Dr. Wiwat Rojanapithayakorn, director of a regional office for infectious disease control in Thailand’s Ratchaburi province, sought to curb AIDS by ensuring that the sex occurring in brothel

Directions: As we look at the burden and course of communicable diseases in low- and midincome countries in your textbook, you will read the following two short case studies included in this document. 1. Preventing HIV/AIDS and Sexually Transmitted Infections in Thailand 2. Controlling TB in China You will then watch two short videos on the effects of HIV and Tuberculosis (TB) infections on the body. https://youtu.be/IZ5P6UcbwS8 HIV AIDs https://www.youtube.com/watch?v=UKV8Zn7x0wM TB Lastly, you review two more videos of people who are living with the diseases. https://www.youtube.com/watch?v=nejZuRbR-os HIV AIDS https://www.youtube.com/watch?v=B-P8DjJJltg TB Lastly, add your questions and answers in a Word doc to DB for grading. First Case Study: Preventing HIV/AIDS and Sexually Transmitted Infections in Thailand In Thailand in 2002, approximately one in every 60 persons were infected with HIV/AIDS, and AIDS had orphaned 75,000 children. Between 1989 and 1990, HIV among sex workers tripled, from 3.1 percent to 9.3 percent, and a year later reached 15 percent. Over the same period, the proportion of male conscripts already infected with HIV tested upon entry to the army at age 21 rose sixfold, from 0.5 percent in 1989 to 3 percent in 1991. The Intervention In 1989, Dr. Wiwat Rojanapithayakorn, director of a regional office for infectious disease control in Thailand’s Ratchaburi province, sought to curb AIDS by ensuring that the sex occurring in brothels would be safe, and going well beyond the government’s approach of raising awareness through mass advertising and education campaigns. Knowing that he could only be effective with political support, he sought the provincial governor’s cooperation. The steep rise in HIV/AIDS persuaded the governor to acquiesce, even though prostitution is illegal in Thailand. The government’s direction could imply that it tolerated or even condoned prostitution. A program was launched with one straightforward rule for all brothels in Ratchaburi: no condom, no sex. Until then, brothels had been reluctant to insist that their clients use condoms for fear of losing them to other establishments where condoms were not required. However, with condom use mandatory in all brothels, the competitive disincentive to individual workers and brothels was removed. Health officials, with the assistance of the police’s help; health officials held meetings with brothel owners and sex workers to provide them with information and free condoms. Men seeking treatment for sexually transmitted infections (STIs) were asked to name the brothel they had last visited, and health officials would then visit the establishment to provide more information. This pilot program had dramatic results, bringing down STIs in Ratchaburi within just a few months. In 1991, the National AIDS Committee, chaired by Prime Minister Anand Panyarachun, adopted this 100 percent condom program at the national level. The Impact Condom use in brothels nationwide increased from 14 percent in early 1989 to more than 90 percent by June 1992. An estimated 200,000 new infections were averted between 1993 and 2000. New STI cases fell from 200,000 in 1989 to 15,000 in 2001, and the rate of new HIV infections fell fivefold between 1991 and 1993-1995. Such dramatic results have raised questions about their accuracy and their real causes, but independent studies have found the program to be genuinely effective. The program did little to encourage the use of condoms in casual but noncommercial sex. Interventions among injecting drug users also did not expand to the national level, and the prevalence of HIV among this group rose as high as 50 percent. Costs and Benefits Total government expenditure on the AIDS program remained steady at approximately $375 million from 1998 to 2001, representing 1.9 percent of the health budget. Of this, 65 percent was spent on treatment and care. Lessons Learned The success of the program was due, in part, to the sheer scale and level of organization of the sex industry in Thailand, assisting officials in tracing and coopting brothel owners. Thailand also had a good network of STI services within a well-functioning health system, providing treatment and advice, as well as crucial data for decision-makers both at the baseline and when the program took effect. Cooperation among health authorities, governors, and the police was critical to success. Strong leadership from the prime minister, backed by significant financial resources, also made swift action possible. Maintaining Thailand’s remarkable results in slowing the AIDS epidemic needs continued vigilance. Due to the high cost of treating STIs, the HIV prevention budget declined by two-thirds between 1997 and 2004. Although the Thai experience provides no blueprint for other countries with very different starting conditions, it does demonstrate that targeted strategies and political courage can effect change in deeply entrenched behaviors. 1. How does HIV affect the body’s cellular functions (how a person knows they have HIV)? Can HIV be cured or eradicated? 2. Why was Thailand able to control the incidence rate of HIV and STI infections in the sex trade, and why does it not work as well in Southern Africa? Did the initiative work well on the general public? Why not? 3. What are the cultural, personal, geographic, and socio-economic factors of HIV transmission in Africa? 4. What can be done to develop policies and enforce the guidelines to control the spread? Second Case Study: Controlling TB in China Although China established a national tuberculosis program in 1981, inadequate financial support hindered its success. In 1991, with a $58 million loan from the World Bank, China embarked on the largest effort in TB control in history: the 10-year Infectious and Endemic Disease Control project in 13 of its 31 mainland provinces. The project adopted the DOTS (directly observed therapy, short course) strategy, which was central to the TB control strategy at the time. Individuals demonstrating TB symptoms were referred to county dispensaries, where they received free diagnosis and treatment. Village doctors were given financial incentives for enrolling patients and completing their treatment. Efforts were also made to strengthen the institutions involved with establishing a national tuberculosis project office and a tuberculosis control center. Each county submitted quarterly reports to the province, the central government, and the National Tuberculosis Project Office, strengthening monitoring and quality control. Impact China achieved a 95 percent cure rate for new cases within two years of adopting DOTS and a remarkable cure rate of 90 percent for previously unsuccessful treatment. The number of people with TB declined by over 37 percent between 1990 and 2000, and 30,000 TB deaths were prevented each year. More than 1.5 million patients were treated, leading to the elimination of 836,000 cases of pulmonary TB. Costs and Benefits The program cost $130 million. The World Bank and WHO estimated that successful treatment was achieved at the cost of less than $100 per person. One healthy life was saved for an estimated $15 to $20, with an economic return of$60 for each dollar invested. Lessons Learned China’s program’s success can be attributed to strong political commitment, leadership, adequate funding, and a sound technical approach delivered through a relatively strong health system. It was found that DOTS could be scaled up rapidly without sacrificing quality. Free diagnosis and treatment served as an effective incentive for patients, and doctors’ incentives to diagnose and complete treatment also worked well. However, the overall case detection rate proved disappointing, mainly due to the inadequate referral of suspected TB cases from hospitals to TB dispensaries; hospitals charging for services had no incentive to refer patients to dispensaries where services were provided for free. Besides, patients at hospitals often abandoned treatment prematurely. Despite the program’s success, TB remains a deadly threat in China, and efforts continue to maintain cure rates and expand TB coverage to the remaining population. 1. What are the different types of TB? What factors contribute to the increase of TB prevalence and incidence in some world regions like Africa, India, and Thailand, and the decrease in the other areas? 2. Why do people who are infected with HIV tend to have tuberculosis too? 3. What are the cultural, personal, geographic, and socio-economic factors of TB treatment in low-income countries? What were the barriers for the young gal in the video? 4. How does the world health community ensure that funding and research are available to continue the fight against TB

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