Thailand

During the 50th Programme Coordinating Board meeting held in Geneva, Thailand announced formally funding community-led health services (CLHS) as public health services. The National Health Security Board of Thailand has approved HIV prevention, treatment, and care to be directly reimbursed by the Universal Health Coverage scheme.

“This is a key milestone for Thailand regarding sustainable community-led service delivery and sustainable financing for community-based organizations. It is a model for the region and countries globally,” said Winnie Byanyima, Executive Director of UNAIDS.

The role of community-led organizations in providing HIV services is well recognized as an essential component leading to ending AIDS by 2030. Using people-centered, rights-based and stigma-free approaches by and for key population community and people living with HIV has shown to lead to   an increased uptake of essential HIV services.

Since 2016, Thailand has started to fund project-based community-led HIV services through the Universal Health Coverage scheme. The allocation of the national budget has increased over time to support community-led organizations (CLO) working with people living with HIV and key populations.

However, until now, year-to-year contracting mechanisms led to operational gaps affecting the provision of HIV services. The formal recognition of community-led health services under the UHC scheme will allow for faster access to funding, continuity of service delivery, and increase CLOs capacity for greater coverage of HIV services. 

“To reach the ambitious goal of ending AIDS, we have partnered with community-based organizations who play a vital role in HIV service provision to hard-to-reach populations and marginalized communities,” said Anutin Charnvirakul, Deputy Prime Minister and Minister of Public Health of Thailand.

Organizations led by communities who are eligible to provide HIV and STI services in their communities can register as service providers under the National Health Security System. To get this recognition, they need at least one year of service experience and require an accreditation by the Ministry of Public Health or other certified bodies. Community health workers with relevant experience also have to be certified by a government agency or accredited organization.

The UNAIDS Thailand office has been working with different partners to support the scale-up of   community health workers' certification and other accreditations as well as strengthening the sustainability of the community response. 

In attendance at the 50th PCB were Dr Jadej Thammatacharee, Secretary General, National Health Security Office, Dr Opart Karnkawinpong, Director General, Department of Disease Control, Ministry of Public Health, Dr Suwit Wibulpolprasert, Advisor to the Office of the Permanent Secretary, Ministry of Public Health and the entire three day meeting was chaired by H.E. Mr Anutin Charnvirakul, Deputy Prime Minister and Minister of Public Health.

Like any other regular day in Bangkok, Thailand, Pete went to work and was living a pretty normal life. He had a business that imported and exported fresh vegetables from neighbouring countries in South-East Asia, a family business that he shared with his sister. He was happy and in a serious long-term relationship with his boyfriend, and everything seemed perfect. That day, he and his partner went to get tested for HIV, and that’s when his life suddenly began to change.

“I found out about my HIV status in 2016 and soon after left my business because I didn’t know if I was going to live much longer. Without guidance and mental health support, I had many misconceptions about HIV, and I started to suffer from depression,” he said.

“I blamed myself for contracting HIV, and I couldn’t cope with this thought. I became a drug user, was engaging in chem sex, broke up with my partner and survived suicide attempts,” he continued. “But after receiving support from local organizations of people living with HIV, I decided to retake control of my life. I started to talk openly about HIV to help other young people live with a positive diagnosis. Even though this was never my plan, I knew I had to do it. That’s why I became an HIV activist,” he added.

Nowadays, Pete (famously known online as Pete Living with HIV) is a well-known HIV activist in Thailand and has come far since his diagnosis. He has spent the past few years building an online community for people living with HIV. In this safe space, people can connect and be comfortable enough to share their stories and experiences in an open environment free from stigma and discrimination. His Facebook group, which has strict membership requirements (for obvious reasons), has more than 1300 members.

“I created this space because I didn’t have a place to share my story. I wanted to create a platform where people living with HIV can be proud of themselves and be reminded they are not alone. No one deserves to be stigmatized, bullied, dehumanized or disrespected. Everyone deserves to be loved, respected and accepted,” he said.

In 2019, the country announced the Thailand Partnership for Zero Discrimination, which calls for intensified collaboration between the government and civil society to work on stigma and discrimination beyond health-care settings, including workplaces, the education system and the legal and justice system. UNAIDS has been involved since the outset of the initiative by providing technical assistance to formulate the zero discrimination strategy and the five-year action plan, develop a monitoring and evaluation plan and operationalize the strategy as a joint effort between the government and civil society.

