Long a poster child for the global fight against HIV/Aids, Thailand has since the early ’90s championed successful condom-promoting campaigns that slashed transmission rates of HIV.
The Universal Coverage Health Scheme now provides all Thais who test HIV-positive with free anti-retroviral drugs irrespective of their immunity levels. Thailand will be one of the first developing countries to eliminate mother-to-child HIV transmission, and is now aiming to “end Aids” by 2030.
But the good news and ambitious goals paint only half the picture. The rate of new HIV infections is not falling fast enough. Currently about 8,000 people get infected every year. Almost a quarter of those already infected are not aware of their status, and, for years now, the number of annual Aids-related deaths has hovered around 20,000.
Last year, a report from by UNAIDS and the Lancet Commission warned governments of the risk of a dramatic rebound of the disease unless they accelerated prevention efforts over the next five years.
“We must face hard truths – if the current rate of new HIV infections continues, merely sustaining the major efforts we already have in place will not be enough to stop deaths from Aids increasing within five years in many countries,” said Professor Peter Piot, co-chair of the Lancet Commission.
The lead author of the report pointed out the importance of sustainable access to treatment, but emphasised that “we will not treat ourselves out of the Aids epidemic. We must also reinvigorate HIV prevention efforts, particularly among populations at highest risk, while removing legal and societal discrimination.”
Ending Aids requires effectively eliminating HIV transmission in all populations. During his recent Bangkok visit, UNAIDS executive director Michel Sidibé made it clear that, “Universalism is key. We must bring services to people regardless of their personal status.”
If any group is left behind in the prevention efforts, it’s only a matter of time before HIV once again explodes in the general population. Already there are worrying signs. Recent studies show HIV prevalence is increasing among certain populations. Among these is young men who have sex with men (MSM), none of whom witnessed the early days of Aids and are thus less likely to practice safe sex or get tested.
An important lesson learned after 30 years of the epidemic is that there’s no “one size fits all” solution. To be effective, a country’s HIV/Aids response must involve a complex programme, with different parts tailor-made to serve different sections of the population. It’s like juggling with several balls of different shapes and sizes in the air at the same time.
Although the Thai government’s hospital-based services may be adequate for serving the public at large, it’s the local non-governmental organisations that are actively extending the reach of HIV protection to the populations who are disproportionately affected by HIV and harder to access due to stigma and discrimination – namely, MSMs, transgender persons, sex workers, people who inject drugs, and migrant workers. These are the “tricky” balls that the government’s hand struggles to catch.
Emphasising the indispensable role of NGOs in reaching key affected populations, Sidibé said, “I don’t see any bureaucratic structures that will be able reach the community and work with them and integrate them. They are not designed for that. They are designed for people to come to them.”
But the future of Thailand’s NGO arm in HIV/Aids response is now uncertain. While the Thai government shoulders around 89 per cent of the country’s overall Aids-related expenses, it funds only about 14 per cent of the work among the key affected populations. The remaining budget overwhelmingly comes from external sources, especially the Global Fund to Fight Aids, Tuberculosis and Malaria (GFATM).
This source of support, however, will soon evaporate. Since Thailand rose to the rank of an upper-middle-income country in 2011, GFATM has indicated that it will soon pull its funding from the country to make way for a fully government-owned HIV/Aids response. The last round of GFATM support will finish at the end of this year, despite the fact that Thai-government support for NGO work among key affected populations is nowhere near sufficient and, worse, hindered by unhelpful laws and regulations.
With the Global Fund’s exit and the government’s lack of preparedness, the country’s HIV response will suddenly have to juggle with one hand tied behind its back, even as the balls are falling faster. Government-NGO coordination in HIV prevention that took years to hone will undoubtedly atrophy, leaving key populations vulnerable again.
This confluence of events couldn’t happen at a worse time, because if Thailand drops the balls during this transition, decades of gains in the national fight against HIV/Aids could be reversed. Announcements of achievements, therefore, are at best premature and at worst misleading.
Paisarn Likhitpreechakul is the Advocacy and Communications Officer at Raks Thai Foundation, a principal recipient of the GFATM-supported “Stop Aids and TB through Reach-Recruit-Test-Treat-Retain Programme”.