Thailand's national strategic plan on antimicrobial resistance: progress and challenges.

Antimicrobial resistance is a serious threat that affects all countries. The Global Action Plan on antimicrobial resistance and the United Nations Political Declaration on antimicrobial resistance set standards for countries to resolve antimicrobial resistance challenges under the One Health approach. We assess progress and challenges in implementing Thailand's national strategic plan on antimicrobial resistance 2017-2022, discuss interim outcomes and share lessons learnt. Major progress includes: establishing a national governance mechanism that leads high-impact policy on antimicrobial resistance and consolidates actions and multisectoral collaboration; creating a monitoring system and platform to track implementation of the strategic plan; and converting strategies of the strategic plan into actions such as controlling the distribution and use of antimicrobials in humans and animals. Interim results indicate that antimicrobial consumption in animals has nearly halved (exceeding the national goal of a 30% reduction) whereas other goals have not yet reached their targets. We have learnt that elevating antimicrobial resistance to high-level visibility and establishing a national governance mechanism is an important first step, and a monitoring and evaluation system should be developed in parallel with implementation. Securing funds is crucial. Policy coherence is needed to avoid duplication of actions. Highly ambitious goals, although yet to be achieved, can advance actions beyond expectations. Political commitment and collaboration across different sectors will continue to play important roles but might not be sustained without a well-designed governance structure to support long-term actions to address antimicrobial resistance.

La résistance aux antimicrobiens fait peser une sérieuse menace sur la planète tout entière. Le Plan d'action mondial pour combattre la résistance aux antimicrobiens ainsi que la Déclaration politique des Nations Unies sur la résistance aux agents antimicrobiens ont défini des normes pour les pays, afin qu'ils puissent faire face aux enjeux liés à la résistance aux antimicrobiens selon l'approche «One Health¼. Nous avons évalué les progrès et défis de la mise en œuvre du plan stratégique national de la Thaïlande en la matière pour 2017­2022, mais aussi discuté des résultats provisoires et partagé les enseignements tirés. Parmi les principaux progrès accomplis figurent l'établissement d'un mécanisme de gouvernance national pour mener une politique à impact élevé sur la résistance aux antimicrobiens, renforcer les actions et favoriser la collaboration intersectorielle; la création d'un système de surveillance et d'une plateforme pour suivre la mise en œuvre du plan stratégique; et enfin, la conversion des stratégies du plan en actions telles que le contrôle de la distribution et de l'usage des antimicrobiens chez les humains et les animaux. Les résultats provisoires indiquent que la consommation d'antimicrobiens chez les animaux a diminué de moitié (ce qui est supérieur à l'objectif national d'une réduction de 30%), tandis que les autres objectifs n'ont pas encore été atteints. Nous avons constaté qu'accroître la visibilité de la résistance aux antimicrobiens et instaurer un mécanisme de gouvernance national constituaient des étapes cruciales, et qu'un système de surveillance et d'évaluation devait être développé parallèlement à la mise en œuvre. L'obtention de financements est elle aussi essentielle. Une politique cohérente est nécessaire pour éviter de multiplier les actions similaires. Fixer des objectifs très ambitieux, même s'ils ne sont pas encore atteints, permet en outre de faire progresser les actions au-delà des attentes. Enfin, l'engagement politique et la collaboration entre différents secteurs continueront à jouer un rôle prépondérant, mais ne pourront peut-être pas se poursuivre sans une structure de gouvernance bien conçue, capable de soutenir des actions à long terme visant à remédier à la résistance aux antimicrobiens.

La resistencia a los antimicrobianos es una grave amenaza que afecta a todos los países. El Plan de Acción Mundial sobre la resistencia a los antimicrobianos y la Declaración Política de las Naciones Unidas sobre la resistencia a los antimicrobianos establecen normas para que los países resuelvan los problemas de resistencia a los antimicrobianos en el marco del enfoque «Una única salud¼. Evaluamos los avances y los desafíos en la aplicación del plan estratégico nacional de Tailandia sobre la resistencia a los antimicrobianos 2017-2022, analizamos los resultados provisionales y compartimos las lecciones aprendidas. Entre los principales avances se encuentran: el establecimiento de un mecanismo de gobernanza nacional que lidera la política de alto impacto sobre la resistencia a los antimicrobianos y consolida las acciones y la colaboración multisectorial; la creación de un sistema de seguimiento y una plataforma para seguir la aplicación del plan estratégico; y la conversión de las estrategias del plan estratégico en acciones como el control de la distribución y el uso de antimicrobianos en humanos y animales. Los resultados provisionales indican que el consumo de antimicrobianos en animales se ha reducido casi a la mitad (superando el objetivo nacional de una reducción del 30 %), mientras que otros objetivos aún no han alcanzado sus metas. Hemos aprendido que elevar la resistencia a los antimicrobianos a una visibilidad de alto nivel y establecer un mecanismo de gobernanza nacional es un primer paso importante, y que debe desarrollarse un sistema de seguimiento y evaluación en paralelo a la implementación. Asegurar los fondos es crucial. La coherencia política es necesaria para evitar la duplicación de acciones. Unos objetivos muy ambiciosos, aunque todavía no se hayan alcanzado, pueden hacer avanzar las acciones más allá de las expectativas. El compromiso político y la colaboración entre los distintos sectores seguirán desempeñando un papel importante, pero podrían no mantenerse sin una estructura de gobernanza bien diseñada que apoye las acciones a largo plazo para hacer frente a la resistencia a los antimicrobianos.

