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Sorakij Bhakeecheep , MD Director National Health Security Office, Region 1 THAILAND.

National ART Program - NAP Utilization of NAP Monitoring data for Policy Decision “Treatment as Prevention”. Sorakij Bhakeecheep , MD Director National Health Security Office, Region 1 THAILAND. Contents. Brief overview ART program Thailand National patient monitoring system - NAP

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Sorakij Bhakeecheep , MD Director National Health Security Office, Region 1 THAILAND.

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  1. National ART Program - NAP Utilization of NAP Monitoring data for Policy Decision “Treatment as Prevention” SorakijBhakeecheep, MD Director National Health Security Office, Region 1 THAILAND.

  2. Contents • Brief overview ART program Thailand • National patient monitoring system - NAP • Utilization of NAP monitoring data for policy decision “Treatment as Prevention”

  3. ART Program in Thailand Advocate TasP (Any CD4) National Health Security Act(Health promotion, Prevention, Cure and Rehabilitation) ART at CD4<200 ART at CD4<350 National Access to ARV Treatment for PLHIV (NAPHA)(Pilot program under GF and MoPHresearch fund) Universal Access to ART ARV research(mono/dual) PMTCT researches PMTCT National Program 14 13 11 12 06 07 02 03 04 05 1997-98 2000 01

  4. ART Coverage among Persons Living with HIVNumber of PLHA Receiving ART (2001-2013) • Area graph shows estimated persons living with HIV by CD4 levels • Linear graph shows number of currently PWHA retain in the cohort • The coverage is 80% according to CD4<350 PLHA-CD4 ≤ 500 246,049 PLHA-≤ 350 80% Coverage of ART need(CD4<350) Source: AIDS Epidemic Model (AEM), NHSO– NAP, SSO, CSMBS, GF, and Thai GPO

  5. National AIDS Program Monitoring System(NAP) • Implemented in April 2007 • Designed for supporting patient care, fund administration and program monitoring • Web application architecture • Centralized user management system • Individual data collecting with transaction oriented (medications, lab, etc) • National ID encryption to avoid data duplication

  6. Overview of NAP System Architecture Link to Birth-Death Registration from ministry of interior Procurement & Logistics AIDS experts Internet VCT facilities Data Processing NAP Database Fund Administration Program Monitoring Laboratories Internet Policy decision & planning Patient monitoring and quality improvement HIV clinics

  7. Concept of Using Data to InformPolicy Knowledge base Policy Decision Resource Preparation Policy Analysis Information base Input Process Output

  8. Evidence Based of Treatment as Prevention: Clinical vs. Public Health Aspect • Currently, there is insufficient evidence and/or favorable risk-benefit profile to support initiating ART at CD4 >500 or regardless of CD4 …. (Clinical aspect) (Reference: WHO Consolidated Guidelines on The Use of ARV Drugs for Treating and Preventing HIV Infection : p. 93) • Observation from HTPN 052 :- PWHA receiving ART with suppressed viral load would reduce risk of HIV transmission to their partners (Prevention aspect) • In conclusion, the benefits of starting ART at CD4 >500 is not for who’s taking ARV drugs, but for their partners (Public Health Benefit)

  9. What should be considered in addition to efficacy and benefit of an intervention? • Cost-effectiveness (Return of investment) • Negative impacts (Retention & Adherence) • Resources availability (Man, Money) • Feasibility & Sustainability • Prioritization • Equity and ethics How can BIG Data answer these questions ?

  10. PWHA Cascade • Only 54% of PWHA can access to ART • 46% cannot access to ART • Among who cannot access to ART, 37% have been registered but lost during follow up • 47% - loss during pre-ART • 53% - loss during receiving ART Source: AIDS Epidemic Model (AEM), NHSO, SSO, CSMBS, GF, and Thai GPO

  11. Proportion of CD4 at Diagnosis and ART Initiation(2008-2013) Median CD4 CD4 at newly HIV+ diagnosis CD4 at ART Initiation • Nearly half of new HIV+ had very low CD4 (less than 100) at the time of diagnosis and ART initiation • These findings demonstrated late access to HIV care services, thus reflecting the performance of HCT program Performance of HCT Program need to be improved

  12. Cascade Accessing and Retention to Care-ART, (2007 – 2013), NAP Monitoring System, NHSO 23,510 (6%) (82%) (71%) (56%) (43%) (38%) Data source: NAP Database , National Health Security Office

  13. Effectiveness of ART Program (2012) Total Registration to care and treatment services = 326,271 Data source: National Health Security Office Retention rate 87% 70% Retention rate 31% Pre-ART Receiving ART • In pre-ART, loss to follow up occurs 3 times higherthan ART group • A number of PWA who are eligible for ART didn’t receive treatment • In ART group, 70% of who retained to ART has viral load suppression Quality of care in ART program need to be improved

  14. Using Projecting Model to Forecast ART Service Demands Data input from NAP is required in order to calculate service demand from Projecting Model Estimated number of PLHA receiving ART 2014-2019

  15. ART Service Demand Forecasting(UHC Schemes only) Within next 5 years (2019), work load will increase ~20 – 50 %

  16. ART Budget Forecasting(2015-2019) Unit = million USD Additional budget needed from baseline scenario ART Unit Cost (Drugs + Lab) = 352 USD/pt/yr, not include cost of HCT, capacity building, operation) • In the next 5 years, additional budget need for drugs and lab would be 18 – 55 mUSD • To end AIDS in the next 10 years, Thailand would spend totally of 400 mUSD in addition to baseline scenario

  17. Issue on Equity and Priority CD4 < 350 CD4 = 350-500 CD4 > 500 Known HIV status 1 3 5 HIV status unknown 2 4 6 • 43% of PWHIV do not know their HIV status. One-third of which urgently need ART (<350). Barriers stop them from accessing to health services. • Initiating ART at any CD4 just only benefit for people who are already accessed to services, but DO NOT solve the existing barriers in the inaccessible group. In resources limited setting, who should we considered a PRIORITY ? National Health Security Office

  18. Conclusion • TasP could reduce new HIV infection and has showed some potential in ending AIDS • To implement this intervention, some critical issues should be seriously considered • Health infra-structure strengthening (including human resources) for: • Extensive HCT scaling up esp. MARPs • Effective quality improvement to increase early access and retention to ART • Long term budget availability including domestic and external resources

  19. Acknowledgement • National Health Security Office (NHSO) • Thailand MoPH-US CDC Collaboration (TUC) • Bureau of AIDS, TB and STIs, MoPH • All ART centers under UHC network

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