, 37449 , , , , , , . »...»" µå ¢Õß°"--°..."Õ¥ å Õ¬à"ß¡'ª­ ``º Health, Nutrition, and Population Series The Economics of »...»" µå Effective AIDS ¢Õß°"--°..."Õ¥ å Treatment Õ¬à"ß¡'ª­ ``º Evaluating Policy °"ª­¡`"ßÕ°TM`ß,¬"¬ Options for Thailand Ì"À--ª­»¬ Ana Revenga, ·Õ" «ß°â", Mead Over, ¡'È¥ ,Õ«Õå, Emiko Masaki, Õ¡`,°­ ¡"´"°`, Wiwat Peerapatanapokin, «`«--å æ'æ--,¿§`, Julian Gold, ®Y'¬ ,°¥å, Viroj Tangcharoensathien, «`,®å µ--Èß®` '¬, Sombat Thanprasertsuk ¡--µ` ·ª­ ` ÿ¢ With a Foreword by Sombat Thanprasertsuk, æâÕ¡§Ì"Ì"®"° æ. ¡--µ` ·ª­ ` ÿ¢ M.D., Ministry of Public Health, Thailand °­«ß "" ÿ¢ ª­»¬ With contributions from Tim Brown, Chris Duncombe, ¥â«¬°" -- ÿ®"° `¡ "«å, §` ¥--§Õ¡å, Jongkol Lertiendumrong, Seri Phongphit, ®ß° `»'¬¥Ì"ß, ' æß»åæ`» Bussaba Tantisak, and David Wilson ÿ..." µ--µ`»--°¥`Ï ·­ ¥«`¥ «` -- "§",° THE WORLD BANK «ÕTM`ßµ-- ¥'´' Washington, DC © 2546 "§"­À«à"ߪ­»æËÕ°"øóôøY·­æ--"/ "§",° 1818 ÕTM µ' ÕÁ ¥--`¬Y «ÕTM`ßµ-- ¥'´' 20433 ,»--æå 202-473-1000 Õ`µÕåÁµ www.worldbank.org Õ'¡å feedback@worldbank.org ß«`¢ ``ϵ"¡°ÆÀ¡"¬ 1 2 3 4 09 08 07 06 "¬ß"©--'È ®--¥Ì"¢÷È,¥¬§­Ì"ß"¢Õß"§"­À«à"ߪ­»æËÕ°"øóôøY·­æ--"/ "§",° °"§âæ °"µ'§«"¡ ·­°" ÿªµà"ßÊ 'Ë· ¥ß«â,,"¬ß"'È ¡à¥â®Ì"ªì«à"®­ ­âÕ÷ߧ«"¡§`¥ÀÁ¢ÕߺYâÕÌ"«¬°"`À"¢Õß"§",°ÀÕ¢Õß--"'˧­Ì"ß" ¥--ß°à"«ªìµ--«·Õ¬Yà "§",° ¡à--ª­°--÷ߧ«"¡Y°µâÕߢÕߢâÕ¡Y'ËÕ¬Yà,,"¬ß"©--'È ¢Õ¢µ ' À૬«--¥ ·­ ¢âÕ¡YÕËÊ'Ë· ¥ß,,·º'Ë,,¥Ê,,"¬ß"©--'È ¡`¥âÀ¡"¬÷ß°"µ--¥ `,,¥Ê ¢Õß"§",° °'ˬ« °-- "­"ß°ÆÀ¡"¬¢Õߢµ·¥,,¥Ê ÀÕ°"--ÕßÀÕ¬Õ¡--¢Õ¢µ¥--ß°à"«·µàÕ¬à"ß,,¥ ``·­°"Õÿ"µ ÈÕÀ"¢Õß `Ëßæ`¡æå©--'ȥ⮥`¢ ``Ï«â·â« °"§--¥Õ° ·­/ÀÕ à"¬,Õ"ß à« ÀÕÿ° à« ¢Õßß"æ`¡æå'È ,¥¬¡`¥â--Õÿ"µ Õ"®Õªì°"­¡`¥`¢ ``ϵ"¡°ÆÀ¡"¬ Õ¬à"ß°Áµ"¡ "ß "§"­À«à"ߪ­»æËÕ°"øóôøY·­æ--"/ "§",° -- ÿ°"º¬·æàß"TM`È'È ·­ ,¥¬--Ë«ª·â« ®­Õÿ"µ,,Àâ¡'°"®--¥æ`¡æå ૵à"ßÊ¢Õßß"¥--ß°à"«´È",¥¬--' À"°µâÕß°"¢ÕÕÿ"µÌ" Ì"" ÀÕæ`¡æå à«,,¥Ê¢Õß"¬ß"©--'È,,À¡à ,ª¥ àߧÌ"¢Õ æâÕ¡--Èß ¢âÕ¡Y,¥¬ ¡Yå¡"'Ë»Y¬å®--¥°"§«"¡'¬âÕ¬¥â"`¢ ``Ï: The Copyright Clearance Center Inc., 222 Rosewood Drive, Danvers, MA 01923, USA; ,»--æå: 978-750-8400; , ": 978-750-4470; Õ`µÕåÁµ: www.copyright.com Ì"À--§Ì""¡ÕËÊ°'ˬ«°-- ``·­`¢ ``Ï «¡--Èß ``,,°"ªìµ--«· °ÿ"µ`¥µàÕ Office of the Publisher, The World Bank, 1818 H Street NW, Washington DC 20433, USA; , ": 202-522-2422; Õ'¡å: pubrights@worldbank.org ISBN >10: 0-8213-6755-2 eISBN: 0-8213-6756-0 ISBN-13: 978-0-8213-6755-1 DOI: 10.1596/978-0-8213-6755-1 ¥â¡'°"¢Õ,,Àâ«¡«â,,"¬°"¢âÕ¡Y `Ëßæ`¡æå¢ÕßÀâÕß ¡ÿ¥-- ¿"·â« "-- ËÕß,,°Õ Yªª­°Õ ·º'Ë ·­µ""ß vii §"Õÿ`» xiii §"" ,¥¬ æ. ¡--µ` ·ª­ ` ÿ¢ xv °`µµ`°¡ª­°"» xvii §"¬àÕ xix ÿª "À--ºYâ`À" xxi 1. §"" 1 2. ,§­"¥Õ¥ å,,ª­»¬,,ªí®®ÿ-- 11 3. 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"°"å'˧"¥«à"®­°`¥¢÷ȵ"¡"ßÕ°µà"ßÊ ,, à«'Ë°'ˬ«¢âÕß °--,§ß°" NAPHA 141 5.2 ®"«ºYâ '¬TM'«`µ'˪ÑÕß°--¥âµ"¡'˧"¥ª­¡"«â ¿"¬,,µâ "°"å '˧"¥«à"®­°`¥¢÷ȵ"¡"ßÕ°µà"ßÊ ,, à«'Ë°'ˬ«¢âÕß°--,§ß°" NAPHA 141 5.3 ®"«ºYâµ`¥TMÈÕ«-- ÕTMÕ«''Ë¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å µ"¡'˧"¥ª­¡"«â ¿"¬,,µâ "°"å'˧"¥«à"®­°`¥¢÷ȵ"¡"ß Õ°µà"ßÊ ,, à«'Ë°'ˬ«¢âÕß°--,§ß°" NAPHA 142 5.4 ®"«Õ"¬ÿ¢--¬'Ë--°..."«â¥âµ"¡'˧"¥ª­¡"«â ¿"¬,,µâ "°"å '˧"¥«à"®­°`¥¢÷ȵ"¡"ßÕ°µà"ßÊ ,, à«'Ë°'ˬ«¢âÕß°--,§ß°" NAPHA 142 5.5 °"§"¥ª­¡"µâÿ,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ,, "°"å'˧"¥«à"®­°`¥¢÷È--Èß 'Ë· 143 5.6 ª­ ``º"ߥâ"µâÿ¢Õß,§ß°" NAPHA ·­ "°"å ¡¡µ`µà"ßÊ¡ËÕ'¬°-- â" 144 5.7 ª­ ``º¥â"µâÿ¢Õß "°"å"ßÕ°µà"ßÊ'Ë --¡æ--å°-- ,§ß°" NAPHA 145 5.8 µâÿ°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢Õß,§ß°" NAPHA ·­ "°"åµà"ßÊ'˧"¥«à"®­°`¥¢÷ÈÀ"°¡'°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (ART) 147 5.9 §«"¡ "¡",,°"®à"¬§à"--°..."¥â«¬¬"µâ"«-- Õ¥ å ·¬°µ"¡ ­¥--"¬¥â 150 x ËÕß,,°Õ Yªª­°Õ ·º'Ë ·­µ""ß 5.10 µâÿ°"--°..."¥â«¬¬"µâ"«-- Õ¥ åµ"¡'˧"¥ª­¡"«â ,, "°"å'Ë¡'°"¥"`,§ß°" NAPHA --Èß'Ë¡'°"--°...",, ¢--È'Ë Õß ·­'Ë¡à¡'°"--°...",,¢--È'Ë Õß 151 5.11 µâÿ·­ºª­,¬TM媭®"ªï®"°°"§"¥ª­¡" ,, "°"å 'Ë¥"`,§ß°" NAPHA ,¥¬¡à¡'°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ,,¢--È'Ë Õß 152 5.12 ª­ ``º"ߥâ"µâÿ¢Õß "°"å'Ë¥"`,§ß°" NAPHA ´÷Ëß¡' ·­¡à¡'°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,¢--È'Ë Õß 153 6.1 ºYâµ`¥TMÈÕ«-- ÕTMÕ«'"¬,,À¡à ·¬°µ"¡Õ--µ"°"µ`¥TMÈÕ,,°ÿࡺYâ'Ë-- °"--°..."¥â«¬¬"µâ"«-- Õ¥ å: "°"å'˧"¥«à"®­°`¥¢÷ÈÀ"° ¡'°"¥"`,§ß°" NAPHA 157 6.2 ¡Y§à"ªí®®ÿ-- ÿ`¢ÕßµâÿµàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â®"° "°"å ¡¡µ`°'ˬ«°--°"µ`¥TMÈÕ 158 6.3 §«"¡ÕàÕÀ«¢Õß°"«`§"­À媭 ``º"ߥâ"µâÿ'Ë¡' µàÕ"§"¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,¢--È·°·­¢--È'Ë Õß 160 6.4 §«"¡ÕàÕÀ«¢Õߪ­ ``º"ߥâ"µâÿ¢Õß,¬"¬ NAPHA 'Ë¡'µàÕæµ`°¡ 'Ë¬ß 163 ·º'Ë 2.1 §«"¡TMÿ°¢ÕßTMÈÕ«-- ÕTMÕ«'/Õ¥ å,,ª­»¬ ·¬°µ"¡®--ßÀ«--¥ 217 2.2 §«"¡TMÿ°¢ÕßTMÈÕ«-- ÕTMÕ«'/Õ¥ å ,,ª­»¬ ·¬°µ"¡Õ"¿Õ 218 2.3 °"§Õ§ÿ¡¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å "À--ºYâµ`¥TMÈÕ «-- ÕTMÕ«''Ë· ¥ßÕ"°" ·¬°µ"¡®--ßÀ«--¥ ¡'"§¡ æ.». 2547 219 2.4 °"§Õ§ÿ¡¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å "À--ºYâµ`¥TMÈÕ «-- ÕTMÕ«''Ë· ¥ßÕ"°" ·¬°µ"¡­¥--Õ"¿Õ·­®--ßÀ«--¥ 220 2.5 °"¢¬"¬,§ß°" NAPHA æ.». 2544-46 221 2.6 Õ--µ"°",,TMâ`°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ,ßæ¬""'Ë¢â" à«¡,§ß°" NAPHA 222 2.7 ,ßæ¬""'Ë¢â"à«¡,§ß°" NAPHA ·­°"¡'°ÿà¡ -- ÿºYâªÉ«¬ ·¬°µ"¡Õ"¿Õ æ.». 2547 223 µ""ß 1.1 "°"å ¡¡µ`'˧"¥«à"®­°`¥¢÷È,,TM`ß,¬"¬ "À--,§ß°" NAPHA 8 2.1 ®"«,¥¬ª­¡"¢ÕߺYâµ`¥TMÈÕÕTMÕ«'/Õ¥ å ­ ¡ æ.». 2547 14 2.2 "§"¢--ȵË",,°"--°..."¥â«¬¬"µâ"«-- Õ¥ å'Ë¥ß,,ª­»¬ 30 ËÕß,,°Õ Yªª­°Õ ·º'Ë ·­µ""ß xi 2.3 ®"«,¥¬ª­¡"¢ÕߺYâ'˵`¥TMÈÕÕ¥ å ºYâªÉ«¬Õ¥ å ®"«ºYâªÉ«¬Õ¥ å 'Ë¥â--"¬ß",,,ßæ¬""-- ·­°"¢â"÷ß°"--°..."¥â«¬¬"µâ" «-- Õ¥ å,,,ßæ¬""-- 31 2.4 ®"«¢ÕߺYâªÉ«¬'Ë¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,ª­»¬ ·¬°µ"¡¿Y¡`¿"§ ¥Õ¡'"§¡ æ.». 2547 32 2.5 ®"«ºYâªÉ«¬'Ë¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å(ART) ·¬°µ"¡ TM`¥¢ÕߺYâ,,Àâ°"--°..." ¥Õ¡'"§¡ æ.». 2547 35 2.6 ¬Õ¥¢"¬¬" GPO-vir ·¬°µ"¡¿"§ à« æ.». 2545-2547 36 2.7 ,§ß°"ª­°-- ÿ¢¿"æ,,ª­»¬ 39 2.8 §à",,TMâ®à"¬°'ˬ«°--Õ¥ å­¥--TM"µ` ·¬°µ"¡Àâ"'Ë æ.». 2543-2546 41 3.1 --°...­'˧--¥ ·­Õ--µ"§«"¡°â"«Àâ"¢Õß,§ ,,°ÿࡺYâªÉ«¬®"° °"µ`¥TMÈÕ«-- ÕTMÕ«''Ë¢â"à«¡,,°"»÷°..." ´÷Ëߥâ®--¥,,Àâ¡'¢÷È ,ßæ¬""®ÿÃ"ß°å¡À"«`¬"--¬ ª­»¬ 2541 48 3.2 Õ--µ"°"§«"¡ 'ˬß,,°"µ`¥TMÈÕ«-- ÕTMÕ«' ·¬°µ"¡«`'°"µ`¥TMÈÕ 49 3.3 §«"¡TMÿ°¢Õß,§µ`¥TMÈÕ©«¬,Õ°" "ß,§,,ÕÕ µ'¬ Õ`¥'¬ ¬ À--Õ¡`°" ·­´"Õ'å 2541 51 3.4 ®"«ºYâµ`¥TMÈÕÕTMÕ«' 'Ë¢â"--°"--°...",,§``°`"¡ ¿"°"TM"¥¬ ®--¥"¥--µ"¡ª`¡"´å CD4 ­À«à"ß æ.». 2540-2548 59 3.5 ®"«ºYâµ`¥TMÈÕÕTMÕ«' 'Ë¢â"--°"--°...",,§``°`"¡ ¿"°"TM"¥¬ ¡ËÕ´å CD4 ¡'§à"µË"°«à" 200 ´åµàÕY°"»°å¡``¡µ ­À«à"ß æ.». 2540-2548 60 3.6 §à" CD4 ·­§à"æ` --¬§«Õå (Interquartile range) ,,TMà«ßµ`¥µ"¡º ,, 15 --ª¥"Àåªì§--Èß'Ë 5 ¡ËÕ'¬°-- â" 68 3.7 §«"¡§`¥ÀÁ¢Õß·æ¬å÷ß "Àµÿ'Ë¡à§àÕ¬¡'°"ªØ`--µ`µ"¡«`'°"--°..." ¥â«¬¬"µâ"«-- Õ¥ åÕ¬à"ߧàߧ--¥ 72 3.8 º'˪쪥â¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ åµàÕ°"·æà ­"¥¢ÕßTMÈÕ«-- ÕTMÕ«' 78 3.9 µâÿ§à"¬"µâ"«-- µàÕºYâªÉ«¬À÷Ëß"¬ ·¬°µ"¡TM`¥¢Õß Yµ¬",, ª­»¬ æ.». 2547 82 3.10 µâÿ,¥¬©'ˬ¢Õß°"--°...",§µ`¥TMÈÕ©«¬,Õ°" µàÕºYâªÉ«¬'Ë¡à¢â" --°"--°..."¥â«¬¬"µâ"«-- µàÕªï ,,ª­»¬ 84 3.11 µâÿµàÕªï¢Õß°ÿà¡ -- ÿºYâµ`¥TMÈÕÕTMÕ«'·­ºYâªÉ«¬Õ¥ å µàÕ 200 °ÿà¡ æ.». 2547 85 3.12 µâÿµàÕªï µàÕºYâªÉ«¬À÷Ëß"¬ ·¬°µ"¡TM`¥¢Õß Yµ¬" 85 3.13 µâÿ,¥¬©'ˬ¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ 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¡¡µ`"¥â",¬"¬ "À-- "°"å'˧"¥«à"®­°`¥¢÷È À"°¡'°" ¥"`,§ß°" VCT, ,§ß°"`°" `¡æ`»... ·­--Èß Õß,§ß°" 140 5.3 "§"'Ë "¡"®à"¬¥â¥â«¬"¬¥â¢Õߧ--«Õ "À--°"--°..."¥â«¬ ¬"µâ"«-- Õ¥ å,,¢--È·°·­¢--È'Ë Õß 148 6.1 --¥ à«¢Õßæµ`°¡"ßæ»'Ë¡'§«"¡ 'Ë¬ß ´÷Ëߥâ--°"ªÑÕß°--¥â«¬ ÿ߬"ßÕ"¡--¬: °"µÕ Õߥâ"æµ`°¡"ßÕ°µàÕ§«"¡æâÕ¡ ,,°",,Àâ°"--°..." ¡¡µ`" "À--°"ª'ˬ·ªß¥â"æµ`°¡ 162 §Ì"Õÿ`» "¬ß"©--'È ¢ÕÕÿ`»,,Àâ·°à `,§-- æ §Õ Õ¥'µ®â"Àâ"'Ë¢Õß"§",° ºYâ,,Àâ §«"¡à«¡¡Õ°----"¬·­Õߧå°"Õ"¡--¬,°,,TMà«ßªï æ.». 2538-2540 ,, °"«`§"­Àåµâÿ·­ºª­,¬TMå¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,­¬­·° `,§-- æ §Õ ªìæËÕ ·­ºYâ,,Àâ§Ì"·­Ì"·°à§­®--¥Ì""¬ß"À"¬à" °àÕ 'Ëà"®­ '¬TM'«`µß°àÕ«--¬Õ--§« ¡ËÕ«--'Ë 19 °ÿ¡¿"æ--å æ.». 2543 xiii §Ì"Ì" æ«°"´÷Ëßà«¡,,,§ß°"ªÑÕß°--·­"ªíÀ"Õ¥ å­¥--TM"µ`·Ààß"TMÕ""®--° ¬ªìºYâ--º`¥TMÕ,,°"®--¥°"--æ¬"°--ÈßÀ¡¥´÷Ëß,,TMâ,,°"ªÑÕß°--¡`,,À⪭TM"TM µâÕßµ`¥TMÈÕ«-- ÕTMÕ«' ·­æËÕ,,À⧫"¡¥Y··­--°..."·°àºYâ'˵`¥TMÈÕ·â« ¥â«¬Àµÿ'È "®÷ßµ­À--°÷ߧ«"¡®Ì"ªì'Ë®­µâÕß â"ß ¡¥ÿ­À«à"ß°",,TMâ--æ¬"°,,¥â"°" ªÑÕß°--°--¥â"°"--°..." ·­TMà¥'¬«°--®â"Àâ"'Ë¢Õß,§ß°" "" ÿ¢,, ª­»ÕËÊ "¡--°®­ª­ 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§ 'Ëæ--"ª YàÕ"°"®ÁªÉ«¬Õ¬à"ßÿ·ß®"°,§ µ`¥TMÈÕ©«¬,Õ°" Õ--ªìº®"°°"µ`¥TMÈÕ ·­¡'ª­TM"TM®Ì"«,,°â§'¬ß°--'˵âÕß '¬TM'«`µª,,·µà­ªï¥â«¬,§·°´âÕ®"°Õ¥ å Õ°®"°'È ¬--ß¡'°"ª­¡`«à" ,, ªï æ.». 2547 ®­¡'ºYâµ`¥TMÈÕ"¬,,À¡àÕ'° 19,500 "¬ (¡ËÕ'¬°--ºYâµ`¥TMÈÕ"¬,,À¡à ®Ì"« 143,000 § ,,ªï æ.». 2537 ·­ 23,676 § ,,ªï æ.». 2545) --"·­ --ߧ¡¬¥â· ¥ß,,ÀâÀÁ÷ߧ«"¡¡ÿàß¡--ËÕ¬à"ß·ß°â"'Ë®­,,Àâ°"¥Y· ·­°" -- ÿ·°àºYâ'ËÕ¬Yàà«¡°--TMÈÕÕTMÕ«'/Õ¥ å (People living with HIV/AIDS- PHAs) Õ¬à"ߧ«ß® ¡ËÕ¡à"¡"'È --"¬æ`Ëß®­ "¡",,Àâ°"--°..."¥â«¬¬" µâ"«-- Õ¥ å·°àºY⧮Ì"«¡"°'Ë· ¥ßÕ"°"®"°TMÈÕ«-- ÕTMÕ«' (µ""ß ES1) ËÕß®"°°"'˪­»¬ "¡"º`µ¬"®'æ',Õ-«'¬å (GPO-vir)1 ÀÕ¬"'Ë¡' à« º ¡¢Õßµ--«¬" "¡TM`¥¥â¿"¬,,ª­» ¥â«¬"§"'Ë "¡"´ÈÕÀ"¥â (ª­¡" 1,200 " ÀÕ 30 À'¬ À--µàÕ¥Õ) ®÷ߪì°"ªî¥,Õ°" ,,Àâ·°àºYâ'ËÕ¬Yàà«¡ °--TMÈÕÕTMÕ«'/Õ¥ å®Ì"«¡"° ´÷Ëß°àÕÀâ"'È¡à "¡"®à"¬ß`,,Àâ°--°"--°..."¥â«¬ ¬"µâ"«-- Õ¥ å¥â ·­¬--ßTM૬,,Àâ°­«ß "" ÿ¢ "¡"¢¬"¬°"ߧå,, µ""ß ES.1 ®"«ºYâµ`¥TMÈÕ«-- ÕTMÕ«'/Õ¥ å ­ ¡,¥¬ª­¡" æ.». 2547 ®"« ­ ¡ ®"«ºYâµ`¥TMÈÕ«-- ÕTMÕ«'--ÈßÀ¡¥ (ºYâ,,Àà·­¥Á°) 1,074,155 ®"«ºYâ '¬TM'«`µ--ÈßÀ¡¥ (ºYâ,,Àà·­¥Á°) 501,600 ®"«ºYâµ`¥TMÈÕ«-- ÕTMÕ«''ˬ--ß¡'TM'«`µÕ¬Yà 572,484 ®"«§"¥ª­¡"¢ÕߺYâµ`¥TMÈÕ«-- ÕTMÕ«'"¬,,À¡à æ.». 2547 19,471 ®"«§"¥ª­¡"¢ÕߺYâªÉ«¬Õ¥ å"¬,,À¡à æ.». 2547 49,542 'Ë¡": §­Ì"ß"¢Õߪ­»¬æËÕ°"§"¥ª­¡"°'ˬ«°--TMÈÕ«-- ÕTMÕ«'/Õ¥ å æ.». 2547 ¿"æ ES.2 °"¢â"÷ß°"--°...""ß°"·æ¬å Ì"À--ºYâµ`¥TMÈÕ«-- ÕTMÕ«'/Õ¥ å ,,ª­»¬ pneumocystic carinii pneumonia ·­ cryptococcal meningitis) °"--°...",§µ`¥TMÈÕ©«¬,Õ°" ,¥¬--Ë«ª (TMà «--,§ °"--°..."¥â«¬¬"TM`¥¥'¬« (AZT) æ.». 2535-2538 °"--°..."¥â«¬¬" ÕßTM`¥ (AZT + ddl ·­ AZT + ddC) æ.». 2535-2539 §Õ¢à"¬°"«`®--¬"ߧ``° Ì"À--ºYâµ`¥TMÈÕÕTMÕ«' (°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¥â«¬ Yµ¬"'˺ ¡--Èß Õß·­ "¡TM`¥) æ.». 2540-2543 ,§ß°"¢â"÷ß`°"¬"µâ"«-- Õ¥ å­¥--TM"µ` Ì"À--ºYâµ`¥TMÈÕÕTMÕ«'/ Õ¥ å (NAPHA) µ--Èß·µà æ.». 2546 ÷ßªí®®ÿ-- 'Ë¡": °­«ß "" ÿ¢ æ.». 2547 ÿª Ì"À--ºYâ`À" xxiii ­¥--°«â"ß æËÕ,,Àâ,,TMâ¬"µâ"«-- Õ¥ åªì¡"µ",,°"--°..." ¥â«¬Àµÿ'È ®Ì"«ºYâ µ`¥TMÈÕ'Ë¢â"--°"--°..." ®÷ßæ`Ë¡¢÷È®"°ª­¡" 3,000 § ,,TMà«ßµâªï æ.». 2545 ¡"ªì 27,000 § ¡ËÕ `Ȫï æ.». 2546 ·­æ`Ë¡¢÷È÷ß 52,593 ¿"¬,,¥Õ °ÿ¡¿"æ--å æ.». 2548 ,§ß°"¥--ß°à"« à«À÷Ëߥâ--ÿ -- ÿ®"°°Õßÿ,° æËÕ°"µàÕµâ",§Õ¥ å «--,§ ·­¡"'¬ (Global Fund to Fight AIDS, Tuberculosis, and Malaria-GFATM) ·­Õ'° à«À÷Ëß¡"®"°ßª­¡"¢Õß--" ,,¢­¥'¬«°-- ®Ì"« "æ¬""¥âæ`Ë¡¢÷È®"° 112 ·Ààß ,,æ.». 2544 ¡"ªì 462 ·Ààß ¡ËÕµâªïæ.». 2546 ·­ 841 ·Ààß ¿"¬,,¥Õ°ÿ¡¿"æ--å æ.». 2548 µ""ß ES.2 · ¥ß÷ß«`«--"°"¢Õß®Ì"«ºYâµ`¥TMÈÕ«-- ÕTMÕ«'/Õ¥ å ,¥¬ ª­¡" «¡--Èß®Ì"«ºYâªÉ«¬Õ¥ å,¥¬ª­¡" ·­®Ì"«¢ÕߺYâ'Ë "¡"¢â"÷ß°" --°..."¥â«¬¬"µâ"«-- Õ¥ å®"°¿"§--,,ª­»¬ ·­¡ËÕ÷ß `Ȫïæ.». 2547 °«à" âÕ¬­ 80 ¢ÕߺYâµ`¥TMÈÕÕ¥ å ®­ "¡"¢â"÷ß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (ÕÕ"å') ®"°¿"§-- ´÷ËßÕ«à"ª­ §«"¡ Ì"Á®ªìÕ¬à"߬`Ëß ª­,¬TMå¢Õߧ«"¡æ¬"¬"¡'Ë®­ªÑÕß°--à«ßÀâ" §«"¡ Ì"Á®,,°"¥Ì"`,§ß°"¿" ¥â â"ߧ«"¡â""¬'Ë Ì"§--µàÕ--"¬·­ --ߧ¡¬ ,,­¬­«"æ'¬ß¡à°'˪ï¡ËÕºYâªÉ«¬Õ¥ å¡'TM'«`µ¬"«"¢÷ÈËÕß®"°°"--°..." ¥â«¬¬"µâ"«-- Õ¥ å ­ "" ÿ¢µâÕß,,Àâ°"¥Y·¡àæ'¬ß·µàºYâµ`¥TMÈÕ,,À¡à®Ì"« 10,000-20,000 "¬µàÕªï ·µà¬--ß«¡÷ߺYâµ`¥TMÈÕ§ÕËÊ'Ë "¡"¡'TM'«`µÕ¬Yà¥â" ¢÷È®"°¬"µâ"«-- Õ¥ å ª­»¬¡'·«,â¡'Ë¥''Ë®­ "¡"µÕ ÕßµàÕ§«"¡ â""¬'È¥â --Èß'ȥ⫬§«"¡¡ÿàß¡--Ë¢Õßÿ°¿"§ à«,, --ߧ¡¬ «¡--Èß»--°¬¿"æ¢Õß ­ "" ÿ¢À--°¢Õߪ­» ·­°"¥â--ÿ -- ÿ®"°¿"¬,,·­¿"¬Õ° ª­» °"'˪­»¬ "¡",,Àâ°"¥Y··°àºYâµ`¥TMÈÕ--ÈßÀ¡¥'È à«À÷Ëß°Áªìº ¡"®"°§«"¡ Ì"Á®¢Õߧ«"¡æ¬"¬"¡,,°"ªÑÕß°--'˺à"¡" °"µ`¥TMÈÕÕTMÕ«'·­®Ì"«ºYâªÉ«¬Õ¥ å®­µâÕß Yß°«à"'˪ì®`ß¡"°,,ÿ°«--'È (¿"æ ES.2) À"°ª"»®"°§«"¡ Ì"Á®,,°"ªÑÕß°--­¥--TM"µ`,,Õ¥'µ "¥âª­¡` «à" À"°¡à¡'§«"¡æ¬"¬"¡¥--ß°à"« ª­»¬®­µâÕß¡'ºYâµ`¥TMÈÕÕTMÕ«'÷ß 7.7 â" § ·­ºYâªÉ«¬Õ¥ å®Ì"« 850,000 § ,, æ.». 2548 ÀÕª­¡" 14 à"¢Õß ·µà­°ÿà¡¡ËÕ'¬°--®Ì"«'Ë°`¥¢÷È®`ß â"Õߧ`¥«à"ª­»¬®­µâÕß,,Àâ°"--°..." ¥â«¬¬"µâ"«-- Õ¥ å·°àºYâµ`¥TMÈÕ®Ì"«¡"°¢"¥'È ßª­¡"'Ë®Ì"ªì®­µâÕß¡"° °«à"'˪ìÕ¬Yà®`ß÷ß 14 à" ·­®­µâÕßæ`Ë¡¢÷ÈËÕ¬Ê ,,Õ'° `ªï¢â"ßÀâ" ·µàËÕß®"° §«"¡æ¬"¬"¡,,°"ªÑÕß°--Õ¬à"ß®`ß®--ß,,­À«à"ß æ.». 2534 ÷ß æ.». 2545 ª­»¬®÷ß¡àµâÕߺTM`§«"¡®Ì"ªì'Ë®­µâÕß,,TMâ®à"¬ß`®Ì"«æ`Ë¡¢÷È÷ß 18.6 æ-- À' À-- (745 æ--â"") Ì"À--°"--°..."µÕ¥TMà«ß `ªïª®÷ß æ.». 2555 ,,TMà«ß»«... 1990 (­À«à"ß æ.». 2533-43) ª­»¬¥â,,TMâß`¡"°°«à" ª­» à«,,Àà,,,§ß°"«-- ÕTMÕ«'/Õ¥ å §à",,TMâ®à"¬®"°ßª­¡"--ÈßÀ¡¥æËÕ °"ªÑÕß°--·­--°...",,­¬­¥--ß°à"« ¡'®Ì"«¡"°÷ß 434 â"À'¬ À-- µ"¡§à" ß`ªïæ.». 2545 (17.3 æ--â"") Õ¬à"ß°Áµ"¡ ®"°°"À'°'ˬߧ«"¡®Ì"ªì ¢ 2547 572,48461,394 81.4 ----- 52,593 2546 ·­°"¢â"÷ß°"--°..."¥â«¬¬"µâ" 603,942 62,871 27,158 43.2 122.6 2547 ° 2545 635,057 64,832 8,341 12.9 35.5 ° 2544 3.1 8.5 °­«ß "" ÿ¢ 665,344 67,057 2,095 2547; ° 2543 3.1 4.5 649,564 68,677 2,095 ·­§­ ,°¥å ° ®"«ºYâªÉ«¬Õ¥ å'Ë¥â--"¬ß",,,ßæ¬""-- 2542 1.6 4.0 2544; 719,765 68,311 1,095 ° ºYâªÉ«¬Õ¥ å 2541 1.7 4.0 740,349 65,333 1,095 ·Ààߪ­»¬ ° 2540 1.8 4.1 751,235 59,752 1,095 (§"¥ª­¡") ®"°¿"§-- ®"°¿"§-- 2545 ÕÕ"å 2548 UNAIDS ®"°,ßæ¬""-- ®"«,¥¬ª­¡"¢ÕߺYâ'ËÕ¬Yàà«¡°--TMÈÕÕTMÕ«'/Õ¥ å (§"¥ª­¡") ÕÕ"å ¡à¡'¢âÕ¡Y=--- ¥â®"° ¥Õ°ÿ¡¿"æ--å ES.2 °"§"¥ª­¡"®"°§­"ß"§"¥ª­¡"ºYâµ`TMÈÕ«-- ÕTMÕ«'/Õ¥ å µ--«¢¥--ß°à"« µ--«¢ xxiv µ""ß «-- Õ¥ å,,,ßæ¬""-- ºYâ'ËÕ¬Yàà«¡°--TMÈÕÕTMÕ«'/Õ¥ å(§"¥ª­¡") ºYâªÉ«¬Õ¥ å ºYâ--`°" ®"«¢ÕߺYâ'Ë¢â"--`°" ,¥¬§`¥ªìâÕ¬­¢Õß®"«ºYâªÉ«¬Õ¥ å,¥¬ª­¡" ®"«¢ÕߺYâ'Ë¢â"--`°"ÕÕ"å' ,¥¬§`¥ªìâÕ¬­¢Õß®"«ºYâªÉ«¬Õ¥ å'Ë¥â--"¬ß" 'Ë¡": À¡"¬Àµÿ: ° ¢ Executive Summary · xxv ÿª Ì"À--ºYâ`À" xxv ¿"æ ES.2 §«"¡ Ì"§--¢Õߧ«"¡æ¬"¬"¡,,°"ªÑÕß°--¡"°àÕ Figure ES.2 ImportanceofPriorPreventionEfforts 10 no intervention ¡à¡'°"·°·´ß (â"§) 8 (millions) ⪭· ¥ß÷ß `Ëß'ËÕ"®°`¥¥â line represents what might have been if 6 À"°¡à¡'°"ª'ˬ·ªß æµ`°¡ behaviors had not changed infections 4 ªÑÕß°--°"µ`¥TMÈÕ infections prevented HIV 2 baseline â" current 0 ®"«ºYâµ`¥TMÈÕÕTMÕ«',,ªí®®ÿ---- 1985 2528 2533 1990 1995 2538 2543 2000 2548 2005 2553 2010 Source: Brown and Peerapatanapokin 2004. 'Ë¡": "«å·­ æ'æ--,¿§` 2547 'Ë®­µâÕß®à"¬ß`®Ì"« 18.6 æ--â"À'¬ À-- (745 æ--â"") ,,TMà«ß `ªï in 2002 dollars (B 17.3 billion). However, by averting the need to µàÕ¡" ß`·µà­À'¬ (ÀÕ") 'Ë¥âßÿª,,TMà«ßæ.». 2533-43 ®­TM૬ spend US$18.6 billion (B 745 billion) over the subsequent decade, each ª­À¬--¥ß`¥â®Ì"« 43 À'¬ À-- (1,720 ") Ì"À--§à",,TMâ®à"¬,,°"--°..." dollar (or baht) invested in the 1990s saved US$43 (or B 1720) in 'Ë®Ì"ªì,,»«...µàÕ¡" needed treatment expenditure in the subsequent decade. It is doubtful that any other Thai government investment achieved such a high ´÷Ëߪì'Ëà" ß --¬«à" °"ßÿÕËÊ¢Õß--"¬®­ "¡"¥â--Õ--µ" ૺª­,¬TMå-µâÿ'Ë Yߢ"¥'ÈÀÕ¡à °­«ß°"§--ߢÕß ª­»µà"ßÊ TMà ®' ·­Õ`¥'¬ ´÷Ëß°"­"¥¢ÕßTMÈÕ«-- ÕTMÕ«'/Õ¥ å æ`Ëß®­Õ¬Yà benefit-cost ratio. The finance ministries of countries such as China ,,­¬­·° §«®­µ­À--°÷ߺµÕ·Õ¬à"ß Yß Ì"À--°"ߧåæËÕªÑÕß°--TMÈÕ and India, where the HIV/AIDS epidemic is at an earlier stage, should be aware of the high return to HIV/AIDS prevention campaigns when «-- ÕTMÕ«'/Õ¥ å ,,°"®--¥ ߪ­¡"¢â"¡¿"§ à«®"°ßª­¡"¢Õß-- they make intersectoral allocations of their governments' budgets. Even in Thailand, however, there is no room for complacency. Õ¬à"ß°Áµ"¡ °"¥Ì"`°",,ËÕߥ--ß°à"«'È,,ª­»¬¬--ߥ⺡àªì'Ëà" æ÷ßæÕ,,®--° ÷ß·¡â«à" ,¬"¬µà"ßÊ®­ª­ §«"¡ Ì"Á®,,°"¥°"µ`¥TMÈÕ"¬,,À¡à Although policies have been successful in lowering new infections, ·µà§«"¡TMÿ°¢ÕßTMÈÕ«-- ÕTMÕ«',,°ÿà¡'Ë¡'§«"¡ 'Ë¬ß Yß--Ȭ--ß§ß YßÕ¬Yà prevalence of HIV in high-risk groups is still high--especially,¥¬©æ"­ among Õ¬à"߬`Ëß ,,°ÿࡵà"ßÊ'Ë¡`¥âªìªÑ"À¡"¬Õ¬à"ß Ì"§-- Ì"À--°"ªÑÕß°--,,Õ¥'µ TMà those groups that past prevention efforts did not explicitly target, such ºYâ,,TMâ¬" æµ`¥TM`¥©'¥ ÀÕTM"¬'˧â"`°""ßæ» Õ°®"°'È ¬--ß¡'À--°"· ¥ß«à" as intravenous drug users (IDUs) or male sex workers. There is also º®"°,§ß°"ªÑÕß°--,,Õ¥'µ°Ì"--ß`Ë¡¥ß evidence that the effect of past prevention campaigns is waning. Recent °" Ì"«®·Ñ"­«--ßæµ`°¡ (Behavioral Surveillance Survey-BSS) ´÷Ëߥâ®--¥Ì"¢÷È¡ËÕ¡à"¡"'È · ¥ß,,ÀâÀÁ rounds of the Behavioral Surveillance Survey (BSS) show that the per- «à" Õ--µ" à«âÕ¬­¢ÕßÀ"°±åæ»TM"¬'Ë"¬ß"÷ߧ«"¡ --¡æ--å"ßæ»°--ºYâ§â" centage of male conscripts reporting sexual relationships with com- `°""ßæ»°--æ`Ë¡ Yߢ÷ÈÕ'°§--Èß,,ªï æ.». 2545-2546 À--ß®"°'Ë¥â¥ßª mercial sex workers, after declining for several years, has started to ·â«À"¬ªï Yª·¥'¬«°--¬--ßÀÁ¥âTM--¥ Ì"À--§YàÕæ»À`ß ·­,,°ÿà¡À" increase again in 2002 and 2003. The same pattern is visible with other °±å'Ë ¡ ·â«·­¡'æ» --¡æ--åÕ° ¡ ,,¢­¥'¬«°-- °",,TMâÿ߬"ßÕ"¡--¬ female sex partners and among married conscripts who have extramar- ,,°ÿà¡À"°±å¬--ß¡à Yß--° ¡'æ'¬ßâÕ¬­ 59 'Ë"¬ß"÷ß°",,TMâÿ߬"ßÕ"¡--¬ ital sex. Condom use among those male conscripts is not high: only 59 Õ¬à"ß ¡Ë" ¡Õ°--ºYâ§â"`°""ßæ» ·­¡'æ'¬ßâÕ¬­ 25 'Ë,,TMâÿ߬"ßÕ"¡--¬°--§Yà percent report consistent use of condoms with sex workers, and only 25 percent do so with nonregular female sex partners. New risk behav- Õæ»À`ßTM--Ë«§"« Õ°®"°'È "¬--ß®Ì"ªìµâÕß°à"«÷ßæµ`°¡ 'ˬß,,À¡àÊ,, iors by other groups, such as youth, also need to be addressed. °ÿà¡ÕËʥ⫬ TMà ,,°ÿ࡬"«TM xxvi »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ °"«--¥º¢Õß,¬"¬°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ËÕß®"°«--µÿª­ ߧå¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å §Õ°"¬¥Õ"¬ÿ ·­ª--ªÿß TM'«`µ¢ÕߺYâ--°"--°..." °±å«--¥ª­ ``º¢Õß,¬"¬®÷ߪì®Ì"«Õ"¬ÿ¢--¬ ÀÕ ®Ì"«ªï'˺Yâµ`¥TMÈÕ¡'Õ"¬ÿ¬¬"«¢÷È®"°°"¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ºYâ «"ß,¬"¬ ""­¡àæ'¬ß·µàµâÕßæ`®""÷ߺ"ߵߢÕß,¬"¬°'ˬ«°--°" `°"¥â«¬¬"µâ"«-- Õ¥ å'Ë¡'µàÕºYâµ`¥TMÈÕ'Ë--°"--°..."à"--È ·µà¬--ßµâÕߧÌ"÷ß÷ß º"ßÕâÕ¡¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å 'Ë¡'µàÕ°"°`¥°"µ`¥TMÈÕÕTMÕ«' "¬,,À¡à¥â«¬ TMà ¡'À--°"æ`Ë¡¢÷È'Ë· ¥ß,,ÀâÀÁ«à" ºYâµ`¥TMÈÕ'Ë--°"--°..."¥â«¬¬" µâ"«-- Õ¥ å ®­¡',Õ°" µ`¥TMÈÕµË"°«à"ºYâ'ˡ৬¥â--¬"µâ"«-- Õ¥ å ÀÕ ºYâ¥â --°"--°..."¥â«¬µ--«¬"æ'¬ßTM`¥¥'¬«ÀÕ ÕßTM`¥ªìÕ¬à"ß¡"° Õ¬à"ß°Áµ"¡ ¬--ß¡' À--°"Õ'°¡"°TM'È,,ÀâÀÁ«à" °"'˧ "¡"¢â"÷ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ¥â¡"°¢÷È--È Õ"®Ì"ª Y৫"¡ªàÕ¬ª­­¬ ·­æ`Ë¡æµ`°¡ 'ˬß,¥¬ºYâ'Ë¥â-- °"--°..."¥â«¬¬"µâ"«-- Õ¥ å ·­ ª­TM"TM'ËÕ¬Yà,,TMÿ¡TM·«¥âÕ¡ (¡à«à"®­¡'TMÈÕ ÕTMÕ«'Õ¬YàÀÕ¡à°Áµ"¡) (¥ÿ䧰Õå ·­§­ 2544; ,µå ·­§­ 2544; ·« ¥Õ « 2548) ,,°"ÕÕ°·,¬"¬ ®­µâÕßæ`®""÷ß°"ª­¡`º¢â"ߧ'¬ß¢Õß°"--°..." ¥â«¬¬"µâ"«-- Õ¥ å'Ë¡'µàÕª­TM"TMÕËÊÕ°ÀÕ®"°ºYâµ`¥TMÈÕ µ""ß ES.3 ¥â ·¬°ª­¿¢Õߺ"ßÕâÕ¡ (ÀÕº¿"¬Õ°) ÕÕ°ªìº"ߥâ"TM'«¿"æ·­º µ""ß ES.3 º'˪쪥â¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ åµàÕ°"·æà­"¥¢ÕßTMÈÕ«-- ÕTMÕ«' `»"ߢÕߺ°­ º¥' (",,Àâ°"·æà­"¥TMâ"ß) º '¬ (àß°"·æà­"¥,,ÀâÁ«¢÷È) ¥°"µ`¥TMÈÕ: °"Õ°æËÕ,,Àâ°`¥°"¥ÈÕ¬": ,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å °"'Ë¡à "¡",,°"°"­µ`¥¬"µâ"«-- Õ¥ å,§ß°" Õ"®¥ª`¡"«-- ,,°­· Õ¥ --°..."¥â«¬¬"µâ"«-- Õ¥ å¥âÕ¬à"ߧàߧ--¥--È ",,Àâ°`¥ ¥--ß--È ®÷ßÕ"®¥§«"¡ 'ˬß,,°"µ`¥ «-- "¬æ--å,,À¡à'Ë¥ÈÕ¬" ´÷Ëß",,Àâ°`¥°"·æà­"¥¥â æµ`°¡ TMÈÕ"ßæ» --¡æ--å ¡'°"µ`¥TMÈÕ,,­¬­«"¬"«"¢÷È: °"'˺Yâµ`¥TMÈÕ´÷Ëߢâ" à«¡,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¡'Õ"¬ÿ¬"¢÷È ",,Àâ°`¥º '¬Õ¬à"ß¡àµ--Èß,,® ,,°"æ`Ë¡­¬­«"'˺Yâµ`¥ TMÈÕÕ"®·æà°­®"¬TMÈÕ«-- ¥â TM`¥¢Õߺ°­ °"°­µÿâ,,Àâ°`¥°"ªÑÕß°-- ,¥¬ æµ`°¡ 'ˬß'Ëæ`Ë¡¢÷È: ©æ"­Õ¬à"߬`Ëß °"µ«® ÕæËÕ ºYâ'Ë¢â"à«¡,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ·­ºYâµ`¥TMÈÕ «``®©--¬: ,§ß°"--°..."¥â«¬¬"µâ"«-- ·­¡àµ`¥TMÈÕ«-- ÕTMÕ«',,TMÿ¡TM'Ë·«¥âÕ¡--È Õ"®¡' à« TM'«¿"æ Õ¥ å Õ"®æ`Ë¡Õ--µ"°"¥"`°`®°¡ à«¡,,æµ`°¡'Ë¡'§«"¡ 'ˬßæ`Ë¡¢÷È ¡"°°«à"'Ë®­ªì¡ËÕ æËÕªÑÕß°-- ,¥¬©æ"­°"¢,,Àâ`°" ¬--ß¡à¡',§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ª÷°..."·­°"µ«®Õ¥,¥¬ ¡--§,,® 'Ë¡": ,Õ«Õå ·­§­ 2547 ÿª Ì"À--ºYâ`À" xxvii "ߥâ"æµ`°¡®"°°"µ`¥TMÈÕ ,,·µà­ª­¿ º°­Àà"'È®­¡'ª­,¬TMå À"°TM૬TM­Õ°"µ`¥TMÈÕ¥â ÀÕªì,... â"Ì",,Àâ°`¥°"µ`¥TMÈÕ¡"°¢÷È °±å«--¥ §«"¡ Ì"§--¢Õߺ,,¥ÊÀà"'È §ÕÕ--µ"¢Õß°"µ`¥TMÈÕ«-- ÕTMÕ«'"¬,,À¡à ÀÕ Õ--µ"Õÿ--µ`°"å¢ÕßTMÈÕ«-- ÕTMÕ«' (HIV incidence rate) æËÕ'Ë®­§"¥ª­¡"÷ßµâÿ¢Õß,¬"¬--°..."¥â«¬¬"µâ"«-- Õ¥ å "¥â,,TMâ ¡¡µ`"'Ë'¬ßà"¬«à" µâÿ à«,,Àà¢Õß,§ß°" ®­°'ˬ«¢âÕß°--ºYâµ`¥TMÈÕ·µà­ "¬,,Yª¢Õß«",,°",,Àâ°"--°..." º`µ¿--±å¬" °"µ«®«`§"­Àå ·­«-- ¥ÿ `È ªÕß'Ë,,TMâ,,°"µ«®--°..." 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(°"--°...",,¢--È'ËÀ÷Ëß·­°"--°...",,¢--È'Ë Õß) «`'°",,Àâ`°" (°",,Àâ°"--°...",¥¬¿"§-- °",,Àâ°"--°...",¥¬¿"§--· `¡ æ`»... ·­°",,Àâ°"--°...",¥¬¿"§Õ°TM) ·­­¬­· ¥ßÕ"°"¢Õß,§ (TMÈÕ«-- ÕTMÕ«'·¡à· ¥ßÕ"°"·­· ¥ßÕ"°") Õ°®"°'È ¬--ß¡' ૪­°Õæ`»...ÕËÊ ,,°"ª­¡`µâÿ,¥¬©'ˬ¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ åµàÕºYâµ`¥TMÈÕ À÷Ëߧ ¥â·°àµâÿ§à"¬"µâ"«-- Õ¥ å (ÕÕ"å«') °"µ«®,,ÀâÕߪØ`--µ`°" ·­ °"µ«®µ`¥µ"¡Õ"°" «¡--Èßµâÿ,,°"--°...",§µ`¥TMÈÕ©«¬,Õ°" (OI) ·­§à" ,,TMâ®à"¬¢Õß°ÿà¡ -- ÿºYâ'ËÕ¬Yàà«¡°--TMÈÕÕTMÕ«'/Õ¥ å --Èß'È ¢âÕ¡Y°'ˬ«°--µâÿ --È ¥â®"°°"»÷°..."'Ë¥"`Õ¬Yà,,ª­»¬ --Èß'Ë¥â--°"µ'æ`¡æå·â«·­¬--ß¡à¥â --°"µ'æ`¡æå ·­®"°°",,Àâ§"ª÷°..."·¡àªì"ß°" ®"°ºYâTM'ˬ«TM"--Èß,, ­¥--âÕß`Ë·­­¥--""TM"µ` µ""ß ES.6 µâÿ§à"¬"µâ"«-- µàÕºâYµ`¥TMÈÕÀ÷Ëß"¬ ·¬°µ"¡TM`¥¢Õß Yµ¬",,ª­»¬ µâÿµàÕ¥Õ µâÿµàÕªï ¬"µâ"«-- " À'¬ À-- " À'¬ À-- Yµ¬"¢--È·° (·«ªØ`--µ`¢Õß°­«ß "" ÿ¢) (1) 3TC + d4T + nevirapine 1,200 30.0 14,400 360.0 (2) d4T + 3TC + efavirenze 2,579 64.5 30,948 773.7 AZT + 3TC + efavirenze 3,819 95.5 45,828 1,145.7 AZT + 3TC + nevirapine° 2,400 60.0 28,800 720.0 (3) d4T + 3TC + IDV/r 3,500 87.5 42,000 1,050.0 AZT + 3TC + IDV/r 4,740 118.5 56,880 1,422.0 µâÿ,¥¬©'ˬ 1,606 40.1 19,271 481.80 Yµ¬"¢--È'Ë Õß (·«ªØ`--µ`¢ÕßÕߧå°"Õ"¡--¬,°) ABC + ddl + LPV/r 22,822 570.6 273,864 6,846.6 ABC + ddl + SQV/r 22,094 552.4 265,128 6,628.2 µâÿ,¥¬©'ˬ 22,458 561.5 269,496 6,737.4 'Ë¡": "--°,§Õ¥ å «--,§ ·­,§µ`¥µàÕ®"°æ» --¡æ--å °­«ß "" ÿ¢ 2547; ¥--§Õ¡å 2547; ·­ Õߧå°"¿ --TM°¡ 2547 À¡"¬Àµÿ: µâÿ§à"¬"µâ"«-- Õ¥ å ®­¬÷¥µ"¡"§"µË" ÿ¥'ËÀ"¥â ¡à«à"®­ªì¬" "¡--ÀÕ¬"'Ë¡'¬'ËÀâÕ,,ª­» ¬ ¡ËÕ¥Õ°--¬"¬ æ.». 2547 Õ--µ"·°ª'ˬ 1 À'¬ À-- = 40 " °. Õߧå°"¿ --TM°¡°"--ßÕ¬Yà,,°­«°"º`µ¬" GPO-Z 'Ë¡' ૺ ¡§ß'Ë (AZT, 3TC ·­ nevirapine) µâÿ¢Õß GPO-Z Õ¬Yà'˪­¡" 1,400 " (35 À'¬ À--) µàÕ¥Õ xxxii »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ µ""ß ES.7 µâÿµàÕªï µàÕºYâµ`¥TMÈÕÀ÷Ëß"¬ ·¬°µ"¡TM`¥¢Õß Yµ¬" µâÿµàÕªï µàÕºYâµ`¥TMÈÕÀ÷Ëß"¬ "¬°"µâÿ ¢--È·° ¢--È'Ë Õß " À'¬ À-- " À'¬ À-- (1) §à"¬"µâ"«-- Õ¥ å (ÕÕ"å«') 18,847 471.2 263,567 6,589.2 (2) °"µ«® Õ,,ÀâÕߪØ`--µ`°" 1,210 30.3 1,210 30.3 (3) °"--°...",§µ`¥TMÈÕ©«¬,Õ°" 4,815 120.4 4,815 120.4 (4) `°"ºYâªÉ«¬Õ° 2,773 69.3 2,773 69.3 (5) `°"ºYâªÉ«¬,, 6,041 151.0 6,041 151.0 (6) §à"¬"µâ"«-- Õ¥ å·­ (1) + (2) 20,057 501.4 264,778 6,619.4 §à"µ«® Õ,,ÀâÕߪØ`--µ`°" (7) `°",ßæ¬"" (4) + (5) 8,815 220.4 8,815 220.4 (8) µâÿ ÕÕ"å' --ÈßÀ¡¥ (3) + (6) + (7) 33,688 842.2 278,408 6,960.2 'Ë¡": »ÿ¿--§§ÿµ` ·­§­ 2547 À¡"¬Àµÿ: µâÿµàÕºYâµ`¥TMÈÕÀ÷Ëß"¬ À¡"¬÷ßµâÿ©'ˬ¢Õß,ßæ¬""­¥--®--ßÀ«--¥·­­¥--TMÿ¡TM OPD > ºYâªÉ«¬Õ° IPD > ºYâªÉ«¬,, µ""ß ES.6 ÿª÷ßµâÿ¢Õß Yµ¬"µà"ßÊ ´÷Ëß¡'Õ¬Yà,,ªí®®ÿ-- ·­ Yµ¬"'Ë,,TMâ ¥â--°"·­"®"°°­«ß "" ÿ¢·­Õߧå°"Õ"¡--¬,° µâÿµàÕªï¢Õ߬" µâ"«-- Õ¥ å ®­·µ°µà"ß°--Õ¬à"ß¡"°,,­À«à"ß Yµ¬"'Ë,,TMâ,,°"--°...",,¢--È·° ·­¢--È'Ë ÕßµàÕºYâµ`¥TMÈÕÀ÷ËߧµàÕªï ®­`Ë¡µ--Èß·µà 14,400 " (360 À'¬ À--) (®"°°",,TMâ GPO-vir) ª®÷ß 273,864 " (6,847 À'¬ À--) (¡ËÕ,,TMâ protease inhibitors ´÷Ëß¡'"§"·æß) ૵âÿ,¥¬©'ˬ¢Õß Yµ¬"µâ"«-- Õ¥ å'Ë ,,TMâ,,°"--°..."¢--È·°µàÕºâYµ`¥TMÈÕÀ÷ËߧµàÕªï ¥â--°"ª­¡`«â'Ë 19,271 " (481.80 À'¬ À--) ,¥¬,,TMâ§à"©'ˬ (weighted average) ¢Õß Yµ¬"µâ"«-- Õ¥ å "¡ª­¿¿"¬,,µâ·«ªØ`--µ`,,°"--°..."¢Õß°­«ß "" ÿ¢3 ૵âÿ ,¥¬©'ˬ¢Õß Yµ¬"µâ"«-- Õ¥ å'Ë,,TMâ,,°"--°..."¢--È'Ë ÕßµàÕºYâµ`¥TMÈÕÀ÷Ëߧ Õ¬Yà'Ë ª­¡" 270,000 " (6,700 À'¬ À--) ´÷Ëß Yß°Õ 14 à"¢Õßµâÿ,¥¬ ©'ˬ¢Õß°"--°...",,¢--È·° Õ°ÀÕ®"°µâÿ§à"¬"µâ"«-- Õ¥ å·â« ¬--ß¡'µâÿÕËÊÕ'°¡"°'Ë°'ˬ«¢âÕß °--°",,Àâ°"--°..."·­µ«®µ`¥µ"¡°"--°..."¥â«¬¬"µâ"«-- Õ¥ å --Èß'È µâÿ¢Õß `°" "À--ºYâªÉ«¬Õ°·­ºYâªÉ«¬,,°Á¡àÕ"®¡Õߢâ"¡ª¥â ËÕß®"°°",,TMâ`°" "ß°"·æ¬å®­æ`Ë¡¢÷È¡ËÕ`Ë¡¥"`°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ®"°°" ª­¡"°"ÈÕߵ⠵âÿ,¥¬©'ˬµàÕªï "À--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,, °"--°..."¢--È·°¢ÕߺYâµ`¥TMÈÕÀ÷Ëß"¬µàÕªÕ¬Yà'˪­¡" 33,700 " (840 À'¬ À--) (,ª¥¥Yµ""ß ES.7) ૵âÿ§à"¬"µâ"«-- Õ¥ å·­°"µ`¥µ"¡ "ßÀâÕߪØ`--µ`°" Õ¬Yà'Ë°ÕâÕ¬­ 60 ¢Õßµâÿ--ÈßÀ¡¥ ¡ËÕ¡'°"--°...",,¢--È·° ·­¡ËÕºâYµ`¥TMÈÕÕ¬Yà­À«à"ß°"--°...",,¢--È'Ë Õß µâÿ¥--ß°à"« ®­æ`Ë¡¢÷ȪìâÕ¬­ 95 ¢Õߧà",,TMâ®à"¬,,°"--°..."¥â«¬¬"µâ"«-- Õ¥ å--ÈßÀ¡¥ ÿª Ì"À--ºYâ`À" xxxiii Executive Summary · xxxiii ¿"æ ES.4 ª­ ``º"ߥâ"µâÿ¢Õß,§ß°"¿" ´÷Ëß¡'°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (ÕÕ"å') ,,¢--È'ËÀ÷Ëß ¡ËÕª'¬'¬°--,§ß°"¿" ´÷Ëß¡'°"--°..."¥â«¬¬"µâ"«-- Õ¥ å Figure ES.4 Cost-EffectivenessofNAPHAwithFirst-LineARTComparedwithNAPHA (ÕÕ"å') --Èß Õߢ--È with Both First- and Second-Line ART 3,000 3%) at 2545 3 2,500 life-year US$2,145 per 2,000 ¢Õßæ.». cost âÕ¬­ discounted of 1,500 dollars value U.S. 1,000 US$736 ¥â«¬Õ--µ" à«¥ À'¬ À--µ"¡§à" present (2002 500 ¡Y§à"ªí®®ÿ-- ÿ`¢ÕßµâÿµàÕªï'ËÕ¥TM'«`µ net saved 0 NAPHA, first-line ART only NAPHA ´÷Ëß¡'°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (ART) ¢--È'Ë 1 NAPHA, first- and second-line ART NAPHA ´÷Ëß¡'°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (ART) ¢--È'Ë 2 'Ë¡":Source:Authors' °"«"ß,§ß â"ߢÕߺYâ¢'¬ construction. °"§âæ'Ë Ì"§-- Main Findings °"»÷°..."§--Èß'È Ì",,Àâ§â檭¥Á Ì"§--µà"ßÊ¥--ßµàÕª'È: The study has several significant findings. °"§âæ'Ë 1: ,§ß°"¢â"÷ß`°"¬"µâ"«-- Õ¥ å­¥--TM"µ` Ì"À--ºYâµ`¥ TMÈÕ·­ºYâªÉ«¬Õ¥ å (¿") ´÷Ëß¡' Yµ¬"--°..." Ì"À--¢--È·°à"--È ªì"ßÕ° Finding 1: NAPHA with First-Line Regimen Only Is the Most TM`ß,¬"¬'Ë¡'ª­ ``º"ߥâ"µâÿ¡"°'Ë ÿ¥,,¥",¬"¬µà"ßÊ 'ËÌ" Cost-Effective Policy Option of Those Studied ¡"»÷°..." ,§ß°"¿" 'Ë«¡©æ"­°"--°...",,¢--È·°à"--È ¡'µâÿ 736 À'¬ À-- ÀÕ NAPHA with first-line therapy only--at a cost of US$736 or B 29,440 29,440 " µàÕªï'Ë¡'TM'«`µÕ¥ ( "§"ªí®®ÿ--) ´÷ËßÕªì"ßÕ°TM`ß,¬"¬'Ë per discounted life-year saved--is the most affordable and cost- "¡"Ì"ª,,TMâ¥âßà"¬'Ë ÿ¥ ·­¡'ª­ ``º"ߥâ"µâÿ¡"°'Ë ÿ¥´÷Ëߥâ«"ßYª· effective policy option modeled in this report. Figure ES.4 presents «â,,"¬ß"©--'È ¿"æ ES.4 · ¥ß÷ßµâÿµàÕ®Ì"«ªï'Ë¡'TM'«`µÕ¥´÷Ëß--°..."«â¥â the cost per life-year saved of NAPHA without second-line drugs ,¥¬,§ß°"¿" ´÷Ëß¡à«¡°"--°...",,¢--È'Ë Õß ¡ËÕª'¬'¬°--µâÿµàÕªï'Ë¡' when compared to the cost per life-year saved of NAPHA with sec- TM'«`µÕ¥´÷Ëß--°..."«â¥â,¥¬,§ß°"¿" 'Ë¡'°"--°..."¢--È'Ë Õߥ⫬ ¥--ß--È °"§âæ ond-line therapy. The central finding is that the NAPHA program 'Ë Ì"§--§Õ ,§ß°"¿" ´÷Ëß¡'°"--°..."¢--È'Ë Õߥ⫬--È "¡"--°..."Õ"¬ÿ¢--¬ÀÕªï with second-line drugs can save years of life for US$2,145, (B 85,800), 'Ë¡'TM'«`µµàÕª¥â¥â«¬µâÿ 2,145 À'¬ À-- (85,800 ") ,,¢­'Ë,§ß°" whereas NAPHA with only first-line therapy is far more cost-effective ¿"´÷Ëß¡'°"--°..."¢--È·°æ'¬ßÕ¬à"ߥ'¬« ®­¡'ª­ ``º"ߥâ"µâÿ¡"°°«à" §Õ at US$736 (B 29,440) per discounted life-year saved. 'Ëdrugs,À'¬ À-- (29,440 ") µàÕªï'Ë¡'TM'«`µÕ¥,,Õ--µ" à«¥ 736 In the absence of significant change in the price of second-line line therapy is high when compared to the substantial health benefits À"°¡à¡'°"ª'ˬ·ªß,,¥â""§"¢Õ߬"'Ë,,TMâ,,°"--°..."¢--È'Ë Õß µâÿ,, the cost of saving an additional life-year through second- °"--°..."TM'«`µ,,ÀâÕ¥ªÕ'°À÷Ëߪï¥â«¬°"--°...",,¢--È'Ë Õß'È ®­Õ«à" Yß¡ËÕ'¬°-- ºª­,¬TMå"ߥâ" ÿ¢¿"æ'Ë¥â®"°,¬"¬°"--°...",,¢--È·°à"--È ¥--ß--È â" of first-line policy only. On a pure cost-effectiveness basis, a policy Ì"ª­¥ÁËÕߧ«"¡¡'ª­ ``º"ߥâ"µâÿ¡",,TMâªì§ËÕß¡Õæ'¬ßÕ¬à"ߥ'¬«,, with first-line therapy only would be superior. However, other consid- erations may weigh heavily on the government's final decision as to xxxiv »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ xxxiv · TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand °"µ--¥ `,,® ,§ß°"¿"'Ë¡'°"--°...",,¢--È·°à"--È®­ªì,¬"¬'ËÀÕ°«à" what policy to adopt. From the perspective of this study, affordability Õ¬à"ßTM--¥® Õ¬à"ß°Áµ"¡ °"µ--¥ `,,®¢--È ÿ¥â"¬¢Õß--",,°"Õ°¥Ì"` and equity are also relevant criteria. ,¬"¬®­µâÕßÕ"»--¬°"æ`®"",,¥â"ÕËʥ⫬ ®"°¡ÿ¡¡ÕߢÕß°"»÷°..."§--Èß'È §«"¡ "¡"'Ë®­Ì"ª¥Ì"`°"¥â·­§«"¡ªì¡Õªì°±å'˵âÕߧÌ"÷ß÷ß An argument for horizontal equity would compare NAPHA with and without second-line therapy to the cost of saving life-years through sub- TMà¥'¬«°-- sidized treatment of other adult illnesses, such as cancer, heart disease, or ¢âÕ,µâ·¬âßæËÕ§«"¡à"'¬¡°--,,·«Õ (Horizontal Equity)¥âª'¬'¬ end-stage renal disease. This comparison would show that NAPHA with ,§ß°"¿"'Ë«¡·­¡à«¡°"--°...",,¢--È'Ë Õß °--µâÿ,,°"--°..."TM'«`µ¢Õß second-line therapy is cost-effective relative to those other interventions. ºYâªÉ«¬¥â«¬,§ÕËÊ¢ÕߺYâ,,Àà ,¥¬'Ë¥â--°"Õÿ¥Àÿ®"°¿"§-- TMà ,§¡­Áß ,§ Advocates of vertical equity would argue that the government should À--«,,® ÀÕ,§µ¢--È ÿ¥â"¬ ૺYâ'Ë -- ÿ§«"¡à"'¬¡,,·«÷° ,§ß°"¿" ensure that the bottom of the income distribution has access to care that 'Ë«¡°"--°...",,¢--È'Ë Õß«â--È ¡'ª­ ``º"ߥâ"µâÿ¡ËÕ'¬°--°" the top one-fifth will purchase for themselves (including second-line Õÿ¥Àÿ'Ë--,,Àâ°--°"--°...",§ÕËÊ¥--ß°à"« ·­'¬°âÕß,,Àâ--" â"ߧ«"¡¡--Ë,,® therapy). «à" ª­TM"TM'Ë¡'"¬¥âµË"§«®­¡',Õ°" ,,°"¥â--°"¥Y·¥â" ÿ¢¿"æà"'¬¡°-- Finding 2: NAPHA with Second-Line Therapy Is Still Affordable ª­TM"TM´÷ËßÕ¬Yà,,°ÿà¡'Ë¡'"¬¥â­¥-- Yß ÿ¥ "¡"´ÈÕÀ"¥â¥â«¬µÕß («¡--Èß°" and Yields Large Benefits in Terms of Life-Years Saved --°...",,¢--È'Ë Õß) By 2015, the current NAPHA policy will have added about 220,000 °"§âæ'Ë 2: ,§ß°"¢â"÷ß`°"¬"µâ"«-- Õ¥ å­¥--TM"µ` Ì"À--ºYâµ`¥ people per year to the living population. Even at the end of the pro- TMÈÕ·­ºYâªÉ«¬Õ¥ å (¿") ´÷Ëß«¡°"--°...",,¢--È'Ë Õß¡'§«"¡ªìª¥â,,°" jection horizon, when the Thai AIDS epidemic is predicted to slow, Ì"ª,,TMâ·­,,À⪭,¬TMå¥â¡"°°«à",,·ßà¢Õß°"¬¥Õ"¬ÿ¢--¬ÀÕ®Ì"«ªï'Ë¡' the NAPHA policy will be saving about 190,000 life-years each year TM'«`µÕ¬Yà (Life-Years) (figure ES.5). Hence,10 percent more life-years would be saved under ¿"¬,,æ.». 2558 §"¥«à" ,¬"¬¿"'Ë,,TMâ,,ªí®®ÿ-- ®­Ì",,Àâ®Ì"«ª­TM"TM'Ë the current NAPHA policy than under an equivalent NAPHA with- ¬--ß¡'TM'«`µÕ¬Yàæ`Ë¡¢÷È 220,000 § µàÕªï ·¡â,,TMà«ßª"¬­¬­«"°"§"¥ª­¡" out second-line therapy. By keeping people alive longer, NAPHA will ¡ËÕ°"·æà­"¥¢Õß,§Õ¥ å,,ª­»¬`Ë¡ÿ"ß ,¬"¬¿" "¡" be associated with an increase in the number of HIV-infected people --°..."Õ"¬ÿ¢--¬«â¥â÷ß 190,000 ªï µàÕªï (¿"æ ES.5) ¥--ß--È "®÷ß "¡"--°..." Figure ES.5 Benefits(Life-YearsSaved)andCostsofNAPHArelativetoBaseline ¿"æ ES.5 ºª­,¬TMå (®Ì"«ªï'ËÕ¥TM'«`µ) ·­µâÿ¢Õß,§ß°"¿" ¡ËÕ'¬°-- â" µâÿ ÿ`¢Õß,§ß°" 250,000 600 net cost 200,000 500 of 400 ART saved 150,000 (2004 ART 300 100,000 US$ â"À'¬ À-- ®"«ªï'ËÕ¥TM'«`µ life-years 200 million) 50,000 100 0 0 25432000 252002 252004 45 47 49 51 53 252006 252008 252010 2555 2012 2014 2016 2018 2020 2022 2024 2557 2559 2561 2563 2565 2567 æ.».2547 ®"«ªï'ËÕ¥TM'«`µ life-years saved net cost of ART µâÿ ÿ`¢Õß,§ß°" ART Source: Authors. 'Ë¡": ºYâ¢'¬ Executive Summary · xxxv ÿª Ì"À--ºYâ`À" xxxv ¿"æ ES.6 À--ß®"° æ.». 2553 µâÿ à«,,Àà ®­ªìªæËÕ°"--°..."¢--È'Ë Õß Figure ES.6 After2010,MostCostsAreforSecond-LineTherapy 500 million) 450 (US$ 400 â"À'¬ À-- 350 300 ,¥¬¿"§-- (NAPHA) 250 ART 200 ART public 150 of 100 cost 50 0 µâÿ--ÈßÀ¡¥¢Õß,§ß°" total 2543 2545 2547 2549 2551 2553 2555 2557 2559 2000 2002 2004 2006 2008 2010 2012 2014 2016 252018 2020 2022 2024 61 63 25 2565 2567 cost of public ART, first-line, asymptomatic µâÿ°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢Õß¿"§--",,¢--È·° "À--ºYâªÉ«¬'Ë¡à· ¥ßÕ"°" µâÿ°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢Õß¿"§--",,¢--È·° "À--ºYâªÉ«¬'Ë· ¥ßÕ"°" cost of public ART, first-line, symptomatic cost of public ART, second-line, asymptomatic µâÿ°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢Õß¿"§--",,¢--È'Ë Õß "À--ºYâªÉ«¬'Ë¡à· ¥ßÕ"°" µâÿ°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢Õß¿"§--",,¢--È'Ë Õß "À--ºYâªÉ«¬'Ë· ¥ßÕ"°" cost of public ART, second-line, symptomatic 'Ë¡": ºYâ¢'¬ Source: Authors. À¡"¬Àµÿ: §Ì"«à" · ¥ßÕ"°" À¡"¬÷ߺYâµ`¥TMÈÕ'Ë· ¥ßÕ"°" ´÷Ëß¡'§à" CD4 µË"°«à" 50 ´åµàÕY°"»°å Note: The notation symptomatic refers to symptomatic patients whose CD4 counts are below ¡``¡µ ૧Ì"«à" ¡à· ¥ßÕ"°" À¡"¬÷ߺYâµ`¥TMÈÕ'Ë¡à· ¥ßÕ"°" ´÷Ëß¡'§à" CD4 Õ¬Yà­À«à"ß 50-200 50 cells per cubic millimeter. The notation asymptomatic refers to asymptomatic patients ´åµàÕY°"»°å¡``¡µ whose CD4 counts are between 50 and 200 cells per cubic millimeter. ®Ì"«ªï'Ë¡'TM'«`µ¿"¬,,µâ,§ß°"¿"'Ë,,TMâ,,ªí®®ÿ-- ¥â¡"°°«à",§ß°"¿"´÷Ëß¡à «¡°"--°...",,¢--È'Ë Õߥâ÷ßâÕ¬­ 10 --Èß'È ®"°°"'ËÌ",,À⪭TM"TM¡'TM'«`µ¬"« in Thailand, as well as with a significant increase in the number of "¢÷È ,§ß°"¥--ß°à"« ®÷ß¡'§«"¡ --¡æ--å°--°"æ`Ë¡®Ì"«ºYâµ`¥TMÈÕ«-- ÕTMÕ«' people living with HIV/AIDS who are on treatment. As a result, ,,ª­»¬·­°"æ`Ë¡®Ì"«ºYâµ`¥TMÈÕÕTMÕ«'/Õ¥ å'ËÕ¬Yà­À«à"ß°"--°..." ¥â«¬ prevalence rates will no longer be an adequate objective for national Àµÿ'È Õ--µ"§«"¡TMÿ° (prevalence rate) ®÷ß¡àÕ"®ªì«--µÿª­ ߧå'Ëæ'¬ßæÕ Ì"À-- HIV strategy (because success in treatment will be tied to an increase °¬ÿå¥â"ÕTMÕ«',,­¥--TM"µ` (ËÕß®"°§«"¡ Ì"Á®,,°"--°..."--È ®­TMËÕ¡,¬ß in the prevalence rate). °--°"æ`Ë¡Õ--µ"§«"¡TMÿ°) The total cost of NAPHA with second-line therapy reaches a ceil- ing at US$500 million or B 20 billion per year in 2020. Beginning in µâÿ«¡¢Õß,§ß°"¿"'Ë«¡°"--°...",,¢--È'Ë Õß ¥â Yß÷ß­¥--æ¥"'Ë 500 À'¬ À-- (20 æ--â"") µàÕªï ,,æ.». 2561 ·­µ--Èß·µàæ.». 2553 2008, expenditure on second-line therapy accounts for more than §à",,TMâ®à"¬ Ì"À--°"--°...",,¢--È'Ë Õß ®­¡'Õ--µ" à«¡"°°«à"§÷ËßÀ÷ËߢÕߧà",,TMâ®à"¬ one-half of total ART spending. By the end of the projection, one- --ÈßÀ¡¥,,°"--°..."¥â«¬¬"µâ"«-- Õ¥ å fourth of the patients receiving second-line therapy will absorb three- ·­¡ËÕ `È ÿ¥TMà«ß°"§"¥ª­¡" À÷Ëß à« 'Ë¢ÕߺYâµ`¥TMÈÕ'Ë¢â"--°"--°...",,¢--È'Ë Õß ¥â,,TMâߪ­¡",,°"--°..."ª fourths of the treatment budget (figure ES.6). The projected cost of ÷ß 3 ,, 4 à« (¿"æ ES.6) µâÿ'˧"¥ª­¡"«â Ì"À--,§ß°"¿"®­Ì",,Àâ NAPHA will increase Thailand's AIDS spending from its current §à",,TMâ®à"¬°'ˬ«°--,§Õ¥ å,,ª­»¬´÷Ëß,,ªí®®ÿ--Õ¬Yà'Ë 100 â"À'¬ À-- level of about US$100 million or B 4 billion per year to more than five (4 æ--â"") µàÕªï æ`Ë¡¢÷ÈÕ'° 5 à" ¿"¬,,æ.». 2563 Õ¬à"ß°Áµ"¡ ·¡â times that amount in 2020. However, even at its peak, total spending °­--Ëß,,®ÿ¥ Yß ÿ¥¥--ß°à"« §à",,TMâ®à"¬,¥¬«¡ Ì"À--°"--°...",§Õ¥ å®­µâÕßÕ"»--¬°" on AIDS treatment will require increasing the total health care spend- æ`Ë¡¢Õߧà",,TMâ®à"¬æËÕ°"¥Y· ÿ¢¿"æ--ÈßÀ¡¥æ'¬ß¡à÷ßâÕ¬­ 25 "®÷ßµ--¥ `,,®«à" ing by less than 25 percent. We judge this level of expenditures to be --"¬ "¡"®à"¬§à",,TMâ®à"¬,,­¥--'È¥â affordable to the Thai government. xxxvi xxxvi · »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand Figure ES.7 ProjectedAnnualLife-YearsSavedunderAlternativeScenariosRelativeto ¿"æ ES.7 °"§"¥ª­¡"®Ì"«ªï'ËÕ¥TM'«`µµàÕªï ¿"¬,,µâ "°"å"ßÕ°¡ËÕª'¬ Baseline '¬°-- â" 300,000 250,000 saved 200,000 life-years150,000 100,000 ®"«ªï'ËÕ¥TM'«`µæ`Ë¡¢÷Èadditional 50,000 0 25420014 252003 252005 2550 2552 2554 2556 2558 2560 2562 2564 2566 2568 46 48 2007 2009 2011 2013 2015 2017 2019 2021 2023 2025 "°"å D1 "°"å D2 scenarioD1 scenarioD2 scenarioD3 "°"å D3 "°"å D4 scenarioD4 Source: Authors. 'Ë¡": ºYâ¢'¬ Finding 3: Policy Options to Enhance Adherence and to Recruit °"§âæ'Ë 3: "ßÕ°TM`ß,¬"¬ æËÕ `¡°"°"°"­µ`¥¬"µâ"«-- Patients Earlier Are a Good Public Investment Õ¥ å·­°"TM--°Ì"ºYâµ`¥TMÈÕ,,Àâ¢â"à«¡,§ß°"Á«¢÷È Õªì°"ßÿ ""­'Ë¥' Timely patient recruitment and enhanced adherence buy additional life-years. If initiated now, the expanded VCT, augmented adherence, °"TM--°®YߺYâµ`¥TMÈÕ,,Àâ¢â"--°"--°..."¥â--«" ·­°" `¡°"°"­µ`¥¬"µâ"«-- and "both" policies would benefit more patients each year until the Õ¥ åÌ",,ÀâºYâµ`¥TMÈÕ "¡"¡'TM'«`µÕ¬Yà¥â¬"«"¢÷È â"`Ë¡µâµÕ'È ,¬"¬ Ì"À-- approaches save, respectively, 18,000, 50,000, and 60,000 additional `°"ª÷°..."·­µ«®À"TMÈÕ«-- ,¥¬ ¡--§,,® («'´'') 'Ë¥â--°"¢¬"¬º «¡--Èß life-years in 2020, on top of the 210,000 life-years saved that were ,¬"¬,,°"ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥¡"°¢÷È ·­,¬"¬'Ë,,Àâ¥Ì"` generated by NAPHA alone in that year (figure ES.7). Thus, for ç--Èß Õß,§ß°"é ®­ÕÈÕª­,¬TMå·°àºYâµ`¥TMÈÕ®Ì"«¡"°¢÷Èÿ°ªï ® "¡"æ`Ë¡ 2020, the alternative policies offer the possibility of improving ®Ì"«ªï'Ë¡'TM'«`µÕ¥¥âÕ¬à"ߪե¿--¬¥â÷ß 18,000, 50,000 ·­ 60,000 ªï NAPHA benefits by almost 30 percent. µ"¡Ì"¥--,, æ.». 2563 Õ°ÀÕ®"°ªï'Ë¡'TM'«`µÕ¥®Ì"« 210,000 ªï 'Ë¥â-- ®"°,§ß°"¿" æ'¬ßÕ¬à"ߥ'¬«,,ªï--È (¿"æ ES.7) ¥--ß--È Ì"À--ªï æ.». 2563 ·â«The,¬"¬"ßÕ°®÷ߪ쪥â'Ë®­Ì",,À⺪­,¬TMå¢Õß,§ß°"¿" æ`Ë¡¢÷È expanded policies, however, also involve additional costs. Of the four policies considered, the current NAPHA policy is the most cost-effective (figure ES.8). The second-most cost-effective is the ÷ß°ÕâÕ¬­ 30 augmented treatment policy, which enhances patient adherence. We Õ¬à"ß°Áµ"¡ ,¬"¬'˥⢬"¬æ`Ë¡µ`¡Àà"'È ®­µâÕß,,TMâµâÿæ`Ë¡TMà°-- ,, estimate that systematically adding patient support groups to all treat- ¥",¬"¬--Èß 'Ë'ËÌ"¡"æ`®"" ,¬"¬¿"'Ë,,TMâ,,ªí®®ÿ-- ®­¡'ª­ ``º ment sites in Thailand would increase the cost per life-year saved by "ߥâ"µâÿ¡"°'Ë ÿ¥ (¿"æ ES.8) à«,¬"¬'Ë¡'ª­ ``º"ߥâ"µâÿ less than US$40 (B 1,600), thereby making this approach a good ¡"°ªìÕ--¥-- Õß ¥â·°à ,¬"¬,,°"--°..."· `¡æ`»... ´÷ËßTM૬æ`Ë¡°" investment. Under the central assumptions of the model, spending ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥¢ÕߺYâµ`¥TMÈÕ "¥âª­¡"°"«à" °"æ`Ë¡ the resources on expanded HIV testing in order to recruit patients in a °ÿà¡ -- ÿºYâµ`¥TMÈÕÕ¬à"ߪ쭢â" Yà "æ¬""ÿ°·Ààß,,ª­»¬ ®­ more timely manner would increase the cost per life-year saved by Ì",,ÀâµâÿµàÕªï'ËÕ¥TM'«`µæ`Ë¡¢÷ÈÕ'°âÕ¬°«à" 40 À'¬ À-- (1,600 ") ¥--ß only another US$60 (B 2,400), which also seems like a good buy. --È ®÷ßÕ«à"ªì°"ßÿ'Ë¥' ¿"¬,,µâ ¡¡µ`"'Ë Ì"§--¢Õß·®Ì"Õß'È °",,TMâ Thus, we recommend that Thailand undertake both of the two ana- --æ¬"°ª°--°"µ«®À"TMÈÕ«-- ÕTMÕ«'æ`Ë¡¢÷ÈæËÕ,,Àâ "¡"TM--°Ì"ºYâµ`¥TMÈÕ,,Àâ lyzed policies to strengthen treatment, bringing the estimated cost per ¢â"--°"--°..."¥âÁ«¢÷È ®­Ì",,ÀâµâÿµàÕªï'Ë¡'TM'«`µÕ¥ Yߢ÷Èæ'¬ßÕ'° 60 À'¬ life-year saved to US$2,243 or B 89,720.4 À-- (2,400 ") ´÷ËߥYÀ¡Õªì°"ßÿ'Ë¥'TMà°-- ¥--ß--È "®÷ß·­Ì"«à" ÿª Ì"À--ºYâ`À" xxxvii Executive Summary · xxxvii ¿"æ ES.8 ª­ ``º"ߥâ"µâÿ¢Õß,§ß°"¿" ·­ "°"å"ßÕ°¡ËÕª'¬ Executive Summary · xxxvii '¬°-- â" Figure ES.8 Cost-EffectivenessofNAPHAandAlternativeScenariosRelativetoBaseline Figure ES.8 Cost-EffectivenessofNAPHAandAlternativeScenariosRelativetoBaseline 3 3,000 life-year âÕ¬­3%)at 3,000 2,600 per US$2,342 US$2,243 life-yearcostperof 3%) US$2,184 at 2,600 2,200 US$2,145 Õ--µ" à«¥discounted US$2,342 US$2,184 US$2,243 costvalueof 2,200 1,800 US$2,145 (US$discounted 1,800 1,400 ¡Y§à"ªí®®ÿ-- ÿ`¢Õߪï'ËÕ¥TM'«`µnet valuepresent saved(US$ 1,400 1,000 present À'¬ À--µ"¡§à"saved NAPHA NAPHA VCT °"ªØ`--µ` adherence VCT + VCT plus adherence 'Ë¡": ºYâ¢'¬ VCT Source:net Authors. 1,000 Õ¬à"ߧàߧ--¥ °"ªØ`--µ`Õ¬à"ߧàߧ--¥ NAPHA VCT adherence VCT plus adherence ª­»¬§«®­¥Ì"`,¬"¬'Ë¥â--°"«`§"­Àå«â--Èß Õß,¬"¬ æËÕ `¡ Finding 4: Public Financing Will Help Ensure Equitable Access Source: Authors. â"ß°"--°..." ,¥¬Ì",,Àâµâÿ,¥¬ª­¡"µàÕªï'Ë¡'TM'«`µÕ¥¡'¡Y§à" 2,243 À'¬ À-- (89,720 ")4 Finding 4: Public Financing Will Help Ensur Equitable Access Suppose that Thailand had reduced the price of first-line ART by authorizing the production of GPO-vir but had refrained from subsi- Suppose that Thailand had reduced the price of first-line ART by °"§âæ'Ë 4: °" -- ÿ,¥¬¿"§--®­TM૬ â"ߧ«"¡¡--Ë,,®÷ß°"¢â"-- dizing treatment. For the top two quintiles in the income distribution, authorizing the production of GPO-vir but had refrained from subsi- °"--°..."¥â«¬¬"µâ"«-- Õ¥ åÕ¬à"ßà"'¬¡ first-line ART could be affordable through user fees (figure ES.9). dizing treatment. For the top two quintiles in the income distribution, Even for the bottom two quintiles, the US$842 or B 33,680 cost of ¡¡µ`«à"ª­»¬¥â¥"§"§à"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,¢--È·° ,¥¬Õÿ"µ first-line ART could be affordable through user fees (figure ES.9). first-line therapy compares with the medical expenses of the sickest ,,Àâ¡'°"º`µ¬" GPO-vir ·µà¬--ß¡à¥â,,Àâÿ -- ÿ°"--°..." Ì"À--§--«Õ'ËÕ¬Yà Even for the bottom two quintiles, the US$842 or B 33,680 cost of households for a single year. The problems for the poorest households ,,°ÿà¡'Ë¡'"¬¥â 40 ªÕ崵巰¢Õߪ­»¬ §--«Õ à«'È "¡"®à"¬ first-line therapy compares with the medical expenses of the sickest are likely to be caused by two unusual features of the cost of treat- §à"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,¢--È·°¥â ,¥¬ºà""ߧà"¡'¬¡®"°ºYâ,,TMâ`°" households for a single year. The problems for the poorest households ment. First, the treatment must continue for the rest of the patient's are likely to be caused by two unusual features of the cost of treat- ment. First, the treatment must continue for the rest of the patient's Figure ES.9 AffordabilityofARTbyIncomeLevel ¿"æ ES.9 §«"¡ "¡",,°"®à"¬§à"--°..."¥â«¬¬"µâ"«-- Õ¥ å ·¬°µ"¡­¥--"¬¥â Figure ES.945,000 Affordability of ART by Income Level 40,000 45,000 35,000 40,000 30,000 35,000 (US$) 25,000 30,000 cost(US$) 20,000 25,000 15,000 cost 20,000 10,000 15,000 µâÿÀ'¬ À-- 10,000 5,000 5,000 0 Q1 Q2 Q3 Q4 Q5 0 Q1 Q2 incomeQ3quintile Q4 Q5 mean household income nonfood expenditure perincome cost of second-line ART household quintile cost of first-line ART "¬¥â§--«Õ,¥¬©'ˬ mean household income medical expenditure per household cost of second-line ART µâÿ¢Õß ART ¢--È'Ë Õß Source: Authors. nonfood expenditure per household cost of first-line ART µâÿ¢Õß ART ¢--È·° §à",,TMâ®à"¬"ß°"·æ¬åµàÕ§--«Õ §à",,TM®à"¬'Ë¡à,,TMàÕ"À"µàÕ§--«Õ â 'Ë¡": ºYâ¢'¬ medical expenditure per household Source: Authors. xxxviii »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ (¿"æ ES.9) ·­·¡â°­--Ëߧ--«Õ'ËÕ¬Yà,, Õß à«'ˬ"°®'Ë ÿ¥ µâÿ,,°" --°..."