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Hiv & Aids in Thailand.

There are very few developing countries in the world where public policy has been effective in preventing the spread of HIV/AIDS on a national scale, but Thailand is an exception. A massive programme to control HIV has reduced visits to commercial sex workers by half, raised condom usage, decreased the prevalence of STIs (Sexually Transmitted Infections) dramatically, and achieved substantial reductions in new HIV infections. 1

Thailand, though, is also a reminder that success can be relative. Its well funded, politically supported and comprehensive prevention programmes have saved millions of lives, reducing the number of new HIV infections from 143,000 in 1991 to 19,000 in 2003. 2 Nonetheless, more than one-in-100 adults in this country of 65 million people is infected with HIV, and AIDS has become a leading cause of death. 3

Unless past efforts are sustained and new sources of infection are addressed, the striking achievements made in controlling the epidemic could now be put at risk. Factors such as an increase in risky sexual behaviour and a rising number of STI cases have led to concerns that Thailand could face a resurgence of HIV and AIDS in coming years. The government has decreased funding for AIDS prevention programmes significantly, and there are signs that public awareness is waning. Complacency - among both the government and the public – poses a real threat to the fight against AIDS in Thailand. 4

The History of HIV and AIDS in Thailand
Early responses
The first case of AIDS in Thailand occurred in 1984. 5 For the next few years, gay men, sex workers, injecting drug users and tourists were more commonly affected than other groups. The government took some basic measures to deal with the issue, but an epidemic was not yet apparent. Most of these measures were aimed at high-risk groups, as the government believed that there was not yet sufficient reason to carry out prevention campaigns among the general public. 6

Girls in Thailand participating in an AIDS education project
At the same time, public awareness of the issue was increasing. The case of Cha-on Suesom, a factory worker who became infected with HIV following a blood transfusion, was widely broadcast through the media after he agreed to allow his story and identity to be publicised in 1987. He became well known after appearing on TV shows and in national newspapers, allowing the public to appreciate the human side of the epidemic. Cha-on and his wife had both been fired from their jobs as a result of his HIV-positive status, and the injustice of this situation helped to increase public sympathy for people living with HIV. 7

Between 1988 and 1989, the HIV prevalence among injecting drug users rose dramatically, from virtually zero to 40%. The prevalence among sex workers also increased, with studies in Chang Mai, northern Thailand, suggesting that 44% of sex workers were infected with HIV. 8 The rising level of infection among sex workers led to subsequent waves of the epidemic among the male clients of sex workers, their wives and partners, and their children. 9

The prevailing view was still that HIV and AIDS had come from abroad and were mostly confined to a few individuals in high-risk groups. It was still not generally recognised that the epidemic would spread more widely. One government official insisted that the situation was under control, and stated that:

“The general public need not be alarmed. Thai-to-Thai transmission is not in evidence.” 10
Some members of Thailand’s parliament proposed that all foreigners should be required to pass an HIV test before being admitted to the country. 11 In keeping with the view that the threat was limited, the government only spent $180,000 on HIV prevention in 1988. 12

The 1990s
It was not until 1991, when a new Prime Minister, Anand Panyarachun, came to power, that AIDS prevention and control became a national priority at the highest level. The new prime minister took several important steps that have since been credited with helping to slow the epidemic.

Firstly, the AIDS control program was moved from the Ministry of Public Health to the Office of the Prime Minister, increasing its political influence, and the budget was increased almost 20-fold to $44 million in 1993. 13

Secondly, a massive public information campaign on AIDS was launched under the leadership of cabinet member Mechai Viravaidya, a well-known Thai AIDS activist and politician. Anti-AIDS messages aired every hour on the country's 488 radio stations and six television networks, and every school was required to teach AIDS education classes.

"We converted the equivalent of 'Jingle Bells' into a safe-sex song." 14
The high-profile campaign was initially unpopular with the influential tourism industry, and tourism indeed temporarily declined. However, once AIDS had a prominent place on the national agenda, opposition to the measures gradually faded and support increased. 15

Thirdly, and perhaps most importantly, the '100 percent condom program' was initiated. 16 This program aimed to enforce consistent condom use in all commercial sex establishments. Condoms were distributed free to brothels and massage parlours, and sex workers and their clients were required to use them. Brothels that failed to comply could be closed. Without this programme, it is estimated that Thailand’s national HIV prevalence would be ten times higher than it currently is. 17

