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This image showcases the different types of public health interventions that countries can use in eradicating diseases within their local populations. Specifically, this image deals more with HIV. HIV eradication would allow for millions of lives to be saved worldwide.

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Thailand's current status toward their 90-90-90 shows us significant progress made throughout the years. This image showcases the 90-90-90 goal since the first HIV case in 1984.

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This article, like the Thailand one, showcases the barriers that men go through within the topic of HIV services. Particularly, Zimbabwe men face the social issues of toxic masculinity in portraying the idea of strong, highly sexually active, and economically productive. These social norms have been preventing many men from accessing services and less supportive social spaces.

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Whilst we did not interview men who had failed to take up services ourselves, our data set included a lot of talk about men and services and a general consensus, echoing findings from elsewhere in sub-Saharan Africa, that fewer men than women made use of HIV services and often only when seriously ill.

"Even in our cohorts, we have very few men. We can initiate a cohort of 30 patients, you will find only one male and the other 29 will be women." Claudius, nurse

Our informants' accounts of men's journey from realising they may have HIV and fearing the consequences of it, to having come to terms with their status and enrolled onto an ART programme, converged on a small number of common themes which are detailed in our thematic analysis.

Social constructions of masculinity

A clear representation of hegemonic masculinity dominated people's accounts of their social reality and their explanations of why men did not take advantage of HIV services. Whilst it was clear that not all men subscribed to this notion of hegemonic masculinity, and others had managed to resist it in making the decision to be tested and treated, it served as a very clear and identifiable reference point in all the interviews. People engaged in constant debate with this notion of masculinity, taking up different positions in relation to it, but always using it as a yardstick against which they defined themselves.

Characteristics of 'a real man'

Men's experiences of self and other were constructed around their accounts of those 'manly' characteristics which distinguished them as superior from their 'weaker' female counterpart. Men perceived themselves as physically strong, tough, resilient, problem solvers and capable of withstanding 'little illnesses'.

"Men are just stronger in terms of resilience... as men, we have been given toughness such that we can pull through even the most difficult situation." James, patient

Women spoke of men differently and often with an awareness of the kind of pressure men were under to be 'a real man'. As Marta, a nurse, also points out, men do not want to show fear. Men are not supposed to show emotion or anxiety about their own welfare. On the contrary, showing they do not care is an essential way in which they 'perform' or construct themselves as men.

"Men, as I see them, don't want to know about their status when they are fit and strong, they do not want to appear afraid I think. Not wanting to know what their status is, is like saying 'I'm strong I'm strong'." Marta, nurse

Charles comments that such expectations make it particularly hard to be a man.

"I feel being a man is really hard in this community. Once you finish school, parents will not help with anything if you are a man. It is different with ladies who still receive the support of the family even when they finish school. Men are expected to be hard enough and strong enough to look after themselves. So I feel the community expect a lot of toughness from us men." Charles, patient

Charles, a man who had managed to access and benefit from services, shows some insight into the socially constructed nature of masculinity in this context. In our study, in accounting for their own acceptance of their HIV status and need for help, male patients often described themselves as different from other men in this regard.

Men's roles and responsibilities

Being 'a real man' translated into many roles and responsibilities. Men, for example, were perceived as household providers and the ones to carry out responsibilities requiring physical strength, whilst women do household duties such as cooking, cleaning and caring for children.

"In terms of household chores, men are supposed to do all the manly duties like looking after livestock and doing most of the farming, while women concentrate with things like fetching water, washing and cooking for the whole family. In this community it is generally men who are supposed to make sure they provide the financial needs of the family, so this includes paying school fees for children." Emmanuel, patient

Such perceptions pressure men into believing that those who cannot fulfill their roles and responsibilities as breadwinners and heads-of-house are not 'real' men, fathers or husbands. It is precisely such perceptions that add to the stress of manhood, making it difficult for men to behave in counter-stereotypical ways. However, as Charles indicated earlier, male ART patients who have come to terms with their HIV status and the physical limitations that come with the disease, adopt a different and more reflective masculinity. Carl, another patient who has constructed a non-hegemonic account of his own masculinity, indicates that, in this family, his AIDS has encouraged them to adopt more fluid gender roles and he gladly engages in cooking and child minding.

"People say that cooking and child care are duties of the wife and any man who does such kind of duties is either bewitched by the wife or is just weak (he laughs). But I don't see anything wrong in cooking and looking after the children when I am at home. Doing such chores can help me because, if my wife falls ill, I will be able to cook for her and the children. I just feel I should be prepared for such kind of situations." Carl, patient

Sexuality and manhood

Whilst a few men, particularly HIV positive men on ART, managed to renegotiate their masculinity in ways that enabled them to access services, men were generally portrayed as engaging in activities that demonstrated their sexuality and manhood. Men were perceived to be 'sexually unstoppable' and whilst men generally needed to appear in control, this was one area where men could admit to being out of control, a 'weakness' leading men to spend considerable time and money in beer halls.

"After getting drunk, some men lose control and end up fondling any woman they come across, that is a weakness of men. Also, men can easily spend all their earnings on alcohol." Godfrey, patient

Unlike women, it was considered normative for men to have extra-marital relationships. Often these required some level of maintenance, taking much needed money away their wives and children. One patient (Samson) said wives were so used to their husbands' infidelities that they readily forgave them for it.

"Men have this weakness of having extra-marital affairs if they are married, or just having more than one girlfriend. It's unfortunate that women have kind of accepted this weakness of men. So much that, if their husbands do that, they are ready to just forgive him and move on with life." Samson, patient

What Samson's quote underlines is an intrinsic acceptance of local constructions of men's sexuality. Men's need to assert their sexuality and manhood is seen as a 'matter of fact'. Not only does this representation serve to justify men's extra-marital affairs, but it also puts tremendous pressure on men to perform and demonstrate their sexuality/manhood. Men's sexuality, roles and responsibilities are under threat by HIV/AIDS, and the reactions of many men, as the next section will show, serve as barriers to men's uptake of HIV services.

