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THAILAND

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THAILAND

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  1. Optimizing PMTCT Program data utilization THAILAND Dr. Suriya Wongkongkathep Ministry of Public Health, Thailand

  2. Thailand PMTCT Headlines • Overview HIV/AIDS surveillance data • PMTCT: Monitoring and Utilization of Data • Key success, Lessons learned and Challenges

  3. Thailand PMTCT • Overview HIV/AIDS surveillance data • HIV surveillance system • HIV seroprevalence among ANC attendant

  4. Thailand PMTCT Evolution of HIV/AIDS epidemic in Thailand First case of AIDS was reported in 1984 Highest peak of HIV infection was 143,000 in 1991, but dropped to 19,000 in 2003 IDU and female CSW were high-risk At the end of 2007, PLWHA remained 610,000 with 53,000 deaths HIV epidemic is changing to a reverse, endemic, and vary among areas and specific populations

  5. HIV/AIDS Surveillance System In Thailand • Passive AIDS case finding using general surveillance report form • HIV Sentinel Surveillance Survey (SSS) • Behavioral Surveillance Survey (BSS) • Perinatal HIV Outcome Monitoring System (PHOMS)

  6. Estimated number of new HIV infection by year, Thailand Number of HIV infection cases 21-29 ปี Source: Integrated analysis and advocacy to improve responses (A2)

  7. Sex ratio in AIDS1989-2006 Ratio ระบบเฝ้าระวังโรคเอดส์โดยการรายงานผู้ป่วย (แบบรายงาน 506/1), สำนักระบาดวิทยา

  8. Thailand PMTCT Trend in annual number of new cases of symptomatic HIV/AIDS per 100,000 population classified by region. No.

  9. Estimated proportion of HIV infection by pattern of transmission, Thailand Source: Integrated analysis and advocacy to improve responses (A2)

  10. HIV Prevalence (%) Sentinel sero-surveillance among most-at-risk population groups Thailand, 1989 - 2007 Peak of new infection 1991 N=97 N=183 N=73 N=128 N=97 N=474 N=48 Surveillance round Remarks : 1. two surveillance rounds during 1989 – 1994 (Rnd 1-12) 2. In 1995 (Rnd13) all CSW included in Indirect CSW Source: Bureau of Epidemiology, MOPH, Thailand

  11. Trends of HIV prevalence among general populations, Thailand 1991 -2006 Army Recruits ANC Clients Source: HIV sero-surveillance, AFRIMS Source: HIV sero-surveillance, Bureau of Epidemiology

  12. Area Distribution of HIV sero-prevalence in Pregnant Women, Thailand 1999-2003 2001 2003 1999 2544 2546 2542 2543 2002 2000 % prevalence 0 2 - 2.9 0.1 - 0.9 3 - 3.9 1 - 1.9 > 4

  13. Trends of HIV prevalence among ANC clients Thailand, 1995 -2006 Source: HIV sero-surveillance, Bureau of Epidemiology

  14. 0.09 (0.05-0.14) 0.07 (0.04-0.10) 0.05 (0.03-0.08) Median HIV Prevalence and BED Estimated Incidence among ANC Pregnant Women in Sentinel Provinces HIV prevalence (%) Prevalence HIV incidence (% per year) BED estimate incidence year Sentinel Provinces: 24 provinces and BMA

  15. Thailand PMTCT HIV Surveillance data Summary • HIV prevalence trends to declinebut BED incidence shows rising • Prevalence increase in some provinces during the last 2 years • Effort was put on 2G Sentinel Surveillance and surveys in specific groups and hard to reach. • BSS discloses prevailing risk among youth.

  16. Thailand PMTCT Challenges • How to jigsaw HIV situation with multiple sources of information • Where, when and how the new infected population might occur • How surveillance data can be used for local action

  17. Thailand PMTCT Headlines • Overview HIV/AIDS surveillance data • PMTCT: Monitoring and Utilization of Data • Key success, Lessons learned and Challenges

  18. Thailand PMTCT Early National Policy on PMTCT 1993 - Importance of HIV/AIDS in children recognized - MOPH began: • Voluntary Counseling and HIV Testing (VCT) for pregnant women • Recommended formula feeding for infants of HIV+ mothers

  19. Thailand PMTCT Pilot PMTCT Program 1995 - MOPH and World Bank reevaluate ARV use: ZDV in pregnant women is the most cost-effective use of ARV 1996-7 Thai Red Cross Society andMOPH begin pilot program providing ZDV to pregnant women and their infants in Zone 10 Activities: 1. Training of health personnel 2. Integration to existing Mother and Child services - Voluntary Counseling and Testing - Provision of ZDV - Provision of infant formula 3. Monitoring & Evaluation