“When a team of reporters decided to test the 100% condom program by visiting Chang Mai with the aim of buying sex without a condom, they failed.” 18

An HIV positive mother with her uninfected daughter
A number of repressive policies, such as mandatory reporting of the names and addresses of people living with HIV who attended hospitals, were also repealed. 19

From 1992 to 1996, the National AIDS program received dramatic increases in funding. The government provided it with more than $80 million annually by 1996, and:

"Every segment of Thai society played a role in AIDS prevention. Everyone was involved - from the medical community to teachers, to monks, to prostitutes and to drug addicts. The government committed funds for research and backed private organisations that attempted to spread the word about how to stop AIDS. Even the powerful Thai military pitched in, running voluntary blood tests for soldiers." 20
Over 3.5% of military recruits aged 21 were reported to be HIV-infected in many parts of the country following a 1992 round of surveys, with a prevalence rate to 20% in Chiang Mai, northern Thailand. 21

The second ‘National Plan for Prevention and Alleviation of the AIDS Problem’, which covered the period from 1997 to 2001, maintained the previous effective programs, whilst adopting a more holistic approach, which included mobilizing the efforts of communities and people living with HIV/AIDS. 22

Between 1996 and 1997, a randomised controlled trial was carried out to study the provision of short-course AZT (zidovudine) to prevent mother-to-child transmission of HIV in Bangkok. This study showed that AZT reduced transmission of HIV from mother to child by 50%. 23 Following this, a number of pilot programs were initiated in Thailand. 24 25 The successful results of the pilot studies led doctors in most provinces to demand government support for short-course AZT to prevent mother-to-child transmission of HIV. By 1999, AZT was being used in most hospitals in Thailand. 26

Then in the late 1990s, the Asian Financial Crisis resulted in a significant reduction and reorientation in the 1998 budget for AIDS prevention and control. Funding for medical interventions (including antiretroviral drug and treatment of opportunistic infections) was scaled back significantly. Support for condom distribution was also reduced. 27 By 2000, domestic funding for HIV and AIDS prevention was roughly one quarter less than it had been in 1997. 28

2000 onwards
In 2000, HAART (Highly Active Antiretroviral Therapy, effective HIV treatment that involves the combination of three or more ARVs) was introduced to Thailand. In subsequent years the number of people accessing this treatment increased dramatically, significantly reducing the number of people dying from AIDS.

In 2003 the government made an official commitment to ensuring adequate treatment for all people living with HIV, and set targets to improve treatment access. As these plans have been carried out, the third "National Plan for the Prevention and Alleviation of HIV/AIDS in Thailand" (which runs between 2002 and the end of 2006), has worked towards the target of reducing HIV prevalence to less than 1% and providing access to care and support for at least 80% of the people living with HIV and other affected individuals.

By the end of 2005, national HIV prevalence was 1.4%, down from 1.8% in 2003 and more than 2% a decade earlier. 29 30

The current situation
Thailand Statistics 31
Estimated total population, July 2005 64,233,000
Estimated number of people living with HIV, end 2005 580,000
Adults (15+) 560,000
Women (15+) 220,000
Children (0-15) 16,000
Estimated adult HIV prevalence 1.4%
Estimated number of AIDS deaths in 2005 21,000

The majority of Thailand’s HIV infections (around 80%) occur through heterosexual sex. 32
HIV affects more men than women in Thailand; the male-female ratio is nearly 3:1. 33
HIV prevalence among pregnant women, which reached a peak of 2.35% in 1995, had fallen to 1.18% by 2003. 34
The distribution of antiretroviral drugs has coincided with a dramatic drop in the number of officially reported AIDS-deaths – from 5,020 in 2004 to 1,640 in 2005. 35
The Need for HIV Prevention
Thailand once led the way in world HIV prevention, with a series of successful campaigns that helped to reduce the national HIV prevalence. However, past successes seem to have lulled the government into complacency. Prevention programmes received just 8% of the national HIV/AIDS budget in 2000, and by 2001 the level of domestic funding for HIV prevention was half of what it had been in 1997. 36 In 2006, UNAIDS reported that Thailand’s government had reduced its HIV prevention budget by two-thirds in recent years. 37

This declining focus on prevention is concerning, and is putting the public at risk. There are already signs that the epidemic could grow in coming years; reports suggest that the rate of STI transmission has increased, condom use has decreased and risky sexual behaviour is on the rise. 38 39 Without new prevention campaigns, safe sex messages will be forgotten and a new generation of young people will grow up ignorant of the risks that they face.

