The last five years have seen astonishing – arguably catastrophic – increases in HIV seroprevalence among Thai gay men and men who have sex with men (MSM). HIV seroprevalence has risen from less than 10 percent early this decade to more than 28 percent by mid-decade.
Major questions of international significance arise:
• How could increases as dramatic as these happen in a country with a previously successful HIV prevention response?
• Is Bangkok merely the precursor for similar HIV catastrophes among the MSM communities of Asia’s other mega-cities?
• What can the world learn from Thailand’s experience in these dramatic increases?
A complex series of factors is involved in analysing why these increases happened – but arguably they add up to Bangkok being a tragic case study of how an effective ‘enabling environment’ for a national HIV response can be inadvertently dismantled – with catastrophic results.
Bangkok has a large MSM community. Low-range estimates place it between 150,000 and 300,000 . There are more than 35 MSM saunas and sex venues in Bangkok alone and the majority of these cater to the “Thai-with-Thai” market – that is, not to foreigners.
That there was alarming HIV seroprevalence rates among Thai MSM became clear in mid-2003 when a large-scale seroprevalence study was conducted by the Thai Ministry of Public Health (MoPH)-U.S. Centers for Disease Control and Prevention Collaboration . The Collaboration set out to ensure the study covered a wide cross-section of Bangkok MSM by working in partnership with Bangkok’s main MSM community organisation, Rainbow Sky Association of Thailand.
The study revealed a startling 17 percent HIV seroprevalence among Bangkok MSM. As more than 1,100 men were interviewed there is little doubt of the validity of the results. Previously it had been widely assumed that HIV among Thai MSM was predominantly among Thai men who prefer sex with white foreigners. This study, however, excluded Thai men who prefer sex with white foreigners as far as possible.
The 17 percent figure was so much higher than expected that initial reactions were disbelief and scepticism. The government was reluctant to release the data for fear that it would reflect badly on Thailand’s response to HIV. It was eventually released publicly – but certainly not promoted: neither among the MSM community or more widely.
In 2005, a follow-up survey was conducted and its scope was extended to include male sex workers in Bangkok and to two locations outside of Bangkok – Chiangmai and Phuket.
These results were even more alarming. HIV seroprevalence among Bangkok MSM had jumped to 28 percent in just two years, while 15 percent of MSM in Chiang Mai were infected. This rate of increase is unprecedented outside of injecting drug use (IDU) populations (e.g., such as is currently occurring in Eastern Europe). Again scepticism reigned initially – but dissipated when similar indicative data from the Thai Red Cross Anonymous Clinic and the Silom Community Clinic corroborated a figure in the 25-30 percent range.
Bangkok had shot to top of the world league for MSM HIV seroprevalence! Inner Sydney, for instance, has only about 15 per cent MSM seroprevalence and San Francisco, one of the cities with the highest rates of HIV among MSM, is around 26-27 percent.
The rapidity of these increases strongly suggested that Bangkok has been suffering an “epidemic of acute HIV infection” over the last five years. That is, rapid rates of transmission arising largely from newly-infected – and therefore highly-infectious – men. Many major Western cities experienced similar such epidemics in the late 1970s and early 1980s – before any of us were aware such a thing could be happening.
How could this be happening in Bangkok now – and why has an effective response been so long in coming?
There are some major contextual factors impacting on the Bangkok’s lack of response to the rising HIV epidemic. These factors need to be understood within the context of Thailand’s culture and particularly its approach to sex and sexuality.
Thai culture and sex between men
Thai culture around sexuality and gender is quite unique – and its nuances frequently misinterpreted by Westerners. For instance, Thai culture frowns upon any overt, public displays of affection, whether between heterosexual people or others such as MSM, but – paradoxically for many Westerners – it is a society very accepting of different sexual practices as long as they are undertaken away from public view. The sex industry thrives – every provincial town has at least a couple of brothels. Thai culture also condones a role for katoey (femininised gay men who usually adopt a transgender role). Sex between men has never been illegal or condemned as sinful by the main religion (Buddhism).
However, any sex, whether it is with a sex worker, sex between men or male-female sex, is private. To talk in public, openly and directly about sex publicly risks losing face. The concept of face and the resulting shame is extremely powerful, a concept that is not well understood by those from Western cultures. But despite these apparent contradictions, many Thai people see sex positively – as a casual, enjoyable recreation – not an activity burdened with all the moral baggage and tension within which Westerners cloak it. Its chief purpose is pleasure. But it’s seldom talked about.
