Prevention with Prevention with Positives:Positives: view from view from

health providerhealth providerSakchai Chaiyamahapurk*Sakchai Chaiyamahapurk*Supasit Pannarunothai**Supasit Pannarunothai**

Office of Disease Control and Prevention 9Office of Disease Control and Prevention 9thth Phitsanulok*Phitsanulok*

PhD. Student, Health System and Policy* PhD. Student, Health System and Policy* Faculty of Medicine, Naresuan University** Faculty of Medicine, Naresuan University**

การประชุ�มเชุงปฏิบั�ติการ การประชุ�มเชุงปฏิบั�ติการ Prevention with Positives Prevention with Positives

เชี�ยงใหม่ สคร เชี�ยงใหม่ สคร 8, 9, 10 (1 8, 9, 10 (1 กย กย 51)51) ขอนแกน สคร ขอนแกน สคร 5, 6, 7 5, 6, 7 เพชีรบุ�ร� สคร เพชีรบุ�ร� สคร 3, 43, 4 กร�งเทพ สคร กร�งเทพ สคร 1, 21, 2 สงขลา สคร สงขลา สคร 11, 12(28 11, 12(28 ตค ตค 51)51)

OutlineOutline

Rationale for Prevention with Rationale for Prevention with PositivesPositives

Objective and methodology of this Objective and methodology of this survey studysurvey study

ResultsResults Ethical dilemmaEthical dilemma Discussion Discussion

Prevention with Positives Prevention with Positives oror

Positives prevention Positives prevention

Health promotion in People with HIV Health promotion in People with HIV and AIDS aim to prevent of STI and and AIDS aim to prevent of STI and HIV re-infection and decrease HIV re-infection and decrease transmission to sexual partnertransmission to sexual partner

New HIV Infections in Thailand New HIV Infections in Thailand by Risk Group Per Year (East by Risk Group Per Year (East

West Center)West Center)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

Extramarital

Female fromHusbandSex worker

Male from wife

Male from sexworkerMale sex with male

Injection DrugUser

Prevention with positive in Prevention with positive in ThailandThailand

Universal access of ART under universal Universal access of ART under universal coverage scheme make HIV a chronic coverage scheme make HIV a chronic treatable disease.treatable disease.

Estimated 500000 PWHA who are alive and Estimated 500000 PWHA who are alive and now 180000 are treated with ARTnow 180000 are treated with ART Increase proportion of HIV who get infected Increase proportion of HIV who get infected

from regular partner compared with casual from regular partner compared with casual and commercial sex.and commercial sex.

Implementation of Prevention with Positive Implementation of Prevention with Positive program were done by Bureau of AIDS, program were done by Bureau of AIDS, Department of Disease Control, Thai MOPH Department of Disease Control, Thai MOPH with 5 workshops during Aug-Oct 2008 for with 5 workshops during Aug-Oct 2008 for HCW around the country .HCW around the country .

Implementation of 6Implementation of 6 Strategies for prevention Strategies for prevention with positivewith positive during clinical visit in Thailand during clinical visit in Thailand

MOPH hospital(2008)MOPH hospital(2008)

• Risk reduction (condom, number of Risk reduction (condom, number of partners)partners)

• STI screening and treatmentSTI screening and treatment• Disclosure to sexual partnerDisclosure to sexual partner• HIV testing for partnerHIV testing for partner• ARV adherenceARV adherence• Prevention of unwanted pregnancy Prevention of unwanted pregnancy

and PMPCTand PMPCT

ObjectivesObjectives

To know attitude of health provider To know attitude of health provider regarding to Prevention with positivesregarding to Prevention with positives

To survey current practice of health To survey current practice of health provider provider

To estimate sexual practice of HIV patients To estimate sexual practice of HIV patients according to the view of health providersaccording to the view of health providers

To view the opinion of health provider To view the opinion of health provider regarding to the intervention at the regarding to the intervention at the societal level such as law on Prevention societal level such as law on Prevention with Positivewith Positive

MethodologyMethodology Cross-sectional studyCross-sectional study Anonymous, self administered questionnaireAnonymous, self administered questionnaire Population – health care providers attending 4 Population – health care providers attending 4

workshops for Prevention with positive around workshops for Prevention with positive around the country during August-October 2008the country during August-October 2008

Questionnaire with Likert scale answer 5 Questionnaire with Likert scale answer 5 point:point:

1. Strongly agree 2. Agree 1. Strongly agree 2. Agree (1,2 grouped as (1,2 grouped as Agree)Agree)

3. Unsure 4. Disagree 5. Strongly disagree3. Unsure 4. Disagree 5. Strongly disagree

Result of the studyResult of the study

Characteristics Characteristics Total respondent: 560, 74% were Total respondent: 560, 74% were

nursenurse Work in HIV clinics, OPD, ANC.Work in HIV clinics, OPD, ANC. Regional hospital 3%, Provincial Regional hospital 3%, Provincial

10%, Community 87%10%, Community 87% Median working experience 5 Median working experience 5

years(1-15) years(1-15)

Attitude on Positive Attitude on Positive preventionprevention

97% agreed they had duty to prevent 97% agreed they had duty to prevent HIV transmission. HIV transmission.

