High risk strategy in HIV prevention : What is appropriate and ...

1. 1 High risk strategy in HIV prevention : What is appropriate and effective? Draft of research Proposal  Sakchai Chaiyamahapurk  Ph.D. student Health System and Policy Faculty of Medicine, Naresuan University. Thank you for your kind introduction. Dear respectful audience Mr. chairman lady and gentl men I would like to present a research proposal on Development of an Optimal Policy Strategy for HIV Testing in Thailand: What is appropriate and effective? Thank you for your kind introduction. Dear respectful audience Mr. chairman lady and gentl men I would like to present a research proposal on Development of an Optimal Policy Strategy for HIV Testing in Thailand: What is appropriate and effective?

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3. 3 HIV/AIDS situation Almost 40 million HIV-infected people worldwide In Thailand, estimated 1,092,437 accumulatively HIV-infected person with report of 541,105 death. Early epidemic, transmission mainly through commercial sex worker to men. Currently, shift toward husband and wife � source of infection. (58.1% of new infection in 2005) HIV/AIDS is still a major health problem of any country, including Thailand. 40 million people had been infected worldwide In Thailand, expert committee estimated that there are more than one million accumulatively HIV-infected. Death number is around 5 hundren thousand, so it is the highest burden of all diseases. During early epidemic, transmission mainly occur through commercial sex workers to men. Currently, it shifts toward husband and wife � source of infection, as 58% of new infection in 2005 was via long term sexual partner such as husband and wife. HIV/AIDS is still a major health problem of any country, including Thailand. 40 million people had been infected worldwide In Thailand, expert committee estimated that there are more than one million accumulatively HIV-infected. Death number is around 5 hundren thousand, so it is the highest burden of all diseases. During early epidemic, transmission mainly occur through commercial sex workers to men. Currently, it shifts toward husband and wife � source of infection, as 58% of new infection in 2005 was via long term sexual partner such as husband and wife.

4. 4 This figure shows the trend of transmission mode. The green line represents transmission from sex worker to male which is the greatest proportion during early epidemic as you can see the peak of the line is in 1993. The pink line is transmission from husband to wife which is a major proportion of current transmission.This figure shows the trend of transmission mode. The green line represents transmission from sex worker to male which is the greatest proportion during early epidemic as you can see the peak of the line is in 1993. The pink line is transmission from husband to wife which is a major proportion of current transmission.

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9. 9 High risk VS Population strategy High risk Advantage: Intervention appropriate to individual, Subject motivation, Physician motivation , Cost-effective, Benefit-risk ratio favorable Disadvantage: difficulties and cost of screening, not radical, behaviourally inappropriate Population Advantage: radical, large potential for population, behaviourally appropriate Disadvantage: small benefit to individual, poor motivation of subject, poor motivation of patients, benefit:risk worrisome Rose, G. (2001). "Sick individuals and sick populations." Int. J. Epidemiol. 30(3): 427-432.

10. 10 Population VS High risk strategy in HIV prevention

11. 11 High risk strategy HIV testing Disclosure Pre-exposure prophylaxis Post exposure prophylaxis Safe sex in PWHA Health promotion among PWHA Public health measure Law or regulation?

12. 12 Access to treatment in Thailand In 2002, Thai MOPH initiated National antiretroviral program (NAPHA) . In 2006, program transferred to National Health Security Office. Up to year 2008, it covered >80,000 PWHA. As you know antiretroviral therapy is now standard of treatment. Access to antiretroviral therapy in Thailand is quite promising. After starting in 2002, National antiretroviral program or NAPHA have covered more than 70, thousands PWHA now in 2007. In 2006, program has been transferred to National health Security Office which guarantee the accessibility of all the PWA to care and treatment under universal coverage scheme. As you know antiretroviral therapy is now standard of treatment. Access to antiretroviral therapy in Thailand is quite promising. After starting in 2002, National antiretroviral program or NAPHA have covered more than 70, thousands PWHA now in 2007. In 2006, program has been transferred to National health Security Office which guarantee the accessibility of all the PWA to care and treatment under universal coverage scheme.

