Best Practice

Khon Kaen Case

Dr. Chuanchom Sakondhavat
Professor, Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Thailand

Dr. Supat Sinawat
Assistant Professor, Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Thailand

Back Ground

Dr. Chuanchom began her presentation with an overview of the health status at the national level. Thailand has a population of almost 62 million, of which only 31% live in urban areas. The country, however, is experiencing rapid urbanization. As a result of intensive family planning initiatives, annual population growth has reduced from 3.1% in 1960 to 0.8% in 2003. Infant mortality has also drastically improved, decreasing from 103 per 1000 in 1960 to 20 per 1000 in 2003.

Adolescent Reproductive Health in Thailand

Dr. Chuanchom defined adolescent reproductive health as referring to the physical and emotional well-being of adolescents and their ability to remain free from unwanted pregnancy, unsafe abortion and sexually transmitted diseases (STDs) including HIV/AIDS. She noted that a recent national survey found that over 45% of young people (58% for men and 36% for women) had had their first sexual encounter by the age of 18, and 25% had by the age of 16, which indicates that today's young adults are becoming sexually active at younger ages compared to previous generations. Furthermore, in a survey of students in Khon Kaen, 73% of males had had sexual intercourse with sex workers, which shows there is high risk of HIV/AIDS being spread to students.

Dr. Chuanchom pointed out that despite decreasing numbers of young people, there is a rising problem related to adolescent reproductive heath. She noted that young people seldom use condoms or other forms of contraception, especially for a first sexual encounter. Although Thailand generally has been successful with its family planning policies, such programs have been directed mostly to married couples, while adolescents have relied on the media, friends and other potentially unreliable sources for reproductive health information.

Dr. Chuanchom explained that abortion is illegal in Thailand, except for women who have been raped or whose health may be detrimentally affected by pregnancy. There are, however, a significant number of illegal abortions performed, including those done by unqualified persons.

HIV/AIDS

The first case of AIDS in Thailand was reported in 1984. The first outbreak of HIV/AIDS was observed among intravenous drug users in Bangkok in 1987, and the second outbreak occurred among sex workers in Chiang Mai in 1989. Between 1990-91, many cases were reported among pregnant women, followed by increasing numbers of infected babies. Today the incidence of HIV infection in pregnant women remains high at around 1.5%. As for the number of young people infected, she explained that 11.1% of the infected population is between the ages of 10 and 24 years.

As of 2004 there have been an estimated 1.1 million HIV/AIDS cases, and over 500,000 deaths due to the disease. New HIV/AIDS cases in 2004 are estimated to number 20,000. She also highlighted that the male-female proportion of AIDS cases has changed significantly overtime, from 4.5:1 in 1995 to 2:1 in 2004.

Dr. Chuanchom outlined Thailand's four major systems for tracking HIV/AIDS: (1) an AIDS reporting system, (2) a sentinel zero-prevalence surveillance system, (3) a STD reporting system, and (4) a behavior surveillance system.

In 1991, the National AIDS Control Committee chaired by the Prime Minister issued a resolution to implement the 100% condom-use program on a national scale. Dr. Chuanchom pointed out that as a result of such initiatives the rate of condom use increased from less that 20% in 1989 to over 95% in the mid 1990s, although it has since dropped back to 90%.

Thailand was the first developing country to launch a national program to prevent mother-to-child HIV transmission. Highlighting the effectiveness of the program, Dr. Chuanchom estimated that assuming a transmission rate of 30% without the program and 8% with the program, approximately 2,225 infections are being prevented each year.

Dr. Chuanchom also outlined Thailand's national AIDS prevention plan, and mentioned the country's programs aimed at youths, such as the National Youth Policy, the Ninth Children and Youth Development Plan and the Long-term Children and Youth Development Plan.

Practices in Khon Kaen

Dr. Supat Sinawat's part of the presentation focused on adolescent reproductive health and HIV/AIDS in Kohn Kaen. He noted a series of programs and strategies that are being carried out in Kohn Kaen relating to education, community involvement, information dissemination, awareness promotion and various means of support.

