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TIIE APPLICATION OF A COMMUNNY-BASED APPROACH (cBA) ON ArDS PREVENTTON Ar\D CONTROL .

IN THAILAI{D

MAIN RESEAR,CEERS :

Dr. Som-arch flongkhomtong Dirct ASEAI{ Institute for Health


Developrnent (AIHD) Mahidol University Nakornpathour" Thailand

Dr. kishio Ono

Teanl*adet JICA Comrunity Health hoject


Offrce of Experts (JICA) Khon l(aen, Thailand

TUIIDING AGEITTCY :

Iapan Foundation for AIDS Prrevention

RESEANCUPERIOD:

April - December 1994

TITE APPLICATION OF A COMMUNITY.BASED APPROACH (cBA) ON AIDS PREVENTTON AI\D CONTROL IN THAILAND

MAIN RESEARCIIERS

Dr. Som-arch wongkhomtong Direct ASEAN Institute for Health Development (AIHD) Mahidol UniversitY Nakornpathom, Thailand

Dr. kishio Ono Team Leader JICA Community Health Project Office of Experts (JICA) Khon Kaen, Thailand

FUNDING AGENCY

Japan Foundation for

AIDS Prevention

RESEARCH PERIOD

April - December 1994

TABI,E OF CONITI\TS

Aoknowledgements

Chapter

1:

Summary of the Researoh

Project

Chapter 2:

The AIDS Situation in Thailand Country Profrle Methodology History of the Epidemic The Current Epidemiological Situation Risk factors in HfV transmission Geographical distribution Future Projections and Repercussions Principles of Community-Based Approach Community Participation . . Partnership Participatory Research Community-Based Aotion Programmes Education for AIDS Prevention Graduate AIDS Volunteers . . . Duang Prateep Foundation . . . Support Groups

4 4 7 7
10 14

l6
20
23

Chapter 3:

26 30 32 34 34 35 38 45

Chapter 4:

NewlifeFriendsAssociation Wednesday Friends Club Care for People with Hry/AIDS . Thammarak Niwet
Chapter 5:

......46
49
53

54

Christian Outreach to AIDS Affected Children . . . Workshop on Community-Based Approaoh for the Prevention and Control of AIDS in Thailand . . . Executive Summary Summary Report

57

63 63

64

References

8l

ACKNO1YLEDGEMH\ITS
This project was funded by Japan Foundation for AIDS Prevention. We would like to express our gratitude to the Foundation for their support of the project. Special thanks are due to the direotors of the case studies reviewed in the project, for oontributing time to discuss their aotivities in detail. The staff of the AIDS division, Ministry of Public Health, were also very helpful. The workshop was a valuable source of ideas and we would like to thank the staff of AIHD and the other institutions within Mahidol University's Salaya Campus who organised it. We would also like to thank all the partioipants who shared their experiences in implementing AIDS control and care programmes. Although we cannot thank all of them here we wish to make special mention of Acharn Jon Ung-pakorn, Father Joseph Meyer and Phra Alongkot Tikkapanyo, who have promoted community prevention of HIV and caring for persons with AIDS in Thailand. Research assistanoe was professionally provided by Wanjiku Kaime-Atterh<ig whose contribution to the project exceeded those normally provided by a research assistant. We would also like to thank all the persons living with HIV/AIDS who gave us an insight of the kind of services and support systems which are appropriate to their needs. It was diffioult and emotionally painfrrl for them to open themselves up to our questions and all did so with dignity and honesty. It is our hope that the contents of this research will oontribute to the improvement of their situation, as well as those in other developing countries.

Dr. Kishio Ono Dr. Som-rch Wongfchomtong

LIST OX'tr.IGURES

Flgur

I
Map of Thailand

X'tgurc 2

HIV

seroprevalence Among IDUs

in Bangkok, Thailand (L987-1991) .

Flgule 3 Distribution of Reported AIDS cases by Year of Diagnosis (1984 ' 1994)

ll

Ftguo 4

HfV Prevalence Among Seleoted Groups


(1989

- 1994',)

L2

Flgur

Distribution of Reported AIDS Cases in Thailand by Route of Transmis$ion (1984 - 1994)


Flgurs 6 Age and Gender Disaggregation of Rates of HIV infection Cumulative to 1990 in Thailand . . .
Ftgore 7

13

15

HIV Sentinel Surveillanoe - Julv


Ftgure 8

1994

17

Hry/AIDS Distribution in Thailand bv Area


and Target Group (1994)

l8

Xlgurc 9 Estimated and Projected HIV infection in Thailand by Age Group

2l

Xlgur

10

Number of AIDS Orphans at Ages Less than Five Years ..... and Twelve Years or Less: Thailand 1990 - 2000

. 22

LIST OF'TABLES

Table

I
Prevention of HlV-infection arnong Population Corresponding to Waves of the Epidemic in Thailand (number of provinces surveyed)

l0

CHAPIT'R

SUMIUARY OF THE RESEARCH PRO.IECT

Main Activities of the Resealch hoject prevention and control in Thailand and the application of a Community Based Approach.
Research

on AIDS

A workshop on Community
control.

Based Approach

for AIDS prevention

and

Backgmund and Rationale

AIDS is considered as one of the most important public and social problems in Thailand because it is a deadly communicable disease that has infected many people. Moreover, there is no vaccine to prevent HIV infection or drug to cure AIDS and current drugs used to lengthen the life of the patients axe very expensive. All these factors contribute to increase the problem of prevention and oontrol of AIDS in every community in Thailand.
On the other hand, education and health promotion are measures that can help people from becoming infected or infecting others, if they are already infected.

Moreover, many people with AIDS spend most of their time living in the oommunity where most of the opportunistic infections can be managed. With this realisation, researchers and scholars are focusirg on a Community Based Approach (CBA) as one of the most effective measures of working with the people to educate and solve their problems. CBA is also considered as an appropriate means to solicit sustainable development. Therefore, the attempt to apply CBA on AIDS prevention and control in Thailand is interesting not only in terms of academic activity but also in terms of its contribution to solve the AIDS problem in Thailand.

Objeclives of the Researth


General Objective:

o To apply a Community

Based Approach to AIDS prevention and control

in

the community in Thailand.


Speoific Obiectives:

o To

study the AIDS situation in Thailand.

o To study the principles,

methods and strengths of a Community Based Approach as a tool to solve the community's problems. using a Community Based Approaoh for AIDS

o To research various projects


prevention in Thailand.

o To organize a workshop under the title of "The Community


the learning about this issue.

Based Approach

and AIDS Prevention and Control", to summarize, synthesize andpropagate

Research Methodology

Literature survey of the AIDS situation in Thailand.

O Literature survey to study the prinoiples, methods, strengths, and possible application of CBA to AIDS prevention and oontrol aotivities.

o To study the Research and Development (R & D) activities in

some

communities which use the prinoiples and method of CBA to prevent and control AIDS in the communitv.

o A workshop

to summarize and propagate CBA experiences in the prevention and oontrol of AIDS.

-2-

Researth Period

Activity
Literature survey activities
Study of Research and DeveloPment

Time period I April to 30 May 1994.

activities in the

communities

June to 30 September 1994-

Workshop
Preparation of Research Report

l0 to 12 October

1994.

15 October to 30 December

t994.

Benefib fiom the Research Pmject

The research project has provided some learning on the strengths and weaknesses of CBA and also recommendations on how to use it for the prevention and control of AIDS in the community in Thailand and in other
developing countries.

Research Resulb

Details of the researoh are described in the following ohapters:


Chapter

2: 3: 4: 5:

The AIDS Situation in Thailand Principles of Community Based Approach


Researoh and Development activities using Community Based Approach for the prevention and control of AIDS in Thailand.
The Workshop on Community Based Approach for the Prevention

Chapter Chapter

Chapter

and Control

of

AIDS in Thailand.

-3-

CHAPTER 2
THE, AIDS SITUATION

IN THAILANI)

Country

hofile

Thailand, or Muang Thai as it is called in the language of the country, means the "Land of the Free." Unlike most of its South East Asian neighbours, Thailand has never been a colony of a Westem nation. Before the nanne was

it was known as Siam. The country covers 513,517 square kilometres of the Indo-Chinese peninsula and is bordered by Laos and
ohanged

in

1939,

Cambodia on the East and Northeast, Burma on the West and Northwest, and Malaysia on the South.

The country is divided into four main geographical regions; the mountainous north where teak and a rflngo of temperate crops are produced; the semi-arid northeast plateau region where some minerals are mined, cash crops such as jute and maize are grown and dry rice oultivation is practiced; the flat, fertile central region which has long attracted settlers and is one of the world's most fertile rioe growing axeas; and the southern peninsula with its baokbone of mountain ranges interspersed with fertile plains, important for its high grade tin ore,
rubber, rice and

paln oil production and for its fishing industry.

Thailands population now stands at 57 million, and is growing at arate of about 1.3 per cent per annum. This low growth rate results from a successful family

planning programme which has substantially lowered the birthrate in the past twenty years. The population is homogenous with about 75 per oent beirg ethnic Thais, 15 per cent Chinese, and the remainder includes Malays, Khmers, Laotians, Vietnamese, Mons, Hilltribe people and a few Westemers.
The Kingdom has been a constitutional monarchy with a parliamentary system of govenrment since 1932. The monarch plays a central role in Thai society and

culture; the King and Queen are much loved and respected. King Bhumibol, who came to the throne in 1946, is a leader of many talents and is on the

forefront of development efforts aimed of the Thai people.

41

improving the health and prosperity

Buddhism is the state religion of Thailand and is practised as well as professed by about 95 per cent of the Thai population. l1{uslims form the largest of the religious minorities and are found mainly in the four southern provinoes. Other minority groups include Hindus, Sikhs and Christians. The Buddhist religion is

an integral part

of Thai life; its influence pervades Thailand's arts, oulture,

arohiteoture, and the character of its people. The Wat, or temple, is the oentre

of community life and its monks are the most important citizens. It is still traditional for young men to be ordained as monks when they reach the age of 20, as a preparation for adult life. As 66nks, they must follow the strict
disciplines of the monastic life. Thailand currently has one of the fastest growing eoonomies in the world and has been dubbed the Fifth Tiger of Asia after the fotu newly industrializing economies (Nms) of Singapore, Hong Kong, Taiwan and the Republic of Korea. Growth has been accompanied by a gradual change of the economy away from one based largely on agricultural oommodities towards one more reliant on manufacturing and services, including tourism. I'hailands major
exports are processed foods, textiles, rubber, tin, and eleotronics. The country's significant economic growth has contributed to a steady increase in the well-being of the majority of its population. The proportion of the

population living below the official poverty line fell from 30 per cent in the mid-1970s to 23 per cent in 1988. However an increasing share of the benefits have been concentrated in the urban af,eas and inoome disparities have widened to the detriment of a rural poor. As the country sfuanges from a rural-based economy to an urban-based economy, so do traditional norms and values of
social and sexual behaviour.

-5-

Flgurt

l:

lVlap of Thailand

OV .\
oQ

(\
Ur:

,!Q
a
0
/r:
.Rt

lruiiilS

r lrlori
Pofhum lhonl

Prochuop Xhrfi Khon

2 wnli
Nonlhqbura

surot lhont

riurr

q:rtg{ori i (*B

THAILAND
lJ:yr?tF'l tYtu
rY

B:

t^ rlo tr ,inon Jrong '.3 porir \o!


f,N8

T
>l,sJ\
,t-""1-.--: '

E ruonrs
NoRTHEAST

s
/l

cENTRAL

souTH

J*" i

!:h1 i

o ..-j

Poplation Density, 1994

Legend

t]

< rff) r0r - 200

person

km3

person / kmz person

Il-'1'-:l 201 - 500 [.: ..'.'J

krn?

I
Source

ffi

501

- t,000

person / km2 person

>

1,000

km2

: . Local Administration ' Local Adrninistrative

Department Announcement, March

31,l9g4

Map and Baseline Data, The National Statistical Oftice, 1990

Methodology The data presented in chapters fwo, three and foru were collected from April to September 1994 from Thailand's four main regions. The study used a documentary research approach entailing four methods. First, available statistical data on HIV/AIDS were collected from several sources inoluding universities, research instifutes, various national, provinoial and district level government offices, and in several cases, from health service centres such as hospitals and

AIDS clinics. The objeotive was to determine the disease's patterns in terms of magnitude and distribution since it was first identifred as well as its projected levels into the future. Second, a literature survey aimed at identifring current trends in AIDS and STDs research with an emphasis on epidemiologioal studies to determine the disease's geographio extent and main target gxoups was used. Literature on community-based approach and espeoially how it can be used for
the prevention and care of AIDS in the oommunity was also reviewed. Data and information on these axeas were supplemented through in-depth interviews with

AIDS researchers and persons working at provincial, district and community levels as well as on-site reviews of on-going AIDS prevention and care
prograrnmes.

Ifistory of the Epidemic


AIDS was fust reported in Thailand in September 1984 in a homosexual male who had lived for some years in the United States. From that time until 1987, a total of 8 cases of full blown AIDS were identified by the Department of Communicable Diseases Control of the Ministry of Public Health (MOPH). The number of AIDS related oomplex (ARC) cases was27 while 907 persons tested HlV-positive (MOPH, 1988). These initial cases of HIV and AIDS in Thailand were confined to Thai homosexuals/bisexuals and foreign tourists, including drug users who oame to northern Thailand for sex and cheap heroin. As a result, AIDS was perceived as a disease of homosexuals and foreigners. Observation of the spread also led to the. speoulation that Thais had some immunity against the disease and the epidemic would thus pass by with only minimal impact. In 1988 the World Health Oryanrzation, which makes a distinction between three HIV spread patterns, classified Thailand as a oategory

-7

III

country. This third pattern describes the epidemiological situation in countries where AIDS appeared relatively late and then only in isolated cases.
However, in that salne yeff, surveillanoe by the Thanyarak Hospital for drug treatment (Unektabh and Phutiprawan, 19SS) and the Bangkok Metropolitan Administration's Health Department (Vaniohseni et al., 1989) indicated an explosive spread of HIV infeotion arnong Intravenous Drug Users (IDUs) in Bangkok. Infeotion levels arnong this group rose from I per oent to 32-42 per cent in the frst 8 months of 1988 (Figure 2'). A study conducted among IDUs at Thanyarak hospital showed that widespread sharing of needles facilitated the rapid spread of the infection pmong this group. Subsequent surveys by the Ministry of Public Health also'showed high rates of infection in various other provinces and remote hilltribe areas.
The second wave of the epidemic ocourred a year later among brothel workersl infected through sexual contaots with infected partners. It is believed that these sexual partners were IDUs and bisexuals infeoted in the first wave of the

epidemic. Previous serosurveys had shown virtually no HfV infection arnong female prostitutes through May 1989. In July, the first national sentinel serosnrvey discovered that 44 per cent (44 out of 100) of low charge prostitutes in Chiang Mai were infected. As of June 1991 every province in Thailand reported HIV infection among brothel workers with provincial rates increasing
steadily.

