External review of the health sector response to HIV/AIDS ... · EXTERNAL REVIEW OF THE HEALTH SECTOR RESPONSE TO HIV/AIDS IN THAILAND. A joint publication of the Ministry of Public

Ministry of Public HealthGovernment of Thailand

A joint publication of the Ministry of Public Health,

Thailand and the World Health Organization,

Regional Office for South-East Asia

EXTERNAL REVIEW OF THE HEALTH SECTOR

RESPONSE TO HIV/AIDS IN THAILAND

A joint publication of the Ministry of Public Health, Thailand and the WorldHealth Organization, Regional Office for South-East Asia


EXTERNAL REVIEW OF THE HEALTH SECTOR RESPONSE TO HIV/AIDS IN

THAILAND

7-19 August, 2005

© WWorld HHealth OOrganization 22005Publications of the World Health Organization enjoy copyright protection inaccordance with the provisions of Protocol 2 of the Universal Copyright Convention.For rights of reproduction or translation, in part or in toto, of publications issued by theWHO Regional Office for South-East Asia, application should be made to the RegionalOffice for South-East Asia, World Health House, Indraprastha Estate, New Delhi-110002, India.

The designations employed and the presentation of the material in this publication donot imply the expression of any opinion whatsoever on the part of the Secretariat of theWorld Health Organization concerning the legal status of any country, territory, city orarea or of its authorities, or concerning the delimitation of its frontiers or boundaries.

Printed in India

ISBN 92 9022 265 7(NLM classification: WC 503.6)

““We are living in the AIDS era. There is no doubt that history

will record our response. There is no time for complacency;

no time to rest on our laurels. It would be a crime to let HIV

continue to spread, while we already know how to interrupt

it. It would be an even greater crime to let people suffer

from AIDS, without access to treatment, while effective

medicine is readily available.

His Excellency Thaksin Shinawatra, Prime Minister of

Thailand at the Opening Ceremony of the XV International

AIDS Conference, Bangkok, 11 July 2004.

1. Executive summary 12. Introduction 63. The status and trends of the human immunodeficiency

virus (HIV) and related epidemics 9Recommendations 12

4. Policy, structures and programmes 134.1 Budget and finances 134.2 Effect of health care reform 14

4.2.1 Decentralization 154.2.2 The 30 Baht scheme and health service restructuring 16

4.3 Human rights 174.4 Non-governmental organizations (NGOs), community-based

organizations (CBOs), and people living with HIV (PHIVs) 194.5 Private sector 204.6 Other government agencies 204.7 International cooperation 214.8 Knowledge management 22

Recommendations 225. Maintaining control of the epidemic - HIV prevention priorities 24

5.1 Sustaining proven interventions with sex workers and their clients 25

5.2 Extending HIV prevention to drug users 265.3 Reaching men who have sex with men (MSM) 275.4 Accessing migrant and mobile populations 275.5 Behavioural change among young people 285.6 Reducing transmission to regular partners 295.7 Bringing together the prevention package 29

Recommendations 30

TABLE OF CONTENTS

6. Access to services 326.1 Thailand's national sexually transmitted infections (STI)

control programme 326.2 Prevention of mother-to-child transmission (PMTCT) plus 336.3 Voluntary counselling and testing (VCT) 346.4 HIV/AIDS care 356.5 Tuberculosis (TB) and human immunodeficiency virus (HIV) 38

Recommendations 397. Monitoring and evaluation (M&E) system 42

7.1 Systems in place 427.2 Development of one integrated national monitoring

and evaluation (M&E) system 437.3 Knowledge management and research 44

Recommendations 458. Moving forward 479. Annex 1: Review team members and facilitators 5010. Annex 2: List of institutions and persons met 5211. Annex 3: List of main documents consulted 5612. List of annexes in electronic format 58

AIDS acquired immunodeficiency syndrome

ANC antenatal care

ART antiretroviral therapy

ARV antiretroviral

ASO AIDS Services Organisation

BATS Bureau of AIDS, TB and STIs

CBO community-based organization

CCC comprehensive and continuum of care

CRN Clinical Research Network

CSMBS Civil Servant Medical Benefit Scheme

DDC Department of Disease Control

DOH Department of Health

EDL Essential Drugs List

FDC fixed dose combination

GDP gross domestic product

GFATM Global Fund to Fight AIDS, TB and Malaria

GPO Government Pharmaceutical Organization

HIV human immunodeficiency virus

IATEC International Antiviral Therapy Evaluation Centre

IDU injecting drug user

IEC information education communication

IHPP International Health Policy Program

ILO International Labour Organisation

M&E monitoring and evaluation

ACRONYMS

viiAcronyms

MCH Maternal and Child Health

MOD Ministry of Defence

MOE Ministry of Education

MOL Ministry of Labour

MOPH Ministry of Public Health

MOSW Ministry of Social Welfare and Human Security

MSF Médecins Sans Frontières

MSM men having sex with men

MTCT mother-to-child transmission

NAA National AIDS Account

NAC National AIDS Committee

NACP National AIDS Control Programme

NAPHA National Access to Antiretroviral Programme for People withHIV/AIDS

NCHECR National Centre in HIV Epidemiology and Clinical Research,Australia

NESDB National Economics and Social Development Board

NGO non-governmental organization

NNRTI non-nucleoside reverse transcriptase inhibitors

NRTI nucleoside reverse transcriptase inhibitors

NVP Nevirapine

OI opportunistic infections

PATH Program for Appropriate Technology in Health

PCR polymerase chain reaction

PCU primary care unit

PHAMIT Prevention of HIV/AIDS in Migrant Workers in Thailand

PHIMS Perinatal HIV Implementation Monitoring System

PHIV people living with HIV/AIDS

PI protease inhibitor

viiiExternal Review of the Health Sector Response to HIV/AIDS in Thailand

PMTCT prevention of mother-to-child transmission

RTG Royal Thai Government

SSS Social Security Scheme

STI sexually transmitted infection

SW sex workers

SWING Service Workers In Group

TB tuberculosis

TBCA Thai Business Coalition on AIDS

TNCA Thailand NGO Coalition on AIDS

TNP+ Thailand Network of People living with HIV/AIDS

TRC-ARC Thai Red Cross AIDS Research Centre

TUC Thai MOPH - U.S. CDC Collaboration

UNAIDS Joint United Nations Programme on HIV/AIDS

UNICEF United Nations Children's Fund

UCS Universal Coverage Scheme

VCT voluntary counselling and testing

VMI vendor management inventory

WCF Workmen's Compensation Fund

WHO World Health Organization

WHO SEARO World Health Organization South East Asia Regional Office

ZDV zidovudine

From 7 to 19 August, 2005, anInternational Review Teamcommissioned jointly by the Ministry ofPublic Health (MoPH) of the Royal ThaiGovernment and the World HealthOrganization (WHO) conducted anassessment of the performances of thenational health sector response tohuman immunodeficiency virus/acquiredimmunodeficiency syndrome (HIV/AIDS)in Thailand. The team found that one ofthe important features of the responsewas its success in scaling up initialprojects which were geographically-limited and narrowly-focused to the levelof national initiatives. These initiativesbenefited from strong politicalcommitment, dynamic management,dedicated human resources, multiplealliances between formal and non-formal sectors, significant funding andprominent leadership provided by anever-growing number of diverse non-governmental and community-basedorganizations. Building on an initialemphasis on prevention, access toantiretroviral therapy is now expandingwith great rapidity. The team concluded that the national goal oftreating 80,000 persons by the end of2005 was achievable.

The first case of AIDS in Thailand wasdiagnosed in 1984. Since its inception in1987, the National AIDS ControlProgramme (NACP) has achieved greatstrides; it has accumulated a vastrepertory of experience and served as asource of learning and inspiration to alarge and growing number of countriesaround the world.

The combined prevention and careresponse has generated considerabledividends. The spread of HIV has slowedsignificantly in most communities, andbehaviours have responded sensitively toan aggressive campaign of informationand education as well as availability ofaccess to services, condoms and support.Although the stigma attached to HIV/AIDSstill persists, the public discourse aboutsexuality and sexual health has becomemore open and objective.

Thailand has already lost more than551,000 of its young people to AIDS.Every life that can be saved throughappropriate treatment among the540,000 people who currently live withHIV infection in the country counts. Theexpanding access to antiretroviralmedicines and the mobilization of

EXECUTIVE SUMMARY

1

financial and human resources on a largeand growing scale, both in the formalsector and within civil society, areconsiderably beneficial to the peopleliving with HIV as well as their families,communities and the nation as a whole.The prevention of perinatal transmissionof HIV is now being implemented withgreat success throughout the country.

HIV transmission fell rapidly in the 1990sas a result of the strong focus onprevention. It has been estimated thatover 5.7 million HIV infections have beenaverted thus far through effectiveprevention. In spite of these efforts,however, in 2004, about 17,000 peoplein Thailand were newly infected with HIV.Although this figure is lower than inprevious years, the following signsindicate that the HIV epidemic isthreatening to rebound:

The annual number of newinfections is no longer declining asrapidly as it did in the last decade.

One-third to half of the new HIVinfections this year (2005) will beamong women who are in a stablerelationship and yet will becomeinfected by their spouses or regularsexual partners.

Adolescent boys and girls engage inrisk behaviours more frequently thantheir peers did a few years ago,exposing themselves to HIV infection.

The achievements of the 100%condom programme are beingchallenged by an insufficientoutreach effort to sex workers (SW),the changing profile of sex work in Thailand, and inadequatecondom supplies.

There are signs of increased risk ofHIV infection among men having sexwith men (MSM), transgender, andother marginalized populations,including minorities, immigrants andtheir dependents, prisoners and drug users.

There is a rise in certain sexuallytransmitted infections (STI) as aresult of relocating diagnosis andtreatment clinics to hospitals whichsex workers are reluctant to attend,resulting in a lowered adherence tosafer sex practices and insufficientsupplies of condoms.

The International Review Team presenteda series of findings andrecommendations as well as specificsuggestions for further considerationand action to the Ministry of PublicHealth, Thailand. These were dividedinto five major programme areas: (1)status and trends of the HIV and relatedepidemics; (2) policy, structures andprogrammes; (3) prevention; (4) careand treatment; and (5) monitoring andevaluation (M&E).

2External Review of the Health Sector Response to HIV/AIDS in Thailand

Moving forwardIn two decades of innovations and hardwork, Thailand has accomplished greatprogress towards bringing the spread ofHIV under control and mitigating itsimpact on individuals infected andaffected by the epidemic. No praise isenough for those who, over the years,have devoted and often sacrificed theirpersonal and professional life to thispowerful movement which has mobilizedpeople, communities and the nation as awhole. Today, the results of this effortspeak for themselves in terms of both thenumber of HIV infections averted throughwell-targeted prevention and years ofhealthy life assured by making treatmentincreasingly available. Importantly, theseresults have created a sense ofconfidence, both within Thailand andabroad, that the HIV/AIDS epidemic canbe overcome when leadership, science,social mobilization and resources arebrought to bear all at once.

It should be noted, however, that thenational response to HIV is also confrontingseveral changed realities (described below)to which it must rapidly adjust.

There are clear signs that theepidemic is pursuing its course,unabated, in specific communitiesof sex workers that have not been orare no longer being reached byprevention approaches suited totheir needs. As a result, the

epidemic threatens to regainmomentum in communities wherecomplacency has set in - amongyoung people, in particular. Itappears to be on the rise in certainpopulations, such as men havingsex with men (MSM), and hasbecome harder to track incommunities driven underground,such as injecting drug users (IDUs).

The urgent scaling up of access totreatment, while essential, isovershadowing the criticalimportance of enhancing preventionsimultaneously with care.

There is a general feeling that theresponse to HIV has moved from apeople-centered approach to apatient-centered approach, driftingaway from the mobilization of forceswithin society for the prevention of thedisease to a more clinical focus oninfection after the disease has set in.

The current and planned investments incare are highly commendable and shouldbe further expanded to best respond tothe growing demand. This investment inhealth and survival makes sense in bothhuman and economic terms. Every HIVinfection prevented alleviates muchsuffering and forestalls costly medicalinterventions in the future. It is, therefore,important to recognize that themovement which has led to behavioural

3Executive Summary


change and a gradual, although slow,disappearance of stigma attached to HIVneeds to be revitalized.

The opportunities and reasons torevitalize the response to the epidemic inthe current context of Thailand are many.Some of them are as follows:

Under the leadership of Government,the expressed national commitmentto this developmental priority shouldreturn HIV to the center of the public debate.

The political and administrativedecentralization under way shouldbring HIV work closer to the people,with a systematic capacity buildingat the local level while the centerretains key enabling, supervisoryand research functions andoperates monitoring and earlywarning systems needed to detectany breakdown in services as thedevolution of responsibilities to theperiphery unfolds.

The health reform shouldspecifically take HIV into accountand ensure that both preventionand access to care are equallyaccessible by all, regardless oftheir economic or legal status,and free of cost or are fullycovered by existing user fees whenthey can be afforded by thoseseeking services.

Sustained access to treatmentshould be facilitated by access tomedicines and reagents at moreaffordable costs to the countrythrough the development ofinnovative procurement schemes,local production, pressure ondomestic and international prices,and where necessary, theapplication of safeguards embodiedin international trade agreements.

Prevention and social support needto be more prominent and beclosely linked to care as access totreatment further expands accordingto existing plans.

A reinforced focus of preventionshould be on young people and onpeople who are married to, or are ina sustained relationship with, HIV-infected partners.

Prevention strategies must adapt tothe evolving patterns of HIV riskbehaviours and risk situationsinvolving sex workers and their clients,men having sex with men, drug usersand minority groups such aspopulations along the internationalborders, as well as legal and illegalmigrants, for their own health and forthe sake of the health of the nation.

