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The History of the AIDS Epidemic in ThailandThere are very few developing countries in the world where public policy has been effective in preventing the spread of HIV/AIDS on a national scale, but Thailand is an exception. A massive program to control HIV has reduced visits to commercial sex workers by half, raised condom usage, decreased 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. Its well funded, politically supported and comprehensive prevention programmes have saved millions of lives, reducing the number of new HIV infections from 140,000 in 1991 to 21,000 in 2003. None the less, one-in-100 Thais in this country of 65 million people is infected with HIV, and AIDS has become the leading cause of death.2 However, 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. There is a need in Thailand to continue strong HIV/AIDS prevention and education efforts in the future, as well as providing treatment and care for those living with HIV/AIDS The Start of the AIDS Epidemic in ThailandThe first case of AIDS was reported in Thailand in 1984, and it is believed that widespread transmission began in the late 1980s.3 4 In 1988-89 in the first major wave of the epidemic, HIV infection exploded among injecting drug-users, rising from almost nil to 40% in a single year. At almost the same time, a second wave of infection spread among sex workers. In 1989, it was found that 44% of sex workers in Chiang Mai, in the north, were infected with HIV.5 The rising infection level among sex workers launched subsequent waves of the epidemic in the male clients of sex workers, their wives and partners, and their children.6 The National ResponseThe initial policy response was limited as in the 1980s the prevailing view was that this was an epidemic brought from abroad that would be confined to a few individuals in high-risk groups, like gay men and injecting drug-users, and would not spread more widely. A government official insisted that the situation was under control and that "Thai-to-Thai transmission is not in evidence."7 and a group of Thai MPs proposed that all foreigners should be required to pass an "AIDS test" before being admitted to the country 8. In keeping with this view, the government spent only $180,000 on HIV prevention in 1988.9 It was not until 1991, with a new Prime Minister Anand Panyarachun, 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 program was moved from the Ministry of Public Health to the Office of the Prime Minister, increasing its political influence, and the budget was increased almost 20-fold to $44 million in 1993.10 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 state-owned radio and television stations, and every school was required to teach AIDS education classes. "We converted the equivalent of 'Jingle Bells' into a safe-sex song'."11 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.12 Thirdly, and perhaps most importantly, the '100 percent condom program' was initiated.13 This program 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. A number of repressive policies were also repealed and those that were under discussion gradually faded from the policy dialogue. One example being the mandatory reporting of the names and addresses of AIDS patients.14 From 1992 to 1996, the National AIDS program received dramatic increases in funding, with the government providing more than $80 million annually by 1996, and: "Every segment of Thai society played a role in AIDS prevention. Everyone was involved- from the medical community to teachers, to monks, to prostitutes and to drug addicts. The government committed funds for research and backed private organisations that attempted to spread the world about how to stop AIDS. Even the powerful Thai military pitched in, running voluntary blood tests for soldiers." 15 Over 3.5% of military recruits aged 21 were reported to be HIV-infected in many parts of the country following a 1992 round of surveys, with a prevalence rate to 20% in Chiang Mai, northern Thailand.16 The second "National Plan for Prevention and Alleviation of the AIDS Problem" which covered the period from 1997 to 2001, maintained the previous effective programs, whilst adopting a more holistic approach, which included mobilizing the efforts of communities and people living with HIV/AIDS.17 Between 1996-97, a randomised controlled trial was carried out in 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%.18 Following this, a number of pilot programs were initiated in Thailand. 