[Tlc] T-Informal Northern Thai Group update

[justinm at ucr.edu]

FYI.
Thanks,
justin


Informal Northern Thai Group Bulletin

4 April 2009


Minutes of the 310th meeting - Tuesday March 17th 2009

HIV research and public health in Thailand: prevention and care

A talk and presentation by Dr. Marc LALLEMANT,
the director of Perinatal HIV Prevention Trials (PHPT)
and his colleague Dr. Gonzague JOURDAIN

Present: Linda Rochester, Christa Süllner, Mark Tuckson, Rebecca Weldon
Sithiwong, Mark and Dianne Barber-Riley, Nance Cunningham, Oliver
Hargreave, Louis Gabaude, Klaus and Heidi Berkmüller, Kongkaew Inthanon. An
audience of 12 plus a few more.

A brief summary of Marc and Gonzague's presentation

This summary is adapted from a paper published in "AIDS in ASIA" (Max
Essex: Editor), Kluwer Boston; 1st ed. (Jul. 14, 2004) with information
available on www.phpt.org

BACKGROUND
Of all Asian countries, Thailand was one of the first and hardest hit by
the first Human Immunodeficiency Virus (HIV-1) pandemic. A national
surveillance system was implemented in 1989 to monitor the spread of the
epidemic to the general population: in 1994, the prevalence of HIV
infection in pregnant women presenting at the antenatal clinics exceeded
10% in highly impacted regions such as Phayao, which is located in the
Northern part of the country. With the nationwide prevention campaigns, the
prevalence rates in pregnant women dropped significantly. In June 2006, the
prevalence rate of HIV-1 among pregnant women was less than 1% nationwide,
with the highest rates found in the Central and Eastern provinces of the
country. Despite this outstanding progress, many infants in Thailand are
still born to an HIV infected mother and are at risk of acquiring the Human
Immunodeficiency Virus (HIV) causing the Acquired Immune Deficiency
Syndrome (AIDS). Thailand currently has an estimated 570,000 people living
with HIV.
Thai response to the epidemic
The Royal Thai Government responded quickly to the HIV/AIDS epidemic and
implemented a multi-sector AIDS program. At its onset, this program
involved all government ministries, non-governmental organizations,
multilateral donors and private businesses. Cooperation at the national
level among ministries was carried out through the National AIDS Prevention
and Control Committee chaired by the Prime Minister.

THE NATIONAL AIDS PROGRAM PARTICULARLY FOCUSED ON:

1. Public information, education and prevention
As early as 1989, bi-annual sentinel surveillance surveys were conducted in
each province among drug users, direct and indirect commercial sex workers,
military recruits, blood donors, and antenatal care women. The data
collected highlighted the most affected provinces and documented the
dynamic of the epidemic spreading from one group of high- risk behaviors
such as sex workers to other sectors of the general population such as the
military recruits. The publication of these prevalence results in the
national newspapers, illustrating the visible progression of the epidemic,
was instrumental in raising public/government awareness towards the spread
of the HIV/AIDS.
The government responded with several national campaigns, bombarding the
public with information on HIV/AIDS using all forms of mass media as well
as innovative and powerful methods of communication. For example, a
nationwide network of volunteers was mobilized to distribute cards,
audio-cassettes and videos containing information about AIDS. Condom use
was heavily promoted through the 100% condom use campaign in which the
active involvement of the charismatic public figure, Mechai Viravaidya was
critical for its success. Finally, HIV testing was rapidly made available
in all government hospitals and in many private facilities.  The
comprehensive monitoring and surveillance system in place since 1989
enabled the documentation of the success of these prevention programs in
curtailing the spread of the epidemic. Indeed, the impact of these
preventive measures was particularly visible in the North. For example, the
prevalence rates in pregnant women dropped from more than 10% to less than
5% between 1994 and 1997 in the Phayao province, to around 2% today. The
surveillance system also allowed observers to follow the epidemic,
demonstrating the overall HIV prevalence decline in commercial sex workers
and in the general population, while pointing out the relative failure of
the campaign among intravenous drug users

2. Human rights and social support
A national counseling plan was launched in 1990 including training of
counselors, and promotion of voluntary anonymous HIV counseling and testing
at the national level. This plan was expanded in 1993 to provide training
for nurses in the antenatal care setting. In addition, the government took
a clear stand against the discrimination of HIV-infected individuals and
the protection of their rights. For example, calls for mandatory blood
testing and result disclosure were strongly opposed to.

