3. National Consultation on the Strategic Use of ARVs
The proceedings of this meeting were recorded by Shravya Kidambi
4. Table of Contents
TABLE OF CONTENTS 4
ACRONYMS 6
EXECUTIVE SUMMARY 7
BACKGROUND & INTRODUCTION 9
DAY ONE: AUGUST 9TH 12
OPENING: THE VISION OF THE NATIONAL HIV STRATEGY, 2012-2016 12
PRESENTATION: THE STRATEGIC USE OF ARVS: GLOBAL EVIDENCE AND EXPERIENCE TO DATE 13
PRESENTATION: THE THAI HIV EPIDEMIC: CAN IT BE CONTROLLED WITH CURRENT APPROACHES?
INSIGHTS FROM MODELING AND EPIDEMIOLOGICAL ANALYSIS 15
CLARIFICATIONS & PLENARY DISCUSSION 16
PANEL DISCUSSION: ADDRESSING CURRENT PRACTICES AND CHALLENGES FOR STRATEGIC USE OF
ANTIRETROVIRAL TREATMENT 18
SUMMARY, CONCLUSIONS, AND OUTLOOK FOR DAY 2 20
DAY TWO: AUGUST 10TH 21
WELCOME BACK AND INTRODUCTION BY MODERATOR TO OBJECTIVES OF DAY 2 21
PRESENTATION: ADDRESSING SERVICE DELIVERY CHALLENGES AND OPPORTUNITIES FOR THE
STRATEGIC USE OF ARVS 21
SITUATION UPDATE ON TESTING AND COUNSELING AND LINKAGES TO TREATMENT AND CARE
IN THAILAND 22
DISCUSSION 23
WORKING GROUP DISCUSSIONS: EXPANDED TESTING AND COUNSELING, LINKAGES TO CARE/TREATMENT,
AND ADHERENCE SUPPORT: OPPORTUNITIES AND CONSIDERATIONS IN THAILAND 24
WORKING GROUPS REPORT TO PLENARY SESSION 24
CLOSING 25
NEXT STEPS 26
NOTES FROM MEETING OF WORKING GROUP – 22/8/2012 27
4
6. Acronyms
AEM Asian Epidemic Model
AIDS Acquired Immune Deficiency Syndrome
ANC Antenatal Care
ART Anti Retroviral Therapy
ARV Antiretroviral
BATS Bureau of AIDS, Tuberculosis and STI
cART Combination Anti Retroviral Therapy
FSW Female Sex Workers
HIV Human Immunodeficiency Virus
IDU Injecting Drug User
KAP Key Affected population
KPI Key Performance Indicators
MARP Most-at-Risk Populations
MSM Men who have Sex with Men
MSW Male Sex Workers
MW Migrant Worker
NHSO National Health Security Office
OPD Outpatient Department
PLHIV People Living with HIV
PMTCT Prevention of Mother-To-Child HIV Transmission
PrEP Pre-Exposure Prophylaxis
S&D Stigma and Discrimination
STI Sexually transmitted infections
TasP Treatment As Prevention
TG Transgender
TNCA Thai NGO (Non-Governmental Organization) Coalition on
AIDS
TNP+ Thai Network of People Living with HIV/AIDS
TUC Thailand Ministry of Public Health - US CDC Collaboration
TWG Technical Working Groups
UNGASS United Nations General Assembly Special Session on
HIV/AIDS
VCT Voluntary Counseling and Testing
6
7. Executive Summary
The National Consultation on the Strategic Use of ARVs was held on 9-10 August,
2012 in Bangkok, Thailand. The consultation was organized by the UN Joint Team on
HIV/AIDS, Thailand MOPH-U.S. CDC Collaboration on HIV and AIDS (TUC), Thai Red
Cross Society, and the Ministry of Public Health.
The primary goal of the consultation was to provide an opportunity for key
stakeholders including decision makers, epidemiologists, modelers, and affected
populations to better understand new evidence around strategic use of ARVs and
potential applications to Thailand’s national AIDS program.
Thailand’s National AIDS Strategy calls for a reduction in new HIV infections by two
thirds by 2016. During Day 1, Dr. Wiwat Peerapatanapokin from the East-West
Center noted that using AEM estimations on current prevention/treatment efforts,
Thailand will fall short of its 2016 target of reducing new infections by approximately
5000 cases. Therefore, new strategies need to be put in place to achieve goals set for
2016.
Dr. Charles Gilks, currently UNAIDS Country Coordinator for India and former
Director of the Treatment and Care Unit of the HIV/AIDS Department for WHO
Geneva, presented the breadth of evidence that exists supporting the early initiation
of ARVs at both individual and population levels (treatment and prevention). While
this was acknowledged by stakeholders as a beneficial intervention, concerns were
raised and discussed related to implementation of treatment as prevention
initiatives both for the overall health system as well as affected individuals.
Following panel discussions and working group sessions, it was agreed that ARVs
should be used strategically in Thailand for treatment and prevention. It was
acknowledged that Thailand already has a best practice example of “treatment as
prevention” in the form of PMTCT. There was consensus that the biggest benefit to
be derived would be in treating all people found to be HIV positive, and strategically
conducting VCT among KAPs (target of 90% of KAPs knowing their serostatus).
However, using ARVs at a much larger scale than now (i.e. treatment as prevention,
PMTCT B+) will require the development of new service delivery models and task
shifting. The introduction of completely new services, like PrEP, will need careful
consideration, planning and monitoring.
