Thailand Country Development Partnership in Health (CDP-Health) Component 1: Improving the Effectiveness of Thailand's HIV Response 55850 "Revitalising HIV prevention in Thailand : a critical assessment" Final report Health Intervention and Technology Assessment Program Thailand Country Development Partnership in Health (CDP-Health) Component 1: Improving the Effectiveness of Thailand's HIV Response Sub-component of "Revitalising HIV prevention in Thailand: a critical assessment" Final report Collaborative works by International Health Policy Program (IHPP) Health Intervention and Technology Assessment Program (HITAP) Disease Control Department, Ministry of Public Health and Faculty of Public Health, Khon Kaen University THAILAND Supported by Ministry of Public Health, Thailand and the World Bank "Revitalising HIV prevention in Thailand: a critical assessment" Printed by The Graphico Systems Co.,Ltd. 119/138 Moo 11, The Terrace, Soi Tiwanon 3, Tiwanon Rd., Talad Khuan, Muang Nonthaburi, Nonthaburi 11000 Tel : 0 2525 1121, 0 2525 4669-70 Fax : 0 2525 1272 E-mail : graphico_sys@yahoo.com "Revitalising HIV prevention in Thailand: a critical assessment" WORKING GROUP of "Revitalising HIV prevention in Thailand: a critical assessment" Author lists 1 CHAPTER 1 Viroj Tangcharoensathien 1 Walaiporn Patcharanarumol 2 CHAPTER 2 Wongsa Laohasiriwong 3 Thanarak Plipat 4 CHAPTER 3 Yot Teerawatananon 4 Jantana Pattanaphesaj 1 CHAPTER 4 Viroj Tangcharoensathien 1 Walaiporn Patcharanarumol 1 Thidaporn Jirawattanapisal Coordinators of this work and the report · Ms Waraporn Poungkantha 1 · Ms Chitpranee Vasavid 1 · Dr Walaiporn Patcharanarumol 1 1 International Health Policy Program (IHPP), Ministry of Public Health 2 Faculty of Public Health, Khon Kaen University 3 Disease Control Department, Ministry of Public Health 4 Health Intervention and Technology Assessment Program (HITAP) i "Revitalising HIV prevention in Thailand: a critical assessment" EXECUTIVE SUMMARY Background The Thailand Government policy of universal access to Anti-retroviral therapy (ART), which was adopted in 2003, has seen a huge proportion of HIV program resources go to treatment. This resulted in reduced share of funding for prevention and mitigation interventions. Implementation of 100% condom use program has been successful in reducing HIV infections among venue based sex workers. However, infections among non-venue based sex workers have increased. The dynamic sex behaviour among the population requires country specific evidence on effective and cost effective interventions. Such interventions affect knowledge and attitudes and influence psychological and social correlates of risk to HIV in different population groups. Among high risk groups such as MSM, IDUs and female sex workers, there is a need for effective interventions and evidence based program re-orientation. Objectives The objective of this study is to systematically assess the coverage of cost effective HIV prevention interventions as well as the coverage of interven- tions proven to be ineffective and non cost effective in nine population risk groups. These are: (a) female sex workers (FSW), (b) men who have sex with men (MSM), (c) injecting drug users (IDUs), (d) sero-discordant couples, (e) pregnant women, (f) prison inmates, (g) healthcare workers, (h) young people and (i) general population. This information is vital for strengthening, scaling up or maintaining high coverage of proven effective and cost effective interventions and curtailing the ineffective and non-cost effective interventions. Methods We applied the evidence on effectiveness and cost effectiveness of HIV prevention interventions by Teerawattananon et al in chapter 3 which is categorized into four main groups: (1) interventions proven both effective and cost-effective, (2) interventions proven effective but without evidence on cost effectiveness, (3) interventions proven effective but not cost effec- tive, and (4) interventions proven neither effective nor cost effective. Ef- fectiveness and cost effectiveness of these interventions are specific for the nine different population groups. In the matrix of interventions, the most recent coverage rates were retrieved from reviews of relevant docu- ments, published and unpublished grey literature in the Ministry of Public ii "Revitalising HIV prevention in Thailand: a critical assessment" Health, and other small programs/pilots. In-depth interviews of key infor- mants were conducted where coverage data does not exist for the best expert estimates. Investment in different prevention interventions re- ferred to various estimates in the National AIDS Spending Assessment. Results Based on a matrix of 25 prevention interventions in 4 clusters, nine tables, one for each of the nine population groups were produced. The table is a matrix of 4 levels of evidence on the effectiveness and cost effectiveness of interventions using the "traffic light colour" system and three stages of implementation: [a] no policy and interventions; [b] interventions exist but no coverage data; and [c] interventions exist with coverage data. A conceptual approach of interpretation of mismatches of intervention was developed. Mismatches are defined as [1] interventions proven effective and cost effective but there is neither policy nor program implementation, and [2] interventions proven ineffective and not cost effective but there is program implementation. Our critical assessment identified seven mismatches in [1]. Two interven- tions require further evidence on applicability, and acceptability to guide policy and programmatic designs. These are: [i] female condoms for FSWs where operational research to test acceptability and program feasibility in the Thai context is needed; and [ii] male circumcision in newborns needs to generate evidence on public acceptability in the Thai context. Two interventions require immediate policy actions: [i] free distribution of condoms to MSM and IDUs; and [ii] needle social marketing for IDUs. Three interventions require attention: [i] provider initiated counselling and testing (PICT) offered to pregnant women; [ii] abstinence plus in young people; and [iii] microfinance policies that are not applicable for the Thai settings, but microfinance combined with education which has been proved to be effective. One mismatch was identified in [2] post exposure prophylaxis (PEP) for healthcare workers is neither effective nor cost effective and should be terminated. However, this is politically not easy on the grounds of occupa- tional safety. It is recommended to keep it as the incidence of occupa- tional injuries and their financial implications to the government are low. PEP should be modified towards a comprehensive prevention package. The matches are [3] interventions proven effective and cost effective are being implemented and [4] interventions proven ineffective and not cost effective are not implemented. iii "Revitalising HIV prevention in Thailand: a critical assessment" Interventions under [3] should be strengthened and/or sustain the high performance. These include free condom distribution to female sex work- ers, methadone substitution treatment in public clinics, VCT and PMTCT for pregnant women, screening of HIV antigens, antibodies and others in all donated blood, and an increase in alcohol tax which has an indirect impact on vulnerability to HIV infections. Note that interventions under [4] must not be initiated. Discussion and policy recommendations Sero-sentinel reports of high prevalence in three population groups, female sex workers, MSM and IDUs, require priority attention. Evidence from the Behaviour Surveillance Survey indicates that young people are emerging as a new priority due to their vulnerability to HIV infection. Inmates are the most vulnerable and socially disadvantaged group, often with repeated imprisonment, especially cases dealing with drugs. They are often IDUs with TB and HIV co-infections. As a captive population, there is a great opportunity to introduce and continue effective interventions in prisons and beyond when they are released back to society. Policy makers may consider offering an integrated package such as distribution of condoms, VCT services, provision of ART and TB treatment, and ensuring continued service beyond prisons after being released back to society. Inadequate capacity to treat sexually transmitted infections (STIs) was identified as a major programmatic bottleneck resulting in a resurgence trend of STI incidence. This requires a major review of the STI program. iv "Revitalising HIV prevention in Thailand: a critical assessment" ACKNOWLEDGEMENTS The IHPP acknowledges financial support from the Ministry of Public Health and the World Bank under the Country Development Partnership in Health (CDP-Health). Special thanks go to Dr David Wilson (Lead Expert), Dr Toomas Palu, and Dr Sutayut Osornprasop, the World Bank, for their technical contribution to the proposal development and this report. We are grateful to the researchers of the Khon Kaen University, Disease Control Department and the Health Intervention and Technology Assess- ment Program team, for their high quality contribution to this report. This work could not be accomplished without all the interviewees, espe- cially the IDUs and MSM in the provinces who made primary data collec- tion possible. Our gratitude goes to all the key informants and partners in and outside the Ministry of Public Health for the useful information and insights on HIV/AIDS, and friendly, collegial working relationship. Special thanks go to Bureau of Epidemiology, Disease Control Department, Minis- try of Public Health for the Behavioural Surveillance Surveys (BSS) data and to Institute of Population and Social Research, Mahidol University for the data from National Sexual Behaviours Survey of Thailand 2006. We thank Ms Artidtaya Thiempriwan and Ms Metta Puangpan for their support on this project. v "Revitalising HIV prevention in Thailand: a critical assessment" ABBREVIATIONS AIDS Acquired Immunodeficiency Syndrome ANC Antenatal Care ART Anti-retroviral Therapy ARV Anti-retrovirals ASO AIDS-response Standard Organization BATS Bureau of AIDS, TB and STIs Department of Diseases Control, Ministry of Public Health BOD Burden of Disease BSS Behavioural Surveillance Surveys CDP Country Development Partnership CSMBS Civil Servant Medical Benefit Scheme DALY Disability Adjusted Life Year FDA Food and Drug Administration FSW Female Sex Workers GDP Gross Domestic Products GPA Gel Particle Agglutination GF Global Fund GF RCC Global Fund: Rolling Continuation Channel Hep B-C Hepatitis B and C HIV Human Immunodeficiency Virus ICD International Classification of Diseases IDU Injecting Drug User IHPP International Health Policy Program IP In-patient KI Key Informant MOE Ministry of Education MOPH Ministry of Public Health MSM Men who have Sex with Men MTCT Mother To Child Transmission NASA National AIDS Spending Assessment NAT Nucleic Acid Test NHSO National Health Security Office NSBS National Sexual Behaviour Survey NGO Non-Governmental Organisation OP Out-patient vi "Revitalising HIV prevention in Thailand: a critical assessment" OOP Out - of - pocket PATH Program for Appropriate Technology in Health PEP Post Exposure Prophylaxis PEPFAR The US President's Emergency Plan for AIDS Relief PICT Provider Initiated Counselling and Testing PLHA People Living with HIV/AIDS PMTCT Prevention of Mother to Child Transmission PubMed A service of the U.S. National Library of Medicine and the National Institutes of Health RCTs Randomised Controlled Trials SDC Sero- Discordant Couples SR Sub Recipients SSO Social Security Office STD Sexually Transmitted Disease STI Sexually Transmitted Infection SW Sex Workers TB Tuberculosis TB-HIV Tuberculosis and Human Immunodeficiency Virus TEA Total Expenditure on HIV/AIDS TUC-MSM Thailand MOPH - U.S. CDC Collaboration on MSM Project TRUST Toluidine Red Unheated Serum Test UNAIDS The Joint United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session US CDC United States Center for Disease Control and Prevention VCT Voluntary Counselling Testing WHO World Health Organization vii "Revitalising HIV prevention in Thailand: a critical assessment" TABLE OF CONTENTS WORKING GROUP........................................................................................... i EXECUTIVE SUMMARY................................................................................... ii ACKNOWLEDGEMENTS.................................................................................. v ABBREVIATIONS............................................................................................ vi TABLES............................................................................................................. x FIGURES........................................................................................................... xii CHAPTER 1: Revitalizing HIV prevention in Thailand............................. 1 1. Thailand's HIV/AIDS epidemic................................................................ 1 2. Expenditure on HIV/AIDS....................................................................... 2 3. Revitalizing HIV prevention..................................................................... 6 CHAPTER 2: Trends of sex behaviour in Thailand: General and specific population subgroups..................................................................... 11 1. Review of HIV epidemics......................................................................... 11 2. Intelligence on HIV dynamics................................................................. 12 3. Objectives................................................................................................ 15 4. Methodologies.......................................................................................... 15 5. Findings.................................................................................................... 17 6. Summary and conclusions...................................................................... 38 7. Policy recommendations.......................................................................... 41 CHAPTER 3: Identifying information regarding effectiveness and cost-effectiveness of policy and strategies reorientation to mitigate the impact of HIV/AIDS in Thailand.......................................... 80 1. Background.............................................................................................. 80 2. Objectives................................................................................................ 81 3. Methodology............................................................................................ 82 A. Criteria for considering studies for this review.................................. 82 B. Sources of information........................................................................ 82 C. Types of studies.................................................................................. 85 D. Scope and types of interventions....................................................... 87 E. Description of studies......................................................................... 98 4. Results..................................................................................................... 99 5. Discussion and conclusion....................................................................... 121 6. References............................................................................................... 124 viii "Revitalising HIV prevention in Thailand: a critical assessment" CHAPTER 4: Revitalizing HIV Prevention Interventions....................... 133 1. Background............................................................................................ 133 1.1 HIV epidemic situation..................................................................... 133 1.2 Why HIV/AIDS matters?.................................................................. 135 1.3 Why revitalizing HIV prevention matters?...................................... 136 1.4 Dynamics of risk behaviour in general population.......................... 137 1.5 Dynamics of risk behaviour in MSM and IDU.................................. 141 1.6 Thailand's expenditure on HIV/AIDS............................................... 143 1.7 Effectiveness and cost effectiveness of prevention interventions.. 145 2. Goal and objectives............................................................................... 146 3. Methodologies........................................................................................ 146 4. Results.................................................................................................... 147 4.1 Convention on colour....................................................................... 147 4.2 Setting the scene on principles for policy recommendations......... 149 4.3 Results of critical assessment.......................................................... 151 4.4 Status of prevention interventions and policy recommendations for nine population groups............................................................... 162 5. Discussions............................................................................................. 176 5.1 Mismatches of intervention.............................................................. 176 5.2 Which priority group?....................................................................... 180 5.3 Cross cutting program bottlenecks.................................................. 181 5.4 Limitations of the study................................................................... 182 6. Annex for Chapter 4............................................................................... 183 7. References for Chapter 4....................................................................... 185 ix "Revitalising HIV prevention in Thailand: a critical assessment" TABLES Table 1.1: Background data on healthcare financing, Thailand 2007...... 2 Table 1.2: Total AIDS expenditure, 2007.................................................. 3 Table 1.3: Total expenditure on AIDS (TEA) by sources and functions, 2007......................................................................... 3 Table 1.4: Total Expenditure on HIV/AIDS, by detail healthcare functions, 2007......................................................................... 4 Table 1.5: National Behavioral Surveillance System, population coverage by rounds................................................. 8 Table 3.1: Keywords and search strategies used for Pub Med.................. 84 Table 3.2: Levels of clinical evidence......................................................... 86 Table 3.3: Classification and definition of HIV prevention interventions under the review....................................................................... 89 Table 3.4: Summary of the effectiveness and cost-effectiveness evidence of HIV prevention interventions................................ 100 Table 3.5: Summary of findings by intervention and target population... 118 Table 3.6: Summary of interventions conducted for each target population................................................................................. 120 Table 3.7: Review profile of domestic literature....................................... 122 Table 4.1: Median HIV prevalence in specific population groups by percentage, Thailand sero-sentinels round 13 (1995) to 24 (2006).................................................................................. 134 Table 4.2: Share of DALY loss, curative expenditure, and productivity loss in terms of premature death and absenteeism from 12 leading burden of disease, 2004.............................................. 135 Table 4.3: Thailand National AIDS spending Assessment, 2000-2004.... 136 Table 4.4: Background data on healthcare financing, 2007..................... 143 Table 4.5: Key parameters of expenditure on HIV/AIDS, 2007................ 143 Table 4.6: Total Expenditure on HIV/AIDS by sources of finance and functions, current year price, 2007.......................................... 144 Table 4.7: Convention on colour................................................................. 147 Table 4.8: Summary of findings by intervention and target population... 148 Table 4.9: Principle of policy recommendations........................................ 149 Table 4.10: Existing prevention activities and coverage by risk groups, according to gradient of effectiveness and cost-effectiveness of HIV prevention intervention................................................. 152 Table 4.11: Summary of current interventions, coverage and recommendations for Female Sex Workers.............................. 162 x "Revitalising HIV prevention in Thailand: a critical assessment" Table 4.12: Summary of current interventions, coverage and recommendations for MSM....................................................... 164 Table 4.13: Summary of current interventions, coverage and recommendations for IDUs....................................................... 166 Table 4.14: Summary of current interventions, coverage and recommendations for Sero-Discordance Couple...................... 168 Table 4.15: Summary of current interventions, coverage and recommendations for Pregnant women................................... 169 Table 4.16: Summary of current interventions, coverage and recommendations for Prison Inmates...................................... 170 Table 4.17: Summary of current interventions, coverage and recommendations for Healthcare Workers............................... 171 Table 4.18: Summary of current interventions, coverage and recommendations for Young People......................................... 172 Table 4.19: Summary of current interventions, coverage and recommendations for the General Population......................... 173 Table 4.20: Conceptual approach of intervention mismatches and correction measures................................................................. 177 Table 4.21: Critical assessment of mismatches of HIV/AIDS interventions............................................................................. 177 xi "Revitalising HIV prevention in Thailand: a critical assessment" FIGURES Figure 1.1: Conceptual framework of the study.......................................... 7 Figure 1.2: Assessment of effectiveness and/or cost effectiveness of prevention interventions........................................................... 10 Figure 2.1: Percentage of respondents who were able to answer all 5 UNGASS HIV prevention knowledge question correctly, 2004-07...................................................... 18 Figure 2.2: Percentage of the respondents who had sexual intercourse experiences, Thailand 1995-2007............................................. 19 Figure 2.3: Percentage of respondents who used condoms consistently when having sex with boy/girlfriends in the past year, Thailand 1995 - 2007................................................................ 19 Figure 2.4: The percentage of respondents who reported having sex with non-regular sexual partners in the past year (solid line), and the proportion of respondents who had sex with female sex workers (dotted line), Thailand 1995 - 2007............................ 21 Figure 2.5: The percentage of respondents who consistently used a condom when having sex with female sex workers in the past 1 year, Thailand 1995 - 2007............................................ 21 Figure 2.6: The percentage of respondents who consistently used a condom when having sex with non-regular sexual partners in the past 1 year, Thailand 1995 - 2007................... 22 Figure 2.7: The percentage of female sex workers who had sex with (1) general clients, (2) regular clients, (3) regular sexual partner/spouses and (4) non-regular sexual partners in the past month, Thailand 1995 - 2007............................................ 22 Figure 2.8: The percentage of female sex workers who consistently used condoms when having sex with (1) general clients,(2) regular clients, (3) regular sexual partner/spouses and (4) non-regular sexual partners in the past month, Thailand 1995 - 2007...... 23 Figure 2.9: Sexual orientation of MSM......................................................... 24 Figure 2.10: Number of sex partners (both men and women) during the past year for MSM............................................................... 24 Figure 2.11: Condom use by MSM for the last sexual intercourse............... 25 xii "Revitalising HIV prevention in Thailand: a critical assessment" Figure 2.12: MSM partners, occasion, and preventive practices for the first sexual intercourse with men.............................................. 25 Figure 2.13: MSM reasons for the first sexual intercourse with men........... 26 Figure 2.14: Protection for having first sexual intercourse with men and women by MSM.......................................................................... 26 Figure 2.15: Influences of person and media on sexual behavior of MSM... 27 Figure 2.16: Most important information sources/channels on HIV/AIDS for MSM during the past year.................................................... 27 Figure 2.17: HIV/AIDS transmission and preventive measures unknown to MSM............................................................................................ 28 Figure 2.18: Percentage of inappropriate attitudes MSM have on condom use and practice........................................................................ 29 Figure 2.19: MSM condom use and sexual behaviors................................... 30 Figure 2.20: Substance types and reasons of the first drug taken by IDUs............................................................................ 31 Figure 2.21: Sources of needles and syringes, and methods used to clean reused needles.......................................................................... 31 Figure 2.22: Sexual orientation of IDUs........................................................ 32 Figure 2.23: Number of sexual partners over the past year for IDUs.......... 32 Figure 2.24: HIV/AIDS preventive practices by IDUs over the last six months.......................................................................... 33 Figure 2.25: IDUs condom use for the last sexual intercourse.................... 33 Figure 2.26: Person and media which had highest influence on IDU sex behavior..................................................................................... 34 Figure 2.27: Most important IDU information channels on HIV/AIDS over the past year..................................................................... 34 Figure 2.28: HIV/AIDS transmission and preventive measures unknown to IDUs....................................................................... 35 Figure 2.29: Common attitudes of IDUs on condom use and sexual practices..................................................................................... 36 Figure 2.30: Risky behavior by IDUs............................................................. 37 Figure 2.31: Effective HIV/AIDS information channel for MSM and IDUs.... 37 Figure 2.32: Profile of counseling services for MSM and IDU who accessed VCT............................................................................. 38 Figure 3.1: Outcome measures for HIV prevention interventions [4]........ 82 xiii "Revitalising HIV prevention in Thailand: a critical assessment" Figure 3.2: Proposed framework for establishing intervention definitions [5]............................................................................ 88 Figure 3.3: Literature review profile of the Thai literature......................... 98 Figure 3.4: Literature review profile of the international literature............ 99 Figure 3.5: Summary of cost-effectiveness data for HIV prevention interventions (PPP$ 2008 per HIV infection averted).............. 116 Figure 4.1: Estimated number of annual new infections and proportion of casual sex in a typical 100-million population setting in Asia.. 138 Figure 4.2: Percentage of the respondents who had sexual intercourse experiences, Thailand 1995-2007............................................. 139 Figure 4.3: Percentage of respondents who used condoms consistently when having sex with boy/girlfriend in the past 1 year, Thailand 1995-2007.................................................................. 139 Figure 4.4: The percentage of respondents who consistently used condoms when having sex with female sex workers in the past 1 year, Thailand 1995 - 2007..................................... 140 Figure 4.5: The percentage of respondents who consistently used condoms when having sex with non-regular partners in the past 1 year, Thailand 1995 - 2007..................................... 140 Figure 4.6: The percentage of female sex workers who consistently use condoms when having sex with general clients in the past month, with regular clients in the past week, with regular partner/spouse in the past month, and with non-regular partners in the past month in Thailand 1995 - 2007............... 141 xiv "Revitalising HIV prevention in Thailand: a critical assessment" CHAPTER 1 Revitalizing HIV Prevention in Thailand Chapter 1 provides the background and rationale for revitalizing HIV prevention in Thailand and outlines the objectives and conceptual framework. Finally, it describes the structure of subsequent chapters. 1. Thailand's HIV/AIDS epidemic Data compiled from the 2007 HIV infection surveillance system concludes that the present epidemic dynamic has evolved from a generalized to a combined generalized and concentrated epidemic. The trend of HIV prevalence in military conscripts and clients of antenatal care (ANC) clinics reached a peak at 3.40% and 2.29% in 1995 and 1992 respectively, and reduced to a plateau of 0.40% and 0.84% in 2007 and 2006 respectively [UNGASSS Thailand country report 2008]. The increasing trend of HIV prevalence in ANC clients at second and third pregnancies indicates that infections are spreading more deeply in families in general, and may remain at relatively high levels going forward. For other groups, HIV prevalence has declined with the notable exception of IDUs and MSM. Data from ad hoc studies indicates linkages of infection among the most-at-risk populations including sex workers (SWs), MSM, and IDUs. There is a continued downward trend of HIV prevalence in female sex workers and male sex workers at STI clinics, excluding Bangkok where the prevalence in male STI clinic clients has not declined. Despite the decline of HIV among IDUs in the North, overall prevalence remains high, with increasing trends in Bangkok and the central region. Regional epidemic trends are most improved in the North, and lagging behind in the South. 1 "Revitalising HIV prevention in Thailand: a critical assessment" The PMTCT policy and its implementation with high coverage could obvi- ously reduce infections in children. In 2003, vertical transmission was at 6.4% before declining to 1.0% in 2006. Estimates from the computer modelling software were applied to Thailand in 2000 (the Asian Epidemic Model - AEM). The HIV epidemiological database was updated in 2005. When controlling for the level of prevention efforts it was found that in 2007 the number of new infections was estimated at 13,936. This number is projected to decline to 10,097 in 2011. The total cumulative number of PLHA is expected to decline from 546,578 in 2007 to 481,770 in 2011. Based on the above estimates (2007-2011), the proportion of new infec- tions by population group and risk behaviour revealed that new infections in women infected by their husbands or sexual partners, and in MSM, are higher than through other routes of transmission. This prompts two policy interventions: (a) identification and prevention of infections among discordant couples and (b) better effective interventions for MSM and IDUs. 2. Expenditure on HIV/AIDS IHPP and its partner agencies in the BATS-MOPH, National Economic and Social Development Board, National Health Security Office, and NGOs estimated the total expenditure on HIV/AIDS, for 2007 as part of the UNGASS 2008 report. Table 1.1: Background data on healthcare financing, Thailand 2007 2007 Population 64,197,000 THE / capita, Baht 3,876 THE/ capita, US$ 115 In 2007, Thailand spent 3,876 Baht per capita, or US$ 115 per capita (exchange rate 33.7 Baht per US$), on healthcare, see Table 1.1. 2 "Revitalising HIV prevention in Thailand: a critical assessment" Table 1.2: Total AIDS expenditure, 2007 2007 Total AIDS expenditure, Baht 6,728,020,682 Forecast Total Health Expenditure, (THE) Baht 248,852,400,000 Total AIDS expenditure 2007, as · per capita population, Baht 105 · per capita PLHA, Baht 11,600 · % GDP 0.08% · % THE 2.7% In 2007, total expenditure on HIV/AIDS was 6.728 billion Thai Baht. This is equivalent to 105 Baht per capita Thai population, or 11,600 Baht per capital PLHA (given the total number of 580,000 PLHA). Total expenditure on HIV/AIDS accounted for 0.08% of GDP in 2007, or equivalent to 2.7% of Total Health Expenditure as shown in Table 1.2. Table 1.3: Total expenditure on AIDS (TEA) by sources and functions, 2007 Type of expenditure/Source of Total % Domestic % International % Finance 1. Prevention Sub-total 949,855,219 14.1 490,291,815 7.3 459,563,404 6.8 2. Care and Treatment 4,830,371,045 71.8 4,523,505,501 67.2 306,865,544 4.6 3. Orphans and Vulnerable 101,296,773 1.5 91,780,000 1.4 9,516,773 0.1 Children 4. Program Management Administration 655,446,352 9.7 337,516,200 5.0 317,930,152 4.7 Strengthening 5. Incentive Human 89,696,764 1.3 29,870,051 0.4 59,826,713 0.9 Resources 6. Social protection and social services excluding 3,326,045 0.0 - 0.0 3,326,045 0.0 Orphans and vulnerable Children 7. Enabling Environment and community 51,050,284 0.8 45,293,000 0.7 5,757,284 0.1 Development 8. Research excluding 46,978,200 0.7 45,630,600 0.7 1,347,600 0.0 operational research Total 6,728,020,682 100.0 5,563,887,167 82.7 1,164,133,515 17.3 3 "Revitalising HIV prevention in Thailand: a critical assessment" In 2007, domestic public financing amounted to 82.7% of TEA, whereas international financing constituted 17.3% of TEA. This finding indicates better self-reliance on HIV/AIDS program financing, and the Royal Thai Government's firm commitment to the Program. In light of universal access to ART which was adopted by the Government in 2003, a lion share of TEA went to care and treatment (71.8%). Of this amount, ARVs and treatment for OI accounted for 92%. This was followed by HIV prevention at 14.1%, and program administration at 9.7%. See summaries in Table 1.3, and detailed expenditures across 8 large items in Table 1.4. A large share of expenditure on care and treatment would continue for some years, or would increase as a result of an introducing nd the more expensive 2 line ART regimens when the first line failed. Approximately 10% per annum failed from the first line regimen. Table 1.4: Total Expenditure on HIV/AIDS, by detail healthcare functions, 2007 Category of healthcare function Baht Percent 1. Prevention Sub-total 949,855,219 14.1% 1.1 Mass media 6,322,000 1% 1.2 Community mobilization 10,691,291 1.3 Voluntary Counselling and Testing 185,240,000 20% 1.4 Program for Vulnerable and special Populations 115,147,373 12% 1.5 Youth in school 46,370,545 5% 1.6 Youth out of school 89,460,554 1.7 Prevention Program for PLHA 3,764,561 0% 1.8 Programs for sex workers and their clients 9,248,564 1% 1.9 Programs for MSM 8,149,570 1% 1.10 Harm Reduction Programs for IDU 17,268,414 2% 1.11 Workplace activities 16,611,941 2% 1.12 Condom social marketing 20,220,000 1.13 Public and Commercial sector condom provision 65,021,724 7% 1.14 Female condom - 1.15 Microbicides - 1.16 Improving management of STIs 2,465,000 0% 1.17 Prevention of mother-to-child transmission 119,348,682 13% 1.18 Blood safety - 1.19 Post-exposure prophylaxis - 1.20 Safe medical injections - 1.21 Male Circumcision - 4 "Revitalising HIV prevention in Thailand: a critical assessment" Category of healthcare function Baht Percent 1.22 Universal Precautions - 1.99 Others / Not-elsewhere Classified 234,525,000 25% 2. Care and Treatment (Sub-Total) 4,830,371,045 71.8% 2.1 Outpatient care - 2.2 Provider initiate testing - 2.3 Opportunistic Infection (OI) Prophylaxis 3,441,282 0% 2.4 Antiretroviral therapy 3,155,178,114 65% 2.5 Nutritional Support 61,440,000 1% 2.6 Specific HIV Laboratory monitoring 134,583,187 3% 2.7 Dental Care - 2.8 Psychological care 4,342,136 2.9 Palliative Care - 2.10 Home-based Care 12,975,848 2.11 Additional / Informal provider 30,832,197 2.12 In-patient Care - 2.13 Opportunistic Infection (OI) Treatment 1,283,171,998 27% 2.99 Others / Not-elsewhere Classified 144,406,283 3% 3. Orphans and Vulnerable Children 101,296,773 1.5% 3.1 Education - 3.2 Basic health care 2,947,661 3.3 Family / Home support - 3.4 Community Support 6,569,112 3.5 Administrative Cost - 3.99 Others / Not-elsewhere Classified 91,780,000 4. Program Management Administration Strengthening 655,446,352 9.7% 4.1 Programme Management 368,954,802 4.2 Planning and coordination 1,454,522 4.3 Monitoring and Evaluation 50,910,637 4.4 Operation Research 139,875,965 4.5 Sero-Surveillance 6,750,000 4.6 HIV drug- resistance surveillance - 4.7 Drug Supply systems - 4.8 Information technology 1,174,679 4.9 Supervision of Personnel - 4.10 Upgrading Laboratory infrastructure 80,112,604 4.11 Construction of new Health centres - 4.99 Others / Not-elsewhere Classified 6,213,143 5. Incentive Human Resources (Sub-total) 89,696,764 1.3% 5.1 Monetary incentive for physicians - 5.2 Monetary incentive for nurses - 5.3 Monetary incentive for other staffs - 5 "Revitalising HIV prevention in Thailand: a critical assessment" Category of healthcare function Baht Percent 5.4 Formative education and build-up of an AIDS Workforce 5,671,000 5.5 Training 28,443,408 5.99 Others / Not-elsewhere Classified 55,582,356 6. Social protection and social services excluding 3,326,045 0.05% Orphans and vulnerable Children(sub-total) 6.1 Monetary Benefits - 6.2 In-Kind Benefits - 6.3 Social services - 6.4 Income generation 3,326,045 6.99 Others / Not-elsewhere Classified - 7. Enabling Environment and community Development 51,050,284 0.8% 7.1 Advocacy and Strategic Communication 2,680,927 7.2 Human Rights 3,250,000 7.3 AIDS-specific institutional development 5,119,357 7.4 AIDS - specific program involving woman - 7.99 Others / Not-elsewhere Classified 40,000,000 8. Research excluding operational research (sub-total) 46,978,200 0.7% 8.1 Biomedical Research 28,561,700 8.2 Clinical Research 17,068,900 8.3 Epidemiological Research - 8.4 Social science research - 8.5 Behavioural research 1,347,600 8.6 Research in economics - 8.7 Research capacity strengthening - 8.8 Vaccine related research - 8.99 Others / Not-elsewhere Classified - GRAND TOTAL 6,728,020,682 100% 3. Revitalizing HIV prevention In the context of universal access to HIV treatment, a large part of the expenditure on AIDS goes to ART and OIs leaving a small amount for prevention. It is therefore important to identify and assess the main weak- nesses in the HIV prevention program, and develop strategies and invest- ment to revitalize and improve HIV prevention efforts in order to reduce the number of new infections. To achieve this, the International Health Policy Program, jointly with other partners, drafted the Terms of Reference (TOR). The TOR was discussed with the World Bank team consisting of Dr David Wilson, Dr Toomas Palu, and Dr Sutayut Osornprasop in late 2007 and early 2008 through several 6 "Revitalising HIV prevention in Thailand: a critical assessment" rounds via teleconference and email exchanges. It was finalized according to the objectives agreed upon by the World Bank and IHPP. 3.1 Objectives · The objectives were: to assess the changing trends of HIV risk behaviour across population groups · to identify the strengths and deficiencies of HIV prevention and ensure effective policy dialogue with the National AIDS Committee · to reorient prevention efforts · to provide policy recommendations on how to sustain the strengths and minimize programmatic deficiencies 3.2 Conceptual framework Figure 1.1: Conceptual framework of the study 3.3 Terms of reference of this study To achieve the goal of revitalizing HIV prevention, the following work is proposed: 7 "Revitalising HIV prevention in Thailand: a critical assessment" CHAPTER 2 Chapter 2 reviews and updates HIV epidemiological profiles, trends and changes in risk behaviour across different population groups. This involved a survey of the knowledge, attitude, practices and risk behaviours of these 1 groups through the National Behavioural Surveillance System [NBSS] shown in Table 1.5. This survey also covered IDUs and MSM and was as executed by Dr Wongsa Laohasiriwong. The IDUs and MSM survey tools applied a comprehensive and comparable behavioural questionnaire. The data pool was male and female students from Grades 8 and 11 and factory workers in the 21-49 years bracket. This made it possible to look at changing sexual and risk behaviours among young adolescents over the past 12 years. A primary survey of IDUs and MSM will provide additional information for this group. Table 1.5: National Behavioral Surveillance System, population coverage by rounds factor workers Grade 11 male female 15-49 Grade 8 male Survey dates schools male General pop, 21 year men Sex workers Pregnancies Male female and female and female and female Vocational Conscript 15-29 yr. male and students students students Round 1 1995 X X X 2-9 1996-2003 X X X X 10- 2004 to date X X X X X X X Source: synthesis from MOPH Bureau of Epidemiology http://203.157.15.12/ centeraids/bss.php retrieved 19 March 2008 Sentinel sites cover 24 provinces o Central: 8 provinces including Nonthaburi, Pathumtani, Lopburi, Nakorn Nayok, Chacherngsao, Trad, Ratchaburi, Samut Songkram. o North: 6 provinces including Chiangrai, Lampoon, Tak, Sukhothai, Phrae, Phitsanulok. o Northeast: 6 provinces: Korat, Buriram, Srisaket, Ubon Ratchatani, Udon Tani, Sakhon Nakorn. o South: 4 provinces including Surat Thani, Pang Nga, Trang and Songkhla. 