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close this bookHIV Prevention Needs and Successes: a tale of three countrie (UNAIDS, 2001, 25 p.)
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View the documentIntroduction
View the documentUganda
View the documentSenegal
View the documentThailand
View the documentSummary

Thailand

Few countries show the link between behaviour and HIV infection as clearly as Thailand.4 Overall, behavioural changes have reduced the number of new HIV infections each year from almost 143,000 in 1991 to 29,000 in 2000.5

4 For more information, see Relationships of HIV and STD declines in Thailand to behavioural change: a synthesis of existing studies, Key Material, UNAIDS/98.2, 1998. See also Collecting lower HIV infection rates with changes in sexual behaviour in Thailand: data collection and comparison, Case Study, UNAIDS/98.15, June 1998, and The success of the 100% Condom Promotion Programme in Thailand: evaluation of the 100% Condom Promotion Programme and the validation of the decline in trends for selected STDs, Institute for Population & Social Research, Mahidol University, Thailand (funded by the Thai Ministry of Public Health and UNAIDS, February 2000).

5 Projections for HIV/AIDS in Thailand: 2000-2020. The Thai Working Group on HIV/AIDS Projection Bangkok, June 2000.

Thailand has a little over 60 million people, about 20% of whom live in cities. The gross national product per capita is equivalent to about US$ 2700. HIV prevalence among adults is estimated at about 1.9%, with higher prevalence in certain geographical areas and among certain groups. Thailand’s HIV prevalence is lower than that of Uganda, but it means a similar number of people living with HIV/AIDS.

Until the end of 1987, ad hoc testing in men having sex with men, in female sex workers and in injecting drug users (IDUs) revealed few HIV infections. Then in 1988, rapid growth of HIV infections among IDUs first gave the Thai authorities a clue that a problem was emerging. The prevention programme in the 1980s focused on knowledge and fear; it was sporadic, lacked continuity and was aimed only at the so-called “high risk” groups.

After the rise in prevalence among IDUs, Thailand quickly set up a national sentinel system. In the first round of testing in June 1989, high infection levels were detected among sex workers in the country’s northern provinces. By June 1990, HIV prevalence among brothel-based sex workers had risen to 15% nationwide. Prevalence was also growing rapidly among young men.

In addition to the research for monitoring the epidemic, Thailand has conducted three rounds of a national survey on sexual risk behaviours using a similar methodology (in 1990 funded by WHO/GPA; in 1993 funded by the office of the Prime Minister; and in 1997 funded by Ministry of Public Health and UNAIDS). The preliminary results of the first national survey were presented rapidly to policy-makers, community leaders and the mass media. The level of risk behaviours among groups of the Thai population was strikingly high and made Thai society open its eyes to the HIV situation. This helped reinforce a push for multisectoral, intensive and extensive prevention efforts.

In 1991, some key government officials, politicians, academics and AIDS activists managed to increase government commitment. The strategies of the 1980s were replaced by a new approach - the so-called intensive and extensive prevention programme for rapid nationwide implementation using combined actions by the mass media and the community. Some of the guiding principles for the programme’s implementation, again based on the lessons learned during the 1980s, were that:

Focusing on populations with high risk behaviour, such as sex workers and injecting drug users (IDUs), is important but not enough - the general population and young people are also critical. Emphasis was placed on the risk behaviour and vulnerability of young people as well as on the more specific risk behaviour of particular groups.

It is necessary to reach the population both extensively (on a broad level) and intensively (through many channels at the same time).

Knowledge and awareness are important but are not sufficient; life skills training (e.g. decision-making and negotiation), condom promotion and long-term approaches such as changing social norms are also necessary.

Socioeconomic interventions were introduced to reduce vulnerability to HIV infection; for example, increasing the opportunity for girls to continue their schooling and to receive vocational training so that they are less likely to become sex workers.6

Rapid implementation aimed at extensive coverage in a short time, with intensive efforts between 1991 and 1993, created both a programmatic momentum that was carried on by subsequent Thai administrations and a societal momentum by which all regions of the country felt they had a part to play.

6 For further information, see the Case Study UNAIDS/99.34E, Reducing girls’ vulnerability to HIV/AIDS: The Thai approach, June 1999).


The effective nationwide prevention programme, which began in 1991, included several elements:

The Prime Minister chaired the National AIDS Programme.

The Office of the Prime Minister took an active role in policy discussion, led the national public education effort using government-run mass media (that is, public, not private), and took part in monitoring.

The Parliament established a sub-committee on AIDS.

The National Economic and Social Development Board worked closely with the Ministry of Public Health to integrate the National AIDS Plan into the five-year National Development Plan.

The government AIDS budget increased drastically during the following years.

Each key ministry had its own AIDS plan and budget as well as a person as the AIDS focal point.

All provincial governors led the AIDS programme in their respective provinces through the provincial development planning system.

The business community, people living with HIV/AIDS, religious leaders and other community leaders became very involved in contributing to policy dialogue, resource mobilization and the local implementation of activities.

