Hiv Treatment For Thai People - Approval For Medicine?

[mcmudden]

It's my understanding that the Thai government will provide - free of charge - the HAART medicine necessary for Thai citizens who are infected with HIV as soon as their CD4 drops to a certain level. Unfortunately, I keep getting different stories as to what CD4 level will trigger the approval of this medicine: 200, 250, or "it's up to the doctor".

My sweetie is affected by this situation, and hasn't been approved for the medicine yet, although his CD4 has fallen as low as 280. Of course, I worry about his long-term health, and I would feel a whole lot better if he were currently taking the medicine. Recently collected data has apparently compelled experts in Western countries to recommend starting the treatment at CD4 levels as high as 350 or even 500, but Thailand seems to still be operating with outdated standards.

Lastly, my partner and I live in Chiang Mai, and I don't know if the standards are different for different provinces.

Does anyone know anything about this, and if it's possible to get approval at levels higher than 200?

Many thanks!

Edited December 29, 2012 by mcmudden

[beano2274]

You can get it free of charge that is correct, I thought that there was not a limit to the CDC count. The one thing that I would think about is that, if your sweetie does register for free treatment, does this in any way get corresponded to his employer.

If your sweetie wants to pay for the bills it can be upto 5000per month, so I see your point about getting the free treatment.

[endure]

This is probably better off in the health forum. Moved.

[Sheryl]

The Thai AIDs program recommends treating ince the CD4 is below 350, this is the first I have heard of a lower cut off under Social Security and it is hard to believe. Suggest contacting the local Social Security Office.

the "up to the doctor" part refers to the fact that HAART can be started at any CD4 level if the person is symptomatic e.g. has had/has AIDs related illnesses.

[Sheryl]

P.S> I also suggestcontacting the Thai Network of People Living with HIV/AIDs

485/30 Soi Charoen Wat Gate, A. Muang, Chiang Mai 50000.

Tel: 053-304-045 Fax: 053-245-775.

Email:. [email protected]

They will know for sure, and may be able to help run interference if needed

[mcmudden]

P.S> I also suggestcontacting the Thai Network of People Living with HIV/AIDs

485/30 Soi Charoen Wat Gate, A. Muang, Chiang Mai 50000.

Tel: 053-304-045 Fax: 053-245-775.

Email:. [email protected]

They will know for sure, and may be able to help run interference if needed

Thanks a lot for all the information!

[mcmudden]

An update on everything I've learned about this: the Thai Social Security department has indeed modified its guidelines (apparently as of October 2012) for HIV patients, to recommend that anyone with a CD4 level below 350 begin taking the medicine. However, the implementation of this national policy is very inconsistent, and is very much dependent upon which hospital is providing the patient care. It's my conclusion that private hospitals have been much slower to follow the new guidelines than the public hospitals.

My partner (who is HIV-positive, and a member of the Thai Social Security system) originally had registered himself for Social Security purposes to receive treatment (for any ailment) with a private hospital here in Chiang Mai. So he and I went to the HIV department of this hospital in January 2013 to get an updated CD4 test and speak to the doctor about starting the medication. Because I was with my partner at the time, I could watch what was playing out first-hand, and I was seriously disappointed, even shocked, with the "professionalism" of the medical staff. The CD4 test result was 321, and after a few quick questions from the doctor about whether he had any symptoms, the doctor declared him in good health, and told him to come back in a few months (I don't remember if it was 3 months, or 6) for another CD4 test and subsequent consultation. However, because I had previously educated my partner about the importance of starting the medicine soon, he pressed the doctor for this, and so the doctor relented, and wrote a prescription for a two-week supply. This was a good thing, but that's where it ended. The doctor then suggested that we come back in two weeks to meet with a different doctor in the same HIV department who could speak English, in order to directly answer any questions that I might have, and so we scheduled this followup appointment. My impression was that the doctor was trying to quickly deal with the large queue of HIV patients in a very short period of time, giving each maybe around 2-3 minutes. And based on feedback from my partner, the nurses appeared to be on a power trip in the midst of a group of nervous, uneducated HIV patients who were desperately happy to have anyone who seemed to be addressing their serious healthcare issue.

