The World Bank 23783 M O N l T O R 11.1 7 -. ! Thailand's Response to AIDS "Building on Success, Confronting the Future" NOVEMBER 2 0 0 0 World Bank Office Bangkok Bangkok, 14th Floor Tower A Country Director: J. Shivakumar November 2000 Diethelm Towers Comments to: 93/1 Wireless Road Martha Ainsworth, Chris Chamberlin Bangkok 10330, Thailand mainsworth@worldbank.org Tel : (662) 256-7792 cchamberlin @worldbank.org The views expressed in the Thailand Social Monitor are entirely those of the authors and should not be cited without prior permission. They do not necessarily represent the view of the World Bank, its Executive Directors, or the countries they represent. The material contained herein has been obtained from sources believed reliable but is not necessarily complete and cannot be guaranteed. hailand's Response to Aff)S: Bfuilding o u CoIfating the Table of contents Preface ..................... ............................................... I Chapter I. Introduction and Summary ................................. ............1 Chapter II. Building on success: The Evolution of Thailand's AIDS Epidemic and the National Response ...... 5 The Early Spread of HIV/AIDS in Thailand ............................5 The Policy Response .................................. .......... 7 The Impact ......................................... ............. 11 Lessons Learned ...............................................12 Chapter III. AIDS in Thailand at the Turn of the Millennium ............ 17 A Severe Epidemic that Continues to Spread...................... 17 Urgent Need to Address Treatment Issues ................... ..........22 The Rising Impact of AIDS Morbidity and Mortality ............... ......28 Reduced Public Expenditure on AIDS Prevention ....... ................32 The Uncertain Impact of Health Sector Reform ...........................35 Chapter IV. Confronting the Future: Strategic Priorities for Enhancing the Response........37 A Framework for Setting Government Priorities ....................38 Strategic Priorities to Strengthen the Response ................. .........42 1. Sustaining and Expanding Condom Use Beyond Commercial Sex 2. A Major New Initiative to reduce transmission by injecting drug users 3. Ensuring Access to Cost-effective Prevention and Treatment for Opportunistic Infections Implications for Public Finance...............................47 Chapter V. Conclusion ............................................ ...... 53 Thailnd's iRes;nse to DS: Bsuilding on Sucess, Confroniting the Future Annexes 1. People consulted ......................................................... 54 2. References ............................................................. 56 3. Notes on Government AIDS program expenditures (Table 1) ...................... .... 63 Boxes I Injecting drug use and the spread of AIDS in Southeast Asia ................ ................ 5 2 Thailand's early success in ensuring a safe blood supply ................................ 7 3 Undocumented sex workers: A 'gap' in the 100% condom program? ............ .............. 20 4 Lengthening and enhancing the quality of life of AIDS patients .......................... 25 5 Preventing transmission of HIV from mother to child ................................. 30 6 AIDS and the private sector ................................................... 37 7 Preventing transmission between spouses: a challenge for AIDS programs .................. 41 8 The changing patterns of risk behavior among Thailand's youth ............................ 43 9 Heroin detoxification programs in Thailand ........................................ 45 Figures I HIV prevalence in high-risk groups ................................................... 6 2 HIV prevalence in military conscripts and pregnant women .................. ................ 6 3 Government and donor spending on AIDS, 1988-97 ................................... 10 4 Rising condom use and declining STDs, 1988-94 ..................................... 11 5 Declining HIV prevalence in 21-year old Thai Army conscripts, 1988-99, by region... ......... 18 6 Percent of 21-year old conscripts with sexual experience in the past year, by type of partner, 1995-99 ................................................... 18 7 Percent of 21-year old conscripts using condoms consistently by type of partner in the past year, 1995-99 ...................................................................... 18 8 Percent of brothel-based sex workers infected with HIV, by region, 1990-98 ................. 19 9 Percent of indirect sex workers infected with HIV, by region, 1990-99 ................ ..... 19 10 Percent of injecting drug users (IDU) infected with HIV, by region, 1990-99 ....... ......... 21 11 Percent of pregnant women infected with HIV by region, 1990-96 and 1997-99 ...... ........ 22 12 Number of reported AIDS cases, 1984 - 99, by region ................................ 23 13 Common AIDS-defining illness among reported AIDS cases over 10 years of age, 1994-98, by region ... ................................. ............................... 23 14 Trends in HIV infection rates among new TB patients, 1989-1998 .................... 24 15 Age-specific death rates for men, 1990 and 1996 .................................... 28 16 Trends in death rates for men age 25-29, by region ...................................... 29 17 Children in government welfare homes, 1992-97 ......................................... 31 18 Condoms purchased by the AIDS division, 1988-2000 .......................... ...... 34 19 Classification of target groups for prevention by riskiness of behavior and accessibility ............... 40 20 Hypothetical impact of a reduction in condom use to 50% in commercial sex in 1998 ............ 42 21 Impact of the 3 expanded intervention scenarios on cumulative HIV infections in the Thai population, 2000-2020 ......................................................... 44 Tables I Evolution of government national AIDS program expenditure in Thailand, 1997-2001 ..... ...... 33 2 Estimated total annual cost of ART, palliative care, and opportunistic infection management, under different scenarios on price and number of persons treated .................................... 50 1i Thaiand's Response to AIDS: Mildin~g on Su~'cc , Cqffrouting the Future Acronyms AFRIMS Armed Forces Research Institute of Medical Sciences AIDS acquired immune deficiency syndrome ART anti-retroviral therapy ARV anti-retroviral drugs AZT zidovudine, an anti-retroviral drug CDC Communicable Disease Control Department, Ministry of Public Health CBO community-based organization DOTS directly-observed therapy, short-course (for TB) HAART highly-active anti-retroviral therapy HIV human immunodeficiency virus IDU injecting drug user MDR-TB multi-drug resistant tuberculosis MOPH Ministry of Public Health MSM men who have sex with men MSW male sex workers MTCT mother to child transmission of HIV/AIDS NEP needle exchange program NESDB National Economic and Social Development Board NGO non-governmental organization OPM Office of the Prime Minister PHA people living with HIV/AIDS RTA Royal Thai Army RTG Royal Thai Government SIP Social Investment Project STD sexually transmitted disease TB tuberculosis UNAIDS Joint United Nations Program on HIV/AIDS UNDCP United Nations Drug Control Program VCT voluntary counseling and testing (for HIV) WHO World Health Organization Exchange rate (baht/$US): 1995 24.92 1996 25.34 1997 31.37 1998 41.37 1999 37.84 p! f,an' Resons t Cj,'fSoAIS Bu4ilinI o; Sucess , Confronting the FWulure Preface There are very few developing countries in the world where public policy has been effective in preventing the spread of HIV/AIDS on a national scale. Thailand-where a massive program to control HIV has reduced visits to commercial sex workers by half, raised condom usage, curtailed STDs dramatically, and achieved substantial reductions in new HIV infections-is an exception. This issue of the Social Monitor considers two important questions arising from Thailand's remarkable achievements in controlling HIV/AIDS. First, what are the lessons of this experience for countries in East Asia and the rest of the world? Half of the population of developing countries lives in areas where HIV is not yet widespread. Does Thailand offer lessons that can help these countries avoid catastrophe? The second question looks to the future: what are the new strategic priorities to control the spread of HIV/AIDS in Thailand's changing social and epidemiological environment? Thailand's signal achievement of reducing the number of new HIV infections over the past decade must be seen in the context of the still enormous impact of this epidemic. Nearly I million Thais have been infected with HIV since the beginning of the epidemic, and 289,000 have already died of AIDS. Nearly 700,000 are currently living with HIV/AIDS out of .a total population of 61 million, due to the past high infection rates and the long incubation period of HIV. As the epidemic matures, an increasing share of those who are HIV-positive will require medical care, and some households will be pushed into poverty. Thus, as we learn about Thailand's past success, we must also consider priorities for the future, given the large number of people infected and the continued spread of HIV. This report was commissioned by the World Bank Office in Bangkok as an outgrowth of our participation in the United Nations Thematic Working Group on HIV/AIDS in Thailand. The report is the work of a team of analysts which visited Thailand in June 2000 to consult with government officials, international agencies, non-govern mental organizations, and research institutes about their perspectives on the Thai HIV/AIDS control program. The report team consisted of Martha'Ainsworth, Ph.D., Senior Economist in the Policy Research Department of the World Bank; Chris Beyrer, M.D., MPH, School of Public Health at Johns Hopkins University; and Agnes Soucat, M.D., Ph.D., Senior Economist for the Africa Region of the World Bank. This report summarizes the results of the consultations and the recommendations of the mission team. The report concludes that Thailand's efforts to slow the AIDS epidemic have shown the potential impact such programs could have worldwide. However, unless past efforts are sustained and new sources of infection are addressed, the striking achievements made in controlling this epidemic could be put at risk. The report identifies several cost-effective investments that would have a large impact on the future course of the epidemic. The report also recommends that the growing demand for treatment and care be addressed urgently with cost-effective, equitable, and affordable solutions. It is also essential that the Government maintain and expand its focus on prevention if future generations are to be spared the threat of HIV/AIDS. In preparing this report, the team has had access to a vast body of empirical evidence on the AIDS epidemic in Thailand and has heard from many dedicated Thai and international professionals on how this public health menace can best be controlled. With the stakes so high, and with the suffering of people with AIDS so tragic and compelling, there is no shortage of passionate argument on the complex issues surrounding the control of HIV/AIDS. We have I Thailaind's Response to Ai3S: Builing on Success, Confronting the Future done our best to reflect these diverse perspectives and to cite the many contributions to our understanding of the HIV/AIDS epidemic in Thailand. Given the extensive work already available on HIV/AIDS in Thailand, the approach of this report is strategic and focuses on the big picture. The report seeks to identify the areas in which the Thai Government, building on past efforts and using its limited public resources, can have the largest impact in reducing the epidemic and in helping those living with HIV/AIDS. The report is not a comprehensive roadmap for the control of HIV/AIDS in Thailand, nor is it a detailed operational plan for new interventions. Those tasks are the responsibility of the Royal Thai Government, working in partnership with civil society organizations, the private sector, and international agencies. We hope this report provides useful guidance on priorities, knowing that the operational policies and decisions will come from the hard work and detailed knowledge of those battling this epidemic in Thailand day to day. On behalf of the team, I would like to thank the many people in and out of government who offered their views and insights as well as valuable data to document the issues. In particular, we would like to thank Dr. Anupong Chitwarakorn and Mr. Chawalit Tantinimitkul (AIDS Division, Ministry of Public Health), Ms. Waranya Teokul (NESDB), and Dr. Ying-Ru Lo (WHO) for their extensive assistance with epidemiological and budget data. The staff of UNAIDS, both locally and in Geneva, and the members of the UN Thematic Working Group on HIV/AIDS here in Bangkok have provided invaluable advice and support. J. Shivakumar Country Director World Bank Office Bangkok and Chairperson, UN Thematic Working Group on HIV/AIDS in Thailand 11 hodcxi's Respwse to AD7S: Building o Success, Conf ronting the Fuure Chapter I: Introduction and Summary This report was commissioned by the World brothel-based sex workers were infected in Bank Thailand Office in Bangkok to address all but one of the 14 provinces sampled. two issues of interest to both internal and The rising infection levels among sex external audiences concerned with the workers, which reached 31% nationally by global AIDS epidemic: (1) What are the 1994, launched subsequent waves of the lessons learned from Thailand's response to epidemic in the male clients of sex workers, the AIDS epidemic for other countries in the their wives and partners, and their children. region and the world? (2) What are the In 1993, infection rates among 21-year old highest priority activities for improving the army conscripts reached 4% nationally. effectiveness of the response to AIDS in Thailand? The report team consulted widely The National Response with key informants in Thailand (Annex 1) and drew on current literature and their own In 1990-91, the government acted areas of expertise to answer these questions. decisively, launching a nationwide campaign to reduce HIV transmission. The Thailand has demonstrated to the world the key elements of the program were a massive enormous scope for slowing an AIDS public information campaign launched epidemic fueled by commercial sex, but through the media, government, and NGOs there are still cost-effective investments that and a program to promote universal and government can make to have a large impact consistent condom use in commercial sex. on the epidemic. While demand for The response was lead by a multi-sectoral treatment must be urgently addressed with National AIDS Prevention and Control cost-effective and equitable solutions, it is Committee, chaired by the Prime Minister, essential for government to maintain and that actively engaged NGOs and civil expand its focus on prevention if future society. The results were dramatic. Fewer generations are to be spared the threat of men went to brothels, condom use in HIV/AIDS. brothels rose to more than 90%, the number of consultations at sexually transmitted The Evolution of the AIDS Epidemic in disease (STD) clinics was reduced by 90%, Thailand and infection rates among army conscripts dropped by half in only a few years. The AIDS arrived in Thailand by 1984, but the most recent epidemiological model by the initial policy response was muted. The Thai Working Group on HIV/AIDS prevailing view was that this was an Projections suggests that the annual number epidemic brought from abroad that would be of new HIV infections peaked in the early confined to a few individuals in high-risk 1990s and has declined by more than 80%. groups, like gay men and injecting drug Since 1993, an estimated 200,000 fewer users, and would not spread more widely. In people have been infected with HIV than 1988-89 that view was challenged. In the would otherwise have been. This is an first major wave of the epidemic, HIV accomplishment that few other countries, if infection exploded among injecting drug any, have been able to replicate. It is a users, rising from almost nil to 40% in a result both of sound policy and the single year. At nearly the same time, a determination of the Thai people. second wave of infection spread among sex Thailand's response is widely cited as one of workers. In 1989, the first national the few examples of an effective national epidemiological surveillance found that 44% AIDS prevention program anywhere in the of sex workers in Chiang Mai, in the north, world. were infected with HIV and 1-5% of Lessons Learned consequences are apparent: Nearly 300,000 people have died of AIDS and 700,000 The Thai experience shows that a national people are living with HIV/AIDS, the result response that mobilized government, the of past infection rates and the long private sector, and NGO partners and that incubation period of HIV. Models suggest targeted the highest-risk transmission can be that in 2000, 55,000 people will develop effective in reducing the scope of the AIDS and roughly the same number will die epidemic, even when action is delayed. The from it. Nearly I million people have been response was able to draw on strong infected with HIV in Thailand since the institutions and traditions: an extensive beginning of the epidemic and this number network of STD services; a successful continues to grow, albeit at a slower rate. family planning program that had promoted The composition of new infections has condoms before the AIDS epidemic; a cadre changed. A decade ago, virtually all of trained epidemiologists; health infections were among adults and more than infrastructure with qualified staff; a tradition 80% were among sex workers and their of evidence-based policy decisions; strong clients. In contrast, of the estimated 29,000 civil society with a tradition of people will become infected in 2000, 4,000 volunteerism; and a pre-existing network of will be children. About half of new adult national development NGOs. A number of infections will be women infected by their factors contributed to the success that may husbands or sex partners, a quarter will be have broader applicability to other countries due to injecting drug use, and one in five in the region: national leadership and among sex workers and their clients. HIV political commitment at the highest levels of prevalence is stable or rising among government; strong epidemiological pregnant women in all regions. The surveillance that served as a critical tool for prevalence of HIV in high-risk groups like generating public awareness and political sex workers, though reduced, is still high. commitment; effective pilot projects that led Condom use among indirect sex workers policy to the right outcomes; the NGO role low and there is evidence that HIV in ensuring non-discrimination, respect for prevalence is on the rise among sex workers human rights and a broad political dialogue in some parts of the country, particularly in on AIDS; the contribution of STD services Bangkok. Infection rates among injecting to raising condom use in commercial sex; drug users have continued to rise to over and multi-sectoral implementation of AIDS 40% nationally. Some of the riskiest programs at a local level, coupled with behaviors in Thailand have not been multi-sectoral dialogue and consensus- addressed and now stand out as major building at the national level. causes of continued HIV transmission. The Current Status of the AIDS Epidemic The Rising Demand for Treatment and in Thailand Weakening Prevention Response Thailand's successful efforts to reduce As those infected in the past fall ill, the transmission of HIV by commercial sex demand for treatment is transforming the have had an enormous impact on the course policy dialogue. The demand for AIDS- of the epidemic. Nevertheless, there is no related medical care-palliative care, room for complacency. At the turn of the prevention and treatment of opportunistic millennium, there is still no cure for AIDS infections, anti-retroviral therapies, and end and no preventive vaccine. Despite the of life care-is rising. At the same time, the success at lowering new infections, HIV sustained response on prevention appears to managed to gain a foothold in the population be in jeopardy. Overall public expenditure before policy was enacted and the on the national AIDS program has declined 2 by 28% since 1997 and the prevention initial trajectory. Condom use has never budget has declined by half. Prevention been universal among 'indirect' sex now accounts for only 8% of the national workers, and sex workers who have been AIDS program budget, at 2 baht per capita trafficked to Thailand from neighboring (5 US cents). countries are a potential gap in the 100% condom program. Behavior change and Strategic Priorities for Improving the condom use among other high-risk groups Response like men who have sex with men, male sex workers, prisoners, fishermen, and others at The National Plan for Prevention and high occupational risk would have a Alleviation of HIV/AIDS sets forth two key relatively large impact on the epidemic objectives-to prevent the spread of HIV in relative to their cost. Action to promote the general public and to reduce the impact condom use more widely in all relationships, of the AIDS epidemic on the population. especially among youth, would be highly Success in overcoming the epidemic will complementary to this objective. require the joint effort of many partners in government, the private sector, and civil 2. A major new initiative to prevent society. Each partner brings a comparative transmission by injecting drug use. HIV advantage in addressing different aspects of prevalence has been high and rising among the problem. Given the current stage of the injecting drug users (IDU), now well above epidemic and competing demands from 40%. Projections now attribute a quarter of other important development programs, the all new adult infections to transmission by report team set out to identify the two or injecting drug use. HIV spreads not only three priority activities or objectives for among addicts but to their partners and government that would have the largest wives, and then to their children. Left impact on the epidemic in the whole unchecked, the high infection rate among population if additional resources were IDU will continue to be a reservoir for HIV made available. These priorities are based transmission to the rest of the population. on extensive consultation with key However, HIV prevention for IDU and their informants in Thailand as well as the team's sex partners has not been a priority in own expertise. This short list is not meant Thailand or in the region, even though IDU to suggest that other activities should not be transmission is an important feature of the undertaken, but rather to draw attention to a AIDS epidemic in almost all countries. To smaller set of priority activities that will have a major impact on the epidemic, the have the largest impact if undertaken same pragmatic policy toward prevention of immediately and in addition to ongoing HIV among sex workers needs to be efforts. extended to drug injectors. There are many international success stories to build on as 1. A renewed effort to sustain condom models for a Thai response. However, it is use in commercial sex and to raise unlikely that the IDU transmission cycle can condom use, encourage safer sexual be broken unless there is simultaneously a behavior, and behavior change among serious effort to prevent HIV in prisons and other groups at high risk and more widely to improve the legal environment for in all relationships. As Thailand recovers behavior change among IDU. from the economic crisis, rising incomes are likely to lead to renewed demand for 3. Ensuring access for people with commercial sex. With 17% of brothel-based HIV/AIDS to cost-effective prevention sex workers already infected, any lapse in and treatment of opportunistic infections. condom use could have an explosive impact People with HIV/AIDS can fall seriously ill on the epidemic, allowing it to regain its and die from curable infections that people 3 Thaaiand's Response to A7IDS: Bulde on SS, Confi onhig the FWure with normal immune systems can resist or the therapies are unaffordable for use on a fight back. The most important of these in wide scale. Problems noted internationally Thailand is tuberculosis (TB), but there are with patient adherence, side effects, viral many others, including pneumocystis carini resistance, and the need for a high level of pneumonia (PCP), cryptococcal meningitis proficiency of health care providers can and other cryptococcal infections, and compromise their effectiveness. Decisions various other fungal infections. All of these regarding public subsidies for funding of infections are treatable and many are anti-retroviral therapies or any other AIDS preventable in people with AIDS, and at treatment should be subjected to the same relatively low cost. Yet it appears that many criteria as treatments for other medical people with HIV/AIDS in Thailand lack conditions. Therefore, Thailand urgently information and access to prevention and needs a thorough, objective and ongoing treatment. Ensuring access by people living review of the costs, effectiveness, benefits, with HIV/AIDS to prevention and treatment affordability, and equity implications of of the major opportunistic infections is anti-retroviral therapies, as the basis for inexpensive, cost-effective, prevents life- rational and fair decision-making on the threatening infections, will extend life and allocation of public resources in this rapidly improve its quality, and will benefit in evolving area of AIDS treatment. As particular poor AIDS patients who otherwise background for assessing the equity and might have gone untreated. finance implications, better information is needed about the distribution of AIDS Implications for Public Finance patients by economic status, particularly the share that are poor, and the extent to which The programmatic implications of this the poor can benefit from these and other strategic agenda and their costs have yet to therapies. In the meantime, there are many be worked out. However, pursuing the actions that could be taken to achieve further agenda will require first and foremost reductions in drug costs, provide increased public spending on prevention in