Date: Sun, 8 Oct 95 0:02:00 -24000 To: From: "Richard Cincotta" Subject: ...no subject... A S I A - P A C I F I C P O P U L A T I O N & P O L I C Y July-August 1995 Number 35 THE HIV/AIDS EPIDEMIC IN THAILAND: ADDRESSING THE IMPACT ON CHILDREN KEYWORDS AIDS infection rates child prostitutes orphans children pediatric AIDS counseling Thailand HIV treatment ----------------------------------------------------------------- In less than a decade, the HIV/AIDS epidemic in Thailand has grown from a handful of infections to a major public health threat. Gaining a foothold in injection drug users and commercial sex workers, HIV quickly spread to a wider population of adult males, from them to their wives and partners, and ultimately to their children. The result is a general population epidemic with wide-ranging medical, social, and economic consequences. The direct effects on children are already obvious. By the end of 1994, 16,000 HIV-infected children had been born, and tens of thousands of child prostitutes and street children were at risk of infection. By the turn of the century, more than one million Thai children will have at least one HIV-infected parent. Some of these children will be orphaned by the disease; others may be abandoned by infected parents. The extent of such problems in the future depends in large parton the action taken today. To help provide an information base for sound policy decisions, the Program on AIDS of the Thai Red Cross Society and the East-West Center's Program on Population recently prepared a report entitled "The impact of HIV on children in Thailand." Save the Children Fund, United Kingdom, contributed financial support. The report takes a critical look at the current situation, estimates the magnitude of futureproblems, and recommends policy responses. This issue of Asia-Pacific Population & Policy summarizes the report's majorfindings. THE CURRENT SITUATION By the end of 1994, about 840,000 Thais had been infected with HIV. The highest infection rates were in northern Thailand, with considerable variation among provinces (Figure 1). More than two-thirds of those infected were men: in 1993, the HIV infection level in 21-year-old males was close to 30 percent in some northern provinces. In the country as a whole, more than 20,000 pregnant women who attended antenatal clinics in 1994 were positive for HIV -- an infection rate of 2 percent for this group. In some northern provinces, the infection rate among pregnant women was more than 10 percent. In one provincial capital, Chiangmai, people with AIDS occupied one-third of all hospital beds. Children infected with HIV/AIDS Records from Thai hospitals indicate that between 26 and 42 percent of pregnant women who are infected with HIV transmit the virus to their unborn children. This would imply that 5,100 to 8,400 infected children were born in 1994 alone. Apart from children infected at birth, the second group of children most vulnerable to HIV are those living in difficult circumstances. These include street children, children living inslums, children of minority populations, and Thailand's 30,000 to 40,000 child prostitutes. For several reasons, HIV prevalence among child prostitutes may be higher than the 30 percent currently estimated for adult female sex workers. Young girls maybe biologically more susceptible than adults to infection; they are also less able to insist that their clients use condoms. Interviews conducted by the Thai Red Cross Society's Program on AIDS found that child prostitutes and street children had heard of AIDS, but most had little understanding of the disease. HIV generally develops into AIDS more quickly in young children than in adults. Records from one Thai hospital showed that about 20 percent of infants infected at birth progressed to AIDS within 15 months. Survival time after a diagnosis of clinical AIDS is usually short: most Thai children who develop AIDS die within four months. Infected children often benefit from treatment with AZT, but many Thai doctors fail to prescribe the drug for children. Counseling services are inadequate at many hospitals, and some medical workers refuse to care for HIV-infected patients, including children. The high mobility of Thai patient populations also makes the long-term care of infected children particularly difficult. Children with HIV-infected parents In 1994, 205,000 children under the age of 15 had mothers infected with HIV (Figure 2). Another 10,000 children had lost their mothers to AIDS. Many of these children had also lost their fathers. The financial impact of illness and death can devastate a household. Studies indicate that an adult dying of AIDS in Thailand is ill for an average of eight months. During this time the family spends about half of its current annual income on medical care. As an adult family member becomes too ill to work, the household may see its income drop by half or more. Children may be forced to leave school to look after relatives, or money for their education may be diverted to health care. Pressure may also increase for children to work outside the home. Such a situation strongly favors the exploitation of child labor and could lead to