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RESEARCH PAPER ON HIV/AIDS IN THAILAND AND ITS PREVENTION COURSE: BIOENGINEERING AND ENVIRONMENTAL HEALTH Submitted by: Mr. Md. Matiar Rahaman ID No. WWF008528 HIV/AIDS IN THAILAND AND ITS PREVENTION 1 Introduction HIV disease is a continuum of progressive damage to the immune system from the time of infection to the manifestation of severe immunological damage by opportunistic infection, neoplasm wasting or low CD4 lymphocyte count that define AIDS. HIV attacks white blood cells called CD4 positive T-cells and with less efficiency macrophages and neurones. T-cells are the component of immune system that are able to fight off diseases like tuberculosis, parasitic infections, fungal infections and infections by viruses. These immune cells also prevent certain cancers such as Kaposi’s sarcoma, non Hodgkins lymphoma, Burkitts lymphoma and primary malignancies of the brain. The virus interacts with the T-cell and causes the death of the cell though the mechanism is not known. The normal level of CD4 cell is about 1200 cells per l. Due to HIV infection the CD4 cells become less than 400 cells per l. 2. Background Information In 1981 Gottlieb reported six cases of pneumocystics pneumonia in homosexual men and suggested a new disease called AIDS. The clinical entity was identified in 1981. AIDS is one of the 15 killer diseases in the world. UNAIDS and WHO estimate that there were more than 33 millions of people infected with HIV at the beginning of 1998. 40 millions are expected to be infected in the world by the year 2000. About 11.7 millions patients have already died from the disease at the beginning of 1998. Despite prevention efforts the virus is spreading causing nearly 16,000 new cases daily throughout the world. AIDS has already left 8.2 millions children without a mother or both parents. The number is expected to reach 13 millions by the year 2000. Very few of the children will leave to see their fifth birth day. More than 90% of the HIV positive people in the world live in an area where there is no access to affordable of available various HIV therapy and as a result HIV is spreading day by day. Various available therapies slow the development of the acquired immunodeficiency syndrome. The global HIV/AIDS epidemic report is shown in Table 1. Table 1. Global HIV/AIDS epidemic report – June 2000. Description People newly infected with HIV/1999 Number of people living with HIV/AIDS AIDS death in 1999 Total number of AIDS death since epidemic Total AIDS orphans Total (million) 5.4 Adult (million) 4.7 Women (million) 2.3 Children <15 years (million) 0.62 34.3 33.0 15.7 1.3 2.8 18.8 2.3 15.0 1.2 7.7 0.5 3.8 13.2 - - - 3. Causative agents In 1984 scientist in the USA and France identified the Human Immunodeficiency Virus (HIV) as causative agents of AIDS. HIV is a retrovirus, member of the family of primate lentivirus. Two types of HIV type HIV-1 is responsible for most of the cases of disease worldwise. Type HIV-2 is a serious concern in sub-saharan Africa and is spreading in Asia. In Thailand the virus sub Btype exists but most infected people have sub-type E. 4. Incubation period The period from HIV infection to development of AIDS is known as the incubation period. The period varies from <1 year to 20 years. The estimate also varies with the age. In case of young adult is 10 years and for infant and old adults varies between infection at the age 20 to 40 years. 5. AIDS survival time The time from first diagnosis of AIDS to death has been studied separately as AIDS survival time. 6. Present situation of HIV in Thailand Thailand is in the third position with respect to HIV infection throughout the world. HIV started in September 1984 in Thailand. The total population of Thailand is about 62 millions in the year 1999. Now the total HIV patients in Thailand are about one million. Total AIDS patients in Thailand are about 142,207 up to April 2000. The total number of patients that of AIDS patients died up to April 2000 is 39,193. The approximate number of HIV patients by the year 2000 is about 1,028,000 and approximate number of AIDS patients by the year 2000 is about 562,000. The infection rate is very high and tends to increase the public health problem in Thailand. Geographically the problem is severe in the northern part of the country where there are more cases in proportion to the capital city. More than half of the new cases occur in the under 25 years population and the Asian economic crisis is likely to increase the HIV burden borne by the younger population. The Asian economic crisis has exacerbated the AIDS problem in Thailand. In Thailand AIDS is a Regional epidemic as in the rest of the Asia. This is due to the development of HIV diseases at different stages at different places. The long latency period of the disease makes it easy to predict that this will be a huge problem. Since, 1989 an explosive epidemic of HIV-1 has occurred among commercial sex workers in a semi-rural areas of Northern Thailand (Chiang Mai). The HIV-1 incidence estimate the highest rate of sexual transmission by the commercial sex workers. Due to poverty and under nutrition the government, political leaders, religious leaders and community leaders of developing countries have often overlooked the significance of AIDS. The long latency period of the virus to cause infection is one of the important reasons of transmission. Thailand was in deep denial about its AIDS problem when new of the epidemic began to surface. The government of Thailand is fearing that negative publicity will hurt the nations largest source of foreign capital i.e. tourism. Prostitution is one of the top monetary contributor to Thailand’s GDP. Virus is spreading rapidly in and around the area known as ‘Golden Triangle’, the meeting point of Lao People’s Democratic Republic, Myanmar and