The use of knowledge acquiredthrough research should be

systematically applied to developingHIV/AIDS policies and strategieswhich, in turn, should inform theresearch agenda, particularly in the field of social, behavioural,health system and intervention-based research.

Civil society, in particular non-governmental and community-based organizations, need to bemore effectively supported andfinanced by national and localsources, and local authoritiesshould be strongly encouraged andrapidly given the capacity to do so.

The response to HIV should work furthertowards incorporating human rightsprinciples enshrined in the nationalconstitution and judicial provisions;mechanisms and instruments should beput in place to achieve this goal.

Given the high level of politicalcommitment, the exemplary capacities ofthe health services staff and the readinessof Thai civil society to confront thedisease, these opportunities can serve asa stepping stone to carry forward apeople-centered response to HIV/AIDS,and thus meet the current and emergingchallenges with confidence.

5Executive Summary

The Thailand National AIDS ControlProgramme is approaching its 20thbirthday. Since its inception in 1987 it hasachieved great strides, has accumulateda vast wealth of experience, and hasserved as a source of learning andinspiration to a large and growingnumber of countries around the world.One of the programme's unique featuresis that it has succeeded in scaling up itsresponse to HIV/AIDS from the initialprojects, which were geographically-limited and narrowly-focused, to nationalinitiatives. The upgraded initiatives havebenefited from a strong politicalcommitment, dynamic management,dedicated human resources, multiplealliances between formal and non-formalsectors, significant funding, and aprominent role played by an ever-growingnumber of diverse non-governmentalorganizations (NGOs) and community-based organizations (CBOs). Theprogramme has generated considerabledividends. Over time, its impact on thespread of HIV within and from differentcommunities became increasingly felt andin many cases measurable; behavioursresponded well to aggressive information,education and access to services,commodities and support; the stigma

initially attached HIV/AIDS began torecede, and the public discourse aroundsexuality and sexual health graduallyemerged. By the late-1990s, there weresigns that if a full-fledged access to thenewly available antiretroviral treatment(ART) combined with sustained or growingHIV/AIDS prevention efforts wereintroduced, the weakening epidemicscould be brought under firm control andtheir impact considerably reduced in aforeseeable future.

As in any other country, the HIV/AIDSsituation in Thailand has been andcontinues to be influenced by the political,economic and social context in which itevolves. The introductory chapter of theNational Plan for the Prevention andAlleviation of HIV/AIDS in Thailand, 2002-2006 (part of which is adapted from theNinth National Economic and SocialDevelopment Plan), projects the vision of anation undergoing a cultural, social,political and economic transformationwhich creates new vulnerabilities and newopportunities with regards to HIV/AIDS.Three elements of this narrative areparticularly relevant to this review: (1) theneed to avoid complacency in the face ofcontinued spread and predictable impact

INTRODUCTION

2

7Introduction

of HIV; (2) the reference to specific societalfactors deemed to undermine communitycohesiveness and capacity and exacerbatepoverty and ill-health; and (3) the structuraltransformation which, in line with the 1997constitution, provides for the transfer ofauthority and resources from the central tolocal political and administrative levels.The 2002-2006 National HIV/AIDS Planspells out goals, targets and strategieswhich emphasize the participation ofindividuals, families and communities inHIV/AIDS prevention and alleviation; thesupport to be extended to them by healthand social welfare services; thedevelopment of knowledge and research;international cooperation; and integratedmanagement of HIV/AIDS prevention andcare. The present review report will beguided by these key programme elementsintended to translate the "holistic, people-centered development approach" of theNinth National and EconomicDevelopment Plan into coordinated andsustained HIV/AIDS-related action.

The 1997 constitution contains severalprovisions highly relevant to HIV/AIDSwith regards to the protection of humandignity, rights and liberty, equality of menand women, non-discrimination, and theright to protect one's reputation andprivacy. As importantly, it establisheshealth as a human right to be protectedby the State. The introduction of theconstitution followed a heath care reformwhich, among other measures, created

equal entitlements to health under aUniversal Coverage Scheme (UCS)through a combination of threeinsurance and cost-recovery systems.Started in 2002, the UCS provides everyThai citizen access to comprehensivehealth care for the payment of a 30-Bahtfee per visit. As antiretroviral therapy(ART) was being introduced and promptlyscaled up in Thailand, the capacity of thenew scheme to cover the cost of qualityART in an equitable, comprehensive andsustainable fashion began to raiseserious doubts.

In summary, the National HIV/AIDSProgramme is currently undergoing adual transition: a political/administrativedecentralization and a health systemreform. Either or both can create newopportunities for greater impact onHIV/AIDS or generate complexities andgaps which may affect the coverage andquality of prevention and care.

Against this backdrop, the RoyalGovernment of Thailand sought thecooperation of the World HealthOrganization in order to conduct anindependent, external review of the progressachieved and constraints experienced by thehealth sector response to HIV/AIDS in thecountry. Such a review had taken place in1990 and again in 1991. Since that time,numerous internal assessments,operational, technical and managerialguidelines as well as formal and informal


meeting reports and research papers havebeen published on a wide variety of topicsrelated to HIV/AIDS in Thailand.

The present review drew a large amount ofquality information from these documents,in particular from those produced since thelaunching of the National Plan for thePrevention and Alleviation of HIV/AIDS inThailand, 2002-2006. This informationwas complemented by findings from face-to-face exchanges of views with Peopleliving with HIV and other key actors in theresponse to HIV/AIDS and by visits toinstitutions and community-based projectsboth in Bangkok and in four regions of the

country. While the review was not designedto include systematic primary datacollection during site visits, it neverthelessprovided multiple opportunities forreviewers to appraise and complement theinformation on record in order to buildtheir conclusions and recommendationson the strongest available evidence.

It is hoped that the conclusions andrecommendations arising from the presentreview will both help learn from theongoing national health-sector responseto HIV/AIDS and inform the next NationalHIV/AIDS Plan, covering the period 2007-2011, now under preparation.

Thailand is among the few countries inthe world to have turned around a rapidlyescalating generalised epidemic. The firstAIDS case was reported in 1984. Muchhas been written on the characteristics ofthe Thai epidemics which evolved inconsecutive waves with particular HIVsubtypes, predominantly in certainpopulations depending on the route oftransmission. Initially concentratedamong injecting drug users (IDUs), thecasualty of the first wave of the epidemic,the disease spread among female sexworkers and their clients and among menhaving sex with men, unleashing thesecond wave. The third wave of theepidemic consisted of widespreadheterosexual transmission within thegeneral population and then came thefourth wave when it spread to childrenborn to HIV-infected parents. Themultisectoral response was rapid andeffective, however, and overall HIVtransmission has dramatically declined.Among pregnant women, HIV prevalencepeaked in the mid-1990s with a nationalmedian at 2.3% in 1995 decliningprogressively to 1% in 2004. Reported

AIDS cases in men and women peaked inthe late-1990s before consistentlydeclining. According to the Thai WorkingGroup on HIV/AIDS Projection, thenumber of new HIV infections wasestimated at 17,000 in 2004 comparedto an estimated 143,000 new infectionsin 1991. It has been estimated that over 5.7 million HIV infections have been averted thus far through effective prevention.

The Thai Working Group on HIV/AIDSProjection estimates at 1,092,327: thecumulative number of people infectedwith HIV in Thailand since the beginningof the epidemic until 2005, including551,505 who died and 540,822currently living with HIV or AIDS. As ofJune 2005, 362,768 AIDS orsymptomatic cases have been reported tothe MoPH, including 86,923 deaths. Theactual number of children affected byHIV/AIDS is unknown. However, it isestimated that there are currently over500,000 children directly affected byHIV/AIDS ( children with one or moreparents who live with HIV or AIDS or have

THE STATUS AND TRENDS OF THEHUMAN IMMUNODEFICIENCY VIRUS(HIV) AND RELATED EPIDEMICS

3

died as a result of AIDS). Among thesechildren are 380,000 orphans who havelost at least one parent to AIDS and30,000 double orphans (children whohave lost both parents to AIDS). Theincidence of orphans is expected to fallsignificantly due to increased access ofparents to ARVs.

Among female direct1 and indirect2 sexworkers, male sex workers, maleconscripts and males attending STIclinics, HIV sero-surveillance showed aconstant and progressive decline in HIVprevalence since the mid-1990s.However, HIV prevalence among IDUs intreatment centers has gradually increasedto exceed 50%. Limited surveys amongMSM point to increasing transmissionwith a prevalence of 17.3% measured in2003 in Bangkok. In addition, there areconsistent reports of increases in riskbehaviours that might affect patterns oftransmission and dynamics of theepidemic. A shift from direct to indirectsex work, as well as to sex work outsideestablishments, both incompletelyreached by prevention programmes, havebeen documented. Furthermore,definitions and strategies for direct and

indirect sex workers vary over time andacross sites. As a result, it has becomeextremely difficult to estimate and projectprevention needs for this population ofsex workers and monitor preventionpractices such as the use of condoms.Working individually outsideestablishments, street-based sex workershave less negotiating capacity with theirclients for the adoption of safer sexpractices than their establishment-basedpeers, are less subjected to regularmedical check-ups and have reduced andshrinking access to free condoms. Tomake things worse, STI clinics which werestrategically located close to sex worksites are now being closed. These clinicswere designed to offer well-adapted andcombined prevention and care services tosex workers and their clients. STI care isincreasingly integrated into primary careunits (PCU) where diagnostic and carecapacity is weak and prevention skillsnon-existent, raising questions about thequality of prevention interventions as wellas about the reliability of STI reporting asan early warning system for sexualtransmission of HIV. Although data aredifficult to interpret as a result of thechange in access and reporting sources,


1 Direct sex workers are defined as women and men exchanging sex for money on the premises whereclient/sex worker encounters takes place (brothels, massage parlours).

2 Indirect sex workers are defined as women and men exchanging sex for money on premisesseparate from where client/sex workers encounters occur (restaurants, karaoke bars). The Teamfound that sex workers meeting their clients on the street were inconsistently categorized as "direct"or "indirect" sex workers. This has significant implications for prevention programme targeting,access and evaluation.

a recent rise in STIs was reportedfollowing closure of STI clinics. The use ofcondoms with sex workers reported bymale conscripts and factory workers hasremained stable at around 60% since1995, whereas female direct sex workerscontinue to report over 90% condom use.These differences in reported rates mayindicate lower condom use in less easy toreach groups of indirect sex workers andmay also reflect some reporting bias.

Apart from high risk behaviours, HIVtransmission among spouses of HIV-infected men is expected to account for30% to 50% of new infections in Thailandthis year (2005), according to the AsianEpidemic Model. Behavioural data showthat young people engage more oftenand earlier in sex whereas their use ofcondoms remains low despite slightincreases in recent years. Mother-to-childtransmission has been dramaticallyreduced due to universal access to ARVprophylaxis. In 2001-2002, nationalperinatal HIV outcome monitoringestablished that 5.4% children born toHIV-infected mothers had been HIVinfected while 3.0% had died beforebeing tested for HIV.

Since early in the epidemics Thailand hasimplemented an exemplary surveillancesystem; based on HIV sentinel sero-surveillance and behavioural surveys,national STI and AIDS case reporting, it iscomplemented since 2004 by HIV

incidence surveillance using newdiagnostic methods. HIV sero-surveillance is conducted every year ineach province targeting eightpopulations: pregnant women attendingANC, direct and indirect female sexworkers, male sex workers, injecting drugusers, blood donors, males attending STIclinics, and military recruits. Behaviouralsurveys are conducted every year in twoprovinces per region targeting male andfemale students, male and female factoryworkers, military recruits, womenattending ANC and, since 2004, thegeneral population. Information obtainedfrom these invaluable sources appears tobe incompletely disseminated and utilizedfor the purposes of identifying needs andplanning responses at different levels.Despite worrisome trends, surveillanceamong IDUs is not systematicallyconducted in all provinces and no dataare available outside rehabilitationcenters. Data on sex workers areincomplete outside establishments.Sparse information is availableconcerning MSM and male prisoners butthere are indications-yet to be confirmedand published-that the rate of HIVprevalence in men having sex with menhas increased significantly in recent years.

Although it is unlikely that the spread of HIVin Thailand will ever rise again to the levelsobserved in the mid-1990s, there are signsthat the country may be at risk of arebounding epidemic. They are as follows:

11The Status and Trends


The annual number of newinfections is no longer declining asrapidly as it did in the last decade.

One-third to one-half of the newHIV infections this year (2005) willbe among women who are in astable relationship and will becomeinfected sexually by their spouse orregular partner.

Adolescent boys and girls engagemore frequently in risk behaviourswhich expose them to HIV infectionthan their peers did a few years ago.

The achievements of the 100%condom programme are beingchallenged by an insufficient outreach

efforts to sex workers, the changingprofile of sex work in Thailand, andinadequate condom supplies.

There are signs of increased risk ofHIV infection among men having sexwith men, transgender, and othermarginalized populations, includingminorities, immigrants and theirdependents, prisoners and drug users.

There is a rise in certain sexuallytransmitted infections as a result ofrelocating diagnosis and treatmentclinics to hospitals which sexworkers are reluctant to attend,lowering the level of adherence tosafer sex practices, and insufficientsupplies of condoms.

1. HIV surveillance should be strengthened by identifying the gaps in informationon current patterns of HIV transmission in IDUs, MSM, sex workers outsideestablishments, prisoners and other vulnerable populations (migrants, mobilepopulations), while upholding ethics and human rights.

2. The Bureau of AIDS, TB and STIs (BATS) should support the standardization of STIsurveillance methods and tools in order to maintain an early warning system forincreasing sexual transmission of HIV.

3. The information produced by the surveillance system on the pattern of HIVtransmission should be more systematically shared and used in driving acomprehensive multisectoral response appropriate to Thailand'sepidemiological transition.

