Risk factors for HIV infection in Thailand.

PIP: The HIV epidemic is far from over in Thailand. A male population with high levels of HIV sexual risk behavior and, in particular, the widespread and frequent use of commercial sex helps to perpetuate the epidemic. Condom use has risen dramatically in commercial sex, but much more remains to be accomplished before HIV is brought under control in Thailand. For example, the Thai population is quite knowledgeable about HIV and AIDS. Efforts must be made, however, to clear up major misconceptions harbored by many people about the disease. Sexually active men must be made aware that they cannot tell by looking at a person whether he or she is infected with HIV. Little is known about risk behaviors or seroprevalence in homosexual and bisexual men. Increasingly, noncommercial casual sexual contacts will assume a much larger role in HIV transmission in Thailand. Available evidence suggests that women are engaging in premarital and extramarital sex often enough to justify intensifying intervention programs targeting these women. The development and implementation of these latter interventions are particularly critical given the high levels of HIV infection among young Thai men and the low levels of condom use in these noncommercial sexual encounters. Blood transfusion is no longer an important route of HIV transmission, although the use of unsterile injection equipment by medical practitioners outside of the formal medical system may still be an issue of concern.^ieng

Risk factors for HIV transmission in Asia and the Pacific.

PIP: One may be at risk of contracting HIV in Asia and the Pacific through unprotected heterosexual or homosexual intercourse, receiving infected blood in a transfusion, and/or the use HIV-contaminated injection equipment. The initial spread of HIV may be more rapid among IV drug users and men who have sex with men, but heterosexual infections will eventually dominate in the region. That will be so due to the large male segments of populations in the region which engage in casual and commercial sex without condom use. Many man become infected by prostitutes during sexual intercourse and then infect their steady female partners and wives. When heterosexual transmission of HIV becomes the dominant mode of infection throughout Asia and the Pacific, the second highest level of risk behavior in the region may well be blood transfusion unless the largest countries of the region expand coverage of their screening practices. Risk behaviors for HIV infection exist to some extent in every country of the region, but in most countries that extent is largely unknown. Solid behavioral research is therefore urgently needed to determine national levels of risk behaviors and their distribution throughout the Asia-Pacific region. Complacency among policymakers will only benefit the epidemic, for it would be a mistake to assume that the epidemic will remain small in a country simply because data are not available on risk behaviors or the extent of HIV spread. This paper presents data on sexual risk behaviors; IV drug use; blood transfusions, medical injections, and traditional practices; special populations; AIDS/HIV knowledge; and other STDs.^ieng

Knowledge, attitudes and behaviour among HIV-positive and HIV-negative clients of a confidential HIV counselling and testing centre in Thailand.

OBJECTIVE: To describe the clients, operation and impact of an Asian public HIV counselling and testing centre. DESIGN AND SETTING: Analysis of samples from clients attending the Thai Red Cross Anonymous Clinic (TRC-AC) in Bangkok, Thailand in 1993. SUBJECTS: HIV-positive and HIV-negative consecutive clients (250 of each). MAIN OUTCOME MEASURES: HIV seroprevalence rates, knowledge, attitudes and behaviour. RESULTS: Overall HIV-1 prevalence was 16%; 13% in men and 24% in women. Reasons for requesting an HIV test were high-risk behaviour (21%), feeling unwell (20%), checking a previous HIV test result (18%), a planned marriage or new relationship (10%), and planning a baby (5%). Heterosexual risk behaviour was reported by 85% of clients, while in each case only 1% reported male homosexual or intravenous drug use risk behaviour. Factors associated with HIV infection on univariate analysis included a history of sexually transmitted disease, not using condoms, a low level of education and salary, and being female. Knowledge about HIV transmission risks and AIDS prevention measures was good, and most clients expressed a caring attitude towards people with HIV and AIDS. A former negative HIV test result was associated with higher levels of condom use, and most clients expressed the intention to reduce their HIV risk behaviour in response to a positive or negative HIV test result (more so if positive). CONCLUSIONS: Our study demonstrates the demand for and the feasibility of confidential HIV counseling and testing services in Thailand and illustrates the value of these services in achieving behaviour changes. Such services should be considered as an additional approach for reducing HIV transmission in Asia, especially in areas with high HIV seroprevalence rates.

