Plhiv & their household impact mitigation by Sukhonta Kongsin

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  • 1. SOCIO-ECONOMIC & MENTAL HEALTH BURDENS OF HIV/AIDS IN DEVELOPING COUNTRIES 21 & 22 NOVEMBER 2011, Kuala Lumpur, Malaysia "People living with HIV/AIDS and Their Households: Impact Mitigation: the Need for Strategic Action" Sukhontha Kongsin, M.Econ., Ph.D. Faculty of Public Health, Mahidol University, Bangkok, Thailand phsks@mahidol.ac.th Sukhum Jiamton, M.D., Ph.D.Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand srsjt@mahidol.ac.th
  • 2. Thailand HIV/AIDS Epidemics Pregnant Youth and Women mobile population Male with From specific Multiple Partners to general populations Prostitutes Injection Drug Users (IDUs) Children Homo/Bisexuals1984 ..……..1988 1989 1990 1991 1992 1993…………..….2004…..2008
  • 3. Impact Mitigation: the Need for Strategic Action State of Art: Impact of HIV/AIDS at the household level; Poverty; Inequality; Food security; Policy to mitigate the impact; inter/multi/trans-disciplinary approaches : What do we know already?Broad scopes:- From HIV vaccines through prevention care support and treatment- Short, medium and long term coping strategies- Trade-offs between resources for HIV/AIDS vs. other issues
  • 4. Health System Health care/services system Ministry of Public Health, Ministry of Finance, pharmaceuticals, medical professions, activists, donors, NGOs, research groups, etc. People Living with HIV/AIDS and Their Households: Impact Mitigation: the Need for Strategic Action Building bridgessocial scientists, epidemiologists, nutritionists, educators and agricultural economists, etc.
  • 5. HIV/AIDS Mortality Impact on Household and its copingPitayanon, S., S. Kongsin, et al. (1997). The EconomicImpact of HIV/AIDS Mortality on Households in Thailand.The Economics of HIV and AIDS. D. Bloom and P.Godwin. Delhi, India, Oxford University Press: 53-101.
  • 6. The economic impact of HIV/AIDS morbidity on households in rural Thailand: An analysis of household coping strategies KONGSIN S (*), SIRINIRUND P ($), JIAMTON S (#), BOONTHUM A (*) , WATTS CH (@)(*) Facultyof Public Health, Mahidol University, Thailand,($) Phayao Provincial Health Office, Thailand,(#) Department of Dermatology, Faculty of Medicine Siriraj Hospital,Mahidol University, Thailand,(@) London School of Hygiene and Tropical Medicine,United Kingdom.
  • 7. Study location: Phayao, Thailandwhere reported HIV/AIDS cases were among the highest in Thailand in 1998multi-sectoral assistance to people and communities affected by AIDS.
  • 8. Study Communities Two districts in Phayao: “Mueng” and “Pong” were chosen as the study location. Mueng district represented a community where there was an active response to HIV/AIDS (active villages), and Pong district as a community with a less active response to HIV/AIDS (less active villages)
  • 9. Community mapping to identify case and control household April-June 1999, 7000 households were contacted and asked about theirmember’s health status, member’s illness, willing to be interviewed or not. (Physical landscape, household location :ID)
  • 10. Selection of comparison districts and sub-districts Phayao Province High prevalence of HIV/AIDS High prevalence of HIV/AIDS (Active response to HIV/AIDS) (Less active response to HIV/AIDS) 9 sub-districts 9 sub-districts(a broad range of HIV/AIDS support and care service) (some HIV/AIDS support and care service) 57 villages 60 villages (3,488 households were contacted) (3,534 households were contacted) selected household case and control selected household case and control (inclusion/exclusion criterias) (inclusion/exclusion criterias) 150 case 150 control 150 case 150 control random sampling random sampling random sampling random sampling
  • 11. People Living with HIV/AIDS and Their Households: Impact Mitigation: the Need for Strategic Action Household level: AIDS, poverty and inequality Conceptualising form of household impact - HIV/AIDS morbidity:Production and labour ; Pattern of consumption; Income and expenditure; Structure and composition; Children ; Elderly social scientists, epidemiologists, nutritionists and agricultural economists, etc.
