Bulletin of the World Health Organization

Thailand’s new condom crusade

Thailand's first free condom campaign in the early nineties was so successful that it was widely copied. Government funding for free condoms was cut back in 1998. Now after 12 years and a spike in HIV infections, the scheme has been brought back. Apiradee Treerutkuarkul reports.

“I never have sex without protection,” says the 33 year-old sex worker, who has come to Bangkok from her workplace in the Pattaya red light district of Chonburi province for a seminar on sex workers held by Thailand’s Department of Disease Control. For this sex worker, who asks to be referred to as ‘A’, insisting that clients wear a condom is not just a matter of protecting herself, it is also about their protection. As obvious as this may seem, it took years of campaigning on the part of Thailand’s public health officials to inculcate this attitude among sex workers.

One of those health officials is Dr Wiwat Rojanapithayakorn. Currently the head of the World Health Organization’s country office in Mongolia, Rojanapithayakorn was recently awarded one of Thailand’s prestigious Prince Mahidol Awards for his work in the late 1980s as director of Thailand’s Center for the Prevention and Control of AIDS.

Mechai Viravaidya at the Cabbages and Condoms restaurant in Bangkok.
Apiradee Treerutkuarkul
Mechai Viravaidya at the Cabbages and Condoms restaurant in Bangkok.

In 1990 Thailand had 100 000 new cases of HIV infection. Just three years later the number of cases had jumped to around one million. In his role as director overseeing seven provinces in the central region and the west, Rojanapithayakorn remembers his growing sense of alarm as he watched the virus spread from community to community. It did not take long to discover that 97% of all cases of HIV infection were linked to sexual transmission from sex workers.

From his experience with previous campaigns to stop the spread of sexually transmitted diseases among sex workers, Rojanapithayakorn was convinced that promoting condom use was the best hope for containing the spread of HIV. But 20 years ago, encouraging sex workers and brothel owners to introduce condoms was no simple matter. “The majority of Thai men preferred unprotected sex,” says Rojanapithayakorn.

There was another significant challenge. The incumbent administration refused to acknowledge the existence of the sex industry, let alone the problems within. So Rojanapithayakorn and his colleagues worked directly with provincial governors and police authorities, as well as with the owners of all sex establishments, to promote a “no condom, no sex” message. Condoms were distributed free to brothels and massage parlours and sex workers and their clients were required to use them. Brothels that failed to comply were threatened with closure.

The results were stunning. New sexually transmitted infections among sex workers fell from 13% in Ratchaburi province to less than 1% two months after introducing the “100% condom use” programme. So successful was the programme that Rojanapithayakorn decided to extend it to other provinces under his supervision.

But despite this success, implementation of the programme could not keep pace with the rapidly spreading virus. Rojanapithayakorn decided to approach policy-makers at the National Committee on AIDS where his programme came to the attention of the committee’s chairman, then Prime Minister Anand Panyarachun.

Panyarachun considered the issue an urgent priority and supported the national launch of the programme. And within three years, condom use among sex workers increased from less than 25% to more than 90%, according to the Department of Disease Control. In the 10 years between 1991 and 2001, new HIV infections dropped from 143 000 per year to less than 14 000. The programme was so successful that similar campaigns were started in Cambodia, China, the Lao People’s Democratic Republic, Myanmar, the Philippines and Viet Nam.

Dr Wiwat Rojanapithayakorn was director of Thailand’s Center for the Prevention and Control of AIDS during the 1980s.
Prince Mahidol Awards Foundation
Dr Wiwat Rojanapithayakorn was director of Thailand’s Center for the Prevention and Control of AIDS during the 1980s.

Prime Minister Panyarachun also took the inspired step of giving Mechai Viravaidya, a flamboyant AIDS activist and politician, the job of launching a public information campaign that included the airing of anti-AIDS messages every hour on the country’s 488 radio stations and six television networks. All this was accompanied by a significant jump in funding. The HIV/AIDS budget for preventive activities was increased almost 20-fold to US$ 44 million in 1993.

But then the Asian financial crisis struck Thailand in mid-1997. In 1998, the administration cut health funding for antiretroviral drugs and condom distribution. By 2000, domestic funding for HIV and AIDS prevention was around 25% less than it had been in 1997. Since 2000, Thailand’s HIV/AIDS containment programme has faltered, and funding has been directed at treatment rather than prevention. For Rojanapithayakorn, this policy shift was of grave concern.

