SURVIVAL CHALLENGE
Deemed a success story in cutting down HIV/AIDS-related deaths, Thailand faces its latest task--what to do when patients stop dying.
Bangkok
Thailand, once considered as an HIV/AIDS hotbed in the Western Pacific, has been receiving considerable international attention for its efforts to contain the disease. In 2004, the World Health Organization's World Health Report commended the country and Cambodia for "chang[ing] the course of their epidemics." If not for massive efforts zeroing in on sex workers and their clients, said the report, the rate of infection would now be 10 to 15 percent, way distant from the current estimate of two to three percent. Official reports say that as of 2002, there were 670,000 Thais living with HIV/AIDS; however, some groups believe the prevalence could be higher than a million.
But aside from the need to prevent the spread of infection is the equally serious challenge of keeping HIV-positive people alive--and well. The introduction of antiretrovirals has considerably slowed down the progression of HIV infection to full-blown AIDS. Although there are still a number of areas concerning their use that remain controversial, they, at least in Thailand, have started bringing in benefits that are now making deterioration and death seem distant possibilities. With the distancing of death comes the need to resume normal life--but mixing HIV/AIDS and "normal life" seems to throw open new areas where other, finer points of the HIV/AIDS war are waged. With support from the AIDS Society of the Philippines (ASP), MEDICAL OBSERVER visited Bangkok in January to see how Thailand is doing in its fight against HIV/AIDS.
Antiretroviral "miracles"
If the national budget for HIV/AIDS services were any indication of the Thai government's seriousness in fighting the disease, then 1.6 billion baht may be seen as fairly serious, if one considers that the amount is already 20 percent of the Philippine health budget. Dr. Somyot Kittimunkong, chief of the Ministry of Public Health's AIDS Cluster, said that there are three major areas on which the government gives special focus--promoting 100-percent condom use, preventing mother-child transmissions, and improving access to antiretrovirals.
 |
The first challenge to improving access to antiretrovirals is the cost. In 1992 Thailand tried putting patients on monotherapy with a nucleoside analog (in this case, zidovudine or AZT), but it proved to be very expensive. A few other trials were conducted-like 1995's trial for combined AZT and didanosine (ddI) or AZT and zalcitabine (ddC)--but eventually, a three-drug cocktail was adopted for first-line highly active antiretroviral therapy (HAART): stavudine (D4T) and lamivudine (3TC), both nucleoside analogs; and nevirapine, a nonnucleoside reverse-transcriptase inhibitor (NNRTI).
Taking all three drugs would normally cost about US$900 a month, which is obviously too expensive for any patient with HIV, let alone someone from a developing country. To solve the problem of cost Thailand's Government Pharmaceutical Organization (GPO) tried to come up with a pill that combined all three. Called GPO-vir, it was tested in 10,000 subjects in 2002, and proved to be effective if taken twice daily. More importantly, treatment with GPO-vir costs only US$30 a month--the only HAART that costs virtually the same is India's triomune, which also combines all three drugs.
 |
Dr. Somsit Tansuphaswadikul, deputy director for international collaboration at the Bamrasnaradura Institute, Thailand's center for infectious-disease research and training, reported that through the National Access to ARV Program for HIV/AIDS (NAPHA), as many as 60,000 patients now have access to GPO-vir. Meanwhile, Kottimunkong reported that for 2005, they are able to raise it to 80,000 in all hospitals affiliated with the Ministry of Public Health. The 80,000 estimate is, of course, outside of the ones who receive free or discounted drugs from various nongovernment organizations, whose work on HIV/AIDS has been equally strong.
Still, access to the necessary drugs is just one part of the issue--the health-care system must also be prepared to look after patients with HIV/AIDS. HAART is not without side effects; the American Foundation for AIDS Research reports that 10 to 15 percent of antiretroviral-naïve patients on GPO-vir experience side effects that may necessitate them to switch to a different regimen. Also, patients with previous antiretroviral therapy may be resistant to new medication.
Therefore, health-care facilities must be able to offer inpatient and outpatient HIV/AIDS services. With the help of a grant from the Global Fund to Fight AIDS, Malaria, and Tuberculosis, major government facilities can now offer even some of the most specialized services to HIV/AIDS patients--from PCR assays to monitoring CD4 counts, from treatment services for coinfections to psychosocial support, and from family-planning services to the prevention of mother-child transmissions.
This is also made possible by the launch of the 30-baht scheme in 2001, which is a variation on universal health insurance. In the scheme, poor people have to secure a special card from health authorities so they would have the privilege to pay only 30 baht every time they visit a doctor.
Now that the health of HIV-positive Thais is getting better, or at least somewhat better than before, what should happen next?
