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.

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

76 Provinces 12 Regional Health Promotion Centers

Bangkok

10

9

8

6

5

7

34

2

1

11

12

Bangkok

Ministry of Public Health

DOH DDC DMD DOMH

Oversee MCH – PMTCT Program

Regional Hospitals (25)

University/Military/ot

hersProvincial hospitals (69)

District hospitals (734)

Health Centers (10,000+)

Services

delivery

communityCourtesy slide from Nareeluck Kullerk, DOH

0.0 0.0 0.0 0.00.7 0.7 1.0 1.0

1.4 1.5 1.8 1.62.3

1.8 1.7 1.5 1.7 1.5 1.4 1.4 1.2 1.1 0.9 0.9 0.8 0.7 0.7 0.70123456 Sentinel

Sources: 1. Serosentinel surveillance, Bureau of Epidemiology 2. PHIMS, Department of Health

%

HIV Prevalence in Pregnant Women(1989-2012)

0.6

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

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

- New PMTCT policy (AZT (28wks) +SD NVP) - CD4 antepartum and q 6 mos

- HAART for mother (CD4<200, symptoms) during ANC

-Tail regimen (AZT+3TC) - DNA PCR for infant diagnosis

HAART for all HIV-infected pregnant women and couples counseling

Major Milestones PMTCT Program Thailand

PHIMS “Perinatal HIV inventory monitoring system” (76 provinces)

PHOMS “Perinatal HIV outcome monitoring system” (4 provinces (2001), 14 provinces (2004)

NAP “National AIDS Program”

Monitoring PMTCT Program Implementation in Thailand 2000-

2012Perinatal HIV Inventory Monitoring System (PHIMS)

Purpose of monitoring Monitor process & service uptake of PMTCT program

Established by Department of Health

Type of monitoring Routine report

How to collect data Aggregate or summary data

Frequency of report Monthly

Perinatal HIV Outcome Monitoring System (PHOMS)

Monitor outcome or impact of PMTCT program (MTCT rate)

Bureau of Epidemiology

Case registry in surveillance 14 provinces

Individual case report

2 times for each baby-At birth-Confirmed infant diagnosis by DNA-PCR or Ab

Monitoring PMTCT Program Implementation in Thailand 2007

National AIDS Program (NAP)

Purpose of monitoring PMTCT program impact on mother to child transmission rate

Established by National Health Security Office

Type of monitoring Routine report

How to collect data Individual dataFrequency of report When request PCR test for HIV exposed

infant

9

Perinatal HIV Intervention Monitoring System(PHIMS)

Process - output monitoring

PHIMS starts Oct 2000 - current

Dept of Health

Developed by DOH with technical support from GAP Thailand/ U.S.CDC

10

Monthly Report Form

ANC Clinic

Delivery RoomWell Child ClinicHealth Promotion Clinic

PHIMS – Data Collection Form

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

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

PHIMS v3.1 (update)Web-based

Hospital Provincial Health Office

DOHDOH - Server

HPCs

Hospital

Hospital

Data entry & data utilization Data utilization, M&E

•System development & maintenance

•Country data analysis

BMA - DMS

14

94

75

100 100

0

25

50

75

100

ANC No ANC

% Receiving Intervention

2001 2002 2003 2004 2005 2006 2007 20082009 2010

HIV Testing Coverage among Women Giving Birth2001-2010

PHIMS: Department of Health 2011No. women giving birth with ANC ~750,000/yr, No ANC rates ~ 2-3%/yr

15

78

25

93

52

97

66

0

25

50

75

100

ARV ANC ARV NoANC

% Receiving Intervention

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

ARV and Formula Receipt by HIV-positive Mothers (2001-2010)

PHIMS: Department of Health 2011

Coverage of PHIMS Report

52

24

4

93

38

6057

64

94

72

95

89

100

8

62

76

28

62

77

59

48

74

80

49 48

78

67

100

9

61

0

10

20

30

40

50

60

70

80

90

100

Rigion 1 Rigion 2 Rigion 3 Rigion 4 Rigion 5 Rigion 6 Rigion 7 Rigion 8 Rigion 9 Rigion 10 Rigion 11 Rigion 12 BKK (BPP) BKK (Hos) Nation FY 2012 FY 2013

Percent

Page 3

Delivery women had HIV tested99 100 100 100 100 100 100 99 100 99

96 99 100 100 99100 100 100 100 100 100 100 100 100 100 100 100 100 100 100

0

20

40

60

80

100

Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Region 9 Region 10 Region 11 Region 12 BKK (BPP) BKK(Hosp.)

