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.pdfCHAPTER 27
RESPONSE TO THE HIV/AIDS EPIDEMIC IN THAILAND
Abstract
In Thailand, a politically supported, well-funded, comprehensive HIV prevention programme has substantially reduced incidence of new HIV infections, raised condom usage, and decreased prevalence of STIs. Widespread transmission of HIV began in the late 1980s among high-risk groups but the initial response to the epidemic was limited. In 1991, HIV prevention and control became a national priority. HIV prevention education was made compulsory in schools, legal reforms carried out and the “100 per cent condom programme” was launched to distribute free condoms and enforce compulsory and consistent use of condoms in all brothel and non-brothel settings. Achievements need to be actively sustained by adopting strategies to match the shifts in the epidemic and by focussing on preventing transmission among IDUs and their sex partners.
Key Words
Bangkok, Chiang Mai, Hundred per cent condom programme, Thailand
27.1 – INTRODUCTION
Thailand is among the few developing countries where public policy has been effective in preventing the spread of HIV/AIDS. The country’s politically supported, comprehensive HIV prevention programme has substantially reduced incidence of new HIV infections, raised condom usage, reduced visits to commercial sex workers, and decreased prevalence of STIs (Kanabus & Fredriksson, 2006). In late 2005, the estimated number of HIV-infected adults and children was 560,000 and 16,000, respectively. The country’s population in July 2005 was 64.23 million. The prevalence of HIV infection in adults was 1.4 per cent. The number of AIDS-related deaths in 2005 was 21,000 (UNAIDS/WHO, 2006).
The first case of AIDS was reported in Thailand in 1984 (Phanuphak et al., 1985). Widespread transmission of HIV began in the late 1980s among high-risk groups. HIV infection among IDUs rose from almost zero to 40 per cent during 1988–89. In 1989, it was reported that 44 per cent of sex workers in Chiang Mai in North Thailand were HIV-infected (Weniger et al., 1991). The infection soon spread from male clients of sex workers to their wives and partners, and their children (Kanabus & Fredriksson, 2006).
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27.2 – RESPONSE TO THE EPIDEMIC
The initial response was limited in the 1980s because the prevailing opinion was that the disease was imported from abroad and would be confined to individuals in high-risk groups such as gay men and IDUs. Legislators proposed that all foreigners should be tested for HIV infection before being admitted into the country. The Thai Government spent only US$180,000 on HIV prevention in 1988 (World Bank, 1997).
In 1991, HIV prevention and control became a national priority. The National Plan for Prevention and Alleviation of HIV/AIDS in Thailand was brought under the Office of the Prime Minister and the budget was increased almost 20 times to US$44 million in 1993 (Owens, 1991). A public information campaign was launched and HIV prevention education was made compulsory in schools. The “100 per cent condom programme” was launched to distribute free condoms and enforce compulsory and consistent use of condoms in all brothel and non-brothel settings where commercial sex was available. Legal reforms were carried out and proposals for mandatory reporting of names and addresses of AIDS patients were overlooked (World Bank, 2000). By 1996, the funding for the programme had increased to US$80 million annually (Kanabus
&Fredriksson, 2006).
The second National Plan for Prevention and Alleviation of HIV/AIDS in
Thailand, which covered the period from 1997 to 2001, mobilised the communities and people living with HIV/AIDS. In the 1990s, a randomised controlled trial carried out in Bangkok to study the effect of short-course ZDV in PMTCT of HIV showed that the transmission was reduced by 50 per cent (Shaffer et al., 1999). By 1999, ZDV was being used for preventing perinatal transmission of HIV in most hospitals in Thailand (Kanshana & Simonds, 2002). Due to the Asian Financial Crisis in the late 1990s, funding for ARV therapy, treatment of opportunistic infections and condom distribution was reduced. In 2000, the funding for the National Programme was US$65 million annually (Kanabus & Fredriksson, 2006).