  • 12. Conceptualising household coping (1999-2000): Short termHousehold coping mechanisms include :• Adjustment of Household available resources, Borrowing, Transfer in/out, Increase market activitiesCommunity and relatives for household coping include :• Community donate or lend food, material, money; e.g. District AIDS Fund, Established community and home based care, Provision of child care, Provision of labour, Community participation and perceived changes, Transfer money in/outSupport from GO/NGO for household coping include :• Child and elderly care, Counselling, Health services utilisation, Schooling and nutrition program, Training to care providers, Job training, Group therapy, meditation practice, Support group of PLHA, Self help group of PLHA, Information support basic care for PLHA
  • 13. Summary of main economic indicators from the historical simulationIndicators Control Case Percentage changeTotal income per capita 3923* 1218* -69Total income of income 19978 3871* -81earner (sick)Total income of income 1919 3345 74earner (non-sick)Total Consumption per capita 3531* 1863* -47Total savings per capita 392 -645 -265Total loans per capital 339Total debt per capita 1486• * indicates that the figures are from the survey data, while others computed from the simulation• The modelling is based on a simple economics identitiy, Y=C+S The modelling is based on a simple Keynesian income function focusing on income consumption and saving
  • 14. Summary of consumption indicators from the historical simulationIndicators Control Case % changeTotal income per capita 3923* 1218* -69Total consumption per capita 3531* 1863* -47Total consumption food per capita 1052 594 -43Total health care for non PLWHA per 237 49 -79capitaTotal health care for PLWHA per capita 939Total schooling consumption per capita 529 239 -55Total other consumption per capita 2016 937 -54
  • 15. Summary of consumption indicators from the alternative simulation Alternative Simulation 20% decrease in health care Indicators % change % change PLWHA (control- (historical- case alternative household) simulation)Total consumption per capita 1835 -47 -1Total other supports per capita 620 -8Total money transfer in per 278 -8capitaTotal selling assets per capita 31 -8Total loans per capita 311 -8Total debt per capita 1340 -9Total saving per capita -617 -257 -4 Before 2003, not much support on the UC program for PLWHA, therefore household had to bear the cost
  • 16. Summary of consumption indicators from the alternative simulation Alternative Simulation 20% increase in health care Indicators PLWHA % change % change (control- (historical- case alternative household) simulation)Total consumption per capita 1891 -46 1Total other supports per capita 670 0.06Total money transfer in per capita 303 0.06Total selling assets per capita 34 0.06Total loans per capita 339 0.06Total debt per capita 1746 17Total saving per capita -672 -271 4 If health care expenses were subsidised by government, then better off !!
  • 17. Household coping: Follow up studies• Action taken to minimise distress, provide follow up support• Follow up studies: approved by renewal IRB (Mahidol University): willing to participate in the studies – 1999-2000: 600 households 324 cases from 300 case households (and 300 control households enrolled- neighbourhood control non AIDS families ) – 2004: 501 households - linked with HH-ID 319 cases from 266 case households + 56 previous control households (and 235 control households enrolled) – 2006: 312 households - linked with HH-ID 285 cases from 121 case households + 81 previous control households (and 191 control households enrolled) – 2008: 278 households (303 cases) - people are moving out, mobilisation or urban migration, etc.
  • 18. Household impact and coping mechanism (2004, 2006)• Household and community level (treatment dynamics and access to support + Universal access to ARTs in 2003, both first and second line): – social and economic impacts - disability grant, support group – socioeconomic status/poverty impact of HIV/AIDS – HIV/AIDS Orphans - missing generation – nutrition status - food security, food production, food supplements – livelihoods - maintain household income/expenditure patterns, alleviating labour shortage – behaviour - effect of ARV • Married persons significantly more likely to have commenced treatment (p<0.001) • More productivity, could earn more money
  • 19. Scope of Accessibility (2004-2008) • Medical services: – VCT & Screening – OI prophylaxis and treatment – ARV therapy for appropriate patients – Specific laboratory access (CD4,VL) (Thira Woratanarat and Anupong Chitwarakorn, 2005) • Psychological support: counseling networks and psychotherapy services for infected people and affected family/household • Socio-economic services: co-operate among various ministries, multisectoral collaboration for support (those who need support)
  • 20. Socio-economic determinants of HIV/AIDS in ThailandKONGSIN S (*), LERTCHAYANTEE S ($), JIAMTON S (#),WATTS CH (@)(*) Facultyof Public Health, Mahidol University, Thailand,($) Phayao Provincial Health Office, Thailand,(#) Department of Dermatology, Faculty of Medicine, Mahidol University,Thailand,(@) London School of Hygiene and Tropical Medicine,United Kingdom.
