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Kiat Ruxrungtham Professor of Medicine Faculty of Medicine, Chulalongkorn University; and

Treatment as prevention How academic sector support for programme implementation on life-long treatment and care . Kiat Ruxrungtham Professor of Medicine Faculty of Medicine, Chulalongkorn University; and HIV-NAT, Thai Red Cross AIDS Research Center Bangkok, Thailand.

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Kiat Ruxrungtham Professor of Medicine Faculty of Medicine, Chulalongkorn University; and

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  1. Treatment as preventionHow academic sector support for programme implementation on life-long treatment and care Kiat Ruxrungtham Professor of Medicine Faculty of Medicine, Chulalongkorn University; and HIV-NAT, Thai Red Cross AIDS Research Center Bangkok, Thailand

  2. Ending AIDS PolicyHow and When? PetchsriSirinirund Advisor on HIV/AIDS Policy and Programme Department of Disease Control, Thailand ICAAP 11, 21 Nov 2013, Bangkok THAILAND

  3. Ending AIDS Working Definition New infection <1000/yr MTCT rate = 0 Target population treatment is well coverage Adapted from Dr. PetchsriSirinirund 50% reduction New Infection In 5 Years End AIDS In 20 years

  4. Is Ending AIDS in Thailand feasible and implementable ? Yes, But……….

  5. Several Factors Support “Yes” • The national AIDS committee has approved this policy together with a significant supported budget • HIV treatment and care system have been well established and continuingly improved in Thailand • Thailand does have a very powerful e-registry database “National AIDS Program plus pr NAP+” and it has been used to monitor and improve the quality of care • Key relevant information are available: HIV care cascade, key-affected populations, key geographical targets • A large implementing research on test &treat in MSM among 8 provinces have been started. This will help to guide the other 27major effected provinces to implement their Test&Treat policy

  6. This NAP+ database are driven by Free ARV supply CD4, VL , DR cost reimbursement Courtesy of Dr. Sorkit

  7. How to detect failure and DR?Time-course of HAART Failure Thai NHSO guidelines: VL q 6 mo, until VL<50, then q 1 yr CD4: q 6 mo, until CD4 >350, q 1 yr CD4 drop Resistance Viral load Non- Adherence Clinical 1 2 3 4 5 Started HAART Time (months –years)

  8. Current Thailand NAP policy for free CD4 and VL monitoring support

  9. WHO 2013 Guidelines Implementation RTTR Diagnosis Efficacy Safety Lab test monitoring

  10. Key steps to Test and Treat Effective Normalize HIV Media MSM Indicators Spousal Tm No. of case BL CD4 increased New Diagnosed Cases With high CD4 count CSWs+ Clients PWIDs Time to Dx to ART % on ART Getting ART % Drop out % VL tested % VL<50 % VF with 2nd Line Retained on ART with good VC Reach Out Routine Testing Annual Check up How to significantly increase testing uptake? In at least 25 of 76 provinces (contributing to 2/3 of total new infection) New infection rate monitoring New infection <1000/y

  11. How academia can contribute in the National Ending AIDS Policy? • Implementation research : to identify proper and effective ways to improve the current HIV care cascade • Reach out approaches : applicability of different settings • Which POC test (CD4, VL) should be used in different settings • Researches to optimize ARV doses or regimens that will further improve treatment adherence • National HIV treatment guidelines 2014 • AIDS expert committee to work with regional/ provincial M&E committee to support improving quality of the TnT services by the use of data generated from the NAP+ db • The Thai AIDS Society (TAS) together with the NAP to support a friendly online consultation system for doctors and nurses from less experienced clinic and comminity-services

  12. How a Country-program Manager Should Design their Proper ART Lab Monitoring Services ? Decentralized Clinical settings QA Centralized Central Laboratory POC diagnostic test POC CD4 test POC VL test (+/-) Simple safety lab tests? DBS VL test DBS DR test • Conventional flow cytometry-based CD4 count • Conventional VL testing • HIV drug resistance testing • Safety lab profiles QA Community-based settings DBS : dried blood spots; QA: quality assurance VL: viral load; DR: drug resistance

  13. Point-of-care CD4 tests BD FACSPresto(BDBiosciences) Pima Analyser,(Alere Inc.) CyFlow CD4 miniPOC (Partec GmbH) Muse Cell Analyzer (Merck)

  14. POC HIV VL in the pipeline (2012)

  15. How National AIDS Program (NAP+) Database Helping Us?

  16. Thailand NAP Retention and Death RatesWorsening among non-ART populations N= 237,000 N= 88,000 Data as of mid of 2013

  17. Lessen Learnt from Bangkok AIDS Committee(BAC)How NAP data-Driven Model can help to Improve HIV Care Quality?

  18. BAC Strategies to Improve the hospital Performances on HIV Care in Bangkok • BAC has meeting q 3-4 months to review and monitor the key indicators of each hospital • Any hospitals with a defined “red alert” indicator especially on low % VL control will be arrange for a supervision visit • Each year, the best performed hospitals by “the targeted criteria : >75% of patients had VL tested and with >75% have VL <50 c/ml” will be awarded during the annual meeting

  19. Proportion Patients with VL<50 c/mlBangkok Only (sites with>100 patients)Overall VL<50 = 71% N= 182 376 N= 124 National AIDS Program (NAP), Thailand. As of October 9, 2008

  20. Reality: Not All Services are Performing WellThailand NAP, Bangkok Region -Achievements N=13,280 in 59 hospitals Bangkok AIDS Program Treatment targets ≥75% of patients are tested for VL once a year, plus ≥75% of patients tested have VL<50 c/ml • 18% (11/59) achieved this ≥75% target • Only 5% of hospitals achieved ≥ 85% of VL<50% Bangkok NHSO, March 2012

  21. Latest performance of hospitals in Bangkok • Overall % patients with VL tested was >75% • And the latest overall % with undetectable VL was >80% • There were however a few hospitals that still require site visit and further support

  22. When to start ART by guidelines

  23. What to start in Resource-limited settings? Three drug combination in Naïve Patients 2 Nucleoside RT Inhibitors + NNRTI or Boosted PIs NtRTIor NRTI NNRTI or Boosted PIs Cytidine Analog + + EFV RPV NVP TDF ABC AZT d4T 3TC FTC + + Alternative LPV/r ATV/r Thai Guidelines 2014

  24. What have we learned from 10 years analyses of the TreatAsia Adult HIV Observational Database (TAHOD) TAHOD nerwork. The 20th IAC, Melbourne, Australia: WEPE070

  25. 10 Years of TreatAsia Adult Cohort N=6521; 21 centers in 12 countries in Asia CD4 baseline increased from 93 (before 2005) to 134 cells/mm3 in 2010-2013 TAHOD nerwork. The 20th IAC, Melbourne, Australia: WEPE070

  26. Factors associated with viral suppression

  27. TreatAsia: TAHOD 10 yrs results

  28. Options after First-line Failure

  29. Standard doses of boosted protease inhibitors (bPIs) associated with a high exposure in Asian van derLugt J, and Avinhingsanon A. Asian Biomedicine Feb 2009

  30. Cost Saving When Using a Lower Dose Atazanavir : from 300 to 200 mg 5 year savings = ≥6900 million Baht to treat 5000 cases with a 5% cases increased/yr

  31. Complete enrollment: Dec 2013, expected results by Jan 2015 ATV/r: atazanavor/ritonavir, PI: protease inhibitor, HAART: highly active antiretroviral therapy, OD: once daily, TDF: tenofovir

  32. WHO 2013 Guidelines Implementation RTTR Diagnosis Efficacy Safety Lab test monitoring

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