By Leslie Evans

Reports from the Field on the HIV/AIDS Epidemic in Myanmar, Vietnam, Cambodia, and Thailand

Epidemiologist Roger Detels and four doctors from Southeast Asia discuss the status of the disease and control programs in key countries of the region.

[HIV and AIDS remain at critical epidemic levels in some of the world's most populous countries, five specialists told a UCLA audience. But despite a general inability to supply patients with the kinds of drugs generally available in the United States, infection rates are going down rather than up in three of the four countries discussed. All four of the countries in the discussion below use HIV sentinel surveillance, periodic spot checking of a fixed size sample of selected risk groups in the population.

[UCLA epidemiologist Roger Detels and four of his graduate students, all doctors in their own right with experience in the HIV/AIDS control programs in their home countries, addressed a well-attended colloquium sponsored by the Center for Southeast Asian Studies in Bunche Hall April 23. The presenters, in addition to Dr. Detels, were Dr. Aye Myat Soe of Myanmar, Dr. Nhu To Nguyen of Vietnam, Dr. Chhorvann Chhea of Cambodia, and Dr. Warunee Punpanich of Thailand.

[Roger Detels has a long experience in the battle against AIDS in China and in many Southeast Asian countries. Dr. Detels is Professor and Chair of the Department of Epidemiology at the UCLA School of Public Health. He is also the Principal Investigator of the Los Angeles Center of the Multicenter AIDS Cohort Study. In addition, Dr. Detels serves is the Program Director of the National Institutes of Health UCLA/Fogarty AIDS International Training and Research Program and the Interdisciplinary Training in HIV/AIDS Epidemiology Program. The Southeast Asian doctors who presented their findings to the meeting are participants in the program. Following is an edited transcript of the presentations.]

* * *

Roger Detels: Where is the epidemic the worst after Sub-Saharan Africa? It is spreading the fastest in some parts of Southeast Asia, in India, Indonesia, China, Russia, and the countries of the former Soviet Union... countries that represent 65% of the world's population.

I'd like to begin any discussion of HIV and AIDS with a picture of the virus [see above] because it is probably the most political disease of the 20th century and may continue to be the most political in the early part of the 21st century. The problem with this epidemic is that there is a tendency to want to blame people or to blame groups for the epidemic. So I want to remind everybody at the beginning of all of my lectures that there is only one bad guy in this epidemic, and this is it, the virus. We need to keep that in mind because of the stigmatization that has accompanied this epidemic, and that was fueled, unfortunately, by many of us, including those of us in the United States. This has retarded control of this epidemic.

The cumulative total number of HIV infections and AIDS cases since the beginning of the epidemic globally has been well over 60 million individuals. The interval between becoming infected and developing the clinical syndrome AIDS is about 8 to 9 years. And then one dies, without treatment, in about 6 months to two years. The number that are currently living with HIV and AIDS who have not died are about 42 million people as of December 31, 2002.

More disturbing than that, however, is that there were 5 million new infections in 2002, which means that the epidemic is very much still continuing and still a tremendous source of concern.

I wanted to give you some perspective of where the epidemic in Southeast Asia fits, in terms of the global picture. Although the epidemic was first identified by a young professor at UCLA, Doctor Michael Gottlieb, in fact the United States is a relatively minor part of the epidemic from a global perspective. The major problem is in Sub-Saharan Africa. But Southeast Asia is rapidly taking over. If we had looked at an AIDS incidence map ten years ago, Southeast Asia would have been relatively uninvolved. The epidemic began in Sub-Saharan Africa and the Caribbean and the United States, probably in the 1970s. But it really did not begin in Southeast Asia until the very late 1980s: 1989, and more in the 1990s. So it's a relatively new epidemic in Southeast Asia.

Today the infection is still spreading most rapidly in Sub-Saharan Africa, but it is spreading very rapidly indeed in South and Southeast Asia as well. This is a major concern, because you have a lot of the population of the world sitting in South and Southeast Asia, whereas Sub-Saharan Africa is not very densely populated. South and Southeast Asia is very densely populated and it is considerably larger than Sub-Saharan Africa.

