Thailand’s experience with using program data to improve PMTCT strategies and outcomes.

1. Thailand’s experience with using program data to improve PMTCT strategies and outcomes. Sarawut Boonsuk, MD. MPH Chief of MCH , Bureau of Health Promotion Department of Health, MOPH, Thailand.

2. Presentation Outlines • PMTCT program over all : • Thailand public health care system • Current situation: • HIV prevalence in pregnant women • Children AIDS case report • PMTCT program Mile stones : from 2000 - 2013 • PMTCT policy • ARV regimen • PMTCT results • PMTCT Monitoring system : • Process/output monitoring • Outcome/impact monitoring system • Electronic national AIDS program database • Conclusion

3. 10 9 6 8 7 5 2 1 4 3 Bangkok Bangkok 11 12 12 Regional Health Promotion Centers 76 Provinces

4. Ministry of Public Health DOH DDC DMD DOMH Services delivery Oversee MCH – PMTCT Program Courtesy slide from Nareeluck Kullerk, DOH community

5. HIV Prevalence in Pregnant Women (1989-2012) % 0.6 Sources: 1. Serosentinel surveillance, Bureau of Epidemiology 2. PHIMS, Department of Health

6. Major Milestones PMTCT Program Thailand HAART for all HIV-infected pregnant women and couples counseling • HAART for mother (CD4<200, symptoms) during ANC • -Tail regimen (AZT+3TC) • - DNA PCR for infant diagnosis • New PMTCT policy (AZT (28wks) +SD NVP) • CD4 antepartum and q 6 mos MTCT-CARE in all provinces - Partner HIV testing - CD4 post partum - Care for mother and family (OI prophylaxis, ARV) National PMTCT policy -Short course AZT (34 wks) -Formula feeding (12 mos) -HIV antibody testing for infants born 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 PHIMS “Perinatal HIV inventory monitoring system” (76 provinces) PHOMS “Perinatal HIV outcome monitoring system” (4 provinces (2001), 14 provinces (2004) NAP “National AIDS Program”

7. Monitoring PMTCT Program Implementation in Thailand 2000-2012

8. Monitoring PMTCT Program Implementation in Thailand 2007

9. Perinatal HIV Intervention Monitoring System (PHIMS) Process - output monitoring Dept of Health PHIMS starts Oct 2000 - current Developed by DOH with technical support from GAP Thailand/ U.S.CDC

10. PHIMS – Data Collection Form Monthly Report Form ANC Clinic Delivery Room Well Child Clinic Health Promotion Clinic

11. PHIMS - Variables • Data summarized from ANC, labor room, nursery logbooks • number of women • delivered, • delivered with ANC, without ANC • had HIV test • HIV+ • Received AZT, Received AZT +other ARV • Received other ARV • Number of infants to HIV-infected mothers • Live birth, received ARV • Received formula before discharge

12. PHIMS v3.1 – Additional Variables • Women received couple counseling • Pretest couple, posttest couple • HIV-positive women received HAART for treatment or for PMTCT • VDRL test • VDRL positive • Syphilis diagnosis and treatment • HIV-positive women, partners, children referred to HIV Care Program

13. PHIMSv3.1 (update)Web-based BMA - DMS Hospital Provincial Health Office HPCs DOH - Server Hospital DOH • System development & maintenance • Country data analysis Hospital Data entry & data utilization Data utilization, M&E

14. HIV Testing Coverage among Women Giving Birth 2001-2010 No. women giving birth with ANC ~750,000/yr, No ANC rates ~ 2-3%/yr PHIMS: Department of Health 2011

15. ARV and FormulaReceipt by HIV-positive Mothers (2001-2010) PHIMS: Department of Health 2011

16. Coverage of PHIMS Report Percent Page 3

17. Delivery women had HIV tested percent Page 6

18. Delivery women HIV positive Percent Page 7

19. Couple counseling ( Pre-test) Percent Page 9

20. Couple counseling ( Post HIV testing) Percent Page 10

21. Coverage of Syphilis (VDRL) Tested Percent Page 12

22. Delivery women who had VDRL positive Percent Page 13

23. HIV infected women received ARV Percent 88 97 100 100 98 98 96 97 96 96 96 97 97 96 94 95 95 94 94 94 94 94 94 93 92 91 90 88 86 FY 2012 FY 2013 Page 16

24. Children born to HIV positive mother received ARV Percent AZT only 100 100 100 100 100 100 100 100 100 100 100 100 99 100 100 100 100 100 100 100 99 99 99 98 98 98 97 95 74 35 FY 2012 FY 2013 Page 20

25. Children born to HIV positive mother received Formula Milk before discharge from hospital Percent Page 21

26. Children born to HIV positive mother weight < 2500 gm Percent Page 22

27. Children born to HIV positive mother had birth defect Percent Page 24

28. Children born to HIV positive mother Received drugs for prevention of PCP percent Page 25

29. Referral of Children for treatment and care Page 27

30. Husband of HIV + mothers received treatment Page 28

31. Pros & Cons • Pros: • Aggregate monthly report is simple and require minimal efforts • Provide program coverage and identify gaps  quick program monitoring • Cons: • Cannot collect individualized details • Do not provide program outcome data • Require coordination among different point of service deliveries (ANC, labor, newborn, Pediatric OPD etc)

32. National AIDS Program Database (Individualized HIV-exposed infant data entry to web-based program) Outcome - impact monitoring NHSO April 2007, orginally developed for AIDS program management Developed by National Health Security Office with technical support for PMTCT outcome report by GAP Thailand - U.S.CDC

33. Data Flow Hospitals Register HIV exposed children and request for EID NAP at NHSO Internet based with central server at NHSO 14 EID Labs Perform PCR test and report PCR results Report PMTCT indicators

35. เข้าสู่เมนูที่การป้องการติดเชื้อจากแม่สู่ลูกเข้าสู่เมนูที่การป้องการติดเชื้อจากแม่สู่ลูก

36. PMTCTindicators from NAP Mother to child transmission rate Early infant diagnosis coverage ARV received by HIV-positive pregnant women CD4 count tested in HIV-positive pregnant women

37. Pros & Cons • Pros: • No additional workloadfor data entry since using routine program electronic individualized data. Hospital has to key in the PCR testing request and lab has to key in result (as part of PCR cost reimbursement so data is quite complete) • Cons: • Denominator is infant requested for PCR test, cannot capture dead/loss to follow up infants

38. Acknowledgements • Dr. Nipunporn Voramongkol and Ms.Nareeluck Kullerk, Department of Health, MOPH • Bureau of Epidemiology, MOPH • Thananda Naiwatanakul, Technical Advisor, PMTCT & Pediatric Section, GAP Thailand and Asia Regional Office, Thailand MOPH – U.S. CDC Collaboration

39. Thank You for Your Attention