(Brief) Overview of the HIV Epidemic and the National HIV/AIDS surveillance

1. (Brief) Overview of the HIV Epidemic andthe National HIV/AIDS surveillance Pasakorn Akarasewi Director, Bureau of Epidemiology Thailand Ministry of Public Health

2. Acknowledgement • Bureau of Epidemiology • Bureau of AIDS, TB and STI • National Institute of Health,DMSc • Disease Control Regional Offices -12 • BMA and 76 Provincial Health Offices • Armed Force Research Institute of Medical Science (AFRIMS) • Thailand MOPH-US CDC Collaboration • People living with HIV/AIDS and local communities.

4. Thailand Health Statistics WHO Report on Health Statistics, 2006

5. The Next Big Things ? Pregnant Women Male withMultiple Partners CommercialSex Workers IntravenousDrug Users Homosexual Children Children 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 -2004 2005-

6. First AIDS Report in Thailand • 28 yeas old Thai male, studied in U.S. with history of homosexual exposure • In 1983, he was admitted at a hospital in USA with Pneumocystis Cariniipneumonia • In 1984, he was referred to Thailand for continuing treatment

7. Interventions  Care and ART  Focus on prevention AIDS in 2 men (homosexual contacts) Rapid spreadingamong IDUs “0%”  “30%” Massive campaign with100% condom Report in blood transfusion Rapid spreading among FSW (44%) Generalized Epidemic:Children born to HIV+ women Thailand HIV/AIDS Epidemic First report  Explosive Epidemic 1984 1989 1991 1987 1988 2000 2007 Concentrated epidemic (MSM, SW and IDUs) • 2007 AEM Estimation: • 14,000 new infections • 1,100,000 cumulative HIV+ • 550,000 Living with HIV

8. Early Surveillance….AIDS case reporting system • Established in 1984 • Voluntary reporting system • Confidential • Hospital-based system • Passive system • To follow the occurrence of AIDS cases

9. Surveillance tools 1. รง.506/1

10. Provincial Health Office 75 Sites Bangkok Metropolitan Administration Regional 1 - 12 Bureau of Epidemiology Office of PermanentSecretary,Ministry of Public Health Other Department and Bureau Epidemiological Surveillances Network

12. Thailand National HIV Surveillance RDS HSS = HIV sentinel sero-surveillance BSS = Behavioral surveillance IBBS = Integrated HIV+STI and BSS PDA = Personal Digital Assisted TLS = Time-Location-Sampling ARV resistance IBBS - FSW IBBS using TLS - MSM Perinatal HIV Infection Surveillance BSS-SAQ BSS-PDA / Audio-PDA BED-CEIA Incidence HSS Passive AIDS reporting 2003 1984 1995 2001 1989 2004 2006 2005 2007

13. Thai HIV Sentinel Serosurveillance Start : June 1989 Site : 14 cities - 31 - 76 Nature : Biannual crossectional : Annually in June 1995 No. Until June 2007 are 25 th round Target : Direct and Indirect P. Male CSWs Male at STD Clinic Pregnant Woman IDUs. Donated Blood Seafarer, Foriegner worker Conscript (Royal Thai Army Military)

14. HIV sero-sentinel surveillance • Bi-annual HIV sero-surveillance among sentinel population in all province of Thailand • First implemented since 1989 • The system was designed to monitor the trend of HIV prevalence

15. HIV sentinel surveillance • 8 sentinel groups • Commercial sex worker: Direct & Indirect • Injection drug users • Male who attended STD clinic • Male in commercial sex worker • Military recruits (army) • Blood donor • Pregnant women who attended ANC

16. IDU Direct SW Indirect SW Male military ANC Explosive HIV Epidemic in Thailand % 40.1 37.5 28.3 3.5 7.6 2.9 2.1 1.4 0 year

17. The First National Policy to Fight with HIV/AIDSOct 21st, 1992 Prevention of HIV/AIDS Policy was announced by the Prime Minister, Chuan Leekpai: • # 8.3.6: Every governmental sectors, private and civil societies play roles in AIDS prevention, including educational and behavioral change communication for Thai population, especially high risk population • # 8.3.7:Set up healthcare services and supportive counseling for HIV/AIDS patients

18. IDU Direct SW Indirect SW Male military ANC Explosive HIV Epidemic and Rapid Response in Thailand National AIDS policy % 28.3 7.6 3.5 5.3 3.5 2.9 2.1 1.4 0.8 0 0.5 year

19. HIV Prevalance among pregnant women by age groups, 1995-2007 year Source: Sentinel Sero-surveillance, Bureau of Epidemiology, Ministry of Public Health

20. HIV Prevalance among pregnant women by gravida, 1995-2007 % Source: Sentinel Sero-surveillance, Bureau of Epidemiology, Ministry of Public Health

21. Percent of pregnant women infected with HIV urban & rural hospital ,1997-2007 % Urban Hospital Rural Hospital Time Source: Serosurveillance, Bureau of Epidemiology, Ministry of Public Health.

