Thailand

The Thai Red Cross AIDS Research Centre (TRC-ARC) has been at the forefront of the response to HIV since the early days of the epidemic, when its director, Praphan Phanuphak, diagnosed Thailand’s first case of HIV, in 1985. Since then, it has continued to develop and promote innovative prevention and treatment approaches, including pre-exposure prophylaxis (PrEP), same-day antiretroviral therapy and key population-led health services.

Located in Bangkok, Thailand, the TRC-ARC is an organization that sits under the umbrella of the Thai Red Cross Society. The Thai Red Cross has been a leading organization in the country’s response to HIV through projects implemented with partners and funded through the United States President’s Emergency Plan for AIDS Relief (PEPFAR).

Since the end of 2014, the TRC-ARC has been offering PrEP to people at higher risk of becoming infected with HIV through projects including the Princess PrEP programme, which is strongly supported by Her Royal Highness Princess Soamsawali. The Princess PrEP programme provides free PrEP services through community-led organizations such as the Service Workers in Group (SWING) Foundation, the Rainbow Sky Association of Thailand, Mplus, CAREMAT and SISTERS. The TRC-ARC also offers members of those community groups comprehensive training on health-care provision, sustainable financing, evaluation and quality control.

Since 2017, the TRC-ARC has also been offering same-day antiretroviral therapy to improve retention in care and adherence to treatment. People who test positive for HIV are initially prescribed a two-week supply of medicine and are then referred to other health facilities to continue their treatment.

Another significant achievement has been the creation of the Tangerine Clinic, the first in the country to offer health care and counselling tailored towards transgender people. The clinic is managed by transgender people and staffed by gender-sensitive medical professionals. It provides sexual and reproductive health-care services, psychosocial counselling, hormone counselling and therapy, HIV testing services and referrals for treatment.

During his recent visit to Thailand, the Executive Director of UNAIDS, Michel Sidibé, paid tribute to the work of Mr Praphan and the TRC-ARC at an event organized by UNAIDS and attended by representatives of the Thai Ministry of Public Health, the Thai Ministry of Foreign Affairs, PEPFAR, USAID, United Nations development partners and civil society organizations.

“The Thai Red Cross AIDS Research Centre has played a key role in developing and promoting innovative and effective prevention and treatment approaches to HIV for more than 30 years,” said Mr Sidibé, “Its contribution expands beyond Thailand, being a catalyst for change across the Asia–Pacific region,” he said.

Mr Praphan thanked UNAIDS for recognizing the achievements of the TRC-ARC and said its work would continue until the end of the AIDS epidemic. “I accept this recognition on behalf of all the people working with me at the Thai Red Cross and in the community to ensure that no one is left behind. We have demonstrated how science, integrated into the community level, can bring health care to the most marginalized groups of people.”

Thailand is starting to roll out pre-exposure prophylaxis (PrEP) for HIV prevention among key higher-risk groups in high burden provinces, scaling up PrEP pilot projects within the national health system. The announcement was made at the satellite session “Breaking barriers and building bridges toward sustainability of the AIDS response in South-East Asia” during the International AIDS Conference in Amsterdam, Netherlands.

At the session, Dr Panumard Yarnwaidsakul, Deputy Director-General of the Department of Disease Control, Ministry of Public Health, said that the country is moving from trials and demonstration projects to policy and practice. PrEP now is a core part of the combination prevention package in the national HIV response in the country. Mr Yarnwaidsakul added that Thailand is also in process of including PrEP provision as part of the benefits package under the country’s universal health coverage.

As with many countries in Asia and the Pacific, Thailand's epidemic is focused among gay men and other men who have sex with men, transgender people and people who use drugs. The representatives of the Thai government acknowledged that PrEP is cost-effective and is an innovative approach for people at substantial risk of HIV infection.

Randomized trials have demonstrated that PrEP can decrease HIV incidence among at-risk populations, including men who have sex with men and sero-discordant couples. It has been shown that offering PrEP can encourage more people at higher risk to attend HIV clinics, undergo HIV testing and access either PrEP or treatment depending on the test result.

In Thailand, the discussion about offering PrEP at scale started in 2010.

The satellite session learned from "The Princess PrEP", a successful key population-led PrEP initiative under the support of Her Royal Highness Princess Soamsawali and PEPFAR/ USAID LINKAGES Thailand project.This effort served as local evidence to support the development of PrEP roll-out, where key population-led health services are a critical component.