Pete thinks this initiative is a cornerstone to ending the AIDS epidemic, as stigma and discrimination continues to be the main barrier to HIV services. “Although it has improved a lot over the years, I still experience stigma and discrimination when I go for regular sexually transmitted infection check-ups. I still receive judgement from nurses and doctors,” he said.

Pete has also become a passionate activist for, and speaks about the importance of, U = U (undetectable = untransmittable) at international forums and conferences. “U = U changed my life. I continue to fight for and promote U = U because its messages have the power to change the lives of people living with and affected by HIV. Still, more importantly, it can change social attitudes and tackle stigma and discrimination,” he said.

With U = U, HIV treatment has transformed the HIV prevention landscape. The message is clear and life-changing: by being on HIV treatment and having an undetectable viral load, people living with HIV cannot transmit HIV to their partners. The awareness that they can no longer transmit HIV sexually can provide people living with HIV with confidence and a strong sense of agency in their approach to new or existing relationships.

Pete launched a campaign in 2020 focusing on U = U and mental health advocacy. “Through my social media channels, I raise awareness about the importance of listening to people and their experiences and respecting them. U = U is key to helping people living with HIV overcome self-stigma and negative feelings like shame, which discourage them from accessing and/or remaining on treatment. U = U is encouraging; it can help remind people living with HIV to be proud of themselves,” he said.

Pete is now strengthening partnerships with national stakeholders and allies of the HIV response to ensure that messages related to U = U, HIV prevention and zero discrimination are amplified and reach different audiences. He is also a representative on a multisectoral task force to design and implement the People Living with HIV Stigma Index in Thailand, which will be conducted this year. He has supported the United Nations in Thailand on various campaigns, including the Everybody Deserves Love Valentine's Day campaign and the zero discrimination campaign, in which he is engaging young people from across Thailand. 

The Bangkok Metropolitan Administration (BMA) in Thailand has been awarded the inaugural Circle of Excellence Award at the Fast-Track cities 2021 conference, held recently in Lisbon, Portugal. The Circle of Excellence Award showcases outstanding work in fast-tracking the HIV response and advancing innovative programming to end the AIDS epidemic in cities by 2030.

“To receive the Circle of Excellence Award for Bangkok is a great honour. It demonstrates not only the past achievements but, moreover, the future commitment to accelerate the HIV response and towards ending AIDS in Bangkok. We are proud that innovations have produced remarkable results, particularly same-day antiretroviral therapy and key population-led health services, such as specialized and holistic services for transgender people and the scale-up of pre-exposure prophylaxis (PrEP) programmes. These innovations are not only applied in Bangkok but have become models for the region,” said Parnrudee Manomaipiboon, the Director-General of the Department of Health, BMA, during the award ceremony.

Organized by the International Association of Providers of AIDS Care, in collaboration with UNAIDS, the Fast-Track Cities Institute and other partners, the Fast-Track cities conference highlighted successes achieved across the Fast-Track cities network, addressed cross-cutting challenges faced by local stakeholders and shared best practices in accelerating urban HIV, tuberculosis and hepatitis B and C responses.

“Bangkok has put in place a 14-year strategic plan for ending AIDS from 2017 to 2030, which is under the leadership of the Bangkok Fast-Track Committee,” said Pavinee Rungthonkij, the Deputy Director-General, Health Department, BMA. “During COVID-19, BMA and partners have introduced innovations such as multimonth antiretroviral therapy, an express delivery of antiretroviral therapy service, sexually transmitted infection self-sampling and PrEP,” she added. Among other achievements, Bangkok has expanded its PrEP services to 16 municipal public health centres and eight city hospitals and implemented citywide awareness campaigns. PrEP in the City was the first citywide PrEP campaign focusing on transgender people in Asia.

“Significant progress has been made in the HIV response since Bangkok joined the Paris Declaration to end the AIDS epidemic in cities in 2014. It shows that mutual commitments and a strengthened partnership between stakeholders at all levels are key to an effective HIV response. Bangkok will continue to leverage support, scale up innovations and Fast-Track solutions to achieve the 2025 targets and end AIDS by 2030,” said Patchara Benjarattanaporn, the UNAIDS Country Director for Thailand.

