Year : 2020 | Volume
: 9 | Issue : 2 | Page : 100--103
Protecting sex workers in Thailand during the COVID-19 pandemic: opportunities to build back better
Surang Janyam1, Dusita Phuengsamran2, Jamrong Pangnongyang1, Wutikan Saripra3, Ladda Jitwattanapataya4, Chalidaporn Songsamphan1, Patchara Benjarattanaporn5, Deyer Gopinath6,
1 Service Workers in Group Foundation, Bangkok, Thailand
2 Institute for Population and Social Research, Mahidol University, Phutthamonthon District, Nakhon Pathom, Thailand
3 Dannok Health and Development Community Volunteers, Dannok, Songkla Province, Thailand
4 Planned Parenthood Association of Thailand, Bangkok, Thailand
5 Joint United Nations Programme on HIV/AIDS Country Office for Thailand, Bangkok, Thailand
6 World Health Organization Country Office for Thailand, Nonthaburi, Thailand
Dr Patchara Benjarattanaporn
Joint United Nations Programme on HIV/AIDS Country Office for Thailand, Bangkok
The Government of Thailand was prompt to launch social and economic measures to mitigate the effects on the general population following lockdown measures to counter coronavirus disease 2019 (COVID-19). However, sex workers were one of the vulnerable groups who were unable to access state support. A rapid survey of sex workers in Thailand showed that almost all had become unemployed and lost their income as a consequence of the lockdown, restrictions on international flights into the country and the closure of entertainment venues. Most were unable to cover the costs of food and shelter for themselves and their dependents. COVID-19 had also disrupted testing and treatment for sexually transmitted infections and HIV services for sex workers. As in other countries, community-based organizations were essential to providing an immediate, short-term COVID-19 response for sex workers. Also as in other countries, the pandemic has demonstrated that many people’s health and well-being depends on very fragile foundations. This presents a clear opportunity to build back better by committing to a longer-term vision for the overall societal inclusion of sex workers. Thailand should advocate for decriminalization of sex work and ensure sex workers are entitled to equal labour rights and inclusion in the government social protection programme. Progress in innovative government initiatives aimed at ending HIV stigma and discrimination show how structural change can come about through harnessing community-based organizations. In turn, HIV services for sex workers need to expand and incorporate targeted interventions to reduce sex workers’ occupational susceptibility to COVID-19.
|How to cite this article:|
Janyam S, Phuengsamran D, Pangnongyang J, Saripra W, Jitwattanapataya L, Songsamphan C, Benjarattanaporn P, Gopinath D. Protecting sex workers in Thailand during the COVID-19 pandemic: opportunities to build back better.WHO South-East Asia J Public Health 2020;9:100-103
|How to cite this URL:|
Janyam S, Phuengsamran D, Pangnongyang J, Saripra W, Jitwattanapataya L, Songsamphan C, Benjarattanaporn P, Gopinath D. Protecting sex workers in Thailand during the COVID-19 pandemic: opportunities to build back better. WHO South-East Asia J Public Health [serial online] 2020 [cited 2021 Jan 22 ];9:100-103
Available from: http://www.who-seajph.org/text.asp?2020/9/2/100/294301
On 14 January 2020, Thailand became the first country outside China to report a laboratory-confirmed case of coronavirus disease 2019 (COVID-19). This was followed by sporadic imported cases and then limited local transmission. In mid-March, entertainment venues, pubs and sporting venues were closed, following clusters of cases. By early April, the Government of Thailand had announced a state of emergency and imposed a curfew, with restrictions on travel and movement including suspension of all commercial international flights, and lockdown measures were being implemented to varying degrees throughout the country to curtail transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
Among the most vulnerable groups affected by these measures were sex workers. The most recent estimate of the number of sex workers in Thailand is 144 000, although this is widely regarded to be a significant underestimate, since sex work is illegal in the country. The nationwide closure of the estimated more than 23 000 entertainment venues where sex workers work meant that overnight most lost the ability to earn an income. The few sex workers who continued to work despite the lockdown did so with very weak negotiating powers, increasing their risk of contracting not only HIV and sexually transmitted infections (STIs) but also COVID-19.
