UNFPA Thai Bestpracticeaids2008 9 E

National AIDS Management Center Department of Disease Control Ministry of Public Health Tiwanon Road, Nonthaburi 11000 Tel:
(+66) 2590 3828-9 Fax: (+66) 2965 9153 e-mail: namc2010@hotmail.com

R e p o r t Best Pratices for HIV/AIDS Response Thailand 2008-2009
Best Pratices
for HIV/AIDS Response Thailand 2008-2009
Report
Management Center
National AIDS
1st
Edition
Report Best Practices for HIV/AIDS Response Thailand 2008-2009
Report Best Practices for HIV/AIDS Response, Thailand 2008-2009 Authors Lamduan Mahawan Sunee Talawat Wilaipan Sawasdipanich Usasinee Riewthong Ittiphol Chaitha Chutima Saisaengjan Editorial Petchsri Sirinirund Committee Niwat Suwanpattana Chuleeporn Jirapongsa Panithi Thamawijjaya Chewanan Lertpiriyasuwat Taitat Phaipilai Translator Anthony Bennett Cover Design Chattong Sawatphiphatphong First Edition 1,000 copies, June 2010 Printer On Print Shop 457/9 soi pradoo1 new road bangkorlaem Bangkok 10120 Tel 0 2688 5869 fax 0 2688 5869 Sponsor United Nations Population Fund (UNFPA) Publisher National AIDS Management Center Department of Disease Control, Ministry of Public Health Tiwanon Road, Nonthaburi 11000 Thailand Tel 66 2 590 3829, Fax 66 2 965 9153 ISBN Title
Acknowledgement
The Technical Working Group on monitoring and evaluation for national HIV/AIDS response, who is responsible for the 2010 UNGASS reporting, recognized the use of writing a section of best practices as a systematic way to document examples of practices to inspire the implementers as well as those who confront the same problems. The selection of best practice is not a competition and does not aim to compare which project is better than others. For the selection of best practice in 2008-2009, the committee has put the emphasis on the issues on gender and HIV prevention among women, since there are not many projects or models on these particular issues, while the evidence has shown the feminization of AIDS epidemic in Thailand. We would especially like to thank UNFPA for financial as well as technical support in establishing the system to identify and document best practices, which will be continued for the following country reports. In addition, we would like to thank the committee for the review and select the project to be documented as best practices for the year 2008-2009. The selection committee includes
- Dr.Usa Duangsa, Faculty of Education, Chiang Mai University - Dr.Taweesap Siraprapasiri, UNFPA - Mr.Sompong Charoensuk, UNAIDS - Ms.Sureerat Treemankla, Advisor, Thai Network of PLHA Last, but not least, the appreciation is forwarded to all those submitting the projects, particularly those who are selected in providing documents describing the concept, implementation process, results and lessons learned. Comments or suggestions are most welcome for better process of identification and documentation. Please contact the National AIDS Management Center, Department of Disease Control, Ministry of Public Health.
Table of contents
Acronyms I. Introduction
7 9 13 16 25
II. Feminization of HIV/AIDS 1. Real Lives Project 2. Voices & Choices Project 3. Prevention of HIV among Pregnant Women through Male Partner Involvement: Couple Ante-natal Care (ANC) 4. Teenpath Project III. AIDS Responses for Marginalized People 1. Anti-retroviral Therapy for Migrants: Experience of Chiang Saen Hospital 2. PHAMIT Project IV. Holistic Care and Support for Children affected by HIV/AIDS 1. Integrated Psycho-social and Clinical Care Project
34 42 48 50 57 68 69
List of Tables
Table 1 Results of couple ANC HIV tests during Phase 1: Up to 2006 Table 2 Results of couple ANC HIV tests during Phase 2: July 2008-September 2009 Table 3 Results of couple ANC HIV tests in 25 hospitals under the Region 3 health zone for the year 2008 Table 4 Results of couple ANC HIV tests in 5 hospitals of Cholburi: 2008 Table 5 Number and coverage of sites and institutions participating in Teenpath project during October 2003 to September 2008 Table 6 Educational media developed by/for PHAMIT by type of media and language 38 38 39 39 AIDS AIDSNet ANC ART CSE DDC DiC DOH ECAT GFATM Figure 1 Condom use at last sex by type of partners Figure 2 Draw not a dark night. Draw strength from life. Figure 3 Lets work together to build a new world order. Help the uncomprehending become an understanding world. 66 75 HIV IEC MHW MHV MOE MOPH MSF Acquired Immunodeficiency Syndrome AIDS Network Development Foundation Ante natal care Anti-Retroviral Therapy Comprehensive Sexuality Education Department of Disease Control Drop-in Center Department of Health Enhancing HIV-related Care and Treatment for HIV Infected Mothers, their Partners and Children Global Fund to Fight AIDS, Tuberculosis and Malaria Human Immunodeficiency Virus Information Education and Communication Migrant Health Worker Migrant Health Volunteer Ministry of Education Ministry of Public Health Medecins Sans Frontieres
Acronyms
46 61
List of Figures
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NAMc NAPHA
National AIDS Management Center National Antiretroviral for People Living with HIV/AIDS NGO Non Governmental Organization NHSP National Health Security Program OI Opportunistic Infection PATH Program for Appropriate Technology in Health PDA Population and Development Association PHAMIT Prevention of HIV/AIDS in Migrant Laborers in Thailand PLHA People Living with HIV/AIDS PMTCT Prevention of Mother to Child HIV Transmission RHD Reproductive Health Division STI Sexually Transmitted Infection TB Tuberculosis TV Television UNFPA United Nations Population Funds UNGASS United Nation General Assembly Special Session on HIV/AIDS UNIFEM United Nations Development Fund for Women VCT Voluntary Counseling and Testing WL/LW Way of Life and Local Wisdom
I.
Introduction
Background
As part of the process of preparing the bi-annual UNGASS Report, the National AIDS Management Center (NAMc) of the Department of Disease Control (DDC) of the Ministry of Public Health (MOPH) was responsible for central coordination of the documentation process. Many partners and stakeholders were involved, government, civil society, institutes, and international organizations. This multi-sectoral effort summarized the state-ofplay of the HIV epidemic and response in Thailand. One of important parts of the UNGASS reporting process is the compilation of best practices which serve as examples and/or inspiration for others that are confronted with similar problems. This report of best practices highlights the issue of the feminization of HIV/AIDS in Thailand which received special attention and financial support from the United Nations
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Population Fund (UNFPA). An increasing number of new HIV cases are among women: Of a total estimated number of 11,753 new cases in 2009, 30% are women infected by their husbands. In addition to this topic, two other themes received special consideration in this review of best practices. These themes are AIDS responses for Marginalization people in Thailand and Holistic care and support for children affected by HIV/AIDS.
Process of preparing the report

The NAMc, as the central coordinating body, contacted experts in the government and civil society sectors who have played a role and have experiences in implementing AIDS projects at the national level to serve as the selection committee.
The criteria to select best practices are as follows:

1. The project worked in the area of AIDS whether that be prevention of new infection, treatment and care of PLHA, or mitigation of the impact of AIDS. The project may either work directly with the intended beneficiaries or indirectly through, for example, policy development, 2. The project is implemented by an agency in the government or civil society, or some combination of sectors. The level of implementation could be the community/tambon, province or national level. 3. The project has one or more of the following characteristics: (1) The project can effectively address AIDS challenges, but not necessarily solve all dimensions of a given problem. It can be effective in a specific area, or activity of limited scope - but that has potential to be a catalyst for larger scale impact over time. (2) The project is scalable in a similar or adapted in different environment.
(3) The project is an innovation or can become a spark of inspiration that leads to more effective implementation that is practiced generally. (4) The core project activities are sustainable (after external funding ends). (5) The project is acceptable to others; the local community feels a sense of ownership of the interventions and is proud of them. The project employs local wisdom and resources and is of benefit to the larger community. (6) The project is integrated into and/or sensitive to the local socio-cultural and sexual norms of the intended beneficiaries, and respects the fundamental human rights. This sensitivity is reflected in the design, implementation and evaluation of the project. (7) The project addresses factors related to the feminization of HIV/AIDS. Government and civil society agencies were invited to submit project descriptions for consideration as best practices as part of a widespread publicity campaign. The announcements were disseminated through electronic newsletters, and public dissemination forums during various meetings. A total of 52 submissions were received. The Selection Committee reviewed 45 projects that qualified for consideration and, of these, selected seven projects as best practices Representatives from the agencies implementing the best practice projects were asked to edit and add to their project descriptions based on recommendations of the Selection Committee. Next the writing team review and explore for more information from the project team on particular topics. The best practices were grouped according to three themes as follows:
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Theme 1: Projects relating to feminization of HIV/AIDS. Four projects were selected under this category. Two projects working with people living with AIDS, the Real Lives Project by the northern regional branch of the AIDSNet Foundation; and the Voices & Choices Project (Phase 3) by the Raks Thai Foundation. One project working with HIV-negative pregnant women with the involvement of their partners: The Pre-natal Couple Care Project by the Reproductive Health Division (RHD) of the Department of Health (DOH) and the Faculty of Nursing of Burapa University. One project working on comprehensive sexuality education for adolescents: Teenpath Project implemented by the Program for Appropriate Technology in Health (PATH). Theme 2: Projects relating to AIDS responses for marginalized people Two projects were selected under this category. One project entitled Anti-retroviral therapy in border areas of the Greater Mekong Sub-region: Experience of the Chiang Saen Hospital by the Chiang Saen District Hospital. One project entitled Prevention of HIV/AIDS in migrant laborers in Thailand (PHAMIT) by the Raks Thai Foundation. Theme 3: Projects relating to holistic care and support for children afftected by HIV/AIDS One project was selected under this category. The Integrated Psycho-social and Clinical Care Project by the We Understand group.
II.
Feminization of HIV/AIDS
HIV/AIDS in Thailand shows a tendency to increasingly afflict women. Projections of new infections for 2009 totaled 11,753, 30% of whom are estimated to have been infected by their husband. This trend is consistent with other countries with more mature epidemics. Accordingly, since 2002 there have been global appeals to intensify HIV prevention efforts for women and girls. Although Thailands effort to promote condom use have been successful in some segments of society with highest risk for HIV, condom use has not increased enough in the general population to protect women in love relationships. There are very few cases of best practice in this area since progress has been so limited. To be effective, prevention programs for women need to take a more in-depth view of socio-cultural factors, beliefs and biases which aggravate the vulnerability of women despite their
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strong desire to protect themselves and their partners from becoming HIV-infected. The feminization of HIV/AIDS in Thailand does not mean that we only focus on women and girls. Instead, there is a need to address values, rights, and prejudices in society at large. Improved sex education for boys and girls, and health services that are more couple-focused are important areas in need of best practices. The following describes four of these projects. The Real Lives and Voices & Choices projects are best-practice examples of how to improve communication about sex, gender, and sexuality among PLHA, using a friends-help-friends approach. Both projects try to promote improved communication to augment the quality of life, care and treatment, reproductive health, and prevention of repeat infection for their beneficiaries. The starting point of the projects differ somewhat. Real Lives starts with men and women who come for ART, whereas Voice & Choices reaches women coming for ante-natal care (ANC) and focuses on strengthening positive womens self-determination in sex and reproductive health. Over time, husbands and partners are brought into the program. The couple ANC project works within the public sector ANC clinic setting to help pregnant women who are HIV-negative to remain negative. A key strategy is to provide couple counseling so that there is better communication about sex, leading to successful prevention of HIV. Similarly, the Teenpath project promotes improved communication about sex through a strategy of comprehensive sexuality education for school-based youth. Teenpath is working at multiple levels including national policy, educational institutions, teachers, in addition to working with the students and their parents. The project aims to help teachers become change agents in promoting sexual health for youth, and promote healthy
adjustment among youth to their own sexual orientation and preferences. The lessons and challenges of these four best practice projects are as follows: 1. Creating a safe space for learning about sex for couples across a range of diverse sexual lifestyles. Communication for comprehensive understanding of where one fits in the sexuality continuum, and how to lead a fulfilling, safe and healthy sex life. 2. Creating a sense of empowerment in women and girls to understand and confront the source of their relegation to secondary status in terms of gender and sexuality. They develop the ability to communicate their sexual intentions and desires in a way that leads to a healthy and fulfilling sex life. 3. Couple ANC and comprehensive sexuality education create a space for full participation of the relevant persons in pursuing sexual and reproductive health across the range of partnerships and sexual lifestyles. An important challenge is the dissemination of the lessons and methods of these best practices so that they are more widely applied in the national AIDS prevention and control program efforts. The challenge is to improve the potential and balance for self-determination in sexual relationships through better communication and understanding of HIV risk, and recognizing the role that ingrained socio-cultural norms and beliefs play in affecting ones self-determination. Ultimately, this issue relates to human rights. The degree to which those rights are realized interacts with lowered or elevated risk for HIV.
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AIDS Network Development Foundation
taking ART. An important element of this concept was to address those challenges mentioned above in a way that entailed full participation of the intended beneficiaries, building on their knowledge, experience, and wisdom. Peer leaders were recruited and trained to extend and expand this wisdom throughout and beyond the PLHA network beginning with the holistic care centers, where services provided by PLHAs in conjunction with hospitals, as a focal point.
Process of implementation
Real Lives Project
Background
Since the year 2000 going forward Thailand has made great advances in extending the availability of ART to more and more PLHA. By 2005, ART was included in the package benefits under the National Health Security Program (NHSP). This development greatly reducing the pain and suffering of living with HIV/AIDS but did not necessarily address other dimensions of a quality life such as prevention of re-infection, sexual life planning for safety and satisfaction, love relationships, pregnancy, visible side effects of ART, and harmonious living with others in society. The Real Lives project aimed to address these other dimensions and challenges of living with HIV that successful ART hasnt always overcome. In 2004, the AIDSNet Foundation consulted with the International HIV/AIDS Alliance on developing a model and guidelines on improving the quality of life for PLHA who were
AIDSNet and the Alliance entered into consultations with PLHA and the PLHA network branch in the upper north of Thailand. Once the concept of the model was fully articulated, a pilot site was chosen for a trial implementation among 13 PLHA groups in 2005. The pilot was successful and was expanded to cover the entire network of PLHA support groups in the upper north of Thailand by 2007. Certain local hospitals in this sub-region were also involved. The model is being expanded to other parts of the country. A curriculum was developed containing five modules under the topic of Real Lives, entailing seven types of activities as described below: Activity 1: Viable options for prevention of HIV/AIDS (The three boats) This activity promoted exchange of information among group members about prevention options with an emphasis on abstinence, mutual fidelity with one person with condom use, and condom use with multiple sex partners. Group members discussed the pros and cons of each option and provided moral support for each others sexual lifestyle, always with an emphasis on prevention, even if one had to change from one option to another.
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Activity 2: Safer sex This activity helped participants view the hierarchy of risk, acceptance of a safe sex lifestyle, promotion of correct condom use, and skills building in negotiating condom use with a partner. Activity 3: Curable STIs This activity helped participants to recognize symptoms of those STIs that can be effectively treated. This activity also promoted STI prevention and informed participants of local, qualified outlets for STI diagnosis and treatment. Activity 4: Disclosing ones serostatus This activity encouraged participants to discuss planning and readiness to reveal ones HIV+ serostatus to others with a sense of safety and satisfaction. Activity 5: Rejection by the community and accepting oneself This activity encouraged participants to discuss the origin of discrimination and rejection by others to participate equally in the community. The group also discussed ways out of these problems through self-help, self-acceptance and self-determination. Activity 6: Reproductive health and life planning choices for PLHA his activity encouraged participants to discuss options for sexual health and to understand the viewpoint of fulfilling and safe sex from the different perspective of men and women, to increase the prevalence of safe sex in love relationships, marriage and the family.
Activity 7: Planning ones life, family formation, pregnancy and problem resolution for PLHA This activity encouraged participants to exchange experience about making life decisions, such as whether to have children, and to review the factors and conditions related to health, economic status, and socio-cultural dimensions. These discussions exposed different viewpoints from the perspective of the PLHA, his/her partner, men, women, the family, community, health care provider and society. This discussion helped the PLHA participants to better understand their reproductive health rights and to make appropriate decisions for themselves and their partner. The activities were applied as part of the curriculum in collaboration with peer group leaders, who would expand upon the activities in spin-off sessions with other network members. Peer leaders would access other PLHA when they came for their checkup and drugs re-supply appointments at the hospital, and reinforce the curriculum content each time with help from other network members. The curriculum and follow-up was continually reviewed, refined and improved through collaboration among the peer leaders, the PLHA network, AIDSNet and the Alliance. Initially, the group activities were supported by special budget allocations; later the project and network supported these activities with funding from the GFATM and NHSP. In some cases the local administrative organizations provided budget to support the activities. During 2006-7, the Real Lives project expanded its implementation strategy to include the hospital(s) and policy makers at the provincial and national level in order to determine the best ways to advance sexual and reproductive heath for HIV+ women and their partners.
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Since 2007 to the present, the Real Lives approach has been integrated with the prevention for positives intervention program being implemented by the Bureau for AIDS, TB and STIs of the DDC. The project is also linked with the PMTCT efforts of the Department of Health (DOH) to help improve the quality of life, care and treatment, and community acceptance of PLHA, and this is an important milestone in the expansion of the project concept. In 2008, AIDSNet collaborated with the Violet Home project (which supports MSM living with HIV) to modify the Real Lives curriculum for use with MSM groups. HIV+ MSM peer leaders were trained in the curriculum and then proceeded to conduct the prescribed activities with their peers.
3. It is important to continue modifying the Real Lives message so that it can be effectively transmitted through word-ofmouth and multiple other channels in order to fully reach those PLHA coming for ARV drug resupply every two to three months, those who dont receive their treatment from the holistic center, and those who are not yet ready to reveal their serostatus. 4. Implementing the Real Lives process on a continuous basis is important in order to ingrain care and support behaviors, and help with sustained planning of new and improved lives for PLHA and their partners.
Successful features
From the initial pilot implementation in the upper north to the present, the Real Lives has been able to reach and help more than 5,000 PLHA. The project has been expanded to the northeast region and other areas in collaboration with the DOH of the MOPH. The level of condom use (last sex) among project beneficiaries increased 20%, Project participants could reveal their serostatus to their par tners more than non-project participants by 20%, and only 12% of project beneficiaries thought it was difficult to reveal their serostatus, compared to 21% of non-project participants who felt this way. The PLHA beneficiaries of the project explained how the project improved their lives and changed their behavior, as in the following words of one PLHA:
Challenges
1. Projects promoting prevention behavior and proper health care among PLHA to prevent further infection with HIV needs to be continually mindful of PLHA rights to choose and ultimately decide for themselves. Implementers need to be sensitive and careful not to further stigmatize and discriminate against this group by refraining from judgment as to whether an action is right or wrong, good or evil. They first must understand the context of the behaviors that the PLHA are confronted with, to see their point of view, and fully respect their human rights. 2. Expanding the Real Lives activities into the area of care and treatment in association with the ART clinics in various hospitals and ANC clinics, requires the skill and involvement of the peer leaders in the holistic centers to implement these activities in the clinical setting with the intended beneficiaries in collaboration with the clinical service providers.
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I learned a lot from the Real Lives activities. This knowledge helped me to live constructively with HIV. The Real Lives was particularly helpful for those in remote areas who dont have access to the common sources of information. Before, they did not think it condoms were still useful for PLHA. But now they know, and they are requesting condoms more often. PLHA age 36 who participated in the Real Lives activities My behavior improved after training. Before, I never used condoms. But the training taught me that I could become infected by other germs or infects my partner. It is important to be aware and concerned about this. If you can accept yourself and your sense of responsibility then there is no need to worry about what others think. However if you worry about what others think and whether they will reject you, then that is a problem. Thus, the best way is to accept yourself and lead your own life. Male PLHA age 29 who participated in the Real Lives activities A preliminary indication of success of the Real Lives project is the improved knowledge, understanding, prevention behavior and health-care seeking, and rights awareness, and planning for health sexual and reproductive health lives with ones partner. This has relieved some of the burden of HIV and HIV risk for women and their partners, for concordant and discordant couples. Not only does this improve the quality of life for direct beneficiaries of the project, but also reduces the spread of HIV in society at large.
The Real Lives has built the capacity and skills in communication and sharing opinions with peer leaders and other infected persons. This is above and beyond the benefits gained from the peer leader through participation in the routine holistic center activities.
