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The Thai National AIDS Strategy and MSM
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 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 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 - 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 behavioural 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 suffering 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'. US government and International NGO policy requiring individuals to purchase condoms has not assisted either.
A sex venue owners/managers group has been established through the Bangkok Rainbow Association (with AFAO's assistance) and there seems to be energy and commitment to develop a self-regulating code of conduct, including achieving 'arms-reach availability' 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 Bangkok. 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 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 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.