83% are comfortable to talk about 83% are comfortable to talk about sex with patient.sex with patient.

Less than half(44%) had time for Less than half(44%) had time for counseling.counseling.

Attitude on Positive Attitude on Positive preventionprevention

74% confident in knowledge and 74% confident in knowledge and skillskill

21% felt that counseling was not 21% felt that counseling was not effective for prevention of effective for prevention of transmissiontransmission

33% feel expert such as 33% feel expert such as psychologist, counselor are more psychologist, counselor are more proper for preventive counsellingproper for preventive counselling

Frequent practice of Frequent practice of Positive prevention in Positive prevention in

clinical settingclinical setting

75% talked about condom use 75% talked about condom use 65% asked whether patient was 65% asked whether patient was

sexually activesexually active 65% talked about disclosure65% talked about disclosure

Estimation of sexual Estimation of sexual practicepractice

Among the PositivesAmong the Positives:view from health care :view from health care

providerprovider

35.4%

23.18%

13.69%

6.387%

3.467%.5474%

17.34%

0-10% 11-20%21-40% 41-60%

61-80% 81-100%unsure

Estimated abstinence rate by HCW

Highest voted abstinence rate = 0-Highest voted abstinence rate = 0-10%10%

14.26%

21.02%

19.01%

19.56%

9.141%

2.559%

14.44%

0-10% 11-20%21-40% 41-60%

61-80% 81-100%unsure

Estimated unsafe sex rate by HCW

Highest voted unsafe sex rate 21-40%Highest voted unsafe sex rate 21-40%

9.307%

13.14%

17.7%

23.91%

17.88%

8.029%

10.04%

0-10% 11-20%21-40% 41-60%

61-80% 81-100%unsure

Estimated dusclosure rate by HCW

Highest voted partner disclosure rate 41-60%Highest voted partner disclosure rate 41-60%

Confidentiality and Confidentiality and Disclosure to third partyDisclosure to third party

More than half(59%) considered public health More than half(59%) considered public health benefit more than individual patient benefit benefit more than individual patient benefit

78% believed that counseling could solve 78% believed that counseling could solve disclosure problems.disclosure problems.

7% did notify directly or indirectly to patients’ 7% did notify directly or indirectly to patients’ partners when patients did not disclose their HIV partners when patients did not disclose their HIV status to partners by themselves. status to partners by themselves.

Most reasons for notifying: preventing of HIV Most reasons for notifying: preventing of HIV transmission and rights of their partners to be transmission and rights of their partners to be informed. informed.

Most reasons for not notifying : patient’s rights, Most reasons for not notifying : patient’s rights, fear of adverse effect on patients. fear of adverse effect on patients.

26.94%

36.71%

24.41%

9.765%2.17%

strongly agree agree

unsure disagreestrongly disagree

Should have law for disclose to sexual partner

30.66%

39.42%

21.35%

6.934%1.642%

strongly agree agree

unsure disagreestrongly disagree

Should have law for disclose to regular partner

16.46%

30.74%

32.91%

14.65%

5.063%.1808%

strongly agree agree

unsure disagreestrongly disagree 7

HCW should have right to disclose to third party when needed

law enforces PWHA disclose to law enforces PWHA disclose to regular partnerregular partner 75%75%

In case patients deny to In case patients deny to disclose and partners have disclose and partners have risk of getting infection, HCW risk of getting infection, HCW should have protected right to should have protected right to inform partnerinform partner 47%47% law enforces PWHA disclose to law enforces PWHA disclose to sexual partnersexual partner 70%70%

DiscussionDiscussion HCWs see Prevention with Positives as priority , HCWs see Prevention with Positives as priority ,

barriers are such as limitation of time and skill of barriers are such as limitation of time and skill of personnel. personnel.

Condom promotion is the most sexual health Condom promotion is the most sexual health promotion intervention in clinical setting. promotion intervention in clinical setting.

Prevention among HIV patients is needed as low Prevention among HIV patients is needed as low abstinence rate, significant unsafe sex and abstinence rate, significant unsafe sex and nondisclosure from view of providers. nondisclosure from view of providers.

Demand for disclosure is clear. Ethical dilemma on Demand for disclosure is clear. Ethical dilemma on disclosure remains unresolved, with conflicts between disclosure remains unresolved, with conflicts between right right

(privacy of patients) and right to be informed of their (privacy of patients) and right to be informed of their partners.partners.

