Outreach, condom provision, and STI clinical services for CSW were critical elements of BMA?s early response to the HIV epidemic. However, changes in both the nature of sex work and in health service delivery under recent health reforms have weakened HIV control efforts among CSW. Sex work has shifted from brothels to more ?indirect? settings such as bars, karaoke, and massage parlors where access by public health staff is more difficult. Street-based or mobile-phone-based CSW are rarely reached at all. Decentralization has meant fewer STI clinics, fewer experienced staff, a major reduction in outreach visits to sex work sites, decreased condom supply and condom promotion among clients of sex workers, and weakening of the monitoring and surveillance system for both STI and condom use trends among sex workers (WHO and MOPH, External review of the health sector response to HIV/AIDS in Thailand, 2005). Funding for STI clinical services and outreach is now integrated into annual capitationbased funding to each province for general medical services under NHSO; the level, quality, and nature of STI services delivered varies widely. HIV prevalence among MSM in Thailand has increased at an alarming rate. In a 2003 survey, HIV prevalence among MSM in Bangkok was 17.3% (van Griensven et al., 2005) and rose to 28.3% in 2005 (data not yet published). The 2005 survey also documented high HIV prevalence in other geographic areas outside Bangkok. In two well-known tourist cities, Chiang Mai and Phuket, HIV prevalence among MSM was 15.3% and 5.5% respectively. HIV prevalence is also high among different subgroups of MSM?15.6% among male sex workers and 13.5% among transgenders. While a few peer-based condom outreach programs and STI services for MSM have started in some areas in Thailand, coverage by these programs is still low, and service models for MSM have not yet been consolidated. In response to the HIV problem facing this population, MOPH is developing a national strategic plan for HIV prevention, aiming to decrease the number of new infections by half within the next 4 years. CSWs and MSM are two of three defined target populations for this decrease. For the national strategic plan to succeed, an effective prevention model for MSM must be defined, and prevention programs and coverage for both CSW and MSM must be expanded.
