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HIV/AIDS
A Review of the Approaches and
Interventions in Thailand
M.S. Shivakumar
V.P. Karunan
A report submitted to CEBEMO
The Netherlands
January 1995
s
HIV/AIDS
A Review of the Approaches and
Interventions in Thailand
M.S. Shivakumar
V.P. Karunan
A report submitted to CEBEMO
The Netherlands
January 1995
Table of Contents
Page #
Descriptions of the Levels of
HIV/AIDS Care
vi
o
Description of Terms and Abbreviations
vn
o
Objectives of the Review
1
o
Review Procedure
1
o
Section 1
Section 2
An Overview of the HIV/AIDS
Situation in Thailand
1.1
Data on HIV/AIDS Incidence
2
1.2
Future Trends and Repercussions
3
The Context and Nature of
Risk Behaviour
2.1
Context of Sexuality and Sexual Behaviour
5
2.2
Attributes of Economic Development
5
2.3
Varying Sexual Behaviours
6
2.4
Gender Roles and Commercial Sex
7
2.5
Power and Prestige
9
2.6
Levels of Risk Behaviour
9
2.7
Sexual Behaviour Patterns Among Youth
10
2.8
Community Perceptions of Risk
and Some Reflections
10
HIV/AIDS in Thailand
[i]
Page
Section 3
Section 4
Section 5
Section 6
HFV/AIDS Knowledge and Attitudes
3.1
Religion and HIV/AIDS
13
3.2
Death of HIV/AIDS Persons and Ceremonies
14
Vulnerable Groups
4.1
Commercial Sex Workers
15
4.2
HIV-infected Women
15
4.3
Children
16
4.4
Street Youth
17
Interventions on HFV/AIDS
5.1
Target Groups for Intervention
19
5.2
Strategies: An Overview
20
5.3
Role of the Thai Government
22
5.4
Some Common Features and
Concerns of Government Interventions
25
5.5
Participation of Bilateral Agencies
27
5.6
Response of the Thai Business Community
28
5.7
Community Outlook and Practices
28
Hospice Approach
6.1
History of Hospice in Thailand
31
6.2
Level of Activity
32
HIV/AIDS in Thailand
[ii]
Page #
f
Section 7
6.3
Land and Building
33
6.4
Hospice Workers
34
6.5
Medical Care/Support and
Life Saving Services
34
6.6
Participation of Family Members
35
6.7
Financial Resources
36
6.8
Cultural Constraints to the Hospice Approach
36
6.9
Some Viewpoints
37
Responses of the Thai NGO Sector
7.1
Background
39
7.2
Approaches to HIV/AIDS Work
39
7.3
Location
40
7.4
Coverage
40
7.5
Level of Implementation
41
7.6
Range of Efforts at Micro Level
41
7.7
Community Participation
42
7.8
HIV/AIDS CadreAVorkers at the Village Level
46
7.9
Performance : Preventive and Curative Functions
48
7.10
Attributes of Care and Concern
49
7.11
Reliability and Level of Utilisation
49
7.12
Training
50
HIV/AIDS in Thailand
[iii]
Page If
Section 8
Section 9
Section 10
7.13
Other Community-level Health Practitioners
50
7.14
Project Support
51
7.15
Problems and Causes
51
7.16
Fresh Strategies
51
7.17
Overall Inferences
52
Responses of Religion
8.1
Buddhist Thought and Action on HIV/AIDS
54
8.2
Christian Missionary Efforts
55
8.3
Islam
57
Popular Strategies
9.1
Condom Distribution and HIV/AIDS
58
9.2
Mass Media, Peer Counselling and Networks
59
9.3
Cultural Activities
60
9.4
Use of Mass Media
60
Home and Community Care and Support
10.1
Home-based Care and Support
62
10.2
Community Counselling
63
10.3
Peer Group Counselling
64
10.4
Women as Community-care Specialists
64
10.5
Therapeutic Communities
64
HIV/AIDS in Thailand
[iv]
Page it
Section 11
HPV/AIDS - Threat to Life and Human Rights
Section 12
Towards New Partnerships in HIV/AIDS Interventions
62
12.1
Circumstances
68
12.2
Basic Assumptions of a Comprehensive Strategy
69
12.3
Clinical Care/Support
70
12.4
Living and Coping with HIV/AIDS : Counselling
71
12.5
Community-based Care and Support
72
12.6
Interventions Among Drug Users
72
12.7
Role of Religious Groups and Individuals
72
12.8
Mass Media
73
12.9
Human Rights
73
12.10 Some Key Problems
73
12.11 Towards New Partnerships and Initiatives
74
Bibiliography
77
Appendix
o
List of NGO Engaged in HIV/AIDS Intiatives
o
Work Schedule
HIV/AIDS in Thailand
[V]
Descriptions of the Levels of HIV/AIDS Care
Home level
The basic unit in any community i.e., the household. Family members are primarily
responsible for activities at this level, whether they are seen as individuals, mothers of
children or heads of the household. Neighbors, as well as home-visiting community
workers of various kinds [including trained health workers] interact with the family and
are directly involved in activities at this level.
Communal level
Activities at this level concern the health of a whole community [village/town or group
of villages] and require common facilities and/or joint voluntary efforts of community
members. Examples are campaigns, construction offacilities, information/education about
HIV etc.
Community resource groups, or equivalent is the central coordinating mechanism for
activities at this level. It also provides support to activities at the other levels, in
particular the home level. The community development committee interacts with, and is
supported by, the individual community members, various community groups, and
provincial sectoral programmes including health programmes.
Community level HFV/AIDS health workers [CWs], as well as other community workers
and volunteers, function at this level both in promotional/informational activities and in
planning and implementation of communal health activities. Many communities provide
space for clinicwor treatment centres.
First health
facility level
This refers to the first level where a trained health professional is available and where
facilities are available for running clinic sessions. The kind of facility and the type of
staff available varies from place to place.
In addition to clinical activities, the staff interact both with the home level [during home
visits] and the communal level. This level also plays a major supportive role in training
and supervision of CWs.
First referral
level
There are two types of referral systems: [a] clinical referral method which includes the
supervision of performance at lower levels; [b] administrative referral, usually involving
the district health office. This is the level involved in planning, management and support
of activities related to disease control campaigns, health education/information, group
support services or liaising with local NGOs.
[vi]
Description of Terms and Abbreviations
AIDS
Acquired Immune Deficiency Syndrome, AIDS, is a predominantly sexually transmitted disease.
The scientific community generally accepts that the human immunodeficiency virus [HIV] is the
cause of AIDS. AIDS usually develops several years after infection with HIV and is the final
manifestation of the destruction of the body’s immune system brought about by the virus.
HIV
Human Immunodeficiency Virus [HIV]. This virus when fully blown turns into AIDS disease.
ARC
AIDS-related cases
NGO
Non-governmental, non-profit, private organisations.
PWA
Persons with AIDS i.e., those who are living with the HIV infection.
CCT
Church of Christ in Thailand
CCHP
Catholic Commission for Health Promotion in Thailand
CW
Community-level HIV/AIDS Worker
csw
Commercial Sex Worker
[vii]
This review documents areas of progress and difficulties encountered in the HIV/AIDS
work being carried out, and is based on an analysis of the current HIV/AIDS interventions in
Thailand. The field work was undertaken between mid-April and mid-August 1994; the synopsis
was prepared between mid-July and end-August 1994, and the draft report was circulated for
comments. The final report was consolidated in December 1994. This review attempts to
summarise the objectives, strategies, and implementation attributes of HIV/AIDS interventions
in Thailand. It is based on documents available and information obtained in interviews with
persons familiar with the HIV/AIDS situation and are active in challenging it. The method of
research based on field-conducted case studies and interviews allowed the writer to identify
common patterns of experience and understanding of the issues.
Objectives of the Review
HIV/AIDS has been understood well with considerable commitment in Thailand, but
implementation strategies are still being tested and assessed, both locally and nationally. Thus,
a key purpose of this analysis was to examine the experience of HIV/AIDS interventions, and
is primarily concerned with community-care support and efforts. The other H/V/4/DS-related
interventions, such as surveillance of STDs and public health efforts - are discussed only as they
relate to and are integrated with HIV/AIDS activities. Specifically, the objectives of this review
are to:o
Identify and discuss the major issues in HIV/AIDS situation in Thailand; and
o
Record and catalogue various interventions to provide insights into their
potentials, strengths, and problems.
Review Procedure
Although HIV/AIDS has occupied substantial space in public and development debate of
Thailand, little comprehensive field-information is available. All the projects and interventions
emerged in recent times and a quantitative study will have no relevance. Therefore, an analysis
based on non-quantitative information was pursued. During the field work the writer participated
in several meetings or interviewed knowledgeable persons. It covered areas of special relevance
i.e., projects, agencies, government and individuals, who plan and implement HIV/AIDS
interventions.
Throughout this analysis, an effort was made to examine the efforts from a number of
viewpoints. Attention is given to the particular role and approach of NGOs, the stage of
implementation, and project’s scale. As much as possible, general HIV/AIDS issues, problems,
and prospects are distinguished from those more closely tied to the operating procedures. Some
commonness was observable in all interventions due to two broad reasons:- [a] the speed with
which the pandemic struck the Thai population led to traumatic socio-economic and even
political experiences; this trauma is still continuing; and [b] most of the strategies primarily
emerged out of the efforts of the larger organisations like Thai Red Cross Society or Ministry
of Public Health - therefore, it was rarely possible to differentiate between specific merits of the
approach/strategy of any single agency.
HIV/AIDS in Thailand
[1]
Section X
An Overview of the HIV/AIDS Situation in Thailand
In Thailand, the first case of HIV/AIDS
reported in September 1984. At that time,
AIDS was believed to be confined only to homosexual men [and possibly restricted to urban
areas]. It was not really perceived as a threat to the community and nation by most people. Four
years later, early-1988, the first signs of the pandemic swept through the intravenous drug users
[IVDUs] in Bangkok Metropolitan area. Even at that stage it was believed that the disease was
limited to homosexuals and the drug user community.
Amongst the heterosexual community it was observed only in the late 1988 i.e., in the
brief span of four years the human immunodeficiency [HIV] has spread from a handful of IVDUs
to several hundred thousand Thai women and men. Since then consecutive "waves" have
occurred and spread to commercial sex workers, their clients and pregnant women. Within the
first decade of its presence in Thailand HIV has rapidly spread to all parts of the nation and all
walks of life - particularly among the poorer sections. The main mode of transmission is
heterosexual contact. The immediate causes are IVDU addiction among the lowest class of
labourers, who in turn, give it to young commercial sex workers [CSWs]. They then spread it
to their patrons i.e., Thai men of all ages and social classes. The distribution throughout the
country is ensured by truck drivers, migrating labourers and a health policy that forces CSWs
to leave the province once the infection is detected.
The origin of the pandemic, as is believed, is through contact with foreigners: the first
HIV/AIDS cases since 1984 could be traced to such contacts, although not in all instances with
complete certainty. It is conceivable that the virus was already introduced to Thailand before
1980: the sudden outburst of the pandemic in 1988, almost simultaneously in different
populations, makes such a preposition probable.
1.1
Data on HIV/AIDS Incidence1
At present two major sources of information and statistics on HIV infection exist in
Thailand i.e., AIDS/ARC Voluntary Reporting System and Biennial Sentinel Seroprevalence
Surveillance. Each source covers a different epidemiological aspect of HIV infection. The
Voluntary Reporting System provide information regarding individuals infected, and provides
important information for planning community and hospital case. The Sentinel Seroprevalence
Surveillance monitors the trend of the epidemic in specific groups reflecting the HIV situation
among the general population.
For reasons of lucidity, this report assumes the availability of data and evidence on HIV/AIDS.
HIV/AIDS in Thailand
[2]
1.2
Future Trends and Repercussions
In a brief period of four to five years, AIDS has risen to pandemic levels in Thailand.
Moreover, several demographic and epidemiological projections estimate that, if current trends
do not change by 1995, two to four million Thais will be infected by the year 2000. While more
males are initially infected, by the year 2000 more women will be infected than men. Available
data predict rising rates of HIV-infected pregnant women, deaths of children under five due to
AIDS/ARC, and AIDS/ARC-related orphan children as AIDS affects families.
Projected levels of illness and death will place significant financial burdens on families
and the government. Health care costs for people with AIDS are estimated to be between US$
660 and US$ 1,000 per year. These estimates are based on conservative assumptions about the
type and level of care required. Treatment costs for AIDS represents between 40-50 per cent of
annual household income for the average Thai family. The inability of families to bear this
financial burden will require the government to fund the cost of care. With current health care
expenditures of US$ 25 per capita, the costs of AIDS treatment will severely strain the
governmental resources. A far greater future cost to the economy will result from deaths of
individuals during their reproductive years. In addition, AIDS is likely to have an even greater
impact on the Thai economy, particularly the most valued sectors of tourism, foreign investment
and labour remittances from abroad2.
HIV/AIDS in Thailand has no territory i.e., it is prevalent both in rural and urban areas.
However, the rural population seems to be the most affected, especially adolescent single males
and adolescent married females. The high prevalence found among army and police recruits is
part of this pattern. There is no definite explanation for the concentration of HIV infection in
the North of Thailand. About 50 per cent of all AIDS/ARC cases from the North suggest that
apart from co-factors such as STDs, the spread in the North is also related to a specific pattern
of sexual behaviour and culture which differs from other regions.
Some questions remain unanswered. For instance, the rapidity and effectiveness of the
spread of HIV among certain sub-populations. For example, in case of IV Drug Users [IVDUs]
not only well known factors of needle sharing and a specific subculture of common drug
preparation and injecting within a closely interacting group were pointed out, but also the active
mobility of IVDU’s in search of treatment, their participation in travelling professions, the wide
availability of drugs and characteristics of law enforcement apparatus - all these elements favour
rapid transmission of HIV over long distances.
2
Based on various documents published the Ministry of Public Health [MoPH] and discussion with Dr. Wiwat, Chief. AIDS Section.
MoPH.
HIV/AIDS in Thailand
[3]
Section 2
The Context and Nature of Risk Behaviour
Thai sociological texts and development experts contend that sex was considered as a
necessary component of Thai life that was recently converted into a marketable commodity
without causing moral conflict. Discussing sex is considere taboo in Thai society; however,
available information suggests that sexual attitudes and the behaviour of both men and women
is changing, from pre-marriage through to wedlock [The Nation, Yearend Review, 1994].
For example, in Thai society, extramarital sex is not only manifest in the patronage of
minor wives, but also in the form of buying one’s pleasure. City men now go to sex
entertainment places for more than just enjoying themselves. The luxurious forms of sex
entertainment, such as offered by cocktail lounges and member clubs, is widely used for the
purpose of business advancement too. A recent research study3 on "educated girls becoming
commercial sex workers" indicates that several firms now allocate some "entertainment" budget
for their executives to pay for their memberships in night-life clubs. This study concludes that:
"generally, Thai men regard purchased sex as windfall profits in life. And when called upon to
entertain their business guests, they often think of sexual services as the most satisfactory
means". It is stated that young Thai females are encouraged to prefer to have sex with persons
from higher socio-economic status or Western "strangers". This nuance is not available either
in the Western or other Asian texts.
A look at the Buddhist forms of Thai sexual culture also reveals interesting elements.
Buddhism preaches modesty, abstinence and chastity - one might deduce that there is a cultural
regularity within Buddhism. However, this regulation does not repress or control sexuality. It
provides positive motivation to give up the search for sexual pleasure or following erotic desire.
If such assertions are true, we confront three major issues on HIV/AIDS.a.
Is there a loosening of social control that resulted in increase of sexual behaviours that
lead to HIV/AIDS infection?
b.
In many ways sex has become a commodity in Thailand. Though Western media has
commercialised sexuality for long, it did not allow commercial sex workers on a large
scale to exist. If so, why and under what conditions commercialisation of sex took place
in Thailand?
c.
Why should newly acquired power and wealth be used to claim sexual services or
command women for sexual needs?
"Educated Girls Becoming Commercial Sex Workers", a thesis submiited to the Graduate School at Srinakhariunwiroj University,
Bangkok by Chongchit Soponkanapom in 1994 [unpublished].
HIV/AIDS in Thailand
[4]
The present state of the commercial sex industry in Thailand is that it is highly visible,
economically successful, internally differentiated and illegal. Commercial sex industry no more
depends on tourists alone, and has established a "local market" too. It is an irony that since the
1960s the main policy issue has been how to reduce the size of the industry while, in fact, this
period saw the greatest growth of the industry, often under the indirect patronage of the
government. Three major factors can be linked to the growth of the commercial sex industry in
Thailand viz., gender roles, economic development and tourism. These factors are discussed
below along with others to provide an overview of the present circumstances.
2.1
Context of Sexuality and Sexual Behaviour
The most discussions on HIV/AIDS is largely limited to the following: human sexuality
and the social consequences viz., [a] those focusing on sexual behaviour itself, its analysis and
change; [b] those focusing on the context that helps to clarify various forms of contemporary
Thai sexual behaviour. The former group emphasise change in "knowledge, attitude and
practice", whereas the latter group look forward to "socio-cultural-structural" changes.
Thailand is sometimes portrayed in the Western mass media as a sexually permissive
society, but the reality is far more complicated. Social conventions governing sexual practices
between unmarried Thais may be changing in response to numerous social, demographic, and
epidemiological pressures; still, these conventions remain quite distinct for Thai men and
women. Evidence is available to indicate that the occurrence of premarital sexual relationships
was not unusual in the Thai society.
2.2
Attributes of Economic Development4
The pandemic of AIDS in Thailand is best understood by looking at the fundamental
changes in rural Thailand that caused massive alterations in the physical and social environment
which led to the substantial migration to the cities since the early 1960s.
Economic development in Thailand has had a strong international orientation. In the
1950s and 1960s, this was immensely related to investments made by the United States. These
investments were mainly undertaken for strategic reasons by the US, but the result was large
transfers of money and men into Thailand. Most of these men were military personnel who came
to Thailand for short periods of time, either to serve at US military bases established in Thailand
or in the neighbourhood. Their presence in Pattaya and other centres allowed the formation of
"night entertainment" centres. After the Americans left, these centres survived and expanded on
the basis of tourists. But the more important US investment has been to transform agricultural
base of the Thai economy into a manufacturing and export-oriented economy. This change
steadily began sometime in 1970s.
Refer to Santasombat, 1992; Sahasakul, 1992; and Krongkaew, 1993.
HIV/AIDS in Thailand
[5]
In the early 1960s, the first National Development Plan was formulated and implemented
under which farmers were persuaded to plant cash crops and new varieties of rice that produced
higher yields. The expected higher cash income was a very persuasive argument and the plan
turned out to be successful. Thus, a subsistence rural economy was transformed into a market
economy. Production of cash crops needed external inputs such as fertilisers, pesticides and
chemicals for which farmers obtained loans from various sources. However, yield was not
sufficient every year, and there were some difficult periods. To avoid destitution, farmers
resorted to seasonal migration to urban areas, and returned to native towns in time for planting
and harvesting. This seasonal movement steadily developed into a quasi-permanent or near
permanent migration to industrial or metropolitan areas seeking a livelihood.
The important military-related investments and impact of national development plan have
been the domestic economic policies which have attempted to transform Thailand’s agricultural
economy into an economy with a high proportion of its nationalproduct derived from the export
of industrial goods and provision of services was introduced in late 1960s through early 1970s.
Economic growth during the 1970s was high, due in large part to high prices of farm products
on the world market, a decline in prices of agricultural goods at the end of the 1970s coupled
with a rapid escalation in the price of oil, depressed the Thai economy and prompted the
government to apply for World Bank structural adjustment loans.
However, a shift in emphasis from agricultural to industrial exports, and from import
substitution to export-led growth, has also resulted a shift in the spatial concentration of
development efforts and in labour force demands. The strategy of structural adjustment was
pursued in conjunction with extracting surplus from the agricultural sector for industrial
investment, subsidising urban dwellers in order to keep urban wages low, encouraging foreign
investment and promoting tourism [TDRI Reports].
A few negative outcomes of this development strategy have been increasing inequality
between areas and among social groups, marginalisation from economic development of some
groups, and the increased commercialisation of Thai society. These processes are apparent in
the contrasting patterns of urban and rural development. Poverty in Thailand is overwhelmingly
rural-based, and its concentration is increasing. It also resulted in the inevitable
commercialisation of the rural economy, and every feature of the villages is integrated with the
urban economics and markets.
The growth of urban economic opportunities has led to increased level of migration,
particularly among females. Migration to urban centres is dominated by women and this
domination has increased over time. Unfortunately, female rural-urban migrants are confronted
with low-paid jobs, which while adequate to meet the costs of urban living, provide them with
little additional money to remit to their families.
2.3
Varying Sexual Behaviours in the Urban Context
Beginning in the 1960s, Thailand experienced two major developments viz., [a] effects
of family planning; and [b] industrialisation, urbanisation and the resultant migration of rural
HIV/AIDS in Thailand
[6]
people to urban areas. Urban areas allowed young people to select a more permissive lifestyle.
