Thailand initiated a national scale-up of HIV antiretroviral treatment (ART) in 2000, which was accelerated by the availability of a generic treatment regime (2003) and integration of ART into Universal Health Coverage (2006) . Despite ART availability, people living with HIV (PLHIV) were identified at a delayed stage (57% with CD4+ < 200 cell/ml) , AIDS-related deaths were not declining  and HIV testing for key populations was suboptimal (30–60%) . Simultaneously, the 2009 Thailand PLHIV Stigma Index survey documented widespread stigma . Spurred by this evidence, the government; in partnership with stakeholders including academia, international agencies, and civil society, resolved to develop and implement a comprehensive stigma and discrimination (S&D)-reduction response as an integral part of the national HIV program. This article shares Thailand's journey through development, implementation, and lessons learned for one of the first national S&D-reduction responses globally.
In 2018, Thailand had one of the highest numbers of PLHIV in the Asia-Pacific region, with 480 000 PLHIV (270 000 men/210 000 women) and a 1.1% adult HIV-prevalence . While Thailand continues to experience overall declines in new HIV infections (59% decline 2010–2018 ), incidence and prevalence rates among key populations are concerning. In 2018, an estimated 56% of new infections were among key populations , with prevalence rates at 11.9% for MSM, 11.0% for transgender people, and 20.5% for people who inject drugs (PWID) .
Stigma, a determinant of health and health inequity , is a social process that consists of identification and labeling of difference, attribution of negative attributes to that difference, separation (us versus them), leading to status loss and discrimination . Discrimination, as defined by UNAIDS, is the unfair and unjust action toward an individual or group on the basis of real or perceived status or attributes . S&D can be brought to bear on an individual or group due to real or perceived status or attributes; for example, due to a medical condition, sex identity, sexual orientation, sex work, or drug use . Stigma can be enacted or experienced (discrimination), anticipated, perceived, and internalized. Intersectional stigma occurs when multiple stigmatized identities converge . Global evidence documents how S&D undermines HIV testing [12–15], linkage to care [16–18], adherence [19–23], and ultimately viral load suppression [24,25], particularly for key populations [26–33].
Three foundational building blocks led to the national S&D response: 1) policy and translation into a roadmap for action; 2) measurement development and routinization to inform intervention design and track progress; 3) intervention development and implementation, beginning with health-facilities.
Building block one: policy
Two steps were necessary to obtain and sustain top-level commitment and collective leadership from all government stakeholders: 1) making S&D-reduction a primary goal, alongside treatment, and prevention, in the national strategy to end AIDS 2014–2016 ; 2) operationalizing S&D-reduction and measurement through inclusion in the National Operational Plan for Ending AIDS 2015–2019 [35,36]. This was achieved through the collective and sustained efforts of stakeholders, including key government officials, civil society advocates, and development agencies working together under the umbrella of the Department of Disease Control (DDC) and coordinated by the Director, National AIDS Management Center (NAMC) – the government body that coordinates Thailand's multisectoral HIV response.
Building block two: measurement
A comprehensive S&D measurement framework was developed and integrated into the national HIV monitoring and evaluation (M&E) plan, leading to a national systematic surveillance system that routinely monitors S&D in health facilities, key populations, and the general population. Under the DDC, NAMC coordinated inputs from national, sectoral, facility, and civil society stakeholders to develop the framework and surveillance system and continues to manage ongoing implementation. Data from this system track progress toward the national S&D-reduction goal.
Indicators and questionnaires for health-facility staff (HFS) and PLHIV-clients were developed through consultative meetings, pretesting, and revisions, resulting in two Thai-context standardized questionnaires . The HFS questionnaire was adapted from a global questionnaire , and measures key actionable drivers of S&D (i.e., worry of acquiring HIV while providing care, stigmatizing attitudes, and health-facility policy and environment) and S&D manifestations (i.e., unnecessary infection control precautions and observed discrimination). The PLHIV-client questionnaire adapted questions from the 2009 Thailand PLHIV Stigma Index survey .