  • 21. Table 1: Demographic characteristics of PLWHA PLWHA Phayao p-valueResults Characteristic (n=324 cases) age (mean) = 31.98, age<=31 [51.5%] age >= 40 [%] 9.7 20.8 <0.0001 male sex [%] 46.3 57.6 <0.0001 no school education [%] 3.7 8.9 0.005 no or primary school education. 42.9 71.0 <0.0001 [%] unemployed 3.2 1.6 <0.0001 [% of labourer, male] agriculturer /labourer [% of 64.6 71.4 >0.05 employed]• The age and sex distribution among PLWHA differs significantly from the general population inthe study location.• The proportion of PLWHA aged 40 and above is 9.7 % among 324 PLWHA, compared to 20.8 %in the general population. The respective proportions for male sex are 46.3% and 57.6%. Thepercentage of PLWHA with no formal education is 3.7%, compared to 8.9% in the generalpopulation. Including primary education, the respective proportions are 42.9% and 71%respectively. Unemployment is higher among PLWHA (3.2 % vs. 1.6%).• Among those who are employed, the proportion of farmers and labourers is slightly lower than inthe general population (64.6% vs. 71.4%) but this is not statistically significant. Significance levelsfor the statistical tests and results are shown in Table 1.
  • 22. Socio-economic indicators PLWHA Phayao p -value Indicator (n=300 households)household income 85,740 82,278 0.0084household members 3.8 4.1 0.0095per capita income 23,889 20,052 0.0059household expenditure 4,157 4,435 >0.05per capita food 679 685 >0.05poverty [%] 23.4 17.5 <0.001 (Thai Baht: THB) • Average household incomes (THB 85,740 vs. THB 82,278) and per capita incomes (THB 23,889 vs. THB 20,052) are significantly higher among PLWHA than in the general population in Phayao. • A small but significant difference exists for the average number of household members (3.8 vs. 4.1). • The proportion of persons with household per capita incomes below the poverty line is significantly higher in the patient group (23.4% vs. 17.5%). •Significance levels for the statistical tests and results are shown in above table
  • 23. Household assets PLWHA Phayao Possession of household (n=300 households) assets [% of households]car 13.4 12.4truck 6.7 7.3motorcycle 59.7 47.5stove 61.2 61.5refrigerator 54.8 49.2rice cooker 71.4 69.1radio 71.7 70.8Television 81.3 80.3 • Household assets are presented at similar proportions in households of PLWHA and the general population. • This observation is made for both "luxury" (e.g., car, television) and "regular" household assets (e.g., rice cooker, stove). • All items (motorcycle, refrigerator) were found slightly more frequently in PLWHAs households than in the general population
  • 24. Age distribution of socio-economic indicatorsAge - age distribution socio-economic indicators by age-group poverty distribution [% of total]group [% of total] primary percapita per capita poverty prevalence educatio income expendit- [%] n [%] [Baht] ure [Baht] Phayao PLWHA all male female crude age adjusted Phayao data20-25 18.8 12.3 66.9 34,056 17,292 12.6 14.5 9.4 4.0 21.2 7.526-30 21.4 32.5 72.9 36,518 17,940 15.4 16.7 11.1 11.1 24.9 24.631-35 20.4 27.4 90.3 28,265 16,620 18.0 16.5 22.4 15.8 19.1 24.036-40 18.6 19.4 93.0 26,971 11,964 17.8 11.4 30.6 14.3 12.1 18.5>40 20.8 8.2 95.5 21,702 11,676 35.0 30.3 42.8 54.8 22.8 25.1 Total for age / sex 73.7% 30,502 16,098 18.9 Total 100 100 100 adjusted data Phayao 75.87 21,618 15,215 16.3 To assess whether the high prevalence of poverty among PLHA (age>40) is different from that observed in the general population, we analysed the age distribution of PLHA with incomes below the poverty line. Fifty five percent of all poor PLHA are 40 years or older in the crude data set. This proportion decreases substantially to 22.8% if the data are age- and sex adjusted. In the general population, 25.1% of all poverty occurs among people older than forty, indicating that the prevalence of poverty in this age group is similar in both PLHA group and general population. Incomes and expenditures, educational achievements, as well as the prevalence of poverty among PLHA are dependent on age and sex. The lowest levels of education, lowest income, and highest prevalence of poverty occurs in PLHA of age 40 or older (30.3% for male, 42.8% for female). Except for the age group 20-30, poverty occurs more frequently among male than female.