¢--È·° ´÷Ëß¡'¡Y§à" 842 À'¬ À-- ÀÕ 33,680 " "¡"'¬ à"°--§à",,TMâ®à"¬¥â"°"·æ¬åÕËÊ¢Õߧ--«Õ'Ë°`¥°"®ÁªÉ«¬¡"°'Ë ÿ¥ Ì"À-- À÷Ëߪïà"--È ªíÀ" Ì"À--§--«Õ'ˬ"°®'Ë ÿ¥--È à"®­°`¥®"°--°...­¡à ª°µ` Õߪ­°"¢Õßµâÿ,,°"--°..." ª­°"·° ¥â·°à °"--°..."®­µâÕߥÌ"` µàÕªµÕ¥TMà«ßÕ"¬ÿ¢ÕߺYâµ`¥TMÈÕ Ì"À--§--«Õ'ËÕ¬Yà,,°ÿà¡âÕ¬­ 80 µË" ÿ¥®"° °"°­®"¬"¬¥â ´÷Ëß "¡"®à"¬ß` 842 À'¬ À-- Ì"À--ªï·° ·­®­°"¬ ªì¿"­Õ--À--°Àà«ßæ`Ë¡¢÷È¡ËÕ¢â" Yàªï'Ë Õß·­ªï'Ë "¡ ૪­°"'Ë Õß §«"¡ À­À«¡,,°"--°..."'Ë°`¥®"°§«"¡¬"°® ®­Ì"ª Y৫"¡â¡À«¢Õß°"--°..." ®Ì",,Àâ°`¥°"æ--" "¬æ--åÿTMÈÕ«-- 'Ë¥ÈÕ¬"·­·æà°­®"¬TMÈÕ«-- ¥--ß°à"«ª ¬--ß'ËÕËÊ ·­Ì",,ÀâºYâµ`¥TMÈÕ®Ì"ªìµâÕߧËÕª Yà°"--°...",,¢--È'Ë Õß ÷ß·¡â®­ªì'ˬա--°--«à" µâÿ¢Õß°"--°...",,¢--È·°--È à«À÷ËßÕ"®¥â ÿ -- ÿ®"°§à"¡'¬¡ºYâ,,TMâ`°" ·µà°"--°...",,¢--È'Ë Õß--È°--¡'"§" ·æß°«à" ,¥¬ Yß°«à""¬¥â«¡¢Õߧ--«Õ÷ßâÕ¬­ 40 ¢Õߪ­TM"° § à« ,,Àà'Ë¢â"--°"--°...",,¢--È·° ,,'Ë ÿ¥·â« °Á®­µâÕß°"°"--°...",,¢--È'Ë Õß ·µà ®­¡à "¡"®à"¬ß`§à"--°..."¥--ß°à"«¥â À"°ª"»®"°§«"¡ -- ÿ®"° ""­ °"§âæ'Ë 5: °",,Àâÿ -- ÿ¢Õß-- "¡" `¡ â"ߺ¢â"ߧ'¬ßTM`ß «° ·­®Ì"°--¥º¢â"ߧ'¬ßTM`ß®"°°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (ÕÕ"å') Õ"®Ì"¡",,TMâæËÕæ`Ë¡ª­ ``º¢Õß °`®°¡°"ªÑÕß°--µà"ßÊ °"·æà­"¥¢Õß,§Õ¥ å Õ¬à"ß°Áµ"¡ º,,¥â"'Ë ªìª­,¬TMå¢Õß,§ß°"'È --ÈÀ¡"¬«¡÷ߧ«"¡æ¬"¬"¡,,°"--°..."·­°" ªÑÕß°--ÕËÊ 'Ë¡'Õ¬Yà·â«,,ª­»¬¥â«¬ °"'Ë¡à "¡"°"°"­µ`¥¬"µâ"«-- Õ¥ å,,TMà«ß°"--°..."¢--È·° Õ"®àß,,Àâ °`¥°"¥ÈÕ¬"¥âÁ«¢÷È ·­®­Ì",,ÀâºYâµ`¥TMÈÕµâÕß°â"«¢â"--°"--°...",,¢--È'Ë ÕßÁ« ¢÷È °"·°·´ß¢Õß--æËÕ -- ÿ°"°"°"­µ`¥¬"µâ"«-- Õ¥ å®÷ßÕ"®®Ì"°--¥ °"°­®"¬¢ÕßTMÈÕ«-- 'Ë¥ÈÕ¬"¥â Õ°®"°'È ®"°¡ÿ¡¡Õߥâ" --ߧ¡·­¥â"ÿ§§ °°,,°" -- ÿ°"°"­µ`¥¬"µâ"«-- Õ¥ å TMà °"¥Y· ÿ¢¿"æ,,¿"§-- æâÕ¡`°"æ`Ë¡µ`¡´÷Ëß"¥â«"ßYª·«â,,"¬ß"©--'È ¡''à"«à"®­¡'ª­ `` ¿"æ"ߥâ"µâÿ «¡--Èß¡'ª­,¬TMå"ߥâ"°"--°..." °"§âæ'Ë 6: À"°§«"¡ Ì"Á®,,°"¢¬"¬,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å Ì",,À⪭TM"TM ÀÕ--" °`¥§«"¡À­À«¡,,°"ªÑÕß°-- ®­Ì",,Àâ µâÿ,,Õ"§µ Yߢ÷ÈÕ¬à"ß¡"° À"° "¡"¥Ì"`,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (ÕÕ"å') ªæâÕ¡°--°" ¥Ì"`,§ß°"ªÑÕß°--Õ¬à"߬--Ë߬¢Õß--" ·­À"°,§ß°"¥--ß°à"«Ì",,Àâ ª­TM"TM¥æµ`°¡ 'Ë¬ß TMà °"©'¥¬" æµ`¥ ·­°"¡'æ» --¡æ--å,¥¬¡à ªÑÕß°-- ®­Õ¥â«à" ª­ ``¿"æ"ߥâ"µâÿ¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- ÿª Ì"À--ºYâ`À" xxxix Executive Summary · xxxix ¿"æ ES.10 ª­ ``º"ߥâ"µâÿ¢Õß "°"å ¡¡µ`À--° ¡ËÕ'¬°-- "°"å'Ë ¡à¡'°"§«§ÿ¡ Figure ES.10 Cost-EffectivenessofMainScenarioscomparedwithDisinhibitionScenario 7,000 US$6,243 6,000 life-year per 5,000 cost 4,000 of (US$) 3,000 value À'¬ À--saved US$2,145 US$2,342 US$2,184 US$2,243 2,000 ¡Y§à"ªí®®ÿ-- ÿ`¢Õߪï'ËÕ¥TM'«`µ present 1,000 net 0 NAPHA NAPHA VCT VCT °"ªØ`--µ`Õ¬à"ߧàߧ--¥ adherence VCT + °"ªØ`--µ`Õ¬à"ߧàߧ--¥ VCT plus adherence ¡à¡'°"§«§ÿ¡ disinhibition Source: Authors. 'Ë¡": ºYâ¢'¬ Õ¥ å'È¡'°"ª--ªÿߢ÷Ȫ­¡"âÕ¬­ 9 ·­®­TM૬,,Àâ§à",,TMâ®à"¬,,Õ"§µ¢Õß Conversely, if the availability of ART crowds out government --" Ì"À--,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å'È®­¥ß÷ß 926 À'¬¥Õà"å expenditure on prevention and leads people to increase their risk À-- ÀÕ 37 æ--â"" ÀÕ §`¥ªìâÕ¬­ 14 behavior back to its levels in the early 1980s, government treatment expenditure will increase more than threefold. In such a case, as shown in figure ES.10, the cost per life-year saved would increase nearly ,,"ߵ߰--¢â"¡ À"°,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢â"ª'¬¥--ߧà",,TMâ ®à"¬¢Õß--",, à«¢Õß°"ªÑÕß°--,§ ·­Ì",,À⪭TM"TMæ`Ë¡æµ`°¡ 'ˬ߮ °--ª Yà­¥--'˧¬ªì,,TMà«ßµâ»«... 1980 (æ.». 2523-2533) §à",,TMâ®à"¬,, threefold, from US$2,145 to US$6,243 (from B 85,800 to B 249,720). °"--°..."¢Õß--"®­æ`Ë¡¢÷È°«à" "¡à" ´÷ËßÌ",,ÀâµâÿµàÕªï'ËÕ¥TM'«`µæ`Ë¡¢÷È ®"° 2,145 À'¬ À-- ªì 6,243 À'¬ À-- (®"° 85,800 " ªì 249,720 Finding 7: Future Government Expenditures on ART and the Lives ") It Will Save Are Highly Sensitive to Negotiated Agreements on the Intellectual Property Rights for Pharmaceuticals °"§âæ'Ë 7: §à",,TMâ®à"¬¢Õß--",,Õ"§µ Ì"À--,§ß°"--°..."¥â«¬¬" µâ"«-- Õ¥ å ·­TM'«`µ'Ë "¡"--°..."«â¥â--È ¡'§«"¡ÕàÕÀ«°--µàÕ¢âÕ Because the drugs used in second-line therapy are patented, produced, µ°ß¥â" ``¥â"--æ¬å `"ߪí" Ì"À--º`µ¿--±å¬"Õ¬à"ß Yß and sold by multinational pharmaceutical corporations, Thailand ËÕß®"°¬"'Ë,,TMâ,,°"--°..."¢--È'Ë Õß--È¡'°"®¥ ``--µ«â «¡--Èߥâ--°"º`µ·­ must either pay the high prices demanded by those monopolies or ®Ì"Àà"¬,¥¬`...--¿ --TM°¡­¥--""TM"µ` ª­»¬®÷ßÕ"®µâÕß®à"¬ß`,,"§" exercise its rights under World Trade Organization (WTO) treaties to Yßµ"¡'Ë°Ì"À¥,¥¬`...--'˺Y°¢"¥Àà"--È ÀÕ,,TMâ ``¢Õßµ¿"¬,,µâ ` --"¢Õß grant a compulsory license for the manufacture of the drug, subject to Õߧå°"§â",°'Ë®­--ߧ--,,Àâ¡'°"º`µ¬"¥--ß°à"« ,¥¬¢÷ÈÕ¬Yà°--§à"¡'¬¡ ``--µ negotiated royalties. 'Ë¥âµàÕÕß«â Because Thailand stands to gain a great deal from bilateral agree- ments to reduce trade barriers with trading partners such as the United States, the Royal Thai government may be tempted to relin- ËÕß®"°ª­»¬¬À¬--¥'Ë®­¥â--ª­,¬TMå®"°¢âÕµ°ß«`¿"§'æËÕ¥ Õÿª §"ß°"§â"°--ª­»§Yà§â"µà"ßÊ TMà À--Õ¡`°" --"¬®÷ßÕ"®µâÕß ¬Õ¡`Èß ``--ߧ--º`µ¬"--°...",§Õ¥ å æËÕ·°°--ºª­,¬TMå¥â"°"§â"'Ë¡'ºYâ Õ quish its rights to grant compulsory licenses for AIDS drugs in ,,Àâ "¬ß"©--'Èæ«à" µâÿ¢Õß°",,Àâ ``æ`»...'È Yß¡"° TMà ¥â«¬°",,TMâ `` exchange for proffered trade advantages. The report finds that the --ߧ--º`µ¬"æËÕ¥µâÿ,,°"--°..."¢--È'Ë ÕߪâÕ¬­ 90 --"®­¥¿"­¥â" cost of such concessions would be large. For example, by exercising compulsory licensing to reduce the cost of second-line therapy by 90 percent, the government would reduce its future budgetary obliga- xl »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ ߪ­¡",,Õ"§µª¥â 3.2 æ--â"À'¬ À--'ËÕ--µ" à«¥ (127 æ--â" " ,,Õ--µ" à«¥) ®÷ß æ.». 2568 ·­ "¡"¥µâÿµàÕªï'ËÕ¥TM'«`µ®"° ,§ß°"¿"ª°«à"§÷Ëß §Õ®"° 2,145 À'¬ À-- ªì 940 À'¬ À-- (85,800 " ªì 37,600 ") µàÕªï'ËÕ¥TM'«`µ ®Ì"«§à"`¢ ``Ï'ËÕߧå°"§â",°°Ì"À¥,,Àâ¡"æâÕ¡°--°"Õÿ"µ,¥¬«`'--ߧ-- --È ¬--ß¡à¥â°Ì"À¥TM--¥® ·­¢÷ÈÕ¬Yà°--°"®®"µàÕÕß ª­»¬ "¡"æ`Ë¡ ÕÌ""®°"µàÕÕß°--`...--¿ --TM°¡­À«à"ßTM"µ`¥â ,¥¬°"à«¡¡Õ°--°--ª­» ÕËÊ 'Ë¡'"¬¥â°Ì"--ßæ--"æËÕ®®"µàÕÕߥ--ß°à"« ÿª·­¢âÕ Õ·­ ,§ß°"¿"¢Õߪ­»¬,,ªí®®ÿ--'È¡'§à",,TMâ®à"¬'Ë "¡"Ì"ª¥Ì"`°"¥â Õ°®"°'È ¿"¬,,µâ ¡¡µ`"¢Õß·®Ì"Õß ,§ß°"¥--ß°à"« ¬--ß¡'ª­ ``º¥â" µâÿ ¡ËÕ'¬°-- "°"å ¡¡µ` ¬`Ëߪ°«à"--È ÷ß·¡â«à" ,¬"¬ `¡--Èß Õß ,¬"¬'Ë"¥âÌ" Õ (°"TM--°Ì",,ÀâºYâµ`¥TMÈÕ¢â"--°"--°..."µ--Èß·µà­¬­·° ,¥¬ Õ"»--¬`°"ª÷°..."·­µ«®À"TMÈÕ«-- ,¥¬ ¡--§,,® («'´'') ·­°"ª--ªÿß°" °"­µ`¥¬"µâ"«-- Õ¥ å,¥¬Õ"»--¬°ÿà¡ -- ÿºYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å,,TMÿ¡TM) ®­¡'ª­ ``¿"æ"ߥâ"µâÿâÕ¬°«à" ·µà¬--ßÕªì,¬"¬'Ë¥' ,¥¬©æ"­ Õ¬à"߬`Ëß ¡ËÕÀ"°Ì",¬"¬--Èß Õß¡"ªØ`--µ`æâÕ¡°-- µâÿ à«,,Àà¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,­¬­¬"«--È ¡'§«"¡ --¡æ--å°--°",,Àâ°"--°...",,¢--È'Ë Õß «`'°"À÷Ëß 'Ë®­®Ì"°--¥¿"­"ß°"ß`'Ë Õ"®°`¥¢÷È §Õ--"¬µâÕßÌ",,Àâ¢Õ¢µ¢Õßæ--­,,°",,Àâ°"--°..."¥â«¬¬"µâ" «-- Õ¥ å,,ÀâTM--¥® --Ë§Õ --"¬¡'æ--­Õ¬à"ß®Ì"°--¥'Ë®­,,Àâ°"--°..."©æ"­ ,,¢--È·°à"--È,,TMàÀÕ¡à Àժ쮭¢¬"¬æ--­°«â"ߢ÷È'Ë®­,,Àâ°"--°...",,­¥-- ,,¥°Áµ"¡'Ë®Ì"ªì·°àºYâµ`¥TMÈÕ §à"ª­¡"°"¢Õߪ­ ``º"ߥâ"µâÿ · ¥ß ,,ÀâÀÁ«à" ,§ß°"¿"'Ë«¡©æ"­°"--°...",,¢--È·°--È ®­¡'ª­ ``º"ߥâ" µâÿ¡"°°«à",¬"¬´÷Ëß«¡°"--°...",,¢--È'Ë Õß --Ë§Õ ¡'µâÿ'Ë 736 À'¬ À-- ÀÕ 29,440 µàÕªï'ËÕ¥TM'«`µ Õ¬à"ß°Áµ"¡ ,§ß°"¿"´÷Ëß«¡°"--°...",, ¢--È'Ë Õß "¡"--°..."®Ì"«ªï'Ë¡'TM'«`µ¥âÕ'°÷ßÀ÷Ëß à« 'Ëâ"ªï «`'°"'Ë Õß 'Ë®­TM૬,,Àâ--"®Ì"°--¥§à",,TMâ®à"¬,,°",,Àâ°"--°..."¢--È'Ë Õß §Õ °",,Àâ ``--µ'Ë,,TMâ,,°"º`µ¬" Ì"À--°"--°...",,¢--È'Ë Õß´÷Ëߥ⮥ ``--µ«â °"°­Ì"TMà'È µâÕßÕ"»--¬§«"¡à«¡¡Õ¢ÕߺYâ`À"­¥-- Yß ´÷ËßÕ¬YàæÈ"¢Õß §«"¡¢â",,®Õ¬à"ßTM--¥®÷ß¿"­'Ë®­¡'µàÕª­»¬ «¡--Èߺª­,¬TMå¥â" ÿ¢¿"æ °"ª­À¬--¥ßª­¡" ·­º"ߥâ"°"§â"¢Õß°"°­Ì"¥--ß°à"« "ßÕ°Õ'°ª­°"§Õ --"µâÕßÀ"°°°"ß`ÕËÊæËÕ -- ÿ°"--°..." ¥â«¬¬"µâ"«-- Õ¥ å «¡--Èß°",,TMâ§à"¡'¬¡ºYâ,,TMâ`°"·­,§ß°"ª­°-- ÿ¢¿"æ,,Àâ¡"°¢÷È ·µàâ"¡Õß,,·ßà¢Õßæ--­'Ë--"¡'µàÕ°",,Àâ°"--°..."¥â«¬¬" µâ"«-- Õ¥ åÕ¬à"ßâ«Àâ"·­¡à§`¥§à",,TMâ®à"¬,¥¬ºà""ß,§ß°"¿"·â« ·º ÿª Ì"À--ºYâ`À" xli °",,¥Ê ¥--ß°à"« ®­µâÕߥâ--°"ÕÕ°·Õ¬à"ß­¡--¥­«--ß æËÕ¡`,,Àâªì°"°'¥°-- ª­TM"TMÕÕ°®"°°"--°..." 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"¬­Õ'¬¥¢Õß AEM ·­¢âÕ ÿª¢Õß·®Ì"Õß ¥âÕ`"¬«â,,'Ë 4 3. ¥â¡'°"°­®"¬È"À--°«â'ËâÕ¬­ 80, 15 ·­ 5 µ"¡Ì"¥-- Ì"À--¬" µâ"«-- Õ¥ å Yµ'Ë (1), (2) ·­ (3) ¥--ß'Ë· ¥ß«â,,µ""ß ES.6 4. ,¬"¬æËÕ `¡ â"ß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (ÕÕ"å') --È ®­ªìÕ°»®"° ·­¡'"§"Y°°«à" °"µ--¥ `,,®'Ë®­,,Àâÿ -- ÿ°"--°...",, ¢--È'Ë Õß Õ°®"°'È À"°ÿ -- ÿ¢Õß--"®­¡',,Àâæ'¬ß°"--°...",,¢--È·° ,¬"¬Àà"'È ®­Õ¬Yà,,"§"'Ë®à"¬¥â¡"°°«à" ·­ªì,¬"¬'˧«ªØ`--µ`¡"°°«à" 5. °"«¡°"--°...",§Õ¥ å¢â"«â,,·º°"¥Y· ÿ¢¿"æ­¥--TM"µ`,, ,§ß°" ç30 " --°..."ÿ°,§é ´÷Ëߪì,¬"¬'Ë°Ì"--ß¡'°"À"Õ°--Õ¬Yà,, ª­»¬ ,¥¬®­µâÕßæ`®""÷ߧà",,TMâ®à"¬'Ë YߢÕß,§ß°"¿" ·­°" °­®"¬"ß¿Y¡`»" µå'Ë¡àà"'¬¡,,ª­»¬ Õ°®"°'È ¢âÕ®Ì"°--¥¥â"æÈ'Ë Ì",,Àâ¡à "¡"«`§"­Àå°°,,°",,Àâÿ -- ÿÕËÊ Ì"À--,§ß°"--°..."¥â«¬ ¬"µâ"«-- Õ¥ å,,ª­»¬ 'Ë 1 `·­ª­ °"å­À«à"ߪ­» À"°¡`¥â--°"--°..."·â« °"µ`¥TMÈÕ«-- 'ËÌ",,Àâ¿Y¡`§ÿâ¡°--¢Õßà"ß°"¬¡ÿ...¬å°æàÕß ÀÕTMÈÕÕTMÕ«' (HIV) ·®­Ì",,Àâ÷ß·°àTM'«`µ¥â,,ÿ°"¬ ,,--Ë«,° ¢­'È TMÈÕ ÕTMÕ«'§Õ "ÀµÿÀ--°'ËÌ",,ÀâºY⧮Ì"«¡"°µâÕß Y '¬TM'«`µ ·­¬--ߪì "Àµÿ Ì"§--¢Õß°" '¬TM'«`µ'Ë°`¥¡"®"°,§µ`¥TMÈÕ ,,ªï æ.». 2548 æ'¬ßªï¥'¬«à"--È ¡' §®Ì"«÷ß 3.1 â"§--Ë«,° µâÕß '¬TM'«`µ¥â«¬,§Õ¥ å(Acquired Immunod- eficiency Syndrome-AIDS) ·­¡'§®Ì"«÷ß 4.9 â"§ µ`¥TMÈÕÕTMÕ«' ´÷ËßÌ",,Àâ ®Ì"«ª­TM"°'Ë¡'TM'«`µÕ¬Yà,¥¬µ`¥TMÈÕÕTMÕ«''È ¡'®Ì"«÷ß 40.3 â"§--Ë«,° (UNAIDS 2005) °"§`¥§â«`'°"--°..."¥â«¬¬"µâ"«-- ÀÕ ÕÕ"å'(Antiretroviral Therapy- ART) ,,TMà«ßª"¬»«... 1980 (ÀÕTMà«ßªïæ.». 2523-33) Õªì°"`Ë¡µâ °"ªØ`Yª°"®--¥°"TMÈÕ«-- ÕTMÕ«' ´÷Ëß "¡"ª'¬¥â°--°",,TMâæ`´``,,°" --°..."°",§µ`¥TMÈÕ®"°·§''¬,,TMà«ß»«... 1940 (ÀÕTMà«ßªïæ.». 2483- 2493) --Èß'È ªÑ"À¡"¬¢Õß°¬ÿå,,°"--°..."¥â«¬¬"µâ"«-- --È §Õ°" °--¥°--È °" â"ß«-- ,,À¡à ·­°"--°..."'˪­ §«"¡ Ì"Á®--È ®­Ì"¡"´÷Ëß°"øóôøY ¿Y¡`§ÿâ¡°-- °"TM­ÕÀÕ¬ÿµ`°"ÿ°"¡¢Õß,§ °"ªÑÕß°--°"¥ÈÕ¬" ·­°"ª--ªÿß §ÿ¿"æTM'«`µ °"--°..."¥â«¬¬"µâ"«-- (ART) ¡`,,TMàªì°"--°...",§ ·µà°"--°..." ¥â«¬¬"µâ"«-- (ART) '˪­ §«"¡ Ì"Á®®­TM૬À¬ÿ¥¬--Èß°"¥ß¢Õß¿Y¡`§ÿâ¡°-- «¡--ÈߪÑÕß°--¡`,,Àâ,§ÿ°"¡ ·­°`¥°" '¬TM'«`µ °"--°..."¥â«¬¬"µâ"«-- (ART) ¥âª'ˬ¡ÿ¡¡ÕߢÕߺYâ'Ë "¡"´ÈÕÀ"¥â ÀÕ "¡"¥â--°"--°..."®"°­¥Y· ÿ¢¿"æ'Ë¡'°"®--¥ --æ¬"°Õ¬à"ߥ' ¡ËÕ¡à"¡"'È °"¢"¥·§,§ß â"ßæÈ"·­--æ¬"° Õ«à"ªìÕÿª § Ì"§-- Ì"À--°"--°"--°..."¥â«¬¬"µâ"«-- (ART) ,,°ÿࡪ­»¬"°® «¡ --ÈßTM°ÿà¡âÕ¬·­ª­TM"°'Ë¥âÕ¬,Õ°" Õ¬à"ß°Áµ"¡ À--°"'Ëæ`Ë¡¢÷È · ¥ß,,Àâ ÀÁ«à" °"--°..."¥â«¬¬"µâ"«-- (ART) --È ¡'§«"¡ªìª¥â·­¡'ª­ ``¿"æ ,,ª­»'ˬ"°® °"»÷°..."Ì"àÕß,,ª­»··Õø`°" (,°µµ`«--«å §¬" ¡""«' ´°-- ·­¬Y°--¥") ´÷Ëß¡'ºYâ¢â"à«¡°«à" 2,000 § ·­,§ß°" "" ÿ¢ ´÷Ëß¡'"·«°«â"ß,§ß°"À÷Ëß,,ª­»"´` ´÷ߥâ--°..."ºYâªÉ«¬°«à" 100,000 § ¥â· ¥ß÷ߧ«"¡ Ì"Á®¢Õß°"--°..."¥â«¬¬"µâ"«-- (ART) ,,¥â"µà"ßÊ µàÕª'È: 1 2 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ ë °"ª--ªÿßÕ¬à"ßÀÁ¥âTM--¥,, à«¢ÕßÈ"À--°, ®Ì"«´å¡Á¥Õ¥¢"« CD4 (´'¥',øå) ·­ª`¡"«-- ,,°­· ,À`µ ë °"¥,Õ°" ,,°"µ`¥TMÈÕ©«¬,Õ°" (Opportunistic Infections>OIs) ë §ÿ¿"æTM'«`µ'Ë¥'¢÷ÈÕ¬à"ßÀÁ¥âTM--¥ °"ª­¡`°"--°..."¥â«¬¬"µâ"«-- (ART) ,,ª­»"´` ,, æ.». 2545 · ¥ß,,ÀâÀÁ«à" ,,TMà«ß®Á¥ªï·° ,§ß°"¥--ß°à"«¥âTM૬¥®Ì"«ºYâªÉ«¬'Ë¢â"-- °"--°...",,,ßæ¬""÷ß 360,000 "¬ Ì",,À⪭À¬--¥§à",,TMâ®à"¬ª¥â÷ß 2.2 æ-- â"¥Õà"å À-- ®"°µâÿ'Ë,,TMâ,,°"--°..."¥â«¬¬"µâ"«-- (ART) Õ°®"°'È Õ--µ"§«"¡TMÿ°¢Õß«--,§¬--ߥߥâ÷ßâÕ¬­ 80 Õ--µ"°" '¬TM'«`µ¥ßâÕ¬­ 50 ·­®"°°"«``®©--¬TMÈÕ«-- ÕTMÕ«' §à"¡--¬"¢Õß°"Õ¥TM'«`µ æ`Ë¡¢÷È®"° 18 ¥Õ ªì 58 ¥Õ (°--,« 2545; 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°" --¡¿"...å"¬ÿ§§°--PHA §"" 7 (ART) ,,·«°«â"ß ·®Ì"Õߥ--ß°à"« ´÷Ëß'¬°«à" ·®Ì"Õß,§­"¥,,ÕTM'¬ (Asian Epidemic Model-AEM) ,¥¬¬÷¥"¢âÕ¡Y¥â"æµ`°¡·­°"·æàTMÈÕ'Ë¡' Õ¬Yà «¡--ÈߧÌ"÷ß÷ߧ«"¡´--´âÕ°'ˬ«°--§«"¡ 'ˬߢÕß°"µ`¥TMÈÕÕTMÕ«',,ª­» ¬ ¥â«¬°" â"ß·®Ì"Õßæµ`°¡¢Õß°ÿà¡ 'ˬ߮Ì"« 8 °ÿà¡ ,,¢­'Ë· ®Ì"ÕßTMÿ¥¥`¡ ¡à¥â«¡÷ߺ¢Õß°"--°..."¥â«¬¬"µâ"«-- (ART) 'Ë¡'µàÕÕ"¬ÿ¢--¬ºYâµ`¥ TMÈÕÕTMÕ«' µàÕ§«"¡ªìª¥â'Ë®­·æàTMÈÕÕTMÕ«' ÀÕµàÕ°"æ--"·­·æà°­®"¬ ¢Õß "¬æ--åÿ«-- 'Ë¥ÈÕ¬" (§­Ì"ß"°'ˬ«°--TMÈÕÕTMÕ«'/Õ¥ å ·Ààߪ­»¬ 2544) ·µà AEM Yª·,,À¡à ´÷Ëߥâæ--"¢÷È¡"æËÕ"¬ß"©--'È ¥â§Ì"÷ß÷ßªí®®--¬ µà"ßÊ ¥--ßµàÕª'È ë ·®Ì"Õß,¥¬­Õ'¬¥· ¥ß÷ß°"TM--°®Yß,,ÀâºYâµ`¥TMÈÕ'Ë¡à· ¥ßÕ"°",,Àâ¢â"--°" --°..."µ--Èß·µà,,­¬­·° ,¥¬Õ"»--¬°",,Àâ`°"ª÷°..."·­µ«®Õ¥À"°"µ`¥TMÈÕ ÕTMÕ«',¥¬ ¡--§,,®ÀÕ«'´'' (Voluntary Counseling and Treatment-VCT) ´÷Ëß ¬--ß¡'§à" CD4 'Ë Yß°«à" æËÕ¥·°"TM--°®YߺYâªÉ«¬'Ë· ¥ßÕ"°",,Àâ¢â"--°"--°..." ,,­¬­À--ß ,¥¬ºà""ß­ ÿ¢¿"æ (´÷Ëß à«,,Àà ®­¡'§à" CD4 µË"°«à"¡"°) ë §Õ¢à"¬°"--°..."'Ë·µ°µà"ß°--ª ( "æ¬""¢Õß--"à"--È " æ¬""¢Õß--"'Ë¡'`°" `¡æ`»... ·­ "æ¬""Õ°TM) ë °"°â"«ª Yà°"Ì"--¥--°...",,¢--È'Ë Õß ("«å ·­ æ'æ--,¿§` 2004°.) ®"°°",,TMâ·®Ì"Õß AEM " "¡"Ì" Õº°­,¥¬ª­¡"®"° " °"å ¡¡µ`,,°",,TMâ,¬"¬µà"ßʵ"¡­¥--µ--«àßTM'ȵàÕª'È ´÷Ëß¡'§«"¡ Ì"§--"ߥâ" "" ÿ¢·­µàÕºYâ«"ß,¬"¬: ë ®Ì"«ºYâµ`¥TMÈÕÕTMÕ«'¥ß ë ºYâµ`¥TMÈÕÕTMÕ«'¡'TM'«`µ¬"«"¢÷È ë µâÿ§à"æ¬"" Ì"À--,§µ`¥TMÈÕ©«¬,Õ°" ¥ß ë °"¢¬"¬µ--«¢ÕßTMÈÕ«-- "¬æ--åÿ¥ÈÕ¬" ë µâÿ¥â"ߪ­¡" Ì"À----" ë º°­--Èߥâ"«°·­¥â"'Ë¡'µàÕ°`®°¡æËÕªÑÕß°--°"µ`¥TMÈÕ ËÕß®"°TMÈÕÕTMÕ«'¡'­¬­«"øí°µ--«'ˬ"«" --ËÀ¡"¬§«"¡«à" ,¬"¬«--'È ®­ àߺ°ÁµàÕ¡ËÕ«"ºà"ªÕ'°-- `ªï °"«`§"­Àå--ÈßÀ¡¥ ®÷ߪì°"§"¥ª­¡" Ì"À--­¬­«" 25 ªï "®÷ߥâÌ" Õµâÿ·­ª­,¬TMå'Ë®­¥â--®"°"ßÕ° µà"ßÊ,¥¬ª­¡" ·­· ¥ß,,ÀâÀÁ÷ߧ«"¡º--º« (Sensitvity) ¢Õߺ'Ë®­°`¥µàÕ Õ--µ"°"¥ß¢Õßµâÿ·­ºª­,¬TMå,,Õ"§µ ºYâ¢'¬¬--ߥâ«"¥¢Õ¢µ¢Õß ·®Ì"Õß®"°§«"¡·­ª­ °"å¢Õߪ­»¬ ·­,,°''ˬ--ß¡à "¡" À"ªí®®--¬ÀÕµ--«·ª,¥¬©æ"­ Ì"À--ª­»¬¥â "ߺYâ¢'¬®­Õ"»--¬§«"¡ °'ˬ«°--,§Õ¥ å·­§«"¡§`¥ÀÁ®"°ºYâTM'ˬ«TM",,­¥--""TM"µ` ËÕß®"°º¢Õß°"Õ°,¬"¬ "¡"· ¥ß,,ÀâÀÁ¥â¥â«¬°"ª'¬'¬«à" 8 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ ®­°`¥Õ­¢÷ÈÀ"°¡àÕ°"ßÕ°¥--ß°à"«·â«à"--È "°"¢Õß°"«`§"­Àå ®÷ߪì°"§"¥ª­¡"¢--ÈæÈ"¢Õß°"¥Ì"`ß",,Õ"§µÀ"°--"¬¡à¥â `Ë¡¢¬"¬,§ß°"¿" ÀÕ¡à,,Àâ°" -- ÿ°"º`µ·­®Ì"Àà"¬¬" "¡--µâ" «-- Õ¥ å'Ë¡'µâÿµË" (®'æ',Õ«'¬å (GPO-vir)) ºà""ßÕߧå°"¿ --TM°¡ °à"« Õ'°--¬À÷Ëß "°"å ¡¡µ`¢--ÈæÈ"'È ¡`¥â¡'" Ì"§--,,°"®--¥ ÀÕ,,Àâ ÿ -- ÿ,,°"--°..."¥â«¬¬"µâ"«-- ÀÕÕ"®¡'"âÕ¬¡"° TMà ºà""ß ,§ß°"Õ" " ¡--§¢"¥Á°'Ë¡'Õ¬Yà·â«¢Õß°­«ß "" ÿ¢ ´÷ËßÌ"ß"ºà" "ߧբà"¬°"«`®--¬"ߧ``° ·­¢â"÷ߪ­TM"TMª­¡" 2,100 §à"--È2 ÷ß·¡â«à" ®­¡'ºYâÕ° "°"å ¡¡µ`,,¢--ÈæÈ"TMà'È §­ºYâ®--¥Ì""¬ß"¬--ß À«--ß«à" âæÈ"¥--ß°à"« ®­¥â--°"µ'§«"¡Õ¬à"ß ­Õ"¥'Ë ÿ¥·­'¬ßà"¬'Ë ÿ¥ (,ª¥¥Y"¬­Õ'¬¥¢Õß "°"åæÈ"'È,,'Ë 4) "®­,,TMâ°"§"¥ª­¡"÷ß "°"åæÈ"'È æËÕªìµ--««`§"­À庢Õß ,§ß°"¿"¢Õß--" (NAPHA) ¿"¬,,µâ«`'ªØ`--µ`,,Yª·µà"ßÊ "ßÕ°¥â" ,¬"¬ Ì"À--,§ß°"¿" (NAPHA) ¥â¡'°" Ì"«®«`'°"µà"ßÊ'Ë®­ÕÌ"«¬§«"¡ ­¥«°,,Àâ·°à°"TM--°®Yߪ­TM"TM æËÕ,,Àâ¢â"à«¡,§ß°"--°..."¥â«¬¬"µâ"«-- µ--Èß·µà,, ­¬­·° ¥â«¬°" `¡ â"ß·­°­µÿâÕÿª ߧå'Ë¡'µàÕ`°"ª÷°..."·­µ«®À"TMÈÕ «-- ,¥¬ ¡--§,,® ·­,,Õ'°¥â"À÷Ëß µâÕß¡'°" Ì"«®À"ß'Ë®­°­µÿâ,,Àâ¡'°" ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥ (adherence) ,¥¬Õ"»--¬°ÿࡺYâµ`¥TMÈÕ«-- ÕTM Õ«'/ºYâªÉ«¬Õ¥ å (PHA) «¡--Èß°­µÿâ°",,TMâ`°",,Àâ§Ì"ª÷°..." °",Õ¬â"¬Õ¬à"ß¡' ßËÕ¢ ·­,§ß°"¥â"Õÿª ߧåÕËÊ3 "ßÕ°TM`ß,¬"¬ Ì"À--,§ß°"¿" (NAPHA) ¥â ÿª«â,,µ""ß 1.1 µàÕª'È: µ""ß 1.1 "°"å ¡¡µ`TM`ß,¬"¬ Ì"À--,§ß°" NAPHA °" àß `¡,§ß°" VCT ·­°"TM--°®Yß,,Àâ¢â"à«¡,§ß°" ART µ--Èß·µà­¬­·° ¡à àß `¡ àß `¡ àß `¡,,Àâ¡'°" ¡à àß `¡ NAPHA(D1):°"¥Ì"`,§ß°" VCT(D2):TM--°®Yß,,ÀâºYâµ`¥TMÈÕ¢â"-- ªØ`--µ`µ"¡«`'°" NAPHA,,¢­'È(TM--°®YߺYâµ`¥TMÈÕ °"--°..."µ--Èß·µà,,­¬­·°,¥¬ºà" --°..."Õ¬à"ß ÕTMÕ«''Ë· ¥ßÕ"°"ºà""ß­ "ß,§ß°"VCT Ì"À--ºYâ'Ë¡'§à" §àߧ--¥ ,¥¬ "" ÿ¢) CD4 Yß°«à",¥¬¡à¡'°"ª--ªÿß°" ºà"·ß®Yß,,® ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥ ¥â"Õÿª ߧå TMà°ÿà¡PHA, àß `¡ °"ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ß VCT·­°"ªØ`--µ`µ"¡«`'°"--°..." ºYâ¢â"à«¡, §àߧ--¥(D3):ªØ`--µ`µ"¡«`'°"--°..." Õ¬à"ߧàߧ--¥(D4):ªØ`--µ`µ"¡«`' ·­°",ÕÕ¬à"ß Õ¬à"ߧàߧ--¥¥â¥'¢÷È,¥¬¡àµâÕßTM--°®Yß °"--°..."Õ¬à"ߧàߧ--¥¥â¥'¢÷È·­ ¡'ßËÕ¢ ºYâªÉ«¬,,Àâ¢â"--°"--°..."µ--Èß·µà,,­¬­ TM--°®YߺYâµ`¥TMÈÕ,,Àâ¢â"--°"--°..."µ--Èß·µà ·° (¬--ߧßTM--°®YߺYâµ`¥TMÈÕ«-- ÕTMÕ«' ­¬­·° (TM--°®YߺYâµ`¥TMÈÕ´÷Ëß¡'§à" 'Ë· ¥ßÕ"°"¢â"à«¡,§ß°"--°..." CD4 Yß°«à",,Àâ¢â"--°"--°..."µ--Èß·µà ,¥¬ºà""ß­ "" ÿ¢ ­¬­·°,¥¬ºà""ß,§ß°"VCT) 'Ë¡": ºYâ¢'¬ §"" 9 "¥â§"¥§­°"·æà­"¥¢ÕßTMÈÕÕTMÕ«'®"° "°"å ¡¡µ`·µà­¢âÕ ·­ ®÷ߥ⪭¡`º¢Õß "°"å®"°µ--«àßTM'ÈÀ--°'Ë¥âÕ`"¬«â°àÕÀâ"'È ,¥¬¥â ª'¬'¬º¢Õßµ--«àßTM'ÈÀà"--È °-- â",,°''Ë¡à¡'°"--°..."¥â«¬¬"µâ" «-- ¬¥--ß'Ë¥â°à"«¡"·â« À--ß®"°--È "®÷ߧÌ"«¡"µ°"æËÕ â"ߪ­ ``º "ߥâ"µâÿ¢Õß"ßÕ°TM`ß,¬"¬ÕËÊ "¬ß"©--'È ·àßÕÕ°ªì 7 'Ë 2 Õ`"¬÷ßæ«--µ·­Yª·¢Õß,§ ­"¥®"°TMÈÕÕTMÕ«',,ª­»¬ ·­ ÿª°"µÕ Õߥâ",¬"¬¢Õߪ­» ¬ 'Ë 3 ®­Õ¿`ª"¬TM`ߧ`§,¥¬ --ߢª°'ˬ«°--°"®--¥°""ß°"«``®©--¬·­ °"--°..." Ì"À--TMÈÕÕTMÕ«'/Õ¥ å «¡--Èߧ«"¡â""¬µà"ßÊ'˵âÕߺTM`,,°"®--¥°" ¥â"°"--°..."¥â«¬¬"µâ"«-- (ART) ºµà"ßÊ ®"°°"¡'TM'«`µÕ¥ °"µ`¥TMÈÕ ·­ °"·æà­"¥¢ÕßTMÈÕ «¡--Èߺ"ߥâ"»...°`® --ߧ¡ 'Ë 3 ¬--ߥâ --ߧ"­Àå ¢âÕ¡Y'Ë¡'Õ¬Yà°'ˬ«°--µâÿ¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ´÷Ëß«¡÷ß°"--°..."°" µ`¥TMÈÕ,§©«¬,Õ°" ·­µâÿ¢Õß`°"ª÷°..."·­µ«®À"TMÈÕ«-- ,¥¬ ¡--§,,® ÀÕ«'´'' (VCT) Ì"À--§--«Õ·­­¥Y· ÿ¢¿"æ "" ÿ¢ À--ß®"°--È ¢âÕ¡Y¥--ß°à"«®÷ß®­Y°Ì"¡",,TMâæËÕª­¡`÷ßµâÿ·­ºª­,¬TMå¢Õß,§ß°" --°..."¥â«¬¬"µâ"«-- ¿"¬,,µâ "°"åµà"ßÊ°-- 'Ë 4 ®­ Õ§â",§ß,,°" «`§"­ÀåæËÕª­¡`,¬"¬,,°"--°..."¥â«¬¬"µâ"«-- «¡--Èß Õº,¥¬ ª­¡"¢Õß,¬"¬¿" (NAPHA) 'Ë,,TMâÕ¬Yà,,ªí®®ÿ--'Ë¡'µàÕ°"--°..."¥--ß°à"« --Èß ®­¡'°",,TMâ§â",§ß'È,,°"§Ì"«÷ߪ­ ``º"ߥâ"µâÿ¢Õß,¬"¬ªí®®ÿ-- ·­Õ¿`ª"¬÷ߧ«"¡À¡"¬"ߥâ"°"§--ß·­°"ß` à«'Ë 5 ®­¢¬"¬°" «`§"­Àå¥--ß°à"« ¥â«¬°"ª­¡`µâÿ·­ºª­,¬TMå¢Õß "°"å"ßÕ°TM`ß ,¬"¬ÕËÊ (,ª¥¥Y "°"å ¡¡µ` D2-D4 ,,µ""ß 1.1) ·­'Ë 6 ®­ ¥Ì"`°"«`§"­À姫"¡« (Sensitivity) 'Ë¡'µàÕµ--«·ª¥â"TM'«¿"æ·­æµ`°¡ «¡--Èß'Ë¡'µàÕ ¡¡µ`"°'ˬ«°--«`«--"°"¥â""§"¢Õß°"--°...",,¢--È'Ë Õß ÿ¥â"¬ 'Ë 7 ®­ ÿª·­· ¥ß¢âÕ Õ·­¢Õߧ­ºYâ®--¥Ì" à«"¬­Õ'¬¥·­ ¢âÕ¡Y¥â"§`§ ®­Ì"¡" --ߧ"­Àå«â,,¿"§º«° À¡"¬Àµÿ: 1. ,ª¥¥Y«Á´µå¢Õß,§ß°" NAPHA ¥â ®"° Ì"--°ß",§Õ¥ å «--,§ ·­ ,§µ`¥µàÕ"ßæ» --¡æ--å °­«ß "" ÿ¢ æËÕ¥Yµ--«¢®Ì"«ºYâµ`¥TMÈÕ«-- ÕTMÕ«'·­ºYâªÉ«¬Õ¥ å¥â'Ë http://www.aidsthai.org.care à" "¡"¢â"¥Yµ--«¢ºYâ µ`¥TMÈÕ'ËÕâ"ß÷ߥâ,,«Á´µå'ÈTMà°-- 2. ,ª¥¥Y'Ë 2 ·­"¬ß"ÈÕßÀ--ß ,¥¬ ,°¥å ·­§­ (2548) ·­ ·ª­ ` ÿ¢ ·­§­ (2548) À"°µâÕß°""§Ì"Õ`"¬,¥¬­Õ'¬¥°'ˬ«°-- «`«--"°"¢Õß,§ß°"¢â"÷ß`°"¬"µâ"«-- Õ¥ å¢Õß--" 10 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ 3. µ--«Õ¬à"ß'Ë®­Ì" ÕTMà °",,TMâ'˪÷°..."'˵âÕß«à"®â"ß æËÕ àß `¡,,Àâ¡'°" ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥ ,¥¬'˪÷°..."¥--ß°à"«ºà"°"ñ°Õ¡¥â" °"·æ¬åæ'¬ßÁ°âÕ¬(ºYâµ`¥µ"¡) Ì",,ÀâºYâ¢â"à«¡,§ß°" ÿ¢¿"æ,,µ"OE`µ` "¡" ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥¥âªìÕ¬à"ߥ' (ø"å¡Õå ·­§­ 2544°, 2544¢, 2546) 'Ë 2 °"­"¥¢Õß,§Õ¥ å,,ª­»¬,,ªí®®ÿ-- °"·æà­"¥¢ÕßTMÈÕ«-- ÕTMÕ«',,°ÿࡪ­TM"°TM"«¬ ÷ß·¡â«à"°"­"¥¢Õß,§Õ¥ å,,ÿ°Êª­»--È®­À¡Õ°-- ·µà°"·æà­"¥ ,,ª­»¬--È ¡àÀ¡Õ,,§,, à«'Ë°'ˬ«°--§«"¡´--´âÕ,,TM`ߪ­«--µ`¥â" ­"¥«`¬" ·­ Ì"À--§«"¡¢â¡·¢Áß,,°"·°âªíÀ"¢Õß--" ·«,â¡·­°"µ`¥µàÕ¢Õß,§­"¥,,TMà«ß'˺à"¡" æ«--µ`¢Õß,§­"¥,,ª­»¬--È ¥â--°"--÷°«âÕ¬à"ߥ',,°"»÷°..."«`®--¬ ®Ì"«¡"° «¡--Èßß"«`®--¬¢Õß"«å·­§­ (æ.». 2537) æY®`·­§­ (æ.». 2541) «`°Õå·­§­ (æ.». 2534) «¡--Èß"§",° (æ.». 2540, 2542, 2543) Õ¬à"ß°Áµ"¡ ®Ì"ªì'Ë®­µâÕß«--°...­¥à"ߪ­°",,°" ­"¥¢Õß,§Õ¬à"ߧà"«Ê ª­»¬¥â¡'°""¬ß"÷ß,§Õ¥ å°'·°Ê,,æ.». 2527 À--ß®"°--È ¥â¡'°""¬ß"÷ß°'¢Õß,§Õ¥ å·­°"µ`¥TMÈÕ«-- 'Ëæ`Ë¡¢÷È,,ªïµàÕÊ¡" ,, ¢­'Ë,§­"¥¥â·æࢬ"¬,,°ÿࡪ­TM"°µà"ßÊ ´÷Ëߥâ­ÿ«âµ"¡ â"ß°"µ`¥ TMÈÕ ¥â·°à °ÿà¡--°à«¡æ» ºYâ,,TMâ¬" æµ`¥TM`¥©'¥ (IDUs) ºYâ¡'§«"¡ --¡æ--å°--æ» µß¢â"¡ «¡--Èß¡"¥"·­"°·°°`¥ ("§",° æ.». 2543) ,,­À«à"ß æ.». 2527-2530 ,§Õ¥ å à«,,Àà ®­°`¥¢÷È,,°ÿà¡TM"¬¬--°à«¡æ» À--ß ®"°--È ®÷ß°`¥°"·æà°­®"¬¢Õß°"µ`¥TMÈÕ«-- ÕTMÕ«'Õ¬à"ß«¥Á«,,°ÿࡺYâ,,TMâ ¬" æµ`¥TM`¥©'¥,,TMà«ß æ.». 2530-2531 ,¥¬Õ--µ"§«"¡TMÿ° (prevalence rate) ¢Õß°"µ`¥TMÈÕ,,°ÿࡺYâ,,TMâ¬" æµ`¥TM`¥©'¥,,°ÿßæoe æÿàß Yߢ÷È®"°âÕ¬­ 0 ªì âÕ¬­ 40 (°­«ß "" ÿ¢ æ.». 2545¢) À--ß®"°--È TMÈÕ«-- ®÷ß·æà °­®"¬ª,,°ÿࡺYâ,,Àâ`°""ßæ»·­Y°§â",, æ.». 2532 ·­ æ.». 2533 ´÷Ëß ¡'ºÌ",,Àâ°"µ`¥µàÕ,,°ÿࡺYâ¡'§«"¡ --¡æ--å°--滵ߢâ"¡--È°"¬ªì â"ß°" 11 12 · TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand 12 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ important route. By 1994, HIV prevalence1--the percentage of the population currently infected--had reached 31 percent nationally µ`¥TMÈÕ'Ë¡'§«"¡ Ì"§--¬`Ëߢ÷È ¿"¬,, æ.». 2537 §«"¡TMÿ°¢ÕßTMÈÕ«-- ÕTMÕ«'1 among brothel-based sex workers and 38 percent in the northern ÀÕÕ--µ" à«âÕ¬­¢Õß®Ì"«ª­TM"°'Ë¥â--º°­Õ¬à"ß·â®`ß--È Yß÷ß region of Thailand (MOPH 2002b). Use of commercial sex was wide- âÕ¬­ 31 --Ë«ª­»,,°ÿࡺYâ,,Àâ`°""ßæ»'ËÕ¬Yà,,´àÕß, ¿' ·­âÕ¬­ 38 spread: a national behavioral survey in 1990 found that 22 percent of ,,¿"§ÀÕ¢Õߪ­»¬ (°­«ß "" ÿ¢ æ.». 2545¢) --Èß'È °",,Àâ men ages 15 to 49, and 37 percent of men ages 20 to 24 had visited a `°""ß滢¬"¬µ--«ªÕ¬à"ß°«â"ߢ«"ß ,¥¬º Ì"«®æµ`°¡­¥--TM"µ`,,æ.». sex worker in the past year (Sittitrai 1992). Condom use in commer- 2533 · ¥ß,,ÀâÀÁ«à" âÕ¬­ 22 ¢ÕߺYâTM"¬«--¬ 15-49 ªï ·­âÕ¬­ 37 ¢Õß cial sex was quite low--only 38 percent of men who frequently used ºYâTM"¬«--¬ 20-24 ªï ¥â§¬,,TMâ`°""ßæ»,,ªï'˺à"¡" ( ``µ 2535) à« sex workers in the 1990 study used condoms all the time. Accordingly, °",,TMâÿ߬"ßÕ"¡--¬,,°ÿࡺYâ,,Àâ`°""ßæ»--È°--¡'âÕ¬ ,¥¬º°"»÷°..." æ.». HIV spread rapidly between sex workers and their clients. By 1994, 1 2533 · ¥ß«à" ¡'æ'¬ßâÕ¬­ 38 ¢ÕߺYâTM"¬'Ë¢â"--`°""ßæ»à"--È'Ë,,TMâÿß in 10 clients was infected with the virus. Those clients then infected ¬"ßÕ"¡--¬µÕ¥«" ¥--ß--È TMÈÕ«-- ÕTMÕ«'®÷ß·æà°­®"¬ªÕ¬à"ß«¥Á«­À«à"ß their wives, who in turn became pregnant and transmitted HIV to ºYâ,,Àâ`°""ßæ»·­Y°§â" ¿"¬,,æ.». 2537 Y°§â"¢ÕߺYâ,,Àâ`°""ßæ» their children. In 1991, the first perinatal cases were reported, and the ®Ì"« 1 ,, 10 § ®­µ`¥TMÈÕ«-- ¥--ß°à"« Y°§â"Àà"--È¥âÌ"TMÈÕ¡"µ`¥¿¬" numbers of infected newborns increased in the following years. ¢Õßæ«°¢" ´÷Ëߥâµ--Èߧ¿å ·­Ì",,Àâ"°,,§¿åµ`¥TMÈÕÕTMÕ«'ª¥â«¬ ,,æ.». 2534 ¥â¡'°""¬ß"÷ß°'ºYâ'˵`¥TMÈÕµ--Èß·µà°Ì"`¥ªì"¬·° ·­®Ì"«¢Õß The trend of the epidemic is charted in figure 2.1, which presents prevalence rates for pregnant women and 21-year-old male conscripts "°·°°`¥'˵`¥TMÈÕ®÷ߥâæ`Ë¡ Yߢ÷È,,ªïµàÕÊ¡" for the 1989­2003 period. HIV prevalence among young male con- ·«,â¡¢Õß,§­"¥--È ¥â· ¥ß«â,,¿"æ 2.1 ´÷Ëß· ¥ß÷ßÕ--µ"§«"¡TMÿ° scripts peaked in 1993 at 4 percent nationally (and at nearly 13 per- ¢Õß µ'¡'§¿å ·­À"°±åæ»TM"¬«--¬ 21 ªï ,,TMà«ßæ.». 2532-2546 Õ--µ" cent in the north), but it has since come down sharply (World Bank §«"¡TMÿ°,,°ÿà¡À"°±å«--¬Àÿà¡ ¢÷È÷ß®ÿ¥ Yß ÿ¥,, æ.». 2536 ,,Õ--µ"âÕ¬­ 4 2000). The same pattern is observed for prevalence rates among sex --Ë«ª­» (·­°Õ÷ßâÕ¬­ 13 ,,¿"§ÀÕ) ·µàÀ--ß®"°--È ®÷ߥâ¥ßÕ¬à"ß workers (figure 2.2). HIV prevalence rates among women attending «¥Á« ("§",° æ.». 2543) à«Õ--µ"§«"¡TMÿ°,,°ÿࡺYâ,,Àâ`°""ßæ»°Á prenatal clinics (a low-risk group) follow the same pattern, but with a ¡'Yª·¥'¬«°-- (¿"æ 2.2) Ì"À--Õ--µ"§«"¡TMÿ°¢ÕßTMÈÕ«-- ÕTMÕ«' ,,°ÿà¡ lag, rising from about 0.89 percent in 1989 to 2.3 percent in 1995, µ''Ë"°§¿å,,§``° (°ÿà¡'Ë¡'§«"¡ 'ˬߵË") --È ÷ß®­¡'Yª·¥'¬«°-- ·µà°`¥ ¢÷È¿"¬À--ß ,¥¬ Yߢ÷È®"°âÕ¬­ 0.89 ,, æ.». 2532 ¡"ªìâÕ¬­ 2.5 Figure 2.1 HIV Prevalence among Pregnant Women, Blood Donors, and 21-Year-Old ¿"æ 2.1 §«"¡TMÿ°¢ÕßTMÈÕ«-- ÕTMÕ«' ,,°ÿà¡ µ'¡'§¿å ºYâ`®"§,À`µ ·­À"°±åTM"¬«--¬ Male Conscripts 21 ªï 4.5 4 3.5 3 2.5 2 Õ--µ" à«âÕ¬­percentage1.5 1 0.5 0 June ¡`.¬.2532 ¡`.¬.2531990June25319914 1989 3 June ¡`.¬. ¡`.¬.25319925 ¡`.¬.2531993 µ'¡'§¿å¡`.¬.2531995¡`.¬.2531996¡`.¬.251998¡`.¬.252000¡`.¬.252002 6 June June ¡`.¬.2531994June 7 8 9 41 43 45 June June June June June À"°±å conscripts pregnantwomen `®"§,À`µ blooddonors 'Ë¡":Source:MOPH °­«ß "" ÿ¢ 2547; ·ª­ ` ÿ¢ 2004; Thanprasertsuk 2004. °"­"¥¢Õß,§Õ¥ å,,ª­»¬,,ªí®®ÿ-- The Thai AIDS Epidemic Now · 13 13 Figure 2.2 HIV Prevalence among Direct and Indirect Sex Workers ¿"æ 2.2 §«"¡TMÿ°¢ÕßTMÈÕ«-- ÕTMÕ«' ,,°ÿࡺYâ§â"`°""ßæ» "ßµß ·­"ßÕâÕ¡ 30 28.0 26.1 25 27.6 28.2 23.0 21.1 20 18 17.8 16 15 15.2 16 12.27 percentageÕ--µ" à«âÕ¬­ 10.1 10 11.76 9.3 7.7 8 8.26 6.7 6.6 5.9 5 4.3 5 4.1 3.12 4.5 3.9 0 0 2 ¡`.¬.253219892531990253199125319922531993253¡`.¬.253¡`.¬.253¡`.¬.25¡`.¬.25 ¡`.¬.25¡`.¬.25¡`.¬.25¡`.¬.25 ¡`.¬.25 3 4 5 6 7 8 9 0 1 2 3 4 5 6 1994 1995 1996 41997 41998 41999 42000 42001 42002 42003 June June June June June¡`.¬. ¡`.¬. ¡`.¬. ¡`.¬. ¡`.¬. June June June June June June June June June June º ¡ mixed "ßµß direct "ßÕâÕ¡ indirect 'Ë¡": °­«ß "" ÿ¢ 2547; ·ª­ ` ÿ¢ 2547 Source: MOPH 2004; Thanprasertsuk 2004. before starting to come down. A comparison of figures 2.1 and 2.2 ,, æ.». 2538 °àÕ'Ë®­`Ë¡¥ß ®"°°"ª'¬'¬¿"æ 2.1 ·­ 2.2 ®­ reveals that the prevalence rate among the high-risk groups of sex ÀÁ¥â«à" Õ--µ"§«"¡TMÿ°,,°ÿà¡'Ë¡'§«"¡ 'Ë¬ß Yß Õ--¥â·°àºYâ,,Àâ`°""ßæ»·­Y°§â" workers and their clients (as proxied by young male conscripts) was an (´÷Ëß¡'À"°±åªìµ--«·) ªìµ--«àßTM'ÈÌ"'ËY°µâÕß Ì"À--Õ--µ"§«"¡TMÿ°,,°ÿà¡'Ë¡' accurate leading indicator of the prevalence rate among low-risk §«"¡ 'ˬߵË"·­ª­TM"°--Ë«ª °"§âæ'È · ¥ß,,ÀâÀÁ«à" °"Ñ"­«--ß©æ"­°ÿà¡ groups and the general population. This finding suggests that sentinel 'Ë¡'§«"¡ 'Ë¬ß Yß--È "¡"TM૬,,ÀâºYâ«"ß,¬"¬¥â§"¥§­÷ߧ«"¡ª'ˬ·ªß'Ë ®­°`¥¢÷È Ì"À--°"·æà­"¥¢Õß,§,¥¬--Ë«ª¥â surveillance of high-risk groups can help policy makers anticipate ÷ß·¡â«à" Õ--µ"§«"¡TMÿ°¢ÕßTMÈÕ«-- ÕTMÕ«'®­¥ßÕ¬à"ßÀÁ¥âTM--¥ µ--Èß·µà°"ß changes in the general epidemic. TMà«ß»«... 1990 ÀÕ­À«à"ßæ.». 2533-2543 ·µà«`°µ°"å¢ÕßTMÈÕ«-- ÕTMÕ«'·­,§Õ¥ å,,ª­»¬¬--ß¡à `È ÿ¥ßßà"¬Ê °"µ`¥TMÈÕ"¬,,À¡àTMà«ß ÿ¥â"¬ Although HIV prevalence rates have come down dramatically since the mid-1990s, the HIV/AIDS crisis in Thailand is far from over. The ,,°ÿà¡ µ'·­ÿµæ`Ëß®­`Ë¡¥ß ·­Õ--µ"§«"¡TMÿ°,,°ÿà¡ 'ˬß"ß°ÿ࡬--ߧßÕ¬Yà last waves of new infections among women and their children have ,,­¥-- Yß¡"° Õ--µ"§«"¡TMÿ°,,°ÿࡺYâ,,TMâ¬" æµ`¥TM`¥©'¥ ´÷ËßÕªì°ÿà¡'Ë¡'Õ--µ" only recently started to decline, and prevalence rates among certain at- §«"¡TMÿ° Yß ÿ¥--È ¬--ß§ß Yß÷ß°ÕâÕ¬­ 50 ·­¬--ß¡à¥ß¡"µ--Èß·µàª"¬»«... risk groups remain very high. Prevalence rates among IDUs--the 1990 (æ.». 2533-43) à«Õ--µ"§«"¡TMÿ°,,°ÿࡺYâ,,Àâ`°""ßæ»--È¥â¥ß group with the highest prevalence--are still close to 50 percent and Õ¬à"ß¡"° Õ--ËÕß¡"®"°°"·°âªíÀ"­¥--ª­»Õ¬à"ß®`ß®--ß ·­,§ß°",,TMâ have not declined since the late 1990s (figure 2.3). Prevalence rates ÿ߬"ßÕ"¡--¬âÕ¬­ 100 Õ¬à"ß°Áµ"¡ ºYâ§â"`°""ßæ» ¬--ßÕªì°ÿà¡ 'ˬß'Ë among commercial sex workers declined considerably in response to Ì"§-- ,, æ.». 2546 Õ--µ"§«"¡TMÿ°¢ÕߺYâ§â"`°""ßæ»,¥¬µß Õ¬Yà'ËâÕ¬­ 11.7 à«Õ--µ"§«"¡TMÿ°¢ÕߺYâ§â"`°""ßæ»,¥¬ÕâÕ¡ Õ¬Yà'ËâÕ¬­ 3.9 à«°ÿà¡ Thailand's strong national response and the 100 percent condom pro- ÕËÊ'Ë¡'Õ--µ"§«"¡TMÿ° Yß ¥â·°à TM"¬'˧â"`°""ßæ» (âÕ¬­ 7.9) TM"«ª­¡ß gram. Nevertheless, sex workers remain a major risk group. In 2003, (âÕ¬­ 6.9) ·­TM"¬´÷Ëߢâ"--°"--°..."¥â«¬,§µ`¥µàÕ®"°æ» --¡æ--å (STI) (âÕ¬ the prevalence rate was 11.7 percent among female direct sex workers ­ 4.6) (·ª­ `°ÿ 254 ) ËÕß®"°¡'ºYâµ`¥TMÈÕ«-- ÕTMÕ«'ªì®Ì"«¡"° and 3.9 percent among indirect sex workers. Other high-prevalence ,Õ°" 'Ë®­¡'°"·æà­"¥¢ÕßTMÈÕ«-- ®÷߬--ߧߡ'Õ¬Yà¡"° À"°¡`¥â¡'§«"¡æ¬"¬"¡ groups include male sex workers (7.9 percent), fishermen (6.9 percent), ªÑÕß°--Õ¬à"ß®`ß®--ß and males presenting at clinics with sexually transmitted infections (STIs) (4.6 percent) (Thanprasertsuk 2004). With a large number of 14 14 · The»...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ EconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand Figure 2.3 HIV Prevalence among IDUs ¿"æ 2.3 °"·æà°­®"¬¢ÕßTMÈÕ«-- ÕTMÕ«' ,,°ÿࡺYâ,,TMâ¬" æµ`¥TM`¥©'¥ 60 51.1 50 50.0 40.0 47.5 47.0 41.7 40 39.0 35.7 38.2 31.4 36.4 35.634.3 37.0 40.0 40.8 30 27.7 30.6 30.0 30.6 percentageÕ--µ" à«âÕ¬­ 20 25.2 10 0 June June June June June June June June June June June ¡`.¬.2532¡`.¬.2533¡`.¬.25319914¡`.¬.25319925¡`.¬.2531993¡`.¬.2531994¡`.¬.25319958 ¡`.¬.251997¡`.¬.251999¡`.¬.252001¡`.¬.252003 1989 1990 6 7 40 42 44 46 'Ë¡": °­«ß "" ÿ¢ 2547; ·ª­ ` ÿ¢ Source: MOPH 2004; Thanprasertsuk 2004. In 2001, the Thai Working Group on HIV/AIDS projected that by ,, æ.». 2544 §­Ì"ß"¢Õߪ­»¬°'ˬ«°--TMÈÕ«-- ÕTMÕ«'/Õ¥ å ¥â 2004 about 572,500 Thais would be living with HIV/AIDS (table 2.1). Õ«à" ¿"¬,,æ.». 2547 ª­»¬®­¡'ºYâµ`¥TMÈÕ«-- ÕTMÕ«'/Õ¥ å ª­¡" Among them, approximately 49,500 would develop serious AIDS- 572,500 § (µ""ß 2.1) ,,°ÿࡧÀà"'È ª­¡" 49,500 § ®­ªÉ«¬¥â«¬,§ related illnesses in 2004, and about the same number would die of â"¬·ß'Ë°'ˬ«ËÕß°--Õ¥ å,,æ.». 2547 ·­ºY⧮Ì"«à"°-- ®­µâÕß '¬TM'«`µ¥â«¬ AIDS-related complications. The group also estimated that 19,500 º¢â"ߧ'¬ßÕËÊ'Ë°'ˬ«ËÕß°--Õ¥ å Õ°®"°'È §­Ì"ß"¥--ß°à"« ¬--ߪ­¡`«à" new HIV infections would occur in 2004 (compared with 143,000 ,,æ.». 2547 ®­°`¥ºYâµ`¥TMÈÕ"¬,,À¡à®Ì"« 19,500 § (,¥¬ª'¬'¬°--ºYâµ`¥ new infections in 1990 and 23,676 new infections in 2002). TMÈÕ"¬,,À¡à®Ì"«143,000 § ,,æ.». 2537 ·­ 23,676 § ,,æ.». 2545) Almost 80 percent of all AIDS cases will occur among people ages ª­¡"âÕ¬­ 80 ¢ÕߺYâªÉ«¬¥â«¬,§Õ¥ å--ÈßÀ¡¥ ®­°`¥¢÷È,,°ÿࡺYâ§'Ë¡'Õ"¬ÿ 20 to 39. Heterosexual transmission remains the main mode of trans- ­À«à"ß 20-39 ªï °"µ`¥TMÈÕ­À«à"ß滵ߢâ"¡¬--ßÕªì«`'°" Ì"§--'ËÌ",,Àâ°`¥ mission, accounting for the bulk of all AIDS cases. But the composi- °"µ`¥TMÈÕ ·­Ì",,Àâ°`¥ºYâªÉ«¬¥â«¬,§Õ¥ å®Ì"«¡"° ·µà ૪­°Õ¢Õß°"µ`¥ tion of infections has changed dramatically. A decade ago, most of the TMÈÕ¥âª'ˬ·ªßªÕ¬à"ßÀÁ¥âTM--¥ ¡ËÕ `ªï'˺à"¡" °"µ`¥TMÈÕ à«,,Àà®­Õ¬Yà,, infections were in adults, and 80 percent were in sex workers and their °ÿࡺYâ,,Àà ·­âÕ¬­ 80 ®­Õ¬Yà,,°ÿࡺYâ§â"`°""ßæ»·­Y°§â" ·µà,,¢­'È clients. Now about one-half of all new infections are in women ª­¡"§÷ËßÀ÷ËߢÕߺYâµ`¥TMÈÕ"¬,,À¡à ®­Õ¬Yà,,°ÿࡺYâÀ`ß´÷Ëßµ`¥TMÈÕ¡"®"° "¡'ÀÕ§Yà infected by their husbands or sex partners. IDUs account for about 5 Õ à«°"µ`¥TMÈÕ,,°ÿࡺYâ,,TMâ¬" æµ`¥TM`¥©'¥µ"¡'Ë¥â--"¬ß"¡" ®­Õ¬Yà'ËâÕ¬ percent of reported infections. Approximately 4 percent of AIDS ­ 5 Õ°®"°'È ª­¡"âÕ¬­ 4 ¢ÕߺYâªÉ«¬¥â«¬,§Õ¥ å,,ª­»¬--È ®­°`¥ cases in Thailand occur in children, and in 2000, one-seventh of new ¢÷È,,°ÿà¡¥Á° ·­,, æ.». 2543 À÷Ëß,,®Á¥¢ÕߺYâµ`¥TMÈÕ"¬,,À¡à ¥â·°à°ÿà¡¥Á° infections were in children. µ""ß 2.1 ®Ì"«,¥¬ª­¡"¢ÕߺYâµ`¥TMÈÕÕTMÕ«'/Õ¥ å ­ ¡ æ.». 2547 Table 2.1 Estimated Cumulative Numbers for HIV/AIDS, 2004 `µ` ®Ì"« Statistic ®Ì"«ºYâµ`¥TMÈÕ--ÈßÀ¡¥ (ºYâ,,Àà·­¥Á°) ®÷ß æ.». 2547 1,074,155 Number Total HIV infections (adults and children) up to 2004 ®Ì"«ºYâ '¬TM'«`µ ­ ¡ (ºYâ,,Àà·­¥Á°) ®÷ß æ.». 2547 1,074,155 501,600 Total cumulative deaths (adults and children) up to 2004 ®Ì"«ºYâµ`¥TMÈÕÕTMÕ«' ,, æ.». 2547 572,484 501,600 People living with HIV in 2004 572,484 Projected new HIV infections in 2004 ®Ì"«ºYâµ`¥TMÈÕÕTMÕ«'"¬,,À¡à '˧"¥§­«â Ì"À-- æ.». 2547 19,471 19,471 Projected new AIDS cases in 2004 ®Ì"«ºYâªÉ«¬¥â«¬,§Õ¥ å"¬,,À¡à '˧"¥§­«â Ì"À-- æ.». 2547 49,542 'Ë¡": §­Ì"ß"¢Õߪ­»¬°'ˬ«°--TMÈÕ«-- ÕTMÕ«'/Õ¥ å, 2544 49,542 Source: Thai Working Group on HIV/AIDS Projection 2001. °"­"¥¢Õß,§Õ¥ å,,ª­»¬,,ªí®®ÿ-- The Thai AIDS Epidemic Now · 15 15 ¿"æ 2.4 °"§"¥ª­¡"®Ì"«ºYâªÉ«¬¥â«¬,§Õ¥ å,,·µà­ªï Figure 2.4 Projected Annual New AIDS Cases 60000 60000 50000 50000 40000 40000 30000 30000 20000 20000 10000 10000 02528 0 1985 2533 2538 2543 2548 2553 2558 2563 1990 1995 2000 2005 2010 2015 2020 'Ë¡" : °"§"¥ª­¡"¢Õߧ­Ì"ß"ª­»¬ æ.». 2544 Source: Thai Working Group Projection 2001. The demand for HIV/AIDS treatment and care is rising as Thai- land's epidemic enters a new phase, with many of those infected during §«"¡µâÕß°"'Ë®­¥â--°"¥Y··­--°..."°'ˬ«°--TMÈÕ«-- ÕTMÕ«'/Õ¥ å--Èæ`Ë¡ Yߢ÷È ¡ËÕ°"­"¥,,ª­»¬¥â°â"« Yà­¬­,,À¡à ,¥¬¡'ºY⧮Ì"«¡"°'˵`¥TMÈÕ the early years of the epidemic becoming ill with symptomatic disease.2 «-- ¡",,TMà«ßªï·°Ê¢Õß°"­"¥ ¥â`Ë¡®ÁªÉ«¬¥â«¬,§'Ë· ¥ßÕ"°"2 ®Ì"« The current number of new annual AIDS cases--just under 50,000--is ¢ÕߺYâªÉ«¬¥â«¬,§Õ¥ 媭®Ì"ªï,,ªí®®ÿ-- ´÷Ë߬--ßµ°«à" 50,000 § --È §"¥«à" ®­¬--ß projected to remain constant until 2006, when it should start to decline §ß'Ë®÷ß æ.». 2549 À--ß®"°--È ®÷ß®­`Ë¡¥µË"ß ËÕß®"°¡'Õ--µ"°"µ`¥TMÈÕ¥ because of the sharp reduction in new infections in the late 1990s (fig- ßÕ¬à"ß¡"°µ--Èß·µàTMà«ßª­¡"ª"¬»«... 1990 (æ.». 2533-43) (¿"æ 2.4) ure 2.4). Meeting this demand for care poses a huge challenge to the °"µÕ Õߧ«"¡µâÕß°"µàÕ°"¥Y·'È Õªì§«"¡â""¬Õ¬à"ß,,ÀàÀ«ß Ì"À-- Royal Thai government and Thai society. In a few years, as AIDS --"·­ --ߧ¡¬ ,,TMà«ß Õß "¡ªï¡"'È ºYâªÉ«¬¥â«¬,§Õ¥ å ¡'TM'«`µ¬¬"«¢÷È patients live longer with antiretroviral therapy (ART), the health sys- ËÕß®"°¥â--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (ART) ¥--ß--È ­ ÿ¢¿"æ ®÷ß®Ì"ªì tem will need to provide care not only to 10,000 to 20,000 new cases µâÕß,,Àâ°"¥Y··°àºYâªÉ«¬ ¡àæ'¬ß·µàºYâªÉ«¬"¬,,À¡àʪ­¡" 10,000-20,000 § per year but also to many of those whose lives have been significantly à"--È ·µà¬--ß«¡÷ߺYâªÉ«¬ÕËÊ'Ë¡'TM'«`µ¬¬"«¢÷ÈÀ--ß®"°¥â--°"--°..."¥â«¬¬"µâ" prolonged by ART. «-- Õ¥ å The National Access to Antiretrovirals Program for People Living with HIV/AIDS (NAPHA) is a comprehensive and ambitious attempt ,§ß°"¢â"÷ß`°"¬"µâ"«-- Õ¥ å­¥--TM"µ` Ì"À--ºYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å (NAPHA) ªì§«"¡æ¬"¬"¡Õ¬à"ߧէÿ¡·­­¬Õ­¬" æËÕ'Ë®­,,Àâ°"¥Y· to provide such care, with ART as the standard. By all measures, given ¥--ß°à"« ,¥¬,,TMâ°"--°..."¥â«¬¬"µâ"«-- Õ¥ åªì¡"µ" --Èß'È À"°¡'§«"¡¡ÿàß¡--Ë the commitment across all segments of Thai society, the country's sig- ,,ÿ°¿"§ à«¢Õß --ߧ¡¬ nificant health system capacity, and the availability of internal and «¡--Èß»--°¬¿"æ¢Õß­¥Y· ÿ¢¿"æ'Ë Ì"§--¢Õß ª­» ·­°",,À⧫"¡ -- ÿ"ß°"ß`"ß¿"¬,,ª­»·­®"°µà"ߪ­» external financing, Thailand has a strong chance of meeting this chal- ª­»¬ Õ«à"¡',Õ°" ¡"°'Ë®­ "¡"µÕ Õߧ«"¡â""¬¥--ß°à"«¥â ·µà lenge. But its ability to even contemplate providing care to all those Õ¬à"ß°Áµ"¡ §«"¡ "¡"¢Õߪ­»¬ 'Ë®­æ`®""÷ß°",,Àâ°"¥Y··°àÿ°§ who need it rests on the success of its past national prevention efforts. '˵âÕß°"--È ®­¢÷ÈÕ¬Yà°--§«"¡ Ì"Á®¢Õߧ«"¡æ¬"¬"¡,,°"ªÑÕß°--,§Õ¥ å­¥-- Without those efforts, HIV infections--and hence AIDS cases-- ª­»'˺à"¡",,Õ¥'µ would be as much as 14 times higher than they are today (figure 2.5) (Thai Working Group on HIV/AIDS Projection 2001). We estimate À"°ª"»®"°§«"¡æ¬"¬"¡Àà"--È ®Ì"«ºYâªÉ«¬¥â«¬,§Õ¥ å®­¡'¡"°°«à"'˪ì Õ¬Yàÿ°«--'È÷ß 14 à" (°"§"¥ª­¡"¢Õߧ­Ì"ß"ª­®Ì"ª­»¬«à"¥â«¬TMÈÕ that, without such efforts, Thailand would have had 7.7 million HIV «-- ÕTMÕ«'/Õ¥ å æ.». 2544) À"°â´÷Ëߧ«"¡æ¬"¬"¡¥--ß°à"« ª­»¬®­¡'ºYâ cases and 850,000 AIDS cases in 2005, roughly 14 times more of each µ`¥TMÈÕ«-- ÕTMÕ«'÷ß 7.7 â"§ ·­¡'ºYâªÉ«¬¥â«¬,§Õ¥ å®Ì"« 850,000 § ,, than was the case. If Thailand were to try to offer ART to this much æ.». 2550 ÀÕª­¡" 14 à"¢Õß°''Ë°`¥¢÷È®`ß À"°ª­»¬®­µâÕß larger number of AIDS patients, its budget requirements would also be 14 times greater--and they would continue to grow over the next 16 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ 16 · TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand ¿"æ 2.5 °"§"¥ª­¡"°"µ`¥TMÈÕ«-- ÕTMÕ«' À"°ª"»®"°§«"¡æ¬"¬"¡,,°"ªÑÕß°--'Ë Figure 2.5 Projected HIV Infections in the Absence of Successful Prevention Effort ª­ §«"¡ Ì"Á® 10 no intervention ¡à¡'°"·°·´ß (â"§) (millions) 8 ⪭· ¥ß÷ß `Ëß'ËÕ"®°`¥¥â line represents what might have been if 6 À"°¡à¡'°"ª'ˬ·ªß æµ`°¡ behaviors had not changed Infections 4 infections ªÑÕß°-- prevented HIV °"µ`¥TMÈÕ 2 baseline â" Current 0 ®"«ºYâµ`¥TMÈÕÕTMÕ«',,ªí®®ÿ---- 2528 2533 1985 1990 1995 2538 2000 2543 2005 2548 2553 2010 'Ë¡": °"§"¥ª­¡"¢Õߧ­Ì"ß"ª­»¬«à"¥â«¬TMÈÕ«-- ÕTMÕ«'/Õ¥ å æ.». 2544 Source: Thai Working Group on HIV/AIDS Projection 2001. decade. Thanks to its substantial prevention efforts from 1991 to 2002, Thailand has avoided the need to spend an additional US$18.6 billion æ¬"¬"¡'Ë®­,,Àâ°"--°..."¥â«¬ ART ·°àºYâªÉ«¬¥â«¬,§Õ¥ å´÷Ëß¡'®Ì"«¡"°¢"¥'Ë (B 745 billion) on treatment over the decade through 2012. §"¥ª­¡"«â--È §«"¡µâÕß°"¥â"ߪ­¡" ®­µâÕß Yߢ÷Ȫì 14 à"TMà°-- ·­®­¬--ßæ`Ë¡ Yߢ÷È,,TMà«ß»«...µàÕª ·µàËÕß®"°§«"¡æ¬"¬"¡'Ë°`¥¢÷ÈÕ¬à"ß HIV/AIDS program. Its total budget expenditure on prevention and ¡"°¡"¬,,TMà«ß æ.». 2538-2545 ª­»¬®÷ß "¡"À'°'ˬߧ«"¡®Ì"ªì'Ë During the 1990s, Thailand spent more than most countries on its treatment combined over this period was a substantial US$434 mil- ®­µâÕß,,TMâߪ­¡"æ`Ë¡µ`¡Õ'° 18.6 æ--â"À'¬ À-- (745 æ--â"") lion in 2002 dollars (B 17.3 billion). However, by averting the need to Ì"À--°"--°...",,TMà«ß»«...¢â"ßÀâ"®÷ß æ.». 2555 spend US$18.6 billion (B 745 billion) over the subsequent decade, the ,,TMà«ß»«... 1990 (æ.».2533-43) ª­»¬¥â,,TMâß` Ì"À--,§ß°" government saved US$43 (or B 1720) for each dollar (or baht) invested °'ˬ«°--TMÈÕ«-- ÕTMÕ«'/Õ¥ å ¡"°°«à"ª­»ÕËÊ à«,,Àà ,¥¬°",,TMâߪ­¡" in the 1990s. It is doubtful that any other Thai government investment --ÈßÀ¡¥ Ì"À--°"ªÑÕß°--·­°"--°..."«¡°--,,­¬­'È Yß÷ß 434 â"À'¬ À-- achieved such a high benefit-cost ratio. ,, æ.». 2545 (17.3 æ--â"") Õ¬à"ß°Áµ"¡ ¡ËÕ "¡"'ˬߧ«"¡®Ì"ªì'Ë®­ µâÕß®à"¬ß`÷ß 18.6 æ--â"À'¬ À-- (745 æ--â"") ,,TMà«ß `ªïµàÕ¡" "ß importance of prevention. When the finance ministries of such coun- --"®÷ß "¡"ª­À¬--¥¥â÷ß 43 À'¬ À-- (1720 ") Ì"À--ÿ°ÊÀ'¬ This experience offers a critical lesson for other countries about the tries as China and India--where the HIV/AIDS epidemic is at an ear- (ÀÕ") 'Ë¥âßÿª,,TMà«ß»«... 1990 (æ.». 2533-43) ´÷Ë߬--ߪì'Ëà" lier stage--make intersectoral allocations of the government's budget, ß --¬«à" °"ßÿÕËÊ¢Õß--"¬ ®­ "¡"Ì"¥â,,Õ--µ" à« ºª­,¬TMå- they should be aware of the high return to HIV/AIDS prevention µâÿ 'Ë Yߢ"¥'ÈÀÕ¡à campaigns. The experience also offers an essential lesson to Thai pol- ª­ °"å§--Èß'È ¥â,,Àâ'¬'Ë Ì"§--·°àª­»ÕËÊ÷ߧ«"¡ Ì"§--¢Õß°" icy makers on the importance of not allowing the demand for treat- ªÑÕß°-- ¡ËÕ°­«ß°"§--ߢÕߪ­»µà"ßÊ TMà ®' ·­Õ`¥'¬ ´÷Ëß°"­"¥¢Õß ment and care to crowd out continued prevention efforts. TMÈÕ«-- ÕTMÕ«'·­,§Õ¥ å¬--ߧßÕ¬Yà,,­¬­µâ ¥â°­®"¬ßª­¡"¢Õß--"ª ,,¿"§ ૵à"ßÊ §«®­µâÕßµ­À--°÷ߺµÕ·Õ-- Yß'Ë®­¥â®"°°"ߧåæËÕ Spatial Patterns of HIV/AIDS in Thailand ªÑÕß°--TMÈÕ«-- ÕTMÕ«'·­,§Õ¥ å Õ°®"°'È ª­ °"å¬--ß°à"« ¬--ߥâ,,Àâ '¬'Ë®Ì"ªì·°àºYâ«"ß,¬"¬TM"«¬ °'ˬ«°--§«"¡ Ì"§--¢Õß°"'Ë®­µâÕß¡àªàÕ¬ The HIV epidemic in Thailand presents some distinct spatial and ,,À⧫"¡µâÕß°"°"¥Y·--°..."--È¡"--ߧ«"¡æ¬"¬"¡ªÑÕß°--Õ¬à"ßµàÕËÕß geographic patterns, which lead to very different needs across regions and geographic areas in terms of availability of treatment. 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·ª­ ` ÿ¢ ·­§­ 2547; "§",° 2543) ­¬­'Ë 2: ­¬­'Ë¡ÿàßâ¥â" --ߧ¡·­æÀÿ¿"§ (æ.». 2534-2539) ,, æ.». 2534 ¿"¬,,µâ°"ª°§Õß,,­¬­ --È¢Õß"¬°--¡µ' Õ"--å ªí¬"TMÿ (æ.». 2534-35) °"ªÑÕß°--·­§«§ÿ¡,§Õ¥ å--È ¥â°"¬ªìª­¥Á'Ë¡'§«"¡ Ì"§--­¥--µâÊ¢Õߪ­» ,¬"¬°'ˬ«°--,§Õ¥ å ¥âY°Ì"¡",,TMâ¿"¬,,µâ°" ª­ "ß"¢Õß Ì"--°"¬°--¡µ' ,¥¬¡'°"°àÕµ--Èߧ­°¡°"ªÑÕß°--·­§«§ÿ¡ ,§Õ¥ å·ÀàßTM"µ` ´÷Ëߪ짭°¡°"¢ÕßÀ"¬¿"§ à«'Ë°àÕµ--ÈßÕ¬à"ߪì"ß°" ,¥¬¡'"¬°--¡µ'ªìª­" °"§ËÕÀ«§--Èß'È ªì --"÷ߧ«"¡¡ÿàß¡--Ë,, ­¥-- Yß ÿ¥¢Õß¿"§°"¡Õß ·­Õ°®"°--È ¬--ߪî¥,Õ°" ,,ÀâÕߧå°æ--"Õ°TM¥â ¢â"¡' à«à«¡Õ¬à"ߪì"ß°",,°­«°"«"ß,¬"¬ --Èß'È §­°¡°"æ--" »...°`®·­ --ߧ¡·ÀàßTM"µ` (NESDB) ¬--ߥâ--¡ÕÀ¡"¬,,ÀâªìºYâ«"ß·º°¬ÿå °'ˬ«°--,§Õ¥ å,,­¥--TM"µ` ´÷Ëߺ'˥⠧Õ,§ß°"§«§ÿ¡,§Õ¥ å,,­¬­ 5 ªï·° «¡--Èßߪ­¡"´÷Ëß·àßÕÕ°ªì°Õßÿ·°àÀ૬ß"--"·­Õߧå°æ--"Õ°TM ®Ì"«À÷Ëß --Èß'È ¥â¡'·º´÷Ëßâ'Ë°"­¥¡ææËÕ,,Àâ --ߧ¡·­TMÿ¡TM¥â¢â"¡' à«à«¡ ,,°"ªÑÕß°--TMÈÕ«-- ÕTMÕ«' ¥â¡' à«¥Y·­ºYâ'Ë®ÁªÉ«¬ ·­TM૬¥°"¥YY°À¬'¬¥ À¬"¡·­Õ°ªØ`--µ` ("§",° æ.». 2543) ¥â«¬°¬ÿ媭¿'È ®÷ߥâ¡'°" «"ß·ºµâ"TMÈÕ«-- ÕTMÕ«'·­Õ¥ å,,­¥--æÀÿ¿"§ à« «¡--ÈßÌ"¡"ªØ`--µ`µàÕª °"­"¥¢Õß,§Õ¥ å,,ª­»¬,,ªí®®ÿ-- 21 ,§ß°"ߧå¥â"¢âÕ¡Y°'ˬ«°--,§Õ¥ åµàÕ ""TM®Ì"«¡"° ¥â``Ë¡¢÷È ¿"¬,,µâ°"Ì"¢Õßÿ§§´÷Ëߪì'˧"æÕ¬à"ß Yß,,ª­»¬ ¥â·°à "¬¡'TM--¬ «'­ The Thai AIDS Epidemic Now · 21 «¬­ ,¥¬ºà""ß ËÕ¡«TM --Èß'È ¥â¡'°",,TMâ¢âÕ§«"¡'Ëâ÷ß°"ªÑÕß°-- °" ª'ˬ·ªßæµ`°¡ ·­°",,TMâÿ߬"ßÕ"¡--¬ «¡--Èß¡'°"àßTM'È÷ß,§Õ¥ å,,"­ ªíÀ" --ߧ¡ ¡`,,TMàæ'¬ßªíÀ"¥â" ÿ¢¿"æà"--È ,¥¬ÿ°°­«ß¥â--°"TM`TM«,,Àâ A massive public information campaign on AIDS was launched ¡' à«à«¡Õ¬à"ß·¢Áߢ--,,°",,Àâ°"»÷°..."·­ñ°Õ¡æ--°ß"¢Õß°­«ß under the leadership of a highly respected Thai figure, Mechai Vira- Õ°®"°'È °­«ß»÷°..."`°" ¬--ߥâ--°"¢ÕâÕß,,Àâ`Ë¡¥Ì"`°"°ÿà¡"ß°" vaidya, through the mass media. The messages emphasized preven- »÷°..."­¥--à"'¬¡°-- §«"¡æ¬"¬"¡¢Õß--" ¬--ߥâ--°" `¡¥â«¬,§ß°"``Ë¡ tion, behavior change, and condom use and identified AIDS as a social problem, not just a health problem. All ministries were recruited to µà"ßÊ¢ÕßÕ°TM --Èß¿"§ÿ°`®·­Õߧå°"æ--"Õ°TM actively educate and train their staffs, and the Ministry of Education was asked to launch peer education groups. Private initiatives by busi- ,§ß°"ÿ߬"ßÕ"¡--¬âÕ¬­ 100 ¥â--°"Ì"¡"ªØ`--µ`--Ë«ª­» æËÕ -- ÿ ,,Àâ¡'°",,TMâÿ߬"ßÕ"¡--¬Õ¬à"ß--Ë«÷ß,,°"§â"`°""ß滵ե«" °° Ì"À-- ness and NGOs complemented the government's efforts. °"µ`¥µ"¡°"¥Ì"`°"µ"¡,§ß°"¥--ß°à"«--È ¥â¡'Õ¬Yà,¥¬Õ"»--¬§Õ¢à"¬Õ--À" The 100 Percent Condom Program was adopted nationwide to ·à¢Õߧ``°'Ë--°...",§'˵`¥µàÕ®"°æ» --¡æ--å ,,,§ß°"¥--ß°à"« ºYâ§â"`°" promote universal use of condoms in commercial sex all the time. The "ßæ»´÷Ëߥâ--°"§--¥°ÕßæËÕÀ",§'˵`¥µàÕ®"°æ» --¡æ--å (STI) ÿ° --ª¥"ÀåÀÕ mechanisms for monitoring compliance already existed through Thai- --ª¥"Àå­ Õߧ--Èß,,§``°--°...",§®"°æ» --¡æ--å¢Õß--" ®­¥â--°"--°..." ·­ land's extensive network of STI clinics. Under the program, sex work- ®­¥â--·®°°àÕß'Ë®ÿÿ߬"ßÕ"¡--¬ø' 100 TM`È ("§",° æ.». 