Barriers to men's HIV services uptake

Men's fear of HIV

Many of our research informants spoke of men having a profound fear of HIV, preventing them from timely HIV testing and treatment.

"Men are generally afraid to be known that they are HIV positive. They are shy and they may only come out after they get seriously ill. Some men are afraid that people in the community will laugh at them or look down upon them for being HIV positive." Johnson, patient

Being HIV positive not only compromises a man's sense of masculinity, it is also a sign of a man being unable to control his sexuality. Whilst having multiple sexual partners is a sign of virility, many men reported feeling embarrassed from failing to protect themselves. Fearing they will lose their dignity if found to be HIV positive, many men opt to ignore HIV services, or if they have been tested, hide their status from their wives and do not seek treatment.

"Sometimes they will not even tell the truth to the nurses fearing that everyone might know that they contracted an STD from their sleeping around. I think this is especially true for men. Some men are getting to the extent of dying with these STDs without seeking treatment, they even hide such illnesses to their wives." Spencer, patient

Although it may be counterintuitive for men to report feeling guilty and embarrassed about their extra-marital affairs when having multiple girlfriends is one way to demonstrate their masculinity, it appears that a healthy sexuality is intrinsically linked to a hegemonic masculine sexuality. A man who engages in extra-marital sexual relationships and gets an embarrassing disease like HIV is perceived to have a weak, diseased, compromised, laughable and despicable sexuality - compromising his manhood. Relatedly, admitting to such a tainted sexuality may compromise a man's relationship with his wife. A number of men feared being left alone should their wives learn that they are HIV positive. Also young men feared that their tainted sexuality would limit their chances of being with women and eventually finding a woman who would take of them.

"For the young men who are still single, they also think about whether they would still be able to get married as they fear that their girlfriends may just shun them if they test HIV positive." Sunny, patient

Delusion, denial and diversion

Men like to see themselves as all-knowing and dominant. To admit there is something they do not know may imply lack of power and will put them in the position of a 'learner', a subservient and unmanly trait. Grounded in a fear of HIV, many men therefore appear to be in denial regarding the seriousness of HIV and AIDS - preventing them from accessing HIV preventative information and from seeking HIV services. As Spencer suggests, men will actively avoid spaces where AIDS is being discussed.

"I think the reason that is there is men who don't want to come out in the open, they want to hide and they don't have the knowledge. If they hear of a place where AIDS is being discussed, they don't want to go to that place, so men do not have that much knowledge." Spencer, patient

This, coupled with a demonstration of macho fatalistic risk taking and holding on to very rigid, inflexible and insecure positions, means many men continue to be at risk of HIV.

"Men are dying and they don't want to be tested. You hear them saying HIV is like an accident and people cannot stop driving because of accidents, so some men will not change their behavior." Stuart, patient

Men tell themselves many things to justify their behaviours. For example, some see HIV as a disease that only exceptionally promiscuous men will contract and therefore not at risk themselves. Illustrating the deep denial of HIV in many men, Godfrey describes the different ways in which he sought to deny that he had contracted HIV.

"I did my own inventory of the women I had had sex with, and I could not even single out one of them as potentially the one who gave me the infection. I really did not believe it. Then I used to feel that I was just unlucky because I knew men who were doing worse things but still going on fit. I got to the extent of even questioning the existence of HIV/AIDS because I thought, if it really existed, why were some very promiscuous men escaping the infection. I also thought even that machine that was used for my HIV tests could have been defective." Godfrey, patient

Whilst Godfrey blamed the HIV testing procedure in his attempt to avoid the reality of AIDS, other men resorted to drinking alcohol. Not only did this contribute to the continued spread of HIV, but also the avoidance of HIV testing and ARV adherence.

"Some men will drink so much that they forget to take their drugs, and even forget that they are patients on ART." Carl, patient

In an attempt to save some dignity, men were reported to blame their wives for bringing HIV into the family. Whilst no men admitted to blaming their wives, this was commonly reported by nurses and female patients.

"Men are stubborn sometimes. They blame the wives for bringing the disease into the home in an attempt to preserve their role as head of household." Bridget, patient

Masculinity conflicts with 'patient persona'

Many men were also alarmed by what it means to be an HIV patient. Not only would men have to admit they were ill and own up to their physical limitations, they would also need to enter female spaces and act in ways that conflicted with hegemonic notions of masculinity. To be enrolled onto ART in this context, patients must attend monthly consultations at a hospital. However, due to women's participation in maternal, infant and child health and related visits to the hospital, hospitals are perceived by many men as female spaces, discouraging them from engaging with HIV services in a hospital setting.

"Men view health issues as female issues. Women always go to the hospital from pregnancy and until the children are grown up. So men feel hospitals and health concerns are for women." Michael, patient

Aside from hospitals being perceived as female spaces, there are numerous potential elements of a hospital visit that conflict with masculinity. One challenge that was frequently referred to relates to men's difficulties in showing up for appointments with health staff.

"When you give them the review dates that you want to give him a counselling session, they do not turn up at the time you specify. They just come when they feel like it - on their own free will time. So men are very difficult to deal with." Claudius, nurse

Different reasons were given to why men struggle showing up for review dates. Men are expected to queue up patiently wait outside the HIV clinic. In doing so, a man will not only run the risk of being recognised as HIV positive, but will have to let go of any sense of control of his time and his freedom, having to follow instructions given to him in this biomedical setting and wait patiently like 'one of the women.'