1 The first round of HIV Behavioural Sentinel Survey was initiated by the MOPH in 1995, and has been sustained to date. The sentinel applied an annual repeated (every June) self administered questionnaire survey in 24 sentinel provinces covering population groups and expanding to cover more target groups in the 10th round in 2004. 8 "Revitalising HIV prevention in Thailand: a critical assessment" Expected outcomes of chapter 2 are:- 1. A better understanding of the trends of HIV risk and risk protection behaviours across population groups, including young adolescents, 2. Identification of risk groups including MSM and IDUs CHAPTER 3 Chapter 3 reviews both global and Thai specific experiences of cost effec- tive HIV/AIDS prevention interventions. It recommends a comprehensive list of preventive interventions that are likely to be effective and cost- effective in the Thai health systems context. The list includes interven- tions that are currently available in Thailand as well as new ones that have not been tried before. Special attention will be paid to identifying information gaps at the na- tional and international levels on the effectiveness and/or cost-effective- ness of HIV/AIDS prevention in general. This will cover specific population groups such as IDUs, MSM, school children and/or teenagers. Expected outcomes of chapter 3 are:- 1. A list of preventive interventions that are neither effective nor cost ineffective 2. A list of effective or cost effective preventive interventions CHAPTER 4 The purpose of chapter 4 is to assess the nature of the current HIV/AIDS programmatic activities. The assessment will include coverage of target population groups (4c), effective coverage of interventions (4b), level of financial investment (from all sources: government, local governments and donors) in these activities (4a), and help to identify programmatic strengths and deficiencies. When comparing results of the TOR with others, two types of mismatches were identified, mismatches in target population (4e) and in preventive interventions (4d). o We compared the current target population with the emerging target population as recommended in chapter 2, and were able to identify the gaps in target population (4e). o The current coverage of prevention interventions, when compared with interventions categorized by effectiveness or cost effectiveness, led to the identification of mismatches of program interventions (4d). See Figure 1.2. 9 "Revitalising HIV prevention in Thailand: a critical assessment" Effective interventions and/or Current coverage Cost effective interventions Yes No A. B. High Sustain high coverage of Discourage and scale down these interventions these interventions C. D. Identification of demand Keep vigilance, not to initiate Low and supply side bottle necks, these interventions in rapid scale up of these prevention programs interventions Figure 1.2: Assessment of effectiveness and/or cost effectiveness of prevention interventions High coverage of cost effective interventions should be sustained (Box A). Interventions which are cost effective but ineffective in coverage should be reviewed to identify demand and supply bottle necks, and prioritize actions to scale them up. See Box C. Interventions classified in Box B should be discouraged and scaled down as they are not cost effective. Findings from the various activities will provide the basis of consultations with key stakeholders (4f) such as the National AIDS Committee, govern- ment sectors, and non-government organizations. The stakeholder con- sultations would ensure ownership of the findings and translate evidence into policy decisions and reorientation of the HIV prevention program. Expected outcomes of chapter 4 are:- 1. The identification of mismatches, strengths and deficiencies of prevention interventions. 2. Policy recommendations on which programs should be maintained, scaling up or down. 10 "Revitalising HIV prevention in Thailand: a critical assessment" CHAPTER 2 Trends of sex behaviour in Thailand: General and specific population subgroups 1. Review of HIV epidemics The HIV epidemic in Thailand is relatively young, though quite mature, in comparison to the epidemics in Africa, Western Europe and North America. However, it is spreading very rapidly and has moved well beyond the initial high-risk populations into the general population1-4. The first case of AIDS 5 in Thailand was reported in 1984 in a 28 year old bisexual male who had just returned from the United States. Progressive numbers of AIDS cases as well as asymptomatic HIV infections were reported over subsequent years. There have been more than 311,000 AIDS cases reported to the Ministry of Public Health (MOPH) since the epidemic began in Thailand6. Early cases were generally confined to homosexual males returning from abroad and members of the extensive network of gay bars and male prostitutes serving foreign men. This was followed by an explosive spread of HIV infection among IDUs in 7-8 1988 and 1989 . HIV seroprevalence increased rapidly in this group, from about 1% in late 1987 to over 40% by August 1988 in some areas. National HIV seroprevalence surveys of IDUs since 1989 remain consis- 4 tently high, with prevalence rates of 30-50% throughout the country . During the same period, another epidemic erupted among female sex workers (FSWs) in brothels throughout the country. Visits to FSWs were 9, 10 common and a somewhat socially acceptable practice among Thai men which led to a rapid spread of HIV infections. As a result, heterosexual transmission has become the most important driver of HIV epidemics in 4, 6 Thailand . Soon after the epidemic spread among FSWs and their clients, infections started to be seen in low risk women. Data from the national HIV sero-surveillance shows that the HIV/AIDS epidemic in the general female population began in 1991. HIV prevalence increased from 0% in December 1990 to 1.78% in June 1994 among women attending antenatal clinics, a surrogate group for all women and the general population. HIV prevalence peaked at 2.29% in June 1995 before it 4 declined to 0.8% in June 2007 . 11 "Revitalising HIV prevention in Thailand: a critical assessment" Thailand's rapid government response in the 1990s helped to control the spread of the epidemic. However, complacency in prevention was observed from the mid 2000s when the government introduced universal access to anti-retroviral treatments (ART) which consumed most of the AIDS program budget. As the focus has shifted from prevention there has been an increase in HIV incidence among pregnant women, army conscripts, direct and indirect female sex workers11. In a situation where most of the country's HIV resources are spent on treatment, there is a need to revitalize prevention efforts. The Royal Thai Government and the World Bank, through the Country Development Partnership, are taking a hard look at HIV prevention in order to strengthen the national response. 2. Intelligence on HIV dynamics Thailand has made some progress in generating evidence to inform policy decisions on key public health problems. The annual sero-sentinel surveillance has become a routine activity with a dedicated budget and staff in all provinces. This activity is conducted in June of each year. Evidence is gathered informs both the decision making and reporting of the Provincial Health Offices, the Bureau of Epidemiology of the Disease Control Department, and other stakeholders. In addition, a National Behavioural Surveillance Systems (NBSS) annual survey employs a self-administered questionnaire in all provinces. Provin- cial Health Offices facilitate data collection, entry, analysis, and use for policy decisions at the local level. 1. National Behavioural Surveillance System (NBSS) The NBSS applies a serial cross-sectional annual survey as its principal surveillance method. Each year, the respondents are selected from the same dynamic population (male and female students studying in Grades 8 nd and 11 and 2 year vocational school students, female sex workers, male and female factory workers ages between 15-59 years). Each sentinel population has different sampling strategies and data collection methods. The Bureau of Epidemiology recommends the data collection methods for each population are as follows: 12 "Revitalising HIV prevention in Thailand: a critical assessment" Students In general, two stage sampling is recommended for students. In the first stage, 10 schools are selected with the simple random sampling method. In each selected school, one classroom is selected at a time. Data is then collected from all students in the selected classroom until the pre-deter- mined number of respondents for each school are reached. TM Palm , a small handheld computer, is used for data collection through a self-administered process. Female sex workers A one-stage sampling technique is recommended for this population. A sex establishment is selected one at a time from a list of known sex estab- lishments in each province, using simple random sampling. All female sex workers in the selected sex establishment are asked to participate in both the HIV sero-surveillance and HIV-related behavioural surveillance. If the number of respondents does not meet the number required in each round of surveillance, another sex establishment is selected until the sample size for each province is saturated. A self-administered questionnaire is used for data collection. Factory workers The sampling strategy and data collection method for factory workers is the same as that of the female sex worker population. Note that in the NBSS, it is not possible to identify two other risk groups, namely IDUs and MSM in the samples. HIV prevalence among this group is so high that an additional survey is required. 2. National Sexual Behaviours Survey of Thailand 2006 (NSBS 2006) The third national representative household survey on risk behaviour and ART knowledge was conducted in 2006. The purpose was to gather information related to knowledge and attitudes about HIV/AIDS, exposure to HIV/AIDS information, knowledge and attitudes about antiretroviral treatments, stigma and discrimination, sexuality and sexual behaviour, drug use, and voluntary counselling. The sample was stratified into three residence categories (Bangkok, other urban areas, and rural areas), gender, and two age groups (18-24 and 25-59 years old). 13 "Revitalising HIV prevention in Thailand: a critical assessment" Data was collected in Bangkok and 14 provinces out of 75 provinces in Thailand). Within each stratum (residential categories, gender and age groups) a sample size of 504 was identified. In Bangkok, 63 election districts were randomly selected from the list of all election districts in Bangkok available from the civil registration. For each election district, four households were systematically sampled from the list, one household per one age/sex category. The selected households were the starting point of the data collection for one age/sex category. At the selected household, the interviewer listed all household members separately by sex and age groups, selected an eligible respondent in the appropriate age/sex category assigned to the household and interviewed the respondent. After the first randomly selected household, interviewers proceeded to the housing unit on the immediate left of the original household and repeated the process of listing all household members and selecting an eligible respondent to be interviewed. The process continued until eight respondents in that age/sex category were reached. Supervi- sors checked the progress to ensure no overlapping of households took place. If the selected respondents were not at home, an appointment to return for an interview was made. In other provinces, the sampling strategy for each stratum was multi-stage. In the first stage, 14 provinces from the 75 provinces were randomly selected, using the probability proportional to population size. For the 14 provincial urban areas, four election districts were randomly selected. For each district, the same method of sampling households and individuals were used. However, within each of the four age/sex categories, nine respondents were sampled for an interview. For the 14 rural areas, two districts and then two sub-districts were randomly selected with the application of probability proportional to population size. Within each of the two sub-districts, three villages were randomly selected with probability proportional to the size of the population, the total number of villages selected was 168. For each village, households were systematically selected from the list of households. In each village, three respondents from each of the age/sex categories were interviewed. The total number of respondents in each village was 12. Information was collected from a total of 6,048 respondents using face-to- face interviews. Female interviewers were responsible for interviewing 14 "Revitalising HIV prevention in Thailand: a critical assessment" female respondents and male interviewers for male respondents. Overall, response rates were between 71% (among male aged 25 - 59 years old) to 90% (among male aged 18 - 24 years old). 3. Objectives The general objectives are to assess the trend of knowledge on HIV/AIDS, sex and other risk behaviours in the different population sub-groups and in two risk groups: MSM and IDUs. Specific objectives 1. To use data from the NBSS to analyze the following: 1.1. The trend of knowledge on HIV/AIDS among population sub-groups 1.2. The trend of sex behaviour and other risk behaviour by population sub-groups and at the sub-national level 2. To conduct a parallel analysis as the BSS dataset, where data allows. 3. To assess the following in the two risk groups, MSM and IDUs. 3.1. Risk behaviours leading to HIV infection 3.2. The adequacy of existing HIV prevention interventions 4. Methodologies Two main approaches were utilized: 1. Using existing NBSS data from 1996 to 2007; trends among different sub-population groups were analyzed. Mahidol University Institute of Population and Social Research conducted a parallel analysis of the National Sexual Behaviour Survey (NSBS) data of 2006. Primary surveys of MSM and IDUs 2. As there are no secondary datasets, the researchers decided to conduct a primary survey among MSM and IDUs. Surveys of both groups were conducted during the months of March to July 2008. 2.1 MSM MSM are a special group which seldom expresses their identity publicly. They are mostly open to their own group or to those they trust. Therefore, it is extremely difficult to identify a sampling frame for MSM and there are no name lists for systematic sampling. The study aimed to select the sample which includes MSM who were not younger than 15 years old, from all socio economic backgrounds in order to reflect the overall MSM population. 15 "Revitalising HIV prevention in Thailand: a critical assessment" Data was collected in 4 regions of Thailand. One province was selected from each region. The sampled provinces were Chonburi, Chiang Mai, Khon Kaen, and Surat Thani. A sample size of 639 was calculated by estimating the population proportion (unknown population). The sample was allocated to each province randomly. In order to select samples which represent the general population of MSM in each province, the snowball technique was used. The sampling process was as follows: Researchers started by contacting persons who identified and contacted MSM in different groups including workers, staff in entertainment businesses, students, government officials and ordinary people. The interviewers were trained by the researchers who closely monitored the quality of the interviews. All question naires were checked for completeness and validity before data processing. After the interviews were completed, the MSM participants were asked to identify other MSM they know. The MSM identified were approached and asked for an interview. They were in turn asked to introduce other MSM for the next interviews until enough samples were obtained. During the process, the appropriate distribution of MSM participants (samples) across ages and socio economic status was ensured. 2.2 IDUs IDUs are generally difficult to identify and contact due to stigma and legal issues. Some IDUs live in communities where they are under rehabilitation through drug dependence treatment centers, while others are confined in prisons. Therefore, we could not apply normal sampling techniques. As with MSM, the snowball technique was applied. Focal points started from the staff in treatment institutions where the IDUs received services. These institutions included public treatment facilities such as drug dependence treatment clinics at hospitals. These were: Jana Hospital of Songkla, Drug Dependence Treatment Centers in Khon Kaen, Chiang Mai, Mae Hong Son, Songkla, Pattani and Thanyarak Institute in Pathumtani. 16 "Revitalising HIV prevention in Thailand: a critical assessment" Private services institutions such as Ban Ozone, Ban Pakjai and the IDU network were also involved. After contacting the focal points and explaining about this research, data were collected by trained interviewers with the supervision of the researchers. Participants were identified and encouraged by their IDU peers to join the research. Data was collected from the 444 IDU samples calculated by estimating population proportion (unknown population) and by randomly allocating a sample size to each province. Samples were distributed appropriately across the institutions, age and socioeco nomic groups to ensure the data was reliable. 5. Findings Part I: Risk and sexual behaviors survey from the National Behavioral Surveillance System (NBSS) 1. Low knowledge of HIV prevention Knowledge among the Thai population about HIV prevention when using the 5 UNGASS HIV prevention knowledge questions was low. Female sex workers were the only population group with more than 50% of respondents able to answer all five questions about prevention in the UNGASS HIV prevention knowledge questionnaire correctly. The proportion of respondents who were able to answer all 5 UNGASS HIV prevention knowledge questions correctly declined in 2004 in almost every population sub-group except FSWs. The proportion of respondents who were able to answer all 5 UNGASS HIV prevention knowledge questions correctly among Grades 8 and 11 and second year vocational school students was very low. The reduction in proportion of respondents who were able to answer all 5 UNGASS HIV prevention knowledge questions correctly was observed in all regions. There was no region that had consistent low proportions of respondents who were able to answer all 5 UNGASS HIV prevention knowl- edge questions correctly as shown in Figure 2.1. 17 "Revitalising HIV prevention in Thailand: a critical assessment" Figure 2.1: Percentage of respondents who were able to answer all 5 UNGASS HIV prevention knowledge question correctly, 2004-07 Source: NBSS MOPH 2. Increasing trend of sexual intercourse experiences among students However, the average age at first sexual intercourse varied by age, education level and residential type. Respondents with a bachelor's degree or higher had their first sexual intercourse when they were older. Respondents in the older age group had a higher average age for their first sex experience. Male respondents who lived in Bangkok had lower average age at the time of first sex than male respondents who lived in the other provinces. The proportions of Grade 11 students in the regular school system who had sexual intercourse were low in 1996, around 10% in males and 4% in females. Unfortunately, these proportions increased over the last 10 years. In 2007, more than 20% of Grade 11 male students and 10% of Grade 11 nd female students had sexual experiences. The proportion of the 2 year vocational school students, who had sexual intercourses, was much higher at almost 30% in females and 40% in males as shown in Figure 2.2. 18 "Revitalising HIV prevention in Thailand: a critical assessment" Figure 2.2: Percentage of the respondents who had sexual intercourse experi- ences, Thailand 1995-2007 3. Low condom use rate among students Students generally had sex with friends. Consistent condom use when having sex with friends in the past year was low as can be seen in Figure 2.3. Female students, especially those in second year vocational school, reported consistent low condom use rates when they had sex with a friend in the past year. Male and female vocational school students reported a consistently lower condom use rate when having sex with friends over the past year than students in grades 8 and 11. Figure 2.3: Percentage of respondents who used condoms consistently when having sex with boy/girlfriends in the past year, Thailand 1995-2007 19 "Revitalising HIV prevention in Thailand: a critical assessment" 4. First sexual intercourse among the general population Data from the National Sexual Behaviour Survey 2006 indicated that among the general population, the average age for first sexual intercourse was 18 years among men and 20 among women. It was found that average age for first sexual intercourse varied by age, education level and residential type and respondents who had a bachelor's degree or higher had their first sexual intercourse at an older age. Respondents in the older age group had a higher average age at first sex. Male respondents who lived in Bangkok had a lower average age at first sex than male respondents who lived in the other provinces. Among males, only 6.9% had first sexual intercourse with their spouse (either registered or not registered), 53.6% had first sexual intercourse with girlfriends. Condom use rate during the first sexual intercourse was 28.2%. Among females, 55.5% had first sexual intercourse with their spouse. 5. Promiscuity and condom use among Thai men Among the male population, the proportion of respondents who had sex with female sex workers in the past year was higher than that of respondents who had sex with non-regular sexual partners as shown in Figure 2.4. Consistent condom use among men who had sex with female sex partners was around 60% in 2007. This proportion increased slowly over the last 10 years as shown in Figure 2.5. The consistent condom use rate when men had sex with non-regular part- ners was low (20%-40%) between 1995 and 2003. However it increased to between 50 and 70% in 2007, a far cry from the low rates between 1995 and 2003 as shown in Figure 2.6. 20 "Revitalising HIV prevention in Thailand: a critical assessment" Figure 2.4: The percentage of respondents who reported having sex with non-regular sexual partners in the past year (solid line), and the proportion of respondents who had sex with female sex workers (dotted line), Thailand 1995 - 2007 Figure 2.5: The percentage of respondents who consistently used a condom when having sex with female sex workers in the past 1 year, Thailand 1995 - 2007 21 "Revitalising HIV prevention in Thailand: a critical assessment" Figure 2.6: The percentage of respondents who consistently used a condom when having sex with non-regular sexual partners in the past 1 year, Thailand 1995 - 2007 6. Female sex workers: multiple partners and condom use Female sex workers had sex with multiple partners. They mostly had sex with general clients and used condoms quite consistently. About 40% of female sex workers had sex with spouse/regular sexual partner and 23.4% had sex with non-client, non-regular sexual partners as shown in Figure 2.7. Consistent condom use when having sex with non-clients, non-regular sexual partners was higher than 80%. However, consistent condom use when having sex with spouse/regular sexual partner was very low as shown in Figure 2.8. Figure 2.7: The percentage of female sex workers who had sex with (1) general clients, (2) regular clients, (3) regular sexual partner/spouses and (4) non-regular sexual partners in the past month, Thailand 1995 - 2007 22 "Revitalising HIV prevention in Thailand: a critical assessment" Figure 2.8: The percentage of female sex workers who consistently used condoms when having sex with (1) general clients,(2) regular clients, (3) regular sexual partner/spouses and (4) non-regular sexual partners in the past month, Thailand 1995 - 2007 Part II: Risk and sexual behaviour survey among MSM and IDUs in 2008 7. High risk of HIV infection among MSM A total of 639 MSM who were over 15 years old and met inclusion criteria were selected through the snow ball technique. The highest proportion of MSM was from Khon Kaen at 28.6% followed by 27.7%, 25.5% and 18.2% from Chiangmai, Chonburi, and Surat Thani provinces respectively. This sample size was assigned in proportion to the size of the population in each province. The average age was 24+7.5 years; 34.7% finished high school or equivalent, 71.8 % were employed, and 27.1% earned between 7,000 to 11,999 baht per month. Almost all (91.2%) had health insurance mostly covered by the Universal Coverage Health Insurance Scheme. Almost half (46.2%) identified themselves as bisexual, 38.7% as homosexual and 15.2% heterosexual, as shown in Figure 2.9. The num- ber of sex partners was alarmingly high. During the past year almost half of them had 1 to 9 sex partners, and 41% had 10-49 sex partners as shown in Figure 2.10. 23 "Revitalising HIV prevention in Thailand: a critical assessment" % 50 40 30 20 10 0 Bisexual Homosexual Heterosexual Figure 2.9: Sexual orientation of MSM % 50 40 30 20 10 0 1-9 10-49 50-99 >100 none person(s) person(s) person(s) person(s) Figure 2.10: Number of sex partners (both men and women) during the past year for MSM During the last six months 41.9% (CI=38.1-45.9%) of the respondents had first sexual intercourse with women, 59% (CI=52.8-64.9%) of them used a condom for the first sexual intercourse with a woman as shown in Figure 2.14. At the last sexual intercourse, 23.5% (CI=20.2-27.0%) of the MSM did not use condoms as shown in Figure 2.11. 24 "Revitalising HIV prevention in Thailand: a critical assessment" % 80 70 60 50 40 30 20 10 0 Used Did not used Figure 2.11: Condom use by MSM for the last sexual intercourse The average age of their first sexual intercourse with men was 16.3 years old. About half (49.3%, CI=45.4-53.2%) had first sexual intercourse with an unfamiliar person, 24.7% (CI=21.4-28.3%) with a friend and 20.3% (CI=17.3-23.7%) with a boyfriend. The occasion for their first sexual intercourse was "being together" (41.5%), during a festival period at 23.2% (CI=19.9-26.6%) and joining the group tour or camp (20.3%, CI=17.3- 23.7%) as shown in Figure 2.12 and Appendix C, Table 3.3. The common reasons for first sexual intercourse with men were being drunk (20.3%) and having sex for rewards (19.9%, CI=16.8-23.2) as shown in Figure 2.13. Only 36.3% (CI=32.7-40.4%) of the respondents used condoms during the first sexual intercourse with men, 31.1% (CI=27.7-35.1%) used oral sex as a protection measure whereas 27.7% (CI=24.4-31.5%) did not protect themselves. % 50 40 30 20 10 0 Figure 2.12: MSM partners, occasion, and preventive practices for the first sexual intercourse with men 25 "Revitalising HIV prevention in Thailand: a critical assessment" % 25 20 15 10 5 0 Figure 2.13: MSM reasons for the first sexual intercourse with men % 60 50 40 30 20 10 0 Using condom Oral sex Extenal ejaculation Unprotected Using condom Oral sex Extenal ejaculation unprotected Protection for 1st Protection for 1st sexual sexual intercourse with men intercourse with women Figure 2.14: Protection for having first sexual intercourse with men and women by MSM The majority of MSM identified close friends as having the highest influ- ence on their sexual behaviours (53.5%, CI=49.6-57.4%). In terms of media channels, internet (39.7%, CI=35.9-43.7%) and television (32.2%, CI=28.6-36.0%) had high influences on their sex behaviour as shown in Figure 2.15 and Appendix C, Table 3.4. 26 "Revitalising HIV prevention in Thailand: a critical assessment" % 60 50 40 30 20 10 0 Figure 2.15: Influences of person and media on sexual behavior of MSM During the past year, 37.4% (CI=33.6-41.3%) of the MSM received HIV/ AIDS information from television, 22.7% (CI=19.5-26.1%) from internet and 12.8% (CI=10.3-15.7%) from advertising billboards. They acquired most of the HIV/AIDS information from colleagues (35.7%, CI=32.0-39.5%) and health personnel (23.2%, CI=19.9-26.6%). Hospitals were identified as a major HIV/AIDS information source for 40.2% (CI=36.4-44.1%) of the MSM, followed by health centres (22.8%, CI=19.6- 26.3%). % 40 30 20 10 0 Figure 2.16: Most important information sources/channels on HIV/AIDS for MSM during the past year Most of the MSM (69.8%) had a high level of knowledge about HIV/AIDS. They had average scores of 15.2?2.0 from the total score of 18. Almost half of them did not know that oral sex could not help prevent HIV infection * (45.5%, CI=41.6-49.5%), that taking addictive substances could increase the risk of HIV/AIDS infection (31.1%, CI=27.6-34.9%), and that 27 "Revitalising HIV prevention in Thailand: a critical assessment" external ejaculation could not prevent HIV/AIDS (30.4%, CI=26.8-34.1%). Some 24.7% (CI=21.4-28.3%) did not know that touching, hugging and holding hands could not transmit HIV/AIDS, and people could not get HIV/ AIDS from some types of mosquitoes (22.5%, CI=19.4-26.0%) as shown in Figure 2.17 and Appendix C, Table 3.6. % 50 40 30 20 10 0 Oral sex Taking External Touch, hug People could could not addicting ejaculation and hold not get preventing substance could not hand could HIV/AIDS contributing preventing not transmit infection HIV/AIDS to higher infection risks for HIV/AIDS HIV/AIDS from some HIV/AIDS infection type's infection mosquitoes Preventive Transmission Figure 2.17: HIV/AIDS transmission and preventive measures unknown to MSM In terms of attitude, most MSM had many false or misleading beliefs. For example, more than 66.2% (CI=62.4-69.9%) believed that blood tests for HIV should be done immediately after risky behaviours. Most of them admitted that expecting a reward or something in return is one of the main reasons for them to have sex with men (57.6%, CI=53.7-61.5%). Further, many of them consider having a higher number of sex partners than their peers as a source of pride (40.4%, CI=36.5-44.3%). Having many male lovers or partners makes one accepted by friends (34.1%, CI=30.4-37.9%), and considered healthy or HIV negative (26.9%, CI=23.5- 30.5%). They also believe that practicing penetrative anal sexual inter- course will not lead to contraction of HIV/AIDS (21.6%, CI=18.5-25.0%). A high proportion of MSM have inappropriate attitudes regarding condom use. Almost half (46.3%, CI=42.4-50.3%) believe that using condoms when having sexual intercourse reduces pleasure, and is a sign of distrust between them and their partners (34.6%, CI=30.9-38.4%). Telling part- ners to use condoms is not appropriate since it shows distrust (30.7%, CI=27.1-34.4%). More than one in five are shy to buy condoms (23.8%, CI=20.5-27.3%). Buying condoms is a burden which they should not pay for (55.2%, CI=51.3-59.1%) as shown in Figure 2.18 and Appendix C, Table 3.7. The majority (84.7%, CI=81.6-87.4%) thought condoms should be free for those in need. 28 "Revitalising HIV prevention in Thailand: a critical assessment" % 70 60 50 40 30 20 10 0 Figure 2.18: Percentage of inappropriate attitudes MSM have on condom use and practice The findings revealed irregular use of condoms over the past year. For example while MSM who always or usually use condoms when having sex with their male lovers were 56.7% (CI=52.4-60.2%), fewer (38%, CI=34.2- 41.9%) never or seldom use condoms when having sex with male sex workers, and about a third of them (32%, CI=28.3-35.7%) usually or often have sexual intercourse with others who are not their regular partners. Almost half of MSM never or seldom use condoms when having sex with women (47.3%, CI=43.3-51.2%), 26.5% (CI=23.1-30.0%) never or sel- dom use condoms when having sex with their partners. An almost similar number do not use condoms with others who were not their partner (23.5%, CI=20.2-27.0%). Most MSM often watch or read pornographic material which stimulate their sexual desires (66.1%, CI=62.2-69.7%). Almost half of them are unable to refuse when asked to have sex (47.8%, CI=43.8- 51.7%), while 42.6% (CI=38.7-46.5%) usually have sex for rewards or expected something in return. Some 30.2% (CI=26.7-33.9%) never or seldom bring condoms when they go out at night, and 28.3% (CI=24.9- 32.0%) have sex with many men to compete with their MSM peers as shown in Figure 2.19 and Appendix C, Table 3.8. 29 "Revitalising HIV prevention in Thailand: a critical assessment" % 70 60 50 40 30 20 10 0 Figure 2.19: MSM condom use and sexual behaviors 8. High risk of HIV infection among IDUs A total of 444 samples of IDUs from four provinces participated in face to face interviews. Most of them were male (76.1%) aged between 15-65 years with a median age of 31 years. Almost all (91.2%) were Buddhists, 97.7% attended school and 33.1% finished secondary school. The majority of them (54.7%) were single, and approximately 29.3% were married. Some 42.6% had temporary odd-jobs, while 23.9% were unemployed. About 35.1% of the respondents had an average monthly income between 3,500 to 6,999 Baht, while 18.9% had no income. Almost all of them (91.1%) had health insurance, 72.7% through the Universal Coverage Scheme. These IDUs started injecting drugs when they were between 9 and 30 years old or a median age of 16 years. The drugs they took for the first time were injecting heroin (38.1%) and amphetamine and amphetamine derivatives (30.0%). They took the drugs out of curiosity (71.2%) or per- suasion by friends (18.5%). Some 45.5% of them used to share needles with other IDU peers and almost all of them (82.9%) bought needles and syringes from drug stores. More than half 56.3% have reused needles for injection. About 40% have washed needles and syringes with clean tap water and dried them, while only 21.8% boil them as shown in Figures 2.20 and 2.21, and Appendix D, Table 4.3. 