Intervention for HIV Care and Evaluation - Report Example

Intervention for HIV Care and Evaluation Name of the Student Name of the University Intervention for HIV Care and Evaluation The first case of AIDS in Thailand was reported in the year 1984 and since then the presence and spread of infection has seen a steady increase in the country. The early cases of HIV/ AIDS in Thailand occurred predominantly among men who had sex with men (MSM) and then spread to injecting drug users (IDUs), followed by sex workers and their clients. By the year 1989, HIV had spread rapidly to the general population of Thailand, primarily through unprotected intercourse between individuals. In 1991, Thailand recorded almost 143,000 more people infected with the HIV virus (USAID, 2005). Between 2003 and 2005, the prevalence of HIV among MSM increased from 17% to 28% and increased from 30% to 50% among IDUs. In the year 2005 more then 40% of new HIV infections in Thailand were among women who were infected by unprotected intercourse with long-term partners (USAID, 2008). Several factors can be attributed to the increase spread of HIV/ AIDS in Thailand. Firstly, the levels of awareness of HIV infection is considerably low. For instance 80% of the HIV positive MSM had never been tested or assumed that they were HIV negative. Secondly, about 35% of IDUs, which makes up a significantly large portion, use non-sterile injection equipment. Thirdly, research found that among female sex workers there was an increase in the trend of erratic condom use. Lastly, there are increasing levels of pre-marital sex among the younger generation of Thailand and only 20 to 30% of these consistently indulge in safe sex by using condoms. What was once a taboo had now become increasingly common and has resulted in the rapid spread of HIV/ AIDS. Thailand was the first Asian nation to recognize the magnitude of its HIV/ AIDS problem and gave it priority on its national agenda. It brought forth the 100% Condom Programme, which insisted and enforced the rule that all establishments and all sex workers must use condoms in every act of sex. This initiative was brought about through a collaborative effort between local authorities, public health care officers and professionals, sex workers and sex establishment owners and ensured that no client could purchase sexual services without the use of a condom. While many people did not believe that the programme would work, it was seen that post implementation, the rates of STDs dropped quickly. Many studies conducted indicate that the use of condoms in brothels and massage parlours exceed 90%. Moreover, nationwide monitoring of condom use by sex workers and the levels of STDs among men has established a strong relationship between increased use of condoms and decreased levels of STD transmission. There are indications that this programme has had an effect on HIV transmission at a national level. Evidence of effectiveness of this programme at a national level shows that the increased usage of condoms has resulted in the decreased rates of transmission of STDs. Evidence on the effectiveness at a provincial level shows that firstly, there is an increase in the use of condoms among sex workers. It was found that 97% used condoms with one time clients and 93% used condoms with regular clients. Condom use was consistent in all types of sex establishments; 96% in brothels, bars, restaurants, hotels etc and 99% in massage parlours. Secondly, condom use among clients was also found to have increased. In most provinces condom use among those visiting sex workers was found to be above 90%. Thus indications from both provincial and national levels show that the 100% condom programme has contributed significantly to increasing condom use and consequentially reducing the rates of transmission of STDs and HIV among the Thai people (UNAIDS, 2000). However, the above programme is the prevention measure taken by the Thailand government. It is important to also analyze the intervention that has been used in Thailand for HIV treatment and care. It is also important to evaluate this intervention. In this context one of the most popular and intervention programmes used for the treatment and care of HIV in Thailand is the Antiretroviral Therapy (ART). Standard Antiretroviral Therapy consists of the prescription and use of at least three antiretroviral drugs to suppress the HIV virus and stop progression of the disease (WHO, 2009). The primary goals of Antiretroviral Therapy are to maximum and robust suppression of viral reproduction, restoration of immune function, reduction of HIV related mortality, improved quality of life and limitation of possible viral resistance to enable future treatment (New York State Department of Health, 2008). The clinical