Nation

Fy 2012 FY 2013

percent

Page 6

Delivery women HIV positive

1.1

0.9

1.4

0.8

0.50.5

0.4

0.7

0.6

0.80.7

0.5

0.9

0.70.6

1.0

0.5

0.9

0.7

0.50.5

0.4

0.6 0.6

0.8

0.6

0.5

0.8 0.8

0.6

0

1

2

Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Region 9 Region 10 Region 11 Region 12 BKK (BPP) BKK Nation

FY 2012 FY 2013

Percent

Page 7

Couple counseling ( Pre-test)

1517 18

3

26 2834

26

19

49

10 710

0

191816

17

912

26

4449

24

56

14 17 19

0

23

0

10

20

30

40

50

60

70

80

90

100

Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Region 9 Region 10Region 11Region 12BKK (BPP)BKK (BPP) Nation

FY 2012 FY 2013

Percent

Page 9

Couple counseling ( Post HIV testing)

1210

14

3

22 25 28 24

13

43

105

10

0

1615 16 168

11

30

37

45

24

53

14 15 17

0

22

0

10

20

30

40

50

60

70

80

90

100

FY 2012 FY 2013

Percent

Page 10

Coverage of Syphilis (VDRL) Tested99 97 99

76

100 99 99 97

87

95

68

98100 100

90

98 100 9995

99 99 99 99 100 98

77

98 99 10096

0

20

40

60

80

100

Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Region 9 Region 10 Region 11 Region 12 BKK (BPP) BKK (BPP) Nation

FY 2012 FY 2013

Percent

Page 12

Delivery women who had VDRL positive

0.2 0.0 0.0 0.30.5 0.2

2.2

0.1

1.9

0.70.2 0.1 0.2 0.1

0.60.60.1 0.2

0.00.4

0.0

1.6

0.0

1.01.3

7.7

0.10.2

13.4

1.2

0

5

10

15

Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Region 9 Region 10 Region 11 Region 12 BKK (BPP) BKK (BPP) Nation

FY 2012 FY 2013

Percent

Page 13

0

20

40

60

80

100

Other regimen

HAART regimen

98 96

HIV infected women received ARVPercent

FY 2012 FY 2013

88 100

9298

94 96 97 9497

94 94 9186

9495100

9397 96 96 94

96 97 9490 88

95

Page 16

100 100

0

20

40

60

80

100

Others HAARTAAT only

Children born to HIV positive mother received ARV

Percent

FY 2012 FY 2013

97100 100 98 100 98 100 100 100 99 99 100 100 100 99100 100

35

95100 99 98 100 100 100 100 100

74

Page 20

AZT only

Children born to HIV positive mother received Formula Milk before discharge from hospital

78 78

100

69 71

79

86 8590

83

63

82

8985

77

55

67

25

49

73

8582

77

8384

71

64

56

90

53

0

10

20

30

40

50

60

70

80

90

100

Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Region 9 Region10

Region11

Region12

BKK(BPP)

BKK Nation

Percent

Page 21

Children born to HIV positive mother weight < 2500 gm

16

22

8

13

1818 18

20 21

27

16

1114

27

17

118

12

17

22

15

24

11

2122

16

19

31

40

16

0

10

20

30

40

50

Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Region 9 Region10

Region11

Region12

BKK(BPP)

BKK Nation

FY 2012 FY 2013

Percent

Page 22

0 0 0

0.5

1.8

1.2

0

3.9

0.6

0

0.50.3

0 0

0.6

1.1

0

0.5

0.8

0

1 1

1.6

00

1.5

1.1

0 0

0.7

0

1

2

3

4

5

FY 2012 Fy 2013

Children born to HIV positive mother had birth defect Percent

Page 24

70

13

100

58

43 41

26

40

14

69

61 60

65

20

5156

14

28

70

48

54

30

54

25

6769

60 64

100

47

0

10

20

30

40

50

60

70

80

90

100

Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Region 9 Region10

Region11

Region12

BKK(Hosp.)

