1. Providing ARVs to children in resource limited settings
“Current practice in Thailand”
Thanyawee Puthanakit, MD
Assistant Professor in Pediatrics
Research Institute for Health Sciences,
Chiang Mai University, Thailand

2. HIV/AIDS situation in Thailand
Population = 65 millions
No. of PLWH
Adults = 700,000
Children = 30,000
HIV prevalence in pregnant
women = 1.04%
Perinatal transmission rate
= %

3. Outline Scale-up of national program
Special issues of pediatric ARV program
Outcome of HAART in Thai children
Challenges of national program

4. Scale-up of ARV Program in Thailand
Components
Thailand program
Political will
National program since 2000
Set target
50,000 by end of 2004
Universal access by 2006
Availability of drugs
Generic drugs
Public health
approach
Integrate to existing health care services
Equal access
Phased-approach

5. Model of Pediatric HIV Care
Harmonize with adult program
Treatment guideline, first-line regimen
Supply chain of ARV
Separate M&E system
Multiple entry points
Pediatric OPD and IPD services
PMTCT program
Related service; adult ARV program

6. Patients on ARV in national program
As of May 2006 Total = 77,758 Pediatric = 5,848
Thai MOPH

7. Appropriate formulations
d4T
5 mg/ml
3TC
10 mg/ml
NVP =
GPOvir
60 tab/bottle
d4T (30 mg) +
3TC (150 mg)+
NVP (200 mg)
5 cm
1 cm

8. Caregivers & Family support

9. Outcome of HAART in Thai children
Clinical outcomes ?
Complications?
Survival rate ?
Hospitalization rate?
CD4 Immune recovery ?
HIV viral suppression ?

10. Baseline patient characteristics
August 2002 to March 2005
Number: 192 children
Age: 7.6 years (range 0.4 to 14.8)
CD4 percentage 5.3% (SD 4.9)
HIV RNA 5.4 log10 copies/mL (SD 0.5)
ARV regimen: d4T+3TC+NVP or EFV

11. Before
Clinical outcomes
2 mo
12 mo
18 mo

12. Complications after HAART
Drug adverse events
Nevirapine: rash 23% (8% substitute with EFV)
Efavirenz: transient CNS 26%, rash 7%
d4T: lipodystrophy 20-40%
Immune reconstitution inflammatory syndrome
Incidence 19%
Common organisms: mycobacterial (non-TB,TB), herpes virus (HSV, VZV), cryptococcus
Puthanakit et al. Clin Infect Dis 2005;41: 100-7
Puthanakit et al. Pediatr Infect Dis J 2006; 25:53-8

13. The survival curve after HAART after first 6 months of HAART
Survival rate = 94.3%
after first 6 months of HAART
Puthanakit et al. Clin Infect Dis 2006 ( in revision)

14. Hospitalization rate after HAART
54 % Pneumonia, bacterial infection
29 % IRIS
10 % Opportunistic infections
Puthanakit et al. Clin Infect Dis 2006 ( in revision)

15. Immunological outcomes after HAART
Puthanakit et al. Clin Infect Dis 2005;41: 100-7

16. HIV viral suppression after HAART
Virological success: HIV viral load < 50 copies/mL
Puthanakit et al. Clin Infect Dis 2005;41: 100-7

17. Challenges of national program
Programmatic challenges
National registry of HIV-infected children
Roll-out program to community hospitals
Clinical management challenges
Early treatment of infant < mo.
Psychosocial & adherence esp. adolescent
Second-line regimens

18. Conclusions
Scale-up of Pediatric ARV program in developing countries are feasible
The outcome of ARV therapy is similar to what observed in developed countries

19. Acknowledgements Dr. Virat Sirisanthana Dr. Thira Sirisanthana
Dr. Penninah Oberdorfer
Dr. Linda Aurpibul
Dr. Noppadol Akaratham
Dr. Pornphan Wannarit
Dr. Suparat Kanchanavanich
Dr. Sunchai Chayasombat
Thai Ministry of Public Health
Thai Government Pharmaceutical Organization
Faculty of Medicine, Chiang Mai University
Research Institute for Health Sciences, Chiang Mai University
Fogarty International Center, National Institute of Health