The 100% Condom Use Programme in Asia

Abstract

One of the main reasons for the rapid spread of HIV in Asian countries is the massive transmission among sex workers and clients. Therefore, effective interventions to prevent HIV transmission through sex work are necessary. Many efforts have been made to promote condom use in sex work. The most significant approach is the 100% Condom Use Programme. Since its conception in 1989, this programme has been implemented in Thailand, Cambodia, Philippines, Viet Nam, China, Myanmar, Mongolia and Laos PDR, with variations in programme components between countries. The main principle is to promote the practice of “No condom – No sex” in all types of sex work, through collaboration between local authorities, sex business owners and sex workers. Variations include formation of sex workers’ self-help groups, peer education and issuance of membership cards by local authorities. Sex workers are empowered when they are able to refuse sex without a condom. In Thailand, the programme has increased the use of condoms in sex work from 14% in early 1989 to over 90% since 1992. The 100% Condom Use Programmes in Thailand and Cambodia, which are being implemented on a nationwide basis, are the main reason for the decline in the HIV epidemic. Scaling-up of activities is taking place in all other six countries.

Résumé

L’une des principales raisons de la propagation rapide du VIH en Asie est la transmission massive du virus chez les professionnels du sexe et leurs clients. Des interventions efficaces sont donc nécessaires. Beaucoup a été fait pour promouvoir l’utilisation des préservatifs dans le commerce du sexe. L’approche la plus réussie est le programme d’utilisation à 100% des préservatifs. Depuis sa création en 1989, ce programme a été appliqué en Thaïlande, au Cambodge, aux Philippines, au Viet Nam, en Chine, au Myanmar, en Mongolie et au Laos, avec des variations selon les pays. Le principe essentiel est : « Pas de préservatif – pas de sexe » pratiqué dans tous les types de commerce du sexe, grâce à la collaboration des autorités locales, des propriétaires d’industries du sexe et de professionnels du sexe. Les variations comprennent la formation de groupes d’auto-assistance des professionnels du sexe, l’éducation par les pairs et la délivrance de cartes de membres par les autorités locales. Les professionnels du sexe s’autonomisent quand ils peuvent refuser les rapports sans préservatif. En Thaïlande, le programme a porté l’utilisation des préservatifs dans le commerce du sexe de 14% début 1989 à plus de 90% depuis 1992. En Thaïlande et au Cambodge, où ils sont appliqués au plan national, ces programmes sont la principale raison du recul de l’épidémie de VIH. Les six autres pays élargissent actuellement leurs activités.

Resumen

Una de las causas principales de la rápida propagación del VIH en los países asiáticos es la transmisión masiva entre los trabajadores sexuales y sus clientes. Por tanto, se necesitan intervenciones eficaces para prevenir la transmisión del VIH por este medio. Se han realizado muchos esfuerzos para promover el uso del condón en el trabajo sexual. La estrategia más importante es la del Programa del Uso del Condón al 100%. Desde su concepción en 1989, este programa ha sido implementado en Tailandia, Camboya, Filipinas, Vietnam, China, Myanmar, Mongolia y Laos, con variaciones en los elementos del programa en cada país. El objetivo principal es promover la práctica de “Sin condón no hay sexo” en todo tipo de trabajo sexual, mediante la colaboración entre las autoridades locales, los propietarios de los negocios de trabajo sexual y los trabajadores sexuales. Algunas variaciones son la formación de grupos de autoayuda para los trabajadores sexuales, educación por pares y emisión de tarjetas de socio por parte de las autoridades locales. Los trabajadores sexuales se empoderan al tener la posibilidad de negarse a tener sexo sin un condón. En Tailandia, el programa ha logrado incrementar el uso del condón en el trabajo sexual de un 14% a principios de 1989 a más del 90% desde 1992. Los programas del Uso del Condón al 100% en Tailandia y Camboya, los cuales están siendo implementados a nivel nacional, son la causa principal del descenso en la epidemia del VIH. En los otros seis países se están ampliando las actividades.