4. To increase the quality of surveillance, human capacity at hospitals and at theprovincial level should be developed.

Recommendations

4.1 Budget and financesTotal government funding for the AIDSprogramme increased from 1.44 to 1.6billion Baht during the period 1999 to2005.3 The largest share of the AIDSbudget in 2005 (75%) financed treatmentand care, including ARV and drugs forOI, HIV testing and social welfare forpeople living with HIV/AIDS (PHIVs).Programmes to prevent the spread ofepidemic accounted for only 15% of thebudget, covering public information,condom promotion (including condomsupply), prevention of mother-to-childtransmission (excluding ARVs) and othercommunity prevention activities. Anadditional 70 million was distributed toNGOs for community level AIDSprevention and care activities. Grantfunding for NGOs remained constantfrom 2001 to 2005, although it isanticipated that the grants for NGOs maybe reduced to 50 million Baht in 2006.However, the perception of many NGOsis that the level of funding to NGOs hasconsistently reduced in recent years and

that funding doesn't always reach NGOs,PHIV groups and other community basedorganisations. The slow disbursement offunds from national to provincial todistrict level is also of concern.

Twelve other ministries apart from Ministryof Public Health received funding from thePrime Minister's office according to theirworkplans. In the last few years, theamount of funds allocated to each ministrywas mostly at a constant amount except forthe Ministry of Interior whose AIDS budgetincreased from 31 million in 2002 to 67million in 2005 for work on empowermentof families and communities. In addition,50 million Baht is distributed annually fromBATS to other ministries for preventionactivities. Noticeably, the Global Fund forAIDS, TB and Malaria (GFATM) has alsocommitted some USD 192 million over afive year period (2003-2007) for HIV/AIDSprevention and care activities.

Apart from GFATM, there are manyadditional external agencies funding

POLICY, STRUCTURES ANDPROGRAMMES

4

3 As of July 2005, the bank exchange rate was at about 40 Thai Baht for 1 US Dollar.

different programmes but there iscurrently no central place where thisinformation is effectively collected andanalyzed. The National AIDS Account(NAA) started in 1994 in partnershipbetween the National Economic andSocial Development Board (NESDB) andthe International Health Policy Program(IHPP). For the period 2000 to 2003, ittracked the total HIV/AIDS expenditurefrom multisectoral public, private,household and external sources, basedon secondary data, or if the data are notavailable, on price/quantity estimates.According to this source, totalexpenditure on HIV/AIDS increased from3,141 million Baht in 2000 to 4,479million Baht in 2003. In that year, thepublic sector accounted for 60% of thetotal expenditures and households for21%. This important contribution ofhouseholds was in part due to the ARTregimens "not covered by the nationalscheme" including 2nd line regimen. Thetwo main components of householdspending on HIV/AIDS were ART (45.6%) and treatment for OI (32.8%).The NAA concluded that there was needfor additional investments in HIVprevention services.

Thailand is in the process of supportingother countries in the region to developNAA. However, even in Thailand,information on economic evaluation,such as cost-effectiveness ofprogrammes, is scarce or unavailable for

most interventions (except ART 1st lineregimen) and more research in this areais urgently needed. It is equally importantthat research be strengthened to providemore accurate and current informationon the situation of international fundingof HIV/AIDS activities in Thailand, ondomestic expenditures and on theprioritization of specific programmes suchas prevention in terms of overall financialallocations. This information is becomingmore critical than ever as decentralizationis expected to diversify further the sourcesand channels of HIV/AIDS spending andas concerns grow about long-term financial sustainability of HIV/AIDS activities.

4.2 Effect of health care reformHealth care reform was long recognizedas essential to the transformation ofThailand's health service system to enableequal coverage of the entire population.The promulgation of the 1997constitution brought the necessarychanges in the socio-politicalinfrastructure for this to take place. As aconsequence, with the election of thecurrent government in 2001, thepromotion of Thai citizens' rights to access basic health services and thepopular "30 Baht scheme" policy becamea priority. Public sector reform,decentralization of central authority, and the restructuring of the Ministry ofPublic Health have been undertaken in accordance with the constitutional


mandate with important consequencesfor the HIV/AIDS response at the national,provincial and local levels.

4.2.1 DecentralizationDecentralization presents a greatopportunity to bring HIV programmescloser to people but also brings a risk thatthe response may become fragmented.While the results of decentralization maybe greater ownership of programmes andmore locally-adapted responses andgreater accountability, the local capacityalso have to be ready to take over keyresponsibilities, including funding,awarding of priority status to HIV-relatedissues, coordination of local initiatives,and establishing linkages between HIVand other local priorities.

With decentralization, provinces willassume an increased responsibility formanagement of the HIV/AIDS response.While some provinces have alreadydeveloped the necessary structures andskills to cope with this change, there is aconcern that many provinces do not havethe required capacity to do so and are notfully prepared to fulfill their new roles.Some provincial and district healthauthorities have demonstrated theircapacity to manage change. However,the commitment from some governorsand local authorities still remains unclear.Many provincial AIDS committees arewell established but weak in actualimplementation; there is a lack of clarity

about funding from the provincial level asnational funding declines; andcompetencies and human resources arelimited, with many officials having toperform multiple tasks. It remains to beseen whether HIV/AIDS networks at theregional and provincial levels will be ableto sustain their activities and continue toplay a crucial role in coordinating andcooperating in the HIV/AIDS preventionand control programme.

One of the key steps to ensure thatdecentralization strengthens rather thanweaken the HIV/AIDS response is tomaintain the high profile of HIV on thenational agenda and secure theengagement of all sectors of government,nationally and locally. The National AIDSCommittee (NAC) has a key role inachieving this, but its visibility, credibilityand efficiency require high-level politicalcommitment, including the PrimeMinister's personal involvement in chairingthe committee, thereby encouraging high-level participation from all ministries.

In addition, there is a need for therepositioning of BATS in its role as thecentral structure in the management ofthe response. Decentralization will mostlikely result in a weakening of the capacityof the Bureau as a result of its shrinkinghuman resources, declining budget, andincreasing administrative and financialreporting burden. It is important that BATSbe supplied with the necessary means to

15Policy, Structures and Programmes


ensure that it is equipped to fulfill itsredefined role, including norm setting,monitoring and surveillance (earlywarning), epidemiological andoperational research, strengthening localcapacity (training and supportive visits)and ensuring close linkages betweenpolicy, programme and research.

Based on this scenario, the role of BATSwill change to that of a facilitator whichwill enable sharing of its experience andknowledge among regional, provincialand local authorities. The existing role ofBATS in directing strategic themes maynot be compatible with envisagedprocesses conducted at the provinciallevel. However, regional and provincialhealth administrators will still need BATSto provide governors with standardguidelines and indicators for technicalprocedures covering allocation of budgetfor AIDS at the provincial and districtlevels. These would enable provincialhealth authorities to request appropriateallocation of provincial and localgovernment budgets.

Under the restructuring process, themission of the Ministry of Public Healthhas shifted from being the main healthcare provider to exercising its leadershipin national health strategicimplementation. Consequently, the role ofthe Department of Disease Control (DDC)evolved from that of vertical programmemanager to the new mission of strategic

manager through technical leadership.Simultaneously, the roles and functions ofnational, regional, provincial and locallevel government agencies in HIV/AIDSmanagement and care have beenadjusted to reflect their newimplementation responsibilities.. Finally,the National Health Security Office'spolicy of universal access to health carehas also necessitated restructuring andfunctional reorientation of the health caresystem and this has, at least temporarily,affected its effectiveness.

4.2.2 The 30 Baht scheme and healthservice restructuring

As of 2002, the Health Security Officehas been appointed as the collectivepurchaser of health services coveringmore than 40 million constituents. As aresult, by 2004, the accessibility to careby Thai nationals increased from around75 % to 95 %. The per capita healthbudget allocation increased from 700Baht in 2001 to 1,396 Baht in 2005, andwill rise further to 1,650 Baht in 2006.The budget for National Health Securityincludes services for the individual andfamilies covering disease prevention,health promotion, therapeutic care andrehabilitation. The service purchasingcriterion is designed as an incentive forthe health care provider to deliver servicewith quality, efficiency and equity. Budgetis allocated to primary care units (PCU)for the areas of prevention and care,ambulatory care, in-patient care,

emergency care and catastrophicillnesses. The purchasing criteria underthe scheme are under development andan increasing number of health servicesare being included. While the NationalHealth Security Office is revisingguidelines for care and financing,accompanying changes in managementmight adversely impact on some verticalprogrammes such as HIV/AIDS as theseare integrated into the health care system.

The challenges which the reform processhave posed to the health care system maybe best exemplified in relation to the TBand STI prevention and controlprogramme which was integrated into thechanging infrastructure over the last fewyears (see Annex 4).

4.2.2.1 Resource allocation and the 30 Baht scheme

The payment mechanism of the 30 Bahtscheme encourages hospitals to reducetreatment costs, with potential implicationsfor the quality of care. The currentcapitation fee is 1396 Baht with a patientcontribution of 30 Baht per consultation.Of this amount, 210 Baht is supposed tobe dedicated to prevention budgets. Dueto cost of treatment over-runs, the fundsallocated for prevention are often used byhealth care facilities for care andtreatment instead.

The allocation of prevention funds to thedistrict level assumes that information,

education, communication (IEC)materials can be developed at the localhealth care facility level. However, thereare major economies of scale in theproduction of IEC materials and it is notfinancially viable to develop and print asmall number of copies of a poster athospital levels. Posters, leaflets and radiospots on CD for community radio requirea central budget and large-scaleproduction and print runs.

In capitation systems, careful strategicplanning is necessary to ensure that thehealth needs of the population are met.Examples of potential gaps includeinterruptions and shortages in the supplyof condoms for sex workers, shortages offunds for community-based programmessuch as village health worker, and supportto people living with AIDS and theirfamilies including affected children.

4.2.2.2 Registration and social exclusionHospital reimbursement takes place onlyfor people registered in a locality. Somecatchment areas include large numbersof unregistered migrant workers. Internalmigrants are often reluctant to registerlocally and international migrants maynot be allowed to do so. In such cases,hospitals may offer care and treatment toa patient upon payment of cost.

4.3 Human rightsEver since its inception, the NACP hasincorporated human rights principles of


non-discrimination, equality andprotection of dignity in its plans andguidelines. As a result of ignorance, fearand stigma, however, instances ofdiscrimination against PHIV on theworkplace, at school and within healthfacilities were reported by community-based organizations and the media. The1997 constitution, the Health Security Act(2002) and the Information Act (1997)embody provisions for protection ofhuman rights and dignity, in particularagainst discrimination. More recently, theMinistry of Labour has produced a Codeof Practice on the Prevention andManagement of HIV/AIDS in theEstablishment (January 2005) applicableto all employers and employees,including job applicants in the public andprivate sectors, in all types ofestablishment both formal and informal.The document encourages all suchestablishments to develop appropriatepolicy and plans of action on a voluntarybasis. To contribute to the adoption andimplementation of sound policies andpractices on HIV/AIDS in the workplace,the Thai Business Coalition on AIDS(TBCA) issued the AIDS-responseStandard Organization (ASO), aninstrument applied to the assessment ofcompliance of establishments with keyprinciples laid out in the Code of Practice.Although not mentioning HIV/AIDSspecifically, the Penal Code containsprovisions concerning privacy and libel.The Medical Council's Regulation on

Professional Medical Ethics (1983)contains clauses on the protection ofconfidentiality in the relationship betweenindividuals and care providers,complemented by specific Guidelines onAIDS for Medical Doctors (2002).

In the course of the review, the ReviewTeam sought from governmental andnon-governmental organizationsinformation on any knowledge they wouldhave of cases of human rights violationsrelated to HIV/AIDS. The Team was toldthat the frequency of such violations-inparticular discrimination on the basis ofHIV status-had been high in the earlystage of the epidemic but had graduallydeclined as a result of information andeducation. The Center for AIDS Rights(CAR), an NGO focused on thepromotion of human rights throughinformation and capacity building, seesthe role of PHIV not only as promoters ofhuman rights in the context of HIV/AIDSbut also in relation to any violation thatmay occur within their community.

A recent study (Sringernyuang L,Thaweesit S, Nakapiew S, personalcommunication, 2005) reviewed thesituation of HIV-AIDS relateddiscrimination in Bangkok. The studyconcluded that human rights violationscontinued to occur in the health caresetting, manifest particularly in suchpractices as refusal to treat or treatingdifferently on the ground of HIV/AIDS


status, testing without knowledge andbreaches of confidentiality.

In recent years, there have beendocumented instances of discriminationbased on HIV status in settings outside thehealth sector. Children with HIV weredenied entry to primary school,employees were summarily dismissed,HIV tests were performed at the request ofprospective employers on job applicants.These instances were resolved throughnegotiations, occasionally supported byNGOs, but no case has thus far beenbrought to court.

Overall, NGOs felt that in Thailand, HIV-related human rights policies andguidelines were sound but lacked explicit legal backing and were notuniformly understood and practiced at thelocal level.

4.4 Non-governmentalorganizations (NGOs),community-basedorganizations (CBOs), andpeople living with HIV(PHIVs)

Since the mid 1990s, there has beensignificant growth in the number ofNGOs and CBOs (including peopleliving with HIV/AIDS groups). At presentthere are over 500 NGOs working inHIV/AIDS and over 800 PHIV groups inthe country. These organizations haveestablished strong networks at the

regional and national level, withrepresentation on key bodies responsiblefor policy and planning.

