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Conquest or Complacency: Field Workers Assess Prospects for Behavior Change in Thailand |
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Recent survey findings suggest that after years of HIV/AIDS education in Thailand, people may be becoming complacent about the epidemic. But outreach workers believe that the behavior change that has slowed the spread of HIV infection in their country will be sustained. Plenary speakers at the XIth International Conference on AIDS in Vancouver hailed Uganda's and Thailand's achievements as evidence that HIV prevention programs can reduce risk behavior on a national scale. Published reports of the decline in brothel patronage among young Thai men (see reference 1), increased condom use (see reference 2), and plummeting STD caseloads (see reference 3), certainly establish that Thailand reacted to the threat of HIV/AIDS with a national movement away from risk. But are Thais becoming weary of the battle against a largely invisible foe? Bangkok is the trend-setter for styles throughout the country, and the AIDS Control and Prevention (AIDSCAP) Project has been evaluating perceptions and risk behavior among the most vulnerable in the capital city from 1993 to 1996. Results from AIDSCAP's behavioral surveillance surveys, conducted periodically among the groups targeted by the project, are encouraging. For example, the number of male blue-collar workers who have multiple sex partners has decreased by one-third, and sexual activity among single women has remained low (below 10 percent) and constant. But the survey teams are beginning to sense complacency among members of the target audience. By the fifth survey round, conducted in mid-1996 among 5,000 men and women, the percentage of respondents who said they had discussed HIV/AIDS or HIV prevention with their partners had declined precipitously. Although respondents believed the epidemic was "closer to them than ever," they also said that the issue of AIDS was commonplace -- nothing to get excited about anymore. Additional survey findings point to worrying trends in sexual behavior. Female vocational students have not reported any increase in sexual activity since the surveys began in 1993, but those who do have sex are using condoms less often because "the guys are from our own group." While condom use is virtually 100 percent among the paying customers of sex workers, nearly half have non-paying partners -- most of whom do not use condoms.
Do these data signal the gradual re-emergence of high-risk behavior in Thai society? Has Bangkok, and perhaps Thailand, reached a prevention plateau? No, this is no collective relapse, say outreach workers who believe that the attitude and behavior changes the AIDSCAP Project has supported will be sustained. Among them are Khom and Som, two of the 70 HIV/AIDS outreach workers who have reached about 70,000 people in Bangkok during the past three years. Experienced AIDS field workers, Khom and Som have spent several years conducting outreach to some of Bangkok's more inaccessible population groups: small-factory workers, garage mechanics and motorcycle taxi drivers. They have developed skills and techniques to quickly reach those in a group of workers who engage in risk behavior. Som, for example, begins by identifying the leaders of a group and gains their trust in two or three outreach sessions. These peer leaders know which of their co-workers are engaging in risk behavior, and can help her be more precise in targeting her outreach efforts first to those at greatest risk of contracting or transmitting HIV. The outreach workers make no attempt to determine someone's HIV serostatus. However, members of the groups who know they are HIV-positive often reveal this information voluntarily to Som and Khom.
Som knows she's had an impact on male motorcycle taxi drivers because of the skills she's watched them develop in applying condoms to wooden penis models and their acceptance of the trade-off of reduced sensation during sex for the longer-term benefit of avoiding a fatal disease by using condoms. Other young men who had held the (probably false) belief that their regular commercial sex partners used condoms with everyone but them were convinced to abandon these high-risk relationships altogether. Khom also attests to reduced risk behavior among the target populations he has worked with but is less sure about how long the changes will last. He cites the case of a garage mechanic who is married with two children but extravagant in his patronage of sex workers. "We went over the common STDs, the link with HIV and the consequences for his wife and children. After two sessions together he seemed to undergo a major change -- a realization that he had to stop -- and, for now, I believe he has stopped. "Another, a motorcycle taxi driver, just had his first child several months ago and came up to talk with me alone," Khom continued. "He used to inject heroin in the past, and one of the members of his injecting circle had died of AIDS. He said he wasn't afraid to die himself but was very concerned about the fate of his wife and child if he was infected. He seems to have become dependent on my visits and the need to discuss his anxiety with me. I know he's changed, but for how long?" Som recalls the comments of other young men in the city who lament to her that her advice may be too late for them. "It's hard to evaluate ourselves since we constantly have to move on to other areas of the city," she said. "But I ask people that I've reached to write me letters and tell me how they are doing. That gives me confidence that we continue to make a difference. The peer educators that we've trained continue the effort." Bangkok (and Thailand) are at a crossroads: The people who have seen friends and relatives die of AIDS need no more convincing of the reality and consequences of HIV infection. However, the vast majority of Thais have no personal experience with HIV. Furthermore, a persistent social stigma keeps AIDS enshrouded in shame and denial. An increasing percentage of the population may be approaching saturation with the prevention message, and complacency may be a symptom of this "concern burn-out." The question is whether the cadres of outreach workers like Som and Khom have already reached and converted enough of those at risk to sustain the impact on the epidemic that prevention leaders in Vancouver cheered. -- Tony Bennett Tony Bennett is senior program officer in AIDSCAP's Asia Regional Office in Bangkok, Thailand. Under the AIDSCAP Worksite Communication Project, PATH provided technical assistance to the ASEAN Institute for Health Development of Mahidol University and to four Thai nongovernmental organizations -- the AIDS Counseling Center for Education and Support Services (ACCESS), the Center for Labor Information and Training, the Thai Association for Voluntary Sterilization and the Urban Development Foundation -- to train and support 70 HIV/AIDS outreach workers. References
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