13. 13 Anti HIV All people at risk through VCT 2 times per year For PWHA ARV CD4 Hemato, Blood Chemistry 2 times per year

14. 14 Exceptionalism of HIV testing Exceptional from other laboratory testing, due to social stigmatization , voluntary counseling testing was adopted as standard of HIV testing. Three principles as norm confidentiality counseling consent Evolution of HIV testing is different from other laboratory test Due to social stigmatization and discrimination, voluntary counseling testing was adopted as standard of HIV testing. Three principles were established as norm, they are confidentiality counseling And consent Evolution of HIV testing is different from other laboratory test Due to social stigmatization and discrimination, voluntary counseling testing was adopted as standard of HIV testing. Three principles were established as norm, they are confidentiality counseling And consent

15. 15 Paradigm shift? Highly Active Antiretroviral Therapy (HAART) now is standard of care From lethal disease to chronic illness with long term care. A delayed diagnosis results in poor treatment outcome and missed opportunity to reduce transmission of HIV through change of risk behavior. However there is a propose to change this practice of HIV testing by public health practitioner Highly Active Antiretroviral Therapy (HAART) now is standard of care. It has changed clinical course of disease from lethal disease without effective treatment to chronic illness which demands long term care. Many proposed that a delayed diagnosis could results in poor treatment outcome and missed opportunity to reduce transmission of HIV through change of risk behavior. However there is a propose to change this practice of HIV testing by public health practitioner Highly Active Antiretroviral Therapy (HAART) now is standard of care. It has changed clinical course of disease from lethal disease without effective treatment to chronic illness which demands long term care. Many proposed that a delayed diagnosis could results in poor treatment outcome and missed opportunity to reduce transmission of HIV through change of risk behavior.

16. 16 Evidence of delayed diagnosis (USA) Up to 280,000 of 950,000 HIV-infected people in USA unaware of their HIV-positive status. Up to 20,000 new HIV infection annually attributed from unaware people with HIV. 41 % diagnosed as AIDS within a year after knowing of HIV-positive status. There are some evidences of delayed diagnosis In USA Up to one-third of 900 thousand of HIV-infected people unaware of their HIV-positive status. 20,000 new HIV infection annually attributed from unaware people with HIV. 41 % diagnosed as AIDS within a year after knowing of HIV-positive status. These reflect the delay diagnosis of HIV There are some evidences of delayed diagnosis In USA Up to one-third of 900 thousand of HIV-infected people unaware of their HIV-positive status. 20,000 new HIV infection annually attributed from unaware people with HIV. 41 % diagnosed as AIDS within a year after knowing of HIV-positive status. These reflect the delay diagnosis of HIV

17. 17 Awareness of HIV status reduce HIV transmission .(Marks, Crepaz et al. 2005) Meta-analysis show 68% reduce of unprotected anal or vaginal intercourse(UAV) in HIV person compared between person who aware their serostatus with those who not. Increased emphasis on HIV testing and counseling is needed to reduce exposure to HIV(+) from persons unaware they are infected. Ongoing prevention services are needed for persons who know they are HIV(+) and continue to engage in high-risk behavior Also, there are evidences that knowing HIV status could reduce HIV transmission. A Meta-analysis shows 68% reduction of unprotected anal or vaginal intercourse(UAV) in HIV person compared between persons who aware their serostatus with those who do not , so emphasis on HIV testing and counseling is needed to reduce HIV transmission. Moreover ongoing prevention services are needed for persons who know their HIV(+) and continue to engage in high-risk behavior Also, there are evidences that knowing HIV status could reduce HIV transmission. A Meta-analysis shows 68% reduction of unprotected anal or vaginal intercourse(UAV) in HIV person compared between persons who aware their serostatus with those who do not , so emphasis on HIV testing and counseling is needed to reduce HIV transmission. Moreover ongoing prevention services are needed for persons who know their HIV(+) and continue to engage in high-risk behavior

18. 18 Sexual risk behavior in PLWH, USA 70% sexually active 10-60% unprotected sexual behavior Psychological, social, interpersonal and medical variables correlate with sexual risk behaviors. About Sexual risk behavior in PLWH Study in USA show that 70% of PWHA were sexually active 10-60% had unprotected sexual behavior Psychological, social, interpersonal and medical variables correlate with sexual risk behaviorsAbout Sexual risk behavior in PLWH Study in USA show that 70% of PWHA were sexually active 10-60% had unprotected sexual behavior Psychological, social, interpersonal and medical variables correlate with sexual risk behaviors

