Calling Mr. Condom

A nervous teenage boy sheepishly walks up to a convenience store counter and whispers softly to the clerk: “Condoms, please.”

“Condoms!” the woman says loudly, prompting everyone in the store to turn and look at the youngster, who suddenly quivers with embarrassment. Then, in a normal voice, she says, “Sir how many packs do you want?”

This television advertisement, part of a campaign called “Proud to Carry Condoms,” is designed to make Thai teenagers understand that it’s normal to practice safe sex. The message sounds harmless enough, but it deeply angered conservative groups here who said it encouraged teenagers to have sex.

On October 12, the ad will stop airing — not because of the moral outrage, organizers say, but simply because the grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria that was funding it is set to expire. In fact, despite opposition from some self-styled moralists and the lack of funds to keep this particular ad running, AIDS activists say that Thailand has actually stepped up its efforts on AIDS prevention in the past year after a big drop off.

Last year the situation appeared much more dire. At the time, Patrick Brenny, head of the UNAIDS office in Thailand, said: “Public information, which was once ubiquitous, has dropped off the radar screen. There is a strong recognition that prevention programming needs to be ramped up.”

This year, Brenny says, the Thai government has done that in a number of ways. First, it came up with a new strategic plan that “talks about at-risk populations in a way that’s more overt.” Second, the National AIDS Committee created a subcommittee on prevention efforts headed by none other than Mechai Viravaidya, widely known as “Mr. Condom.” Third, it has taken the nearly $15 million saved from issuing compulsory licensing on patented AIDS drugs this year and re-invested it into prevention activities.

“My sense is that we will actually see more and more ads this coming year,” Brenny said. “Before, in the early 1990s, you couldn’t go half an hour listening to the radio without hearing an ad about condoms and HIV. I don’t know if it will reach that level again, but people certainly know they cannot just check a box and say we are done with AIDS prevention.”

Indeed, back in the 1990s Thailand became a case study for AIDS prevention. When Prime Minister Anand Panyarachun took power after a 1991 coup, Thailand was reeling from the incurable disease. About 143,000 new infections were recorded in 1991 alone, and experts predicted that up to 10% of Thais would die from AIDS over the following two decades.

The budget on AIDS prevention activities quickly jumped from $2.6 million in 1991 to $46 million in 1993 to $462 million in 1994. Much of the money was spent on a sweeping countrywide education and media campaign whose public face quickly became Mechai and his condoms.

The results were excellent. New infections fell by more than 80%, and experts estimated that the massive campaign prevented about two million AIDS cases.

But when Thaksin Shinawatra became prime minister in 2001, the government’s priorities shifted. Prevention budgets were slashed by about two-thirds in favor of offering universal access to anti-retroviral drugs for AIDS patients.

“The government has spent about $100 million per year on fighting AIDS for roughly the past six or seven years, but how they cut the pie has changed,” Brenny said. “The new success is that 130,000 people are now accessing treatment. That is a great success, but the pie didn’t grow.”

Indeed, the Public Health Ministry rocked the pharmaceutical industry earlier this year when it issued compulsory licenses on a number of first and second-line anti-retrovirals. The government defended the program so it could expand treatment for more HIV patients.

Crucial to Thailand’s successful AIDS treatment program, ironically, was its prevention efforts in the 1990s. A World Bank report in August 2006 found that Thailand saved about $43 in treatment for every $1 spent on prevention.

“Officials have realized that if they don’t turn off the tap [of new AIDS patients], they will not make any headway against AIDS,” Brenny said. “To ensure the sustainability of the treatment program, they must work harder on prevention. Otherwise, they are not turning off the tap.”

Although Thailand is not at risk of another AIDS explosion, Brenny said “there is very fertile ground for a second wave of infections if something is not done.”

Particularly alarming are increased prevalence rates among specific groups, including teenagers, the spouses of men who visit sex workers, intravenous drug users, men who have sex with men and migrants. The UN said earlier this year that housewives comprise 40% of Thailand’s 18,000 new annual cases, followed by gay men with 28% and sex workers with 10%.

A Thai government survey earlier this year found that infection rates among sex workers last year had risen to 35 per 1,000 from 23 per 1,000 a year before. Another study found that about 70% of Thai 18-19 year olds don’t use condoms. Mechai—Mr. Condom himself—has lamented that condom use has fallen to about 20% from 90% at the turn of the century.

“Over the past five years, the government has been asleep at the wheel,” Mechai said. “During the Thaksin era prevention efforts declined.”

The current government, he said, “has done a good job on prevention and they have expanded treatment.”

Mechai said the government plans to continue prevention efforts with an advertising blitz and talks in schools. The groups who oppose condom ads for teenagers are “crazy,” he said, adding that most of the country supported safe-sex campaigns.

“We need people to know that it’s fine to have condoms,” he said. “AIDS is still the number one killer in Thailand. These prevention efforts must continue.”

Though it may seem obvious, experts see a direct correlation between prevention campaigns and new infections, as could be seen in the steep drop during the 1990s and the increases among certain key groups during the past few years. Less spending on prevention in recent years has boosted HIV prevalence among some groups.

“Over the last two or three years there has been increasing concern among NGOs and nurses and doctors who work with people with HIV about the little that has been done in terms of working with teenagers,” said Paul Cawthorne, the head of mission for Medicins Sans Frontieres in Bangkok. “They see the results of that in the rising number of sexually transmitted diseases and groups practicing unsafe sex. STDs are usually a good indicator of HIV trends.”

“I’m not saying just throw money at the problem and it will go away,” he added. “But there is fairly strong evidence that if you have reasonably well-defined prevention programs and senior politicians on board, then the number of new infections can drop.”