MSW-TSW FSW Year B ah t
Figure 2: Implementation Costs for National AIDS Operational Plan for FSWs and MSWs-TSWs (baht) from 2015-2019
In 2015, FSWs were allotted 298 million baht, which increased to 380.6 million by 2019. Over the four-year period, they were allotted 1.75 billion baht, the most for any key affected population (KAP). In comparison, MSWs and TSWs (grouped into one category) were allotted 47.6 million baht in 2015 and 60.1 million baht by 2019. Over the four years, costs for
implementing their packages reached 277.2 million baht. Despite increases in funding across all sex worker groups, the total baht allocated for MSWs and TSWs over the four-year period
difference in the number of sex workers by gender. In 2016, the MSW population comprised 25.79% of the total FSW population. However, an estimated 50% of new HIV infections were among MSM (including MSWs and TSWs), compared to 10% among FSWs. The difference in budget allotment compared to the reality of HIV infections demonstrates the need to invest more in preventing and treating HIV among male and TSWs.
Collection of Surveillance Data
The collection of surveillance data changed with changes in the government’s HIV policy priorities. Early interventions solely focused on condom distribution and reducing HIV incidence among commercial sex workers and their clients.
"A survey of commercial sex premises in January 1998 showed a slight increase in the number of such premises, from 7,208 in 1997 to 8,016 in 1998. However, the number of female sex workers does not seem to have increased, being 63,526 in 1997 and 63,941 in 1998." (Funding priorities for the HIV/AIDS crisis in Thailand, p. 17, 1999)
Surveillance existed to record the instances of HIV, collect population numbers of sex workers, and understand what proportion of sex workers were infected. Data collected in the 1990s focused on gathering information to promote prevention of HIV. However, the government acknowledged that they needed better collection of surveillance data. With the divergence of HIV infection rates between direct sex workers and indirect sex workers, reported surveillance data needed to be separated by type of sex worker. As a result, surveillance data collected from 2006 onwards differentiated between types of sex worker. The same measures were not used to capture data between MSWs and FSWs. The measures used for FSWs captured a larger range of HIV prevention and treatment measures. Similarly, the network coverage for FSWs was much larger than that for MSWs. However, starting from 2010, the Thai government changed its reporting mechanisms and MSWs were thereafter reported in the same ways as FSWs. Specific
As Thailand moved away from purely prevention-based policy, the data reported also changed. Currently, the Thailand National Operational Plan employs the Reach, Recruit, Test, Treat, and Retain Model. Objectives under this model require surveillance data not only of HIV prevention coverage, but also for testing rates, recruit (providing access to) testing, treatment rates, and retainment in treatment. This expansion of policy imperative also requires an expanded surveillance data collecting system. The Thai government responded by rolling out data
collection systems in high-risk provinces (urban areas, tourist cities, areas where the population is mobile, etc.) first before expanding to other provinces across the nation.
Policy Interventions
Focus on Female Sex Workers
From the advent of the Thai AIDS epidemic in the 1980s, interventions for FSWs continue to dominate the policy landscape in ending the spread of HIV/AIDS. Successful interventions for FSWs serve as models for MSWs and TSWs. Beginning in 1992, the Royal Thai Government implemented the 100% Condom Program as a means of combatting the spread of HIV by encouraging condom use among female commercial sex workers and their clients in every sexual encounter.
“Segments on radio and TV candidly emphasized the risk of contracting HIV and other sexually-transmitted diseases and stressed the need for condom use, particularly in commercial sex. They even offered tips for women to try to persuade their partners to use condoms.” (Thailand’s Response to HIV/AIDS: Progress and Challenges, p. 14, 2004) Although the program is recognized as a key model for success, it only addressed HIV spread through a singular network: heterosexual transmission through commercial sex. The campaign specifically targeted FSWs, emphasizing that they need to insist that their clients use condoms. It was evident that heterosexual transmission was the primary policy concern, "Programme
prevention of heterosexual infection." (Funding priorities for the HIV/AIDS crisis in Thailand, p. 18, 1999) This 1999 statement asserts that condom distribution is only meant to target
heterosexual transmission as the primary mode of transmission. Other forms of sexual infection spread by non-FSW were not concerns. The legacy of the 100% Condom Program establishes condom promotion and distribution as primary modes of prevention among all populations of sex workers. The statement above demonstrates that the only sex workers targeted by the program were women. Despite ignoring other components of the HIV epidemic, the program was effective in reducing HIV prevalence and spread.