HIV/AIDS is often viewed as a gay white disease in the United States, Australia, and to some extent Europe, but it is not. It is an epidemic of the developing countries. 95% of new infections in 2002 were in developing countries. And those are the countries that are least able to cope with this epidemic. So it is a particularly tragic epidemic. But it is even more tragic because a high proportion of those individuals are 15 to 49. This is the age when most people get infected. But in fact, half of the individuals who get infected are actually under 24 years of age. And that represents the future of every country. It also represents the producers and the future producers.

Every country has a balance between producers and dependents. And the economic and social well being of any country depends on the ratio of the producers to the dependents. In developing countries that ratio is very very critical. A slight change in it by reducing the producers and increasing the dependents can have devastating effects on the economy and the social well being of that country.

About 50% of infections are now women. We tend to think of the epidemic as being a pandemic, a super epidemic. But the HIV epidemic is actually many smaller epidemics. This is illustrated by the fact that the major modes of transmission are very different, depending on which area of the epidemic you are looking at. In the United States, Canada, and Mexico, this is an epidemic occurring primarily among men who have sex with men and among injection drug users, although now, in 2003, it is also an epidemic of the minority populations, particularly the African American population.

If you go into Sub-Saharan Africa there are almost no infections that are drug users or men who have sex with men. It is almost exclusively a heterosexual epidemic.

If you go into East Asia and South and Southeast Asia, it is primarily an epidemic among heterosexuals, although I will comment a little bit more about that.

This epidemic has a steep curve that begins slowly. Typically what happens is that the epidemic starts very slowly, and then it suddenly takes off when it reaches a critical mass. And that pattern is very consistent in the Americas, in Africa, in Europe, and in Southeast Asia. This is very helpful. Because in countries where the epidemic has not started or is in the early stages, the experience in these other areas tells the country that the epidemic is coming and that they need to do something about it.

Where is the epidemic the worst after Sub-Saharan Africa? It is spreading the fastest in some parts of Southeast Asia, in India, Indonesia, China, Russia, and the countries of the former Soviet Union. Now why is that disturbing? It is disturbing because if you take India, China, Indonesia, and the former Soviet Union you have just accounted for over 65% of the population of the world. So this epidemic is really taking off in the most populous countries in the world and is therefore a source of tremendous concern.

Now I would like to turn to a discussion of Asia and an overall picture of Southeast Asia before each of the students talks about the epidemic in their respective countries. In 1984 there was no involvement of any of the countries of the region in the epidemic. The first cases started to occur in 1985. By 1989 the epidemic had taken hold and the focus was in the area called the Golden Triangle, which included Thailand, Myanmar, the northeastern states of India -- Manipur, Assam, Nagaland -- and Thailand. The first identified cases were homosexual men, but it soon spread into injection drug users in the Golden Triangle. And then it really took off.

Then by 1994 we had the involvement of Cambodia, while Vietnam was still relatively spared. The epidemic in 1994 was primarily confined to elderly drug users in the southern part of Vietnam. However, by 1999 the epidemic had exploded in Vietnam, involving not just southern Vietnam but northern Vietnam and spreading rapidly into the heterosexual population among commercial sex workers. A number of our students were involved in documenting this new epidemic.

The Epidemic in China

I thought I would just throw in China because I anticipated questions about it although it isn't Southeast Asia. The epidemic began about 1989, and it began down in Yunnan province. Yunnan abuts northern Myanmar, and the border between northern Myanmar and Yunnan isn't there. I have walked across it many times. And from there into northern Thailand and into the northeastern Indian states.

It took some time before the epidemic then involved every one of the 31 provinces in China. China is also rather interesting. Although the origins of the epidemic were in injection drug users, a major focus of the epidemic has become plasma donors. In 1995 one of my students and I published a paper in Lancet about the epidemic occurring in Anhui province among plasma donors. We found that 15% of plasma donors were infected in 1995. In the older groups the infection rates were up higher, on the order of 30%. Subsequently it has become clear that the epidemic is also in Henan province and Shansi province and to some extent in Hunan province. This has been a major problem.

The Chinese government took immediate action, and closed all of the illegal plasma donor centers. But, using the pattern that they subsequently used with SARS, they refused to admit that they had a problem until one of the physicians trying to deal with all of the infected plasma donors leaked the story to the New York Times, around 2000 or 2001. That is a major focus of the epidemic.

Now I will turn it over to the students. I say students, but each of these individuals has actually worked in the HIV/AIDS control program in their country, so they are very conversant about the epidemic and the control efforts in their country.

