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Countdown To Zero , Elimination of MTCT in Thailand

Countdown To Zero , Elimination of MTCT in Thailand . Sarawut boonsuk MD,MPH Chief of Maternal and child Group Department of Health Focal point PMTCT program , DOH,Thailand. HIV/AIDS Epidemic in Thailand.

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Countdown To Zero , Elimination of MTCT in Thailand

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  1. Countdown To Zero ,Elimination of MTCT in Thailand Sarawutboonsuk MD,MPH Chief 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. HIV Prevalence in Pregnant Women by ANC Status 1989-2011 % Sources: serosentinelsurveillance, BoE PHIMS, Department of Health

  4. Estimated Number of New HIV Infections per YearAdults ≥ 15 y, classified by Sub-population, Thailand, 2001-2020 4.8% 20.5% 6.3% 2.4% 5.5% 48.6% 11.9% Source: 2009 AIDS Epidemic Projection and Estimation Modeling (AEM)

  5. (40.6%) Total new HIV infection among couple = 13,614 (31.6%) (22.8%) (10.4%) (8.8%) (8%) (6.2%) (3.1%)

  6. Thai National PMTCT Policy Evolution HAART for all HIV-infected pregnant women and couples counseling • HAART for mother (CD4<200,symptoms) during ANC • -Tail regimen (AZT+3TC) • - DNA PCR for infant diagnosis • New PMTCT policy (AZT (28wks) +SD NVP) • CD4 antepartum and q 6 mos 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 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 National PMTCT M&E system PHIMS “Perinatal HIV inventory monitoring system” (76 provinces) PHOMS “Perinatal HIV outcome monitoring system” (4 provinces (2001), 14 provinces (2004) NAP “National AIDS Program”

  7. 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 months Triple ARVs (LPV/r-based HAART) for all HIV-infected pregnant women, AZT or triple ARVs for HIV-exposed babies EID at 1-2 and 4-6 months of age

  8. Uptake of HIV Testing and Syphilis Testing among Pregnant Women, Thailand Oct 11-Sep 12(n = 416,626) 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% % PHIMS, Thailand DOH

  9. Percentage of HIV+women receiving ART/PMTCT Prophylaxis (Oct 11-Aug 12) (N=4,615) Receiving CD4 84% %

  10. EID Coverage among HIV-Exposed Infants Chi square for linear trend p <0.001 53% * ** Data from Ministry of Interior, # Data from national PMTCT monitoring system, Department of Health, MOPH NAP Database June2012

  11. Mother-to-Child HIV Transmission Rate 2008-2012, PCR Testing Results & Weighted Average Estimation HAART for All (Boosted PI-based HAART70-80%)

  12. Continuum of Care in HIV-infected Infants NAP database: 30 Jun 2012

  13. 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

  14. Sterilizing cure: lessons learned No RNA/DNA BMT donor cells without CCR5 2nd BMT for relapse AML AML diagnosis cART cART 107 106 Brain biopsy 105 HIV-1 RNA (copy/mL) 104 CSF GI tract biopsy 103 GI tract biopsy 102 2009 2007 2008 2012 Modified from the slide collection of Prof. Sharon Lewin. Hutteret 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

  15. The Mississippi Baby: Functional Cure of HIV HIV RNA 19,812 copies/ml HIV RNA Loss to follow up and stop ART at age 18 months 30 hours HIV DNA+ AZT/3TC/LPV/r from day 7 AZT/3TC/NVP started at 31 hours Persaud D, 2013 CROI, Abstract 48LB

  16. At 24 months of age • 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

  17. Goal for Elimination Mother-to-Child HIV Transmission, in Thailand by 2015 50% reduction of AIDS mortality in children 1. 50% reduction in number of new pediatric HIV infection 2. 50% reduction of AIDS mortality rate among HIV+ mothers and babies -Promote early infant diagnosis -Early access to Rx and care -Improve quality of pediatric HIV treatment, promote ARV adherence and reduce complication Prong 1 target Prong 2 target Prong4 target Prong 3 target Reduce MTCT rate to < 2% 95% of HIV+mothers and family refer to treatment and care Reduction of new HIV infection among women 15-45 years for 2/3 of estimated number Reduction of unmet family planning need to zero sarawut boonsuk DOH,MOPH 2012

  18. 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

  19. 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)