"The key factors which led to the decline in HIV spread include the 100% condom use campaign in commercial sex establishments, which began in 1992 and contributed to national change in behavioral norms in commercial sex. However, efforts to promote safe behavior in other risk networks was less thorough and, thus, infections have continued to occur in these other transmission networks." (UNGASS Country Progress Report
Thailand, p. 30, 2008)
The Thai government applauds the 100% Condom Program as a key strategy for reducing HIV despite ignoring many networks for transmission. Policy priorities centered around reducing HIV from contact with FSWs because that was the hub of the epidemic. Although this is
understandable for curbing infections during the peak of the epidemic during the 1980s and 1990s, the Thai government does not explain why other populations and risky populations were subsequently ignored. Despite the misgivings of the program, the Thai government and
international communities applaud it as a model for success. Similar condom coverage programs continue to be implemented for MSWs and TSWs after the end of the official end of the 100% Condom Program.
"The CHAMPION Project (HIV prevention among KAPs), with support from the Global Fund, has been implemented in 30 provinces, which has started in late 2010. The
Department for Disease Control has strengthened related work in 47 provinces outside the CHAMPION target areas, mainly through condom distribution, condom points,
Although the CHAMPION Project (initiated in 2010) is not exclusively directed towards sex workers, MSWs and FSWs are both defined as KAPs that the program will target. The focus of this project is condom distribution and encouraging condom use, extremely similar to the 100% Condom Program. The Department of Disease Control’s strengthening of this project
demonstrates a dedication to reducing the spread of HIV by expanding condom distribution as an existing model of success to new at-risk populations. The Thai government also compares other KAPs to FSWs.
"Moreover, the trend of the spread of HIV through sexual intercourse in the drug addicts both the intravenous injection and other groups, who neglected the safe sex, was probably high too. The effective prevention should be sought like the success with female sex workers." (Follow-Up to The Declaration of Commitment on HIV/AIDS, p. 19, 2006) The above statement compares the current spread of HIV among people who inject drugs (PWID), a KAP, to FSWs. This suggests that there are similarities between the two populations, validating targeting PWID with the same prevention strategies as those for FSWs, and that using such methods will lead to the same level of success. These comparisons establish FSWs as the standard for new policy interventions. This poses problems because the needs for all KAPs are not the same as those for FSWs. MSWs and TSWs were either not included in policies and strategies, or policies did not include specific provisions for them (often grouping them with MSM in general) for the majority of the duration of the AIDS epidemic.
Although the Thai Ministry of Public Health collected data for MSWs since 1997, it was not to the same extent as FSWs nor reported on in policies until 2006-2007. TSWs were not included in collection data until 2015. Even after policies officially started reporting on and including MSWs and TSWs, they were not policy priorities.
certain respects. For example, with administrative decentralization efforts, many local communities either do not see this as a priority, or lack the capacity to effectively program HIV prevention activities for these populations.” (Thailand AIDS Response Progress Report, p. 5, 2012)
The accomplishments achieved for FSWs do not extend to MSWs and TSWs. Although
programming for MSWs and TSWs are on the policy agenda, evident by their mere inclusion in the 2012 AIDS Progress Report, implementation of such programming is lacking. As a result, reducing HIV incidence for non-FSW populations has been difficult. Local administrations do not view HIV prevention for these populations as a priority concern and therefore do not implement the corresponding interventions. These difficulties arise in part because FSWs were historically the primary focus population of HIV policies, normalizing the association between HIV and female sex work. The normalization of FSWs as the default population for HIV
prevention is further cemented in the current national AIDS strategy. In the National Operational Plan Accelerating Ending AIDS for 2015 – 2019, different service packages were created to create targeted HIV prevention and treatment strategies for all KAPs. Of the 6 pages detailing the specific contents of these packages, 4 outlined package provisions for FSWs. MSWs and TSWs were grouped into a singular category, and the plan dedicated 2 pages discussing package provisions for that group as a whole. Inclusion of new groups and shifting policy focus requires not only that the policy agenda change, but that political willingness to include these new groups into existing policies also needs to change. The difference in strategized commitment
demonstrates that there is much ground left to cover for MSWs and TSWs to rise to the same level of priority as FSWs.