Is the Islamic World Exempt?

Question from the audience: Generally the Muslim world has been somewhat spared except for Indonesia. Do you have any comment on that?

Roger Detels: First of all I don't accept that it has been spared. The highest risk factor for HIV in the Philippines is overseas workers sent to the Arab countries in the eastern Mediterranean. One rift within the Muslim world is that the Pakistanis are mad as hell at the rich Arab countries, because they send Pakistani workers over HIV free, because they have to be tested before they can be accepted in those countries, and they come back infected. So what is happening is that those countries are just not reporting it. I have no idea what the prevalences are in those countries, but I know that the rates that you are reading are incorrect. They have a serious problem.

Indonesia did not have a serious problem until about 2 years ago. They had one focus in Papua New Guinea seeded by Thai sailors. But recently, in 2002, a focus occurred in southern Sumatra. We kept expecting it to occur in Bali, but that wasn't where it appeared. So Indonesia is now on that upward swing.

The only country of Southeast Asia that is not heavily involved is the Philippines. And that is because their sexual mixing pattern is not high enough. The average commercial sex worker in Manila, according to studies that were done by two of my students of male sex workers and female sex workers, is about one client every three nights. In northern Thailand the average number of clients per night ranges from three to ten. So -- this is my interpretation -- the Philippine sexual mixing rate is not high enough. Also the spread depends very much on what the sexual behavior of the general population is. Surveys have suggested that extra marital sex is not as frequent a phenomenon in the Filipino culture as it is in many of the other Southeast Asian cultures.

Dr. Aye Myat Soe, Myanmar: The major problem in our country is drug abuse. We have to control the drug abuse and then we can prevent HIV.

I am working as an assistant biologist at the National Health Laboratory in Yangon, Myanmar. The population in Myanmar is 51.1 million. The country is divided administratively into 7 states and 7 divisions. First I will take up our administrative structure and programs and turn to the disease.

The National Health Committee is a high level body taking a leadership role and providing guidance and recommending a health program. Under the National Health Committee we have organized a National AIDS Committee, which acts to carry out the Ministry of Health's National AIDS Program.

We have established 39 HIV/AIDS control teams in all administrative states and divisions of Myanmar. Our first health priority is malaria control, which is endemic in Myanmar, followed by tuberculosis. HIV/AIDS is third on our priority list.

The intervention program has fourteen activities. First is education, followed by a blood safety program. Another is early diagnosis and treatment of STDs. There is also HIV sentinel surveillance and second generation surveillance. There is counseling. There is home care and nursing care and social support.

We work on prevention of mother to child transmission. We use nevirapine to control mother to child transmission. We were able to use this drug in 12 towns during 1999 to 2002. We start at delivery to give nevirapine to both the child and the mother.

We have a campaign for 100 percent condom use, starting in the big cities. We have started an HIV education program for high school children.

The major problem in our country is drug abuse. We have to control the drug abuse and then we can prevent HIV. We collaborate with Thailand in an anti-TB program and also in an AIDS program. We also collaborate with nongovernmental organizations in this work.

Over the period from 1988 through 2001 the National AIDS Program has recorded a cumulative prevalence of 39,466 HIV positive cases among blood donors and hospital patients and 5,140 AIDS patients. The reported AIDS deaths are 2,364 from hospitals in different parts of the nation. The male-female positive ratio is 6 to 1, primarily in the 19 to 39-year-old group.

Sentinel Surveillance Began in Myanmar in 1985

Myanmar began active surveillance in 1985. The first HIV positive case was only in 1988. The first AIDS patient was reported in 1991 and was an injection drug user. We do a biannual HIV surveillance beginning in 1992. We began with 9 sites, and these were expanded to 29 sites by 2002. We have expanded our STD surveillance along with our HIV sentinel surveillance. We collect data from male STD patients in 29 townships, with a sample size of 100, and from female patients in 8 sentinel sites. We have two sentinel sites for commercial sex workers, Yangon and Mandalay, the big cities.

We have 27 special sites for pregnant women with a sample size of 200. We select 600 new military recruits in each round of the surveillance for testing. All blood donors coming to the National Health Laboratory and the central national blood bank are screened during two months of each surveillance round.

HIV positive rates jumped from 4,717 in 2000 to 8,013 in 2001, but the new full-blown AIDS cases dropped in the same years from 816 to 668.