information about the costs and benefits of general and greater targeting of subsidies to anti-retroviral therapy, and improve its NGOs for prevention among hard-to-reach affordability to patients who wish to marginalized groups at high risk of purchase it privately. contracting HIV and spreading it further. The public finance implications of wider Organization of the Report access to prevention and treatment of opportunistic infections are difficult to The next chapter reviews the evolution of pinpoint, as there is still uncertainty about the HIV/AIDS epidemic in Thailand, the the existing level of access, use, and finance. government response and its impact, and the However, given the relatively low costs of lessons for the international community. most of these measures and the many The third chapter reviews the current status different sources of finance, the cost is not of the HIV/AIDS epidemic in Thailand, expected to be insurmountable. Newer highlighting important trends in the spread treatments for HIV/AIDS-combination of HIV and its impact that are of concern in antiretroviral therapy (ART)-have had the next phase of the response. The fourth dramatic impacts on lowering AIDS chapter proposes a framework for setting mortality in high-income countries. They priorities for government action and are not a cure and must be taken for life. At identifies three strategic priorities for the present, the drugs remain very expensive, at next phase of the national response. The over $8,100/year, and there are many other concluding chapter summarizes the findings costs involved beyond the drug costs. Even and recommendation. were drug prices to decline by two-thirds, 4 a iiand's R esp(;nse to A Buiding on Succes, Confronting the Fu!wue Chapter II: Building on Success: The Evolution of Thailand's AIDS Epidemic and the National Response AIDS arrived in Thailand in the mid-1980s, The Early Spread of HIVAIDS in but the initial response was muted. When Thailand infection exploded among injecting drug users and sex workers in 1988-89, the Thailand's AIDS epidemic spread in a series government acted decisively, launching a of epidemic 'waves' in subgroups of the nationwide campaign to reduce HIV population based on all of the major transmission via commercial sex. The transmission routes: homosexual, injecting result-a dramatic increase in condom use, a drug use, heterosexual, and from mother to reduction in demand for commercial sex and child. The first case of HIV/AIDS was a reduction in new HIV infections-is detected in September 1984 among gay men widely cited as one of the few examples of returning from abroad. Substantial spread an effective national AIDS prevention was not noted until 1987-88, however, when program anywhere in the world. The Thai infection among injecting drug users (IDU) experience shows that a national response in Bangkok skyrocketed, from virtually nil that mobilized key government and NGO to more than 40% in a single year. Similar partners and targeted the highest-risk jumps among IDU were seen eventually in transmission can be effective in reducing the other countries in the region (box 1). scope of the epidemic, even when action is Injecting drug users were the second wave delayed. of Thailand's epidemic Box 1. Injecting drug use and the spread of AIDS in Southeast Asia Injecting drug users (IDU) have played central roles in the spread of HIV in South and Southeast Asia in every country with a significant HIV epidemic except, perhaps, Cambodia (Beyrer et al 2000). HIV transmission through shared injection equipment is significantly more efficient than through sex, leading to rapid spread among networks of IDU. Asian HIV outbreaks among IDU have had several consistent features: c They have been explosive: HIV prevalence among Bangkok IDU rose from 2 to 40% in 6 months in 1989, with clear links to incarceration (Weniger et al 1991). " They have been transnational: the highest prevalence zones in China and India (Yunnan and Manipur States, respectively) are along their borders with Myanmar. i They have spread among non-injecting sex partners of IDU in China, India, and Thailand. j They have been proven difficult or impossible to control, given both the state of drug treatment in the affected countries, and the lack of HIV prevention measures among IDU. Countries with either initial or predominant IDU-related epidemics include China, India, Kazakhstan, Malaysia, Myanmar, the Russian Far East, Thailand, and Vietnam (Beyrer et al 2000). In Malaysia and Vietnam IDU have remained the predominant risk group since the beginning of the epidemic, accounting for roughly 60-70% of cumulative infections in both countries (UNAIDS 1999). China's three most affected provinces-Yunnan, Xinjiang, and Guangxi, in order of prevalence-all have outbreaks due to needle-sharing among IDU (Yu et al 1999). IDU were the first group in which HIV was identified in Myanmar where the UN Drug Control Program (UNDCP)/Ministry of Health identified drug use rates of 2-25% among adults in 36 townships in 1995. IDU remain at extraordinary risk, with HIN prevalence rates of 60-95% nationwide (Beyrer et al 2000). HIV does not stay within groups of IDU: In Yunnan Province of China, for example, where HIV first appeared among IDU in the early 1990s HIV is spreading to female sex partners and children, particularly among ethnic minority communities where drug use rates are high (Wu et al 1997). In Manipur State of India, within two years of the first case of HIV among injecting drug users. 6% of their non-injecting sexual partners became infected (Sarkar and others 1993). The prevalence rate among pregnant women rose to 2% within a few years. Prevention of HIV among IDU therefore prevents the spread of HIV in a wider group of the population. 5 Thailatnd 's Response' to AIDSi: Buildin" on ""ccess', Co onaing Ftu In parallel, HIV found its way into the old conscripts in the Royal Thai Army-a population of sex workers and their clients, nationally representative sample of young the third and fourth waves. In June 1989, men who are prime clients of commercial the first round of national epidemiological sex-rose from to 0.5% in 1989 to peak at surveillance found that 44% of brothel- 4% nationally (figure 2) and nearly 13% in based sex workers in the town of Chiang the North in 1993. Because army conscripts Mai in Northern Thailand were infected with are young, their infections can be assumed HIV. Infection was not limited to the North: to be recent. Thus, trends in HIV prevalence it was detected in brothel-based prostitutes among cohorts of conscripts are often in all but one of the 14 provinces sampled, at considered as a proxy for trends in HIV levels of 1-5%. By 1994, HIV prevalence- incidence, the number or rate of new the percent of the population currently infections annually. infected-reached 31% nationally among brothel-based sex workers (figure 1) and While the infection rates among conscripts 38% in the North. Use of commercial sex have declined since 1993, the large cohort of was widespread: a national behavioral men infected early in the epidemic served as survey in 1990 found that 22% of men 15-49 a launching pad for the most recent waves of and 37% of men 20-24 had visited a sex infection among spouses and their children, worker in the last year (Sittitrai et al 1992). through transmission from mother to child. Condom use in commercial sex was quite These last waves are still expanding. At low-only 38% of men who frequently used present, about 2% of women attending sex workers in the 1990 study used condoms antenatal clinics are infected with HIV, and all of the time. HIV thus spread rapidly they give birth to an estimated 4,000-5,000 between sex workers and their clients. HIV HIV-infected children annually. prevalence in successive cohorts of 21-year Figure 1: HIV prevalence in high-risk grous Figure 2: HIV prevalence in military conscripts and pregnant women 4.0 4.5 .-... - -- - -- -- --- 400 1.5 35 3. - - - -__ _ _ _ _ 15 10-0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Coscript Pregnant womn: Pregnant women: all IDU BroM-basr Source: AIDS Division, MOPH, and A FRIMS data. Note: Figures are mean HIV prevalence. Data for Source: AIDS Division, MOPH. pregnant women from 1990-96 are from sentinel Note: Figures are mean HIV prevalence. In 1995. surveillance sites; from 1997-99 they represent data for direct and indirect sex workers were pooled antenatal women at all provincial hospitals in the and cannot be separated. SW: Sex workers three months prior to the observation. 6 Bulin n Success. ConiGwnwng the Ftr The Policy Response complex were reported to the Ministry of Public Health's AIDS Control Center Thailand is now well known for its (Phoolcharoen et al 1998). The system progressive approach to control of failed to detect the rapid spread of HIV HIV/AIDS, but this was not always the case. infection, which is asymptomatic for many Understanding how this response emerged is years before the onset of AIDS disease. as important as the policies themselves, in Further, the small surveys of HIV terms of extracting lessons for other seroprevalence in Bangkok through 1987 countries.' found little evidence of HIV. There was very limited information on the extent of Prior to 1989, government policy on risky behavior that might spread HIV in the HIV/AIDS control followed a standard general population. Policies were put into public health approach, which place early, however, to ensure that the emphasized case reporting of AIDS country's blood supply was protected (box through the medical system (Phoolcharoen 2). Government representatives initially et al 1998). As has been the case in many down-played the significance of the countries, AIDS was largely thought of as a epidemic to the general population, foreigner's disease, a point of view that was encouraged or at least did nothing to correct supported by the fact that the first cases the public perception that AIDS was likely were among gay men returning from abroad. to affect only marginal groups like gay men, The standard reporting system did not male sex workers, and IDU, and focused discover many cases: in the five years after their preventive activities on those groups the first case was reported, only 43 AIDS (Porapakkham et al 1996). cases and 145 cases of AIDS- related Box 2: Thailand's early success in ensuring a safe blood supply Thailand was among the first Asian nations to reform its blood banks to prevent HIV transmission in the health system. Screening of blood donations for HIV antibodies was introduced in 1986. The Ministry of Public Health made anti- HIV screening of all blood units mandatory in 1989 (Chiewsilp et al 1993). Most blood banks were using the Abbott ELISA system with automated ELISA reading equipment. All blood specimens are now tested for hepatitis B3 and C. syphilis, and HIV, using both HIV antibody and the more sensitive p24 antigen test, which can detect HIV before newly infected persons develop antibodies (Wongsena et al 1997). In parallel, Thailand reduced the share of HIV-positive donors by discouraging higher risk paid and professional donors, encouraging voluntary donation, and screening potential donors to discourage those with risk factors for HIV from donating (Sawanpanyalert et al 1996). Since 1992, no paid donors have been used in Thailand. The prevalence among donors in the north declined from 4% in 1991 to 0.7% in 1998, due in significant part to the reduction in higher risk donors. Most blood banks now use computer systems to enter and store demographic and screening data on all donors and use a self- administered questionnaire to screen out donors who are at risk for infectious diseases. These reforms have reduced the rate of HIV transmission through blood products in Thailand to one in 80.000 transfusions, among the lowest in any developing country. The rate in the United States, for comparison, is estimated at one in 300,000 transfusions. The difference is accounted for by the higher prevalence of HIV in Thailand in the general population, which raises the likelihood that donors are in the acute (pre-antibody or antigen) phase of infection when HIV is difficult to detect. The material in this section draws hcaviiy on several excellent reviews of AIDS poiicy in Thailand. by Phoolcharoen e( al (1998). Porapakkham et al ( 1996). and Teokul (1998). as well as an excellent overview of STD policy in Thailand by Chitwarakorn et al (1998). 7 7,7aiawu! '~S esonse~ to "4 IS7: 11ilding an ~ /uiigthe Futu~re The implementation of the national The finding that HIV infection already 'sentinel' surveillance system to monitor had a foothold in the Thai population HIV infection in key population groups in transformed the perception of the disease 1989 and the public dissemination of to one that posed a threat to the whole results made it difficult to maintain an population (Porapakkham et a] 1996). The official position of denial and helped public availability of the epidemiological initiate the change in social norms surveillance results helped NGOs accelerate necessary to change behavior. The first their prevention, treatment, and human evidence that HIV could spread rapidly in rights activities in key populations and the Thai population did not occur until 1988, created an important constituency and when HIV testing was introduced into lobbying group for expanded AIDS policy government methadone treatment centers for (Porapakkham et al 1996). An NGO heroin addicts (Phoolcharoen et al 1998, consortium on AIDS was formed in 1989. Weniger et al 1991). This coincided with Nevertheless, there were still segments of the development of a short-term AIDS plan the media that wanted to downplay the developed by the Communicable Disease danger because of possible impacts on Control (CDC) Department of MOPH and tourism (Phoolcharoen et al 1998) and most supported by the World Health Organization financial support for the AIDS program (WHO). The explosive spread of HIV in came from abroad. In addition, several IDU in that single year prompted both the repressive measures had already been Royal Thai Army and the Epidemiology implemented or were under discussion: Division of the MOPH to launch HIV Physicians were required to report the names surveillance of specific groups of the and addresses of all HIV-positive or AIDS population, in 1989. In mid-1989, testing patients to the government. An amendment was launched in samples of 100-200 persons to the Immigration Act forbade HIV- from each of several 'sentinel' groups of the positive and AIDS patients from entering the population-IDU; brothel-based, 'indirect'2, country. A proposed "AIDS Bill", under and male sex workers; male patients at discussion since 1990, would have required sexually transmitted disease (STD) clinics; reporting of all newly discovered cases blood donors; pregnant women; new within 24 hours, compelled any member of a prisoners and ex-prisoners. Beginning with high-risk group to be tested without their 14 provinces in mid-June, the testing was consent, and made it a crime for an HIV expanded to 31 provinces by the end of 1989 positive person to donate blood, engage in and all 73 provinces in 1990. Late in 1989, prostitution, have medical procedures the Royal Thai Army launched biannual without informing medical staff, and have testing of the 60,000 21-year old army sex without a condom (Porapakkham et al conscripts chosen annually by national 1996). lottery, finding an HIV prevalence rate of 0.5% during the first round (Phoolcharoen et It wasn't until 1991, under the short, al 1998). The first national survey of transitional government of Prime behavioral risks for HIV infection (Partner Minister Anand Panyarachun (1991-92), Relations Survey) was launched in 1990, that AIDS prevention and control became sponsored by WHO and conducted by the a national priority at the highest level, Thai Red Cross and Chulalongkorn emphasizing progressive policies to University (Sittitrai et al 1992). encourage safer behavior, and galvanizing the efforts of many sectors as well as NGOs. There were four important 2 "Indirect" sex workers are in restaurants. massage developments during the Anand parlors, and hotels, and are believed to be 'higher administration that had a profound and class' than brothel-based workers. They often do not lasting effect on AIDS policy beyond his self-idernify as sex workers, but do engage in sex for pay.Thend and 8 ,.,ailand 's [e pfspne( Ai$ B!uiltfinq an Sucee.s. Coni-onling the iiere 1. AIDS policy was brought under media, including mandatory 1-minute AIDS the coordination of the Office of the education spots every hour on TV and radio. Prime Minister (OPM), with an officially These messages emphasized prevention, multi-sectoral National AIDS Prevention behavior change, condom use, and AIDS as and Control Committee, chaired by the not just a health problem but a social Prime Minister. This signaled political problem. All ministries were actively commitment at the highest level but also involved in providing education and training ushered in the formal participation of NGOs to their staff and population groups they in the policy-making process. The NGOs work with. The Ministry of Education lobbied strongly for wider public launched peer education programs among information, protection of human rights, and students and an annual national competition compassionate care for AIDS patients. among schoolchildren at different levels in Their participation formally opened up the essay writing on HIV/AIDS, greatly raising dialogue to those outside the health sector. their level of awareness. Government While on paper this was a multi-sectoral efforts were complemented by private program with participation by all ministries, initiatives, such as the Thailand Business and was embraced as such by the Coalition on AIDS (TBCA), formed in 1993 international community, in fact the main to promote HIV/AIDS education and players were the OPM, the Ministry of prevention in the workplace and other Public Health (MOPH), and the NGO appropriate HIV/AIDS workplace policies. community (Porapakkham et al 1996, A program was launched to discourage Teokul 1998). The other ministries, even young girls from entering into prostitution, when allocated resources, initially had little by providing scholarships for continuing expertise with which to conduct these their education and enhancing their programs, which went beyond their sectoral employment opportunities. mandates. The National Economic and Social Development Board (NESDB) was 3. The "100% Condom Program" given responsibility for planning the was adopted nationwide to promote national AIDS strategy, a responsibility universal use of condoms in commercial formerly with the MOPH. The NESDB sex all of the time (Rojanapithayakorn and drew up the first five-year AIDS control Hanenberg 1996). Originally piloted in program and budget, allocating resources to Ratchaburi Province in 1989, the program other ministries besides MOPH and to was expanded for national replication in NGOs (Teokul 1998). The plan emphasized 1991-92 (Chitwarakom et al 1998). mobilization of society and communities to Prostitution was and still Is illegal. participate in prevention of HIV, to care for However, authorities adopted a more those who are sick, and to reduce stigma and pragmatic approach of encouraging discrimination facing those who are living widespread condom use to prevent HIV with HIV/AIDS. (Phoolcharoen et al 1998, transmission, rather than attempting to Porappakkham et al 1996, National AIDS suppress commercial sex. The program Committee 1997, Teokul 1998) involved collaboration at the provincial and local levels between public health officials, 2. A massive public information brothel owners, the local police, and sex campaign on AIDS was launched under workers. By ensuring compliance in all sex the leadership of cabinet member Mechai establishments, those that enforced condom Viravaidya, a well known national figure use would not lose business to those that did with deep roots in past family planning not. The mechanisms to monitor campaigns and strong ties to non- compliance already existed-Thailand's governmental and community groups. extensive network of STD treatment clinics Intensive public information on HIV/AIDS and the public health service's list of sex prevention was launched through the mass establishnents. Under the program, sex 9 Tho Uand' Rxiesj)onse to) A [Ul3S 111tilding a Succe!;s. O117fronling 1he 1fut-twe workers were screened for STDs weekly or spending from the government AIDS control biweekly at government STD clinics, budget had reached $82 million annually- treated, and provided with a box of 100 free more than $1 per capita-of which 96% was condoms (Chitwarakorn et al 1998, financed by the Royal Thai Government. Chamratrithirong et al 1999). Male patients Even this understates the magnitude of the presenting at the government STD clinics mobilization: in 1991, private business were considered evidence of non-use of contributed an estimated $32 million (800 condoms. Compliance could be checked million baht) for education programs in the through tracing the STD patients back to the workplace and $48 million (1.2 billion baht) brothels where they were infected. Health in free commercial air time for AIDS workers could then follow up with visits, messages-a total of $80 million more providing additional information and (Viravaidya et al 1993). condoms. The cooperation of the police was also sought, and potential sanctions included Figure 3: Government and donor spending on AIDS, 1988-97 the threat of closure of the sex 100 establishment. However, it appears that 90 police action was rarely invoked _0 (Chamuatrithirong et al 1999). a 70 4. A number of repressive policies 4- were repealed and those that were under L4 discussion gradually faded from the 0 policy dialogue. Activist NGO members of the cabinet succeeded in abolishing the mandatory reporting of names and addresses 10 of AIDS patients and in getting the 01 regulations that prohibited immigration of HIV-positive people reversed. Following I Donr H NESDB. several public hearings, the AIDS Bill made Suc:WO ISDvso/OH ED3 seveal ubli herins, te ADS Bll ade Note: Government spending includes only spending no further progress and was never adopted out of the AIDS budget and excludes expenditure on (Porappakkham et al 1996). The principle health care related to AIDS from the general MOPH of voluntary, anonymous, confidential budget. counseling and testing was established. The progressive policies and broader Between 1987 and 1997, public spending participation in AIDS policy formulation on AIDS prevention and control in launched during the Anand government Thailand expanded dramatically, a sign were sustained after his short tenure, of the greatly increased commitment of although the pace of change slowed. The the Royal Thai Government (RTG). Total key elements of policy were already in AIDS spending by donors and government place. Periodic surveys to monitor risky rose from $684,000 in 1988, most of which behavior in the population ("behavioral was financed by WHO, to $10.1 million in surveillance") were launched in 1995 in 19 1991, more than 72% of which was financed provinces (Phoolcharoen et al 1998). The by the RTG (figure 3). 3y 1997, total number of NGOs involved with AIDS increased from 23 to 184 between 1992 and 3 These figures do not include expenditures by private 1997, and the number of groups of people households on prevention (condoms), counseling and living with HIV/AIDS (PHA) rose from II testing, STD treatment or AIDS-related health care, nor do they include outlays by government for TB treatment, which is the main opportunistic infection and public expenditure on AIDS-related health care nationally and an important component of AIDS should have been relatively low, as most infections treatment. However, at least in the early years. private were asymoptomatic. 10 IUdig ai? Success, Coi-oWi,the utre to 108 between 1994 and 1997. The 20,000 in 1995. The number of new cases NESDB again developed, with broad of STD declined from 6.5/1000 in 1989 to participation from NGOs and civil society, 3.2/1000 in 1991 and 1.6/1000 in 1993. At the second "National Plan for Prevention the same time, two-thirds of the drug stores and Alleviation of the AIDS Problem" for surveyed in 24 provinces reported a decline the years 1997-2001, in parallel with the in the sale of antibiotics for STD treatment National Development Plan for the same and a sustained increase in sale of condoms, years (National AIDS Committee 1997, confirming that patients were not simply Teokul 1998). This new plan, while diverted to private treatment sources maintaining the effective programs of the (Chamratrithirong et al 1999). past, represented a more holistic approach, mobilizing the efforts of communities and Between 1990 and 1993, the percent of men people living with HIV/AIDS (PHA), to reporting any premarital or extramarital sex strengthen human development and a dropped from 28% to 15%, the percent supportive environment for prevention, care, visiting sex workers dropped from 22% to and mitigation of the impact of AIDS. Many 10%, and the percent consistently using of these enabling activities are in fact condoms in commercial sex rose from 36% already in the mandates of other ministries to 71% (Phoolcharoen et al 1998). HIV and reinforce ongoing programs in terms of prevalence among 21-year-old army their importance to the AIDS epidemic. A conscripts, which had risen to 4% in 1993, larger share of resources is allocated to began a steady decline to 1.56% In 1999 NGOs for implementation and ministries (refer back to figure 2). have latitude to request funds for activities beyond 'prevention' and 'treatment'. Figure 4: Rising condom use and declining STEs, 198894 Nevertheless, in terms of the allocation across sectors, both the "budget and talent Male STD cases workers (thousands) are ... skewed toward the health sector" 100% 250 (Teokul 1998). 