The challenges of ending AIDS in Asia: outcomes of the Thai National AIDS Universal Coverage Programme, 2000-2014

Abstract

Objectives: We sought to determine Thai National AIDS Program (NAP) outcomes and gaps, and success in reaching the WHO 90:90:90 goals.

Methods: Retrospective study of treatment outcomes, mortality and loss to follow-up (LTFU), of all individuals aged >15 years who registered to the NAP from 2000 to 2014. We focused outcomes on data from 2008 when the NAP was linked to the death registry.

Results: A total of 429,294 patients registered to the NAP up to November 2014, and 309,313 patients aged >15 years started ART. Median (IQR) age was 37 (31-43) years; 51% were male. From 2008 to 2014, long-term follow-up rates per 100 person-years were 3.2 in those who started ART vs 3.5 in those who did not (P<0.001) and mortality rates per 100 person-years were 3.5 in those who started ART vs 4.9 in those who did not (P<0.001). Mortality reduced from 16% in 2008 to 3% in 2014 for those who started ART. For patients starting treatment since 2000, 87% of those alive and with a recent viral load (VL) result had <50 copies/mL, and 6% had VL ≥1000 copies/mL. In a continuum-of-care analysis from 2008 to 2014, 68% were living and retained on ART, and 46% of diagnosed individuals were virally suppressed at <50 copies/mL.

Conclusions: In the Thai NAP, death and LTFU are major factors disrupting the care-continuum, and many patients initiate ART with low CD4 cell counts. Rolling out systems for early detection and treatment for all, regardless of CD4 cell count, are essential and under way.

Keywords: HIV, treatment outcomes, Thailand, universal health coverage.

Figure 1.

The National AIDS Program (NAP) database description and analysis population. LFTU: lost to follow-up

Figure 2.

(A) Loss to follow-up rates in the NAP, by year of ART-initiation (ART patients) or year of registration (non-ART patients). (B) Mortality rates in the NAP, by year of ART-initiation (ART patients) or year of registration (non ART-patients). (C) Proportion of subjects who started ART in the NPA and died, against the median patient baseline CD4 cell count, by year of ART initiation. Difference in proportions in Figures 2A and 2B is significant in each year at P<0.001

Figure 3.

(A) Proportion of patients, starting ART in NAP between 2008 and 2014, who had a plasma HIV-1 RNA (viral load, VL) test >6 months and <1 year after ART initiation. (3) Proportion of patients in the NAP program, with plasma HIV-1 RNA (VL) < 50 copies/mL and VL > 1,000 copies/mL, who had repeated viral load tests, and initiated treatment from 2008–2014

Figure 4.

HIV care continuum in the NAP from 2008 to 2010, and 2011 to 2014. Estimates for 2011–2014 are those patients with at least 1 year of follow-up