HIV and AIDS: The Global Inter-Connection

WE MUST BE A CARING SOCIETY, NOT A SCARED SOCIETY

By Prateep Ungsongtham Hata

By the end of the 1980s the myth that HIV was not a Thai disease was shattered by alarming figures showing the spread of HIV throughout our population. Today, although estimates of incidence vary, two points are clear: the country is in crisis, and heterosexual contact is the major mode of HIV transmission.

Silence and denial characterized the government's initial response, prompted by fear of the disease's impact on tourism and foreign investments, and by an official reluctance to acknowledge the presence of a booming commercial sex work industry.

To date, preventive measures have been minimal and largely ineffective. Few programmes have been developed for either HIV-positive people or those who have been diagnosed with AIDS.

The spread of HIV in Thailand is primarily due to the powerful illegal commercial sex work industry. Contrary to popular belief abroad and foreign press statements notwithstanding, the overwhelming majority of clients are Thai men, not foreign tourists.

When it was no longer socially acceptable for Thai men to have more than one wife, the habit of frequenting brothels became an accepted practice. A Thai man who does not visit commercial sex workers after the age of fifteen is not considered a man. By the time they reach the age of nineteen, more than 90 per cent of Thai men frequently interact with commercial sex workers. Visiting brothels is a socially accepted activity, usually preceded by an all-male evening of dining and drinking. This custom crosses all social and economic boundaries. A tacit, fundamental national belief exists that men and women have differential sexualities. Men are seen as needing sex and a variety of sexual partners. Women are expected to remain virgins until marriage and assumed not to have sexual needs or to enjoy sex.

Sex is rarely discussed between men and women. While women often joke about men's "bad habits" among themselves, most accept this behaviour and consider it preferable to the potential rivalry of an additional wife. In the context of the Thai male's demand for an industry that ensures the availability of sex outside traditional relationships with women, HIV is clearly a cultural issue.

There are both economic and cultural reasons for the overwhelming numbers of Thai women now working as sex workers. The national development policies of the past thirty years have led to rapid, but geographically uneven, economic growth. The resulting decline of agriculture and the disintegration of rural society have caused economic hardship and cultural changes. Migration rates have soared as young people move to urban areas in search of jobs that will enable them to send money home to their parents.

Thai Buddhist culture stresses the importance of loyalty to parents. Sons can show filial gratitude by becoming monks but no similar spiritual solution exists for daughters. Tradition demands that they provide for the needs of their parents and families. Young rural women, newly arrived in the cities, have little access to well-paid employment. Commercial sex work is by far the most lucrative job that a woman with low-level education can find.

As rural impoverishment intensifies and the demand for consumer goods among villagers grows, the sex work industry continues to expand, and with it the spread of HIV. Thus the epidemic in Thailand is also a development issue.

Today many NGO's throughout Thailand are focusing on HIV, attempting to fill the gaps in public services by providing education, counselling and support systems. The Duang Prateep Foundation (DPF) was one of the first to address the issue.

At the Foundation we recognize that although HIV and AIDS are international problems, the issues surrounding HIV transmission and medical treatment vary across local and national boundaries. It is in this light that we wish to share the experience of our community-based development organization as we work to fight HIV in Klong Toey, Bangkok's largest squatter community.

Klong Toey

Bangkok has a population of approximately 9 million, representing more than a tenth of Thailand's total population. It is estimated that 20 per cent of Bangkok residents live in illegal squatter settlements. Klong Toey, which is located next to the harbor on swampland belonging to the Port Authority of Thailand, has existed for more than forty years. Approximately 60,000 of Bangkok's low-paid workers have built homes here that are accessed by a network of wooden boardwalks traversing swampland and rubbish heaps. The people mainly live in extended family groups organized along the lines of a traditional village.

Klong Toey is divided into eighteen subcommunities, each with an elected council that receives limited recognition from public authorities. The residents are always vulnerable to eviction. Overcrowding strains such basic services as drainage and refuse collection and threatens the safe-water supply.

Both within and outside the community, the residents are almost universally regarded as second-class citizens with no hope of improving their circumstances. Persuading them to abandon this view of themselves is essential to any form of community action or education.

The easy availability of drugs around the port and a desire to escape the harsh realities of Klong Toey life have contributed to a high incidence of drug use. The Duang Prateep Foundation first became aware of the presence of HIV in Klong Toey in May 1988, when injecting drug users attending the foundation's Freedom From Drug Abuse Programme were tested. Thirty-six per cent were found to be HIV-positive.

Initially we thought that HIV in Klong Toey would be too large for a non-governmental organization to manage. However, the lack of government response to HIV and our unique position in the community coupled with a sense of responsibility to those around us, led us to establish the HIV project.