"So men find it hard to just go to the clinic... you can imagine men waiting in these queues here, men do not have a lot of patience to wait in these queues but women are used to coming here and waiting in these queues. A man would really feel belittled to wait in these queues the whole day shoving and jostling with women." Emmanuel, patient

Some men explained that they cannot afford to wait a whole day to be seen by a nurse as this compromised their head-of-house duties. As part of their monthly consultations, ART patients must adhere to a complex and strict treatment regimen where pills must be taken timeously and where certain activities are strongly discouraged. A number of men explained that their work activities made it difficult for them to carry around their medicine and to take it in a timely manner. Furthermore, ART patients are advised to eat healthily, apply creams to sores, quickly respond to potential opportunistic infections, refrain from unprotected sex, smoking and drinking alcohol. These, and many other instructions worry men to such an extent that some fear enrolling onto ART.

"I think some men know that what they are doing is not good for their health, so they fear the nurses advising them to stop a lot of their activities including drinking alcohol." Daya (female), patient

As many men fail to abide by what is expected of an ART patient, at least until they are more comfortable with their new identity as an ART user and have adopted a more ART-friendly masculinity, they are subject to reprimanding from nurses. The frustration experienced by some nurses as a result of men's inability to adhere to treatment results in nurses occasionally giving up on certain male patients as they repeatedly fail to act upon the advice given to them.

It is clear that men face numerous barriers in accessing HIV services. Grounded in a profound fear of HIV/AIDS as well as perceptions and experiences of HIV services, this section has highlighted some of the ways in which men avoid and delay HIV service use in order to protect or demonstrate their masculinity and dignity. With such strong barriers to HIV services, what opportunities are there for men to make use of HIV services?

Facilitators of men usage of HIV services

Our discussion above indicates that men face very specific challenges in accessing HIV services. However, in the case of our male informants who are now accessing and adhering to ART, it has been possible to overcome these obstacles and construct new masculine identities more in line with the 'patient persona'. In this section, we will highlight some of the pathways through which men can make use of HIV services.

Persuasion and need

As men fear the consequences of being HIV positive and how it may adversely impact their representation of their manhood, being persuaded to make use of HIV services from someone whom they trust often served as a strategy to give men the push they needed to make use of HIV services.

"My wife was worried and was always asking about my health. The swellings were not painful to me at all, so she was always asking what sort of disease it was. I told her I was fine but she insisted that I should go back to the hospital and show them those swellings. She would always push for me to go to hospital every day until I felt I should just go to the hospital to honour her wish." Emmanuel, patient

"Usually we will try all means to make the husband come. We sometimes send a message through village health workers or we send it through the husband's best friend to go and talk to him." Claudius, nurse

But not all men could be persuaded and many only got access to HIV services when they were too sick to move and assert their masculinity and ended being brought to the hospital in wheelbarrows.

"Men will only come to us when they are bedridden and brought to us in a wheelbarrow." Collin, nurse

This was the single most frequently mentioned route through which men arrived at hospital and were initiated onto ART. Many of our male participants, who are now living positively and on ART, admitted to also being brought to the hospital in wheel barrows after continuously denying their illness. Having said this, other facilitators of men's HIV service usage were identified and study participants provided us with pointers as to how HIV services and the local environment can help men overcome gender-related obstacles.

Gender sensitive HIV management services

Much of what we have discussed so far suggests that the need for gender sensitive HIV services. Men require counselling that challenges the versions of masculinity that prevent them from living positively and on ART. Although these groups were open to both women as well as men, rather than men-only spaces as is the case in other settings [e.g. [ 33]] our interviews suggested that counselling was often key to helping our male (patient) participants come to terms with their HIV status, demystifying inaccurate perceptions and helping men to step away from hegemonic notions of masculinity - in favour of revised identities that placed key emphasis on previously less important roles, such as being a family man or playing an active role in encouraging other men to make use of available HIV services in a caring and supportive way.

"To be honest with you that counseling opened my eyes to the fact that my HIV status will not necessarily affect my role in the family, rather my family now understands me better. But initially that feeling of being reduced to an HIV sufferer who is good for nothing gripped me, but now I am doing well." Emmanuel, patient

The health clinics in our study area group ART users together into (again mixed gender) support groups to facilitate ART adherence. In the support groups, ART users can negotiate and renegotiate identities that help them both navigate through local struggles and meet the expectations of a 'patient persona'. As outlined by one male patient (Stephen), the support groups allow men to come to terms with their status through acceptance and support from other members as well as access food aid.

"Now we have these support groups that are well known to be a platform for HIV/AIDS sufferers to give each other support; it was never like that before. In the past, nobody would really want to be associated with such a disease, a lot of people now want to get tested so that they can also get some food which is sometimes given to people living with HIV/AIDS." Stephen, patient

It appears that food aid, distributed through support groups for ART users, is highly beneficial to men as it allows men to reconcile the 'patient persona' with their local obligation as breadwinners. This is illustrated by the dramatic increase of men actively seeking HIV testing in the hope that they may be positive and qualify for food aid.

"I had never seen a man coming to be tested when they could still walk until recently when Africare [NGO providing food aid for ART users] came. Now we are seeing more men coming for tests." Lydia, nurse

This sub-section has given a few examples of how HIV services interact with masculinities and provide a platform for men to construct new and more ART-friendly masculinities.

Constructing responsible masculinities

In order for men to cope with the stresses of HIV and to make use of HIV services, they often have to undergo a remarkable transformation, breaking free from socialised norms of what it means to be a 'real man' and to live by revised or renewed versions of 'manhood'. This can take a while and many men fail to adhere to ART as they continue to abide to the traits of hegemonic masculinities. However, with time and through self-reflection, as well as the kind of support discussed above, some men are able to construct a new set of representations, another version of masculinity, integrating key traits of hegemonic masculinities with their life circumstances (being HIV positive and on ART). One dominant representation that male patients appeared to adopt is that of being a responsible and valuable citizen. They are socially responsible because they took the difficult step to get tested, have gained a lot of knowledge (through counselling and peer support groups) about HIV/AIDS management and now pass this on to the fearful 'ignorant other.'