Women too gained mobility and access to contraception which altered their outlook. At the same
time, remained as urban male-dominated, tourist-oriented economy feature of the city. As
Thailand opted to promote tourism as one of its leading sources of revenue, it has also selected
to sell all possible commodities, including its women. Most of the "tourist" places e.g.,
entertainment centres or service organisations - centred around women to bring in cash.
Different forms of commercial sex was made available to accommodate various demands of male
customers. As "casual" evening encounters occurred in the urban areas where there is less social
control and probable anonymity, women were more free to make use of those meetings; the
sexual behaviour is considered as an individual act or choice.
The rapid change in sexual behaviour and attitudes among urban youth adolescents,
especially those who migrated recently from rural areas and lived in non-family settings, led to
several other changes within the community. It is obvious that attitudes within this group reflect
such changes from traditional norms of behaviour, but also a continuity with the traditional
differentiation of gender roles. The traditional pattern requires unmarried girls to refrain from
sex; for boys it leaves the option to visit commercial sex centres. This pattern continues to exist,
but a new pattern arises where boys [mainly in university campuses] search actively for sex with
girlfriends and where girls, while avoiding casual sex, accept it within steady relationships change of the old active-passive gender differentiation.
It is no surprise that these relationships are not immediately stable or permanent. In
practice, serial friendships with different partners take place. It is obvious that the threat of an
overlap of two patterns i.e., sex with commercial sex workers and sex with girlfriends. The
passive, non-initiative role of the girls suggest that they are almost powerless to address, discuss
or demand safe sex techniques.
2.4
Gender Roles and Commercial Sex
Traditional views explain sexual relations as a passage to marriage and the starting of a
family, as defined by family, kin and community. The sexual behaviour of an individual was a
community concern as well, and the community members had various means of sanctioning
sexual behaviour, such as ancestral spirit cults or gossiping. Hos has this process of social
control altered in recent times?
In this context, the position of women in Thai society has been the subject of much
debate, partly because of the complexity of defining women’s status, and largely due to current
role women have in the urban or household economy. A common assessment based on socio
economic indicators such as education and labour force participation, is that Thai women do not
suffer major disadvantages compared to men [Limanonda, 1992; Wathinee, 1994]. Patterns of
economic development have increased women’s economic roles and reinforced their autonomy.
However, there are a number of factors which run counter to these trends and have created an
ideology in which a woman’s physical beauty is considered as her major asset. Key among these
factors has been the expansion of upper-class values associated with the roles of women.
HIV/AIDS in Thailand
[7]
In the rural areas, Thai women always had major economic roles and a high degree of
autonomy. Much of Thai society, especially in the North is matrilineal, with the youngest
daughter expected to inherit the family’s agricultural properties. But in upper-class Thai society,
women were totally separated from economic activities and were expected to pursue "feminine"
interests [Santasombat, 1992]. Many of these interests were focused on pleasing their husbands.
Additionally, polygamy was widely practised by Thai upper-class men and was viewed as a
prerogative of psoition and economic success. This stress placed on feminine values found in the
upper class has spread throughout Thai society, even though there has been concurrent
improvements in female education and access to modern sector occupations. The stress placed
on beauty and service to men was reinforced by the mass media.
Women had less mobility, less access to travel and less sexual freedom than men, though
there was the possibility of pre-marital sex. Rural women married at a young age, and the
marriages are not arranged. Thus, marriages are pragmatic unions and marriage partners are
chosen first and foremost for their reputation as reliable. As such, some women saw marriage
as an avenue for social mobility, or a vehicle to escape obligations to her family. The
unbalanced societal expectations of boys and girls in relation to the family stipulated that, for
example, in case of hill tribes, women take responsibility for virtually everything.
It is in this context that some researchers [for example, VanLandingham et al., 1993] and
activists agree that many women view commercial sex as a tool to become upwardly mobile, and
not in opposition to moral principles, if there are no alternatives to "fast-buck" employment
[Chayan, 1993]. Many women also tend to internalise the external associations with commercial
sex, such as male attention, entertainment or wealth. For example, commercial sex may be seen
as a much more glamorous job than working at a construction site. Moreover, the tendency to
relate commercial sex with tourism is discounted by many [e.g., Chayan, 1993].
Other factors associated with women’s roles in Thai society also help explain the constant
supply of women available to work in commercial sex industry. There is a deep-rooted cultural
expectation that daughters contribute in every way to support their parents and families. This
expectation, in conjunction with an economic structure which provides relatively high rewards
for work in the commercial sex units, can represent a strong motivation for young women to
enter into selling sex. The matrilineal basis of Northern Thai society provides an added incentive
for daughters to support their parents as they would eventually inherit from their parents
[Pramualratana, 1990].
The view that men are sexual predators and that their sexual appetites must be satisfied
if the virtue of "good" women is to be protected is also common in Thai society. Many even
argue that "sex-related crime rates would increase if commercial sex centres are banned". This
view supports the continuance of commercial sex centres as outlets to protect the larger society!
Thai women, in contrast, report extremely low levels of premarital or extramarital sexual
activity, do not make use of commercial sexual outlets [although some of them have experience
in selling commercial sex], have had fewer STDs, and make little use of drugs or alcohol. Based
on observations and documents one could conclude that for the majority of Thai women, their
major HIV risk factor is sex with their husband or regular partner. In fact, the rate of infection
HIV/AIDS in Thailand
[8]
at antenatal clinics is increasingly rapidly as a consequence of this. A small number of women
may also be at risk from non-commercial casual sex that is now common among never married
women [living both in urban and rural areas]5.
Among women, HIV/AIDS risk perceptions are varied: married women attempt to assess
the sexual behaviour of their husbands or partners; never married women maintain a lesser check
list. This may be due to poor knowledge of HIV transmission modes or lack of knowledge of
risk behaviours on the part of their partners. Commonly, risk perceptions did not influence their
spouses or partners to reduce or eliminate risk behaviours.
Generally, Thais6 tend to describe the political economy of sexuality and locate the issues
of HIV/AIDS that has allowed within various forms of "less control" and "change of contents".
2.5
Power and Prestige
An attempt to understand the sexual relations and sexual behaviour of contemporary Thai
society has to look at the phenomenon of rural-urban transformation and power relations.
Generally, increased mobility plus urban lack of social control created a series of opportunities
for sexual liaison of a casual, not necessarily commercial nature. Most interestingly, the pattern
described varied clearly from a universal Western-style. These relations, for example, were not
characterised by individually-expressed personal emotions, but showed a high degree of
instrumentality; sex was used as an instrument to achieve something else e.g., access to power,
wealth or prestige [Chayan, 1993].
Thai sociologists concede that the socio-cultural forces play a significant role and altered
the sexual norms of adolescents. The changes were attributed to a general loosening of family
control over young people’s behaviour, increased inter-sex interaction of young people, and to
liberal access to sexually stimulating materials. Part of this might be due to some global trends
that induces people to seek material aspirations.
2.6
Levels of Risk Behaviour
The change in the risk perceptions of the sexual behaviour needs some attention i.e., [a]
an individual choice or act in the urban area; [b] no longer part of the biological life cycle and
aimed at reproduawion; and [c] sex is merely viewed as a pleasure act. This description
somewhat fits into the middle class universal perception of ’’sex as an instrument for useful
purposes". Thai situation may not support that notion, but what is slowly occurring is: increased
permissiveness is felt and a process defined as sex becoming a commodity and as urban
phenomenon. Thus, a new form of sexual expression has gained acceptability i.e., sex without
commitment.
5
For example, Werasit et al., November 1992.
6
For example, Chayan V., 1993 and discussions Khun Sunatree of CARE, Chiang Mai.
HIV/AIDS in Thailand
[9]
Descriptions of change in sexual behaviour and related risk behaviours within their
meaningful context demonstrates that the observed changes amongst Thais are not identical with
Western patterns of increased sexual freedom or looseness. It is only that there is greater
tolerance among Thai youth for pre-marital sex, continued gender differentiation, extreme gender
disparity which does not fit into any Western discourse. Thai women, historically, had more
freedom to act and move autonomously, to make decisions on marriage or migration. One
possible conclusion from this: different mode control over sexuality constitute variations in, for
instance, form, organisation and openness of commercial sex.
Some analysts [e.g., Phongpaichit, 1991] even argue that women have become free from
older forms of control, decline in population growth as less time was spent on child care or
women who migrate and engage in sexuality for survival. However, they admit that even non
commercial sex is dominated by money and power.
2.7
Sexual Behaviour Patterns Among Youth
Boys were, and still are, socialised from a young age to value experience and knowledge
gained from the concept of f,pai aoe sao" [visiting and courting girls], and have more freedom
and few responsibilities. Most young men learn about sex by visiting prostitutes, or being with
girls who are sexually experienced. It is their peers and elder friends who help teach them to
go through the process of sexual initialization.
2.8
Community Perceptions of Risk and Some Reflections7
If the self-reported information gathered by several surveillance centres [e.g., Thai Red
Cross Society; San Sai Health Centre, Chiang Mai] is correct, then men and women exhibit
radically different patterns of HIV risk behaviour. Many Thai men have large numbers of sexual
partners, both pre-martially and extra-martially. They visit female commercial sex workers, and
generally do not use condoms. Majority of them drink alcohol, reported sex after drinking,
occasional use of drugs and have had experience with STD-infected persons.
There might be a "concealed reporting" of sexual behaviour by women e.g., many of the
males reported that their first sexual associate did not become their spouse or regular partner.
If men have a great deal of sex outside of relationships and women having little means, then
there must exist a small portion of the female population which is very active and is servicing
the majority of the male population. These individuals are commercial sex workers, who are
readily visible and accessible throughout Thailand, in both urban and rural areas.
Because such a small female population is servicing a large male population, both the
frequency of encounters and the risk of HIV infection for these women must be high, especially
given the low levels of reported condom use in commercial sexual centres/transactions. This risk
7
This section is based on discussions with Dr Chayan, Dr Praphan, Dr Wiwat, Dr Bennett and Dr Peacock.
HIV/AIDS in Thailand
[10]
is reflected in the phenomenal high rate of HIV infection in the commercial sex workers,
especially in those working in low paying brothels who have many customers each day. At the
same time, these women are also at risk of other STDs which may enhance the transmission of
HIV, both from customer to sex worker and from sex worker to clients and/or children, placing
both at greater risk. This is supported by the fact that so many males in every area have reported
experience with STDs and also by the high rates of HIV infection in men attending STD clinics
in the country.
Men living in rural areas prefer to maintain anonymity and do not openly accept visiting
commercial sex centres. Moreover, for married men it might be difficult to spend evenings
engaging in commercial sex, or lower economic ability of these to obtain the cash required to
purchase it. One could conclude that in the rural areas it is mostly young, single men who might
predominantly engage in commercial sex and condom use amongst them may be lower.
Almost every "normal" man one encounters view themselves at no risk of HIV infection.
This indicates an immediate need to raise risk perceptions and make clear to the public the high
levels of HIV infection in Thailand.
Several people present during field discussions believed that one of the high risk group
is "military men". Ties between military men and rural communities is strong as most soldiers
come from rural villages and a significant proportion are stationed in rural areas during part, if
not all their time of service.
Besides the movement of these relatively high risk groups, other forms of internal
migration are also taking place in Thailand at a significant rate. Particularly noteworthy is the
movement of unskilled labourers, men and women, from rural communities into urban areas.
Because of the workers’ high level of replaceability, their jobs are among the least secure in the
event that they come down with the disease. Thus, the cost of AIDS to them and their families
is high. Also, important is the "reverse" migration of adults from urban areas to rural areas in
the North and Northeast.
Finally, mention must be made of the substantial number of Thais travelling overseas in
search of employment. It is estimated that about 100,000 Thais [most from rural areas] are
working at low skilled jobs in the Middle East and East Asia. While many of these workers are
tested for HIV antibodies before leaving the country, an unknown number re-enter Thailand
carrying the virus. The risk is particularly high for women who are hired to work as bar girls
and entertainers in Japan and/or other Asian nations.
The widespread movement of individuals, especially those already infected with HIV
suggests the need to distinguish between the site of HIV transmission and the eventual
distribution of people with HIV/AIDS. While the former information is important for the
planning of AIDS prevention and education campaigns, the latter may prove more important in
gauging the long-term impact of the pandemic.
HIV/AIDS in Thailand
[11]
I
Section 3
HFV/AIDS Knowledge and Attitudes
During field work, Phra Pong Thep informed that someone had died/suffering from
HIV/AIDS in two villages i.e., Bang San and Ban Chan near Chiang Mai8. We visited these two
villages and met village leaders, youth and school teachers. Recent HIV/AIDS deaths in this area
enabled us to question people on on their attitudes towards [i] those living with HIV or, [ii|
those dead [s/he] as her/his health slowly deteriorated as a result of suspected HIV infection.
Progressively, we built a discussion on their knowledge and attitude of HIV/AIDS.
Most Thais are aware of HIV/AIDS, and the problem has passed the stage of "denial".
They are aware of HIV/AIDS, but there are gaps in their knowledge. Some view it with
trepidation, others with little hope or rationalise their risk behaviours. People believe that they
can always detect an HIV carrier, which may allow them to rationalise risk behaviours. A large
majority of Thais do not know specific transmission modes and discreet efforts are made to
stigmatise those infected. There is widespread discrimination of those infected, and it is believed
that only the poor will get easily infected. The speed with which HIV moved from the relative
confinement of homosexual and IVDU communities to the wider heterosexual community has
been been a point of discussion among the general Thais and their response to HIV/AIDS.
For many, an awareness of the significance of HIV and behaviourial modification took
place only when they saw physical results of HIV/AIDS. The response was with a "disbelief" as
AIDS-related case [ARC] deaths began to rock their own villages. In the initial stages it surprised
many as one was generally confronted with "healthy Thai people" with sufficient income levels.
They began to accept prevalence of HIV/AIDS in their villages once many persons were reported
affected and it became "normal" to be a PWA in the area. It is not clear as to when this change
process occurred. Some village leaders speculate that "acceptance" of HIV/AIDS began sometime
in late 1992.
The general reaction of villagers to those with HIV/AIDS was clear: ostracism of the
afflicted, and an environment of shame both for the afflicted and their families. Informants
claimed that they feel sympathetic for those infected with the HIV and care for close kin, they
would not do so for those who were not so close. Some women were rejected by their husbands
or children if they contracted HIV; in some cases, women have also rejected their HIV-infected
husbands.
Largely, individual members of the families, isolated persons living with HIV/AIDS
provide only little care. Discussions regarding the care of people with HIV/AIDS suggest that
there is little understanding of issues such as a lack of appetite and the need for emotional
8
With Phra Pong Thep, the members of the study team [Vitoon, a local anthropologist, Shivakumar and Som| visited two villages in
the area on July 14th and 15th, and had discussions with the people on the local "development" issues in the area. This discussion
slowly matured into a debate on HIV/AIDS situation and their personal views were elicited.
HIV/AIDS in Thailand
[12]
support. Villagers place some restrictions on the persons living with HIV/AIDS e.g., separation
of food, communal facilities like water; methods to minimise physical contact with persons living
with HIV.
As a result of this highly negative response to people with AIDS [or PWAs], a prominent
feature of the pandemic is a high suicide rate amongst those infected with HIV. There is little
official data on this; village informants and NGOs suggest that many infected with HIV exhibit
a suicide syndrome. Suicide may take place either on learning of infection, or when it becomes
difficult to hide the condition from others due to opportunistic infections associated with AIDS.
As AIDS and ARC-deaths have become a prominent feature of many Northern Thai
communities over a relatively short period of time, some of their reaction towards people living
with AIDS and to ARC-deaths seem exaggerated and irrational, and suggest a lack of
understanding about AIDS. It could be argued that these are couched in traditional cosmological
classifications and patterns of reactions to any contagious disease and deaths.
3.1
Religion and HIV/AIDS
In Buddhist villages of Thailand, where the concepts of sin and morality are
fundamentally different from those found in the West, the cultural basis of the stigmatisation of
people with HIV/AIDS function differently from that found in disease epidemics in Christian
Europe or Islamic nations. Moreover, given the absence of moral restraints on male sexual
activity and the lack of moral opprobrium attached to sexually acquired diseases, people like
Phra Chamaroon of Saraburi suggest that it is unlikely that HIV/AIDS in Thailand would be
stigmatised only on moral grounds. Additionally, the stigmatisation of people with AIDS or
AIDS-related illnesses in Thailand must be differentiated from contexts where HIV/AIDS is
primarily associated with homosexuality or drug abuse, and where such persons are popularly
categorised as deviant. Therefore, it is more useful to view Thai response to HIV/AIDS as part
of values concerning illness, contagious diseases, and general beliefs regarding social pollution.
Some of the villagers even asserted that HIV/AIDS infection was a matter of karma, the
rule of mere retribution. In such a context, the conditions of karma must be accepted "because
there is nothing one can do about them." This is particularly the case with respect to issues
concerning health and diseases, where the notion of karma has always served as an important
explanatory tool. Sometimes this tendency attempts to personalise the causes of HIV/AIDS
infection.
In the Thailand of the 1990s, explanations of illness are somewhat complex, and notions
of karma are synthesised with medical model of health and disease. In this context, an
understanding of more serious contagious diseases such as leprosy, cancer and tuberculosis may
be important to understand the Thai reaction to HIV/AIDS. Phra Pong Thep, Rev. Sanan and
Rev. Jerry of CCT summarised that the general response to leprosy, in the past, was a mixture
of "horror" stories and avoidance, and the infected persons were either denied physical care by
their families or, were rejected by their fellow villagers due to fear of contagion from the
disease. Later the situation changed with more exposure and education on the disease and its
HIV/AIDS in Thailand
[13]
effects; for example, those who suffer from cancer may combine merit making and meditation
with radiotherapy and traditional herbs. They anticipate a similar response of the Thais toward
HIV/AIDS which is part of the cultural pattern of reactions to disease epidemics.
3.2
Death of HIV/AIDS Persons and Ceremonies
Death from ARC and related conditions may take place either at home or in hospital. In
case of death at hospital, the corpse may be cremated but, more usually, it is placed in a plastic
bag and taken home for the performance of the mortuary rite. Significantly, the funerals of those
who have died of AIDS related conditions, and who are publicly known to have died of such
conditions, are different from those who die from other causes.
Death from AIDS also characterise "bad death" i.e., it is untimely, it is painful and
prolonged, it is expensive, and disfiguring, and critically, it is the death over which humans
apparently have no control. The mortuary rites of those who have died, or who are suspected
of having died from AIDS, are very similar to the mortuary rites given to those who have died
a bad death i.e., short funerals, restrictions on common sense and fears of entering the house
of the deceased due to contagion. This clearly shows that AIDS related deaths are considered
bad deaths - deaths which are highly inauspicious, highly polluting, and highly dangerous for
those in the neighbourhood. Thus, Thai people, especially in the rural areas, lack knowledge on
AIDS and its attributes - yet prefer to honour the dead through cultural and religious methods
which are carried out in a mechanistic way.
In the Chiang Rai area, several "cremation" associations have been established by local
touts that seek to make quick profits from those who are infected with HIV. These associations
offer "honourable" death ceremonies for those living with AIDS for a huge lump sum payment
in advance.
I
HIV/AIDS in Thailand
[14]
Section 4
Vulnerable Groups
4.1
Commercial Sex Workers9
Most Commercial Sex Workers [CSWsJ consider their occupation as temporary, and
generally feel that HIV/AIDS is not their biggest health problem or concern. They realise that
their occupation is filled with all types of social and health consequences, and AIDS is just one
among them. CSWs have a tendency not to request a "clean" or "regular" client to use a
condom. Their main objective is to serve as many clients a day as possible, and in their overall
opinions, condom use hinders this process. Additionally, if a CSW requests a "regular" client
to use a condom, possibly this might ruin their mutual relationship and trust.
As for the clients, they use price and appearance as screening devices to indicate "AIDS
Free" to CSWs and one for which they will not have to use a condom. Many male members also
appear not to use condoms with their wives, girl friends and casual sex partners. For clients who
do not use condoms with CSWs, they may serve as a bridge for spreading the disease among low
risk groups.
4.2
HIV-infected Women
If the HIV-infected person is a woman, the issue assumes a different perspective within
the family and community. In reality, the number of HIV/AIDS infection cases among pregnant
women, mothers and children are increasing every year. At least half of the pregnant women,
who are HIV positive are housewives. This reflects the painful fact that HIV/AIDS is no longer
outside the family domain, but it is becoming an even more devastating part of it.
Although women were initially mislead to a false sense of security as many of those who
contracted AIDS were men - today there is greater awareness that women are the most affected.
AIDS has become the leading cause of death among women in North and Northeastern parts of
Thailand. Women are particularly vulnerable to HIV infection and the discrimination
accompanying it. Their disadvantaged and subordinate role in Thai society hampers their ability
to both protect themselves from infection and to defend themselves from prejudice and
intolerance. They do not have sufficient opportunities to learn about the disease or how to
prevent it because of the lack of equal access to education and health services.
