Utility weights study in TOP 5 diseases in Thailand. W. Thanawat MD.,M.P.A.
Sorakij Bhakeecheep , MD Director National Health Security Office, Region 1 THAILAND.
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Transcript of Sorakij Bhakeecheep , MD Director National Health Security Office, Region 1 THAILAND.
National ART Program - NAP
Utilization of NAP Monitoring data for Policy Decision “Treatment as Prevention”
Sorakij Bhakeecheep, MDDirector
National Health Security Office, Region 1THAILAND.
Contents
• Brief overview ART program Thailand• National patient monitoring system - NAP• Utilization of NAP monitoring data for policy
decision “Treatment as Prevention”
ART Program in Thailand
1997-98 2000 01 02 03 04 05 06 07 11
ARV research(mono/dual)
National Access to ARV Treatment for PLHIV (NAPHA)(Pilot program under GF and MoPH research fund)
PMTCT researches
National Health Security Act(Health promotion, Prevention,
Cure and Rehabilitation)
12 13
PMTCT National Program
14
ART at CD4<350
Advocate TasP (Any CD4)
Universal Access to ART
ART at CD4<200
ART Coverage among Persons Living with HIVNumber of PLHA Receiving ART (2001-2013)
20012002
20032004
20052006
20072008
20092010
20112012
20132014
20152016
20172018
20192020
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
PLHA-CD4 > 500
62,330
137,090
76,371
PLHA-CD4 ≤ 500
Source: AIDS Epidemic Model (AEM), NHSO – NAP, SSO, CSMBS, GF, and Thai GPO
PLHA-≤ 350246,049
•Area graph shows estimated persons living with HIV by CD4 levels•Linear graph shows number of currently PWHA retain in the cohort•The coverage is 80% according to CD4<350
80% Coverage of ART need(CD4<350)
National AIDS Program Monitoring System(NAP)
- Implemented in April 2007- Designed for supporting patient care, fund
administration and program monitoring- Web application architecture- Centralized user management system- Individual data collecting with transaction oriented
(medications, lab, etc)- National ID encryption to avoid data duplication
Overview of NAP System Architecture
Health Service Providers National Health Security Office
VCT facilities
HIV clinics
Laboratories
Procurement & Logistics
Link to Birth-Death Registration from ministry of interior
AIDS experts
Internet Data Processing
NAP Database
Internet
Fund Administration
Program Monitoring
Policy decision & planningPatient monitoring and
quality improvement
Concept of Using Data to Inform Policy
Information base
Policy AnalysisPolicy Decision
Resource Preparation
Knowledge base
Input Process Output
Evidence Based of Treatment as Prevention: Clinical vs. Public Health Aspect
• Currently, there is insufficient evidence and/or favorable risk-benefit profile to support initiating ART at CD4 >500 or regardless of CD4 …. (Clinical aspect)(Reference: WHO Consolidated Guidelines on The Use of ARV Drugs for Treating and Preventing HIV Infection : p. 93)
• Observation from HTPN 052 :- PWHA receiving ART with suppressed viral load would reduce risk of HIV transmission to their partners (Prevention aspect)
• In conclusion, the benefits of starting ART at CD4 >500 is not for who’s taking ARV drugs, but for their partners (Public Health Benefit)
What should be considered in addition to efficacy and benefit of
an intervention?
1. Cost-effectiveness (Return of investment)2. Negative impacts (Retention &
Adherence)3. Resources availability (Man, Money)4. Feasibility & Sustainability5. Prioritization6. Equity and ethics
How can BIG Data answer these questions ?
