HIV and AIDS: The Global Inter-Connection

HEADING OFF A CATASTROPHE

 Mechai Viravaidya
Interviewed by Wasant Techawomgtham

I regard HIV not just as a health problem but as a societal problem. So long as there are no drugs to treat it and no vaccine to inoculate against it, there is only one thing we can do: take preventive measures. Since there is no effective treatment, we must care for people living with HIV and AIDS with compassion and respect for their human rights.

Prevention is the only cure. This is the key issue. There are three main factors in the government's prevention programme: education, condoms, and the reduction of sexually transmitted infections (STIs).

We have launched an extensive education campaign to be included in school curricula from the primary level through the university, the workplace, and rural areas. All five television stations and 485 radio stations throughout Thailand are now broadcasting a thirty-second radio spot every programme hour, with a focus on prevention and compassion. The prevention focus tells you what HIV is, how you contract it, how to prevent it, and what to do if you become HIV positive. For example, people are urged not to have unprotected sex and they are discouraged from patronizing the commercial sex trade. The compassion message is that anyone can contract HIV, that HIV is not contagious through everyday human contact, and that infected people have a place in our society and rights just like everyone else.

The second part of the campaign focuses on condoms. They have been used in Thailand for a long time. We have factories producing condoms for domestic use and for export. The supplies are available both from the government and from well over 130,000 stores. The problem is to ensure their use. The issue of cost is invalid because if one can pay for commercial sex, one can pay for condoms.

Thai males' sexual behaviour is the primary factor in the spread of HIV. Men patronize sex workers and do not use condoms. We must ensure that people understand they should reduce the number of sexual partners and that they should use condoms when they have sex. At this time, men are the focal point of our education programmes.

The message on condoms is also being sent to the brothels and we are trying to push them as hard as we can toward maximum use of condoms. The "100 per cent condom use" programme, a pilot project initiated in a few provinces, involves the governor, the provincial health office, the police and operators of sex-service places of business. Sex-service operators agree to allow the health office to conduct STI checks and blood tests for HIV on the women they employ. In return, they are allowed to conduct their business without police interference as long as no coercion is used on the women and no child prostitution is involved. If a brothel turns up with an STI, this indicates that condoms were not used. That brothel will be penalized by being prevented from operating for one day. The second time it is closed for a week, the third time for a month. The fourth time this occurs the brothel is closed permanently.

The third major aspect of our prevention campaign focuses on treating STIs. This is a very important issue because we know STIs are a major factor in the transmission of HIV. People with STIs are much more susceptible to being infected with the virus. So you have to encourage people to get treatment but you cannot force them. The first thing we do is send out a general message to make people understand: "If you have an STIs, your chances of contracting HIV are much higher. So come in, get treated and use condoms to avoid any infection."

Sometimes people have STIs and are not even aware of the condition. Women are particularly vulnerable. Unlike their Western counterparts, Thai women do not go for a medical checkup every six months or once a year, and some have never gone at all. We must get our message out simply, maybe through women's magazines or even by inserting little booklets inside sanitary-napkin boxes. The message must be clearly addressed to women, to let them know they are at risk. A lot of them are going to be bystanders who unknowingly contract STIs or HIV from their husbands or boyfriends.

Our prevention programme must reach people in the rural areas as well as those in the cities. The government has already begun to reach down to the village level. Starting with the governors, every province has an AIDS plan. Every workplace in the community, including the village committees, will be trained to provide information to the people. At the same time, the importance of compassion and understanding will be stressed by reminding others that we have people in our own villages who are infected and that we should take care of them. Chiefs, rural development officials, women's groups, health volunteers, private organization volunteers, monks, and teachers all must be taught to pass this message on.

I hope we don't leave any stone unturned. There are programmes geared toward the entire population and some just for adults. Others are designed for very specific groups in the workplace: vendors, construction workers, people working in gas stations, small restaurant employees, and those who are self-employed or in the informal work sector. These workplace programmes are being administered by non-governmental organizations (NGOs) in conjunction with local government agencies, the police, and the Ministry of Interior. We have programmes to educate university students who will also go out and teach the public. Our school programme focuses on children to prevent our problem from becoming more difficult in the future. HIV has been with us in Thailand for a long time and we have to work with that in mind.

Prevention also requires addressing commercial sex work; both its demand and supply. People continue to market and recruit young girls. There has been no effort to go to the villages and discourage girls from entering the sex trade. A recent study indicates it's not just poverty that forces women into sex work. It's the consumerism and glamour that go with it, the glamour of having material possessions.

Basically, education has a lot to do with it. Among all the commercial sex work who have been interviewed, only 1 per cent have secondary education. Girls with secondary education have more employment options. So the more girls who can get a secondary education, the fewer who will be attracted to sex work.

Obviously there is a need to provide alternative sources of income. That's why I've gone to the business sector for help. The need is for specific training with a product or a service for which there is a market or demand. This is going to be a long-term process. We also will try to decentralize small factories, such as we have done with girls making shoes in the northeast as part of a subcontract with Bata shoes.