Women face many difficulties in negotiating safe sex with husbands or partners or clients.
If infected they face the decision of whether to have children, and whether to abort if they are
already carrying a child. Abortion is illegal in Thailand, and young women seek medical
9
Based on literature review and discussions with ACCESS, Empower, Dr Chayan and Rev. Sanan.
HIV/AIDS in Thailand
[15]
I
assistance from make-shift "abortion clinics" which have no facility to perform such tasks.
Recent news reports on "illegal abortion centres" confirm the probability that one of the
transmission routes could be through such places. If they abandon their traditional roles and
insist that their husbands or partners use condoms, the response may be at best mockery or
rejection, at worst violence and abuse. Many married women fear beating or divorce if they
refuse sex or press their husbands to use condoms. They have even less leverage in trying to
promote reductions in their husbands extra-marital affairs.
Women living with HIV infection may be denied medical assistance, rejected by her
family and friends, and forced to leave her job and home. She may be physically abused by her
partner and thrown out onto the streets. Such stigmatisation has occurred even when the woman
has been infected through a monogamous relationship or through rape.
In many districts of the North the rate of HIV infection among pregnant women is
approximately 6 per cent. Women are vulnerable in the spread of HIV/AIDS and are
inadvertently put in a very responsible position: to protect themselves, their husbands and their
children - and care for family members.
The women at highest risk are those under 19 years of age, of low economic status, and
especially those experiencing their first pregnancy. The risk factor associated with infected
pregnant women is the STDs history of their husbands.
Some data is available on the pediatric AIDS that seek to explain clinical and
epidemiological aspects of the pandemic. However, no substantial information is available on
the psychosocial consequences affecting HIV positive women/mothers and children, how they
cope with their lives, and how families and communities react or adjust [positively or negatively]
to the particular issue.
4.3
Children
Yet another vulnerable group are the millions of marginalised children who live on the
streets of the urban centres like Bangkok, Chiang Mai, Khon Kaen and Pattaya. Most of them
are without health care or identity cards. Many of them turn to commercial sex for survival. A
NGO working with the street children in Pattaya and Chiang Mai has regularly screened these
children and estimates that about eleven per cent of them were HIV positive. Street children, by
and large, view adults as enemies, so reaching them is difficult. Three NGOs have opened up
exclusive "shelter centres" for children infected with HIV positive. Several NGOs and
government agencies now focus on campaigns like "children and AIDS".
Some of the recent studies and available data [e.g., Wathinee Boonchalaksi and Philip
Guest, Mahidol University, 1993; surveillance data at the San Sai Health Centre and Health
Sciences Research Institute, Chiang Mai, 1993] indicate that if there is no change in sexual
behaviour related to HIV infection and fertility, the number of child and infant deaths will
increase from several hundred in 1990 to over twenty thousand by the year 2000, and the effects
on mortality will be significant. Also, changes in behaviour can have large effects on the number
HIV/AIDS in Thailand
[16]
of children dying from AIDS. Lower levels of fertility for women infected with HIV virus would
also have an obvious reducing effect on the number of children who would die from AIDS.
The projections predict that by the year 2000 there will be approximately 86,000,000
children aged 12 years and below, and 30,000 children aged under 5 years would have lost their
mothers because of HIV/AIDS. Thus, the number of children exposed to the risk of being
orphaned will grow rapidly over the decade of 1990s. By 2000 AD, there will be over 350,000
living children born to mothers who are infected with HIV, compared to only 5,000 in 1990;
and these children will be less than 5 years.
By the year 2000 almost 7 per cent of children aged 5 will be directly affected by the
AIDS pandemic. A portion of 0.6 percent will have already been orphaned through the death
of their mother and additional 6 per cent will be orphaned or themselves die as a result of AIDS
sometime soon around the turn of 2000 AD.
In any event, the number of AIDS orphans would continue to increase throughout the
decade of 1990s and in the year 2000 a total over 53,000 children aged 12 years and under.
4.4
Street Youth10
Street youth as a group were plagued by family conflict, parental rejection, abuse and
personal adjustment problems. A number of pathways led them to the dangers of city streets.
Most were intermittently on the street for short periods when forced to leave each of a series
of living arrangements provided by parents, friends, relatives, agencies and other social service
organisations.
While on the street they become physically run down because they slept and ate
irregularly, and were unable to keep themselves clean and adequately clothed. Most also
compromised their health and values by using drugs, become sexually promiscuous and, once
entrenched in street life, some resorted to criminal activities, and a few to violence. Many
submitted themselves to the influence of a street subculture that endorsed these activities because
friendships were crucial to their emotional and physical well-being.
It is not known as to what proportion of young people on the streets engage in
commercial sex, unsafe sex, violent sex, and IV drug use with shared equipment. There is some
evidence to suggest that this group has limited and possibly inaccurate information on HIV/AIDS,
its transmission and its prevention. Comprehensive sources of information on the lifestyles of
these young people are lacking. It seems realistic to speculate that street youth may be at
particular risk for contracting this deadly illness. Much of the adolescent behaviour consists of
experimenting with a variety of activities, many potentially perilous, including sex, substance
use and violence.
7
Based on discussions with Duang Prateep Foundation, Empower, Fr Maier and Fr John.
HIV/AIDS in Thailand
[17]
These young people, transient and distrustful of "straight" society, are a difficult group
to reach with social and health services. The effectiveness of education depends on how the
youth view service available.
Currently, a few NGOs have a programme component to particularly take care of "street
children and youth who are infected with HIV" [e.g., Foundation for Better Life; Weing Ping
for Children Group]. If the present indicators are correct, then it appears that this group is the
most vulnerable and their numbers might increase in the coming years.
HIV/AIDS in Thailand
[181
Section 5
Interventions on HIV/AIDS
It is believed that an effective vaccine for AIDS will not appear on the scene until the
end-1990s. In the foreseeable future, communication and education are the only preventive tools
to inform people that they need not "die of ignorance". What strategies have been pursued by
various agencies? Do these strategies have an impact?
Three broad categories of groups participate in the intervention efforts on HIV/AIDS care
and control in Thailand i.e., [a] Government; [b] Bilateral and multilateral agencies [either
independently or through Government]; and [c] numerous non-profit, non-government
organisations [NGOsJ.
5.1
Target Groups for Intervention
Target groups for intervention are classified based on their current occupational or
educational status. Each section contains a mixture of women and youth.
a.
Young Persons
Because of prevailing social practices, many married and unmarried young persons [men
and women] are exposed to HIV and other sexually transmitted diseases [STD]. Those who are
married can, in turn, transmit infection to their wives. In some provinces [e.g., Khon Kaen,
Songkla and Chiang Rai] and among some population groups this spread has already been
documented as well as alarming.
As a result of changing life styles, considerable commercial sex in all urban centres, and
general ignorance regarding AIDS and other sexual transmitted disease, urban youth are
increasingly at risk of HIV infection. Youth with lower income are particularly vulnerable e.g.,
construction and factory workers, people working in tourism and other service industries.
Because of prohibitive medical costs and to maintain anonymity, many young persons
approach pharmacies for self-treatment. Not only do they often get inadequate treatment, but
they receive nothing in the way of advice on how to avoid STD and particularly HIV in the
future.
b.
Women
Women are the most vulnerable group and have become the largest group of HIV
carriers. A rapid increase in HIV transmission has been noted for vertical transmissions from
mothers to their infants. No other mode of transmission involved a higher rate of increase since
the late 1990. Data of ANC clinics are not comprehensive, but indicate 4.5 per cent of pregnant
HIV/AIDS in Thailand
[19]
women tested who are HIV positive in some northern areas to less than 0.5 per cent in other
provinces. The current national average is estimated at one per cent [Refer Ministry of Public
Health documents]. About 70 per cent of pregnant women attend Ante-Natal Clinics and other
Mother and Child Health and Care services and contact Family Planning Clinics - and this
infrastructure to reach this "risk" group and has received strong support from the Government
Departments and to extent some NGOs [e.g., Empower and Access].
c.
University Students and Youth
Middle class young people, including university students, increasingly have access to
information about AIDS and to health services through public and private clinics. The lower
income working youth however, have less access if any to such information. In addition, they
are usually disinclined to use the services of public and private clinics, even when there are
symptoms of STD. There are also psychological barriers to visit public clinics for reasons of
confidentiality and the private ones because of a feeling that they are for other classes.
Youth [Rural and Urban]
e.g., factory workers, construction workers, fishermen,
boat drivers, co-residing workers such as those living in
dormitories, teenagers [including teenage mothers], slum
dwellers and the hill tribes.
Campus Groups
e.g., students, teachers and administrators of first,
secondary and vocational schools.
Out-of-school Youth
e.g., unemployed and/or hard to reach persons including
adolescents, slum dwellers, street children, the homeless,
teenage gang members.
Women at Reproductive Age
e.g., the asymptomatic women attending family planning
and ante-natal care clinics.
Occupational
Groups
5.2
e.g., commercial sex workers, managers
establishments, matchmakers, co-workers.
of sex
Strategies : An Overview
The strategies pursued by the Government and others so far could be classified as: [a]
clinical care; and [b] social care/concerns. The strategies at the local level generally is clinical
i.e., efforts that aim to develop the capacity of district [amphur] level hospitals to deliver care,
treatment and testing services. These service centres are close to most communities to be used,
but far enough from the village community to provide confidentiality desired by the clients.
These services are also offered on an anonymous basis and linked to existing ANC and family
planning services. Some information and education activities will also reach out into village
communities of the district under the general guidance of the physicians. Efforts are made to
strengthen the laboratories, testing facilities and equipments.
HIV/AIDS in Thailand
[20]
The social care proposes to develop AIDS counselling network through activities, such
as training of physicians on AIDS issues; curriculum development for counsellors; to provide
counselling and psychological support to those already infected with HIV; to promote low-risk
behaviour of young factory workers and commercial sex workers; focus group discussions, in
depth interviews, and other social-behavioral efforts to determine appropriate interventions;
development, field testing and use of educational materials.
The present education policy supports inclusion of HIV/AIDS knowledge in the content
of primary and secondary school curricula on Life Experience and Character Development
subjects as well as extra curricula activities such as sports, art, boy-girl scouts, red cross and
girl guides. The main objectives are to develop healthy attitudes to sexuality in children and to
improve their personality development. The Ministry of Education has prepared HIV/AIDSrelated curriculum and instructional materials for the two educational levels, including teaching
guides, lesson plans and reading materials. In collaboration with the Ministry of Health, posters,
pamphlets, slides and videos on AIDS prevention have also been produced. The major concern
of the NGOs at present is not to simply make it another educational module but to involve
children, teachers and parents to make practical use of the knowledge gained.
As a complementary to the above, interventions are made among teachers to provide onthe-job training for primary and secondary schools teachers on how to effectively run an AIDS
education programme; train student leaders to increase knowledge on HIV/STDs and to develop
attitudes for behavioral change and the prevention of HIV/STD\ and increase and improve the
active role of trained student leaders in social activities concerning HIV/AIDS and STD
prevention. This is expected to prepare them to assume leadership roles in HIV/AIDS prevention.
Some groups of concerned people have already commenced interventions among [i]
orphan children; [ii] paediatric AIDS; and [iii] those engaged in fishing, farming and such other
non-urban occupations. In summary, the present efforts are:Clinical Care
o
increased diagnostic facilities, treatment options and maintenance
of progress reports
o
locally developed clinical training kits on HIV/AIDS for physicians
[though still in the preliminary stages]
o
HIV Testing facilities [e.g., trained laboratory staff, test kits and
monitoring to assure accuracy of test results]
o
motivate self-referral by blood donors; periodic versus routine
screening of donors
o
sentinel surveillance to determine the prevalence of HIV [i.e., to
rely more on anonymous testing]
o
sentinel surveillance to include private sector units, commercial sex
workers and IV drug users
HIV/AIDS in Thailand
[21]
Social
Care
0
voluntary confidential HIV-testing at sites separate from blood
banks where persons wanting to be screened can be screened with
appropriate pre- and post-counselling - this is pursued by both
physicians and NGOs
o
monitor use of language in relation to the pandemic
o
regulate information circulated for accuracy, value-freeness and
positive attitude
o
distribution of information e.g., brochures with cartoons and
interesting stories; posters containing information about the
transmission, prevention, diagnosis and treatment of STDs and
AIDs; short video presentations which are interesting and designed
to appeal to specific groups like commercial sex workers by
depicting them in their everyday work context; reinforcement of
STD and AIDS messages by counselling by the clinic staff.
o
Group meetings and peer counselling e.g., Wednesday Club;
Penpals of persons living with AIDS; Women’s Support Groups.
Interventions based on Human Rights Perspective
5.3
o
raise awareness to integrate law and ethics into HIV
policies and programmes; to provide input into legal policy
formulation and legal and ethical advocacy.
o
to appraise individuals affected by HIV of their legal rights
by integrating legal advice into general HIV counselling
o
to file test cases or public interest litigation on select HIVrelated issues
o
to provide a forum for discussion and debate about the role
of the law in the pandemic, and for a comparative
examination of legal strategies adopted by other countries
within the region and internationally.
Role of the Thai Government
Since its establishment in 1942, the Ministry of Public Health [MoPH] has continually
expanded its services in Thailand. MoPH is a complex organisation with responsibilities relating
to the physical and mental health of the whole nation, and each department and each
geographical area has multiple goals that are indicated in their yearly plans.
HIV/AIDS in Thailand
[22]
In January 1987, MoPH stated that the two major public health problems it then
confronted were: [i] the nutritional deficiencies of the Thai diet, especially for poor urban and
rural children; and [ii] some contagious diseases had to be eradicated from some locations of
Thailand. Malaria eradication in rural areas was observed to be illusive. During that time there
was a resurgence of interest in traditional medicine that received Royal sponsorship. Several
NGOs also supported such a move. The 1987 document of MoPH also was concerned with
continued neglect of health needs in Cambodia and Laos that border Thailand. Thus, we observe
that HIV/AIDS was not considered as a "problem" by MoPH as recently as in 1987.
Though HIV/AIDS action was initiated around 1984, yet it was within the context of
health care and attached to public health principles as an extension of STD. Government
initiatives were largely care and support programmes, focussing on institutional care with large
support from bilateral and multilateral agencies, like the World Health Organisation, UNICEF
or USAID.
Some of the earliest attempts at operationalising community health concepts were made
in the context of programmes that promoted the use of contraceptives for family planning. This
pioneering work provides some of the practical demonstrations of the approach on a major scale,
and helped to develop many state-of-art techniques.
Thailand’s National AIDS Programme began in 1987 following a cabinet decision to
develop a national response to the AIDS pandemic. Since then, the Royal Thai Government has
focussed the country’s attention on the HIV/AIDS situation, and has developed numerous national
strategies to address the health, social and economic aspects of AIDS.
In 1987, the cabinet approved the launching of "Thailand's AIDS Prevention and Control
Programme [1988-1991]", as developed and proposed by the Ministry of Public Health. The
following year, with technical assistance from the World Health Organisation, the MoPH
formulated a "Short Term Programme" with an initial funding of USS. 500,000.
Thailand’s "Medium Term Programme" for the Prevention and Control of AIDS began
in 1989. The programme, implemented and directed by MoPH, was a three year plan with
detailed workplans that were developed annually. It included activities in programme
management, health education, counselling, training, surveillance, monitoring, medical and
social care, laboratory and blood safety initiatives.
It was only in 1990, plans were announced to establish AIDS Rehabilitation Centres in
the four regions of Thailand. Some provincial governors opposed this move on economic reasons
as that might affect the tourist trade. While such protests were purely motivated by economic
considerations, some of the government’s attitudes to this programme was also criticised by
social activists and public health educators.
It was during the brief tenure of Dr Mechai Viravaidya as Deputy Prime Minister in the
military-nominated Government in 1991 that the Government publicly acknowledged the
seriousness of HIV/AIDS situation, and announced ''Thailand National AIDS Prevention and
Control Plan [1992-1996]" on HIV/AIDS in September 1992. Quite interestingly, it was not a
HIV/AIDS in Thailand
[23]
simple rhetoric statement; but an amalgam of a wide range of political, legal and constitutional,
and administrative instruments. Perhaps the most significant was the political commitment to
accept the scene on HIV/AIDS, and welcome every NGO, community organisation and social
group to work towards the containment and elimination of HIV/AIDS. This led to the expansion
of NGO activities on HIV/AIDS. Chantiwipa of Empower summarised the effect of that
Government initiative as: "an unique policy statement which provided us the legitimacy to work
with the communities or intervene at the commercial sex establishment level. We could openly
talk about HIV or AIDS."
It was only in September 1992 that the Thai Government publicly acknowledged spread
of HIV/AIDS and noted that:-
"In the past AIDS prevention and control activities have lacked a frame for coordination
of implementation and continuity of effort. Therefore, the National Economic and Social
Development Board [NESDB] has developed this National AIDS Prevention and Control
Plan for the period 1992-1996 under the 7th Five Year National Economic and Social
Development Plan to serve as a framework for coordinated AIDS prevention and control
throughout the nation
This policy aims to prevent transmission with relation to behaviour [sexual and drug-use
practices], and in the medical care setting, to improve the understanding and acceptance
of HIV-infected persons so that they can remain integral members of society. This will
be accomplished through the mobilisation of resources and manpower in the sectors of
government, business, non-government non-profit agencies, and the international donor
community to work together to prevent and control AIDS through support for
implementation of the following four programmes:- public information and education;
medical treatment and care; human rights and social support; and research and
evaluation11.
The Thai government allocated substantial funds to various hospitals and departments
under "clinical care" to HIV/AIDS work. In reality, its major responses were:-
a.
Political will and policy commitment
Public acknowledgement of the prevalence of HIV/AIDS', establishment of serosurveillance centres, National AIDS Committee with the Prime Minister as the
Chairperson; a central coordination body that runs to provincial levels.
b.
Public education
Prior to 1990 the government was reluctant to discuss about AIDS in public as that might
"hurt" tourism and the image of Thailand. Since then television and radio spots have
h
Thailand National AIDS Prevention and Control Plan [1992-1996] published by the Office of the Permanent Secretary, Thailand.
HIV/AIDS in Thailand
[24]
been aired on prime time that warn about the danger of AIDS and explain exactly how
to prevent it. The messages are explicit and clear, and stress the idea that men who sleep
with commercial sex workers should change their behaviour or else use condoms.
Education on AIDS was also placed on the school curriculum.
c.
Protection of blood supply
This was the first prevention strategy of the Government. With the collaboration of all
hospitals, the government established measures to prevent HIV transmission through
blood transfusion. Mandatory screening of blood donations was implemented.
d.
STD control
The government has 215 specialised STD treatment and control units in all 73 provinces
of the country. STD unit provides routine physical check-up and early treatment of STD
for commercial sex workers and male clients with minimal charges. Available data
indicates that with good coverage of STD services both by the government and private
sectors, the rate of all STD has declined since 1988.
e.
Promotion of condoms among CSWs
In the beginning of 1991 with the collaboration between the Ministry of Health, Ministry
of Interior and the Governor of each province, the "condom only" policy in all sex
establishments was launched. The condoms used by the clients of commercial sex
workers is reported increasing and that might have led to reduced STD infections.
Government efforts were also disturbed by ’’fear" campaigns by vested interests within
the provinces or communities. For example, a small centre in Chonburi Province was never
regarded as "successful" and attempts to establish a centre in Lampang Province in the North
on a plot of land allocated for a leper colony, away from water sources, populated communities
and tourist spots, was thwarted.
5.4
Some Common Features and Concerns of Government Interventions
Any government development initiative has numerous complex components. HIV/AIDS
interventions also face similar challenges that most government initiatives confront. The studied
observations and views of those interviewed could be summarised to concisely locate the
response of the Thai Government to the pandemic12. Acting primarily from a social planning
approach that over time has included some aspects of the goals proposed by the Government and
the following has been the development techniques used by the government [and MoPH] via.,:-
12
These observations were received through personal communication from Dr. Praphan, Fr. Jean Barry both of Thai Red Cross, Dr.
Voravut of San Sai Hospital and Phra Charmoon of Saraburi.
HIV/AIDS in Thailand
[25]
o
o
o
o
o
o
o
o
Infrastructure development in health care
Government facilities improvement
Creation of new Departments or Bodies
Allocate more resources
Encourage self-help by individuals and community groups
Expansion of knowledge and change in attitudes or values [through campaigns]
Improvement of quality of services being provided
Collaboration with NGOs
The weakness of the responses of the Thai Government to HIV/AIDS work can be
summarised as follows:o
Screening and treatment only to "Thai nationals" is discriminatory as those
"illegal" migrants from Myanamar and Cambodia do not come forward for testing
or clinical care; this is applicable even for those hill tribes in the Northeast, who
have not yet "joined" the mainstream Thai society.
o
Many of the initiatives lack commitment, and merely show a Government
presence in the affected areas. Therefore, resources are not allocated in time for
intervention.
o
Government is merely keen to minimise the damage to Thailand’s image and its
tourism development plans through a comprehensive propaganda that informs
"absence" of HIV/AIDS to public.
o
Government has made elaborate tourism development plans that aim to increase
more tourism-based development opportunities in the border areas offer economic
hopes to rural poor through relocation and migration opportunities; this depriortises the prevailing pandemic conditions.
o
Neglect of formal education [general and specialised] that would stress on
integrated social development rather than economic gains alone
o
Inadequate expansion of basic facilities and services
o
Refusal of the Government to legalise commercial sex establishments [and
therefore possibility to regulate commercial sex establishments and CSffly]; in
fact, Dr. Praphan argues that legalisation of commercial sex centres would allow
medical personnel to intervene among women who sell sex. In his view this is
necessary to curb spread of HIV infection.