1200 The Impact The demand for commercial sex declined, condom use in commercial sex rose, STD 4 100 cases plummeted, and the prevalence of Male STO cases HIV among army conscripts dropped by 20. more than half. Condom use in brothels Condom use rose from about 14% to more than 90% 0 1 1 1 11 between 1988 and 1992 (figure 4). High 18 1989 199 1991 1992 1993 1994 condom use has been maintained: a 1997 Source: Rojanapithayakorn and Hanenberg (1996) as survey of nearly 2,000 sex workers (mostly reported in World Bank (1999). brothel-based) in 24 provinces found that 97% of sex workers always used condoms The decline in HIV prevalence among army with casual customers and 93% always used conscripts was even more pronounced in the them with . regular customers Upper North, falling from more than 12% (Chamratrithirong et al 1999). (similar to levels found in Sub-Saharan The number of male STD patients reporting 4 The drop in STD cases is even more remarkable. to public clinics fell precipitously, from considering that 507 new district-level STD clinics were established between 1991-95 as part of the policy about 220,000 per year in 1988 to about to integrate STD services with primary health care, a development that should have improved reporting (Chilwarakorn et al 1998). 11 Africa) to less than 2% between 1992-99. infrastructure with qualified staff; a tradition The annual incidence of HIV among army of supporting basic and applied research and conscripts in 6 provinces of northern making decisions informed by data; civil Thailand during their 24-month military society with a tradition of volunteerism; and service declined from 2.48% in 1991-93 to a pre-existing network of national 0.55% in 1993-95 (Celentano et al 1998). development NGOs. Nevertheless, the Further, there was a very strong association evolution of Thailand's AIDS policy and the between increased condom use, reduction in impact of programs in reducing HIV visits to sex workers, and reduced incidence transmission In commercial sex suggests of STDs and HIV over a relatively short important lessons that may be of use for period of time. The prevalence of HIV other countries in the region and the world. among young women (<25) giving birth to their first child at Chiang Rai hospital rose 1. Effective action requires national from 1.3% in 1990 to 6.4% in 1994, then leadership and political commitment at declined to 4.6% in early 1997 (Bunnell et al the highest levels. How can such leadership 1999). be encouraged as early as possible and how can it be sustained? In Thailand, the leader Since 1993, behavior change in Thailand with commitment to the most progressive has prevented an estimated 200,000 HIV AIDS policies served during a short, infections that would have otherwise transitional and unelected government that occurred by 2000. The most recent was not beholden to special constituencies. estimates of the cumulative number of The Anand govemment had far-reaching infections in Thailand in 2000, by the Thai powers that elected governments do not Working Group on HIV/AIDS Projections, have. This was somewhat unique and are 29% less than what was projected to be clearly not generalizable; many unelected the case by the NESDB Working Group in governments might equally implement 1994. Of this difference of 395,000 repressive policies if given the opportunity, infections, about half can be attributed to and some have. Political majorities can also difference in the models and half to real lead to repressive or ill-informed policies in differences in behavior (Tim Brown, democratic societies. Is there any lesson personal communication). The number of that can be gleaned from this experience for new HIV infections in Thailand has dropped other countries? The results of discussions from about 137,000 per year in 1990 to with our informants suggest that there are 29,000 per year in 2000 (Thai Working some factors that may be more likely to Group 2000). result in greater and sustained commitment of political leadership: Lessons Learned a) Epidemiological surveillance is a In responding to AIDS, Thailand clearly was critical tool for generating public able to draw on strong institutions and awareness, political commitment and traditions that may not be present in other action. The fact that HIV can spread widely countries: an extensive network of STD through the population with initially very services; a strong and successful family little obvious morbidity has made it planning program that had promoted extremely difficult in most countries to condoms before the AIDS epidemic; a cadre convince policymakers to launch adequate of trained epidemiologists supported by the measures early enough to prevent a serious field epidemiology training program;5 health epidemic. In Thailand, the extensive epidemiological surveillance system was 5 Th Fild Eideioloy Tainig Pogra is critical to demonstrating the rapid and far- SThe Field Epidemiology Training Program is recigsea of sypmtcHI sponsored by the U.S. Centers for Disease Control and thg the oation tevn w Her Prevention. making decson f at a civil 12 were very few AIDS cases. Equally policies of behavior change. Early in an important is the fact that the Thai sentinel AIDS epidemic, there are many social forces surveillance system had national coverage- at work that would rather deal with the detecting, for example, the high levels spread of HIV/AIDS through draconian among sex workers in the North-and many measures against those at greatest risk of different groups at high risk of contracting contracting and spreading the virus. HIV/AIDS, in addition to low-risk Thailand was no exception. The existence populations. In contrast, other countries of well-established development NGOs, like have found it less controversial and more the Population and Community convenient to monitor infection trends in Development Association (PDA), the Thai pregnant women, where infection rates are Red Cross Society, and the Planned likely to show up last. Once infection rates Parenthood Association of Thailand (PPAT) are made available to the government and meant that there were already organizations the public, it becomes very difficult for to speak on behalf of marginalized either to deny the potential for a large-scale constituencies. They were rapidly joined by epidemic. Epidemiological surveillance also new AIDS NGOs, like EMPOWER and provides important evidence of the outcome ACCESS. In many countries, these of different policies; in the case of Thailand, organizations also have a key role in the availability of epidemiological data for implementing prevention and care each province provided information for interventions among those at highest risk. decentralized decision-making. However, as the epidemic matures and NGOs increasingly represent those who are b) Effective programs may 'lead' policy to infected, their priorities may shift from the right outcomes. This is a point made in prevention to care; this is already happening the review by Porapakkham and colleagues in Thailand (Teokul 1998). (1996) that is compelling. In Thailand, good policy arose from the example of good These three factors are not sufficient to programs. The decision to collect extensive guarantee the emergence of active, sentinel surveillance data, for example, can committed, progressive leadership on AIDS, be justified on purely public health, but in the Thai case they encouraged and technical grounds, which may not be reinforced it, and thus are aspects that other controversial and does not necessarily countries would do well to emulate even in require strong political leadership to launch. the absence of strong leadership. Opportunities may exist to pilot excellent programs and demonstrate their impact 2. Thailand's experience shows that before national policy is solidified. For a nationwide program that reduces example, the feasibility and potential transmission via commercial sex-the success of the 100% condom program was engine of the Thai epidemic-can have a established before leadership agreed to potentially great impact on the course of national replication. In Thailand there is an the epidemic, even if enacted late. Given environment that is conducive to operational the high resort to commercial sex in Thai research and evidence-based decision- society, low condom use, and rapidly making. We believe that such pilot growing HIV among sex workers, the focus programs are likely to have the largest on reducing transmission in commercial sex influence on policy when the impact is well clearly had a large impact on reducing documented, which often is not the case. transmission to the rest of the population. Equally important was the decision to work c) Non-governmental organizations can with sex workers and their clients to play a key role in ensuring non- increase safe sex, rather than to attempt to discrimination and respect for human marginalize them further. This is a very rights and in sustaining progressive important message for other countries in the 13 ThCiflana"s Resfoas to f~ B~uidig oil siccess, ther>eiin 'cFittelr region where commercial sex is also illegal denying that Thailand's AIDS epidemic may but has traditionally been dealt with through have been less severe because of its enforcement actions and incarceration. excellent STD services, it wasn't until Although action was too late to prevent condom use rose and the demand for spread from the infected clients to their commercial sex declined that HIV and STD wives, an estimated 200,000 infections have incidence dropped dramatically been averted since 1993. The impact would (Chitwarakom et al 1998).7 However, the have been much greater had the 100% extensive STD services were clearly critical condom program and information and elements to the success of the 100% condom education activities been launched five program: for providing information, free years earlier. In addition, while the change condoms, and treatment to sex workers; for in sexual behavior and condom use is well monitoring compliance among sex workers documented, it is far more difficult to and clients; and for measuring the impact of establish which activities among those the program. While it might have been launched had the greatest impact on this possible to provide the information, outcome. The 100% condom program and condoms and treatment to sex workers mass media campaigns were clearly through other points of access (had there not important components, but many other been this network of extensive services), it activities were also simultaneously would have been very difficult to monitor launched. Their scope is not well and enforce compliance without an objective documented and their independent impacts indicator of non-use of condoms, such as are unknown. Unfortunately, this successful contracting an STD. Ensuring adequate principle of working with high-risk groups compliance in 100% condom programs in to make their behavior safer has not been countries without a network of STD services adopted in Thailand nor in most other Asian will be more difficult. country to prevent HIV transmission among injecting drug users. 4. The 100% condom program exemplifies the potential success of multi- 3. Good STD services are not sectoral collaboration at the provincial insurance against an AIDS epidemic, but and local levels when local leaders have they were very important to the success of the political mandate, a well-defined the 100% condom program. There has objective, support from the center, and been a great deal of international research on benchmarks for measuring success. While the role of STD treatment in HIV the recent evaluation of the 100% condom transmission, suggesting in one case that program emphasizes that there were many syndromic treatment of STDs can lower variants on implementation in different HIV incidence by 40% or more (Grosskurth provinces, there are some common et al 1995, Wawer et al 1998). Based on elements. Such a program probably could these findings and the plausible arguments not have been implemented successfully for a biological role of STDs in enhancing HIV transmission, expanded and improved the VD treatment unit was created at Bangrak Hospital STD treatment has been promoted in many in Bangkok. In addition, STD clinics are offered in 7 of the poorest countries as a primary hospitals in Bangkok, health centers of the Bangkok intervention to prevent HIV/AIDS. In the Metropolitan Authority (BMA), 50 general clinics. 12 case of Thailand, however, one of the best regional, 75 provincial, and 40 provincial and district- networkslevel hospitals, and 507 district-level centers. In netwrksof ublc ST clnic inany addition, there are 3,500 private clinics and hospitals developing country was not sufficient to in Thailand where people can get treated prevent a sexually-spread AIDS epidemic (Chitwarakorn eta] 1998). (Chitwarakorn et al 1998). 6 Without One informant pointed out that the condom program has saved the Thai government 73 million baht by preventing 260.000 STD cases/year and the related 6 Government STDe services daxe back to 1930. when treatment costs. 14 without the local collaboration of a select society, to engage new participants in the number of sectors-health (AIDS and STD), policy dialogue, and to set national the police, brothel owners, and some priorities. Despite the fact that many NGOs-under the leadership of the ministries and sectors are represented in the provincial governor. What made this Thai response and have budgeted activities, effective collaboration possible? There are the key actors in terms of program certainly many views on this, but we would implementation in this multi-sectoral like to highlight a few that stand out. First, alliance at the national level are the MOPH the limited objective of raising condom use and OPM (Porapakkham et a] 1996, Teokul in commercial sex was clear and well 1998). The review by Porapakkham et al understood by all parties, and methods for (1996) maintains that the initial adoption on monitoring success were available locally paper of a multi-sectoral AIDS program in through the sentinel surveillance and STD Thailand in 1991 was largely symbolic; it clinics. Second, there was a strong political responded to the popular movement in mandate from the national government and international circles for a 'multi-sectoral support in the form of technical advice, free approach' emphasizing impacts and condoms and the public information responses across all sectors, but in fact was campaign that complemented actions used to justify a shift of control of resources directly with sex workers. The recent from the MOPH to the OPM and NGOs, evaluation emphasized that the 100% with the NESDB as the agency charged with condom program was largely implemented planning.9 There was initially low through better coordination of existing ownership by other ministries, which were resources in the provinces and aside from given budgets and then asked to develop these inputs did not involve large resource programs. These ministries had other transfers from national government for mandates; budget allocations did not come implementation (Chamratrithirong et al from a reasoned program and the staff 1999). Local administrators sometimes lacked the necessary expertise to design it raised additional resources locally to (Porapakkham et al 1996, Teokul 1998). implement the program. Third, Much of the budgetary allocation for other programmatic decision-making on how to ministries was therefore used for training the allocate resources and coordinate the effort staff in the basics of AIDS transmission and was decentralized, and could therefore prevention, rather than on specific programs respond to local circumstances. Fourth, the (Teokul 1998). Technical expertise was and involvement of a smaller group of 'core' still is concentrated in MOPH. Nevertheless, actors at the provincial level-rather then all the multi-sectoral organization of Thailand's sectors-clarified the role of each response since 1991 has been highly participant and minimized the potential for successful in engaging NGOs, civil society, duplication of activities and wasted energy and other sectors in policy formulation and to coordinate sectors not central to these priority setting at the national level, giving specific objectives (Porapakkham et al direction and political mandate to local, 1996). decentralized, multi-sectoral implementation of key programs. This role in priority 5. The main contribution of the multi-sectoral approach at the national level in Thailand has been to raise the profle f th AIS poble acoss change in control of the AIDS program did not have to profiledo with the multi-sectoral approach or competing priorities: "the NAC tended to be dominated by In Phitsanuloke province, for example, this 'core communicable disease control experts who excluded team' consisted of the Provincial Chief Medical not only NGOs but other departments of the MOPH Officer, the regional CDC office, the Army regional from the national program effort-. This had not headquarters, and the regional office of the Population happened with the successful family planning model. and Community Development Association, in which NGOs and government worked together. 15 , hliland's Riespnse to AIIDS: iding o c onfroning Ike Future setting and consensus building at a societal level is extremely important to the process of political mobilization and may be the most important contribution of national-level multi-sectoral organi- zations. 16 Thaiand xewose to / S: uhilding on Success, Con fionthig the Fiere Chapter III: AIDS in Thailand at the Turn of the Millennium Thailand's successful efforts to reduce of rising HIV prevalence among sex workers in transmission of HIV, especially by commercial some regions, especially Bangkok. Preventing a sex, have had an enormous impact on the course new outbreak in the population requires of the AIDS epidemic. Models of the spread of sustained behavior change as new cohorts of HIV run in 1991 predicted that by 2000 there young people enter adulthood. Some of the would be more than 3 million cumulative riskiest behaviors in Thailand have never been infections in Thailand in the absence of action addressed and now stand out as major causes of (Virvaidya et al 1993). The NESDB Working continued HIV transmission. In the meantime, Group projections from 1994, which took into HIV continues to spread outward to the lower- account the behavior change that had already risk population of wives and children. As those occurred in the early 1990's, predicted that there infected in the past fall ill, the demand for would be 1.4 million cumulative infections in treatment is transforming the policy dialogue. 2000, with no additional behavior change. The Public expenditure on prevention, which was Thai Working Group on HIV/AIDS Projections already low, has declined by half in recent years, estimates that as of this year there have been while expenditure on treatment is rising rapidly. 984,000 cumulative HIV infections. Some of these differences in the projected number of A Severe Epidemic that Continues to cumulative HIV infections have to do with Spread modeling techniques, without a doubt. But it is clear that risk behavior in Thailand-at least The Thai Working Group on AIDS with respect to commercial sex-has changed Projections estimates that 29,000 people in dramatically since the late 1980s and has been Thailand will become newly infected with sustained, saving many lives. According to the HIV in 2000-25,000 adults and 4,000 most recent model, the number of new infections children. A decade ago, virtually all infections annually has dropped by 80% since 1990. This were among adults and more than 80% were is an enormous accomplishment that few other among sex workers and their clients. However, countries, if any, have been able to replicate. It the composition of new infections has changed. is a result both of sound policy and the About half of new adult infections will be determination of the Thai people. women infected by their husbands or sex partners, a quarter will be due to injecting drug Nevertheless, there is no room for complacency. use, and one in five will be among sex workers At the turn of the millennium, there is still no and their clients. The share of infection due to cure for AIDS and no preventive vaccine. injecting drug use, including women infected by Despite the success at lowering new infections, needle-sharing partners, is projected to increase HIV managed to gain a foothold in the to 41% of new infections by 2005 in the absence population before policy was enacted and the of action. consequences are severe: Nearly 300,000 people have died of AIDS and 700,000 people The decline in HIV prevalence among army are living with HIV/AIDS, the result of past conscripts-a proxy for incidence-has infection rates and the long incubation period of slowed in some regions, stalled in others and HIV. The Thai Working Group model suggests has increased in Bangkok (figure 5). While that in 2000, 55,000 people will develop AIDS overall infection rates among army conscripts and roughly the same number will die from it. have fallen from roughly 4% in 1993 to 1.3% in The number of people infected continues to 1999, most of this decline can be attributed to grow, at a slower rate. HIV infection rates in dramatic changes in the Upper North, where many high-risk groups in Thailand remain prevalence among conscripts peaked in the 1992 unacceptably high. Condom use outside of cohort at more than 12% and has since dropped brothel-based sex is low, and there is evidence to 1.7%. Since 1996, prevalence has continued a 17 Thailand 's Response to fiS: Building on Seccess, Conftowing the Futue very slow decline among conscripts from the Figure 6: Percent of 21-year old conscripts with sexual Central, Lower North and Northeast regions, but experience in the past year, by type of partner, 1995-99 has stagnated in the South at a high level-about 70 684 2.4%--and has increased from 2.11% to 2.44% in Bangkok. 60 Figure 5: Declining HIV prevalence in 21-year old Thai conscripts, 1989-99, by region 0 10 20 8- 10- --- -- _ _ - - - 10 -7.49. 45 0 N 1995 1996 1997 1998 1999 i Female casual partner MFemale sex worker .Girlfriend 4Male partne Source: Division of Epidemiology, MOPH (2000b). 0L -____________________________ i Figure 7: Percent of 21-year old conscripts using condoms Nov-91 1992 May-93 Nov-94 1995 1996 1997 1998 1999 70consistently, by type of partner in the past year, 1995-99 Central Bangkok- Upper North- Lower North Northeast South 64 Source: AFRIMS data. 55 50. 50* -_____ The share of young men engaging in commercial sex has declined. However, they 30 use condoms in commercial sex only about & 39.4 two thirds of the time and are engaging in 242 many other types of sexual relationship for 20 ---2210 which condom use is even lower (figures 6& A 123 7). Nearly a quarter of conscripts visited a female sex worker in the past year-half the rate 0- in 1995-but only 64% of them consistently 1995 1996 1997 1998 1999 used condoms (Epidemiology Division 2000b). +jemalecasual *Female sex -Girlfriend Male- This is far less than might be implied by the Source: Division of Epidemiology, MOPH (2000b) 100% condom program, but this category includes both brothel-based and indirect sex The behavioral surveillance surveys have not workers, with whom condom use is lower. An charted sex with steady girlfriends in previous even greater share (38.7%) had sexual relations rounds. However, it is widely believed that with a casual female partner for which condom young men have compensated for the decline in use was even lower-only 24%. About 5 demand for commercial sex by an increase in percent of conscripts had sex with men in the casual female partners or steady girlfriends. The past year, using condoms only 29% of the June 1999 round of behavioral surveillance time-a figure of great concern, given the very found that 68% of conscripts had had sex with a high risks of HIV transmission of unprotected lover in the past year, but only 12% consistently anal intercourse. Condom use is increasing used condoms-the lowest condom use rote of only very slowly in commercial sex and shows any group. While use of sex workers is on the no sign of increasing among male partners or decline, young Thai men clearly still have many casual female partners. different types of sex partners in overlapping relationships with low levels of condomn use. 18 Thailand's Resp se tu DS: Biuilditg on Success, Conftonig Ith § ure These lovers are therefore at very high risk of Figure 8: Percent of brothel-based sex workers infected acquiring HIV if their male partner is infected. HIV,byregion,1990-99 HIV infection among sex workers has declined but is still very high, raising the risk of HIV transmission when condoms are not used consistently in commercial sex or 4) between sex workers and their regular 20 partners or spouses. There are now fewer sex workers than in the 1990s and a very high share of commercial sex acts among brothel-based sex workers are protected by condoms. The level of infection among sex workers has declined over time-whether1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 use, mortality of HIV-positive sex workers, and/or turnover. Nevertheless, because of their Central*Bangko--North Northeast South large number of partners and occasional lapsesAIDS Division, MOPH. larg nuberof prtnrs nd ccasona lasesNote: In 1995, data for direct and indirect sex workers in condom use or breakage, many sex workers were pooled and cannot be separated. eventually become infected (Kilmarx et al 1999). In 1999, about 17% of brothel-based sex Figure 9: Percent of indirect sex workers infected with HIV workers and 8% of sex workers in massage 16 -- parlors, restaurants, and hotels ('indirect' or high-class sex workers) were infected with HIV. Because of these high infection rates, 12 inconsistent condom use, even if rare, is much 0 more likely to result in HIV transmission. a. Further, these national averages hide very large - regional differentials: roughly one in five 4 brothel-based sex workers is infected in the North and Central Regions compared to one in ten sex workers in the Northeast (figures 8 & 9). 