As a next step, the Ministry of Public Health aims to train health care workers and key population peer providers to deliver PrEP.

Stigma and discrimination in health-care settings is a major obstacle to ending AIDS. Widespread across the world, stigma and discrimination seriously reduces the quality of life of people who experience it and hinders their access to health and HIV services.

How to catalyse country initiatives and reduce stigma and discrimination in health-care facilities was the focus of a session at the International AIDS Conference on 23 July in Amsterdam, Netherlands. The session, Catalyzing Thailand and Regional Initiatives on Zero Discrimination in Healthcare Settings and Building Bridges Towards a Global Compact to Eliminate all Forms of HIV-Related Stigma and Discrimination, brought together representatives of the Governments of Thailand, Viet Nam and the Netherlands and representatives of regional civil society networks, the United States Centers for Disease Control and Prevention and UNAIDS.

Thailand is acknowledged as a pioneer in reducing stigma and discrimination in health-care settings in Asia through its innovative system-wide response. The event heard that the Thai stigma and discrimination reduction package is based on global measuring tools and contains a permanent monitoring system, evidence-informed actions at health facilities and community engagement at all levels.

Viet Nam piloted a stigma and discrimination reduction programme in Ho Chi Minh. At the session, Huu Thuy Do, Head of the Information, Education and Communication Department of the Viet Nam Administration for AIDS Control, explained how Viet Nam learned from cooperation with Thailand and how the Thai model was translated to the city level in Viet Nam.

Based on the experiences of Thailand and Viet Nam, speakers encouraged countries to foster cross-border links on stigma and discrimination reduction efforts in health-care settings in order to achieve more effective and efficient joint global action.

The participants also learned from the Dutch approach, which directs attention to the inequality of access to HIV prevention and treatment services while promoting an enabling legal environment to prevent stigma and discrimination.

The participants heard that the greater engagement of communities, people living with HIV and key populations in the development and monitoring of programmes against stigma and discrimination is a core element for successful stigma and discrimination reduction programmes. Their participation not only increases access by hard-to-reach communities, but also helps ensure that a rights-based approach is used.

The event concluded with the presentation of the Global Framework for Action, an initiative led by civil society that aims to catalyse and accelerate the implementation of commitments made to end HIV-related stigma and discrimination in different settings.

The Ministry of Public Health of Thailand has launched its new 2017–2030 National AIDS Strategy, which provides a road map for ending the AIDS epidemic as a public health threat in Thailand by 2030. Narong Pipatanasai, Deputy Prime Minister and Chair of the National AIDS Committee, led the launch at the Government Complex in Bangkok, Thailand, on 13 September.

The 13-year plan adapts the latest global commitments to Thailand, ensuring an effective, cost-efficient and high-impact HIV response. A recent UNAIDS report on the global AIDS epidemic finds that annual new HIV infections dropped by 50% in Thailand between 2010 and 2016, the steepest decline for any country in the Asia and the Pacific region.

During the launch, 19 representatives of ministries and government offices signed a commitment to end AIDS. Deirdre Boyd, United Nations Resident Coordinator for Thailand, congratulated the government on the strategy and Apiwat Kwangkaew, the Vice-Chair of the Thai Network for People Living with HIV, stressed the need to ensure there is no stigma towards people living with HIV, so they can access key services. The Deputy Prime Minister acknowledged that government agencies cannot effectively reach key populations without the support of community groups. He said that while he had not seen important collaboration between key partners in response to other diseases, collaboration was a hallmark of the HIV response.

The strategy’s goal is to further reduce new HIV infections from 6500 to less than 1000, cut AIDS-related deaths from almost 13 000 to under 4000 and reduced HIV-related discrimination in health-care settings by 90% by 2030.

The new strategy commits to a Fast-Track phase, where an all-out effort is made to reach the global 90–90–90 targets by 2020, whereby 90% of people living with HIV know their HIV status, 90% of people who know their HIV-positive status are accessing treatment and 90% of people on treatment are virally suppressed. Thailand has already achieved the first 90.