19. 19 Early detection of HIV by clinical symptom is difficult A study in the Kaiser Permanente Medical care program in USA , looking for early detection of HIV infection,reasonable access to medical care, a high prevalence of HIV infection nearly one half with newly diagnosed HIV infection had AIDS-defining CD4 cell depletion or another AIDS-defining condition at first diagnosis of HIV infection, and 62% need ART at diagnosis effective risk assessment before symptoms arise offers greater potential for raising the mean CD4 cell count at diagnosis than doesincreased awareness of selected HIV-associated clinical prompts. Klein, D., L. B. Hurley, et al. (2003). "Review of medical encounters in the 5 years before a diagnosis of HIV-1 infection: implications for early detection." J Acquir Immune Defic Syndr 32(2): 143-52.

20. 20 Evidence in Thailand A study from Thai red cross clinic in Bangkok, Thailand in 1993/94 showed that 80% having decreased their sexual activity and their number of sexual partners since receipt of the positive HIV test result. more often abstaining from sex (42% vs 14%) more often using condoms during all their last three incidences of sexual intercourse (44% vs 14%). (Muller, Sarangbin et al. 1995)

21. 21 Sexual risk behavior in PWHA, Thailand Young HIV patients treated with antiretroviral in Bangkok consistent condom use at baseline (55.6%) at 3-month visit (58.3%) Sexual acts without a condom in both genders and nondisclosure among males were concerning. Rongkavilit, C., S. Naar-King, et al. (2007). "Health risk behaviors among HIV-infected youth in Bangkok, Thailand." J Adolesc Health 40(4): 358 e1-8.

22. 22 Four types of HIV testing (UNAIDS/WHO) Voluntary counselling and testing : Client-initiated HIV testing Diagnostic HIV testing includes HIV testing for all tuberculosis patients. Routine offer of HIV testing for asymptomatic people by health care providers (PITC?) STD clinic ANC clinic clinical and community based health service settings where HIV is prevalent and antiretroviral treatment is available (IDU, ER, in-patients , out-patients) Mandatory HIV screening for transfusion or for manufacture of blood products

23. 23 Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings, CDC 2006 Diagnostic HIV testing and opt-out HIV screening as routine clinical care Screening for HIV Age 13-64 Setting: ER, urgent-care, IPD, STD, TB, IVDU, community, correctional, primary care clinic Unless prevalence<0.1%(1/1000) All TB, STI patients Repeat screening Annually for high risk ie. CSW, IDU, MSM, partner of PWA

24. 24 Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings, CDC 2006 Consent and pretest information Voluntary and patient can opt-out Informed orally or in written information General informed consent for medical care is enough, no separate consent for HIV testing If patient decline, decision should be documented in medical record

25. 25 Major revisions of CDC recommendation of HIV testing in health-care settings Opt-out screening, patient is notified that testing will be performed unless the patient declines annually test for persons at high risk for HIV infection written consent for HIV testing may not be required; general consent for medical care is sufficient Prevention counseling not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings. HIV prevention counseling- interative process of assessing risk, behaviors, plan to reduce risk

26. 26 For pregnant women HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women. HIV screening is recommended after the patient is notified that testing will be performed unless the patient declines (opt-out screening).

27. 27 Arguments support PITC Reliable and inexpensive screening test Available effective treatment (HAART) Awareness of HIV status decrease HIV transmission Link clinical care with prevention Decrease barrier for testing ( work load for counseling, reluctance of provider and client for sexual risk assessment) Destigmatize the testing process Successful of PMTC program Right to know Impact on equity � due to high levels of fear in people aware of their increased risk can lead to avoidance behaviour, less accessible of information to people with low literacy skills. There are some reasons supporting PITC HIV disease fall in the disease category that screening would do more benefit than harm because of reliable screening test and available effective treatment. Screening would detect early case ,decrease morbidity and mortality. The successful of PMPCT program which can reduce children with HIV through screening of all mother regardless of their risk. Counseling take too much time and may not be time efficient especially in low risk group. Awareness of HIV status decrease HIV transmission Stigmatization during testing process, As it could be risk labeling when provider do HIV risk assessment on clients. This can make physician and patients reluctant to talk openly about sexual risk. There are some reasons supporting PITC HIV disease fall in the disease category that screening would do more benefit than harm because of reliable screening test and available effective treatment. Screening would detect early case ,decrease morbidity and mortality. The successful of PMPCT program which can reduce children with HIV through screening of all mother regardless of their risk. Counseling take too much time and may not be time efficient especially in low risk group. Awareness of HIV status decrease HIV transmission Stigmatization during testing process, As it could be risk labeling when provider do HIV risk assessment on clients. This can make physician and patients reluctant to talk openly about sexual risk.

