1. From Research to Practice: HIV/AIDS in Thailand Thira Sirisanthana, MD Chiang Mai University

2. Outline:  Use the HIV/AIDS epidemic to demonstrate how RESEARCH help form EVIDENCE-BASED PUBLIC HEALTH POLICY in Thailand  The Thai epidemic in relation to the world’s  Thailand’s success from the beginning of the epidemic until 2551 Commercial sex workers PMTCT Access to HAART  Thailand’s remaining problem areas: IDU, MSM, Youth (and low usage of VCT)  LESSONS LEARNED for กรมควบคุมโรค

3. Initial Reports  June 5, 2524: 5 cases of PCP in gay men from UCLA (MMWR)  July 3, 2524: 26 additional cases  Dec 10, 2524: 3 NEJM papers describe cases Gottlieb MS NEJM 2001;344:1788-91 From: Glesby MJ, NY/NJ AIDS Education and Training Center

4. Other Early Developments (1)  2525: Term “AIDS” coined First cases in women reported First transfusion and vertically transmitted cases reported  2526: Isolation of a retrovirus from a patient with AIDS by Montagnier’s group  2527: Detection of HTLV-III in pts with and at risk for AIDS (Gallo) From: Glesby MJ, NY/NJ AIDS Education and Training Center

5. Other Early Developments (1)  2525: Term “AIDS” coined First cases in women reported First transfusion and vertically transmitted cases reported  2526: Isolation of a retrovirus from a patient with AIDS by Montagnier’s group  2527: Detection of HTLV-III in pts with and at risk for AIDS (Gallo) From: Glesby MJ, NY/NJ AIDS Education and Training Center 2527: The first reported case of AIDS in Thailand

6. Other Early Developments (2)  2528: FDA approves first commercial HIV antibody test  2529: NIH establishes the AIDS Clinical Trials Groups (ACTG and PACTG)  2530: AZT = first antiretroviral approved by FDA From: Glesby MJ, NY/NJ AIDS Education and Training Center

7. Other Early Developments (2)  2528: FDA approves first commercial HIV antibody test  2529: NIH establishes the AIDS Clinical Trials Groups (ACTG and PACTG)  2530: AZT = first antiretroviral approved by FDA From: Glesby MJ, NY/NJ AIDS Education and Training Center Thai institutes that are research sites for ACTG and PACTG (now called IMPAACT) IMPAACT: Siriraj Hospital, Chonburi Hospital, Prapokklao Hospital, Chiang Rai Hospital, Bhumibol Adulyadej Hospital, Phayao Hospital, Chiang Mai University ACTG: Chiang Mai University

8. Other Early Developments (2)  2528: FDA approves first commercial HIV antibody test  2529: NIH establishes the AIDS Clinical Trials Groups (ACTG and PACTG)  2530: AZT = first antiretroviral approved by FDA From: Glesby MJ, NY/NJ AIDS Education and Training Center Other U.S. NIH–associatied AIDS Thai research sites Treatment trials: HIVNAT Thai Red Cross (CIPRA and INSIGHT) Prevention trials: Chiang Mai University (HPTN) Prevention of mother to child transmission: Thai MOPH / PHPT Vaccine trials: Thai MOPH (Rayong-Chonburi), Chiang Mai University (HVTN) Voluntary counseling and testing: Chiang Mai University

9. Other Early Developments (2)  2528: FDA approves first commercial HIV antibody test  2529: NIH establishes the AIDS Clinical Trials Group  2530: AZT = first antiretroviral approved by FDA

10. Other Early Developments (2)  2528: FDA approves first commercial HIV antibody test  2529: NIH establishes the AIDS Clinical Trials Group  2530: AZT = first antiretroviral approved by FDA 2531: Beginning of the Thai HIV/AIDS epidemic

11. Number of new HIV infections by transmission mode From: Peerapatanapokin W, Thai MOPH

12. Current State of the Thai Epidemic 1,100,000 adults have been infected since start 560,000 adults have died of AIDS 550,000 adults currently living with HIV or AIDS 14,000 new infections (adults & children) will occur this year 46,000 adults currently living with AIDS illness. From: Peerapatanapokin W, Thai MOPH (2007)

