Towards Ending AIDS : Equal Access to Antiretroviral Treatment Services with the Close Partnerships
Bureau of AIDS, TB and STIs Department of Disease Control, Ministry of Public Health,Thailand

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
HIV continues to be a major global public health issue, having claimed more than 35 million lives so far. In 2015, approximately 1.1 million people died from HIV-related causes globally. There were around 36.7 million people living with HIV/AIDS (PLHA) at the end of 2015 with approximately 2.1 million people becoming newly infected with HIV in 2015 globally. Thailand had the first AIDS patient imported in 1984. The epidemic in 1991 had resulted in 143,000 newly HIV infected people. Most of them were in working ages. Around 15 percent were housewives. Before 2002, getting infected with HIV for Thais was comparable to a death sentence. Almost everyone who had AIDS would die soon after. There were over 50,000- 60,000 AIDS related deaths per year before antiretroviral therapy (ART) was universally accessed in Thailand health service system. In 2001, only 3,000 (5%) out of an estimated number of 650,000 people living with HIV were able to get antiretroviral drugs. The main obstacle was the cost of effective combination of antiretroviral drug for one person was over 6,000 USD per year while the GDP per capita was about 2000 USD. Moreover, there were only a small number of hospitals that were able to provide services and most of them located in big cities. This had resulted in a long list of people living with HIV in each hospital waiting for the drug quota of their pass away friends. Many poor and most vulnerable people who got infected with HIV died without any access to antiretroviral drugs. There were not only severity of physical illness of HIV and opportunistic infections, but also mental health problems related to stigma and discrimination. PLHA often feared of losing respect and being discriminated from their families and communities therefore were discouraged to disclose their HIV status. They just sought any kind of treatments according to their misbeliefs that put them end up in painful and severe illnesses, despairs and deaths. The lost of head of families had left behind orphans and elderly people who could not earn their own living causing a huge burden to societies. With an aim to prevent AIDS transmission, the Department of Disease Control (DDC) therefore authorized the Bureau of AIDS and STIs to implement the National Strategic Plan on HIV/AIDS. One of the main strategies of the plan was the expansion of antiretroviral treatment (ART) to all people aiming to bring back healthy and productive life to PLHA who had lived without hope in the past. The strategy was later incorporated into the country’s Universal Health Coverage (UHC) Scheme. Implementation efforts of the government sector in partnership with civil society had increased coverage of the ART services to a certain level. However, there were obstacles to bring PLHA embedded in many communities to get access to the available treatment services mainly due to their fear to come out. The DDC therefore initiated an intervention, a people-center approach, on expanding ART services with close partnerships of PLHA network and civil society.

B. Strategic Approach

 2. What was the solution?
According to Thailand’s experiences on nationwide efforts to fight HIV/AIDS problem, PLHA network was considered a missing link for achievement of strategic expansion of ART services. DDC therefore established a PLHA network in Chonburi province in 1997. Government officials then empowered the PLHA network to provide joint efforts with civil society on planning and providing of ART services under the UHC Scheme with an aim to ensure coverage, equity and quality regardless of gender, domicile, and socioeconomic status.