Young people
At the launch of a new UNAIDS report in June 2006, UNAIDS Country Coordinator for Thailand Patrick Brenny stated that:

“Public information, which was once ubiquitous, has dropped off the radar screen… Thailand must revive its flagging HIV/AIDS awareness programmes to reach out to a new generation of young people, who currently see the virus as a problem largely affecting their elders. They are clearly vulnerable to infection with HIV.” 40
There have not been any mass public prevention campaigns carried out in Thailand for over a decade. This has led to a decline in awareness and possibly an increase in unsafe sexual behaviour, especially among young people who are often not old enough to remember campaigns that were carried out during the 1990s. It is thought that around 85% of Thai youth do not see HIV as something that they should be concerned about, even though 70% of all STI cases in Thailand occur among this group. 41 Premarital sex has become more common among young Thais, but only 20-30% of sexually active young people are using condoms consistently. 42

Injecting drug users
Thailand has not had a great deal of success in reducing HIV among injecting drug users. Infection rates among injecting drug users have remained extremely high, at 35-50%, and are still rising in some areas. 43 HIV spreads not only among drug users but to their partners and their children, and left unchecked the high infection rate among injecting drug users will continue to be a reservoir for HIV transmission to the rest of the population.

HIV prevention for injecting drug users and their sexual partners has not been a priority in Thailand even though this route of transmission plays a significant role in the spread of HIV. 44 In 2004 Prime Minister Thaksin told an international AIDS conference that the government saw the need to treat drug users as patients, not criminals, and proposed plans to reduce transmission among this group. However, the schemes that he outlined, which included free needle distribution and methadone treatments, have yet to emerge. Since a heavy-handed government operation to crackdown on drug trafficking in 2003, drug use has been driven underground, making it more difficult for prevention campaigns to target this group. 45

Men who have sex with men (MSM)
MSM are currently a major risk group in Thailand, accounting for about one-fifth of all HIV infections. In Bangkok (Thailand’s capital and largest city), HIV prevalence among MSM rose from 17% to 28% between 2003 and 2005. HIV prevalence among MSM younger than 21 years of age tripled in the same period. 46

It was not until February 2006 that Thailand’s first campaign to prevent HIV among MSM was initiated. The seven-month campaign, known as ‘Sex Alert’, is jointly run by US non-governmental organisation (NGO) Family Health Planning, the Minstry of Health and local NGOs. It intends to provide MSM with information on safer sex through magazine and radio adverts, text messages, posters and the Internet. Flyers, condoms and lubricant will also be distributed. 47

Before Sex Alert, MSM had generally been neglected by prevention campaigns and had not featured in national AIDS strategies. Sex Alert marks a welcome change, but it is essential that more prevention campaigns target this group to stem rising infection rates.

Migrant workers
It is estimated that there are around 2 million migrant workers living in Thailand, although only around 700,000 are registered with labour authorities. 48 A lot of these workers travel from neighbouring countries such as Cambodia and Myanmar (Burma). They form an important part of Thailand’s workforce, but the difficulties that they commonly face - such as language difficulties or fear of arrest and deportation – can prevent them from accessing information about HIV and AIDS, as well as healthcare and other social services. In general, knowledge about HIV and AIDS among this group is extremely poor. Their mobile lifestyle can put them into contact with a higher number of sexual networks than other people, increasing both the risk that they will become infected and that they will spread infection to other areas of the country. 49

It is difficult to track the exact level of HIV infection among migrant workers, and rates vary between areas. Studies have suggested that, in some areas, HIV prevalence among pregnant migrant workers is more than twice as high as the prevalence among pregnant Thai women. Female migrants, especially those drawn into commercial sex work, are particularly affected by the epidemic. 50

Sex workers
The ‘100% condom’ program, which enforced mandatory condom use in brothels, played a significant role in reducing Thailand’s HIV prevalence in the 1990s. Campaigns that reduced the demand for sex work also contributed to this decline.

The 100% condom program is still officially in place, although it does not seem to be followed as thoroughly as it once was. Sex work has become increasingly common, with a 50% increase in the total number of establishments offering sex services recorded between 1998 and 2003. The majority of these establishments are not brothels, and are therefore not reached by the 100% condom program. Women who solicit sex in ‘unofficial’ venues, such as bars and restaurants, are not thought to use condoms regularly, and it is difficult for authorities to monitor how they are being affected by the epidemic due to the hidden nature of their work. 51

A greater focus on outreach work, where HIV prevention messages are enforced through programs that gain access to networks of sex workers and encourage peer-education, would be one way to ensure that infection rates do not rise among sex workers that work outside brothels.