It was also noted that the Government has not taken steps to strengthen additional
supportive environment for primary prevention of HIV, such as expansion of education, reform
social norms related to multiple partners, regulations on abortions, materialism and overcome
poverty in rural areas. The preventive efforts remain weak as not much information is made
available on specific underprivileged population subgroups, who are vulnerable to the pandemic.
HIV/AIDS in Thailand
[26]
5.5
Participation of Bilateral Agencies
Bilateral aid to challenge AIDS was quite significant since the 1980s. It now provides
somewhere between USS 100-120 million per year. This aid has enabled free flow of technical
expertise or equipment, and opportunities for broader exposure and study that often accompany
aid projects. These agencies considerably support HIV/AIDS education programmes for people
who are not infected with HIV, to educate them to understand and accept that such infection is
preventable by maintaining or altering one’s sexual and/or drug use behaviour. Basically the
efforts aim to reassure people that HIV infection can be controlled and that they themselves are
able to manage it.
Agencies like AIDSCAP, have evolved multi-sectoral involvement as an essential
component to develop an adequate local understanding of the determinants and consequences of
the pandemic, and was therefore planned as an integral element of their activities. The
experience of these agencies indicate that multi-sectoral involvement requires much more than
just education/information activities provided through different sectors to address determinants
and consequences of the pandemic, development of adequate infrastrastructure within
communities and workplace policies, and implementation of effective strategies to deal with the
complex interactions between HIV and development. They also work to integrate HIV into the
normal work of various local level government departments.
Bilateral organisations have also independently launched AIDS programmes in Thailand:
The AIDS Control and Prevention Project [AIDSCAP] of the Family Health International
is designed to support the local capacity to prevent and control AIDS. It aims to reach
individuals at risk of HIV infection through clinical care, education and increased access
to and use of condoms. It takes an active role in ensuring that policy makers have
complete information on HIV infection and prevention activities, have best available
analysis of likely outcome of various policy choices, and become, when appropriate,
personally vested in prevention and control efforts. It has policy support, grants and
research activities.
CS3
Thai-Australia Northern AIDS Program [NAPAC], Thai-Australia Non-Northem AIDS
Program [NONAP] or, Australian International Development Assistance Bureau
[AIDABJ's AIDS Programme aims to reduce the rate of transmission of HIV/AIDS
infection in Thailand. These efforts collectively assist government, non-government and
private sector organisations to develop effective measures for the prevention and control
of the disease, and to develop and implement strategies for the care of those infected with
HIV/AIDS. It provides financial support to AIDS initiatives developed by local
organisations to various regions in Thailand. Currently, about fifteen projects are
supported and a larger number is linked through networks.
rar
Independent initiatives of agencies, like USAID or the Dutch Embassy, is generally
through a local partner organisation. For example, USAID works closely with AIDSCAP
and Duang Prateep Foundation; the Dutch Embassy supports the programmes of the Thai
Red Cross Society [in collaboration with UNICEF].
HIV/AIDS in Thailand
[27]
5.6
Response of the Thai Business Community13
Continued economic boom will result in enhanced roles of the private sector at all levels
of the Thai society. In Thailand, rapid economic development and urbanisation have resulted in
greatly increased numbers of young people working in factories. The most important age group
among young factory workers also shows the highest HIV/AIDS prevalence rates. The 15-24
years age group, both male and female, accounts for 66.3 per cent of all presently HIV infected
people. Most factory workers have only primary education and in general have less access to
health services and information/education services on STD/HIV/AIDS, due to their socio
economic status. Most of the workers live in dormitory-type of residential units without any
normal family ties, and fall prey to the usual attractions within an urban setting. Many of the
workers were observed to be sexually active with CSWs. This in turn affected the employee
turnover and may affect productivity.
The business community began to consider HIV/AIDS as a problem sometime in early
1992 when casual medical tests of workers indicated the arrival of HIV/AIDS in the factory
premises. The nature of business community’s attitude has undergone a quick change over a
period of two years, both through private and government stimulation. The current thrust of the
business community is to press for more open propaganda and other forms of communication
that are more informative and persuasive. Some industrial units in Khon Kaen, who have
participated in the programmes of the Thai Red Cross Society, do have some guidelines and
internal policy on such issues like maternity leave or abortion. Their strategies include:-
5.7
o
Authorise increased ’’educational’' campaigns and distribution of condoms within
the factory premises [Thai Red Cross and UNICEF are currently carrying out
some programmes at the factory premises e.g., UNICEF and Thai Red Cross
initiatives in the industrial units located in Khon Kaen region; a day workshops
on HIV/AIDS of Thai Red Cross organised at various industrial units in Thailand].
o
Allow regular visit of Counsellors/Trainers to the factories.
o
Financial contribution for HIV/AIDS activities within and outside factory premises
e.g., workers’ residential areas.
Community Outlook and Practices
It is a tradition in Thai society that relatives look after their own sick family members.
At the village level, people do visit a sick person and provide support. In the same vein, many
people would indeed take care of their family members when any of them were ill of HIV
infection. This is despite the fear of stigma, and possibly the family itself supports the seemingly
irrational fear of transmittablity. There were at least four instances, in Bang Chan village and
neighbourhood, where the family members remained compassionate towards the ill person, and
13
Based on discussions with Dr. Peacock, Dr. Kruse and Dr. Barry.
HIV/AIDS in Thailand
[28)
long discussions with them indicated that their personal support has encouraged the sick person
to recover well.
Generally, the initial response was compassion and sympathy. They did express fears of
infection - yet "duty" concept within the family made them to overcome ambivalent feelings and
be sensitive to the HIV-infected person or PWAs. Overall, it is evinced that the family will take
care of any members who might receive HIV infection, the family can and will attempt to
provide good care and support, with some reservarions. Protection care at household level was
taken, such as: separate dishes, offer clean and separate toilet facilities.
The difficulty appears to have arisen only where the family disregards the ill person.
Such an attitude limits the integration of PWAs or HIV-infected person into the community. The
discrimination and stigma associated with them outside the family raises the questions as to
whether there will be individuals without families to support them. However, during the field
visit, the researcher did notice a number of HIV-infected persons without family-support. One
could conclude that the community at large responds positively if and when the family is
supportive and helpful.
HIV/AIDS in Thailand
[29]
Section 6
Hospice Approach14
In Thailand, most of those infected with HIV are from poorer communities, and at times
refugees from the neighbouring nations; half of all deaths are infants, children or women. In
many poor communities HIV-infected women and children are scorned and neglected. In
general, refugees and poor people’s lives are characterised by almost continuous ill-health; a
high proportion are also disabled. Therefore, the problem of HIV has to be viewed in terms of
severity, scale and, in some cases, residential location among the poorer sections.
The poor in urban areas live in crowded tenements, cheap boarding houses or illegal
housing and usually suffer comparable or even higher rates of disease and death than their rural
counterparts. The close proximity of large numbers of HIV-infected persons in urban areas, in
an environment which provides no protection, often results in disastrous epidemics and quick
social isolation of PWAs.
On the other hand, in the rural areas the reality is different: population density is less;
social and family fabric is strong; and, therefore, chances of a PWA gaining good health and
confidence appears bright. However, in the countryside, people are fed with myths, rumours and
soap opera stories on HIV/AIDS, and this results in PWAs constantly moving out of the villages
to protect their identity and honour.
In such circumstances, it is imperative to increase the PWAs access to health care and
emotional support, and enable reunion with their families and rehabilitation possibilities. Such
an effort, even symbolic, could demystify some of the misinterpretations on HIV/AIDS, provide
hope to PWAs and their families. As a response, a few NGOs have pursued "hospice" approach a strategy that was effectively used among cancer patients, a century ago, when that disease was
considered as dreadful. This approach was considered necessary as more and more HIV-infected
people were found to have been rejected by their families and remain without appropriate
support and social-psychological backing. The main purposes of hospice are:o
o
o
14
to offer immediate nursing care, counselling service to any HIV infected person;
to enable PWAs and their families gain proper understanding on HIV/AIDS, their
physical conditions and enable them to live confidently as a normal member of
the society; and
it is considered as a wholistic care in which members of the family are
encouraged to accept PWAs.
Data for this section was gathered between April and August 1994; a second round of information collection was pursued between
20th and 24th October 1994. During the second round of interviews following persons were met: Fr. Jean Barry [20th]; Fr. Giovanni
and Ms. Usanne [21st]; monks at Dhammarak Nives, Lop Buri [22nd]; and visit to the National Institute for Communicable Diseases,
Bamrasnardoon Hospital [24th]. For purposes of easy reference and to maintain independence of this Section, discussions here are
not explicitly quoted elsewhere in this report.
HIV/AIDS in Thailand
[30]
Hospice approach relies on three major components: [a] terminal and continuing care;
[b] elicit family support and enable PWAs re-integrate with their families; and [c] train people
on symptom control. Generally, when the members of the family get involved, they learn also
on symptom control. Thus, the approach is much more than mere medical support; it has
elements of personal and spiritual care too. Commonly, hospice projects require the following
as the essential resources
O
O
o
o
o
o
6.1
proper understanding of the HIV/AIDS issues;
land and building;
trained personnel;
availability of medical care/hospital and life saving services;
participation of family members; and
finance/material support.
History of Hospice in Thailand
In Thailand, hospice concept was introduced and nurtured by Fr. Adriano, a catholic
priest15; he was earlier affiliated to the National Institute of Communicable Diseases
[Bamrasnardoon Hospital] in Bangkok which was the only centre where HIV-infected people
could be accommodated for medical/nursing care till early 1992. However, the number of
patients who sought care and support at this hospital rapidly increased, and the hospital
authorities could not accept more persons though deserving, and needed immediate attention and
care. In due course Fr. Adriano also observed that many PWAs were rejected by families and
remain as "social orphans".
To cater to this category of PWAs, Fr Adriano established a small "hospice" centre, with
a capacity to accommodate a maximum of five persons, at the Our Lady of Mercy Church, a few
kilometers away from the Bamrasnardoon Hospital in the Nonthaburi Province. There were no
specialist doctors on HIV/AIDS to take care of the patients or offer training to other paramedical
workers who could take care of PWAs. The resident-PW/Ls of the Church could get general
medical care from the Hospital, and the volunteers of the Church provide emotional and spiritual
care at the hospice centre. After sometime the Parishoners raised objections to the continuation
of the "hospice centre" within the Church premises.
Fr. Adirano explored several other locations [including some of the Buddhist temples]
but could not establish the centre as people were not enthusiastic to welcome HIV-infected
persons in their neighbourhood or in the temples. It was only in 1993 that the Carmillian Priests
could rent a small place to accommodate fifteen PWAs. Even today, in the strict sense, this
Centre cannot be classified as an hospice venue as it offers only some facilities and amenities.
A few even argued that presence of PWAs within the religious premises would diminish the
sanctity of that place.
15
Traditionally, Buddhist monks are considered as "healers" also. Temples and monks did respond to some of the earlier health issues,
and their approach is somewhat similar to "hospice". However, in reality, those healing efforts were considered as part of emotional
and spiritual support that a religious person provides to his/her followers.
HIV/AIDS in Thailand
[31]
However, in the meantime, the hospice approach was enthusiastically adopted by two
Buddhist monks i.e., Phra Alongkot [Dhammarak Nives in 1992] and Phra Pongthep [The
Friends for Life Project, 1994]. Doi Saked in Chiang Mai encouraged monks and citizens to
understand the principles of hospice so that PWAs within the family or neighbourhood could be
taken care of. The Buddhist Sangha has not explicitly recognised their work; nevertheless,
several monks come over to these two centres to listen to some introductory lectures on
HIV/AIDS and the role of Buddhism and Buddhist monks. In all these efforts, Fr. Adirano
played a significant role: he inspired, animated, persuaded and offered necessary training to
enable them adopt hospice principles and implement them.
6.2
Level of Activity
The hospice centres in Thailand always do not expect PWAs to visit them; in fact, staff
of the hospice centres undertake regular "family visits" that serve as a survey of infected persons
or possible infections, and maintain contact with the family members and community; some
centres also pursue "AIDS Education" through public health education efforts. The care and
support under hospice is both "sought" and "delivered", and is part of a larger initiative.
There are eight organisations in Thailand which presently pursue [or recommend] the
hospice approach viz.,
o
St Camillus Foundation [Relief Centre], Bangkok, has rented a place that could
accommodate up to 15 persons, where PWA [either alone or with some of his/her
family members] could stay for a period of four to five weeks. Currently, it
maintains an "in-patient" strength of 15 persons, and has a waiting list of around
40 PWAs. Generally, every day the centre receives 3 to 4 fresh requests for
admission into the centre. Over a period of time, a PWA is trained to serve as the
Manger of the Centre i.e., Mr. Wiboonchai Yureun-ngam; he takes care of
administrative and training aspects of the Centre.
o
Dhammarak Nives [Lop Buri] established in mid-1992 by Phra Alongkot is an
important hospice centre that has 75 beds with rehabilitation facilities, and the bed
strength is expected to be increased to 100 by end-1995. In a limited way, it also
serves as a training centre for those who are keen to work with HIV/AIDS
persons. This centre is now completely occupied by PWAs and the monks could
not even register new requests as the "waiting list" for admission is around 600
persons. PWAs generally stay for six weeks; in some cases, they even stay
longer, and serve as "volunteers" in the activities of the temple.
o
Urban Development Foundation [Welcome House], Bangkok, is involved in AIDS
education since 1992. It functions from a rented place and recently constructed
its own building that they are yet to occupy. Currently eight to ten PWAs reside;
when they move to the new premises, it is expected that the occupancy level may
be increased to 15 persons. As the House is located in one of the huge urban poor
settlements in Bangkok [i.e., Klong Toey], it receives ten fresh, personal requests
HIV/AIDS in Thailand
[32]
a day from the families who reside in the neighbourhood. Except in rare cases,
PWAs do not stay for more than two weeks; but after their "discharge” from the
House, they visit almost every day for two or three months; sometimes, they
engage in other activities of the Foundation like card making or candle making.
o
Franciscans' AIDS Care Centre, Pathumthani near Bangkok was established in
early 1993. It has an occupancy level of 10 PWAs, and concentrates on family
orientation. As the centre is located on the outskirts of the city, it has a large
farm land in which PWAs and/or their family members could work. There is no
time limit for the PWAs stay but decided on the basis of the progress made.
o
The Friends for Life Project [Chiang Mai] was established only in early 1994 and
is a small hospice centre. It can receive upto six PWAs, and relies on para
medical workers for nursing care. Being a new centre it remains informal and has
little procedures for "stay-in” PWAs.
o
Meditation Centre [Mae Hong Saon Province] has no regular "resident” system.
It welcomes PWAs to undergo a training session on meditation to overcome
emotional stress, provide counselling to members of the family. The training
session is limited to a week.
o
Doi Saked Temple [Chiang Mai] has a demonstration centre on hospice to train
women and monks in HIV/AIDS work, and is expected to remain as a training
centre on hospice and family-care nursing support to PWAs.
0
Phra Manat Nathipitak’s Dhamma Training Centre in Phayao province follows
the perspectives and practices of the Doi Saked Temple in a micro format.
In aggregation, about 150 PWAs who are either rejected by their families or do not have
a secure place to reside and live, are presently covered by the "hospice" approach. These centres
also adopt varying components of the "hospice" approach, and no one organisation has adopted
all principles/components of it in total. Currently, all hospice centres are fully occupied; non
cooperation by many general hospitals have forced many PWAs/families seek support of hospice
centres, and about 2,000 persons have registered in the "waiting list" seeking admission into any
one of the hospice centres. A PWA is taken care at the centre for a maximum period of four to
six weeks under "hospice" treatment; later, if s/he continues to reside, then s/he generally
engages in some employment activities. In few cases, the long-time residents serve as resource
person for training programmes on HIV/AIDS.
6.3
Land and Building
High vulnerability of the HIV/AIDS persons living in low-income settlements is obvious.
Their vulnerability is associated with three key factors: the character of the settlement, the
physical environment, and the social environment. Whereas the HIV/AIDS persons need utmost
nursing attention and care, the availability of land/building is severely limited for them. Many
HIV/AIDS in Thailand
[33]
in their readiness to participate; therefore, the time and effort require vary from family to
family.
Therefore, overall, results have been mixed. Families have collaborated with the centreinitiated activities, and considered it as one-time effort. Many factors have been identified to
explain the generally low level of family participation. Much of its principles, perspectives and
contents remain unexplained to common people. Foremost among these is the vagueness of the
intentions of the hospice centre to foster and monitor progress of the ’’family". Also, little time
and money, and too few human resources are allocated to continuously organise families, sustain
and support them. The other reason could be that most of the PWAs come from poorer
households, and the economic pressures of the family determine their continued presence at the
hospice centre and learn.
GJ
Financial Resources
The analysis of the hospice centres confirm what a knowledgeable student of community
development would consider as "fair" i.e., hospice centres, though relevant, provide limited
services to the infected persons and therefore, restricted in its scope. Hence it is not surprising
that all the eight projects reviewed above face serious financial difficulties; limited resources
significantly hamper their ability to sustain themselves and train others. Moreover, with
inadequate resources, hospice centres could not attract trained personnel.
6.8
Cultural Constraints to the Hospice Approach
The perspectives of hospice approach in Thailand rely on one of the most fragile cultural
components of the society. The two key cultural paradigms16 of the Thai society are: [a]
projection of social-political consensus on any issue [so that economic development is not
disturbed]; and [b] efforts are made to "cover" up bad features. For example, AIDS in Thailand
has received a good deal of political and media attention. In addition, there are numerous local
and international agencies which write reports on it, and initiate projects to solve what is
invariably seen as a "problem". The proposed solutions are generally directed towards women
as CSWs while disregarding men. Those that focus on men typically stress on short-term strategy
of invoking some health care. Many a times hospitals are constantly surveyed by a few overjealous media persons [or even fake doctors looking for a prey] who might "exaggerate" fears
of the pandemic which would ultimately affect the economy of Thailand - especially that of
tourism sector - and "image" of the country.
To protect the national economy and Thai image [and national honour], at any cost,
several steps are taken to '’minimise’’ the destruction that emerge out of any socio-political
problem. One such effort is to ’’cover up" the existence of HIV/AIDS. It is argued that a number
of government agencies, NGOs and activists [supported by the mainstream media, populist
16
Paradigms are quoted based on discussions with Professor Surichai Wangaeo and Professor Chayan.
HIV/AIDS in Thailand
[36]
middle class, business groups and elites] do not consider hospice as a necessary strategy to
challenge HIV/AIDS - as that would "expose" the conditions in Thailand to the outside world,
and adversely affect the national economic development efforts - and this refusal to accept
hospice is considered as a "cover-up" paradigm of the Thai society! Thus, there is some
resistance to establish, support or recognise hospice as relevant. Inspite of this denial, many
view that hospice is an essential tool to meet the growing challenges of HIV/AIDS situation.
6.9
Some Viewpoints
Many non-hospice NGO projects, who concentrate on "AIDS Education", question the
relevancy of "hospice" approach in the long-run. They consider that a large investment to offer
services to few persons could be avoided. In general, all those engaged in hospice centres are
missionaries [i.e., Buddhists or Christian], and remain committed despite adverse
criticism/publicity to their work. They reason that:o
o
o
o
it is necessary to demystify some of the interpretations or understanding on
HIV/AIDS', until then some social groups will have to take care of the infected or
rejected persons, especially from the poorer communities;
human beings are discriminated on the basis of the disease which is a violation
of human rights;
a person merits a helping hand to "die in honour"; and
for the households and society to understand the circumstances of HIV/AIDS, the
re-integration of PWAs into the families is essential.
Those engaged in hospice strategy offer counter-critique to the "prevention" or
"educational" approach. They consider prevention or educational strategy as:o
o
o
o
"cover up" efforts of the mainstream activists;
easy and painless to pursue;
most tasks are desk-oriented, office-based and generally terminates in some
meeting or a statement [i.e., conventional/institutional approach]; and
remains as an attractive package to donor agencies.
