FHI - Final AIDSCAP Report on Thailand

Table of Contents

Executive Summary

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

III. Subproject Highlights

part 1
part 2

VI. Attachments

Annex 1: List of References

Glossary of Acronyms

I. Country Program Description

C. Accomplishments and Constraints

STI Strengthening in the Public, Private and Commercial Sectors (continued)

Conclusion: Private Clinic Intervention

In order to strengthen private STI clinic services in Bangkok, two training courses on STI case management and HIV/AIDS counseling were developed and delivered along with new reporting and referral systems. The half day refresher courses were well received and showed some impact in pre- and post-test scores. However, the attempt to add new activities to the clinic operations unrelated to income generation were not successful. Reported treatment practices were generally good but a planned mystery shopper assessment to confirm self-reports was rejected by the subproject technical advisory committee as being "unethical". Clinic materials (such as treatment guideline flip charts and flow charts) were well received by the participants but little used in practice. Materials for distribution such as His and Hers STI pamphlets and condoms were also distributed to STI patients. STI caseloads were lower than expected despite the fact that it is generally assumed that more STI patients seek medical treatment at private clinics rather than government outlets.

In an atmosphere of declining STI caseloads, it is difficult to mobilize the private sector to become actively involved in STI case management and counseling. This subproject was not able to recruit the targeted number of STI clinics primarily because many clinics had closed (presumably due to the plummeting STI prevalence in the country) and because of the small numbers of caseloads in clinics which still treat STIs. Nevertheless, the subproject did engage a sizable number of clinic staff and met its service objectives in a reasonable manner. Concise, half-day training on weekends is about the maximum that is feasible with cost-conscious private practitioners. Additional services which don't have an immediate impact on clinic revenue are unlikely to succeed however. Hence, referral cards, service statistics forms, and counseling were not well accepted by private practitioners in Bangkok. However, as approved therapies for HIV become more effective and affordable, it can be expected that there will be a resurgence of private clinic activity related to HIV and STI. At that time, integrated STI and HIV treatment networking and training should receive extensive interest among the private clinic practitioners in Bangkok.

Perhaps the most important STI service site in any comprehensive prevention program is the pharmacy. For example, the results of caseload surveys of pharmacists, private clinics and BMA STD service outlets centers, the AIDSCAP Thailand office estimated that slightly over half of STI treatment encounters occur at drug stores. A semiformal association of pharmacists in Chiang Mai city (northern Thailand) had pioneered a subproject to improve over-the-counter contraceptive prescribing practices. This group was also contracted by AIDSCAP to develop communication materials, a newsletter and training package for drug sellers on STI and HIV/AIDS. The experience of the AIDSCAP-funded Chiang Mai version of this subproject is summarized below. However, it should be noted that the European Community funded the replication of this model for drugstores in Bangkok as one contribution to the Bangkok Fights AIDS effort of the BMA.

The assessment of pharmacists and drug sellers in relation to STI drugs yielded the following results: There are 256 drugstores in the province of Chiang Mai which sell modern medicine. Of these, 149 drugstores are licensed to sell prescription medicines because they are owned by a registered pharmacist (78 stores), or have a pharmacist managing them (71 stores). The remaining 107 drugstores which sell modern medicines sell only over-the-counter (prepackaged) medication. Such stores are mostly managed by a nurse or by those who have passed a training conducted by the Thai Ministry of Public Health. Most of these drugstores open at about 8:00 a.m. and close around 10:00 p.m. The personnel in the drugstores owned by a pharmacist usually consists of the owner, the owner's immediate family members, and 1 to 4 additional employees. The drugstores which are not owned by a pharmacist usually hire a pharmacist to oversee the selling and dispensing and use pharmacy students as sales personnel. Services are aimed at facilitating a sale. For example, sellers ask customers for their preferred brand and show the product. Some drugstores ask for symptoms before selling any medicine, however, this was not a common practice.

Based on standards set in the STI Medical Handbook (Dr. Anupong Chitvarakorn et al, 1993), the survey revealed:

Only 110 out of 256 drugstores dispensed medication for gonorrhea correctly.
Only 27 out of 45 drugstores dispensed medication for chancre sores correctly.
Only 2 out of 30 drugstores dispensed medication for syphilis correctly.
Only 1 out of 10 drugstores dispensed medication for buboes correctly.
All 4 out of 4 drugstores sold "preventive and cleansing" agents. ("Preventive and cleansing" agents here mean those popular medications commonly believed to be able to prevent disease transmission after sexual contact with commercial sex workers.)
Most medicines sold were tetracycline, phenazopyridium, ampicillin or other antibiotics.

Small group discussions were held for in-depth analysis of the different problems faced by sellers. The discussions also generated solutions which would be easily applicable. The results are summarized below:

Drugstore personnel often have a problem determining what disease their client has due to a lack of basic knowledge. They are also often not updated on the current facts regarding medications appropriate for certain diseases and organisms resistant to currently used medications in certain regions. This is especially true of their knowledge of STI medications. This lack of knowledge often results in the sale of drugs which do not work because of drug resistance or simply because it is of the wrong type.
The interaction between drugstore personnel and the customer needs to be strengthened. There is usually very little investigation of the customers' symptoms and barely any recommendations on the use of the medication. This is especially true during peak hours when very little time is given to customers. The drugstores in the countryside have more time to give each customer, but have a limited number of medicines from which to choose.
The drugstore personnel usually receive information about the medications from only one source, the drug companies. There are only a few stores which look for the information themselves in drug specific literature or other sources. There is definitely inadequate access to information sources. The problem is compounded by the lack of interest of drugstore personnel in looking for information.
Another problem is related to the economic ability of customers. Customers often do not have enough money to obtain a full course of the medication they require. Consequently sellers offer the inappropriate drugs or the inadequate amount first so as not to lose the business opportunity. Customers often do not return to purchase the remaining dose, thus giving rise to drug resistance and repeat infections.
The following solutions were prepared by the groups: (1) Organize a training course to supplement the knowledge of both pharmacist and non-pharmacist drugstore personnel; (2) develop a simplified version of this same information on drug use for dissemination to the public and especially to the high-risk groups; and (3) develop educational materials which are appropriate for use in the drugstores and will allow the drugstore personnel to use them as a tool for educating their customers (e.g., a countertop flip chart with photographs of common STI symptoms).

PATH/Thailand provided key technical assistance to this subproject and also conducted a project evaluation. Excerpts from the evaluation report are as follows:

The official and unofficial meetings and discussions of the subproject provided a framework in which the participants could offer their numerous ideas and views. These views could then be gathered as data and used in the summary of the various problems present. This then allowed for the solution of these problems as part of the improvement of the medication services of drugstore personnel.

The activities of this subproject that were carried out by the participants provided a good working relationship between the members of the Chiang Mai Pharmacist Club and the Chiang Mai Drugstore Club. This relationship proved useful for the overall improvement of drugstore medication services and will be beneficial for future projects involving the members of these two groups. This subproject gave the participants of all professional levels the opportunity to get some practical experience with improving one's own potential throughout the length of the training process as well as for the future. The general role and the public relations capabilities of the pharmacists with the public were expanded as a result of this subproject.

The inclusion of pharmacy students in the activities of this subproject allowed the students to get firsthand information about the current drugstore situation. It also provided the students with a base of knowledge upon which they can also strive for self-improvement when the time comes for them to become active pharmacists or drugstore personnel.

Conclusion: Pharmacy Intervention

This subproject addressed the importance of the drugstore sector in the overall health care system. Results show that given proper education, drugstore personnel develop responsible attitudes about their role. Drugstore personnel are very diverse, and consequently different methods are required in training them. These methods must be based on respect for their views and a belief in their capability to contribute to their own development.

Inviting the pharmacy students to participate in this subproject gave them firsthand experience. This experience will be helpful to developing a future generation of responsible drugstores committed to provide appropriate and safe medications.

The subproject design is replicable and could be used to cover other themes. For example, improving AIDS counseling services could be one such topic. Various aspects that would be covered are:

Implications of counseling service on pharmacist's time, image, income
Practical difficulties of such a service
Use of AIDS patients of drugstore services

The subproject can be conducted in other settings. Appropriate baseline research must be conducted. To replicate it in a large city such as Bangkok would require consideration of the habits and types of drugstore customers, the characteristic levels of education, the pace of life, travel limitations and all other things which have some bearing on the drugstore situation. One approach would be to have a small scale subproject.

