Thailand was a model for how a country should respond to the HIV epidemic. Whenever there was an HIV innovation -- whether it be a drug or a behavioural approach -- Thailand would be one of the first countries to adopt it. This began with the 100% Condom Programme in the early 1990s and continued all the way to 2016, when WHO declared that Thailand was the first country in Asia to eliminate mother-to-child transmission of both HIV and syphilis, an impressive feat many countries are still hard-pressed to mimic. Thailand became one of the first middle-income countries in 2014 to embrace pre-exposure prophylaxis (PrEP) by supporting community-based organisations (CBOs) to test key populations, such as men who have sex with men and transgendered individuals, for HIV and provide this critical drug to them.
It was a simple yet successful formula: let community organisations who are led and staffed by LGBTQ individuals serve their own communities and they will deliver. And they did -- by the end of 2022, these passionate and dedicated organisations were responsible for over 70% of the PrEP doses delivered in the country, not to mention a huge amount of HIV testing which allowed people to know if they were HIV+ and to get on life-saving anti-retroviral drugs.
So overwhelmingly successful was this recipe that UNAids held its Programme Coordination Board (an equivalent of a Board of Directors) meeting in December of 2022 to showcase the Thai response and to heartily congratulate the Ministry of Health and its community partners on a job well done.
Before the ink was even dry on the article, the praises to the Thai government were no longer justified. Thailand's HIV-fighting community organisations were hit with a double blow from the government.
First, the National Health Security Office (NHSO) decided to no longer reimburse CBOs for services provided to some clients whom they said should have their own insurance to pay or that the country's other leading national insurance agency, the National Social Security Agency, should support. Their decision meant that CBOs forfeit approximately 50% of funding they were counting on for their HIV testing, prevention, and treatment services. SWING has already announced that they may need to close their flagship clinic in the Silom area which serves more than 10,000 clients every year.
The second blow came from the Ministry of Public Health that decided in December last year that community-based organisations were apparently not professional enough to give PrEP to their clients and so they immediately forbade those organisations without a direct link with a public hospital from further prescribing PrEP. This decision immediately affected SWING and Rainbow Sky Association of Thailand (RSAT), two leading organisations who have become known globally for their successes in reaching men and women who would rather be tested for HIV by peers and/or experienced civic groups like SWING and RSAT than go to a public or private hospital.
The Ministry of Public Health and NHSO should and must reinstate their funding support to community organisations as well as their permission to allow them to administer PrEP to those who need it. Sceptics at the Ministry of Public Health will undoubtedly point to the need to have doctors in hospitals do the prescribing of PrEP. But these perhaps well-meaning policymakers have not heard of the successes of the de-medicalisation of PrEP services and of "lay" providers such as those at SWING and RSAT who are able to reach and administer PrEP with advice and counselling that is specifically tailored to sex workers, gay men, and transgenders.
And regarding the financing now in question from NHSO, they have never totally paid for all the costs of these community organisations anyway. The other half -- and yes, it's approximately 50% -- has come from foreign donors. In the case of RSAT and SWING and a few others, this funding support has come from a United States Agency for International Development (USAID) project that my own organisation, FHI 360 (formerly Family Health International), manages.
USAID has historically covered the costs of effective community-based HIV responses in many low- and middle-income countries, including Thailand. But the Thailand partnership was different and uniquely innovative. The financing from USAID to pay for the operations of the community organisations became less and less as the Thai government picked up more of the costs. When this started about six years ago, the UN and USAID started to send representatives from other countries to learn from Thailand. After all, no other country had this level of cooperation between community activists-turned-service providers and government.
Even though Thailand still has a lot to claim with regard to successes against HIV, the developments now are more than just an unfortunate deep freeze in the relationship between government and community. Thailand is no longer the regional leader it once was. The governments of India and the Philippines, to name just two, have made great strides in providing their own funds to community-based organisations, in many ways surpassing what Thailand does. But the real losers here will be those Thais -- often poor and stigmatised sex workers, gay men, and transgender women -- who will have doors closed on them when they try to seek friendly and qualified HIV services. Thailand's quick pace to reach the end of its HIV epidemic has now slowed to a crawl and may soon go in reverse.
Stephen Mills, PhD, is a Bangkok-based epidemiologist and the Regional Director for the USAID-supported EpiC project at FHI 360, also known as Family Health International, a US-based health and development organisation.
