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Final Report for the
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Table of Contents I. Country Program Description 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 (See Below)
III. Subproject Highlights
Community Mobilization for AIDS Prevention
AIDSCAP concentrated its resources in Bangkok in an attempt to stem the rapidly growing epidemic there. AIDSCAP and the Faculty of Public Health (FPH) of Mahidol University jointly coordinated multiple subprojects under the Bangkok Fights AIDS Program. The BMA created multisectoral DACs in each of the city's 36 districts comprised of local government and community leaders and health care providers. The FPH had extensive experience implementing community health development programs in Bangkok and across Thailand, relying on mobilizing local networks of key individuals to help diagnose needs and steer action toward larger development goals. In this subproject FPH mobilized communities in six Bangkok districts to adopt comprehensive AIDS prevention strategies, thereby magnifying and sustaining the effect of technical strategies introduced in other AIDSCAP subprojects. The community mobilization strategy had three components: first FPH conducted an inventory of the organizations, institutions and networks and individuals in each district who were called upon to mobilize their own constituencies. In each district, these individuals and institutions assessed popular attitudes towards HIV/AIDS and helped develop a plan for AIDS prevention programming in their district. Second, FPH conducted trainings, meetings, preparatory activities and project review seminars with the DACs to build their capacity to plan, coordinate and monitor the AIDS prevention activities of local implementing agencies. Finally, FPH and the DACs collaborated with community representatives and networks to build community support for AIDSCAP strategies and set expectations for implementation. With technical support from FPH, the DACs administered block grants to fund gatherings of representatives from community networks and other activities supporting AIDSCAP technical packages. With additional funding in 1995, portions of the community mobilization were expanded to cover all districts of Bangkok.
Support for the Operating Center of the Bangkok AIDS Committee
AIDSCAP's strategy for Bangkok combined technical packages such as AIDS education and mass communication with support for community mobilization, orchestrating separate AIDS prevention activities into a coherent, comprehensive package for this large metropolis. The Bangkok AIDS Committee (BAC) played a crucial role, supervising and directing the 36 District AIDS Committees it created citywide to coordinate and monitor community mobilization at the local level. AIDSCAP provided material and technical support to build the capacity of the BAC to coordinate AIDS prevention activities. This two-year subproject provided startup funds for an administrative office of the BAC, called the "Operating Center" which carried out the concrete functions of coordinating DAC activities. AIDSCAP supported the Operating Center by funding meetings, staff training, and equipment purchases. The Operating Center arranged and managed monthly meetings of the BAC where citywide coordination was planned, as well as quarterly meetings between groups of DAC members and key members of the BAC. Consultants trained Operating Center staff in electronic data collection, compilation, management, analysis and dissemination back to the BAC and DACs. AIDSCAP also supported the Operating Center's production of a bimonthly newsletter (containing policy statements from the BAC, data on the epidemic, and updates on projects and meetings) and distribution of the newsletter to government and non-government agencies in Bangkok. In post-project interviews with key BAC staff, the feeling emerged that AIDSCAP had not done enough to build the capacity of the BAC staff to manage a set of activities as complex as the Bangkok Fights AIDS Program.