2543) °" ers were screened for STIs weekly or biweekly at government STI ª"°Øµ--«¢ÕߺYâªÉ«¬æ»TM"¬,,§``°--°...",§'˵`¥µàÕ®"°æ» --¡æ--å--È ªìÀ--° clinics, were treated, and then were provided with a box of 100 free "÷ß°"¡à,,TMâÿ߬"ßÕ"¡--¬ ·­¥â¡'°" "«'Ë¡"°--ª¬--ß´àÕß, ¿' ´÷ËߺYâTM"¬ condoms (World Bank 2000). The presentation of male patients at Àà"'ȵ`¥,§¡" À--ß®"°--È ºYâ¥Ì"`ß""ߥâ" ÿ¢¿"æ®÷ߥâµ`¥µ"¡º ¥â«¬°" STI clinics was considered evidence of lack of use of condoms, and the ÕÕ°µ«®´àÕß, ¿' ·­,,­À«à"ß°"ÕÕ°µ«®--È °Á¥â¡'°"·®°®à"¬¢âÕ¡Y·­ sources were traced back to the brothels where the men were infected. ÿ߬"ßÕ"¡--¬¥â«¬ Health workers then followed up with visits to the brothels, during which they provided information and condoms. The campaign was very effective: condom use among direct sex ,§ß°"ߧå¥--ß°à"«¡'ª­ ``¿"æÕ¬à"ß¡"° °",,TMâÿ߬"ßÕ"¡--¬,,°ÿࡺYâ§â" `°""ßæ»,¥¬µß--È æ`Ë¡¢÷È®"°âÕ¬­ 14 ,,µÕ`Ë¡,§ß°" ªªì°Õ âÕ¬­ 100 Õ°®"°--È °" Ì"«®·Ñ"µ`¥µ"¡§--Èßà" ÿ¥ ¬--ߥⷠ¥ß,,ÀâÀÁ«à" workers went from 14 percent at the start of the program to nearly °",,TMâÿ߬"ßÕ"¡--¬,,°ÿࡺYâ§â"`°""ßæ»,¥¬µß--È ¬--ß§ß YßÕ¬Yà (÷ß·¡â®­¡à 100 percent. Recent sentinel surveys suggest that condom use among â«Àâ") ,,Õ--µ"ª­¡"âÕ¬­ 95 (¿"æ 2.6) Õ¬à"ß°Áµ"¡ ,§ß°"ߧå¥--ß direct sex workers remains high (although not universal) at about 95 °à"« Õ«à"¡'§«"¡ Ì"Á®âÕ¬°«à" Ì"À--°ÿࡺYâ§â"`°""ß·ß Ì"À--·«,â¡'Ë percent (figure 2.6). The campaign had somewhat less success among ¿"æ 2.6 °",,TMâÿ߬"ßÕ"¡--¬,,°ÿࡺYâ§â"`°""ßæ» Figure 2.6 Condom Use among Commercial Sex Workers 100 80 60 percentage 40 Õ--µ" à«âÕ¬­ 20 0 1997 1998 1999 2000 2001 2002 2540 2541 2542 2543 2544 2545 ºYâ§â"`°""ßµß direct ºYâ§â"`°""ßÕâÕ¡ indirect 'Ë¡": °­«ß "" ÿ¢ 2547; ·ª­ ` ÿ¢ 2547 Source: MOPH 2004; Thanprasertsuk 2004. 22 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ à"ªìÀà«ß'È °",,TMâÿ߬"ßÕ"¡--¬,,°ÿࡺYâ§â"`°""ßæ»,¥¬·ß Õ"®¥ß®÷ß µË"°«à"âÕ¬­ 85 (·ª­ ` ÿ¢ 2547) Õ°®"°'È ®â"Àâ"'Ë¢Õß°­«ß "" ÿ¢¬--ߥâ--Yâ«à" °",,TMâÿ߬"ßÕ"¡--¬'Ë¥ß,,°ÿࡺYâ§â"`°""ßæ»,¥¬·ß --È §Õ "Àµÿ¢Õߧ«"¡°--ß«·­ªì --"÷ߧ«"¡®Ì"ªì'Ë®­µâÕß`Ë¡¥Ì"`,§ß°" ,,À¡à æËÕ°­µÿâ,,Àâ¡'°",,TMâÿ߬"ßÕ"¡--¬,,°ÿࡺYâ,,Àâ`°""ßæ»ÿ°§ µ--Èß·µà`Ë¡,§ß°" °" àß `¡°",,TMâÿ߬"ßÕ"¡--¬--È ¥â¢¬"¬ªÑ"À¡"¬ª¬--ß °ÿà¡ 'ˬß'Ë°«â"ßÕÕ°ª ,¥¬¥â--§«"¡ Ì"Á®º ¡º "°--ª ¥--ß'Ë· ¥ß,,¿"æ 2.6 °ÿࡺYâ§â"`°""ßæ»··ß--È ¡`¥â,,TMâÿ߬"ßÕ"¡--¬°--,¥¬--Ë«ª Õ°®"°'È Õ--µ"°",,TMâÿ߬"ßÕ"¡--¬,,°ÿà¡TM"¬'˧â"`°""ßæ» ¬--߬`ËßµË"ߪÕ'° ,¥¬°ÿà¡'È ,,­¬­·° ¡`¥âªì°ÿࡪÑ"À¡"¬¢Õß,§ß°"ÿ߬"ßÕ"¡--¬âÕ¬­ 100 ,,°" Ì"«®'Ë®--ßÀ«--¥TM'¬ß,,À¡à ¡'æ'¬ß°«à"âÕ¬­ 50 ¢ÕßTM"¬'˧â"`°""ßæ»à"--È 'Ë ¥â"¬ß"÷ß°",,TMâÿ߬"ßÕ"¡--¬°--Y°§â"Õ¬à"ß ¡Ë" ¡Õ à«°",,TMâÿ߬"ßÕ"¡--¬ Õ¬à"ß ¡Ë" ¡Õ°--§YàÕ'Ë¡`,,TMàY°§â"°--¬`ËßµË"ߪÕ'°Õ¬à"ßÀÁ¥âTM--¥ à«°ÿà¡ÕËÊ'Ë Õ--µ"°",,TMâÿ߬"ßÕ"¡--¬¬--ßÕ¬Yà,,­¥--µË"¥â·°à ºYâ§â"`°""ßæ»Õ¬à"ߺ`¥°ÆÀ¡"¬ ÀÕ¡`¥â--°"--÷°«â (À"¬"¬Õæ¬æ¡"®"° ""--ª­TM"TM"« ¡'¬¡à"å ·­ª­»æËÕâ"ÕËÊ) «¡--ÈßTM"«ª­¡ß'ËÕæ¬æ¡"®"°°--¡æYTM"·­¡'¬¡à"å °",,TMâÿ߬"ßÕ"¡--¬Õ¬à"ß¡à ¡Ë" ¡Õ,,°ÿࡪ­TM"TM--Ë«ª §ÕTMàÕß«à"ß'Ë Ì"§-- Õ'°ª­°"À÷Ëß Ì"À--°"µàÕµâ"TMÈÕ«-- ÕTMÕ«'¢Õߪ­TM"° °" Ì"«®,¥¬Ñ" ­«--ßæµ`°¡,,­¬­«" 5 ªï '˺à"¡" · ¥ß,,ÀâÀÁ«à" Yª·¢Õßæµ`°¡"ß æ»'Ë¡'§«"¡ 'ˬß--È ¥âª'ˬ®"°°"'˺YâTM"¬¢â"--`°"®"°ºYâ§â"`°""ßæ» ªªì°"'˺YâTM"¬¡'§«"¡ --¡æ--å"ßæ»°--§YàÕæ»À`ßTM--Ë«§"«ÀÕæËÕ "« ·­°--ºYâTM"¬§ÕËÊ (·ª­ ` ÿ¢ 2547) Õ--µ"°",,TMâÿ߬"ßÕ"¡--¬,,§«"¡ --¡æ--åTM`¥ÕËÊÀà"'È («¡--ÈߺYâ'Ë¡'§«"¡ --¡æ--å°--§YàÕæ»À`ß·TM--Ë«§"«·­ °--æËÕ "«'˧°--·"«) Õ«à"§àÕ¢â"ßµË" Ì"À--°" Ì"«®,¥¬Ñ"­«--ß æµ`°¡,,°ÿà¡À"°±å--È · 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TMà¥'¬«°--§Õ¢à"¬¢ÕߺYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å (PHA) °­«°"¥--ß°à"«¥âÕ"»--¬ª­ °"å®"°°"ªÑÕß°--·­¥Y·ºYâµ`¥TMÈÕ«-- ÕTMÕ«'·­,§Õ¥ å 'Ë¥â--¡",,TMà«ß»«...·°'Ë°`¥,§­"¥¢÷È,,ª­»¬ º'Ë¥â§Õ ,§ß°"'Ë°`¥¢÷È¥âTM૬,,ÀâºYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å (PHA) ¡'"'Ë Ì"§-- ,,"­--æ¬"°ÿ§§'Ë®Ì"ªì,,°"µàÕµâ"TMÈÕ«-- ÕTMÕ«'/,§Õ¥ å Õ°®"°'È ¬--ß¡'°" àß `¡,,Àâ°`¥§«"¡à«¡¡Õ­À«à"ß°ÿࡺYâµ`¥TMÈÕ/ºYâªÉ«¬Õ¥ å ·­ ­À«à"ߧբà"¬¢ÕߺYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å °--,§ß°"­¥--TM"µ` æËÕ,,ÀâºYâµ`¥TMÈÕ ·­ºYâªÉ«¬Õ¥ å "¡"¢â"¡' à«à«¡Õ¬à"ß·¢Áߢ--,,°"«"ß·º·­Ì",§ß°" °'ˬ«°--TMÈÕ«-- ÕTMÕ«'/Õ¥ å'Ë¡'Õ¬Yà¡"°¡"¬¡"ªØ`--µ`®"°­¥--TM"µ`ª¬--ß­¥--TMÿ¡TM ·º¥--ß°à"« ¥â â"ߢ÷È¡"®"°ª­ °"å ¥--ß--È ®÷ߪì°"«"ß°¬ÿå®Ì"« À÷Ëß æËÕ `¡ â"ß°"µÕ Õߥâ",¬"¬°'ˬ«°--TMÈÕ«-- ÕTMÕ«'·­,§Õ¥ å ¥--ßµàÕª'È: ë ¥Ì"`,§ß°"æËÕ `¡ â"ß°"--YâµàÕª ë àß `¡§Õ¢à"¬ -- ÿ¢ÕßTMÿ¡TM·¥--Èߥ`¡ ë °"«¡°"ñ°Õ¡°'ˬ«°----°...­,,°"¥Ì"`TM'«`µ¢â"°--À--° Yµ¢Õß,ß'¬ ë °"¢¬"¬°`®°¡ àß `¡ ÿ¢¿"æµà"ßÊ «¡--Èß°"¥Y·--°..."¥â"°"·æ¬å Ì"À-- ºYâ'˵`¥TMÈÕ«-- ÕTMÕ«'·­ºYâªÉ«¬Õ¥ å --Èß,, "'Ë"ߥâ" "" ÿ¢·­,, TMÿ¡TM «--µÿª­ ߧå'Ë Ì"§-- §Õ â"ß°°'Ë®­,,Àâ`°"¥â" ÿ¢¿"æ·­ «-- ¥`°"·°àºYâµ`¥ TMÈÕ·­ºYâªÉ«¬Õ¥ å (PHA) ,,--°...­¢ÕßÕߧ嫡 ´÷Ëߧէÿ¡÷ß°"ªÑÕß°-- °" ¥Y· ·­°""º°­¥â"»...°`® --ߧ¡Õ--°`¥®"°,§Õ¥ å ·º­¥--TM"µ` æËÕ°"ªÑÕß°--·­°""ªíÀ"®"°TMÈÕ«-- ÕTMÕ«'/Õ¥ å (æ.».2545-49) ·ºæËÕ®--¥°"°--TMÈÕ«-- ÕTMÕ«'/Õ¥ å·º,,À¡àà" ÿ¥--È §Õ°"¥Ì"`°"µàÕ®"° ·º©--°àÕÀâ"'È ,¥¬,,TMâ·«ªØ`--µ`·Õߧ嫡ૡ°-- ·­â'Ë°"¢â"¡' à« à«¡¢Õß¿"§Õ°TM --" «¡--ÈßTMÿ¡TM ,,°"µàÕ Yâ°--,§Õ¥ å ·º'È ¥â°Ì"À¥÷ß °ÿࡪÑ"À¡"¬--Èß "¡°ÿà¡Õ¬à"ßTM--¥®: ë Õ--µ"§«"¡TMÿ°¢ÕßTMÈÕ«-- ÕTMÕ«',,°ÿࡪ­TM"°'ËÕ¬Yà,,«--¬®`æ--åÿ ®­¥ß ÀÕµË"°«à"âÕ¬­ 1 ¿"¬,,æ.». 2549 ë Õ¬à"ßâÕ¬ âÕ¬­ 80 ¢ÕߺYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å (PHA) ·­ÿ§§'Ë¥â--º °­®­ "¡"¢â"÷ß ·­¥â--°"¥Y··­§«"¡ -- ÿ®"°ºYâ,,Àâ`°"--Èß ¢Õß--" Õ°TM ·­TMÿ¡TM ,,¥â" --ߧ¡ »...°`® °"»÷°..." ·­`°"¥Y· ÿ¢¿"æ¢--ȵâ ,,--°...­'ËÀ¡"­ ¡·­¬ÿµ`¡ 24 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ ë ºYâ`À"âÕß`Ë·­Õߧå°TMÿ¡TM ®­µâÕß¡'°"«"ß·ºÕ¬à"ß¡'ª­ ``¿"æ·­ ª­ ``º «¡--Èß¡'°"¥Ì"`ß"µ"¡·º æËÕªÑÕß°--·­"ªíÀ"®"° TMÈÕ «-- ÕTMÕ«'·­,§Õ¥ å °¬ÿå'Ë Ì"§--"ߪ­°",,·º­¥--TM"µ` ¥â·°à: ë °" -- ÿ,,Àâ¡'°",,TMâÿ߬"ßÕ"¡--¬·­æ»»÷°..."·°à¬"«TM ë °"ªÑÕß°--°"µ`¥TMÈÕÕTMÕ«'®"°¡"¥" Yàÿµ (PMTCT) `°",,Àâ§Ì"ª÷°..."·­ µ«®À"TMÈÕ«-- ,¥¬ ¡--§,,® (VCT) Ì"À-- µ'¡'§¿å--È ¥â`Ë¡Ì"¡",,TMâ§--Èß·° ,, æ.». 2538 ·­§àլʢ¬"¬ÕÕ°ª® "¡"¢â"÷ߺYâÀ`ß®Ì"« 559,702 § ¥â,,æ.». 2545 --Èß'È ¥âæ«à" ª­¡"âÕ¬­ 1.1 ¡'º°"µ«®À"TMÈÕ ÕTMÕ«'ªì«° ,,°ÿà¡'È âÕ¬­ 80 ¥â--°"--°...",,­¬­ --ȥ⫬ AZT (zidovudine) ,,TMà«ßµ--Èߧ¿å·­,,¢­§Õ¥ ,,¢­'Ë¥Á°"°âÕ¬­ 95 °`¥ ®"°¡"¥"'˵`¥TMÈÕ«-- ÕTMÕ«' ,,æ.». 2546 Yµ¬"'Ë,,TMâ,,°"ªÑÕß°--°"µ`¥ TMÈÕ®"°¡"¥" Yàÿµ ¥âª--,,Àâ«¡µ--«¬" AZT °-- nevirapine ¢â"ª¥â«¬ º'˥⠧հ"¥§«"¡ 'ˬߢÕß°"µ`¥TMÈÕ Yà¥Á° ®"°âÕ¬­ 30 ªìâÕ¬­ 8 ´÷ËßÌ",,Àâ ¥Á°Õ¥®"°°"µ`¥TMÈÕª­¡" 2,500-3,000 §,,·µà­ªï ë VCT: °",,Àâ§Ì"ª÷°..."·­°"µ«®À"TMÈÕ«-- ,¥¬ ¡--§,,®--È "¡"°­Ì"¥â ,,,ßæ¬""®--ßÀ«--¥·­ÕÌ"¿Õ°Õÿ°·Ààß «¡--Èß»Y¬åÕ"¡--¬"ß·Ààß ·­,, ¿"§Õ°TM ë °"¥°"µ`¥TMÈÕ,,°ÿࡺYâ,,TMâ¬" æµ`¥TM`¥©'¥ ,§ß°"--°..."¥â«¬¬"--È ¥â`Ë¡µâ ¢÷È,,°ÿßæoe ·­»Y¬å--°..."¬" æµ`¥­¥--¿Y¡`¿"§Õ'° 5 ·Ààß ë °"¢â"÷ß°"¥Y· (´÷ËßµàÕª ®­¢¬"¬ªì,§ß°" NAPHA): ®­¡'°"¢¬"¬ `°" Ì"À--°"--°..."·­ªÑÕß°--,§ (prophylaxis) ®"°°"µ`¥TMÈÕ©«¬,Õ°" ,¥¬--Ë«ªæËÕ,,Àâ§Õ§ÿ¡¥â¡"°¬`Ëߢ÷È Õ°®"°'È ¬--ß¡'°"æ--"`°"æËÕ,,Àâ "¡",,Àâ°"--°..."¥â«¬¬"µâ"TMÈÕ«-- Õ¥ å (ART) Ì"À--ºYâµ`¥TMÈÕ«-- ÕTMÕ«' 'Ë· ¥ßÕ"°" ,¥¬¡'ªÑ"À¡"¬'Ë®­¢â"÷ߺYâ'Ë¡'º«°,,°"µ«®À"TMÈÕÕTMÕ«' ª­¡" 80,000 § °àÕ `Ȫïæ.». 2548 ë °"µÕ ÕߢÕßTMÿ¡TM: ¡"µ°"À"¬ª­°"Y°Ì"¡",,TMâæËÕ àß `¡" ¢ÕßTMÿ¡TM,,°"®--¥°"·­¥Ì"`°`®°¡,,°"ªÑÕß°-- ¥Y· ·­ -- ÿ ,¥¬ ©æ"­Õ¬à"߬`Ëß ,,`«TM ë §«"¡ -- ÿµàÕÕߧå°"æ--"Õ°TM ·­ PHA: ,§ß°"ª­ "ß"¢Õß Õߧå°æ--"Õ°TM,,ª­»¬°'ˬ«°--,§Õ¥ å--È ªìµ--«·¢ÕßÕß§å° æ--"Õ°TM°«à" 200 ·Ààß ´÷Ëß°Ì"--ߥÌ"`°"Õ¬Yà°'ˬ«°--,§Õ¥ å--Ë«ª­» ¬ «¡--Èߧբà"¬¢ÕߺYâµ`¥TMÈÕ«-- ÕTMÕ«',,ª­»¬ ¡'§Õ¢à"¬¢Õß Õߧ尺YâªÉ«¬Õ¥ å°«à" 300 ·Ààß--Ë«ª­» --Èß ÕßÕߧå°'È ªìµ--«·Õ¬Yà,, §­°¡°"Õ¥ å­¥--TM"µ` (National AIDS Committee) °"­"¥¢Õß,§Õ¥ å,,ª­»¬,,ªí®®ÿ-- 25 º°­ '¬'Ë¥â-- ·­§«"¡ 'Ë¬ß §«"¡ Ì"Á®,,°"µÕ Õߥâ",¬"¬­¥--TM"µ`'Ë·¢Áß·°àߢÕߪ­»¬µàÕTMÈÕ «-- ÕTMÕ«'/Õ¥ å--È ¥â--°"--÷°«âÕ¬à"ß°«â"ߢ«"ß (®Ì"-- `ß§å ·­§­ 2542; æY®`·­§­ 2541; æY®`·­§­ 2547°; "§",° 2543) ª­ °"å¢Õߪ­»¬ ¡--°®­¥â--°"°à"«÷ß,,"­µ--«Õ¬à"ߢÕß°"·°â 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§Õ°"¥â--§«"¡à«¡¡Õæ`Ë¡¢÷È (·­§«"¡ -- ÿ¡"°¢÷È) ®"°°­«ß»÷°..."'Ë°" æËÕ,,Àâ¡'°"®ÿÀ--«¢âÕ°'ˬ«°----°...­,,°" ¥Ì"ßTM'«`µ¢â",,À--° Yµ «¡--Èß,,Àâ¢âÕ¡Y°'ˬ«°--ÕTMÕ«' ·­º¬·æ৫"¡YâæÈ"°'ˬ«°--,§ ¥--ß°à"«ºà""ß­,ß'¬ Ì"À--,§ß°"``Ë¡ÕËÊ¢Õß--" 'Ë°'ˬ«°--¬"«TM·­ æµ`°¡"ß滢Õ߬"«TM ¥â·°à: ë ¢âÕ Õ,,Àâ¡'°"®Ì"°--¥«"ÕÕ°Õ°â"¢Õ߬"«TM ë °"Ì",§ß°"ªÑÕß°--¡`,,Àâ¢â"÷ß«Á´µå'Ë¡'ÈÕÀ"°'ˬ«°--°"æ--ÀÕ¿"æ"¡°Õ"®" ë °`®°¡ª­TM" --¡æ--åÕËÊ æËÕ'ˬߧ«"¡ ,,®¢Õ߬"«TMÕÕ°®"°ËÕßæ» ¡ËÕ ¬"«TMÀà"'È ¬--ß¡à çæâÕ¡é TMà °"®--¥À--° YµæËÕ,,Àâ¢âÕ¡Y°'ˬ«°--,§Õ¥ å,,,ß'¬ ·­°"§«§ÿ¡ÀÕæ--°,, "»÷°..." 28 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ ¿"æ 2.7 °"¢â"÷ß°"¥Y·--°...""ß°"·æ¬å Ì"À--ºYâªÉ«¬¥â«¬TMÈÕ«-- ÕTMÕ«'/Õ¥ å (TMà «--,§ pneumocystic carinii pneumonia ·­ cryptococcal meningitis) °"--°...",§µ`¥TMÈÕ©«¬,Õ°" ,¥¬--Ë«ª °"--°..."¥â«¬¬"TM`¥¥'¬« (AZT) æ.». 2535-2538 °"--°..."¥â«¬¬" ÕßTM`¥ (AZT + didanosine ·­ AZT + zalcitabine) æ.». 2535-2539 HIV CRN (°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¥â«¬ Yµ¬"'˺ ¡ Õß·­ "¡TM`¥) æ.». 2540-2543 ATC·­--°...",§µ`¥TMÈÕ©«¬,Õ°" ) (¬"µâ"«-- Õ¥ å Yµº ¡ "¡TM`¥ ·­°"ªÑÕß°-- µ--Èß·µà æ.». 2543 NAPHA µ--Èß·µà æ.». 2546 'Ë¡": °­«ß "" ÿ¢ 2547; ·ª­ ` ÿ¢ 2547 ÿª«à" ,§ß°"¥--ß°à"« ¡'µâÿ Yß ·­¡'ºª­,¬TMå,,­¥--µË"µàÕ°ÿࡪ­TM"° ªÑ"À¡"¬ (§ÿ"ÿ ±å ·­§­ æ.». 2538) ¢âÕ ÿª¥--ß°à"« Õ`ßµ"¡Õ--µ"°" §Õ§ÿ¡'˵Ë" °"'˧¢â¢â"--°"--°..."Õ¬à"ßµàÕËÕß®Ì"«âÕ¬ ·­Õ--µ"°" ¬°`°°"µ`¥µ"¡º,,­¥-- Yß (æ §Õå æ.». 2540) ­¬­'Ë 2: §Õ¢à"¬°"«`®--¬"ߧ'`°: ®"°°"«,,§--Èß'È ®ÿ¥â¢Õß,§ß°" ART ®­ª'ˬ·ªßª ·'Ë°­«ß "" ÿ¢®­Ì"Àâ"'˪ì»Y¬å°"ß,,°" ·®°®à"¬¬"µâ"«-- Õ¥ å·°à,ßæ¬""µà"ßÊ "ߧբà"¬°"«`®--¬"ߧ``° (Clinical Research Network>CRN) ®­ªìºYâ°­®"¬¬"µâ"«-- Õ¥ å·°à,ß æ¬""µà"ßÊ'Ë¥âÕ°«â ´÷Ëßµ°ß'Ë®­¢â"à«¡,,°"«`®--¬TM`ߪØ`--µ`°" °"TMËÕ¡ ,¬ß°"«`®--¬"ߧ``°¢â" Yà°"¢â"÷ß°"¥Y·--°..."Õ¬à"ߧ«ß® ´÷Ëß«¡÷߬"µâ" «-- Õ¥ å Ì"À--ºYâªÉ«¬®"°TMÈÕ«-- ÕTMÕ«'·­,§Õ¥ å--È ®­ªìæÈ"¢Õß ,§ß°"¬"µâ"«-- Õ¥ å´÷Ëߥâ--ÿ -- ÿ®"°--µàÕª®÷ßæ.».2543 ,§ß°"¥--ß°à"«ªì à«À÷ËߢÕß°¬ÿå­¥--TM"µ`æËÕªÑÕß°--·­--°..."ÕTMÕ«'/ Õ¥ å ´÷Ëß«¡÷ß,§ß°"µà"ßÊ Ì"À-- PMTCT °"`®"§,À`µÕ¬à"ߪե¿--¬·­ °"æ--"«--§´'ªÑÕß°--ÕTMÕ«' «¡--Èß°"ߧå,,Àâ¡'°",,TMâÿ߬"ßÕ"¡--¬ ,¥¬,, ¢--È·° §Õ¢à"¬ª­°Õ¥â«¬,ßæ¬""µà"ßÊ®Ì"« 45 ·Ààß (´÷Ëß¿"¬À--ߥ⢬"¬ ªì 58 ·Ààß) ,, 20 ®--ßÀ«--¥ ´÷Ëߥâ,,Àâ¬"µâ"«-- Õ¥ å·°àºYâªÉ«¬®Ì"« 1,095 § --Èß'È ,,­¬­·° ¥â,,TMâ«`'°"--°..."«`'¥'¬« ·µàÀ--ß®"° æ.». 2541 °"--°..."·§Yà ¢" ,¥¬,,TMâ¬"µâ"«-- Õ¥ åÀ"¬TM`¥'ËÀ¡"­ ¡¡"º ¡º "°-- ¥â°"¬ªì ¡"µ",,°"--°...",§ ¥â¡'°"ª­¡`º¢Õß CRN ,,¥Õ°°Æ"§¡ æ.». 2543 ,¥¬"¬ß"'Ë °"­"¥¢Õß,§Õ¥ å,,ª­»¬,,ªí®®ÿ-- 29 Õߧå°"Õ"¡--¬,°ªìºYâ®--¥Ì"à«¡°--°Õß,§Õ¥ å °¡,§µ`¥µàÕ¢Õß°­«ß "" ÿ¢ ¥â--°"µ'æ`¡æåÕÕ°¡"¡ËÕ«--'Ë 21 --«"§¡ æ.». 2543 (°­«ß "" ÿ¢ æ.». 2543) "¬ß"¥--ß°à"« ÿª«â«à" ,,­¬­«" 3 ªï 'Ë"ß CRN ¥Ì"`ß"¡" º'Ë¡'µàÕ°"«"ß·º,§ß°"æËÕªÑÕß°--·­¥Y·ºYâµ`¥TMÈÕ«-- ÕTMÕ«' ·­ºYâªÉ«¬Õ¥ å--È¡'®Ì"°--¥ ËÕß®"°",,°"«`®--¬"ߧ``°·­°`®°¡æËÕ°" ªÑÕß°--·­¥Y·--È¡`¥â--°"°Ì"À¥,,ÀâTM--¥® Õ°®"°'È ,ßæ¬""·­ "-- «`®--¬µà"ßÊ,,§Õ¢à"¬ â«¡'ß"¡"°°`ª ·­§Õ¢à"¬°Á¬--ß¡'--æ¬"°¡àæ'¬ßæÕ ­¬­'Ë 3: °"§ËÕ'Ë Yà°"¢â"÷ß,§ß°"¢â"÷ß`°"¬"µâ"«-- Õ¥ å (ART) ,,­¥--ª­»: ,, æ.». 2543 °­«ß "" ÿ¢¥â®--¥,§ß°"¢â"÷ß °"¥Y·--°..." (Access to Care>ATC) ¢--ÈÌ"àÕß æËÕ®--¥,,Àâ¡'°"--°..."¥â«¬¬"µâ" «-- Õ¥ å (ART) ,¥¬ºà""ߧբà"¬ CRN «¡--Èß,ßæ¬""­¥--ÕÌ"¿Õ·­ ®--ßÀ«--¥Õ'° 109 ·Ààß ´÷ËßÌ",,ÀâºYâªÉ«¬ "¡"¢â"÷ß,§ß°"¥âæ`Ë¡Õ'° 1,000 § °±å,,°" ¡--§¢â" Yà,§ß°"¥â·°à: ë ¥â--°"«``®©--¬«à"¡'°"µ`¥TMÈÕ©«¬,Õ°" ®"°,§Õ¥ åÀÕ¡­Áß ë ¡'°"µ`¥TMÈÕÕTMÕ«'·· ¥ßÕ"°" ë §à" CD4 «--¥¥âµË"°«à" 200 ´åµàÕY°"»°å¡``¡µ ,§ß°"¥--ß°à"« ¥â Õ Yµ,,°"--°..."¥â«¬ ART 8 TM`¥ Ì"À--ºYâ,,Àà ·­ 12 TM`¥ Ì"À--¥Á° ª­¡"âÕ¬­ 78 ¢ÕߺYâªÉ«¬--ÈßÀ¡¥ ®­¥â--°"--°..."¥â«¬ Nucleoside reverse transcriptase inhibitors (NRTIs) Õߧ--Èß ·­ Nonnucleoside reverse transcriptase inhibitors (NNRTIs) À÷Ëߧ--Èß ,,¢­'ËâÕ¬­ 22 ¢ÕߺYâªÉ«¬ --ÈßÀ¡¥ ®­¥â-- Nucleoside reverse transcriptase inhibitors (NRTIs) À÷Ëߧ--Èß ·­ Protease inhibitor À÷Ëߧ--Èß à«°",,Àâ¬"µâ"«-- Õ¥ å,,,§ß°"'È ®­°­Ì"¥â ,¥¬,,ÀâºYâªÉ«¬à«¡TMÌ"­§à"¬"¥â«¬ TMà °­«ß "" ÿ¢®­,,Àâ efavirencz ÀÕ ritonavir-boosted indinavir ,¥¬¡à§`¥§à",,TMâ®à"¬ ૺYâªÉ«¬®­´ÈÕ¬" backbone nucleoside Õß à« æËÕÌ"¡",,TMâà«¡°--ªì°"--°..."¥â«¬¬"µâ"«-- "¡ª­¿ ,,¢­'Ë¥âæ--",§ß°" ATC "ß--"°Á¥âµ--¥ `,,®'Ë®­ `¡ â"ß»--°¬¿"æ ­¥--ª­»,,°"º`µ¬"µâ"«-- TM`¥µà"ßÊ'ˬ--ß¡`¥â®¥`¢ ``Ï«â ¥--ß--È ¬" "¡-- µâ"«-- ¢ÕßÕߧå°"¿ --TM°¡ ®÷ßTM૬¥"§"¬"Àà"'È,,ª­»¬¥âÕ¬à"ß¡"° (µ""ß'Ë 2.2) ·­'Ë Ì"§--'Ë ÿ¥ "ßÕߧå°"¿ --TM°¡ ¥â`Ë¡º`µ¬"'Ë¡' ૺ ¡ ¢Õßµ--«¬" "¡TM`¥,,À÷Ëß¡Á¥ '¬°«à" ®'æ',Õ-«'¬å (GPO-vir) (stavudine + lamivudune + nevirapine) ¥â«¬"§" 30 À'¬ À-- (1,200 ") µàÕ¥Õ7 ¥â«¬ Yµ¬"º ¡,,À÷Ëß¡Á¥'Ë'¬°«à" GPO-vir ´÷Ëߥâ`Ë¡Ì"ÕÕ°,,TMâ,, æ.». 2545 'È Ì",,Àâ,§ß°" ATC ¥â¬°­¥--¢÷È ·­¬" GPO-vir ¥â°"¬ªì Yµ°"--°..."¢--ȵâ Ì"À--ºYâªÉ«¬,,­¬­·° °"'Ë "¡"º`µ¬"µâ"«-- 'Ë¡à¡'¬'ËÀâÕ,,"§"µàÌ"¥â«¬ ૺ ¡¢Õßµ--«¬" "¡TM`¥¥â Õªì°"ªî¥,Õ°" Ì"À--°",,TMâ°"--°..."¥â«¬¬" µâ"«-- ·°àºYâªÉ«¬'ËÕ¬Yà,,°±å®­¥â--°"--°..."®Ì"«¡"°¥â (µ""ß 2.2) 30 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ µ""ß 2.2 "§"¢--ȵË",,°"--°..."¥â«¬¬"µâ"«-- Õ¥ å'Ë¥ß,,ª­»¬ Yµ¬" ART "¡TM`¥ ªï "§" (" µàÕ¥Õ)° 2 NRTIs+PI °àÕ æ.». 2543 > 25,000 2 NRTIs+PI 'Ë¡'°"°­µÿâ æ.». 2543 13,000 æ.». 2545 6,000 2 NRTIs + NNRTI °àÕ æ.». 2543 15,000 TMà«ßµâ æ.». 2544 TMà«ß°"ß æ.». 2544 <13,000 6,000 TMà«ßª"¬ æ.». 2544 2,3000 GPO-vir æ.». 2545 1,200 GPO-vir æ.». 2547 1,200 'Ë¡": æY®`·­§­ 2547¢ À¡"¬Àµÿ: NRTI = Nucleoside reverse transcriptase inhibitor; NNRTI = Nonnucleoside reverse transcriptase inhibitor; PI = Protese inhibitor ° §Õ"§"¬"'˵Ë"'Ë ÿ¥,,ª­»¬ Ì"À--¿"§-- "§"·â®`ß'˵âÕß®à"¬Õ"®µà"ß®"°'È¡"° ,§ß°" ATC ¢--ÈÌ"àÕß ¥â--°"ª­¡`º§--Èß·°,,,ßæ¬""À"¬·Ààß,, 6 ®--ßÀ«--¥¿"§ÀÕ ,, æ.». 2544 (`Ë« ' ·­§­ æ.». 2545) ,,­À«à"ß¥Õ °ÿ¡¿"æ--å÷ßµÿ"§¡ æ.». 2544 ºYâªÉ«¬¥â«¬TMÈÕ«-- ÕTMÕ«'«--¬ºYâ,,Àà®Ì"« 774 § ®"°,ßæ¬""­¥--ÕÌ"¿Õ·­®--ßÀ«--¥®Ì"« 54 ·Ààß ¥â¢â"à«¡,§ß°" ¥--ß°à"« ,,TMà«ß`Ë¡,§ß°" §à"©'ˬ¢Õߪ`¡" CD4 ¥â·°à 84 ´åµàÕY°"»°å ¡``¡µ À--ß®"°--ÈÕ'° 24 --ª¥"Àå ºYâªÉ«¬®Ì"«âÕ¬­ 68.6 ¬--ߧߢâ"--°" --°..."Õ¬Yà "Àµÿ¢Õß°"À¬ÿ¥°"--°..." ¥â·°à: ë º,,"ß ë '¬TM'«`µ (ºYâªÉ«¬ 41 § ÀÕâÕ¬­ 5.3) ë §«"¡â¡À«,,°"--°..."'Ë¡à¥â­ÿTM--¥® (ºYâªÉ«¬ 42 § ÀÕâÕ¬­ 5.4) ë ¡à¡'°"µ`¥µ"¡º (ºYâªÉ«¬ 35 § ÀÕâÕ¬­ 4.5) ë ÕËÊ (ºYâªÉ«¬ 24 § ÀÕâÕ¬­ 3.1) °"ª­¡`,§ß°" ACT Õ¬à"ß«¥Á«'Ë¥â¥Ì"`°"ªæâÕ¡Ê°--,,¿"§ÀÕ Ì",,Àâæ«à" ¡'Õ--µ"°"À¬ÿ¥--°..."'Ë Yß°«à" (ÀÕª­¡"âÕ¬­ 45) (¿"§«`TM"°" ·æ¬åTMÿ¡TM ¡À"«`¬"--¬TM'¬ß,,À¡à æ.». 2545) --Èß'È °"ª­¡`º--Èß Õß à«'È ÿª¥â«à" ®Ì"ªìÕ¬à"߬`Ëß'Ë®­µâÕß¡'°"æ--",§ß°" æËÕ,,Àâ¡'ºYâà«¡,§ß°"--°..." µàÕª¡"°¢÷È à«'Ë­ÿ«â«à"§«®­µâÕß¡'°"ª--ªÿß ¥â·°à: ë §«"¡®Ì"ªì'Ë®­µâÕß¡'°" â"ß»--°¬¿"æÕ¬à"ßµàÕËÕß Ì"À--°"`À"°"--°..." ¥â«¬¬"µâ"«-- Õ¥ å (ART) ,,°ÿࡺYâ,,Àâ`°"¥â" ÿ¢¿"æ ,¥¬©æ"­Õ¬à"߬`Ëß æ¬""·­¿ --TM° °"­"¥¢Õß,§Õ¥ å,,ª­»¬,,ªí®®ÿ-- 31 ë "'ˢ⡷¢Áߢ÷È¢Õß'˪÷°..." ë §Õ§--« ·­TMÿ¡TM §«¡' à«à«¡¡"°¢÷È,,°",,Àâ°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ·­,,°",,À⧫"¡ -- ÿ·°àºYâªÉ«¬ °"¬°­¥--,§ß°" ACT ¢â" Yà­¥--TM"µ` ,,æ.». 2546 --"¬¥â¢¬"¬,§ß°" ATC ,¥¬¡'æ--­ --" Ì"À--­¬­«" 4°"¥Y·--°..."2546-49) æËÕ,,Àâ¬"µâ"«-- Õ¥ å·µ--«¬" "¡TM`¥ªì¡"µ",, ªï (æ.». «--µÿª­ ߧå¢Õß,§ß°"¥--ß°à"« ´÷Ëß'¬°«à" ,§ß°"æ--"°"¢â" ÷ß`°"¬"µâ"«-- Õ¥ å­¥--TM"µ` Ì"À--ºYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å (National Access to Antiretrovirals Program for People living with HIV/AIDS) ÀÕ NAPHA --È §Õ æËÕ,,ÀâºYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å'Ë· ¥ßÕ"°"®Ì"«¡"° "¡"¢â"÷߬"µâ"«-- ·'Ë¡'µ--«¬" "¡TM`¥¥â¿"¬,, æ.». 2547 ®Ì"«ºYâµ`¥TMÈÕ«-- ÕTMÕ«'·­ºYâªÉ«¬ Õ¥ å (PHAs) 'Ë¢â"--¬"µâ"«-- 'È æ`Ë¡¢÷È®"° 3,000 § ,,TMà«ß`Ë¡,§ß°"¡ËÕ æ.». 2545 ¡"ªì 27,000 § ¡ËÕ `È æ.». 2546 ·­ 52,000 § ,,¥Õ °ÿ¡¿"æ--å æ.». 2548 ,§ß°"'È à«À÷Ëߥâ--§«"¡ -- ÿ¥â"°"ß`®"° °Õßÿ­¥--,°æËÕµàÕµâ",§Õ¥ å «--,§ ·­¡"'¬ (Global Fund to Fight AIDS, Tuberculosis, and Malaria>GFATM) ·­ à«À÷Ëß ¡"®"°ßª­¡"¢Õß --"·Ààß®Ì"« "'Ë,,Àâ°"--°..." æ`Ë¡¢÷È®"° 112 ·Ààß ,, æ.». 2544 ¡"ªì 462µ""ß'Ë,,TMà«ßµâ æ.». 2546 ·­ 841 ·Ààß ,,¥Õ°ÿ¡¿"æ--å æ.». 2548 2.3 · ¥ß,,ÀâÀÁ÷ß«`«--"°"¢Õß®Ì"«ºYâµ`¥TMÈÕ«-- ÕTMÕ«'·­ºY⠪ɫ¬Õ¥ å (PHAs), ºYâªÉ«¬¥â«¬,§Õ¥ å ·­°"¢â"÷߬"µâ"«-- Õ¥ å¢Õß--",, ª­»¬ ¡ËÕ÷ߪ"¬ æ.». 2547 °«à"âÕ¬­ 80 ¢ÕߺYâªÉ«¬,§Õ¥ å "¡" ¢â"÷߬"µâ"«-- Õ¥ å (ART) ¢Õß--"¥â ´÷Ëßժ짫"¡ Ì"Á®'Ëà"÷Ëß ¿"æ µ""ß 2.3 ®Ì"«,¥¬ª­¡"¢ÕߺYâ'˵`¥TMÈÕÕ¥ å ºYâªÉ«¬Õ¥ å ®Ì"«ºYâªÉ«¬Õ¥ å'Ë¥â--"¬ß",,,ß æ¬""-- ·­°"¢â"÷ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,,ßæ¬""-- TM`¥¢ÕߺYâªÉ«¬ 2540 2541 2542 2543 2544 2545 2546 2547 ºYâµ`¥TMÈÕ«-- ÕTMÕ«'/Õ¥ å 751,235 740,349 719,765 649,564 665,344 635,057 603,942 572,484 ºYâªÉ«¬Õ¥ å 59,752 65,333 68,311 68,677 67,057 64,832 62,871 61,394 ºYâ--`°" ART ®"°,ßæ¬""-- 1,095° 1,095° 1,095° 2,095° 2,095° 8,341° 27,158 52,593¢ âÕ¬­¢ÕߺYâªÉ«¬Õ¥ å 'Ë--`°" ART ®"°¿"§-- 1.8 1.7 1.6 3.1 3.1 12.9 43.2 81.4 âÕ¬­¢ÕߺYâªÉ«¬'Ë¥â-- "¬ß"«à"µ`¥Õ¥ å·­-- `°" ART ®"°¿"§-- 4.1 4.0 4.0 4.5 8.5 35.5 122.6 ---- 'Ë¡": ª­¡"°"®"°§­Ì"ß"°'ˬ«°--TMÈÕ«-- ÕTMÕ«'/Õ¥ å ·Ààߪ­»¬ 2544; ,°¥å ·­§­ 2547; °­«ß "" ÿ¢ 2547 À¡"¬Àµÿ : ---- = ¡à¡'¢âÕ¡Y °. ¥Ì"`°"µ"¡ ªØ`"«à"¥â«¬æ--­'Ë¡'µàÕÕTMÕ«'/ Õ¥ å (UNGASS) "¬ß"­¥--ª­» 2545 ¢. µ--«¢ °ÿ¡¿"æ--å 2548 ¢âÕ¡Y®"° Ì"--°,§Õ¥ å «--,§ ·­,§µ`¥µàÕ®"°æ» --¡æ--å °­«ß "" ÿ¢ (2547) 32 32 · TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ Figure 2.8 People Living with AIDS and Public ART Provision ¿"æ 2.8 ºYâªÉ«¬,§Õ¥ å·­°",,Àâ`°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢Õß¿"§-- (Public ART) 80,000 70,000 68,677 64,832 62,871 61,394 60,000 50,000 50,000 40,000 30,000 20,000 16,630 10,000 8,431 2,095 0 2000 2543 2545 2002 2546 2003 25472004 ,¥¬ª­¡" est. PLWA ºYâªÉ«¬,§Õ¥ å Public ART °"`°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢Õß¿"§-- 'Ë¡": °"§"¥ª­¡" Ì"À--ªï 2544 ¢Õߧ­Ì"ß"°'ˬ«°--ÕTMÕ«'/Õ¥ å; ,°¥å ·­§­ æ.». 2548; "¬ß"«à"¥â«¬ Source: Thai Working Group on HIV/AIDS Projection 2001; Gold and others 2005. Clinical Õ° "§«"¡ªì¡""ߧ``°æËÕ¢¬"¬°"¢â"÷ß ART ,,ª­»¬ æ.». 2547; °­«ß "" ÿ¢ æ.». 2547 --Èß'È Background Paper for Expanding Access to ART in Thailand Report 2004; MOPH 2004. The ºYâ¢'¬¥â--¢âÕ¡YÀà"'È®"° Ì"--°,§Õ¥ å «--,§ ·­,§µ`¥µàÕ®"°æ» --¡æ--å °­«ß "" ÿ¢ æ.». 2547 data were provided to the authors by the Bureau of AIDS. TB, and STI at MOPH 2004. the proportion of people living with AIDS in Thailand with access to 2.8 ¥â· ¥ß·«,â¡¥--ß°à"« æËÕ,,ÀâÀÁ«à" Õ--µ" à«¢ÕߺYâªÉ«¬,§Õ¥ å,,ª­» public ART has increased sixfold since 2002. ¬'Ë "¡"¢â"÷߬"µâ"«-- Õ¥ å¢Õß--"¥â--È æ`Ë¡¢÷È÷ß 6 à" µ--Èß·µà æ.». 2545 ªìµâ¡" Table 2.4 shows the number of people on public ART by region as of March 2004, as well as the ART targets that MOPH set for the end µ""ß 2.4 · ¥ß,,ÀâÀÁ÷ß®Ì"«¢ÕߺYâ'Ë--¬"µâ"«-- Õ¥ å (ART) ®"°--" of 2004. These targets were calculated as a function of the estimated ·¬°µ"¡¿Y¡`¿"§ µ--Èß·µà¥Õ¡'"§¡ æ.». 2547 «¡--ÈߪÑ"À¡"¬¢Õß,§ß°" ART number of AIDS and symptomatic HIV cases in the corresponding 'Ë°­«ß "" ÿ¢¥â°Ì"À¥«â¿"¬,, æ.». 2547 ªÑ"À¡"¬Àà"'È ¥â§Ì"« region (as reported by the hospital system for reporting AIDS cases). æËÕ,,Àâªìøíß°åTM--Ë¢Õß®Ì"«ºYâªÉ«¬Õ¥ å·­ºYâµ`¥TMÈÕÕTMÕ«''Ë· ¥ßÕ"°",¥¬ The table shows that some regions have come closer to reaching their ª­¡" Ì"À--¿Y¡`¿"§'Ë°'ˬ«¢âÕß (µ"¡'Ë¥â--"¬ß",¥¬­°""¬ß"ºYâªÉ«¬ targets than others: the north and the northeast have the highest Õ¥ å¢Õß,ßæ¬"") µ""ß· ¥ß,,ÀâÀÁ«à" "ß¿Y¡`¿"§¥â¢â",,°âªÑ"À¡"¬¡"°°«à" ratios of people on ART relative to their targets. This finding may ¿Y¡`¿"§ÕËÊ TMà ¿"§ÀÕ·­¿"§µ­«--ÕÕ°©'¬ßÀÕ¡'Õ--µ" à«¢ÕߺYâ'Ë¢â"--°" --°..."¥â«¬¬"µâ"«-- Õ¥ å¡"°'Ë ÿ¥¡ËÕ'¬°--ªÑ"À¡"¬ °"§âæ'È Õ"® ­âÕ÷ß Table 2.4 Number of Patients on ART in Thailand by Region, March 2004 µ""ß 2.4 ®Ì"«¢ÕߺYâªÉ«¬'Ë¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,ª­»¬ ·¬°µ"¡ ¿Y¡`¿"§ ¥Õ¡'"§¡ æ.». 2547 Accumulated Current patients Region patientsa on ART New patients Target in 2004 Bangkok ¿Y¡`¿"§ ,,æ.».5,830 ªÑ"À¡"¬ Central ºYâªÉ«¬ ­ ¡1 ART2,648 2,846 ®"« ºYâªÉ«¬'Ë¢â"--`°" 7,491 6,749 ,,ªí®®ÿ-- ºYâªÉ«¬"¬,,À¡à 272 1,537 16,240 2547 North °ÿßæoe 8,7772,846 7,459 2,648 1,030 272 5,830 11,648 Northeast ¿"§°"ß 7,6437,491 6,983 6,749 1,461 1,537 16,240 8,673 South ¿"§ÀÕ 3,2328,777 2,825 7,459 1,030 213 11,648 6,109 Other (PHPT) ¿"§­«--ÕÕ°©'¬ßÀÕ 494 7,643 6,983 494 1,461 -- 8,673 1,500 Total ¿"§,,µâ 30,4833,232 27,158 2,825 4,513 213 6,109 50,000 Source:MOPH 2004. ÕËÊ (PHPT) 494 494 ---- 1,500 Note: PHPT = Program for HIV Prevention and Treatment (PHPT): Clinical trials on the prevention of «¡ 30,483 27,158 4,513 50,000 mother to child transmission of HIV; -- = not available. 'Ë¡": °­«ß "" ÿ¢ 2547 a. Accumulated from ATC 2000 up to NAPHA, March 2004. À¡"¬Àµÿ: PHPT = ,§ß°"ªÑÕß°--·­--°..."TMÈÕ«-- ÕTMÕ«': °"¥Õß"§``æËÕªÑÕß°--°"µ`¥TMÈÕ«-- ÕTMÕ«'®"°¡"¥" Yàÿµ; --- = ¡à¡'¢âÕ¡Y 1. ­ ¡®"° ATC 2543 ÷ß,§ß°" NAPHA ,,¥Õ¡'"§¡ æ.». 2547 °"­"¥¢Õß,§Õ¥ å,,ª­»¬,,ªí®®ÿ-- 33 ¢âÕÁ®®`ß'Ë«à" ¿Y¡`¿"§Àà"--È "¡"¢¬"¬,§ß°"`°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¥âÁ«°«à" ¡' "æ¬""´÷Ëß,,Àâ°"--°..."¥â«¬¬"µâ"«-- Õ¥ å®Ì"« ¡"°°«à" ÀÕÕ"® ­âÕ,,ÀâÀÁ÷ßÕ--µ"°"--¬"'Ë Yß°«à" Õ¬à"ß°Áµ"¡ µ--«¢¥--ß°à"« ¡`¥â ªî¥,Õ°" ,,Àâ·¬°­À«à"ߧ«"¡ªìª¥â--Èß Õߪ­°"'È ·º'Ë 2.3 ,, à«¢Õß·º'Ë¥â"À--ßÀ--ß Õ©--'È ¥âÌ" Õ¿"æ"ߥâ"æÈ'Ë ¢Õß°"¢¬"¬,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,ª­»¬ ,¥¬· ¥ß,,ÀâÀÁ÷ß °"°­®"¬ºYâªÉ«¬'Ë--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,ªí®®ÿ-- ·­ºYâªÉ«¬¥â«¬TMÈÕ ÕTMÕ«''Ë¡'Õ"°" (´÷Ëߪìµ--«·¢Õߪ­TM"°°ÿࡪÑ"À¡"¬,¥¬ª`¬"¬¢Õß,§ß°" --°..."¥â«¬¬"µâ"«-- Õ¥ å (ART)) ,¥¬·¬°µ"¡®--ßÀ«--¥®÷ߥա'"§¡ æ.». 2547 ·º'Ë 2.4 ,,Àâ¡ÿ¡¡Õß'Ë·µ°µà"ßÕÕ°ªÁ°âÕ¬°'ˬ«°--°"§Õ§ÿ¡ ,¥¬ · ¥ß÷ß°"°­®"¬ºYâªÉ«¬®"°TMÈÕ«-- ÕTMÕ«''Ë· ¥ßÕ"°" ¡ËÕ'¬°--°"§Õ §ÿ¡¢Õß,§ß°" ART ,,­¥--®--ßÀ«--¥ ( à«¢âÕ¡Y¢Õß ART ,,­¥--ÕÌ"¿Õ--È¡à Õ"®À"¡"¥â) À--°"'˪ì°Á¥Á°°Á¥âÕ¬ «¡--Èß°" "°--°­«ß "" ÿ¢ TM૬ ,,ÀâÀÁ«à"µß°--¢â"¡°--'Ë¥â§"¥«â ¡'°"¢â"÷߬"µâ"«-- 'Ë®--¥ ªí à«,¥¬--" æ'¬ßÁ°âÕ¬à"--È ,ßæ¬""À"¬·Ààß,, ૵à"ßÊ¢Õߪ­» ¥â"¬ß"«à" ¡`¥â¡'°",,TMâ¬"µâ"«-- Õ¥ å--ÈßÀ¡¥'Ë¥â--·®°ª °"¢"¥°"ªí à«TMà'È Õ"® °`¥¢÷È¥â ËÕß®"°»--°¬¿"æ¢Õß,ßæ¬"",,°",,Àâ¬"µâ"«-- Õ¥ å--È °--Y°Ì" ª,,TMâ,,¥â"ÕËÊ (TMà °"¢"¥·§--æ¬"°ÿ§§'Ë "¡"·­µÁ¡,,®,,Àâ`°" ¬"µâ"«-- Õ¥ å) Õ°®"°'È ¬--ߪ쪥â«à" ºYâ'˵`¥TMÈÕÕ¥ åÕ"®¡à¬Õ¡¢â"--°" --°...",, "æ¬""¢Õß-- ÀÕ®­¬Õ¡ª°ÁµàÕ¡ËÕ¡'Õ"°"ªÉ«¬à"--È °"¥YÀ¡`Ë À¬'¬¥À¬"¡ °"Õ°ªØ`--µ` ·­°"¡àª­ ߧ宭ªî¥º¬µÕß--È â«ªìºâ"¬ µàÕºYâªÉ«¬Õ¥ å'Ë¢â"¡"--°"--°..."--Èß--È °"¢â"÷߬"µâ"«-- Õ¥ å'Ë--"®--¥,,Àâ--È ®Ì"ªìÕ¬à"߬`Ëß'˺YâªÉ«¬Õ¥ å®­µâÕߪ¬ "­¢ÕßµµàÕ,ßæ¬""âÕß`Ë §«"¡ °--«'Ë®­¥â--°"Õ°ªØ`--µ`µàÕµÕß·­§Õ§--«--È Ì",,ÀâºYâªÉ«¬À"¬§ µâÕßÀ" "ß--°"--°..."¿"¬Õ°ÕÌ"¿Õ ÀÕ®"°,ßæ¬"",,ÕÌ"¿ÕÕË ÀÕ®"°¿"§Õ°TM (,ª¥¥Y°'µ--«Õ¬à"ß'ËÌ" Õ,, 'Ë 1 °Õ 1.1) ´÷Ëß,,--Èß Õß°''È ºYâªÉ«¬ ®Ì"ªìµâÕß®à"¬ß`§à"¬"µâ"«-- Õ¥ å®°`ߪ­¡" ´÷Ëß®­°"¬ªì¿"­"ß°" ß`®Ì"«¡"°¡"¬ °" --¡¿"...åºYâªÉ«¬Õ¥ å,,¿Y¡`¿"§µà"ßÊ· ¥ß,,ÀâÀÁ«à" ÷ß·¡â°"¥YÀ¡`ËÀ¬'¬¥ À¬"¡·­°"Õ°ªØ`--µ`®­ªìªí®®--¬À÷Ëß ·µàºYâªÉ«¬À"¬§¬--ßTM'È,,ÀâÀÁ«à" °"¢"¥ §«"¡æâÕ¡'Ë®­,,Àâ`°",,,ßæ¬""'Ë¡' à«°'ˬ«¢âÕß,,°",,Àâ°"--°..."¥â«¬¬" µâ"«-- Õ¥ å--È ¬--ߪìÕÿª § Ì"§--Õ'°ª­°"À÷ËßµàÕ°"¢â"÷߬"µâ"«-- Õ¥ å Õ°®"°'È ¬--ߥâ°à"«÷ßÕÿª §"ߥâ"°"ß` ,,"­'˪ìªí®®--¬ Ì"§--Õ'°ª­°" À÷Ëߥ⫬ ,¥¬©æ"­Õ¬à"߬`Ëß Ì"À--ºYâ'Ë¡à¥âªì à«À÷ËߢÕß,§ß°" ç30 " --°..."ÿ°,§é (,§ß°"ª­°-- ÿ¢¿"æâ«Àâ") (æß»åæ`» 2547) ·¡â°­--Ëß Ì"À-- ºYâ'ËÕ¬Yà¿"¬,,µâ,§ß°"ª­°-- ÿ¢¿"æâ«Àâ"·­ "¡"--¬"µâ"«-- Õ¥ å¥â,¥¬ ¡àµâÕß '¬§à",,TMâ®à"¬·â« µâÿÕ¬à"ßÕˬ--ßÕ«à" Yß¡"° TMà µâÿ,,°"µ«®Õ¥ æËÕµ`¥µ"¡º (,¥¬©æ"­Õ¬à"߬`Ëß °"«--¥§à" CD4 ·­°"À"ª`¡"«-- ,,°­· Õ¥) --È ®­µâÕß¡'§à",,TMâ®à"¬´÷ËߧàÕ¢â"ß Yß "§" Ì"À--°"µ«®§à" CD4 ¥â«¬«`' ¡"µ" ®­Õ¬Yà­À«à"ß 200 ÷ß 800 " (5>20 À'¬ À--) ¢÷ÈÕ¬Yà°-- "-- 34 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ 'ËÌ"°"µ«® (,ª¥¥Y 'Ë 3) Ì"À--"§"§à"µ«®À"ª`¡"TMÈÕ«-- ÕTMÕ«',, °­· Õ¥ (viral load) Õ"® Yß÷ß 3,500 " (90 À'¬ À--) Õ°®"°'È °" µ«®À"§à" "§¡'æËÕ§«"¡ªÕ¥¿--¬æÈ"µà"ßÊ «¡--Èß°"µ«®À"SGOT (serum glutamic oxaloacetic transaminase), creatinine ·­°Y,§ ¡'"§"÷ß 100 " (2.50 À'¬ À--) Ì"À--Õÿª §'Ë Ì"§--Õ'°ª­°"À÷ËßµàÕ°"¢â"÷ß--È §Õ°" ¢"¥¢âÕ¡Y°'ˬ«°--¬"µâ"«-- Õ¥ å (æß»åæ`» 2547) °" ¡--§¢â"à«¡,§ß°"`°"¬"µâ"«-- Õ¥ å (ART) ,,­¥--TM"µ` ªì§«"¡ ¡--§,,®¢Õß,ßæ¬""µà"ßÊ ,¥¬¡'À"¬,ßæ¬"" ¥âÕ°'Ë®­¡à¢â"à«¡,§ß°" ÀÕÕ°'Ë®­--ºYâªÉ«¬,,Õ--µ"æ'¬ßÁ°âÕ¬ Õ¬à"ß°Áµ"¡ ·ºº--ß 2.5 ¥â,,Àâ¡ÿ¡¡Õß Õ'°¡ÿ¡À÷ËߢÕß°"¢¬"¬°ÿà¡ NAPHA ¥â«¬°"· ¥ß,,ÀâÀÁ÷ß°"æ`Ë¡®Ì"« " æ¬""'Ë,,Àâ°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ,¥¬®Ì"«--Èß `È æ`Ë¡¢÷È®"° 112 ·Ààß ,,æ.». 2544 ªì 462 ·Ààß ,,æ.». 2545 ·­æ`Ë¡¢÷ÈÕ'°®÷ß 841 ·Ààß ¿"¬,, æ.». 2546 °"¢¬"¬®Ì"« "æ¬""'Ë,,Àâ°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ­À«à"ß æ.». 2544 ÷ß æ.». 2546 ¡'§«"¡ --¡æ--åTM`ß¿Y¡`»" µå°--°"°­®"¬°' ¢ÕߺYâªÉ«¬Õ¥ å ­ ¡·­ºYâµ`¥TMÈÕÕTMÕ«''Ë· ¥ßÕ"°" Õ°®"°'È ·ºº--ß'Ë 2.6 ¬--ß · ¥ß÷ß®Ì"«,¥¬©'ˬ¢ÕߺYâ¢â"à«¡,§ß°"¬"µâ"«-- Õ¥ åµàÕ®Ì"«,ßæ¬"" 'Ë¢â" ¡--§,,,§ß°" NAPHA --Èß'È ,ßæ¬""'Ë----°..."ºYâªÉ«¬®Ì"«¡"°'Ë ÿ¥µàÕ "æ¬""--È µ--ÈßÕ¬Yà,,°ÿßæoe·­¿"§ÀÕ °"--°..."¥â«¬¬"µâ"«-- Õ¥ å (ART) ®"°¿"§--æâÕ¡¥â«¬`°" `¡æ`»... Õ°ÀÕ®"°ºYâ'Ë¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,¥¬ºà""ß­ ""­·â« ¬--ß¡'ºYâµ`¥TMÈÕÕTMÕ«'/Õ¥ å (PHA) ®Ì"«À÷Ëß 'Ë¢â"--°"--°..."æ¬""'Ë,ßæ¬"" ¢Õß-- ,, "'Ë´÷Ëß ç¡'`°" `¡æ`»...é (augmented) ,¥¬¥â--§«"¡ -- ÿ Õ¬à"ß·¢Áߢ--®"° "--Õ°TMµà"ßÊ TMà ¿"°"TM"¥¬·­Õߧ尷æ¬åâæ¡·¥ (Medicins sans Frontieres-MSF) «¡--Èß»Y¬åª­ "§«"¡à«¡¡Õ­À«à"ß ¬ ÕÕ µ'¬ Õå·¥å æËÕ°"«`®--¬"ߧ``°¥â",§Õ¥ å (HIV-Netherlands AustraliaThailandResearchCollaboration(HIV-NAT)) ·­°"¡' à«à«¡æ`Ë¡¢÷È®"° °ÿà¡ -- ÿºYâµ`¥TMÈÕÕTMÕ«'/Õ¥ å TMà "ß MSF ¥âÌ"ß"à«¡°--,ßæ¬"" ÕÌ"¿Õ 3 ·Ààß ,,ª­»¬ µ--Èß·µà æ.». 2543 æËÕ,,Àâ°"¥Y·--°..."ºYâªÉ«¬®Ì"« ª­¡" 330 § ¥â«¬`°"¬"µâ"«-- Õ¥ å ·­®"°°"ª­¡` §"¥«à" ¡'ºYâªÉ«¬Õ'° ª­¡"1,800§'Ë°Ì"--ߥâ--`°"¬"µâ"«-- Õ¥ åæ`Ë¡µ`¡¥--ß°à"«(µ""ß2.5) ,,·¢Õß MSF °"¥Y·--°..."ºYâªÉ«¬--È ªì§«"¡--º`¥TMÕ¢Õß,ßæ¬"" ÕÌ"¿Õ ,¥¬§­Ì"ß"®"°À"¬«`TM"TM'æ´÷Ëß`À",¥¬æ¬""®­ªìºYâ,,Àâ°"¥Y·­ --°..." §­Ì"ß"¥--ß°à"« «¡÷ß·æ¬å ¿ --TM° æ¬"" TMà"ߧ`§ÀâÕߪØ`--µ` °" ·­ºYâ,,Àâ§Ì"ª÷°..."·°àºYâµ`¥TMÈÕÕTMÕ«'/Õ¥ å ,¥¬--Ë«ª·â« À--«Àâ"§­Ì"ß" ¥--ß°à"« ¡--°®­ªìæ¬""Õ"«ÿ, 'Ë¡'ª­ °"å·­ÕÌ""®æ'¬ßæÕ'Ë®­®--¥°" ¡"TM`°,,§­Ì"ß"®"°«`TM"TM'æÕËÊ ËÕß®"°·æ¬å,,,ßæ¬""ÕÌ"¿Õ--È¡'ß" ¬ÿàß¡"° ,¥¬·æ¬åÀ÷Ëß"¬¡--°®­µâÕß--º`¥TMÕ,,°",,Àâ§Ì"ª÷°..."·°àºYâªÉ«¬Õ°÷ß 100 §µàÕ«-- ·­¬--ßµâÕߥY·ºYâªÉ«¬®"°ÀÕºYâªÉ«¬·­ÀâÕß©ÿ°©` ¥--ß--È ¡à,,TMà«à" ºYâªÉ«¬ÿ°§'Ë¢â"--`°"¬"µâ"«-- Õ¥ å®­¥âæ·æ¬åÿ°§--Èß'Ë--¥ Õ°®"°'È ºYâªÉ«¬®­Y° àßµàÕ,,Àâ·°à·æ¬åæËÕµ«®À"ªØ`°``¬""ß°-- ÀÕ¡ËÕ¡'¢âÕ ß --¬«à" ®­¡'°"µ`¥TMÈÕ©«¬,Õ°" ,, "'Ë·Ààß'È'˪÷°..."¢ÕߺYâµ`¥TMÈÕÕTMÕ«'/Õ¥ å®­¡' °"­"¥¢Õß,§Õ¥ å,,ª­»¬,,ªí®®ÿ-- 35 "'Ë Ì"§--¡"°¡"¬ ¥â·°à: ëëëëë "¬ß"µàÕTMÿ¡TM«à"¡'`°",,Àâ°"--°..."'ÈÕ¬Yà ,,Àâ¢âÕ¡YæÈ"·°àºYâªÉ«¬¥â«¬¿"..."'Ë¢â",,®¥âßà"¬ ª÷°..."À"Õ÷ß·º°"--°..."·­°"ªî¥º¬ ·°âªíÀ",,°''Ë¡à¡'°"µ`¥µ"¡°"--°..."Õ¬à"ß®`ß®--ß ¢â"¬'ˬ¡ºYâªÉ«¬'Ëâ" ,,°''Ë¡à "¡"µ`¥µ"¡º¥â Õ°®"°ªìºYâ,,Àâ¬"·â« "ß MSF ¬--ߥâ,,À⧫"¡ -- ÿÕ¬à"ßµàÕËÕß ´÷Ëß«¡÷ß °",,Àâ§Ì"ª÷°..."à«¡°--·­°"ÕÕ°¬'ˬ¡â"ºYâªÉ«¬ «¡--Èß°"ª­TMÿ¡À"Õ÷ß°' ¢ÕߺYâªÉ«¬ ·­°"ñ°Õ¡--Èß Ì"À--§­Ì"ß",,,ßæ¬""·­ºYâµ`¥TMÈÕÕTMÕ«'/ Õ¥ åºYâªÉ«¬'Ë¢â"--`°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,, "æ¬""¢Õß--'Ë¡'`°" («` --·­øÕå¥ æ.». 2547) `¡æ`»...'È à"®­¥â--ª­,¬TMå®"°°",,Àâ§Ì"ª÷°..."·­§«"¡ -- ÿÕ¬à"ß·¢Áߢ-- ¡"°°«à" ®"°ºYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å"¬ÕËÊ ¡ËÕª'¬'¬°ºYâªÉ«¬'Ë¢â"--°" --°..."¥â«¬¬"µâ"«-- Õ¥ å,¥¬¡à¥â--ª­,¬TMå®"°°"¡' à«à«¡¢ÕßÕߧå°æ--" Õ°TM (NGO) µà"ßÊ --Èß'È ¡'°"§"¥À«--ß«à" °" `¡`°"æ`»...'È®­TM૬,,ÀâºYâªÉ«¬ "¡"ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥ (adherence)¥âÕ¬à"ß ¡Ë" ¡Õ µ"¡ ®`ß·â« ª­ °"å,,­¬­«" "¡ªï'˺à"¡"¢Õß MSF TM'È,,ÀâÀÁ«à" °ÿࡺYâµ`¥TMÈÕ ÕTMÕ«'/ºYâªÉ«¬Õ¥ å (PHA) "¡"¡' à«TM૬¥âÕ¬à"ß¡"°,,°",,À⧫"¡ -- ÿ æËÕ,,Àâ°`¥°"ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥ §«"¡TM૬ÀÕ¥--ß°à"« ¡"®"° §«"¡µÁ¡,,®¢Õß°ÿà¡ PHA 'Ë®­TM૬ÀÕºYâ'˵`¥TMÈÕÀ¡Õ°-- «¡--Èß·°ª'ˬ ª­ °"å­À«à"ß°-- ·µà°"ñ°Õ¡·­°"ª­ "ß"'Ë®Ì"ªì--È ®­µâÕßÕ"»--¬ ÿ -- ÿ,,­¬­¬"«·­§«"¡ -- ÿ¥â"§`§Õ¬à"ßµàÕËÕß ·µàËÕß®"°°ÿà¡ ºYâµ`¥TMÈÕÕTMÕ«'/ºYâªÉ«¬Õ¥ å,¥¬--Ë«ª--È¡'­¥--°"»÷°..."'˧àÕ¢â"ßµË" ®÷ß®Ì"ªìµâÕß ,,À⧫"¡ ,,®ªìæ`»...µàÕ°"æ--"­°""¬ß"'Ë,,TMâ¥âßà"¬·­TMËÕÕ¥â («` -- ·­øÕå¥ 2547) µ--Èß·µà¥Õµÿ"§¡ æ.». 2546 "ß TNP (§Õ¢à"¬ºYâµ`¥TMÈÕÕTMÕ«'/Õ¥ å·Ààß ª­»¬) «¡--Èß MSF ·­¡Y``æËÕ°"¢â"÷ß,§Õ¥ å ¥âà«¡¡Õ°--æËÕµ'¬¡ °ÿࡺYâµ`¥TMÈÕµàÕª 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,ßæ¬""'Ë¥âß­'¬«â ( ¡¡µ`"«à" ,ßæ¬""¡'¬" Ì"À----°..."Õ¬Yà ,¥¬"ߢµ Õ"®µâÕß¡'°"¢â"TMËÕÕ--°"--°...") ºYâªÉ«¬®­µâÕß®à"¬ß`Õß Ì"À--°" µ«®®Ì"«¡Á¥Õ¥¢"« CD4 (ª­¡" 500 ") ૧à",,TMâ®à"¬,,°"µ«® µ`¥µ"¡·­µ«® Õ--ÈßÀ¡¥À--ß®"°'˥⠡--§¢â",§ß°"·â« ®­Õ¬Yà¿"¬,,µâ§«"¡-- º`¥TMÕ¢Õß NAPHA TMà¥'¬«°--µâÿ§à"¬" Õ¬à"ß°Áµ"¡ ,,"ߪØ`--µ`·â« ,ß æ¬""®­µâÕß,,TMâ«`®"",,°"¢Õ,,ÀâºYâªÉ«¬¥âà«¡TMÌ"­§à",,TMâ®à"¬ ,¥¬¢÷ÈÕ¬Yà°-- °"ª­¡`¥â«¬«`'¢ÕßµÕß °"À"Õ¥--ß°à"« ¥â¥Ì"`µàÕª,,°ÿࡺYâ«"ß,¬"¬·­--°°"¡Õß°'ˬ«°-- §«"¡ª­ ߧå'Ë®­Ì"°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢â"«¡,,,§ß°"ª­°-- ÿ¢¿"æ â«Àâ" --Èß'È "ß--¡µ'°­«ß "" ÿ¢ ¥â· ¥ß§«"¡¡ÿàß¡--Ë"ß°"¡Õß'Ë ®­«¡Õ"`°"--°..."¥â«¬¬"µâ"«-- Õ¥ åÕ¬à"ßTM--¥®,,À"¬,Õ°" ·­¡ËÕÁ«Ê 'È¢÷È,,¥Õ°°Æ"§¡ ,,°"ª­TMÿ¡TM`ß«`TM"°"«à"¥â«¬,§Õ¥ å­À«à"ß°ÿßæoe·­""ª­» ´÷Ëß®--¥ æ.». 2547 "¬°--¡µ'¥â· ¥ß§«"¡¡ÿàß¡--Ë¥--ß°à"«¥â«¬µ Õß ¥--ß--È ®÷ߧ"¥À«--ߥâÕ¬à"ß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (ART) ®­¥âÌ"¡" «¡«â¿"¬,,µâ,§ß°"ª­°-- ÿ¢¿"æâ«Àâ",,¡àTMâ" ®÷ß¥Õ `ßÀ"§¡ æ.». 2547 ,§ß°"¢â"÷ß`°"¬"µâ"«-- Õ¥ å­¥--TM"µ` Ì"À--ºYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å (NAPHA) ¬--ߥâ§Õ§ÿ¡°"¢â"÷ß`°"¬"µâ" °"­"¥¢Õß,§Õ¥ å,,ª­»¬,,ªí®®ÿ-- 41 «-- Õ¥ å·°àºYâµ`¥TMÈÕÕTMÕ«'/Õ¥ å'ËÕ¬Yà,,,§ß°"ª­°-- --ߧ¡ ,¥¬¿"¬,,µâ,§ß°" ª­°-- ÿ¢¿"æâ«Àâ"--È ºYâªÉ«¬'Ë¡'ª­°-- --ߧ¡®­µâÕß®à"¬ß` Ì"À--§à"µ«®§à"¡Á¥ Õ¥¢"« CD4 §--Èß·°Õß ·µà°"µ`¥µ"¡·­¥ ÕÕËÊÀ--ß®"°--È «¡--Èßµâÿ §à"¬"µâ"«-- Õ¥ å ®­Õ¬Yà¿"¬,,µâ§«"¡--º`¥TMÕ¢Õß,§ß°"¢â"÷ß`°"¬"µâ" «-- Õ¥ å­¥--TM"µ` Ì"À--ºYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å (NAPHA) (÷ß·¡â«à" °"TMÌ"­ß` à«¡°--'È®­µâÕߪ쪵"¡«`®""¢Õß,ßæ¬""TMà°--) Ì"À--°"¥Y·ºYâªÉ«¬ Õ°·­ºYâªÉ«¬,,,,°ÿࡺYâµ`¥TMÈÕÕTMÕ«'/ºYâªÉ«¬Õ¥ å--È ®­Õ¬Yà¿"¬,,µâ°"¥Y·¢Õß ,§ß°"ª­°-- --ߧ¡ ¿"¬,,¥Õ `ßÀ"§¡ æ.». 2548 ,§ß°"ª­°-- --ߧ¡®­¥â «¡°"¢â"÷ß`°"¬"µâ"«-- Õ¥ å«âªì à«À÷ËߢÕß°"¥Y·ºYâµ`¥TMÈÕÕTMÕ«'/ Õ¥ å¥â«¬ ¥--ß--È ºYâªÉ«¬'Ë¡'ª­°-- --ߧ¡--ÈßÀ¡¥´÷Ëߥâ--°"--°..."¿"¬,,µâ,§ß°"¢â" ÷ß`°"¬"µâ"«-- Õ¥ å­¥--TM"µ` Ì"À--ºYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å (NAPHA) ®÷ß®­ µâÕßY°,Õ,,Àâ·°à,§ß°"ª­°-- --ߧ¡ (ª­¡" 13,000 "¬) ·«ªØ`--µ` Ì"À-- °"--°..." («¡--Èß"ßÕ° Ì"À-- Yµ¬",,°"--°..."¢--ȵâ) ®­µâÕß¡'°"Õâ"ßÕ`ßæËÕ ,,Àâ§â"¬§÷ß°--­À«à"ß,§ß°"ª­°-- --ߧ¡·­,§ß°"¢â"÷ß`°"¬"µâ"«-- Õ¥ å­¥--TM"µ` Ì"À--ºYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å (NAPHA) Ì"À--,§ß°" «-- ¥`°" æËÕ--°..."æ¬""¢Õßÿ§"°¿"§-- (Civil Servant Medical Benefit Scheme> CSMBS) --È ®­§Õ§ÿ¡°"¥Y·ºYâµ`¥TMÈÕ«-- ÕTMÕ«'/Õ¥ å --ÈßÀ¡¥ «¡÷ß°",,Àâ `°"¬"µâ"«-- Õ¥ å «¡--Èß°"µ«®µ`¥µ"¡·­¥ Õ'Ë°'ˬ«¢âÕß) ·«,â¡¢Õߧà",,TMâ®à"¬°'ˬ«°--,§Õ¥ å ®"°--TM',§Õ¥ å­¥--TM"µ` (Teokul ·­§­ æ.». 2548) §à",,TMâ®à"¬¥â" ÿ¢¿"æ --ÈßÀ¡¥'Ë°'ˬ«°--ÕTMÕ«'/Õ¥ å ¥âæ`Ë¡¢÷È®"° 2.996 æ--â"" (74.4 â" À'¬ À--) ,,æ.». 2543 ¡"ªì 4.188 æ--â"" (101.3 â"À'¬ À--) µ""ß 2.8 §à",,TMâ®à"¬°'ˬ«°--Õ¥ å­¥--TM"µ` ·¬°µ"¡Àâ"'Ë æ.». 2543 - 2546 Àâ"'Ë æ.». 2543 æ.». 2544 æ.». 2545 æ.». 2546 §à",,TMâ®à"¬¥â" ÿ¢¿"æ,,ªí®®ÿ-- (â"") 3,154 3,999.6 °"¥Y·ºYâªÉ«¬,, 2,690 2,922 432.5 431.6 °"¥Y·ºYâªÉ«¬Õ° 687.1 715.7 1,242.9 1,010 1,033 ART 836.5 928.4 2,099 PMTCT 606.9 797.1 184.2 140.1 VCT 210.8 188.7 24.9 39.5 §«"¡ªÕ¥¿--¬¢Õß,À`µ 28.5 27.6 84.3 84.3 ,§ß°"ÿ߬"ßÕ"¡--¬ 84.3 84.3 69.7 42.2 °"»÷°..."ËÕßÕ¥ å 49.4 35.5 29.5 41.3 °"¥Õ--µ"¬¢Õß IDU 36.2 100.2 21.7 59.3 73.4 °"Ñ"­«--ß 28.1 16.9 15.2 °"`À",§ß°" 19.1 18.0 ---- ---- §à",,TMâ®à"¬'Ë°'ˬ«¢âÕß°--°"¥Y· ÿ¢¿"æ 45.5 63.2 (°"«`®--¬·­æ--" °"ºñ°Õ¡) 3,253.5 5.94 4,188.0 102.7 «¡ (â"") 3,312.4 104.9 2,996.0 201.1 «¡ (â"À'¬ À--) 74.4 70.4 75.9 101.3 'Ë¡" : Teokul ·­§­ æ.». 2548 À¡"¬Àµÿ: ---- = ¡à¡'¢âÕ¡Y 42 42 · The»...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ EconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand expenditure going to ART increased from 20.3 percent in 2000 to ,,æ.». 2546 ,¥¬§à",,TMâ®à"¬'Ëæ`Ë¡¢÷È¡"°'Ë ÿ¥,,­¬­'È ¡"®"°,§ß°"--°..."¥â«¬¬" 50.1 percent in 2003. Jointly, ART and treatment of opportunistic µâ"«-- Õ¥ å ÀÕ ART (´÷Ëß¡'§à",,TMâ®à"¬¡"°¢÷È°«à" "¡à") ·­®"°°"¥Y·--°..." infections account for 85.1 percent of total AIDS spending. The share ºYâªÉ«¬Õ° (µ""ß 2.8) ¥--ß--È à«·àߢÕߧà",,TMâ®à"¬°'ˬ«°--Õ¥ å'Ë,,Àâ·°à,§ß°" of spending going to prevention activities has declined sharply, from `°"¬"µâ"«-- Õ¥ å--È æ`Ë¡¢÷È®"°âÕ¬­ 20.3 ,,æ.». 2543 ¡"ªìâÕ¬­ 9.3 percent in 2000 to 5.1 percent in 2003, but the level has remained 50.1 ,,æ.». 2546 ´÷Ëß¡ËÕ«¡°--·â« ,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å·­°" roughly constant in current prices. Within the prevention budget, the --°..."°"µ`¥TMÈÕ©«¬,Õ°" ¡' --¥ à«÷ßâÕ¬­ 85.1 ¢Õߧà",,TMâ®à"¬°'ˬ«°--Õ¥ å--Èß sharpest decline in both share and levels has occurred in harm reduc- À¡¥ --Èß'È à«·àߢÕߧà",,TMâ®à"¬ Ì"À--°`®°¡æËÕªÑÕß°----È¥â¥ßÕ¬à"ß«¥Á« tion activities for IDUs. ®"°âÕ¬­ 9.3 ,,æ.». 2543 ¡"ªìâÕ¬­ 5.1 ,,æ.». 2546 ·µà­¥--¥--ß°à"« §àÕ¢â"ß®­§ß'Ë,,ªí®®ÿ-- Ì"À--ߪ­¡",,°"ªÑÕß°----È --ÈßÕ--µ" à«·­­¥-- Sources of Financing ¥â¥ßÕ¬à"ß«¥Á«,,°`®°¡æËÕ¥Õ--µ"¬ Ì"À--ºYâ,,TMâ¬" æµ`¥TM`¥©'¥ (IDU) Most expenditures on HIV/AIDS have been financed from public 'Ë¡"¢Õßÿ -- ÿ budgetary sources, which accounted for about 65 to 80 percent of §à",,TMâ®à"¬°'ˬ«°--ÕTMÕ«'/Õ¥ å à«,,Àà ¥â--ÿ -- ÿ®"°·Ààßߪ­¡" total AIDS expenditure during 2000 to 2003 (figure 2.9). The share of ""­ ´÷Ëß¡' --¥ ૪­¡"âÕ¬­ 65 ÷ß 80 ¢Õߧà",,TMâ®à"¬°'ˬ«°--Õ¥ å--ÈßÀ¡¥ financing coming from the two main health insurance schemes, SSS ,,TMà«ßæ.». 2543 ÷ß æ.». 2546 (¿"æ 2.9) ,¥¬ à«·àߢÕßÿ -- ÿ¥--ß°à"« and CSMBS, has remained stable at about 2.5 percent and 3 percent, ´÷Ëߥâ¡"®"°,§ß°"ª­°-- ÿ¢¿"æ'Ë Ì"§-- Õß,§ß°" Õ--¥â·°à,§ß°"ª­°-- respectively, for the same period. However, the share of spending by --ߧ¡ (SSS) ·­,§ß°" «-- ¥`°"--°..."æ¬""¢Õßÿ§"°¿"§-- (CSMBS) ¬--ß SSS is expected to increase; the scheme recently started to cover ART. §ß'ËÕ¬Yà,,Õ--µ" ૪­¡"âÕ¬­ 2.5 ·­âÕ¬­ 3 µ"¡Ì"¥--,,­¬­«"¥'¬«°-- Under this new policy, about 13,000 patients are expected to shift Õ¬à"ß°Áµ"¡ §"¥«à" à«·àߢÕߧà",,TMâ®à"¬,¥¬,§ß°"ª­°-- --ߧ¡--È®­æ`Ë¡¢÷È from NAPHA to SSS. Household out-of-pocket spending has also ËÕß®"°"ß,§ß°"æ`Ëß®­`Ë¡§Õ§ÿ¡°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ¿"¬,,µâ played a significant role in financing AIDS expenditures, accounting ,¬"¬,,À¡à'È §"¥«à" ºYâªÉ«¬ª­¡" 13,000 "¬ ®­ª'ˬ®"°,§ß°" NAPHA ¡" Yà,§ß°"ª­°-- --ߧ¡ Õ°®"°'È °"®à"¬ß`µ"¡®`ߢÕߧ--«Õ ¬--ß¡'"'Ë for 27 to 28 percent of total AIDS spending. Other donor sources Ì"§--µàÕ°",,Àâÿ -- ÿ§à",,TMâ®à"¬°'ˬ«°--Õ¥ å ´÷Ëߧ`¥ªì --¥ à«âÕ¬­ 27-28 played a negligible role until 2003, when resources from the GFATM ¢Õߧà",,TMâ®à"¬°'ˬ«°--Õ¥ å--ÈßÀ¡¥ Ì"À--·Ààß'Ë¡"¢ÕߺYâ`®"§ÕËÊ ¬--ß¡'"'Ë started to kick in, raising the share of financing by external sources to ¡à Ì"§----°®÷ß æ.». 2546 ¡ËÕ`Ë¡¡'--æ¬"°®"° GFATM ¢â"¡" ,¥¬æ`Ë¡ à« about 9 percent of the total.9 ·àߢÕßÿ -- ÿ®"°·Ààß'Ë¡"¿"¬Õ°¢÷È¡"ªìâÕ¬­ 9 ¢Õßß`ÿ--ÈßÀ¡¥9 Figure 2.9 Sources of HIV/AIDS Program Financing, 2000­2003 ¿"æ 2.9 ·Ààß'Ë¡"¢Õßÿ -- ÿ,§ß°"°'ˬ«°--ÕTMÕ«'/Õ¥ å æ.». 2543-2546 100 16.5 17.6 9 27.8 80 22 60 40 77.7 76.3 66.7 63.7 20 0 2543 2000 25442001 2545 2002 2546 2003 ¿"§-- Public CSMBS SSS §--«Õ CSMBS SSS Household à«ÕËÊ¢Õß,° Rest of world 'Ë¡":Source:Teokul 2548 Teokul ·­§­ and others 2005. °"­"¥¢Õß,§Õ¥ å,,ª­»¬,,ªí®®ÿ-- The Thai AIDS Epidemic Now · 43 43 ¿"æ 2.10 °"®--¥ ߪ­¡"Õ¥ å­¥--TM"µ` æ.». 2539 - 2547 Figure 2.10 National AIDS Budget Allocation, 1996­2004 60 50 40 (USD) 30 (À'¬ À--) â"Millions 20 10 0 2539 2540 2541 2542 2543 2544 2545 2546 2547 1996 1997 1998 1999 2000 2001 2002 2003 2004 Prevention °"ªÑÕß°-- Treatment and care °"¥Y·--°..." Research and management °"«`®--¬·­`À" °Õßÿ­¥--,° Global Fund 'Ë¡": °­«ß "" ÿ¢ °"®--¥ ߪ­¡"æËÕ°"ªÑÕß°--·­"Õ¥ å­¥--TM"µ` ,¥¬--"¬ æ.». 2547; Ì"--°,§Õ¥ å «--,§ ·­,§µ`¥µàÕ"ßæ» --¡æ--å °­«ß "" ÿ¢ Source: MOPH, National Prevention and Alleviation of AIDS Budget Allocation by the Royal æ.». 2547; °­«ß "" ÿ¢ æ.». 2547 Thai Government 2004; Bureau of AIDS, TB, and STI at MOPH 2004; MOPH 2004. °"®--¥ ߪ­¡"­¥--TM"µ`æËÕªÑÕß°--·­--°..."Õ¥ å National Budget Allocations for AIDS Prevention and Treatment ¿"æ 2.10 · ¥ß÷ß«`«--"°"¢Õßߪ­¡"Õ¥ å­¥--TM"µ`,,TMà«ßæ.». 2539- Figure 2.10 shows the evolution of the national AIDS budget for the 2546 Yª·,,°"®--¥ ߪ­¡"--È ¢"ª°--Yª·'Ë· ¥ß«â,,--TM',§ period 1996­2003. The patterns in the budget allocation parallel Õ¥ å­¥--TM"µ` TMà ¡'°"æ`Ë¡­¥--·­ à«·àߢÕߧà",,TMâ®à"¬ Ì"À--°"--°..."·­ those reflected in the National AIDS Accounts--namely an increase °"¥Y· ,¥¬'Ë à«·àß'Ë Ì"§--'Ë ÿ¥ ¡"®"°°"`°"--°..."¥â«¬¬"µâ"«-- Õ¥ å in the level and share of expenditures on treatment and care, of which (ART) ·­¡'°"¥ßÁ°âÕ¬ Ì"À-- à«·àß·­­¥--¢Õߧà",,TMâ®à"¬,,°"ªÑÕß°-- the largest share is due to ART, and a slight reduction in the share and level of prevention spending. À¡"¬Àµÿ Notes1. §«"¡TMÿ° (prevalence) ¢ÕßÕTMÕ«' À¡"¬÷ߪ`¡"°"µ`¥TMÈÕ'Ë¡'Õ¬Yà «",,¥«"À÷Ëß ,,¢­'ËÕÿ--µ`°"å (incidence) ¢ÕßÕTMÕ«' À¡"¬÷ß°"À «'¬¢Õß°"µ`¥TMÈÕÕTMÕ«'"¬,,À¡à,,­¬­«"'Ë°Ì"À¥«â °"¢â"÷ß,§ß°" 1. HIV prevalence refers to the stock of existing infections at a `°"¬"µâ"«-- Õ¥ å (ART) ¥â¡"°¢÷È--È ¥âª'ˬ·ªßæ«--µ¢Õß,§­"¥ point in time; HIV incidence refers to the flow of new HIV infections Õ¥ å §«"¡TMÿ°¢ÕßÕTMÕ«'Õ"®¥ß ¡à«à"®­ËÕß¡"®"°°" '¬TM'«`µ¢ÕߺYâªÉ«¬ at a given period of time. Greater access to ART has changed the Õ¥ å ÀÕËÕß®"°¡'°"µ`¥TMÈÕ"¬,,À¡à,,°ÿࡪ­TM"°âÕ¬­ §«"¡ Ì"Á®,,°" dynamics of the AIDS epidemic. HIV prevalence can decline either æ`Ë¡­¥--°"`°"¬"µâ"«-- Õ¥ å--È ®­æ`Ë¡Õ--µ"§«"¡TMÿ°¢ÕßÕTMÕ«' Õ--ªì with more deaths among AIDS patients or with fewer new infections º¡"®"°°"¬¥­¬­«"°" '¬TM'«`µ¢ÕߺYâªÉ«¬Õ¥ å ·­°"æ`Ë¡­¬­«"°"¡' among the population. Successful scale-up of ART would increase TM'«`µÕ¬Yà®"°°"--°..." ,,¬ÿ§¢Õß°"¢â"÷ß ART Õ¬à"ßâ«Àâ"'È Õ--µ"°"°`¥¢÷È HIV prevalence as a result of both delays in AIDS deaths and ¢ÕßÕTMÕ«' increased life expectancy with treatment. In the era of universal access ®­ "¡"ªìµ--««--¥§«"¡ Ì"Á®,,°"ªÑÕß°--¥â¥'°«à"'Ë®­,,TMâÕ--µ" §«"¡TMÿ° to ART, incidence rate is a better measure of prevention success than prevalence rate. 44 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ 2. ,¥¬©'ˬ·â« ,,ª­»¬ ­¬­«"­À«à"ß'Ë`Ë¡µ`¥TMÈÕÕTMÕ«'°--«"'Ë `Ë¡· ¥ßÕ"°"¢ÕßÕ¥ å ®­Õ¬Yà'Ë 7 ÷ß 10 ªï (,ª¥¥Y'Ë 3) 3. §«"¡À"¬"°'È ªìËÕß'Ë¡àæ÷ߪ­ ߧå ËÕß®"°µ--«àßTM'È"ߥâ"»...°`® --ߧ¡¢Õß°"µ`¥TMÈÕ«-- ÕTMÕ«' ¬--ßà"®­ àߺµàÕ§«"¡µâÕß°"'Ë¡'µàÕ°",,Àâ§Ì" ª÷°...",¥¬ ¡--§,,® ·­°"¥ Õ·­°"`°"«-- Õ¥ å TMà¥'¬«°--'Ë¡' Õ``æµàÕ°"§ß¥Ì"`°`®°¡µàÕª 4. 'È ¥â,,TMâ¢âÕ¡Y à«,,Àà®"°°"»÷°..."¢Õß"§",°§--Èß'˺à"¡" ("§",° æ.». 2543) ®"°"¬ß"æÈ"°'ˬ«°--°"æ--",¬"¬ ´÷Ëß®--¥ µ'¬¡,¥¬ Ì"--°,§Õ¥ å «--,§ ·­,§µ`¥µàÕ"ßæ» --¡æ--å °¡§«§ÿ¡,§ °­«ß "" ÿ¢ (·ª­ ` ÿ¢ ·­§­ æ.». 2547) ·­®"°"¬ß"¢Õß ,§ß°"æ--"·Ààß Àª­TM"TM"µ` (UNDP) «à"¥â«¬,§Õ¥ å ´÷Ëß«¡Õ¬Yà,,"¬ß" ªÑ"À¡"¬°"æ--"·Ààß À-- «... (æY®` ·­§­ æ.». 2547°) 5. °" Ì"«®æËÕÑ"­«--ßTMÈÕ«-- ÕTMÕ«'--È ,,µÕ·° ¥â¥Ì"`°"ªï­ Õߧ--Èß À"°µ--Èß·µà°"µ`¥TMÈÕ"¬,,À¡à`Ë¡¥ßµ--Èß·µà æ.». 2538 ®÷ߥâ¥Ì"`°" Ì"«®¥--ß°à"«æ'¬ßªï­À÷Ëߧ--Èß (,,¥Õ¡`ÿ"¬) ,,°ÿࡪÑ"À¡"¬'Ë Ì"§-- 5 °ÿà¡ ,,¢­'Ë¢'¬"¬ß"©--'È °" Ì"«®§--Èßà" ÿ¥¥â®--¥Ì"¢÷È,,¥Õ¡`ÿ"¬ æ.». 2546 6. 'È ¥âÌ"¢âÕ¡Y¡"®"°Õ° "¢Õß ¥--§Õ¡å (æ.». 2547) ·­· ª­ ` ÿ¢ (æ.». 2547) 7. 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CD4 <200-499 169 93 47.1 9.1 (5.4-16.0) 366 343 6.6 1.3 (0.7-2.3) 500+ 222 713 6.0 1.0 °ÿà¡ 'Ë¬ß --°µà"ßæ» 562 321 11.7 1.0 --°à«¡æ» 104 501 13.6 1.1 (0.7-1.9)/2.4 (1.4-4.0) ºYâ,,TMâ¬" æµ`¥TM`¥©'¥ 57 480 13.4 1.1 (0.5-2.4)/1.8 (0.9-3.9) ÕËÊ 19 588 6.9 0.6 (0.1-2.5)/1.8 (0.4-7.5) æ» TM"¬ 644 355 13.1 1.0 À`ß 113 384 5.4 0.4 (0.2-0.9)/0.4 (0.2-1.0) Õ"¬ÿ¡ËÕ¢â"--°"--°..." <20-29 20 23 471 0.0 1.0 343 373 10.8 1.4 (0.9-2.2)/1.1 (0.7-1.8) 30-39 233 324 13.7 1.6 (0.9-2.7)/1.3 (0.7-2.3) 40-49 115 332 14.5 ¬"µâ"«-- Õ¥ å (,¥¬--Ë«ª®­ªì zidovudine) ,,TMâ 452 456 9.2 1.0 ¡à,,TMâ 305 277 15.5 1.7 (1.2-2.5)/0.9 (0.7-1.7) 'Ë¡": ª­¬ÿ°µå®"° «¡' ·­§­ 2541 ¢âÕ --ß°µ«à" ®Ì"«¡Á¥Õ¥¢"« CD4 ¢--ÈæÈ",,°ÿࡺYâµ`¥TMÈÕ­¬­·°--È ®­¡' §à"©'ˬ'Ë 764 ´åµàÕY°"»°å¡``¡µ ¡ËÕª'¬'¬°--§à"©'ˬ 988 ´å µàÕY°"»°å¡``¡µ ´÷Ëߥâæ,,°"»÷°..."°ÿࡺYâªÉ«¬Õ¥ å'Ë¡'»Y¬å°"ßÀ"°À"¬ ,, À--Õ¡`°" (Õß°Õå·­§­ 2539) ®Ì"« CD4 ­¬­·°'˵Ë"°«à",,°ÿà¡ ºYâªÉ«¬TM"«¬ Õ"®ªì "Àµÿ¢Õß°"'Ë®Ì"« CD4 ¥ßª÷ßµË"°«à" 200 ´å µàÕY°"»°å¡``¡µ µ--Èß·µà­¬­·° ËÕß®"° â"µË"°«à" ¢âÕ --ß°µ'Ë¡'§«"¡ --¡æ--å°--§«"¡°â"«Àâ"¢Õß,§ª­°"À÷Ëß ¥â·°à Õ--µ"°" Ì""¬´å¡Á¥Õ¥¢"« CD4 ®"°°"»÷°..."à«¡¬âÕÀ--ß¡ËÕ¡à"¡"'È ´÷Ëߥ⠥Ì"`°",,"­'˪ì à«À÷ËߢÕß°"«`®--¬æÈ" Ì"À--°"»÷°..."§--Èß'È'Ë,ß æ¬""»``"TM¥â¡'¢âÕ Õ«à" °"¥ß¢Õß®Ì"«´å¡Á¥Õ¥¢"« CD4 ,,°ÿà¡ ºYâµ`¥TMÈÕ®"°ª­»¬ ¥â ­âÕ÷ß®Ì"«'Ë --ß°µ¥â,,ª­»Õÿµ "À°¡ HIV/AIDS and Antiretroviral Therapy · 49 ÕTMÕ«'/ Õ¥ å ·­°"--°..."¥â«¬¬"µâ"«-- Õ¥ å 49 Figure 3.1 Decline in CD4 Count by Year of Follow-Up, Siriraj University Hospital, ¿"æ 3.1 °"¥ß¢Õߧà" CD4 µàÕªï ®"°°"Ñ"µ`¥µ"¡¢Õß,ßæ¬""»``"TM ª­»¬ Thailand 450 420 400 L)µ350 /.¡.) 300 278 (´å(cells/ 250 227 209 200 179 µàÕªïcountCD4 150 CD4 100 84 57 50 32 0 0 1 2 3 4 5 6 7 years ªï 'Ë¡": --µ ÿ« 2547 Source: Ratanasuwan 2004. À¡"¬Àµÿ: n = 117; §à"©'ˬ,,°"µ`¥µ"¡ ¥â·°à 48 ¥Õ Note: n = 117; mean follow-up is 48 months. °"µ`¥TMÈÕ«-- ÕTMÕ«',,°ÿà¡ 'ˬߵà"ßÊ Transmission of HIV in Various Risk Groups «`'°" Ì"§--¢Õß°"µ`¥TMÈÕ«-- ÕTMÕ«'--È ¥â--°"Õ`"¬ªìÕ¬à"ߥ' ·­¡'°" The main modes of transmission of HIV are well described and are --÷°«â--Èß,,`°«â"ßÊ Ì"À--ª­»¬,¥¬©æ"­ (°­«ß "" ÿ¢·­ documented both in a broad context and for Thailand in particular °Õß­"¥«`¬" ,,ªïµà"ßÊ; æY®` ·­§­ 2547¢; "§",° 2543) Õ--µ" (MOPH and Division of Epidemiology various years; Phoolcharoen §«"¡ 'ˬß,,°"µ`¥TMÈÕ·¬°µ"¡«`'°"µ`¥TMÈÕ ¥--ß'Ë¥â¢âÕ¡Y®"°ª­ °"å--Ë«,° and others 2004b; World Bank 2000). A range of transmission risks by (Õ¬´å ·­§­, 2540) ¥â· ¥ß«â,,µ""ß 3.2 mode of transmission, drawn from worldwide experience (Royce and others 1997), is presented in table 3.2. µ""ß 3.2 Õ--µ"°"§«"¡ 'ˬß,,°"µ`¥TMÈÕ«-- ÕTMÕ«' ·¬°µ"¡«`'°"µ`¥TMÈÕ Table 3.2 Average Transmission Risk of HIV by Mode of Transmission Mode of transmission «`'°"µ`¥TMÈÕ §«"¡ 'ˬß,,°"µ`¥TMÈÕ Risk of infection Sexual intercourse °"¡'æ» --¡æ--å Female-to-male transmission °"µ`¥TMÈÕ®"°À`ß YàTM"¬ 1111 ,, 700inin÷ß 1 ,,in3000 1 in 700 to 1 in 3,000 Male-to-female transmission °"µ`¥TMÈÕ®"°TM"¬ YàÀ`ß ,, 200 ÷ß 1 ,, 2000 1 in 200 to 1 in 2,000 Male-to-male transmission °"µ`¥TMÈÕ®"°TM"¬ YàTM"¬ ,, 101 ÷ß101to,,116001,600 Fellatio °"¡'æ» --¡æ--å"ߪ"° (Fellatio) ,, 131 ÷ß131to,,117in17 Needles ¢Á¡©'¥¬" Needle stick ·àߢÁ¡©'¥¬" 1 in 200 Needle sharing °",,TMâ¢Á¡à«¡°-- Transfusion of infected blood °"à"¬Õ¥'˵`¥TMÈÕ 1195,, 200 ,,,,150 1 in 150 95 in 100 100 Transmission from mother to infant °"µ`¥TMÈÕ®"°¡"¥" Yàÿµ Without AZT treatment ¡à¡'°"--°..."