Behavior Change Communication in the Worksite, Community and Home

Behavior change communication (BCC) in the BFA Program encompassed interpersonal communication through outreach, mass communication and public relations. The vast majority of AIDSCAP BCC resources funded outreach. In retrospect it seemed like a daunting task to reach a critical mass of the Bangkok target population of 1.5 million men and women age 15 to 29 with enough interpersonal communication necessary to achieve sustained low risk behavior. Diffusion theory suggests that 15% to 20% across the range of a socially-linked community need be reached in order for messages and perceived norms to spread to all or most of a target audience (Kegeles et al.) That is equivalent to reaching between 200,000 and 300,000 persons with small group or individual communication -- much larger than the target populations of any published reports of prevention interventions through interpersonal communication in any single program.

In late 1992, after the launch of the Community Mobilization Project, the designers of the AIDSCAP Thailand program were absorbed with the task of mounting an outreach offensive on the streets and in slum communities of Bangkok to begin the process of personalizing the risk for HIV. At this time, HIV was found in 3.3% of young men and 1.2% of young, married women in Bangkok. Given the enormous size of the target population the challenge was to identify enough technical agencies that could carry out the formidable task of recruiting, training and overseeing a small army of outreach workers. The solution was a consortium of NGO, university and BMA agencies -- each responsible for a different segment of the lower income Bangkok population, 15 to 49. To simplify the case somewhat, the target populations for outreach fell into four groups:

Female and male commercial sex workers (direct and indirect)
Married women and adolescents in low-income communities
Female and male wage laborers in large formal worksites (e.g., large factories)
Female and male wage laborers in small and informal worksites (e.g., small factories, garages, motorcycle taxi stands)

The following presents highlights of the implementation of each of these outreach subprojects.

Outreach to Commercial Sex Workers

Staff of the Health Department of the BMA had been conducting sporadic outreach education for Bangkok CSWs when AIDSCAP began. However, the BMA felt that this component needed to be revitalized, especially in view of the related STI strengthening subproject (described earlier). A strong BCC component was needed to encourage CSWs to visit the "new and improved" BMA network of STI clinics. Prior to the subproject implementation, the implementers reviewed existing formative research and conducted a limited number of focus group discussions with Bangkok CSWs. The purpose of the study was to give the CSWs an opportunity to express their view of obstacles to risk reduction, attitudes toward health care services and their preferences for new BCC materials.

Key findings from the formative data collection are briefly noted as follows:

Some CSWs do not use condoms with every customer especially when:

They are regular customers
They look clean
They are drunk
The negotiation skills of the CSW for condom use are poor

CSWs still have misconceptions about proper prevention, for example:

Using soda water or pineapple juice to douche after having sex, or
Applying Vaseline or lotion on condoms as lubricants, could protect them from STI.

CSWs were bored with the repetitiveness of the AIDS communication materials used by health staff and tired of being lectured to and bled so often.

The objective of this activity was to find ways to correct the above shortcomings and help CSWs protect themselves from HIV more completely. AIDSCAP encouraged the BMA to create a technical working group (TWG) with staff from the BMA, AIDSCAP and communication specialists. This working group would conduct the planning and provide technical oversight for all phases of the subproject and was seen by AIDSCAP as an essential ingredient for successful implementation. Staff from 60 health centers and health officers from 38 district offices were recruited for the outreach education teams. Each outreach team consisted of two nurse health educators, one health officer from the district, and a driver. Each team was responsible for conducting three rounds of outreach education sessions in at least eight establishments in their zone.

Two meetings with CSE owners were held in order to obtain input, support and cooperation from the owners and managers of the establishments. The first meeting was held in January, 1994 with a group of CSE owner representatives. Senior BMA level officials joined in the sessions. Some of the issues that emerged from the participants in this meeting include the following:

Even though the 100% condom use policy has been promoted, some CSWs are not able to use condoms with every client.
There are contradictions in government policies (e.g. public health and law enforcement) which impede cooperation from the CSE owners.
Most establishments have regular and adequate condom supplies.
Private STI clinics are preferred over government clinics because of the belief that they provide better service and quality of treatment.

A one-day training workshop for the outreach teams was conducted before each round of the outreach education. The curriculum included details on the latest information of STIs and AIDS, communication techniques and skills development. New BCC materials were developed for each round of outreach. These included an anatomy model (to help explain contraception and STI/HIV transmission); a 6-part video drama; and a flip chart. Posters with new themes and a photonovella were also produced as part of this subproject. Each outreach team was given specific training in the use of these materials. A total of 120 health educators from 60 health centers and 60 staff from the local district office from all 38 districts participated in the training.

The three rounds of outreach education were carried out mostly during 1994 with two months in between each round. After the second round of outreach education, the outreach team recruited certain CSWs, touts and establishment managers, who were enthusiastic and appeared to be good educators, to become "peer educators". The peer educators were invited for a training on STIs and AIDS which emphasized misconceptions of CSWs about HIV/AIDS, and encouraged them to be key informants and helpers to their peers. Altogether 329 peer educators were recruited into this activity.

To evaluate the outreach activity, the BCC TWG interviewed CSWs, CSE owners, and health educators, and observed outreach sessions. Figure 2 presents the PIF data over the subproject period compared with trends in risk behavior from the BSS. Narrative results of the evaluation are briefly summarized as follows:

In general, the respondents agreed that this outreach education subproject was a beneficial activity which used new approaches that were appropriate for their needs. All education materials developed and produced for the subproject attracted considerable interest. The anatomy models and the dramatized video were the most popular media (and have been distributed to similar programs in other parts of Thailand and other countries in Asia). A majority of the health educators agreed that having training prior to the outreach activity helped them in exchanging ideas and preparing for the sessions. Each group of respondents agreed that conducting the outreach activity in the CSEs on a continuous basis is appropriate. One round every four to six months is optimal.

Figure 2: Bangkok Fights AIDS -- CSW Outreach Activity and Condom Use Among Indirect CSWs Over Time

A "direct" CSW refers to a brothel worker; "indirect" refers to nightclub hostess or massage parlor workers who may negotiate sex for sale in addition to their non-sex services.

Major constraints found during the implementation of the outreach activity can be summarized as follows: (1) inadequate understanding and support from supervisors of the outreach team members; (2) inadequate coordination between outreach team members (who came from different BMA offices); (3) too frequent changes in outreach team members during the subproject implementation which disrupted continuity and adequate understanding of the activities; (4) inadequate cooperation from some CSE owners; (5) high mobility of CSWs disrupted peer recruitment and opportunities for education reinforcement; (6) limited numbers of the anatomy models led to delays in implementing outreach; and (7) inadequate travel compensation for outreach team members who had to return home late in the evening.

Conclusions: CSW/CSE Outreach Intervention

Lessons from this outreach activity include the following:

The BMA has a top-down management style, and the appointed technical working group (TWG) members were not initially enthusiastic, presumably because their superiors had not explicitly assigned this work to them. Once a sense of ownership was created among working committee members (through greater participation in BCC media design for example) enthusiasm increased noticeably.
The officials of the local district office are the key channel for BMA health care providers to reach CSWs in Bangkok. At the CSE, owners/managers are the essential point of contact.
New and innovative BCC materials and communication techniques are essential in attracting and maintaining target group attention and willingness to participate in the educational activities.

Recommendations for future activities are as follows;

Standard guidelines should be developed and provided to the outreach team to promote consistency in outreach education.
Training for CSW peer educators should occur at least every six months and budget for evaluation should be made part of the routine budget (of the BMA in this case).
The outreach education activities should be conducted at least twice a year, so as to provide an update on STI/AIDS knowledge. New materials for outreach should be developed to maintain interest by the target audience

Thailand: Outreach Workers on the March

Results of behavioral surveillance surveys conducted by AIDSCAP in Bangkok between 1993 and 1996 revealed that the number of male blue-collar workers who had multiple sex partners decreased by one-third and sexual activity among single women remained below 10%. Also, published reports indicated a decline in brothel patronage among young Thai men, an increase in condom use and a plummeting of STD caseloads. A considerable amount of the credit for these behavior changes could be attributable to the work of dedicated outreach workers trained and supported by the AIDSCAP Project.

Som and Khom are two of this cadre of 70 well-trained, highly motivated outreach workers in Bangkok who bring the AIDS prevention message to segments of the hard-to-reach Thai society known traditionally to engage in high-risk behavior. Outreach workers in general are selected based on their ability to be flexible in their approach to potential clients, sensitive to each person's needs and concerns and able to adapt their approach accordingly. Som declares, "Each of us has our own style but we all work toward the same goal -- to carry the message most effectively to the most people about the need to change behavior to prevent getting and spreading AIDS." Som's method is to try to identify the leaders of the group she wants to contact, gain their confidence and support and in turn access to members of the group. Som then works to alert them to the dangers of engaging in promiscuous and unprotected sex. She explains the importance of protecting themselves and their partners and trains them in the correct use of condoms.