In

HIV infection was reported arnong heterosexual men marty of whom are clients of prostitutes. This third wave of the epidemic was fust discovered arnong men seeking treatment at public Sexually Transmitted Disease (STD) clinics. From 1990 to 1993, sentinel surveillance conduoted by the Ministry of Public Health documented a near doubling of HIV infeotion arnong urban STD clinic affendees annually in all regions of the country. The prevalence of HfV
1990,

tA homogenous sex industry does not exist in Thailand. Sexual servioes can be purchased through a number of institutional anangements such as brothels, hotels and motels, tea-rooms, massage parlors, call-girl and escortgirl servioes, bars, night-olubs, A-Go-Go bars, cooktail-lounges, restaurants, golf clubs, discos, pubs etc. Commeroial sex workers in brothels are referred to as "direct" prostitutes while the "indirect" prostitutes are those that operate under the guise of some other activity.

-8-

4mong blood donors, mostly men, also increased from 0.56 per cent
1.03

in

1989 to

in 1990.

The wives and girlfriends of infected men constituted the next wave of the epidemic. The MOPII sentinel surveillance survey data of 73 provinces showed 0.21 per cent prevalence in June 1990. By Deoember 1990, the survey revealed a 225 per cent increase to 0.70 per cent among 49 provinces. While in 1988 and 1989 most HlV-positive pregnant women were reported to be IDU, by 1991 the proportion of HlV-positive pregnant women infected by their husbands exceeded those who were prostitutes or IDU.

figur 2: HIV Seropnvalence Among

IDUs in Bangkok (1985-199f)

4('"i,.719

q,9nv %9te %9A394

A total of 36,788 patients were admitted and tested for HIV at Thanyarak Hospital from August *Eady ad hoc 1937 through July 1991, for mean of 766 patients per month during the period. surveys in 1985, 1986 and 1987 detected no infections. Souroe: Ministry of Health

In the fifth and last wave of the epidemic HlV-positive women infected their infants. A third or more of infants of infected mothers will be infected during
pregnancy or childbirth. Aocording to the MOPH, at least 3000 infants had been

born to HlV-positive mothers nationwide since the first pediatrio AIDS case attributed to HIV in Thailand was reported in 1989. Table I illustrates individual waves and the rapid spread of the epidemic.

-9-

Table 1: HlV-positive Population Conrsponding to Waves of the Epidemic in Thailand (Number of hovinces Suveyed)

Population Crroup

Jrrne

Dec June
1989 1990
32.25 35.56

Dec
1990

1989

IDUs

33.43

32.04 (31)
17.00

(14)

(26) (4e) 9.82 t3.78 (2e) (70)


3.69

Brothel Prostitutes

6.37

(r2)
Males in STD Clinics
1.29

(41)
5.80

(14) Blood Donors


0.56

(2e)
0.96

4.39 (70) 0.60 (72) 0.21 (73)

(42)
1.03

(13)

(30)
0.41

(46)
0.70

Women in ANC Clinics

0.15

(13)

(28)

(4e)

Souroe: Sentinel Swveys, Ministry

of Public Health

The Cunent Epidemiological Situation Ten years after the first AIDS case was reported in Thailand, the epidemic is spreading rapidly among all groups. There have been a total of 9,923 AIDS related complex (ARC) and firll blown AIDS cases reported to the Ministry of

Public Health since the beginning of the epidemic until July 1994. In lgg3 alone, the Ministry of Health revealed 5717 cases of ARC and firll-blown AIDS, 55 per cent of the total number of all reported oases (Figure 3). Because the epidemic is still in the early stages, and it takes an average of ten years from the initial infection with HIV to the onset of AIDS, the number of people who have become sick or died is still small. Since 1991, the Thai govenrment has relied on the AIDS voluntary reporting system whereby health institutions and physicians are enoouraged to report the specific details of AIDS oases

-10-

anonymously to the Ministry of Health. It is likely that under-reporting of AIDS cases has helped to conceal the true levels of infection. This oan happen due to
a number

of reasons:

o some people may never seek hospital care for AIDS; o some doctors may not want to record a diagnosis of AIDS because of the stigma attaohed to it; and o some people with HIV infection may die of other diseases before they are ever diagnosed as having AIDS; and o some rural health care facilities may not have the capability to test for HIV
infection.

Flgur

3:

Dishibution of Repofted AIDS Cases by Year of Dirynosis (1984-1994)

Distribution of Reported AIDS Cases in Thailand by Year of Diagnosis, 1984-1994 (data as of September 30, 1994) Number of Cases

1984. 't988

1989

1990 1991
Year

1992

1993

1994

Division of Epidemiology; Ministry of Public Health

- ll

In addition to the voluntary reporting system, the Ministry of Health derives data on HfV infection from the national surveillance survey which was commenced in 1987. The cross-sectional suruey collects data biannually (June and December) from a number of diif;ferent population groups throughout the nation (Figure 4). As with any other oountry in the absence of systematic screening for HIV, the actual number of cases of HIV infection in Thailand is
believed to be considerably higher than the number of offi.cially reported cases. The Thai working group whioh comprises representatives from the Ministry of

Public Health, Ministry

University Affairs, Non-governmental and Governmental Organizations and WHO estimated that 600,000 people were infected at the end of 1993.

of

Flgue

4: IIIV Ittvalence among Selected Groups 1989-t994

HIV Prevalence amcng Selected Groups

2C.00

15.00

10.00

Dec-89 Ju1-90 Dec.go Jun.g.l Dec.91 JtiI.gZ Doc.92 Jurrg3 Division of Epidemiology, Ministry of pr.rblic Heatth

Dec-93

-t2-

According to the latest findings, 75 per oent of HIV infections are attributed to heterosexual transmissions. Although decreasing, infeotion among IDUs remains high and accounts for 8 per oent of the total AIDS oases. Gay and bisexual men have trailed off with one per cent despite the expectation that they would experience rapid transmission. Infeotion is concentrated in people aged 15 to 45 years. Although transmission throughout the sexually active population will continue to render infection levels equal between males and females, presently more men axe infeoted and male to female ratio is 6.6 to 1. Majority of the infected men afe aged 20 to 40 years, of whom alrnost 90 per cent are poor fanners or labourers. Reports show that the oustomers of low-prioed brothels and IDUs oome from this ocoupational group (Koetsawang and Ford, 1993)'

Ftgur 5: Distuibution of Repofied AIDS

cases

in Thailand

by Mode of Tmnsmission (1984'1994)

Distribution of Fteported AIDS Cases in Thailand by Route offransmisiion, igB4-1994 (data as of Septemlrer 30'1994)

Unk

"TL"'i?:o

9%

Division of Epidemiology, Ministry ef Public Health

-13-

Women in Thailand are infected at a signifioantly younger age than men (Figure

6). The Majority of HlV-positive oases among women (5 out of 7) are found in the 15 to 24 age braoket and related to heterosexual sex activities such as prostitution. The level of infeotion among brothel based prostitutes is much higher (27 per oent) than that of high class prostitutes (13 per oent). An alarming development is the rise of HIV infeotions among housewives. Since 1987, seroprevalence rates among pregnant women have almost doubled every six months. In certain Northern provinoes antenatal clinics (ANC) prevalence rates reach 4.5 per cent. Elsewhere prevalence of less than 0.5 per cent has been reported. This indicates that infection is rapidly spreading among the population at large, and not solely among the so-called "high risk groups."

hansmission has also been noted for vertical transmissions from mothers to their infants. At present 430 pediatric AIDS oases (225 male,2O5 female) from perinatal transmission have been reported to the Ministry of Public Health. The actual number may be much higher. The rate of vertical transmission varies from 2l per cent to 33 per cent in Bangkok to 42 per cent to 46 per cent in the north (Thisyakom et al., 1994).
Transmission through blood and blood products is not reported to be a serious problem in Thailand. Since 1989 all donated blood has been screened for HIV antibodies to help ensure a safe national blood supply. Voluntary blood donors are recruited and donors are asked to self-select. However, results from screened

rapid increase in

Hry

blood indicate that the virus is spreading among that part of the population which does not consider itself to be at risk of infection. Seroprevalence amon.g blood donors rose from .28 per cent in 1989 to .81 in 1993.

Risk Factors for HfV Infection

contributing to Hry transmission among heterosexual men is unprotected sex with female prostitutes. Numerous sfudies have shown that 50 per cent of Thai men have sex before 18 years, and most of them have their frst sexual experienoe with a sex worker (Sittitrai et al., 1992). A large proportion of Thai males continue to patronize sex workers even

The primary factor which

is

after marriage.

-14-

Flguc 6:

Age and Gender Disaggrcgation of Rates of HIV Infection Cumulalive to 1990

HIV

porltive raL Por

IO,OOO

Female

ftfil

Mab

o-4 sS

10'14 15-19 2S24 2r'?F n&4Gi-3940'+4 45-49 50+t 56-59 80+

Ago In ycan

Sowce: United Nations Development Programme

Data from the surveillance survey indicate that the majority of Thai women face the most risk of HIV infeotion from sex with their husbands or sex parbters.

The traditional custom requiring girls to refrain from se until after marriage is changing. Thai girls, especially those migrating from rural areas and living in non-family settings, now accept sex within relationships (Sittitrai,1993). Owing

to the non-permanent nature of

these relationships, serial friendships with different partners take plaoe. An overlap of two patterns, sex with a girlfriend and sex with a oommeroial sex worker, is also a oommon practice among their

boyfriends.

HIV among housewives is simply being married, with the husband as the veotor of HIV infection. Social lore
The major risk for becoming infected with
teaches a Thai wife that to be accepting and unoomplaining is the best strategy to effect the refurn of an errant spouse. Thus many women, both urban and

rural, prefer the casual liaisons of husband over the threat of him finding

15 -

second wife. The lower status of women means that women often lack oontrol

over their sexual life and are unable to insist on safe sexual behaviour. Moreover, the use of barrier proteotion to reduoe HfV fiansmission presents difficulties for many women beoause of the desire and, in malxy cases, the cultural imperative to bear children. Women who do not want to conceive and have access to condoms have difficulty in persuading their husbands to use
them without jeopardizing the relationship.

By virtue of their profession prostitutes oome in contact with many persons who engage in high risk behaviows. Unsafe sexual aotivity therefore places comttteroial sex workers at high risk of being infected with HIV. Research on the use of condoms suggests that low class prostitutes have lower level of condom use and report higher rates of HIV infections than high class prostitutes

working in massage palours, cocktail lounge etc. Researchers have attributed this to the educational level of their olients. Clients of low-priced brothels are labourers and farmers with low educational status who are among the most infected group in Thailand and who may already be infected. Low priced brothel prostitutes and those working in high class establishmsnls do not use condoms with regular customers in order to keep them (Koetsawang and Ford,
1ee3).

Until recently, the barrier method of preventing Hry infection was the male
condom, and use depended largely on the man's decision. The female condom, femidon, provides women with the option to protect themselves from unsafe sex. However, the relatively high price could mean that low-priced brothel prostitutes, among whom risk of HIV infection is high, cannot afford to
purchase it.

Geognphical Dis hibutio n


There is a wide variation in the prevalence of HIV between different groups and

within different axeas. Rapid economic change in the last decade has contributed to widespread mobility among people in Thailand. As a result, levels of HIV infection in rural areas axe now comparable to urban ones. The HIV sentinel surveillance carried out by the MOPH every six months provides valuable indication of the levels of infection among different groups in the country.

-16-

These include blood donors, IDUs, pregnant women, male STD patients, direct and infirect prostitutes. Results of the HIV sentinel survey for July L994 and

the top five provinoes in eaoh oategory are shown in the following Figrse.

Ilgure

7:

HfV sentinel suweillance - ftly

1994

ToP 5 Prcvinces in each catego4Y

Blood

Donors

Moe Hong Sorn (8.0%), chiangmai (7.2o/o), Praohuab Kirikan (3.0o/o)


Chentaburi (2'9o/o'), Pitsenalok (2.8o/o)

IDUs

YaJr- (66.10/o),

Pattani (57.9o/o'), Ubon Ratohateni (56.3), Rayong (56'00/o),

Chianetnai (51.0o/o) pregnant

women

Phayao (I0.7o/o), Reyong (10.5%), Chiangrai (8.0%), chianonnai (8.0%)' Phuket (4.5o/o)

Male STD Patients Phayao (3S.0%), Lamphun (28.0o/o), Petohaburi (23.5o/o), Samut Sakhon
(22.2o/o), Patteni ( f
8.

9%

Direot Prostitutes Lamphun (61.2o/o), Petohaburi (59.4o/o), Phayao (58'0%), Nakhon Pathom
(5 l.3o/o),

Prachuab Kirikan (48'7o/o)'

Indireot Prostitutes Nongkai (40.6%), Chachonsol (34.0%>, Pethumthani (33.7o/o), Prachueb Kirikan (32.9o/o), Sukhothsi (I7 .7 o/o)

As shoum in Figure 8, suweillance data as of July 1994 indicate that the epidemic is most advanced in four major national zones and associated
provinces arnong frve category groups: blood donors,IVDUs, pregnant women' male STD patients, direct and indirect CSWs. Of these, Phayao in the north, Rayong province along the eastern seaboard and Petohaburi province in the Central region axe the most critical provinces.

Ftgut

8: HMAIDS distuibution in Thailand


by area and taryet gmup (1994)

Sentinel Surveillance
Blood Donor Drug Abuse
Pregnant at ANC Clinic

8.1En
Fj;..4";i1

fio't"
t-z

louo
H
fiililn

<70

Ao

F"T:.l to-zo co

lo E<tEo Fll t-t'to


olo

Vo

ffi>zz,

ffi

zr-qo Eo >qo qo

ffTIl+s

z
Eo

W>s

Malc at STD Clinic

Direct I'rostitute

Indirect Prostitute

Wo
E=l
<

Eo

E
"/o

<10

7o
nto

ffis-to

vo qo

Ffl

to-zo

Toco Fl.t07o
FA rc-zoco

ffllfi l-zo

lfllll zr-so

s6

ffi

>20

o/o

ffi>30Eo

ffi

>20

qo

Remark,

[-l

No

data

Source: Epidemiology Division , MOPFI

-18-

of Northem Thailand and the provinces of Lamphun, Chiangmai, Chiangrai and Phayao. Of these, Phayao has the highest HlV-prevalence. The occurence of HlV-positive cases in this zone is apparently affeoted more by oommercial sex workers
z,one One: This zone includes the upper border and tourist areas

(CSWs) than other sources of infection. The four provinces share three oommon phenomena which facilitate the infection's prevalence. First, in traditional northern Thai society women play an important role as family breadwinners and in maintaining parental old age seourity. Consequently, prostitution is seen as a sonrce of high income to provide for family welfare, and northern women
represent one of the largest categories of CSWs in the nation. The north is also noted as a gateway through which young women from Burma are recruited and

trained as CSWs. Lastly, this zone attracts a high number of tourists, which along with local demand, increases the inoidence of virus transmission from commercial sex workers to client and vice versa. As a result, the infection is transmiffed to other indirect target groups such as pregnant women. comprised of Nakhon Pathom, Pathumthani, and Petchaburi provinces. These areas are within the Central region and are charactetized by high industrialization and wbanization, espeoially in terms of expanding service and manufacturing sectors. Consequently, they are absorbing a tremendously high number of migrants from other Thai regions such as the
T,one Two: This zone

is

North and Northeast who work as wage labourers. This zone contains a high proportion of HlV-positive CSWs. Research studies have noted that brothels are often located near areas oontaining construction sites and factories.
7.one Thrce: This encompasses the provinces of Rayong and Chantaburi whioh

are along the border between the Bangkok Metropolitan Region and Thailand's rapidly industrializing eastern seaboard and Cambodia. Hence, those areas are

in industtialization (most notably a rise in the services sector) and thus a high influx and mobility of male and female labour force members, Of these two provinces, Rayong is most critical with high rates of HlV-positive rates for IDUs and pregnant women. Changing
aharacteized by tourism, an increase economio and demographic patterns associated with this zone) as well as zone two, have major implications for the ourrent AIDS/IIIV situation.