The philosophy behind our project reflects not only our commitment to community-based action but also a realization that Thailand's medical system is ill-equipped to cope with the morbidity and mortality associated with this epidemic.

Any campaign to mitigate the effects of HIV must focus on preventing transmission and on promoting social acceptance of people living with HIV. Moreover, since habitual male recourse to commercial sex services puts every member of society at risk of infection, we regard HIV as a social, rather than a medical, problem. The project's aims are to teach people how to protect themselves and their families from infection; to promote understanding, not fear, of people living with HIV; and to provide practical assistance that will enable them to live in a supportive community.

After ensuring that our own staff was fully informed about HIV, we first held street parades with educational messages displayed on floats and banners, and prevention slogan competitions in local schools. Most of our educational activities have been aimed at teaching injecting drug users, their families, and commercial sex workers how to protect themselves and how to pass this information on to others.

We started with injecting drug users focusing on prevention by offering counselling and general information about HIV, AIDS, safe-sex and needle sterilization, as well as health checks, blood tests, free condoms, and bleach to decontaminate needles and syringes.

An educational campaign aimed at commercial sex workers in the community was launched in September 1990. As with injecting drug users, most of the commercial sex workers are known to us via our networks in the community, and we visit them where they work.

We have secured the cooperation of brothel owners and local police in encouraging women to attend our information seminars and have recruited two female commercial sex workers for further training as peer educators. Despite the Duang Prateep Foundation's urging that men who refuse condoms be turned away, many prostitutes cannot afford to do so. Studies in Chiang Mai and Ratchaburi provinces indicate that brothel policies of "no condom, no sex" can be successful if they have police support and if every brothel in the province adheres to them. Nor can those who know they are infected afford to stop working.

Strict Thai social rules concerning status and respect place a commercial sex worker at the bottom of the social scale and usually leave her powerless to insist on condom use. Meanwhile the male customers, who refuse condoms and even sometimes offer to pay more for unprotected sex, have been exempt from criticism.

We thus decided to make male customers the focus of our next campaign, starting with the young men who provide cheap motorcycle taxi service around the area. Seventy-three per cent of the 489 questioned visit commercial sex workers regularly. Not only are they at risk of infection but so too are their male passengers.

Eighty-seven drivers attended the first training session in December 1990 and were taught how to protect themselves from infection and how to pass on safe-sex messages to their customers. They were also issued brightly-coloured vests bearing our anti-HIV logo, to raise public awareness.

Education for the entire community, especially via peer groups, is the focus of our current campaign. Because Klong Toey residents often feel marginal and disconnected from the rest of society, they are inclined to believe that information "from above" or from outside the community is not truly applicable to them. The peer group approach is therefore more successful, because it helps people to relate the information to themselves and their lives.

We actively seek volunteers from the community. We began with fifteen mae bahn (housewives), who attended information sessions and shared what they learned with friends and neighbors. We are also sending mobile teaching units door-to-door to ensure that information is disseminated throughout the community, not just to those who choose to obtain out.

Currently, most people living with HIV are still asymptomatic and some are reluctant to acknowledge their illness. We have expanded our work to assist them in coping with life with HIV. People practicing high-risk behaviours identified via community contacts, receive home visits from volunteers and offered counselling and support.

Indifference to HIV, despite local and national education programmes, is still the prevailing attitude. Even those who are fully informed about the disease, its transmission and eventual symptoms do not, on the whole, perceive themselves to be at risk and have not modified their behaviour. Among the men, peer pressure to "be manly" and reluctance to change habits are still stronger influences on behaviour than fear of HIV. The widespread belief that the

King's daughter (currently involved in HIV research) or foreign doctors will soon find a cure also diminishes fear.

It is possible that people will take HIV more seriously once they see many members of the community falling ill and dying. Today more immediate threats, such as eviction, fire, unemployment, and more common illnesses such as hepatitis, take priority.

The biggest challenge we face in our work is winning and maintaining the trust of injecting drug users and commercial sex workers. Their experiences with other agencies tend to make them suspicious of everyone except their peers. When our need for data in planning the project led us to accept outside assistance, we experienced comparable problems and attitudes. The aims of academic researchers did not always coincide with ours and their inappropriate and intrusive questioning damaged our relationship with the Klong Toey population. We are working hard to restore trust within the community, and we now treat data collection more cautiously.

Being singled out for questioning on serious and personal issues is a disturbing experience for most Thais, putting him or her in an inferior or defensive position. The Thai concept of kreng jai, an awareness of social hierarchy, and one's own place in it, combined with the desire to please or placate one's superiors, dictates that often answers will be tailored to please the interviewer rather than express the interviewees true thoughts.