Key Words:

• HIV prevention
• condoms
• sex work
• 100% condom use programme
• Asia

One of the main reasons for the ineffectiveness of HIV prevention programmes in many countries today is the failure to address the vulnerability to infection of certain population groups. This has led to the massive spread of HIV in those countries. The epidemic of sexual transmission of HIV in both Thailand and Cambodia began with transmission by infected men to a small number of female sex workers who, given the nature of sex work, transmitted HIV to other customers. The subsequent chain of transmission included many more sex workers, casual sex partners, wives and newborns. When the connection between sex work and the threat of the HIV epidemic became clear, many governments began to act by trying to eliminate the sex business. This was because sex work is illegal in most countries, in Asia and elsewhere. So far, however, not a single country has been successful in this approach. One reason for this is the failure to recognise changes taking place in the sale of sex services. In Asia, an “indirect sex business” is now expanding to replace traditional brothel-based services.¹ Given the failure to eliminate sex work, there is a need for alternative options, including condom promotion in the sex business.

It is not easy to promote condom use in sex work. Most sex workers in Asia are powerless, and subject to triple vulnerability: being women, being financially dependent (which forces them to be sex workers) and being involved in a profession that is illegal. In most Asian countries, sex workers have often had very little education, they are working under pressure and with a limited capacity to negotiate with other sectors in society. They are in great need of income to pay off the debts of their family. Efforts are needed to help them. Sex workers in Asia are different from sex workers in developed countries, who are often very knowledgeable and independent, among whom many have a strong voice in the society. In the past, programmes to train sex workers in negotiating skills were found to be ineffective because sex workers had little or no power to say “no” to their clients, who insisted on not using a condom. What we always hear and see is that when sex workers begin to negotiate condom use, customers will resist. Some of them will even offer more money for condom-free sex, and most of the times sex workers have to comply with these demands because the “customer always has more power”. On many occasions, the owners of sex establishments have forced sex workers to comply with whatever their customers wanted, including provision of condom-free sex.

Based on this experience, another approach was developed to address the need for effective condom use in sex work; this was the 100% condom use programme.

What is the 100% condom use programme?

The 100% condom use programme is a collaborative programme between local authorities (health services, police, public security, local governor or government office) and all sex entertainment establishments (owners, managers and sex workers) that aims to reduce the sexual transmission of HIV and STIs by assuring high condom use among sex workers and clients. In other words, the programme aims to promote the use of condoms 100% of the time in 100% of risky sexual relations, and in 100% of the sex entertainment establishments in a large geographic area, whether a town, district, province or whole country. The main characteristic of the programme is the empowerment of sex workers to be able to practise “No condom – No sex” in sex work everywhere. Nationwide implementation of such a programme is expected to reduce transmission of HIV and STIs among sex workers and clients effectively, and to stop the spread of HIV into the general population.

Begun in Thailand in 1989, the 100% condom use programme approach is now being implemented in many Asian countries including Cambodia, Viet Nam, China, Myanmar, Philippines, Mongolia and Laos PDR. Only two countries to date are implementing the programme on a nationwide basis, Thailand and Cambodia. They are also the only two countries in the region where HIV trends are declining.²

Principle behind the 100% Condom Use Programme

The principle behind the 100% condom use programme is to address the issue of vulnerability of sex workers.³ The programme is intended to empower sex workers (i.e. to reduce the power of clients). The main principle is to create a monopoly environment in such a way that condom use is required for all penetrative sex services. In such a situation, customers have no choice because all sex establishments have the same rule “No condom – No sex”. In implementing this, the most important people to deal with are the owners of sex establishments.