Tnne foun This comprises the provinces

of Yala and Phuket in

Southem

Thailand. Surprisingly, tourism as

well as industrialization (especially for

-19-

Phuket) are not having the sarne impact as in zones two and three. Instead, IDUs rather than CSWs are the main source of HIV infeotion.
These four zones and their provinoes are the main areas with high HlV-positive

for southern Thailand is different from other regions. Though epidemiological data do not show high AIDS or STDs
prevalence. The AIDS situation prevalence rates in the South, the region is a major area of disease contraotion,

though not overt manifestation. Hypothetically, this potentially establishes a disease cycle that is influenced heavily by migration.
The Southern region is noted for tourism as well as ocoupations such as fishing

which are closely associated with AIDS and STDs transmission. The cyole begins when CSWs, who originate from Northeast and Northem regions, migrate to suoh Southern axeas as Songkhla. They practice their profession until they are diagnosed as beirg HlV-positive or suffering from STDs. Their employers then send them back home or elsewhere. Since these women are still asymptomatic, no one suspeots their disease status and they either get married or oontinue working as CSWs. Meanwhile other CSWs are recruited from the satne areas and the cycle begins again. The south therefore represents the sending agent, while the north and northeast are the recipient provinces.

f,lrfurc hojections and Repercussions


The Thai Working Group has projected that at the present rate of infection, two to four million Thais will be infected by the turn of the century and 130,000 to

will die from AIDS. While more males are currently infected, by the year 2000 more women will be infected than men. People in the 15 to 34 age group will be most infected. Urban prevalence rates among the general population will increase from 0.9 per cent to ll.2 per cent and rural prevalenoe rates will increase from 0.12 to 2.5 per cent between 1991 and 2000.
160,000 people

Heterosexual transmission is beooming the major mode of transmission. With increasing evidence of heterosexual transmission, the number of infeoted women

is increasing. Most infeoted women are of ohild bearing age and more than 80 per cent of HIV infeoted children acquire the infection from their mothers through vertical transmiSsion. Therefore, the expected increase in the number

-20-

of infected women will directly affect the number of pediatrio AIDS cases. The number of children who will be orphaned by AIDS will also increase. Boonchalaksi and Guest (1993) estimate that by the year 2000 there will be approximately 86,000 children aged 12 years and under who will be orphaned

by the epidemic.

Flgue

9:

Estimated and projected HMnfections in Thailand by age gmup

Thousando

1990

Fffil o-o Yearr [---l g o. Y" r, "

li$$! to-t9 Ycrrt Y&Z tor'r

Source: Viravaidya et al.,

l99l

The projected levels of iltness and death

will place significant financial burdens on families and the government. Health oare costs for people with AIDS are estimated to be between US$ 660 and US$ 1,000 annually per patient (Viravaidya et el., 1993). These estimates af,e based on conservative
assumptions about the type and level of care required. Treatment costs for AIDS

annual household income for the average Thai family. The inability of families to bear this finanoial burden will require the government to fund the oost of oare. With current health care expenditures of US$ 20 per capita, the costs of AIDS treatment will severely strain the government resources. A far greater future cost to the economy will
represents between 40

to 50 per cent of

-2t-

result from deaths of individuals during their productive years. AIDS is likely to have an even gteater impaot on the Thai economy, particularly the most

valued seotors of toruism, foreign invesbnent and labour remittances from abroad (MOPH, various documents).

Flgut 1O: Number of AIDS

Oryhans at Ages Less lhan Xlve and Twelve yean or Less: Thailand 1990-2UlO

100
N u m b o f
I

BO

60 40 20
o

T
h

o
u

a n d 3

1990 1991 1992 1993 1994 1995 1996 1997 1998 .1999 2000 Year

W'i'to Change: FIll No Change:

Lese

NNN Change: Leae

12 & tes6

change: 12 & leea

Note:Chango lr bag6d on lh ao$umpilon of tha ccar!silon ot .t994

HIV lnfectlon at tho end of

Source: Boonohalaksi and Guest 1993

-22-

CHAPTER 3
PRINCIPI-,ES OF COMMT]NITY.BASBD APPROACH

The AIDS epidemic is a social as well as biomedical phenomenon. From a biomedical perspective, AIDS is a disease caused by a virus, tha! is transmitted by anal or vaginal intercourse, by exposure to oontaminated blood (either through shared injeotion equipment associated with intravenous drug use or transfusion), ffid from mother to fetus. Once acquired, the HIV infection appeaxs to persist for life. The AIDS virus destroys sub-populations of white blood cells that are crucial to normal functioning of the immune system. As the immune system deteriorates, infeoted individuals are no longer able to ward off infections, and some develop unusual uncompfomised immune functioning. A sizable proportion of the people who were infected have, after variable periods of time, progressed to severe disease and death. At present, there is no cure for AIDS and no vaccine to prevent infection. The only means available to prevent further spread of the epidemic are strategies to alter the behaviours that transmit the virus. From a social perspective, AIDS is, for the most part, a preventable disease that is rooted in the behaviours that transmit HIV. Halting the progression of the epidemic will thus require a better understanding of the distribution of risk-associated behaviours, the sooial ssffings in which they are enacted, and the mechanisms that facilitate change in these behaviours (Piot and
Carael, 1988).

In Thailand, spread of the virus has largely been amongst social groups whoSe sexual activities are illegal (male and female commeroial sex workers) and amongst groups both legally and socially marginalised (for example IDUs). The proportion of AIDS oases arnong heterosexual males is growing, and a significant fraction of these report contact with a female oommercial sex worker. Also of concern is the rise in the number of women infected by their husbands or boyfriends. As more women are infected the number of infants contracting the virus from their mothers has become prominent. The Thai Working Group has estimated that there are 500.000 to 600,000 persons currently infected, and six per oent of these develop AIDS every year. They

further predict that by the year 2000, the numbers of those infected will rise to 2-4 million with 350,000 to 650,000 oumulative oases of AIDS (MOPH, 1994).

fully developed AIDS syndrome and those experiencing the preliminary stages of AIDS is handled mainly by university clinics and maximum care hospitals. As the numbers of patients with HIV and AIDS are increasing, the wards and outpatient department will be unable to oope with them. Many of the patients cannot afford to pay for their drugs and hospital stay which means that the economic burden of caring for HfV-positive and AIDS patients will increasingly strain the ability of hospitals and clinics to care for non-HfV-related illness. Moreover, by their nature, these health institutions are unable to meet all the needs of their patients which are not restricted to the field of medicine. People with HIV/AIDS need medical and nursing care, as well as mental and sooial
The in-patient and out-patient care of persons suffering from the support. The physioal and medical needs include maintenanoe of general health,

for example, nutrition, hygiene, stress reduotion, contraception, perinatal oare;


treatment for commonAlDS-related problems inoluding opportunistic infeotions,

prophylactic treatment for tuberculosis and palliative care (care that provides relief of symptoms, but not a cure). Psyohosocial needs include counselling, discussion of AIDS at farnily level, emotional support from family and community, self support groups and access to voluntary counselling and testing. The social welfare needs include protection from discriminatory practices and care of dependents (Praag, 1993).

Although many of the opportunistic infections that occur as a result of the compromised imn'unity of AIDS need in-patient therapy, most symptoms can be dealt with at home. People with AIDS need not be bed-ridden for long periods of time as the syndrome is characterised by periods of severe illness interspersed by periods of relative health. Given that many people with AIDS will spend most of the time between diagnosis and death in the community, the training of community-based primary health care teams should be a national priority. The development of a continuation of care and support linking health faoilities at all levels with communities and homes through a discharge and referral system is crucial. The membership of these teams should include doctors, district nwses, commslily health oare workers and the community. It is within this network of commtrnity support that the quality of life for people with AIDS can be sustained. Involving communities in caring for people with

-24-

AIDS will also invariably result in an awareness of the magnitude of the


epidemio and the associated pain and tragedy. This prevent further spread of the disease.

will

stimulate a desire to

Flgue 11: HIV Conlinuum of Carc

-+.n* polntc for HIV/A!B9 care .ff dbchnrgo/roforral Piannlmg

Souroe:

k*9,

GPA/WHO,

1993:,2

Entry points along the continuum could be a voluntary counselling and testing site or a clinical diagnostic facility, or in some oases through referral from a blood transfusion service. The keys to successful ooordination along the continuum are disoharge planning and referral between the services with active involvement of the patient and their family.

-25-

The components of comprehensive care along the oontinuum are:

Clinical Management
This inoludes diagnosis and treatment of HlV-related diseases in people seekitg clinical care ateach phase of the care continuum. Medioal follow-up is provided

in order to detect reclurence or new infeotions eady. Various health care staff are involved in clinical management.

Nusing Carrc This includes the care of PWAs in oollaboration with families and also the promotion, maintenance and restoration of health and well-being of those who are siok and unable to provide such care for themselves, or for those dying from AIDS (palliative care). Prevention of STD/tilV transmission in the health care setting and education of patients and family members including promotion of condoms, is part and parcel ef nulsing caf,e.
Counselling Counselling is provided for people with HIV infection and their families to help reduoe the psychological impact of HIV/AIDS. Counselling also enables

planning of the future, provides education and faoilitates behavioural ohange. Counselling is as well an integral part of HIV testing. PWAs and their families need HIV/AIDS counselling and education about care and prevention in order to psychologically cope with their diagnosis to meet their oum health care needs and to minimise HfV transmission. Home Care Home care includes basic management of oommon symptoms such as fever, diarrhoea, cough and other HfV-related problems. Palliative caf,e is also provided by family members, lay persons, oommunity health care workers or any person with training in areas such as social work, oounselling and nutrition.

COMMUNITY PARTICIPATION
Since the 1970s "participation" has become the most critical concept in strategies for development as a result of a reappraisal of the nature and content of the developing process of developing countries. The essence of this ooncept

-26-

is that, whatever material form the development process may take, the active participation of the people must be encouraged in any activities proposed or undertaken (Piyaratn, undated). Early on and at the community level, villages oftentimes did not have adequate opportunities to manage their own community development efforts; they lacked the information needed to fuel the engine of development and lift themselves up from their poverty, ignoranoe and ill-health. With participation and if proper development procedures axe followed, people could then realise that they are not obligated to accept oonventional solutions to their problems which, more often than not, night be inappropriate. Rather, they could improvise and innovate based on their own local conditions and resogrce constraints. They could then be able to identif, problems, weigh the various possibilities, select ways of solving them, provide for their own means, their own resowoes and development. Through increased awareness of problems and limitations, as well as realising the possibility for development, local motivation and a sense of community consciousness could be enhanced along with the will to make the required changes (Chanawongse, 1990).
and manage

Up to now, the vast amount of literature on participation has emphasized two schools of thought as described by Ockley (1989).
One school makes the assumption that there is little generally wrong with the direction of the development process and that past failures have largely occurred because the human element has been neglected and people have not wanted to involve themselves in projeots about which they had little information or of whose value they were not convinced. This assumption has been the basis of measures to fill the gap, to provide more information and to inorease the knowledge of the local people concerned, It is believed that this information and knowledge will persuade people to become involved,1s ssmmit themselves, and thus help ensure the success of the projeot or prograrnme.

The other school argues that the direction of the development process is fundamentally misconceived. It is not the failure to take the human factor into account that is at fault, but rather the unreflecting way in whioh people have been left out of the development equation and treated as passive recipients rather than aotive participants. The new appfoach, therefore, is to seek innovative and flexible procedures, taking into aocount the knowledge already possessed by local people. Partioipation, in this sense, is conoerned with the production of knowledge, new

-27 -

directions and new modes of organisation, rather than with the wider dissemination of the procedures adopted hitherto.
These

two schools of thought define "participation" as the two ends of

oontinuum: participation as a means and participation as an end.

"Partioipation as a means" is a way of using the eoonomic and social resouroes of people to aohieve predetermined targets. The results of participation in the achievement of the predetermined targets axe more important than the act of
participation.

"Participation as an end" is a process in whioh confidence and solidarity arnong people are promoted. The process of participation is seen as a permanent and intrinsic feature of development that enhances and strengthens any development project. It will not only last the life of the project but, more importantly, will extend beyond the project in the shape of a permanent dynamic involvement. It is not seen merely as a management technique, but rather as a means of enabling people to become more directly involved in development. This form of participation does not necessarily begin with any preoonoeived set of quantifiable targets and objectives; it is more oonoemed with developing a genuine dynamism of analysis and involvement and then allowing the process to follow its natural course.

Various approaches have been utilized by developing countries to promote people participation in the development process at the community level. In most cases, the common form of community participation is induced through stimulation by a catalyst, a civil servant of the country or a volunteer. One review has pointed out that the community development approach offers a number of advantages ovet the other approaohes, particularly if a comprehensive nationwide approach to co--unity development can be successfully established (Conyers, I 982).

F'ACTORS WHICH INHIBIT PARTICIPATION

From a review of the subject (UN-ESCAP, 1989) and personal experience freld workers, factors that inhibit participation may be categorized as:

of

-28-

X'acton rcoted in the sommrrnif5r

i8elf

o division iunong people in communities along the lines of class, caste,


language, sex and age;

o absence of a workable orgalizational


integrate all groups of people;

base

at the community level to

o dispersion of

population over nral areas or excessive ooncentration of population in wban areas with a lack of sense of community;
are not strongly cooperation-minded, poverty and inequality tend to discourage, rather than encourage cooperation in communities;

o in contrast to the general belief, traditional communities

o laok of effective leadership at the community level as well as lack of


partnership between local people and the governnent;

people do not feel a need for, or want to be involved in, activities that are traditionally decided at central level or by professionals;
curers and elite groups when they feel threatened by the introduction of innovation;

o opposition from vested interests of such people as traditional o help provided by government
o

or other outside agencies may be peroeived people; and exploitation by local

as

problems in communities pointed out by outsiders are not recognised by the local oommunity people as their own.