0 Th nfcin ae a ee eciig vr ie1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 The infection rate has been declining over time except for Bangkok, where HIV is increasing entrarl Bangkok' North -_Noheast-__ uth among brothel-based sex workers. In most Source: AIDS Division, MOPH. Note: In 1995, data for direct and indirect sex workers regions the infection rates among brothel-based were pooled and cannot be separated. sex workers in 1999 were still higher than in 1990. Among indirect sex workers, infection The prevalence and incidence of HIV among rates range from 5-9% and in three regions-the male sex workers (MSW)-a group not South, Northeast and Bangkok-infection rates explicitly targeted by the 100% condom in indirect sex workers are rising. Any decline program-have remained very high. HIM in condom use with these high infection levels prevalence in male sex workers in Phuket and could re-ignite the explosive epidemic in Chonburi (Pattaya) was 12.4% and 9.3%, commercial sex of a decade ago. respectively, in 1999.10 The largest study of male sex workers to date, in Chiang Mai city between 1991-96, found that male sex workers "' The total number of MSW sampled in Phuket was 296 and in Pattaya 227. Because of relatively small sample sizes, the infection rate has fluctuated between 10 and 20% in these two cities, as well as in Chiang Mai. 19 have a very high turnover rate and, for the 18% infection rate among newly-admitted male remaining in the industry 6 months or more, a prisoners was 12% in 20 provinces and 19% very high and steady rate of new HIV infection among those about to be discharged in 10 (incidence) of 11.6% per year (Kunawararak et provinces (Weniger et al 1991). Sine the al 1997). Information on condom use among beginning of the epidemic, 2% of all AIDS cases male sex workers is scarce, but appears to be among men have been diagnosed in prison much lower than for brothel-based female sex (AIDS Division). Commercial fishermen who go workers: In the Chiang Mai survey, consistent out for 5-10 day excursions in the Gulf of condom use with clients was reported by just Thailand and Andaman Sea had an infection rate over 50% of MSW, and with non-commercial of 15.5% in 1998: 46% visited sex workers in partners (male partners, girlfriends and wives) the past year, including 21.6% who used sex was markedly less (Kunawarak et a] 1997). workers 6 or more times (Entz et al 2000). Only 76% used condoms. A high share of these Other high-risk groups have high infection fishermen (29%) were from Myanmar and rates and low access or use of condoms. Sex Cambodia, highlighting the need to include non- workers from Myanmar and other neighboring Thai nationals in effective domestic programs countries, many of whom have been smuggled and to help raise the priority of HIV/AIDS in to Thailand illegally, are at high risk of neighboring countries. contracting HIV and spreading it, but have low access to prevention and are threatened by deportation if they contact public services (box 3). Prisoners are at high risk for both sexual and injecting transmission. In 1991, the median Box 3: Undocumented sex workers: A 'gap' in the 100% condom program? While the 100% condom program and public awareness programs on AIDS prevention have reached many brothel-based sex workers and their clients, there is an important group of sex workers and their clients who are at continued risk of infecting themselves and their partners: women and girls (and, in some cases, men and boys) trafficked from neighboring countries or from ethnic minority and tribal groups, either in Thailand or her neighbors, whose legal status is less than full Thai citizenship. These "undocumented" sex workers, mainly from Myanmar, Cambodia, China, and Laos as well as hill tribes in Thailand have clear risks for HIV infection, including illiteracy, vulnerability to trafficking, low levels of HIV and STD awareness, limited access to health care, very limited ability to negotiate with clients, and a reluctance to seek services even when they are available because of fear of arrest and deportation. Since these women are breaking two sets of laws (prostitution laws and illegal entry and work in Thailand) they are highly vulnerable to arrest, detention, and abuse from male guards. The number of undocumented sex workers is difficult to quantify because of the illicit nature of the industry and their need to avoid detection. In a study done in three northern provinces in 1995 (Chiang Mai, Lamphun, and Phayao), more than 40% of brothel-based sex workers were from Myanmar, mostly ethnic Shans (Beyrer et al 1995). A recent study along the coast of Myanmar in the fishing areas of Ranong Province, found that more than 80% of women in the sex trade were from Myanmar (Pyne 1998). NGOs active in Thailand put the number at perhaps 10,000 to 20,000. In addition, significant numbers of women from Cambodia, Laos, China's Yunnan Province, and Russia work in the Thai sex industry. Recently, women from CIS States, including Uzbekistan, have been trafficked as well. (Personal communication, International Organization for Migration/Bangkok.) Undocumented male sex workers are probably a relatively small group. One investigation in Chiang Mai in 1995. however, found (mostly Shan) boys from Myanmar working in 3 of 17 gay bars in Chiang Mai City (Fairclough 1995). The presence of a large number of sex workers not reached by current efforts may hinder Thailand's sustained success in promoting 100% condom use. No information is available about the number of partners or condom use rate of these undocumented sex workers. However, given the nature of their job and the large number of sexual partners, in the absence of condom use they are at very high risk of acquiring HIV and in turn transmitting it to clients, whether Thai or foreign, thus spreading the epidemic more widely. A further challenge for migrant women and girls in the sex industry is in preventing HIV in detention centers and prisons. The International Detention Center in Bangkok, as an example. has significant numbers of detained women from the sex industry. almost exclusively male guards, and no condom distribution program. 20 f~d1ix' uu ~ &i/>:i;hzgthe F1.4ure Infection rates among injecting drug users commercial sex had dropped to 72.8%, while the have remained extremely high-at 35-50% share attributable to sex between men accounted and are rising in Bangkok, the Central region, for 12.6% of the risk-nearly twice the percent and the South (figure 10). Only in the North is of sexually active conscripts who reported ever there some initial indication of a decline, having sex with a male partner (6.7%). although the reason remains unclear." Controlling for the presence of STDs, sex with Nevertheless, a multi-year study of HIV risks women, and sex with prostitutes, conscripts among northern Thai military conscripts found entering the military in 1995 who reported same that the share of HIV due to injection drug use sex behavior were significantly more likely to be increased from less than 2% of infections in infected with HIV (Beyrer et a] 1995).12 Thai 1991 to 27% of infections in 1998 (Nelson et al men who have sex with men (MSM) are a 1999). Among HIV-infected 21-year olds with a 'bridge' population in transmitting HIV between history of IDU behavior, more than 95% also other MSM, women, and male and female sex reported being sexually active. However, the workers.'3 Almost all (97%) of the conscripts pragmatic approach followed in preventing HIV reporting male sexual partners also reported transmission in commercial sex, which is also having female partners and had nearly double illegal, has not been followed for IDU, who the number of lifetime female sexual partners remain highly stigmatized, and frequently (32.5) compared to heterosexual men (17.8). incarcerated. Yet IDU will continue to be a MSM were more likely to have visited a female reservoir of infection and will pass HIV not only sex worker than were heterosexual men (95.5% to other IDU, but their sexual partners and vs. 84.9%), and more than a third (36.6%) had children. The last study to estimate the number visited a male sex worker. A study of Northern of IDU, in 1994, estimated 100,000-250,000 army conscripts in 1993 also found that MSM nationwide. were significantly more likely to be married and to have a girlfriend than were heterosexual men Figure 10: Percent of injecting drug users (IDU) infected with (Beyrer et a] 1995). Thus, Thai MSM are not HIV, by region, 1990-99 only at very high risk of becoming infected, but 50 73also passing HIV on to many male and female 45 - partners in other high- and low-risk groups if 40 ____condoms are not used consistently. However, 35 S 30 __condom use among MSM is very low. 0 20 The delayed implementation of programs to 1reduce transmission in commercial sex set the Source: AIDS Division, MOPH. 10 sag fohr dnfthe svtudylwasuthad repore ofe Sex between men is a growing risk factor fora s ild en HIV infection. In 1991, all HIV infectiontd in ern eve 199 191 992199 194 995196 197 99 19 mehodsc among osresgondante wofe MSattnging among Northern army conscripts could be afomnato 14%. dee on th e ri of uti attributed either to commercial sex (90.9%) or adcntetaiyasrne.Ti ugssta ikdt sex with girlfriends (9.1I%)(Beyrer et al 1998). o htrsxa"mnadml T ainsms lob However, by 1995, the share attributable to itree wit caution S his behavior aern Ti sM i tenha eond among HIV ~ ~ ~ ~ ~ ~ ~ ~ ~~o 12.6%ion I191alHI 'Ifcin suymtofs Te ruiusneal twicfeen thpercient mo ia azi conscwhere rouly 40% of MSM neinr ''Tends iNo fecn are onotrelie for d het Groig fortd bse aivt n the pnrcio o S us toears atbeued ther l sampleorc mex (90.). (donfect it Lim HIV Cos et ye ea ) da mexwihgrlried.n hohavi men (ms ar Hoevr,by195 te hreatriutbe o 'btrrid pop cultion.i rnmtin I ewe o3Thbe avMSM,pwomern and smale totad femaleamsex workeBaz,whrse lostgall (97% of the conscripts ''Tens n DU nfctonareno rliblefo te orteat eisreport e bsexual artntervou also ere becus othesmllsamle fr smeyers <10th(e nu mb c of letim feal sexal9arter (32.5 comaredto heerosxualmen 1) Thailand's Responise to AI)S: on Success, Conf ronting the fuire 1996, trends in HIV prevalence in this group Figure 11: Percent of pregnant women infected with HIV were monitored by the 'sentinel' surveillance by region,1990-96 and 1997-99 4 - ----- --------- ---- -.. ---- --- - ----- - -- - - - system that monitored women in selected antenatal clinics. This series showed a slow increase of HIV in pregnant women, shadowing 3 the increase among army conscripts, and an 2.5 apparent 'peak' of infection among pregnant 2 women in 1995 at 2.3%, followed by a decline a. in 1996. Beginning in 1997, the CDC started monitoring women attending antenatal clinics in all provincial hospitals for a period of three months prior to each round. As a result, the J number of women tested for each round nearly 199 1991 1992 1993 1994 1995 199 1997 1998 1999 doubled to around 62,000 annually. The data on entr4B-nkok -4 Noth Northeast South pregnant women from 1997 onward are thus Source: AIDS Division, MOPH. from a different and much larger sample that is Noie: Prior to 1997, data are from sentinel surveillance more representative of all pregnant women. sites, which may not be representative of the population of pregnant women. From 1997 onward, the data are from all women attending antenatal clinics in provincial The new series of women attending antenatal hospitals, for 3 months before the observation. clinics, in contrast to the sentinel data, tells a very different story: HIV prevalence among Urgent Need to Address Treatment Issues pregnant women continues to rise, from 1.74% in 1997 to 2.02% in 1999.14 HIV Thailand's epidemic is entering a new phase, infection is climbing among pregnant women in as many of the people infected during its every region except the Northeast, where it has explosive start are becoming ill with stabilized at between 1-1.5% (Figure 11). In symptomatic disease. People with HIV/AIDS Bangkok, the infection rate in pregnant women (PHA) can be asymptomatic for 8-10 years jumped one percentage point since 1997, from before the immune system begins to fail and the 1.3% to 2.3%. There is no region in Thailand first opportunistic illnesses appear. Thus, AIDS where infection rates among pregnant women morbidity and mortality do not tend to rise have declined recently. dramatically until several years after the start of an epidemic. Between 1984 and the end of March 2000, a total of 142,072 AIDS cases were reported in Thailand. More than 80 percent of these have occurred since 1995. Between 1994 and 1996, the annual number of reported AIDS cases nearly doubled, from 12,005 to 22,542, before leveling off at roughly 24,000 new cases annually In 1997-98. However, this is surely an underestimate based on those who report to the health system with an AIDS-defining illness. The Thai Working Group on AIDS Projections estimates that the true number of new AIDS cases In 2000 will be 55,000 (more than double the officially reported number) and that pTrends in the mean infection rate for pregnant women, cumulatively there have been 358,000 AIDS The epidemiological surveillance system uses medians, but cases since the beginning of the epidemic. The this actually increases the volatility of the measures over overwhelming number of AIDS cases to date are time. For the 1999 figure. We use the national mean aor ANC women, provided by the AIDS division (2.O2) the among men, reflecting the transmission pattern published mean for the 17' round of HIV sentinel of a decade ago among (primarily male) IDU Surveillance Was slightly higher 2.f7%. 22 haiand's iesf;onse to AIDS: fBuildingq on IScess, Confiontfing the FOure and the male clients of commercial sex. age and older, 31.1% were diagnosed with AIDS However, the share of female cases is because of a clinical diagnosis of TB (figure 13). increasing, reflecting the later outward spread to TB is especially common among AIDS patients the low-risk female partners of higher-risk men in Bangkok (43%), and much more common (figure 12). among IDU (47.6% present with TB) than among patients who acquired HIV through An important research priority is to learn more sexual transmission (27.5%). This is even more about the socio - economic profiles of people pronounced in Bangkok, where 75.7% of AIDS with AIDS. Aside from the age and gender of patients among IDU present with TB, compared AIDS cases, little is known beyond their to 38.8% of those who acquired HIV sexually. occupation. Since the beginning of the More than a fifth (21.8%) of the newly epidemic, 47% of reported AIDS cases have diagnosed AIDS cases nation-wide presented been among laborers and 21% among those with a strain of pneumonia-pnetnocystis working in agriculture. Five percent were carinii pneumonia (PCP)-very common among unemployed, 3% were housewives and 2% were AIDS patients but uncommon in people with prisoners. Nearly 9% were government healthy immune systems. Cryptococcal officials, businesmen, office employees or shop meningitis and other cryptococcal infections keepers. This pattern reflects infections that rank third most common (17.6%), followed by occurred much earlier in the epidemic, so does esophagal candidiasis (4.4%). Penicillium not reveal the distribution of new infections by mameffei has also emerged as an important occupation. There's an urgent need for more AIDS associated opportunistic infection in information on the socioeconomic profile of Thailand (about 2.4% of cases, but much more AIDS patients and the impact of AIDS on the common among patients from the North). These poorest households, to design efficient programs last three Ols are fungal infections- for prevention, care, and social support that cryptococcal meningitis is a fungal meningitis, target the neediest individuals and families. candidiasis is a fungal infection that presents itself as a white coating on the mouth, tongue, Figure 12: Number of reported AIDS cases, 1984-99, by and the lining of the esophagus, and P. mameffei gender is a fungal yeast. Many AIDS patients will 20000 - ------- --- - OMale O Female le eventually suffer from more than one of these aoae Ols, so these figures are an underestimate of 15000 - - - - - i - - their prevalence among AIDS patients in the course of the disease. Figure 13: Common ADSdefining illness among reHorted AIDS N cases over 10 yeas of age, 1994-98, by region - 3 02 50 -- -- -- --------------- -- --I-- ----- - - - 1 - --- - -- --- - ---- -- --- - - - DO000 -- -- -- -- - --- - - 45 -43----------- - - - - -- -- -- ----------- ~4O- - - - - - - - - - - - 39.1 a93195 19 1998 199 1984-91 1992 193 1994 19 196 1997 19 4 u25 - - l 1 - -24 M 1- - - Source: AIDS Division, MOPH. E* 20 19 71 -- - - - - i Note: Figures for 1999 are incomplete due to delayed - 165. 17. 16 reporting. People who develop AIDS get life-threatening 0 opportunistic infections (01) that people with Bm9kok CmtrA North Norhest South healthy immune systems can suppress. The 1 ts OWisyndrome OP'oeaa(PCP) OCryptococalmervagiaa most common 01 in Thailand is tuberculosis Source: Chariyalertsak et al 2000. (TB)-of the 24,654 newly diagnosed AIDS cases reported in 1998 among those 10 years of 23 After years of progress in reducing the Figure 14: Trends in HIV infection rates among new T1 patients, incidence of TB, there has been a resurgence - 989-19gB - in cases due to AIDS. As of 1998, 15.8% of all 40 new TB cases are HIV-positive and thus due 35 directly to the impact of the AIDS epidemic (figure 14).'s The impact on TB has been particularly severe in the Upper North. In Chiang Rai province, the incidence of TB2 dropped from about 50 cases per 100,000 population in the early 1980s to 30 per 100,000 by 1991. However, in the next two years TB 5 - incidence rose back up to over 50 per 100,000, 0 1989 1990 1991 1992 1993 1994 1995 1996 1997 1999 surpassing levels of the 1980s (Yanai et al - 1996). At Chiang Rai hospital, the share of TB N Source: Tuberculosis Division, Depai-tnent of patients who were HIV-positive rose from 1.5% Communicable Diseases Control in 1990 to 45.5% in 1994 (Yanai et al 1996). Since the number of HIV-negative TB patients Despite the mounting burden of AIDS has remained stable, the increase in TB morbidity, there has been no systematic incidence in the region is entirely attributable to review of the access of AIDS patients in HIV. Also as a result of AIDS, new TB patients Thailand to different types of treatments or are now considerably younger than they once therapies provided by the public or private were: in Chiang Mai, for example, the share of sectors, the likely benefits and gaps. AIDS is TB patients under 45 rose from 34% in 1989 to a fatal condition, but there are treatment options 51% in 1992 (National TB Program). Multi-drug that can extend the length and quality of life of resistant (MDR) TB is a growing problem: at the AIDS patients (box 4). The AIDS Division of Central Chest Clinic in Bangkok, MDR-TB rose MOPH has published clinical guidelines for from 1.9% of all cases in 1991 to 6.2% in 1994 health providers for treatment. However, there (Sawert et al 1997). A study in the same clinic is currently no recommended package of cost- in 1995-96 found that HIV-positive TB patients effective treatments for people living with had a risk of MDR-TB 12 times higher than HIV/AIDS covered by all insurance schemes. As HIV-negative TB patients (Punnotok et al 2000). a consequence, the type of care that PHA receive In provinces highly affected by HIV, like is highly variable from health facility to health Chiang Rai, MDR-TB levels are three times the facility and large variations in 01 treatment are national level. As many as 10% of patients observed. There is limited but disturbing seens with TB and AIDS at the Chiang Mai evidence that many, if not most PHAs in University Hospital are infected with MDR-TB Thailand, are not currently reached by cost- (T. Sirisanthana, personal communication), effective prevention, treatment and care programs for opportunistic infections. Voluntary counseling and testing (VCT)-an important service to identify those who can benefit from early treatment-is widely available in Thailand but underutilized; the quality of counseling services and their link to care programs has not yet been evaluated. 15 The higher prevalence of TB3 due to AIDS also poses VCT is available at nearly all provincial and increased risk among the HIV-negative population of community hospitals, through the private sector contracting TB. Thus, improving the detection, treatment. and (in the northern region) at health centers. and prevention of TB atmong PHA is not only beneficial to PHA but to the population at large by lowering their risk of Nevertheless, VCT can only be beneficial to contracting TB. those who seek it; most people with HIV/AIDS 24 luilding on Success, Con i gthe FmrIlwh find out that they are infected only when their where social stigma may be more prevalent. A health begins to fail; many who could benefit broader awareness among the public and from earlier detection are not getting tested. health providers of the potential benefits of Fear of social stigma, harm, and isolation were early diagnosis would likely lead to greater also cited frequently by Thai PHAs and care demand for VCT, prevention and treatment givers as reasons for not seeking VCT. This of 01, and improved health outcomes for appears to be a particular concern in rural areas, PHA. and the Southern and Northeastern regions, Box 4: Lengthening and enhancing the quality of life of AIDS patients There is no cure for AIDS, but there are services or treatments that can help AIDS patients to live longer lives in better health, and reduce their pain and suffering in the final stages. Voluntary counseling and testing (VCT). Because HIV infection is asymptomatic for many years, people who might benefit from early treatment or who should be taking extra precautions to prevent spreading the virus are often not aware that they are infected. Voluntary counseling and testing for HIV can help those who seek it to arrange for early clinical management of their disease before presentation with an AIDS-defining condition. VCT has also been shown to encourage sexual behavior change to prevent HIV, particularly in stable sexual partnerships (Coates et al 2000). Treatment and prevention of opportunistic infections. All of the major opportunistic infections-TB, PCP, and the fungal infections-can be treated and prevented successfully in AIDS patients, extending both the quality and length of life. The life- extending benefits of TB prevention and treatment in HIV-positive patients are real, since those with active untreated TB will most likely die of it. And there are public health benefits to this approach, since TB in patients with HIV can be highly infectious for others. PHA can be treated successfully for TB and cured, using the same 6-month course of treatment as for HIV-negative patients. Prevention of TB requires screening PHA for active TB, treating active cases, and providing treatment for 9 months with Isoniazid (INH) for those without active TB disease. Primary prevention against PCP is recommended by the World Health Organization (WHO) for all HIV-positive patients with diminished immune systems (CD4 T-cell counts below 200), for any patient with an AIDS-defining illness. A single daily dose of TMP-Sulfa (Bactrim, Co-Trimoxazole) can prevent this common and potentially fatal infection, but must be taken for life at a cost of $10/year. The three major fungal infections-candida, cryptococcal meningitis, and pennicilin marfei-respond well to prevention with anti-fungal drugs (Supparatpinyo et al 1998). Anti-retroviral therapy (ART). ART suppresses HIV, maintaining the integrity of the immune system and postponing development of deadly opportunistic infections. First introduced in 1986, ART has evolved from mono (single)-drug therapy (AZT. or zidovidine) to dual drug regimens (including AZT plus ddl, or AZT and /or ddl with d4T and 3TC) to triple-drug therapy, usually adding a protease inhibitor, in 1996. Protease inhibitors are a new class of anti-viral drug that prevents the HIV virus from making the proteins it needs to make new viruses in HIV-infected cells. Single drug therapy has been shown to have little effect on morbidity and mortality and is no longer used for treatment. Two-drug regimens are only moderately effective in reducing morbidity, add less than one year of disease-free survival and have no real benefit on length of life (Concorde 1994). Effective ART generally requires a minimum of three agents used in combination to show real benefits in disease-free survival times and quality of life. 