Anyway, because I had previously researched the subject, I was already aware of the importance of:
- knowing about the existence of any other yet untreated diseases in the HIV patient (like Hep B, Hep C, TB) before starting HIV meds;
- verifying whether the patient was currently taking any medications which might cause a drug interaction with the HIV meds;
- establishing a medical baseline (including a complete blood test, and possibly a viral load test and HIV drug resistance test) for the HIV patient before starting any HIV meds.

But the doctor hadn't bothered with (or mentioned) any of this. When I asked about Hep B (as an example), they said that my partner's medical record indicated that he was Hep B-negative, although he had never been tested for this. When confronting the nurse with this information, she expressed surprise and "wondered" how the incorrect information could have been entered into his medical record.

Shortly after leaving the doctor, his staff handed over the pills, one of the usual "cocktail" regimens which included three medicines. So now we had the pills, but because I was concerned about the lack of all the other information (and preparation) mentioned above, I recommended to my partner that he not yet start taking the pills, and to just keep them in the refrigerator until we were both sure about everything else.

Two weeks later, we went to the followup appointment, during which the authoritarian nurses berated my partner for not yet starting the medicine. The (English-speaking) doctor also challenged him about this, and so the doctor and I had a direct conversation, during which I voiced all my medical concerns. The doctor's (admittedly somewhat apologetic) response was that the policy he was supposed to follow was to only prescribe medicine to HIV patients who either:
- were Hep B positive
- were pregnant
- were seriously symptomatic
- or had CD4 levels below 200.

So, even though the previous doctor had provided the meds, this doctor felt that this approach was inappropriate. It wasn't clear if he would have renewed the prescription if my partner had actually started taking the medicine, and had used up the limited pill supply which had previously been provided.

My concern at this point was to identify a qualified doctor within the Thai Social Security system who would follow the October 2012 HIV guidelines, and prescribe the correct medicine in the context of having already gathered all the important information mentioned above, within the limits of what the Social Security system would pay for. My partner and I had already decided that we were willing to pay for any important tests if Social Security would not, in order to give him the best treatment possible.

Because of information provided in this thread by Sheryl (and thank you, thank you, thank you), we contacted both the Social Security department, and also the Thai Network of People Living with HIV/AIDS. We spoke at length with a rep from the Thai Network (who was very helpful, and who spoke English relatively well), who basically told us that the public hospitals will give much better care for HIV Social Security patients than the private hospitals. We also learned that the Social Security system allows a period of time every year (January through March, apparently), during which any member can elect to change which hospital they use. After considering several options, we consulted with an HIV doctor at a public hospital in our area which we learned has a very proactive, helpful (and, dare I say it, CARING) staff of people in the HIV department. During this visit, we spent over an hour in actual consultation with the doctor and nurses, much of it with the doctor. They were very patient and informative, and answered every question that I had. I was ecstatic at having found this jewel of a resource, especially after my previous experience with the Soviet-style healthcare people in the private hospital. My partner agreed, and has since changed his Social Security registration to this public hospital.

Over the next couple of weeks, my partner and I went out (on our own) to a medical lab and had him tested for Hep B, Hep C, Syphilus, and did a TB skin test, all of which fortunately came back negative. And after having consulted with the doctor at the public hospital, we also decided to have my partner tested for HIV drug resistance. We're currently awaiting the results of the drug resistance testing, at which point we intend to present them to the new doctor at the public hospital so that he can make an informed decision about the best regimen of medicine to use. Hopefully, within the next couple of weeks, my partner will be taking the medicine, and will be well on his way to an undetectable viral load and a more normal CD4 count, not to mention some peace of mind about the entire issue.

Lastly, for what it's worth, I've attached a couple of PDF files which describe (in both English and Thai) what the current HIV treatment guidelines are, for anyone who might benefit:

ThaiGuidelineonHIVdiagnosisandtreatment2010.pdf

Thai HIV ART guidelines.pdf

[Sheryl]

Many thanks for the update. Your partner is fortunate to have you.

[mcmudden]

Many thanks for the update. Your partner is fortunate to have you.

And we, you!

[geriatrickid]

Another group you may wish to contact is the Thai AIDS Treatment Action Group (TTAG) it is linked in to a broader umbrella group.

