The challenges of ending AIDS in Asia: outcomes of the Thai National AIDS Universal Coverage Programme, 2000-2014

OBJECTIVES

We sought to determine Thai National AIDS Program (NAP) outcomes and gaps, and success in reaching the WHO 90:90:90 goals.

METHODS

Retrospective study of treatment outcomes, mortality and loss to follow-up (LTFU), of all individuals aged >15 years who registered to the NAP from 2000 to 2014. We focused outcomes on data from 2008 when the NAP was linked to the death registry.

RESULTS

A total of 429,294 patients registered to the NAP up to November 2014, and 309,313 patients aged >15 years started ART. Median (IQR) age was 37 (31-43) years; 51% were male. From 2008 to 2014, long-term follow-up rates per 100 person-years were 3.2 in those who started ART vs 3.5 in those who did not (P<0.001) and mortality rates per 100 person-years were 3.5 in those who started ART vs 4.9 in those who did not (P<0.001). Mortality reduced from 16% in 2008 to 3% in 2014 for those who started ART. For patients starting treatment since 2000, 87% of those alive and with a recent viral load (VL) result had <50 copies/mL, and 6% had VL ≥1000 copies/mL. In a continuum-of-care analysis from 2008 to 2014, 68% were living and retained on ART, and 46% of diagnosed individuals were virally suppressed at <50 copies/mL.

CONCLUSIONS

In the Thai NAP, death and LTFU are major factors disrupting the care-continuum, and many patients initiate ART with low CD4 cell counts. Rolling out systems for early detection and treatment for all, regardless of CD4 cell count, are essential and under way.

Life expectancy after initiation of combination antiretroviral therapy in Thailand

BACKGROUND

Access to combination antiretroviral therapy (cART) has decreased mortality in HIV-positive people. We aimed to estimate the expected additional years of life in HIV-positive Thai people after starting cART through the National AIDS Program (NAP), administered by the Thai National Health Security Office (NHSO).

METHODS

The NHSO database collects characteristics of all Thai HIV-infected patients through the National AIDS Program, including linkage with the National Death Registry for vital status. This study included patients aged ≥15 years at cART initiation between 2008 and 2014. The abridged life table method was used to construct life tables stratified by sex and baseline CD4⁺ T-cell count. Life expectancy was defined as the additional years of life from age at starting cART.

RESULTS

201,688 eligible patients were included in analyses, contributing 618,837 person-years of follow-up. Median CD4⁺ T-cell count was 109 cells/mm³ and median age 37 years. The overall life expectancy after cART initiation at age 20 was 25.4 (95% CI, 25.3, 25.6) years and 20.6 (95% CI, 20.5, 20.7) at age 35 years. Life expectancy at baseline CD4⁺ T-cell count ≥350 cells/mm³ was 51.9 (95% CI, 51.0, 52.9) years for age 20 years and 43.2 (95% CI, 42.4, 44.1) years for age 35 years, close to life expectancy in the general Thai population.

CONCLUSIONS

Increasing life expectancy with higher baseline CD4⁺ T-cell counts supports the guideline recommendations to start cART irrespective of CD4⁺ T-cell count. These results are beneficial to forecast the treatment cost and develop health policies for people living with HIV in Thailand and Asia.

Recent HIV Testing Among Young Men Who Have Sex with Men in Bangkok and Chiang Mai: HIV Testing and Prevention Strategies Must Be Enhanced in Thailand

HIV infection among men who have sex with men, particularly in Thai urban settings and among younger cohorts, is escalating. HIV testing and counseling (HTC) are important for prevention and obtaining treatment and care. We examine data from a 2013 survey of males, 15-24 years, reporting past-year sex with a male and living in Bangkok or Chiang Mai. Almost three quarters of young MSM (YMSM) in Bangkok and only 27 % in Chiang Mai had an HIV test in the previous year. Associations for HIV testing varied between cities, although having employment increased the odds of HIV testing for both cities. In Bangkok, family knowledge of same sex attraction and talking to parents/guardians about HIV/AIDS had higher odds of HIV testing. Expanded HTC coverage is needed for YMSM in Chiang Mai. All health centers providing HTC, including those targeting MSM, need to address the specific needs of younger cohorts.

HIV service delivery models towards 'Zero AIDS-related Deaths': a collaborative case study of 6 Asia and Pacific countries

BACKGROUND

In the Asia-Pacific region, limited systematic assessment has been conducted on HIV service delivery models. Applying an analytical framework of the continuum of prevention and care, this study aimed to assess HIV service deliveries in six Asia and Pacific countries from the perspective of service availability, linking approaches and performance monitoring for maximizing HIV case detection and retention.

METHODS

Each country formed a review team that provided published and unpublished information from the national HIV program. Four types of continuum were examined: (i) service linkages between key population outreach and HIV diagnosis (vertical-community continuum); (ii) chronic care provision across HIV diagnosis and treatment (chronological continuum); (iii) linkages between HIV and other health services (horizontal continuum); and (iv) comprehensive care sites coordinating care provision (hub and heart of continuum).

RESULTS

Regarding the vertical-community continuum, all districts had voluntary counselling and testing (VCT) in all countries except for Myanmar and Vietnam. In these two countries, limited VCT availability was a constraint for referring key populations reached. All countries monitored HIV testing coverage among key populations. Concerning the chronological continuum, the proportion of districts/townships having antiretroviral treatment (ART) was less than 70% except in Thailand, posing a barrier for accessing pre-ART/ART care. Mechanisms for providing chronic care and monitoring retention were less developed for VCT/pre-ART process compared to ART process in all countries. On the horizontal continuum, the availability of HIV testing for tuberculosis patients and pregnant women was limited and there were sub-optimal linkages between tuberculosis, antenatal care and HIV services except for Cambodia and Thailand. These two countries indicated higher HIV testing coverage than other countries. Regarding hub and heart of continuum, all countries had comprehensive care sites with different degrees of community involvement.