Lessons
1. Results of the Real Lives project that relate to how the PLHA beneficiaries carried out their life in a more fruitful way include the following: The participatory discussion process in a friends-helpfriends atmosphere, free from value judgments, helped the PLHA to adopt personal health maintenance behaviors, acquire information and tips from their peers in the group. Thus, this highly relevant counsel and advice was more likely to fit in with their lifestyle and needs. Activity participants learned about the diversity of sex lifestyles and learned how to protect their own sexual health, as reflected in the improved condom use behavior. The exchange of knowledge was especially valuable if men and women could participate together. In this way, they could understand and work as a couple to pursue higher quality sexual and health lives. 2. Lessons regarding the process of implementation include the following: Building skills in the area of exchanging opinions through conversation allowed peer leaders to better help group members to access needed services. There was better understanding of these services, and this facilitated the decision-making process of beneficiaries, resulting in more appropriate and sustainable outcomes.
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Implementation through a participatory approach between the PLHA network groups and AIDSNet was effective in extending the resources of the networks both in terms of structure and strategy, and in the work of the peer leaders through the holistic care centers. This contributed to an overall sense of ownership of the project activities, outputs and outcomes, and made the expansion process that much easier at the provincial, regional, and national levels. 3. In the area of collaboration with health services, it was found that: Creating a space and opportunity for participatory learning among the service providers, providers helpers, service recipients, can help to develop understanding and implementation that takes a more comprehensive view of life, from a broader perspective and deeper in meaning. Building collaboration and cooperation between the peer leaders and the hospital staff who served as mentors in the ART clinic was an important ingredient for good interaction with the PLHA clients. Peer leaders gained confidence and pride in their ability to help the hospital and the PLHA. Quality of life enhancements require good collaboration among the treatment and care services and the sexual and reproductive health services at both the clinical service level and the policy level.
Raks Thai Foundation
Voices & Choices Project
Background
Voices & Choices Project for Positive Women (Phase 3: 2006-2009) The Voices & Choices project has the guiding principle that building the capacity of positive women peer leaders through a process of learning and empowerment will result in promoting inner strength and positive change in the persons life. This process involves self-examination and others in a safe environment in which people listen to each other in a nonjudgmental way. This helps to break the ice so that frank discussion of sex, power relations, gender roles, and realizing sexual and reproductive health can take place. Participants have greater selfawareness, accept their friends and peers more fully, and can acknowledge mistakes when applying their new knowledge and skills without feeling guilty, but as a learning experience. This gives
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them confidence to communicate and share information and experience that is useful to others. These peer leaders are key to the expansion of the project activities with the goal of promoting sexual and reproductive health of women living with HIV. The project also aims to promote self-determination among these women in making and carrying out life decisions. Because most Thai men do not prefer to use condoms in a love relationship, many women have become infected through no risk behavior of their own. Mutual monogamy is a strategy too late for them. In the matter of vertical transmission of HIV, women are subtly seen as the perpetrator of transmission. Thus, nearly all Thai pregnant women are screened for HIV. When they learn the results, it is hard for them to accept their serostatus, the implications for the pregnancy, and the family problems that will result. Some are abandoned by the husbands or partners. Some are pressured not to have children. Others are sterilized without their consent or knowledge. Society is not very aware of the suffering these women experience since they have no voice, and are only seen as the immoral spreader of AIDS. During 1999 to 2002, a study was conducted of positive women in Chiang Rai, Khon Kaen, and Bangkok (Voices & Choices Phase 1) with support from the Ford Foundation. The study was expanded to include Ranong and Narathiwat in the South during Phase 2 (2002 to 2005). This phase was collaboration between the Life Force Group and the Raks Thai Foundation. During this phase, positive women were trained to be counselors at the hospital, given their personal experience with HIV. The counseling and interaction among these women showed that many positive women initially dont understand why they should be suffering this fate. At this stage, they are given moral support and are helped to accept the HIV+ diagnosis so that can face the subsequent challenges. But many are not able to cope with
or overcome the many obstacles and problems, especially those related to sexual and reproductive health. In Phase 3 of the Voices and Choices project (2006 to 2009), implementation was expanded to strengthen the inner strength and assertiveness of the women with respect to sex and partner relations. The project used a friends-help-friends strategy to implement this component. The peer leaders first had to learn about themselves and to know how to take care of themselves, before they could begin to help others. They also learned how to work with the staff mentors of the local hospital and other allies in the network of providers both at the implementation and policy levels.
Voices & Choices was implemented in 15 provinces, including each geographic region of the country: North: Chiang Rai, Chiang Mai, Phayao, Lamphun East: Chanthaburi, Trad Central: Samut Prakan Northeast: Ubol Ratchathani, Srisaket, Udon Thani, Khon Kaen South: Ranong, Surat Thani, Pattalung, Nakorn Sri Thammarat Voices & Choices started out by recruiting and training peer leaders among women living with HIV. The first cohort included 30 women and was expanded in Phase 2 to include training on inner strength and capacity building. They were encouraged to share intimate details about their sex life, power dynamics, and gender relations. These activities took place in a safe space with careful, non-judgmental listening. Ultimately, the project produced 95 peer leaders in 15 provinces who were able to spread knowledge
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and understanding to help reduce risk behavior for improved sexual and reproductive health. Approximately 3,000 positive women were reached and served by the project. The project trained the peer leaders so that they achieved a sufficient level of self-awareness and confidence, and could understand the root causes of their predicament, and view it not as a matter of fate or karma, but as a result of ignorance and inequality in power relationships and the gender roles of men and women in Thai society. At this point, the peer leaders were ready to analyze the problems of their peers despite the different socio-cultural environments and contexts. This knowledge was converted into a curriculum as guidance for friends-help-friends activities to determine the best way to help each woman in a manner that would be most appropriate for her conditions and circumstances. The first cohort of peer leaders developed tools to help their peers learn about sexual and reproductive health. They compiled the most common problems that women in the different regions faced and, from this, constructed region-specific curricula that could be applied anywhere in the country. Different content of the curricula included the following special issues in addition to the core topics: Northern curriculum: Entering a love relationship; revealing ones serostatus, sex humor, STIs Eastern curriculum: Sex happiness, having safe and fulfilling sex Northeastern curriculum: Communication for prevention of transmission in a discordant couple; discussing sex with a child Southern curriculum: Is withdrawal safe sex? These four curricula were adaptable and flexible so that they could be appropriate for a given group of peers. Toward the end of the project, modules on cervical cancer and pelvic exam were added based on expressed need.
The peer educators in each province in the project coordinated with each other to form a regional network, with Bangkok serving as a central coordination mechanism. The peers in each region made appropriate adjustments to the curriculum to make it more suitable to the local circumstances. Each draft curriculum was pre-tested with positive women and couples to improve couple understanding of sexual and reproductive health. The participants gained confidence and ability in negotiating decisions for safe and fulfilling sex lives. After this the activities were expanded to achieve the widest possible coverage, in order to begin the process of breaking down harmful traditions and practices, dispelling myths, and reduce outdated biases about sex that contribute to the vulnerability of men and women. The most continuous activity of the peers and positive women network was the creation of a safe place for positive women to come to share experience and concerns about sex and reproductive health rights, understanding oneself and ones partner. In this way, many more women developed the confidence and ability for self-determination in the couple setting, and were more accepting of their life circumstances as long as they could play a significant role in determining their present and future condition.
Important Challenges
The topic of sexuality and sex lifestyles is not easily discussed openly by Thais due to the generally conservative social atmosphere. This is especially true for women, less so for men. For HIV+ women to be discussing sex can bring even more negative stigma to them from men or others who are ignorant in society. During the three years of implementation (August 1, 2006 to December 31, 2009) the network of positive women in this project encountered many obstacles. These include the challenges
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regarding traditional values of society, misunderstanding, difficulty collaborating with the hospital-based mentors, and the general assortment of problems faced by positive women when returning home to their partner and household. The project network convened periodic experience-sharing meetings to help these women cope. The most common challenges were identified and this led to strategies for addressing these at the field level, department level and ministerial level. This policy advocacy action was an important feature of the project in addressing the specific problems of each locality.
Successful features
The combined efforts of the peer leaders and positive women network members in this Voices & Choices Project (Phase 3) was implemented through a friends-help-friends approach that instilled a deeper understanding of the problems and solutions in pursuing sexual and reproductive health and rights. Participants developed skills in discussing sex with their partner, their friends, and other relevant individuals. The participants felt a sense of ownership of the project, and felt they were part of the project team in advancing the objectives. They continuously built their capacity over time and dedicated themselves to helping their peers. This united force of motivated women helped the project to move toward its goals. The project achieved more than its target of 100 peer leaders and reached more than 3,000 positive women. These women clearly felt they were better able to discuss sex and condom use more assertively with their partner after participating in the project (see the separate statistical evaluation report of the project). Project staff could also clearly observe the changes in the degree of participation and openness of the women during the course of repeated group meetings and activities. Over time, more positive women would bring their partner/husband to join the activities.
Partners of the peer leaders were also effective in mobilizing men to get involved in support of the project objectives. In some sites, the peer leaders were invited to be speakers or resource persons for training activities for school-based and out-of-school youth. Initially, the development and evolution of the project training curriculum and peer network intersected with the other PLHA support group network activities, such that some raised the question of duplication or interference. However, once they better understood the project and what it was doing, the other PLHA networks saw the benefit of linking with the project and learning from its experience and methods. More and more positive women who wish to become pregnant are not discouraged from doing so and are well-treated by the hospital-based mentors who respect the self-determination of the positive woman more than before, as it is their right, not just as PLHA, but as humans. 1. The first cadre of peer leaders achieved greater selfawareness, better understanding of sex, sexual health and reproductive rights. They acquired skills in communication about making sex safe and enjoyable, and to express their desires in an appropriate way to their partner, service providers and other relevant individuals. 2. The project training curriculum was integrated with other courses such as the reproductive health service training of the DOH. Project peer leaders helped with this process and even served as resource persons for the DOH training from the initial pilot stages to the stage of national replication that is currently underway. 3. In the second cohort of peer leader training, 100 positive women were recruited and trained. In turn, they were able to reach over 1,000 PLHA and their partners.
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4. The project activities on sex communication and safe, enjoyable sex expanded to include a male partners forum to increase acceptance and participation. This forum was convened in each of the four regions with 60 male PLHA participating. Most participants recognized the value of better understanding of ones self, ones partners and constructive communication about sex, risk, satisfaction, and safety. 5. Other agencies in the project area are showing greater acceptance of the project principles and objectives. The project peer leaders are invited to be speakers at training events for persons outside the target population of the project such as in the Chiang Rai prison, youth camps in Ranong, Surat Thani, and Nakorn Sri Thammarat, special tutoring on sex education in schools in Ubol Ratchathani, and presentations on sexual health for community residents in Lamphun. 6. Hospital service providers and mentors also participated in project training events and learned more profoundly about the situation of positive women and what goes on in their heart and mind when confronting the challenges of HIV infection. These staff acquired a more positive and admiring opinion of the positive women and this helped to improve the hospital services and coordination with the PLHA peer leaders who were their assistants at the hospital.
3. The topic of sex is still sensitive in Thai society. Discussion of sex issues and training in this area needs to be conducted in a safe space, with careful and non-judgmental listening. This should be done with a group or organization that can provide financial, technical and psycho-emotional support to the beneficiaries.
Future directions
In addition to the activities of Voices & Choices supported by the Ford Foundation through the Raks Thai Foundation, the project is expanding the implementation network and mobilizing other sources of support at many levels. The core topics are being integrated into other training activities. Examples of this include the friends-help-friends activities conducted at holistic centers outside the project area with support from the NHSP, the project to care for post partum women of the Thai National AIDS Foundation, and the activities of UNIFEM in their support for projects addressing violence against women in the north and northeast regions of Thailand. The network of positive women created in this project have become an entity unto themselves and continue to conduct activities with the target beneficiaries with support from other sources including the Womens Health Advocacy Foundation and the Johnson & Johnson Foundation.
Lessons
1. Change from within and empowerment is a strong force for women to learn and work toward sexual health and reproductive health rights. 2. Allowing the challenged to understand and face their own problems and find their own solutions yields the most appropriate outcome and improves other areas of their life as well.
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Reproductive Health Division, DOH and the Faculty of Nursing of Burapa University
Prevention of HIV among Pregnant Women through Male Partner Involvement: Couple Ante-natal Care (ANC)
Thailand each year. Therefore, there is a clear and urgent need to work together to find solutions to this problem to reduce incidence of HIV. According to ANC records from Cholburi Provincial Hospital during 1998 to 2004 there were 430 ANC clients who were HIV+. Of these, 214 of their current partners came for HIV testing, among whom 100 were also HIV+ (46.7%). To be successful, any project working with discordant couples must include them as part of the behavior change planning and implementation process. The ANC visits are a golden opportunity to engage both partners in a discussion of prevention of HIV. These visits are also a way to help women reveal their serostatus to their partner in a controlled and safe setting, so that there is sympathetic understanding within the couple, family and community. Thus, couple ANC is one strategy to reduce HIV transmission among discordant couples and improve communication between husbands and wives.
Process of implementation Background