Action items to be taken up following the consultation were identified within six
major work streams:
1. Service Delivery: Explore options for decentralized care and VCT; sustain /
enhance success of PMTCT program; develop strategy to improve coverage of
VCT
7
8. 2. Monitoring: Develop centralized data repository to monitor/evaluate VCT in
parallel with building up capacity of data use at service and provincial levels
3. Policy: Develop practical and concrete recommendations on testing and
treatment; determine the target population for interventions (e.g. should they
be aimed at the general public or at key affected populations?); review ARV
policies/legal barriers for migrants, non-Thais, and youth (under 18)
4. Modeling: Develop more cost/benefit and cost effectiveness analyses on using
antiretroviral agents as prevention; update Asian Epidemic Model estimates on
IDUs, Transgenders, and the effects of behavioral change.
5. Operational Research: Explore possibility of launching a pilot PrEP program;
analyze workloads of healthcare personnel to determine current limitations
6. Public Communication: Develop a public communication campaign for increased
understanding of potential use of ARVs for HIV prevention
8
9. Background & Introduction
HIV/AIDS is an issue of continued political and public health significance in Thailand.
According to the 2010-2011 Global AIDS Response Country Progress Report for
Thailand, there are an estimated 500,000 adults and children living with HIV1 and
10,450 new cases in 20112. According to the Asian Epidemic Model (AEM), it is
estimated that 43,040 new infections will occur during 2012-2016.
Thailand’s successful anti-retroviral treatment program currently reaches two-thirds
of adults and children in need of treatment (CD4 200 cells/mm3 and below), and has
contributed to transforming HIV for people in Thailand from a fatal illness to a
chronic condition. Free access to ARVs and free universal health care has contributed
to people living longer and healthier lives. Thailand has been lauded for several
aspects of its HIV prevention policy, ranging from universal HIV counseling and
testing in ANC settings (PMTCT) with ARV prophylaxis provision as needed, to the
100% condom use policy among sex workers. PMTCT interventions alone have
reduced the number of new infections in children to fewer than 350 cases per year3.
Despite Thailand’s success in scaling up critical HIV care/treatment, AIDS remains the
number one cause of death among men and women in their prime (ages 15 – 49). It
is the official cause of death for 22.6% of males and 30.7% of females in this age
group4.
The 2010 Thai National HIV/AIDS Diagnostic and Treatment Guidelines recommend
CD4 count <350 cells/mm3 as the threshold for ART initiation in patients. The current
median CD4 count at ART initiation in Thailand is 63 cells/mm3,5. Late HIV testing
and/or delayed CD4 count measurement after HIV diagnosis may explain the delayed
initiation of ART in many settings. At the same time, delayed treatment initiation can
lead to sub-optimal clinical outcomes for the individual, and contribute to ongoing
HIV transmission as people with high viral loads continue to spread HIV throughout
their respective communities.
During 2010-2011, five new prevention trials showed a positive effect from the use
of antiretroviral agents for prevention: four used antiretroviral agents for pre-
exposure prophylaxis for primary prevention and one randomized clinical trial, HPTN
052, studied the prevention benefit through early use of treatment among infected
individuals. The evidence from these studies suggests that the use of antiretroviral
agents can be effective in significantly improving clinical outcomes, but also serves as
an effective HIV prevention measure.
1
Preliminary data from 2011 estimates, UNAIDS/WHO, 2011
2
Ibid.
3
Global AIDS Report
4
Preliminary data from 2011 estimates
5
Nittaya Phanuphak. (March, 2011). Active Voluntary Counseling and Testing with Integrated CD4
Count Service Can Enhance Early HIV Testing and Early CD4 Count Measurement: Experiences From
the Thai Red Cross Anonymous Clinic in Bangkok, Thailand. Clinical Science. Volume 56.
9
10. A recent meta-analysis of ARV provision among sero-discordant couples reviewed
the results from HPTN 052 and seven observational studies. The eight studies
identified 464 episodes of HIV transmission, of which 72 were among treated
couples and 392 among untreated couples. The conclusion was that even in the
worst case scenario, when the HIV infected individual in a sero-discordant couple
was taking ARVs; the risk of transmission was more than three times lower than in
situations where the infected sexual partner was not taking ARVs6. The biological
rationale behind this protective effect is that viral load reduction to undetectable
levels significantly decreases the risk of sexual transmission.
Thailand, as an upper middle income country, with declining HIV prevalence (under
1.5%)7, is well positioned to consider whether earlier initiation of antiretroviral
agents would be a feasible and effective way of reducing new HIV infections.
The National Consultation on the Strategic Use of ARVs was held on 9-10 August,
2012 in Bangkok, Thailand. The consultation was organized by UNAIDS, UNICEF,
WHO, Thailand MOPH-U.S. CDC Collaboration on HIV and AIDS (TUC), Thai Red Cross
Society, and the Ministry of Public Health.
The primary goal of the consultation was to provide an opportunity for key
stakeholders including decision makers, epidemiologists, modelers, and affected
populations to better understand new evidence around treatment as prevention and
its potential applications to Thailand’s national AIDS program.
