thailands experience with using program data to improve pmtct strategies and outcomes. sarawut...
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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 Provinces12 Regional Health Promotion Centers
Bangkok
10
9
8
6
5
7
34
2
1
11
12
Bangkok
Ministry of Public Health
DOH DDC DMDDOM
H
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 0.0
0.7 0.71.0 1.0
1.4 1.51.8 1.6
2.31.8 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
1
2
3
4
5
6Sentinel
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 data
Frequency 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 FormMonthly Report Form
ANC Clinic
Delivery Room
Well 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 Birth
2001-2010
PHIMS: Department of Health 2011
No. 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 2528 24
13
43
10
5
10
0
1615 16 16
811
30
37
45
24
53
14 1517
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
9899 100
96
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
92
9894 96 97
94
97
94 9491
86
9495100
9397 96 96 94
96 9794
9088
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 99
100100
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
11
14
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 care
RegionNo. 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
เข้�าสู่��เมนู�ที่��การป้�องการติ�ดเชื้��อจากแม�สู่��ลู�ก
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
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