PAPER: Elimination of mother-to-child transmission of HIV: lessons learned from success in Thailand



Writer: Usa Thisyakorn

Title   :


Elimination of mother-to-child transmission of HIV: lessons learned from success in Thailand 




To cite this article: Usa Thisyakorn (2017) Elimination of mother-to-child transmission of HIV: lessons learned from success in Thailand, Paediatrics and International Child Health, 37:2, 99-108, DOI: 10.1080/20469047.2017.1281873

MY SUMMARY:

HIV prevalence in pregnant women has decreased from 2% in the mid-1990s to 0.6% in 2015, and MTCT has fallen from 20–40% to 1.9% (WHO elimination target <2% in non-breast-feeding populations). The use of ART for PMTCT has increased from 64.6% in 1998 to 95.6% in 2015 (WHO elimination target >90%) [38].pp 104

Some supportive factors that contribute to elimination of mother-to-child transmission of HIV in THAILAND, our neighbour-Indonesia, including:


1.     “SAVE CHILD FROM AIDS”
2.   Children are investment for future, HIV-positive child will have burden on social and economic cost
3.     Integrated information system for pregnant women and HIV-positive women in majority of health sectors
4.     Free infant-formula feeding till 12 months
5.     Leadership and cooperation with multisectoral organisations: governments and non-governments, like Thai Red Cross zidovudine donation programme
6.     Non-commerisalisation on ARV medicine [generic] and domestic pharmacist production- only $360/patient/year
7.     The Government provide the funding for the program, not depend on overseas funding, only 4 % by donation since 1997
8.     Political and mass-media comitment, campaign, and investment on condom
9.     Caesarian elective only for late detection of pregnant women, viral load >1000 copies/mL at 36 weeks or previously unknown viral load, poor compliance with ART or late ANC with <4 weeks of ART, no ANC and no ART as well as according to general obstetric indications for Caesarian section
10.  HIV test for pregnant woman in the first ANC
11.  School curiculum on reproductive health for young generation by Ministry of Public Health (MOPH)
12.  Intensive workshop for health workers. School-based education on the risk of HIV transmission Cooperation of health education expert to develop a good curriculum for health students, that containing two main component.
13.  Trained health workers will be a local consultant for their areas.
14.  The Thai national PMTCT guidelines recommend dual methods of contraception for HIV-infected women and their partners
15.  In 2000, the MOPH introduced the Perinatal HIV Intervention Monitoring System (PHIMS) to monitor PMTCT services. PHIMS collects monthly reports from hospitals of HIV testing of pregnant women and their partners as well as ART coverage for PMTCT. PHIMS is integrated into routine hospital reporting activities. Pp 104


ABSTRACT –pp99
In 1988, the generalised HIV/AIDS epidemic in Thailand began and in the same year the first HIV-exposed infant in Thailand was born at King Chulalongkorn Memorial Hospital, Bangkok. From the early to mid-1990s, an epidemic wave of HIV-infected women and infants occurred. Heterosexual HIV transmission, as described in the Asian Epidemic Model, was the major mode of spread in Thailand, causing an increasing number of HIV-infected pregnant women. The early and concerted multi-sectoral response of Thai society reduced the prevalence of HIV infection in pregnant women from 2% in the mid-1990s to 0.6% in 2015 and mother-to-child transmission of HIV (MTCT) from an estimated 20–40% to 1.9%. Thus, Thailand became the first Asian country to achieve the World Health Organization’s (WHO) targets for the elimination of MTCT. In this narrative review, the key historic evolutions of the science and policy of prevention of mother-to-child transmission of HIV (PMTCT) in Thailand that addressed the four prongs of the recommended WHO PMTCT strategy are described, and the lessons learned are discussed. Abbreviations: ANC, antenatal care; ART, anti-retroviral therapy; AEM, Asian Epidemic Model; CMR, child mortality rate; CDC, communicable disease control; EID, early infant diagnosis; EPP, Estimation and Projection Package; FSW, female commercial sex worker; HSM, heterosexual men; HAART, highly active anti-retroviral therapy; IDU, intravenous drug users; MOPH, Ministry of Public Health; NGO, non-government organisation; PACTG, Paediatric AIDS Clinical Trials Group; PLWHA, people living with HIV/AIDS; PHIMS, Perinatal HIV Intervention Monitoring System; PHOMS, Perinatal HIV Outcome Monitoring System; PCR, polymerase chain reaction; PROM, premature rupture of membranes; STI, sexually transmitted infection; TRCS, Thai Red Cross Society; TDR, triple-drug regimen; WLWHA, women living with HIV/AIDS



