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Thailand's strategic use of ARV meeting report

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    Thailand's strategic use of ARV meeting report Thailand's strategic use of ARV meeting report Document Transcript

    • ReportNational Consultation onthe Strategic Use ofARVs - Thailand9 and 10 August 2012
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    • National Consultation on the Strategic Use of ARVsThe proceedings of this meeting were recorded by Shravya Kidambi
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    • AcronymsAEM Asian Epidemic ModelAIDS Acquired Immune Deficiency SyndromeANC Antenatal CareART Anti Retroviral TherapyARV AntiretroviralBATS Bureau of AIDS, Tuberculosis and STIcART Combination Anti Retroviral TherapyFSW Female Sex WorkersHIV Human Immunodeficiency VirusIDU Injecting Drug UserKAP Key Affected populationKPI Key Performance IndicatorsMARP Most-at-Risk PopulationsMSM Men who have Sex with MenMSW Male Sex WorkersMW Migrant WorkerNHSO National Health Security OfficeOPD Outpatient DepartmentPLHIV People Living with HIVPMTCT Prevention of Mother-To-Child HIV TransmissionPrEP Pre-Exposure ProphylaxisS&D Stigma and DiscriminationSTI Sexually transmitted infectionsTasP Treatment As PreventionTG TransgenderTNCA Thai NGO (Non-Governmental Organization) Coalition on AIDSTNP+ Thai Network of People Living with HIV/AIDSTUC Thailand Ministry of Public Health - US CDC CollaborationTWG Technical Working GroupsUNGASS United Nations General Assembly Special Session on HIV/AIDSVCT Voluntary Counseling and Testing 6
    • Executive SummaryThe 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 onHIV/AIDS, Thailand MOPH-U.S. CDC Collaboration on HIV and AIDS (TUC), Thai RedCross Society, and the Ministry of Public Health.The primary goal of the consultation was to provide an opportunity for keystakeholders including decision makers, epidemiologists, modelers, and affectedpopulations to better understand new evidence around strategic use of ARVs andpotential applications to Thailand’s national AIDS program.Thailand’s National AIDS Strategy calls for a reduction in new HIV infections by twothirds by 2016. During Day 1, Dr. Wiwat Peerapatanapokin from the East-WestCenter noted that using AEM estimations on current prevention/treatment efforts,Thailand will fall short of its 2016 target of reducing new infections by approximately5000 cases. Therefore, new strategies need to be put in place to achieve goals set for2016.Dr. Charles Gilks, currently UNAIDS Country Coordinator for India and formerDirector of the Treatment and Care Unit of the HIV/AIDS Department for WHOGeneva, presented the breadth of evidence that exists supporting the early initiationof ARVs at both individual and population levels (treatment and prevention). Whilethis was acknowledged by stakeholders as a beneficial intervention, concerns wereraised and discussed related to implementation of treatment as preventioninitiatives both for the overall health system as well as affected individuals.Following panel discussions and working group sessions, it was agreed that ARVsshould be used strategically in Thailand for treatment and prevention. It wasacknowledged that Thailand already has a best practice example of “treatment asprevention” in the form of PMTCT. There was consensus that the biggest benefit tobe derived would be in treating all people found to be HIV positive, and strategicallyconducting 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 taskshifting. The introduction of completely new services, like PrEP, will need carefulconsideration, planning and monitoring.Action items to be taken up following the consultation were identified within sixmajor 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
    • 2. Monitoring: Develop centralized data repository to monitor/evaluate VCT in parallel with building up capacity of data use at service and provincial levels3. 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 limitations6. Public Communication: Develop a public communication campaign for increased understanding of potential use of ARVs for HIV prevention 8