'Highly-active' ART (HAART), which is used in high-income countries, is advanced anti-viral therapy that includes combinations of 3 and as many as 5 drugs, usually from 1-3 different classes of drugs, including protease inhibitors, multiple regimens and combinations, and intensive monitoring of patients for resistance. HAART is a highly individualized treatment that evolves over time as patients develop resistance or side effects that cannot be tolerated, requiring alternative drug combinations. As far as is now known, ART must be taken for life, and must be used with high physician and patient compliance to be effective. For those who can comply with the therapy, it can greatly enhance the length and quality of life. End of life care and management of pain and suffering. Palliative care aims to reduce suffering and enhance quality at the end of life. This includes home-based and hospice-based care for the dying and the management of pain, symptoms like diarrhea, and prevention and treatment of bedsores for patients no longer ambulatory. The Soros Foundation is funding several investigations. worldwide of death with dignity with a focus on access to pain medications, and this approach could be used to evaluate the needs of Thai PHAs. A 2000 WHO report on the status of palliative care worldwide identified lack of access to pain medication for terminally ill patients as one of the most extreme inequities in global health care. 25 Thailand's -esponse to Biiding on Succe. Coirontig the Fit4ure There are important gaps in TB treatment buy the more expensive patented version (D. and control that affect the access of AIDS Wilson, personal communication). There has patients to treatment. While the TB Division been no recent assessment of the availability of of the MOPH has been progressively these drugs in public hospitals, but a 1996 study implementing the "directly observed therapy, in the Upper North found that anti-fungal drugs short-course" (DOTS) for TB patients across the have the biggest supply and availability country, coverage is still not national. problems (Suwanvanichikij et al 1996). In Launched in 1996, DOTS is implemented in half contrast, other drugs, like amphotericin B for of the districts and will cover all of them by treatment of cryptoccocus, remain under patent 2003, according to WHO. The program is very and are expensive. Hospital managers are successful in some regions (as in the North-East sometimes reluctant to keep in stock these where all districts have implemented DOTS)" expensive drugs for which they are incompletely but less in others (only 20% of districts in the reimbursed by public assistance and voluntary province of Chiang-Mai and in Bangkok). In health card schemes. There are disturbing 1998, 40% of districts were covered by the anecdotes concerning attitudes of providers who DOTS program; in those districts, high smear consider expenditure on treatment of TB and conversion rates of 76% and cure rates of 68% other Ols in AIDS patients to be a waste of were realized. Inadequate treatment, due mainly resources, given that their condition is ultimately to noncompliance with regimens, is leading to fatal. It is unknown how prevalent these MDR-TB, an expensive and challenging attitudes are or how important they are as a infection to treat. While the cost of drugs for barrier to treatment but if true, AIDS patients treatment of non-resistant TB is $US 343 per will be discouraged from obtaining treatment, case in Thailand (National TB Program), the even if low-cost drugs are available. When cost of successful treatment of a case of MDR- AIDS patients lack access to TB treatment and TB in 1995 was estimated at $1,000-$10,000 prevention-regardless of the cause-there can (Sawert et al 1997). TB treatment is financed by be substantial negative impacts on TB in the rest government and offered free of charge. In of the population. To make better care a contrast, the drug costs of TB prevention with a reality, physician and care giver resistance to 9 month course of INH is less than $3. managing HIV infected patients warrants close examination. Provider attitudes and shortages of some drugs restrict access of AIDS patients to The sharp rise in TB associated with HIV and treatment for other opportunistic infections. the high prevalence of PCP and other Several of the drugs for prevention and preventable Ols are clear evidence that many treatment of Ols-including the TB drugs, if not most PHA are not receiving primary fluconazole for treatment of fungal infections, prophylaxis18 for these Ols in Thailand, even and cotrimoxazole for PCP prevention-are though these drugs have been shown to be generic. Nevertheless, some are in short supply. effective and low-cost. An informal survey Generic fluconazole, for example, is not conducted by Medecins sans Frontidres/ universally available and many patients must Belgium earlier this year interviewed 134 Thai PHA, all of whom were active in advocacy for 16 The DOTS strategy improves patient compliance by AIDS patients. These individuals represent having a local worker watch the patient take treatment, at "leaders" of the PHA community, and all had least during the first two of the 6-8 month regimen. It also been diagnosed with HIV or AIDS. Among the allows for patients to be treated in their homes or nearby . . health facilities, which are more convenient and involves 134, 81 individuals met clmcal or laboratory better detection and monitoring of cases and outcomes. criteria for PCP prophylaxis, but only half (40) DOTS has produced much higher patient compliance and treatment success than traditional TB therapeutic strategies, and has proven far more cost-effective. 18 Primary prophylaxis for 01 is preventive therapy initiated 17 In districts will "full implementation" of DOTS. all when a patient's immune system is weakened, before onset people identified with TB are treated with high levels of of the 01. Secondary prophylaxis is preventive therapy compliance. against recurrence of an 01. 26 'ha1tuui 's cspIsc t; As': Building on Success, Comfroniing the utIwre had received it. An additional 93 PHA who effectiveness: patient compliance (Proctor et al sought clinical evaluation from MSF were 1999) is difficult to sustain; patients can develop interviewed. More than a third (37) had been drug resistance during therapy (Ross et al 2000); told by their primary care provider that they debilitating side affects can reduce patient needed to be on PCP prophylaxis but had not yet compliance (Behrens et al 2000); and difficult received it. With respect to TB prevention, treatment requires highly trained and equipped improvements in DOTS implementation should providers. Since 1998, the declines in mortality make possible its broader use, through seen in the U.S. have flattened, suggesting the improving case finding and access to household limits even of HAART. contacts of active TB cases in need of preventive TB therapy. The current cost of drugs alone for a standard three-drug ARV regimen in Thailand is 27,000 Combination anti-retroviral therapies are in baht (US$ 675) per month, about 324,000 baht limited use in Thailand, remain expensive, ($8,100)/year. There is some hope that the high and the therapies in use are of uncertain costs of these drugs will go down, perhaps to as benefit. About 2,100 AIDS patients in Thailand low as 8,000 baht (US$ 200) per month and are enrolled in clinical trials of combination 96,000 baht ($2,400)/year if drug companies act antiretroviral (ARV) drugs-two-drug therapy on their public statements to lower their prices (2000 patients) or triple-drug therapy (100 for developing countries. In addition, the patients)-funded primarily through the Government Pharmaceutical Organization government AIDS budget. 19 In addition, an (GPO) is producing AZT, didanosine (ddl) and unknown number of patients-almost certainly stavudine (d4T) generically at substantially fewer than I % of Thais aware of their HIV lower prices than imported name-brand drugs status-are purchasing combination ARV (A. Eksaengsri, personal communication). therapies from private medical sources. The Implementing this therapy successfully also therapies in use are generally two-drug requires extensive monitoring. Viral load testing therapies. An evaluation of the results of clinical is recommended for monitoring combined ARV studies of dual therapy is underway through the treatment. The incremental cost per test is 5,000 Thai Clinical Research Network. baht/patient ($ 125) and is generally available only in regional and university hospitals, to only However, even when implemented in the best of a small fraction of Thai PHA. Expanded conditions, dual therapy is expected to be of availability of ART would require investment in limited benefit, based on international more testing facilities, which is not included in experience. The declines in AIDS deaths in the these incremental costs per test. U.S. and Europe were seen not after the introduction of I or 2 drug therapies, but only The majority of PHAs end their lives at home, after the 1996 introduction of highly-active anti- cared for by family members and supported retroviral therapy (HAART), which consists of 3 in some cases by the services of NGOs and or more drugs, of which one is a protease community-based organizations (CBO). There inhibitor. These therapies can prolong and appears to be considerable regional variation in greatly improve the quality of life for patients home-based and community care programs for who adhere to the regimens. However, they are PHAs. In the upper north, a number of NGO not a cure and must be taken indefinitely. and PHA groups offer care and support International experience has highlighted a programs for PHAs, and MOPH visiting nurse number of issues with the existing ART services reach a significant portion of those in technology that can compromise its need in some districts. However in rural areas, 1 Of the antiretroviral medications used in Thailand. 2) Of the antiretroviral medications used in Thailand, zidovudine (AZT) is available in most hospitals, didanosine zidovudine (AZT) is available in most hospitals, didanosine (ddl) and zalcitabine (ddC) in some. Stavudine (d4T). (ddl) and zalcitabine (ddC) in some. Stavudine (d4T), lamivudine (3TC) and protease inhibitors are rarely used. lamivudine (3TC) and protease inhibitors are rarely used. 27 7Thiland' Respnse toADS u o Confnn the --ntFe in the South, Northeast, and in Bangkok, Figure 15: Age-specific death rates for men, 1990 and 1996 programs appear limited or non-existent. A number of hospice programs are offered by the Buddhist and Christian clergy. Projects like the Chiang Mai-based Sanghametta Project offer training to monks in care for terminally ill patients with AIDS. This approach has - - - significant benefits not only in terms of care, but -- in reducing stigma through associations with the revered clergy. The demand for community- - based care can only grow as more HIV-positive [1I persons in Thailand progress to AIDS. While improved care and ART may lessen the burden 59 1014 1519 2024 25-29 3 - 4 45-49 504 55-59 to some extent on communities, AIDS remains a Agegroup fatal illness and support for hard-hit Source: van Griensven et al (1998) communities will be crucial to ensuring the success of these programs. Access and The impact of AIDS is already evident in the affordability of pain medication for the changing national pattern of adult mortality. terminally ill has not been studied in Thailand. Between 1990-96, there was a marked increase There has been no systematic assessment of in the age-specific death rates of men 15-50, the the type of services, coverage and ages when a person is most likely to contract geographical gaps in terminal home-based HIV (figure 15).21 The death rate for men age care support provided by NGOs and CBOs 25-29 has increased in every region of Thailand, on a national level. but most notably in the North, where it has more than quadrupled (figure 16) and 80% of deaths The Rising Impact of AIDS Morbidity among those 25-29 can be attributed to AIDS and Mortality (van Griensven et al 1998). In Chiang Rai and Phayao provinces, the death rate in this age The increase in the number of symptomatic group has increased tenfold, to 22 per thousand HIV patients poses an increased burden for (van Griensven et al 1998). Life expectancy for hospitals, especially in the North. Between Northem children aged 0-4 has dropped by 10- 1992-98, the number of annual inpatient days in 13 years for boys and 5 years for girls (van Chun Hospital, a community hospital in Phayao Griensven et a] 1998). Estimates made by the province, grew by 61%, from 7,337 to 11,847. U.S. Bureau of the Census suggested that life More than half of the increase (2,594 days) was expectancy in Thailand is 2-3 years less than it due to the rising burden of AIDS would have been in the absence of AIDS (World hospitalizations, which were virtually nil six Bank 1999). years earlier (Sunwanmalee 1999). The average length of stay of AIDS inpatients was more than double that of patients with other conditions. Hospital expenditures over that period rose by 120% in real terms and a quarter of the increase could be attributed to HIV/AIDS. By 1998, prevention and care for HIV patients represented 16% of total hospital expenditures and 30% of inpatient expenditure. The budget allocation for HIV/AIDS from the national government covered only 20% of the additional cost of AIDS patients; 80% of the increase was borne by the hospital general budget and insurance schemes. 2F Based on deaths recorded by the vital registration system. 28 Buidin onSuce s Co31frot'ling the F' uture Figure 16: Trends in death rates for men age 25-29, by region positive, a short regimen of AZT before and 12 -__ __- after delivery, AZT syrup for the child, and a one-year supply of breastmnilk substitute (box 10 - - - - - - - - - - - - - - - - - --- - 5). When fully implemented, this policy should mother to child transmission. Initial results from 0 regional pilot programs are very encouraging: In Zone 10 (North), where 3.7% of women are HIV-positive, 98% of pregnant women in the Sthose testing positive received AZT (Thaineua et orproeactfereanggreedThoilandested, andunts of al 2000). The transmission rate has been c reduced to 7.7%. In Zone 7 (Far East), where 1984 1988 1986 1987 1988 1989 1990 1991 1992 1993 1994 1998 1999 HIV prevalence is lower (<1%), 69% of nNorth wCentraI Northeast wSouth pregnant women agreed to be tested and 69% of Source: Im-em (1999). those testing positive agreed to take AZT (Kanshana et a 2000). The transmission rate High infection rates in pregnant women have was reduced to 8.2%. Because fertility is low resulted in a growing number of young and the number of children infected is relatively children with HI/AIDS. Without any small, this intervention may be affordable in medical intervention, roughly 25-35% of HIV Thailand. Based on the experience in the North positive pregnant women will pass HIV to their (Thaineua et al 1998), the cost per child HIV newborn children during pregnancy, childbirth, infection averted for a national plan that covers or breastfeeding. In Thailand, this amounts to 60% of pregnant women can be estimated at an estimated 4,000-5,000 HtV-positive children $2,000s3 000.2 Life expectancy for children born to women living with HIV/AIDS annually. who are not helped by this intervention is short, Research has shown that a short course of AZT half of them dying by age 5 (Dabis et al 2000). during pregnancy and labor can reduce the While young children can also benefit greatly probability of HIV transmission from mother to from prevention and treatment of opportunistic child among non-breastfeeding mothers by half infections, their access is likely to be much (Shaffer et a( 1999). lower. Parents find it very difficult to cope with both their own and their children's illness, and s ,when children's prime caregivers fall ill, on children, Thailand has been phasing in a children are subject to neglect. new policy of providing free HIV testing to all pregnant women and, for those who are HIV 22 This estimate assumes that the transmission rate without any intervention is 30% and that transmission will be reduced by 60% using the short AZT regimen and breastmilk substitute (BMS). Costs include the costs of counseling, training, supervision, and consurables. Against these costs, prevention of HIV transmission from mother to child will also produce some savings in terms of reduced cost of caring for HIV-positive children. Further, there may be secondary benefits of the counseling and testing of women in terms of preventing spread of HIV with their spouses and sexual partners. 29 Thinds Response to AIDYS: Building on Success, Confionting the Future Box 5: Preventing transmission of HIV from mother to child HIV can be transmitted from mother to child before birth, during labor and delivery, and after birth, by breastfeeding. In the absence of any intervention, about 30% of HIV-positive pregnant women who breastfeed would pass HIV infection to their children. Since 1995, voluntary HIV testing and counseling for pregnant women has been progressively implemented throughout Thailand. Initially, HIV-positive mothers were provided with breastmilk substitute for replacement feeding (RF), to prevent HIV transmission through breastfeeding. This probably reduced HIV transmission to the newborn by about one third, to 20% (see figure). The Thai Red Cross subsequently implemented the long regimen of zidovudine (also known as AZT or ZDV) during pregnancy for HIV-positive mothers (ACTGO76 regimen), which should have reduced transmission to less than 10%. However, a short regimen of AZT, which is also less expensive, has also been shown to be effective in Thailand in a controlled trial. The Upper North region of Thailand rapidly scaled up its program, introducing a short regimen of AZT during the antenatal period and delivery, AZT syrup to the baby, and replacement feeding on a routine basis. More than 70% of HIV-positive mothers of this region benefited from the treatment in 1999. When fully implemented, the transmission rate from mother to child should be cut by two-thirds (see figure). The intervention has been shown to be cost-effective, even at less than 5% HIV prevalence among pregnant women. There are, however, still discussions about which regimen to use in countries where replacement feeding may not be easily implemented on a large scale because of the increased risk of child illness and mortality when water sources are unsanitary and caring practices are poor. There are many different regimens to chose from, with different benefits, levels of complexity, and costs. As a large part of HIV transmission via breastfeeding occurs after 6 months, exclusive breastfeeding (EBF) for six months and early cessation of breastfeeding may be an alternative in countries where early replacement feeding is not an option for most women. Estimated Rates of Mother-Infant HIV Transmission by Intervention 0 10 20 30 No Intervention Exclusively Breast-Feeding and early cessation only Replacement Feeding only Short regimen ZDV only Exclusive Breast- Feeding + early cessation+i-short regim en ZDV EBF+ short regimen AR V+ newborn ARyV+ early cessation Short regimen ZDV+RF Niverapine+RF ACTGO76 Short regimen ZDV+ Nrverapine+R F ACTGO76+Cesaerian Section C om bined AR V Transmission Rate (%) Prevention of Mother to Child Transmission of HIV: Implementation Issues in Developing Countries Agnes So cat (1) Potschrl Sirinirund (2) R.J Simonds (3) (4) Rudolf Knippenborg 30 ildingon uces Co ing the F'uure Adult AIDS mortality is also dramatically for a child in the Vienping home are 30,000 increasing the number of Thai children who baht/year (excluding staff costs), compared with have lost one or both parents. The results of 24,000 baht/year for children in foster care, and the "Global Orphans Study for Thailand" 6,000 baht/year in support for children cared for estimated that in 1998 there were 34,372 in the homes of relatives. children under the age of 15 who had already lost their mothers to AIDS, 57,049 whose Figure 17: Children in government welfare homes, 1992-97 mothers were living with AIDS, and 420,731 5 T whose mothers were HIV-positive but asymptomatic (UNICEF 2000). A survey of 40O8_ - - public and private agencies involved in helping PHA and children in 17 northern provinces 3000 -------- counted 7,247 children age 0-18 who had either lost parents to AIDS or whose parents were 2000 living with AIDS. A second enumeration in ----------- ------- 1413 2000 counted 10,270, 35% of whom were 2- 1 13 113 parent orphans (Vienping Children's Home 2000). Most children orphaned by AIDS in 0 - Thailand, including HIV-positive children, are 1992 1993 1994 1995 1999 1997 cared for by surviving parents and relatives. The F New cases Old number of admissions in government children's Source: Children and Youth Welfare Division, Department homes nationally rose 25% between 1992-97, of Public Welfare. while the number of continuing cases has An increasing number of HIV-positive remained fairly stable, rising only 11% over that children are being abandoned or left with period (figure 17). This increase may be due to children's homes. By 1997, the number of many different causes, not necessarily to the annual new admissions of HIV-positive children AIDS epidemic, including population growth, an to government children's homes had risen to increase in the number of children's homes, or 109, from roughly one tenth that number five broader cultural change. Many orphanages years earlier, bringing to 201 the number of engage in extensive outreach, not reflected in the children with HIV/AIDS being cared for that number of resident children, to keep children in year (Children and Youth Welfare Division, their communities-programs to encourage Department of Public Welfare). Several private adoption, to place children in foster or group orphanages have sprung up that specialize in homes, to place children in private orphanages care of HIV-infected children, offering more with more resources, and to support children intensive care and treatment of the children, living in the homes of their relatives and/or including in some cases ART. The support and HIV-positive parents (M. Yoktree, personal treatment costs in these homes can be quite communication). This strategy allows the high-the Support the Children Foundation in support of more children in a better Chiang Mai spent 3.7 million baht (nearly environment, at lower cost: The support costs $100,000) for anti-HIV drugs and another 3 million baht for caregivers for roughly 24 23 This estimate assumes that the transmission rate without per c uation). Th q ityare any intervention is 30% and that transmission will be tha c mbe cprovie deends o pre reduced by 60% using the short AZT regimen and breastmilk substitute (BMS). Costs include the costs of donations. Clearly, the number of children counseling, training, supervision, and consumables. infected with HIV can be reduced considerably Against these costs, prevention of HIV transmission from by wider implementation of MTCT mother to child will also produce some savings in terms of reduced cost of caring for HIV-positive children. Further. there may be secondary benefits of the counseling and only partly effective, and the HIV-negative testing of women in terms of preventing spread of HIV children born to infected women will still endure with their spouses and seXUal partners. 31 al i " IC V' the impact of losing their mothers. This Total funding for AIDS programs declined by underscores the importance of preventing 9% between 1996-97 (from 2,187.5 million to infection in women of childbearing age, which 1,986.1 million baht) and has declined more protects not only the women but their children as dramatically, by 27.8%, since the economic well. crisis (1997-99). The hardest hit has been prevention expenditure, which dropped by half Reduced Public Expenditure on AIDS since 1997 and has declined as a share of the Prevention total AIDS budget, from 11% to 8%. Current levels of government spending amount to only 2 In 1999, the Royal Thai Government spent baht per capita (5 US cents) to prevent HIV 1.4 billion baht ($37.9 million), or about 24 transmission among roughly 40 million adults. baht (63 cents) per capita from its national Expenditure on treatment and care was also cut AIDS program budget to prevent by about a third (34.4%). However most of this transmission of HIV, to care for and treat decline could be attributed to completion in AIDS patients, to mitigate the impact of 1998 of a program to construct patient wards at AIDS, and to support AIDS research (table five hospitals in 1998 (Waranya Teokul, 1).24 The largest share of the AIDS budget personal communication). If one excludes this (63%) financed treatment and care, including component, then spending on medical treatment antiretroviral and opportunistic infection drugs and counseling was relatively protected during for clinical trials, HIV testing and counseling, and after the crisis, with a 9.3% cut. In fact, the blood screening, and universal precautions to AIDS budget line for treatment is only a share of prevent HIV infection in medical settings. Of the total public spending on AIDS treatment, as it total of 24 baht per capita spent out of the AIDS covers drugs only for a small group of AIDS budget, 15 baht (40 cents) is spent on treatment patients enrolled in clinical trials. Health care and care. The next largest share (16%) was needs of other AIDS patients are financed spent on services to mitigate the impact of through the regular budget of MOPH for care AIDS, including programs to prevent and cannot be easily disassociated from the transmission of HIV from mother to child, care health care consumed by other patients. Grant of orphans, subsidized living arrangements for funding for NGO activities has remained people living with HIV/AIDS who are out of constant from 1997-99. The two main work, skills training and legal counsel for PHA. categories that received increased spending are Programs to prevent the spread of the epidemic programs to mitigate the impact of AIDS- in the population accounted for only 8% of the notably the financing of programs to reduce HIV budget, covering public information, purchase of transmission condoms for free distribution, condom promotion, and other community prevention activities. An additional 6% of the AIDS budget was distributed as grants to NGOs for community-level AIDS prevention and care activities. The remaining 7.2% of the AIDS budget was allocated to management and research. 24 This figure excludes the cost of treating other sexually transmitted diseases, tuberculosis in AIDS patients and other public Subsidies for health care that are used by AIDS 25 Because the convenions for classifying different types of patienps. The AIDS budget funds activities in MOPH as AIS expenditure changed in 1997. it is not possible to well as other ministries (e.g.. OPMb Ministry of Defense, show the breakdown by program component for previous Ministry of Educauion, Social Welf1re Ministry). years in a way that is comparable. 32 Table 1: Evolution of government national AIDS program expenditure in Thailand, 1997-2001 1997 1998 1999 2000 2001a Millions Millions Millions Millions Millions Program component of baht Percent of baht Percent of baht Percent of baht Percent of baht Percent Prevention 217.3 10.9 138.3 9.3 108.9 7.6 108.9 7.9 121.6 8.2 Treatment and care 1,379.4 69.5 980.7 66.2 905.3 63.1 948.2 64.9 936.1 62.9 Medical treatment 973.0 49.0 895.4 60.4 893.5 62.3 939.6 64.3 927.2 62.4 Counseling 25.2 1.3 11.6 0.8 11.8 0.8 8.6 0.6 8.9 0.6 Facilities/equipment 381.2 19.1 73.7 5.0 0 0 0 0 0 0 Mitigating the impact 142.7 7.2 174.2 11.8 228.3 15.9 235.4 16.1 235.1 15.8 MTCT & other 57.5 2.9 72.0 4.9 138.8 9.7 147.8 10.1 146.7 9.9 Social services 85.2 4.3 102.2 6.9 89.5 6.2 87.6 6.0 88.4 5.9 NGO activities 90.0 4.5 90.0 6.1 87.6b 6.1 60b 4.1 70b 4.7 Research 32.9 1.7 46.7 3.2 54.6 3.8 50.7 3.5 54.6 3.7 Management 123.8 6.2 51.6 3.5 48.9 3.4 56.7 3.9 69.6 4.7 TOTAL 1,986.1 100.0 1,481.5 100.0 1,433.6 100.0 1,460.2 100.0 1,487.0 100.0 Notes: Condom budget 29.2 36.0 35.7 43.2 Condoms purchased (m.) 20 24.9 25.3 31.5 AIDS treatment drugs 172.5c 309.1c 256.1cd 280.0e 440.9 ARV for treatment 172.5c 242.8c 248.9d 289.7 01 drugs Oc 66.4c 7.2c 151.2 TB budget 360.1 333.6 310 Source: Based on Bureau of the Budget data compiled by the Social Projects Division, NESDB. Figures for 1997-99 are actual expenditures; figures for 2000-2001 are budgeted or proposed. Notes: a. Proposed. b. Source is AIDS Division, Communicable Disease Control Department, MOPH. Excludes planned disbursements for the $2.6 million SIP component on AIDS prevention and care in 2000-2001. c. Expenditure by AIDS Division only; excludes spending on AIDS treatment drugs by the rest of MOPH and drugs for treating TB. d. Includes grant from Japan for 125,778,903 baht for ARV drugs in 1999, which induced a reduction of the AIDS division budget for ARV to 123 million baht. e. Assumes that 167 million baht was reinstated in 2000, to replace the contribution made by Japan the previous year. The allocation between 01 and ARV has not yet been decided. 