¥â«¬ AZT 1 in 3­5 With AZT treatment ¡'°"--°..."¥â«¬ AZT Combination ART °",,TMâ¬"µâ"«-- À"¬TM`¥à«¡°-- 1<1 ,, 3-5in 1 in 10 ,, 501 1 ,,<1050 'Ë¡": ª­¬ÿ°µå®"°¢âÕ¡Y¢Õß Õ¬´å ·­§­ 2540 Source: Adapted from Royce and others 1997. 50 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ `ËßÀà"'È §Õ§«"¡ 'ˬß,¥¬--Ë«ª Õ¬à"ß°Áµ"¡ ,,­¥--ÿ§§·â« §«"¡ 'ˬß,¥¬ ©æ"­µàÕ°"µ`¥TMÈÕ«-- ÕTMÕ«' Õ"®º--·ªªÕ¬à"ßÀÁ¥âTM--¥ ,¥¬¢÷ÈÕ¬Yà°--ªí®®--¬ µà"ßʺ ¡º "°--,,®--ßÀ«­'Ë¡',Õ°" --TMÈÕ ®ÿ¥ Ì"§--'Ë ÿ¥ ¥â·°à §«"¡ "¡" ,,°"µ`¥TMÈÕ¢Õßÿ§§'˵`¥TMÈÕ ´÷Ëß¡'§«"¡ --¡æ--åTM`ß«°°--ª`¡"«-- ,,°­· ,À`µ ·­§«"¡ÕàÕÀ«µàÕ°"µ`¥TMÈÕ¢ÕߺYâ'Ë¡',Õ°" --TMÈÕ ´÷Ëß®­ Yß°«à" À"° ÿ§§¥--ß°à"«¡'°"µ`¥TMÈÕ"ß·º®"°æ» --¡æ--åÕ¬Yà·â« ´÷ËߥⷰàºYâ--TMÈÕ®"°°" ¡'æ» --¡æ--å ÀÕTM"¬'Ë¡à¥â¢`ª"¬Õ«--¬«­æ» Õ°®"°'È TMÈÕ«-- ÕTMÕ«'TM`¥ 'Ë·µ°µà"ß°--°Á¡'§«"¡ "¡"'˵à"ß°--,,°"µ`¥TMÈÕ TMà TMÈÕ«-- °ÿ࡬àÕ¬ C ´÷Ëß ¡`¥â·æà°­®"¬,,ª­»¬ °--ªì'˧"¥°--«à" "¡"µ`¥µàÕ¥âßà"¬'Ë ÿ¥ °"--°..."°"µ`¥TMÈÕ©«¬,Õ°" ¥â«¬°"--°..." ÀÕ¡à--°..."¥â«¬¬"µâ"«-- Õ¥ å (ART) ÷ß·¡â®­¡'°",,TMâ¬"µâ"«-- Õ¥ åæ`Ë¡¢÷È,,ª­»°Ì"--ßæ--"µà"ßÊÀ"¬ª­» °"«``®©--¬,§'ËÀ¡"­ ¡·­°"®--¥°"°--,§µ`¥TMÈÕ©«¬,Õ°" (OI) '˧ÿ°§"¡·­ ¡­Áß'Ë°'ˬ«¢âÕß°--TMÈÕ«-- ÕTMÕ«' ¬--ߧߪ쪭¥Á Ì"§--'Ë ÿ¥,,°",,Àâ°"¥Y·ºY⠪ɫ¬®"°TMÈÕ«-- ÕTMÕ«' °"µ`¥TMÈÕ©«¬,Õ°" ·­¡­Áß ¡--°®­`Ë¡µâ,,­¬­«" Õ¬à"ßâÕ¬ 5-7 ªï À--ß®"°'Ë¥â--TMÈÕ«-- ·­°`¥¢÷ÈÕ¬à"ßÿ¥Àâ" ¡ËÕ°"·àßµ--« ¢ÕßTMÈÕ«-- ÕTMÕ«'Õ¬à"ߧ«§ÿ¡¡à¥â--È¢â"Ì""¬­¿Y¡`§ÿâ¡°-- (,§--¥Õå ·­ `ø 2538; ¡Y,´, ´"` ·­ øî`ª å 2540) ¡ËÕÿ§§À÷Ëß ¡'°"µ`¥TMÈÕ ©«¬,Õ°" ÀÕ¡­Áß ´÷Ëߥâ--°"«``®©--¬"ߧ``°ÀÕ¥â°--°"¬¬--®"°ÀâÕß ªØ`--µ`°" ÿ§§¥--ß°à"«Õ«à"ªì,§Õ¥ å °"µ`¥TMÈÕ'ËYâ®--°°--,,"¡¢ÕßTMÈÕ©«¬ ,Õ°" °`¥¢÷È®"°­µà"ßÊ´÷ËßÕ¬Yà,, ¿"æ·«¥âÕ¡¢Õßà"ß°"¬ TMà º`«À--ß ,, ªÕ¥ ÀÕ,,­"ߥ`Õ"À" ´÷Ë߬--ߧ߷ߵ--«Õ¬Yà®°«à"®­Y°°­µÿâ¢÷È¡" ·­®­ °"¬ªìTMÈÕ,§¡ËÕTMÈÕ«-- ÕTMÕ«'¥âÌ""¬­¿Y¡`§ÿâ¡°-- °"µ`¥TMÈÕ,§©«¬,Õ°" ·­¡­ÁßTM`¥µà"ßÊ °«à" 20 TM`¥ ¡'§«"¡ --¡æ--å°-- §«"¡ ËÕ¡¢Õß¿Y¡`§ÿâ¡°--¢--Èÿ·ß TMÈÕ,§©«¬,Õ°" ·­¡­Áßµà"ßÊÀà"'È «¡÷ß ­µà"ßÊ®"°TMÈÕ,§"ßTM'«¿"æTM`¥µà"ßÊ ´÷ËßÕ"®°`¥¢÷È,, ¿"æ·«¥âÕ¡ª­®Ì" «--¢Õߧ" ­¥--§«"¡´--´âÕ°`¥¢÷ȵ--Èß·µà°"µ`¥TMÈÕ«-- ÕTMÕ«'´÷Ëߺ--·ªª,, ·µà­ª­» ·­ ­âÕ,,ÀâÀÁ÷ߧ«"¡·µ°µà"ߢÕßµ--«Ì"°"µ`¥TMÈÕ ´÷Ëߪ­TM"° ¥âºTM`¡"°àÕÀâ"'È ÀÕ¥âæÕ'°§--Èß¡ËÕ¿Y¡`§ÿâ¡°--Y°Ì""¬ ,,ª­»µ­«--µ° ,§®"°TMÈÕ©«¬,Õ°" 'Ëæ¥â¡"°'Ë ÿ¥ ¥â·°à cerebral toxoplasmosis, cryptococal meningitis, cryptosporidium diarrhea, cytomegalovirus (CMV) retinistis, Kaposiûs sarcoma, oesophageal candidiasis ·­ PCP ("´"å ·­§­ 2537; OEY«Õå ·­§­ 1993; ·®«"å ·­§­ 2539; ´`§, µ"åTMÕå ·­ §Õ" 2530) ,,ª­»¬·­ª­»'ˬ"°®"ß--æ¬"°ÕËÊ ËÕß®"°¡'æÈ" ,,°"°`¥µ--«Ì"°"µ`¥TMÈÕÕËÊ'Ë Yß°«à" ®÷ߥâæ,§ cryptococal meningitis, âÕß '¬®"°°"µ`¥TMÈÕ, nonspecific wasting syndrome (,§ºÕ¡), toxoplasma encephalopathy, ·­«--,§ ¥â¡"°°«à" (¥Yµ""ß'Ë 3.3) (®` ·­§­ 2537; ÕTMÕ«'/ Õ¥ å ·­°"--°..."¥â«¬¬"µâ"«-- Õ¥ å 51 µ""ß 3.3 §«"¡TMÿ°¢Õß,§µ`¥TMÈÕ©«¬,Õ°" "ß,§,,ÕÕ µ'¬ Õ`¥'¬ ¬ À--Õ¡`°" ·­ ´"Õ'å 2541 °"µ`¥TMÈÕ,§©«¬,Õ°" ÕÕ µ'¬ Õ`¥'¬ ¬ À--Õ¡`°" ´"Õ'å Candidiasis 30 40-60 40 25 Cytomegalovirus 30 10 13 Cryptococcus 5-10 <2-510 20 1357 20 Pneumocytosis carinii pneumonia 30-50 2-5 15-20 65 < 2 % Penicilliosis ¡àª"°Ø 5-25 ¡àª"°Ø ¡àª"°Ø Toxoplasmosis 52 5 10 Tuberculosis 103 45-65 30-40 53 40 'Ë¡" : UNAIDS 2541 ·TMÁ§,° ·­§­ 2538; OE`", ¥YªÕßµå ·­ »`` --" 2541; ´°--ªµâ", ", ·­ ¥``«" 2537; Õ--`§`TM--·­§­ 2536) ­¬­«"µ--Èß·µà°"«``®©--¬«à"ªìÕ¥ 媮÷ß '¬TM'«`µ ®­¢÷ÈÕ¬Yà°--TM`¥¢Õß°" µ`¥TMÈÕ,§©«¬,Õ°" (OI) «¡--Èß°"¥Y·--°..."·­°"ªØ`--µ`µÕ¬à"ߧàߧ--¥¢Õß ºYâªÉ«¬µ"¡«`'°"ªÑÕß°--·­--°...",§'Ë°Ì"À¥«â °"­ÿ°Õ«",¥¬©æ"­ Ì"À--°"¡'TM'«`µÕ¥µ--Èß·µà¥â--°"«``®©--¬«à"ªìÕ¥ å--È ¥â°"¬ªìª­¥Á'Ë¡' §«"¡°'ˬ«æ--°--âÕ¬ß ¡ËÕºY⧠"¡"¢â"÷ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¥â ¡"°¢÷È Õ¬à"ß°Áµ"¡ «`'°"ªÑÕß°--¢--ȵâ Ì"À--°"µ`¥TMÈÕ,§©«¬,Õ°" --È ¬--ß §ßªì°¬ÿå'Ë Ì"§--'Ë ÿ¥'ˬ--ߧߥÌ"`Õ¬Yà·­ª­ §«"¡ Ì"Á® ,,°",,À⧫"¡ ¥Y··°àºYâªÉ«¬¥â«¬,§'Ëæ--"¡"®"°TMÈÕ«-- ÕTMÕ«' Ì"À--ª­»¬--È °àÕ Àâ"'È¥â¡'°"¡Õß«à" ¬--ß¡à¡'°"¬Õ¡--"¢Õß«`'°"ªÑÕß°--,§Õ¬à"ßæ'¬ßæÕ --˧հ"ªÑÕß°--,§· PCP Prophylaxis "¡"§Õ§ÿ¡¥âæ'¬ßâÕ¬°«à" âÕ¬­ 50 ¢ÕߺYâªÉ«¬'Ë¡'TMÈÕ«-- ÕTMÕ«'ªì«°·­¥â--°"¥Y·,¥¬§Õ¢à"¬ºY⠪ɫ¬Õ¥ å·Ààߪ­»¬ (Thai Network of People Living with AIDS) ´÷Ëߪì Õߧå°æ--"Õ°TM («` 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¡ËÕ¡'TMÈÕ«--,§´÷Ëß°`¥¢÷È·µà¬--ß¡à¥â--°" «``®©--¬Õ¬Yà Õ"®Ì",,Àâ°`¥,§·°´÷Ëߧÿ°§"¡µàÕTM'«`µ Õ--ËÕß¡"®"°,§'Ë°'ˬ«°--°" â"ß¿Y¡`§ÿâ¡°--,,À¡à ´÷Ëߧ"¥«à"®­°`¥¢÷È÷ßâÕ¬­ 35 ¢ÕߺYâªÉ«¬'Ë`Ë¡--°"--°..."¥â«¬ ¬"µâ"«-- Õ¥ å ,¥¬¡'§à" CD4 µË"°«à" 50 ´åµàÕY°"»°å¡``¡µ °"»÷°..." §--Èß Ì"§--®"°,ßæ¬""«ßÕ°°"ß (Central Chest Hospital) ´÷ËßÕ¬Yà,,°â °ÿßæoe ¥âº¬÷ߢâÕ¡Y'Ëà"À«--Ë°'ˬ«°--°"µ`¥TMÈÕà«¡°--¢ÕßTMÈÕ«-- ÕTMÕ«' ·­«--,§ (Punnutok ·­§­ 2543) ,,°"»÷°..."¥--ß°à"« ´÷Ëߥâ®--¥Ì",,TMà«ß æ.». 2538-2539 ¥â¡'°"æ`®""æËÕ,,ÀâºYâªÉ«¬'Ë¥âß­'¬,,À¡à®Ì"« 2,587 "¬ ´÷Ëß ß --¬«à"®­ªì«--,§ªÕ¥ ¥â¢â"--°"µ«®§--¥°ÕßTMÈÕ«-- ÕTMÕ«' ,, ¥"ºYâªÉ«¬®Ì"« 1,091 "¬ ´÷Ëߥâ--°"¬¬--«à"ªì,§ æ«à" ¡'Õ--µ"°"·æà °­®"¬¢ÕßTMÈÕ«-- ÕTMÕ«'÷ßâÕ¬­ 22 ·­¡ËÕ¥âÌ"ºYâªÉ«¬Àà"--È¡"ª'¬'¬ °--ºYâªÉ«¬«--,§'Ë¡à¡'TMÈÕ«-- ÕTMÕ«' ºYâ¥Ì"`°"»÷°..."¥âæ«à" ºYâªÉ«¬«--,§'Ë¡' TMÈÕÕTMÕ«'¡'·«,â¡'Ë®­ªì«--,§'Ë¥ÈÕ¬"ª­¿ isonizid (âÕ¬­ 10.9 ¡ËÕ '¬°--âÕ¬­ 3.5) ·­«--,§'Ë¥ÈÕ¬"À"¬TM`¥ ( multidrug-resistant TB) ¥â ¡"°°«à" (âÕ¬­ 5.2 ¡ËÕ'¬°--âÕ¬­ 0.4) --Ë§Õ °"§âæ¥--ß°à"« ¥â Õ «à" «--,§'Ë¥ÈÕ¬"À"¬TM`¥ ( multidrug-resistant TB>MDR-TB) Õ"®æ--"¢÷È,, °ÿࡺYâªÉ«¬«--,§'Ë¡'TMÈÕ«-- ÕTMÕ«' ·â«®÷ß°­®"¬ª YàºYâ'Ë¡à¡'TMÈÕ«-- ÕTMÕ«' ¥--ß--È ,¬"¬¢Õߪ­»¬ ,,°",,Àâ°"--°..."«--,§,¥¬°"Ñ" --ß°µ,¥¬µß ´÷Ëߥâ--°"ÕÕ°·¡"æËÕ,,Àâ¡'°"ªØ`--µ`°"--°..."«--,§ Yß ÿ¥ ·­æËÕ¥°" æ--"«--,§·¥ÈÕ¬"À"¬TM`¥ (MDR-TB) ®÷ß¡'§«"¡ Ì"§--¬`Ëߢ÷ȪÕ'° Ì"À-- ºYâªÉ«¬«--,§'˵`¥TMÈÕÕTMÕ«' §--Ë«ª¡--°§`¥«à" §«"¡·µ°µà"ß,,°"ª"°Ø¢Õß,§Õ¥ å,,ª­»'Ë¡'§«"¡ ¬"°®TM`ß--æ¬"° ¡ËÕª'¬'¬°--ª­»µ­«--µ°·â« à«À÷Ëß ¡"®"°ºY⠪ɫ¬¡à°'Ë"¬ ´÷Ëß¡'TM'«`µÕ¥®"°§«"¡®ÁªÉ«¬®"°Õ¥ å,,­¬­·° ®¿Y¡`§ÿâ¡°--Y° Ì""¬ª¡"°æÕ'Ë®­¡'ªØ`°``¬"µàÕ CMV ÀÕ MAC ¥--ß--È §«"¡·æàÀ"¬,,°" ¥Ì"`°"·°·´ßÕ¬à"ß'¬ßà"¬ TMà ,,TMâ¬" trimethoprim-sulfamethoxazole æËÕ ªì«`'°"ªÑÕß°--· PCP ®÷ß¡'ºÕ¬à"ßÀÁ¥âTM--¥ ,,°"Ì",,Àâ°`¥ PCP TMâ"ß ´÷Ëß PCP --È ÕªìÕ"°"'ËÌ",,Àâ "¡"àßTM'È«à"ªìÕ¥ å,,­¬­·°¥â¡"°'Ë ÿ¥ ·­ ¥--ß--È ®÷ß àߺ,,Àâ,Õ°" ,,°"¡'TM'«`µÕ¥ Yߢ÷È (OEY«Õå ·­§­ 1993) Õ¬à"ß °Áµ"¡ °"ªÑÕß°-- PCP ¡à "¡"¬--¬--Èß°"Ì""¬Õ¬à"ß¡àÀ¬ÿ¥¬--ÈߢÕß­¿Y¡` §ÿâ¡°--,¥¬ `ÈTM`ß ·­ "¡"¬¥TM'«`µÕÕ°ª¥âæ'¬ß,,­¬­ --Èà"--È «`'°"¥'¬« 'Ë®­À¬ÿ¥ ÀÕTM­Õ§«"¡°â"«Àâ"¢Õß,§Õ--°`¥®"°TMÈÕ«-- ÕTMÕ«'¥â §ÕªÑÕß°-- °"·àßµ--«¢Õß«-- ´÷ËߪìªÑ"À¡"¬¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (ART) ÕTMÕ«'/ Õ¥ å ·­°"--°..."¥â«¬¬"µâ"«-- Õ¥ å 53 º¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (ART) µàÕ°"¡'TM'«`µÕ¥ ªì'Ë"°--«à" ­¬­«"´÷ËߺYâµ`¥TMÈÕÕTMÕ«'®­µâÕߺà"µ--Èß·µà¡ËÕ¡'°"µ`¥TMÈÕ,, ­¬­·° ª®÷ß°"¡'Õ"°"¢--È·°¢Õß,§ ·­÷ß°" '¬TM'«`µ «¡--Èß°"µÕ Õß´÷Ëßÿ§§¥--ß°à"«¡'µàÕ°"--°..."--È ®­¡'§«"¡·µ°µà"ß°--ªÕ¬à"ß Yß ·­¢÷ÈÕ¬Yà °----°...­¢Õßÿ§§ TMÈÕ«-- Yµ¬"'Ë,,TMâ--°..." «¡--Èß`"ß --ߧ¡ à« `Ëß´÷Ëß ªì'Ë"°--âÕ¬°«à" ·µà°Á¡'§«"¡ Ì"§--Õ¬à"ßà"'¬¡°--µàÕ°"§"¥§­º¢Õß ,¬"¬°"--°..." ¥â·°àº°­¢Õßµ--«·ªÀà"--È 'Ë¡'µàÕ§«"¡,â¡Õ'¬ß¢Õß ÿ§§'Ë®­· «ßÀ"°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ·­ªØ`--µ`µ"¡«`'°"--°..." ¥--ß°à"«Õ¬à"ߧàߧ--¥À--ß®"°'Ë¥â`Ë¡µâª·â« ¿"§º«° ° ¥â ÿª÷ߢâÕ¡YTM`ß ª­®--°...å'Ë¡'Õ¬Yà,,¢­'Ë¢'¬"¬ß"°'ˬ«°--§«"¡ --¡æ--å­À«à"ßµ--«·ªÀà"--È ·­§«"¡°â"«Àâ"¢Õß,§ «¡--Èß°'ˬ«°--°­«°"'Ë¡'§«"¡´--´âÕ"ߥâ" §`§ ´÷Ëß"¥âª­¡`÷ßYª·Àà"--È ®"°¢âÕ¡Y'Ë¡'Õ¬Yà·­®"°§«"¡§`¥ÀÁ¢Õß ºYâTM'ˬ«TM" 'È ®­¥âTM૬ --ߧ"­Àå°"À"Õ¥--ß°à"« æËÕºYâÕà"'Ë¡à¡'§«"¡Yâ¥â" §`§¡"°--° æËÕ§"¥°"å¿"¬,,µâ"ßÕ°TM`ß,¬"¬"ߪ­°" "¥â,,TMâ ¡¡µ`"· '¬ßà"¬°'ˬ«°--°"· «ßÀ"°"--°..." °"¥Ì"`°"--°..."Õ¬à"ßµàÕËÕß ·­°"¡' TM'«`µÕ¥ µ"¡'Ë¥â--Õ``æ®"°µ--«·ªÀ"¬ª­°" ,¥¬µ--«·ª "¡ª­°",,°ÿà¡ 'ȥⷰà: ë °"--°..."--È`Ë¡µâ§àÕ¢â"ßÁ« (,,®ÿ¥'˪`¡" CD4 Õ¬Yà­À«à"ß 50-200 ´åµàÕY°"»°å¡``¡µ) ÀÕ§àÕ¢â"ßTMâ" (,,®ÿ¥'˪`¡" CD4 Õ¬Yà'Ë 50- 200 ´åµàÕY°"»°å¡``¡µ ÀÕµË"°«à") ë °",,Àâ°"--°..."--È ¥â--°" àß `¡,¥¬°"¡'°ÿࡺYâµ`¥TMÈÕ«-- ÕTMÕ«'·­ºY⠪ɫ¬Õ¥ å (PHA) 'Ë¡'ª­ ``¿"æÀÕ¡à ë ºYâªÉ«¬--È ¥â--°"Ì"--¥,,­¬­·° ÀÕ­¬­'Ë Õß2 ¿"æ 3.2 --Èß ÕßµÕ · ¥ß÷ß°"°Ì"À¥--°...­ Ì"À--§Ì"¬"¬·­§«"¡§`¥ ÀÁ®"°ºYâTM'ˬ«TM""ߥâ"§``° °'ˬ«°--Õ--µ" à« ­ ¡¢ÕߺYâªÉ«¬'ËÀ¬ÿ¥,,TMâTMÿ¥¬" æËÕ°"--°..." ¡à«à"®­¥â«¬°"À¬ÿ¥°"--°..."ª¬ ÀÕ Ì"À--ºYâªÉ«¬'Ë--°"Ì"--¥ ,,¢--È·° Õ"®ª'ˬ®"°°"--°...",,¢--È·°ª¬--ß°"--°...",,¢--È'Ë Õß ¿"æ (°) · ¥ß÷ßYª·¢ÕߺYâªÉ«¬,¥¬--Ë«ª ´÷Ëß`Ë¡°"--°..."TMâ" à«¿"æ (¢) · ¥ß÷ßYª ·¢ÕߺYâªÉ«¬´÷Ëß`Ë¡µâ°"--°..."¥âÁ« ,¥¬ Õß,, 'ËYª·¿"¬,,·µà­¿"æ ®­ · ¥ß÷ßYª·,,°"¬ÿµ`°"--°..."'Ë¥âµ--Èß ¡¡µ`"«â Ì"À--ºYâªÉ«¬·µà­"¬'Ë¢â" --°"--°..."¥â«¬¬"µâ"«-- Õ¥ å®"°,ßæ¬""-- --Èß,,­¬­·°·­­¬­'Ë Õß ,¥¬·°¢«"ß®­«--¥­¬­«"µ--Èß·µà`Ë¡µâ¢Õß°"--°..."ª­¿--È ËÕß®"°ºYâªÉ«¬ ,¥¬--Ë«ª®­`Ë¡µâ°"--°..."­¬­'Ë ÕßÀ"¬ªïÀ--ß®"°'Ë¥â--°"--°..."­¬­·° ¥--ß--È Õ--µ"°"Õ¥TM'«`µ'ËâÕ¬ß'È à«À÷Ëß ®÷ßÕ`"¬¥â¥â«¬®Ì"«ªï'Ë®ÁªÉ«¬ªì «""¢÷È 54 54 · TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ Figure 3.2 Persistence Assumptions for Patients Receiving Public and Augmented Public ¿"æ 3.2 ¡¡µ`"¢Õß°"§ß°"--°..."µàÕª Ì"À--ºYâªÉ«¬'Ë--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,, ART "æ¬""¢Õß--'Ë¡'`°" `¡æ`»... (°)(a)or ºYâªÉ«¬--Ë«ª Typical patients ÀÕ 1 survive 0.9 °"--°..." who 0.7 dropping 0.8 not ·µà¬--ß¡'TM'«`µÕ¬Yà..." 0.6 0.5 those 0.4 of regimens 0.3 0.2 0.1 0 proportion switching Õ--µ" à«¢ÕߺYâ'Ë¡à¥ââ¡`° ¡à¥âª'ˬ Yµ¬"'Ë--° 0 10 20 30 40 50 years from start of treatment ®"«ªïµ--Èß·µà`Ë¡°"--°..." ¬--ߧß--°...",, "æ¬""-- ,¥¬¢â"--°"--°..."¢--È·°¥âTMâ" publicpersistence,latefirstline ¬--ߧß--°...",, "æ¬""--'Ë¡'`°" `¡ ,¥¬¢â"--°"--°..."¢--È·°¥âTMâ" augmentedpublicpersistence,latefirstline ¬--ߧß--°...",, "æ¬""-- ,¥¬¢â"--°"--°..."¢--È'Ë ÕߥâTMâ" publicpersistence,latesecondline ¬--ߧß--°...",, "æ¬""--'Ë¡'`°" `¡ ,¥¬¢â"--°"--°..."¢--È'Ë ÕߥâTMâ" augmentedpublicpersistence,latesecondline (¢)(b)ºYâªÉ«¬'Ë¢â"--°"--°..."Á«°`ª Patients who begin too early ÀÕ or 1 survive 0.9 0.8 °"--°..." dropping who 0.7 not ·µà¬--ß¡'TM'«`µÕ¬Yà..." 0.6 0.5 those 0.4 of regimens 0.3 0.2 0.1 switching 0 Õ--µ" à«¢ÕߺYâ'Ë¡à¥ââ¡`° ¡à¥âª'ˬ Yµ¬"'Ë--° proportion 0 10 20 30 40 50 years from start of treatment ®"«ªïµ--Èß·µà`Ë¡°"--°..." publicpersistence,earlyfirstline ¬--ߧß--°...",, "æ¬""-- ,¥¬¢â"--°"--°..."¢--È·°¥âÁ« augmentedpublicpersistence,earlyfirstline ¬--ߧß--°...",, "æ¬""--'Ë¡'`°" `¡ ,¥¬¢â"--°"--°..."¢--È·°¥âÁ« publicpersistence,earlysecondline ¬--ߧß--°...",, "æ¬""-- ,¥¬¢â"--°"--°..."¢--È'Ë ÕߥâÁ« augmentedpublicpersistence,earlysecondline ¬--ߧß--°...",, "æ¬""--'Ë¡'`°" `¡ ,¥¬¢â"--°"--°..."¢--È'Ë ÕߥâÁ« 'Ë¡": ºYâ¢'¬ Source: Authors. care. Because the typical patient on second-line therapy would be starting after several years of first-line therapy, the less successful sur- À--ß®"°'È ®÷ß°Ì"À¥ â,§âߢÕß°"¡'TM'«`µÕ¥ ´÷ËߪìßËÕ¢ Ì"À--ºYâªÉ«¬'Ë vival is partly explained by these extra years of sickness. ¡`¥â¬ÿµ`°"--°..." ÀÕ,,°'¢ÕߺYâ'Ë¥â--°"--°...",,­¬­·° À¡"¬÷ߺYâ'Ë¡`¥â¢â" --°"--°...",,­¬­'Ë ÕßµàÕ ¿"æ 3.3 --Èß Õß à« · ¥ß÷ß ¡¡µ`"¢Õß"°'ˬ« °--°"¡'TM'«`µÕ¥Õ¬à"ß¡'ßËÕ¢¢ÕߺYâªÉ«¬ ´÷Ëß¡`¥â¬ÿµ`°"--°..."ÀÕª'ˬª--°" A survival curve can then be defined that is conditional on patients not dropping out of treatment or, for those on first-line therapy, not moving on to second-line therapy. The two panels of figure 3.3 display --°...",,¢--È'Ë Õß ¿"æ (°) · ¥ß÷ßYª·,,°"¡'TM'«`µÕ¥ Ì"À--ºYâªÉ«¬'Ë`Ë¡°" our assumptions regarding the conditional survival of patients who do --°..."TMâ" §Õ¡ËÕª`¡" CD4 ¡'§à"ÀÕæ'¬ß 50 ´åµàÕY°"»°å¡``¡µ ÀÕ not drop out or move on to second-line therapy. Panel (a) gives the sur- µË"°«à"--È ¿"æ (¢) · ¥ßYª·,,°"¡'TM'«`µÕ¥ Ì"À--ºYâ'Ë`Ë¡°"--°..."¥âÁ« ÕTMÕ«'/ Õ¥ å ·­°"--°..."¥â«¬¬"µâ"«-- Õ¥ å HIV/AIDS and Antiretroviral Therapy · 55 55 Yª·--Èß 'Ë,,·µà­¿"æ vival patterns for patients who begin late, when their CD4 counts are 50 ®­· ¥ß ¡¡µ`" Ì"À--«`'°"--°..."¢Õß----Èß Õß«`' ·­ Ì"À--°"Ì"--¥,,¢--È·°·­¢--È'Ë Õß Ì"À--¿"æ 3.2 ,Õ°" Õ¥TM'«`µ'Ë¡' cells per cubic millimeter or below. Panel (b) gives the survival patterns âÕ¬°«à"¢ÕߺYâ¢â"--°"--°...",,¢--È'Ë Õß--È à«À÷ËßÕ`"¬¥â¥â«¬®Ì"«ªï'Ë®Á for early starters. The four patterns within each panel give the assump- ªÉ«¬´÷Ë߬"«"¢÷È ·­µâÕß '¬ª°--°"--°..."¢--È·°'Ë⪭ ``¿"æ Yª·¥--ß tions for the two public modes of treatment and for first-line and °à"« · ¥ßÕ¬à"ßTM--¥®÷ߧ«"¡ Ì"Á®'Ë¡"°¢÷È¥--ß'˧"¥«â°àÕ ®"°°"--°...",¥¬ second-line therapies. As for figure 3.2, the less successful survival of ¿"§-- ¡ËÕ¥â--°"¢¬"¬º¥â«¬°" -- ÿ®"°°ÿࡺYâªÉ«¬Õ¥ å ´÷ËßÕÌ"«¬§«"¡ those on second-line therapy is partly explained by the extra years of ­¥«°·°àºYâªÉ«¬æËÕ,,Àâ "¡"ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥ sickness already spent on ineffective first-line therapy. The patterns clearly show the greater presumed success of public therapy when it is ºYâªÉ«¬'ËÕ°--°"--°...",,¿"æÕ°TM,,ª­»¬--È Õ«à"ªìªµ"¡Yª · Ì"À--°"¥Ì"`°"--°..."µàÕªÕ¬à"ßµàÕËÕß·­,,°"¡'TM'«`µÕ¥ TMà¥'¬« augmented by a supportive PHA group that facilitates patient adherence. ¿"æ 3.3 ¡¡µ`"¢Õß°"¡'TM'«`µÕ¥ Ì"À--ºYâªÉ«¬'Ë--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,, " æ¬""¢Õß--'Ë¡'`°" `¡æ`»... Figure 3.3 Survival Assumptions for Patients Receiving Public and Augmented Public ART (°)(a)ºYâªÉ«¬'Ë`Ë¡°"--°..."¥âTMâ" Patients who begin late ÀÕ or 1 survive 0.9 °"--°..." dropping 0.8 who 0.7 not ·µà¬--ß¡'TM'«`µÕ¬Yà..." 0.6 0.5 those 0.4 of regimens 0.3 0.2 0.1 switching 0 Õ--µ" à«¢ÕߺYâ'Ë¡à¥ââ¡`° ¡à¥âª'ˬ Yµ¬"'Ë--° proportion 0 10 20 30 40 50 years from start of treatment ®"«ªïµ--Èß·µà`Ë¡°"--°..." ¬--ߧß--°...",, "æ¬""-- ,¥¬¢â"--°"--°..."¢--È·°¥âTMâ" publicsurvival,latefirstline ¬--ߧß--°...",, "æ¬""--'Ë¡'`°" `¡ ,¥¬¢â"--°"--°..."¢--È·°¥âTMâ" augmentedpublicsurvival,latefirstline ¬--ߧß--°...",, "æ¬""-- ,¥¬¢â"--°"--°..."¢--È'Ë ÕߥâTMâ" publicsurvival,latesecondline ¬--ߧß--°...",, "æ¬""--'Ë¡'`°" `¡ ,¥¬¢â"--°"--°..."¢--È'Ë ÕߥâTMâ" augmentedpublicsurvival,latesecondline (¢)(b)ºYâªÉ«¬'Ë¢â"--°"--°..."Á« Patients who begin early ÀÕ or 1 survive 0.9 °"--°..." dropping 0.8 0.7 not ·µà¬--ß¡'TM'«`µÕ¬Yà..." who 0.6 0.5 those 0.4 of regimens 0.3 0.2 0.1 proportion switching 0 Õ--µ" à«¢ÕߺYâ'Ë¡à¥ââ¡`° ¡à¥âª'ˬ Yµ¬"'Ë--° 0 10 20 30 40 50 years from start of treatment ®"«ªïµ--Èß·µà`Ë¡°"--°..." publicsurvival,earlyfirstline ¬--ߧß--°...",, "æ¬""-- ,¥¬¢â"--°"--°..."¢--È·°¥âÁ« augmentedpublicsurvival,earlyfirstline ¬--ߧß--°...",, "æ¬""--'Ë¡'`°" `¡ ,¥¬¢â"--°"--°..."¢--È·°¥âÁ« publicsurvival,earlysecondline ¬--ߧß--°...",, "æ¬""-- ,¥¬¢â"--°"--°..."¢--È'Ë ÕߥâÁ« augmentedpublicsurvival,earlysecondline ¬--ߧß--°...",, "æ¬""--'Ë¡'`°" `¡ ,¥¬¢â"--°"--°..."¢--È'Ë ÕߥâÁ« 'Ë¡": ºYâ¢'¬ Source: Authors. 56 · TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand 56 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ Patients who choose private sector care in Thailand are assumed to follow persistence and survival patterns identical to those that they °--Yª·'Ë®­µâÕß°­Ì"À"°¢â"--°"--°...",,¿"§--'Ë¥â--°" àß `¡ ¥--ß--È would follow with augmented public care, hence obviating the need ®÷ßÌ",,Àâ¡à®Ì"ªìµâÕß· ¥ßYª·¥--ß°à"«,, Õß¿"æ'È §­ºYâ®--¥Ì""¬ß" TMËÕ for the display of such patterns in the two figures. The report team «à" ¡¡µ`"'È ¡Àµÿº ËÕß®"°°"--°..."¢Õß¿"§Õ°TM à«,,Àà,,ª­»¬ believes that assumption is plausible because most private treatment in --È §àÕ¢â"ß®­¡'§ÿ¿"æ Yß ·­ËÕß®"°ºYâªÉ«¬´÷ËßµÁ¡,,®·­ "¡"®à"¬§à"--°..." Thailand is of relatively high quality and because the patients who are ¥â«¬¬"µâ"«-- Õ¥ å,,¿"§Õ°TM--È ,¥¬--Ë«ª·â« ®­¡'·ß®Yß,,®·­§«"¡ willing and able to pay for private ART typically have the motivation -- ÿ"ß --ߧ¡æÕ'Ë®­ "¡"Ì",,ÀâªØ`--µ`µ"¡«`'°"--°..."¥âÕ¬à"ߧàߧ--¥,, and the social support to achieve high levels of adherence. Further- ­¥-- Yß ¬`Ëߪ°«à"--È ,,¢­'Ë¡'°"·¢àߢ-- Yߢ÷È®"°­°"--°..."¢Õß¿"§--'Ë more, in the face of growing competition from the augmented public ¡'°"æ`Ë¡µ`¡--È ºYâ,,Àâ`°"¿"§Õ°TM 'Ë¡'Õ--µ"§«"¡ Ì"Á®´÷ËߥYÀ¡Õ®­µË"--È system, private caregivers with low perceived success rates will fail to ®­¡à "¡"¥÷ߥY¥ºYâªÉ«¬¥â attract patients. ®"°§«"¡´--´âÕ¢Õß"ßÕ°Àà"--È °"§Ì"«,¥¬µß ¡àÕ"®,,Àâ§Ì"µÕµàÕ §Ì""¡æÈ"¥âÕ¬à"ßßà"¬¥"¬ --˧աËÕ¡'§«"¡ªìª¥â'Ë®­¡'°" '¬TM'«`µ ¬°`° Because of the complexity of those options, direct computation does not easily yield an answer to this basic question: given the possi- °"--°..." ÀÕ§ËÕª Yà°"--°...",,¢--È'Ë Õß ´÷ËߺYâªÉ«¬Õ"®¬°`°°"--°..."Õ'° bilities of dying, dropping out, or moving to second-line therapy, §--Èß ÀÕÕ"® '¬TM'«`µ¥â Yª·¢Õß°"¡'TM'«`µÕ¥,¥¬--Ë«ª¢ÕߺYâªÉ«¬'Ë`Ë¡--°" where the person might again drop out or die, what is the overall --°..."¥â«¬¬"µâ"«-- Õ¥ å (ART) ®­ªìÕ¬à"ß «`''Ë¥''Ë ÿ¥'Ë®­TM૬,,Àâ--§Ì"µÕ likely survival pattern of an individual who begins ART? The best way --È ¥â·°à°",,TMâ·®Ì"ÕߢÕß,§­"¥,,ÕTM'¬ (Asia Epidemic Model>AEM) to derive such an answer is to use the Asian Epidemic Model (AEM) æËÕª­°ÕYª·¢÷È¡"®"°§«"¡ªìª¥â--ÈßÀ¡¥ ´÷Ëß"Ì"TMà--ȥ⫬°" to assemble a pattern from all the possibilities. We do so by compar- ª'¬'¬°"§"¥§­¢Õß AEM Ì"À-- â"¢Õß"--È§Õ ¡'°"--°..."¥â«¬¬" ing the predictions of the AEM for our baseline--where there is very µâ"«-- Õ¥ åâÕ¬¡"° °--°"§"¥§­®"° ¡¡µ`"'¬¡´÷Ëß â"ߢ÷È¡"ªì little ART--with the predictions from a specially constructed artificial æ`»... ,¥¬,,Àâ°ÿࡺYâªÉ«¬°ÿà¡À÷Ëß`Ë¡--°"--°...",, æ.». 2545 --Èß'È º'˥⠮­ scenario in which a single cohort of patients begins treatment in 2002, · ¥ß«â,,¿"æ 3.4 but new treatment starts revert to baseline levels in subsequent years. By comparing those two scenarios, we estimate the survival of the patients in that single 2002 cohort. Figure 3.4 presents the results. ¿"æ 3.4 °"¡'TM'«`µÕ¥¢Õß°ÿࡺYâªÉ«¬ 'Ë¥â--°"--°..."¥â«¬ Yµ¬" Ì"À--°"--°..."¢--È·°·­¢--È'Ë Figure 3.4 Survival of a Model Cohort of Patients across First-Line and Second-Line Õß ¡ËÕºYâªÉ«¬Àà"'È ¥â--°"TM--°®Yß,,Àâ¢â"--°"--°..."¥âÕ¬à"ßÁ« ÀÕÕ¬à"ßTMâ" Treatment Regimens If They Are Recruited Early or Late 1.0 0.9 0.8 ¡'TM'«`µÕ¬Yà surviving 0.7 0.6 cohort 0.5 °ÿࡺYâªÉ«¬'Ë of 0.4 0.3 0.2 Õ--µ" à«¢Õß proportion 0.1 0 2003 2546 2548 252007 252009 252011 2552013 252015 252017 252019 252021 252023 252025 2005 50 52 54 6 58 60 62 64 66 68 earlyrecruitment ¢â"--°"--°..."¥âÁ« ¢â"--°"--°..."¥âTMâ" laterecruitment 'Ë¡": ºYâ¢'¬ Source: Authors. ÕTMÕ«'/ Õ¥ å ·­°"--°..."¥â«¬¬"µâ"«-- Õ¥ å 57 ¥--ß'˧"¥«â®"°¢âÕ¡Y'Ë,,TMâ,,·®Ì"Õß ª­ °"å,,°"¡'TM'«`µÕ¥--È ®­¥' °«à"Õ¬à"ßÀÁ¥âTM--¥ Ì"À--ºYâªÉ«¬'Ë¥â¢â"à«¡,§ß°"¥âÁ« §Õ¡ËÕª`¡" CD4 Õ¬Yà ­À«à"ß 50-200 ´åµàÕY°"»°å¡``¡µ ¡"°°«à"ºYâªÉ«¬'Ë¢â"à«¡,§ß°"¥âTMâ" §Õ¡ËÕª`¡" CD4 Õ¬Yà'Ë 50 ´åµàÕY°"»°å¡``¡µ ÀÕµË"°«à" Õ°®"°'È ¡ËÕµ--¥ â,§âß·Ààß°"¡'TM'«`µÕ¥ÕÕ°,, æ.». 2568 ÀÕ,,ªï'Ë 23 "®­ "¡" ª­¡` ­¬­«",,°"¡'TM'«`µÕ¥,¥¬©'ˬ Ì"À--ºYâ¢â"à«¡,§ß°"µ--Èß·µà·°·­ ,,­¬­À--ß à«°"¡'TM'«`µÕ¥æ`Ë¡µ`¡,¥¬©'ˬ ´÷Ëß`Ë¡µ--Èß·µà«"'Ë`Ë¡°"--°..." ·­¡ËÕª'¬'¬°--°"'Ë¡à¥â--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å Ì"À--ºYâ'Ë¢â" à«¡,§ß°",,­¬­·° ¥â·°à 10.3 ªï ¡ËÕª'¬'¬°--­¬­«" 8.0 ªï ¢ÕߺY⠪ɫ¬'Ë¢â"à«¡,§ß°"´÷Ëß¡'§à" CD4 '˵Ë"°«à" ¥--ß--È Ì"À--ºYâªÉ«¬"¬,,À¡àÿ°§'Ë ¥â--°"TM--°TM«,,Àâ¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å·â« ®÷ßà"°--«à"·µà­§ ·­ --ߧ¡,¥¬«¡ ¥â¡'TMà«ß«"'Ë®­¡'TM'«`µÕ¬Yàæ`Ë¡¢÷È ,,°"µ'§«"¡µ--«¢Àà"'È "®Ì"¥â«à"ºYâªÉ«¬´÷Ëߢâ"à«¡,§ß°"¥âÁ« ®­¡'«" ª­¡" 18-30 ¥Õ°àÕ '¬TM'«`µ ,,¢­'˺Yâ'Ë¢â"à«¡,§ß°"'À--ß ®­¡'«" ª­¡" 6-12 ¥Õ°àÕ '¬TM'«`µ ¥--ß--È ®÷ߪ­¡`¥â«à" °"¢â"à«¡,§ß°" --°..."¥â«¬¬"µâ"«-- Õ¥ å (ART) ¥âµ--Èß·µà­¬­·° ®­TM૬æ`Ë¡«"Õ'° 10.3 ªï ,,Àâ·°àºYâ'Ëà"®­¡'TM'«`µÕ¬Yà¥â 18-30 ¥Õ à«°"¢â"à«¡,§ß°"--°..."¥â«¬¬"µâ" «-- Õ¥ å¿"¬À--ß ®­TM૬æ`Ë¡«",,ÀâÕ'° 8.0 ªï ®"°«"'˧"¥«à"®­¡'TM'«`µÕ¬Yà¥â¢Õß §°ÿà¡'È --ËÀ¡"¬§«"¡«à" ®"°Yª·¥--ß°à"« ·­¢âÕ ¡¡µ`"'Ë¥âÕ`"¬«â °àÕÀâ"'È ÿ§§'Ë`Ë¡°"--°..."Á«¢÷È Õߪï à"°--«à" ¥âæ`Ë¡«",,Àâ·°àTM'«`µ¢Õß µ¡"°°«à" Õßªï ·­À"°"Õß`ÈßËÕߢÕßÕ--µ" à«¥·­µâÿÕËÊÕ°ÀÕ ®"°«"¢Õßÿ§§--È·â« °"ßÿ--°..."ªì­¬­«" Õߪï--È ¥YÀ¡Õ®­¡'§à" Õ¬à"߬`Ëß®"°¡ÿ¡¡ÕߢÕßÿ§§ --Ë§Õ «" Õߪï¢Õß°"`Ë¡µâ--°..."¥âÁ« Ì",,Àâ "¡"¡'TM'«`µ¬¬"«ÕÕ°ª¥âÕ'° 3 ÀÕ 4 ªï ¡ËÕ"ª­¡`÷ߪ­ ``º"ߥâ"µâÿ¢Õß,¬"¬,,°"--°..."¥â«¬¬" µâ"«-- Õ¥ å·â« "®­,,TMâ­¬­«"'Ë¡'TM'«`µæ`Ë¡¢÷ȵàÕÿ§§´÷Ëß`Ë¡--°"--°..." æËÕªì¡"µ«--¥ºª­,¬TMå'ËÕ`ßÕÿ--µ`°"å ËÕß®"°TMà«ß«"°"¡'TM'«`µæ`Ë¡Õ'° 10.3 ªï ÀÕ 8.0 ªï --È®­æ`Ë¡¢÷È¡ËÕ«"ºà"ª TMà«ß«"¥--ß°à"« ®÷ß®­µâÕßY°º-- ,,Àâªì«"¢ÕßTM'«`µ'货 ,¥¬,,TMâÕ--µ" à«¥'Ë,,TMâ,,°"«`§"­Àå'È TMà À"° µâÿ·­ºª­,¬TMå--È¥ßâÕ¬­ 3 ®Ì"«¢Õß«"'Ë¡'TM'«`µÕ¬Yà´÷Ëßæ`Ë¡¢÷ȵàÕºY⠪ɫ¬"¬,,À¡à'Ë¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ®­°"¬ªì 7.9 ·­ 6.5 ªï ¢Õß°"¡'TM'«`µÕ¥,¥¬µ--¥ à«¥ª·â«µ"¡Ì"¥-- °"®--¥°"¥â"§``° Ì"À--,§Õ--°`¥®"°TMÈÕ«-- ÕTMÕ«',¥¬°"--°..."¥â«¬¬"µâ" «-- Õ¥ å (ART) °"®--¥°"--°..."¥â«¬¬"µâ"«-- Õ¥ å--ȪìËÕß´--´âÕ ·­¡àæ'¬ß·µàµâÕßÕ"»--¬ »--°¬¿"æÕ¬à"ß Yß,,°",,Àâ`°"¥â" ÿ¢¿"æà"--È ·µà¬--ßµâÕߪ­°Õ¥â«¬°",,Àâ§Ì" ª÷°..." °"µ«® Õ ·­`°""ßÀâÕߪØ`--µ`°"µà"ßÊ ®"°§«"¡®Ì"ªìÀà"'È 58 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ °"æ`Ë¡­¥--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (ART) ®÷ß· ¥ß÷ߧ«"¡â""¬,,TM`ß ªØ`--µ`'Ë®`ß®--ßÕ¬à"߬`Ëß §«"¡â""¬Àà"'È¡'Õ¬Yà,, "'Ëÿ°·Ààß ,¥¬©æ"­Õ¬à"߬`Ëß ,, ¿"æ·«¥âÕ¡'ËÕ"®¢"¥·§,§ß¢à"¬æÈ"'Ë®Ì"ªì"ߥâ"°"¬¿"æ·­ ¡ÿ...¬å §«"¡ 'ˬß,,°",,Àâ°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,¥¬¡àªØ`--µ`µ"¡§Ì"·­ Ì"·­¡"µ"'˵°ß°--,,°"¥Y·ºYâªÉ«¬Õ¬à"ߧàߧ--¥ §Õ®ÿ¥'ËÌ",,Àâ°`¥°"¥ÈÕ ¬"À"¬TM`¥¢ÕßTMÈÕ«-- ÕTMÕ«' Õ¬à"ß°Áµ"¡ §«"¡ Ì"Á®¢Õß°"»÷°..."¢--ÈÌ"àÕß ,,·Õø`°"·­"´` · ¥ß,,ÀâÀÁ«à" °"--°..."¥â«¬¬"µâ"«-- Õ¥ å--È Õ"®°­Ì" ¥â¥'æÕ,, "'Ë´÷Ëß¡'--æ¬"°®Ì"°--¥ ·­Õ--µ"°"¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ åÕ¬à"ßµàÕËÕß,,ª­»¬"°®--È Õ"®®­ Yßà" ÀÕ Yß°«à" Õ--µ"'Ëæ¥â,, ª­»'Ë¡'§«"¡Ë"«¬"ß--æ¬"° ,,ª­»¬¡ËÕ`Ë¡¡'°",,TMâ¬" GPO-vir ·¡Á¥¥'¬«--È "ßÕߧå°æ--"Õ°TM (NGOs) ¥â"¬ß"÷ßÕ--µ"¢Õß°" ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥'Ëæ`Ë¡¢÷È®"°°àÕÀâ"'È ´÷Ë߬--ß,,TMâ°"--°..."¥â«¬ µ--«¬"Õ¬à"ߥ'¬«ÀÕ ÕßÕ¬à"ß'˵âÕß--ª­"¬"À"¬¡Á¥ à«"ßÕߧ尷æ¬åâ æ¡·¥ (Medicins sans Frontieres-MSF) ¥â"¬ß"÷ß°"--°..."Õ¬à"ßµàÕËÕß Ì"À--°«à"âÕ¬­ 95 ¢Õß°ÿà¡'˪­°Õ¥â«¬ºYâªÉ«¬°«à" 400 § 'Ë¥â--ª­,¬TMå ®"°§Õ¢à"¬ -- ÿ¢ÕßTMÿ¡TM'Ë¡'°"«"ß,§ß â"ß«â («` --·­øÕå¥ 2547) ,,Ì"Õߥ'¬«°-- °"ª­¡`Õ¬à"ß«¥Á«¡ËÕ¡à"¡"'È ÷ß°"¥Ì"`°"--°..." ¥â«¬¬"µâ"«-- Õ¥ åÕ¬à"ßµàÕËÕß,,°ÿࡺYâªÉ«¬Õ¥ å,,®--ßÀ«--¥TM'¬ß,,À¡à´÷ËßÕ¬Yà"ß µÕÀÕ¢Õߪ­»¬ ´÷ËߥÌ"`°",¥¬°­«ß "" ÿ¢·­ ¿"ª­TM"° ¥â· ¥ß÷ßÕ--µ"°"--°..."Õ¬à"ߧàߧ--¥ª­¡"âÕ¬­ 85 ( "¢"°"·æ¬åTMÿ¡TM ¡À"«`¬"--¬TM'¬ß,,À¡à 2545)3 Õ¬à"ß°Áµ"¡ ¢âÕ¡Y®"°,ßæ¬""»``"TM Õ «à" °"ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥--È ¡àÕ"® ÿª¥â,¥¬Õ--µ,¡--µ` --Ë§Õ ,,°ÿࡺYâªÉ«¬ 122 "¬´÷Ëß`Ë¡°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (,¥¬,,TMâ¬" GPO-vir) ¡'æ'¬ßâÕ¬­ 60 'Ë "¡"--°..."ª`¡"«-- ,,°­· Õ¥'Ë¡àÕ"®µ«®æ¥â À--ß®"° 12 ¥Õ (--µ ÿ« 2547) §«"¡·µ°µà"ß­À«à"ߺ¢Õß,ßæ¬"" ·­º'Ë¥â®"° MSF ·­,,TM'¬ß,,À¡à--È Õ"® ­âÕ÷ß"'Ë Ì"§--¢Õß§Õ ¢à"¬ -- ÿ'Ë¡',§ß â"ß ·­°ÿࡺYâªÉ«¬Õ¥ å¥â«¬°--'Ë®­TM૬,,Àâ¡'ªØ`--µ`µ"¡«`' °"--°..."Õ¬à"ߧàߧ--¥¥â ·­'Ëà" ,,®§Õ Õ--µ"°"ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ß §àߧ--¥¢Õß,ßæ¬""»``"TM--È §â"¬§÷ß°--Õ--µ"'˧"¥«â,,°ÿà¡'Ë¢â"à«¡°" »÷°..." à«,,Àà,,ª­»µ­«--µ° °"«``®©--¬TMÈÕ«-- ÕTMÕ«'·­°"TM--°®YߺYâªÉ«¬æËÕ¢â",§ß°"--°..."¥â«¬¬" µâ"«-- Õ¥ å (ART) °­«--»å,,Õÿ¥¡§µ` Ì"À--°"¥Y·ºYâµ`¥TMÈÕ«-- ÕTMÕ«' §Õ°"«``®©--¬TMÈÕ« -- ÕTMÕ«'¥âµ--Èß·µà,,­¬­·° ·­'Ë¥'°«à"--È §Õà"®­ªìTMà«ß'Ëÿ§§Àà"--Ȭ--ß¡' ÿ¢¿"æ¥' ·­°àÕ'Ë®­¡',Õ°" à"¬Õ¥TMÈÕ«-- ÕTMÕ«'ª¬--ßÿµÀÕºYâ'Ë¡'æ» --¡æ--å¥â«¬ ÀÕ,¥¬ºà""ß°"µ`¥µàÕ¢Õß,À`µ °"«``®©--¬¥--ß°à"« §«®­ ª­°Õ¥â«¬°",,Àâ§Ì"ª÷°..."°'ˬ«°--§«"¡--º`¥TMÕ--Èߥâ" ૵--«·­"ߥâ" "" ÿ¢ À--ß®"°--È ºYâªÉ«¬§«®­¥â--°"µ`¥µ"¡ªìª­®Ì" ®°­--Ëß`Ë¡ ÕTMÕ«'/ Õ¥ å ·­°"--°..."¥â«¬¬"µâ"«-- Õ¥ å 59 æ--"§«"¡®ÁªÉ«¬'Ë°'ˬ«°--TMÈÕ«-- ÕTMÕ«' ÀÕ¡ËÕæ«à"ª`¡" CD4 ¥ßµË" °«à" 200 ´åµàÕY°"»°å¡``¡µ ·­ºYâªÉ«¬Àà"'ȧ«®­`Ë¡--°"--°..."¥â«¬¬" µâ"«-- Õ¥ å ¡ËÕ¥â--¢âÕ¡YÕ¬à"ßæ'¬ßæÕ·­¡ËÕ¡'­ -- ÿ'Ë®Ì"ªì--ÈßÀ¡¥ æËÕ,,Àâ "¡"¢â"--°"--°..."Õ¬à"ßµàÕËÕߥâ¡"°'Ë ÿ¥ ®"°§à" CD4 'Ë«--¥¥â,, ­¬­·° ºYâªÉ«¬Õ"®µâÕߥâ--°"µ«®µ`¥µ"¡ÿ°Ê 6 ¥Õ ,,ª­»¬ °¬ÿå ªí®®ÿ--,,°"«``®©--¬TMÈÕ«-- ÕTMÕ«'·­°"Ì"ºYâªÉ«¬¢â"--°"--°..."¥â«¬¬"µâ" «-- Õ¥ å °Ì"--ß¡ÿàß¡--ËæËÕ®­ª,,Àâ÷ßÕÿ¥¡§µ`¥--ß°à"«'È ·µà,¥¬--Ë«ª·â« ºYâªÉ«¬®­¥â --°"«``®©--¬,,­¬­À--ߢÕß,§ §Õ¡ËÕ§à" CD4 Õ¬YàµË"°«à" 200 ´åµàÕY°"»°å ¡``¡µ TMà ®"°°"»÷°..."°ÿࡺYâµ`¥TMÈÕÕTMÕ«'/Õ¥ å ¢Õß ¿"°"TM"¥¬ æ«à" âÕ¬­ 63 ¢ÕߺYâ'Ë¢â"--°"--°..."'˧``°`"¡,,TMà«ßªï 2540-2548 ¡'§à" CD4 µË"°«à" 200 ´åµàÕY°"»°å¡``¡µ ,,¢­'Ë¥â--°"«``®©--¬«à"¡'TMÈÕ«-- ÕTM Õ«' (µ""ß 3.4) (¥--§Õ¡å 2547) ¢âÕ¡Y®"°°­«ß "" ÿ¢·­ MSF ¥â,,Àâ º'˧â"¬°-- °"«``®©--¬'Ë°`¥¢÷È¥âTMâ" ·­§«"¡®Ì"ªì'˵âÕß`Ë¡--°"--°..."¥â«¬ ¬"µâ"«-- Õ¥ å°Õ®­,¥¬--'--È Õ"®Ì",,Àâ¡'ªíÀ"¡"°¢÷ȵàÕ°"'Ë®­¢â"--°" --°..."Õ¬à"ßµàÕËÕß ·­Õ"®Ì",,Àâ°`¥,Õ°" Yß ÿ¥µàÕ°"ªìæ`...·­°"æ--",§'Ë °`¥®"°°" â"ß¿Y¡`§ÿâ¡°--,,À¡à (immune reconstitution disease) ¢âÕ¡Yæ`Ë¡µ`¡°'ˬ«°--°"«``®©--¬TMÈÕ«-- ÕTMÕ«''Ë°`¥¢÷ÈTMâ",¥¬--Ë«ª--È ¥â ®"°°" Ì"«®µ--Èß·µà¥Õ¡°"§¡ æ.» 2547 ÷ߥա°"§¡ æ.». 2548 ,,°ÿà¡ ºYâÌ"°"--°...",,ª­»¬ (,°¥å ·­§­ 2548) ,¥¬·æ¬å®­¥â--§Ì"¢Õ,,Àâ ª­¡`Õ--µ" à«¢ÕߺYâªÉ«¬'Ë`Ë¡--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ¡ËÕ¡'§à" CD4 µàÌ"°«à" 50 ´åµàÕY°"»°å¡``¡µ --Èß'È ,¥¬¡à§Ì"÷ß«à"ªì "æ¬"",, --ß°--¥,,¥ (Õ°TM --" ¡À"«`¬"--¬ ÀÕÕߧå°ÕËÊ) ·æ¬å¬¥â"¬ß"«à" ºY⠪ɫ¬ à«,,Àà `Ë¡--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ¡ËÕª`¡" CD4 ¡'§à"µË"°«à" 50¢âÕ¡YÕËÊ ´åµàÕY°"»°å¡``¡µ (¿"æ 3.5) Õ«à" ¡ËÕ°"--°..."'ÈÌ"¥â¡"°¬`Ëߢ÷È ·­¡ËÕÕTMÕ«'ªì'ˬա-- ¥âÕ¬à"ß°«â"ߢ«"ߢ÷È,, --ߧ¡¬ ºY⧮÷ßæ¬"¬"¡µ«® ÕÀ"TMÈÕ«-- ÕTMÕ«'µ--Èß ·µà,,­¬­·°¢Õß,§ ¢âÕ¡Y®"°§``°`"¡ ¿"°"TM"¥¬ · ¥ß,,ÀâÀÁ÷ß°" «``®©--¬'ËÁ«¢÷È ®"°TMà«ßªï æ.». 2540-2548 (µ""ß'Ë 3.5) ¢âÕ¡Y--È,,Àâ°Ì"--ß,,® ¥â«¬°" Õ«à" °"--°...",§'Ë¡'Õ¬Yà ®­TM૬,,Àâ¡'°"¢â"--§Ì"ª÷°..."·­µ«®À" TMÈÕÕTMÕ«',¥¬ ¡--§,,®¥â¡"°¢÷È µ""ß 3.4 ®Ì"«ºYâµ`¥TMÈÕÕTMÕ«' 'Ë¢â"--°"--°...",,§``°`"¡ ¿"°"TM"¥¬ ®--¥Ì"¥--µ"¡ ª`¡"´å CD4 ­À«à"ß æ.». 2540-2548 ª`¡" CD4 (´å/.¡¡.) ®Ì"«ºYâ'Ë--°"µ«® Õ âÕ¬­µàÕ®Ì"«--ÈßÀ¡¥ <100-200 100 6,655 41.3 3,554 22.0 200-350 3,133 19.4 > 350 2,784 17.3 «¡ 16,126 100.0 'Ë¡": ¥--§Õ¡å 2547 60 60 · TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ Figure 3.5 Thai Doctors' Estimates of Patients Who Started ART with CD4 Counts of Less ¿"æ 3.5 °"ª­¡"°"¢Õß·æ¬å¬÷ß®Ì"«ºYâªÉ«¬'Ë`Ë¡--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å Than 50 Cells per cubic millimeter ¡ËÕ¡'§à" CD4 µË"°«à" 50 ´åµàÕY°"»°å¡``¡µ 100 ART 80 started¢â"-- ºYâªÉ«¬'Ë 60 patients w/CD4<50 <504CD" 40 ART ¥â«¬§à percentage 20 Õ--µ" à«âÕ¬­¢Õß 0 ¿"§-- public private Õ°TM ¡À"«`¬"--¬ university other ÕËÊ doctors' affiliation ¡"§¡·æ¬å 'Ë¡": ,°¥å, ¥--§Õ¡å, ·­¡"´"°` 2548 Source: Gold, Duncombe, and Masaki 2005. Table 3.5 Anonymous Clinic Attendees of Thai Red Cross Anonymous Clinic Whose CD4 Count Was Less Than 200 Cells per cubic millimeter, 1997­2003 µ""ß 3.5 ®Ì"«ºYâµ`¥TMÈÕÕTMÕ«' 'Ë¢â"--°"--°...",,§``°`"¡ ¿"°"TM"¥¬ ¡ËÕ´å CD4 ¡' §à"µË"°«à" 200 ´åµàÕY°"»°å¡``¡µ ­À«à"ß æ.». 2540-2548 Year ªï Number of CD4 cell counts performed ®Ì"«'Ë¡'°"--§à" CD4 Attendees with CD4 < 200 cells/mm3 (%) ºYâ'Ë¡'§à" CD4<200 ´å/ .¡¡. 1997 341 79.5 1998 2540 1,387 341 79.5 84.4 1999 254 1,387 2,712 84.4 88.1 2000 2542 2,712 2,706 88.1 52.8 2001 2543 2,706 2,505 52.8 64.2 2002 2544 2,505 3,194 64.2 55.9 2003 2545a 3,194 3,281 55.9 55.0 Overall 2546° 16,126 3,281 55.0 63.3 Source: Duncombe 2004. «¡ 16,126 63.3 a. Up to December 18. 'Ë¡": ¥--§Õ¡å 2547 °. ®÷ß«--'Ë 18 --«"§¡ To assess the importance of early diagnosis, one can compare the costs of care for patients who start ART while their immune function is still competent with the costs of care for those who start very late, as æËÕª­¡`÷ߧ«"¡ Ì"§--¢Õß°"«``®©--¬¥âµ--Èß·µà,,­¬­·° "Õ"®ª'¬ occurs throughout Thailand. Some indication may be gained from a '¬­À«à"ßµâÿ,,°"¥Y·ºYâªÉ«¬'Ë`Ë¡--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,¢­ recent Canadian study (Krentz, Auld, and Gill 2004). In that study, 'Ë¿Y¡`§ÿâ¡°--,§¬--ßÌ"ß"¥â¥'Õ¬Yà °--µâÿ,,°"¥Y·ºYâªÉ«¬´÷Ëß`Ë¡°"--°..."TMâ"¡"° the authors compared a range of hospital and treatment costs for ¥--ß'Ë°`¥¢÷È--Ë«ª,,ª­»¬ °"àßTM'È¥--ß°à"« Õ"®¥â®"°ß"«`®--¬¡ËÕ¡à"¡" patients who presented for care at a CD4 count of less than 200 cells 'È¢Õߪ­»·§"¥" (§´å, ,Õ¥å ·­ °` 2547) ,,°"»÷°..."¥--ß°à"« ºYâ per cubic millimeter with costs for those patients who presented with ¢'¬¥âª'¬'¬µâÿ¢Õß,ßæ¬""·­,,°"--°..." Ì"À--ºYâªÉ«¬'Ë¢â"-- a CD4 count of greater than 200 cells per cubic millimeter. Patients °"--°..."¡ËÕ¡'§à" CD4 µË"°«à" 200 ´åµàÕY°"»°å¡``¡µ °--µâÿ Ì"À--ºYâ who presented with a CD4 count of less than 100 cells per cubic mil- ªÉ«¬'Ë¢â"--°"--°..."¡ËÕ¡'§à" CD4 ¡"°°«à" 200 ´åµàÕY°"»°å¡``¡µ ºYâ limeter incurred almost three times the additional costs compared ªÉ«¬'Ë¡'§à" CD4 µË"°«à" 100 ´åµàÕY°"»°å¡``¡µ ®­µâÕß,,TMâµâÿ¡"°¢÷È÷ß with those patients with CD4 counts greater than 200 cells per cubic "¡à" ¡ËÕª'¬'¬°--ºYâªÉ«¬'Ë¡'§à" CD4 Yß°«à" 200 ´åµàÕY°"»°å ÕTMÕ«'/ Õ¥ å ·­°"--°..."¥â«¬¬"µâ"«-- Õ¥ å 61 ¡``¡µ µâÿ¥--ß°à"« à«,,Àà·â« ®­°`¥®"°°"¢â"--°"--°...",,,ß æ¬""·­°"--°...",§µ`¥TMÈÕ©«¬,Õ°" (OI) °àÕ'Ë®­--°"--°..."¥â«¬¬"µâ" «-- Õ¥ å °"§âæ¥--ß°à"« ¥â--°"¬¬-- Ì"À--ª­»¬TMà°-- ®"°°" »÷°..."¡ËÕ¡à"¡"'È ´÷Ëߥâæ«à" ,¥¬©'ˬ·â« ºYâªÉ«¬´÷Ëß¡'§à" CD4 µË"°«à" 50 ´åµàÕY°"»°å¡``¡µ ¡ËÕ¢â"--°"--°...",,"­ºYâªÉ«¬Õ°§--Èß·°--È Ì",,Àâ °`¥µâÿ'Ë Yß°«à"ºYâªÉ«¬´÷Ëß¡'§à" CD4 Yß°«à" 200 ´åµàÕY°"»°å¡``¡µ ÷ß âÕ¬­ 30 (37,190 "µàÕªï ¡ËÕ'¬°-- 28,986 "µàÕªï) (»ÿ¿--§¢--µ` ·­ §­ 2547) §«"¡â""¬"ߧ``°,,°"`Ë¡--°..."¥â«¬¬"µâ"«-- Õ¥ å TMà¥'¬«°--¬"ÕËÊ ¬"µâ"«-- Õ¥ å°Á¡',Õ°" 'Ë®­ªìæ`... ´÷Ëß®­·µ°µà"ß°--ªµ--Èß ·µà°"­§"¬§ÕßÁ°âÕ¬ª®÷ß°"§ÿ°§"¡µàÕTM'«`µ ÷ß·¡â«à" §«"¡ªìæ`...µàÕ ÿ§§·­©æ"­°'--È®­ªì'Ë"°--Õ¬Yà ·µà¬--ß¡'§«"¡¬"°Ì""°'Ë®­Ì""¬ Õ¬à"ßTM--¥® «à"ºYâªÉ«¬"¬,,¥®­æ--"Õ"°"ªìæ`...¢÷È¡" ·­ºYâªÉ«¬¥--ß°à"«®­µÕ ÕßµàÕ°"--°..."ªØ`°``¬"Õ--¡àæ÷ߪ­ ߧå--È¡ËÕ·­Õ¬à"ß §«"¡ªìæ`...¢Õß ¬"Ì",,À⺪­,¬TMå¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¥ß --Èß,,°"Ì",,Àâ°`¥ ªíÀ"¥â" ÿ¢¿"æÕ¬à"ßÿ·ßµàÕºYâªÉ«¬ ·­¥,Õ°" '˺YâªÉ«¬®­§ß--°"--°..." Õ¬à"ßµàÕËÕßµàÕª ºÀà"'È Õ"®Õ«à"ªìÀµÿ°"å'Ë°`¥¢÷ÈÕ¬à"ß©--æ--ÀÕ ÈÕ--ß°Á¥â ·µà"®­µâÕß--Yâ«à" ËÕß®"°æ`...'Ë®­· ¥ßÕÕ°,,µ--«ÿ§§·µà­§--È ·µ°µà"ß°--ª ¬"µ--«À÷Ëß®"°°ÿà¡,,¥°ÿà¡À÷ËßÕ"®¡àÀ¡"­ ¡ ,,¢­'ˬ"Õ'°µ--« À÷Ëß,,°ÿà¡¥'¬«°-- Õ"®æÕ¬Õ¡--¥â (¥--§Õ¡å 2547; ,°¥å ·­§­ 2548) §«"¡°--ß«°'ˬ«°--°"æ--"§«"¡ªìæ`...¢Õ߬",,­¬­¬"«¥â°­µÿâ,,ÀâÀ૬ ß"¥â"°"·æ¬å,,À"¬ª­» «¡--Èߪ­»¬ ,,Àâ,,TMâ·«"ßTM`ßÕÿ--°...å `¬¡ Ì"À--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ·«ªØ`--µ`,,­¬­À--ß'È®­·­Ì",,Àâ ,,TMâ¬"µâ"«-- Õ¥ å Ì"À--ÿ§§'Ë¡'§«"¡ 'ˬß,,§«"¡°â"«Àâ"¢Õß,§ Yß°«à" §«"¡°--ß«'ËÕ"®°`¥¢÷È°'ˬ«°--µ--«¬"à"--È (§"åæµÕå ·­§­ 2543) ¢âÕ¡YµàÕªï'È ,,°"'Ë®­`Ë¡µâ--°..."¥â«¬¬"µâ"«-- Õ¥ å¡ËÕ,,¥ ·­Õ¬à"ß ¥â¬÷¥ µ"¡·«ªØ`--µ`­¥--ª­» Ì"À--°"®--¥°""ߧ``°°'ˬ«°--°"µ`¥TMÈÕ«-- ÕTMÕ«',,¥Á°·­ºYâ,,Àà (°­«ß "" ÿ¢ 2545) ¡ËÕ,,¥®÷ߧ«`Ë¡µâ °±å,,°"¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å Ì"À--ºYâ,,Àà¡'¥--ßµàÕª'È ë ¡ËÕªì,§Õ¥ å ë ¡ËÕªì,§®"°TMÈÕ«-- ÕTMÕ«''Ë· ¥ßÕ"°" ¡à«à"®­¡'§à" CD4 µË"°«à" 250 ´åµàÕY°"»°å¡``¡µ ÀÕ¡à°Áµ"¡ (CDC Clinical B or C) ë ¡ËÕ¡'TMÈÕ«-- ÕTMÕ«''Ë¡à· ¥ßÕ"°" ·µà¡'§à" CD4 µË"°«à" 200 ´åµàÕY° "»°å¡``¡µ 62 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ Ì"À--¥Á° °±å,,°"¢â"--°"--°..."¡'¥--ßµàÕª'È: ë ¥Á°ÿ°§'Ë¡'Õ"¬ÿµË"°«à" 12 ªï ë ¥Á°Õ"¬ÿ 12 ªï ÀÕ¡"°°«à" ´÷ËßÕ¬Yà,,¢--È B ·­ C µ"¡°±å"ߧ``°¢Õß Õߧå°"Õ"¡--¬,° ÀÕ¡'§à" CD4 µË"°«à" 200 ´åµàÕY°"»°å¡``¡µ ®­`Ë¡µâÕ¬à"ß? Yµ¬"µâ"«-- Õ¥ å,,­¥--·°'Ë·­Ì",,ª­»¬ §Õ Yµ¬"'˺ ¡º " Õ¬à"ߧß'Ë­À«à"ß "¡`«Y¥' (lamivudine) µ"«Y¥' (stavudine) ·­«`"æå (nevirapine) ´÷Ëߺ`µ·­®Ì"Àà"¬,¥¬Õߧå°"¿ --TM°¡ ,,"¡¢Õß GPO-vir 4 Õ°®"°'È "ß°­«ß "" ÿ¢ ¬--ߥâ°Ì"À¥ Yµ¬"Õ'° Õß Yµ Ì"À--ºYâªÉ«¬'Ë `Ë¡¡'ªØ`°``¬"µàÕµ--«¬"µ--«,,¥µ--«À÷Ëß'˪ì ૪­°Õ¢Õß GPO-vir ¥â«¬ ¥--ß--È Yµ¬" Ì"À--°"--°...",,¢--È·°'Ë¡'Õ¬Yà "¡ Yµ ¿"¬,,µâ,§ß°"°"¢â"÷ß°"--°..." ¥â«¬¬"µâ"«-- Õ¥ å­¥--TM"µ` Ì"À--ºYâµ`¥TMÈÕ«-- ÕTMÕ«'·­Õ¥ å (NAPHA) ¥â·°à: ë stavudine + lamivudine + nevirapine (GPO-vir) ë stavudine + lamivudine + efavirenz ë stavudine + lamivudine + indinavir/ritonavir ¥â¡'°"ª­¡`«à" ºYâªÉ«¬ª­¡"âÕ¬­ 80 ¥â,,TMâ¬" Yµ·° ,,¢­'˪­¡" âÕ¬­ 15 ,,TMâ¬" Yµ'Ë Õß ·­ª­¡"âÕ¬­ 5 ®­µâÕßÀ--¡",,TMâ Yµ'Ë "¡,,'Ë ÿ¥ ¥â¡'°"ª­¡`º÷ß°",,À⺥' §«"¡ªÕ¥¿--¬ ·­§«"¡µàÕ à«º ¡¢Õ߬" GPO-vir ,,ºYâªÉ«¬'Ë--°"--°..."¥â«¬¬"µâ"«-- Õ¥ åªì§--Èß·° ,,°"»÷°..." 2NN ´÷Ëß®--¥Ì"¢÷È,,À"¬ª­» (·« ·­§­ 2547)5 °"»÷°..." 2NN 'È ªì°"ª'¬'¬,¥¬«`'°" ÿà¡ ÷ß°"¥Õß,,TMâ¬"µâ"«-- Õ¥ å,,¢--È·°,¥¬ ªî¥º¬TMËÕ¬" ,,¬" Yµ'˪­°Õ¥â«¬ nevirapine, efavirenz ÀÕ--Èß Õßµ--««¡°-- Õ°ÀÕª®"° stavudine ·­ lamivudine ,,°"--°..."ª­TM"°'ˡ৬--°" --°..."¡"°àÕ --°...­¢Õߪ­TM"°ºYâªÉ«¬,,°"»÷°..." 2NN 'È §â"¬§÷ß°-- ª­TM"°'˵âÕß°"°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,ª­»¬ --Èß'È ,,°"»÷°..." ¥--ß°à"« ¡'ºYâ¢â"à«¡,§ß°"´÷Ëߡ৬--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¡"°àÕ ®Ì"« 1,216 "¬ ®"° 17 ª­» ,¥¬¡' 200 "¬'Ë¢â"à«¡,§ß°"§«"¡à«¡ ¡Õ­À«à"߬ ÕÕ µ'¬ Õå·¥åæËÕ°"«`®--¬"ߧ``°¥â",§Õ¥ å (HIV- NAT) 'Ë»Y¬å«`®--¬¢Õß ¿"°"TM"¥¬,,°ÿßæoe ,,°ÿࡺYâ¢â"à«¡,§ß°"»÷°..." ¥--ß°à"« ¡' 607 "¬ 'Ë¥â--°" ÿà¡,,Àâ--¬" stavudine (§--Èß­ 40 ¡``°--¡ Õߧ--Èß µàÕ«-- â"¡'È"À--°µ--«¡"°°«à" 60 °`,°--¡ ·­§--Èß­ 30 ¡``°--¡ Õߧ--ÈßµàÕ«-- â"¡'âÌ"À--°µ--«âÕ¬°«à" 60 °`,°--¡) ¬" lamividine (§--Èß­ 150 ¡``°--¡ Õߧ--Èß µàÕ«--) ·­ nevirapine (§--Èß­ 200 ¡``°--¡ Õߧ--ÈßµàÕ«--) ,,¥"ºYâ¢â"à«¡ ,§ß°"'Ë¡'°" ÿࡵ--«Õ¬à"ß,,°ÿà¡'È 607 "¬ ¡' 387 "¬'ËæâÕ¡ Ì"À--°" «`§"­Àå,, 48 --ª¥"Àå·° °"«`§"­Àå§--Èß--È · ¥ß,,ÀâÀÁ«à" âÕ¬­ 65.4 ¢Õß ºYâ'Ë¢â"à«¡ ¡'ª`¡"«-- ,,°­· ,À`µâÕ¬°«à" 50 «-- µàÕ¡```µ À--ß®"°'Ë ÕTMÕ«'/ Õ¥ å ·­°"--°..."¥â«¬¬"µâ"«-- Õ¥ å 63 °Õ 3.1 §«"¡â""¬'Ë Ì"§-- Ì"À--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,¢--È'Ë Õß,,ª­»¬ °Æ­'¬ Ì"À--°"¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢--È'Ë ÕߢÕß°­«ß "" ÿ¢ æÕ ÿª¥â¥--ß µàÕª'È: ë §«"¡â¡À«'Ë°`¥®"°§à" CD4 '˥ߪ°«à"âÕ¬­ 30 (§«"¡â¡À«¥â"¿Y¡`§ÿâ¡°--) ÀÕ®"°°" µ`¥TMÈÕ,§©«¬,Õ°" À--ß®"°'Ë¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ åªì«" Õߪï (§«"¡â¡À« "ߧ``°) ëëë ¡'°"µ«® Õª`¡"«-- ,,°­· ,À`µªï­À÷Ëߧ--Èß (§«"¡â¡À«¥â"«-- ) ¡'°"¥ Õ°"¥ÈÕ¬" À"°ª`¡"«-- ,,°­· ,À`µ¡"°°«à" 5000 «-- µàÕ¡```µ Yµ¬"'Ë¡',,ÀâÕ° "¡ Yµ ¥â·°à: --- Didanosine + lamivudine + idinavir/ritonavir Didanosine + lamivudine + lopinavir/ritonavir lopinavir/ritonavir + saquinavir Õ¬à"ß°Áµ"¡ °Æ­'¬'Ë¡'Õ¬Yà Ì"À-- Yµ¬",,°"--°..."¢--È'Ë Õß,,ª­»¬ µâÕߺTM`°--§«"¡â""¬'Ë Ì"§--,,°"¥Ì"`°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,À⪭ §«"¡ Ì"Á® ËÕß®"°°"«``®©--¬§«"¡â¡À«,, °"--°..."'Ë°`¥¢÷ÈTMâ" «¡--Èß°"¥ÈÕ¬"¢â"¡ "¬æ--åÿ'Ë°`¥¢÷ȵàÕ¬" nucleoside reverse transcriptase inhibitor ª­,¬TMå'Ë¥â--´÷Ëß¡'®Ì"°--¥ «¡--Èßµâÿ¬"'Ë Yß ¥--ß--È ª­»¬®÷ß®Ì"ªìµâÕß»÷°..."÷ß"ßÕ° TM`ß,¬"¬ÕËÊ´÷Ëß®­Ì"ª Yà°"¥Ì"`,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ 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In 2003, HIV prevalence in preg- «-- ÕTMÕ«',,°ÿà¡ µ'¡'§¿å,,¿Y¡`¿"§¥--ß°à"« Õ¬Yà,,Õ--µ"âÕ¬­ 1.5 à«,, æ.». 2549 æ¬"" nant women in the region was 1.5 percent. In 1996, a senior nurse with a special Õ"«ÿ, à"À÷Ëß'Ë¡'§«"¡ ,,®ªìæ`»...,,°",,Àâ§Ì"ª÷°..."°'ˬ«°--§«"¡ Y '¬ interest in bereavement counseling set up a support group for relatives of patients ¥â®--¥µ--Èß°ÿà¡,,À⧫"¡ -- ÿ·°à"µ`¢ÕߺYâªÉ«¬'Ë '¬TM'«`µ ¡ËÕ¡'°"µ--Èß°ÿà¡¥--ß°à"«¢÷È¡" ¡'ºYâÀ`ß "¡§¥â¢â"à«¡°ÿࡪì who had died. As it happened, the three people who attended regularly were HIV- ª­®Ì" ,¥¬--Èß "¡§'È¡'TMÈÕÕTMÕ«' ·­ "¡'¢Õßæ«°Õ¥â '¬TM'«`µªæ"­Õ¥ å °ÿà¡¥--ß°à"«¥âæ--" positive women whose husbands had died of AIDS. The group developed into a PHA ¢÷Ȫì°ÿà¡ -- ÿºYâµ`¥TMÈÕ«-- ÕTMÕ«'·­ºYâªÉ«¬Õ¥ å (PHA) ·­¥âµ--ÈßTMËÕ°ÿà¡«à" µ",µ¥ (À¡"¬ peer support group; was named Tan Tanod (meaning palm sugar, a local product); ÷ßµâµ" Õ--ªìº`µºâÕß`Ë) ·­¥â`Ë¡¥Ì"`°"Õ¬à"ߪì"ß°",, æ.». 2541 ,¥¬¡'ÀâÕߪ­TMÿ¡ and was formally launched in 1998 with a permanent meeting room in the hospital "«,,,ßæ¬"" ·­¥âÿ -- ÿ®"°--"âÕß`Ë Õ°®"°'È ®"°§Ì"¢Õ¢Õß"ß,ßæ¬"" MSF and with funding from the local government. At the request of the hospital, MSF pro- ®÷ߥâ,,Àâ°"ñ°Õ¡°'ˬ«°--°"¥Y·­ ÿ¢¿"æ·­°",,À⧫"¡ -- ÿ¥â"§`§Õ¬à"ßµàÕËÕß·°à--Èß®â" vided training on health care and ongoing technical support for both hospital staff Àâ"'Ë¢Õß,ßæ¬""·­ºYâµ`¥TMÈÕ«-- ÕTMÕ«'·­ºYâªÉ«¬Õ¥ å ,,¢­'È °ÿࡵ",µ¥¡' ¡"TM`° 114 § and PHAs. Tan Tanod currently has 114 members. 250 "°"å¢ÕߺYâµ`¥TMÈÕÕTMÕ«'·­ºYâªÉ«¬Õ¥ å ®"« 175 § 'Ë,ßæ¬""â"·À¡ æ.». 2547 situation of 175 PHAs at Ban Laem Hospital in 2004 200 Y° àßµàÕª¬--ßÕ"¿ÕÕË referred to other attending districts Hospital 150 --¬" ARV taking ARV PHAs of Laem 100 '¬TM'«`µ°àÕ--¬" ARV died before ARV ºYâµ`¥TMÈÕÕTMÕ«'·­ºYâªÉ«¬Õ¥ å Ban '¬TM'«`µ°'ˬ«°--µ-- died from liver disease numbers 50 ®"« Y°¬â"¬ª¬--ß'ËÕË moved away 'Ë¢â"--°"--°...",,,ßæ¬""â"·À¡ 0 ¡à¡'°±å"ß°"·æ¬å no medical 2544 2545 2546 2547 2001 2002 2003 2004 °'ˬ«°-- ARV criteria for ARV ,§ß°"°'ˬ«°--¬"µâ"«-- Õ¥ å (ARV) ,,â"·À¡ ¥â`Ë¡µâ¡ËÕ¥Õµÿ"§¡ æ.». 2544 ,¥¬ The antiretroviral (ARV) drug project in Ban Laem was launched in October 2001 ¡'§­°¡°",§ß°" 10 à" ´÷Ëߪ­°Õ¥â«¬®â"Àâ"'Ë,ßæ¬"" 4 à" ºYâµ`¥TMÈÕ«-- ÕTMÕ«'·­ºYâ with a 10-person project committee comprising four hospital staff members, four ªÉ«¬Õ¥ å (PHA) 4 à" ·­®â"Àâ"'Ë®"° MSF Õ'° 2 à" --Èß'È ¥â¡'°"°àÕµ--Èߧ``° Ì"À--ºYâµ`¥TMÈÕ PHAs, and two MSF staff members. An HIV clinic was set up, initially on one day per «-- ÕTMÕ«'¢÷È¡" ,¥¬,,¢--È·°ªî¥Ì"°" --ª¥"Àå­ 1 «-- ,,æ.». 2544 ¡'ºYâµ`¥TMÈÕ«-- ÕTMÕ«'·­ week. In 2001, 120 PHAs visited the hospital for treatment. Soon after ARV drugs ºYâªÉ«¬Õ¥ å 120 "¬ ¢â"--°"--°..."'Ë,ßæ¬"" ·­¡à"À--ß®"°'Ë`Ë¡¡'°",,TMâ¬"µâ"«-- Õ¥ å,, became available in the hospital, the number of PHAs visiting the hospital increased. ,ßæ¬"" ®Ì"«ºYâªÉ«¬¥âæ`Ë¡ Yߢ÷È --·µà--Ȫìµâ¡" "ß,ßæ¬""®÷ߥâª'ˬ·«§`¥ ´÷Ëß®"° The hospital has since moved from the concept of an ARV drug project with a limited ¥`¡¡'°"¥Ì"`,§ß°"¬"µâ"«-- Õ¥ å'È°--ºYâªÉ«¬,,®Ì"«®Ì"°--¥à"--È ¡"ªì·«§`¥'Ë«à" Õ¥ å °Á quota of patients to the concept that AIDS is like other diseases, and all patients with À¡Õ°--,§ÕËÊ ·­ºYâªÉ«¬ÿ°§'Ë· ¥ßÕ"°""ߧ``° ®­¥â--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å À--ß clinicalindicationsaretreatedwithARVdrugs.Clinicdaysincreasedtotwiceweekly ®"°--È «--Ì"°"¢Õߧ``° ®÷ߥâæ`Ë¡¢÷Ȫì --ª¥"Àå­ 2 «-- ¡ËÕºYâªÉ«¬'Ë--¬"µâ"«-- Õ¥ å ¡'®Ì"« when the number of patients on ARV drugs increased beyond 75. Home visits are æ`Ë¡¢÷ÈÕ'° 75 "¬ Õ°®"°'È ¬--ß¡'°"ÕÕ°µ«®ºYâªÉ«¬÷ßâ" --ª¥"Àå­ 3 «-- ,¥¬°ÿࡺYâµ`¥TMÈÕ«-- donethreedaysperweek--byPHAsontwodaysperweekandjointlybyPHAsanda ÕTMÕ«'·­ºYâªÉ«¬Õ¥ å --ª¥"Àå­ 2 «-- ·­,¥¬°ÿࡺYâµ`¥TMÈÕ«-- ÕTMÕ«'·­ºYâªÉ«¬Õ¥ å·­æ¬""Õ'° nurse on the remaining day. In 2003, the hospital installed two condom vending À÷Ëßà",,Õ'° 1 «--'ËÀÕ ,,æ.». 2546 "ß,ßæ¬""¥âµ`¥µ--ÈߧËÕß®Ì"Àà"¬ÿ߬"ßÕ"¡--¬ 2 §ËÕß machines; two condoms are dispensed for B 5 (US$0.12). ,¥¬®Ì"Àà"¬ÿ߬"ßÕ"¡--¬ 2 TM`È ,,"§"æ'¬ß 5 " (0.12 ¥Õà"å À--) During 2004, 175 PHAs visited the hospital for treatment. Among those PHAs, 4 camefromother districts and were referred to their localhospital;86(49percent)now ,,TMà«ßªïæ.». 2547 °ÿࡺYâµ`¥TMÈÕ«-- ÕTMÕ«'·­ºYâªÉ«¬Õ¥ å®Ì"« 175 "¬ ¥â¢â"--°"--°..."'Ë,ß æ¬"" ,,°ÿࡺYâªÉ«¬Àà"'È ¡' 4 "¬ 'Ë¡"®"°ÕÌ"¿ÕÕË ·­Y° àßµàÕª¬--ß,ßæ¬""âÕß`Ë ·­,, ¢­'È ¡' 86 "¬ (âÕ¬­ 49) 'Ë¥â--¬"µâ"«-- Õ¥ å à«Õ'° 32 "¬ (âÕ¬­ 18) ¥â '¬TM'«`µª take ARV drugs; 32 (18 percent) died before ARV drugs were initiated; and 13 (7 per- cent)--all with very low CD4 counts--died of OIs within two months of starting ARV °àÕ'Ë®­`Ë¡,,TMâ¬"µâ"«-- Õ¥ å ·­Õ'° 13 "¬ (âÕ¬­ 7) ´÷Ëß¡'§à" CD4 µË"¡"° µâÕß '¬TM'«`µæ"­°" drugs. One has since died of end-stage liver disease, and three others have moved to 76 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ µ`¥TMÈÕ,§©«¬,Õ°" ¿"¬,, 2 ¥Õ À--ß®"°'Ë`Ë¡--¬"µâ"«-- Õ¥ å ¡'ºYâªÉ«¬À÷Ëß"¬'Ë '¬TM'«`µ¥â«¬,§ µ--,,­¬­ ÿ¥â"¬ ·­Õ'° 3 "¬ ¥â¬â"¬ªÕÌ"¿ÕÕË Õ°®"°'È ºYâªÉ«¬ 36 "¬ (âÕ¬­ 21) ¡à¡' §ÿ ¡--µ`µ"¡°±å"ß°"·æ¬å'Ë®­`Ë¡,,TMâ¬"µâ"«-- Õ¥ å¥â ËÕß®"°¡à· ¥ßÕ"°" ·­§à" CD4 ¬--ß§ß Yß°«à" 250 ,¥¬ºYâªÉ«¬°ÿà¡'È--ÈßÀ¡¥ªìæ»À`ß ·­¥â--°"«``®©--¬«à"¡'TMÈÕÕTMÕ«',,¢­µ--Èß §¿åÀÕ¡ËÕÕ¬Yàà«¡°--§Yà¢Õßµ ,,¥"ºYâµ`¥TMÈÕ«-- ÕTMÕ«'·­ºYâªÉ«¬Õ¥ å®Ì"« 120 "¬ 'Ë¢â"-- °"µ«®'Ë,ßæ¬"",,TMà«ß æ.». 2544 °àÕ'Ë®­`Ë¡,§ß°"¬"µâ"«-- Õ¥ å ¡'ºYâªÉ«¬®Ì"« 87 "¬ (âÕ¬­ 79) 'Ë®Ì"ªìµâÕߢâ"--°"--°...",,"­ºYâªÉ«¬,, ·­Õ'° 30 "¬ (âÕ¬­ 25) ¥â '¬TM'«`µß ·­ ¡ËÕæ.». 2547 Õ--µ"°"--ºYâªÉ«¬¢â"--°...",, ,ßæ¬"" ¥ßÀÕâÕ¬­ 22 ·­Õ--µ"°" '¬TM'«`µ¥ ßÀÕâÕ¬­ 8 Õ--µ"°" '¬TM'«`µâÕ¬­ 25 ,,æ.». 2544 ¡'§«"¡°'ˬ«,¬ß°--°"--°...",§µ`¥TMÈÕ©«¬ ,Õ°" Õ¬à"ßY°µâÕß,,,ßæ¬"" ·­°"¡',§ß°"¥Y·--°..."'Ëâ" ´÷ËßÀ"°ª"»®"°ªí®®--¬Àà"'È·â« Õ--µ"°" '¬TM'«`µà"®­ Yß°«à"'È "Àµÿ'ËÕ--µ"°" '¬TM'«`µ¥ß®"°âÕ¬­ 25 ¡"ªìâÕ¬­ 8 §ÕºYâµ`¥TMÈÕ ·­ºYâªÉ«¬Õ¥ å à«,,Àà®­¡à¢â"¡"'Ë,ßæ¬""®°«à"®­ªÉ«¬ËÕß®"°¿Y¡`§ÿâ¡°--Y°Ì""¬Õ¬à"ßÿ·ß à«,,°ÿࡺYâªÉ«¬'Ë--¬"µâ"«-- Õ¥ å--È §à"¡--¬"¢Õß CD4 ,,¢­'Ë`Ë¡,,TMâ¬"µâ"«-- Õ¥ å ®­Õ¬Yà'Ë 26 ´åµàÕY°"»°å¡``¡µ À--ß®"°'Ë--¬"µâ"«-- Õ¥ åªì«" 1 ªï ºYâÌ"¢Õß°ÿࡵ",µ¥ ¥âµ--Èߧ¿å¢÷È,,ªï æ.». 2546 ·­,,Àâ°Ì"`¥ÿµTM"¬"·¥'Ë¡' ÿ¢¿"æ¥'´÷Ëߪì'ˬ`¥'¢ÕßæàÕ·¡à¬`Ëß--° À--ß®"°--È ºYâÌ"°ÿࡺYâµ`¥TMÈÕ«-- ÕTMÕ«'·­ºYâªÉ«¬Õ¥ å"¬,,À¡à (´÷ËßÕ¬Yà,,­À«à"ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ åTMà°--) ¥â--°"«à"®â"ß ®"°,ßæ¬"",,Àâªìæ--°ß"TMà«ß°"ߧ ´÷Ëß'˪ì --"'Ë¥'«à" ,ßæ¬""·Ààß'ÈÕ«à"Õ¥ åªì,§ ¡¥",§À÷Ëß --Èß'È ,,ª­»¬ ¡à,,TMàËÕß·ª°'Ë,ßæ¬""®­¡ÕÀ¡"¬",,°"ªìºYâÌ",,Àâ ·°àæ--°ß"'Ë"«à"ªìºYâµ`¥TMÈÕ«-- ÕTMÕ«' ,¥¬©æ"­Õ¬à"߬`Ëß ºYâ'˪¬ "°"åµ`¥TMÈÕ¢ÕßµµàÕ TMÿ¡TM à«,ßæ¬""ÕÌ"¿Õ,,®--ßÀ«--¥æTMÿ' °Á¥â,,Àâ`°"¬"µâ"«-- Õ¥ åTMà°-- ,¥¬§Õ¢à"¬ºYâµ`¥ º°­¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (ART) µàÕ°"·æà°­®"¬¢ÕßTMÈÕ «-- ÕTMÕ«' ºYâ°Ì"À¥,¬"¬ ""­ ¡àæ'¬ß·µà®Ì"ªìµâÕßæ`®""÷ߺ,¥¬µß¢Õß,¬"¬ °'ˬ«°--,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å'Ë¡'µàÕºYâªÉ«¬'Ë--¬"¥--ß°à"«à"--È ·µà¬--ß µâÕßæ`®""÷ߺ"ßÕâÕ¡¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å 'Ë¡'µàÕ°"Ì",,Àâ °`¥°"µ`¥TMÈÕ«-- ÕTMÕ«'"¬,,À¡à¥â«¬8 TMà ¡'À--°"æ`Ë¡µ`¡«à" °"¡',§ß°" --°..."