Human immunodeficiency virus (HIV) remains a major global health challenge despite decades of progress in research. According to the World Health Organization, at the end of 2024, the number of people living with HIV was estimated at 40.8 million, of whom 1.4 million were aged 0 to 14 years, and 39.4 million were aged 15 years and older. In Thailand, the number of people living with HIV in 2023 was estimated at 560,000, with the highest prevalence rate—1.3%—observed in Chiang Mai Province. 

The vast majority of new infections occur through sexual contact between men, marital transmission, sexual contact between sex workers and their clients, casual sex outside of marriage, and injection drug use. In fact, studies among migrants have shown that they were often unaware of HIV before moving to Chiang Mai or Thailand. Gaps in HIV knowledge are most prevalent among women, especially those with less than five years of education, as well as among agricultural workers, seafarers, and those who don't know anyone living with HIV. At the same time, even among those with some knowledge of risk factors, safe sex practices are often not followed.

Since Chiang Mai has one of the highest numbers of Burmese living and working in the province, we initiated this study among HIV-positive Burmese migrants living in Chiang Mai. We examined psychological empowerment and the positive impact of a supportive social structure on reducing the stigma often experienced by these migrants, using the social ecological model as a lens.

The questionnaire was based on the Stigma Index Thailand by the Thai Network of People Living with HIV/AIDS, led by Tawat Maneepong, and translated into Thai and Burmese. Participants were patients at the Saraphi Community Hospital, Saraphi district, Chiang Mai Province, Northern Thailand. We asked questions about socio-demographic and socio-economic status, lifestyle, and a series of questions about their experiences in Thailand: social stigma, self-stigma, discrimination, protection of positive rights through law, policy, coercion, or any changes they had experienced in the past 12 months.

Most of the participants were Tai Yai, Buddhists, and nearly two-thirds reported no formal education. Just over half of the migrants had lived in Thailand for eight years or more, and the most common occupations were laborers and casual workers. In fact, all disagreed with statements that their HIV status affected their participation in family activities and rejected the idea that they had been verbally abused or intimidated, physically abused, psychologically pressured, harassed, or discriminated against by other HIV-positive people.

Almost no one cited their HIV status as a reason for being denied a promotion. However, family planning services and children's education were reported to be the most common sources of HIV-related stigma over the past 12 months. Over 43% of families were denied access to family planning services due to their HIV status. Approximately 27% of families had their children expelled, suspended, or not admitted to school for the same reason. It was also found that native Thai speakers were six times more likely to report guilt about their HIV status. Those who had immigrated more recently were ten times less likely to report guilt about their HIV status. Furthermore, an interesting relationship was observed between age and guilt: those aged 29–33 were 25 times more likely to experience guilt than those aged over 33, who were twice as likely to report guilt as those aged under 29.

We also examined how the conceptual framework of the socio-ecological model, which aims to facilitate the effective implementation of public health programs, including HIV treatment and prevention programs. This model comprises five core principles and multilevel factors influencing health behaviors associated with the risk of HIV infection, including intrapersonal, interpersonal, institutional, societal, and policy factors. This comprehensive approach to integrating the multilevel socio-ecological model can help high-risk patients receive the necessary social and psychological support to avoid pitfalls that lead to ineffective disease treatment and reduce stigma, which can help patients feel part of the treatment and prevention program rather than seeing themselves as carriers of the disease.

We also suggested how, by organizing HIV care outside of institutional structures and emphasizing the value of the social-ecological model, health care providers and community members can simultaneously improve treatment outcomes and reduce the perceived stigma that HIV-infected people experience toward their family members. Healthcare and educational institutions across Thailand must play a key role in creating an enabling environment that addresses issues of isolation, self-efficacy, and relational factors that impact decision-making, which can help prevent the spread of the infection.

Alas, we concluded that even knowledge of HIV risk does not motivate adherence to recommendations. Thus, decades of research in this area have yielded little progress, due to people's needs and relationships at the intrapersonal, interpersonal, institutional, social, and policy levels.