Early prevention of MTCT response

The first case of HIV in a pregnant woman in Thailand was reported in 1988 and increasing HIV prevalence among pregnant women and other populations was recognized in the early 1990s (3,5). In 1996, after the ACTG 076 trial* (6), the Thailand Ministry of Public Health (MOPH) and Siriraj Hospital, in collaboration with CDC Thailand/Southeast Asia Regional Office, launched a trial of short-course oral AZT, a regimen feasible for use in Thailand (2). The trial demonstrated a 50% reduction in MTCT.

In 1996, Her Royal Highness Princess Soamsawali donated funds to the Thai Red Cross Society to make antiretrovirals for prevention of MTCT available to hospitals around the country. During 1997–1999, the MOPH implemented pilot prevention of MTCT projects in northeastern (7) and northern Thailand (5) to provide HIV testing for pregnant women and AZT for prevention of MTCT, and to implement a pilot prevention of MTCT monitoring system. In 2000, the Department of Health (DOH) MOPH announced the first national prevention of MTCT policy and issued guidelines for all government hospitals to integrate prevention of MTCT activities into routine maternal and child health services, including HIV testing for all pregnant women, antiretroviral therapy for prevention of MTCT, and infant formula for infants born to HIV-positive mothers. The prevention of MTCT program covers all public and private health care facilities. The Thai government funds prevention of MTCT services for Thais under the universal health coverage policy. During 2007–2014, non-Thai HIV-positive pregnant women could access prevention of MTCT services through a Global Fund project; these services can currently be accessed through hospital social welfare funds, the Princess Soamsawali prevention of MTCT fund, government-sponsored migrant health insurance, or other special projects (1) (Figure 1).

Antiretroviral regimens for Thailand’s national prevention of MTCT program have evolved with prevention science. In 2000, HIV-positive pregnant women were offered AZT starting at 34 weeks gestation and their infants received AZT for 4 weeks. A single-dose of nevirapine (WHO option A) was added in 2004; next, in 2010, highly active antiretroviral therapy (WHO option B) was provided during pregnancy and continued based on CD4 count; and finally, in 2014, highly active antiretroviral therapy for life regardless of CD4 count (WHO option B+) became the standard. HIV testing of couples was implemented in 2010 (1).

Infant HIV testing guidelines have also evolved. During 2000–2006, HIV diagnosis in infants aged 12 months and 18 months was accomplished using antibody tests; diagnoses in some infants aged >2 months were made using DNA polymerase chain reaction (PCR) testing as part of research studies or other projects. In 2007, HIV DNA PCR testing was implemented for infants aged 1–2 months and 2–4 months using national HIV/AIDS funds. In 2014, the national prevention of MTCT guidelines were modified to classify infants based on their risk for acquiring HIV. Infants with standard risk receive AZT for 4 weeks, and HIV DNA PCR testing is performed at age 1 month and 2–4 months. Infants with high risk (maternal plasma HIV viral load >50 copies/mL or infants born to mothers taking highly active antiretroviral therapy for <4 weeks before delivery) receive AZT, lamivudine, and nevirapine for 6 weeks, and HIV DNA PCR testing is performed at ages 1, 2, and 4 months. All children born to HIV-positive mothers have confirmatory HIV antibody testing at age 18 months (1).

Stigma and discrimination against women living with HIV continues to prevent some women from accessing antenatal clinic services (1). Women living with HIV in Thailand and civil society organizations have worked with the MOPH to develop and implement a training curriculum for hospital personnel that aims to reduce stigma and discrimination (1).