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Final Report for the
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Table of Contents I. Country Program Description (See Below) A. Introduction B. Country Program Context: A Focus on Bangkok C. Accomplishments and Constraints D. Implementation and Management Issues II. Lessons Learned and Recommendations Country Program Description A. Introduction
At the time that AIDSCAP was launched, Thailand had already begun to build up its national program. The national AIDS budget of the Royal Thai Government (RTG) increased from $7 million in 1991 to $25 million in 1992. By contrast, AIDSCAP earmarked approximately $6 million to be programmed in Thailand over the five years of AIDSCAP; a little over $1 million per year. Clearly, the AIDSCAP Thailand Program could not aspire to be national in scope, yet it strove to fill important gaps that the RTG AIDS program did not cover. In consultation with, and with concurrence from the Ministry of Public Health and the Office of the Prime Minister, the AIDSCAP Thailand Country Program Design Team decided to focus solely on the urban province of Bangkok for the five years of AIDSCAP. This decision was made in view of the fact that most of the RTG AIDS prevention budget was being channeled to provinces outside of Bangkok and because of the heavy migration into Bangkok of unattached, lower-income men and women in the peak ages of potential sexual activity. In addition, by the end of 1991, it was clear that the HIV epidemic had become "disseminated" among the general population, i.e., serious transmission risk was no longer confined to the core populations of brothel customers and CSWs. Accordingly, the entire Bangkok population of lower income men and women were the target for the comprehensive prevention program that emerged and which is described in the following pages. The name "Bangkok Fights AIDS" or BFA is a translation of the Thai name for what has been described as the Comprehensive Bangkok Program (CBP). Log Frame: Thailand Country Program - 1992
B. Country Program Context: A Focus on Bangkok So much has been published, presented and otherwise disseminated about the HIV epidemic in Thailand and the national policy/program response that it would be redundant to summarize that information in this final report. Instead, less is widely known about the epidemiology of sexually transmitted infection (STI) and HIV in Bangkok and the prevention program setting there at the time when the AIDSCAP Thailand Program began in 1992. Although the heterosexual HIV epidemic began in 1989 (in Chiang Mai), as late as 1992 there was still no organized HIV prevention program for Bangkok City as a whole. A number of independent pilot subprojects were being managed by NGOs such as the Klong Toey Slum Project by Duang Prateep Foundation, the Taxi Driver Outreach Program by the Population and Community Development Association, the counseling training program of PATH/Thailand and the telephone hotline service of ACCESS to name just four. But there was no master plan for the city of a comparable nature to the Medium Term Plan (MTP) of the Ministry of Public Health (MOPH) for provincial (non-Bangkok) Thailand. Because the MOPH was the focal point for AIDS planning up to 1991, and because the Ministry of Health infrastructure was more well developed in the 72 provinces outside of Bangkok, the Thai National AIDS Program effectively ignored Bangkok -- by default. Most of the national AIDS resources were funneled into the national MOPH public health network of hospitals and clinics. Public health services in Bangkok, by contrast, are not managed by the MOPH but are controlled by the Ministry of Interior and this Ministry had little AIDS budget and less experience in public health programs. Ironically, Bangkok, with six million registered citizens (or ten percent of the Thai population) received only one percent of the National AIDS budget for much of the history of the epidemic. One oft-cited rationale for this shortfall was that the Bangkok City government should be able to draw upon municipal tax revenues to meet its needs. Yet no RTG master plan ever reflected this thinking. A more plausible explanation for the neglect of Bangkok is simply that the MOPH controlled the AIDS prevention agenda up to 1991 and the MOPH infrastructure had been developed, historically, to serve the provinces outside Bangkok. Correspondingly, international donor assistance, guided by the national MTP of the MOPH, was steered mostly toward the north region of Thailand, where the epidemic was spreading most rapidly. Thus, foreign donor assistance also mostly by-passed Bangkok during the late 1980s and the early 1990s. Without ample domestic or international resources for HIV prevention activities, the Bangkok City Government in 1991 did not have the means or see the need to either set up an AIDS prevention unit in City Hall or to develop a prevention plan. In the meantime, however, it was clear to HIV prevention professionals of the GPA and FHI that the Bangkok population had every potential to experience as serious an epidemic as northern Thailand.
