|Partners in Prevention: International case studies of effective health promotion practice in HIV/AIDS (Best Practice - Key Material) (UNAIDS, 1998, 84 p.)|
by Dr Wiput Phoolcharoen, Director, AIDS Division,
Department of Centre for Disease Control, Ministry of Public Health, Thailand
Thailand is a tropical country in South-east Asia with a population of sixty million. Over the last two decades, Thailand has been transformed from a subsistence agrarian society into a rapidly industrializing, free-market country. This change has affected not only the labour structure, income distribution and migration patterns, but also disease patterns. Thai society is experiencing a morbidity transition wherein the diseases of affluence are increasing, traditional infections are diminishing, and certain emerging and re-emerging infectious diseases continue to threaten the progress made.
The changes in the economic structure from an agriculture-based to an industry-based economy, with a high concentration of the service sector in the metropolitan area, has brought about large-scale, rural-to-urban migration of labourers who often leave their families behind. Extended families give way to nuclear families, in which often both father and mother have to struggle to earn a living. This is gradually resulting in the breakdown of family ties. This situation has become worse with the influx of Western influence, as well as that of information technology and various forms of non-indigenous entertainment - all of which have affected national and regional culture and traditions.
OVERVIEW AND CONTEXT
It is just more than a decade since HIV/-AIDS emerged and spread in Thailand.
With the effective HIV surveillance system in Thailand, data are now available to track prevalence, temporal trends and incidence. To date, 850,000 cases of HIV infection have been recorded in the country, although the real figure is estimated to be much higher. The predominant means of HIV transmission has changed over time. In 1984, the first cases of AIDS were recorded among homosexual men. Three years later, the importance of male-to-male sex as a risk factor was quickly overshadowed by the rapid increase in infection among injecting drug users, followed by a parallel increase in seroprevalence among female sex workers. Subsequently, the third wave of infection appeared in clients of sex workers, reflected in an increase of seroprevalence among men attending government sexually transmissible diseases clinics. The fourth wave indicates a spread to the wives and girlfriends of men who visit sex workers, reflected through increasing seropositive rates of women attending antenatal clinics. As a result, the incidence of reported paediatric AIDS cases also increased and can be observed as evidence of the fifth wave of the epidemic.
History and structure of community-based response
Communities in Thailand may be economically poor, but they are culturally rich. The major richness lies in their human resources and the social and cultural values that have been transmitted through generations. 'Community' in Thailand is understood as:
· geographical community: these are village communities (70,000 in the country) or slums in urban centres (1,000 in Bangkok, 26 in Chiang Mai);
· groups of community-based organizations (CBOs) from many village communities, linked together through networks around particular issues (environment, agriculture, HIV/AIDS, etc.) or according to geographical areas (district, province, region);
· groups of individuals according to their status: monks, teachers, academics, business people, students, sex workers, factory workers, gays, and NGO workers.
· 'communities of needs' or 'communities of life': group of individuals linked by common interests needs, problems, goals and activities, e.g. people with HIV/AIDS groups, associations or clubs.
Thailand is traditionally a patronage society where the government provides a wide range of social services for its people. At present, the governmental system is highly centralized and not necessarily responsive to community involvement. In addition, international development assistance partners are inclined to promote the policies of their respective organizations rather than cater for different priority needs of the people. In rural areas, villagers are being incorporated into health schemes through the establishment of local networks that link village-based volunteers with government or development agencies. Although top-down education programmes have alerted the Thai population to the present and potential threat of HIV/AIDS, this information alone has not resulted in behaviour change. Local participation in community-based projects is crucial to complement national initiatives, both to personalize their relevance and to develop appropriate responses that fit community practices and needs.
Since the first National Economic and Social Development Plan was launched in 1961, Thailand has had a consistent economic growth rate averaging 8 to 9% per year (with 12% in 1989 - 1990). Despite the high growth rate, the gap between the rich and the poor is widening. Educational and political systems are weak. This is the socio-economic context in which the HIV epidemic emerged and through which it has grown rapidly.