 3. How did the initiative solve the problem and improve people’s lives?
Tertiary care service for providing Antiretroviral (ARV) therapy although had been available at all regional and provincial government hospitals and medical schools was not accessible for many people living with HIV. The main obstacle apart from the limited amount and the expensive cost of ARV, was risen from the PLHA’ s fear especially those in rural areas. The services therefore were strengthened by integrating ART into comprehensive care and support programme for PLHA at clinical service centers through capacity building and networking. In order to ensure coverage, equity and quality of the ART service, the involvement of PLHA network and civil society was sought out. The initiative targeted the persons who lived their normal lives due to proper ART to become the PLHA network leaders. The Holistic Care Centers in hospitals were also established for these peer leaders to provide counseling and quality care. Moreover, together with existing civil society they actively to help PLHA in the communities. Once empowered these leaders of the PLHA network were able to use their direct personal experiences and lessons learned to voice needs and advocate their peers to engage in the treatment programme. The became inspiration model who provided knowledge on HIV/AIDS, shared personal experiences, counseling as well as empathy to PLHA and families. Their PLHA peers then had courage to disclose their HIV status, has positive view on the ART and came out for the care services providing at Holistic Care Centers in hospitals. They also were able to comply with the ARV regimen and can take good care of their health, physically and mentally. Their health status improved dramatically and thus were later able to join occupational development projects which in turn improve their quality of life. Negative impact on children and older people from losing of the head of families or mothers declined. In addition, access to ART among pregnant women and children also reduced the mother-to-child transmission of HIV and child mortality. The initiation was a people-centered approach grounded in principles of human rights and health equity. It had been able to reach the poor and vulnerable groups as well as housewives and bring more HIV infected people out from community into the care system. As the implementation of the initiative had shown the potential of PLHA leaders and network, it was agreed to expand the ART services for a high level of coverage by integrating it into the UHC scheme. It thus had contributed to a continuous improvement and help promote accessible and quality long-term ART care services based on the needs of the target populations and the local context.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
To improve the care access, HIV services need to be decentralized so that communities can involve and take a greater role in service delivery. The initiative on establishing and empowering PLHA network and leaders was an initiative turned out to be a key component of such community involvement to booster credibility, trust and success of the ART strategy. The empowerment of persons living with HIV to be leaders in promotion of access to ART and care was carried out with the specific objective to adapt the role PLHA as service receivers to be service co-providers as well. As they had overcome their illnesses and tough period, they thus were fully eager to provide mind voluntary service to others as peer-to-peer approach. They effectively acted as a life media who can communicate and reach the target populations. The services passively were delivered at the Holistic Care Centers in hospitals including patient counseling and group meeting for experience sharing on health self-care. Proactive service was done by house-to-house visit for treatment outcomes, sharing of knowledge and understanding HIV/AIDS to patients and their families as well as other involved community members. This was a unique context of Thai society in rural communities.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The Department of Disease Control (DDC) designated the Bureau of AIDS and STIs to implement the National Integrated Action Plan on HIV/AIDS Prevention and Control. The Bureau acted as the national focal point who work closely with multi-sectoral sectors and civil society. At the community level, DDC supported the empowerment for PLHA network and leaders, a people-centered approach, to play an important role on ART service provision both financially and technically. Budget for action plan implementation was provided by the government sector, i.e. the DDC, MOPH. Supplemented fund for research and development was granted by the Global Fund and the Thai-US CDC Collaboration on Health (TUC). Civil society contributed its own budget for their related field activities. DDC provided capacity building though training, technical guideline and manuals, and communication media such as pamphlets, posters, videos, etc. DDC implemented policy advocacy, model development of quality treatment and care with the involvement and contribution of civil society and PLHA network leaders. The strong participation of them both had very much helped to reveal their real problems and needs in different contexts. This was also useful to shave Thailand’s plan on HIV/AIDS response relevant to the real problems. Policy then was converted to effective actions that aim to improve equal access to quality ART services and high coverage grounded in principles of human rights and health equity. In this way, the initiative had helped with the reduction of cases and deaths among approximately 50,000 PLHA including the poor and vulnerable persons living in remote areas with difficult access to health service in hospitals.
 6. How was the strategy implemented and what resources were mobilized?
The innovative strategy was implemented through empowerment of people living with HIV themselves and related community networks to help promote accessible and quality long-term care services through a people-centered approach grounded in principles of human rights and health equity. During 1997 – 1999, The pilot project on empowerment of PLHA in involvement of ART services was carried out in Chonburi province, one of the provinces with high HIV/AIDS prevalence. The Department of Disease Control, by the Office of Disease Prevention and Control, Region 3 Chonburi, provided government budget, office space for the PLHA Club, recruitment and training of mentors. Chonburi hospital supported room for carry-out of activities for the PLHA network which later called the “Holistic Care Center”. The Center then was ready for activities including network members’ gathering for peer-counseling, mentoring on treatment and care. The Pear S. Buck organization, civil society sector, was a mentor on administration and running of activities. During the initial phase, there were 8 club members being the club committee members and leaders. The network agencies jointly provided capacity building for leaders on relevant aspects such as health, mental support, confidence on the ART services. Knowledge and skills needed for implementation were also given such as co-infections, complications and especially treatment and care with ARV. The emphasis was placed on compliance to the drug regimen and its possible complications, holistic health care, counseling skills, meeting with the peer group, PLHA’s household visits for advice and care. The mentor teams performed their support to the activities and evaluated the performance. Based on the good performance detected, the project implementation was then subsequently expanded to other districts and provinces. The second phase, during 2000 – 2002, The Ministry of Public Health (MOPH), by the Department of Disease Control (DDC), had successfully improved the ART in order to increase the service system effectiveness. DDC thus empowered the civil society together with the PLHA network to help with planning and implementation of the ART services strengthening. The project financial support was distributed through the regional DDC offices and provincial health offices to the networks to expand the activities for co-delivery of ART service to cover other areas of the country at all levels. Civil society and PLHA were empowered to act as committee and working group members to implement the ART services. The strong contribution of them at national and local levels had supported the national authorities’ decision to produce local made ARV helping to bring down the price of the drug to an affordable level. In the year 2004, there was a joint effort between the public sector and the civil society sector to implement the expansion and integration of ART services into the national Universal Health Coverage (UHC) scheme. This was done under the National Access to Antiretroviral Program for PHA (NAPHA) project with an aim to ensure coverage, equity and quality regardless of gender, domicile, and socioeconomic status of the services. The project focused on expanding standard treatment and care for HIV infected persons and AIDS patients with an increase coverage from 10,000 to the national target of 50,000 persons. Apart from the government budget, fund was allocated also from the Global Fund (GF) for structure development basic services. The capacity building for network hospitals was aimed for system strengthening of long-term and holistic ART, counseling and care services for HIV infected persons and AIDS patients. In addition, the activity monitoring and evaluation and empowerment were also provided continuously.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Stakeholders involved in the design and implementation of the initiative on equal access to ART services with close partnerships with PLHA network and civil society can be divided into 3 groups as the followings: 1. Public institutions of the Ministry of Public Health (MOPH) The Department of Disease Control took the leading role, with close collaboration of the national and international experts, in knowledge development, management and quality improvement on treatment and care of HIV/AIDS patients including PLHA. The DDC also transferred knowledge and skills to its networks. The Department of Health carried out the service on prevention of mother-to-child transmission of HIV and care for mothers with ART and their families. Hospitals under the MOPH, ART service units, provided laboratory diagnosis and treatment to PLHA. The Government Pharmaceutical Organization performed research and development, manufactured, distributed ARV under the Vender Managed Inventory (VMI) system. 2. Other related public institutions The National Health Security Office (NHSO) and the Comptroller General’s Department managed the health care fund for government officials. The Social Security Office was in charge of health care fund for private employees with health insurance. Laboratories in the medical schools and some regional and provincial hospitals provided diagnosis on CD4 level, viral load and drug resistance. International organizations handed technical supports and knowledge and experience sharing from the international perspectives. 3. Civil society sector Civil society including NGOs on AIDS, such as the Medicins Sans Frontieres Foundation and Raks, Thai Foundation played a significant role at both national and local levels on the policy development on AIDS and human rights based on the real needs. They managed the HIV/AIDS projects at the community level and also supported PLHA networks' activities including the seeking of welfare fund for PLHA and their families.