Rena Janamnuaysook steps off the Skytrain in Bangkok’s bustling Sukhumvit shopping district. She looks up, filled with a sense of joy as her eye catches an advert just beyond the platform. The advert is promoting the PrEP in the City campaign to raise awareness and increase the uptake of PrEP among Thai transgender women and shows glimpses of the lives of four transgender women as they juggle their busy work schedules, their role as a mother and their relationship with loved ones, all the while taking control of their health with their daily dose of pre-exposure prophylaxis (PrEP). For Ms Janamnuaysook, a transgender advocate and Program Manager for Transgender Health at the Institute of HIV Research and Innovation (IHRI), this first-ever PrEP campaign for transgender women in Thailand signals promise for the country’s HIV response.

“PrEP campaigns of the past were only targeting other key populations, especially men who have sex with men and gay men. Transgender women were left out from PrEP campaigns or public messages,” says Ms Janamnuaysook. 

HIV prevalence among transgender people in Thailand was estimated to be 11% in 2018, with no sign of a decline in the past few years, and the current uptake of PrEP among transgender women is only 7%, making the group a particularly at-risk population. Less than half (42%) of transgender people reported that they are aware of their HIV status, while services catering to their specific needs are limited.

Limited awareness and knowledge about PrEP contribute to the low uptake. The campaign strategy includes reframing the conversation on PrEP use and challenging negative perceptions of PrEP within the transgender population. “For transgender women who know about PrEP already, they still don't want to get it because it has been associated with risky behaviour or negative behaviour. In Thai society, if you use PrEP then you are perceived to have multiple partners, be a sex worker or must have unprotected sex,” says Ms Janamnuaysook.

Ms Note, a client at the Tangerine Clinic, South East Asia’s first transgender-specific sexual health clinic that offers gender-affirming integrated health care and PrEP, among many other health services, speaks of the perception of PrEP, saying, “I had to be cautious so that nobody sees me taking the pills because sometimes people are worried and think that I am sick.” A goal of the campaign is to normalize the use of PrEP and promote continued use, particularly important when evidence suggests that nearly half of transgender women (46%) in Thailand did not return for their one-month visit after starting PrEP.

“The campaign makes taking PrEP seem similar to taking vitamins or supplements for good health. It removes the image that PrEP is suitable for only certain groups, when in fact it can be taken by anybody,” said Ms Note.  

Adverts for the campaign are on billboards across Bangkok, illustrative of the collaboration with the Bangkok Metropolitan Administration and the commitment to achieve the city’s Fast-Track Targets. Online, IHRI has enlisted various social media influencers, bloggers and opinion leaders in the transgender community to share information about the campaign.

“I personally feel proud to have participated in this campaign, which makes people see the other sides of us, transgender women, and our potentials,” says Jiratchaya (Mo) Sirimongkolnavin, a model and beauty blogger featured in the campaign, who is a former winner of Miss International Queen, one of the world’s largest transgender beauty pageants. She goes on to explain, “It encourages people to have general conversations about sex and how to protect themselves from HIV infection.”

Promoting positive representations of Thai transgender women is an underlying focus of the campaign. “I think the story in the video will help wider audiences to see the diversity among transgender people that actually exists in today’s society,” said Ms Note. “The fact that transgenders have many occupations and abilities.”

At a launch event for the campaign, Satit Pitutecha, Deputy Minister of Public Health, spoke about the government’s commitment to strengthening the HIV response, stating, “The Ministry of Public Health has committed to working in partnership with communities and civil society to promote access to HIV and other health services for transgender people.”

Ms Janamnuaysook is proud of the buzz that the campaign has catalysed, which has been shared widely in Thailand and in surrounding countries. She hopes that this campaign, with its tailored messaging for transgender women, won’t be the last and believes that it can serve as a model for future campaigns focusing on other key populations.

The PrEP in the City campaign was developed by IHRI and is supported by the United States President’s Emergency Plan for AIDS Relief through the United States Agency for International Development’s LINKAGES Thailand Project, managed by FHI 360 and the United States Centers for Disease Control and Prevention, the Bangkok Metropolitan Administration, the Division of AIDS and STIs of the Ministry of Public Health and the UNAIDS Asia–Pacific Office.

When the Thai government ordered the closure of entertainment venues in the country in March, it didn’t just signal an end to pulsating music and rounds of drinks shared with friends. It also signalled the start of difficult times for an estimated 145 000 sex workers living in Thailand.

Initially, Service Workers in Groups (SWING), a Thai national organization providing HIV services and advocating for sex workers’ rights, received requests from sex workers for the most basic of needs—food. As requests began flooding in, it became clear that without a source of income many sex workers were unable to cover the cost of daily expenses, housing and medicine.

