Of Thailand’s population of over 60 million, it is estimated that 440,000 people were living with HIV and that 18,000 people died of AIDS-related illnesses in 2013.1 After sub-Saharan Africa, Asia and the Pacific is the region with the largest number of people living with HIV, with Thailand accounting for approximately 9%.2
Thailand has had significant success with HIV prevention. A study has shown that nearly 10 million people avoided HIV transmission because of early intervention programmes with key affected populations between 1990 and 2010.3 Between 2005 and 2013, a 56% decline in AIDS-related deaths was reported.2
However, the rate of decline is slowing down and the prevalence of HIV in key affected populations is still much higher than in the general population. Access to prevention services has improved and safer behaviours are practiced more consistently; but these need to increase significantly to reduce the rate of new infections.4
Key affected populations in Thailand
Men who have sex with men (MSM) and HIV
Data suggests that 90% of new adult HIV infections in Thailand are transmitted via unprotected sex. Of all new infections, 41% were among men who have sex with men (MSM), male sex workers (MSW), and transgender people, making this population a priority for prevention work.4
Prevention and treatment programmes in Thailand have to factor in huge geographical variations in prevalence among MSM. For example in Bangkok, HIV prevalence was 24.4% compared to the national HIV prevalence of 7% for this population across all of Thailand.2
The coverage of prevention services has improved for men who have sex with men, but is still insufficient and new infections have not declined as much as intended.4
Prevention programmes also haven’t reached as many young MSM (compared to older MSM) meaning they are less likely to know where to obtain an HIV a test, or understand their risk.5 Even when HIV prevention is good and people are aware of the risks, there’s often a low risk perception among young men who have sex with men. This, alongside multi-partner sex fuelled by performance enhancing drugs, can result in low condom use.2
Sex workers and HIV
In Thailand, HIV prevalence is far greater among male sex workers than female. Between 2009 and 2013, of an estimated 123,530 sex workers in Thailand, HIV prevalence was approximately 12% for male sex workers (MSW), but only 3% for female sex workers (FSW).2
However, data suggests that of all new HIV infections in Thailand, 12% were in female sex workers and their clients.4
Urban settings have shown to yield exceptionally high HIV prevalence among FSW, such as 20% in Bangkok.6 However female sex workers who are based at a specific venue are less at risk that FSW who see clients in public spaces. HIV prevalence among venue-based female sex workers has declined from 2.7% in 2010 to 2.2% in 2012.
Globally, transgender people are the most at-risk group of sex workers, with HIV prevalence estimated to be on average nine times higher than for female sex workers and three times higher than for male sex workers.2
Transgender people and HIV
In Bangkok, Chiang Mai and Phuket, it was estimated that HIV prevalence among transgender people was 10.4% in 2010, making them a particularly at-risk population.7
There are a number of reasons transgender men and women are being left behind in prevention and treatment work, including family rejection. One study has shown that 21% of Thai transgender women reported paternal rejection when transitioning.8 Other reasons this population is so heavily affected are discriminatory heath systems, transphobia and a lack of access to education and employment. These discourage transgender people from seeking HIV services.
A large proportion of transgender people also sell sex making them increasingly vulnerable to HIV.2
People who inject drugs (PWID) and HIV
HIV can spread rapidly among people who inject drugs and prevalence is highest in this group compared to all other key affected populations in Thailand, with numbers continuing to increase.4
This is largely because harm reduction services for PWID, such as needle and syringe programmes, still aren’t adequately available. In 2012 it was reported that only 12 sets of clean needles/syringes were distributed per person who injects drugs per year (against Thailand’s national target of 88 sets4 and the regional median of 116 sets). High coverage is defined as more than 200 needles per person who injects drugs.2
Awareness of the risks of HIV is also low – with condom use estimated at 49% among PWID, and less than half have had an HIV test (44%).4
Migrants and HIV
Migration can put people in situations of heightened vulnerability to HIV, due to factors such as social exclusion and a lack of access to healthcare services or social protection. In South-East Asia, HIV prevalence among migrants to Thailand from neighbouring countries is up to four times the rate of HIV prevalence found among the general population.2
The highest prevalence among migrants in Thailand was found in the fishing industry, with rates of 2% among fishermen and 2.3% among fishery workers, compared to HIV prevalence of 1.1% and 0.74% among factory workers and farm workers, respectively.9
In Thailand, the vast majority of sex workers are migrants from villages, who use the income from sex work to support families in their home communities.2 Migrant sex workers in low-income places appear to be at particularly high risk of HIV. 10
HIV testing and counselling (HTC) in Thailand
New approaches have been introduced to increase access to and demand for HTC among key affected populations, including the following:
- implementing community-based HTC to expand outreach work
- ensuring that HTC outlets provide same-day results.