There are scant data on the effect of COVID-19 on increased risks in sex work, but a rapid online survey of more than 20 000 lesbian, gay, bisexual, transgender and intersex (LGBTI) people in 138 countries carried out during April and May 2020 found that the pandemic had pushed 1% of respondents to start engaging in sex work and that 2% continued to sell sex during the COVID-19 pandemic, risking exposure to the coronavirus. In April, a global survey to understand the impact of COVID-19 on sex workers received responses from 55 different countries and found that many social protection and economic support schemes – such as income support, emergency funds, food packages, and rent or mortgage relief – that were in place for members of the general population were not always accessible to sex workers.
The Government of Thailand was prompt to announce a series of stimulus packages to mitigate the negative socioeconomic impact of COVID-19 on the general population. In April 2020, it was announced that 1 374 288 workers covered by the social security system (SSS) were to receive compensation of 62% of their daily wage for a period of 3 months. Furthermore, 15.1 million workers not covered by the SSS and not in the agricultural sector and another 7.1 million workers not covered by the SSS and in the agricultural sector were to receive a direct transfer of 5000 baht per worker per month for 3 months. However, since commercial sex is illegal in Thailand, sex workers unable to access the SSS were left to fend for themselves. Sex workers who are migrants or from tribal communities and have no Thai ID are formally undocumented; they therefore not only lack access to government support but also risk being arrested because of their illegal status in the country.
Assessing and addressing the immediate impact on sex workers
A rapid, community-led survey of sex workers carried out shortly after the national lockdown illustrated the impact of the measures on sex workers. The survey was prompted when Service Workers in Group (SWING), a Thai national organization providing HIV services and advocating for sex workers’ rights, began to receive requests from sex workers for help with the most basic of needs, such as food, housing and medicine. The survey was carried out in collaboration with the Planned Parenthood Association of Thailand (PPAT) and Dannok Health and Development Community Volunteers, with support from the Joint United Nations Programme on HIV/AIDS (UNAIDS). Respondents were from the cities of Bangkok and Pattaya and the town of Dannok, on the Thai–Malaysia border. There were 255 respondents in total: 234 sex workers (170 female, 38 male and 26 transgender; 207 Thai and 27 non-Thai) and 21 community-based organizations. The survey was carried out using an online self-administered questionnaire during 13–26 April 2020. There was no compulsion to respond, and responses were anonymous.
COVID-19 and the limits of social protection for sex workers
Almost all respondents (232, or 91%) said that they had become unemployed and lost their income as a consequence of the lockdown, restrictions on international flights into the country and the closure of entertainment venues. Of the respondents, 191 (75%) could not make enough money to cover daily expenses and 154 (66%) could no longer cover the cost of food, daily necessities and housing/accommodation, both for themselves and for their dependents. Owing to interprovincial travel restrictions, 100 of the respondents (43%) were not able to travel to their home town; disturbingly, 47 (18%) reported that they had had to move out of their accommodation or had nowhere to live.
Less than one third of the respondents stated that they were seeking access to government relief measures. Overall, 183 respondents (72%) reported that, because their occupation was illegal, they would not be eligible for any government assistance. Of the respondents, 102 (40%) felt that they could not ask their employer to vouch for them as an employee so that they could access the 5000 baht per month in financial aid, and a further 102 (40%) were not registered with the SSS and could therefore not seek compensation from it for lost income.