“When the COVID-19 outbreak began, nobody was talking about sex workers, and no measures were in place to help them,” said Surang Janyam, Director of SWING.

Spurred by growing concerns about how the outbreak has impacted the lives of sex workers, SWING, in collaboration with Planned Parenthood Association Thailand and Dannok Health and Development Community Volunteers, with support from UNAIDS, launched a community-led rapid assessment of 255 sex workers from Bangkok, Pattaya and Dannok and community-based organizations throughout the country.

The outbreak has had a severe socioeconomic impact on the lives of sex workers, further exacerbated by the lack of social protection measures. According to the findings from the rapid assessment, 91% of respondents became unemployed or lost their source of income following the start of the COVID-19 outbreak. Three quarters of the respondents could not make enough money to cover daily expenses and 66% could no longer cover the cost of housing.

Ms Janyam spoke about the difficulties faced by sex workers and how the priorities for SWING’s work have shifted. “As a sex worker-led organization, we cannot provide only HIV services while sex workers are hungry and lack the basic needs to survive,” she said. She explained that many of the sex workers expressed that they were not eligible for the government assistance of 5000 baht. Answering the call for help, SWING staff have taken to the streets to raise donations and deliver food to sex workers in their network. 

Widespread coverage in the media and on personal blogs has catalysed a public conversation about the lack of social protections for sex workers. Ms Janyam also points to donations from local businesses and visits from younger people wanting to help as promising signs of how wider audiences are becoming more engaged on the topic of supporting sex workers in their communities.

The COVID-19 outbreak has also contributed to new challenges for HIV prevention. Fears of COVID-19 have deterred people from visiting clinics to be tested for HIV. Additionally, the rapid assessment findings revealed that almost half of the sex workers surveyed had difficulty accessing sexually transmitted infection screenings. In response to those observations, SWING partnered with a hospital capable of conducting COVID-19 testing, thereby drawing in sex workers interested in being tested for COVID-19 and creating an opportunity to counsel them about HIV tests. These changes in practice show possible synergies in prevention measures for both COVID-19 and HIV prevention and treatment.

“The results from the rapid assessment have proven to be a strong tool for advocacy and decision-making. Stakeholders of the AIDS response have collectively identified and started to implement priority actions as an immediate response to the needs of sex workers during the COVID-19 pandemic,” said Patchara Benjarattanaporn, UNAIDS Country Director for Thailand.

Ms Janyam reflects on what this will mean for SWING’s work and recalls the ways in which sex workers were not afforded the same social safeguards as others—they were forgotten. “We must transform ourselves. Community-led organizations must apply a holistic and comprehensive approach, providing immediate basic needs, integrating a package of prevention for both COVID-19 and HIV health services, as well as mental health support for sex workers,” she said.

She affirms that SWING and other charitable groups will continue to seek donations and provide basic provisions for sex workers, recognizing that the need for assistance will remain long after the situation eases, long after the bars and restaurants have reopened.

Boy Somjai and Jam Chainukul (not their real names) are a young same-sex couple from Bangkok, Thailand. At the start of their relationship, they decided to take HIV tests for the first time. Looking for information online, their friends suggested the Rainbow Sky Association of Thailand (RSAT), a community-based HIV clinic located off a busy street in Bangkok.

RSAT, with four clinics and 10 drop-in centres in different cities across Thailand, serves as a one-stop service where gay men and other men who have sex with men and transgender people can access HIV prevention services and take part in HIV-related information sessions, with flexible service hours suitable for the lifestyles of many people from key populations.

Danai Linjongrat, the Executive Director of RSAT, said, “Access to HIV services for key populations is among the biggest challenges to the HIV response in the country. It is extremely important that key populations can access HIV prevention and treatment services without fear of discrimination.”

Mr Boy and Mr Jam, who now return to RSAT every three months for regular check-ups, said, “When we first visited the clinic, we were really nervous, as we were looking for a place that respects our confidentiality. Here we found more than an HIV clinic—we found a place we can trust, like a family. The health staff made us feel comfortable to share our story; they did not judge us and they understood our needs with an open mind.”

The success of RSAT is credited in part to its health workers being members of the populations they serve. RSAT has adopted the country’s key population-led health services model, in which people from key populations identify and meet the HIV and other health-related needs of their peers. “We understand the needs of our clients, what they want, where they live and how they feel, because our staff members are people from the communities,” says Mr Linjongrat.

