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The Race to Beat AIDS on the Lao-Thai Border |
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Creative prevention activities along the Lao-Thai border show that traditional festivals can offer unique opportunities to raise awareness about HIV/AIDS and promote safer sex. MAY 2003 — During the Boat Race Festival in the Lao People's Democratic Republic (PDR), people throw aside their inhibitions. "Old people say the festival is a time when people are supposed to do mad things, to turn things upside down, so that the gods will stop the rains," a Lao colleague explained. But in several border towns during last year's festival, the antics of some participants surprised even veteran observers of boat festivals. Middle-aged women danced in the streets with condoms, rowers paddled past in T-shirts emblazoned with a condom cartoon character and performers sang about how to avoid the AIDS virus. Condoms and HIV/AIDS prevention messages were a prominent part of the Boat Race festivities held October 26-28, 1996, in the capital, Vientiane, and two other Lao towns across the Mekong River from Thailand. Mass education, condom distribution and outreach activities during the festival marked the launch of an innovative safer sex promotion campaign designed by the AIDS Control and Prevention (AIDSCAP) Project and CARE International to reach people from both sides of the river with timely HIV/AIDS prevention messages and methods. Early Warning The communication campaign in the Lao PDR is one of a number of AIDSCAP projects promoting safer sexual behavior among cross-border populations in Asia. Funded by the U.S. Agency for International Development (USAID) and implemented by CARE, the Lao project targets people who regularly traverse the Lao-Thai border and their sexual partners. Unlike Thailand, the Lao PDR has low rates of HIV infection. The most recent data, from March 1995, show that 59 of the 20,700 people who had been tested for HIV were infected with the virus. But a February 1994 assessment conducted by AIDSCAP and CARE along the Lao-Thai border sounded a warning that Laotians cannot afford to be complacent about the HIV/AIDS epidemic. The assessment report describes a porous border, with hundreds of thousands of tourists, traders, businessmen, truckers, migrant workers and transient tribal minorities crossing from Thailand into the Lao PDR each day. "Due to the dynamics of border movements where people seek entertainment and develop casual and commercial sex contacts among populations in Thailand with high HIV infection rates, the Lao PDR is rapidly approaching the exponential growth phase of the epidemic curve," the assessment team warned. To avert escalation of the HIV epidemic in the Lao PDR, assessment team members recommended a comprehensive set of interventions aimed at reducing sexual transmission of the virus. One of these interventions, the CARE/AIDSCAP communication campaign to encourage sexual behavior change among vulnerable border and urban populations in three provinces, was funded by USAID and approved for implementation by the Lao National Committee for the Control of AIDS (NCCA) in 1996. CARE collaborates with the government and other important sectors of society to realize the project's goals. Project working teams in each province include representatives of CARE, the provincial AIDS committee, the Lao Women's Union, the Youth Union and trade unions. These teams held focus group discussions with members of the target groups to enlist their help in developing effective messages and materials. They also worked with the NCCA and the provincial AIDS committees to determine the best time to launch a safer sex promotion campaign. Festival Time Experience with HIV/AIDS interventions suggests that timing can be crucial to their success, yet the timing of most HIV/AIDS prevention activities is dictated by administrative requirements. Opening and closing ceremonies or launches of new communication materials, for example, usually take place at times convenient for the organizers. Internal scheduling constraints are sometimes unavoidable, but with careful planning it is possible to tie project activities to events of local significance, to greater effect and at little or no extra cost. In the Lao PDR, the traditional festival season following the Buddhist Lent seemed an opportune time for launching HIV/AIDS prevention activities. Although no studies have examined sexual behavior and HIV/AIDS risk during Lao festivals, research in neighboring Thailand suggests that some festivals provide opportunities for HIV transmission. In northern Thailand, sexually transmitted disease rates increase noticeably at the end of April after the three-day Songkran (Thai New Year) celebrations. There are also accounts of commercial sex and casual gay sex being negotiated at temple fairs in rural areas.1 And certain hill tribe New Year celebrations in both Thailand and the Lao PDR are known as occasions for courting and sexual activity. Of course, not every festival is suitable for condom promotion, as HIV/AIDS organizations found when they asked whether they could include a banner in a solemn religious procession during one festival. However, the fairs and dances that accompany such occasions may provide opportunities for discreet and carefully targeted condom distribution. Other religious festivals, such as Thailand's Thod Pa Bam, when Buddhists donate robes and other necessities to monks, have been used to promote the need for care and support of people living with HIV/AIDS. Awk Phansa, the end of the Lenten period of