An excerpt from UNAIDS publication - 100pcCUP (CONDOM USAGE PROGRAMME) in Thailand
Introduction: A Brief History of the 100% Condom Programme
The urgency of the HIV situation in Thailand
Thailand was the first Asian nation to recognize that it had a major HIV/AIDS problem, a problem so serious as to deserve priority on the national agenda. While sporadic testing among female sex workers, injecting drug users (IDUs), and men having sex with men detected little HIV through the end of 1987, the rapid growth of HIV infections among IDUs in early 1988 spurred efforts to monitor the epidemic systematically.
By mid-1989, a national sentinel serosurveillance system had been established. In the first round of testing in 14 provinces conducted in June 1989, high infection levels were detected among sex workers in the countryÕs northern provinces, especially among sex workers in brothels. By June 1990, with the system expanded to include all 73 provinces, HIV prevalence among brothel-based sex workers had risen from 3.1 per cent in June 1989 to 9.3 per cent nationally (provincial median) and was climbing fast. By June 1991, it had grown to 15.2 per cent. Prevalence was also growing rapidly among young Thai men - who were tested when conscripted into the military at age 21 - from 0.5 per cent in November 1989 to 3.0 per cent in November 1991. Studies of behaviour and HIV infection among these conscripts and other populations soon demonstrated that most new HIV infections in Thailand were occurring through commercial sex.
The programme makes a difference
Initially, many people did not believe the programme would work. For example, reporters from a Thai newspaper went to Chiang Mai in 1991, shortly after the implementation of the programme there, seeking to purchase sex without a condom. To their surprise, they were unable to do so. Small studies have examined the ability to purchase sex without a condom, and have found that most sex workers are quite resistant to the idea. Numerous other studies, as well as questions asked of sex workers during the national sentinel serosurveillance, now routinely find that condom use in brothels and massage parlours exceeds 90 per cent (for a review of these studies, see UNAIDS 1998). These findings imply that the 100% Condom Programme, in combination with other prevention efforts, has been very effective at discouraging unprotected intercourse in establishment-based sex work (Chamratrithirong et al. 1999a).
There are clear indications that these efforts have had an impact on HIV transmission at the national level. Nationwide monitoring of condom use in brothel-based sex work and of levels of reported STDs among men has shown a strong relationship between the increase in condom use and the rapid decline in STDs. Data from studies of army conscripts have shown a steady increase in their use of condoms with sex workers, a decline in the number of visits to sex workers, and a decline in reported histories of STDs and in HIV prevalence. Studies found a tenfold reduction in STD incidence and a fivefold reduction in HIV incidence among young Thai men between 1991 and 1993 (Celentano et al. 1998). Thus, all indications are that the 100% Condom Programme has been an important contributor to large-scale reduction of HIV transmission throughout the country (see UNAIDS 1998).
Best Practice Criteria
This programme meets four of the UNAIDS best practice criteria:
Effectiveness
The 100% Condom Programme has contributed to substantial and well-documented increases in condom use in sex work throughout Thailand. While use rates are not 100 per cent, they do exceed 90 per cent in many direct and some indirect sex establishments. The programme has had somewhat less success in some harder to reach indirect sites, but condom use rates in these sites are still substantially higher than they were before the start of the programme. Given the role of sex work in HIV transmission in Thailand, and how well the increases in condom use in sex work mirror the major reductions in STDs and HIV incidence observed in the country, this programme has clearly assisted in efforts to control the HIV/AIDS epidemic (UNAIDS 1998). In concert with the National AIDS Education and Condom Promotion Campaign, this programme has also contributed to observed prevalence declines of HIV among young Thai men, pregnant women, and sex workers on a national scale.
Other complementary programmes aimed at young people and the general population also increased condom use in non-commercial sexual relationships. This is especially important because of a shift in sexual behaviour away from commercial sex towards more casual sex. In 1997, a survey showed that condom use with girlfriends had risen to 40% and with other women to more than 60% (see Table 1). In a survey in 1990 (Sittitrai et al. 1992), consistent condom use with non-commercial female partners was closer to 20%, rising to roughly 30% in a survey in 1993 (Thongthai and Guest 1995). That represents a major change in behaviour between 1990 and 1997.
