้งครรภ์

เด็กเล็ก

23

Process of Risk management in EMTCT

Center Manager

Provincial Manager

Regional Manager

Area Management Team

DHS/MCH cup

SRR-MCHT

Risk analysis

Report

M/E

Boonsuk s. DOH Thailand

24

Acknowledgements

• Thananda Naiwatanakul CDC –Thailand • Rangsima Lolekha CDC –Thailand• UNICEF –Thailand

25

THANK YOU