1. Thailands experience with using program data to improve PMTCT strategies and outcomes. Sarawut Boonsuk, MD. MPH Chief of MCH, Bureau of Health Promotion Department of Health, MOPH, Thailand.

2. Presentation Outlines PMTCT program over all : –Thailand public health care system –Current situation: HIV prevalence in pregnant women Children AIDS case report –PMTCT program Mile stones : from 2000 - 2013 PMTCT policy ARV regimen PMTCT results PMTCT Monitoring system : –Process/output monitoring –Outcome/impact monitoring system –Electronic national AIDS program database Conclusion

3. 3 76 Provinces 12 Regional Health Promotion Centers Bangkok 10 9 8 6 5 7 34 2 1 11 12 Bangkok

4. Ministry of Public Health DOH DDC DMD DOMH Oversee MCH – PMTCT Program Regional Hospitals (25) University/Military/other s Provincial hospitals (69)District hospitals (734) Health Centers (10,000+) Services delivery community Courtesy slide from Nareeluck Kullerk, DOH

5. Sources: 1. Serosentinel surveillance, Bureau of Epidemiology 2. PHIMS, Department of Health % HIV Prevalence in Pregnant Women (1989-2012) 0.6

6. 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 MTCT-CARE in all provinces - Partner HIV testing - CD4 post partum - Care for mother and family (OI prophylaxis, ARV) National PMTCT policy -Short course AZT (34 wks) -Formula feeding (12 mos) -HIV antibody testing for infants born -New PMTCT policy (AZT (28wks) +SD NVP) -CD4 antepartum and q 6 mos -HAART for mother (CD4<200, symptoms) during ANC -Tail regimen (AZT+3TC) - DNA PCR for infant diagnosis HAART for all HIV-infected pregnant women and couples counseling Major Milestones PMTCT Program Thailand PHIMS Perinatal HIV inventory monitoring system (76 provinces) PHOMS Perinatal HIV outcome monitoring system (4 provinces (2001), 14 provinces (2004) NAP National AIDS Program

7. Monitoring PMTCT Program Implementation in Thailand 2000-2012 Perinatal HIV Inventory Monitoring System (PHIMS) Purpose of monitoringMonitor process & service uptake of PMTCT program Established byDepartment of Health Type of monitoringRoutine report How to collect dataAggregate or summary data Frequency of reportMonthly Perinatal HIV Outcome Monitoring System (PHOMS) Monitor outcome or impact of PMTCT program (MTCT rate) Bureau of Epidemiology Case registry in surveillance 14 provinces Individual case report 2 times for each baby -At birth -Confirmed infant diagnosis by DNA-PCR or Ab

8. Monitoring PMTCT Program Implementation in Thailand 2007 National AIDS Program (NAP) Purpose of monitoringPMTCT program impact on mother to child transmission rate Established byNational Health Security Office Type of monitoringRoutine report How to collect dataIndividual data Frequency of reportWhen request PCR test for HIV exposed infant

9. 9 Perinatal HIV Intervention Monitoring System (PHIMS) Process - output monitoring PHIMS starts Oct 2000 - current Dept of Health Developed by DOH with technical support from GAP Thailand/ U.S.CDC

10. 10 Monthly Report Form ANC Clinic Delivery Room Well Child Clinic Health Promotion Clinic PHIMS – Data Collection Form

11. 11 PHIMS - Variables Data summarized from ANC, labor room, nursery logbooks number of women –delivered, –delivered with ANC, without ANC –had HIV test –HIV+ Received AZT, Received AZT +other ARV Received other ARV Number of infants to HIV-infected mothers –Live birth, received ARV –Received formula before discharge

12. PHIMS v3.1 – Additional Variables Women received couple counseling –Pretest couple, posttest couple –HIV-positive women received HAART for treatment or for PMTCT –VDRL test –VDRL positive –Syphilis diagnosis and treatment HIV-positive women, partners, children referred to HIV Care Program

13. PHIMS v3.1 (update) Web-based Hospital Provincial Health Office DOH DOH - Server HPCs Hospital Data entry & data utilization Data utilization, M&E System development & maintenance Country data analysis BMA - DMS

14. 14 HIV Testing Coverage among Women Giving Birth 2001-2010 PHIMS: Department of Health 2011 No. women giving birth with ANC ~750,000/yr, No ANC rates ~ 2-3%/yr

15. 15 ARV and Formula Receipt by HIV-positive Mothers ( 2001-2010) PHIMS: Department of Health 2011