goals of antiretroviral therapy are to prolong life and improve quality of life. The virologic goals include greatest possible reduction in the viral load for the longest duration possible to halt progression and to delay resistance. The immunologic goals include the reconstitution of immunity both quantitatively as well as qualitatively. The therapeutic goal is to rationally sequence drugs to achieve the virologic and immunologic goals. Finally the epidemiological goal is to reduce the transmission of HIV. Since its introduction in the 1990s, the benefits of using antiretroviral therapy for the management of HIV have been established. The HIV infection is now manageable as a chronic disease who have access to medication and who are successful in achieving durable virologic suppression (Rathbun et al., 2009). Thailand implemented a limited public sector ART programme to people from the low-income group in the year 1992 (Tantivess & Walt, 2006). The number of patients enrolled in the programme increased from 350 to 3,600 in 1995. This was however suspended due to concerns about quality of care and the costs involved. In the year 2000, The Access to Care initiative was formulated to provide highly active Antiretroviral Therapy (HAART), on a service basis. Between 1996 and 2000, the number of patients benefited by the ART programme was maintained at 2000 per year, which is roughly about 3 to 6% of the AIDS inflicted population. Following this a dramatic shift in the health policies by the newly elected government in late 2001, provided free treatment to all clinically eligible patients who were affected by HIV/ AIDS. This was done through the recently initiated Universal Health Coverage (UC) scheme. After this the number of people treated increased from 6500 in 2002 to 23,000 and 50,000 in 2003 and 2004 respectively. The ART program continued to be financed by the Health Ministry until it was incorporated into the UC benefit package in 2005. The Universal Health Coverage plan aimed to ensure that equitable access to essential healthcare services to all Thai people. Between February and October 2001, intense campaigns were run to promote ART programmes. An analysis of the ART program between March and November 2001, indicated that apart from intense domestic campaigns that programme expansion was also done. There were several changes in the administration, and the inclusion and involvement of new players such as Health Ministers, health system reformists, NGOs etc., a well-developed healthcare system, lessons from small scale initiatives and a global campaign to promote ART access in all parts of resource-poor countries. All of these factors together justified the change in policy by increasing affordability, feasibility and political appeal of the provision of the ART programme through public healthcare services. The substantial decrease in the prices of drugs was due to local production of the same. Policy discussions for healthcare financial reforms were undertaken and this brought about policy changes. The introduction of a Universal Health Coverage Scheme and the scaling up of ART, making it easily accessible to more Thai people, had the underlying principle and ideal that it was people’s right to access all essential healthcare services. While, allocation of public resources to make ART accessible to the Thai people has mostly been motivated by policy considerations of resource availability and affordability, there have been instances when it has been driven by human rights and equity. It has already been established that Thailand was one of the foremost Asian nations to recignise the magnitude of the HIV issue and implement interventions such as the ART programme, it is important now to consider and evaluate such an intervention. Available evidence and many other studies indicate that the provision of antiretroviral drugs has reduced the progression and transmission rates in HIV infected patients. In a study that was conducted among 436 serodiscordant couples, it was found that the use of the antiretroviral drug, zidovudine by the infected partner, caused a 50% reduction in the risk of HIV transmission to the sexual partner (Cohen & Bate, 2002). The concentration of HIV in semen increases the risk of transmission. Antiretroviral drugs were seen to suppress the HIV in seminal plasma with reasonable durability thereby reducing risk of transmission ((Cohen & Bate, 2002). Similarly, antiretroviral drugs are also said to reduce risk of transmission of HIV from mother to child. Antiretroviral drugs, such as nevirapine, lamivudine and zidovudine were seen to reduce the risk of transmission from mother to child by 33 to 36% (Wegbreit rt al., 2006). Treatment with antiretroviral drugs can reduce transmission in general between 