13. Other Early Developments (2)  2528: FDA approves first commercial HIV antibody test  2529: NIH establishes the AIDS Clinical Trials Group  2530: AZT = first antiretroviral approved by FDA 2531: Beginning of the Thai HIV/AIDS epidemic

14. Early Antiretroviral Therapy (1)  2534-35: ddI, ddC approved Sequential monotherapy  2536: Concorde: no difference in clinical endpoints over 3 yrs with early vs. deferred AZT From: Glesby MJ, NY/NJ AIDS Education and Training Center

15. Early Antiretroviral Therapy (1)  1991-92: ddI, ddC approved Sequential monotherapy  1993: Concorde: no difference in clinical endpoints over 3 yrs with early vs. deferred AZT From: Glesby MJ, NY/NJ AIDS Education and Training Center 1992-1995: AZT monotherapy available to selected (few) Thai AIDS patients

16. Early Antiretroviral Therapy (2)  2537: ACTG 076: AZT reduces mother-to-child transmission of HIV Dual nucleoside therapy better than monotherapy (Delta, ACTG 175, ZDV/3TC)  2537-38: era of dual combination therapy From: Glesby MJ, NY/NJ AIDS Education and Training Center

17. Early Antiretroviral Therapy (2)  2537: ACTG 076: AZT reduces mother-to-child transmission of HIV Dual nucleoside therapy better than monotherapy (Delta, ACTG 175, ZDV/3TC)  2537-38: era of dual combination therapy From: Glesby MJ, NY/NJ AIDS Education and Training Center 2541 – “Bangkok study” conducted at the Queen Sirikit Children Hospital of the Thai MOPH shows effectiveness of short-course AZT

18. Early Antiretroviral Therapy (2)  2537: ACTG 076: AZT reduces mother-to-child transmission of HIV Dual nucleoside therapy better than monotherapy (Delta, ACTG 175, ZDV/3TC)  2537-38: era of dual combination therapy From: Glesby MJ, NY/NJ AIDS Education and Training Center

19. Early Antiretroviral Therapy (2)  2537: ACTG 076: AZT reduces mother-to-child transmission of HIV Dual nucleoside therapy better than monotherapy (Delta, ACTG 175, ZDV/3TC)  2537-38: era of dual combination therapy 1995-2000: Dual therapy available to a few Thai patients, but the majority are on no antiretroviral treatment 2538-43: Dual therapy available to a few Thai patients, but the majority are on no antiretroviral treatment

20. The New Treatment Era 2538-39: HIV viral load testing became available  Clinicians could directly assess the effect of antiretrovirals on viral replication (HIV RNA) First protease inhibitors approved by FDA From: Glesby MJ, NY/NJ AIDS Education and Training Center

21. The New Treatment Era 2538-39: HIV viral load testing became available  Clinicians could directly assess the effect of antiretrovirals on viral replication (HIV RNA) First protease inhibitors approved by FDA 2538-43: Dual therapy available to a few Thai patients, but the majority are on no antiretroviral treatment

25. The New Treatment Era 2538-2539: HIV viral load testing became available  Clinicians could directly assess the effect of antiretrovirals on viral replication (HIV RNA) First protease inhibitors approved by FDA From: Glesby MJ, NY/NJ AIDS Education and Training Center

26. 0 5 10 15 20 25 30 35 40 2538253925402541254225432544 Deaths per 100 person-years 0 25 50 75 100 Percentage of patient-days on ART DEATHS USE OF ART Mortality vs. ART utilization Palella F et al. 8th CROI 2001; abstract 268b. AIDS Mortality Rates: 2539-44 From: Glesby MJ, NY/NJ AIDS Education and Training Center

27. Number of projected annual deaths: effect of the Thai MOPH free HAART program From: Peerapatanapokin W, Thai MOPH Thai government free HAART program started in 2543-6. About 100,000 are receiving treatment as of 2551