The simple life
"Stigma kills" is a common slogan in the fight for people with HIV/AIDS to resume normal life. This particular fight is now being fought most potently in three major areas--the workplace, in schools, and in communities.
In a survey of 125 companies conducted by the Thailand Business Coalition against AIDS (TBCA) in 2001, it was shown that many of them implement "bad management" practices regarding HIV/AIDS--little to no training on HIV/AIDS in the workplace; compulsory HIV testing for employees and applicants; and worst of all, terminating employees who turn out to be HIV-positive. Anthony Pramualratana, TBCA executive director, said that many companies believe HIV/AIDS "is not related to the company…should [only] be the government's concern."
Pramualratana added that some companies don't take the risk of HIV/AIDS seriously. Some companies don't believe AIDS is really a big problem in Thailand, he said; others don't believe they are at risk at all, because "the employees are educated and married."
Some of those who do realize the extent of the problem believe that having HIV-positive employees would run against their interest--they expect absenteeism, additional health-care or even death benefits, the need to get new employees when someone dies, even tension among coworkers. But Pramualratana insisted that employing an HIV/AIDS-sensitive management strategy would actually prevent these problems. He said that it is not the sickness that results in absenteeism but the low self-esteem that results from being discriminated against. In addition, tackling the HIV/AIDS problem directly would give them the chance to implement measures that would help prevent infections. This, they need to realize, will have greater economic impact on their business than ignoring the problem altogether--if only considering that most people with HIV/AIDS are in their most productive years.
After 12 years, TBCA is seeing some progress in their effort to educate companies about the impact of HIV/AIDS in the workplace. They have also received support from government, nongovernment, and international agencies. In fact, the need to implement HIV/AIDS management practices has led to the formation of the Asian Business Coalition on AIDS (ABC on AIDS) in 2002. "[HIV/AIDS in the workplace] is not about death and dying," said Pramualratana. "A lot of companies [now] realize it's about life and living."
Meanwhile, children orphaned because of HIV/AIDS or have HIV/AIDS themselves face a similar, if not worse, problem. They get discriminated against in schools and in communities, and many of them no longer have parents to protect them. Some parents even abandon their kids when they learn about their children's condition.
One of the groups fighting actively for children with or orphaned because of HIV/AIDS is the Mercy Center, which can be found in an urban-poor community in Bangkok. The Mercy Center offers not only medical care for children with HIV/AIDS, it also fights for these kids to stay in school and stay in their communities. Said Usanee Janngeon, representative from the Mercy Center: "Love, care, and affection are not enough; we need to think of their future."
Like many HIV/AIDS-related projects, the Mercy Center in its early years was faced with problems, even hostility--in this case, from the community. People from the community were vocal in expressing their disapproval, recalled Janngeon. Also, the kids were pointedly disallowed from going to school, that they really had to "fight for them to go to school." Eventually, people realized the value of what the Center is doing; in fact, about 80 percent of the volunteers now working at the Center come from the community. Also, about 50 kids from the Center can now freely go to regular schools.
One of the key principles now guiding the Mercy Center's activities is reintegration--the kids are once again given the chance to live in communities and to study in regular schools. Again, because of the availability of antiretrovirals (with support from the MOPH, Family Health International, and local corporations), survival rates are getting better. Only when the child needs special medical attention is he or she brought to the Center's 25-bed hospice facility.
In schools kids with HIV mingle freely with other kids, "liv[ing] as normally as possible." And with the Mercy Center's After-School Project, some kids stay in school an hour or two longer than usual, to discuss not only how HIV/AIDS affects their lives, but also other social and personal problems that all kids deal with, whether they are HIV-positive or not. This reinforces efforts to prevent the spread of HIV as well as helps them become more aware of the things that go on around them.
Against the flow
But while many organizations are working hard to expand access to antiretrovirals and reintegrate people with HIV/AIDS into their communities, one group is perceived as encouraging the continuing segregation of people with HIV/AIDS. And this group happens to be composed of Buddhist monks.
Lop Buri is an agricultural town 120 kilometers north of Bangkok. In the reign of King Narai in the mid-1600s, it was briefly the capital of Siam; now it's known for Wat Phra Baht Nam Phu, the AIDS Temple.
Situated in the hills of Lop Buri, Wat Phra Baht Nam Phu didn't become an "AIDS Temple" until Alongkot Dikkapanyo, a monk from the temple, started bringing people dying of AIDS to the temple so he could take care of them.
As in most other groups taking up HIV/AIDS as a cause to fight for in the early 1990s, the AIDS Temple had also earned the ire of the community it was in. The people of Lop Buri didn't want the temple to have anything to do with HIV/AIDS; the farmers even believed that water passing the temple grounds got contaminated with the virus, and infected their crops.