With this cultural setting it is not surprising that Thailand had an early, rapid, sexual-transmission-driven HIV epidemic. And given that overall cultural context, it is particularly admirable that the “100%-Condom Use for Commercial Sex” campaign of the early 1990s dramatically turned around Thailand’s high rates of HIV infection among its general population, including MSM.
Changes in the Thai political environment
The foundations for the current explosive HIV epidemic among MSM were laid following a change in government in 2001. The new government, under Prime Minister Thaksin Shinawatra, began implementing its election-campaign-promised “Social Order Campaign”, initiated by Interior Minister Purachai Piamsomboon, aiming to rid Thailand of its reputation for prostitution and return society to ‘Thai traditional values’. This wide-ranging program included a range of measures to force the early closure of bars in both tourist areas and other areas, the now notorious ‘elimination’ of drug dealers, on-the–spot surprise urine testing for drug use, no access to any entertainment venue for those under 21 and a crack-down on the sex industry. Some of the subsequent police raids on MSM sex venues and prostitution were highly publicised.
Under the Social Order Campaign, police in effect had the power to harass, threaten with closure and extract bribes from the owners/managers of sex venues. This harassment effectively forced the removal of condoms at MSM sex on premises venues because, although sex between men is not illegal in Thailand, prostitution is illegal and a condom can be used as evidence of prostitution, either in a sex venue or being carried by a person in certain public places, for instance a park or particular streets or lanes at night.
One consequence of the simultaneous early bar and venue closures was the subsequent intense concentration of young men – ‘primed for action’ – moving on to parks or to the few sex venues operating illegally after hours.. Rather than reducing ‘illicit’ behaviour, the Social Order Campaign’s composite effect was in fact to concentrate and intensify opportunities for sexual encounters – but force it into environments where condoms were even less likely to be available or used.
Heterosexual sex venues were better able to cope with the police bribery and threats of closure as their revenue base is larger and more flexible. They charge a fee for every sexual transaction and so are more easily able to increase revenue to cope with increased bribes. Most MSM sex premises, in comparison, charge only an entry fee, leading to a much smaller cash flow and less financial flexibility to pay enhanced bribes. Their managers had to remove the condoms or face immediate closure.
In some countries the health ministry has been able to intervene in such situations and ensure government policy did not allow such direct undermining of HIV prevention programs. In Thailand however, as in many Asian countries, the Interior Ministry is much more powerful than the Public Health Ministry. In the context of the government’s Social Order Campaign the Thai Ministry of Public Health faced major hurdles in attempting to change both the Interior Ministry policy and the practices of local police on the ground.
Paralysis – or prejudice – at the Ministry of Public Health
The results in mid-2005 of the second MSM HIV Seroprevalence study – showing the dramatic increase from 17 percent to 28 percent – should have provided an excellent opportunity for a rapid and powerful intervention by the government. Unfortunately, at this critical moment Prime Minister Thaksin changed the Minister of Public Health, installing a Minister with a reform agenda – not necessarily a bad thing in itself – who promptly removed several of the Ministry department heads and rotated all of the others.
This, and the ensuing public furore it caused, appeared to paralyse the upper echelons of the Ministry at precisely the time that decisive action was needed to intervene in the MSM HIV epidemic. However, this paralysis was selective: during this period the Ministry was able to design and move to implementation of some very strong and far-reaching limitations on the sale and availability of tobacco and of alcohol. Perhaps it was more prejudice than paralysis that effectively prevented a bold and vigorous response from the Ministry’s most senior levels. The Ministerial situation was not resolved until late 2005, so for six critical months little progress was made on addressing what can now be seen as the HIV crisis that it was.
The subsequent and continuing government and political turmoil in Thailand remains a problem in developing an effective response, though not as debilitating as the previous episode: the Thai civil service has an honorable record of managing the country’s affairs effectively through times of extended political uncertainty.
Focus shift in Thailand’s HIV response
Thailand had successfully reversed HIV infection rates in the early and mid-1990s. During the late ‘90s and through this decade, the primary focus of the Thai response shifted to access of HIV treatments. To its outstanding credit the Thai government, through the Ministry of Public Health, developed and rolled out an access to HIV treatments program in 800 hospitals across the country, working in partnership with PLWHA organisations. Among low and middle income countries, only Brazil can claim similar success. And this was done notwithstanding the country’s financial constraints in the years following the Thai baht crash of 1997.
But there was a price to be paid. In retrospect it is now clear that the treatments access program pre-occupied the government’s policy and financial focus, and, with no additional funds provided to the AIDS budget, prevention education inevitably declined, a decline unfortunately intensified by the tone and programs instituted under the Social Order Campaign.