    • Background & IntroductionHIV/AIDS is an issue of continued political and public health significance in Thailand.According to the 2010-2011 Global AIDS Response Country Progress Report forThailand, there are an estimated 500,000 adults and children living with HIV1 and10,450 new cases in 20112. According to the Asian Epidemic Model (AEM), it isestimated that 43,040 new infections will occur during 2012-2016.Thailand’s successful anti-retroviral treatment program currently reaches two-thirdsof adults and children in need of treatment (CD4 200 cells/mm3 and below), and hascontributed to transforming HIV for people in Thailand from a fatal illness to achronic condition. Free access to ARVs and free universal health care has contributedto people living longer and healthier lives. Thailand has been lauded for severalaspects of its HIV prevention policy, ranging from universal HIV counseling andtesting in ANC settings (PMTCT) with ARV prophylaxis provision as needed, to the100% condom use policy among sex workers. PMTCT interventions alone havereduced 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 thenumber one cause of death among men and women in their prime (ages 15 – 49). Itis the official cause of death for 22.6% of males and 30.7% of females in this agegroup4.The 2010 Thai National HIV/AIDS Diagnostic and Treatment Guidelines recommendCD4 count <350 cells/mm3 as the threshold for ART initiation in patients. The currentmedian CD4 count at ART initiation in Thailand is 63 cells/mm3,5. Late HIV testingand/or delayed CD4 count measurement after HIV diagnosis may explain the delayedinitiation of ART in many settings. At the same time, delayed treatment initiation canlead to sub-optimal clinical outcomes for the individual, and contribute to ongoingHIV transmission as people with high viral loads continue to spread HIV throughouttheir respective communities.During 2010-2011, five new prevention trials showed a positive effect from the useof antiretroviral agents for prevention: four used antiretroviral agents for pre-exposure prophylaxis for primary prevention and one randomized clinical trial, HPTN052, studied the prevention benefit through early use of treatment among infectedindividuals. The evidence from these studies suggests that the use of antiretroviralagents can be effective in significantly improving clinical outcomes, but also serves asan effective HIV prevention measure.1 Preliminary data from 2011 estimates, UNAIDS/WHO, 20112 Ibid.3 Global AIDS Report4 Preliminary data from 2011 estimates5 Nittaya Phanuphak. (March, 2011). Active Voluntary Counseling and Testing with Integrated CD4Count Service Can Enhance Early HIV Testing and Early CD4 Count Measurement: Experiences Fromthe Thai Red Cross Anonymous Clinic in Bangkok, Thailand. Clinical Science. Volume 56. 9
    • A recent meta-analysis of ARV provision among sero-discordant couples reviewedthe results from HPTN 052 and seven observational studies. The eight studiesidentified 464 episodes of HIV transmission, of which 72 were among treatedcouples and 392 among untreated couples. The conclusion was that even in theworst case scenario, when the HIV infected individual in a sero-discordant couplewas taking ARVs; the risk of transmission was more than three times lower than insituations where the infected sexual partner was not taking ARVs6. The biologicalrationale behind this protective effect is that viral load reduction to undetectablelevels significantly decreases the risk of sexual transmission.Thailand, as an upper middle income country, with declining HIV prevalence (under1.5%)7, is well positioned to consider whether earlier initiation of antiretroviralagents 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 CrossSociety, and the Ministry of Public Health.The primary goal of the consultation was to provide an opportunity for keystakeholders including decision makers, epidemiologists, modelers, and affectedpopulations to better understand new evidence around treatment as prevention andits 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 population2. 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 workforce3. 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 resistance6 Anglemyer, et al. Antiretroviral therapy for prevention of HIV transmission in HIV-discordantcouples. Cochrane HIV/AIDS Group, 10 August, 2011. Accessed at:http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009153.pub2/abstract;jsessionid=49148A2B82BE2904BDC4 B6B103451B0C.d02t027 UNAIDS Country Profile, accessed online at:http://www.unaids.org/en/regionscountries/countries/thailand/ 10
    • 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 stigmatization5. 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 ARTExpected 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 infections2. 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
