“Getting to Zero: Thailand’s Experience with E-MTCT”

Petchsri SirinirundAdvisor on HIV/AIDS Policy and Programme

Department of Disease Control, Thailand

Validating the Elimination of Mother-to-Child Transmission has been Achieved: What is the Global Criteria and Current Regional and Country Status?

Satellite session sponsored by UNICEF and WHO, 21 July 2014

The 20th International AIDS Conference, Melbourne

THAILAND

Presentation Overview

• E-MTCT - component of the national plan to end AIDS

• Progress towards E-MTCT in Thailand

• Estimation of MTCT rates

• Thailand’s approach to E-MTCT

THAILAND

"Ending AIDS”• Certain number of new HIV infections per year <1,000 cases

(90% reduction)

• Mother to child transmission is virtually eliminated

• All PLHIV receive ART at early stage for their quality of life as well as prevention of transmission to partners

• AIDS is accepted by society as a chronic medical condition

THAILAND

Target 2016 Achieved 2013

Number of infants born to HIV+ mothers infected perinatally

70 117

PROGRESS TOWARD E-MTCT

THAILAND

2000 2002 2004 2006 2008 2010 2012 2013

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 every 6 mos-Care for partners and family

-HAART for mother (CD4<200,symptoms) during ANC -Tail regimen (AZT+3TC) -DNA PCR for infant diagnosis-Formula feeding (18 months)

HAART for all HIV-infected pregnant women and couples counseling

National PMTCT Policy in Thailand

Option A

Option BCD4<350

Option B and B+ for subpopulations

B+ for CD4<500 serodiscordant couples, coinfection of TB, HBV, HCV

Prepared by Rangsima Lolekha, TUC, 2013

Mother: ARV prophylaxis coverage

HIV testing coverage in

women giving birth99.7 98.9 95

71.5

99.5 97.8

0

25

50

75

100

HIVtesting

HIVtesting(nonThai)

MotherARV

MotherARV (non

Thai)

NewbornARV

NewbornARV (non

Thai)

% R

eceiv

ing I

nte

rventi

on

Thailand PMTCT Program Coverage 2013

• Estimated 804,484 deliveries

• Nearly all Thai pregnant women attending ANC (93.7% for non Thai)

• HIV prevalence among pregnant women =0.7% Source: 2014 Thailand AIDS Response Report (Department of Health: PHIMS)

Newborn: ARV prophylaxis coverage

Updated from slide prepared by Rangsima Lolekha, TUC, 2013

Indicators 2012 2013

% of infants born to HIV+ mothers receiving a virological test within 2 months of birth 77.2 72.9

Estimated MTCT rates (%) 2.7 2.3

Estimated MTCT rates (%) - (non Thai) NA 4.8

% of pediatric HIV cases on ART 70.8 75.5

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Key Indicators

ESTIMATION OF MTCT RATES

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Estimation of MTCT rates1. Calculate number of HIV+ve mothers from

percentages got from program reports– ANC rates– HIV+ve rates among ANC / non ANC

2. Calculate percentages of HIV+ve mothers receiving ARV from percentages got from program reports– No ARV, each regimen

3. Multiply calculated percentages of HIV+ve mothers not receiving and receiving ARV with MTCT rate got from the survey

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ARV regimenMTCT rates n/N

overall HAART 1.4 % 12/848Dual ARV 5.5 % 3/55Mono ARV 3.8 % 20/526Unspecified regimen / partial ARV 5.7 % 22/385No ARV (from prior study Perinatal study) 12.0 %

2733 women with HIV were reviewed 1779 (63%) infants had HIV outcomes(Yr 2008-2011)

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ARV regimenweighted

Coverage in 2013

MTCT rate (reviewed data from program record)

Estimated rates

No ARV/only formula feed 0.1% 12.0% 0.0%

Partial prophylaxis 10.6% 5.7% 0.6%

Dual ARV 5.6% 5.5% 0.3%

Triple ARV prophylaxis 18.9% 1.4% 0.3%

Triple ARV treatment 64.8% 1.4% 0.9%

100.0% 2.10%

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To improve the validity of the calculation of MTCT rates

• Real time monitoring– Only for HIV+ve pregnant women– Pilot test on using LINE application – Develop specific application• Monitored by hospitals and the Department of Health• Using as an alert system

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THAILAND’S APPROACH TO E-MTCT

Key interventions for ending AIDS

1. Extend combination prevention (BCC and HTC) to cover 90% of key populations

2. Treat all PLHIV early at any CD4 level (Option B+ for PMTCT)

3. Support ARV adherence

4. Adapt data management towards strengthened case management and retention of individuals in care

5. Normalize HIV

THAILAND

Elimination of MTCT – Global criteria

Impact indicators

1. ≤ 50 new pediatric HIV cases per 100,000 live births and (Thailand ≤

400 cases )

2. < 2% MTCT rate

Process indicators (2 out of 3)

3. ≥ 95% ANC coverage at least 1 visit

4. ≥ 95% HIV testing of pregnant women

5. ≥ 90% ART coverage of HIV - positive pregnant women

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E-MTCT in National Operational Plan to end AIDS, 2015-2019

• Encourage and support provinces to achieve respective E-MTCT targets – Data by province

• Data by hospitals in each province• Thai and non Thai

• Active case management of exposed and infected infants – ANC through testing for babies and ART initiation for positive

children

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Sub-national targetsIndicators Baseline

20132015 2016 2017 2018 2019

1. # of provinces with ≥ 5% MTCT of HIV

10 8 6 4 3 2

2. # of provinces with < 95% ANC coverage

6 5 4 3 3 3

3. # of provinces with <95% coverage of pregnant women who know their HIV status

TBD 3

THAILAND

Indicators Baseline2013

2015 2016 2017 2018 2019

4. # of provinces with < 90% HAART coverage among HIV+ pregnant women

45 35 25 15 5 3

5. # of provinces with < 80% of infants with HIV test within 2 months of birth

69 60 45 30 15 5

6. # of provinces with <95% of infants born to HIV+ women receive ARVs

13 10 8 6 4 2

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Sub-national targets - 2

Challenges for EMTCT• Late ANC, particularly for known HIV+ cases

• Late ART initiation for HIV+ infants

• Limited insurance for Non-Thai families

• Strategic information (separate databases, under reported services, particularly from university and private hospitals)

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Thank you

• Hospitals and provincial health offices

• Department of Health: Bureau of Health Promotion

• Thailand MOPH-US CDC Collaboration (TUC)

• Department of Disease Control: National AIDS Management Center

• UNICEF