27.3 – CURRENT SITUATION
The third National Plan for Prevention and Alleviation of HIV/AIDS in Thailand was launched in 2001 and covers the period from 2002 to 2006. This plan envisaged the reduction of adult HIV prevalence to less than 1 per cent by the end of the plan period and the provision of access to care and support for at least 80 per cent of the people living with HIV/AIDS. Work on prevention and alleviation of HIV/AIDS was to be planned and implemented by local administrations and community organisations throughout the country. By 2003, the national adult HIV prevalence fell steeply to about 1.5 per cent (UNAIDS/WHO, 2006). Triple combination ARV therapy was introduced in 2000. Due to availability of cheaper generic drugs and external funding, the
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programme expanded more than eightfold between 2001 and 2003, with only a 40 per cent increase in budget (Ford, 2004). Between 72,000 and 91,000 persons in need of ARV treatment were receiving it by the end of 2005 (WHO, 2006).
27.4 – CONCLUSION
Thailand’s epidemic is currently more diverse than it was a decade ago and the routes of transmission have been changing. This indicates that Thailand’s achievements have to be actively sustained by effective programmes that adopt strategies to match the shifts in the epidemic. As many as half of new HIV infections every year are occurring within marriage or steady relationships where condom use tends to be very low (UNAIDS, 2002). The “100 per cent condom” programme aimed at 100 per cent condom use for all commercial and casual sex. But, the programme has not had much impact on transmission of HIV from infected male clients of female sex workers and from infected male IDUs to their wives and regular sex partners (WHO, 2002). There are concerns regarding the decreasing rates of condom use in non-brothel settings by indirect sex workers and rising HIV prevalence in some parts of Thailand, especially in Bangkok (World Bank, 2000). Over 10 per cent of brothel-based sex workers and 45 per cent of IDUs attending treatment clinics were found to be HIV-infected in 2003 (UNAIDS/WHO, 2006).
There has been a huge increase in the number of non-brothel sex service establishments such as massage parlours and clubs. This will require revamping safe sex campaigns in circumstances where patterns of commercial sex have changed. The neglected dimensions of Thailand’s epidemic are premarital sex among sexually active young people, MSM, and IDUs. There has been an increase in HIV prevalence among IDUs in every region of the country. An estimated one-fifth of new HIV infections in the previous decade have been attributed to injecting drug use. Yet only a small proportion of Thailand’s HIV prevention efforts are focussed on this high-risk group (Kanabus & Fredriksson, 2006).
Till date, Thailand’s HIV prevention programmes have not focussed on preventing transmission among IDUs and their sex partners. In 2002, UNAIDS recommended that giving clean needles to IDUs should be considered to combat the spread of the epidemic (Bhatiasevi, 2002). HIV prevalence among previously imprisoned IDUs and that among their never-imprisoned counterparts was 49 and 20 per cent, respectively. Thus, incarceration appears to be a significant risk factor for HIV infection among drug injectors in Thailand, as in Indonesia. Many of the drug users were probably infected in prison (UNAIDS/ WHO, 2006).
It is estimated that use of condoms by sexually active adolescents is less than 50 per cent. Thus, adolescents form a high-risk group. The Health Ministry in Thailand is planning to add more condom vending machines in public places. However there are also reports about authorities refusing to install condom vending machines fearing they promote promiscuity (World Bank, 2000).
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REFERENCES
Bhatiasevi A., 2002, Thailand – Call to provide clean needles to drug users. Bangkok Post November 27. Cited by Kanabus A., and Fredriksson J., 2006.
Ford N., 2004, The role of civil society in protecting public health over commercial interests: lessons from Thailand. Lancet 363. Cited in: Kanabus A., and Fredriksson J., 2006.
Kanabus A. and Fredriksson J., 2006, HIV and AIDS in Thailand. www.avert.org/aidsthai.htm. Last updated 13 July 2006.
Kanshana S. and Simonds R.J., 2002, National Programme for preventing mother-to-child HIV transmission in Thailand: successful implementation and lessons learned. AIDS 16: 953–959.