A priority for HIV testing and counselling needs to be young people among the key affected populations of men who have sex with men including transgender people, male and female sex workers and their clients. A much lower percentage of young female sex workers have had an HIV test compared to older female sex workers. Similarly, lower percentages of young men who have sex with men have been reached by prevention programmes and therefore know where to obtain an HIV test, compared to older men who have sex with men.5
Prior to 2012, Thai Medical Council Regulations required parental consent for HIV testing of people under 18. Although age of consent restrictions are there to protect young people, they can actually serve as a disincentive to young people knowing their HIV status and serve as barriers to accessing health services. This regulation was later changed to allow adolescents to test without parental consent, as long as counselling is provided.11
HIV prevention programmes in Thailand
HIV prevention among young people
Surveys show that people under the age of 25 have lower levels of HIV knowledge and HIV testing and counselling than those over age 25.4
In recent years, efforts have been made to address this, with a more systematic approach to sex education in schools, and more prevention activities in both school and community settings. Although this has led to improvements in the health behaviour of young people, the impact has only been seen in areas where there have been intensive interventions on a continuous basis. The scale of these improvements is also too low to have an impact on national sexually transmitted infection (STI) rates.
Despite the youth-friendly sexual health services that have been expanded nationwide, the current prevention system isn’t effectively reaching more vulnerable young people.4
Thailand’s National AIDS Strategy 2012-2016 includes a specific objective relating to youth, and commits to reviewing laws and policies to promote access to services. The Strategy will introduce a system of participatory youth-friendly services (for in and out of school youth) in the areas of reproductive health, adolescent health, sexual health, and HIV.12
Preventing mother to child transmission (PMTCT)
Thailand has an extremely high coverage of PMTCT, with the mother-to-child-transmission (MTCT) rate decreasing from 2.7% in 2012 to 2.3% in 2013. Thailand is even on track to be one of the first countries in the world to achieve the target of reducing MTCT to under 2% by 2016.4
Nearly all Thai pregnant women receive antenatal care from a clinical outlet and most (99.7%) are screened for HIV. 95% of HIV-positive pregnant women receive treatment to prevent transmission to their child, and virtually all (99.5%) of their infants receive antiretroviral prophylaxis.
However areas for improvement include:
- increase in couples counselling during antenatal care (currently only 38%)
- continuous ART (antiretroviral treatment) provided throughout the first year of an infant’s life
- increasing PMTCT coverage for foreign pregnant women who are living with HIV.
Antiretroviral treatment (ART) in Thailand
In 2013, Thailand was one of only two countries in Asia and the Pacific, (along with Cambodia) that had more than 50% of people living with HIV on antiretroviral treatment. In Thailand, 56% of adults who are eligible for treatment are receiving it, alongside 62% of children.2
In 2012, Thailand revised its policy for initiating ART by increasing eligibility from a CD4 count of 200 to 350 cells/mm3. This was so ART could be initiated faster, to improve efficacy and reduce deaths from AIDS-related illnesses. In October 2014, antiretroviral treatment was extended to all regardless of CD4 count in line with the most recent World Health Organisation (WHO) HIV treatment guidelines. More thorough identification of new cases was introduced to ensure people start receiving treatment as soon as possible after diagnosis.4
Since 2005, people have been receiving access to free antiretroviral treatment and voluntary HIV testing and counselling as part of the country’s universal health insurance scheme. Integrating HIV with broader health sector funding instruments is an effective way to reduce dependency on international HIV funding.13
The Thai National AIDS Strategic Plan has committed to reach 90% of eligible adults and children with life-saving antiretroviral therapy by 2016.4 However, the new treatment guidelines mean that more people are now eligible for treatment, meaning the targets are now out of reach by the end of 2016.
Barriers to HIV prevention in Thailand
Law enforcement can act as an obstacle to HIV treatment and prevention, so Thailand is one of several Asian countries that have put in place programmes to prevent this.14 This includes protective legislation that guarantees the right to basic healthcare for migrants.2
However, despite improved laws and policies to protect people living with HIV, case studies from Thailand show that undocumented migrants face stigma and discrimination from healthcare workers and employers. This is one of the main barriers they face when accessing treatment.15 These barriers exist despite the protective legislation mentioned above.