33 dailand's Response fo A Building on Success, Con fioning the Future from mother to child (41.4% increase since provided to the mission, none of the 1997)-and research, which increased by prevention budget is allocated for 66%. The 2000 and 2001 budgets do not prevention of HIV transmission by suggest much of a change in the status quo, injecting drug use, which accounts for a with some modest increases in prevention growing share of total transmission and (11.7% increase of 12.7 million baht, still where HIV infection levels have risen, not leaving nominal spending on prevention declined. 44% below 1997 levels), medical treatment (3.8% increase, 33.7 million baht), and Figure 18: Condoms purchased by the AIDS division, mother-to-child transmission (5.6% 988-2000 increase, 7.9 million baht). Funding for 52. 53 53 NGOs is projected to decline, but these 50 47T- figures exclude the AIDS component of the 0 Social Investment Project loan, financed by C4 the World Bank, with projected 0 315 disbursements of 27 million baht in 2000 and 45 million baht in 2001. 20 The cut in prevention expenditure reflects 10 1v a dramatic decline in finance of condoms for free distribution. The number of condoms purchased by the MOPH for free2000 distribution to high-risk groups dropped by Source: AIDS Division, MOPH. 62 percent, from 53 to 20 million pieces (70 million to 29 million baht), between 1996- Public spending on treatment from the 97 (figure 18). These cuts were primarily AIDS budget is dominated by the the result of a decision to transfer more of purchase of expensive anti-retroviral the costs of condoms to beneficiaries, but drugs for small numbers of AIDS patients coincided with the economic crisis. Several enrolled in clinical trials. With the informants felt that 1996 condom levels exception of financing AZT for prevention represented oversupply, and that a modest of mother-to-child transmission, government reduction in publicly financed condoms and most insurance providers in the health might have been in order. Monitoring of the system do not subsidize antiretroviral epidemic and of risk behavior in the therapies, such as the expensive triple- population during the crisis years suggests combination therapies used widely in the that high levels of condom use in West. This policy is consistent with that for commercial sex were sustained despite these public funding of other very expensive cuts (Pothisiri et al 1999, treatments, like kidney dialysis, which is not Tangcharoensathien et al 2000). However, subsidized. However, in the case of AIDS, the crisis most likely reduced the demand there is an exception for some 2,100 persons for commercial sex, reducing the demand enrolled in clinical trials of dual or triple for condoms and thus reducing the impact of antiretroviral therapy, whose drug costs are the cut in the condom budget. Many other financed by the AIDS budget as part of high-risk groups highlighted earlier in this clinical trials. The proposed drug budget for report still have low condom access and use. 2001 for ARV (289.7 million baht) amounts The cuts in condom purchase in 1996-97 to 31% of the proposed allocation for have by and large not been reinstated, with medical treatment and roughly one fifth of projected condom purchases for 2000 (31.5 the entire AIDS budget (NESDB). If million condoms) at only 59% of 1996 100,000 people in Thailand are currently levels. According to the Information living with AIDS, this means that one fifth of the national AIDS program budget and 34 Thailand's Response to A[IDS: Budding on Success, COaftanaing the Trwe more than twice the amount spent on allocate funds to smaller NGO collaborators. prevention is being used to finance ART Little information is available about the for 2% of all AIDS patients, at an average precise activities of the NGOs, the coverage cost of 138,000 baht or US $3,449 per or effectiveness of their activities, and their patient annually. An unknown share of the potential complementarity with other public regular MOPH budget is also spent on and private programs. In particular, health care of AIDS patients not in these information is not readily available on the clinical trials, but the MOPH budget does extent to which they are involved in not finance ART for treatment, and in prevention activities, as opposed to patient general there is no clear policy on funding of care, and whether the prevention activities drugs for opportunistic infections. Drugs for are focused on those at greatest risk of treatment of Ols are financed through other transmitting AIDS to others, or on the budgets of the MOPH, through hospitals and general population. While financing of other health facilities, and out of pocket, and NGO activities is a small share of overall these expenditures have certainly increased expenditures (6.1% in 1999, or about I baht over time with the growing number of AIDS of the 24 baht per capita)-the NGO share is patients. Hospitals can allocate some of only slightly less than the share spent on their non-earmarked drug budgets to drugs prevention (7.6%). The complementarity of for opportunistic infections. Thus, it is very these activities with both the prevention and difficult to track actual spending on 01 treatment components of the budget, their drugs (treatment and prevention), and in coverage and effectiveness deserves 26 some cases, the same drugs are used to treat review. AIDS patients and those with other conditions. The main exception is the TB budget, which is funded centrally. Despite Te Unert the dramatic increase in TB associated with HIV infection, the TB budget declined in nominal terms by 14% between 1997-99, Thailand is in the process of from 360.1 million to 310 million baht. implementing far-reaching reforms in the way that health care is delivered and Budget allocations to NGOs have financed, and the outcome can have remained steady since the crisis, although major implications for the effectiveness of the mix of services provided, program HIV/AIDS control. Not all of the details coverage, and likely impact have not been have been worked out, but the thrust of the studied. NGOs have played an important reform involves improving the equity in role in the response to AIDS in Thailand; resource allocation between provinces, their critical role in facilitating care for decentralizing health budgets and decision- AIDS patients is often cited. In 1999, the making to provinces and sub-districts, AIDS Division allocated 87.5 million baht performance-based budgeting, and increased to 465 projects of 373 organizations, for an involvement of civil society in health-related average outlay of 188,200 baht ($4,704) per decisions. Beginning in FY 2001, local project. In 2000 and 2001, the allocations for NGOs declined, but this will in part be 26 An evaluation is underway by the Foundation for compensated for by the $2.6 million AIDS Thai Development Fund to review the budget componentallocation process, the impact of community based compnentof he Wrld ankfinacedgroups funded by the AIDS program from FY 1992- Social Investment Project (SIP). In 2000, 99. and the allocation of expenditure by objective. the AIDS budget will allocate 60 million impact and target population. A similar one-year baht to nearly 300 NGOs for prevention and evaluation of the SIP project is underway. Both care, and the SIP project an additional 27 reports are due to bc completed by the end of September. Some of the funds allocated to NGO are million baht to six major NGOs who will used for capacity building to be more effective in deliv pring interventions. 35 aDuIiad's R?espojnse to ADS: Bulding on~ Success, Conflfnting the Fviture governments (provinces and municipalities) North can also decrease the overall cost of will be allocated 20% of tax revenue, a care, as shown in Phayao province budget from which they will have to conduct (Charoendee 1999). Performance-based some health activities. In addition, the budgeting will likely require that provinces MOPH has developed the capacity to sub- report on their performance in fighting contract for both prevention and care HIV/AIDS in order to be eligible for services to NGOs. The respective roles of financing. This may also clarify the the MOPH, the provincial governments, the expectations of the MOPH in terms of a Tambon Administrative Organizations, the satisfactory provincial response to provincial health offices and the health care HIV/AIDS, including the package of health providers are currently being delineated. care benefits to which AIDS patients are entitled, either through health insurance or Decentralization is an opportunity to subsidized by MOPH. better involve local political authorities in the fight against HIV/AIDS and to involve However, decentralization can also lead to PHA in decisions about health services. fragmented capacity and responsibilities The reform aims to facilitate the and reduced accountability for results, in involvement of civil society in health communicable disease control programs, decisions. This means that people living including HIV prevention. Plan for with HIV/AIDS will have the opportunity to decentralization health services are not yet participate in the management of health available in Thailand. As in other countries, services at the Tambon level and on hospital prevention and control of a communicable boards. This would give them a mechanism disease like HIV/AIDS cannot depend solely for raising issues around packages of on local decision-making, which is highly benefits, quality of care and access to drugs. variable and likely to lead to implementation Existing networks are already playing an in a patchwork fashion from locality to important role in advocating increased locality. Likewise, localities cannot be access to essential drugs for AIDS patients. expected to be responsible for ensuring Decentralized DOTS, PCP prevention, VCT provision of national public goods and and prevention of mother to child sectoral coordination; this requires leadership transmission at the health center level in the at the center. 36 Thailand' 's R?sponse tep A IIS: Building on Success, o if4onling 0*he 1futre Chapter IV: Confronting the Future: Strategic Priorities for Enhancing the Response The National Plan for Prevention and Thailand's AIDS epidemic is severe; Alleviation of HIV/AIDS, 1997-2000 sets success in overcoming it will require the forth two key objectives: to "reduce new joint effort of government, the private HIV infection in the general public" and to sector, and civil society. Each partner in "reduce the impact of the AIDS problem on this effort brings a comparative advantage in the socioeconomic and health status of the addressing different aspects of the problem. population" (National AIDS Committee Government brings its public mandate, 1997). The Plan emphasizes that meeting technical expertise, finance, and sectoral these objectives is not the sole responsibility coordination. NGOs bring diversity, of government-"all related actors" need to flexibility, possible cost-effectiveness in be strengthened and will be essential for implementation, and credibility among PHA success. To make this a reality, the Plan and marginalized populations. Private firms underscores the importance of investing in have their own interest in investing in the capacity of individuals and of prevention in the workforce to maximize communities "so that all individuals have productivity and prevent high treatment full potential to prevent HIV/AIDS and costs. They also have an important role in other social problems..." and of "creating an mobilizing private funds for AIDS enabling environment for the individual.. prevention, treatment, and care (box 6). that is conducive to AIDS prevention and ... The collaboration of the public, private, and alleviation". The Plan thus charts out many NGO sectors has been an important element different types of interventions-individual of Thailand's successful response; these and societal-that can be mobilized in the partnerships need to be reinforced and the national effort to prevent HIV and its private sector mobilized to an even greater impacts. extent as a partner in AIDS prevention and care. Box 6: AIDS and the private sector The AIDS epidemic can have serious impacts on businesses, including the loss of experienced staff, absenteeism among workers, greater worker turnover and training costs, greater health care costs, and low morale from lack of information and understanding of AIDS in the workplace. The private sector thus has strong incentives to ensure AIDS information, prevention, and non-discrimination policies in the workplace. It also has excellent and inexpensive access to their employees. The private sector is often key to mobilizing financial resources for philanthropy such as for AIDS care for orphans or employees. Since 1993, the Thailand Business Coalition on AIDS (TBCA) has been working with businesses "to create AIDS- supportive work environments by providing HIV/AIDS education and prevention seminars and promoting the adoption of appropriate HIV/AIDS workplace policies" (TBCA 2000). In addition to providing services to more than 80 member companies, the TBCA has helped in the development of sister organizations for the private sector in Malaysia, South Africa, Botswana, and Zambia. International businesses with branches in Thailand have often led the way. For example, Shell/Thailand launched a program with UNICEF called "Peer education at the pump" , which provided AIDS education to more than 800 young people working as service station attendants. The Regent Bangkok hotel provides workplace AIDS education to new and continuing employees. Property Care Cleaning Services provides staff training, assistance to PHA. and free condoms. (Continued on next page) 37 Bi(lingr on. Success, nl/I ' he uture Box 6 (continued) Smaller-scale businesses have also had an impact on. raising awareness and sponsoring services. In Phayao province, the Business AIDS Network for Development (BAND)-a coalition of small businesses, government, NGOs, and PHA-helps youth who are infected or whose parents have AIDS through a referral network that includes technical training, scholarships, social support for PHA and their families, and income generating projects. Members of BAND, including the Rotary, the Lions Club, the Chamber of Commerce, the Department of Commerce, the MOPH, businesses, and PHA, are committed to keeping people at work as long as they can be productive. Preventing HIV/AIDS is particularly important to life insurance companies. The American International Assurance company, the largest life insurance company in Thailand, will offer as much as a 10% reduction in the life insurance premia to their policy holders if they have workplace HIV/AIDS education programs. By offering similar financial incentives or tax breaks to businesses, government can greatly expand the reach of AIDS prevention and care programs to those in formal private sector employment at potentially little extra marginal cost. Given the current stage of the epidemic in epidemic and that the private sector has Thailand and competing demands from insufficient incentives to produce (World other important programs in health and Bank 1999). These include: other sectors, which activities are priorities for government? There are many * Production of 'public goods', like things that government could do, but epidemiological surveillance, public resources are scarce. Not all activities can information about how HIV is spread have equal priority. Further, there are some and can be prevented, evaluation of AIDS prevention and care activities that are interventions, and information about the more effective for a given expenditure than costs and effectiveness of prevention others. The report team set out to address the and treatment measures. Sectoral question of strategic priorities for enhancing coordination and regulatory authority Thailand's response to AIDS, and in are other important public goods. The particular those that require government private sector will never provide public leadership. The challenge was to identify, goods in sufficient quantity, because among the many things that government everyone can benefit from them could do, those that should be done first to regardless of who pays. 25 have the greatest impact for a given investment. The team drew on their own * Ensuring that those who are most expertise and disciplines and the views likely to become infected with HIV and expressed in extensive consultation with key to pass it to others have access to the informants in Thailand (see Annex 1). information and the means to adopt Those consulted were asked to identify two safer behavior.26 People who practice or three priority activities or objectives that unprotected sex (sex without a condom) in their view would maximize the impact on with many partners and those who share the epidemic in the whole population, if injecting equipment are most likely to additional resources were made available. become infected with HIV and also to The views of those consulted and the pass it on to their partners, even to those conclusions of the report team were remarkably consistent. 25 Public goods have two key characteristics: once A Framework for Setting Government produced, no one can be excluded from consuming them; and consumption by one person does not Priorities exclude consumption by others. 26 In the terms of 'public economics', the high-risk The highest priority activities for behavior of some individuals creates negative consequences (or 'negative externalities') for the rest government involvement are those that of the population by raising the level of HIV and thus are essential to controlling the AIDS everyone's risk, even those who practice safe sexual and injecting behavior. 38 TS e to iD S: who do not practice risky behavior. has identified many groups with high-risk Ensuring that these individuals practice sexual behavior, low use of condoms or safer behavior than they would chose on unsafe injecting practices-indirect sex their own prevents not only their own workers, undocumented sex workers, infection, but indirectly many additional injecting drug users, men who have sex with infections in the rest of the population. men, prisoners and long-range fishermen, to Government is in a unique position to name a few.27 Ensuring that these people, act on behalf of society to encourage many of whom are at the margins of society, safer behavior among those at greatest have the knowledge and the means to adopt risk of passing HIV to many others. safer practices and protect themselves and their partners is a fundamental responsibility Governments can do more and should not of government and key to reducing further necessarily limit themselves to these items. the spread of the epidemic. However, However, providing public goods and because some of these individuals are addressing the highest risk behavior are engaged in illegal activities, a direct fundamental to controlling the epidemic. If government approach will not be successful. government does not take a leadership role NGOs, subsidized by government, thus have and see that they get done, no one else will. a key role in reaching these marginalized Failure to address these issues will make groups with prevention measures. The other public and private investments in success of these efforts will often require AIDS prevention and care less effective. legal, regulatory or social reforms that will Government need not be directly involved in improve the enabling environment for implementing these priorities, but it needs to behavior change. ensure that that they get done. At the same time, even though high-risk Thailand's response to AIDS thus far has behaviors continue to generate indirectly highlighted in a very positive way these more infections in the general population, two important roles of government. The reaching these groups may be difficult strong epidemiological surveillance of HIV, and costly. Figure 19 maps different groups public information programs, operational of the population according to their degree research on innovative pilot interventions of risk behavior and their ease of access. for national replication, and the intersectoral Those that are more accessible will likely be coordination provided by the National AIDS less costly to reach with preventive Committee are all excellent examples of interventions, and those that are less 'public goods' that have been essential to accessible, more costly. Behavior change the success of the response to date. among those on the upper half of figure 19 Likewise, Thailand's efforts to raise condom reduces the chance of infection among those use in commercial sex by improving the in the lower half. This figure is dynamic in motivation of sex workers and their clients the sense that over their lifetimes, people and providing the means to change move across risk and access quadrants. The behavior-generally without stigma or objective of public policy is to change arrest-are key examples of this second principle, and a model for other countries in 27 To label these groups as 'high risk' is not to imply changing high-risk behavior on a national that every individual in a given group practices risky scale. behavior or that there are not people in 'low risk' groups that also practice risky behavior. There is However, Thailand has not exhausted the heterogeneity in all populations. However, on opportunities for improving the average. the behavior of the high-risk groups is more prone to spread HIV and to generate secondary cases effectiveness of the response in terms of of HIV indirectly to those at lower risk. Once HIV reducing high-risk behavior. This report spreads to people with low-risk behavior, it is very difficult to prevent transmission. 39 Thaikand's Respon;:,e in Building on Success, Confi-oning he r behavior at the top of the chart, through behavior among those in the upper right services and information targeted to these quadrant are a priority for government and groups and through complementary broader likely to be very cost-effective. Other based programs aimed at the general public groups are more difficult and possibly more that will improve the environment for costly to reach, like IDU out of treatment behavior change. and undocumented sex workers (upper left quadrant of figure 19). Public policies can Thailand's AIDS prevention program has have an impact on the costs and ease of effectively reached brothel-based sex access of these groups, not only by workers, a high-risk group that is subsidizing NGOs to provide prevention relatively easier to reach and monitor. services, but also by reducing social stigma Other high-risk groups are still highly and law enforcement efforts that make it infected and at high risk of transmitting HIV difficult for public health services to reach to others. A few of these-like prisoners them and by launching broader programs of and IDU in treatment-are 'captive' public awareness that improve the enabling populations and thus relatively easy to reach environment for behavior change. (upper right quadrant of figure 19). Direct and indirect programs to promote safer Figure 19: Classification of target groups for prevention by riskiness of behavior and accessability Undocumented sex workers Sex workers in brothels Out-of-treatment IDU IDU in treatment programs Prisoners Homosexual/bisexual men Military, police, sailors, fishermen More Indirect sex orkers difficult Easier access access Rural women Employees of large firms Women attending antenatal clinics Children in school, university students figure 19-people who have low-risk There are also examples of groups with behavior (are unlikely to spread HIV to low-risk behavior, like school children others) and who are costly to reach. These and pregnant women, who are unlikely to individuals need essential information and spread HIV widely but for whom access is access to prevention so that they can protect easy and low-cost (lower right quadrant of themselves; their behavior is unlikely to figure 19). Not many secondary HIV cases spread the epidemic further in the will be averted in this quadrant, but the costs population. The most cost-effective way of of reaching people are so low that such lowering their risk of infection will be to programs may still be cost-effective. reduce others' high-risk behavior (upper Finally, there is the lower left quadrant of quadrants of figure 19). Many of the 40 L, ii1ing oil suaei uninfected spouses of discordant couples schooling, poverty, social capital and (couples in which one partner is infected) economic development. This environment are in the lower left quadrant-they have is very important to the present and future low-risk behavior and are very difficult to course of the AIDS epidemic; policies to identify, and yet at high personal risk of affect it are pursued via complementary being infected (box 7). In the background of programs in various economic and social figure 19 is the economic and social sectors. environment that conditions these behaviors-factors like women's status and Box 7: Preventing transmission between spouses: a new challenge for AIDS programs Sexual transmission of HIV between spouses now accounts for about half of the 25.000 new adult HIV infections annually in Thailand (Thai Working Group 2000). Men or women who previously became infected through commercial sex or other risk behavior unknowingly pass HIV to their steady partners. Preventing these spousal infections poses a new challenge for AIDS prevention. First, discordant couples-couples in which one partner is infected with HIV and the other is not-are difficult to identify. Until one of them gets sick, there is usually no objective sign to either spouse that one of them is infected. Further, the infection may have occurred in the distant past, before a marriage or the current relationship, when the infected spouse was engaging in riskier behavior than at present. So there may be no current risk behaviors that would lead the individual to believe that he/she is infected or at risk, nor would there be any obvious way for a program to identify him/her based on current behavior. Second, the cost- effectiveness of preventing transmission among discordant couples is likely to be low. Unless some way can be found to get these couples to self-identify themselves for specific programs by being tested, prevention programs are faced with having to reach large numbers of couples with interventions when only a few are in fact at risk of transmission. Third, even if a spouse suspects that he/she may be infected, dealing