X'acton Inherent in A dminis

tative

Oqg

anizations budget

o the frequent need to show fast results in order to justi& future


allocations, which leads
achievements;

to

"overselling" and exaggerated reporting of

inter-ministerial and interdepartmental competition and infighting as well personal "empire building" by ambitious administrators;

as

o the tendency of low-level

workers to strive to please their superiors at the expense of the people they are expeoted to serve;

-29-

o the danger that multipurpose worker will be foroed to o

spread his or her talents too widely, ffid thus not be genuinely effective in any specific area;

over emphasis on the technical aspects of 'fcommunicationt' at the expense of a full appreciation of what audiovisual devices actually convey to the people toward whom they are directed;

o the low

of community workers, whioh results in poorly qualifred and often passive employees, or ambitious personnel who look upon their assignments as springboards to more prestigious work; and
status

the lack of decentralization and other mechanisms to support participatory actions in communities.

The following two statements about participation are enlightening:

First, from Esman (1974):


"The romance of participation should not lead administrators to expect that the results will be painless either to themselves or to citizens. Participation will generate conflict. It will make more work for offioials, but hopefully it will improve the relevance and the effectiveness of developmental public services."

Second, from Kaunda (1974\:

"We need to remember that efficienoy oannot be measured rarholly, or even chiefly, in terms of results that oan be reduced to quantifiable terrns. The mere fact of decentralization and the winning of power by the people to do things for themselves and to run their own affairs produce results in terms of human dignity and human self-fuIfiI'lment which are incapable of being expressed io any statistical form at all. Yet they remain of profound importance in terms of quality of life of our people."

PARTNERSHIP

In addition to "partioipation", "parhrership" is another critical concept for development. If it is aooepted that participation implies that every person and
all people must share in the decisions whioh shape the course of development, then parhrership, a means of enabling people to work together, is neoessary for effective participation and development. Specifioally, partnership is seen as a

-30-

to create linkages which will bring more people into the development process, thereby providing better information and more widely dispersing responsibility for decisions.
means

The nature of partnerships oan be summarised as follows:

o A partnership must have a purpose, but it


work towards a common goal.

more than just an agreement to

o A parhrership

entails a partioular way of working, beoause it is founded on

mutual respect.

o Through the sharing and the communication

necessary in a parbrership people can learn from each other and increase their mutual capaoity to acoomplish various goals.

o Partnerships are dynamic and their purposes can change because the
experience of parbrerships leads to greater understanding and an inoreased capacity for constructive action.

of a partnership, and the general procedure for dealing with these is through a process of mutual
There

will be tensions

and problems in the working

discovery resulting from frank and open communication which enables everyone to be more aw4re of himself/herself and of others. It is the continuing

identification of mutually shared common ground which makes a partnership


viable.

will be an activity of great social and politioal significanoe and will therefore be difficult to organise and maintain as it begins to firnction effectively. However, if people are not prepared to engage in development
Such a partnership

aotivities and relationships which have such politioal and social significanoe, there will be little hope of improving the record of development, for if it is not a lack of physical and technical oapacity which limits the success of development, it surely follows that political and social processes are presently
inadequate. The development of partnerships, as well as participation, can be part of a sustained process of change in which the expanding linkages and the increasing involvement of people can prepare the way for further ohange leading to sustainable human development.

- 31 -

PARTICIPATORY RESEARCH
One of the means of promoting participation and partnership is what is known as "participatory research." It is an alternative style of research using a three part process of social investigation, education and action to share the oreation

social knowledge with people. It is more than a new set of research techniques. It is a systematic approach to personal and social transformation. This particular style of researoh aims to develop critical consoiousness to improve the lives of those involved in the research prooess, and to transform fundamental societal structures and relatio6hips (Piyaratn, 1989). Partioipatory research is, without doubt, a potent took for developing the participation and partnership needed in the prooess of development at all levels and within

of

different seotors. In conclusion, the experience of the past has suggested that certain prerequisites are needed for fostering participation and partnership for community
development. These include:

o Legitimisation of participation as an essential part of overall development


activities.

Establishment of an organisation at the community level that concems itself with all aspeots of community life without being limited to any particular conoern such as health or environment.

o A proper balance between oentral direotion and local autonomy in decisionmaking which allows the people to work toward goals that respond to their individual and collective needs.

o Training of oommunity leaders, as well as government workers, in


partioipatory and partnership skills as well as skills of self management, the operation of cooperatives, organising community groups and the like.

o External stimulation

and support are needed at first by communities in terms of finanoe, material and technology to organize and sustain their development activities, including income-generatin g activities.

o A oomprehensive public information and education prograrnme, as well as provision of appropriate technology and support services, are required to
motivate people to participate.

o Participation and partnership are also prerequisites for a problem-solving


process or partioipatory development at any level and in various sectors. This process must also be an integral part of an overall development plan that aims to sustain development for quality of life.

-33 -

CHAPTER 4

COMMTINIIY.BASED ACTION PROGRAMMES

EDUCATION FOR AIDS PREVENTION


began immediately after the initial cases of AIDS appeared in 1984. Television and radio programmes covered basic issues on the meaning, cause, symptoms, transmission and

Public health education oampaigns

in Thailand

prevention of AIDS. Pamphlets, posters and other oommunication messages and

media have also been widely distributed throughout the country and AIDS education has been incorporated into the ourrioulum of elementary and high schools. While these approaches seem to have raised awareness of HIV infection arnong the general population, AIDS eduoation messages in the print and broadoast media alone are insufficient to produoe meaningful, wide-soale change in actual risk behaviow (Kelly and Lawrence, 1988). Public opinion research shows that people gain knowledge about events taking place around them and form opinions about those events as a result of personal oommunication with others (Kleppner et al., 1983; Kotler, 1983). Information
presented

in the context of talking or disoussion has a number of advantages

relative to printed materials alone. Discussion-based presentation of information

provides an opportunity for the listener to ask questions and have those questions clarified. Motivational encowagement to put information into praotioe is also more easily afforded in oonversational exohanges than in brief printed materials. And, uften the person is presenting information is perceived as credible, sympathetic, and similar to the listener, the information conveyed is high in influence and believability (Kleppner et a1.,1983). This realisation has led to a shift in education programmes in Thailand and health educators now target groups of known higher sero-prevalence, or with a greater likelihood of future infection, providing risk-reduction advice specific to those cultures.

CASE STUDIES
The Gnduate AIDS Volunteers2
The ASEAN Institute for Health Development (AIHD), jointly with Program for Appropriate Technology (PATI{), initiated the Graduate AIDS Volunteers

Project for a pilot period of 18 months beginning in June 1993. The ASEAN Institute has had experience in using Crraduate Health Volunteers in Primary Health Care activities since 1985. Experienoe gained from working with the rural population has impressed on the Institute that participatory development is the best approaoh in enabling communities to become self reliant and allow them to take pa,rt in the formation of their orrm organization. The Graduate AIDS Volunteer projeot draws on this knowledge and uses peer education techniques in AIDS prevention and control among factory workers aged 15 to 29 years.

Four districts were ohosen in the greater Bangkok area for the initial
intervention: Minburi, Bankhen, Pasicharoenand Bangkhuntian. Factories within each district were selected based on their interest in the project. In the field, the

project team fust organized a meeting with offioials from the District Health Division. Discussion at the meeting centered on how to establish relations with managers of factories within the respective districts. Faotories that had previously cooperated with the goveflrment on various activities were suggested and an official from the District Health Division was assigned to serve as the contact person between the project and the factories. Next, the project team collected baseline data on the situation and needs of the target groups within the factories. In-depth interviews were conduoted with the administration teams regarding produotion, working process, number of employees and group activities. The "look and listen" method was also used to gain an understanding of the issues about which people have the strongest feelings. Suoh issues included relationships between people, deoision making
prooess and recreation. This data was partly used

in the seleotion of factories

'Based on discussions with Associate Prof. Yawarat Parapakkham, Graduate AIDS Volunteer Project Director, and a review of documents.

-35-

well as for compiling a flaining manual for the volunteers. A meeting was then arranged where representatives from the Distriot AIDS Committee and the selected faotory managers were informed about the project's objectives and methodology. It was agreed that the project would not interfere with other issues pertaining to the factory, such as their sanitation or welfare programmes.
as

The Graduate AIDS Volunteers are the backbone of the projeot. Their selection and training is therefore a crucial component of the projeot. It was decided that
the volunteers would be men or women, 30 years or younger, who had at least

bachelor degree and were strongly dedicated to oommunity work. Advertisements were sent to the daily newspapers, government ofEces, as well as radio stations. Subsequently,45 volunteers were selected and participated in a one month training course conducted by the ASEAN Institute for Health Development, with facilitators from PATH. The curriculum included: faots about AIDS, understanding common perceptions about AIDS, communications skills, data collection skills, and some information on sexual behaviour trends in general, and of industrial factory workers in partioular. On-the-job training was also provided after the volunteers had began working. The topics varied from more information on sexually transmitted diseases, use of puppet theatre to role playing in small groups.

As part of the training the volunteers visited several government and nongovemment facilities currently caring for persons with HIV/AIDS. Through this
fust hand experience the volunteers learned the essential elements of providing care which gave them confidenoe to oonvey information to factory workers about AIDS prevention and caxe of AIDS patients. Study tours to sex entertainment clubs were necessary as most of the volunteers lacked "sex education". In addition, the volunteers had an experience of the workers' lifestyles and general atmosphere of the factory when they visited factories located near the training centre. They also practiced their oommunication skills by engaging in conversation with groups of workers and by collecting questionnaire data improved their data collection skills.
Onoe the course was completed, the volunteers were paired and sent to the selected factories. The aotivities varied from factory to factory depending on the size, type and working process. However, the main aotivities involved three
steps:

-36-

Increasing a\uartness of acquiring tre disease: The volunteers in each selected factory conduoted aotivities

to increase

the

target group's knowledge about AIDS and the sexual behaviour that put them at risk of being infected. They enoouraged the workers to participate in analysing their own behaviour, in briefings and in small group discussions.

These activities covered about 100 people per site and involved use of communication media in conveying the information.
Small grcups activities for behaviour change: The volunteer team's role is not only to impart information about AIDS prevention but also to establish supports and norms favouring reduced-risk conduct in the target group. To facilitate this, volunteers organized sessions where a small group of workers met informally and disoussed various issues concerning risk reduction. Other participatory techniques such as role playing, demonstrations on condom use were used. In order to ensure behaviour change is sustained over a long period, the volunteers establish peer leader groups from among factory workers to continue the work in disseminating information to encourage behaviour modifioation of other factory workers based on the model "Friends helping Friends".

Aclivities for plevention of AIDS among workers: During this final step, the volunteers involved factory managers, peer leaders and other interested workers in organizing activities for the prevention of AIDS such as a poster or slogan oontest. These aotivities stimulate people's interest in re-evaluating their attitude and values towards AIDS issues and will serve as data for managers to plan their prevention activities.
The Graduate AIDS Volunteers project is finanoially supported by AIDSCAP. It is managed by a project direotor with the assistance of support staff from the research division of AIHD. This team is responsible for supervision of the volunteers on a regular basis and evaluation of the project. The volunteers meet fwice a month to share experience and plan for future aotivities. To ensure that
the volunteers work to their fullest capacity without having to worry about their

living expenses, they are paid government salaries that correspond to their level of education. In addition, they are provided with accident and life insurance during the duration of the project.

-37

The Graduate AIDS volunteers have helped to inorease awareness of HIV/AIDS among factory workers. Since it is suoh a young project it is difficult to

semment on its impact in terms of changing sexual behaviour arnong these workers. flowever, the volunteers report successful establishment of peer leaders who continue the AIDS prevention aotivities after the project is terminated. The volunteers found that the support of faotory managers was neoessary to sustain the project and activities in the factories. A good relationship was thus fostered and volunteers were flexible to adjust their plans and strategies to change in situations. They were prompt in organizing activities to avoid
urnecessary production loss and educational sessions were sometimes conduoted on the employee bus or residenoe. Despite this, some managers lamented that

the activities took a lot of the workers' time which meant a loss of revenue. According to one manager of a partioipating factory, " ... consideration should be given to the arnount of loss of revenue as a result of lost time, and then evaluate if the project is worth it".

I)uang hateep X'oundation"

Klong Toey is a low-income neighbourhood bordering the dooks along the Chao Phraya River, in the southeast corner of Bangkok. In 1992, there were more than 60,000 people living in some 13,500 family units. This makes Klong Toey one of the largest of the many illegal squatter settlements in Bangkok. Officially known as a slum, the neighbourhood is divided into 25 suboommunities, each with an eleoted counoil recognised to some extent by the
municipal authorities.
Surveys of the extent of the HIV infection in Klong Toey as a whole have not

by L992 it was likely that at least three per cent of the total population was already HlV-positive.. The community has a high
been carried out, but

proportion of sexually active people, many irljecting drug users, &d signifioant numbers of both male and female sex workers and their olients. Despite national and looal AIDS campaigns, it has been difficult to impress on the people of
3Based

on discussions with Nitaya Promphochuebun, the Director, and documents from the Duang Prateep Foundation.

AIDS

Programme

Klong Toey the dangers of HIV infection. This is partly due to the long incubation period of the disease. Very few people in Klong Toey have yet developed AIDS and it is difficult to convinoe the community of the seriousness of an infection they can not see nor feel. However, AIDS is expeoted to affect the lives of a growing number of people in Klong Toey during the mid 1990s, when many HfV-positive IDUs will start showing symptoms. By 1998, an even larger group, including sex workers and their clients, will need care.