The economic development in the past decades has resulted in new social problems: migration from rural to urban centres (more than 1,000 slums in Bangkok with 1.5 million slum dwellers); disintegration of traditional community and values; deterioration of environment (reduction of forest areas from over 60% in 1961 to about 19% in 1990); prostitution; child labour and child prostitution; drug use; and crime. The urban and industrial society has been extended without appropriate societal and cultural binding, resulting in deterioration of its social structure. Thus, some sections of the urban community have become marginalized and vulnerable.
In many parts of the country, especially the north and the north-east, village communities are deserted, particularly during the dry season. Most young people and adults migrate to urban centres or other regions in search of work. They are to be found in construction sites, in factories, in service enterprises such as restaurants, hotels and tourist sites, in gas stations and garages, in rubber and cash crop plantations, and on fishing boats. About 300,000 Thai workers are to be found in Taiwan, Japan, Brunei, Hong Kong, Singapore and the Middle East. At the same time, there are more than one million migrants from Thailand's neighbouring countries who cross the borders to find work in Thailand.
During the past two decades, the government, realizing the effects of economic development, has placed particular emphasis on rural community development. In most of the 70,000 village communities in the country, there are community-based organizations supported by government and non-governmental organizations (NGOs) or initiated by the villagers themselves. These include groups for farmers, women, youth, rice banks, medicine banks, cooperative shops, savings groups and handicraft groups. There are also public health village volunteers trained by the Ministry of Public Health as part of the primary health care programme.
For several decades, various NGOs throughout Thailand have made attempts to generate fundamental changes to social and political systems. There are approximately 200 to 300 NGOs that have set up operations in the past fifteen years. Although some may more actively challenge the dominant ideology than others, they frequently undertake activities to correct inappropriate government policy. Health is usually considered within the broad perspective of integrated community development and, at face value, this is very similar to the goals of the government's Primary Health Care programme. NGOs frequently act as coordinating bodies, and it is in this capacity that there is some uniformity in their functioning. Their role of developing links with the hard-to-reach communities, the private sector and the government are imperative to strengthen the foundation of civil society.
Besides many existing community-based organizations in most village communities, there are new community-based organizations being formed to deal with HIV/AIDS problems in the community. Although some models of CBOs were promoted and supported by local government organizations at the beginning of initial response to HIV in 1991, the number has not increased. A small number of village communities have formed extra CBOs to deal with HIV/AIDS. In these situations, they have preferred to include HIV/AIDS as an integral part of community development activities. Many NGOs and scholars who are experienced in community development have adjusted their role to strengthening community organization in order to cope with HIV/AIDS related problems. The lesson learned from a decade of working with community has culminated in clearer policies to counteract HIV/AIDS.
The current strategies from the National AIDS Plan for strengthening social support are aimed at two important targets. The first strategy is targeted at community involvement and organizations that encourage a healthy lifestyle as a social norm and foster community action for health. The second strategy targets systems that provide the infrastructure for health care services and related development activities that have an impact on health. Both of these strategies need to be supported and instilled into community awareness.
Role of NGOs
The rapidly increasing number of NGOs has contributed to a multisectoral and holistic approach, and HIV/AIDS has become an integral part of community development programmes. NGOs cooperate well with government organizations at national and local levels. In 1995, the Ministry of Public Health granted about US$200,000 to NGOs involved in HIV/AIDS. In 1996 the budget was increased to US$3.2 million for NGOs and PLWHA groups.
NGOs involved with HIV/AIDS can be roughly grouped according to their target groups. They have an important role in coordinating groups of people with HIV/AIDS groups and are the main players in advocacy and human rights. Initially, NGOs were involved in HIV/AIDS counselling activities and raising public awareness. Their targets were the general public (hot-line telephone counselling, radio programmes), school and college students, commercial sex workers, factory workers, gay communities, poor urban and rural communities, advocacy and human rights. Since 1991, NGOs working in a range of community development and other programmes have broadened their involvement to include HIV/AIDS. An important part of their work with communities has been to organize seminars and training programmes for representatives from village communities.