The country’s epidemic is concentrated among key populations, including men who have sex with men, transgender people, people who inject drugs and sex workers. With the new plan, the government commits to supporting combination prevention programmes for key populations and working in partnership with community-led organizations to reach people at higher risk in the locations where they live and work. The strategy gets to the subnational level, tailoring programmes to specific populations in specific locations. It also plans to increase the integration of HIV health services with hepatitis C, tuberculosis and other infectious diseases. 

Thailand’s private sector has teamed up with civil society to launch the AIDS Almost Zero campaign, which aims to raise funds for HIV prevention initiatives run by community groups of key populations. Admiral Narong Pipatanasai, Deputy Prime Minister of Thailand, opened the campaign at the Government House of Thailand in Bangkok on 8 May.

Since the early days of Thailand’s epidemic, civil society has a played a crucial role in the HIV response by helping to reach key populations, including sex workers, gay men and other men who have sex with men, people who inject drugs and transgender people. However, much of the funding for community organizations has come from international funding, which is no longer available since Thailand has attained middle-income status.

Since early 2015, UNAIDS in Thailand has been working with more than 30 civil society organizations to develop a resource mobilization consortium, which would help to cover the funding gap left by the withdrawal of international resources. In 2016, the consortium, led by the Raks Thai Foundation and the Thai National AIDS Foundation, organized a series of consultations with private sector representatives that were chaired by Anand Panyarachun, the former Prime Minister of Thailand. Thailand’s leading property developer, Sansiri Public Company Limited, participated in the consultations and provided financial support for the development of the AIDS Almost Zero campaign.

The speakers at the launch included Mechai Viravaidya, former minister of the Prime Minister’s office, Promboon Panitchpakdi, Executive Director of the Raks Thai Foundation, and Steve Kraus, Director of the UNAIDS Regional Support Team for Asia and the Pacific.

The aim is to raise US$ 1.4 million in 2017. At the launch, organizers announced that more than US$ 60 000 had already been secured from the Siam Commercial Bank, the Sansiri Public Company and other donors. One promoter for Thai boxing plans to organize a match at one of the country’s most famous boxing stadiums, with some of the proceeds going to the fund.

The Bamrasnaradura Infectious Disease Institute in Nonthaburi is one of Thailand’s premier hospitals in AIDS treatment and care. Its waiting rooms welcome many patients. This month, people waiting for appointments will see on hospital screens stories about people living with HIV who overcame stigma thanks to support from their communities. Bamrasnaradura is one of around 1000 hospitals in Thailand that have joined the zero discrimination in health-care settings campaign.

The Ministry of Public Health of Thailand, the Thai Network of People Living with HIV/AIDS (TNP+) and UNAIDS launched the campaign on 2 March at Bamrasnaradura. 

“More than 30 years since HIV was detected in Thailand, stigma still remains a major challenge,” said Jessada Chokdamrongsuk, Director-General, Department of Disease Control, Ministry of Public Health. “Thailand is committed to ensuring health-care settings are safe and supportive environments.”

The campaign features a video with a short message from the popular Thai singer and UNAIDS National Goodwill Ambassador for Thailand, Chalatit Tantiwut, in which he encourages everyone to join the zero discrimination movement.

“Discriminating against anybody for any reason is always out of bounds,” said Mr Chalatit. “Making music is what I do best and I think it’s my duty to contribute to society and make some noise about zero discrimination.”

This initiative is part of an ongoing effort by the Ministry of Thailand to tackle stigmatizing behaviours and attitudes among staff towards people living with HIV. A survey of 1600 Thai health-care workers showed that more than 60% of workers feared an HIV infection while performing routine tasks and 90% admitted to at least one stigmatizing attitude.

The Ministry of Public Health, with support from civil society, UNAIDS and the United States Agency for International Development, has developed a comprehensive stigma reduction programme that is gradually being scaled-up to include all public hospitals.

“Thailand is showing how to tackle HIV-related stigma and discrimination in hospitals and clinics, “said Tatiana Shoumilina, UNAIDS Country Director for Thailand. “This problem is persistent and pervasive in many parts of the world. Only by overcoming this challenge will we Fast-Track the response to HIV and end the AIDS epidemic as a public health threat.”

“Zero Discrimination Day on 1 of March is now a well-recognized event both in Thailand and globally,” said Apiwat Kwangkaew of TNP+. “However, I would like to urge people to practice zero discrimination every day. Fear of HIV transmission and prejudice against people living with HIV are holding back access to treatment and care, employment and education.”

