Most Bangkokians would have stayed indoors last December 22.
Thanks to a ridge of high pressure coming down from China, the whole
kingdom of Thailand was unseasonably cool. But the temperature did
little to dampen the determination of 120 demonstrators camped out
inside the compound of the Ministry of Public Health in Nonthaburi
Province. "Two or three people caught a cold, but we were not giving
up just yet," recalls Paisan Tanud, 35, chairperson of the Thai
Network of People Living with HIV/AIDS. Although the turnout was
modest by ACT UP-heyday standards in the West, the gathering was
nothing less than historic for Thailand: Most of the protesters were
HIV positive. "It was the first time we came out to voice our
demands and our plight," Tanud says. "It was a very important step
for us, to draw national and international attention to Thais' lack
of access to HIV and AIDS drugs."
The protest was peaceful and colorful, with demonstrators
carrying banners and placards, and cheering speeches. But the issue
at hand was truly a matter of life and death. While Thailand has
made a generic version of AZT at a quarter of its brand-name price
since 1993, Bristol-Myers Squibb (BMS) still controlled the
manufacture and sale of ddI (Videx), which, at $4.40 a day, exceeded
the Thai daily minimum wage. For Thai PWAs, the vast majority of
whom are low-wage earners, the medicine situation is critical:
Studies at Bangkok's Bamrasnaradura Hospital, which treats the
country's largest number of AIDS patients, found that just 5 to 10
percent had access to any anti-HIV meds. Longtime activist Thai
senator Jon Ungpakorn says that the number may in fact be much
Development of the drug had been financed by the U.S. National
Institutes of Health and licensed to BMS with a never-enforced
clause requiring "reasonable pricing." BMS had applied for a Thai
patent as early as 1992, and Thailand's Department of Intellectual
Property (DIP) granted it in 1998. However, critics like Jiraporn
Limpananond, a pharmacist and lecturer at Thailand's prestigious
Chulalongkorn University, challenged the validity of BMS' patent.
"One of the considerations under Thailand's 1989 Patent Act is that
the product should not have been available in the country before its
patent was sought," she argues. And in fact, ddI was available in
Thailand before 1992.
HIVers and activists were demanding that the Thai government
issue a compulsory license for ddI production. This legal mechanism,
allowed by Thai law and longstanding worldwide trade agreements,
permits countries to hand over production rights on an
already-patented product to another company or agency, if that is
deemed in the public interest or in order to reduce an unreasonable
price. Minimal compensation must be provided to the patent holder,
but this need not be prenegotiated.
In the case of Thailand and ddI, if the Government Pharmaceutical
Organization (GPO) was allowed to produce the drug, it would cut the
cost in half, says Krisana Kraisintu, M.D., head of research and
development. Before BMS obtained the Thai patent, the GPO's plans to
patent its own ddI were well underway. "We even bought 780 kilograms
of antacid, to be used as a buffer in ddI," she recalls. But last
November, when her office requested the DIP license, the agency told
its governmental colleagues to initiate negotiations with BMS -- an
intimidating prospect. Six high-level BMS executives flew in to meet
her. "They warned me against producing ddI, saying that they would
soon get the patent. I never knew that, because officials at the DIP
had always assured me that no one else was asking to patent ddI.
That lulled us into a false sense of comfort, only to find that we
were deceived by our own." When BMS got its patent, Kraisintu says,
"there was nothing we could do."
Casting a pall over all these patent machinations is the ongoing
threat of U.S. government sanctions against Thailand (similar to
those directed at two dozen other countries) if it acts in a manner
that big drug companies deem unfavorable to their profit margins.
Any such retaliation would be particularly damaging to an economy
just beginning to get its legs, given that a quarter of Thai exports
go to the United States. In 1992, under a threat by the U.S. trade
representative to limit textile imports, Thailand passed its first
law to recognize product patents, but added a provision establishing
a review board to collect and analyze data on the cost of drug
production. After constant U.S. pressure -- threatening drastically
increased tariffs on Thai exports of wood products and jewelry --
and despite a protest by AIDS organizations outside the U.S.
Embassy, the Thai parliament in 1998 disbanded the board and limited
the right to issue compulsory licenses.
The recent ddI tug-of-war is just the latest in a series of
skirmishes over the Thai government's efforts to produce generic
AIDS drugs. For example, fluconazole (Diflucan), an effective
treatment for deadly HIV-related cryptococcal meningitis and serious
candidiasis, is patented in the developed world by the giant Pfizer
Pharmaceutical, yet the company has no Thai patent. But in 1992, the
Thai government granted all drug companies, including Pfizer, six
years of exclusive marketing rights for all new products, even if
not locally patented. Pfizer's $7-per-pill price for Diflucan was
out of reach for nearly all Thai PWAs. In 1998, the government
released fluconazole for generic production. Two local companies
began selling the drug for between $.26 and $.93 per pill.