With the exception of a few international NGOs, most involved in HIV/AIDS are small. They have only a few staff and volunteers. They usually have no legal status; however, this does not prevent cooperation with government organizations and other agencies, including receiving financial support from government and the business sector. NGOs are also supported partly by international NGOs, bi- and multi-lateral organizations, and partly by the Thai government through the Ministry of Public Health and the business sector.
A good example of this work is the Thai-Australia Northern AIDS Prevention and Care Programme (NAPAC), a bilateral project located in Chiang Mai. Since 1993, NAPAC has been providing financial and technical support to many NGOs, CBOs, PLWHA groups and some projects by local government organizations in Chiang Mai, Chiang Rai and Phayao provinces in the North. NAPAC is a new model of support organization or donor located close to communities instead of being based at the central level with a ministry in Bangkok. It has significantly contributed to the role of 'communities' in HIV/AIDS prevention and care, not only in the Northern region but also for the rest of the country and other countries in this region. NAPAC has encouraged and supported the formation of PLWHA groups and their network in the North. NAPAC also has a resource centre to coordinate and disseminate information to local agencies working at community level. At the same time, it acts as coordinator between local implementing agencies, communities and policy makers at local, national and international levels. NAPAC has become an important catalyst, facilitating platforms and opportunities for meetings of field workers, local government organizations, NGOs, CBO leaders, academics, researchers, and policy makers.
CONCEPT OF PREVENTION
The concept of HIV/AIDS prevention has rapidly evolved during the last decade. This dynamic response to the epidemic has led to changes in approaches from the individualist and information-driven notions of HIV/AIDS education to more multidimensional models of collective empowerment and community mobilization, as these provide a more effective strategy for the long term.
Over the first decade of the epidemic in Thailand, HIV/AIDS prevention principles were dominated by the notion of 'individual risk', i.e. that specific behaviours which open the way for HIV transmission are linked to individual attitudes and beliefs. After years of deliberation by the academic community and the experience of AIDS activists in the country, this conception of risk was broadened to a more collective social configuration. This paradigm shift was reflected in the National AIDS Plan for the period of 1992 - 1996, then reformulated in the strategic plan for 1997 - 2001. This demonstrated the shift from the notion of individual risk to a new understanding of 'social vulnerability'.
Another important issue concerns the scope of implementation of HIV/AIDS programmes. In the first few years of epidemic, government sectors and some NGOs with international financial support played a major role in the HIV prevention programmes. In the early 1990s, the government initiated a national programme with a fiscal budget and provided a leadership role through the National AIDS Plan. A few years later, more partners - the private sector, community-based organizations and the academic community - participated in this programme, thus expanding the civil response to HIV/AIDS. The nature of the programme changed from a project-based approach to an empowerment approach, which allowed participation with equity.
Another important issue was the concern about PLWHA. In the early days of epidemic, the crucial aim was to prevent the transmission of HIV. Within a decade, it was realized that the HIV epidemic had become endemic, with nearly a million people infected with HIV in the country. Medical and social technology to treat PLWHAs developed rapidly and HIV/AIDS has almost become a manageable chronic illness. Programmes now focus on PLWHAs as an essential human resource to prevent further transmission, rather than as a consequence or reservoir of the epidemic. Collaboration with PLWHAs has been developed, and they are partners in planning and in the implementation of a wide range of prevention programmes from the national plan to community action.
Specific approaches to prevention
The HIV sentinel surveillance programme is an information system developed in 1989 to trace the magnitude of the disease in Thailand. Information from this system has enabled social and behavioural research to be developed, and has provided for policy makers with useful data and the public with innovative forms of knowledge. It has been a challenge to change the beliefs of different sectors of the society toward the people with HIV/AIDS and to eliminate discriminatory practices. Collaboration between the media, journalists, NGOs and entertainment leaders has been used to develop public information to mobilize society around a common objective to fight together against discrimination and stigmatization.