Initially, most NGOs were engaged inprevention. However, their role evolvednaturally towards care and support and,until recently, the activities of most NGOsgenerally included a combination ofprevention, care and support. At present,however, it appears that NGOs are lessengaged in prevention, with an increasedshift towards care. The complex reasonsfor this shift include: (1) care is timeconsuming but more urgent and visiblyrewarding; (2) available external fundingis increasingly targeted to care andsupport (3) concerns that the overallamount of national money available toNGOs has been reduced; and (4) recentchanges in disbursement of funds fromthe MOPH, with monthly financialreporting, imposes an excessive burden.Given this situation, preventive work,which is generally seen as a more flexible,though still important, activity, is the firstto be dropped.

A significant trend, seen particularly amongNGOs working with young people, is theevolution of more comprehensiveapproaches, addressing other issues inaddition to HIV/AIDS. This appears to begenerally consistent with a particular socialand economic context. For example, inareas where drug use is high demandreduction may be a priority. Similarly, where


unemployment is a priority among youngpeople, the main focus may be onoccupational development, rather thandirectly on HIV/AIDS. In Muslimcommunities in the far South, currentlyaffected by civil unrest, HIV/AIDS life skillseducation for young people may need tobe combined with skills on conflictresolution. This is a good and naturalprogression and can help ensuresustainability of HIV/AIDS responses.

NGOs, CBOs and the PHIV network arein an ideal position to reach the most hardto reach, vulnerable groups (IDU, MSM,migrants, non-registered populations,youth, street-based sex workers anddiscordant couples) but require flexibility infunding "tailored" technical support(including targeted IEC materials) and"light" reporting to allow for innovativeapproaches to these vulnerable groups.

4.5 Private sectorWith a few notable exceptions, the privatesector has been slow to become engagedin HIV/AIDS. Despite the relative prosperityof some companies and individuals,Thailand has not yet seen the emergenceof generous wealthy private sector donorssuch as those in Western countries. TheThai business people's approach todonating funds is different and may requirea new outlook. Nevertheless, manycompanies and individuals havecontributed to the HIV response. The TBCAhas been an important catalyst in

mobilizing the involvement of the privatesector, and development of AIDS in theworkplace initiatives, including promotionof HIV standards among employers. Theprivate health sector has also recentlybecome engaged, in cooperation with theMinistry of Labour (MOL), TBCA and ILO,in development of health care coverage forworkers and the AIDS Standardsorganization (ASO).

Private hospitals supply a significantnumber of PHIV with treatment and carebut there remain concerns about thecomprehensiveness of service supplied bysome of these hospitals.

4.6 Other government agenciesFor sectors outside health, governmentagencies such as Ministry of Labour,Ministry of Education, Ministry of Defence,and Ministry of Social Welfare (now theMinistry of Social Development andHuman Security) were initially not engagedin the HIV/AIDS response. However, allbecame engaged when funds wereallocated from the Prime Minister's officebut have been less forthcoming inproviding funding from their own budgetsand developing specific HIV/AIDSstrategies and work plans as an integralpart of their work. At the moment, theseministries appear to be largely dependenton the limited funding available fromBATS. Despite the constraints, someagencies appear highly committed, andthere are examples of useful contributions,


such as the MOL's promotion of the Codeof Practice for HIV in the workplace.

One important issue which needs to beaddressed is the inconsistency of policiesbetween different ministries. This isparticularly relevant in the area of the law.For example, the use of condoms by policeas evidence of commercial sex is at oddswith the condom promotion by MOPH forsex workers. Information fromconsultations suggests that this practicemay also discourage condom use forprevention amongst young people as wellas restrict the condom distribution activitiesof outreach workers. Inconsistencies canalso be seen in the area of administration,such as in the Ministry of Finance's use of amonthly disbursement system for release ofsmall grants payment to NGOs andcommunity organizations, which greatlyincreases the administrative burden onboth recipients and the MOPH.

4.7 International cooperationMany international agencies havecooperated with Thailand in the HIV/AIDSresponse. These include organizationswithin the UN system, the Global Fund forAIDS, TB and Malaria (GFATM), bilateralagencies, research institutes and INGOs.The technical and financial support fromthese agencies has made an importantcontribution. However, differences inadministrative requirements, such asreporting formats, have presentedchallenges. The reporting requirements of

GFATM, in particular, were reported asbeing a heavy burden.

Many international donors have reducedbilateral funding support to Thailand inrecent years and these funds areincreasingly targeted at treatment andcare rather than prevention. Moreover,funds for prevention activities frominternational donors may not be availablefor NGOs that do not commit themselvesto the ABC concept (Abstinence, Befaithful, use Condoms). This is part of apattern that has seen HIV/AIDS work inThailand being increasingly influenced byinternational political agendas.

In addition to traditional questions ofsustainability, changing political agendaswithin Thailand have recently increasedambiguities around the role of internationalresources. The picture has been furthercomplicated by decentralization, as there is alack of clarity about how internationalcooperation will function in the new politicallyand administratively decentralized system.

Thailand is now also playing an importantinternational role in the global HIV/AIDSresponse. Based on the valuableexperience and lessons learned from herHIV/AIDS programme, Thailand hascontributed in some key areas, including:

Sharing its HIV/AIDS experiencewith others through South-Southcooperation such as workshops andstudy visits, technical support in


developing NAA in neighbouringcountries

Commitment of US$ 1million forfive consecutive years to GFATM

Extension of direct bilateralassistance to neighboring countries

Regrettably, the view that Thailand is asuccess story has led to a certain level ofcomplacency in the national response toHIV/AIDS.

4.8 Knowledge managementAs a result of the HIV/AIDS response,there is now a huge body of knowledgeand expertise in Thailand. It is importantthat there are structures in place to enable

sharing of this knowledge and expertise, inorder to promote coordination, learningand development of more effectiveapproaches. Regional-level lessons-learned forums have been held on an adhoc basis, for example, in the UpperNorth and Region 5 in the Northeast. Inaddition, the national bi-annual AIDSseminar provides an important platformfor sharing of knowledge. However, inorder to ensure the maximum benefit isderived from such forums it is importantthat civil society and government agenciesparticipate as equal partners in planningand organization of forums. Owing to afeeling that the content of this year'snational seminar was over-driven byspecific agendas, civil society is planningan additional forum in November 2005.


1. The place of HIV/AIDS within the national agenda should be strengthened by (i)revitalizing the role of the NAC, and (ii) ensuring that it receives once againcontinuous attention by its chair, the Prime Minister, so as to generate thehighest level of interest and commitment by its members.

2. Mechanisms should be put in place to ensure that total government HIV/AIDSbudgets do not recede but continue to grow during the process of decentralization.

3. Resource mobilization should be planned to ensure stable and long-termfunding for NGOs that are increasingly dependent on support from largedonors such as the Global Fund for their work.

4. Other ministries should earmark budgets for HIV-related activities independently ofMoPH budgets and incorporate a specific HIV/AIDS component as an integral partof their ministries' strategies and work plans.

Recommendations


5. Coordination between ministries and departments should be improved toensure consistency of policies, in particular the policies relating to access topreventive measures, such as condoms.

6. Together with the building of competency at the provincial level and below,interest should be stimulated in building the evidence, advocating for moreengagement at local levels, revitalizing Provincial HIV/AIDS Committees,offering increased support for NGO/CBO networks, as well as building theircapacity in advocacy and service delivery.

7. Based on existing management-information systems, an early warning systemshould be developed to detect failures in essential services as responsibilitiesand resources are being decentralized.

8. The formulation of the next five-year plan and related budgets should begeared to support:a. the technical and monitoring functions of BATS,b. the leadership and managerial function of provincial teams, andc. the capacity development of NGOs/CBOs.

9. Support for those NGOs and CBOs that are able to reach populations livingon the margins of society (substance users, MSM, and illegal immigrants, forexample) whose HIV/STI/TB prevention and care needs must be met for thesake of their own health and that of the general public, should be reinforced.

10. Forums for sharing and exchange among partners at all levels should be promotedto enable learning, more effective monitoring, accountability and transparency.

11. An inventory of non-governmental sources of funding for HIV/AIDS-relatedactivities in Thailand should be established.

12. There should be a stronger than existing linkage between economic analysis ofcosts and cost-effectiveness, and between strategic prioritization at the nationallevel and programme implementation at the local level.

13. A financial monitoring system should be introduced to determine (i) actualexpenditures by priority areas and (ii) whether hospitals are conforming to government guidelines on allocation of funds to both prevention and care activities.

Thailand's HIV epidemic has changedsignificantly in recent years withprogressively lower levels of transmissionaffecting more diverse population groups(see Annex 4 for more detail on statusand gaps in prevention efforts). Newstrategies are needed to better reachthese groups with effective prevention.

While new approaches are needed, it iscritical that Thailand maintain the highlyeffective interventions that rapidlycontained HIV spread in commercial sexearly in its epidemic. Yet Thailand's STIclinics and 100% condom use programmeare in jeopardy. In fact, regional teamsdocumented that the 100% condom use isin a state of collapse in many areas leavingsex workers without access to condoms orSTI services. In Chonburi province, forexample, the Pattaya clinic is the only STIclinic remaining out of 11 two years ago,and it is struggling to maintain basicoutreach and clinical services for anestimated population of 14,000 femaleand male sex workers.

Condom supply to the regions has beencut to 25% of previous levels in some areas

visited. According to persons interviewedincluding sex workers, interventions withsex workers are no longer able to provideadequate supplies. Other vulnerablepopulation are not yet covered by the100% condoms programme. Condomsare generally not provided to people livingwith HIV/AIDS despite ongoing risk oftransmission to regular partners.

One of the most worrisomeconsequences of recent changes is theloss of an 'early warning system' to detectincreasing HIV and STI transmissiontrends. Until recently, reliable reportingfrom all provinces through the STI clinicnetwork permitted Thailand to monitorthe progress of its epidemic and fine-tuneits response. Regional visits documentedthat, while surveillance activities continueunder new structures, data are no longerreliable due to collapse of regularoutreach work to sex establishments.

Despite these data limitations, the reviewteam found evidence that STI and HIVtransmissions may be on the rebound inseveral areas. For example, HIVprevalence among military recruits and

MAINTAINING CONTROL OF THEEPIDEMIC - HIV PREVENTION PRIORITIES

5

indirect sex workers in Region 3 doubledin 2004. On a national level, increases inSTIs are being seen for the first time inover 15 years even though fewer STIclinics are reporting (see Annex 5).

Health reforms have also had a dramaticimpact on the implementation of publichealth interventions for HIV, STI and TBprogrammes. While some services - suchas prevention of mother-to-childtransmission (PMTCT) and ART - appearto be well-implemented underdecentralized health services, otherprogrammes are clearly threatened.Decreasing levels of funding and accessissues raise questions about survival ofkey prevention and disease controlprogrammes during this transition.

5.1 Sustaining proveninterventions with sexworkers and their clients

Sex work has changed over the years andmore sex workers are working in less easyto reach 'indirect' settings including bars,karaoke and massage parlours. There isalso a reported increase in male andtransgender sex work that is not beingadequately reached by currentinterventions. New patterns ofcommercial sex warrant new strategies toensure maximum reach and impact ofprevention efforts. Appropriateinterventions to reach sex workers indifferent settings - such as indirect andmale sex work - include peer-based

outreach, provision of condoms and non-judgmental clinical services.

Field visits confirmed that a number ofchanges related to recent health reformsweaken Thailand's ability to control HIVand STI transmission among sex workersand their clients. These include:

Fewer STI clinics and a weakening ofservices (staff shortages, low priorityto providing services for sex workers,new and inexperienced staff)

A large reduction in outreach visitsto sex work sites for condompromotion and prevention work

Decreased condom supply atnational level has limited distributionto sex work settings. Severalprovinces report receiving only 25%of requested number of condoms.

Relaxation of condom promotionefforts targeted to clients andpotential clients of sex workers

General weakening of the monitoringand surveillance system that has beenkey in informing the MoPH about trendsin condom use and STI among sexworkers. It will be very difficult to interprettrends because of a decrease in sitesreporting and turnover of trained staff.

Currently, there seems to be less focus onclients and potential clients of sex workers

25Maintaining Control of the epidemic – HIV prevention priorities

than there was previously. The armedforces reported stagnant and insufficientbudgets for HIV prevention work despitetrends towards more commercial andcasual partners reported by militaryrecruits (see Annex 4).

Another cause for concern is decreasingsupport and collaboration of lawenforcement for HIV prevention amongsex workers. For example, it has beenwidely reported that sex workers, MSMand even young people who are foundcarrying condoms are fined or charged bythe police. As a result, condoms arereportedly not found at certainentertainment sites and it is likely thatmany indirect sex workers do not carrycondoms with them.

5.2 Extending HIV preventionto drug users

Drug use including alcohol andmethamphetamine can impair judgmentand increase high-risk behaviour. Inaddition, HIV can spread extremely fastthrough networks of injecting drug usersas a result of sharing injection equipment.In Thailand, HIV prevalence among IDUsincreased from 2% to 43% in one year(1987-1988). Since then, HIV prevalencehas fluctuated with about half of injectingdrug users in contact with treatmentservices testing positive.

It is unclear what impact Thailand's war ondrugs is having on overall drug use and

drug injecting. Disrupted surveillance andrestricted access to prevention serviceshave made it difficult to determine theimpact on HIV and effectiveness of currentprevention efforts. Even with an overalldecrease in drug use, which is difficult toverify, it is likely that remaining and newdrug users will engage in riskierbehaviours to avoid detection and will bereluctant to access drug treatment andHIV prevention services.

HIV prevention among injecting drugusers has been largely lost in Thailand'soverall response to drug use. Nationalefforts focusing mostly on supply anddemand reduction have not beenmatched by interventions to reduce drug-related harm, despite strong internationalevidence of their effectiveness. The realdanger of such an unbalanced strategy isthat drug users will be drivenunderground, away from prevention andtreatment services, facilitating HIV spreadboth within drug using populations andthrough sexual partners to other sectors ofthe population.

