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 and 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 history of HIV and AIDS in Thailand

Early responses

The first case of AIDS in Thailand occurred in 1984.⁴ 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.⁵

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. ⁶

Between 1988 and 1989, the HIV prevalence among injecting drug users rose dramatically from almost zero to 40%. The prevalence among sex workers also increased, with studies in Chang Mai suggesting that 44% of sex workers were infected with HIV.⁷ 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.⁸

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.”⁹

Some members of Thailand’s parliament proposed that all foreigners should be required to pass an HIV test before being admitted to the country.¹⁰ In keeping with the view that the threat was limited, the government only spent $180,000 on HIV prevention in 1988.¹¹

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 programme was moved from the Ministry of Public Health to the Office of the Prime Minister, which increased its political influence. The budget increased almost 20-fold to $44 million in 1993.¹²

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.

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.¹³

Thirdly, and perhaps most importantly, the '100 percent condom program' was initiated.¹⁴ This programme 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.¹⁵

“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.”¹⁶

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.¹⁷

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.

The second ‘National Plan for Prevention and Alleviation of the AIDS Problem’, which covered the period from 1997 to 2001, maintained the previous effective programmes, whilst adopting a more holistic approach, which included mobilizing the efforts of communities and people living with HIV/AIDS.¹⁸

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%.¹⁹ Following this, a number of pilot programs were initiated in Thailand.^{20 21} 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.²²

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.²³ By 2000, domestic funding for HIV and AIDS prevention was roughly one quarter less than it had been in 1997.²⁴

2000 onwards

In 2000, combinations of antiretroviral drugs (ARVs) started to be used to treat people living with HIV in Thailand. This therapy, sometimes known as HAART (Highly Active Antiretroviral Therapy), can prolong the lives of people living with HIV and delay the virus from progressing to AIDS. In subsequent years the number of people accessing ARVs increased dramatically, significantly reducing the number of people dying from AIDS. In 2000 the government also started a national system to monitor its mother-to-child transmission of HIV programme.²⁵

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 2007, national HIV prevalence was 1.4%, down from 1.8% in 2003 and more than 2% a decade earlier.^{26 27}

The current situation

Thailand Statistics28
Estimated total population, 2008	65,493,000
Estimated number of people living with HIV, end 2007	610,000
Adults (15+)	600,000
Women (15+)	250,000
Children (0-15)	14,000
Estimated adult HIV prevalence	1.4%
Estimated number of AIDS deaths in 2007	31,000

• The majority of Thailand’s HIV infections (around 80%) occur through heterosexual sex.²⁹
• HIV affects more men than women in Thailand; the male-female ratio is 7:5.³⁰
• HIV prevalence among pregnant women, which reached a peak of 3.4% in 1992, had fallen to 0.87% by 2006.³¹
• An estimated 1 in 5 new HIV infections in Thailand are attributable to unprotected sex between men.³²

HIV prevention and affected groups

Thailand once led the way in world HIV prevention, with a series of successful campaigns that helped to reduce the national HIV prevalence. However, in the new millennium there were signs of 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 1997.³³ In 2006, UNAIDS reported that Thailand’s government had reduced its HIV prevention budget by two-thirds.³⁴

There were concerns that the declining focus on prevention was putting the public at risk. Reports suggested that condom use had decreased and the rate of STI transmission had risen.^{35 36} Without new prevention campaigns, there was a risk that safe sex messages would be forgotten and a new generation of young people would grow up ignorant of the risks they face.

In September 2006 following a military coup, a new Thai government was installed. In light of the concerns about a resurgence of the epidemic, the new government decided to increase HIV/AIDS prevention efforts. In 2007 a three-year strategic plan was announced, which would focus on those most at risk of HIV infection, and difficult-to-reach groups.³⁷

Young people

Young people have become one of the main risk groups for HIV in Thailand. Most teenagers and young adults will probably not remember the prevention campaigns that were carried out during the 1990s and therefore will be unaware of the risk of unsafe sexual behaviour. 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.”³⁸

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.³⁹ Premarital sex has become more common among young Thais, but only 20-30% of sexually active young people are using condoms consistently.⁴⁰

In an attempt to address these issues, a television campaign was launched in 2007, funded partly by a grant from the Global Fund.⁴¹ The advertisements promote condom use among adults and teenagers. However the campaign was not well received by everyone, with some arguing that it damaged Thai culture and encouraged sexual activity among teenagers.⁴²

Thailand’s ‘Condom King’, Mechai Viravaidya – so-called due to his extensive work promoting accessible contraceptives over the past 30 years – is also promoting a new campaign aimed at Thailand’s teenage population. With slogans such as ‘if you still want to fly before your time, have a parachute’, Viravaidya hopes to target those who may have missed out on the extensive HIV/AIDS awareness campaign in the 1990s.⁴³

Injecting drug users

Injecting drug users (IDUs) were among the first groups identified as being at high risk of HIV infection. It is estimated that within the first few years of Thailand's epidemic, the HIV prevalence among IDUs rose from 0 to 40 percent.⁴⁴ Today a large number of people inject drugs in Thailand – it is thought around 100,000 to 275,000 use heroin, 80 percent of whom inject.⁴⁵

HIV spreads not only among drug users but also to their partners and their children. Left unchecked the high infection rate among IDUs will continue to be a reservoir from which HIV is transmitted to the rest of the population.