In Thailand, television is a primary source of knowledge about HIV/AIDS prevention. Since 1990, warning messages about HIV/AIDS have been aired regularly and repeatedly on television as part of the national strategy to minimize transmission of HIV. The education and prevention messages chosen do more than suggest measures to avoid infection. They have also tended to define the characteristics of people who are signified as threatening agents of infection. In Thailand, sex workers and drug users are portrayed as the 'feared other'. Because sex work is so widespread, the demarcation of sex workers as a high-risk group signals a threat that cannot be easily subjected to conceptual distancing.
The 100 percent Condom Campaign has contributed significantly to the decrease of HIV transmission among female commercial sex workers and their clients. The programme was invented and developed at the end of 1980s and launched as an innovative national programme in 1991. Under this programme, the government provides condoms and education through existing STD clinics to sex workers and at the same time encourages brothel owners to insist on their clients using condoms. The increasing rate of condom use in commercial sex has been reported as evidence of this successful programme.
Educational and service programmes have learnt that they have a limited influence on the reduction of HIV transmission without the involvement of the infected community. By 1995, the approach to HIV/AIDS prevention at the community level gradually became 'holistic', with a focus on strengthening the community and developing a greater level of self-reliance economically, socially and culturally. Holistic also means multisectoral and integrated community development, an approach represented in the statement 'Only if the community is strong, will we be able to cope with HIV/AIDS'. To reach this level of self-reliance, people need to be involved in their own community development. They have to play a major role in all programmes and projects. To this end, local community initiatives are promoted.
Workshops and group interaction
During the recent years, there was a shift from presentations in big seminars and training to small workshops, focus groups, and more interpersonal and interactive methodology, from mass media to more local and cultural media with local community participation, taking cultural diversity into consideration.
Community leaders have played a significant part in raising awareness and reducing fear. At the beginning of the social intervention period, stigma was a major problem of HIV/AIDS, and it was foreseen that many Buddhist temples would become hospices and that PLWHAs would die in the temple because they were not accepted by their families and communities. In Chiang Mai, in the north of the country, for example, a hospice run by Phra Phongthep found that most patients were taken to the hospice because relatives had an incorrect understanding of HIV/AIDS. He would spend time talking with relatives, and as a consequence many relatives would take the patient home, while others would stay at the hospice only for one or two days. Today, there are only three hospices in Thailand, two run by Buddhist monks and one by Catholic monks (Franciscans). Most of the monks involved in HIV prevention at community level provide moral support and places to meet in the community, include HIV information in their sermons, and visit people with HIV/AIDS. Some are trained counsellors in HIV/AIDS.
Another important group at inter-village communities level are traditional healers. Only a small number of the 200,000 traditional healers in Thailand retain their traditional function and virtues. They play an important role in providing medical and psychosocial care to people with AIDS and their families. Their treatment is holistic and includes traditional use of herbs, oil, massage, alternative and complementary therapies. Many of these healers are important resource persons and are well respected and listened to by their communities.
Some new initiatives are being taken by community savings groups. These groups use part of the dividend fund from yearly profits to support families affected by HIV/AIDS. An NGO in the North has been providing matched funds (a long-term loan with an interest rate decided by the community) to these savings groups, with the condition that the profit gained should be used for the welfare of community members. Although this NGO has not directly mentioned that the group should share the profits with affected families, many groups have started to do so. Some savings groups provide members with a small sum for their hospital fees and for funeral or cremation expenses. There are savings groups in the Southern region that pay the hospital bills of members and provide scholarships to children with their self-supported welfare fund created by the savings groups. Although it is only a small amount of money, it is a meaningful act of solidarity of the community towards PLWHAs and their families. Some communities have created other forms of fundraising. One of the most popular ways is the 'Pha-pa' ceremony. It is a traditional Buddhist ceremony whereby people make an offer to the temple in cash or in kind. Many Buddhist monks have given all the offerings to set up a fund to support people with HIV/AIDS and their families and to support HIV/AIDS activities in the community. These models have been proposed as an alternative and adjunct to government funds and may contribute to the creation of community welfare system and social security that will be important step towards self-reliance of the community.