In several instances, hospice centres have faced "resistance" from some of the
mainstream sources. For example, Government refrains from establishing hospice centres on its
own for fear of continued obligations that might prove to be a financial burden. The Thai
business sector is worried as news of AIDS might affect investment/export markets. For many
existence of a hospice centre confirms the "scope and magnitude" of the problem in Thailand,
and that they would like to hide that fact at any cost! Some activists [both pro-hospice and anti
hospice proponents] consider that the forceful promotion of "condoms" as a panacea for the
HIV/AIDS problem is part of an "institutional resistance", and possible "cover up" strategy of
the government and a few pro-establishment agencies. Experienced AIDS workers believe that
use of condoms will not merely serve as an insurance against infection, and, any way, many
men are reluctant to use it.
HIV/AIDS in Thailand
[37]
settlements also develop bias against PWAs and do not allow them to live in the vicinity or
neighbourhood. The possibility of social deviance is also high. Street violence is a major issue
in these settlements. Thus, a poor HIV/AIDS person is exposed to serious risks to his/her life.
Therefore, it is necessary that PWAs are provided a balanced environment during the period of
treatment and intensive care.
Capital expenses for a hospice centre in Bangkok is calculated to be around USD 75,000
[excluding land costs]. Escalating land prices do not allow establishment of hospice centres in
the urban areas. Many temples/churches do have vacant land in the city; however, internal
bureaucracy and people’s hesitation fail to help the situation even in rural areas. The running
costs of the centre remains modest. For example, Dhammarak Nives spends about USD 60,000
per year on operational expenses; Relief Centre has a budget of USD 15,000 per year.
Therefore, one could tentatively conclude that establishment of an hospice centre requires
substantial capital whereas operating expenses will be marginal.
Some Buddhist monks express willingness to take care of PWAs, who need nursing and
spiritual support; however, members of the religious community generally do not accept
establishment of any centre for HIV/AIDS persons within the premises of the temple/church.
6.4
Hospice Workers
Training paramedical workers to provide services at the hospice centre is a common
strategy of all organisations and aimed at providing culturally appropriate and affordable support.
The approach is based on the fact that the most common care and support can be provided by
someone with brief training and understanding of the situation. Projects do report difficulty in
recruiting and training small number of "hospice cadre". This is also hampered by social
discrimination of "AIDS Centres" where PWAs reside [e.g., objections raised by Church
parishoners in Bangkok or Members of Buddhist Temples].
In Thailand, no qualified doctor in HIV/AIDS work was available till 1992; even today
only eight medical personnel are specifically trained to focus on HIV/AIDS work. In addition,
there is no institution which trains personnel on HIV/AIDS care. National Institute of
Communicable Diseases in Bangkok has a short-term programme for "all" medical and non
medical men. The contents of this training vary from dealing with sophisticated epidemiological
data to mere first aid and care.
The first part of a somewhat comprehensive training programme for grassroot level AIDS
workers on the "Context of Sexuality and HIV/AIDS" was organised in November 1994 by the
Relief Centre.
6.5
Medical Care/Support and Life Saving Services
Hospice centres exclusively rely on "outside" sources for nursing/medical care. Even
Dhammarak Nives which has a clinic within its premises, transports PWAs from Lop Buri to
Bangkok twice a week for some of the specific treatments and medication. Unquestionably,
PWAs living in an hospice centre require nursing care, but each project has to realistically assess
HIV/AIDS in Thailand
[34]
what configuration of facilities it can offer. Thus, hospice programmes are inherently difficult
to manage and support. Experienced persons like Fr. Giovanni or Phra Alongkot also find it
difficult to determine as to whether certain packages or mixes of services were more required
than others, and what combination and use of hospice will be most cost effective and improve
conditions of PWAs.
In their normal living areas, only a small proportion of HIV/AIDS persons can obtain
access to an ambulance in an emergency. Many hospitals reportedly turn away HIV-infected
persons for fear of losing others. Most cannot obtain quick treatment from trained health
personnel. Most of the low-income people, among whom incidence of HIV/AIDS is higher, live
in settlements where serious accidents and emergencies are much common because of the lack
of infrastructure and services, the poor quality and overcrowded housing, and poor quality sites.
They also face the dual burden of housing and living environments which make them far more
vulnerable to accidents and injuries, combined with little access to nursing care.
\ reduction of vulnerability requires both environmental improvement and increased
availability of nursing services. A key requirement in both cases is an intervention of what can
be termed "regularisation" that involve [a] improvement in the confidence of the person and
his/her family; and [b] provision of basic needs. In such a content, hospice centres tend to
provide only minimum services, and their quality is debateable.
6.6
Participation of Family Members
An important component of hospice approach is to enable family members understand
the nature/characteristics of the disease, accept the PWA-member within the household, and later
serve as "home care givers". The role of family members varied considerably in the hospice
centres, indicating that organisations receive PWAs who have different backgrounds and levels.
Some families have stayed at the centre for sometime, volunteered to work for other PWAs and
returned home with confidence and pride. In such circumstances, a PWA reciprocates well.
Important strides have been made in some cases like family offering to finance purchase of drugs
for PWA.
Insufficient Planning
The stimulation of family members to get involved in the hospice effort has received only
few resources and support. Generally, an hospice centre is considered as "personal" experience
and the members do not share their learning with others in the community. This may be because
of unfavourable Government attitudes or lack of awareness of the level of effort and complexity
of fostering family participation.
Inflexible
The education, motivation, organisation, and support of a large number of members are
not activities conducive to have fixed schedules and to use of management planning techniques
which programme activities for certain period of time. Individual members of the families differ
HIV/AIDS in Thailand
[35]
Section 7
Responses of the Thai NGO Sector
The recent list of NGOs, who challenge HIV/AIDS situation in Thailand, is found through
their "AIDS Action Networks" or "National AIDS Prevention Activities in Thailand", which is
largely complete. A close scrutiny of the available data indicates that [entries are multiple]: there
are about 42 NGOs/agencies who are actively involved in HIV/AIDS treatment, care, control and
prevention, and educational activities. Of these, 23 groups are engaged in public health work,
14 relating to education, 10 provide vocational training, 12 relate to art and culture, 7 have
formed women’s support groups, 16 serve other NGOs, and 4 provide financial assistance for
action.
The NGO17 projects/initiatives reviewed were selected at random by the researcher with
the help of social activists, policy-makers and NGOs. For purposes of the review/interview,
following criteria was maintained
an NGO or its project should express a goal to engage in HIV/AIDS work;
currently be in operation; and
SI
pursue some form of intervention in HIV/AIDS.
The NGOs/projects reviewed were classified and examined [Refer to the list provided in
the Appendix] according to a number of variables, including health care approach; operational
level, or population covered in the project area; project history/implementation; and range of
services provided at the most marginal level.
To explore the role of NGOs and understand their work it is necessary to examine and
document responses to the following questions:-
17
o
how NGOs specifically focused upon HIV/AIDS came into being;
o
why existing NGOs have turned their attention to HIV/AIDS work, and what has
been the outcome; and
o
how and why NGOs operating outside the health sector have or have not become
involved in HIV-related activites.
o
what do NGOs share in common vis-a-vis challenges from HIV/AIDSl Is a
categorisation of them possible on the basis of their activities and coverage?
In this section the terms "NGO" and "project" are interchangeably used to refer to similar organisational arrangements and convey
the same meaning. Fr. J. Barry, Dr. Bennett and Dr. Praphan offered useful clues to organise this section.
HIV/AIDS in Thailand
[38]
7.1
Background
The Thai NGO sector, in fact, had responded to the HIV/AIDS pandemic much before
the official acknowledgement of the situation. Some NGOs like Empower, ACCESS were
established by the mid-1980s to challenge the emerging situation among the urban poor youth
or commercial sex workers. Population and Community Development Association [with which
Dr. Mechai is associated] launched its "Say Yes to Condom" campaign by 1988 itself. It is even
argued that the NGOs forced the Thai government to accept the prevalence of HIV/AIDS in the
country and that needed serious attention.18.
In the kind of expansion of NGO activities, the reaction of the government, and the
policies laid down by government with respect to NGOs, proved to be crucial. Until official
recognition of the HIV/AIDS problem by the MoPH in 1991, Government was merely tolerating
the "campaigns" of the NGOs on HIV/AIDS but did not allow appropriate mechanisms to be in
place and work. But with the acceptance of the problem, public institutions were accelerated to
work with the communities and funds made available.
7.2
Approaches to HIV/AIDS Work
All the NGOs/projects follow one of the two major approaches to extend support and
solidarity in HIV/AIDS work: community-based or facility-based [that includes clinical care].
Most of the projects are community-based and focus on ’’prevention and education" activities
through trained staffpersons or community volunteers. This approach can be subdivided into
those who depend on volunteers, and those in which community workers are paid a salary. Some
projects use a more conventional, facility-based delivery mechanism combined with peer group
counselling [e.g., The Friends for Life Project, Chiang Mai; CARE; Thai Red Cross]. This
division highlights difference in the programmes and emphasise the implications of the
variations.
Community-based projects tend to rely on either volunteers from the community or paid
community level workers, or even government personnel [e.g., Thai Red Cross]. In some
projects [e.g., Northnet, Chiang Mai] health workers at the most minor levels are usually
selected from the community [in some instances PWAs also serve as volunteers]. However, such
efforts are merely experiments and sporadic. The community plays a planned and pivotal role
in all the projects.
In some places [e.g., Chiang Rai and Phayao] NGOs have trained few members of the
community and paid them ’’allowances’’ to support efforts in their respective villages. In this
category of projects, the community’s role is much smaller than that the preceding category
[e.g., Duang Prateep and World Concern]. In the rural poor settlements, however, it would be
unrealistic to look for communal financial support for the volunteers.
18
Based on available literature and discussions with Dr Chayan.
HIV/AIDS in Thailand
[39]
The Friends for Life Project, Saraburi Buddhist Monastery, Mercy Home, St Camillus
Foundation of Thailand, few of the hospice centres, and to some extent Thai Red Cross, which
rely on clinical care, attempt to introduce exclusively trained new categories of community
HIV/AIDS workers to help bridge the perceptional gap between care givers and people.
Location
37 NGOs/agencies have units located in Bangkok, 15 in Chiang Mai, 6 in Phuket and 6
in Khon Kaen. Some groups have two or three "field centres". [Refer Table 01]
7.4
Coverage
To classify the projects according to coverage, the planned scope of operation of the
project was used, rather than current/actual coverage, because the framework of operation was
considered as important to review the implementation experience. Also, estimates of coverage
[planned and actual] are not always given in project documents, and they are of limited value
to understand the attributes of the projects - as projects regularly expand coverage and modify
geographic boundaries. The difference between planned scope of operation and actual coverage
does not appear to be great for the small and medium-scale projects, but it is great for some
national-scale projects. In discussing the coverage of the HIV/AIDS projects, it is important to
bear in mind that, for most groups, coverage is determined by availability of funds. National
scale projects almost always involve multi-donor financial support.
The projects examined in this report range from national efforts to small pilot, or
demonstration, programmes. As Table 01 shows, 14 are national in scope, 12 are regional
projects designed to reach from 500,000 to 2 million people; 27 are smaller, local level projects
with populations ranging from 100,000 to 500,000; and 7 are small-scale experimental projects
designed to cover fewer than 100,000 people. The remaining 3 projects/agencies provide general
institutional support to various programmes and have no field component. This coverage scene
provides a perspective on the role of project size in the type and severity of implementation
problems encountered.
Of the 14 national projects, approximately one-half are currently operating nationwide,
with activities in more than two regions. These are Empower, ACCESS, Duang Prateep,
FARM, Thai Red Cross, CARE and World Vision. Some agencies [e.g., AIDSCAP] though
national in character, tend to function more as ’’supporters” of the initiatives rather than
’’implementing" groups. Some projects are still expanding coverage, region by region.
In addition, two smaller projects located in Phayao and Saraburi are integral parts of
national implementation efforts [i.e., World Vision and ACCESS]. Sometimes smaller projects
are planned as an integral part of a larger regional or multi-regional programmes of a group. For
example, Northnet’s specific HIV/AIDS programme covers only 40 villages whereas it has
activities in about 90 villages.
HIV/AIDS in Thailand
[40]
7.5
Level of Implementation
The NGOs/projects described in this review are in various levels/stages of
implementation. Approximately 60 per cent were initiated before or during 1991. Because one
or more years of start-up activities typically are required to establish the work, many of the
projects have begun to intervene or deliver services or commence education programmes at the
village level only within the last two or three years.
A number of projects have varied background and long histories. The most notable are:
Empower, Phra Charmoon, ACCESS, Population and Community Development Association,
Relief Centre and Thai Red Cross. All groups use volunteers, and the last employs governmentsalaried personnel too. Other projects, such as Duang Prateep or Welcome House, represent
expansions of programmes that have been underway since the mid-1970s, under either
community development or urban poor development initiatives. The projects that were more than
five years old do offer a clear perspective and clarity of their "vision and mission" towards
implementation; they do show effectiveness in implementation and intervention areas.
7.6
Range of Efforts at Micro Level
One of the objectives of HIV/AIDS work is to make essential care/support available to
everyone. The components of the care and support-services were obtained from the discussions,
and it could be categorised as follows:OS’
Clinical care [i.e., appropriate testing facilities, treatment and provision of essential
medicines]
iry
Preventive efforts [i.e., maternal and child health care; immunisations; stress on safe sex
or condom use].
C33
Educational support [i.e., public education in the recognition, prevention, and control
of prevailing circumstances/problems with a specific focus on HIV/AIDS', promotion of
adequate food and nutrition standards, and facilitate access to it]
NGOs differed in the number of support-efforts they plan to undertake. Most cover a
range of curative, promotive, preventive and educational aspects. Majority of the projects are
planned to be preventive and educational. However, many do include simple curative care, offer
some referral services, monitor nutritional status, provide immunisations, although less than onethird have plans to promote ''safe sex" and implement "use condom" campaigns.
Many NGOs have recognised one serious impediment to their effort: lack of beds in the
hospitals to take care offully blown HIV cases, and provide confidence and support to PWAs
and their families. The "waiting" period to get admission into a hospital for treatment is about
six months, and reducing this, for concerned persons like Dr Praphan, is a major challenge to
the government and other agencies.
HIV/AIDS in Thailand
[41]
In analysing planned interventions by NGOs, one has keep two facts in mind viz.,
7.7
US3
In some instances, HIV/AIDS work is only one of many programmes, and vertical
programmes may well operate side by side with them [e.g., Duang Prateep or
Northnet]. Many years may be required before existing categorical [vertical]
programmes are integrated into their work, in the interim, similar or overlapping
efforts may co-exist.
cy
Although a large number of support efforts are planned in most projects, close
scrutiny reveals that many planned care or support-services are not being
provided at this time.
Community Participation19
Community participation is the key word in NGO activities. Progress of community
support was examined with reference to generally ’’inhibited’’ programmes like HIV/AIDS of
NGOs. Information was gathered from NGOs, professionals and people themselves during the
field visits.
The degree of community participation varies considerably. However, participation
expected from the communities commonly takes on three forms: helping to organise a project,
contribute financial support/resources, or actually carry out HIV/AIDS [prevention or curative]
activities.
Mobilising Community Support
In many projects, community support vision/perspectives have not been translated into
clearly defined activities on which project staff can focus and which can be reviewed well.
Although certain expected forms of participation [e.g., the selection of AIDS cadre and the
formation of health committees] are well-defined, neither the communities nor project personnel
appear to have precise understanding about what they should do or what they should expect from
general community participation goals, such as communities’ actively seeking solutions to
HIV/AIDS problems.
Most NGOs agreed that community support to specific and concrete functions and
activities [e.g., training programmes or provision of labour for activities] has been successful,
but other kinds of activities have not. Communities tend to support activities, but not initiate
them. Some feedback received from the NGOs/MoPH officials on community participation and
support to initiatives is summarised below:-
At least 80 per cent of the projects have proposed village level committees as the
organisational framework for community participation at the local level, and to promote
o
19
This part is based on the information provided by Dr. Praphan, Dr. Seri and others.
HIV/AIDS in Thailand
[42]
interaction between the community and HIV/AIDS programme personnel. Some NGOs
have used existing development organisational frameworks to elicit community
participation [e.g., training school teachers on HIV/AIDS by the women’s project of
World Vision in PhayaoJ. In some of the villages in Northeast, Women’s Clubs [mostly
comprising of PWAs or AIDS-related destitute] are responsible for the village
programmes and its members take an active role.
o
In addition to work on HIV tasks, some committees have been given responsibility to
stimulate community efforts to solve complex environmental, economic, and social
problems that may contribute to spread of HIV in the community. Community "self-help
health committees" with broad directives were found in Duang Prateep, CCTand CCHP.
o
Generally, local committees undertake few of the responsibilities, and they are active
during the "crisis" phases.
o
Typically, some groups have sought local contributions for clinical care [e.g., medicines
or testing facilities] and support of the village level worker. The problem has not been
to get individuals to pay for medicines, but to obtain sufficient money or in-kind
contributions at an acceptable and consistent level. None of the NGO could achieve selfsufficiency through "user fee" collection.
o
Most projects pay minimum attention to finance village level worker to continue efforts
on a long-term basis. The need for village level support is mentioned, but concrete plans,
yet there is no clear strategy to generate income. Some of the projects initiated by
NAPAC have paid more attention to the issue of community financing, wherein the
experiences of the earlier projects are being considered. Some projects opt for
collaboration with the community to work out suitable methods to mobilise resources
before commencing interventions at the village level. Phra Pong Thep, for example,
insists that the village committees work out a viable financial plan before they can begin
work or training on HIV/AIDS.
o
Direct community interest has been considerable in many areas, but little effort is made
to stimulate/encourage communities to recognise HIV/AIDS problems, develop solutions,
and mobilise resources to challenge the issues; hospice centres have been successful in
stimulating family interest. There has been only limited and occasional community
support to undertake even general health care activities. The strongest evidence of
community-initiated activities was provided by least 10 projects, and the contributions
occured in cases:-
SI
Some projects commenced work with a Knowledge-Attitude-Practice Survey
[KAP], and struck a good rapport with the local community. Using the contacts
of that survey and its results, these projects/NGOs were easily able to form
’’AIDS Support Committees" at the village level, and implemented HIV/AIDS
related programmes that include the construction of "care centres" and
development of community gardens.
HIV/AIDS in Thailand
[43]
Some communities have initiated activities such as the "voluntary medical check
up", peer education programmes, Women PWAs Clubs or Mothers’ Clubs.
These NGOs/projects share two important characteristics: all are small-scale and half
have been implemented by local people. Three projects have populations of fewer than 60,000
persons; two are under 100,000. All the projects have long experience in the areas, and
community participation is an integral part of their philosophies. It appears that - experience and
orientation to community participation - provide the sensitivity to both the culture and the
process of community development that is needed to undertake successfully the difficult task of
HIV/AIDS work.
NGOs who have succeeded to elicit community support for HIV/AIDS work, and that
involvement varies widely in their characteristics and implementation histories. They, however,
share a number of common attributes:-
a.
Financial support
In all the projects, the major capital-investment costs of HIV work are borne by either
the Government sources or the donor agencies; community has seldom mobilised
resources. May be it too early to look for community efforts to mobilise resources to
support the initiatives.
b.
One-time effort
Few NGOs have undertaken some discrete construction efforts. They also tend to involve
one-time efforts that require little community involvement or attention [other than
maintenance] once they are completed. Unlike communal gardens, the community
mobilisation effort can be concentrated during a brief period, and follow-up can be
sporadic.
c.
Community organisation efforts
Many NGOs stand out as having given more than the usual attention to generate
community support. Of the 18 projects closely reviewed, only 4 appeared to have
expended considerable effort in this area [e.g., ACCESS, Empower, Thai Red Cross and
Care].
Factors that inhibit community support/participation
Discussions with NGOs and people indicate that the generally low to moderate level of
community participation in HIV/AIDS work was the result of both pre-existing community and
government outlook, and of shortcomings in project design and implementation. These factors
are summarised below:-
HIV/AIDS in Thailand
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in HIV/AIDS work. Training these workers as "care givers" represents, for most projects, a
major change in intervention strategies. Every project considers mid-level staff to be critical as
it is they who handle identification of HIV infection within the community, refer for treatment,
follow it up, take that opportunity as an entry point for community discussion and possible
action. They provide varying orientation to HIV/AIDS care at the village level. This is possible
because these are "new" categories of personnel whose responsibilities and training incorporate
this dual orientation.
Community level workers generally perform a variety of tasks that include:cy
Thai Red Cross: Trained nurse-clinicians and care givers provide curative
services for some of the common problems in HIV/AIDS and perform essential
preventive, promotive and educational activities. They are trained to diagnose and
treat common HIV/AIDS problems, organise preventive health care for children
and mothers, institute public health measures, and stimulate community
development efforts.
CS3
Dhammarak Nives, Relief Centre, CCHP, CCT and World Vision: Para
professionals are being trained to provide a wide variety of basic curative care to
initiate public health measures; they also provide social care and counselling.
These personnel are located within the communities.
US’
Saraburi Buddhist Monastery [and some of the hospice centres]: A new
category of care givers were trained and introduced to provide support for
common HIV/AIDS problems, to promote community level education programmes
and to supervise community health cadre formation. This is being followed in a
number of projects in North and Northeast of Thailand.