“Prior to 1997, Thailand’s Public Health Ministry earmarked 50 million baht (US$ 1.5 million) for the distribution of free condoms to sex workers and other at-risk groups, such as men who have sex with men,” he says. “For this relatively small investment, the state saves something like 73 million baht in sexually transmitted infection treatment costs annually, and a further 100 billion baht for the treatment of HIV/AIDS.”

Rojanapithayakorn is convinced that finding that money is a simple matter of shifting priorities. With construction costs for one kilometre of new road in Thailand roughly equivalent to the costs required for the free condom programme, he suggests the reduction of road construction by one or two kilometres could prevent millions of cases of HIV infection. “Preventing each person from contracting the virus can reduce treatment cost worth millions of baht,” he says.

Petchsri Sirinirund, director of the National AIDS Management Center, is also concerned about the shift from HIV prevention to treatment in the health ministry’s budget allocation. However, she acknowledges that this partly reflects the changing capacities and responsibilities of the health-care system. In the past, “mental support was the only option for those infected with HIV because antiretroviral drugs were very expensive and they could not receive free treatment from the national health care scheme”.

In 2004, AIDS activists including Nimit Tienudom, the AIDS Access Foundation director, pressured the government to provide free treatment using a locally produced antiretroviral called GPO-VIR, a generic fixed-dose combination of stavudine, lamivudine and nevirapine, which costs about 1200 baht a month. Treatment with the drug has since been included under Thailand’s universal coverage scheme.

Petchsri Sirinirund is director of the National AIDS Management Center.
Apiradee Treerutkuarkul
Petchsri Sirinirund is director of the National AIDS Management Center.

However, one of the unforeseen effects of the introduction of GPO-VIRs is that some people have come to see AIDS as a treatable, if not curable, disease. “Attitudes to high-risk sexual behaviour have relaxed and that has coincided with the tailing-off of the prevention campaign,” Sirinirund says.

Sirinirund believes the absence of a sustained prevention campaign was the reason for the failure to meet the current five-year target of the national AIDS strategy to reduce the new HIV infection rate to 5000 per annum by 2011. Estimated new infections are occurring at a rate of 11 753 cases per year. In January 2010, the number of people living with HIV/AIDS in Thailand was 364 052, according to Thailand’s Bureau of Epidemiology.

Since Prime Minister Abhisit Vejjajiva was elected in December 2008, there has been a renewed focus on HIV prevention. The Abhisit administration has been credited with refocusing attention on AIDS and has revived the prevention campaign by restarting distribution of free condoms after the programme was shelved for a decade. An accelerated plan for the prevention of HIV is now being drafted by the National AIDS Committee but Sirinirund fears that the initiative is “too little, too late”.

For Mechai Viravaidya, who also received a Prince Mahidol Award for his work on AIDS prevention in 2009, the battle to contain the spread of HIV is the same as it was in the late 1980s, the only difference being that a new generation of young people needs to be addressed.

Over the past 35 years, Viravaidya has gone to great lengths to raise awareness about the importance of condom use, often in controversial ways. He has, for example, promoted condom-blowing competitions among teachers and students, sent a mobile sex education van around schools and encouraged a form of peer education in which university students help teach secondary students about condom use.

“Thailand is asleep at the wheel,” he says, noting that despite years of education campaigns, condom use is still not as widespread as he would like. This is confirmed by the Bureau of Epidemiology which reports from a 2007 study of grade 11 students that fewer than 50% of male students use a condom when they have sex for the first time, while only 43% of female students insist that their partners use condoms. Currently, only 20–40% of sexually-active teenagers are reported to use condoms.

In response to the problem, the Department has tried to revive the national AIDS prevention strategy. A series of television advertising campaigns that used the slogan “Proud to carry condoms” (Yued ok pok thung) was launched in 2007. Aimed at promoting condom use among teenagers, the campaign showed a teenage girl telling her new boyfriend that she and her ex-boyfriend had both had several partners before and ended with the message that condom use was essential and commendable. But the campaign was harshly criticized by conservative social and parental groups, who said that it undermined Thai cultural values and encouraged promiscuity. The advertisement was withdrawn ostensibly for budgetary reasons even though Thailand received US$ 98 million funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria and the Abhisit administration gave strong policy support on the national AIDS strategy.

Viravaidya believes that such “narrow-minded thinking” puts young people at risk and is committed to continuing to spread the word about condoms and the risks they prevent. “I want to send a message that condoms are common in today’s society and it should be a duty of young people to carry condoms to protect themselves and their partners,” he says. He encourages parents to be open-minded: “We need to look for ways to let our children know that condoms are a part of daily life just like salt and pepper,” he says. “Prevention is the most effective cure.”