 8. What were the most successful outputs and why was the initiative effective?
Expanding ART for persons living with HIV and expanding prevention choices can help avert AIDS-related deaths and new infections. Clear evidence was confirmed by the results of the initiative implementation. The implementation was successful in the establishment of over 1,000 ART service groups run by the PLHA network and civil society. More than 200 groups were also set up in the hospitals’ Holistic Care Centers. There were more than 2,000 strong PLHA leaders of which around 60% were female. There were 76 female PLHA groups working for the female and child targets in all regions of the country. Number of hospitals increase from 119 in 2001 to 491 in 2003. The achievements over the past years on the equal access to quality care service had helped PLHA to live a better life. This was resulted from the provision of the equal access to ART no matter what the CD4 levels were and no social stigmatization and discrimination. In the year 2016, Thailand was able to provide ART services to approximately 366,250 persons of which 55% were female. (children 3,219 , female 132,089 male 148,657, pregnant 19,160) The rural remote Thais as well as migrant workers with health insurance also got this benefits, Moreover, Thailand also achieved the elimination of mother-to-child transmission of HIV by reducing the infection rate among pregnant women, under antenatal care, aged 15 to 24 years to less than 0.27% which was lower than the global target of equal or less than 0.33%. Due to the availability of good and lower cost ARV together with the ART co-provider volunteer groups nationwide, HIV services became a long term and continuum service. Thailand therefore has set up the landmarked target towards ending AIDS according to the United Nations’ Sustainable Development Goals (SDGs).