The government also supported many Non Governmental Organizations (NGOs)
involved in various aspects of HIV/AIDS prevention and care including home
care, building AIDS patients network, income generating activities, family
support groups, etc. For example, the Thai Business Initiative in Rural
Development, a project aimed at diverting young rural women from
prostitution by providing them with training and employment.

3. Promotion of research
Important epidemiological, clinical, virological and socio-behavioral
research programs conducted in Thailand were encouraged and supported by
the Ministry of Public Health. The research allowed a better understanding
of the dynamic of the epidemic and documented uniquely in the world the
success of the prevention campaigns (Nelson et al, 1996). These research
programs also helped instigate pilot projects, which were launched at the
regional level, and proved to be crucial in guiding interventions and
policies at the national level. The close collaboration between researchers
and policy makers at the Ministry of Public Health was particularly
effective in the field of mother-to-child prevention. Finally, Thailand was
and continues to be actively involved at the forefront of the global
research effort towards an HIV/AIDS vaccine, coordinated by a National HIV
vaccine committee of knowledgeable experts.

4. Medical treatment and care
The use of zidovudine (AZT), the first antiretroviral with proven clinical
efficacy, was approved in 1987, and until the mid nineties it was provided
by the Ministry of Public Health to HIV-infected patients. The Thai Food
and Drug Administration (FDA) then rapidly allowed the importation of many
other antiretrovirals. Later, an agreement between the Thai government and
the manufacturer of AZT allowed the Government Pharmaceutical Organization
(GPO) to purchase the drug in bulk at a competitive price. In 2002, the GPO
started producing several generic antiretroviral fixed dose combinations
(ARV) including GPOvirS® and GPOvirZ® pills to be taken twice a day opening
access to triple therapy at affordable price (1200 Baht per month in 2004).
With the expansion of access to treatments through the national program, in
2009 over 197,000 persons receive antiretroviral treatments under the
universal coverage system. Approximately 50,000 receive treatment from
other programs.

A success story : Prevention of mother-to-child transmission program
Within the national HIV/AIDS prevention program, Thailand specifically
targeted mother-to-child transmission of HIV.

>From as early as 1990, even before any measures to reduce mother-to-child
transmission of HIV were discovered, some hospitals were conducting HIV
testing for pregnant women. At that time, this practice reflected general
fears among health care workers who felt the need to know the HIV status of
their patients in order to protect themselves. However, when discovered to
be HIV-positive, most women were informed of their HIV status.
Theoretically, the women could then make a decision with regard to the
continuation of their pregnancy; decide about infant feeding mode,
post-partum contraception and prevention of sexual transmission to their
partners. At this time, most women confirmed as HIV positive had their
pregnancy terminated, while many of those who continued with their
pregnancy were sterilized thereafter. This trend reflected the fact that
most health care workers felt they had nothing to offer these women who
were often perceived as unable to manage a pregnancy and raise a child.
This attitude amongst the health care workers changed significantly, from
1993, when the intense training on HIV counseling provided by the Ministry
of Public Health was extended to nurses within the antenatal care settings.

In the same year, in response to the clear evidence that HIV could be
transmitted through breastfeeding, the Ministry of Public Health
recommended formula feeding to HIV-infected women only, while continuing to
support the UNICEF Baby-Friendly Initiative and promoting breastfeeding in
the general population. In the public hospitals, formula milk was provided
for free to the poorest of HIV-infected women until the child reached 18
months of age. The Ministry of Public Health ensured that this
recommendation was only targeted towards HIV-infected women who could then
decide on the safest mode of feeding for their infants.

As soon as the results of a clinical trial in the United States and France
were released in 1994, demonstrating the remarkable efficacy of zidovudine
(AZT) in reducing perinatal transmission of HIV, the Ministry of Public
Health reevaluated its HIV treatment program and concluded that, given
Thailand's budget for antiretrovirals and the quality of its health care
infrastructure, AZT prophylaxis for HIV-infected pregnant women and their
newborns was feasible, affordable and by far the most cost-effective way to
use the budget for antiretrovirals compared to the use of AZT mono-therapy
for patients. At about this time, the Thai Food and Drug Administration
approved the use of AZT for the prevention of perinatal HIV.