The frustratingly fitful advances that Thailand has made in
seeking greater access to pricey AIDS drugs stand in stark contrast
to the brilliant breakthroughs achieved in condom distribution and
use, a program now touted as one of the world's most
With her steady supply of free condoms, activist Sommart Troy was
in 1987 a familiar and welcome face among the U.S. marines anchored
at the seaside town of Pattaya for sand, sun and sex. Her message
was clear, but the Thai government, which had sporadically been
waging its own HIV prevention campaigns for two years, begged to
differ. Having decreed 1987 "Visit Thailand Year" in order to entice
visitors to a tropical nation fabled for its beaches and sex trade,
officials viewed Troy as a meddling alarmist who was scaring off
But two years later, her cries in the wilderness were vindicated.
Surveys done by the Ministry of Public Health revealed a staggering
prevalence of HIV among sex workers -- 15 percent nationwide and as
high as 40 percent in some northern provinces.
Panic set in. The government proposed -- and then aborted -- an
AIDS law that would have required, among other things, a compulsory
blood test, quarantine of HIVers, "AIDS Free" cards for sex workers
and an entry ban against HIVers. Not surprisingly, Thailand's early
HIV prevention programs played on ignorance and fear. TV and radio
spots aired the government's "AIDS kills but is preventable" slogan,
while posters depicted AIDS as a "demon." The Thai media contributed
to the hysteria by "outing" celebrities and others who were not in
But with the release of the doomsday infection rates, the
government changed course. Each key ministry was given its own AIDS
plan and budget, and all governors led AIDS programs in their
respective provinces. In 1991, Prime Minister Anand Panyarachun
agreed to chair the National AIDS Prevention and Control Committee,
becoming one of the first heads of state to personally lead a
nation's fight against HIV. Still, HIV infection rates rose rapidly
among pregnant women and military conscripts -- barometers of
heterosexual prevalence. Thailand's huge sex trade was one reason.
Visits to sex workers are a common rite of passage for male high
school and college students. (Thai men have a saying that wherever
they go, they must have sex with the local women.) "These are major
factors that needed to be taken into consideration when designing
intervention," says Chaiyos Kunanusont, M.D., director of the AIDS
Division of the Ministry of Public Health.
By 1993, the national prevention budget stood at $447,000, up
from the $257,000 of the year before, and the Thai media began to
play a more helpful role in disseminating the government's messages.
This was particularly the case with Thailand's now-famous push for
"100 Percent Condom Use" in all brothels throughout the country, the
brain-child of Wiwat Rojanapitayakorn, M.D., health chief of
Ratchaburi province. Under the program, brothels and other sex
establishments would accept only clients who would agree to use
condoms. The provincial governor agreed to give the idea a try.
Rojanapitayakorn succeeded in getting enough brothel owners to
comply that the Ministry of Public Health decided to include condom
distribution in the national AIDS agenda.
By 1996, Rojanapitayakorn, who now leads UNAIDS' Asia Pacific
Intercountry Team, had achieved a near miracle. Condom use in
brothels rose to 93 percent (up from 87 percent in 1993) and STD
cases plummeted to a low of 50,000. New HIV infections also fell.
Among sex workers, the HIV prevalence rate declined to 28 percent
(down from 36 percent in 1994), and the infection rate among
pregnant women dropped to 1.8 percent from a 1995 peak of 2.3
percent. There was also a steady decline in infections among
military conscripts in the northern region, and visits to commercial
sex workers were decreasing among men. Since then the "100 Percent
Condom Use" initiative has been imported by Cambodia, the
Philippines and China, with varying results.
Still, many at the frontline of Thailand's prevention efforts are
reluctant to call their country a "success story." "No, we should
not be called a model for others to follow," AIDS Division Director
Kunanusont says. "Our house was set on fire, and we had to put it
In Senator Ungpakorn's view, Thailand's much-vaunted prevention
campaigns are far from flawless. The fear-mongering,
stigma-triggering programs put "too much focus on sex workers while
ignoring other groups, making a horror out of AIDS and making HIVers
a target of discrimination." He also says Thailand's efforts have
failed to reach laborers, youth, housewives and prisoners.
Chansuda S., a Bangkok-based contact for the International
Community of Women Living with HIV/AIDS (ICW), says the government's
campaigns gave people "an old image of AIDS as death and evil. They
see it as something that happens to sex workers and other 'bad'
people -- they do not consider themselves at risk."