    • Day One: August 9thOpening: The vision of the National HIV Strategy, 2012-2016Delivered by:Dr Sumet Ongwandee, BATSDr. Somsak Akkasilp, Deputy Director General, Department of Disease ControlDr. Michael Hahn, UNAIDSThe National Consultation for the Strategic Use of ARVs began with opening remarksby Dr. Sumet Ongwandee from the Bureau of AIDS, TB and STIs (BATS). Hecommented on the success of Thailand’s current ARV program that reaches overtwo-thirds of the population in need (CD4 count below 200 cells/mm3) and that hastransformed the disease from an infectious disease with a high case-fatality rate intoa chronic illness. He also praised several specific initiatives such as the universalcoverage program, PMTCT initiatives that have reduced the number of newinfections in newborns to 350 cases per year and the 100% condom policy for sexworkers.Dr. Sumet also noted the fact that AIDS still remains the number one cause of deathfor men and women in the 15-49 age range (a total of 28,000 deaths wereattributable to AIDS in 20118). In addition, the median CD4 count for ART initiation inThailand is extremely low (63 cells/mm3)9. This leads to suboptimal morbidity andmortality outcomes and increased viral load in the community.Lastly, Dr. Sumet touched upon the consultation’s goal of reviewing variouspolicy/implementation issues on the strategic use of ARVs to meet the goal of zeroincidence and zero AIDS-related deaths. He further noted the critical importance ofpolicy discussions that involve key stakeholders from diverse backgrounds.Dr. Somsak Akksilp echoed Dr. Sumet’s remarks and noted that a consultationimplies a true collaboration. He invited all participants to bring their insights andcomments to the forefront and highlighted the appropriateness in holding thisconsultation immediately following the International AIDS Conference 2012 inWashington, DC. He reiterated Thailand’s many accomplishments but cautionedthat a high percentage of Thai residents still do not have access to HIVcare/treatment. Lastly, Dr. Somsak challenged participants to come up with clearand practical policy recommendations to present to the Ministry of Public Health interms of strategic use of ARVs and revitalized VCT.Dr. Michael Hahn representing the UN Joint Team on HIV/AIDS noted that there isfinally strong evidence to suggest that antiretroviral agents can be strategically usedas preventative tools. As a middle income country with a low prevalence of HIV and a8 Preliminary data from 2011 estimates9 Nittaya Phanuphak. (March, 2011). Active Voluntary Counseling and Testing with Integrated CD4Count Service Can Enhance Early HIV Testing and Early CD4 Count Measurement: Experiences Fromthe Thai Red Cross Anonymous Clinic in Bangkok, Thailand. Clinical Science. Volume 56. 12
    • strong healthcare system and pharmaceutical industry, Thailand is in a very goodposition to implement treatment as prevention programs compared to othercountries; it is not a matter of whether these programs will be implemented butwhen these programs will be implemented. Since the lives of thousands of Thairesidents are at stake, it is important to dedicate our attention to how this paradigmshift will take place and how we can deliver HIV/AIDS services more effectively sothat we can reach our goal of an AIDS-free Thailand.Presentation: The Strategic Use of ARVs: Global Evidence andExperience to DatePresented by Dr. Charles GilksUNAIDS Country Coordinator for India and Former Director of HIV and AIDS Treatment and CareUnit, WHO headquarters in GenevaART has been a successful intervention: Figure 1:Cumulative Life-Years Gained from Antiretroviral Therapy, 1996–2011the cumulative number of lives gained asa result of treatment is now heading 25towards 25 million life-years (Figure 1). Cumulative life-years gained (in millions)Biologic plausibility exists in strategicallyusing ARVs for prevention. There is a cleargradation of viral load on infectivity andthe PACTG 076 trial in 1994 shows that 0AZT given to pregnant mothers prevents 1996 2011mother to child transmission. Source: Joint United Nations Programme on HIV/AIDS, 2012.Current ARV initiatives include the global treatment scale up since 2001 and steadilyincreasing availability of ARV prophylaxis for prevention of HIV transmission frompregnant women to their infants. However, the strategic use of ARVs for preventionhas 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 Africasuggests 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 PrEPstudies of discordant couples in Sub-Saharan Africa together with epidemiological 13