Treatment for people living with HIV
Since 2000, the government has provided HAART to people living with HIV through more than 914 public hospitals. 52 Initially, branded drugs were mostly used, but an increase in the production of cheap generic drugs within Thailand has allowed the government to obtain the medicines at much lower prices. The use of generic drugs led to more than an eight-fold expansion in treatment provision between 2001 and 2003, with only a 40% increase in budget. 53 The national treatment campaign was further boosted by a US$209 million grant from the Global Fund to Fight AIDS, TB and Malaria, most of which is being used to support the provision of ARVs. By the end of 2005, 60% of those requiring ARVs were receiving them. 54

Recently, however, Thailand’s treatment program – in particular the use of generic drugs – has come under threat from international pressures. The US has encouraged Thailand to sign a bilateral trade agreement, which would reduce its ability to produce generic versions of patented drugs. This agreement, the US claims, would give drug companies more incentive to develop new, better drugs, and to sell them to Thailand. Yet many people are concerned that the greater cost of branded ARVs will lead to a situation where far fewer people will have access to treatment.

“"We fear that if the Thai government accepts the US proposal, doctors in Thailand will face substantial obstacles in providing treatment to their patients living with HIV/AIDS, especially for those that require newer antiretroviral (ARV) medicines to survive."
- Paul Cawthorne, Medecins Sans Frontiers, Head of Mission in Thailand - 55
The US government has succeeded in establishing similar agreements with other developing countries. In taking this approach, it seems to be putting the rights of patent-holders ahead of public health concerns. They argue that, by relying on generic drugs, developing countries reduce companies’ motivation to develop new treatment. Others claim that this argument is flawed, because companies that develop new drugs will still make vast profits in developed countries where patent laws are much stricter. 56

The way forward
Along with countries such as Brazil and Haiti, Thailand has shown the world that it is possible for a developing country to form an effective response to HIV and AIDS. For all its successes, though, Thailand’s epidemic has never eased off in certain regions and among certain groups. With a serious shortage of HIV prevention programs being carried out, there is a widespread fear that Thailand will witness a resurgence of HIV and AIDS in coming years.

"There are some very clear warning signals that the epidemic is on the move… you now have a recipe for a resurgence of HIV.”
- Hakan Bjorkman, UNAIDS -57
The government of Thailand needs to increase prevention efforts, especially among high-risk groups such as men who have sex with men and injecting drug users, but also among the general population.

With Prime Minister Thaksin recently overthrown by a non-violent military coup, Thailand’s political direction is changing. It is likely that the new government will bring changes to HIV prevention, but whether the situation will improve or decline is yet to be seen. If fast, effective action is taken, thousands of deaths could be prevented; otherwise, Thailand’s past achievements will soon be forgotten:

"There is still an opportunity to prevent resurgence, to nip it in the bud, but to do that the government has to focus on prevention, and that isn't happening."
- Swarup Sarkar, UNAIDS - 58
Written by Annabel Kanabus & Jenni Fredriksson. Updated by Graham Pembrey.