30 "Revitalising HIV prevention in Thailand: a critical assessment" % 80 70 60 50 40 30 20 10 0 For happiness Heroine Want to try To be able to work harder Amphetamine and amphetamine derivative Marihuana Friend persuasion To forget sadness Type of first addicting substance Reasons of first drug taking Figure 2.20: Substance types and reasons of the first drug taken by IDUs % 90 80 70 60 50 40 30 20 10 0 Figure 2.21: Sources of needles and syringes, and methods used to clean reused needles 31 "Revitalising HIV prevention in Thailand: a critical assessment" Most of the IDUs identified themselves as heterosexual (83.1%) whereas 11.7% were homosexual as shown in Figure 2.22. Over the past year, they had 1 to 120 partners with the mode of one partner as shown in Figure 2.23. Over the last 6 months, 62.6% (CI=57.9-67.1%) of the respondents had sexual intercourse (either with men or women) and 37.6% (CI=33.1-42.3%) of them used condoms (Figure 2.24). However, only about half (45.7%, CI=41.0-50.5%) of them used condoms during the last sexual intercourse as shown in Figure 2.25 and Appendix D, Table 4.4. % 90 80 70 60 50 40 30 20 10 0 Heterosexual Homosexual Bisexual Figure 2.22: Sexual orientation of IDUs % 60 50 40 30 20 10 0 1 person 2-5 6-9 10-49 >50 persons persons persons persons Figure 2.23: Number of sexual partners over the past year for IDUs 32 "Revitalising HIV prevention in Thailand: a critical assessment" % 40 35 30 25 20 15 10 5 0 Using External Oral sex Unprotected condom ejaculation Figure 2.24: HIV/AIDS preventive practices by IDUs over the last six months % 60 50 40 30 20 10 0 Used Did not used Figure 2.25: IDUs condom use for the last sexual intercourse Television (78.4%, CI=74.3-82.1%) had the highest influence on their sex behaviour as shown in Figure 2.26 and Appendix D, Table 4.5, followed by close friends (39.9%, CI=35.3-44.6%) and parents (39.4%, CI=34. 8-44.1%). IDUs identified television (68%) and campaigns (9.9%) as having had the greatest influence on their knowledge, attitude and practices in AIDS prevention as shown in Figure 2.27 and Appendix D, Table 4.6. 33 "Revitalising HIV prevention in Thailand: a critical assessment" % 80 70 60 50 40 30 20 10 0 Figure 2.26: Person and media which had highest influence on IDU sex behavior Over the past year, 68.0% (CI=63.5-72.3%) of the IDUs received HIV/ AIDS information from television, less from campaigns such as World AIDS Day and leaflets and brochures. They acquired most of the HIV/AIDS information from health personnel (56.3%) and less from other sources such as village health volunteers and neighbours. Hospitals were identi- fied as a major source of HIV/ AIDS information for them as shown in Figure 2.27 and Appendix D, Table 4.6. % 70 60 50 40 30 20 10 0 Figure 2.27: Most important IDU information channels on HIV/AIDS over the past year 34 "Revitalising HIV prevention in Thailand: a critical assessment" Most IDUs had a high level of knowledge of HIV/AIDS (73.2%) with an average score of 15.1 + 2.1 out of the total score of 18. About 95.7% (CI=93.4-97.4%) knew about the causes of HIV infection. However 41.2% (CI=36.6-46.0%) did not know that taking addictive substances contrib- uted to higher risks for HIV/AIDS infection, and oral sex could not prevent HIV infection **(31.1%, CI=26.8-35.6%), and that external ejaculation could not prevent HIV/AIDS (31.1%, CI=26.8-35.6%). A small number knew that presently there is no vaccine to prevent HIV/AIDS (27.9%, CI=23.8-32.4%), touching, hugging and holding hands could not transmit HIV/AIDS (24.5 %, CI=20.6-28.8%), and people could not get HIV/AIDS infection from some types of mosquitoes (21.8%, CI=18.1-26.0%) as shown in Figure 2.28 and Appendix D, Table 4.7. % 45 40 35 30 25 20 15 10 5 0 Figure 2.28: HIV/AIDS transmission and preventive measures unknown to IDUs These IDUs believed that blood tests should be done immediately after unprotected sex (83.8%, CI=80.0-87.1%). The majority of the IDUs be- lieved that HIV is mostly spread by sex workers and MSM (68.7%, CI=64.2- 73.0%). Just over half 55.0% (CI=50.2-59.6%) reasoned that married men should not use a condom when having sex with their wives and that it was normal for men to obtain services from sex workers (50.6%, CI=45.9- 55.4%) as shown in Figure 2.29. ** Oral sex can also spread HIV/ AIDS when one partner is HIV positive and another had a lacerated in his/her mouth. In this study about 31 % of IDUs believed that they could not contract HIV through oral sex. 35 "Revitalising HIV prevention in Thailand: a critical assessment" Close to half of the IDUs 45.9% (CI=41.2-50.7%) thought that using condoms when having sex resulted in less pleasure, and using condoms meant distrust between them and their partners (27.3%, CI=23.2-31.6%). Most IDUs thought condoms should be free for those in need (85.1%, CI=81.5-88.3%) as shown in Appendix D, Table 4.8. % 90 80 70 60 50 40 30 20 10 0 Figure 2.29: Common attitudes of IDUs on condom use and sexual prac- tices IDU practices over the past year were as follows: The majority had either never or seldom used condoms when having sex with their husband/wife (70%, CI=65.5-74.2%), never or seldom used condoms when having sex with male/female sex workers (62.8%, CI=58.2-67.3%), and never or seldom used condoms when having sex with their lovers (61.1%, CI=56.3- 65.6%) or girlfriends (60.8%, CI=56.1-65.4%). See Figure 2.30. The majority never or seldom carried condoms with them when going out at night (65.1%, CI=60.5-69.5%). Just over half or 51.8% (CI=47.0- 56.5%) had injected drugs during the past year. Of these, 19.8% (CI=16.2- 23.8%) often or usually injected drugs and 20.0% (CI=16.4-24.1%) shared needles. About a third or 30% (CI=26.2-34.9%) had participated in a "joint party" where they used drugs and had sex under the influence. Another 30.3 % (CI=25.9-34.7%) had sex after taking drugs as shown in Appendix D, Table 4.9. 36 "Revitalising HIV prevention in Thailand: a critical assessment" % 70 60 50 40 30 20 10 0 Figure 2.30: Risky behavior by IDUs 9. HIV/AIDS information channels should be developed MSM and IDUs received most of their knowledge and information on HIV through television (79.8%, with CI=75.9-83.3% for MSM, and 87.8%, with CI=84.1-90.9% for IDUs), and campaigns such as World AIDS Day (50.4% with CI=45.8-55.0% for MSM, and 70.5%, with CI=65.7-75.0% for IDUs). In addition, the internet was also a fairly effective source of information for MSM (45.4%, CI=40.8-50.0%) in providing appropriate knowledge, and influencing their attitude and practices as shown in Figure 2.31 and Appendix E, Tables 5.1-5.2. 80 70 60 50 40 MSM IDU 30 20 10 0 Television Advertising Campaign Internet cutout Figure 2.31: Effective HIV/AIDS information channel for MSM and IDUs 37 "Revitalising HIV prevention in Thailand: a critical assessment" 10. Limited access to VCT The study revealed generally low usage of counselling and sex education services among MSM and IDUs. Only 27.7% (CI=24.3-31.3%) of MSM and 42.1% (CI=37.5-46.9%) of IDUs had received counselling services on sex education or sexually transmitted infections. Of those who accessed VCT services, 80.2% of MSM (CI=73.6-85.8%) and 89.8% of IDUs (CI=84.6-93.8%) received counselling on AIDS and STI prevention, overall knowledge on AIDS, STIs and sex education (78.5%, with CI=71.7-84.3% of MSM and 86.1%, with CI=80.3-90.7% of IDU), and treatment of AIDS (43.5%, with CI=36.1-51.1% of MSM and 68.4%, with CI=61.3-75.0% of IDU). See Figure 2.32 and Appendix E, Tables 5.3-5.4. 90 80 70 60 50 MSM 40 IDU 30 20 10 0 AIDS and STI Knowledge on VCT and STI Treatment of prevention AIDS, STI and checkup AIDS and STI sex education Figure 2.32: Profile of counseling services for MSM and IDU who accessed VCT 6. Summary and conclusions The HIV epidemic analysis of the NBSS applied a serial cross-sectional survey. Data on male and female students, grades 8 and 11, second year vocational school students, FSWs, and male and female factory workers were collected as recommended by the Bureau of Epidemiology. Each sentinel population had different sampling strategies and different data collection methods. Overall, 7,131 respondents were used to collect information using face-to-face interviews. Trend analyses were conducted on NBSS information among different sub-population groups. The primary survey of HIV risk behaviour of MSM and IDUs was conducted in 4 regions of Thailand. It employed the snowball technique to select the samples. The results are presented in proportions with a 95% confidence interval (CI). 38 "Revitalising HIV prevention in Thailand: a critical assessment" Trend analysis of the 1995 to 2007 National Behaviour Surveillance Survey conducted by the Ministry of Public Health, and the primary survey of MSM and IDUs, indicates the following: Part I: the risk and sexual behaviours survey from the NBSS Knowledge about HIV prevention when using the 5 UNGASS HIV prevention knowledge questions among Grades 8 and 11, and second year vocational school students was very low. Unlike all other sub groups, more than 50% of FSWs were able to answer all 5 UNGASS HIV prevention knowledge questions correctly. Average age at first sexual intercourse varied by age, education level, and residential types. Respondents in older age groups, respondents who had a bachelor's degree or higher, and male respondents who did not live in Bangkok had a higher average age at first sexual intercourse than other groups. The proportion of grade 11 students in the regular school system and second year vocational school who had sexual intercourse increased. In 2007, more than 20% of male and 10% of female students in regular schools and 40% of male and 30% of female vocational students had sexual experiences. For the general population, the average age at first sexual intercourse was 18 years among men and 20 years among women. About half of the general male sample had their first sexual intercourse with girlfriends. Only 6.9% had their first sexual intercourse with their spouse. The condom use rate during the first sexual intercourse was 28.2%. Students generally had sex with friends and consistent condom use over the past year was low. The consistent condom use rate among Thai males when having sex with female sex workers, commercial sex partners, and non-regular sexual partners increased slowly over the past years. The consistent condom use rate for FSWs when having sex with non-clients, non-regular sexual partners was very high, but consistent condom use when having sex with spouse/regular sexual partner was very low. Part II: the risk and sexual behaviours survey among the MSM and IDU on HIV/AIDS in 2008 From the primary surveys for MSM sexual behaviour, almost half the MSM surveyed identified themselves as bisexual (46.2%) and homosexual (38.7%). The average age of first sexual intercourse with men was 16.3 years. About half had first sexual intercourse with an unfamiliar person (49.3%); the occasion for their first sexual intercourse was mostly "being together" (41.5%); the most common reasons for first sexual intercourse 39 "Revitalising HIV prevention in Thailand: a critical assessment" was being drunk (20.3%). Number of sex partners was alarmingly high (1-9 persons). The proportion of condom use for the first sexual intercourse with men (36.3%) was lower than first sexual intercourse with women (59.0%). The majority of MSM reported that close friends, the internet, and television had the highest influence on their sexual behaviour. They also received appropriate knowledge, attitude and practices from these sources/chan- nels which included advertising billboards. Most MSM had a high level of knowledge on HIV/AIDS but did not know some key issues, for example that oral sex could not help prevent HIV infection (45.5%), taking addictive substances contributed to higher risks for HIV/AIDS infection (31.1%), and external ejaculation could not prevent HIV/AIDS (30.4%). They had an inappropriate attitude regarding condom use. Almost half believed that using condoms when having sexual intercourse reduced pleasure (46.3%), using condoms meant distrust between them and their partners (34.6%), and telling partners to use condoms is not appropriate as it shows distrust (30.7%). More than one in five were shy to buy condoms (23.8%), and thought that condoms should be free for those who need them (84.6%), and that buying condoms is a burden they should not pay for (55.2%). Over the past year, almost half of them never or seldom used condoms when having sexual intercourse with male lovers (43.3%), women (47.3%), male sex workers (38.0%), and partners (26.5%). Almost half did not refuse when asked to have sex (47.8%) and many of them had sex for rewards or expected something in return (42.6%). The majority watched or read material which simulated their sexual drive (66.1%). The IDUs began injecting drugs when they were very young (median age of 16 years). The most common first drugs taken were heroin, amphet- amines and amphetamine derivatives. The reasons they took the drugs were wanting to try (71.2%) and persuasion by friends (18.5%). Almost half of them used to share needles with other IDU peers (45.5%) and almost all of them bought needles and syringes from drug stores (82.9%). Half of them reused needles for injection (56.3%). The most common methods of cleaning before reuse were washing needles and syringes with tap water and drying them (40%), only 21.8% boiled them. Most of them identified themselves as heterosexual (83.1%). Over the past year, 37.6 % used condoms when having sexual intercourse. About half of them used condoms during the last sexual intercourse (45.7%). Close friends, 40 "Revitalising HIV prevention in Thailand: a critical assessment" parents, and television had the highest influence on their sexual behaviour. They identified television, the internet, AIDS campaigns, leaflets and brochures, as major sources of appropriate knowledge, attitude, and practices in HIV/AIDS prevention. Most IDUs had a high level of knowledge of HIV/AIDS. However, they still had some knowledge gaps. For example, they did not know that taking addictive substances contributes to higher risks for HIV/AIDS infection (41.2%); that oral sex could not prevent HIV infection (31.1%); and that external ejaculation could not prevent HIV/AIDS (31.1%). Most of them believed that using condoms during sexual intercourse reduced pleasure (45.9%), and that condoms signified distrust between them and their partners (27.3%). Most of them thought condoms should be free for those who needed (85.1%) them. In the past year, most of the IDUs never or seldom used condoms when having sex with their husband/wife (70.0%), male/female sex workers (62.8%), their lovers (61.1%) and girlfriends (60.8%). Not many MSM and IDUs access counselling services on sex education or sexually transmitted infections (STIs). Most of those who accessed VCT, received counselling on AIDS and STI prevention, overall knowledge on AIDS, STI and sex education, and treatment of AIDS. 7. Policy recommendations 1. School based HIV prevention program and/or life skills program. The results of this analysis show that knowledge of HIV prevention in the Thai population is low, even among population groups that are easy to reach such as students. For harder to reach teenagers and youth, knowledge about HIV prevention is thought to be even lower. Second year vocational school students who had higher risk of contracting HIV had lower knowledge about HIV prevention when compared with grade 11 students. The proportion of students who had basic knowledge about HIV prevention was very low among grade 8 students. School based HIV prevention and life skills programs have been discussed and planned for quite some time in Thailand but have never been seriously implemented. With changes in social norms and beliefs and increased diversity in life style, these programs need to be more intensified and developed innovations to counteract the spread of the epidemic. 41 "Revitalising HIV prevention in Thailand: a critical assessment" 2. New strategies to increase condom use. Consistent condom use among men who had sex with female sex workers showed somewhat different results. Data from the 2006 National Sexual Behaviour Survey of Thailand showed higher condom use among men who had sex with FSWs than data from the National Behavioural Surveillance System. Data from the general population also showed a significant increase of consistent condom use (when comparing the data with the previous round of surveying). Consistent condom use with commercial partners of students, and male workers were far lower than the general population. The low level of consistent condom use with commercial partners is worrisome and suggests gaps in Thailand's condom campaign and the need for strengthening. Our analysis suggests that condom use with non-commercial partners, which is the more frequently reported type of partner, needs to be seriously addressed. Condom use with casual partners has generally been lower than with commercial partners. However, the increasing prevalence of casual partners needs serious attention. 3. Appropriate HIV prevention services for sex workers The lower demand for commercial sex and high rates of condom use by brothel-based sex workers helped Thailand reverse its epidemic in the early 1990s. Maintaining pressure on brothel-based HIV transmission needs to be continued. The structure of a successful HIV prevention program for commercial sex and sexually transmitted infections clinics, needs to be sustained. This was a very important channel which delivered the 100% condom use program, HIV prevention services and also provided a strong link between sex workers and the health care system. The health care system itself also needs to adapt to work with the new environment of emerging new types of commercial sex workers. Efforts to prevent HIV transmission in commercial sex should be extended to the informal or non-venue-based or non-visible type of commercial sex. 4. HIV prevention services for teenage and youth While the majority of Thai students are exposed to media with sexual content through internet, books, VDOs, VCDs, DVDs and other types of media, it is estimated that less than 5% of young people are being reached by adequate HIV prevention services. Public awareness campaigns have faded away. Urgent actions required now include programs that match 42 "Revitalising HIV prevention in Thailand: a critical assessment" the diversity of risk behaviours of youth. A number of models have been tested with promising results. These need to be continued and expanded in order to reach the youth who need them. 5. Urgent need for appropriate HIV prevention programs for MSM and IDUs Both MSM and IDUs are vulnerable to HIV infection as a result of their risk behaviours. A high proportion of both MSM and IDUs do not use condoms. MSM mostly have unprotected sex with multiple partners. Many of them believe condoms reduce sexual pleasure. IDUs still share needles. Harm reduction could help minimize their risk of contracting HIV. Health education through appropriate channels such as television and the internet for MSM, and television and peers for IDUs, could help them gain more knowledge. A clearer message on HIV prevention should be emphasized to correct the wrong perceptions on transmission and prevention. Counselling is needed for adolescents on sex education and HIV prevention. Training on life skills, especially on how to say no to tempta- tions such as "having sex" and "drugs" should be regularly organized both in schools and communities. Not many MSM (27.7 %) and IDUs (42.1%) had access to VCT. However, more than 80 % of those who got VCT received counselling on HIV/AIDS and STI prevention. Therefore, VCT should be made available and accessible for MSM and IDUs and it should focus on changing their attitude and practices. Appropriate HIV awareness and prevention campaigns targeting IDUs and MSM are needed. In particular, campaigns during special events and in night life areas are necessary to prevent HIV/AIDS among MSM and their clients. The government should allocate more resources such as health personnel to combat the HIV epidemic. Condoms should be free and easily accessible to all in need. Better attitudes towards MSM are needed. Stressing that they are normal but have different sexual preferences should be emphasized to include them in society in order for them to have a normal life and access to information and services. IDUs are also not criminals and need special care in order to return to normal life. Harm reduction should be emphasized for them. Prevention for adolescents in not becoming involved in drugs should require collaboration among all sectors, including the government, NGOs, communities, schools and families. 43 Appendix of Chapter 2 Appendix A Table AA 2.1: Demographic characteristics of respondents, male students grade 11, Thailand 1996 - 2007 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Number of respondents 6,486 5,886 5,827 6,168 6,838 6,478 5,842 4,867 5,746 5,893 5,707 6,370 Average age 17 17 17 17 17 17 17 17 17 17 17 17 Currently living with Parents -- -- -- -- -- -- -- -- 75.6 73.5 75.1 75.6 44 Either father or mother -- -- -- -- -- -- -- -- 12.3 11.0 11.4 10.8 Friend -- -- -- -- -- -- -- -- 0.7 0.0 0.5 0.4 Boy/girlfriend -- -- -- -- -- -- -- -- 0.4 0.0 0.0 0.1 "Revitalising HIV prevention in Thailand: a critical assessment" Relative -- -- -- -- -- -- -- -- 8.1 9.4 8.4 9.9 Living alone -- -- -- -- -- -- -- -- 0.8 0.9 0.8 0.4 Students who had experiences -- -- -- -- -- -- -- -- -- 53.0 62.8 63.2 surfing pornograpic websites Students who had experiences using -- -- -- -- -- -- -- -- -- 81.7 82.4 36.3 pornograpic media, (books, video, VCD) Table AA 2.2: Demographic characteristics of respondents, female students grade 11, Thailand 1996 - 2007 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Number of respondents 7,161 6,463 6,715 6,871 7,350 7,104 6,293 5,182 6,496 8,074 7,713 9,734 Average age 17 17 17 17 17 17 17 17 17 17 16 16 Currently living with Parents -- -- -- -- -- -- -- -- 74.0 73.7 70.9 73.1 Either father or mother -- -- -- -- -- -- -- -- 12.8 11.8 12.6 12.5 Friend -- -- -- -- -- -- -- -- 0.7 0.3 0.4 0.6 Boy/girlfriend -- -- -- -- -- -- -- -- 0.2 0.0 0.0 0.1 Relative -- -- -- -- -- -- -- -- 9.0 9.4 10.0 10.1 45 Living alone -- -- -- -- -- -- -- -- 0.4 0.3 0.2 0.5 Students who had experiences -- -- -- -- -- -- -- -- -- 17.9 25.8 26.0 surfing pornographic websites "Revitalising HIV prevention in Thailand: a critical assessment" Students who had experiences using -- -- -- -- -- -- -- -- -- 48.3 54.4 53.6 pornographic media, (books, video, VCD) "Revitalising HIV prevention in Thailand: a critical assessment" Table AA 2.3: Demographic characteristics of respondents, second year voca- tional school students, Thailand 1996 - 2007 Male Female 2004 2005 2006 2007 2004 2005 2006 2007 Number of respondents 6524 7668 7054 8296 6730 7063 7611 8396 Average age 17.0 16.9 16.8 17.0 16.7 16.6 16.6 16.6 Currently living with Parents 69.5 70.5 71.3 71.9 67.2 65.8 67.6 66.6 Either father or 11.5 9.8 9.5 10.4 9.0 12.1 12.1 11.2 mother Friend 4.0 3.8 3.9 2.7 4.0 3.6 4.0 2.3 Boy/girlfriend 1.2 0.8 1.0 0.9 0.7 0.8 1.6 1.4 Relative 10.1 9.7 9.1 8.9 9.2 10.8 10.2 10.7 Living alone 0.8 1.4 1.6 1.3 1.6 0.8 1.0 0.9 Students who had -- 56.8 61.0 67.7 -- 24.6 26.0 31.5 experiences of surfing pornographic websites Students who had -- 89.1 87.1 89.4 -- 58.8 59.4 64.5 experiences using pornographic media, (books, video, VCD) 46 Table AA 2.4: Demographic characteristics of respondents, male workers, Thailand 1996 - 2007 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Number of respondents 3,926 4,863 4,306 4,604 4,285 4,858 4,796 4,142 3,899 6,716 6,240 5,642 4,287 Age (Years) 15-19 24.0 21.2 20.8 18.6 20.3 15.1 14.5 14.5 11.3 7.2 5.2 5.8 5.1 20-24 38.1 38.7 41.5 37.9 41.1 39.3 40.1 38.9 42.9 24.7 21.9 22.1 20.1 25-29 35.7 37.0 34.5 41.9 41.9 42.2 44.2 45.1 44.3 28.9 28.8 29.8 30.8 30-34 - - - - - - - - - 15.0 17.8 19.5 20.9 35-39 - - - - - - - - - 11.3 11.8 12.4 13.2 40-44 - - - - - - - - - 6.1 6.4 6.6 6.6 47 45-49 - - - - - - - - - 1.8 2.9 3.8 3.3 Marital status Single 56.7 57.8 59.0 55.9 55.9 54.5 54.1 56.5 55.4 41.7 38.8 37.2 38.7 "Revitalising HIV prevention in Thailand: a critical assessment" Married 39.0 36.9 36.3 40.4 39.3 41.4 40.2 40.4 41.5 52.7 55.5 56.6 55.0 Divorced/separated 1.8 1.9 1.8 1.5 1.9 1.6 2.2 1.7 1.7 4.7 4.3 5.5 5.6 Widowed 0.7 0.9 0.3 0.6 0.6 0.4 0 0.6 0.3 0.7 0.5 0.7 0.7 Highest grade of education completed Primary school 49.4 38.6 39.5 32.8 33.1 32.7 26.1 20.9 16.9 22.6 19.4 19.1 20.0 Secondary school 1-3 years 23.6 24.3 24.6 25.3 25.7 29.4 28.9 27.8 22.8 24.5 24.4 24.8 23.1 Secondary school 4-6 years 10.1 10.8 13.7 16.1 13.4 14.5 17.2 19.8 26.8 23.0 24.1 25.9 22.9 Vocational/diploma 8.4 15.2 15.0 11.5 14.7 13.9 16.7 18.5 19.3 16.1 21.6 19.7 22.1 Higher than bachelor's degree 2.1 1.9 1.7 3.0 2.3 4.5 4.1 4.9 5.7 7.9 10.7 10.4 11.9 Table AA 2.5: Demographic characteristics of respondents, male workers, Thailand 1996 - 2007 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Number of respondents 4,911 5,299 4,918 5,182 5,467 5,617 5,618 4,824 3,800 4,903 6,078 5,854 4,732 Age (Years) 15-19 26.2 26.5 21.8 21.6 19.1 18.5 15.7 13.1 - 6.4 5.6 6.0 4.8 20-24 38.2 38.5 42.1 39.7 41.5 40.9 41.7 50.0 - 27.4 21.1 21.6 19.9 25-29 35.6 35.0 36.2 38.8 39.4 40.6 42.6 46.0 - 33.4 27.9 26.5 27.3 30-34 - - - - - - - - - 19.9 19.8 20.1 20.7 35-39 - - - - - - - - - 14.0 14.4 14.2 14.6 40-44 - - - - - - - - - 7.2 7.9 8.0 8.7 48 45-49 - - - - - - - - - 3.2 3.4 3.5 4.0 Marital status Single 28.6 31.0 11.4 43.8 40.6 39.0 40.6 37.8 35.8 62.0 27.5 28.3 30.3 "Revitalising HIV prevention in Thailand: a critical assessment" Married 51.4 47.9 50.8 48.0 47.6 53.3 54.1 56.2 58.2 25.6 63.0 60.7 58.8 Divorced/separated 3.6 4.1 4.4 4.0 4.9 5.6 4.8 4.9 4.6 8.3 7.1 8.5 8.5 Widowed 1.1 1.1 1.1 1.5 1.4 1.4 1.3 1.1 1.1 2.0 1.8 2.5 2.4 Highest grade of education completed Primary school 62.3 51.1 43.8 46.3 41.1 38.4 32.9 29.9 24.0 27.1 23.4 25.3 24.3 Secondary school 1-3 years 22.7 26.9 49.9 26.0 30.6 31.2 30.3 30.5 25.8 19.5 20.7 22.1 19.9 Secondary school 4-6 years 7.7 9.7 4.5 12.1 15.3 17.3 20.5 20.8 24.3 19.8 19.7 23.5 20.2 Vocational/diploma 3.9 7.3 1.1 6.5 7.8 8.0 10.4 11.8 13.9 14.8 14.6 15.2 18.0 Higher than bachelor's degree 1.6 1.5 0.2 3.4 2.6 2.6 3.8 4.3 6.4 10.3 13.3 14.0 17.7 "Revitalising HIV prevention in Thailand: a critical assessment" Table AA 2.6: Demographic characteristics of respondents, female sex workers, Thailand 2004 - 2007 General information 2004 2005 2006 2007 Total number of respondents 2,749 3,499 2,092 1,351 Age (Mean) 27 29 28 27 Marital status Single 30.9 25.7 33.3 32.8 Married 16.3 18.8 17.5 15.7 Separated 17.6 19.6 18.2 21.1 Divorced 28.7 28.6 26.8 26.2 Widowed 4.2 5.2 2.9 3.5 Highest grade of education completed Primary school 57 52.5 48.9 41.6 Secondary school 1-3 years 24.7 26.8 27.3 31.8 Secondary school 4-6 years 10.3 10.5 9.9 19.0 Vocational/diploma 3.4 3.4 2.9 4.7 Higher than bachelor's degree 0.2 0.6 0.5 1.2 Age at first sexual intercourse 18.0 18.4 18.3 18.0 Age at first sex work 23.7 -- 24.0 25.0 Duration which involved in commercial sex Less than 1 year 2.2 6.1 9.7 38.9 1-2 years 47.1 46.2 44.8 13.6 3-4 years 18.5 16.6 11.4 14.0 5-9 years 18.1 16.4 14.5 16.7 More 10 years 14.1 14.7 19.5 13.8 Income before becoming sex worker Less than 5,000 Baht 69.1 68.2 75.2 70.0 5,000 - 14,999 Baht 26.4 26.2 22.8 24.6 15,000 - 19,999 Baht 0.6 0.6 0.6 1.9 More than 20,000 Baht 3.9 5.0 0.0 2.6 Current income Less than 5,000 Baht 24.5 25.0 27.0 31.5 5,000 - 14,999 Baht 38.2 16.4 56.9 38.9 15,000 - 19,999 Baht 5.7 4.8 5.9 6.8 More than 20,000 Baht 7.7 9.5 9.2 12.0 49 "Revitalising HIV prevention in Thailand: a critical assessment" Table AA 2.7: Demographic characteristics of respondents from National Sexual Behaviour Survey of Thailand 2006 Demographic Characteristics Male (%) Female (%) Total (%) Age (Years) 18-19 19.7 19.0 19.4 20-24 30.3 31.0 30.6 30-34 7.7 7.0 7.3 35-39 8.4 8.8 8.6 40-44 8.9 8.1 8.5 45-49 7.4 7.4 7.4 50-54 5.7 7.6 6.6 55-59 3.9 4.8 4.4 Marital status Single 51.3 32.6 41.9 Married 45.7 59.6 52.6 Widowed/divorced/separated 3.1 7.8 5.5 Highest grade of education completed Never attended school 0.3 1.7 1.0 Primary school 33.0 37.9 35.5 Secondary (G1-3) 28.2 23.3 25.7 Secondary (G 4-6) 26.1 26.1 26.1 Vocation/Diploma 6.7 5.2 6.0 Bachelor's degree 5.4 5.5 5.5 Higher than bachelor's degree 0.2 0.2 0.2 Religion Buddhism 93.8 93.2 93.5 Islam 5.0 5.7 5.4 Christianity 1.1 1.1 1.1 50 "Revitalising HIV prevention in Thailand: a critical assessment" Appendix B Grade 11 students % 80 70 60 50 40 30 20 10 0 2004 2005 2006 2007 2004 2005 2006 2007 Male Female Parents Either father of mother Relative Friend boy/girlfriend Living alone Figure AB 2.1: Proportion of male and female grade 11 students currently living conditions, Thailand 2004-2007 % 90 80 70 60 50 40 30 20 10 0 2005 2006 2007 2005 2006 2007 Male Female Pornography website Pornography book/video/VCD Figure AB 2.2: Proportion of Grade 11 male and female students who were exposed to pornography, Thailand 2005-2007 51 "Revitalising HIV prevention in Thailand: a critical assessment" nd 2 year vocational school students % 80 70 60 50 40 30 20 10 0 2004 2005 2006 2007 2004 2005 2006 2007 Male Female Parents Either father of mother Relative Friend boy/girlfriend Living alone Figure AB 2.3: Proportion of second year vocational school male and female students living conditions, Thailand 2004-2007 % 90 80 70 60 50 40 30 20 10 0 2005 2006 2007 2005 2006 2007 Male Female Pornography website Pornography book/video/VCD Figure AB 2.4: Proportion of second year vocational school male and female students, who were exposed to pornography, Thailand 2005-2007 52 "Revitalising HIV prevention in Thailand: a critical assessment" Worker % 35 30 25 20 15 10 5 0 2004 2005 2006 2007 2004 2005 2006 2007 Male Female 15-19 20-24 26-29 30-34 35-39 40-44 45-49 Figure AB 2.5: Proportion of male and female workers in each age group, Thailand 2004-2007 % 70 60 50 40 30 20 10 0 2004 2005 2006 2007 2004 2005 2006 2007 Male Female Single Married Divorced/separated Widowed Figure AB 2.6: Proportion of married and unmarried male and female workers, Thailand 2004-2007 53 "Revitalising HIV prevention in Thailand: a critical assessment" % 30 25 20 15 10 5 0 2004 2005 2006 2007 2004 2005 2006 2007 Male Female Primary school Secondary school 1-3 years Secondary school 4-6 years Vocational/diploma Higher than bachelor's degree Figure AB 2.7: Male and female workers' educational attainment, Thailand 2004-2007 54 "Revitalising HIV prevention in Thailand: a critical assessment" Female sex worker % 35 30 25 20 15 10 5 0 2004 2005 2006 2007 Single Married Separated Divorced Widowed Figure AB 2.8: Marital status of female sex workers, Thailand 2004-2007 % 60 50 40 30 20 10 0 2004 2005 2006 2007 Primary school Secondary school 1-3 years Secondary school 4-6 years Vocational/diploma Higher than bachelor's degree Figure AB 2.9: Female sex workers' educational attainment, Thailand 2004-2007 55 "Revitalising HIV prevention in Thailand: a critical assessment" % 30 Age (years) 25 20 15 10 5 0 2004 2005 2006 2007 Age at first sexual intercourse Age at first sex work Figure AB 2.10: Average age (years) at first sexual intercourse and first sex work of female sex workers, Thailand 2004-2007 % 50 45 40 35 30 25 20 15 10 5 0 2004 2005 2006 2007 Less than 1 year 1-2 years 3-4 years 5-9 years More 10 years Figure AB 2.11: Duration as sex work for female sex workers, Thailand 2004-2007 56 "Revitalising HIV prevention in Thailand: a critical assessment" % 80 70 60 50 40 30 20 10 0 2004 2005 2006 2007 Less than 5,000 Baht 5,000 - 14,999 baht 15,000 - 19,999 Baht More than 20,000 Baht Figure AB 2.12: Proportion of income before becoming sex worker of female sex workers, Thailand 2004-2007 % 60 50 40 30 20 10 0 2004 2005 2006 2007 Less than 5,000 Baht 5,000 - 14,999 baht 15,000 - 19,999 Baht More than 20,000 Baht Figure AB 2.13: Percentage of current income of female sex workers, Thailand 2004-2007 57 "Revitalising HIV prevention in Thailand: a critical assessment" Appendix C Table AC 3.1: Number and percentage distribution of sample size of MSM in all regions (n=639) Province Region Number Percent Khon Kaen Northeast 183 28.6 Chiang Mai North 177 27.7 Chonburi Central 163 25.5 Surat Thani South 116 18.2 Total 639 100.0 Table AC 3.2: Number and percentage of demographic and socio- economics characteristics of MSM (n=639) Demographic and Socio-economics Data Number Percent Age <20 yrs 199 31.1 20-29 yrs 316 49.5 30-39 yrs 91 14.2 40-49 yrs 24 3.8 50-59 yrs 9 1.4 Mean (SD) 24.0 (7.5) Median (Min-Max) 22.0 (15-57) Education attainment No formal education 5 0.8 Primary school (grade 6-7) 55 8.6 Secondary school (grade 9) 201 31.5 High school or equivalent (grade 12/basic vocational school) 222 34.7 Certificate/higher vocational school 77 12.1 Bachelor degree 70 11.0 Master degree 9 1.4 Higher than master degree 5 0.8 Marital status Single 477 74.6 Married with man 79 12.4 Married with woman 34 5.3 Divorced 28 4.4 Separate 21 3.3 58 "Revitalising HIV prevention in Thailand: a critical assessment" Demographic and Socio-economics Data Number Percent Religion Buddhism 608 95.1 Christian 22 3.4 Muslim 9 1.4 Staying Parents 178 27.9 Shared apartment with friend 134 21.0 Alone 125 19.6 Relative/siblings 73 11.4 Colleague 85 13.3 Spouse 44 6.9 Occupation Do not work 180 28.2 Temporary job 162 25.4 Waiter in the restaurant/bar beer 144 22.5 Private business 96 15.0 Temporary employee in government sectors 29 4.5 Employee in private sectors, company or shop 23 3.6 Agriculturist 5 0.8 Estimate monthly family income < 3500 Baht/month 37 5.8 3,500 - 6,999 Baht/month 129 20.2 7,000 - 11,999 Baht/month 173 27.1 12,000 - 19,999 Baht/month 110 17.2 20,000 - 29,999 Baht/month 77 12.1 30,000 - 39,999 Baht/month 42 6.6 40,000 - 49,999 Baht/month 27 4.2 50,000 - 59,999 Baht/month 15 2.3 60,000 - 79,999 Baht/month 12 1.9 > 80,000 Baht/month 8 1.3 No income 9 1.4 Extra job No extra job 303 47.4 Waiter in the restaurant/bar beer 128 20.0 Temporary work 112 17.5 Private business/freelance 80 12.5 Employee in private sectors, company or shop 16 2.5 Health insurance Universal coverage health insurance 348 54.5 Social security/workman compensation 157 24.6 Private health insurance 45 7.0 Civil servant medical benefit 33 5.2 No health insurance 56 8.8 59 "Revitalising HIV prevention in Thailand: a critical assessment" Table AC 3.3: Number and percentage of sexual behaviour of MSM (n=639) Sexual Behaviour Number Percent Sexual orientation Bisexual (Sex with either women and men) 295 46.2 Homosexual (Sex with men) 247 38.7 Heterosexual (Sex with women) 97 15.2 Sexual partner (both with men and women) during the past 1 year None 11 1.7 1-9 299 46.8 10-49 262 41.0 50-99 44 6.9 > 100 23 3.6 Mean (SD) 19.0 (29.3) Median (Min-Max) 10.0 (0-200) Age at the first sexual intercourse with men < 15 yrs 190 29.7 15-19 yrs 363 56.8 20-30 yrs 86 13.5 Mean (SD) 16.3 (3.0) Median (Min-Max) 22.0 (9-30) First sexual intercourse partner Unfamiliar person 315 49.3 Friend 158 24.7 Boyfriend or lover 130 20.3 Male sex worker 36 5.6 Occasion for the first sexual intercourse with men Just being together 265 41.5 Festival 148 23.2 Group tour/camp 130 20.3 Party 96 15.0 Protection for the first sexual intercourse with men Using condom 232 36.3 Oral sex 199 31.1 Unprotected 177 27.7 External ejaculation 31 4.9 60 "Revitalising HIV prevention in Thailand: a critical assessment" Sexual Behaviour Number Percent Reason for first sexual intercourse with men Drunk 130 20.3 Want reward 127 19.9 Like the appearance 90 14.1 Love 83 13.0 Group's fashion 59 9.2 Got opportunity 54 8.5 Persuasion 47 7.4 Innocent 36 5.6 Coercion 13 2.0 First sexual intercourse with women during the last 6 months No 371 58.1 Had 268 41.9 Protection for first sexual intercourse with women Using condom 158 59.0 External ejaculation 55 20.5 Oral sex 2 0.7 Unprotected 53 19.8 Using condom for the last sexual intercourse Did not use 150 23.5 Used 489 76.5 Table AC 3.4: Number and percent of person and media had highest influence on sexual behaviour of MSM (n=639) Item Number Percent Person who had highest influence on MSM sexual behaviour Closed friend 342 53.5 Superstar/ Singers/Actor/Actress 100 15.6 Colleague 94 14.7 Family's Member 52 8.1 Health worker 14 2.2 None 26 4.1 Teacher/lecturer 11 1.7 Media which highest influence on MSM sexual behaviour Internet 254 39.7 Television 206 32.2 Book/journal 109 17.1 Electronic media (VCD, DVD, Clip video) 64 10.0 Radio 6 0.9 61 "Revitalising HIV prevention in Thailand: a critical assessment" Table AC 3.5: Number and percentage of channels through which MSM attain information on HIV/AIDS during the past 12 months (n = 639) Channel Number Percent Television 239 37.4 Internet 145 22.7 Advertising cutout 82 12.8 Campaign such as Global AIDS Day 44 6.9 Leaflet, brochure, letter 29 4.5 Newspapers 23 3.6 Journal / magazine 21 3.3 Community radio broadcasting 15 2.3 Training material 14 2.2 Radio 12 1.9 Exhibition 8 1.3 Never get information 7 1.1 Person Number Percent Colleague 228 35.7 Health personnel (doctor, nurse, public health staff) 148 23.2 Parents / siblings 48 7.5 Teacher / lecturer 42 6.6 Classmate 41 6.4 Neighbour 30 4.7 Relatives 26 4.1 Village health volunteer 25 3.9 Husband/ wife 14 2.2 Student 12 1.9 Social welfare worker 1 0.2 Never get information 24 3.8 Institutions Number Percent Hospital 257 40.2 Health centre / Primary care unit 146 22.8 School 62 9.7 District health centre/ Provincial health centre 40 6.3 Health promotion centre 31 4.9 Private clinic 30 4.7 Foundation 23 3.6 Municipality / local administration organization 7 1.1 Temple 3 0.5 Never get information 25 3.9 62 "Revitalising HIV prevention in Thailand: a critical assessment" Table AC 3.6: Number and percentage of MSM's knowledge on HIV/AIDS (n=639) Know Did not know Questions Number Percent Number Percent 1. AIDS causes by virus resulted in 601 94.1 38 5.9 immune deficiency. 