Owens C., 1991, Alarming spread of AIDS virus in Thailand may threaten country’s recent economic gains. Asian Wall Street Journal 13(51): 4.
Phanuphak P., et al., 1985, A report of three cases of AIDS in Thailand. Asian Pac J Allergy Immunol 3: 195–199.
Shaffer N., et al., 1999, Short-course zidovudine for preventing perinatal HIV-1 transmission in Bangkok, Thailand: a randomised controlled trial. Lancet 353: 773–780.
UNAIDS, 2002, AIDS epidemic update. Geneva: UNAIDS, p 10.
UNAIDS/WHO, 2006, 2006 Report on the global AIDS epidemic. Geneva: UNAIDS/WHO. Weniger B.G., et al., 1991, The epidemiology of HIV and AIDS in Thailand. AIDS 5 (Suppl 2):
S71–S85.
World Bank, 1997, Confronting AIDS: public priorities in a global epidemic. Oxford: Oxford University Press, pp 275–276.
World Bank, 2000. Thailand’s response to AIDS: Building on success, confronting the future. Thailand Social Monitor 5: 1–11. Cited by Kanabus A. and Frediksson J., 2006.
WHO, 2002, HIV/AIDS in Asia and the Pacific region. Geneva: WHO, pp 21–23.
WHO, 2006, Progress on global access to HIV anti-retroviral therapy – Report on ‘3 by 5’ and beyond. Geneva: WHO, 28 March.
CHAPTER 28
RESPONSE TO THE HIV/AIDS EPIDEMIC IN CHINA
Abstract
The response to the HIV epidemic in China has been relatively slow for want of political commitment, openness to confronting the epidemic, adequate resources, and a favourable legal and institutional environment. During the first phase of the epidemic (1985–1988), cases of AIDS were primarily among foreigners or Chinese people who had travelled overseas. The second phase (1989–1993), began with the detection of HIV infection among IDUs; AIDS and drug addiction were perceived as consequences of contact with the West and AIDS was known as aizibing, or the “loving capitalism disease”. During the third phase (1994–2001) a major scandal resulted in blood or plasma donation-related HIV infection. The fourth phase started in 2001, when a Plan of Action to contain, prevent, and control HIV/AIDS was published. Subsequently, the “Four Frees and One Care Policy” and “China CARES”, a com- munity-based HIV treatment, care and prevention programme were announced. Recently introduced interventions include a policy of 100 per cent condom use (in some regions), detection and treatment of STIs, peer education, and VCT.
Key Words
Aizibing, China, China Comprehensive AIDS Response, Four Frees and One Care
Policy
28.1 – INTRODUCTION
The first case of AIDS was reported in Beijing, China in 1985 (Kanabus & Noble, 2006). In January 2006, the Chinese Government, along with the WHO and UNAIDS, jointly estimated that 650,000 people were HIV-infected in China, including 75,000 AIDS patients (Ministry of Health et al., 2006). However, the overall prevalence of HIV infection in China is considered “low” because China’s population is estimated at about 1.3 billion. The 2006 estimate is lower than the 2003 estimate of 840,000 HIV-infected persons due to improved methods of estimation. Estimates of prevalence of HIV infection are difficult due to under reporting, shortage of testing equipment and trained staff. Estimations forecast a generalised epidemic in China with between 10 and 20 million HIV-positive Chinese (Kanabus & Noble, 2006).
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28.2 – PHASES OF CHINA’S EPIDEMIC AND RESPONSE
The epidemic in China has been described in four distinct phases (Zhang & Ma, 2002).
Phase I: The first phase, from 1985 to 1988, was characterised by few cases of AIDS in coastal cities primarily among foreigners or Chinese people who had travelled overseas. In 1986, the Health Ministry announced plans to test all foreign students for HIV infection if they had been in the country for more than 1 year and students entering China would require a certificate from their country of origin affirming that they were not HIV-infected. The authorities believed that homosexuality and “abnormal” sexuality were a “limited” problem (Kanabus & Noble, 2006).
