Prevention With Positives Anupong Chitwarakorn Senior Expert Department of Disease Control

Epidemiology of HIV infection in Thailand: * Estimated HIV infection in 2008 · Cumulative HIV infected cases 1,137,836 Cumulative deaths 697,757 · PWHA(HIV+AIDS) 440,079 PLWA (AIDS) 59,029 New AIDS cases in ,681 · New HIV infections in ,766 Reduction of new HIV infection New HIV infections in ,819 New HIV infections in ,749 New HIV infections in ,790 New HIV infections in ,685 New HIV infections in ,919 * Scenarios based on data as of year 2000 ( PMTCT implemented in 2000, Access to ARV in 2003)

New HIV Infections in Thailand by Risk Group Per Year (East West Center)

การป้องกันการติดเชื้อเอชไอวี การป้องกันปฐมภูมิ : กิจกรรมการป้องกันในประชากรกลุ่มที่ยังไม่ติดเชื้อ โดยเฉพาะกลุ่มเสี่ยง - ผู้ให้บริการทางเพศ - ผู้ฉีดยาเสพติดเข้าเส้น - ชายรักชาย - ผู้ที่มีคู่นอนหลายคน - ผู้ที่มีเพศสัมพันธ์โดยไม่ได้ป้องกัน การป้องกันทุติยภูมิ : กิจกรรมการป้องกันในประชากรที่ติดเชื้อเอชไอวี การให้คำปรึกษาและตรวจ เลือดโดยสมัครใจ และส่งต่อ เข้าสู่ระบบบริการ

Strategies for Primary HIV Prevention Activities directed to keeping an HIV negative person staying negative Proved effective strategiesNeed more data (Ongoing studies)  ABC (Abstinence, Be faithfulness, Condom use)  Voluntary Counseling and Testing (VCT)  Behavior intervention  Testing and treatment of STIs  Needle exchanges programs  Male circumcision  Cervical barriers: vaginal diaphragms  Exposure prophylaxis: PEP  Pre-Exposure prophylaxis (PrEP)  Microbicides  Immunization vaccines  HSV-2 suppressive therapy

Area of intervention for PLWHA Psychological counseling and support Disclosure, partner notification, testing and counseling OI treatment and prophylaxis STI and reproductive tract infection PMTCT Harm reduction; NSP, substitution Family planning Selected vaccine for preventable diseases Nutrition, water, sanitation and hygiene Preventing malaria Ref: Essential Prevention and Care Interventions for adults and adolescences living with HIV in Resource Limited settings. WHO. 2008

Secondary HIV Prevention “Prevention With Positives” To make sure the infected person:  Does not transmit HIV to others  Remains healthy over time  Does not become re-infected with the virus (if the person is reinfected with strains of the virus that are resistant to specific antiretroviral medications, this could have a significant impact on disease treatment) HIV transmission prevention among HIV-positive persons MMWR 2003;52 (RR-12)1-25

Prevention With Positives: Why  Increased access for antiretroviral treatment  Sexual activity may increase  Sexual risk behavior may increase  PLHA can live longer  increase number of PLHAs Sexual Risk Behaviors of HIV+ Clients receiving HIV care at Bamrasnaradura Institute (July February 2006)  N = 894; 395 (44%) men and 499 (56%) women  Median age: 36 years  64% received ARV with good adherence (missing doses last 3 days < 1%)  Median CD4 cell count 246 cell/mm 3  Partner HIV testing 56% (39% HIV negative)  82% of women and 66% of men had disclosed their HIV status to their partners (p-value<0.01)  61% reported active sexual intercourse in the last 3 months  Among the sexually active persons, –65% men and 82% women reported using condom last sex with a steady partner (P-value < 0.01) –40% men and 14.3% women reported having sex with casual partners (p-value <0.01) (range 1-10) and 52% used a condom last sex –44/178 (25%) men reported having sex with men. Of these, 20/33 (60.6%) had UAI last sex with partners –43/223 (19%) men bought sex and only 7/26 (27%) used a condom during last sex  Combined syphilis, gonorrhea, and chlamydial infection prevalence ranged from 8% to 30% 1 in women and 4% in men 2

Sexual risk behaviors of 100 MSM HIV+ Bangrak hospital, Preliminary data analysis Median age 29 years old 88% had sex in last 3 months 15% had female sex partner in last 3 months 61% had steady partner –94% had male steady partners (44% had UAI last sex) –13% had female steady partners (14% used no condom last sex) 48% had casual partners –93% had male casual partners (38% had UAI last sex) –12% had female casual partners (40% used no condom last sex) Partner HIV testing 38% HIV disclosure to male steady partner 35% Palanuvej T, Sirivongrangsan P and team, Bangrak hospital

Prevention With Positives: Why  High HIV discordance rate (30-53%) Bennetts A, et al. AIDS care 1999 Hong DS, et al. AIDS Educ Prev 2006  Awareness of serostatus among persons with HIV leads to decreased HIV Transmission. Fleming, 9th CROI, CDC unpublished data  Providing prevention services to people with HIV is beneficial to people with HIV, partners of people with HIV, families and communities

Prevention with Positives: Why Now? Increases in funding and scale-up of antiretroviral therapies availability will dramatically increase:  HIV testing rates  Identification of HIV infected individuals  Opportunities for treatment, care, and prevention services for infected persons Modified from slide’s set of Belcher L, Ph.D, GAP, CDC, Atlanta

6 กลยุทธ์ในการดำเนินการป้องกันในกลุ่มผู้ติดเชื้อเอชไอ วีแนะนำโดยสำนักโรคเอดส์ วัณโรค โรคติดต่อทาง เพศสัมพันธ์ 1. การส่งเสริมการลดพฤติกรรมเสี่ยง 2. การคัดกรองโรคติดต่อทางเพศสัมพันธ์ และรักษา 3. การส่งเสริมการเปิดเผยผลเลือดให้กับคู่นอน 4. การส่งเสริมการตรวจเลือดให้กับคู่นอน 5. การส่งเสริมการกินยาต้านไวรัสอย่างเหมาะสม 6. การลดการตั้งครรภ์ไม่พึงประสงค์และป้องกันการติดเชื้อเอช ไอวีจากแม่สู่ลูก