with issues of trust, past behavior, infidelity, or whatever else led to the infection are very sensitive and often difficult to discuss. This is a disincentive to learning one's HIV status. How can these spousal infections be prevented in a cost-effective manner? One way is to prevent either spouse from becoming infected in the first place through programs that reduce high-risk behavior, promote condom use, or safe injecting behavior. These programs reduce the number of discordant couples in the future. The cost-effectiveness of programs to prevent transmission among currently discordant couples can be improved if some incentive can found for couples to seek voluntary HIV counseling and testing. Many suggestions have been made-expanding the availability of VCT, campaigns to encourage couples to get tested, voluntary pre-marital counseling and testing, improving information on the benefits of early detection, and reducing stigmatization of AIDS. Finding effective and efficient ways of helping these couples will require substantial experimentation. In addressing AIDS treatment and care, a Thailand, about one third of health priority for government is to ensure expenditure is financed by the public sector fairness in public finance, cost-effective and two-thirds by private individuals and services, and non-discrimination of AIDS firms (Tangcharoensathien et al 1999). patients. It is a fundamental responsibility Subject to these societal norms, fairness of government to ensure that the human considerations suggest that AIDS patients rights of AIDS patients are respected and to should be entitled to the same level of public prevent discrimination socially and in health subsidy as others with equally severe health care. Most of the benefits of curative care conditions-no less and no more. To the accrue to the individual, so curative services extent that the public sector does subsidize are often considered by economists to be treatment, financing services that are cost- 'private goods' that should be paid for by effective ensures that more people can be the individual, out-of-pocket or through helped within a given budget and reinforces insurance arrangements. Nevertheless, the equity objective. societies differ in their judgements about the share of curative care that should be funded from public and private sources. In 41 uiling on Success, Conf -onting the Future Strategic Priorities to Strengthen prevalence among direct and indirect sex the Response workers in Bangkok. RaiinecndmRseanpofenbhaio The team identified three strategic priorities aong o h sk grous. behavior for government to have the largest impact on angoandrcondomruse amongsotherahigh the epidemic with the resources at hand. risk grou l ie sex okers, undocumented sex workers, prisoners, 1. Sustaining and expanding condom fishermen, MSM, and male sex workers use beyond commercial sex would have a large impact relative to their costs. Some of these groups are less easily The highest priority for improving the reached than brothel-based sex workers. effectiveness of the response is a renewed Government subsidies can be targeted to push to sustain the high levels of condom support NGOs specifically to address the use in commercial sex and to raise needs of these groups, in a systematic way. condom use, encourage safer sexual Pilot projects, properly evaluated, can then behavior and behavior change among be implemented on a national scale, as has other high-risk groups and more widely been done so successfully in the 100% in all relationships. This was the number condom and MTCT programs. However, one priority of both the report team and these targeted activities are unlikely to be those consulted. Sexual transmission successful unless other public policies that remains the engine of the AIDS epidemic. inhibit marginal groups from protecting A lapse in behavior is the greatest threat to a themselves are also addressed. For example, resurgence, while lack of access of other sex workers from Cambodia and Myanmar groups at high risk holds back even greater in non-registered brothels will not be easy to progress in slowing the epidemic and reach with condom programs if they fear reducing infection levels in the whole that they will be deported when they contact population. public health workers. Low condom use among undocumented sex workers can keep Sustaining behavior change in the virus circulating among clients who commercial sex. As Thailand recovers from frequent Thai as well as other nationality sex the economic crisis, rising incomes are workers. likely to lead to renewed demand for commercial sex. At the same time, public Figure 29: Hypothetical impact of a reduction in subsidies for free condoms to brothel-based condom use to 50% in commercial sex in 1998 sex workers are still at a historic low. With 2500 17% of brothel-based sex workers already infected, any lapse in condom use is likely 2000 to result in substantial additional infections. E In the meantime, condom use has never been i: 1500 very high among 'indirect' sex workers and brothel-based undocumented sex workers !, 1000 have unknown levels of risk and condom use. The Thai Working Group on AIDS 500 Projections has shown the potentially explosive impact of lapses in condom use in 0 commercial sex, allowing the epidemic to CP K D regain its initial trajectory (figure 20). There are already signs of increase in HIVeai Source Thai Working Group on AIDS Prkjections (2000). 42 Buln g o! n Suces. On fotn the Futurwe Raising condom use in all relationships. low levels of condom use with regular The most cost-effective strategy for partners, boyfriends and girlfriends, casual reducing sexual transmission will be to non-commercial partners, and same-sex change behavior among those most likely to relations between men. Young men are spread HIV, once infected. Achieving this visiting sex workers less often, but are goal will surely involve both direct/targeted increasingly engaged in other types of interventions and indirect methods that relationships and using condoms improve the environment for condom use infrequently (box 8). Public information outside of commercial sex. Informants campaigns should emphasize the benefits of indicated that the public associates HIV condom use in all sexual relationships and transmission with commercial sex, and that efforts should be launched to improve the people feel 'safe' not using condoms in availability of condoms more generally, other relationships. This is borne out by the especially among youth. Box 8: The changing patterns of risk behavior among Thailand's youth While young Thai men are now significantly less likely to engage in commercial sex than the previous generation, reducing the risk of HIV, sexual behavior has changed in other ways that put youth at increased risk. Findings from a recent study in Chiang Rai (Northern Thailand) are cause for concern (van Griensven et al 2000). More than 1,700 students aged 15-21 in two private vocational schools were surveyed in late 1999, with computer-based, self- administered questionnaires. Among the entire sample, 0.3% were infected with HIV. Close to half of male students (48%) and 43% of female students had ever had intercourse, with a mean of 4.6 and 2.8 partners among sexually active males and females, respectively. Seven percent of male students had paid for sex and 3% of male and female students had sold sex. A quarter of the sexually active females had been pregnant and 84% of the most recent pregnancies ended in an abortion. Condom use was low-only one third of male students and one half of female students consistently used condoms with casual partners and only 15.6 % of males and 10.5% of females used them with steady partners. More than 20% of female students and 7% of male students reported forced sex. More than a quarter of the students (29%) reported prior metamphetamine use and 10% of urine samples from the respondents tested positive for this drug. It is difficult to know how representative these vocational students are of the rest of the population of young adults in Chiang Rai or elsewhere. However, the high HIV infection rate and low condom use puts these youth at substantial risk of HIV infection, in addition to risk of pregnancy and infection with other STDs. This underscores the need to intensify and expand behavior change education and training for HIV prevention among young people. Interventions include peer education, sex/reproductive health education, and life skills training to youth and young adults in school and workplace settings. Messages need to be tailored to these new patterns of behavior, while reinforcing past messages about commercial sex. It also underscores the need to make condom use the norm for all sex among youth, which will require improving their access to condoms. The high rates of metamphetamine use are equally of concern. They not only reduce judgement in sexual encounters but also (under current policy) place youth at high risk of being sent to prison. Once there, they will be exposed to the high HIV infection rates in the prison population, with virtually no access to condoms and other prevention. Partnerships between government ministries, NGOs, community organizations, and the business sector can assure adequate resources and coverage of these programs to reduce risk among young people. 2. A major new initiative to reduce infections to injecting drug use. Left transmission by injecting drug users. unchecked, IDU will continue to be a reservoir for transmission of infection to the A major new effort needs to be launched rest of the population. Yet, in Thailand as in to prevent infection and transmission of other countries in the region, HIV HIV among injecting drug users and their prevention for IDU and their sex partners partners. HIV prevalence has been steady has not been a priority. Simulations by the or rising among IDU; the Thai Working Thai Working Group on HIV/AIDS Group on HIV/AIDS Projections now Projections have shown the high potential attributes a quarter of all new adult impact of a concerted effort to prevent HIV 43 h;aiiani s ,vspose to IS fBuilding on Success, ConiP iig the Future among IDU (figure 21, the difference Note: Scenario 2: MTCT; scenario 3: MTCT plus between scenarios 3 and 4). reinvigorated condom promotion; scenario 4: previous scenario plus harm reduction for IDU; scenario 5: previous scenario plus promotion of condoms in IDU in Thailand have very low access to marriage. prevention. Addicts can legally purchase syringes over the counter in pharmacies. Nevertheless, there are proven, effective Nevertheless, infection rates are high, interventions to reduce the prevalence indicating that at least 40% of IDU have and incidence of HIV among injecting been sharing equipment; IDU are also drug users. The most effective programs frequently incarcerated, which easily can -"harm reduction"-reduce unsafe induce needle sharing within prisons and behaviors among IDU through needle could account in part for the high infection exchange programs (NEP), bleach for rate. Thailand's network of methadone disinfection of injecting equipment, and clinics for heroin addicts is potentially an educational outreach. Many of these important contact point for reaching IDU programs provide referral services for drug with harm reduction interventions (box 9). treatment programs and condoms to prevent Voluntary drug detoxification is unavailable transmission between IDU and their sexual and methadone is illegal in neighboring partners. These programs tend to be countries-China, Laos, Malaysia and controversial, because they are sometimes Myanmar. Thailand has allowed at least one perceived by the public as supportive of 'harm reduction' project on a feasibility injecting drug use. However, evaluations of basis, among Akha community members in NEPs in six industrial countries failed to villages with high heroin use in the upper find any evidence that these programs raised north (Gray et al 1998). However, among the number of IDU, induced people to the great majority of injectors, who are initiate drug use, or increased the number of urban, these approaches have yet to be improperly discarded needles (Lurie and implemented. National HIV prevention others 1993, Normand et al 1995, U.S. GAO programs for youth, school and community 1993). based education programs, and multi- sectoral programs have focused largely on The clearest example of the success of HIV sexual transmission, and have not included prevention among IDU in the Asia-Pacific prevention messages for drug use. region is Australia, with well documented success in peer outreach, harm reduction, Figure 21: Impact of the three expanded intervention needle exchange programs, drug treatment, scenarios on cumulative HIV infections in the Thai population 2000 to 2020 1300 With support from UNAIDS and the 1300 -------- -------------- ------------ -- -- --------- 1 UNDCP, Vietnam has piloted harm Tr 1250 -- - - - - - - - 1250- ---reduction and outreach programs for IDU, 1200mass education campaigns for youth, and __ __0__ -.---sehn crop substitution in opium growing areas to 1100 --- - - - - - - - -*--scenario3 cc--Scnro reduce supply. However, the efficacy of the -*-- Scenario 4 1050 -- x -K-Scenario5 in HIV Incidence has not yet been studied. 0 950 Source: Thai Working Group on HIVAIDSs o s5icin puarmoreductinafor ppu;lceari and haverthees heflrafu are prve,efet thos ndernteafmHIV resume injecting behiors yarsngGoDU 1993,Mcgh nd Srojrctions ThaiWoe others 1997). However, drug treatment Protonctirnh M20f0h. proram prvid reerrl srvies or 4ru 4P n , I Ig I he it it e centers do have an important role to play as safer injecting behavior among those who a point of contact for reaching IDU with resume it (Blix and Gronbladh 1998, preventive interventions, and can encourage Metzger 1997, Rezza et al 1988). Box 9: Heroin detoxification programs in Thailand Since virtually all IDU in Thailand use heroin, heroin detoxification is the most important drug treatment program with respect to reducing HIV spread through injection behaviors. Drug treatment programs in Bangkok have been the provenance of the Bangkok Metropolitan Authority, while nationally they have been centered in five drug treatment centers, initially created with funding from USAID and run by the MOPH. These centers provide short (21 day) inpatient drug detoxification regimens on voluntary and involuntary bases. The largest. the Northern Drug Treatment Center in Mae Rim, treats 2,800-3,000 drug users per year and includes programs for opiate addicts, IDU, alcoholics, and those addicted or dependent on all other drugs, including amphetamines and anxiolytics. Heroin detoxification and treatment in Thailand is limited by law to a 45-day course of methadone, based on a regulated "taper" of declining methadone dosage. Longer term methadone maintenance, the mainstay of heroin addiction treatment worldwide, is not available. Preliminary data for a cohort of IDU in Mae Rim suggest that most addicts find this short course inadequate. Perhaps 85% or more of IDU begin using heroin again by the third or fourth of the methadone taper. when doses fall below 20mg/day and cannot contain opiate craving (unpublished data, courtesy Dr. Jaroon Juttiwutikarn). It is widely acknowledged, however, that physicians circumvent the restrictions by "re-enrolling" IDU who repeatedly fail treatment on short course therapy. The sole study of longer term methadone treatment in Thailand was conducted in 1989-90 in the BMA (Vanichseni et al. 1991). This study showed clear benefits to long-term methadone maintenance, including high rates of retention in drug treatment, lower rates of return to injection than short-course detoxification, and greatly improved compliance with the treatment program. The impact on HIV rates and behavior change for HIV prevention were not assessed. Unfortunately, the findings did not convince decision-makers and long-term detoxification with methadone or other substitutes or therapies remains unavailable To have a major impact on the epidemic, the legal environment for behavior the same pragmatic policy toward change among IDU. Half of the IDU in prevention of HIV among (illegal) treatment in the early 1990s had been commercial sex workers needs to be previously incarcerated; studies have found extended to drug injectors. Thailand a statistically significant relation between should consider evaluating these approaches incarceration and HIV infection among IDU. on a pilot basis in collaboration with NGOs, The Thai prison population, including adapting aspects of the harm reduction persons in detention, convicted offenders, model where appropriate, and implementing and persons in International Detention them. The lack of NGOs focused on IDU Centers, is large and rapidly expanding. was identified by several informants as a Thai prisons currently do not provide constraint in expanding harm reduction in condoms to prisoners, increasing the risks of Thailand. However, this shortage could be HIV infection among men having sex with addressed through targeted subsidies to men, a common occurrence worldwide, and NGOs for capacity building in harm among female prisoners and male prison reduction and to provide these services. staff. Numerous studies have shown strong Given the high infection rate among IDU, a associations between incarceration and HIV crucial component of any programs aimed at infection in Thai men, due to sex, and to IDU will include promotion of condom use injection drug use in prison, where needles with their sexual partners. and syringes are in extremely short supply. To the extent that IDU may currently be It is unlikely that the IDU transmission targeted by law enforcement, a more tolerant cycle can be broken, however, unless approach (similar to that for sex workers) there is simultaneously a serious effort to would keep them out of prison and less prevent HIV in prisons and to improve likely to get or transmit HIV. The ability of 45 Biit- an Surces , /a,u Ci Uu NGOs to work with IDU to adopt safer Bangkok. Because TB is an infectious behavior can easily be undermined by law disease and prevention and treatment of one enforcement actions that put self-identified case prevents many others in the population, IDU in jail. there is a strong case for government subsidies for both TB treatment and, among 3. Ensuring access to cost-effective AIDS patients, TB prophylaxis. Failure to prevention and treatment for offer treatment or prophylaxis to HIV- opportunistic infections positive patients not only will shorten their lives, It will raise TB, infection levels in the Ensuring access by people living with whole population. Thus, provider attitudes HIV/AIDS to prevention and treatment of (to the extent that they exist) that discourage the major opportunistic infections is HIV positive patients from obtaining inexpensive, cost-effective, prevents life- treatment or that make less of an effort to threatening infections among PHA, and reach the HIV-positive are not only unfair will benefit the poorest AIDS patients and discriminatory, their actions have very who otherwise might have gone negative implications for the spread of TB in untreated. Thailand is a middle-income Thailand. TB prophylaxis for HIV-positive country with a strong health infrastructure, patients (9 months) will effectively treat the yet both key informants and the evidence on TB before the immune system fails, AIDS-defining conditions strongly removing the risk of the major opportunistic suggested that access to relatively infection AIDS patients, and the major cause inexpensive treatment and prevention of the of death. TB and PCP prophylaxis are most common Ols is not a reality for people inexpensive (less than $3 in drug costs for a with HIV/AIDS in Thailand. Many 9-month regime of INH to prevent TB, and contributing factors were mentioned: lack $10 per year for PCP prophylaxis). They of information among PHA about available would benefit virtually all AIDS patients in treatment; provider attitudes that discourage Thailand at very little cost, whether paid for AIDS patients from pursuing treatment; low by the public sector, by an insurance availability of some drugs in health scheme, or by the patients themselves. facilities; weak TB infrastructure in Bangkok; and the absence of a well-defined Efforts to improve access to 01 'package' of health care benefits in the prevention and treatment warrant different public insurance schemes for immediate attention. An action plan would people living with HIV/AIDS. The report likely begin with a comprehensive team did not have sufficient time to explore assessment of actual use by PHA and these issues further, but all of them warrant availability of 01 prevention and treatment immediate attention. The press has focused in the public and private sectors and barriers on access of AIDS patients to expensive to wider use. Review and clarification of antiretroviral therapies, yet this more cost- the package of health care services for 01 effective option of 01 treatment that can be prevention and treatment in public insurance effective even among the poor has not been programs would likely immediately improve adequately pursued. Eventually even access to these services for PHA. Pilot patients taking combination ARV develop projects to raise access to 01 prevention and viral resistance and will be stricken with Ols treatment urgently need to be launched and like TB and PCP, in the absence of evaluated, for national replication. prophylaxis. There's evidence of a need for renewed efforts in TB prevention and control in the face of the epidemic, particularly in 46 Thathmgd's Response to A i Buildig inSccs. Confr-ontig the Ftr Implications for Public Finance of resources to NGOs that undertake prevention activities with key marginalized Because the objective of this study was populations (undocumented sex workers, strategic, the team intentionally resisted MSM, IDU, etc.). making recommendations about operational or programmatic requirements to address Expanded coverage of cost-effective these priorities. We leave it to technical prevention and treatment of OIs experts, NGOs, and representatives of key constituencies (sex workers, IDU, PHA) to Public funding of medical care for AIDS craft an operational plan, set benchmarks for patients occurs through many different measuring impact, and identify the resources health care budgets-the government health needed to meet these objectives. budgets, health insurance providers, hospital Nevertheless, even without detailed revenues, patients, and others. In the case operational budgets, these strategic priorities of Chun hospital, 20% of the costs of AIDS and the analysis that informed them do have patients were paid for by the AIDS budget broad implications for public finance and the other 80% was financed by insurance schemes and the general hospitai Raising resources for prevention budget. We actually do not know at present how much is being spent on prevention and Addressing the first two strategic priorities treatment of Ols or by whom. will surely require a substantial increase in the resources devoted to HIV/AIDS One of the first pieces of information prevention. Most public expenditure on necessary to launch this initiative is a better HIV/AIDS prevention comes from the understanding of which AIDS patients are budget of the national AIDS program. At receiving these services, how much the present, only 8% of that budget-109 services cost and how they are currently million baht, scarcely 2 baht/capita-is being financed. This will lead to proposals explicitly allocated to prevent the spread of to improve the access of PHA to 01 this 100% fatal infectious disease. It has prevention and treatment and to improve the been shrinking recently and none of it is for efficient allocation of existing resources. preventing transmission among IDU. Yet The budgetary implications are not clear; the prevention of HIV/AIDS and production of expansion could be financed by increased public goods are the major rationale for a public resources, reallocations of existing separate HIV/AIDS budget. Thus, a major budget, or mobilization of funding from implication of this exercise will be a request insurance schemes and the patients for additional resources for prevention, and themselves. The decision on public finance particularly programs to support safer should be guided by the same criteria as for behavior among those most likely to other curative care-cost-effectiveness, contract and spread HIV. affordability, and fairness. A reallocation of funds within the clinical trials line item of To improve the efficiency of prevention the AIDS budget, from ART to 01, could programs, it will also be necessary to finance operational research on improving understand better how NGO activities might the quality and impact of a basic package of be better focused to support the renewed 01 preventive and curative care for PHA. prevention agenda. NGOs have proven themselves capable in both prevention and Thefiture ofARTin Thailand care, but there is very little information about the types of activities they are International compassion for the plight of undertaking and their target constituencies. AIDS patients in developing countries and This review would result in better targeting their lack of access to many treatments used 47 Thailand's RespOnsN to A'pIS: 3ilding on Success. Conf-onling the IFuure in the North has led to increased pressure for widespread drug resistant strains of HIV. public policy on combination ART. Many Therefore, once government makes a people feel that these therapies may have a commitment to subsidize this type of role in the Thai health system, given the treatment for a cohort of patients, there's no relatively strong health infrastructure, going back for the life of that cohort. It is a Thailand's level of income, and recent decision that must be taken very carefully opportunities to obtain lower-price drugs. with a full understanding of the long-run However, drug prices are coming down implications. from a very high level to a level that is still relatively high (Bilous 1999, Boulet 1999, On cost-effectiveness, ART is a life- Wilson et al 1999). There are also the costs prolonging therapy but not a cure for a of diagnosis and monitoring (including the disease that is 100% fatal. The dual marginal costs of tests and investments in therapies currently being financed in setting up the necessary facilities), managing Thailand have been found elsewhere to have side-effects, and ensuring adequate training limited