Community health workers provide needs-based and client-centred services, including pre-exposure prophylaxis (PrEP), legal consultations, harm reduction, screening for sexually transmitted infections, counselling and hormone level check-ups for transgender people. Depending on the outcome of a person’s HIV test, they are offered a referral for antiretroviral therapy or an in-depth discussion about taking PrEP, all in a non-judgemental and supportive atmosphere.

RSAT is one of seven community-based organizations in Thailand that provide PrEP services free of charge through lay providers under the Princess PrEP Project. Currently, 1200 people are accessing PrEP through RSAT clinics and drop-in centres. The Thai Red Cross AIDS Research Centre, with the support of the United States President’s Emergency Plan for AIDS Relief through the LINKAGES Thailand project, implements continuous capacity-building to ensure that community health workers can provide HIV services in accordance with national standards.

RSAT uses different ways to generate demand for and promote its programmes and to carry out outreach work. Phubet Panpet, Deputy Director at RSAT, said, “Depending on our target audience, we go to different places, such as saunas, entertainment complexes, schools and universities, to raise awareness about HIV prevention and encourage people to get tested for HIV.”

Kunpawee Isalam, a staff member of the outreach team in Bangkok, is a transgender person who understands the stigma and discrimination faced by the transgender community. “We plan outreach activities that we know transgender people will be interested in, with the aim of increasing their self-confidence. For many, it is so hard to feel they can get support, and they fear discrimination. RSAT provides a safe space and HIV prevention options,” she said.

RSAT uses social networking sites to reach out to young gay men and other men who have sex with men. Staff members register as users and create profiles on dating applications to share HIV-related information. “At the beginning of the conversation, the outreach worker explains about the clinic and engages people in a conversation related to HIV prevention,” said Mongkol Jaidee, a field officer. “I choose the location, see who is connected, and send them personal messages to introduce the services provided by the clinic. I normally receive positive feedback, and it is common for people to come back later with questions and visit us in the following days.”

Mr Linjongrat concluded, “We differ from other services by caring for people by looking into what they need and what we can do to help them. Community-led services are a proven strategy and an essential feature of the HIV response in Thailand.”

There are approximately 24 000 young people aged 15–24 years living with HIV in Thailand. In 2018, young people accounted for nearly half of the 6400 new HIV infections in the country.

Thailand has made great strides in its AIDS response, providing antiretroviral therapy free of charge as part of its universal health coverage scheme. However, adolescents and young people living with HIV often fall out of care or do not receive the support they need to remain on treatment. Self-stigma, stigma and discrimination and transition from paediatric care to adult care are some of the challenges faced by adolescents and young people living with HIV.

To close this gap, three years ago the United Nations Children’s Fund (UNICEF) and other national partners led by the Thai Network of People Living with HIV created the Thai Network of Youth Living with HIV. The main objective was to empower adolescents and young people living with HIV to be agents of the change that they wanted to see in their lives. The network’s capacity was built to provide referral services, life-skills training and peer-to-peer support for adolescents and young people living with HIV.

Kritthanan Ditthabanjong, one of the first active members, is now Head of Corporate Communication at the network. Studying to become a journalist, he also works as a content editor for websites and magazines in Thailand and is a well-recognized young leader. Mr Ditthabanjong represents the network at public events and in the media, voicing the needs of young people living with HIV.

“I have publicly disclosed my HIV-positive status because I want other people to learn from my experiences and to give young people the information they need to lead healthy and dignified lives. I feel confident to speak out because I have support from my friends and community,” he said.

With technical and financial support from UNICEF and other partners, and through a variety of platforms and strategies, the network offers emotional support around receiving an HIV-positive diagnosis, provides HIV information to reduce self-stigma, builds coping skills and creates a supporting network to tackle stigma and discrimination. “Young people living with HIV need emotional support and a community they can trust,” said Mr Ditthabanjong.

Trained young leaders with the network provide counselling for young people living with HIV and link them to health facilities, hospitals and community-led services for HIV treatment and care. The young leaders also accompany young people living with HIV to medical appointments and carry out follow-up home visits to help them adhere to treatment.

The network uses social media to reach out to young people, providing information on HIV and promoting self-acceptance. Initiatives such as the online campaign Growing Up with HIV offer safe spaces that enable young people to ask questions about different topics, including HIV prevention and safe sex, and share opinions and thoughts.