¥â«¬¬"µâ"«-- Õ¥ å Õ"®Ì"ª Y৫"¡Ì"æÕß,,®·­°`¥æµ`°¡ 'ˬßæ`Ë¡¢÷È ,,°ÿࡺYâ'ËÕ¬Yà,,,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ·­Ì",,Àâ°`¥º,,·ßà¡ÿ¡µà"ßÊ --Èߥâ"·­«°°'ˬ«°--TMÈÕ«-- ÕTMÕ«',,TMÿ¡TM'Ë°'ˬ«¢âÕß (¥ÿâ°°Õå ·­§­ æ.». 2544; ,µå ·­§­ æ.». 2544; ·« ¥Õ « ·­§­ æ.». 2548) °" ª­¡`º°­¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å'Ë°`¥¢÷È--Ë«ª°--ÿ§§ µà"ßÊÕ°ÀÕª®"°ºYâªÉ«¬--È Õªì à«'Ë¢"¥¡à¥â,,°"«"ß,¬"¬ µ""ß 3.8 ¥â®--¥°ÿà¡¢Õߺ°­"ßÕâÕ¡ ÀÕ¿"¬Õ° ª®÷ߺ"ߥâ"TM'«¿"æ·­ æµ`°¡'Ë¡'µàÕ°"·æà°­®"¬¢ÕßTMÈÕ«-- ,¥¬,,·µà­ª­¿--È º°­ µà"ßÊ §«®­ªìª­,¬TMå,,°"TM­Õ°"·æà­"¥ ÀÕÕ"®ªìª,,"ߵ߰-- ¢â"¡ §Õàß,,Àâ¡'°"·æà­"¥Á«¢÷È ÕTMÕ«'/ Õ¥ å ·­°"--°..."¥â«¬¬"µâ"«-- Õ¥ å HIV/AIDS and Antiretroviral Therapy · 77 77 TMÈÕÕTMÕ«'·­ºYâªÉ«¬Õ¥ å,,ª­»¬ «¡--Èß MSF ·­ Ì"--°ß" "" ÿ¢®--ßÀ«--¥ ¥âà«¡°--Ì"ß" æËÕ°àÕµ--Èß·­ `¡ â"ß°ÿࡺYâµ`¥TMÈÕ«-- ÕTMÕ«'·­ºYâªÉ«¬Õ¥ å,,,ßæ¬""'ËÕ¬Yà¢â"ߧ'¬ß ®÷ßÀ«--ß«à" Network of PHA groups, MSF, and the provincial health department are working °ÿà¡Àà"'È ®­TM૬,,À⧫"¡ -- ÿ,,TM`ߪØ`--µ`·°àºYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å ´÷Ëߥâ--ª­,¬TMå®"°°"¢â" together to establish and strengthen PHA groups in the neighboring hospitals. One ÷߬"µâ"«-- Õ¥ å'Ë¢¬"¬°«â"ߢ÷È hopes that these groups can provide practical support for PHA benefiting from the wider access to ARV drugs. Õ--µ"°"--¢â"--°..." ·­Õ--µ"°" '¬TM'«`µ À--ß®"°`Ë¡¡'°"`Ë¡--°..."¥â«¬¬"µâ"«-- Õ¥ å 'Ë,ßæ¬""â"·À¡ Admission rate and death rate following introduction of ARV in Ban Laem Hospital 80 70 60 50 (âÕ¬­)(percent)40 Õâµ"rate 30 20 10 0 2001 2544 2545 2546 2547 2002 2003 2004 ºYâªÉ«¬·­ºYâµ`¥TMÈÕ'˵âÕߢâ"--°"--°..." ºYâªÉ«¬·­ºYâµ`¥TMÈÕ'Ë '¬TM'«`µ PHArequiringadmission PHAwhodied 'Ë¡": «` --·­øÕå¥ 2547 ¥â«¬§«"¡TM૬ÀÕ®"° TM"µ`TM"¬ "Õß ·Ààß,ßæ¬""â"·À¡ Source: Wilson and Ford 2004, with help from Chatchai Lalong of Ban Laem Hospital, who ´÷ËߪìºYâ,,Àâ `µ` provided statistics. °"¥°"µ`¥TMÈÕ Reduces Infectiousness °"ª÷°..."À"Õ,,ªí®®ÿ--°'ˬ«°--ª­,¬TMå,,°",,Àâ`°",§ß°"--°..."¥â«¬¬" µâ"«-- Õ¥ å (ART) ·°àª­TM"TM,,ª­»'ˬ"°®TM`ß--æ¬"°--È ¥ââ'Ë Current discussions about the benefits of providing ART to popula- §«"¡ "¡"¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ,,°"¥ª`¡"«-- ,,¢Õß tions in resource-poor countries focus on the ability of ART to reduce À«,,à"ß°"¬ ·­¥--ß--È ®÷ß "¡"¥§«"¡ 'ˬß,,°"·æà­"¥ («Õå´´à" the quantity of virus in bodily fluids and therefore to reduce the risk of ·­§­ æ.». 2542) ®"°°"'ËÑ" --ß°µ÷ß°"¥ß¢Õߪ`¡"«-- ,,æ" ¡" transmission (Vernazza and others 1999). On the basis of the observed ¢ÕßÕ¥ ºYâTM'ˬ«TM"¥âÌ""¬«à" §«"¡ "¡",,°"µ`¥TMÈÕ¢ÕߺYâµ`¥TMÈÕ«-- ÕTM reduction in viral load in blood plasma, experts have predicted that Õ«''Ë¢â"à«¡,,,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ®­¥ßª,,Õ--µ"­À«à"ß Õß the infectiousness of an HIV-infected person on ART would be ÷ß·ª¥ --ËÀ¡"¬§«"¡«à" ,Õ°" 'Ë®­°`¥°"µ`¥TMÈÕ®"°°"¡'æ» --¡æ--åæ'¬ß§--Èß reduced by a factor of somewhere between two and eight. That is, the ¥'¬« ®­¥ßªÕ¬Yà,,TMà«ß­À«à"ßâÕ¬­ 12.5-50 ¢Õߧà"ª°µ` (,Õ«Õå ·­§­ probability of transmission on a single sexual encounter would be æ.». 2547) Õ¬à"ß°Áµ"¡ À--°"¢Õߧ«"¡TMËÕ¡,¬ß­À«à"ߪ`¡"«-- ,, reduced to somewhere between 12.5 and 50 percent of its normal æ" ¡"¢ÕßÕ¥·­°"¥°"µ`¥TMÈÕ--Ȭ--ߧߺ ¡ªª°--Õ¬Yà ®`ßÊ·â« °" value (Over and others 2004). However, evidence on the links »÷°..."¡ËÕ¡à"¡"'È ¥â· ¥ß,,ÀâÀÁ«à" «-- 'ˬ--ß·¢Áß·ßÕ¬Yà Õ"®Y°·¬°ÕÕ°¡"®"° between reduced viral load in the plasma and reduced transmission is TMàÕߧե ·¡â°­--Ëß¡ËÕ¥YÀ¡Õ®­¡'°"§«§ÿ¡«-- ,,æ" ¡"¢ÕßÕ¥Õ¬à"ßæ'¬ß mixed. Indeed, some recent studies have shown that active virus can æÕ·â« (¬åÕå ·­§­ æ.». 2542; ·TMß ·­§­ æ.». 2541) Õ°®"°'È be isolated from the genital tract even when there seems to be ade- 78 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ µ""ß 3.8 º'˪쪥â¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ åµàÕ°"·æà­"¥¢ÕßTMÈÕ«-- ÕTMÕ«' `»"ߢÕߺ°­ º¥' º '¬ (Ì",,Àâ°"·æà­"¥TMâ"ß) (àß°"·æà­"¥,,ÀâÁ«¢÷È) ¥§«"¡ "¡",,°"µ`¥TMÈÕ: °"Õ°æËÕ°"¥ÈÕ¬": ,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å °"'Ë¡à "¡"ªØ`--µ`µ"¡«`'°"--°..."¢Õß Õ"®¥ª`¡"«-- ,,°­· Õ¥ ,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¥âÕ¬à"ß ·­¥--ß--È ®÷ßÕ"®¥§«"¡ 'ˬß,, §àߧ--¥--È Ì",,Àâªì°"Õ° "¬æ--å °"µ`¥TMÈÕ"ßæ» --¡æ--å «-- 'Ë¥ÈÕ¬" ´÷ËßÌ",,Àâ°`¥°"·æà­"¥¥â TM'«¿"æ ¡'°"µ`¥TMÈÕ,,­¬­«"¬"«"¢÷È: °"'˺YâªÉ«¬´÷Ëߢâ"à«¡,§ß°"--°..."¥â«¬ ¬"µâ"«-- Õ¥ å¡'Õ"¬ÿ¬"¢÷È Ì",,Àâ °`¥º '¬Õ¬à"ß¡àµ--Èß,,® ,,°"æ`Ë¡­¬­ «"'˺YâªÉ«¬Õ"®·æà°­®"¬TMÈÕ«-- ¥â TM`¥¢Õߺ°­ °"°­µÿâ,,Àâ°`¥°"ªÑÕß°-- ,¥¬©æ"­ æµ`°¡ 'ˬß'Ëæ`Ë¡¢÷È: Õ¬à"߬`Ëß °"µ«® ÕæËÕ«``®©--¬: ºYâ'Ë¢â"à«¡,§ß°"--°..."¥â«¬¬"µâ"«-- ,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å Õ¥ å ·­ºYâ'Ë¡'TMÈÕ ·­¡à¡'TMÈÕ«-- ÕTMÕ«' æµ`°¡ Õ"®æ`Ë¡Õ--µ"°"¥Ì"`°`®°¡æËÕ ,,TMÿ¡TM'Ë·«¥âÕ¡--È Õ"®¡' à«à«¡,, ªÑÕß°-- ,¥¬©æ"­°"ª÷°..."·­°" æµ`°¡'Ë¡'§«"¡ 'ˬßæ`Ë¡¢÷È ¡"°°«à"'Ë µ«®À"TMÈÕ«-- ,¥¬ ¡--§,,® ®­ªì¡ËÕ¬--ß¡à¡',§ß°"--°..."¥â«¬¬"µâ" «-- Õ¥ å 'Ë¡": ,Õ«Õå ·­§­ 2547 °"»÷°..."Õ'°À"¬§--Èß ¥âÕ`"¬÷ߧ«"¡À"·à¢Õ߬"®"°,§ß°"--°..."¥â«¬¬" µâ"«-- Õ¥ åµà"ßÊ,,µ--«Õ¬à"ßÕ ÿ®` °"»÷°..."Àà"'È TM'È,,ÀâÀÁ÷ߧ«"¡·µ°µà"ßÕ¬à"ß ¡"°,,­¥--¢Õ߬"·µà­TM`¥,,Õ ÿ®` ·­¡à¡'§«"¡ --¡æ--åÕ¬à"ß"«­À«à"ß­¥-- ¢Õß,À`µ·­Õ ÿ®` °"¥°"µ`¥TMÈÕ'Ë°`¥®"°,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å--È à«,,Àà·â« ®­¢÷ÈÕ¬Yà°--«à" ºYâµ`¥TMÈÕ«-- ÕTMÕ«'·­ºYâªÉ«¬Õ¥ å¥â`Ë¡--°"--°..."¥âÁ«æ'¬ß,,¥ À--°"à" ÿ¥· ¥ß,,ÀâÀÁ«à" °"·æà­"¥°`¥¢÷ÈÕ¬à"ß¡à ¡ --¥ à«,,TMà«ß --ª¥"Àå ·°ÊÀ--ß®"°'Ë¡'°"µ`¥TMÈÕ ¡ËÕºYâµ`¥TMÈÕ«-- ÕTMÕ«' à«,,Àà ¬--ß¡à"÷ß ¿"«°"åµ`¥TMÈÕ¢Õßµ (æ`TMÕå ·­§­ æ.». 2544) Õ¬à"ß°Áµ"¡ ,§ß°" --°..."¥â«¬¬"µâ"«-- Õ¥ å à"®­`Ë¡µâ,,­¬­À--ߢÕß°"°`¥,§ ¥--ß'Ë·­Ì"«â,, ·«ªØ`--µ`¢ÕßÕߧå°"Õ"¡--¬,°©--à" ÿ¥°'ˬ«°°"æ`Ë¡­¥--°"--°..."¥â«¬¬" µâ"«-- Õ¥ å,, "'Ë´÷Ëß¡'--æ¬"°®Ì"°--¥ (Õߧå°"Õ"¡--¬,° æ.». 2547¢) --Èß'È ªí®®--¬µà"ßÊ«¡°-- ¥â·°àTMÈÕ«-- '˧ߧâ"ß,,Õ«--¬«­æ» ´÷Ëß¡',Õ°" Ì",,Àâµ`¥TMÈÕ ¥â Yß,,­¬­·° «¡--Èß°"`Ë¡,,TMâ¬"µâ"«-- Õ¥ å¥âTMâ" ®­ªì°"®Ì"°--¥º ª­,¬TMåTM`ߪÑÕß°--¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å9 ÕTMÕ«'/ Õ¥ å ·­°"--°..."¥â«¬¬"µâ"«-- Õ¥ å 79 °"°­µÿâ,,Àâ°`¥°"ªÑÕß°-- ,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (ART) Õ"®æ`Ë¡·ß®Yß,,®,,Àâ,,TMâ`°"æËÕ°" ªÑÕß°--,§ --Èß'È §«"¡ªìª¥â¥--ß°à"« ¡--°Y°À¬`¬°¢÷È¡"Õâ"ß÷ß,,°",µâ'¬ß °'ˬ«°--°"¢¬"¬°",,Àâ`°",,,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,ª­» ¬"°® ¢âÕ,µâ·¬âߥ--ß°à"«§Õ °"¡'«`'--°..."'Ë¡'ª­ ``¿"æ Õ"®°­µÿâ,,À⧢â"À" `°"ª÷°..."·­µ«®À"TMÈÕ«-- ,¥¬ ¡--§,,® (VCT) ¡"°¢÷È ´÷ËßÕ--µ"°"-- VCT 'Ë Yߢ÷È À¡"¬§«"¡«à" ¡'§®Ì"«¡"°¢÷È'Ë¢â"--§Ì"ª÷°...",,TM`ߪÑÕß°-- ·­®­ "¡"µ«®æºYâµ`¥TMÈÕ«-- ÕTMÕ«'¥â¡"°¢÷È µ--Èß·µà,,­¬­·°¢Õß°"°`¥,§ Õ°®"°'È Õ--µ"¥--ß°à"« ¬--ßÕ"®À¡"¬§«"¡«à" ºYâµ`¥TMÈÕ«-- ÕTMÕ«'·­µâÕß°"-- °"--°..."®­ "¡"`Ë¡¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¥âÁ«¬`Ëߢ÷È ·'Ë®­ Õ®°«à"®­ªÉ«¬®µâÕߢâ"--`°",,­ "" ÿ¢ Õ¬à"ß°Áµ"¡ §«"¡ Ì"§-- Õ--·â®`ߢÕߧ«"¡æ¬"¬"¡,,°"ªÑÕß°--'È ®­¢÷ÈÕ¬Yà°--`·­ªí®®--¬µà"ßÊ TMà ¢"¥¢Õß°"æ`Ë¡¬"'Ë--ª­" --°...­ 'ˬߢÕߺYâ'Ë-- VCT ·­§ÿ¿"æ¢Õß°" ,,Àâ§Ì"ª÷°..." à«À÷ËߢÕߧ«"¡â""¬,,°"¥Ì"`,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å §Õ °­µÿâ,,ÀâºYâµ`¥TMÈÕ«-- ÕTMÕ«'¥â¢â"--°"µ«®µ--Èß·µà,,­¬­·°¢Õߧ«"¡®ÁªÉ«¬ ,¥¬,,TMâ`°" VCT æËÕTMËÕ¡,¬ß`°"¥--ß°à"«¢â"°--°"`À",§ß°"--°..."¥â«¬ ¬"µâ"«-- Õ¥ å (ART) ·­æËÕ â"ߧ«"¡¡--Ë,,®«à" ºYâªÉ«¬®­ªØ`--µ`µ"¡«`'°"--°..." 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'Ë¡": ºYâ¢'¬ º®"°,¬"¬Õ¥ å¢Õߪ­»¬,,ªí®®ÿ-- 93 "ßÕ°'Ë "¡--È¡'Õ¬Yà,,ª­»¬°«à" `ªï¡"·â« ËÕß®"°°"``Ë¡¢ÕßÕß§å° æ--"Õ°TM­¥--""TM"µ` TMà Õߧ尰"·æ¬åâæ¡·¥ ÀÕ ¡Á¥¥Õ·´ß ´Õß å øÕßµ`·¬å (Medecins sans Frontieres>MSF) ·«§`¥¢Õß°ÿà¡ -- ÿ'Ë ¥â--ÿTM૬ÀÕ ´÷Ëß,¥¬--Ë«ª·â«®­ª­°Õ¥â«¬ºYâµ`¥TMÈÕ«-- ÕTMÕ«'/Õ¥ å æ`Ëß ®­¥â--°"--Õß®"°--" ·­¥â--ÿ -- ÿ®"°°Õßÿ­¥--,°æËÕµàÕ Yâ Õ¥ å «--,§ ·­¡""'¬ ¥--ß--È ®Ì"«¢Õß°ÿࡺYâµ`¥TMÈÕ¥--ß°à"« ®÷ߢ¬"¬µ--«¢÷È °"®­§ËÕYª·TM`ß·«§`¥,,¿"æ 4.2 ¡"ªìYª·®Ì"Õß'Ë "¡" Õ`"¬·­§"¥ª­¡"æµ`°¡,,§«"¡ªì®`ߥâÕ¬à"ß ¡Àµÿº "®­µâÕß Õ°°"Ì" Õ"ßÀâ"'Ë¢Õߺ°­®"°"§" °"¡'Õ¬Yà ·­µ--«·ªÕËÊ Ì"À-- °"Õ°·,,°"--°..."¢ÕߺYâªÉ«¬ ·­æËÕÀ'°'ˬߧ«"¡´--´âÕÕ--°`¥®"°°" --§«"¡§`¥ÀÁ®"°Yª·¥â"­"¥«`¬"¡" YàYª·¥â"§«"¡µâÕß°" "®­µ--Èß ¡¡µ`"«à" --°...­¢ÕßYª·,,°"--°..." àߺ°­µàÕ --¥ à«¢ÕߺYâªÉ«¬'Ë Õ°--°"--°...",,·µà­Yª· ,¥¬¡à°'ˬ«°--®Ì"«¢ÕߺYâªÉ«¬ ¬`Ëߪ°«à"--È "¥âÀ"Yª·"ß°"Ì"ß" ´÷Ëß--Õß«à" ¡à«à"®­,,TMâ ૺ ¡¢Õߧÿ--°...­¢Õß °"--°...",,Yª·,,¥ --¥ à«¢ÕߺYâªÉ«¬'ËÕ°Yª·,,°"--°..."--Èß 'Ë·--È ®­ «¡°--ªìÀ÷Ëß (ªì 1.0) --Èß'È Yª·,,°"Ì"ß" ´÷ËßÌ"¡",,TMâ,,«°¡ ¡"°'Ë ÿ¥ §ÕYª· multinomial logit ´÷Ëß¡'ª­«--µ`´÷Ëߪì'ˬա--,,°"«"ßYª· ,,Àâ·°à"ßÕ°¢ÕߺYâ`,¿§ Ì"À--"ßÕ°À"¬"ß ,¥¬ à«À÷Ëߪìæ"­¡' --°...­'Ëæ÷ߪ­ ߧå Õߪ­°" ,,°'¢Õß" §«"¡µâÕß°"'Ë¡'µàÕ,§ß°" --°..."¥â«¬¬"µâ"«-- Õ¥ å,¥¬¿"§-- ´÷Ëß,,TMâYª·,,°"Ì"Àâ"'Ë¥--ß°à"« ®­ ¢'¬¥â¥--ßµàÕª'È q_pub_art = e(_pub +.LN (Ppub_art) + . LN (Dpub_art) x = { pub, apub, priv,e no} (_x_art + .LN (Px_art) + . LN (Dx_art)) ,¥¬ LN À¡"¬÷ß Õ°"`÷¡¡TM"µ` (natural logarithm) e À¡"¬÷ß "¢ÕßÕ°"`÷¡¡TM"µ` q_pub_art = --¥ à«¢ÕߺYâªÉ«¬'ËÕ°--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢Õß-- Px_art = "§"'˺YâªÉ«¬®à"¬ Ì"À--°",,Àâ`°"æ¬"",,Yª· x ´÷Ëß°Ì"À¥ «â,,·,,¥·À÷Ëߥ--ßµàÕª'È: pub = °",,Àâ`°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢Õß-- apub = °",,Àâ`°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢Õß--,¥¬¡'`°" `¡ priv = °",,Àâ`°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢ÕßÕ°TM no = °"--°...",§µ`¥TMÈÕ©«¬,Õ°" ,¥¬¡`¥â--°..."¥â«¬¬"µâ"«-- Õ¥ å 94 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ TMà¥'¬«°-- Dx_art = ­¬­"ß,¥¬©'ˬ ®"°ºYâªÉ«¬ª¬--ßYª· "`°" x ¥--ß'Ë °Ì"À¥«â¢â"ßµâ x_art = §à"§ß'Ë ´÷Ëß«¡--°...­ÕËÊ¢ÕßYª· "æ¬"" x ´÷Ëß¡' Õ``æ µàÕ°"Õ°¢ÕߺYâªÉ«¬ TMà §ÿ¿"æ ·­¢âÕ¡Y = §«"¡¬¥À¬ÿà¢Õߧ«"¡µâÕß°"¢ÕߺYâªÉ«¬'Ë¡'µàÕ"§" = §«"¡¬¥À¬ÿà¢Õߧ«"¡µâÕß°"¢ÕߺYâªÉ«¬'Ë¡'µàÕ­¬­"ß øíß°åTM--Ë¥â"§«"¡µâÕß°" Ì"À--Yª·,,°",,Àâ`°"ÕËÊÕ'° "¡Yª· ®­ ªìª,,--°...­¥'¬«°-- Õ°®"°«à" Yª·'Ë°Ì"À¥«â«à" pub ,,µ--«·ªµ"¡ (dependent variable) ·­,,®Ì"«'˪ì»...®­¥â--°"·'˥⫬°"°Ì"À¥Yª ·'ËÀ¡"­ ¡4 µ--«·ª Ppub_art, Dpub_art, Papub_art, Dapub_art, Pno_art ·­ Dno_art §Õ§ËÕß¡Õ"ߥâ",¬"¬´÷Ëß--" "¡"Ì"¡",,TMâæËÕ,,Àâ¡'ºµàÕ"ßÕ°Yª· ,,°"--°..."¢ÕߺYâªÉ«¬ ¥--ß--È µ--«Õ¬à"ß"ßÕ°¢Õß" ª­°Õ¥â«¬°"§"¥ ª­¡"÷ß"ßÕ°¢Õßµ--«·ªÀà"'È æËÕ'Ë®­§"¥ª­¡"÷ßYª·¢Õß à«·àß ºYâªÉ«¬'Ë¢â"--°"--°...",,·µà"ßÊÀà"'È,,TMà«ß«"À÷Ëß "®­µâÕßÕ°§à"¢Õß æ""¡`µÕå ·­ ·­§à"--Èß 'Ë¢Õß _x --Èß'È "¥â Õ'¬æ""¡`µÕåÀà"'È Ì"À--ºYâªÉ«¬ Õß°ÿà¡ §ÕºYâªÉ«¬°ÿà¡'Ë· ¥ßÕ"°" ·­°ÿà¡'Ë¡à· ¥ßÕ"°" µ""ß 4.1 ¥â,,Àâ§à"§«"¡¬¥À¬ÿà (elasticity value) Õߧà" ·­§à"¢Õß®ÿ¥µ--¥ (intercept values) '˧à" Ì"À--ºYâªÉ«¬,,·µà­ª­¿ æ""¡`µÕå'Ë· ¥ß§«"¡¬¥À¬ÿà (elasticity parameters) Õ"®µ'§«"¡¥â«à" ªì Õ--µ" à«âÕ¬­¢Õß°"ª'ˬ·ªß,, odds ratio ­À«à"ß"ßÕ° ÕßYª· 'Ë ¡'µàÕ°"ª'ˬ·ªßâÕ¬­ 1 ,,Õ--µ" à«¢Õß"§"ÀÕ­¬­"ß5 ¥--ß--È §à" §«"¡¬¥À¬ÿà'Ë >0.5 ¢ÕߺYâªÉ«¬'Ë· ¥ßÕ"°" ´÷Ëß¡'µàÕ"§"¢Õß,§ß°"--°..."¥â«¬ ¬"µâ"«-- Õ¥ å À¡"¬§«"¡«à" ,Õ°" 'Ëÿ§§À÷Ëß ®­Õ°°"--°...",,Yª·,,¥ µ""ß 4.1 §à"ª'¬'¬¢Õßæ""¡`µÕå´÷ËßÕ°--°...­"ßÕ°¢ÕߺYâªÉ«¬ "À--«`'°"--°...",, ª­»¬ ª­¿¢ÕߺYâªÉ«¬ æ""¡`µÕå · ¥ßÕ"°" ¡à· ¥ßÕ"°" §«"¡¬¥À¬ÿà¥â""§" -0.50 -1.00 §«"¡¬¥À¬ÿà¥â"­¬­"ß -1.50 -0.50 ®ÿ¥µ--¥ °"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢Õß-- 7.08 4.42 °"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢Õß--'Ë¡'`°" `¡æ`»... 8.14 3.52 °"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢ÕÕ°TM 10.15 4.49 ¡à¡'°"--°..."¥â«¬¬"µâ"«-- Õ¥ å 1.00 1.00 'Ë¡": °"ª'¬'¬¢âÕ¡Y ­ ¡,,ª­»¬ µ--Èß·µà æ.». 2544-2546 ,¥¬ºYâ¢'¬ º®"°,¬"¬Õ¥ å¢Õߪ­»¬,,ªí®®ÿ-- 95 ®­Õ¬Yà¥ßâÕ¬­ 0.5 Ì"À--Õ--µ""§"­À«à"ßYª·'Ëæ`Ë¡¢÷ÈâÕ¬­ 1 ·­ ËÕß®"°ºYâªÉ«¬¥`"ßÌ""° "®÷ßµ--Èß ¡¡µ`"«à" æ«°¢"à"®­¡'°"µÕ Õß µàÕ­¬­"ß ,¥¬¡'§à"§«"¡¬¥À¬ÿà'Ë Õ'¬·â«Õ¬Yà'Ë >1.5 à«æ""¡`µÕå¢Õß ®ÿ¥µ--¥--È ®­¡'§à"ª°µ`Õ¬Yà'Ë 1 Ì"À--°"'Ë¡à¢â"à«¡,§ß°"--°..."¥â«¬¬"µâ" «-- Õ¥ å Õ--µ" à«¢Õß®ÿ¥µ--¥ÕËÊ µàÕ®ÿ¥µ--¥¢Õß ç¡à¢â",§ß°"--°..."¥â«¬¬" µâ"«-- Õ¥ åé ­âÕ÷ߧ«"¡æ÷ߪ""ÀÕ§ÿ¿"æ,,°"`°"'˪짫"¡ Yâ ÷° ૵--«,, "¬µ"¢ÕߺYâªÉ«¬ À"°®­æ`®""÷ߪ­ ``¿"æ¢Õß,§ß°"--°..." ¥â«¬¬"µâ"«-- Õ¥ å,,°""Õ"°"·­¬¥TM'«`µºYâªÉ«¬·â« ®÷ß¡àà"·ª°,,®'Ë æ""¡`µÕå'Ë®ÿ¥µ--¥ Ì"À--"ßÕ°,,°"--°..."--Èß "¡"ß ®­°«â"ß°«à""ßÕ°'Ë ®­¡à--°"--°..." ,,¥""ßÕ°,,°"--°..."--Èß "¡"ß--È °"--°...",¥¬ Õ°TM¥YÀ¡Õ®­Õ¬Yà,,Õ--¥-- Yß ÿ¥ Õ"®®­ËÕß¡"®"°°"'Ë "¡"--°..."§«"¡-- ¥â¥'°«à" «¡--Èß`°"Õ¬à"ߪì ૵--« Õßß¡" ¥â·°à °"--°..."¢Õß--· `¡ æ`»... ,,¢­'È'Ë°"--°..."¢Õß--®­âÕ¬°«à" ´÷ËßÕ"® ­âÕ÷ß¡ÿ¡¡Õß'Ë«à" °"¡' Õߧå°æ--"Õ°TM¢â"¡" `¡ ®­TM૬ª--ªÿߧÿ¿"æ,,°"¥Y·ºYâªÉ«¬ ¿"æ 4.2 ¬"¬÷ß··«§`¥¢Õß°"µ--¥ `,,®'Ë®­· «ßÀ"°"--°...",¥¬ ÿ§§´÷Ëß¡'Õ"°"¢ÕßÕ¥ å (ºYâµ`¥TMÈÕ«-- ÕTMÕ«''Ë· ¥ßÕ"°") ·­¥â¢â"¡"'Ë "`°"µà"ßÊæËÕÀ""ß"§«"¡®ÁªÉ«¬ ºYâªÉ«¬ à«,,Àà´÷ËßÀ""ß--°..." ,,ª­»¬ ®­Õ¬Yà,,°ÿà¡'È ·­¡'Õ"°"¢Õß,§Õ¥ å'Ëæ--"ª®¡'§à" CD4 'Ë 50 ´åµàÕY°"»°å¡``¡µÀÕµàÌ"°«à" Õ¬à"ß°Áµ"¡ ªí®®ÿ--¡'§«"¡§`¥ÀÁ "ß°"·æ¬å«à" ­¬­«"Õ--À¡"­ ¡'Ë®­`Ë¡µâ,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å--È §«®­ªì,,­¬­·°Ê ´÷Ëߧà" CD4 ¢ÕߺYâªÉ«¬¥â¥ß®"°­¥--ª°µ` ­À«à"ß 600-1,000 ß¡"Õ¬Yà,,­¥-- 200 ´åµàÕY°"»°å¡``¡µ ·µàºYâªÉ«¬ °ÿà¡'È à«,,Àà¬--ß¡à¡'Õ"°" ·­Õ"®®­¬--ߡ൭À--°÷ߺª­,¬TMå'˵®­¥â-- ®"°,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å Õ°®"°«à" ®­¥â¢â"¡"µ«®Õ¥æËÕÀ" °"µ`¥TMÈÕÕTMÕ«' ¥--ß--È â"ß Yà°"--°..." 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ÀÕ 114 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ 114 · TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand ¿"æ 4.7 Õÿª ߧå'Ë¡'µàÕ°",,Àâ°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢Õß¿"§-- ´÷Ëߪìµ--«·ª¢Õß"§" Ì"À-- Figure 4.7 Demand for Public ART as a Function of its Price to the Patient ºYâªÉ«¬ (°)(a)Õÿª ߧå,¥¬ºYâªÉ«¬Õ¥ å'Ë· ¥ßÕ"°" Demand by symptomatic AIDS patients "§"ªïæ.». 2544 2001 price and scale) ·­Õ--µ" à«¢Õß ART: "°"å ¡¡µ`¢--ÈæÈ" proportion of ART: "§"§"¥ª­¡" ¢Õߪïæ.». 2568 baseline scenario (logscale) ·­Õ--µ" à«TMÕß ART: "°"å ¡¡µ`'Ë¡'°"¥"` Projected 2025 price and proportion of ART: 2547(log 10,000 ,§ß°" NAPHA NAPHA scenario æ.».baht 1,000 Demand in 2025 Õÿª ߧåªïæ.». 2568 "°"å ¡¡µ` 2004in 100 NAPHA scenario 'Ë¡'°"¥"`,§ß°" NAPHA price 10 Õÿª ߧåªïæ.». 2544: Demand in 2001 "§"µ"¡§à"ß` "°"å ¡¡µ`¢--ÈæÈ" baseline scenario 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Õ--µ" à«¢ÕߺYâªÉ«¬Õ¥ å'Ë· ¥ßÕ"°" ´÷Ëß· «ßÀ" ART proportion of symptomatic AIDS patients seeking public ART ,, "æ¬""¿"§-- (¢)(b)Õÿª ߧå,¥¬ºYâªÉ«¬Õ¥ å'Ë¡à· ¥ßÕ"°" ·µà¥â--" "¿"æ¢Õßµ Demand by asymptomatic HIV-positive patients who are informed of their status ·­¡'--°...­Õ¬Yà,,°±å'˵âÕß--°"--°..." and eligible for treatment scale) (logscale) 2547(logbaht 10,000 1,000 æ.».2004 Õÿª ߧåªïæ.». 2568 "°"å ¡¡µ` 'Ë¡'°"¥"`,§ß°" NAPHA Demand in 2025 NAPHA scenario in 100Õÿª ߧåªïæ.». 2541: Demand in 2001 price 10 "°"å ¡¡µ` ¢--ÈæÈ" baseline scenario "§"µ"¡§à"ß` 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Õ--µ" à«¢ÕߺYâªÉ«¬Õ¥ å'Ë¡à· ¥ßÕ"°" ·µà--" "¿"æ¢Õßµ proportion of informed asymptomatic AIDS patients seeking public ART ·­· «ßÀ" ART ,, "æ¬""¿"§-- 'Ë¡": ºYâ¢'¬ Source: Authors. in 2025 that will result from this combination of policies, 49 percent ®"°¿"§Õ°TM Ì",,ÀâÀÕÕ'°âÕ¬­ 27 'ËÕ¬YàÀà"ß°°`ª ¬"°®°`ª ÀÕ¡' of the symptomatic AIDS patients will use public sector ART. ¢âÕ¡YâÕ¬°`ª°«à"'Ë®­,,TM⪭,¬TMå®"°°"--°...",,¿"§--¥â Another 24 percent will use augmented public or private sector treat- ¿"æ (°) Õ"®Ì"¡",,TMâæËÕ«`§"­Àå÷ߺ°'ˬ«ËÕß®"°°"¥"§"·­°"æ`Ë¡ ment, leaving 27 percent too distant, too poor, or too ill informed to ®Ì"«¬"--°..."µàÕ°"ª--ªÿß°",,Àâ`°"--°..."¥â«¬¬"µâ"«-- Õ¥ å'˧"¥ take advantage of public treatment. ª­¡"«â ®"°,§ß â"ßÕÿª ߧå¥--ß°à"« °"¥"§"æ'¬ßÕ¬à"ߥ'¬«®­æ`Ë¡°" ¢â"--°...",,,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ åæ'¬ßâÕ¬­ 0.2 ®÷ß¡"°°«à"âÕ¬ Panel (a) can be used to analyze the relative contribution of the price decrease and the availability increase on projected improve- ­ 1 æ'¬ßÁ°âÕ¬¢ÕߺYâªÉ«¬'Ë· ¥ßÕ"°" à«°"¡'¬"--°..."æ`Ë¡¢÷È®­Ì",,Àâ®Ì"« ments in ART use. According to this demand structure, the price ºYâ¢â"à«¡,§ß°"æ`Ë¡¢÷È®"°âÕ¬­ 0.2 ªìâÕ¬­ 20 ¢Õß°ÿࡺYâªÉ«¬'Ë· ¥ß decrease alone would increase ART use only from 0.2 percent to Õ"°" Õ¬à"ß°Áµ"¡ â",§ß â"ߥ--ß°à"«Y°µâÕß °"¥"§"µàÕª¢Õß¿"§--°Á¡' º®"°,¬"¬Õ¥ å¢Õߪ­»¬,,ªí®®ÿ-- 115 ·«,â¡'Ë®­æ`Ë¡ --¥ à«¢ÕߺYâªÉ«¬Õ¥ å--ÈßÀ¡¥ ,¥¬ à«À÷Ëß¡"®"°ºYâ'˧¬,,TMâ`°" ,, "æ¬""¢Õß¿"§Õ°TM ·­Õ'° à«À÷Ëß ¡"®"°ºYâ'Ë¡à "¡"®à"¬§à"--°..." æ¬""¥â À"°"§"¡à¥ß ¿"æ (¢) · ¥ßËÕß"«'˧â"¬°--°'ˬ«°--Õÿª ߧå'Ë¡'µàÕ°"¥Y·--°...",,°ÿࡺYâ'Ë ¡à· ¥ßÕ"°"ªÉ«¬ ·µà¥â--°"µ«®«``®©--¬«à"µ`¥TMÈÕ«-- ÕTMÕ«' ·­Õ¬Yà,,°±å 'Ë®­µâÕߥâ--°"--°..." ,§ß â"ߢÕß·®Ì"Õߥâ"Õÿª ߧå¢Õß"Õÿ¡"«à" ËÕß ®"°,¥¬--Ë«ª·â« ºYâªÉ«¬Àà"'È ®­¡'Õ"°"âÕ¬°«à" ÀÕ¡à¡'Õ"°"¬ §°ÿà¡'È®÷ß ¡'°"µÕ ÕßµàÕ"§"¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¡"°°«à" ËÕß®"° §°ÿà¡'È¡'Õ"°"ªÉ«¬âÕ¬°«à" æ«°¢"®÷ß "¡"¥`"ߪ· «ßÀ"°"--°..."¥â ¡"°°«à" ¥--ß--È "®÷ß --`..."«à" §°ÿà¡'È®­¡'°"µÕ ÕßµàÕ°"æ`Ë¡®Ì"«¬" --°..."¥ââÕ¬°«à" ¥--ß--È æËÕ ­âÕ÷ß ¡¡µ`"Àà"'È â,§âß· ¥ßÕÿª ߧå Ì"À-- ºYâªÉ«¬'Ë¡à· ¥ßÕ"°" ·µà--¢âÕ¡Y·­Õ¬Yà,,°±å'Ë®­µâÕߢâ"--°"--°..." ®÷ßªì ·«"°«à" â,§âߢÕߺYâªÉ«¬'Ë· ¥ßÕ"°" (--Ë§Õ ¡'°"µÕ ÕßµàÕÕ"°"âÕ¬ °«à") ·­Õ¬Yà,,°â°--¡"°°«à" (· ¥ß÷ߺ®"°°"ª--ªÿßËÕ߬"--°..."âÕ¬°«à") Õ--µ" à«'Ë«--¥¥â®"°·°¢«"ߢÕß¿"æ (¢) §Õ à«À÷ËߢÕß®Ì"«ºYâµ`¥TMÈÕ«-- ÕTMÕ«''Ë--"¢âÕ¡Y·­Õ¬Yà,,°±å'Ë®­µâÕߥâ--°"--°..."·µà¡à· ¥ßÕ"°" ®"°,§ß â"ߢÕß·®Ì"Õß'È ®ÿ¥,,¥°Áµ"¡ â,§âß· ¥ßÕÿª ߧå'Ë¡'µàÕ°" --°..."¥â«¬¬"µâ"«-- Õ¥ å Ì"À--ºYâªÉ«¬'Ë¡à· ¥ßÕ"°",,¿"æ (¢) ®Ì"«ºYâªÉ«¬ --ÈßÀ¡¥'Ë¢â"--°"--°..."®­¢÷ÈÕ¬Yà°--®Ì"«ºYâ'Ë· «ßÀ"°"--°..."ªì Ì"§-- ,¬"¬ 'Ëæ`Ë¡Õÿª ߧåµàÕ°"--§Ì"ª÷°..."·­°"µ«®À"°"µ`¥TMÈÕ,¥¬ ¡--§,,® ,¥¬©æ"­ Õ¬à"߬`Ëß ,,°ÿࡺYâ'Ë¡'§«"¡ 'ˬߵàÕ°"µ`¥TMÈÕ Yß ÿ¥ ®­æ`Ë¡®Ì"«ºYâµ`¥TMÈÕÕTMÕ«''Ë ¥â'¬Yâ÷ß "°"åµ`¥TMÈÕ¢Õßµ ·­µâÕß°"`Ë¡--°..."¥â«¬¬"µâ"«-- Õ¥ åÁ« æÕ,,¢­'ˬ--ß¡à· ¥ßÕ"°" ¿"æ 4.8 · ¥ß â,§âßÕÿª ߧå'Ë¡'µàÕ°"--§Ì"ª÷°..."·­°"µ«®À"TMÈÕ,¥¬ ¡--§,,® ,¥¬°ÿࡧ'Ë¡'§«"¡ 'ˬߵË" ·­°ÿà¡'Ë¡'§«"¡ 'Ë¬ß Yß ¿"¬,,µâ "°"å ¥--ßµàÕª'È ë "°"åæÈ" ë "°"å'Ë¡',§ß°"¿" ë "°"å'Ë¡'°"--§Ì"ª÷°..."·­°"µ«®À"TMÈÕ,¥¬ ¡--§,,®18 §Ì"«à" §«"¡ 'Ë¬ß Yß·­§«"¡ 'ˬߵË" ªì ૪­°Õ'Ë¢÷ÈÕ¬Yà°--°ÿࡪ­TM"° ª­¿µà"ßÊ,,·®Ì"Õß,§­"¥,,ÕTM'¬ ´÷Ëß°ÿà¡'Ë"¥â«¡«â,,°ÿࡧ«"¡ 'Ë¬ß Yߥⷰà À`ߧâ"`°""ßæ» Y°§â"¢ÕßÀ`ß°ÿà¡'È TM"¬--°à¡æ» ·­ºYâ,,TMâ¬" æµ`¥TM`¥©'¥ ,,·®Ì"Õß,§­"¥,,ÕTM'¬ ÿ§§®­Õ¬Yà,,°ÿà¡À÷Ëß°ÿà¡,,¥'Ë¡' §«"¡ 'Ë¬ß YßµàÕ°"µ`¥TMÈÕ¥--ß°à"«æ'¬ßTM--Ë«§"« °àÕ'Ë®­¬â"¬ªÕ¬Yà,,°ÿà¡ÕË ´÷Ëß ,¥¬--Ë«ª·â« ®­¡'§«"¡ 'ˬߵË"°«à" "µ--Èß ¡¡µ`"«à" "§"§à"`°"°"--§Ì"ª÷°..."·­°"µ«®À"TMÈÕ,¥¬ ¡--§ ,,® ®­Õ¬Yà'Ë 30 " ,,ÿ° "°"å ® `È ÿ¥­¬­«"§"¥ª­¡" Õ¬à"ß°Áµ"¡ 116 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ 116 · TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand ¿"æ 4.8 Õÿª ߧå'Ë¡'µàÕ°"--§Ì"ª÷°..."·­°"µ«®À"TMÈÕ,¥¬ ¡--§,,® ´÷Ëߪìµ--«·ª¢Õß"§" Ì"À-- Figure 4.8 Demand for VCT as a Function of the Price of Public Sector ART: Baseline, °"--°..."¥â«¬¬"µâ"«-- Õ¥ å,, "æ¬""¢Õß--: "°"å ¡¡µ`¢--ÈæÈ", "°"å ¡ NAPHA, and VCT Scenarios ¡µ`'Ë¡',§ß°"¿" ·­ "°"å ¡¡µ`'Ë¡'°"--§Ì"ª÷°..."·­°"µ«®À"TMÈÕ,¥¬ ¡--§,,® (°)(a)Õÿª ߧå,¥¬°ÿࡧ«"¡ 'Ë¬ß Yß Demand by the high-risk group scale)scale) (log(log 10,000 2547baht2004 1,000 Õÿª ߧåªïæ.». 2568 "°"å ¡¡µ` Demand in 2025 æ.».in 'Ë¡'°"¥"`,§ß°" VCT VCT scenario ART 100 of Õÿª ߧåªïæ.». 2568 Demand in 2025 µ"¡§à"ß`price 10 Õÿª ߧåªïæ.». 2541: Demand in 2001 "°"å ¡¡µ`'Ë¡'°" "°"å ¡¡µ`¢--ÈæÈ" baseline scenario ¥"`,§ß°" NAPHA NAPHA scenario ART 0 "§" 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Õ--µ" à«¢Õß°ÿà¡ 'Ë¬ß ´÷Ëß· «ßÀ" ART ,, "æ¬""¿"§-- proportion of risk group seeking public VCT (¢) Õÿª ߧå,¥¬ºYâªÉ«¬Õ¥ å'Ë¡à· ¥ßÕ"°" ·µà¥â--" "¿"æ¢Õßµ (b) Demand by asymptomatic HIV-positive patients who are informed of their status ·­¡'--°...­Õ¬Yà,,°±å'˵âÕß--°"--°..." and eligible for treatment scale) (logscale) 2547(log 10,000 æ.».baht2004 1,000 Õÿª ߧåªïæ.». 2568 "°"å ¡¡µ` 'Ë¡'°"¥"`,§ß°" VCT Demand in 2025 VCT scenario in 100 Demand in 2001 Õÿª ߧåªïæ.». 2541: baseline scenario "°"å ¡¡µ`¢--ÈæÈ" price 10 "§"µ"¡§à"ß` Õÿª ߧåªïæ.». 2568 "°"å ¡¡µ` Demand in 2025 'Ë¡'°"¥"`,§ß°" NAPHA NAPHA scenario 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Õ--µ" à«¢Õß°ÿà¡ 'Ë¬ß ´÷Ëß· «ßÀ" ART proportion of risk group seeking public VCT ,, "æ¬""¿"§-- 'Ë¡": ºYâ¢'¬ Source: Authors. individual is only temporarily in one of these categories and at higher risk of infection before migrating to another, typically lower-risk "Õ«à" --Èß"§"·­®Ì"«¬"µâ"«-- Õ¥ å ®­ àߺ°­µàÕÕÿª ߧå'Ë¡'µàÕ category. `°"°"--§Ì"ª÷°..."·­°"µ«®À"TMÈÕ,¥¬ ¡--§,,®ËÕß®"°--Èß°"--°..."¥â«¬¬" µâ"«-- Õ¥ å ·­ °"--§Ì"ª÷°..."·­°"µ«®À"TMÈÕ,¥¬ ¡--§,,®µà"ßÕÈÕÀÿ °--We assume the price of VCT remains at B 30 in all the scenarios until the end of the projection period. However, we assume that both °"¥"§"§à"¬"µâ"«-- Õ¥ å ÀÕ°"æ`Ë¡®Ì"«¬" ®÷ߪì°"°­µÿâÕÿª the price and the availability of ART affect the demand for VCT. ߧå'Ë¡'µàÕ°"--§Ì"ª÷°..."·­°"µ«®À"TMÈÕ,¥¬ ¡--§,,® ¥â«¬Àµÿ'È ®÷ß®Ì"ªì'Ë®­ Because ART and VCT are complements in consumption, reductions µâÕß â"ß â,§âß· ¥ßÕÿª ߧåµàÕ°"--§Ì"ª÷°..."·­°"µ«®À"TMÈÕ,¥¬ ¡--§,,® in the price of ART or improvements in its availability stimulate the ,,Àâªì°±å Ì"À--"§"¢Õß`°"--°..."¥â«¬¬"µâ"«-- Õ¥ å º®"°,¬"¬Õ¥ å¢Õߪ­»¬,,ªí®®ÿ-- 117 ¿"檭°Õ (°) ¢Õß¿"檭°Õ 4.8 · ¥ß÷ߺ'Ë¡'µàÕ --¥ à«¢Õß°ÿà¡ 'Ë¬ß Yß´÷ËßµâÕß°"`°"°"--§Ì"ª÷°..."·­°"µ«®À"TMÈÕ,¥¬ ¡--§,,® ,¥¬ªìµ--« ·ª¢Õß"§"·­®Ì"«¬"µâ"«-- Õ¥ å'Ë¡' â,§âߥâ"´â"¬ ÿ¥· ¥ß,§ß â"ß ¢ÕßÕÿª ߧå Ì"À-- æ.». 2544 ¢­'Ë°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¬--ß¡'"§"·æß ·­¡' "æ¬""æ'¬ß 119 ·Ààß'Ë,,Àâ`°"¥--ß°à"« ´÷Ëß,,ªï--È¡'æ'¬ßâÕ¬­ 2 ¢Õߪ­TM"°'Ë¡'§«"¡ 'Ë¬ß Yߢâ"--°"µ«® ÕæËÕÀ"TMÈÕ«-- â,§âß'Ë Õß · ¥ßº¢Õß°"ª--ªÿߥâ"®Ì"«¬"µâ"«-- Õ¥ å¿"¬,,µâ,¬"¬¿" ´÷Ëß §ËÕ'˪"ߢ«",,ÿ°®ÿ¥"§"¢Õߧà"--°..."¥â«¬¬"µâ"«-- Õ¥ å¿"¬,, æ.». 2568 --Èß'È °"¥"§"§à"--°..."¥â«¬¬"µâ"«-- Õ¥ å ®"° 8,530 " ¡"ªì 650 " §"¥«à" ®­Ì",,Àâ¿"«­ ¡¥ÿ¢ÕßÕÿª ߧå Ì"À--°"--§Ì"ª÷°..."·­°" µ«®À"TMÈÕ«-- ,¥¬ ¡--§,,®¥ß¡"µ"¡ â,§âß· ¥ßÕÿª ß§å ®÷ß®ÿ¥'˪­¡" âÕ¬­ 30 ¢Õß°ÿà¡ 'Ë¬ß Yß'Ë· «ßÀ"°°"µ«® ÕÀ"°"µ`¥TMÈÕ ¿"檭°Õ (¢) ¢Õß¿"æ 4.8 · ¥ß,§ß â"ß'˧àÕ¢â"ß·µ°µà"ßÕÕ°ª Ì"À --Õÿª ߧå'Ë¡'µàÕ°"--§Ì"ª÷°..."·­°"µ«®À"TMÈÕ,¥¬ ¡--§,,® Ì"À--°ÿà¡ 'Ë¬ß µàÌ" ´÷Ëß¡'ª­¡" 20 à"¢Õß°ÿà¡'Ë¡'§«"¡ 'Ë¬ß Yß19 â,§âß´â"¬ ÿ¥· ¥ß÷ßÕÿª ߧå¿"¬,,µâ "°"åµ--«Õ¬à"ߢ--ÈæÈ" ¡ËÕ"§"§à"--°..."¥â«¬¬"µâ"«-- Õ¥ å ¬--ß Yß ·­®Ì"« "æ¬""'Ë,,Àâ°"--°..."¬--ß¡'®Ì"°--¥ ÷ß·¡â«à" --¥ à«¢ÕߺYâ'Ë · «ßÀ"`°"°"--§Ì"ª÷°..."·­°"µ«®À"TMÈÕ,¥¬ ¡--§,,® 'Ë¥â§"¥§­«â Ì"À--°ÿà¡'È ¬--ß¡'æ'¬ßâÕ¬­ 0.2 ÀÕª­¡"À÷Ëß à« `¢Õß°ÿà¡ 'Ë¬ß Yß ®Ì"« ÿ`¢ÕߺYâ'Ë¡'§«"¡ 'ˬߵË"'Ë¢â"--°"µ«® Õà"®­µâÕß¡'¡"°°«à"®Ì"«ºYâ 'Ë¡'§«"¡ 'Ë¬ß Yß'Ë¢â"--°"µ«® Õ,, æ.». 2544 ÷ß Õßà" ËÕß®"°Õ--µ" §«"¡TMÿ°¢ÕßTMÈÕ«-- ÕTMÕ«',, æ.» 2544 âÕ¬°«à"âÕ¬­ 1 æ'¬ßÁ°âÕ¬,,°ÿà¡ ºYâ,,Àà'Ë¡'§«"¡ 'ˬߵË" ·­ Yß°«à"âÕ¬­ 4 ,,°ÿࡺYâ,,Àà'Ë¡'§«"¡ 'Ë¬ß Yß °ÿà¡'Ë¡' §«"¡ 'Ë¬ß Yß ®÷ß¡'º°"µ«® Õ'Ë· ¥ß«à"¡'°"µ`¥TMÈÕ«-- 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¡"µ°"TM`ß,¬"¬'Ë·¢Áß·°àß·­ÀÁ¥âTM--¥--È ®­¡'æ'¬ß§°ÿà¡Á°Ê®"° ª­TM"°,¥¬--Ë«ªà"--È 'Ë®­¥â'¬Yâ°'ˬ«°-- "°"åµ`¥TMÈÕÕTMÕ«'¢Õßµ ·,¬"¬¥--ß°à"«¥â· ¥ßÕ--µ" à«âÕ¬­¢ÕߺYâ'ËÕ¬Yà,,°ÿà¡ 'ˬ߷µà­°ÿà¡'Ë · «ßÀ"`°"ª÷°..."·­°"µ«®À"TMÈÕ,¥¬ ¡--§,,® ·­°"°­®"¬ --¥ à«¢ÕߺY⠪ɫ¬'Ë· ¥ßÕ"°"·­¡à· ¥ßÕ"°",,°"--°..."--Èß 'Ë·,,·µà­ªï¢Õß­¬­«"'Ë æ`Ë¡¢÷È ¿"æ 4.9 · ¥ß°"§"¥ª­¡" 3 · Ì"À-- "°"åæÈ" ,, æ.». 2544 ·­ Ì"À-- "°"å ¡¡µ`'Ë¡'°"¥Ì"`,§ß°"¿",, æ.». 2568 à«'È· ¥ß,,ÀâÀÁ«à" ·®Ì"Õß,¬"¬TMËÕ¡,¬ß§«"¡ª'ˬ·ªß,,§ËÕß¡Õ TM`ß,¬"¬ TMà ,¬"¬°'ˬ«°--°"ª'ˬ·ªß°"°­®"¬Õÿª ߧå'Ë¡'µàÕ ,§ß°"°"--§Ì"ª÷°..."·­°"µ«®À"TMÈÕ,¥¬ ¡--§,,® ·­°"--°..."¥â«¬¬"µâ" «-- Õ¥ åÕ¬à"ß ´÷Ëß°"°­®"¬µ"¡ --¥ à«¥âÌ"¡",,TMâªì¢âÕ¡YªÑÕ¢â"æËÕ¢-- §ËÕ·®Ì"Õß,§­"¥,,ÕTM'¬ ,, ૵àÕª ®­µ«® Õº¥â" ÿ¢¿"æ·­ °"ß`¢ÕߢâÕ¡YÀà"'È,,`¢Õß,§ß â"ߥâ"­"¥«`¬"·­ª­TM"°»" µå ¢Õß,§­"¥,,ª­»¬ º¢Õß,¬"¬ªí®®ÿ-- (,§ß°"¿") °"Õ¿`ª"¬,,µÕ°àÕÀâ"'È ¥â· ¥ß,,ÀâÀÁÕ¬à"ßTM--¥®«à" ,¬"¬,,°"--°..." ,§Õ¥ å¢Õߪ­»¬¥âª'ˬ·ªßª¡"°æ'¬ß,,¥,, æ.». 254521 ¥â«¬ «"æ'¬ß¡à°'Ë¥Õ "§"¢Õ߬"µâ"«-- Õ¥ å'Ë,,Àâ`°",¥¬-- ¥â¥ß÷ßâÕ¬­ 92 ,,¢­'Ë®Ì"«¬"'Ë¡'--Èæ`Ë¡¢÷È÷ßâÕ¬­ 620 ËÕß®"°¬" "¡--µâ"«-- Õ¥ å'˺`µ¢÷È¡",,À¡à,,"§"'˵Ë" Ì",,Àâ¬"µâ"«-- Õ¥ å'Ë,,Àâ`°",¥¬Õ°TM¥ ß÷ßâÕ¬­ 30 ,,`'È °"§"¥ª­¡"`»"ߢÕß,¬"¬¿",,ªí®®ÿ-- ®÷ߧàÕ¢â"ß®­ªì°"¥Ì"`°"Õ¬à"ß¡à¡'°Æ°±å " --`..."«à" ®Ì"«¢Õß "æ¬"" ®­æ`Ë¡¢÷È,,Õ--µ"âÕ¬­ 1.5 µàÕªï ·­®Ì"«ºYâªÉ«¬'Ë¥â--°" --°...",, "æ¬""·µà­·Ààß ®­¡'®Ì"«æ`Ë¡¢÷ÈæËÕµÕ ÕßµàÕÕÿª ߧå'Ëªì º¡"®"°­¬­"ß­À«à"ߺYâªÉ«¬°-- "æ¬""'货 µ"¡ ¡¡µ`"¥--ß°à"« ¿"æ 4.10 · ¥ß÷ߺ'Ë¥â¡'°"§"¥ª­¡"«â,, °àÕÀâ"'È --Ë§Õ ¡ËÕ "¡"Ì",,ÀâºY⧡'TM'«`µÕ¬YàµàÕª¥â ,¬"¬¿" («¡--Èß °"--°...",,¢--È'Ë Õß) ¥âæ`Ë¡®Ì"«ºYâµ`¥TMÈÕ«-- ÕTMÕ«',,ª­»¬ ¡ËÕ ª'¬'¬°--®Ì"«ºYâµ`¥TMÈÕ'Ë®­¬--ߧߡ'TM'«`µÕ¬YàÀ"°¡à¡'°"--°..."¥--ß°à"« · ®Ì"Õß'È ®÷ߧ"¥ª­¡"«à" ¿"¬,, æ.». 2568 ®Ì"«ºYâ,,Àà'˵`¥TMÈÕ«-- ÕTMÕ«' ®­¡"°¢÷Ȫì 'Ëà"¢Õß®Ì"«'Ë®­ªìÀ"°¡à¡',§ß°"¿" (263,000 "¬ ·'Ë®­ªì 62,000 "¬) ®Ì"«'Ëæ`Ë¡¢÷È'È à«,,Àà®­ªìæ"­ºYâªÉ«¬'Ëà" ®­ '¬TM'«`µæ"­Õ¥ å °-- "¡"¡'TM'«`µÕ¬Yà¥â¬"«"¢÷È ·µà à«À÷Ëߪìæ"­ °`¥°"·æà­"¥¡"°¢÷È ®"°ºYâµ`¥TMÈÕ«-- ÕTMÕ«''Ë¡'TM'«`µÕ¬Yà"¢÷È22 ¿"æ 4.11 · ¥ß÷ߺ¢Õß,§ß°"¿" °--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,, ¢--È'Ë Õß 'Ë¡'µàÕ®Ì"«ºYâ,,Àà'Ë '¬TM'«`µ--ÈßÀ¡¥,,·µà­ªï,,ª­»¬ ®Ì"«ºYâ º®"°,¬"¬Õ¥ å¢Õߪ­»¬,,ªí®®ÿ-- 119 ¿"æ 4.9 º'˧"¥ª­¡"¢Õß,¬"¬¿" 'Ë¡'µàÕÕÿª ߧå¢Õß,§ß°"°"--§Ì"ª÷°..."·­°" The Effects of Thailand's Current AIDS Policy · 119 µ«®À"TMÈÕ,¥¬ ¡--§,,® ·­°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (°) Õ--µ" à«¢Õß°ÿà¡'Ë¡'§«"¡ 'ˬߵË"·­°ÿà¡'Ë¡'§«"¡ 'Ë¬ß Yß ´÷Ëß· «ßÀ"`°" VCT ,, "°"å Figure 4.9 Projected Effects of the NAPHA Policy on Demand for VCT and ART ¡¡µ`¢--ÈæÈ" ·­ "°"å'Ë¡'°"¥"`,§ß°" NAPHA (a) Poportion of low- and high-risk groups seeking VCT in baseline and NAPHA scenarios. 80 VCT (%) 70 VCT 60 50 seeking 40 30 groups (âÕ¬­) of 20 10 share 0 Õ--µ" à«¢Õß°ÿà¡'Ë· «ßÀ"`°" 2001 2025 §«"¡ 'ˬߵË" §«"¡ 'Ë¬ß Yß Low risk High risk (¢) Õ--µ" à«¢ÕߺYâªÉ«¬'Ë¡à· ¥ßÕ"°" ´÷Ëß· «ßÀ"`°" ART ,, "°"å ¡¡µ`¢--ÈæÈ" ·­ "°"å'Ë¡'°"¥"`,§ß°" NAPHA (b) Proportion of asymptomatic patients seeking ART in baseline and NAPHA scenarios. 100 90 80 70 asymptomatic (âÕ¬­)(%) 60 50 40 informed patients à«¢ÕߺYâªÉ«¬'Ë¡à· ¥ßÕ"°"of 30 µ"¡'Ë¥â--·®âß 20 --¥ à«share 10 0 2001 2025 ¿"§-- Public ¿"§-- `¡æ`»... Augmented public ¿"§Õ°TM ¡à¡' Private None (§) Õ--µ" à«¢ÕߺYâªÉ«¬'Ë· ¥ßÕ"°" ´÷Ëß· «ßÀ"`°" ART ,, "°"å ¡¡µ`¢--ÈæÈ" ·­ "°"å'Ë¡'°"¥"`,§ß°" NAPHA (c) Proportion of symptomatic patients seeking ART in baseline and NAPHA scenarios. 100 (%) 90 80 patients 70 60 50 (âÕ¬­) 40 symptomatic 30 of 20 10 --¥ à« à«¢ÕߺYâªÉ«¬'Ë¡à· ¥ßÕ"°" share 0 2001 2025 ¿"§-- Public ¿"§-- `¡æ`»... Augmented public 'Ë¡": ºYâ¢'¬ ¿"§Õ°TM ¡à¡' Private None Source: Authors. 120 · »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ 120 TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand Figure 4.10 Projected Current HIV Cases ¿"æ 4.10 ®Ì"«ºYâµ`¥TMÈÕ«-- ÕTMÕ«''˧"¥ª­¡"«â 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 "°"å ¡¡µ`¢--ÈæÈ" NAPHAscenario baselinescenario "°"å ¡¡µ`'Ë¡'°"¥"`,§ß°" NAPHA Source: Authors. 'Ë¡": ºYâ¢'¬ longer. Figure 4.11 also reveals why "deaths averted" is not a good '¬TM'«`µ'Ë¥ßÕ¬à"ß¡"° ®­ÀÁ¥âµ--Èß·µàTMà«ß`Ë¡,§ß°" ´÷Ëߪ캡"®"°°ÿࡺYâ measure of the success of the ART program. By preventing the deaths µ`¥TMÈÕ«-- ÕTMÕ«''Ë`Ë¡--°"--°..."·­¡'TM'«`µÕ¥¥â¬"«"¢÷È Õ°®"°'È ¿"æ of many AIDS patients beginning in 2002, NAPHA postpones those 4.11 ¬--ß· ¥ß,,ÀâÀÁ«à" ç°" '¬TM'«`µ'˪ÑÕß°--¥âé ¡à,,TMà¡"µ«--¥§«"¡ Ì"Á®¢Õß deaths about 12 years. When the patients eventually begin to die, total ,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å'Ë¥' µ--Èß·µàæ.». 2545 ,§ß°"¿" "¡"¬¥ deaths rebound upward until, in 2017, they exceed the number who ­¬­«"°" '¬TM'«`µ¢ÕߺYâªÉ«¬Õ¥ å®Ì"«¡"°ÕÕ°ª¥âÕ'°ª­¡" 12 ªï ·­ would have died that year without NAPHA. The considerable achieve- ,,'Ë ÿ¥ ¡ËÕºYâªÉ«¬`Ë¡ '¬TM'«`µß ®Ì"«ºYâ '¬TM'«`µ®­°-- Yߢ÷ÈÕ'° ®°­--Ëß,, æ.». ment of NAPHA is to shift the survival distribution of AIDS patients 2560 §"¥«à"®Ì"«ºYâ '¬TM'«`µ®­ Yß°«à"®Ì"«ºYâªÉ«¬'Ë '¬TM'«`µ,,ªï¥'¬«°--À"°¡à¡' to longer survival times, so that the average AIDS patient lives between ,§ß°"¿" ¥--ß--È §«"¡ Ì"Á®¢Õß,§ß°"¿"§Õ°"¬¥­¬­«"°"¡'TM'«`µÕ¬Yà 5 and 15 years longer. Because everyone dies eventually, the additional ¢ÕߺYâªÉ«¬Õ¥ å æËÕ,,ÀâºYâªÉ«¬,¥¬©'ˬ¡'TM'«`µ¬"«"ÕÕ°ªÕ'°ª­¡" 5-15 ªï deaths after 2017 are not a negative consequence of the program, but a ·­ËÕß®"°,,'Ë ÿ¥·â« ÿ°§°ÁµâÕßµ"¬Õ¬Yà--ËÕß ®Ì"«ºYâ '¬TM'«`µ'Ëæ`Ë¡¢÷ÈÀ--ß reflection of the longer survival times of the patients. ®"°æ.». 2560 ®÷ß¡à,,TMຠ'¬¢Õß,§ß°" ·µà®­ªì°" ­âÕ÷ß­¬­«"°" ¡'TM'«`µÕ¬Yà'ˬ"«"¢÷È¢ÕߺYâªÉ«¬--ËÕß Figure 4.11 Projected Annual AIDS Deaths ¿"æ 4.11 °"§"¥ª­¡"®Ì"«ºYâ '¬TM'«`µ®"°,§Õ¥ å,,·µà­ªï 60,000 50,000 40,000 30,000 20,000 10,000 0 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 "°"å ¡¡µ`¢--ÈæÈ" baselinescenario NAPHAscenario "°"å ¡¡µ`'Ë¡'°"¥"`,§ß°" NAPHA Source: Authors. 'Ë¡": ºYâ¢'¬ The Effects of Thailand's Current AIDS Policy · 121 º®"°,¬"¬Õ¥ å¢Õߪ­»¬,,ªí®®ÿ-- 121 The cumulating number of patients under treatment has direct impli- ®Ì"«ºYâªÉ«¬ ­ ¡'Ë¢â"--°"--°..." ¡'--¬,¥¬µß,,·ßà¢Õß¿"­,,°"--°..."'Ë¡' µàÕ¿"§ "" ÿ¢ ¿"æ 4.12 · ¥ß÷ß¿"­,,°"--°..."¢Õߪ­»'Ëæ`Ë¡¢÷Ȫì cations for the treatment burden on the health sector. Figure 4.12 shows æ`»... Õ--ËÕß¡"®"°,§ß°"¿"æâÕ¡¥â«¬°"--°..."¥â«¬¬"µâ"«-- ,,¢--È'Ë Õß the extraordinary increase in the national treatment burden attributable ¿"¬,,µâ ¡¡µ`"¢Õß·®Ì"Õß°'ˬ«°--ª­,¬TMå¢Õß°"--°..." ·­°"¥ß¢Õß to NAPHA with second-line therapy. Under the model's assumptions ®Ì"«ºYâµ`¥TMÈÕ«-- Õ¥ å"¬,,À¡à ®Ì"«ºYâµ`¥TMÈÕ«-- ÕTMÕ«'·­ºYâªÉ«¬Õ¥ å'Ë-- regarding the benefits of treatment and the declining incidence of new °"--°..."¿"¬,,µâ,§ß°"¿"¢÷È÷ß®ÿ¥ Yß ÿ¥,, æ.». 2558 '˪­¡" 230,000 HIV cases, the number of PHAs on treatment under NAPHA peaks in "¬ ·­`Ë¡¥ßÕ¬à"ßTMâ"Ê ·µàºYâªÉ«¬Àà"'È¡àÀ¡Õ°--ºYâªÉ«¬TM"«¬ à«,,Àà,, 2015 at about 230,000 and then begins to decrease slowly. Unlike the vast °'ÕË --Ë§Õ ºYâªÉ«¬Õ¥ å ´÷Ëߪì,§ÈÕ--ß ®­¡'§«"¡ --¡æ--åÕ¬à"ßµàÕËÕß°-- majority of Thai patients, these chronic AIDS patients will have ongoing ­ "" ÿ¢ª÷ß `ªïÀÕ¡"°°«à"--È ¥--ß--È æËÕ'Ë®­,,Àâ°"¥Y·'Ë¡'§ÿ¿"æ relationships with the public health system that will last a decade or ¥âÕ¬à"߬--Ë߬ ­ "" ÿ¢®÷ß®­µâÕßæ--"·­,,TMâ«`'°" ¡--¬,,À¡à,,°"®--¥°Á more. To provide and sustain high-quality care, the system will have to --÷°ºYâªÉ«¬,, "æ¬""À"¬âÕ¬·Ààß--ÈßÀ¡¥ ·­®"°°"'˺YâªÉ«¬®­µâÕߢâ" develop and apply modern methods of handling patient records at all the --`°",,­ "" ÿ¢àÕ¬§--Èß ºYâªÉ«¬ ®­¡'¢âÕ¡Y¡"°¢÷È ·­¡'·«,â¡'Ë®­ hundreds of treatment sites. Through repeated experience with the TM'È÷ß®ÿ¥°æàÕß'Ë¡ÕßÀÁ¥â¡"°¬`Ëߢ÷È ¥--ß--È ß",,°"®--¥°"¥â"°" ËÕ "°-- health care system, patients will become increasingly informed and thus ª­TM"°ºYâªÉ«¬'Ëæ`Ë¡¢÷È ®÷ß¡'§«"¡ Ì"§--¡"°¢÷È--Èß,,¡ÿ¡¡Õߥâ"°"·æ¬å·­ increasingly likely to point out deficiencies they perceive. So the task of °"¡Õß managing communications with this growing patient population will increase in importance from both a medical and a political perspective. "¥â,,TMâ®Ì"«ªï'Ë¡'TM'«`µÕ¥¥â"¢÷ÈÌ"¡"§Ì"«ªì®Ì"«¢Õߪ­TM"TM'Ë ¡'TM'«`µæ`Ë¡¢÷È,,ªï'Ë°Ì"À¥23,24 æËÕ«--¥ºª­,¬TMå,¥¬µß¢Õß,¬"¬,,°",,Àâ As a measure of the direct benefits of an ART provision policy we use `°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ¿"æ 4.13 · ¥ß÷ß°­· ¢Õߪï'Ë¡'TM'«`µÕ¥¥â the number of life-years saved, computed as the number of additional "¢÷ȵ"¡'˧"¥ª­¡"«â ´÷Ëߪ캡"®"°°"¥Ì"`,§ß°"¿"æâÕ¡--Èß°" people alive in any given year.23,24 Figure 4.13 presents the predicted --°..."¥â«¬¬"µâ"«-- Õ¥ å,,¢--È'Ë Õß ¿"檭°Õ'È ¥â· ¥ß÷ߪ­,¬TMåÕ¬à"ß flow of saved life-years that result from the implementation of NAPHA ¡"°¡"¬'Ë¥â--®"°,¬"¬¿" ¿"¬,, æ.». 2558 ,§ß°"¥--ß°à"« ®­TM૬,,Àâ¡' with second-line therapy. This figure illustrates the dramatic benefits ª­TM"°'Ë¡'TM'«`µÕ¬Yàæ`Ë¡¢÷ÈÕ'°ª­¡" 220,000 § ·­·¡â°­--ËßTMà«ß `È ÿ¥­¬­ achieved through the NAPHA policy. By 2015, it will have added about «"§"¥ª­¡" ¡ËÕ§"¥«à",§­"¥Õ¥ å,,ª­»¬®­¡'§«"¡ÿ·ßâÕ¬ß 220,000 people to the living population. Even at the end of the projec- ,¬"¬¿" ®­--°..."Õ"¬ÿ¢--¬¢ÕߺY⧥⪭¡" 190,000 ªï,,·µà­ªï tion horizon, when the Thai AIDS epidemic is predicted to be less severe, the NAPHA policy will save about 190,000 life-years each year. ¿"æ 4.12 °"§"¥ª­¡"®Ì"«ºYâ'˵`¥TMÈÕ«-- ÕTMÕ«' 'Ë--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å Figure 4.12 Projected Number of HIV-Positive People on ART 250,000 200,000 150,000 100,000 50,000 0 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 "°"å ¡¡µ`¢--ÈæÈ" baselinescenario NAPHAscenario "°"å ¡¡µ`'Ë¡'°"¥"`,§ß°" NAPHA 'Ë¡": ºYâ¢'¬ Source: Authors. 122 · »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ 122 TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand Figure 4.13 Projected Annual Flow of Life-Years Saved under NAPHA ¿"æ 4.13 °"§"¥ª­¡"°­· Õ"¬ÿ¢--¬'Ë--°..."«â¥â,,·µà­ªï¿"¬,,µâ,§ß°"¿" 250,000 200,000 150,000 100,000 50,000 0 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 NAPHAscenario "°"å ¡¡µ`'Ë¡'°"¥"`,§ß°" NAPHA Source: Authors. 'Ë¡": ºYâ¢'¬ Costs and Cost-Effectiveness of Current Policy µâÿ·­ª­ ``º"ߥâ"µâÿ¢Õß,¬"¬ªí®®ÿ-- --¬¥â"ߪ­¡"¢Õß,¬"¬¿" §ÕÕ­ ·­--"¬ "¡"--¿"­¥--ß What are the budget implications of the NAPHA policy, and can the °à"«¥âÀÕ¡à? "¥â,,TMâ,§ß â"ߢÕßµâÿ'Ë¥âÕ`"¬«â¢â"ßµâ,,°' ¡¡µ` Thai government afford them? To answer those questions, we apply ¢--ÈæÈ" (°) ·­,,°' ¡¡µ`'Ë¡',§ß°"¿" (ß1) æËÕ'Ë®­µÕ§Ì""¡Àà"'È the cost structure described above to the baseline scenario (A) and the NAPHA scenario (D1). µâÿ®"°°"§"¥ª­¡" (°' ¡¡µ`¢--ÈæÈ"·­°''Ë¡',§ß°"¿") Projected Costs (Baseline and NAPHA) ¿"æ 4.14 · ¥ß÷ß--¬"ߥâ"°"ß`¢Õß,¬"¬¿" æâÕ¡¥â«¬°"--°..."¥â«¬¬" µâ"«-- ¢--È'Ë Õß,¥¬ª'¬'¬°--°' ¡¡µ`¢--ÈæÈ" "§"¥ª­¡"µâÿ Figure 4.14 displays the financial implications of the NAPHA policy ªìß`¥Õà"å À-- ·­· ¥ß,,ÀâÀÁ«à" ,,¡àTMâ" µâÿ¥--ß°à"« æ`Ë¡¢÷Ȫì 30 with second-line therapy compared with those of the baseline. We à"¢Õßµâÿ'Ë°`¥¢÷È,,°' ¡¡µ`¢--ÈæÈ" µâÿ§"¥ª­¡"¢Õß,§ß°" project costs in millions of U.S. dollars and show that they soon attain --°..."¥â«¬¬"µâ"«-- Õ¥ å--Ȫìµâÿ ÿ` ´÷Ëß«¡÷ßµâÿ§à"¬"µâ"«-- Õ¥ å §à"`°"ÕËÊ¢Õß,ßæ¬"" §à"`°"--§Ì"ª÷°..."·­°"µ«®À"TMÈÕ,¥¬ ¡--§ Figure 4.14 Projected Net Costs of ART under NAPHA ¿"æ 4.14 °"§"¥ª­¡"µâÿ ÿ`,,°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¿"¬,,µâ,§ß°"¿" 600 500 400 million 300 â"¥Õ"å À--US$ 200 100 0 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 NAPHAscenario "°"å ¡¡µ`'Ë¡'°"¥"`,§ß°" NAPHA 'Ë¡": ºYâ¢'¬ Source: Authors. The Effects of Thailand's Current AIDS Policy · 123 º®"°,¬"¬Õ¥ å¢Õߪ­»¬,,ªí®®ÿ-- 123 ,,® ·­µâÿ ÿ`§à"--°..."§«"¡®ÁªÉ«¬®"°°"µ`¥TMÈÕ©«¬,Õ°" °"§Ì"« a sum more than 30 times the cost of the baseline scenario. Projected µâÿ ÿ`Àà"'È costs of ART are the net costs, which add the costs of ART drugs, other hospital services, VCT, and the net cost of treating opportunis- ¥âµâÿ'ËÀ"¬ª¢Õß°"--°..."§«"¡®ÁªÉ«¬,,TMà«ß`Ë¡ ,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ·­«°µâÿ--È°--¢â"ª Yà¬Õ¥«¡¡ËÕ°" --°..."¡à Ì"Á® µâÿ®­¢÷È÷ß®ÿ¥ Yß ÿ¥÷ß 500 ¥Õà"å À-- µàÕªï,, æ.» 2562 tic illnesses. These net cost computations subtract the forgone costs of ,¥¬§`¥µ"¡§à"ß`,, æ.». 2547 ( 2 À¡Ëâ"") °àÕ'Ë®­`Ë¡¥ß treatment of those illnesses at the beginning of ART and then add those costs back to the total when treatment fails. Costs will peak in 2019 at US$500 million in 2004 dollars (B 20 billion) per year before ¿"æ 4.15 ·¬°µâÿ«¡¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢Õß¿"§-- ,, °' ¡¡µ`'Ë¡',§ß°"¿"ÕÕ°ªì ૪­°Õ 4 ª­°" ¥â·°à: ëleveling off. Figure 4.15 breaks the total cost of public ART in the NAPHA sce- ºYâªÉ«¬'Ë· ¥ßÕ"°" ,,°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢--È·° ënario ºYâªÉ«¬'Ë· ¥ßÕ"°" ,,°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢--È'Ë Õß into four components: ë· symptomaticpatients,,°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢--È·° ºYâªÉ«¬'Ë¡à· ¥ßÕ"°" infirst-linetherapy ë· symptomaticpatients,,°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢--È'Ë Õß ºYâªÉ«¬'Ë¡à· ¥ßÕ"°" insecond-linetherapy · asymptomatic patients in first-line therapy ®"°ªï æ.» 2553 §à",,TMâ®à"¬ Ì"À--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,¢--È'Ë Õß --È §`¥ªì°«à"§÷ËßÀ÷ËߢÕßµâÿ,,°"--°..."--ÈßÀ¡¥ æÕ÷ßTMà«ß `È ÿ¥°"§"¥ · asymptomatic patients in second-line therapy. ª­¡" °"--°...",,¢--È'Ë Õß Ì"À--ºYâªÉ«¬®Ì"«À÷Ëß,, 'Ë¢ÕߺYâªÉ«¬--ÈßÀ¡¥ §`¥ ªì "¡ à« 'Ë¢Õßߪ­¡",,°"--°..." (¿"æ 4.16) Beginning in 2010, expenditures on second-line therapy generate more than half the cost of treatment. By the end of the projection, second-line therapy for one-fourth of all the patients are responsible for three-fourths of the treatment budget (figure 4.16). ¿"æ 4.15 °"§"¥ª­¡"µâÿ«¡,,°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢Õß¿"§-- ¿"¬,,µâ,¬"¬ ¿" ·¬°µ"¡ª­¿¢Õß°"--°..." Figure 4.15 Projected Total Cost of Public ART under NAPHA by Line of Treatment 500 450 400 350 300 million 250 â"¥Õ"å À--US$ 200 150 100 50 0 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 °"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢--È·° "À--ºYâªÉ«¬'Ë¡à· ¥ßÕ"°" first-line ART for asymptomatic patients °"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢--È'Ë Õß "À--ºYâªÉ«¬'Ë¡à· ¥ßÕ"°" second-line ART for asymptomatic patients °"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢--È·° "À--ºYâªÉ«¬'Ë· ¥ßÕ"°" first-line ART for symptomatic patients °"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢--È'Ë Õß "À--ºYâªÉ«¬'Ë· ¥ßÕ"°" second-line ART for symptomatic patients 'Ë¡": ºYâ¢'¬ Source: Authors. 124 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ 124 · TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand ¿"æ 4.16 Õ--µ" à«âÕ¬­¢Õßµâÿ--ÈßÀ¡¥¢Õß,§ß°"¿" ´÷Ëß°`¥®"°°"--°..."¥â«¬¬"µâ"«-- Figure 4.16 Percentage of Total Cost of NAPHA Attributable to Second-Line ART Õ¥ å,,¢--È'Ë Õß 100 80 60 âÕ¬­ percentages 40 20 0 2543 2545 2547 2549 2551 2553 2555 2557 2559 2561 2563 2565 2567 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 cost of first-line ART µâÿ¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢--È'ËÀ÷Ëß µâÿ¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢--È'Ë Õß cost of second-line ART patients on second-line ART ºYâªÉ«¬'Ë¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢--È'Ë Õß 'Ë¡": ºYâ¢'¬ Source: Authors. As explained above, these projections assume constant future ¥--ß'Ë¥âÕ`"¬«â¢â"ߵ⠰"§"¥ª­¡"¥--ß°à"« ®­¬÷¥µ"¡ ¡¡µ`""§"§ß'Ë prices. Of course, if the price of second-line treatment falls as much as ,,Õ"§µ ·àÕ«à" À"°"§"§à"--°...",,¢--È'Ë Õߥߪ¡"°à"'Ë"§"§à"--°..." the price of first-line treatment has fallen, the cost of second-line ,,¢--È·°¥â¥ß µâÿ¢Õß°"--°...",,¢--È'Ë Õß ·­µâÿ--ÈßÀ¡¥®­¥ßª¥â«¬ treatment--and thus the overall costs--will be greatly reduced. How- Õ¬à"ß¡"° Õ¬à"ß°Áµ"¡ °"®®"µàÕÕߢÕßÕߧå°"§â",° ·­°"®®"­¥-- ever, ongoing World Trade Organization negotiations and bilateral «`¿"§'­À«à"ߪ­» À--Õ¡`°"°--ª­»ÕËÊ TMà "´` ®' ·Õø`°",,µâ negotiations between the United States and countries such as Brazil, ·­ª­»¬'Ë°Ì"--ߥÌ"`°"Õ¬Yà ¥YÀ¡Õ«à"®­ `¡ â"ß°"ªÑÕß°--¥â" `` China, South Africa, and Thailand are tending to strengthen patent --µ Ì"À--¬"--ÈßÀ¡¥ ¥--ß--È ,, "°"å®Ì"ÕßÀà"'È "®÷ß,,Àâ§à"¬"§ß'˵ե protection regimes for all drugs. Accordingly, in these simulations, we TMà«ß­¬­°"§"¥ª­¡" ,,'Ë 6 "®­«`§"­Àå÷ߧ«"¡°­°­Õ¢Õß keep drug prices unchanged throughout the projection period. In °"§"¥ª­¡"¥â"µâÿ ·­º°'ˬ«°--ª­ ``º¢ÕßµâÿµàÕ°' ¡¡µ`ÕËÊ chapter 6, we analyze the sensitivity of the cost projections and the «¡--Èߧ«"¡ªìª¥â'Ë®­¡'¬"µâ"«-- Õ¥ å¢--È'Ë Õß'Ë¡'µâÿµË" cost-effectiveness results to various alternative assumptions, including the possibility of low-cost second-line drugs. --¬"ߥâ"°"ß`¢Õß,§ß°"¿" °"§Ì"«¢â"ߵ⠥â§"¥ª­¡"÷ßµâÿ'Ëæ`Ë¡¢÷È,,·µà­ªï¢Õß,§ß°"¿"'Ë¡' Financial Implications of NAPHA µàÕ--"¬ °"§"¥ª­¡"µâÿ · ¥ß,,ÀâÀÁ«à" ¿"¬,,µâ,§ß â"ß,¬"¬ The calculations above project the annual incremental cost of the ¿" ¥--ß'Ë¥â¡'°"«"ß·®Ì"Õß«â µâÿ®­æ`Ë¡¢÷ÈÕ¬à"ßTM--¥® ,¥¬ Yߢ÷Ȫì NAPHA program to the Thai government.25 Cost projections show "¡à"¢Õߧà",,TMâ®à"¬,,°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,ªí®®ÿ--¿"¬,,¡à°'Ëªï ·« that under the NAPHA policy as modeled here, costs increase sharply, ,â¡¢Õß°"µ`,µÕ¬à"ß«¥Á«TMà'È ®­ªìª®÷ß æ.». 2563 ´÷Ëßµâÿ,¥¬«¡ tripling current ART expenditures in a few years. The trend of rapid ®­Õ¬Yà'Ë­¥--,,°â§'¬ß°-- 500 â"¥Õà"å À--µ"¡§à"ß`¥Õà"å À--,, æ.». growth continues until 2020, when total expenditure levels off at close 2547 (4 À¡Ëâ"") µàÕªï §à"ªí®®ÿ-- Ì"À--°­· §à",,TMâ®à"¬æ`Ë¡µ`¡,,Õ"§µ to US$500 million in 2004 dollars (B 40 billion) per year. The present ´÷Ëß°`¥®"°,§ß°"¿"§`¥ªìß`«¡ 5.6 æ--â"¥Õà"å À-- ÀÕ 226.4 æ-- value of the future stream of additional expenditures engendered by â"" ®÷ß æ.» .2568 ,¥¬§`¥µ"¡§à"ß`¥Õà"å Ì"À--,, æ.». 2547 º®"°,¬"¬Õ¥ å¢Õߪ­»¬,,ªí®®ÿ-- 125 ª­»¬ "¡"·°--§à",,TMâ®à"¬¡À"»"¢"¥'È¥âÀÕ¡à? --Èß'È §Ì"«à" "¡"--¥â--È ¡à¡'§Ì"®Ì"°--¥§«"¡"ߥâ"»...»" µåÕ¬à"ßµ"¬µ--« §«"¡ "¡",,°"·°--¿"­¥--ß°à"«¥â ,,'Ë ÿ¥·â« ªì°"µ--¥ `"ߥâ"°"¡Õß «à"ºYâ¡' à«¥â à« '¬'Ë°'ˬ«¢âÕß ®­ "¡"--¿"­§à",,TMâ®à"¬,,­¥--'Ë°Ì"À¥«â¥â ÀÕ¡à Õ¬à"ß°Áµ"¡ ,,·ÿ°ª­» °"æ`Ë¡¢÷ÈÕ¬à"ß¡"°·­,¥¬--'¢Õß ®Ì"«·­Õ--µ" à«¢Õߧà",,TMâ®à"¬¢Õß--" ´÷ËßµâÕßÕÿ`»,,Àâ·°à,§æ'¬ß,§¥'¬«--È ®÷ߪìËÕß'˵âÕß¡'°"æ`®""µ--¥ ` °"æ`Ë¡¢÷È¢Õßµâÿ¥--ß°à"« ´÷Ëߥâ--°" --÷°«âªì°"ø,,°àÕÀâ"'È Õ«à"ªì°"æ`Ë¡¢÷ÈÕ¬à"ß©--æ--·­¡"°¡"¬ ¡à«à"®­¥â«¬¡"µ",,¥ µ""ß 4.7 ·­ 4.8 ª'¬'¬§à",,TMâ®à"¬,,Õ"§µ®"°°"§"¥ª­¡"´÷Ëß «¡÷ßߪ­¡"Õ¥ å,,­¥--'˧"¥«â °--ߪ­¡"¥â" ÿ¢¿"æ--ÈßÀ¡¥ ,¥¬µ--Èß ¡¡µ`"«à" ߪ­¡"--Èß Õß à«æ`Ë¡¢÷È,,Õ--µ"§ß'Ë'ËâÕ¬­ 5.2 µàÕªïµ"¡§à"'Ë ·â®`ß ,, æ.». 