  20. Thailand PMTCT PMTCT as National Policy

  21. Thailand PMTCT National Policy on PMTCT, Thailand (1999) • VCT for all pregnant women • ZDV for all HIV+ pregnant women from 34 wks • ZDV for all infants born to HIV+ women: • 1 wk if mother’s treatment is more than 4 wks • 6 wks if mother’s treatment is less than 4 wks • Infant formula for 12 months to replace breastfeeding • HIV test for infant at 12 months; if +, re-test at 18 months • Appropriate care for mothers and children

  22. - Mothers ZDV from 28 wks gestation Single dose of NVP to mother during labor Infants ZDV for 1 wk (if mother received at least 4wks) or 6 wks (if mother received less than 4 wks) Single dose of NVP to infant within 72 hrs of birth - HIV-exposed Infants Cotrimoxazole from 4-6 wks of age HIV Diagnosis by ELISA at 12 – 18 months No breastfeeding Thailand PMTCT National Policy on PMTCT (revised Dec. 2003)

  23. Thailand PMTCT National Policy on PMTCT, Thailand (revised April 2006) • VCT for all pregnant women • for all HIV+ pregnant women • start ZDV from 28 wks • during labour ZDV 300 mg every 3 hrs.+ NVP 200 mg SD • After delivery to prevent NVP resistance, add ZDV+3TC 1 wk • for all infants born to HIV+ women: • Syr NVP 6 mg SD • Syr ZDV 1 wk if mother’s treatment is >4 wks • Syr ZDV 6 wks if mother’s treatment is < 4 wks • If HIV+ preg women with symptoms or CD4 <200 • ZDV 200 mg q 12 hr + 3TC 150 mg q 12 hr + NVP 200 mg q 12 hr until delivery • Continue treatment during postpartum period • Infant formula for 18 months to replace breastfeeding • HIV test for infant at 12 months; if +, re-test at 18 months (PCR) • Appropriate care for mothers and children

  24. Perinatal Transmission Ratesin Thailand, 1992 - 2003 Formula + AZT>34 wk Breastfeeding no AZT Formula + AZT>36 wk Formula no AZT Formula + AZT>28wk+NVP

  25. Thailand PMTCT PMTCT Results

  26. Early Result of Thai National ZDV Program for PMTCT, 2001-2002 Women who gave birth 1,248,679 -- with ANC1,208,318 (96.7%) -- with HIV test result 1,180,360(97.6%) -- HIV positive 14,283 (1.2%) -- took ZDV 10,441 (73%) Live births to HIV+ 13,957 -- took ZDV syrup12,876 (92.2%) -- took formula 11,680 (81.3%) Estimated infections prevented 2,457

  27. Thailand PMTCT Report of PMTCT Programs 2001-2007 2001 2002 2003 2004 2005 2006 2007 No. of women delivering at ANC 654,572 670,257 645,303 673,030 678,005 589,891 538,643 % of HIV positive 1.3 1.2 1.1 1.0 0.9 0.86 0.79 No.of infants born of HIV+ mother 7,523 7,388 6,537 6,379 5,895 5,050 4,269 No. of infants infected • With no intervention (TR 30%) 2,256 2,216 1,961 1,913 1,769 1,515 1,281 • With MOPH Program (TR 8 %) 602 591 523 510 472 404 342 % HIV + women participate 77.4% 76.2% 79.4% 86% 89.7% 91.9% 93.7% No. prevented cases of infection 1,654 1,625 1,438 1,403 1,297 1,111 939

  28. Thailand PMTCT Program Coverage: 2001-2004 HIV Testing PHIMS: Department of Health 2005

  29. Thailand PMTCT Program Coverage: 2001-2004 ARV and Formula PHIMS: Department of Health 2005

  30. Thailand PMTCT AIDS Cases in Children 0-4 Years from MTCT Thailand, 1984-2006 AZT short course VCT + formula AZT 28 wks + SD NVP Ministry of Public Health, Thailand

  31. Report of new AIDS cases aged 0-14 years during 1984-2006 cases Year Epidemiology Division, Jan 2007

  32. Thailand PMTCT PMTCT Program Monitoring

  33. PMTCT monitoring system 1. To provide information for improving quality of the program implementation 2. To follow HIV prevalence among pregnant women 3. To promote the use of executive summary for health administrators Objectives