2. HIV can be transmitted through 616 96.4 23 3.6 sexual intercourse, from mother to child, and through blood. 3. An HIV infected person can spread 538 84.2 101 15.8 the disease even when he/she tests negative for HIV. 4. Oral sex could not prevent HIV 348 54.5 291 45.5 infection. 5. People could not get HIV/ AIDS 495 77.5 144 22.5 infection from some types mosquitoes. 6. Touch, huge and hold hand could 481 75.3 158 24.7 not transmit HIV/AIDS. 7. AIDS could transmit when sharing 596 93.3 43 6.7 syringe among injection drug users. 8. There is no vaccine to prevent 518 81.1 121 18.9 HIV/AIDS at present. 9. Appropriate self-care could help 600 93.9 39 6.1 PLWHA could live normal life and delayed showing AIDSí symptoms. 10. At present, there is no drug which 581 90.9 58 9.1 could cure AIDS. 11. External ejaculation could not 445 69.6 194 30.4 prevent HIV/AIDS. 12. HIV/AIDS could spread from male to 547 85.6 92 14.4 male or female to female. 13. Having multiple sex partners are 546 85.4 93 14.6 risk for HIV infection. 14. AIDS patients might have chronic 610 95.5 29 4.5 diarrhoea, common cold, loose weight, oral thrush and lymph node enlargement. 15. Taking antibiotics before sexual 574 89.8 65 10.2 intercourse could not prevent HIV/AIDS infection. 16. Using condom for every sexual 588 92.0 51 8.0 intercourse could prevent HIV/AIDS 17. Taking Addicting substance 440 68.9 199 31.1 contributing to higher risks for HIV/AIDS infection 18. Sexual intercourse through anus 600 93.9 39 6.1 also have possibility to get HIV/AIDS infection 63 "Revitalising HIV prevention in Thailand: a critical assessment" Table AC 3.7: Number and percent of MSM's attitude on HIV/ AIDS (n= 639) Totally Totally Your Opinion disagree Disagree Indifferent Agree agree 1. Using condom when having 72 116 155 199 97 sexual intercourse caused (11.3) (18.2) (24.3) (31.1) (15.1) less pleasure. 2. You are shy to buy condom. 118 105 264 111 41 (18.5) (16.4) (41.3) (17.4) (6.4) 3. Using a condom means 115 169 134 121 100 distrust between you and (18.0) (26.5) (20.9) (18.9) (15.7) your partner. 4. Having sex with a permanent 237 209 72 101 20 male partner will not lead (37.1) (32.7) (11.3) (15.8) (3.1) to HIV infection 5. Should use condom every 11 15 38 196 379 time of having sex with (1.7) (2.4) (5.9) (30.7) (59.3) male sex worker. 6. Had sex with a male is less 228 236 100 52 23 likely to get HIV infection (35.7) (36.9) (15.7) (8.1) (3.6) than having sex with a female 7. Being the incentive partner 231 221 49 71 67 in anal sexual intercourse (36.1) (34.6) (7.7) (11.1) (10.5) will not get HIV/AIDS 8. Sex without a condom or if a 30 29 45 239 296 condom slips off during (4.7) (4.5) (7.0) (37.5) (46.3) intercourse increases the risk of HIV infection. 9. A healthy looking person 191 174 102 123 49 cannot be HIV positive (29.9) (27.2) (15.9) (19.3) (7.7) 10. At present we should not 373 190 34 31 11 give priority to HIV (58.4) (29.7) (5.3) (4.9) (1.7) prevention since there is anti retroviral therapy. 11. It is not necessary to get 237 172 74 93 63 blood test even though you (37.1) (26.9) (11.6) (14.6) (9.8) ever have sexual intercourse with men, since you will not have any change to get infected 12. Blood test should be done 45 85 86 227 196 immediately after having (7.0) (13.3) (13.5) (35.5) (30.7) risking behaviour. 64 "Revitalising HIV prevention in Thailand: a critical assessment" Totally Totally Your Opinion Disagree Indifferent Agree disagree agree 13. Having many male lovers, 104 114 203 112 106 or male partners make one (16.3) (17.8) (31.8) (17.5) (16.6) getting acceptance from friends 14. Having more sex partners 82 109 190 110 148 than other mean superb. (12.8) (17.1) (29.7) (17.2) (23.2) 15. Having sex is both sides 234 195 75 107 28 pleasure, therefore should (36.6) (30.5) (11.7) (16.7) (4.5) not use prevention. 16. Having rewards or something 63 87 121 136 232 in return is one of a major (9.9) (13.6) (18.9) (21.3) (36.3) reason for you to have sex with male. 17. Having sex with many people 87 110 196 142 104 mean you are superb (13.6) (17.2) (30.7) (22.2) (16.3) 18. Telling one 's partner to use a 173 157 113 145 51 condom is not appropriate (27.1) (24.6) (17.7) (22.7) (7.9) since it shows distrust. 19. There is no need to use a 70 73 143 214 139 condom when having sex (10.9) (11.4) (22.4) (33.5) (21.8) with one's wife 20. Condoms should be free for 8 15 75 213 328 all need them. (1.3) (2.4) (11.7) (33.3) (51.3) 21. Access to condoms is difficult 115 175 164 123 62 when about to have sex. (18.0) (27.3) (25.7) (19.3) (9.7) 22. Buying condom is a burden 64 104 118 156 197 which you should not pay for. (10.0) (16.3) (18.5) (24.4) (30.8) Table AC 3.8: Number and percent of MSM's practice related to HIV/ AIDS (n= 639) Some During the last 12 months Never Seldom Often Usually times 1. You had sexual intercourse 124 151 160 102 102 with someone who is not (19.5) (23.7) (25.0) (15.9) (15.9) your partner. 2. You had sex with male 316 129 77 58 59 sex workers. (49.4) (20.2) (12.1) (9.1) (9.2) 3. You used a condom when 80 89 110 116 244 you had sex with your partner. (12.5) (13.9) (17.2) (18.2) (38.2) 65 "Revitalising HIV prevention in Thailand: a critical assessment" Some During the last 12 months Never Seldom Often Usually times 4. You used a condom when 80 70 82 139 268 you had sex with others (12.5) (10.9) (12.8) (21.9) (41.9) who are not your partner. 5. You used a condom when 209 34 69 92 235 you had sex with male sex (32.7) (5.3) (10.8) (14.4) (36.8) workers. 6. You used a condom when you 272 30 79 83 175 had sex with women (42.6) (4.7) (12.4) (12.9) (27.4) 7. You are an injection drug user. 517 81 30 8 3 (80.9) (12.7) (4.7) (1.3) (0.4) 8. You were drunk and had 266 193 136 28 16 unprotected sex (41.6) (30.2) (21.3) (4.4) (2.5) 9. You brought condoms with 158 35 125 109 212 you when you went out (24.6) (5.5) (19.6) (17.1) (33.2) at night. 10. You had sex with many 492 67 44 8 28 people at the same time (77.0) (10.49) (6.89) (1.25) (4.38) without changing a condom. 11. You did not use a condom 362 139 102 17 19 when you had sex with (56.7) (21.8) (15.9) (2.7) (2.9) your male lover. 12. You had STI such as 541 70 19 7 2 Syphilis, Gonorrhoea. (84.8) (10.9) (2.9) (1.1) (0.3) 13. You got treatment for STI 404 113 73 27 22 from a reliable doctor. (63.2) (17.7) (11.4) (4.2) (3.5) 14. During the last 12 months, 430 116 75 7 11 had you every joint any (67.3) (18.2) (11.7) (1.1) (1.7) party using drug and unconsciously had sex. 15. Were you able to refuse 201 104 215 79 40 when asked for sex? (31.4) (16.3) (33.6) (12.4) (6.3) 16. Did you or your partner 230 120 203 61 25 practice external ejaculation. (35.9) (18.8) (31.8) (9.6) (3.9) 17. Your male partner used 489 65 54 16 15 microbicides after sexual (76.5) (10.2) (8.5) (2.5) (2.3) intercourse. 18. You had sex for a reward or 168 79 120 72 200 something in return (26.3) (12.3) (18.8) (11.3) (31.3) 19. Your male partner received 389 111 90 22 27 a reward after sex (60.9) (17.4) (14.1) (3.4) (4.2) 20. You had sex with many men 238 85 135 108 73 to compete who will have more (37.3) (13.3) (21.1) (16.9) (11.4) 21. You have watched or read 28 57 132 159 263 ponographic material to (4.4) (8.9) (20.6) (24.9) (41.2) stimulate your sex drive. 66 "Revitalising HIV prevention in Thailand: a critical assessment" Appendix D Table AD 4.1: Number and percentage distribution of sample size for IDUs in all Regions (n=444) Site / Region Number Percent North 159 35.8 Central 118 26.6 Northeast 104 23.4 South 63 14.2 Total 444 100.0 Table AD 4.2: Number and percent of demographic and Socio-economics Charac- teristics of IDU (n=444) Demographic and Socio-economics Data Number Percent Sex Male 338 76.1 Female 106 23.9 Age <20 yrs 16 3.6 20-29 yrs 161 36.3 30-39 yrs 204 45.9 40-49 yrs 49 11.0 50-59 yrs 13 2.9 > 60 yrs 1 0.2 Mean (SD) 31.8 (7.7) Median (Min-Max) 31.0 (15-65) Education attainment No formal education 10 2.3 Primary school (grade 6-7) 140 31.5 Secondary school (grade 9) 147 33.1 High school or equivalent (grade 12/basic vocational school) 112 25.2 Certificate/higher vocational school 21 4.7 Bachelor's degree 13 2.9 Master's degree 1 0.2 Marital status Single 243 54.7 Married 130 29.3 Separate 31 7.0 Divorced 32 7.2 Widow 8 1.8 67 "Revitalising HIV prevention in Thailand: a critical assessment" Demographic and Socio-economics Data Number Percent Religion Buddhism 405 91.2 Muslim 30 6.8 Christian 9 2.0 Dependents under responsibility in family None 121 27.3 Children < 15 years 68 15.3 Elderly > 60 years 186 41.9 Both 69 15.5 Children < 15 years old 1 child 95 21.4 2 children 55 12.4 > 3 children 37 8.3 Mean (SD) 1.8 (1.2) Median (Min-Max) 1 (1-7) Elderly > 60 years 1 elder 96 21.6 2 elders 33 7.4 > 3 elders 8 1.8 Mean (SD) 1.4 (0.8) Median (Min-Max) 1.0 (1-6) Occupation Do not work 106 23.9 Temporary job (workers) 189 42.6 Private business 66 14.9 Employee in a private company or shop 29 6.5 Temporary government employee 29 6.5 Agriculturist 21 4.7 Employee in government/state enterprises 3 0.7 Fisherman 1 0.2 Average monthly family income < 3500 Baht/month 74 16.7 3,500 - 6,999 Baht/month 156 35.1 7,000 - 11,999 Baht/month 88 19.8 12,000 - 19,999 Baht/month 18 4.1 20,000 - 29,999 Baht/month 12 2.7 30,000 - 39,999 Baht/month 4 0.9 40,000 - 49,999 Baht/month 3 0.7 50,000 - 59,999 Baht/month 2 0.5 60,000 - 79,999 Baht/month 2 0.5 > 80,000 Baht/month 1 0.2 No income 84 18.9 68 "Revitalising HIV prevention in Thailand: a critical assessment" Demographic and Socio-economics Data Number Percent Health insurance Universal coverage health insurance 323 72.7 Social security/workman compensation 56 12.6 Private health insurance 14 3.2 Civil servant medical benefit 7 1.6 No health insurance 44 9.9 Table AD 4.3: Number and percent of Drug Use Practices of IDU (n=444) Substances used Number Percent Type of addicting substance ever used (could answer more than 1) Injection 444 100.0 Amphetamine and amphetamine derivative 72.3 72.3 Inhalation substance 253 57.0 Type of addicting substance in last 1 year (could answer more than 1) Amphetamine and amphetamine derivative 249 56.1 Injection 172 38.7 Inhalation substance 161 36.3 Age at first drug use <10 yrs 2 0.5 10-19 yrs 338 76.1 20-29 yrs 98 22.1 > 30 yrs 6 1.4 Mean (SD) 17.4 (3.6) Median (Min-Max) 16.0 (9-34) Type of first drug taken Heroine 169 38.1 Amphetamine and amphetamine derivative 133 30.0 Marihuana 84 18.9 Inhalation substance; glue 58 13.1 Reasons of the first attempt at taking drugs Want to try 316 71.2 Persuaded by a friend 82 18.5 To deal with sadness 26 5.9 For happiness 11 2.5 To be able to work harder 9 2.0 69 "Revitalising HIV prevention in Thailand: a critical assessment" Substances used Number Percent Have you shared a needle with other IDUs? Never shared a needle 242 54.5 Shared needle sometimes 177 39.9 Often shareds a needle with others 21 4.7 Always shareds a needle with others 4 0.9 Source of syringe and needle (could answer more than 1) Buy from drug store 368 82.9 Friend 108 24.3 Private clinic 46 10.4 Got from local health care facility 17 3.8 Provided by employer 2 0.5 Reuse the needle Yes 250 56.3 None 194 43.7 How do you clean needles before reusing them? (could answer more than 1) Wash with clean water and dry it 176 39.6 Boil 97 21.8 Soak it in disinfectants 23 5.2 Wash with soap/ detergent, and then dry it 5 1.1 Never cleaned it at all 6 1.4 Table AD 4.4: Number and percentage distribution of sexual behaviour of IDU (n=444) Sexual Behaviours Number Percent Group of sexual Heterosexual 369 83.1 Homosexual 52 11.7 Bisexual 23 5.2 Sexual partner (both with men and women) during last 1 year Never have 35 21.4 Yes 349 78.6 1 198 56.7 2-5 118 33.8 6-9 9 2.6 10-49 21 6.0 > 50 3 0.9 Mean (SD) 2.8 (8.2) Median (Min-Max) 1.0 (1-120) 70 "Revitalising HIV prevention in Thailand: a critical assessment" Sexual Behaviours Number Percent Sexual intercourse (with men and women) during the last 6 months Yes 278 62.6 No 166 37.4 Protection during sexual intercourse during last 6 months Using condom 167 37.6 External ejaculation 16 3.6 Oral sex 6 1.4 Unprotected 94 21.2 Using a condom during the last sexual intercourse Used 203 45.7 None use 241 54.3 Table AD 4.5: Person and Media which had highest influence on IDUs' sex behaviour (n=444) Person influenced their sex behavior Number Percent Closed friend 177 39.9 Parent/ Relative/siblings 175 39.4 IDU group 44 9.9 Colleague 24 5.4 Hyper self-confidence 13 2.9 Health worker 10 2.3 Teacher 1 0.2 Media influenced behaviour Number Percent Television 348 78.4 Book/journal 54 12.2 Internet 30 6.8 Radio 12 2.7 71 "Revitalising HIV prevention in Thailand: a critical assessment" Table AD 4.6: Number and percentage of channels through which IDUs attain information on HIV/AIDS during the past one year (n = 444) Attaining information on HIV/AIDS Number Percent Channel Television 302 68.0 Campaigns such as WORLD AIDS Day 44 9.9 Leaflet, brochure, letter 37 8.3 Newspapers 13 2.9 Advertisement 12 2.7 Journal/ magazine 9 2.0 Training material 7 1.6 Internet 8 1.8 Radio 6 1.4 Community radio broadcasting 5 1.1 Exhibition 1 0.2 Person Health personnel (doctor, nurse, others) 250 56.3 Village health volunteer 44 9.9 Neighbour 42 9.5 Parents/ siblings 29 6.5 Classmate 28 6.3 Student 20 4.5 Social welfare worker 10 2.3 Relatives 7 1.6 Husband/ wife 7 1.6 Colleague 5 1.1 Teacher / lecturer 2 0.5 Institutions Hospital 248 55.9 Foundation 87 19.6 Health centre / Primary care unit 50 11.3 District health centre/ Provincial health centre 26 5.9 Health promotion centre 15 3.4 School 8 1.8 Municipality / local administration organization 5 1.1 Temple 3 0.7 Private clinic 2 0.5 72 "Revitalising HIV prevention in Thailand: a critical assessment" Table AD 4.7: Number and percentage of IDUs' knowledge on HIV/AIDS (n= 444) Know Did not know Questions Number Percent Number Percent 1. AIDS causes by virus resulted in 425 95.7 19 4.3 immune deficiency. 2. HIV/ AIDS could infect people through 429 96.6 15 3.4 sexual intercourse, from mother to child and blood. 3. HIV infected person could spread the 401 90.3 43 9.7 disease even the test for HIV is - ve. 4. The oral sex could not prevent HIV 306 68.9 138 31.1 infection. 5. People could get HIV/ AIDS infection 347 78.2 97 21.8 from some types mosquitoes. 6. Touch, huge and hold hand could not 335 75.5 109 24.5 transmit HIV/AIDS. 7. AIDS could transmitted when sharing 418 94.1 26 5.9 syringe among injection drug users. 8. There is no HIV/AIDS prevention 320 72.1 124 27.9 vaccine at present. 9. Appropriate self-care could help 426 95.9 18 4.1 PLWHA could live normal life and delayed showing AIDS' symptoms 10. At present, there are drugs which 392 88.3 52 11.7 could cure AIDS 11. External ejaculation could prevent 306 68.9 138 31.1 HIV/AIDS 12. HIV/AIDS could spread from male to 369 83.1 75 16.9 male or female to female 13. Having multiple sex partners are 414 93.2 30 6.8 risk for HIV infection. 14. AIDS patients might have chronic 425 95.7 19 4.3 diarrhea, common cold, loose weight, oral thrush and lymph node enlargement 15. Taking antibiotics before sexual 424 95.5 20 4.5 intercourse could prevent HIV/AIDS infection 16. Using condom at every sexual 383 86.3 61 13.7 intercourse could prevent HIV/AIDS 17. Using Addicting substance contributing 261 58.8 183 41.2 to higher risks for HIV/AIDS infection 18. Sexual intercourse through anus also 413 93.0 31 7.0 have possibility to get HIV/AIDS infection 73 "Revitalising HIV prevention in Thailand: a critical assessment" Table AD 4.8: Number and percentage of IDU's attitude on HIV/ AIDS (n= 444) Totally Totally Your Opinion Disagree Indifferent Agree disagree agree 1. Using a condom when 23 73 144 148 56 having sex reduces (5.2) (16.4) (32.4) (33.3) (12.6) pleasure. 2. You are shy to buy condom. 44 106 171 96 27 (9.9) (23.9) (38.5) (21.6) (6.1) 3. Using a condom means 58 173 92 92 29 distrust between you and (13.1) (39.0) (20.7) (20.7) (6.5) your partner. 4. Using injecting narcotic drug, 210 134 34 29 37 could not get HIV infection (47.3) (30.2) (7.7) (6.5) (8.3) 5. It is normal for men to go to 41 60 118 172 53 brothel or getting services (9.2) (13.5) (26.6) (38.7) (11.9) from sex worker. 6. Husband should use condom 28 127 45 166 78 when having sex with other (6.3) (28.6) (10.1) (37.4) (17.6) women but no need to use it with his wife. 7. Spreading of HIV/AIDS is 14 97 28 167 138 mostly caused by commercial (3.2) (21.9) (6.3) (37.6) (31.1) sex workers and men having sex with men. 8. Sexual intercourse without 14 22 22 221 165 using condom or slip off (3.2) (5.0) (5.0) (49.8) (37.2) condom could have chances to get HIV infection. 9. Looking healthy person 61 196 63 85 39 should not be HIV +. (13.7) (44.1) (14.2) (19.1) (8.8) 10. At present we should not 167 200 29 30 18 give priority to HIV/ AIDS (37.6) (45.1) (6.5) (6.8) (4.1) prevention since there are anti retroviral therapy. 11. We should not take blood 127 185 55 52 25 test before getting married (28.6) (41.7) (12.4) (11.7) (5.6) since it shows distrust. 12. Blood test should be done 18 29 25 189 183 immediately after having (4.1) (6.5) (5.6) (42.6) (41.2) risk behavior. 74 "Revitalising HIV prevention in Thailand: a critical assessment" Totally Totally Your Opinion Disagree Indifferent Agree disagree agree 13. Having sex with friend 97 227 58 43 19 will not get HIV infection. (21.9) (51.1) (13.1) (9.7) (4.3) 14. It is not necessary to use 129 238 41 28 8 condom from having sex (29.1) (53.6) (9.2) (6.3) (1.8) with friend. 15. Having many lovers, or 94 166 105 60 19 partners make one getting (21.2) (37.4) (23.7) (13.5) (4.3) acceptance from friends. 16. Having more sex partners 122 154 103 47 18 than other mean superb. (27.5) (34.7) (23.2) (10.6) (4.1) 17. Having sex is both sides 33 91 142 136 42 pleasure; therefore it is not (7.4) (20.5) (32.0) (30.6) (9.5) necessary to wait until getting married. 18. Having rewards or something 85 182 96 63 18 in return is one of a major (19.1) (41.0) (21.6) (14.2) (4.1) reason for you to have sex. 19. Having sex at young age 92 185 91 92 185 mean attractive. (20.7) (41.7) (20.5) (15.5) (1.6) 20. Shared needle with familiar 175 179 33 42 15 people will not get AIDS (39.4) (40.3) (7.4) (9.5) (3.4) 21. To live together before 19 39 187 162 162 getting married is normal. (4.3) (8.8) (42.1) (36.5) (8.3) 22. Condom should be free for 7 19 40 206 172 anyone who needed. (1.6) (4.3) (9.0) (46.4) (38.7) 23. It is difficult for you to 51 147 119 102 25 access to condom when you (11.5) (33.1) (26.8) (23.0) (5.6) want to have sexual intercourse. 24. Buying condom is a burden 73 120 90 116 42 which you should not pay for it. (16.4) (27.0) (21.0) (26.1) (9.5) 75 "Revitalising HIV prevention in Thailand: a critical assessment" Table AD 4.9: Number and percent of IDU's practice related to HIV/ AIDS risk and prevention (n= 444) Practice during the Some Never Seldom Often Usually last one year times 1. You had sex with someone 239 102 62 25 16 who is not your husband (53.8) (23.0) (14.0) (5.6) (3.6) or wife. 2. You had sex with male 295 89 38 13 9 and female sex workers (66.4) (20.0) (8.6) (2.9) (2.0) 3. You had sex with a person 350 40 27 12 15 who is the same sex as you. (78.8) (9.0) (6.1) (2.7) (3.4) 4. You used a condom when 242 69 65 25 43 you had sex with your (54.5) (15.5) (14.6) (5.6) (9.7) husband/wife. 5. You used a condom when 207 63 62 27 85 you had sex outside your (46.6) (14.2) (14.0) (6.1) (19.1) marriage 6. You used a condom when you 243 36 33 28 104 had sex with male/female (54.7) (8.1) (7.4) (6.3) (23.4) sex workers. 7. You use a condom when having 344 17 26 16 41 sex with a person of the same sex. (77.5) (3.8) (5.9) (3.6) (9.2) 8. How often do you 214 89 53 39 49 inject drugs? (48.2) (20.0) (11.9) (8.8) (11.0) 9. You share needles with others. 287 68 62 19 8 (64.6) (15.3) (14.0) (4.3) (1.8) 10. You bring a condom with 229 60 57 27 71 you each time you go out (51.6) (13.5) (12.8) (6.1) (16.0) at night 11. You go out for night life. 148 142 98 26 30 (33.3) (32.0) (22.1) (5.9) (6.8) 12. You do not change your 147 50 50 48 149 behaviour after knowing that (33.1) (11.3) (11.3) (10.8) (33.6) your colleague is HIV positive 13. You use a condom when 205 66 60 29 84 having sex with your lover. (46.2) (14.9) (13.5) (6.5) (18.9) 76 "Revitalising HIV prevention in Thailand: a critical assessment" Practice during the Some Never Seldom Often Usually last one year times 14. You have ever had an STI 398 26 12 4 4 such as Syphilis, Gonorrhoea (89.6) (5.9) (2.7) (0.9) (0.9) 15. You got treatment for an 266 61 53 19 45 STI from a reliable doctor. (59.9) (13.7) (11.9) (4.3) (10.1) 16. You used a condom when you 202 68 75 26 73 had sex with your girlfriend. (45.5) (15.3) (16.9) (5.9) (16.4) 17. During the last 12 months, 225 84 85 23 27 how often had you ever joint (50.7) (18.9) (19.1) (5.2) (6.1) any party using drug and unconsciously had sex? 18. You had sex after 240 70 78 30 26 taking a drug. (54.1) (15.8) (17.6) (6.8) (5.9) 19. You had sex with more 397 26 13 3 5 than one person at the (89.4) (5.9) (2.9) (0.7) (1.1) same time. 77 "Revitalising HIV prevention in Thailand: a critical assessment" Appendix E Table AE 5.1: Number and percentage of channels for information on HIV/AIDS of MSM (n = 639) Yes Never Channels Number Percent Number Percent Television 380 79.8 96 20.2 Advertising Cutout 252 52.9 224 47.1 Newspapers 250 52.5 226 47.5 Campaign such as WORLD AIDS Day 240 50.4 236 49.6 Leaflet, brochure, letter 223 46.8 253 53.2 Internet 216 45.4 260 54.6 Journal/ magazine 212 44.5 264 55.5 Radio 195 41.0 281 59.0 Exhibition 148 31.1 328 68.9 In-service training 85 17.9 391 82.1 Community Broadcasting 79 16.6 397 83.4 Table AE 5.2: Number and percent of channel for attaining information on HIV/ AIDS of IDU (n = 444) Yes Never Channels Number Percent Number Percent Television 345 87.8 48 12.2 Leaflet, brochure, letter 181 78.0 51 22.0 Campaign such as WORLD AIDS Day 277 70.5 116 29.5 Advertisement 255 64.9 138 35.1 Newspaper 233 59.3 160 40.7 Radio 206 52.4 187 47.6 Journal/ magazine 172 43.8 221 56.2 Exhibition 153 38.9 240 61.1 In-service training 131 33.3 262 66.7 Community radio broadcasting 95 24.2 298 75.8 Internet 70 17.8 323 82.2 78 "Revitalising HIV prevention in Thailand: a critical assessment" Table AE 5.3: Number and percentage of counselling services including sex edu- cation and information on sexually transmitted infections (STI) of MSM (n = 639) Counselling services including sex Yes Never education and information on sexually transmitted infections Number Percent Number Percent (STI) and HIV/AIDS HIV and STI prevention 142 80.2 35 19.8 Overall knowledge on HIV and STIs 139 78.5 38 21.5 Sex education 127 71.8 50 28.2 VCT and STI check up 77 43.5 100 56.5 Treatment of HIV and STIs 77 43.5 100 56.5 Table AE 5.4: Number and percentage of counselling services including sex edu- cation and information on sexually transmitted infections (STI) of IDU (n = 187) Yes Never Counselling service Number Percent Number Percent Causes of HIV and STIs 170 90.9 17 9.1 AIDS and STI prevention 168 89.8 19 10.2 Sex education 161 86.1 26 13.9 VCT and STI check up 137 73.3 50 26.7 Treatment of HIV and STI 128 68.4 59 34.6 79 "Revitalising HIV prevention in Thailand: a critical assessment" CHAPTER 3 Identifying information regarding effectiveness and cost-effectiveness of policy and strategies reorientation to mitigate the impact of HIV/ AIDS in Thailand 1. Background In Thailand in recent years, as in other developing countries, there has been an increasing impetus to justify resource allocation decisions in the health sector, especially after the introduction of the universal health insurance coverage policy in 2001.[1] The term "evidence-based decision making" was, therefore, introduced to ensure that decisions about health and health care are based on the best available knowledge. To use such an approach it is necessary to appraise what constitutes evidence in relation to health-enhancing interventions. While it is still a common practice to use data on effectiveness to justify health care resource allocation, decision makers, academics and health care professionals are becoming more interested in health economic evaluation, which is designed to guide explicit health resource allocation decisions. This is done by comparing the marginal costs and consequences of alternative health care interventions.[2] The second edition of "Disease Control Priorities in Developing Countries" hereafter "DCP2", aims to support a World Bank initiative in the late 1980s which sought informative evidence to guide policy makers in identifying cost-effective interventions for combating major health problems.[3] This is important because evidence suggests that proven effective and cost-effective interventions could save millions of lives in developing countries. However, the prioritisation of strategies for dealing with sexually transmitted infections and HIV/AIDS, which are among the highest disease burdens in Thailand and many other developing countries, appeared in chapters 17 and 18 of the DCP2 respectively, and was done with several limitations.[3] Firstly, a lack of reliable evidence regarding the effectiveness and cost-effectiveness of many potential strategies was 80 "Revitalising HIV prevention in Thailand: a critical assessment" addressed throughout the chapters. This underlines the fact that many HIV/AIDS programs have been carried out without close monitoring, and rarely incorporated well-defined control groups necessary to show the effectiveness of the intervention. In addition, the authors did not comprehensively and systematically search for evidence, which resulted in the exclusion of a number of published and unpublished literature. Secondly, the book provides policy recommendations across health care settings which raise concerns about the transferability of the findings from one setting to another. For example, the infrastructure, social and cultural issues that are specific to the Thai health care system may not be well recognised. Lastly, there were no clearly defined strategic plans for the implementation of the recommendations. Some of the recommendations such as school-based education or peer-based programs are too broad, and would need fine tuning before implementation. This project therefore aims to elaborate on the achievement of DCP2 by offering precise information about the effectiveness and cost-effective- ness of HIV/AIDS interventions that are specific to the Thai setting. This information will be crucial for guiding public investment to lessen both the short and long-term impact of HIV/AIDS in Thailand. In addition, in the context of universal access to ART, evidence from the National AIDS Spending Assessment indicates a decreasing proportion of expenditure on prevention interventions, hence the need to revitalize HIV prevention. By assessing the effectiveness and cost-effectiveness of prevention interventions, this paper provides useful data that will hopefully guide policy makers in their resource allocation decisions. 2. Objectives 1. To produce a comprehensive list of prevention interventions that are likely to be cost-effective under the Thai setting (the list will include both interventions that are currently available and not available in Thailand); 2. To identify information gaps at the national and international levels concerning the effectiveness and/or cost-effectiveness of HIV/AIDS prevention interventions in general and/or in relation to specific population groups. 81 "Revitalising HIV prevention in Thailand: a critical assessment" 3. Methodology A. Criteria for considering studies for this review The primary criteria for selection of studies was that they report the effectiveness or cost effectiveness of HIV prevention intervention(s). Nevertheless, the effectiveness of such interventions can be measured in a number of ways. Figure 3.1 shows the concept of outcome hierarchies that emphasize the difference between `proximal', `intermediate' and `distal' outcomes of HIV interventions. It can be seen that the scale of immediate measures of effectiveness of HIV intervention are characterised by the change in knowledge, attitude, perception and skills of the individuals. In many HIV programs, the changes were reported in terms of trust, caution and received assurances. Further along the continuum, these immediate changes can subsequently affect the determinants of health or health behavior, for example, condom use, abstinence or fewer partners in the case of HIV/AIDS interventions. Finally, changes in incidence or morbidity or mortality should be evaluated as the final or ultimate goal of the program. Figure 3.1: Outcome measures for HIV prevention interventions [4] As it is not always the case that changes in immediate outcomes lead to changes in intermediate and final outcomes, this study considered only the effectiveness of interventions in terms of the changes in HIV risk behaviour (intermediate outcomes) and HIV incidence (final outcomes). Furthermore, the review included only economic evaluation studies that presented the results in terms of cost per HIV infection averted, or cost per Quality-Adjusted Life Year (QALY) gained, or cost per Disability- Ad- justed Life Year (DALY) gained. B. Sources of information The review gave a higher priority to studies conducted within the Thai setting. These studies better recognise the limitations of resources and 82 "Revitalising HIV prevention in Thailand: a critical assessment" infrastructure that are specific to the health care system in Thailand, and the effectiveness of the many interventions which are determined by different context specific factors. The review of the Thai literature, therefore, included both published and unpublished (grey) literature such as research reports, Master's dissertations or Ph.D. theses, which are considered to be important in the Thai context. If the local data on the effectiveness or cost-effectiveness of interventions were available, then no further search for international evidence was made. For interventions with no supporting local evidence, a systematic search for evidence from international databases was done. Box 3.1 provides detailed information of data sources used for the review. Box 3.1: A list of databases that were used for reviewing information on the effectiveness and cost-effectiveness of HIV/AIDS prevention. Domestic databases: - Thai HTA database (http://www.db.hitap.net/); - Health Systems Research Institute database (http://www.hsri.or.th) - Journal of Health Science (http://pubnet.moph.go.th) - Thai thesis database (http://thesis.tiac.or.th) - Thai Index Medicus (http://161.200.96.194) - The Thailand Research Fund (http://www.trf.or.th) - International Health Policy Program (http://ihpp.thaigov.net) - Research Library of National Research Council of Thailand (http://www.riclib.nrct.go.th) - Raks Thai Foundation - PHAMIT - International Organization for Migration (IOM) International databases: - Pubmed; - Cochrane library: Because the Thai databases were quite small and the intent was to include as many studies as possible in the review, only `AIDS' OR `HIV' were used as keywords for searching from Thai databases. For international databases, various keywords and search strategies were used to identify the relevant papers. Table 3.1 reveals keywords and search strategies used for the Pub Med database. For Cochrane, we used `searched by topic' by selecting `HIV/AIDS'. 83 "Revitalising HIV prevention in Thailand: a critical assessment" Table 3.1: Keywords and search strategies used for Pub Med Search 1 : International evidence for cost-effectiveness analysis abstracts #7 #4 AND #6 Limits: Publication Date from 1997/01/01 to 236 2008/04/30, English #6 #4 AND Review 444 #5 #4 Limits: Publication Date from 2005/01/01 to 2008/04/30, English 513 #4 #3 AND economics 3660 #3 #1 AND #2 NOT Vertical Transmission 41452 #2 Prevention and Control OR Primary Prevention OR 722080 Intervention Studies OR Early Intervention #1 Acquired Immunodeficiency Syndrome OR HIV 220908 Search 2 : International evidence of effectiveness #8 #7 Limits: Publication Date from 1997/01/01 to 2008/04/30, English 102 #7 #5 AND Review 126 #6 #5 Limits: Publication Date from 2005/01/01 to 2008/04/30, English 373 #5 #4 NOT Vertical transmission 1288 #4 #1 AND #2 AND #3 1482 #3 Randomized Controlled Trial 302239 #2 Prevention and Control OR Primary Prevention OR Intervention 785868 Studies OR Early Intervention #1 Acquired Immunodeficiency Syndrome OR HIV 221573 Search 3 : International evidence by risk group #23 #22 Limits: Publication Date from 2005/01/01 to 2008/07/31, English 4 #22 #1 AND #2 AND #5 AND #21 5 #21 migrant worker 6549 #20 #19 Limits: Publication Date from 2005/01/01 to 2008/07/31, English 50 #19 #1 AND #2 AND #5 AND #18 163 #18 iv drug user 10036 #17 #16 Limits: Publication Date from 2005/01/01 to 2008/07/31, English 49 #16 #1 AND #2 AND #5 AND #15 130 #15 Search Male Homosexuality OR gay 19013 #14 #13 Limits: Publication Date from 2005/01/01 to 2008/07/31, English 35 #13 #1 AND #2 AND #5 AND #12 107 #12 prostitution OR "sex workers" 5017 84 "Revitalising HIV prevention in Thailand: a critical assessment" Search 3 : International evidence by risk group abstracts #11 #10Limits: Publication Date from 2005/01/01 to 2008/07/31, English 8 #10 #1 AND #2 AND #5 AND #9 18 #9 discordant* 12552 #8 #7 Limits: Publication Date from 2005/01/01 to 2008/07/31, English 22 #7 #1 AND #2 AND #5 AND #6 77 #6 breast feeding 23834 #5 #3 OR # 4 688368 #4 observation 161732 #3 Randomized Controlled Trial 305945 #2 Prevention and Control OR Primary Prevention OR Intervention Studies OR Early Intervention 903379 #1 Acquired Immunodeficiency Syndrome OR HIV 225001 C. Types of studies For the purpose of this review, studies were identified as being one of the following design types: 1. Systematic review and meta-analysis of randomised controlled trials (RCTs) 2. Systematic reviews of case controls or cohort studies 3. Case control studies 4. Cohort studies Descriptive or qualitative reports were deliberately excluded from the review. Because the above information is vulnerable to different degrees of bias, systematic review and meta-analysis of high quality RCTs are the most favourable data sources [2]. The advantages of using systematic reviews of clinical effects are two fold: First, a more precise estimate can be attained from combining the outcome data from a number of studies. Second, by using the results from studies carried out in a range of settings, assuming that these studies are sufficiently homogenous to be comparable, the estimate can then be applied to a more general patient population with different baseline risks, rather than specifically for a population group selected for an individual trial. In cases where a meta-analysis of RCT(s) was not available for particular reasons, then evidence available in a higher hierarchy, based on Table 3.2, which presents a broad agreement on the level of clinical evidence, was considered. 85 "Revitalising HIV prevention in Thailand: a critical assessment" Table 3.2: Levels of clinical evidence 1++ Systematic reviews & meta-analyses of RCTs or RCT(s) conducted in Thailand with a very low risk of bias. 1+ Systematic reviews & meta-analyses of RCTs or RCT(s) conducted internationally with a very low risk of bias. 1- Systematic reviews & meta-analyses of RCTs or RCT(s) conducted in Thailand with a high risk of bias. 1-- Systematic reviews & meta-analyses of RCTs or RCT(s) conducted internationally with a high risk of bias. 2++ Systematic reviews of case control or cohort studies conducted in Thailand with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal. 2+ Systematic reviews of case control or cohort studies conducted internationally with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal. 2- Case control or cohort studies conducted in Thailand with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal. 2-- Case control or cohort studies conducted internationally with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal Adapted from [2] Economic evaluation can be carried out using a number of different perspectives. These range from the broadest societal perspective, which includes all health and non-health care expenses paid by health providers, health insurers, patients' employers and households, to a narrow individual patient perspective, which only includes expenses paid by patients. As there is general consensus among health economists that the societal perspective is the most useful for priority setting in health care, this review compared the value for money of different HIV/AIDS preventive interventions using a societal viewpoint. However, if the economic evidence of the societal viewpoint was not provided, only the health care provider perspective was used. In addition, different monetary currencies and unit costs associated with particular resources between locations and overtime are among the most commonly cited obstacles to applying economic evaluation findings across settings. This study adjusted all cost-effectiveness ratios in a common currency, the international dollar, and at present value-2008, using the local Consumer Price Index (CPI) from the study country and Purchasing 86 "Revitalising HIV prevention in Thailand: a critical assessment" Power Parity (PPP) information from the World Bank (12.609 National currency per current international dollar). D. Scope and types of interventions Interventions under this investigation were those that showed evidence of reducing HIV incidence or risk behaviour likely to affect horizontal and vertical HIV transmission. The set of interventions was not restricted to those in practice in Thailand or funded by the Thai government. It also covered interventions provided at all levels, i.e. individuals, groups, and communities, which are likely to be beneficial in the reduction of the HIV/ AIDS epidemic worldwide. Given that a wide range of interventions were included in this study, it is vital that they have clear definitions and detailed information. This would help to ensure better understanding of each specific intervention, its delivery mode, and target population group. A lack of clarity and descriptive detail of specific interventions makes it difficult to assess and/ or compare their effectiveness and cost-effectiveness in different settings. It is also impossible to make sensible recommendations for policy decision making if there are no concise definitions for commonly implemented intervention approaches. It is necessary that this study establish or adopt a standard structure on how to define and classify interventions for the prevention of HIV/AIDS. Fortunately, a recent framework for classifying HIV prevention interventions proposed by UNAIDS serves this purpose well. The UNAIDS framework recommends that an intervention should be defined based on: i) foundation of brief description including descriptions of activities or services and commodities provided in the intervention and, when relevant, key message content included with the intervention, and ii) detail codified in quality standards namely message content, the method of delivery, target population, setting and the desirable outcomes, and its theoretical ground (see Figure 3.2). 