Training Community Level HIV/AIDS Workers/Educators
Training villagers [or co-industrial workers] to provide their communities with HIV/AIDS
care/support is a common strategy amongst most of the projects. Large segments of rural
populations do not live within easy reach of health facilities, and even though new facilities may
be constructed, these cannot be expected to cover large, dispersed populations adequately.
Community-level HIV/AIDS workers [CWs], therefore, could reach unserved populations. In
addition the use of community workers is presumably more cost-effective than the use of facility
based paraprofessionals. Physical barriers - transport or travel time - could be reduced through
such an intervention.
Among the NGOs reviewed, CW's responsibilities vary widely. Most of the programmes
have trained one person to perform a number of promotive, curative, and preventive tasks - the
full range of care provided at the village level. But a number of groups have assigned curative
functions to one kind of worker and promotive and curative functions to another [or sometimes
several types]. In these projects, the different categories of workers function as a team.
HIV/AIDS in Thailand
[471
Those programmes that divide functions among different CWs usually depend, at least
in part, on volunteers. The use of this strategy probably reflects an attempt to limit the amount
of time any one person must volunteer. The worker with preventive and educative functions
usually is given much briefer training, and is expected to contribute less time and effort, than
his curative counterpart.
Although division of tasks may facilitate the CWs ability to provide the full range of
HIV/AIDS care and support, because each worker is responsible for learning and performing
fewer tasks, this strategy brings with it problems in generating financial support, if any of the
workers are to be compensated. Generally, neither the Government nor communities can afford
to finance two workers per village.
7.9
Performance : Preventive and Curative Functions
Discussion with the field Coordinators of the NGOs indicate that CWs actually perform
only a limited number of the tasks for which they are trained. It is asserted by them that with
the increasing incidence of HIV-infection CWs are forced to concentrate on curative or referral
activities, to the neglect of preventive and promotive functions. The reasons for this are not
clear. It may be that the CWs are assigned an impossibly large number of tasks, that their
training or supervision is deficient, or that community support and incentives largely determine
what work CWs carry out.
The average HIV/AIDS worker is generally trained to handle a number of tasks. For
example, in Lampang [near Chiang Mai], the village health volunteer [CW] is responsible for
providing basic curative care, including first aid; organising educational events; providing basic
health education in schools; assist some of the control programmes; monitor children and
mothers’ health conditions; and promote community participation. Almost everywhere CWs are
expected to conduct educational activities. Condom promotion campaigns by CWs is common.
Most projects also include a number of maternal, child health and family planning activities too.
Without exception, NGO documents and action plans stress on preventive care and
education, but on the whole programmes have experienced difficulty both at the village and
family levels. For example:o
Daughters of PWAs [Phayao] found that village level HIV/AIDS workers rarely
spend time doing anything other than dispensing medicines as the pressure for
clinical care was substantial.
o
Welcome Home Project staff found that it was difficult to sustain the interest of
the people in preventive care in Bangkok as the community was eager to obtain
curative care; even family members begin to evince interest to participate in the
training programmes only after adequate care was ensured to PWAs.
o
Relief Centre could not train PWAs, who are destitutes or refugee-orphans, as
they were keen to become economically independent by taking up a job.
HIV/AIDS in Thailand
[48]
7.14
Project Support
An analysis of HIV/AIDS projects/programmes confirms what one might consider as
possible - that management problems are the most pervasive and serious cause of the
implementation difficulties encountered by NGOs/Government. Although implementation is just
beginning in many of the projects that were examined, a pattern is discernible; Government has
little difficulty completing the start-up activities of an initiative [e.g., Wednesday Club of Thai
Red Cross], but once health workers have been deployed and require support, serious problems
arise in managing the project. Specifically, these are problems of administration, logistics,
transportation, supervision, and collection and use of information.
It is noteworthy that staff from the NGOs with the longest operational experience are
frequently the persons who stress most strongly the importance and the difficulty of establishing
adequate support services. Despite the progress some NGOs have made in different areas of
management, none of the longer-running projects has satisfactorily solved its management
problems.
7.15
Problems and Causes
Nearly every NGO is burdened by serious problems in one or several areas of
management, including:o
Organisation [arrangements to support programme objectives, to reduce
duplication of effort, and to avoid internal conflicts];
o
Finance [i.e., NGO funding comes from a wide range of world wide sources. A
few NGOs intentionally avoid foreign funding];
o
Personnel [i.e., staff, job descriptions, assignments, training, permanency,
salaries and benefits, commitment, and satisfaction]; and
o
Supervision and material support [i.e., planning, implementation, management
and monitoring; complex yet simple simple tasks like transportation and
procurement and distribution of educational materials and others]
Causal factors vary, depending on the economic, cultural, and political conditions in the
area, as well as on the size of the project, key personnel and donor agency. However, certain
factors are common to nearly all NGOs/projects. These are the pace of HIV/AIDS spread; lack
of funds; the shortage of trained human resources; and underdeveloped institutions and
infrastructures.
7.16
Fresh Strategies
Many NGOs are experimenting with new appraoches and strategies. Of particular interest
were the following components:-
HIV/AIDS in Thailand
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o
Employment initiatives [Some groups have began programmes to place PWA or their
families in gainful employment - this includes training in self-employment];
o
Local resources [In Phayao and Khon Kaen, communities are motivated to develop, as
a precondition for continuity of the programme of HIV/AIDS education, a viable
financing plan to pay local volunteers; this effort is still under discussion];
o
Condom distribution [PDA, Empower and other groups experiment with the use of a
commercial pharmaceutical supplier to provide condoms for distribution at the village
level through CWs. However, Dr. Voravut of San Sai Hospital asserts that NGOs are
trained neither for medicine distribution nor clinical care; he does not perceive a role for
NGOs in long-term clinical care efforts];
o
Medication/treatment costs [e.g., Folk Doctor, CCPN and CCT have introduced use of
inexpensive traditional medicines into the health education system in an effort to reduce
programme costs].
o
Use of local health care providers [e.g., CCT, CCPH, ACCESS and World Vision are
training pharmacists or other para-medical personnel in an effort to upgrade the
diagnostic and prescriptive skills of these widely-used private sector health agents.
Projects in Phayao and Khon Kaen are testing their effectiveness as distributors of
condoms and leaflets].
o
Curative-preventive care [Every project has been designed to establish clinical support
at the community level before preventive/educational components are introduced].
o
Community participation [The projects in Chiang Mai and Phayao - small scale - have
achieved considerable extent of people’s participation through active and vibrant health
committees at the community level that are established through non-formal education
efforts. These committees focus on peer education or use of PWAs as resource persons
for the HIV/AIDS campaigns].
o
Mass media support [news, views and concerns on HIV/AIDS have received plentiful
cooperation and solidarity from the newspapers, radio and television programmes].
7.17
Overall Inferences
Through sustained campaigning NGOs have placed HIV/AIDS on the national debate and
agenda, and also successfully carried out several preventive and curative programmes. One may
consider that the initial phase to consolidate NGO activities is complete, and the most
challenging test for them is ahead i.e., how to proceed from here and make it more purposeful?
In general, the essential components of NGO interventions consist of education, campaigning
and propagation of home-based care and counselling. Many NGOs consider home care is a
useful entry point when it aims to develop the communities’ own capacity to prevent and control
HIV/AIDS. This appears appropriate for three reasons:-
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o
Firstly, it places organised response to the pandemic, slowly, at the level of the
community, where NGOs function effectively, where communities’ coping strategies can
be built upon and beneficiaries are more likely to be involved in decision-making and
management; this will also help to eliminate expensive centralised, national
bureaucracies.
o
Secondly, this community-level response tends to spread family’s financial burden among
community members, a kind of risk-sharing necessary for long-term financing of the
pandemic, which is also a community-building strategy.
o
Thirdly, it encourages solidarity support among NGOs and enable them respond to the
specific needs of individuals, groups and communities.
In addition, traditionally non-health sector NGOs [e.g., women’s groups, development
groups, self-help groups and other empowerment initiatives] have evinced keen interest [or have
already began] to work in some method to control the spread of HIV/AIDS and educate people.
All these groups are expected to build multi-level solidarity and generate prevention and the
impact-reduction activities working through their particular constituencies and interests.
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Section 8
Responses of Religion
Apart from numerous NGOs, an important role is played by religious groups in Thailand,
who publicly participate in HIV/AIDS clinical care and education. These institutions could be
classified based on their faith denominations as: [a] Buddhists; [b] Christians [either Catholic or
Protestant]; and [c] Muslims.
8.1
Buddhist Thought and Action on HIV/AIDS21
Traditionally, Buddhist monks themselves were healers and known for their knowledge
on herbal treatments; the temples and monasteries have beds for in-patients. Their social and
public health concerns were obviously to participate in the efforts that was not supported by the
"traditional" schools within the monasteries. In some places, members of the local community
disapproved the proposal [e.g., one abbot discussed a proposal to establish an "AIDS Care
Centre" that was not accepted by the community as it might disrupt the sanctity of the temple
and cause inconvenience during ceremonial occasions. However, this abbot has initiated a
training programme on HIV/AIDS for monks and villagers].
Many villagers [who were met during the field visit] agreed that the monks need not have
any physical or administrative involvement in such works, but hire trained nurses or lay people
to care for the persons with AIDS, allowing monks to merely coordinate the function of
operations which would be in a special building in the temple grounds, or, they may wish to
only provide spiritual guidance and support. In this sense, it would be a care support primarily
provided by the community.
The querry on the use of the temple for care and education of HIV/AIDS purposes has
received a mixed response from the Buddhist clergy and common people alike. It is a rather
radical concept as people have conservative views on the role of the temple and monk. Initially,
people reacted with a negative view and found the premises to be "unsuitable" for HIV/AIDS
work as:- [a] purity of the monks may be contaminated; [b] youth who may have to stay in the
temple might tarnish the image; and [c] should at least be prohibited for infected women.
In many temples it appears that the villagers, perhaps more so than the monks, would
not agree to a hospice centre, nor do they agree to general sermons on AIDS prevention and
control. It may be the case that a hospice in a temple is only possible when the monk is fully
supportive and knowledgeable, and can influence local villagers.
21
Based on discussions with Phra Pong Thep and views of several other monks who participated in a training programme on HIV/AIDS
specially organised for them on July 12, 1994 at Chiang Mai.
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Each Thai village usually has a temple and all may not be suitable to establish a hospice
centre. Many may have one or two monks only with very little facilities. For example,
meditation temples may not be appropriate and that temples where the main activity was teaching
and conducting rituals would not be suitable or would not be open to such suggestions. Some
temples could be classified as "development" temples, where monks are well-informed,
interested and involved in community development, and it would be the most appropriate.
The proposal to establish a hospice programme in a temple has financial benefits too as land does not have to be purchased and volunteers are the main care givers. Villagers
normally supply all food and provisions for the monks and temple activities are supported by
donations and voluntary labour, as is much of general maintenance. The temple, in this sense,
is a community resource while at the same time being sacred in nature.
The reluctance of the people to establish HIV/AIDS Centres at the temples reveal some
tension between the monks themselves to accept infected persons as normal members of the
community and teaching villagers to accept them without any stigma. Phra Phong Thep argued
that HIV persons will not defile the temple any more than youth attending violent movies and
listening to loud contemporary music within the temple grounds. However, first of all, monks
have to develop this level of understanding themselves through training, and able to face the
issues associated with HIV/AIDS.
Monks may be an important adjunct in offering moral support through counselling. This
would require that they are fully trained in order to have a comprehensive understanding of the
HIV/AIDS pandemic. Thousands of monks have been trained throughout the country, and over
1,200 monks have been trained in the North, through temple and non-government initiatives.
Monk training emphasises on care and control of the spread of HIV/AIDS. The training
sessions are similar in content to other training programmes meant for lay people. Strategies of
care and control are, of course, essential to slow the rapid spread of HIV/AIDS; however, it is
becoming increasingly important that the concept of living with AIDS be widely promoted also.
It is here that the monks have a significant role to play as they could blend Buddhist teaching
with "care, affection and love" to HIV/AIDS persons, thereby reduce tensions between people,
groups, and with no offence to any person.
7.2
Christian Missionary Efforts
Protestant work in Thailand began some time in the 1830s covering public health and
educational activities as an integral part of the Christian mission to Thailand. By the 1950s,
agricultural support had been acknowledged as also needed and an important activity to be
engaged by the churches at least by the Presbyterian, Disciples of Christ and American Baptists.
Some missionaries moved from China to Thailand after World War II and that was mostly nondenominational work.
However, involvement by Protestant Christians in development activities has probably
increased in recent years although types of programmes undertaken has changed. For example.
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the Church of Christ in Thailand [CCT] maintains an extensively coordinated programme that
include highland development, agricultural support, handicrafts promotion, public health and
leadership training to rural people in about fifteen provinces in the North, Northeast and South
of Thailand. CCT is actively engaged in provision of care services to persons living with
HIV/AIDS and has an elaborate education programme in the rural areas. Issues pertaining to
HIV/AIDS are discussed during Sunday assembly or posters/leaflets distributed everywhere. CCT
considers HIV/AIDS work as a source of empowerment and a tool for securing public and social
accountability of the society at large. YMCAs [e.g., Chiang Mai and Bangkok] have also taken
some initiative to train school teachers on HIV/AIDS tasks; they also have small-scale outreach
programmes.
Catholic missionary work in Thailand has been very diverse and until the late-1960s some
development efforts without much coordination was pursued. The formation of Catholic Council
of Thailand for Development [CCTD] provided a new perspective and framework for the
Catholic institutions and personnel to act. Four broad areas of action include:- emphasis on self
help; conscientisation of religious and lay leaders as to the wholistic nature of development;
work towards purposeful decentralisation of responsibility at all levels; and reciprocity between
leaders and target group people to mutually share in planning and action.
The Catholic Commission for Health Promotion [CCHP] with its headquarters based at
St Louis Hospital in Bangkok, plays a significant role to develop fresh thought and action among
Catholic missionaries to encourage community health initiatives on HIV/AIDS. CCHP has given
due importance to this programme since 1990 and included the following activities: motivation
of missionaries to gather information, gain understanding, promote awareness and support to
fight against AIDS, in aspects of both prevention and assistance; developed and supported
personnel involved in the work on AIDS through: provision of temporary shelter [e.g., Mercy
Home, Welcome Home, St Carmillus Foundation and others], groomed counselling skills,
coordinated with NGOs and state agencies as well as other religious organisations involved in
AIDS work. Under the auspices of the Catholic Church about fifteen initiatives are in progress
in Thailand and a small training network is available amongst them.
Norwegian Church Aid has formulated a comprehensive strategy to intervene in
HIV/AIDS conditions in the Northeast of Thailand. Despite this, they tend to remain as
"projects" and limited to some select locations.
Christian missionaries established hospice approach in Thailand through numerous
training, information sharing and persuading Buddhist monks to participate in such efforts. In
general, many missionaries [along with some Buddhist monks] convincingly propose hospice care
method as an effective response to the challenges as: [a] majority of those affected from the
poorer communities, who lack access to medical care, and generally neglected by the
government programmes; [b] it fits into the basic socio-cultural orientation; [c] stress on "dignity
for those dying"; and [d] extension of their traditional pastoral care.
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8.3
Islam
The Southern part of Thailand has a substantial Muslim population. It appears that most
Thai Muslims, at best, have taken a passive attitude towards government-sponsored development.
Few groups perceive an active resistance by the Muslim elite to many development activities,
especially education because they bring closer Thai government involvement in and undeniable
disruption of parts of traditional "Malay-Muslim" religious and cultural life, attempt to reduce
separatist and pro-Malaysia feelings, and are part of a larger effort to reduce ethnic solidarity
of the Muslims of southern Thailand. There is no group that subscribes to Islamic principles
which is active in HIV/AIDS work.
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Section 9
Popular Strategies
Risk avoidance in case of HIV/AIDS is very difficult to propagate. A virus and the
immune system are not easy concepts to grasp. The situation is complicated with several hearsay
proposition that circulate on AIDS. People often try to distance themselves and disbelieve things
they do not understand. However, many groups have initiated popular strategies to educate
"person in the street". This section elaborates a few such approaches.
9.1
Condom Distribution and HIV/AIDS22
One of the key strategies of Thailand’s National AIDS Prevention and Control
Programme has been condom promotion. Condoms are commercially available throughout the
country at affordable prices. Government policy for years has been open and supportive of
condom use, both for family planning and STD prevention. Subsidised and free condoms are
made available through family planning, clinics, drug treatment centres, STD/AIDS clinics,
entertainment places and through community volunteers.
In 1991, the National AIDS Committee approved a Government plan to implement a "100
Percent Condom Promotion" programme in all of the provinces. This nation-wide programme
combines the unique skills and political networking of provincial governors, police and public
health authorities to address the issues of commercial sex, condom use and empowerment of
women. Some agencies like UNICEF consider it as a "success story".
Government funding has expanded to ensure an adequate supply of free condoms
throughout the year to all targeted populations. In addition, condom logistics and distribution
systems have been strengthened, as well as facilities for condom quality assurance testing.
Efforts are on to assess the feasibility of female condoms, particularly among commercial sex
workers.
Early days, the association of condom with sexually transmitted diseases and illicit sex
inhibited their promotion in a public way. Currently, condom promotion campaigns seek to
tackle the spread of HIV/AIDS, and condoms are generally distributed for a price or free of
charge. However, the distribution was symbolic as the total condoms distributed were less than
5 per cent of total sales.
An active anti-AIDS campaigns that use some of the imaginative techniques to promote
"safe sex" methods are undertaken e.g., condom inflation contests and raids on bars by people
in condom costumes; graphic educational material on condom use were produced for homosexual
22
Based on discussions with PDA, Empower and Thai Red Cross.
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and bisexual person with some results of reported increase in adoption [e.g., activities of NGOs
like PDA or Empower].
Some organisations like Thai Red Cross/PDA/Empower/A/oPH have launched radio
campaigns, and claim that mass media techniques and community-based distribution methods
have increased condom usage. Their promotion methods also include point-of-purchase
advertising such as posters, comic books, calendars, shopping bags, T-shirts, as well as
exhibitions at local fairs and mass media such as songs and music videos, television and radio
public service announcements, talk shows and dramas - all promote responsible sex and condom
use. Condom distribution for prevention of AIDS has increased with political commitment in
1991 to open and aggressive techniques, opening the door for other contraceptives too.
9.2
Mass Media, Peer Counselling and Networks
Although the Thai Government and international agencies have geared up to a wide-scale
publicity campaign to prevent spread of HIV/AIDS, results have so far been mixed. A major,
multi-media campaign in 1992-93 increased awareness but little to change the behaviour of the
average heterosexual, sexually active person or commercial sex workers. The average number
of partners and use of condoms among heterosexuals remained the same throughout the country
even after that high profile campaign. Campaigns which position AIDS as the ’’grim reaper’’,
intending to send fear into the general population about sexual promiscuity, have not been very
successful.
General messages prove to be ineffective because they are not meaningful and easily
shrugged off as "someone's else" problem. But wide-scale public messages aimed at specific
groups, such as homosexual and bisexual men, helped the Government and NGOs to reinforce
the concept that AIDS is a "gay disease". In Phayao, an AIDS education programme aimed at
sexually-active heterosexual public had little effect on attitudes/actions concerning the number
of sexual partners permissible, in spite of a high level of knowledge about HIV heterosexual
transmission [e.g., World Concern].
In Khon Kaen, the free distribution of condoms to a group of commercial sex workers,
together with intensive counselling, was found to have increased the use of condoms from twelve
per cent before the programme to about 45 per cent six months after the programme started23.
This indicates that people would respond to such efforts but require constant encouragement and
educational input to sustain it.
In Chiang Mai, peer education, formal and non-formal, has been proved as an effective
strategy to reduce at-risk behaviour. This programme included planned peer education, taping
into an already existing network of commercial sex workers who knew little about HIV/AIDS.
Early discussions led to the formation of a group of six women leaders as peer educators who
talked to several others. In the early stages of this experiment, only one in every three women
23
"AIDS Education among Female Prostitutes: An Experimental Study ", Department of Obstetrics and Gynecology, Faculty ofMedicine,
Prince of Songkla University, Hat Yai, Songkla; March 1991.
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understood the issue, whereas at the end, six out of ten understood it. In fact, word-of-mouth
dissemination of the programme was found to be successful that many commercial sex workers
enrolled in a supplementary programme, purchasing condoms at a wholesale price [Refer to the
works of Chayan V.].
A similar approach has been successfully carried out in the suburbs of Bangkok and
Pattaya [e.g., Duang Prateep Foundation] where AIDS transmission has been largely
heterosexual. Leaders among commercial sex workers were trained to provide health education,
support and condoms to their co-workers. Sex market places, such as one-night-stand hotels,
were ordered to provide condoms free to their customers and commercial sex workers were
taught to incorporate condoms into their foreplay with customers.