  20. Active Case Management Network for eMTCT & Ped HIV Cure DMSc, NHSO DOH DDC PCR Labs Network (14DMSc, 1CMU) DOH Case Manager (D-CM) BATS Case Manager (B-CM) Early ANC, PMTCT • New PCR Positive Case EID Regional Case Manager (R-CM) Hospital Case Manager (H-CM) • if PCR positive, investigate and manage • - PCR 2 ASAP • Early ART ASAP if PCR2 positive • Care & Support Ped Cure research Advisory Committee Oversees “Elimination of MTCT & Pediatric HIV Cure”

  21. Action Plan for Prevent new HIV infections among women of reproductive age and Unwanted pregnancy Integrate PP area base Funding Service Setting วิธีการดำเนินงาน Percentage of pregnancy women HIV infected < 0.5 Increasing to care in Vulnerable group Outcome Indicator Prevent unwanted pregnancies among women living with HIV/AIDS 1.อัตราการคลอดในมารดาอายุ 15-19 ปี ไม่เกิน 50 ต่อ ประชากรหญิงอายุ 15-19 ปีพันคน 2.ร้อยละการตั้งครรภ์ช้ำในวัยรุ่น 15-19 ปี ร้อยละ 10 Impact Process Indicator *Counseling *condom Free *safety pregnancy *IT/HBSS • SRR MCHT • YFHS • Psychosocial Clinic • OSCC 1. ร้อยละของศูนย์ให้คำปรึกษาคุณภาพ (Psychosocial Clinic) และเชื่อมโยงกับระบบช่วยเหลือนักเรียนใน โรงเรียน เช่น ยาเสพติด บุหรี่ เอดส์ OSCC คลินิกวัยรุ่น ฯ ไม่น้อยกว่า 70 2.ร้อยละ ของหญิงติดเชื้อได้รับการให้คำปรึกษาการคุมกำเนิด และความเสี่ยงในการตั้งท้องช้ำ

  22. Action Plan forPrevent HIV transmission from women living with HIV/AIDS to their infants using ARV prophylaxis บูรณาการกองทุนตำบล Service Setting วิธีการดำเนินงาน Transmission rate < 1 % New case HIV infection in infant < 50 cases ฝากท้องไว คลอดปลอดภัย PCR ทันใจ ใส่ใจ ARV Outcome Indicator Risk Management หญิงตั้งครรภ์ เด็กเล็ก ร้อยละ หญิงตั้งครรภ์ติดเชื้อได้รับยาต้านไวรัสร้อยละ100 ร้อยละเด็กอายุน้อยกว่า1ปีที่ติดเชื้อได้รับARV >80% Process Indicator Impact • คัดกรองความเสี่ยง /Lab • แก้ไขความเสี่ยงโดยเร็ว • -ARV • ANC&LR/WCC • /DCC • มีคุณภาพ • -SRR MCHT 1. ร้อยละของหญิงตั้งครรภ์ได้รับการฝากครรภ์ครั้งแรกอายุครรภ์น้อยกว่าหรือเท่ากับ 12 สัปดาห์ไม่น้อยกว่า 60 2. ร้อยละของบริการ ANC คุณภาพ ไม่น้อยกว่า 70 3. ร้อยละของห้องคลอดคุณภาพ ไม่น้อยกว่า 70 4.ร้อยละหญิงตั้งครรภ์ได้รับตรวจเชื้อ เอสไอวีร้อยละ 100 5.หญิงตั้งครรภ์ได้รับการให้คำปรึกษาแบบคู่ร้อยละ 35 6.ร้อยละทารกที่เกิดจากแม่ติดเชื้อได้รับการตรวจPCR ที่ 1 เดือนร้อยละ 80 7.ร้อยละหญิงตั้งครรภ์และเด็กที่ติดเชื้อ หรือมีความเสี่ยงได้รับการติดตามเป็นรายบุคคล มากกว่าร้อยละ 80 การเข้าถึงบริการของหญิงตั้งครรภ์ - ฝากท้องทุกที่ ฟรีทุกสิทธิ์

  23. Process of Risk management in EMTCT SRR-MCHT Center Manager Risk analysis Provincial Manager Regional Manager Report M/E Area Management Team DHS/MCH cup Boonsuk s. DOH Thailand

  24. Acknowledgements • ThanandaNaiwatanakul CDC –Thailand • RangsimaLolekha CDC –Thailand • UNICEF –Thailand

  25. THANK YOU

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