Activists and authorities alike are increasingly worried that the
government is prematurely resting on its laurels -- especially in
light of budget cuts resulting from the recent Asian economic
crisis. The AIDS Division's Kunanusont warns against a "second wave"
of infections, pointing to a recent rise in infection rates among
pregnant women. The news is bad for others, too: The once-declining
prevalence is now as high as 40 percent for IV-drug users; among sex
workers, 30 percent. The rate of infection among young Thais is also
alarming, says Paul Cawthorne, Thailand coordinator for the Nobel
Prize-winning Doctors Without Borders. And by year's end,
Thailand's AIDS orphans are estimated to number as high as a
Sadly, even Thailand's star as a "condom nation" is falling. Now,
Chansuda reports, HIV-positive women are saying that "they did not
get condoms, because hospital officials said the government has cut
the budget for condoms, and there are no more left." Surang
Chanyaem, head of Empower, an advocacy organization for sex workers,
says that there are "no more condoms at sex venues, and several NGOs
had to pool money to buy condoms for the sex workers." Considering
that each sex worker has three to five clients per shift, Chanyaem
wonders how NGOs can sustain the effort.
In addition, Thailand has yet to confront confidentiality issues.
HIV-positive pregnant women and children, marked by conspicuous "HIV
positive" stamps on their health-record cards, are often forced to
go from hospital to hospital in search of services.
Rampant anti-PWA discrimination and lack of treatment remain
Thailand's major challenges. Despite the recent appointment of
people with HIV to national committees, Paisan Tanud of the Thai
Network of People Living with HIV/AIDS says that PWA input has a
long way to go. "We cannot propose our own agenda or our own
representatives," he says. "Our role is still just that of
Toh -- who founded APN+, an intercountry network of Asians with
HIV, and who has been HIV positive himself for 11 years -- is more
upbeat. He says that PWA networks in Thailand are some of the
strongest in the developing world, providing support and wielding
bargaining power to get the government's attention.
Number of people with
Number of people with
openly positive NA
3% Blood products
A prevention success story, this comparatively
prosperous nation's "100 Percent Condom Use" policy in
brothels checked exploding infection rates in the '90s.
Thailand launched the developing world's first HIV
vaccine trial in March 1999.
Indeed, after last December's well-publicized demonstration for
generic ddI, Public Health Minister Korn Dabaransi promised to
respond by the protesters' January 17 deadline -- and did. He said
that Thai officials couldn't strike an agreement with Bristol-Myers
Squibb, and therefore they would not issue a compulsory license for
ddI's pill form. However, the GPO would be allowed to produce a
generic powdered form of ddI. Thai officials said privately
that U.S. trade pressures lay behind the decision. The next day, 150
activists -- with the support of Doctors Without Borders -- gathered
outside the U.S. Embassy, calling for the pressure to be withdrawn,
echoing similar demands made a week earlier at a Washington, DC,
meeting between an ACT UP-initiated coalition and U.S. trade
officials. On January 27, a top U.S. trade rep sent a letter to Thai
activist Tanud declaring that U.S. officials would not object to any
compulsory licensing that complied with international law -- a
significant victory for HIVers that extended the precedent won last
year with South Africa.
Meanwhile, BMS has kept a low profile, refusing to comment to
Thai media. Some observers say that the company's close ties with
the Public Health Ministry -- its main customer in Thailand -- means
that generic production ultimately will have little or no effect on
profits. Perhaps it's not surprising, then, that the GPO's
Kraisintu, who reports that she has received big orders for powdered
ddI from private hospitals, says that not a single order has been
placed by the Ministry of Public Health. And the battle may soon
escalate, as Doctors Without Borders has requisitioned not only
generic ddI but another BMS antiretroviral, d4T (Zerit), which is
not patent-protected in Thailand. According to a Thai press report,
BMS is threatening to sue the GPO if it fills the order for the
generic d4T, which would be 80 percent cheaper than its own product.
(A BMS spokesperson says she has no knowledge of the threat.)
Neither AZT nor ddI monotherapy is advised for HIVers in Western
countries, but for the vast majority of Thai PWAs, such as Poy, a
29-year-old hairdresser and mother of a 6-year-old, who asked only
to be identified by her first name, below-standard treatment is her
only hope. "I'm doing just fine, but I don't know what it would be
like if I couldn't get the drugs," she says. Every day, Poy takes
nine pills, totaling $157 per month. Poy, who earns only $131 a
month, holds a government-issued low-income health-care card that,
theoretically, entitles her to free medical services. But she and
many other card-holders often find that the reality is much harsher.
"Hospital officials say that HIV medication is not included in the
national list of essential drugs to be provided free of charge," she
says. "We patients have to buy the drugs ourselves."
The only other way for Poy to get medicine would be to use the
government hospital's assistance program, which offers discounts for
poor patients. But even with this reduction, the drugs would be out
of Poy's reach. "Some hospitals ask me to pay half of the drug's
cost, which I cannot afford to pay." Nor would she be able to get
the meds by participating in the government's research program,
which requires a minimum CD4 count of 200. Her latest checkup showed
a count of 96.
Poy falls silent for a moment when asked about the future. "I
dare not get my hopes up for anything," she says finally. "What I
want is just to be able to live for another day, to take care of my
daughter." She also wants her government to be the tiger on the
treatment front that it was about prevention. "Even though I may not
live long enough to use the cheaper drugs," she says, "at least
others will have a chance."