Young People and HIV/AIDS Young People at the Centre of HIV/AIDS Epidemic The population of Thailand was estimated to be about 62.5 million in 2004 with 27% in the 10-24 year age group1. According to estimates, the HIV prevalence among young people aged 15-24 years was 0.88% among males and 1.32% among females (Figure 1) . Percent
Figure 1: HIV prevalence among youth (2001) 1.4 1.2 1 0.88 1.32
Thailand was the first country in Asia to document the HIV/AIDS epidemic. According to the 2006 UNAIDS report the number of people estimated to be living with HIV in 2005 was 580 000 (330 000 – 920 000). The adult
0.8 0.6 0.4 0.2
Table 1: Reported AIDS cases by age group (September 1984-April 2005) Age group (in year) 0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60 + Male 4 289 1 460 222 963 14 198 47 563 52 251 34 213 18 110 9 137 4 289 2 280 2 914 Female 3 779 1 348 334 1 174 10 512 20 479 17 080 10 383 5 837 2 997 1 383 780 731
0 Male Youth (15-24 years) Female
Source: Health related Millennium Development Goals 2005, WHO.
fishermen and male STD clients3. HIV prevalence among pregnant women has declined from 2.35% in 1995 to 1.18% in 2003. HIV prevalence has also decreased among military conscripts from 4% in 1993 to 0.5% in 2003 (Table 2).
Table 2: HIV prevalence in selected high risk groups (2003) High risk groups Injecting drug users Female direct sex workers Male sex workers Fishermen Male STD clients HIV Prevalence 33% 10.87% 7.90% 6.86% 4.0% 3.67% 1.18% 0.5% 0.27%
Source: Bureau of Epidemiology, MoPH, Thailand, 2005.
HIV prevalence was 1.4% (0.7% - 2.1%)2. The number of reported AIDS cases in the age group of 10-24 years (Table 1) was more than 10%. Data from sentinel surveillance system indicates high HIV prevalence among injecting drug users, direct and indirect female sex workers, male sex workers,
Female indirect sex workers Pregnant women Military conscripts Blood donors
Source: Epidemiological fact sheets on HIV/AIDS & STIs, Thailand, UNAIDS, UNICEF, WHO 2004 update
Thaileand Option 2.pmd
1
11/22/2006, 12:56 PM
THAILAND 1
Fact Sheet
THAILAND
The first case of AIDS in Thailand was reported in September 1984. HIV originally spread within groups that engaged in risk behaviours. Currently, however, the disease has been transmitted to the general population and the rate of spread is highest among young people and women4.
Table 3: Cumulative number and percent of young people’s death due to AIDS (November 1984 – 31 December 2003) Sex No. of YP* cases 3 790 2 823 6 613 Percent Total deaths due to AIDS 47 370 16 129 63 499 * Young People
Male Though past efforts to control HIV have shown a measurable success in reducing the rate of infection, AIDS is one of the major causes of death among Thai young people (Table 3). Female Total
8.0 17.5 10.4
Source: Bureau of Epidemiology, Department of Disease Control, Thailand
Young People Are Vulnerable to HIV & STIs Currently, the primary modes of HIV transmission in Thailand include sexual transmission, unsafe injection practices and vertical transmission. Of the AIDS cases reported till 2003 with a known route of transmission, heterosexual contact accounted for 88%, followed by injecting drug use (6%) and perinatal transmission (5%)3. Percent 25 20 15 10 5 · · · · · ·
Figure 3: Percent of STI patients by age group (October 1999 - September 2004)
Figure 2: Rate of STI cases reported per 100 000 population by age group
0 <15 15-19 20-24 25-29 30-34 35-39 40-44 45> Age group (in years)
2000 5.4 6
2001
2002
2003
2004
>44
7.7 10.1 8.1 20.2 18.2 22.3 26.7
Source : STIs Cluster, Bureau of AIDS, TB & STIs, Department of Disease Control, Ministry of Public Health Thailand (2000-04).