A Decrease in Infection Rates

Our sentinel sites indicate over the last ten years that the worst epidemic is among the intravenous drug users. But there has been some progress, with the HIV infection rates for drug users dropping from 62% to 41% between 1992 and 2001. Rates among commercial sex workers rose until 1999, reaching 48%, but then they also declined after 2000 and are now about 32%. At this time the infection rate among military recruits and blood donors is only 1%, but that is a national average. The rates are higher on the border with Thailand.

Sexually Transmitted Diseases have also declined. For injection drug users, from 9% incidence of syphilis in 1997 to just under 3% in 2000.

Among HIV positive cases in Myanmar, the overwhelming majority are males, and the peak years of those infected are between the ages of 20 and 39.

Sexual Mores of a Buddhist Society

In looking at some of the problems with controlling HIV/AIDS I want to emphasize the customs and culture of our country. Because our country is a Buddhist society we prefer to deny promiscuity, while commercial sex thrives.

Sexual decision-making is still in the hands of husbands. As one untrained urban woman from Bago described a typical situation, ?I discuss household decision-making with my husband, but not sexual matters. Being a Myanmar Buddhist woman, it is shameful as well as disgraceful to talk about sex.? It is difficult to have sex education or to convey information to women. To translate knowledge into behavior, women need an enhanced ability to negotiate and discuss sexual issues with their husbands.

There is also a financial problem. There is no budget to allow for follow-up support after treatment or for research and experimentation. We cannot afford to give HIV testing when people ask for it, except for premarital testing.

We are working to expand blood testing and the condom use program and trying to eradicate opium plantations -- in the Golden Triangle the virus moves along with the drugs.

Nhu To Nguyen, Vietnam: By December 2002, the number of HIV infections was 59,200 and the number of recorded cases of AIDS was 9,437.

Vietnam now has a population of 80 million inhabitants. It is one of the most densely populated countries, at 240 people per square kilometers. Urbanization and industrialization has created a group of migrant workers who go back and forth between the rural and urban areas, which has a high risk of transmitting HIV.

The first HIV infection was detected in the south of Vietnam in 1990. The first case of AIDS was detected in 1993. Between 1990 and 1993, HIV spread from one province to 29 of the then-57 provinces. There were 1,100 HIV cases in 1993. This doubled by 1997-98. By that time there were cases in all provinces, which had been increased to 61.

We conducted HIV sentinel surveillance in 8 provinces after the first AIDS outbreak in 1993. This was increased in 1995 to 12 provinces, and to 20 provinces in 1996. By 2001 we had HIV sentinel surveillance in 30 provinces, half of the country.

By December 2002, the number of HIV infections was 59,200 and the number of recorded cases of AIDS was 9,437. The epidemic can be divided into three periods. The first period, between 1990 and 1993, was mainly located in the south and among elderly injection drug users.

The second period, between 1993 and 1997, was mainly in the south, but had spread out to a second risk group, female sex workers. The third period, since 1998 up to now, the epidemic has spread out to the whole country, north and south, and to the border with Cambodia, among injection drug users and the general population.

The distribution by gender is mostly in men, 85%. This is a common early stage of an HIV epidemic, beginning with the men and then spreading out to the women. In the distribution by risk group, the injection drug users are by far the largest, at 60% of the total, while female sex workers are only 4%, TB patients 4%, and other smaller groups.

In the age distribution for HIV, the main group is 20-29. But when the infection began, it was mostly in the 30-39 age group, and was then transmitted to the younger age group. If we look at AIDS cases reported by year, the graph shows an exponential increase.

Through the end of 2002 there were 4,649 deaths from AIDS cases. Compared to other countries in Southeast Asia like Thailand and Cambodia, the HIV prevalence among adults 15-24 in Vietnam is pretty low, less than 1%. The second thing is that in Vietnam the prevalence among women is less than among men. That shows it is an early stage, compared to Thailand where only 66% as many men have the disease relative to women, or Cambodia, where almost three times as many women are HIV positive compared to men.

I should say that the numbers I have given are only the reported cases. The estimated number of HIV infection cases in Vietnam in 2000 was 160,000.