16. Coverage of PHIMS Report Percent Page 3

17. Delivery women had HIV tested percent Page 6

18. Delivery women HIV positive Percent Page 7

19. Couple counseling ( Pre-test) Percent Page 9

20. Couple counseling ( Post HIV testing) Percent Page 10

21. Coverage of Syphilis (VDRL) Tested Percent Page 12

22. Delivery women who had VDRL positive Percent Page 13

23. 98 96 HIV infected women received ARV Percent FY 2012 FY 2013 88 100 92 98 94 96 97 94 97 94 91 86 94 95 100 93 97 96 94 96 97 94 90 88 95 Page 16

24. 100 Children born to HIV positive mother received ARV Children born to HIV positive mother received ARV Percent FY 2012 FY 2013 97 100 98 100 98 100 99 100 99 100 35 95 100 99 98 100 74 Page 20 AZT only

25. Children born to HIV positive mother received Formula Milk before discharge from hospital Percent Page 21

26. Children born to HIV positive mother weight < 2500 gm Percent Page 22

27. Children born to HIV positive mother had birth defect Percent Page 24

28. percent Children born to HIV positive mother Received drugs for prevention of PCP Page 25

29. Referral of Children for treatment and care Region No. of children diagnosed HIV infected No. of children HIV infected enrolled for treatment Y 2012 Y 2012 Y 2013 Y 2013 Y 2012 Y 2012 Y 2013 Y 2013 Nation4935 38 (78%) 30 (86%) Region 1 21 1 (50%) 0 (0%) Region 2 01 0 (0%) 10 (100%) Region 3 06 0 (0%) 6 (100%) Region 4 13 1 (100%) 3 (100%) Region 5 33 2 (67%) 1 (33%) Region 6 78 6 (86%) 7 (88%) Region 7 23 1 (50%) 3 (100%) Region 8 12 1 (100%) 2 (100%) Region 9 30 2 (67%) 0 (0%) Region141 12 (86%) 1 (100%) Region 11 114 8 (73%) 3 (75%) Region 12 13 1 (100%) 3 (100%) BKK (hosp.)30 3 (100%) 0 (0%) BKK. 10 0 (0%) Page 27

30. Husband of HIV + mothers received treatment Region No. of HIV +ve husband No.of HIV+ve husband enroll for ARV treatment FY 2012 FY 2012 FY 2013 FY 2013 FY 2012 FY 2012 FY 2013 FY 2013 Nation945846 516 (55%) 290 (34%) region 1 4534 27 (60%) 10 (30%) region 2 33 2 (67%) 3 (100%) region 3 277 2 (100%) 71 (92%) region 4 102372 42 (41%) 26 (7%) region 5 6629 58 (88%) 18 (62%) region 6 12165 68 (56%) 27 (42%) region 7 266129 38 (14%) 27 (21%) region 8 4117 33 (80%) 14 (82%) region 9 396 27 (69%) 5 (83%) region 10 11434 103 (90%) 27 (80%) region 11 8542 74 (87%) 34 (81%) region 12 4323 31 (73%) 17 (74%) BKK ( hosp.) 154 11 (73%) 4 (100%) BKK31 0 (0%) Page 28

31. Pros & Cons 31 Pros: Aggregate monthly report is simple and require minimal efforts Provide program coverage and identify gaps quick program monitoring Cons: Cannot collect individualized details Do not provide program outcome data Require coordination among different point of service deliveries (ANC, labor, newborn, Pediatric OPD etc)

32. National AIDS Program Database (Individualized HIV-exposed infant data entry to web-based program) Outcome - impact monitoring April 2007, orginally developed for AIDS program management NHSO Developed by National Health Security Office with technical support for PMTCT outcome report by GAP Thailand - U.S.CDC

33. Data Flow 33 Hospitals NAP at NHSO Internet based with central server at NHSO Report PMTCT indicators Register HIV exposed children and request for EID 14 EID Labs Perform PCR test and report PCR results

36. PMTCT indicators from NAP 1.Mother to child transmission rate 2.Early infant diagnosis coverage 3.ARV received by HIV-positive pregnant women 4.CD4 count tested in HIV-positive pregnant women

37. Pros & Cons 37 Pros: No additional workload for data entry since using routine program electronic individualized data. Hospital has to key in the PCR testing request and lab has to key in result (as part of PCR cost reimbursement so data is quite complete) Cons: Denominator is infant requested for PCR test, cannot capture dead/loss to follow up infants

38. Acknowledgements Dr. Nipunporn Voramongkol and Ms.Nareeluck Kullerk, Department of Health, MOPH Bureau of Epidemiology, MOPH Thananda Naiwatanakul, Technical Advisor, PMTCT & Pediatric Section, GAP Thailand and Asia Regional Office, Thailand MOPH – U.S. CDC Collaboration

39. Thank You for Your Attention