By Jan Willem de Lind van Wijngaarden, La Trobe University
It's 10 years since the first evidence emerged of what was until then a completely hidden HIV epidemic among men who have sex with men in Bangkok, Thailand. The term includes all men who engage in sexual activity with other men regardless of how they or others sexually identify them.
Bangkok has an population of about 300,000 to 400,000 men who have sex with men. In 2003, about 17% of those randomly sampled from different gay entertainment venues had HIV. When the study was repeated in 2005 it had risen to more than 28%. A more recent study suggests it's still around 30%.
Similar epidemics have also been discovered in Chiang Mai, Phuket, Pattaya/Chonburi and other Thai cities, albeit at a slightly lower level.
While the Bangkok epidemic appears to have plateaued, HIV incidence (the number of new infections in a population over a certain time period) remains stubbornly high despite years of investment in HIV prevention, and especially among the youngest men.
A persistent epidemic
There are a number of reasons that have led to, and sustained, the epidemic.
Thailand's economy has been booming and there has been a significant increase in gay entertainment venues, including gay saunas, karaoke, pubs and night clubs, and men who can afford them. Internet apps such as chat platform CamFrog, Grindr and Jack'D and a plethora of other gay dating websites have made hooking up for sex easier than ever before.
The availability and use of party drugs such as crystal meth are widely available and are associated with low levels of condom use and longer sex sessions, sometimes with multiple partners.
Low condom use is a big problem. Although a push to stem HIV in sex workers was successful, condoms are widely associated with female prostitution, unfaithful (heterosexual) men and distrust in a sexual partner.
There are cultural reasons too. In Thai sexual culture, men are allowed to have “fun”, but sexual liberty for women is still widely frowned upon. As long as their sex lives are kept out of public scrutiny, Thai men (including men who have sex with men) generally feel little guilt or discomfort in enjoying sex.
And while Thailand is widely considered in the west to be liberal and accepting towards homosexuality, in reality it's tolerant rather than truly accepting. Men often keep their sex lives completely separate from their family, social and work lives, which leaves freer to engage in sexual exploits than if their sexuality was more integrated.
Heteronormativity – where everything is focused on the needs and expectations of heterosexuals – permeates Thai society, including the education system. The sexual health needs of young homosexual men are completely ignored.
Homosexual relationships have also been traditionally defined by difference; lovers should complement each other, rather than be similar. Age-discrepant relationships (between a young man and a (much) older man) are also common and could be a factor in the rise of HIV in the youngest age groups.
Thais learn from an early age to respect and be docile towards older people and not question their judgement, which may also affect condom use. This could also happen in the case of a dominant partner.
Deafening silence
There's a deafening silence around HIV. Most men with HIV don't know they have it or don't disclose their status to their families, friends and lovers. The topic is rarely, if ever, discussed in public. More anonymous and free HIV testing services would help enrol more men in treatment and reduce the “community viral load”.
Condoms, lubricants and information about testing have to become part and parcel of the entire entertainment environment. That the epidemic is so invisible in these venues is surprising given the ten years since it was identified, and also if one realises that at least a third of the patrons on any given evening probably have HIV.
The 15-22 age group has to be targeted since HIV incidence is highest here. Unfortunately, the Thai Ministry of Education is not known for its sense of responsibility for sexual health, let alone homosexual health. But more schools could be recruited to initiatives (including web and social media-based ones) run by NGOs, as is already happening.
The older strata of same-sex attracted men are now faced with HIV prevalence levels of up to 45-50%. Many young men, when finding their first lover, are swept off their feet and believe they have found the love of their life. By the time they discover the realities of heartbreak and multiple concurrent or subsequent short-term “love” relationships that characterise segments of Bangkok's gay life, quite a few will have been infected. It's unhelpful to cast blame, but older men should be nudged to protect younger men.
Public health campaigns also fail to engage with the complexity of infection. The message “always use a condom” is too simplistic and doesn't distinguish between different gradations of risk between oral, anal and vaginal sex, insertive or receptive positions, the availability of water-based lubricants (which don't degrade condoms) and whether orgasms happen inside or outside the body. They also need to focus on encouraging regular testing and the benefits of HIV treatment.
Anal sex is estimated to be up to 10 times more efficient at transmitting HIV than vaginal sex. After not using a condom in one sexual activity, some may decide not to use them during anal sex unaware of the hugely different risks involved. Small things, such as encouraging more oral sex could make a huge difference in a reinvigorated push for prevention.
It's clear there are no quick answers but a concerted combination of approaches offer the best hope for an HIV-free generation of gay men in Thailand.
Jan Willem de Lind van Wijngaarden does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