87 "Revitalising HIV prevention in Thailand: a critical assessment" Figure 3.2: Proposed framework for establishing intervention definitions [5] The same UNAIDS report also provides guidance for classifying HIV prevention interventions. Based on its recommendations, interventions are grouped into five broad categories as follows: 1. interventions that affect knowledge, attitude and beliefs and influence psychological and social correlates of risk; 2. harm reduction interventions that lower the risk of a behaviour, but do not eliminate the behaviour; 3. biological/biomedical interventions that strive to reduce HIV infection and transmission risk; 4. mitigation of barriers to prevention and negative social outcomes of HIV infection; and 5. mitigation of biological outcomes of HIV infection.However, as the fifth category was not related to HIV prevention interventions, it was not included in the review. From the above recommendations, we provide a definition and classifica- tion of each HIV prevention intervention in Table 3.3. 88 Table 3.3: Classification and definition of HIV prevention interventions under the review Target Name of Message content (if Delivery Activities, services, commodity population/ Outcomes/ theory intervention relevant) mode setting I. Interventions affecting knowledge, attitudes and beliefs and influencing psychological and social risk correlates Abstinence Abstinence-only programs often target the social, health- Varies young people to encourage both primary family involvement and community related, and (10-24 years) abstinence (remaining a virgin) and norms, as well as individual behaviour psychological benefits who may not yet secondary abstinence (returning to by addressing multiple influences on of abstaining from have initiated abstinence after sexual activity) to knowledge, attitudes, and values. sexual activity-most sexual activity refrain from sexual activity/ Abstinence-plus program promote of them note the theoretical underpinnings include sexual abstinence as the best means potential harm of social learning theory, the health- of preventing HIV, but also encourage sexual activity belief model, cognitive-behavioural 89 condom use and other safer-sex outside marriage theory, the theory of social practices for sexually active inoculation, the culture of participants. poverty perspective, and utility maximization perspectives "Revitalising HIV prevention in Thailand: a critical assessment" Community- This program affects community-wide Varies Varies Broad Social change theory based behaviour change. In this approach, population education popular opinion leaders are trained to base (including disseminate risk reduction messages opinion to their peers, and thereby influence leader other group members to re-evaluate programs) their own HIV risk, modify their attitudes toward safer sexual practices, and change their behaviour. Target Name of Message content (if Delivery Activities, services, commodity population/ Outcomes/ theory intervention relevant) mode setting Peer The peer education intervention is a Varies: e.g. Peer Typically Varies: includes diffusion-based education model of training that supports mitigation of stigma educators, targeted to interventions that strive to affect intervention participants to develop and then and discrimination trained smaller, unique behaviour through the dynamics of deliver information to their peers. towards people living outreach populations social networks with HIV workers Life Skills- LSBE refers to an interactive process It is being adopted as Varies Young people Enhanced self-efficacy Based of teaching and learning which enables a means to empower (10-24 years) Education learners to acquire knowledge and to young people in (LSBE) develop attitudes and skills which challenging support the adoption of healthy situations. behaviour. 90 Mass media Mass communication potentially to Varies e.g. people Television, Typically large Varies: reduced HIV-related campaigns influence social norms, expectation in the community are radio, public segments of the risk behaviour, changes in social and behaviour related to HIV/AIDS at risk of HIV events population, but norms "Revitalising HIV prevention in Thailand: a critical assessment" infection through content can be sexual behaviour targeted to subpopulations Provider- All patients are offered HIV testing and e.g. Uptake of Healthcare People visiting To increase uptake of VCT and early initiated HIV consent to be tested is implied as with client-initiated HIV providers health care recruit to ART if positive, or counselling any other clinically indicated laboratory testing and facilities for any maintain low risk behavior in the and testing test; patients may opt out if they do counselling has been purpose population when detected negative (PICT) not want to be tested. hampered by many of the same factors that limit uptake of other HIV-related services, Target Name of Message content (if Delivery Activities, services, commodity population/ Outcomes/ theory intervention relevant) mode setting including stigma and discrimination, limited access to treatment, care and health services in general, as well as gender issues. School- School-based education programs, an Varies Teacher, School children Varies based aspect of information, education, and healthcare education communication, provide information to provider young people and reinforce healthy norms in a school setting. 91 Voluntary Individual or group of people are taught Causes and risk Trained Varies Varies counselling about HIV/AIDS. When HIV testing is factors of AIDS, the counsellor (with/ performed, counsellors notify their steps necessary to "Revitalising HIV prevention in Thailand: a critical assessment" without HIV clients of their HIV status and provide prevent HIV infection, and how to testing) counselling support to help them cope prevent the spread of with the outcome. This intervention the disease for those must be performed on a voluntary who have already basis. been infected with HIV Workplace- This program communicates HIV pre- Varies healthcare Varies Varies based vention messages to employees in ei- provider, education ther formal or informal settings, acts peer- (including as a role model for behaviour change, educator, prison-based and distributes and demonstrates the trainer education) correct use of condoms. Target Name of Message content Delivery Activities, services, commodity population/ Outcomes/ theory intervention (if relevant) mode setting Workplace- This program communicates HIV Varies healthcare Employee It induced changes in knowledge, based prevention messages to employees provider, attitudes, and risk behaviour. education in either formal or informal settings, peer- (including acts as a role model for behaviour educator, prison-based change, and distributes and demon- trainer education) strates the correct use of condoms. II. Harm reduction interventions that lower the risk of a behaviour, but do not eliminate the behaviour Male and This program provides free condoms - Varies, but Sexually active Decrease risk from unprotected female in readily visible and accessible sites typically free at-risk in sexual intercourse condom use through health care facilities and distribution dividuals and/or private businesses (through social in public marketing) serving populations at high distribution settings risk of STIs and HIV. Needle and This program provides a way for Most Injecting drug Decrease use of contaminated 92 - syringe those IDUs who continue to inject typically users injection equipment to safely dispose of used needles and exchange community- syringes and to obtain drug injection equipment at no cost. It provides a based "Revitalising HIV prevention in Thailand: a critical assessment" range of related prevention and care services that are vital to helping IDUs reduce their risks of acquiring and transmitting blood-borne viruses as well as maintain and improve their overall health. Needle The intervention aimed to reach all - Most Injecting drug Decreased use of contaminated social IDUs at both detoxification centres typically users injection equipment and local health institutions e.g. marketing community- drug stores, community hospitals and private clinics. In detoxification based centres, the intervention mainly consisted of health education provided by health workers. In the community, health workers or peer educators visited drug users' Target Name of Message content (if Delivery Activities, services, commodity population/ Outcomes/ theory intervention relevant) mode setting homes or places where they gathered. The Intervention included face-to- face health education, dispensing and recalling needles. Drug users could also collect materials/needles from the local hospitals or Centres for Disease Control (CDC) and from peer educators. III. Biological/biomedical interventions that strive to reduce HIV infection and transmission risk Anti- It is a combination between HIV - Primarily Infants born to Reduction in mother-to-child retroviral counselling and testing, anti-retroviral clinic-based, HIV-positive transmission and prevalence/ prophylaxis prophylaxis and breastfeeding which is mothers incidence of HIV positive infants 93 for vertical substitution. The Thai PMTCT program linked to provides free services for voluntary HIV HIV antenatal counselling and testing (VCT) for transmission services all pregnant women (approximately "Revitalising HIV prevention in Thailand: a critical assessment" 0.8 million per annum), at first antenatal visit and at 28 weeks. HIV infected pregnant women receive free antiretroviral drugs, breast milk substitutes for 12 months and counselling with their partner to test their newborn babies at 12 and 18 months, and recruit them into universal ART programs when CD4 counts indicate the necessity. Breastfeeding Require access to clean water for - Via HIV-positive Reduction in mother-to-child substitution feeding preparation distribution mothers and transmission and prevalence/ for HIV of feeding their infants incidence of HIV positive infants positive substitutes mothers Target Name of Message content Delivery Activities, services, commodity population/ Outcomes/ theory intervention (if relevant) mode setting Diagnosis The process should be confidential, - healthcare Varies Reduced prevalence of sexually and voluntary and non-coercive and provider, transmitted infections-thought to treatment include all sexual partners involved typically also reduce HIV incidence of sexually with each STI patient. clinic-based transmitted infections Drug Methadone administered orally - healthcare Injecting drug Decreased dependence on treatment as syrup is the pharmacological agent provider users/specialist injecting drugs and therefore including that is most commonly used for drug and alcohol minimize use of contaminated drug substitution treatment of opioid treatment injecting equipments dependence worldwide. There are substitution program two types of interventions. 1) treatment Methadone maintenance treatment 94 (60 mg/day or more) 2) Detoxification, the schedule is completed in 90 days. Data about HIV risk behaviour was reported for weeks one and "Revitalising HIV prevention in Thailand: a critical assessment" two of treatment while participants were stabilised on methadone (40 mg/day) and weeks five and six at the commencement of the dose taper HIV vaccine The first efficacy trial (Phase III) in - healthcare varies Reduced incidence of HIV Thailand of an HIV candidate provider infection vaccine (containing gp120 B and E subtypes) was initiated in 1999. It was conducted among injection drug users attending 17 Bangkok Metropolitan Administration (BMA) drug-treatment clinics. Eligibility criteria were: aged 20-60 years, drug injection during the previous year, being negative for HIV-1 by Target Name of Message content Delivery Activities, services, commodity population/ Outcomes/ theory intervention (if relevant) mode setting ELISA at screening and baseline. Vaccine or placebo was injected intramuscularly at months 0, 1, 6, 12, 18, 24, and 36 (36 months of follow-up). The primary end point for vaccine efficacy was HIV-1 infection. Male Male circumcision is the surgical - healthcare Males/typically Reduced biological risk of HIV circumcision removal of all or part of the foreskin provider clinic-based acquisition of the penis. Mass or The treatment consisted of - healthcare All consenting Reduced prevalence of sexually community azithromycin (1,000 mg single dose provider adults aged transmitted infections-thought 95 treatment of oral), ciprofloxacin (250 mg single 15-59 years to also reduce HIV incidence sexually dose oral) and metronidazole (2.0 g were given transmitted oral). Ciprofloxacin (FDA category C) directly infections was not given to pregnant women, observed "Revitalising HIV prevention in Thailand: a critical assessment" who instead received cefixime 400 mg treatment of oral. Metronidazole (2.0 g oral) is STI at home the recommended single-dose regimen every ten for trichomoniasis and provides months, short-term remission in 70-85% of irrespective cases of bacterial vaginosis; it is of laboratory safe in pregnancy (FDA category B). testing results Benzathine benzylpenicillin (2.4 or the presence million IU intramuscular injection) of symptoms. was given in the home to TRUST (Toluidine Red Unheated Serum Test--the syphilis screening)-positive intervention-group participants Target Name of Message content Delivery Activities, services, commodity population/ Outcomes/ theory intervention (if relevant) mode setting within 24 hr of serum collection; treatment was based on serological findings, since the administration of injections to uninfected individuals would be unacceptable. The drug regimen was given over 2 days (azithromycin and ciprofloxacin in day 1; metronidazole and intramuscular benzathine benzylpenicillin on day 2). Microbicides Microbicides are compounds - Varies, but All women were One of the important concepts in formulated as gels, films, foams, typically free advised to vaginal microbicide development is 96 suppositories, or creams and which, distribution use vaginal that it is a female-controlled when inserted into the vagina, will in public microbicides method that does not necessarily prevent male-to-female transmis settings prior to each require negotiation with a male "Revitalising HIV prevention in Thailand: a critical assessment" sion of HIV and other STIs. Nonoxynol-9, episode of sexual partner for use especially in one potential vaginal microbicide, intercourse. the context of lower power is widely used spermicide. The relationship. dosage ranged from 70 to 1,000 mg depending on the dosage form. Post- Two or more antiretroviral drugs - healthcare Healthcare Reduced incidence of HIV exposure are recommended for duration of 4 provider workers, rape infection prophylaxis weeks to reduce the likelihood of victims and HIV infection after potential exposure, others exposed either occupationally or through sexual to bio hazardous intercourse. material Target Name of Message content Delivery Activities, services, commodity population/ Outcomes/ theory intervention (if relevant) mode setting Screening Blood screening should be anonymous, - healthcare Recipients Reduction in iatrogenic blood the test result cannot be linked with provider of blood transmission of HIV through products the person whose blood has been products/and transfusion of blood/and blood and donated tested, other than by the person donated organs products organ for themselves or a counselor. Normally HIV the blood sample is given a number or code, so that the person can be contacted if their results are positive. IV. Mitigation of barriers to prevention and negative social outcomes of HIV infection Microfinance The intervention employs such - Varies, Individuals Economic empowerment. May assets as savings accounts, family individuals, and families also reduce secondary transmission microenterprises, and scholarships microfinance economically of HIV 97 to fight poverty and promote health and affected by AIDS and social functioning. For example; microcredit, loans were administered for the social "Revitalising HIV prevention in Thailand: a critical assessment" development of income generating protection, activities with a group lending model. insurance Increases in - - Legal system Legislators, A more restrictive alcohol alcohol politicians policy through supply and dem- taxes decision-makers and side interventions reduces alcohol consumption, which in turn decreases risky sexual activity. "Revitalising HIV prevention in Thailand: a critical assessment" E. Description of studies A search of Thai databases was carried out and a total of 932 abstracts were initially identified (see Figure 3.3). Of these, 890 abstracts were excluded based on our exclusion criteria namely: i) publications of the same study, ii) descriptive studies, iii) assessment of satisfaction, knowledge and attitude towards HIV/AIDS, risk behaviour and program activities (not outcomes), iv) reports of case studies, v) unit cost analysis. Of the 42 papers reviewed, only 14 were found to be relevant and included in the analysis. Of the 28 papers excluded, 25 reported only immediate outcomes of the HIV prevention programs. For example, two papers which reported the effectiveness of the distribution of condom vending machines in the communities, only used numbers of condoms sold per machine and/or customer's satisfaction as their outcome measures. [6, 7] Three other papers that evaluated drug regimens for the prevention of vertical HIV transmission were excluded because the regimen under investigation, i.e. AZT only regimens, is now not in clinical practice in Thailand. [8-10] Figure 3.3: Literature review profile of the Thai literature 98 "Revitalising HIV prevention in Thailand: a critical assessment" A total of 1392 abstracts were identified through international searches (see Figure 3.4). Of these, 1203 studies were eliminated because they were editorials, descriptive, or qualitative reports. Also excluded were a number of studies that assessed the effectiveness and cost-effectiveness of programs for the prevention of mother-to-child HIV transmission because Thai studies had already been identified. The full text of the remaining 189 studies was reviewed and 71 studies were found to be relevant and included in the analysis in the final stage. Figure 3.4: Literature review profile of the international literature 4. Results Table 3.4 Summarizes the effectiveness and cost-effectiveness of each HIV prevention intervention based on the review of domestic and interna- tional studies. It was not surprising that a much larger proportion of effec- tiveness and cost-effectiveness studies were conducted in international settings, mainly the US followed by Sub-Saharan Africa. There were more effectiveness studies than cost-effectiveness studies conducted for HIV prevention within the Thai setting (11 effectiveness studies vs. 3 cost-effectiveness studies). More effectiveness studies were identified than cost-effectiveness studies from international settings (45 effectiveness studies vs. 26 cost-effectiveness studies). Furthermore, most of the assessments focused on interventions affecting knowledge, attitudes and beliefs (48/95 or 51%), followed by biological/ biomedical interventions (28/95 or 29%), harm reduction interventions (16/95 or 17%) and, lastly, mitigation of barriers to prevention and negative social outcomes of HIV infection (3/95 or 3%). 99 Table 3.4: Summary of the effectiveness and cost-effectiveness evidence of HIV prevention interventions Effectiveness Cost-effectiveness Interventions Population Level of Incremental cost- Settings Findings Perspective Setting Comparators evidence effectiveness ratio(s) I. Interventions affecting knowledge, attitudes and beliefs and influencing psychological and social risk correlates Abstinence- Young people 1+ High-income No evidence that the programs NA NA NA NA only programs countries can reduce HIV risk. [11] Abstinence- Young people 1+ High-income It found a significantly protective NA NA NA NA plus programs countries effect on sexual risky behaviours i.e. incidence and frequency of unprotected/protected sex; number of sexual partners; increased condom use. However, no significant effect on biological outcomes i.e. incidence of STI and pregnancy. [12, 13] 100 Community- Young girls 1-- US During 3-12 months of follow-up at NA NA NA NA based a health care setting, the education intervention reduced sexual risk "Revitalising HIV prevention in Thailand: a critical assessment" behavior (e.g., vaginal sex without use of condom, giving oral sex, and alcohol and drug use before sex). [14, 15] Community- Young 1-- South Africa There was no significant NA NA NA NA based people in improvement for HIV sero-status education rural areas and sexual risk behavior after 2 years of follow-up. [16] Community- Injecting 2- Thailand Drug use and sharing injection NA NA NA NA based drug users equipment with others was not education significantly decreased after 1 month follow-up. [17] Effectiveness Cost-effectiveness Interventions Population Level of Incremental cost- Settings Findings Perspective Setting Comparators evidence effectiveness ratio(s) Community- Women living 1-- US The intervention improved HIV Societal US `do nothing' ICER is PPP$ 2,551,240 based in low income knowledge, partner communication, per HIV infection averted. education housing risk-reduction behavioral intentions, [19] developments and condom use, and decreased perceived barriers to condom use after 6-12 months follow-up. [18, 19] Community- Female sex 2+ India HIV prevalence among sex workers NA NA NA NA based inter worker (< 10%) had been lower than the vention national average (~30%). [20] (Sonagachi) Community- Men who 1+ Various The interventions were effective Societal US `do nothing' ICER is PPP$ 165,346 per based have sex in reducing unprotected sex by 35% HIV infection averted [23] education with men at follow-up intervals ranging from 4 101 (including months to 1 year. They were also opinion leader effective in increasing reported program) condom use during anal intercourse by 59 %. [21, 22] "Revitalising HIV prevention in Thailand: a critical assessment" Mass media general 2-- US The media campaign would increase Health care US `do nothing' ICER is PPP$ 87,124 per campaigns population condom use from 48 to 57%. [24] provider's HIV infection averted. [24] aged 17-45 years Peer Injecting 1-- US After 6 months of follow-up, the NA NA NA NA education drug users intervention produced a 29% greater intervention decrease in overall injection risks relative to the control (OR 0.71; 95%CI 0.52- 0.97), and a 76% decrease compared with baseline. Sexual risk behaviour and safe injection were also decreased from baseline, but they did not differ between trial arms. [25, 26] Effectiveness Cost-effectiveness Interventions Population Level of Incremental cost- Settings Findings Perspective Setting Comparators evidence effectiveness ratio(s) Peer Female sex 2+ Kenya Peer-mediated interventions were NA NA NA NA education worker associated with an increase in intervention protected sex after 5 years follow-up. Female sex workers (FSW) who received peer interventions had more consistent condom use with clients compared with unexposed FSW (86.2% vs 64.0%; adjusted odds ratio = 3.6, 95% CI = 2.1-6.1). These differences were larger among female sex workers with greater peer- intervention exposure. HIV prevalence was 25% (17/69) in 102 FSW attending > 4 peer-education sessions, compared with 34% (25/73) in those attending 1-3 sessions (P= 0.21). [27] "Revitalising HIV prevention in Thailand: a critical assessment" Peer Men who 2+ UK Scotand Peer education was less effective in NA NA NA NA education have sex with sexual behaviour change among intervention men MSM. No significant difference between control and intervention group in the proportion reporting unprotected anal intercourse (OR = 1.12, 95%CI 0.81- 1.55) and negotiated safety (OR = 1.11, 95% CI 0.79-1.57). [28-30] Peer educa- Young people 2+ Italy, US, The intervention improved neither NA NA NA NA tion interven- Kenya condom use nor number of tion sexual partners after 2 years follow-up. The percentage of Effectiveness Cost-effectiveness Interventions Population Level of Incremental cost- Settings Findings Perspective Setting Comparators evidence effectiveness ratio(s) students reporting condom use during the most recent sexual intercourse slightly decreased from 55.1% to 49.7% in intervention arm, though the decrease was not significant. The percentage of students with more than one partner was increased. [31-33] Routine Adults aged 1++ Thailand Routine provider initiated HIV Healthcare Thailand `no screening' ICER is PPP$ 22,899.16 (provider- 15-65 years screening significantly increased provider's per HIV infection averted initiated) the acceptance rate of HIV testing [34] voluntary and the number of HIV infection HIV screening detected, compared to the standard at healthcare practice of patient-initiated HIV 103 settings testing (5.59% VS 0.32%) and (23 VS 10 HIV detection within 2 months in 8/8 case and control community hospitals), respectively. [34] "Revitalising HIV prevention in Thailand: a critical assessment" School-based Young people 2- Thailand Three studies show improvements NA NA NA NA sex education in AIDS preventive behavior i.e. program decreased number of visits to night (combined clubs, decreased incidence of with life skills) watching arousal media, increased sporting activities, decreased consumption of alcohol , decreased number of sex partners, and increased condom use in the experimental group. However, these changes were not significant after 4-6 weeks of follow-up. [35-37] One study found that the sexual risk behavior was significantly improved after 4 month follow-up. [38] Effectiveness Cost-effectiveness Interventions Population Level of Incremental cost- Settings Findings Perspective Setting Comparators evidence effectiveness ratio(s) School-based Young people 1-- US, Italy, The results of meta-analysis of 12 Societal India / `standard ICERs ranged from PPP$ sex education Mexico controlled studies in the US indicated US / practice' 4,853 [41] to program that the overall mean effect size Cameroon 137,950,790 [42, 43] per for abstinent behaviour was very HIV infection averted. small (effect size=0.05, 95%CI 0.01-0.09). [39] In addition, the intervention targeted to improve sexual risk behavior did not induce change in condom use or number of sexual partners after 1-year follow-up. The only apparent benefit was a greater improvement in knowledge of HIV. [40] 104 Voluntary HIV HIV-negative 1-- Zimbabwe Highly acceptable VCT did not reduce NA NA NA NA counselling employee HIV incidence at 2-year follow-up. and testing HIV incidence was higher in the (VCT) at intensive VCT arm (mean per-site "Revitalising HIV prevention in Thailand: a critical assessment" workplace HIV incidence 1.37 per 100 person-years follow-up (PYFU) than in the standard VCT arm (mean per-site HIV incidence 0.95 per 100 PYFU), but the difference was not significant (adjusted rate ratio 1.49; 95%CI, 0.79-2.80). [44] Voluntary HIV Prison NA NA NA Societal US `no HIV ICER of offering VCT at counselling inmates at or prisons counselling prisons was PPP$ 508,651 and testing near their and testing per HIV case averted. [45] (VCT) in time of provided at Prisons release Prisons' Effectiveness Cost-effectiveness Interventions Population Level of Incremental cost- Settings Findings Perspective Setting Comparators evidence effectiveness ratio(s) Voluntary HIV Men who 1+ Various Interventions delivered at the NA NA NA NA counselling have sex with individual level were effective in and testing men reducing unprotected anal (VCT) and intercourse (UAI) by 43% OR=0.57, STD services 95% CI=0.37-0.87). These effects at both clinic were significant in both the setting and short- (median 6 months) and long- community term (median 12 months). It also setting improves sexual risk behavior: condom use with anal intercourse (OR=1.55, 95%CI 0.73-3.29), number of sex partners (OR=0.97, 95%CI 0.45-2.06), unprotected oral sex (OR=0.58, 95%CI 0.28 -1.24), incident HIV (OR=0.62, 95%CI 0.36- 105 1.06). [22] Voluntary HIV HIV sero- 2-- Zambia Proportion of reported condom use NA NA NA NA counselling discordant increased from <3% to >80% and "Revitalising HIV prevention in Thailand: a critical assessment" and testing couples remained stable through > 12 (VCT) plus STI months of follow-up. Since services and underreporting was common, HIV free condom transmission was still detected when couples had reported always using condoms. DNA sequencing confirmed that 87% of new HIV infections were acquired from spouses. [46] Workplace- Male 2++ Thailand Intensive workplace-based education NA NA NA NA based conscripts in programs for male conscripts (over education military 15 months) successfully decreased camps incidence of HIV infection by 50% during the period of two years but not statistically significant (RR 0.49, 95%CI 0.11-2.26). [47] Effectiveness Cost-effectiveness Interventions Population Level of Incremental cost- Settings Findings Perspective Setting Comparators evidence effectiveness ratio(s) Workplace- Female sex 2- Thailand Risky sexual behavior significantly NA NA NA NA based workers decreased in the intervention group education + compared to the control group after condom 1-week follow up. [48, 49] distribution Workplace- Female sex 2+ Indonesia, Interventions were effective in Health care India/ `do nothing' ICER of the mixed based workers China increasing condom use (from provider's Cameroon interventions targeted education/ 55-60% to 67-85%, p<0.01) and sex workers ranged reducing STIs among sex workers condom from PPP$ 279 to 566 per at 12 months evaluation. Prevalence distribution/ HIV infection averted. of gonorrhea fell from 26% to 4%, free STD clinic [53, 54] and Chlamydia fell from about 41 to visits 26%. [50, 51] The prevalence of HIV remained low throughout the study. [52] 106 II. Harm reduction interventions that lower the risk of a behaviour, but do not eliminate the behaviour `100% Male 2- Thailand The data suggests that increased NA NA NA NA condom conscripts condom use along with some program' decrease in the frequency of "Revitalising HIV prevention in Thailand: a critical assessment" commercial sex among military conscripts led to a marked decline in STI and also to a subsequent reduction in HIV incidence. [55] Condom use Sexually 2+ Various HIV incidence in the `always' Healthcare US `do nothing' Increase availability / (availability active (reviewed condom user group was 1.14 (95% provider's accessibility of condoms in and heterosexual evidence) CI 0.56-2.04) per 100 person-years. low HIV prevalence accessibility) The HIV incidence in `never' condom population (1.6% in men couples user group was 5.75 (95%CI 3.16- and 0.6% in women) 9.66) per 100 person-years. appears to be cost- Proportionate reduction in HIV effective with ICER ranged from PPP$ 7669 to seroconversion with condom use was 247,775 per case of HIV approximately 80%. [56] averted [42, 57] or about PPP$ 22,065 per QALY saved. [58] Effectiveness Cost-effectiveness Interventions Population Level of Incremental cost- Settings Findings Perspective Setting Comparators evidence effectiveness ratio(s) Condom use HIV sero- 2- Thailand, Condom use with regular partner NA NA NA NA and sex discordant India, reached 100% at one-month education couples Uganda follow-up visit. At three-month follow up, more than 90% of the participants reported having been able to communicate and felt more comfortable discussing AIDS with their partner, and very confident that they could refuse sex if their partner refused to use a condom (an increase from 70% at baseline, p=0.0001). [59] Introduction Female sex 2-- Kenya The introduction of female condoms No specify/ South `do nothing' ICER ranged from PPP$ of Female workers led to a small, but significant, 107 Health care Africa/ 934 to 7,863 per HIV condom increase in consistent condom use provider's Kenya infection averted [41, 53] with all partners. Adjusted odd ratio for consistent condom use after "Revitalising HIV prevention in Thailand: a critical assessment" female condom introduction was 1.7 (95% CI: 1.4 to 2.2). [60] Needle social Injecting 1-- China Needle social marketing can reduce NA NA NA NA marketing drug users risky injecting behavior and HIV transmission among injecting drug users after 12-month follow-up. Needle sharing reduced significantly from 68.4% to 35.3%. However, the number of needle-sharing partners and sharing of water was unchanged. The HIV infection rate decreased but was not statistically significant. [61] Effectiveness Cost-effectiveness Interventions Population Level of Incremental cost- Settings Findings Perspective Setting Comparators evidence effectiveness ratio(s) Needle and Injecting 1-- Canada At the 6 months follow-up, it was Societal US `do nothing' ICER is PPP$ 53,285 per syringe drug users found that more consistent use of a HIV infection averted [63] exchange supervised safer injecting facility (under (SIF) was associated with positive supervision of changes in injecting practices, medical staff) including less reuse of syringes, increased use of sterile water, cleaning of injection sites and filtering of drugs (OR 2 - 3, 95%CI 1.38 - 4.37). [62] Street Injecting 2+ Various Injecting drug users changed their Health care Ukraine `do nothing' ICER is PPP$ 309 per HIV outreach drug users baseline drug-related and sex- provider's infection averted [67] related risk behaviour. Significant 108 reductions in drug injection, multi- person reuse of syringes and needles and other injection equipment was found. The studies also showed a "Revitalising HIV prevention in Thailand: a critical assessment" significant growth in promoting entry into drug treatment and incr- easing needle disinfection. However, although there was a reduction among drug users concerning sex- related risks and an increase in condom use, the majority still practiced unsafe sex. Regarding dosage effects, the longer the exposure to outreach-based in- terventions, the greater the reductions in drug injection frequency. [64, 65] At cross border Effectiveness Cost-effectiveness Interventions Population Level of Incremental cost- Settings Findings Perspective Setting Comparators evidence effectiveness ratio(s) areas between China and Vietnam, new injectors declined 3-14% after 36-month follow-up. HIV prevalence and estimated incidence fell by approximately half at the 24-month survey and by approximately three quarters at the 36-month survey in both areas (P<0.01). [66] III. Biological/biomedical interventions that strive to reduce HIV infection and transmission risk HIV vaccine Injecting 1++ Thailand The phase III HIV vaccine trial in Not clearly Thailand `do nothing' At the assumption of 30% drug users Thailand demonstrated that the specify vaccine efficacy, the ICER vaccines are safe and well tolerated. of vaccination, HAART, 109 However, after 36-month follow and their combination up, there was no difference in were about PPP$ 265, PPP$ new HIV infection between the 2,158, and PPP$ 944 per vaccine and placebo arms (vaccine DALY averted compared "Revitalising HIV prevention in Thailand: a critical assessment" efficacy was estimated at 0.1%, 95% with the do-northing CI -30.8% to 23.8%). [68] strategy. [69] Improved STI Persons with 1+ various Improved STI treatment services Healthcare Tanzania `standard ICERs is PPP$ 916 per HIV treatment suspected significantly reduced HIV incidence. provider's /US practice' infection averted. [41] services STI The two large systematic reviews indicated odd ratios ranging from 0.58 (95%CI 0.42-0.70) to 0.77 (95%CI 0.68-0.87). [70] Male Heterosexual 1-- Various Results from the review of existing Health care South `do nothing' Male circumcision appears circumcision male (mainly observational studies demonstrated provider's Africa/ to be very cost-effective Africa) a strong association between male US in areas with high HIV circumcision and prevention of HIV, prevalence (PPP$ 1,668 especially among high-risk groups per HIV infection averted [71-73]. in areas with HIV Effectiveness Cost-effectiveness Interventions Population Level of Incremental cost- Settings Findings Perspective Setting Comparators evidence effectiveness ratio(s) Moreover, a randomized trial in prevalence of 8.4% and Uganda showed that male circumci- PPP$ 548 per HIV infection sion reduced HIV incidence in men averted in areas with HIV without behavioral disinheriting after prevalence of 25.6%). [75] 24-month follow-up. HIV incidence However, this intervention was 0.66 cases per 100 person-years is unlikely to be cost- in the intervention group and 1.33 effective in the US where cases per 100 person-years in the baseline HIV prevalence is control group (estimated efficacy of relatively lower (2%) and intervention 51%, 95% CI 16-72; homosexual and infection p=0.006). [74] from needle sharing were major causes of HIV infection. [42, 71] 110 Mass or Adults aged 1+ Rural areas in After three rounds of mass treatment Healthcare Tanzania `standard ICERs is PPP$ 694,605 per community 15-59 years Uganda with (30 months) there was no evidence provider's /US practice' HIV infection averted. [42] treatment of high rates of indicating that universal treatment of sexually HIV and STI STIs reduced new HIV infections "Revitalising HIV prevention in Thailand: a critical assessment" transmitted (rate ratio of 0.97% with 95%CI = infections 0.81 to 1.16). [76] (STI) Microbicides Female sex 1+ Various There is no evidence that nonoxynol- NA NA NA NA workers 9 protects against vaginal acquisition of HIV infection (RR 1.12, 95%CI 0.88-1.42). Nevertheless, the risk of genital lesions was significantly greater among women receiving nonoxynol-9 (RR 1.18, 95%CI 1.02- 1.36). [52] Effectiveness Cost-effectiveness Interventions Population Level of Incremental cost- Settings Findings Perspective Setting Comparators evidence effectiveness ratio(s) Post-exposure Healthcare 2+ Various No evidence suggests that offering NA NA NA NA prophylaxis workers (reviewed post-exposure prophylaxis with evidence) Zidovudine lowers the rate of HIV infection compared to `no intervention'. Please note that no studies were found that evaluated the effect of two or more antiretroviral drugs. [65, 77] Post-exposure Men and 2-- US There was not a significant difference NA NA NA NA prophylaxis women with in the proportions of sero-converters (using two a potential (85.7%) and non sero-converters antiretroviral sexual or (94.1%) who were initially prescribed drugs for 28 days and if injection antiretroviral therapy (P=.4). [78] subject drug use 111 reported exposure to having HIV in the recently had a previous 72 detectable hrs plasma HIV "Revitalising HIV prevention in Thailand: a critical assessment" RNA level, then a protease inhibitor was also offered Prevention of Pregnant 1++ Thailand A randomized clinical trial demon- Healthcare Thailand `do nothing' Combining the administra- mother- women strated that a combination of providerís tion of AZT and NVP is the to-child Zidovudine (AZT) and a single dose most cost-effective drug transmission of Nevirapine (NVP), administered option. Cost-effectiveness of HIV both to the mother during labour and ratio per averted infection to the newborn, is highly effective in of single VCT (1D) is PPP$ prevention of HIV vertical transmis- 1,938. Cost-effectiveness sion, resulting in only 2.2 (+0.6) % ratio per averted infection of children being born with HIV of double VCT (2D) is PPP$ compared to 6.9 (+1.4)% in the 4,412. [79] AZT-only arm. [79, 80] * Effectiveness Cost-effectiveness Interventions Population Level of Incremental cost- Settings Findings Perspective Setting Comparators evidence effectiveness ratio(s) Screening Blood NA NA NA Healthcare US/ `no test' HIV antibody testing for blood donations provider's Sub- donated blood is a products and Saharan cost-saving intervention in donated Africa the US [81] and very organs for HIV cost-effective in Sub- Saharan Africa (ICER PPP$ 64-870 per HIV infection averted). [41, 53] Substitution Injecting 1+ Various Follow-up interviews from one month NA NA NA NA treatment drug users to 18 to 24 months found that the intervention was associated with statistically significant reductions in illicit opioid use, injecting use and 112 sharing of injection equipment. It was also associated with reductions in multiple sex partners or exchange of sex for drugs or money, but had "Revitalising HIV prevention in Thailand: a critical assessment" little effect on condom use. The reporting period for assessment of HIV risk behavior ranged from 2 weeks to 6 months. Reductions in risk behavior relating to drug use translated into reductions in cases of HIV infection.