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
76 Provinces
12 Regional Health
Promotion Centers
10
9
6
8
7
5
2
1
4
3
Bangkok
Bangkok
11
12
3
Ministry of Public Health
DOH
DDC
DMD
DOMH
Regional Hospitals (25)
Oversee MCH –
PMTCT Program
University/Military/other
s
Provincial hospitals (69)
District hospitals (734)
Health Centers
(10,000+)
Courtesy slide from
Nareeluck Kullerk, DOH
community
Services
delivery
HIV Prevalence in Pregnant Women
(1989-2012)
%
6
5
Sentinel
4
3
2.3
2
1
0
0.7 0.7
1.0 1.0
1.4 1.5
1.8 1.6
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
0.7 0.6
0.0 0.0 0.0 0.0
Sources: 1. Serosentinel surveillance, Bureau of Epidemiology
2. PHIMS, Department of Health
Major Milestones
PMTCT Program Thailand
HAART for all
HIV-infected
pregnant
women and
couples
counseling
-HAART for mother (CD4<200, symptoms)
during ANC
-Tail regimen (AZT+3TC)
- DNA PCR for infant diagnosis
-New PMTCT policy (AZT (28wks) +SD NVP)
-CD4 antepartum and q 6 mos
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
2000 2001 2002 2003
2004
2005
2006
2007
2008
PHIMS “Perinatal HIV inventory monitoring system” (76 provinces)
2009
2010
PHOMS “Perinatal HIV outcome monitoring system” (4 provinces (2001), 14
provinces (2004)
NAP “National AIDS Program”
Monitoring PMTCT Program Implementation
in Thailand 2000-2012
Perinatal HIV Inventory
Perinatal HIV Outcome
Monitoring System (PHIMS) Monitoring System (PHOMS)
Purpose of monitoring Monitor process & service
uptake of PMTCT program
Monitor outcome or impact of
PMTCT program (MTCT rate)
Established by
Department of Health
Bureau of Epidemiology
Type of monitoring
Routine report
Case registry in surveillance 14
provinces
How to collect data
Aggregate or summary data
Frequency of report
Monthly
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 data
Frequency of report
When request PCR test for HIV exposed
infant
Perinatal HIV Intervention Monitoring System
(PHIMS)
Process - output monitoring
Dept of Health
PHIMS starts Oct 2000 - current
Developed by DOH with technical support from
GAP Thailand/ U.S.CDC
9
PHIMS – Data Collection Form
Monthly Report Form
ANC Clinic
Delivery Room
Well Child Clinic
Health Promotion Clinic
10
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
11
– 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
BMA - DMS
Hospital
Provincial
Health Office
Hospital
DOH - Server
Hospital
Data entry & data utilization
Data utilization, M&E
HPCs
DOH
•System
development &
maintenance
•Country data
analysis
HIV Testing Coverage among Women Giving Birth
2001-2010
2001
2009
2002
2010
100
2003
2004
2005
2006
2007
2008
100
94
100
75
75
% Receiving
Intervention 50
25
0
ANC
No ANC
No. women giving birth with ANC ~750,000/yr, No ANC rates ~ 2-3%/yr
PHIMS: Department of Health 2011
14
ARV and Formula Receipt by HIV-positive Mothers
(2001-2010)
2001
2002
2003
100
2004
2005
2006
2007
2008
2009
2010
97
93
78
75
% Receiving
Intervention
66
52
50
25
25
0
ARV ANC
PHIMS: Department of Health 2011
ARV NoANC
15
Coverage of PHIMS Report
Percent
100
100
95
94
93
89
90
80
80
77
76
100
78
74
72
67
70
64
62
59
60
62
60
61
57
52
49
48
50
40
48
38
28
30
24
20
8
10
9
4
0
Rigion 1
Rigion 2
Rigion 3
Rigion 4
Rigion 5
Rigion 6 Rigion 7
FY 2012
Rigion 8
Rigion 9 Rigion 10 Rigion 11 Rigion 12 BKK (BPP) BKK (Hos) Nation
FY 2013
Page 3
Delivery women had HIV tested
percent
100
99 100
100 100 100 100
100 100 100 100
100 100
100 100 99 100 100 100
99 100
96
100 99 100 100 100 100
100 99 100
80
60
40
20
0
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)
Fy 2012
BKK
(Hosp.)
