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

Thai National PMTCT Policy Evolution DNA PCR based on risk of MTCT DNA PCR (2 times) - HIV antibody at 12-18 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 2000 2004 2005 2007 2010 2014 1993-2000 VCT and infant formula x 12 mo

GAP-PMTCT Projects (2004-2016) Perinatal research (1991-2003) 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….. 2000 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 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

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

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

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

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)

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

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)

Probability of MTCT by duration of ART, n= 6206 VL near time of delivery (copies/mL) MTCT rate (%) <50 0.05 50-399 1.1 400-999 1.9 1000-9999 3 >10,000 9.2 VL <1000: 6-8 wks VL <50: 12 wks Townsend CL et al. AIDS 2014

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. 2015 May-Jun; 26(3): 145–150.

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

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

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

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

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

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