THAILAND

Monitoting and Evaluation of HIV/AIDS programs

Vichai Poshyachinda and Vipa Danthamrongthul

Background

Thailand has nearly 60 million people and a GNP per capita of US$ 2,740 (1995). The first case of AIDS was identified in 1984. Until 1988, HIV prevalence was low, but increased rapidly thereafter: first among intravenous drug users (IDU), then female p rostitutes, and subsequently in the general population. By 1993 HIV prevalence levels reached a peak, indicating a generalized epidemic. In the five following years HIV prevalence of national aggregate from sentinel serosurveillance has been fairly consta nt in female prostitutes, IDU, male STD clients and ANC clinic attenders, and has declined slightly in blood donors. There are marked regional differences in HIV prevalence levels and trends.

National response

The national AIDS prevention project was established in 1987, followed by the formulation of the first medium term plan 1988-91. Increasing HIV prevalence prompted the upgrading of the prevention project to the status of centre for prevention and contr ol of AIDS in the communicable disease center in the Ministry of Public Health. A national committee, chaired by the Minster of Public Health was created in 1990.

The HIV prevention programme in Thailand has adopted a two-pronged approach: intensive public campaigns through various mass media and a variety of educational and behavioural modification interventions targeted towards high-risk groups and vulnerable sectors of the population. A key component of the strong and continuous safe sex programme is the 100% condom programme.

Monitoring and evaluation

From the first recognition of the epidemic monitoring was a key component of the programme. Cross-sectional screening surveys were carried out among high-risk groups during 1985-87.

Screening of donor blood started in 1987 and became an epidemic monitoring instrument early in the epidemic. The monitoring system has five components:

Resources for HIV/AIDS increased from US$ 0.7 million in 1988 to $6.9 million in 1990 and $53.4 million in 1994. The national contribution to the budget increased from 38% in 1990 to 85% in 1994, reducing dependency on international contributions.

Following are resources from which data used in monitoring and evaluation are drawn:

1. Communicable disease registry and record system: this was an existing monitoring system based on hospitals and clinics and HIV/AIDS was merely added to the system. Information on background characteristics and possible mode of transmission is included
2. Sentinel sero-surveillance and related monitoring: a system of biannual data collection had been in place in multiple sites (all provinces) and in different sub-populations since 1989. From 1995 the collection is once per year. Compilation is done at the province level and data are sent to the central level on computer disks. Annual behavioural surveillance was added in 1995 and also included multiple sites and different sub-populations.
3. Specific target group population monitoring system: includes IDU, female and male prostitutes, military conscripts, STD clients.
4. Provincial health office and district hospital HIV monitoring: locally initiated and more focused on local situation than central agency monitoring.
5. Cross-sectional and cohort studies: large numbers of cross-sectional studies have been carried out (hundreds), but only a small number of cohort studies. The latter appear to yield more relevant information, especially on the impact of interventions.< /LI>

HIV monitoring is a composite function of multiple health agencies mostly under the Ministry of Public Health. The extensive collaboration to monitor and infectious disease has no precedent in Thailand. The Division of Epidemiology in this Ministry has the operational responsibility for providing technical support, data management and acting as information clearinghouse.

In recent years HIV monitoring has changed with an increased focus on local area monitoring and a reduced surveillance frequency to save costs. Among the problems associated with operating such an extensive HIV monitoring system are: sampling biases es pecially among high risk groups; poor reporting by hospitals (underreporting, inaccurate diagnoses and data processing errors); weekly epidemiological surveillance reports which may need more in-depth analysis as they may arrive at different conclusions.< /p>

The contribution of a strong HIV monitoring component to policy and strategy formulation or other decision making in association with interventions cannot be easily identified. Information from multiple sources influences policy. For instance, the wide publicity given in the press to the illness and death of a single man who became infected through blood transfusion may also have influenced policy during 1986-91.

Throughout the epidemic research results seemed have reached policy makers and may have influenced policy and programme implementation. There are many examples to indicate that HIV prevalence data from high-risk groups and the general population have a ffected national policy making.

Proximate determinants

A large number of studies have described changes in sexual behaviour in Thailand during the last five years or more years.

A reduction in the frequency of visits to commercial sex workers, but more markedly, a rapid increase in the use of condoms in non-regular relationships has been observed. Detailed studies of the effects of interventions are relatively few.

HIV and STD

HIV monitoring is extensive and detailed. The decentralized system ascertains that many different population groups are included, but at the central level a well-organized reporting and analysis system provides regular data at the national level.

Conclusion

Thailand has developed a strong and concerted response to the AIDS epidemic. HIV prevalence monitoring has made a significant contribution to the response, both in terms of the tempo and size. Furthermore, research has been an integral part of the moni toring system and has contributed to further development and improvement of the monitoring system.

With the changing face of the epidemic, current important issues include adapting the monitoring system to capture a local focus and optimizing the frequency of monitoring.