FHI - Bridging Borders in Southeast Asia: The Politics of HIV Prevention for Women

The personal is political. This feminist rallying cry, born in the 1960s, has for decades expressed a core idea for women: that personal struggles—within the family, within relationships, within society and the workplace—are universal experiences for women that can become a catalyst for political action.

Exploring the political aspects of an issue as personal as protecting oneself from AIDS was the focus of a unique gathering, the first-ever interregional workshop on HIV prevention for women and their families to examine the need for cross-border solutions. Held in Chiang Mai, Thailand, from July 3 to 7, the "Women, Family and AIDS Prevention" workshop included representatives from bordering nations in Southeast Asia: Laos, Thailand, Cambodia, Vietnam and China.

Hosted by the Women's Studies Center of Chiang Mai University and funded by the AIDS Control and Prevention (AIDSCAP) Project, the Ford Foundation and the United Nations Fund for Population (UNFPA), the workshop examined gender-power relations, regional economic interdependence, national policies, community responses, family responsibilities and social and cultural expectations, placing the daily lives and struggles of Southeast Asian women and their families within a political context. The goal: to develop ways to help women—and men—actively fight the epidemic both at home and across borders.

"Where does political will come from?" asked one participant, Nimalka Fernando, coordinator of the human rights desk of the Asia Pacific Forum on Women, Law and Development. "How do you motivate it at the community level in a way that includes women?"

Each of the invited countries sent a three-person delegation spanning the professional world of HIV/AIDS prevention: an academic researcher, a representative from a nongovernmental organization (NGO), and a public health specialist. In most cases, representatives from the same countries had not worked together before. Despite language barriers, participants from different countries involved in similar disciplines often found common ground in their work.

The Growing Crisis

The multinational character of the workshop reflected the kind of cross-border response that is now needed to stem the virus as it spreads across Asia. Many international health experts fear that, with its huge population, high rates of sexually transmitted diseases and flourishing commercial sex industry, Asia could become the epicenter of the epidemic in the next century. The workshop enabled participants to examine how HIV is crossing borders, cultures, languages and nationalities to affect communities and families throughout the continent, including an ever-growing number of women.

Thailand, Laos, Cambodia, Vietnam and China's Yunnan Province are neighbors. Regional economic growth, new trade initiatives and the growing openness between countries—as well as ongoing internal and international strife—have led to increased movement of people across their borders. The new Friendship Bridge across the Mekong River between Thailand and Laos is a striking symbol of the expansion of trade and collaboration. But as goods move across this bridge, so do people, and so does the virus that causes AIDS.

A researcher investigating this dynamic reported his findings to workshop participants. Through an AIDSCAP research initiative, Dr. Anthony Pramualrat of Thailand's Mahidol University had conducted a rapid assessment of activity along the Thai-Cambodian border at three different cross points. At each site, brothels on the Cambodian side served an increasing demand from both the local community and Thai men crossing the border.

Unfortunately, knowledge of how to prevent HIV does not appear to be so mobile. On the Thai side of the border were health outposts with posters and pamphlets about HIV prevention. If you asked people there about AIDS, they could explain how to prevent it.

But at the health outposts just a few kilometers within Cambodia, there was no information on HIV prevention, and few people knew about the virus. Young women in the brothels—most of them Vietnamese—knew nothing about HIV, nor would they have been able to read prevention posters in Khmer and Thai had they been available.

Women's Vulnerability

Changing socioeconomic conditions in the region that directly affect women are largely driving this epidemic. Increasing poverty in rural areas due to a shrinking agricultural land base forces many to migrate to the cities in search of income. Some village families sell their daughters to brokers for urban commercial sex establishments; other young women leave the countryside voluntarily to join the sex industry in order to send money back to their partners and families. Financially, successful sex workers in northern Thailand have often been regarded as role models in their villages: young women who have provided well for their parents and extended families and come back to marry and begin their own homes. It is only now, as these young women return with AIDS, that these practices are being questioned.

Monogamous and married women are also increasingly at risk of HIV infection because of the extramarital sexual activities of their male partners. This population of women is seldom perceived as vulnerable to HIV and is thus rarely targeted by AIDS prevention campaigns. Even when monogamous women become aware of the risk to themselves, they have little power to demand condom use or other safer sex practices by their partners.

Learning from Each Other

The workshop's opening days offered participants sessions exploring gender dynamics and HIV prevention, the changing context of the family in Asian societies, international strategies to incorporate women's rights within the human rights movement, women's networks in Asia, and the experiences of the host country, Thailand, in HIV prevention and care. Participants also exchanged information on the HIV epidemic and prevention activities within their own countries. Finally, members of each profession (researchers, NGO representatives and public health officials) met together to devise action plans for regional collaboration.

But the workshop didn't just stay indoors. Thailand has the most advanced HIV epidemic in Southeast Asia. More than 16,000 people in Thailand have been diagnosed with AIDS, and an estimated 700,000 are thought to be HIV-positive. Northern Thailand, where Chiang Mai is located, struggles with particularly high rates of seroprevalence.

With the surrounding communities as a vast learning laboratory, participants visited hospitals, health departments and various Thai NGOs working in AIDS care and prevention. On these field trips, participants met many people living with HIV or AIDS (PWAs). They spoke to commercial sex workers. They held AIDS orphans. For many of these physicians, public health workers and academics, it was their first experience meeting an HIV-positive person.

Participants were surprised by what they saw and heard. "She was so young. And she's chubby, too." "I'm impressed by how the community and their families have accepted them. I'm impressed by how much PWAs are doing things for themselves."

