BUILDING STRENGTH ON STRENGTH LESSONS FROM COMMUNITY RESPONSES TO HIV IN NORTHERN THAILAND BUILDING STRENGTH ON STRENGTH LESSONS FROM COMMUNITY RESPONSES TO HIV IN NORTHERN THAILAND Copyright © 2007 United Nations Development Programme Rajdamnern Nok Avenue Bangkok 10200 Thailand Tel: (66-2) 288 2130 Fax: (66-2) 280 0556 Email: [email protected] Web site: www.undp.or.th Design and layout by Keen Media (Thailand) Co., Ltd. ISBN: 978-974-13-1350-1 FOREWORD Thailand’s response to HIV is a story of impressive past achievements and new prevention and treatment challenges. Since 1991, yearly new infections have fallen dramatically and millions of lives have been spared. Thailand has demonstrated that a well-funded, politically supported and wisely implemented response can change the course of the HIV epidemic, and that to be successful, this response needs to be sustained over time, particularly when such efforts begin to bear fruit. The purpose of this publication is to share some of Thailand’s experiences and lessons learned in its response to HIV with other developing countries and development partners within the region and beyond. Thailand is one of the very first countries to have achieved the Sixth Millennium Development Goal target to reverse the spread of HIV by 2015 well in advance of the target date. One of the success factors for Thailand in the fight against the HIV epidemic has been the active involvement of and support for community groups, HIV activists, people living with HIV and non-governmental organizations (NGOs). These groups have pioneered community-based efforts at the local level, and have often initiated activities to further support the public sector’s services and/or to fill any gaps in required services. While this publication focuses on efforts in six northern provinces in Thailand, there are various projects and activities on HIV that have been initiated by community groups in all parts of Thailand, with financial support from different sources, including government, international donors/ NGOs, and their own mobilized community resources. This publication is the product of a joint partnership of the Faculty of Nursing of Chiang Mai University, the Thailand International Development Cooperation Agency (TICA) of the Ministry of Foreign Affairs and the United Nations Development Programme (UNDP) in Thailand. The preparation of this publication brought together key eminent experts, government officials, academics, NGOs and people living with or affected by HIV in a long process of consultations and dialogues. The organizing members for this publication wish to express sincere appreciation to the members of the Faculty of Nursing of Chiang Mai University, who guided much of the work for this publication. It is hoped that this publication will be a valuable contribution for Thailand to share lessons learned and best practices, along with analytical views on key elements and options for such successful cases, with policy makers and development partners within and outside Thailand. iii CONTENTS Foreword iii A Note on Terminology vi What is HIV and What is AIDS? vii Acronyms viii Executive Summary 1 Overview of HIV in Northern Thailand 5 1 Support and Care for Children Affected By HIV 7 2 HIV Prevention and Youth: Promoting and Protecting the Promise of the Future 19 3 Older People and HIV 29 4 Mobilizing the Strength of People Affected by HIV and AIDS 35 5 Faith-Based Responses to HIV 44 6 Developing Community- and Home-Based Care 53 7 Accepting Our Differences: Working with Marginalized Populations 69 Appendix: Statements from Youth Leaders 79 References 84 Contact list 93 A NOTE ON TERMINOLOGY AIDS (acquired immunodeficiency syndrome) is but once aspect of living with HIV. Many people have HIV yet do not have AIDS. HIV can lead to a fall in the number of a certain type of white blood cells and can cause a variety of opportunistic infections. The presence of certain opportunistic infections combined with a low count for a specific type of white blood cells – all caused by the presence of HIV – may lead to a diagnosis of AIDS. The infections and social issues that people living with HIV deal with are all a result of having HIV, but only under specific circumstances can these be directly attributed to a diagnosis of AIDS. Because of this, and in the interest of better comprehending the many effects of HIV, this document rarely refers to AIDS. Instead, this document refers to HIV-related illnesses or infections. However, since some statistics were collected using the definition “AIDS”, those statistics are still referred to with that description. Names that have usually been translated from Thai using the word “AIDS” remain the same. Person living with HIV refers to a person who has been diagnosed by a medical doctor as being infected by the HIV virus and being asymptomatic. If the person is symptomatic, he or she must have physical symptoms that are not severe, such as weight loss, diarrhoea, oral candidiasis and lymphadenopathy. Person with an HIV-related illness refers to a person living with HIV who has the manifestation