HIV/AIDS Estimates and Projections
While the surveillance data for Bangkok were alarming to epidemiologists, often it is the estimate of caseloads of persons infected with HIV and projected AIDS cases that ultimately convinces policy makers of the need to rearrange priorities today. AIDSCAP contracted with the Thai Red Cross Society Program on AIDS to conduct national and Bangkok estimates and projections of HIV/AIDS caseloads. Estimates of the current prevalence of HIV infection in the population and projects of the future course of the epidemic were developed. Using state-of-the-art computer modeling data from the semiannual seroprevalence surveys of pregnant women and army conscripts were analyzed. The data were combined with three other data sets: the Partner Relations Survey, the Study of Provincial Sex Networking and HIV seroincidence rates for 21 year-old men to improve the predictive power of the computer model. A variety of potential scenarios were examined under assumptions about the extent of high-risk sexual activity, condom use in high and low-risk sexual relations, and the prevalence of STIs. Ten-year projections were calculated by simple extrapolation assuming the epidemic would follow the course it did in the north. This subproject exposed weaknesses in a sophisticated, behavior simulation model in trying to explain the course of an Asian HIV epidemic. The authors note that, "...epidemics in Asian countries, which are driven largely by commercial sex, do not fit easily into the iwgAIDS [computer model] mold. This means that extreme caution should be taken in applying this model and that, in fact, such modeling efforts may have few advantages over simpler curve fitting with such programs as EPIMODEL." The authors used alternative methods of estimating and projecting the HIV disease burden and the results of those forecasts were used by the Bangkok Fights AIDS Program in convincing policy makers of the seriousness of the HIV threat in Bangkok. Technical Assistance to Strengthen the Health Education Subcommittee on AIDS and the Health Education Division of the Ministry of Public Health
Although the primary focus of the AIDSCAP Thailand Program was Bangkok, the Ministry of Public Health requested AIDSCAP to support an additional policy intervention because of the design team's expertise in health education. The Health Education Division (HED), a division of the Ministry of Public Health works with the Health Education Subcommittee, an advisory committee to the National AIDS Committee (NAC), to coordinate and strengthen AIDS health education programs and communication strategies in Thailand. The HED approached AIDSCAP in 1992 for technical assistance to strengthen its institutional capacity to draft policy initiatives and to develop and implement an effective long-term planning process. The HED created a working group comprised of eight staff from the Health Education, AIDS, Training and Venereal Disease Divisions of the MOPH. The group acted as a "think-tank" and met every two to three weeks to develop proposals and drafts on communication and education initiatives and to improve the quality of and access to HIV/AIDS information. The group produced an AIDS Education Master Plan for the MOPH and national guidelines for AIDS prevention messages. The working group also arranged four brainstorming sessions which focused on topics related to AIDS communication, and developed and submitted proposals to the Health Education Subcommittee to strengthen the capabilities of health personnel in information, education and communication skills and to set up behavioral surveillance. Finally, in an effort to strengthen information networks, the HED created a key informant directory and a database of baseline information on health education activities across Thailand. Upgrading the Bangkok Metropolitan Administration (BMA) STD Clinic and Outreach Network
The STI infrastructure of the MOPH was established over a period of decades and covered every province by the advent of the HIV epidemic in the late 1980s. However, health services in Bangkok are not managed by the MOPH and thus the public infrastructure is, ironically, weaker in Bangkok than in the provinces. When considering that the de facto population of Bangkok is also much larger than the registered residents, it is understandable that the BMA did not have the resources to expand coverage of STI diagnosis and treatment to those in need. Although caseloads of new STIs at government clinics was declining at the launch of AIDSCAP/Thailand in 1992, STIs were still prevalent among both the high and low risk populations for HIV. AIDSCAP provided funding and technical assistance to the BMA to improve access to and use of comprehensive STI services at 11 of its 60 health centers, especially to the population at highest risk, lower income men and women 15 to 29 years of age. This subproject upgraded STI services at BMA clinics and health centers and community outreach education. Two STI clinics were expanded to extend services in the evening and two other health centers were upgraded to provide STI services for the first time. The BMA upgraded laboratory and clinical services at nine STI clinics by purchasing new lab equipment and supplies, increasing testing capabilities, improving standardized lab procedures including quality control, and training lab workers to implement these systems. Nurses, who provided the STI services under supervision of a physician, were trained in syndromic diagnosis using national standard treatment protocols; counseling to encourage risk reduction; compliance with medical prescriptions; and partner notification. Drug procurement was improved to ensure affordable, available STI drugs. AIDSCAP and the BMA established a community outreach education program to commercial sex establishments, based on the network of 60 BMA health center, Each health center provided one outreach team consisting of a driver, two nurse/health educators, and health officer from the clinic's local district office. Teams received a one-day training before each of the three rounds of outreach education in their territory. Three hundred CSWs were recruited as peer educators and participated in the final round of training and outreach. A local public relations firm developed educational materials for male STI clinic patients, housewives and sex workers who received them in health centers and clinics and through educational outreach.
