1. Rangsima Lolekha, MD CDC/DGHT Thailand/Asia Regional Office
Getting to Zero: How will Thailand’s Strategies and Interventions Eliminate Mother-to-Child HIV Transmission by 2020?
Rangsima Lolekha, MD
CDC/DGHT Thailand/Asia Regional Office

2. Thai National PMTCT Policy Evolution
DNA PCR based on risk of MTCT
DNA PCR (2 times)
- HIV antibody at months
Early infant diagnosis
Infant formula (12 mo)
- Infant formula (18 mo)
Infant feeding
PMTCT
infant
AZT x 4 wks or
AZT/3TC 6 wks +NVP 2-4 wks
AZT/3TC/NVP 6 wks
PMTCT
Pregnant women
Short course AZT
(34 wks)
AZT 28 wks+ NVP 1 dose
HAART for all pregnant women (14 wks) and continue for eligible women
HAART for all ASAP and continue HAART for all who are willing to take ART
AZT 28 wks+ NVP 1 dose and HAART for eligible women
แสดงพัฒนาการนโยบายป้องกันการติดเชื้อในไทย
VCT/PITC
Couples HIV testing and counseling
VCT
VCT and infant formula x 12 mo

3. GAP-PMTCT Projects (2004-2016)
Perinatal research ( )
5. Hospital-based model of CHTC at ANC setting
6. Expansion of CHTC model to MOPH and BMA hospitals
3. Evaluation of national PMTCT program outcomes
4. Early Infant Diagnosis (EID) survey
1. Develop and transfer National PMTCT program (process/outcome) monitoring system (PHIMS, PHOMS) to RTG
2. Update PMTCT monitoring system to web-based program, integrate and promote data utilization
7. TA for EMTCT validation
8. Active case management network for early ART and EMTCT
PHIMS, PHOMS
AZT pilot study region 7, 10
AZT short course
and other PMTCT research studies
1995…
Strategies (all projects collaborated with key partners)
Research
Promote strategic data use for program improvement and strengthen system
Develop replicable model
Support replicable model expansion, promote data use and strengthen system

4. Selected Achievements
PMTCT data from PHIMS web based used for national PMTCT monitoring
Results from PMTCT studies, evaluation, EID survey, pilot projects led to
Policy changes (e.g. AZT implementation, EID training, transition from option A to B, CHTC policy to recommend “all public hospitals should provide CHTC services at ANC settings”, implementation of dried blood spot HIV PCR at birth)
PMTCT, CHTC Tools and materials were developed
Curricula were developed by MOPH and GAP Thailand e.g. CHTC, PMTCT for international delegates
ACC network project promoted early ART initiation among HIV- infected infants. 80% of HIV+ infants initiated ART by 1 year of life in 2015 compared to 52% in 2012
Example of GIS
Coverage of CD4 among delivery HIV+ women by province

5. Number of pediatric AIDS cases aged 0-4 years born to HIV positive mothers during 1984-2014
Operational research
on ARV prophylaxis
VCT for all pregnant women, formula feeding
AZT pilot study region 7 & 10
Cases
AZT short course
AZT 28 wks + SD NVP
HAART
Option B+
Decrease in paediatric HIV infections after implementation of prevention of mother-to-child transmission programme in Thailand
Epidemiology Division, June 2015.
Year

6. WHO 2014
summarizes the global minimum required impact and process indicators for validation of
EMTCT of HIV and/or syphilis.

7. Reporting units
Thai: 826/913 (90%) hospitals
Non-Thai: 341/913 (37%) hospitals
Coverage of HIV testing, ART and CD4 testing among Thai vs. non-Thai pregnant women and their babies, Thailand
July 2014-June 2015 (N=504,202 vs. 38,161)
HIV+
0.61%
HIV+
0.65%
~800,000 deliveries per year %
ANC rate = 98%
Source: PHIMS, DOH (Accessed 30 Sep 15)

8. National MTCT Rates (GARP Report 2014)
In 2014 Thailand almost achieve the eMTCT impact indicator of <2% MTCT rate.
Year