Specifically, the consultation aimed at addressing the following objectives:
1. Understanding the evidence from completed studies regarding both the impact
of ART on improving clinical outcomes at the individual level, as well as its
efficacy in reducing the incidence of new infections in the broader population
2. Understanding the perspective of policy makers with respect to changes in
treatment initiation considerations, including cost, cost effectiveness,
affordability, feasibility, ethics/human rights issues, and burden on healthcare
facilities and associated workforce
3. Understanding the perspective of the clinical community and the potential
impacts of earlier initiation of treatment on clinical outcomes, adherence and
potential for development of resistance
6
Anglemyer, et al. Antiretroviral therapy for prevention of HIV transmission in HIV-discordant
couples. Cochrane HIV/AIDS Group, 10 August, 2011. Accessed at:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009153.pub2/abstract;jsessionid=49148A2B
82BE2904BDC4 B6B103451B0C.d02t02
7
UNAIDS Country Profile, accessed online at:
http://www.unaids.org/en/regionscountries/countries/thailand/
10
11. 4. Understanding the perspective of civil society and affected populations both with
respect to reasons they may support or oppose the promotion of earlier
treatment, including the potential for improved quality of life or increased
stigmatization
5. Understanding the gender dimensions associated with earlier treatment
including any potential negative and positive consequences for men and women
having their HIV status identified and beginning lifelong ART
Expected Outcomes:
1. Key policy dialogue on evidence from completed studies regarding both the
impact of ART on improving clinical outcomes at the individual and population
level, as well as its efficacy in reducing the incidence of new infections
2. Policy dialogue on the factors to be considered for prioritization of access to
treatment and prevention services using ARVs (considering—among others—
cost, cost effectiveness, affordability, feasibility, ethics, equity and human rights
issues) and review their integration in the decision making process
11
12. Day One: August 9th
Opening: The vision of the National HIV Strategy, 2012-2016
Delivered by:
Dr Sumet Ongwandee, BATS
Dr. Somsak Akkasilp, Deputy Director General, Department of Disease Control
Dr. Michael Hahn, UNAIDS
The National Consultation for the Strategic Use of ARVs began with opening remarks
by Dr. Sumet Ongwandee from the Bureau of AIDS, TB and STIs (BATS). He
commented on the success of Thailand’s current ARV program that reaches over
two-thirds of the population in need (CD4 count below 200 cells/mm3) and that has
transformed the disease from an infectious disease with a high case-fatality rate into
a chronic illness. He also praised several specific initiatives such as the universal
coverage program, PMTCT initiatives that have reduced the number of new
infections in newborns to 350 cases per year and the 100% condom policy for sex
workers.
Dr. Sumet also noted the fact that AIDS still remains the number one cause of death
for men and women in the 15-49 age range (a total of 28,000 deaths were
attributable to AIDS in 20118). In addition, the median CD4 count for ART initiation in
Thailand is extremely low (63 cells/mm3)9. This leads to suboptimal morbidity and
mortality outcomes and increased viral load in the community.
Lastly, Dr. Sumet touched upon the consultation’s goal of reviewing various
policy/implementation issues on the strategic use of ARVs to meet the goal of zero
incidence and zero AIDS-related deaths. He further noted the critical importance of
policy discussions that involve key stakeholders from diverse backgrounds.
Dr. Somsak Akksilp echoed Dr. Sumet’s remarks and noted that a consultation
implies a true collaboration. He invited all participants to bring their insights and
comments to the forefront and highlighted the appropriateness in holding this
consultation immediately following the International AIDS Conference 2012 in
Washington, DC. He reiterated Thailand’s many accomplishments but cautioned
that a high percentage of Thai residents still do not have access to HIV
care/treatment. Lastly, Dr. Somsak challenged participants to come up with clear
and practical policy recommendations to present to the Ministry of Public Health in
terms of strategic use of ARVs and revitalized VCT.
Dr. Michael Hahn representing the UN Joint Team on HIV/AIDS noted that there is
finally strong evidence to suggest that antiretroviral agents can be strategically used
as preventative tools. As a middle income country with a low prevalence of HIV and a
8
Preliminary data from 2011 estimates
9
Nittaya Phanuphak. (March, 2011). Active Voluntary Counseling and Testing with Integrated CD4
Count Service Can Enhance Early HIV Testing and Early CD4 Count Measurement: Experiences From
the Thai Red Cross Anonymous Clinic in Bangkok, Thailand. Clinical Science. Volume 56.
12
13. strong healthcare system and pharmaceutical industry, Thailand is in a very good
position to implement treatment as prevention programs compared to other
countries; it is not a matter of whether these programs will be implemented but
when these programs will be implemented. Since the lives of thousands of Thai
residents are at stake, it is important to dedicate our attention to how this paradigm
shift will take place and how we can deliver HIV/AIDS services more effectively so
that we can reach our goal of an AIDS-free Thailand.
Presentation: The Strategic Use of ARVs: Global Evidence and
Experience to Date
Presented by Dr. Charles Gilks
UNAIDS Country Coordinator for India and Former Director of HIV and AIDS Treatment and Care
Unit, WHO headquarters in Geneva
ART has been a successful intervention: Figure 1:Cumulative Life-Years Gained from
Antiretroviral Therapy, 1996–2011
the cumulative number of lives gained as
a result of treatment is now heading 25
towards 25 million life-years (Figure 1).
Cumulative life-years gained
(in millions)
Biologic plausibility exists in strategically
using ARVs for prevention. There is a clear
gradation of viral load on infectivity and
the PACTG 076 trial in 1994 shows that 0
AZT given to pregnant mothers prevents 1996 2011
mother to child transmission. Source: Joint United Nations Programme on HIV/AIDS, 2012.
Current ARV initiatives include the global treatment scale up since 2001 and steadily
increasing availability of ARV prophylaxis for prevention of HIV transmission from
pregnant women to their infants. However, the strategic use of ARVs for prevention
has not yet been widely adopted for the following reasons:
Persistence of a false dichotomy in either focusing on treatment or prevention
Challenges to the continued production of affordable ARVs in light of current
trade policy agreements. There is also a fear that funding would be diverted from
prevention programs.