Relevance
The 100% Condom Programme was designed and implemented with a good understanding of both the context and importance of sex work in Thai sexual culture. Rather than trying to eliminate sex work, it chose a pragmatic and cooperative approach of working within the existing institutions to prevent HIV and STD infection. This was strongly in keeping with the traditional non-confrontational nature of Thai society. The programme made good use of existing governmental structures of more than one ministry to enlist the active participation of various sectors of society. Finally, it was aimed at the source of most new infections in the Thai epidemic, as determined from careful epidemiological and behavioural monitoring in the country, making it directly relevant to the local situation. Over time, the shift to indirect forms of sex work has lessened its relevance to the current state of the Thai epidemic, and the programme needs to make greater efforts to find effective approaches for those sites.
Efficiency
Good use was made of existing public health and authority structures and personnel within the country to produce rapid increases in condom use on a national scale and rapid expansion of the programme to national coverage. The activities were implemented according to locally developed strategies, with good monitoring and evaluation of behavioural and epidemiological outcomes using existing sources of STD and HIV data, and in accordance with policies laid out at the national level. While considerable resources went into expanding STD care and promoting and delivering condoms as part of this programme, the benefits in infections averted vastly outweigh the resources invested.
Sustainability
The programme has contributed to changes in norms regarding condom use in sex work and visits to sex workers, changes that are likely to persist. Among young males, condom use in commercial sex is now expected, and reductions have already been seen in the percentage of men visiting sex workers. The programme is sustainable because it was institutionalized within existing national policy, national plan and health infrastructures with strong involvement of people at all levels (national, regional, provincial, and district). In fact, it encourages stronger links between the national, regional, and local efforts because of the technical assistance efforts between the national programme, the RCDCs, and the PPHOs. A strong sense of ownership of the programme was expressed in interviews in almost all provinces, along with a belief that the activities being undertaken were making a difference.
The improved relationships among health workers and owners and managers of establishments have made ongoing activities easier. Finally, the national policy and implementation of the 100% Condom Programme have been functioning since the early 1990s. However, in terms of future sustainability, new strategies need to be developed that can be effective in indirect sites.
Introduction: A Brief History of the 100% Condom Programme
The urgency of the HIV situation in Thailand
Thailand was the first Asian nation to recognize that it had a major HIV/AIDS problem, a problem so serious as to deserve priority on the national agenda. While sporadic testing among female sex workers, injecting drug users (IDUs), and men having sex with men detected little HIV through the end of 1987, the rapid growth of HIV infections among IDUs in early 1988 spurred efforts to monitor the epidemic systematically.
By mid-1989, a national sentinel serosurveillance system had been established. In the first round of testing in 14 provinces conducted in June 1989, high infection levels were detected among sex workers in the countryÕs northern provinces, especially among sex workers in brothels. By June 1990, with the system expanded to include all 73 provinces, HIV prevalence among brothel-based sex workers had risen from 3.1 per cent in June 1989 to 9.3 per cent nationally (provincial median) and was climbing fast. By June 1991, it had grown to 15.2 per cent. Prevalence was also growing rapidly among young Thai men - who were tested when conscripted into the military at age 21 - from 0.5 per cent in November 1989 to 3.0 per cent in November 1991. Studies of behaviour and HIV infection among these conscripts and other populations soon demonstrated that most new HIV infections in Thailand were occurring through commercial sex.
The programme makes a difference
Initially, many people did not believe the programme would work. For example, reporters from a Thai newspaper went to Chiang Mai in 1991, shortly after the implementation of the programme there, seeking to purchase sex without a condom. To their surprise, they were unable to do so. Small studies have examined the ability to purchase sex without a condom, and have found that most sex workers are quite resistant to the idea. Numerous other studies, as well as questions asked of sex workers during the national sentinel serosurveillance, now routinely find that condom use in brothels and massage parlours exceeds 90 per cent (for a review of these studies, see UNAIDS 1998). These findings imply that the 100% Condom Programme, in combination with other prevention efforts, has been very effective at discouraging unprotected intercourse in establishment-based sex work (Chamratrithirong et al. 1999a).
