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HIV & AIDS in Thailand
Thailand is an example of a developing country where public policy has been effective in preventing the transmission of HIV on a national scale. In the 1990s, a massive programme that began to control HIV reduced visits to commercial sex workers by half, raised condom usage, achieved substantial reductions in new HIV infections, and decreased the prevalence of STDs ( Sexually Transmitted Diseases) dramatically. 1
Thailand, though, is also a reminder that success can be relative. The country's 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 9,700 in 2011. 2 3 Nonetheless, 490,000 people in Thailand are living with HIV, and 23,000 people died from AIDS-related illnesses in 2011. 4
Unless past efforts are sustained and new sources of infection are addressed, the striking achievements made in controlling the epidemic could be put at risk. Factors such as an increase in high-risk sexual behaviour among young people, including inconsistent condom use, 5 have led to concerns that Thailand could face a resurgence of HIV and AIDS in coming years.
|Thailand Statistics 6|
|Estimated total population, July 2013 7||67,448,120|
|Estimated number of people living with HIV, end 2011||490,000|
|Adults aged 15 and over living with HIV, end 2011||480,000|
|Women aged 15 and over living with HIV, end 2011||200,000|
|Estimated adult (15-49) HIV prevalence, end 2011||1.0%|
|Estimated number of AIDS deaths in 2011||23,000|
- The majority of Thailand’s HIV infections occur through unsafe sex, particularly among at-risk groups such as men who have sex with men (MSM), female sex workers (FSWs) and their clients, and injecting drug users (IDUs). 8
- Antiretroviral treatment (ART) access among pregnant women attending antenatal clinics has consistently been above 90 percent for the last six years. This has substantially reduced mother-to-child transmission of HIV as a significantly transmission route. 9
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 percent of the national HIV/AIDS budget in 2000, and this has increased to only 13 percent in 2011. 10 11 Currently, 82 percent of the national HIV/AIDS budget is from domestic sources, but most of this is spent on treatment rather than prevention. 12
There are concerns that the limited focus on prevention is putting the public at risk. It is suggested that the major reasons for HIV transmission today include declining HIV knowledge, an increase in multiple partners and inconsistent condom use. 13 14 15 Without new prevention campaigns, there is a risk that safe sex messages are being forgotten and a new generation of young people are growing up unaware of the risks they face.
The National AIDS Strategic Plan for 2012-2016, ‘AIDS Zero’, has two major strands: boost HIV prevention initiatives especially amongst at-risk groups; and maintain the initiatives which are already working well such as PMTCT. 16 ‘AIDS Zero’ prioritises the creation of an HIV prevention fund, with the goal of generating the funds domestically. 17
- decreases in HIV knowledge
- more people with multiple sex partners
- lower consistent condom use.
Most teenagers and young adults may 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.” 18
The highest number of STIs and unwanted pregnancies are among 15-24 year olds, suggesting safe sex messages are not reaching this age group. 19 Premarital sex has become more common among Thai youths, but only 20-30 percent of sexually active young people are using condoms consistently. 20 Parental consent is also needed for voluntary counselling and testing (VCT) if a young person is under 18 years of age; reducing the confidential nature of an HIV test. 21
In an attempt to address these issues, a television campaign was launched in 2007, funded partly by a grant from the Global Fund. 22 The advertisements promoted 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. 23
Injecting drug users
- HIV prevalence among IDUs is 22 percent
- HIV prevalence among people who inject heroin and/or opium is as high as 30-50 percent
- Condom use at last sex is only 46 percent
Since a strong government operation to crackdown on drug trafficking in 2003, drug use has been driven underground and users branded as ‘criminals’, making it more difficult for prevention campaigns to target this group. 26
To address this, projects like CHAMPION-IDU are using the concept of peer educators (PEs) to access these hard to reach people. The role of the PEs is to inform and educate IDUs on HIV prevention, and help them to access HIV and harm reduction services. 27 28
The National AIDS Committee approved a harm reduction policy in 2010, and the 2012-2016 National AIDS Plan commits to its implementation, with support from NGOs and projects such as CHAMPION-IDU. 29 It is hoped that policies like this will override the hard line stance on drug users and stop them from being marginalised from HIV services.
Men who have sex with men (MSM)
- HIV prevalence was 20 percent in 2010 (Bangkok, Phuket and Chiang Mai)
- HIV prevalence was 31.3 percent in 2010, in the capital Bangkok
- 41 percent of HIV infections in Thailand are transmitted via MSM 30
Men who have sex with men are currently a major risk group in Thailand. A study published in 2013 described the HIV prevalence among MSM in Bangkok as an 'explosive epidemic'. 31 HIV prevalence is highest in the large tourist cities like Bangkok, Phuket and Chiang Mai but even in remote provinces, MSM have a far higher rate of HIV infection compared to the general population. HIV prevalence among transgender people in Thailand is much lower at 10 percent. 32
The Rainbow Sky Association of Thailand is the country's first gay organisation and coordinates the largest network of MSM peer educators in Thailand. 33 Apart from establishing local community centres for men who have sex with men across the country where MSM can meet and socialize, the Rainbow Sky Association trains mentors who provide prevention programmes targeted at other MSM in their communities.