Persistent views that it is not possible to ‘treat our way out of the epidemic’ since
the behavioral component also needs to be addressed
Data showing the constant decline in HIV incidence regardless of the global scale
up suggests that treatment has no impact on incidence. However, treatment
initiation occurs at a median CD4 count that is too low to expect any impact
(mean CD4 count at ART initiation is below 200 cells/mm3 in Low and Middle-
income Countries.)
Evidence from ecological epidemiology studies in Taiwan, Canada, and South Africa
suggests that there is demonstrated effectiveness of ART scale up on prevention.
There have also been randomized clinical trials such as the HPTN 052 study and PrEP
studies of discordant couples in Sub-Saharan Africa together with epidemiological
13
14. modeling that explores this question.
Figure 2:The Test and Treat Model
The test-and-treat model, shown in
Figure 2 models the impact of increasing
the coverage and intensity of HIV
treatment in South Africa. Results show
that immediate treatment after testing
leads to almost zero incidence.
The HIV Modeling Consortium TasP
Editorial Writing Group also created a
framework to understand the
epidemiological impact of cART on HIV
transmission (Figure 3). As can be seen, Figure 3: A framework to understand the epidemiological
two-thirds of HIV transmission occurs at impact of cART to onward HIV transmission
CD4 levels less than 200 cells/mm3 and
approximately a half occurs at CD4
levels less than 350 cells/mm3.
The randomized HPTN 052 study of
healthy, serodiscordant couples showed
that treatment reduces by more than
90% the risk of passing along infection
to non-infected partners and this finding
has been confirmed by several other
randomized clinical trials. There have The HIV Modelling Consortium TasP Editorial Writing Group
PLoS Medicine 2012 vol 9 e1001259
also been several studies to show the
effectiveness of PMTCT, including the use of the new “Option B+” (life-long
treatment initiated in pregnant women regardless of CD4 count).
Moving forward, Thailand should continue to build on its current successes with its
PMTCT program. In addition, PrEP can be used as an additional intervention for key
affected populations (e.g., MSM, transgender and people who inject drugs). Two
randomized studies found that taking ARVs by the HIV-negative partner in a
discordant couple (pre-exposure prophylaxis or PrEP) reduced transmission
substantially10. Note that the guidances on PrEP are conditional recommendations
by the WHO because to-date, only a few studies exist that address this topic. For
oral PrEP, the reservoir of uninfected people is far too large and the challenge rests
with identifying those at risk for HIV acquisition. While this may be relatively
straightforward for some groups, the potential for PrEP remains unclear for others 9.
Thailand should revise the threshold for ART initiation (currently CD4 <200 cells/mm3
and below) and improve coverage to 80%, noting that under the test-and-treat
model, this will lead to an additional 120,000 patients. While there are concerns
related to funding and drug resistance, these concerns should not deter efforts to
10
James Shelton. (December, 2011). ARVs as HIV Prevention: A Tough Road to Wide Impact. Science
23. Vol. 334 no. 6063 pp. 1645-1646
14
15. promote expanded ARV treatment. Dr. Gilks noted that treatment as prevention has
community, in addition to, individual level advantages.
Presentation: The Thai HIV Epidemic: Can it be Controlled with Current
Approaches? Insights from Modeling and Epidemiological Analysis
Presented by Dr. Wiwat Peerapatanapokin
East-West Centre/Policy Research and Development Institute Foundation
The National AIDS plan calls
Figure 4:Baseline Scenario for HIV in Thailand
for a two-thirds reduction of
new HIV infections by 2016. 1,400,000
1,200,000
Number of infection
The Asian Epidemic Model 1,000,000
(AEM) is a behavioral model 800,000
600,000
that simulates the 400,000
transmission dynamic in low 200,000
0
level and concentrated 85
90
95
00
05
10
15
20
25
19
19
19
20
20
20
20
20
20
epidemics.
Living w/HIV and AIDS Cumulative HIV New HIV
AEM provides valuable Figure 5:Comparison of Baseline Projections versus Goals
projections in concentrated
HIV settings, particularly in
Thailand. Figure 4 shows the
baseline scenario for HIV in
Thailand. It is estimated that
43,040 new infections will
occur during 2012-2016. In
Figure 5, the baseline scenario is compared with goals stated in the National AIDS
plan. The graph shows that status quo, new infections in 2016 are projected to fall to
7000 per year. This falls short of the expected target of approximately only 3000 new
cases, demonstrating that a change is needed in current policies in order to further
reduce the incidence of new HIV infections.
A deeper review of the situation shows that the three groups that have the lowest
projected drop in new HIV infections based on current behavioral initiatives are
females having sex with their husbands/spouses, men who have sex with men
(MSMs) and injection drug users (IDUs). To reduce infections by two-thirds, the
following behavior changes need to occur by 2016:
Increase in condom use among MSMs to 90% (from current level of 70%)
Increase in condom use by female sex workers (FSWs) to 95% (from current level
of 82%)
Increase in condom use among regular partners to 45% (from current level of
2%)
Increase in condom use during casual sex to 75% (from current level of 45%)
Reduction of injection sharing by IDUs to 18% (from current level of 36%)
15
16. In summary, it seems extremely difficult to achieve the behavioral change levels
needed to reach the 2016 targets and that additional interventions will also be
needed to reach desired goals.