Sex work in most Asian countries takes place mainly in establishments, both of the direct and indirect type. Owners of sex establishments always listen to the local authorities because otherwise they can be shut down. The main strategy is to hold consensus-building meetings and discussions with owners of establishments, who are asked by local authorities to instruct sex workers in their establishments to provide condom-only sex services in all sexual encounters, and refuse to provide sex services to customers who are not willing to use condoms. Thus, there is a need to convince and get approval from local leaders, e.g. the provincial governor and the police, so that they understand the strategy and work closely with sex establishment owners to ensure its implementation. In this way, HIV transmission will be greatly reduced.

A WHO publication describes implementation of the 100% condom use programme in detail.⁴ Implementation includes the following activities:

•	Organising a meeting of local HIV/AIDS committees or local authorities to raise awareness of the threat of the HIV/AIDS epidemic, obtain consensus and agreement to implement the 100% condom use programme and develop a work plan for its implementation;
•	Holding a meeting between the HIV/AIDS committee, the owners of sex establishments (and senior sex workers) to get cooperation in implementing the programme;
•	Educating sex workers about the programme (including peer education);
•	Providing logistical support for the programme (condoms, water-soluble lubricants, STI services and educational materials); and
•	Monitoring and evaluation of the programme.

There are three main sectors that need to take responsibility for the programme:

•	Health sector, who are responsible for condom supply; STI services for sex workers and clients, health education and information for target groups; collecting data on condom use by STI patients; and reporting non-cooperative sex establishments to the responsible teams or the monitoring working groups;
•	Police sector, who are responsible for participating in the monitoring working groups to manage non-cooperative sex establishments;
•	Local administrative sector, such as the governor’s office, who are responsible for coordination between all sectors and participation in the monitoring working groups to manage non-cooperative sex establishments.

Management of non-cooperative sex establishments is an important component of the programme. The objectives of this “sanction” management are to make the sex business sector aware of the methods that will be used to monitor and verify the use of condoms in sex work, so that more attention is paid to ensure a high level of condom use. Management of non-cooperative establishments may include regular warnings, temporary or permanent closure or withdrawal of their business permit. Since the nationwide implementation of the programme in Thailand in 1992, my observation has been that sanction management has not been necessary, as all sex establishments agreed to the requirement as long as all the others followed the same principle.

Other stakeholders who can be involved in programme implementation may include:

•	sex business managers, sex workers themselves and others linked to the sex trade;
•	other government sectors, including those working in social welfare, culture, registration of the entertainment industry;
•	other health services, such as family planning;
•	NGOs involved in e.g. condom social marketing and sex worker self-help groups;
•	the media; and
•	donor agencies.

Nationwide implementation of the 100% Condom Use Programme in Thailand

The 100% Condom Use Programme was started in November 1989 in Ratchaburi, a province in central Thailand, and slowly expanded to nearby provinces. It was very effective; the rate of condom use in sex work rapidly increased, and a rapid decline in sexually transmitted infections was observed. Realising how effective the policy was, the Thai National AIDS Committee, chaired by the Prime Minister, agreed in August 1991 to implement the programme nationwide. Condom use rates in sex work nationally then began to increase, from 14% in early 1989 to over 90% from June 1992. The annual incidence of STIs at national level dropped very rapidly, from almost 400,000 cases per year before the programme started to less than 15,000 cases per year since 2000, a more than 95% reduction (see Figure 1). In addition, the prevalence of HIV in all sexual risk groups (sex workers, male STI patients, blood donors and pregnant women) has been found to decline (see Figure 2 for the trends in blood donations, army conscripts and pregnant women).

Figure 1. Number of STI cases, 1970-2004, and condom use rate in sex establishments, 1989-2004, Thailand⁵, ⁶

Figure 2. HIV prevalence among pregant women, blood donations and male army conscripts, 1989-2003, Thailand⁷

Based on assessments conducted by many expert groups, million of people are believed to have been protected by the programme. In the mid-1990s, an independent research group came to Thailand to study the impact of the programme, and concluded in their presentation at the International Conference on AIDS in Vancouver in 1996 that “the 100% Condom Programme adopted by the Thai Government may already have prevented more than 2 million HIV infections in Thailand”.⁸ In July 2004, Dr Thaksin Shinawatra, the Prime Minister of Thailand, said in his opening speech to the 15th International AIDS Conference in Bangkok that “the 100% Condom Programme has already prevented over 5 million HIV infections in Thailand”.⁹