"So I have learnt a lot from going to counseling, and now I even encourage fellow men to consider getting tested rather than them suffering in silence, fearing that they may be told that they are HIV positive." Emmanuel, patient

Furthermore, in lieu of representations of AIDS-affected people as unproductive and a burden, unable to care for their families, many of our male informants spoke about how being on ART had enabled them to participate in productive activities and contribute to the long-term of their family, highlighting their social value.

"What makes me look forward to the future is my health which is in a good condition. Also my family. I look forward to building a good future with my family." Nick, patient

Men often spoke about their role in the family and how ART had enabled them to live up this role. In constructing socially responsible masculinities, men also explained how they had stopped drinking alcohol or were no longer engaging in extra-marital affairs - emphasising their family role.

"I have also stopped drinking so that I can concentrate on my treatment [...] I take this programme seriously because my family depends on it." Charles, patient

Their sense of having some kind of control over their health and still being able to fulfil some of the key traits of being a 'real man' has also been a building block for men to resist derogatory stereotypes from their peers. Seeing themselves as responsible and informed and their peers as fearful and 'ignorant', male ART users are able to create a distance from otherwise hurtful attitudes and actions.

"They also use derogatory names and they do it openly, I think they have not yet understood the importance of treating an HIV sufferer as a normal human being. Maybe they don't know that we are just the same." Johnson, patient

This section has outlined some of the opportunities that exist in this context in facilitating men's use of HIV services. Men drew on the facilitators in different ways and at different stages, highlighting the complex transformation process, which many men will have to endure in order to make use of HIV services.

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Masculinity as a barrier to men's use of HIV services in Zimbabwe - Globalization and Health

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Background A growing number of studies highlight men's disinclination to make use of HIV services. This suggests there are factors that prevent men from engaging with health services and an urgent need to unpack the forms of sociality that determine men's acceptance or rejection of HIV services.

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This article describes the barriers and way of life that men who have sex with men have to deal with in terms of HIV topic. "Participants also reflected on the provision of quality health care as part of participation in the trial, as well as support from clinical research staff, family and friends as helpful in supporting high rates of study medication adherence. Discourse concerning challenges to adherence included medication taking behavior, which was contextualized by lifestyle, living arrangement, social life, social stigma in terms of being mistakenly identified as HIV positive or unintentional disclosure of sexual identity to family and friends, and relationship conflicts with partners" (Tangmunkongvorakul et. al 2012).

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In 2008, the Pre-exposure Prophylaxis Initiative (iPrEx) study expanded to include men who have sex with men (MSM) in Chiang Mai, Thailand. In full, 114 participants from Chiang Mai joined this international double-blinded trial of daily FTC-TDF (Truvada®) or placebo as a pre-exposure prophylaxis (PrEP) HIV prevention strategy. To better understand the characteristics of iPrEx participants specifically from this underserved population in Thailand, and gain insights into their experiences of trying to take a daily tablet as part of this blinded PrEP trial, we conducted a qualitative study. In 2010, 32 MSM iPrEx participants provided in-depth interviews and an additional 14 joined focus group discussions. Results of the qualitative analyzes suggested that participants held generally positive attitudes toward the iPrEx study and study medication and related this to high rates of adherence to the daily regimen. Participants also reflected on the provision of quality health care as part of participation in the trial, as well as support from clinical research staff, family and friends as helpful in supporting high rates of study medication adherence. Discourse concerning challenges to adherence included medication taking behavior, which was contextualized by lifestyle, living arrangement, social life, social stigma in terms of being mistakenly identified as HIV positive or unintentional disclosure of sexual identity to family and friends, and relationship conflicts with partners. The results provide broader perspectives of participant experiences of the study medication and daily adherence in the larger contexts of the MSM community, close relationships, and the study climate, and can be leveraged in constructing PrEP adherence support approaches within these communities.

Acknowledgements

This study was part of the Chemoprophylaxis for HIV Prevention in Men study, based in Chiang Mai and supported by the Gladstone Institute of Virology and Immunology, University of California, USA. We thank the research staff in Thailand and the USA for their support, without which this work would not have been possible. We also thank the participants of Chiang Mai for their contributions.

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Facilitators and barriers to medication adherence in an HIV prevention study among men who have sex with men in the iPrEx study in Chiang Mai, Thailand

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In 2008, the Pre-exposure Prophylaxis Initiative (iPrEx) study expanded to include men who have sex with men (MSM) in Chiang Mai, Thailand. In full, 114 participants from Chiang Mai joined this international double-blinded trial of daily FTC-TDF (Truvada®) or placebo as a pre-exposure prophylaxis (PrEP) HIV prevention strategy.

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This article showcases the improving rates of HIV incidence within the country due to public health interventions. In terms of numerical data, as of 2016, "89% of people living with HIV know their status, 72% receive ART and 82% have viral load testing – 99% of whom are suppressed" (Siraprapasiri 2016). Policy changes such as no longer requiring parental consent for HIV testing in young people and better health insurance access has contributed to these numbers. But at the same time, there is still a number of stigma and discriminations being faced by HIV-positive individuals that will possibly take a long while to change.

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Abstract

Introduction

Thailand has been heralded as a global leader in HIV prevention and treatment, and its experience with the HIV/AIDS epidemic holds valuable lessons for public health. This paper documents Thailand's response to its HIV epidemic from the late 1980s until today, and analyses its epidemiological impact (incidence and mortality). We discuss the association between the trajectory of HIV incidence and mortality rates over time, and the programmatic investments, policies and interventions that were implemented in the last three decades.