Thailand where most of the worlds opium and heroin are produced. The recent global HIV/AIDS epidemic report of June 2000 of Thailand is shown in Table 2. Table 2. Global HIV/AIDS epidemic report of Thailand – June 2000 Description People living with HIV/AIDS AIDS orphans Total adult and children 755,000 Adult 15-49 years 740,000 Women 15-49 years 305,000 Children <15 years 13,900 75,000 - - - 66,000 - - - AIDS death 7. AIDS distribution in Thailand For the duration from September 1984 to April 2000 Thailand faced the spreading of HIV infection problem and AIDS patient problem which impact Thai population strongly and continuously. However, the number of patients that is reported may be less than 30% of the real numbers. The year wise distribution of AIDS cases in Thailand is shown in Table 3. Table 3. Year wise distribution of AIDS cases in Thailand from September 1984 to April 2000. Description Number of AIDS cases Year 1984-85 1996 1997 1998 1999 43,665 24,201 26,164 25,691 20,416 April 2000 1890 Total number of AIDS case 142,027 Total death 39,193 8. Age and sex-wise AIDS distribution In Thailand in the year 1998 the HIV/AIDS patients are screened on the basis of the age and sex and the following information are obtained. The age and sex-wise patients distribution is shown in Table 4. Sex-wise distribution – approx. male and female ratio is 4:1. Age wise distribution – below 20 years male and female ratio is 1:1. - above 20 years male and female ratio is 4:1 Table 4. Age and sex-wise distribution of AIDS patients in Thailand in the year 1998 Description Number of male patients Number of female patients Age group (years) 20-29 30-39 40-49 0-4 5-9 10-19 318 55 60 4185 5403 277 68 63 1973 1203 50-59 60+ 1553 333 182 365 91 23 9. Mode of HIV transmission in Thailand 9.1. Heterosexual transmission is 82.6%. Among these percentage about 97-98% of HIV transmitted by the commercial sex workers and the remaining is transmitted by the normal heterosexual relations among non commercial partners, e,g, girlfriend, boyfriend, wife-husband. Among men who visited prostitutes about 75% are Thais and 20% are foreign men visiting Thailand. 87% of the women and children in prostitution in the north of Thailand in Chiang Mai and Chiang Rai are HIV positive. This is because the women of north Thailand are very beautiful because of their mixed heritage – Thai Laotian, Cambodian, Burmese, Chinese. They are recruited into the sex trade as men find these women desirable. The aggressive advertising campaign by the ‘Condom King’ got the word to the Thai speaking people that commercial sex workers will die if they do not use condoms. This caused the sex industry to become undesirable. As a result people recruit sex workers from northern hilly and border areas as well as from villages. These women do not speak Thai as they are illiterate and can not understand the warnings given by the government in Thai language and as result they became infected with HIV. Young adolescent girl prostitutes are at great biological risk of HIV infection, as they have to meet with elderly clients who have history of several exposures. The remaining portion which is transmitted by the normal heterosexual relations among non-commercial partners are due to lack of faithfulness of the partners. For married women it has become high risk behaviour to have unprotected sex with their husbands, unless they are absolutely certain that their husbands are not visiting sex industry. 9.2. Intravenous drug users is 5.3% of the HIV infected population. The Thai Ministry of Public Health has found that 30-40% of drug users have HIV. The AIDS epidemic in Thailand gained an early foothold among intravenous drug users. People who inject drugs tend to be associated with poverty and crime. Needles and syringes are expensive so, many people improvise intravenous equipment, which they then share with others, due to poverty. 9.3. From mother to child transmission is 5.03%. High prevalence of HIV is found among pregnant Thai women attending pre-natal clinic for examination. Transmission of HIV from mother to child occurs during pregnancy, delivery and through breast feeding. One half of the transmission occurs during breast-feeding. 9.4. Through blood transfusion the disease transmitted to 0.05%. 9.5. The other unknown causes of transmission is 7.02%. 9.6. Homosexual transmission virtually non existent 10. Cofactors for disease progression Endogenous biologic or psychologic factors, other infections, behaviours, or other environmental factors that alter the natural history of HIV infection may be cofactors for disease progression. They include genetic factor, age, sex, route of HIV infection, other infection, poverty, nutrition, smoking, descrimation, sexual inequality, inadequate health and social services, rapid urbanization, inappropriate development and increase labour migration. Increased labour migration is an important factor in the spreading of HIV. Since mobility of the labour is a primary cause of changing behaviour and seeking new partners for sexual activity. Economic development stimulated population movement. As they leave in search of livelihood elsewhere they are exposed to a new socio-economic environment. Working in a foreign land does not allow access to information on HIV/AIDS and reduce the quality of health services due to language barrier. The risk of HIV also dramatically increases with disaster, war, political and economic crisis. 