Involvement of PLWHAs
The first group for PLWHAs, the 'Wednesday Friends Group', was coordinated by the Thai Red Cross Society in 1991, followed by the 'Thursday Friends Group' which set up by a branch in Chiang Mai. In 1993, the 'New Life Friends Association' (NLF) was established and this was the first group to be run by PLWHAs. The group now has several hundreds of members and is supported by NAPAC and NGOs. NLF provides counselling services to people with HIV/AIDS and their families. They also visit people with HIV/AIDS and their families in urban and rural communities and are well-recognized resource persons for meetings, seminars, training and conferences at all levels. Association members speak to village communities, to school and college students, and to Rotary and Lion Clubs. The board members identify themselves and tell their stories to the public. To date, twelve life stories of NLF members have been published by NAPAC in a weekly magazine, as a way of raising awareness and to raise funds for people with HIV/AIDS. They are now being republished by the Ministry of Education to be distributed to all schools in the country.
Soon after the formation of the NLF Association, the Widows of Doi-Saket formed their group. These women had lost their husbands to AIDS, and some of these women and their children were infected with HIV. They got together to support one another and their communities. Since many suffered financial hardship and could not continue working, they would meet at the community temple to produce brooms, clothes and other handicrafts to earn some money for their families. The Doi-Saket Widows have become well known to the public since an appearance on national TV. The Widows group has now changed its name to the 'Women's Friendship Group' as most of its members have remarried. They actively participate in the district AIDS programme of Doi-Saket, one of the most successful examples of HIV/AIDS prevention and care programme at community level. Today, there are twenty-six groups representing people with HIV/AIDS in the Chiang Mai province, about thirty groups in the other provinces of the North, and about eighty groups in the whole country. They can be grouped as following:
· self-organizing groups, such as NLF and Widows group;
· groups initiated and supported by NGOs;
· groups initiated and supported by community hospitals;
· groups initiated and supported by Buddhist monks and temples.
Most of these groups are situated in communities. The NLF and a few other groups are located in towns. They have between 50 to 200 members, and most of these members are full-time or part-time volunteers, providing service to their members, families and communities. They visit families, give counselling and information about basic health care, help solve psychosocial problems, assist and coordinate support with hospitals and local government organizations and NGOs. Some of them have become community 'leaders', not only in HIV/AIDS but also in other matters of community concern.
Academics and researchers have participated in HIV prevention and care, not only through their research activities and contribution to medical and social science, but also through direct involvement in communities in urban and rural areas. They have been resource persons for seminars and training for government organizations, NGOs, CBOs, PLWHA groups, providing information and technical support. Involvement of social researchers commenced in the late 1980s. Many researchers have been catalysts for HIV prevention activities. They have coordinated meetings of government organizations, NGOs, CBOs, PLWHA groups, to assess situations and discuss issues for cooperation among local organizations. They process data and information, especially 'lessons learned', and facilitate forums for the exchange of information.
The Social Research Institute (SRI) at Chiang Mai University has played an important role in facilitating the process of learning for all parties involved in HIV/AIDS. They have developed a number of participatory action-research projects within communities. SRI has also given technical support to the networks of NGOs, groups of PLWHAs, traditional healer groups, CBOs and Buddhist monks activities. SRI also includes HIV/AIDS in their other projects including environmental CBOs and NGOs, advocacy and human rights groups. Some SRI and Faculty of Education researchers are directly involved in the application of Participatory Rural Appraisal (PRA). They are important resource persons for the training of trainers, not only in the Northern region but also in neighbouring countries. Many of them have been working directly with slum communities, construction workers living at the construction sites, and street children. They assist schools with curriculum development in applying PRA and Life Skill training in the schools. The Women's Study Centre at Chiang Mai University also plays an important role in HIV prevention. In addition to organizing meetings, seminars and workshops on women and HIV/AIDS, it conducts and coordinates many participatory action-research projects.
