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.
· 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.
The background
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 (then) Prime Minister Thaksin Shinawatra, began implementing its 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 practises 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!
In part 2 to be published tomorrow, Baxter discusses the Thai National AIDS Strategy and MSM, the gay community's response and the future of Bangkok - and elsewhere in Asia. The article was first published in HIV Australia, vol 5., no 2. and is reproduced with permission.
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.