And ironically, as the economy recovered from the Thai baht crash over the last four years, Thailand has now come to be seen as a country with an “economy in transition”, which has effectively reduced the willingness of international donors and NGOs to provide assistance to Thailand. Donor governments such as Australia, the UK and the US have reduced funding or ceased altogether!
The Thai National AIDS Strategy and MSM
A further compounding factor militating against a rapid response was the absence of specific mention of MSM in Thailand’s National AIDS Plan at the time. The absence of MSM in the strategy made it difficult for Ministry of Public Health officials to allocate specific resources to an MSM intervention program, notwithstanding the obvious urgency created by the epidemic of acute infection.
This lack of ‘authorisation’ for MSM programs by the National Plan was made worse by the concurrent paralysis within the Ministry. Officials appeared reluctant to make any decisions on matters where there was the slightest doubt about their authority to do so. It appears this situation embarrassed key personnel within the Ministry to the extent they felt not able to take even the standard responsibility of such agencies – bringing the key stakeholders together to gain a comprehensive understanding of the situation and begin planning a strategy to address it.
This situation did not resolve until the new National AIDS Plan (for 2006-2010) was put into place early this year. Meanwhile the epidemic of acute infections among MSM continued throughout this period – virtually unchallenged.
Gay community response
Thailand has never developed a strong gay rights or gay pride movement – even though it has a long-standing and very large social and commercial gay/MSM sector. Sex between men has never been illegal, the state religion does not condemn it as sinful and homophobic violence within Thailand appears to be minimal – thus there have not been the ‘drivers’ for political organisation and action among gay men/MSM as there has been in other countries. Moreover, the Thai approach to sexuality generally – that it is essentially a private matter which may bring shame or loss of face if discussed directly publicly – also militates against Thai MSM ‘coming out’ publicly, or even to their families. Many families know their son is gay – but the matter is seldom acknowledged or discussed – even when boyfriends or sexual partners stay over in the family house!
By way of contrast however, the other community groups at risk of HIV infection – sex workers and IDUs – are very well-organised at the community level and operate with considerable political sophistication, as do the PLWHA community organisations.
The lack of a politically organised community among MSM meant that there was no group able to take a vigorous and forthright response when the explosive rate of new infections became known. In western countries with a strong gay movement, such as Australia or the US, the 2003 seroprevalence survey result would have led to a vigorous public push to alert the gay community about what was happening and also to pressure the government to take action. This is precisely what happened in Sydney with an increase of 18 percent in the rate of annual HIV diagnoses (not of seroprevalence) in the same year (2003): large posters appeared everywhere in the gay venues and media that boldly stated “18% and increasing”, followed up by an intensive, comprehensive campaign extending over two years involving community organisations, sex on premises venue owners, gay media, entertainers and social groups in the community, as well as government agencies.
The Thai MSM organisations were reluctant to take this vigorous approach, not having the experience of designing large-scale community health promotion interventions nor having the funds and social marketing skills to undertake such action – but also having doubts that it would be effective. It was ‘not the Thai way’ of doing things.
Research data vacuum
Planning for an effective intervention in the epidemic has also been hindered by a gaping lack of research on Thai MSM generally. There have been no significant social and behavioral studies or surveys conducted among Thai MSM about HIV. It is generally agreed among the stakeholders that the much-reduced availability of condoms is the chief factor underlying the increased infections; however, we do not have sound data on MSM condom use previously. Perhaps condom usage rates were always low among the ‘Thai-with-Thai’ men – but high in sex with foreign partners. And we have minimal research providing any insight on Thai MSM ‘treatments optimism’ following the roll-out of the successful Thai treatments access program.
This failure to invest in MSM research arises from a set of factors – MSM not being named in the National AIDS Plan, a conservative Thai academic and research academy in which prospective researchers find MSM work to be ‘career-limiting’, post-grad students unable to find supervisors, and sexuality not considered a topic for direct and open analysis and discussion.
Three years on – have we intervened effectively?
It is now three years since the startling 17 percent seroprevalence figure was announced – and 12-months since the alarming 28 percent figure revealed that Bangkok was continuing to suffer an epidemic of acute HIV infection among its MSM population.
While some elements of a response are being put in place, these do not yet add up to a comprehensive program capable of reversing the acute-infections epidemic.
A planning group involving all key stakeholders was finally convened in February 2006 (at AFAO’s initiative and encouragement) and under Ministry of Public Health leadership but it has not yet developed a comprehensive strategy which addresses the priorities and the current gaps in the response.