Implementation of the 100% Condom Use Programme in other Asian countries¹⁰¹¹

Cambodia was the second country to begin implementing the programme. Subsequently, WHO has provided technical and financial support to establish the programme in other countries in the Asia region. In each of the implementing countries, the programme began with a demonstration project at one or two pilot sites. Criteria for selection of the sites were strong willingness, commitment and support from the local authorities at all levels (provincial and district governors, police, military police, commune councils and village chiefs, establishment owners and sex workers); high prevalence of HIV and STIs; low consistent condom use rates among sex workers; high numbers of establishment-based sex workers (both direct and indirect); and available STI services. The current extent of the programme in the implementing countries is as follows.

Cambodia

The programme was piloted in Cambodia beginning in October 1998 in Sihanoukville, a seaside tourist province in the south of the country with a large sex work district. With early evidence of success, the project quickly captured the attention of national authorities, and in October 1999, the Cambodian Prime Minister Hun Sen asked all governors of provinces and municipalities to efficiently apply the 100% condom use programme countrywide. Nationwide implementation was accomplished in 2001. Evaluations and behavioural surveys have demonstrated impressive reports of consistent condom use in sentinel groups, along with declines in HIV and STI prevalence among sex workers and client groups (Figure 3).

Figure 3. Condom use, HIV and STI prevalence among brothel-based sex workers, 1996-2001, Cambodia¹²

Philippines

The 100% Condom Use Programme was initiated in April 1999 in three cities: Angeles in the North, General Santos in the South and Cebu in the Central region. The national Department of Health, with support from WHO, had expanded the project to six more sites by 2002, four more in 2003 and four more by the end of 2005. Further expansion is underway using funding support from the Global Fund and UNFPA.

Viet Nam

The 100% Condom Use Programme was first piloted in Viet Nam in 2000 in Halong city, Quang Ninh province in the North, and Can Tho province in the South. The programme was expanded to Ha Tay and Dong Nai in 2002 and to Thanh Hoa in 2003. To date, the programme has been expanded to cover 21 of the country’s 64 provinces with the support of the Asian Development Bank, World Bank, UK Department for International Development and Norwegian Agency for Development Cooperation.

Condom promotion in sex work in Viet Nam had been a sensitive topic because of strong government policy that sex work should remain illegal. This perspective is changing to one that is now more favourable. The 100% condom use strategy was included as a main component of the National Strategy on HIV/AIDS Prevention and Control for the years 2004–2010.¹³

China

In 2000, the Chinese Ministry of Health requested support from WHO to pilot the 100% Condom Use Programme at two sites, Huangpi district of Wuhan city in Hubei province and Jingjiang county in Jiangsu province, where it was estimated that between 1,900 and 2,500 sex workers were operating out of bathhouses and brothel-like establishments in each site. Based on positive experiences at these two sites, the Ministry of Health expanded the strategy to two additional sites in 2002, Danzhou City in Hainan and Lixian County in Hunan.

By mid 2006, over 10 out of 31 provinces were implementing this approach. Given the huge size of each province (e.g. the population of Hunan of over 66 million is slightly larger than the total population of Thailand), initial implementation was confined to one city or county among the average of 20–30 counties in each province. Most provinces subsequently scaled-up the approach so that to date there is:

•	total provincial coverage in Hubei and Hainan;
•	increased coverage in Hunan (65 sites: cities or counties), Guizhou (22 sites), Shanxi (25 sites), Jiangsu (12 sites), Xinjiang (5 sites) and Gansu (3 sites); and
•	at least one site each in Guangxi, Shandong and Liaoning.

China has got funding support for over US$190 million from the Global Fund for its three AIDS proposals, which together cover 21 provinces. These proposals cover a broad area of prevention and care, of which the 100% condom use strategy is a significant component in all three.