In addition to major universities in Bangkok and three other regions (Chiang Mai, Khon Khaen, and Songkhla), there are thirty-six Rajaphat Institutes (former Teachers Colleges) located mostly in provincial towns all over the country. Many of these are involved in HIV prevention programmes. Since most of the students are from the rural areas, they have great potential to work with communities. Rajaphat Institute, Chiang Rai, is known for their HIV/AIDS prevention programmes in communities and their projects with traditional health care. This Institute is also known for its involvement with farmers' cooperatives, savings groups, and Life Skills training for street children in Chiang Mai. An important role for academics and researchers has been to monitor and evaluate HIV/AIDS prevention and care programmes and projects implemented by government organizations, NGOs, CBOs and PLWHA groups.
COMMUNITY AND GOVERNMENT
The Ministry of Public Health has played a major role in facilitating and coordinating the HIV/AIDS partnership. At provincial level, the governor heads the provincial AIDS committee, with a provincial chief medical officer as secretary, and representatives of other ministries as members. At district level, the head of the district chairs a district AIDS committee, with the district public health officer or director of community hospital as secretary, and district representatives from other ministries as members. Health officers are appointed to provide care at this level and their activities include home visits, facilitating focus groups in primary and secondary schools, colleges and universities, collaborating and coordinating with other local government organizations, NGOs, CBOs, and PLWHA groups. In every province, an HIV/AIDS Foundation has been established to raise funds to support HIV/AIDS prevention and care programmes. The Ministry of Interior, Ministry of Labour (with its Department of Welfare and Department of Human Resource Development) and Ministry of Education actively participate in the HIV prevention programmes at provincial, district, sub-district and village community levels.
Phayao, a small province in the North, has become a model for all other provinces in the country for HIV/AIDS prevention and care. It has set up a provincial AIDS centre, which provides information, health promotion resources, and coordinates human and financial resources from all ministries, including plans and action programmes. In 1994, the centre trained trainers and a group of resource persons from all ministries in the province to train others at district, sub-district and village community levels. About 650 resource persons have been trained through the PRA method. The aim of this programme is to assist CBOs in all village communities to plan and undertake their own actions. They are supported by seeding funds from the provincial AIDS centre.
At a district level, heads of districts coordinate representatives of other ministries to strengthen communities. There are groups of volunteers consisting of teachers and representatives of ministries, heads of village communities and CBOs, and PLWHAs who facilitate focus group discussions not only to raise awareness of the community, but also to prevent and solve problems related to HIV/AIDS. The communities are given a major role in solving their own problems. The government organizations provide them with facilities, seeding funds and advice. The Ministry of Labour has also established workplace HIV prevention programmes, which includes seminars and training are organized for both owners, human resource managers and workers. Some of the events are organized jointly with NGOs.
Schools curricula include HIV/AIDS education. Although the majority of schools still follow the curriculum developed at the Ministry of Education in Bangkok, there are some schools that have developed their own HIV prevention programmes. Within many schools there are teachers who are actively involved in community activities and where there is close cooperation with communities and NGOs. They have anti-AIDS clubs, in and outside of school activities, organizing youth camps, drama groups playing in schools and in communities.
The Bangkok Metropolitan Administration has its HIV prevention programme in all its districts through community health centres and hospitals. This includes the 'Friends Help Friends' project, curriculum development for schools, and support to NGOs working in slums, with street children, factory workers, sex workers, the gay community, and other specific target groups and areas. Besides counselling, the programme includes home health care and urban community development schemes.
From 1984 to 1990, HIV/AIDS was perceived to be a newly emerging public health problem. The Ministry of Public Health became a major player in determining national policies and strategies for HIV/AIDS. In 1991, there was a turning point in the Royal Thai Government's AIDS policies, strategies and programmes. The epidemic had spread to all sectors of the society and it became apparent that more concerted efforts and innovative strategies were needed. Hence, the National AIDS Prevention and Control Committee under the chairmanship of the Prime Minister was established. Members of this committee comprised representatives from the government sector, the private sector, NGOs and academia. In the current National AIDS Prevention and Control Committee there are two members who are representatives of PLWHAs.