    • modeling that explores this question. Figure 2:The Test and Treat ModelThe test-and-treat model, shown inFigure 2 models the impact of increasingthe coverage and intensity of HIVtreatment in South Africa. Results showthat immediate treatment after testingleads to almost zero incidence.The HIV Modeling Consortium TasPEditorial Writing Group also created aframework to understand theepidemiological impact of cART on HIVtransmission (Figure 3). As can be seen, Figure 3: A framework to understand the epidemiologicaltwo-thirds of HIV transmission occurs at impact of cART to onward HIV transmissionCD4 levels less than 200 cells/mm3 andapproximately a half occurs at CD4levels less than 350 cells/mm3.The randomized HPTN 052 study ofhealthy, serodiscordant couples showedthat treatment reduces by more than90% the risk of passing along infectionto non-infected partners and this findinghas been confirmed by several otherrandomized clinical trials. There have The HIV Modelling Consortium TasP Editorial Writing Group PLoS Medicine 2012 vol 9 e1001259also been several studies to show theeffectiveness of PMTCT, including the use of the new “Option B+” (life-longtreatment initiated in pregnant women regardless of CD4 count).Moving forward, Thailand should continue to build on its current successes with itsPMTCT program. In addition, PrEP can be used as an additional intervention for keyaffected populations (e.g., MSM, transgender and people who inject drugs). Tworandomized studies found that taking ARVs by the HIV-negative partner in adiscordant couple (pre-exposure prophylaxis or PrEP) reduced transmissionsubstantially10. Note that the guidances on PrEP are conditional recommendationsby the WHO because to-date, only a few studies exist that address this topic. Fororal PrEP, the reservoir of uninfected people is far too large and the challenge restswith identifying those at risk for HIV acquisition. While this may be relativelystraightforward for some groups, the potential for PrEP remains unclear for others 9.Thailand should revise the threshold for ART initiation (currently CD4 <200 cells/mm3and below) and improve coverage to 80%, noting that under the test-and-treatmodel, this will lead to an additional 120,000 patients. While there are concernsrelated to funding and drug resistance, these concerns should not deter efforts to10 James Shelton. (December, 2011). ARVs as HIV Prevention: A Tough Road to Wide Impact. Science23. Vol. 334 no. 6063 pp. 1645-1646 14
    • promote expanded ARV treatment. Dr. Gilks noted that treatment as prevention hascommunity, in addition to, individual level advantages.Presentation: The Thai HIV Epidemic: Can it be Controlled with CurrentApproaches? Insights from Modeling and Epidemiological AnalysisPresented by Dr. Wiwat PeerapatanapokinEast-West Centre/Policy Research and Development Institute FoundationThe National AIDS plan calls Figure 4:Baseline Scenario for HIV in Thailandfor a two-thirds reduction ofnew HIV infections by 2016. 1,400,000 1,200,000 Number of infectionThe Asian Epidemic Model 1,000,000(AEM) is a behavioral model 800,000 600,000that simulates the 400,000transmission dynamic in low 200,000 0level and concentrated 85 90 95 00 05 10 15 20 25 19 19 19 20 20 20 20 20 20epidemics. Living w/HIV and AIDS Cumulative HIV New HIVAEM provides valuable Figure 5:Comparison of Baseline Projections versus Goalsprojections in concentratedHIV settings, particularly inThailand. Figure 4 shows thebaseline scenario for HIV inThailand. It is estimated that43,040 new infections willoccur during 2012-2016. InFigure 5, the baseline scenario is compared with goals stated in the National AIDSplan. The graph shows that status quo, new infections in 2016 are projected to fall to7000 per year. This falls short of the expected target of approximately only 3000 newcases, demonstrating that a change is needed in current policies in order to furtherreduce the incidence of new HIV infections.A deeper review of the situation shows that the three groups that have the lowestprojected drop in new HIV infections based on current behavioral initiatives arefemales having sex with their husbands/spouses, men who have sex with men(MSMs) and injection drug users (IDUs). To reduce infections by two-thirds, thefollowing 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
