In a 1997 article supporting human rights as a framework for public health, Jonathan Mann wrote “all public health policies and programs should be considered discriminatory until proven otherwise” (1). Mann also recognizes a counterargument to this position, that “excessive respect for human rights cripple[s] public health efforts and is therefore responsible for the intensifying and expanding AIDS epidemic” (1). Thailand has received much praise for its 100% Condom Use Program (100% CUP). It has been described as a benefit to society, a “win-win strategy in the fight against HIV/AIDS” and a “success” by reputable organizations such as UNAIDS (2)(3). This paper will examine the 100% CUP in the context of these human rights arguments.
In response to Thailand’s growing HIV epidemic, officials in the Ratchaburi province mandated that all sex workers (SW) in the province use condoms during sex (3). Officials noted that without universal mandates, SWs not enforcing condoms would have more clients than those enforcing condoms. Thus, economically, SWs would be disinclined to use condoms. As rates of sexually transmitted diseases (STDs) in Ratchaburi plummeted, other provinces mandated 100% condom use and, by 1991, the program was nationally implemented (3).
The program is regionally managed by the provincial public health offices. The offices provide free condoms and STD clinics to the SWs. SWs are required to have 2 – 4 check ups per month. The offices also work closely with police and sex establishment owners to ensure adherence by SWs and sex establishment owners (3). As a result, condom use among SWs rose dramatically. A UNAIDS study of 2000 SWs reports consistent condom use with one-time clients as high as 99% (3). In 1993, UNAIDS reported an HIV prevalence of 15.3% for SWs. By 2004, this dropped to 4.3% in urban areas and to 6.3% in rural areas (4). The success of this program kept Thailand’s adult HIV prevalence at 1.4%. Although the HIV epidemic is still severe, the Thai Working Group on HIV/AIDS projected a prevalence of 10% had there been no behavior change intervention (5). While the 100% CUP produced good results, its weaknesses must also be examined.
According to the Oxford English Dictionary, to discriminate against means “to make an adverse distinction with regard to; to distinguish unfavorably from others” (6). The Universal Declaration of Human Rights (UDHR), recognized by all countries as a contract between governments and their people, protects an individual’s right to social security, to “just and favorable” work conditions, and to a standard of living “adequate for the health” of oneself and one’s family, including medical care and necessary social services (7). It also declares that everyone is entitled to these rights, without discrimination (7). Despite the success of the 100% CUP, it can also be interpreted as a program that distinguishes female sex workers (FSWs) by treating them as vectors of disease rather than human beings and thus violates their human rights as described by the UDHR.
First, there is an interesting lack of information on how tourists, clients of FSWs and male sex workers (MSW) are affected by this program. In Wathini Boonchalaski and Philip Guest’s book, Prostitution in Thailand, they observe that HIV programs focused on female sex workers, not men (8). A more equitable response may have been behavior change interventions focused on clients, MSWs and tourists, as they all participate in commercial sex transactions.
Second, SWs are provided STD clinics, but not health care. As indicated by India’s community empowerment program, the Sonagachi Project, SWs should receive general health care to guarantee occupational health and safety (9). Sex workers in Thailand are simply treated for their STDs (3). This suggests a one-dimensional view of SWs; they are not afflicted with other health problems, like the “normal” population.
Third, condom marketing and promotion in Thailand seems to have focused on SWs and not the general population, further discriminating against them as vectors of disease.
UNAIDS reports condom use in non-commercial encounters varies between 32% and 75% (3). Studies show that condom use is lower in non-commercial relationships because condoms insinuate a lack of trust between partners (10). In Cheewanan Lertpiriyasuwat, Tanarak Plipat and Richard A. Jenkins study on risk behaviors for HIV infection in a northern region of Thailand, the authors review the differences between non-regular partnerships and commercial partnerships and illustrate that in 2001, more people were engaging in sex with non-regular partners than with commercial SWs. Out of the 630 participants, 15.9% had sex with non-regular partners in the last year while only 9% engaged in sex with commercial SWs in the previous year (11). As a result of a focus on SWs as vectors of transmission, the shape of the epidemic in Thailand is changing and in 2007, 48% of new HIV infections were from spousal intercourse, 3% were from casual sex and 12% were from sex between SWs and clients (10).
