The Feminization of the HIV/AIDS Epidemic in Bangkok, Thailand: Examining the Breadth of Women’s Burden

 Thailand’s 100 percent condom campaign has been heralded as a major success in achieving a lasting reduction in HIV infection rates across the country [1]. The government’s prevention program began in 1991, targeting schools, the media, the workplace and brothels, which were believed to be at the epicenter of the epidemic. Overall HIV prevalence peaked in 1995 at over two percent but has since decreased to roughly 1.4 percent—around 610,000 people. 

In the midst of the widespread success of the Thai government’s 100 percent condom campaign, an alarming trend has emerged. HIV prevalence has increased among pregnant women, who are the only demographic to experi-ence a rise in infection since the campaign began. Pregnant women’s rates of infection jumped significantly from 0.2 percent in 1990 to 1.2 percent in 2005 [2]. Unfortunately, the increased prevalence of HIV among pregnant women in Thailand is consistent with a worldwide trend. Globally, young women are 1.6 times more likely to have HIV/AIDS than young men [3]. In South Asia, the risk factors associated with HIV/AIDS include poverty, early marriage, trafficking, sex work, migration, gender discrimination, and violence [2]. In addition to these factors, studies show that women are at risk for HIV because of the sexual behavior of their partners [4]. One study in particular noted that HIV prevalence in pregnant women increased consistently in Bangkok from 1991 to 1996, and the only identifiable risk factor for 52 percent of women was sex with their current partners [3]. In other words, it seems that husbands are infecting their wives after contracting HIV themselves from premarital or extramarital relationships. 

The burden of HIV infection for pregnant and married women presents a major challenge as far as interventions are concerned. Experts fear that the 100 percent condom campaign, which so successfully reduced HIV prevalence in the general population and among sex workers in the 1990s, will not be as effective in preventing infection among married couples, who are less likely to use condoms during sex [6]. For those working to stop the HIV epidemic in Thailand, the question has become, how can married and pregnant women—those whose infection rates are currently on the rise—be the target of an HIV prevention campaign? After all, the only “risky behavior” that these women exhibit is unprotected marital sex—an all-around conventional, os-tensibly safe act. 

It would seem that the most logical way to prevent pregnant women from contracting HIV would be to focus on the behavior of their male partners—namely, to discourage men from engaging in extramarital affairs, thereby lessening the risk of HIV transmission from mistress to husband to wife. However, the Thai government has traditionally avoided any public health campaigns that target male behavior and has instead redirected these efforts to exert pressure on women in increasingly innovative and insidious ways. 

In the late 1980s, when Thailand’s HIV outbreak began, the commercial sex industry was identified at the core of the epidemic. The 100 percent condom campaign specifically targeted female commercial sex workers, many of whom worked in bars that were known to double as brothels, despite the fact that prostitution is technically illegal in Thailand. The HIV prevalence among these “bar girls” peaked in some areas, such as Chiang Mai, at a shockingly high twenty-five percent. As a result, government officials distributed a sup-ply of free condoms to the bar owners, insisting that all “bar girls” use them during sex acts performed with male clients. In order to enforce this procedure, undercover government officials went to brothels posing as clients. According to a Joint Report by various UN agencies, the World Health Organization (WHO), and the World Bank, the focus on brothels as centers of HIV transmission “has been highly successful” and “Reported condom use in brothels increased from only 14 percent of sex acts in 1989 to over 90 percent by 1994” [1].  The Thai government’s focus on brothels as hotspots of HIV infection effectively decreased HIV prevalence, but the fairness of its methods is questionable, considering that female commercial sex workers were charged with the sole responsibility of enforcing condom use. Consequently, these women faced enormous pressure, especially in the early stages of the intervention, when male clients were much more resistant to condom use than they are today (Janyam S, Director of SWING [Service Workers IN Group], inter-view, 2008 July). Female commercial sex workers face the constant threat of job termination, and because prostitution itself is illegal, they lack any legal protection. As a result, many have to bribe doctors for negative HIV test results to present to their employers in order to keep their jobs. In essence, the 100 percent condom campaign demands that these women enforce safe sex, but it exempts their male clients from pressure to do the same. 