"AMR Dialogues": a public engagement initiative to shape policies and solutions on antimicrobial resistance (AMR) in Thailand.

Background: The use of antimicrobials in Thailand has been reported as one of the highest in the world in both the human and animal sectors. The objectives of this project are: (1) to improve understanding of the issue of antimicrobial resistance (AMR) among adult Thai communities and (2) to drive change through the national AMR policy to include context-specific and locally-driven solutions. Methods: The project contains two components conducted in parallel: the "AMR Dialogues" public engagement project and the embedded evaluation of the project. We will bring together AMR stakeholders and members of the public through a series of conversation events to co-create an AMR stakeholder map, engagement strategy, and context-specific solutions to reduce the burden of AMR. There will be a combination of regional in-person events ('regional conversations') and national online events ('national conversations') with members of the public. The conversations will follow this sequence: introduce and explore issues related to AMR, brainstorm solutions and finally propose promising/feasible solutions to take forward. Evaluation of the project will be conducted to assess if the AMR Dialogues objectives have been achieved using feedback forms and qualitative methods. Ethics: Approval of the evaluation component of the project has been obtained from the ethics committee of the Thailand Institute for the Development of Human Subject Protection (IHRP2021059) and the Oxford University Tropical Research Ethics Committee (OxTREC 529-21). Dissemination: The results of these conversation events will inform the next Thailand National Strategic Plan on AMR. The learning and outcomes will be disseminated to AMR policy makers, academic audiences, and participants of all the conversation events. Thaiclinicaltrials.org registration: TCTR20210528003 (28/05/2021).

Drug Use Evaluation of Letrozole in Breast Cancer Patients at Regional Cancer Hospitals in Thailand.

BACKGROUND: Medication policy development in Thailand is continually promoting rational drug use. Letrozole, an endocrine therapy drug, is usually prescribed for post-menopausal status early and advanced stage breast cancer. After Ministry of Public Health announced Letrozole as compulsory licensed drug in 2009, more breast cancer patients can access to this drug at low cost especially those within universal coverage schemes. To ensure that Letrozole is rationally prescribed, the drug utilization study was conducted. OBJECTIVES: The aim of this study was to describe the appropriate use of Letrozole in breast cancer and the relationship between appropriate use and health benefit schemes. MATERIALS AND METHODS: A retrospective study to evaluate use of Letrozole in breast cancer patients was performed for six months between January - June 2010 in seven regional cancer hospitals, Thailand. All prescriptions of Letrozole were identified from pharmacy dispensing databases and prescription papers. A medical record review was also performed to evaluate appropriate use referring to the drug use evaluation criteria. The approved criterion of this study was referred from the guideline of Thai National Formulary version 2010. RESULTS: There were 681 prescriptions of Letrozole for 254 breast cancer patients with an average age of 58.6 ± 10.0 years. The patients in universal coverage scheme (UCS), civil servant medication benefit scheme (CSMBS) and social security scheme (SSS) were 77.7%, 18.5% and 8.7% respectively. 10.6% were prescribed Letrozole for the first time. Letrozole were prescribed by oncologists (82.8%). The average number of tablets per prescription was 58 ± 10. Calcium supplements were prescribed concomitant with Letrozole for 19.4%. To assess drug use evaluation criteria, 45 prescriptions were excluded because of uncompleted clinical data, 636 prescriptions were evaluated. The study showed 86 prescriptions (13.5%) with inappropriate use including 6 (0.9%) not prescribed for estrogen receptor (ER) and/or progesterone receptor (PR) positive, 31 (4.9%) not prescribed for post-menopausal and 49 (7.7%) not prescribed for an appropriate duration. Appropriate use percentages in different health benefit schemes were similar, 85.7% of CSMBS, 86.4% of SSS and 86.7% of UCS. The relationship between health benefit scheme and appropriate use of Letrozole was not significantly different, χ2 (2, N = 636) = 0.081, p > 0.05. CONCLUSIONS: The study showed inappropriate use in breast cancer patients because of non-compliance with duration, menopausal status and hormone receptor requirements. To prescribe appropriate indication did not referred to the appropriate practice along the treatment. Drug use evaluation proved very useful for detecting the sign of inappropriate use and allows immediate feedback to the stakeholder for developing medication policy in the future. Importantly, there was no significantly difference in appropriate use of Letrozole across health benefit schemes.