28. 28 Arguments against PITC Lack of patient �s autonomy Violate human rights Without the three Cs, testing loses its power as a prevention tool VCT not failed , but not adequately financed. Increase negative outcomes of testing False negative results can give false reassurance Resource allocation (cost-effectiveness of intervention) right not to be opportunistically confronted with knowledge about biomedical risks unrelated to reasons for seeing the doctor. Conflict between provider and client (individual and pubic health interest) Arguments against PITC Lack of patient �s autonomy Violate human rights Without the three Cs, testing loses its power as a prevention tool VCT is not failed , but it is not adequately financed and staffed. Increase negative outcomes of testing such as violence on the women after disclosure of test Arguments against PITC Lack of patient �s autonomy Violate human rights Without the three Cs, testing loses its power as a prevention tool VCT is not failed , but it is not adequately financed and staffed. Increase negative outcomes of testing such as violence on the women after disclosure of test

29. 29 HIV testing in Thailand

30. 30 SUPPLY CAPACITY FOR SCALING UP THE VOLUNTARY COUNSELING & TESTING AND ART PROGRAM IN THAILAND Chariyalertsak, S., P. Sanchaisuriya, et al. (2006). IHPP. MOPH 95 hospitals in 8 province in study VCT evolve from in STD clinic at PHO, VCT in PMPCT program ?VCT and ART clinic High coverage across the country-at least one VCT in each district Three components: HIV counseling, voluntary testing, confidentiality Model: one stop service, integrated to general service model and extended clinic

31. 31 SUPPLY CAPACITY FOR SCALING UP THE VOLUNTARY COUNSELING & TESTING AND ART PROGRAM IN THAILAND Chariyalertsak, S., P. Sanchaisuriya, et al. (2006). IHPP. MOPH Service Utilization fiscal year 2005 ANC clinic 53860/54351 Pretest counselling 98.7% HIV testing 99.1 % HIV positive rate 1.21% Return rate for post test counseling 95.8 % Couples service rarely performed �fear of separation� OPD 45619/7810397 Pretest counselling rate 5.73 per 1000 OPD case HIV testing 5.84 per 1000 OPD case HIV positive rate 9.29% Return rate for post test counseling 79.1 % community hospital 97.9 % large hospital 45.8 % In general, hospital do not follow the people who did not return for the test results Waiting time for patient to prepare mind for getting HIV test results

32. 32 SUPPLY CAPACITY FOR SCALING UP THE VOLUNTARY COUNSELING & TESTING AND ART PROGRAM IN THAILAND Chariyalertsak, S., P. Sanchaisuriya, et al. (2006). IHPP. MOPH Model for VCT activation-target groups Sex worker Migrant worker Young worker in industrial unit Adolescent both in and out school Drug user Pre-marriage couple

33. 33 Study from IHPP Thai know ART more than VCT 64% of Thai population knew about ART 50% of Thai population knew about VCT, 31% had ever tested

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35. 35 Premarital testing Sound logically effective to prevent transmission between regular partner Criticized as violation of human right High cost with low yield May be cost-effective in high risk group: cohabitation, marginalized group the counseling alone without testing for low and no risk and testing for the higher risk groups may be more cost effective.

36. 36 Premarital testing in Illinois, USA Start in 1988- 3 years In 6 months period, 8 of 70846 applicants found positive 312,000 US dollar per case identified Decrease of marriage license by 22%, increase in surrounding state.

37. 37 Premarital testing in Mexico 7 of 32 states made mandatory premarital testing Study from 1992-1993 in a state 4 of 9014 (0.04%)applicants found positive, including one false positive.

