| 4. In which ways is the initiative creative and innovative?
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There are two main reasons as follows;
Firstly, the Thai socio-cultural context was a significant challenge in designing the initiative because women with HIV might be seen as sinful. Declaring their HIV status might lead to family breakdown. Many housewives usually unexpected discovered their HIV status. Finding HIV cases, particularly housewives, and recruiting them to the treatment program was difficult and sometimes impossible. The PMTCT initiative used an antenatal service approach and changed the way to reach out to the case in more acceptable way by encouraging full participation from families through the Couple Counseling technique. Also, cases were reached in a cost-effective way rather than outreaching as was previously done.
Secondly, we broke through the bureaucratic way of thinking and management. The PMTCT was one of the most innovative public health policies in Thailand of all time because it has never been implemented anywhere else due to the massive amount of money, tools, technology, and cross-sectoral collaboration required. To afford this policy, the Royal Thai Government has set it as a national priority agenda and integrated it into the universal health coverage scheme. The Royal Thai Government is the first country in Asia that established the ‘PMTCT’ successfully.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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At national level, the Department of Health, Ministry of Public was the national focal point responsible for planning, implementing, monitoring, and evaluation of the initiative with good collaboration from various agencies both in public and private sectors, research groups, universities, civil society and international organizations. The National AIDS committee also played an important role in giving recommendation and making decision on PMTCT implementation. The National Health Security Office was involved in budget allocation and procurement of anti-retroviral drugs. The Bureau of Budget was an important partner that allocated budget for infant formula procurement every year using information from the Department of Health as evidence-based for budget estimation.
At regional and provincial levels, regional and provincial Health Offices were the hubs for policy communication from policy maker level to practitional level. All public health facilities joined in the initiative as implementator unit of the PMTCT program. Regional Health Promotion Centers, under the Department of Health, worked closely with the Provincial Health office to provide training and technical support in order to build capacity of health professional in every health care facility to capable for providing PMTCT services with good standards. Due to the availability of antenatal clinic in all public health care facilities, almost all pregnant women could easily access to PMTCT services regardless of their ability to pay or socio-economic status.
Consequently, 99.9% of 800,000 pregnant women received Voluntary Counseling and Testing. 93%-98% of HIV-positive pregnant women received anti-retroviral therapy. Almost accumulated 100,000 HIV-infected mothers were treated properly under the program. Moreover, all children born from HIV-infected mothers received free infant formula supplies once they born and continue to 18 months from health care facilities
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| 6. How was the strategy implemented and what resources were mobilized?
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The PMTCT initiative has been implemented under the National AIDS Plan and periodically developed according to the development of drug and technology, and the decision making after program monitoring and evaluation.
I. Strategy implemented in terms of target group based on disease prevention principle:
1. Preventing newly infected patients by HIV screening and counseling in pregnant women and their partners
2. Preparation for HIV infected pregnant women who decided to have baby. The couple who wants to have a baby must complete 1) counseling session and 2) taking highly active anti-retroviral treatment (HAART) to decrease viral load in blood to as low as possible.
3. Prevention of HIV infection in infant: women and partners will be provided services according to standard and guideline set by National AIDS Committee.
II. Strategy implemented in terms of management and systematic approach:
1. PMTCT National Policy: The Policy to eliminate mother-to-child transmission of HIV have been set in the National AIDS Strategy 2012 – 2016 aiming to reduce new HIV-infected infants to lower than 2%, and reduce neonatal syphilis to lower or equal to 0.5 per 1000 live births. The Department of Health is responsible for overall strategy planning, monitoring and evaluation for PMTCT.
2. Financial management: The majority of the program budget is funded by the Royal Thai Government by two main channels, first channel through universal health coverage scheme including the cost of antiviral drugs and laboratory diagnosis and services provided in hospital under PMTCT. The second channel is through Bureau of Budget including infant formula supply and human resource development. Some budgets are supported by the Thai MoPH-US CDC Collaboration Center, UNICEF, UNFPA, UNAIDS, WHO, Global Fund, civil society and Thai Red Cross to strengthen service systems, training, research and evaluation.
3. Human Resources and Workforce: Working on eliminating mother-to-child transmission of HIV requires continuous capacity building among health care providers. Training courses have been developed focusing on knowledge, attitude, and management for health personnel to provide services efficiently.
4. Data Management and Monitoring and Evaluation: Data Management system has been run through 1) Perinatal HIV Intervention Monitoring System: PHIMS, 2) Medical and Health Knowledge Center monitoring system (43 files of MoPH) 3) National AIDS Program (NAP) monitoring system and 4) 506 and 506/1 report. The Department of Health and National Health Security Office uses data and information from all of these data system to monitoring and evaluation the program implementation.
5. Health Service Delivery: Pregnant women could receive PMTCT services at both public and private hospitals, from primary to tertiary care. Maternal and child health services are provided by a multidisciplinary team under the standards and guidelines. For example, early case detection and recruitment, PMTCT case management (transmission prevention), early infant diagnosis and treatment (PCR and HIV Ab), continuum of care for postpartum HIV-infected mothers and families for longer lifespan and raising children.