    • In summary, it seems extremely difficult to achieve the behavioral change levelsneeded to reach the 2016 targets and that additional interventions will also beneeded to reach desired goals.As a next step, the Asian Epidemic Model was used to study the effects ofintroducing ARV as prevention. The model assumed that use of ARVs reducedinfectivity by 96% but that it did not influence behaviors. Results are shown in Figure6. Figure 6: New HIV Infections for Various Treatment as Prevention InterventionsThe model shows that increasing the CD4 threshold for treatment initiation reducesthe number of new infections. In addition, expanding VCT from 30% to 90% in keyaffected populations further reduces the incidence of HIV. Note that increasingtesting and treatment coverage will require additional healthcare capacity since thenumber of people on treatment is expected to increase to 350,000 (up from 200,000currently on treatment.)Clarifications & Plenary DiscussionCo-chair: Dr. Somsak AkkasilpDeputy Director General, Department of Disease ControlCo-chair: Ms. Supatra NacapewThai NGO Coalition on HIV and AIDS (TNCA)Several participants commented on the usefulness of both presentations in helpingto disseminate necessary information needed for effective policy making. Thefollowing table summarizes the major concerns raised as well as responses bypanelists/other stakeholders: Question/ Concern AnswerTreatment as prevention All medicines are toxic. There are side effects instrategies involve giving toxic terms of long term adherence. Motivation stemssubstances to asymptomatic from individual desire to stay healthy despite 16
    • Question/ Concern Answerpeople. How can incentives be minor side effects. The risk benefit equation isdesigned 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 replacingreplace 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 thescale up of ARVs to be used as implementation of this strategy. It should also beprevention noted that in the long term, treatment as prevention can be more cost-effective.Additional capacity does not  Need to conduct further analysis of workloadsexist in health system to of healthcare personnelaccommodate the influx of  Task shifting can help in improving capacity inpatients that would result from the current health delivery systema scale up in testing andtreatmentStigma/discrimination still  Need to develop effective publicremains a major issue in communication in partnership with the targetproviding services to PLHIVs or community; this includes increased focus onKAPs – this issue should be communicating the benefits of earlieraddressed first before new treatment and enhanced prevention throughinitiatives 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 importantShould improvements be made The strategic use of ARVs should be seen as anin condom intervention that will be used in conjunction withprogramming/condom stock current prevention initiatives.outs before adopting newstrategies 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 discussionIssues with patent protection Strong activism and policy dialogue is needed toand drug pricing address changing trade policies at the international level. 17
    • Question/ Concern AnswerPrEP might be used as a PrEP should be seen as an addition, not asubstitute for condoms replacement of current interventions and this needs to be communicated to the target populationItems 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 initiativesPanel Discussion: Addressing Current Practices and Challenges forStrategic Use of Antiretroviral TreatmentModerator: Dr. Petchsri Sirinirund, the National AIDS Management CenterPanelists:Dr. Usah Pruetijirawongse, the Office of Permanent Secretary, MOPHDr. 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 HospitalMr. 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 benefitof ARVs and to recognize some of the structural barriers to the implementation ofthese strategies.Apiwat Kwangkaew started the discussion by stating that the initial global campaignto scale up ARV treatment involved a target of 15 million individuals. Currently, 6-7million people are still waiting for treatment worldwide. Furthermore, a number ofindividuals that are eligible for treatment do not have easy access to services leadingto wide disparities in the availability of care. He also brought forward the perspectiveof a person living with HIV in viewing ARVs as toxic substances and noting that theimplementation of treatment as prevention requires an attitudinal change andfurther education on the part of the target population. In addition, the communityshould also be educated that ARVs should be used in conjunction with condoms asthere appears to be a popular misconception that treatment usurps consistentcondom use. Lastly, he highlighted the importance of further discussing theindividual risk decision making process and its importance in the demand for VCT.Supatra Nacapew echoed that the ARV treatment as prevention initiatives cannot beseparated from other HIV prevention initiatives including use of condoms and 18