Twelve provinces and Bangkok Metropolitan area (economic centers of their regions and the location of the regional DDC office) were selected as sentinel surveillance sites. HFS and PLHIV-clients were surveyed in all health-facilities. Sample size across health-facilities was calculated to allow provincial-level estimates of key S&D indicators. A random sample was generated from each health-facility's staff list, proportional to the number of HFS for the province. HFS used their own phones, project tablets or hospital computers for the self-administered questionnaire. A convenience sample of PLHIV-clients was collected by asking PLHIV attending ART clinics on data collection days to participate. Those interested were enrolled consecutively until sample size was reached. Interviews were either self-administered via participant's own phones or by non-HIV services staff. The online data collection system facilitated data collection, allowing data management, analysis, and reporting to be expedited with results available for utilization by health-facility administrations immediately upon data collection completion.
Ethical clearance was not sought because the data is solely for programmatic improvement purposes and national reporting. Participants provided verbal consent and were informed that participation was voluntary and nonparticipation would not affect their employment or healthcare.
Questions recommended by the Global Stigma and Discrimination Indicator Working Group  were added to existing national representative household surveys which interview adults aged 20–59. An indicator for discriminatory attitudes against PLHIV was determined by two questions about buying fresh or ready-to-eat food from a PLHIV and whether children living with HIV should be allowed to attend school with other children.
Thailand defines key populations as MSM, transgender women, sex workers, PWID, and migrant workers. Draft S&D questions for each population were developed through stakeholder meetings, piloted in Bangkok and Chiang Mai, and then finalized. Items include key population S&D experienced in the family, school/workplace and health-facility settings, internalized stigma, and sexual violence. These were added to the biannual key population integrated biobehavioral surveys (IBBS)  which use time-location sampling in urban areas of selected provinces to identify MSM, transgender women, and male sex workers. A screening questionnaire with identification criteria for each key population is administered to determine respondent inclusion.
Building block three: intervention development and implementation
S&D-reduction intervention development, piloting, and expansion forms the third building block. Health-facilities were a priority starting point for interventions given their direct contact with PLHIV and role in proving care and influencing health outcomes. The Division of AIDS and sexually transmitted infections (STIs) (DAS) under the DDC, rather than NAMC, coordinates the work, with support of civil society and outside technical assistance. A national S&D team within DAS coordinates and supports implementation.
The process began with development of a S&D-reduction package for health-facilities – the 3 × 4 approach. Informed by global best practices , the package is based on a socioecological model [42,43] and seeks to address the individual, facility systems and facility-community linkage levels with interventions that address four key drivers of stigma (awareness, worry of workplace acquisition of HIV, attitudes, and facility environment)  (Fig. 1). This package was developed in a workshop by a combined team of ministry of health, civil society, and international experts.
The participatory S&D-reduction training curriculum, the main individual-level activity of the 3 × 4 approach, was developed by adapting a global tool  through a multistage process. A stakeholder workshop of PLHIV, key populations, local and international non-governmental organizations (NGOs), development partners and government representatives, adapted an initial set of 21 exercises. These were further adapted by a team of national master stigma-reduction trainers who created one new module and reduced the selected modules to fit a 2-day training period. After testing in two health-facilities, the final curriculum included 10 training modules spanning 12 h and covering the actionable drivers of S&D, human rights, a client panel, and action planning. The health-facility systems and facility–community linkages activities are developed by each facility to build ownership and sustainability and led by champion teams of HFS endorsed by the hospital director and board. Support was provided by a team from the provincial health authority and by the DAS S&D team where needed.
In 2016, The 3 × 4 approach was piloted in six community hospitals in three provinces in different regions (North, East, and South). A prepost intervention evaluation was conducted using the national questionnaire previously described. All staff were invited to participate in self-administered paper-and-pen baseline (2016) and endline surveys (2017). The endline surveys were conducted 1–2 months after the training, at which point varying levels of additional activities beyond training had been implemented across hospitals. The DAS S&D team conducted data entry, cleaning, and analysis. Additional information was gathered through progress reports, observations of trainings, meetings with champion teams, individual discussions with champion team leads, and a few training participants. Insights from these program sources have informed the design of the approach expansion.
Given the promising pilot results and lessons learned, expansion of a modified 3 × 4 approach was launched in 2017. A key part of the expanded approach is prepost intervention data collection with HFS and PLHIV, following the national surveillance process described above. Participating hospitals conducted baseline surveys (November 2017–July 2018) and follow-up surveys (November 2018–April 2019). For community hospitals, the samples encompassed all staff. For general and regional hospitals, the sample was all staff in HIV-related services and simple random sampling of other staff. A convenience sample was drawn for the PLHIV-client survey as per the national process described above. Electronic data collection allows each hospital to receive their results immediately in a preformatted template, providing ‘real-time’ evidence to shape the participatory training and quality improvement efforts.