  • 25. • Age- and sex standardisation of patient data results in a decrease of the average poverty level from 23.4% to 17.9% (vs. 17.5% in the general population). Standardised data also show slightly higher per capita expenditures in the PLWHA (THB 16,098 p.a. vs. THB 15,215 p.a.), while the relation is the reverse for unadjusted data (Table 3). Standardisation substantially decreases the proportion of PLWHA with no or primary education (from 42.9% to 73.7%, vs. 75.9% in the general population).• From our study, we are unable to determine whether our finding is based on more recent developments or represents a chronic disease distribution within the Thai population. The age- group 20-39 years, which is strongly affected by the HIV epidemic in study population, is also the age group that has the highest average income among PLWHA households (Table 2). This observation may indicate a spread to more specific groups under the impact of the HIV epidemic.• While the prevalence of poverty in PLWHA (age>40) is very high, this finding is again a reflection of the situation in the general population of the study location (Table 5). We can therefore not identify poverty as a risk factor to explain the higher incidence HIV/AIDS among this group in our sample.• It should be noted that our results could not be interpreted as a refutation of claims about the importance of socio-economic factors for susceptibility to HIV/AIDS. It is possible that most of or all of the unreported cases have low incomes that higher deter them from attending government services. In addition, treatment services in Thailand are still centralised at district hospitals, so that travel expenses are required for many PLWHA to visit these hospitals. Although these expenses are considered to be "minimal", people with incomes below poverty line may nevertheless be unaffordable for most cases whose expenditure is most likely to be stressed directly on their basic necessities like food consumption (Table 3).
  • 26. Household impact and coping mechanism (2006, 2008)• Impact Mitigation: Community strengthening to support long term and continuous care – environmental and institutional factors: Physical/geographical – increase investment from local authority in impact mitigation – community coping responses: traditional grassroots or indigenous organisations, formal community-based organisations (external support from NGOs or other agencies) – migration and complex emergencies - drug resistance – health services and policy (including access to health care, quality of care, and health sector reform) – development policy- Healthy Public Policies, Social Safety Net
  • 27. The HIV/AIDS Continuum of Care Primary HealthCommunity coping responses Care Secondary -Health posts Health -Dispensaries Care District -Traditional Hospitals -Orphan care HIV Clinics Social/legal Support Community Care Hospice Voluntary NGOs Churches Counseling Youth Groups Testing Volunteers Specialists Palliative and Specialised PLHA emotional and Care facilities spiritual support The entry self care point Peer support Tertiary Health Care Home care Thira Woratanarat and Anupong Chitwarakorn, 2005
  • 28. Mainstream HIV/AIDS to Impact MitigationPolicy Nexus: What evidence is needed to help policy-makersmake informed decisions? What challenges do policy-makers face in using research on economic impacts of HIV/AIDS to inform their policymaking process? What policies is this impact mitigation best able to inform?
  • 29. Initiative mainstream HIV/AIDS to impact mitigation• nourishing families• incentives for the vulnerable to re-invest in productive farming• food security, nutrition, gender, methods, targeting, M&E and impact assessments• nutritive value - genetic/ post-harvest fortification, for example, aflatoxin reduction• scaling out improved varieties with market traits, and• strengthen partnerships.
  • 30. Potential focus areas for strategic mainstreaming at the household level in impact mitigation• Strengthen partnerships: partnership between the communities, governments, donor agencies, international NGOs, local NGOs, private sector and others in mitigating the impacts of HIV/AIDS.• The relationship between households and social networks: including both how these networks affects the impact of and responses to the epidemic and how they, in turn, are affected.• Greater focus on the informal economy and possible support mechanisms: looking at the links between HIV/AIDS and households ability to generate income, etc.