2547 µâÿ ÿ`¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¿"¬,,µâ ,§ß°"¿"Õ¬Yà'˪­¡" 773. â"¥Õà"å À-- (3,000 â"") ´÷Ëß Yß°«à"'Ë ßª­¡"Õ¥ å'Ë«"ß«â Ì"À--ªï--È÷ßâÕ¬­ 26 ·­§`¥ªìâÕ¬­ 6.5 ¢Õßß ª­¡" ÿ¢¿"æ¢Õߪ­» ®"°°"'˵âÕß,,TMâߪ­¡"ª­¡"âÕ¬­ 1 ¢Õßß ª­¡" ÿ¢¿"æ--ÈßÀ¡¥ ·­ª­¡"À÷Ëß,, "¡¢Õßߪ­¡"Õ¥ å,, æ.». 2544 ®÷ß¡'°"§"¥ª­¡"«à" ¡ËÕ÷ß æ.». 2556 µâÿ,,°"--°...",§Õ¥ å ®­ æ`Ë¡¢÷È®÷ß°ÕÀ÷Ëß,, 'Ë¢Õßߪ­¡" ÿ¢¿"æ,¥¬«¡ ·­ª­¡"®Á¥à"¢Õß ßª­¡"Õ¥ å'˧"¥ª­¡"«â ('ËÕ--µ"°"æ`Ë¡·§ß'Ë) ૵âÿ¿"¬À--ß ­¬­ «"¥--ß°à"« ®­æ`Ë¡¢÷È,,Õ--µ"'ËTMâ"ß ¥--ß--È æÕ÷ߪï æ.». 2568 µâÿ ¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ®­Õ¬Yà'˪­¡" 'Ëà"¢Õßߪ­¡"Õ¥ å'Ë¡' °"æ`Ë¡¢÷ÈÕ¬à"ߧß'Ë ·­ª­¡"âÕ¬­ 13.5 ¢Õßߪ­¡" ÿ¢¿"æ'Ë¡'°"§"¥ ª­¡"«â Õ°ÀÕ®"°"¬--,¥¬--Ë«ª·â« ª­»¬¬--ß¡'·Ààßß`ÿÕ'° Õß·Ààß'Ë ®­,,Àâÿ -- ÿµâÿ'Ëæ`Ë¡¢÷ÈÕ¬à"ß«¥Á«,,°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ·Ààßÿ·Ààß·° §Õ °Õßÿ,°æËÕµàÕµâ",§Õ¥ å «--,§ ·­¡"'¬ (The Global Fund to Fight AIDS, Tuberculosis, and Malaria>GFATM) ´÷Ëߥâ,,Àâÿ ®Ì"« 200 â"¥Õà"å À-- (8 æ--â"") ·°àª­» Ì"À--Õ'° Õß "¡ªï¢â"ß Àâ" ,¥¬ÿ¥--ß°à"« ®Ì"« 13.5 â"¥Õà"å À-- (540 â"") ¥â®"­®ß,,Àâ ·°à°­«ß "" ÿ¢æËÕ,,Àâ§Õ§ÿ¡µâÿ¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,, æ.». 2547 Ì"À--·Ààßß`ÿ·Ààß'Ë Õß ¥â·°à,§ß°"ª­°-- ÿ¢¿"æ ­¥--TM"µ`À"¬,§ß°" TMà ,§ß°"À--°ª­°-- ÿ¢¿"æâ«Àâ" (Universal Coverage Scheme-UCS) ,§ß°"ª­°-- --ߧ¡ Ì"À--ºYâ'˧¬Ì"ß",,Õߧ尡" °àÕ ·­,§ß°"ª­°-- ÿ¢¿"æ¢â""TM°" ´÷Ëß,§ß°"Àà"'È ¬--ߪì·Ààßÿ -- ÿ,,°"¥Y·ºYâµ`¥TMÈÕ«-- ÕTMÕ«'·­ºYâªÉ«¬Õ¥ å «¡--Èß,§ß°"--°..."¥â«¬ ¬"µâ"«-- Õ¥ å¥â«¬ ,, æ.». 2544 ª­»¬ "¡"ÿªÑ"À¡"¬,,°"¥Y· ÿ¢¿"æÕ¬à"ßâ«Àâ"¥â ¥â«¬°"¢¬"¬§«"¡§Õ§ÿ¡¢Õߪ­°--,¥¬ºà""ß ,§ß°"À--°ª­°-- ÿ¢¿"æâ«Àâ" ,,ªï æ.». 2547 ,§ß°"À--°ª­°-- ÿ¢¿"æ 2555 11.1 4.7 0.7 6.6 2.2 421.9 150.5 260.9 61.9 19.5 2554 11.6 4.7 0.7 6.4 2.2 391.2 148.0 232.7 59.5 18.0 2544-2568 2553 12.0 4.6 0.7 6.2 2.3 355.4 143.2 201.8 56.8 16.4 æ.». 2552 12.2 4.5 0.7 6.1 2.3 314.8 135.5 169.0 53.7 14.7 2551 12.4 4.4 0.8 6.1 2.4 270.5 125.0 135.5 50.1 13.0 2550 12.4 4.4 0.8 6.2 2.4 224.0 112.0 102.4 45.7 11.1 2549 12.4 4.3 0.8 6.3 2.5 176.8 96.6 71.1 40.2 9.1 «¡--Èß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,¢--È'Ë Õß 2548 12.4 4.3 0.8 6.3 2.5 130.8 78.8 43.3 33.1 6.9 2547 12.5 4.3 0.8 6.3 2.5 77.3 46.4 21.6 27.9 6.3 2546 12.4 4.2 0.8 6.1 2.3 33.3 18.9 8.3 24.8 5.9 2545 11.4 4.0 0.6 5.6 2.2 19.2 10.3 2.7 14.3 3.7 2544 10.7 3.3 0.4 3.5 1.6 10.9 3.3 0.5 4.8 2.3 2543 ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- (%) (%) (%) µâÿ§"¥ª­¡"¢Õß,¬"¬¿ "À--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å(ÕÕ"å') ¿" 4.7 (%) 126 µ""ß ¢--ÈæÈ" µâÿ ÿ`¢ÕßÕÕ"å' µâÿÕÕ"å'¢--È·° µâÿÕÕ"å'¢--È'Ë Õß à«·àߢÕßµâÿ ÕÕ"å'¢--È'Ë Õß à«·àߢÕߺYâ'Ë--°" --°..."¥â«¬¬"µâ"«-- Õ¥ å,,¢--È'Ë Õß ,,TMâ,¬"¬ µâÿ ÿ`¢ÕßÕÕ"å' µâÿÕÕ"å'¢--È·° µâÿÕÕ"å'¢--È'Ë Õß à«·àߢÕßµâÿ¢--È'Ë Õß à«·àߢÕߺYâ'Ë--°" --°..."¥â«¬¬"µâ"«-- Õ¥ å,,¢--È'Ë Õß 2568 7.0 4.4 0.5 7.8 1.8 477.0 111.4 355.3 74.5 31.2 2567 7.3 4.6 0.6 8.0 1.8 485.3 115.0 360.0 74.2 30.7 2566 7.5 4.7 0.6 8.1 1.9 492.7 118.8 363.7 73.8 30.2 2565 7.9 4.8 0.6 8.3 1.9 498.9 122.6 366.1 73.4 29.6 2564 8.2 5.0 0.7 8.3 1.9 503.8 126.6 367.1 72.9 28.9 2563 8.5 5.1 0.7 8.3 2.0 507.0 130.6 366.3 72.2 28.2 2562 8.8 5.1 0.7 8.2 2.0 508.1 134.5 363.4 71.5 27.4 ¡à¡'¢âÕ¡Y= 2561 9.1 5.1 0.7 8.1 2.0 506.7 138.4 358.2 70.7 26.6 ------- 2560 9.4 5.1 0.7 7.9 2.0 502.4 142.0 350.2 69.7 25.6 2547 2559 9.6 5.1 0.7 7.7 2.1 æ.».,, 494.8 145.3 339.3 68.6 24.6 2558 9.9 5.0 0.7 7.4 2.1 483.4 148.1 325.0 67.2 23.5 2557 10.2 4.9 0.7 7.2 2.1 467.7 150.1 307.3 65.7 22.2 · ¥ßªìÀ૬â"¥Õà" À-- 2556 10.7 4.8 0.7 6.9 2.2 447.3 151.0 285.9 63.9 20.9 µàÕ (%) (%) (%) ¿" §à"¢Õßß`--ÈßÀ¡¥ 4.7 (%) ºYâ¢'¬ µ""ß ¢--ÈæÈ" µâÿ ÿ`¢ÕßÕÕ"å' µâÿÕÕ"å'¢--È·° µâÿÕÕ"å'¢--È'Ë Õß à«·àߢÕßµâÿ ÕÕ"å'¢--È'Ë Õß à«·àߢÕߺYâ'Ë--°" --°..."¥â«¬¬"µâ"«-- Õ¥ å,,¢--È'Ë Õß ,,TMâ,¬"¬ µâÿ ÿ`¢ÕßÕÕ"å' µâÿÕÕ"å'¢--È·° µâÿÕÕ"å'¢--È'Ë Õß à«·àߢÕßµâÿ¢--È 'Ë Õß à«·àߢÕߺYâ'Ë--°" --°..."¥â«¬¬"µâ"«-- Õ¥ å,,¢--È'Ë Õß 'Ë¡": À¡"¬Àµÿ: 127 2555 11.1 61.1 1,799.6 18.2 0.6 421.9 61.1 1,799.6 690.2 23.4 2554 11.6 58.1 1,709.1 20.0 0.7 391.2 58.1 1,709.1 673.3 22.9 2553 12.0 55.2 1,623.0 21.8 0.7 355.4 55.2 1,623.0 643.5 21.9 2552 12.2 52.5 1,541.3 23.3 0.8 314.8 52.5 1,541.3 599.6 20.4 ,¥¬§`¥ªìÕ--µ" à«âÕ¬­¢Õßߪ­¡"Õ¥ å·­ 2551 12.4 49.9 1,463.8 24.8 0.8 270.5 49.9 1,463.8 542.1 18.5 2550 12.4 71.8 1,390.1 17.3 0.9 224.0 71.8 1,390.1 312.0 16.1 «¡--Èß°"--°...",,¢--È'Ë Õß 2549 12.4 69.5 1,320.1 17.9 0.9 176.8 69.5 1,320.1 254.5 13.4 (ÕÕ"å') 2548 12.4 67.2 1,253.7 18.5 1.0 130.8 67.2 1,253.7 134.6 10.4 ¡à¡'¢âÕ¡Y= ------- 2547 12.5 61.4 1,190.6 20.3 1.0 77.3 61.4 1,190.6 125.6 6.5 2547 2546 12.4 29.7 1,130.7 41.7 1.1 33.3 29.7 1,130.7 112.1 2.9 æ.».,, 2545 11.4 36.8 1,130.7 31.0 1.0 19.2 36.8 1,130.7 52.1 1.7 2544-2568 2544 10.7 37.2 0.9 1.0 1,130.7 28.9 10.9 37.2 1,130.7 29.2 æ.».,, 2543 ---- ---- ---- ---- ---- ---- ---- ---- ---- ---- · ¥ßªìÀ૬â"¥Õà" À-- µâÿ§"¥ª­¡"¢Õß,¬"¬¿" Ì"À--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (%) (%) (%) (%) ¿" §à"¢Õßß`--ÈßÀ¡¥ 4.8 ºYâ¢'¬ 128 µ""ß ßª­¡" ÿ¢¿"æ--ÈßÀ¡¥ ¢--ÈæÈ" µâÿ ÿ`¢ÕßÕÕ"å' ߪ­¡"Õ¥ å ߪ­¡" ÿ¢¿"æ Õ--µ" ૵àÕß ª­¡"Õ¥ å Õ--µ" ૵àÕß ª­¡" ÿ¢¿"æ ,,TMâ,¬"¬ µâÿ ÿ`¢ÕßÕÕ"å' ߪ­¡"Õ¥ å ߪ­¡" ÿ¢¿"æ Õ--µ" ૵àÕß ª­¡"Õ¥ å Õ--µ" ૵àÕß ª­¡" ÿ¢¿"æ 'Ë¡": À¡"¬Àµÿ: 2568 7.0 118.1 5.9 0.2 ·­§à" 3,521.7 477.0 118.1 3,521.7 403.7 13.5 2567 7.3 112.3 6.5 0.2 3,344.4 485.3 112.3 3,344.4 432.1 14.5 2566 7.5 106.7 7.1 0.2 ߪ­¡" ÿ¢¿"æ 3,176.1 492.7 106.7 3,176.1 461.5 15.5 ¥â«¡÷ß°"®--¥ ߪ­¡"§--Èß 2565 7.9 101.5 7.7 0.3 3,016.2 498.9 101.5 3,016.2 491.7 16.5 2547-2551 2564 8.2 96.5 8.5 0.3 2,864.4 503.8 96.5 2,864.4 522.3 17.6 "À--ߪ­¡"Õ¥ å µàÕªï 2563 8.5 91.7 9.3 0.3 2,720.3 507.0 91.7 2,720.3 552.9 18.6 5.2% 2562 8.8 87.2 2,583.3 10.1 0.3 508.1 87.2 2,583.3 582.9 19.7 2561 9.1 82.8 2,453.3 10.9 0.4 506.7 82.8 2,453.3 611.6 20.7 ,,Àâ,,TMâÕ--µ"°"µ`,µ --Èß'È "À--ߪ­¡"Õ¥ å,,­À«à"ߪïæ.». 2560 9.4 78.8 2,329.8 11.9 0.4 502.4 78.8 2,329.8 638.0 21.6 2547 2547 æ.». 2559 9.6 æ.».,, 74.9 2,212.6 12.9 0.4 494.8 74.9 2,212.6 660.9 22.4 ·­¡"'¬ 2558 9.9 «--,§ 71.2 2,101.2 14.0 0.5 483.4 71.2 2.101.2 679.3 23.0 ,¥¬¬÷¥µ"¡µ--«¢¢Õߪï 2557 10.3 67.6 1,995.4 15.2 0.5 467.7 37.6 1,995.4 691.4 23.4 · ¥ßªìÀ૬â"¥Õà"å À-- 2547-2568 2556 10.7 64.3 1,895.0 16.6 0.6 447.3 64.3 1,895.0 695.0 23.6 æ.». µàÕ (%) (%) (%) (%) ®"° ®"°°Õßÿ,°æËÕ--°...",§Õ¥ å §à"¢Õßß`--ÈßÀ¡¥ 4.8 ºYâ¢'¬ µ""ß ¢--ÈæÈ" µâÿ ÿ`¢ÕßÕÕ"å' ߪ­¡"Õ¥ å ߪ­¡" ÿ¢¿"æ Õ--µ" ૵àÕß ª­¡"Õ¥ å Õ--µ" ૵àÕß ª­¡" ÿ¢¿"æ ,,TMâ,¬"¬¿" µâÿ ÿ`¢ÕßÕÕ"å' ߪ­¡"Õ¥ å ߪ­¡" ÿ¢¿"æ Õ--µ" ૵àÕß ª­¡"Õ¥ å Õ--µ" ૵àÕß ª­¡" ÿ¢¿"æ 'Ë¡": À¡"¬Àµÿ: ,,TMâ®à"¬ "" ÿ¢ ·°·­§--Èß'Ë Õß 129 130 · »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ 130 TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand covered by NAPHA), with a nominal fee of less than US$0.80 per â«Àâ" ¥â§Õ§ÿ¡÷ßµâÿ°"--°...",§®"°°"µ`¥TMÈÕ©«¬,Õ°" «¡--Èß°" visit (B 30). The Social Security Scheme covers treatment of oppor- ¥ Õ,,ÀâÕߪØ`--µ`°" ·­`°",ßæ¬"" (¬°«âµâÿ§à"¬"µâ"«-- Õ¥ å tunistic infections and, since August 2004, also the cost of ART (with Ì"À--ºYâªÉ«¬'ËÕ¬Yà,,,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ´÷ËßÕ¬Yà¿"¬,,µâ,§ß°"¿") caps) for its affiliated members (but not for their families). The Civil ,¥¬¡'§à"¡'¬¡'Ë°Ì"À¥«ââÕ¬°«à" 0.80 ¥Õà"å À-- µàÕ°"¢â"æ·æ¬å Service Medical Benefit Scheme covers all care for PHAs including À÷Ëߧ--Èß (30 ") Ì"À--,§ß°"ª­°-- --ߧ¡ ®­§Õ§ÿ¡°"--°..."°"µ`¥TMÈÕ ART (see chapter 2). ,§©«¬,Õ°" ·­µ--Èß·µà¥Õ `ßÀ"§¡ æ.». 2547 ªìµâ¡" ,§ß°"¥--ß°à"« ¬--ß §Õ§ÿ¡÷ßµâÿ¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (,¥¬¡'°"®Ì"°--¥®Ì"«) Although the projection shows a significant increase in ART expen- diture over time, it remains less than 24 percent of the (constant Ì"À--ºYâ'ËÕ¬Yà,,,§ß°"ª­°-- --ߧ¡ (·µà¡à«¡÷ß ¡"TM`°§Õ§--«) à«,§ß°" growth) national health budget. Because a reduction of more than 20 ª­°-- ÿ¢¿"æ¢â""TM°"--È §Õ§ÿ¡°"¥Y·--ÈßÀ¡¥ Ì"À--ºYâµ`¥TMÈÕ«-- ÕTMÕ«' percent in other health expenditures is unlikely, Thailand can finance ·­ºYâªÉ«¬Õ¥ å ´÷Ëß«¡÷ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¥â«¬ (,ª¥¥Y'Ë 2) these additional expenditures from such outside sources as the ÷ß·¡â«à" °"§"¥ª­¡"®­· ¥ß÷ߧà",,TMâ®à"¬'Ëæ`Ë¡¢÷È®Ì"«¡"°¢Õß,§ß°" GFATM and health insurance schemes, or it can increase the size of --°..."¥â«¬¬"µâ"«-- Õ¥ å¡ËÕ«"ºà"ª ·µà§à",,TMâ®à"¬¥--ß°à"« ¬--ߧߵË"°«à"âÕ¬ the overall health budget as a share of total government spending. ­ 24 ¢Õßߪ­¡" ÿ¢¿"æ­¥--TM"µ` (´÷Ëß¡'°"æ`Ë¡¢÷ÈÕ¬à"ߧß'Ë) ËÕß®"°°" ¥§à",,TMâ®à"¬¥â" ÿ¢¿"æ,,¥â"ÕËÊ°«à"âÕ¬­ 20 --È·®­ªìª¡à¥â ª­» Cost-Effectiveness of NAPHA ¬®÷ßµâÕßÀ"ÿ -- ÿ§à",,TMâ®à"¬¥--ß°à"«®"°·Ààßÿ¿"¬Õ° TMà °Õßÿ,° æËÕµàÕµâ",§Õ¥ å «--,§ ·­¡"'¬ ·­,§ß°"ª­°-- ÿ¢¿"æµà"ßÊ ÀÕ Figure 4.17 presents the model's projections of the annual benefits and Õ"®æ`ˡߪ­¡" ÿ¢¿"æ,¥¬«¡ ,¥¬Õªì§à",,TMâ®à"¬ à«À÷ËߢÕß--" the annual costs of the NAPHA policy, compared with the baseline scenario of limited public sector access to ART. The annual benefits ª­ ``º"ߥâ"µâÿ¢Õß,§ß°"¿" measured in life-years saved increase rapidly, peaking in 2017. These ¿"æ 4.17 · ¥ß°"§"¥ª­¡"¢Õß·®Ì"Õß ÷ߪ­,¬TMå,,·­µâÿ¢Õß benefits begin to level off as the stock of AIDS patients gradually ,¬"¬¿",,·µà­ªï ,¥¬ª'¬'¬°-- "°"å¢--ÈæÈ",,°''ˬ--ß¡'¢âÕ declines. Because of the slow transition of patients to the more expen- ®Ì"°--¥,,°"¢â"÷ß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢Õß¿"§-- ૺª­,¬TMå sive second-line therapy, costs continue rising, peaking at about 'Ë¥â--,,·µà­ªï ®­«--¥®"°®Ì"«Õ"¬ÿ¢--¬'Ë--°..."«â¥â (life-years saved) ´÷Ëßæ`Ë¡ US$500 million (B 20 billion) in 2020 before leveling off. ¢÷ÈÕ¬à"ß«¥Á« ,¥¬¡'®Ì"« Yß ÿ¥,, æ.». 2560 ´÷Ëߺª­,¬TMå¥--ß°à"« ®­`Ë¡ Figure 4.17 Benefit (Life-Years Saved) and Costs of NAPHA Relative to Baseline ¿"æ 4.17 ºª­,¬TMå (®Ì"«Õ"¬ÿ¢--¬'Ë--°..."«â¥â) ·­µâÿ¢Õß,§ß°"¿" ¡ËÕ'¬°-- "°"å ¡¡µ`¢--ÈæÈ" 250,000 600 200,000 500 400 US$ saved 150,000 â"¥Õà"å À-- million 300 Õ"¬ÿ¢--¬'Ë--°..."«â¥â 100,000 life-years 200 ®"« 50,000 100 0 0 2543 2545 2547 2549 2551 2553 2555 2557 2559 2561 2563 2565 2567 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 ®"«Õ"¬ÿ¢--¬'Ë--°..."«â¥â life-years saved µâÿ ÿ`¢Õ߬"µâ"«-- Õ¥ å net cost of ART 'Ë¡": ºYâ¢'¬ Source: Authors. The Effects of Thailand's Current AIDS Policy · 131 º®"°,¬"¬Õ¥ å¢Õߪ­»¬,,ªí®®ÿ-- 131 ¥­¥--ß ¡ËÕ®Ì"«ºYâªÉ«¬Õ¥ å'Ë¡'Õ¬Yà§àÕ¬Ê '¬TM'«`µß ·­ËÕß®"°ºYâªÉ«¬`Ë¡ When the benefits of any intervention occur relatively soon after ª'ˬª--°"--°...",,¢--È'Ë Õß'Ë¡'"§"·æß°«à"Õ¬à"ßTMâ"Ê Ì",,Àâµâÿ¬--ß Yߢ÷È the program is launched and costs occur later, discounting reduces the µàÕª ·­¢÷È÷ß®ÿ¥ Yß ÿ¥'˪­¡" 500 â"¥Õà"å À-- (2 À¡Ëâ"") ,, importance of the future costs in relation to the near-term benefits æ.». 2563 °àÕ'Ë®­`Ë¡¥­¥--ß and thus improves the cost-effectiveness of the program. Figure 4.18 presents the net present value of the cost per life-year saved for the ¡ËÕª­,¬TMå®"°°"·°·´ß,,¥Ê°`¥¢÷ȧàÕ¢â"ßÁ«À--ß®"°`Ë¡,§ß°"¥â¡à " ,,¢­'˵âÿª"°Ø¢÷È¿"¬À--ß Õ--µ" à«¥®­¥§«"¡ Ì"§--¢Õßµâÿ,, NAPHA policy, with all costs and benefits discounted back to 2002. Õ"§µ°'ˬ«°--ºª­,¬TMå'Ë¥â,,­¬­«"Õ--,,°â ·­¥--ß--È ®÷ßÌ",,À⪭ ``º The choice of discount rate has a small but significant effect on the "ߥâ"µâÿ¢Õß,§ß°"¥--ß°à"«¥'¢÷È ¿"æ 4.18 · ¥ß÷ß¡Y§à"ªí®®ÿ-- ÿ`¢Õß result. At a zero discount rate, the NAPHA program costs close to µâÿµàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â,,,¬"¬¿" ´÷Ëßµâÿ·­ºª­,¬TMå--ÈßÀ¡¥®­¥ US$2,200 (B 88,000) per life-year saved, whereas at a 15 percent dis- ,¥¬¬âÕ°--ª÷ß æ.». 2545 "ßÕ°¢ÕßÕ--µ" à«¥ (discount rate) 'È®­¡'º count rate, the cost of the same life-year saved would be US$2,000 æ'¬ßÁ°âÕ¬·µà¡'§«"¡ Ì"§--µàÕº'Ë°`¥¢÷È ®ÿ¥'ËÕ--µ" à«¥ªì»Y¬å ,§ß°" (B 8,000). At the conventional discount rate of 3 percent, the cost per ¿"¡'µâÿ,,°â§'¬ß°-- 2,200 ¥Õà"å À-- (88,000 ") µàÕÕ"¬ÿ¢--¬'Ë--°..."«â life-year saved for the NAPHA policy is US$2,145 (B 85,800), slightly ¥âÀ÷Ëߪï ,,¢­'Ë,,®ÿ¥'ËÕ--µ" à«¥âÕ¬­15 µâÿµàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â--È®­ greater than Thailand's 2002 gross national income per capita of ªì 2,000 ¥Õà"å À-- (80000 ") Ì"À--Õ--µ" à«¥¥`¡'ËâÕ¬­ 3 US$2,000 (B 80,000). µâÿµàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â®"°,¬"¬¿" ¥â·°à 2,145 ¥Õà"å (85,800 Is US$2,145 (B 85,800) a large or a small price for the Thai govern- ") ´÷Ëß¡"°°«à""¬¥â¡««¡ª­TM"TM"µ`µàÕ§,, ªï æ.». 2545 ª­»¬ 'Ë ment to pay to save years of life through a special treatment subsidy 2,000 ¥Õà"å À-- (80,000 ") æ'¬ßÁ°âÕ¬ program? Different observers have differing views. An argument for horizontal equity would ask whether the government is willing to pay ß`®Ì"« 2,145 ¥Õà"å À-- (85,800 ") ªì®Ì"«ß`'Ë¡"° ÀÕ âÕ¬ Ì"À----"¬'Ë®­µâÕß®à"¬ æËÕ,,ÀâºYâªÉ«¬¡'TM'«`µ¬"«"¢÷È®"°,§ß°",,Àâ as much to buy life-years through subsidized treatment of other adult ÿ -- ÿ°"--°..."ªìæ`»...TMà'È? ºYâ --ß°µ°"åÀ"¬à"µà"ß°Á¡'§«"¡§`¥ÀÁ illnesses, such as cancer, heart disease, or end-stage renal disease. 'Ë·µ°µà"ß°--ª §«"¡ÀÁ,µâ·¬âßæËÕ,,Àâ°`¥§«"¡à"'¬¡°--,,·«°«â"ß ®­"¡«à" Advocates of vertical equity would point out that this sum is small --"¬`¥''Ë®­®à"¬ß`¡"°¢"¥'È æËÕ¬¥TM'«`µ¢ÕߺYâªÉ«¬,¥¬°" -- ÿ°"--°..." enough to make treatment a good personal investment for people in ,§¿--¬¢â®ÁÕËÊ¢ÕߺYâ,,Àà TMà ¡­Áß ,§À--«,,® ÀÕ,§µâ¢--È ÿ¥â"¬ ÀÕ¡à ¿"æ 4.18 ª­ ``º¥â"µâÿ¢Õß,§ß°"¿",,Õ--µ" à«¥µà"ßÊ°-- Figure 4.18 Cost Effectiveness of NAPHA at Different Discount Rates 2,800 2,600 2,400 2,200 $2,145 2,000 US$1,800 â"¥Õà"å À-- 1,600 1,400 1,200 1,000 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Õ--µ" à«¥âÕ¬­ discount rate (%) µâÿµàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â cost per life-year saved gross national income per capital "¬¥â¡««¡ª­TM"TM"µ`µàÕ§ 'Ë¡": ºYâ¢'¬ Source: Authors. 132 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ ૺYâ'Ë -- ÿ§«"¡à"'¬¡,,·«÷° ®­TM'È,,ÀâÀÁ«à" ß`®Ì"«¥--ß°à"« ¬--ßÕ «à"¡'®Ì"«âÕ¬æÕ'Ë®­Ì",,Àâ°"--°..."'È ªì°"ßÿ¥â"ÿ§§'Ë¥' Ì"À-- ª­TM"TM'ËÕ¬Yà,, à«®"°Àâ" à«¢Õß°"°­®"¬"¬¥â,,ª­»¬ ´÷Ëß¡'"¬ ¥âµàÕÀ--«°`°«à" 10,000 ¥Õà"å À-- (400,000 ") ¥--ß--È æËÕ,,Àâ°`¥§«"¡ à"'¬¡,,TM`ß÷° --"§« â"ߧ«"¡¡--Ë,,®«à" ª­TM"TM,, 'Ë à«¥â"à"ߢÕß°" °­®"¬"¬¥â--È ®­ "¡"¢â"÷ß°"¥Y·--°..." ´÷Ëߪ­TM"TM'ËÕ¬Yà,, à« ÿ¥ ®"°Àâ" ૵"¡°"°­®"¬"¬¥â--È "¡"´ÈÕÀ"æËÕµÕߥ⠰àÕ'Ë®­À"Õ°-- ,,ËÕß'ȵàÕª (,,'Ë 6) "®­°--ª'˧Ì""¡«à" °"ª--,§ß°"¿" ®­ àß º÷ߪ­,¬TMå'Ë®­¥â--·­µâÿÕ¬à"ß ,¥¬'˪쪥â«à"®­Ì",,Àâ,§ß°"à" ,,®¡"°¢÷È"­,¬"¬¥â" ÿ¢¿"æ À¡"¬Àµÿ: 1. §` µ'¬ -- (æ.». 2519) §Õµ--«Õ¬à"ßÀ÷Ëß'Ë°`¥¢÷È,,­¬­·°Ê ,ª¥¥Y ·ÀàßÕË'ËÕâ"ß÷ß Ì"À--°"Ì"¡",,TMâ,,`¢Õß°"æ--" ¡à¡'ºYâ¢'¬à",,¥ æ`®""÷ߧ«"¡µâÕß°"¢âÕ¡Y,,°"«``®©--¬,,"­'˪ìµ--«àßTM'Èà«ßÀâ"÷ßÕÿª ߧå 'Ë¡'µàÕ°"¥Y·--°..." ¥--ß'Ë"¥âÌ"«â,,°"Õ`"¬¿"æ 4.2 2. ,,...Æ'»...»" µå®ÿ¿"§ ¡¡µ`"'È Õ«à"ªì·...Æ'¥'ˬ« ·­ ¡--°®­Ì"¡",,TMâæËÕª--ªÿß°"À"àÕßÕ¬¢Õß·®Ì"Õß"ß»...»" µå°'ˬ«°-- Õÿª ߧå 3. ·¡§·ø¥¥Á (æ.». 2517) ¥â,,TMâ¢âÕ°Ì"À¥ logit À"¬µ--«·ª·¡'ßËÕ¢ ªì§--Èß·° æËÕ«"ßYª·"ßÕ°¢ÕߺYâ¥`"ß ­À«à"ß°"¥`"ß,¥¬ ª­®Ì""ß ¬µå ·­ø ,,`«Õà"«´"ø"´` ,° 4. ,ª¥ --ß°µ«à" µ--«¢'˪ì»... 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"§"¢Õß«'´'' (") 30 30 30 È"À--°¢ÕßÕÿª ߧå'Ë¡'µàÕ«'´'',,­¬­ --È«¡--Èß `È (âÕ¬­) 100.0 100.0 100.0 Õ--µ"°"µ`,µ¢Õß "æ¬""'Ë,,Àâ`°"«'´'' 15.0 0.0 10.0 "§"§à"--°..."¥â«¬¬"µâ"«-- Õ¥ å (") 4.5.6.7. ¿"§-- 650 650 650 ¿"§--·¡'`°" `¡æ`»... 1,880 650 650 ¿"§Õ°TM 9,534 9,534 9,534 ¡à¡'°"¥"`,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å 30 30 30 ª`¡"¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ,, æ.». 2546 (®"« "æ¬"") 8. ¿"§-- 860 860 860 10.9.¿"§Õ°TM ¿"§--·¡'`°" `¡æ`»... 100 100 100 100 100 100 11. ¡à¡'°"¥"`,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¬ 10,282 10,282 10,282 µ--«·ª"ߥâ"Õÿª"ÕËÊ¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å 12. Õ--µ"°"µ`,µ¢Õß "æ¬""'Ë,,Àâ°"--°..."¥â«¬¬"µâ" «-- Õ¥ å (âÕ¬­) 2.5 1.5 2.5 13. Õ--µ"°"µ`,µ¢Õß "æ¬""'Ë,,Àâ°"--°..."¥â«¬¬"µâ" «-- Õ¥ å·¡'`°" `¡æ`»... (âÕ¬­) 5.0 20.0 20.0 14. Õ--µ"°"µ`,µ¢Õß "æ¬""'Ë,,Àâ°"--°..."¥â«¬¬"µâ" «-- Õ¥ å,,¿"§Õ°TM (âÕ¬­) 4.0 2.0 3.0 15. ®"«`Ë¡µâ¢ÕßTMÿ¥¬"--°..."µàÕ "æ¬""¢Õß-- (©'ˬ) 54 54 54 16. ®"«`Ë¡µâ¢ÕßTMÿ¥¬"--°..."µàÕ "æ¬""¢Õß--'Ë¡' `°" `¡æ`»... (©'ˬ) 56 56 56 17. Õ--µ" à«¢Õß»--°¬¿"æ,,°"--°..." 'Ë°"À¥«â,,Àâ·°àºYâªÉ«¬ 'Ë· ¥ßÕ"°" °àÕ'Ë®­¬Õ¡--ºYâªÉ«¬'Ë¡à· ¥ßÕ"°" ´÷Ëß¡'§à" CD4 âÕ¬°«à" 200 ´å/¡¡.3 90.0 90.0 90.0 18. Õ--µ"°"µ`,µ¢Õß "æ¬"",,¿"§----ÈßÀ¡¥ 2.0 2.0 2.0 19. ®"«TMÿ¥¬"--°...",, æ.». 2545 8,341 8,341 8,341 20. ®"«TMÿ¥¬"--°...",, æ.». 2545 16,663 16,663 16,663 'Ë¡": ¢âÕ¡Y¢Õß°­«ß "" ÿ¢·­°"ª­¡"¢ÕߺYâ¢'¬ µ--Èß·µà,,­¬­·° Àե⫬§«"¡ -- ÿ®"°Õߧå°æ--"Õ°TM ¿"æ 5.1 · ¥ß º'˧"¥ª­¡"«â Ì"À--,¬"¬Àà"'È ,, à«'Ë°'ˬ«°--,¬"¬¿"¢--ÈæÈ" ,¬"¬'Ë¥â--°" àß `¡--Èß "¡·--È ¥âæ`Ë¡®Ì"«ºYâµ`¥TMÈÕ«-- ÕTMÕ«'·­ºY⠪ɫ¬Õ¥ åÕ¬à"ßÀÁ¥âTM--¥ ,¬"¬æ`Ë¡µ`¡´÷Ëߪ"»®"°°"TM--°®Yß,,ÀâºYâªÉ«¬¢â"--°" --°..."µ--Èß·µà,,­¬­·° §"¥«à"®­¡'ª­ ``º Yߢ÷Ȫì "¡à",,·ßà'È ¡ËÕ'¬°-- ,¬"¬,,°"TM--°®Yß,,ÀâºYâªÉ«¬¢â"--°"--°..."µ--Èß·µà,,­¬­·° ·µà°"æ`Ë¡°"TM--°®Yß ,,ÀâºYâªÉ«¬¢â"--°"--°...",,­¬­·° (D2) ¢â" Yà`°" `¡æ`»... (D3) ¥âæ`Ë¡ ®Ì"«¢ÕߺYâ'ËÕ¥TM'«`µ®"°TMÈÕ«-- ÕTMÕ«'/Õ¥ å ÷ß 10,000 § ,, æ.». 25683 ¿"æ 5.2 · ¥ß«à" ,¬"¬"ßÕ°--Èß "¡,¬"¬--È ¥âËÕ­¬­«"°" '¬TM'«`µ'Ëà"®­°`¥¢÷È¿"¬,,µâ,§ß°"¿"ÕÕ°ªÕ'° ·­Õ'°§--ÈßÀ÷Ëß'Ë,¬"¬°" Policies to Strengthen Treatment Programs · 141 ,¬"¬æËÕ `¡ â"ß,§ß°"--°..." 141 Policies to Strengthen Treatment Programs · 141 ¿"æ 5.1 ®Ì"«ºYâµ`¥TMÈÕ«-- ÕTMÕ«',,ªí®®ÿ--µ"¡'˧"¥ª­¡"«â ¿"¬,,µâ "°"å'˧"¥«à"®­ °`¥¢÷ȵ"¡"ßÕ°µà"ßÊ ,, à«'Ë°'ˬ«¢âÕß°--,§ß°"¿" Figure 5.1 Projected Current HIV Cases under Alternative Scenarios Relative to NAPHA Figure 5.170,000 Projected Current HIV Cases under Alternative Scenarios Relative to NAPHA 60,000 70,000 50,000 60,000 cases ofcasesof 50,000 40,000 ºYâµ`¥TMÈÕ 40,000 30,000 ®"« number 30,000 20,000 number 10,000 20,000 10,000 0 0 2543 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 2545 2547 49 51 53 5 2000 2002 2004 "°"å 2008 2010scenarioD32014 2016 2018D42020 2022 2024 2561 2563 2565 2567 scenarioD2 252006 25D2 25 2552012 2557 2559scenario "°"å D3 "°"å D4 'Ë¡": ºYâ¢'¬ Source: Authors. scenarioD2 scenarioD3 scenarioD4 À¡"¬Àµÿ: "°"å D2 = ,¬"¬«'´''; "°"å D3 = ,¬"¬°",,Àâ`°" `¡æ`»...,, "æ¬""¢Õß--; Source: Authors. Note: Scenario D2 = VCT policy; scenario D3 = augmented public policy; scenario D4 = both "°"å D4 = °",,TMâ--Èß Õß "°"å (,¬"¬«'´'' + ,¬"¬°",,Àâ`°" `¡æ`»...,, "æ¬""¢Õß--) (VCT + augmented) policy. Note: Scenario D2 = VCT policy; scenario D3 = augmented public policy; scenario D4 = both (VCT + augmented) policy. ¿"æ 5.2 ®Ì"«ºYâ '¬TM'«`µ'˪ÑÕß°--¥âµ"¡'˧"¥ª­¡"«â ¿"¬,,µâ "°"å'˧"¥«à"®­°`¥¢÷È Figure 5.2 Projected Deaths Averted under Alternative Scenarios Relative to NAPHA µ"¡"ßÕ°µà"ßÊ ,, à«'Ë°'ˬ«¢âÕß°--,§ß°"¿" Figure 5.2 Projected Deaths Averted under Alternative Scenarios Relative to NAPHA 5,000 5,000 4,000 4,000 3,000 3,000 averted 2,000 ¬TM'«`µ'˪ÑÕß°--¥â 'ºYâ averted 2,000 deaths 1,000 deaths 1,000 ®"« 0 0 ­1,000 2001 2003 2005 2007 2009 2011 2013 2015 2017 2019 2021 2023 2025 ­1,000 25420014 252003 46 2520058 4scenario 20092 2011 20136D320158 2017 20192 20214 20236 2025 252007 50 25scenario 255 2560 256 256 256 2568 54 255 scenarioD4 scenarioD2 scenarioD3 scenarioD4 'Ë¡": ºYâ¢'¬ Source: Authors. "°"åD2255 "°"å D3 "°"å D4 D2 Source: Authors. À¡"¬Àµÿ: "°"å D2 = ,¬"¬«'´''; "°"å D3 = ,¬"¬°",,Àâ`°" `¡æ`»...,, "æ¬""¢Õß--; Note: Scenario D2 = VCT policy; scenario D3 = augmented public policy; scenario D4 = both (VCT + augmented) policy. Note: Scenario D2 = VCT policy; scenario D3 = augmented public policy; scenario D4 = both "°"å D4 = °",,TMâ--Èß Õß "°"å (,¬"¬«'´'' + ,¬"¬°",,Àâ`°" `¡æ`»...,, "æ¬""¢Õß--) (VCT + augmented) policy. mented policy (D3) is superior to the VCT policy (D2), and the both mented policy (D3) is superior to the VCT policy (D2), and the both ,,Àâ`°" `¡æ`»... (D3) --ÈÀÕ°«à",¬"¬°",,Àâ`°"ª÷°..."·­µ«®Õ¥ policy (D4) dominates the other two. In 2010, for example, the policy (D4) dominates the other two. In 2010, for example, the À"°"µ`¥TMÈÕÕTMÕ«',¥¬ ¡--§,,® («'´'')(D2) ·­,,,¬"¬'Ë,,TMâ--Èß Õß,§ß°" NAPHA policy would avert about 15,000 deaths in comparison with NAPHA policy would avert about 15,000 deaths in comparison with (D4) ®­Õ¬YàÀÕ°«à"Õ'° Õß,¬"¬ TMà ,, æ.». 2553 ,¬"¬¢Õß,§ß°"¿" the baseline. Figure 5.2 shows that in 2010 the both policy (D4) would the baseline. Figure 5.2 shows that in 2010 the both policy (D4) would ®­ "¡"¬--¬--Èß°" '¬TM'«`µ 15,000 "¬ ¡ËÕ'¬°-- "°"å¢--ÈæÈ"'Ë¡à¡' avert an additional 4,400 deaths, an improvement of about 30 percent. avert an additional 4,400 deaths, an improvement of about 30 percent. pleThese These social (and private) gains are the result of keeping more peo- °"¥Ì"`,§ß°",,¥¬ ¿"æ 5.2 · ¥ß«à" ,,æ.». 2553 ,¬"¬'Ë,,TMâ--Èß Õß social (and private) gains are the result of keeping more peo- ,§ß°" (D4) ®­TM૬¬--¬--Èß°" '¬TM'«`µ¥â 4,400 "¬ ´÷ËßÕªì°"ª--ªÿߢ÷È÷ß ple on ART. Figure 5.3 shows how many additional people will be on on ART. Figure 5.3 shows how many additional people will be on ART in each year in comparison with the NAPHA scenario. The âÕ¬­ 30 ART in each year in comparison with the NAPHA scenario. The ranking is the same, with the augmented scenario (D3) keeping about ranking is the same, with the augmented scenario (D3) keeping about 60,000 additional people on ART, more than twice as many as would 60,000 additional people on ART, more than twice as many as would º¥âµàÕ --ߧ¡ (·­ ૵--«) ªìº¡"®"°°"'ËÌ",,Àâ¡'ºYâ¢â"à«¡,§ß°"--°..." ¥â«¬¬"µâ"«-- Õ¥ åæ`Ë¡¢÷È ¿"æ 5.3 · ¥ß,,ÀâÀÁ«à" ®­¡'ª­TM"TM®Ì"«¡"° 142 · TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand 142 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ Figure 5.3 Projected HIV-Positive People on ART under Alternative Scenarios Relative to ¿"æ 5.3 ®Ì"«ºYâµ`¥TMÈÕ«-- ÕTMÕ«''Ë¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ åµ"¡'˧"¥ª­¡"«â NAPHA ¿"¬,,µâ "°"å'˧"¥«à"®­°`¥¢÷ȵ"¡"ßÕ°µà"ßÊ ,, à«'Ë°'ˬ«¢âÕß°--,§ß°"¿" 80,000 ART 70,000 on 60,000 --°"--°..."¥â«¬â" 50,000 people 40,000 µ`¥TMÈÕ'Ë¢ºYâ ¬"µâ"«-- Õ¥ å 30,000 20,000 ®"« HIV-positive10,000 0 2542001 2003 2005 252007 252009 252011 25520136 252015 252017 2019 256 4 2546 2548 50 52 54 58 60 2562 20214 252023 20258 66 256 "°"å D2 scenarioD2 "°"å D3 scenarioD3 "°"å D4 scenarioD4 'Ë¡": ºYâ¢'¬ À¡"¬Àµÿ: "°"å D2 = ,¬"¬«'´''; "°"å D3 = ,¬"¬°",,Àâ`°" `¡æ`»...,, "æ¬""¢Õß--; Source: Authors. Note: Scenario D2 = VCT policy; scenario D3 = augmented public policy; scenario D4 = both "°"å D4 = °",,TMâ--Èß Õß "°"å (,¬"¬«'´'' + ,¬"¬°",,Àâ`°" `¡æ`»...,, "æ¬""¢Õß--) (VCT + augmented) policy. Figure 5.4 Projected Annual Life-Years Saved under Alternative Scenarios Relative to ¿"æ 5.4 ®Ì"«Õ"¬ÿ¢--¬'Ë--°..."«â¥âµ"¡'˧"¥ª­¡"«â ¿"¬,,µâ "°"å'˧"¥«à"®­°`¥¢÷ȵ"¡ NAPHA "ßÕ°µà"ßÊ ,, à«'Ë°'ˬ«¢âÕß°--,§ß°"¿" 80,000 70,000 60,000 saved 50,000 40,000 30,000 Õ"¬ÿ¢--¬'Ë--°..."«â¥â life-years 20,000 10,000 0 2544 2001 2003 2005 2007 2009 2011 255 2546 2548 2550 2552 2554 6 2013 2015 2017 2019 2021 2023 2025 2558 2560 2562 2564 2566 2568 "°"å D2 scenarioD2 "°"å D3 scenarioD4D4 scenarioD3 "°"å 'Ë¡": ºYâ¢'¬ Source: Authors. À¡"¬Àµÿ: "°"å D2 = ,¬"¬«'´''; "°"å D3 = ,¬"¬°",,Àâ`°" `¡æ`»...,, "æ¬""¢Õß--; Note: Scenario D2 = VCT policy; scenario D3 = augmented public policy; scenario D4 = both "°"å D4 = °",,TMâ--Èß Õß "°"å (,¬"¬«'´'' + ,¬"¬°",,Àâ`°" `¡æ`»...,, "æ¬""¢Õß--) (VCT + augmented) policy. be added in the VCT scenario (D2). Again, the both scenario (D4) accumulates the largest number of ART patients. ¢÷ÈÕ'°à",,¥ 'Ë®­¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,·µà­ªï ¡ËÕª'¬'¬ °-- "°"å'˧"¥«à"®­°`¥À"°¡'°"¥Ì"`,§ß°"¿" --Èß'È Ì"¥--¬--ߧߪì À¡Õ¥`¡ ,¥¬ "°"å'Ë¡'°"`°" `¡æ`»... (D3) ®­TM૬,,Àâ¡'ºYâ¢â"-- The result of these enhancement policies is to increase the number of life-years saved in each year. These incremental benefits are shown in figure 5.4 to be quite high. We showed in chapter 4 that by starting `°"--°..."¥â«¬¬"µâ"«-- Õ¥ åæ`Ë¡¢÷ÈÕ'°ª­¡" 60,000 § §Õ¡"°°«à" Õß people on ART in 2002 (the NAPHA scenario) about 210,000 more à"¢Õß®Ì"«'Ë®­æ`Ë¡¢÷È¿"¬,,µâ "°"å'Ë,,TMâ,§ß°"«'´''æ'¬ßÕ¬à"ߥ'¬« people would be alive in 2020. Figure 5.2 shows that the VCT, aug- (D2) ·­Õ'°§--ÈßÀ÷Ëß 'Ë "°"å´÷Ëß¡'°"¥Ì"`--Èß Õß,§ß°" (D4) ®­Ì",,Àâ¡' mented, and both policies save (respectively) 18,000, 50,000, and ®Ì"«ºYâªÉ«¬'Ë¢â"--`°"--°..."¥â«¬¬"µâ"«-- Õ¥ åæ`Ë¡¢÷È¡"°'Ë ÿ¥ Policies to Strengthen Treatment Programs · 143 ,¬"¬æËÕ `¡ â"ß,§ß°"--°..." 143 60,000 additional life-years in that year. Thus, the alternative policies º¢Õß,¬"¬ `¡Àà"'È §Õæ`Ë¡®Ì"«ºYâªÉ«¬'Ë¡'TM'«`µÕ¥,,·µà­ªï ª­,¬TMå 'Ëæ`Ë¡¢÷È¥--ß°à"« ´÷Ëß· ¥ß«â,,¿"æ 5.4 --ȧàÕ¢â"ß Yß "¥â· ¥ß«â,,'Ë 4 «à" offer the possibility of improving the benefits in 2020 by almost 30 ®"°°"'Ë`Ë¡,,ÀâºYâªÉ«¬¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,æ.».2545 ( " percent. °"å'Ë¡'°"¥Ì"`,§ß°"¿") ºYâµ`¥TMÈÕ'Ë®­¬--ߧߡ'TM'«`µÕ¬Yà,,æ.». 2563 ®­¡' These projections tell us the incremental benefits of the enhanced ®Ì"«æ`Ë¡¢÷Ȫ­¡" 210,000 § ¿"æ 5.2 · ¥ß,,ÀâÀÁ«à" ,¬"¬«'´'', policies. Now we turn to consideration of their incremental costs. `°" `¡æ`»... ·­°",,TMâ--Èß Õß,¬"¬ ®­TM૬--°..."Õ"¬ÿ¢--¬¥âæ`Ë¡¢÷ÈÕ'° 18,000, 50,000, ·­ 60,000 ªï µ"¡Ì"¥--,,ªï--È ¥--ß--È ,¬"¬"ßÕ° µà"ßÊ ®÷ß Õ§«"¡ªìª¥â,,°"æ`Ë¡ºª­,¬TMå'Ë®­¥â--,, æ.». 2563 ¥âÕ'° Costs of Alternative ART Policies °ÕâÕ¬­ 30 Figure 5.5 shows the projections of the net cost of the NAPHA policy °"§"¥ª­¡"¥--ß°à"« Õ°"÷ߺª­,¬TMå'Ëæ`Ë¡¢÷È®"°,¬"¬'Ë¡'°" àß `¡æ`Ë¡µ`¡ ·­µÕ'È "Õß¡"æ`®""÷ßµâÿ'Ëæ`Ë¡¢÷È°--â"ß and of the three enhanced policies. The net cost is defined as the total cost of ART plus the cost of any VCT expenses, minus the cost of any µâÿ¢Õß,¬"¬"ßÕ° Ì"À--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å reduced expenditure on the treatment of opportunistic infections. The bottom line in the figure gives the projection of the net cost of ¿"æ 5.5 · ¥ß÷ß°"§"¥ª­¡"µâÿ ÿ`¢Õß,¬"¬,§ß°"¿" ·­ the NAPHA scenario, which is very similar to the projected gross cost ,¬"¬ `¡ "¡ª­°" --Èß'È µâÿ ÿ` À¡"¬÷ßµâÿ--ÈßÀ¡¥¢Õß°"--°..."¥â«¬ of NAPHA (D1) given in figure 4.14. The two estimates are similar ¬"µâ"«-- Õ¥ å «°°--µâÿ¢Õߧà",,TMâ®à"¬,,¥Ê,,,§ß°"--§Ì"ª÷°..."·­°" because VCT costs are small in the NAPHA policy and savings from µ«®À"TMÈÕ,¥¬ ¡--§,,® ·â«¥â«¬µâÿ¢Õߧà",,TMâ®à"¬'˥߮"°°"--°..."°"µ`¥ reduced opportunistic infections are small relative to the magnitude of TMÈÕ,§©«¬,Õ°" --¥ ÿ¥â"¬,,¿"æ'È ®­TM૬,,Àâ "¡"§"¥ª­¡"÷ßµâÿ ART costs. ÿ`¢Õß "°"å'˧"¥«à"®­°`¥¢÷ÈÀ"°¡'°"¥Ì"`,§ß°" NAPHA ´÷Ëߧâ"¬°-- According to these projections, the VCT (D2) and the augmented µâÿ«¡--ÈßÀ¡¥¢Õß,§ß°"¿" (D1) ¥--ß'Ë· ¥ß«â,,¿"æ 4.14 °"ª­¡`--Èß (D3) policies have roughly similar costs, while the both (D4) policy is Õߧà"'È ®­§â"¬§÷ß°-- ËÕß®"°µâÿ¢Õß«'´''®­âÕ¬°«à"µâÿ¢Õß,¬"¬¢Õß about 10 percent more costly than either. Even the most expensive of ,§ß°"¿" ·­®Ì"«ß`'˪­À¬--¥¥â®"°°"µ`¥TMÈÕ,§©«¬,Õ°" 'Ë¥ß--È the policies never exceeds 30 percent of the projected national health §àÕ¢â"ßâÕ¬ ¡ËÕ'¬°--¢"¥¢Õßµâÿ,,°"--°..."¥â«¬¬"µâ"«-- Õ¥ å budget, which itself is only 1.3 percent of the entire national budget.4 ¿"æ 5.5 °"§"¥ª­¡"µâÿ,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ,, "°"å'˧"¥«à"®­°`¥ ¢÷È--Èß 'Ë· Figure 5.5 Projected Net Cost of ART for All Four Scenarios 80,000 70,000 60,000 million) 50,000 (US$ 40,000 (â"¥Õà"å À--) cost 30,000 net20,000 µâÿ ÿ` 10,000 0 2544 2001 2003 2005 2007 2009 2011 255 2546 2548 2550 2552 2554 2013 2015 2017 2019 25 6 2558 2560 2562 202 2023 2025 641 2566 2568 "°"å D1 "°"å D2 scenarioD1 scenarioD2 "°"å D3 scenarioD3 "°"å D4 scenarioD4 'Ë¡": ºYâ¢'¬ Source: Authors. À¡"¬Àµÿ: "°"å D1= ,¬"¬¿"; "°"å D2 = ,¬"¬«'´''; "°"å D3 = ,¬"¬°",,Àâ`°" Note: Scenario D1 = NAPHA policy; scenario D2 = VCT policy; scenario D3 = augmented public `¡æ`»...,, "æ¬""¢Õß--; "°"å D4 = °",,TMâ--Èß Õß "°"å (,¬"¬«'´'' + ,¬"¬°",,Àâ`°" policy; scenario D4 = both (VCT + augmented) policy. `¡æ`»...,, "æ¬""¢Õß--) 144 · TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand 144 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ The Cost-Effectiveness of Alternative ART Policy Scenarios ®"°°"§"¥ª­¡"¥--ß°à"« ,§ß°"«'´'' (D2) ·­,¬"¬,,°"`°" Assembling the costs and effects of the four policies allows two types of `¡æ`»... (D3) --È ¡'µâÿ'˧àÕ¢â"ߧâ"¬§÷ß°-- ,,¢­'Ë,¬"¬'Ë,,Àâ¥Ì"` analysis. First, one can analyze the cost-effectiveness of any of the four --Èß Õß,§ß°" (D4) --È ®­¡'µâÿ¡"°°«à"Õ'° Õß,§ß°"ª­¡"âÕ¬­ 10 against the baseline. At this early stage in Thailand's implementation of ·µà·¡â°­--Ëß,¬"¬'Ë¡'"§"·æß'Ë ÿ¥ °Á¬--ß¡à°`âÕ¬­ 30 ¢Õßߪ­¡" NAPHA, such an analysis can guide current policy 4into a more cost- ÿ¢¿"æ­¥--ª­»'Ë¥â§"¥ª­¡"«â ·­ßª­¡" ÿ¢¿"æ¥--ß°à"« §`¥ªì effective path. One can instead consider the NAPHA scenario (D1) as Õ--µ" à«æ'¬ßâÕ¬­ 1.3 ¢Õßߪ­¡"--ÈßÀ¡¥¢Õߪ­» a new point of comparison and analyze the cost-effectiveness of the VCT (D2), augmented (D3), or both (D4) policy in comparison with ª­ ``º"ߥâ"µâÿ¢Õß "°"å'˧"¥«à"®­°`¥¢÷È Ì"À--,¬"¬µà"ßÊ,, that new baseline. The advantage of this approach is that, where an °",,Àâ`°"--°..."¥â«¬¬"µâ"«-- Õ¥ å enhanced policy costs more per life-year saved, one can ask whether °"«¡µâÿ·­º¢Õß,¬"¬--Èß 'Ë µâÕß,,TMâ°"«`§"­Àå ÕßTM`¥ TM`¥·° " the additional life-years saved are worth the extra expenditure. "¡"«`§"­Àåµâÿ-ª­ ``º¢Õß,¬"¬,,¥Ê°Áµ"¡¿"¬,, 'Ë,¬"¬'Ë°à"« ÷ßFigure 5.6 presents the first of these analyses. Of the four policies, ,¥¬Ì"ªª'¬'¬°-- "°"åæÈ",,­¬­·°'Ë¥Ì"`,§ß°"¿" the current baseline NAPHA policy (D1) is the most cost-effective. °"«`§"­Àå'È "¡"Ì",¬"¬ªí®®ÿ--ª,,TMâ,,"ß'Ë¡'ª­ ``º"ߥâ"µâÿ The second most cost-effective is the augmented policy (D3). This ¡"°°«à" ÀÕ"Õ"®æ`®"",,Àâ "°"å'ËÕ"®°`¥¢÷ÈÀ"°¥Ì"`,§ß°"¿" finding is not surprising because the augmented policy achieves two (D1) ªì®ÿ¥ª'¬'¬®ÿ¥,,À¡à ·­«`§"­Àå÷ßµâÿ-ª­ ``º ¢Õß,¬"¬ or three times as many incremental life-years saved at roughly the ,§ß°"«'´'' (D2), ,§ß°"`°" `¡æ`»... (D3) ÀÕ,¬"¬,,°"Ì"--Èß Õß same cost as the VCT scenario (D2). Because it combines the two ,§ß°"¡"ªØ`--µ` (D4) ,¥¬ª'¬'¬°-- â",,À¡à'È ª­,¬TMå¢Õß«`''È§Õ "pure" enhancement strategies, the cost per year of the both scenario ,,¢­'Ë,¬"¬'Ë¡'°" `¡æ`»...--È ®­¡'µâÿ¡"°¢÷ȵàÕÿ§§'Ë "¡"¬¥­¬­ (D4) lies between the costs per year of the other two scenarios. «"°"¡'TM'«`µÕÕ°ª¥â "Õ"®µâÕß"¡«à" °"--°..."TM'«`µÿ§§µàÕª«â¥â--È §ÿâ¡ °--§à",,TMâ®à"¬'Ëæ`Ë¡¢÷ÈÀÕ¡à If all four policies achieved the same objectives, it would be wise to choose the most cost-effective, eschewing the enhancements. How- ¿"æ 5.6 · ¥ß°"«`§"­Àå§--Èß·°,,¥",¬"¬--Èß 'Ë'È ,¥¬,¬"¬¿" ever, we have already seen that the enhanced policies achieve more (D1) ´÷Ëߪì â",,À¡à'È Õ«à"¡'ª­ ``º"ߥâ"µâÿ¡"°'Ë ÿ¥ à« than the simple NAPHA policy. Each enhancement saves additional ,¬"¬'Ë¡'ª­ ``º"ߥâ"µâÿªìÕ--¥-- Õß ¥â·°à ,¬"¬,,Àâ`°" `¡ life-years at some additional cost. In comparison with the NAPHA æ`»... (D3) °"§âæ¥--ß°à"« ¡à,,TMàËÕßà"ª­À"¥,,® æ"­,¬"¬,,°" Figure 5.6 Cost-Effectiveness of NAPHA and Alternative Scenarios Relative to Baseline ¿"æ 5.6 ª­ ``º"ߥâ"µâÿ¢Õß,§ß°"¿" ·­ "°"å ¡¡µ`µà"ßÊ¡ËÕ'¬°-- â" ¥â«¬ 3,000 2,600 life-year (US$) US$2,342 per 3% US$2,243 at 2,200 US$2,145 US$2,184 cost (¥Õà"å À--)3 of âÕ¬­ 1,800 value discounted 1,400 present Õ--µ" à«¥ saved net 1,000 'Ë¡": ºYâ¢'¬¡Y§à"ªí®®ÿ-- ÿ`¢ÕßµâÿµàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â "°"å D1 "°"å D2 "°"å D3 "°"å D4 scenario D1 scenario D2 scenario D3 scenario D4 Source: Authors. À¡"¬Àµÿ: "°"å D1= ,¬"¬¿"; "°"å D2 = ,¬"¬«'´''; "°"å D3 = ,¬"¬°",,Àâ`°" Note: Scenario D1 = NAPHA policy; scenario D2 = VCT policy; scenario D3 = augmented public `¡æ`»...,, "æ¬""¢Õß--; "°"å D4 = °",,TMâ--Èß Õß "°"å (,¬"¬«'´'' + ,¬"¬°",,Àâ`°" policy; scenario D4 = both (VCT + augmented) policy. `¡æ`»...,, "æ¬""¢Õß--) Policies to Strengthen Treatment Programs · 145 ,¬"¬æËÕ `¡ â"ß,§ß°"--°..." 145 `°" `¡æ`»...--È "¡"--°..."TM'«`µºYâªÉ«¬¥â¡"°¢÷È ÷ß 2 ÀÕ 3 à" ,,¢­'Ë scenario, the projections predict that the VCT scenario would save an µâÿÕ¬Yà,,­¥--,,°â§'¬ß°-- "°"å'˧"¥«à"®­°`¥¢÷ÈÀ"°¥Ì"`,¬"¬«'´'' additional 144,737 discounted life-years, whereas the augmented sce- (D2) nario would save an additional 414,840 life-years. Implementing both Ì"À-- "°"å'˧"¥«à"®­°`¥¢÷ÈÀ"°¥Ì"`--Èß Õß,§ß°" (D4) ËÕß®"°,¬"¬¥--ß°à"« ¥â«¡°¬ÿå,,°" àß `¡,¥¬ ç` ÿ`Ïé «â÷ß Õß enhancements would save 490,844 life-years in addition to those saved °¬ÿå ¥--ß--È µâÿµàÕªï¢Õß "°"å¥--ß°à"« ®÷ßÕ¬Yà­À«à"ßµâÿµàÕªï¢ÕßÕ'° by the NAPHA baseline policy. Õß,§ß°" The decision on whether to enhance NAPHA in any of these three ways should be based on the costs of these additional health benefits. The À"°,¬"¬--Èß '˵à"ß°ÁÿªÑ"À¡"¬¥'¬«°-- °Áà"®­¥'°«à"â"®­Õ°,¬"¬ `¡'Ë¡'ª­ ``¿"æ¥â"µâÿ¡"°'Ë ÿ¥·­À'°'Ë¬ß à« `¡µà"ßÊ ·µàÕ¬à"ß cost projections predict that the present value of the additional expendi- °Áµ"¡ "¥âÀÁ·â««à" ,¬"¬'Ë¡'°" `¡æ`»... ®­¥âº¡"°°«à",¬"¬¿" tures required to save the 144,737 life-years would be US$860 million æ'¬ßÕ¬à"ߥ'¬« °" `¡æ`»...·µà­Õ¬à"ßTM૬,,ÀâºYâªÉ«¬¡'TM'«`µ¬"«"¢÷È ,¥¬¡' (B 33.6 billion), or about US$5,941 (B 237,640) for every additional µâÿæ`Ë¡¢÷ÈÁ°âÕ¬ ¡ËÕª'¬'¬°-- "°"å'˧"¥«à"®­°`¥¢÷ÈÀ"°¥Ì"` life-year for the VCT scenario. Because the augmented scenario is ,§ß°"¿" °"§"¥ª­¡"'È · ¥ß,,ÀâÀÁ«à" "°"å'Ë,,TMâ,§ß°"«'´''®­ projected to cost an additional US$1 billion (discounted dollars), TM૬--°..."Õ"¬ÿ¢--¬,,Õ--µ" à«¥¥âÕ'° 144,737 «ªï ,,¢­'Ë "°"å'Ë,,TMâ (B 40 billion) it could be used to add to the health benefits at a cost of ,§ß°"`°" `¡æ`»... ®­TM૬--°..."Õ"¬ÿ¢--¬¥â 490,844 ªï Õ°ÀÕª®"°ºYâ US$2,430 (B 97,200) per additional life-year saved. The program com- ªÉ«¬'ËTM૬TM'«`µ¥â¥â«¬,¬"¬¿"¢--ÈæÈ" bining both of these two enhancements would cost an additional US$1.3 billion (B 52 billion), or an average of US$2,77 (B 110,840) per additional °"µ--¥ `,,®«à"®­ `¡,§ß°"¿"¥â«¬«`',,¥«`'À÷Ëß,, "¡«`''ÈÀÕ¡à §«®­ µâÕ߬÷¥µ"¡µâÿ¢Õߺª­,¬TMå¥â" ÿ¢¿"ææ`Ë¡µ`¡'Ë®­¥âÀà"'È life-year saved. These costs are displayed in figure 5.7. ®"°°" ª­¡"°"µâÿ ®­ÀÁ«à" ¡Y§à"ªí®®ÿ--¢Õߧà",,TMâ®à"¬æ`Ë¡µ`¡æËÕ--°..."Õ"¬ÿ¢--¬ In view of those results, which program should Thailand undertake? 144,737 ªï ®­ªì 860 â"¥Õà"å À-- (33.6 æ--â"") ÀÕª­¡" The answer depends on the value that Thailand places on a life-year 5,941 ¥Õà"å À-- (237,640 ") Ì"À--ÿ°ªï'Ë¡'Õ"¬ÿ¬"«"¢÷È®"° saved. Suppose that value is US$2,200 (B 88,000). This number is "°"å'˧"¥«à"®­°`¥¢÷ÈÀ"°¡'°"¥Ì"`,§ß°"«'´'' Õ°®"°'È ËÕß®"° greater than the cost per life-year saved under NAPHA but less than "°"å¢Õß,§ß°",,Àâ`°" `¡æ`»...®­¡'µâÿ,¥¬ª­¡"æ`Ë¡¢÷È®"° 1 the incremental cost per life-year saved under any of the three enhanced æ--â"¥Õà"å À--(Õ--µ" à«¥) (4 À¡Ëâ"") ®÷ßÕ"®,,TMâ "°"å¥--ß programs. In this case, assuming that Thailand has already exhausted °à"«æËÕæ`Ë¡ºª­,¬TMå¥â" ÿ¢¿"æ¥â«¬µâÿ 2,430 ¥Õà"å À-- (97,200 all other opportunities to save years of life for less than US$2 ") µàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥âæ`Ë¡µ`¡À÷Ëߪï (B 88,000), the country should choose the basic NAPHA modeled here. à«,¬"¬'˵âÕß¡'°"¥Ì"` ¿"æ 5.7 ª­ ``º"ߥâ"µâÿ¢Õß,§ß°"¿" ·­ "°"å ¡¡µ`µà"ßÊ¡ËÕ'¬°-- â" Figure 5.7 Cost-Effectiveness of Alternative Scenarios Relative to NAPHA 7,000 6,000 US$5,940.3 life-year 5,000 per 4,000 cost (US$) of 3,000 US$2,771.3 (¥Õà"å À--) saved US$2,430.3 value 2,000 1,000 present ¡Y§à"ªí®®ÿ-- ÿ`¢ÕßµâÿµàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â net 0 "°"å D2 "°"å D3 "°"å D4 scenario D2 scenario D3 scenario D4 'Ë¡": ºYâ¢'¬ Source: Authors. À¡"¬Àµÿ: "°"å D2 = ,¬"¬«'´''; "°"å D3 = ,¬"¬°",,Àâ`°" `¡æ`»...,, "æ¬""¢Õß--; Note: D2 = VCT policy; scenario D3 = augmented public policy; scenario D4 = both (VCT + "°"å D4 = °",,TMâ--Èß Õß "°"å (,¬"¬«'´'' + ,¬"¬°",,Àâ`°" `¡æ`»...,, "æ¬""¢Õß--) augmented) policy. 146 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ ,§ß°"--Èß Õß ®­¡'µâÿæ`Ë¡ 1.3 æ--â"¥Õà"å À-- (52 æ--â"") ÀÕ ©'ˬ'Ë 2,777 ¥Õà"å À-- (110,840 ") µàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥âæ`Ë¡µ`¡À÷Ëß ªï --Èß'È µâÿ¥--ß°à"« ¥â· ¥ß«â,,¿"æ 5.7 ¡ËÕ¡Õß÷ߺÀà"'È ª­»¬§«¥Ì"`,§ß°",,¥? §Ì"µÕ®­¢÷ÈÕ¬Yà°-- ¡Y§à"'˪­»¬¥â,,Àâ·°àÕ"¬ÿ¢--¬'Ë--°..."«â¥âªïÀ÷Ëß ¡¡µ`«à" ¡Y§à"¥--ß°à"« Õ¬Yà'Ë 2,200 ¥Õà"å À-- (88,000 ") µ--«¢¥--ß°à"« ®­ Yß°«à"µâÿµàÕÕ"¬ÿ¢--¬ ÀÕ«",,°"¡'TM'«`µÀ÷Ëߪï'Ë--°..."«â¥â¿"¬,,µâ,§ß°"¿" ·µàâÕ¬°«à"µâÿæ`Ë¡ µ`¡®"°,§ß°" `¡ÕËÊ,, "¡,§ß°"'Ë°à"«÷ß ,,°''È â"ª­»¬¥â,,TMâ ,Õ°" ÕËÊ'Ë®­TM૬¬¥­¬­«"°"¡'TM'«`µ¢ÕߺYâªÉ«¬¥â«¬µâÿ'˵àÌ"°«à" 2,200 ¥Õà"å À-- (88,000 ") ·â« ª­»¬ °Á§«®­Õ°,,TMâ,§ß°"¿"¢--È æÈ"¥--ß'Ë¥â«"ß·®Ì"Õß«â,,"¬ß"©--'È ¥--ß--È ,§ß°" `¡æ`»...Àà"'È §«¢÷ÈÕ¬Yà°--°"µ--¥ `,,®ªì ૵--«¢Õßÿ§§'Ë "¡",,TMâ`°",§ß°"¥--ß°à"« ¥â ·­¬`¥''Ë®­®à"¬ß`æ`Ë¡¢÷È®"°°­ªÜ"¢ÕßµÕß ÀÕ®"°°"ª­°-- ÿ¢¿"æ ¡¡ÿµ`«à" ª­»¬,,Àâ¡Y§à" 4,000 ¥Õà"å À-- (160,000 ") ÀÕ ª­¡" Õßà"¢Õß"¬¥â¡««¡ª­TM"TM"µ`µàÕ§ µàÕÕ"¬ÿ¢--¬ÀÕ«",,°"¡' TM'«`µ'Ë--°..."«â¥âÀ÷Ëßªï ·­ËÕß®"°ºYâTM'ˬ«TM"­À«à"ߪ­»"ߧ Õ«à" Õ"¬ÿ¢--¬ÀÕ«",,°"¡'TM'«`µ--È §«®­Õ«à"¡'§à" Yß÷ßÀâ"à"¢Õß"¬¥âµàÕÀ--« §à" ª­¡`'Ë 4,000 ¥Õà"å À-- (160,000 ") ®÷ß¡`¥â Yß°`ª Ì"À--ª­» ¬ ,,°''È ª­»¬§«¡'§«"¡ª""'Ë®­¥â¡"´÷Ëߺª­,¬TMå Yß ÿ¥"ß ¥â" ÿ¢¿"æµ"¡'Ë¥â Õ«â,,°"«`§"­Àå'È ´÷Ëß "¡"Ì"¥â¥â«¬,§ß°"'Ë¡',,® ÿ'Ë ÿ¥à"--È à«ª­ ``º"ߥâ"µâÿ,,°" àß `¡,§ß°"æÈ"¥â«¬ ,¬"¬--Èß Õß §Õ (°) ,§ß°"°"--§Ì"ª÷°..."·­°"µ«®À"TMÈÕ,¥¬ ¡--§,,® ·­ (¢) °" `¡`°""ߥâ"Õÿª ߧå,¥¬°ÿࡺYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å·­Õß§å° æ--"Õ°TM --ȧàÕ¢â"ßà" ,,® ,¥¬¡'µâÿÕ¬Yà'Ë 2,771 ¥Õà"å À-- (110,840 ") µàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥âÀ÷Ëßªï ¡à«à"ª­»¬®­,,Àâ§ÿ§à"·°àÕ"¬ÿ¢--¬ÀÕ®Ì"«ªï'Ë¡'TM'«`µÕ¬Yà --°à",,¥°Áµ"¡ °"«`§"­Àå'È Õ«à" "ߪ­»¬¡à§«,,TMâ,¬"¬'˪--ªÿß©æ"­°"TM--° TM«,,À⪭TM"TM¢â"à«¡,§ß°"°"--§Ì"ª÷°..."·­°"µ«®À"TMÈÕ,¥¬ ¡--§,,® ,¥¬¡àª--ªÿß°"ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥ ¥--ß®­ÀÁ¥â«à" " °"å ¡¡µ`¥--ß°à"« (D2) ®­¥âÕ¬°«à",¬"¬'Ë¡'°" àß `¡Õ'° Õß«`' ·«ªØ`--µ`"ߥâ"°"ß`·­°"§--ߢÕß "°"å'˧"¥«à"®­°`¥¢÷ÈÀ"°¡'°" --°..."¥â«¬¬"µâ"«-- Õ¥ å ,,'Ë 4 "¥âª'¬'¬°­· §à",,TMâ®à"¬ª­®Ì"ªï'˧"¥ª­¡"«â Ì"À--°" --°..."¥â«¬«-- Õ¥ å,¥¬¿"§-- °--­¥--µà"ßÊ '˧"¥ª­¡"«â¢Õßߪ­¡" Õ¥ 巭ߪ­¡"¥â" ÿ¢¿"æÕËÊ®÷ß æ.». 2568 ,, à«'È "®­æ`Ë¡°" «`§"­Àå'˧â"¬§÷ß°-- Ì"À-- "°"å'˧"¥«à"®­°`¥¢÷È Ì"À--,§ß°"'Ë¥â-- Policies to Strengthen Treatment Programs · 147 ,¬"¬æËÕ `¡ â"ß,§ß°"--°..." 147 ¿"æ 5.8 µâÿ°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢Õß,§ß°"¿" ·­ "°"å ¡¡µ`µà"ßÊ'Ë¡'°" --°..."¥â«¬¬"µâ"«-- Õ¥ å Figure 5.8 ART Cost of NAPHA and Alternative ART Scenarios 600 (°) °"--°..."¢--È·° (a) First-line 500 400 million 300 ¥Õà"å À--â"US$ 200 100 0 2005 2015 2025 "°"å D1 "°"å D2 "°"å D3 "°"å D4 scenario D1 scenario D2 scenario D3 scenario D4 ߪ­¡"Õ¥ å AIDS budget 600 (¢) °"--°..."¢--È'Ë Õß (b) Second-line 500 400 million 300 ¥Õà"å À--â"US$ 200 100 0 2005 2015 2025 "°"å D1 "°"å D2 "°"å D3 "°"å D4 scenario D1 scenario D2 scenario D3 scenario D4 ߪ­¡"Õ¥ å AIDS budget 'Ë¡": ºYâ¢'¬ Source: Authors. À¡"¬Àµÿ: "°"å D2 = ,¬"¬«'´''; "°"å D3 = ,¬"¬°",,Àâ`°" `¡æ`»...,, "æ¬""¢Õß--; Note: Scenario D2 = VCT policy; scenario D3 = augmented public policy; scenario D4 = both "°"å D4 = °",,TMâ--Èß Õß "°"å (,¬"¬«'´'' + ,¬"¬°",,Àâ`°" `¡æ`»...,, "æ¬""¢Õß--) (VCT + augmented) policy. °" àß `¡µà"ßÊ Õ°®"°'È ¬--ß®­ª'¬'¬§à",,TMâ®à"¬µàÕÕ"¬ÿ¢--¬ÀÕ«"'Ë¡'TM'«`µ that, unless the AIDS budget grows faster than gross domestic prod- Õ¬Yà °--"¬¥â¢Õß°ÿà¡"¬¥âµà"ßÊ,,ª­»¬ æËÕ'Ë®­ª­¡`÷ߧ«"¡ "¡" uct, the cost of first-line ART can easily exhaust the AIDS budget; à«ÿ§§,,°"®à"¬§à"--°..."æ¬"" however, panel (b) shows that second-line therapy will have a substan- ª'¬'¬ "°"å'˧"¥«à"®­°`¥¢÷È--Èß 'Ë "°"å°--ߪ­¡"Õ¥ å tially larger budget impact. Already by 2015 the projected cost of the second-line therapy alone will be more than three times greater than ¿"æ 5.8 · ¥ß«à" °",,TMâߪ­¡" à«,,Àà,,°"Õ° "°"å®Ì"Õß®"° the projected level of recent AIDS budgets. ,§ß°" `¡µà"ßÊ ®­¬--ß¡àªì'ËYâ ÷°®°­--Ëßæâ­¬­°"§"¥ª­¡" As discussed earlier, recent AIDS or health sector budgets provide¡ËÕ no "°"å®Ì"Õß'Ë¡'°"¥Ì"`--Èß Õß,§ß°" (D4) ®­¡'§à",,TMâ®à"¬¡"°°«à" sure way of judging the affordability of any project. Suppose Thailand "°"å'Ë,,TMâ,¬"¬¢Õß,§ß°"¿" æ'¬ß,§ß°"¥'¬« (D1) ª­¡"À÷Ëß has the opportunity to invest in life-saving therapy at a cost of à« 'Ë Õ°®"°'È µ--«¢¥--ß°à"« ¬--ß· ¥ß,,ÀâÀÁ«à"µâÿ®­ªìÕ¬à"ß ¡ËÕª'¬ US$2,430 (B 97,200) per life-year and has exhausted other opportuni- '¬°--ߪ­¡"Õ¥ å,,­¬­À--ß'È ´÷Ëߧ"¥«à"®­æ`Ë¡¢÷È,,Õ--µ"°"µ`,µ¢Õß ties to lengthen the productive lifetimes of its citizens at this cost. Its º`µ¿--±å¡««¡ª­TM"TM"µ`'˧"¥ª­¡"«â ¥â·°àâÕ¬­ 5.2 à"--È ,,¿"æ decision on whether to spend this money should be based not on any ª­°Õ 5.8 à« (°) · ¥ß,,ÀâÀÁ«à" â"ߪ­¡"Õ¥ å¡à¡'°"æ`Ë¡¢÷ÈÁ«°«à" putative criterion of affordability but simply on whether it values º`µ¿--±å¡««¡ª­TM"TM"µ`·â« µâÿ¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,¢--È healthy life-years at least this highly. If it does, then it should either ·° Õ"®,,TMâߪ­¡"Õ¥ 媮À¡¥¥âßà"¬Ê Õ¬à"ß°Áµ"¡ ¿"檭°Õ à« tax or borrow to finance these expenditures. 148 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ §«"¡ "¡"'Ë®­®à"¬¥â Ì"À--§--«Õ,,¿"§Õ°TM "ßÕ°À÷Ëß Ì"À--°",,Àâÿ -- ÿ¢Õß--"µàÕ°"--°..."