Systematic efforts to integrate S&D-reduction into quality improvement systems were added to the 3 × 4 approach and carried out with support from the DAS S&D team and a Healthcare Accreditation Institute technical advisor. Together they provided coaching and support to hospitals at regional meetings and through online consultation.
Results (lessons learned)
Our results include a description of the key activities achieved to date for each building block and selected results and lessons learned during implementation. Figure 2 presents the three-building block's key S&D-reduction activities across time and planned new activities.
Building block 1: policy
Joint advocacy, coordinated by NAMC, with the active participation of national stakeholders, (in particular civil society and networks of PLHIV) resulted in the inclusion of S&D-reduction as a strategic goal in the National AIDS Strategic Plan (2014–2016)  for the first time. The plan emphasized structural changes in the healthcare system (stigma-free health services), legal (HIV-related discrimination law, no mandatary testing policies at employment) and social environment (public communication) to reduce S&D to facilitate access to HIV prevention and treatment services. It was endorsed by the National AIDS Committee and the Cabinet and reaffirmed in their commitment to the current national strategy to end AIDS: 2017–2030 . Next, the S&D-reduction goal was cemented through a costed operational plan with clearly agreed upon results. This serves as a roadmap for building partnerships to translate the policy goal into actionable S&D measurement and intervention activities. S&D-reduction remains a national HIV agenda priority due to continuing advocacy from a broad range of stakeholders across sectors and at all levels of government that catalyzes national leadership and political commitment.
A key lesson learned from this process is the power of partnerships, between government, civil society, persons affected by stigma, NGOs and development partners, to put S&D-reduction onto the national agenda. The incorporation of S&D-reduction at the same level as treatment and prevention goals in the HIV National Strategic Plan, endorsed by the National AIDS Committee and the Cabinet, was critical to catalyzing and sustaining political commitment and leadership to accelerate the funding and implementation of a national S&D-reduction response. This resulted in S&D-reduction becoming a priority agenda at all levels of the public health system; from the national–sectoral level in the Health Ministry – supported by the Director General of the DDC and the AIDS Program manager – to the regional level and down to health-facilities where S&D-reduction champion teams are endorsed by the hospital director and board. Concretely operationalizing future costed measurement and interventions was critical to leveraging resources (government and donor), kick-starting partnerships for implementation, and providing an accepted national ‘roadmap’ that provided clear strategic direction on how to move forward.
Building block 2: measurement
A comprehensive S&D measurement framework that captures strategic information from relevant groups of people and events (Table 1) was incorporated into the National HIV M&E plan for 2012–2016 . This includes S&D questions added to a representative national household survey held every 3–5 years, biannual health-facility surveys of HFS and PLHIV-clients in sentinel surveillance provinces, and S&D questions added to the biannual key population IBBS.
S&D questions were added into the 2014 National Health Examination Survey  and the 2015–2016 Multiple Indicator Cluster Survey . Results are presented elsewhere [46,47].
The first-round (2015) of national S&D health-facility surveillance data was collected in five provinces, the second-round (2017) added eight new provinces for a total of 13. Eleven (2015) and eight (2017) provinces participated using their own funds. The health-facility survey results are immediately accessible for use by staff at local, regional, and national levels. A yearly national multistakeholder meeting reviews the health-facility survey results with the goal of improving S&D-reduction interventions, providing national estimates, and developing policy recommendations.
