HOW IT STARTED

The AIDS Counselling and Training (ACT) programme began work in Klong Toey in November 1990. The programme was managed by World Concern International, a US-based Christian organisation with over 10 years experience working with displaced persons and community-based projects in Thailand. Funding was provided by Norwegian Church Aid.

World Concern's original intention was to start an AIDS counselling and testing centre in one of Bangkok's red light districts. On closer examination, however, it became clear that trying to reach commercial sex workers at their workplace would only appear to threaten their livelihood. As one pimp said, "If you even mention the word 'AIDS' around here people will run from you."

After further investigation it was decided to start an AIDS outreach programme in Klong Toey. This decision was influenced by several factors. Klong Toey represented a well-defined community in need of AIDS intervention and community leaders were willing to participate in the kind of project that ACT wanted to put together. ACT knew of no other organisation that was involved in AIDS counselling in the slum communities. The choice was also influenced by the existence of the "Poor People's Clinic", which had been started by a Church organisation but had been forced to close down 12 months earlier due to a lack of operating funds. Renamed the 'ACT Center', the clinic became the operational base for the ACT programme in Klong Toey, while also providing two hours of outpatient medical services five days a week.

THE AIMS OF THE PROGRAMME

The goal of ACT'S programme was to prevent HIV infection by educating the community about HIV/AIDS, especially those practising high-risk behaviours. In working with such groups, the programme aimed to promote risk reduction through behaviour modification, above all through encouraging those with multiple sexual partners to use condoms.

The specific objectives that ACT defined for its programme were: to establish an AIDS awareness programme for 15 slum communities in Klong Toey; to counsel individuals practising high-risk behaviours in order to stimulate and assist them to modify, minimize or eliminate these behaviours; to offer free and confidential blood tests to all those at risk of HIV infection, in order to promote modification of high-risk behaviours; to identify a professionally-acceptable referral system for HIV-positive persons and those otherwise at risk; and to establish a system for the training of volunteers from universities, churches and other organizations working for AIDS prevention.

PROGRAMME ACTIVITIES AND STAFFING

One of the initial constraints that the programme faced was the lack of personnel with the necessary training and experience to work towards the achievement of the objectives.

ACT was unable to find willing volunteers from Klong Toey, so they identified appropriate men and women drawn from university student groups and from churches participating in the ACT programme and trained them as either 'educators' or 'counsellors'.

ACT recognised the importance of these volunteers: "we relied on feedback from the community to monitor our progress. Volunteers helped us to gauge changes in the communities' perception of the epidemic." By April 1992, the programme had seven full-time staff: a manager/counsellor, a medical advisor, an administrator/counsellor, a laboratory technician, a nurse, and two administrative assistants. The programme was assisted by four part-time volunteer counsellors and 12 volunteer community educators. A doctor also worked 2 hours a day at the out-patient clinic.

The programme was implemented through a two-pronged approach: an outpatient clinic at the ACT Center; and an outreach programme within the community. The clinic offered diagnosis and treatment for common diseases, with referral to government hospitals where necessary. Between November 1990 and July 1991 a total of 1,866 patients attended the clinic. The clinic also provided counselling and HIV testing. Counselling took place in a special room on an individual basis. Testing was completely confidential and done only with the informed consent of the client. Before testing, the client was urged to give up any high risk behaviour. The client was told the test result by a counsellor. The clinic also provided printed materials on AIDS and video films were shown continuously in the waiting room, where a 'floating AIDS counsellor' talked informally with people.

The outreach programme, which began in April 1991, became the centre of ACT'S educational activities. It aimed to create a healthy awareness of the nature and spread of HIV, and to promote compassionate attitudes towards those already infected with HIV. On Tuesday and Saturday afternoons, trained volunteers carried out house-to-house visits in order to contact, inform, educate and stimulate behaviour change among community members at risk of HIV infection because of high-risk behaviours. The volunteers carried supplies of attractively designed educational materials (a booklet, bookmarks and stickers), which at first glance had no obvious connection with AIDS. This made it easier for people to accept and use the materials. A nurse also accompanied the outreach team to take blood, after on-the-spot counselling, from those wishing to be tested for HIV. The result of the test was communicated to the person at the ACT Center, after further counselling.

A special aspect of the outreach programme consisted of contacting locally-based female sex workers through the owners or managers of the brothels where they lived and worked. ACT made contact with the owners by asking the brothel staff whether the management would allow the young women to receive counselling and voluntary testing. This was done in the spirit of helping them and their employees. Several brothel owners subsequently referred their sex workers for testing at the clinic.

There was a growing group of NGOs which, though not providing AIDS services, opened their doors to people affected by AIDS in one way or another. World Concern had begun a forum where Christian organisations met every other month to discuss relevant issues and to coordinate efforts. But although individuals might realise that they needed help, they refused to be referred due to the fear of being 'found out'. Wherever possible, ACT did refer individuals to other organisations, including the House of Hope (a halfway house for recovering drug addicts); House of Peace (a home for teenage commercial sex workers); ACET (providing follow-up care for PWAs); Christian Outreach (providing a paediatric AIDS programme and orphanage); and to Duang Prateep.

BUILDING ON THE ACHIEVEMENTS

Over the 18 months since they started, ACT had covered a lot of ground in their work with the Klong Toey communities and were proud of their achievements. A report of their progress covering the period from November 1990 to July 1991 showed that an impressive amount had been achieved in the areas of HIV/AIDS information, education, counselling and testing. (See Exhibit 1.)

The ACT programme was still at the stage of creating widespread public awareness of the nature and extent of the AIDS epidemic within the Klong Toey neighbourhood. During the next stage, ACT intended to initiate specific activities aimed at reducing the spread of the epidemic and meeting the most urgent needs of HIV-infected individuals and their families. Strategies they were considering included, for example, peer education among high-risk groups such as female prostitutes and injecting drug users, and the training of local volunteers to work with other sections of the community, including people with HIV/AIDS and their families.