|NGO Responses to HIV/AIDS In Asia (UNDP, 1992)|
|KLONG TOEY: FACING UP TO AIDS IN A BANGKOK SLUM: The Duang Prateep Foundation and the AIDS Counselling and Training Centre|
|KLONG TOEY: FACING UP TO AIDS IN A BANGKOK SLUM - The Duang Prateep Foundation and the AIDS Counselling and Training Centre|
The Duang Prateep Foundation was established in 1979 by Prateep Ungsongtham, who was born in Klong Toey and worked on the docks from the age of 12 to put herself through secondary school at night. In April 1992, the Foundation had over 100 staff members, most of whom had been recruited from the Klong Toey community itself. There was also a large network of Klong Toey volunteers who helped Duang Prateep to run its wide range of educational and community development programmes, including kindergartens, educational sponsorship, vocational training, income generation, an anti-drugs campaign, and, the latest addition, an AIDS prevention programme. The variety of their programmes helped Duang Prateep staff and volunteers in their HIV/AIDS work since they could visit members of the communities without fear of breaching confidentiality or causing undue embarrassment. The community was involved in the administration of most of the programmes.
It was through their Freedom From Drug Abuse programme, which began in 1986, that Duang Prateep first became aware of the rapid spread of HIV in Klong Toey. In May 1988, the programme tested a group of IDUs who had been sent by the community for inpatient drug treatment and were shocked to find that 75% tested HIV-positive. Realising the potential impact of AIDS on the community, and in view of the low priority given to AIDS by the government at that time, Duang Prateep decided to start a two-year pilot programme in three of the Klong Toey communities.
Duang Prateep started by educating themselves and key members of the community about HIV/AIDS. With the assistance of Family Health International (U.S. based organisation), a seminar was held for members of the Foundation, community leaders and the police. At the seminar it was agreed that the overall aim of the AIDS programme should be prevention of HIV infection. Three target groups were identified as priorities for interventions: all members of the three communities; all IDUs, especially those known to be HIV+ and their families; and sex workers. The specific objectives were defined as: (a) to teach people how to protect themselves and their families from infection; (b) to promote understanding rather than fear of people who are HIV+; (c) to enable seropositives to live in a supportive community.
Following this seminar, the AIDS programme staff were given further training in the transmission and prevention of HIV infection and in counselling. But Duang Prateep recognised that the best education that people can have is by learning from their own experiences. So the AIDS programme staff met regularly as a group - first monthly, then weekly - to discuss their experiences', what they had learned from them, and how to use this learning to make their activities more effective. The four main programme activities during the pilot phase were as follows.
INJECTING DRUG USERS
When the first group of 169 IDUs agreed to be tested for HIV, information was also collected on their residence, family situation, age and sex. It was found that 4 out of 5 of the youngest age group (less than 20 years) were HIV+. There were also significant differences in the prevalence rates between the three communities. Further investigation revealed that the higher rates in one community might be explained by two factors. IDUs in this area tended to live together, so increasing the likelihood of needle-sharing. Secondly, most of the dealers lived in this neighbourhood, and as the IDUs tended to use dealer-supplied needles and as these needles were often used by other drug users, this also increased the chances of spreading infection.
Armed with this information, the programme tried to recruit former IDUs as peer educators, but failed because the ex-IDUs were reluctant to let others know that they had once used drugs. The programme then decided to use Duang Prateep staff to make regular home visits to the IDUs, to give information about HIV infection and AIDS, to teach them methods of prevention including the cleaning of syringes and needles, and the use of condoms. They also provided supplies of condoms and bleach. The home visits were reinforced by encouraging small groups of IDUs (and sometimes their families) to meet at Duang Prateep to talk about their experiences and their concerns, and to provide them with opportunities to ask questions. Both the non-judgemental attitudes of the staff and these meetings helped enormously to build up trust between the addicts and the programme.
Duang Prateep was convinced that if they were to encourage people to stop using drugs and to reduce behaviours that can lead to AIDS, they must help the IDUs to develop some hope for the future. "Filling them with a lot of 'don't do this' instructions" was unlikely to motivate them to make the necessary changes in their life unless they were also provided with alternative strategies for survival. To do this, the programme also provided vocational training for the IDUs and made small, interest-free loans available to them to develop income generating activities.
In 1990, a little over a year after the programme started, a second survey was carried out among the IDUs in the pilot communities to collect data that would help improve the programme. The survey looked at the age at which the IDUs began using drugs (the highest proportion was found to be between 15-19 years), the amount of money spent on drugs as compared to the earnings of the IDUs (drug costs were found to exceed income), the extent to which the IDUs used drugs in groups, and the sexual habits of the IDUs (none used condoms, although several visited prostitutes). These findings led to a stronger emphasis on educating the IDUs about cleaning their equipment, more efforts to promote the use of condoms, and an understanding that attention needed to be given to the design of drug and HIV-prevention strategies for children and adolescents. The data also increased the fears that IDUs, both male and female, were increasingly turning to commercial sex work to earn the money for heroin. The need to continue to help IDUs to find jobs was reinforced.
THE COMMERCIAL SEX WORKERS
In 1990, the programme used the police to encourage local brothel owners to send their sex workers to a training seminar to learn about HIV/AIDS and how to protect themselves. It also explored strategies that could be used to get the clients to use condoms. All the sex workers were tested for HIV and completed a questionnaire about AIDS.
