Of Thailand’s population of more than 60 million, in 2016 it was estimated that 450,000 people were living with HIV and that 6,400 people died of AIDS-related illnesses.1 After sub-Saharan Africa, Asia and the Pacific is the region with the largest number of people living with HIV, with Thailand accounting for approximately 9%.
Nearly 10 million people avoided HIV transmission because of early intervention programmes with key affected populations between 1990 and 2010.
Although the HIV epidemic is declining, certain groups have much higher rates of HIV compared to the general population. Those most affected are men who have sex with men, male and female sex workers, transgender people and people who inject drugs. Spouses of these populations and people living with HIV, migrant workers and prisoners are also more vulnerable to HIV than others.
Thailand’s declining epidemic is the result of successful HIV prevention programmes. A study has shown that nearly 10 million people avoided HIV transmission because of early intervention programmes with key affected populations between 1990 and 2010. Between 2005 and 2016, AIDS-related deaths declined by almost two thirds.
There were 6,400 new HIV infections in Thailand in 2016. Most will have occurred through unprotected sex, which is estimated to account for 90% of all new HIV infections. Unsafe injecting drug use is the second biggest transmission route.
Increased access to prevention services has resulted in new infections decreasing among some groups, however they are rising among others. For example, while the rate of new infections through injecting drug use steadily decreased between 1995 and 2015, the rate of new infections through male-to-male sex dramatically increased over the same period.
Key affected populations in Thailand
Men who have sex with men (MSM) and HIV
Of all new infections, 50% were among men who have sex with men (sometimes referred to as MSM), male sex workers, and transgender people, making this population a priority for prevention work.
Overall, in Thailand 9.15% of men who have sex with men are living with HIV, although prevalence varies greatly depending on location. For example, in Bangkok prevalence is estimated at 28.6%.
Condom use among men who have sex with men is high, estimated at more than 82.1%. But, although the availability of prevention services has improved, new infections have not declined as much as intended.
Prevention programmes also haven’t reached as many young men who have sex with men, meaning they are less likely to know where to obtain an HIV a test, or understand their risk. This, alongside a perception of low risk and multi-partner sex fuelled by performance enhancing drugs, can result in low condom use. A 2013 study of men who have sex with men in Bangkok found HIV incidence to be much higher in younger men (8.8 per 100 person-years among those aged 18 to 21, compared to 3.7 per 100 person-years among men over 30).
Pre-exposure prophylaxis (PrEP), antiretroviral treatment taken by HIV negative people before potential exposure to HIV in order to stop transmission, is currently being piloted in five sites in Thailand for men who have sex with men. This includes the Thai Red Cross Anonymous Clinic, which has been trialing PreP since 2014. Users are charged US$ 1 a day for their supply of pills, along with counselling and health evaluations.
Sex workers and HIV
In Thailand, HIV prevalence is far greater among male sex workers than female. In 2014, of the estimated 141,769 sex workers in Thailand, HIV prevalence was approximately 12% among male sex workers and 2% among female sex workers. However, urban settings have shown to yield exceptionally high HIV prevalence among female sex workers, such as 20% in Bangkok.
2013 data suggests that female sex workers account for 10% of all new HIV infections in Thailand. This may be the result of a lack of information about HIV or a lack of access to services. For example, a 2015 UNICEF study of young key populations in Thailand found only 31% of young female sex workers in Bangkok and 50% in Chiang Mai had received any HIV-related information or services in the past 12 months, compared to 80% of the other key populations surveyed such as men who have sex with men and people who inject drugs. The same study found that, of the young female sex workers surveyed, only 12% in Chiang Mai and 18% in Bangkok had tested for HIV in the past 12 months.
Globally, transgender people are the most at-risk group of sex workers, with HIV prevalence estimated to be on average nine times higher than for female sex workers and three times higher than for male sex workers.
Transgender people and HIV
There are more than 75,600 transgender people living in Thailand. In Bangkok, Chonburi, Chiang Mai, Chonburi and Phuket, the median HIV prevalence among this group was estimated at 12.7% in 2014, making transgender people a particularly at-risk population.
A large proportion of transgender people also sell sex making them increasingly vulnerable to HIV. For example, a 2015 study by UNICEF found 39% of young transgender people had sold sex.
In 2014, data from the five areas above found condom use among transgender people to be at 84%. Around 59% of transgender people in these areas were accessing prevention services and 34% were testing for HIV. Chiang Mai was the only city where testing had increased over time, from 22% in 2005 to 43% in 2014.