Khom states "I think I have the most success by working with married men. They worry about the life and health of their wives and children. So on that basis I try to convince them to stop or reduce their extramarital activity or at least to use condoms for protection." Khom adds " We also try to talk about their superstitions because unless we can convince them of the true facts, they'll never change their behavior. That means they'll always be vulnerable."

Som and Khom and the other outreach workers feel good about their accomplishments particularly when they hear about their impact on the group from the peer educators they have trained to continue the work after the outreach worker has moved on. However, the outreach workers express concern that the general population can become easily bored hearing the same messages repeatedly. Therefore generic IEC materials and personal messages particularly those focused on vulnerable groups need to be refreshed and refurbished periodically to keep these populations alerted and to avoid progressive apathy.

Source: AIDScaptions 11/96

Outreach to Married Women and Adolescents in Low-Income Communities

The outreach to Bangkok CSEs and CSWs described above is different from all other outreach subprojects in the Bangkok Fights AIDS Program in one important way. While the BMA relied on existing government staff to conduct outreach after routine government work hours, the other outreach subprojects employed full-time, salaried outreach workers. This difference has important implications for budget, sustainability and flexibility in reaching diverse and mobile populations. Two subprojects funded by AIDSCAP attempted to reach women and adolescents in low-income communities. The highlights of those subprojects are described next.

The "Low Income Outreach Subproject" of the BFA targeted 100 of Bangkok's 1,000 low-income communities. The implementing agency was the Planned Parenthood Association of Thailand (PPAT). The subproject aimed to support the general BFA goal in three ways: (a) reduced risk behavior through interpersonal communication with trained outreach workers and through peer-based information dissemination; (b) increased condom use; and (c) increased accurate self-risk perception. Population surveys were conducted at the beginning and toward the end of the subproject period which describe the target population in terms of process and outcome indicators. The outreach workers (OWs) convened 374 group discussions in 85 communities with about 6,000 persons. Information from these sessions helped explore in greater depth why some people engage in risk behavior while others do not.

The task of the OWs was to reach an estimated total of 16,000 male and female slum dwellers aged 15 to 29 through small group sessions and home visits. Another 9,000 persons were expected to be reached by peers and local agents recruited by the subproject. To help with these tasks, the OWs recruited approximately eight indigenous AIDS resource persons in each community. In addition, the subproject staff informed persons in the subproject area about the subproject by site/home visits. In all, subproject field workers made a total number of 564 visits in 100 communities reaching 5,550 persons with BCC interactions.

OWs conducted interpersonal discussions on self-risk perception, how to reduce risk behavior, STI-related issues and sex-decision making. These activities were conducted in 90 communities with a total of 1,752 participants. To spark wider interest, innovative approaches were used to convey risk messages. A number of "AIDS Campaign in Low Income Communities" fairs were staged which included slogan competition, plays, and quizzes. A total of 58 campaigns were held in 58 communities reaching 3,392 persons.

World Vision Relief and Development implemented a more intensive outreach subproject under the "Bangkok Fights AIDS" banner in 43 low-income communities over a period of three years. This subproject was funded under the PVO competitive grants program of AIDSCAP/HQ. The subproject targeted adolescents and young mothers (age 15 to 29) and used a similar, comprehensive approach that was being implementing under the BFA. This subproject reprinted materials used by other BCC subprojects of the BFA and worked more closely with the local District AIDS Committee than any other of the BFA subprojects.

Figure 3 shows the combined output data for these two projects and results from pre-test, posttest behavioral surveys in some of the low-income communities.

Figure 3: Bangkok Fights AIDS -- BCC outreach among low-income community residents and condom use over time

Conclusion: Outreach to Community-based Wives and Adolescents

Some of the lessons from these two subprojects of the BFA Program are as follows:

It is imperative to retain as well as recruit an adequate number of dedicated outreach workers who, in turn, must recruit the cadre of community AIDS resource persons. The subproject managers felt at least two OWs per district (one male, one female) is the minimum necessary. In addition, turnover of both the outreach workers and community volunteers was unacceptably high. However, the subproject staff were not able to explain how OWs could be retained citing the competitive commercial market (higher salaries) and the increasing lack of a "development orientation" in the new generation of young Thai men and women.
Easy access to the slum communities must be assured from the beginning of the subproject. Although subproject staff met with DACs and occasionally participated in DAC meetings, the link between the [PPAT] subproject and the community mobilization component was inadequate. Consequently, the subproject staff had to spend an exorbitant amount of time establishing contact in the target communities before activities could be held. With greater support from the local DACs, this delay in implementation could have been avoided and acceptance of the subproject by local communities would be enhanced. The WVRD subproject had less difficulty in this regard because, initially, they located their subproject headquarters in the DAC office itself.
The [PPAT] subproject reached 60% of the 25,000 targeted audience in 100 slum communities. More coverage could have been achieved if the following had happened:
Overall, flip charts proved to be the most suitable materials for behavior change communication (BCC) in the slum communities. Videos still present technical problems and printed pamphlets are not well read. Comic books without too much text are a popular format for materials that are to be distributed to the target audience.
A group counseling approach (conducted by a trained counseling professional) seemed very successful, especially for low-income women, in helping them express their frustrations, boost their self-esteem and to draw upon group member experience in presenting solutions to behavioral problems.
Drug use among adolescents is becoming endemic and is a formidable obstacle to more successful outreach and risk reduction. Glue sniffing is the most common drug used but marijuana and heroin are easily obtained. Drug addiction among adolescents must be addressed if BCC interventions are to be applied and sustained.
Taking adolescent community resource persons out of Bangkok for two nights (three days) for orientation in a camp setting is an effective approach to providing the basic information on HIV/AIDS, the mechanics of an outreach subproject and the adolescent's role as a community agent.

Outreach to Wage Laborers in Large, Formal Worksites

Over the past decade Thailand has become an increasingly popular site for international manufacturers. Hundreds of thousands of Thailand's relatively well-educated men and women work on assembly lines in and around Bangkok producing the full range of consumer or industrial products, from cars to computers and ships to shoes. Behavioral research conducted by ICRW has poignantly described the vulnerability of factory workers, especially young women, to casual relationships that carry with them the risk for HIV (see Cash in References annex). For prevention interventions, large factories offer the advantage of providing convenient access to a large number of the target population -- when they get off work. In the family of BFA interventions, the Factory Outreach subproject of the Asian Institute for Health Development (AIHD) was unique in that it mobilized the Thai version of the US Peace Corps, to recruit and train BA graduate volunteers to serve the development goals of the country by providing AIDS outreach to lower income Bangkok factory workers age 15 to 29.

A total of 45 volunteers signed up for 18-month service and were given three weeks training in the principles of HIV/AIDS, BCC, group dynamics, planning and evaluation. The subproject managers selected the largest factories that could be easily accessed through cooperation with the DACs. The chief of the local BMA health center (also a DAC member) served as an intermediate gatekeeper for the outreach teams to gain access to the factory populations. Factories in Bangkok do not generally allow access to the work force because of potential disruption to productivity and concern about labor organizing activities (only 5% of the Thai labor force was unionized at the beginning of the BFA Program.) A target of 25,000 male and female factory workers was arrived at after identifying appropriate sites and gaining up-to-date data on the work force. The graduate volunteers were divided into coed teams of three to four individuals. Each team was deployed at a particular factory for a period of four months. Large group orientation of the work force was followed by small group sessions (10 to 20 persons) over a one-week period for each group. Time during lunch hour was used to conduct these sessions. From their closer interaction with factory workers, the graduate volunteers were able to identify candidates for more intensive training as peer educators.

Once all peers were trained, the outreach team could move on to a new factory. Although the formal time with the target audience was limited to a brief period each day, the outreach teams had extensive informal contact before and after factory hours. Indeed, in some cases the graduate volunteers were so well-accepted by management that they were allowed to join the assembly line and, in this way, have more in-depth exchange with the target population. This approach to outreach was unique among the outreach subprojects of the BFA Program in that the OWs immersed themselves in the workers' lifestyle and work environment. They were able to establish a high level of trust an rapport with the target but had more limited reach of the total factory worker population in Bangkok. However, because of the large budget of the project, the AIDSCAP Thailand Country Program Office requested a cost-effectiveness analysis of this subproject. Accordingly, the AIDSCAP/HQ commissioned a study which concluded that the recurrent cost per worker reached was $12. In addition, if the outreach was 100% successful in preventing future infection then the benefit of investing in the outreach education is about 10 times greater than the cost over a ten-year period. The difficulty in interpreting this analysis however is that it is not possible to know how effective an outreach interaction is on average -- in most cases, the value is probably considerably less than 100%.