“Growing Up with HIV allows young people to be part of our community and make them feel they are not alone,” continues Mr Ditthabanjong.

Mr Ditthabanjong engages in other campaigns and social media initiatives with UNICEF that address young people in general in Thailand but also allow him to bring in the voices and perspectives of young people living with HIV. He has recently joined Dare to Dream, a public campaign created by UNICEF for Thai young people to voice their opinions on education and what is required to prepare them for the transition to adulthood. “From a shy adolescent who did not wish to speak and constantly glanced at his counsellor for approval a few years ago, Mr Ditthabanjong followed a path with us and he was one of nine motivational speakers at the Dare to Dream youth campaign, a role model for young people in his country,” said a UNICEF staff member.

Mr Ditthabanjong concludes, “One day I had an interview on social media. As soon as I came off, I received a text from a young person who had recently been diagnosed with HIV. “My mum and dad do not accept me, and I want to kill myself,” he said. I phoned him, met him and convinced him to join our network. Now this person is doing well. Our work is impacting people’s lives.”

The UNAIDS Country Office in Thailand, with a small team of three staff members, is located in Bangkok. Orawan Bettenhausen, the Administrative Assistant, has been part of the team for almost 20 years. “Being part of the UNAIDS family has empowered and transformed me into who I am today. I have been very fortunate to have had country directors who have coached me, and great colleagues and peers, both within and outside of UNAIDS, who have assisted, supported and inspired me,” she said.

Ms Bettenhausen recalls meeting a person living with HIV, a representative of the Thai Network of People Living with HIV, in her first weeks with UNAIDS. “I asked him about his life. When he finished talking, I was in tears,” she said. “To my surprise, he told me that neither he nor any other person living with HIV would want me to feel sorry for them. They just wanted to be accepted for who they are. He taught me a huge lesson, and I made a commitment to work for people living with and affected by HIV.”

Throughout the years, she has assisted the Country Director and the team to get communities, civil society organizations and people living with HIV meaningfully involved and engaged in the AIDS response. “As the Administrative Assistant , I do feel that I support our community partners in different ways, such as contributing to the execution of joint projects, facilitating logistic support to make sure communities can attend regional and national events and providing interpretation from Thai to English and vice versa. I feel I am giving community members the opportunity to overcome language barriers, to be present in decision-making spaces to voice their needs and showcase their work outside Thailand,” she explained.

Ms Bettenhausen has witnessed important changes in the AIDS response in Thailand. For example, she remembers UNAIDS implementing projects in collaboration with civil society organizations and facilitating dialogues between policymakers, HIV programme implementers and community representatives at a time when stigma and discrimination against people living with HIV and key populations was a major concern in the country.

Since 2015, Thailand has implemented the 3-by-4 Package for Stigma-Free Health Facilities, with comprehensive programmes to address and remove barriers to accessing health services. In 2019, the country announced the Thailand Partnership for Zero Discrimination, which goes beyond health settings and includes areas such as workplaces and the education system. UNAIDS has been involved since the outset of the initiative by providing technical assistance to formulate the zero discrimination strategy, to develop a monitoring and evaluation plan and to operationalize the strategy in a joint effort with the Thai Government and civil society.

“My contribution to this achievement was to provide continuous support to the Country Director, who played a critical role in linking stakeholders from different sectors and bringing them together, making sure that communities were always involved and enabled to speak up. Now our government counterparts work alongside civil society organizations. All key stakeholders are equal and come together to make decisions and move in the same direction. A true partnership!” said Ms Bettenhausen.

Ms Bettenhausen grew up in northern Thailand. Her passion for the public sector started in early childhood, as she watched her father improve the livelihoods of farmers and their families through his work as an adviser for the German Government and rural development donors. Later, while studying for a master’s degree in management, she realized business was not her calling and made the decision to write her dissertation on the Human Development Center, a nongovernmental organization working in the Klong Toey slum in Bangkok. The two months that she spent working in the slums and collecting data for her dissertation gave her insight into urban poverty, drug use, child abuse and HIV. “After I graduated, I joined the business world for two years, but I felt my vocation was to follow in my father’s footsteps and to work for people. Fate was on my side and I got a position with UNAIDS,” she said.