CONCLUSIONS

The analytical framework was useful to identify similarities and considerable variations in service availability and linking approaches across the countries. The study findings would help each country critically adapt and adopt global recommendations on HIV service decentralization, linkages and integration. Especially, the findings would inform cross-fertilization among the countries and national HIV program reviews to determine county-specific measures for maximizing HIV case detection and retention.

Counting hard-to-count populations: the network scale-up method for public health

Estimating sizes of hidden or hard-to-reach populations is an important problem in public health. For example, estimates of the sizes of populations at highest risk for HIV and AIDS are needed for designing, evaluating and allocating funding for treatment and prevention programmes. A promising approach to size estimation, relatively new to public health, is the network scale-up method (NSUM), involving two steps: estimating the personal network size of the members of a random sample of a total population and, with this information, estimating the number of members of a hidden subpopulation of the total population. We describe the method, including two approaches to estimating personal network sizes (summation and known population). We discuss the strengths and weaknesses of each approach and provide examples of international applications of the NSUM in public health. We conclude with recommendations for future research and evaluation.

HIV/AIDS care and treatment in three provinces in northern Thailand before the national scale-up of highly-active antiretroviral therapy

In 2003, Thailand launched a program to place 50,000 persons on highly active antiretroviral therapy (HAART) by the end of 2004, following a series of efforts since the early 1990s to develop comprehensive HIV/AIDS care services. To evaluate existing services and needs in advance of the national HAART scale-up, in 2002 we surveyed 31 hospitals and 389 community health centers in three northern Thai provinces, and interviewed 1,015 HIV-infected patients attending outpatient clinics. All hospitals offered voluntary HIV counseling and testing, 84% provided primary prophylaxis for Pneumocystis carinii pneumonia, 58% for tuberculosis, 39% for cryptococcal meningitis, and 87% had some experience providing antiretroviral therapy. Community health centers provided more limited service coverage. Of patients interviewed, 63% had been diagnosed with symptomatic HIV disease, and of these, 32% reported ever receiving antiretroviral therapy; 51 % of all patients had received a CD4 T-lymphocyte count. Thailand's current national HAART scale-up is being performed in a setting of well-developed hospital-based services introduced over the course of the epidemic.

Environmental isolation ofCryptococcus neoformans from an endemic region of HIV-associated cryptococcosis in Thailand

We successfully isolated Cryptococcus neoformans from chicken faeces in suburban areas of Thailand. C. neoformans was isolated from 36/150 houses (24.0%) in the dry season and 6/150 (4.0%) in the rainy season. All environmental isolates were of serotype A. The high isolation rate of 24% from chicken faeces has never been reported previously. Our environmental study could probably explain the high incidence of cryptococcal meningitis in HIV patients in Thailand.

From research to practice: use of short course zidovudine to prevent mother-to-child HIV transmission in the context of routine health care in Northern Thailand

Thailand has made remarkable progress in battling the HIVepidemic, as the decreases in HIV prevalence and changes in sexual behavior attest. Yet, in Phayao, a northern province severely affected by HIV, approximately 280 HIV-infected women, or 5% of all pregnant women, gave birth to an estimated 70 infected children in 1997. As many of these infants die within their first year of life, the infant mortality rate is on the rise after years of decline. The province, however, responded quickly to this crisis. Since July 1997, the Ministry of Public Health (MOPH) offers through Phayao's seven public hospitals a short regimen of zidovudine to all consenting HIV-infected women to prevent mother-to-child transmission of the virus. The overall prophylactic coverage for the province reached 68% of all HIV-infected pregnant women in the fourth quarter of 1997, either through the MOPH program or through the North Thailand Perinatal HIV Prevention Trial, the parallel clinical trial conducted by the MOPH and the Ministry of University Affairs. Analysis of the data collected showed that compliance to the intervention was excellent, around 90%. This was achieved at an additional cost of US$ 0.13 per capita per year, affordable even in the context of the economic crisis, and represents less than 1% of public health expenditures in Thailand. The cost per Disability Adjusted Life Years saved is approximately US$35, making it highly cost-effective. In less than a year, the MOPH implemented this program on a large scale in this relatively poor province, with limited external support. Women receive pretest counseling at their first prenatal visit, are offered HIV testing and, if they accept, return for posttest counseling two weeks later. In the case of a positive test result, a confirmation test is performed at the provincial hospital. HIV-infected women are offered zidovudine the 34th week of pregnancy or as soon as possible thereafter. Before starting treatment, the women's hemoglobin, CBC and platelets are measured. Infants begin taking oral zidovudine shortly after birth and continue until they are one week old. Subsequently, health centers regularly follow the infants, and volunteers provide case management of childhood illness, nutrition problem solving, childhood immunizations and home visits. Mothers feed the infants breastmilk substitutes, and women with insufficient income receive the substitutes free of charge. The northern Thailand experience provides important insights into the feasibility of large scale interventions to prevent perinatal HIV, such as the need for the reorganization of the delivery of health care and quality counseling. On the basis of this experience, a simplified schedule of three intervention phases (Screen, Treat and Care), which can be incorporated into routine mother and child health care, is proposed. Follow-up of the child, however, will require more frequent and intensive contact with health care services than usual. At a time when many countries are reevaluating their health care systems, these insights should be considered, so as to additional better the needs of HIV-infected women during pregnancy and beyond.