Thailand has been quite successful in preventing motherto-child transmission (PMTCT) of HIV. Around 800,000 Thai pregnant women have received voluntary HIV counseling and testing (VCT) during ANC visits. A woman who is found to be HIV+ receives ARV drugs for PMTCT, and ART for her and her family members in need. That said, there are no standard procedures for ANC clients who test negative, yet may have risk for HIV. In the past the project implementers noticed that there are women who initially tested negative during a prior pregnancy, yet who were HIV+ during a subsequent pregnancy. The proportion of new infections resulting from marital sex is increasing in The Reproductive Health Division (RHD) of the Department of Health (DOH) in collaboration with UNFPA d eveloped a model and guidelines for helping pregnant women stay negative through communication and cooperation with their partner. The model was designed for implementation at ANC and family planning clinics. The first phase of implementation was during 2004 to 2006 in the health promotion hospitals of Bangkok, Ratchaburi, Nakornsawan, Chiang Mai, Khon Kaen, and Ubol Ratchathani. The following are key aspects of the process: 1. At least four couple ANC visits during the pregnancy; 2. Provide information on health and care for the pregnant woman and infant, including prevention of STIs/AIDS, and the role of the woman and man;
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3. Promotion of condom use; and 4. Promotion of couple HIV VCT Next, during the implementation plan period for 2007 to 2011, the model was expanded to regional, general, and community hospitals in many provinces, always emphasizing the male role in protecting the health of the mother and child. Services have been expanded from the ANC and family planning clinics to the post-partum and well-baby wards. Male partners are expected to attend sessions during ANC, post-partum and at well-baby clinic visits. The couple VCT training curriculum has been revised and improved with better techniques for providing post-test results to couples, and persuading male partners to keep attending the project services. The regional health center # 3 in Cholburi, under the DOH, looks after health promotion and reproductive health for nine provinces in eastern Thailand. They have formalized the couple ANC service by including it as part of staff training, with experts from the Faculty of Nursing of Burapa University for nurses and health staff who are responsible for counseling in the ANC clinics of the 25 pilot sites in the nine provinces. Data have been collected from these sites for monitoring and evaluation, and participating hospitals present up-dates of performance, challenges and successes at periodic meetings. In addition, there is regular field supervision and follow-up of couple ANC sites. In-depth interviews are conducted with post-partum women and attending nurses who provided the couple ANC service. The project proceeded with an initial pilot effort in five sites, then adding three more, and expanding gradually overtime while modifying and improving the model during the process of replication. The provincial administrative organization provided support for experience-sharing meetings between pilot and expansion site hospitals.
Couple Counseling
Couple counseling is a process in which the counselor and client develop a relationship to promote self-reflection, understanding, problem analysis, causes and desires, and joint problem solving. Key features of this process include the following: 1. Pre-post test counseling for both the pregnant woman and her partner together; 2. Voluntary HIV testing and other screening tests as appropriate, together; 3. Sharing test results with mutual agreement as to next steps and informing others of the test results. During the couple ANC counseling the counselor helps the couple to see their lives and relationship more clearly, and acts as a go-between to improve couple communication and mutual decision making. In this way, the couple learns more about AIDS, prevention, their health status, and options. The couple gains confidence in the confidentiality of their personal information and agrees to work with the counselor to make decisions about family planning, preventing unwanted pregnancy, and reduce risk of disease transmission. The couple sees the value of each other and looking after each other and the family, and jointly plans their future together.
Results
The results of the couple ANC service in six health promotion hospitals as of 2006 show that a total of 6,126 couples attending couple ANC and agreed to HIV VCT, or 38.7% of the total ANC caseload. See details in Table 1.
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Table 1 Results of couple ANC HIV tests during Phase 1: Up to 2006 Couples 1. Both members of the couple HIV negative 2. Both members of the couple HIV positive 3. Discordant: male partner is HIV positive 4. Discordant: pregnant woman is HIV positive 6,060 27 25 14 % 98.9 0.4 0.4 0.2
Table 3 Results of couple ANC HIV tests in 25 hospitals under the Region 3 health zone for the year 2008 Couples 1. Both members of the couple HIV negative 2. Both members of the couple HIV positive 3. Discordant: male partner is HIV positive 4. Discordant: pregnant woman is HIV positive 1,816 18 19 25 % 96.7 1.0 1.0 1.3
Phase 2 was implemented during July 2008 to September 2009. A total of 724 couples participated in the couple ANC service, or 19.3% of the total caseload of ANC clients. See details in Table 2. Table 2 Results of couple ANC HIV tests during Phase 2: Jul 2008-Sep 2009 Couples 1. Both members of the couple HIV negative 2. Both members of the couple HIV positive 3. Discordant: male partner is HIV positive 4. Discordant: pregnant woman is HIV positive 712 1 2 1 % 99.3 0.1 0.3 0.1
In 2008, the five pilot hospitals in Cholburi Province reported that 358 couples attended the couple ANC service for the first time, among whom 340 (95.0%) agreed to HIV testing. The details are shown in Table 4. Table 4 Results of couple ANC HIV tests 5 hospitals of Cholburi: 2008 Couples 1. Both members of the couple HIV negative 2. Both members of the couple HIV positive 3. Discordant: male partner is HIV positive 4. Discordant: pregnant woman is HIV positive 328 6 5 1 % 91.6 1.7 1.4 0.3
During 2008, results for all 25 hospitals affiliated with the project found that there were 3,242 couples who appeared for couple ANC counseling for the first time and 1,878 agreed to couple HIV testing (57.9%). The details are shown in Table 3.
Lessons
Couple ANC provides another channel to increase togetherness and warmth in the family, especially since it creates an opportunity for men to listen to the needs of their partners and learn how their behavior affects the couples prospects. Couple ANC is especially important for discordant couples to help them find a way to help the uninfected partner remain negative.
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In addition to the benefits to the couple relationship, twothirds of service providers reported that couple HIV VCT gave them an increased sense of happiness and pride in helping the pregnant woman and her partner overcome a personal crisis, improve family bonds, recognize the seriousness of HIV infection, and change behavior to reduce transmission. Nevertheless, obstacles remain. There is still reluctance to use condoms in a love/marital relationship. The condom is still seen as something that is used during commercial sex. Using a condom in marriage shows a lack of trust by at least one of the partners. Depending on the skill of the counselor, couples can be convinced to use condoms, at least for the duration of the pregnancy. During later sessions the counselor can work with the couple for longer-term behavioral adjustments to ensure good reproductive health for both. In addition, discussing sex in the family is still somewhat taboo in Thai society, especially given the gender inequality that prevails. This affects the womans ability to negotiate safe sex or sex on her terms. Another challenge concerns the cost to the couple of the HIV exam. Also, the husband or male partner may not be free on the day of the ANC visit because of work or because he lives in a different locality. Finally, most of the couples are wage laborers and cannot easily get time off from their jobs to attend the minimum recommended number of couple ANC sessions. Regarding the service provider, sometimes the large caseload prevents thorough or complete interaction with a given couple. There is too few trained staff to meet the need, and these staff also has other obligations outside the ANC clinic. Some staff see ANC services as being for the woman only. Having men in the clinic increases the burden to these staff and may cause discomfort among other female ANC clients. Some facilities do not have enough private rooms for the counseling session, and this reduces
the sense of confidentiality. In other sites, the hospital administrators were not fully aware of the policy (for couple ANC) and may not have fully supported the idea, resulting in too few staff, budget or facilities allocated for this service. Based on the project experience so far, the following are recommendations for improving the project model and replication. High-level policy makers need to issue clear policy statements and directives in support of couple ANC, including supplemental budget and staffing guidelines to ensure adequate supply to meet demand. The policy makers and senior managers need to issue clear guidance and standards for new ANC cases. As of this writing, the DOH is preparing a set of guidelines for couple-based services, extending from ANC to the post-partum period to help make this a national practice. This will be integrated into the parents school and Sai Yai Rak Haeng Krob Krua projects. In addition, the MOPH should do more to publicize the couple ANC initiative through TV and radio public service announcements. Students in the upper grade levels should learn about couple responsibility and partner communication with each other for prevention of STIs/ HIV and unwanted pregnancy, and the value of couple ANC. The MOPH should help reduce the cost barrier to having the husband come for HIV testing with his partner. It has been proposed to the NHSP to include couple testing as part of the health insurance benefits package. Couple ANC should also be covered by other health insurance programs as well. Companies and businesses should be more flexible in allowing working couples to take leave for couple ANC without losing pay, as long as they show a medical certificate as evidence.
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Program for Appropriate Technology in Health
was developed for an in-school program called Teenpath to be implemented in collaboration with the Ministry of Education (MOE) and the MOPH with support from Round 1 of the GFATM. The first phase of Teenpath was implemented during the five years from October 2003 to September 2008. The results were satisfactory and, accordingly, the GFATM awarded a grant for a six-year, continuing program (R1-RCC) implementation (October 2008 to September 2014).
Teenpath Project
Background
Over the past two decades of the Thai HIV epidemic, both in- and out-of-school youth are at increased risk of HIV infection. The government has not yet systematically addressed this situation. The projects that do exist are usually in the form of pilot efforts with limited scope or among specific sub-groups of youth. Sex education is internationally accepted as an effective way to reduce youth risk yet, in Thailand, given the prevailing socio-cultural environment, significant challenges remain. In 2003, PATH, with over 20 years of experience in working with in-school and out-of-school youth, collaborated with the Department of Disease Control (DDC) of the MOPH, to develop a project to expand best practices in the area of sex education and AIDS to achieve greater coverage of all Thai youth. Initially, a plan
Because sex education still has no clear place in the standard MOE school curriculum it has been difficult to extend coverage of a standard set of sex education instruction throughout the school system, other than as a special or ad hoc activity. In addition, understanding and acceptance of comprehensive sexuality education, or CSE, (covering the six dimensions: human development, relationships, life skills, sex behavior, sexual health and socio-cultural aspects) is still limited among teachers and MOE administrators. As a result, most of the sex education that occurs in Thai schools is related to physiological development, general health and hygiene, and disease prevention. In implementing Teenpath, the goal is to promote a process of change among youth in school, through a strategy that involves MOE policy, school administrators, and teachers so that CSE is widely accepted and implemented continuously over multiple grade levels. The end result is not simply the reduction of HIV transmission among youth, but the creation of successive cohorts of young adults who develop in a constructive way, have healthy and satisfying sex lives and relationships, and are socially responsive and responsible.
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The specific objectives of Teenpath are as follows: To advocate for each school to have a policy which supports the teaching of sex education and AIDS as part of the formal curriculum consuming at least 16 hours per academic year, and creating an environment conducive to healthy and satisfying sex lives for youth. To develop the process of sex education in schools so that it is standard and systematic through the use of activity sets and lesson plans that are tailored for youth, and to develop the skills of the instructors so that they have the requisite knowledge, attitudes, and abilities to deliver sex education in an efficient way. To provide a forum for youth to display their potential, and support youth to be responsible when they become sexually active and can access prevention and sexual health services as appropriate. To create a social network, including the public media, to increase participation in creating an environment conducive to sex education and responsible sex behavior among adolescents. Teenpath focuses on school-based adolescents aged 12 to 24 years. PATH has selected implementation partners in the various regions and sectors to help push for CSE in basic education school, vocational schools, non-formal education classes, and in the network of teachers colleges (Ratchapat University). PATH provides technical assistance and concept development in the preparation of the training curricula and strategies for implementation. PATH also helps with direct implementation of Teenpath in Bangkok and is the central focus of coordination for all implementing partners. In the first five years of implementation, Teenpath had ten partners to help advance the course of CSE in schools. These partners include the Office of the Basic Education Commission,
the Office of Vocational Education Commission, the Office of Non-Formal Education, Ratchapat University (Ayuthaya branch), AIDS ACCESS, the Faculty of Nursing of Srinakarin University, Srimahapo Hospital, the Lampang Provincial Health Office, the Region 5 Disease Control Center (Korat), and the Department of Education of the Bangkok Metropolitan Administration.
Results
The five years of Phase 1 implementation achieved important gains in promoting CSE in Thai schools, as follows: Created model schools which implement CSE at all grade levels and include CSE as a part of the formal curriculum. Created a network of teachers who understand the process of delivering CSE and positive youth development. Created a cadre of CSE resource persons in the project areas. Established a model of CSE for different levels of instruction from high school grades 1 to 6, vocational school, nonformal education instruction, and teachers education college students. Promoted adolescent solidarity for better understanding of AIDS and sex education in the classroom and the community. Youth peer leaders played a role in implementation and were accepted by project partners in the region. Mobilized local resources to support implementation of CSE. News items on CSE for adolescents increased, including references to and quotes from Teenpath partners.
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Table 5 Number and coverage of sites and institutions participating in Teenpath project during October 2003 to September 2008 Site Provinces Education zones High schools Vocational schools Primary schools Teachers colleges Non-formal education Total 76 185 2,589 404 29,691 40 889 Total participating Coverage 71 71 326 242 132 10 48 93% 38% 13% 60% 0.4% 24% 5%