As a next step, the Asian Epidemic Model was used to study the effects of
introducing ARV as prevention. The model assumed that use of ARVs reduced
infectivity by 96% but that it did not influence behaviors. Results are shown in Figure
6.
Figure 6: New HIV Infections for Various Treatment as Prevention Interventions
The model shows that increasing the CD4 threshold for treatment initiation reduces
the number of new infections. In addition, expanding VCT from 30% to 90% in key
affected populations further reduces the incidence of HIV. Note that increasing
testing and treatment coverage will require additional healthcare capacity since the
number of people on treatment is expected to increase to 350,000 (up from 200,000
currently on treatment.)
Clarifications & Plenary Discussion
Co-chair: Dr. Somsak Akkasilp
Deputy Director General, Department of Disease Control
Co-chair: Ms. Supatra Nacapew
Thai NGO Coalition on HIV and AIDS (TNCA)
Several participants commented on the usefulness of both presentations in helping
to disseminate necessary information needed for effective policy making. The
following table summarizes the major concerns raised as well as responses by
panelists/other stakeholders:
Question/ Concern Answer
Treatment as prevention All medicines are toxic. There are side effects in
strategies involve giving toxic terms of long term adherence. Motivation stems
substances to asymptomatic from individual desire to stay healthy despite
16
17. Question/ Concern Answer
people. How can incentives be minor side effects. The risk benefit equation is
designed to encourage this? drastically different for people that are healthy
versus people that are sick and symptomatic but
in order to increase adherence, individuals need to
understand that treatment as prevention will
bring benefits to the entire community.
The strategic use of ARVs will Treatment should not be perceived as replacing
replace prevention initiatives prevention. It instead should be seen as a
component of prevention strategies.
Funding is not available for the Funding should not serve as a barrier for the
scale up of ARVs to be used as implementation of this strategy. It should also be
prevention noted that in the long term, treatment as
prevention can be more cost-effective.
Additional capacity does not Need to conduct further analysis of workloads
exist in health system to of healthcare personnel
accommodate the influx of Task shifting can help in improving capacity in
patients that would result from the current health delivery system
a scale up in testing and
treatment
Stigma/discrimination still Need to develop effective public
remains a major issue in communication in partnership with the target
providing services to PLHIVs or community; this includes increased focus on
KAPs – this issue should be communicating the benefits of earlier
addressed first before new treatment and enhanced prevention through
initiatives are put in place earlier diagnosis rather than the stigma of
being identified as infected with HIV.
Major behavioral change is needed to improve
treatment for infected individuals to reduce
transmission.
Activism for rights-based approaches to HIV
treatment, care and support is extremely
important
Should improvements be made The strategic use of ARVs should be seen as an
in condom intervention that will be used in conjunction with
programming/condom stock current prevention initiatives.
outs before adopting new
strategies for prevention?
Drug resistance Studies show that incidence of drug resistance
with ARV scale up is relatively low
Transmission of resistant strains is very limited
and has a low incidence
Issues for drug resistance with PrEP should be
a separate discussion
Issues with patent protection Strong activism and policy dialogue is needed to
and drug pricing address changing trade policies at the
international level.
17
18. Question/ Concern Answer
PrEP might be used as a PrEP should be seen as an addition, not a
substitute for condoms replacement of current interventions and this
needs to be communicated to the target
population
Items requiring follow up/ further discussion:
Analyze workloads of healthcare personnel to determine current limitations
Update Asian Epidemic Model estimates on IDUs, Transgenders, and the effects
of behavioral inhibition
Review ARV policies/legal barriers for migrants, non-Thais, and youth (under 18)
Develop strategy to improve coverage of VCT – without improved HIV case
detection, a strategy applying treatment as prevention is unlikely to be successful
Determine the target population for strategic use of ARV initiatives
Panel Discussion: Addressing Current Practices and Challenges for
Strategic Use of Antiretroviral Treatment
Moderator: Dr. Petchsri Sirinirund, the National AIDS Management Center
Panelists:
Dr. Usah Pruetijirawongse, the Office of Permanent Secretary, MOPH
Dr. Peerapol Suthivisetsak, Deputy Secretary-General of the Nation Health Security Office (NHSO)
Ms. Supatra Nacapew, Thai NGO Coalition on HIV and AIDS (TNCA)
Dr. Panita Pathipvanich, Lampang Hospital
Mr. Apiwat Kwangkaew, Thailand Network of People Living with HIV and AIDS (TNP+)
The objective of the panel session was to discuss strategies to maximize the benefit
of ARVs and to recognize some of the structural barriers to the implementation of
these strategies.
Apiwat Kwangkaew started the discussion by stating that the initial global campaign
to scale up ARV treatment involved a target of 15 million individuals. Currently, 6-7
million people are still waiting for treatment worldwide. Furthermore, a number of
individuals that are eligible for treatment do not have easy access to services leading
to wide disparities in the availability of care. He also brought forward the perspective
of a person living with HIV in viewing ARVs as toxic substances and noting that the
implementation of treatment as prevention requires an attitudinal change and
further education on the part of the target population. In addition, the community
should also be educated that ARVs should be used in conjunction with condoms as
there appears to be a popular misconception that treatment usurps consistent
condom use. Lastly, he highlighted the importance of further discussing the
individual risk decision making process and its importance in the demand for VCT.