31. Thailand’s success in the control of AIDS From: Björkman H, UNDP

32. From: Pattarakulwanich S, Thai Ministry of Public Health

33. Thailand prevented millions of AIDS death

34. From: Pattarakulwanich S, Thai Ministry of Public Health

35. Outline:  Use the HIV/AIDS epidemic to demonstrate how RESEARCH help form EVIDENCE-BASED PUBLIC HEALTH POLICY in Thailand  The Thai epidemic in relation to the world’s  Thailand’s success from the beginning of the epidemic until 2551 Commercial sex workers PMTCT Access to HAART  Thailand’s remaining problem areas: IDU, MSM, Youth (and low usage of VCT)  LESSONS LEARNED for กรมควบคุมโรค

36. Injecting drug use in Thailand  The actual number of users who inject drugs is not known  Estimates range from 100,000 to 250,000 addicts  Most of them are males (around 90 percent) and mostly aged between 20-24 years From: Khondkar L, Tackling HIV/AIDS among Thai IDU (www.aids2006.org/Web/TUAE0103.ppt)

37. HIV/AIDS among IDUs  About one quarter of all new infections is occurring through unsafe injecting drug use  Median HIV prevalence among IDUs is as high as 50%  HIV is a major killer of IDUs in Thailand  The situation has remained consistent for nearly 15 years  The high prevalence is due to the frequency of injecting, widespread sharing of needles, and imprisonment of IDUs From: Khondkar L, Tackling HIV/AIDS among Thai IDU (www.aids2006.org/Web/TUAE0103.ppt)

38. Limitations in addressing HIV/AIDS among IDUs  Little collaboration between drug control programs and HIV/AIDS response  Narcotic Control legislation does not pay attention to the prevention of HIV among IDUs  Lack of communication between AIDS control authorities, Office of Narcotics Control Board, and those working in drug treatment  Technical skills are not very high in addressing HIV/AIDS among drug users From: Khondkar L, Tackling HIV/AIDS among Thai IDU (www.aids2006.org/Web/TUAE0103.ppt)

39. Summarizing the challenges  Criminal justice approach taken by government  Non-availability of harm reduction programs  Limited prevention coverage  Ineffective treatment interventions  Discriminatory practices in society and health care facilities  Lack of opportunity for IDUs to take part in decision making process affecting them From: Khondkar L, Tackling HIV/AIDS among Thai IDU (www.aids2006.org/Web/TUAE0103.ppt)

40. HIV prevalence among MSM – Bangkok From: Thai MOPH, U.S. CDC, Thai Red Cross, Family Health International, and Purple Sky

41. HIV in Thai teenagers  2001HIV positive 7.1 %  2002 HIV positive 7.9 %  2003 HIV positive 13.6 % Anonymous clinic : Thai Red Cross, Bangkok

42. Casual sex  For male group, the value changed from 5% in 1996 to 20% in 2004  For the female, the value changed from 2% in 1996 to 10% in 2004 From: Peerapatanapokin W, Thai MOPH

43. Outline:  Use the HIV/AIDS epidemic to demonstrate how RESEARCH help form EVIDENCE-BASED PUBLIC HEALTH POLICY in Thailand  The Thai epidemic in relation to the world’s  Thailand’s success from the beginning of the epidemic until 2551 Commercial sex workers PMTCT Access to HAART  Thailand’s remaining problem areas: IDU, MSM, Youth (and low usage of VCT)  LESSONS LEARNED for กรมควบคุมโรค

44. Lessons learned for กรมควบคุม โรค (1):  Use past success as a guidance, even in the new role as an “academic” Department  Many “facts/evidences” have already been published  Identify specific “gaps” that the Department has to do research to guide MOPH policies

45. Lessons learned for กรมควบคุม โรค (2) :  Research should be “need-driven” NOT “investigator-driven”  The Department needs “block grant” NOT grant for individual proposal and needs to set specific themes and objectives identified as MOPH priorities

46. Thank you