Overall, the evaluation of the project attests that the design and methods of Teenpath were correct, even though the data do not yet reflect statistically significant changes in adolescent behavior. This discrepancy is because behavior change requires a whole constellation of forces working together. Nevertheless, the evaluation did show improvements in knowledge and attitudes about CSE among students in project schools compared with students in non-project schools.
question, analyze and participate fully in the education process. In this approach a wide range of information is made available to the student to help them make informed decisions and develop skills in forming relationships with and accepting others, and forming a sense of mutual responsibility. This is in contrast to an abstinenceonly instructional approach, or one that emphasizes the negative consequences of sex only. A punitive approach to sex education will only aggravate the problem. Instead, a more effective approach is one that allows for open learning through discussion, respect for others opinions, rational decision-making, and questioning things that dont seem right. CSE needs to be implemented in a clear, systematic and continuous way. There should be a formal establishment of eight hours of instruction per term at all levels instead of including it as a special or ad hoc activity for certain students or grades. Importantly, students and adolescents must be encouraged to participate in this process of learning, content development, and ensuring that the curriculum can be adapted to evolve along with changes in society.
Lessons
Lessons from implementation during Phase 1 include the following: Clear policy in support of CSE for all appropriate grade levels is imperative to give the implementers and society the confidence to embrace CSE for adolescents and as a formal part of the school curriculum. Key individuals in the MOE system need to fully understand CSE as delivered through a student-centered approach to learning in which the adolescent has the opportunity to
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III. AIDS Responses for Marginalized People
between the foreign laborers and Thai services. The MHWs conduct outreach to the work sites and residences of the migrant laborers, and the project has established drop-in centers (DiCs) to improve access to primary care and support services. The DiCs and MHWs serve as referral mechanisms for migrants who need services at the local health facilities or hospitals. These two projects are good examples of best practice models for marginalized populations. They share the following positive attributes of a successful project: 1. The heart and success of the service is based on recognizing the value and common humanity of others in need. 2. Delivering prevention, care and treatment needs support from the local and policy levels, and requires effective collaboration between Thailand and its neighbors. 3. The participation of the beneficiary community and volunteers is a critical extension of the project service model. An important challenge of these approaches is to establish a policy and sustainable system of support to extend these services over the long-term, in terms of the performance of the volunteers, the local community, and local health service outlets.
The Chiang Saen Hospital has been developing a model of ART service delivery for border populations in the Mekong Subregion for many years. The service is especially valuable for cross-border populations and foreign migrants who lack any formal access to treatment, either in their home country or in Thailand. The Chiang Saen project is an example of how to mobilize local resources from many different sources through multi-sectoral collaboration and drawing upon local wisdom to develop the service model for disadvantaged populations. At the same time, the PHAMIT project has developed a comprehensive HIV prevention service model for foreign migrant laborers working in Thailand. A key element of the success of PHAMIT has been the creation of a cadre of bi-lingual and bi-cultural migrant health workers (MHW) to bridge the gap
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Chiang Saen Hospital
Anti-retroviral Therapy for Migrants: Experience of Chiang Saen Hospital
Background
In 2004, the Thai government guaranteed to provide ART to all eligible Thais covered under the NHSP. However, this policy did not cover undocumented ethnic minorities and foreign migrants living and working in Thailand. To address this gap in services, the MOPH decided to launch a pilot project with support from the EU and Medecins Sans Frontieres (MSF-Belgium) with collaboration from the Thai PLHA network and the Population and Community Development Association (PDA). The goal was to provide comparable ART service to those not eligible for the NHSP coverage. Chiang Saen was one of two districts in Chiang Rai Province selected as pilot sites, and shares a border with both Myanmar and Laos. The Chiang Saen Hospital also had a sufficient level of readiness to provide the service and a strong PLHA support group. The initial target for the two-year pilot was to treat 30 cases
for OIs and/or provide ART as appropriate. The Chiang Saen Hospital has 30 beds and, at the time of the pilot, had registered 400 Thais for ART under the NHSP, with an indication of more Thais enrolling over time. Thus the hospital staff already had a considerable service burden before the pilot project, and this was aggravated by problems of drug resistance among the people on first-line ART, others who resumed risk behavior after feeling well while using ART, and a variety of other complicated issues. Because Chiang Saen has borders with two of Thailands neighbors and has river links with China, the population of traders has customers, friends and relatives in multiple countries, entailing frequent cross-border travel. As the non-Thais in Chiang Saen who were HIV+ began to develop symptoms of AIDS, they sought treatment at the local hospital. Some were legal migrants, others illegal or undocumented. Almost all were low-income. With more hospital beds being taken up by non-paying patients, the hospital began to incur more and more debt. Yet out of respect for human rights, they could not turn these patients away. Participating in the pilot project was one way to begin to address the increased service burden and unmet need of cross-border populations.
Due to the limited duration of the project, and in view of the need for lifelong ART, the hospital needed to devise a sustainable model for long-term patient care. The hospital clearly recognized that merely providing ART and OI prophylaxis would not address the patients needs in a holistic way. In the first year of the project (2004) the hospital encountered a number of limitations that werent budgeted for in the pilot budget. For example, there was the cost of transportation for referral to the provincial hospital, the cost of home visits by
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PLHA peer outreach volunteers, and other constraints. Initially, the hospital did not publicize the pilot project to limit the demand for service. Clients learned about the service through word of mouth. Criteria for inclusion were that the PLHA had to be at least 15 years of age, living in Chiang Saen, and clinically eligible to receive ART. The Thai PLHA support group members were instrumental in helping the target population access services, and served as interpreters for patients. A key feature of the project was to train patients and their families to perform self-care and home care to minimize the need for hospital treatment. Every six months the hospital convened meetings of Thai PLHA to help share experience with the hospital staff and cross-border patients on self-care. Despite this, three patients died in the first year of the project due to severe drug reaction, which could possibly have been prevented by referral to the regional hospital for specialized care. Thus, MSF joined the pilot project to help support referral transportation costs through a revolving fund managed by the local PLHA network. In Year 2 of the pilot (2005), it was found that a number of PLHA had returned to their home countries, but crossed back to Chiang Saen for drug re-supply on a regular basis. Thus, Chiang Saen created links with counterpart hospitals on the Lao side of the border and, in particular, with Ton Pheung Hospital which had worked with Chiang Saen on earlier AIDS and drug addiction prevention activities. Norwegian Church AID (NCA) helped sponsor this part of the cross-border collaboration and helped build capacity of three border hospitals in Lao (Ton Pheung, Bo Kaew, and Luang Nam Ta). After the completion of the two years of pilot activities, a third year was supported by MSF for continuation and expansion
of the service, which had been proven to be feasible. In this 3rd year, eligibility for participation was extended to those living outside of Thailand; the only condition was that the PLHA could be followed up back home in Lao PDR or Myanmar. At this time, Chiang Saen was also starting to see pediatric AIDS cases among the crossborder populations. These cases are more complicated to treat and Chiang Saen had to adapt its service model to build capacity to manage the special needs of pediatric AIDS cases. In Year 4 of this project (2007) Chiang Saen Hospital and MSF implemented service delivery systems in the Lao hospitals nearest the Chiang Saen border, including a drug bank system, lab monitoring, referral, and record keeping. At the same time, the Chiang Saen Hospital began comparing the charts of Thai and cross-border patients for ARV side effects and found a rather high proportion of cases of lipodystrophy and other preventable conditions. As a response, the hospital developed a self-care manual called Way of Life and Local Wisdom (WL/LW) based on principles of sufficiency economy. Later, local wisdom from Lao PDR and Myanmar were incorporated. Thirty PLHA with experience in managing drug side effects were trained as mentors for other PLHA. In addition, the project developed tri-lingual IEC media and materials to help service providers communicate with patients. Regarding cross-border referral to Lao PDR, initially the Lao hospitals worked in collaboration with Chiang Saen and MSF. Later they linked with Laos own public health network for support. For follow-up in Myanmar, Chiang Saen networked with the Rose Virginia Good Shepherd Association (RVGSA) and local PLHA support groups. Because the Thai government budget was not adequate to support all the drug costs for the cross-border populations coming to Chiang Saen for treatment, the hospital mobilized local
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resources from community stakeholders to help make ends meet. In addition, international and local NGOs continued to support this effort including NCA (which has provided assistance to Chiang Saen over a period of 16 years, PDA which focused its support on socio-cultural dimensions, and the International Organization for Migration (IOM) which helped in linking the cadre of migrant health workers with local PLHA support groups. These networks and linkages continue to the present day and are formally called the Chiang Sean Cross Border Network, or CS-CBN. A key ingredient of this success was the bottom-up approach to collaboration (rather than waiting for multi-national-level agreements and programs among the three countries). Following five years of pilot implementation, the MOPH in 2009 proposed and received GFATM funding for the NAPHA Extension project to expand the model to other sites in Thailand. NAPHA helped fill treatment gaps when MSF discontinued support for ART. However, NAPHA is not able to support all the essential patient costs involved in accessing ART, and support from civil society has also declined in recent years. While the project network has tried to mobilize funds from the local administrative organizations and other sources, this is difficult when the beneficiaries are not documented Thai citizens. Therefore, some PLHA continue to be underserved.
Results
The Chiang Saen Hospital pilot project demonstrated the feasibility of providing cost-effective ART to marginalized cross-border populations in a comprehensive and holistic way. The hospital integrated external and local resources to extend and expand coverage from 50 to 80 to 101 patients in 2006, 2007, and 2008 respectively. As of this writing, 99 patients were being treated including 17 Lao (13 living in Lao PDR), and 82 Burmese (26
living in Myanmar). In a quantitative study of 73 patients during July 2004 to June 2007 it was found that adherence to the treatment regimen was 98.2% at 36 weeks with survival at 96% (three patients died, two from AIDS-related causes and one from an unrelated cause). Not a single patient was lost-to-follow-up or discontinued treatment. Thirty percent of patients needed drug substitution. All patients had improved health and could pursue normal lifestyles in the community. The patients participated actively with others in the network of PLHA and helped as resource persons in promoting HIV/AIDS prevention. A total of four cases became pregnant after starting ART (three intentionally). Chiang Saen Hospital provided standard care for the pregnant women including counseling, PMTCT, postpartum care, and provision of infant formula. In 2008, the DOH of the MOPH launched a project to provide ART for ethnic minority pregnant women. There was active referral among Chiang Saen and other participating hospitals to ensure comprehensive care for these women. The use of WL/LW for self-care built capacity among PLHA, their families and the community to be more self-sufficient in AIDS management. This helped in sharing advice and moral support with other PLHA as well. Through the CS-CBN, the project developed and disseminated multi-lingual IEC media and materials for patients and the community, increasing knowledge and self-care skills for many. The many years of collaboration between Chiang Saen Hospital and civil society contributed to its reputation and the trust it received from the local community. This fostered good participation and local contributions. A good example of this is the revolving loan funds and educational scholarship system that PDA was able to set up for PLHA and their dependents.
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Lessons
The Chiang Saen Hospital developed a feasible system for treatment of OIs and care for PLHA among cross-border populations in the Greater Mekong sub-region in a resourceconstrained setting. Access to ART helped draw patients in to treat their OIs at an early stage who otherwise might not have sought care. The service helped reduce stigma and discrimination among different ethnic groups. Ultimately, each locality needs to identify sustainable sources of care and support without having to cross borders or travel long distances to access these. The project experienced excellent cross-border collaboration among service providers. This was backed up by multi-national policy support. Civil society also helped forge collaborative relationships across borders. All participating groups were united in recognizing the value and humanity of persons in need. The service model had a clear set of procedures that were logical and easy to follow, as well as being adaptable to the changing circumstances of the different service settings. Evaluation and experience-sharing was facilitated by using simple and nonburdensome data gathering methods. The implementers were always mindful of the need to encourage full participation of the beneficiaries in the service process, thus strengthening the PLHA and their families, especially those who became project volunteers to help their peers on a formal basis in all three countries. As long as Thailand, Myanmar, and Lao PDR see the value of continued collaboration, cross-border efforts such as the Chiang Saen model are sure to succeed and expand. There is a need to continue to study these efforts as they evolve.
Raks Thai Foundation
PHAMIT Project
Background
Through regular migration to Thailand by people seeking work, the number of foreign migrants in Thailand has swelled to an estimated 2.5 million persons. Less than half of these are officially registered to work and, therefore, can access the coverage under the Health Insurance Program, organized by the MOPH. Migration in and of itself does not confer AIDS risk, as long as there is access to information, condoms, and reproductive health services, and fair treatment of migrants. Data from HIV surveillance among fishermen during 2002 to 2004 found that 4% to 9% were HIV-infected, with an average of 6.7% and 5.3% infected in 2002 and 2004 respectively.
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Collaboration during implementation