The Duang Prateep Foundation was established

in

1979

by

Prateep

Ungsongtham, rarho was born in Klong Toey and worked on the dooks from the age of 12 to pay her school fees. In March 1994, the Foundation had over 100 staff members, most of whom had been recruited from the Klong Toey

community itself. There was also a large network of Klong Toey volunteers who helped Duang Prateep to run its wide range of eduoational and community development programmes. These included kindergartens, educational sponsorship, vocational training, income generation, an anti-drugs campaign, and, the latest addition, an AIDS prevention prograrnme. The variety of their programmes helped Duang Prateep in their HIV/AIDS work since they could visit members of the communities without fear of breaching confidentiality or

causing undue embarrassment. The oommunity was involved administration of most of the programmes.

in

the

was through their Freedom From Drug Abuse Programme, whioh began in 1986, that Duang Prateep first became awaxe of the rapid spread of HIV in Klong Toey. In May 1988, the programme tested a group of IDUs who had

It

been sent by the community for inpatient drug treatrnent and were shocked to find that 75 per cent tested HlV-positive. Realising the potential irnpact of AIDS on the community, and in view of the low priority given to AIDS by the

govemment at the time, Duang Prateep decided to start a two-year pilot programme in three of the Klong Toey communities. Duang Prateep started by educating themselves and key members of the oommunity about HIV/AIDS. With the assistance of Family Health International (a U.S. based organization), a seminar was held for members of the Foundation, community leaders and the police. At the seminar it was agreed that the overall aim of the AIDS programme should be prevention of HIV infection. Three target groups were identified as priorities for interventions. All members of the

-39-

three communities; all IDUs, especially those tested HlV-positive and their families; and sex workers. The speoific objeotives wefe defined as:

o To teach people how to protect themselves and their families from infeotion; o To promote understanding rather than fear of persons with HIV; o To enable HlV-positive persons to live in a supportive community.
Following the seminar, the AIDS programme staff were given further training in the transmission and prevention of HIV infection and in counselling. But Duang Prateep reoognised that the best education that people oan have is by leaming from their own experienoe. So the AIDS prograrnme staffmet regularly as a group, first weekly and then monthly, to discuss their experiences, what they had learned from them and how to use this learning to make their activities more effective. The four main prograrnme activities dwing the pilot phase were
as follows:

Injecl'ng Dmg Usen: When the fust group of 169 IDUs agreed to be tested for HIV, information was also colleoted on their residence, family situation, age and sex. It was found that four out of five of the youngest age group (less than twenty years) were HIVpositive. There were also significant differences in the prevalenoe rates between the three communities. Further investigation revealed that the higher rates in one community might be explained by two factors. IDUs in this area tended to live together, thus increasing the likelihood of needle sharing. Secondly, most of the dealers lived in this neighbourhood, and as the IDUs tended to use dealersupplied needles and as these needles were often used by other drug users, this also increased the ohances of spreading infeotion. Armed with this information, the prograrnme tried to recruit former IDUs as peer educators, but failed because the ex-IDUs were reluctant to let others know that they had once used drugs and did not want a reminder of their old situation. The programme then decided to use Duang Prateep staff to make regular home visits to the IDUs, to give information about HIV infection and AIDS, to teach them methods of prevention including the cleaning of syringes and needles, and the use of condoms. They also provided supplies of condoms and.bleach. The home visits were reinforced by encouraging small groups of IDUs (and sometimes their families) to meet at Duang Prateep to talk about

-40-

their experiences and their concerns, and to provide them with opportunities to ask questions. Both the non-judgmental attitudes of the staff and these meetings helped enonnously to build trust between the addicts and the pfogramme. Duang Prateep was convinced that if they were to encourage people to stop using drugs and to reduce behaviour that can lead to AIDS, they must help the IDUs to develop some hope for the future. Education filled with a lot of "do this" and "do not do this" instructions was unlikely to motivate them to make the necessary changes in their life unless they were also provided with alternative strategies for survival. To do this, the programme also provided vocational training for the IDUs and made small, interest-free loans available

to them to develop income generating activities.

In 1990, a little over a year after the programme started, a seoond survey

was

carried out among the IDUs in the pilot oommunities to collect datathat would help improve the prograilrme. The survey looked at the age at which the IDUs began using drugs (the highest proportion was found to be between 15 to 19 years), the amount of money spent on drugs as compared to the earnings of the IDUs (drug costs were found to exceed income), the extent to which IDUs used

drugs in groups, &d the sexual habits of the IDUs (none used condoms, although several visited prostitutes). These findings led to a stronger emphasis on eduoating the IDUs about oleaning their needles, more efforts to promote the use of condoms, and an understanding that attention needed to be given to the design of drug and HIV prevention strategies for children and adolescents. The data also increased the fears that IDUs, both male and female, were inslsasingly turning to commercial sex work to earn the money for heroin. The need to continue to help IDUs to find jobs was reinforced. Commercial Sex Worken: In 1990, the programme asked the police to enooutage local brothel owners to send their sex workers to a training seminar to learn about HIV/AIDS and how to protect themselves. It also explored strategies that could be used to get the clients to use condoms. All the sex workers were tested for HIV and completed
a questionnaire on AIDS.

Twenty per cent of the women tested HlV-positive. The questionnaire showed that 94 per cent of the women knew that sex without condoms could lead to

-41

HIV infeotion, but condoms were only used, on average, in one out of every three acts of sexual intercourse. The results also revealed important knowledge gaps and misconceptions: 68 per cent thought AIDS could be contracted
through mosquito bites, and 84 per cent believed that regular blood tests would prevent infection.

After the seminar, the programme team tried to persuade the brothel owners to promote the use of condoms among clients. Although some agreed to allow the sex workers to refuse a client who would not use a oondom, they would not make this a house rule.

The programme also tried to recruit peer eduoators from among the sex workers, but this was not sucoessful as the workers ohanged their workplace frequently and the peer educators olaimed they had no authority. Programme staff visited those who tested positive to give support and address their conoerns. The constraints faced in this component encouraged programme staff to approach the polioe to ensure that brothel owners insist on the use of condoms, and to work more aggressively with the younger sex workers.
Motorcycle Taxi Drivers: Approximately 650 men were thought to work as motorcycle taxi drivers in Klong Toey and the sexual behaviour of many of this group put them at high risk of HfV infection. In 1990, the AIDS programme organized two one-day training sessions attended by 498 motorcycle taxi drivers, with an average age of 26. During the session, a survey was conducted to determine each man's age,

marital status, sexual behaviour and knowledge of HIV/AIDS. When asked if they frequented brothels, 71 replied that they did so at least once a month, but only 9 per oent reported that they used a oondom every time, and over half said they regarded condoms as a nuisance. Only 39 (28 per cent) of the participants took up the offer to have their blood tested for HfV infection, and only two of these tested positive. This result was not felt to be representative because the majority declined to have their blood tested.
Participants in the training sessions were taught about HIV and AIDS, and particularly about the use of condoms. They were encouraged to talk with their clients about AIDS, and given small information cards as memory aides. To encourage discussions, they were also provided with T-shirts and distinctive

-42-

pink vests oarrying AIDS messages. The progr:unme put up billboards with AIDS information at motorcyole taxi stops. A review of the situation some time later revealed that the motorcycle taxi drivers talked about AIDS only if their clients made comments or asked questions about the slogans on their vest or Tshirt. Either they did not yet have the self-confidenoe to broach the subjeot of their own accord, or this was felt to be culturally inappropriate. The programme planned to conduct a follow-up survey of motorcyole taxi drivers to see how much knowledge about Hry/AIDS they had retained. The survey also trught the prograrnme staff that to promote oondom-use arnong these young men, they needed to focus their efilorts on explaining the pros and oons of oondoms, thus allowing them to make an informed deoision.
The Genenl Public: Before Duang Prateep decided on the contents of an AIDS prevention oampaign, it carried out a baseline KAP survey among a sample of residents. The results showed that although 90 per cent of those interviewed knew that AIDS could be contracted through sexual interoourse or sharitg needles with an infeoted person, there were also many alarming misconceptions and knowledge gaps. Half the respondents believed that HIV could be transmitted by mosquitoes, by sneezing, by sharing clothes or soap, s1 simply by talking to an infected person. Only 33 per cent knew that a person with ffry can still look heatthy, and only 34 per oent suggested the use of condoms as protection
against infection. Half thought they could easily be infected simply by sharing

with an infected person, and only 4l per cent said they would remain friends with a person with AIDS.
a house

The programme's initial response was to mount a series of high- profile public events with the broadest possible mass appeal. The aotivities included a rally

and speeches by prominent persons, AIDS eduoation bulletin boards were


erected, posters displayed, and stickers and pamphlets distributed. Over the next

several months, similar mass events were organized, a week-long AIDS exhibition, a "slogan for AIDS" competition, and a parade through the streets of the neighbourhood.

But the programme staff soon realised that all the aotivities were attracting the same group of active and interested members of the community while a large proportion of the community was not participating atall. A KAP study canied

-43-

out seven months after the launch of the prograrnme found little or no change in either knowledge or in attitudes towards people with HIV/AIDS.
These findings led

to a reassessment of the AIDS progremme strategy and efforts to improve participation by a number of methods. A small team started to take a mobile audio-visual presentation on AIDS issues to the slum
communities, followed by a question-and-answer session, and this beoame the focus of community aotivity. The programme also organised one-day educational seminars for key groups in the community, suoh as the police, youth leaders, kindergarten parents, women and school students. It was hoped that

they would become trusted sources of information about AIDS within their families, at the workplace, and with their neighbours and friends. Duang Prateep also decided to broaden their volunteer base. It trained a group of housewives to act as volunteer AIDS educators, visiting neighbours to teach them about AIDS, and providing regular supplies of free condoms.
The prograrnme planned to expand its activities into nine additional Klong Toey

communities and has oompleted baseline surveys in eaoh area. The snrveys would be repeated in the future to evaluate the suocess of the eduoational activities. They also planned to increase work with children, to bring prevention into schools and existing youth groups in the community. Duang Prateep does not plan to provide medical oare to people with HIV/AIDS and their families. They felt that other, more speoialised agencies were better equipped to provide this service and that their own unique strength lay in their deep roots within and their relationship with, the community of Klong Toey.

-44-

SUPFORT GROT]PS

Living with HIV/AIDS has a considerable amount of stress associated with it. Infected people face the threat of death, and while they are frghting for their lives they often face discrimination. For people living with HIV/AIDS, the fear of an unsympathetic society can be more devastating than the disease itself. Many persons with HIV/AIDS in Thailand have been denied medical treatment and housing, including education for their children once their sero status was known. Yet others live and work in hostile environments due to misconceptions about how the virus is transmitted at home and places of work.a AIDS patients blame the initial negative campaigns run by the government for causing discrimination against them (Puu:personal communication, 1994). The first
campaign portrayed AIDS as a deadly disease to create fear among the publio and people saw not only AIDS but also those infeoted as dangerous thereby fearing contact with them. Although the present campaign promotes compassion
and understanding towards infected persons, the horrifuing picture of AIDS has

stuck in peoples minds and their attitudes

will

take time to change.

Self-help groups in Thailand have developed in the past few yeaf,s out of need for psychological and other support for the increasing number of infeoted persons. These groups of carriers have been formed among people who share

the same problem and are therefore capable

of

supporting eaoh other in

maintaining a positive attitude. Support of this kind has helped infected persons to recover their self-respeot and self-confidence and to plan positively for their future. In addition, individual behaviour change has been observed among many who now lead socially useful lives as a result of information provided by their peer groups. Despite the increa5ing recognition of self-help groups in Thailand, some encounter obstacles from government and medioal bodies. Presently, it is estimated that there are fourteen such organizations in the country, the majority of which are based in the North where many persons living with HIV/AIDS are concentrated @mpower: personal oommunication, 1994). The two biggest semmunities of people living with HIV/AIDS in the country are: New Life

oA plan is underway for HIV/AIDS carriers to form a national allianoe to inorease their bargaining power in calling for their basic needs to be met. They plan to work together in seeking laws to protect their rights.

-45-

Friends Association in Chiang Mai with 2000 members and the Bangkok-based Wednesday Friends Club which has 600 members'

New Life Xliends Associations

A chain of unusual

circumstances led

to the fsunding of the assooiation. It

started with Mr. Wichai distributing medicinal herbs believed 16 improve the oondition of those infected at no charge to his patients. News of the "miracle

worker" spread and the number of those demanding the medicine inoreased to more than a thousand. With their numbers increasing, the patients felt obliged to raise money to cover the costs inourred by the distributor in obtaining the medicine, including a small remuneration for the herbalist preparing the medicine. Thus an association was formed with eaoh member paying 100 baht ($4) monthly. [n retum, the patients were assured of a bag of herbs each day for the duration of the month. This arrangement worked well for all concerned for a few months. However, in February 1994, Mr. Wichai was arrested on the charge of distributing drugs without authority and defrauding the public.

A
a

separate association by the name of New Friends Association was formed by

few patients receivirg the medioation shortly before his arrest. The president, Mr. Chamlong, helped the group to organize themselves to protest for the release of Mr. Wichai. He also presented the case to the Prime Minister during a brief visit to Chiang Mai and together with other members and related Non Governmental Organizations, met the Deputy Minister for Public Health. As a result of these mssfings, members of the association were allowed to continue preparing their herbal treatments but were forbidden to advertise it. Chamlong then tunred his house into an office where members could oontinue to receive their herbal treatments. However, with his health deteriorating in April6, the assooiation elected another president and relied on the goodwill of the staff at the Health Promotion Office of the Church of Christ in Thailand who allowed them to use part of their office. Northem AIDS Prevention and Care (NAPAC)
Based on documents from the Northem AIDS Prevention and Care (NAPAC), discussions held with members of the Assooiation and a site visit. 6He
5

died on 4th June and spent the whole of May in hospital

-46-

approved to fund a project to set up the association with its own premises, and at the end of May they finalty found a suitable house to rent which now serves

as an office. The association members are unable to advioe the many people who ask on how they should go about eglaflishing one in their respective provinces. They doubt the assooiation would have developed had it not been for Wichai and his herbal medicines, his arrest and the protests that followed,

including Chamlong's dynamic leadership.

The office is sparsely furnished with a small table and three stools where registrations are made and information recorded. There are also two fans which have been donated to the centre. Apart from that there are only mats on the floor for people to sit on. Many visitors have promised to help the association get things they need including a television and video which would be useful for the people using the centre's services. It would give them access to the different Epes of news reports and information which are beitg released in a variety of
forms, especially video. Most of the members are ordinary householders, farmers and labourers. There are also people who hold important positions, but cannot go public and therefore send their relatives, ftiends or children to collect the medicine for them. Not all of the current two thousand members of the assooiation come from Chia.g Mai. Some oome from the neighbouring provinces while others
come from the central region and the Northeast. Out-of-town members jointly rent a vehicle and come once a week to receive their medicine. The rate of membership has increased rapidly with up to a hundred applying each week.

The association is managed by Ms. Alisa, a young widow and mother of two. As the only salaried staff, she shares her money with the f6s1 esmmittee members who live at the centre and assist her with work. Other ssmmiffee members and volunteers work elsewhere but come in to help with dispensing the medicines and giving moral support to members, refurning to their work once the crowds disperse. The association meets every Monday, Wednesday and Friday when people oome to receive their medicine.

The main objective of the New Life Friends Association is to bring HIV infected people together to help each other solve problems relating to their physical and mental well-being, as well as sooial problems arising from the

-47-

spread of AIDS. Various services are offered at the Centre and can be broadly

classified as follows: Medical support Members are assrued of a daily supply ofmedioinal herbs that help improve their health condition. In addition, a team of doctors and nurses from Chiang Mai University visit the association every Monday and provide medical check-ups and give esunsslling. Information on how to take care of their health and look after themselves properly is also provided. An important pieoe of advice handed out in leaflets is dietary information and advice on foods whioh they should or should not avoid. This experience is based on personal
experience of other members. Psychological and social support The association is run by HIV infected people for people with the HIV virus. Thus it is a place where they can be among

friends who understand each other and give each other the moral support that they need. Members have an opportunity to meet and exchange ideas and experiences. Those receiving medioines for relatives or friends are encouraged to ask them to come and meet other members and be reassured that they have new friends. In addition the members also look after the malry families who are faoing serious problems, particulady widows and orphans, many of who are also infected and have been left to fend for themselves. pubtic education: The Association is also involved in eduoating rural and urban communities about AIDS. They help workers and students to not only gain ,o6e1s1anding about AIDS, but know how to avoid it and how to protect themselves. Those members who are willing to appear in public serve as speakers at seminars and meefings organized by the government and private sectors in Chiang Mai and the neighbouring provinces. They are planning to set up a mobile unit that will enable them to go out and give talks in schools, work places and the community.