40 to 70%. Now that the effectiveness of ART has been established, it is important in this context to evaluate the ART program in Thailand and few other Asian countries. The ART programme review was conducted in 2004 by a team of national and international experts (WHO & Ministry of Public Health Thailand, 2007). The team noted that the Royal Thai Government had made very good progress in expanding access to and coverage of treatment in Thailand. It had achieved the national treatment target of delivering the ART programme to more than 50% of those in need between the years of 2001 and 2004. This expansion of ART coverage was achieved through strong political commitment, and leveraging the full potential of the public healthcare system. The procurement and supply management element of the ART programme was well-developed and well-planned and no shortage of drugs was found. With a view to strengthen capacity for the ART programmed, close to 8000 healthcare professional were trained. Thailand has also developed a strong HIV laboratory network along with proper validation and an external quality assurance system for testing. The programme has actively involved civil society involvement and partnership. However, while the aimed coverage had been achieved there were several issues that were present and had to be considered for future progress. Firstly, a proportional increase in staff and capacity did not accompany the rapid expansion of the programme. The managerial capacity required for high quality care and monitoring did not increase with the expansion. Human resource constraints were found to be very acute. Secondly, while the expansion and reach of the ART programme was considerable, it did not reach certain sections of the society where HIV presence was high. One such section is prisons in Thailand. Prisons in particular have been unable to access this programme. A study by Wilson et al. (2007), shows that there is a considerable effectives of these programmes in prisons but poor access to the ART programme ensures the consistent presence of HIV among prisoners. Wilson et al., say that most prisoners come from marginalized groups such as drug users, sex workers or migrants. They say that the programme in prison will have a sustained impact and prevention programmes must include mechanisms to change attitudes and behaviour in both prisoners as well as prison guards. Implementing treatment and intervention programmes like ART in prisons will provide an opportunity for the government to target and work with particular groups who would not normally seek or be given care and treatment. Hence effective strategies must be implemented to increase capacity and to provide health care services to specific groups in need. References USAID (2005). Health Profile: Thailand. US Agency for International Development. USAID HIV/AIDS Website. Retrieved September 14, 2009. http://library.cph.chula.ac.th/Ebooks/HIV-AIDS/Health%20Profile_Thailand_HIV-AID.pdf USAID (2008). HIV/AIDS Health Profile: Thailand. US Agency for International Development. USAID HIV/AIDS Website. Retrieved September 14, 2009. http://www.usaid.gov/our_work/global_health/aids/Countries/asia/thailand_profile.pdf Wilson D, Ford N, Nagammee V, Chua A, Kyaw M K (2007). HIV Prevention, Care and Treatment in Two Prisons in Thailand. PloS Medicine. Vol. 4, Issue 6. WHO & Ministry of Public Health Thailand (2007). Scaling Up Antiretroviral Treatment: Lessons Learnt from Thailand. Report of an External Evaluation. UNAIDS (2000). Evaluation of the 100% Condom Programme in Thailand. UNAIDS Case Study. Retrieved September 14, 2009. http://data.unaids.org/Publications/IRC-pub01/JC275-100pCondom_en.pdf Cohen M S & Bate J H (2002). HAART and Prevention of HIV Transmission: Role of Antiretroviral Therapy in the Prevention of HIV Transmission. Medscape HIV/ AIDS. 2002;8(2). Wegbreit J, Bertozzi S, DeMaria L M and Padian N S (2006). Effectiveness of HIV Prevention Strategies in Resource-Poor Countries: Intervention Effectiveness AIDS. 2006;20(9):1217-1235. Lippincott Williams & Wilkins. Rathbun R C, Liedtke M D, Lockhart S M and Greenfield R A (2009). HIV Infection, Antiretroviral Therapy. Medscape. Retrieved September 14, 2009. http://emedicine.medscape.com/article/1533218-overview New York State Department of Health (2008). Antiretroviral therapy. New York (NY): New York State Department of Health; 115 p. WHO (2009). Antiretroviral Therapy. WHO Website. Retrieved September 14, 2009. http://www.who.int/hiv/topics/treatment/en/index.html Tantivess, S and Walt, G (2006). Using cost-effectiveness analyses to inform policy: the case of antiretroviral therapy in Thailand. BioMed Central Ltd. Retrieved September 14, 2009. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1779364 Read More