¥â«¬¬"µâ"«-- Õ¥ å §Õ°",,Àâÿ -- ÿ Ì"À--µâÿÿ° à« ,¥¬ºà""ߧà"¡'¬¡ºYâ,,TMâ µ""ß 5.3 · ¥ß÷ߧ«"¡ "¡"¢Õß¿"§Õ°TM,,°"®à"¬§à"--°..."¥â«¬¬"µâ" «-- Õ¥ å¥â«¬­¥--"¬¥â,,§--«Õ µ"¡¢âÕ¡Y'Ë¥â®"°°" Ì"«®,,¥â"»... °`® --ߧ¡ª­®Ì"ªï æ.». 2545 "¬¥â©'ˬ'Ë°Ì"À¥«âµàÕ§--«Õ Ì"À--ª­TM"TM âÕ¬­ 20 'ˬ"°®'Ë ÿ¥ ¥â·°à 4,043 ¥Õà"å À-- (161,720 ") ´÷Ëß,,"¬ ¥â®Ì"«'È 1,678 ¥Õà"å À-- (67,120 ") µâÕß,,TM⪰--§à",,TMâ®à"¬'Ë¡à,,TMà Õ"À" ·­Õ'° 300 ¥Õà"å À-- (12,000 ") µâÕß,,TM⪰--§à",,TMâ®à"¬¥â"°" ·æ¬å,¥¬©'ˬµàÕªï ,,"ߵ߰--¢â"¡ Ì"À--°ÿà¡'Ë¡'"¬¥â Yß ÿ¥ ´÷Ëß¡'Õ--µ" à« À÷Ëß,,Àâ"¢Õߪ­TM"°--ÈßÀ¡¥--È ¡'"¬¥â¡"°°«à"°ÿà¡·°÷ß 10 à" ·­,,TMâß` °--§à",,TMâ®à"¬¥â"°"·æ¬å¡"°°«à"°ÿà¡·°ª­¡" 12 à",¥¬©'ˬ °"ª'¬'¬µâÿ°"--°..."¥â«¬¬"µâ"«-- Õ¥ å°--§à"©'ˬ¢Õߧ--«Õ Àà"'ȪìËÕ߬"° ª­°"·° §--«Õ'Ë¡' ¡"TM`°ªì,§Õ¥ å Õ"®·µ°µà"ߪ ®"°§--«Õ'Ë¡à¥â¡' ¡"TM`°´÷Ëߪì,§Õ¥ å ¡à«à"®­®°«à" ÀÕ«¬°«à" ÀÕ ·¡â·µà°àÕ'˺YâªÉ«¬Õ¥ å®­`Ë¡¡'Õ"°"ªÉ«¬®`ßÊ 5 ª­°"'Ë Õß §«"¡®ÁªÉ«¬--È ¥YÀ¡Õ«à"®­¥º`µ¿"æ¢ÕߺYâªÉ«¬ ·­¥--ß--È ®÷ߥ"¬¥â¢Õߧ--«Õ¥â«¬ ª­°"'Ë "¡ §«"¡ªì ¡"TM`°¢Õߧէ--«--È¡'§«"¡¬¥À¬ÿàÕ¬Yà,,µ--«Õß --Ë§Õ µ""ß'Ë 5.3 "§"'Ë "¡"®à"¬¥â¥â«¬"¬¥â¢Õߧ--«Õ "À--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,, ¢--È·°·­¢--È'Ë Õß °"·àßTMà«ß"¬¥âÕÕ°ªì 5 à« (Quintile) 1 (®'Ë ÿ¥) Q2 Q3 Q4 5 («¬'Ë ÿ¥) "¬¥â©'ˬ¢Õߧ--«Õ (¥Õà"å À--) 4,042.70 6,678.10 9,806.10 15,434.00 40,253.20 §à",,TMâ®à"¬'Ë¡à,,TMàÕ"À", §--«Õ (¥Õà"å À--) 1,678.40 3,127.90 4,983.90 8,525.30 25,597.60 §à",,TMâ®à"¬¥â"°"·æ¬å, §--«Õ (¥Õà"å À--) 300.00 512.30 754.70 1,165.50 3,633.00 µâÿ ART (¢--È·°) 842.20 842.20 842.20 842.20 842.00 µâÿ ART (¢--È'Ë Õß) 6,960.20 6,960.20 6,960.20 6,960.20 6,960.20 µâÿ ART (¢--È·°) '˪ì --¥ à«¢Õß"¬¥â§--«Õ (%) 21 13 2 --¥ à«¢Õߧà",,TMâ®à"¬'Ë¡à,,TMàÕ"À" (%) 50 27 179 105 --¥ à«¢Õߧà",,TMâ®à"¬¥â"°"·æ¬å (%) 281 164 112 72 233 µâÿ ART (¢--È'Ë Õß) '˪ì --¥ à«¢Õß"¬¥â§--«Õ (%) 172 104 71 45 17 --¥ à«¢Õߧà",,TMâ®à"¬'Ë¡à,,TMàÕ"À" (%) 415 223 140 82 27 --¥ à«¢Õߧà",,TMâ®à"¬¥â"°"·æ¬å (%) 2,320 1,359 922 597 192 'Ë¡": °"§"«¢ÕߺYâ¢'¬ ¬÷¥µ"¡°" "«®¥â"»...°`®·­ --ߧ¡¢Õߪ­»¬ æ.». 2545 À¡"¬Àµÿ: ®"«ß`--ÈßÀ¡¥ ªìß`¥Õà" À-- µ"¡¡Y§à",, æ.». 2547 ,¬"¬æËÕ `¡ â"ß,§ß°"--°..." 149 §--«Õ "¡"À" ¡"TM`°,,À¡àæËÕTM૬,,°"¥Y·­ºYâªÉ«¬ ÀÕÕ"®· «ßÀ"â"æ--° TM--Ë«§"« Ì"À-- ¡"TM`°§Õ§--«'˵âÕß°"ªìÕ` ­®"°¿"­¢Õߧ«"¡®ÁªÉ«¬ ºY⠪ɫ¬Õ¥ åÕ"®¬â"¬ªÕ¬Yà§--«Õ,,À¡à Õ"®®­æËÕ,,Àâ,,°â°-- "æ¬""ÀÕºYâ,,Àâ °"--°..."'ËTMËÕÕ À"°¡à§Ì"÷ß÷ߪ­¥ÁÀà"'È "¥â --ß°µ«à" µâÿª­®Ì"ªï¢Õß°"--°..."¥â«¬ ¬"µâ"«-- ,,¢--È·°--È Yß°«à"§à",,TMâ®à"¬"ß°"·æ¬åª­®Ì"ªï,¥¬©'ˬ¡"°©æ"­ ,,°ÿࡧ--«ÕâÕ¬­ 40 'ˬ"°®'Ë ÿ¥ ¥--ß--È Ì"À--§--«Õ'ËÕ¬Yà§÷Ëß,,·ßà ¢Õß°"°­®"¬"¬¥â "¡"®à"¬ß`æËÕ--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¥â ·¡â °­--Ëß Ì"À--§÷Ëß'ˬ"°®'Ë ÿ¥,,¥"§--«Õ--ÈßÀ¡¥ µâÿ®Ì"« 842 ¥Õà"å À-- (33,680 ") Ì"À--°"--°...",,¢--È·° "¡"Ì"¡"ª'¬ '¬°--§à",,TMâ®à"¬"ß°"·æ¬å Ì"À--§Õ§--«'˪ɫ¬'Ë ÿ¥¿"¬,,À÷Ëßªï ªíÀ" Ì"À--§--«Õ'ˬ"°®--È ¡''à"«à"®­°`¥®"°--°...­'˺`¥ª°µ` Õß ª­°"°'ˬ«°--µâÿ,,°"--°..." ¥â·°à: ë °"--°..."--È®­µâÕߥÌ"`µàÕªµÕ¥TM'«`µ¢ÕߺYâªÉ«¬ Ì"À--§--«Õ'ËÕ¬Yà,, °ÿà¡âÕ¬­ 80 ,,­¥--µË" ÿ¥¢Õß°"°­®"¬"¬¥â ´÷Ëß "¡"À"--æ¬"° ¡"æËÕ®à"¬ß`®Ì"« 842 ¥Õà"å À-- Ì"À--À÷Ëßªï ·µà°"TMÌ"­ß` Ì"À-- ªï'Ë Õß·­ªï'Ë "¡--È°--°"¬ªì¿"­¡"°¢÷Èÿ°' ë §«"¡À¬àÕ¬",,°"--°..." ®­Ì"ª Y৫"¡â¡À« °"æ--" "¬æ--åÿ¥ÈÕ¬" ¢ÕßTMÈÕ«-- °"°­®"¬ "¬æ--åÿ¥ÈÕ¬"ª YàºYâÕË ·­§«"¡®Ì"ªì'˺YâªÉ«¬®­µâÕß §ËÕª Yà°"--°...",,¢--È'Ë Õß `Ëßµà"ßÊÀà"'È ªìºâ"¬Õ¬à"ßÿ·ßµàÕºYâªÉ«¬ ·­,,°''¡'°"·æà°­®"¬¢ÕßTMÈÕ«-- "¬æ--åÿ¥ÈÕ¬" Õ«à" ªìºâ"¬µàÕ --ߧ¡TMà°-- °"'˧à"--°...",,¢--È·°¡'"§" Yߢ÷È Ì"ª YàÕ--µ"§«"¡â¡À«'Ë Yߢ÷È Ì"À-- °"--°..."¢--È·°¥â«¬ ®÷ßÕ«à"ªì°"æ`Ë¡µâÿ¢Õß,§Õ¥ åµàÕÿ§§·­ --ߧ¡ "ßÕ°,,°"à«¡,,Àâÿ -- ÿ°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,¥¬°Á§à" ¡'¬¡®"°ºYâ,,TMâ--È §«®­¥â--°"--°..."· ¡Yå¬`Ëߢ÷È°«à"'˪쪥â,,'Ë'È Õ¬à"ß°Áµ"¡ "â«à" °"¥°"ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥Õ--ËÕß¡" ®"°"§"--È ®­ àߺ°­,,"ßâ"¬ªÿ° à« °"ª'¬'¬µâÿ°"--°..." ,,¢--È·°°--­¥--"¬¥â·­§à",,TMâ®à"¬¢Õߧ--«Õ (¿"æ 5.9) · ¥ß,,ÀâÀÁ«à" ·¡â«à"°"--°...",,¢--È·°®­¬"° Ì"À--§--«Õ'ˬ"°®'Ë ÿ¥'Ë®­À"ÿ -- ÿ ,¥¬©æ"­,,­¬­¬"« ·µà§«,,À⧫"¡ ,,®Õ¬à"ß­¡--¥­«--ßæËÕµ--¥ `«à" ºYâªÉ«¬"¬,,¥ ®­ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥ ÷ß·¡â«à"®­µâÕß®à"¬ß`,,"§"·æß ·­ "¬,,¥®­¡àªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥ ºYâ'Ë®­¡àªØ`--µ`µÕ¬à"ߧàߧ--¥ --È ¡à§«®­¥â--°"--°...",¥¬¡à§`¥§à",,TMâ®à"¬ ,,"ߵ߰--¢â"¡ §«¡'°",,Àâ "ß«--·°àºYâ'˪Ø`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥ --ËÀ¡"¬§«"¡«à" "ߧ--Èß "§" Ì"À--ºYâªÉ«¬"ߧ--È Õ"®ªì 150 · TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand 150 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ Figure 5.9 Affordability of ART by Income Level ¿"æ 5.9 §«"¡ "¡",,°"®à"¬§à"--°..."¥â«¬¬"µâ"«-- Õ¥ å ·¬°µ"¡­¥--"¬¥â 45,000 40,000 35,000 30,000 (US$) 25,000 ¥Õà"å À--)( 20,000 income "¬¥â 15,000 10,000 5,000 0 Q1 Q2 Q3 Q4 Q5 ­¥--"¬¥â·àߪì 5 à« income quintile mean household income "¬¥â©'ˬ¢Õߧ--«Õ cost of second-line ART µâÿ§à"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢--È'Ë Õß nonfood expenditure per household §à",,TMâ®à"¬'Ë¡à,,TMàÕ"À"µàÕ§--«Õ cost of first-line ART µâÿ§à"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢--È·° medical expenditure per household §à",,TMâ®à"¬¥â"°"·æ¬åµàÕ§--«Õ 'Ë¡": ºYâ¢'¬ Source: Authors. adhere--despite paying a higher price--and which will not. Those who will not should receive free care--or should even be rewarded for good adherence. In other words, perhaps the price to some patients should be negative. ÷ß·¡â«à" µâÿ¢Õß°"--°...",,¢--È·° §«®­¥â--°" -- ÿ¥â«¬§à" ¡'¬¡¢ÕߺYâ,,TMâªì"ß à« ·µà°"--°...",,¢--È'Ë Õß--È°--¡'"§"·æߢ÷ȪÕ'° ,¥¬¡'¡Y§à"°`"¬¥â--ÈßÀ¡¥¢Õߧ--«Õ Ì"À--âÕ¬­ 40 ¢Õß®Ì"«ª­TM"° Although the cost of first-line therapy could be partially financed with user fees, second-line therapy is much more expensive, exceeding total household income for 40 percent of the population. A large pro- Õ¬à"ß°Áµ"¡ ºYâªÉ«¬ à«,,Àà'Ë¢â"--°"--°...",,¢--È'ËÀ÷Ëß ,,'Ë ÿ¥·â« °Á®Ì"ªì®­ portion of those on first-line therapy will eventually need second-line µâÕß--°"--°...",,¢--È'Ë Õß ¬`Ëߪ°«à"--È °"'Ë¡à "¡"ªØ`--µ`µ"¡«`'°"--°..." therapy. Furthermore, poor adherence to first-line therapy speeds the Õ¬à"ߧàߧ--¥,,¢--È'ËÀ÷Ëߥ⠪ì°"àß°"æ--"°"¥ÈÕ¬" ·­Ì",,ÀâºYâªÉ«¬µâÕß development of resistance to those drugs and hastens the day when §ËÕª Yà°"--°...",,¢--È'Ë ÕßÁ«¢÷È ¥--ß--È ®"°¡ÿ¡¡ÕߢÕß --ߧ¡·­¢Õßÿ§§ the patient must move to second-line therapy. Accordingly, from a °°,,°" -- ÿ°"ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥ TMà °"¥Y·¢Õß social as well as an individual perspective, adherence support mecha- ¿"§--,¥¬¡'`°" `¡æ`»... ´÷Ëß"¥â«"ßYª·«â,,"¬ß"©--'È ¥YÀ¡Õ«à" nisms such as the augmented public care we model in this report are ®­¡'ª­ ``º"ߥâ"µâÿ TMà¥'¬«°--'Ë¡'ª­,¬TMå,,°"--°..." likely to be cost-effective as well as therapeutically beneficial. À"°§«"¡ -- ÿ¢ÕßÕߧå°æ--"Õ°TM·­°ÿࡺYâµ`¥TMÈÕÕTMÕ«'·­ºYâªÉ«¬ Õ¥ å'Ë¡'µàÕ°"ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥--È¡' à« Ì"§--,,°"TM૬ ÀÕ ·­À"°°ÿࡵà"ßÊÀà"'È "¡" `¡`°"¥Y·ºYâªÉ«¬¢Õß¿"§-- (·­"ß Given the potentially important contribution that NGO or PHA support groups might make to adherence, if they effectively augment public (and perhaps also private) care, the problem of financing §--Èß Õ"®«¡÷ß¿"§Õ°TM) ªíÀ"°'ˬ«°--°",,Àâÿ -- ÿ Õ"®®­µâÕßÌ"¡"ªì should perhaps be posed as one of designing the optimal financing ª­¥Á,,°"ÕÕ°·°°°",,Àâÿ -- ÿÕ¬à"ßÀ¡"­ ¡ Ì"À--°ÿࡵà"ßÊ mechanism for these groups. If membership dues increase the stability Àà"'È â"°"§°Ì"À¥¢Õß ¡"TM`° "¡"æ`Ë¡§«"¡¡--˧߷­§«"¡à"TMËÕÕ and the accountability of these groups to their constituents, then per- ¢Õߧ°ÿà¡'È'Ë¡'µàÕ "--¢Õßµ "ß' Õ"®µâÕß Ì"«®§à"¡'¬¡ºYâ,,TMâ¥--ß°à"« haps this form of user fee should be explored in addition to--or Õ°ÀÕ®"° ÀÕ·'Ë §à"¡'¬¡'Ë®à"¬,¥¬µßµàÕ­--°..." ÿ¢¿"æ instead of--fees paid directly to the health care system. ,¬"¬¿"´÷Ëß¡à¡'º`µ¿--±å¬"'Ë¡'¬'ËÀâÕæËÕ,,TMâ,,°"--°..."¢--È'Ë Õß Policies to Strengthen Treatment Programs · 151 ,¬"¬æËÕ `¡ â"ß,§ß°"--°..." 151 NAPHAPolicywithoutBrand-NameSecond-LinePharmaceuticalProducts ,,'Ë 4 °"«`§"­Àå¥â"°"ß` Ì"À--,¬"¬¿" · ¥ß,,ÀâÀÁ«à" ¬",,°" --°..."¢--È'Ë Õß--È ¡'µâÿà"°----TM' Ì"À--ߪ­¡"ª­®Ì"ªï·--ÈßÀ¡¥ In chapter 4, financial analysis of the NAPHA policy demonstrated ¿"¬,,¡à°'˪ï ÷ß·¡â«à" ¡'ºYâªÉ«¬æ'¬ßÁ°âÕ¬'Ë¥â,,TMâ,¬"¬¥--ß°à"« Õ¬à"ß°Áµ"¡ that second-line drug costs account for most of the annual budget ,,'Ë ÿ¥·â« ºYâªÉ«¬ÿ°§°Á®­µâÕß°"°"--°...",,¢--È'Ë Õß ¥--ß--È °"·¬°¬",,°" after a few years, though only a minority of patients use them. How- --°..."¢--È'Ë ÕßÕÕ°®"°ºYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å ever, virtually all patients eventually need second-line therapy. Hence, ®­¥ª­,¬TMå"ß ÿ¢¿"æ¢Õß ,§ß°" ·­Ì",,Àâ­¬­«"'˧"¥«à"®­¡'TM'«`µ¢ÕߺYâªÉ«¬ --Èß ÷ß·¡â®­¡'§«"¡ excluding second-line drugs from NAPHA reduces the health benefits µâÕß°"æ`Ë¡¢÷È®"°ºYâµ`¥TMÈÕ«-- ·­ºYâªÉ«¬Õ¥ å·­TMÿ¡TMÕ¥ å­À«à"ߪ­» ,, of the program and shortens the life expectancy of patients. Despite ¢­'È --"¬ ¬--ß¡à¥âµ--¥ `,,®Õ¬à"ßTM--¥®°'ˬ«°--°",,Àâ°"--°..."¥â«¬¬"µâ" growing needs and demands from the PHA and international AIDS «-- Õ¥ å¢Õß¿"§-- ´÷ËßÕ¬Yà,,­¥--'ËÀÕª°«à" Yµ¬"'Ë¡'Õ¬Yà,,¢­'È Ì"À--°" communities, at present the Thai government has not yet made an --°...",,¢--È·° ,,µÕ'È "®­ª'¬'¬÷ߪ­,¬TMå·­µâÿ¢Õß,¬"¬ explicit decision regarding public provision of ART, beyond the cur- ¿"¢--ÈæÈ"¥--ß'Ë¥â«`§"­Àå«â,,'Ë 4 æâÕ¡--Èß,¬"¬©--'Ë·¬°°"--°..." rently available drug regimens for first-line therapy. In this section, we ,,¢--È'Ë ÕßÕÕ°ª "Õ«à" °"ª­À¬--¥µâÿ'Ë°`¥¢÷È--È "ß--"®­ªìºYâ-- compare the benefits and costs of the basic NAPHA policy analyzed ¿"­Õ"«â--ÈßÀ¡¥ Ì",,Àâ¡àÀÕµâÿ'Ë®­µâÕß®à"¬ Ì"À--ºYâªÉ«¬'Ë¡'°"ª'ˬ·ªß in chapter 4 with a version of the policy that excludes second-line ¥--ß°à"« ·­º°Á§Õ Õÿª ߧå'Ë¡'µàÕ«'´'' ·­µàÕ°"--°..."µà"ßÊ--È ¡à¥âª'ˬ·ªß therapy. We assume the resulting cost savings are absorbed entirely by ËÕß¡"®"° "°"åµ--«Õ¬à"ߢâ"ßµâ the government, leaving no cost implications for the patient from this µâÿ®"°°"§"¥ª­¡" change. Consequently, the demand for VCT and for treatment does not change relative to our earlier scenarios. ¿"æ 5.10 · ¥ß÷ßµâÿ®"°°"§"¥ª­¡" Ì"À-- "°"å'Ë¡'°"¥Ì"` ,§ß°"¿" Projected Costs --Èß'Ë¡'°"--°..."·­¡à¡'°"--°...",,¢--È'Ë Õß ,¥¬µâÿ¢Õß ,§ß°"¿"'Ë¡'°"--°..."¢--È'Ë Õß ¥âÌ"¡"· ¥ß,,À¡à®"°¿"æ 4.14 --Èß'È ®"°§à" ¬",,°"--°..."¢--È'Ë Õß µâÿ¢Õß,§ß°"¿"æÿàß Yߢ÷ÈÕ¬à"ßTM--¥®®÷ß®ÿ¥ª'ˬ Figure 5.10 presents the projected cost of the NAPHA scenario with and ,§âß,,­À«à"ߪïæ.». 2551-2552 ·­®÷ß`Ë¡TMâ"ß®÷ßæ¥"'Ë 500 â"¥Õà"å without second-line therapy. The cost of NAPHA with second-line ther- À-- (2 À¡Ëâ"") ,,æ.». 2560 ,,"ߵ߰--¢â"¡ ,¬"¬¿"'Ë,,TMâ©æ"­ apy is reproduced from figure 4.14. With second-line drugs, NAPHA ¬" Ì"À--°"--°..."§--Èß·° ¡'µâÿÕ¬Yભ¡"À÷Ëß à«Àâ"¢Õßµâÿ'Ë®­µâÕß®à"¬ costs increase sharply to an inflection point in 2008­09 and then level off to a ceiling of US$500 million (B 20 billion) by 2017. In contrast, the ¿"æ 5.10 µâÿ°"--°..."¥â«¬¬"µâ"«-- Õ¥ åµ"¡'˧"¥ª­¡"«â ,, "°"å'Ë¡'°"¥Ì"` ,§ß°"¿" --Èß'Ë¡'°"--°...",,¢--È'Ë Õß ·­'Ë¡à¡'°"--°...",,¢--È'Ë Õß Figure 5.10 Projected ART Costs of NAPHA Scenarios with and without Second-Line ART 600 500 400 million) ¥Õà"å À--)((US$ 300 200 µâÿcost 100 0 2543 2545 2000 2002 252004 252006 2008 2010 2012 2014 2016 252018 252020 2022 2024 47 49 2551 2553 2555 2557 2559 61 63 2565 2567 "°"å A scenarioA NAPHA Yµ¬" "À--°"--°...",,¢--È·°à"--È NAPHA,first-lineregimenonly 'Ë¡":Source:Authors. ºYâ¢'¬ NAPHA Yµ¬" "À--°"--°...",,¢--È·°·­¢--È'Ë Õß NAPHA,first-andsecond-lineregimens 152 · TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand 152 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ Figure 5.11 Projected Annual Costs and Benefits of NAPHA Scenario without Second-Line ART 200,000 140 120 150,000 100 US$ â"¥Õà"å À-- saved 80 'Ë--°..."«â¥â million 100,000 60 ®"«ªïlife-years 50,000 40 20 0 0 25432000 252002 45 252004 252006 25 25 2555 2557 2559 47 49 51 53 2008 2010 2012 2014 2016 2018 2020 2022 2024 2561 2563 2565 2567 life-years saved ®"«ªï'Ë--°..."«â¥â net cost of ART µâÿ ÿ`¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å 'Ë¡": ºYâ¢'¬ Source: Authors. NAPHA policy using only first-line drugs costs only about one-fifth as much as it would when second-line drugs are included. When sec- â"«¡§à"¬",,°"--°..."¢--È'Ë Õߥ⫬ ·­¡ËÕ¡à¥â«¡§à"¬",,°"--°..."¢--È'Ë Õß ond-line drugs are not included, the total cost peaks at about US$130 µâÿ®­¢÷È÷ß­¥-- Yß ÿ¥'Ë 130 â"¥Õà"å À-- (5.2 æ--â"") µàÕªï ,, million (B 5.2 billion) per year in 2013, before leveling off. æ.». 2556 °àÕ'Ë®­`Ë¡¥­¥--ß Projected Costs and Benefits µâÿ·­ºª­,¬TMåµ"¡°"§"¥ª­¡" Excluding coverage for second-line drugs (and assuming patients do not °"'Ë,§ß°"¿"¡à¥â«¡°"--°...",,¢--È'Ë Õß«â¥â«¬ (·­Õ«à" ºYâªÉ«¬¡à¥â®à"¬ buy them on their own) reduces the benefits of NAPHA as well as the §à"¬"Õß) Õ°®"°®­¥µâÿ·â« ¬--ߥª­,¬TMå'Ë®­¥â--®"°,§ß°"¥â«¬ costs. Figure 5.11 presents both the benefits (on the left vertical axis) ¿"æ 5.11 · ¥ß÷ߪ­,¬TMå (·°µ--Èߥâ"´â"¬) ·­µâÿ (·°µ--Èߥâ"¢«") ¢Õß and the costs (on the right vertical axis) of NAPHA without second-line ,§ß°"¿"'˪"»®"°¬" Ì"À--°"--°..."¢--È'Ë Õß ¡ËÕª'¬'¬°--Yª¿"æ'Ë drugs. In comparison with the similar figure 4.17, the line graph repre- §â"¬§÷ß°--,, 4.17 °"ø âµß 'Ë· ¥ß÷ߺª­,¬TMå¥â" ÿ¢¿"æ ®­¢÷È Yß senting health benefits rises almost as high but declines more quickly, °Õà"°-- ·µà°--¥ßÁ«°«à" ,¥¬¡'ºYâÕ¥TM'«`µÀÕÕ¬Yàæ'¬ß 150,000 § ,, with only about 150,000 survivors in 2025 instead of the almost 200,000 æ.». 2568 ·'Ë®­ªì°Õ 200,000 § â"¡'°",,TMâ¬"æËÕ--°...",,¢--È'Ë Õß survivors when second-line drugs are included. In contrast, the costs to ,,"ߵ߰--¢â"¡ µâÿ Ì"À----" ¬--ߧßÕ¬Yà'˪­¡" 120 â"¥Õà"å À-- the government remain about US$120 million (B 4,800) per year, or (4,800 â"") µàÕªï ÀÕª­¡" 1 ,, 5 ¢Õß¡Y§à"'Ë«¡¬" Ì"À--°"--°..." about one-fifth the value when second-line drugs are included. ,,¢--È'Ë Õß«â¥â«¬ Cost-Effectiveness Analysis °"«`§"­À媭 ``º"ߥâ"µâÿ Figure 5.12 presents the cost per life-year saved of NAPHA without ¿"æ 5.12 · ¥ß÷ßµâÿµàÕªï'Ë¡'TM'«`µÕ¥®"°,§ß°"¿" 'Ë¡à«¡°"--°...",, second-line therapy compared with the cost per life-year saved of ¢--È'Ë Õß ¡ËÕ'¬°--µâÿµàÕªï'Ë¡'TM'«`µÕ¥®"°,§ß°"¿"'Ë«¡°"--°..."¢--È'Ë NAPHA with second-line therapy (from chapter 4). The central find- Õß«â¥â«¬ (®"°'Ë 4) `Ëß'˧âæ'Ë Ì"§--§Õ ,§ß°"¿" "¡"Ì",,ÀâºYâªÉ«¬ ing is that NAPHA can save a year of life for US$2,145 (B 85,800).6 §À÷ËßÕ¥TM'«`µª¥âÕ'°À÷Ëßªï ¥â«¬µâÿ 2,145 ¥Õà"å À-- (85,800 ") The figure shows that NAPHA with first-line therapy only, at just ¿"æ· ¥ß,,ÀâÀÁ«à" ,§ß°"¿"'Ë«¡©æ"­°"--°...",,¢--È·° ´÷Ëß¡'µâÿÕ¬Yà'Ë Policies to Strengthen Treatment Programs · 153 ,¬"¬æËÕ `¡ â"ß,§ß°"--°..." 153 ¿"æ 5.12 ª­ ``º"ߥâ"µâÿ¢Õß "°"å'Ë¥Ì"`,§ß°"¿" ´÷Ëß¡' ·­¡à¡'°"--°..." ¥â«¬¬"µâ"«-- Õ¥ å,,¢--È'Ë Õß Figure 5.12 Cost-Effectiveness of NAPHA Scenarios with and without Second-Line ART ¥â«¬ 3,000 2,500 life-year (US$) US$2,145 per 3% 2,000 at cost of (¥Õà"å À--)3 1,500 value âÕ¬­ discounted1,000 US$736 present saved, 500 net Õ--µ" à«¥ 0 ¡Y§à"ªí®®ÿ-- ÿ`¢ÕßµâÿµàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â NAPHA Yµ¬" "À--°"--°...",,¢--È·°à"--È NAPHA, first-line regimen only NAPHA Yµ¬" "À--°"--°...",,¢--È·°·­¢--È'Ë Õß NAPHA, first- and second-line regimens 'Ë¡": ºYâ¢'¬ Source: Authors. 736 ¥Õà"å À-- (29,440 ") µàÕªï'Ë¡'TM'«`µÕ¥,,Õ--µ" à«¥ Õ«à"¡' US$736 (B 29,440) per discounted life-year saved, is far more cost- ª­ ``º"ߥâ"µâÿ¡"°°«à",§ß°"¿"'Ë«¡°"--°...",,¢--È'Ë Õß effective than NAPHA with second-line therapy, which costs ´÷Ëß¡' µâÿ÷ß 2,145 ¥Õà"å À-- (85,800 ") µàÕªï'Ë¡'TM'«`µÕ¥,,Õ--µ" à«¥ US$2,145 (B 85,800) per discounted life-year saved. (As before, a dis- (TMà¥'¬«°--°àÕÀâ"'È Õ--µ" à«¥'ËâÕ¬­ 3 µàÕªï ¥âÌ"¡",,TMâæËÕ§Ì"«¡Y§à" count rate of 3 percent per year was used to compute the net present ªí®®ÿ-- ÿ`¢Õßµâÿ·­ºª­,¬TMå'Ë®­°`¥¢÷È,,Õ"§µ) values of the future streams of costs and benefits.) This result poses important questions for the Royal Thai govern- ment: Should it commit to public provision of the much more expensive º'Ë¥â'È Ì",,Àâ°`¥§Ì""¡'Ë Ì"§--µàÕ--"¬ --Ë§Õ Õ°ÀÕ®"°°"--°..." ,,¢--È·°·â« "ß--"§«®­¡ÿàß¡--Ë'Ë®­,,Àâ`°"--°...",,¢--È'Ë Õß´÷Ëß¡'"§"·æß °«à"¡"°·°àª­TM"TMÀÕ¡à? second-line therapy in addition to first-line therapy? Or should it limit ÀÕ§«®­®Ì"°--¥æ--­©æ"­,,°"--°..."¢--È·° à"--È ,¥¬ --"«à" ®­,,Àâ°"¥Y·--°..."æËÕ"Õ"°" Ì"À--ºYâ'Ëâ¡À«®"° its commitment to providing only first-line therapy, with a promise to °"--°..."¢--È·°? À"°¡à¡'°"ª'ˬ·ªßÕ¬à"ßTM--¥® Ì"À--§à"¬",,°"--°..." provide palliative care for those who fail first-line treatment? In the ¢--È'Ë Õß·â« µâÿ Ì"À--°"--°..."TM'«`µºYâªÉ«¬æ`Ë¡¢÷È,¥¬Õ"»--¬°"--°..."¢--È'Ë Õß absence of significant change in the price of second-line drugs, the cost --È®­ Yß¡"° ¡ËÕ'¬°--ºª­,¬TMå"ß ÿ¢¿"æ¡"°¡"¬'Ë®­¥â®"°,¬"¬°" of saving an additional life-year through second-line therapy is high --°...",,¢--È·°æ'¬ßÕ¬à"ߥ'¬« â"æ`®""µ"¡À--°¢Õߪ­ ``º"ߥâ"µâÿ when compared with the substantial health benefits of first-line policy æ'¬ßÕ¬à"ߥ'¬«·â« ,¬"¬'Ë,,TMâæ'¬ß°"--°..."¢--È·°Õ¬à"ߥ'¬«--Èà"®­¥'°«à"7 only. On a pure cost-effectiveness basis, a policy with first-line therapy only would be superior.7 À¡"¬Àµÿ Notes ª--ªÿß°"¢â"÷ß`°"--§Ì"ª÷°..."·­°"µ«®À"TMÈÕ,¥¬ ¡--§,,® 'Ë¡'ºµàÕ 1.1. °"Õ¿`ª"¬÷ß¿"æ 4.8 · ¥ß÷ß«`'°"'Ë,,TMâæËÕ§"¥ª­¡"º¢Õß°" The discussion of figure 4.8 presents the methods used to project °"¥Ì"`,§ß°"¥--ß°à"« the effect of improved VCT accessibility on the use of VCT. 2.2. The transformation of hundreds of public treatment locations °"ª'ˬ "æ¬""¢Õß--À"¬âÕ¬·Ààß ,,Àâªì "æ¬""¢Õß--'Ë ¡'`°" `¡æ`»... ®­Ì",,Àâ¬"°'Ë®­æ`Ë¡»Y¬å`°",,Àâ§Ì"ª÷°..."·­°"µ«®À" into augmented public treatment locations would make it difficult to TMÈÕ,¥¬ ¡--§,,®,,Õ--µ"âÕ¬­ 15 µàÕªï ¥--ß--È "®÷ߥªÑ"À¡"¬ªìâÕ¬­ 10 grow the VCT centers at 15 percent per year. So we decrease that tar- ,, "°"å ¡¡µ`¥--ß°à"« get to 10 percent a year in this scenario. 154 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ 3. ¥--ß'Ë¥âµ--ÈߢâÕ --ß°µ«â,,'Ë 4 °"§"¥ª­¡"Àà"'ÈÕ«à" "ßÕ°,¬"¬ °"--°..."--È ¡à¥â¡'ºµàÕæµ`°¡ 'Ë¬ß ¥--ß--È ®Ì"«ºYâ'˵`¥TMÈÕ«-- ÕTMÕ«'æ`Ë¡ µ`¡--È ®÷ߪ캡"®"°°"¡'TM'«`µÕ¥'Ëæ`Ë¡¢÷È ·­¢âÕÁ®®`ß'Ë«à" ºYâ'˵`¥TMÈÕ«-- ÕTMÕ«''Ë¡'TM'«`µÕ¬Yà¥â"¢÷È ¡',Õ°" 'Ë®­·æà°­®"¬°"µ`¥TMÈÕ¥â¡"°¢÷È 4. °"§"¥ª­¡"µâÿ,,°"»÷°..."'È ¡à¥âæ`Ë¡"§"ß",,Àâ°--µâÿ¢Õß --æ¬"°,,¿"§-- ËÕß®"°"§"ß"--È ,¥¬--Ë«ª·â«®­Õ¬Yà'˪­¡"âÕ¬­ 10 °"§"¥ª­¡"'È ®÷ߧ«®­¢â",,®÷ߧà" '¬,Õ°" ¢Õß,§ß°"Õ¥ å'˪­¡" âÕ¬­ 10 5. µ--«Õ¬à"ßTMà ,,§"°" ª­»·´"'¬ §--«Õ'Ë¡' ¡"TM`° '¬TM'«`µ,,TMà«ß «--¬ºYâ,,Àà'Ë¡'ª­ ``¿"æ Yß ÿ¥ ¡'·«,â¡'Ë®­Ë"«¬°«à"§--«ÕÕËÊ°àÕ'Ë ¡"TM`° "¬'È®­ '¬TM'«`µ ("§",° 2542) 6. °"ª­¡"ª­ ``º¥â"µâÿ --Èß Õß· Ì"À--ª­»¬ µ"¡'Ë¥â "¬ß"«â,,¿"æ 5.12 --È Õ«à"¡"°°«à"'˪­¡"«â,,°"»÷°..."'˧â"¬§÷ß°-- ,,ª­»Õ`¥'¬ ´÷Ëß ÿª«â«à" ,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ®­TM૬ ª--ªÿß ÿ¢¿"æ'˵âÿµË"°«à" 300 ¥Õà"å À-- (12,000 ") µàÕºYâ'ËÕ¥TM'«`µ ÕÕ°ª¥âÕ'°,,ª­» (,Õ«Õå ·­§­ æ.». 2547) §«"¡·µ°µà"ß,,¥â" µâÿ--È à«À÷Ëß°`¥®"°°"ª­¡`µâÿ"ߧ``°'Ë Yß°«à",,ª­»¬ ·­,,°'¢Õßµ--«¢ 2,145 ¥Õà"å À-- (85,800 ") --È °`¥®"°°"«¡ °"--°..."¢--È'Ë Õß«â¥â«¬ ´÷Ëß°"--°..."¥--ß°à"« ¡à¥âÌ"¡"æ`®""¥â«¬,,°"»÷°..." ¢Õߪ­»Õ`¥'¬ 7. À"°Ì",§ß°"¿"'Ë¡à«¡°"--°...",,¢--È·° ¡",,TMâªì°'æÈ" ¥--ß--È °"æ`Ë¡°"--°..."¢--È'Ë Õߢâ"ª ®­TM૬--°..."Õ"¬ÿ¢--¬ÀÕ®Ì"«ªï'Ë¡'TM'«`µÕ¥¥âÕ'° 395,665 ªï,,Õ--µ" à«¥ ,¥¬¡'µâÿæ`Ë¡¢÷ÈÕ'°°Õ 4 æ--â"¥Õà"å À-- (160 æ--â"") ,,TMà«ß 23 ªï¢Õß°"§"¥ª­¡" ¥--ß--È µâÿ¢ÕߺYâªÉ«¬'Ë Õ¥TM'«`µª¥âÕ'°ªï®"°°"--°...",,¢--È'Ë Õß--È ®­Õ¬Yà'˪­¡" 10,000 ¥Õà"å À-- (400,000 ") µàÕªï'Ë¡'TM'«`µÕ¥ ´÷Ëߪìß`®Ì"«'Ë Yß¡"°¡ËÕ'¬°-- "¬¥â¡««¡ª­TM"TM"µ`¢Õߪ­»¬ ,¥¬©æ"­¡ËÕª'¬'¬°--ß`®Ì"« 736 ¥Õà"å À-- (29,440 ") 'Ë--"®­µâÕß®à"¬æËÕ,,Àâ¥âª­,¬TMå"ß ÿ¢¿"æÕ¬à"ß¡"°¡"¬®"°,¬"¬¿"'Ë¡'°"--°...",,¢--È·°à"--È ¡à«à"--" ®­µ--¥ `,,®,,Àâÿ -- ÿ°"--°...",,¢--È'Ë ÕßÀÕ¡à--È ®­¢÷ÈÕ¬Yà°--«à" "-- "ß°"¡Õß®­,,À⧫"¡ -- ÿµàÕ°"--°...",,¢--È'Ë Õß,¥¬¡à§`¥§à"`°"ÀÕ¡à ·­¢÷ÈÕ¬Yà°--«à" §à"¬" Ì"À--°"--°..."¢--È'Ë Õß--È "¡"¥µË"ß°«à""§" ªí®®ÿ--¥â¡"°ÀÕ¡à 'Ë 6 º§«"¡ÕàÕÀ«¢Õß°"®--¥Õ--¥--,¬"¬ 'Ë¡'µàÕ ¡¡µ`"À--° °àÕÀâ"'È ¥â â"ß·®Ì"Õß (model) "ߥâ"»...»" µå·­­"¥«`¬" ¢Õß°"--°..."¥â«¬¬"µâ"«-- ÀÕ ÕÕ"å' (ART) æËÕ,,Àâ "¡"ª­¡"°" Õ¬à"ßTM--¥®÷ߪ­ ``º"ߥâ"µâÿ¢Õß,§ß°"¿" (NAPHA) ·­"ßÕ° æËÕ `¡,§ß°"Õ'° 3 ª­°" ¢âÕ -- ÿ'Ë¥â®"°°" --ß°µ°"å·­¥Õß Ì"À-- ¡¡µ`"À"¬ª­°"¢Õß·®Ì"Õߥ--ß°à"«--È®­·µ°µà"ß°--ª "ß ¡¡µ`" ®­¥â--§«"¡ -- ÿªìÕ¬à"ß¡"° TMà Yª·,,°"Õ¥TM'«`µ¢ÕߺYâ µ`¥TMÈÕ«-- ÕTMÕ«'/Õ¥ å'Ë¡à¥â--°"--°..." à«"ß ¡¡µ`" Õ"®¥â--§«"¡ -- ÿæ'¬ßÁ°âÕ¬ TMà °"µÕ ÕߢÕßÕÿª ߧå¢Õß`°"ª÷°..."·­µ«® Õ¥À"°"µ`¥TMÈÕÕTMÕ«',¥¬ ¡--§,,®ÀÕ«'´'' (VCT) 'Ë¡'µàÕ"§"·­­¬­"ߢÕß °ÿà¡ 'ˬ߷µà­°ÿà¡ à« ¡¡µ`"ÕËÊ ®­°'ˬ«¢âÕß°--«`«--"°"¢Õߧ,,¬' ·­"§" ´÷Ëߪ쪭¥Á'Ë"¥â·µà§"¥¥",¥¬Õ"»--¬¢âÕ¡Y «`'°"À÷Ëß'Ë®­®--¥°"°--§«"¡¡à·àÕ¢ÕßËÕßÀà"'È §Õ°"«"ß,¬"¬µ"¡ --TM"µ`",¥¬¡àµâÕßÕâ"ß÷ßYª·'ËTM--¥®,,¥Ê àÕ¬§--Èß '˺Yâ«"ß,¬"¬®Ì"ªì µâÕß--ߧ--,,TMâ,¬"¬¥â«¬«`''È Õ¬à"ß°Áµ"¡ ,,°''Ë,¬"¬Àà"'È¡'Àµÿº ,¬"¬¥--ß°à"« ®­¢÷ÈÕ¬Yà°--Yª·,¥¬ª`¬"¬·­ ¡¡µ`" ·­ËÕß®"°¡à¡'°" À"ÕÕ¬à"ßTM--¥® Yª·,¥¬ª`¬"¬'È®÷ßÕ"®¡'§«"¡¡à Õ¥§âÕß¿"¬,, ÀÕÕ"®¢÷È Õ¬Yà°-- ¡¡µ`"'Ë¡à¥â­ÿ«â ¥--ß--È ®÷ßÕ"®Ì",,ÀâºYâ«"ß,¬"¬·­§­¥Ì"`°" º`¥æ"¥,, `Ëß'Ë "¡"À'°'ˬߥâÀ"°,,TMâYª·'ËTM--¥® ª­,¬TMå¢Õß°",,TMâ·®Ì"Õß'ËTM--¥®¥--ß'Ë"¥â°­Ì" 'Ë'È §Õ Õ"®Ì",,Àâ ¡¡µ`"TM--¥®¢÷ȥ⠷­Õ"®»÷°..."Õ``æ¢Õß ¡¡µ`"Àà"'È'Ë¡'µàÕº'Ë®­¥â -- ,¥¬,,TMâ°"«`§"­À姫"¡ÕàÕÀ« 155 156 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ §«"¡ÕàÕÀ«'Ë¡'µàÕ ¡¡µ`"¥â"TM'«¿"æ·­"§" ,,'È "¥â¥Ì"`°"«`§"­À姫"¡ÕàÕÀ« Ì"À-- ¡¡µ`" Õß°ÿà¡ ë °ÿà¡·° "»÷°..."º¢Õß ¡¡µ`""ßÕ°°'ˬ«°----°...­"ßTM'«¿"æ'Ë Ì"§-- ¢Õ߬"µâ"«-- «¡--Èß"§"·­§«"¡ "¡"'Ë®­¢â"--°"--°..."¥â«¬¬"µâ" «-- Õ¥ å ë °ÿà¡'Ë Õß "¥â»÷°..."º¢Õß ¡¡µ`""ßÕ°,,¥â"æµ`°¡ °"«`§"­Àå--ÈßÀ¡¥ ¥â°­Ì",¥¬ª'¬'¬°--°"§"¥ª­¡",§ß°"¿" (NAPHA) ´÷Ëß«¡°"--°...",,¢--È'Ë Õß ¥--ß'˥ⷠ¥ß«â,,'Ë 4 µ--«·ª'Ë Ì"§--"ßTM'«¿"æ ¡' ¡¡µ`""ßTM'«¿"æÀ"¬ª­°"'Ë¡'Õ``æµàÕº'Ë¥â-- --Èß'È "®­"¬ß" ÷ß°"«`§"­À姫"¡ÕàÕÀ«°'ˬ«°-- ¡¡µ`" 2 ª­°" Õ--¥â·°à °"µ`¥TMÈÕ ·­ °"¥ÈÕ¬" °"µ`¥TMÈÕ ,,·®Ì"Õߢ--ÈæÈ"¢Õß" "µ--Èß ¡¡µ`"«à" °"µ`¥TMÈÕ¢ÕߺYâ'Ë¢â"--°" --°..."¥â«¬¬"µâ"«-- (ÕÕ"å') ®­¥ßâÕ¬­ 75 æËÕ«--¥§«"¡ÕàÕÀ«¢Õߺ'Ë ¡'µàÕ ¡¡µ`"¥--ß°à"« "®÷ßÕߧ"¥ª­¡"÷ß "°"å ¡¡µ`--Èߥâ"«°·­ ¥â" (¥ß¥ââÕ¬­ 100 ÀÕ¡à¥ß¬) ¿"æ 6.1 "¬ß"÷ߺ¢Õß ¡¡µ`"°'ˬ«°--°"µ`¥TMÈÕ'Ë¡'µàÕµ--«àßTM'ÈÀ--°,,°"µ`,µ¢Õß,§­"¥ ´÷Ëß¥â·°à ®Ì"«ºYâµ`¥TMÈÕ"¬,,À¡à,,ªï'Ë°Ì"À¥ --Èß'È â,§âß â°"ß ´÷Ëߢ÷È÷ß®ÿ¥ Yß ÿ¥'Ë 1,823 ,, æ.». 2555 ·­¥ß¢â"À"­¥-- 1,000 --È · ¥ß÷ß®Ì"«ºYâµ`¥TMÈÕ "¬,,À¡à °"µ`¥TMÈÕ¥--ß°à"«°`¥¢÷È¿"¬,,µâ,§ß°"¿" ,¥¬ºYâµ`¥TMÈÕ¥`¡'ˬ--ߧߡ' ÿ¢¿"æ¥'Õ--ËÕß¡"®"°°"--°..."¥â«¬¬"µâ"«-- (ÕÕ"å') ·­ËÕß®"°°"--°..." ¥â«¬¬"µâ"«-- àߺ,,ÀâºYâªÉ«¬¡'æµ`°¡'˪ե¿--¬¬`Ëߢ÷È °"µ`¥TMÈÕæ`Ë¡µ`¡'È®÷ß °`¥®"°°"'˺YâªÉ«¬Õ¥ å¡'TM'«`µ¬"¢÷Èà"--È °"§"¥ª­¡"÷ß "°"å¢--ÈæÈ",,°''Ë¡à¡',§ß°"¿" ( "°"å A1) · ¥ß,,ÀâÀÁ«à" ®Ì"«¢ÕߺYâµ`¥TMÈÕ«-- ÕTMÕ«'"¬,,À¡à ®­¥ß ®"° 17,000 "¬ ,, æ.». 2546 ¡"ªì 3,600 "¬ ,, æ.». 2558 ·­ª­¡" 2,400 "¬ ,, æ.». 2568 ¡ËÕª'¬'¬°--µ--«¢,, âæÈ"Àà"'È â,§âß °"ß,,¿"æ 6.1 ®÷ß· ¥ß«à" ,§ß°"¿" ®­æ`Ë¡®Ì"«ºYâµ`¥TMÈÕ"¬,,À¡àÕ¬à"ß¡"° ,¥¬©æ"­,,ªïÀ--ßÊ --Èß'È ,,Yª¢ÕßÕ--µ" à«âÕ¬­ ,§ß°"¿" ®­æ`Ë¡®Ì"«ºYâ µ`¥TMÈÕ"¬,,À¡àª­¡"âÕ¬­ 40 ,,·µà­ªï µ--Èß·µà æ.». 2555 ÷ß 2568 à« â ,§âߥâ"à"ß ÿ¥,,¿"æ 6.1 · ¥ß«à" ®Ì"«ºYâµ`¥TMÈÕ"¬,,À¡à®­¥ßÀ"°°"--°..." ¥â«¬¬"µâ"«-- "¡"¬--¬--Èß°"µ`¥TMÈÕ®"°ºYâ'˵`¥TMÈÕ¥â,¥¬ ¡Yå (¥ßâÕ¬­ 100) ,,°''È °"æ`Ë¡¢ÕߺYâµ`¥TMÈÕ"¬,,À¡à'Ë°`¥®"°,§ß°"¿" ®÷ߪ캡" §«"¡ÕàÕÀ«¢Õß°"®--¥Õ--¥--,¬"¬'Ë¡'µàÕ ¡¡µ`"À--° 157 Sensitivity of the Policy Rankings to Key Assumptions · 157 ¿"æ 6.1 ºYâµ`¥TMÈÕ«-- ÕTMÕ«'"¬,,À¡à ·¬°µ"¡Õ--µ"°"µ`¥TMÈÕ,,°ÿࡺYâ'Ë--°"--°..."¥â«¬¬"µâ" «-- (ÕÕ"å'): "°"å'˧"¥«à"®­°`¥¢÷ÈÀ"°¡'°"¥Ì"`,§ß°"¿" Figure 6.1 New HIV Cases by Infectivity Rates among People on ART: NAPHA Scenario 6,000 5,000 4,000 cases 3,000 of 2,000 ®"«ºYâµ`¥TMÈÕ number1,000 0 ­1,0002544 2546 2548 2550 2552 255 â"2556 2558 2560100%25reduction 2001 2003 2005 2007 2009 2011 2013 2015 2017 2019 2021 2023 2025 4 62 2564 2566 2568 0%reduction ¥ßâÕ¬­ 0 75%baseline 'ËâÕ¬­ 75 ¥ßâÕ¬­ 100 Source: Authors. 'Ë¡": ºYâ¢'¬ in figure 6.1 shows that the number of new infections is reduced if ART is assumed to completely eliminate transmission by the infected ®"°§«"¡â¡À«,,°"--°..." ¡ËÕ°"--°..."¥â«¬¬"µâ"«-- ¡àÕ"®--°..." ÿ¢¿"æ person (100 percent reduction). In this case, the only increase in new ÀÕ¢--¥¢«"ß°"µ`¥TMÈÕ¥âÕ'°µàÕª infections attributable to NAPHA is the result of treatment failure, when ART can no longer sustain health or impede transmission. â,§âß à« ÿ¥,,¿"æ 6.1 · ¥ß«à" º¢â"ߧ'¬ß¢Õß°"¡'Õ"¬ÿ¬¬"«¢÷È ®­¡' ¡"°¢÷È À"°°"--°..."¥â«¬¬"µâ"«-- --È¡à¥â àߺ°­¥â"TM'«¿"æµàÕ°"µ`¥ The top curve in figure 6.1 shows that the spillover effect from TMÈÕ ¥--ß'Ë,Õ«`å ·­§­ (æ.». 2547) Õâ"ß«â Õ°®"°'È ®"°°"æ`Ë¡¢Õß greater longevity would be far greater if, as argued by Auvert and oth- ®Ì"«ºYâªÉ«¬"¬,,À¡àªï­ª­¡" 5,000 "¬ µ--Èß·µàÀ--ߪï æ.». 2554 ªìµâ¡" ers (2004), ART had no biological impact on infectivity. By increasing ,§ß°" NAPHA ®­æ`Ë¡®Ì"«ºYâµ`¥TMÈÕ"¬,,À¡à÷ß Õßà"ÿ°Êªïµ--Èß·µàªïæ.». 2555 the number of new infections by about 5,000 in every year after 2011, ·­®Ì"«ºYâµ`¥TMÈÕ"¬,,À¡à®­æ`Ë¡¢÷Ȫì "¡à",,TMà«ß '˪ï ÿ¥â"¬¢Õß°"§"¥ NAPHA would more than double the new infections in every year ª­¡" §Õµ--Èß·µà 2,500 "¬µàÕªï ¡"ªì 7,500 "¬µàÕªï after 2012 and would triple the number of new infections in the last four years of the projection, from about 2,500 per year to about 7,500 ÷ß·¡â®­¡'ºÕ¬à"ß¡"°µàÕ®Ì"«ºYâµ`¥TMÈÕ«-- ÕTMÕ«'"¬,,À¡à °"ª'ˬ·ªß Õ--µ"°"µ`¥TMÈÕ ¡'º§àÕ¢â"ßâÕ¬µàÕº--æå¥â"ª­ ``º"ߥâ"µâÿ ¥--ß'Ë per year. · ¥ß«â,,¿"æ 6.2 ¿"¬,,µâ "°"å ¡¡µ`'Ë«â"¬'Ë ÿ¥ §Õ¡ËÕÕ--µ"°"¥°" Despite its sizable effect on the number of new HIV cases, a change µ`¥TMÈÕ,,°ÿࡺYâªÉ«¬'Ë¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¡'§à"ªì»Y¬å µâÿµàÕ ºYâ'ËÕ¥TM'«`µµàÕªï®"°,§ß°" NAPHA æ`Ë¡¢÷Èæ'¬ßâÕ¬­ 5 §Õ ®"° 2,145 in the infectivity rate has a relatively minor effect on the cost- ¥Õà"å À-- (85,800 ") Ì"À--,§ß°"¢--ÈæÈ" ¡"ªì 2,257 ¥Õà"å effectiveness results, as shown in figure 6.2. Under the worst-case sce- À-- (90,280 ") º--æå¥--ß°à"« °`¥¢÷È,¥¬µßÀ--ß®"°¥â,,TMâ¢Õ¢µ,,°" nario of zero reduction in infectivity for ART patients, the cost per «"ß·ºÕ¬à"ߥÁ¥¢"¥,,ªï æ.». 2568 ËÕß®"°­¬­­À«à"ß°"µ`¥TMÈÕÕTMÕ«'ª life-year saved of NAPHA rises by only 5 percent, from US$2,145 ®÷ߧ«"¡µâÕß°"'Ë®­--°"--°..." ®­µâÕß,,TMâ«",,­¬­«"©'ˬª­¡"®Á¥ªï (B 85,800) for the basic program to US$2,257 (B 90,280). This result ·­°"--°...",,¢--È·°®­¬¥­¬­«"¢ÕߺYâªÉ«¬ÕÕ°ª®"°®ÿ¥--È¥âªì«"Õ'° follows directly from our adoption of a finite planning horizon of À"¬ªï ¥--ß--È ®÷ß¡'ºYâ'˵`¥TMÈÕ®"°ºYâªÉ«¬Õ¥ åæ'¬ß¡à°'˧,, "°"å ¡¡µ`Àà" 2025. Because progression from HIV infection to a need for treat- --È 'Ë®­æ--"Õ"°"ª®µâÕߢâ"--°"--°...",,­¬­'Ë Õß´÷Ëß¡'"§"·æß°àÕ'Ë®­ ment takes a median time of seven years and first-line therapy will sus- ÷ßTMà«ßª"¬¢Õß­¬­«"«"ß·º tain people from that point for several more years, few of those infected by AIDS patients in any of these scenarios will progress to expensive second-line therapy before the end of the planning period. 158158 ·»...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º:°"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand ¿"æFigure ¡Y§à"ªí®®ÿ-- ÿ` (Net Present Value) ¢ÕßµâÿµàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â®"° "°"å 6.2 6.2 Net Present Value of Cost per Life-Year Saved by Infectivity Scenario ¡¡µ`°'ˬ«°--°"µ`¥TMÈÕ 3,000 2,600 life-year (US$) per cost (¥Õà"å À--)3 2,300 3% US$2,257 at US$2,145 US$2,107 of âÕ¬­ 1,800 value discounted 1,400 present saved, net ¡Y§à"ªí®®ÿ-- ÿ`¢ÕßµâÿµàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â ¥â«¬Õ--µ" à«¥ 1,000 0% reduction ¥ßâÕ¬­ 0 â" 'Ë¡":Source:Authors. ºYâ¢'¬ 'ËâÕ¬­ 75 75% baseline¥ßâÕ¬­ 100 100% reduction °"¥ÈÕ¬" Resistance ¡¡µ`" Ì"§--ª­°"'Ë Õß'ËÌ"¡",,TMâ,,°"«`§"­Àå'È §ÕÕ--µ"°"¥ÈÕ¬",,°ÿࡺYâ The second key assumption used in the analysis is a rate of resistance ªÉ«¬'Ë¢â"--°"--°..."¥â«¬¬"µâ"«-- (ÕÕ"å') ´÷Ëߡભ §«"¡ Ì"Á®,,°" among the ART patients for whom first-line ART therapy failed. The --°..."¢--È·° ·®Ì"Õß'È ¥â,,TMâ ¡¡µ`"«à" âÕ¬­ 80 ¢ÕߺYâ'Ë¢â"--°"--°..." model uses the assumption that 80 percent of people on ART develop ¥â«¬¬"µâ"«-- (ÕÕ"å') ®­æ--" "¬æ--åÿ¥ÈÕ¬" ¡ËÕ°"--°..."¥â«¬¬"µâ"«-- resistance strains when first-line ART therapy fails for them. In Thai- Õ¥ å,,¢--È·°¡à¥âº ,,ª­»¬ " --`..."«à" °"¢"¥·§·æ¬å'Ë¡' land, we assume that because of the lack of physicians experienced ª­ °"å,,°"--°..."¥â«¬¬"µâ"«-- (ÕÕ"å') ·­¢âÕ®Ì"°--¥°'ˬ«°--°"µ«® with ART treatment and the limited availability of viral-load testing at À"ª`¡"«-- ,,°­· Õ¥,, "æ¬""­¥--ÕÌ"¿Õ--È ªì "Àµÿ,,ÀâºYâªÉ«¬'Ë district level facilities, some 20 percent of ART patients are switched ¢â"--°"--°..."¥â«¬¬"µâ"«-- (ÕÕ"å') ª­¡"âÕ¬­ 20 ¥âª'ˬª--°" to second-line ART without having any resistant strains. However, --°..."¥â«¬¬"µâ"«-- ,,¢--È'Ë Õß ,¥¬¡à¡' "¬æ--åÿ¥ÈÕ¬"·µàÕ¬à"ß,,¥ Õ¬à"ß°Áµ"¡ more trained physicians and wider availability of viral-load testing throughout the country would reduce this proportion and allow only ·æ¬å'Ë¥â--°"Õ¡¡"°¢÷È ·­§«"¡æâÕ¡¢Õß°",,Àâ`°"µ«®À"ª`¡" patients with resistant virus to switch to second-line ART therapy. «-- ,,°­· Õ¥´÷Ëß°«â"ߢ«"ߢ÷È--Ë«ª­» ®­TM૬¥ --¥ à«¥--ß°à"« ·­Ì",,Àâ¡' Weconductedsensitivityanalysisbyusingresistanceassumptionsof50 æ'¬ßºYâªÉ«¬'Ë¡'TMÈÕ«-- ¥ÈÕ¬"à"--È 'Ë®­ª'ˬª--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å and 100 percent. The results indicate that with 100 percent resistance ,,¢--È'Ë Õߥâ approximately 23 percent more HIV-positive people carry resistant strains by 2025 than do under our starting assumption of 80 percent "¥Ì"`°"«`§"­À姫"¡ÕàÕÀ« ,¥¬,,TMâ ¡¡µ`"¥â"°"¥ÈÕ¬"'ËâÕ¬­ 50 ·­âÕ¬­ 100 º--æå'Ë¥â TM'È,,ÀâÀÁ«à" ¥â«¬Õ--µ"°"¥ÈÕ¬"'ËâÕ¬­ 100 ®­¡'ºYâ resistance. When a 50 percent resistance rate is used instead, the preva- µ`¥TMÈÕ«-- ÕTMÕ«'æ`Ë¡¢÷ÈÕ'°ª­¡"âÕ¬­ 23 'Ëæ--" "¬æ--åÿ¥ÈÕ¬"¿"¬,,ªï lence of resistant strains is reduced by 14 percent. However, again æ.».because of¡"°°«à"'Ë®­ªì,,°'¢Õß ¡¡µ`"¢--È·°changes make almost no 2568 the 20-year planning horizon, these ´÷ËßÕ--µ"°"¥ÈÕ¬"Õ¬Yà'Ë âÕ¬­ 80 ·µà¡ËÕÌ"Õ--µ"°"¥ÈÕ¬"âÕ¬­ 50 ¡",,TMâ· §«"¡TMÿ° (Prevalence) difference in the number of new HIV cases or the cost per life-year saved. ¢Õß "¬æ--åÿ¥ÈÕ¬"--È®­¥ß÷ßâÕ¬­ 14 Õ¬à"ß°Áµ"¡ ËÕß®"°¢Õ¢µ°"«"ß ·º--È÷ß 20 ªï §«"¡ª'ˬ·ªßÀà"'È ®÷ß·®­¡à¥â â"ߧ«"¡·µ°µà"ß,,¥Ê Price of First- and Second-Line ART Therapy ,, à«¢Õß®Ì"«ºYâµ`¥TMÈÕ«-- ÕTMÕ«'"¬,,À¡à ÀÕµâÿµàÕºYâªÉ«¬'ËÕ¥TM'«`µ¥â Chapter 3 presented the estimated unit cost for both first- and second- line therapy based on current drug regimens and using the current "§"¢Õß°"--°..."¥â«¬¬"µâ"«-- (ÕÕ"å') ,,¢--È·°·­¢--È'Ë Õß prices of both generic and branded drugs in Thailand. If current efforts 'Ë 3 Õ÷ßµâÿµàÕÀ૬'˪­¡"°"«â Ì"À--°"--°...",,¢--È·°·­¢--È'Ë Õß ,¥¬,,TMâ°Ø°±å¢Õß°",,TMâ¬",,ªí®®ÿ--·­"§"¬"--Èß'˪ì¬" "¡--·­¬"'Ë¡' §«"¡ÕàÕÀ«¢Õß°"®--¥Õ--¥--,¬"¬'Ë¡'µàÕ ¡¡µ`"À--° 159 ¬'ËÀâÕ,,ª­»¬ªì" â"§«"¡æ¬"¬"¡,,ªí®®ÿ--¢ÕߺYâº`µ"ß¿ --TM°¡ ,,­¥--""TM"µ`'Ë®­¢¬"¬°"§ÿ⡧Õß ``--µ,,Àâ·°à¬"'Ë,,TMâ,,°"--°..."¢--È'Ë Õß --Ȫ­ §«"¡ Ì"Á® "§"¬"'Ë,,TMâ--°...",,¢--È'Ë Õß--È¡'à"'«à"®­¬--ߧßÕ¬Yà,,­¥-- Yß ·µàâ"À"°§«"¡æ¬"¬"¡¥--ß°à"«¡àª­ §«"¡ Ì"Á® "§"¢Õ߬"'Ë,,TMâ,,°" --°..."¢--È'Ë Õß--È ®­¥ßà"°--'Ë"¥âÀÁ"§"¢Õ߬"'Ë,,TMâ,,°"--°..."¢--È·°¥ ß,,¡à°'˪ï'˺à"¡" Õ¬à"ß°Áµ"¡ ¡ËÕ¡à"¡"'È ª­»Õ`¥'¬¥â¡'°"ª'ˬ ·ªß"ߥâ"­'¬°ÆÀ¡"¬«à"¥â«¬·ßà¡ÿ¡µà"ßÊ¢Õß ``¢Õß--æ¬å `"ߪí"'Ë °'ˬ«°--°"§â" (Trade-Related Aspects of Intellectual Property Rights>TRIPS)1 æËÕ,,Àâ Õ¥§âÕß°--¢âÕµ°ß¢ÕßÕߧå°"§â",° (World Trade Organization>WTO) °"ª'ˬ·ªß'È Ì",,Àâ°`¥¢âÕ°--ß««à" µâÿ«--µÿ¥`'˪­»¬µâÕßÌ"¢â"®"° Õ`¥'¬æËÕ¡"º`µ¬"®'æ',Õ-«'¬å (GPO-vir) ®­æ`Ë¡ Yߢ÷È àߺ,,Àâµâÿ¢Õß®'æ',Õ- «'¬å (GPO-vir) 'Ë,,TMâ,,°"--°..."¢--È·° Yߢ÷Ȫ¥â«¬ ,, à«'È¢Õß "®­¡àª'ˬ·ªß¢âÕ°Ì"À¥TM`ߧ`§¢Õß°"--°..."¥â«¬¬" µâ"«-- (ÕÕ"å') --Èß,,°"--°..."¢--È·°·­¢--È'Ë Õß æËÕ'Ë®­§Ì"«ª­ ``º "ߥâ"µâÿ ¢Õß"¬°"µàÕª'È: ë "§"§à"--°..."¥â«¬¬"µâ"«-- ,,¢--È'Ë ÕߥßâÕ¬­ 50 ë "§"§à"--°..."¥â«¬¬"µâ"«-- ,,¢--È·°¥ßâÕ¬­ 25 ·­"§"§à"--°..."¥â«¬ ¬"µâ"«-- ¢--È'Ë ÕߥßâÕ¬­ 50 ë "§"§à"--°..."¥â«¬¬"µâ"«-- ¢--È·°æ`Ë¡¢÷ÈâÕ¬­ 25 ,, "°"å®Ì"Õß--ÈßÀ¡¥ "µ--Èß ¡¡µ`"«à" "§"'˺YâªÉ«¬µâÕß®à"¬®­¡à¡' °"ª'ˬ·ªß ¥--ß--È æµ`°¡¢ÕߺYâªÉ«¬®÷ß¡àª'ˬ ·­--"®­ªìºYâ-- à« ¢Õßµâÿ'˪­À¬--¥¥â®"°°"¥"§"«âÕß2 º¢Õß ¡¡µ`"¥â""§"¢Õß°"--°...",,¢--È·°·­¢--È'Ë ÕßÀà"'È ¥â· ¥ß«â,, ¿"æ 6.3 --Èß 'Ë à« à«·° (°) ¥â¬âÌ" `Ëß'˧âæ,,'Ë 5 ´÷Ëß· ¥ß«à" ,§ß°" ¿"ªì"ßÕ°'Ë¡'ª­ ``º"ߥâ"µâÿ¡"°'Ë ÿ¥ µ"¡¡"¥â«¬°"¥Y·--°..." æ`Ë¡µ`¡·¢¬"¬º --Èß'È Õ'° "¡ à«¢Õß¿"æ®­· ¥ß÷ߺ--æå¢Õߪ­ ``º "ߥâ"µâÿ'Ë°`¥®"°°"ª'ˬ·ªß¢Õß"§"°"--°..."¢--È·°·­¢--È'Ë Õߥ--ß 'Ë­ÿ«â¢â"ߵ⠿"æ à« (¢) ·­ (§) · ¥ß«à" À"°"§"§à"--°...",,¢--È'Ë ÕߥßâÕ¬­ 50 ª­ ``º"ߥâ"µâÿ¢Õß "°"å ¡¡µ`¥â",¬"¬--ÈßÀ¡¥®­¥'¢÷Ȫì Õ¬à"ß¡"° --Èß'È ¡àÀ¡Õ°--"ßÕ°'Ë ç¡à¡'¢--È'Ë Õßé ´÷Ëß®Ì"Õß«â,,µÕâ"¬ 'Ë 5 "°"å®Ì"ÕßÀà"'È ¬--ߧß--°..."ºª­,¬TMå"ߥâ" ÿ¢¿"æ¢Õß°" --°...",,¢--È'Ë Õß«â¥â,,¢­'Ë "¡"®à"¬,,"§"'ËâÕ¬°«à" Õ°®"°'È ¡--¬--ß Õ÷ߺª­,¬TMå'Ëà"®­°`¥¢÷È·°àª­»¬®"°°"µàÕÕßæËÕ"§"'Ë¥'°«à" Ì"À--§à"¬",,°"--°..."¢--È'Ë Õß®"°Õߧ尭¥--""TM"µ`À"¬·Ààß ÀÕÕ'°"ß À÷Ëß ®"°°",,TMâ¡"µ°"--ߧ,,TMâ ``¢Õß-- (Compulsory Licensing) µàÕ`...--¬" Àà"'È 160 · TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand 160 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ Figure 6.3 Sensitivity of the Cost-Effectiveness Analysis to Prices of First- and ¿"æ 6.3 §«"¡ÕàÕÀ«¢Õß°"«`§"­À媭 ``º"ߥâ"µâÿ'Ë¡'µàÕ"§"¢Õß°"--°..."¥â«¬¬" Second-Line ART µâ"«-- ,,¢--È·°·­¢--È'Ë Õß (°)(a) §à"ªí®®ÿ-- ÿ`¢ÕßµâÿµàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â (¢) §à"ªí®®ÿ-- ÿ`¢ÕßµâÿµàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â (b) Net present value of cost per ÀÕªï'ËÕ¥TM'«`µ ,¥¬§`¥,,Õ--µ" à«¥ âÕ¬­ 3 Net present value of cost per ÀÕªï'ËÕ¥TM'«`µ ,¥¬§à"¬"µâ"«-- Õ¥ å¥ß âÕ¬­ 50 life-years saved with 50% price life-year saved, discounted at 3% reduction in second-line ART 3,000 3,000 2,600 US$2,342 US$2,184 US$2,243 2,600 2,200 US$2,145 2,200 US$ 1,800 US$ 1,800 US$1,686 US$1,585 ¥Õà"å À-- US$1,476 US$1,519 1,400 ¥Õà"å À-- 1,400 1,000 1,000 (§)(c)ÀÕªï'ËÕ¥TM'«`µ §à"ªí®®ÿ-- ÿ`¢ÕßµâÿµàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â Net present value of cost per (ß) §à"ªí®®ÿ-- ÿ`¢ÕßµâÿµàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â life-year saved with 50% reduction (d) Net present value of cost per ÀÕªï'ËÕ¥TM'«`µ ,¥¬§à"¬"µâ"«-- Õ¥ å in second-line¥ßâÕ¬­25% ,,¢--È'Ë Õß,¥¬§à"¬"µâ"«-- Õ¥ å ART and 50 life-year saved with 25% price ·­,,¢--È·° æ`Ë¡¢÷È âÕ¬­ 25 reduction in first-line ART ·­,,¢--È·° ¥ßâÕ¬­ 25 increase in first-line ART 3,000 3,000 2,600 2,600 US$2,429 US$2,231 US$2,274 US$2,333 2,200 2,200 US$ US$ ¥Õà"å À-- 1,800 US$1,599 1,800 US$1,390 US$1,429 US$1,496 1,400 ¥Õà"å À-- 1,400 1,000 1,000 "°"å D1 "°"å D2 "°"å D3 "°"å D4 scenario D1 scenario D2 scenario D3 scenario D4 Source: Authors. 'Ë¡": ºYâ¢'¬ ¿"æ (ß) · ¥ß÷ߺ--æå¢Õß"§"'Ë Yߢ÷È Ì"À--°"--°...",,¢--È·° (´÷ËßÕ"®®­ °`¥¢÷È®"°°ÆÀ¡"¬,,À¡à,,ª­»Õ`¥'¬) ,¥¬"§"§à"--°...",,¢--È'Ë Õß¡àª'ˬ ·ªß "°"å®Ì"ÕßTMÿ¥'È· ¥ß,,ÀâÀÁ«à" ,,`'Ë¡'§®Ì"«¡"°--°"--°..." Panel (d) shows the result of higher prices for first-line therapy (perhaps caused by the new legislation in India) with unchanged prices for second-line therapy. This set of simulations shows that in a context ,,¢--È'Ë Õß´÷Ëß¡'"§"·æß °"æ`Ë¡µâÿ§à"¬" Ì"À--°"--°..."¢--È·°æ'¬ßÁ°âÕ¬ where many people receive expensive second-line care, a small "¡"ªì'ˬա--¥â§àÕ¢â"ßßà"¬ Õ¬à"ß°Áµ"¡ À"°¡à¡'¬" Ì"À--°"--°...",,¢--È increase in the cost of first-line drugs could be absorbed relatively eas- 'Ë Õß °"æ`Ë¡'Ëà"°--¢Õßµâÿ§à"¬"'Ë,,TMâ,,°"--°..."¢--È·°®­¥Yæ`Ë¡Õ¬à"ß¡"°â" ily. However, if second-line drugs were unavailable, the same increase §`¥ªìÕ--µ" à«âÕ¬­ ·­Õ"®Ì",,Àâ°`¥ªØ`°``¬""ߥâ"°"¡Õß in the cost of first-line drugs would be larger in percentage terms and ,,¥"--Èß 'ËYª'È ¡à¡'Yª,,¥'Ë°"®--¥Ì"¥--"ßÕ°¥â",¬"¬¡'°"ª'ˬ might cause a political reaction. ·ªß ,,--Èß 'Ë¿"æ ,¬"¬¿"·¥'ˬ« ( "°"å ¡¡µ` D1) ®­¬--ߧߡ' ª­ ``º"ߥâ"µâÿ Yß ÿ¥ ·­,,¥"--Èß 'Ë¿"æ °"æ`Ë¡¢÷È¢ÕßµâÿµàÕ Õ"¬ÿ¢--¬'Ë--°..."«â¥â,,"ßÕ°'˵âÕߥÌ"`--Èß Õß,§ß°" ( "°"å ¡¡µ` D4) In none of the four panels does the ranking of policy options change. In all four, the pure NAPHA policy (scenario D1) remains the most cost-effective. In all four, the increase in cost per life-year ·'Ë®­,,TMâ,§ß°" NAPHA æ'¬ßÕ¬à"ߥ'¬«--ȧàÕ¢â"ß®­âÕ¬ ËÕß®"°--Èß Õß"ß saved of the both option (scenario D4) over the NAPHA-only option Õ° "¡"--°..."TM'«`µºYâªÉ«¬¥âªì®Ì"«¡"° ¥--ß--È ,,--Èß 'Ë°' §Ì"·­Ì"§Õ,,Àâ is small, given that the both option saves many more lives. Accord- Õ° "°"å'Ë¡'°"¥Ì"`--Èß Õß,§ß°" --˧հ" àß `¡°",,Àâ`°"--°..." ingly, in all four cases the recommendation would be to choose the ¥â«¬¬"µâ"«-- (ÕÕ"å') ºà"°"TM--°®YߺYâªÉ«¬,,Àâ¢â"--°"--°..."µ--Èß·µà­¬­·° both scenario, which enhances public ART delivery with both early (,¥¬,,TMâ«'´'' (Voluntary Counseling and Testing-VCT)) ·­,,À⧫"¡ -- ÿ,, recruitment (using VCT) and adherence support (using groups of °"ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥ (,,TMâ°ÿࡺYâµ`¥TMÈÕÕTMÕ«'/ºYâªÉ«¬Õ¥ å people living with HIV/AIDS).3 (PHAs))3 §«"¡ÕàÕÀ«¢Õß°"®--¥Õ--¥--,¬"¬'Ë¡'µàÕ ¡¡µ`"À--° 161 §«"¡ÕàÕÀ«µàÕ§«"¡ª'ˬ·ªß,,æµ`°¡ 'Ë¬ß °"«"ß·®Ì"Õß´÷ËߥⰭÌ",,'Ë 4 ·­ 5 ¡' ¡¡µ`"«à" ,¬"¬,,°" --°..."¡à¥â¡'ºµàÕæµ`°¡ 'Ë¬ß ·µà ¡¡µ`"'È Õ"®¡à¥âªìTMà--È®`ß ¥--ßTMà 'Ë· ¥ß,,ÀâÀÁ,,'Ë 2 ·­,,--¥ ÿ¥â"¬¢Õßµ""ß 3.8 ,,'Ë 3 æµ`°¡ 'ˬßÕ"®µÕ Õß--Èß,,"ß«°ÀÕ"ßµàÕ°"--°..."¥â«¬¬"µâ"«-- (ÕÕ"å') 'Ë¡'ª­ ``º·­"§"Y° --Èß'È "¥â«"ßYª·¢Õߺ,,"ß«°¢Õß°"--°..." ¥â«¬¬"µâ"«-- (ÕÕ"å') 'Ë¡'µàÕ§«"¡µâÕß°"`°"ª÷°..."·­µ«®Õ¥À"°" µ`¥TMÈÕÕTMÕ«',¥¬ ¡--§,,®ÀÕ«'´'' (µ"¡°"µÕ Õß'Ë¡'µàÕ"§"'˵Ë"°«à" ·­ ­¬­"ß'Ë®­¢â"--°"--°..."¥â«¬¬"µâ"«-- ) Õ¬à"ß°Áµ"¡ ,,·®Ì"Õß,¬"¬ æÈ"·­Yª·"ß­"¥«`¬"´÷Ëߥâ,,TMâ,,'Ë 4 ·­ 5 --È ¡à¥â°Ì"À¥,,Àâ ,§ß°"«'´''¡'º,¥¬µßµàÕæµ`°¡ 'Ë¬ß ,, "°"å ¡¡µ`¢--ÈæÈ"·­,, "°"å ¡¡µ`¡ËÕ¡'°",,TMâ,¬"¬--Èß 'Ë æµ`°¡ 'ˬ߮­¡'°"ª--ªÿß'Ë¥'¢÷È Ëլʵ"¡·«,â¡¢Õß­¬­«" 15 ªï '˺à"¡" ´÷ËߪìTMà«ß'Ë°"--°..."¥â«¬¬"µâ" «-- (ÕÕ"å') ¡à¥â¡'ª­ ``º¡"°--°ÀÕ¢â",,TMâ`°"¥âßà"¬--° 'È ®÷ßÌ" Õº¢Õß°"«`§"­À姫"¡ÕàÕÀ« (sensitivity analysis) °'ˬ«°--æµ`°¡ 'Ë¬ß ,¥¬®­,,TMâ,§ß°"¿" ( "°"å ¡¡µ` D1) ®"°'Ë 4 æËÕªìµ--«ª'¬ '¬ æËÕ· ¥ß,,ÀâÀÁ«à" µâÿµàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â®­Y°°­®"°ªØ`°``¬" "ßæµ`°¡'Ë çªìª­,¬TMåé ÀÕ çªì,...é ®"°ª­TM"°°ÿࡵà"ßÊ µ""ß 6.1 · ¥ß ¡¡µ`""ßÕ°°'ˬ«°--æµ`°¡ 'ˬߴ÷Ëß®­¡'°"«`§"­Àå §«"¡ÕàÕÀ« ·«µ--Èß·«·°¢Õßµ""ß · ¥ß÷ß ¡¡µ`"°"ß ´÷ËߥâÌ"¡",,TMâæËÕ §Ì"«÷ß "°"å®Ì"Õßµà"ßÊ --Èß A, D1, D2, D3 ·­ D4 ,,'Ë 4 ·­ 5 à«¢âÕ¡Y·«µ--Èß'Ë Õß·­ "¡ · ¥ß÷ß ¡¡µ`",,"ß'˪쪭,¬TMå·­ªì ,...¢Õßæµ`°¡'ËµÕ ÕßµàÕ§«"¡æâÕ¡,,°"--°..." °"«`§"­À姫"¡ÕàÕÀ«'È ®­ª'¬'¬º¥â"ª­ ``º¥â"µâÿ¢Õß ,§ß°"¿" ¿"¬,,µâ ¡¡µ`"æµ`°¡°"ß'Ë¡à¡'°"ª'ˬ·ªß --Ë§Õ µâÿ 'Ë 2,145 ¥Õà"å À-- (85,800 ") µàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â °--ª­ ``ºµàÕ µâÿ¢Õß,§ß°"¿"¡ËÕæµ`°¡ª'ˬ·ªßªæËÕµÕ ÕßµàÕ°"--°..." --Èß'È ®­¥âæ`®""÷ß°"µÕ Õߥâ"æµ`°¡ 4 ª­¿ ¥--ßµàÕª'È: ë æµ`°¡¢--ÈæÈ" ´÷Ëß,,TMâ ¡¡µ`"°"ß ë °àÕª­,¬TMå ë Ì",,Àâ°`¥,... ë Ì",,Àâ°`¥,...Õ¬à"ß·ß æµ`°¡'Ë°àÕª­,¬TMå ®­°'ˬ«æ--°--§«"¡æâÕ¡,,°"--°..."'Ë¥'¢÷ÈæâÕ¡°-- °",,TMâÿ߬"ßÕ"¡--¬æ`Ë¡¢÷È,,°ÿà¡ 'ˬßÿ°°ÿà¡ --Èß'È §"¥«à"°",,TMâÿ߬"ßÕ"¡--¬®­ æ`Ë¡¢÷È®"° ¡¡µ`"°"ß'Ë,,TMâ,,ÿ° "°"å ¡¡ÿµ`°àÕÀâ"'Ȫ ®÷ß ¡¡µ` "¢Õßæµ`°¡'Ë°`¥ª­,¬TMå'Ë--÷°«â,,µ""ß 6.1 º'Ë¥â§Õ ®Ì"«Õ"¬ÿ¢--¬ 162 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ 'Ë--°..."«â¥â¡"°¢÷È '˵âÿ,,°"--°..."à"°-- ÀÕµË"°«à" Õ°®"°'È ª­ ``º "ߥâ"µâÿ®­¥'¢÷È ®"° "°"å®Ì"Õߥ--ß°à"« º'˥⮭· ¥ß«â,,¿"æ 6.4 ¥â«¬µâÿµàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â®­¥ß®"° 2,145 ¥Õà"å À-- ªì 1,952 ¥Õà"å À-- ´÷Ëߪì¥'¢÷Ȫ­¡"âÕ¬­ 9 à«°"µÕ Õߥâ"æµ`°¡'ËÌ",,Àâ°`¥,... ¥â®Ì"Õß«â,¥¬µ--Èß ¡¡µ`"«à" °",,TMâÿ߬"ßÕ"¡--¬,,°ÿà¡ 'ˬßÿ°°ÿࡥ߮"°­¥--°"ß'˵--Èß«â°àÕÀâ"'È ª¬--ß ­¥--'˵Ë"°«à" ´÷Ëß· ¥ß«â,,TMàÕß çªì,...é ¢Õßµ""ß 6.1 ,,°''È ¥--ß'Ë· ¥ß«â ,,¿"æ 6.4 ª­ ``º"ߥâ"µâÿ¢Õß,¬"¬,§ß°"¿"®­¥ß ¥â«¬µâÿ 'Ëæ`Ë¡¢÷È®"° 2,145 ¥Õà"å À-- ªì 2,587 ¥Õà"å À-- (85,000 " ªì 99,480 ") µàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â Õ°®"°'È "¬--ߥâ®Ì"Õß "°"å'˺ ¡º "­À«à"ß°"ª'ˬ·ªß æµ`°¡'˪쪭,¬TMå·­ªì,... ¡¡µ`"'Ë«à" æµ`°¡ 'ˬß,,°ÿà¡'Ë ¢â"--°"--°..."¥â«¬¬"µâ"«-- --È®­¥'¢÷È ,,¢­'Ëæµ`°¡ 'ˬß,,°ÿࡺYâ'Ë¡à¥â ¢â"--°"--°..."¥â«¬¬"µâ"«-- ®­ ËÕ¡ß º¢Õß°"º ¡º "æµ`°¡TMà'È ,,Àâº--Èß"ß·­"ß«° Õ¬à"ß°Áµ"¡ ËÕß®"°°ÿà¡'Ë¡'æµ`°¡ ËÕ¡ß--È ¡'¡"°°«à" ·­â"§Ì"÷ß÷߷ߺ--°'ËÌ",,Àâ°`¥,§­"¥¥â«¬·â« º'Ë¥â®÷ß,,°â §'¬ß°-- "°"å ¡¡µ`,,"ß'Ë°`¥,...¡"°°«à""ß'Ë°`¥ª­,¬TMå º¥--ß°à"« ¡à¥âÌ"¡"«¡«â,,°"Õ¿`ª"¬·­¿"檭°Õ,,'Ë'È ·­ ÿ¥â"¬ "¥â Ì"«®÷ßæµ`°¡¢Õß·®Ì"Õß¿"¬,,µâ ¡¡µ`",,"ß Õ¬à"ßÿ·ß ,,'Ë'È "¥â,,TMâ ¡¡µ`",,·ßàâ"¬ «à"°",,TMâÿ߬"ßÕ"¡--¬,,°ÿࡺYâ¡' §«"¡ 'Ë¬ß Yß °"·°ª'ˬ¢Á¡©'¥¬",,°ÿࡺYâ,,TMâ¬" æµ`¥ ·­Õ--µ"§«"¡TMÿ°¢Õß µ""ß 6.1 --¥ à«¢Õßæµ`°¡"ßæ»'Ë¡'§«"¡ 'Ë¬ß ´÷Ëߥâ--°"ªÑÕß°--¥â«¬ÿ߬"ßÕ"¡--¬: °"µÕ Õߥâ"æµ`°¡"ßÕ°µàÕ§«"¡æâÕ¡,,°",,Àâ°"--°..." ¡¡µ`" "À--°"ª'ˬ·ªßæµ`°¡ °ÿà¡ 'Ë¬ß °"ß ªìª­,¬TMå ªì,... ªì,...Õ¬à"ß·ß Yß ºYâ§â"`°""ßæ» 85 95 75 60 Y°§â" 85 95 75 60 TM"¬--°à«¡æ» 85 95 75 60 ºYâ,,TMâ¬" æµ`¥TM`¥©'¥ 20 30 10 10 µË" æ»TM"¬,¥¬--Ë«ª 35 45 25 25 æ»À`ß,¥¬--Ë«ª 35 45 25 25 °ÿà¡ 'Ë¬ß °"ß ªìª­,¬TMå ªì,... ªì,...Õ¬à"ß·ß Õ--µ" à«âÕ¬­¢ÕßTM"¬ 'Ë,,TMâ`°" ºYâ§â"`°""ßæ»,¥¬µß 10 20 20 ºYâ§â"`°""ßæ»"ßÕâÕ¡ 10 55 20 20 §«"¡TMÿ°¢Õß,§µ`¥µàÕ"ßæ» --¡æ--å (,,°ÿࡺYâ§â"`°""ßæ») 1.8 0.6 3.4 10.1 'Ë¡": ºYâ¢'¬ Sensitivity of the Policy Rankings to Key Assumptions · 163 §«"¡ÕàÕÀ«¢Õß°"®--¥Õ--¥--,¬"¬'Ë¡'µàÕ ¡¡µ`"À--° 163 ¿"æ 6.4 §«"¡ÕàÕÀ«¢Õߪ­ ``º"ߥâ"µâÿ¢Õß,¬"¬¿" (NAPHA) 'Ë¡'µàÕæµ`°¡ 'Ë¬ß Figure 6.4 Sensitivity of the Cost Effectiveness of NAPHA Policy to Risk Behavior ¥â«¬ 7,000 US$6,243 life-year 6,000 (US$) per 3% 5,000 cost of (¥Õà"å À--)3 at 4,000 value âÕ¬­ discounted3,000 US$2,487 US$1,952 US$2,145 present saved, 2,000 net Õ--µ" à«¥ 1,000 ¡Y§à"ªí®®ÿ-- ÿ`¢ÕßµâÿµàÕÕ"¬ÿ¢--¬'Ë--°..."