Selected results from 2015/2017 are presented in Table 2 under ‘HIV-related stigma in healthcare setting’. Among HFS, negative attitudes toward PLHIV remained high across both years with about 84% of respondents agreeing to at least one of four stigmatizing statements. Worry of contracting HIV while caring for PLHIV dropped from 61 to 50%, however, use of unnecessary infection control measures with PLHIV-clients rose from 53 to 61%. Roughly a quarter of HFS reported observed stigma in the past 12 months in both years (23.7 and 27%). PLHIV reported reductions for three indicators between years, for example, experienced lack of confidentiality with respect to HIV results in the past 12 months declined from 14.5 to 10.3%. However, PLHIV reported about the same amount of experienced discrimination in health-facilities in both years (11–12%)
To date, S&D questions have been incorporated into the 2016 IBBS  and 2018 IBBS . Selected results are shown in the lower half of Table 2 under ‘key population-related stigma’. Experienced stigma declined for transgender women and MSM from family, school/workplace, and health-facilities, with the highest level of stigma experienced in the school/workplace, followed by health-facilities. Anticipated stigma leading to avoiding health-facilities also declined for all three groups. Shame declined more for transgender women (22–9%) than for MSM (19–14%) or male sex workers (20–17%). Forced sex was reported by all three groups in both 2016 and 2018, with a small decline.
A critical lesson learned in implementing this building block was the importance of evidence for advocacy and intervention design. Ensuring S&D measurement is included as part of routine HIV indicators collected to monitor progress toward goals in the national strategy has been critical for maintaining momentum on S&D-reduction as part of the national HIV response. Developing simplified, and standardized S&D measures that were easy to collect on a regular basis was key to providing data to communicate and demonstrate issues effectively. The value of these S&D data is underscored by the additional 19 provinces that chose to conduct S&D surveys using their own provincial funds.
Building block 3: intervention development and implementation
Baseline results [84.6% response rate (RR)] generated awareness and advocacy within hospitals, informed the finalized participatory training curriculum, and each hospital's specific S&D-reduction response beyond the training. In total, 52.3% (665 of 1272) of all levels of staff (clinical and nonclinical) in six hospitals received participatory S&D-reduction training through 20 workshops.
At the health-facility systems level, activities included the establishment of core teams of S&D-reduction champions, sanctioned by and reporting to the hospital management committee. These teams led facility-specific tailored S&D-reduction activities which included code of practice establishment, linking S&D-reduction with existing HIV policy and/or service quality, and using solutions from trainings to change service flow, practices and policy.
Community linkages involved PLHIV and key population members as cotrainers alongside HFS, as part of panel discussions in the training, or as trainees alongside HFS. Some facilities also held ‘learning sessions’ with clients to hear their perspectives.
Selected HFS pilot prepost results (top half of Table 3) show significant declines in a bivariate analysis of key indicators amongst HFS. The endline RR was 85.6%. Negative attitudes towards PLHIV dropped from 85.4 to 64.5% (P < 0.01). Worry of contracting HIV while caring for PLHIV dropped from 80.7 to 59% (P < 0.01) and use of unnecessary infection control measures declined from 67.4 to 38.8% (P < 0.01). Observed stigma towards PLHIV in the past month went from 15.2 to 12.2% (P = 0.03).
A key lesson learned during the pilot was the critical importance of the participatory nature of the training. This not only effectively built awareness of stigma, knowledge around HIV transmission and standard precautions, and challenged stigmatizing attitudes of participants, but also created a safe space for staff to share concerns about challenging issues in their facilities and reflect on what they could change individually and what needed joint action. Staff collectively developed action plans to address S&D in their own facilities, building ownership of the response.
The importance of data was reaffirmed throughout this approach. Baseline data helped both management and staff at facilities understand the different forms of stigma, their prevalence and impact, and plan for action within facilities, and nationally, for intervention improvement in the expansion phase. Endline results illustrated both areas of success and those needing more work. It is critical that this data is not used to blame anyone or any facility but is instead utilized to strengthen and achieve high-quality stigma-free services. The logistical and financial practicalities of hiring PLHIV or key population clients to be trainers or participate in-person on a training panel at each facility was a key challenge for the facility-community linkage and training. In response, video testimonials were developed for use in the expansion phase, instead of the in-person panel.
In late 2017, implementation of a modified 3 × 4 approach began in 48 health-facilities (44 new and four of the pilot facilities) of varying sizes. Key adaptations to support scale-up included shortening the participatory training to allow for training larger numbers of staff and integrating S&D-reduction with existing hospital quality improvement systems.
The shortened training curriculum includes sessions on key drivers of S&D, developing an action plan and code of conduct, and video testimonials to replace the in-person client panel. A total of 6 h of training are delivered in either 1 full day or across 2 afternoons, led by two to three staff facilitators from each facility. Staff facilitators received a 5-day training covering S&D concepts, conducting the survey, participatory training techniques, and linking S&D with quality improvement. To date, 7482/33 551 staff in the 44 new hospitals (22.3%) have been trained through 144 workshops.