of the symptoms developed from opportunistic infections, such as persistent fever or respiratory tract infection that causes diseases like pneumonia or tuberculosis. Caregiver refers to a person who provides care directly to a person with HIV or a person with an HIV-related illness without expecting wages or any kind of remuneration. vi What is HIV and What is AIDS? HIV is the abbreviation for the human immunodeficiency virus, which weakens the immune system. Contracting HIV can ultimately lead to acquired immunodeficiency syndrome, more commonly known as AIDS. An immune system weakened by the HIV virus can be vulnerable to certain opportunistic infections such as tuberculosis, toxoplasmosis or a rare cancer called Kaposi’s Sarcoma. Many of these opportunistic infections can themselves be fatal. The diagnosis of AIDS is made for a person living with HIV when he or she has one or more of these opportunistic infections, especially when found in combination with a low number of a certain type of white blood cell commonly referred to as “T-cells.” T-cells are integral to the immune system and help defend the body against disease. A person living with HIV does not by definition have AIDS and may live many years without experiencing HIV-related health problems. However, the weakening of an immune system by HIV commonly causes progression to AIDS. People with HIV and low T-cell counts often take drugs referred to as antiretrovirals (ARVs) to decrease the amount of HIV in their blood and to help improve their immune system. This is known as antiretroviral therapy (often abbreviated as ART). If a person has an opportunistic infection, he or she may take other drugs to treat that specific disease. HIV is most commonly spread through sexual intercourse without condoms, unsafe blood supply practices, not taking proper precautions in medical settings or by injecting drugs with contaminated injecting equipment such as a needle that has recently been used by another person and has not been sterilized. HIV cannot be contracted through sharing food or utensils with another person, kissing, shaking hands, breathing the same air as a person living with HIV, sharing sanitary facilities or undertaking other normal daily activities. vii ACRONYMS ABC “abstain, be faithful, use condoms” (HIV prevention advocacy method) AIDS acquired immunodeficiency syndrome ART antiretroviral therapy ARV antiretroviral AZT Zidovudine (a widely used ARV) BMT Baan Metta Tham (Phayao) CAM Church of Christ in Thailand AIDS Ministry CCCC Centre of Comprehensive and Continuous Care CCN Community Care Network (Chiang Mai) CCT Church of Christ of Thailand CNN “condom, needle exchange and negotiation” (HIV prevention advocacy method) ECI Enhancing Care Initiative GIPA greater involvement of people living with HIV and AIDS HCCP Home and Community Care Project (Chiang Mai) HIV human immunodeficiency virus IEC information, education and communication MTCT mother-to-child transmission NGO non-governmental organization PHO Chiang Mai Provincial Public Health Office STI sexually transmitted infection TICA Thailand International Development Cooperation Agency of the Ministry of Foreign Affairs TNP+ Thailand Network of People Living with HIV and AIDS UN United Nations UNAIDS Joint United Nations Programme on HIV and AIDS UNDP United Nations Development Programme UNESCO United Nations Educational, Scientific and Cultural Organization UNICEF United Nations Children’s Fund VCT voluntary counselling and testing WHO World Health Organization YAPS Youth and Adult Partnership with Schools YFCD Youth Family and Community Development project (Chiang Mai) viii EXECUTIVE SUMMARY Six provinces that are part of Thailand’s Upper North region – Chiang Mai, Lamphun, Lampang, Mae Hong Song, Chiang Rai and Phayao – have borne the brunt of the HIV epidemic in Thailand, accounting for approximately 40 percent of the country’s AIDS cases. Since the late 1980s, a multi-sectoral holistic response has developed in the Upper North which has provided examples of effective practices in HIV prevention, care and support work. Thailand’s past success in reducing the number of new annual HIV infections has made it one of the first countries to meet Millennium Development Goal number 6 of reversing the spread of HIV and AIDS by 2015. This document describes some of the good practices in HIV work that have been implemented. Many organizations have contributed to the development of an effective response to HIV in Thailand. Practicality dictates that only a few can be discussed here. Absence of mention in this document by no means indicates a lack of quality or effectiveness for any organization’s activities or programme. The document focuses on 1.) Providing support and care for children affected by HIV; 2.) HIV prevention efforts aimed at youth and youth leadership on HIV; 3.) Working with older people on HIV issues; 4.) Mobilizing the strengths of people affected by HIV; 5.) Faith-based responses to HIV; 6.) Developing community and home-based care and support; and 7.) Working on HIV issues with marginalized populations.