fasting and penitence, signals the beginning of the festival season in Thailand and the Lao PDR. It marks the end of the rainy season and the end of the period when Buddhist monks are confined to their temples. A number of traditional festivals occur after Awk Phansa in the Lao PDR, starting with the Boat Race Festival in late October and ending with the Lao New Year in early April. These occasions are celebrated by feasting, dancing, games and other fun. Part of the fun is drinking -- and sometimes having sex. During the Boat Race Festival, thousands of spectators line the banks of the Mekong River to cheer on teams from different villages and city districts. Both men's and women's teams row long boats in a series of heats culminating in a final race. Before each race, long lines of dancing, joking villagers escort the rowers to their crafts. Some dancers paint their faces and carry phallic carvings. Such festivals provide an opportunity for mass communication as town populations swell with villagers from outlying areas, visitors from other provinces and tourists from other countries. These opportunities are often employed to great advantage by private enterprise: at the most recent Boat Race Festival in Vientiane, for example, huge banners on barges floating mid-river advertised such products as Marlboro and Dunhill cigarettes and B and W whiskey. CARE decided to use the festival to promote a healthier "product" -- safer sex. Different activities were planned for each of the project sites, but in all sites the focus of the activities was, naturally, the Mekong River. Targeted Distribution In Vientiane, a fair is held along the river bank every night during the Boat Race Festival, with bands performing at open-air dance floors. It would have been possible to hand out condoms to fairgoers or to the crowds watching the races, but a limited supply of condoms was available. Taking their cue from a study that questioned the value of mass condom distribution during carnival celebrations in São Paulo, Brazil (only 9.7 percent of participants reported engaging in risky behavior during the festivities),2 project planners worked with the NCCA secretariat to devise a strategy that would get condoms to those who needed them most. CARE staff made cardboard "point of sale" display boxes bearing the campaign logo, filled them with condoms and placed them in men's toilets at drink shops, restaurants and nightclubs near the river during the festival. In some cases, male CARE staff members stood by the display to explain why the condoms were there and how to use them. The outreach and condom distribution was conducted at the start of the festival each day, where possible before the nightspots began to fill up, and at intervals during the evening. The condoms were well-received by male and female bar workers, band members, announcers, management and clients alike. As CARE staff arrived at one nightclub, workers crowded around to find out what they were carrying. Upon learning that it was a box of condoms, all the men and some of the women immediately demanded their share. The club owner helpfully instructed his employees to leave the condoms in the display boxes for patrons because condoms would be distributed directly to staff. Two hours later, club employees greeted CARE staff with smiles and laughter, announcing that almost all the condoms were gone. By this time it seemed that condoms had become the theme for the evening. The master of ceremonies was making announcements from the stage about using condoms and said that he would sing a song of his own composition about them. He proffered free condoms on stage to anyone who wanted them. Amid clapping and cheering from staff and other patrons, two men walked up from the table where they had been sitting with friends and bar girls to claim their condoms. One bar patron told a CARE worker that he deeply appreciated such efforts to protect peoples' health. The simple logo and message designed for the Boat Race Festival in Vientiane featured a cartoon of a condom in a boat raising a paddle aloft in victory with the message, "Sai Tung Yang Anamai Sana AIDS Touk Hop" (Using a condom you beat AIDS every round). Both were printed on small posters and T-shirts. The most memorable display of the logo occurred when some members of a village women's group wore the T-shirts as they danced their village's team down to the river. (Other members of the group wore T-shirts distributed by the Australian Red Cross or the NCCA.) CARE also provided these middle-aged women with condoms to display during the dance. One of the women had brought two little plastic snakes as part of her "act." This mother of six and grandmother of fourteen nearly collapsed with laughter as she demonstrated putting the condom on over a snake's head. Joining the Race The CARE working teams organized a variety of prevention activities in Huai Sai, a northern Lao town of 40,000 people that lies just across the river from Chiang Rai, one of the Thai provinces hardest hit by HIV/AIDS. Each of the 291 rowers participating in the boat race received and wore a T-shirt printed with a condom cartoon and an HIV/AIDS awareness message. During the races every rower had a large cartoon condom on the back of his or her T-shirt, recognizable from a considerable distance. T-shirts were distributed before the festival to members of the project's specific target groups: 66 drivers of samlors and tuk-tuks (local variations of the motorized rickshaw) and 55 speedboat drivers. While they were distributing the T-shirts, CARE staff ran entertaining HIV/AIDS educational sessions for groups