Best Practice Criteria

This programme meets four of the UNAIDS best practice criteria:

Effectiveness

The 100% Condom Programme has contributed to substantial and well-documented increases in condom use in sex work throughout Thailand.

While use rates are not 100 per cent, they do exceed 90 per cent in many direct and some indirect sex establishments. The programme has had somewhat less success in some harder to reach indirect sites, but condom use rates in these sites are still substantially higher than they were before the start of the programme. Given the role of sex work in HIV transmission in Thailand, and how well the increases in condom use in sex work mirror the major reductions in STDs and HIV incidence observed in the country, this programme has clearly assisted in efforts to control the HIV/AIDS epidemic (UNAIDS 1998). In concert with the National AIDS Education and Condom Promotion Campaign, this programme has also contributed to observed prevalence declines of HIV among young Thai men, pregnant women, and sex workers on a national scale.

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.

In 1997, a survey showed that condom use with girlfriends had risen to 40% and with other women to more than 60% (see Table 1). In a survey in 1990 (Sittitrai et al. 1992), consistent condom use with noncommercial female partners was closer to 20%, rising to roughly 30% in a survey in 1993 (Thongthai and Guest 1995). That represents a major change in behaviour between 1990 and 1997.

Table 1 Percentage of men using condoms every time by type of partner in the past 12 months, 1997.

Relevance

The 100% Condom Programme was designed and implemented with a good understanding of both the context and importance of sex work in Thai sexual culture. Rather than trying to eliminate sex work, it chose a pragmatic and cooperative approach of working within the existing institutions to prevent HIV and STD infection. This was strongly in keeping with the traditional non-confrontational nature of Thai society. The programme made good use of existing governmental structures of more than one ministry to enlist the active participation of various sectors of society. Finally, it was aimed at the source of most new infections in the Thai epidemic, as determined from careful epidemiological and behavioural monitoring in the country, making it directly relevant to the local situation. Over time, the shift to indirect forms of sex work has lessened its relevance to the current state of the Thai epidemic, and the programme needs to make greater efforts to find effective approaches for those sites.

Efficiency

Good use was made of existing public health and authority structures and personnel within the country to produce rapid increases in condom use on a national scale and rapid expansion of the programme to national coverage. The activities were implemented according to locally developed strategies, with good monitoring and evaluation of behavioural and epidemiological outcomes using existing sources of STD and HIV data, and in accordance with policies laid out at the national level. While considerable resources went into expanding STD care and promoting and delivering condoms as part of this programme, the benefits in infections averted vastly outweigh the resources invested.

Sustainability

The programme has contributed to changes in norms regarding condom use in sex work and visits to sex workers, changes that are likely to persist. Among young males, condom use in commercial sex is now expected, and reductions have already been seen in the percentage of men visiting sex workers. The programme is sustainable because it was institutionalized within existing national policy, national plan and health infrastructures with strong involvement of people at all levels (national, regional, provincial, and district). In fact, it encourages stronger links between the national, regional, and local efforts because of the technical assistance efforts between the national programme, the RCDCs, and the PPHOs. A strong sense of ownership of the programme was expressed in interviews in almost all provinces, along with a belief that the activities being undertaken were making a difference. The improved relationships among health workers and owners and managers of establishments have made ongoing activities easier. Finally, the national policy and implementation of the 100% Condom Programme have been functioning since the early 1990s. However, in terms of future sustainability, new strategies need to be developed that can be effective in indirect sites.