Myanmar

Beginning in early 2001, the Myanmar Ministry of Health began to pilot its 100% condom use programme starting in four pilot townships: Bago, Pyay, Kawthaung and Tachileik. The programme was gradually expanded to cover 152 of the 324 townships by early 2006 with support from UNAIDS, WHO, UNFPA, the UN Development Programme (UNDP) and Funds for HIV/AIDS in Myanmar. The programme is entitled the “100% Targeted Condom Promotion” (TCP) in order to reduce social and cultural sensitivity about condoms and indicate that it is not for the general population. The programme has contributed significantly to the increase in condom use among sex workers and clients and resulted in a reduction of STI transmission. Data from the pilot sites show that condom use among sex workers increased from 60.7% in 2001 to 91.0% in 2002, and the prevalence of syphilis dropped from 6.0% to 3.0%.¹⁴ Data on HIV impact are not available.

Mongolia

The 100% Condom Use Programme was initiated in mid-2002 in Darkhan, a province with around 300 sex workers, of whom the vast majority were freelance. With funding from the Global Fund, the programme has been gradually expanded to cover 11 of 21 provinces in the country (Darkhan-Uul, Selenge, Orkhon, Uvurkhangai, Dornod, Khubsugul, Khovd, Zavkhan, Dornogobi, Tuv and nine districts of the capital Ulaanbaatar). In April 2005, the Prime Minister issued a decree on expansion of the programme, which is expected to cover the whole country by the end of 2008.

Lao People’s Democratic Republic

In July 2003, the Lao People’s Democratic Republic launched its first pilot site in Savannakhet province. Two additional provinces (Oudomxay and Khammouane) were subsequently added with the support of the Asian Development Bank. Scaling-up activities to cover all 17 provinces are underway with support from the Global Fund.

Specific aspects of 100% condom use programmes

Type of sex work

Although the main principle of the 100% condom use programme is the same, approaches have varied between sites and countries. Generally, sex work in Asia is either establishment-based or non-establishment based. The establishment type, which exists in all implementing countries, includes both direct sex establishments, such as brothels and low-class hotels, and indirect sex establishments, such as bars, nightclubs and restaurants where some workers also provide sex services upon negotiation with clients. The non-establishment type includes mainly freelance, street-based sex workers. The proportion of direct and indirect sex workers varies from country to country and changes regularly. In Thailand, when the pilot project was started in 1989, the proportion of direct sex workers was around 46%. In 2003, that proportion had fallen to around 10%, of whom two-thirds were brothel based and the rest were mainly freelance.¹⁵ Data on these proportions in others countries are not available.

Initially, the 100% condom use programme was designed for establishment-type sex work. After introduction into many Asian countries, however, it was found that it was applicable to all types of sex work, and the approaches to working with the various sex establishments are very similar in the different countries, as described above.

It is more difficult to normalise condom use among freelance sex workers, and Mongolia was the first country to try it. Two strategies have been used in Darkhan, the first pilot site in Mongolia, and are currently being scaled-up to other provinces with a similar composition of sex work:

•	Support for the formation of a sex workers’ self-help group. This NGO conducted outreach and peer education activities to raise awareness of HIV/AIDS and the need to use condoms for HIV prevention, and to distribute condoms to peer sex workers.
•	The use of membership cards, or the so-called “green cards”. In collaboration with the local police, the provincial health department equips sex workers with green cards, to indicate their participation in the programme, encourage monthly STI check-ups at local STI clinics and also to immunise them from police arrest for carrying condoms.

Public campaigns about the programme

In Thailand, since implementation began, there has been no public campaign on the 100% Condom Use Programme, because it was considered easier to work directly with people in the sex business. The message to the public has been, mainly, to refrain from using sex services. This type of approach is also more acceptable in the Philippines, Myanmar and many regions in China, where general condom promotion is considered a sensitive issue. This is different from Cambodia, where active mass media and community campaigns were conducted during the initial piloting of the programme. In China, public campaigns through the media (television and newspapers) have been a key component of the programme in Hunan province, but less so or almost not at all in all other provinces, due to the sensitivities expressed by local authorities.