In the urban poor settlements of Bangkok, an extensive publicity campaign also involved
an exchange programme for needles and syringes and distribution of condoms among addicted
commercial sex workers. In addition, a local NGO [e.g., Empower] involved the target group
to design the educational intervention, paying attention to the lifestyles of the average drug user
and appealed to them to stabilise their social relationships, employment patterns, and illegal
activities. These very liberal interventions and open communication about the problem had a
positive impact in that the residents were more open to accept the problem as "prevalent" and
decided to take effective action.
9.3
Cultural Activities
Many NGOs [e.g., Thai Red Cross’s Cabaret Shows] have formed cultural troupes to
spread the message on HIV/AIDS. Family planning education was traditionally pedantic,
unimaginative and in most cases, failed to reach youth. The present band of artistes, on the other
hand, try to meet youth at the discos, streets and clubs, and bring in essential messages which
blend in with their culture and view of the world. Popular youth music stars use their talent to
promote sexual responsibility. They give messages on literacy, family planning, sex education
and women’s welfare. To a large extent these initiatives have succeeded in raising awareness and
creating demand, especially among the urban youth.
In Phuket area, a local artist, an AIDS victim himself, took up the cause and made
HIV/AIDS an acceptable subject to talk about. He produced pictures and displayed them at
prominent points in the city. His battle for life caused a public stir for weeks. This new openness
facilitated awareness campaigns aimed at the general public as well as programmes aimed at
specific risk-groups.
9.4
Use of Mass Media
Apart from the coverage in newspapers, television spots on HIV/AIDS have become a
common feature and, in addition, many regular programmes and documentaries were created by
NGOs [e.g., PDA] and agencies for wider dissemination. This partnership led to the formation
of a group "Partners in AIDS Education", who were prominent members of the society e.g.,
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artistes, sports persons, writers or politicians. Its members posed for posters, addressed rallies,
toured outlying areas, appeared for television spots and gave press interviews to support AIDS
education. By publicly endorsing such an issue, they became high-visible advocates for the AIDS
education. Amongst the NGO community, theatre and cultural groups were formed to support
AIDS education, and the themes were commonly linked it with other social issues.
However, it is cautioned that in HIV/AIDS prevention programmes, mass media alone
appears to have had a limited effect. Emphasis on mass media campaigns may leave out
significant at-risk portions of the population who have little or no access to the media. Very
general messages carried over mass media may have little effect on the average person who may
shrug of the message.
In appears that the most successful approaches in condom distribution and AIDS
education have been those aimed at specific at-risk groups where interpersonal communication
and peer counselling were encouraged to play a significant role. There is a growing awareness
to address the problems of groups, such as commercial sex workers, drug addicts and street
children.
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Section 10
Home and Community Care and Support
10.1
Home-based Care and Support
Increasingly, home-based care and support is recognised as being indispensable to reach
the wider community. Successful mobilisation of community energy for AIDS care, prevention
and control is considered as the real challenge. It is most likely to be sustained by building an
understanding of counselling in the community, and of community development.
AIDS programmes that focus on family and community strength is in progress in the
following places apart from the large Thai Red Cross Society’s effort. For example: [a] Duang
Prateep Foundation - ACT Power; [b] Dhammarak Foundation’s efforts; [c] ACCESS; and [d]
Christian Missionaries work in hospice centres, and in the North and Northeastern parts of
Thailand. A few have formed an AIDS Care Unit that include a home care team. The decision
to shift the emphasis from the hospital to the community was based on several assumptions:o
o
o
o
o
that other health programmes need to continue;
that the family is the greatest long-term strength;
that patients prefer to die at home;
people learn best by talking together; and
that behaviour change can be achieved through activating traditional leadership
and facilitating responsibility transfer for care and prevention.
The objectives of the AIDS Care Unit also include identifying specific target groups for
education, and coordinating medical policies for management within the hospital. The objectives
of the home care team were primarily to care for patients by supporting families, to maintain
a data base, and to promote HIV/AIDS control through contact tracing and the development of
strategies for behaviour change by the community.
In some organisations [e.g., Thai Red Cross], the AIDS Team is a multi-disciplinary
group - the precedent for this was already established through the leprosy, drug de-addiction and
primary health care programmes. It was felt that people should be informed of the diagnosis and
provide adequate follow-up. This was consistent with the hope that a realistic strategy for AIDS
could eventually emerge.
In discussing programme development and the impact of the Saraburi Centre of AIDS
and Dhammarak Nives, it was observed that a home support work, through which information
can be obtained, could be established effectively.
Prevention and control strategies can then begin to develop strategies which are locally
relevant, and which recognise the inability of established health system to deal with the problem
except through a recognition and facilitation of community capacity. Defining locally applicable
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management principles if the first step to consolidate the initiatives. This guards against loss of
momentum, and promotes capacity for change. Through home based care, motivation for
prevention within the community is positively emphasised. The "bottom up" approach is one that
is preferred by those who suffer most, and it will therefore be sustained.
For the Government, Thai Red Cross and numerous NGOs, future success is likely to
be found in those programmes which explore the principles of community development that
respects local community initiative and are much more likely to implement the primary health
principles determined in the late 1970s.
10.2
Community Counselling
The purpose of education and counselling and all other disciplines of AIDS management
is behaviour change in a specific direction. This is mediated most effectively through counselling
which will take the form of individual, family and community counselling. Some Buddhist
monks and Christian missionaries have integrated it with education that functions as a tool, just
as it is for pastoral care, and for community development.
Community counselling on HIV/AIDS is still in its experiment stage. Largely, it is an
activity that focus on groups and communities to promote responsibility transfer for behaviour
change to the whole community. Generally, the community has group structures, shared values
and mutual concerns. This is relevant for crisis issues such as AIDS. Community counselling
is also needed for measurement of behaviour change. There is evidence in the Bang Chan area
[Chiang Mai district] of the powerful influence of family and community on individual behaviour
e.g., decisions on means of ritual cleansing, established certain community structures such as
temples, the re-introduction of the teaching of taboos, re-introduction of formal wedding
ceremonies, and elders settling family disputes in an amicable way.
Since late-1989 several community counsellors were trained by various agencies [e.g.,
Thai Red Cross and Empower], and these are now active in their respective areas. By joining
the existing village health work teams, these animators have become part of health service
structure. They work with community health workers and, if felt appropriate by the community,
can fill both roles, though it should be noted that this rarely happens.
The process requires a community counselling team. Training in HIV/AIDS counselling
for non-formal counsellors has been incorporated into the AIDS education and prevention
programme since 1991. For example, UNICEF and the Thai Red Cross have taken a pioneering
lead to pursue this training effort among industrial workers.
The team at Northnet [Chiang Mai] has now worked with many communities at various
stages of the process that include strategy formulation and implementation. This is the critical
point for training community counsellor from within each community, to work as an "insider”,
rather than one who views the community from outside. Almost all efforts rely on peer-group
networking approach. Peer-group approach is popular among industrial workers, in particular
those living in provincial urban centres outside Bangkok.
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10.3
Peer Group Training
Peer-group training in the industrial community is an eight-hour session [given in one day
or two] that enable the participants to counsel other industrial workers at their workplace.
Workers who have received training can serve as peer counsellors, provide counsel and advice
to their peers. These workers, in turn, are likely to pass the information on to their families and
friends in their hometowns. It helps to ensure that words on AIDS reach everyone in the
provinces within short time.
Workers in the training programme are taught in sessions comprising thirty people,
represent as many factories, as possible at the rate of about one trainee for every fifty workers.
Trainees learn about the situation of HIV/AIDS in Thailand, the nature of the disease, its mode
of transmission and prevention and the importance of relationship building among HIV-infected
and non-infected workers. The workers are taught basic communication skills as well as teaching
and counselling techniques. They are also provided with materials like flip charts and videos to
present to fellow workers in their provinces. The training sessions are conducted by social
workers and health educators. The training for non-formal AIDS Counselling programme for
1992 and 1993 targeted at seventeen northeastern provinces and fourteen central provinces.
The community counsellor/peer group educator is viewed as a key support component
in AIDS care and prevention, because s/he is community selected and based, with specific
training in HIV/AIDS work. The community counsellor is a significant and specific indication
of community involvement and is likely to prove in the long term to be the chief factor in
sustaining the commitment of all the people in the community to care for those who suffer, to
prevent the disease in those who are still seronegative, and ultimately, to control the disease in
the area, as counselling teams are formed within communities to reach other communities.
10.4
Women as Community Care Specialists
Women, and primarily housewives, are the main care-givers in the affected families.
Women’s groups do appear to have the potential to support each other. A school teacher [who
works with a Catholic School] in the Northeast who is an AIDS educator among women,
suggested that the housewives’ group has been formed to collectively help families and
individuals afflicted by HIV/AIDS. Women in the focus groups close to Chiang Mai collect food,
money, laundering of clothes and other basic needs. Some women informed that the informal
support of neighbours or people outside the family was limited. Family members also prefer not
to seek help - for fear of "social oppression".
10.5
Therapeutic Communities
Apart from the Government’s successful intervention through the Thai Red Cross Society,
the Lampang Project, Southeast of Chiang Mai, has evolved more advanced programmes over
the past four years despite adverse propaganda. A local monk has staked claims to manage this
project but the government has kept the proposal "under consideration". At this place, the monk
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has prepared for what is known as ''Therapeutic Community", where HIV people would be able
to stay for extended periods accompanied by family or friends, if necessary. The efforts pursued
include counselling, occupational training if appropriate, and medical and nursing care. The
ultimate objective is to build "self-reliant" individuals and families of PWAs to enable them cope
up with the situation.
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Section 11
HFV/AIDS - Threat to Life and Human Rights24
Persons living with HIV/AIDS face double threat: they face death, and while they are
fighting for their lives, they often face discrimination. This discrimination is manifested in all
areas of life i.e., from health care to housing; from work to travel. It is generally based on
ignorance and prejudice and is expressed in particularly harsh forms against the most vulnerable:
homosexual men, women, children, prisoners, and refugees among them. Whereas most illnesses
generate sympathy and support from family, friends and neighbours, persons with AIDS are
frequently feared and shunned.
In 1989, Empower, Phram Charmoon, Fr Giovanni and other activists observed that some
persons living with AIDS [PWAs] were confined against their will in a special prison-type
shelters, where a strict surveillance system was in force. Since then many groups have
documented discrimination patterns against persons with AIDS as well as measures to provide
protection for them. A few even suggested that a legal examination to seek remedies available
to those subjected to discrimination. Their search and efforts highlighted the dangers to public
health of discrimination against AIDS-infected persons.
Punitive measures and discrimination against HIV-infected people have become
widespread, interfering with their right to work, education, housing, travel and medical
treatment. Homes, hospitals and the workplace have become hostile environments for many with
AIDS. Discriminatory measures such as denial of medical treatment, quarantine, restrictions on
movement, social ostracism are increasingly reported. This creates misery for those already
suffering from a life threatening disease, and make public health efforts to control the pandemic
more difficult. Those who might benefit from counselling and medical care are often reluctant
to seek help because of well-founded fears that breaches of confidentiality might result in loss
of jobs, housing, or insurance, and abandonment by friends, co-workers, and family. Such a
situation make it more difficult to carry out studies needed to quantify the prevalence of HIV
and to monitor its spread.
AIDS served as a convenient excuse to further malign people and stigmatise them, and
was seen as a punishment for their sinful and aberrant behaviour. It was not the disease which
was judged, but the acceptability of individuals affected by it. A serious consequence of
prejudice has been medical neglect of those afflicted. Phra Pong Thep summarised the situation
as follows: "The response of the government and medical community would have been different
if the same disease had appeared among businessmen or showbiz people. Unfortunately, it
started with the poor and sometimes commercial sex workers that it was stigmatised." At the
beginning of the pandemic, many Thais had little sympathy for persons living with AIDS. The
feeling was that somehow people from certain groups "deserved" their illness. Nitaya of Duang
24
This section is based on discussions with Empower, Dr. Seri, and Dr. Chayan.
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Prateep Foundation concluded: "We are fighting a disease and not people. An infection is used
as an excuse to discriminate some groups and individuals."
Few Thais, in fact, refuse to work beside a person with AIDS, and such prejudices
against them are common. In the initial stages of the pandemic, HIV-infection led to termination
of employment in the industrial units or restaurants. In some instances, the status of the worker
was changed - for example, from a permanent employee to a piece-work labour after testing HIV
positive.
Children with AIDS [or born to HIV-infected persons] face deprivations of their human
rights. Many are born into poverty-stricken families which cannot afford medical treatment.
Because of lack of parental care, they do not receive proper education; those admitted in schools
are shunned and excluded. The strains on the ability of extended families to care for HIVinfected children or orphaned children have become too burdensome.
After several years of discriminatory practices, Thais have been developing greater
tolerance toward HIV-infected children [or children born to HIV-infected persons] at school.
Some orphaned children are placed in institutions where they receive care. A few provincial
schools have been successful in challenging exclusionary policies such that it is now fairly well
settled that there is no medical justification to exclude HIV-positive children from schools.
There have also been cases of students and their parents trying to force out teachers
infected with HIV from schools. Students were encouraged to boycott classes/schools taught by
a HIV-infected person.
The following human rights violations against persons with AIDS were specified in
discussions:o
o
o
o
o
o
o
o
o
attempt to kill commercial sex workers who are HIV-infected or suspected of
infection;
the segregation of prisoners
forced confinement of ///V/zl/DS-infected patients in institutions or colonies
isolated from the rest of society;
compulsory testing of individuals and groups;
restricting movement of infected persons, and denial of entry to selected racial
groups unless they submit to tests;
termination of employment or denial of employment because of HIV status;
denial of housing to AIDS-infected persons and eviction of infected persons from
their homes;
exclusion of children who are infected or thought to be infected, from school; and
exclusion of persons with AIDS from access to social security, welfare and other
services.
HIV/AIDS in Thailand
[67]
Section 12
Towards New Partnerships in HIV/AIDS Interventions
Notwithstanding Thailand’s recent economic boom, AIDS pandemic represents added
strain on its developmental fabric that is already hit by several factors. Growing incidence of
AIDS in the neighbouring nations like Myanmar, Cambodia, Laos and Vietnam multiplies its
burden. Moreover, obviously, a growing nation like Thailand does not have the requisite
resources to deal with a problem of this magnitude.
In developing nations, health systems are institutionally weak, per capita health
expenditures are less and health budgets have been declining in real terms. For the health system
to cope with the HIV/AIDS pandemic on top of an already over-stretched personnel and financial
situation is far out of reach. For example, the direct treatment cost of an HIV/AIDS person is
estimated to be around 10,000 Bahts, and as a nation Thailand cannot afford to treat all
HIV/AIDS persons adequately.
Additionally, it is not possible to ’’seal" all the transmission routes of the HIV virus
immediately; probably, government cannot even bar "illegal" immigrant women from bordering
nations to enter into commercial sex. Therefore, HIV-infected persons, especially those from
the poorer families, will have to be taken care now to avoid rapid transmission, and build
confidence among people that HIV/AIDS is a manageable disease. However, the response of the
Government is generally cautious.
If government bankruptcy and family and community impoverishment are to be avoided,
however, some mechanism to challenge the pandemic must be found. This third alternative is
found in the NGOs. Traditional roles for health sector NGOs in Thailand tended to vary between
conventional charity type activities, essentially meeting the gaps in government services, and
innovative, trend-setting by small-scale activities, piloting models with a flexibility and care the
public institutions cannot manage. Perhaps a major third role that is emerging which appears
more appropriate for dealing with the HIV pandemic i.e., to provide on a large scale an extra
layer of social welfare service, establish primary responses, referral mechanisms and links
between private and government institutions, and between the government institutions and
communities.
12.1
Circumstances
The spread of HIV/AIDS was rather rapid in Thailand and the transmission route appears
more or less clear now i.e., the infection spread from homosexuals to drug users who share
needles, to commercial sex workers, to men to housewives, and now remains a "family"
concern. As coping with the disease is getting more and more difficult for people in the affected
communities, people are steadily approaching various agencies and sources for support. The
initial fear that the agencies, religious heads may turn away from the HIV/AIDS as it is seen by
some as a punishment from God [i.e., karma} has now receded.
HIV/AIDS in Thailand
[68]
Several groups and organisations now demonstrate solidarity with the affected and
rejected. Bearing in mind the inadequacy of trained health care workers, services etc., one has
to embark on a strategy based on three main areas of action, aiming to provide: emotional
support, medical support and family services. The objectives can be achieved through training,
increased medical support and counselling.
In the absence of an effective, affordable, and widely available vaccine, prevention
programmes for the foreseeable future must concentrate on curbing the spread of HIV/AIDS by
modifying high-risk behaviours and provide health care facilities. However, to date, regional or
ethnic differences have received little consideration in setting policies, and interventions have
not been tailored to these cultural differences. Critical issues to be addressed include:-
What are our assumptions regarding risk groups and risk behaviour? How do these
assumptions stigmatise groups? How are populations determined and boundaries defined
in terms of coverage for care?
ny
What are the assumptions regarding specific interventions, and their impacts on policy?
o
o
o
o
o
o
o
o
population-based testing and counselling;
coordination with other health and education programmes;
control of HIV in the commercial sex industry;
socio-economic "predisposing" factors and impact on individual
households;
HIV transmission by IV drug use;
vaccine trials and immunisation;
care for HIV infected patients and support for families; and
rights and obligations of HIV positive persons.
cy
How can knowledge and cultural diversity at best be integrated into planning and
implementing HIV control and treatment policies and interventions? e.g., integration of
minority ethnic group members; support of socio-behaviourial efforts.
is*
What are the limits to and potential hazards of national policies?
Some other questions that support the response to the above are: Can narcotics control
policies that led to the suppression of poppy cultivation be modified to reduce the risk of HIV
transmission? How far commercial sex industry will respond to legal measures to prevent
recruitment of workers; is it possible to propose a care system for the ’’illegal” immigrant
CSWs? Will legalisation of prostitution help or hinder HIV/AIDS control? Will more focus on
HIV/AIDS imply neglect of other preventable, treatable or curable conditions? Will failure to
stop transmission because of fear of offending rights of privacy?
12.2
Basic Assumptions of a Comprehensive Strategy
a.
Evidence indicates that one type of risky behaviour, sex with multiple partners,
is not confined to commercial sex workers or their clients, that there are many
HIV/AIDS in Thailand
[69]
gradations between monogamous individuals and commercial sex workers and
their clients, and that gender-based double standard of sexual behaviour, is
widespread. In sum, risky behaviour is not confined to isolable sub-populations.
Available information shows that stigmatisation increases the difficulty to control
the spread of HIV and caring for HIV positive persons, ARC and AIDS patients
by modifying behaviour.
At present there is no strategy that recognises the different levels of risk
associated with identifiable groups and minimise the potential socially,
psychologically and epidemiologically harmful effects of the stigma.
12.3
b.
Present interventions appears to assume that the epidemiological boundaries are
similar with national, social or ethnic boundaries. However, information and data
from neighbouring countries, minorities and tourists indicate that there are no
strict pattern of flow of the virus between the sub-populations. Therefore, tourists
and transborder movement of people should be included in the intervention
policies and programmes. This is more so if one considers the migration of
people from the Shan province of Myanmar to North and Northeastern parts of
Thailand.
c.
Some of the present interventions are limited to "high risk" groups or "captive
audience", such as military recruits, commercial sex workers and women
delivering in hospital. Persons in such groups move many a times before they
"settle" down; this makes surveillance and follow-up difficult.
Clinical Care/Support
The health community [i.e., medical personnel and public health officials] have
responded well to the spread of HIV/AIDS by directing considerable resources and energy
towards development of policies, programmes, and interventions that will help prevent
and control the disease. Non-governmental organisations are giving increased attention
to HIV/AIDS, and their expertise has become an important resource in the drive against
the spread of the disease. Several international agencies have also launched programmes
to prevent and control the spread of the pandemic in the region.
When speaking of HIV/AIDS, the terms "prevention and control" are frequently used to
describe the necessary initiatives related to the pandemic. However, it is true to say that
prevention of the pandemic has not been successful in Thailand, which has put care and
alleviation of consequences on the priority action agenda.
A serious concern expressed by Dr. Praphan and others relate to availability of beds "in
time" and "in adequate number" for the PWAs. Everyone agrees that "unless infected
persons are taken care and health institutions illustrate that AIDS can be tackled and
cured - no one is going to believe it as a normal disease that could be controlled" - till
such time HIV/AIDS will remain as a "soap opera" illness!
HIV/AIDS in Thailand
[70]
Preventive Measures
As the situation is grim, it is not possible to differentiate between preventive and curative
measures. Making AIDS visible through care, support and openness is considered
important as a preventive measure. Personal contact with AIDS may, therefore, stimulate
prevention as: it is primarily a coping process, usually carried out one-to-one or in small
personalised groups, initiated by a distressed PWA and aims to reduce stress by means
of dialogue.