To evaluate other aspects of the subproject, a variety of methods were used. In addition to the PIF data, baseline and follow-up surveys were conducted by the subproject staff. All 45 outreach workers kept personal diaries which describe their daily interactions with the target audience and the changes that occurred over the course of the subproject. Some of the key results of the pre- and post-surveys as conducted by AIHD are presented in Table 2 below.

Table 2: Selected Results of Baseline and Follow-up Surveys, Factory Outreach Subproject

Category

Baseline

Follow-up

% of men who have only 1 sex partner

54%

61%

% of men who have more than one sex partner

22%

13%

% of men who always use condoms with non-marital, noncommercial sex partners

33%

42%

% of men who always use condoms with commercial sex partners

72%

83%

The tabular data show improvements in risk reduction across a range of options including reduced sex networking and increased condom use among male factory workers. Data from the diaries of outreach workers also provide interesting insights into how female factory workers were changing in response to the outreach team efforts. Excerpts from these October 1993 personal accounts are presented below:

Miss "M"

"I have had three sexual relationships but I'm still looking for "Mr. Right". I had heard of AIDS before but it didn't seem like something for me to worry about. Now I'm worried and I am changing (my behavior). I will stick to one man. I may even go to for a blood check."

Mrs."K"

"Before I talked with the outreach workers I only knew a little about AIDS. After talking with them I learned much more. I have decided that before marrying, a couple should have a blood check (for HIV). I have spoken to my husband about using condoms. At first he grumbled but later got used to the idea."

Miss "G"

"Before the team (AIHD outreach workers) came to talk with us I was reckless in my sex relationships. AIDS wasn't a threat. Now I'm worried and I don't want to risk (catching HIV). I plan to select my future sex partner more carefully and not rush into a relationship."

Outreach to Wage Laborers in Small and Informal Worksites

The largest subproject of all interventions in the BFA was the Service Workers Outreach subproject (SWOP). Although workers in large factories may outnumber those in smaller Bangkok worksites, wage laborers in small and informal worksites present a much greater outreach challenge. Motorcycle taxi driver, gas station attendant, restaurant waiter and waitress, bus conductor, construction site worker -- these occupations attract a constant stream of migrant Thai labor from throughout the country. Since these jobs require little formal training, turnover of the work force is high and the educational level is lower than for those in the large factories. Nor is there any real structure to provide services to this disparate group of itinerant young men and women. Street-based outreach at the site of employment was the only way feasible to engage these persons in some dialogue about HIV risk and safer sex options. For this task, a consortium of street-smart NGOs was formed from some of the most experience of Bangkok service organizations: ACCESS, UDF, CLIST, TAVS and TRRM. PATH/Thailand provided close BCC technical assistance to this and the Factory Outreach subproject described above since many elements of the training and communication strategies were the same.

As with the Factory Outreach Subproject, SWOP recruited full-time outreach workers to canvass the worksites and train peer educators. SWOP was conducted in two phases: first in the six Phase I Zone districts and then expanded to cover most of Bangkok. The 54 full-time outreach workers reached an enormous number of highly mobile Bangkok wage-labor service workers. Over 2,700 men and women were trained as peers, and 80,000 workers were reached through interpersonal communication. Nearly one-half million educational materials were distributed and 350,000 condoms were distributed free. One of the more unique outputs of this project were the co-gender handbooks that were produced for the outreach workers ("The Male Formula for Love" and "Women DO Know How to Love"). In straight language, with colorful illustrations, these manuals explained sex decisions from the man's and woman's perspective, pointing out the different motivations each may have for intimacy and step-by-step instructions on how to skillfully negotiate sex (or abstinence) on one's own terms. These booklets epitomize the BCC approach to interpersonal communication used in the BFA Program: (1) comparable emphasis on men and women, (2) consideration of risk behavior from the perspective of the target audience, (3) exploration of a range of low-risk options, (4) skills building to help apply a self-selected option.

. Country Program Description

C. Accomplishments and Constraints

STI Strengthening in the Public, Private and Commercial Sectors (continued)

Conclusion: Private Clinic Intervention

Based on standards set in the STI Medical Handbook (Dr. Anupong Chitvarakorn et al, 1993), the survey revealed:

Only 110 out of 256 drugstores dispensed medication for gonorrhea correctly.
Only 27 out of 45 drugstores dispensed medication for chancre sores correctly.
Only 2 out of 30 drugstores dispensed medication for syphilis correctly.
Only 1 out of 10 drugstores dispensed medication for buboes correctly.
All 4 out of 4 drugstores sold "preventive and cleansing" agents. ("Preventive and cleansing" agents here mean those popular medications commonly believed to be able to prevent disease transmission after sexual contact with commercial sex workers.)
Most medicines sold were tetracycline, phenazopyridium, ampicillin or other antibiotics.

Drugstore personnel often have a problem determining what disease their client has due to a lack of basic knowledge. They are also often not updated on the current facts regarding medications appropriate for certain diseases and organisms resistant to currently used medications in certain regions. This is especially true of their knowledge of STI medications. This lack of knowledge often results in the sale of drugs which do not work because of drug resistance or simply because it is of the wrong type.
The interaction between drugstore personnel and the customer needs to be strengthened. There is usually very little investigation of the customers' symptoms and barely any recommendations on the use of the medication. This is especially true during peak hours when very little time is given to customers. The drugstores in the countryside have more time to give each customer, but have a limited number of medicines from which to choose.
The drugstore personnel usually receive information about the medications from only one source, the drug companies. There are only a few stores which look for the information themselves in drug specific literature or other sources. There is definitely inadequate access to information sources. The problem is compounded by the lack of interest of drugstore personnel in looking for information.
Another problem is related to the economic ability of customers. Customers often do not have enough money to obtain a full course of the medication they require. Consequently sellers offer the inappropriate drugs or the inadequate amount first so as not to lose the business opportunity. Customers often do not return to purchase the remaining dose, thus giving rise to drug resistance and repeat infections.
The following solutions were prepared by the groups: (1) Organize a training course to supplement the knowledge of both pharmacist and non-pharmacist drugstore personnel; (2) develop a simplified version of this same information on drug use for dissemination to the public and especially to the high-risk groups; and (3) develop educational materials which are appropriate for use in the drugstores and will allow the drugstore personnel to use them as a tool for educating their customers (e.g., a countertop flip chart with photographs of common STI symptoms).

PATH/Thailand provided key technical assistance to this subproject and also conducted a project evaluation. Excerpts from the evaluation report are as follows:

Conclusion: Pharmacy Intervention

The subproject design is replicable and could be used to cover other themes. For example, improving AIDS counseling services could be one such topic. Various aspects that would be covered are:

Implications of counseling service on pharmacist's time, image, income
Practical difficulties of such a service
Use of AIDS patients of drugstore services

Behavior Change Communication in the Worksite, Community and Home

Female and male commercial sex workers (direct and indirect)
Married women and adolescents in low-income communities
Female and male wage laborers in large formal worksites (e.g., large factories)
Female and male wage laborers in small and informal worksites (e.g., small factories, garages, motorcycle taxi stands)

The following presents highlights of the implementation of each of these outreach subprojects.

Outreach to Commercial Sex Workers

Key findings from the formative data collection are briefly noted as follows:

Some CSWs do not use condoms with every customer especially when:

They are regular customers
They look clean
They are drunk
The negotiation skills of the CSW for condom use are poor

CSWs still have misconceptions about proper prevention, for example:

Using soda water or pineapple juice to douche after having sex, or
Applying Vaseline or lotion on condoms as lubricants, could protect them from STI.

CSWs were bored with the repetitiveness of the AIDS communication materials used by health staff and tired of being lectured to and bled so often.

Even though the 100% condom use policy has been promoted, some CSWs are not able to use condoms with every client.
There are contradictions in government policies (e.g. public health and law enforcement) which impede cooperation from the CSE owners.
Most establishments have regular and adequate condom supplies.
Private STI clinics are preferred over government clinics because of the belief that they provide better service and quality of treatment.

Figure 2: Bangkok Fights AIDS -- CSW Outreach Activity and Condom Use Among Indirect CSWs Over Time

A "direct" CSW refers to a brothel worker; "indirect" refers to nightclub hostess or massage parlor workers who may negotiate sex for sale in addition to their non-sex services.

