Visuals from the AIDS 2004 conference, Bangkok
HIV: The Thai response
Thailand is held up as a beacon of hope, a model of a successful comprehensive national response to HIV. How did Thailand achieve such a dramatic turnaround and what challenges does it face now?
In the early 1990s thing were very different. Thailand stood on the threshold of a HIV infection disaster with 143,000 new infections in 1991 alone out of a population of approximately 60m.
HIV was first reported in Thailand in 1984. In 1988/89 the infection rate exploded among injecting drug users (IDUs) (from nil to 40% in one year) and among sex workers (44% recorded in Chang Mai province in 1989).
In the late 1980s the Thai government marginalised the issue. It was thought that HIV was confined to high risk groups and would not spread to the rest of the population. According only US$180,000 was spent on HIV prevention in 1988 and no national response was deemed necessary.
HIV was first reported in Thailand in 1984. In 1988/89 the infection rate exploded among injecting drug users (IDUs) (from nil to 40% in one year) and among sex workers (44% recorded in Chang Mai province in 1989).
In the late 1980s the Thai government marginalised the issue. It was thought that HIV was confined to high risk groups and would not spread to the rest of the population. According only US$180,000 was spent on HIV prevention in 1988 and no national response was deemed necessary.
Three crucial steps
At this moment Thailand stood at the crossroads and chose a course of immediate and decisive action.
In 1991 three crucial steps were taken by the new Thai government to push back the tide of HIV:
1) Responsibility for HIV control was moved from the Ministry of Public Health to the more important Office of the Prime Minister with an associated jump in political priority and funding, which reached US$44m in 1993.
2) A national education campaign was launched with the full support of the government. HIV and safe sex education was introduced into all schools, broadcast continuously on the numerous government radio and TV channels and displayed on posters and billboards. Although stigma surrounded HIV and AIDS, public discussion on sex and sexual health became more open and objective.
3) All workers in commercial sex establishments were required to use condoms at all times and such establishments could be shut down for a failure to comply. This became known as the '100% Condom Program'. Condoms were freely distributed to these establishments. Acknowledgement of and engagement with the commercial sex industry was crucial to the success of this program.
An important feature of the response was the rapid scaling up of localised and narrowly focussed programs into national initiatives. During 1996 government funding for HIV prevention had jumped to US$80m per year.
By taking the issue of HIV out of the public health arena and placing centre stage the Thai government paved the way to integrate every aspect of Thai society into the response.
Everyone from prostitutes to monks to the army was involved in spreading the word about how to prevent HIV infection.
Between 1997 and 2001 more resources began being channelled into helping communities and people living with HIV. In particular large scale provision of antiretroviral drugs was commenced and treatments to prevent mother to child transmission.
By the end of 2005 it was estimated that 80,000 people living with HIV were receiving antiretroviral treatment.
In 1991 three crucial steps were taken by the new Thai government to push back the tide of HIV:
1) Responsibility for HIV control was moved from the Ministry of Public Health to the more important Office of the Prime Minister with an associated jump in political priority and funding, which reached US$44m in 1993.
2) A national education campaign was launched with the full support of the government. HIV and safe sex education was introduced into all schools, broadcast continuously on the numerous government radio and TV channels and displayed on posters and billboards. Although stigma surrounded HIV and AIDS, public discussion on sex and sexual health became more open and objective.
3) All workers in commercial sex establishments were required to use condoms at all times and such establishments could be shut down for a failure to comply. This became known as the '100% Condom Program'. Condoms were freely distributed to these establishments. Acknowledgement of and engagement with the commercial sex industry was crucial to the success of this program.
An important feature of the response was the rapid scaling up of localised and narrowly focussed programs into national initiatives. During 1996 government funding for HIV prevention had jumped to US$80m per year.
By taking the issue of HIV out of the public health arena and placing centre stage the Thai government paved the way to integrate every aspect of Thai society into the response.
Everyone from prostitutes to monks to the army was involved in spreading the word about how to prevent HIV infection.
Between 1997 and 2001 more resources began being channelled into helping communities and people living with HIV. In particular large scale provision of antiretroviral drugs was commenced and treatments to prevent mother to child transmission.
By the end of 2005 it was estimated that 80,000 people living with HIV were receiving antiretroviral treatment.
Results?
So, what was achieved by this response? The numbers speak for themselves:
- New infections fell from 143,000 in 1991 to 17,000 in 2004.
- Estimated that 5.7m new infections have been averted.
- Infection rate among sex workers fell from 50% in 1991 to 20% in 2001.
- Infection rate among pregnant women fell from 2.3% in 1995 to 1% in 2004.
Dangers
Despite the enormous steps taken by Thailand, there is a threat that the HIV epidemic will rebound.
The danger signs are growing:
The danger signs are growing:
- The annual rate of new infections is not declining as rapidly as in the 1990s.
- The rate of transmission from the infected male clients of sex workers and from infected IDUs to their regular partners has not been significantly reduced. In 2005 it was estimated that a third to a half of all new infections were of women in stable relationships.
- Support for the 100% condom program seems to have faltered. Free condom distribution to sex workers has reduced. More indirect commercial sex is occurring outside of known establishments resulting in less testing and support for indirect sex workers and lower condom usage.
- Increased infection rates among at risk minority groups such as IDUs (30% to 50%), men having sex with men (17.3% in Bangkok in 2003), immigrants and prisoners.
- Increased infection rates of certain sexually transmitted infections as a result of closing or relocating certain treatment clinics available to sex workers.
- Young people are having sex earlier and more frequently and condom use remains low. HIV infection rose from 11% to 17% among Thai teenagers in 2002. The government intends to increase free condom distribution, however resistance has arise among local authorities which believe that this will promote promiscuity.
The future
On a positive note, the Global Fund for Aids, TB and Malaria has committed US$192m for HIV care and prevention activities in Thailand over 5 years (2003 – 2007).
Thailand has created a sense of hope that the focussed combination of leadership, science, community and resources can overcome the HIV epidemic. However it also provides stark warning that if such successful programs are not rigorously pursued and adapted to changing challenges, HIV can and will reassert itself and devastate lives and communities.
The next few years will show whether Thailand tackles its new challenges and continues to lead the way in responding to HIV.
Thailand has created a sense of hope that the focussed combination of leadership, science, community and resources can overcome the HIV epidemic. However it also provides stark warning that if such successful programs are not rigorously pursued and adapted to changing challenges, HIV can and will reassert itself and devastate lives and communities.
The next few years will show whether Thailand tackles its new challenges and continues to lead the way in responding to HIV.
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