Final Report for the
AIDSCAP Program in Thailand
November 1991 to September 1996

Executive Summary

When AIDSCAP/Thailand was launched in 1992, the Royal Thai Government had already established a national program that was focused on provinces outside of Bangkok. International donor assistance, guided by the first Medium-Term Plan of the Ministry of Public Health, was steered mostly toward the northern region of Thailand, where the epidemic was spreading rapidly.

The urban province of Bangkok, which was not directly targeted for prevention activities, experienced a significant migration of unattached lower-income men and women in the peak age range for sexual activity (estimated at 10,000 persons per month in 1992). It became clear that the HIV/AIDS epidemic was present among the general population and was no longer confined to the core population of CSWs and their clients. At the request of Thailand's National AIDS Control Program, USAID supported AIDSCAP to design a comprehensive HIV prevention program for the lower-income population of Bangkok. The goal was to slow the transmission of HIV in the Bangkok population aged 15 to 29 with a comprehensive program of mutually reinforcing interventions.

Epidemiologically, data from HIV sentinel surveillance of the female population in Bangkok were beginning to show significant levels of infection by 1992. For all three sentinel populations of women (direct and indirect commercial sex workers [CSWs] and antenatal clinic clients) the level of HIV infection in Bangkok was higher than for the rest of Thailand. One-third of direct (brothel-based) CSWs in Bangkok were infected, compared to one-fourth nationally. The prevalence of HIV infection among Bangkok's indirect CSWs (who usually work out of bars, restaurants, and night clubs) was twice that for all of Thailand. Finally, in 1992, infection in young married women in Bangkok surpassed the national average.

When AIDSCAP began implementation, services for sexually transmitted infection (STI) treatment, condom distribution, and behavior change communication (BCC) existed in Bangkok, but they were small-scale and not readily accessible. By forging an alliance of prevention agencies and creating a program identity (Bangkok Fights AIDS), AIDSCAP sought to promote community action and targeting of services to the most vulnerable populations.

Some of the unique aspects of the AIDSCAP comprehensive program in Thailand were (1) the interlinkage of subprojects through community mobilization and district AIDS committees; (2) the creation of a project identity ("Bangkok Fights AIDS") to establish a sense of indigenous partnership; and (3) the use of behavioral surveillance to measure synergistic outcomes of multiple subprojects.

AIDSCAP achieved a number of accomplishments during the life of the project, the highlights are as follows:

A total of 28 subprojects were implemented by 20 agencies from the public, private, and university sectors under AIDSCAP. These subprojects provided approximately 9,000 persons with curriculum-based training, reached more than 200,000 lower-income women and men with BCC messages, and distributed more than 800,000 BCC materials and 1.6 million condoms free-of-charge.

AIDSCAP supported the Faculty of Public Health at Mahidol University to work through district AIDS committees (DACs) to identify and strengthen networks of members of high-risk communities. Technically skilled agencies directed targeted communications to these vulnerable networks through a variety of channels. In addition, clinical service structures were strengthened to increase access to STI services, counseling, and condoms. Throughout this process, community networks were identified, created, and reinforced to increase the opportunities for communication and diffusion of STI/HIV/AIDS information to other networks.

AIDSCAP used mass media, outreach, public relations, and interpersonal and peer education communications to reach female and male CSWs, adolescents and married women in low-income communities, and female and male wage earners in large formal and small informal worksites. As a result of BCC activities, these target groups, with the exception of non-CSW single women, reported adopting safer sexual behaviors. As shown by behavioral surveillance surveys (BSS) of members of target groups showed increases in condom use in high-risk situations, and a decline in the proportion of men visiting CSWs.

Projects were developed to extend and strengthen the ability of Bangkok service providers to rapidly diagnose and treat STIs in the target population of lower-income young men and women and to conduct outreach BCC. Eleven Bangkok Metropolitan Administration (BMA) STI clinics and their laboratories received the necessary equipment to diagnose and treat STIs, and the hours of operation were extended in two clinics.

Competency-based training curricula in STI management were developed, and physicians in the public and private sectors and nurses and laboratory technicians in the public sector were trained in the syndromic approach. Laboratory technicians were also trained to improve quality control and other standardized laboratory procedures, to perform more diagnostic tests, and to implement the new systems. Nurses who provide STI services under the direction of a physician received training in the national guidelines for the syndromic approach, HIV prevention, compliance with medical prescriptions, and partner notification. In addition, approximately 900 outreach staff members from 60 BMA clinics were trained in outreach education.

As persons with STIs in Thailand frequently seek treatment from pharmacies without prior medical diagnosis of their illness, AIDSCAP supported the development of a model intervention for improving pharmacy-based STI diagnosis, referral, and prevention services. AIDSCAP trained pharmacists and nonpharmacist staff from 210 drugstores in Chiang Mai, where a successful pharmacy training program in contraceptive services had been conducted in 1990. The training project was later replicated in Bangkok with funding from the European Community.

With condom availability already high in Bangkok, AIDSCAP focused on addressing cultural barriers to condom use through BCC materials, community outreach, and mass media. For example, AIDSCAP attempted to modify social norms in a way that would allow single women to be more assertive in condom use. Booklets, pamphlets, and videos encouraged women to acquire condoms themselves and insist on their use if they were unsure about their partner.

BSS were conducted at intervals among cross-sections of Bangkok population groups that were similar to those targeted by AIDSCAP interventions. Surveys were administered to school youth; employees of offices, factories, and brothels; male STI clinic patients; and antenatal clinic patients. The five survey rounds revealed a decline in the proportion of men visiting CSWs and a significant increase in condom use in high-risk situations. In addition, condoms were reportedly used more consistently. Single females reported no increase in sexual activity.

Key findings include the following:

• 93 to 94 percent of men surveyed in 1996 among various populations in Bangkok reported using a condom during their last sexual contact with a CSW, compared with 88 to 92 percent in 1993.
• 89 percent of indirect CSWs surveyed in 1996, 89 percent reported using a condom with every client, compared with 56 percent in 1993.
• 29 percent of indirect CSWs surveyed in 1996 reported using a condom with every nonpaying sexual partner, compared with 23 percent in 1993.
• 18 percent of single women (non-CSWs) reported using a condom during their last sexual contact in both 1993 and 1996.

Despite the accomplishments noted above, there were constraints which prevented larger program impact. These constraints included the inability of the program to launch a mass media campaign to modify social norms on negotiating sex decisions, the high turnover of the Bangkok lower income population, the difficulty in creating social networks through which to channel services and information, and the limited commitment of some stakeholders to adopt the "Bangkok Fights AIDS" program as their own. Nevertheless, as this document will attest, a tremendous amount was learned from the five years of implementation and these lessons can serve other large urban-based prevention programs in Asia and other regions of the world.