Policy Profile: HIV/AIDS Policy Lessons: Learning from Thailand

Those who participated in AIDS policy debates in Thailand during the past decade shed new light on the evolution of the country's policies in an AIDSCAP study that offers lessons for other nations grappling with emerging epidemics.

When Thailand became the first developing country to document nationwide behavior change to reduce the risk of HIV infection, it was not unexpected. After all, the Thai government's response to the epidemic had often been cited as a model for others in the developing world.

But less than a decade ago, few Thai officials recognized the threat HIV posed to the health of their country's citizens and its economy. AIDS was considered an affliction of foreigners and marginalized groups in Thai society, dismissed by the prime minister as "just like any other disease," and reports of AIDS cases were downplayed for fear of discouraging tourism.

How did the country move from denial to more progressive policies and programs that have led to declines in HIV prevalence and cases of other sexually transmitted diseases (STDs)? A study commissioned by the AIDS Control and Prevention (AIDSCAP) Project provides some answers to that question in order to help other countries learn from Thailand's successes -- and its mistakes.

"In most countries, the national response to HIV/AIDS follows a similar pattern, moving slowly from denial to acceptance," said Neil Brenden, director of AIDSCAP's Asia Regional Office in Bangkok. "We hope that by identifying the events and forces that triggered public policy changes in Thailand, we can help other countries accelerate the policy evolution process."

Conducted by researchers from the ASEAN Institute at Thailand's Mahidol University and a U.S. consultant, the study describes the development of national HIV/AIDS policies and programs under five prime ministers from 1984 to 1994. Unlike earlier analyses of the Thai response to HIV/AIDS, the AIDSCAP study is based on interviews with many of the participants in AIDS policy debates during the past decade. Twenty key informants from government, universities and nongovernmental organizations (NGOs) were interviewed and assured that their comments would not be identified by name so that they could speak frankly.

These interviews and careful analysis of government documents and newspaper articles yielded a detailed picture of how political forces and public events shaped Thailand's response to HIV/AIDS. In their report, the researchers identify three important periods of policy evolution from 1985 to 1992, describe the catalysts for policy development during each period, and propose lessons from the Thai experience that may be relevant for other countries.

Business as Usual

The first case of AIDS in Thailand was reported in 1984 during the six-year rule of General Prem Tinsulanonda, a former army commander who was appointed premier in 1982. Prem and his business-oriented cabinet were not about to let reports of a new disease thwart their plans to boost Thailand's economy.

News of AIDS among Thais was particularly unwelcome in 1987 during "Visit Thailand Year," a multimillion-dollar campaign to boost international tourism. In fact, some critics charge that efforts to promote sex tourism were intensified during the late 1980s.

Most of the AIDS cases reported to the public during the 1980s were in Thais who had been infected abroad, which allowed the government to dismiss AIDS as a "foreigners' problem." Reports of AIDS among homosexuals, commercial sex workers and injecting drug users only reinforced the belief that the disease was not a concern for the majority of Thai citizens.

"The cases of AIDS are among populations with extensive risk," one government official said in a February 1987 speech. "The general public need not be alarmed."

Policies and programs established during the 1980s reflected this view of AIDS as a disease of foreigners and other "outsiders." Convicts and injecting drug users were tested for HIV before they could donate blood. Physicians were required to report AIDS patients and those infected with HIV by name to the Ministry of Public Health, and immigration law was amended to prohibit entry of anyone who had AIDS or was HIV-positive.

"The disease was blamed on foreigners, intravenous drug users and homosexuals, and activities carried out by the government were targeted toward these communities," the AIDSCAP report notes. "Once AIDS became associated with these marginalized groups, it was very difficult to alter that perception."

But in 1987, Cha-on Suesem began to change the Thai perception of AIDS as a disease of "outsiders." A factory guard who became infected by HIV through a blood transfusion in 1986, Cha-on agreed to speak to reporters, appear on televised talk shows, and visit offices and other workplaces to talk about his experiences. The nation witnessed his rapid decline on national television and the front pages of national newspapers.

The AIDSCAP study identifies Cha-on's case as one of the most influential events in the evolution of Thailand's AIDS policy. Like the actor Rock Hudson, who made AIDS a household word in the United States, Cha-on brought the threat of HIV infection home to mainstream Thai society.

Toward Acceptance

After Cha-on spoke out, government efforts to downplay the significance of AIDS had to compete with society's demand to know more about the virus and the epidemic. This demand led to public release of the results of the government's first round of HIV sentinel surveillance surveys in 1989.

The most startling finding -- that in June 1989, 44 percent of all sex workers in the brothels of the northern city of Chiang Mai were HIV-positive -- was actually leaked to the press by government epidemiologists who braved the disapproval of their superiors. The news spread throughout Thailand and had a far-reaching impact on the sexual behavior of Thai men.

The Chiang Mai findings shocked the Thai population because they revealed that HIV had taken hold in the large commercial sex networks of northern Thailand. "The explosive epidemic in brothels whose patrons are mostly Thai was a prime factor which shifted the scope of policy inward to Thai men instead of outward to the red light zones with foreign customers," a government official told the researchers.

Concern over the Chiang Mai findings eventually led to outreach programs for sex workers, distribution of free condoms in brothel bedrooms, and the Thai government's well-publicized "100 Percent Condom" policy requiring condom use in brothels.

Data from surveys of sentinel populations, including pregnant women, men being treated for STDs, blood donors, injecting drug users and sex workers, enabled an assessment team from the World Health Organization's Global Programme on AIDS to make the first accurate estimates of the number of HIV infections in Thailand in 1990. The next year, epidemiologists from government, NGOs and academia reached a consensus that 300,000 Thais had been infected by mid-1991.