At present they are undergoing training on how to be good speakers with an


informed knowledge of AIDS. They are beirg taught how to present themselves

effectively and give information based on personal knowledge and experience. Many of them are being trained in giving counselling, while others are being eduoated in other areas such as nutrition, health care, and meditation so that

-48-

they can be of help to their friends as well as a large number of other people

in society.

Wednesday lhiends' Club

The Wednesday Friends' Club has its origins in the weekly Tmmune Clinic for people with HIV and AIDS in the Outpatients Department at Chulalongkorn

Hospital. At frst, patients did not talk much with each other, preferring to keep their thoughts, problems and anxieties to themselves. But gradually, with the assistance of social worker Khun Kamolseth, a few began chatting, found they enjoyed one anothers' company, and started going out for meals together. ln March 1990, with encouragement from Khun Kamolseth and other staff of the Thai Red Cross Sooiety, ten HfV-positive people decided to form the Wednesday Friends Club, which began meeting regularly on a Wednesday afternoon, once a month. The main objeotives of the club were to provide
members with information and mutual support, and to make the general public

more aware of HIV and AIDS.

At frst the club found it difficult to make headway. The founding members, anxious to preserve their anonymity because of the fear of discrimination
against themselves and their families, felt they had to take a cautious approach

in dealing with the mass media. However, word about the club began to

get

about. Counsellors at the Thai Red Cross Society's Anonymous Clinic informed

their clients about the club. Doctors and counsellors at the fmmune Clinic at Chulalongkorn Hospital also helped to spread the word. Many were still reluctant to join the olub because they were afraid it would mean that their names and faces would appear in the newspapers and on television, with disastrous social consequences for them and their families. The Thai Red Cross Society provided the club with office space, furniture, access to a telephone and a word processor, stationery and small amounts of money for purposes such as travel. Red Cross social workers, doctors and nurses were always on hand to provide advice or information whenever necessary, but the society did not try to impose an organizational plan on the
'Based on documents from the Thai Red Cross

-49-

club, or diotate the running of its affairs. The club's activities and structure developed acoording to the needs, interests and capacities of its members.

With time the number of those visiting the Wednesday afternoon 6ssfings increased. By mid 1994, the olub had over 600 members from a wide variety of professional backgrounds, including shopkeepers, sales representatives, engineers, offioe workers, entrepreneurs, civil servants, teaohers, domestic
servants, plumbers, electricians and construction workers. Most of the members

come from Bangkok, while some attend the meetings at the suggestion of their

doctors from looal district hospitals.

The affairs of the club are managed by a five-persol esmmittee, elected


annually by the members, with a full-time secretary who receives a small salary. The olub now meets twice a month, on the second and fourth Wednesdays, in

room in the Outpatients Department of Chulalongkom Hospital. The olub has developed a wide range of activities, which fall under four broad categories:
a

Psychological and social support: The club organi'es group counselling sessions on the second Wednesday of every month, mainly for people who have recently leamed they are HfV-positive.

A few members of the club have

been trained

in counselling but have leamed, through experience, how to talk to other HlV-positive people about living with Hry. Khun Kamolseth, a sooial worker and AIDS counsellor from the Thai Red Cross Society who has encowaged the development of the club sinoe its hesitant beginnirrgs in February 1990, facilitates the meeting in a friendly way. The proceedings start with everyone introdusing themselves in turn, but some newcomers prefer not to give their names or speak dwing the
as counsellors. Most have not had any formal training

meeting. In order to make them feel at ease, a few long standing members talk about their experiences of being HfV-positive and how they have learned to cope. "They are like veteran soldiers and they can explain to the new comers how they have been able to live for so long with the virus. They give them information and enoouragement to keep on living. Before, a lot of people with HfV used to try to kill themselves, but that doesn't happen so muoh now", explains Khun Mee, Deputy Chairman of the club.

In addition, the club organizes informal counselling for patients of the Immune Clinis at Chulalongkom Hospital on Tuesday mornings. After the clinic, a

-50-

group of club members visit friends who happen to be admitted to hospital for treatment. Sooial gatherings and occasional outings to the seaside help to build

feelings of friendship.

The club has also organized training and practice sessions in Buddhist
meditation, which have helped some members to attain greater peace of mind. Special events such as the annual Candlelight Night on World AIDS Day help to strengthen the bonds of trust and oommon interest.

N{aterial and medical support The club receives donations from various sources, insluding the Thai Red Cross Society, Ministry of Publio Health, individual supporters, and also from its oram fund-raising activities. Some of these funds are used to purchase drugs overseas, which are then sold to members at a reduced price. The club has also helped a number of members to obtain expensive drugs such as Zidovudin (AZT) free of charge from the Immune Clinic at Chulalongkorn Hospital. Some of the olub's income is also used on an occasional basis to assist particularly needy members, for example to pay house rent for the family of a member in hospital, or to pay travel expenses for a member who urgently needs to visit his or her family outside Bangkok. Several members of the club earn money working as fieldworkers in research projects or as resorrce pelsons in AIDS education training for looal
businesses and government agenoies.

Infomation for members: On the fourth Wednesday of every month, 30 to 60 members of the club meet to hear a speaker on a topic of relevance to their lives as people tiving with HIV. Doctors have spoken about diet and HfV, and scientific experts about researoh on possible oures for HIV infeotion. Prominent Buddhist leaders have spoken about spiritual dimension of illness, and in particular about the role of meditation in coping with HIV and AIDS. Members of the olub also contribute articles, letters and drawings to the quarterly magazine No Name. This is distributed to members and to health institutions as a means of sharing experiences and providing practical information about cornmon problems among people living with HIV.
Advocacy and public educalion: On a few occasions the club has organized a petition to protest against cases of discrimination against people with HIV. The club's most prominent form of advocacy on behalf of people with HIV and

- 51 -

AIDS, however, is the annual "candlelight Night' on World AIDS Day. The first ceremony, held on 1 December 1991 outside the Thai Red Cross Sooiety's Anonymous Clinic, was presided over by Her Royal Higbness Princess Soamsawali. The event was attended by over 50 HlV-positive people and their families, as well as about 200 other guests. It was the fust time in Thailand that a large group of people with HIV had "come out" to mingle with the public.
Royal Highness Princess Soasawali. After the ceremony the Princess made a point of meeting with about 30 members of the Wednesday Friend's Club in the Anonymous clinic. This meeting, which was widely reported in the national press, was significant in reducing public hysteria about AIDS.

The ceremony

in December 1992 was also presided over by Her

1993 over 500 people, including about 100 members of the Wednesday Friend's Club, attended the Candlelight Night ceremony, whioh was broadcast live by Radio Thailand. Members of the Wednesday Friend's Club performed a musical play which called on sooiety to show greater understanding and solidarity towards people with HIV and their families. In order to help educate people and dispel irrational fears, eight members of the Wednesday Friends' Club speak to audiences at schools, colleges, factories and the anned forces.

In

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CARE trOR PNRSONS WITH HIV/AIDS

A few religious

groups and non-govenrmental organizations have expanded their roles toward sooial welfare and health service for HIV/AIDS.

Christian work in Thailand began in the 1830s covering public health and educational activities as a part of its mission. In the era of AIDS, the missionaries are engaged in pioneering efforts incorporating home-based care and support for those infected and their families. Christian groups also run shelters and hospice centres to care for persons with HIV/AIDS. They support these kind of care methods as they are an extension of their pastoral work and stress on dignity for those dying. Catholic groups extend care and support services to all in need regardless of their faith and put no demands on patients to convert to Christiantty after they ,t" adnitted. Some Lutheran groups in Bangkok are more hesitant to do so and require those under their care to attend bible class (Somsak:personal communioation, 1994). Traditionally, Buddhist monks were healers and knoum for their knowledge on herbal treatments; the temples and monasteries have beds for in-patients (Bessey, undated). The International Network for Engaged Buddhists (INEB) has since 1992 encouraged monks to establish hospices for persons with HIV/AIDS within their temples. However, the use of the lsmple for this pu{pose has received a mixed response from the Buddhist clergy and lay people alike. Many view the temple as unsuitable for HIV/AIDS work as the purity of the monks may be oontaminated, and youth as well as women who may have to stay in the temple might tarnish its image. Despite this strong opposition, some temples have opened their doors to AIDS patients, and monk training is emphasizing the concept of living with AIDS (Bessey, ibid). Non-governmental Organizations play a major role in the provision of alternative care for persons with HIV/AIDS. Majority already have programmes in place to care for destitute or orphaned children and women in distress; they have extended these services to inolude those under their care that are found to be HlV-positive. Some have built separate shelters for those infected, while others continue to live together.

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CASE STTJDIES
Thammarak Niwets

Abbot Alongkot of Wat Phra Baat Nam Phru in Lop Buri province praotioes what he teaches, "Mahakarunathikun" or compassion without boundaries. The Abbot tumed his temple into a hospice for AIDS patients n 1992 after a proposal from the Intemational Network for Engaged Buddhists (INEB) encouraging monks nationwide to take up this role in society. The temple initially provided care to ten people and within two years it has beoome one of Thailand's biggest hospices for AIDS sufferers. Phra Alongkot offers his patients holistic care taking into oonsideration their physical, psychologioal, sooial and spiritual needs. ImFortanoe is place4 s1 improving the quality of remaining life. Thammarak Nivet also aims to:
o Emphasrze ttie role

of the temple as the centre of

providing
philosophy.

social solution

to a

oommunity life by sooietal problem through Buddhist

o Enoourage other religious organtz"ations and people to offer compassion and consideration for each other.

o Show how Buddhist philosophy can be used in providing praotical care for
the sick. o Increase awareness of needs of the sick and their families and how these can be met through alternative care that differs from the standard hospital care. o Become a souroe of information on holistio oare.
has more than ten bungalows, eaoh with one to eight beds, to separate the patients and avoid the spread of various diseases. Those patients vvho have not oome to terms with the disease and are not prepared to

At present the temple

talk to others about their condition occupy the one-bed bungalows. A newly
sBased

on doouments from the projeot, disoussions held with the Abbot and a visit to the project site.

-54-

opened twenty-bed ward separated from the bungalows, houses full bloum AIDS patients in their last stage of life. The temple has a capacity to care for about seventy persons. Two more newbuildings are under construotion enabling 100 patients to be handled by the end of the year. Phra Alongkot observes that the expansion would still be inadequate to oater for the increasitg number of

HIV/AIDS persons seeking care at the temple.e

Most-of the patients at Thammarak Nivet arc young people from average
inoome to low income groups. Their families have little understanding about the disease

6d simply reject living with them onoe they axe aware of their HfV

infection.lo According to the Abbot, most relatives bring the sick person to the temple and never return to visit them, even at the point of death. The temple has to oonduct religious rites when they finally die and send ashes to the families who are willing to have them. However, the ashes of many remain at the temple. The Abbot realises the need for family support and visiting relatives are offered free food and acoommodation. A new rule also requires relatives to bring and care for the sick person for a few days in order to be admitted at the
hospioe. They are also required to visit at least onoe a month or when able, the

patient

will visit them. The temple

does not keep the patients for more than a

few months and encorrages them to go to their families when their condition improves. The Abbot tries to convince their families to help take care of their own people when cases are not too serious and oould be treated at home but he has not been sucoessful.
Patients are accepted into the temple on a first come first served basis but full bloum AIDS patients, who are nearly helpless, are given fust priority. They are

provided with nutritious food, shelter and other basic essentials free of charge. Those who wish to buy additional personal items make various kinds of handicrafts during their free time and sell to those visiting the temple. Residents are to live in an atmosphere of mutual respect and ooncern. They have to follow

eApproximately two hundred HIV/AIDS patients suffering from tuberoulosis and skin infection are registered on the temple's waiting list. explains why eighty per cent of those whose conditions improve continue to stay at the temple, living little room to take in new patients with worse oonditions.
r0This

-55-

the five basic precepts striotly and daily,tt inform the caretakers when leaving the temple and not bring strangers to the temple. Moreover fighting, gambling

and drugs are prohibited and smokers axe encowaged to stop. Those who violate these regulations are given tw'o warnings after which they are dismissed from the temple. Every newcomer is given a three-day orientation when these conditions are explained. The orientation also involves planting a tree of new life. The Abbot maintains that peace of mind is the most important medicine to fight AIDS and depending on their health, patients are encouraged to participate in daily activities such as: o morning and evening chanting o goup meditation
O dhamma study

o exeroise o cleaning their room and surrounding area o watering trees and plants around the building o siesta
Phra Alongkot has established a network of oare givers to assist him run the hospice.r2 Patients whose health has improved are trained to care for those in

a worse state and with daily chores while volunteers from the nearby village help with slsaning and preparing food, as well as encouraging the infected persons. Beoause of the Hry/AIDS residents' lowered resistance to disease and infection, two resident nurses and an assistant nurse monitor their health very
closely. They take their temperature and blood pressure every day. Doctors and
nnrses from the nearby hospital also provide check-ups once a week. Spiritual
care is offered by the monk and all patients are encouraged to practice dhamma

by meditating, yoga and chanting. The Abbot and nurses also give counselling in order to foster a sense of purpose in their patients, to whom life has become meaningless in the faoe of imminent death.

rrThese are: do not take life; do not steal; do not commit adultery; do not tell untruths; and, refrain from intoxicants.

tThere are currently 62 staffand 15 trained volunteers who come and go. An additional 20 volunteers are AIDS sufferers who have recovered at
the temple.

-56-

Thammarak Niwet is financially supported by the Ministry of Publio Health and private donors. The Abbot feels discouraged by the growing number of infected
persons in Thailand and society's response to those infected. He is often invited to share his experience with others throughout the country. The temple receives

about 100 visitors daily who come on study tours. A hall is currently under construction, where information about the project will be provided to visiting groups using audio visual aids and other media. This will give the patients more privacy.

