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This paper documents Thailand's response to its HIV epidemic from the late s until today, and analyses its epidemiological impact incidence and mortality. We discuss the association between the trajectory of HIV incidence and mortality rates over time, and the programmatic investments, policies and interventions that were implemented in the last three decades.
This is a review paper that draws on published literature, unpublished sources and routine behavioural and serological surveillance data since The public health response to HIV in Thailand has averted 5. If Thailand had not responded in to the HIV epidemic, and had there been no prevention and ART provision, the country would have experienced an estimated ,—, deaths in the — period.
This figure would have risen to ,—, in the — period.
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A total of , deaths were averted between and If ART scale-up had not occurred in , Thailand would have experienced between 50, and 55, deaths per year in the period —, and 31,—46, annual deaths between and The main impact in terms of deaths averted is seen from onwards, reflecting treatment scale up.
In the context of Thailand's ageing population, it is faced with the twin challenges of maintaining life-long quality services among HIV patients and sustaining behaviour change to maintain primary prevention gains. Thailand's first case of HIV was reported in The epidemic has evolved and changed strikingly over the last three decades. The virus then quickly spread to populations of female sex workers FSWs , with increasing documentation of subtype E . The epidemic spread rapidly in the early s, driven by infections among sex workers and their clients [4—6].
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There were clear geographical differences in the prevalence of HIV. The upper-northern provinces accounted for a disproportionate number of HIV case reports . By , some ,—, people were estimated to be living with HIV .
A HIV prevalence among key populations from to The sample size for PWID was inadequate and limited to fewer than 10 sites after B HIV prevalence in the general population in Thailand, — Cross-sectional survey data of hospital admissions between and also indicated that the most common AIDS-defining conditions were cryptococcosis, tuberculosis and HIV-wasting syndrome; PWID were more likely to have tuberculosis or suffer from HIV-wasting syndrome .
As HIV prevalence began to decline among FSWs and their clients in the mids, data from serial prospective cohorts among young Thai military conscripts also showed simultaneous declines in the incidence of both HIV and sexually transmitted infections, suggesting successful interventions and changes in transmission patterns . The early s saw marked changes in the transmission routes in Thailand, with sharp increases in the estimated HIV incidence among young men who have sex with men MSM — from 4.
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The HIV epidemic up to is mature and abating rapidly. The estimated HIV prevalence among adults was 0. There were an estimated new infections in , including in newborns. A quarter of adult infections occurred in women, of them in FSW, and the remaining in other groups of women, particularly discordant couples and partners of members of key populations. The transmission of HIV from parents to children has been successfully controlled. AIDS-related deaths have been steadily falling since , with a sharp drop observed from following the scaling up of ART.
Thailand has been heralded as a global leader in HIV prevention and treatment, and its experience with the AIDS epidemic holds valuable lessons for public health. This paper documents Thailand's response to its HIV epidemic from the late s until today, and analyses its scope and epidemiological impact incidence and mortality.
In doing so, we document and describe not just the public health interventions, but also consider issues of governance, universal health coverage as well as structural and policy constraints that influence public health outcomes. This review draws on published literature and unpublished sources and routine behavioural and serological surveillance data since Key peer-reviewed journals published between and were searched.
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Serological and behavioural data collected by the Bureau of Epidemiology BOE , covering the period since the establishment of the HIV sero-surveillance system and the behaviour sentinel surveillance programme were also reviewed. These data provide information on key affected populations KAPs and the general population.
Finally, AEM models to assess impact on incidence and mortality in conjunction with vital registration data were also analysed. We distinguish our findings over two phases. First, we present the outcomes and impact of Thailand's early prevention interventions — Timeline of HIV interventions and investments in Thailand, — This led to HIV being classified as a reportable disease and the development of the surveillance system, which resulted in the case-based reporting system in By , a surveillance system had been established across Thailand and an accurate assessment of high-risk groups and behavioural patterns provided strategic information for evaluations and resource allocation .
With the exception of , Thai domestic resources have accounted for the vast majority of funding for the AIDS response.
Despite the financial collapse during the Asian financial crisis in the late s, Thailand sustained a lowered, but substantial investment in the AIDS response.
This financial commitment reflects the Thai government's strong commitment to control HIV.
STI rates in the cohort declined even more sharply: from 17 per person years to 1. The annual number of new infections fell dramatically after , from , in to 28, in Thai Working Group on HIV Estimation and Projection, Modelling using the AEM suggests that by , the total number of averted infections since had risen to 5.
If Thailand had not responded in to the HIV epidemic, and had there been no prevention and ART provision, the country would have experienced an estimated ,—, deaths in the period — Impact of early prevention on new infections in Thailand — , and the potential costs of inaction.