Nation
FY 2013
Page 6
Delivery women HIV positive
Percent
2
1.4
1.1
1
1.0
0.9
0.9
0.9
0.8
0.8
0.5
0.8
0.7
0.7
0.5
0.5
0.6
0.8
0.7
0.6
0.6 0.6
0.6
0.6
0.5
0.8
0.7
0.5
0.5
0.5
0.4 0.4
0
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)
FY 2012
BKK
Nation
FY 2013
Page 7
Couple counseling ( Pre-test)
Percent
100
90
80
70
60
56
49
50
44
40
34
30
20
10
49
28
26
18
15
17
16
26
26
24
23
19
18 17
9
17
14
12
10
3
19
7
19
10
0 0
0
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
Page 9
Couple counseling ( Post HIV testing)
Percent
100
90
80
70
60
53
50
45
37
40
30
30
25
22
20
12
10
43
16
15
14 16
8
10
28
24
24
14
13
11
22
15
10
3
5
17
16
10
0 0
0
FY 2012
FY 2013
Page 10
Coverage of Syphilis (VDRL) Tested
Percent
100
99 98
97 100
99 99
100 99
95
99 99
99
99 97
100
99
95
98
98
100
99 100
100
96
90
87
80
98
77
76
68
60
40
20
0
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
Page 12
Delivery women who had VDRL positive
Percent
15
13.4
10
7.7
5
2.2
1.9
1.6
0.6
0.2
0
0.0 0.1
0.0
0.2
0.3
0.5
0.0
0.4
0.2
0.0
1.3
1.0
1.2
0.7
0.2
0.1 0.0
0.1
0.1
0.2
0.2
0.6
0.1
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)
FY 2012
Nation
FY 2013
Page 13
HIV infected women received ARV
Other regimen
Percent
100
95
88 100 100
93
97
98 96
92
94 96 96 94
97 96
94
98
97
96
HAART regimen
97
94
94 94
94 95
91 90
86
88
80
60
40
20
0
FY 2012
FY 2013
Page 16
Children born to HIV positive mother received ARV
Percent
100
100
97
100
100
100
98
95
100 100
98
99
100
98
100
Others
HAART
AAT only
only
AZT
100
100 100 99
100 100 100 99 100 99 100 100 100 100
74
80
60
35
40
20
0
FY 2012
FY 2013
Page 20
Children born to HIV positive mother received Formula Milk
before discharge from hospital
Percent
100
100
90
85
90
86
85
83
82
80
78
79
78
71
69
70
83
84
85
82
77
77
73
71
67
63
60
90
89
64
56
55
53
49
50
40
30
25
20
10
0
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
Page 21
Children born to HIV positive mother weight < 2500 gm
Percent
50
40
40
31
30
27
27
24
22
20
18
17
16
13
20
8
21 21
19
18
18
17 16
16 16
15
14
12
11
10
22
22
11
11
8
0
Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Region 9 Region
10
FY 2012
Region
11
Region
12
BKK
(BPP)
BKK
Nation
FY 2013
Page 22
Children born to HIV positive mother
had birth defect
Percent
5
3.9
4
3
1.8
2
1.6
1.5
1.2
1.1
1
0.5
0
0
0
0
0
1.1
1
1
0.8
0.7
0.6
0.5
0.5
0
0
FY 2012
0
0
0
0.6
0.3
0 0
0
0
Fy 2013
Page 24
Children born to HIV positive mother
Received drugs for prevention of PCP
percent
100
100
100
90
80
70
69
70
70
69
67
61
60
58
56
54
60
65
64
60
54
51
48
50
43
47
41
40
40
30
28
30
26
25
20
20
14
13
14
10
0
Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Region 9 Region
10
FY 2012
FY 2013
Region
11
Region
12
BKK
(Hosp.)
BKK
Nation
Page 25
Referral of Children for treatment and care
Region
No. of children
diagnosed HIV infected
Y 2012
Y 2013
No. of children HIV
infected enrolled for
treatment
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
No. of
HIV +ve husband
Region
FY 2012
FY 2013
No.of HIV+ve husband
enroll for ARV treatment
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
Pros:
• Aggregate monthly report is simple and
require minimal efforts
• Provide program coverage and identify
gaps  quick program monitoring
Cons:
• Cannot collect individualized details
• Do not provide program outcome data
• Require coordination among different point
of service deliveries (ANC, labor, newborn,
Pediatric OPD etc)
31
National AIDS Program Database
(Individualized HIV-exposed infant data
entry to web-based program)
Outcome - impact monitoring
NHSO
April 2007, orginally
developed for AIDS program
management
Developed by National Health Security Office with technical
support for PMTCT outcome report by GAP Thailand U.S.CDC
Data Flow
Hospitals
Register HIV exposed children and request for EID
NAP at NHSO
Internet based with central
server at NHSO
14 EID Labs
Perform PCR
test and report
PCR results
Report PMTCT indicators
33
เข้ าสู่ เมนูทกี่ ารป้องการติดเชื้อจากแม่ สู่ ลูก
PMTCT indicators from NAP
1. Mother to child transmission rate
2. Early infant diagnosis coverage
3. ARV received by HIV-positive pregnant
women
4. CD4 count tested in HIV-positive pregnant
women
Pros & Cons
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
37
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