Dr. Supat said that sex education in Thailand is still a sensitive issue due to conservative elements of society, even though it has been taught in primary and secondary schools (as "family life planning") for over 20 years. Because people today are becoming sexually active at younger ages, it is important to have sex education implemented in primary schools, as secondary school may be too late for many people.

Khon Kaen University is the only medical university in northeast Thailand. Teams from the Faculty of Medicine provide courses to secondary school students on sexuality, STDs, HIV/AIDS and other reproductive health issues. Furthermore, research and other efforts in HIV/AIDS by faculty members such as Dr. Chuanchom have spurred various programs at the local level that have eventually been adopted as national policy. In 2000, the university established a designated AIDS institute to serve as a center for sharing information, promoting prevention and treatment, encouraging research and building cooperation between government and NGOs.

Dr. Supat stressed that community involvement is a very important and effective approach in promoting reproductive health awareness and programs. He cited as a prime example Khon Kaen's "mobile education teams" that go out into the community to strengthen educational participation and encourage people to trust and follow the proper information. Furthermore, he suggested it was important to involve as many people from as many segments of the community as possible, and cited as an example his experience that even monks can contribute by allowing use of temple space for health-related activities. As Dr. Haryono mentioned in his presentation as well, involving the religious leaders of the community in some capacity is an important component of the goal to have the participation of multiple agencies and facets of society.

Other educational activities conducted in Khon Kaen include training courses in sexuality and reproductive health counseling for school teachers and various levels of meetings for medical personnel to share and disseminate current information on reproductive health and HIV/AIDS.

Khon Kaen has also set up visits to specific subgroups in order to obtain better information about high-risk groups, such as the military, sex workers, factories, homosexual groups and isolated housewives. Dr. Supat explained that conducting questionnaires during the visits provides data that can be used to supplement the government data, which can be unreliable. He suggested giving participation incentives to factories and other organizations in the form of some kind of accreditation for cooperation. Such visits are also used as opportunities to provide counseling and ensure accessibility to information, and at the same time condoms can be distributed.

In Khon Kaen and nationwide, HIV/AIDS counseling and testing are available at nearly all community hospitals and higher levels. Counseling on reproductive health is available in secondary schools and hospitals and also through a telephone hotline.

Questions and Answers

Discussion that followed the presentation included the following points:

Q: Has the rate of HIV infection in youths been increasing or decreasing?

A: The rate has been decreasing thanks to reproductive health education and changing attitudes about condom use.

Q: Relating to condom use, how do you transform knowledge and awareness into actual behavior change? For example, how can women force men to use condoms? Are condoms distributed free of charge?

A: This is a difficult problem because the women, especially prostitutes, are often vulnerable to the wishes of the men. As an alternative to condoms, we have tried distributing female condoms, but these are relatively expensive. Condoms are no longer available free to everyone, but they are available at subsidized prices for those who are not getting them free.

Q: What steps are you taking to prevents HIV/AIDS among university students?

A: 20-25% of students are sexually active, so effective strategies are needed. We have found that lectures are not effective, so we prefer to organize peer counseling. Furthermore, for a decade, sex education has been compulsory from primary school upward.

Q: Are the strategies and programs you mentioned being implemented at the national or provincial level?

A: In fact, many strategies were initiated in Khon Kaen and then brought up to national level since they were proven to be effective. Many were pilot projects as part of the research by Dr. Chuanchom, which were then forwarded to the then Prime Minister, who was very open and cooperative on the issues. Successful reduction of cases today is largely a result of this cooperation.

Editor's Note:This article is a summary of the presentation on best practice in Surabaya delivered by Dr. Haryono Suyono and the presentation on best practice in Khon Kaen delivered by Dr. Chuanchom Sakondhavat and Dr. Supat Sinawat at the First 2005 Workshop. AUICK takes full editorial responsibility for the content.