Therefore, Thailand should act quickly toscale up outreach and related harmreduction programmes particularly inurban areas where drug supply and use ismost likely to continue. Such interventionshave been shown to reduce risk of HIVtransmission and do not result in morepeople using drugs. In addition, becauseof high HIV prevalence rates for nearly


two decades, drug users also need HIV-related services including voluntarycounselling and testing (VCT), care,support and ART, yet little has been doneto address specific challenges ofproviding these services.

5.3 Reaching men who havesex with men (MSM)

Men who have sex with men (MSM) forma diverse group in Thailand that overlapswith and extends beyond commercial sexnetworks. Various studies report thatbetween 3.3% to 16.0% of Thai maleshave had some kind of same-sex sexualexperience, commercial or non-commercial. Among surveyed male sexworkers, most identify themselves asheterosexual and also have femalepartners. For these reasons, the potentialfor HIV transmission both within andbeyond MSM networks is high.

In 2003, research conducted by ThailandMOPH-U.S.CDC Collaboration (TUC)found that HIV prevalence among MSMin Bangkok (recruited from saunas, parksand bars) was 17.3%. Preliminary resultsof the follow-up study in 2005 show28.3% HIV prevalence.

According to MOPH surveillance, thenumber of male sex workers increasedfrom 4,132 in 2000 to 4,460 in 2004,most of them found in gay bars, karaokebars and on the street. In 1997, HIVprevalence among male sex workers in

Chiang Mai, Chonburi and Phuket wasabout 21% (BATS report). In 2003,MOPH surveillance reported 20% HIVprevalence among male sex workers. The2005 TUC Bangkok study reported HIVinfection rates of 22.6% (38 of 168)among freelance-male sex workers and15.4% (28 of 182) among venue-basedmale sex workers.

Marginalization and discrimination inhibitHIV prevention with MSM. As with indirectsex workers and IDUs, MSM withoutaccess to HIV services are mostvulnerable to HIV. Male and transgendersex workers have special HIV preventionneeds due to high visibility and stigma.

Peer outreach can help identify newvenues (such as bars, saunas and streetlocations) and extend prevention efforts tobetter reach MSM networks. Better accessto clinical services, adapting provenmodels used with female sex workers,would further strengthen HIV and STIprevention in this group. In addition, itshould be recognized that men in prisonfrequently have sex with other men andshould have ready access to preventioninformation health services and condoms.

5.4 Accessing migrant andmobile populations

Migrant and mobile populations arehighly vulnerable to HIV, and often havepoor access to HIV-related services.Migrants, such as seafarers, construction


and factory workers, generally live underconditions of difficult jobs, low wages,poor housing and sanitation, low literacyand lack of access to education. Limitedaccess to health information and servicesincluding condoms, as well as culture andlanguage barriers, increase vulnerability.Health risks include very low condom usewith sex workers, drug use, alcoholconsumption, accidents and injuries. As aresult, HIV prevalence among migrants isfrequently higher than among Thainationals living in the same area.

Most interventions with migrants areconducted by NGOs in partnership withMOPH, and funded by the Global Fundand other international organizations.Existing interventions largely targetseafarers in the South and East. Gaps remain among other migrantpopulations working as construction andfactory workers.

Policies that impede access should bereviewed. Registration poses clearproblems of access to public services formigrant workers, and may also affect, tosome extent, the urban poor, indigenoushill tribe peoples, and others; the samefactors that exclude them fromrecognition by the Thai government mayalso make them vulnerable to HIVinfection. Prevention programmes formigrants should address their specific HIVprevention and treatment needs, and bescaled up to fill existing coverage gaps.

5.5 Behavioural change amongyoung people

Young people account for an increasingproportion of new HIV and STI cases. Recentsurveillance assessing risk behaviours to HIVinfections show that Thai youth continue toengage in HIV risk behaviours. Theseinclude a higher proportion of sexualexperiences, high rates of unprotectedsexual intercourse, and, among sexuallyactive youth, low rates of consistent condomuse with both steady and casual partners.Modern technology such as mobile phones,internet, video and other media haveopened up many new channels for exposureof young people in Thailand to informationabout sex, as well as increasedopportunities for sexual experience.

Young people in Thailand especiallyvulnerable to HIV/AIDS include streetchildren, MSM and transgender, youngpeople from ethnic minorities, mobile andborder populations, drug users, youngpeople living with HIV, young people fromslum communities, and those in remoterural communities.

Issues identified by young peoplethemselves include increased access toinformation about HIV/AIDS, especially thatwhich is consistent with their needs, and informs, including language and style, whichare easily accessible to young people.Young people also want to acquire life skillsto protect themselves from infection withHIV, or to help them to live better with HIV.


Further, young people also want access toservices, such as counselling which isfriendly to young people, and condoms.

Prevention models among youth havebeen piloted and scaled up nationwide byMinistry of Health, Ministry of Educationand PATH. While the educational systemshould urgently strengthen efforts to buildappropriate life skills among students,attention also needs to be paid tovulnerable young people who are at riskof adopting high-risk sexual or drug-usingpractices. There are some good examplesof effective models for peer-basedHIV/AIDS prevention and care activitiesfor young people. However, theseactivities need to be scaled up in order toaccess vulnerable populations.

5.6 Reducing transmission toregular partners

Transmission to regular partners is agrowing concern as Thailand's epidemicages. Since HIV transmission incommercial sex settings has been soeffectively controlled, an increasingproportion of infections are found amongregular partners of men and womenpreviously infected. Awareness of HIVstatus is generally low in regularrelationships as is condom use.

Several areas of intervention should bestrengthened. These include reinforcingHIV prevention in sexual and reproductivehealth services, promotion of HIV testing

and counselling for couple, support fordisclosure, risk reduction counselling bothfor those who test HIV-positive and thosewho test negative. 'Positive prevention'refers to specific prevention support toPLHA that should be a part of everycontact with health services.

Prevention efforts should also be maintainedand strengthened in diverse occupationalsettings. For example, HIV preventionbudgets in the military are currently low andstagnant, limiting possibilities for promotingprevention among men who frequently havecommercial and casual as well as regularpartners. Workplace programmes ingeneral should be strengthened to reinforceprevention both within and outside regular relationships.

5.7 Bringing together theprevention package

Despite impressive achievements in thepast, Thailand should avoid set ideasabout its HIV epidemic and complacencyin its response. An evolving epidemic withmultiple potential foci presents newchallenges and calls for vigilance andflexibility in response. Prevention effortsshould maintain and improve what hasworked in the past while introducing,evaluating and adapting appropriate newapproaches to identify and intervene inpopulations where risk of infection is high.

For populations at risk, effectiveinterventions combine peer-based


outreach with non-judgmental services forHIV prevention, care, support andtreatment, as well as development ofappropriate IEC material for each group.Scale-up of such interventions has thepotential of reaping significant public

health benefits that far outweigh the costsof programme implementation. Themillions of HIV infections averted inThailand because of earlier interventions isample testimony to the effectiveness ofsuch approaches.


1. A focus on HIV/AIDS should be a component of Healthy Thailand policy toboost awareness of HIV, which has decreased in recent years.

2. Thailand should ensure that key components of its successful public healthresponse to HIV (such as STI clinic network and sex work interventions) are notweakened by current changes in the health sector.

3. Better size estimations and mapping of most-at-risk populations should becarried out to facilitate planning, scale-up and monitoring of interventions.

4. Interventions to reach indirect sex workers working in bars, karaokes, massageparlours, etc. and in outside establishments should be extended and strengthened.

5. Increased support should be provided to build the capacity of NGOs to scale upoutreach and prevention programmes with sex workers, MSM, drug users, migrantpopulations and others who are unlikely to access health services on their own.

6. Condom availability should be ensured for sex workers, IDU, MSM, youngpeople, migrant populations and people living with HIV.

7. MOPH should work with the National Bureau of Police to increase support ofprevention work, particularly among female and male sex workers and injectingdrug users. Interference with condom promotion, efforts such as using condompossession as evidence of prostitution, should stop.

8. Thailand should set clear policies on the importance of harm reductioninterventions in reducing HIV transmission among drug users.

9. Successful pilots, especially outreach and methadone maintenance therapy,should be scaled up with initial focus on urban areas where continued injectingdrug use is most likely.

Recommendations


10. HIV-related services such as VCT, care, and ART should be strengthened andaccess to these services by most-at-risk populations ensured. Positive preventionshould be fully integrated into all care, support and treatment services.

11. Drug hazard, sex and HIV/AIDS education should be included in the corecurriculum in schools and promoted among youth out of school. To supportsuch curriculum, the Ministry of Education should build teacher capacity atall Rachaphat universities and ensure nationwide implementation.

(See Annex 4 for more detailed recommendations for strengthening prevention efforts.)

6.1 Thailand's nationalsexually transmittedinfections (STI) controlprogramme

Effective STI services were a key elementin the early and rapid success ofThailand's response to HIV and remainimportant today. High rates of curable STIsuch as gonorrhoea, syphilis andchancroid acted as potent cofactors thatfacilitated HIV transmission between sexworkers and their clients, and clients inturn efficiently transmitted infection totheir regular partners. Rapid control ofthese STIs thus had impact on HIVtransmission above efforts to increasecondom use. Because of these combinedefforts, chancroid disappeared fromThailand as an endemic disease and STIincidence overall decreased by over 90%in the 1990s. Ongoing surveillance andcontrol activities have helped maintainthese low rates until recently when the firstincreases in STI rates in 15 years werereported from some provinces.

STI services directly support the 100%condom policy by providing regularexaminations and treatment for sexworkers. Monitoring of infection ratesamong sex workers and STI patients

provides direct evidence of 100% CUPimplementation; high STI rates fromspecific sex work establishments signalspoor compliance.

On a provincial and national scale, rapidreductions in STI rates provided the earliestevidence of success of the interventions.Similarly, a strong national network of STIclinics reporting regularly from allprovinces provides an early warning systemfor a possible resurgence of sexual HIVtransmission due to intervention weaknessor behavioural change.

STI services have been impacted byhealth reforms in a number of ways.There are fewer STI clinics and reportedlyless outreach activities to promoteprevention among sex workers. Policiessuch as early retirement and a 5% layoffresulted in loss of experienced staff,undermined motivation and weakenedservices. STI reporting from provinces hasdeclined from 76 provinces in 2002 to 53in 2004.

Under the new hospital-based STI servicesin many provinces, important activities tocontrol STI and HIV among sex workers intheir workplaces have been seriously

ACCESS TO SERVICES

6

compromised. Most STI clinics under thenew system are not full function institutions,frequently lacking outreach, partnernotification and counselling services. Sexworkers are reportedly less likely to use thenew services because of negative attitudesof other patients and hospital staff andinadequate provision for outreach. Lack ofan established relationship as previouslyexisted between sex workers and STI clinicstaff is a key factor.

Under the new system, STI services areoften low priority in the hospital. STIclusters, DDC centers and provincialhealth offices have no authority to pushthe hospitals to improve the STI servicesat the hospitals due to the differentadministrative line.

6.2 Prevention of mother-to-child transmission(PMTCT) plus

The first paediatric AIDS case of mother-to-child HIV transmission was reported in1988. By 1990s, 2.3 % of pregnantwomen were HIV infected and it isestimated that between 8,000 to 10,000HIV-infected women were giving birth peryear at the beginning of the 1990s.

Initially, the Ministry of Public Healthprovided formula feeding to all HIVinfected mothers and providededucation to avoid breast-feeding, whilethe Thai Red Cross implemented aprogramme for the prevention of mother

to child HIV with the use of zidovudineand support the provincial hospital toprovide PMTCT service.

Since 1999, after the successful field trialof the combination zidovudine nevirapinein north-eastern and Bangkok regions,the Department of Health (DOH),Ministry of Public Health, launched thecountry wide programme to cover thePMTCT over the entire ante-natal care(ANC) clinics (see Annex 6 - componentsof the PMTCT).

Thailand's policy of offering HIV testing asa routine part of antenatal care hasallowed nearly all women receivingantenatal care to learn their HIV statusbefore giving birth. However, PMTCTcoverage is still at 89%, meaning that atleast 11% of women in Thailand did notenter the programme or choose to optout. Around 12 % of HIV-seropositivewomen giving birth did not haveantenatal care. Offering rapid HIV testingaround the time of delivery provided HIVtesting to 71 % of women who did notreceive antenatal care. Women withpositive test results could learn theirserostatus in time for interventions toreduce mother-to-child transmission risk.

Perinatal HIV Implementation MonitoringSystems (PHIMS) was launched sinceOctober 2000 to enable the provincialand national level to monitor andevaluate the ongoing programme. The

33Access to Services

PHIMS was applied in every hospitals andyielded effective indicators for monitoringthe programme. It is completed by thePerinatal HIV Outcome MonitoringSystem in place in 6 sentinel provinces todocument the HIV status of all babiesborn from HIV+ mother.

During the review field visits to provincialhospitals, it was found that the supplychain for ARV and formula milk wereoccasionally discontinued and thatpractitioners had to mobilize otherresources in order to bridge the gaps.

Currently, the DOH has extended theservice to cover the medical care formothers, their spouses and children, andthe extended service is called PMTCTplus. However, the PMTCT plus has stillbeen separated from care and treatmentfor PHIVs in most of the hospitals as aresult of the division of responsibilitiesbetween the DDC and DOH. In 2006, itis planned that the programme will beadministrated under the 30 Baht schemeand this will resolve the managerial issuesof the programme.