Supatra Nacapew echoed that the ARV treatment as prevention initiatives cannot be
separated from other HIV prevention initiatives including use of condoms and
18
19. behavior change. Successfully implementing strategies such as treatment as
prevention will require commitment from stakeholder leadership. She also
reiterated the concerns raised in the Clarifications & Plenary Sessions in terms of
improving the condom program, issues with patent protection and TRIPS in
impacting the affordability of ARVs, the role of stigma and discrimination and the
need to develop better mechanisms to increase demand for VCT.
Dr. Panita Pathipvanich brought forth a physician perspective and stated that there
should be a continuous pipeline of healthcare personnel in the system to
accommodate the high turnover and retirement rates. She also confirmed that it will
be impossible for the burden to be borne solely by medical professionals and
supported the development of task shifting initiatives. In terms of HIV/AIDS
initiatives, Dr. Panita emphasized that the three most important things were
adherence, earlier testing and increased condom use.
Dr. Usah Pruetijirawongse discussed the governance structure in the MOPH in terms
of implementation, noting that there is room for improvement in this process. He
also clarified the role of the Office of the Permanent Secretary in being responsible
for the implementation of programs. He stressed the importance of supporting the
National AIDS Strategy for 2012-2016, which promotes harmonization and
optimization of HIV services.
Healthcare financing is usually viewed as poverty reduction instead of looking at
financing from the perspective of outcomes said Dr. Peerapol Suthivisetsak. Health
financing also involves improving manpower and contributing to the local economy
so it can also be viewed from the perspective of poverty prevention instead of
poverty alleviation. Dr. Peerapol also provided insight into the health budgeting
process, noting that the budget for HIV has increased since last year and is
continuing to respond to ever increasing demand. In terms of treatment as
prevention and other initiatives, he stressed the importance of cost-benefit analyses
in guiding NHSO funding.
Discussion
Panelists encouraged the audience to share their thoughts on key policy issues
related to treatment as prevention but cautioned that these issues should not be
viewed as obstacles to implementation. One of the biggest issues was
stigma/discrimination – stakeholders highlighted the importance of setting a
target of zero stigma/discrimination as well as zero new infections in order for
any strategy to be effective. It was also noted that the existing healthcare system
is already stretched thin and increasing capacity may mean that task shifting
initiatives need to be taken into consideration. On the positive side, it was
acknowledged that using ARVs as prevention makes sense since it involves
prevention for an entire community as opposed to just for an individual. In
addition, stakeholders agreed that individuals should know their serostatus as
soon as possible but care must be taken to create an environment of
confidentiality so people feel comfortable getting tested and post-test counseling
must be offered to all in order to improve adherence and knowledge of potential
side effects. 19
20. Summary, Conclusions, and Outlook for Day 2
Presented by Dr. Somsak Akkasilp
Deputy Director General, Department of Disease Control, Ministry of Public Health
The first part of this session was dedicated to recognizing that existing funds need to
be used as effectively as possible since some funding streams for prevention
interventions were ending in the next few years. Dr. Peerapol confirmed that the
NHSO is reaching the limit of its fiscal space but noted that funding will always be
made available for evidence based interventions.
Building on this, Michael Hahn added that a scientific base already exists in terms of
the strategic use of ARVs. In addition, he challenged stakeholders to think about the
possibility of reimbursing community organizations for the provision of HIV/AIDS
services in light of the shortage of medical professionals. Specifically, he broached
the idea of community based testing and services or home based testing as a way to
improve coverage and reduce stigma/discrimination.
Dr. Somsak closed the session by stressing the importance of moving outside our
comfort zones and taking into consideration a variety of factors outside of budget
considerations in order to develop a strategy. Scientific evidence for treatment as
prevention exists but discussion points from the day show that the concern is
centered on the implementation of the intervention, which will be discussed during
Day 2.
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21. Day Two: August 10th
Welcome Back and Introduction by Moderator to Objectives of Day 2
Delivered by Dr. Petchsri Sirinirund
National AIDS Management Centre (NAMC)
Dr. Petchsri Sirinirund began the second day of the consultation by summarizing the
key issues that were brought up in terms of implementation during the previous
day’s discussions and stressed the need to create policy recommendations by the
end of the day, as an output of the meeting.
Presentation: Addressing Service Delivery Challenges and
Opportunities for the Strategic Use of ARVs
Presented by Dr. Charles Gilks
UNAIDS Country Coordinator for India and Former Director of HIV and AIDS Treatment and Care
Unit, WHO headquarters in Geneva
There are three main domains for the strategic use of ARVs in Thailand: PMTCT, early
ART and PrEP for MSMs. Thailand already has an extremely successful PMTCT
program but continued investment is required to ensure that the country does not
revert back to its earlier state. Thailand should also stretch its goals by safely
targeting less than 2% mother-to-child transmission rates 11. One way of achieving
this is by providing Option B+ as standard first line therapy for HIV positive women
that are pregnant or are thinking of becoming pregnant. The benefits of early ART
were noted in Dr. Gilks’ previous presentation on Day 1 but it should be noted that
service delivery needs to be massively expanded if prevention benefits are to be
realized. There is a need for new service delivery models that focus on retaining at-
risk negative HIV individuals. This should be done before considering PrEP as an
option for MSMs since the intervention will not prove effective through existing ART
centers.
The guiding principles of Treatment 2.0 are focused on radical simplification of ART
with accelerated scale-up and full integration with prevention. Thailand should focus
on the fourth and fifth action areas: adapting delivery systems and mobilizing
communities/protecting human rights.