Clinical care of a person infected with HIV or a patient with AIDS can considerably
improve his or her quality of life. However, there is still an element of denial and
complacency within the medical profession itself, mainly due to the fact that AIDS has
no cure so far, and the meagre resources, it is felt, may be utilised for treating other
diseases whose cure is known. Coupled with this are myths about HIV and AIDS which
have made the clinical management of people with HIV or AIDS a very difficult task
indeed. Therefore, there is an urgent need to educate health professionals and health care
providers on the true nature of the issues involved in managing HIV infection and AIDS.
HIV-infected persons [PWAs] with recurrent illness require clinical management,
including occasional hospitalisation. At the minimum, clinical care should include pain
relief and treatment for common opportunistic infections; this requires adequately trained
health-care providers and a reliable supply of essential drugs and medicines. It is more
than mere medical management.
12.4
Living and Coping with HIV/AIDS : Counselling
In Thai culture, counselling is limited largely to religious sermons. There is no pre
marital or post-marital counselling sessions. Even in the urban areas, counselling is not
popular for non-AIDS problems too. Thus, counselling has not yet penetrated into the
society as an element of normal suggestion seeking and guidance.
A diagnosis of HIV infection or AIDS, or a suspicion or recognition of the possibility
of infection, brings with it profound emotional, social, behaviourial and medical
consequences. Subsequent individual and social adjustments required often have
implications for family life, sexual and social relations, work, education, spiritual needs,
legal status and civil rights. Adjustment to HIV infection demands constant stress
management and adaptation. It is a dynamic evolutionary and a life-long process that
makes new and changing demands on the infected individuals, their families and
communities in which they live.
HIV/AIDS counselling is a continuous process that aims to prevent transmission of the
infection and provide psychosocial support to those already infected. Thus, it is different
from education, as it deals with a specific risk group member. Generally, counselling is
extended to members of the family, peer-groups and neighbours.
HIV/AIDS in Thailand
[71]
12.5
Community-based Care and Support
Within the health sector, efforts need to be undertaken to ensure the involvement of
families and others in HIV treatment centres and in drug de-addiction treatment centres.
Many NGOs [e.g., Empower, Northnet, World Concern and NAPAC] have also
indicated willingness to increase their involvement to promote and organise community
based care centres i.e., hospice centres within the community.
A large number of NGOs and activists believe that family and community-based care for
people who are ill, is a deeply rooted aspect of Thai culture and that it is expected that
such care will relatively easily be provided to people with HIV.
More comprehensive strategies will be required soon to determine feasibility of strategies
to develop the capacity of communities to provide such care, especially in circumstances
where water supply and sanitation are inadequate, where people with HIV care are
estranged from their families due to distance or culture, or where hospitals simply
become overwhelmed by large numbers of people with AIDS-related conditions.
12.6
Interventions among Drug Users
Interventions among IVDUs is a disheartening task due to the complex issues involved.
The major objective is to prevent drug abuse. In such situations abstinence-oriented
treatment approach, a series of subtle harm reducing strategies are to be promoted. Peerto-peer programmes to convert drug injectors to drug inhalers, education for
decontamination of needles and syringes with bleach are pursued by various agencies
[e.g., Thai Red Cross or Duang Prateep Foundation].
The enormity of the task makes it difficult to pursue a single strategy in Thailand.
Possible interventions will have to scrutinise access to opium areas with determination
to evolve an action plan.
12.7
Role of Religious Groups and Individuals
The response of the religious organisations and personnel [i.e., Buddhist Wat or Church]
has been generally ambivalent. Some of the efforts undertaken by them were out of
personal conviction and commitment rather than institutional policies. As Buddhism plays
a major role in rural life, one could explore the possibility of building "healing
communities" that include pastoral care, to work against the discrimination and
oppression, and to ensure protection of human rights of persons affected directly or
indirectly by AIDS.
Moral, theological and ethical debates certainly delayed the Church’s response to the
AIDS problem. Beginning in 1985, several initiatives were taken to promote hospice
centres, education, pastoral care and advocacy. The challenge for the religious
communities was to deal with prejudices surrounding the issue of AIDS [e.g.. Relief
HIV/AIDS in Thailand
[72]
Centre and Dhammarak Nives], to assist people in their dying and to offer them a sense
of peace, a feeling of acceptance and love. Church institutions in Thailand continue to
seek, listen to and learn from partners around the world confronting the realities of AIDS
and to encourage the exchange of ideas through dialogue and exchange of experiences.
Within the Buddhist and Church communities discussions are now being pursued to
sharply focus on the imperative to recognise and rediscover the role of the local
monasteries and congregations in the context of the social ministries of religion. Pastoral
care is seen as a challenge to enable building a caring community within the area and
neighbourhood where religious personnel work. They are more concerned with provision
of ’’terminal care’’ for the PWAs and performance of death-related ceremonies.
12.8
Mass Media
Mass media has significantly contributed to raise the awareness of people on HIV/AIDS.
However, past experience indicates that reporting of HIV and AIDS issues is casual that
led to inaccuracies, sensationalisation of information or failure to keep pace with rapidly
changing information.
It is stressed that adoption of standard terminology while writing about HIV/AIDS is
essential to overcome the problems. This will avoid misconceptions and mass hysteria
about HIV/AIDS.
12.9
Human Rights
People with HIV or AIDS [PWAs] deserve the same dignity and human rights as any
other person. Present public health principles tend to succumb to scapegoating,
stigmatising or discrimination against HIV-infected persons in the vain hope of curtailing
the pandemic. Non-discrimination is not only a human rights need but viewed as a sound
strategy to ensure that infected persons are not driven underground or remain inaccessible
to education programmes. There is a significant need to protect and promote
confidentiality of the PWAs as the possibility of discrimination and ostracism is
extremely high.
12.10 Some Key Problems
Orphans25
AIDS orphans represent the final stage in the social and financial destabilisation of the
Thai family affected by AIDS. Orphans in Thailand are usually considered as children
whose mothers have died, even if the father is still alive [or] those left alone by their
25
Norwegian agencies have developed some framework on "how to deal with the AIDS-orphan children".
HIV/AIDS in Thailand
[73]
parents to search for a living. Women are primary caretakers in the Thai society, and
public or private social service programmes to help people cope with child-rearing are
virtually non-existent. AIDS orphans will undoubtedly pose one of the greatest challenges
to the development of Thailand, because of the rapidly increasing numbers of adult and
childhood AIDS cases, because the disease usually kills both parents, and destroys family
networks, because of the stigma often associated with AIDS.
Some government departments and NGOs are beginning to discuss ways to meet the
needs of AIDS orphans in the future. The concept of singling out AIDS orphans for
special assistance, however, is rejected by some people [e.g., Northnet and Empower],
because they feel it increases the potential for further discrimination against these
orphans. It is considered that support to AIDS-orphans conversely discriminates against
children orphaned from other causes who may be equally disadvantaged and in need.
In the past, most Thai orphans have been absorbed by the extended family. Confidence
in the tradition of the Thai extended family has created complacency about the future of
AIDS orphans. While the extended family has coped well with the burden of children
orphaned by other causes in the past, it will not be able to cope with the large numbers
of orphans which might be created by AIDS. Besides, its economic, coping, and caring
capacity has become extremely fragile. This is increased by the pressures of AIDS.
Currently, many AIDS orphans caretakers are grandparents - too old and too poor to
raise the children well.
Phra Pong Thep asserted that non-biological children in an extended family may be
discriminated and end up being servants. Therefore, the myth that the extended family
can cope with the increasing AIDS-orphans’ burden without external support is
erroneous.
Many AIDS orphans will not have access to an extended family or to organised care,
particularly as their numbers increase. Many urban women with AIDS were already
marginalised and rejected by their own communities before infection, and AIDS has
broken the final link. Their children may not be accepted in other families. Children with
no satisfactory home will become "street children" and will be vulnerable in their turn
to HIV-infection, as the need to exchange sex for food, shelter or comfort is more.
The major responsibility for assisting AIDS orphans in the rural areas of Thailand will
certainly fall on NGOs or religious groups, as they have the most significant experience
in implementing social service activities/programmes. The key will be to find methods
to encourage extended families to accept the children, and enable them to care for the
AIDS orphans. There are some difficulties viz., constraints in identifying children in
need as they may dispersed; enormous logistical and distribution problems.
12.11 Towards New Partnerships and Initiatives
Providing essential support services [i.e., supervision, drugs, transportation, counselling
etc] to numerous and scattered PWAs along with preventive and educational programmes for the
HIV/AIDS in Thailand
[74]
community is a challenge; and this is characteristic of any developmental intervention as it views
elimination of HIV infection from the community as paramount - it remains as a major problem
that prevents many agencies from adopting strategies such as hospice approach.
In summary, the programmes to date have promoted understanding of the nature of HIV
and routes of transmission. The next step is to invoke strategies which enable individuals and
communities to incorporate that knowledge into their own decision-making about behaviour
pattern and the factors which influence their own and others’ behaviours. Such strategies,
everyone oncurs, should include peer education that provides access to community-wide
discussions about changing economic and cultural circumstances in which behaviour take place,
possible options for prevention of further HIV transmission, skills development, and the
promotion of peer support for behavioural change.
cy
Facilitate Change of Behaviour
The primary emphases of the present strategies to promote behaviour changes have
been:O
o
o
the use of mass communication techniques - leaflets, billboards, limited use of
videos and radio;
use of training strategies; and
popularise statements of intent about the use of peer education strategies, and very
limited introduction of peer involvement in other parts of the programme, often
with little resourcing from the programme.
These fields in which knowledge has advanced internationally during the past five years,
particularly as a result of new health promotion strategies adopted in response to the HIV
pandemic, and more effective ways of using these methods could be introduced in
Thailand.
Access to information about what works to promote behaviour change has been limited
in the current efforts of the Government and NGOs, and the next phase should include
strategies to improve skills in these areas.
B33
Hospice Approach
Hospice centres are complex projects and require substantial ’’implementing capacity” and
resources than other forms of intervention. It is much more than mere institutional care;
it views symptom control within the families as important; it seeks personal, spiritual and
emotional support for the infected persons. Therefore, the complexity of its function has
major implications for the leaders’ capacity to build cadres, convince PWAs and their
families.
Three themes in regard to hospice approach have recurred in our discussions and appear
to be central to the promotion of that approach for HIV/AIDS care and awareness,
especially for a resource constrained nation like Thailand.
HIV/AIDS in Thailand
[75]
a.
The current rate of HIV infection and the approaches show that even if the efforts
are scaled up severalfold, it would not have much positive impact. The scale of
failure of the Government and other agencies to effectively predict the prevalence
of HIV before it assumed alarming propositions recurred in the interviews was
placed as evidence. This failure is considered as an illustration as to how the
Government machinery is powerless and NGO efforts remain "predictable".
The obvious weaknesses in "prevention and education" strategies were often cited
as inadequate preparatory works carried out by both Government and NGOs. For
those, engaged in hospice work, "prevention and education" will be effective only
when it is shown that the present medical system and the society, in general, can
take care of HIV/AIDS conditions. This strategy may not have developmental
perspective, but has some moral and educational validity.
b.
The factors responsible for the spread of HIV infection [e.g., IV drug use or
unprotected sex] are the result of many factors as broad as the international
context which affects each nation’s economic performance and the possibility of
the Government losing some investments or access to export markets. Such an
impact will immediately affect the industrial workers, unorganised sector and
urban poor, and as a mere survival strategy might force some of the PWAs to
hide their infection.
c.
Efforts should include promotion of more widespread consideration about which
people are at high risk of infection, and what non-personal factors limit or
enhance their choices and options for prevention of further transmission.
At the hospice centres and counselling places, current efforts to involve those who are
already HIV-infected [PWAs] is receiving a good response. However, what appears to
be needed is a national strategy to promote development of peer education and other
activities in thousands of localities that would result in establishment of "hospice centres"
at the community level. Such a strategy should consider appropriate processes to increase
the effectiveness of community-based care possibilities in the future. These will include
the later development by communities of their own localised programmes to care and
support those who are dependent on people, who are ill, or who have died, and the
surviving children or elderly people.
cy
The challenge for a moderately developed nation like Thailand is to address HIV/AIDS
problems in a more low profile manner26, and make best use of its resources,
knowledge and institutional capacity [e.g., cultural, religious and human] that would be
culture-specific and minimise damage to the poorer communities, and to the nation.
26
Government efforts on HIV/AIDS would much depend on the popular pressure of Thais themselves, and which in turn would rely
on popular awareness on this issue. Any high profile effort, generally, has received indifferent response amongst Thai public [e.g.,
campaigns to ban commercial sex centres]. As many of those affected come from poorer families and to be sensisitive to cultural
precepts of the Thai society - low profile strategies could be pursued. Simultaneously, such efforts should help develop informal
mechanisms among people’s organisations, professionals and other interested parties to respond to issues relating to HIV/AIDS. This
will facilitate to raise public awareness and slowly break culture of silence, which is essential to carry out large scale preventive
efforts. It is also essential to evolve sub-regional mechanisms to share information and knowledge on HIV/AIDS.
HIV/AIDS in Thailand
[76]
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[79]
List of NGOs Engaged in HIV/AIDS Initiatives
Activities
Data
Source1
Activity
Area2
1. Thai Red Cross
Clinical care, training, media
development, counselling and research.
I + D
National
2. Hot Line Foundation
Counselling and networks.
I + D
BKK +
CNX
3. World Concern
Counselling, training and networks.
I + D
BKK +
Phy +
CNX
4. The Association for
Improvement of Home
Services for Infected
Prostitutes
Home services, vocational training and
counselling.
I + D
BKK +
CNX
Research, grant-making and
intervention.
I + D
National
Organisation
5. Family Health
International
[AIDSCAP]
6. Association for the
Strengthening of
Integrated National
Population and Health
Development Activities
Training.
D
BKK
I + D
BKK +
others
7. Duang Prateep
Foundation
Health education, surveillance,
counselling and peer education.
8. The Planned
Parenthood
Association of
Thailand
Training and educational curriculum
development.
I + D
BKK
9. Foundation for
Agricultural and Rural
Management [FARM]
Training and clinical care.
I + D
BKK +
North
Note
Data Source for the Review
1
I .. Interview; D .. Document Review.
Activity Area
2
BKK .. Bangkok; Phy .. Phayao; CNX .. Chaing Mai; C'Rai .. Chiang Rai.
Organisation
Activities
Data
Source
Activity
Area
I +D
BKK 4
Phy and
C'Rai
10 World Vision
Clinical care, health education and
pastoral support, where possible.
11 Chulabhom Research
Institute
Research, policy-support and training.
D
National
12 National Women's
Council of Thailand
Health education and policy-support.
D
National
13 ACCESS
Counselling, hotline service and training.
I + D
BKK *
Public relations, media development,
training and interventions.
I +D
National
AIDS education materials development,
training and intervention programmes.
I 4- D
BKK and
others
Health education, surveillance,
counselling and peer education at the
commercial sex areas.
I +D
BKK 4
CNX
14 Population and
Community
Development
Assocation
[PDA]
15 Programme for
Appropriate
Technology for Health
[PATH]
16 Empower
Foundation
CNX +
17 FACT
Training and educational curriculum
development on AIDS.
I+D
BKK
18 Media Link
Group
Health education and media development.
I + D
BKK and
others
Organisation
Activities
19 CARE, Thailand.
Clinical care at the field level, health
education and networks.
20 YMCA, Chiang Mai
Training and health education.
21 Daughters' Education
Program, Chiang Mai.
Health education, training and formation
of women's groups.___________________
22 Women and Youth
Devt Project, Chiang
Mai.
Counselling, hotline service and training.
23 NorthNET
Data
Source
I + D
I + D
Activity
Area
BKK 4Phy +
CNX 4C'Rai
CNX 4CKai
I + D
CNX and
suburbs
I + D
CNX
Public relations, media development,
training and community development
activities.
I + D
CNX and
suburbs
24 ACT Centre
AIDS education materials development,
training and intervention programmes.
D
BKK 4CNX .. ..
25 Mirror
Group
Health education and training.
D
BKK
26 Nithat Show
Training and counselling.
27 Rural Doctor Club
Health education and counselling.
I + D
BKK .. ..
I + D
BKK and
others
Activities
Data
Source
Activity
Area
28 St Camillus
Foundation
Clinical care at the field level, health
education and networks.
I + D
BKK +
suburbs
29 Urban Development
Foundation [UDF]
Training and health education.
I + D
BKK
30 Catholic Reflief
Services [CRS]
Health education, training and
formation of PWAs groups.
I + D
BKK
31 Coordinating
Committee for
Primary Health
Care of Thai NGOs
Training, counselling and health
education.
D
BKK
and
others
32 Welcome House
Clinical care, terminal care, training
and counselling.
33 Health Development
of Teenagers
Organisation
AIDS education materials
development, training and intervention
programmes among young persons and
in campuses._____________________
34 Church of Christ
in Thailand [CCT]
Health education, training and family
support programmes.
I + D
35 International
Network
of Engaged
Buddhists
Training and counselling through
propagation of Buddhist values and
with monks.
I + D
National
36 The Friends for
Life Project
[Chiang Mail
Clinical care, family support, training
and health education through
preaching of Buddhist values.
I + D
CNX
37 Catholic
Commission for
Health Promotion
[CCHP]
Clinical care, pastoral support, enable
formation of religious groups,
training and networks.____________
I + D
National
38 Rebirth Centre
Clinical care and general support
Organisation
I + D
D
D
BKK
and
suburbs
BKK
and
suburbs
Mainly
in the
North
but
national
BKK
Additional List
A
Funding / Technical Assistance / Research
o
o
B
Funding/Technical Assistance/Pilot Implementation
o
o
o
o
o
o
o
o
o
C
AIDS Crusade [Bangkok]
Foster Parents Plan International
Pearl S Buck Foundation, Inc. [Thailand]
Thailand Fertility Research Association [TFRA]
Catholic Commission for Health Promotion [CCHP]
Church of Christ in Thailand [CCT]
Government/International Agencies
o
o
o
E
Programme for Appropriate Technology in Health [PATH]
Redd Barna Thailand
World Vision Foundation of Thailand
The Save the Children Fund [UK]
Family Planning International Assistance [FPIA]
Norwegian Church Aid [NCA]
Thai-Australia Northern AIDS Prevention and Care Program [NAPAC]
Thai-Australia Non-Northern AIDS Program [NONAP]
Thai Red Cross Society
Initiation/Implementation of Activities
o
o
o
o
o
o
D
Family Health International [FHI]
AIDS Control and Prevention Project of FHI i.e., AIDSCAP
Ministry of Public Health
UNICEF [through Thai Red Cross Society]
World Health Organisation [through MoPH]
Research and Training
o
o
o
o
o
Thai Red Cross Society
Chulabhorn Research Institute
Chiang Mai University Social Research Institute
Chulalongkorn University Social Research Institute
Thailand Development Research Institute
Work Schedule
April
22
26
29
AIDSCAP/FHI
Hotline Foundation
Duang Prateep Foundation
02
04
06
07
09
10
11
12
20
21
23
Chulalongkorn University/Dr Abha
The Association for Improvement of Home Services for Infected
Prostitutes
Empower
The Planned Parenthood Association of Thailand
Dr Wiwat, Ministry of Public Health.
Nithat Show
Rural Doctor Club and International Network of Engaged Buddhists
Thai Red Cross Society
UNICEF, Bangkok.
World Concern
FACT and Media Link Group
04
05
Thailand Development Research Institute
Chulabhorn Research Institute
12 to 16
Chiang Mai
May
July
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
NPAC/NONAP/Australian Overseas Aid Bureau
Chiang Mai University Social Research Institute
The Friends for Life Project
Northnet
Church of Christ in Thailand
DISAC, Chiang Mai.
Dr Anchalee and Dr Ron of Phayap University.
World Concern
World Vision
CARE
San Sai Medical Centre/Dr. Voravut
YMCA, Chiang Mai.
Daughters’ Education Programme
Women and Youth Development Project
ACCESS
i
o
o
o
o
19
20
21
24
25
26
27
28
29
Health Sciences Research Institute
Villages located in the suburbs
Dr. John Peacock, formerly of UNICEF
Church of Christ in Thailand
Population and Community Development Project
FARM
SCF, Bangkok.
Fr. Jean Barry s.j.
AIDSCAP
Catholic Commission for Health Promotion
Some of the Catholic Organisations [i.e., Welcome House; Catholic Relief
Services; St Camillus Foundation]
Urban Development Foundation
Fr. Jean Barry s.j.
August
02 to 06
International Christian AIDS Network Conference [I-CAN], YMCA,
Bangkok.
10 to 16
20 to 28
Preparationn of blueprint for the draft report
Finalisation of the draft
September
07 to 12
Preparation and submission of provisional report to CEBEMO [including
editing and formating]
October
20
21
22
24
31
Fr. Jean Barry
Reflief Centre [Fr. Giovanni] and Ms. Usance.
Dhammarak Nives, Lop Buri.
National Institute of Communicable Diseases, Bangkok.
Submission of Section on "hospice'' approach.
December
*
Receipt of comments
Consolidation of the final report
ii
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