The Thai Red Cross PMTCT Program
Middle-income countries with adequate health system infrastructure and willingness to provide PMTCT services can implement different PMTCT guidelines than those recommended by WHO for low-income countries. Thai Red Cross AIDS Research Centre advocates for and provides triple-drug ART for all pregnant women regardless of their CD4 counts, when the monitoring of pregnant women with frequent clinic visits and low-cost laboratory tests are feasible. Currently, PMTCT regimens recommended by the National PMTCT Program simply follow the WHO guidelines. Thai Red Cross AIDS Research Centre advocates for and follows guidelines developed specifically for Thailand and other Middle income countries in order to prevent NVP resistance and increase efficacy.
- The goal is to promote a national ART regimen that reduces prenatal transmission while preserving the best treatment options after delivery.
- Primary prevention and prevention of unwanted pregnancies among HIV infected women are equally important components of the PMTCT program (as well as promotion of PICT, early ANC attendance, and couple C&T).
- Outreach to all 939 healthcare facilities across the country that provide PMTCT services includes data regarding clinical indicators and offers support for Thai Red Cross recommended PMTCT ARV regimen. Thirty hospitals have shown interest. Medications are sent to those hospitals and the hospital later returns clinical data to Thai Red Cross.
- Thai Red Cross AIDS Research Center trains hospitals that deliver the more advanced PMTCT ARV regimen, updating them on any changes and explaining the rationale behind guidelines.
- ART is provided free of charge to any hospital that prefers to use more advanced PMTCT regimens.
- The latest PMTCT regimen, in use since April 2004, is to provide a three-drug regimen to all pregnant women, irrespective of their CD4 count. - Group 1: Pregnant women with CD4 count <250 cell/mm3 receive AZT/3TC/NVP and continue after delivery. NVP-based regimen was shown to be as safe in pregnant women with low CD4 count as non-pregnant adults. - Group 2: Pregnant women with CD4 count between 250-350 cell/mm3 receive AZT/3TC/NVP or EFV or LPV/r and continue after delivery only if symptomatic. Data on liver toxicity from NVP-based regimen in this group of pregnant women were controversial (although was shown to be safe in Thai pregnant women) so we also provide options to use EFV or LPV/r. EFV-based regimen is much cheaper than LPV/r but will need 1-week AZT/3TC if discontinued post-partum. - Group 3: Pregnant women with CD4 count >350 cell/mm3 receive AZT/3TC/EFV or LPV/r and discontinue after delivery. NVP-based regimen is not recommended in this group of women due to high rate of liver toxicity. Similar to group 2, EFV-based regimen is much cheaper than LPV/r but will need 1-week AZT/3TC if discontinued post-partum.
- Thai Red Cross PMTCT guidelines are more efficacious in reducing perinatal HIV transmission than WHO guidelines while also reducing the development of NVP resistance in mothers and infants thus preserving the best options for their future treatment.
- 5731 participated from February 1996 - April 2004 (AZT monotherapy or AZT plus single-dose NVP) Approximately 1500 participated from April 2004 up to now (triple-drug ART)
- Guidelines for PMTCT in resource-limited settings may not always be applicable for middle-income countries where HIV prevalence and health system infrastructure may enable more complicated ARV regimens for HIV-infected pregnant women.
- Feasibility, affordability, and cost effectiveness of the guidelines are under evaluation in Thailand, Brazil, South Africa, India and China before they can be implemented in any middle-income countries worldwide.