HIV/AIDS in Thailand – working with the Muslim community in the troubled southern border provinces

MSF has been working with the Muslim community in the southern provinces of Yala, Pattani and Narathiwat since 2005, which has seen an increase in insurgency activity over the past four years. The lack of awareness about HIV/AIDS still keeps many from access to treatment and care. MSF project assistant, Sapiyah YUSOH is from the South of the country and has been working closely with religious leaders and the local population to improve the situation in her community.

What does your job consist of?

I joined MSF in 2005 and currently we are a team of three field workers working on the project. We focus on capacity building with local organisations, and conduct counselling and group activities for People Living with HIV/AIDS (PLHA) but we also run workshops with religious leaders, raise awareness in schools and train medical staff at the local hospitals. Our aim is to change the community's attitude towards HIV/AIDS and inform people on how to get treatment and protect themselves in a way that's in line with Islamic principles. It covers prevention, treatment, stigma and discrimination. We also try to reach the most vulnerable part of the population.

Thailand has been lauded for its policies on HIV/AIDS. There is for example successful universal ARV coverage. From what you've observed, what is the situation in the southern border districts?

The southern provinces where we work are ten years behind the rest of the country in terms of  HIV/AIDS. It's true there has been great progress made in Thailand but not in the South. Here, drug users are still dying every day not knowing they could be treated for free. Many of those who are HIV positive were infected when they were young, when they used to inject drugs. They knew nothing about transmission. They often gave up the habit and got married but they then infected their wives. Theres still a lot of stigma regarding both drug use and HIV. Its difficult to reach this population. They find themselves rejected by the community if their status is disclosed because its regarded as a sin. They feel they will be blamed, they are afraid and dont trust people enough to seek the treatment they need.  In general they wont go to the hospital and the family takes care of them but they hide them because its a dishonour for them.

Why do you think these provinces are lagging behind the rest of the country in terms of HIV/AIDS?

There were efforts to raise awareness about HIV/AIDS here too at the time but I think the way it was done didn't address the specific needs of the Muslim community. It's a very sensitive issue and if you come in and talk directly about condoms for example, the community will reject it. I think people gained little information because the community withdrew into itself and just ignored the previous awareness campaigns.

What kind of challenges do you meet working with the community?

In three years I think we've made a lot of progress gaining the trust of the community. At the beginning it was very hard because they just didn't accept that Muslims could be HIV positive. It was totally unacceptable even to talk about it. They'd say there is nothing to talk about. They only saw two sides: we would promote condoms and birth control, which is prohibited for them and which would promote promiscuity or sex outside marriage. There was very little information available for those who needed it.  It's still very hard to talk about condoms and we don't do it publicly.

Religious leaders have a key role to play because people will come and see them rather than a doctor. They will seek approval from their leader and advice on what to do.

We invite religious leaders to our training to teach them about HIV/AIDS, opportunistic infections, stigma and prevention in accordance with Islamic principles. For example according to the Koran you can't just abandon a patient or a family member who is sick. A lot of the outcome depends on them. Some might refuse but we've been very successful in some districts and many now understand what's at stake.

What do you see as the main priority to make things change?

More information and more psychosocial support. People don't die from lack of treatment but lack of information. ARVs are available for free at the hospital but people don't go because of the lack of information and the stigma. ARV treatment on its own is not enough. Discrimination comes from a lack of knowledge, when people get information their behaviour changes. I saw one woman who had been infected by her husband. She became sick, developed opportunistic infections and black marks appeared on her body. Her mother prayed and fasted and firmly believed her daughter was being punished by God for being bad. Her behaviour changed when she understood these signs were symptoms.

And the need for more information also applies to hospital staff. We train them because few of them really understand HIV/AIDS and they are not supportive of patients. For example a drug user who goes to the hospital with an opportunist infection is often only treated for this infection, and this is because they think drug users are not responsible enough to take ARV treatment. They don't give enough information to patients who then don't really know or understand what's happening to them. There is also a language barrier, doctors speak Thai but patients speak Malay and don't understand Thai.

How does the local security situation affect your work?

We can work but we have to be aware of the security situation. We check before we visit communities. I'm used to it now but I think it can stop people from going to the hospital sometimes.