Author: Janjaroen, W. S.; Khamman, S.
Thailand is widely acknowledged to have effectively contained its HIV/AIDS epidemic. Despite the country's success in reducing the number of new HIV infections over the last decade, however, infection of females by husbands and children by mothers has gradually increased. Studies suggest that approximately 4,000 Thai children contract HIV each year. By the end of 2000, some 47,000 children had died of AIDS, another 63,000 children were HIV-positive, and a total of 109,000 children under the age of 15 had lost their mothers to AIDS-related illnesses. By 2005, the number of children in the latter group will have risen to 232,000.
Purpose / Objective
This report examines the following issues: (1) the long-term socio-economic impact of HIV/AIDS on children and Thailand's policy responses in the areas of prevention, treatment and mitigation; (2) lessons learned in Thailand that might be applicable in other countries around the world; and (3) appropriate policy recommendations derived through consultation with key informants, a review of current literature, and the research team's own conclusions.
This study was conducted as a desk review supplemented by qualitative research in specific areas. Provinces with the highest incidence of HIV/AIDS were selected: Payao Province in the North, Khon Khaen Province in the Northeast, Rayong Province in the East, and Phuket Province in the South. Target groups included support service providers (public and private providers as well as NGOs and communities) and people living with HIV/AIDS. The sample size was 15 people for each group per province (for a total of 150 samples).
Sampling was undertaken by the research team at area hospitals, NGO offices, and public health offices with the full consent of all concerned. Provider groups were asked to comment upon: (1) service and resource management, work cooperation, and referral system between units; (2) the socio-economic impacts of HIV/AIDS on infected children, infected/non-infected orphans, abandoned children who had lost one or another of their parents to AIDS and had no other relatives; discrimination against and stigmatization of children with infected parents; and (3) the appropriateness and effectiveness of HIV/AIDS prevention and control programs, including proposals to minimize problems.
The recipient group consisted of people from households that had lost a member of the family to HIV/AIDS and households that had HIV-positive members, as well as relatives and community members whose lives had been affected by the HIV epidemic. For recipient groups, discussion centered upon welfare services and social/economic assistance obtained from various funding sources. Other topics included the impact on children's education, recognition from social, community and peer groups, employment discrimination and the types of assistance that the government and other agencies ought to be providing.
Key Findings and Conclusions
As of 30 June 2001, some 172,760 AIDS cases had been recorded in Thailand. Of these, 47,798 cases have died. Over the course of the epidemic, the infection pattern has changed. Calculated as a percentage of all cases, the number of males infected by sharing needles increased from 5% in 1990 to 18% in 2000 and is projected to rise to 30% by 2005. Most will be in the 25-45 year old age bracket. Meanwhile, the number of infected non-sex worker females as a percentage of all cases is projected to decrease from 42% in 2000 to 29% in 2005.
The most disturbing pattern is among children. As a percentage of all cases, the number infected by mothers has risen from 6% in 1995 to 14% in 2000 and will increase to 29% in 2005. As a result of AIDS-related deaths, the number of orphans also increased from 15,400 in 1997 to 23,400 in 2001. NESDB projections suggest that 63,000 children were infected with HIV and 47,000 had died of AIDS by late 2000. It also estimated that 232,000 children under the age of 15 will have lost their mothers to the disease by 2005.
Policy responses have evolved over time from an initial focus on health (1984-1990) to take into consideration social factors (1991-1996) and relevant aspects of civil society (1997-2001). Since the Eighth National Economic and Social Development Plan, planning efforts have taken a "holistic approach," building the capacity of communities to participate in the development process. The results of these efforts have been dramatic; the most recent epidemiological model showed that the annual number of new infections declined by more than 80% after peaking in the early 1990s.
The government AIDS budget increased until 1996 and, thereafter, fell slightly as a result of the economic downturn. The average budget for the period was around 1,500 million baht per year (Table 2.3). Despite the decline, efforts were made to keep the budget for maternal and child health and HIV/AIDS activities at FY 1997 levels. The government also recognized the importance of NGO and CBO involvement in HIV/AIDS prevention and control by allocating additional funds to such organizations.
AIDS awareness campaigns, educational efforts, and the promotion of condom use have been core components of the battle to control the epidemic. Campaigns to end discrimination and win greater acceptance for PHA were later introduced to alleviate suffering. Policy responses were gradually expanded to take into account social and developmental factors that had an immediate bearing upon the adoption of 'at-risk' behavior. Still, policy continued to be formulated from the top down, with each ministry taking responsibility for its own target groups. Although prevention efforts had been comparatively successful, a need remained to increase the participation of communities, PHA, and other groups affected by HIV. Subsequently, however, NGO-government partnerships at the local level have begun to develop appropriate linkages between programs and services by providing joint training of counselors, educators, and trainers.
Although efforts to control the AIDS epidemic are heading in the right direction, some adjustments are needed to deal with the changing nature of the problem. While estimates suggest that the number of AIDS cases in Thailand will not increase, the disease continues to have negative repercussions for many families, communities and society as a whole. Current and future infections will result in significant income losses and reduced household savings. PHA and their family members also continue to face a degree of social discrimination. To prevent the disease and alleviate AIDS-related suffering, it is still necessary to improve public awareness and understanding while enhancing the cooperation of all sectors in the society.
1. The commitment of national leaders at the highest levels is required for effective action. Political leaders must recognize the devastating scale of the epidemic and be willing to discuss openly the enormity of the HIV/AIDS problem.
2. Social capital and civil society are also important ingredients for success. In Thailand, key actors have emerged not only from the public sector but also the private. NGOs, communities, religious groups as well as families have all played a significant role in caring for PHA and mitigating the impact of HIV/AIDS. Having recognized their vital role in assisting vulnerable people in communities, the government has encouraged local people to form such groups by providing financial and technical support.
3. Effective programs lead to effective outcomes. Pilot programs can, and should, be employed to demonstrate effective outcomes before national policy is formulated. Policy, in turn, should take shape as a result of operational research and evidence-based decision making.
4. A people-centered approach to program development should also be adopted. At the core of this approach is the idea that a solution cannot be one-sided. To the contrary, its underlying premise is that societies and environments are comprised of complex and delicately balanced relationships, linkages and networks that must be taken into careful consideration. The importance of doing so, in addressing the AIDS problem, can be seen from the fact that PHAs suffer not only a serious medical problem but also economic vulnerability and social discrimination.
As a cure for HIV/AIDS has yet to be found, attention should be placed upon prevention programs, especially for individuals in high-risk groups such as MTCT, teenagers, and intravenous drug users. Preparations should be made to cope with the increasing problems of orphans and abandoned children.
There should be a national policy for strengthening the capacity of the government, communities, and families to provide a supportive environment for orphans infected by HIV/AIDS. It should include the provision of appropriate counseling and psychosocial support. A strategy should also be adopted to ensure non-discrimination and equal rights.
Develop counseling and mental care services to address the specific problems of target groups. This includes providing professional counseling on a regular basis and providing counseling training to government personnel and volunteers (family and community counseling volunteers). Establish a risk factor warning system at the community level so that risk groups can be assisted in a timely manner.
Further research and development is crucial. The aim should be to make HIV vaccines and HIV/AIDS-related drugs more readily available and affordable for those who need them. Encourage the development of national and international research infrastructure, laboratory capacity, improved surveillance systems, and improved data collection, processing and dissemination.
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HIV/AIDS - Situation Analysis