Four High Risk Groups: Injection Drug Users, Female Sex Workers, STD Patients, and TB Patients

HIV sentinel surveillance has been established in Vietnam since 1994. We have six different monitored groups: four high risk groups -- injection drug users, female sex workers, STD patients, and TB patients; and 2 low risk groups -- pregnant women and military recruits. The sample size per province is 400 for high risk groups and 800 for low risk groups. The testing is confidential.

In the sentinel surveillance data for injection drug users, the trend has been an increase, from 18% in 1994 to about 30% in 2002, with a drop in 1995 and 1996 to a low of 9% but increasing every year since. This is the most serious problem.

Among female sex workers there has been the same steady increase, but from a lower level, rising from half of one percent in 1994 to nearly 6% in 2002. Compared to Thailand or Cambodia this is very low, but we predict that it will increase much more if we do not take an intervention right now. Among male STD patients the HIV rate is about 2% positive. And among TB patients there is the same upward trend, now at about 3.5% HIV positive rate.

Among the low risk groups, army recruits and prenatal attendees, the rates are very low. Among pregnant women the infection rate is only 0.4%. Among army recruits it is about 0.7%.

Low Condom Use

We began behavioral sentinel surveillance in 2000. In the first year this was done in only 5 provinces, 2 in the north, 2 in the south, and one in the middle. We found that sharing needles among injection drug users was over 40% in Ho Chi Minh City. There is a mixed interaction between two high risk groups: injection drug users having sex with female sex workers. This is pretty high, about 20% of drug users in Hanoi. The use of condoms is also low among injection drug users, with a disparity between use with female sex workers, casual partners, and regular partners (in Ho Chi Minh City, 45%, 18% and 15% of the time respectively). This suggests a high probability of transmission from injection drug users to female sex workers and their other sex partners.

We see the same pattern among female sex workers. A very low percentage use condoms with their non-paying partners or their regular clients. There is also a large number of female sex workers who are injection drug users: 21% in Hanoi and 15% in Ho Chi Minh City.

Prevention and Control Efforts

So what have we done? The National Committee on HIV/AIDS Prevention was established in 1988, two years before the first HIV infected case was detected. A set of guidelines for HIV prevention and treatment was established. Government has cooperated with mass organizations in HIV prevention activities. We have increased the safety of blood donations, particularly among voluntary donors, which accounts for 64% of donated blood.

There are still a lot of weaknesses. There is the barrier of social stigmatization of those with HIV/AIDS. People look on this as a social evil, especially among drug users and female sex workers. This makes monitoring and intervention very difficult.

There are also limitations in the sentinel surveillance systems both for HIV and for risky behaviors. Only 50% of the country have this system, not the whole country. There are also limits to HIV/AIDS treatments. The drugs are not available for the whole general population. They are only available for some groups.

We are working to improve our STD reporting system. And there has been a lack of efficiency in evaluating prevention programs.

In the future we want to put more effort into the 100% condom use campaign, free needle exchange among drug users, increased testing and counseling, and work to reduce transmission from mother to child at the time of delivery.

Up to this time the HIV epidemic is concentrated in a small percentage of the population, the injection drug users and female sex workers. In the general population the infection rate is still below 1%. The conditions are present, however, for an enormous spread of the epidemic in Vietnam if we don't intervene now.

Comment by Roger Detels: Note that the epidemic took off comparatively late, in 1998, and that it is the only country in Southeast Asia that has a significant proportion of the commercial sex workers who are injection drug users. This is a particular concern as they are especially vulnerable to infection from two different routes and then act as an amplifier to the rest of society. And as you can see the condom use rate was not very high for that group.

Dr. Chhorvann Chhea, Cambodia: We have no documented cases of transmission by injection drug use or homosexuality in our country.

Cambodia is south of Laos and Thailand, and west of Vietnam. The country is very small. We have 181,000 square kilometers. We have a lot of problems in Cambodia. Not only HIV, but before HIV we had a lot of infectious diseases that are a leading cause of death: tuberculosis, malaria, cholera, and Dengue fever. The infant mortality rate is very high, at 89.4 per 1,000 live births in 1999. Life expectancy is 50.7 for males and 58.6 for females. Very short.

I would like to share with you the characteristics of the epidemic, which in Cambodia is mostly spread by heterosexual contacts, and now we have found that mother to child transmission is increasing. We have no documented cases of transmission by injection drug use or homosexuality in our country. We have believed that there are no homosexuals in our country, but now we are beginning to realize that it may be possible. [Comment from the audience: More than possible!]

