Lessons Learned

Because the HIV/AIDS epidemic continues in Thailand, the Thai Red Cross foresees the necessity of maintaining the zidovudine donation programme. Several plans, with some modification, have been laid out for the continuation of the programme.

We have recently analysed the data from this programme. The analysis showed that the transmission rate in women who received zidovudine less than or equal to 8 weeks before delivery was not statistically different from the transmission rate in those who received zidovudine more than 8 weeks before delivery (3.4 per cent and 6.5 per cent, respectively). In response to this finding, by late 1999 the Thai Red Cross advised that antepartum zidovudine for pregnant women in this programme should be started at 32 weeks’ gestation and be continued till labour. This will help save the fund and the medication without compromising the effectiveness of the regimen, enabling the programme to provide the medication to more women. The intrapartum and the neonatal components of this prophylactic regimen remain unchanged. Periodic assessments have taken place thereafter to assure that the transmission rate remains within an acceptable range.

Since the medical knowledge in the field of HIV evolves rapidly, the Thai Red Cross recognizes that this programme may need to be frequently updated to provide the greatest benefit to patients. A recent study from Uganda (HIVNET 012) compared the safety and efficacy of nevirapine with zidovudine in the reduction of mother-to-child transmission. Both medications were well tolerated with no different adverse events observed in both groups. The transmission rate was almost 50 per cent lower among those receiving nevirapine compared with those receiving the short-course zidovudine. This new information has led the Thai Red Cross to develop a new intervention strategy. In the year 2000, nevirapine as described in HIVNET 012 study will be incorporated into the programme’s regimen. Both zidovudine and nevirapine will be offered to all participating pregnant women and infants. Theoretically, using both medications together to tackle the virus may lead to further reduction of transmission.

The zidovudine donation programme has proved feasible and successful in the Thai setting. The next step that the Thai Red Cross plans is to communicate with hospitals that have not yet taken part in this programme. In addition, the Thai Red Cross has recently been made a UNAIDS collaborating centre. This will expand the role of the organization in this region. The model of this programme can possibly be used as a demonstration or a prototype for other countries in this region.

Despite its clear effectiveness, the programme has some weakness as follows:

* Although the health care providers are asked to return all follow-up forms, this is not mandatory in practice. Many patient forms were missing. This makes a retrospective assessment difficult.

* There is no direct information on patient’s adherence to the medication and to the medical follow-up. Without complete and accurate information, it is difficult to evaluate all aspects of the programme.

* Giving the nature that the programme is not a research project, some health care providers therefore did not send the infants’ dried blood spots for HIV testings. It is possible that some infants may not have been brought in for follow-up, some families may have relocated, and some infants may have been tested locally by their primary care physicians.

* Although the programme has been publicized for almost 4 years, some antenatal care facilities may not be aware of it. As a consequence, the pregnant women may not be adequately counselled, the decision to participate may not be appropriately reached and zidovudine prophylaxis may not be properly offered.

* Whereas the programme focuses on reducing the number HIV-infected children, the future of the uninfected children is not addressed, particularly the issue of orphaning. In addition, there are no set medical care plans for the infected parents. Multidisciplinary approaches are absolutely necessary to solve the problems of this magnitude.

Although no formal evaluations have taken place, the Thai Red Cross periodically arranges a meeting with all participating hospitals. The discussions are generally focused on the problems that health care providers and the Thai Red Cross have faced and how to solve them. This has led all parties to a better understanding and cooperation, which ultimately benefits pregnant women and children.