1. National ART Program - NAP Utilization of NAP Monitoring data for Policy Decision “Treatment as Prevention” Sorakij Bhakeecheep, MD Director National Health Security Office, Region 1 THAILAND.

2. Contents Brief overview ART program Thailand National patient monitoring system - NAP Utilization of NAP monitoring data for policy decision “Treatment as Prevention”

3. ART Program in Thailand 1997-982000 01 02030405 0607 11 ARV research (mono/dual) National Access to ARV Treatment for PLHIV (NAPHA) (Pilot program under GF and MoPH research fund) PMTCT researches National Health Security Act (Health promotion, Prevention, Cure and Rehabilitation) 12 13 PMTCT National Program 14 ART at CD4<350 Advocate TasP (Any CD4) Universal Access to ART ART at CD4<200

4. ART Coverage among Persons Living with HIV Number of PLHA Receiving ART (2001-2013) PLHA-CD4 ≤ 500 Source: AIDS Epidemic Model (AEM), NHSO – NAP, SSO, CSMBS, GF, and Thai GPO PLHA-≤ 350 246,049 Area graph shows estimated persons living with HIV by CD4 levels Linear graph shows number of currently PWHA retain in the cohort The coverage is 80% according to CD4<350 80% Coverage of ART need (CD4<350)

5. National AIDS Program Monitoring System (NAP) -Implemented in April 2007 -Designed for supporting patient care, fund administration and program monitoring -Web application architecture -Centralized user management system -Individual data collecting with transaction oriented (medications, lab, etc) -National ID encryption to avoid data duplication

6. Overview of NAP System Architecture Health Service ProvidersNational Health Security Office VCT facilities HIV clinics Laboratories Procurement & Logistics Link to Birth-Death Registration from ministry of interior AIDS experts Internet Data Processing NAP Database Internet Fund Administration Program Monitoring Policy decision & planning Patient monitoring and quality improvement

7. Concept of Using Data to Inform Policy Information base Policy Analysis Policy Decision Resource Preparation Knowledge base InputProcessOutput

8. Evidence Based of Treatment as Prevention: Clinical vs. Public Health Aspect Currently, there is insufficient evidence and/or favorable risk-benefit profile to support initiating ART at CD4 >500 or regardless of CD4 …. (Clinical aspect) (Reference: WHO Consolidated Guidelines on The Use of ARV Drugs for Treating and Preventing HIV Infection : p. 93) Observation from HTPN 052 :- PWHA receiving ART with suppressed viral load would reduce risk of HIV transmission to their partners (Prevention aspect) In conclusion, the benefits of starting ART at CD4 >500 is not for who’s taking ARV drugs, but for their partners (Public Health Benefit)

9. What should be considered in addition to efficacy and benefit of an intervention? 1.Cost-effectiveness (Return of investment) 2.Negative impacts (Retention & Adherence) 3.Resources availability (Man, Money) 4.Feasibility & Sustainability 5.Prioritization 6.Equity and ethics How can BIG Data answer these questions ?

10. PWHA Cascade Source: AIDS Epidemic Model (AEM), NHSO, SSO, CSMBS, GF, and Thai GPO Status Reported number HIV+ currently alive (Estimated)459,509 (100%) HIV+ currently access to treatment246,049 (54%) HIV+ not accessed to treatment (if treat for all)213,460 (46%) never HIV+ never registered to National registry133,781 (63%) HIV+ ever registered to National registry79,679 (37%) Lost of follow up during pre-ART (CD4 > 350) 37,292 (47%) Lost of follow up during receiving ART 42,387 (53%) Only 54% of PWHA can access to ART Only 54% of PWHA can access to ART 46% cannot access to ART 46% cannot access to ART Among who cannot access to ART, 37% have been registered but lost during follow up Among who cannot access to ART, 37% have been registered but lost during follow up 47% - loss during pre-ART 47% - loss during pre-ART 53% - loss during receiving ART 53% - loss during receiving ART

11. Proportion of CD4 at Diagnosis and ART Initiation (2008-2013) CD4 at newly HIV+ diagnosisCD4 at ART Initiation Nearly half of new HIV+ had very low CD4 (less than 100) at the time of diagnosis and ART initiation These findings demonstrated late access to HIV care services, thus reflecting the performance of HCT program Performance of HCT Program need to be improved Median CD4

12. 23,510 (6%) (71%) (82%) (43%) (56%) (38%) Cascade Accessing and Retention to Care-ART, (2007 – 2013), NAP Monitoring System, NHSO Data source: NAP Database, National Health Security Office

13. Effectiveness of ART Program (2012) Data source: National Health Security Office Total Registration to care and treatment services = 326,271 Pre-ART Retention rate 87% Retention rate 31% Receiving ART In pre-ART, loss to follow up occurs 3 times higher than ART group A number of PWA who are eligible for ART didn’t receive treatment In ART group, 70% of who retained to ART has viral load suppression Quality of care in ART program need to be improved 70%

14. Using Projecting Model to Forecast ART Service Demands Data input from NAP is required in order to calculate service demand from Projecting Model Estimated number of PLHA receiving ART 2014-2019

15. ART Service Demand Forecasting (UHC Schemes only) Within next 5 years (2019), work load will increase ~ 20 – 50 %

16. ART Budget Forecasting (2015-2019) Scenario 20152016201720182019 Additional budget needed (drugs+lab) Total program budget rising from 2014 -Any CD4 + Current HCT 2.13.23.84.45.118.632.8 -Any CD4 + 25% increasing HCT 2.33.85.67.69.72943.2 -Any CD4 + 50% increasing HCT 2.44.47.310.313.437.852 -Any CD4 + 100% increasing HCT 2.65.410.415.6215569.2 ART Unit Cost (Drugs + Lab) = 352 USD/pt/yr, not include cost of HCT, capacity building, operation) Unit = million USD Additional budget needed from baseline scenario In the next 5 years, additional budget need for drugs and lab would be 18 – 55 mUSD To end AIDS in the next 10 years, Thailand would spend totally of 400 mUSD in addition to baseline scenario

17. National Health Security Office 17 CD4 < 350 CD4 350-500 CD4 > 500Total # Estimated PWHIV308,37974,76076,371459,510 Known HIV status (Above water)246,0498,9716,109261,129 HIV status unknown (Under water)62,33065,78970,262198,381(43%) % coverage80%12%8% 57% CD4 < 350 CD4 = 350-500 CD4 > 500 Known HIV status unknown Issue on Equity and Priority 1 3 5 462 43% of PWHIV do not know their HIV status. One-third of which urgently need ART (<350). Barriers stop them from accessing to health services. already accessed DO NOTexisting barriers Initiating ART at any CD4 just only benefit for people who are already accessed to services, but DO NOT solve the existing barriers in the inaccessible group. In resources limited setting, who should we considered a PRIORITY ?

18. Conclusion TasP could reduce new HIV infection and has showed some potential in ending AIDS To implement this intervention, some critical issues should be seriously considered Health infra-structure strengthening (including human resources) for: – Extensive HCT scaling up esp. MARPs – Effective quality improvement to increase early access and retention to ART Long term budget availability including domestic and external resources

19. Acknowledgement National Health Security Office (NHSO) Thailand MoPH-US CDC Collaboration (TUC) Bureau of AIDS, TB and STIs, MoPH All ART centers under UHC network