Conclusions: CSW/CSE Outreach Intervention

Lessons from this outreach activity include the following:

The BMA has a top-down management style, and the appointed technical working group (TWG) members were not initially enthusiastic, presumably because their superiors had not explicitly assigned this work to them. Once a sense of ownership was created among working committee members (through greater participation in BCC media design for example) enthusiasm increased noticeably.
The officials of the local district office are the key channel for BMA health care providers to reach CSWs in Bangkok. At the CSE, owners/managers are the essential point of contact.
New and innovative BCC materials and communication techniques are essential in attracting and maintaining target group attention and willingness to participate in the educational activities.

Recommendations for future activities are as follows;

Standard guidelines should be developed and provided to the outreach team to promote consistency in outreach education.
Training for CSW peer educators should occur at least every six months and budget for evaluation should be made part of the routine budget (of the BMA in this case).
The outreach education activities should be conducted at least twice a year, so as to provide an update on STI/AIDS knowledge. New materials for outreach should be developed to maintain interest by the target audience

Outreach to Married Women and Adolescents in Low-Income Communities

Figure 3 shows the combined output data for these two projects and results from pre-test, posttest behavioral surveys in some of the low-income communities.

Figure 3: Bangkok Fights AIDS -- BCC outreach among low-income community residents and condom use over time

Conclusion: Outreach to Community-based Wives and Adolescents

Some of the lessons from these two subprojects of the BFA Program are as follows:

It is imperative to retain as well as recruit an adequate number of dedicated outreach workers who, in turn, must recruit the cadre of community AIDS resource persons. The subproject managers felt at least two OWs per district (one male, one female) is the minimum necessary. In addition, turnover of both the outreach workers and community volunteers was unacceptably high. However, the subproject staff were not able to explain how OWs could be retained citing the competitive commercial market (higher salaries) and the increasing lack of a "development orientation" in the new generation of young Thai men and women.
Easy access to the slum communities must be assured from the beginning of the subproject. Although subproject staff met with DACs and occasionally participated in DAC meetings, the link between the [PPAT] subproject and the community mobilization component was inadequate. Consequently, the subproject staff had to spend an exorbitant amount of time establishing contact in the target communities before activities could be held. With greater support from the local DACs, this delay in implementation could have been avoided and acceptance of the subproject by local communities would be enhanced. The WVRD subproject had less difficulty in this regard because, initially, they located their subproject headquarters in the DAC office itself.
The [PPAT] subproject reached 60% of the 25,000 targeted audience in 100 slum communities. More coverage could have been achieved if the following had happened:
Overall, flip charts proved to be the most suitable materials for behavior change communication (BCC) in the slum communities. Videos still present technical problems and printed pamphlets are not well read. Comic books without too much text are a popular format for materials that are to be distributed to the target audience.
A group counseling approach (conducted by a trained counseling professional) seemed very successful, especially for low-income women, in helping them express their frustrations, boost their self-esteem and to draw upon group member experience in presenting solutions to behavioral problems.
Drug use among adolescents is becoming endemic and is a formidable obstacle to more successful outreach and risk reduction. Glue sniffing is the most common drug used but marijuana and heroin are easily obtained. Drug addiction among adolescents must be addressed if BCC interventions are to be applied and sustained.
Taking adolescent community resource persons out of Bangkok for two nights (three days) for orientation in a camp setting is an effective approach to providing the basic information on HIV/AIDS, the mechanics of an outreach subproject and the adolescent's role as a community agent.

Outreach to Wage Laborers in Large, Formal Worksites

Table 2: Selected Results of Baseline and Follow-up Surveys, Factory Outreach Subproject

Miss "M"

"I have had three sexual relationships but I'm still looking for "Mr. Right". I had heard of AIDS before but it didn't seem like something for me to worry about. Now I'm worried and I am changing (my behavior). I will stick to one man. I may even go to for a blood check."

Mrs."K"

"Before I talked with the outreach workers I only knew a little about AIDS. After talking with them I learned much more. I have decided that before marrying, a couple should have a blood check (for HIV). I have spoken to my husband about using condoms. At first he grumbled but later got used to the idea."

Miss "G"

"Before the team (AIHD outreach workers) came to talk with us I was reckless in my sex relationships. AIDS wasn't a threat. Now I'm worried and I don't want to risk (catching HIV). I plan to select my future sex partner more carefully and not rush into a relationship."

Outreach to Wage Laborers in Small and Informal Worksites

I. Country Program Description

C. Accomplishments and Constraints

Behavior Change Communication in the Worksite, Community and Home (continued)

Figure 4 below shows behavior change among service workers (from the BSS) and person-contacts of outreach conducted by the SWOP field team and the peer educators. (This graph also includes the outreach activities of the Factory Outreach subproject given the similarities of the target audience.) The graph suggests that there is some relationship between the amount of outreach contacts and reduced risk behaviors of commercial sex and sex with multiple partners among men. Without a control population to compare with, it is not possible to conclude whether these improvements are general trends among the Thai population or BFA-attributable outcomes.

Figure 4: Bangkok Fights AIDS -- Service Worker (SWOP I & II and Factory Outreach)

Evaluation of SWOP was also conducted by two outside research groups which looked specifically at the worksites where SWOP outreach workers visited. A pre-post survey with 800 blue collar workers found that exposure to AIDS information increased from 67% to over 90% for posters and from 37% to 80% for leaflets/booklets (see Table 3 below). Just under half of the men and women had read the SWOP His & Hers handbooks referenced above (data not shown). Both men and women show a heightened sense of concern that a past partner could have been HIV infected and, accordingly over three-fourths of both groups believe asking the sex history of a prospective partner is appropriate. While women show an increased ability to insist on condom use, men are less likely to suggest condoms or refuse sex in the absence of condoms. In addition, the percentages for these variables are unacceptably low for both women and men.

Table 3: Data from Quantitative Evaluation of Service Workers Outreach Project (expansion)
(N = 800 men and women from blue collar worksites)

Category

Before

After

% who received AIDS information from:

- posters

67%

90%

- leaflets\/booklets

37%

80%

% who are not sure whether past sex partner was HIV-infected (among those who are sexually active):

- men

68%

77%

- women

44%

68%

% who feel it is important to ask a potential sex partner about their sex history:

- men

61%

76%

- women

85%

88%

% who have proposed condom use with partner (among the sexually active):

- men

35%

27%

- women

11%

29%

% who have refused sex when no condom was available:

- men

34%

25%

- women

19%

22%

Conclusion: Outreach to wage workers in formal and informal worksites

The major concern of the BFA Program partners with regard to this critical activity was how to attract sustainable sources of support for non-formal worksite outreach. In the cost-effectiveness analysis described earlier, the Policy Unit of AIDSCAP headquarters compared the cost-benefit ratios for the Factory Outreach Subproject and the SWOP Subproject. Fully 70 to 90% of the project costs are recurrent costs and most of the recurrent costs are payments for outreach workers. With a more dispersed (though perhaps more vulnerable) population to reach the SWOP Subproject cost more than twice as much per outreach contact than the Factory Outreach Subproject ($32 versus $12). The inescapable conclusion of the authors of the cost study was the following:

A comprehensive HIV/AIDS prevention program at the workplace which includes condom distribution and peer education does require the commitment and financial resources of businesses. This commitment cannot be sustained from outside the private sector, but rather requires the full cooperation and commitment of the business themselves.

Mass media for norm change/sustainability

Beginning in the late 1980s, Thailand experienced aggressive mass media coverage of the progress of HIV through the society and, by the time of the launch of AIDSCAP in 1992, had generally educated the majority of the population on the four basic facts that:

AIDS is real and here in Thailand now
AIDS is fatal but there are no symptoms for many years
HIV/AIDS is spread mainly by sexual intercourse
Prevention of infection is possible by using condoms with sex partners who are infected or who may be infected with HIV

Yet HIV was continuing to spread in 1992 and, as observed elsewhere around the world, new cohorts of the young, sexually active and core transmitter groups continued to practice risky sex behavior because of the perceived risk-benefit, the enjoyment of risk itself or the lack of power to protect against a sex partner's behavior. At that stage of social awareness of the AIDS threat, the designers of the AIDSCAP/Thailand program felt that little more would be accomplished by repeating factual information about transmission and prevention. Instead, the designers felt that messages and images were needed to create new social norms and role models that would lead to more responsible sexual behavior for the individual and a social consciousness to serve the community.

AIDSCAP had planned to commission the activities of a mass communication board to guide the development of a unified campaign theme which would extend over the life of the AIDSCAP Project. The campaign would have produced generic slogans, images, jingles, color codes, characters or mascots which would appear through a variety of media channels including television, radio, newsprint, posters, billboards and T-shirts. Specific subprojects would be awarded to production houses to create the various prototypes for dissemination. Prime time airing of radio and TV spots would be arranged through government funding and sponsorship and/or the contribution of an individual or a consortium of donors.