40-44
31.5 28 24.7
The predominant mode of transmission of both HIV and STI is sexual intercourse. Increasing sexual risk 48.3 45.5
35-39
31.2
Age group (in years)
behaviours among young people increases their 52.9
30-34
34.8 30.7
42.6
vulnerability to sexually transmitted infections. The 57.8
25-29
35.1
41 48 53.2 55.7 53 54.7 56.5 61.9
presence of an STI increases the risk of HIV transmission manifold. Evidence of increasing risk of young people to HIV includes the progressively lower age of those attending STI clinics (Figure 2,3). In 2003 young people with sexually transmitted diseases accounted for almost one third (31.7%) of the total number of STD cases reported. The proportion of gonorrhoea cases found among 15-19 year olds
20-24 27 26 24.1 23.6 1.9 1.4 1.9 2 1.7 42
45
15-19
< 15
0 2000
10
20
30
40
50
60
70
increased from 8.39% in 2001 to 16.67% in 2004. While only 3% of new STI cases were reported among students in 2000, the figure had increased to more than 10% by 20045.
2001
2002
2003
2004
Source: Summary data fromAnnual Report (2000-04) STI Cluster, BATS, Thailand.
2
Thaileand Option 2.pmd
2
11/22/2006, 12:56 PM
Effective STI services were a key element in the early and rapid success of Thailand’s response to HIV. However, the increasing proportion of new STI infections among youth that makes them more vulnerable to HIV indicates that there is an urgent need
to strengthen efforts towards preventing, diagnosing and treating STIs in this age group. Special attention is also needed for the especially vulnerable young people who are at risk of adopting high-risk sexual or drugusing practices.
Many Young People Are Especially at High Risk Girls and young women New epidemic trends in the country reveal increasing levels of HIV/AIDS among women. This is evident from Thailand’s changing HIV epidemic scenario where the transmission of the virus is affecting a diverse population. or regular partnerships where condom use tends to be very low7. Along with biological vulnerability, the socio-cultural and economic disadvantages faced by girls and young women greatly increase their risk of contracting HIV. They have limited access to reproductive health services and gender power imbalances often prevent them from insisting on adopting prevention methods such as condoms in their relations with their sexual partners. 1990-91 90 5 5
Figure 4: Estimated percent of new HIV infections in Thailand showing changing mode of transmission
Young sex workers HIV prevalence among direct female sex workers was found to be 10.87% at the end of 20033. The main factor responsible for the explosive spread of HIV in the late
Years
2000-01
15 50 20 15
1980s and early 1990s in Thailand was sex work. An effective national response resulting in high levels of condom use in commercial sex and rapid control of sexually transmitted infections (STIs) marked the turning point that was effective in changing the risk behaviour patterns in the country resulting in the percentage of adult men visiting female sex workers falling from 25% to 10% annually. The use of condoms with sex workers also reached consistent levels 8. However, there are indications of a rising number of STI cases among sex workers and an increase in the numbers of indirect sex workers who are out of reach of prevention efforts. In Bangkok alone, an estimated 34 000 women were trading sex in non –brothel settings such as massage parlours in 20037. Consequently, the epidemic threatens to regain momentum in vulnerable populations such as young sex workers.
