HIV is making a comeback and no one’s talking. In 1993, with cases of over 800,000 people infected with HIV, higher than any other country in the world, Thailand went up in arms with massive anti-HIV campaigns. We succeeded with lowering the rate of infection, however, the hot issue of HIV became cold and forgotten after the late 90s’ economic crisis. By 2000, funding for HIV prevention was one quarter less than it had been in 1997. Without Philadelphia to pull our heartstrings, massive campaigns, nor media outrage, the crisis is now going unchecked and unvoiced.
For men who have sex with men (MSM), the situation is already catastrophic. As of 2007, one in three venue-going MSMs were infected by HIV, according to a joint study on male Thai nationals frequenting gay venues in Bangkok carried out by the Thai Ministry of Public Health and the US Center for Disease Control and Prevention (see A Controversial Study, this page). HIV is a sexually transmitted disease. Discuss HIV and you must discuss risky sexual behaviors: unprotected sex, multiple partners, sex under the influence, the list goes on. This is not to be confused with a description of a gay lifestyle. Nor is it a comparison with straight men or straight couples. Without further data to clearly state why the number is so high and what exactly are the causal factors, we at BK spoke to the experts facing the problem to examine some of the behaviors that could be linked to the alarming infection figures.
SEX UNDER THE INFLUENCE
In the aforementioned 2007 Thailand Ministry of Public Health and US Center for Disease Control and Prevention (TUC) study, 20.7% of the men sampled used drugs such as MDMA (ecstasy or E), methamphetamine (ice, crystal), ketamine (K), cocaine and poppers (an inhalable nitrate)—a huge leap from 2003’s 3.6%. Experts say it’s difficult to establish how exactly drug use can be linked to HIV infection but it’s clear that it needs to be taken into account. Among HIV positive men, the TUC study revealed the ratio of poppers users compared to non-users was 2.29 to 1. Medical social research assistant of the Thai Red Cross AIDS Research Center, Thaneth Kanteeranon states, “Drugs can be a part of the problem. There are all sorts of drugs ice, poppers, E—that can have an impact [on sexual behavior]. Once you mess with these things, the ability to control yourself decreases and you take more risks.”
Kem (not his real name), 21, a student, spoke to us of his use of drugs when having sex: “I take ice. It gets me excited. I also take E. Mainly, I take it during sex. The sex gets better. I get more courageous and the sex lasts longer.”
Less sensational, alcohol is perhaps much more deadly because of how readily available it is. Alcohol consumption in the TUC study was at 77.6%. Alcohol may be legal, but it still produces some of the same effects as illegal drugs: diminished self-control, bad judgment and less consideration of risks.
Top (not his real name), 26, recalls, “I had a boyfriend, we always had protected sex. One night, we both got drunk and had sex without using condoms. The following morning, I was really scared and said we needed to get tested. At first, he didn’t want to go but then we went to Bumrungrad and got the test. He found out he was HIV positive.” Top’s insistence on going to the hospital paid off. Top had a prophylactic treatment (see Resources, below) that was successful and he subsequently retested as HIV negative (he was lucky, too, see Tips for Safer Sex, page 13). Top’s friend received treatment for HIV.
VENUES
Massage parlors, clubs, saunas: it’s impossible to get an exact figure of the number of places where gays might meet a potential sex partner. Kittinun Daramadhaj, president of Rainbow Sky Association of Thailand believes that there’s been a big increase in such venues and that this could be cause for the increase in HIV infection rates.
However, there is no hard data to support this claim; indeed, the alternative must be considered. In other countries or even cities in Thailand without gay venues, sexual encounters happen outdoors or in public toilets. In these places, there’s no way to reach out to gays with the education (pamphlets, posters) and equipment (condoms and lubricant) needed to fight HIV. Gay venues are just the opposite—ideal spots to reach gays and attempt HIV prevention at the moment when it matters most. Even so, a lot of saunas in Thailand could do more. Kittinun says, “Customers will get a condom in their locker and can ask for more at the front desk.” Nonetheless, speaking to gays here who had been to saunas abroad, Thailand has a long way to go, compared to some other countries where you’ll find saunas with overflowing condom and lube dispensers in every booth.
“Not everyone who goes to a gay sauna will have penetrative sex,” says Kittinun. “Of course, those that do have anal sex need condoms but some choose not to use any. Either because they dislike it or can’t be bothered to go to the desk to get one.”
DOT COM SEX
“I use the Internet a lot,” says Kem. “I’ll find a guy, we chat and if I like him, we meet up. If I don’t, it ends there. There are a lot of people on the internet now.” That’s an understatement. Visit gay.com, gaydar.co.uk or fridae.com and you’ll find thousands of profiles for gay Bangkokians. It’s no secret gays are using the web to hook up and that, just like gay venues, make finding multiple partners easier. But they can also help fight HIV by providing education about the disease. Currently, fridae.com’s KYS (Know Your Status) campaign encourages its users to get tested and practice safe sex while providing information on HIV (www.fridae.com/kys).
Unfortunately, just as some saunas do little to prevent HIV transmission, not all gay websites (or websites used by gays) practice this kind of social responsibility. “I’m really worried about the internet. It includes all those networking sites, Hi5, Camfrog, etc,” says Kittinun of popular networking websites used by gays here to hook up. “Cam sex is safe, of course, but the majority of users then go and meet each other.”