[82-84] Using nucleic Blood 2- Thailand It was estimated that there were Healthcare Thailand `serology test ICER of providing NAT for acid test donations approximately 38 to 155 additional provider's without NAT' blood donations was PPP$ screening units of donated blood detected with 100,923 - 404,498 per (NAT) of hepatitis B and C and HIV compared hepatitis B or C or HIV volunteer to the current practice (serology detection PPP$ 36,897 - blood screening without NAT). [85] 129,181 per QALY. [85] donations Effectiveness Cost-effectiveness Interventions Population Level of Incremental cost- Settings Findings Perspective Setting Comparators evidence effectiveness ratio(s) IV. Mitigation of barriers to prevention and negative social outcomes of HIV infection Increased General NA NA NA Health care US `current ICER is PPP$ 5,484 [42] alcohol tax population provider's practice' Microfinance Community 1-- Africa The intervention did not affect HIV NA NA NA NA incidence (adjusted RR 1.06, 95% CI 0.66-1.69) or rate of unprotected sexual intercourse with a non- spousal partner (adjusted RR 0.89, 95% CI 0.66-1.19). Experience of intimate-partner violence was reduced by 55% (adjusted RR 0.45, 95% CI 0.23-0.91; adjusted risk difference -7.3%, -16.2 to 1.5).[86] 113 Microfinance female aged 2- Africa Young participants were less likely to NA NA NA NA (combined 14-35 year have unprotected sex at last with training intercourse with a non-spousal "Revitalising HIV prevention in Thailand: a critical assessment" intervention) partner (adjusted risk ratio 0.76, 95% CI 0.60-0.96) after 2 years of follow-up when compared with controls. In addition, they had higher levels of HIV-related communication (adjusted risk ratio 1.46, 95%CI 1.01-2.12) and were more likely to have accessed voluntary counseling and testing (aRR 1.64, 95% CI 1.06-2.56). [87] RR = relative risk RCT = randomised controlled trials *We did not report results from another observational study because it would not change the overall conclusion but provide weaker evidence. [88] "Revitalising HIV prevention in Thailand: a critical assessment" There were thirteen interventions where effectiveness and cost- effectiveness information were both available for the same population groups. These included: · Community-based education among MSM and women living in low income housing developments; · Improved sexually transmitted infection treatment services; · Male and female condom use; · Mass media campaign; · Mass treatment of sexually transmitted infections; · Male circumcision; · Needle and syringe exchange; · Nucleic acid test for voluntary blood donations; · Program for PMTCT - prevention of mother-to-child HIV transmission; · Provider-initiated HIV screening at health care settings; · School-based education; · Street outreach program for IDUs; · Workplace-based education for FSWs. Five of the above thirteen interventions, namely (1) male condom use, (2) street outreach program for UDUs, (3) male circumcision, (4) needle and syringe exchange, and (5) PMTCT through a combination of antiretroviral drugs and breastfeeding substitutes, showed significant benefits in reducing HIV incidence among target populations. In addition, although there was no reduction in HIV incidence, community-based education among MSM and workplace-based education for FSWs showed a reduction in HIV risk behaviour than the school-based education program. Only mass treatment of STIs showed no evidence of reducing either risk behaviour or HIV incidence in clinical studies. Economic modelling, however, indicated a range of 916 to 695,000 PPP$ per HIV infection averted. Twelve interventions had information on effectiveness but lacked cost-effectiveness evidence. These are: · Abstinence only program; · Abstinence-plus program; · Community-based education among young people, IDUs and FSWs.; · Drug substitution treatment; · HIV vaccine for IDUs. · Microbicides; 114 "Revitalising HIV prevention in Thailand: a critical assessment" · Microfinance; · Needle social marketing; · Peer education intervention; · Post-exposure prophylaxis; · Voluntary counselling and HIV testing for HIV-negative employees, MSM and HIV serodiscordant couples; · Workplace-based education among male conscripts. Overall, treatment of STIs was the only intervention that showed a significant reduction in HIV incidence. There were some indications that abstinence-plus programs, community-based education, drug substitution treatment, needle social marketing, peer education, and VCT reduced HIV risk behaviour among the target populations. However, their respective studies were not designed to assess reduction in HIV incidence. In comparison to `standard' or `current' practice, there was no evidence of better effectiveness (i.e. reduction of HIV incidence and HIV risk behaviour) for the following interventions: i) abstinence only program, ii) single ante-retroviral drug for post-exposure prophylaxis, iii) HIV vaccine for IDUs, iv) microfinance, and v) workplace-based education among male conscripts. There were four interventions where only cost-effectiveness information was available through the use of mathematical estimations. These were: · HIV vaccine for ten-year-old uninfected children; · Increased alcohol tax; · Screening blood products and donated organs; · Voluntary counselling and HIV testing for prison inmates; Notably, the cost-effectiveness of the HIV vaccine was based on the assumption that the vaccine would be available at 30% efficacy. Figure 3.5 compares the cost per HIV infection averted of each HIV prevention intervention. Cost-effectiveness ratios vary largely, ranging from 70 PPP$ per HIV infection averted for screening blood products, to 2,000,000 PPP$ per HIV infection averted for community-based education for women living in low income housing. It is likely that biological/biomedical interventions (highlighted in blue) are more cost-effective than those interventions affecting knowledge, attitudes and beliefs (highlighted in pink). 115 "Revitalising HIV prevention in Thailand: a critical assessment" $1,000,000,000 $100,000,000 Cost/HIV infection avarted $10,000,000 $1,000,000 $100,000 $10,000 $1,000 $100 $10 $1 Figure 3.5: Summary of cost-effectiveness data for HIV prevention interventions (PPP$ 2008 per HIV infection averted) Table 3.5 Summarises the findings from the reviews. It prioritises HIV prevention interventions based on effectiveness and cost-effectiveness evidence. The table presents results by target population including FSWs, IDUs, MSM, and sero-discordant couples, who are currently the major sources of HIV infection in Thailand. Interventions proven to be both effective and cost-effective for FSWs were: VCT, workplace-based education, and male and female condom use. Community-based education and improvement of STI services proved to be effective, but no evidence regarding the value for money among FSWs was found. The study found that microbicides were not effective in preventing HIV transmission amongst FSWs. Condom use was proven to be the only effective and cost-effective intervention for MSM, while VCT and improved STI treatment services demonstrated effectiveness but lacked cost-effectiveness information. Community-based education was clinically effective but not cost effective. 116 "Revitalising HIV prevention in Thailand: a critical assessment" For IDUs condom use, VCT and street outreach were shown to be both effective and cost-effective. Needle social marketing, improved STI treatment services and substitution treatment demonstrated clinical effectiveness but were not supported by economic evidence. Needle and syringe exchange under the supervision of medical staff was proven to be effective but not cost effective. Community based education; HIV vaccines and post-exposure prophylaxis were shown to be ineffective in the prevention of HIV transmission amongst IDUs. Condom use was the only intervention proven to be both effective and cost-effective for sero-discordant couples. Voluntary HIV counselling and testing, and improvement of STI treatment services were amongst the interventions proven clinically effective but no cost-effectiveness information was available. Overall, VCT and condom use were the only interventions where extensive evaluations of the effectiveness and cost-effectiveness across population groups were done. Meanwhile, improved STI treatment service was proven to be clinically effective across most target populations. However, no economic evaluation study was conducted for the intervention. It can be observed that in the information gap for 1) many interventions, including routine (provider-initiated) voluntary HIV screening at healthcare settings, introduction of female condoms, HIV vaccine, male circumcision, microbicides, and post-exposure prophylaxis, and 2) some targeted populations, namely sero-discordant couples, prison inmates, health care workers both effectiveness and cost-effectiveness studies need to be conducted to provide proper evidence to guide resource allocation decisions regarding HIV prevention and control. 117 "Revitalising HIV prevention in Thailand: a critical assessment" Table 3.5: Summary of findings by intervention and target population Interventions FSW MSM IDU SDC Preg PI HCW Young G pop I. Interventions that affect knowledge, attitude and beliefs and influence psychological and social correlates of risk Abstinence-only programs Abstinence-plus programs Community-based education Mass media campaigns Peer education Routine (provider-initiated) voluntary HIV screening at healthcare settings School-based sex education programs (combined with life skills) Voluntary HIV counselling and testing (VCT) (+ STI clinic and condom distribution) Workplace-based education (+condom distribution / free STI clinic) II. Harm reduction interventions that lower the risk of a behaviour, but do not eliminate the behaviour Condom use (availability and accessibility) Introduction of female condoms Needle and syringe exchange Needle social marketing Street outreach III.Biological/biomedical interventions that strive to reduce HIV infection and transmission risk HIV vaccine Improved STI treatment services Mass or community treatment of sexually transmitted infections Male circumcision Microbicides Post-exposure prophylaxis Prevention of mother-to-child transmission of HIV Screening blood products and donated organs for HIV Substitution treatment Using nucleic acid test screening (NAT) of volunteer blood donations IV. Mitigation of barriers to prevention and negative social outcomes of HIV infection Increased alcohol tax Microfinance Microfinance (combined with education) 118 "Revitalising HIV prevention in Thailand: a critical assessment" Abbreviations FSW - Female sex worker MSM - Men who have sex with men IDU - Injecting drug user SDC - Serodiscordant couples Preg - Pregnant women PI - Prison inmate HCW - Healthcare worker Young - People aged 10-24 years old G pop - General people The colour of effectiveness and cost-effectiveness Cost- Colours Effectiveness Description effectiveness The intervention is proven to be effective and Yes Yes cost-effective Data not The intervention is proven to be effective but Yes available no evidence regarding cost-effectiveness The intervention is proven to be effective Yes No but not cost-effective No, data not The intervention is proven to be neither No available effective nor cost-effective Data not Data not No evidence concerning effectiveness or available available cost-effectiveness of the intervention The intervention is not relevant or used for a particular target population In general, decision makers prefer to use local evidence over international information when making policy decisions. However, the study found a glaring lack of local information on the effectiveness and cost-effective- ness of HIV prevention among the groups most at risk of HIV infection in Thailand namely, young people, MSM, IDUs, FSWs, and sero-discordant couples. See Table 3.6. 119 "Revitalising HIV prevention in Thailand: a critical assessment" Table 3.6: Summary of interventions conducted for each target population Interventions Target populations Domestic studies International studies Young people - School-based education - Abstinence programs - School-based education - Community-based education - Peer education intervention Men who have sex NA - Community-based education with men - Voluntary HIV counselling and testing - Peer education intervention Injecting drug users - Community-based - Street outreach education - Drug substitution treatment - HIV vaccine - Community-based education - Needle social marketing - Needle and syringe exchange - Post-exposure prophylaxis - Peer education intervention Female sex workers - Workplace-based - Workplace-based education / education condom distribution/free STI clinic visits - Community based intervention (Sonagachi) - Microbicide - Introduction of female condom - Peer education intervention HIV sero-discordant NA - Increase condom use couples - Voluntary HIV counselling and testing/STI services/free condoms Male - Workplace-based education - Condom distribution - 100% condom program - Circumcision Prison inmates NA - HIV screening Pregnant women - Program for prevention of NA (stop the search) mother-to-child transmission Health care workers NA - Post-exposure prophylaxis General population - Provider-initiated HIV - Mass media campaign screening - Mass treatment of STI - HIV screening for blood - Community-based education donations - Microfinance - Voluntary HIV counselling and testing Infrastructure NA - Increased alcohol tax - Improvement of STI treatment services 120 "Revitalising HIV prevention in Thailand: a critical assessment" 5. Discussion and conclusion The review highlighted several limitations in using effectiveness and cost- effectiveness evidence for HIV/AIDS policy decision making or program reorientation. First, the lack of proper assessment of effectiveness and/or cost-effectiveness outcomes of many interventions poses a significant challenge in making evidence-informed health policy decisions. During the review, we found that most domestic studies evaluated the effectiveness or cost-effectiveness of interventions using measures such as knowledge, attitudes, perception, and skills. The use of such measures will severely limit the usefulness of the evaluations because they do not allow for the comparison of value for money across different types of interventions due to variation in outcome measurement. In addition, the outcomes of such measures may not be of primary interest to decision makers or health care planners in considering health resource allocation. Second, although evidence for assessing the effectiveness of interventions was found to be of high quality, a major concern was the strength of evidence used to generate information on cost-effectiveness. For example, many cost-effectiveness studies did not obtain intervention effectiveness from data sources that minimized the potential for bias such as systematic reviews or experimental studies. Rather, they obtained data from expert opinions with unconvincing assumptions.[69] Economic evaluations can be useful for guiding policy decisions only when performed correctly and reported accurately; these findings clearly depict barriers that would diminish the use of cost-effectiveness evidence to inform policy decisions. Third, given that a lot was invested in determining local information for HIV prevention, the majority of studies reporting the effectiveness and cost-effectiveness of HIV interventions were identified from international publications rather than domestic journals or grey literature (see Table 3.7). This reflects the fact that good quality studies are likely to be published in international journals. Thus, it is sensible to recommend that international databases are still major sources of information, and can be used to inform decision making about the effectiveness and cost-effective- ness of HIV prevention interventions. 121 "Revitalising HIV prevention in Thailand: a critical assessment" Table 3.7: Review profile of domestic literature Initial Review of Final Type of literature search full text inclusion Articles published in domestic journals 528 16 1 Articles published in international 111 11 5 journals Theses/dissertations 99 11 5 Research reports 24 3 2 Conference proceedings 170 1 1 Total 932 42 14 This study found that male/female condoms, street outreach programs, programs for the prevention of mother-to-child HIV transmission, improvement of STI treatment services and circumcision, were the only interventions that showed strong evidence of reducing HIV infection among target populations. The DCP2 also included these four interventions, excluding circumcision, in its recommendations for concentrated epidemic areas in the East Asia and the Pacific region. [3] [note that Thailand is now classified as a concentrated epidemic] [89] The differences between recommendations from the DCP2 and our findings are as follows: · Although it was recommended in the DCP2, lack of strong evidence proved that community-based education offers good value for money in the prevention of HIV infections in either low or high HIV prevalence settings. · There were consistent results showing that screening blood products and donated organs for HIV is very cost-effective, while there was little reference made to this intervention in the DCP2. · This study found that there was potential for interventions that aim to mitigate barriers to prevention and negative social outcomes of HIV infection such as higher alcohol tax and micro financing. These interventions should be carefully considered in the future. It is interesting to note that very limited local information was found about HIV interventions for the populations most at risk of HIV infection in Thailand. These include: IDUs, MSM, FSWs, and young people. Of the nine interventions identified from our review, only one study on an HIV vaccine 122 "Revitalising HIV prevention in Thailand: a critical assessment" for IDUs was conducted in Thailand with an usual assumption of vaccine efficacy. Moreover, HIV preventive vaccines are not available on the global market. These findings underline the urgent need to prioritize health research in resource allocation in order to assess the effectiveness and cost-effectiveness of HIV interventions that could curb infections among high risk groups. Caution should be made when applying the effectiveness and cost- effectiveness data from this study to inform policy decision making. Firstly, because many studies were conducted in various settings with target populations of different sizes, different HIV prevalence, different attitudes towards HIV/AIDS and socio-economic and cultural determinants of risk behaviours responses to interventions, these factors would greatly affect not only the effectiveness of the intervention but also its value for money. Furthermore, we would argue that this matter is rather more important because almost all preventive interventions need to be delivered on a population basis. Secondly, although we have made explicit criteria to judge whether the effectiveness studies/data are good enough to be used in decision making, there was no standard to measure the quality of cost-effectiveness studies. While we found most effectiveness studies to be of good quality st nd (mainly in the 1 or 2 hierarchy), we were unsure of the quality of data used in many of the cost-effectiveness studies. 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National AIDS Prevention and Alleviation Committee: UNGASS COUNTRY PROGRESS REPORT THAILAND. 2008. 132 "Revitalising HIV prevention in Thailand: a critical assessment" CHAPTER 4 Revitalizing HIV Prevention Interventions 1. Background 1.1 HIV epidemic situation [1] UNAIDS and WHO categorize HIV epidemics as low level, concentrated or generalized scenarios. Low-level scenarios are those with HIV prevalence levels of below 1% and where HIV has not spread to significant levels within any subpopulation group. Concentrated scenarios are those where HIV prevalence is high in one or more sub-population such as men who have sex with men, injecting drug users or sex workers and their clients, but the virus is not circulating in the general population. Generalized scenarios are those where HIV prevalence is 1% to 15% among pregnant women attending antenatal clinics. This indicates that HIV prevalence is present among the general population at sufficient levels to enable sexual networks that drive the epidemic. Finally, hyper-endemic scenarios refer to those areas where HIV prevalence exceeds 15% in the adult population driven through extensive heterosexual multiple concurrent partner relations with low and inconsistent condom use. In past years, Thailand was classified as a generalized epidemic, with prevalence among pregnant women at more than 1%. Recently, the epidemic has evolved from a generalized to a concentrated epidemic in specific population groups. High HIV prevalence of over 15% has been observed among MSM, while prevalence among pregnant women has gone [2] down to 0.8%. However, some experts in the HIV control program contend that the epidemic has not yet fully evolved to a concentrated scenario. They argue that at 0.8%, prevalence among pregnant women is marginal, and could move up to more than 1%. Thus there is no room for complacency and revitalizing HIV prevention is critical. As a starting point in revitalizing HIV prevention, it is vital to acknowledge that the situation in Thailand is a mixture of both concentrated and 133 "Revitalising HIV prevention in Thailand: a critical assessment" generalized epidemics. See Table 4.1 on HIV prevalence estimates from the annual National Sero-Sentinel Survey, every June, for rounds 13 to 24 [3] (1995 to 2006) , which are similar to other countries such as South [4] Africa, Egypt, Russia, and Papua New Guinea . The survey clearly indicates program failure in bringing down prevalence among IDUs (33%) and the continuing high prevalence among direct female sex workers (4.59%) and indirect female sex workers (2.27%). The only exception was the prevalence among pregnant women which decreased steadily to 0.87% in 2006. Table 4.1: Median HIV prevalence in specific population groups by percentage, Thailand sero-sentinels round 13 (1995) to 24 (2006) Blood Male STI FSW FSW Year Round IDU ANC donor clinics direct indirect 1995 13 0.63 37.00 2.29 8.16 NA 17.19 1996 14 0.56 43.26 1.81 8.00 27.78 10.14 1997 15 0.56 40.00 1.71 7.07 26.14 8.22 1998 16 0.39 46.88 1.53 9.30 21.13 6.74 1999 17 0.44 50.77 1.74 8.71 16.00 6.56 2000 18 0.31 47.17 1.46 5.96 18.46 5.51 2001 19 0.30 50.00 1.37 5.08 16.56 5.03 2002 20 0.24 44.91 1.39 4.76 12.34 4.07 2003 21 0.27 46.80 1.18 4.00 10.63 3.67 2004 22 0.23 42.22 1.04 5.00 7.36 4.00 2005 23 0.22 37.64 1.01 4.13 6.80 3.37 2006 24 0.29 33.33 0.87 3.39 4.59 2.27 2007 25 0.21 25.62 0.76 4.55 5.57 3.23 2008 26 0.18 48.15 0.72 3.19 4.67 2.64 Source: Bureau of Epidemiology [4] 134 "Revitalising HIV prevention in Thailand: a critical assessment" 1.2 Why HIV/AIDS matters? Table 4.2: Share of DALY loss, curative expenditure, and productivity loss in terms of premature death and absenteeism from 12 leading burden of disease, 2004 ICD Burden of DALY Curative expenditure Premature Absenteeism code diseases loss OP IP Total death OP IP OP+IP 1 A3 HIV/AIDS 19% 28% 4% 17% 35% 6% 8% 6% 2 F5 Liver cancer 8% 1% 2% 1% 10% 1% 3% 1% 3 H DM 9% 31% 4% 18% 4% 35% 9% 32% 4 J1 Depression 7% 1% 0.1% 0.4% 0% 1% 1% 1% 5 J4 Alcohol 7% 0.4% 1% 1% 1% 2% 5% 2% 6 L2 Cataracts 2% 3% 8% 6% 0% 5% 4% 5% 7 M3 IHD 7% 7% 11% 9% 6% 5% 6% 5% 8 M4 CVD 13% 4% 10% 7% 9% 4% 9% 5% 9 N1 COPD 6% 3% 5% 4% 3% 8% 6% 7% 10 O2 Cirrhosis 3% 1% 2% 1% 6% 2% 3% 2% 11 R2 Osteoarthritis 3% 7% 3% 5% 0% 5% 1% 4% 12 U Traffic accidents 15% 14% 50% 31% 26% 28% 45% 30% Total from 12 leading BOD 100% 100% 100% 100% 100% 100% 100% 100% Million Baht, except DALY 4,780,000 32,452 29,484 61,936 208,287 9,836 1,437 11,273 loss in years th Source: A report on "Investment in health sector in the 10 National Socio-Economic Development Plan 2007-2011 (2550-2554 BE)" by the Interna- [6] tional Health Policy Program Note: DM = Diabetic Mellitus, IHD = Ischemic Heart Disease, CVD = Cerebo- Vascular Disease, COPD = Chronic Obstructive Pulmonary Disease [5] A major study by the International Health Policy Program assessed the economic loss due to the top ten priority burden of diseases in Thai men and women. Among the twelve disease groups which were selected from the top ten diseases selected in men and women, Table 4.2 clearly indicates that HIV/AIDS is responsible for the highest DALY loss or 19% of total DALY loss. HIV/AIDS registered the third highest curative expenditure or 17% of total spending. HIV/AIDS was also responsible for causing the highest economic loss (35%) due to premature deaths, and the fourth highest cause of economic loss due to absenteeism (6% of total OP and IP absenteeism loss). 135 "Revitalising HIV prevention in Thailand: a critical assessment" Economic loss due to premature mortality in adults is a major policy concern for which the universal ART policy was introduced in 2003. The policy was found to be cost effective due to Thailandís capacity to produce low cost combination triple antiretroviral therapy, programmatic [6] feasibility, and the role of state and non-state actors , though ex-post [7] evidence found to be ART cost effective . This evidence supports the notion that HIV/AIDS is one of the key national health agendas. 1.3 Why revitalizing HIV prevention matters? Thailand launched a universal ART program in 2001 and today close to 150,000 individuals are on regular treatment. A National AIDS Spending [8] Assessment report indicates that the proportion of spending on treatment and care increased from 64.3% in 2000 to 84.6% 2004 while spending on prevention decreased from 18.4% in 2000 to 13% in 2004, as shown in Table 4.3. A 2008 UNGASS report indicated that spending on [9] prevention had insignificantly increased to 14.1% in 2007. The decreasing trend of prevention spending is worrisome. Table 4.3: Thailand National AIDS spending Assessment, 2000-2004 Activities 2000 2001 2002 2003 2004 1. Prevention 18.4% 21.9% 24.5% 14.7% 13.0% 2. Treatment and care components 64.3% 59.5% 66.9% 74.2% 84.6% 3. Orphans and Vulnerable Children 3.2% 3.3% 2.6% 2.3% 0.8% 4. Program cost 14.0% 15.4% 5.9% 8.8% 1.6% Total spending on HIV/AIDS, % 100% 100% 100% 100% 100% Total spending on HIV/AIDS, 2,623.3 2,571.8 3,174.2 3,549.4 4,943.3 million Baht Total spending on HIV/AIDS, 65.4 57.9 73.9 85.6 122.9 million US$ [9] Source: A National AIDS Spending Assessment report To sustain past achievements on HIV prevention, two policy concerns can be raised. Does Thailand spend enough on prevention in light of the ever increasing fiscal demand for treatment? Does Thailand spend limited resources on prevention wisely to realize value for money? This study attempts to answer the second question through a critical assessment of the performance of prevention interventions. Special focus is given to the effectiveness and cost effectiveness of prevention interven- tions, in the context of sex behaviour among young adolescents, MSM and IDUs. 136 "Revitalising HIV prevention in Thailand: a critical assessment" 1.4 Dynamic of risk behaviour in general population A report by the Commission on AIDS in Asia does not show that casual sex among the youth is a major risk factor. This is largely because of socio-cultural restrictions on women's sexual freedom. Increases in unprotected casual sex are unlikely to lead to a larger HIV epidemic in the future, as shown in Figure 4.1. A large proportion of those at a high risk of HIV infection are young, but this does not mean that large numbers of young people are at high risk of HIV infection in every country in Asia. More than 98% of young women and 90% of young men neither sell nor buy sex, and neither inject drugs. Finally, the Commission on AIDS in Asia [10] concludes that there is not a high risk of HIV infection . However, this study shows that the changing sexual behavior of young [11] people in Thailand is worrisome. The Bureau of Epidemiology of the Ministry of Public Health conducted a review of risk behaviour based on: (1) the 1996 to 2007 National Behavioural Surveillance Surveys - BSS data, and (2) trend analysis among different sub-population groups using the National Sexual Behaviour Survey (NSBS) datasets 2006, conducted by Mahidol University, Institute of Population and Social Research. Results of this assessment are highlighted below. 1. Knowledge on HIV prevention was low among adolescents in Grades 8 (14 years old) and 11 (17 years old). Less than 20% and 30% respectively had an accurate understanding of the five UNGASS HIV prevention questions. Complacency is the enemy of successes; these findings call for effective HIV learning and awareness programs among these young people who are most vulnerable to HIV infections. 2. In the general population, the average age of first sexual intercourse was 18 years among men and 20 among women. This information is vital for intervention design well before the age of sexual debut. 3. Over the last 12 years, an increasingly high proportion of students, especially from vocational schools, had sexual intercourse experiences; men had more experiences than women. Vocational school students had more sex experiences than Grade 11 students; and again men had more sex experiences than women, as shown in Figure 4.2. 137 "Revitalising HIV prevention in Thailand: a critical assessment" 4. Condom use among students when having sex with boyfriends or girlfriends was low (less than 30% in most groups). Although a slight increase over the last 12 years was observed, overall condom use levels were worrisome, as shown in Figure 4.3. 5. Consistent condom use among male workers (15 to 49 years old) and students when having sex with sex workers and non-regular partners were low, around 60% or less, though an increase was observed in 1995-2007, Figures 4.4 and 4.5. 6. Among female sex workers, consistent condom use varied by types of their partners. Condom use was lowest when having intercourse with a regular partner or spouse. Condom use was high, around 90% to 95%, when intercourse was with general and regular clients, and 80% for non-regular partners in 2007, Figure 4.6. Figure 4.1: Estimated number of annual new infections and proportion of casual sex in a typical 100-million population setting in Asia Source: Asia Commission estimate based on Asian Epidemic Model, using regional averages. 138 "Revitalising HIV prevention in Thailand: a critical assessment" Figure 4.2: Percentage of the respondents who had sexual intercourse experiences, Thailand 1995-2007 Figure 4.3: Percentage of respondents who used condoms consistently when having sex with boy/girlfriend in the past 1 year, Thailand 1995-2007 139 "Revitalising HIV prevention in Thailand: a critical assessment" Figure 4.4: The percentage of respondents who consistently used condoms when having sex with female sex workers in the past 1 year, Thailand 1995 - 2007 Figure 4.5: The percentage of respondents who consistently used condoms when having sex with non-regular partners in the past 1 year, Thailand 1995 - 2007 140 "Revitalising HIV prevention in Thailand: a critical assessment" Figure 4.6: The percentage of female sex workers who consistently use condoms when having sex with general clients in the past month, with regular clients in the past week, with regular partner/spouse in the past month, and with non-regular partners in the past month in Thailand 1995 - 2007 1.5 Dynamics of risk behaviour in MSM and IDU The annual sero-sentinel survey results alarmed policy makers over the consistent high and increasing trend of HIV prevalence among MSM and IDUs in the Bangkok Metropolitan area. HIV prevalence in MSM increased [12] from 17% in 2003 to 30% in 2007 , while among IDUs prevalence was [13] at 33.3% in 2006 . To better understand the risk behaviour of these two [14] groups, a special survey was conducted by Laohasiriwong from March to July of 2008. A sample of 639 adult MSM (over 15 years old) was identified from 4 provinces (Chonburi, Chiang Mai, Khon Kaen, and Surat Thani) using the snow ball approach. A sample of 444 adult IDUs was identified from treatment clinics and through the snow ball approach in Jana Hospital of Songkla, Drug Dependence Treatment Center in Khon Kaen, Chiang Mai, Mae Hong Son, Songkla, Pattani and Thanyarak Institute in Prathumtani. Others were identified in Baan Ozone, Baan Pakjai and IDU networks. Face to face interview ques- tionnaires, approved by the National Ethical Review Committee, were used for both groups. 