Methods

This is a review paper that draws on published literature, unpublished sources and routine behavioural and serological surveillance data since 1989. It is informed by the modelling of epidemiological impacts using the AIDS Epidemic Model. The AIDS Epidemic Model and Spectrum were used to assess the impact on incidence and mortality. Apart from epidemiological data, National AIDS Spending Assessment and programme data were also used to assess financial investments.

Results

Thailand is well on its way to meeting the 90-90-90 targets, the goal that by 2020, 90% of people living with HIV know their HIV status, 90% of people with diagnosed HIV infection receive sustained antiretroviral therapy, and 90% of people receiving antiretroviral therapy (ART) are virally suppressed. In Thailand, 89% of people living with HIV know their status, 72% receive ART and 82% have viral load testing - 99% of whom are suppressed. The public health response to HIV in Thailand has averted 5.7 million infections since 1991. If Thailand had not responded in 1991 to the HIV epidemic, and had there been no prevention and ART provision, the country would have experienced an estimated 158,000-225,000 deaths in the 2001-2006 period. This figure would have risen to 231,000-268,924 in the 2007-2014 period. A total of 196,000 deaths were averted between 2001 and 2014. If ART scale-up had not occurred in 2001, Thailand would have experienced between 50,000 and 55,000 deaths per year in the period 2001-2006, and 31,000-46,000 annual deaths between 2007 and 2014. The main impact in terms of deaths averted is seen from 2004 onwards, reflecting treatment scale up.

Conclusions

Thailand's AIDS response has prevented needless morbidity and mortality due to the HIV epidemic. In the context of Thailand's ageing population, it is faced with the twin challenges of maintaining life-long quality services among HIV patients and sustaining behaviour change to maintain primary prevention gains. Keeping the focus of the policy makers and health administrators on 'Ending the HIV epidemic' will require consistent advocacy, and evidence-based, innovative and efficient approaches.

Keywords: HIV/AIDS, Thailand, incidence, impact, interventions, ART, universal health, health governance

Introduction

Thailand's first case of HIV was reported in 1984. The epidemic has evolved and changed strikingly over the last three decades. The early phase of the epidemic was mostly that of HIV-1, subtype B, which rapidly escalated among people who inject drugs (PWID) in 1988 [1,2]. The virus then quickly spread to populations of female sex workers (FSWs), with increasing documentation of subtype E [3]. The epidemic spread rapidly in the early 1990s, driven by infections among sex workers and their clients [4-6]. The prevalence among direct FSWs was much higher, peaking in the mid-1990s, and declining rapidly after that (Figure ). There were clear geographical differences in the prevalence of HIV. The upper-northern provinces accounted for a disproportionate number of HIV case reports [7]. By 1993, some 600,000-800,000 people were estimated to be living with HIV [11]. At the same time, the prevalence of HIV in the general population - as measured by women attending antenatal clinics, newly recruited male conscripts as well as blood donors - also showed an increase, peaking in the early 1990s, and then declining slowly (Figure ).

Data based on AIDS case surveillance between 1984 and 1998 showed that the most frequently reported opportunistic infections were tuberculosis (19%), Pneumocystis carinii pneumonia (19%), cryptococcosis (17%), candidiasis of oesophagus, trachea or lung (5%) and recurrent bacterial pneumonia (4%) [2]. Cross-sectional survey data of hospital admissions between 1993 and 1996 also indicated that the most common AIDS-defining conditions were cryptococcosis, tuberculosis and HIV-wasting syndrome; PWID were more likely to have tuberculosis or suffer from HIV-wasting syndrome [8].

As HIV prevalence began to decline among FSWs and their clients in the mid-1990s, data from serial prospective cohorts among young Thai military conscripts also showed simultaneous declines in the incidence of both HIV and sexually transmitted infections, suggesting successful interventions and changes in transmission patterns [7]. The early 2000s saw marked changes in the transmission routes in Thailand, with sharp increases in the estimated HIV incidence among young men who have sex with men (MSM) - from 4.1% to 7.7% between 2003 and 2007 [9], with a median of 9.2% as a national estimate in 2014. Prevalence among MSM in Thailand has remained high (Integrated Biological Behavioral Surveillance Round, 2014). HIV incidence among MSM is especially high among those living in large urban areas and international tourist destinations for example, Bangkok, Chiang Mai, Phuket and Pattaya. In a large clinic-based study of MSM coming forward for testing at the Silom Community Clinic in Bangkok, an incidence of 12.2 per 100 person years was found among 15-21 year old men, this is almost twice as high as among all ages, which was 6.3 per 100 person years [10].

The HIV epidemic up to 2015 is mature and abating rapidly. According to the AIDS Epidemic Model, Global AIDS Report for Thailand 2015, in 2014 there were an estimated 445,504 people living with HIV in Thailand, including 175,716 women and 6875 children. The estimated HIV prevalence among adults was 0.83%. There were an estimated 7816 new infections in 2014, including 121 in newborns. A quarter of adult infections (1944) occurred in women, of them 221 in FSW, and the remaining 1723 in other groups of women, particularly discordant couples and partners of members of key populations.

The transmission of HIV from parents to children has been successfully controlled. According to programme data from the Department of Health, the parent-to-child transmission (PTCT) rate was 1.9% in 2015. AIDS-related deaths have been steadily falling since 2001, with a sharp drop observed from 2006 following the scaling up of ART. The National AIDS Management Centre estimates that there were 20,492 deaths among people living with HIV/AIDS in Thailand in 2014 (modelling estimates from the AIDS Epidemic Model). However, programme data from the National Health Security Office, based on an analysis of records from the Ministry of Interior's Civil Vital Registration System, suggests that there may be fewer than 16,000 AIDS-related deaths.