  • 31. Estimated number of new HIV infections, projected by utilising Asian Epidemic Model Year MSM, Sex Spousal Casual and Total workers and transmission extramarital sex clients, IDU 2012 5,608 3,231 634 9,473 2013 5,461 2,920 579 8,959 2014 5,331 2,674 530 8,535 2015 5,221 2,475 488 8,184 2016 5,126 2,313 450 7,890 2012-2016 26,746 12,613 2,681 43,040% of total 62% 32% 6% 100%new HIVinfections 31
  • 32. Coverage of PLHIV in need for ART, Thailand 2004-2009 ART Need Current Receiving300,000 75.8 % 67.1 %250,000 56.4 % 51.5 %200,000 42.5 % 2,983,773,000 Baht150,000 32.5 % 4,382,400,000 Baht100,000 3,855,600,000 Baht 50,000 0 2547 2548 2549 2550 2551 2552 (2004) Source: UNGASS 2010 Report
  • 33. National AIDS Spending Assessment Cost categories 2008 2009 Mil. Baht % Mil. Baht %1. Prevention 1,500 21.7 987 13.72. Care and treatment 4,560 65.8 5,483 76.13. Assistance for children affected by AIDS 50 0.7 52 0.74. Management and strengthening 397 5.7 250 3.5planning5. Compensation for staff 44 0.6 208 2.96. Rights protection and social service 219 3.2 171 2.47. Improving environment and community 2 0.0 8 0.1development8. Research 156 2.3 49 0.7Total 6,928 100.0 7,208 100.0Domestic source (%) 85 % 93%Remarks# 6 : care for children is not included# 8: operational research is not included
  • 34. Possible key questions are:• How do the social networks that exist affect vulnerability to HIV/AIDS (specific emphasis on economic vulnerability/ poverty)?• How do social networks mitigate impact and affect responses to the pandemic?• How does HIV/AIDS at an individual/household level impact on social networks (e.g. issues of extended family support; foster parents; social support mechanisms, effects on types of income sources and migration)?• On the basis of a greater understanding of social networks, how can one (re)define an affected household to try to achieve a more accurate assessment of impact?
  • 35. Overarching issues• Quality and representativeness of data• Produce information appropriate for policy development (not “policy evidence base”)• Extend focus beyond the rural economy• Interdisciplinary, multidisciplinary approach• Methodological innovation (nature of attrition bias, statistical power, econometrics: two-step model, results may be specific to context/setting)• Be prepared for the unexpected• Better dissemination of information
  • 36. Thailand Getting to ZeroNational Strategy on HIV/AIDS 2012 - 2016
  • 37. Vision and Goals Vision: To get to Zero New HIV Infections Goal for 2016: • New HIV infections reduced by two-thirds • Rate of vertical transmission of HIV less than 1%Vision: To get to Zero AIDS-related Vision: To get to ZeroDeaths DiscriminationGoal for 2016: Goal for 2016:• Equal access to quality treatment, • All laws and policies which blockcare and support for all people living effective responses removedwith HIV in Thailand • Reported violence related to• People living with HIV and gender reduced by ..households affected by HIV are • Reported incidents related toaddressed in social protection stigma and discriminationsstrategies and have equal access to reduced by 50%quality care and support•TB/HIV deaths reduced by 50%
  • 38. Zero discriminationAccess to Access toprevention treatment Treatment as Zero prevention Zero AIDS-related new HIV infection deaths 38 Enough resources for all PLHIV
  • 39. AcknowledgementsMy household respondentsTony Barnett and Alan Whiteside Charlotte WattsSukhum Jiamton Anne MillsViroj Tangcharoensathien Yot TeerawattananonPetchsri Sirinirund Swarup SarkerAnita Albun Kanchit LimpakarnchanaratMartha Ainsworth Wiwat RojanapithayakornMead Over Wichai ChoakwiwatGermano Mwabu Professsor Pirom kamolrattanakulWiput Phoolchareon Pasakorn AkarasewiSuwit Wibulpolprasert Caitlin Wiesen
  • 40. HIV Situation and National AIDS Strategy Thailand
  • 41. Thailand IBBS 2010: Integrated Bio-Number of people living Behavioural Surveillance with HIV: HIV prevalence:Low 418,070 / average FSW 2.7% MSW 16.3% 532,461 / high 662,143 MSM 10.1% IDU 26.0%HIV prevalence: Condom use:Low 0.78 / average 1.30 / FSW 97.9% MSW 77.5% high 1.6 MSM 64.7% IDU 49.0%HIV incidence: 0.03 / 0.04 Use sterile injecting equipment 75.8%Total population: 68.1 mil HIV testing in last 12 months: FSW 56.3% MSW 42.0% MSM 27.9%
  • 42. Reported AIDS cases and Deaths from AIDS 1984-2010, ThailandSource: Bureau of Epidemiology
  • 43. Sentinel sero-surveillance among most-at-risk population groups Thailand, 1989 - 2007HIV Prevalence (%) N=97 N=183 N=73 N=128 N=97 N=474 N=48 Surveillance roundRemarks : 1. 2 surveillance rounds during 1989 – 1994 (Rnd 1-12) 2. In 1995 (Rnd13) all CSW included in Indirect CSWSource: Bureau of Epidemiology, MOPH, Thailand