Further, enforcing a simple intervention on a diverse group, such as Thai SWs, is not likely to improve the situation of the group in question as it will not meet the varied needs of the group. Thailand’s sex industry is diverse (12). In 1994, 37 different categories of commercial sex establishments were documented (12). Sex work is often divided into the categories of direct and indirect: direct sex work can take place in streets, brothels, bars, nightclubs, or massage parlors, while indirect sex work can occur in the same locations, but differs because it is often unplanned or opportunistic sex for gain of drugs or supplemental income for low or irregularly paid workers (13). People who participate in indirect sex work do not always identify as sex workers (13). Each different type of sex work incurs different risks, such as the absence of condoms, the presence of drugs and alcohol, or the lack of peer support for the sex worker (13). As UNAIDS shows, in 2004 SWs still had a much higher prevalence of HIV than the general population (4). This intervention could be interpreted not as a method of protection for SWs, but for the general population from “disease-ridden” SWs.
Finally, as implied above, the 100% CUP addresses individual behaviors, but not the social and economic determinants that increase vulnerability to HIV. Sex workers, by nature of their work, are at a higher risk of HIV infection than workers in other occupations. Chomnad Manopaiboon et al. explain that the main motivations to pursue sex work are financial (14). Wawer et al. study origins and working conditions of Thai FSWs and reveal that traditionally, Thai women are “obliged to ensure familial well-being through income generating …activities” (15). In Chomnad Manopaiboon’s study, this obligation to the family’s well being became a barrier to leaving sex work (14). Sex work, according to Wawer, provides more pay than other positions available to women and girls with little education (15). In their study of 678 FSWs, Wawer et al. report that the education level of the sample was relatively low and that while most of the sample had completed primary education, 19% had no primary education (15). The study further reports that the monthly income these women received was approximately 5000 baht (around 200 USD), which was “considered ‘astronomical’ for women with their relatively low educational level” (15). To reduce risk of HIV infection for SWs, vocational training and education programs could be started. By simply providing condoms, the government is not addressing the economic dependency on sex work.
Thailand is a perfect example of the dilemma facing many public health workers: is it possible to balance human rights and public health work? Thailand was clearly successful in limiting the magnitude of their epidemic, but human rights violations are evident as well. The Thai government should proceed with a more comprehensive prevention and treatment plan: condom promotion should be addressed to every citizen, education and vocational training programs should be implemented to reduce dependency on sex work, and wage schemes should be restructured. Jonathan Mann states that to be involved in public health is to be committed to social change (1). If the Thai government follows these recommendations and includes marginalized populations instead of isolating them, they are likely to be more successful in their fight against HIV.
(1) Mann, Jonathan. Medicine and Public Health, Ethics and Human Rights. The Hastings Center Report. 1997 May-June; 27(3): 6-13.
(2) Rojanapithayakorn, Wiwat. The 100% Condom Use Programme in Asia. Reproductive Health Matters. 2006: 14(28): 41-52.
(3) UNAIDS. Evaluation of the 100% Condom Use Programme in Thailand: A Case Study. 2000 July. UNAIDS/00.18E: In collaboration with AIDS Division, Ministry of Public Health, Thailand.
(4) UNAIDS [Internet]. Country Responses: Thailand. Epidemiological Fact Sheet on HIV/AIDS 2008. Available from: http://www.unaids.org/en/CountryResponses/Countries/thailand.asp
(5) Ainsworth M, Beyrer, C, Soucat A. Successes and New Challenges for AIDS Control in Thailand. AIDScience Vol 1, No 5, July 13 2001.
(6) Oxford English Dictionary [Internet]. “Discriminate”. Available from: http://www.oed.com.ezproxy.bu.edu/
(7) UN [Internet]. Universal Declaration of Human Rights. Available from: http://www.un.org/en/documents/udhr/
(8) Boonchalaski W, Guest P. Prostitution in Thailand. Mahidol University: Institute for Population and Social Research; 1994
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(11) Lertpiriyasuwat C, Plipat T, Jenkins R. A survey of sexual risk behavior for HIV in Nakhonsawan, Thailand, 2001. AIDS Vol 17, 2003
(12) Hanenberg R, Rojanapithayakorn W. Changes in Prostitution and the AIDS Epidemic in Thailand. AIDS Care. 1998: 10(1), 69-79.
(13) Harcourt C, Donovan B. The Many Faces of Sex Work. Sexually Transmitted Infections. 2005: 81, 201-206.
(14) Manopaiboon C, Bunnell RE, Kilmarx PH, Chaikummao S, Limpakarnjanart K, Supawitkul S et al. Leaving sex work: barriers, facilitating factors and consequences for female sex workers in northern Thailand. AIDS Care. 2003: 15(1), 39-52.
(15) Wawer MJ, Podhista C, Kanungsukkasem U, Pramualratana A, McNamara R. Origins and working conditions of female sex workers in urban Thailand: consequences of social context for HIV transmission. Social Science and Medicine. 1996 February: 42(3), 453-462.