From Research to Practice: HIV/AIDS in

Thailand

Thira Sirisanthana, MDChiang Mai University

Outline: Use the HIV/AIDS epidemic to demonstrate

how RESEARCH help form EVIDENCE-BASED PUBLIC HEALTH POLICY in Thailand

The Thai epidemic in relation to the world’s Thailand’s success from the beginning of the

epidemic until 2551 Commercial sex workers PMTCT Access to HAART

Thailand’s remaining problem areas: IDU, MSM, Youth (and low usage of VCT)

LESSONS LEARNED for กรมควบค�มโรค

Initial Reports

June 5, 2524: 5 cases of PCP in gay men from UCLA (MMWR)

July 3, 2524: 26 additional cases Dec 10, 2524: 3 NEJM papers

describe cases

Gottlieb MS NEJM 2001;344:1788-91From: Glesby MJ, NY/NJ AIDS Education and Training Center

Other Early Developments (1) 2525:

Term “AIDS” coined First cases in women reported First transfusion and vertically transmitted cases reported

2526: Isolation of a retrovirus from a patient with AIDS by

Montagnier’s group

2527: Detection of HTLV-III in pts with and at risk for AIDS (Gallo)

From: Glesby MJ, NY/NJ AIDS Education and Training Center

Other Early Developments (1) 2525:

Term “AIDS” coined First cases in women reported First transfusion and vertically transmitted cases reported

2526: Isolation of a retrovirus from a patient with AIDS by

Montagnier’s group

2527: Detection of HTLV-III in pts with and at risk for AIDS (Gallo)

From: Glesby MJ, NY/NJ AIDS Education and Training Center

2527: The first reported case of AIDS in Thailand

Other Early Developments (2)

2528: FDA approves first commercial HIV antibody test

2529: NIH establishes the AIDS Clinical Trials Groups

(ACTG and PACTG)

2530: AZT = first antiretroviral approved by FDA

From: Glesby MJ, NY/NJ AIDS Education and Training Center

Other Early Developments (2)

2528: FDA approves first commercial HIV antibody test

2529: NIH establishes the AIDS Clinical Trials Groups

(ACTG and PACTG)

2530: AZT = first antiretroviral approved by FDA

From: Glesby MJ, NY/NJ AIDS Education and Training Center

Thai institutes that are research sites for ACTG and PACTG (now called IMPAACT)

IMPAACT: Siriraj Hospital, Chonburi Hospital, Prapokklao Hospital, Chiang Rai Hospital, Bhumibol Adulyadej Hospital, Phayao Hospital, Chiang Mai University

ACTG: Chiang Mai University

Other Early Developments (2)

2528: FDA approves first commercial HIV antibody test

2529: NIH establishes the AIDS Clinical Trials Groups

(ACTG and PACTG)

2530: AZT = first antiretroviral approved by FDA

From: Glesby MJ, NY/NJ AIDS Education and Training Center

Other U.S. NIH–associatied AIDS Thai research sites

Treatment trials: HIVNAT Thai Red Cross (CIPRA and INSIGHT)

Prevention trials: Chiang Mai University (HPTN)

Prevention of mother to child transmission: Thai MOPH / PHPT

Vaccine trials: Thai MOPH (Rayong-Chonburi), Chiang Mai University (HVTN)

Voluntary counseling and testing: Chiang Mai University

Other Early Developments (2)

2528: FDA approves first commercial HIV antibody test

2529: NIH establishes the AIDS Clinical Trials Group

2530: AZT = first antiretroviral approved by FDA

Other Early Developments (2)

2528: FDA approves first commercial HIV antibody test

2529: NIH establishes the AIDS Clinical Trials Group

2530: AZT = first antiretroviral approved by FDA

2531: Beginning of the Thai HIV/AIDS epidemic

Number of new HIV infections by transmission mode

0

20,000

40,000

60,000

80,000

100,000

120,000

Num

ber

new

infe

ctio

ns in

last

yea

r Injection DrugUserMale sex withmaleMale from sexworkerMale from wife

Sex worker

Female fromHusbandExtramarital

From: Peerapatanapokin W, Thai MOPH

Current State of the Thai Epidemic

1,100,000 adults have been infected since start

560,000 adults have died of AIDS 550,000 adults currently living with

HIV or AIDS 14,000 new infections (adults &

children) will occur this year 46,000 adults currently living with

AIDS illness.