 9. What were the main obstacles encountered and how were they overcome?
Although the efforts has an impact on mind set changing on the disease among PLHA and their families, the stigma and discrimination in some settings including work places and schools were still observed. The problem was raised by the networks and then was brought up to the national attention. The national strategy on reducing stigmatization and discrimination was issued and later was disseminated to all concerned sectors at all levels, e.g. public health agencies, educational institutions, local government organizations, to put the policy into actions nationwide. Recognition by rewards for outstanding performances was issued to agencies with best practices. The obstacle was also observed among the PLHA as they had to take a regular life-long ART medication. Some had co-infections that needed more amount of ARV which in turn resulted in more complications. This had made PLHA, especially the youths, become bored and did not want to take the medicine or took the ARV at irregular time causing ineffective treatment and even drug resistance. Therefore, the specific network to think and solve the problem was established. For example, the infected child care network which comprised multi-disciplinary personnel, relevant civil society that came to join the problem solving and modified a suitable service of each age group. The holistic care was aimed for a better quality of life and a proper development of the children. On the obstacle of limited quantity and considerable high cost of ARV, joint discussion was set up and criteria on suitable provision of ARV was developed. Moreover, the ARV fund was established aiming to give free loan or co-payment for the ARV buying. This had urged the GPO to produce more affordable ARV according to the customer needs. The national policy on ARV equal access by blending it into the UCH scheme then finally became reality.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Focused and continuous efforts coordinated by the DDC with close and proactive involvement of civil society had successfully brought PLHA, stakeholders of the treatment and care, to willingly volunteer as co-service providers for their friends. Perception of the community changed from “HIV/AIDS is a 100% fatal infectious disease” to a positive thinking such as “HIV/AIDS if Rapidly detected, can be cured” and “We can live with PLHA with no harm”. Change the PLHA from being hopeless to belief in their own value and potential and were able to disclose their HIV status to their families and communities. Hospitals with participation of PLHA at the Holistic Care Centers can bring in more PLHA into the ART services. Moreover, the forming of PLHA peer group also helped the more vulnerable such as the poor and women to stand out in reality. These people had chance to be trained on occupational skills, worked and earned money for their families. The quality of the PLHA then improved. The forming of PLHA peer groups at provincial, regional, and national levels with civil society involvement had created strong networks nationwide. The networks, besides helping return healthy PLHA back to their communities, they also played other important roles, e.g. protecting patients’ rights to stop stigmatization and discrimination at work place. For policy formulation on treatment and care, they worked with government sector on the equal access to ART services for all groups of people, i.e. the UHC, civil servant, and private employee health insurance funds. There were 33,837 PLHA received the ARV and care. The accumulated numbers of PLHA who received the services rose to 355,125 in 2016. compared to 1,710 in 2001. The success being seen increasingly had resulted in policy advocacy towards ending AIDS such as ART services for all with any CD4 levels, strategy on reduction of stigmatization and discrimination. In 2016, Thailand had approximately 500,000 PLHA under treatment and care. Among them, 55% were women and 7,000 were children and youths. The key achievement was the elimination of mother-to-child transmission of HIV by reducing the infection rate among pregnant women, under antenatal care, aged 15 to 24 years to less than 0.27% which was lower than the global target of equal or less than 0.33%.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The response to solve the AIDS problems was set as a national agenda. The implementation was based on transparency on information and integrity of implementation. The emphasis was placed on the promotion of equal access to ARV to cover all including the poorest and most vulnerable. In this way, strategy on multi-sectoral cooperation among public, private and civil society was implemented throughout the country. All sectors and stakeholders, especially PLHA and civil society, were involved in all processes, i.e. pre, during, and post implementations. Public-Private-Civil Society and PLHA joined and learned AIDS response strategies and development of activities and targets on patient treatment and care. Civil Society and PLHA networks identify problems and needs of the program’s target groups. The approach had led to appropriate projects that served the real needs and thus effectively solved the problems. During the participatory monitoring and evaluation process and the knowledge management process, all sectors jointly analyzed performance data, obstacles and ways for problem solving. Moreover, they also involves in the allocation of budget and other supports as well. The participation mechanisms were agreements, guidelines, SOPs done by multi-sectoral committees. The allocation of budget for continuous activity implementation of AIDS prevention and response to non-profit organizations was done with a transparency approach. The establishment of committee on budget allocation was agreed upon. Therefore the committee was a multi-sectoral one which was comprised of committee members from the public, NGOs, PLHA and academic sectors of a ratio 1:1:1:1. Budget was also allocated transparently for procurement of ARV under the UHC Scheme. PLHA including women and their children thus had equal access to ART services. Later, they were brave enough to stand out and joined the occupation skill building, took care of their families and finally had normal ways of living.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Since the early phase of the initiative implementation, it was found that most of the PLHA who joined the empowerment on personal and peers care were female. Most were housewives who got the disease from their husbands who later passed away leaving them in physical and mental pain from the disease and social stigma. Responsibilities for their parents and children further put a pressure on them. By joining the PLHA group, they then gained back confidence to receive the empowerment on leadership to help themselves and other women and children. The holistic empowerment process gave them a good chance of learning on the disease, sex and birth control as well as socio-economic aspect including development of occupational skills. They were trained on mental support skills, perception change on sex from shameful to be human natural story, risk assessment technique, problem solving in a risky situation. PLHA women, while playing a role model on peer assistance, also worked closely with civil society to build self esteem and target of life among children and female youths. The benefits thus reached un-infected female youths to develop leaders skills, joined the group on promotion activities to prevent AIDS and STIs.

Contact Information

Institution Name:   Bureau of AIDS, TB and STIs Department of Disease Control, Ministry of Public Health,Thailand
Institution Type:   Government Department  
Contact Person:   Yupin Chinsanuankait
Title:   Chief of Organization Development  
Telephone/ Fax:   +(66) 2 590 3213 / +(66) 2 591 8413
Institution's / Project's Website:  
E-mail:   yupinchin@gmail.com  
Address:   88/21 Tiwanon Road , Taladkwan
Postal Code:   11000
City:   Meung
State/Province:   Nontaburi
Country:  

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