It provided voluntary and free testing for all pregnant women, provision of free ART to pregnant women and newborn infants, and free formula feeding for infants for the first 12 months . In the period —, the transmission risk among those completing a short course of zidovudine ZDV -only regimen declined from By , By , this share had risen to In , In Thailand was officially certified by the World Health Organization as having eliminated mother-to-child transmission of HIV and congenital syphilis.
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HIV treatment with antiretroviral drugs was first started in with ZDV monotherapy, and later, dual therapy. At the end of , approximately people were being treated .
In , two critical events facilitated the massive scale-up of ART in Thailand.
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The roll-out of ARVs was made a priority not just for adults, but also for children, with children put on ART between and . An assessment of treatment outcomes for ART among adults in Thailand — showed that outcomes remained good, with much improved survival rates, despite the rapid scale-up of ART .
At the end of , Thailand was well on its way to reach the targets. Testing and treatment cascade, Thailand This data excludes tests and treatment in the private sector. An estimated additional 15, people are on ART in the private sector, which is not routinely reported, bringing the total number on ART to , estimates based on data from the Government Pharmaceutical Organisation.
If ART scale-up had not occurred in , Thailand would have experienced between 50, and 55, deaths per year in the period —, and between 31, and 46, annual deaths in the period — Thai Working Group on HIV Estimation and Projection, The impact of the response to HIV in Thailand is also reflected in the burden of disease analysis. In , HIV was the top cause of death in men 26, deaths , and the second most common cause in women 11, deaths . We have reviewed and synthesised published evidence, programme data and the results of modelling exercises to gauge the impact that these efforts have had.
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We argue that while the evidence and our analysis does not allow us to attribute direct causality, there are strong temporal associations between these efforts and the impact on HIV incidence and AIDS-related mortality. We have assessed the impact of the programme specifically in terms of declines in incidence and mortality.
It is important, however, to acknowledge that some key governance, financial and policy inputs into the national AIDS control efforts have strongly influenced those outcomes. The role of Thailand's well-developed health infrastructure, the government's strong political commitment and the stewardship from the Prime Minister's office have been well described elsewhere .
We highlight three key issues that have been critical in ensuring that interventions in Thailand could be implemented early, at scale and in a sustained fashion: health governance, reform and partnership with civil society. Thailand has gone through a major reform of governance and its health service system with the Decentralization Act in November and the introduction of universal health coverage in Government reform involved the devolution of authority for some operations from the central government to the provincial and local administrations.
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There were changes to the structure of the Ministry of Public Health, and in the management of the AIDS budget as part of this decentralisation. Following enactment of the official ministerial proclamation in , the Ministry of Public Health implemented structural reforms at central and regional levels. In particular, at the central level, the role of the National AIDS Committee shifted from policy and budget support for implementation and development to co-ordination, monitoring and technical support.
A portion of the prevention budget and much of the task of implementation was decentralised to local administrative organisations. Other related line ministries made budget requests for HIV prevention activities through their own agencies.
Apart from antiretroviral treatment, which has been centrally managed, the budget for HIV clinical services for opportunistic infections was integrated into the national health insurance scheme, and allocated to health service outlets in the form of per capita lump sum payments .
The national AIDS response is integrated into numerous and diverse programmes of participating agencies and line ministries. However, starting in , no specific AIDS budget was defined. It became the responsibility of each ministry to allocate a budget line for HIV control.
The budget for health of the population was allocated as a lump sum based on per capita needs, including AIDS. This approach promoted a multi-sectoral response and removed the constraints of a centralised budget.
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For example, under the arrangement, local administrative organisations were made responsible for paying a monthly allowance to PLHIV.
Provinces were also expected to prioritise and budget for health issues at the local level. This made financing directly available at the local level rather than indirectly through a centralised funding mechanism.
While this decentralisation has led to some positive changes, the risk that there may be varying capacities and awareness across provinces regarding continued investment and engagement with HIV has remained a challenge . This package entitled all Thai citizens to free medical services and health promotion and prevention. At the introduction of the scheme, antiretroviral treatment was excluded from the service package, but included in The Ministry of Public Health had begun to engage with civil society partners in Thailand on the issue of HIV prevention and treatment since the early s.
Apart from working closely with the government, Thai civil society has successfully held governments accountable, and championed the cause of equal access.
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The minister agreed, in principle, to their demands, and doubled the budget for ART and also committed the government to include ARVs in the universal health scheme. At that time, there were fewer than individuals receiving ART. Arguably, civil society action has been fundamental in shaping government policy, an illustration that a well-informed and motivated civil society, which is able to negotiate and partner with government agencies, can be highly beneficial to the AIDS response.
We conclude by noting that, despite the outstanding successes of Thailand's AIDS response, the programme is faced by a multitude of challenges.