The PHAMIT Project received support from the GFATM for the periods of 2003 to 2008 and for 2009. PHAMIT is implemented by seven organizations including Raks Thai Foundation (as the principal recipient), World Vision Thailand, AIDS Rights Foundation, the MAP Foundation, the Stella Maris Center, EMPOWERChiang Mai, and the Pattanarak Foundation. Other collaborating partners include the Department for Health Service Development, MOPH, and PATH as a technical advisor for delivering user-friendly services to migrants. Project beneficiaries include labor migrants and their families whose home country is Myanmar or Cambodia, and live in 19 coastal provinces and three land-locked provinces. In addition, PHAMIT gives special consideration to migrants working in commercial sex and entertainment industry occupations.
Strategy and activities for behavior change

PHAMIT uses an integrated approach to comprehensive implementation which is flexible and adaptable in field outreach, field services, communication models, condom distribution, and referral for reproductive health services.
The outreach team

The outreach team is the heart of the behavior change strategy. This team conducts activities for migrants in different settings including the worksite, residence, and/or places where migrants congregate and socialize. A network of volunteers assists in the outreach. In the past five years of implementation, PHAMIT has delivered services to over 442,260 persons. The PHAMIT outreach team consists of at least one migrant health worker (MHW) and one Thai field worker. By 2008, PHAMIT had recruited and trained 150 MHWs. The MHWs are recruited directly from the predominant ethnic groups of the migrants. Next they are intensively trained in HIV and reproductive health, with up-dates at monthly meetings, and refresher training once a year. Another key feature of PHAMIT is the recruitment of migrant health volunteers (MHV) from the community of migrants. The MHVs disseminate information and provide continuous reinforcement for behavior change among the harderto-reach groups of migrants. The successful MHV should be a good conversationalist and have some understanding of Thai language. MHVs should be interested in health issues and express a desire to help the community of migrants. MHVs should spare enough time to conduct project activities. Special consideration is given to candidates with good multi-lingual and communication skills, are self confident, and show no aversion to PLHA. Those MHVs who perform the best are eligible to be up-graded to MHW.
The PHAMIT concept

