Bangkok Post - November 30, 2005
Vitit Muntarbhorn

The HIV/Aids epidemic continues to wreak havoc and poses a pervasive challenge for the world community. The latest Aids epidemic update from United Nations (UN) agencies indicates some 40.3 million people living with HIV in 2005, while the number of those newly infected with HIV is 4.9 million. Aids deaths in 2005 total some 3.1 million people globally. In Thailand, statistics for 2004 indicate some 570,000 of those with HIV/Aids, with some 58,000 Aids-related deaths in 2003.

Thailand has often been cited as a success story in tackling the epidemic, and there are valuable lessons to be learned - while inviting caution against complacency. In the early 1990s, the HIV infection rate was around 140,000, but effective policies helped to reduce this to some 21,000 in 2000.

Credit on this front was due to various factors. A comprehensive national plan was evolved from the beginning of the 1990s to address the issue in a humane manner. Not only were prevention programmes introduced extensively, such as on condom use and related education, but also the message was to counter discrimination and respect the rights of those living with HIV/Aids.

There was broad mobilisation of both the government and non-governmental sectors to cooperate in addressing the issue, aiming for openness rather than denial.

Currently the country is in the midst of the 3rd National Plan (2002 to 2006) that highlights the need to reduce infection rates among adults, the reinforcement of access to care, and the mobilisation of localities, including local administrations and civil society, in action to prevent and mitigate the problem.

There is also increasing emphasis on enabling those with HIV/Aids to have access to antiretroviral drugs to help attenuate the infection. There have been commendable lessons in regard to the country's priority in enabling pregnant women to access these drugs to prevent mother-to-child transmission.

Yet, the epidemic is posing additional challenges today. First, it must be recognised that the problem is mutating. In the early 1990s there was much emphasis on action to deal with the spread in the commercial sex sector, particularly through 100 per cent condom use in relation to brothels and "direct sex workers". Today, it is those involved indirectly who need to be targeted - such as services beyond traditional brothels. The infection rate has been rising in some parts of the country, a testament to weaker information and prevention campaigns.

Second, not enough has been done to tackle the spread of the disease in regard to those using drugs illegally, particularly intravenous drugs users - those using needles. UN statistics indicate some 35 to 50 per cent of this group are being affected - and the spread is also to their partners.

Globally it is interesting to note this worrying dichotomy: Many drug users who are customers of sex services avoid using condoms, while many drug users who provide sex services also shun condoms.

Countries are often in a quandary as to what harm reduction techniques are to be promoted. Thai authorities are reticent to adopt needle exchange programmes, since there is a tendency to classify the use of needles among drug users as illegal. The campaign on the part of the authorities a couple of years ago for "quick fixes" in eradicating drug users posed additional problems due to the myriad of alleged extra-judicial executions - which are still unresolved today.

Third, there is the issue of adolescents. Statistics indicate a rise of infections among this group. To what extent is there an effective prevention campaign such as condom use on this front? This is a persistent cultural challenge since the more conservative sector of society claims, with a tint of moralisation, that access to condoms may fuel more sexual activities among the young (catchword: "Promiscuity"). There is the still-prevalent cultural taboo against educating the young generation about safe sex techniques; one lobby advocates abstinence as the key to prevention. In this regard, there are recurrent stories of condom machines being pulled down by conservative forces.

Fourth, while in the 1990s the misleading classification that HIV/Aids was a "gay" phenomenon was debunked by both the national policy and reality that the disease affected all groups - heterosexuals and others, and was crossing over into families with dire consequences for women and children, the issue of the spread among men who have sex with men is emerging today, as the infection rate among this group is on the rise.

Fifth, there seems to be a decline in the national budget accorded to anti-HIV/Aids programmes, while prevention campaigns have become less sustained. Although the country has a national committee that deals with the issue, it seems to be less energetic than in the past, perhaps due to the tendency to see the HIV/Aids problem as lower priority. There is the crunch of how to translate the national policy into decentralised programmes involving local players, such as the Tambon (district) administrative organisations.

Those shortcomings are compounded by the exclusion of a number of those living with HIV/Aids from enjoying their human rights, particularly from the angle of equal treatment and non-discrimination. In a UN study on Thailand in 2004, it was noted that a quarter of these people complained that they had been stigmatised due to their HIV status, while some 40 per cent claimed that there had been breaches of confidentiality in their health status.

This had, and has implications particularly for the medical sector and the employment sector, where the issue of privacy and human rights was, and is at times raised.