141 "Revitalising HIV prevention in Thailand: a critical assessment" 1.5.1 MSM Six months prior to the survey, 42% of MSM respondents had sex with women, and 59% used condoms while having sex with women. At the last sexual intercourse, 23.5% of these MSM did not use condoms. Many of them perceived that having more sex partners than peers means being superb (40.4%), having many male lovers, or male partners makes one accepted by friends (34.1%), the outlook of being a healthy person should not be HIV+ (26.9%) and having penetrative anal sexual intercourse will not result in getting HIV/ AIDS (21.6%). A high proportion of MSM who were surveyed had inappropriate attitudes on condom use. Almost half (46.3%) believed that using condoms when having sex reduces pleasure, and one in three (34.6%) believed that using condoms means distrust between them and their partners. Close to a third (30.7%) of them believed that telling partners to use condoms is not appropriate since it shows distrust. Almost one in five (23.8%) said they were shy to buy condoms and more than half (55.2%) reasoned that buying condoms is a burden they should not pay for. However, the majority (84.7%) thought condoms should be free for those who need them. See Annex 1. Finally, during the past year, slightly more than half of MSM (56.4%) always or usually used condoms when having sex with their male partners, 38% never or seldom used condoms when having sex with male sex workers, and 32% often had sex with non-regular partners. 1.5.2 IDUs Most IDUs (70%) had never or seldom used condoms when having sex with their husband/wife, 63% never or seldom used condoms when having sex with male/female sex workers, and 61% never or seldom used condoms when having sex with their lovers and girlfriends. Only 51.8% had injected drugs during the past year, of which 19.8% often injected drugs, and 20.1% had shared needles with others. About 30% participated in a `party' of sharing needles for injecting drugs and had sex under the influence, and 30.3% had sex after injecting drugs. Not many MSM and IDUs access counselling services on sex education or sexually transmitted infections. In this study, only 27.7% of MSM and 42.1% of IDUs had received counselling services on sex education or sexually transmitted infections. 142 "Revitalising HIV prevention in Thailand: a critical assessment" In summary, this survey highlights a gloomy situation for MSM and IDUs, though their population size is not large. MSM are estimated at 0.1-0.3% of male adults between the ages of 15-49 in Thailand. Therefore there are approximately 0.53 million MSM, of which 60% (0.32 million) engaged in risky behaviour. The number of IDUs is unknown, but both groups have extremely high HIV prevalence which warrants immediate policy attention. 1.6 Thailand's expenditure on HIV/AIDS In 2007, total health expenditure in Thailand was 3,876 Baht per capita population, or US$ 115 per capita (exchange rate 33.7 Baht per US$), see Table 4.4. Table 4.4: Background data on healthcare financing, 2007 Population 64,197,000 Total Health Expenditure · per capita, Baht 3,876 · per capita, US$ 115 · % GDP 2007 3.4% Source: Estimates by the Thai working group on NASA - Thursday, January 24, 2008. Note that IHPP developed and maintained the National Health Account in a long series from 1994 to 2005. To comply with the UNGASS 2008 reporting requirements, IHPP estimated total health expenditure per capita based on the 1994 to 2005 series of National Health Account. [9] According to the UNGASS report , in 2007 total expenditure on HIV/ AIDS was 6.728 billion Thai Baht. This is equivalent to 105 Baht per capita, or 11,600 Baht per capital PLHA, given the total number of 580,000 PLHA. Total expenditure on HIV/AIDS accounted for 0.081% of GDP in 2007, or was equivalent to 2.7% of Total Health Expenditure as shown in Table 4.5. Table 4.5: Key parameters of expenditure on HIV/AIDS, 2007 Total Expenditure on HIV/AIDS, million Baht 6,728.0 Estimated Total Health Expenditure, Baht 248,852.4 Total Expenditure on HIV/AIDS, · per capita population, Baht 105 · per capita PLHA, Baht 11,600 · % GDP 0.081% · % of Total Health Expenditure 2.7% Source: Estimated by the Thai working group on NASA - Thursday, January 24, 2008 143 "Revitalising HIV prevention in Thailand: a critical assessment" With regard to sources of financing for HIV/AIDS programs in 2007, it was indicated that domestic public financing had the highest share or 82.7% of Total Expenditure on HIV/AIDS (TEA). International resources accounted for 17.3% of TEA. This finding indicates better self-reliance for HIV/AIDS program financing, and reflects the firm commitment of the Royal Thai Government to the fight against HIV. In light of the universal access to ART which was adopted by the Government in 2001, a huge share of total expenditure on HIV/AIDS (71.8%) went to care and treatmen . HIV prevention activities accounted [3] for 14.1% , and program administration, 9.7% of total spending on HIV/ AIDS (Table 4.6). Financing HIV/AIDS programs in Thailand relies mostly on domestic resources, 82.7% of total expenditure, as shown in Table 4.6. This clearly reflects the government's financial commitment and little external donor influence in program direction. This is different from countries in the Asia Pacific Region where financing HIV/AIDS programs relies solely on external donor resources, and is vulnerable to fragmentation and lack of [9] harmonization across programs and projects Table 4.6: Total Expenditure on HIV/AIDS by sources of finance and functions, current year price, 2007 Type of expenditure Domestic International Total 1. Prevention 7.3% 6.8% 14.1% 2. Care and Treatment 67.2% 4.6% 71.8% 3. Orphans and Vulnerable Children 1.4% 0.1% 1.5% 4. Program Management Administration Strengthening 5.0% 4.7% 9.7% 5. Other related work e.g. research, social services, incentive human 1.80% 1.04% 2.84% resources Total, row percent 100% 100% 100% Total, million Baht 5,563.9 1,164.1 6,728 Total, column percent 82.7% 17.3% 100.0% Source: UNGASS report [9] 144 "Revitalising HIV prevention in Thailand: a critical assessment" 1.7 Effectiveness and cost effectiveness of prevention interventions [1] A study by Teerawatananon et al assesses the effectiveness and cost-effectiveness of prevention interventions in Thailand through a review of published and unpublished grey literature. In addition, a systematic search for evidence from international databases was conducted. In this study, a total of 932 Thai abstracts were identified through search definitions, of which 890 were excluded as irrelevant. Some 42 full papers were reviewed, 28 were excluded after reading the full texts, and only 14 were included in the analysis. Additionally, a total of 1,395 international abstracts were identified through search definitions, of which 1,213 were found to be irrelevant and excluded. Overall, 182 full papers were reviewed, of which only 63 were included in the analyses. The 63 included 15 systematic reviews or meta-analysis, 17 economic evaluations, 18 randomized control trials, and 13 observational studies. Findings indicated that the interventions that showed strong evidence of reducing HIV infection among the target populations were: (1) male/ female condoms for female sex workers, (2) a street outreach program for IDUs, (3) a program for prevention of mother-to-child HIV transmission in pregnant women, (4) improvements in sexually transmitted infections treatment services and (5) male circumcision. A key finding echoed a recommendation in Disease Control Priorities in [15] Developing Countries. the lack of significant evidence indicated that community-based education for various target groups e.g. FSW, MSM, IDUs, young and general population, offer good value for money in prevention of HIV infection either in low or high HIV prevalence settings. This review found potential for interventions that aim to mitigate barriers to preven- tion and minimize the negative social outcomes of HIV infection such as increased alcohol tax, financial and in-kind support. The review further highlighted serious limitations of local evidence on the effectiveness of HIV interventions among high risk populations in Thailand such as IDUs, MSM, FSW and young people. Thus international experiences on effectiveness and cost effectiveness may not be applicable for the local Thai context and call for prioritizing local research to assess the effectiveness and cost effectiveness of prevention interventions. 145 "Revitalising HIV prevention in Thailand: a critical assessment" 2. Goal and objectives The goal of this study is to provide policy recommendations on revitalizing HIV prevention interventions in the context of universal ART and increas- ing expenditure on treatment. Based on reviews of the effectiveness and cost effectiveness of prevention interventions, this study aims to assess the coverage of these interventions among nine risk population groups: (a) FSW, (b) MSM, (c) IDUs, (d) sero-discordance couples, (e) pregnant women, (f) prison inmates, (g) healthcare workers, (h) young people, and (i) the general population. The study seeks to: (1) assess the adequacy of prevention programs in population coverage and program spending in order to scale up or maintain high coverage of proven effective and cost effective interventions, and (2) to assess the coverage of interventions proven to be ineffective and not cost effective that could be scaled down or terminated. 3. Methodologies We apply the evidence on effectiveness and cost effectiveness of HIV prevention intervention by Teerawattananon et al in chapter 3 which can be categorized into four main groups: (1) interventions proven both effective and cost-effective, (2) interventions proven effective but with no evidence on cost effectiveness, (3) interventions proven effective but not cost effective, and (4) interventions proven neither effective nor cost effective. Effectiveness and cost effectiveness of these interventions are specific to the nine different population groups. In the matrix of 25 interventions accross the nine target groups, the most recent coverage rates were selected from relevant documents, published and unpublished grey literature in the Ministry of Public Health and other small scale program/ pilot information. In-depth interviews of key informants were conducted where coverage data does not exist for the best expert estimates. Investment in different prevention interventions referred to various estimates in the National AIDS Spending Assessment. Where appropriate in the results section of IDUs, MSM, young adolescents and the general population, comments refer to reports by the Bureau of Epidemiology and a special survey by Laohasiriwong in chapter 2. 146 "Revitalising HIV prevention in Thailand: a critical assessment" 4. Results 4.1 Convention on colour Table 4.7: convention on colour Colour Description Intervention proven both effective and cost-effective Intervention proven effective but with no evidence on cost-effectiveness Intervention proven effective but not cost-effective Intervention proven neither effective nor cost-effective No evidence on effectiveness and cost-effectiveness Intervention does not match with target group Table 4.7 Aids the colour interpretation of effectiveness and cost effective- ness of interventions. This colour convention, a traffic-light system, used [1] by the study of Teerawattananon et al , will be applied throughout the rest of this report. For example, dark green refers to interventions proven to be both effective and cost-effective; and red refer to interventions proven neither effective nor cost effective. Table 4.8 shows the results of the [1] Teerawattananon et al study . [1] Note that the study by Teerawattananon et al assesses both Thai published and grey literatures from all possible sources; whereby internationally published literatures were systematically searched from Pub Med and Cochrane library. However, that study was dominated by international publications whereby local Thai evidence on the effectiveness of interventions among high risk populations such as IDUs, MSM, female sex workers and young people are very limited. 147 "Revitalising HIV prevention in Thailand: a critical assessment" Table 4.8: Summary of findings by intervention and target population Interventions FSW MSM IDU SDC Preg PI HCW Young G pop I. Interventions that affect knowledge, attitude and beliefs and influence psychological and social correlates of risk [16] Abstinence-only programs [17,18] Abstinence-plus programs [19,20,21,22,23,24,25] Community-based education [26] Mass media campaigns [27,28,29,30,31,32,33,34,35] Peer education Routine (provider-initiated) voluntary HIV screening at healthcare settings [36] School-based sex education programs (combined with life skills) [37,38,39,40,41,42] Voluntary HIV counselling and testing (VCT) (+ STI clinic and condom distribution) [43,44,45,46,47,48] Workplace-based education (+condom distribution / free STI clinic )[49,50,51,52,53,54,55,56] II. Harm reduction interventions that lower the risk of a behaviour, but do not eliminate the behaviour Condom use (availability and accessibility) [57,58,59,60,61] [44,56, 62] Introduction of female condoms [63,64] Needle and syringe exchange [65] Needle social marketing [66,67,68,69] Street outreach III. Biological/biomedical interventions that strive to reduce HIV infection and transmission risk [70,71] HIV vaccine [44, 72] Improved STI treatment services Mass or community treatment of sexually transmitted infections[45, 73] [45, 74,75,76,77,78] Male circumcision [45] Microbicides [68,79,80] Post-exposure prophylaxis Prevention of mother-to-child transmission of HIV [81,82] Screening blood products and donated organs for HIV [44,56,83] [84,85,86] Substitution treatment Using nucleic acid test screening (NAT) of volunteer blood donations [87] IV. Mitigation of barriers to prevention and negative social outcomes of HIV infection [45] Increased alcohol tax [88] Microfinance [89] Microfinance (combined with education) 148 "Revitalising HIV prevention in Thailand: a critical assessment" 4.2 Setting the scene on principles for policy recommendations The finite HIV/AIDS resources are mostly allocated to treatment and care under universal coverage launched in 2001; it is unaffordable to spend unnecessarily on the ineffective and non-cost effective interventions. Table 4.9 provides a generic principle on how we craft our policy recommenda- tions for scaling up, scaling down and termination. Table 4.9: Principle of policy recommendations A B C D Stage of Proven effective and Proven effective but no Proven Proven intervention cost effective evidence on cost- effective neither effectiveness but not cost effective nor cost effective effective 1. No policy A1 B1 C1 D1 intervention Generate evidence Lower priority, it is high Least priority, Discourage through e.g. operational priority if the HIV discourage attempts to research to assess program had introduced the attempt introduce implementation all proven effective and to initiate policy or feasibility, in order to cost effective interven- program program introduce policy and tions, as country should program implementa- invest more on preven- tion and rapid scale up tion interventions in the to highest possible light of universal ART coverage 2. Inter- A2 B2 C2 D2 ventions Develop effective Where existing program Least priority Terminate exist, but no information systems to operate with no coverage assess coveragee coverage data, we data recommend develop coverage data. Though not cost effective, it is effective and may support the implementa- tion of proven effective and cost effective intervention 3. Inter- A3 B3 C3 D3 ventions Sustain and scale up to Where existing program Scale down Terminate exist, and reach the highest operates with high unless programs coverage possible coverage coverage level, maintain convincing and reallocate data these coverage, as it is argument to resources for is available effective and may maintain effective and support the implemen- program or or cost tation of proven other ethical effective effective and cost justifications interven- effective interventions tions 149 "Revitalising HIV prevention in Thailand: a critical assessment" The matrix presents the interventions in four groups by level of evidence of effectiveness and cost effectiveness using colour conventions in four columns (A. dark green, B. light green, C. yellow and D. red colour). It also presents three stages of interventions in three rows: (1) no policy or program interventions; (2) interventions exist but no coverage data; and (3) interventions exist and coverage data is available. From an understanding of this matrix, we developed a generic principle for recommendations. In the matrix, there are 12 cells of possible recommendations. Where interventions are proven to be effective and cost effective these fall in the "dark green column." If there is no policy intervention (Box A1), it is recommended to generate evidence through operational research to assess programmatic and implementation feasibility and socio-cultural acceptability, in order to introduce policy and program implementation and rapid scale up to the highest possible coverage. From interventions in Box A2, it is advisable to rapidly install information systems in order to verify the coverage rate which facilitates program performance assessment. Likewise, in Box A3 where interventions exist, it is recommended to sustain the current high coverage or to scale up to reach the highest possible coverage. Program barriers should be identified and overcome to reach the highest possible coverage. Interpretation for the "red colour column" where interventions are proven neither effective nor cost effective indicates it is advisable to terminate these programs, or not to initiate. Financial resources and programmatic efforts should be given to interventions in the "dark green" and "light green" groups. In the "light green column" where interventions are proven effective, but there is no evidence on cost effectiveness, we recommend to initiate a program if there is none, or to scale up these interventions to reach a high coverage level. This is because investment in prevention interventions is small, 14.1% of total spending on HIV/AIDS (see Table 4.6), with a decreasing trend in terms of proportion of total spending on HIV/AIDS as a result of scaling up universal ART. Another argument in favour of spending on more on prevention interventions classified as light green: HIV/AIDS is consistently the top first burden of disease in terms of Disable [90] Adjusted Life Year-DALY loss in 1999 and 2004 , see also Table 4.3. 150 "Revitalising HIV prevention in Thailand: a critical assessment" Based on these arguments, we tend to recommend in favour of interven- tions which fall under the "light green category" to scale up and reach high coverage instead of scaling down; while efforts should be made to uncover the cost effectiveness of these interventions. Compared to "light green category", we tend to not favour scaling up interventions which fall under the "yellow colour category". This is because though effective, it is not cost effective or efficient to do so. Programmatic efforts should be given to "dark green" and "light green" categories. 4.3 Results of critical assessment [1] With reference to Teerawattananon et al , Table 4.9 is the main result of our assessment of population coverage for all current prevention interventions which are relevant to the nine population groups. Table 4.10 is self-explanatory; there are 25 interventions under four clusters for nine population groups. In addition to the Green, Yellow and Red traffic light convention, the white represents interventions that do not have evidence on effectiveness and cost effectiveness while the grey refers to interventions not applicable to that specific population. Based on the matrix in Table 4.10 we produced nine tables (Table 4.11 to 4.19), one for each population group, where specific recommendations can be made. 151 Table 4.10: Existing prevention activities and coverage by risk groups, according to gradient of effectiveness and cost-effectiveness of HIV prevention intervention A B C D E F G H I Sero- Young Female sex Pregnant Prison Healthcare General Interventions MSM IDU Discordant people workers women inmate Workers population couples (10-24 yrs) I. Interventions that affect knowledge, attitude and beliefs and influence psychological and social correlates of risk 1. Abstinence-only No policy, programs but some small a project 2. Abstinence-plus No policy, but programs b some debates are discussed c 3. Community-based 100% Activities are No data at Some Similar to education coverage for provided by national activities Young Pop 152 direct FSW TUC+MSM level, but are provided in Bangkok some by health consortium, h only. There small scale centres its coverage were small projects are but data of about 6.25% "Revitalising HIV prevention in Thailand: a critical assessment" scale project available and coverage is of target its coverage in some f unavailable. d group was about provinces In addition, 50% of target (estimated g GF RCC group 75,046 direct round e FSW) 1 has a plan All projects for many get govern- projects ment budget support 4. Mass media Sporadic campaigns activities by government j or GF but no coverage data A B C D E F G H I Sero- Young Female sex Pregnant Prison Healthcare General Interventions MSM IDU Discordant people workers women inmate Workers population couples (10-24 yrs) 5. Peer education Peer Activities are Peer In 2006 group- provided by group- reported for education TUC+MSM activity in 465 students T for direct consortium, every year, in 16 schools g sex workers its coverage since 2004 with about 6.25% community of target f based group education d, [51], 6. School-based sex Coverage education program 40.5 % of k (combined with life target school skills) In addition, 153 GF RCC round 1 2008 has a plan for many projects "Revitalising HIV prevention in Thailand: a critical assessment" 7. Routine No policy on No policy on No policy on (provider-initiated) PICT yet for PICT yet for PICT yet for voluntary HIV any group any group any group screening at healthcare settings (PICT) 8. Voluntary HIV Coverage No coverage Activities to At initial 99.1% of National No data on No data on counselling and data data, stigma educate IDUs phase of pregnancies policy of Dept VCT for this VCT for this testing (VCT) is incomplete:- is a major and inmate in policy covered by of Correction group group 100% barrier to prisons, no implement- VCT (2007) to provide Current policy Current policy Note: VCT services coverage for VCT. regular ation, a compre- on free access on free access in 2008 was the Direct Therefore number of 257,457 FSW in A B C D E F G H I Sero- Young Female sex Pregnant Prison Healthcare General Interventions MSM IDU Discordant people workers women inmate Workers population couples (10-24 yrs) cases l but did have Bangkok and coverage coverage data problems hensive VCT, to VCT by any to VCT by any breakdown data some brothels should be low Coverage was encountered, provision of individual individual who got the in Chiang Mai d 0.9 % of the no data on condom, walk in and walk in and services These project in coverage education, request for request for activities got Bangkok m treatment and VCT VCT financial care for prison support from inmate but no government coverage data n 9. Workplace-based Doubtful ASO Thailand education systematic was national (+condom policy implemented distribution/ interventions, since 2000, free STD clinic no coverage with 10% 154 visits) data Safe sex coverage for education in employees. some Condom o provinces vending "Revitalising HIV prevention in Thailand: a critical assessment" but no machines in coverage data many places p II. Harm reduction interventions that lower the risk of a behaviour, but do not eliminate the behaviour 10. Condom use Clear Clear Clear Clear Clear Clear 10.1 Condom government government government government government government provided by policy on free policy on free policy on free policy on free policy on free policy on free government condom condom condom condom condom condom distribution, distribution, distribution, distribution, distribution, distribution now 100 % but has not be but has not but has not but has not but has not coverage for the first been the first been the first been the first been the first d, p priority as FSW, priority as priority as FSW priority as FSW Direct FSW priority as MSM most FSW. IDU, but and possible and possible FSW accesses by may access by access by access by self-purchase self-purchase self-purchase self-purchase A B C D E F G H I Sero- Young Female sex Pregnant Prison Healthcare General Interventions MSM IDU Discordant people workers women inmate Workers population couples (10-24 yrs) 10.2 Condom use rate 96.2 % with Condom use Condom use No coverage Condom use Condom use k f clients rate with men rate was 35% k data. When rate 60-70% rate 50.9% 89.9% but but another SDC is when have or adult men with women report showed identified, sex with FSW, and women m 76.5 % k, 48% advice to 10-50 % with having sex but recently practice safe boy/girl- with partner k, q survey sex provided, friend 60% for Thai showed condom use men having lower rate of from self- sex with FSW q p condom use, purchase with men 78.5%, with women q 155 52.7% 11. Introduction of No policy, an female condom introduction "Revitalising HIV prevention in Thailand: a critical assessment" for optional use, promoted by UNFPA with GF support 12. Needle and No policy syringe exchange 13. Needle social No policy marketing 14. Street outreach Small scale pilot projects g A B C D E F G H I Sero- Young Female sex Pregnant Prison Healthcare General Interventions MSM IDU Discordant people workers women inmate Workers population couples (10-24 yrs) III. Biological/biomedical interventions that strive to reduce HIV infection and transmission risk 15. HIV vaccine In clinical trial phase 3 16. Improved STI No data, See No data, See No data, See No data, See No data, See No data, See treatment services comments in comments in comments in comments in comments in comments in Annex 2 Annex 2 Annex 2 Annex 2 Annex 2 Annex 2 17. Mass or No policy community treatment of STI 18. Male circumcision No policy 156 19. Microbicides No policy 20. Post-exposure No policy Policy to "Revitalising HIV prevention in Thailand: a critical assessment" prophylaxis provide one month ART to health personnel exposed to HIV for occupational r safety 21. PMTCT 95.90 % k coverage A B C D E F G H I Sero- Young Female sex Pregnant Prison Healthcare General Interventions MSM IDU Discordant people workers women inmate Workers population couples (10-24 yrs) 22. Screening blood Policy to screen products and HIV antibody donated and antigen and Hep B-C organ for HIV were well in place and funded, In 2008, coverage 99.79 % k 23. Substitution Application of treatment Methadone maintenance 100% coverage in public 157 g services 24. Using nucleic No policy but acid test screening available for (NAT) of volunteer affordable "Revitalising HIV prevention in Thailand: a critical assessment" blood donations patient (1,500 s units/day) IV. Mitigation of barriers to prevention and negative social outcomes of HIV infection 25. Increased Current alcohol tax advocated for the national policy. The trend of having sex after alcohol consumption is increasing, with 39.80 % condom used rate m A B C D E F G H I Sero- Young Female sex Pregnant Prison Healthcare General Interventions MSM IDU Discordant people workers women inmate Workers population couples (10-24 yrs) 26. Microfinance No policy and not applicable. 27. Microfinance No policy combined with and not education applicable. 158 "Revitalising HIV prevention in Thailand: a critical assessment" Footnotes for Table 4.10 a Thailand is not a recipient of the PEPFAR grant. However, there are some small scale projects initiated by individual interest e.g. abstinence advocacy project of "Rak Neuan Sagnuan Tau" led by a former senator; Rabiabrat Pomgpanich. b Abstinence and encourage condom use and other safer sex practice for sexually active participants. c Nevertheless, some debates are being discussed among different groups (e.g. MOPH vs MOE) about the right to encourage condom use. d Information is from the interview of Ms. Vipada Maharattanaviroj, STIs cluster, Bureau of AIDS, TB, and STIs, Department of Disease Control, Ministry of Public Health. There are small scale projects of community-based education and peer groups in some provinces, especially the upper North and East of Thailand; i.e. Chiang Mai, Phrae, Lam pang, Chon Buri. e This is survey data in 2001 using geographical mapping. Source of data is the website of STIs Cluster, Department of Disease Control, Ministry of Public Health http://www3.easywebtime.com/aids_stis/statvd2.html access on 12 January 2009. 159 f TUC and MSM Consortium estimated 0.01-0.03% of male adults, around 0.53 million, were MSM, of which 60% had risk behaviour, 0.32 million. The consortium provided activities on community-base education to 20,000 individuals. Therefore, the coverage was 6.25% (20,000/320,000=0.0625). "Revitalising HIV prevention in Thailand: a critical assessment" g Refer to the report of the study of AIDS prevention and alleviation during 2002 - 2006 the Bureau of AIDS, TB and STIs, Department of Disease Control, Ministry of Public Health, activities for IDU groups are (1) community-based education for harm reduction and HIV/AIDS and Peer group activities since 2004 to 2005, (2) incorporate HIV/AIDS Education in Exchange needing program for 9 villages in Amphur Maechan, Chiang Rai Province and ARKA hill tribe in the North, (3) small scale project on street outreach for IDU groups organized by Thanyarak Institute and all 8 regional Addiction Treatment Centres and (4) Methadone replacement Program throughout the country under the Universal Health Care Coverage Program, 100% coverage. However, this is available only 147 public hospitals. h Information is from Key Informant interview. KI is Mr.Sorakij Bhakeechip, Director of AIDS Management Fund, the National Health Security Office (NHSO). NHSO provided financial support, 37.50 baht per capita, to the local government unit in order to support health facilities to conduct community-based education program. Nevertheless, the amount of financial support (37.50 baht per capita) is for all diseases. Assuming that some amount would be used for community based education of HIV/AIDS. i Refer to the working group of AIDS project RCC Round 1 2008, the summary report of the first meeting for the Coordinating and Development of AIDS Project of Sub Recipients (SRs) in 2009, Principle Recipient office (PR), Department of Disease Control, Ministry of Public Health, there is a plan for an implementation of training project aiming to develop good practice of students and school model or so called "Learning Resource". It has been implemented in 2008 only 1 school each province, 43 provinces out of 76 provinces. In addition, youth network in school will be established. PATH and BATS are the main responsible unit for these projects and get support from GF. The same projects will be applied for general population as well. j Information is from Key Informant interview. KIs are Dr.Cheewanan Lertpiriyasuwat and Dr. Petchsri Siriniran, Department of Disease Control, Ministry of Public Health. There are 4 campaigns in each year supported from different sources i.e. government budget and GF. For example mass media campaign on the World AIDS day, Valentine 's Day and the New Year. There are other sporadic projects as the National media via TV and posters in several circumstances e.g. (1)"Yeud Ok Pok 160 To o n g", encouraging condom use, supported from GF 20 Million baht per year, (2) "Kui Rak Puerd Jai, §ÿ ¬ -- ° ªî ¥ ,,®", sincere talk among lovers", for the family life education and counselling and (3) "Vending machine for condom, °ß¡"ÿ߬"ß,". k Coverage data is from the UNGASS country progress report 2008: Thailand, reporting period: January 2006 - December "Revitalising HIV prevention in Thailand: a critical assessment" 2007. There are three patterns of school based education which are (1) at least 5 hours per year inserted in the subject, (2) at least 10 hour on life skills and sex education and at least 16 hours intensive class on sex education. l Total annual VCT services in 2008 was 257,457 cases (73% was NHSO service, 15 % was SSO service, and 12% was CSMBS, and 6 % was other services) There is no breakdown who are these VCT subpopulation, except pregnancy as it was already reported in the PMTCT system. This data was retrieved from the NHSO routine report (AIDS Management Fund, National AIDS Program Report 2008, NHSO) which was likely to be under-report. These figures were the public services, not included private sector. m Bang-on Thepthien and Parinda Tasee. 2008 Behavioral related to HIV infection among drug user in 4 years round Bangkok Metropolitan. Journal of Public Health and Development. Vol.6 No. 1. n Information is an interview of Dr.Weerakit Hanpharipan, AIDS Cluster, Medical Correctional Institution, Department of Corrections, Ministry of Justice. There is more information that about 506 prison inmate volunteered to get VCT and HIV testing; reported HIV positive (6.5 %). o Some safe sex education programmes for FSW at the work places in Bangkok. For example 14 night clubs (about 2,000 workers), 13 KARAOKE places, public parks in BKK (e.g. Silom, Klonglord, Wang Saranrom). p Information from the interview of Dr.Cheewanan Lertpiriyasuwat, AIDS cluster, Bureau of AIDS, TB, and STIs, Department of Disease Control, Ministry of Public Health. ASO is "AIDS-response Standard Organization". q Surveyed by Dr. Wongsa Laohasiriwong, CDP-Health HIV/AIDS r US.CDC is concerned that appropriate post-exposure management is an important element of workplace safety. Reference is made to Adelisa LP, Denise M C, Lisa AG, Walid H, Clara SR. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR Recomm Rep 2001;50 (RR-11):1-52. Refer to Policy and guidance: Technical Policies of the UNAIDS Programme by UNAIDS 161 2008, it recommends PEP in comprehensive prevention package which emphasizes primary prevention, even HIV-PEP was proved that is not 100% effective. s Laboratory Centre of Thai Red Cross, Thailand. No government policy to provide NAT but voluntary NAT testing in blood use "Revitalising HIV prevention in Thailand: a critical assessment" paid by patient is available (1,500 units/day). Therefore, in fact, only patients in private hospitals could access to NAT. T Refer to the report of the study of AIDS prevention and alleviation during 2002 - 2006. Bureau of AIDS, TB and STIs, Department of Disease Control, Ministry of Public Health, activities for young group are 19 training course including peer group educational in every year since 2004, campaign, counselling services. "Revitalising HIV prevention in Thailand: a critical assessment" 4.4 Status of prevention interventions and policy recommendations for nine population groups 4.4.1 Female Sex Workers Table 4.11: Summary of current interventions, coverage and recommendations for Female Sex Workers Effective Proven effective but no Neither Coverage of Proven effective and cost but not evidence on cost- effective nor intervention effective cost effectiveness cost effective effective No policy Female condom use is not No policy to intervention a policy. introduce microbicide, We recommend evaluation but it is in the of programs in UNFPA sites study process and conduct operational for policy research to test if female recommend- condoms are acceptable, ation assess program feasibility Recommend- in the Thai context ation: Do not initiate Interventions 1.No systematic intervention exist, but on workplace education and no coverage peer group education, and no data coverage data Recommend to introduce clear policy interventions, rapid scale up and develop coverage data 2.No coverage data on the existing STI treatment services Recommend to improve information on coverage and improve user friendly STI treatment services Interventions 1. 100% free condom High coverage of exist, and distribution in direct community based coverage data FSW, 96.2% condom use education for FSW in is available with clients BKK, small scale pilots in other provinces Recommend to adequately fund and sustain program Recommendation: coverage rapid scaling up community based 2. 100% coverage of VCT education program for for FSW in Bangkok, few FSW sites in other provinces. Recommend to urgently scaling up to national coverage 162 "Revitalising HIV prevention in Thailand: a critical assessment" Female sex workers (FSW) are most vulnerable to infection, and require special attention and continued efforts of effective interventions. Of the interventions under the "dark green" banner; female condom use was not a policy, for which operational research to assess its applicability for Thai context is urgently required as an alternative to male condoms when clients refuse to use condoms. Workplace education, peer education and the existing STI treatment services are not systematically fostered without coverage data. This requires a major review and effective and wide coverage of workplace education programmes and friendly services. Free condom distribution and high level of use by clients must be sustained at the highest level possible. Wide coverage of quality VCT for FSW is recommended. Interventions under "light green" banners: as a result of public sector reform a few years ago, STI treatment services were transferred from the STD Clinic under the Provincial Health Office to the Provincial Hospital Obstetric Gynaecology Department. The transfer was based simply on the grounds that the Provincial Health Office is an administrative arm and should not provide clinical services. This is a major negative impact, as STD clinics not only provide health checkups but were actively involved in the past few decades on prevention, education of sex workers, peer education, trust partnership building with brothel owners in ensuring a high level of condom use. Staffs in the Obstetric Gynaecology Department did not have such skills, partnership and management with owners, managers of brothels and other indirect sex establishments. STI treatments for FSW in provincial hospitals do not provide adequate barri- ers to prevent exposure of FSW to general patients. STI service is therefore not carried out in a user friendly manner. STI service requires major revisiting and program leadership to solve the protracted problems. Microbicide, is an intervention in the study for policy recommendation. During the time of the investigation in this study, it was found to be neither effective nor cost-effective should not be initiated which distracts program focuses, until the study will prove effectiveness and/or cost-effectiveness. 