child prostitution. Children of HIV-positive parents also experience discrimination in many social and institutional settings. Families may be shunned and children driven out of school. Relatives may be unwilling to look after children whose parents have died, particularly if the children are also infected with HIV, and such children may be rejected by orphanages. PROJECTED IMPACTS With technical assistance from the East-West Center, the Thai government's National Economic and Social Development Board (NESDB) has projected the prevalence of HIV in the Thai population through 2005. These projections have been used to estimate HIV and AIDS infections among children as well as the number of children who will be affected by AIDS in the adult population. The baseline NESDB projections show that almost one million Thais will be infected with HIV in 2005, or 1.5 percent of a total population of 65 million. Another 800,000 will have died of AIDS. Of these totals, 84,000 infants and young children will have died, and 18,000 will be infected. By 2005, 160,000 children under 15 -- including 17,000 under 5 --will have lost their mothers to AIDS. Another 330,000 children under 15 will have mothers infected with HIV. Even larger numbers of children will have had to cope with the illness or death of their fathers. If everyone with AIDS seeks medical care, annual hospital costs will be US$40 million by the turn of the century. One result of this diversion of funds may be a drop in Thailand's primary and secondary school enrollment, currently one of the highest in Southeast Asia. POLICY RECOMMENDATIONS Thailand has several advantages as it faces the difficulties that lie ahead: a tradition of family and community care for orphans, a good public health infrastructure, an active national AIDS program, and low fertility. With sound planning and early action, the Thai government and community organizations may be able to reduce the number of infected and affected children and minimize the HIV-associated problems they face. Preventing infection Clearly, the best approach to the problems that HIV and AIDS create for children is primary prevention--keeping parents and children from becoming infected. Training courses in communities, factories, and schools can provide young men and women with the social and decision-making skills they need to protect themselves from infection. Promotion of voluntary premarital testing can help reduce HIV transmission between spouses, and anonymous testing services can increase the likelihood that men and women who are already infected will take measures to protect their partners. Programs to prevent mothers with HIV from infecting their children should include nondirective counseling on futurere productive options, provision of AZT to pregnant women to reduce mother-to-child transmission, and provision of infant formula to mothers along with advice not to breastfeed. Improving counseling Integrated reproductive health services should be introduced in all hospitals, antenatal clinics, and district (tambon) health centers. These should combine the traditionally separate functions of family planning, sexually transmitted disease (STD)testing and treatment, pregnancy care, HIV testing and treatment, and counseling. The focus on district health centers is particularly important to improve services to Thailand's large rural population. More aggressive testing, treatment, and follow-up of STDs is important because such infections greatly facilitate the transmission of HIV. Couples with HIV need to be counseled on future reproductive decisions, care of infected children, and how to provide for their children after the parents' deaths. Addressing child prostitution The issue of child prostitution has received considerable media coverage in Thailand. Focus groups interviewed by the Thai Red Cross Society's Program on AIDS suggested that legal efforts to eliminate child prostitution will attract greater popular support if they concentrate on punishing brothel owners, agents who bring children into prostitution, and parents who sell their daughters --rather than on punishing clients. Media campaigns should dissuade men from visiting child prostitutes and should encourage citizens to report violations of the child-prostitution laws. One important policy change that would strengthen efforts to end child prostitution would be to eliminate the three-year gap between compulsory schooling and entry into the job market. Today most Thai children complete primary school when they are 12 years old, but they cannot legally work until they are 15. The government is gradually implementing a requirement for three years of secondary schooling, but these efforts must be accelerated. In addition, many of the children at risk of becoming child prostitutes will need financial support if they are to continue their education. In particular, scholarship programs for rural Thai girls should be expanded. Helping children in difficult circumstances Street children and children who live in slum areas are atconsiderable risk of HIV infection. They need HIV/AIDS education,condoms, and reproductive health services in easily accessible street settings. In