PHA-Exchange> PHM media coverage in THE LANCET- (AIDS conference)

[UNNIKRISHNAN P.V. (Dr)]

      World Report   Volume 364, Number 9431     24 July 2004  THE LANCET 


      Thailand glimpses success  

      The devastation caused by AIDS in Africa has yet to emerge in Asia. But with rates of infection increasing at an alarming rate, a focus on prevention is essential. Stuart Spencer and Stephanie Clark travel to Bangkok and reveal what the rest of Asia can learn from Thailand's achievements.  




Asian countries are only now beginning to notice the effects of the sweeping epidemic of AIDS that has long been predicted. Watching the devastation in Africa, experts speaking at Barcelona's international AIDS conference 2 years ago warned that a catastrophe was about to hit Asia. As if to confirm these gloomy predictions, Vallop Thaineua, Thai minister of public health, declared at this year's Bangkok gathering, "Asia is home to one-quarter of new infections in the world each year". 

Unlike in Africa, Asia's AIDS epidemic has spread rapidly through users of injection drugs. From these communities, the virus has spread to other high-risk groups including sex workers, men who have sex with men, and prison populations. Africa's epidemic, by contrast, took hold in the sex-worker population first and moved into the general population before HIV and AIDS were recognised. There are cultural differences too: in Asia up to 20% of men visit sex workers and more than 10% are men who have sex with men. Most of such men are bisexual and married, so provide a ready conduit for the disease to spread to the general population. 

There is hope that with a greater understanding of the way the infection is spread it can be more effectively contained in Asia than has been the case in Africa. Even so, some Asian governments have been reluctant to acknowledge the issue. The Thai government is not one of them. 

At the opening ceremony of this year's 15th International AIDS conference in Bangkok, July 11-16, the prime minister of Thailand, Thaksin Shinawatrab, spoke of his government's commitment to halting the progress of the disease. Thailand has been at the forefront of attempts to control HIV. Along with neighbouring Cambodia, the Thai government introduced a "100% condom programme" in the early 1990s, encouraging the population to protect themselves. The prevalence of HIV immediately stabilised and now shows signs of decreasing. 

Drug users in Thailand have, until now, not been included in these efforts. In fact, in February, 2003, the government implemented a controversial "war on drugs" campaign, which, according to Human Rights Watch, resulted in the unexplained killings of more than 2000 drug users. Since then, the government insists it has undergone a change of heart--a sentiment that was clear in Shinawatrab's conference address. "We now see drug users as patients who require our support and treatment", he said. 

Thailand has also moved quickly to provide treatment for people with AIDS. Shinawatrab has promised free antiretrovirals for all AIDS patients under the government's 30-Bhat scheme. Thongchai Thavichachart, managing director of the Government Pharmaceutical Organisation (GPO) in Thailand, which manufactures medicines for the government, told The Lancet that this organisation has now scaled up production of generic antiretrovirals and is ready to supply all patients with a CD4 count of less than 200. 

However, Médecins Sans Frontières (MSF) claims that children are being neglected. Paediatric formulations of antiretrovirals are rare, but the Thai government is planning to provide a chewable pill for this purpose. In many countries, children are given a scaled-down dose of the product for adults, which can mean children having to take large pills, causing poor compliance. 

The Thai government has also put resources into helping patients on antiretrovirals get back into mainstream society. According to Mechai Viravaidya--known as "Mr Condom, Mr Senator" because of his support for Thailand's 100% condom programme--people can apply for a loan of US$300 to help them earn a living. To qualify, applicants have to become business partners with people who are not infected. Viravaidya believes that once people start to realise that those infected with HIV do not pose a threat, and can repay their loans, attitudes will improve and the discrimination experienced by many living with HIV will lessen. The programme began about 2·5 years ago and so far about 1000 loans have been given out. On the basis of this success there are plans to extend the programme to Cambodia and other Asian countries. 

