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. In the 1990s, a massive programme that began to control HIV reduced visits to commercial sex workers by half, raised condom usage, decreased the prevalence of STDs (Sexually Transmitted Diseases) dramatically, and achieved substantial reductions in new HIV infections.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 19,000 in 2003.2 Nonetheless, over half a million people in Thailand are living with HIV, and in 2009 28,000 people died from AIDS.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 among young people and a rising number of STI cases4 have led to concerns that Thailand could face a resurgence of HIV and AIDS in coming years.

back to top 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 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 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.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 HIV 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 1993.13

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.

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.14

Thirdly, and perhaps most importantly, the '100 percent condom programme' was initiated.15 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.16

“When a team of reporters decided to test the 100% condom programme by visiting Chang Mai with the aim of buying sex without a condom, they failed.”17
HIV-positive mother with her uninfected daughter, Thailand 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.18

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.

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.19

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%.20 Following this, a number of pilot programmes were initiated in Thailand.21 22 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.23

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.24 By 2000, domestic funding for HIV and AIDS prevention was roughly one quarter less than it had been in 1997.25

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.26

A year later the government made an official commitment to ensuring adequate treatment for all people living with HIV, and set targets to improve treatment access.27 As these plans have been carried out, 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% 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.28 29

back to top The current situation

Thailand Statistics30
Estimated total population, end 201131
66,720,153
Estimated number of people living with HIV, end 2009 530,000
Adults aged 15 and over living with HIV, end 2009
 520,000
Women aged 15 and over living with HIV, end 2009 210,000
Estimated adult (15-49) HIV prevalence, end 2009 1.3%
Estimated number of AIDS deaths in 2009 28,000
  • The majority of Thailand’s HIV infections occur through heterosexual sex.32
  • HIV prevalence among pregnant women, which reached a peak of 3.4% in 1992, had fallen to under 1% by 2009.33

back to top 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 1997.34 In 2006, UNAIDS reported that Thailand’s government had reduced its HIV prevention budget by two-thirds.35 From 2008 to 2009, the percentage of the total AIDS budget spent on prevention decreased from 21.7% to 13.7%.36

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.37 38 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.39

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.”40

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

In an attempt to address these issues, a television campaign was launched in 2007, funded partly by a grant from the Global Fund.43 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.44

Injecting drug users

Within the first few years of Thailand's epidemic, HIV prevalence among IDUs rose from 0 to 40 percent.45 Around 100,000 to 275,000 people in Thailand are thought to use heroin, 80 percent of whom inject.46 Other drugs, including methamphetamines, opium and cocaine are also injected.

Thailand has not had a great deal of success in reducing HIV infections among IDUs; infection rates remain extremely high, at 35-50%.47 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.48 In 2004, Prime Minister Thaksin told an international AIDS conference that the government saw the need to treat drug users as patients, not criminals. However, in 2008, a new government reinstated the traditional hard-line 'war on drugs', with the Interior Minister declaring that drugs would be 'suppressed' even if "thousands of people have to die".49 The controversial policy had earlier been linked to the deaths of 2,500 people, not all drug dealers.

Despite this, Thailand's 2007-2011 national AIDS plan, which was introduced under the new government, commits to ensuring access to HIV prevention, treatment and care for IDUs.50 From 2008-2009, the Ministry of Health and the Narcotics Control Board convened a series of meetings with other government agencies and non governmental organisations (NGOs) to assess the benefits of pursuing a harm reduction policy for IDUs.51 Harm reduction strategies include needle exchange programmes, as well as methadone substitution therapy (the provision of oral opiods that eliminate the risks associated with injecting drug use). The meetings led to a 'memorandum of understanding' between various government agencies, who stated their intent to work together to implement harm reduction for IDUs. The bureau for AIDS, TB and STIs has since developed implementation guidelines for health workers to deliver harm reduction but implementation has not been mainstreamed by public health providers, as local health workers and the police are reportedly reluctant to cooperate.