Phase II: The second phase, from 1989 to 1993, began with the detection of HIV infection in 146 drug users in southwest Yunnan province. At the end of 1989, 153 Chinese and 41 foreigners were reported as HIV-infected. AIDS and drug addiction were perceived as consequences of contact with the West and AIDS was known as aizibing, or the “loving capitalism disease” (Kanabus & Noble, 2006).
Phase III: The third phase began in late 1994, when HIV infection spread beyond Yunnan province. By the year 1998, HIV infection was reported from all 31 provinces, autonomous regions and municipalities. Heterosexual transmission accounted for 7 per cent of infections while 60–70 per cent of reported HIV infections were among IDUs (Zhang & Ma, 2002). In November 1998, the State Council published the Medium and Long Term Plan for AIDS Prevention and Control with the specific objectives of stopping HIV transmission through blood supply by 2002, controlling spread of HIV among IDUs, restricting number of China’s HIV infections to fewer than 1.5 million by 2010, providing information about HIV/AIDS and preventing STIs to over 70 per cent of the population, including 45 per cent of rural inhabitants and 8 per cent of persons with high-risk behaviour by the year 2002 (Kanabus & Noble, 2006).
Phase IV: The fourth phase started in 2001, when events suggested that the silence surrounding HIV/AIDS in China was beginning to end. In June 2001, the “China Plan of Action to contain, prevent and control HIV/AIDS (2001–2005)” declared that blood for clinical use would have to undergo complete HIV testing. In August 2001, there were between 600,000 and 800,000 HIV-infected persons, with about 6 per cent of these infections caused by contaminated blood. In December 2003, the “Four Frees and One Care Policy” was announced. The new policy had the following objectives:
1.Free ARV treatment for all rural residents or poor urban residents who need treatment.
2.Free VCT.
3.Free ARV treatment for HIV-infected pregnant women to prevent MTCT and HIV testing of newborn babies.
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4.Free schooling for children orphaned by AIDS.
5.Care and economic assistance to households of people living with HIV/AIDS. In 2003, the Chinese Government launched “China CARES” (China Comprehensive AIDS Response), a community-based HIV treatment, care and prevention programme. By October 2003, a pilot programme was launched in seven provinces to provide free domestically produced ARV drugs. However, more than one-fifth of the 5,000 patients receiving ARV treatment dropped out of the programme, primarily because these drugs caused strong side effects. About 1,100 health care providers were trained in HIV care during 2004 (WHO, 2005a). ARV treatment has been introduced in 28 provinces and autonomous regions and by June 2005, about 20,000 people were receiving these drugs (UNAIDS/WHO, 2005). In 2004, local governments were instructed to undertake mass education campaigns for the general population and to counter stigma and discrimination. The Chinese Government also increased its support for harm reduction among IDUs and condom use among high-risk groups (Kanabus & Noble, 2006).
28.3 – GEOGRAPHICAL VARIATIONS
Though HIV infection has been reported from all 31 provinces, autonomous regions, and municipalities, there are wide variations in HIV prevalence across the country. In some areas, more than 1 per cent of pregnant women are HIVpositive, implying that these areas have entered the stage of generalised epidemic (Kanabus & Noble, 2006). The majority of HIV infections have been detected in urban areas of Guangdong, Yunnan, and Henan provinces and Guangxi autonomous region. Currently, Qinghai province and Tibet autonomous region are the least affected (UNAIDS/WHO, 2005). The epidemic in high-prevalence areas is described below.
Yunnan Province: HIV infection rates are very high (50–80 per cent) among IDUs in certain cities of Yunnan province. Sexual transmission accounted for 15 per cent of infections in 2000. Most of the infections are reported in young people aged between 15 and 30 years and are equally distributed among minority populations and the majority Han population. The male to female ratio has shifted from 4:1 in 1997 to 3:1 in 1998 (UNAIDS, 2002).