PIP: Data are presented from HIV serodiagnoses and knowledge, attitude, and behavior questionnaire responses for 250 HIV-positive and 250 HIV-negative consecutive clients attending the Thai Red Cross Anonymous Clinic in Bangkok, Thailand in 1993. The study was conducted to describe the clients, operation, and impact of the public HIV counseling and testing center. The men and women were of mean age 26-29 years in a range of 16-64 years. 16% overall were HIV-1-seropositive; 13% of men and 24% of women. 21% requested the HIV test in response to previous high-risk behavior, 20% felt sick, 18% were checking a previous HIV test result, 10% planned marriage or a new relationship, and 5% planned to have a baby. Heterosexual risk behavior was reported by 85% of clients, but only 1% reported male homosexual or IV drug use risk behavior. These behaviors were reported despite the existence among the sample of ample information about HIV transmission risks and AIDS prevention measures. An history of sexually transmitted disease, not using condoms, low education and salary levels, and being female were associated with HIV infection. Former negative HIV test results were associated with higher levels of condom use, while most clients expressed the intention to reduce their HIV risk behavior in response to either a positive or negative HIV test result. Most clients had caring attitudes toward people with HIV and AIDS. The authors note that sufficient demand exists for confidential HIV counseling and testing services in Thailand. Such services should be considered as a means of reducing HIV transmission in Asia, especially in areas of high HIV seroprevalence.

The recent epidemiology of HIV and AIDS in Thailand.

PIP: HIV infection is firmly established in the general population of Thailand and will soon exact substantial medical, social, and economic effects at the community and household levels. The primary risk behavior for infection in Thailand is heterosexual intercourse compounded by high levels of other sexually transmitted diseases (STD) and the general cultural acceptance of commercial sex. The June 1993 round of sentinel surveillance for HIV seroprevalence found median and provincial ranges as follows: 35.2% in the range of 13.3-70.8% among IV drug users, 28.7% in the range of 5.1-64.1% among direct sex workers, 7.6% in the range of 0.0-37.3% among indirect sex workers, 8.0% in the range of 0.0-33.0% among men attending STD clinics, 1.4% in the range of 0.0-7.6% among women attending antenatal clinics, and 0.74% in the range of 0.0-8.4% among blood donors. HIV seroprevalence was 4.0% among military conscripts in May 1993. Men and women in Thailand with no other risk factor than sex with a spouse are often at risk of infection with HIV. Urban/rural differentials are minimal, with HIV infection strewn across the country. HIV seroprevalence levels continue to climb despite some success with interventions in slowing the rate of infection among military conscripts and reducing the incidence and prevalence of STDs. Interventions, health care, and coping responses therefore need to be delivered at the community level throughout the country. Although much emphasis has been given to the prevalence of HIV infection in Northern Thailand, seroprevalence data show that other parts of the country will soon experience the same explosion of AIDS cases observed in the North over the past two years.^ieng

The emerging epidemic of HIV infection and AIDS in Asia and the Pacific.

PIP: The countries of Asia in 1988 did not seem to be at great risk of sharing in the virtually global HIV/AIDS epidemic. HIV transmission was not occurring on a large scale in those countries and no dominant pattern of transmission had been established. That situation has, however, dramatically changed such that Asia and the Pacific are now fully part and parcel of the global pandemic. Indeed, Australia and New Zealand were among the first developed countries to record high rates of AIDS incidence during the early 1980s, while Thailand had documented alarming increases in HIV seroprevalence by 1988. In New Zealand and Australia, sex between men was quickly established as the dominant route of transmission, with IV drug use remaining a rare mode. IV drug use appears to have been the major transmission route in southern China, northern Malaysia, and northern Myanmar, while heterosexual transmission dominates in the majority of Asian and Pacific countries. Tuberculosis is the major opportunistic infection in the countries of Asia and a fungal pathogen of increasing importance in the region, Penicillium marneffei, had not been associated with HIV infection until the virus reached Asia. Some governments have been slow to respond, yet others including Australia and Thailand have implemented comprehensive national strategies. Many community level prevention activities are ongoing. Despite these activities and some important successes, HIV infection and its related social, economic, and political consequences continue to threaten Asia and the Pacific.^ieng

Two views of risky sexual practices among northern Thai males: the Health Belief Model and the Theory of Reasoned Action.

We apply the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA) to an analysis of unsafe sexual practices (inconsistent condom use with commercial sex workers) among men living in a high HIV-prevalence area. The empirical analysis is based primarily on a survey of sexual practices that was conducted by the authors during the fall of 1991. The survey sample includes university undergraduates, soldiers, clerks, and laborers living in Chiang Mai, Thailand. There is much overlap between the two theories, and both provide useful frameworks for examining condom use in this population. However, the Bayes Information Criterion (BIC) approach provides very strong evidence that TRA is the more plausible model, given the data. The success of TRA appears to be due to its more adequate incorporation of peer group effects. Other covariates positively associated with consistent condom use in the multivariate models include knowledge about the consequences of HIV infection, knowledge about the benefits of condom use for preventing infection, and positive attitudes about condoms.

AIDS education and intervention trials among youths in factories: a pilot project.