  • 44. Estimated number of new HIV infections, projected by utilising Asian Epidemic Model Year MSM, Sex Spousal Casual and Total workers and transmission extramarital sex clients, IDU 2012 5,608 3,231 634 9,473 2013 5,461 2,920 579 8,959 2014 5,331 2,674 530 8,535 2015 5,221 2,475 488 8,184 2016 5,126 2,313 450 7,890 2012-2016 26,746 12,613 2,681 43,040% of total 62% 32% 6% 100%new HIVinfections 45
  • 45. Coverage of PLHIV in need for ART, Thailand ART Need Current Receiving300,000 75.8 % 67.1 %250,000 56.4 % 51.5 %200,000 42.5 % 2,983,773,000 Baht150,000 32.5 % 4,382,400,000 Baht100,000 3,855,600,000 Baht 50,000 0 2547 2548 2549 2550 2551 2552 Source: UNGASS 2010 Report
  • 46. National AIDS Spending Assessment Cost categories 2008 2009 Mil. Baht % Mil. Baht %1. Prevention 1,500 21.7 987 13.72. Care and treatment 4,560 65.8 5,483 76.13. Assistance for children affected by AIDS 50 0.7 52 0.74. Management and strengthening 397 5.7 250 3.5planning5. Compensation for staff 44 0.6 208 2.96. Rights protection and social service 219 3.2 171 2.47. Improving environment and community 2 0.0 8 0.1development8. Research 156 2.3 49 0.7Total 6,928 100.0 7,208 100.0Domestic source (%) 85 % 93%Remarks# 6 : care for children is not included# 8: operational research is not included
  • 47. National AIDS Committee National AIDS Management CenterSubcommittee for Subcommittee Subcommittee Subcommitteeplan / budget and to advance for AIDS for vaccine trials implementation HIV Rights coordination prevention protection and Promotion Provincial AIDS Provincial AIDS Committee Action Center
  • 48. Thailand Getting to ZeroNational Strategy on HIV/AIDS 2012 - 2016
  • 49. Vision and Goals Vision: To get to Zero New HIV Infections Goal for 2016: • New HIV infections reduced by two-thirds • Rate of vertical transmission of HIV less than 1%Vision: To get to Zero AIDS-related Vision: To get to ZeroDeaths DiscriminationGoal for 2016: Goal for 2016:• Equal access to quality treatment, • All laws and policies which blockcare and support for all people living effective responses removedwith HIV in Thailand • Reported violence related to• People living with HIV and gender reduced by ..households affected by HIV are • Reported incidents related toaddressed in social protection stigma and discriminationsstrategies and have equal access to reduced by 50%quality care and support•TB/HIV deaths reduced by 50%
  • 50. Zero discriminationAccess to Access toprevention treatment Treatment as Zero prevention Zero AIDS-related new HIV infection deaths 51 Enough resources for all PLHIV
  • 51. 2 Strategic DirectionsInnovation and Change • New HIV infections reduced by • Expand rights based and gender sensitive two-thirds comprehensive prevention services for • Rate of vertical transmission of HIV population/risk behavior with high number of HIV less than 1% transmission • Change laws and policies which hinder access to •Equal access to quality treatment, prevention and care services care and support for all people living • Increase shared responsibility: local ownership with HIV in Thailand and funding to an expanded response to HIV • People living with HIV and households affected by HIV are • Develop a new generation of strategic addressed in social protection information to inform and guide the national strategies and have equal access to response at all levels quality care and supportMaintain, Optimize and Consolidate • TB/HIV deaths reduced by 50% • Treatment, Care and Support • All laws and policies which block • PMTCT effective responses removed • Reported violence related to • Prevention among Young People gender reduced by .. • Mass communication • Reported incidents related to stigma and discriminations reduced • Comprehensive condom program by 90% • Stigma and Discrimination • Blood Safety and Universal Precautions
  • 52. Innovation and Change Maintain, Optimize and Consolidate Core Themes• People centered : Empowering people and community• Working paradigm: HIV is not only a disease but is about life• Rights respect Rights based prevention and care services• Focus: Increased focus, efficiency and mutual accountability• Leadership and locally owned sustainable responses• Partnership: Synergies maximized sand efficiencies achieved with GO, CSO and private sectors
  • 53. Getting to Zero New HIV Infections Focus where most new infections occur... Population Groups: Geographic Focus: (Mode of Transmission) 100% 6% Casual and 90% Extramarital sex 80% 32% Spousal transmission 70% 41% 60% Injection Drug 10%94% of User 50%new 11% 70% of new HIVinfections Sex worker and 40% clients infections happen in 30% Male who had sex 27 provinces 41% 20% with male 10% 0% 2012-2016