0
20 Sex worker
40 Spouse
60 IDU th
80 MTCT
100
Estimated percent of new HIV infections
Source: Report on the global AIDS epidemic, 4 Global report, UNAIDS, 2004
Figure 4 shows the changing mode of infection in Thailand with heterosexual transmission of HIV in cohabiting partners increasing dramatically over HIV transmission through sex work. Marriage and other long-term monogamous relationships do not protect young women from HIV. A 1999 study in Thailand found that 75% of HIV infected women were likely to be infected by their husbands. Nearly half of these women reported sex with their husbands as their only HIV risk factor6. Male clients of sex workers also infect their wives and girlfriends, as a result of which as many as half of the new HIV infections each year occur within marriage
Young men who have sex with men (MSM) In 2003, Thailand’s Ministry of Public Health surveillance reported 20% HIV prevalence among male sex workers. The TUC (Thai MoPH –U.S. CDC Collaboration) Bangkok study in 2005 reported HIV
Thaileand Option 2.pmd
3
11/22/2006, 12:56 PM
THAILAND 3
THAILAND
infection rates of 22.6% among freelance male sex workers and 15.4% among venue-based male sex workers . Though age-specific data on young men who have sex with men (MSM) is unavailable, recent studies indicate signs of increased HIV infection among men having sex with men in Thailand. Between 3.3% to 16.0% of Thai males report having had some kind of same sex sexual experience in commercial or non commercial setting . A recent study in Bangkok found 17% MSM to be HIV-positive and that one quarter of them had sex with women as well . Since many MSM also buy and sell sex along with having sex with women, the potential for HIV transmission within and beyond MSM social networks is high. Marginalization and discrimination also inhibit HIV prevention services to reach MSM making them more vulnerable. 7 5 5
the Central and Southern Regions. It has been estimated that as many as one-fifth of new HIV infections in the past 10 years has been due to unsafe modes of injecting drugs7. Findings of the 10th round of the National Behavioural Surveillance (2004) revealed the presence of drug and substance abuse among secondary school students with a higher percentage of young males using drugs as compared to females of the same grade (Figure 5). In 2001, a study of 46 936 students in all types of educational institutions found that the main reasons for student involvement with drugs were curiosity, peer pressure, lure of a trendy practice and family problems coupled with lack of awareness of the consequences. Besides, students were able to obtain these drugs easily. Young female drug injectors too were found to be engaging in risky sexual behaviours along with the sharing of needles. High rates of unprotected sexual activity and multiple partnerships were also reported (Figure 6).
Young injecting drug users (IDUs) Use of contaminated injecting equipment to inject drugs is a highly efficient mode of HIV transmission which has played a major role in the spread of Thailand’s HIV epidemic. HIV prevalence among injecting drug users remained highest in Thailand at 33% nationally in 2003 and poses a major challenge to the control of the virus. Recent findings show that HIV prevalence in drug injectors has risen in every region of Thailand over the past years reaching 61% in the
Figure 6: Profile of young female drug users in Northern Thailand admitted to drug treatment centres (1999-2000)
30 5
Criteria
Northern Region and 45% or higher in Bangkok and
47 83 80 24
Figure 5: Drug and substance use among 2nd year (8th grade) secondary school students, 2004 2.5
0 10 HIV positive
20
30
40
50
60
70
80
90
Percent Ever used condom < 25 years IDU Multiple sex partners 2 1.5 1 0.5 0
Sharing needles
Percent
Source: “Women who use drugs and their HIV risks in northern Thailand”. Srirak, Namtip, et.al., 2001. Sixth International Congress on AIDS in Asia and the Pacific, Melbourne, Australia a Krat om m mine ijuan Ecst ac inne Opiu bsta n ces rs y
heta
Mar
/ Th
Glue
er Su
amp
High HIV prevalence among injecting drug users for nearly two decades has increased the need for HIVrelated services. Established guidelines for management of HIV infection for IDUs and no specialized services providing Anti Retroviral Therapy (ART) in tandem with drug dependence treatment services are required.
Meth
Males
Females
Source: Bureau of Epidemiology, Department of Communicable Disease Control, Ministry of Public Health. Report on the HIV/AIDS Situation in Thailand, 2004
4
Thaileand Option 2.pmd
4
Oth
11/22/2006, 12:56 PM
Other young people especially vulnerable to HIV/ AIDS in Thailand include streetchildren, young people from ethnic minorities, mobile and border populations,
young people from slum communities, and those in remote rural communities.
Why Young People Are More Vulnerable Early initiation of sexual activity Recent data from the National Behavioural Surveillance among secondary school students (2004) indicates that young men and women in Thailand are initiated early into sexual activity. The average age of first sex among sexually active 8th grade students was 13 years for both Percent 14 12 10 8 6 4 2.9 3.5 0.8 1.3 1.4 1.8 5.2 13.2
Figure 8: Partner types of sexually active male secondary school students in 2004
boys and girls (Figure 7).
