Paper: Preventing Mother-to-Child HIV Transmission The First Year of Thailand's National Program

July 10, 2002

Preventing Mother-to-Child HIV TransmissionThe First Year of Thailand's National Program

Pornsinee Amornwichet, MPH; Achara Teeraratkul, MD; R. J. Simonds, MD; et alThananda Naiwatanakul, MSc; Nartlada Chantharojwong, MSc; Mary Culnane, MS, CRNP; Jordan W. Tappero, MD, MPH; Siripon Kanshana, MD, MPH

Author Affiliations

JAMA. 2002;288(2):245-248. doi:10.1001/jama.288.2.245

Abstract

Context Each year in Thailand, about 10 000 children are born at risk for mother-to-child human immunodeficiency virus (HIV) transmission. In 2000, Thailand implemented a national program to prevent mother-to-child HIV transmission.

Objective To describe the results of implementation of the program.

Design Monthly collection of summary data from hospitals.

Setting Public health hospitals (n = 822) in all 12 regions of Thailand, representing 75 provinces, excluding Bangkok.

Participants Women giving birth from October 2000 through September 2001, including HIV-seropositive women and their neonates.

Main Outcome Measures Percentages of women giving birth who were tested for HIV, HIV-seropositive women giving birth who received antenatal prophylactic antiretroviral drugs, and HIV-exposed neonates who received prophylactic antiretroviral drugs and infant formula.

Results Among 573 655 women (range, 27 344-77 806 by region) giving birth, 554 912 (96.7%) received antenatal care (range, 91.9%-98.8% by region). Of 554 912 women giving birth who had antenatal care, 517 488 (93.3%) were tested for HIV (range, 87.7%-99.4% by region) before giving birth; of 18 743 women giving birth who did not have antenatal care, 13 314 (71.0%) were tested for HIV (range, 21.7%-92.9% by region). Of 6646 HIV-seropositive women giving birth, 4659 (70.1%) received prophylactic antiretroviral drugs before delivery (range, 55.3%-81.2% by region). Of 6475 neonates of HIV-seropositive women, 5741 (88.7%) received prophylactic antiretroviral drugs (range, 67.4%-96.9% by region) and 5386 (83.2%) received infant formula (range, 65.3%-100% by region).

Conclusions Major program components of Thailand's national program for preventing mother-to-child HIV transmission were implemented. Thailand's experience may encourage other developing countries to implement or expand similar national programs.

Comment

Results of the first year of monitoring Thailand's national program for preventing mother-to-child HIV transmission demonstrate high uptake of major program components and increasing percentages of women being tested for HIV and of newborns receiving prophylactic antiretroviral drugs. Moreover, the high participation in reporting by hospitals suggests that a national monitoring system with a limited number of data items can be implemented successfully. Although the impact of the national program on preventing infant HIV infections is not yet known, we expect the national experience to resemble that of 2 large regional pilot programs in which the mother-to-child HIV transmission rate among HIV-seropositive women who used short-course zidovudine and did not breastfeed was about 8%.^4,5,10,11 A recent cost-effectiveness analysis of these 2 pilot programs showed that $88 to $138 was spent per disability-adjusted life-year gained; 64% of the costs were for HIV testing and counseling.¹²

Thailand's policy of offering HIV testing as a routine part of antenatal care has allowed nearly all women receiving antenatal care to learn their HIV status before giving birth. However, a substantial percentage (12%) of HIV-seropositive women giving birth did not have antenatal care. Offering rapid HIV testing around the time of delivery provided HIV testing to 71% of women who did not receive antenatal care. Women with positive test results could learn their serostatus in time for interventions to reduce mother-to-child transmission risk.

Although the level of antenatal zidovudine alone or with other prophylactic antiretroviral drug use is relatively high in every region, a substantial number of women either did not receive zidovudine or received it for fewer than 4 weeks (which might reduce its effectiveness). Based on a recent evaluation, the most common reasons for not taking zidovudine were not knowing about zidovudine, difficulty attending antenatal care facilities where zidovudine was available, and premature delivery.¹³ Extending administration of infant zidovudine to a duration of 6 weeks for children born to these women should provide additional postexposure prophylaxis.¹⁴ Nevirapine, which is effective even if started during labor,¹⁵ might be a useful addition to zidovudine; this combination is currently being studied in Thailand (S.K., unpublished data, April 2002).

Despite the strength of this monitoring system in collecting information on nearly two thirds of the approximately 900 000 annual births in Thailand, its simplicity precludes collecting data on individuals, infection outcomes of children, reasons for not using program services, or services (eg, provision of infant formula) received outside the program. Other data systems are being developed to collect some of this information. Also, hospitals in Bangkok and those outside the Ministry of Public Health system had not yet contributed data to this system. Data from 2 large Bangkok hospitals, however, corroborate these findings, showing 68% uptake of antenatal zidovudine and 100% uptake of newborn prophylactic zidovudine among 356 HIV-seropositive women who gave birth in 1999-2001.¹⁶

The early success of implementing this program will help support its continuation and national monitoring data will help guide program modifications to further reduce mother-to-child HIV transmission. Moreover, although many circumstances in Thailand that have facilitated program implementation (eg, established antenatal care system infrastructure, clean water, 95% of deliveries occurring in health facilities) may not be present in other countries, Thailand's experience may nonetheless encourage other countries to implement and expand programs to prevent mother-to-child HIV transmission.