In addition to generating a new social norm, the campaign would provide the means by which AIDSCAP could attribute the inputs of the Bangkok Fights AIDS to behavior change. Because all the BFA interventions incorporated the core theme messages and images of the communication campaign, the macro evaluation would be able to measure exposure to these images and assess these levels against the reported beliefs and behavior change in each survey round.

The AIDSCAP Thailand Program designers had reason to believe that this approach to mass communication was feasible in the Bangkok context. Previously, a successful anti-litter campaign ("Magic Eyes") had instilled new norms throughout the city for cleaner streets. The Magic Eyes campaign created a logo (two eyes against a green foreground), a slogan ("Ah, ah - Magic Eyes are watching - don't litter"), a jingle, new trash receptacles throughout the city with the logo and slogan, billboards and posters throughout Bangkok, a school-based component in primary schools to teach children the musical jingle, and mass media spots on TV and radio. It is especially noteworthy that the Magic Eyes program was able to raise corporate sponsorship for virtually all the creative production and dissemination costs. This was done by establishing a board of prominent business representatives to endorse the campaign.

Although changing sexual behavior norms does not lend itself to a "magic eyes" approach, the basic concept of the campaign should be able to be adapted to any cause in Bangkok which was attempting to change social norms on a massive scale. A local, Thai-owned advertising agency was approached to develop such a campaign to create a new image for the target population of lower income 15 to 29 working men and women in Bangkok. Mockups for a three-part TV campaign with supporting materials and displays were developed and presented to AIDSCAP and the BMA. The three spots showed Thai women refusing sex without a condom, carrying condoms in their purse, and negotiating condom use with non-marital partners in a persuasive way. Although some representatives of the BMA initially had objections to the portrayal of single Thai women as sexually active and carrying condoms, they did not veto the campaign but made some constructive suggestions on how to modify certain images.

However, the mass media component as designed above never took place. It is important to analyze this failure since the Bangkok Fights AIDS comprehensive HIV prevention program cannot be considered complete without this component. There are several reasons for this unfortunate gap in the Program.

Due to the inexperience of the AIDSCAP Thailand Country Program office in dealing with commercial firms, it was not until a subagreement proposal had been drafted that it was discovered that, for a grant of this size, an international competitive bidding process was required. Over a number of months, bids were solicited and one advertising agency was selected. Then, in further discussions with the designated implementing agency, it became clear that the agency would not be able to adhere to certain fundamental AIDSCAP/USAID contracting procedures (separate bank account, separate account books, external audits). At this point, approximately one year after this component was scheduled to be launched, negotiations with the ad agency broke down. In addition, worldwide funding reductions for AIDSCAP in 1994 required that approximately US $1 million had to be cut from the Thailand Country Program core budget. The funds that had been set aside for the mass media component were accordingly removed. In an attempt to reinstate some of the funding for mass media, other sources of USAID funds were obtained -- although the amount was only one-third of the original mass media allocation. It was no longer feasible to produce a prime time TV spot campaign and the Thailand Program Managers used an alternative, public relations leveraging approach which is described in the next section.

However, even without the above constraints, it is not clear whether corporate sponsorship of the prime time spots would have been obtained. While the business sector gladly supported the environmentally friendly Magic Eyes campaign, corporate boards might be reluctant to sponsor ads which are contrary to traditional Thai cultural sex behavior norms. It was estimated that approximately $1 million per year would be required to pay for prime time and prime location dissemination of the BFA theme. The AIDSCAP and BMA were only able to identify potential contributions of $50,000/year from Bangkok business sources. In addition, any ads appearing on Thai television have to be approved by the (rather conservative) Media Censorship Board. AIDSCAP and the BMA never had any assurances that the theme and images of the campaign would have been approved.

Undeniably, mass media needs to be a part of any comprehensive prevention program -- if only to unite the implementing partners within a common program identity. The designers of the AIDSCAP/Thailand Program still believe in certain basic criteria: (1) private advertising firms should be engaged to develop the creative aspects of the campaign after a full orientation by the HIV prevention specialists; (2) the campaign must be aired on prime time through prime channels, avoiding the temptation of free public service announcements that may be disseminated at inappropriate times; (3) adequate budget and flexible contracting mechanisms need to be available to engage the commercial sector in this work; and (4) some non-vested sources of non-corporate funding need to be made available to help underwrite expensive television and radio air time.

It is not possible to know how much additional impact the BFA would have achieved if the designed mass media campaign had been implemented. However the results from the 1995 external assessment and the behavioral surveillance data lead one to the conclusion that the BFA Program identity never really caught on, and that only a small portion of the target audience can identify BFA services or materials. A great opportunity was lost to AIDSCAP/USAID and the HIV prevention community -- in this case to evaluate a complete, comprehensive program. Without the essential mass media component any conclusions about the true potential of the AIDSCAP strategy will remain in doubt.

Leveraging the Media

The above section describes the inability of the AIDSCAP Thailand Program to mount a mass media campaign that would have reinforced the outreach effort significantly, contributed to changing social norms and linked program components under a common theme. In lieu of that campaign, the AIDSCAP/Thailand Program planners decided to try to leverage the existing media and creative forces already prevalent in Bangkok as the most cost-effective means of reaching a broader audience. In the final two years of AIDSCAP/Thailand, grants were awarded to a variety of agencies linked with the Bangkok mass media (TV, radio, newspaper, PR firms, etc.). The goal was to integrate BFA themes and concepts into existing programs such as radio and TV talk shows, advice columns, special events, etc. This approach has the advantage of removing most of the creative and production costs from AIDSCAP but has the disadvantage of loss of control over whether or not messages will get properly integrated and disseminated to the target of lower income 15 to 29 year old working men and women. A unique aspect of this phase of the BFA was a shift from a focus on HIV/AIDS to the creation of a sexual lifestyle image. This shift is most appropriate for the new generation of sexually active people who may not feel vulnerable to the threat of HIV/AIDS and can respond rapidly to "new" fashions.

Presented below are just some of the mass media activities conducted. Most were allocated a small budget compared to what commercial advertisers invest to reach the Bangkok market. As a consequence, AIDSCAP was restricted to using relatively inexperienced and shorthanded media firms in the process of implementation. As a substitute for the originally planned, fully-funded mass media campaign, it is clear that this media leveraging component was not cost-effective. Only a few of the activities were implemented as intended and are being sustained by local sources of funds. What is more, in the intensely competitive media environment in Bangkok, it is difficult to expect to leverage existing creative artists, production houses and ad agencies to contribute their effort pro bono. If the Thai case is any example, a mass media effort should be fully funded or not at all.

A total of 15 activities were conducted under this component. The implementing agencies included a television production house and a public relations firm. No formal evaluation was conducted. The following descriptions and judgments are based on the AIDSCAP staff who monitored the implementation.

Phone-in Radio Program: "Love and Healthy Sex"

This 90-minute program aired weekly for 39 weeks during 1995-96. One moderator and one to two guest speakers appeared on each show. Each week a new topic was addressed and listeners were encouraged to phone in. Some of the topics included "How do you know when... for sex," "Women and Sex," "Teenagers and Love," "Condoms and You," "PLWAs and the Community." Approximately 10 to 15 calls were received each week; most callers were men who were concerned about the consequences of their past sexual behavior. The scheduling of "Love and Healthy Sex" directly prior to a popular music program on late Sunday mornings was felt to be an effective strategy to maximize exposure and participation.

Pre-film Slide Shows in 3rd Class Cinema Halls

Two pairs of slides were developed to be shown in 13 theaters in BFA Program neighborhoods. The first slide was a provocative, eye-catching image followed by a safe sex message in the second slide. This activity suffered from lack of adequate implementation. Not all theaters received slides. Those that did were not closely monitored to see if the slides were shown as intended. Exposure to this intervention is not known but assumed to be insignificant. Possible reasons for the poor execution of this activity was lack of clarity of roles and responsibilities among BFA partners and lack of BMA support for this approach.

Scoops and Press Releases

Two scoops and eight press releases were published in business and financial newspapers. The purpose of this mass media effort was to announce upcoming BFA activities. (Scoops are half-page in-depth reports whereas press releases are a single paragraph.) Due to limited resources and increasing cost of advertising the implementing agency was not able to publish the scoops in any of the three mass dailies. However, the mass dailies are more likely to be read by the BFA target population than the business newspapers. Thus, this activity was a mismatch of media channel and audience segment.