Thailand has not had a great deal of success in reducing HIV infections among IDUs. Despite evidence that harm reduction measures can effectively lower transmission, the government have failed to adopt such strategies and infection rates remain extremely high, at 35-50%.⁴⁶ 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.⁴⁷

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, in 2006 a study found no improvement – only 2-3 percent of male IDUs in Bangkok and Chiang Mai were accessing condom and behaviour change programmes.⁴⁸

Thailand's 2007-2011 national AIDS plan, which was introduced under the new government, commits to ensuring sufficient access to HIV prevention, treatment and care for IDUs.⁴⁹

Men who have sex with men (MSM)

Men who have sex with men 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.⁵⁰

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 Ministry 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.⁵¹

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.⁵² 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.⁵³

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.⁵⁴

Sex workers

The ‘100% condom’ programme, 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.⁵⁵

A greater focus on outreach work, where HIV prevention messages are enforced through programmes 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.

AVERT.org has more about HIV prevention and sex workers.

Treatment for people living with HIV

Since 2000, the government has provided antiretroviral drugs (ARVs) to people living with HIV through more than 914 public hospitals.⁵⁶ 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.⁵⁷ 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 2006, around 88% of those requiring ARVs were receiving them,⁵⁸ although recent UNAIDS figures suggest this could be as low as 60%.⁵⁹

Despite these successes, the increased access to ARVs has brought with it a rising number of people who are becoming resistant to the drugs, or for whom treatment has stopped working. People in this situation require ‘second-line’ drug regimens. Since second-line ARVs are much more expensive than first-line drugs, and are not as widely available, they are not provided through Thailand’s national AIDS programme. Those in need have had to pay up to 18,000 baht (US$480) a month to get this treatment privately.⁶⁰ Most Thais requiring treatment simply cannot afford this.

In the face of this crisis, a World Bank report in late 2006 suggested that the Thai government should perhaps do what AIDS activists had long been calling for – issue a ‘compulsory license’ to produce generic versions of patented second line ARVs, without the consent of the companies that developed them. This is legal under the international TRIPS agreement, when a government declares it to be a public health emergency:

“Because the drugs used in second-line therapy are patented, produced and sold by multinational pharmaceutical corporations, Thailand must either pay high prices demanded by those monopolies or exercise its rights under World Trade Organization (WTO) treaties to grant compulsory license for the manufacture of the drug.”World Bank ⁶¹

In November 2006, the newly installed Thai government decided to issue a compulsory license for the ARV efavirenz. The patent owner, Merck, was already selling this drug for a non-profit price of 1,400 baht per month, but by producing generic versions of the drug, the government could offer it to patients for half of this price.⁶² The government followed this by announcing in February 2007 that it would also break the patent on the drug Kaletra, and that more compulsory licenses would follow.⁶³

Most developing countries have hesitated to break patents on AIDS drugs, for fear of trade repercussions, so the Thai government’s decision was a brave move, and has been widely applauded by activists and AIDS organisations. The pharmaceutical industry, on the other hand, has generally condemned the move. The drug manufacturer Abbott, which produces Kaletra, announced that it would cancel applications to sell seven of its drugs in Thailand as a result of the government’s actions. One of these products, a new formulation of Kaletra, would have been extremely useful in Thailand, as it is heat resistant.⁶⁴

Thailand is no stranger to disputes with pharmaceutical companies over AIDS drugs. The previous government faced pressure from the United States government to sign a bilateral trade agreement, which would have limited the production of generic drugs in favour of branded ones.⁶⁵ In February 2006 it also faced attempts by pharmaceutical giant GlaxoSmithKline to patent Combid, an ARV which is derived from combinations of existing drugs. The company eventually backed down, after pressure from activists who argued that the medication does not warrant a patent, because combinations of existing drugs do not constitute a new invention.⁶⁶

It is thought that the government's decision to issue compulsory licenses for ARVs will save them substantial amounts of money, and many lives. The compulsory license for Kaletra alone is predicted to save Thailand as much as US$24 million a year.⁶⁷ It is yet to be seen what the long-term effects of the government’s decision to break patents will be, but many involved in the global fight against AIDS support the move, and see it as evidence of the government’s commitment to tackling the AIDS crisis.

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, there are still certain regions and groups badly affected by the epidemic.

The government's complacency during the first half of the millennium and subsequent shortage of prevention programmes is thought to have contributed to a lack of awareness of HIV and AIDS. A rise in STI transmission and high-risk sexual behaviour means there is now a fear that the country will witness a second wave of the epidemic.

"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 ⁶⁸

Thailand's national strategic HIV and AIDS plan for 2007-2011 shows its commitment to increasing prevention efforts. If fast, effective action is taken, thousands of deaths could be prevented; otherwise, Thailand’s past achievements will soon be forgotten.

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