It was recognized that a comprehensive multisectoral approach was highly desirable, and efforts were undertaken to involve all government agencies, NGOs, the business sector and the community. As it was seen as a national development issue, the National AIDS Prevention and Control Plan for 1992 - 1996 was formulated under the coordination of the office of the National Economic and Social Development Board (NESDB), which is the national planning authority. This was to ensure smooth cooperation among the government agencies, NGOs and the private sector in formulating a comprehensive action plan for the medium term. According to this plan, government funding was allocated to meet the initial demands. In 1993, all fourteen ministries submitted funding requests in accordance with the programmes specified in the National AIDS Plan, amounting to US$44 million. The National AIDS Programme's budget was subsequently increased to US$82.3 million in 1996.
In 1995, the national strategic plan was revised and the National AIDS Prevention and Alleviation Plan for 1997 - 2001 was formulated to address another crucial turning point in HIV/AIDS government policy. The plan shares concepts and features of the National Development Plan, which are holistic, people-centred and participatory. A crucial focus of the strategy is empowering the people to prevent and solve HIV/AIDS problems with their families and communities, and to creating an enabling environment. In the next five years, the plan will provide a management approach to strengthen civil society and to increase the efficiency, flexibility and accountability of the civil services, in order that it can respond to local problems more effectively. In this sense, the national HIV/AIDS plan will be an effective mechanism for enhancing as well as accelerating the development of the whole nation.
MEASURES OF SUCCESS
The indicators to measure the success of interventions to contain the HIV epidemic are:
HIV epidemiological data have revealed that the rapid upsurge of HIV infection among injecting drug users and sex workers has not been matched by interventions among these groups, e.g. the prevalence of HIV infection among injecting drug users is as high as 46.7%. Government suppression of sex work in 1995 resulted in difficulties in accessing these people, so sex workers were not categorized and the rates of HIV infection among this group appeared low at 16.7% in June 1996. These indicators reflect the failure to stop transmission in these vulnerable populations.
Since 1991, there has been an aggressive approach to HIV public education for the general population. This appears to have resulted in an increased knowledge and behavioural change among some population groups, in particular young men. HIV seroprevalence rates among new military conscripts reflects this behaviour change among young Thai men. Surveys of army conscripts are conducted annually in May and November. The peak of HIV prevalence was about 4% in May 1993 and then declined to 1.9% in November 1996. A behavioural study of the sexual behaviour of army conscripts in the last few years found a decline in visits to sex workers, while those attending brothels were using condoms more often. These changes of practice were seen to be associated with increased knowledge of HIV/AIDS. Another change has been in rates of infection among antenatal clients. Within this group, HIV had been gradually increasing since 1991; in June 1995, rates of HIV began to decrease from 2.6 % to 2.3 % in December 1995 and to 1.7% in June 1996.
The public in Thailand appears to be 'getting used' to HIV/AIDS. However, the level of acceptance of people with HIV/AIDS varies between urban and rural areas, and among rural village communities from one district to another, one province to another, one region to another. In the three Northern provinces, where HIV prevalence includes about half of the total number of people with HIV/AIDS in the country, and where HIV/AIDS prevention and care programmes have been intensively implemented since 1990 by government organizations, NGOs, CBOs and PLWHA groups, the level of awareness of communities is high compared with neighbouring provinces.