Local discourse on antiretrovirals and the lived experience of women living with HIV/AIDS in Thailand.

Antiretrovirals (ARVs) have been seen as life-saving for HIV-positive people. However, ARVs have a darker side. Since 2000, many HIV-positive people in Thailand have received ARV treatments, but the understanding of ARVs and practices of medication-taking among HIV-positive women have not received much attention. We discuss local discourses employed by HIV-positive women and health work by these individuals in their attempts to adhere to ARVs restrictions. The local discourse of ARVs was ya tan rok AIDS "medications that could resist HIV/AIDS." ARVs provided hope for the women. Although the women were affected by the side effects of ARVs, they continued to take their medication to be able to live longer and perform their duties as mothers and carers. They were more concerned about the practice of medication-taking. Understanding why these women were adherent to their ARVs offers insights into the social impact of these ARVs on their lives.

Living positively: the experiences of Thai women living with HIV/AIDS in central Thailand.

Living with an incurable illness such as HIV/AIDS is a stressful experience. However, many HIV-positive individuals are able to maintain their emotional well-being. This begs the question of what strategies these individuals employ to allow them to do so. In this article, we examine how Thai women living with HIV/AIDS learned about their health status, what feelings they had, and how they dealt with the illness. In-depth interviews were conducted with 26 women in central Thailand. The women adopted several strategies to deal with their HIV status, including taking care of themselves, accepting their own faith, disclosing their HIV status to family, and joining AIDS support groups. These strategies can be situated within the "living positively" discourse, which helped to create a sense of optimism to combat the HIV epidemic among the women. Additionally, the acceptance of their HIV status played an essential role in the meaning-making process because it assisted the women in sustaining the equilibrium of their emotional well-being.

High rates of midazolam injection among drug users in Bangkok, Thailand.

BACKGROUND: Reports from Thailand suggest that a growing number of people who inject drugs (IDU) are now injecting midazolam, a legal benzodiazepine with potent amnestic and ventilatory depressant effects. We therefore sought to examine midazolam injection among a community-recruited sample of Thai IDU. METHODS: We examined the prevalence and correlates of midazolam injection among 252 IDU participating in the Mitsampan Community Research Project, Bangkok, using multivariate logistic regression. We also examined the use of midazolam in combination with other drugs. RESULTS: 252 IDU participated in this study, including 66 (26.2%) women. In total, 170 (67.5%) participants reported ever having injected midazolam, and 144 (57.1%) reported daily midazolam injection in the past six months. In multivariate analyses, a history of midazolam injection was independently associated with using drugs in combination (adjusted odds ratio [AOR] = 5.86; 95% confidence interval [CI]: 2.96-11.60), younger age (AOR = 0.43; 95%CI: 0.22-0.83), having a history of methadone treatment (AOR = 3.12, 95%CI: 1.55-6.90), and binge drug use (AOR = 2.25, 95%CI: 1.09-4.63). The drugs most commonly used in combination with midazolam were heroin (72.3%) and yaba (methamphetamine) (30.5%). CONCLUSION: We observed a high rate of midazolam injection among Thai IDU. Midazolam injection was strongly associated with polysubstance use and binge drug use, and was most commonly used in combination with both opiates and methamphetamines. Our findings suggest that midazolam injection has become increasingly common within Thailand. Evidence-based approaches for reducing harms associated with midazolam injection are needed.

HIV and AIDS, stigma and AIDS support groups: perspectives from women living with HIV and AIDS in central Thailand.

In this paper, community attitudes toward women living with HIV and AIDS at the present time from the perspectives of women in Thailand are examined. We also look at strategies women use in order to deal with any stigma and discrimination that they may feel or experience in the community. The paper is based on our larger study of the experiences of women living with HIV and AIDS and their participation in clinical trials. In late 2007 and early 2008 we carried out a number of in-depth interviews with women living with HIV and AIDS in central Thailand. We find that women living with HIV and AIDS still deal with stigma and discrimination in their everyday life. However, from the women's narratives, we also find more positive attitudes from local communities. Some women deal with stigma and discrimination by joining and participating in HIV and AIDS support groups that have emerged in response to the AIDS epidemic in Thailand. We argue that women are not passive victims, but that they act in their own agencies to counteract any negativity they might encounter.