6.3 Voluntary counselling andtesting (VCT)

The first VCT service was established in1991 in Chiangmai province with thesupport of the Thai-Australia NorthernAIDS Prevention and Care Programme andCommunicable Disease Control Region10. It was followed by the opening of an

anonymous clinic by the Thai Red Cross inBangkok. These VCT settings weredesigned to serve preventive measures tothe general population. Subsequently, theMinistry of Public health promoted thedevelopment of anonymous clinics inpublic hospitals throughout the country.However, the hospital's anonymous cliniccould often not be sustained. Althoughthere were a number of trainings organizedfor nurse counselors, the hospitals couldnot keep the nurses working only on VCTdue to the workload. Also, the increasingdemands for VCT created heavy workload,burnout and resignation of staff. HIV/AIDScounselling and voluntary counselling andtesting (VCT) are now available atapproximately 1,000 hospitals and clinicsacross the country. These services can bedelivered in specific HIV counselling unitsor are integrated in outpatients department(OPD) or in general health counsellingunit. All prenatal care units also deliverVCT. Thailand has a comprehensive andextensive network of voluntary counsellingservices staffed by trained counsellors andsupported by extensive referral networks.Psychosocial support is provided by mentalhealth professionals linked to psychiatrichospitals, counsellors working ingovernment regional, general, communityand private hospitals, health centers andby partners in non-governmental andcommunity-based organizations. VCTaccounted for 2 % of the total HIV/AIDSexpenditure among MoPH budget in 2003.


The Review Team noted that VCT servicesin hospitals are constrained by theshortage of human resources andinadequate training of staff. The referralsystem for psychological support is oftennot operational. Most of the practitionerscount VCT as a diagnostic test ratherthan an opportunity to promoteprevention. VCT is charged (under 30Baht scheme if prescribed by a doctor, athigher cost if self-referral for VCT) and conducted without anonymity.Counselling services are deliveredindividually or in group.

With the maturing of the HIV epidemic,there is a need to support workersincluding counsellors to enable them tocope with excessive workloads andburnout. There is a need to roll outadherence counsellor training to supportscaling up of ART and to scale upimplementation of evidence basedpsycho-social care interventions tovulnerable populations including IDUs,MSM, mobile populations, children andadolescents. It is critical that VCT policyand legislative gaps are quickly clarifiedand addressed.

6.4 HIV/AIDS careThe review team was made aware of a "3by 5" (3 million people on ART by 2005initiative) evaluation conducted in thesecond half of 2004. The followingsection of the review report include theirkey observations.

6.4.1 StatusExceptional progress has been made bythe Royal Thai Government (RTG) inscaling up access to treatment inThailand, achieving the nationaltreatment target of deliveringantiretroviral treatment (ART) to morethan 50% of those in need within 2001 to2004. As of February 2005, some60,000 PHIVs in Thailand had receivedART. Expanding ART coverage has beenachieved rapidly through high politicalcommitment and harnessing the fullpotential of the strong public healthsystem. Subsequently, in July 2004, theRTG declared its commitment towards theultimate goal of universal access to ART.

A one-stage approach to ART with first-linetherapy regimen for adults and children,fully subsidized by the RTG, as well as acomprehensive approach to the epidemicwhere care and treatment are linked withprevention have been adopted. The servicedelivery model for HIV/AIDS care and ARTis through the public health care systeminvolving the different levels up to districthospitals. Expansion to private hospitalsstarted only recently.

The procurement and supplymanagement component of the nationalART scale-up strategy has been wellplanned. Only in 2005, a shortage ofefavirenz occurred during a short period,partly solved by an urgent redistribution ofstocks available in the treatment units. A


strong HIV, CD4 and viral load laboratorynetwork has been developed (see Annex7 - ARV, other drugs and reagents).

In collaboration with the government andindependently, the Thai PHIV movementand community sector have played a keyrole in scaling-up treatment access. Anationwide programme to increaseaccess to the prevention and treatment ofopportunistic infections (OIs) hasprovided a basis for treatment literacyand education for antiretrovirals (ARVs)and the establishment of comprehensiveand continuous care (CCC) centersoperated by PHIV volunteers andsupported by health care workers in 129district hospitals covering 10 000 clientson ART.

The IHHP conducted a cost effectivenessanalysis of the NAPHA programme. Thismodel did not include the cost for 2ndline regimen. In 2004, ART costeffectiveness was estimated at US$ 592per life year saved and at US$ 614 peryear of orphan-hood prevented.

The ARVs are presently supported throughdifferent funding mechanisms, includingNAPHA, Gobal Fund to Fight AIDS, TBand Malaria (GFATM), Social SecurityScheme (SSS) and PMTCT-Care.Integration of the HIV/AIDS care into thegovernment 30 Baht scheme will soon beimplemented. The scheme will supportsecond-line treatment regimens.

The total health expenditure on HIV/AIDSincreased from 2996 million Baht in 2000(US$ 74.4 million) to 4188 million Baht in2003 (US$ 101.3 million). The largestincrease in spending during this periodcame from the ART programme (whichmore than tripled in spending) and fromoutpatient care. In response, the share oftotal AIDS expenditure going to ARTincreased from 20.3% in 2000 to 50.1%in 2003. Jointly, ART and OI treatmentaccount for 85.1% of total AIDS spending.

Modelling indicates that under the MOPHguidelines in 2004, the cost of the ARTprogramme alone is expected to reachUS$ 74 million in 2010, which willdouble the current expenditure of allHIV/AIDS programmes. (See Annex 8 -Projected Cost of Scaling-up of ART.) Ofimportance, the share of ART drug costsaccounts for more than 85% of the totalcost of the ART programme. The ARTprogramme expenditure in percentage ofthe National Health Budget is expected toincrease from 6.1% in 2004 to 10.2% in2010.Considering that a large proportionof those on first -line therapy willeventually need second line therapy,expenditures of second line may then startto account for more than one-half of thetotal spending. By 2020, second linetherapy for one quarter of all patients willbe absorbing three quarters of thetreatment budget and the cost of ART withsecond line regimens could reach US$500 million per year.


6.4.2 Analysis and observationsThe rapid expansion of the ARTprogramme for the past three years hascreated a substantial additional workloadon health professionals andadministration of the universal coveragescheme. Staff are overstretched and itmay lead to burn out.

The ART programme is only monitoringtwo indicators. The selection of a nationalset of indicator consistent withinternational recommendations couldassist in cross-country comparisons andsharing of best practices. The introductionof cohort analysis, as done with TB,should be considered. With metabolicside-effects of ART often reported, dataon treatment adherence should bemonitored, particularly considering thatpoor adherence to first line therapy willspeed the development of resistance.

The lack of appropriate paediatricformulations is of major constraint.Paediatric ART guidelines and the PMTCTguidelines also need revision in light ofrecent scientific knowledge. Children withHIV also face difficulties in relation toadherence, as carers are often ill or aged,and unable to provide adequatesupervision to ensure ARVs are taken atthe correct dosage or time.

ART should be used to increase theuptake for prevention activities andseveral opportunities are opening up for

accelerating prevention. These includeconcentrating on "prevention for positives"by specifically targeting condompromotion to those on ART (especiallyimportant to reduce onward transmissionof any resistant virus that may emergeduring therapy); and the promotion ofharm reduction interventions as an entrypoint to HIV/AIDS care and treatment.

There are no specific data available withregards to enrolment of high-riskbehaviour groups/hard-to-reach groupssuch as injecting drug users (IDUs), sexworkers, prisoners and migrants toNAPHA. The review team noted that insome sites active drug users are notincluded into NAPHA. However, sexworkers are generally enrolled in NAPHAwithout any discrimination and pilotproject for prisoners are initiated. HIV-positive migrants find it difficult to enrolinto HIV prevention and ARV treatmentprogrammes because of language issues,their mobility and lack of legal status inthe country. Efforts are made toincorporate the 30 Baht scheme to themand to develop specific communicationmaterials for HIV prevention by theMOPH. Those who are not registered withthe national health system also includethe poor in urban centres and indigenoushill tribe peoples. The government shouldensure an enabling environment forpreventing HIV infection and providingcare and treatment to these vulnerablegroups / hard to reach groups.


Although efforts are under way to ensurelong term sustainability of ARV, e.g. withthe development of a scheme of costsharing with government, HIV/AIDSprojections and economic modellingindicate rapid increasing cost of ART,mostly associated with the cost of secondline therapy. While it is clear that thefinancial needs for firsts and second line,even third line ARV regimen, requireaggressive measures to reduce costs,there is a need to further study thefeasibility and impact of introducing theseregimens and to look at mechanisms toreduce costs.

6.5 Tuberculosis (TB) andhuman immunodeficiencyvirus (HIV)

It is estimated that 10% - 25% of TBpatients are co-infected with HIV and thatTB morbidity in HIV individuals is around20% - 40%. TB/HIV co-infection results ina decreased TB treatment success rateand an increased TB mortality. Thetreatment success rate (72% in 2002cohort) is still below the Global DOTStarget of 85%, suggesting somedifficulties with implementation. TB casefinding has improve these past few years.However, with the TB case managementat hospital level, DOTS implementation isencountering difficulties.

The Review Team noted that TB/HIV iswidely recognized as a public healthproblem and that there is adequate

knowledge and analysis of the TB/HIVsituation at the national level. TB andHIV programmes are now structurallyintegrated at the national and regionallevels. The TB/HIV integrated strategyprepared aims at the delivery of anintegrated TB/HIV package in all healthservices settings to follow internationalguidance. TB/HIV activities have beeninitiated at the national level and arenow expanding to the provincial anddistrict levels.

TB programme's budget has beendevolved and is currently implemented asa part of 30 Baht scheme. Consequently,TB patients have to pay 30 Baht for eachvisit. Also, the supervision mandatedthrough the former vertical programmedisappeared and the purchase of TBdrugs, case finding, DOTSimplementation and follow up of TBcases is difficult to sustain. The central,provincial and community hospitals areoften overloaded due to the increasingdemand in medical services resultingfrom the universal coverage policy.Consequently, the fundamental activitiesof TB control are not alwaysimplemented.

The Review Team noted that TB and HIVhave been very well integrated in thesmall district hospitals where the sameservice manages both TB and HIV. Intertiary hospital, services are most oftime jointly delivered with referral of


patients between the two. TB patientswere not offered HIV VCT in all thecenters visited during the review teamfield visits.

Groups of PHIVs, NGOs and CBOs aresupporting the implementation of TB/HIVactivities. (For additional analysis of TBHIV status, see Annex 9).


STI services

1. STI and reproductive health services should be extended to specific populationsat risk (sex workers, MSM, young people with STI or sexual concerns) and accessto services ensured as the health system undergoes reform.

2. Department of Disease Control (DDC), including BATS and 12 regional STIclinics, should have a clear role in directly supporting STI services at the provinciallevel to maintain key outreach, monitoring and surveillance functions of thepreviously successful programme. DDC-supported STI clinics in each region orprovince could serve as learning sites to support decentralized STI services atcommunity hospital level and maintain standardized STI management.

3. Appropriate mechanisms and budget should be developed to maintainoutreach activities to sex workers in each province. Primary care units (PCU)should be involved to ensure that outreach to populations at risk in theircatchment areas is carried out as an integral component of its STI preventionand treatment work. Outreach should be extended in collaboration with NGOsto better reach indirect and male sex workers.

4. Bureau of AIDS, TB and STI (BATS) should develop plans to transfer skills fromexperienced STI clinic staff to new staff providing decentralized STI services at hospitalsand PCU through training and supervision at the regional and provincial levels.

5. Bureau of AIDS, TB and STI (BATS) should build its capacity to provide leadership inHIV/AIDS prevention and better technical support to provinces and other ministries.

Prevention of mother-to-child transmission (PMTCT) plus

1. HIV/AIDS care and treatment and PMTCT should be streamlined with a unifiedframework of technical support and an effective supply chain.

2. The informed consent of pregnant women to counselling and HIV testing, andpre- and post test counselling should be systematically ensured.

Recommendations


3. An evaluation of the profile of pregnant women not reached by the PMTCTprogramme should be conducted with special emphasis on migrants andmobile populations.

Voluntary counselling and testing (VCT)

1. A clear national policy of VCT should be strengthened in line with Thailand'snational guideline for protection of individuals and privacy, and in compliancewith the promotion of free and anonymous access to VCT.

2. VCT should be encouraged and promoted as a service for the general population,not only restricted to population at risks or symptomatic clients with HIV infection.

3. VCT services should be strengthened through capacity building and support, sothat there will be sufficient counsellors to provide service in every health caresetting responsible for HIV/AIDS, TB and STI care.

4. VCT for mobile and hard to reach populations should be specially developedto overcome the communication and social barriers.

5. Under the 30 Baht scheme, VCT should include provision of condoms and, forthose clients testing positive, a systematic clinical examination and CD4 count.

Care

1. Health benefit scheme should be harmonized in order to optimize resource useand unify the benefit package among the collective health care purchasers (30Baht scheme, CSMBS and SSS).

2. HIV/AIDS care and treatment functions should be delegated to the primaryhealth care infrastructure so as to reach PHIVs in their community and alleviatethe burden of tertiary hospitals.

3. Employment opportunities and income-generating activities should bedeveloped for PHIVs in care.

Antiretroviral treatment (ART)

1. ART programme should be expanded towards universal access as planned.Strict attention should be given to regular adjustments of treatment andmonitoring strategies, especially with second line and salvage treatmentregimens in the near future.


2. Staff and managerial capacity at the National AIDS Programme for the ARTprogramme should be strengthened at all levels, in particular for M&E. Theproportion of resources allocated to staff (e.g. short-term consultants,temporary staff) should be increased during the initial rapid expansion of theART programme.

3. The coordination and management between PMTCT-Care and NAPHAprogramme should be streamlined at all levels.

4. Access to ARV paediatric formulation should be developed as an urgent priority.

5. Efforts should be made to increase access to ART for high-risk groups such assex workers, MSM, migrant workers and IDUs with promotion of enablingservices such as harm reduction, both in communities and within closed settings.