The discrimination factor is also mutating. Today, various groups who are already marginalised are being doubly or multiply victimised by HIV/Aids-related discrimination. On the one hand, it is well known that a number of children living with HIV/Aids are bullied at school, are prevented from entering school, or are driven out of school due to stigmatisation. On another front, the issue of non-discrimination is tested to the limit in regard to minorities and ethnic groups, including hill tribes and migrant workers. A challenging area is the Muslim population in southern Thailand, and there is the question of whether prevention programmes reach out to such groups effectively in a culturally sensitive, and today violent environment.

To overcome the exclusion factor which is both a cause and consequence of discrimination, there is a need to improve access to services and a human rights mindset with various dimensions.

First, access to information. This implies the need for more outreach programmes aimed at preventing and mitigating the spread of the disease, including creative and participatory awareness campaigns, condom availability and accessibility, safe sex techniques and harm reduction measures. More should be done to address risk-prone behaviour and reach out to the various groups noted above, such as indirect commercial sex workers, drug users, adolescents, men who have sex with men and mobile populations such as migrant workers.

There is also a need to discard arbitrary anti-drugs programmes which lead to violence against drug suspects and to approach the situation more from a community-based, rehabilitative angle.

Second, access to education. This calls for guaranteed entry of all children into the educational system and protection from discrimination and stigmatisation. At school, there is the importance of teacher, student and parent activities and associations to nurture understanding of the HIV/Aids phenomenon and to counter misconceptions about the disease which lead to the exclusion of those with HIV/Aids from their right to education.

Those living with HIV/Aids have a key role to offer peer education to others so as to foster mutual understanding. On another front, there is the importance of ensuring access to at least primary education for all children, including stateless children and the children of refugees and migrant workers, as a basic right. There is also a need to work with religious and community leaders - especially their liberal wings - to act as a force for educating the public, particularly in culturally sensitive areas, about prevention of HIV/Aids and non-discrimination, eschewing a moralistic tone.

Third, access to medical care. Although Thailand is targetting increasingly many of those with HIV/Aids in their access to antiretroviral drugs, there is still a need to work towards universal coverage of all who are affected by HIV/Aids. Fortunately flexibility in the intellectual property regime and related patents has allowed the production of these drugs at more moderate prices, and this process needs to be maximised to ensure more extensive access to those with HIV/Aids, in addition to providing medical care free or at least at reasonable prices. Likewise, access to medical services as a whole should be promoted on a non-discriminatory basis. The medical profession has a key role to encourage its members to ensure confidentiality and the right to privacy, and to provide incentives for ethical conduct.

Fourth, access to equal opportunities. This implies opportunities in a variety of sectors, including employment, vocational training and economic channels. As an example, Thailand already has a business coalition on Aids which helps to promote good practices in the workplace, such as voluntary testing for HIV/Aids, related counselling and non-discrimination. There is the call to promote the understanding and practice that those with HIV/Aids can continue to work on a par with others, in keeping with their skills, capacities and capabilities.

Fifth, access to remedies. A most sensitive challenge is what to do when there are violations of the human rights of those living with HIV/Aids. Clearly, although the judicial system may provide some legal remedies, those affected are unlikely to resort to such system for fear of exposing their identity with the looming potential of more stigmatisation. There is thus the need to explore a various of remedies and related mechanisms - formal and non-formal. In regard to the latter, various non-governmental organisations, related centres and shelters play a key role in advocating protection and in seeking justice for those affected.

In effect, the issue is not only one of legal remedies but also socio-cultural and political pressures for accountability. When gauged from the perspective of more decentralisation in the country under the current national plan, there is an essential role to be played by local organisations and personnel - governmental and non-governmental - to exert pressure for responsible treatment of those with HIV/Aids. For instance, the Tambon administrative organisations offer an opportunity for the concretisation of local workplans on HIV/Aids and a catalytic window for HIV/Aids-related programming, with local resourcing.

Significantly, under the new child protection legislation in Thailand, every province is due to have a child protection committee, composed of both public officials and civil society, and this system offers monitoring and a mechanism, albeit nascent, to protect children living with HIV/Aids from discrimination.

Inclusive policies towards those with HIV/Aids ultimately depend upon the fostering of the knowledge base, attitude, skills and behaviour embodying non-discrimination. They are propelled by good examples, sustained political commitment and resourcing, and broad public participation, of all age groups and genders, including those living with HIV/Aids.

Vitit Muntarbhorn is a professor of law at Chulalongkorn University. This speech was prepared for the 60th anniversary celebrations of Unesco. He has helped the UN in a variety of capacities, including as expert, consultant and special rapporteur.

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