Henan Province: In 2000, a major scandal among paid plasma donors received wide coverage in the international media. Though the actual number of persons infected with HIV through contaminated blood transfusions is unknown, it is estimated that there could be more than one million victims in Henan province alone (Watts, 2003a). However, other estimates of HIV infection range from below 150,000 to above one million (UNAIDS, 2002).
Guangdong Province: In late 2002, injecting drug use and sexual transmission accounted for 82 per cent and 2 per cent of HIV infections, respectively.
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Guangxi Zhuang Autonomous Region: In some parts of this region, HIV infection among IDUs is between 20 and 70 per cent. Condom use is low among commercial sex workers and HIV infection has been detected among non-injecting patients with STIs. There is a risk of an impending heterosexual HIV epidemic in this region (UNAIDS, 2002).
Xinjiang Uygur Autonomous Region: While the majority of HIV infections in this region are related to injecting drug use, local female sex workers were also found to be infected in 1998. The reported number of HIV infected persons more than doubled from 2,125 in 1998 to 4,416 in 2000. In 2000, the male to female ratio was 6:1 (UNAIDS, 2002).
Sichuan Province: This province lies on a major drug trafficking route. Since 1996, HIV infection has been reported among IDUs. By 2000, injecting drug use, transfusion-related infections, and sexual transmission accounted for 68 per cent, 23 per cent, and 6 per cent, respectively, of all new HIV infections in this province. In 2000, the male to female ratio was 4:1 and 93 per cent of new HIV infections were among persons under 30 years (UNAIDS, 2002).
28.4 – HIGH-RISK GROUPS
HIV/AIDS epidemic in China has been associated with high-risk groups. But, as HIV infection spreads among the general population, heterosexual transmission would become the predominant route (Kanabus & Noble, 2006).
Injecting Drug Users: It is unofficially estimated that there are between six and seven million drug users in China, of which about three to three and a half million inject drugs. But only 860,000 persons were registered drug users in the country in 2000. Chinese law prescribes harsh punishments for manufacturing, trafficking, and supplying illicit drugs and drug users are sent to compulsory rehabilitation centres. During 2004, there was a change in attitude towards preventing HIV transmission among IDUs and a pilot programme for providing methadone treatment was launched. A study found that the rates of injecting drug use and drug use-related crime had decreased in the areas where the pilot programme was operational. In the same year, clean needle exchange programmes were established at about 50 sites in several provinces (Kanabus & Noble, 2006). The Chinese Government has announced plans to establish more than 1,400 needle exchange sites and over 1,500 drug treatment clinics in seven provinces in southern and western China, where an estimated two million IDUs live (UNAIDS/WHO, 2005).
Paid Blood/Plasma Donation: In 1988, importing of blood and blood products was prohibited by the Chinese Government to prevent blood-borne transmission of HIV. This ban provided opportunities for local commercial blood collecting companies. These companies operated illegally and collected blood/plasma from blood collection centres in remote and poor areas to avoid interference from the authorities (UNAIDS, 2002). Poor people sold blood to commercial blood
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processing companies to increase their income. Frequently, the blood was simultaneously collected from several persons and mixed together in a container and plasma was removed. The remaining blood, mixed with the blood of others, was transfused back to the donors. Such procedures, along with the reuse of needles and non-sterile equipment, favoured the transmission of HIV infection. By September 2003, blood or plasma donation-related HIV infection had been reported in all provinces, autonomous regions, and municipalities, except Tibet autonomous region. Since the mid-1990s, illegal blood collection companies have been closed. But it is reported that even some of the official blood collection centres fail to meet the necessary standards and some people are still paid to donate blood (Kanabus & Noble, 2006).
Commercial Sex Workers: Most commercial sex workers in China (estimated at between four and six million in 2000) are women from rural areas who have migrated to big cities seeking better incomes. The Chinese Government has established “re-education centres” in every province where “re-education” emphasises mainly on the “social evils” of prostitution. Limited information is provided on sexual health and safer-sex practices. Commercial sex is illegal in China. The infrequent use of condoms is made more difficult because a woman carrying condoms may be arrested by the local police because this is viewed as “proof” of prostitution. This is despite a 1998 regulation repealing the previous rules (Settle, 2003).