In terms of adapting delivery systems, Thailand needs to:
Decentralize services to be as close to the individual as possible since treatment
occurs over the long term
Integrate prevention, diagnosis and treatment
Expand options for HIV testing and counseling to increase coverage and make
people more willing to seek counseling
Expand task shifting in response to the shortage of qualified health workers
11
International Training Course of Programme Management of Prevention of Mother to Child HIV
Transmission, World Health Organization
21
22. Shift away from the stand-alone delivery of ART services in order to de-
stigmatize HIV services
Strengthen procurement and delivery systems
Mobilizing communities involves focusing on the demand side of the equation.
Communities need to be engaged in testing and counselling, service delivery,
adherence and provision of care and support. Models already exist to prove that
community led initiatives work in building adherence. Therefore, there needs to be
strong public communication that HIV/AIDS is a community level disease with
community level benefits in terms of prevention of transmission. The biggest
challenge preventing the success of community initiatives will be getting to zero
stigma/discrimination.
When implementing treatment as
Figure 7:The Test, Treat and Retain Cascade
prevention programs, the test,
treat and retain cascade must be ART eligible
Pre-ART
considered (Figure 7). The most care and ART
support
important piece in this cascade is HIV+
creating the demand for testing
and counseling by inducing
behavior change. Programs need
PrEP for Couple
to address individuals’ fear that target groups Counselling
the negative consequences
outweigh the positive benefits. In
addition, programs need to ensure that they create a safe and confidential
environment for individuals.
Other considerations in terms of implementation include task shifting and treatment
simplification. Key stakeholders in Thailand need to consider what roles and
responsibilities within HIV care can be reliably provided by the community, as is the
case with diabetes care/treatment. Task shifting also needs to be endorsed both by
the medical community and by community members in order to be effective. Lastly,
there should be a push towards a simplification of the treatment to one pill a day
since it improves delivery and adherence both for first line and second line
treatments.
Situation Update on Testing and Counseling and Linkages to Treatment
and Care in Thailand
Presented by: Dr. Sumet Ongwandee
Bureau of AIDS, TB, and STIs (BATS)
& Mr. Nimit Tienudom
AIDS Access Foundation
Dr. Sumet Ongwandee provided an overview in terms of the key statistics and
initiatives related to testing and counseling and linkages to care in Thailand. The VCT
process, shown in Figure 8, is both client and provider initiated. The lack of a central
repository of information makes VCT difficult to track. The NHSO VCT database
22
23. showed that in 2011, there were Figure 8:VCT Process
488,469 counseling cases for adults
and 16,943 cases. In addition, it was
found that 41.82% of people with STIs
opt for VCT in STI clinics versus 16.87%
in general OPD.
In terms of the strategic approach,
there are several initiatives in place to
promote testing such as national call centers, anonymous testing and counseling and
free HIV testing twice a year, to name a few. The AIDS management center is also
implementing several projects in order to strengthen access to VCT. Despite current
efforts, gaps still exist in testing among youth and KAPs and in linkages to treatment.
Nimit Tienudom re-emphasized the importance of testing and spoke to the biggest
gaps in HIV care from his perspective:
A large percentage of the population are still unaware of their serostatus and
practice unsafe sex
Lack of awareness among the HIV positive population of their rights to treatment
and care
Lack of individual awareness of their own risks
Lack of streamlined care from initial HIV counseling and testing to treatment
Lack of a unified public awareness campaign
Stigma/discrimination
Discussion
Co-Chair: Dr. Suwat Chariyalertsak
Chiang Mai University's Research Institute for Health Sciences (RIHES)
Co-Chair: Dr. Nittaya Phanuphak
Thai Red Cross AIDS Research Centre
Discussion
In order to make treatment as prevention more feasible, the upstream process of
counseling and testing needs to be strengthened. There are still a number of those
who do not come back for post test counseling. Same day results and intensified HIV
case finding were also suggested as methods to drive increased testing. There was
some debate in terms of the target population for testing and further discussion
needs to take place on this issue.
On the supply side, it was acknowledged that decentralization is necessary for
healthcare delivery and that people in the local communities should drive the
change. For task shifting, it is possible for medical technologists to be trained as
counselors. However, training other health professionals to do testing should be
considered for scaling up the VCT services. As previously mentioned, education
campaigns also need to be conducted so that individuals are aware of their
entitlements to care.
23
24. Items requiring follow up/ further discussion:
Develop centralized data repository to monitor/evaluate VCT
Develop practical and concrete recommendations on testing and treatment
Determine the target population for interventions: should they be aimed at the
general public or at key affected populations?
Develop more cost/benefit and cost effectiveness analyses on using
antiretroviral agents as prevention
Working Group Discussions: Expanded testing and counseling, linkages
to care/treatment, and adherence support: opportunities and
considerations in Thailand
Group 1 Practical options for Co-chair: Dr. Nittaya Phanuphak
improving HIV testing Thai Red Cross AIDS Research Centre
and counseling Co-Chair: Dr. Ake-Chittra Sukkul
Thailand MOPH-U.S. CDC Collaboration on HIV
and AIDS (TUC)
Group 2 Options for improving Co-Chair: Mr. Nimit Tienudom
linkages to care and AIDS Access Foundation,
supporting treatment Co-Chair: Mr. Apiwat Kwangkaew
adherence in the Thailand Network of People Living with HIV
community and AIDS (TNP+)
Group 3 Examining options for Co-Chair: Dr. Panita Patheepawanich, Lampang
service delivery Hospital,
including task shifting Co-Chair: Ms. Chonlisa Chariyalertsak
Head of STD/AIDS Prevention & Control
Section, Provincial Health Office, Chiang Mai
Working Groups Report to Plenary Session
Co-Chair: Dr. Suwat Chariyalertsak
Chiang Mai University's Research Institute for Health Sciences (RIHES)
Co-Chair: Dr.Sombat Thanprasertsuk, Senior expert of preventive medicine/ Department of Disease
Control (DDC)
Dr. Sombat Thanprasertsuk summarized the results of each working group by
highlighting four main streams of work:
1. Increasing the scale of VCT
2. Creating linkages between VCT and treatment
3. Strengthening human resources
4. Establishing a dedicated working group to address stigma/discrimination
He also suggested establishing a focal point responsible for building evidence around
the four main work streams mentioned above and creating an action plan to drive
24
25. this initiative forward. Leadership should also consider proposing a pilot PrEP project
to the NHSO, which can be scaled up if successful.