Participation of NGOs and community-based organisations

There has been almost no involvement of NGOs in the implementation of the 100% Condom Use Programme in Thailand. This is true also in China, Viet Nam and Lao PDR. Involvement of NGOs is observed in Mongolia (including sex work groups and the hotel owners’ association) and in the Philippines (club owners’ associations). In most countries, there has been involvement of international NGOs, particularly through funding support and condom supply through condom social marketing.

There is currently a tendency towards more NGO involvement, for example, professional organisations like the China STI and AIDS Association and China Family Planning Association, and community-based organisations such as the Maternal and Child Welfare Association and Guest House Association in Myanmar, and the Cambodian Women’s Network in Cambodia. Their main involvement is through participation in local working groups to coordinate and monitor programme implementation.

Condom supplies

In Thailand, the Ministry of Public Health has been disseminating free condoms to the public and high-risk sub-populations since the beginning of the AIDS epidemic, and is the main source of condom supply for the 100% Condom Use Programme. Condoms are widely commercially available throughout the country, as there is no condom social marketing activity.

Condom social marketing plays a key role in condom supply in most of the other countries: Cambodia, Myanmar, Lao PDR, Mongolia and Viet Nam. Free condoms are available for the 100% Condom Use Programme in all these countries, but supplies are always limited. The main source of condoms is through social marketing.

In China, condoms are mostly sold in drug stores across the country, and condom vending machines are available in many provinces. Some international NGOs are actively promoting and providing free condoms to STI clinics and/or sex establishments in high prevalence provinces.

Monitoring condom use and evaluating the programme

There are many methods to monitor condom use in the programme. The two most recommended methods are, first, interviewing every patient with an STI receiving services at local STI clinics. This is normal practice in STI control, to assess the STI risk and information about the possible sexual contacts who need to be followed up and screened for possible infection. To benefit the 100% condom use programme, patients should be interviewed about the locations where they most recently bought sexual services and their use of condoms during the sexual encounter. Second is getting information via a contact tracing system. Thus, if a tourist comes to the province, has sex with a sex worker without a condom and subsequently develops

Karaoke bar, Guangdong provine, China, 2002

an STI while outside the province, the contact tracing system will provide information on the location of the entertainment establishment where a condom was not used. The information is obtained from patient interviews in the same manner as at an STI clinic. These two methods are the most appropriate, economical and unbiased approaches but they require a well-functioning STI service system, which may not be available in some locations.

Checking STIs in sex workers during routine health checks is the most commonly used method in Cambodia, China, Philippines and Mongolia. However, it is not recommended for the verification of condom use; it is not very reliable because sex workers might have contracted the STI from a regular partner and used condoms all the time with clients. However, the data can be used to monitor STI trends in sex workers, and thus is helpful for assessing the impact of the 100% condom use programme. Current global efforts to promote STI services will help countries to use information from male STI clients for condom use monitoring.

Assessing condom use using mystery clients is another method, i.e. using volunteers who pretend to be customers and who insist on not using a condom.

Measuring the number of condoms provided to sex establishments monthly, quarterly or annually. This is applicable in countries where condoms are provided from only a few sources, either by a governmental free condom supply unit or a local social marketing agency. After a few months of programme implementation in Samutsakon province of Thailand, for example, the demand for condoms increased from 10,000 to 50,000 per month (unpublished data).

Programme evaluation is performed using the following indicators:

•	Comparing the incidence and trends of STIs. This is easily done in places where routine reporting of STIs is in place.
•	Measuring the prevalence of HIV infection in target populations using the routine HIV/AIDS surveillance system.
•	Surveys of attitudes and practices of the different population groups regarding condom use practice, including surveys to determine the extent of condom use by sex workers and interviews with sex workers on the use of condoms with their most recent customers.
•	Measuring and comparing the number of condoms supplied to sex establishments and/or changes in the level of condom sales.