DIRECT QUOTATION

Prong 3: Prevention of HIV transmission from a woman living with HIV to her infant and Prong 4: Provision of appro- priate treatment, care and support to women and children living with HIV and their families. Thailand has had great success in addressing prongs 3 and 4. In 2015, PHIMS data reported 95.6% of HIV-positive pregnant women and 99.5% of HIV-infected infants received free WHO Option B + through the national PMTCT programme [38]. The Thai 2014 national PMTCT guidelines are in accordance with WHO recommendations for Prongs 3 and 4, and these overlap in interventions aimed at them. Prong 3 includes testing pregnant women for HIV, providing HIV-infected pregnant women with ART as soon as possible and measures to reduce the risk of MTCT. Prong 4 includes HIV testing of women, male partners and children, CD4 testing and clinical staging to deter- mine eligibility for ART in both pregnant women and infants, screening for and treatment of opportunistic infections and linkages to longitudinal child, reproductive and HIV health services [53]. The high ANC rates in Thailand are key as it is the rest part of a ‘cascade’ leading to appropriate ART for mother and infant and access to other health services. Thai guidelines recommend pre- test counselling and voluntary HIV rapid test at the rst ANC visit with same-day results and re-testing later in the pregnancy for HIV-negative women and their partner if possible. Guidance for women presenting late to ANC, at labour, at delivery or post-partum recommends vol- untary testing immediately with same-day results. CD4 testing and referrals and consultations with other health care services are o ered to any seropositive pregnant woman [42].
Reducing the cost of providing ART is crucial to PMTCT programmes in resource-limited settings. Initially in 1996, the expense of the PACTG 076 protocol regimen was prohibitive, and donations from Thai society and foreign NGOs were necessary. Thus, studies establish- ing the eficacy of shorter, less expensive ART regimens were conducted to reduce the cost of therapy. Legal battles were also fought with pharmaceutical companies because of the World Trade Organization’s Agreement on Trade-Related Aspects of Intellectual Property Rights that limited the scope of generic drug production in Thailand since compliant Thai government regulations were introduced in 1998 under threat of sanctions from the United States of America. The solution to prohibitive costs was compulsory licensing of non-commercial (government) use and patent challenges. Thailand’s Government Pharmaceutical Organisation has been producing generic ART since 1995, and the price dif- ference between these generic and patented ART is large. For example, a generic xed-dose triple combi- nation of stavudine, lamivudine and nevirapine cost US$360/patient/per year compared with US$4376 for the patented equivalent in 2007 [54].

Conclusion –pp 107
The prevalence of HIV in pregnant women has decreased substantially during the past two decades. MTCT has been drastically reduced by early and concerted efforts in many sectors. The shared commitment, decision- making, resources and efforts by all sectors of Thai society to achieve the goals of elimination of MTCT have been necessary. The government, NGOs, businesses and Thai communities, including community opinion leaders and PLWHA, have all played a part in an elective multi-sectoral response. Leadership has also been required because the cost of indecision and delay would be high. Every additional HIV-infected child would increase the ultimate economic and social cost to the country. Children are the future. The country’s response to their problems indicates how highly Thailand values its future. Pp 104

pp.105
Infant formula for HIV-infected mothers
Free infant formula continues to be provided by the national PMTCT policy despite the introduction of free, point-of-care WHO option B + in 2014. The MOPH main- tains this policy to achieve <1% perinatal transmission by 2030, and Thailand has an established programme to support infant formula replacement feeding. Perinatal transmission may still be possible in a breast-feeding mother taking the WHO option B+. A study amongst infants and mothers on lifelong ART estimated a rate of transmission at 18 months of 4.1% (95% CI 2.2–7.6) [28]. The vast majority in Thailand also have access to safe drinking water, good sanitation and a guaranteed free supply of infant formula, and mothers and caregivers are usually competent to safely bottle-feed infants and have access to comprehensive child health services. Pp 101
Chikhungu L, Bispo S, Newell ML. Postnatal HIV transmission rates at age 6 and 12 months in infants of HIV-positive women on antiretroviral therapy initiating breastfeeding: a systematic review. In: Updates on HIV and infant feeding guideline. Geneva: WHO; 2016.
Thai Red Cross zidovudine donation programme
The ART regimens for the ‘Save a Child’s Life from AIDS’ programme of the TRCS have also evolved with advances in prevention. At its inception in 1996, zidovu- dine was o ered at any time from 14 to 34 weeks ges- tation until delivery along with peripartum 3 × 100 mg tablets zidovudine q3 h. A single dose of nevirapine for the mother during labour and the newborn within 72 h of birth was added in 2000 after the HIVNET 012 proto- col demonstrated an almost 50% reduction in the risk of postpartum perinatal transmission of HIV during the rst 14–16 weeks in breast-feeding women compared with zidovudine (transmission rates 9.4 and 18.9%, respectively) [34]. In 2004, a triple-drug regimen (TDR) of zidovudine and lamivudine with one of nevirapine, efavirenz or lopinavir/ritonavir was introduced, achiev- ing a transmission rate as low as 1.1% in 1832 pregnant women between 2004 and 2010 at a duration of TDR of 10.4 (7.3–13.4) weeks [35]. Zidovudine for 6 weeks post- partum and free infant formula until 12 months of age have also been provided for all TRCS regimens. Pp 102