Husbands Bring HIV to their Wives

The epidemic began among female sex workers, then spread to a bridge group, men who frequently use commercial sex services. We do not think that women mainly bring HIV to their husbands, but that husbands bring HIV to their wives.

Our sentinel surveillance looks at prevalence rates among 5 groups: direct female sex workers, indirect female sex workers (the difference is that direct sex workers work in brothels, while indirect female sex workers are freelance), TB patients, police, and pregnant women.

Direct sex workers have the highest prevalence, at 28.5%, as of 2002. There was a gradual downward trend here, from 42.6% in 1998. There was also a slight reduction in infection rates among indirect sex workers, from 19.2% in 1998 to 14.8% in 2002. Among urban police the trend is also downward. It started at 6% in 1998 and went down to 3.9% in 2002.

The trend goes the other way for TB patients with AIDS. It started at 2.5% in 1995 and reached 8.4% in 2002. We study this group because people who already have HIV in their bodies are more likely to develop TB. We started to monitor pregnant women in 1997. The prevalence among this group has fluctuated a bit. It started at 3.2%, went down to 2.3% in 2000, then back up to 2.8% in 2002. But the difference is not significant so we consider that the prevalence among this group is stable.

In regard to HIV infections reported to the Ministry of Health, which is not the full total, the number rose quickly from 3 cases in 1991 to 2,520 in 1995, to 7,726 in 1999, to 14,473 in 2001. The same curve is shown for actual AIDS, which rose from one case in 1993, to 2,556 in 1999, to 4,665 in 2001. There were 721 AIDS deaths in 2001. In our country the treatment for HIV is not available, or still too expensive for the general population.

At this time the prevalence is not increasing among the sentinel groups. It continues to decline among direct and indirect female sex workers. This may be due to a program we have to promote the consistent use of condoms. Prevalence among police groups seems to be leveling off. Among TB patients, the prevalence is gradually increasing as expected. This indicates that the incidence of AIDS is rising. In the absence of effective treatment, mortality must also be increasing, which is consistent with increasing reports of AIDS deaths. There is an increase of the proportion of mother to child transmission. The numbers of mothers who are HIV positive is stable, but compared to Vietnam it is high and the HIV is transmitted to the babies, which is increasing.

Program for 100% Condom Use

We do have some strategies to try to do better. We have a program to encourage 100% condom use. We started this in 1998 among high risk groups, the direct and indirect sex workers. We started in one province and have now extended the program to almost all provinces. We provide free STD services. There is a problem because of the stigmatization. Many people who get STDs are afraid to go to a government clinic, so they go to a black market pharmacy.

We have a very new service for voluntary testing and counseling. We have only six functioning centers in 24 provinces, very few. Not a lot of people know about this yet. We need to do more on this one.

We provide many types of education. There is education for high risk groups, in the brothels. Education for schools. And education for the general public. We have some short training for students in the schools.

Because AIDS cases have increased in Cambodia, we have started AIDS care services. The effectiveness of this service is very limited because this service needs a lot of budget to support treatment and drugs. This is very expensive. We provide some home-based care and some hospital care.

We also cooperate with nongovernmental organizations and with all donors who are interested in fighting HIV/AIDS in Southeast Asia. we do not have enough financial support. Our program is not sponsored by the Ministry of Health. It is based on volunteers and donors. For that reason we can only make yearly and five-year plans. We cannot make longer plans.

There are other major health issues to be considered. We have tuberculosis, we have malaria. AIDS needs 8 or 10 years to kill one person. Malaria needs just one week to kill one person. So in terms of how serious it is, people will refer the budget to that disease. We have a lot of poverty. Poverty causes poor education. And this makes things worsen and worsen. We have low community participation because people are poor. They try to survive; they don't care much about their health.

And lastly there is a lack of cooperation between the government and nongovernmental organizations. Some organizations seem to ignore the importance of the local people. They have money and they go there and they work on their own. This can cause a misuse of the program and waste a lot of money.

Comment by Roger Detels: Cambodia has one of the worst epidemics of Southeast Asia. It is only recently out of a civil war and has very limited resources, and funders who feel that they know better than the government does what needs to be done. Despite all of that, Cambodia has been able to slow the epidemic down. That is quite a testimony to the Cambodians that they have been able to do it.