In particular, condoms are still not readily accessible/available in the sex venues; these 35 plus venues remain major engines of the epidemic. While some venues provide condoms for sale or have installed a vending machine these are usually near the venue entrance, often several floors away from where the sex happens and require coins to be carried or found: this does not amount to making condoms ‘readily-available-at-arm’s-reach-in-MSM-sex-venues’. Moreover, US government and International NGO policy requiring individuals to purchase condoms has not assisted ready condom availability as well.
A sex venue owners/managers group has been established through the Bangkok Rainbow Association (with some assistance from AFAO) and there seems to be energy and commitment to develop a self-regulating code of conduct, including achieving ‘arms-reach availability’ for condoms and lube in the participating venues. Progress, however, is slow. Meanwhile, the virus marches on.
The Ministry has begun playing a convening and initiating role – and has also engaged with the Ministry of the Interior to bring about a policy change on harassment and arrest on the basis of ‘possession of condoms as evidence of prostitution’. However, until this is widely known among MSM and venue owners/managers – and believed by them – then reluctance to carry or provide condoms will continue.
The Ministry’s epidemiologists have recently (in June 2006) acknowledged that most new HIV infections in Thailand will be among its MSM population and their male and female sexual partners.
To alert the MSM community, the Rainbow Sky Association produced and distributed a clever poster alerting MSM to increased infections (funded by AFAO) and Family Health International commissioned McCann Ericson to produce a multi-media social marketing campaign – ‘Sex Alert’ – for the MSM and mainstream media. It is not yet clear how much resonance these have had among Thai MSM.
Outreach work to venues and to some parks, including condom distribution, has intensified over the last six- months, though starting from a very low base.
A specialist MSM sexual health clinic has been opened in the Silom area by the Thai Ministry of Public Health-US CDC Collaboration – and the Ministry of Public Health and the Bangkok Metropolitan Authority has announced they will establish several Male Sexual Health Clinics across the country and in additional Bangkok locations. While very welcome in themselves it is important to keep in mind that clinics are essentially a reactive and predominantly clinical public health response and cannot be expected to make a major, immediate intervention in a highly-active epidemic.
Only minimal progress has been made on research which assesses Thai MSM’s changing beliefs and actions around condom use or the extent that they are aware of and accept the data indicating the extraordinarily increased rate of HIV seroprevalence within their community and what they think this means.
Despite this patchwork of initiatives, there has not been a substantial, strategic financial investment made by either the Thai government or by international donors for intervening and reversing this acute epidemic. Yet the downstream treatment and care costs over the next 30 to 40 years dwarf the comparatively small investment required immediately to reverse the epidemic. Meanwhile, the downstream cost continues to grow exponentially.
The future: Bangkok – and elsewhere in Asia
Will this patchwork of initiatives reverse – or even slow – the rate of new HIV infections among MSM in Bangkok?
Without ready availability of condoms and lube, and their consistent, regular use – along with a much better understanding of how Thai MSM are reacting to the situation – any significant reversal seems unlikely. If the epidemic of acute infection remains largely unchallenged then the parabolic curve will continue more steeply upwards and we are possibly looking at approaching or going beyond 50 percent seroprevalence by the time of the 2007 survey. This will be a tragic – and ultimately very expensive – outcome.
Will similar seroprevalence explosions occur in other Asian cities?
The situation in Thailand is an example of an effective enabling environment being inadvertently dismantled by government while attempting to achieve other, quite unrelated, policy objectives. The situation was compounded by government paralysis and inaction even two years after the crisis situation and its long-term implications and costs were starkly clear.
The result is a rapid HIV epidemic among Thai MSM – so far unabated.
With rapid social change through much of Asia, and particularly in India, China, Indonesia and Vietnam, there is the potential for similar major MSM epidemics to erupt in large cities during the next 10-20 years. Increasing urbanisation and the penetration of the internet in these countries are already greatly enhancing MSM social and sexual contact. Ho Chi Min City, with MSM HIV seroprevalence at around six to eight percent, may already be at a take-off point for a rapid epidemic if policy settings shift away – either intentionally or unintentionally – from the constructive direction in which they are currently heading. Jakarta, Manila, Tokyo, Osaka, Hong Kong, Shanghai, Beijing and 20 other Chinese cities with populations of more than four million people could well move into this position within a decade, and a number of India’s major cities may already be there.
Given the range of factors which can significantly impact on a desirable and effective enabling environment for preventing HIV transmission among MSM then the prospects across Asia’s mega-cities are frightening unless we learn from the mistakes made – by all parties involved (including AFAO) – in Bangkok.
* Don Baxter is the honorary Regional Coordinator of APCASO (Asia Pacific Council of AIDS Service Organisations) and the Executive Director of AFAO (Australian Federation of AIDS Organisations). The views expressed in this article are his own.