When participants later shared information on the epidemic in their countries, evidence of the virus' border-crossing abilities appeared again and again. Of the 59 people reported with AIDS in the Lao People's Democratic Republic, most had been in Thailand for trade or business, or were border guards or men who had visited neighboring Thai brothels. In Cambodia, a high percentage of infected people are female sex workers—most of them Vietnamese—who work in brothels along the Thai border. A 1994 study by the Cambodian AIDS Programme found 38% of sex workers in Sihanoukville to be HIV-positive. Nine out of ten infections reported in China are in Yunnan Province, primarily in the three districts sharing borders with Thailand and Burma. Many infections are attributed to drug use in the "Golden Triangle" of Thailand, Vietnam, Burma and Yunnan Province.

The Family Context

The workshop's focus on women within their families reflected the cultural, social and gender realities of Southeast Asia. Western health systems target individuals for behavior change messages to prevent HIV infection, but the lives of Asian women and their ability to remain free from infection cannot be removed from the context of family and community.

For some who attended the workshop, trying to change traditional gender relations in the family to give women greater negotiating power with their male partners was not realistic. Income generation projects for village women in Thailand, designed to offer alternatives to prostitution or to economic dependence on male partners, were regarded with skepticism by participants from Laos, Vietnam and Cambodia, who were pessimistic that such efforts could change fundamental attitudes about gender in their countries.

"Even if a woman earned more money than her husband, it would not change the power relationship," insisted one participant from Laos.

Despite differing views on economic empowerment, workshop participants did agree that HIV care and prevention projects for Southeast Asian women worked best within family and community settings. Thai intervention projects, such as the group Women Against AIDS, that use drama in the communities and schools and make AIDS care and prevention a family and community concern were seen as powerful models.

The Politics of Implementation

The strength of NGOs in Thailand and their close collaboration with the Thai government was both a surprise and an inspiration to participants from neighboring countries. Several representatives spoke of the marginality of nongovernmental efforts in socialist countries, where governments are often suspicious of NGOs and limit their activities.

"In my country, we only have foreign NGOs, and my friends from Laos tell me the same is true there," said a participant from Vietnam. "There are no local NGOs."

The concept of an indigenous women's group with no links to the government was also nearly inconceivable to the Chinese, Cambodian, Laotian and Vietnamese representatives. In their countries, all "women's activities" are handled by the women's union or a related youth union or labor union.

Even as some participants were astonished by the autonomy of Thai NGOs, they were also impressed by the Thai government's own activities in AIDS prevention and care. The coordination of programs from the national to the provincial and community levels seemed particularly remarkable.

Dr. Hehe Chang of the Yunnan Provincial Health and Anti-Epidemic Center suggested sending a Chinese delegation to Thailand to learn about HIV prevention and care strategies.

"Here, people look similar, the villages look similar, and the culture and family structure are similar," she said. "I think we should be learning from one another in the region."

Other programs in Thailand that impressed workshop participants are the HIV surveillance system and the government's "100 percent condom-only" brothel policy, which imposes legal sanctions on brothel owners who do not require their employees to use condoms with all clients. But the possibility of replicating similar programs in neighboring countries seems remote. Chinese participants remarked that the programs created for and initiated by sex workers in Thailand could not exist in China, where laws not only outlaw prostitution but also punish any person or group providing support or information to sex workers.

The independence and collective strength of people with AIDS who have implemented their own support projects was also a surprise. "HIV-positive people in my country do not come together like this—they go back quietly to their homes, " said one participant from Laos. "We don't know how to work with people with HIV," a Chinese participant observed. "We think of managing them and putting them away from us so as not to infect others."

Advocacy Across Borders

As participants examined common issues, they agreed that the essential next step was policy advocacy. Building intergovernmental relationships that foster collaboration, as well as strengthening national programs, was considered critical to slowing the epidemic in the region.

"We need networks for local public health care people along the borders," said Dr. Tawesak Nopakesorn, a Thai military physician involved with the National Economics and Social Board of Thailand.

International lobbying efforts were discussed as an outcome of this workshop, including plans for a policy statement on women, family and AIDS prevention in borderingnations to be drafted at the Fourth United Nations World Congress on Women at Beijing. Nimalka Fernando of the Asia Pacific Forum on Women, Law and Development hopes to incorporate AIDS prevention as a women's issue on the Forum's agenda and facilitate networking on this topic through its international network. A follow-up workshop, "Creating an Asian Network on Women and AIDS," hosted by AIDSCAP at the Third International Conference on AIDS in Asia and the Pacific last September, continued to build the network beyond this five-country region.

Participants discussed the possibilities of creating a health care workers' network within and between countries, publishing a newsletter, creating linkages with national and regional women's organizations, contacting journalists to share the insights of the workshop, and forming both cross-border committees and intersectoral committees that will build relationships between researchers and public health implementers.

In the months since the workshop met, several of these proposals have taken shape. One newsletter has been published. The initiation of cross-border health posts was discussed in late July by Thailand's National Economic and Social Planning Board during its Five Year Plan (1997—2001) proposal development. And in Cambodia, meetings have been held with the Secretariat of States for Women's Affairs and the HIV/AIDS Coordinating Committee to debrief them on the workshop and to further initiate national networking on women and AIDS issues.

This workshop was a first: a first chance for health practitioners and researchers to share experiences across borders, to see how neighboring countries are working to stem HIV, and to discuss how to overcome national and regional barriers to create a comprehensive, regional strategy to protect women from AIDS. If the determination of the participants is any indication, the momentum generated in Chiang Mai can become a model for similar regional efforts on behalf of women in other parts of the world.

-- Kari Hartwig, AIDSCAP/Thailand

Kari Hartwig is a program officer in AIDSCAP's Asia Regional Office in Bangkok.