Introduction
Despite the tremendous progress in HIV prevention and treatment availability that has been made in Thailand since the peak of the epidemic two decades ago, AIDS remains the 9th most deadly cause in the overall population (1). Among young individuals ages 15 to 49, AIDS was even deadlier, ranked third only behind cancer and transport injuries. 470,000 people in Thailand currently live with HIV (2, 5, 6).
Adolescents between the ages 15 and 24 accounted for nearly half of new infections, now amounting to 24,000 young individuals who live with HIV (5). Furthermore, approximately 40% of all new infections are among men who have sex with men, young men in particular (6).
An estimated 12-15% of men who have sex with men live with HIV in Thailand and rates are even more concentrated in large cities such as the capital Bangkok where an estimated 30% of men who have sex with men are infected (7). Although Thailand boasts an excellent service landscape for free HIV testing and treatment, service uptake is limited. Only 23% of high-risk men who have sex with men get tested and only a fourth of those who test positive start antiretroviral therapy.
Stigma surrounding HIV and AIDS has been one of the greatest barriers contributing to the stagnated progress, especially in the affected young key population of adolescent men who have sex with men. In fact, three quarters of Thais cited anticipation of stigma as primary reason to not get tested for HIV in a recent survey (8). This results in wide-spread fear of an HIV infection.
The pervasiveness of HIV stigma thus puts young men who have sex with men at particular risk by barring them from accessing services and promoting risky behaviors borne out of fear, such as not disclosing their status. Stigma thus directly results in higher rates of HIV and AIDS-related deaths (9, 10).
The campaign
To combat stigma surrounding HIV and AIDS and empower young people to engage in healthy behaviors and avoid risky behaviors, the "It's Okay" campaign will use personal narratives of adolescent peers affected by HIV to normalize activities related to HIV prevention and treatment.
In cooperation with the city governments and local NGOs, the campaign will run for six months in line with Thailand's pledge to Zero Discrimination (11). It consists of seven personal narratives, captured in posters, smaller social media advertisements, and a website which also features additional resources. Optimistic colors were chosen to instill courage and positivity in the audience. The primary audience is young men who have sex with men. The campaign further aims to reach their immediate social network including their friends, families and partners. It hopes to relieve the fear associated with HIV and AIDS by normalizing these topics. While there are many approaches to counteract stigma, due to the effectiveness of peer-related approaches and narratives for an adolescent population, this particular campaign was chosen. The narratives are tailored to typical adolescent experiences in Thailand, spanning a range of geographies, religions, and living situations. All materials were translated to Thai to make them more approachable for the local population.
All the materials are below, including a brief explanation and reasoning behind them. Every poster features the hashtags #it'sokay and #fightHIVstigma
Combat stigma related to HIV generally
HIV is still a source of fear and uncertainty for many people. To normalize the disease, one story about simply living with HIV will be featured. A recent survey found that more than 60% of Thais would not buy vegetables from an HIV-positive shopkeeper (4).
IT'S OKAY TO HAVE HIV (Kittisak, 20 years old)
He was diagnosed at the age of 19. Thanks to effective treatment he can live a normal life.
Descriptive sentence/call to action: HIV-infected people who receive effective treatment do not harm their partners.
Narrative featured on website: Kittisak was diagnosed when he was 19. He thought HIV is his death sentence. In reality, nothing has changed other than going for regular check-ups and taking his medication in the morning. He was born in Lampang and now lives in Bangkok. "Living with HIV is so much better now than it was before. Now, there is treatment available and I don't experience any side effects. My doctor really helped me understand the effectiveness of treatment. For me it's a no-brainer, since otherwise my HIV status could actually impact my health and others. But with treatment, it doesn't."
Combat stigma related to HIV prevention and testing
There are many potential strategies that address HIV prevention and testing. The campaign intentionally does not include condom use as previous campaigns already have extensively focused on this topic and stigma is not as relevant to condom use as it is to use of PrEP (8). Instead, one poster addresses testing, as stigma has been still cited as one significant barrier (8). Another poster will mention PrEP which has already been rolled out in recent years with the Princess PrEP program in order to continue its success (4).
Testing
IT'S OKAY TO GET TESTED (Somsak, 17 years old)
Gets tested regularly for HIV to protect others.
Descriptive sentence/call to action: Get tested today! It’s free! Testing protects you and others.
Narrative on website: Somsak was born and raised in Chiang Mai. He still lives in Chiang Mai with his parents and 4 younger brothers. He is a senior in high school. Every month, he goes to a local clinic to get tested for HIV for free. "I was very nervous the first time I went" - he says. "However, I realized that the staff is very professional and keeps everything confidential. It only takes a few minutes and I feel good about protecting others by knowing my status."
PrEP
IT'S OKAY TO TAKE PREP (Athit, 17 years old)
Athit takes PrEP to protect his sexual partners.
Descriptive sentence/call to action: PrEP protects you from an HIV infection. People who use PrEP cannot harm others.
Narrative on website: Athit who lives in Bangkok gets free PrEP (Pre-Exposure Prophylaxis). It protects him from HIV. Even if he has sex with someone who is positive, he is protected. "PrEP is a huge relief to me. I started taking it a couple of months ago and I know I can really trust in it and not be worried about getting HIV anymore. Of course, I still use condoms to protect myself from other diseases, but at least I know that HIV is not a threat to me anymore. And it's free!"
Combat stigma related to HIV treatment
Treatment adherence and even initiation are serious issues in Thailand. Only 75% of people survive after starting antiretroviral therapy (7). This low rate of survival is mostly attributable to a late start in treatment, oftentimes due to stigma surrounding HIV and AIDS.