The doctor said if I use drugs, I can’t have ART. —Chai L., age 45, HIV-positive drug user52

Effective harm reduction and needle exchange services are currently carried out mainly by NGOs, although in Bangkok 20 public methadone clinics are providing services to IDUs.53 Despite the government's admission that there is an 'urgent need' to 'develop and improve' harm reduction services, Thailand's overriding hard line stance on drug users will continue to seriously hamper any large scale efforts to reduce HIV transmission in this population.

Men who have sex with men (MSM)

Men who have sex with men are currently a major risk group in Thailand. In Bangkok (Thailand’s capital and largest city), HIV prevalence among MSM rose from 17% to 28% between 2003 and 2005 and has since dropped to 24.7% in 2009.54 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.

The Rainbow Sky Association of Thailand is the country's first gay organisation and coordinates the largest network of MSM peer educators in Thailand.55 Apart from establishing local community centers 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.

Migrant workers

It is estimated that there are around 2.5 million migrant workers living in Thailand, although only around 1.5 million are registered with labour authorities.56 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. Migrants are also more likely to buy commercial 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.57

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.58

Sex workers

Sex work is illegal in Thailand but there are still thousands of commercial sex establishments (CSEs) in operation. These include brothels, massage parlours, karaoke bars and saunas. The ‘100% condom’ programme, which enforced mandatory condom use in all CSEs, played a significant role in reducing Thailand’s HIV prevalence in the 1990s.

Not all sex is sold in commercial sex establishments. Although it is difficult to monitor free lance sex workers (part time sex workers who solicit sex in public places or restaurants and bars), signs are that HIV prevalence is increasing within this group and among male sex workers in general. According to one study conducted by the government 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.59

The percentage of sex workers who have had an HIV test and know there results has declined; whereas around half of sex workers surveyed had been tested in the past 12 months in 2007, this had dropped to around a third in 2009.60

Outreach work, where HIV prevention messages are delivered to networks of sex workers, are generally conducted by NGOs, and not the government, in Thailand. Organisations such as EMPOWER, SWING and Issarachon distribute condoms, and reach sex workers outside of brothels with HIV/STD prevention messages, counseling and information on health services in their area.61 One particularly innovative project is the Can do Bar. The first of its kind in Thailand, the Can do Bar is an initiative of EMPOWER and is owned and operated by a collective of sex workers. They are paid above minimum wage and provided with regular time off, sick leave, paid holidays as well as regular access to information on safer sex.

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

back to top Treatment for people living with HIV

In 2001, the government committed to providing antiretroviral drugs (ARVs) free of charge to people living with HIV under the National Access to Antiretroviral treatment programme for People Living with HIV/AIDS (NAPHA).62 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.63 The national treatment campaign was further boosted by a US$209 million grant from the Global Fund, most of which was used to support the provision of ARVs.

World AIDS Day 2006 event in Bangkok, Thailand World AIDS Day 2006 event in Bangkok

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.

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.64 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.65

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, generally condemned the move.66

It is thought that the government's decision to issue compulsory licenses for ARVs have already saved substantial amounts of money, and many lives. The compulsory licenses for Efavirenz and Kaletra are predicted to have saved Thailand as much as US$37 million in three years.67 In August 2010, the Public Health Ministry reextended compulsory licensing for Efavirenz and Kaletra until their patents expire (January 2012 for Efavirenz and December 2016 for Kaletra).68

Despite these successes, a third of people in need of treatment in Thailand are not receiving it.69 In addition, half of all people who begin antiretroviral treatment in Thailand already have AIDS symptoms or very low a CD4 count (<100 cells/mm), highlighting the need for access to early HIV diagnosis.70 Lack of knowledge about treatment or referral to treatment by healthcare providers are also factors contributing to this late uptake of treatment.71

back to top 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.72

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.

Nominet Winner 2012

References back to top

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