There are a number of reasons transgender men and women are being left behind in prevention and treatment work. Discriminatory heath systems, transphobia, family rejection and a lack of access to education and employment all discourage transgender people from seeking HIV services. Indeed, the 2015 UNICF study mentioned above found only 32% of young transgender people had correct HIV knowledge.
People who inject drugs (PWID) and HIV
Within the first few years of Thailand’s epidemic, HIV prevalence among people who inject drugs (sometimes referred to as PWID) rose from 0 to 40%. By 2011, prevalence had halved to 22%. However, prevalence began to rise again after 2011, and stood at 19.02% in 2016, the most recent data available.
This is largely because harm reduction services for people who inject drugs, such as needle and syringe programmes, still aren’t adequately available. On average, a person who injects drugs in Thailand received just six clean needles and syringes per year in 2014/15 compared to 371 in Cambodia, the South East Asian country with the highest coverage. High coverage is defined as more than 200 needles per person who injects drugs.
Despite this, there has been an increase in the percentage of people who report using sterile injecting equipment the last time they injected (from 42% in 2009 to 84.88% in 2016).
Condom use among people who inject drugs was less than 50% in 2016. However, Thailand’s National AIDS Committee (NAC) reported an increase in the percentage of people testing for HIV from 40% in 2009 to 61.2% in 2014, but warns that its data is limited as it is based on research from just three areas.
Migrants and HIV
Migration can put people in situations of heightened vulnerability to HIV, due to factors such as social exclusion and a lack of access to healthcare services or social protection. In South-East Asia, HIV prevalence among migrants to Thailand from neighbouring countries is up to four times higher than among the general population.
The highest prevalence among migrants in Thailand was found in the fishing industry, with rates of 2% among fishermen and 2.3% among fishery workers, compared to HIV prevalence of 1.1% and 0.74% among factory workers and farm workers, respectively.
In a behavioral survey conducted in 24 provinces among migrant workers aged 15-49, 21.6% of male workers had sex with more than one partner in the previous year compared with 4.6% female workers. Fishermen and those working in the sea-food processing industry were particularly likely to pay for sex. A 2016 study of more than 2000 migrant workers from Myanmar found more than half did not know or were not certain where to test for HIV.
In Thailand, the vast majority of sex workers are migrants from villages, who use the income from sex work to support families in their home communities. Migrant sex workers in low-income places appear to be at particularly high risk of HIV.
In 2013, Thailand’s Ministry of Public Health announced a policy to provide health insurance (with antiretroviral treatment coverage included) for cross‐border migrant workers who are not covered by social security, including both registered and unregistered migrants. As of September 30, 2014, the number of migrants who registered with the migrant health insurance stood at 1.4 million, an increase from previous years.
HIV testing and counselling (HTC) in Thailand
A 2015 study of young people from key affected populations found testing rates to vary widely between groups – from a low of 12% (young female sex workers based in Chiang Mai) to a high of 73% (young men who have sex with men based in Bangkok). Overall, it found young female sex workers to be the least likely to test.
New approaches have been introduced to increase access to and demand for HTC among key affected populations, including the following:
- implementing community-based HTC to expand outreach work
- ensuring that HTC outlets provide same-day results.
One such programme is the USAID and PEPFAR-funded LINKAGES programme. This is a five-year project which started in 2015 and is being implemented in Thailand by FHI 360 and local community based organisations. LINKAGES sees members from key populations (known as ‘peer mobilisers’) reach out to their peers in order to link them to HTC services. Those who test positive for HIV are then supported by their peers to access treatment and care. First year results found HTC had significantly increased among key populations inareas where LINKAGES is being implemented.
HIV prevention programmes in Thailand
HIV prevention among young people
Surveys show that people in Thailand under the age of 25 have lower levels of HIV knowledge and HIV testing and counselling than those over age 25. New HIV and sexually transmitted infections (STI) are rising among this age group, suggesting HTC needs to be better prioritised.
In recent years, efforts have been made to address the sexual and reproductive health of young people. A ban on people aged 18 and under testing for HIV without parental consent was lifted in 2012. A more systematic approach to sex education in schools and communities, including HIV prevention activities, has also been implemented. Although this has led to improvements in the health behaviour of some young people, the impact has only been seen in areas where there have been intensive interventions on a continuous basis. The scale of these improvements is also too low to have an impact on national STI rates.