  34. PMTCT monitoring system 893 public hospitals nationwide - regular report 80-90 % coverage ~ 700,000 deliveries per yr. - approx. 80-90 % annual deliveries Achievement

  35. PMTCT Program Monitoring PHIMS (Perinatal HIV Intervention Monitoring System) Started in Oct 2000 PHOMS (Perinatal HIV Outcome Monitoring System)

  36. PMTCT monitoring system Main Features 44-item, hospital-based summary record at monthly basis Data entry at site of service (electronic file) Data transferred via diskette or e-mail to generate provincial, regional and national reports Data summarized by month in headlines: Antenatal clinic Perinatal Newborn ART & milk formula Reporting regularity

  37. Process / Output Indicators 888 public (community) hospitals with maternity services 888 Public Hospitals 75 Provincial Health Offices 12 Regional Health Promotion Centers Monthly completes 44 aggregated items PHIMS Hospitals in Bangkok Department of Health BMA  Standard feedback reports generated at provincial, regional, and national levels

  38. PMTCT Key indicators Process-Outputs: PHIMS • % Ante-natal care • % VCT among pregnant women with and without antenatal care • % ARV for PMTCT among HIV-infected pregnant women with and without ANC • # HIV-exposed children born • % received ARV drugs intervention • % received formula substituted breast-fed • % received HIV testing before 2 years old

  39. Output / impact Indicators PHOMS Data Flow: Bureau of Epidemiology MOPH ANC Clinic Delivery Room Well baby clinic Provincial Health Office

  40. PMTCT Key indicators Outcomes-Impact: PHOMS To analyze MTC transmission via infant monitoring (6 provinces) To reduce incidence of HIV-infection among infants born to HIV infected mothers • Pediatric AIDS incidence • MTC transmission rate

  41. Thailand PMTCT Thailand current PMTCT Outcome • Universal ANC service, thus high ANC coverage of pregnant women (98.1%) • High acceptance rate of linked testing (>95%) • High ART coverage (93.3%) • reducing MTCT from 33% to 7.1-8.7% overview, ZDV+NVP is the most effective 3.3% • Prevalence ratio of ANC:Non-ANC is 1:5.4 • PMTCT performed in national standard with good quality of data (regularity 90%)

  42. PMTCT monitoring system Problems too many points of data collection in one hospital Human error due to summarizing case records into digital record Limitation of data analysis due to using aggregate data instead of individuals High drop out in follow up HIV exposed infants (18%)

  43. CHILD record system Commenced in 2004, nationwide 2006 Data entry by individual record of HIV+ mothers & their children More flexibility of data treatment Extensive data analysis including viral transmission, HIV+ care monitoring

  44. Outcome evaluation 2001-2006 (PHOMS) HIV exposed children >18 yr 2,559 Identify HIV status 2,118 (82%) Unable to identify HIV status 441 (18%) delayed report 3 (1%) Dead 51 (11%) Loss FU 387 (88%) Bureau of Epidemiology; April 2006

  45. MTC Transmission Rate (N 2,118) HIV+ N % (95% CI) Bureau of Epidemiology; April 2006

  46. MTC HIV Transmission Rate HIV+ N % (95% CI) Bureau of Epidemiology; April 2006

  47. PMTCT Data Framework BIRTHS Women with ANC Women no ANC HIV + HIV + No ZDV No ZDV ZDV ZDV NB with ZDV +FML NB w/o ZDV +FML NB with ZDV +FML NB w/o ZDV +FML NB with ZDV +FML NB w/o ZDV +FML NB with ZDV +FML NB w/o ZDV +FML

  48. PMTCT Data 2007 538,643 BIRTHS 98.2 % 1.8 % Women with ANC Women no ANC 99.9 % tested 97.3 % tested HIV + HIV + 3.7 % 0.7 % 96.3 % 64.6 % 3.7 % 35.4 % No ZDV No ZDV ZDV ZDV NB with ZDV +FML NB w/o ZDV +FML NB with ZDV +FML NB w/o ZDV +FML NB with ZDV +FML NB w/o ZDV +FML NB with ZDV +FML NB w/o ZDV +FML with formula 93.5 % No. HIV+ M/NB 4,201 With ZDV 99.6 %,

  49. Thailand PMTCT Effectiveness of PMTCT in Thailand % pregnant women % HIVprevalence

  50. Thailand PMTCT Effectiveness of PMTCT in Thailand % pregnant women % HIVprevalence