Christian Outeach to AIDS Affected Childrcnr3 Christian Outreach established its AIDS prograrnme in 1991. At the time, the epidemic in Thailand was spreading to the heterosexual community as was evident in the increasing number of infected women at antenatal clinics. In order to curb the rise in the number of children infected by their mothers, health personnel urge HfV-positive women to terminate their pregnancies. Christian Outreach AIDS project founder and manager, Khun Somsak, felt that lowincome, illiterate women are often not given a choice. They may not be aware that their infants had a one in three chance of contraoting the virus and that

powder milk eliminated the risk of transmitting the virus through breast milk. Consequently, a network was established with government and nongovemmental hospitals and health centres who referred their patients to Christian Outreach after they were diagnosed as HlV-positive.rn Christian Outreach then offered care and basic support to these women and their families from the pregnant stage, through delivery, post-natal and beyond. They ensure that infants are not abandoned, that ohildren who test negative after 18 months are securely placed with the extended family and that the family lives in confidenoe in their own community despite their HIV infeotion. Christian Outreach has ourrently 45 families under their care, many of whom are yonng couples with an average of two children. The majority of their
t'Based on documents from Christian Outreach and discussions with Somsak Wiangyangk*g, AIDS project manager. enter the programme on a voluntary basis and all services and supplies are provided free of charge.
raPatients

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patients are migrants from the Central and Northeastern regions and are likely to be unemployed, homeless or living in slum communities in Bangkok. More recently, Christian Outreach has extended their services to Burmese immigrants

who are taken in as "special cases". They provide care to all poor families referred to them regardless of their faith.
The home visit team consists of a social worker, nurse, public health eduoator and caretaker. Al1 are women as much of their work is with infected mothers and their infants. They are selected aocording to a set of criteria to ensure that

they are well suited for the work.l5 The team has been well trained by experts from abroad who are involved in AIDS home care programmes. Christian Outreach provides adequate support for staff to ensure their physical and emotional well-beirg, and to offer them training opportunities that will enhance the team's capabilities. The team members meet daily after the home visits to review their current work and onoe a week to plan futtue aotivities. Once the patient is referred to them, team members will visit her at home and record data about her health, family and social background. They provide a wide range of services depending on the needs of the patients and their families. These include the following:

Social and Psychological Support Many of the families have economic problems and thus the first challenge is often to meet their basic needs. It may involve finding them work and/or accommodation, providing food and other essentials. They encorrage the young mother to stay home with the baby after birth to establish essential bonding and often support her financially to look after her baby rather than let her go to work and leave the baby. Assisting the patients to regain their self-esteem and oonfidence is another important task for the team. This takes many months of visits to oounsel and provide guidance as the stigma attached to the disease is very strong in Thailand. The Christian Outreach team also visits their parents and relatives who may have ostraaized, their children to olear any fears and misoonceptions about AIDS. In all oases, they have taken their infeoted children back into the family circle and accepted

ttAll the staff at Christian Outreaoh are devout Christians. They dedicate
their lives to serve others and view their work as a calling. Thus money should not be the major reason for working. The nurse, for example, is paid a monthly salary of 7000 baht and would earn more in a private hospital.

-58-

to care for their infants after their death. The team encourages the patient not to isolate themselves but to participate in community activities and maintain an aotive life. Some families opt to return to their home villages but still maintain the relationship with Christian Outreach staff through conespondence. Once they have gained the trust of their patients, they begin to focus on the future of the ohildren. Most parentg are healthy and do not feel the urgenoy in making arrangements for the futire oare of their children. Christian Outreach staff therefore enconrage them to plan and inform members of the extended family
who will take care of the children after their death. Somsak observes that many of them have been sexually abused by their father or brother-in-law and are hesitant to return home. In such cases, the team has to searoh for other altematives. They maintain contact with the family once the child is in their possession and provide basic essentials if required.
lVledical Care and Support The Christian Outreach team does not treat their patients but rather monitors their health to establish when such care is required. They organize hospital visits, accompany their patients and visit them when they are admitted. The team follows them up after they are discharged to ensure that they take their medicine acoording to prescriptions. Mothers are taught how to prepare the milk and to take better oare of their babies. The team monitors the baby's weight gain and development olosely, ensuring that they receive all the vaocinations. The team also provides the patients with information on

HIV/AIDS, proper diet and hygiene. They enoourage them to take proper caxe of themselves by leading a risk-free lifestyle and having regular medioal checkups in order to prolong their lives. This not only gives them more time to be with their children but also provides them an opportunity to take advantage of
a breakthrough when

it

comes.

The Christian Outreach AIDS project is financially supported by ohurch groups in Europe, the Ministry of Public Health, Unicef and individual donors. To maximise the use of existing resources, Christian Outreach seeks to coordinate its efforts with other organizations working in this field. Some of these inolude government hospitals and health centres, Suan Santithan Hospice in Pathum Thani, and Shelter for Women in Distress in Bangkok. Patients are referred to these institutions at various stages of their illness. Many of the patients prefer

to die at home and, if families are supportive, they will return to their parents in the countryside when their condition worsens.

-59-

Although hard, the staff find their work leussrding and would encourage the govemment and NGOs to replioate their model in other areas. They plan to start a similar projeot in the North of Thailand where the epidemio is most severe. The team has leanned that women do not want to abort and that families want to stay together if there is a choioe. Somsak believes their face-to-face education and counselling method is effective for this low-income group sinoe they are able to ask questions if they do not understand. "Behaviour ohange is slow and it takes time for them to stop visiting prostitutes, smoking or gambling", adds
Somsak. However, some families settle well when Christian Outreach helps them to find work and do not need to be under their oare. They have a good family life and come to the office to visit the team as friends.

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X'lgue 12: Education and Carr for HIV/AIDS Clients by ftc Home Care Visit Team

Bc available for counselling, advice, encou.ragement and emotional help Advice re work and benefi.ts.

Contact with hospitals and other agencies who may providb supPort and helP. * Contact and search for relatives of clients. * Counselling re family Problems.
Help in planning for childlen's future after the death of parents.

To educate and make suggestions to clients as to how to eare for the health of the family. Advise ctitnts- is to *tren to go for medical

treatment.' Advice to the client as to how to care for


the baby's heal"r"h.

?'0{". iko.tid Educator

* To study and search for data on family. * To provide kreou'ledge re IIIV/AIDS. * 'lo advise re nutrition for t'he familyTo keen up to date with latest I{IV/AIDS inform^ati6rr and knowledge and report back and to rePort back to the teem*.

11"r 9' ":"' :g"i:ry:-13:1


Ib irelp clients in traveling
to hospitals, etcTo accompany the s<lcial worker, ntlrse, cducator to assist with their work-

Caregiver

-61 -

tr'tguc

13:

lVlanagement for Visidng HIV/AIDS CIienS at Home

Social Worker

Hospital

Educator

Caregiver

--i-Wi Return Home


I I I

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CHAPTER 5 WORKSHOP ON COMMT]NITY.BASED APPROACA FOR THT. PRf,,VrcNTION AI{D CONTROL OF AIDS IN THAILAI\U)

Executive SrrnrmAry The ASEAN Institute for Health Development (AIHD) and other institutions within Mahidol University's Salaya Qampus collaborated to organize an academic seminar on community-based prevention and care of AIDS that took place on 10 to 12 October, 1994.

Purpose

o To have those attending the conference

formulate amodel that oan overoome the prevailing obstacles in uniting the community to develop 4 ssrnmoo bond and unite in the fight against the AIDS epidemio.

To report existing findings from international and national community based AIDS prevention pilot programmes. exchange ideas and experiences in implementing AIDS prevention and control programmes.

o To allow seminar participants the opportunity to

Results

There is a persistent exponential increase in the number of HIV infeoted cases

in Thailand. Those with the virus require appropriate health care. At this time, public hospitals bear most of the burden to oare for these AIDS patients, but these hospitals have a limited number of beds available for AIDS victims. If this situation oontinues, AIDS cases,will overwhelm hospitals. Government and non-goveflrment sectors need to invest more attention into home oare and

community care. Pilot projects to ascertain models for home oare and oommunity care should be studied with an emphasis on community participation and involvement. Many of the pilot projects implemented in Lopburi province and other axeas of the north seem to be quite effective in giving health oare to AIDS patients, and in creatively using oommunity organizatrons to inform villagers about AIDS. Even, HlV-positive groups organize themselves together to help each other.
In relation to AIDS prevention, education measures aimed at educating people in factories. The Graduate AIDS Volunteers Project eTas implemented by AIHD with the intention of enabling factory workers to retain information about AIDS and safer sexual practioes. Many non-government organizations (NGOs) promote educatron at the grass roots level (family and community level).
Participants of the seminar agreed that AIDS is a social problem. Social, cultural, and economio factors that contribute to AIDS should be critioallv
considered.

In oonclusion, government and NGOs cooperation in the prevention and control of AIDS have to continue with the acceptance and understanding of each other's roles. The broadsning of community-based prevention and care of AIDS has to be done with an inorease in the quality of these prograrnmes. In addition, the human rights of AIDS patients should be critically reviewed.

STJMMARY REFORT

The AIDS epidemic does not only affect Thailand, or any one particular country, but the disease has spread to all parts of the world. As a result, many countries accept the fact that AIDS is a global problem that concerns everyone. In order to ascertain a solution to this growing problem, community
partioipation is necessary. From the International AIDS Conference in Yokohama, Japan held during the beginning of August 1994, it was reported that Asia has the highest percentage of HIV infected citizens. Africa, which has already lost a large number of citizens to AIDS, held the number one position before Asia. Unfortunately,

-64-

Thailand still shows many indicators that it will continue to have the largest number of AIDS cases in Asia despite joint efforts from government and private organizations to try and keep the epidemic from spreading" The epidemic has sent such disturbing waves in Thailand's economy, society, culture, and lifestyle that it would be rather diffrcult to try and solve this problem unless the entire community whole heartedly joins together to help one another. Many areas of Thailand have already implemented this approach and have had successful results. Apparently, this has proven to be a betler approach for our present
situation. Therefore in order to develop a model to solve the AIDS epidemic in whioh the

community's effort and support is clear ancl critical, the ASEAN Institute for Health Developrnent(AlHD) aod other institutions within Mahidol University's Salaya Campus has collaborated to organize 'Mahidol Univenity, Salaya Academic Wee\ 1994t'with an emphasis on AIDS.

FEA

TIIRE PRIIS ENT^rr TIONS


based AIDS prevention prograrnmes and Quality clevelopment.

o Exhibitions of community
of Life (QoI)

o The 8th Natth

Bhamarapravati's Memorial Lecture: "The medical, public health, and education systems in Thai sooiety during free market economy era." by Dr.Wirapong R.amaungkul, Former Minister of Financial Affairs

o Presentations and lectures on AIDS

and health development from various government and non-govemment organizations.

-65-

PURPOSE

o To have those attending the conference

formulate a model that can overcome the prevailing obstacles in uniting the community to develop a common bond and unite in the fight against the AIDS epidemic. findings from international and domestic oommunity based

o To report existing o To allow

AIDS prevention pilot programmes.


conference participants the opportunity to exohange ideas and experiences in implementing AIDS prevention and control programmes.

DT]R,A.TION

o Monday

October 10, 1994 to Wednesday October 12, 1994.

LOCATION

o ASEAN

hrstitute for Health Development (AIHD) at Mahidol University,

Salaya Campus.

PARTICIPANTS

o Teachers, professors, researchers,

specialist, community leaders, physicians,

nurses, offrcials from the health departrnent, social workers, counselors, mass

communication officers, and other interested persons from government and public organizations.

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SUMMARY Mondav 10. _Qgtqber 19%


Roles of Non-government Organizations (NGOs) on the hevenlion and Caring of AIDS Patients."
Disoussion on:

'{he

Panel:

Prof. Dr. Prasert Thongchareon Senior Advisor, Mahidol University Prof. Dr. Damrong Boonyuen Director General, Center of Disease Control (CDC).
Assoc. Prof. Dr. Yawarat Porapakkham Senior Advisor of AIHD

Archarn Jon Ung-pakorn Direotor of Aocess


Moderator:

Prof. Dr. Debhanom Muangman 'Dean, Faculty of Environment &


Resource Studies, Mahidol University

Statement by hufessor I)n Damlong Boonyuen In the past, the Ministry of Public Health(MOPII) had many responsibilities in the fight against AIDS. For example, they were responsible for: educating the

public so that they would change their sexual behavior, and financially
supporting the governments' and NGOs' efforts.

Currently, there are more aspeots of the epidemic that must be confronted and a plausible solution must challenge these aspects. The govemment is looking towards a "grass roots" effort at the community level while at the same time supporting these commslilies with research results and health eduoation. All of these efforts are for the purpose of focusing the government's objeotive.

-67-

In oonolusion, the govemment should inorease its support on the prevention of the AIDS epidemio, because ourrently govemmental allooation in this area is limited.
Statement by hofcssor Dr.

hasefi Thongcharcon

Because this university is supported by the govemment, the university has been conducting researoh on AIDS ever since the discovery of AIDS in Thailand. The university has taken three approaohes to fighting AIDS: biomedical(vaccine research), educating the medical community on proper health care teohniques,

and educating the public on AIDS and its prevention. Statcment by Associate hofessor

I)n Yawant Porapakkham

AIHD works with hospice organizations to emphasize AIDS awareness so that citizens will follow safe sexual practices. However, our efforts are weaken by the fact that we do not have the resources to follow up on the progress of our
educational efforts. Projects target educating potential community leaders so that

of AIDS and AIDS victims to their respective communities. With the support of the medical
these leaders could convey awareness and understanding

community, home care techniques are taught to these leaders. Community-based programmes from the government and NGOs are still lacking research and

effectiveness evaluations. Without them, there


reference.

is no

standard

for

future

Shtement by Archam .hn Ung-palrom There are 44 distinotive NGOs with different approaohes and objeotives. However, there are five primary goals:

o To give AIDS awareness to the public and change


AIDS victims.

citizens' attitudes toward

o To give emotional support to victims o To educate their own staff on AIDS.

and their families.

o To frght for the rights of AIDS victims.


o To ascertain a olear approach to prevent
the spread of AIDS.

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Discussion on: rhoblems and Obstacles in homoring Community participation

in AIDS hrcvention programmes.rr


Panel:

Viput Pulcharoen Director of AIDS Division Ministry of Public Health (MOPI{) Dr. Sayri Pongpis Dilector of Northem AIDS Prevention and Care (NAPAC)
Father Joseph H. Meyer

Director of Center of Human Development


Moderator:

Assist. Prof. Dr. Som-aroh Wongkhomthong Director of AIHD

Statement by Mr. Viput Pulcharoen

The objective of the MOPH is to change sexual behavior and improve the health condition of Thailand's residents with the assistance of the medical oommunity. Our first priority from 1992-1996 is to emphasize mass communication of AIDS information. After that, we will try to change sexual behavior using three methods:

counseling the entire public on safer sexual practices; and sub-districts

o changing the attitudes and biases of those in small villages


towards AIDS viotims: and

o uniting the efforts of social workers in MOPH and other


method according
dilemma.

government

agencies. hr conclusion, the government needs citizens to ascertain the best

to their specific needs and limitations to solve this

-69-

Statcment by Dn Sayri Pongpis

The real problem of AIDS is not disoovering which method will stop the spread, but how to make society understand and accept AIDS victims. The discrimination that victims receive makes their life seem like a living death. The solution has to be decided on by the entire community and not just be a model handed to them by researchers.
Statement by X'ather.bseph

II. Meyer

o If citizens

want the epidemic to stop spreading, then they have to depend on themselves to solve this problem and not any particular organization.
advocacy agencies have to ask themselves if they are really willing to work with the community in order to solve this problem. researchers confuse citizens

o All AIDS

o AIDS is everybody's problem, but sometimes

with their scientific terminology and proposals. There needs to be some


middle ground that both groups must find so that they can understand eaoh other. T'he most important thing that needs to be done is for researchers to consider the needs of the public when trying to formulate an experimental preventing/coping model.

Special lecture on 'The Role of Buddhist Monks in Caring for AIDS Palientsrf by Phra Alongkot Tikkapanyo, Director of Thammarak Nivej Project,

Wat Prabat Nam Pu, Lopburi Province.