Thailand has been heralded as a global leader in HIV prevention and treatment, and its experience with the AIDS epidemic holds valuable lessons for public health. This paper documents Thailand's response to its HIV epidemic from the late 1980s until today, and analyses its scope and epidemiological impact (incidence and mortality). We discuss the association between the trajectory of HIV incidence and mortality rates over time, and the programmatic investments, policies and interventions that were implemented in the last three decades. In doing so, we document and describe not just the public health interventions, but also consider issues of governance, universal health coverage as well as structural and policy constraints that influence public health outcomes.

Methods

This review draws on published literature and unpublished sources and routine behavioural and serological surveillance data since 1989. It is informed by the modelling of epidemiological impacts using the AIDS Epidemic Model (AEM). Electronic data sources include Medline, PubMed, the Social Sciences Citation Index, Social Sciences Index and Abstracts, and the International Bibliography of the Social Sciences. Key peer-reviewed journals published between 1984 and 2015 were searched. Serological and behavioural data collected by the Bureau of Epidemiology (BOE), covering the period since the establishment of the HIV sero-surveillance system (1989) and the behaviour sentinel surveillance programme (1995) were also reviewed. These data provide information on key affected populations (KAPs) and the general population. Finally, AEM models to assess impact on incidence and mortality in conjunction with vital registration data were also analysed.

Apart from epidemiological data, we used information from National AIDS Spending Assessment (NASA) and programme data from the Ministry of Public Health (MOPH) and National Health Security Office (NHSO) to assess financial investment and track monetary flows to specific interventions.

Results

We distinguish our findings over two phases. First, we present the outcomes and impact of Thailand's early prevention interventions (1990-2000). Second, we present and discuss the impact of the country's prevention of mother-to-child transmission (PMTCT) programme, the scaling up of treatment with antiretroviral drugs (2000-2015; Figure ).

Phase 1

The public health responses started within the Division of Venereal Diseases under the Communicable Disease Control Department and the Division of Epidemiology of the Office of Permanent Secretary Office after the first AIDS case report from a tertiary hospital in Bangkok in 1984. This led to HIV being classified as a reportable disease and the development of the surveillance system, which resulted in the case-based reporting system in 1984. The National AIDS Programme was launched in 1987 with the establishment of the Center of AIDS Prevention and Control, which subsequently became the Division of AIDS under the Department of Communicable Disease Control of the Ministry of Public Health. By 1989, a surveillance system had been established across Thailand and an accurate assessment of high-risk groups and behavioural patterns provided strategic information for evaluations and resource allocation [2]. By 1992, the HIV/AIDS programme was being co-managed by the Ministry of Public Health and the Office of the Prime Minister - controlling the epidemic had become a priority national agenda.

Concomitantly, the Thai Government stepped up its investment in HIV control, from just US$180,000 in 1988, to US$44.33 million in 1993. By 1996, the government allocated US$81.96 million to its response to control the spread of HIV [11].

A remarkable aspect of the Thai national response to HIV has been the government's strong financial ownership of the programme, even when Thailand was classified as a 'lower-middle income' country. With the exception of 1989, Thai domestic resources have accounted for the vast majority of funding for the AIDS response. In addition, the early prevention efforts and treatment scale-up were funded through the national budget (Figure ). Despite the financial collapse during the Asian financial crisis in the late 1990s, Thailand sustained a lowered, but substantial investment in the AIDS response. This financial commitment reflects the Thai government's strong commitment to control HIV. Funding from the Global Fund for HIV, TB and Malaria (GFATM) first became available in 2003, and has accounted for between 10 and 15% of the money spent in Thailand's response since then, with most funds being used for treatment and prevention in young people in the first 5 years and later on a focus in prevention among KAPs (Figure ).

By the end of 1991, Thailand's well-documented 100% Condom Use Programme had been initiated following the Ratcharaburi model [12-14]. Condom use increased dramatically in sex-work settings from 14% to 94% between 1989 and 1993 [15]. A 79% decrease in sexually transmitted infection (STIs) rates among men was attributed to the 100% Condom Use Programme [16]. Other studies among male conscripts during the period 1991-1993 ( n=4086) also showed that HIV incidence declined from 2.48 per 100 person years between 1991 and 1993 to 0.55 between 1993 and 1995 [17]. STI rates in the 1991 cohort declined even more sharply: from 17 per 100 person years to 1.8 per 100 person years in the 1993 cohort [17].

The AEM shows that the impact of early prevention in Thailand averted 2,170,000 infections (Figure ). The annual number of new infections fell dramatically after 1992, from 168,485 in 1991 to 28,241 in 2000 (Thai Working Group on HIV Estimation and Projection, 2015). Modelling using the AEM suggests that by 2013, the total number of averted infections since 1991 had risen to 5.7 million (Thai Working group on HIV Estimation and Projection 2015). If Thailand had not responded in 1991 to the HIV epidemic, and had there been no prevention and ART provision, the country would have experienced an estimated 158,000-225,000 deaths in the period 2001-2006. This figure would have risen to 231,000-268,924 in the period 2007-2014 (Thai Working Group on HIV Estimation and Projection, 2015).

Phase 2

In 2000, Thailand initiated its nationwide PMTCT programme [18]. It provided voluntary and free testing for all pregnant women, provision of free ART to pregnant women and newborn infants, and free formula feeding for infants for the first 12 months [19]. The effectiveness of Thailand's PMTCT programme has been rigorously assessed [20,21]. In the period 2001-2003, the transmission risk among those completing a short course of zidovudine (ZDV)-only regimen declined from 18.9-24.2% to 6.8% (CI 5.2-8.9%). Among those who received ZDV along with nevirapine (NVP), the transmission was 3.9% (CI 2.2-6.6%) [19]. By 2005, 89.8% of HIV-positive pregnant women were receiving ART to reduce MTCT. By 2009, this share had risen to 94.7% [22]. In 2010, a triple ART regimen began to be used for PMTCT, when the Thailand National Health Security Office, supported by cost-benefit analysis data, advised the use of HAART over ZDV + single-dose-NVP in HIV-positive women [23,24]. In 2015, 95.8% of Thai and non-Thai HIV-positive pregnant women received drugs to reduce MTCT. Some 76% of infants born to HIV-positive mothers received virological testing within two months of birth, and only 2.1% of infants born to HIV-positive mothers were infected [25,26]. Unpublished estimates using Spectrum by the National AIDS Management Centre indicate that between 2000 and 2014, the PMTCT programme prevented a total of 15,760 infants from being infected and 7440 deaths. In 2016 Thailand was officially certified by the World Health Organization as having eliminated mother-to-child transmission of HIV and congenital syphilis.