COVID-19 and access to STI and HIV services
Lack of access to STI testing and treatment (reported by 122 respondents, or 48%) was the most common difficulty encountered in terms of access to health services as a consequence of the COVID-19 situation. Although the survey was not designed to assess differences, difficulty in accessing STI services was more common among female sex workers and non-Thai sex workers. A separate analysis in seven STI sentinel clinics in Thailand found that COVID-19 coincided with a 90% reduction in sex workers presenting for screening for STIs (Dr Rossaphorn Kittiyaowamarn, Department of Disease Control, Ministry of Public Health, personal communication, 13 May 2020). The other main problems encountered were lack of access to condoms, pre-exposure prophylaxis (PrEP), and harm reduction and drug treatment services. Sex workers living with HIV also reported difficulties accessing antiretroviral therapy (ART). This reflected the finding that, between March and June 2020, 40% of 86 UNAIDS country offices reported that HIV services for sex workers had been disrupted by COVID-19 lockdown measures.
Emergency responses led by community-based organizations
As in other countries, community-based organizations were essential to providing an immediate, short-term COVID-19 response for sex workers. [Box 1] provides examples of various forms of rapid assistance for sex workers in Thailand provided or coordinated by community organizations.[INLINE:1]
Committing to longer-term initiatives to protect sex workers
Opportunities for structural change: social protection and decriminalization
In the longer term, the lack of social protection for sex workers in Thailand will need to be resolved. Social and structural interventions require a long-term vision for the overall societal inclusion of sex workers. Decriminalizing sex work is not a new topic of discourse in Thailand or globally. In Thailand, entertainment venues earn around US$ 6.4 billion a year in revenue, and sex workers create roughly 4–10% of the kingdom’s gross domestic product. Thailand should advocate for decriminalization of sex work and ensure sex workers are entitled to equal labour rights and inclusion in the government social protection programme. The impetus for such reform could be catalysed by political will and structural change, by a grass-roots movement – or by both in combination.
Recent innovations in Thailand’s health sector provide lessons on how structural change can come about through harnessing community organizations. The nationwide 3-by-4 package for stigma-free health facilities was designed to address stigma and discrimination within and beyond the health system, with one stigma-free health facility in each province as a catalyst “node” for expanding facility–community linkages. Led by the government body that coordinates Thailand’s multisectoral HIV response, this initiative involves key government officials, civil society advocates and development agencies. It is anticipated that one of the outcomes, as the initiative continues to evolve and innovate, will be an online community-led crisis response and reporting system on HIV-related human rights violations. Similarly, the newly established Thailand Partnership for Zero Discrimination brings together stakeholders from justice, education and the workplace with the Ministry of Public Health and civil society and international development partners to build a strategic alliance to implement and scale up programmes aimed at ending HIV stigma and discrimination.
The COVID-19 pandemic may therefore present an opportune time to reconsider social protection and decriminalization, with the involvement of sex worker-led organizations. Such an approach would accord with WHO guidance stating: “Laws, legal policies and practices should be reviewed and, where necessary, revised by policy-makers and government leaders, with meaningful engagement of stakeholders from key population groups, to allow and support increased access to services for key populations.”
Opportunities for enhancing holistic services for sex workers
On 10 July 2020, the UNAIDS Interagency Working Group on Key Populations released a statement underscoring the needs to (i) make quality, non-discriminatory HIV prevention, treatment, care and support services, and health services in general, available to vulnerable populations and (ii) rapidly adapt HIV service provision to take into account the new realities of the COVID-19 pandemic.
Sex workers and their clients account for around 10% of new HIV infections in Thailand; therefore, it is essential that sex workers are able to access the HIV services that have been reconfigured as a result of COVID-19. Various changes to services have been implemented to date. A new policy was endorsed by the National AIDS Commission in March 2020 that aims to reinforce adherence to existing guidance to ensure ART continuity and minimize the risk of COVID-19 exposure in health facilities by recommending rescheduling hospital visits, dispensing antiretroviral drugs by post and using multi-month dispensing. Although there has been progress, with major health insurance schemes – the Universal Coverage scheme and the SSS – offering patients a stock of at least 3–6 months’ supply, efforts need to be made to ensure that sex workers can also benefit from these changes. As recommended by the UNAIDS working group, HIV service provision also needs to take into account the new realities of the COVID-19 pandemic, by enabling safe access to home HIV testing or self-testing and remote counselling.