9. Remaining causes for MTCT in Thailand (90 HIV+ infants, Aug 14-Aug15)
Late presenters (<4 wks), poor ARV adherence: (81%)
Not disclose HIV status to partner
Teenage pregnancy
Multiple partners, multi-parity
Incarceration, addiction
Non-Thai with no health insurance system 7/90 (8%)
Aware of HIV status but didn’t want to come for ANC (stigma) %
Mother HIV+ during pregnancy, seroconvert during pregnancy or postpartum
HIV+ at one hospital and delivered at another hospital
ACC database, MOPH as of Aug 31, 2015
Maternal HIV negative and seroconvert during pregnancy or postpartum: 7/90 (8%)
ANC at private clinic, no HIV test from private hospital: 1/90 (1%)
Health care system (Tested positive at one hospital and delivered at another hospital, did not repeat HIV test) 1/90 (1%)
Others (unknown)

10. Probability of MTCT by duration of ART, n= 6206
VL near time of delivery (copies/mL)
MTCT rate (%)
<50
0.05
50-399
1.1
1.9 3
>10,000
9.2
VL <1000: 6-8 wks
VL <50: 12 wks
Townsend CL et al. AIDS 2014

11. Time to achieve HIV viral load <1000 copies/mL and <50 copies/mL after raltegravir initiation during the third trimester (n=10). Dotted lines represent CIs
Case series have reported rapid viral decay with the use of raltegravir initiated late in pregnancy to achieve viral suppression and reduce the risk of MTCT
De Hoffer L. J chemother 2013; Cha A.J Int Assoc Provid AIDS Care. 2013; Taylor N. Int J STD AIDS. 2011
Can J Infect Dis Med Microbiol May-Jun; 26(3): 145–150.

12. Challenges for eMTCT and responses: Thailand case study
Responses and next steps
Late presenter
Revised national PMTCT guidelines 2016: Include raltegravir* as an option for late presenter (GA 32 wks) in addition to HAART
DOH-TRC pilot study for raltegravir in late presenters
Discordant couples and HIV seroconvert after delivery
Revised national PMTCT guidelines 2016: Emphasize importance of couples HIV testing and counseling
*DHHS 2015; BHIVA 2014

13. Challenges for eMTCT and responses: Thailand case study (2)
Responses and next steps
Management of non-Thai women
Encourage migrants to purchase migrant health insurance
Special project supported by TRC through DOH
Maternal child health card
Migrant health insurance card
that provides health benefit package similar to universal health coverage scheme for Thais

14. A significant improvement in Sexual Reproductive Health (SRH) discrimination in 2014
Source: International Health Policy Program (IHPP), 2014

15. Thailand National Validation Committee and Working Groups were established, February 2015
Dec 2015: Thailand Minister of Public Health presented awards to 41 provinces that achieved EMTCT goal
Thailand MOPH has submitted an application letter for validation of EMTCT of HIV and syphilis to the WHO regional secretariat in December 2015

16. Conclusions: EMTCT of HIV by 2020 requires
Leadership and commitment from MOPH and policy makers
Update PMTCT national guidelines/technical knowledge: HAART for all, option B+, intensive PMTCT regimen, couples HIV testing and counseling
Funding for universal health coverage benefits for HIV testing and ARV for PMTCT & infant formula
High quality of MCH and PMTCT services: High coverage of ANC, Good HIV prevention program among reproductive health women, prevention of unintended pregnancy among HIV+women, universal HIV testing, high coverage of PMTCT services and high retention in a program
Adequate workforce/training
Robust PMTCT national monitoring system
Address stigma and discrimination and support for vulnerable population
Setting up the national eMTCT validation committee, engaging key stakeholders to review data and plan for improvement

17. Acknowledgements Thailand National EMTCT working groups
All staff/hospitals working on PMTCT in Thailand
Thailand MOPH
Department of Diseases Control (Bureau of AIDS, TB, STIs and Bureau of Epidemiology)
Department of Health
Department of Medical Sciences
Department of Medical Technology, Chiang Mai University
Chiang Rai Prachanukroh Hospital, Chiang Rai
Srinakarind Hospital, Khonkaen
Prachomklao Hospital, Petchburi
Hatyai Hospital, Songkla
Siriraj Hospital
Queen Sirikit National Institute of Child Health
Rajavithi Hospital
HIV Netherland Australia Thailand Research Collaboration (HIVNAT), Bangkok
CDC/DGHT Thailand/Asia Regional Office