Figure 7: Average age of first sexual encounter among sexually active 2nd year (8th grade) secondary school students, 2004 14
2 13 13
0 8th grade male students Female sex worker Other women
Age in years
12 10 8 6 4 2 0 2004
11th grade male students Girlfriend or lover Other males
Source: Bureau of Epidemiology, Department of Communicable Disease Control, Ministry of Public Health. Report on the HIV/AIDS Situation in Thailand, 2004
premarital and casual sex among young Thai men and women, compared to earlier generations6. Adolescent Females
Males
boys and girls also engage in risk behaviours more frequently than their peers did a few years ago, thereby exposing themselves to HIV infection5.
Source: Bureau of Epidemiology, Department of Communicable Disease Control, Ministry of Public Health. Report on the HIV/AIDS Situation in Thailand, 2004
The most common reported sexual partner by sexually active male students were their girlfriends followed by casual partners and female sex workers. Homosexual relationships were also reported by both the eighth and eleventh grade students (Figure 8). National Behavioural Surveillance data from 1996 to 2004 shows a significant rise in the proportion of secondary school students who are sexually active (trends for both male and female students of 5 year of secondary school are shown in figures 9-10). Another study among vocational students in Chiang Rai province revealed that while 7% of the young men surveyed bought sex almost half of both male and female students were sexually active . Results of other studies also reveal an increase in 6 th
Figure 9: Sexual behavior of 5 year th (11 grade) male secondary school students classified by year and partner type 14 12 10
th
Percent
8 6 4 2 0 2001 1998 1996 1997 1999 2000 2002 2003 2004
* Female sex worker Girlfriend or lover
*
Other women Other males
Source: Bureau of Epidemiology, Department of Communicable Disease Control, Ministry of Public Health. Report on the HIV/AIDS Situation in Thailand, 2004
Thaileand Option 2.pmd
5
11/22/2006, 12:56 PM
THAILAND 5
THAILAND
Figure 10: Sexual behaviour of 5 year th ( 11 grade) female secondary school students by year and partner type 4 3.5 3
th
Young people lack informations and skills Most young people have heard of HIV/AIDS in Thailand (91%)10. However, National Surveillance (2004) data among secondary and vocational students show that less than 20% of both male and female students of secondary and vocational schools could answer all questions about HIV/AIDS correctly (Figure 12).
Percent
2.5 2 1.5 1 0.5 0
1996
1997
1998
1999
2001
2000
2002
2003
2004
Figure 12: Percent of 5 year* secondary and 2nd year* vocational school students answering all questions about HIV/AIDS correctly, 2004 25 20 14.9 16.2 14.3 19.3
th
Boyfriend or lover
Other male
Source: Bureau of Epidemiology, Department of Communicable Disease Control, Ministry of Public Health. Report on the HIV/AIDS Situation in Thailand, 2004
Young people, especially girls and young women, are also more susceptible to coercive sex. National Behavioural surveillance (2004) data on 8 th
Percent
15
10
grade 5 2004
secondary school students reveals that the first sex experience for 50% girl students was forced (Figure 11). Violent or forced sex also increases the risk of transmitting HIV as forced vaginal penetration commonly causes cuts that allow the virus to cross the vaginal walls more easily. Another survey conducted among 6 700 female students across 24 provinces of Thailand found 1 448 of them to be already sexually active. About 500 female students reported that their first sex experiences were forced and that these first time partners were mostly older men while 80 students admitted to having more than 20 casual partners9.
M (VSS)* F (VSS)^
M (SSS) F (SSS)
* 11th grade
Source: Bureau of Epidemiology, Department of Communicable Disease Control, Ministry of Public Health. Report on the HIV/AIDS Situation in Thailand, 2004 * VSS - Vocational school student ^ SSS - Secondary school student
Recent surveillance assessing risk behaviours vis-à-vis HIV infection show that Thai youth continue to engage in risky sexual practices. These include high rates of unprotected sexual activity among sexually active youth, with consistent use of condom being lowest with steady partners and other males (Figure 13).