Still, the number of dying AIDS patients continued to grow in the temple. Patients who had been cast out by their families, evicted from their homes, and receiving little to no health care thought the temple was the only place that would willingly accept them. Other patients were simply left at the temple gates in the middle of the night.
Through donations the temple started offering not only hospice care, but also housing. As of January this year, there were about 400 HIV/AIDS patients living on the temple grounds.
Museum of life
The first thing any visitor to the temple sees is the "Museum of Life." Life, however, is the last thought that comes to the visitor's mind: several formaldehyde-preserved corpses are laid out on tables--women, men, a child--with a picture of them when they were still healthy, and a description of how they got infected. In published interviews, Dikkapanyo explained that the museum is their way to teach people about HIV/AIDS. "When they see the real thing, the death, they become more aware," he said.
Some reports say that in treating the patients at the temple, only "natural" medicine is used; antiretrovirals are not allowed. However, Thailand's Nation newspaper reported in July last year that antiretroviral therapy had been recently introduced. The Radio Netherlands web site also reported that the temple management was having "second thoughts" about antiretrovirals, saying that the center was put up to "provide accommodation and care for terminal patients."
Still, despite conflicting reports, the number of dying patients has been decreasing. If in the past as many as 10 patients died every day, now the temple reportedly has to put some people who want to enter the temple on an ever-growing wait list. Also, the number of critically ill patients had reportedly gone down from 60 to 20. Very few of these patients actually receive visitors.
In just a decade, thousands of patients at the temple have already died. The monks try to send back the cremated remains of the patients to their families. The ashes are rarely accepted; most times, they are sent back to the temple. At the temple, the ashes are left in labeled boxes in a room adjoining the crematorium. Others, more than 2,000 labeled bags, are left at the foot of a statue of the Buddha. Still others are mixed in with resin to form sculptures depicting the different ways one may get infected with HIV/AIDS.
Again, some groups perceive the temple's way of addressing the HIV/AIDS problem undermines the current paradigm of reintegrating patients into their communities, to show that having an HIV/AIDS patient around is hardly any different from having a diabetic or heart-disease patient. However, the reason the temple exists is to take in those who are refused by the very people and institutions that should accept them. Also, many of the still-healthy people at the temple said that they actually prefer to be on the hills of Lop Buri, helping the monks care for the very ill-and away from their communities.
NOT COMPLETELY CONDOM FRIENDLY
The World Health Organization (WHO) estimates that current condom use among Thai sex workers and their clients has exceeded 90 percent. Aside from benefiting from the massive (if initially controversial) awareness campaigns that started in the early 1990s, latex condoms have become inexpensive and widely accessible. (Incidentally, Thailand has one of the world's leading rubber industries.) They are usually sold in packs of two for only five baht; aside from convenience stores and drug stores, they are readily available in strategically located dispensers. This may somehow convey the message that condoms are no longer controversial in Thailand, but it is not entirely true.
Dr. Somyot Kittimunkong, chief of the Ministry of Public Health's AIDS Cluster, pointed out that in 2004 that they had attempted to install condom dispensers in schools, since there had been reports of increased high-risk sexual activity among 15- to 20-year-olds. However, this move was widely criticized, particularly by parents, and they had to scrap the plan.
Also, having condoms in one's pockets could put sex workers, especially freelance workers, in trouble. Although the notorious "night life" in Bangkok's Patpong district--or even the Nana area, where nonlocal women, many of whom come from former Soviet states, work in bars--has given many foreigners the impression that commercial sex is legal in Thailand, it is not. It is more or less tolerated, but officially, there is no such thing as a sex industry in the country. This whole "illegal but tolerated" scenario can best be described by something a bar-based sex worker says when he or she decides to go with a client--"[I] did not sell my body; you're paying for my taxi."
Surang Janyam, director of the Patpong-based Service Workers In-Groups (SWING) Foundation, said that the police make arbitrary arrests of people suspected of engaging in freelance sex work--they are even fined 50 baht for every condom found in their possession. Even SWING members and volunteers, she added, had to watch out for police when they are distributing condoms.
There have also been reports, said Janyam, of sex workers who, after being abused by clients, seek the help of the police--and end up being treated badly again. This is particularly bad for the younger ones; SWING reported that a number of freelance sex workers are very young--14 or 15 years old, or even 12.
SWING is one of the nongovernment organizations working for the empowerment of commercial sex workers, not only in Bangkok but also in the rest of the country, particularly those with active night-life districts like Phuket. They do this through education and counseling. Since many sex workers also go to school during they day, SWING offers space for them to study in between work and school. They are also planning on offering free clinics.
J. P. de Guzman
|