Training in HIV counselling and ART has improved.
University experts, public health programme managers at various levels, physicians, scientists, researchers, NGOs and PLWHA developed the curriculum with two components. The first described global and national policy, trends in ART, general HIV knowledge and HIV care including prevention and treatment of oppor-tunistic infections, and ART management. The second focused on specific training in management of the drug supply chain for pharmacists, diagnostic and monitoring laboratory techniques for collecting and sending blood specimens and reagent supply chain management for laboratory technicians, and HIV and ARV counselling for adults and children and adherence issues for counsellors. Multi-sectoral collaboration and partnerships between the Departments of Health, Mental Health and Medical Services, the Thai AIDS Society, NGOs and PLWHA provided the training. Trained health-care professionals who had attended trainer training courses became consult-ants in their local areas [41]. Pp 103
The monitoring of HIV/AIDS in Thailand has improved. Before the national PMTCT policy was introduced, the army and the Epidemiology Division of the MOPH began surveillance in high-risk groups in 1989. Initially, data on pregnant women were collected through ANC ser- vices in 14 provinces, expanding to all 73 provinces by 1990. In 2000, the MOPH introduced the Perinatal HIV Intervention Monitoring System (PHIMS) to monitor PMTCT services. PHIMS collects monthly reports from hospitals of HIV testing of pregnant women and their partners as well as ART coverage for PMTCT. PHIMS is integrated into routine hospital reporting activities. By 2015, PHIMS covered 92% of government hospitals (77% of total deliveries including Thais and non-Thais). To monitor perinatal HIV outcomes, the MOPH created the Perinatal HIV Outcome Monitoring System (PHOMS) in 2001. Initially, 64 public hospitals in four of the coun- try’s 77 provinces submitted data on the number of infants born to HIV-positive mothers, the number of HIV-infected infants and the MTCT rate. This system expanded to 191 facilities in 14 provinces during 2004– 2007. In 2008, the National AIDS Programme to moni- tor national HIV treatment and care services replaced PHOMS. Infant HIV DNA PCR test results reported by the National AIDS Programme are used to calculate MTCT rates. From 2001 to 2012, these rates included HIV- exposed infants who were not tested for HIV or whose test results were not reported. Adjusted MTCT rates from 2013 to 2015 have been calculated using SPECTRUM version 5.4 [38]. Pp 104
Lolekha R, Boonsuk S, Plipat T, et al. Elimination of mother- to-child transmission of HIV — Thailand. MMWR Morbid Mortal Wkly Rep. 2016;65:562–566.
Elective Caesarian section is recommended at 38 weeks of confirmed gestation for HIV-infected women in a setting that is safe and feasible with the following indications: viral load >1000 copies/mL at 36 weeks or previously unknown viral load, poor compliance with ART or late ANC with <4 weeks of ART, no ANC and no ART as well as according to general obstetric indications for Caesarian section. For vaginal deliveries, inva- sive procedures such as foetal scalp electrodes, forceps extraction, vacuum extraction and arti cial membrane rupture are not recommended, unless indicated. This is because MTCT risk is increased by premature rupture of the membrane (PROM)>4 h prior to delivery. If PROM has occurred, labour should be induced to reduce delivery time. Episiotomy should be performed carefully at the correct time to reduce the risk of exposing the newborn to maternal blood and body uid [42]. Pp 104
From the early multi-sectoral response to the HIV epidemic to the evolution of an elective national PMTCT policy under a strong national health care ser- vice, Thailand has successfully eliminated MTCT. In 2015, 98.3% of pregnant women attended an ANC clinic at least once (WHO elimination target >95%). The percentage of pregnant women tested for HIV has increased from 61.9% in the pilot PMTCT projects in 1998 to 99.6% under the national PMTCT policy in 2015 (WHO elimina- tion target >95%). HIV prevalence in pregnant women has decreased from 2% in the mid-1990s to 0.6% in 2015, and MTCT has fallen from 20–40% to 1.9% (WHO elimination target <2% in non-breast-feeding populations). The use of ART for PMTCT has increased from 64.6% in 1998 to 95.6% in 2015 (WHO elimination target >90%) [38].pp 104
Addressing the four prongs of the WHO PMTCT strategy
Prong 1: Primary prevention of HIV in women of childbearing age. WHO recommendations include condom use, information and counselling about the risk of sexual HIV transmission, testing and counselling for pregnant and post-partum women as a part of routine reproductive health services and management of STI in women of reproductive age.