Poster Calendars

A provocative poster image of a man and a women on a motorcycle was intended to reach the premarital, sexually active segment of the BFA target. 10,000 copies were produced but were they were produced 3 months late and not distributed as widely as intended. Most distribution was conducted by the BFA outreach implementing agencies instead of the mass media contractor. While the BFA logo appeared on the posters, the names of participating agencies were omitted out of concern for conservative reaction.

Wallet Cards

15,000 wallet cards were produced with a calendar on one side and a provocative photograph on the other side. The target audience for this medium was young, single sexually active men. Spot checks found that distribution was not widespread and few men were found who carried the card.

Love and Sex Fair

Despite its title this activity was a wholesome one-day event, staged at a large shopping mall where lower income laborers tend to gather on Sundays. The event consisted of booths manned by all of the BFA partners. Entertainment was provided by local musicians and comedians. During the nine hours of the fair, an estimated 3,000 persons visited the various booths. The booths were divided into five themes: (1) "Talking to your children about sex"; (2) "Communication between men and women;" (3) "Love and health"; (4) "Safe sex; and (5) "Living with PLWAs".

Condoms

The designers of the AIDSCAP/Thailand Program were well aware that condoms had been aggressively promoted through commercial sex establishments countrywide since the late 1980's. In addition, there was ample empirical evidence that condoms were available in most if not all of the ubiquitous pharmacies around Bangkok -- at low cost and with a variety of selection. The Ministry of Health provided close quality control on all condoms manufactured in the country (which account for most of the public and commercial sector supply). Thus, there was no intervention to increase the number of or (physical) access to condoms in the BFA Program. Instead, the BFA recognized the existence of cultural barriers to condom access and tried to address these through the BCC materials, outreach and mass media.

At the time when AIDSCAP began, single Thai women were becoming more sexually active, yet traditional norms still dictated that women should be virgins at marriage (or at least until engagement) and that carrying condoms was the prerogative of the man. With the absence of an affordable and effective barrier method which did not interfere with sexual intercourse, sexually active women in Bangkok had to rely on the male partner for protection -- or no protection -- as the case usually was. To begin to tip the power balance more toward the woman's favor, AIDSCAP attempted to modify social norms in a way that would allow single women to be more assertive in condom use. The attempt to use mass media for this is described in a separate section below. Booklets, pamphlets and videos produced by the BFA subprojects all encouraged women to acquire condoms themselves and insist on their use if they were unsure about their partner.

Table 4 shows data from the behavioral surveillance on condom use trends over time for men and women in Bangkok. Condom use levels in commercial sex confirm that use has become a norm and that accessibility does not seem to be a barrier for either male customers or the female CSWs. What stands out however are the poor levels of condom use among nonpaying partners of CSWs and among men with non-CSW single female partners. To the extent that these male partners are infected or engaged in risky sex with multiple partners posing a continuing and significant risk for their female partners, both commercial and noncommercial. Some improvements are noted, although modest, for condom use by indirect CSWs with nonpaying partners. Ominously though, no improvements are noted for condom use among partners of single, sexually active Thai women who are not CSWs.

Table 4: Trends in Indicators of Condom Use among Various Populations in Bangkok

Populations

T1 (1993)

T2 (1994)

T3 (mid-1995)

T4 (late-1995

T5 (mid-1996)

% of men who reported using condoms with last CSW:

- service worker

89.2

92.7

89.1

92.9

93.7

- office worker

88.4

96.0

–

–

–

- student

92.0

83.3

95.7

95,2

94.4

% of indirect CSWs who reported using condoms:

- With every paying customer

55.6

57.9

76.8

84.1

89.0

- With every nonpaying customer

23.2

14.1

14.9

25.4

28.5

% of single women (non-CSW) who used condoms for last sex:

- all groups combined

18.6

23.1

20.5

19.5

18.9

Evaluation

The amount of data available to evaluate the Bangkok Fights AIDS Program is extensive. The data range from outputs to outcome to biological indicators of trends in syphilis and HIV prevalence. Qualitative data are available from a number of subproject evaluations. However the challenge for evaluators of the BFA Program is to assess the holistic impact of the many components. Because the designers of the AIDSCAP Thailand Program believed that there would be a synergistic effect of the combination of inter-linked activities above and beyond the separate achievements of those subprojects, the evaluation of outcome was conducted independently of the individual subprojects. Therefore, in addition to subproject evaluation, AIDSCAP commissioned an overall, citywide evaluation of risk perception and risk behavior among 15 - 29 year-olds. These "behavioral surveillance surveys" (BSS) were implemented by the Office of Population and Technical Assistance (OPTA) with extensive technical assistance from the AIDSCAP Asia Regional Office. Over 20,000 interviews were conducted over five rounds of surveys with working men and women from the same districts in which the BFA Program was being implemented. The data for women and men are stratified into groups as follows:

Women: Blue Collar (service¹) Workers

Office workers
Vocational students
ANC clinic clients
Commercial sex workers

Men: Blue Collar (service) Workers

Office workers
Vocational students
Male STI clinic clients

Three different questionnaire modules were used for men, women and non-CSW women. While asking some basic questions on socio-demographic variables and AIDS awareness as a warm up, the bulk of the questionnaire focused on sexual behavior. Trained, full-time field workers conducted face-to-face interviews that lasted approximately 20 minutes on average. Male interviewers interviewed men and female interviewers interviewed the women. For the section on sex behavior, single women filled out a self-administered questionnaire. The data on service workers -- as opposed to the higher income office workers -- is emphasized in this analysis because they more closely represent the target population of the BFA Program interventions.

The data from the BSS are one of the most important sources of data for evaluating the BFA Program and this section presents some of the key findings of the five rounds of surveys. It is important to note that the samples of respondents by group are not necessarily representative of the entire Bangkok population. Thus, the levels of risk behavior do not necessarily describe the level of risk in Bangkok generally. Instead, the data should be viewed in terms of the changes over time. The trends in risk behavior should accurately reflect the general changes that occurred in Bangkok during the BFA Program.

The first set of figures (5-8) review the aggregate PIF data over time to establish the fact that activities did occur at a large enough scale to generate some change in behavioral outcome.

Figure 5: Outputs -- Bangkok Fights AIDS
PIF Thailand Summary: People Trained

NSG: non-specified gender

Figure 6: Outputs -- Bangkok Fights AIDS
PIF Thailand Summary: Person Contacts

NSG: non-specified gender

Figure 7: Outputs -- Bangkok Fights AIDS
PIF Thailand Summary: Condoms Distributed (Free)

Figure 8: Outputs -- Bangkok Fights AIDS
PIF Thailand Summary: Materials Distributed

The following figures and tables present key findings from the BSS:

Table 5: Outcome -- Bangkok Fights AIDS
% Who Feel HIV Is "Near Them"

	Mid 1995	Late 1995	Mid 1996
Male	64%	61%	67%
Female	57%	65%	60%

Figure 9: Outcome -- Bangkok Fights AIDS
Inappropriate HIV/AIDS Risk Perception, by Group

Note: % of males who reported high risk but thought themselves unlikely to become HIV infected.

Table 6: Outcome -- Bangkok Fights AIDS
% of single women and men who feel that a single woman can refuse sex

	Mid 1995	Late 1995	Mid 1996
Male	86%	91%	94%
Female	78%	82%	83%

Table 7: Outcome -- Bangkok Fights AIDS
% of single women and men who feel like they can insist on condom use

	Mid 1995	Late 1995	Mid 1996
Male	92%	94%	95%
Female	65%	70%	65%

Figure 10: Outcome -- Bangkok Fights AIDS
% male service workers who had commercial sex in past year

Table 8: Outcome -- Bangkok Fights AIDS
% of single women who were abstinent in the past year

	1993	1994	Mid 1995	Late 1995	Mid 1996
Student	96%	97%	95%	97%	98%
Service Worker	92%	89%	95%	96%	94%

Figure 11: Outcome -- Bangkok Fights AIDS
% of CSWs who used condoms with last nonpaying partner

The data for STI and HIV prevalence among different populations of Bangkok are presented in this next group of tables and figures:

Figure 12: Biological Indicators -- Syphilis and HIV seroprevalence among pregnant women in Bangkok

Syphilis: Chulalongkorn, Siriraj Hospital and BMA Health Centers
HIV: Chulalongkorn, Siriraj Hospital and Rajvithi Hospital

Table 9: Biological Indicators -- HIV prevalence among pregnant women in Bangkok and Central Thailand