Strengthening Private STD Clinics in Bangkok
A study of male health seeking behavior in Bangkok estimated that most go to private clinics or pharmacies as the point of first contact. Thus, the designers of the AIDSCAP Thailand Program knew that, in order to have a comprehensive STI control program in Bangkok, the private sector outlets must be brought into the constellation of programs. The Thai Medical Society for the Study of STIs (TMS-STD) was established by Thai STI physicians to support research and continuing medical education in the field of STIs through training courses, meetings and publications. TMS-STD, with assistance from PATH/Thailand and AIDSCAP implemented a subproject to establish effective and comprehensive STI patient management practices in 200 private clinics in the inner districts of Bangkok. The subproject had three components: the creation of a new STI management course, the establishment of support systems, and the design of a plan to extend activities to other districts of Bangkok. The new STI patient management course for private physicians was based on a needs assessment and surveys of STI management practices. The course was institutionalized in the TMS-STD and included in their regular schedule of continuing medical education courses. TMS-STD worked with private clinics to design, implement and evaluate support systems such as a partner referral system, distribution systems for educational materials and condoms, and a STI/HIV testing and counseling referral network. A wrap-up seminar was conducted to explore strategies to expand the subproject to other districts of Bangkok. AIDSCAP supported PATH to provide technical assistance to the TMS-STD in implementing this subproject. PATH/Thailand staff, experienced in the previous AIDSTECH/FHI-funded subproject entitled "Upgrading Private STD Clinics" implemented by PATH provided the assistance. PATH assistance focused on strengthening TMS-STD's capacity to coordinate and implement the subproject; and establishing a condom distribution network in private clinics. Technical assistance also included assistance in hiring and training subproject staff and consultants , conducting training workshops and developing curricula, survey instruments and modifying BCC materials. A particularly noteworthy product of the subproject was the dual-gender STI pamphlet that was distributed throughout the clinic network. This pamphlet contained flip-side descriptions of STI problems in men and in women, thereby encouraging both men and women to learn about each others symptoms and ways to avoid and recognize these infections.
Model STD Intervention for Pharmacists
In Thailand, patients with STIs commonly seek treatment at pharmacies without prior medical diagnosis of their illness. Some pharmacists and drugstore personnel are already familiar with the symptoms of common, treatable STIs and prescribe correct treatment regimens. Drugstores are also sources for condoms. Thus, pharmacists have the opportunity to promote condoms for prevention of STI infections. PATH, a US PVO and AIDSCAP subcontractor, successfully collaborated with pharmacists and drugstore owners in late 1990 to improve the quality of oral contraceptive services delivered by pharmacies in Thailand. In the process, PATH helped organize the Chiang Mai Pharmacists Club, a local professional association of pharmacists from drugstores, hospitals and the Chiang Mai University School of Pharmacy. In the subproject for AIDSCAP, PATH again collaborated with the Pharmacists club to develop a model intervention for improving pharmacy STI diagnosis, referral and prevention services. It was hoped that this model would then be replicated in Bangkok as the third piece of STI strengthening in the Bangkok Fights AIDS comprehensive prevention program. PATH trained 210 pharmacists and non-pharmacist staff from the 210 drugstores in Chiang Mai in the role of STIs in HIV transmission, standardized syndromic diagnosis of GUD and urethritis, the appropriate use of a referral system, prevention education, promoting compliance with treatment, condom promotion and correct use, and partner notification through contact cards. Training included exercise to promote a sense of partnership and community service and improve interpersonal communication skills, and activities to increase team building between pharmacists and drugstore personnel. PATH and the Pharmacists Club, with technical assistance from AIDSCAP, designed the pharmacist training curricula and other materials such as posters and condom promotion displays for point-of-purchase, and simple reference materials such as flyers showing correct condom use and pocket-sized cards with AIDS and STI prevention messages for customers. All materials were developed based on initial research including focus group discussions, individual interviews with pharmacists, and "secret shopper" visits" made by 10 to 15 trained subproject staff to at least half the participating drug stores. A noteworthy product of the subproject were the countertop flip charts with explicit photographs of common STI symptoms among Thai men and women and with syndromic guidelines for proper course of action. Radio and TV spots publicized the subproject and PATH made presentations of the model to professional association including the Pharmaceutical Association of Thailand. The ultimate test of the subproject however was the expansion of the model in Bangkok with funding from the European Community. Service Worker Outreach Subprojects