38. 38 Principles of partner notification (according to WHO) Voluntary Confidentiality Access to appropriate care and support Protection against physical harm such as violence, abuse and abandonment Protection against social and economic harms

39. 39 Methods of partner notification Provider referral Patient referral Conditional referral

40. 40 Factors to consider (2) Time period for eliciting partners Risk of violence Number of partners to trace Staff training (communication skills) Staff time

41. 41 Does partner notification work? Cochrane review of 11 RCT studies of PN effectiveness A systematic review of strategies for partner notification for sexually transmitted diseases, including HIV/AIDS.Mathews C, Coetzee N, Zwarenstein M, Lombard C, Guttmacher S, Oxman A, Schmid G. Int J STD AIDS. 2002 May;13(5):285-300.

42. 42 Finding Provider-led referral (or a choice between provider- and patient-led referral) is more likely to result in partners presenting for medical care when compared to patient-led referral Conditional referral for patients with GC is more effective compared to patient referral Quarrels and domestic violence were reported from 3 studies 6% women had not told their partner due to fear of violence 11-19% of men and women had experienced quarrels and fighting in relation to partner notification Women fear violence, Men fear being brought to court Negative attitudes among health workers were considered a hindrance for seeking STI care Men did not bring partners due to lack of money Difficult to know which partner to bring

43. 43 "Factors associated with non-disclosure of HIV infection status of new mothers in Bangkok." Skunodom, N., R. W. Linkins, et al. (2006). Southeast Asian J Trop Med Public Health 37(4): 690-703. 2 ANC clinic of hospitals in Bangkok N=799 Complete f/u at 1, 4 month= 647 of 799(81%) 453/647=70% disclose at 1 mth 647-453=194 , 48/194=24.7% disclose at 4 mth 22.6% (146/647) still not disclose by 4 month not include those who lost to f/u n=152

44. 44 Disclosure rate

45. 45 Disclosure

46. 46 Rationale for the study High prevalence of HIV infection in Thailand Highly accessible antiretroviral treatment Estimated transmission between the spouses take around 58.1% of new infection in 2005, this might be prevented if people know their HIV status. Uncertainty about Uptake of HIV testing in STI patient Cost-effectiveness of HIV screening in TB patients Delay diagnosis of HIV infection by doctor Feasibility and cost-effectiveness of HIV screening in premarital testing Promotion of safe sex in PWHA Role of partner notification Why this study should be carried out in ThailandWhy this study should be carried out in Thailand

47. The Conceptual framework is hypothesis of the relationship between each step of hiv testing and other related factors. HIV testing leads to awarness of HIV seropositive which in turn makes people decrease or stop unintentional HIV transmission There are many factors that influence HIV testing. Enabling factors for HIV testing are Clients � awareness of HIV risk and available service Free and convenient service Confidentiality Available treatment Explicit guideline for HIV testing Barriers are Fear of stigma Time constraint of health care provider for voluntary counseling testing Awareness of clinician Reluctance of both provider and client for discussion of HIV risk Risk labelling when prescribing HIV testing Language barrier for minority or foreign immigrant worker Informed consent In people who are aware of HIV seropositive, there are also some factors that influence HIV transmission. Enabling of safe sex are Disclosure of HIV status to sexual partner Good social support Restriction by Law? The Conceptual framework is hypothesis of the relationship between each step of hiv testing and other related factors. HIV testing leads to awarness of HIV seropositive which in turn makes people decrease or stop unintentional HIV transmission There are many factors that influence HIV testing. Enabling factors for HIV testing are Clients � awareness of HIV risk and available service Free and convenient service Confidentiality Available treatment Explicit guideline for HIV testing Barriers are Fear of stigma Time constraint of health care provider for voluntary counseling testing Awareness of clinician Reluctance of both provider and client for discussion of HIV risk Risk labelling when prescribing HIV testing Language barrier for minority or foreign immigrant worker Informed consent In people who are aware of HIV seropositive, there are also some factors that influence HIV transmission. Enabling of safe sex are Disclosure of HIV status to sexual partner Good social support Restriction by Law?

48. 48 Purpose of the study To find the optimal and appropriate HIV testing policy and intervention in vulnerable group that will benefit both individual and public health goal.