Young people are the only group in which infection rates are rising in Thailand. The government is therefore planning to launch an improved sex-education programme in schools designed for primary or lower secondary levels, which is much earlier than at present. Public health minister Sudarat Keyuraphan's "social vaccine" programme includes information on HIV/AIDS so that youngsters learn to avoid high-risk behaviours. Orphans are the subject of a separate new proposal. The government has developed a programme for providing scholarships for more than 13 000 children, to enable them to continue their education until they are old enough to earn their living. 

The HIV epidemics in other Asian countries such as China, Vietnam, and Indonesia lag behind those in Thailand and Cambodia. But infection rates are rising rapidly in high-risk groups. Key cultural features of these countries are the high number of men who visit sex workers--which puts a staggering 34 million men at risk of HIV infection--and the few women under age 20 years who have sex. In Asian countries between 3% and 20% do so, compared with 40-60% in Africa. Bisexuality is common in Asian countries, providing another avenue for spread into the heterosexual community. 

In Vietnam, the epidemic is in its infancy. According to Family Health International, rates of infection in injection-drug users are high at almost two-thirds, but are very low in sex workers (6%). However, it is only a matter of time before HIV spreads from drug addicts to the sex-worker population, and from there into the general population. 

Worryingly, few of these countries have followed Thailand's example by introducing prevention programmes. But there are encouraging signs of positive movement in China, where about 840 000 people are known to be infected. But major problems, such as the illegality of drug use and commercial sex, are hindering progress. Ignorance and poverty are further barriers to success in rural areas. 

HIV infection is common along the drug trafficking routes emanating from the golden triangle of northern Thailand, Burma, and Laos. Mobile populations such as migrant workers and truck drivers are another high-risk group, Chung To, of the Peoples Health Movement told The Lancet. Young girls from poverty-stricken villages line the routes where long-distance drivers, many of whom are drug users, pay for sex. 

Chinese people who are HIV-positive face discrimination and a legal struggle in their day-to-day lives. Prostitution and use of injection drugs are illegal, so many who are infected risk jail by disclosing their status. Discrimination is a serious problem. Selina Lo of MSF told The Lancet that staff working on pilot treatment programmes in China take care not to ask patients what their sexual orientation is, or whether they are an injecting drug user. These agencies are campaigning for new legal structures to help support HIV-infected people. For instance, in Hong Kong, To said, employers cannot dismiss people for being HIV-positive, but no such protection exists in other parts of China. 

The Chinese government is beginning to respond positively to the crisis facing its country. The newly launched China CARES programme--which was discussed by Sarah Palmer and colleagues from US National Institutes of Health at the Bangkok conference--aims to provide free treatment for all. 

Prevention strategies are also contributing to successes. 12 months after the introduction of needle-exchange programmes, needle sharing fell by half in Guangdong and Guangxi Provinces, with no change in controls. According to Zunyon Wu of Chinese Centre for Disease Control, "The Chinese government is committed" to tackling the spread of AIDS among drug users. 

The Chinese ministry of health and other ministries set up a community-based methadone programme as recently as February, 2004, as part of the countries' prevention strategy. Methadone programmes help to reduce the number of injecting drug users and thus the risk of infection by this route. In China, drug users are either imprisoned or enrolled in mandatory treatment schemes, but in the new programme methadone is provided free to injection-drug users with at least a 2-year history of heroin use who have failed compulsory treatment. Eight clinics in five provinces are taking part and the plan is to expand to 16 by the end of the year. In this respect China is ahead of Thailand, where no such programmes are in place as yet. 

Wiwat Peerapatanapokin, speaking at the conference, asserted that "the epidemic in Asia can be controlled", as Thailand's progress shows. Furthermore, early results from new but small initiatives in China indicate that similar success can be achieved there, and in the many other countries in Asia. But governments and agencies would do well to reflect on the words of Nelson Mandela at the close of the Bangkok conference: "We know what needs to be done--all that is missing is the will to do it." 
Stephanie Clark and Stuart Spencer 


Dr. Unnikrishnan PV
Emergencies & Human Security Advisor (Asia)
International Emergencies Team, ActionAid International 
Cell: +91 98450 91319
E-mail: unni at actionaidasia.org 
www.actionaid.org
 

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