«â¥â ªìª­,¬TMå beneficial ªì,... adverse ªì,...Õ¬à"ß·ß extremely adverse baseline â" 'Ë¡": ºYâ¢'¬ Source: Authors. À¡"¬Àµÿ: ªìª­,¬TMå = º'Ë¡'ª­,¬TMå (¥æµ`°¡ 'ˬß) µàÕºYâ'Ë--°"--°..."¥â«¬¬"µâ"«-- Note: Beneficial = beneficial effects (reduced risk behavior) of those who are on ART and ·­ºYâ'Ë¡à¥â--°"--°..."¥â«¬¬"µâ"«-- (ÕÕ"å'); ªì,... = º'ËÌ",,Àâ°`¥,... (æ`Ë¡æµ`°¡ 'ˬß) those who are not on ART. Adverse = adverse effects (increased risk behavior) of those who µàÕºYâ'Ë--°"--°..."¥â«¬¬"µâ"«-- ·­ºYâ'Ë¡à¥â--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (ÕÕ"å');; ªì,... are on ART and those who are not on ART. Extremely adverse = adverse effects (increased Õ¬à"ß·ß = º'ËÌ",,Àâ°`¥,... (æ`Ë¡æµ`°¡ 'ˬß) µàÕºYâ'Ë--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ·­ºYâ'Ë¡à risk behavior) of those who are on ART and those who are not on ART, with the risk behavior ¥â--°"--°..."¥â«¬¬"µâ"«-- (ÕÕ"å'); ¥â«¬æµ`°¡ 'ˬß,,­¥--¥'¬«°--,,ªï æ.». 2523 at the same level as in 1980. hypothesis that condom use in high-risk contacts, needle exchange ,§µ`¥µàÕ"ßæ» --¡æ--åÕËÊ ¥â°-- Yà­¥--'ˡ৬ªì¡"°àÕµ--Èß·µàTMà«ß·°÷ß among drug users, and the rates of prevalence of other sexually trans- TMà«ß°"ß»«... 1990 (­À«à"ߪïæ.». 2533-2543) --Ë§Õ "°"å ¡¡µ` 'Ëmitted infections all return to levels not seen since the early to mid- 1990s. In contrast to the "adverse" scenario described above, this çªì,...Õ¬à"ßâ"¬·ßé 'È ®­µà"ß®"° "°"å'Ë çªì,...é ´÷ËߥâÕ`"¬«â °àÕÀâ"'È ,¥¬ "°"å¥--ß°à"« ®­àß,,Àâ°`¥°"µ`¥TMÈÕ"¬,,À¡àÕ¬à"ß«¥Á« "extremely adverse" scenario produces a dramatic acceleration in new --˧ծ­¡'°"µ`¥TMÈÕ"¬,,À¡à 85,000 "¬µàÕªï ¿"¬,,æ.». 2558 ·'Ë®­ªì HIV infections: 85,000 new infections per year by 2015, instead of æ'¬ß 5,000 "¬ ¿"¬,,µâ "°"å'Ë¡'°"¥Ì"`,§ß°"¿" ·­¡à¡'°"ª'ˬ only 5,000 under the NAPHA scenario with no change in risk behav- ·ªßæµ`°¡ 'Ë¬ß Õ°®"°'È ¿"¬,,ªïæ.». 2568 ®Ì"«ºYâµ`¥TMÈÕ"¬,,À¡àª­®Ì" ªïior.®­ Yߢ÷È®¡"°°«à" 180,000 "¬ ¡ËÕª'¬'¬°--ºYâµ`¥TMÈÕ"¬,,À¡à®Ì"«µË" By 2025, the annual number of new HIV infections rises to more than 180,000, as compared with less than 3,000 new infections under °«à" 3,000 "¬ ¿"¬,,µâ°"§"¥ª­¡"¢--ÈæÈ"¢Õß" ·­÷ß·¡â¢Õ¢µ,, our baseline projection. Despite the 20-year planning horizon, which °"«"ß·º 20 ªï ®­¡à«¡µâÿ à«,,Àà,,°"--°..."ºYâµ`¥TMÈÕ"¬,,À¡àÀ"¬æ--§ excludes most of the cost of treating these thousands of new infections, ·µàµâÿµàÕºYâªÉ«¬'ËÕ¥TM'«`µµàÕªï,,,§ß°"¿" --Èæ`Ë¡¢÷È°Õªì "¡à" §Õ 6,243 ¥Õà"å À-- (249,720 ")4 the cost per life-year saved for NAPHA would almost triple to US$6,243 (B 249,720).4 One lesson of this sensitivity analysis is that where effective prevention '¬À÷Ëß®"°°"«`§"­À姫"¡ÕàÕÀ«'È§Õ ¡ËÕ°"ªÑÕß°--Õ¬à"ß¡'ª­ `` º¥â®Ì"°--¥°"µ`,µ¢Õß,§­"¥ ·­¡ËÕ°",,TMâÿ߬"ßÕ"¡--¬--ȧàÕ¢â"ß·æà has already greatly limited the growth of the epidemic and condom use is À"¬,,°Õÿ°°ÿà¡ ª­ ``º"ߥâ"µâÿ¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- quite high among almost all groups, the cost-effectiveness of ART is less ®­¡'§«"¡ÕàÕÀ«µàÕæµ`°¡âÕ¬°«à"'˧«®­ªìÀ"°Õ¬Yà,,¿"«­,§­"¥¥--Ëß'Ë sensitive to behavior than it would be in an epidemic like that in India, °`¥¢÷È,,ª­»Õ`¥'¬ ´÷Ëß¡'°"µ`¥TMÈÕ--È·æà°­®"¬ªÕ¬à"ß«¥Á«®"°ª­TM"° whereinfectionsarespreadingrapidlyfromacoreofhigh-riskpopulations 'Ë¡'§«"¡ 'Ë¬ß Yß'˪ì°ÿà¡À--° ª YભTM"°--Ë«ª'Ë¡à¥â¡'°"ªÑÕß°-- ·¡â°­--È into an unprotected general population. Nevertheless, the Thai govern- --"¬ ¬--ßµâÕߧլ­«--ߧ«"¡ªìª¥â'Ë®­°`¥§«"¡Ì"æÕß,,®Õ¬à"ß Yß'ËÌ",,Àâ°" ment must guard against the possibility that extreme complacency would ,,TMâÿ߬"ßÕ"¡--¬--ȥߪ®µË"°«à"'Ë"¥âµ--Èß ¡¡µ`"«â,, "°"å'Ë çªì decrease condom use even more than we have assumed in our "adverse" ,...é °"¥°",,TMâÿ߬"ßÕ"¡--¬Õ¬à"ßÀÁ¥âTM--¥ ®­Ì",,Àâ,§­"¥°--¡"Õ'°§--Èß scenario. Dramatic reductions in condom use would indeed reignite the epidemic.AsecondlessonfromthissectionisthatpoliciesthatuseARTto 164 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ à«'¬'Ë Õß®"° à«'È§Õ ,¬"¬'Ë,,TMâ°"--°..."¥â«¬¬"µâ"«-- (ÕÕ"å') æËÕæ`Ë¡§«"¡æ¬"¬"¡,,°"ªÑÕß°-- Õ"®TM૬ª--ªÿߪ­ ``º"ߥâ"µâÿ¢Õß °",,TMâÕÕ"å',,ª­»¬¥â÷ßâÕ¬­ 10 À¡"¬Àµÿ 1. °àÕªïæ.».2548 °ÆÀ¡"¬ ``--µ¢Õߪ­»Õ`¥'¬®­·µ°µà"ß®"°°ÆÀ¡"¬ ``--µ¢Õߪ­»ÕËÊ ËÕß®"°¥â¡'°",,Àâ ``--µ,¥¬©æ"­·°à°­«°" ·'Ë®­ªì°",,Àâ ``--µ·°àº`µ¿--±å ¿"¬,,µâ°ÆÀ¡"¬¥--ß°à"« ºYâº`µ¬",, Õ`¥'¬ "¡"®­º`µ¬"'Ë'¬·¬"'Ë¡' ``--µ­À«à"ߪ­»¥â«¬°"æ--" °­«°",,À¡à,,°"º`µ ·µàæËÕ'Ë®­,,Àâªìªµ"¡¢âÕ°Ì"À¥¢ÕßÕߧå°"§â",° °'ˬ«°-- ``¢Õß--æ¬å `"ߪí" -- ¿"Õ`¥'¬®÷ßµâÕߺà"æ­"TM----µ` `` --µ©--,,À¡à,,«--'Ë 23 ¡'"§¡ æ.».2548 ´÷Ë߬°`° ``--µ¥â"°­«°" æËÕ,,Àâª'ˬ¡",,TMâ ``--µ¢Õߺ`µ¿--±å ·­,,Àâ°"¬Õ¡-- ``--µ¢Õߺ`µ¿--±å ­À«à"ߪ­» ¿"¬,,µâ°ÆÀ¡"¬,,À¡à'È `...--¬",,Õ`¥'¬Õ"® "¡"º`µ·­ ®Ì"Àà"¬¬"'Ë®¥ ``--µ­À«à"ߪ­»«â À"°¬"Àà"--È¡'°"®¥ ``--µ«â°àÕ æ.». 2547 Õ¬à"ß°Áµ"¡ `...--Àà"'È®­µâÕßµàÕÕßËÕߢâÕµ°ß¥â"°"Õÿ"µ 'Ë®­,,ÀâÌ"'¬··­®Ì"Àà"¬¬"'Ë,,À¡à°«à" TMà ¬"'Ë,,TMâ,,°"--°..."Õ¥ å,,¢--È'Ë Õß ·µà¬--ß¡à¡'§«"¡TM--¥®«à" `...--Õ`¥'¬ ®­®à"¬§à"`¢ ``Ϫì§--Èß·° Ì"À--¬" °à"'Ë,,TMâ,,°"--°..."¢--È·°ÀÕ¡à 2. "¥â§Ì"«µâÿ·­ª­ ``º"ߥâ"µâÿ¢Õß°"--°..." â"°"--°..." ,,¢--È'Ë Õß--È¥â¥"§"ªâÕ¬­ 90 3. â"°"--°..."¢--È'Ë Õߥ"§"ߪìâÕ¬­ 10 ¢Õß"§"ªí®®ÿ-- µâÿµàÕªï Õ"¬ÿ¢--¬'Ë--°..."¥â¥ßÀÕ 940 ¥Õà"å À-- (37,600 " µàÕªï'ËÕ¥TM'«`µ ¿"¬,,µâ "°"å ¡¡µ`'Ë¡'°"¥Ì"`,§ß°"¿" (NAPHA) ´÷Ëß¡"°°«à"µâÿµàÕ ªï,,°"--°..."TM'«`µºYâªÉ«¬æ`Ë¡¢÷Èæ'¬ßÁ°âÕ¬®"°°"--°...",,¢--È·°à"--È ¡Y§à"ªí®®ÿ--¢Õߧà",,TMâ®à"¬,§ß°"--°..."¥â«¬¬"µâ"«-- ,,Õ"§µ®­¥ß ®"° 5.7 æ--â"¥Õà"å À-- (228 æ--â"") ®÷ߪï æ.». 2568 ¡"ªì 2.5 æ--â" ¥Õà"å À-- (100 æ--â"") --Ë§Õ "¡"ª­À¬--¥ª¥â÷ß 3.2 æ--â" ¥Õà"å À--,,Õ--µ" à«¥ (128 æ--â"") 4. º'Ë¥â'È®­·µ°µà"ß®"°º¢Õß·®Ì"Õß,,ª­»Õ`¥'¬ ´÷Ëß°"¥°",,TMâÿß ¬"ßÕ"¡--¬®"°âÕ¬­ 50 ªìâÕ¬­ 40 --Èæ'¬ßæÕ'Ë®­¥·ºª­,¬TMå --ÈßÀ¡¥'Ë¥â®"°°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (,Õ«Õå ·­§­ æ.». 2547, Àâ" 101) --Èß'È º°­'˧"¥ª­¡"«â Ì"À--°"ª'ˬ·ªß¥â"æµ`°¡'˪ì ,... 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÷ß°"¡'TM'«`µÕ¥'ËÕ°ÀÕª®"°TMà«ß«" 7 ªï¢ÕߢâÕ¡YÀà"'È ª®÷ß°«à" 20 ªï À--ß®"°°"µ`¥TMÈÕ §«"¡¬"°Ì""°,,°"Ì"ß"'ȥ⫬§«"¡'Ë¬ßµß ®­ÀÁ¥â ®"°¢âÕÁ®®`ß'Ë«à" TMà«ß§«"¡¡--Ë,,®,,¿"æ °. 1 ¢¬"¬ÕÕ°ª°«à"âÕ¬­ 10 ¿"¬,, ªï'Ë 7 ¬`Ëߪ°«à"--È ¢âÕ¡Y,,¿"æ¥--ß°à"« ¥â°Á¡",,TMà«ß'ËTM"¬¬ "¡"¢â" ÷ß°"--°...",§µ`¥TMÈÕ©«¬,Õ°" 'Ë¥'¥ââÕ¬°«à"'˪ìÕ¬Yà,,­¬­À--ß ¥--ß--È æËÕ'Ë ®­ â"ßYª·¢Õß°"¡'TM'«`µÕ¥'Ëà"TMËÕÕ Ì"À--ª­TM"TMTM"«¬'Ë¡àªì,§ Õ¥ å,,­¬­ `ªïÀ--ß'È "®Ì"ªìµâÕߪ-- â,§âß,¥¬¬÷¥µ"¡¢âÕ¡Y¢Õß--ß `åÿ æËÕ ,,Àâ "¡"ª­¡"Yª·¢Õß°"¡'TM'«`µÕ¥'Ë¥'¢÷È,¥¬ª"»®"°°"--°..."¥â«¬¬" µâ"«-- Õ¥ å,, à«ÕËÊ¢Õß,° ´÷Ëß"®­°--¡"'Ë®ÿ¥'ÈÕ'°§--Èß,,¬àÕÀâ"µàÕʪ Õ¬à"ß°Áµ"¡ "®­`Ë¡æ`®""«à" ®­,,TMâ¢âÕ¡Y¢Õߧ«"¡Õ¬YàÕ¥ª­®Ì"ªïTMà'ÈÕ¬à"ß ,,Yª·®Ì"Õß'˧"¥ª­¡"ª÷ßÕ"§µÕ'° 20 ªï¢â"ßÀâ" ÀÕ¡"°°«à"--È ¿"§º«° ° 175 (%) (9) 98.7 97.0 94.9 91.0 82.4 71.8 64.5 °"Õ¥TM'«`µ¢ÕßKaplan-Meier ·­§"«(8) ´÷Ëߥâª--§à"·â« (%) °--·«'Ë (8) 1.3 1.7 2.2 4.1 9.5 12.8 10.3 Õ--µ"¬,,À÷Ëßªï ´÷Ëߪ--§à"·â« ®­Y°"¡"·°æËÕ,,Àâ Õ¥§âÕß(4) ®­¥"`°"ª--µ"¡§«"¡(8) (%) à«·«'Ë(2) Kaplan-Meier Õ--µ"¬ (7) 1.3 1.7 2.2 4.1 9.4 12.2 7.5 ·­(3) (2), ,,À÷Ëߪï ,¥¬·«'Ë (6) ¡'TM'«`µÕ¥ 231 227 222 213 189 147 56 ¡"À"¥â«¬·«'Ë(5) ¡ËÕ `È ÿ¥ªï ¢Õß--ß `ÿå2 (5) 3 4 5 9 20 23 11 75 ºYâ '¬TM'«`µ § 235 ®­§"«ßà"¬Ê¥â«¬°""·«'Ë (4) ®"« ª--¢âÕ¡Y®`ß µ"¡§«"¡ 'Ë¬ß 234.5 231 227 222 211 179.5 107 --È(7) ®­,,TMâ Yµ¡"µ" "À--Õ--µ"§«"¡Õ¬YàÕ¥'Ë®"°--¥¢Õß(9) ·«'Ë (3) 1 0 0 0 4 19 80 ¡à "¡" µ`¥µ"¡¥â 104 "À--·«'Ë ¥â"¡" â"ß·«·°·­ Õß·« ÿ¥â"¬,,À¡à,,µ""ß'Ë(6) ¢Õß--ß `ÿå2 ·­ ¡'TM'«`µÕ¬Yà (2) 235 231 227 222 213 189 147 ¡ËÕ`Ë¡µâªï æ.».2547 (5), (1), §«"¡Õ¬YàÕ¥¢ÕßTM"¬¬'˵`¥TMÈÕ«-- ÕTMÕ«'1°. HIV ·­§­ ·«'Ë (1) --ß `ÿå µ""ß ªï'˵`¥TMÈÕ 1 2 3 4 5 6 7 «¡ 'Ë¡": À¡"¬Àµÿ: °--¢âÕ¡Y'˵'æ`¡æå·â«,,µ""ß'Ë ®ß`´÷Ëߥâ"¡",,TMâ,,µ""ß· ¥ß°"¡'TM'«`µ·­,,TMâ,¥¬--ß `ÿå µ"¡·¢Õß--ß `ÿå 176 · TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand 176 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ Figure A.1 SurvivalCurveforaCohortof235HIV-PositiveThaiMen ¿"æ °.1 â,§âß· ¥ß§«"¡Õ¬YàÕ¥ Ì"À--°ÿà¡TM"¬¬'˵`¥TMÈÕÕTMÕ«'®Ì"« 235 §'Ë¢â"à«¡ °"»÷°..." 1.0 1 0.9 4 surviving Õ¥µ"¡ --¥ à« 0.8 19 °"¡'TM'«`µproportion 0.7 136 0.6 0 2 4 6 8 «",,°"«`§"­Àå analysis time TMà«ß§«"¡¡--Ë,,® 95% 95% confidence interval øíß°å¢--Ë¢Õߧ«"¡Õ¬YàÕ¥ survivor function 'Ë¡": --ß `åÿ ·­§­ æ.».2547 µ""ß'Ë 2 Source: Rangsin 2004, table 2. À¡"¬Àµÿ: ¿"æ'È ¡àÀ¡Õ°-- â,§âß· ¥ß§«"¡Õ¬YàÕ¥¢Õß--ß `åÿ ËÕß®"°,,TMâ¢âÕ¡Y'Ë·àß°ÿà¡ ·'Ë Note: This figure is not identical to Rangsin's survival curve, because it uses the grouped data ®­,,TMâ¢âÕ¡Y¥`¡ rather than the original data. need to adjust a curve based on the Rangsin data to more closely °"§"¥ª­¡"÷ß°"¡'TM'«`µÕ¥Õ°ÀÕ®"°¢âÕ¡Y'Ë¡'Õ¬Yà--È Ì",,ÀâµâÕßÌ" approximate the better survival patterns experienced without ART in other parts of the world. We return to this point in a few paragraphs. ¢âÕ¡Y¥--ß°à"«¡",,TMâ°--·øÕ塵"¡Àâ"'˵à"ßÊ'˪쪥⠷⫮÷ߧ"¥ª­¡" However, first we will examine how to use annual survival data like æÈ"¢Õß"ßÕ°,,°ÿà¡°"Ì" Õµ"¡Àâ"'ËÀà"'È --Èß 'Ë à«¢Õß¿"æ °. 2 these in a model that projects 20 or more years into the future. ¥â· ¥ß÷ߺ¢Õß°"§"¥ª­¡"'È ,¥¬¿"æ (°) ®Ì"Õß¡"æËÕ,,ÀâÕâ"ßÕ`ߥâßà"¬ ÷ß â,§âß· ¥ß°"¡'TM'«`µÕ¥®"°¿"æ °. 1 ¿"æ (§) · ¥ßº¢Õß°"Ì"¢âÕ¡Yª fitting the data to one of several possible functional forms and then pro- ,,TMâ°--Yª·µ"¡Àâ"'Ë §Õ log-logistic ¿"æ (ß) §"¥ª­¡"÷ß log-logistic Making a projection of survival beyond the available data amounts to jecting on the basis of a choice among these functional representations. function ,,Õ"§µ¥â«¬TMà«ß§«"¡TMËÕ¡--ËâÕ¬­ 95 ·­¿"æ (¢) · ¥ß«à" â,§âß'Ë The four panels of figure A.2 show the results of such a projection. The §"¥ª­¡"«â·­TMà«ß§«"¡¡--Ë,,®®­¡'°"ª'ˬ·ªßÕ¬à"ßÀ"°Yª·°"Ì" panel (a) replicates for easy reference the survival curve from figure A.1. Àâ"'Ë ®­,,TMâ· Gompertz ·'Ë®­ªì log-logistic The panel (c) shows the result of fitting one particular functional form, ,ª¥ --ß°µ÷ߧ«"¡«Õ¬à"ß YߢÕߺ'Ë°`¥¢÷È,,ªï'ËÕ¬Yà°ÕÕ°ª´÷Ëß¡'µàÕ°" the log-logistic, to the data. Panel (d) projects that log-logistic function Õ°Yª·°"Ì"Àâ"'Ë --Èß'È log-logistic ®­¡Õß,°,,·ßà¥'°«à" Gompertz °'ˬ« into the future with a 95 percent confidence interval. Panel (b) shows °--§«"¡Õ¬YàÕ¥'˧"¥ª­¡"«â ,¥¬,,ªï'Ë 10 ·øÕå¡ log-logistic §"¥ how the projected curve and its confidence interval would change if the ª­¡"«à" âÕ¬­ 41.1 ¢ÕߺYâµ`¥TMÈÕÕTMÕ«' ®­¬--ߧߡ'TM'«`µÕ¬Yà·¡â®­¡à¡',§ß°" functional form were the Gompertz instead of the log-logistic. --°..."¥â«¬¬"µâ"«-- Õ¥ å ,,¢­'Ë Gompertz §"¥ª­¡"«à" ®­¡'æ'¬ßâÕ¬­ 13.4 à"--È'ˬ--ߧߡ'TM'«`µÕ¬Yà Õ°®"°'È "¬--ßÌ"¢âÕ¡Yª,,TMâ·­§"¥ª­¡" ¥â«¬ selection of functional form. The log-logistic function is much more ·øÕå¡¢Õß Weibull ´÷Ëߧ"¥ª­¡"«à" Õ--µ" à«âÕ¬­,,­¥--°"ß §Õ 33.5 Note the extreme sensitivity of the results in outer years to the optimistic about projected survival than is the Gompertz. At year 10, ¢ÕߺYâµ`¥TMÈÕ ®­¬--ß¡'TM'«`µÕ¥,,ªï'Ë 102 the log-logistic projects that 41.1 percent of HIV-infected people §«"¡æ¬"¬"¡,,¢--È·° 'Ë®­ª'¬·®Ì"Õß,§­"¥,,ÕTM'¬ÀÕÕÕ'ÕÁ¡ would still be alive without ART, whereas the Gompertz projects that (AEM) ©--ªïæ.». 2540 °--¢âÕ¡Yªí®®ÿ-- ¥â,,TMâÕ--µ"§«"¡°â"«Àâ",¥¬ª"»®"° only 13.4 percent would be alive. We also fit and projected with the ,§Õ¥ å´÷Ëߥâ¡"®"°øíß°åTM--Ë log-logistic ÈÕߵ⠪­°Õ°--¢âÕ¡Y¢Õߪ­»¬ Weibull function, which predicts that an intermediate percentage of ®"°--ß `åÿ (æ.». 2547) Õ¬à"ß°Áµ"¡ °"§"¥ª­¡",¥¬,,TMâÕ--µ"§«"¡°â"« 33.5 would be alive in year 10.2 Àâ"'ËÁ«'Ë ÿ¥--È Ì",,Àâ§"¥¥"¥â«à" ®Ì"«ºYâªÉ«¬Õ¥ å'Ë· ¥ßÕ"°"--ÈßÀ¡¥,,ªï Appendix A · 177 ¿"§º«° ° 177 Figure A.2 ProjectingSurvivalwithoutART (°) °"Õ¥TM'«`µ¢Õß Kaplan-Meier (a) Kaplan-Meier survival (¢)(b)°"Õ¥TM'«`µ¢Õß Gompertz Projected Gompertz survival 1.0 1 1.0 0.9 0.8 surviving 4 0.6 Õ¥µ"¡ --¥ à« 0.8 19 0.4 0.7 136 0.2 proportion 0.6 0.0 °"¡'TM'«`µ 0 2 4 6 8 0 5 10 15 20 25 «",,°"«`§"­Àå analysis time year ªï (§) °"Õ¥TM'«`µ· log-logistic 'ËÀ¡"­ ¡ (c) Fitted log-logistic survival (ß)(d)°"Õ¥TM'«`µ· log-logistic µ"¡°" Projected log-logistic survival §"¥ª­¡" 1.0 1.0 0.9 0.8 surviving 0.6 Õ¥µ"¡ --¥ à« 0.8 0.4 0.7 0.2 proportion 0.6 °"¡'TM'«`µ 0.0 0 2 4 6 8 0 5 10 15 20 25 «",,°"«`§"­Àå analysis time year ªï 'Ë¡": --ß `åÿ ·­§­ æ.».2547; °"§Ì"«¢ÕߺYâ¢'¬ Source: Rangsin and others 2004; authors' calculations. æ.».Initial ®­¡'âÕ¬°«à" 30,000 § ·µàËÕß®"°¢âÕ¡Y®"°°­«ß "" ÿ¢ Model (AEM) to current data used the progression rate without AIDS 2547efforts to recalibrate the 1997 version of the Asian Epidemic ¢Õߪ­»¬· ¥ß«à" ¡'ºYâªÉ«¬®Ì"«÷ß 40,000 °Ì"--ß--°"--°..."¥â«¬¬"µâ" «-- Õ¥ åÕ¬Yà ´÷ËߺYâªÉ«¬Àà"'È à«,,Àà®­· ¥ßÕ"°"·â«¡ËÕ`Ë¡¢â"--°"--°..." given by the above log-logistic function fitted to the Thai data from ¥--ß--È °"§"¥ª­¡"ÈÕߵ⠮÷ߥYÀ¡Õ®­µË"°`ª Ì"À--ªïªí®®ÿ-- ®"°°" Rangsin (2004). However, projections using this fast progression rate §âæ§--Èß'È ·­®"°°"Ñ" --ß°µ«à"°"--°...",§µ`¥TMÈÕ©«¬,Õ°" ,,ª­»¬ predict that the total number of symptomatic AIDS patients in 2004 --È¥'¢÷È À--ß®"°°"°Á¢âÕ¡Y'Ë¥â--°"«`§"­Àå,¥¬--ß `åÿ ¥--ß--È "®÷ß ÿª¥â«à" would be fewer than 30,000. Because data from the Thai Ministry of ª­ °"å,,°"¡'TM'«`µÕ¥¢ÕߺYâªÉ«¬'Ë¡à¥â--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å Public Health (MOPH) indicate that as many as 40,000 people are cur- æ`Ëß®­¥'¢÷È°«à"'Ë¥â--°"§"¥ª­¡"¡ÕÀâ"ªï'Ë·â«®"°¢âÕ¡Y¢Õߪ­»¬ rently receiving ART, almost all of whom were symptomatic when recruited, this projection seems to be substantially too low for the cur- rent year. From this finding and from the observation that treatment Õ'°"ßÕ°À÷Ëß Õ°®"°®­µâÕßÕ"»--¬°"§"¥ª­¡"¢Õß--ß `åÿæ'¬ß Õ¬à"ߥ'¬« "¥âÀ--ª,,TMâ§Ì"·­Ì"¢Õß°ÿà¡Õâ"ßÕ`ߢÕß,§ß°"§«"¡à«¡¡Õ·Ààß Àª­TM"TM"µ`«à"¥â«¬TMÈÕ«-- ÕTMÕ«'/Õ¥ å (Joint United Nations Programme on for opportunistic infections has improved in Thailand since the data HIV/AIDS (UNAIDS)) «à"¥â«¬°"ª­¡"°" «"ßYª· ·­°"§"¥ª­¡" analyzed by Rangsin were collected, we conclude that the survival ¥--ß'˥ⷠ¥ß«â,,"¬ß"'Ë¥â--°"µ'æ`¡æå (°"¬ å ·­§­ ªï æ.». 2547) ·­ experience of patients without ART has recently been better than ,,As could have been predicted five years ago from the Thai data. ,µ«Õå (ªï æ.». 2545) ,¥¬¿"æ °. 3 ¥âª'¬'¬°"§"¥ª­¡"¥â«¬ ·øÕå¡ log-logistic ®"°¢âÕ¡Y¢Õß--ß `åÿ °--Yª·°"¡'TM'«`µÕ¥Õ¬à"ßTMâ"Ê an alternative to relying entirely on a projection from the Rangsin ,¥¬ª"»®"°,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å´÷Ëߥâ--°"·­Ì"®"° UNAIDS data, we turn to the advice of the Joint United Nations Programme on3 ,ª¥ --ß°µ«à" Yª·'Ë Õ,¥¬ UNAIDS --È ,,°â§'¬ß°--¢Õ¢ÕßTMà«ß§«"¡ HIV/AIDS (UNAIDS) Reference Group on Estimates, Modeling, and ¡--Ë,,®,, 10 ªï·°®"°°"§"¥ª­¡"¥â«¬¢âÕ¡Y¢Õߪ­»¬ ·­À--ß®"°--È Projections, as presented in their published report (Ghys and others ®÷ߪ'ˬª,,·ßà¡"°¢÷È 2004) and in Stover (2002). Figure A.3 compares the log-logistic projec- tion from the Rangsin data with the slow survival pattern without ART 178 · »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ 178 TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand Figure A.3 ComparisonofSurvivalCurveEstimatedfromThaiDatawithSurvivalCurve ¿"æ °.3 °"ª'¬'¬ â,§âߢÕß°"¡'TM'«`µÕ¥ ´÷Ëߪ­¡"°"®"°¢âÕ¡Y¢Õߪ­»¬ ,¥¬ Recommended by UNAIDS Reference Group â,§âß· ¥ß°"¡'TM'«`µÕ¥¥â--°"·­Ì"®"°°ÿà¡Õâ"ßÕ`ߢÕß UNAIDS 1.0 0.8 0.6 surviving Õ¥µ"¡ --¥ à« 0.4 °"¡'TM'«`µproportion 0.2 0.0 0 5 10 15 20 25 year §"¥ª­¡"°"Õ¥TM'«`µ· log-logistic à« 95% projectedsurvivalusinglog-logistic upper95%bound à«à"ß 95% lower95%bound §«"¡°â"«Àâ"Õ¬à"ßà"TMâ"®"°°"Õâ"ßÕ`ߢÕß UNAIDS slowprogressionUNAIDSreference Source: Projection and confidence interval are authors' calculations; UNAIDS reference sur- 'Ë¡": °"§"¥ª­¡"·­TMà«ß§«"¡¡--Ë,,® ¡"®"°°"§Ì"«¢ÕߺYâ¢'¬; Õ--µ"°"Õ¥TM'«`µ ´÷ËßÕâ"ß®"° vival rates are the average of the "slow men" and "slow women" rates from Stover's table 2 UNAIDS §Õ§à"©'ˬ¢ÕßÕ--µ" çºYâTM"¬'ËTMâ"é ·­ çºYâÀ`ß'ËTMâ"é ®"°µ""ß'Ë 2 ¢Õß ,µ«Õå (2545, 19) (2002, 19). that is suggested by UNAIDS.3 Note that the pattern suggested by UNAIDS is close to the upper bound of the confidence interval of the º°­¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ,¥¬¥â--§«"¡ -- ÿ ·­,¥¬'Ë¡à first 10 years of the projection from the Thai data and then turns much ¥â--§«"¡ -- ÿ ®"°°ÿࡺYâµ`¥TMÈÕ«-- ÕTMÕ«'/Õ¥ å more pessimistic. ¢âÕ¡Y'Ë¡'Õ¬Yà°'ˬ«°--º°­¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å'Ë¡'µàÕÕ--µ" ¥â ÿª«â,,Õ° "ÈÕßÀ--ߢÕß The Impact of ART with and without Support §«"¡°â"«Àâ"¢Õß,§,,°ÿࡺYâªÉ«¬Õ¥ å--È from Groups of People Living with HIV/AIDS "¬ß"©--'È ËÕß®"°¡à¡'°"»÷°..."©--,,¥'Ë¡'Õ¬Yà ´÷Ëß¡'§«"¡ ¡Yåà"°-- ¢âÕ¡Y¢Õß--ß `åÿ °'ˬ«°--ºYâªÉ«¬'Ë¡à "¡"¢â"÷ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å The existing data on the impact of ART on the rate of disease pro- ¥â ºYâ¢'¬"¬ß"æÈ""ߥâ"§``° ®÷ߥâ,,TMâ°­«°"Õ--µ«` --¬ªì"ß à« gression of AIDS patients are summarized in background papers to æËÕ,,Àâ¢âÕ¡Y§«"¡°â"«Àâ"'Ë --ߧ"­Àå¢÷È Ì"À--·µà­ "°"å ¡¡µ`,,·®Ì" this report. Because none of the available studies is as complete as the ÕߢÕß" µ""ß °.2 Õ¢âÕ¡Y'Ë --ߧ"­Àå¢÷È¡"¢Õß°ÿࡺYâªÉ«¬®Ì"« 100 Rangsin data for patients without access to ART, the authors of the §µ"¡ ¡¡µ`" ´÷Ëß`Ë¡--°"--°...",, "°"å·,,¥·À÷Ëß clinical background studies have provided, through a partly subjective ¿"æ (°) ¢Õßµ""ß °.2 · ¥ß÷ß°ÿà¡'Ë¡à "¡"µ`¥µ"¡¥â °ÿà¡'ˬâ"¬ª¢â"-- process, synthetic progression data for each scenario in our simulation °"--°...",,¢--È'Ë Õß(ËÕß®"°§«"¡â¡À«,,°"--°...") ·­°ÿà¡'Ë¥â '¬TM'«`µß model. Table A.2 presents these synthetic data for hypothetical ¡ËÕ°"ªØ`--µ`µ"¡«`'--°..."Õ¬à"ߧàߧ--¥ÀÕ°"--ª­"¬",¥¬ ¡Ë" ¡Õ--È ªì cohorts of 100 patients beginning ART in each of two situations. §«"¡--º`¥TMÕ à«ÿ§§¢ÕߺYâªÉ«¬·­§Õ§--«à"--È ,¥¬¡à¥â--ª­,¬TMå®"° §«"¡ -- ÿ¢ÕßÕߧå°æ--"Õ°TM (NGO) à«¿"æ (¢) · ¥ß°"ª--ªÿß Panel (a) of table A.2 presents those lost to follow-up, those moved to second-line therapy (because of treatment failure), and those who ¿"§º«° ° 179 (%) (9) 90.0 84.0 79.6 74.2 66.0 53.8 30.7 (%) (10) 0.0 2.6 3.2 5.5 9.4 19.2 39.1 Õ--µ"Õ¥TM'«`µ¢Õß Kaplan-Meier °"ª--ªÿߢÕß Kaplan-Meier (%) ¢â"--°"--°...",,­¬­À--ß (8) (%) (9) 90.0 86.6 82.7 79.7 75.6 73.0 69.8 Õ--µ"¬µàÕ 10.0 6.7 5.3 6.8 10.7 18.8 42.9 TMà«ß«" Õ--µ"Õ¥TM'«`µ¢Õß Kaplan-Meier (%) (8) 3.8 4.5 3.7 5.1 3.4 4.3 (7) 75 57 44 28 16 7 0 Õ--µ"¬µàÕ TMà«ß«" 10.0 æâTMà«ß«" (7) 80 67 54 39 29 23 20 '¬TM'«`µ (6) 10 5 3 3 3 3 3 30 æâTMà«ß«" 3 3 2 2 1 1 2 '¬TM'«`µ (6) 10 22 'Ë¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,ª­»¬: (5) 3 5 5 8 6 3 1 31 "¬ ,,¢--È'Ë 2 100 ¬â"¬ª--°"--°..." 0 5 5 8 6 3 1 ,¥¬¡à¡'°ÿࡺYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å'Ë®­ -- ÿ,,Àâ¡'°"ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥ ,¥¬¡'°ÿࡺYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å'Ë®­ -- ÿ,,Àâ¡'°"ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥ (5) 28 ,,¢--È'Ë (4) 12 8 5 5 3 3 3 39 ¬â"¬ª--°"--°..." °"¡à "¡" µ`¥µ"¡¥â (4) 10 5 5 5 2 2 1 30 °"¡à "¡" µ`¥µ"¡¥â (3) 1 1 1 2 5 5 5 20 §«"¡¬"«¢Õß ­¬­«" (3) 1 1 1 2 5 5 5 20 §«"¡¬"«¢Õß ­¬­«" --°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,¢--È·°D1 (2) 100 75 57 44 28 16 7 --°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,¢--È·°D3 «"'Ë`Ë¡°"--°..." «"'Ë`Ë¡ °"--°..." (2) 100 80 67 54 39 29 23 2548 ¢âÕ¡Y°"¡'TM'«`µÕ¥'Ë --ߧ"­Àå®"°ºYªÉ«¬Õ¥ åµ"¡ ¡¡µ`" °.2 "°"å(°) (1) "°"å(¢) (1) ,°¥å·­§­ µ""ß ªï'˵`¥TMÈÕÕTMÕ«' 1 2 3 5 10 15 20 «¡ ªï'˵`¥TMÈÕ ÕTMÕ«' 1 2 3 5 10 15 20 «¡ 'Ë¡": 180 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ ¢Õß°"¡'TM'«`µÕ¥ ·­°"§ßÕ¬Yà,,°"--°..."¢--È·° ¡ËÕÕߧå°æ--"Õ°TM'Ë ¢â¡·¢Áß ´÷ËßÕ"®ª­°Õª¥â«¬Õ" " ¡--§´÷ËߪìºYâµ`¥TMÈÕ«-- ÕTMÕ«'À¡Õ°-- ¥â ¢â"¡"TM૬,,ÀâºYâªÉ«¬ "¡"--¬"¥âÕ¬à"ß ¡Ë" ¡Õ ·­¢â"--°"µ«®À"TMÈÕ«-- µ"¡°Ì"À¥ ªìµâ à«·« ÿ¥â"¬¢Õß¿"æà"ß ÿ¥ · ¥ß®Ì"«¢Õß®ÿ¥âÕ¬­ ¢Õß°"ª--ªÿߢÕßÕ--µ"°"¡'TM'«`µÕ¥´÷Ëߪ캡"®"°§«"¡ -- ÿ¢ÕßÕß§å° æ--"Õ°TMÀÕ°ÿࡺYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å (PHAs) --Èß'È °"ª--ªÿߥ--ß°à"« ¥âæ`Ë¡¢÷ÈÕ¬à"ß ¡Ë" ¡Õ ®"°®ÿ¥âÕ¬­ 5 ¡ËÕªï'Ë 5 ¡"ªì®ÿ¥âÕ¬­ 19 ¡ËÕªï'Ë 15 ·­®ÿ¥âÕ¬­ 39 ¡ËÕªï'Ë 20 æËÕ--÷°Yª·§«"¡°â"«Àâ"¥--ß°à"«,,·®Ì"Õß ¡¡µ`TMà ÕÕ'ÕÁ¡ (AEM) ´÷Ëß®­«--¥«",,· ` à«¢ÕßÀ÷Ëߪï "®÷ßµâÕß·°Yª·°"¡'TM'«`µÕ¥ ·­ §Ì"«§«"¡À"·à¢Õß°"¡'TM'«`µÕ¥ Ì"À--ºYâªÉ«¬·µà­°ÿà¡ ªíÀ"'È®­¬ÿà߬"° ¢÷ȥ⫬¢âÕÁ®®`ß'Ë«à" "®­µâÕߪ­¡"°"®"°µ""ß °.2 ÷ߧ«"¡ªìª¥â¢Õß "°"å·µà­Õ¬à"ß,, "¡ "°"å 'ËÕ"®Ì",,Àâÿ§§â¡`°°"--°...",,¢--È ·° ·'Ë®­µ--¥§'Ë¡à "¡"µ`¥µ"¡¥âÕÕ°®"°µ--«À" ¥--ß'˥ⰭÌ",,Àâ°" «`§"­À姫"¡Õ¬YàÕ¥¡"µ" "®­µâÕߪ­¡`÷ߧ«"¡ªìª¥â «à"ÿ§§À÷Ëß ®­â¡`°°"--°...",,¢--È·°æ"­ "Àµÿ--È ¥--ß--È "®÷ß "¡"«"ßYª·«à" ÿ§§¥--ß°à"«®­°--ªÕ¬Yà,,°ÿࡺYâµ`¥TMÈÕÕTMÕ«''Ë¡à¥â--°"--°..."¥â«¬¬"µâ" «-- Õ¥ å (--Ë§Õ ÕÕ'ÕÁ¡ (AEM) "¡"Ì"ºYâªÉ«¬Àà"'È°--ªÕ¬Yà,,·· ¥ß §«"¡°â"«Àâ"¢ÕߺYâªÉ«¬'Ë¡à¥â--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ÀÕ`Ë¡Ì"°-- ª Yà°"TM--°®YßæËÕ,,Àâ¢â"--°"--°..."Õ'°§--ÈßÀ÷Ëß) Õ°®"°'È "¬--ß®Ì"ªìµâÕß ª­¡`§«"¡ªìª¥â'Ëÿ§§®­ª'ˬª¢â"--°"--°...",,¢--È'Ë Õß æËÕ«"ßYª ·°"§ËÕ¬â"¬¢ÕߺYâªÉ«¬,, "°"å ¡¡µ`'Ë«¡§«"¡ªìª¥â¥--ß°à"« ¬`Ëß ª°«à"--È "¬--ßµâÕߪ­¡`÷ߧ«"¡ªìª¥â'˺YâªÉ«¬®­ '¬TM'«`µÕ'°¥â«¬ «`'°"¢Õß"§Õ Õ`"¬ "Àµÿ¢Õß°"ÕÕ°®"°°"--°..."¢--È·°¥â«¬Àµÿº,,¥Ê °Á¥â TMà 秫"¡â¡À«é ,¥¬®--¥°ÿà¡ "Àµÿ'˪쪥â "¡ª­°"¢â"¥â«¬°-- Ì"À--°"ÕÕ°®"°°"--°..."¥--ß°à"« ¥â«¬°"«¡¢âÕ¡YTMà'È "®­ "¡" ª­¡` â,§âߢÕß°"¡'TM'«`µÕ¥¥â,¥¬¡àµâÕßµ--¥¢âÕ¡Y,,¥Ê À--ß®"°--È "®÷ß·¬° §«"¡ªìª¥â¢Õß°"ÕÕ°®"°°"--°..."¢--È·°ÕÕ°ªì ૪­°Õ--Èß "¡ Õ-- ¥â·°à °"¡à "¡"µ`¥µ"¡¥â °"¬â"¬ª¢â"--°"--°...",,¢--È'Ë Õß ·­°" '¬ TM'«`µ º¢Õß°"ª­¡`¢--È·° ·­°"·¬°ÕÕ°ªì ૪­°Õ "¡ à«'È ¥âÌ" Õ«â,, à« (°) ·­ (§) ¢Õß¿"æ °.4 Õ°®"°'È ¥â«¬°",,TMâ«`'°"'˧â"¬°-- Delphi ºYâ¢'¬"¬ß"ÈÕßÀ--ß"ß §``° ¬--ߥ⪭¡`÷ßYª·§«"¡°â"«Àâ"¢ÕߺYâªÉ«¬ 100 § ´÷Ëß`Ë¡--°"--°..." ,,¢--È'Ë Õß À--ß®"°'Ë°"--°..."¢--È·°â¡À«ß (µ""ß °.3) ¿"§º«° ° 181 Appendix A · 181 ¿"æ °.4 §«"¡°â"«Àâ"®"°°°"--°..."¢--È·°·­¢--È'Ë Õß ,¥¬¥â--§«"¡ -- ÿ ·­¡à¥â-- §«"¡ -- ÿ®"°°ÿࡺYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å æËÕ,,ÀâªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥: °"TM--°®Yß ,,Àâ¢â"à«¡,§ß°"--°...",,­¬­À--ß Figure A.4 ProgressionfromFirst-andSecond-LineTherapywithandwithoutPHA Group Support of Adherence Behavior: Late Recruitment (°) øíß°åTM--Ë°"Õ¥TM'«`µ: ,§ß°" NAPHA Õ¬à"ߥ'¬« (a) Survival functions: NAPHA only, (¢) øíß°åTM--Ë°"Õ¥TM'«`µ: ,§ß°" NAPHA Õ¬à"ߥ'¬« °"--°..."¥â«¬¬"µâ"«-- Õ¥ å ¢--È·° (b) Survival functions: NAPHA only, first-line ART °"--°..."¥â«¬¬"µâ"«-- Õ¥ å ¢--È'Ë Õß second-line ART 1.0 1.0 0.5 0.5 0.0 0.0 (°) øíß°åTM--Ë°"Õ¥TM'«`µ: ,§ß°" NAPHA Õ¬à"ߥ'¬« (°) øíß°åTM--Ë°"Õ¥TM'«`µ: ,§ß°" NAPHA Õ¬à"ߥ'¬« ·­°ÿࡺYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å (PHA) (c) Survival functions: NAPHA and (d) Survival functions: NAPHA and ·­°ÿࡺYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å (PHA) °"--°..."¥â«¬¬"µâ"«-- Õ¥ å ¢--È·° PHA groups, first-line ART °"--°..."¥â«¬¬"µâ"«-- Õ¥ å ¢--È'Ë Õß PHA groups, second-line ART 1.0 1.0 0.5 0.5 0.0 0.0 0 10 20 30 40 0 10 20 30 40 year ªï year ªï °"Õ¬YàÕ¥ ,,·ßà¢Õߧ«"¡â¡À«"ß°"--°..." Survival with respect to treatment failure Survival with respect to death °"Õ¬YàÕ¥ ,,·ßà¢Õß°" '¬TM'«`µ °"Õ¬YàÕ¥ ,,·ßà¢Õß°"¡àÕ"®µ`¥µ"¡º¥â Survival with respect to loss to follow up Survival with respect to second-line therapy °"Õ¬YàÕ¥ ,,·ßà¢Õß°"--°...",,¢--È'Ë Õß 'Ë¡": °"§Ì"«¢ÕߺYâ¢'¬ Source: Authors' computations. °"TM--°®Yß,,Àâ¢â"--°"--°...",,­¬­·°ª'¬'¬°--°"¢â"--°"--°...",,­¬­ patients who initiate second-line therapy after first-line therapy failed À--ß (table A.3). ®"°°"»÷°..."¢Õß ®ß° ·­§­ (æ.». 2547) ,,ª­»¬ §à"¡--¬"¢Õß Early versus Late Recruitment CD4 Ì"À--ºYâªÉ«¬'Ë¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,¥¬ºà""ß,§ß°"°" ¢â"÷ß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å­¥--TM"µ` Ì"À--ºYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å According to the study from Jongkol and others (2004) in Thailand, the ÀÕ ,§ß°"¿" (NAPHA) ¥â·°à 45 ´åµàÕY°"»°å¡``¡µ --Èß'È ¥â¡'°" median CD4 count for patients entering ART through NAPHA ÿª,,§«"¡­À«à"ߪ­»«à" §«"¡ Ì"Á®¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (National Access to Antiretrovirals Program for People Living with ®­¢÷ÈÕ¬Yà°-- ¿"æ¢Õß­¿Y¡`§ÿâ¡°--¢Õßÿ§§,,¢­'Ë`Ë¡Ì"°"--°..." TMà ,, AIDS) is 45 cells per cubic millimeter. It is established in the interna- ß"«`®--¬¢Õß OEÁÕ° ·­§­ (ªïæ.». 2544) ·­¡Õå ·­§­ (ªïæ.». 2540) tional literature that the success of ART depends critically on the state ¿"æ °.5 ¥âÌ"¿"æ®"°ß"«`®--¬¢Õß OEÁÕ° ·­§­ (ªïæ.». 2544) ¡"®--¥Ì",,À¡à of the individual's immune system at the time treatment is initiated. See, ,¥¬· ¥ß,,ÀâÀÁ«à" §«"¡ªìª¥â¢Õß°"¡'TM'«`µÕ¥,, "¡ªï--È ¥ß®"°âÕ¬­ for example, Hogg and others 2001; Mellors and others (1997). Figure 96 Ì"À--°ÿࡺYâªÉ«¬'Ë`Ë¡°"--°..."¡ËÕ¡'§à" CD4 Yß°«à" 200 ´åµàÕY°"»°å A.5 reproduces the figure from Hogg and others (2001), which shows ¡``¡µ ¡"ªìâÕ¬­ 87 Ì"À--°ÿࡺYâªÉ«¬'Ë`Ë¡°"--°..."¡ËÕ¡'§à" CD4 Õ¬Yà that the probability of three-year survival drops from 96 percent for ­À«à"ß 50-200 ´åµàÕY°"»°å¡``¡µ ·­¥ß¡"÷ßâÕ¬­ 75 Ì"À-- those starting treatment at CD4 counts higher than 200 cells per cubic millimeter, to 87 percent for those with counts between 50 and 200 cells °ÿࡺYâªÉ«¬'Ë`Ë¡°"--°..."¡ËÕ¡'§à" CD4 µË"°«à" 50 TMåµàÕY°"»°å¡``¡µ per cubic millimeter, down to only 75 percent for those beginning treatment at CD4 counts lower than 50 cells per cubic millimeter. 182 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ (%) (%) (10) 2.0 4.3 9.2 12.4 17.8 24.9 36.6 ºYâ'Ë¢â"--°"--°..." (8) 92.0 83.6 72.6 61.1 47.1 30.9 9.7 °"ª--ªÿߢÕß Kaplan-Meier(%) Õ--µ"Õ¥TM'«`µ¢Õß Kaplan-Meier (8) 94.0 87.9 81.8 73.5 64.9 55.8 46.3 Õ--µ"Õ¥TM'«`µ¢Õß Kaplan-Meier (%) (%) (7) 8.0 9.1 6.0 6.5 7.0 Õ--µ"¬µàÕ 13.2 15.9 22.9 34.4 68.8 (7) 10.1 11.8 14.0 17.0 ­¬­«" Õ--µ"¬µàÕ ­¬­«" (6) 88 76 63 48 32 16 0 (6) 93 86 79 68 57 47 37 50 ,¥¬¡à¡'°ÿࡺYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å'Ë®­ -- ÿ `È ÿ¥­¬­«" ,¥¬¡'°ÿࡺYâµ`¥TMÈÕ·­ºYâªÉ«¬Õ¥ å'Ë®­ -- ÿ `È ÿ¥­¬­«" 'Ë¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ å¢--È'Ë Õß,,ª­»¬:§ ¢--È'Ë Õß (5) 8 8 10 10 11 11 11 69 (5) 6 6 6 8 8 8 8 13 100 ®Ì"«ºYâ '¬TM'«`µ ®Ì"«ºYâ '¬TM'«`µ ,,Àâ¡'°"ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥ (4) 4 4 3 5 5 5 5 31 ,,Àâ¡'°"ªØ`--µ`µ"¡«`'°"--°..."Õ¬à"ߧàߧ--¥ (4) 1 1 1 3 3 2 2 20 °"¡à "¡" µ`¥µ"¡¥â °"¡à "¡" µ`¥µ"¡¥â °"¢â"--°"--°..."¥â«¬¬"µâ"«-- Õ¥ åD1 (3) 1 1 1 2 5 5 5 20 --°"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,¢--È'Ë ÕßD3 (3) 1 1 1 2 5 5 5 §«"¡¬"«¢Õß ­¬­«" §«"¡¬"«¢Õß ­¬­«" "°"å(°) "°"å(¢) (2) 100 88 76 63 48 32 16 «"'Ë`Ë¡ °"--°..." (2) 100 93 86 79 68 57 47 «"'Ë`Ë¡°"--°..." 2548 ¢âÕ¡Y --ߧ"­Àå÷ß°"¡'TM'«`µÕ¥¢ÕߺYâªÉ«¬Õ¥ åµ"¡ ¡¡µ`" °.3 (1) ªï'˵`¥TMÈÕ ÕTMÕ«' (1) ,°¥å·­§­ µ""ß ,,­¬­À--ß ªï'˵`¥TMÈÕÕTMÕ«' 1 2 3 5 10 15 20 «¡ 1 2 3 5 10 15 20 «¡ 'Ë¡": Appendix A · 183 ¿"§º«° ° 183 Figure A.5 CumulativeMortalitybyBaselineCD4Counts ¿"æ °. 5 Õ--µ"°" '¬TM'«`µ ­ ¡ ·¬°µ"¡§à" CD4 ¢--ÈæÈ" 100 98 )(% 96 94 Õ¥% 92 90 88 survival, 86 of 84 82 probability80 §«"¡ªìª¥â,,°"¡'TM'«`µ 78 76 74 72 0 0 6 12 18 24 30 36 ¥Õ µ--Èß·µà`Ë¡¡'°"--°..."¥â«¬¬"µâ"«-- Õ¥ å months from start of ART CD4 cell count (cells/mm3): §à" CD4 (´å/.¡¡.): 200 50­199 < 50 'Ë¡":Source·­§­ 2544 OEÁÕ°: Hogg and others 2001. À¡"¬Àµÿ Notes 1.1. æËÕ®Ì"Õß°"§Ì"«¢ÕߺYâ¢'¬ "®­µâÕß,,TMâ«`'ª--¢âÕÁ®®`ß To replicate the authors' calculations, one must apply the so- called actuarial adjustment. 2. «"¡--¬",,°"¡'TM'«`µÕ¥ Ì"À--Yª·°"Ì"ß"--Èß "¡ ¥â--°"®--¥ Õ--¥--,,--°...­¥'¬«°-- ,¥¬Yª·'˪ì·ßà¥''Ë ÿ¥ §Õ log-logistic ¥â,,Àâ§à"°"Õ¥ 2. The median survival times for the three functional forms were TM'«`µ¢--È¡--¬"ªì«" 8.9 ªï ,,¢­'Ë Gompertz ·­ Weilbull ,,Àâ§à"°"Õ¥TM'«`µ ranked in the same way. The most optimistic function, the log-logistic, ªì 7.89 ·­ 8.50 ªï µ"¡Ì"¥-- yields a median survival of 8.89 years, whereas the Gompertz and the Weibull functions yield 7.89 and 8.50 years, respectively. 3. Yª·Õâ"ßÕ`ߢÕß UNAIDS 'Ë· ¥ß°"æ--"Õ¬à"ßTMâ"Ê,,¿"æ °.3 §Ì"« ,¥¬,,TMâ§à"À÷Ëߥ⫬§à"©'ˬ¢Õߧ«"¡ªìª¥â ­ ¡,,°" '¬TM'«`µ¢ÕßTM"¬·­ À`ß ®"°µ""ß'Ë 2 ¢Õß Stover (2002, 19) Õ¬à"ß°Áµ"¡ ·ßà'Ë¥â®"° 3. The slow progression UNAIDS reference pattern in figure A.3 is ¡¡µ`"¢Õß UNAIDS ,,ªïÕËÊ Õ"®°`¥®"°°",,TMâøíß°åTM--Ë¢Õß Weibull ·'Ë®­,,TMâ computed as one minus the average of the male and female cumulative log-logistic function probabilities of death from table 2 of Stover (2002, 19). The greater pes- simism of the UNAIDS assumptions in the outer years is probably due to the use of a Weibull function rather than the log-logistic function. ¿"§º«° ¢. µâÿ°"--°..."°"--°..."¥â«¬¬"µâ"«-- Õ¥ å 'Ë 3 ¢Õß"¬ß"©--'È Õ¢âÕ¡Y ÿª°'ˬ«°--µâÿµàÕÀ૬¢Õß°"--°..." ¥â«¬¬"µâ"«-- Õ¥ å (ART) ´÷Ëß,,µÕ--È ¥â,,TMâæËÕÌ"¡" â"ß "°"å ¡¡µ` æËÕ°"§"¥ª­¡"´÷Ëߪ"°Ø,,µàÕÊ¡" ,, à«¿"§º«°'È ®­,,Àâ¢âÕ¡YæÈ" ´÷ËߥâÌ"¡",,TMâæËÕ â"ßµ""ß 3.9 æËÕ· ¥ßµâÿ¢Õ߬"µâ"«-- Õ¥ å ·­µ""ß 3.10 æËÕ· ¥ßµâÿ,,°"--°...",§®"°°"µ`¥TMÈÕ©«¬,Õ°" ´÷Ëߥâ°à"«÷ߪ ·â«,,'Ë 3 µâÿ¢Õ߬"µâ"«-- Õ¥ å®­¢÷ÈÕ¬Yà°--µ--«¬"'Ë,,TMâ ª`¡"¢Õ߬"'Ë µâÕß--ª­" ·­"§"'Ë·â®`ߢÕ߬"·µà­TM`¥,,ª­»¬ ËÕß®"°¢âÕ¡Y µà"ßÊÀà"'È·µ°µà"ß°--ª,, Ì"À--ºYâªÉ«¬·µà­§ ·æ¬å·µà­"¬ ·­,,·µà­ TMà«ß«" ®÷ßµâÕß¡'°"«Õ¬à"ßµàÕËÕß 'Ë 4 ¥â«`§"­Àå÷ߧ«"¡ÕàÕÀ« ¢Õߺ Ì"§--®"°°"ª'ˬ·ªß"§"¬" ÷ß·¡â«à" "¡à¥âæ`®""÷ߧ«"¡ªì ª¥â«à" "ßÕ°¢Õ߬"µà"ßÊ Õ"®ª'ˬ·ªß¥â ·µàµ""ß ¢.1 ¥â Õ÷ß"§" ¢Õ߬"·µà­TM`¥,, æ.». 2547 ,,ª­»¬ ·­,,ÀâºYâÕà"¥âæ`®""÷ߺÕ-- Õ"®®­°`¥¢÷È¥â,,°"ª'ˬ·ªßµâÿµàÕÀ૬,,°"--°..."æ¬"" °"--°..."¥â«¬¬"µâ"«-- Õ¥ å'˪­ §«"¡ Ì"Á® À¡"¬÷ß°"ËÕ­¬­«" 'Ë®­µâÕß®à"¬§à",,TMâ®à"¬ à«,,Àà,,°"--°..."°"®ÁªÉ«¬®"°°"µ`¥TMÈÕ©«¬,Õ°" ÕÕ°ª®°«à"°"--°..."¥â«¬¬"µâ"«-- Õ¥ å®­¡à¥âº ´÷ËßÕ"®®­¡"÷ߺYâµ`¥TMÈÕTMâ" ÀÕÁ«¡àà"°-- "Õ«à" ºYâµ`¥TMÈÕ®­°`¥°"®ÁªÉ«¬®"°°"µ`¥TMÈÕ©«¬,Õ°" ¡ËÕ °"--°..."¥â«¬¬"µâ"TMÈÕ«-- Õ¥ åâ¡À« ´÷Ëߪì `Ëߥ'¬«°--'Ëæ«°¢"µâÕߺTM` TMà¥'¬«°--°--°"¡à¥â¢â"--°"--°..."¥â«¬¬"µâ"TMÈÕ«-- Õ¥ å ¥--ß--È °" ª­À¬--¥ß`'ËÌ"¥â¥â«¬°"ËÕ­¬­«"°"--°...",§®"°°"µ`¥TMÈÕ©«¬,Õ°" Ì"À--ºYâªÉ«¬§À÷Ëß ®÷ߪ­°Õ¥â«¬§«"¡·µ°µà"ߢÕß¡Y§à"°"¥«"°"--°..." ªí®®ÿ-- ­À«à"ß°"'Ë,,TMâ°"--°..."¥â«¬¬"µâ"TMÈÕ«-- Õ¥ å°--«"'Ë°"--°..."¥â«¬ ¬"µ--«'È¡à¥âº °"ª­À¬--¥TMà'È®­Ì"¥â¡"° â"µâÿ,,°"--°...",§®"°°"µ`¥ TMÈÕ©«¬,Õ°" --È Yß°«à" ÀÕâ"Õ--µ" à«¥¡'¡"°°«à" µ""ß ¢.2 ·­ ¢.3 ,,¿"§ º«°'È · ¥ß÷ߢâÕ¡Y¢Õß°"°­®"¬§«"¡®ÁªÉ«¬®"°°"µ`¥TMÈÕ©«¬,Õ°" µà"ßÊ ,,ª­»¬ ®"°§«"¡'Ë --¡æ--åÀà"'È µ""ß 3.10 ¥â Õ¢âÕ¡Y'Ë¡'Õ¬Yà°'ˬ«°-- 185 186 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ µâÿ,,°"--°...",§®"°°"µ`¥TMÈÕ©«¬,Õ°" µà"ßÊ Ì"À--ºYâªÉ«¬TM"«¬,¥¬--Ë«ª °"ª­¡"°"å'È¥âÌ"¡",,TMâæËÕ,,Àâ¡--Ë,,®«à" °"§"¥ª­¡"µâÿ,,Õ"§µ¢Õß °"--°..."¥â«¬¬"µâ"«-- Õ¥ å,,ª­»¬ ®­¡"®"°ß`'˪­À¬--¥¥â®"°°" ËÕ­¬­«"°"--°...",§'Ë°`¥®"°°"µ`¥TMÈÕ©«¬,Õ°" ÕÕ°ª µâÿ à«À÷Ëß,,¥" ૪­°Õ¢Õßµâÿ'Ë Ì"§--'Ë ÿ¥,,°"--°..."¥â«¬ ¬"µâ"«-- Õ¥ å ¥â·°àµâÿ,,°"µ«®À"§à" CD4 »Y¬åª­ "§«"¡à«¡¡Õ ­À«à"ß ¬ ÕÕ µ'¬ Õå·¥å æËÕ°"«`®--¬"ߧ``°¥â",§Õ¥ å HIV- NAT (Netherlands-Australia-Thailand) ¥âÌ"°" Ì"«®·æ¬å¬'Ë,,Àâ°"--°..." ¥â«¬¬"µâ"«-- Õ¥ å ¥â Õ"¡·æ¬åæËÕ¢Õ¢âÕ¡Y°'ˬ«°--µâÿ,,°"µ«®À" §à" CD4 ¢ÕߺYâªÉ«¬ ¿"æ ¢.1 · ¥ß,,ÀâÀÁ«à" ÷ß·¡â,§ß°"¿"¥â¥Ì"`¡"°«à" À÷Ëߪï·â« ¬--ß¡'§«"¡·µ°µà"ßÕ¬à"ß¡"° Ì"À--"§"'Ë®à"¬æËÕ°"µ«®¥--ß°à"« ,, ¢­'Ë"¥â,,TMâ"§"ª"°"ß Ì"À--µâÿ,,°"À"§à" CD4 ,,°"§"¥ª­¡" ¢Õß" --"¬§«µ­À--°«à" ºYâµ`¥TMÈÕ"ߧÕ"®Y°¢Õ,,Àâ®à"¬¡"°°«à" ÀÕ¢Õ ,,Àâ¢â"¡¢--ȵÕ'˪ì ૪­°Õ Ì"§--¢Õß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å'Ë¥'¢--È µÕ'Ë Ì"§--'È ¿"§º«° ¢ 187 n.a. 15.0 180.0 63.0 81.0 306.0 450.0 n.a. 270.0 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. À'¬ À-- ¬" "¡-- " n.a. 600 7,200 2,520 3,240 12,240 18,000 n.a. 10,800 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. µâÿµàÕºYâªÉ«¬/ªï 887.0 310.0 .n.a À'¬ À-- 1,814.4 1,243.8 1,297.8 1,393.2 2,502.0 695.7 499.8 1,458.0 2,803.2 762.6 2,952.0 972.0 3,807.6 3,589.2 ¬"¡'¬'ËÀâÕ " 35,480 12,400 72,576 49,752 51,912 55,728 100,080 27,828 19,992 .n.a 58,320 112,128 30,504 118,080 38,880 152,304 143,568 n.a. 1.3 15.0 5.3 6.8 25.5 37.5 .n.a 22.5 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. À'¬ À-- ¬" "¡-- " .n.a 50 600 210 270 1,020 1,500 n.a. 900 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. æ.».2547 µâÿµàÕºYâªÉ«¬/¥Õ 252.0 25.8 151.2 103.7 108.2 116.1 208.5 58.0 41.7 n.a. 121.5 233.6 63.6 246.0 81.0 317.3 299.1 æ»®`°"¬ À'¬ À-- ¬"¡'¬'ËÀâÕ " 10,080 1,033 6,048 4,146 4,326 4,644 8,340 2,319 1,666 n.a. 4,860 9,344 2,542 9,840 3,240 12,692 11,964 ·­ 1x 2x 1x 6x 10x 2x 10x 4x 6x 2x (¡°.) 2x 4x 2x 2x30 2x40 2x300 2x150)+ 300 100 150 600 200 300 400 250 100 100 400 33.3)+ 100)+ ¢"¥ª`¡"`,¿§µàÕ«-- (300 (133.3 (1000 (IDV/r) (LPV/r) (SQV/r) µâÿ¢Õ߬"µâ"«-- Õ¥ å'Ë¡'¬'ËÀâÕ·­¡à¡'¬'ËÀâÕ,,ª­»¬ (ABC) (ddl) (3TC) (d4T) (d4T) (AZT) (NVP) (SQV) ritonavir ritonavir ¢.1 3TC+ (EFV) (TDF) (IDV) (NFV) (RTV) µ""ß ¬"µâ"«-- Õ¥ å NRTI abacavir didanosine lamivudine stavudine stavudine zidovudine AZT NNRTI Efavirenz Nevirapine NtRTI Tenofovir PI indinavir nelfinavir ritonavir saquinavir indinavir+ lopinavir+ saquinavir+ritonavir 188 »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ 360.0 396.0 773.7 À'¬ À-- 1,145.7 720.0 1,050.0 1,422.0 «--­§--Èß ¬" "¡-- ¡°. " 14,400 15,840 30,948 45,828 28,800 42,000 56,880 250 ·­ µâÿµàÕºYâªÉ«¬/ªï À'¬ À-- 3,558.0 3,612.0 3,753.9 3,001.8 5,305.2 4,030.2 6,309.6 2,916.3 2,670.6 6,846.6 6,628.2 2547 °°.60 ¬"¡'¬'ËÀâÕ MSF " 142,320 144,480 150,156 120,072 212,208 161,208 252,384 116,652 106,824 273,864 265,128 2547; 30.0 33.0 64.5 95.5 60.0 87.5 118.5 À'¬ À-- ¬" "¡-- Õߧå°"¿ --TM°¡ "À--ºYâªÉ«¬'Ë¡'È"À--°¡"°°«à" " 1,200 1,320 2,579 3,819 2,400 3,500 4,740 2547; «--­À÷Ëߧ--Èß µâÿµàÕºYâªÉ«¬/¥Õ 296.5 301.0 312.8 250.2 442.1 335.9 525.8 243.0 222.6 570.6 552.4 ¥--§Õ¡å À'¬ À-- ¡°. ¬"¡'¬'ËÀâÕ 400 " §Õ 11,860 12,040 12,513 10,006 17,684 13,434 21,032 9,721 8,902 22,822 22,094 1x 1x 2x °­«ß "" ÿ¢ ·­ 2x 2x 2x 150+ 800/100 '˺ ¡°--µ--«¬"ÕË (¡°.) 600+2x 600+2x 800/100+ 600+ 200/300+ 1000/100) ¢"¥ ª`¡"`,¿§µàÕ«-- 200)+30+ 200)+40+ 150)+ 150)+ 150+ 200)+ +150+ 150+ 100+ +100 400*++ didanosin (150 (150 (40 (300 (300 300/40 300 800 800 (300 æËÕ ·­,§µ`¥µàÕ"ßæ» --¡æ--å ÀÕâÕ¬°«à" 3TC+ «--,§ °°.60 µàÕ NVP+ NVP+ EFV+ EFV+ NVP+ IDV/r+ IDV/r+ Õå·¥å EFV+ AZT+ LPV/r+ SQV/r+ LPV/r+ SQV/r+ ª`¡"`,¿§µàÕ«--¢Õ߬" ¢.1 d4T+ d4T+ 3TC+ 3TC+ 3TC+ 3TC+ 3TC+ ÕÕ µ'¬ RTV+ RTV+ ddl+ ddl+ ddl+ ddl+ "--°,§Õ¥ å ¡à¡'¢âÕ¡Y= µ""ß ¬"µâ"«-- Õ¥ å ¬"µâ"«-- YµæÈ" (·«ªØ`--µ`¢Õß°­«ß "" ÿ¢) 3TC 3TC d4T AZT AZT d4T AZT ¬"µâ"«-- Yµ "Õß (»Y¬åª­ "§«"¡à«¡¡Õ­À«à"ß ¬ °"«`®--¬"ߧ``°¥â",§Õ¥ å HIV-NAT) IDV IDV ¬"µâ"«-- Yµ "Õß (·«ªØ`--µ`¢ÕßÕߧå°"Õ"¡--¬,°) ABC ABC TDF TDF 'Ë¡": À¡"¬Àµÿ: "À--ºYâ'Ë¡'È"À--° n.a. ¿"§º«° ¢ 189 µ""ß ¢.2 §«"¡TMÿ°¢Õß°"µ`¥TMÈÕ,§©«¬,Õ°" ¢ÕߺYâªÉ«¬Õ¥ å ,ßæ¬""»``"TM æ.». 2545- 2547 TM`¥¢Õß°"µ`¥TMÈÕ §«"¡TMÿ° (âÕ¬­) «--,§ 29.3 Pneumocystis carinii pneumonia 18.7 ,§¬ËÕÀÿâ¡ ¡ÕßÕ--° ®"°TMÈÕ" (Cryptococcal meningitis) 15.7 Cytomegalovirus infection 6.3 ¡­ÁßµàÕ¡È"ÀÕß (Lymphoma) 6.3 ÁÕ°,´æ" ,¡´' (Toxoplasmosis) 5.7 Õÿ®®"­à«ß (Salmonellosis) 6.0 Cryptosporidium 5.3 ÕËÊ 5.0 'Ë¡": --µ ÿ« æ.». 2547 À¡"¬Àµÿ: ,§ÕËÊ ¥â·°à histoplasmosis, mycobacterium avium complex, PML, candida esophagitis ·­ rhodococcosis µ""ß ¢.3 °"µ`¥TMÈÕ,§©«¬,Õ°" '˪"°Ø,,°ÿࡺYâ¢â"à«¡,§ß°"»÷°..."¢ÕßÕߧå°"Õ"¡--¬,° ®"« 282 "¬ ,,,ßæ¬""-- 32 ·Ààß æ.». 2545-2547 TM`¥¢Õß°"µ`¥TMÈÕ âÕ¬­ «--,§ 34.7 Pneumocystis carinii pneumonia 19.0 ,§¬ËÕÀÿâ¡ ¡ÕßÕ--° ®"°TMÈÕ" (Cryptococcal meningitis) 15.8 PPE 13.7 ÁÕ°,´æ" ,¡´' Toxoplasmosis 3.2 ,§µ`¥TMÈÕ",,TMàÕߪ"° (Oral candida) 4.2 ÕËÊ 8.4 ¡à¡'¢âÕ¡Y 3.2 'Ë¡": Supakankunti ·­§­ æ.». 2547 À¡"¬Àµÿ: ,§ÕËÊ ¥â·°à penicilosis, chronic fever ·­,§ßY «--¥ (herpes zoster) 190 · »...»" µå¢Õß°"--°..."Õ¥ åÕ¬à"ß¡'ª­ ``º: °"ª­¡`"ßÕ°TM`ß,¬"¬ Ì"À--ª­»¬ 190 TheEconomicsofEffectiveAIDSTreatment:EvaluatingPolicyOptionsforThailand Figure B.1 CostofCD4Counts ¿"æ ¢.1 µâÿ¢Õß°"À"§à" CD4 20 17 15 test of 10 10 9 9 9 frequency §«"¡'Ë,,°"µ«® Õ 5 2 2 1 1 0 0 250 500 750 1,000 1,250 1,500 1,750 2,000 2,250 2,500 cost to patient (baht) µâÿµàÕºYâªÉ«¬ (") 'Ë¡": °" Ì"«®·æ¬å¬ ,¥¬ »Y¬åª­ "§«"¡à«¡¡Õ­À«à"ß ¬ ÕÕ µ'¬ Õå·¥å Source: HIV-NAT survey of Thai Physicians 2004. æËÕ°"«`®--¬"ߧ``°¥â",§Õ¥ å HIV-NAT (Netherlands-Australia-Thailand) æ.». 2547 ¿"§º«° §. µâÿ¢Õß°ÿà¡ -- ÿ ºYâ'ËÕ¬Yàà«¡°--TMÈÕÕTMÕ«'/Õ¥ å °ÿࡺYâ,,À⧫"¡ -- ÿ·°àºYâ'ËÕ¬Yàà«¡°--TMÈÕÕTMÕ«'/Õ¥ å (PHA peer support Groups) °àÕµ--Èߢ÷Ȫì§--Èß·°,,ª­»¬,,TMà«ßµâ»«... 1990 (æ.». 2533-2543) ,,¥Õæ...¿"§¡ æ.». 2548 ¡'°ÿࡺYâ,,Àâ°" -- ÿ·°àºYâ'ËÕ¬Yà à«¡°--TMÈÕÕTMÕ«'/Õ¥ å´÷ËßÌ"ß"Õ¬à"ß·¢Áߢ--®Ì"« 800 °ÿà¡--Ë«ª­» ,¥¬ à«,,Àà®­¡'"Õ¬Yà,,,ßæ¬""-- ·­Õ¬Yà¿"¬,,µâ°"¥Y·¢Õßæ¬""ª­®Ì",ß æ¬""ÀÕ--° --ߧ¡ ߧ"­Àå ,,æ.». 2541 ¥â¡'°"°àÕµ--Èߧբà"¬ºYâµ`¥TMÈÕÕTM Õ«'/Õ¥ å ª­»¬ (TNP+) æËÕª­ "ß"°`®°¡¢Õß°ÿࡺYâ'ËÕ¬Yàà«¡°--TMÈÕ ÕTMÕ«'/Õ¥ å°ÿࡵà"ßÊ ªí®®ÿ-- §Õ¢à"¬ TNP+ ¡' Ì"--°ß" 7 ·Ààß ,,¿Y¡`¿"§ µà"ßÊ¢Õߪ­»¬ §Õ¢à"¬ TNP+ `Ë¡,§ß°",,À⧫"¡ -- ÿ°"°"­µ`¥¬"µâ"«-- Õ¥ å ´÷Ëߪì à«À÷ËߢÕß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å (ART) ¢Õß°­«ß "" ÿ¢ ,¥¬`Ë¡µâ¥Ì"`°"¡ËÕ¥Õ°°Æ"§¡ æ.» .2545 (§Ì"æ`--°...å ·­ §­ æ.». 2547) §Õ¢à"¬ TNP+ ¥â--§«"¡ -- ÿ¥â"§`§·­ñ°Õ¡ ®"°Õߧå°"·æ¬åâæ¡·¥ (Medecins sans Frontieres>MSF) ·­¡Y``¢â"÷ß Õ¥ å (AIDS Access Foundation) ª­°Õ¥â«¬ ·æ¬åÀ÷Ëߧ®"° MSF (Ì"ß" âÕ¬­ 10 ¢Õß«"Ì"ß") æ¬"" 4 § ·­--° --ߧ¡ ߧ"­Àå 5 § ´÷ËßÌ"ß" µÁ¡«" ,¥¬¡'ºY⪭ "ß"®"°§Õ¢à"¬ TNP+ 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Data °­«ß "" ÿ¢ §«"¡TMÿ°¢ÕßTMÈÕ«-- ÕTMÕ«'/Prevalence Cumulative ¢âÕ¡Y®"°,§ß°"TMÈÕ«-- ÕTMÕ«'/Õ¥ å Bangkok; 2.22.2 'Ë¡":Source: °ÿßæoe; tion, ·º'ËMap ART of ·¬°µ"¡®--ßÀ«--¥ <30 30­50 50­80 80­100 Percentage coverage coverage ART of 2004 March Percentage Ì"À--ºYâµ`¥TMÈÕÕTMÕ«''Ë· ¥ßÕ"°" Province, by HIV MOPH., Symptomatic <1,000 1,000­2,000 2,000­4,000 4,000­8,000 for cases AIDS °­«ß "" ÿ¢Epidemiology Programs 2547 of ART of æ.». Bureau symptomatic of from °"§Õ§ÿ¡¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å ¡'"§¡ Data Coverage Number 2.3 ¢âÕ¡Y®"° Ì"--°­"¥«`¬" 2.3 'Ë¡":Source: ·º'Ë Map ART of HIV of data ·¬°µ"¡­¥--ÕÌ"¿Õ·­®--ßÀ«--¥ <30 30­50 50­80 80­100 >=100 No 0­150 150­300 300­600 600­1,500 level Organization, Percentage coverage Number symptomatic cases provincial Cultural the and at ·­«--¡·Ààß Àª­TM"TM"µ` Scientific, coverage «`¬"»" µå ART Coverage Ì"À--ºYâµ`¥TMÈÕÕTMÕ«''Ë· ¥ßÕ"°" Educational, ART Nations Õߧå°"»÷°..." United Province-Level 2004 data Project, ·­°"§â"¡ÿ...¬å and No 0­150 150­300 300­600 600­1,500 March raffickingT District- cases, and TMà¥'¬«°--¢â"ßµâ by above. HIV as HIV HIV/AIDS Same from symptomatic MOPH. Symptomatic °"§Õ§ÿ¡¢Õß,§ß°"--°..."¥â«¬¬"µâ"«-- Õ¥ å Data °­«ß "" ÿ¢ ¢âÕ¡Y®"°,§ß°"TMÈÕ«-- ÕTMÕ«'/Õ¥ å 2.4 2.4 Reported Source: Bangkok; Map ·º'Ë 'Ë¡": °ÿßæoe; 2003 hospitals 2547 2002 NPHA of 0 1­10 10­20 20­30 Number æ.».,,Õ'° 2004. in 2544-46 æ.».2001­03 NAPHA joined NAPHA, of MOPH. from hospitals 2001 Data new ¡à¡',ßæ¬""·Ààß,,À¡à¢â"à«¡,§ß°"¿" °"¢¬"¬,§ß°"¿"Expansion ¢âÕ¡Y®"°°­«ß "" ÿ¢ No 2.52.5 'Ë¡":Source: À¡"¬Àµÿ: Note: ·º'ËMap <25 25­50 50­75 >=75 hospital per participants ART ,ßæ¬""'Ë¢â"à«¡,§ß°"¿" 0 1­10 10­20 20­30 Hospitals NAPHA 2003 in °­«ß "" ÿ¢ at Use MOPH. hospitals ART from of NAPHA Data Õ--µ"°",,TMâ`°"--°..."¥â«¬¬"µâ"«-- Õ¥ å Rate 2.6 2.6 Source: ¢âÕ¡Y®"° Ì"--°­"¥«`¬" 'Ë¡": ·º'Ë Map ·º'Ë 2.7 ,ßæ¬""'Ë¢â"à«¡,§ß°"¿" ·­°"¡'°ÿà¡ -- ÿºYâªÉ«¬ ·¬°µ"¡ÕÌ"¿Õ Map 2.7 NAPHAHospitalsandPresenceofPatientSupportGroupsbyDistrict,2004 æ.». 2547 NAPHA hospitals and presence of patient support groups by districts no NAPHA hospital or patients' group NAPHA hospital present patients' group and NAPHA hospital present 'Ë¡": ¢âÕ¡Y®"°,§ß°"TMÈÕ«-- ÕTMÕ«'/Õ¥ å ·­°"§â"¡ÿ...¬å Õߧå°"»÷°..." «`¬"»" µå ·­ Source: Data from HIV/AIDS and Trafficking Project, United Nations Educational, Scientific, «--¡·Ààß Àª­TM"TM"µ` °ÿßæoe; °­«ß "" ÿ¢ and Cultural Organization, Bangkok; MOPH. °"µ«® ÕTM`ß`«»å ECO-AUDIT âÕ¬·ß°'ˬ«°--ºª­,¬TMå¢Õß `Ëß·«¥âÕ¡ ENVIRONMENTAL BENEFITS STATEMENT "§",° ¡'§«"¡¡ÿàß¡--Ë'Ë®­Õÿ--°...åªÉ"·­--æ¬"°¡TM"µ`'Ë The World Bank is committed to preserving endan- ,,°â®­ Yæ--åÿ¥--ß--È "®÷ßÕ°'Ë®­µ'æ`¡æåÀ--ß Õ ç»...»" µå gered forests and natural resources. We have chosen ¢Õß°"--°...",§Õ¥ åÕ¬à"ß¡'ª­ ``º: "ßÕ°TM`ß,¬"¬ to print The Economics of Effective AIDS Treatment: Pol- Ì"À--ª­¬é ¥â«¬°­¥"...´÷Ëß,,TMâ,,¬·Ì"°--¡",,TMâ,,À¡àÀ--ß icy Options for Thailand on 30% post-consumer recy- °",,TMâß"âÕ¬­ 30 °àÕÀâ"'È "§",° µ°ß'Ë®­ªØ`--µ`µ"¡ cled fiber paper. The World Bank has formally agreed ¡"µ"'Ë¥â--§Ì"·­Ì"°'ˬ«°--°",,TMâ°­¥"...,¥¬ ,§ß°"``Ë¡ to follow the recommended standards for paper usage æËÕ `Ëßæ`¡æåTM`ßÕÿ--°...å (the Green Press Initiative) ´÷Ëߪì,§ß°" set by the Green Press Initiative, a nonprofit program ¡à· «ßº°Ì"æËÕ -- ÿ Ì"--°æ`¡æå,,°",,TMâ,,¬°­¥"...´÷Ëß¡à¥â supporting publishers in using fiber that is not sourced Ì"¡"®"°ªÉ",,°â®­ Yæ--åÿ À"°µâÕß°"¢âÕ¡Yæ`Ë¡µ`¡ ,ª¥¬'ˬ¡ from endangered forests. For more information, visit TM¡¥â'Ë www.greenpressinitiative.org www.greenpressinitiative.org. saved the following: °"æ`¡æåÀ--ß Õà¡'È,¥¬,,TMâ°­¥"...'ËÌ"°--¡",,TMâ,,À¡à The printing of these books on recycled paper "¡"TM૬ª­À¬--¥--æ¬"°µà"ßÊ¥â¥--ßµàÕª'È: ë· µâ¡â 19 µâ (§«"¡ Yß 40 øÿµ âºà"»Y¬å°"ß 6-8 `È«) 19 trees (40' in height. 6­8 inches in diameter) ë· ¢Õß '¬'˪ì¢Õß·¢Áß ,,ª`¡" 910 ªÕ¥å 910 pounds of solid waste ë· È" 7,088 ·°Õ 7,088 gallons of water ë· °ä"´Õ°­®°ª`¡" ÿ` 11,708 ªÕ¥å 11,708 pounds of net greenhouse gases ë· æ--ßß"--ÈßÀ¡¥ 14 â" ''¬Y 14 million BTUs of total energy ,§ß°"``Ë¡æËÕ `Ëßæ`¡æåTM`ßÕÿ--°...å .. 2527 .. 2546 (ART) 700-2,400 : 12 ISBN 0-8213-6755-2