Diagramas de flujo o fluxogramas

My thesis examined how gender of targeted sex worker populations shaped national HIV policy interventions and popular perception of sex work and HIV through a city context lens. Social constructions of sex workers associated with HIV, political changes, and changes in the HIV epidemic shape the policy and news media response. I conducted a qualitative analysis examining the similarities and differences in the ways that HIV policies target male, female, and TSWs as KAPs defined by the Thai government. To conduct this analysis, I reviewed policy reports from 1984 – 2017 and measured changes in funding, types of policy interventions implemented, and the language and coverage of each sex worker population. Using the findings from the policy analysis, I reviewed news articles published in the Thai media from 1990 – 2019 to capture the popular representation of sex work and HIV. The news analysis uncovered the differences in city coverage and gender construction of sex work by the Thai media. I focused on implementation of HIV policies and how that was similar to or different from the descriptions found in the policy reports.

Discussion and Implications

Reviewing Thailand’s HIV policy documents revealed inconsistent policy categorizations for MSWs and TSWs. Without standardized group definitions, it becomes difficult to formulate targeted interventions for specific populations. The Thai government’s goal is to end HIV/AIDS by 2030. In order to do that, interventions should be specific to the needs of the target

population, otherwise resources will go towards tackling HIV for populations that are at lower risk. Specificity and consistent grouping allow for the better allocation of funds and detailing what policy activities are necessary. This adds responsibility to implementing agencies to

actually enact the proposed interventions without missing hard-to-reach populations under the guise of implanting the intervention for a blanket group.

Reporting for sex workers is not equal by gender both in policy reports and news media. Due to size of population differences, there is not necessarily a need for equal coverage of male, female, and TSWs. The population of FSWs in Thailand is significantly larger than that of MSWs and TSWs. However, reporting and policy coverage should reflect the HIV burden of the population. HIV prevalence is currently lowest among FSWs, but coverage is highest for that population. Improved reporting enables the opportunity to make better interventions tailored for the needs of a specific at-risk population. Currently, limited data is available for MSWs and TSWs relative to FSWs, explaining why HIV policies for all sex workers are modeled after ones that were successful for FSWs.

The findings show that coordination between the popular perception and policy

perception of sex work and HIV can more directly demonstrate future policies and interventions that would be directly beneficial for the target population. The news media revealed a desire among sex workers and advocacy groups to improve police training and changing prostitution legislation, contrasting government condom distribution efforts. The popular perception shows what issues can be added policy agenda based on what those who work closest with sex workers. Coordinating the media image with the policy image provides a window into examining the involvement of stakeholders, community organizations, and the potential impact that they can have. Community organizations have the best knowledge of the population needs because they directly work with the target population. It is up to the Thai government to coordinate with these groups to provide adequate support, funding, and resources so they can continue to engage with populations overlooked and underreached by the government.

The language used to describe sex workers shapes how receptive people will be to the population and associated HIV policies. Presenting sex workers as deviants or villains will push the narrative that sex workers need to be punished, and contributes to stigma surrounding sex work and HIV. However, portraying sex workers as victims takes away their agency over their own body and health, removing their decision-making capabilities. As a result, they are limited from actively seeking out knowledge about HIV. Gendered characterization of sex workers implies how implemented HIV policies will be received and any associated stigma. There is not only stigma from being a sex worker, but also from HIV status, and gender of sex worker as a deviation from traditional Thai norms of sexuality.

Lastly, examining the differences between Thai media and policy shows that coordination between government agencies can explain gaps in coverage. Human trafficking of children was highly covered by Thai news, but not by HIV policy. This could be because another Thai government agency other than the Ministry of Public Health is responsible for researching trafficking. However, the gap in coverage shows where there can be overlap in the

responsibilities of different agencies. Coordinating between the two could reveal a new population that needs to be addressed both from a public health perspective and from a trafficking perspective.