Combined S&D-reduction champion and quality improvement health-facility teams selected S&D concerns to be addressed through quality improvement. These varied across facilities based on issues found during the participatory training or baseline surveys, as well as facility capacity to respond. Using quality improvement tools , changes were made in staff and facility's practice, service flow (e.g., not putting PLHIV last in the queue for dental or surgical treatment) and structure (e.g., separate zone abrogation for PLHIV). Some hospitals incorporated S&D into their service quality assessment and improvement metrics, using S&D as one of the quality indicators to be assessed as part of their official Certification for HIV services under the Healthcare Accreditation System.
The modified 3 × 4 approach from the first phase of scale-up was accepted in facilities and practical to implement in a range of health-facility types. In smaller facilities, achieving 50% training coverage of all facility staff was feasible. However, larger facilities needed to target training to HIV services and specific departments. Despite the reduced curriculum and lower proportional coverage of staff in the larger facilities compared with the pilot phase, prepost data demonstrated significant reduction in key stigma indicators (Table 3) as measured with HFS and PLHIV-clients. For example, use of unnecessary infection control precautions with PLHIV dropped from 61 to 43.2% (P < 0.01), while PLHIV reporting experienced discrimination in health facilities in the past 12 months dropped from 10.9 to 7.9% (P < 0.01).
In 2019, a further expansion of the 3 × 4 approach was implemented in 60 additional hospitals covering 57 new provinces. By the end of this expansion phase, 71/77 provinces had at least one facility implementing the 3 × 4 approach, covering a total of 110 of 1000 public health-facilities in Thailand. The goal was to have at least one stigma-free health-facility in each province as a catalyst ‘node’ for expanding the 3 × 4 approach to other facilities. These facilities lead by example, demonstrating that S&D-reduction is feasible and welcomed by HFS and shared their experiences in monthly province-wide facility-management meetings held by the provincial health departments. Trainers from node hospitals have also helped train S&D-reduction facilitators in other hospitals and supported implementation of other S&D-reduction activities.
Discussion and conclusion
In Thailand, as globally, the need to tackle S&D for an effective HIV response and to reach the 90–90–90 targets has become increasingly apparent and urgent. In its journey to develop and scale a national response to S&D, Thailand has been a pioneer for the future of S&D-reduction approaches. To the best of our knowledge, Thailand is the only country that has systematically moved forward to scale-up a response to HIV S&D as part of the national HIV response, though there are other smaller efforts focused on health-facility S&D-reduction that have implemented similar approaches [51–53]. For example, Viet Nam  pilot tested the data collection and participatory training in one city, and work in Ghana [53,55] and Tanzania  piloted tested a ‘total facility’ approach that has similarities to the 3 × 4 approach, including the collection of data, participatory training and the formation of champion teams who developed and implemented additional facility-specific stigma-reduction activities.
The Thailand approach for building blocks two and three was built on global measurement  and participatory training tools [38,44,56–58], as well as intervention experience [59–61]. Both global measurement and participatory training tools were easily adapted to the Thai context. This underscores the utility of existing global best practices, frameworks, and tools and potential for adaptation to different contexts.
Looking forward, the national S&D-reduction program has recognized several implementation challenges and is working to address them: busy health-facilities; implementing a robust community-facility linkage piece of the 3 × 4 approach, and stretched resources of the S&D national team to provide coaching and oversight to an exponentially growing number of facilities with differing capacity for implementation. To respond to this last challenge, the national team is building capacity at regional and provincial levels to provide onward support to health facilities. To respond to the reality of busy health-facilities and resource constraints, while still trying to reach a high proportion of staff in every facility in the country with S&D-reduction, an E-learning curriculum addressing S&D drivers was developed and launched in late 2019. This will complement the shortened in-person training for those receiving it, as well as provide stand-alone training for those who do not receive in-person training.