49. 49 Objectives of study To identify, clarify the practice of the HIV testing in STI patients To propose the practice of HIV testing in TB patients and its cost-effectiveness. To study the outcome of treatment of patient in national antiretroviral program. To study the feasibility of Premarital testing To identify delay diagnosis of HIV infection and barrier of diagnosis of HIV by doctor. To identify the practice of promotion of safe sex in PWHA To identify the practical and effective way of partner notification in HIV patients Objectives of study are What is the evidence of benefit and effectiveness of HIV testing for prevention of HIV transmission What is the current performance of HIV testing in Thailand? What should be the appropriate practice of HIV testing What should be the impacts of expanded HIV testing focusing on psycho-social and ethical aspect? Objectives of study are What is the evidence of benefit and effectiveness of HIV testing for prevention of HIV transmission What is the current performance of HIV testing in Thailand? What should be the appropriate practice of HIV testing What should be the impacts of expanded HIV testing focusing on psycho-social and ethical aspect?

50. 50 Research question 1.What is the practice of the HIV testing in STI patients identifying the current coverage of HIV testing in STI patients with respect to geographic and demographic variations and trends over time; exploring the practice variations of screening programs implemented at the health facilities assessing barrier and enabling factors of HIV testing in STI patients Research question(1) What is the evidence of benefit and effectiveness of HIV testing for prevention of HIV transmission? Research question(1) What is the evidence of benefit and effectiveness of HIV testing for prevention of HIV transmission?

51. 51 2. To propose the alternative practice of HIV testing in TB patients and its cost-effectiveness. What is the most cost-effectiveness way of HIV testing according to HIV prevalence in different area. Another interesting question Another interesting question

52. 52 3. To study the outcome of treatment of patient in national antiretroviral program. What is the outcome, long term survival of patient in national antiretroviral program Is there any improve of CD4 at first visit of patients in later cohort.

53. 53 4.To study the feasibility of Premarital testing What is the most possible model of pre-cohabitation and premarital HIV testing. What is the impact on budget and ethical issue Which model is the most cost-effectiveness model.

54. 54 5. To identify delay diagnosis of HIV infection and barrier of diagnosis of HIV by doctor How much is delay diagnosis of HIV infection in Thailand. What are the barrier and enabling factor for HIV diagnosis by doctor. Another interesting question Another interesting question

55. 55 6.To identify the practice of promotion of safe sex in PWHA What is the role of health provider in promotion of safe sex in PWHA What is the role of HIV community in promotion of safe sex in PWHA What is the role of government, policy and law in promotion of safe sex in PWHA

56. 56 7. To identify the practical and effective way of partner notification in HIV patients How much health provider talked about disclosure during clinical encounters. What approach health provider use for improve disclosure rate in HIV patients. Another interesting question Another interesting question

57. 57 Proposed methodology in the research Literature review Documentary review Observational epidemiological study Cross-sectional survey Cohort study Economic evaluation Qualitative study In depth interview Focus group discussions Literature review Documentary review Observational epidemiological study Cross-sectional survey Cohort study Qualitative study In depth interview Focus group discussionsLiterature review Documentary review Observational epidemiological study Cross-sectional survey Cohort study Qualitative study In depth interview Focus group discussions

58. 58 Current practice, coverage and barrier for HIV testing in STI patients in Thailand. No previous data about coverage of HIV testing in Thai STD patients From expectation: Low coverage Missed opportunity for identifying case in High risk group

59. 59 Practice of provider initiated counseling testing: case study from TB clinic TB/HIV project implementation in many sites across the country Prevalence of HIV in TB ~10% , varying according to geographic area Budget support to hospital increase uptake of HIV testing Suspicion about cost-effectiveness in low prevalence area and low risk group Uptake might depend on attitude of counselor

60. 60 Conclusion HIV testing is seen as a tool for early detection of HIV infected patients for the benefit of individual from early treatment and of public health from prevention of transmission by unawareness HIV-infected patients. Research is needed for guiding HIV testing policy in Thailand such as Current situation of HIV testing , barriers for testing Evidence of delayed diagnosis of HIV Trading off between individual and public health benefit Budget impact and economic evaluation of HIV testing in different scenario.

61. 61 Thank you I would like to Thank Dr. Supasit , Dr. Tawesak and Dr. Mark for their suggestions and revisions Thank you for your attention It is my pleasure to get your comment and suggestion.I would like to Thank Dr. Supasit , Dr. Tawesak and Dr. Mark for their suggestions and revisions Thank you for your attention It is my pleasure to get your comment and suggestion.