22. Reported AIDS Cases by year, Thailand 1984-2007 Number of cases Source: Bureau of Epidemiology, MOPH,Thailand data as of September 30 , 2007

23. Reported AIDS Cases by age, gender, Thailand 1984-2007 Number of cases Source: Bureau of Epidemiology,MOPH,Thailand data as of September 30, 2007

24. Risk Factor of AIDS Cases from 1984-2007, Thailand Source: Bureau of Epidemiology,MOPH,Thailand data as of September 30, 2007

25. Proportion of Opportunistic infection in AIDS Cases Cases reported from 1984 – 2007 % Source: Bureau of Epidemiology, MOPH,Thailand data as of September 30, 2007

26. Number of AIDS and TB/AIDS, Thailand, 1993 - 2007(data up to September,2007) Number of Patient AIDS AIDS/OITB Year Source: Bureau of Epidemiology, MOPH,Thailand data as of September 30, 2007

27. Behavior Surveillance Additional tool to Better understand HIV Dynamism Background • In 1989 HIV/AIDS Surveillance was established • The HIV prevalence continued worrisome • In 1995, a Behavioral Sentinel Surveillance system (BSS) was established and conducted annually

28. Objectives • To follow the trends of high risk sexual behavior among target populations in Thailand

29. 12 Population groups • Male conscripts • Female commercial sex workers • Male and female general population aged 15-49 • Male and female factory workers • Male and female students grade 8th • Male and female students grade 11th • Male and female 2nd year vocational school students

30. Key Information • Demographic data • Gender • Age and year of birth • Marital status • Education • Income

31. Key Information (cont.) • HIV/AIDS related behavior • First sexual experience • Sex experience and condom use within 12 months • STD and STD treatment • Drug use and alcohol consumption • HIV/AIDS knowledge • HIV testing

32. Female school students grade 11th

33. Male factory workers

34. Male conscripts

35. Reports of ever-had-sex among high school students, 1996-2006 % Male Female SAQ PASI Source: Bureau of Epidemiology, Department of Disease Control, MOPH Note SAQ = Self administered questionnaire PASI = Personal digital assisted self interviewing

36. Fig. 5 Proportion of male conscripts, male factory workers and male students who used condoms consistently with commercial sex workers from 1995 – 2005

37. Fig. 11: Proportion of male conscripts, factory workers, and students who had STD symptoms in the past year

38. Monitoring Care and Treatmentfor HIV/AIDS Along with the development of Anti-retroviral Treatment policy And TB/HIV

39. Fig.3 HIV testing and counseling in TB patients among 12 pilot provinces, Thailand, 2005 – 2006 Percent Cohort Year2006 Year 2004 Year2005 Source of data : Bureau of Epidemiology,MOPH Nonthaburi , Thailand

40. National HIV/AIDS ART Treatment Program National Access to ARV Treatment for PLHA (NAPHA) NationalHealthSecurityProgram Global Fund PMTCT national program SocialSecurity Civil servant fund ARV mono and dual therapy under research settings 2002 2003 2004 2005 2006 2007 1997-1998 2000 2001

41. Number of Currently Received ARV, Thailand Up to 130,000 PLHA accumulatively received treatmentin 2007 by different schemes of health care services

42. Thailand National HIV Surveillance RDS HSS = HIV sentinel sero-surveillance BSS = Behavioral surveillance IBBS = Integrated HIV+STI and BSS PDA = Personal Digital Assisted TLS = Time-Location-Sampling ARV resistance IBBS - FSW IBBS using TLS - MSM Perinatal HIV Infection Surveillance BSS-SAQ BSS-PDA / Audio-PDA BED-CEIA Incidence HSS Passive AIDS reporting 2003 1984 1995 2001 1989 2004 2006 2005 2007

43. Among successes, there are failures. The challenges Can we build to last (long)….

44. The gathering storm….and the need to concern

45. HIV, Chlamydia, and Gonorrhoeae Infection among Street Female SW in 2007 RDS survey Prevalence of infection (%) Chlamydia trachomatis Neisseria Gonorrhea HIV

46. HIV Prevalence among MSMIBBS using Time-Location Sampling, 2003-2007 % Thailand MOPH-U.S. CDC Collaboration Sentinel provinces

47. Year

48. HIV incidence (% per year) HIV prevalence (%) 0. 59 (0.35-0.84) 0.47 (0.23-0.71) 0.28 (0.15-0.40) 0.09 (0.04-0.15) Year Median HIV Prevalence and BED Estimated Incidence among Indirect Female SW in Sentinel Provinces

49. Warning Signs of Rising HIV Prevalence • Non-access non-venue based (e.g., street, call girls) sex workers • High HIV prevalence as 18-30% were reported • Un-save sex behaviors, especially among youth • About 20-50% using condom with regular and casual sex partners • Multiple sexual partners • Exchange sex for money or gifts • Persistently high prevalence among IDU and MSM • Indirect evidence on rising trend of HIV incidence by BED-CEIA HIV seroincidence surveillance

50. Current Situation 2007 Estimation, 2008 Report on the global AIDS epidemic