In Thailand, 1991 was the turning point on human rights protection for people living with HIV/AIDS. HIV was removed from the list of diseases that required notification to the health authority. The ban on entry to Thailand of people with HIV/AIDS was lifted. A set of national policy guidelines to protect the rights of people living with HIV/AIDS was issued.7

7 Jon Ungphakorn and Werasit Sittitrai. The Thai response to the HIV/AIDS epidemic, AIDS 1994, 8 (Supplement), pp./S155-S163.

One of the most striking effects of the national programme was shown in the number of visits to sex workers. This is the behaviour most closely associated with HIV infection in Thai studies.

Fig. 10 shows the figures for urban men aged 20-24 and 25-29 who visited sex workers. The proportion of the younger group who said they had visited a sex worker in the past year fell to about 17% in 1993 from over 35% in 1990. It fell even more sharply among those aged 25-29. Men aged 15-49 visiting sex workers dropped from approximately 19% in 1990 to 9% in 1993.8 The proportion has changed little since 1993, but the lower levels have been sustained according to the 1997 survey.

8 Thai Working Group on HIV/AIDS Projection. Projections for HIV/AIDS in Thailand: 2000-2020. Bangkok, June 2000.


Fig. 10: Substantial and sustained risk reduction in urban males visiting sex workers 1990-1997

An effect of this nationwide intensive and extensive prevention programme can be seen in the drastic reduction in the number of Thai men having commercial sex not only in Bangkok but also in all other regions.

Sustained increase in condom use is a major indicator of success in the Thai prevention effort. Between 1990 and 1993, data from national surveys show a sharp increase in consistent condom use among men who visited sex workers. This increase occurred in Bangkok and in all four regions of the country.

Another study in Bangkok (Fig. 11) shows that the percentage of males visiting sex workers declined according to the data of 1993, 1994 and 1996 among all three groups (STI clinic attendees, service workers and students).


Fig. 11: Risk reduction continues


Fig. 12a: Risk reduction still continues

How does behavioural change correlate with the prevalence of HIV and STIs?

Between 1991 and 1998, researchers found among military conscripts of northern Thailand a reduction in visits to sex workers, lifetime history of visiting sex workers, and HIV prevalence, while at the same time condom use with sex workers increased dramatically (Fig. 12a and 12b).


Fig. 12b: HIV prevalence in northern Thai military conscripts, 1991–1998

How do we link the epidemiological patterns with these behavioural changes? The patterns of other STIs are independently related both to commercial sex and to HIV infection. Logic suggests that condom use would be associated with lower rates of STIs. That logic is borne out in Thailand (Fig. 13).


Fig. 13: Comparison of increase in condom use with decline in reported male STIs on a national scale, Thailand 1989 to 1994

At the time of the study shown in Fig. 13, the intensive and extensive prevention programme had been in effect nationally for six years. During that time, reported STI rates in the country fell by over 90%, as did condom “non-use”, which tends to change in step with STI prevalence.

Major prevention packages were implemented side by side and each one reinforced the achievement of the other. These were intensive media campaigns, peer education, workplace AIDS programmes, life-skills training for young people, non-discrimination campaigns, and the famous 100% condom programme in all commercial sex establishments (which was accompanied by the distribution of free condoms and the campaign for condom use among the general male population).

In this context, what happened to HIV prevalence on a national scale? Evidence shows that it declined substantially.


Fig. 14: Trend in HIV prevalence in 21-year-old Thai military conscripts

When military conscripts from all regions of Thailand were tested in 1999, a considerably lower proportion of 21-year-old conscripts were found to be infected than in the peak years of 1992-93 (Fig. 14). This indicates that very significant changes in behaviour among young Thais have continued. A recent study shows that HIV prevalence among 21-year-old conscripts had fallen to 1% by 1991 from a peak of 3.5% in 1992.9

9 The Armed Forces Research Institute of Medical Sciences


Fig. 15: Reduction in male, female, and total STIs reported at government clinics between 1985 and 1996

As in Senegal, the number of reported cases of new STIs may be an indicator of recent sexual risk behaviour.

Thai government clinic data here suggest strongly that unprotected sex with high- risk partners continues to decline (Fig. 15). In 1985, about 400,000 people were diagnosed with STIs, with men much more represented. The numbers began to fall sharply around the time that the national AIDS strategy got under way. By 1996, the total was under 50,000.10 An independent evaluation review in 1997 confirmed this decline through data from population and drugstore surveys on self-reporting of STIs and sales of antibiotics. The 1997 survey also showed that over 70% of sex workers in a range of establishments (brothels, hotels, bars, massage parlours, restaurants) had STI checks at least once a week (Fig. 16). STIs among sex workers were roughly at 25% in 1989 and fell steadily to 1.6% in 1999.11


Fig. 16: Percentage distribution of frequency of STI checks of sex workers by sector of employment – 1997

As in Senegal, the number of reported cases of new STIs may be an indicator of recent sexual risk behaviour.