Changes made to HIV prevention services to mitigate the overall impact of COVID-19 should also be incorporated into targeted interventions to reduce sex workers’ occupational susceptibility to SARS-CoV-2. Prevention packages that have proven to be useful in Thailand in the initial months of the COVID-19 pandemic and could perhaps be improved and scaled up have included an emphasis on personal hygiene, with provision of condoms, masks, sanitizers, etc. A full package of services should include interactive messaging with sex workers, clients and advice providers; education and training for sex workers on the proper implementation of prevention measures; and, of course, unrestricted provision of PPE and related material. These new prevention packages must also cater for and be available to non-Thai sex workers.
If these gaps are not addressed, sex workers will continue to be left behind in the global response and the world will not meet the goals it needs to achieve to end the HIV epidemic and the COVID-19 pandemic. Community-led organizations must take a holistic and comprehensive approach, providing for immediate basic needs and implementing an integrated package covering COVID-19 prevention, HIV health services and mental health support for sex workers. It is important to bear in mind that the need for assistance will remain long after the COVID-19 situation has eased, and long after the bars and restaurants have reopened.
Disclaimer: The contents of the article are the sole responsibility of the authors and do not necessarily reflect the views and positions of the affiliated authors’ agencies and funding agencies.
Acknowledgments: We would like to thank UNAIDS, which supported this initiative. We are also grateful for advice and guidance on questionnaire development from Shona Wynd, UNAIDS Regional Support Team for Asia and the Pacific, and Kamma Blair of the United Nations Population Fund’s Regional Office for Asia and the Pacific. We also thank Dr Sombat Thanprasertsuk, Senior Advisor in the Department of Disease Control, Thai Ministry of Public Health, for his leadership and guidance on bringing in stakeholders in the AIDS response to collectively identify and implement priority actions, including comprehensive and integrated approaches for HIV and COVID-19 prevention, as an immediate response to the needs of sex workers. Finally, we thank sex workers and organizations working for sex workers for their participation and for providing valuable information to make this study possible.
Source of support: UNAIDS Country Office, Thailand.
Conflict of interest: None declared.
Authorship: SJ, DP, PB and LJ designed the concept and aspects of the study. SJ, JP, WS, CS and LJ were responsible for managing the data collection. SJ, DP and PB oversaw activities and conducted data analysis. SJ, DP, PB and DG drafted and finalized the manuscript. All authors read and approved the final manuscript.
|1||Novel coronavirus 2019 pneumonia situation. Bangkok: Emergency Operation Center, Department of Disease Control, Ministry of Public Health, Government of Thailand; 14 January 2020 (https://ddc.moph.go.th/viralpneumonia/eng/file/situation/situation-no11-140163.pdf, accessed 21 July 2020).|
|2||Thailand AIDS Response Progress Report 2018. Nonthaburi, Thailand: National Monitoring and Evaluation Unit, Bureau of AIDS, TB and STIs; 2018 (https://hivhub.ddc.moph.go.th/Download/Report/APR/2018/EN_GAM%202018.pdf, accessed 5 August 2020).|
|3||Entertainment closures to go nationwide. Bangkok Post; 20 March 2020 (https://www.bangkokpost.com/thailand/general/1883225/entertainment-closures-to-go-nationwide, accessed 19 July 2020).|