Dr. Warunee Punpanich, Thailand: Four Ever Larger Waves, from Homosexuals to Drug Users to Sex Workers to Housewives

At this time in Thailand we have 1,030,000 people infected with HIV, and have had 400,000 AIDS deaths. In 2003 we project to have 21,000 new HIV infections, to see 630,000 people living with HIV/AIDS, to have 50,000 people develop full-fledged AIDS, and to see 52,000 die of AIDS. This is out of an overall population of 53 million.

The epidemic in Thailand has come in four waves. The first signs came in 1984. The first wave was a group of homosexual men in 1985-86. This spread in 1987-88 to a larger group of injecting drug users. The third wave, which was again larger, was female sex workers and their male clients in 1989-90. Then a still larger fourth wave of housewives, in 1991,who infected newborns through vertical transmission.

Of the AIDS cases reported to the government, the infections were predominantly male, at 74%, with females at 26%. In the age distribution, the majority of AIDS cases have been in the most productive years, from 20 to 39, with the peak infection in the 30-34 age group (for the years 1984 to 2002).

Heterosexual Transmission the Principal Route of Infection

On mode of transmission, the great majority, 82%, were by heterosexual transmission, followed by intravenous drug users, at only 5% of cases, and mother to child at 4%. Homosexuals account for only 1% of the AIDS cases in Thailand and blood transfusions are only 0.3%.

Sentinel surveillance in Thailand began in 1989. We divided it into high risk populations and low risk populations. High risk included commercial sex workers, injecting drug users, male patients at STD clinics, and fishermen. Low risk groups included pregnant women attending antenatal clinics, military recruits, and blood donors. We also have included migrant workers from neighboring countries.

We added sexual risk behavior surveillance in 1995. For this we monitored populations of military recruits (21 years old), pregnant women (15-29), high school students (16-17 years old), and workers in factories (15-29 years old). The behaviors we asked about were condom use rate, age at first sexual intercourse, and type and number of sex partners. We established sentinel sites in 20 provinces, which have a relatively high incidence rate of HIV. We administer a confidential self-administered questionnaire. We had a sample size of 5,000-6,000 per group.

HIV Prevention and Control Programs

We have established a four-prong HIV prevention and control program in Thailand, beginning in 1988 with education in the mass media. We added education of school children in the early 1990s. We have a 100% condom use program, which is implemented at all sex establishments, and this includes education of male clients at brothels.

We use community intervention to induce risk behavior change, since the mid-1990s. This is mostly at schools and work places. To prevent mother to child HIV transmission we provide an AZT Bangkok regimen, and infant formula for up to 12 months.

There has been improvement since the 100% condom use program was implemented in 1992. HIV infection among military recruits, which had been increasing rapidly, began to decline after June 1993. Rates for pregnant women began to decline after June 1995. There were also declines in HIV infection rates among high risk populations -- brothel workers and freelance sex workers -- beginning around the end of 1996.

In our current projections for HIV in Thailand through 2020, we see new HIV cases dropping to about 18,000 per year by 2005, and to about 8,000 by 2020. We expect the number living with HIV/AIDS to drop from its current 2003 total of 604,000 to about 158,000 by 2020, the number being this large partly because people will be living longer. But the cumulative total for those who have had HIV/AIDS will grow to 1.25 million.

I don't mean to imply that the struggle against HIV/AIDS in Thailand is over. We still need to do quite a few things. For example, including government intervention, the strengthening of social inclusion, cultural and behavioral changes. We also need to focus more on the gender-based response to HIV/AIDS in order to find a way to reduce the inequality between men and women [female infection rates are higher than males in Thailand]. We also need to work to adopt a holistic, human-centered approach to the treatment and care of HIV as well as try to fill the urgent need for feasible and cost effective antiviral treatment in HIV infected patients.

Comment by Roger Detels: Thailand was the first country where HIV took hold in Southeast Asia. The Thais responded very vigorously with a very broad intervention program. I think to me the most interesting aspect of the intervention program was that the Ministry of Health in the government did not use tactics of dictating to the various risk groups such as the brothels. They used a system of persuasion and negotiation, which appears to have had a dramatic impact and is in some respects a unique Thai approach to epidemic control.

Published: Friday, May 2, 2003