What if PREP works? National governments and their responsibilities

1. What if PREP works?National governments and their responsibilities Dr Anupong Chitwarakorn Department of Disease Control Ministry of Public Health, Thailand Presented at the 16th World AIDS Conference, Toronto, 13-18 August 2006

2. Creating effective partnerships for HIV prevention trails • To define model for building and sustaining partnership for preventive research • To develop and deliver Standard of Prevention Trial • To develop and deliver antiretroviral therapy for trial volunteers

3. Model for building and sustaining partnership for preventive research • Funding agencies should provide resources to develop innovative approaches to partnership and community to establish Community Advisory Boards • UNAIDS/WHO should sponsor the development of guideline for Good Community Practice • National government with UNAIDS/WHO should explore to establish national or other board to review, approve and monitor research partnership for regulatory or ethic review • Partnership agreement should include clear roles for all stake holders and specify responsibility/right of sponsor, government, community, advocacy organization and media

4. Developing and delivering Standard of Prevention Trial • Researchers should engage appropriate stake holders in design, implementation and oversight of risk reduction intervention, tailored to the specific, need and risk of trail participants in the community • National and international research oversight group should evaluate the pros and cons of the independent organization implementing risk reduction intervention in prevention trial • Sponsors, researchers and activist should continue to resolve ongoing conflict about risk reduction intervention for injecting drug user (needle/syringe exchange, methadone maintenance….. To develop common standard of prevention

5. Developing and delivering antiretroviral therapy for trial volunteers • Sponsor and researchers should specify in protocol what community how to provide service, care and treatment for volunteer who becomes HIV infected during trial • Researcher oversight groups should develop standard for care and treatment of study participants • National AIDS plan should provide clear guideline on care and support for trial participants who become HIV infected with responsibility of government, research sponsors and all stakeholders

6. Role and responsibility of government and Ministry of Health in consideration on new preventive technology • develop HIV prevention research plans as part of National AIDS plans • Include clear requirements for stake holder partnership and for care and support for trial volunteers and participants • together with international agencies, expand effort to strengthen national capacity using existing review process and regulatory and ethical review • Identify and estimate potential factors related to new HIV prevention technology for public health intervention: costs, efficacy, potential group population, equity, financing, etc

7. Epidemiology of HIV infection in Thailand: 1989-2020*  Estimated HIV infection in 2006 · Cumulative HIV infected cases 1,108,960 Cumulative deaths 660,689 ·PWHA(HIV+AIDS) 508,323 PLWA (AIDS) 60,052 New AIDS cases in 2006 48,692 ·New HIV infections in 2006 16,633 Reduction of new HIV infection New HIV infections in 1991 142,819 New HIV infections in 1996 60,749 New HIV infectionsin 2001 25,790 New HIV infections in 2010 11,685 New HIV infectionsin 2020 7,919 * Scenarios based on data as of year 2000 ( PMTCTimplemented in 2000, Access to ARV in 2003)

8. Number of new HIV infections by transmission mode 100% condom use program initiated in 1989and implemented nationwide in 1992

9. Setting National Targets and Strategies Using Data Analysis and Modeling ARV budget Key issue: Treatment cost • Cost for ARV treatment for a person per year is about $ 2,200 • Total treatment cost will reach 350 million US dollars per year by 2010 70 m. us$ 6-8 m $

10. Key Issues HIV Prevalence is high in many groups • MSM national 7%, Bangkok 28% • Injecting Drug user 40-50% • Sex workers 4-10% • Fishermen 4-13%

11. Key IssuesHigh Risk behaviors exist • Youth have first sex younger • 20% of men and 5-10% of women have non-commercial sex outside their regular partners and only one-third of them use condom • 10% of men still visit sex workers • Less than 10% of discordant couples use condom • One-Third of injecting drug users share needles

12. Factors for public health implementation: future possible HIV prevention, PREP • Efficiency • Drug resistance • Potential groups of population • Cost, demand • Financing • Existing interventions

13. How much will it cost to achieve the Prevention goal? …in fact, we need to answer two questions … • What level of program coverage of targeting the various risk groups is needed to achieve this magnitude of behavior change? • What will it cost to implement the levels of program coverage to achieve the prevention goal?

14. Strengthening Prevention ScenarioTarget of Change in Risk Behaviors

15. Financial Resource Requirements to achieve the Prevention Goal • 2004 prevention expenditure: $10 m • To meet the prevention goal an increase of 3-4 times in cumulative prevention budget over the period 2006-2008

16. Example of the impact scenario: course of epidemic with different vaccine intervention

17. Evidence of continuing behavioral change (visits to female sex workers and condom use at last visit) in 21 year old males in the north. Percent of sample

18. STD and condom use among FCSWs

19. Thailand’s National PMTCT ProgramNumber of Infections Prevented,2001-2003 • Number of births to HIV-infected women 18,888 • Number of infants infected: • With no intervention TR = 30% 5,666 • With MOPH program TR = 8%, 75.9% HIV+ women participate 1,147 Estimated Infections Being Prevented : 4,519

20. Thank you