From: Peerapatanapokin W, Thai MOPH (2007)

Other Early Developments (2)

2528: FDA approves first commercial HIV antibody test

2529: NIH establishes the AIDS Clinical Trials Group

2530: AZT = first antiretroviral approved by FDA

2531: Beginning of the Thai HIV/AIDS epidemic

Early Antiretroviral Therapy (1)

2534-35: ddI, ddC approved Sequential monotherapy

2536: Concorde: no difference in clinical endpoints

over 3 yrs with early vs. deferred AZT

From: Glesby MJ, NY/NJ AIDS Education and Training Center

Early Antiretroviral Therapy (1)

1991-92: ddI, ddC approved Sequential monotherapy

1993: Concorde: no difference in clinical endpoints

over 3 yrs with early vs. deferred AZT

From: Glesby MJ, NY/NJ AIDS Education and Training Center

1992-1995: AZT monotherapy available to selected (few) Thai AIDS patients

Early Antiretroviral Therapy (2)

2537: ACTG 076: AZT reduces mother-to-child

transmission of HIV Dual nucleoside therapy better than

monotherapy (Delta, ACTG 175, ZDV/3TC)

2537-38: era of dual combination therapy

From: Glesby MJ, NY/NJ AIDS Education and Training Center

Early Antiretroviral Therapy (2)

2537: ACTG 076: AZT reduces mother-to-child

transmission of HIV Dual nucleoside therapy better than

monotherapy (Delta, ACTG 175, ZDV/3TC)

2537-38: era of dual combination therapy

From: Glesby MJ, NY/NJ AIDS Education and Training Center

2541 – “Bangkok study” conducted at the Queen Sirikit Children Hospital of the Thai MOPH shows effectiveness of short-course AZT

Early Antiretroviral Therapy (2)

2537: ACTG 076: AZT reduces mother-to-child

transmission of HIV Dual nucleoside therapy better than

monotherapy (Delta, ACTG 175, ZDV/3TC)

2537-38: era of dual combination therapy

From: Glesby MJ, NY/NJ AIDS Education and Training Center

Early Antiretroviral Therapy (2)

2537: ACTG 076: AZT reduces mother-to-child

transmission of HIV Dual nucleoside therapy better than

monotherapy (Delta, ACTG 175, ZDV/3TC)

2537-38: era of dual combination therapy

1995-2000: Dual therapy available to a few Thai patients, but the majority are on no antiretroviral treatment

1995-2000: Dual therapy available to a few Thai patients, but the majority are on no antiretroviral treatment

2538-43: Dual therapy available to a few Thai patients, but the majority are on no antiretroviral treatment

The New Treatment Era

2538-39: HIV viral load testing became

available Clinicians could directly assess the effect

of antiretrovirals on viral replication (HIV RNA)

First protease inhibitors approved by FDA

From: Glesby MJ, NY/NJ AIDS Education and Training Center

The New Treatment Era

2538-39: HIV viral load testing became

available Clinicians could directly assess the effect

of antiretrovirals on viral replication (HIV RNA)

First protease inhibitors approved by FDA

2538-43: Dual therapy available to a few Thai patients, but the majority are on no antiretroviral treatment

The New Treatment Era

2538-2539: HIV viral load testing became

available Clinicians could directly assess the effect

of antiretrovirals on viral replication (HIV RNA)

First protease inhibitors approved by FDA

From: Glesby MJ, NY/NJ AIDS Education and Training Center

0

5

10

15

20

25

30

35

40

2538 2539 2540 2541 2542 2543 2544

Dea

ths

per

100

per

son

-yea

rs

0

25

50

75

100 Percen

tage o

f patien

t-days o

n A

RT

DEATHS

USE OF ART

Mortality vs. ART utilization

Palella F et al. 8th CROI 2001; abstract 268b.