Building facility-community linkages beyond the HFS has been challenging. In response, two efforts are underway. The first is building and piloting an on-line community-led crisis response and reporting system on HIV-related human rights violations with an anticipated full launch in 2020. The second is a new initiative – Thailand Partnership for Zero Discrimination – which brings together cross-sectoral stakeholders from justice, education and the workplace with the ministry of public health, civil society, and international development partners, to build a strategic alliance to implement and scale up programs toward ending HIV S&D. This builds on an overarching lesson learned about the importance of linkage and building upon the existing national and local systems for an efficient and sustainable response in the health system and beyond.
As Thailand continues to evolve and innovate responding to S&D as an essential part of our national response to HIV, our experience and lessons learned to date may offer a roadmap for other countries who may want to begin or strengthen their own efforts to integrate S&D-reduction into their national HIV responses.
Authors’ contributions: T.S., K.S., P.C., N.S., S.O., P.B., L.N. designed concept and aspects of the study. T.S., K.S., P.C., N.S., S.O., P.B., P.K. were responsible to oversee and implement activities together with conducting data collection and analysis. T.S., K.S., P.B., N.S., S.O., L.N. guided and advised through study implementation. T.S., K.S., P.C., P.B., N.S., P.M., L.N. drafted and finalized the article. All authors read and approved the final article.
We would like to thank all the donors who supported this work through the years. The stigma work reported in this article was collectively funded by multiple internal and external sources. The Royal Thai Government provided funding through both central funding from the Department of Disease Control (DDC) of Ministry of Public Health, Chiang Mai University through AIDS research cluster, and local funding through participating facilities. External funding sources included: the UN joint team on AIDS (ILO, UNDP, UNFPA, UNICEF, and UNAIDS); the Global Fund to fight AIDS, Tuberculosis, and Malaria (GFATM); the US President's Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID) to the Research Triangle Institute, International (RTI) and Health and Human Resources Services (HRSA) to the HEALTHQUAL Project (University of California at San Francisco), and the Division of Global HIV and TB of the Thailand Ministry of Public Health – United States Centers for Disease Prevention and Control Collaboration (DGHT of TUC); RTI International institutional funds.
We are also grateful for all the advice, guidance and support by experts and staff from Division of Epidemiology and Division of AIDS and STI from DDC, Research Institute of Health Science of Chiangmai University, Faculty of Medicine and Faculty of Public Health from Chiangmai University, International Health Policy Program of Ministry of Public Health, Foundation for AIDS Rights (FAR), AIDS Access Foundation, Thailand Nongovernment Organization Coalition on AIDS (TNCA), Thailand Network of People Living with HIV (TNP+), Healthcare Accreditation Institute of Thailand, UCSF-HEALTHQUAL, UNAIDS, RTI, and DGHT of TUC.
We would like to thank Ms Jarunee Siriphan from FAR, Ms Amnuayporn Saelim from AIDS Access Foundation for being master trainers and provide coaching support; Dr Suwat Chariyalertsak from Chiangmai University, Dr Nareerat Pudpong and Dr Phusit Prakongsai from IHPP for the development of S&D measurement; Ms Niramon Pansuwan from Division of Epidemiology of DDC for SD measurement in key populations, Mr Ross Kidd for participatory training tool development, Ms Felicity Young and Dr Richard Reithinger from RTI International for their overall support, Dr Walairat Chaifu and Dr Samarn Futrakul from Division of AIDS and STI of DDC, Ms Thananda Naiwatanakul from DGHT of TUC for S&D efforts in health facilities during expansion, Dr Cha-nane Wanapirak from Chiangmai University and Dr Bruce Agins from UCSF-HEATHQUAL for QI support, Ms Supatra Nacapew Chair-person of FAR, Mr Apiwat Kwangkeaw Chair-person of TNP+, Dr Petchsri Sirinirund, Former Director of National AIDS Management Center of DDC, Dr Sophon Mekthon, Former Director-General of DDC, and Dr Suwannachai Wattanayingcharoenchai, Director-General of DDC on their leadership, contribution and support on S&D. Our sincere appreciation is given to coordinators and trainers from participating institutes and facilities, particularly the stigma teams at the central, regional, provincial, and facility level from government, non government, and community entities who are the real champion on driving forward efforts on stigma measurement and intervention in Thailand.
The contents in the article are the sole responsibility of the authors and do not necessary reflect the views and position of the affiliated author's agencies and funding agencies.
Conflicts of interest
There are no conflicts of interest.
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