Figure 11: First sex of sexually active 2 year* female secondary school students, 2004 80 70 60 50 50 66.7
nd
Figure 13: Condom use among sexually active male secondary school students classified by partner type, 2004 60 50 51.3 43.1 37.5 33.3 25.7 38.3 27.3
50
Percent
40 30 20 10 0 *8th Grade female students With boyfriends or lover Involuntary
Percent 6
40 30 20 10 0
Source: Bureau of Epidemiology, Department of Communicable Disease Control, Ministry of Public Health. Report on the HIV/AIDS Situation in Thailand, 2004
8th grade male 11th grade male students students With female sex worker With other women With girlfriend or lover With other males
Source: Bureau of Epidemiology, Department of Communicable Disease Control, Ministry of Public Health. Report on the HIV/AIDS Situation in Thailand, 2004
6
Thaileand Option 2.pmd
11/22/2006, 12:56 PM
The trends show that over a period of time condom use by young males has gone down even with highrisk partners such as female sex workers. Condom use by sexually active male secondary students with female sex workers was 73.9% in 1996 but had come down to 43.1% by 2004. Use of condom was less than 40% for all other partner types as well (Figure 14).
Figure 15: Condom use among sexually th th active 5 year (11 grade) female secondary school students classified by year and partner type 18 16 14
Figure 14: Condom use among sexually active th th 5 year (11 grade) male secondary school students classified by year and partner type 80 70 60
Percent
12 10 8 6 4 2 0
* 2001 2003 1999 1998 2000 1997 2002 2004
Percent
1996
* * *
*
*
*
*
50 40 30 20 10 0 1997 2001 2000 2002 1996 1999 2003 1998 2004
With boyfriend or lover
*
With other males
*
Source: Bureau of Epidemiology, Department of Communicable Disease Control, Ministry of Public Health. Report on the HIV/AIDS Situation in Thailand, 2004
poorly informed about the consequences of unsafe sex. At times they also lack the skills to say no to unwanted sex or to negotiate safer sex. Sometimes awareness and knowledge of risks does not translate into safe sexual behaviour due to a variety of factors like social norms, lack of education or unavailability of services consistent with their needs. This results in exposing young people to HIV. Issues identified by young people themselves include increased access to information about HIV/AIDS, especially that which is consistent with their needs. Young people also want to acquire life skills to protect themselves from infection with HIV or to live better with HIV. They need access to services, such as counselling which is friendly, and condoms5. With female sex worker With girlfriend or lover With other women With other males
Source: Bureau of Epidemiology, Department of Communicable Disease Control, Ministry of Public Health. Report on the HIV/AIDS Situation in Thailand, 2004
*
Condom use patterns among sexually active 11 grade female secondary students show almost negligent use with males who are not boyfriends and less than 18% use with boyfriends (Figure 15). Another study in Northern Thailand revealed that less than one third of all the young men who reported buying sex said they always used condoms7. Young people adopt risky behaviours as they are often
th
Focusing on the Young to Halt the Spread of HIV/AIDS HIV prevention and control was declared a national priority in Thailand in 1991. Several important steps have since been taken to help slow the epidemic and the reduction in STIs and HIV prevalence is evident in nearly all monitored population groups. The initiatives taken by the government include: · Massive public information campaign on HIV/ AIDS: Anti-AIDS messages aired every hour on the country’s 488 state-owned radio and television · stations, and every school required to include information on HIV/AIDS in its curriculum. ‘100 percent condom program’: This programme aimed at enforcing consistent condom use in all commercial sex establishments. Condoms were distributed free at brothels and massage parlours and sex workers and their clients were required to use them. The second “National Plan for Prevention and
Thaileand Option 2.pmd
7
11/22/2006, 12:56 PM
THAILAND 7