163 "Revitalising HIV prevention in Thailand: a critical assessment" 4.4.2 MSM Table 4.12: Summary of current interventions, coverage and recommendations for MSM Neither Coverage Proven effective but no Effective but Proven effective effective of inter- evidence on cost- not cost and cost effective nor cost vention effectiveness effective effective No policy Very low inter- coverage vention of peer education 6.25% Recom- mendation: this is not high prior- ity for MSM program interven- tions Interven- 1. Priority group. No coverage data of VCT tions exist, MSM most due to stigmatization but no accesses condoms Recommend: minimize coverage by out of pocket stigmatization and data payment. develop reporting Recommend to systems provide more free condom distribu- tion, create awareness for sustaining high coverage 2.No coverage data on the existing STI treatment services Recommend to improve informa- tion on coverage and improve user friendly STI treat ment services Interven- Very low coverage of tions exist, community-based and education 6.25% coverage Recommendation: data is this is not a high available priority for MSM program interventions 164 "Revitalising HIV prevention in Thailand: a critical assessment" MSM are not covered by sero-sentinel surveys despite their high HIV preva- lence. Surveys among MSMs by Rainbow Sky Association of Thailand (RSAT or Fah Si Roong) show consistent increase in HIV prevalence from 17% in 2004 to 28.8% in 2005, and 30.2% in 2007. The 2008 survey is expected to show even higher prevalence. In Table 4.11, interventions under the "dark green" banner such as free distribution of condoms to MSM are under a policy vacuum. Though MSM [14] access condoms through self-purchasing, evidence from surveys shows very low rate of condom use. An evidence informed policy for effective condom distribution and use advocates through MSM peer groups and NGOs should be tested, reviewed, and advocated. However, the major barriers are stigmatization and difficulty of reach, with skilful health work- ers in the localities where they live and work; they may have comparative advantages to overcome these barriers. For interventions under the "light green" banner, there is no coverage data on VCT services for MSM, but it is low due to stigma as confirmed by [14] surveys in this group . It is recommended that the social stigma barriers must be minimized to accommodate better access to VCT services. Access to and use of STI treatment services is a cross cutting problem across the whole spectrum of clients who may use it, as discussed in the female sex workers above on negative outcomes of public sector reform and termination of STD clinics in the Provincial Health Offices. Similar recommendations are made. For interventions under the "yellow" banner, the low coverage of commu- nity based education does not matter as it was proven not to be cost effective; this intervention should be given low priority. For interventions under the "red" banner, the review reported no effective- ness and cost-effectiveness. These interventions should not be provided if there is no proof for effective and/or cost-effectiveness. 165 "Revitalising HIV prevention in Thailand: a critical assessment" 4.4.3 IDUs Table 4.13: Summary of current interventions, coverage and recommendations for IDUs Effective Proven effective but no Neither Coverage of Proven effective and cost but not evidence on cost- effective nor intervention effective cost effectiveness cost effective effective No policy 1. priority group. MSM most No policy on needle 1. No HIV intervention accesses condoms by OOP social marketing vaccine , but in payment. the clinical trial Recommendation: IDU most accesses condoms phase 3 though no evidence if by OOP it is cost effective, it is 2. No policy on Recommend to provide more effective and should post-exposure free condom create aware- have a clear policy but prophylaxis ness in order to reach high requires extraordinary Recommend to coverage strong leadership in discourage the light of "cracking 2.No policy on needle and these policy down drug". syringe exchange interventions Recommend to stay as is, this is least priority to do Interventions 1.Small scale pilot project on exist, but no street outreach supported by coverage data GF, no coverage data Strongly recommend to rapidly scale up 2.No coverage data on the existing STI treatment services Recommend to improve information on coverage and improve user friendly STI treatment services Interventions VCT project supported by Methadone Small scale exist, and GF, low coverage at 0.9% substitution project of coverage data treatment, high community- Strongly recommend to is available coverage at public based rapidly scale up clinics education, with 50% Recommend to sustain coverage of the program target group Recommend to terminate this interven- tion 166 "Revitalising HIV prevention in Thailand: a critical assessment" For interventions under the "dark green" banner in Table 4.13, it is unacceptable that effective and cost effective interventions such as free distribution of condoms and needle syringe exchange to IDUs with very high HIV prevalence are not endorsed by policy. However, reaching this group is a major programmatic barrier, as the current government policy against "drugs" drives all IDU movement under-ground. Distribution of condoms through peer groups and NGOs is one of the possible solutions. Street outreach has yet to be scaled up and develop information on coverage rates. VCT services are poorly performed with an extreme low coverage rate and should be rapidly scaled up. As for interventions under the "light green" banner, it is not unexpected as there is no government policy on needle social marketing to prevent sharing of syringes and needles, as it contradicts with the policy on "drugs." We argue that it is effective, though there is no evidence if it is cost effective; it is one of a few interventions available among IDUs to prevent sharing of injecting implements. A pilot of integrated different interventions in one setting of social marketing of needles and syringes, such as condom distribution, VCT and STI treatment, delivered by IDU peer groups or NGOs would be an innovation and overcome various barriers. Interventions that fall under the "red" banner, there is no policy on post- exposure prophylaxis and must wait for the study results if it can be proven for effectiveness or cost-effectiveness in the future. One should not initiate these ineffective and non-cost effective interventions. Community based education for IDU groups should be replaced by integrated social marketing of needles, syringes and provide VCT and STI treatment services. 167 "Revitalising HIV prevention in Thailand: a critical assessment" 4.4.4 Sero-Discordance Couple Table 4.14: Summary of current interventions, coverage and recommendations for Sero- Discordance Couple Effective Proven effective but no Neither Coverage of Proven effective and cost but not evidence on cost- effective nor intervention effective cost effectiveness cost effective effective No policy Priority group. They mostly intervention access condoms by OOP payment. Interven- No coverage data on the Initial phase of VCT tions exist, existing STI treatment implementation, no but no services coverage data coverage Recommend to improve Recommend to scale data information on coverage and up the program and improve user friendly STI improve information treatment services on coverage Interventions exist, and coverage data is available Under the "dark green" banner in Table 4.14, MSM who are the priority group mainly accesses condoms by out of pocket payments. We recommend that a policy should be established regarding not only stand-alone effective condom distribution, but providing a more comprehensive approach integrating condom distribution with VCT services and STI treatment where sero-discordant couples are identified. Psycho-social dimensions and issues on HIV disclosure between discordant couples should be well understood through qualitative research to inform policy and guide effective program design. 168 "Revitalising HIV prevention in Thailand: a critical assessment" 4.4.5 Pregnant Women Table 4.15: Summary of current interventions, coverage and recommendations for Pregnant women Effective Proven effective but no Neither Coverage of Proven effective and cost but not evidence on cost- effective nor intervention effective cost effectiveness cost effective effective No policy No policy on PICT for intervention pregnant women Recommend to formulate national policy and clearly spell out and rapidly scale up in order to reach high coverage Interventions exist, but no coverage data Interventions 1. Effective VCT with high exist, and coverage coverage 2. Effective PMTCT with high data is coverage available Strongly recommend to sustain high coverage and program achievement HIV vertical transmission prevention among pregnant women through the PMTCT program is a success story with high coverage. There are several enabling factors: · High ANC coverage, 98% in 2000-2006, high level of skilled attendant at delivery, 97% in 2000-2006, and high level of [91] institutional care, 97% in 2000-2006 . · Strong MOPH policy commitment, including full support of free breast milk substitutions for 18 months to babies born by PMTCT and good information systems. · Simple programmatic design: ART delivery to pregnant women and new born babies, In Table 4.15, interventions under the "dark green" banners such as VCT with high coverage, PMTCT with very high coverage were fully implemented. As a result, in the 14 provinces with good monitoring systems of the out- comes of PMTCT, infection rates were constant at 6.4% between 2001 and [10] 2004, and a declined sharply to 1.3% in 2006 . 169 "Revitalising HIV prevention in Thailand: a critical assessment" Under the "dark green" banner, Provider Initiated Counselling and Testing (PICT) was effective and cost effective for pregnancies, but there was no PICT policy for clients in ANC. In light of high coverage of VCT and PMTCT, offering PICT to pregnant women has no role, but the program has to sustain high coverage of VCT and PMTCT. Policy options to consider include diversifying PMTCT to offer VCT to husbands in ANC through advocates of couple counselling. Offering quality VCT to husbands in ANC is another key potential strategy to boost awareness of safe sex in and enrolment into universal ART program for negative counselling. 4.4.6 Prison Inmates Table 4.16: Summary of current interventions, coverage and recommendations for Prison Inmates Proven Proven Neither effective but Coverage of effective effective no evidence Effective but not cost effective intervention and cost nor cost on cost- effective effective effectiveness No policy intervention Interventions exist, but no coverage data Interventions VCT implementation with low coverage exist, and As there is no cost effective intervention coverage for this captive population, it is strongly data recommended to scale up due to its is available effectiveness and continuity of ART or VCT after being discharged from prison. For prison inmates, a package of integrated services should be considered such as distribution of condoms, VCT, treatment of TB-HIV, provision of ART. Intervention under the "yellow" banner in Table 4.16, include VCT services among prison inmates which, though effective, was proved not to be cost effective. VCT coverage in prisons is lower than 30%. Prevention interventions had inadequately addressed problems among prison inmates, the most vulnerable population group. In 2007 there were 168,656 male and 24,660 female prisoners in 162 prisons throughout the country. About 52% of them had sentence terms of less than 5 years, 36% were 5-20 years, 10% were 20-50 years, 1.5% were life-imprisonment, [92] and 0.09% had death penalty sentences. Between January and 170 "Revitalising HIV prevention in Thailand: a critical assessment" December 2008, there were 46,981 juvenile delinquents (boys 91% and [93] girls 9%) in 5,451 mid-way homes . There is a great opportunity to introduce effective and continued interventions in the prisons and beyond when they are released back to the society. To ensure health equity, more resources and program efforts should be given to this group e.g. free condom distribution. It is unfortunate that there is no evidence on effectiveness and cost-effectiveness of condom distribution in prison inmates under the `white banner' (Table 4.9). Evidence indicates VCT is effective but not cost-effective for this group. We recommend scaling up VCT services in general. Policy makers should consider offering an integrated package such as distribution of condoms, quality VCT services, treatment of TB-HIV, provision of ART, and ensuring continued service beyond their release from prison. Strong collaboration between the Ministries of Justice and Health is an important foundation for effective policy formulation and implementation. 4.4.7 Healthcare Workers Table 4.17: Summary of current interventions, coverage and recommendations for Healthcare Workers Proven Proven Effective effective but Coverage of effective but not Neither effective nor cost effective no evidence intervention and cost cost on cost- effective effective effectiveness No policy intervention Interventions exist, but no coverage data Interventions Post exposure prophylaxis: government exist, and policy to provide one month ART to health coverage data personnel exposed to or suspect to expose is available to HIV in their clinical services. Despite evidence on ineffective and non CE, UNAIDS and US-DDC recommend this intervention as an occupational safety. It is not easy to terminate the ongoing program. 171 "Revitalising HIV prevention in Thailand: a critical assessment" Interventions under the "red" banner, Table 4.17; Post-Exposure Prophylaxis was found ineffective and non cost effective for healthcare workers. The government provides full support for a free one-month course of ART to health care workers who are exposed to or are suspected to have been exposed to HIV infection in their clinical services. In theory, PEP should be terminated but politically, it is not that easy to terminate on the grounds of occupational safety in addition to full investment in Universal Precautions. Otherwise they would be discouraged to provide health services to HIV/AIDS patients. However, incidence of occupational injuries is very low; therefore there is little financial implication to the government. It is further recommended to modify conventional PEP towards a comprehensive prevention package. 4.4.8 Young People Table 4.18: Summary of current interventions, coverage and recommendations for Young People Proven effective but no Neither effective Coverage of Proven effective Effective but not evidence on cost- nor cost intervention and cost effective cost effective effectiveness effective No policy Young mostly No policy on No policy on intervention accesses condoms abstinence-plus PICT for young by OOP payment. programs people Recommend to Recommendation: Recommenda- sustain provide Although this is less tion: This is the free condom priority, it should be least priority distribution and considered to advocate create awareness in conjunction with other CE interventions Interven- No coverage data VCT, no coverage data Community- Despite no tions on the existing based education government Recommend to scale up exist, but no STI treatment with govern- policy, there the program and coverage services ment financial were small improve information on data support, no projects of Recommend to coverage coverage data abstinence-only improve informa- tion on coverage Recommenda- Recommend to and improve user tion: This is least terminate friendly STI treat priority ment services Interventions School-based sex exist, and education coverage program, 40.5% data is coverage available Recommend to strengthen and scale up to achieve 100% coverage 172 "Revitalising HIV prevention in Thailand: a critical assessment" For interventions under the "dark green" banner, in Table 4.18, the priority group is the young population (10-24 years old) most of whom access condoms by out of pocket payment. A recent policy on installing condom vending machines in wash rooms in high schools and universities resulted in hot debates both for and against and in the end it was not successful. However, young people access condoms in convenient shops and out of pocket payment. The most important point is to create awareness of safe sex behaviour in this group. The low coverage, at less than half of school based sex education program should be accelerated. Friendly STI services also need to be promoted. Interventions under the "light green" banner, abstinence plus programs should be integrated with school based sex education. By nature, VCT services for young people are not easy to scale up; therefore program efforts should be given to school based education. Interventions under the "yellow" banner, PICT and community based education for young people should receive lower priority. Abstinence only under the "red" banner should be terminated. 4.4.9 General Population Table 4.19: Summary of current interventions, coverage and recommendations for the General Population Coverage Neither Proven effective Proven effective but no Effective but not of inter- effective nor and cost effective evidence on cost-effectiveness cost effective vention cost effective No policy 1. They can 1. No policy on microfinance 1. No policy on No policy on inter- access condom combined with education community- mass or vention by OOP based education community Recommend to scale up the treatment of Recommend to intervention 2. No policy on STI maintain public PICT to general awareness on safe population Recommend sex and condom not to initiate Recommenda- use purchase by such program tion: These inter- their own ventions are of 2. No policy 2. No policy on low priority on male circumcision microfinance Recommend to Do not generate evidence recommend on public because it is acceptability of not applicable male circumcision in Thailand in Thai context 173 "Revitalising HIV prevention in Thailand: a critical assessment" Coverage Neither Proven effective Proven effective but no Effective but not of inter- effective nor and cost effective evidence on cost-effectiveness cost effective vention cost effective Interven- No coverage data Existing VCT for walk in 1. Despite no tions exist, on the existing individuals but no coverage policy, NAT was but no STI treatment data implemented for coverage services patient in Recommendation to scale data private Recommend to up this and improve hospitals, no improve informa- information on coverage coverage data tion on coverage but should be and improve user very low friendly STI coverage treatment services Recommend to bargain the price of the test to reach the CE level and advocate as a national policy to achieve 100% coverage 2. Sporadic activities of mass media campaigns by government j or GF but no coverage data Despite evidence on effective but non CE, the existing program should be Interven- 1. Existing policy 1. Existing intervention on tions exist, to increase workplace-based education and Alcohol Tax but low coverage coverage Recommend to Recommend to maintain the data is maintain high intervention and increase available level of taxation coverage on alcohol 2. Extremely high coverage of screening blood products and donated organ for HIV Recommend to maintain high coverage 174 "Revitalising HIV prevention in Thailand: a critical assessment" Interventions under the "dark green" banner in Table 4.19, it is reasonable that they can access condom by out of pocket payments. It is advisable to increase and maintain public awareness on safe sex and use of condoms. Male circumcision is not a customary practice for newborns; it is recommended that policy is guided by research and evidence on public acceptability in the Thai context. Policy to increase Alcohol Tax is recommended. Interventions under the "light green"banner, microfinance and education should be addressed for policy recommendation; scaling up STI treatment faced a common problem of incompetent providers and user unfriendly services in provincial hospitals as a result of recent public sector reforms discussed in other sections. Work-place based education has high potential for extension due to the nature of the institutionalized population. However, the Ministry of Labour has yet to buy into this policy and provide an enabling environment, incentives and other mechanisms to facilitate implementation. HIV and other essential screening in blood safety programs is performing well, all donated blood was tested with HIV antibody and antigen tests, other agents such as Hepatitis A, B and C were also screened. It is recommended to sustain the high performing blood safety program. Control of alcohol consumption has an indirect positive impact on HIV prevention and others such as violence and injuries. It is recommended to maintain a high alcohol tax and other measures to control supply and advertising. These are in the legislative framework but have yet to improve the enforcement capacity. VCT for the general population should be scaled up and improve information coverage. Interventions under the "yellow" banner; show that it is advisable that community-based education and PICT are a low priority, in view of other cost effective interventions and have not yet fully materialized in this group and other risk groups such as FSW, IDUs and MSM. It is recommended to scale up to full coverage of Nucleic Acid Testing (NAT) of all donated blood, to address the inequity problem between public and private hospitals blood services, ensure the highest possible safety blood service to prevent law suits from medical errors and iatrogenic HIV infection. The cost of laboratory test is still unaffordable, the Thai Red Cross Society, as the designated National Blood Centre, has yet to better perform in bringing down the price of this test. It is possible that NAT will become cost effective when the cost of laboratory tests decreases. 175 "Revitalising HIV prevention in Thailand: a critical assessment" Finally regarding interventions under the "red" banner, the development of a policy on mass community treatment of STIs should be discouraged by all means. Despite the evidence, mass media campaigns are neither effective nor cost effective. The existing program should be modified to minimize stigma and create public awareness on safe sex. 5. Discussions In the results section, it is imperative to report the results in the performance assessment of interventions used with different population groups, and to provide discussion and policy recommendations. Discussion focuses on mismatches of interventions, priority groups, and cross cutting issues around program bottle necks. 5.1 Mismatches of intervention We define mismatches between the stage of interventions verified against evidence on effectiveness and cost effectiveness. Mismatches are (1) the proven effective and/or cost effective interventions (combined dark green and light green banners) that were not implemented, and (2) the proven ineffective and non-cost effective interventions (red banner) that were actually implemented. Table 4.19 depicts a conceptual thinking of mismatches. Interventions falling in Box A1 and C3 are the mismatches where evidence based policy formulation, effective programme design and implementation are required for Box A1 and terminations are required in Box C3. Likewise, in Box A2 and A3, interventions match with evidence on effectiveness or cost effectiveness and require scaling up for Box A2 while maintains high performance in Box A3. 176 "Revitalising HIV prevention in Thailand: a critical assessment" Table 4.20: Conceptual approach of intervention mismatches and correction measures Proven effective and Stage of cost effective, proven Effective but not cost Neither effective nor intervention effective but no evi- effective cost effective dence on cost effective No policy, no A1 B1 C1 intervention Mismatches, Borderline, Match, Needs evidence based Scale up or low priority Discourage attempts to policy formulation, is on case by case initiate effective program review design and implementation Interventions A2 B2 C2 exist, poor Matches, Borderline, Mismatches, performed Need for scaling up Scale up or low priority Needs to terminate is on case by case review Interventions A3 B3 C3 exist, good Matches, Borderline, Mismatches, performed Need to maintain high Scale up or low priority Needs to terminate performance is on case by case review Table 4.21: Critical assessment of mismatches of HIV/AIDS interventions Proven effective and Stage of cost effective, proven Effective but not cost Neither effective nor intervention effective but no evi- effective cost effective dence on cost effective No policy, no A1 B1 C1 intervention - Free distribution of - PICT for young - Microbicide in FSW condom to MSM, IDU, people, general - HIV vaccine Discordance couples, population - PEP for IDU young people and - Community based - Mass community general population education in general treatment of STI for - PICT offered to population general population pregnant women - Needle social market- - Microfinance policies - Abstinence plus in ing for IDU young people - Male circumcision in male newborns - Needle and syringe exchange for IDU - Microfinance combined with education for general population - Female condom for FSW 177 "Revitalising HIV prevention in Thailand: a critical assessment" Proven effective and Stage of cost effective, proven Effective but not cost Neither effective nor intervention effective but no evi- effective cost effective dence on cost effective Interventions A2 B2 C2 exist, poor - Work place education - VCT for prison inmate, - Community based performed for FSW general population and peer education for - Community based - Community based IDU education and peer education for young - Abstinence only in education for FSW people young people - STI treatment for all - Mass media campaign population groups in general population - VCT for FSW, MSM, - Nucleic Acid Test for IDU discordance donated blood couples, young people - Street outreach for IDU - School based sex education program for young people - Workplace-based education in general population - Community based education for and peer education MSM Interventions A3 B3 C3 exist, good - Free condom - PEP for healthcare performed distribution for FSW workers - High coverage of methadone substitu- tion treatment in public clinics - VCT and PMTCT for pregnant women - Screening of HIV antigen, antibodies and other in all donated blood - Increase alcohol tax With the application of a conceptual framework, Table 4.21 synthesizes all HIV/AIDS prevention interventions categorized as Green, Yellow and Red banners for all nine population groups by three stages of implementation. There are seven mismatches in Box A1 for which different policy recommendations are made. From the critical assessment and understandings from discussions with key informants, we suggest the following: 178 "Revitalising HIV prevention in Thailand: a critical assessment" Four interventions require further evidence on applicability, acceptability and programmatic designs. These are: o Female condoms for FSW: operational research to test if it is acceptable, assess program feasibility in the Thai context o Male circumcision in male newborns: generate evidence on public acceptability in Thai context o Female condom use and microbicides which are in the study process for policy recommendation Two interventions require immediate policy actions. o More availability of free distribution of condoms to MSM and IDUs. Condoms can be integrated in a comprehensive package by peer groups and NGOs. For example integration of VCT, condom distribution, STI treatment service and ART. Condom distribution to discordant couples can be done in VCT clinics. Condom distribution to young people and the general population are not easy in terms of programmatic design, but creating awareness of safe sex is essential. o Needle social marketing for IDUs: there is a need for a clear policy but requires extraordinary strong leadership in the light of "cracking down on drugs." Two interventions do not require attention. o PICT offered to pregnant women, as the program should focus on sustaining high coverage of PMTCT. Opportunities exist to extend VCT services to husbands in ANC clinics o Abstinence plus in young people is not a policy culture in Thailand; safe sex and condom use are main programmatic focuses. There is one serious mismatch in Box C3, the PEP for healthcare workers. It should be terminated but politically not easy on the grounds of occupational safety. We recommended keeping it, as incidence of occupational injuries is low and financial implications to the government would be low. Conventional PEP should be modified towards a comprehensive prevention package. We commend the good performance contained in Box A3, and recommend sustaining its high performance, such as free condom distribution to female sex workers, methadone substitution treatment in public clinics, 179 "Revitalising HIV prevention in Thailand: a critical assessment" VCT and PMTCT for pregnant women, screening of HIV antigen, antibodies and others in all donated blood, and increased alcohol tax which has an indirect impact on vulnerability to HIV infections. In Box A2, many activities require rapid and wide scale up. For example, community-based education, peer education and VCT for FSW in Bangkok which showed high coverage, although other provinces were lagging behind. These interventions should be scaled up throughout the country with sufficient support from the government. 5.2 Which priority group? Based on sero-sentinel evidence of high prevalence and high risk of infections and transmission of HIV to others, three population groups require priority attention: FSW, MSM and IDUs. As clearly reflected in a [14] survey conducted by Laohasiriwong indicating that MSM and IDUs have multiple partners and clients of sex workers, unsafe sex practices and low condom use rate, sharing needle and syringe among IDUs, are the main drivers of HIV transmission. Specific recommendations for these three population groups were provided in section 4.4.1 FSW, 4.4.2 MSM, and 4.4.3 IDUs. Accordingly, to more precisely measure incidence of HIV infection, the Medical Sciences Department and AFRIMS, with technical support from the US Centers for Disease Control conducted a pilot study of the BED IGG CAPTURED IMMUNOASSAY (BED-CEIA) among pregnant women and FSWs in Bangkok and 24 provinces, and army recruits from 2004 to 2007. The results suggest that HIV incidence increased among the general population, pregnant women and indirect FSWs. In sum, data from the national HIV surveillance and other ad hoc sero-surveys shows an epidemic pattern that is a combination of generalized and concentrated epidemics. There is evidence of declining prevalence in almost all groups, however prevalence is still high among IDUs, and there are indications of increasing prevalence among MSM. Recent studies of incidence provide a [10,94] warning sign to Thailand that rapid spread of HIV could be returning Based on BSS, young people emerge as a new priority and vulnerable to HIV infection which requires specific monitoring for HIV infection 180 "Revitalising HIV prevention in Thailand: a critical assessment" prevalence and interventions because of the sexual behaviour which might be risky to infection. For example, knowledge on HIV prevention was low among young adolescents, less than 20% to 30% had accurate understanding on the five UNGASS HIV preventions. Over the last 12 years, an increasingly high proportion of students, especially from vocational schools had sexual intercourse experiences. Condom use rate among students was less than 30% in most groups. However, the report [11] of the Commission on ASIA AIDS does not show concern about this group . From this study, it is recommended that young people, including young sex workers, young IDU, and young MSM are particularly vulnerable to HIV infection, and deserve greater attention in HIV prevention programs. Prison inmates are the most vulnerable and socially disadvantaged group, often with repeated imprisonment, especially cases dealing with drugs. Most of them are IDUs with TB and HIV co-infections. As a captive population, there is a great opportunity to introduce effective and continued interventions in the prisons and beyond when they are released back to the society. It is recommended to scale up VCT services. Policy makers may want to consider offering an integrated package including distribution of condoms, VCT services, treatment of TB-HIV and provision of ART, and ensure services continue beyond prisons after their release back to the society. This will require a strong collaboration between the Department of Corrections, Ministry of Justice and Ministry of Public Health. 5.3 Cross cutting program bottlenecks As a result of public sector reform - termination of STD clinics under Provincial Health Offices, and transfer of mandates to Provincial Hospitals- the STI treatment services were weakened with a resurgence trend of STI incidence (see Annex 2). In this context, it is imperative that HIV pro- grams build and strengthen skills to work with communities in particular owners of, and sex workers in brothel and non-brothel based sex establishment. Priority should be given to developing user friendly STI services, accessible by all, in particular FSW, MSM, and IDUs, as well as integrating STI treatment with quality VCT services. 181 "Revitalising HIV prevention in Thailand: a critical assessment" 5.4 Limitations of the study Due to data limitation, this study cannot assess the financial resources spent in each of the 25 interventions currently employed by the national HIV/AIDS program specific to the nine population groups. As evident in Annex 1, total prevention expenditure in 2007 was 950 million Baht, which provides a good enough breakdown of expenditure on some detailed prevention interventions. In addition, this study did not aim and was not designed to conduct expenditure projection of financial resources and programmatic capacity required for scaling up recommendations provided in the "dark and light green" banners which is unmatched in Box A1, and described as low performance in A2, or to sustain high coverage in A3 in Table 4.21. 182 "Revitalising HIV prevention in Thailand: a critical assessment" 6. Annex for Chapter 4 Annex 1 Attitude of MSM and IDUs about free condoms and buying condoms [14] Attitude of MSM that "Condom should be free for anyone who needed" by income % 84.0 85.2 84.3 85.7 84.7 90 80 70 60 50 40 30 20 10 0 <6,999 7,000-19,999 20,000-49,999 >50,000 All income Baht/month Baht/month Baht/month Baht/month Agree lndifferent Disagree Attitude of MSM that "Buying condom is a burden which you should not pay for it" by income % 58.3 58.9 60 54.3 55.2 51.6 50 40 30 20 10 0 <6,999 7,000-19,999 20,000-49,999 >50,000 All income Baht/month Baht/month Baht/month Baht/month Agree lndifferent Disagree Attitude of lDU that "Condom should be free for anyone who needed" by income % 89.7 84.4 85.7 85.8 90 80 70 60 50 40 30 20 10 0 <6,999 7,000-19,999 >20,000 All income Baht/month Baht/month Baht/month Agree lndifferent Disagree Attitude of lDU that "Buying condom is a burden which you should not pay for it" by income % 70 60 50 38.9 40 35.6 30.9 30 20 14.3 10 0 <6,999 7,000-19,999 >20,000 All income Baht/month Baht/month Baht/month Agree lndifferent Disagree 183 "Revitalising HIV prevention in Thailand: a critical assessment" Annex 2 Annual STI cases reported by routine surveillance 1996 to 2007 Source: MOPH Bureau of AIDS, TB and STI, various years In the figure above, there was a resurgence trend of STIs reported in 2004 to 2007, reversing the decreased trend from 1996 to 2003. This is not a good sign that condom use rate might reduce, and STI incidence is a proxy indicator of HIV prevalence. Note that this is a voluntary report by mostly public providers, excluding private pharmacies and clinics. In addition, the STI report covered the whole population and did not distinguish whether they were FSW, MSM, IDU or any other subpopulation group. 184 "Revitalising HIV prevention in Thailand: a critical assessment" 7. References for Chapter 4 1 UNAIDS. Practical Guidelines for Intensifying HIV Prevention: towards universal access. Geneva, Joint United Nations Programme on HIV/AIDS (UNAIDS) 2007. 2 National AIDS Prevention and Alleviation Committee (2008). UNGASS country progress report: Thailand, reporting period: January 2006 - December 2007. Thailand, Ministry of Public Health 3 Bureau of Epidemiology. Results of national sero-sentinel for HIV prevalence, various rounds. Nonthaburi, Ministry of Public Health 4 Wilson D, Halperin DT. 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