The Thammarak Nivej Project was established to be a last resort for AIDS victims. It was set up in September 1992 with the idea of using the Buddhist teaohings as its primary objective. In addition to the teachings, the project teaches viotims and their families how to oare for AIDS patients. Emphasis is given on emotional support so victims do not feel alienated from the community. This project was able to build patient facilities that received national and international attention.
Conclusion for Monday 10, October L994 While the govenrment wants its citizens

to have a more active role in


is a general

ascertaining the best method to live with and fight AIDS, there

-70-

feeling that the government also needs to increase its role. Many projeots from govemment and NGOs are in force. However, these programmes aJe weakened

by the fact that they do not report negative fildings and lack follow

up

evaluations. Some believe that the society should focus on changing its attitude toward those infeoted with the HIV virus. While some others strongly feel that

the best solution


the community.

is community based, and that those organizations and


of

researchers working on the epidemic must consider the needs and limitations

Tuesday-[_l;QEtober

199 4

Natth Bharmarapravati Memorial Lecture: rThe Medical, Public Healft, and Education Systems in Thai Society During Xhe Market Economy Emr? by Dr. Wirapong Ramaungkul, Former Minister of Financial Affairs.
Introduction:

Prof. Dr. Natth Bhamarapravati Former President of Mahidol Universitv Advisor of Institute of Science and T'echnology Development, Mahidol University

Complete details of this lecture oan be obtained from Bharmarap r av ati Memorial Lecture, publication.
Room

.the annual 'Natth

A: Government Sector Aotivities on AIDS


Archam Sommai Wansorn Archarn Kanchana Tangchonlatip

Chairman: Secretary:

Special Lecture: 'f Bangkok F'tghting with AIDS by Prof. Dr. Chaiyan Kampanartsanyakom Deputy Goveneor of Bangkok Metropolitan

Administration (BMA).

This office recognizes the increasing severity of the AIDS epidemic in


Bangkok. The are many factors that have lead to the exponential spread of the

virus. For instance, tourists pafiorizing the red light districts and many

-71 -

intravenous drug users living in Bangkok. In the past, no government oryanrz,ation was directly responsible for preventing and controlling the spread of AIDS. Recently, a control center on AIDS was established. This government agenoy works closely with the public and international orgaruzations. There are
six objectives soheduled for 1994-1996:

o To change the sexual behavior of the publio. o To increase public health services. o To give counselitg on AIDS. o To increase research done on AIDS. o To use the law to protect the rights of victims. o To develop the organizationfs leehniques.
In my opinisn, polioies will not succeed if there is no real support from
adm

the

inistration of

re

sponsible organizations.

rThe Role of Graduate AIDS Volunteon in AIDS hrvention Among Factories

Worken in Bangkokrf by Assist. Prof. Dr. Alisra Chuchat, Project Direotor, AIFID
Realizing the importance of the AIDS situation, Program for Appropriate Technology in Health (PATID, AIDSCAP of the Family Health International, and AIHD decided to pilot test a ns\M implementing mechanism by having target groups participate in forming their own small groups to assist each other
and to implement the programme by themselves later on. The projeot's objeotive

is to reduce the incidenoe rate of AIDS arnong factory workers aged 15-29 with

an emphasis on changing the risk behavior. Graduate volunteers dedicate one

month to an intensive training course on leadership skills and information necessary for them to train and educate factory workers. This is an l8-month project whioh is implemented in four areas of Bangkok: Minburi, Bangkaen, Paseecharoen, and Bangkhuntein. These four areas are locations of large and medium size factories.

At the end of the project, 35 graduate students would have provided eduoation to over 30,000 workers and trained 1,100 factory volunteers from 30

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participating faotories. AIHD will evaluate the performance of the graduates and factory volunteers by interviewing management staff at each of the factories. AIHD is to assess the suooess of this projeot in terms of its ability to ohange the attitude and behavior of faotory workers towards AIDS prevention and oontrol.
Results of the assessment are to be used to develop strategies to improve future prograrnmes.

hoject : A Village Xlte fmm AIDS " by Sanun Natsuwun, Director of Deparbnent of Health
Mae Chun, Chiengrai

r'lVlae Ctun

This project teaches volunteers (housewives, husbands, teenagers) from the community to become AIDS awareness activists. flowever, this projeot can only survive with the help of govenrment agepcies like publio hospitals and social workers. The benefits are the awareness that the community gains. As a result, AIDS victims are no longer alienated from the community. This project is an example for other communities.

Case study on: I'Cultually Appopriate AIDS

hrvention Intenention Among

Khon-Kaen Vocational Students: A Participatory Approach " by Taratip Thumnavapud, Provincial Health Office, Khon-Kaen.

This projeot targets vocational students by using peer advocates to oreatively educate other students about AIDS. The benefits are active partioipation and learning from students, while at the same time, educating the public.
Conclusion for Room

A: Govemment Scctor

Of the many govemment AIDS prevention activities, the ones that seem to be most suocessful are those community based programmes that use peer eduoation techniques. Some benefits using these teohniques are active leanring and reduced discrimination towards AIDS victims. In addition, a govemment control oenter on AIDS has recently been established with six clear objectives.

-73 -

Room B: Intemational Forum on Participatory Action Researoh (PAR) for AIDS Prevention and Community Health Development
Chairman:

Co-Chairman:
Secretary:

Prof, Dr. Serene Piboonnivom Dr. Ono Kishio Ms. Sunsiri Inchun

rlEco-health and Urban Populalion in the Development Counties of South Asiatt

by Dr. Almas Ali, South Solidarity in New Delhi.

fn areas of India, a study was done in order to pinpoint communities that are or have the potential to be degraded by the introduction of an epidemic. In other words, the community would not be able to cope and this would lead to a doumward spirat to the bond of the citizens as well as their individual well
being. These problematic communities can be pinpointed using a number indicators, and comparing the results to a baseline community.

of

After pinpointing these communities, developmental workshops can be offered (e.g. advocacy roles, sensitizing, and home care training). In all ecosystems (e.g. rural, urban), the major impact will be the involvement of the citizens. How is this connected to AIDS? In a broad sense it has implications. We can identifu the areas that may be most problematic. The key is that awareness must be placed into all axeas of the environment.

"Application of Participatory Research in AIDS hevention and Training hogrammes fr by Ms. Korrie De Korning, The Education Resouroe Group, Liverpool School of Tropioal Medioine, University of Liverpool.
There are different approaches to health education and promotion. Most studies focus on knowledge, attitude and behavior and how prograrnmes affeot behavior
shanges. These behavior changes are decided by professions.

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In the prevention of HIV/AIDS, we need to use a variety of

strategies,

understand that practice does not necessarily reflect knowledge, and tealize that counselling and development of intra-personal skills are important.

Participatory action research was developed to empower the oppressed. It uses different approaches to encowage dialogue and discussion for reflections. Participatory Rural Appraisal (PRA) uses visual group methodology' Body mapping uses drawings to portray points of views. Grounded in the praotice are:

o Identi& the problem (cyclic prooess) o Observation and investigation o Implementation o Evaluation
This type of research is practical for any setting except those with controlled
situations.

tThe Role of Communication in Participatory Researrcht' by Dr. Ono Kishio, Team leader Community Health Project, Japanese International Corporation Agenoy (JICA), Khon Kaen.
The focus of this project is on oommunication. Similar to the Friendship House (Japan), the Urban Health Projeot (Khon Kaen) was established to provide: primary health cate (PHC) services, health education, and information
consultants. People living in slum areas used the PHC centers as a public place for communicating with each other (community organizatrons' meetings) and

with government officials (medical visits). We discovered that internalization of information depends on many factors: needs, demands, benefits, risks,
personal values, circumstances, environmellt, and others.

Conclusion for Room B: Intemational Forum Many AIDS educationaVactivist programmes are constructed by professionals and researchers. There are a number of factors that must be considered when

formulating these programmes. However, the prograrnmes should consider the needs of the target group as well as emphasize communication iunong all parties

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involved. Another helpful procedure is to pinpoint and target those communities that would be most degraded by the introduction of an epidemic.

Room C: Family Institution and AIDS


Chairman:

Co-Chainnan:

Assist. Prof. Somsong Burusphat Assist. Prof. Chanya Sethatput

Case Study on: 'Sex Behavior in the Family of of the Nor{hem Region Thailand 1994 n

Rual Feople in Southem Part

by Kitti Puthikanon, Communicable Disease Control Region 9, Pitsanuloke.

In the above mentioned region, the spread of the HIV virus has reached

critioal stage. Therefore, I decided to research sexual behaviors in this region. I discovered that residents of this area spend most of their earnings patronizing escort services, and this is the primary sorrce for the introduction of HIV into the family environment. Many housewives have affairs and do not practice safe sexual activities. In conclusion, the sexual behaviors of these residents must change by promoting safe sex education.

tSex: Afiifude and Behavior of Women fmm Low Income Community by Assist. Prof. Dr. Chai Podisita, Institute for Population and Social Researoh. Mahidol Universitv.

"

The following data is based on foru interviews from the research project, "Behavior for AIDS research in Thailand(BRAID)." The four groups are low
income workers(male and female), truok drivers, and escorts. The average age

of interviewees was 25.4 with all having some secondary education. The results were that the majority thought that it was acceptable for men and not women to be promiscuous. 54.6 percent of those interviewed had premarital sexual
activities(a practice that use to be extremely taboo), and of those 54.6 percent, many do not use condoms with partners that they know well. In my opinieq there should be an emphasis on promoting oondom usage because most people do not see the importance of prophylactics.

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'rAfritude
palientstt

of the F'amily in Northem Part of Thailand: community & AIDS

by Assist. Prof. Saovapa Pornsiripong, Institute of Language and Culture for Rural Development, Mahidol University.

of the high incidence of AIDS cases. Public health officers were assigned to ask the residents their attitudes towards the 25 AIDS patients in the commslily. With eaoh increase in the number of cases, the communities increased their sympathy and understanding for victims. At first because of community pressure, family members of victims would alienate members with AIDS even though that

A qualitative study was done in this region

because

person might be the main financial supporter. After information on AIDS was

given to the community, there was a law set up to fine anyone who did not attend the cremation of any community member. This was done in order to promote understanding of those who die from AIDS. As a result, the attitudes of families with AIDS infected members as well as the community changed. If community leaders organized these events, then they usually had a high success rate. The main point is the community and its leaders have a cruoial role in the
acceptance of AIDS victims.

'Dducation on AIDS hrcvention Among Constuction Worken hovincett by Mr. Sirin Wannarat, Non-formal Education Center, Region 10, Chiangmai.

in Chiangmai

Construction workers in the Chiangmai area tend to follow the northern tradition of leaving their ofFspring with their parents. This allows the workers to have a worry free lifestyle similar to that of singles. Like other areas of Thailand, men then have the free time to solicit esoort services and women the opportunity to have affails. In 1991, this projeot was established in order to educate these workers by using exhibitions, lectures, videos, and monthly publioations. At the end of 1994, we will start training volunteers from the work force to become guidance counselors.

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"Activilies on AIDS hsvention in slum Area' chiangmai hovince" by Mr. Somboon Meeboon
The goal is to slow the spread of AIDS eduoate the public about the disease.

organizattons(housewives, teenagers) From these organizations, we took volunteers and supported their individual creative efforts to inform the residents about AIDS. The most important lesson,

in densely populated axeas, and to We used established community to bring awareness to the oommunity.

we got from this activity was that we had to consider the community's needs while trying to accomplish our goals. Conclusion for Room C: Family Institution and AIDS In many northern provinces of Thailand, there is an exponential spread of the HIV virus. The rapid increase in number of cases is largely beoause of promiscuous unprotected sexual behavior. Many residents are lack AIDS information. The most suooessful educational techniques were those that: 1) considered the community's needs and 2) used oommunity organizations and leaders as informational liaisons between residents and knowledgeable
professionals.

Wednesday 12. October 1994.


Chairman: Secretary:

Prof. Dr. Debhanom Muangman Assist. Prof. Dr. Alisara Chuchat

rThe l)evelopmcnt of Community Participation in Contol and Care o1$sv'.ally Transmifred Diseases and AIDS"

by Tipaporn Aksorntanasombat, Communioable Disease oontrol Region 10, Chiangmai.

We used a community based approaoh. It was a joint effort between the govemment and local communities. First, we had to make the residents understand that they had to work on their own solution. We supported their creative informative exhibitions and trained them to become village care providers. Although we found a lot of success in our program, we laoked the required supply of public health eduoators to meet the publio's demands. It

seems that we had

a gteat interest in our programme from the community,

however, because there was no follow up, we cannot truly estimate the success

of our prograilrme.

'Model of Caring HIV Infectcd Penons at Hometr by Aoharn Sanant Wuthisasanacharn, Christian Congress in Thailand
The project's purpose was to teach home oare techniques to those families of AIDS victims, and be a support group to anyone in the community' Besides teaching these techniques, we made house oalls to AIDS victims. We placed an emphasis on the spiritual well being of victims.

ItCommunity ts Reaction to AIDS Patienb" by Dr. Varavud Surapruch, Director of Sansai Hospital, Chiangmai. The reperoussions of the AIDS epidemic effeots four areas: the economy, the

society, the affitude of citizens, and the stability of the work foroe and govenrment. In the economy, we see: a reduction in the gross national product(GNP), an increase in the government's budget for the treatment of health care workers infected on the job, a reduction in the work force, an increase in each citizen taxes to support AIDS viotims, and a decrease in the tourism. Observation of the community show us: problems with families ties, problems with infected orphans or those that may have lost family members, alienation, and a lack of respect for the human rights of victims. The publics' attitude shows us: lingerirrg fear and discrimination toward HIV carriers. While on the other hand, victims: want to remain anonymous, show suioidal tendencies, &d have retaliatory thoughts against society. In terms of stability we observe: a marred image of the country, a reduction in the counfil's work force and intelligence, and a reduotion in foreign investment. In my opinieq sooiety is acoepting our situation, not because they understand AIDS, but because the problem is overwhelming.

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rThe Experiences fmm Housewives Volunteer in Caring for HIV Infected People in Slum Artastt by Nittaya Prompochunbun, Duang Prateep Foundation
The Klong Toey slum area is an extremely populated area with over 100,000 residents. In 1984, drug addicts were taken to looal hospitals for treatuents, unfortunately, the real cause of their deteriorated conditions was discovered to be beoause of AIDS. Looal newspapers named the 16 infected, whioh caused an uproar in the neighborhood and a protest to expel the 16 residents. Because of this reaction, a group of housewives joined foroes to educate the neighborhood, espeoially drug users and prostitutes. As a result of these suooessful efforts, a teenage group has recently been formed to target other groups. Another problent we worked on was domestic disputes based on married individuals' fear of contaoting AIDS from their partners who have had extramarital affairs.

Conclwion for Wcdnesday 12, October 1994 Many community based peer eduoation prograrnmes have had great suooess in informing residents on current AIDS facts, in facilitating understanding and sympathy for AIDS victims, and in teaching home oare teohniques. There is a lack of both financial and human resouroes to manage this overwhelming
problem.

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