AIDS Mortality Rates: 2539-44

From: Glesby MJ, NY/NJ AIDS Education and Training Center

Number of projected annual deaths: effect of the Thai MOPH free HAART program

0

10,000

20,000

30,000

40,000

50,000

60,000

From: Peerapatanapokin W, Thai MOPH

Thai government free HAART program started in 2543-6. About 100,000 are receiving treatment as of 2551

Thailand’s success in the control of AIDS

From: Björkman H, UNDP

From: Pattarakulwanich S, Thai Ministry of Public Health

Thailand prevented millions of AIDS death

From: Pattarakulwanich S, Thai Ministry of Public Health

Outline: Use the HIV/AIDS epidemic to demonstrate

how RESEARCH help form EVIDENCE-BASED PUBLIC HEALTH POLICY in Thailand

The Thai epidemic in relation to the world’s Thailand’s success from the beginning of the

epidemic until 2551 Commercial sex workers PMTCT Access to HAART

Thailand’s remaining problem areas: IDU, MSM, Youth (and low usage of VCT)

LESSONS LEARNED for กรมควบค�มโรค

Injecting drug use in Thailand The actual number of users who inject drugs is

not known Estimates range from 100,000 to 250,000

addicts Most of them are males (around 90 percent)

and mostly aged between 20-24 years

From: Khondkar L, Tackling HIV/AIDS among Thai IDU (www.aids2006.org/Web/TUAE0103.ppt)

HIV/AIDS among IDUs About one quarter of all new infections is

occurring through unsafe injecting drug use

Median HIV prevalence among IDUs is as high as 50%

HIV is a major killer of IDUs in Thailand The situation has remained consistent for

nearly 15 years The high prevalence is due to the

frequency of injecting, widespread sharing of needles, and imprisonment of IDUs

From: Khondkar L, Tackling HIV/AIDS among Thai IDU (www.aids2006.org/Web/TUAE0103.ppt)

Limitations in addressing HIV/AIDS among IDUs

Little collaboration between drug control programs and HIV/AIDS response

Narcotic Control legislation does not pay attention to the prevention of HIV among IDUs

Lack of communication between AIDS control authorities, Office of Narcotics Control Board, and those working in drug treatment

Technical skills are not very high in addressing HIV/AIDS among drug users

From: Khondkar L, Tackling HIV/AIDS among Thai IDU (www.aids2006.org/Web/TUAE0103.ppt)

Summarizing the challenges Criminal justice approach taken by government Non-availability of harm reduction programs Limited prevention coverage Ineffective treatment interventions Discriminatory practices in society and health

care facilities Lack of opportunity for IDUs to take part in

decision making process affecting them

From: Khondkar L, Tackling HIV/AIDS among Thai IDU (www.aids2006.org/Web/TUAE0103.ppt)

HIV prevalence among MSM – Bangkok

From: Thai MOPH, U.S. CDC, Thai Red Cross, Family Health International, and Purple Sky

HIV in Thai teenagers 2001 HIV positive 7.1 %2002 HIV positive 7.9 %2003 HIV positive 13.6 %

Anonymous clinic : Thai Red Cross, Bangkok

Casual sex For male group, the value changed from

5% in 1996 to 20% in 2004 For the female, the value changed from

2% in 1996 to 10% in 2004

From: Peerapatanapokin W, Thai MOPH

Outline: Use the HIV/AIDS epidemic to demonstrate

how RESEARCH help form EVIDENCE-BASED PUBLIC HEALTH POLICY in Thailand

The Thai epidemic in relation to the world’s Thailand’s success from the beginning of the

epidemic until 2551 Commercial sex workers PMTCT Access to HAART

Thailand’s remaining problem areas: IDU, MSM, Youth (and low usage of VCT)

LESSONS LEARNED for กรมควบค�มโรค

Lessons learned for กรมควบค�มโรค (1): Use past success as a guidance, even in

the new role as an “academic” Department

Many “facts/evidences” have already been published

Identify specific “gaps” that the Department has to do research to guide MOPH policies

Lessons learned for กรมควบค�มโรค (2) : Research should be “need-driven” NOT

“investigator-driven” The Department needs “block grant” NOT

grant for individual proposal and needs to set specific themes and objectives identified as MOPH priorities

Thank you