Positive features of the 100% Condom Use Programme

Implementation of the 100% Condom Use Programme has had several positive consequences for our societies. Although sex work is illegal in all countries in Asia, the authorities seem to accept the existence of the sex business as long as it does not spread HIV to the general population. In my view, the acceptance of the programme by the authorities is a sign of acceptance of sex work in the society, and sex work is indirectly decriminalised thereby.

In the 100% Condom Use Programme, sex workers are the key to success. They are not coerced by the programme, but they are protected by it. With it, they have power to refuse HIV risk. At the same time, the local authorities are compelled to accept the existence of sex work, and the police are indirectly compelled not to arrest sex workers who are helping the country to prevent the HIV epidemic.

It should be noted that acceptance of the 100% Condom Use Programme by the Government of Thailand does not mean sex work is legal. Sex business owners, pimps, customers and parents of sex workers will be arrested if they are managing a sex business involving a child aged under 18, if a woman is trafficked, forced, chained or beaten to sell sex or if the business involves an illegal immigrant. It should also be noted that in Thailand under the current Prostitution Act (amended 1996), sex workers are no longer subject to punishment. Sex business owners, pimps, customers and parents of sex workers are the targets of the law.

The 100% Condom Use Programme promotes multi-sectoral collaboration, including with sectors other than the health sector to work together in the fight against the HIV epidemic.

All sectors of society benefit. It is a win-win strategy in the fight against HIV/AIDS. For example, sex business owners get the same or higher level of income as they have the same level of business as before, but less expense for STI treatment costs for employees. Sex workers themselves get benefit from the high level of income with very low or even no risk of acquiring an STI and HIV; they are also decriminalised by the programme. Clients of sex workers and their family members benefit from being free of HIV infection. The health sector benefits from a lower HIV/STI workload, and the province and country benefit from lower prevalence of both HIV and STIs in the general population.

Condom use is accepted as an important tool to prevent the HIV epidemic in the country. In general, many governments feel reluctant to promote condom use for social and cultural reasons. The high benefit of prevention of HIV and STIs has shifted the perception of many governments towards greater acceptance of condom promotion in their countries.

There has been a very high economic return from the programme. In Thailand, for example, there has been almost no additional investment required to run the programme nationwide. The existing STI services network takes the main responsibility for coordinating the programme in all provinces. The biggest investment in the Thai programme is to buy condoms to supply free of charge to all target groups. At the beginning, the cost for condoms was not included in the calculation, because there were millions of condoms already available in the country. The 100% Condom Use Programme serves to promote utilisation of existing condoms. For other countries, the cost of condoms is not considered as a programme cost, as they are distributed through social marketing mechanisms.

As mentioned above, the programme was estimated to have prevented more than two million HIV infections in Thailand from 1989 to 1995 alone. In addition, it has prevented more than 260,000 STI cases per year that would have been seen in government STI services and four times more cases of patients attending private clinics and drug stores. The reduction in STI cases annually in government clinics alone has resulted in savings of over 70 million baht (US$1.8 million) a year, which would have been spent for the STI drugs alone. This amount is higher than the investment of 60 million baht (US$1.55 million) used for the yearly procurement of free condoms supplied to sex establishments and the public. This calculation does not include the saving of billions of dollars for drugs to treat opportunistic infections and lifelong antiretroviral therapy if several million cases of HIV infection had not been prevented.

Pitfalls and problems

The 100% Condom Use Programme is a programme to promote more condom use among people at high risk of contracting HIV from sexual transmission. The implementation strategy is quite straightforward, and is unlikely to produce a negative impact. However, there may be certain concerns and problems perceived by those involved in implementing the programme and among some sectors of society.