of about ten drivers at a time, using group discussions and playing games to teach the men how to prevent HIV transmission. The condom rower logo appeared around town on photocopies made by CARE staff and posted in small drink shops, restaurants and public places along the riverbank. Some tuk-tuk drivers asked for copies of the poster to display on their vehicles. On the day of the festival, Huai Sai was a sea of HIV/AIDS T-shirts worn by the Boat Race Committee members, heads of provincial government departments, rowing teams and drivers. Race announcers read HIV/AIDS prevention messages over the public address system. Many people were heard to remark on "the AIDS explosion." In fact, at the illuminated boat festival, where small decorated "boats" carved from banana tree trunks are floated down the river, the winning boat bore an AIDS logo carefully copied from the image on the T-shirts, although the entrants had not been part of any of the education sessions. At the third project site, Pakse in the southern province of Champassak, the rowing teams were also decked out in condom T-shirts. The drama troupe of the Provincial Department of Information and Culture performed for race spectators, and songs with prevention messages were sung at an open-air concert by the river, reflecting the southerners' traditional skills and interest in music. Encouraged by the enthusiastic response to these activities during the festival, the Pakse project working team planned outreach and education visits to factory workers at the end of each month. Visits are scheduled to coincide with pay day, which workers have acknowledged is the time they are most likely to go out for a night on the town. The teams in each project site continue to make links with local events wherever appropriate. During the 1997 celebrations of the International New Year, for example, two safer sex posters produced for bar workers and patrons were handed out as New Year gifts. More research is needed to understand the potential role of festivals and other celebrations in HIV/AIDS prevention. But it was evident that the project working teams were able to make the most of opportunities offered by the Boat Race Festival in the Lao PDR, reaching large numbers of people with prevention education, condoms and advice on safer sex at times and places where they were most likely to be applied. -- Prudence Borthwick References
Prudence Borthwick, coordinator of the HIV/AIDS and International Development Network of Australia (HIDNA), served as health advisor to the CARE/AIDSCAP/NCCA project in the Lao PDR for four months in 1996. From 1993 to 1995 she worked with the Northern AIDS Prevention and Care Programme in Chiang Mai, Thailand.
HIV/AIDS prevention projects in many countries have targeted transport workers, military troops and other populations whose transient life styles seem to make them particularly vulnerable to HIV infection. Such projects usually promote individual behavior change. But results from a series of studies sponsored by the AIDS Control and Prevention (AIDSCAP) Project suggest that the environment that these mobile populations encounter on their travels may be a more significant HIV risk factor than their own attitudes or habits. Since 1994, AIDSCAP has commissioned five studies of mobile populations in border areas in Asia to assess their level of risk for HIV and identify opportunities for prevention interventions. Studies were conducted in port towns in Papua New Guinea, fishing ports and land crossings along the Thai-Cambodian border, truck crossings between India and Nepal, port cities connecting Indonesia and the Philippines, and river trade routes and land border crossings between Thailand and the Lao PDR. The initial focus of the assessments was the mobile populations found in these border-crossing areas. But as the results from the various studies accumulated, an interesting hypothesis began to emerge: Perhaps it is the atmosphere of a border-crossing, more so than a traveler's motivation, that encourages uninhibited behavior. All five studies found a distinctly higher concentration of options for risk behavior in the border-crossing areas than in other urban locations farther from international borders. These include a multitude of low-cost drinking establishments and opportunities for low-fee commercial sex. The common wisdom holds that mobile men with money are prone to engage in HIV and STD risk behavior along their routes of travel. However, the destinations along the way may act as transmission zones where multiple, anonymous partner sharing is intense. This phenomenon is even more apparent at a border crossing than in an average trade town. Are individuals with a tendency toward risk behavior attracted to migratory lifestyles, or does an environment remote from family, community and law enforcement encourage such behavior in otherwise low-risk individuals? Both explanations may apply -- any single answer to this question would be a simplification of a complex situation. What we can say is that in addition to prevention activities for individuals on-the-go, there is a need for more contextual interventions that address the risk environment in cross-border sites. Examples of possible structural interventions in these locations include:
These interventions could be costly. However, if -- as suggested by the AIDSCAP findings -- more HIV transmission per capita occurs in these border zones of high risk than in other areas, then the cost per infection averted could be attractive to national and regional prevention programs. |
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