Limitations

In my analysis, I did not review primary source policy documents. With the exception of the National AIDS Operational Plan, the policy documents I examined were reports that had already been summarized and analyzed by the Thai Ministry of Public Health. These documents did not include the unedited HIV strategy, rather they were summaries of existing policies and

evaluation data. The actual strategy and legislation documents could offer more specific information about designed interventions that I did not examine in this study.

I also looked at a relatively small sample of sources, both policy and news sources. All the documents I examined were written in English and available in the United States. However, this is a small subset of the information available. However, I was limited by my own access to resources directly from the Thai government and capacity to read Thai.

Policy Recommendations

To simplify future policy interventions and analyses, the Thai Ministry of Public Health should develop standard group definitions for KAPs to use not only for designing future policy interventions, but also for collecting surveillance data. Standardized definitions will provide clearer understanding of delineated ways in which groups are affected by interventions. Using standardized definitions will also make comparisons between groups and across time clearer, providing better evidence of changes in the HIV epidemic and the orientation for future policies. Clear definitions can clearly delineate the needs of specific populations rather than previously inconsistent groupings.

The Ministry of Public Health also must expand existing surveillance data collection methodology to include better surveys for MSWs and TSWs. Current data collection for these groups is limited to select provinces that have the highest concentration of sex workers.

However, the scope of data collected is smaller than that for FSWs. Therefore, to better capture the needs for MSWs and TSWs, surveillance methods need to be more expansive.

Community organizations offer valuable insight, and future policy development should include the input and involvement from stakeholders. Engaging with groups that directly interact with KAPs can provide innovative ideas for achieving hard-to-measure goals. For example, one

policy goal of the Thai government is reducing stigma and discrimination. Community

organizations directly work with sex workers and can provide evidence of the current climate of stigma, and where improvements should be made. Similarly, these organizations have a valuable position in the community and building trust with KAPs through these organizations, will help keep individuals invested in all aspects of the HIV care continuum as defined by the RRTTR model.

The HIV response also needs to keep up with innovative technologies and treatments. The Thai government should increase access to PreP for all sex workers to make it more

available and financially accessible. Currently, although some clinics offer PreP, it is not on the essential medicines list for HIV. By expanding the list to include PreP, thereby making it available under the existing 30 baht plan, more sex workers will be able to get prevention through means other than condom distribution.

Many existing interventions take a direct approach in tackling HIV, such as distributing condoms and providing ART. As Thailand gets closer to reaching ending HIV/AIDS by 2030, the Thai government should enact more policies to improve the general state of the sex work environment to maintain existing successes with HIV. Fostering a safe environment for sex workers decreases the likelihood for sex workers to engage in risky sexual behaviors and reduces stigma and misinformation about HIV. Improving the environment can be done by

decriminalizing prostitution, so sex workers no longer have to fear arrest by the police. The government can also start initiatives to change the existing victimizing attitude surrounding FSWs, and continue education campaigns to improve knowledge about HIV. In essence, fear and shame should not hinder sex workers from seeking out healthcare, knowledge, and materials to empower their personal HIV treatments.

Further Research

The existing research on Thai sex work is limited, and most of the research focuses on the impact of the 100% Condom Program. The research must be updated to fit the current state of HIV and the sex work industry. Future research should examine, through qualitative means, how sex workers are personally affected by policies and whether they truly notice any changes with government involvement in managing the HIV epidemic. Qualitative methods can also be used to research the existing public health policy environment in Thailand to understand how Ministry of Public Health officials actually develop HIV policies. More research in general needs to be conducted on MSWs and TSWs. Existing sex work research focuses on FSWs. Often, the research on MSWs and TSWs is done in combination with MSM, there is not enough distinct research conducted. Lastly, more geographic analysis needs to be done to address the domestic sex trade between Bangkok and Chiang Mai. The research gap does not address the passage of people from the north to Bangkok and its implications for the HIV epidemic. The current state of research is limited, but more work can be done to better address sex workers and curb

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