BKK Nation

FY 2012 FY 2013

percent

Children born to HIV positive mother Received drugs for prevention of PCP

Page 25

Referral of Children for treatment and careRegion

No. of children diagnosed HIV

infected

No. of children HIV infected enrolled for

treatment Y 2012 Y 2013 Y 2012 Y 2013

Nation 49 35 38 (78%)

30 (86%)

Region 1 2 1 1 (50%)

0 (0%)

Region 2 0 1 0 (0%)

10 (100%)

Region 3 0 6 0 (0%)

6 (100%)

Region 4 1 3 1 (100%)

3 (100%)

Region 5 3 3 2 (67%)

1 (33%)

Region 6 7 8 6 (86%)

7 (88%)

Region 7 2 3 1 (50%)

3 (100%)

Region 8 1 2 1 (100%)

2 (100%)

Region 9 3 0 2 (67%)

0 (0%)

Region 14 1 12 (86%)

1 (100%)

Region 11 11 4 8 (73%)

3 (75%)

Region 12 1 3 1 (100%)

3 (100%)

BKK (hosp.) 3 0 3 (100%)

0 (0%)

BKK. 1 0 0 (0%) 0 (0%)

Page 27

Husband of HIV + mothers received treatment

RegionNo. of

HIV +ve husbandNo.of HIV+ve husband

enroll for ARV treatment FY 2012 FY 2013 FY 2012 FY 2013

Nation 945 846 516 (55%)

290 (34%)

region 1 45 34 27 (60%)

10 (30%)

region 2 3 3 2 (67%)

3 (100%)

region 3 2 77 2 (100%)

71 (92%)

region 4 102 372 42 (41%)

26 (7%)

region 5 66 29 58 (88%)

18 (62%)

region 6 121 65 68 (56%)

27 (42%)

region 7 266 129 38 (14%)

27 (21%)

region 8 41 17 33 (80%)

14 (82%)

region 9 39 6 27 (69%)

5 (83%)

region 10 114 34 103 (90%)

27 (80%)

region 11 85 42 74 (87%)

34 (81%)

region 12 43 23 31 (73%)

17 (74%)

BKK ( hosp.)

15 4 11 (73%)

4 (100%)

BKK 3 1 0 (0%) 0 (0%)

Page 28

Pros & Cons

31

Pros:• Aggregate monthly report is simple and

require minimal efforts • Provide program coverage and identify

gaps quick program monitoringCons:• Cannot collect individualized details• Do not provide program outcome data• Require coordination among different

point of service deliveries (ANC, labor, newborn, Pediatric OPD etc)

National AIDS Program Database(Individualized HIV-exposed infant data

entry to web-based program)

Outcome - impact monitoring

April 2007, orginally developed for AIDS program management

NHSO

Developed by National Health Security Office with technical support for PMTCT outcome report by GAP

Thailand - U.S.CDC

Data Flow

33

Hospitals

NAP at NHSOInternet based with

central server at NHSO

Report PMTCT indicators

Register HIV exposed children and request for EID

14 EID LabsPerform PCR

test and report PCR

results

เขาสเมนทการปองการตดเชอจากแมสลก

PMTCT indicators from NAP

1. Mother to child transmission rate2. Early infant diagnosis coverage3. ARV received by HIV-positive pregnant

women4. CD4 count tested in HIV-positive

pregnant women

Pros & Cons

37

Pros:• No additional workload for 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

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

Thank You for Your Attention