|Sexually Transmitted Diseases (STD) Prevention: New Challenges, New Approaches (AIDSCAP/FHI - USAID, 1996, 47 p.)|
by Robert Hanenberg and Wiwat Rojanapithayakorn
A poster encourages commercial sex workers in Thailand to protect themselves from HIV and other STDs for the sake of someone who is waiting for you. (Michael Buja/AIDSCAP)
In 1988, government-initiated testing in Thailand revealed that HIV was spreading rapidly among intravenous drug users in Bangkok and among low-fee commercial sex workers (CSWs) in northern Chiang Mai city. These early indicators of growing seroprevalence were soon recognized by health officials as a warning that Thailand, with its large population and widespread commercial sex industry, faced an exploding HIV epidemic.
A year later, the Ministry of Public Health launched a massive expansion of its HIV/AIDS Prevention and Control Program, a comprehensive national prevention effort featuring advertising and condom distribution campaigns. But its boldest initiative was and remains the 100 Percent Condom Program, which seeks to enforce condom use in all commercial sex establishments (CSEs) nationwide-100 percent of the time.
This ambitious and innovative campaign, built upon the foundations of Thailand's 45-year-old venereal disease prevention program, is proving effective against the spread of not only HIV but other major sexually transmitted diseases (STDs) plaguing the country.
Commercial Sex and STD Control
In Thailand the main transmission route for STDs is between female CSWs and male clients, then from male clients to their wives, and finally from wives to children through perinatal transmission. Extramarital and premarital noncommercial sex accounts for very little STD transmission.
Although prostitution has been illegal in Thailand since 1960, the government has tried to control rather than suppress it. The brothels, restaurants and bars identifiable to customers as CSEs are also well known to public health authorities and the police. With the chain of transmission so clearly defined, one easily located link in it between CSWs and male clients became a target for intervention by the government's Venereal Disease (VD) Units.
Sex workers at a nightclub in Bangkok. (Ron Giling/Panos Pictures)
Before the HIV epidemic, the VD Units, based in every province, served two main functions. First, they provided STD services to the general population, both male and female, and to CSWs, who were treated and urged to stop receiving customers until they were cured. Second, they provided contact tracing of the STDs back to the sexual partner.
Thailand's boldest anti-AIDS initiative remains the 100 Percent Condom Program, which seeks to enforce condom use in all commercial sex establishments nation-wide - 100 percent of the time.
Contact tracing in STD treatment programs usually takes the form of partner identification and notification, but in Thailand, an additional step was taken. Whenever a man came to a government clinic with an STD, he was asked where he had contracted it, and almost always named a specific CSE. Outreach workers then went to that establishment to test the CSWs and encourage them to seek treatment at the clinics. The VD Units were thus able to develop and maintain rosters identifying every CSE in the province and the number of women working at each.
In 1989, these rosters showed 85,000 CSWs throughout the country, a figure that is roughly accurate (except for the figures for Bangkok, which are underreported). That year, the average number of CSEs within Thailand's 76 provinces aside from Bangkok and Chonburi Province was 67, and the average number of female CSWs was 681. This relatively small number of CSWs, working in a limited number of CSEs, was also a factor in making it possible for provincial VD Units to exert some control over the commercial sex industry and the spread of STDs.
Another government response to the epidemic has been to rapidly increase the number of facilities to both treat and track STDs. Before 1991, there were 85 government VD clinics. In 1991, in response to the HIV epidemic, 40 new VD/AIDS Units were created in district towns, 91 more in 1992, 101 in 1993 and 157 in 1994.
The Campaign Against HIV
After 1988 and the first detection of increasing seroprevalence rates, other indicators of transmission began to rise. The percentage of direct* HIV-positive CSWs rose from 4 percent in 1989 to 31 percent in 1994. From 1989 to 1993, the percentage of HIV-positive young men inducted into the army increased from half a percent to a peak of 4 percent, and the percentage of HIV-positive pregnant women in urban areas rose from 0 in 1989 to 1.8 percent in 1994.
*Direct CSWs are based in brothels and generally receive cash for payment. Indirect CSWs work in more informal settings out of a bar or at home and may receive food or other goods rather than cash for payment.
In 1989, as soon as health authorities realized what was happening, they reoriented the HIV/AIDS Prevention and Control Program toward condom promotion in commercial sex and flooded the country with millions of condoms, enough to protect all commercial sex acts. They conducted an advertising campaign advising promiscuous men and women to use condoms. And in 1991 they created the 100 Percent Condom Program, which national law enforcement authorities back up with sanctions and tough fines for establishments that do not comply.