There are clear indications that these efforts have had an impact on HIV transmission at the national level. Nationwide monitoring of condom use in brothel-based sex work and of levels of reported STDs among men has shown a strong relationship between the increase in condom use and the rapid decline in STDs. Data from studies of army conscripts have shown a steady increase in their use of condoms with sex workers, a decline in the number of visits to sex workers, and a decline in reported histories of STDs and in HIV prevalence. Studies found a tenfold reduction in STD incidence and a fivefold reduction in HIV incidence among young Thai men between 1991 and 1993 (Celentano et al. 1998). Thus, all indications are that the 100% Condom Programme has been an important contributor to large-scale reduction of HIV transmission throughout the country (see UNAIDS 1998).
Best Practice Criteria
This programme meets four of the UNAIDS best practice criteria:
Effectiveness
The 100% Condom Programme has contributed to substantial and well-documented increases in condom use in sex work throughout Thailand. While use rates are not 100 per cent, they do exceed 90 per cent in many direct and some indirect sex establishments. The programme has had somewhat less success in some harder to reach indirect sites, but condom use rates in these sites are still substantially higher than they were before the start of the programme. Given the role of sex work in HIV transmission in Thailand, and how well the increases in condom use in sex work mirror the major reductions in STDs and HIV incidence observed in the country, this programme has clearly assisted in efforts to control the HIV/AIDS epidemic (UNAIDS 1998). In concert with the National AIDS Education and Condom Promotion Campaign, this programme has also contributed to observed prevalence declines of HIV among young Thai men, pregnant women, and sex workers on a national scale.
Other complementary programmes aimed at young people and the general population also increased condom use in non-commercial sexual relationships. This is especially important because of a shift in sexual behaviour away from commercial sex towards more casual sex. In 1997, a survey showed that condom use with girlfriends had risen to 40% and with other women to more than 60% (see Table 1). In a survey in 1990 (Sittitrai et al. 1992), consistent condom use with non-commercial female partners was closer to 20%, rising to roughly 30% in a survey in 1993 (Thongthai and Guest 1995). That represents a major change in behaviour between 1990 and 1997.
Relevance
The 100% Condom Programme was designed and implemented with a good understanding of both the context and importance of sex work in Thai sexual culture. Rather than trying to eliminate sex work, it chose a pragmatic and cooperative approach of working within the existing institutions to prevent HIV and STD infection. This was strongly in keeping with the traditional non-confrontational nature of Thai society. The programme made good use of existing governmental structures of more than one ministry to enlist the active participation of various sectors of society. Finally, it was aimed at the source of most new infections in the Thai epidemic, as determined from careful epidemiological and behavioural monitoring in the country, making it directly relevant to the local situation. Over time, the shift to indirect forms of sex work has lessened its relevance to the current state of the Thai epidemic, and the programme needs to make greater efforts to find effective approaches for those sites.
Efficiency
Good use was made of existing public health and authority structures and personnel within the country to produce rapid increases in condom use on a national scale and rapid expansion of the programme to national coverage. The activities were implemented according to locally developed strategies, with good monitoring and evaluation of behavioural and epidemiological outcomes using existing sources of STD and HIV data, and in accordance with policies laid out at the national level. While considerable resources went into expanding STD care and promoting and delivering condoms as part of this programme, the benefits in infections averted vastly outweigh the resources invested.
Sustainability
The programme has contributed to changes in norms regarding condom use in sex work and visits to sex workers, changes that are likely to persist. Among young males, condom use in commercial sex is now expected, and reductions have already been seen in the percentage of men visiting sex workers. The programme is sustainable because it was institutionalized within existing national policy, national plan and health infrastructures with strong involvement of people at all levels (national, regional, provincial, and district). In fact, it encourages stronger links between the national, regional, and local efforts because of the technical assistance efforts between the national programme, the RCDCs, and the PPHOs. A strong sense of ownership of the programme was expressed in interviews in almost all provinces, along with a belief that the activities being undertaken were making a difference.
The improved relationships among health workers and owners and managers of establishments have made ongoing activities easier. Finally, the national policy and implementation of the 100% Condom Programme have been functioning since the early 1990s. However, in terms of future sustainability, new strategies need to be developed that can be effective in indirect sites.
No comments:
Post a Comment