Inconsistent Groupings by Gender
was no mention of specific interventions designed for MSWs, they were either grouped with MSM or with FSWs to form a comprehensive sex worker category.
"Programs for male sex workers did not achieve the same degree of coverage as for female sex workers perhaps because MSM accessed commercial sex in non establishment locales (such as parks, public toilets, and other MSM cruising locations)." (UNGASS Country Progress Report Thailand, p. 42, 2008)
The assessment of programs above implies that sex workers are only female, pushing MSWs into the categorization of MSM. By grouping MSWs with non-sex workers, the
categorization ignores the specific challenges and circumstances that these two distinct groups face with regards to HIV incidence and risk. Not considering the unique conditions of MSWs makes it difficult to develop programs that will effectively target MSWs as a specific population. Similarly, in the 2015 National AIDS Progress Report, sex worker interventions are not gender- specific. Instead, “sex worker” is a group that includes both MSWs and FSWs. An outlier to this trend is the National Operational Plan, which identifies specific intervention for MSWs
(although still grouped with TSWs) separate from MSM. This is the most recent Thai HIV strategy, indicating that future policies may continue to show this differentiation.
Unlike interventions that do not separate MSWs from other groups, surveillance data does once collecting information about MSWs was initiated. However, data on MSWs was not consistently reported nor collected until 2010.
"Percentage of female and male sex workers reporting the use of a condom with their most recent client: NA, Data among MSW is not reported since questions used to
construct this indicator are difference from standard definition suggested in the UNGASS guide. But this indicator will be available starting from 2010 onward." (UNGASS
Country Progress Report Thailand, p. 24, 2010)
This shows an acknowledgement of the deficiencies of previous data collection methods and that newly collected data will be more consistent and specific to MSWs. This statement demonstrates
that MSWs and female are different, but that the blanket term of "sex worker” originally referred to females, and that FSWs are the assumed default.
TSWs are almost always grouped with transgender people in general or with MSM. Only in the National AIDS Operational Plan, they are grouped with MSWs. Transgender people were not substantially included in policy reports until the 2014 National AIDS Progress Report. In the 2014 definition of KAPs, “Thailand has continued intensifying the focus on HIV prevention among the vulnerable populations of MSM, TG, MSW, FSW and their clients.” (p. 7) In the population definition, transgender people are a separate category, but in reported surveillance data, they are grouped with MSM, “Of all new infections, 41% were among MSM, MSW, and TG, 12% were in FSW and their clients" (p. 14) Firstly, these groupings ignore the specific challenges that TSWs face aside from those faced by transgender people in general. Asserting that all transgender people are sex workers and face equal risk for HIV is a false assumption. Grouping transgender people with MSM is also problematic because it does not consider individual gender identity. Particularly, the experiences of kathoey sex workers who identify as women are not accurately captured by a metric describing cisgender men. Grouping transgender individuals with cisgender individuals removes the need to consider gender identity as a source of stigma and barrier in determining the efficacy of HIV interventions.
Overall, inconsistent categorizations of MSWs and TSWs is problematic because these inconsistencies also lead to inconsistent policy. In the National AIDS Operational Plan, male, female, and TSWs are relatively separate groupings. These separate groupings allow for the delineations of separate HIV intervention packages for each population. Such a standardized policy procedure clearly outlines policy targets and activities for each population, making policy evaluation and targeting much more efficient. When there is not clear definition of a group,
certain population subsets can be ignored under the guise of targeting a large blanket group. This removes responsibility from implementing agencies to address the needs of most at-risk
populations, and setting policy priorities becomes more subjective. It also removes the imperative to set specific goals.