Because of the illegality of sex work, some people may feel uncomfortable working with sex workers. In addition, many people feel that if the police close a sex establishment it represents a failure or a negative result of the programme. However, participation of sex establishments in the 100% Condom Use Programme does not protect the sex business if it exploits children as sex workers, forces women to sell sex or includes illegal immigrants in establishments.

It must be understood that 100% condom use is not an achievable target. Calling for “100% condom use” is the ultimate goal, i.e. the highest possible level of condom use in sex work, in the same way as the global targets of “Health for All by the Year 2000”, or “Universal Child Immunisation” are not reachable in full. Thailand has never achieved 100% condom use after 15 years of implementation. However, the country has achieved over 90% condom use since the mid-1990s, which has still produced a huge benefit.

Effective implementation of the programme requires an uninterrupted supply of condoms. The participation of condom social marketing agencies is crucial to address this concern. In countries where donor support also exists, the budget for condom supplies should be secured to ensure sufficient supplies of condoms.

Many people feel that the mobility of sex workers is a major constraint on these programmes, and may result in low condom use among new sex workers moving into a location. Mobility of sex workers has been a problem in countries where the programme is being implemented on a pilot basis or only in some locations. There is a need to continue education about local policy and the condom use requirement for all new sex workers. The mobility of sex workers ceases to be an issue when the programme is implemented countrywide, as all sex workers have to use condoms with clients no matter where they are working.

Human rights issues have been raised in relation to implementation of the programme, in that regular STI checks (or said differently, mandatory STI screening) among sex workers have been viewed as an inappropriate approach. To address this issue, it is recommended that STI checks in sex workers should not be required to verify condom use, which in any case is inaccurate, as described above, but only for the sake of the health of the sex workers and their clients.

There are legitimate concerns about sanctions for not using condoms resulting in negative outcomes for sex workers, i.e. they are punished by local authorities or sex establishment owners because of the failure to use condoms. The policy of imposing sanctions on un-cooperative entertainment establishments is meant to help increase the effectiveness of the programme. Implementers are advised to avoid such problems and to learn how to apply sanctions in a way that protects the confidentiality of sex workers and clients and protects human rights.

Lastly, there is the problem of customers offering incentives to sex workers for not using condoms. There have been anecdotes about clients offering higher prices for sex services if no condom is used, and sex workers might accept such offers. This problem can be addressed by advising sex workers that many men are currently infected and are not afraid of HIV anymore. In effect, they are trying to spread more HIV in the society by offering more money for condom-free sex. Sex workers are thus advised to refuse the incentive and strictly follow the requirement of “No condom – No sex”.

The need for the 100% Condom Use Programme in Asia

In 2001, Dr James Chin, a well-known epidemiologist and the editor of the American Public Health Association’s 17th edition (2000) of Control of Communicable Diseases Manual, wrote in a document published by WHO:

“To ensure that extensive HIV transmission will not occur, or will not continue to occur in Asia– Pacific countries, public health programmes must fully implement the “100% condom programme” for all commercial and casual sex encounters. Such programmes are urgently needed in current high prevalence countries and in present low HIV prevalence countries before HIV prevalence rises to detectable levels”.¹⁶

Many experts feel that this type of programme is appropriate for countries in other regions as well, particularly where organised sex work is predominant. The implementation of this approach in the Dominican Republic, for example, has resulted in many positive findings.¹⁷

In conclusion, the 100% Condom Use Programme has produced effective outcomes in terms of the increase in condom use among sex workers and their clients and declines in STIs and HIV among them. Continued expansion of the approach is underway in all implementing countries in the Asia region. Experts from the World Health Organization and donor agencies have conducted regular technical and evaluation visits to review and advise countries and help them to improve the programme. The WHO Western Pacific Regional Office (WPRO), has produced a report on the outcomes and impact of the programme in the implementing countries which confirms the feasibility and effectiveness of the approach in increasing the use of condoms and preventing STIs and HIV.⁹ WHO WPRO has also produced and disseminated over ten documents on various aspects of the programme (Box 1), which are available at <www.wpro.who.int>.