By 1996-1997, after completing preliminary research studies, the Thai Red
Cross began providing AZT to HIV-infected pregnant women in its affiliated
hospitals throughout the country using funds raised with the help of
members of the royal family. Knowing that most mother-to-child transmission
occurs close to delivery, the Ministry of Public Health quickly initiated
in northern Thailand a pilot perinatal HIV prevention program using a short
course AZT treatment. This program was established in collaboration with a
large clinical trial, the Perinatal HIV Prevention Trial (PHPT-1, see
www.phpt.org) conducted by Harvard University and the French Institut de
Recherche pour le Développement (IRD). The main objective of this trial was
to compare the efficacy of abbreviated AZT treatments in mothers and/or
children with the regimen tested in the US and France. PHPT-1 demonstrated
that a short course of AZT prophylaxis (delayed until 35 weeks gestation,
and for 3 days in the newborn) was less effective than a long one (from 28
weeks gestation and 6 weeks in the newborn) with transmission rates of
10.5% versus 4.1%, respectively. Both programs, the Ministry of Public
Health program in the North and the PHPT-1 research study complemented each
other greatly and both benefited from the other's program in terms of
training, coverage, and capacity building.

In December 1999, the Ministry of Public Health convened a meeting to issue
national guidelines on perinatal HIV transmission prevention, based on
evidence from clinical trials, along with the pilot programs and the
Ministry of Public Health decided to launch its first nationwide perinatal
transmission prevention program.

These great achievements were made possible due to a variety of factors:
the pragmatic approach of the Ministry of Public Health using the latest
scientific knowledge from clinical research, testing them through pilot
projects before scaling up to the national level; emphasizing on training
particularly on HIV counseling, the high quality of HIV testing and health
care system delivery.

The most striking results of the Prevention of Mother to Child Transmission
of HIV (PMTCT) program is uniquely illustrated by the dramatic drop in
number of pediatric AIDS cases reported to the Ministry of Public Health,
although this also reflects the impact of the public campaigns on the
prevention of sexual transmission.

Following the results of another trial in Uganda demonstrating the efficacy
of one dose of nevirapine (NVP) at onset of labor and 2 days after birth in
the newborns, the Perinatal HIV Prevention Trial 2 (PHPT-2; see
www.phpt.org) tested the addition of one single oral 200 mg dose of
nevirapine at onset of labor and one 6 mg dose for the newborn 48 to 72
hours after birth to the standard AZT regimen. The transmission rate in
women who received zidovudine (AZT) plus nevirapine (NVP) was 2.0%,
significantly lower than the 6.3% transmission rate experienced by women
who received AZT alone. This simple regimen of AZT during the last
trimester of pregnancy combined with a single dose of NVP at onset of labor
is able to achieve transmission rate as low as those obtained using a
triple combination regimen, or Highly Active Antiretroviral Therapy (HAART)
during pregnancy. Following the remarkable results of this trial, the
Ministry of Public Health has again responded in a pragmatic manner,
convening a meeting of experts and reviewing its national guidelines for
the prevention of mother-to-child transmission of HIV in order to advance
the initiation of AZT from 28 weeks gestation and incorporate nevirapine
(NVP) in the prevention package. Also, the World Health Organization (WHO)
decided to recommend this treatment for pregnant women who do not need
immediate combination therapy for their own health.

Moving towards Access to Highly Active Antiretroviral Therapy (HAART)
The extension of the Prevention of Mother to Child Transmission of HIV
(PMTCT) program to include long term provision of Highly Active
Antiretroviral Therapy (HAART) to immuno-compromised mothers and to the few
infected children is referred to as "PMTCT Plus". For example,
immuno-compromised HIV-infected mothers and infected children who had
participated in the Perinatal HIV Prevention trials have received
antiretroviral fixed dose combinations (ARV) drugs since 1999 and continue
to be closely monitored. The follow-up of these cohorts has demonstrated
that "PMTCT Plus" was feasible, well accepted and highly beneficial to the
patients involved. "PMTCT Plus" was also identified as a unique opportunity
to reach out and treat HIV-infected fathers/partners so that both parents
can care for their children.
In May 2001, during the Third International Symposium on Pediatric AIDS in
Thailand, in a public Declaration, the clinicians, researchers and public
health officers requested from the Ministry of Health the provision of
Highly Active Antiretroviral Therapy (HAART) to infected mothers, children
and families within the Thai national Prevention of Mother to Child
Transmission of HIV (PMTCT) program.