The project aimed to conduct a pilot study and intervention trials among youths in a factory of Khon Kaen. After contacting and obtaining agreement from owners/managers of factories, a survey using a self administered questionnaire, in-depth interview and focus group with workers to determine their level of knowledge and awareness of AIDS and high risk behaviour. A series of in-depth interviews with 16 workers and group discussion with 8 groups were conducted to find out their possible motivation for prevention and their acceptance of interventions/media. The data was used as a baseline for evaluating change after interventions and to modify the intervention education strategies and content. The study showed that the groups of factory workers which were not involved in the AIDS prevention had a different level of knowledge, attitudes, and behavior related to AIDS prevention than the groups which received the intervention and the methods used in the intervention achieved a level of success. The information we collected also showed that the best kinds of media for this purpose were videos and informational cartoons, which were also of special interest to the study group. It is hoped that the models will be adopted by relevant government and non-government agencies to be used in factories throughout the country.

PIP: This article presents the results of the pilot study and intervention trials conducted among youths in a factory in Khon Kaen, Thailand. A survey using a series of self-administered questionnaire, in-depth interview, and focus group was carried out to determine the level of knowledge and awareness of AIDS and high-risk behavior of the workers. To find out their possible motivation for prevention and acceptance for intervention, 16 workers underwent in-depth interviews and 8 other groups held discussions. The control group (from another factory) that did not receive the intervention was studied as well. The data was used as a baseline for evaluating change after interventions and to modify the intervention education strategies and content. Findings showed that most of the people in groups which received the intervention had better knowledge, attitudes and behavior related to AIDS-prevention than groups which had not yet received the intervention. This shows that the methods used in the intervention achieved a level of success. The information collected also showed that the best kinds of media for this purpose were videos and informational cartoons, which were also of special interest to the study group. It is hoped that the intervention models will be adopted by relevant government and non-government agencies to be used in factories throughout the country.

AIDS prevention strategies for rural families in northeastern Thailand.

The project AIDS Prevention Strategies for Rural Families in Northeastern Thailand aimed to find effective strategies for AIDS education for rural families to promote non-risk behavior, non-discrimination while supporting care for individuals with HIV/AIDS in their families and in the community; to provide opportunities for family members, community leaders and HIV/AIDS organizations to cooperate, exchange ideas, and to participate in campaigns at the community level; and, to find appropriate media to improve the knowledge, understanding and awareness of HIV/AIDS among rural families. Data was collected through interviews by questionnaires, group discussions and in-depth interviews in two districts in the target province. A comparison of pre- and post test data analyzing knowledge of HIV transmission, AIDS prevention and treatment, attitudes and motivations, prevention behavior and women's empowerment all showed a significant improvement in all the above areas for the trial population.

Outreach to bar workers in Bangkok.

In the course of a campaign to provide AIDS education, information and related services to bar workers, outreach is a necessary strategy. This paper describes what "outreach" is, the direction it may take, who the bar workers are, where outreach is conducted, who performs the outreach, what "community preparation" or prior work is necessary, and useful tips for effective, ethical, outreach programmes.

The HIV / AIDS epidemic in Thailand: addressing the impact on children.

PIP: Within the space of a decade, the level of HIV infection in Thailand has grown to epidemic proportions. With regard to children, 16,000 had been born with HIV by the end of 1994, while tens of thousands of child prostitutes and street children are at risk of infection. By the year 2000, more than one million Thai children will have at least one HIV-infected parent. Many of these children will therefore become either orphans or abandoned by their infected parents. The magnitude of these problems over the course of the lives of HIV-affected children depends heavily upon actions taken now. This paper summarizes the joint report of the Thai Red Cross Society and the East-West Center's Program on Population on the impact of HIV on children in Thailand. The current situation, projected impacts, and policy recommendations are described. No other country has had as complete a monitoring system or as early a warning of the problems ahead. Some recommended approaches are familiar and simply need to be strengthened and expanded to the regional or national level, while others require field testing. The authors stress the need for shared commitment, ideas, resources, and efforts of all sectors of society to plan for the future needs of children affected by HIV, to protect them from infection, and to provide them with the social and economic support, medical treatment, and legal protection they need.^ieng

Levels of HIV risk behaviour and AIDS knowledge in Thai men having sex with men.

Although many of the earliest cases of AIDS and HIV infection in Thailand were men who had sex with other men (MHSWM), transmission by heterosexual intercourse and needle sharing rapidly became dominant. This resulted in comparatively little attention being given to studies of risk behaviour and seroprevalence in groups of MHSWM with a consequent lack of information about these populations relevant to designing effective interventions. In the Partner Relations Survey, 3.3% of male Thais described their orientation as bisexual or homosexual, most probably an underestimate of the occurrence of same sex behaviour in Thai males. This paper briefly reviews the situation and presents results from a survey in the northeast of Thailand among men who have sex with men. Substantial levels of risk behaviour were found in MHSWM in the Northeast, with high rates of partner exchange and low levels of consistent condom use in insertive and receptive anal intercourse. Significant defects in AIDS knowledge existed implying a strong need for enhanced and expanded interventions in this community. Factors relevant to the design of interventions are highlighted and recommendations for further studies of MHSWM in Thailand are presented.