Jun 92

Dec 92

Jun 93

Dec 93

Jun 94

Dec 94

Jun 95

Central

1.2%

1.7%

1.6%

1.7%

2.2%

21.%

2.75%

Bangkok

1.2%

1.1%

no data

1.2%

1.8%

no data

1.9%

Source: Division of Epidemiology, Ministry of Public Health

Table 10: Biological Indicators -- Bangkok HIV prevalence
Pre-inductees, Bangkok and Central Thailand

	1992	1993	1994	1995
Central	2.9%	3.0%	2.7%	3.0%
Bangkok	3.3%	3.2%	3.0%	2.6%

Finally, process, outcome and impact data are presented in various combinations to visually examine trends over time:

Figure 13: Bangkok Fights AIDS -- HIV seroprevalence among 21 year-old pre-inductees and risk behavior among low income single men over time

Figure 14: Bangkok Fights AIDS -- HIV prevalence in ANC clients and risk behavior of married men over time

Output Level

Nearly 9,000 people received professional, curriculum-based training in this project. Equal proportions of men and women were trained. This training led to over 200,000 person-contacts for self-risk assessment and referral. Outreach activity peaked in 1994, midway through the AIDSCAP support for the BFA Program and stabilized at about 50,000 person-contacts per year in 1995 and 1996. Equal proportions of men and women were reached by the BFA Program. Although there was no AIDSCAP procurement of condoms in this Program, government supplies were made available for distribution through the network of BFA service providers. Over 1.6 million pieces of condoms were distributed (free) to the target population in Bangkok. Distribution of printed materials, posters, flip charts and videos increased threefold between 1993 and 1994 and tripled between 1995 and 1996. A total of 800,000 materials were distributed to support the goals of this Program.

Outcome Level

Outcome, as generally applied by AIDSCAP, refers to the increase or maintenance of behaviors that are low risk for HIV transmission via sexual intercourse. AIDSCAP also endorses the AIDS Risk Reduction Model of the Center for AIDS Prevention Studies which contends that a person must accurately perceive that s/he has a risk for HIV and makes a commitment to change in a way to reduce that risk. The BSS probed this dimension of pre-action through several questions about self-risk and perceived ability to insist on condoms. Qualitative research had shown that some groups of Bangkok blue collar workers express self-risk as whether HIV is "near" to them or "far" from them. This phrasing was then inserted into the BSS questionnaire for rounds 3 to 5 and the data are shown in Table 5.

Considering that HIV has only infected 2% of Thai adults, the perception by over 50% in both men and women that HIV is near them is impressively high. According to this indicator, the men have a slightly greater perception of vulnerability than the women however women's perceived risk is declining -- when in fact that might not be the case. The ability to protect oneself however depends on the power to refuse sex or insist on condom use. One BSS question asked single women if they thought they could refuse unwanted sex. Interestingly, more men felt that single women had the power to refuse sex and the trend is slightly increasing for both sexes. A second BSS question asked men and women if they felt they could insist on condom use: Men, almost universally, felt in control, whereas less than three-fourths of women felt so.

The BFA was not able to close the power gap in sex decisions between single men and women. Yet the BSS data suggest that single, lower income women in Bangkok are choosing to remain abstinent: over 90% of single women did not report being sexually active in the year prior to the survey across all five rounds. While, abstinence was one of the risk-reduction options promoted by the BFA BCC component, it was not emphasized at the expense of other options. Given the increasing pressure to become sexually active in the modern urban environment of Bangkok it is surprising that there is little (reported) change in sex behavior².

The risk for Thai men comes from their tendency to prefer sex with multiple partners -- especially those partners that are widely shared with other men. Table 8 shows the extent of sexual "bridging"³ behavior that occurred over the duration of the BFA Program. By the first round of the BSS in 1993, the prevalence of men who had both commercial and noncommercial sex in the previous year was not high, the trend was toward increased bridging behavior. By 1995, a sharp decrease in this sexual "mixing" is observed and remained at about 5% at the end of AIDSCAP's support for the BFA.

It was AIDSCAP's assessment that the greatest risk for female CSWs in Bangkok comes from their regular customers and nonpaying partners (i.e., boyfriends). Accordingly, a major focus of BFA BCC materials for CSWs emphasized this risk. Figure 11 shows that the condom use with nonpaying partners increased approximately 10 percentage points for both direct and indirect CSWs. The 1996 level of 30% use is still dangerously low however and presents a major risk for CSWs in the years to come.

Impact Level

Thailand is somewhat unique among countries for the amount of HIV and STI prevalence data it collects on a national scale. All pregnant women at government antenatal clinics are screened for syphilis using VDRL. These data are available at the clinic, district, provincial, regional and national level. The national sentinel surveillance has conducted semiannual national serosurveys including women attending antenatal clinics, commercial sex workers, male STI clinic clients and IV drug users at detoxification clinics. The Thai military screens all (21-year-old) conscripts prior to induction and these data are tabulated by province and district of residence. Tables 9 and 10 present some of the serosurvey results for Bangkok and compares these with the only other comparable part of the country: the central region (excluding Bangkok).

The Central region of Thailand contains 26 provinces which surround Bangkok in horseshoe shape. Although many have argued that it takes years to demonstrate impact of a prevention program on biological indicators, this has not been true in the case of Thailand. Condom use increased so rapidly in 1990 that accelerating declines in STI were observed only months after high levels of use were achieved. Similarly, the slowing down of increases in prevalence (i.e., incidence reduction) was detectable as soon as one year after the accelerating declines in STI cases. Thus, it is not unreasonable, in the Bangkok case, to look at biological trends for STIs and HIV among the populations that the BFA Program was trying to reach.

By comparing trends in Bangkok with the Central region, the analysis can control (somewhat) for the national secular trends in declining STIs and HIV among some populations. Army conscripts represent the younger and lower income population of males in Thailand. They are tested for HIV before they enter the army so their infection status represents a cumulative measure of risk since they became sexually active. The data in Table 10 show that young Bangkok men had initially higher HIV prevalence than their counterparts in provinces of the Central region. However, successive cohorts of young Bangkok recruits had accelerating reductions in prevalence while the Central region prevalence declined more slowly and irregularly. If these declines in HIV among young Bangkok men represent general male reduction in risk, then STI prevalence among young women should show a decline. Figure 12 compares antenatal syphilis prevalence for lower income women in Bangkok over time and indeed there is a distinct and sustained decline in syphilis.

A composite of indicators is shown in Figures 13 and 14. General levels of risk behavior of single Bangkok men declines during 1992 through 1995 while HIV prevalence among 21-year old men declines as well. However, among older, married men, while commercial sex declines sex with multiple non-CS partners compensates with an equivalent increase. HIV is stable among married women perhaps because of (initially) lower transmission risk among non-CS partnerships. The data for cumulative number of BFA outreach contacts in Bangkok shows a geometric increase during the time when HIV begins an accelerated decline while the trends in the non-Bangkok Central Region show no such decline. Overall outreach also coincides with an accelerated decline in syphilis prevalence among married Bangkok women during 1993 to 1994. The decline is modest however and may not reflect declines in other more prevalent STIs such as chlamydia and gonorrhea.

A Note of Caution

Despite all the apparent progress that Thailand has recorded in combating the HIV epidemic, there are signs of a reversion to risk. The BSS measured self-risk perception compared against actual behavior to obtain a "lapse" factor. The percentage of men who accurately assessed their risk for HIV declined sharply during the peak years of the BFA Program (see Figure 9). However as outreach activities declined somewhat in late 1995 and 1996, an increase once again in the percent who may be reverting to old sexual behavior patterns yet denying their risk. The BFA Program cannot afford to relax the BCC component and may need to apply periodic booster events to prevent a resurgence of risk.

Endnotes

Note: Service worker denotes blue collar workers in factories, restaurants, construction sites, motorcycle taxi drivers, garage and gas station attendants, bus conductors and other, generally, wage-labor groups. "Service worker" does not include commercial sex workers in this analysis.
This low level of single female sexual activity, of course, may be the result of underreporting due to the persistent cultural norm that instructs Thai women to be virgins at marriage. Yet, if behavior was liberalizing then some downward trend for this variable should have been observed. It is noteworthy from the data in Figure 20 that the middle class single female office workers are more sexually active than the lower income. This may reflect the fact that service workers include more recent arrivals from the rural area -- especially northeast Thailand -- where sexual norms are more conservative.
"Bridging" is a concept developed in studies of sexual networking and refers to act of having sexual contact with members of very high risk populations and low risk populations during the same time period.

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

See Also:

Final Report for theAIDSCAP Program in ThailandNovember 1991 to September 1996

See Also:

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