6. Tool and Technology
Anti-retroviral and HIV and syphilis drug distribution are managed by the Government Pharmaceutical Organization (GPO). Vendor-managed inventory (VMI) was used in the distribution system all over the country for effective drug replacement at all time.In terms of laboratory, every hospital has standard and accredited laboratory. The distribution of Infant Formula Supply was designed in systematic way by distributing through the existing health service system including regional, provincial, and district hospitals. All children born from HIV-infected mothers could receive the formula for free until 18 months old.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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There were three components of stakeholders involved in designing and implementing the PMTCT initiative. Firstly, the political component leading by the Ministry of Public Health and other governmental organization were the key actors who set the goal, objectives, overall strategies, and plan of actions. The Department of Health, Ministry of Public Healht acted as the national focal point for the PMTCT initiatives due to its legal and functional role as national focal point in health promotion for mother and children. It was responsible for program monitoring and evaluation in overall strategies.
Secondly, the academic components including Thai-US Coperation, research units, and universities played crucial roles in technical support and generated evidence-based information for program design and development. This group of actors also engaged in redesigning the implementation plan in terms of development of anti-retroviral therapy, service delivery uptake, and coverage rate of HIV screening and treatment output
Thirdly, the civil society including private sectors particularly domestic NGO were seen to be key drivers who reflect the success of the program implementation, and address the gaps and solutions from real context. This group of people especially voluntary health volunteers and peer group always speak on behalf of HIV patient to call for program improvement. In terms of International organizations such as UNAIDs, UNICEF and Global Fund, their funding and technical support were vital for program planning, implementation, and monitoring.
Setting up the National AIDS Committee since the starting point before program design encouraged these 3 components working together. The PMTCT implementation would be a dream that never come true if there was no cooperation from one of these 3 actors.
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| 8. What were the most successful outputs and why was the initiative effective?
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The most successful outputs are:
1. Perinatal HIV Intervention Monitoring System: PHIMS is used to continuously monitor the PMTCT program which has been integrated into maternal and child health services under the Universal Health Coverage since the year 2000, from community level to provincial/regional-hospital level, as well as other hospitals outside the jurisdiction of the Ministry of Public Health through networking system.
2. Long-term infant formula supply chain: The Department of Health provides infant formula to all target group through provincial health offices and hospitals nationwide. The Thai government financially support 70 million baht (2 million USD) annually for infant formula. Health care providers worked hard by empowering mothers and families to ensure that they could be aware of the risk of breastfeeding and overcome their guilt for not breastfeeding. Finally, we achieved 100% of infant formula uptake among children born from HIV-infected mothers.
3. High coverage of HAART distribution: Highly active anti-retroviral therapy in pregnant women and infants has been managed through the GPO’s VMI system. Under this scheme, hospitals will order drugs types according to the standard and number of patients, the GPO will manage the supply to the hospitals on a weekly basis.
4. National guidelines and standards of PMTCT: The PMTCT national guidelines and standard takes into account standard, benefit-based service provision, human rights and equality, including counseling and HIV testing in pregnant woman and her partner, anti-retroviral drugs for treating pregnant woman and her partner, early infant diagnosis, and treatment to prevent opportunistic infection. The national guidelines were developed in 2000. It has been updated many times until the latest version was published in 2015. We are highly confident that this guideline could be a pragmatic model of PMTCT program for implementing in other countries.
5. Networking for PMTCT: the National AIDS Committee including public and private agencies, universities, international organizations in Thailand (WHO, UNICEF, UNAIDS, CDC, as well as civil society sectors), that meet once a year to strengthen the implementation and enhance the PMTCT program with updated evidence-based practice. At regional and provincial level, the MCH Board are networks to implement and solve problems.
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| 9. What were the main obstacles encountered and how were they overcome?
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As Thailand is still a developing country, we have limited resources in terms of budget including the high cost of anti-retroviral drugs and infant formula supply. Another main problem was burden for health workforce. Previously, health care providers greatly suffered as they have to carry on their responsibility while they have negative attitude towards HIV-infected persons.
For limited resource, we solved the problem by firstly built up the commitment from high-level policy makers so that they aware of necessity of PMTCT program and put it in national strategy as top priority agenda. As a result, the government then continually allocate annual budget for the infant formula supply. Moreover, integrating the PMTCT program into routine health care services using funding from universal health coverage scheme help sustain the program implementation. Additionally, we developed the criteria for ARV drug administration and infant formula distribution. Although at the beginning only the most critical/low CD4 cases could access to the ARV drug, nowadays all of HIV-infected pregnant women can receive HAART due to lower price of drug and more budget allocation.
In terms of health workforce, numerous training course focusing on universal precaution and capacity building program were conducted. These activities affected to increasing level of health literacy about HIV of health care providers. So, they could overcome their fear and work smoothly with decreased suffering.
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