Working Group Discussion
Group 1: Practical options for improving HIV testing and counseling
Develop a media and social network strategy to reduce stigma/discrimination
Use trained counselors that have an understanding of the concerns of each risk
group
Create a market survey to understand the needs of the population
Create a safe and confidential environment for testing and counseling
Establish linkages between public and private facilities
Start conversations with the Ministry of the Interior and the Ministry of Labor to
develop a common policy for VCT among migrants
Group 2: Options for improving linkages to care and supporting treatment
adherence in the community
Engage community in designing HIV/AIDS services
Create a communication plan and a national labor campaign that is supported by
the private sector
Train staff in understanding the need for linkages
Improve service quality at centers and create a culture of mutual ownership
Standardize services across all platforms to ensure equality in terms of service
Build awareness among individuals of their own risk and create a sense of
ownership so that people do not leave the system midway through the process
Create awareness campaigns to ensure that people understand what their
entitlements are in terms of the three healthcare schemes
Group 3: Examining options for service delivery including task shifting
Implement system of same day results. Leverage best practices in order to
institute the program in the most efficient and cost effective way possible
Build awareness of VCT
Closing
Delivered by Dr. Jakkriss Bhumisawasdi
Chief of Inspector General, Ministry of Public Health
Reported by Dr. Petchsri Sirinirund
National AIDS Management Centre (NAMC)
Dr. Petchsri thanked all stakeholders for the intense and fruitful discussions over the
past two days. She commented on how Dr.Gilks’ presentations framed the
conversations around treatment as prevention and thanked him for his valuable
25
26. input. While treatment as prevention was acknowledged as a method of both
enhancing the quality of life and reducing the number of new HIV infections,
stakeholders voiced a number of concerns that needed to be addressed before
implementing such initiatives. The prevention effect of treatment can only start
when all people including both Thai and non-Thai who need treatment are actually
treated. One of the first priorities should be to strengthen the system to treat people
that are eligible first (<350 CD4 count). Other implementation concerns raised were
ARV prices and patents, stigma and building individual ownership of health.
Dr. Jakkriss closed the consultation by reminding stakeholders that the success of
the initiative depends on integration at all levels. He thanked stakeholders for their
participation and welcomed comments and suggestions to MOPH based on the
outputs from the consultation.
Next Steps
In order to reach the goal of equity of HIV treatment for everyone with a focus on
recruiting KAPs for VCT, the following action items were identified within six major
work streams:
Service Delivery:
1. Explore options for decentralized (i.e. community based) system of care and VCT
2. Sustain and enhance success of PMTCT program
3. Develop strategy to improve coverage of VCT – necessary before treatment
strategy can be assessed
Monitoring:
1. Develop centralized data repository to monitor/evaluate VCT in parallel with
building up capacity of data use at service and provincial levels
Policy:
1. Develop practical and concrete recommendations on testing and treatment
2. Determine the target population for interventions: should they be aimed at the
general public or at key affected populations?
3. Review ARV policies/legal barriers for migrants, non-Thais, and youth (under 18)
Modeling:
1. Develop more cost/benefit and cost effectiveness analyses on using
antiretroviral agents as prevention
2. Update Asian Epidemic Model estimates on IDUs, Transgenders, and the effects
of behavioral inhibition
Operational Research:
1. Explore possibility of launching a pilot PrEP program
2. Analyze workloads of healthcare personnel to determine current limitations
26
27. Public Communication:
1. Develop an education campaign targeted at altering risk behavior, attitudes
towards health, and knowledge of health entitlements
Notes from Meeting of Working Group – 22/8/2012
Following the National Consultation of the Strategic Use of ARVs, Dr. Petchsri
convened a meeting to discuss key issues raised during the consultation and next
steps. During the meeting, the group mirrored consensus that the goal in terms of
treatment as prevention is option 5 shown in figure 9 below but with the
modification that VCT will be targeted at KAPs and serodiscordant couples since they
account for 94% of new infections.
Figure 9: TasP ART Eligibility Policy
1 2 3 4 5
CD4 ≤ 200
Recommended
Since 2003
In order to attain this goal, the group identified the following as key next steps:
1. Modeling, cost effectiveness, cost benefit, workload, feasibility, and adherence
analyses
2. Policy dialogue, advocacy, and operational plan to reach 90% VCT among KAPs
3. Policy dialogue, advocacy, and operational plan for treat all seropositive partners
in serodiscordant couples regardless of CD4 count
4. Consultations on:
Option B+ for pregnant women
Treatment regardless of CD4 count for sex workers, IDU, MSM
Treatment regardless of CD4 count for all
5. Consultations on PrEP for:
Seronegative partners in serodiscordant relationships
Seronegative KAPs
6. Operational plan for public communications
27