Thailand’s HIV-related stigma reduction programme for health-care workers is one of the world’s most ambitious initiatives and it has been such a success that it is being adapted and implemented in other South-East Asian countries.

After a survey in 2014 of people living with HIV found that stigma and discrimination in health-care settings was a significant issue in Viet Nam, health officials started exploring best practices and the Thai model seemed a good example.

In Ho Chi Minh City, the Viet Nam Administration for AIDS Control, with support from UNAIDS, has started pilot-testing the programme. The initiative began with a survey of three hospitals in the city, which led to a programme for health workers tailored to the Vietnamese context. A training in how to capacitate health-care workers to reduce stigmatizing attitudes and behaviours is under way in the city from the 28 February to 3 March.

“We will conduct an assessment at the end of this pilot project. I hope the lessons learned from this pilot will help further improve the methodology of measuring HIV-related discrimination in health-care settings and programme approaches, so we can expand the practice nationwide,” said Hoang Dinh Canh, Vice-Director, Viet Nam Administration for AIDS Control.

The Lao People’s Democratic Republic is also adapting Thailand’s initiative and Myanmar has expressed an interest in a similar approach. Discrimination is a barrier to accessing health services for people living with HIV globally, which is why UNAIDS dedicated this year’s Zero Discrimination Day on 1 March to elimination discrimination in health-care settings.

The Prince Mahidol Award Conference brought together international leaders in public health to discuss high-priority health issues in Bangkok, Thailand. The 10th annual gathering was held under the theme “Addressing the health of vulnerable populations for an inclusive society” and took place from 29 January to 3 February.

Her Royal Highness Princess Maha Chakri Sirindhorn attended the opening session, which included a keynote address from Nobel Laureate Amartya Sen, of Harvard University, who spoke about how living in a sharply unequal society affects health.

UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria organized a session called From Exclusion to Leadership: Learning from the AIDS Response. The session explored how knowledge from the response to HIV could be used in addressing vulnerability, marginalization and social exclusion at the global, regional and national levels. It looked at lessons and approaches that are transferable to the broader health agenda.

Another session co-organized by UNAIDS and the World Health Organization was entitled Discrimination in Health Care—Determinants and Consequences. It examined how discrimination leads to poor health outcomes, leaving people who are stigmatized even more vulnerable to ill-health and its consequences.

The Thai Red Cross Anonymous Clinic (TRCAC) sits back from a busy street in Bangkok, Thailand. It’s a familiar place for Jonas Bagas, who visits the leafy compound regularly because he is taking pre-exposure prophylaxis (PrEP) as part of a project being piloted by the clinic.

PrEP is the use of antiretroviral medicine in the form of a daily pill to prevent people from acquiring HIV. It is demonstrated to be highly effective in preventing the transmission of HIV among people at high risk of becoming infected.

“One reason I started was because I had a sexual partner who was HIV-positive,” explains Mr Bagas, who is from the Philippines but living in Bangkok for his job with APCASO.

TRCAC started its PrEP project at the end of 2014. Users are charged US$ 1 a day for their supply of pills, along with the recommended counselling and health evaluations. PrEP is only for people who are HIV-negative, so users undergo an initial HIV test and a check for other sexually transmitted infections as well as tests to measure how the liver and kidneys are functioning. After the first month, users repeat the evaluation and then return for testing every three months.

The most common side-effects of PrEP are nausea, headache and weight loss in the first month, but no serious toxicity has been observed during trials. “I find a huge urge to sleep right after taking PrEP, but since I take it at night, that’s not a huge minus,” said Mr Bagas.

While adherence and regular HIV testing present challenges for scaling up PrEP use, researchers describe it is a breakthrough in HIV prevention. Consistent condom use remains low in Asia. In most major cities less than half of gay men and other men who have sex with men are using condoms consistently, which is too low to have an impact on stopping the AIDS epidemic. UNAIDS and the World Health Organization recommend PrEP as an additional prevention choice for people at substantial risk of HIV exposure and who are ready to have regular HIV testing.

“We have been waiting quite a long time to get an HIV prevention method that you can use in privacy and without anxiety. PrEP is the answer to that,” said Nittaya Phanuphak, Head of the Prevention Department at the Thai Red Cross AIDS Research Centre.

PrEP does not prevent other sexually transmitted infections and is not a contraceptive, so health experts say it is best integrated with other sexual and reproductive health services, including the supply of condoms.

