Published in collaboration with the AIDS Division, Ministry of Public Health, Thailand, this 55-page Joint United Nations Programme on HIV/AIDS (UNAIDS) case study examines the effectiveness of 100% Condom Programme, which was pioneered in Ratchaburi province, Thailand. This initiative drew on the observation that sex work establishments requiring condom use or sex workers insisting on condom use would often lose clients and money to those who did not. In response, a collaborative effort was developed among local authorities, public health officers, sex establishment owners, and sex workers to ensure that clients could not purchase sexual services without condom use in the province.

As reported here, despite initial doubt that such a programme would really make it impossible to purchase sex without a condom, earlier studies reviewed here found that the pilot programme, as initiated in Ratchaburi province, was (in combination with other prevention efforts) very effective at discouraging unprotected intercourse in establishment-based sex work; sexually transmitted infection (STI) rates were found to have dropped quickly and significantly. Noting this success, efforts were made to make this programme national policy; the programme was institutionalised within existing national policy and health infrastructures with strong involvement of people at all levels (national, regional, provincial, and district). By mid-1992, all provinces reported that the 100% Condom Programme was in place.

A number of communication approaches were used to support this effort; they are detailed in this report. For example, in Phuket, the Provincial Public Health Office (PPHO) worked closely with police in visiting sex establishments and encouraging the owners to cooperate. Other activities included having condoms available in every hotel room, providing 100-baht health vouchers to sex workers, displaying stickers and posters advocating condom use, and holding meetings among sex establishment owners and sex workers to provide information on STIs, HIV/AIDS, and proper condom use.

To evaluate the impact of such strategies in the context of the national programme, in mid-1997 UNAIDS and the Ministry of Public Health of the Royal Thai Government (MOPH) commissioned a study that was carried out by the Institute for Population and Social Research (IPSR) of Mahidol University. The IPSR research team developed a 2-phase strategy to explore the effectiveness of the programme in 24 out of 76 provinces. In the first phase, they analysed existing data and held in-depth interviews with key provincial officials involved in the implementation of the programme; detailed questionnaires were then designed. The second phase of the project surveyed implementing officials, pharmacists, sex establishment owners and managers, sex workers, and young men to measure the programme inputs at the local level.

Key provincial activities for implementing programme components are described and evaluated in detail. To cite only one (an activity seen in virtually all provinces), "pro-active" health workers made frequent visits to sex establishments to discuss prevention alternatives with sex workers and to provide STI testing and treatment. These visits were found to "clearly play an essential role in raising awareness, building demand for condom use, and keeping the focus on the issues." STI check-ups and care are described here as playing the most important role both in directing prevention activities to the sites of greatest need and in evaluating the success of the 100% Condom Programme.

The report suggests that the programme meets 4 of the UNAIDS best practice criteria (effectiveness, relevance, efficiency, and sustainability). It has contributed to changes in norms regarding condom use in sex work and visits to sex workers - changes that evaluators deem likely to persist. Among young males, condom use in commercial sex is now expected, and reductions have already been seen in the percentage of men visiting sex workers. (However, while "the 100% Condom Programme has contributed remarkably to raising condom use between sex workers and clients, [it] has had little impact on condom use in non-commercial sexual relationships..."). A strong sense of ownership of the programme was expressed in interviews in almost all provinces, along with a belief that the activities being undertaken were making a difference. The improved relationships among health workers and owners and managers of establishments have made ongoing activities easier.

Factors influencing successful implementation, considerations for strengthening the programme, and lessons learned are shared. One key theme to emerge from these reflections is the importance of political commitment at both the national and local level, and the centrality of close collaboration of all the actors: "The governors and police helped to open the doors, the owners provided the access, the sex workers convinced the clients to use condoms, the clients recognized the need for condoms. This demonstrates that the most effective prevention efforts are those that involve multisectoral efforts."