In 1999, China’s first-ever condom advertisement was shown on Chinese television and was promptly banned because condom advertisements were illegal. In 2002, to make condom promotion legitimate, the Ministry of Health redefined the condom as a “medical device” rather than a “sexual commodity”. Inspired by Thailand’s success in reducing its number of new HIV infections, some regions in China have recently introduced a policy of 100 per cent condom use. Other recently introduced interventions include detection and treatment of STIs, peer education, and VCT for HIV (Kanabus & Noble, 2006).
Men having Sex with Men: In 2001, homosexuality ceased to be illegal and it was deleted from the official list of “mental disorders”. An estimated 2–6 million MSM (Zhang & Ma, 2002). There are concerns that the high rates of unprotected sex (49 per cent) among MSM could result in a significant rise in prevalence of HIV infection (Choi et al., 2003). Homosexual men in China face severe social pressure to hide their sexual orientation and to get married (UNAIDS, 2002). Stigmatisation of homosexual behaviour impedes open discussion of risky behaviour, precludes adoption of safer-sex practices and fuels an HIV epidemic (Pilcher, 2003). The prevalence of HIV infection among MSM is unknown. Lack of approved organisations or networks to support gay men adversely affects HIV prevention programmes. Access to the Internet may help sharing of information on HIV/AIDS with gay organisations in other countries (UNAIDS, 2002). However, there are allegations that the Chinese Government censors educational websites (Kanabus & Noble, 2006).
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Migrant Workers: The total number of temporary and permanent migrant workers in China is estimated at around 120 million. Many migrants are young unmarried males with higher disposable incomes. Due to peer pressure and the relative anonymity in larger cities, young male migrants are likely to visit commercial sex workers. Since most STIs are notifiable, migrant workers are frequently unwilling to seek health care from public health care facilities fearing discrimination and loss of their jobs. HIV epidemic among migrant workers can be fuelled by factors such as lack of family and community support, limited access to HIV prevention services, and lack of information on HIV/AIDS. Returning or visiting migrant workers, many of whom do not know their HIV status, may infect their wives or other sex partners in their own community (Kanabus & Noble, 2006).
28.5 – CONCLUSION
The relatively slow response to the HIV/AIDS epidemic in China is attributed to several factors: (a) lack of political commitment; (b) lack of openness in confronting the epidemic; (c) lack of adequate resources; (d) severe stigma and discrimination against people infected by HIV/AIDS; and (e) unfavourable legal and institutional environment. China is facing a challenge of educating people on the correct and consistent use of condoms and of providing adequate supply of quality condoms (Settle, 2003). In early 2003, the sales of condoms in China were reported to be two billion per year, though the male population is 650 million (Kanabus & Noble, 2006). Since 1998, various plans announced the commencement of HIV prevention education in schools. However, the extent of implementation of this plan is not known. Poor public awareness about the HIV epidemic and the stigma and discrimination experienced by people living with HIV are among the constraints that hinder a more effective response to the epidemic in China (UNAIDS/WHO, 2005).
The continuing stigma and discrimination has been attributed to failure of the Government to educate the public in the early years of the epidemic and the continued inadequacy of correct information on HIV/AIDS. Consequently, HIV infection remains hidden and implementation of effective HIV prevention programmes is hindered. Till recently, HIV-infected persons in China did not have any legal protection against discrimination. In June 2005, it was announced that a law banning discrimination against people with HIV/AIDS would be effective by the end of 2005 (Kanabus & Noble, 2006).
MTCT of HIV remains low in China. However, once increasing numbers of women in reproductive age group are infected by their partners, perinatal transmission would increase. It is unofficially estimated that about one million children in Henan province alone would be orphaned as a result of the blood collection scandal. However, the Chinese Government estimates that 260,000 children may be orphaned by 2010. Many school-going children have allegedly been taken out of school because they must work and care for their sick parents (Kanabus & Noble, 2006).