As a side note, there are some hidden opportunities in respect to medication and access to innovative intervention. Use of the public system allows one to access some of the programs that pop up. Almost all of the foreign funding for these programs is channeled through the MoH and offered via the public system. The key is to keep reminding your primary care physician that you are open to participating in potential clinical trials and any program made available through groups such as the Bill Clinton Foundation or the US CDC and NIH. In the past these groups have funded medication for both innovative drugs and the standard drugs. The advantage of a clinical trial participation is that that there is a 50% chance of being in the control group which means all regular treatment medications are taken care of, and the other 50% chance of being in the trial therapy is that there is a possibility of having access to something that works better. Although the downside is that the subject regimen may not be effective, the close monitoring should allow for a quick intervention if something doesn't work. The overall benefit is that the access to lab tests is paid for and the surveillance and access to medical personnel is excellent. My point is that one has to ask, and to keep asking. Often the formal notices that are posted on funding websites don't specify which hospials are participating, so it is best to ask your attending physician about availability.

In respect to the negative impression obtained via the private hospital, IMO it is attributable to the limited opportunity for chargebacks to the MoH. In plain language, the private sector cannot make money from a public benefits patient and the incentive then is to discourage them from seeking treatment at a private facility. My personal opinion and bias, but I base it upon where the funding goes and the intent of the MoH to disburse within the public system along with foreign funders' rules that their programs are not for profit.

[mcmudden]

Another group you may wish to contact is the Thai AIDS Treatment Action Group (TTAG) it is linked in to a broader umbrella group.

As a side note, there are some hidden opportunities in respect to medication and access to innovative intervention. Use of the public system allows one to access some of the programs that pop up. Almost all of the foreign funding for these programs is channeled through the MoH and offered via the public system. The key is to keep reminding your primary care physician that you are open to participating in potential clinical trials and any program made available through groups such as the Bill Clinton Foundation or the US CDC and NIH. In the past these groups have funded medication for both innovative drugs and the standard drugs. The advantage of a clinical trial participation is that that there is a 50% chance of being in the control group which means all regular treatment medications are taken care of, and the other 50% chance of being in the trial therapy is that there is a possibility of having access to something that works better. Although the downside is that the subject regimen may not be effective, the close monitoring should allow for a quick intervention if something doesn't work. The overall benefit is that the access to lab tests is paid for and the surveillance and access to medical personnel is excellent. My point is that one has to ask, and to keep asking. Often the formal notices that are posted on funding websites don't specify which hospials are participating, so it is best to ask your attending physician about availability.

In respect to the negative impression obtained via the private hospital, IMO it is attributable to the limited opportunity for chargebacks to the MoH. In plain language, the private sector cannot make money from a public benefits patient and the incentive then is to discourage them from seeking treatment at a private facility. My personal opinion and bias, but I base it upon where the funding goes and the intent of the MoH to disburse within the public system along with foreign funders' rules that their programs are not for profit.

Many thanks for your input above. I'll mention to my partner about the possibility of his participation in a clinical trial, and maybe both of us can have a chat with his HIV doc about this as well. And I'll make a note about the alternative HIV support organization that you mention above, it certainly couldn't hurt.

As far as your comment about the private hospitals, although I was unaware of the specifics of funding for HIV patients, I had already come to the conclusion that it was a lack of opportunity for profit that explained the disinterest on the part of private hospitals to treat HIV patients. Your observations further reinforce my earlier conclusion. After all, it makes sense: private hospitals are like any other business--they seek profit, above all. There are parallels with HMO's in my home country!

[Sheryl]

I believe that the Thai SS system operates on a capitation basis, meaning that hospitals in the scheme get paid a flat amount for each eligible person enrolled there regardless of services rendered. This alone makes many private hospitals unwilling to be in the scheme. Those who are in it, have every motive to try to minimize the cost of the care they provide under it, since they will not only make less money, they may even lose money by providing costly services.

Anyone under the SS scheme is thus best advised to register at either a government hospital or a non profit.

[Potosi]

If he doesn't get it for free, buy it. Costs 800 Baht per month at the government hospitals.