With the increasing production of generic drugs worldwide, the price of
antiretroviral fixed dose combinations (ARV) drugs has dropped
dramatically, and the possibility of providing long term ARV treatment to
HIV-infected patients has become more realistic. In Thailand, the
Government Pharmaceutical Organization (GPO) started producing GPOvir, a
combination of d4T, 3TC and nevirapine in a single pill to be administered
twice a day, which costs approximately US$30 a month.

Using the same strategy of building upon the success of small pilot
programs before scaling up nationally and using the results of the clinical
trials performed in Thailand, the Ministry of Public Health organized in
2003 the revision of the national guidelines for the use of antiretroviral
fixed dose combinations (ARV) and launched, in collaboration with the
Global Fund, a national program to provide access to Highly Active
Antiretroviral Therapy (HAART) to 70,000 patients over the next five years.
In clinical trials, antiretroviral therapy has been shown to have a
dramatic impact on reducing the risk of progression to AIDS and death in
HIV-infected adults and children. Large observational cohorts in Europe and
the US demonstrated the impact of antiretroviral therapy on mortality in
HIV-infected patients in routine care settings, with up to 70% reductions
in risk of death.

With support from the Thai Ministry of Public Health, Oxfam GB and the
Global Fund, PHPT/IRD program has been working within 50 public hospitals
throughout Thailand to provide treatment for the participants of the
research studies and other people living with HIV/AIDS. All patients in
this treatment cohort are monitored to ensure their safety and to examine
the efficacy and impact of the treatment provided.

In 2002, Perinatal HIV Prevention Trial (PHPT) submitted a joint proposal
to the Global Fund to fight AIDS, TB and Malaria (GFATM) to demonstrate the
feasibility of the provision of high quality HIV care including
antiretroviral treatment. The PHPT-GFATM program will have provided
antiretroviral fixed dose combinations (ARV) treatment and monitoring to
more than 2,000 patients, one third of whom are children.

To ensure optimal use of antiretrovirals and the durability of drug
regimens, the program highlights the critical importance of active
involvement of People Living with HIV/AIDS, the need for hands-on training
of medical professionals and the benefits of establishing independent
networks of HIV care specialists. The development of clear procedures for
patient screening, clinical and biological evaluations and systematic data
collection enabled the program to document the high rate of virological and
immunological success and low rate of mortality achieved.

This cohort is closely monitored with regular clinical and demographic data
collection. To inform future policies and programs in order to optimize
benefits of antiretroviral therapy, data are analysed to address the
following key research areas:

… Long term efficacy of antiretroviral therapy: long term survival, factors
associated with survival, immunological and virologic response
… Antiretroviral safety: incidence and risk factors to toxicities,
incidence of hospitalisation/serious adverse events (HIV related, ARV
related, others)
… Drug resistance: durability of first line regimen and patterns of
resistance, resistance mutations at baseline.
… Co-infections: HIV and Hepatitis B, Hepatitis C and tuberculosis
… Adherence to therapy
… Cost effectiveness of antiretroviral treatment: diagnosis strategies for
infants born to HIV infected mothers, treatment regimens, monitoring
strategies.

Through ongoing training and the development of specific clinical
procedures, the program will continue to strengthen HIV care teams and
their collaboration with people living with HIV/AIDS.

For more information, please visit the www.phpt.org website.

The presentation concluded with a question and answer in which members of
the audience asked the speakers for more information on many of the topics
outlined in their talk.

FUTURE MEETINGS: Just now, no meeting is scheduled for April. Enjoy Songkrant!

INTG CONTACTS:

1) Convenor: Brian Hubbard. Email: <brihubb at loxinfo.co.th>; Tel./Fax: 053
40 94 18. Address: 106/18 Moo 2 - Potharam Road, Soi Pai di-Ma di, Chiang
Mai 50300

2) Secretary: Louis Gabaude: e-mail: <gabaudel at loxinfo.co.th>. H/O Phone:
053 11 73 19; Mob. 087 188 50 99. H/O Fax: 053 85 04 85.