6. The human resource development component of the ART programme, inparticular at the district and sub-district levels, should be further strengthened.This could be complemented by a mentoring system.

7. Monitoring and reporting should be standardized for all public sector ARTprogrammes with the introduction of cohort analysis.

8. Research should be undertaken to explore the feasibility and impact of costsharing and co-payment by patients and local government.

9. Sustained access to treatment should be facilitated by access to medicines andreagents at more affordable costs to the country through the development ofinnovative procurement schemes, local production, pressure on domestic andinternational prices and, where necessary, the application of safeguardsembodied in international trade agreements.

Tuberculosis (TB) and human immunodeficiency virus (HIV)

1. The budget for TB drugs should come from a central allocation rather than fromthe 30 Baht scheme, as it is established for ART. This would provide incentivefor practitioners in hospital to provide proper care to TB and AIDS clients.

2. TB case finding and VCT should be recognized as preventive measures andincluded in the 30 Baht scheme's benefit package free of charge so that thebudget allocations can be mobilized to support these activities.

The national allocation of resources forsurveillance and monitoring of the AIDSepidemic and responses is less than 1% ofthe total government HIV/AIDS budget.The M&E systems include two maincomponents: first, a series of statisticaldata collection instruments that are usedpartly for management and partly forreporting purpose, and, second, amanagement-based system that consistsmostly of meetings between stakeholdersand different levels of the system to reviewchanges in the situation and programmemanagement. One result ofdecentralization is that there has beensome fragmentation of national statisticalreporting systems and an increasedemphasis on local managementinformation systems often based onmeetings between stakeholders.

7.1 Systems in placeSeveral key HIV-STI-TB statisticalmonitoring systems have been inoperation for some years, with variedcoverage of the population. The AIDScase reporting system is very welldeveloped but under-reports the totalnumber of cases as in any case reporting

system. The information is used at thelocal and national levels to monitor theevolution of the epidemics. Sero andbehavioural surveillance through sentinelsites has been effective for two decadesbut there is some concern that shifts inresponsibilities from provincial level tohospital units may affect coverage. Thereare currently eight databases onHIV/AIDS, STI and TB surveillance underthe management of the Ministry of PublicHealth and other Ministries. There aresome overlaps between these databases.Coordination between agencies andrationalization (by government requiringall agencies to use the same software) ofinformation into a single database wouldimprove access to information; it wouldalso make it easier to obtain the 'bigpicture' on the epidemic and to use themonitoring systems to obtain informationon outcomes and impacts.

Local level programme and operationalmanagement information systems are lessdeveloped, as is monitoring of coverageof prevention and community-basedprogrammes such as community basedcare and support, voluntary counselling

MONITORING AND EVALUATION (M&E) SYSTEM

7

and testing, condom distribution andinterruptions in supply to sex workers andIEC activities.

Monitoring of coverage of treatment withARVs, especially PMTCT is virtuallycomplete. HIV drug resistance surveillancehas been established this year, with a firstsurvey among new HIV+ sex workers in24 sentinel sites. Information on migrantpopulation is limited similar to thecoverage of services; this is important, asthere are some indications that HIV ishigher in migrant populations.

Outputs of other government sectors (suchas education), the Global Fund, and otherinternational and NGO activities cannotbe traced in the National AIDS ControlProgramme monitoring system, making itimpossible to obtain an aggregate pictureof the collective response.

Health reform and decentralization arealready having significant effects on themonitoring system. As monitoring systemscontinue to adapt to local situations andpriorities, reporting on national levelindicators is increasingly fragmented.Some health facilities have stoppedsubmitting data on indicators such asnumber of commercial sex establishmentcensus, estimated numbers of sexworkers, and STI case reports.

At the same time, decentralization ofdecision-making has resulted in an

increased importance of local HIV-AIDSCommittees, and an increased demandfor feedback and programmemanagement information.

Ministry of Public Health officialsindicated that the quality of HIV/AIDSdata is declining. Development ofeffective strategies for groups such asyouths, IDUs, MSM, mobile populationsand ethnic minorities is constrained bylack of information. "Second generation"surveillance systems to capture thechanging dynamics of the epidemic andfacilitate responsive planning are underdevelopment.

7.2 Development of oneintegrated nationalmonitoring and evaluation(M&E) system

There is an urgent need for a nationalmulti-sectoral M&E framework. Atpresent, even the core indicators have notbeen agreed upon, but it is important thatthis be a short list, and that thegovernment resists international pressuresto proliferate the numbers of indicators. Aunified system extending from national toprovincial levels is needed. Without this,the big picture of the national situationand collective response will not beavailable to decision-makers.

Thailand is producing a large amount ofhigh quality surveillance information andresearch. The main sources of data in

43Monitoring and Evaluation (M&E) System

Thailand include HIV-AIDS-STI casereporting and sentinel surveillance systems,behavioural surveillance, routineprogramme management information,quality assurance assessment, qualitativeresearch and ethnographic research. Ananalytical process of validation of thesedisparate sources by triangulation, and ofintegration and synthesis of information isneeded to support evaluation ofprogramme effectiveness. This will helpdecision-makers to identify and prioritisethe most effective programmes andenhance the impact of the AIDSprogramme. A central body to coordinatedata collection from all partners, undertakecapacity development and synthesise theinformation is required to achieve this goal.

The HIV epidemic in Thailand is changingand evolving and the health system is alsochanging. To continue to be useful, theM&E system has to change from series ofvertical systems to a single integrated andmulti-sectoral system.

7.3 Knowledge managementand research

The strategy to mobilize research capacityas wisdom of National AIDS Plan wasexplicitly expressed in 1996 with a budgetallocated to the research plan. Inaddition, the Ministry of Public Health hasimplicitly allocated some part of medicalcare budget to support the collaborationof clinical trial networks. All theseinvestments may still be too modest

contribution to research. Nevertheless,there has been a growing community ofresearchers in multi-disciplinary areas toattain knowledge for AIDS solutions,including vaccine development. Researchresults have been integrated in thedevelopment of policy; e.g. the launch ofthe national PMTCT programmefollowing the results of clinical trials. Themajor driving force has come fromforeign or international donors. Thus,many of researchers had to compromisewith initiative demand of those donors.

Situation analysis and knowledge to keeppace with the rapidly evolving epidemicand cope with the emerging problems needfurther support. Critically, the risk behaviourof different communities needs to beanalysed to develop improvedprogrammes. Future operational researchshould address maximizing theopportunities for ART implementationpresented by the 30 Baht scheme which hasconsiderably increased access to healthcare in the country. At the same time,challenges posed during the on-goingtransitional adjustments concurrent withhealth sector reform need to be addressed.Areas for future operational research thatwere identified during the review were:

Evaluation of ART implementationthrough the contracting units forprimary care (CUP),

Evaluation of the processes andoutcomes of ART implemented


through partnerships, including jointHIV-TB interventions undertakenthrough collaboration with thenational TB programme and inacademic institutions,

Long term financial sustainability ofART and the whole AIDS programmefocusing on: 1) future increasingtrend of ART expenditure (per PLHAand as percentage of current healthexpenditure), reduction of OItreatment, and further reduction inprevention expenditure, and 2)streamlining programme (CSMBS,

SSS and NAPHA), standardisedtreatment regimen and cost sharing by concerned parties ontraining of human resources oradequate budget,

In-depth analysis of data at nationaland sub-national levels for a betterunderstanding of HIV/AIDS trendsand impact of the epidemics, and

Development of improvedmechanisms to ensure treatmentobservation, patient transfers andreferrals in order to improve outcomes.

45Monitoring and Evaluation (M&E) System

1. With decentralization, local authorities have increasing responsibilities. Capacitydevelopment in the use of information for decision-making should be urgentlyconsidered.

2. The NAP should develop a knowledge management strategy and a researchmanagement plan integrating the activities of the different agencies involved,enabling the identification of crucial gaps and facilitating the dissemination ofthe information needed by programme managers and policy makers.

3. The DDC, the BATS and the regional offices of Disease Prevention and Controlshould focus on programme-related and technical issues.

4. Information should be validated by triangulation, and synthesis and analysis toprovide better decision-making tools to policy makers.

5. HIV drug resistance surveillance should be urgently strengthened, targeting newHIV cases and patients on ART.

6. A single national M&E system should be put in place. This single system wouldrequire development of a national integrated M&E plan, a central coordinatingbody for HIV/AIDS-STIs and TB, and a government requirement that all

Recommendations


involved agencies use the same database. (Use of DevInfo software,recommended as the new standard for all UN agencies by Kofi Anan last year,should be considered.)

7. The AIDS cluster should continue to collaborate with universities and institutionsfocusing on programme-oriented operational research.

8. Efforts should be made to simultaneously strengthen the research capability ofHIV/AIDS and public health personnel at both central and provincial levels, incollaboration with research departments at universities.

In two decades of innovations and hardwork, Thailand has accomplished greatprogress towards bringing the spread ofHIV under control and mitigating its impacton individuals infected and affected by theepidemic. No praise is enough for thosewho, over the years, have devoted andoften sacrificed their personal andprofessional life to this powerful movementwhich has mobilized people, communitiesand the nation as a whole. Today, theresults of this effort speak for themselves interms of both the number of HIV infectionsaverted through well-targeted preventionand years of healthy life assured by makingtreatment increasingly available.Importantly, these results have created asense of confidence, both within Thailandand abroad, that the HIV/AIDS epidemiccan be overcome when leadership,science, social mobilization and resourcesare brought to bear all at once.

It should be noted, however, that thenational response to HIV is alsoconfronting new realities and challengeswhich it must address. Some of thesechallenges are as follows:

There are signs that the epidemic ispursuing its course, unabated, inspecific communities of sex workers

that have not been or are no longerbeing reached by preventionapproaches suited to their needs. Asa result, the epidemic threatens toregain momentum in communitieswhere complacency has set in -among young people, in particular.It appears to be on the rise incertain populations, such as menhaving sex with men (MSM), andhas become harder to track incommunities driven underground,such as injecting drug users (IDUs).

The urgent scaling up of access totreatment, while essential, isovershadowing the criticalimportance of enhancing preventionsimultaneously with care.

There is a general feeling that theresponse to HIV has moved from apeople-centered approach to apatient-centered approach, driftingaway from the mobilization of forceswithin society for the prevention of thedisease to a more clinical focus oninfection after the disease has set in.

The current and planned investments incare are highly commendable and should

MOVING FORWARD

8


be further expanded to best respond to thegrowing demand. This investment in healthand survival makes sense in both humanand economic terms. Every HIV infectionprevented alleviates much suffering andforestalls costly medical interventions in thefuture. It is, therefore, important torecognize that the movement which hasled to behavioural change and a gradual,although slow, disappearance of stigmaattached to HIV needs to be revitalized.

The following opportunities and reasonsstress the need to revitalize the responseto the epidemic in the current context ofThailand:

Under the leadership ofGovernment, the expressed nationalcommitment to this developmentalpriority should return HIV to thecenter of the public debate.

The political and administrativedecentralization under way shouldbring HIV work closer to the people,with a systematic capacity buildingat the local level while the centerretains key enabling, supervisoryand research functions andoperates monitoring and earlywarning systems needed to detectany breakdown in services as thedevolution of responsibilities to theperiphery unfolds.

The health reform shouldspecifically take HIV into account

and ensure that both prevention andaccess to care are equallyaccessible by all, regardless of theireconomic or legal status, and freeof cost or are fully covered byexisting user fees when they can beafforded by those seeking services.

Sustained access to treatmentshould be facilitated by access tomedicines and reagents at moreaffordable costs to the countrythrough the development ofinnovative procurement schemes,local production, pressure ondomestic and international prices,and where necessary, theapplication of safeguards embodiedin international trade agreements.

Prevention and social support needto be more prominent and beclosely linked to care as access totreatment further expands accordingto existing plans.

A reinforced focus of preventionshould be on young people and onpeople who are married to, or are ina sustained relationship with, HIV-infected partners.

Prevention strategies must adapt tothe evolving patterns of HIV riskbehaviours and risk situationsinvolving sex workers and theirclients, men having sex with men,

49Moving Forward

drug users and minority groups suchas populations along theinternational borders, as well aslegal and illegal migrants, for theirown health and for the sake of thehealth of the nation.

The use of knowledge acquiredthrough research should besystematically applied todeveloping HIV/AIDS policies andstrategies which, in turn, shouldinform the research agenda,particularly in the field of social,behavioural, health system andintervention-based research.

Civil society, in particular non-governmental and community-based organizations, need to bemore effectively supported andfinanced by national and local

sources, and local authoritiesshould be strongly encouraged andrapidly given the capacity to do so.

The response to HIV should workfurther towards incorporatinghuman rights principles enshrined inthe national constitution and judicialprovisions; mechanisms andinstruments should be put in placeto achieve this goal.

Given the high level of politicalcommitment, the exemplary capacities ofthe health services staff and the readinessof Thai civil society to confront theepidemic, the above-mentionedopportunities can clearly serve as astepping stone to carry forward a people-centered response to HIV/AIDS, and thusmeet the current and emergingchallenges with confidence.