    • behavior change. Successfully implementing strategies such as treatment asprevention will require commitment from stakeholder leadership. She alsoreiterated the concerns raised in the Clarifications & Plenary Sessions in terms ofimproving the condom program, issues with patent protection and TRIPS inimpacting the affordability of ARVs, the role of stigma and discrimination and theneed to develop better mechanisms to increase demand for VCT.Dr. Panita Pathipvanich brought forth a physician perspective and stated that thereshould be a continuous pipeline of healthcare personnel in the system toaccommodate the high turnover and retirement rates. She also confirmed that it willbe impossible for the burden to be borne solely by medical professionals andsupported the development of task shifting initiatives. In terms of HIV/AIDSinitiatives, Dr. Panita emphasized that the three most important things wereadherence, earlier testing and increased condom use.Dr. Usah Pruetijirawongse discussed the governance structure in the MOPH in termsof implementation, noting that there is room for improvement in this process. Healso clarified the role of the Office of the Permanent Secretary in being responsiblefor the implementation of programs. He stressed the importance of supporting theNational AIDS Strategy for 2012-2016, which promotes harmonization andoptimization of HIV services.Healthcare financing is usually viewed as poverty reduction instead of looking atfinancing from the perspective of outcomes said Dr. Peerapol Suthivisetsak. Healthfinancing also involves improving manpower and contributing to the local economyso it can also be viewed from the perspective of poverty prevention instead ofpoverty alleviation. Dr. Peerapol also provided insight into the health budgetingprocess, noting that the budget for HIV has increased since last year and iscontinuing to respond to ever increasing demand. In terms of treatment asprevention and other initiatives, he stressed the importance of cost-benefit analysesin 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
    • Summary, Conclusions, and Outlook for Day 2Presented by Dr. Somsak AkkasilpDeputy Director General, Department of Disease Control, Ministry of Public HealthThe first part of this session was dedicated to recognizing that existing funds need tobe used as effectively as possible since some funding streams for preventioninterventions were ending in the next few years. Dr. Peerapol confirmed that theNHSO is reaching the limit of its fiscal space but noted that funding will always bemade available for evidence based interventions.Building on this, Michael Hahn added that a scientific base already exists in terms ofthe strategic use of ARVs. In addition, he challenged stakeholders to think about thepossibility of reimbursing community organizations for the provision of HIV/AIDSservices in light of the shortage of medical professionals. Specifically, he broachedthe idea of community based testing and services or home based testing as a way toimprove coverage and reduce stigma/discrimination.Dr. Somsak closed the session by stressing the importance of moving outside ourcomfort zones and taking into consideration a variety of factors outside of budgetconsiderations in order to develop a strategy. Scientific evidence for treatment asprevention exists but discussion points from the day show that the concern iscentered on the implementation of the intervention, which will be discussed duringDay 2. 20
    • Day Two: August 10thWelcome Back and Introduction by Moderator to Objectives of Day 2Delivered by Dr. Petchsri SirinirundNational AIDS Management Centre (NAMC)Dr. Petchsri Sirinirund began the second day of the consultation by summarizing thekey issues that were brought up in terms of implementation during the previousday’s discussions and stressed the need to create policy recommendations by theend of the day, as an output of the meeting.Presentation: Addressing Service Delivery Challenges andOpportunities for the Strategic Use of ARVsPresented by Dr. Charles GilksUNAIDS Country Coordinator for India and Former Director of HIV and AIDS Treatment and CareUnit, WHO headquarters in GenevaThere are three main domains for the strategic use of ARVs in Thailand: PMTCT, earlyART and PrEP for MSMs. Thailand already has an extremely successful PMTCTprogram but continued investment is required to ensure that the country does notrevert back to its earlier state. Thailand should also stretch its goals by safelytargeting less than 2% mother-to-child transmission rates 11. One way of achievingthis is by providing Option B+ as standard first line therapy for HIV positive womenthat are pregnant or are thinking of becoming pregnant. The benefits of early ARTwere noted in Dr. Gilks’ previous presentation on Day 1 but it should be noted thatservice delivery needs to be massively expanded if prevention benefits are to berealized. 