HIV treatment with antiretroviral drugs was first started in 1992 with ZDV monotherapy, and later, dual therapy. At the end of 1995, approximately 4200 people were being treated [27]. In 2000 the concept of providing ART free of charge took concrete shape under the Access to Care (ATC) programme, drawing on the principles of equal access to HAART and quality of services for all. In 2002, two critical events facilitated the massive scale-up of ART in Thailand. First, the Government Pharmaceutical Organisation (GPO) began producing GPO-VIR (a fixed-dose generic combination of stavudine, lamivudine and NVP). Second, more funding was made available: the government doubled the budget for ART due to the exclusion of ART from universal health coverage and in 2004 Thailand received supplemental support from Round 1 of the GFATM for the ART programme. The ATC programme was renamed the National Access to Antiretrovirals Programme for People living with HIV/AIDS (NAPHA), and massively scaled up ART - treating 58,133 PLHIV, with a total budget of ฿800 million (approximately US$23 million) [27].The roll-out of ARVs was made a priority not just for adults, but also for children, with 7543 children put on ART between 2000 and 2007 [28]. An assessment of treatment outcomes for ART among adults in Thailand (2000-2007) showed that outcomes remained good, with much improved survival rates, despite the rapid scale-up of ART [29]. By 2010, more than 150,000 patients were receiving ART [30] with doctors using a treatment initiation criterion of CD4 cell count <350cells/mm ³[30]. In 2014, based on new evidence, new guidance recommended ART initiation irrespective of an individuals' CD4 cell count [31].

At the end of 2015, Thailand was well on its way to reach the 90-90-90 targets. Of the 437,700 estimated PLHIV in 2015, 389,027 (89%) had been diagnosed with the virus (these figures exclude HIV tests in the private sector), and 336,541 were in care (National ADS Programme Database, National Health Security Office, 2015). Of those in care, 288,231 were on ART and 231,794 were virally suppressed (NAP Database 2015). The main areas of loss from the care cascade (defined by more than a 10% difference between any two points in the cascade) were between those in HIV care and those commencing ART, and those on ART and those who were virally suppressed (see Figure ).

The impact of the large-scale provision of ART in Thailand between 2001 and 2014 was assessed using the AEM. A total of 196,000 deaths were averted between 2001 and 2014 (Figure ). If ART scale-up had not occurred in 2001, Thailand would have experienced between 50,000 and 55,000 deaths per year in the period 2001-2006, and between 31,000 and 46,000 annual deaths in the period 2007-2014 (Thai Working Group on HIV Estimation and Projection, 2015). The vast majority of the impact in terms of deaths averted is seen from 2004 onwards, reflecting treatment scale up (Figure ).

The impact of the response to HIV in Thailand is also reflected in the burden of disease analysis. In 2004, HIV was the top cause of death in men (26,400 deaths), and the second most common cause in women (11,000 deaths) [32]. However, between 1999 and 2004, the burden of death and disease attributable to HIV/AIDS fell from 32.3 to 21.1 disability-adjusted life years per 1000 men, and to a lesser extent in women (from 12.2 to 9.3) [32]. In 2015, HIV/AIDS was the sixth most common cause of death surpassed only by coronary heart disease, stroke, road traffic accidents and other causes [33].

Discussion

This paper takes stock of the HIV/AIDS response in Thailand, and looks at more than 30 years of prevention, care and treatment efforts in the country. We have reviewed and synthesised published evidence, programme data and the results of modelling exercises to gauge the impact that these efforts have had. We argue that while the evidence and our analysis does not allow us to attribute direct causality, there are strong temporal associations between these efforts and the impact on HIV incidence and AIDS-related mortality. We have assessed the impact of the programme specifically in terms of declines in incidence and mortality. It is important, however, to acknowledge that some key governance, financial and policy inputs into the national AIDS control efforts have strongly influenced those outcomes. The role of Thailand's well-developed health infrastructure, the government's strong political commitment and the stewardship from the Prime Minister's office have been well described elsewhere [11]. We highlight three key issues that have been critical in ensuring that interventions in Thailand could be implemented early, at scale and in a sustained fashion: health governance, reform and partnership with civil society.

Health governance and reform

Thailand has gone through a major reform of governance and its health service system with the Decentralization Act in November 1999 and the introduction of universal health coverage in 2002. Government reform involved the devolution of authority for some operations from the central government to the provincial and local administrations. There were changes to the structure of the Ministry of Public Health, and in the management of the AIDS budget as part of this decentralisation. Following enactment of the official ministerial proclamation in 2002, the Ministry of Public Health implemented structural reforms at central and regional levels. In particular, at the central level, the role of the National AIDS Committee shifted from policy and budget support for implementation and development to co-ordination, monitoring and technical support. A portion of the prevention budget and much of the task of implementation was decentralised to local administrative organisations. Other related line ministries made budget requests for HIV prevention activities through their own agencies. Apart from antiretroviral treatment, which has been centrally managed, the budget for HIV clinical services for opportunistic infections was integrated into the national health insurance scheme, and allocated to health service outlets in the form of per capita lump sum payments [34].