Thailand’s National AIDS Strategy 2012-2016 included a specific objective relating to youth. However, NAC’s 2015-2019 Operational Plan for Accelerating Ending AIDS (OPAED) does not name young people as a key affected population or include a specific objective on youth, other than youth in prison.
Preventing mother to child transmission (PMTCT)
Thailand has made great strides in reducing its mother-to-child-transmission (MTCT) rate. In 2015 rate of MTCT of HIV stood at 1.1%. This equates to 86 children becoming infected with HIV through this route, a decline of more than 90% over the past 15 years.
A transmission rate of 2% or below is considered by the World Health Organization (WHO) as effectively eliminating MTCT of HIV. Thailand is the first country in the Asia Pacific region to reach this important milestone.
In 2016, 95% of Thai and non‐Thai pregnant women living with HIV received antiretroviral drugs to reduce the risk of MTCT. 80% of infants born to HIV‐positive women were tested for HIV within two months of birth.
Despite these successes, areas for improvement include:
- coverage of couples HIV testing in antenatal care (ANC) increased from 38% in 2013 to 41% in 2014, but remained significantly below the 2016 target of 60%
- a number of pregnant women still have not registered for ANC, so the full picture is not known
- access to prevention of MTCT services for foreign pregnant women who are living with HIV is not universal with many having to pay.
Antiretroviral treatment (ART) in Thailand
Thailand provides antiretroviral treatment (ART) for free as part of the country’s universal health insurance scheme. It is one of only two countries in Asia and the Pacific that has more than 50% of people living with HIV on ART, the other being Cambodia. In 2016, 68% of adults who are eligible for treatment were receiving it, alongside more than 86% of children.
In October 2014, Thailand extended ART to all those living with HIV, regardless of their CD4 count (which indicates the health of the immune system), in line with the most recent WHO treatment guidelines. Since then, more thorough identification of new cases has been introduced to ensure people start receiving treatment as soon as possible after diagnosis.
Thailand committed to reach 90% of eligible adults and children with life-saving antiretroviral therapy by 2016. However, the adoption of these new treatment guidelines means it has now missed these targets.
Barriers to HIV prevention in Thailand
Law enforcement can act as an obstacle to HIV treatment and prevention, so Thailand is one of several Asian countries that have put in place programmes to prevent this. This includes protective legislation that guarantees the right to basic healthcare for migrants mentioned above.
However, despite improved laws and policies to protect people living with HIV, research shows that undocumented migrants face stigma and discrimination from healthcare workers and employers. This is one of the main barriers they face when accessing treatment.
Factors preventing people who inject drugs from accessing services include misconceptions such as that the distribution of needles promotes drug addiction. People who inject drugs also experience prejudice and stigma from public health service providers and law enforcement, and tackling this has been highlighted as a priority in Thailand’s current HIV strategy.
Despite same sex activity long being legal in Thailand, and the passing of the Gender Equality Act in 2015 to quell discrimination against lesbian, gay, bisexual, transgender people and men who have sex with men, homophobia can still prevent people from accessing HIV services.
Historically, Thailand has relied on international financial support to finance its HIV response, with the majority of the country’s prevention work being funded externally. However, this has changed in recent years, with 89% of Thailand’s HIV response funded domestically in 2014.
It’s important that this spending commitment continues in order to maintain the momentum of Thailand’s HIV response, particularly as funding from international donors continues to fall. For example, funding from the Global Fund to Fight AIDS, Malaria and Tuberculosis dropped from US $39 million in 2014 to about US $14 million in 2015-2016, and is being phased out entirely in 2016.
The future of HIV and AIDS in Thailand
Although Thailand made enormous progress with HIV prevention in the 1990s, the decline in HIV prevalence has slowed down in recent years. Access to prevention services and behavior-change communication hasn’t been enough to significantly reduce the rate of new infections, particularly among men who have sex with men.
NAC’s 2015-2019 strategy states that Thailand will be one of the first countries in the world to successfully end AIDS by 2030, and the first country in the region. Indeed, from 2015 the Ministry of Public Health increased its budget to prepare for implementing its strategy to end AIDS. Its spending commitments must remain a focus if real progress is to be made.
Furthermore, to be in with a real chance of ending AIDS by 2030, Thailand will need to give significant focus to new and innovative strategies to reach both young people and key affected populations, particularly men who have sex with men.
Source : avert.org