The 100% Condom Programme and public health education campaigns to promote safe sex and discourage high-risk behaviour have been crucial in preventing HIV infection in women of reproductive age by breaking the chain of transmission by HIV-infected FSW to HSM and consequently to non-FSW Thai women.
By 1997, government spending on the programme had increased to US$82 million with only 4% being donations. This political commitment and increased investment included the provision of 60 million free condoms in the 100% Condom Programme and mass media campaigns. These were elective in increasing condom use and decreasing high-risk sexual behaviour amongst men [31].
School-based education on the risk of HIV transmission has been provided by the MOPH since 1990, and conventional HIV/AIDS education has evolved from Thai studies of risky behaviour and its determinants. Pp 105
In 2016, the Thai PMTCT programme includes counselling and voluntary HIV testing as part of a comprehen- sive package of ANC services. Pp 105
ANC services also include testing for hepatitis B, syphilis and other STIs if suspected, and referral to STI services is recommended [42]. The interventions addressing Prong 1 have decreased the estimated number of new HIV infections in adult women from 34,710 in 1992 to 2226 in 2016 [45]. Pp 106
Prong 2: Prevention of unintended pregnancies in women living with HIV.
The Thai national PMTCT guidelines recommend dual methods of contraception for HIV-infected women and their partners to avoid unintended pregnancy as recommended by the WHO based on studies which show that 14–21% of people who use condoms only become pregnant in the rst year of use [51]
Prong 3: Prevention of HIV transmission from a woman living with HIV to her infant and Prong 4: Provision of appro- priate treatment, care and support to women and children living with HIV and their families. T
The high ANC rates in Thailand are key as it is the rst part of a ‘cascade’ leading to appropriate ART for mother and infant and access to other health services. Thai guidelines recommend pre- test counselling and voluntary HIV rapid test at the rst ANC visit with same-day results and re-testing later in the pregnancy for HIV-negative women and their partner if possible. Guidance for women presenting late to ANC, at labour, at delivery or post-partum recommends voluntary testing immediately with same-day results. CD4 testing and referrals and consultations with other health care services are o ered to any seropositive pregnant woman [42].
Thailand. Bureau of AIDS, TB and STIs, Department of Disease Control, Ministry of Public Health. [Essentials of HIV/AIDS Treatment and Prevention; 2014]. Available from: http://thaiaidssociety.org/images/PDF/essentials_of_hiv_ aids_treatment_and_prevention_2014_thailand.pdf
Thailand’s Government Pharmaceutical Organisation has been producing generic ART since 1995, and the price dif- ference between these generic and patented ART is large. For example, a generic xed-dose triple combi- nation of stavudine, lamivudine and nevirapine cost US$360/patient/per year compared with US$4376 for the patented equivalent in 2007 [54].
Ford N, Wilson D, Costa Chaves G, et al. Sustaining access to antiretroviral therapy in the less-developed world: lessons from Brazil and Thailand. AIDS. 2007;21(Suppl 4):S21–29.

The future challenges and evolution of PMTCT in Thailand
Despite significant achievements, challenges remain for Thai PMTCT. Coverage of couple counselling (60% of service outlets in 2014) and testing (only 42% of couples in ANC services) is low. More innovations, training, sta incentives and outcome monitoring are needed to increase levels of service delivery. NonThai pregnant women do not universally access PMTCT services in Thailand, possibly because the service is not free to them through the national PMTCT programme [55]. Thus, funding must be found for this population. Pooled funding from multiple domestic sources has been proposed [56]. More interventions are required to encourage mothers who are HIV-positive to access post-partum care services because 40% do not. The PHIMS monitoring system needs to be expanded to include private hospitals and large hospitals outside the MOPH system [55].

REFERENSI TAMBAHAN

The Asian Epidemic Model (AEM) projections for HIV/AIDS in Thailand: 2005–2025. Family Health International and Ministry of Public Health, Thailand. Available from: http:// www.aidsdatahub.org/sites/default/files/documents/ The_Asian_Epidemic_Model_Projections_for_HIVAIDS_ in_Thailand_2005_2025.pdf


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