Treatment
IT'S OKAY TO GET TREATED (Praew, 22 years old)
He was diagnosed at the age of 20. Thanks to effective treatment he can live a normal life.
Descriptive sentence/call to action: HIV treatment is free and effective!
Narrative on website: Praew was born and raised in Krabi. He was diagnosed when he was 20. He was hesitant to get treatment, but then he realized it is not scarier than just taking daily vitamins. "Treatment allows me to live a normal life. Since I started early, I'm not any different from any of my friends. I feel great. Honestly, the treatment is not even that daunting, it is like taking supplements. With treatment I regained the confidence to look at my future happily, knowing I will be fine and I can protect everyone around me."
Combat stigma related to sharing HIV status
Beyond the conventional preventative and healthy behaviors, the campaign will also aim at normalizing conversations about HIV. Supportive networks have been found to be crucial in supporting HIV positive adolescents (12). They should therefore play a central role in managing the HIV epidemic in Thailand.
Sharing with family
IT'S OKAY TO TELL YOUR FAMILY (Kobsuk, 19 years old)
He is relieved after telling his family about his HIV status.
Descriptive sentence/call to action: Your family can help. Just tell them!
Narrative on website: Kobsuk was devastated at first when he got diagnosed with HIV at age 18. He is from Nakhon Si Thammarat and born into a Muslim family. Kobsuk was feeling very depressed for months after the diagnosis. "It was especially difficult pretending that everything's alright. It felt like I was keeping a secret from the people I love the most - my family. I was so afraid that they would not like me anymore if they know I'm HIV-positive." - he says. "My friends supported me and one day I finally told my family. We are now even closer than before. Of course, it was not easy, especially given our religion, but now they support me and I feel relieved not having to live with this secret anymore."
Sharing with friends
IT'S OKAY TO TELL YOUR FRIENDS (Channarong, 18 years old)
He knew he was not alone / had to deal with this on his own.
Descriptive sentence/call to action: You are not alone. It's easier to deal with HIV together with friends.
Narrative on website: Channarong received his diagnosis only a month ago. He went to get tested with his best friends in Pattaya City. At first, he was very ashamed that he got a positive result back, but the support from his friends really helped him deal with the news. "My friends were there for me after I got diagnosed. They supported me with treatment decisions right after. It feels scary to be so young and have HIV, but my friends truly support me. And I'm feeling great with the treatment I receive. My friends even come with me to regular checkups. It is good to know I can count on them."
Sharing with partners
IT'S OKAY TO TELL YOUR PARTNER (Kraisi, 20 years old)
Kraisi tells his partners about his HIV status.
Descriptive sentence/call to action: The truth protects your partner! You shouldn't be ashamed of it.
Narrative on website: Kraisi has been with his boyfriend for one year. They currently live in Phuket. Even on their first date Kraisi told him that he was HIV positive. "You are always afraid of getting rejected when sharing your status. However, I could not put others at risk. Staying single for the rest of my life was also not an option. In fact, I was surprised how open most people were to going on a date with me. HIV did not really hold me back - and now I have a supportive boyfriend."
References
1. GBD Compare 2019 [Internet]. Institute for Health Metrics and Evaluation, University of Washington. 2019. Available from: https://vizhub.healthdata.org/gbd-compare/.
2. 2021 World Population Data Sheet [Internet]. Population Reference Bureau. 2021. Available from: https://interactives.prb.org/2021-wpds/data-sheet-download/.
3. UNAIDS. HIV and AIDS in Thailand. 2020.
4. UNAIDS. UNAIDS Data 2020. Geneva, Switzerland: UNAIDS; 2020.
5. UNAIDS. Empowering young people living with HIV to become agents of change in Thailand. 2020.
6. UNAIDS. UNAIDS Data 2019. Geneva, Switzerland: UNAIDS; 2019.
7. Carstens A. High mortality of people living with HIV in Thailand highlights the need for early diagnosis and treatment. 2021.
8. Srithanaviboonchai K, Chariyalertsak S, Nontarak J, Assanangkornchai S, Kessomboon P, Putwatana P, et al. Stigmatizing attitudes toward people living with HIV among general adult Thai population: Results from the 5th Thai National Health Examination Survey (NHES). PLoS One. 2017;12(11):e0187231.
9. Sapsirisavat V, Phanuphak N, Sophonphan J, Egan JE, Langevattana K, Avihingsanon A, et al. Differences between men who have sex with men (MSM) with low CD4 cell counts at their first HIV test and MSM with higher CD4 counts in Bangkok, Thailand. AIDS and Behavior. 2016;20(3):398-407.
10. Logie CH, Newman PA, Weaver J, Roungkraphon S, Tepjan S. HIV-related stigma and HIV prevention uptake among young men who have sex with men and transgender women in Thailand. AIDS Patient Care and STDs. 2016;30(2):92-100.
11. Lertprapan T, Wattanayingcharoenchai S, Benjarattanaporn P. Let's end HIV/Aids stigma now. Bangkok Post. 2019.
12. The School of Global Studies TU, Rangsit Campus. Situational analysis of young people at high risk of HIV exposure in Thailand. UNICEF; 2014.
Credits and acknowledgements
Translations were provided by a native Thai professional (https://www.fiverr.com/samdxnth)
Portraits of Thai adolescents as templates for cartoonization were obtained and licensed through Adobe Stock, as per the following credits:
Adobe Stock #112127705 “close up shot of Asian face” by Kencana Studio
Adobe Stock #99903806 “group of happy teen high school students outdoors” by Nonwarit
Adobe Stock #44678352 “Teenager boy hugging laptop computer” by Patrick Foto
Adobe Stock #272362394 “Portrait of young handsome Asian man in pink shirt” by Atstock Productions