3) INTG Website: http://www.intgcm.thehostserver.com



ANNOUNCEMENT  1

>From the Center of Ethnic Studies and Development (CESD) at the Social
Research Institute (Chiang Mai University)

A new website for the study of ethnicity in Southeast Asia

At http://www.cesd-thai.info you can now download newspaper articles as
well as pictures related to ethnic groups in Southeast Asia. The website
also contains references to academic articles, an NGO directory, an
e-museum as well as conference and workshops announcements.

This database is the result of a 4-year collaboration between the Center of
Ethnic Studies and Development (CESD), a research group of the Social
Research Institute, Chiang Mai University, and the Institute of Research
for Development (IRD, France). The website is conceived as a tool for
researchers and students who are interested in the contemporary history of
ethnicity in this region.

The collection of newspaper articles in particular is used to support
teaching and research as well as publishing a yearly assessment of the
situation of ethnic groups in Southeast Asia.
The newspapers database currently contains 12,750 newspaper articles in
English and/or Thai language covering the period from 1965 to present time.
New articles are regularly added. Most articles are available in pdf
format. More recent articles are available in html format.
Over 5,000 articles in English language are extracted mainly from the
Bangkok Post, Chiang Mai Mail, The Nation, Vientiane Times and Irrawaddy.
One set (1965 to 1990) comes from the archives of the former Tribal
Research Institute (TRI), the others (1990 to present) come from CESD
archives.
Over 7,600 articles in Thai language are extracted from various newspapers:
… Khon Muang, Siamrath, Thairath, Thin Nue, Daily News, Daily Mail for the
articles of the TRI archive (1965-1990).
… Chiangmai News, Thai News, Matichon, Thairath for the articles of the
CESD archives (1990-2009).
Most of the articles focus on Thailand and Burma but some of them also deal
with Laos, Vietnam, Cambodia, East India, Malaysia and Indonesia. Search
can be done by newspaper name, by title, by date and by keywords. Articles
in English have been indexed only with English keywords and articles in
Thai only with Thai keywords. For each article, CESD staff has selected
four categories of keywords:
… country
… ethnic group
… main theme
… acronyms

A complete list of keywords in English and in Thai is available by clicking
on the "help" icon on the search page. The list is constantly updated.

The website also contains 4,000 pictures with detailed captions (some of
them parts of privates collections from Hans Mansdorff, Jacques Lemoine or
Paul T. Cohen for instance) and a e-museum where you can download video
clips on ethnic cultures.



ANNOUNCEMENT  2

The Gate Theater rresents

Strange Snow

A story of love, loss, healing and hope

Written by Stephen Metcalfe

Directed by Stephan Turner

Featuring Robert Young, Peter Mushenko and Veronica Guarino

Performances: Fridays and Saturdays at 7.00pm on 10th &  11th April 2009

Suggested donation: 300 Baht

At the Studio Theater, 7th floor, Kad Suan Kaew

For information contact: 0871772195, 0866713371

Email: thegatetheater at asia.com

Website www.gate-theater.com

The First Live English Language Theater in Chiang Mai

=====================================
Répondez-moi toujours à / Please answer always at:
<gabaudel at loxinfo.co.th>

Louis Gabaude
124/123 Soi Suraphon Niwet
San Kamphaeng Road
CHIANG MAI 50000
THAILANDE

Tel. Chiang Mai: +66 (0)53 11 73 19
Fax Chiang Mai: +66 (0)53 85 04 85
Mob. +66 (0)87 188 50 99
e-mail: <gabaudel at loxinfo.co.th>

Ecole francaise d'Extreme-Orient:
http://www.efeo.fr/documentation/bibliothequecm.shtml

Informal Northern Thai Group: http://www.intgcm.thehostserver.com/

Aux dates suivantes, je serai en déplacement et ne pourrai sans doute
pas répondre immédiatement à vos courriels / At the following dates,
I will be away from home and may not be able to answer your mails
right away:

21/04 > 25/04/2009 : France : Lyon
06-08/2009: France
=====================================





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______________
Dr. Justin McDaniel
Dept. of Religious Studies
3046 INTN
University of California, Riverside
Riverside, CA 92521
951-827-4530
justinm at ucr.edu