Strategy for Positive Strategy for Positive preventionprevention

(International HIV/AIDS alliance)(International HIV/AIDS alliance) Individually focused health educatio

n and support Ensuring access, scaling up and impr

oving service delivery Community mobilisation Advocacy and policy change

Ethical dilemma facing Ethical dilemma facing HCWHCW

ConfidentialityConfidentiality

VSVS Duty to warnDuty to warn

Disclosure and notificationDisclosure and notificationUNAIDS :hUNAIDS :httpttp://://datadata..unaidsunaids..orgorg//pubpub//BaseDocumentBaseDocument

2008/20080731_jc1513_policy_2008/20080731_jc1513_policy_criminalization_encriminalization_en..pdfpdf

Some countries enact legal obligation to Some countries enact legal obligation to disclose HIV status to partner or HCWdisclose HIV status to partner or HCW

UNAIDS does not support due to right UNAIDS does not support due to right to privacy of health status, stigma, to privacy of health status, stigma, discrimination and violencediscrimination and violence

All people have the ethical obligation not to harm others

Empower HIV-positive people to Empower HIV-positive people to practice safer sex and/or voluntarily practice safer sex and/or voluntarily disclosedisclose

C riteria to inform their patients’ sexual partners of the HIV status of their patien

t. The International Guidelines on HIV/AIDS and Human Rights

httphttp://://datadata..unaidsunaids..orgorg//pubpub//BaseDocumentBaseDocument//2008/20080731_jc1513_policy_crimin2008/20080731_jc1513_policy_crimin

alization_enalization_en..pdfpdf thoroughly counselled. failed to achieve appropriate behavioural ch

anges. refused to notify or consent to the notificatio

n A real risk of HIV transmission. reasonable advance notice. - conceale identity of the HIV positive person

from the partner(s) Follow up to ensure support

Ethical dilemma facing Ethical dilemma facing PWHAPWHA

Right to confidentiality VS Right to Right to confidentiality VS Right to be informed be informed

Do no harm to other VS Right to Do no harm to other VS Right to privacy and avoid stigma and privacy and avoid stigma and discriminationdiscrimination

Criminalization of HIV Criminalization of HIV transmissiontransmissionUNAIDS and UNDPUNAIDS and UNDP

httphttp://://datadata..unaidsunaids..orgorg//pubpub//BaseDocumentBaseDocument//2008/20080731_jc1513_policy_crimin2008/20080731_jc1513_policy_criminalization_enalization_en..pdfpdf Should be applied only in overt case; Should be applied only in overt case;

knowing their status, intentionally act, knowing their status, intentionally act, does in fact transmit.does in fact transmit.

could increase stigma and could increase stigma and discrimination discrimination

Drive PWHA from treatment and Drive PWHA from treatment and preventionprevention

Establishment of fact is difficultEstablishment of fact is difficult No evidence of deterring behavior. No evidence of deterring behavior.

Thai law related to HIV Thai law related to HIV disclosuredisclosure

National Health Act- personal health National Health Act- personal health information is protected under privacy information is protected under privacy law except that when other law allows. law except that when other law allows.

State Information Act- personal medical State Information Act- personal medical record cannot be disclosed to others(record cannot be disclosed to others(ม่าตรา ม่าตรา 15) except that disclosure is benefit for 15) except that disclosure is benefit for benefit or health of others(benefit or health of others(ม่าตรา ม่าตรา 20) .20) .

Criminal Code- doctor, nurse have liability Criminal Code- doctor, nurse have liability if they disclose patient information and if they disclose patient information and cause adverse effect on patient cause adverse effect on patient

QuestionsQuestions

How to resolve disclosure of HIV dilemmaHow to resolve disclosure of HIV dilemma Which ethical principle dominate.Which ethical principle dominate. Disclosure need law or ethic.Disclosure need law or ethic. What is the best strategy for PwP: What is the best strategy for PwP:

individual counseling, community individual counseling, community mobilization, social marketing or law and mobilization, social marketing or law and policy.policy.

What is public opinion to this dilemmaWhat is public opinion to this dilemma Status Quo or Proactive policyStatus Quo or Proactive policy

Proposal for further Proposal for further studystudy

Qualitative and quantitative study Qualitative and quantitative study about public /professional opinion on about public /professional opinion on disclosure issue among vulnerable disclosure issue among vulnerable group and stakeholdergroup and stakeholder

Follow up study for change of opinion Follow up study for change of opinion of HCW in one year after PwP in of HCW in one year after PwP in clinical setting implementation clinical setting implementation

Experimental study of effectiveness of Experimental study of effectiveness of PwP program is ongoing.PwP program is ongoing.

AcknowledgementAcknowledgement

Bureau of AIDSBureau of AIDS Dr. Tawesak Nopkesorn, Naresuan Dr. Tawesak Nopkesorn, Naresuan

universityuniversity Dr. Rangsima Lohlekhla , TUC Dr. Rangsima Lohlekhla , TUC

ThailandThailand Staff of 12 regional DPC officeStaff of 12 regional DPC office All health care provider who attend All health care provider who attend

Prevention with Positives workshops.Prevention with Positives workshops.

Thank you for Thank you for your attentionyour attention