Buddhism Beliefs and HIV Stigma in Thailand: An Intervention Study

HIV Stigma and Health among People Living with HIV (PLWH):

Stigma is a primary risk factor affecting the well-being and survival of PLWH, in particular PLWH who are marginalized by society. HIV has long been a highly stigmatized disease, and researchers have made great efforts to study various dimensions of HIV stigma, resulting in an established body of literature. HIV stigma is conceptualized as "a collection of adverse attitudes, beliefs, and actions" of others against PLWH (external stigma), which may result in "internalized beliefs or actions" taken by PLWH (internal stigma), leading to negative health outcomes. Three decades of research have converged, demonstrating that HIV stigma, both external and internal, can negatively impact the well-being and survival of PLWH across the globe through multiple pathways. Populations that have been socially marginalized, such as women, ethnic minorities, and sexual and gender minorities, are particularly vulnerable to the negative impact of HIV stigma. HIV stigma is a huge barrier to accessing social support and health services, with negative impacts on PLWH's mental health and optimal self-management of their HIV, such as adherence to medication. For PLWH in Asia, HIV stigma negatively impacts mental health and HIV self-managing behaviors, leading to deteriorated subjective well-being, physical health, and survival.

HIV Epidemic and AIDS Care System in Thailand:

Thailand has the highest HIV prevalence rate in the Asian-Pacific region, with an estimated 1.2% of its adult population infected. Because of this high prevalence rate, Thailand remains one of the countries with the largest number of people living with HIV (PLWH) in the Asia-Pacific region. Thailand only follows India, China, and Indonesia in number of PLWH, although its population size is ranked 11th in the region. Currently there are 0.5 million PLWH living in Thailand. Although, historically, HIV affected mostly female sex workers and their clients in Thailand, the HIV epidemic has changed drastically due to proactive interventions in the 1990s. Recently, the HIV epidemic has come to resemble those in other developed countries, with men who have sex with men (MSM; 9.2-40%), transgender individuals (12%), sex workers (1-16%), and substance users (19%) sharing the increasing burdens of HIV. Additionally, due to unequal distributions of vulnerable populations and risk factors for HIV infection, it is estimated that 30 Thai provinces account for 75% of the country's HIV infections, with Chiang Mai being one of the provinces having the highest prevalence.

As part of its response to the HIV epidemic, the Thai government began to provide free antiretroviral treatment (ART) for PLWH with impaired immune functions (≤ CD4 350 cell/mm3) in the early 2000s. It then expanded the program to all PLWH, regardless of their immune function, in 2014. This policy has enabled high ART accessibility in Thailand, making it one of the few countries in Asia-Pacific region that has more than 50% of PLWH to be on ART. Due to high ART coverage, Thailand experienced success in reducing HIV mortality: an estimated 196,000 deaths were averted between 2001 and 2014. In addition, Thai PLWH increased their life expectancy to 71 years old or longer, which is close to that of the general Thai population. Despite these important gains, however, the number of PLWH has constantly decreased by approximately 10,000 per year over the past decade, which could be attributed to high mortality rates that surpassed incidence rates. In 2016, it was estimated that while there were 6,400 new HIV cases, there were 16,000 HIV-related deaths, resulting in an overall mortality rate of 3.56%. Compared with the 0.6% mortality rate in the United States during the same period, the mortality rate in Thailand remained 5 times higher. Indeed, HIV still remains one of the top 10 most common causes of death in Thailand. This high mortality rate may be partially explained by the notable HIV treatment cascade in Thailand: among all Thai PLWH, 74% were retained in care, 68% received ART, and only roughly 50% reached viral suppression. An important reason for the low viral suppression rate is that HIV remains a highly stigmatized disease in Thailand, HIV-related stigma still poses significant barriers for Thai PLWH to access healthcare and carry out health-protective behaviors to manage their HIV, including adherence to medications.