benefits. The cost of triple drug for physicians. There continue to be therapy is very high and there are many important scientific debates about key issues issues in implementation and compliance in prescribing these therapies, which affect that can reduce its effectiveness. In addition their costs and impact: when to start to the drugs, this complex technology treatment; the number and combinations of requires very skilled medical personnel who drugs that are effective; interactions of must specialize in these therapies to do them drugs; management of side effects; the well. There's an opportunity cost to other extent to which monitoring is necessary; and patients in the health system when the most incomplete patient compliance and its skilled human resources are diverted to consequences for the circulation of resistant AIDS from other specialties. It is difficult strains. The therapies are still generally very to make a strong case for funding ART, in complicated to take and to adhere to, any event, until the more cost-effective especially for low-income patients. The treatment options for treating AIDS patients, effectiveness of clinical trials of dual and like prevention and treatment of Ols, have triple ART in various Thai universities has been fully exploited, which it appears they not been evaluated; given that the trials have have not been conducted in very controlled conditions, the outcomes are likely to over- Even if ART could be to be shown to be state the effectiveness of the therapies if cost-effective, it remains very expensive. If implemented more widely in the population. few people were infected with HIV and national income were high, then perhaps Decisions regarding public subsidies for even an expensive therapy might be anti-retroviral therapies or any other affordable. But in Thailand, 2% of the adult AIDS therapy should be subjected to the population is infected with HIV and 700,000 same criteria as medical treatments for people are living with HIV/AIDS. In other health conditions, notably cost- contrast, the adult infection rate in Brazil, effectiveness, affordability, and fairness / which has decided to fully subsidize ART equity. However, for ART we must add a for all AIDS patients, is 0.6%, less than a fourth criteria, sustainability. Once a group third the rate in Thailand, it has fewer of AIDS patients starts taking ART, they people infected (580,000), and it's GNP per must take it for life. A decision by capita is more than twice as great ($4,630 government to discontinue treatment for a vs. $2,160 for Brazil and Thailand, large number of patients-during an respectively) (World Bank 2000). economic crisis, for example-would be a public health disaster, generating 48 kailaids Response to ADS: i.tlin on icc ess. C','on ting the Fu-ure Is ART affordable? systems who would potentially benefit from ART ); 55,000 (the number of people who To put the affordability and sustainability of develop AIDS annually); 25,000 (the ART in perspective, we have done some number of people officially diagnosed with simple calculations in Table 2 of the cost AIDS annually); and 10,000 (a sub-set of implications for Thailand of financing those diagnosed with AIDS most capable of different levels of coverage of ART, in adhering to the therapy). absolute terms and relative to both the AIDS budget and the overall government health At current prices, it would cost 32 billion budget. In FY 2000, the proposed health baht ($810 million), or nearly half the sector budget amounted to 65.2 billion baht overall health budget and 2000% of the ($1.56 billion), or 1,069 baht per capita AIDS program budget, to provide drugs for ($26.73). The approved budget for the a single year of ART to all 100,000 people national AIDS program came to 1.46 billion who might benefit. Under the optimistic baht ($36.5 million), or 2.2% of the total scenario of a significant drop in drug costs, health budget. We estimate the affordability the total would be reduced to 9.6 billion of a triple-drug regimen that includes a baht, or 15% of the health sector budget. protease inhibitor, as these are the regimens Even were the beneficiaries limited to the that seem to have lowered mortality 25,000 people who develop an AIDS- significantly in some high-income countries. defining illness every year the total would There are two drug price scenarios: a high come to 2.4 billion baht ($60 million), or price, reflecting the current situation nearly 4% of the health sector budget and (324,000 baht/$8,100 per year), and a low 164% of the AIDS program budget. Those price, based on use of generic drugs and costs would be for the first year. Assuming voluntary price reductions from the that these therapies can raise the survival of pharmaceutical companies (96,000 patients, they must be subsidized in the baht/$2,400 per year). These costs include following years as well, while new PHA only the drugs and thus understate the true who become immune compromised are financial impact of ART. We show four added to the group. different levels of coverage: 100,000 (the number of PHA with compromised immune 49 Table 2. Estimated total annual cost of ART, palliative care, and opportunistic infection management, under different scenarios on price and number of persons treated Unit cost Number of persons with HIV/AIDS treated Treatment (annual) 10,000 25,000 55.000 100,000 Total annual cost (millions of baht and dollars) ART (high cost) 324,000 baht 3,200 8,100 17,600 32,000 ($8,100) ($81.0) ($202.5) ($445.5) ($810) ART (low cost) 96,000 baht 960 2,400 5,300 9,600 ($2,400) ($24) ($60) ($132) ($240) Palliative care 32,800 baht 320.0 820.0 1,760 & all Ols ($820) ($8.2) ($20.5) ($45.1) Palliative care 7,080 baht 70.8 177.0 389.4 & low cost Ols ($177) ($1.77) ($4.425) ($9.74) As a percent of the FY 2000 AIDS budget (1.46 billion baht) ART (high cost) 219 555 1205 2192 ART (low cost) 66 164 362 658 Palliative & all Ols 22 56 83 Palliative & low cost Ols 5 12 27 As a percent of the FY 2000 health sector budget (65.2 billion baht) ART (high cost) 4.9 12.4 27.0 49.1 ART (low cost) 1.5 3.7 8.1 14.7 Palliative & all Ols 0.5 1.3 2.7 Palliative & low cost Ols 0.1 0.3 0.6 Notes: 1. Estimates of average annual cost of opportunistic infection prevention and treatment in Thailand were calculated by J. Perriens (UNAIDS) in 1997, as reported in World Bank (1999). Costs were based on the number of episodes expected among AIDS patients in Thailand per 100 person years; the costs per type of illness are thus weighted by the probability of a patient having the illness in a given year. Results are in 1996 dollars, transformed here into baht at a rate of 40/$. Palliative care includes treatment for diarrhea, rash, cough, fever, headaches and pain, nausea and shortness of breath, which is estimated to cost US$19/year. Inexpensive Ols include TB, PCP, toxoplasmosis, oral and esophageal thrush, and pneumonialsepticemia. Expensive Ols include cryptococcosis, herpes simplex, penicilliosis, cytomegalovirus, and mycobacterium avium/complex. The estimates include drugs only. The additional estimated annual cost of inpatient care was $673 and outpatient visits $163. 2. Low and high-cost ART includes three drugs, one of which is a protease inhibitor. Diagnostic and monitoring costs are not included, nor are any in- or out-patient visits. The drug costs are for 2000. The total additional annual cost to patients above these drugs was estimated in 1996 to be $2,500 (J. Perriens, in World Bank 1999). Inclusion of these costs would essentially double the estimates of the low-cost ART. The precise drug costs are difficult to estimate, because people on these therapies typically must switch drugs several times due to resistance and side effects. 3. Per capita public expenditure on health from the central budget in 2000 was 1,069 baht ($26.73), assuming a total population of approximately 61 million. The AIDS budget represented 2.2% of the MOPH budget. 50 Thailand's Response to A S: Bul/ding on success, Co0oatinTg the Future We show for comparison some estimates of Finally, there are two dimensions of equity, the cost of palliative care and or fairness, in decisions on public subsidies prevention/treatment of Ols calculated by J. for ART. First, there's fairness across Perriens (UNAIDS) for Thailand in 1997 patients with health conditions that are very (World Bank 1999).28 This type of expensive to treat. The government does not treatment would be appropriate mainly for offer free treatment for many other costly those who have developed AIDS, so they health conditions: kidney dialysis and open- are not calculated for everyone who is heart surgery are examples. A funding immune compromised. We show two decision on ART should be consistent with different estimates of the annual cost of 01 policy on public subsidies for these other prevention and treatment-one that includes expensive therapies. Failure to do so, or to palliative care and Ols that are inexpensive explain the rationale for an exception is not to treat/prevent and the other that includes only unfair but could lead to resentment all palliative care and 01 prevention and toward those with AIDS. The second treatment. Palliative care and treatment of element of fairness has to do with the extent inexpensive Ols for the 55,000 people who to which public subsidies for ART would develop AIDS annually would cost 389 skew health spending toward those who are million baht (compared to 17.6 billion baht not poor. In the case of ART, it has often for ART) , the equivalent of 27% of the been observed that the patients who are most AIDS budget or 0.6% of the health budget. likely to be able to comply with the therapy If the package were offered only to PHAs as are from better-off households. If they were diagnosed with an AIDS-defining compliance is one of the criteria for illness (25,000 per year), the cost would selecting patients for ART, then it is highly come to 177 million baht ($4.4 million) likely that the majority receiving the subsidy annually, or 12 % of the AIDS budget and will be people who are wealthier. One way only 30 million more baht than is currently to deal with this would be to offer subsidies being spent on MTCT. In the case of 01, based on the patient's economic status, however, an unknown share of this requiring the better off households to pay a expenditure is already occurring through substantial share of the total cost. various sources of finance of medical care. Thus, the calculations for 01 overstate the The need for periodic review of rapidly additional resources that would be needed.29 evolving therapies 28 These estimates of the costs of 01 prophylaxis and The availability, effectiveness, and cost of treatment are for comparison only and should not be combination antiretroviral treatments has interpreted as an endorsement of any particular been evolving quite rapidly and will 'package' of services. In this case, the estimates include all Ols as well as palliative care. While these estimates are a few years old, the mix of conditions urgent need of an objective review of the and the treatments for them have not changed. A few costs, benefits, affordability, and equity of the drugs used in the calculations may have become implications of different types of generic, lowering the price. Most likely, this is an combination therapies for AIDS patients, overestimate of the current cost. 29 If the estimated 55,000 people who develop on the allcto of publ AIDS each year live two years and have 10 inpatient days and 12 outpatient visits annually, resources. It has been several years since half of each in district hospitals and half in the issue of government priorities with provincial/regional/university hospitals, then current spending on AIDS treatment within the health system would be roughly 1.776 billion from the Chun hospital study. However, a study baht, or 2.7% of the FY 2000 health sector is urgently needed to review the access to and budget. These calculations are based on the data use of different types of care by AIDS patients 51 respect to anti-retrovirals has been assessed poor and non-poor AIDS patients. To the (Prescott 1997), and it is time for a re- extent that resources are available for assessment that would include the following additional field trials or pilot testing, they key issues: should be directed to reinforce the strategic agenda on 01 prevention and treatment, * a review of the costs and benefits of which is more likely than ART to be funded technical alternatives in treatment; and about which important insights could be * the potential demand for these learned on the cost-effectiveness in the Thai treatments in Thailand; context. * the rationale for public finance-do these therapies address either public Improving private decisions on use of ART goods or epidemiological externalities? Are they in line with policy on other Government can continue to put pressure on health care?; pharmaceutical companies to lower the cost * the potential for private provision of of ARV drugs and can ease regulatory these treatments and the potential barriers that limit access to low-cost generic diversion of privately financed patients drugs. Reductions in the prices of to the public sector; antiretroviral drugs will inevitably lead to * the affordability of these therapies, their broader private use by AIDS patients given potential demand, and any public in Thailand who can afford them. and private cost savings; Government can improve private decisions * the implications of public finance of on the use of anti-retroviral therapies by combination ART for the fairness of the making available objective information health system-in terms of the potential about the benefits and costs of alternative access of both rich and poor AIDS treatment regimens and by removing patients and fairness across patients with barriers to private use of these therapies other serious and incurable health through regulatory action (Velasquez and conditions. Perriens 2000, Perriens 1999, Boulet 1999, Bilous 1999). Regulatory action and This review would provide objective professional accreditation can improve the information for decision-making on the quality of service delivery by HIV allocation of public resources. It would also clinicians. In parallel, safeguards against help AIDS patients to make better-informed improper use of these drugs can be put in health care decisions. Deliberations on the place to limit the emergence of viral proper role for ART in Thailand should not resistance and preserve the effectiveness delay the urgent agenda to increase the ARV drugs for future AIDS patients when access of AIDS patients to life-saving the drugs become more affordable. prophylaxis and treatment of the most common opportunistic infections, which are inexpensive to provide and will benefit both 52 Thaladl Resone t ADS -ddn Su ttccess, CPo/oln heFtr Chapter V: Conclusion Thailand has demonstrated to the world groups. Thailand has an opportunity to the enormous scope for slowing an AIDS reduce the AIDS epidemic in injecting drug epidemic fueled by commercial sex, by users, leading the way for neighboring providing the information and means for countries whose epidemics are based in IDU sex workers and their clients to adopt transmission, and thereby reducing the safer behavior. Since 1993, behavior epidemic in the region. change and condom use have prevented an estimated 200,000 HIV infections in Thailand faces a second enormous challenge Thailand. Based on discussions with key of ensuring compassionate and cost- informants and examination of several effective care for nearly 700,000 people excellent policy reviews, the report team has living with HIV/AIDS. Short of a cure, tried to highlight factors that helped to shape there is presently no way to prevent the this response. Hopefully, other countries tragic morbidity and mortality of those will benefit from this experience, adopt already infected. However, there are similar programs even earlier and prevent an affordable and cost-effective treatments to explosive epidemic. prolong life and improve its quality. Given Thailand's level of income and its strong These actions greatly slowed the spread of health infrastructure, it can again show HIV/AIDS in Thailand but they did not stop international leadership by being one of the epidemic. Even while policymakers the first developing countries to ensure took action, HIV had already infiltrated universal access to cost-effective many groups. The outward spread into the prevention and treatment of opportunistic general population had already been infections for people living with launched. In the year 2000, two percent of HIV/AIDS, both rich and poor. It can also Thai adults are infected with HIV/AIDS, an provide critical information to patients about incurable, fatal infectious disease, and the costs and benefits of alternative 29,000 people are getting infected every treatments, reduce the barriers to year. Nevertheless, there is room for antiretroviral treatment for patients who can optimism in further controlling the Thai afford to purchase it privately, and AIDS epidemic. There are still highly cost- implement adequate safeguards to minimize effective investments that can be made to inappropriate use of antiretroviral drugs. have a large impact on the future spread Underpinning this effort is the commitment of HIV--efforts to sustain condom use in to ensure that AIDS patients receive the commercial sex, to dramatically raise same quality and access to care in the health condom use among marginalized groups system as patients suffering from other life- with high risk of contracting and threatening conditions, without spreading HIV, and to launch effective discrimination. prevention among injecting drug users. This renewed commitment to prevention While demand for treatment will continue will, in many ways, be more difficult than to mount and must be urgently addressed past efforts. Behaviors that are socially and with cost-effective and equitable politically more controversial will have to be solutions, it is essential for government to confronted. It will require coordination maintain and expand its focus on between sectors, government, and NGOs, prevention if future generations are to be targeted subsidies to NGOs who can work spared the threat of HIVIAIDS. with highly stigmatized populations, and investments in an enabling environment to support behavior change among these 53 Thailand's R~esponse to AIDS: 4!i ! Stuccess, olifrwnfing the Future Annex 1: People Consulted Ministry of Public Health Dr. Somsong Rugpoa, Director-General, Department of Communicable Disease Control Dr. Anupong Chitwarakorn, Director, AIDS Division, Department of Communicable Disease Control Dr. Chaiyos Kunanusont, Former Director, AIDS Division (1999-2000) Dr. Kamnuan Ungchusak, Division of Epidemiology Mr. Chawalit Tantinimitkul, Chief, Planning Section, AIDS Division National Economic and Social Development Board Ms. Waranya Teokul, Associate Director for Economic Preparedness Ministry of Social Welfare Ms. Mayuree Yoktree, Superintendent, Viengping Children's Home, Chiang Mai Bangkok Metropolitan Authority Ms. Krisadaporn Sirikul, Chief of Planning and Epidemiology Section, AIDS Control Division, Dept. of Health UNAIDS Asia-Pacific Intercountry Team Dr. Wiwat Rojanapithaya, Team Leader Dr. Maurice J. Apted, Intercountry Advisor on Communication, Social Mobilization and TB-HIV David Bridger, Information Support Advisor Dr. Aninkya Chatterjee, Intercountry Technical Advisor on Drug Use Mr. Steven J. Kraus, Programme and External Relations Advisor Mr. Tony Lisle, Technical Advisor on Mobile Populations and HIV Mr. Paul Toh, Technical Advisor on Care and Support for PLWHAs International Organizations Mr. Gamini Abeysekera, Representative, UNICEF/Thailand Ms. Revathi Balakrishnan, Rural Sociologist and Women in Development Officer, FAO Mr. Wayne Bazant, Demand Reduction Adviser, United Nations Drug Control Programme Ms. Regina Boucault, Chief of Mission, International Organization for Migration Mr. Sompong Chareonsuk, UNDP Dr. Brian Doberstyn, World Health Organization Representative Mr. J. K. Robert England, Resident Representative, United Nations Development Program/Thailand Dr. Ying-Ru Lo, Medical Officer, AIDS Division, World Health Organization Mr. Naren Prasad, Assistant Programme Specialist, UNESCO Regional Office for Asia-Pacific Dr. Holger Sawert, WHO Medical Officer, TB Mr. Fida Shah, UNICEF Mr. J. Shivakumar, Country Director for Thailand, World Bank Ms. Laksami Subsaeng, WHO National Professional Officer, AIDS/WHO Thailand Ms. Pornchai Suchitta, UNFPA Nongovernmental organizations Ms. Joanna Busza, Programme Officer, Population Council, South & East Asia-Thailand Office Mr. Greg Carl, Researcher, Thai Red Cross AIDS Research Center Dr. Christopher J. Elias, Country Representative, Population Council, South & East Asia-Thailand Office Dr. Philip Guest, Population Council/Horizons Project Mr. Steve Mills, Associate Director, Technical, Family Health International 54 Theiland'sfesonse toADS euk mn oSucs,confronting the Pfuture Dr. Praphan Phanuphak, Director, Thai Red Cross AIDS Research Center and Faculty of Medicine, Chulalongkorn University Mr. Promboon Panitchpakdi, Country Representative, CARE/Thailand Ms. Patchara Rumakom, Programme Officer, Population Council, South & East Asia-Thailand Office Dr. R. D. Simonds, CDC/Atlanta HIV/AIDS Collaboration Mr. Ton Smits, Executive Officer, Asian Harm Reduction Network, Chiang Mai Mr. Mechai Viravaidya, Senator, Businessman Dr. Vicharn Vithayasai, President, Support the Children Foundation, Chiang Mai Dr. Tido von Schoen-Angerer, Drug Project Coordinator, Medecins sans frontieres/Belgium and colleagues Research Institutes Dr. Tim Brown, Senior Research Associate, East-West Center, Honolulu, Hawaii, USA Dr. Usa Duongsaa, Chiang Mai University Dr. Siriwan Grisurapong, Associate Professor, Faculty of Social Sciences and Humanities, Mahidol University Dr. Wiput Phoolcharoen, Director, Health Systems Research Institute, Ex-Director, AIDS Division (19...) Dr. Thira Sirisanthana, Department of Medicine, Chiang Mai University Dr. Frits van Griensven, Social Epidemiologist, The HIV/AIDS Collaboration 55 T;ha;land'Is PResponTse t AES Buviilng on Success, cozifrtinthe Futuzre Annex 2: References AIDS Division, Ministry of Public Health (2000). 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Journal of Acquired Immune Deficiency Syndrome 22(2):180-188. 62 Annex 3: Notes on Government AIDS program expenditures (Table 1) Prevention includes expenditures on: (1) Social Services includes allocations for the "Strengthening community capacity to manage Department of Social Welfare (care of orphans AIDS", which includes the Department of and subsidized living arrangements; 500 Communicable Disease Control (CDC) budget baht/month for people living with HIV/AIDS for condoms and condom promotion, training of (PHA) who have no job), the Department of staff of the Bangkok Metropolitan Authority Labor Welfare and Protection (up to 3 months' (BMA) and Ministry of Interior, village center income for PHA fired because they have training in prevention (for 1,000 of 80,000 HIV/AIDS), the Department of Development of villages nationally) by the Department of Social Labor's Skills (skill training for PHA), and the Welfare (proposed for 2000), and that part of the Office of the Attorney General (legal counsel for activities of the Department of Religious Affairs PHA). that is for prevention; and (2) "Modifying the learning process", including public information, NGO activities are grants to non-governmental peer education, and communication of the Office organizations for AIDS prevention and care, of the Prime Minister, Department of Public financed through the budget line for HIV/AIDS Relations, and Ministries of Education and management of the CDC department of MOPH. Defense, and other departments within. NGOs working in the BMA are also financed through this budget line. Medical treatment includes antiretroviral drugs for clinical trials, drugs for treating opportunistic The NGO budget does not include expenditures infections, HIV testing, blood screening and from the $2.6 million AIDS component of the universal precautions to prevent HIV infection Social Investment Project (SIP), financed by a in medical settings, as provided by the military World Bank Loan. The first disbursements for (Royal Thai Army, Navy, and Air Force), police, this project component, to be implemented by the 79 government hospitals financed through NGOs, occurred in February 2000. Again, these the office of the Permanent Secretary to Public projects are difficult to separate according to Health, the Dept. of Medical Service, the prevention, care and mitigation. They include Communicable Disease Control Department of five types of project: AIDS care model at the MOPH, and 8 universities. It also includes provincial, district, and community level; AIDS 'Work on improving medical support' of the prevention in the community; HIV care (home Department of Medical Science and expenditure based?); community capacity building; and on hospice care by the Department of Religious social service & HIV occupational assistance. Affairs. Research includes grants to the Royal Thai Mother to child transmission (MTCT) includes Army, the BMA, the Departments of Medical the allocation for "Modifying health services for Science and CDC of the MOPH, the Food and preventing and controlling HIV/AIDS" of the Drug Administration, the Ministry of University Department of Health (AZT prophylaxis and Affairs, and the Office of the Permanent breastmilk substitute) and separate allocations Secretary to Public Health on 'Developing for the CDC and the BMA, which include conventional wisdom and AIDS research' and mother-to-child transmission, screening, on 'AIDS vaccine development research'. updating guidelines for health personnel, and training of health personnel.o Management includes the salaries of the AIDS Division of the CDC Department, MOPH. 30 In 1998. 1.000 mothers were budgeted to be treated with AZT (out of an estimated total need of 20,000 HIV-positive pregnant women). 7.500 in 1999 and 2000, and 9.700 for breastmilk substitute was 6.900 in 1999. 7.500 in 2000. and 2001 and 2002. The number of women to be given 9.700 in 2001 and 2002. Source: NESDB. 63  WORLD BANK OFFICE BANGKOK Diethelm Towers 14th Floor Tower A Printed By 93/1 Wireless Road DESNE COPYP Bangkok 10330, Thailand Tel. (662) 256-7792 3lphouraphms Printshops Of The Future Fax (662) 256-7794-5 Tel. 266-5335-8 Fax. 266-5330