In another reflection of the lack of MOPH infrastructure in Bangkok, epidemiological data for Bangkok were less plentiful and less detailed than that for the provinces. Nevertheless, values from the HIV sentinel surveillance of the female population were beginning to show worrisome levels of infection when the AIDSCAP Country Program was in the design phase. For all three sentinel populations (direct and indirect sex workers and ANC clinic clients) the level of HIV for women in Bangkok was higher than that for the rest of Thailand in 1992. One-third of direct CSWs in Bangkok were infected at the time compared to only one-fourth nationally. The prevalence of HIV among indirect CSWs in Bangkok was twice that for all Thailand in 1992. Finally, infection among young married women in Bangkok surpassed the national average in 1992 after generally lagging behind the rest of the nation. These alarming trends prompted the Thailand Country Program Design Team to conduct a baseline assessment of Bangkok. The goal of this assessment was to assemble all the relevant data on risk behaviors, condom use, STIs and HIV and attempt some analysis of the potential for further spread of HIV in the nation's Capitol. (Note: This assessment resulted in the dramatic FHI-Thai MOPH publication in 1994 which is one of the most cited references of evidence of program effectiveness in the world today; see Hanenberg et al). The assessment uncovered a number of new and important findings. The population of Bangkok at the beginning of the decade was particularly vulnerable to a disseminated epidemic because of:
Taken together, these factors created an environment for multiple partner sexual relationships with a bridge to a highly infected core population. In addition, the large volume of in-migration (estimated at 100,000 low-income persons per month in 1992) meant that most of the vulnerable population did not reside in a nuclear family setting in a traditional community. Instead, many lived in worksite housing, low-income communities, dormitories and rented houses. Thus, the new design represented by the AIDSCAP Project was ideally suited for mounting a comprehensive, integrated prevention program for the lower income population of Bangkok. Data from the 1990 census suggested that the population of 15 to 29 year-olds was about 1.5 million. This group of people became the target for the five-year AIDSCAP/Thailand Program. The HIV prevention program of AIDSCAP and the Bangkok Metropolitan Administration (BMA) was not the only large program for AIDS prevention in Bangkok during 1992-96. However AIDSCAP was the only agency attempting to set up a comprehensive program to reach all vulnerable people in the metropolis. At this time the BMA was developing other citywide programs, though with a narrower scope than the BFA. The Jariyatham Fights AIDS Program attempted to promote adherence to the five precepts of Buddhism to encourage people to reduce risk. This program was aired through radio broadcasts, cassette tapes and letter writing (in the manner of an advice column). The BMA also promoted the "Friends Help Friends" Program for Bangkok adolescents which, through a chain mechanism, encouraged a core group of trained peers to each enlist five friends to talk together about HIV prevention through life skills. Each of the five friends would then engage an additional five friends, and so on. The National AIDS Program of the MOPH, while targeting the entire country through television and radio spots and newspaper columns, certainly reached a vast number of those residing in Bangkok with general, one-way communication. The MOPH continued to provide ample supply of free condoms for distribution to commercial sex establishments and clients at BMA health clinics throughout the city. Throughout the duration of AIDSCAP/Thailand, the commercial sector continued to provide affordable and easy access to a variety of quality condoms. The BMA and the MOPH provided STI services, but these were sparse -- offered out of 9 BMA clinics and 7 MOPH clinics. Certain large government hospitals operated STI clinics for men and women but these were marred by difficult access and long waits. By contrast, a number of private clinics catered specifically to STI patients but were more expensive than government service and not always backed up by accurate diagnosis. Pharmacies, then and now, provide OTC antibiotics and, with the advent of new generation antibiotics such as the quinolones, drug sellers were able to provide an effective treatment for the least time and travel for the patient. Although international donors were not eager to fund large-scale programs in Bangkok in the early 1990's, the fact that AIDSCAP made a large and long-term commitment may have encouraged others to join. In particular, the European Community (EU) built upon AIDSCAP pilot experience and structures to fund large STI interventions targeting private clinics and pharmacies. In addition, the EU "bought into" the same implementing structure for low-income community outreach to sustain and expand AIDSCAP's efforts in this important area. These inputs came in the final phase of AIDSCAP's involvement in the BFA but ensured some measure of sustainability of the STI component. UNICEF/Thailand provided funds for factory outreach along the same lines as was pioneered by the AIHD of Mahidol University, PATH and AIDSCAP. The Thai Red Cross AIDS Program fielded important interventions in the area of mobile STI counseling vans and continued to provide the premier anonymous counseling and HIV testing service in the city. In sum, when AIDSCAP began in early 1992, services for STI, condoms and behavior change communication (BCC) existed in many places in Bangkok -- if one made the effort to find them. Yet no organized program was steering all three services to the most vulnerable populations -- literally taking them to the neighborhood. This is the gap that the BFA Program would try to fill. By forging an alliance of prevention agencies -- public, private, NGO, commercial and community -- and creating a unique Program identity ("Bangkok Fights AIDS"), the AIDSCAP Thailand Program designers hoped to create a social consensus and community action to stop the advance of HIV in Bangkok -- in five, short years. Thailand Country Program Timeline
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