PWHA Cascade
Source: AIDS Epidemic Model (AEM), NHSO, SSO, CSMBS, GF, and Thai GPO
Status Reported number
HIV+ currently alive (Estimated) 459,509 (100%)
HIV+ currently access to treatment 246,049 (54%)
HIV+ not accessed to treatment (if treat for all) 213,460 (46%)
HIV+ never registered to National registry 133,781 (63%)
HIV+ ever registered to National registry 79,679 (37%)
Lost of follow up during pre-ART (CD4 > 350) 37,292 (47%)
Lost of follow up during receiving ART 42,387 (53%)
• Only 54% of PWHA can access to ART• 46% cannot access to ART • Among who cannot access to ART, 37% have been registered but lost during follow up
• 47% - loss during pre-ART• 53% - loss during receiving ART
Proportion of CD4 at Diagnosis and ART Initiation(2008-2013)
CD4 at newly HIV+ diagnosis CD4 at ART Initiation
• Nearly half of new HIV+ had very low CD4 (less than 100) at the time of diagnosis and ART initiation• These findings demonstrated late access to HIV care services, thus reflecting the performance of HCT program
Performance of HCT Program need to be improved
98 94101 98 97
109 84 75 88 97 97
111 Median
CD4
Children Adults
331,357381,717 286,214 227,451 175,813 155,221
23,510 (6%)
(71%)(82%)
(43%)(56%)
(38%)
Cascade Accessing and Retention to Care-ART, (2007 – 2013), NAP Monitoring System, NHSO
Data source: NAP Database , National Health Security Office
Effectiveness of ART Program (2012)
Data source: National Health Security Office
No ART Alive Retained to care
CD4<350 or OI
0
20,000
40,000
60,000
80,000
100,000 88,761
57,658
18,01710,287
0
100,000
200,000
300,000
237,510214,016
185,726
131,093
Total Registration to care and treatment services = 326,271
Pre-ART
Retention rate87%
Retention rate31%
Receiving ART
• In pre-ART, loss to follow up occurs 3 times higher than ART group• A number of PWA who are eligible for ART didn’t receive treatment• In ART group, 70% of who retained to ART has viral load suppression
Quality of care in ART program need to be improved
70%
Using Projecting Model to Forecast ART Service Demands
Data input from NAP is required in order to calculate
service demand from Projecting Model
Estimated number of PLHA receiving ART 2014-2019
2013
2014 (BL)
2015
2016
2019
Number of PWHA receiving ART -Baseline (CD4 < 350)
171,028
182,217
192,188
201,116
222,505(22%)
-Any CD4 + Current HCT
171,028
182,688
198,238
210,117
236,997(30%)
-Any CD4 + 25% increasing HCT
171,028
182,688
198,650
211,968
249,932(37%)
-Any CD4 + 50% increasing HCT
171,028
182,688
198,986
213,488
260,643(43%)
-Any CD4 +100% increasing HCT
171,028
182,688
199,660
216,528
282,064(54%)
Increased # PWHA receiving ART compare to baseline scenario of the same year-Any CD4 + Current HCT - 470 6,050 9,001
14,492 (7%)
-Any CD4 + 25% increasing HCT - 470 6,462
10,852
27,427 (12%)
-Any CD4 + 50% increasing HCT - 470 6,798
12,372
38,138 (17%)
-Any CD4 + 100% increasing HCT - 470 7,472
15,412
59,559 (27%)
ART Service Demand Forecasting (UHC Schemes only)
Within next 5 years (2019), work load will increase ~20 – 50 %
ART Budget Forecasting (2015-2019)
Scenario
2015 2016 2017 2018 2019
Additional budget needed
(drugs+lab)
Total program
budget rising from 2014
-Any CD4 + Current HCT
2.1 3.2 3.8 4.4 5.1 18.6 32.8
-Any CD4 + 25% increasing HCT
2.3 3.8 5.6 7.6 9.7 29 43.2
-Any CD4 + 50% increasing HCT
2.4 4.4 7.3 10.3 13.4 37.8 52
-Any CD4 + 100% increasing HCT
2.6 5.4 10.4 15.6 21 55 69.2
ART Unit Cost (Drugs + Lab) = 352 USD/pt/yr, not include cost of HCT, capacity building, operation)
Unit = million USD
Additional budget needed from baseline scenario
•In the next 5 years, additional budget need for drugs and lab would be 18 – 55 mUSD•To end AIDS in the next 10 years, Thailand would spend totally of 400 mUSD in addition to baseline scenario
National Health Security Office 17
CD4 < 350 CD4 350-500 CD4 > 500 Total
# Estimated PWHIV 308,379 74,760 76,371 459,510
Known HIV status (Above water) 246,049 8,971 6,109 261,129
HIV status unknown (Under water) 62,330 65,789 70,262 198,381(43%)
% coverage 80% 12% 8% 57%
CD4 < 350CD4 = 350-500
CD4 > 500
Known HIV status
HIV statusunknown
Issue on Equity and Priority
1 3 5
4 62
• 43% of PWHIV do not know their HIV status. One-third of which urgently need ART (<350). Barriers stop them from accessing to health services.• Initiating ART at any CD4 just only benefit for people who are already accessed to services, but DO NOT solve the existing barriers in the inaccessible group.
In resources limited setting, who should we considered a PRIORITY ?
Conclusion• TasP could reduce new HIV infection and has showed some
potential in ending AIDS
• To implement this intervention, some critical issues should be seriously considered
• Health infra-structure strengthening (including human resources) for:– Extensive HCT scaling up esp. MARPs
– Effective quality improvement to increase early access and retention to ART
• Long term budget availability including domestic and external resources
Acknowledgement
• National Health Security Office (NHSO)• Thailand MoPH-US CDC Collaboration (TUC)• Bureau of AIDS, TB and STIs, MoPH• All ART centers under UHC network