The national AIDS response is integrated into numerous and diverse programmes of participating agencies and line ministries. Up until 2005, these ministries prepared AIDS budgets in collaboration with the Ministry of Public Health. However, starting in 2005, no specific AIDS budget was defined. It became the responsibility of each ministry to allocate a budget line for HIV control. The budget for health of the population was allocated as a lump sum based on per capita needs, including AIDS. This approach promoted a multi-sectoral response and removed the constraints of a centralised budget. For example, under the arrangement, local administrative organisations were made responsible for paying a monthly allowance to PLHIV. Provinces were also expected to prioritise and budget for health issues at the local level. This made financing directly available at the local level (rather than indirectly through a centralised funding mechanism). While this decentralisation has led to some positive changes, the risk that there may be varying capacities and awareness across provinces regarding continued investment and engagement with HIV has remained a challenge [35].

With the ultimate goal of equal rights to the access of quality health services for all - as stipulated under Section 52 of the 1997 Constitution - the government also implemented the Universal Health Security Scheme namely the '30 Baht scheme' (in addition to the Social Security Scheme and the Civil Servant Medical Benefit Scheme). This package entitled all Thai citizens to free medical services and health promotion and prevention. At the introduction of the scheme, antiretroviral treatment was excluded from the service package, but included in 2006. The National Health Security Office-supported ART programme is highly cost effective at less than US$1 per day per patient, and was supported by the government's bold policies in initiating generic production, cost negotiation and compulsory licensing of ARV drugs, specifically for efavirenz and lopinavir/ritonavir [36,37].

Partnership

The Ministry of Public Health had begun to engage with civil society partners in Thailand on the issue of HIV prevention and treatment since the early 1990s. A key partner is the Thai NGO Coalition on AIDS (TNCA), a network of 168 Thai NGOs, which aims to improve the quality of life of PLHIV. It is notable that the Bureau of AIDS, TB and STIs (BATS) not only worked in close partnership with TNCA from the beginning of the epidemic, but also provided it with an annual budget of ฿65-90 million to support their activities. TNCA was seen, along with the Thai Network of People Living with HIV/AIDS (TNP+), as an equal partner in the AIDS response, with a dedicated line of funding from the NHSO.

Apart from working closely with the government, Thai civil society has successfully held governments accountable, and championed the cause of equal access. For example, on 30 November 2001, 1200 PLHIVs from all parts of the country demonstrated in front of parliament and met with Minister of Public Health. The minister agreed, in principle, to their demands, and doubled the budget for ART and also committed the government to include ARVs in the universal health scheme. The working committee, which consisted of representatives from TNP+, NGO/AIDS and the government, was set up to prepare for implementation of the scheme. At that time, there were fewer than 4000 individuals receiving ART. Arguably, civil society action has been fundamental in shaping government policy, an illustration that a well-informed and motivated civil society, which is able to negotiate and partner with government agencies, can be highly beneficial to the AIDS response.

Conclusions

We conclude by noting that, despite the outstanding successes of Thailand's AIDS response, the programme is faced by a multitude of challenges. A key dilemma is how to position HIV in the era of the sustainable development goals and move towards 'Ending AIDS'. HIV is a chronic disease, and in the context of Thailand's ageing population, it poses the twin challenges of maintaining life-long quality services for HIV patients and sustaining behavioural change to maintain primary prevention gains. Keeping the focus of policymakers and health administrators on 'Ending the HIV epidemic' requires consistent advocacy, evidence-based cost effectiveness and innovative approaches to addressing shortages of human resources.

Stigma and discrimination in healthcare settings is still a major obstacle to a more effective response to HIV. Observed behaviours towards KAPs among health staff in two Thai provinces indicate disturbing levels of discrimination [38]. Thailand has also struggled with ongoing policy and legislative barriers that have an impact on access and quality of services. Despite recent progress in reducing barriers to access (for example, no further requirement for parental consent for HIV testing in young people; a pilot harm reduction policy in 19 provinces; and health insurance for healthcare for migrants) Thailand has a rocky road to travel before ending AIDS [24]. Some regulations, such as those that only allow a 'medical technologist' under the responsibility of a physician to provide HIV test results, do not promote community-based testing.

To support Thailand in achieving the ambitious 'Fast Track' End AIDS and move towards the attainment of the Sustainable Development Goals, the Ministry of Public Health and other partners are working towards establishing policies and systems to increase funding flows to community partners at national and regional levels, including the accreditation of community services, and continuing 'test and start ART' for all HIV-infected people. The Ministry of Public Health is also implementing a programme to reduce system-wide stigma and discrimination in healthcare settings, and address human rights concerns.

In order to 'End AIDS', Thailand will need to focus on areas that enhance the ability of the programme staff, service providers, health insurance agencies, civil society partners and PLHIV to work in a co-ordinated manner, and develop the capacity of the health and community system to move beyond a 'control' agenda to an 'Ending AIDS' agenda.

Acknowledgements

We would like to acknowledge Dr Nima Asgari from WHO Thailand for reviewing early drafts of this paper. We would also like to acknowledge Tom F Joehnk for editorial support.

Declaration of conflict of interest

The authors do not have any conflict of interest to declare.

Disclaimer

MS is a staff member of the World Health Organization. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy or views of the World Health Organization.

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The impact of Thailand's public health response to the HIV epidemic 1984-2015: understanding the ingredients of success

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Thailand has been heralded as a global leader in HIV prevention and treatment, and its experience with the HIV/AIDS epidemic holds valuable lessons for public health. This paper documents Thailand's response to its HIV epidemic from the late 1980s until ...

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In order to provide for a better global health, we, as public health officials, need to recognize and address some of the vulnerabilities we have as a society in regards to disease eradication. These vulnerabilities can come from both a national and international scale in which individual countries need to prioritize public health within their populations. Interventions such as better public awareness, push back against stigma, and easier available treatment services are prime examples of what we can do in creating a world without diseases.