The primary objective of PHAMIT is to increase condom use and reproductive health care for migrant laborers and other populations who are in contact with the migrants. Secondary objectives include: (1) Create a system of user-friendly health services for migrants for prevention and treatment; (2) Create a conducive environment for positive psycho-social adaptation, and strengthen the community of migrants and their families; and (3) Improve the political environment at the national and international level so that it is more supportive of health and treatment rights of labor migrants.
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The MHVs have multiple responsibilities such as distributing condoms and educational material, maintenance of condom distribution containers, reporting of changes in the community, and otherwise are the eyes and ears of PHAMIT. The MHVs also link with the PHAMIT outreach teams to let them know when there is a good opportunity to conduct outreach education, such as when the fishing boats come in to dock (after weeks or months at sea) or when there are migrants with special needs. MHVs help conduct small group activities and provide information in a friends-help-friends format, and provide referral as appropriate.
PHAMIT developed a variety of educational media for the project to promote behavior change and other benefits for the migrant laborers (see table 6). Table 6 Educational media developed by/for PHAMIT by type of media and language Language Type of media Topic
Drop-in centers
In the initial stages of outreach to work sites, which is a crucial step in determining the success of PHAMIT, the field coordinator and Thai field staff meet with the owners and managers of the local companies and businesses which employ and/or interact with the migrants. This includes the health service providers, government officials, community leaders, police, and labor office. The purpose of these meetings is to introduce the PHAMIT project, explain the objectives, and emphasize the activities to promote health and prevent health problems. Another key strategy of PHAMIT is the creation of drop-in centers (DiCs) near to the fishing boat docks. These DiCs are to serve as a place for migrants to relax, to conduct project activities to attract involvement of the migrants, and as a social gathering site. As of 2008, PHAMIT had established 38 DiCs in 21 provinces. A migrant-friendly DiC should be one that is easy to access and conveniently located. It should be a safe space that helps migrants to relax and feel a sense of ownership of the activities there. PHAMIT Thai staff make sure to explain the DiC to local government officials, police and local leaders so the there will be no harassment of migrants at this site.
Burmese
Khmer
Karen
Lahu
Lao
1) Picture storybook; HIV prevention - spread, 2) booklet and leaflet; prevention, condoms 3) newsletter; Sexual and reproductive health - STIs, sexual organ/ 4) poster 5) VCD film; body enhancements and risk, 6) karaoke VCD; family planning, pregnancy 7) tape/CD of songs and child care Living with HIV HIV VCT, 1) Picture storybook; caring for PLHA, self-care 2) booklet and leaflet; for PLHA, ART 3) VCD film; General health diseases 4) poster spread by mosquitoes 5) local newsletter (malaria, dengue), environmental health and CDs hygiene, TB Rights Health rights, labor 1) CDs; rights, human rights, child 2) cassette tapes; education rights 3) booklet and leaflet Pocket book For use during training and to assist the 1) Booklet; work of MHV and MHW 2) poster in health, HIV, community health. Content is in simple language.
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Language Hmong
Type of media 1) Film VCD; 2) local newsletter; 3) picture storybook 1) Karaoke VCDs; 2) sound tape; 3) booklet and leaflet 1) Calendar and planner (for sex workers); 2) poster; 3) leaflet
Topic Local newsletter Relevant news and items of interest to the migrants
Shan
Hours and days for service were arranged to be the most convenient for the migrants; NGO partners were able to lower the cost of travel for service by developing a group service approach ; Improved efficiency of services at the health outlet was achieved by reducing the need for an individual migrant health service. A mobile clinic service helped bridge the gap between migrants and the local hospital. Translators were available to interpret for nurses and doctors.
Thai
Migrant health workers (MHWs)

The PHAMIT MHWs were recruited, trained and deployed in ten provinces with a large number of foreign labor migrants (Chiang Mai, Tak, Cholburi, Samut Prakan, Samut Sakorn, Ranong, Phuket, Pattani, and Songkhla). The MHW assists Thai service providers by serving as an interpreter, and helps with the counseling service for the migrants. The MHW follows up service recipients to see how they are doing back in their residential community. PHAMIT collaborated with PATH, the Department of Health Service Development and other partners to develop a training curriculum and tools for MHWs and health service providers for use in HIV counseling. The following are key objectives of this component: To provide confidential HIV VCT for HIV prevention and health promotion To help translate for counselors To build capacity using the Thai counselor as a mentor for the MHW To expand availability of counseling (e.g., into the ANC clinic, the TB clinic, the STI clinic and other service sites).
Condoms
Throughout the implementation of the project, there was condom distribution for the migrant laborers and entertainment establishment workers. Over 6.8 million pieces of condoms were distributed by PHAMIT partners through 1,920 channels. These channels consisted of: condom distribution containers, and MHVs and work site managers. Condom distribution was conducted during outreach and other field visits.
Improvements to access and delivery of reproductive health services

The DiCs can be considered as a referral nexus for migrants to access diagnosis and treatment for STIs and MCH. The MHVs help as a service liaison, and follow up referral outcomes. By using a client-centered approach, PHAMIT was able to provide enhanced services as follows:
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To more fully integrate PHAMIT activities into the implementation area The MHWs also play a key role in counseling for pregnant migrants seeking service at the hospital. The ANC clinic is one of the most popular health services used by migrants. Fully 2,763 pregnant women have been reached and/or referred by PHAMIT to the ANC service during the project. Nevertheless, there remain obstacles and challenges in the policy area that impede implementation of the MHW role. These include the following: Even though, in 2009, a new category of worker was created in the government system (social worker hired by a foundation), the Ministry of Labor (MOL) would not guarantee that the MHW are covered by this new category since it is viewed as a skilled occupation category. Because government offices are not allowed to hire foreign migrants, this prevents hospitals from formally bringing the MHW into the workplace. Only a few of the government hospitals affiliated with PHAMIT are willing to use their own non-public funds to support the services of the MHW. The relevant offices at the central government offices have not taken any steps to find a way to formalize the MHW function in other hospitals not affiliated with PHAMIT.
link with the local health center and hospital for OI case management. PLHA are encouraged to form support groups to provide additional psycho-emotional support to the infected migrants.
ART for migrants