These things are being done in many areas through the Thai Business Initiative in Rural Development programme (TBIRD). In this programme, a company is asked to take on one village, with the major objective of providing economic opportunities for the villagers so that there's no migration. Obviously, migration means migration to any job, including sex work. The major emphasis is on young girls in the villages. Sixty companies have cooperated. In the villages we have gone to, not one girl has left to become a commercial sex work, because we told them about HIV and provided them with alternative income. At our urging, people are coming back to their villages.

Thai male sexual behaviour is key. If it does not change, we'll have more HIV infection and this shall have a great economic impact. There are basically three kinds of economic cost. The first is what is called foregone earnings, the income that is lost because infected people live shorter lives. An infected person, once he or she becomes ill, has to stop working. Once a person stops working, he or she stops receiving wages. We assume that each person will lose twenty-five years of his or her working life. Let's say each person earns about $1,000 a year, which is a low figure, even lower than our per capita income. If we take into our calculation a social discount rate of 5 per cent, we lose about $17,200 of income for that person. Multiply that by the number of infected people, and you get a total income loss equivalent to more than fifteen times the value of the gross domestic product.

The second cost is that of health care, which we estimate to be about $1,000 per person per year. Again, this is a very conservative estimate. We assume that infected people will stay in cheaper government hospitals rather than in private facilities or they will stay at home. We also do not figure in the cost for expensive antiviral drugs like AZT. We have roughly calculated that the total annual health care cost plus the value of lost income will grow from $100 million in 1991 to $2.2 billion by the year 2000. Over this ten-year period, we will probably lose about $8.7 billion due to HIV and related illness and death.

The third cost is the macroeconomic cost, including tourism, the export of labour and the loss of prospective foreign investment. It will take time to calculate the total cost, but if you add up all these costs, the total is tremendous. Land prices will drop, as will tourism and labour exports.

The important point to consider is what the damage is likely to be if we don't take action now. The sooner we slow the infection rate, the more manageable the situation becomes. Let's consider 1993 as the peak year. The worst-case scenario is that we will have more than 275,000 new HIV infections that year. This means that ten years from now, the cumulative number of infected people would be more than 2 million. If we get serious in our prevention programme now, things may not be as bad as we think by the year 2001. However, if we stand idly by and the infection rate peaks in 1997 instead, we will have 765,000 more new cases of HIV infection by the time 2001 rolls around.

The good thing about seeing a projection like this is that once we identify the worst-case scenarios, we'll be able to make another projection based on what we can do. For example, if we promote condom use, how many cases can we prevent? How many more if we tackle the STI situation?

If we stay on course, we will still have a problem, but it is no longer a catastrophe. The infection rate will peak in 1993, and we probably can prevent 600,000 cases from the cumulative number of more than 2 million originally projected for the year 2001. This will be more than a 25 per cent reduction.

Right now we have about 80,000 hospital beds and they are not enough. If nothing is done, if we leave the situation to continue as it is, in the year 2000 we'll have about 180,000 people diagnosed with AIDS and 160,000 deaths that year. One hundred and eighty thousand is already more than double the number of beds in our hospitals.

What we need is a home-based care system, in which people with HIV-related illness may spend a couple of days each month in a hospital as necessary and the rest of their time at home. Then the community and family can take care of each other with the assistance of mobile doctors. The Ministry of Public Health and all universities with medical schools have had meetings to plan an ambulatory home-based care system.

Obviously, the extended families will have to give care. This is why 50 per cent of our campaign focuses on compassion. Whenever the family cannot help, or where it is impossible because they have all died, the Buddhist temples would be key as places of solace and as orphanages in the future.

It's always daunting when you examine how much money must be spent. However, if you take a look at how much money is going to be lost if we don't begin prevention now, you will begin to see the sense in investing in prevention programmes. Luckily, our mass media are owned by the government, because otherwise the half-minute HIV education messages would cost approximately $48 million. Government personnel who will be involved in the education programming are already paid for. Companies will be participating on their own time and use their own resources. We have estimated that the cost of the program in kind and in cash this year comes to about $112 million.

HIV has done damage here as in every other country. Whether the damage can be contained depends very much on the leadership. We have to follow through on our campaign. We must be vigilant. If people are seriously involved, it will put pressure on the government to pay attention. I would say, don't just let the government set the direction. As a private citizen I campaigned until the government had to respond. Don't assume that the government will think for itself. We now have a very good leadership on this issue. But if the next government is not concerned, we will have to push from the outside to force them to address the epidemic. Otherwise we will all pay a price we cannot afford.

Biographical note

Mechai Viravaidya is the founder and chairman of the Population and Community Development Association of Thailand (PDA), a private and non-profit family planning and rural development agency. An outspoken advocate for family planning, Mr. Viravaidya became known for his use of humour in family planning advocacy campaigns. He has been one of the nation's leading activists on the issues of HIV and AIDS and an early supporter of condom use for HIV prevention. He has served in numerous government positions, including senator, press spokesman for the prime minister and minister in the Office of the Prime Minster.

Wasant Techawomgtham is a features writer for the Bangkok Post, an English-language newspaper in Thailand. He has been reporting on HIV and AIDS issues for the past four years.