As sentinel surveillance data and caseload estimates made it increasingly clear that HIV/AIDS was spreading rapidly among the general population, the position of Prime Minister Chatichai Choonhaven's government shifted toward greater recognition and openness. But the prime minister stopped short of giving HIV/AIDS prevention and control efforts his unconditional support.

"Thai businesses were heavily involved in the government at the time," a government official explained. "The general mood was to avoid discouraging investment and tarnishing the image of the country."

It wasn't until just before he was ousted from power that Chatichai made the government's first clear policy statement about AIDS, saying that HIV/AIDS prevention would be a high priority for his government. Nevertheless, under Chatichai Thailand became the first Asian nation to establish a medium-term (1988-90) AIDS control plan. Although the majority of funding still came from international and bilateral donors, the government increased its commitment to HIV/AIDS from U.S.$400,000 in 1989 to $2.63 million in 1990.

Government Activism

The wealth of seroprevalence data that became available in 1989 and 1990 paved the way for an extraordinary period of government activism against HIV/AIDS under the interim government of Anand Panyarachun. Appointed prime minister after a military coup d'etat in February 1991, Anand selected a cabinet of technocratic activists, including a prominent AIDS activist who was put in charge of the AIDS agenda.

Anand's appointment coincided with public recognition of an explosive HIV/AIDS epidemic among the general population. Ironically, his appointed government was able to adopt far more progressive policies than the democratically elected Chatichai administration. Because Anand and many of his appointees were not politicians, they were not constrained by the need to please various political factions.

"The unusual circumstance of having pragmatic non-partisan technocrats and NGO and academic activists in positions of high government cabinet power with no opposition shows the potential when government and nongovernment forces merge," a university academic noted in an interview with one of the researchers.

Unlike previous administrations, Anand's government was eager to publish HIV/AIDS statistics and worked closely with the media to raise awareness of the epidemic and the threat it posed to Thai society. It thwarted discriminatory AIDS legislation that had been proposed by the previous administration, repealed the ban on immigration by people living with HIV/AIDS, and announced resolutions to restrict arbitrary or compulsory HIV testing.

Three of the most important measures adopted by the Anand government remain cornerstones of Thai AIDS policy today. The prime minister chairs the national AIDS Committee, a national AIDS plan is integrated into the country's five-year development plan, and substantial government support -- now close to $U.S.1 per capita per year -- is committed to AIDS. Since 1991, government funding for HIV/AIDS prevention and care in Thailand has surpassed that of international donors.

Lessons Learned

Many of the forces and political structures that shaped Thailand's public policy response to the HIV/AIDS epidemic are unique. But AIDSCAP and ASEAN staff believe that the Thai experience can be instructive for other nations, particularly those in Asia.

The AIDSCAP report reveals how local and national political and economic interests influence a country's response to the HIV/AIDS epidemic. "Thailand's experience shows how these interests can change with new evidence and new political players," said Bill Rau, AIDSCAP's associate director for policy.

Thailand's extensive sentinel surveillance system enabled a handful of concerned people to detect the emergence of a widespread epidemic, and the findings helped galvanize government action. The research team recommends that sentinel surveillance systems be directed to local sexual networks of people who tend to have many sex partners. Multidisciplinary working groups should be convened to estimate HIV caseloads, and the results should be publicized and endorsed by government and NGOs to maintain the government's credibility and provide a realistic guide for policymakers.

Publication of sentinel survey results by the mass media was one of the most important catalysts for HIV/AIDS policy development in Thailand. The AIDSCAP report emphasizes the importance of an independent media.

"An open and unrestricted commercial mass media gives credibility to government information about the epidemic," a representative of an international HIV prevention agency in Bangkok said. "It provides the only forum for the national policy dialogue necessary to reform societal norms to combat HIV."

The Thai media also played a critical role in publicizing Cha-on's story. As his case dramatically illustrates, nationwide publicity of an individual's experience with HIV/AIDS -- with his or her informed consent -- is an effective way to personalize HIV for society. In Thailand and other countries, courageous individuals who have given the epidemic a human face have built support for compassionate rather than punitive prevention policies and programs.

The report notes that such policies are not necessarily prerequisites for effective programs. In Thailand an AIDS policy was not formally announced until mid-October 1992, after the principal elements of the country's prevention program were in place.

The lesson to be learned, the researchers conclude, is that sound programs can foster constructive policy. "Since formal policy may only emerge after programs are mounted," the AIDSCAP report says, "the lack of policy should never be an excuse to delay the launch of a prevention program."

In addition to refuting the assumption that progressive policies led to strong prevention programs in Thailand, the researcher team criticized the country's much-touted multisectoral approach to HIV/AIDS prevention as "a crude attempt at centralized multisectoralism." The true model was developed independently by an enterprising group of four government and NGO staff in Pitsanuloke province, suggesting that implementation of a multisectoral approach to HIV/AIDS prevention should begin at the community -- not national -- level.

On the other hand, Thailand's experience does support the widely held belief that policy development should be a joint effort of government officials and representatives of the NGOs with daily experience in AIDS prevention and care. The collaboration between AIDS advocates inside and outside of government during the Anand administration, the report says, shows that "constructive policy for HIV prevention emerges most rapidly when nongovernment and government resources are merged."

The report, The Evolution of HIV/AIDS Policy in Thailand 1984-1994, is available from AIDSCAP's Policy Unit as Policy Working Paper #5.

-- Kathleen Henry