Prevention of HIV/AIDS Among Migrant Workers in Thailand

PHAMIT Site Profiles

Pattanarak Foundation

Kanchanaburi Province (Sangklaburi)

Sangklaburi, a district in Kanchanburi Province, is an active border area with Burma (the official border crossing is at Three Pagoda Pass). Migrants regularly pass through Sangklaburi on their way into Thailand and on their way back to Burma. In addition, there are many others who simply live on the Thai side of the border. In 2004, over 32,000 migrants, including dependents, registered under the state registration in Kanchanaburi, with over 17,000 securing work permits. In 2005, just over 12,000 received work permits. Directly at the border, Sangklaburi's population consists of around 12,000 Thais, 3,500 refugees living in camps, and an estimated 23,000 migrants from Burma who are not living in camps.

Those migrants who register at the border receive a color coded card that allows them to legally stay in their locale, but restricts their ability to move outside of the area to other parts of Thailand. Many migrants that have been arrested by police for not having proper documentation are regularly repatriated through this border point as well. Sangklaburi's population, both Thai and non-Thai, is generally very poor, and there are few work opportunities in the area, mostly in agriculture.

In the Sangklaburi area there are around nine migrant communities of Mon and Karen ethnicity. Sangklaburi is adjacent the Mon State on the Burma side, and thus the Mon community is large, extending along both sides of the border. One Mon community located on the Thai side has an estimated 9,000 people, complete with a Mon temple and monks. The community is well organized, is very clean and has its own economy. Because this community is so large and close to the border it also acts as a transit point for many migrants, and it is believed that there are numerous brokers present who assist migrants who wish to move deeper into Thailand for work.

Karen communities are scattered around the area, sometimes adjacent Mon communities. There are no problems between the two groups, even though the two communities are distinctly different. Many Karen in this area have the “colored card” migrant status, which permits them to remain at the border area, but does not give them full rights of citizenship.

Due to Sangklaburi's remote location at the border and extreme weather conditions there are high levels of disease, including malaria and TB. There is a high rate of malaria at the border, with some of the most virulent and drug-resistant strains found in this area. Long-standing residents have developed a resistance to the local strains of malaria, however migrants have not and are therefore especially susceptible. Other diseases that threaten the health of locals and migrants include measles, especially among children, nutritional problems including scurvy, and gastro-intestinal conditions related to unclean water. Due to variations in the climate, with hot, dry days followed by cold nights and excessive amounts of rain during the rainy season, respiratory tract infections, such as influenza, pneumonia and TB are common, the latter two are often attributed to HIV/AIDS.

There is a high rate of HIV in the area and a considerable number of people suffering from symptomatic HIV/AIDS. (Surveillance in 2003 indicated that 1.76% of migrant women testing at the ANC clinic had HIV.) The high number of PHA in the area is partly influenced by the number of migrants being repatriated, some of who may be sick with HIV/AIDS, but are unable to return to their home or make it back into Thailand. Although migrants in the area report that they understand about HIV transmission, there is still some stigma of PLHA, such as people not buying vegetables from vendors they know have HIV/AIDS.

There are a number of sex establishments in the area with approximately one-hundred sex workers present at any one time. All of the women are from the Burma side, mostly of Burmese ethnicity with Tavoy (Dawei) also being a prominent group; the rest are of Mon and Karen ethnicity, with reports of Nepalese women present. Some sex workers cross the border on a daily basis, working at night and going back in the morning, while most stay at the brothel or karaoke the whole time. Most clients are locals or traders, while uniformed officers, tourists and other migrants constitute the rest. Many of the women stay only temporarily, moving along a circuit of “hotspots” along the border, within Burma, or else deeper into Thailand, and some women are reportedly trafficked. HIV rates among direct sex workers in Kanchanaburi Province were reportedly 10.3% in 2003 and 6.9% in 2004, although these rates do not distinguish between Thai and non-Thai.

A “safe house” supported by the Burma Border Consortium provides temporary shelter for migrants sent to the border who are infirm or recovering and have no place to stay. Some of these individuals are outpatients referred from the Kwai River Christian Hospital who may need continued treatment but no longer need hospitalization, such as TB patients. A high percentage of individuals arrive very sick, and approximately fifty percent of those who are physically infirm have died from their maladies, including a large number suffering from advanced AIDS. The Kwai River Christian Hospital, which has a TB ward and specializes in treatment of malaria, provides treatment to migrants and members of the surrounding community. For migrant patients who have recovered enough to leave the hospital but still need treatment, or are simply too weak to return home, they are referred to the safe house. Those patients who receive treatment for TB are also tested for HIV, and 16 out of 99 new TB patients (16 percent) tested positive for HIV in 2004. Even though there are staff who speak Burmese and other ethnic languages, providing HIV counseling to migrants is problematic, as few are even familiar with HIV/AIDS in the first place.

As with most organizations that utilize volunteers, Pattanarak identifies potential volunteers from its outreach activities. Those who show interest are selected to become volunteers. Many of the volunteers working for Pattanarak, it seems, were doctors or teachers previously in Burma. Volunteers attend a large three-day initiation training. The training emphasizes knowledge on certain topics, such as HIV transmission and prevention, family planning methods with an emphasis on condoms concerning, HIV and STI prevention also focusing on condom use, referral for ANC, general health including vaccinations, and how to lead small group activities. Currently, there are at least two to four trained volunteers in each of the villages covered.

Pattanarak works with sex workers at two villages near the border. The Pattanarak team approaches owners by asking them about the women's health problems and how they get treatment. Once they establish trust and gain access to the venues, they set up small group activities using life skills techniques to discuss what they do about health problems and about contraception, emphasizing that only condoms can prevent pregnancy as well as STIs and HIV. Through these activities they recruit women to act as peer educators among sex workers. There are currently seven volunteers among sex workers. In some cases, Pattanarak has assisted with sex workers who wish to change jobs by assisting with small income generating activities, such as embroidery and weaving as well as helping establish small shops.

Condom distribution is done mainly through condom boxes. There is a very popular one located in front of the Pattanarak office, which numerous people pass on their way from the town to the Mon community. Other than that, there are three boxes in one community and two more in another community. Condom boxes are located at volunteers' houses and are maintained by volunteers. Volunteers not only maintain the box by restocking it, they also provide education on proper use to community members. Sometimes staff and volunteers distribute condoms directly, such as during events or holidays, and always at outreach activities.

A malaria center has recently been opened in three adjacent villages comprised of Mon and Karen communities at the border. The center is a collaborative project between District Health and Pattanarak, and has a team that consists of a District Health officer, eleven volunteers from the community, and Pattanarak staff. Volunteers are trained in taking blood smears and using microscopes to detect malaria, and the health staff dispenses medicines. In its prevention efforts, the team does a situation assessment of the community once a month, reviewing environmental and social factors that contribute to the spread of malaria, and Pattanarak then provides assistance to communities in purchasing necessary supplies .