Surveys of potential users in Asia find that there is still a low awareness of PrEP as a prevention method. “I hope that PrEP becomes available in the Philippines soon,” said Mr Bagas.

In fact, the nongovernmental organization LoveYourself is starting a pilot project for PrEP, including regular check-ups, risk reduction and adherence counselling, in two of its clinics in Manila, Philippines, in November. “We will embed PrEP education in the HIV testing process. So all those who are going through HIV testing in our clinics, which is about 60 to 100 people a day, will be given PrEP information,” says Chris Lagman, the Director of Learning and Development at LoveYourself. 

Sixteen years ago, Anya Nopalit was thrilled to learn that she was pregnant, but then she received devastating news. “I learned that I had HIV. I was really sad and disappointed. I wondered, why did this happen to me?” said Ms Nopalit, who lives in a fishing village in Chantaburi province in south-east Thailand.

Her doctor encouraged her to have an abortion, but she was determined to keep her baby. “I thought what will be, will be,” said Ms Nopalit.

Luckily, in the very same year that Ms Nopalit learned about her diagnosis, Thailand became one of the first countries in the world in which pregnant women living with HIV had access to free antiretroviral therapy. Untreated, women living with HIV have up to a 45% chance of transmitting the virus to their children during pregnancy, delivery or breastfeeding. However, the risk drops dramatically if HIV treatment is given to both mother and child.

Ms Nopalit followed the treatment regimen advised by her doctor and her son was born HIV-free.

“I was so happy when the doctor told me he was HIV-negative,” said Ms Nopalit.

Thailand’s early commitment to stop babies from being born with HIV has saved many lives and in June 2016 the country received validation from the World Health Organization (WHO) for having eliminated not only the transmission of HIV but also of syphilis from mothers to their children.

According to Thailand’s Ministry of Public Health, the number of children who became infected with HIV in 2015 was 86, a decline of more than 90% over the past 15 years. The rate of mother-to-child transmission of HIV in Thailand declined from 13.6% in 2003 to 1.1% in 2015. The WHO global guideline considers mother-to-child transmission of HIV to be effectively eliminated when the rate of transmission falls below 2%.

At the Tha Mai Hospital in Chantaburi province, where Ms Nopalit accesses her HIV treatment, paediatric HIV cases have become uncommon.

“For the last three years, there were no new cases of mother-to-child transmission,” said Monthip Ajmak, Senior Nurse, Antenatal Care, Tha Mai Hospital.

One of the factors behind Thailand’s remarkable achievement is a well-developed national health system that provides quality services in even the most remote areas. According to Thai health authorities, nearly all pregnant women are routinely screened for HIV and if they are found to be HIV-positive the women start lifelong antiretroviral therapy. More than 95% of pregnant women diagnosed with syphilis also receive treatment.

In Thailand, health-care services for mothers living with HIV are fully integrated into maternal and child health-care programmes in hospitals and are covered by Thailand’s universal health-care coverage.

“Public sector staff receive continuous training, from basic counselling skills to providing a treatment regimen,” said Danai Teewanda, Deputy Director-General, Department of Health, Thailand Ministry of Public Health.

Community leadership has ensured that mothers living with HIV are linked to hospitals and supported throughout their pregnancy. The Best Friends Club at the Thai Mai Hospital has 160 members, who include men and women living with HIV. The club is divided into three groups, with more recent members meeting every month and long-time members meeting twice a month.

“Our club provides counselling services at the antenatal clinic. We coordinate with the hospital staff and provide information to women on how to take care of themselves,” said Malinee Vejchasuk, a counsellor with the Best Friends Club.

Ms Nopalit and her husband wanted to have another child. Four years ago, she gave birth to her second son.

“I am so happy that my two children are healthy and HIV-free. They are lively and play like their friends,” said Ms Nopalit.

When he is not in school, her eldest son now accompanies his parents when they catch crabs, which is their family business, while their youngest son runs around the beach and builds sand castles.

Video: Thailand is first country in Asia to eliminate mother-to-child HIV transmission

Thailand has received validation for having eliminated mother-to-child transmission of HIV and syphilis, becoming the first country in Asia and the Pacific region and also the first with a large HIV epidemic to ensure an AIDS-free generation. Meet Anya Nopalit, a mother living with HIV who has two HIV-negative children.