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 anoption for MSMs since the intervention will not prove effective through existing ARTcenters.The guiding principles of Treatment 2.0 are focused on radical simplification of ARTwith accelerated scale-up and full integration with prevention. Thailand should focuson the fourth and fifth action areas: adapting delivery systems and mobilizingcommunities/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 workers11 International Training Course of Programme Management of Prevention of Mother to Child HIVTransmission, World Health Organization 21
    •  Shift away from the stand-alone delivery of ART services in order to de- stigmatize HIV services Strengthen procurement and delivery systemsMobilizing 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 thatcommunity led initiatives work in building adherence. Therefore, there needs to bestrong public communication that HIV/AIDS is a community level disease withcommunity level benefits in terms of prevention of transmission. The biggestchallenge preventing the success of community initiatives will be getting to zerostigma/discrimination.When implementing treatment as Figure 7:The Test, Treat and Retain Cascadeprevention programs, the test,treat and retain cascade must be ART eligible Pre-ARTconsidered (Figure 7). The most care and ART supportimportant piece in this cascade is HIV+creating the demand for testingand counseling by inducingbehavior change. Programs need PrEP for Coupleto address individuals’ fear that target groups Counsellingthe negative consequencesoutweigh the positive benefits. Inaddition, programs need to ensure that they create a safe and confidentialenvironment for individuals.Other considerations in terms of implementation include task shifting and treatmentsimplification. Key stakeholders in Thailand need to consider what roles andresponsibilities within HIV care can be reliably provided by the community, as is thecase with diabetes care/treatment. Task shifting also needs to be endorsed both bythe 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 daysince it improves delivery and adherence both for first line and second linetreatments.Situation Update on Testing and Counseling and Linkages to Treatmentand Care in ThailandPresented by: Dr. Sumet OngwandeeBureau of AIDS, TB, and STIs (BATS)& Mr. Nimit TienudomAIDS Access FoundationDr. Sumet Ongwandee provided an overview in terms of the key statistics andinitiatives related to testing and counseling and linkages to care in Thailand. The VCTprocess, shown in Figure 8, is both client and provider initiated. The lack of a centralrepository of information makes VCT difficult to track. The NHSO VCT database 22
    • showed that in 2011, there were Figure 8:VCT Process488,469 counseling cases for adultsand 16,943 cases. In addition, it wasfound that 41.82% of people with STIsopt for VCT in STI clinics versus 16.87%in general OPD.In terms of the strategic approach,there are several initiatives in place topromote testing such as national call centers, anonymous testing and counseling andfree HIV testing twice a year, to name a few. The AIDS management center is alsoimplementing several projects in order to strengthen access to VCT. Despite currentefforts, 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 biggestgaps 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/discriminationDiscussionCo-Chair: Dr. Suwat ChariyalertsakChiang Mai Universitys Research Institute for Health Sciences (RIHES)Co-Chair: Dr. Nittaya PhanuphakThai 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
