Intimate Partner transmission of HIV

Thailand
This summary is based on research undertaken by Plurpol Consulting (1) for UN Women. Updated statistics and references are cited as appropriate.

In Thailand, where HIV prevalence is estimated to be 1.20% [1.10% - 1.20%] (2) an estimated 38.7% (6,399) of new infections are women infected through their husbands while 9.6% (1,578) of new infections are men who were infected via their wives (3). The National HIV Plan 2007-2011 identified women at risk of infection from their from husband/regular partner and promoted them as target for HIV prevention programme development. Programme coverage included the national prevention of mother to child transmission response and sex education in schools. Within Thailand, UNFPAs Stay Negative campaign is a good example of a programme that targets women in relationships. To date the programme has not yet expanded to national coverage but has the potential to impact on a significant number of women. While this initiative targets women who interact with mother and child hospitals, a comprehensive programme aimed at women in relationships will need to reach women before they become pregnant and present themselves at pre and antenatal care clinics where service-provider initiated testing takes place.

Womens status in legislation

Thailand has comprehensive legislation and therefore has the advantage of promoting the rights of women in a wide range of areas. A disadvantage to this more broad and complex legislative framework is that previously genderflawed legislation was pervasive in legal language and wider societal attitudes. The year of 2006 saw many of these gender-biased laws amended and, as with all changes in legislation, it will take time to see new approaches become part of societal norms. From the perspective of the in-country researchers the policy and practice of the health service in particular continue to promote a morally polarized view of women. This demonstrates the need for capacity building among service providers to not only to help them understand the legislative framework, but also to give health workers the skills to provide an equitable service without prejudice to all members of society.

of infection coming forward for testing and treatment. There appears to be an increase in the reluctance of sex workers, drug users and men who have sex with men in accessing these more mainstream services. These services also need to support people to come for testing with their partners, and help people living with HIV to disclose their status to their partners.

Vulnerability to HIV transmission among women in relationships

Gender inequality is a pervasive theme throughout the analyses of all three countries. In Thailand gender expectations of women and men are perhaps less pronounced on the surface but there is an underlying moral polarization of women. The expectation (or acceptance) that men will have many partners creates a paradox if women are expected not to have sex, and therefore creates a demand for sex workers in all three countries. The HIV prevention response needs to be continually updated to take account of changing behaviour patterns and new understandings of societal factors which have the potential to increase HIV transmission. Even in Thailand where there is confidence in the existing strategies, unforeseen consequences to changes in the health system structure are already being identified, namely the reluctance of most at risk populations to present to large hospitals for testing and treatment of STIs. Additionally the discrepancies between reported

Availability of treatment
Thailand has impressive coverage of prevention of vertical transmission programmes. Despite this, support to women to remain HIV negative, outside of the Stay Negative programme coverage, seems inadequate. Equally, there seems little programme response designed to reach women with information before they become pregnant. Further challenges lie ahead in monitoring

whether the changes in the health sector (especially the transfer of dedicated STI clinics to hospitals) produce any detrimental impacts of people most at risk

condom use of female sex workers and mail clients need to be further

understood. The differences may easily be explained: a sex worker who has sex without a condom with just one client may record her consistency at 99%, while man who has had sex without a condom with a sex worker once out of three encounters that his consistency at 66%. At the same time the generally punitive rather than protective approach to sex workers in Thailand may discourage their accurate self-reporting of actual levels of condom use. Low levels of condom use among couples are common throughout Indonesia, Laos PDR and Thailand. In all three countries the emphasis on condoms for sex workers has firmly associated them with infidelity and mistrust making a virtue impossible for men and women to suggest that their partners or spouse is using them. One strategy could be to promote condom is an alternative to hormonal contraception and permanent sterilization. The challenge that

The dual benefits of condoms to prevent both pregnancy and STIs are not widely recognized The practice of no sex during pregnancy legitimizes mens visits to sex workers or sexual relationships outside marriage Between leaving school and a womens first pregnancy there are few opportunities to reach her and her partner/husband with targeted sexual and reproductive health information

Men are likely to seek preventative and sexual health information and access services only after they are symptomatic and need treatment The 100% condom use campaign has not adapted to the changing epidemic, and clients report much lower condom use than sex workers (60% and 95% respectively)

The decentralization of the health system has resulted in STI clinics relocating to hospitals. Sex workers attend these relocated clinics less because of the perceived bureaucracy, waiting times, less sympathetic (i.e. trained) and specialist staff,

continues to exist with condom is that, as pointed out by the positive networks, sex is more pleasurable without a condom. All of the above discussion on condoms has focused on male condoms. The first generation of female condoms was distributed two female sex workers in Thailand but the general feedback was negative: they were considered noisy and a ring of their entrance uncomfortable to wear. As a result they have not been made widely available in any country and are more expensive to purchase and male condoms. New phases of the female condom are now available as it may be possible to introduce fees to married couples rather than sex workers to avoid the stigmatization that male condoms now suffer from. Stigma and discrimination continue around HIV and STIs, as does misinformation. In Lao PDR this translates as a relatively low level of knowledge, while in Indonesia myths seem pervasive and are closely linked to mens image of their masculinity and therefore their invulnerability to infections. The lack of information and the existence of misinformation put both men and women at higher risk of HIV and STI transmission.

Neither men nor women are empowered to prioritize their own or their partners sexual health needs Migrants and other non-Thai speakers are excluded from access to STI information, broader health services and legal protection

Bibliography
1. Kaybryn, Jo. Responding to the Feminization of AIDS: Women and Intimate

Partner Transmission of HIV, Indonesia, Laos PDR and Thailand. Bangkok :

UN Women, 2009. 2. UNAIDS. UNAIDS Thailand Profile. UNAIDS. [Online] 2012. [Cited: December 30, 2012.]

http://www.unaids.org/en/regionscountries/countries/thailand/. 3. NCAPA. The National Plan for Strategic and Integrated HIV and AIDS

Prevention and Alleviation 2007-2011. Bangkok : National Committee for HIV

and AIDS Prevention and Alleviation, 2007.

Summary of womens vulnerabilities to HIV transmission in Thailand

Mens unsafe sex with commercial partners and very low condom use within marriage/long term relationships The association of condoms with sex work create a barrier to both men and women requesting condom use with their partners

Plurpol Research Summaries 2012

For electronic versions of this and other briefings visit Plurpol Consulting www.plurpol.org or email policy@plurpol.org