Thai government clinic data here suggest strongly that unprotected sex with high- risk partners continues to decline (Fig. 15). In 1985, about 400,000 people were diagnosed with STIs, with men much more represented. The numbers began to fall sharply around the time that the national AIDS strategy got under way. By 1996, the total was under 50,000.10 An independent evaluation review in 1997 confirmed this decline through data from population and drugstore surveys on self-reporting of STIs and sales of antibiotics. The 1997 survey also showed that over 70% of sex workers in a range of establishments (brothels, hotels, bars, massage parlours, restaurants) had STI checks at least once a week (Fig. 16). STIs among sex workers were roughly at 25% in 1989 and fell steadily to 1.6% in 1999.11

10 In Thailand, STI prevalence data are available only for people who seek treatment at government clinics. There is a sizeable private sector client base that is not included in these figures.

11 Thai Working Group on HIV/AIDS Projection. Projections for HIV/AIDS in Thailand: 2000-2020. Bangkok, June 2000.


Fig. 17: Increase in condom use with recent clients as reported by sex workers at direct sex establishments, 1989–1997 (data from 1995 to early 1997 are not available)

The 1997 survey shows that consistent condom use among sex workers increased from over 50% in 1990 to almost 90% in 1996 (Figs. 17, 18, 19).


Fig. 18: Percentage distribution of reported regularity of condom use with casual customers by type of SE - 1997

The news is not uniformly good, however. Condom use appears to be lower among men from rural areas, and among men with limited formal education. National behavioural surveillance in the provinces revealed that only half the men reporting commercial sex said they had always used a condom. As in the case of Uganda, different or more intensive strategies appear to be necessary for rural populations.

The 100% condom programme was remarkably successful in expanding condom use between sex workers and clients. Other complementary programmes aimed at young people and the general population also increased condom use in non-commercial sexual relationships. This is especially important because of a shift in sexual behaviour away from commercial sex towards more casual sex


Fig. 19: Percentage distribution of reported regularity of condom use with regular customers by type of sex establishment - 1997

The figures for condom use with minor wives (that is, mistresses), girl-friends and friends are between 40% and 60% according to the 1997 survey (Fig. 20). The figures were much lower in the 1990 survey. That represents a major change in behaviour between 1990 and 1997. There is a misconception that if people know someone who has AIDS this will increase their level of consistent condom use. This does not, however, seem to be the case in many African countries where HIV prevalence is very high and condom use remains low. Successes in increasing condom use seem rather to be the result of intensive intervention programmes.


Fig. 20: Percentage of men using condoms every time by type of partner in the past 12 months – 1997

In Thailand, condom use during commercial sex increased rapidly between 1991 and 1993, during the first two years of the extensive and intensive prevention programme. These increases in condom use occurred uniformly across the country, both in regions where there were many people living with AIDS, such as the upper north, and in regions were there were few, such as the north-east. Thus, during that time, most people did not know anyone with AIDS but condom use increased anyway.

Later, according to the 1997 survey, an equal percentage of two groups of sex workers (those who knew and those who did not know someone with AIDS) always used condoms with their clients (Fig. 21). According to the Thai Working Group on HIV/ AIDS Projection, condom use in brothels nationwide rose from 15% in 1989 to 85% in 1999.


Fig. 21: Percentage distribution of risk status related to condom use by sex workers who know somebody who has AIDS – 1997

In summarizing Thailand’s experience, two implications are clear:

A national effort to promote safe behaviour and to change norms was followed by a drop in visits to sex workers and an increase in condom use during both commercial sex and casual sex.

Those changes in behaviour have been rewarded by a rapid decline in STIs and new HIV infections.



Fig. 22: Total number of people living with HIV and AIDS, new HIV infections, and cumulative HIV infections over time in Thailand - Baseline Scenario

According to the Thai Working Group on HIV/AIDS Projection, “the baseline scenario (Fig. 22) shows the number of HIV infections over the course of the epidemic and the fall in the number of new infections over the course. Since the start of the epidemic, 984,000 people (951,000 adults and 33,000 children) have been infected with HIV in Thailand. Of these, 289,000 people have died of AIDS. There are currently 695,000 people living with HIV/AIDS in the country. It is predicted that within the next year, there will be 29,000 new infections and 55,000 Thais will develop serious AIDS related illnesses requiring medical care and approximately the same number will die of AIDS complications”.

The evidence gathered by Thailand’s epidemiological and behavioural information systems has had many benefits. Perhaps the most important was to demonstrate convincingly that adopting safe behaviours can change the course of the epidemic on a national scale. These changes in behaviours, norms and the course of the epidemic can be achieved on a national scale in a few years - and these efforts need to continue.

According to the Thai Working Group on HIV/AIDS Projection, projections show that unless prevention levels are sustained at a high level, the epidemic could quickly gain momentum and start to increase rapidly. So the successes so far must not lead to complacency.