|4||Equity Initiative. A glimpse into COVID-19 in South-East Asia (http://www.equityinitiative.org/news/vignettes-of-equity-a-glimpse-into-covid-19-in-southeast-asia/, accessed 2 July 2020).|
|5||Joint United Nations Programme on HIV/AIDS. Survey shows that the COVID-19 pandemic increases vulnerability of LGBTI people; 10 July 2020 (https://www.unaids.org/en/resources/presscentre/featurestories/2020/july/20200710_survey-covid19-lgbti-people, accessed 10 July 2020).|
|6||Global Network of Sex Work Projects. Impact of COVID-19 on sex workers in Asia and the Pacific; 18 June 2020 (https://www.nswp.org/news/impact-covid-19-sex-workers-asia-and-the-pacific, accessed 8 July 2020).|
|7||Burton J. PM warns not everyone eligible for 5000 baht aid package. The Thaiger; 1 April 2020 (https://thethaiger.com/coronavirus/ pm-warns-not-everyone-eligible-for-5000-baht-aid-package, accessed 2 July 2020).|
|8||Foreign Correspondents’ Club of Thailand. Recording of a virtual panel discussion, “Helping Thailand’s most vulnerable: sex workers and COVID-19, the fallout”; 21 May 2020 (https://www.facebook.com/ 266552830096341/videos/1319505565106184/, accessed 30 June 2020).|
|9||Community-led rapid assessment of the impact of COVID-19 on sex workers (Thailand). Bangkok: Service Workers in Group Foundation; 2020.|
|10||Global AIDS update 2020: seizing the moment – tackling entrenched inequalities to end epidemics. Geneva: Joint United Nations Programme on HIV/AIDS; 2020 (https://www.unaids.org/sites/default/files/media_asset/2020_global-aids-report_en.pdf, accessed 12 July 2020).|
|11||Platt L, Elmes J, Stevenson L, Holt V, Rolles S, Stuart R. Sex workers must not be forgotten in the COVID-19 response. Lancet. 2020 Jul;396(10243):9–11. https://doi.org/10.1016/S0140-6736(20)31033-3 PMID:32422122|
|12||Nortajuddin A. Thai sex workers hit hard by virus lockdown. The ASEAN Post; 14 April 2020 (https://theaseanpost.com/article/thai-sex-workers-hit-hard-virus-lockdown, accessed 8 July 2020).|
|13||Siraprapasiri T, Srithanaviboonchai K, Chantcharas P, Suwanphatthana N, Ongwandee S, Khemngern P, et al. Integration and scale-up of HIV-related stigma measurement and reduction towards ending AIDS: the experience of Thailand. AIDS (in press).|
|14||Lertprapan T, Wattanayingcharoenchai S, Benjarattanaporn P. Let’s end HIV/AIDS stigma now; 1 March 2019 (https://www.bangkokpost.com/opinion/opinion/1637074/lets-end-hiv-aids-stigma-now, accessed 19 July 2020).|
|15||Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations. Geneva: World Health Organization; 2014 (https://apps.who.int/iris/bitstream/handle/10665/128048/9789241 507431_eng.pdf;jsessionid=14EF832A1B270BD8294895897A2F8 F44?sequence=1, accessed 5 August 2020).|
|16||Statement of the Joint United Nations Programme on HIV/AIDS (UNAIDS) Interagency Working Group on Key Populations on the need to ensure access to quality, safe, and non-discriminatory services for HIV key populations and migrants in the context of the COVID-19 pandemic. Geneva: UNAIDS; 10 July 2020 (https://www.unaids.org/sites/default/files/media/images/Statement%20of%20the%20IAWG%20on%20Key%20Populations%20-%20COVID_19.pdf, accessed 5 August 2020).|
|17||Avert. HIV and AIDS in Thailand; last updated 28 February 2020 (https://www.avert.org/professionals/hiv-around-world/asia-pacific/thailand, accessed 8 July 2020).|
|18||Joint United Nations Programme on HIV/AIDS. Thai hospitals to provide three- to six-month supplies of antiretroviral therapy; 25 March 2020 (https://www.unaids.org/en/resources/presscentre/featurestories/2020/march/20200325_thailand, accessed 18 August 2020).|