addition, expanded vocational training, social and health services, and safe housing can help reduce their vulnerability. Addressing the needs of street children will become even more critical as their numbers swell with the addition of children orphaned by AIDS. Reducing discrimination Steps to reduce discrimination against families living with HIV are a critical aspect of Thailand's efforts to cope with the epidemic. A multifaceted approach should include legislation to protect the rights of people living with HIV to housing, employment, education, and health care. Media efforts should shift from fear campaigns to messages that encourage support and compassion. Schools and businesses should be encouraged to implement humane staffing and admissions policies, and traditional leaders--such as village headmen, teachers, and monks--should be enlisted as models. Schools will need to assume new roles in educating children about HIV/AIDS and providing social and psychological support to affected children. Improving medical treatment Even with better prevention, the number of Thai children infected with HIV will increase over the next 10 years. Health agencies should distribute a set of locally relevant guidelines for the diagnosis of pediatric AIDS and the inexpensive treatment of opportunistic infections. Families need guidelines on home care for infected children, on the importance of regular medical follow-up, and on identification of symptoms or illnesses that require prompt medical treatment. Health agencies need to normalize HIV treatment in medical settings, emphasizing universal precautions to protect healthworkers and their patients without stigmatizing those infected with HIV. They also need to improve the continuity of care for HIV-positive mothers and children. Finally, a system of nationwide data collection on pediatric AIDS, maternal HIV, and treatment of infected children would help anticipate future health-care needs. Providing for AIDS orphans In Thailand, abandoned children and orphans have traditionally been absorbed into the family network. Parents infected with HIV need to plan for their children's future, including strengthening their children's ties with other relatives. Traditional systems of integrating orphans into the community should be revitalized and new systems developed, such as day-care centers with expanded night care for children in need. Existing programs for adoption and fostering should be strengthened, and institutional care should be enhanced to handle the medical and psychological needs of children affected by HIV. Finally, affected children need support to maintain their access to education. This might include subsidies, day care for younger siblings, or vocational programs with opportunities to earn an income. CONCLUSIONS Thailand has the advantage of going into the HIV/AIDS epidemic with its eyes wide open. No other country has had as complete a monitoring system or as early a warning of the problems to come. Some of the policies recommended here are new approaches that require testing in the field; others are existing efforts thatcan be strengthened and expanded to attain regional or national coverage. None of this can be accomplished by any one agency or group alone. It will take the shared commitment, ideas, resources, and efforts of all sectors of society to plan for the future needs ofchildren affected by HIV, to protect them from infection, and to provide them with the social and economic support, medical treatment, and legal protection they urgently need. This issue of Asia-Pacific Population & Policy is based on:Tim Brown and Werasit Sittitrai. 1995. "The impact of HIV onchildren in Thailand." Program on AIDS, Thai Red Cross Society, Bangkok. ----------------------------------------------------------------- FIGURES Photograph of a poster produced by the Program on AIDS, Thai Red Cross Society. Caption: "`I have AIDS--hug me.' HIV/AIDS awareness campaigns in Thailand are shifting from fear tactics to a greater emphasis on compassion." Figure 1. Percentage of women attending antenatal clinics by province who were HIV-positive as of December 1993. Figure 2. Living children under 15 years old whose mothers arepositive for HIV or have died of AIDS: recent trends and projections.[The photograph and the two figures from the printed version of this publication cannot be reproduced in this text document (see below for ordering information).] ----------------------------------------------------------------- ABOUT THE SERIES Asia-Pacific Population & Policy, published since 1987, summarizes research on population and reproductive health for policymakers and others concerned with the Asia-Pacific region. The Office of Population of the United States Agency for International Development provides support for this publication under a cooperative agreement with the Program on Population of the East-West Center. Writers: Tim Brown and Werasit Sittitrai Series Editor: Sidney B. Westley Graphic Artist: Russell Fujita Editorial Committee: Philip Estermann Andrew Kantner Karen Oppenheim Mason James Palmore Robert D. Retherford Sandra E. 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