Twenty percent of the women tested HIV positive. The questionnaire showed that 94% of the women knew that sex without condoms could lead to HIV infection, but condoms were only used, on average, in one out of every three acts of sexual intercourse. The results also revealed important knowledge gaps and misconceptions: 68% thought AIDS could be contracted through mosquito bites, and 84% believed that regular blood tests would prevent infection.
After the seminar, the programme tried to persuade the brothel owners to promote the use of condoms among clients; although some agreed to allow the sex workers to refuse a client who would not use a condom, they would not make this an order.
The programme also tried to recruit peer educators from among the sex workers, but this was not successful as the workers changed their workplace frequently and the peer educators claimed they had no authority. Programme staff visited those who tested positive to give support and address their concerns. The constraints faced in this component encouraged programme staff to approach the police to ensure that brothel owners insist on the use of condoms, and to work more aggressively with the younger sex workers.
MOTORCYCLE TAXI DRIVERS
Around 650 men were thought to work as motorcycle taxi drivers in Klong Toey and the sexual behaviour of many of this group put them at high risk of HIV infection. In 1990, the AIDS programme organised two one-day training sessions attended by 498 motorcycle taxi drivers, with an average age of 26. During the session, a survey was conducted to determine each man's age, marital status, sexual behaviours and knowledge of HIV/AIDS. When asked if they frequented brothels, 71% replied that they did so at least once a month, but only 9% reported that they used a condom every time, and over half said they regarded condoms as a nuisance. Only 139 (28%) of the participants took up the offer to have their blood tested for HIV infection, and only two of these tested positive. This result was not felt to be representative because most of those practising high-risk behaviour declined to have their blood tested.
Participants in the training sessions were taught about HIV and AIDS, and particularly about the use of condoms. They were encouraged to talk with their clients about AIDS, and given small information cards as memory aides. To encourage discussions, they were also provided with T-shirts and distinctive pink vests carrying AIDS messages. The programme put up billboards with AIDS information at motorcycle taxi stops. A review of the situation some time later found that the motorcycle taxi drivers talked about AIDS only if their clients made comments or asked questions about the slogans on their vest or T-shirt. Either they did not yet have the self-confidence to broach the subject of their own accord, or this was felt to be culturally inappropriate. The programme planned to conduct a follow-up survey of motorcycle taxi drivers to see how much knowledge about HIV/AIDS they had retained. The survey also taught them that to influence condom-use among these young men, who felt they were too young to die, they needed to focus their efforts on explaining the pros and cons of condoms, thus allowing them to make an informed decision.
THE GENERAL PUBLIC
Before Duang Prateep decided on the contents of an AIDS prevention campaign, it carried out a baseline KAP survey among a sample of residents. The results showed that although 90% of those interviewed knew that AIDS could be contracted through sexual intercourse or sharing needles with an infected person, there were also many alarming misconceptions and knowledge gaps. Half the respondents believed that HIV could be transmitted by mosquitoes, by sneezing, by sharing soap or clothes, or simply by talking with an infected person. Only 33% knew that a person with HIV can still look healthy, and only 34% suggested the use of condoms as protection against infection. Half thought they could easily be infected simply by sharing a house with an infected person, and only 41% said they would remain friends with a person with AIDS.
The programme's initial response was to mount a series of high-profile public events with the broadest possible mass appeal. The activities included a rally and speeches by prominent persons, AIDS education bulletin boards were erected, posters displayed, and stickers and pamphlets distributed. Over the next several months, similar mass events were organised; a week-long AIDS exhibition, a 'Slogan for AIDS' competition, and a parade through the streets of the neighbourhood.
But the programme staff soon realised that all the activities were attracting the same group of active and interested members of the community; a large proportion of the community was not participating at all. A KAP study carried out seven months after the launch of the programme found little or no change in either knowledge or in attitudes towards people with HIV/AIDS.
These findings led to a reassessment of the AIDS programme strategy and efforts to improve participation by a number of methods. A small team started to take a mobile audio-visual presentation on AIDS issues to the slum communities, followed up by a question-and-answer session, and this became the focus of community activity. The programme also organised one-day educational seminars for key groups in the community, such as the police, youth leaders, kindergarten parents, women and school students, in the hope that they would become trusted sources of information about AIDS within their families, at their workplace, and with their neighbours and friends. Duang Prateep also decided to broaden their volunteer base. It trained a group of housewives to act as volunteer AIDS educators, visiting their neighbours to teach them about AIDS, and providing regular supplies of free condoms.
The programme planned to expand its activities into nine additional Klong Toey communities and had completed baseline surveys in each area. The surveys would be repeated in the future to evaluate the success of the educational activities. They also planned to increase work with children, to bring prevention into the schools and existing youth groups in the community. Duang Prateep did not plan to provide medical care to people with HIV/AIDS and their families. They felt that other, more specialised agencies were better equipped to provide this service and that their own unique strength lay in their deep roots within and their relationship with, the communities of Klong Toey.
1. What strategies did ACT use to try and match its AIDS activities to the needs of the community?
2. To what extent did ACT achieve the objectives of its AIDS programme?
3. What suggestions could you make to ACT on how it might assess the effectiveness of their programme?
4. What recommendations would you make to ACT on the activities and the approaches it might build into its AIDS programme in the future?