Ms Bettenhausen’s main challenge at the Country Office is to keep up with the various tasks, as administrative work is often time-consuming. Nevertheless, she believes that everything done with due diligence is contributing to making a difference. Her work is not only critical to ensuring that the UNAIDS Country Office can fulfil its mandate, but also key to achieving the goal of ending AIDS by 2030.

It is a morning like any other at the Thai Red Cross AIDS Research Centre, a civil society organization operating under the umbrella of the Thai Red Cross Society. In a building in the heart of Bangkok, nurses, doctors, counsellors and peer educators are busy with their daily work, providing HIV services for the 200 people who attend the Thai Red Cross Anonymous Clinic every day for medical check-ups, HIV tests and HIV prevention services, including condoms and pre-exposure prophylaxis (PrEP).

When he was 35 years old, Praphan Phanuphak―the Director of the centre, which he co-founded in 1989―discovered the first case of HIV in Thailand. “It happened by accident. A patient was referred to me to investigate why he had a recurrent fungal skin infection,” he recalled. “In February 1985, this patient was admitted with pneumocystis pneumonia. During that month, another man was referred to the hospital with generalized cryptococcus infection. Both were diagnosed with HIV. Since then, I have devoted my life to treating people living with HIV and developing solutions to expand access to HIV services in the country.”

Mr Praphan remembers that in the early days of HIV the response in Thailand faced several challenges. At the time, Thai law required hospitals to report the names of people diagnosed with HIV to the Ministry of Public Health, which contributed to increasing stigma and discrimination against people living with HIV. In response, the Thai Red Cross established the Thai Red Cross Anonymous Clinic, Asia’s first anonymous clinic, and advocated with the Thai Government to remove the reporting law. The Anonymous Clinic remains the most renowned centre providing voluntary HIV testing in the country.

“Until the beginning of 2000, antiretroviral medicines were not available through public health facilities in Thailand, and many people living with HIV could not afford to buy them,” said Mr Praphan. He said that in 1996 the Thai Red Cross AIDS Research Centre was the first to provide free antiretroviral medicines as part of its clinical trials through the HIV Netherlands–Australia–Thailand Research Collaboration.

“After years of despair, a time of hope finally came. For that, I want to thank Her Royal Highness Princess Soamsawali, who stood by our side by setting up a fund for the prevention of mother-to-child transmission of HIV in 1996, several years before the Thai Government started its successful prevention programme,” said Mr Praphan.

The AIDS response in Thailand has changed dramatically over the years. In 2006, Thailand integrated its HIV services, including antiretroviral therapy, into its universal health coverage scheme. Since 2014 Thailand has provided antiretroviral therapy for all regardless of their CD4 level. Everyone can access treatment for free, and people living with HIV are offered treatment immediately after diagnosis.

However, many people are starting antiretroviral therapy late. “We have the medicines, but many people are not being diagnosed fast enough,” warned Mr Praphan. Despite tremendous progress, the HIV epidemic is not yet over in Thailand. HIV remains concentrated among key populations: almost 50% of new HIV infections in 2018 were among gay men and other men who have sex with men. Low uptake of HIV testing among key populations is related to the acceptability of services and stigma and discrimination, which hinder access to HIV diagnosis, prevention and care.

“From our experience, helping key populations to reach their peers and bring them to HIV drop-in centres, where they can be tested, is the best way to detect and diagnose people living with HIV early enough,” said Mr Praphan, who successfully advocated to amend Thai law to allow certified lay providers from key populations to provide a number of HIV services.

The Thai Red Cross AIDS Research Centre’s approach focuses on undertaking pilot projects to generate evidence to inform national planners and policymakers. That evidence provides a foundation for national acceptance and the roll-out of innovation on a national scale.

Taking the lead in reaching out to key populations, the centre has been offering PrEP to people at substantial risk of HIV since 2014 through projects such as the Princess PrEP Programme. In October 2019, Thailand introduced PrEP under its universal health coverage benefits package as a pilot phase in efforts to scale up PrEP nationwide.

Mr Praphan believes that policymakers and programme implementers should understand that, “We cannot continue to do business as usual. In Asia and the Pacific, several countries are still either sceptical or conservative in terms of promoting the necessary approaches to change the course of the HIV epidemic.” He thinks that the region cannot achieve the 90–90–90 targets by 2020 at the current pace. “We need to think out of the box and look at what other countries are doing that can be taken as a model. This is how we can move faster on our way towards ending AIDS as a public health threat.”