From 1989 to 1995, the number of men coming to government clinics for STD treatment declined by more than 90 percent, thanks primarily to widespread use of condoms.
Many elements of the program relied on the STD prevention infrastructure already in place. Every CSW who came for a regular STD checkup to a government clinic was offered a box of 100 condoms, or as many boxes as she wanted. Every health official who visited a CSE brought along boxes of condoms.
The 100 Percent Condom Program also relied on this decades-old STD prevention infrastructure. Just as STD prevention authorities used the reports of patients to identify the CSEs that were the sources of infection, the same procedure was used to find out which establishments were not enforcing condom use. Strong pressure, sometimes from the police, was brought to bear on uncooperative brothel owners. Since the pressure was applied uniformly to all CSEs, clients could not simply go where condoms were not used. Owners and CSWs, once they understood that they would not lose business to other establishments that did not insist on condoms, were inclined to cooperate
The results were dramatic. Before the epidemic struck, surveys showed that the percentage of commercial sex acts where condoms were used was around 15 percent. This percentage began rising immediately in 1989, and by 1994 had reached more than 90 percent. From 1989 to 1995, the number of men coming to government clinics for STD treatment declined by more than 90 percent, thanks primarily to widespread use of condoms.
In 1993, the most sensitive indicator of HIV transmission in Thailand, the percentage of army conscripts testing HIV-positive at induction, started falling. Recent data have shown that the incidence of HIV transmission in commercial sex has also decreased to a very low level.1
Perhaps the main reason for the campaign's success was its concentration on a limited objective-the consistent and widespread use of condoms in commercial sex- rather than on wider goals, such as eliminating commercial sex altogether, or the improvement of public morality.
Throughout the campaign, STD treatment played a minor role. Several hundred new STD treatment centers were set up in district hospitals, but these were used less for treatment of STDs (whose numbers were falling fast) than for prevention education, counseling of both infected and uninfected people, and condom distribution.
The Program's Future
While the first link in the chain of STD transmission between male clients and female CSWs has been interrupted, it has not been cut entirely. Condom use in commercial sex remains high, yet it is not 100 percent. Men who still do not use condoms despite widespread condom promotion campaigns must be considered a particularly high-risk group, responsible for the continuing transmission of HIV to uninfected CSWs. One of the most difficult challenges for health authorities now is reaching these men.
While condom use may eventually decline, many public health officials are optimistic that it has become an ingrained practice in commercial sex. Moreover, because many of those infected with HIV early in the epidemic are becoming ill, AIDS has become visible, which may motivate continued condom use.
It's also possible that the HIV epidemic, which was exacerbated by commercial sex in the first place, has altered the commercial sex industry itself. Since 1989, the number of CSWs has decreased by about 25 percent. Men patronize CSWs less, and women are less willing to engage in commercial sex, especially based in brothels. Commercial sex has shifted to the less direct forms and has become more expensive.
Lower levels of brothel patronage mean less transmission. But indirect commercial sex is more difficult to control, because indirect CSWs, who tend to have sex off premises, are less able to insist on condom use. Moreover, as the number of Thai women willing to work as CSWs decreases, women from other countries are taking their place. Women who are in Thailand illegally and who do not speak Thai well may be hard for the authorities to identify, counsel and treat.
As fewer men are infected with HIV, the infection of wives will diminish as well. But this link in the chain can sometimes be interrupted directly when, for example, a couple gets tested for HIV before marriage. The government now offers anonymous counseling and testing in most provincial and district health facilities.
Models of the epidemic show that commercial sex should remain the main target for control of HIV in Thailand, and Thai health authorities continue to focus on the commercial sex industry. They are also considering distributing female condoms and lubricants, developing vaginal microbicides and providing outreach services in languages other than Thai. But, given the success of the 100 Percent Condom Program, the chief policy aims of the Thai program will undoubtedly be to keep condom use high in commercial sex and to strive to make it truly 100 percent.
An outreach worker discusses an AIDS prevention brochure with a personnel training officer at a Pepsi Cola factory near Bangkok. AIDS education in workplaces helps promote condom we in Thailand. (Lance Woodruff )
1. Rojanapithayakorn, W. and R. Hanenberg. 1996. The 100% condom program in Thailand. AIDS 10(1):1-7.
Robert Hanenberg, PhD, is a research associate, Asia Region, for Family Health International in Bangkok. Wiwat Rojanapithayakorn, MD, is chief medical officer in the Department of Communicable Disease Control of the Ministry of Public Health, Bangkok.