AIDSCAP funded the Bangkok Fights AIDS (BFA) Program which targets 15 to 29 year-olds for AIDS prevention. Workplaces were key sites for intervention given the large number of young, rural men and women who migrate to Bangkok each month looking for wage labor. The Thailand Rural Reconstruction Movement (TRRM) ,a non-governmental umbrella organization with 20 years of experience implementing integrated development programs with grassroots organizations, worked with Bangkok's urban residents, many of whom were migrants from rural areas. AIDSCAP supported TRRM in a subproject to increase and sustain low-risk sexual behavior among service sector workers in the six districts targeted in the BFA Program. Later, the subproject was expanded to include all districts of Bangkok with a heavy concentration of service workers. TRRM provided administrative oversight for the five local NGOs to recruit, train and deploy outreach worker teams among 30,000 service sector employees and their managers, promoting sound workplace policies and individual behavior change. Each NGO conducted outreach among populations with whom it had the most experience; 54 outreach staff and 14 supervisors were trained for each target population. In each district, outreach workers established rapport with taxi and bus drivers, construction workers, restaurant staff and small factory laborers. In one-on-one discussions and interactive small group sessions, outreach workers helped employees understand the AIDS epidemic, means of transmission and prevention of HIV, their personal risk, supportive resources, and how to negotiate condom use. In large group meetings, involving workers, managers and owners, outreach workers emphasized the impact of the epidemic on workplaces, supportive workplace policies and planning for worksite HIV prevention programs. Outreach teams provided the six AIDS Committees with updated information on the target audience. In the expansion phase of the subproject, TRRM continued to serve as the umbrella agency for a reduced set of four NGOs who managed the outreach: ACCESS (AIDS Counseling Centers and Educational Support Services), UDF (Urban Development Foundation), CLIST (Center for Labor Information, Services and Training), and TAVS (Thailand Association for Voluntary Sterilization. This phase of the subproject planned to reach a much larger target population than the previous phase. TRRM was responsible for overall coordination of the four NGOs to recruit, train and deploy outreach worker teams to reach 103,000 service sector employees and their managers, promoting sound workplace policies and individual behavior change. With AIDSCAP support, PATH/Thailand strengthened the capacity of selected implementing agencies to design, implement and evaluate AIDS interventions in factories, congregating sites for mobile employees in initially six, then all Bangkok districts with a concentration of service workers. PATH provided on-the-job training in the development of HIV prevention intervention designs, facilitated the linkage and involvement of workplace implementing agencies with other AIDSCAP subproject implementers, and facilitated the transference of skills in existing implementing agencies to other agencies working with similar target groups in other districts of Bangkok. Training was geared towards the target group of 15 to 29 year-old employees with lower socioeconomic status. Through on-the-job training and workshops with core staff, PATH transferred skills in the following areas: audience analysis, development of training curricula and outreach planning, development of communication and training materials, training of outreach workers to use communication packages, monitoring of outreach workers performance, and evaluation and/or training of outreach workers to evaluate interventions. Three different training packages were developed and utilized. The "Outreach Package" prepared outreach workers to reach the target audience, the "Worker Communication Package" emphasized personalizing risk and instigation of behavioral change through changing perceived norms so that low-risk behavior can be seen as socially acceptable, and the "Decision Maker Package" was designed to influence policy makers to personalize the risk of HIV to the business and to be aware of the need to change high-risk practices of workers. Meetings between the core staff of the implementing agencies and DACs were organized and strategies for influencing decision makers of targeted worksites were created.
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