In Thailand, pregnant women are administered HIV tests as part of routine prenatal care. The issue of “informed consent” with respect to HIV tests is a pressing one because pregnant women are often tested for HIV without fully un-derstanding the implications of a positive result. The Ministry of Public Health claims that these tests are “voluntary,” but studies show that seventy-nine percent of women who were tested said they were unprepared for the test, thirty-five percent said the test was “mandatory,” only thirty percent received pre-test counseling, and twenty percent said they were coerced into being tested. Most pregnant women do not test positive for HIV, but those who do must then bear the burden of informing their husbands, who are likely to be HIV-infected as well.

From a public health perspective, involuntary testing of pregnant women seems like an effective way to ensure awareness of HIV status and to prevent vertical transmission from mother to child. However, many consider the involuntary testing to be a violation of human rights. Additionally, this type of testing and coerced partner notification may lead to both physical and emotional domestic violence (Phanuphak P, Director, Thai Red Cross AIDS Research Center, interview, 2008 June). 

Like female commercial sex workers, pregnant women carry an inequitably heavy burden in the fight against HIV. When hospitals administer involuntary HIV tests to preg-nant women, they strip pregnant women of their right to confidentiality, while sparing men from shared responsibility in HIV prevention. 

The effects of globalization in modern-day Thailand are promising in terms of the HIV/AIDS epidemic. Young Thai men are increasingly monogamous and are less likely to visit commercial sex workers than their fathers and grandfathers were. Therefore, their sexual networks are less exposed to the risk of HIV transmission [6]. Also, young women in Thailand are more likely to attend school than they were twenty years ago. They enjoy the educational opportunity that permits increased financial and social autonomy and affords them more power to avoid the poverty and dependence that can lead to high-risk sexual behavior and increased risk of HIV infection. 

In order to address the disturbing reality of increasing infection rates among pregnant women and to alleviate the excessive burden that women bear with respect to HIV, the Thai government can support equitable policies consistent with these globalization trends. By instituting voluntary HIV testing and counseling for both partners during pregnancy, supporting domestic caregivers, requiring universal educa-tion for young people, and criminalizing violence against women, the Thai government can promote shared respon-sibility between men and women for HIV prevention. Also, by legalizing commercial sex work, the Thai government can ensure that female commercial sex workers have access to health care and other legal protections that allow them to work more safely. 

When women and men share the burden of HIV, in-cluding prevention, testing, partner notification, care, and support, not only will women’s infection rates decrease, but the HIV/AIDS epidemic will begin to lose its overall momentum.  

Sarah Schoenbrun is an undergraduate student at Brown University.

References:

[1] Thailand achieves sustained reduction in HIV infection rates [Online]. 2000 [cited 2009 Apr 17]; Available from: URL:http://www.who.int/inf-new/aids1.htm[2] Epidemiological fact sheet on HIV and AIDS: Thailand [Online]. 2008 Sep [cited 2009 Apr 17]; Available from: URL:http://www.who.int/globalatlas/predefinedReports/EFS2008/full/EFS2008_TH.pdf[3] Women and HIV/AIDS: confronting the crisis [Online]. 2004 [cited 2009 Apr 17]; Available from: URL:http://www.unfpa.org/hiv/women/docs/women_aids.pdf [4] Siriwasin W, Shaffer N, Roongpisuthipong A, Bhiraleus P, Chinayon P, Wasi C et al. HIV prevalence, risk, and partner serodiscordance among pregnant women in Bangkok. JAMA 1998 Jul;280(1):49-54.[5] Nelson KE, Celentano DD, Eiumtrakol S, Hoover DR, Beyrer C, Suprasert S et al. Changes in sexual behavior and a decline in HIV infection among young men in Thailand. N Engl J Med 1996 Aug;335(5):297-303.[6] National sexual behavior survey of Thailand 2006 [Online]. 2007 [cited 2009 Apr 17]; Available from: URL:http://www.ipsr.mahidol.ac.th/IPSR/BookDetail/Download/National%20Sexual%20Behavior%20Survey%20of%20Thailand%202006.pdf[7] Condoms by Paul Keller. Flickr under CC-BY 2.0. Available from: http://www.flickr.com/photos/paulk/1241749044/[8] -1 by Emery Co. Flickr under CC-BY-SA 2.0. Available from: www.flickr.com/photos/emerycophoto/2892182827/.