In consultation with the Department for Disease Control (DDC), an opportunity emerged to use funds left over from the NAPHA project (to extend ART for Thais) to provide ART for undocumented persons, using funds from GFATM Round 1. Of these, 1,527 were migrants, 511 were ethnic minorities, and 87 were refugees.
Results
Despite the lack of continuous HIV surveillance data for migrants, the incidence of HIV among migrant fishermen has declined by a median of 2.0 percentage points (range: 0.7% to 5.0%) between 2004 and 2008. The overall HIV prevalence among migrants remains higher than that for the general Thai population (ranging from 0.4% to 2.5% with a median of 1.4%). The percent of migrants who know that condoms can prevent HIV increased from 79% to 89%. All groups showed increased agreement with the statement: Condom use for every sex is an effective way to prevent HIV. At the same time, among male migrants, self-reported condom use in last sex with a non-regular partner increased from 43% in 2004 to 90% in 2008 (see Figure 1).
PLHA
It has been observed that the number of PLHA among the migrant community is increasing. Many of these infected persons do not want to stop working or return home. PHAMIT has assisted these PLHA with social services and home-based care through training of MHWs and MHVs who conduct visits to migrants who are suffering with OIs. The MHWs and MHVs also
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Figure 1 Average response from all sites: Condom use at last sex by type of partner
97% 90%
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
91%
49% 43%
97%
Sex worker
Non-regular partner 2004 2008
Regular partner
Prevention of HIV transmission leads to requests for treatment The PHAMIT HIV prevention efforts increased awareness among those who learned they were infected to seek help, and required the PHAMIT project to adjust its strategy to accommodate this need. Projects working with marginalized populations need to emphasize rights and community-based approaches The issue of rights and policy has a direct impact on the security of the migrants. Their welfare depends on conditions in the community. To focus narrowly on HIV will not address this need and, therefore, could undermine the success of the program. Thus, working with migrants needs to take a holistic approach by addressing the issue of migrant rights and welfare along with the community outreach for HIV prevention.
The proportion of female migrants who reported receiving appropriate ANC was 93%, an increase of ten percentage points from the previous round of data collection. In addition, in 2008, 88% of migrant women said they were interested in receiving services from the local provincial hospital, and this was significantly higher than the proportion who said so in 2004 (74%).
Lessons
Participation by the intended beneficiary is very important PHAMIT consistently worked to increase the capacity of the migrants in a participatory way, and to take a direct role in the service provision process. This helped to reduce barriers to service and communication.
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IV. Holistic Care and Support for Children Affected by HIV/AIDS
We Understand Group
Integrated Psycho-social and Clinical Care Project
The We Understand group and partners have worked for six years to develop a model for care of children with HIV. The model is based on a foundation of psycho-social care, extending from basic physical care. The model uses the creative arts to help build self-esteem to meet lifes challenges and combat myths and prejudices of society. The model is a holistic and integrated approach to care and support that can be applied at many levels to help children affected by AIDS and other chronic illnesses.
Background
In 2001, the MOPH estimated that there were 2,000 infants born with HIV. This did not include those infected children born to mothers who did not go to ANC due to financial constraints or fear of stigma. Thus, more children are growing up with HIV and suffering the prejudices and abuse of society due to ignorance about AIDS. These children are deprived of adequate socio-psychoemotional and physical care. Growing up amidst discrimination, aversion, abuse and social isolation, absent of a familys warmth and love can lead to physical and psychological injury and can prevent the development of life skills in forging positive relationships with others. Limited education oppor tunity leads to underemployment and vulnerability to exploitation as the positive child grows older.
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Past projects with pediatric and adolescent PLHA have emphasized clinical care, welfare and material support. The psycho-emotional needs of these children have been neglected, even though they can assume equal importance with physical needs in many cases. This pilot project was implemented during 2004-7 in three provinces: Chiang Rai, Khon Kaen, and Petchburi. The project collaborated with AIDS ACCESS in Chiang Rai, MSF-Belgium, Phrachomklao Hospital in Petchaburi, Sri Nakarin Hospital in Khon Kaen, and the Thai network of PLHA. There were a total of 400 children participating in the project, most of who were primary school ages. In addition to coordinating the care and treatment of these children through the public sector, NGO and PLHA support group network linkages, the project also worked with arts and media groups such as the Arts Education Program of the National Brain Trust, the Laem Khom Arts Academy, and the Deo Documentary group. Management of the project was conducted through a working group of representatives from each of the implementation partners, with the We Understand group as the focal point. The project was supported by UNICEF-Thailand, the Australian Federation of AIDS Organizations, with counterpart funding from local organizations, and private donations.
Phase 1 implementation
During 2004-7, the project focused on child needs other than just the physical and clinical considerations. The project assessed the feelings of the PLHA youth and provided counseling and communication opportunities for them. The project helped link the affected children with social welfare and educational support, and conducted community awareness-raising on living
harmoniously with infected children. Later, the model of psychosocial support for PLHA children was developed. This model emphasized including the children in mainstream society through greater involvement in the arts to increase quality of life. At the time, counseling for children was a relatively new area. Thus, one of the first tasks of the working group was to compile and develop media as tools for communicating about HIV with children. The media consisted of books with questions and answers, pictures, VCD, hand puppets, and childrens games. The working group also developed a handbook for working with children, addressing their physical, emotional and social needs. Initially, the project recruited interested children age 9 to 10 years into the pilot. The first cadre included 16 children; the 2nd cadre included 26 children; and the 3rd cadre included 118 children. Every three months arts camps were held for these children. The first step in the process was to use arts to help the children express inner feelings, their hopes and sorrows. This information helped later in the counseling process. At the same time, it was felt that the arts activity was therapeutic for the children in its own right. Part of this was because the children had grown up hearing that children with HIV cant do anything; are weak; will get sick and die soon; they have no value. Thus, at first, many children had not done arts before and didnt believe they were capable of creating anything worthwhile. However, with persistent training, the children realized that they could express themselves, and werent inhibited from trying something new since they were with a group of peers and understanding arts teachers and project staff. This increased their self-esteem and willingness to continue to participate in the project activities, which enhanced the overall learning process.
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The next step was to display the art work of the participants to give them a forum for social expression and increase their sense of value when they presented their creations. Some of the themes of these art exhibitions were as follows: no one catches HIV from living with an infected child; ART for children makes them strong and live normal lives; HIV+ children should be diagnosed and treated as early as possible before symptoms get worse; segregation of children with HIV destroys their quality of life; all children, including those with HIV, can learn how to solve the problems they face. In addition to these quarterly exhibitions, the artwork was used as a method of fund-raising to increase the amount of resources that could be used to help the infected children. The exhibitions and sharing of the art work was done in a way that protected the childs and the familys anonymity, and was always done with informed, voluntary consent. The project working group developed a comprehensive training curriculum covering aspects of physical, emotional, and social health, communicating with and counseling children, conducting activities on sex education, AIDS and life skills, creative arts for emotional development, and training network members to participate in the process. The PLHA support group members in each project area became active participants in the project as supporters of the educational activities and network strengthening to help children living with HIV.
Creative arts for essential knowledge This activity used children from the pilot project to show how they used the arts to learn and develop, so that their peers in other areas could benefit from the process. The project supported the formation of youth volunteer groups. The arts activities were used to integrate knowledge sharing in the area of AIDS, sex, life skills, health maintenance, and income generation. In addition, project staff continued to counsel children and support them in discovering their potential and special skills through the creative arts, and to apply their skills in continued education in the local community to help sustain the learning process indefinitely. Social campaigns These were adapted from larger campaigns, which require extensive resources, to smaller campaigns focusing on the local community, with greater involvement of the local youth volunteers. A website was developed called www.thaipositivekids.com to increase the channels of communication and fund raising. Knowledge and technical development A computer program was developed to store comprehensive data on the children related to their psycho-social health, education, and economic status, to help analyze the best ways to help these children and identify shortcomings. The project model was expanded to the southern region of Thailand (Songkhla and Trang). The project also expanded the population of beneficiaries to include (HIV-negative) children affected by AIDS (in Chiang Rai), and include children with chronic conditions such as cancer, blood and kidney disorders, etc., in Khon Kaen.
Phase 2 implementation
The project continued to implement activities during 2008 to 2010 in the original project sites and expanded to new sites and new groups of children. Key activities include the following:
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Success
Children and their families improved in the following ways: The children experienced internal development from being creative through the arts. This helped them improve selfawareness, identify problems, and see the solutions more clearly. They learned to control their emotions, ease stress, and concentrate. Arts is a way to communicate with others and improve the counseling and assistance process. The children developed positive life experiences with their peer group since they had to learn to work together, adapt to different situations, and build a sense of social responsibility. They developed mutually-rewarding friendships through the project. They could build and promote their life ideals through exhibitions of their creations to the wider society. The children realized their worth as humans, and this helped reduce the negative self-image of the past. They became stronger, especially as their artwork was accepted and appreciated by others. When others witnessed this positive change, it made them want to accept and help the infected children even more. Children increased their aspirations as a result of the project. Before the project, approximately 20% of the project beneficiaries did not practice self-care or show interest in continued education. After the project almost showed more interest in selfcare and continued learning. They said they were happier and suffered less. Nine youth groups comprising 200 youth PLHA at the provincial and district levels were developed by the project to help expand the project activities. This helped in advocating policies for supporting children with HIV. The youth groups were recognized as innovative leaders, and worked collaboratively with adults and their peers.
Figure 2 Draw not a dark night. Draw strength from life.
My father is like the moon that encourages me to move out of the dark. In this picture, I am coming into the light. At first, I didnt know how to do this. But once I could see the light, I could find the way. My future will thus be bright. Not dark, not weak. Clear. With community acceptance and understanding. This drawing is by a girl named Bua age 13, 2004 while a 6th grade student. She did not want to continue her education because of weakness and bullying. Now (2009), Bua is 18 years old and a successful vocational school student. She is also active in the youth volunteer group. She has the following observations about her experience with the project: I help in the arts camps to teach the youngsters how to draw, act in plays, and other arts activities. Many dont think we can do this, but we can and we get better by trying. I tell them that they must have the confidence to express themselves, and we can learn from them this way too. We will walk this road together.
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Project staff and network members achieved success in the following ways: Many different support networks were formed by the project. Participants included the project staff, the child care providers, artists, donors, adults and adolescents living with HIV, all who move obstacles through mutual effort and collaboration. There has been policy improvement for support for children with HIV, including clinical facilities, welfare agencies (public and prihelped give energy to the project. They helped fill gaps and revate), in the university (Thammasat and Khon Kaen) in the area of using the arts for child development and to mobilize society to protect the rights of the child. The project was expanded to other regions, including the South. The network of agencies helping children with HIV has expanded. The project model is used with children affected by AIDS (though not infected), and children with chronic conditions. Social mobilization Exhibiting the art of the children achieved the following success: Viewers of the artwork developed a greater appreciation for the impact that AIDS has on children. Viewers saw the importance of supporting the development of these childrens potential. They saw how arts can help alleviate the problems that children face. There were more requests for art exhibitions than the project had planned on. The media and materials produced by the project achieved wide interest and had to be reproduced in larger quantities. A project booklet contains descriptions of these media, the childrens art work, and content about the project. The number of volunteers in support of the project goals increased.
Lessons
Stigma, discrimination in the family and community related to HIV infection is a key force affecting a childs selfesteem. Children who leave the school system engage in risk behavior more than those who stay in. Thus, reaching infected children early, understanding their emotions, and helping them combat the negative consequences of HIV, and helping them stay in school can help mitigate the impact of HIV in the long-run. A key factor in successfully using the arts to address emotional needs of children needs to create an environment for independent expression, and not try to dominate or steer. The environment should promote good relationships among the children and with the project support staff. The art work should not be over-challenging, and should use simple materials. There should be no value judgments or competitive comparisons of the art work. The training needs to be reinforced multiple times until the children develop an inner confidence that I can do it myself. Discovering ones potential, social responsibility to others and gaining acceptance are key features in developing self-esteem. A childs life is a dynamic interaction between the age of development and the environment. Thus, the project activities to build self-esteem need to extend beyond the duration of the project and continue throughout the childs development, while taking the different life contexts into consideration. Education for youth with HIV about prevention of transmission should be done in a neutral way, careful to not let the infected child feel that s/he is a spreader of disease. Yet, the infected adolescent needs to know how to protect oneself and ones sex partner as they become sexually active. They need to be skilled in negotiating the terms of sex and developing healthy relationships. They need to be able to talk positively about their infection in a way that will not impact negatively on their relationships.
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A key factor in the positive interest in the social campaigns is the exhibition of the art work of the infected children themselves, and the way that the project staff and artists publicized the creative ability of the youth. Even the mass media took an interest in these events. Protecting the rights of the child is an important area of learning for the affected children. They need to play an active role in exposing and preventing rights violations using their creative skills. Supporting staff who work with children In addition to building understanding of the problems that infected children face, these staff need to learn how to use simple methods to work with the children, adjust their attitudes about the childs potential, and reduce their expression of authority as adults over the child. Youth volunteers (friends) These HIV+ youth volunteers play a key role in expanding the project reach to other groups of needy children. This also builds their sense of pride in helping the younger cohorts of infected children. They are more accepted by the children. This helps sustain motivation for them and the child learners. Fund raising through requests for donations and sales of the childrens artwork has helped but not solved the problem of sustainability of the project model. Thus, the project implementers need to continue to request grant assistance to continue to reach the children in need.
Figure 3 Lets work together to build a new world order. Help the uncomprehending become an understanding world.
This drawing was made by Geng, age 14 in 2006 while still undergoing treatment. Geng died at age 15 in 2007. All those who were in contact with Geng admired his strength in the face of such a painful illness, and are trying to continue on in his spirit of determination.
Remarks: The pictures displayed in this report have been reviewed by the children and/or their families and who have given consent for these to be disseminated without identifying the childs full name or family address.
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National AIDS Management Center Department of Disease Control Ministry of Public Health Tiwanon Road, Nonthaburi 11000 Tel:

(+66) 2590 3828-9 Fax: (+66) 2965 9153 e-mail: namc2010@hotmail.com

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Process of preparing the report

The criteria to select best practices are as follows:

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

AIDS Network Development Foundation

Real Lives Project

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Raks Thai Foundation

Voices & Choices Project

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Process of implementation Background

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Program for Appropriate Technology in Health

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

III. AIDS Responses for Marginalized People

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Chiang Saen Hospital

Anti-retroviral Therapy for Migrants: Experience of Chiang Saen Hospital

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009

Report Best Practices for HIV/AIDS Response Thailand 2008-2009