"Within the service delivery category which includes commodities, apart from FSWs accounting for 39% of the entire allocation in recognition of the large population size, MSM-TG are allocated the highest share of the resources as 28% of the total cost in recognition of the burden of new HIV infections in this population." (Thailand National Operational Plan Accelerating Ending AIDS, p. 36, 2015)
Evident in the 2015 and 2017 National AIDS Progress Reports, by grouping MSWs, TSWs, transgender people, and MSM together there is no standard for allocating money for each of those groups. There are nuances to the impact of the HIV epidemic for each of those groups and group separation is necessary to capture the different needs of each population and determine funding allotments.
Changes in HIV, Changes in Policy
The Thai government has acknowledged that the HIV/AIDS epidemic has changed over the past three decades. Originally, the hub of the HIV/AIDS epidemic was among FSWs and their clients, but has since spread to more of the general population. However, rates of HIV continue to be highest among sex workers and other KAPs.
“By risk group, 44% of the new adult infections were among MSM (including TG), 11% among PWID, and 10% among sex workers and their clients. It is projected that, in the subsequent five years, more than half of all new infections will be among MSM (including TG).” (Thailand AIDS Progress Report 2017, p. 13, 2017)
The impact of HIV is less prevalent among sex workers than it once was, and the main burden of disease has passed onto other populations, such as intravenous drug users. The shift in
emerge. Other KAPs have higher rates of new infections, and MSM (MSM) are projected to become the driver of the HIV epidemic. Although sex workers remain an at-risk population, they are no longer the only risk population. The Thai government has responded by strategizing HIV response packages for all KAPs.
"The Operational Plan consolidates and refocuses key interventions among key
populations (KPs) in high priority geographical sites, with the specific aim of addressing gaps between the current response and a targeted, optimized response needed to achieve Thailand’s goal of ending AIDS by 2030." (Thailand National Operational Plan
Accelerating Ending AIDS, p. 14, 2015)
Recent policies emphasize creating targeted approaches to reach KAPs because of the diverse needs among KAPs. Early responses to HIV focused on controlling the spread of the epidemic by targeting one primary group driving transmission. However, as HIV transmission lessened, HIV prevalence declined, and more people became aware of their status, the policy priorities changed. Thailand’s main concern is ending AIDS by 2030, and the government’s focus on creating targeted interventions shows that mass control of HIV is no longer the most effective policy solution. However, despite these changes in the epidemic itself, FSWs remain seen as a threat.
"A drop in the demand for commercial sex, and high rates of condom use by brothel- based sex workers helped reverse Thailand’s epidemic during the 1990s. Those
achievements can and should be sustained. But HIV infection rates among brothel-based sex workers remain high – a reminder that a significant proportion of HIV infections are still occurring in the sex trade. If the guard is dropped, more vigorous HIV spread could resume among sex workers." (Thailand’s Response to HIV/AIDS: Progress and
Challenges, p. 80, 2004)
Regardless of the successes had with encouraging condom use and reducing HIV infection among FSWs, the Thai government still held the notion that sex workers still carry risk with them. This justifies continuing strong prevention programs for that population even though FSWs are not the leading cause for new infections, and HIV prevalence among FSWs is lower
than that among other KAPs. The policies indicate that dropping prevention programs for FSWs threaten a return of high rates of HIV. Preventing HIV among FSWs remains a policy threat because the original chain of transmission that started the epidemic was between FSWs and their clients, who then spread it to their female romantic partners.
"The HIV/AIDS pandemic began with the first HIV/AIDS transmission from an infected homosexual to a commercial sex worker in Thailand. Since then, it had spread to
promiscuous men, housewives and eventually to the general public." (Follow-Up to The Declaration of Commitment on HIV/AIDS, p. 4, 2006)
There is a perception that HIV/AIDS started with deviant populations, who then put the rest of the unassuming population at risk through their nontraditional behaviors. Homosexuals and sex workers both carry significant stigma surrounding their identities and professions that are outside