References
UNDP (2004), 'Thailand's Response to HIV/AIDS'
Ibid.
UNAIDS/WHO 2006 Report on the global AIDS epidemic
International Herald Tribune (November 2005), ‘Thailand faces new AIDS threat’
Phanuphak P, Locharernkul C, Panmuong W., Wilde H. (1985) 'A report of three cases of AIDS in Thailand', Asian Pac J Allergy Immunol 3:195-199
Porapakkham Y., Pramarnpol S. et al. (1995), The Evolution of HIV/AIDS Policy in Thailand: 1984-1994
Ibid.
Weniger B.G. et al (1991) 'The epidemiology of HIV infection and AIDS in Thailand', AIDS, 5 (suppl 2): S71-S85
Viravaidya M. et al (1993) 'The economic impact of AIDS on Thailand' in 'Economic Implications of AIDS in Asia' edited by Bloom D.E. and Lyons J.V., p.9
World Bank (1997) 'Confronting AIDS: public priorities in a global epidemic', Oxford University Press, p.275-276
Telegraph Magazine (8th August 1992), 'Terror in the land of smiles'
World Bank (1997) 'Confronting AIDS: public priorities in a global epidemic', Oxford University Press, p.276
Owens C. (1991) 'Alarming spread of AIDS virus in Thailand may threaten country's recent economic gains', Asian Wall Street Journal Vol.13, no.51, P.4
Garbo J. (2000) 'Southeast Asia's urgent Call for HIV Prevention', Gayhealth, December 15
World Bank (1997) 'Confronting AIDS: public priorities in a global epidemic', Oxford University Press, p.276
Hanenberg R.S., Rojanapithayakorn W., Kunasol P. Sokal D.C.(1994) 'Impact of Thailand HIV-control programme as indicated by the decline of sexually transmitted diseases', the Lancet 344:243-245
UNAIDS, 2006 Report on the Global AIDS Epidemic
UNDP (2004), ‘Thailand's Response to HIV/AIDS’
World Bank (2000) 'Thailand's Response to AIDS: Building on Success, Confronting the Future', Thailand Social Monitor V, p.10
Morse A. (2002) '20 years and still fighting', abcnews.com, July 13
WHO (1995) '1992-1993 Progress Report Global programme on AIDS', Geneva
World Bank (2000) 'Thailand's Response to AIDS: Building on Success, Confronting the Future', Thailand social Monitor V, p.10-11
Shaffer N. et al (1999) 'Short-course zidovudine for perinatal HIV-1 transmission in Bangkok, Thailand: a randomised controlled trial', The Lancet, Vol.353, March 6
Thaineua V. et al (1998) 'From research to practice: use of short course zidovudine to prevent mother -to -child HIV transmission in the context of routine health care in Northern Thailand', Southeast Asian J Trop Med Public Health, 29:429-442
Kanshana S. et al. (2000) 'Implementing short-course zidovudine to reduce mother-infant HIV transmission in a large pilot program in Thailand', AIDS, 14:1617-1623
Kanshana S. and Simonds R.J. (2002) 'National program for preventing mother-child HIB transmission in Thailand: successful implementation and lessons learned', AIDS, 16:953-959
Pothisiri P. et al. (1998) 'Funding priorities for HIV/AIDS crisis in Thailand', 12th World AIDS Conference, Geneva, Switzerland, June
UNDP (2004), ‘Thailand's Response to HIV/AIDS’
UNAIDS, 2006 Report on the Global AIDS Epidemic
International Herald Tribune (November 2005), ‘Thailand faces new AIDS threat’
UNAIDS, 2006 Report on the Global AIDS Epidemic
USAID, USAID's HIV/AIDS program in Thailand, April 2005
UNAIDS website, country pages, Thailand
Ibid.
UNAIDS, 2006 Report on the Global AIDS Epidemic
UNDP (2004), ‘Thailand's Response to HIV/AIDS’
UNAIDS, 2006 Report on the Global AIDS Epidemic
The Nation (May 2006), ‘HIV prevention forgotten, 'now verging on crisis'’
Medical News Today (May 2006), ‘Thailand's HIV/AIDS Prevention Program Absent, Endangering Country, Advocates Say’
IRINnews (May 2006), ‘Increased HIV/AIDS awareness needed – UNAIDS’
Ibid.
UNAIDS, 2006 Report on the Global AIDS Epidemic
UNDP (2004), ‘Thailand's Response to HIV/AIDS’
UNDP (2004), ‘Thailand's Response to HIV/AIDS’
Human Rights Watch (2004), ’Not enough graves: the war on drugs, HIV/AIDS, and violations of human rights’, Vol. 16 No. 8 (C)
Ibid,
The Nation (February 2006), ‘Anti-AIDS campaign to focus on gay men’
The Nation (May 2006), ‘HIV prevention forgotten, 'now verging on crisis'’
UNDP (2004), ‘Thailand's Response to HIV/AIDS’
Ibid.
Ibid.
Ford N. (2004), 'The role of civil society in protecting public health over commercial interest: lessons from Thailand', The Lancet, Vol. 363, 14 February
Ibid.
UNAIDS/WHO (2006), Progress on Global Access to HIV Antiretroviral Therapy, March 2006
Medecins Sans Frontiers press release (January 11th 2006), US-Thailand Free Trade Agreement: MSF Calls on Thailand to Protect Access to Medicines in the Face of US Pressure
Oxfam briefing paper (April 2006), ‘Public health at risk: A US free trade agreement could threaten access to medicines in Thailand’
International Herald Tribune (November 2005), ‘Thailand faces new AIDS threat’
Ibid.
Last updated October 16, 2006

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