Factors preventing people who inject drugs (PWID) from accessing services include misconceptions such as that the distribution of needles promotes drug addiction. PWID also experience prejudice and stigma from public health service providers and law enforcement, and tackling this has been highlighted as a priority in Thailand’s National AIDS Strategic Plan.4
Stigma associated with homosexuality and homophobia can also act as a deterrent to young men who have sex with men and transgender people from accessing HIV services, particularly if they fear arrest or breach of privacy and disclosure of their sexuality or gender identity to their family and community.5
Another issue has been how heavily Thailand has relied on international financial support to finance its HIV response, with the majority of the country’s prevention work being funded externally. In the last two years however, Thailand has increased the amount of domestic budget it spends on prevention activities, which has had a real impact. It’s important that this spending commitment continues in order to maintain the momentum, and Thai National AIDS Strategic Plan aims to increase the amount it spends on HIV in priority provinces by 2016.4
Thailand’s Ministry of Public Health has also announced a policy to provide health insurance (with antiretroviral therapy included) for registered and unregistered cross-border migrant workers. Prior to this, prevention work for migrant workers had been largely funded from overseas.4
The future of HIV and AIDS in Thailand
Although Thailand made enormous progress with HIV prevention in the 1990s, the decline in HIV prevalence has slowed down in recent years. Access to prevention services and behaviour-change communication hasn’t been enough to significantly reduce the rate of new infections.4
People aged under 25 in both key affected populations and the general population are increasingly not being reached with HIV prevention efforts, so Thailand will need to focus its efforts on new and innovative strategies to cover these demographics.
People who inject drugs account for the greatest burden of HIV in the country, so reaching this population also needs to be a priority. In fact, the Thai National Aids Strategic Plan aims to reduce HIV transmission among PWID by two-thirds by 2016.4
From 2015, the Ministry of Public Health has increased its budget to prepare for implementing the strategy to end AIDS,4 but the lack of public spending must remain a focus if real progress is to be made.
For example there is still a lack of budget in support of migrant workers, despite the recent access to health insurance and right to antiretroviral therapy (ART) among this population. This is because many vulnerable migrant workers fall outside of the traditional target populations of the National Aids Strategic Plan.4
- 1. UNAIDS (accessed May 2015) ‘AIDSinfo tool’
- 2. a. b. c. d. e. f. g. h. i. j. k. l. m. UNAIDS (2014) 'The Gap Report'
- 3. Thai Working Group on HIV/AIDS Prevention (2001) ‘Projections for HIV/AIDS in Thailand, 2000–2020’, cited in UNAIDS (2014) ‘The Gap Report’
- 4. a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. q. r. s. Thai National AIDS Committee (2014) ‘2014 Thailand AIDS Response Progress Report’
- 5. a. b. c. UNESCO Bangkok (2013) ‘Young People and the Law in Asia and the Pacific: a review of laws and policies affecting young people’s access to sexual and reproductive health and HIV services’
- 6. Manopaiboon C et al (2013) ‘Unexpectedly high HIV prevalence among female sex workers in Bangkok, Thailand in a respondent-driven sampling survey’, International Journal of STD and AIDS, [Epub ahead of print]
- 7. HIV and AIDS Data Hub for Asia Pacific (www.aidsdatahub.org), based on integrated biobehavioural surveys reported in global AIDS response progress reports from 2012, (cited in UNAIDS (2014) ‘The Gap Report’)
- 8. Winter S., (2009) ‘Lost in translation: transpeople, transprejudice and pathology in Asia’, International Journal of Human Rights, Volume 13(2)
- 9. UNDP (2012) ‘Meeting report: consultation on the memorandum of understanding to reduce HIV vulnerability associated with population movement. Bangkok, 11–13 July 2012’
- 10. Platt L et al (2013) ‘Systematic review examining differences in HIV, sexually transmitted infections and health-related harms between migrant and non-migrant female sex workers, Journal of Sexually Transmitted Infections, Volume 89, Pages 311-9
- 11. Bangkok Post (2012) ‘HIV test made more accessible to teens in Thailand’
- 12. Thailand National AIDS Committee (2012) ‘Thailand National AIDS Strategy for 2012-2016, In brief’
- 13. UNAIDS (2013) ‘Global Report 2013’
- 14. UNAIDS (2012) ‘Regional Fact Sheet 2012: Asia and The Pacific’
- 15. Amon J, Todrys K., (2009) ‘Access to antiretroviral treatment for migrant populations in the global South’, International Journal of Human Rights, Volume 6(10), Pages 154–177