Global Health Intervention Proposal

Charissa Zhu
University of Maryland
CPGH 101
May 1, 2019
 In the late 20th century, there was an intervention implemented in Thailand that aimed
to prevent HIV/AIDS and sexually transmitted infections. Epidemiologist and STI expert Dr.
Wiwat Rojanapithayakorn spearheaded this campaign (C​enter for Global Development, 2019)​.
Recognizing that there was a small chance people would entirely stop engaging with sex
workers, Dr. Rojanapithayakorn then turned to encouraging safe sex among sex workers and
their clientele. In 1989, the Thai province of Ratchaburi was the first to implement a program
that enforced the rule of “no condom, no sex.” Health officials met with those involved in the
commercial sex industry to inform them on sexually transmitted infections (STIs) and proper
condom usage, then provided free condoms. When someone visited a government clinic with
an STI, they were asked to name the establishment they had visited, under the assumption that
the presence of a sexually transmitted infection indicated failure to properly use a condom.
Local health officers then visited the aforementioned commercial sex establishment to give
more information about condom use. In 1991, this condom program was expanded to the
national campaign against HIV/AIDS and sexually transmitted infections, along with an
expanding budget. Data from the Thai Ministry of Public Health found that condom usage
increased to more than 90% by June 1992, compared to 14% in early 1989 (CGD, 2019). Cases
of HIV and sexually transmitted infections both declined rapidly, which closely tracked the
increasing rates of condom usage (CGD, 2019).
It is not clear whether the program directors did consider ethical boundaries when
creating this intervention. Prostitution is often a contentious subject, especially with regards to
the political sphere and while this intervention was implemented with very good intentions,
perhaps the execution did not respect the personal boundaries of those involved. For example,
when men sought medical treatment for sexually transmitted infections, they would be asked
to name the commercial sex establishment they visited. Then, government officials would visit
said establishment to implement further training regarding safe sexual practices. The ethics of
this process are questionable, as it is not clear whether these commercial sex establishments
were visited with consent or prior notification. The leaders of the establishments also were
compelled to meet with these officers because failure to obey led to legal action. Of course this
then exposes an ethical and legal dilemma of prostitution itself, as officials were aware that this
practice was illegal yet still worked with those involved. Conversely, one could say that the
officials did consider both the ethics and the cultural context of this intervention. Looking at it
from another perspective, authorities chose not to persecute those in the commercial sex
industry. Dr. Rojanapithayakorn acknowledged that it would be nearly impossible to stop the
commercial sex industry as a whole; rather, their resources should be better spent enforcing
safe sex (CGD, 2019). The HIV/AIDS and sexually transmitted infection intervention was
constructed with this cultural context in mind, as brothels were not shut down and instead
given condoms and education to encourage safe sex. Additionally, this demonstrates that
during the design of this intervention, social determinants of health were taken into account.
With the goal of public safety and wellbeing, officials considered the social norms and attitudes
towards the commercial sex industry, as well as the cultural context previously mentioned.
However, there were several shortcomings to this intervention. It was not effective in
increasing condom use for those that engaged in casual, noncommercial sex, as well as for
younger populations that don’t recall the HIV/AIDS epidemic in the early 1990s (CGD, 2019)​.
To improve upon this intervention, it would be most beneficial to focus on education of
condom usage in the younger Thai population, as this was the specific audience for which the
past intervention was least effective in. One study investigated condom use within the Thai
youth population as it related to sexually transmitted infections and HIV/AIDS (Haque &
Soonthorndhada, 2009). A preliminary study again found that within the Thai population, the
young adult population, specifically ages 15 through 24, did not properly use condoms and used
them at an extremely low rate (Haque & Soonthorndhada, 2009). Additionally, men aged 21 to
25 years were especially displaying high-risk behavior with regards to contracting HIV/AIDS
(Haque & Soonthorndhada, 2009). A comprehensive sexual education program was
experimentally implemented in Thai schools to see if it would mitigate sexually transmitted
infections and encourage safe sex practices (Thato, Jenkins, & Dusitsin, 2008). It was found that
participants in this program reported increased intention to use condoms, as well as increased
knowledge about STIs, compared to the control group (Thato et al., 2009). In addition to
implementing a sexual education program for the youth population, officials should distribute
condoms to facilitate access now that the youth population is educated on how to properly use
them.
In order to implement this intervention, there are inputs and resources needed to
ensure its success. Inputs include funding and human resources, both of which are needed for
this proposed intervention. There is available funding for this proposed intervention, as $82
million was allotted for the program led by Dr. Rojanapithayakorn at the height of the
campaign, 96% of which was from the Thai government itself (Center for Global Development,
2019). Therefore, it is clear that the monetary funds are available for this program, but it just
needs to be apportioned to this project. If the money provided by the government is not
sufficient with regards to the funds required, donations can be made from international aid
organizations, such as the United States Agency for International Development (USAID) or the
U.S. President's Emergency Plan for AIDS Relief (PEPFAR). PEPFAR’s mission aligns with this
proposed intervention program, because of its focus on HIV/AIDS prevention.
Additionally, human resources are also required for this undertaking. Qualified staff are
needed to educate the youth and also physically distribute condoms. Community leaders
should take these leadership roles in educating and working with the Thai youth and young
adults to ensure effectiveness and sustainability of this program. For the former, if members of
the community, rather than outsiders perhaps from international organizations or government
agencies, are those that are educating the youth, participants will be more inclined to listen to
those they have a personal connection to. With regards to sustainability, a recent study into the
sustainability of evidence-based interventions in public health discovered that community
engagement is one of the key factors in ensuring sustainability within public health
interventions (Shelton, Cooper, & Stirman, 2018). Therefore, to ensure sustainability within this
proposed program, community engagement must be emphasized. If community leaders are the
ones educating the youth on safe condom usage and STIs, the intervention itself will be more
likely to be sustainable. In addition to being sustainable, it is likely that the impact of this
proposed intervention will be significant. With the previous success with dramatically reducing
STIs and HIV/AIDS within the Thai commercial sex industry, it is very possible that the same
success will be seen with the Thai youth and decreased rates of sexually transmitted infections
due to the intervention. The outputs of this program include condom distribution to Thai youth,
as well as an education campaign on proper condom usage, leading to outcomes like increased
access to condoms and increased awareness of safe sex practices among younger populations.
 References
Center for Global Development. (2019). Case 2: Preventing HIV and sexually transmitted
infections in Thailand. Retrieved April 24, 2019, from Center for Global
D​evelopment website:
https://www.cgdev.org/page/case-2-preventing-hiv-and-sexually-transmitted-inf
ections-thailand​.
Haque, M. R., & Soonthorndhada, A. (2009). Risk perception and condom-use among Thai
youths: Findings from Kanchanaburi Demographic Surveillance System site in
Thailand. ​Journal of Health, Population, and Nutrition​, 27(6), 772–783.
Shelton, R. C., Cooper, B. R., & Stirman, S. W. (2018). The Sustainability of Evidence-Based
Interventions and Practices in Public Health and Health Care. ​Annual Review of
Public Health,​ ​39,​ 55–76.
Thato, R., Jenkins, R.A., & Dusitsin, N. (2008). Effects of the culturally-sensitive comprehensive
sex education programme among Thai secondary school students. ​Journal of
Advanced Nursing​, 62(4).