- 5 million migrant workers live in Thailand. 34
- HIV prevalence among migrants from: Cambodia (2.15 percent), Myanmar (1.16 percent), Lao PDR (0.51 percent)
Migrants form an important part of Thailand’s workforce, but the difficulties that they commonly face - such as language difficulties, exploitative working conditions, and frequent migration– can prevent them from accessing information about HIV and AIDS, and healthcare. Knowledge about HIV and AIDS among this group is extremely poor. 35
Migrants are also more likely to pay for sex and have multiple non-regular partners which increases both the risk that they will become infected and that they will spread infection to other areas of the country. 36
The Thai government has recognised the issues faced by this at-risk group and in the National AIDS Plan for 2012-2016, have stated that antiretroviral drugs will be available to all people living in Thailand, irrespective of nationality. A memorandum has also been signed by six neighbouring nations to collaborate on 'Reducing HIV Vulnerability Associated with Population Movement'. 37
- 1.8 percent of venue based female sex workers (FSWs) are living with HIV 38
- HIV prevalence among non-venue based sex workers is very difficult to monitor
- Sex work is illegal in Thailand, but there are still thousands of commercial sex establishments (CSEs)
According to the most recent study of its kind, in Bangkok in 2007, HIV prevalence among freelance sex workers in Bangkok was 19 percent whereas HIV prevalence had declined to 4.3 percent in CSEs in that year. 39 This shows the vast difference in access to HIV information and condoms between venue- and non-venue-based sex workers.
In 2010, it was found that among venue-based sex workers, only 50 percent had an HIV test in the last year and know their results, and only 57 percent were reached with HIV prevention programmes. 40 The illegal nature of sex work and CSEs makes it difficult for HIV prevention workers to distribute knowledge and condoms among this at-risk group. However it was found that 96 percent were using a condom with their most recent client, 41 perhaps a result of the ‘100% condom’ programme, which began enforcing mandatory condom use in all CSEs in the 1990s.
Continued progress has been made in HIV prevention work for FSWs as of 2011: there are now 185 STI/HIV clinics; 42 UNFPA’s Comprehensive Condom Programming (CCP) project has been implemented; 43 and organisations such as SWING are advocating for the rights of male, female and transgender sex workers. 44
Treatment for people living with HIV
- 71 percent of people in need of treatment are receiving it, 2011 45
- 97 percent of whom are adults, 3 percent are children 46
- 90 percent of people’s ART is paid for by governmental health security schemes 47
Thailand follows the World Health Organisation (WHO) guidelines of initiating antiretroviral drugs (ARVs) at CD4 levels of <350 cells/mm3, rather than the previous 200 cells/mm3, and the phasing out of stavudine (d4T). Therefore a larger treatment budget has been needed since 2010, reflected in the fact that 74 percent of the domestically generated HIV/AIDS budget is spent on treatment.
Producing cheap generic drugs within Thailand has allowed the government to obtain certain ARVs at much lower prices. In November 2006, the new 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. 48 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, to the dismay of pharmaceutical companies. 49 50 In August 2010, the Public Health Ministry re-extended compulsory licensing for Efavirenz and Kaletra until their patents expire 51 (August 2013 for Efavirenz and December 2016 for Kaletra). 52
The Thai government faces some challenges in reaching the universal access target of 80 percent of all people eligible for treatment receiving it. Currently, 60 percent of people testing positive for HIV already have CD4 levels as low as 100 cells/mm3. 53 The government has therefore prioritised improving the promotion and quality of VCT, and the administration of ARVs immediately. 54 Allocating extra time and money for the provision of ARVs for migrant workers in the coming years will be another challenge.
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 heavily 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 STD transmission and high-risk sexual behaviour, especially among young people, means there is now a fear that the country will witness a second wave of the epidemic. 55
Thailand's national strategic HIV and AIDS plan for 2012-2016 shows its commitment to increasing prevention efforts. If fast, effective action is taken, Thailand will see a drop in new infections; otherwise, Thailand’s past achievements will not make a lasting impact.
The history of HIV and AIDS in Thailand
- The first case of AIDS in Thailand occurred in 1984. 56
- For the next few years, gay men, sex workers, injecting drug users and tourists were more commonly affected than other groups.
- Government response was aimed at high-risk groups, as they believed that there was not yet sufficient reason to carry out prevention campaigns among the general public. 57
- 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. 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. 58
- Between 1988 and 1989, the HIV prevalence among injecting drug users rose dramatically from almost zero to 40 percent.
- The prevalence among sex workers also increased, with studies in Chang Mai suggesting that 44 percent of sex workers were infected with HIV. 59 60
- 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.
- Some members of Thailand’s parliament proposed that all foreigners should be required to pass an HIV test before being admitted to the country. 61
- New Prime Minister, Anand Panyarachun came to power in 1991, and HIV prevention and control became a national priority at the highest level.
- The budget increased almost 20-fold to $44 million in 1993. 62
- 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 '100 percent condom programme' was initiated. 63 This programme aimed to enforce consistent condom use in all commercial sex establishments. Without this programme, it is estimated that Thailand’s national HIV prevalence would be ten times higher than it currently is. 64
- 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. 65
- From 1992 to 1996, the National AIDS programme received dramatic increases in funding; the government provided it with more than $80 million annually by 1996.
- Between 1996 and 1997, a randomised controlled trial was carried out in Bangkok, showing that AZT reduced transmission of HIV from mother to child by 50 percent. 66 67 68 By 1999, AZT was being used in most hospitals in Thailand. 69
- 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. By 2000, domestic funding for HIV and AIDS prevention was roughly one quarter less than it had been in 1997. 70
- In 2000, combinations of ARVs started to be used to treat people living with HIV in Thailand.
- 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. 71
- A year later the government set targets to improve treatment access. 72 The third 'National Plan for the Prevention and Alleviation of HIV/AIDS in Thailand' (which ran between 2002 and the end of 2006), worked towards the target of reducing HIV prevalence to less than 1 percent and providing access to care and support for at least 80 percent of the people living with HIV and other affected individuals.
- By the end of 2007, national HIV prevalence was 1.4 percent, down from 1.8 percent in 2003 and more than 2 percent a decade earlier. 73 74
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