Review team membersDr Daniel Tarantola Professor of Health and Human Rights, The University Chair of New South Wales, Sydney, Australia

Dr Wiput Phoolcharoen Research Consultant, BangkokCo-chair

Dr Pachara Rumakom Program specialist USAID Regional Development Mission/Asia, Bangkok

Dr Achara Teeraratkul Chief Surveillance and M&E SectionCDC GAP, Bangkok

Ms Nonglak Boonyabuddhi Program Specialist, CDC GAP, Bangkok

Mr Tony Bates Regional Programme Advisor, UNAIDS RegionalSupport Team for Asia and the Pacific, Bangkok

Dr. Mahesh Patel Regional Social and Economic Policy Adviser, UNICEF EAPRO, Bangkok

Dr. Scott Bamber HIV/AIDS Officer,UNICEF Thailand, Bangkok

Mr Paul Cawthorne Head of Mission, Médecins Sans Frontières Belgium,Bangkok

Dr Fonny J. Silfanus Programme Coordinator, Global FundAIDS Project, Jakarta, Indonesia

Dr Sukhontha Kongsin Assistant Professor Faculty of Public Health,Mahidol University, Bangkok

Mr Kamon Upakaew Thailand Network of People Living with HIV/AIDS(TNP+), Bangkok

Mr Nimit Tienudom President, Thai NGO Coalition on HIV/AIDS

Dr Gilles Poumerol TB/HIV Task ForceDepartment of HIV/AIDS, WHO Geneva

ANNEX 1 : REVIEW TEAM MEMBERS ANDFACILITATORS

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51Annex

Mr Richard Steen Treatment & Prevention Scale UpDepartment of HIV/AIDS, WHO Geneva

Dr Jean Michel Tassie ConsultantWHO SEARO, New Delhi

Ms Laksami Suebsaeng Technical Officer (AIDS)WHO SEARO, New Delhi

Facilitators from the Bureau of AIDS, TB and STI:

Dr Payont Hanpadungkit Dr Somyot Kittimunkong

Ms Suthida Kungsanthiah Ms Kanitha Tantaphan

Ms Vipada Maharatanaviroj Ms Wasna Nimvorapun

Ms Nutchanart Keawdumkerng Ms Tanaphan Fongsiri

Ms Lisa Kuntamala Ms Parita kuikeatkul

Ms Vipa Pawanaporn Ms Bussaba Tantisak

Ms Panatda Khaosa-ard Ms Parichat Chancharas

Mr Surasak Thanaisawanyangoon Ms Somchit Leknimit

Ms Chittra Onnom Ms Sunisa Chaisupa

Ms Panipak Thongchang Ms Naporn Hantrakoon

Ms Amnat Srikeat Ms Nanatawan Yantadilog

Facilitator WHO Thailand:Mr Chawalit Tantinimitkul, APO

Resource persons:Dr Sombat Thanprasertsuk Dr Petchsri Sirinirund Director, Bureau of AIDS, TB and STIs Senior ExpertDepartment of Disease Control Department of Disease ControlMinistry of Public Health Ministry of Public Health

Dr Jai P NarainDirector, Department of Communicable Dr Ying-Ru LoDiseases (CDS) Regional Adviser (HIV/AIDS)WHO SEARO, New Delhi WHO SEARO, New Delhi

ANNEX 2 : LIST OF INSTITUTIONS ANDPERSONS MET

The list of persons met is not exhaustive and limited to the main speakers during thevisits conducted in the institutions. The review team members would like to thank all thepersons who participate and who are not quoted in this list.

BATS Dr Sombat Thanprasertsuk

Department of Disease Control Dr Phetsri SirinirundDr Daranee Viriyakitja

AIDS cluster, BATS Dr Sanchai Chasombat

TB cluster, BATS Dr Sirinapha Jittimanee Ms Suporn Sukhapesna

STI cluster, BATS Dr Angkana CharoenwattanachokchaiMr Sutin Phong-phaew

Bureau of Epidemiology Dr Thanarak Plipat

Bureau of Strategy and Planning Dr Suwat SiasiriwattanaMs Rossukon Kangvallert

Bumrasnaradura Institute Dr Atchara Choavavanich Mrs Yaowarat Inthong

International Health Policy Program Dr Viroj Tangcharoensathien

National Health Security Office Dr Taworn Sakonphanit

Samutpakarn Hospital Mr Supoj Thungserisub

BMA Health Clinic Wat That Thong Dr Kovith Yongvanichit

SamutSakorn Provincial Health Office Ms Rasri Satayawirut

Office of the Permanent Secretary for Mr Akrapol WanaphutiMinistry of Labour and Social Welfare

Department of Employment, Ministry Ms Duangmon Booranalitof Labour and Social Welfare

Department of Skill Development, Ms Pundharika SamitiMinistry of Labour and Social Welfare

Social Security Office, Ministry of Ms Kanjana DhewasilchaikulLabour and Social Welfare

Office of Permanent Secretary for Ms Manthana SungkitEducation Ministry of Education

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53Annex

Ministry of Defence Major Smith Wattanathankam

Thai Red Cross Dr Praphan Phanuphak

East West Center Dr Wiwat Peerapatanapokin

Bangkwang Central Prison Dr Manop Srisuphanthavorn

Mercy Center Ms Usanee JanngeonMr John Mactaggart

Bangkraui Hospital Ms Pranee Kreethapirom

MSF - Belgium Mr Ian Naewbanij

Thailand MOPH - U.S. CDC Dr Jordan Tappero Collaboration Dr Frits Van Griensven

Rainbow Sky Mr Rapeepun Jommareoeng

Heath Promotion Center Mr Salantorn Eiamsuntorn

Population & Community Senator Mechai ViravaidyaDevelopment Association Mr Praween Payapvipapong

TBCA Dr Anthony Pramualratna

Access foundation, Path Ms Phakamas Ardphoom

PWLA Network Mr Chalermchai Phueanbuaphan

Duang Prateep Foundation Ms Nittaya Prompochuanboon

Swing Group Ms Wassana Warint

Region 3 : Cholburi Regional Office of Disease Prevention Dr Prasong Pagehavoenpoland Control Mrs Yupin shinsa-nguankeitChonburi Provincial health office Mrs Ruchanee Tarasuntisur

Sattahio kg 10 Hospital Dr Apinya VongkeewDr Ramase Amphaidis

Camillion Center Office Ms Naruemon KotcharinMs Phantira Jitman

Sex entertainment place, Pattaya city Ms Kanjana TongjineMr Supachai Tilump

Ruam-Kra-Ton-Club Team Ms Sunistha Pao-in

Rayong Provincial Health Office Mrs Wotcharee ThepnarongMr Somsak WiangyanghungDr Wiwat Wiriyakijja

Ban chay district Hospital Dr Weerasak Sakronsatean

Region 5

Regional Office of Disease Prevention Dr Tanapong Jinvongand Control Dr Tawat Buranatawonsom

Ms Panadda Chaichompoo

Nakhonratchasima Provincial Dr Samroeng Yanggratog Health Office Ms Boonchoay Nasungnoun

Maharaj Nakhonratchasima Hospital Dr Werasuk KiatpalangkulMs Patcharee Boonse

Slum Community beside realway Ms Bunsong Sadanglit

CommunityHospital,Jukkarat Dr Chokchai ManaturaMr Niwat Ruangdat

Burerum Provincial Health Office Dr Wichai Kuttiyavittayakul Ms Nipa Sutthipun

Beowlong School Ms Charunee OrosramMr Arayachai ChanavisetMr Sukon Sanmanee

Region 10 : Chiang Mai

Regional Office of Disease Prevention Dr Tasana Leusaree and Control Dr Kriangsak Jitvatcharanun

Chiang Mai Provincial Health office Dr Surasing Visrutaratna Ms Chonlisa Chaliyalettsak

The Church of Christ in Thailand Rev Sanan Wutti AIDS Ministry Ms Jaruwan Wutti

Nakornping Hospital, Chaing Mai Dr Prattana LeenasirimakulDr Suparat Kanjanavanit

Technical Promotion and Support Office Mr Jarun Siriwan 10th, Ministry of Social Development and Human Security

Sansai District Prakru Samu Vicien, Wat Chedi Mae KruePrakru Maethawat Chittathanto, Wat Nhong ma jab

Drug User Network Thailand Ms Dampawan PinitsuwanMs Kastanavadee KhamsurinMr Natthaphol ThananchaiMr Yanyong Jaiwang


Program for HIV Prevention and Dr Marc Lallemant Treatment Thailand

Region 11 : Nakornsri Thammaraj

Regional Office of Disease Prevention Dr Charn Uahgowitchaiand Control Ms Ketsasa Yanvaidsakul

Nakornsrithammarat Provincial Dr Sathit PaiprasertHealth office Ms Pacharee pechukson

Suratthani Provincial Health Office Ms Wandee Suppawongsanond Mr Soontorn Jearapan

Sritawee Temple & Community Ms Tadsanee ThailekMr Pongprajak Prajen

Maharaj Nakornsri Thammaraj Hospital Dr Bunphong LuengaronMs Pattara Bunpan

Twin lotus hotel Ms NoyMs Dang

Si-chon Community Ms Tharee ThanomnounMs Wachaya Cholasin

PHC Nala Ms Onouma Janjit

Sichon Hospital Mr Suppawat Chnnarong

PHC Tonreang Ms Supranee Bunsawang

Kanchanadit Hospital Dr Aakcha MukdapiraksMr Sontiya Suntamanon

Phang-nga Provincial Public Health office Mr Suthep Rukmoung

Temporary Primary Health care unit Mr Boonsong Chaysawai(Baan Bang muang)

Baan Num Khem Community and Mr Dumrong LuesiangPrimary School Ms Nanthna Lothong

Ta Kua Pa Hospital Dr Somsak ChksuchortMs Suchada Ploroy

55Annex

Opening speech by His Excellency Thaksin Shinawatra, Prime Minister ofThailand at the opening ceremony of the XV International AIDS Conference,Bangkok, 2004.

Policy of the Government. Policy statement of the government of His ExcellencyDrThaksin Shinawatra Prime Minister of Thailand delivered to the NationalAssembly on Wednesday 23 March 2005.

Summary reports prepared by BATS for the review:Management and administrationMonitoring and evaluationPrevention of Mother to Child TransmissionHigh risk groups, andHIV/AIDS care

An external review of Thailand's National medium term programme for theprevention and control of AIDS. 1991

National plan for prevention and alleviation of HIV/AIDS in Thailand 2002-2006

Project on drafting the national integration plan on HIV/AIDS prevention andalleviation in Thailand (2007-2011)

AIDS budget allocation by Royal Thai Government between 1996-2004

Achieving universal coverage of health care in Thailand through 30 Baht scheme, byDr Pongpisut Jongudomsuk. Health Care Reform Office, Ministry of Public Health

Analysis of policy development on antiretroviral treatment service, its advocacy andintegration into universal health insurance, BATS, 2004

Situational analysis of the process for developing antiretroviral treatment policy bythe Royal Thai Government, by Dr Sombat Thanprasetsuk and al. BATS and SiamUniversity, 2005

Evolution and development cycle of Thailand's Health Systems; from "health forall to all for health". By Wiput Phoolcharoen

HIV/AIDS analytical situation in Thailand. AIDS Division, June 2005

ANNEX 3 : LIST OF MAIN DOCUMENTSCONSULTED

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57Annex

Projection for HIV/AIDS in Thailand, 2000-2020. Thai working group onHIV/AIDS projection. March 2001

HIV/AIDS in Thailand by Wiput Phoolcharoen and al. 2004

Thailand. Epidemiological fact sheet. UNAIDS, 2004

HIV/AIDS voluntary counselling and testing and psychological support: needsand services. Department of Mental health. 2004

The integrated HIV/TB care strategies for the control and prevention of tuberculosisin Thailand. National recommendations guidelines. 2001

National policy guidelines for the newly revised TB control strategy in Thailand. Agencyroles and personnel responsibilities at Regional and District levels. MoPH, 1998

The success of the 100% Condom programme in Thailand: policy implicationsand recommendations (in Evaluation of the 100% condom promotion and thevalidation of the decline in trends for selected STDs)

Evaluation of the 100% condom programme in Thailand. Case study. UNAIDS,July 2000

Executive summary. "3 by 5" mission Thailand. October 2004

The National Access to Antiretroviral Program for PHIV (NAPHA) in Thailand, bySanchai Chasombat and al (draft 2005)

Involvement of people living with HIV/AIDS in treatment preparedness inThailand. Case study. WHO, 2004

Consultation wit young people on HIV/AIDS 2004. Thailand country report.UNICEF, May 2004

Thailand's response to AIDS "building on success, confronting the future". TheWorld Bank, November 2000

Reversing the spread of HIV/AIDS in Thailand: success and challenges. ThematicMDG report, March 2004

A situation analysis of HIV/AIDS related discrimination in Bangkok, Thailand. ByLuechai Sringernyuang and al.

Thailand National AIDS Account. National Economics and Social DevelopmentBoard, Office of the Prime Minister and International Health Policy Program-Thailand, Ministry of Public Health. 2004

Cost and consequence of ART policy in Thailand. Background paper: economicevaluation of Antiretroviral policy. By Jongkol Lertiendumrong, Chavewan Yenjitrand Viroj Tangcharoensathien. International Health Policy Program with thesupport of the World Bank, March 2004

External Review of the Health Sector Response to HIV/AIDS in Thailand

The following annexes are in electronic format and are available upon request [email protected]

Annex 4: Detailed review analysis of the HIV prevention activities

Annex 5: STI services

Annex 6: Components of the PMTCT

Annex 7: ARV, others drugs and reagents

Annex 8: Projected costs of scaling up of ART and review brief overview

Annex 9: Details on HIV-TB status

Annex 10: Press Release 19 August 2005

LIST OF ANNEXES IN ELECTRONIC FORMAT

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A joint publication of the Ministry of Public Health,

Thailand and the World Health Organization,

Regional Office for South-East Asia

EXTERNAL REVIEW OF THE HEALTH SECTOR

RESPONSE TO HIV/AIDS IN THAILAND

External review of the health sector response to HIV/AIDS ... · EXTERNAL REVIEW OF THE HEALTH SECTOR RESPONSE TO HIV/AIDS IN THAILAND. A joint publication of the Ministry of Public

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External review of the health sector response to HIV/AIDS ... · EXTERNAL REVIEW OF THE HEALTH SECTOR RESPONSE TO HIV/AIDS IN THAILAND. A joint publication of the Ministry of Public