19 20 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.21 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.22 In 2000, the total amount of funds dedicated to HIV/AIDS programmes in Thailand from all sources was $65 million.23 The third "National Plan for the Prevention and Alleviation of HIV/AIDS in Thailand" which covers the period from 2002-2006, was launched at the end of 2001, and continues the work of the previous National Plan (1996-2001).24 There are three specific targets in relation to this plan. Firstly, to reduce adult HIV prevalence to less than 1% by the end of the plan period. Secondly, to provide access to care and support for at least 80% of the people living with HIV/AIDS and other affected individuals. Thirdly, local administrations and community organisations throughout the country, will both plan and carry out work on HIV/AIDS prevention and alleviation. Five strategies have also been identified by the government as a priority in tackling the HIV/AIDS epidemic in Thailand. Firstly, individuals, families and community organisations have to be made aware of the role they play in the prevention and alleviation of HIV/AIDS. Secondly, health and social welfare services will be established for the prevention and alleviation of HIV/AIDS. Thirdly, knowledge and research will be developed, along with the fourth part of the strategy, that of international cooperation. Finally, a management system will be developed to integrate the tasks of HIV/AIDS prevention and alleviation. Current Statistics
Future ChallengesChanging Routes of TransmissionThe main routes of HIV transmission have recently been changing. During the 1990s, most HIV transmission occurred through commercial sex. But the noted 'success' of the 100% condom programme with the aim of 100% condom use for all commercial and casual sex, has not had much effect on the slow but steady transmission of HIV from the infected male clients of female sex workers, and from infected male IDUs to their regular sex partners (wives and girlfriends).26 Now half of the newly identified infections are occurring among the wives and sexual partners of men who got infected several years ago.27 Injecting Drug Users (IDU)Thailand has not had a great deal of success in reducing HIV among injecting drug users. Infection rates among IDUs have remained extremely high, at 35-50%, and are still rising in some areas. HIV spreads not only among drug users but to their partners and their children, and left unchecked, the high infection rate among IDUs will continue to be a reservoir for HIV transmission to the rest of the population. However, HIV prevention for IDU and their sex partners has not been a priority in Thailand even though IDU transmission is an important feature of the AIDS epidemic.28 At the end of 2002, UNAIDS urged Thailand, among other Asian countries, to consider giving clean needles to injecting-drug users to combat the HIV/AIDS epidemic.29 Commercial Sex WorkersIt has been recognised from the start of the epidemic in Thailand that most HIV infections were occurring through commercial sex, and major efforts were made to reduce the number of men visiting female sex workers and to promote condom use in all commercial and casual sexual interactions. These efforts significantly changed the levels of risk behaviour in Thailand. The known HIV infection rate among commercial sex workers was reduced from 50% in 1991 to 20% in 2001.30 However, the prevalence rate of HIV in sex workers, although reduced, is still high. Condom use among indirect sex workers is low and there is evidence that HIV prevalence is on the rise among sex workers in some parts of the country, particularly in Bangkok.31 Young PeopleThere are also signs that unsafe sexual behaviour is increasing among young people in Thailand. The Health Ministry in Thailand has noted that the rate of HIV infection among teenagers rose during 2002 from 11 to 17%. The Ministry is now aiming to make condoms available for young people more freely, since it is estimated that less than 50% of teenagers use condoms and therefore they form a high-risk group. The Ministry is aiming to buy 26 million condoms to distribute at health offices and they are also adding more condom vending machines in public places. However, Thailand's National AIDS Prevention and Control Commission has complained about the authorities removing vending machines or refusing to install them fearing they promote promiscuity. 32 The Provision of TreatmentAs those infected in the past fall ill, there is an increasing demand for AIDS-related medical care - palliative care, prevention and treatment of opportunistic infections, anti-retroviral therapies, and end of life care. It has been estimated that each year, up until the end of 2006, over 50,000 Thais will die from AIDS-related causes. Over 90% of these deaths will occur in people aged 20-44, the most productive sector of the workforce.33 It was announced at the beginning of 2003 that Thailand will receive US$209 million over the next five years from the Global Fund to fight AIDS, TB and Malaria.34 The money is to be used to provide antiretroviral treatment for AIDS patients amongst other HIV/AIDS related items. It was reported that 13,000 patients were receiving antiretroviral treatment in May 2003. In December 2004, UNAIDS/WHO estimates suggested that the country had likely achieved its target of 50,000 people receiving treatment by the end of the year. 35 Access to treatment is planned to increase to 70,000, using funds from the government and the Global Fund. It is hoped that 10% of people with HIV/AIDS in Thailand will receive treatment by the end of 2005.36 For more information, go to our who is getting AIDS drugs page. This page was written and edited by Annabel Kanabus and Jenni Fredriksson
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Last updated February 4, 2005 |