    • 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 preventionWorking Group Discussions: Expanded testing and counseling, linkagesto care/treatment, and adherence support: opportunities andconsiderations in ThailandGroup 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 MaiWorking Groups Report to Plenary SessionCo-Chair: Dr. Suwat ChariyalertsakChiang Mai Universitys Research Institute for Health Sciences (RIHES)Co-Chair: Dr.Sombat Thanprasertsuk, Senior expert of preventive medicine/ Department of DiseaseControl (DDC)Dr. Sombat Thanprasertsuk summarized the results of each working group byhighlighting four main streams of work:1. Increasing the scale of VCT2. Creating linkages between VCT and treatment3. Strengthening human resources4. Establishing a dedicated working group to address stigma/discriminationHe also suggested establishing a focal point responsible for building evidence aroundthe four main work streams mentioned above and creating an action plan to drive 24
    • this initiative forward. Leadership should also consider proposing a pilot PrEP projectto 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 VCTClosingDelivered by Dr. Jakkriss BhumisawasdiChief of Inspector General, Ministry of Public HealthReported by Dr. Petchsri SirinirundNational AIDS Management Centre (NAMC)Dr. Petchsri thanked all stakeholders for the intense and fruitful discussions over thepast two days. She commented on how Dr.Gilks’ presentations framed theconversations around treatment as prevention and thanked him for his valuable 25
    • input. While treatment as prevention was acknowledged as a method of bothenhancing the quality of life and reducing the number of new HIV infections,stakeholders voiced a number of concerns that needed to be addressed beforeimplementing such initiatives. The prevention effect of treatment can only startwhen all people including both Thai and non-Thai who need treatment are actuallytreated. One of the first priorities should be to strengthen the system to treat peoplethat are eligible first (<350 CD4 count). Other implementation concerns raised wereARV prices and patents, stigma and building individual ownership of health.Dr. Jakkriss closed the consultation by reminding stakeholders that the success ofthe initiative depends on integration at all levels. He thanked stakeholders for theirparticipation and welcomed comments and suggestions to MOPH based on theoutputs from the consultation.Next StepsIn order to reach the goal of equity of HIV treatment for everyone with a focus onrecruiting KAPs for VCT, the following action items were identified within six majorwork streams:Service Delivery:1. Explore options for decentralized (i.e. community based) system of care and VCT2. Sustain and enhance success of PMTCT program3. Develop strategy to improve coverage of VCT – necessary before treatment strategy can be assessedMonitoring:1. Develop centralized data repository to monitor/evaluate VCT in parallel with building up capacity of data use at service and provincial levelsPolicy:1. Develop practical and concrete recommendations on testing and treatment2. 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 prevention2. Update Asian Epidemic Model estimates on IDUs, Transgenders, and the effects of behavioral inhibitionOperational Research:1. Explore possibility of launching a pilot PrEP program2. Analyze workloads of healthcare personnel to determine current limitations 26
    • Public Communication:1. Develop an education campaign targeted at altering risk behavior, attitudes towards health, and knowledge of health entitlementsNotes from Meeting of Working Group – 22/8/2012Following the National Consultation of the Strategic Use of ARVs, Dr. Petchsriconvened a meeting to discuss key issues raised during the consultation and nextsteps. During the meeting, the group mirrored consensus that the goal in terms oftreatment as prevention is option 5 shown in figure 9 below but with themodification that VCT will be targeted at KAPs and serodiscordant couples since theyaccount for 94% of new infections. Figure 9: TasP ART Eligibility Policy 1 2 3 4 5 CD4 ≤ 200 Recommended Since 2003In order to attain this goal, the group identified the following as key next steps:1. Modeling, cost effectiveness, cost benefit, workload, feasibility, and adherence analyses2. Policy dialogue, advocacy, and operational plan to reach 90% VCT among KAPs3. Policy dialogue, advocacy, and operational plan for treat all seropositive partners in serodiscordant couples regardless of CD4 count4. Consultations on:  Option B+ for pregnant women  Treatment regardless of CD4 count for sex workers, IDU, MSM  Treatment regardless of CD4 count for all5. Consultations on PrEP for:  Seronegative partners in serodiscordant relationships  Seronegative KAPs6. Operational plan for public communications 27