Scaling up antiretroviral therapy: learning from Thailand

Whilst many conference sessions at the XIV International AIDS Conference continue to be dominated by demands for reductions in drug prices, and drug company stands have been targets of angry demonstrations, some sessions at the conference have been moving beyond the war of words to look at the challenges in scaling up antiretroviral therapy as drugs become affordable for some countries.

Thailand is already far down this path, as a detailed presentation made clear today. Furthermore, the Thai approach reflects some common themes that have emerged during the conference, namely the development of clear guidelines for who is eligible, the need to publicise the availability of treatment, and the need to involve the community in decisions about who is eligible for treatment, with a preference given to those who have demonstrated an ability to attend for clinical care at one site.

Thai researchers reported on a government pilot project to scale up antiretroviral treatment delivery through regional hospitals in Northern Thailand. Eight hundred and eighteen people began triple antiretroviral therapy during late 2000 and 2001 in six Thai provinces, and 73% of all hospitals participated in the study.

The regimens used were either NNRTI-containing triple therapy (usually nevirapine) or a triple regimen using a boosted protease inhibitor (usually ritonavir/saquinavir).

People were eligible for treatment if they had symptomatic HIV disease or AIDS, or a CD4 cell count below 200 and a Karnofsky score above 70. People with HIV and AIDS were involved in the selection of people for treatment, and all other factors being equal, people who had attended the clinic on a regular basis were prioritised.

At baseline, the mean CD4 cell count of people starting treatment was 95 cells/mm³, and 53.8% had CD4 cell counts below 50 cells/mm³.

After 24 weeks CD4 cell counts had risen by an average of 87 cells/mm³. 46 deaths occurred and 34% of all patients stopped treatment, 16.4% due to side effects, 5.8% died, 9.8% were lost to follow up and 2.3% stopped due to virological failure. The investigators concluded that the treatment discontinuation rate could be reduced by improving the management of adverse events.

Dr Kirengkrai Srithanaviboonchai described the scaling up process. First of all, sites were selected by mailing all hospitals in the region and asking centres to apply. Patients who were eligible were then enrolled, by an anonymised assessment conducted by a panel composed of health care workers, people with HIV and NGO representatives, based on a medical report and a social report.

Guidelines for management were distributed and each clinic was required to form a HAART team, composed of a doctor, nurse, pharmacist, counsellor and laboratory technician, who all received a two day training programme covering antiretroviral therapy, clinical management, counselling and monitoring.

Monitoring systems were established to collect information on individual patient visits, lab results, drug utilisation at each centre and costs at hospital level, so that data could be collected at a regional level.

Each site selected a focus person who liaised with the Health Ministry at a regional level, and took responsibility for addressing logistic issues in treatment delivery at their centre.

Finally, the scheme was announced to the public in February 2001. The pilot phase will be followed by the integration of HAART into the national health insurance system, although how this will be done has still to be defined.