PIP: The percentage of boys and men in Thailand which identifies itself as bisexual or homosexual is most likely larger than the 3.3% suggested by data in the Partner Relations Survey. Accordingly, this study was conducted with the purpose of examining the sexual behavior, AIDS knowledge, and networks of sexual contacts of men who have sex with men in northeast Thailand. Findings are based upon information from 157 surveyed men aged 15-57 of mean and median ages 26.4 and 24 years, respectively. 95.5% of the participants were single and 77.1% lived in the metropolitan area. Examination of the data indicates that these men have a great deal of unprotected sexual intercourse with many different partners of varying types; partners include male and female prostitutes as well as strangers. Only low levels of consistent condom use exist during insertive and receptive anal intercourse. Moreover, most men with lovers have substantial levels of sex outside of the relationships without protection. Significant deficiencies in AIDS knowledge point clearly to the need for HIV preventive interventions in the community. These interventions should attempt to increase the levels of condom use and safer sex practice, reduce the number of partners, improve the recognition and early treatment of sexually transmitted diseases which may enhance HIV transmission, and improve the knowledge of AIDS/HIV and its prevention. While interventions could be made at the policy level or through the mass media to increase the awareness and perceptions of personal risk in the general population, interpersonal interventions are most likely to be effective. Recommendations are made for the further study of men who have sex with men in Thailand, while opening sections discuss the background of the Thai AIDS epidemic, the prevalence of male homosexual behavior, and behavioral and seroprevalence studies to date.

Partner patterns in the sexual behavior of unmarried, rural Thai men.

"After a brief discussion of related studies of Thai youths' attitudes toward sexual activity, data from a 1988 national survey of young males (ages 15-24) about their family planning knowledge, attitudes, and practices are used to document the age pattern of sexual initiation, the prevalence of youths' encounters with commercial sex workers, the prevalence of their experience with non-commercial partners...and the degree to which the two patterns--commercial and noncommercial--are 'networked' because young men engage in both types of sexual activity. Finally, background characteristics of male youths that are associated with these patterns of sexual activity are examined."

Living arrangements of the elderly in Thailand: Views of the populace.

Qualitative data collected in Thailand through a series of 26 focus groups held separately with elderly individuals and adults with elderly parents provides insights into Thai views on a variety of issues related to the living arrangements of the elderly. These include the benefits and problems associated with coresidence, the choice of the coresident caregiver, mechanisms encouraging co-residence, alternatives to living with children, and the impact of social changes on living arrangements. The normative expectation that adult children should care for and support their elderly parents remains deeply ingrained in Thai culture and includes a strong sense of obligation to have at least one child coreside with or live in close proximity to elderly parents is clearly borne out in the focus group discussions.

Birth order distribution as a family planning program evaluation indicator.

PIP: This research aims at deriving a simple indicator for measuring fertility and family planning program output at various administrative levels of the country. The proportion of 1st and 2nd births to total registered births (FSB) is proposed as an ideal measure of family planning performance at the provincial and regional level. The FSB indicator is simple to understand and analyze and it can be obtained in the existing registration system of Thailand. This indicator is highly correlated with the contraceptive prevalence rate, the crude birth rate and the total fertility rate. Based one the findings of this study, it is assured that the FSB is a practical indicator of the family planning program performance at any level of administrative unit in Thailand. It is recommended that the service statistics reporting system should begin including the FSB tabulations for regions, provinces, and districts immediately.^ieng

Women's work and family size in rural Thailand.

PIP: Surveys of 612 couples in 2 districts of rural Thailand were conducted to analyze the extent to which the birth of each child and the cumulative effect of childbearing interrupts, interferes with, or influences women's economic activity. The districts were in a northern area, Lamphun, where fertility has declined rapidly since the 1960s, and central Suphanburi province where the decline has been slower. Couples were selected for having completed families or 1 or 2 children, or 4 or more surviving children, and were matched for age. Information was obtained by survey questionnaires and by focus groups. Small family couples were somewhat better educated and of higher socioeconomic status, and tended to be farmers, while large family couples were more likely to engage in wage labor. These couples viewed women's labor as an economic necessity, either for survival or to educate and provide for their families. To cope with child care, women resorted to relatives, older children, hired child care, nursery school, primary school, took their children with them to work or modified their work schedule. The double burden of income-earning activity and child care caused considerable strains for working mothers. There was an overwhelming consensus among both groups that childbearing interrupts and that child care interferes with women's work. 95% of the small and 90% of the large families felt that more work could be done if families were kept small. Implications of this study are that government sponsored family planned should continue, and that some type of subsidized day care is needed, including early morning hours when farm women leave for work.^ieng