THAILAND
Alleviation of the AIDS Problem” which covered the period from 1997 to 2001, continued with the previous effective programmes, while adopting a more holistic approach which included mobilizing the efforts of communities and people living with HIV/AIDS. The third “National Plan for the Prevention and Alleviation of HIV/AIDS in Thailand” (2002-2006) was launched in end-2001, and continues the work of the previous National Plan (1996-2001). There are three specific targets in relation to this plan. · To reduce adult HIV prevalence to less than 1% by the end of the Plan period. · To provide access to care and support for at least 80% of the people living with HIV/AIDS and other affected individuals, and · To enable local administrations and community organisations throughout the country to both plan and carry out work on HIV/AIDS prevention and alleviation. Thailand has achieved a substantial success in controlling the spread of HIV/AIDS with the number of new infections falling progressively each year due
to effective interventions in high- risk commercial sex settings. However, recent HIV and behavioural data suggests that currently the most important source of new infections is from HIV-positive men, many previously infected through commercial sex, to their wives, followed by injecting drug users. Increasing sexual and drug-using risk behaviours among young people continue to increase their vulnerability and provide conditions that could support a resurgence of HIV in the country. Different strategies are needed to reduce this evolving epidemic5. Key strategies have been identified by the government as a priority in tackling the HIV/AIDS epidemic: · Individuals, families and community organizations to be made aware of the role they play in the prevention and alleviation of HIV/AIDS. · Health and social welfare services will be established for the prevention and alleviation of HIV/AIDS. · Knowledge and research will be developed along with international cooperation. · A management system will be developed to integrate the tasks of HIV/AIDS prevention and alleviation.
References: Mahidol University. Mahidol Population Gazette volume 15, 2006. Nakhorn Pathom: Institute for Population and Social Research, 2006. (Accessed 13 October 2006, http://www.ipsr.mahidol.ac.th/content/Publication/GAZETTE.HTM). 2. 2006 report on the global AIDS epidemic, a UNAIDS 10th anniversary special edition. Geneva: UNAIDS 2006 3. World Health Organization. Epidemiological factsheets on HIV/AIDS & STIs. Geneva, 2004 (Accessed 13 October 2006, http://www.who.int/hiv/pub/epidemiology/pubfacts/en/). 4. Chitwarakorn A. National Plan for the Prevention and Alleviation of HIV/AIDS in Thailand, 2002-2006. Bangkok: Ministry of Public Health, Department of Communicable Disease Control. (Accessed 10 October 2006, http://www.aidsthai.org/download/ PlanAIDS02061.doc). 5. External review of health sector response to HIV/AIDS in Thailand. New Delhi: World Health Organization, Regional Office for South-East Asia and Bangkok, 2005. (Accessed 10 October 2006, http://w3.whosea.org/LinkFiles/ News_and_Events_ThailandProgrammeReviewNEW.pdf#search=%22external%20review%20of%20health%20sector% 20response%20to%20HIV%2FAIDS%20in%20thailand%22). 6. Report on the global AIDS epidemic. Geneva: UNAIDS, 2004. (Accessed on 10 October 2006: http://www.unaids.org/bangkok2004/ GAR2004_html/GAR2004_00_en.htm). 7. AIDS epidemic update: December 2005. Geneva: UNAIDS / WHO, 2005. (Accessed 13 October 2006, http://www.unaids.org/epi/ 2005/doc/ EPIupdate2005_pdf_en/epi-update2005_en.pdf). 8. HIV/AIDS in Asia and the Pacific Region. New Delhi: World Health Organization, Regional Office for South-East Asia and Regional Office for the Western Pacific Region, 2001 ( Accessed 13 October 2006, http://www.wpro.who.int/publications/ pub_9290611642.htm). 9. Situation review on adolescents and HIV/AIDS in East Asia and Pacific. UNICEF, June 2005. 10. Young people and HIV/AIDS: opportunity in crisis. Geneva: WHO / UNICEF / UNAIDS, 2002 (Accessed 13 October 2006, http://dosei.who.int/uhtbin/cgisirsi/CTKjpta8sz/55780007/9). 1.
8
Thaileand Option 2.pmd
8
11/22/2006, 12:56 PM