Because we do not wish to subject members of the community to a demeaning experience, nor damage our relations with them, our information is gathered through informal interviews, stories and impressions collected by project workers.

The Foundation's efforts will continue to focus on education. We will also continue to develop appropriate teaching materials. These are the key to our efforts although some of the existing materials are not as effective as we would like. Our aim is to educate everyone in the community to protect themselves and to accept people living with HIV. We wish to encourage and support families in the community who are taking care of their members and we plan to open a community support center to provide education and counselling for families of people living with HIV.

At the Duang Prateep Foundation we believe that our resources are best utilized in educational campaigns. Other agencies, with appropriate expertise and funding, must assume the responsibility for providing financial aid and medical assistance to an ever-increasing number of us who are infected with HIV.

What of Tomorrow?

Within the Klong Toey community, we expect an increasing incidence of people with AIDS in the next few years, as injecting drug users, whose immune systems are already weakened, begin to display symptoms. In the near future more people, including commercial sex workers and their clients, will also need medical attention. We foresee that housewives and the babies they subsequently bear will soon be severely affected by the virus.

We have no way of knowing when large numbers of mothers and infants will begin to show symptoms, nor to what extent our prevention programmes have protected them. Thailand may mirror the experiences of some African countries, with equal numbers of men and women contracting the virus, a high rate of perinatal infection and many children left parentless.

The economic implications of the epidemic in Thailand are appalling. The cost in terms of lost productivity will be massive as the virus takes its toll on Thais of working age. Perhaps the worst effect will be when investors begin to lose confidence in Thailand and its future. Foreign investment, tourism, and demand for Thai labour abroad may decline if Thailand is seen to have a large HIV-positive population. The impact of an economic recession on Klong Toey would be enormous because poor areas are invariably the first to suffer.

The financial strain on the health-care system will increase yearly. By the year 2000 more than 500,000 Thais may die of HIV-related illnesses and many more will be ill. The health-care system is obviously ill-equipped to handle an epidemic of this scale. The generally poor level of health and sanitation throughout the country, especially in the slum areas, leads us to expect that the life expectancy of people living with HIV in Thailand will be low.

Family and community ties have always been strong in Thailand, and this is highly evident in Klong Toey. The economic hardship and social discrimination that people living with HIV and their families may face will pose a severe strain on these ties. In Klong Toey, care for those diagnosed with AIDS will, in most cases, be provided by the family, which may face a seriously lowered standard of living. The wage-earning capacity of the ill person and his or her family custodian will be lost, with severe consequences for families already struggling to survive.

Women, as traditional caregivers, will be the most heavily burdened. Support will be needed for the parentless children who are infected and for their healthy siblings, as well. In many instances, grandparents or other relatives will raise them, but others will become street children, unless alternative caregivers can be found.

The Thai tradition of the extended family may be threatened by the epidemic, separating people spiritually and socially, and turning a caring society into a scared society. To avoid the breakdown of these ties, building community acceptance and understanding is important.

Buddhism teaches tolerance of others and compassion for the sick. It will be important for the Sangha (our highly respected Buddhist monkhood) to take an active part in promoting a supportive attitude towards people who are HIV-positive.

Eighteen of the most prominent NGO's have formed a coalition known as the Thai NGO Coalition Against AIDS. Many of the members of this coalition believe that commercial sex work must be legalized in order to stop the spread of HIV. Absolute enforcement of the use of condoms will be possible only if brothels are under strict government control.

The key to halting the spread of HIV in Thailand does not lie in discouraging men from visiting brothels. Behavioural change on such a large scale involves changing the fundamental nature of relationships between men and women. It would simply take too long. In the short term, the epidemic must be stopped by encouraging men to use condoms. All sexually active women must be empowered to insist that men wear condoms. Sex education, including information on safe sex practices, must be offered in the schools and through public education campaigns. New employment opportunities must be made available to Thai women as alternatives to commercial sex work. The roots of the epidemic lie in Thailand's socioeconomic structure, and it is there that solutions must be found.

Biographical note

Prateep Ungsongtham Hata was born and raised in Klong Toey. Recognizing that education could transform the lives of children and lead the way to development in poor communities, she established a school in her community. She was a winner of the Magsaysay Award in 1978 for her work, she used the proceeds to establish the Duang Prateep Foundation, which has become a major force for slum development in Thailand. The foundation's HIV and AIDS project is a community-based programme run by local volunteers. This article was written with the assistance of Julia V. Bindman, a former DPF volunteer, and Jenny Godley, a former DPF staff member.