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
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.