In most communities, PLWHAs live ordinary lives as community members cared for by family members, relatives and friends. This generally is the case for PLWHAs who were 'good' members of the community, particularly women infected by their husbands. There is still discrimination towards those who are considered less worthy of care, and they are often left to care for themselves within their communities. In many rural areas, PLWHAs are often known in their communities. Some choose to reveal themselves, while others are known about. Many of them join PLWHA groups near their home. The level of acceptance of HIV/AIDS among communities is reflected in the number of PLWHA groups and a large number of people within communities becoming volunteers. Forming groups of people with HIV/AIDS does not mean creating separate identities that may isolate people with HIV/AIDS within communities. It becomes a means to an end. PLWHAs are developing solutions to their own problems, which existing CBOs cannot always address. Through forming a group, they can also assist the community in both prevention and care activities. One major measure of success is that now more and more communities, rural and urban, are supported by government organizations and NGOs in taking a leading role in HIV/AIDS prevention and care. They actively participate in the decision-making, planning and implementation of projects within their community. HIV/AIDS is integrated into general community development programmes and new initiatives are emerging which will lead to greater self-reliance and sustainable community development.
AT WHAT COST?
In 1988, the initial funding for the National AIDS Programme was US$ 180,000 million. The budget in the first few years covered the dissemination of educational messages and health care reorientation to ensure the safety of all health facilities. Under the National AIDS Prevention and Control Committee, the national budget in the financial year 1992 was increased to US$25.5 million and around 50% of this was for education, information and communication. In 1996, the budget increased to US$82.3 million for the National AIDS Prevention and Control Programme. Around 40% of the budget was used to strengthen the medical care and health care for people with AIDS, while prevention efforts were funded through another 40% covering socio-behavioural modification and HIV medical safety. Social welfare activities for the people with HIV/AIDS and their families amounted to 8% of the budget. The rest of the budget is utilized for research and administrative activities.
Community resource mobilization
Resources are provided by the government, local and international NGOs, bi- and multi-lateral organizations; however, the business sector has yet to find its place. It is hoped that tax incentives will encourage further resources from the business sector. Much is still to be done in workplaces and there is an urgent need to involve the community of 'business people'.
As Thailand is becoming a newly industrialized country, there is less and less financial support from international NGOs, bi- and multi-lateral organizations for local NGOs. Prevention and care programmes have to rely more and more on local resources from the government and from the public. It is a challenge for them to create mechanisms to pull resources from various sources within the country to ensure the sustainability of programmes. It is not only the funds, but how to combine fund-raising and awareness-raising in the same activities, and how to include them in the process of learning and in the process of development.
For a sustainable HIV/AIDS prevention and care programme, all kinds of communities need to be involved. They must have an active role in decision-making, planning and implementing prevention and care programmes. Government organizations, NGOs and other parties should support their efforts and initiatives. While rural communities seem to be on the right track, much is still to be done as far as urban communities are concerned. There is much to be done to strengthen civil society, especially urban centres, service and industrial sectors. Gender issues need to be addressed and programmes that enable financial support and improve the status of women need to be developed. Additionally, there needs to be contributions from the academics and researchers towards greater understanding of gender issues.
The most important lesson learned is the possibility of working in partnership. Government organizations, NGOs, CBOs, PLWHAs, academics and business people are major partners. Where they have been able to work in partnership, half of the success is already ensured. Partners have to have a common understanding at least of the basic issues, starting with developing human and personal relationships. Not everybody can become partners and work in partnership with others. It is about creating a 'strategic alliance', where it is essential to identify who will be included, how the alliance will be developed, and how partnership arrangements will work in practice.
Many resources exist within communities and much needs to be done to mobilize all possible resources. There is a need for innovative strategies and mechanisms to raise resources. Matching village funds or savings group to create sustainable community welfare systems is one feasible and practical strategy. PRA, Life Skills and focus groups are examples of how to involve communities. Tax reduction for a company's investment in education and welfare measures for people with HIV/ AIDS in workplaces is a potential means for more active involvement by the private sector. In each 'community', there is an urgent need to develop appropriate mechanisms to raise the awareness and involvement of its members.
The holistic approach is most appropriate to deal with HIV/AIDS. Only integrated, multisectoral community development can make it possible for communities to cope with this disease. HIV/AIDS has necessitated cooperation of all parties to work together. Even if, one day, there is a vaccine against HIV/AIDS, the better 'vaccine' is family warmth, love and compassion, values of life, strong community, self-help organization and self-reliance.
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