HIV prevalence among 21-year-old military conscripts in Thailand

Increasing condom use by sex workers and decline in STIs* in Thailand

 

Thailand achieves sustained reduction in HIV infection rates

In Thailand, government determination to enforce 100% condom use in brothels and to ensure wide access to HIV prevention campaigns through schools, the mass media, and the workplace have been key factors in lowering HIV infection rates. The broad-based campaign has led to an increase in condom use, a reduction in visits to sex workers, and a dramatic reduction in HIV infection rates.

A sustained and dramatic reduction in infection rates for HIV and other sexually transmitted infections has been achieved in Thailand over the past decade through government efforts to promote safe sex. From the early 1990s, the government worked in collaboration with brothel owners to ensure that the commercial sex industry did not become the main engine for a nationwide epidemic of HIV/AIDS.

As a result, Thai men are today far less likely to visit sex workers. And those who do are more likely to use condoms. Meanwhile, condom use has also increased both among young people and in the general population.

During the late 1980s, explosive epidemics of HIV among sex workers and injecting drug users threatened to spiral out of control -- sparking off a major AIDS epidemic. In 1988, infection rates among injecting drug users rose alarmingly from zero to 30% over six months. A year later, the national HIV surveillance system revealed that in the northern city of Chiang Mai, 44% of sex workers were infected with HIV. There were fears that the HIV epidemic would seed itself in the general population -- fuelled by the high proportion of men who visited sex workers.

In response, a new national HIV prevention programme was launched in 1991 with high level political commitment at both national and regional levels. Each key government ministry developed its own AIDS plan and budget and government funding for HIV/AIDS was stepped up. The government forged partnerships with NGOs, the business community, people living with AIDS, religious leaders, and community leaders -- engaging them in dialogue and resource mobilization for HIV prevention and care programmes.

Although prostitution remains illegal in Thailand, the government took the pragmatic step of working with brothel owners to enforce 100% condom use in all commercial sex establishments. Under the scheme, condoms are distributed free to brothels, and sex workers are told to insist on condom use by all clients. Government efforts to police the scheme have included STI contact tracing and the use of government inspectors posing as would-be-clients in brothels. Commercial sex establishments that fail to comply can be shut down.

The scheme has been highly successful. Reported condom use in brothels increased from only 14% of sex acts in 1989 to over 90% by 1994. Over the same period, the number of new STI cases among men treated at government clinics plummeted by over 90%. Regular surveys among young male recruits in the Thai army reveal similar changes in sexual behaviour and infection rates. HIV infection rates among 21-year-old military conscripts peaked at 4% in 1993 before falling steadily to below 1.5% in 1997. By 1995, fewer recruits were visiting sex workers (down from almost 60% of recruits in 1991 to about 25% by 1995) and condom use had increased. These changes in sexual behaviour were paralleled by a decline in HIV infections and other STIs.

The HIV prevention programme also included a mass media campaign, workplace AIDS programmes, life-skills training for teenagers, peer education, and anti-discrimination campaigns. The media campaign urged respect for women and discouraged men from visiting brothels. And improved educational and vocational opportunities were made available for young women, especially in rural areas, to keep them out of the sex industry.

However, problems remain. Infection rates among injecting drug users remain high at 20%-45% nationwide. And in rural areas, HIV infection rates among sex workers have increased. In 1997, 20% of sex workers in rural areas were HIV-positive compared with only 7% in Bangkok. To make matters worse, studies carried out in rural areas reveal that only 50% of men who visit sex workers consistently use condoms. And as risk behaviour increasingly shifts from commercial sex to unprotected casual sex, efforts will be needed to sustain reduced infection rates.

Over the past decade, Thailand's HIV prevention programme has been supported by an effective disease surveillance system which has succeeded in mapping the course of the epidemic. And it has also relied heavily on regular input from the behavioural information systems that were developed to monitor social and sexual behaviour patterns. Through its successful efforts to prevent high-risk sexual behaviour and promote safe sex, the government has demonstrated that it is possible to reverse the course of the epidemic nationwide within a relatively short period.