11. HIV prevention measures HIV prevention programme should be a multidisciplinary approach combining behavioural science, social science and biological methods to fight against the spread of HIV. The goal of our fight against HIV is to benefit people affected by or at risk of HIV/AIDS, so that they receive better care, greater respect and more integration in the society. Moreover it should create and promote an enlightened medical view on HIV/AIDS. The following general measures can be taken for the prevention of HIV infection and as well as AIDS: i) A health policy relating to HIV/AIDS prevention should be developed ii) Education – medical education including responsibility and regular advice for the health professional. Promotion of education to the policy makers about ethical, social policy and human rights of HIV/AIDS. Health education regarding safe sex, HIV prevention and sexual health promotion to the public and continuing debating on the ethical issue of HIV. iii) Health development has to be adopted to economic, political and social change iv) Health legislation that reflects the principles of social, medical, ethics and human rights v) Broad social policy. Integrated approach for HIV/AIDS prevention with care is of great value. Integration of all service in the health sector and other sectors such as business, tourism, the armed forces, education, religious organization, developmental agencies and mass media – to create a more favourable environment for HIV risk reduction strategies and measures that bring about social, cultural and economic changes. Active community participation of different community organizations and social movements can change the attitudes and practices of the people regarding risky sexual behaviour and injectable drug use. High level political commitment for prevention of HIV is of value. In the early 1989 the Thai government acknowledged the spreading epidemic and instituted a wide spread initiative of AIDS education and prevention. Mr. Mechai ViraVaidya the ‘condom king’, a government minister who initiated a radio and television campaign warning against the danger of HIV/AIDS. He popularised the use of condoms, which slowed the acceleration of the spread of HIV infection. A nation wide 100% condom programme has encouraged commercial sex workers to use condoms free of cost. Condom use among commercial sex workers has increased to about 90% and resulted in a sharp decrease in STD including HIV. Prevention of sexual transmission of HIV Prevention of new HIV infections involves changing people’s behaviour related to sex, drug use and medical practice. i) ii) iii) iv) v) vi) 100% use of condom during sexual activity. Condoms are classified as medical device and are regulated by the FDA. Use of condom while engaging in sexual intercourse vaginal, anal or oral can greatly reduce a person’s risk to HIV. Changing people’s behaviour related to sex by comprehensive and early sex education and by training in prevention skill, safer sex etc., can reduce the risk of HIV transmission. Successful behavioural strategies as well as cutting edge bio-medical technologies are necessary to cut the spread of HIV. Behavioural strategies have cut infection rates by 50% in developing countries. Providing confidential voluntary counselling and testing of HIV Illegal commercial sex worker (CSW) industry should be stopped and rehabilitation of CSW is needed for prevention. Since CSW industry is so widespread in Asia may be we could try to rehabilitate CSW and also localised prostitution so that we can provide CSW with health care, give them free condom etc. Providing monetary incentives to the girls to complete secondary education Provision of comprehensive service delivery and medical care for STD by the medical and paramedical professional and community workers. Community workers should reach out and deliver basic services including condoms and STD treatment and cover the whole range of the community talking with men and women. Prevention of IDU Needle exchange programme has cut HIV transmission among IV drug users. Treatment and rehabilitation centres for IV drug users play an important role in HIV prevention and drug users come back to their normal life. Prevention of HIV through blood transfusion by blood-screening technology can able to prevent transmission of HIV 99%. Prevention of transmission from mother to child can be prevented if both father and mother get tested for HIV before pregnancy. If the results are positive and the pregnancy is desirable then by using anti-retroviral regimen (AZT) the transmission can be cut down during pre-natal period. World Health Organization (WHO) view regarding prevention measures is almost similar to that described above. View of BMA (British Medical Association) foundation for AIDS Principle- The foundation believes that the experience gained through HIV and AIDS should be incorporated into wider professional learning and understanding. Approaches to HIV/AIDS should be based in medical science, clinical and public health experience. Strategy – BMA is taking a leadership role in creating and promoting consensus on the planning and the provision of national health services. United Nations Development Programme (UNDP) - HIV and Development in Asia It aims to reduce vulnerability through development and to prevent HIV risk linked to development by integrating poverty alleviation, good governance, gender and rights. The project focuses on the following points to prevent HIV risk in relation to socio-economic development through: i) Capacity building with government and non-government and local community to reduce HIV risk ii) Social mobilisation to promote resilience to HIV by engaging communities and other sectors iii) Institutional partnership building between health and education sectors iv) Advocacy and information dissemination 12. Conclusion Prevention is better than cure. The drugs, which are used in the treatment of AIDS have no curative value rather than suppression of the disease and are not able to prevent transmission of viruses. Prevention methods coupled with unsqueamish public awareness campaigns to make those methods widely known and adopted can start to turn the tide and check the inexorable spread of this insidious disease.