Top says, “I’m sick of going online, but I just can’t stop myself. I’m always looking for a guy. I don’t even know why I’m doing it. I have safe sex but when you have a lot of partners, accidents happen. I’ve had three real scares from having sex with guys I met online. I’m really lucky to still be HIV negative.”
SILENCE=DEATH
Yes, some gays have behaviors that are risky and increase their risk of getting infected with HIV. No, cracking down on them or their venues is not the solution, on the contrary. What is needed is plans that understand and accept these behaviors and finds ways to encourage safe sex that speak to MSMs.
So why is this not happening? “If I had to put my money anywhere, it’s homophobia and stigma. These are so powerful that it could lead to other things that we know increase the risk of acquiring HIV, that includes alcohol, drug use, depression, suicidal thouhts,” says Thomas Guadamuz, who collaborated on the 2005 TUC study. “During our research, we couldn’t find an MSM community, because it’s so underground. We can’t just go to Silom Soi 2 and 4, that does not represent all of the MSMs in Bangkok.”
Tied in with the double lives many MSMs lead, the secrecy and the sense of isolation, is the lack of sex education in Thai schools and society. Thanet believes that, “Thai education provides little sex education. It exists but just not enough. They don’t teach students how to put on condoms, how to use the different equipments properly, they don’t provide straight-forward ways of prevention.”
Kittinun agrees, “Simply put, if you don’t talk about homosexuality, gays, MSMs and transgenders, then you’re not tackling HIV.”
Guadamuz adds, “Most Thai guys are living with their families and are in the closet at work. When you don’t have an MSM community to belong to, the only place to meet other gays, even if it’s just to talk, is online or at gay venues.”
According to him, the infection rate is either staying the same or is on the increase. Either way, help is needed now: “They [MSMs] are just not getting the message. We need more money and support to make them understand. They need to get the message, ‘Look you’re in trouble.’”
“I’m terrified. I know there are a lot of people infected with HIV out there,” says Kem. “If I keep on living like this, I probably will die.”
Unfortunately, it’s not fear of death that makes people wear condoms, it’s love of life. “I think people’s perception of HIV/AIDS hasn’t changed in recent years,” says Wipas Wimonsate, medical research technologist for TUC. “There is still fear and discrimination. People should understand HIV/AIDS is treatable, although not yet curable, and not a stigma.” Get tested, know your status, play it safe.
A Controversial Study
In 2003, 2005 and 2007, the Thailand Ministry of Public Health in association with the US Center for Disease Control and Prevention, the LGBT (lesbian, gay, bisexual, transgender) group the Rainbow Sky Association of Thailand (RSAT) and the MSM Community Advisory Board (M-Cab) conducted a survey on venue-going MSMs (men who have sex with men).
The research sampled gay-identified locations such as saunas, bars/clubs, parks and male restrooms where it tested MSMs for HIV. In 2007, the sample population was young (73% were under 29), educated and, shockingly, showed an HIV prevalence of 30.7%. The study also stated that 65.8% of those sampled showed low rates of consistent condom use and that only 52.2% of them have gone for HIV testing.
Thomas E. Guadamuz, PhD, a postdoctoral fellow at the University of Pittsburgh’s Department of Behavioral and Community Health Sciences who collaborated on the 2005 TUC study believes that the high rate of infection is due to the notion that general MSMs don’t see themselves as being at risk: “When people think of the ‘risky population,’ which is horrible, because there is no such thing as a risky population, just risky behavior, they almost always think of sex workers. So when they visit the go go bars they will use a condom. But imagine a Chula student who goes to a sauna and meets another Chula student, they think, ‘We don’t have to use condoms, we both go to an elite university,’ or ‘We have the same light skin.
Kittinun Daramadhaj, president of RSAT, doesn’t fully trust the study, though. “They need to do random research. I don’t really believe in these numbers. It doesn’t include everyone,” he says. “If you go to the river, you’ll find water, you need to walk on the roads and you might find a pond. That’s what they need to be doing. When you’re at the hotspots, you’re obviously going to get high ratios.”
Guadamuz states, “If you’re focusing on venue-going general MSMs, the study is solid. It can’t be seen as a representation of the entire MSM population, though.”
Tips for Safer Sex
One Condom
Yes, some people are silly enough to try using two condoms for “extra” safety. It actually increases the risk of breaking the condoms. Always use a condom but only one at a time!
Oral Sex
You do have risks of getting STDs through oral sex. There is a less than 1% chance of acquiring HIV through oral sex but that is still a considerable risk. Do not perform oral sex when you have lesions or sores in your mouth or esophagus or receive oral sex from someone who has lesions (or if you have lesions on your penis). Brushing your teeth before oral sex can also create lesions and gum bleeding that increases the risk of HIV transmission.
One at a time
By putting more objects into the cavity, you risk tearing the cavity and so a higher chance of getting infected. You also increase the risks of condoms slipping or tearing.
Multiple Partners Increase Risk
There is no 100% safe sex, only safer sex. Multiple partners increase your chance of exposure to HIV. If you’re engaging in group sex, you need to be even safer. In particular, be careful that “top” partners use a different condom with each “bottom” partner.
Prophylaxis
Prophylactic treatments are only 70-80% effective if you receive them within 48 hours and 50% effective within 72 hours. (Beyond that, it’s too late.) They are not a good way to stay HIV negative and do not replace safe sex. Still, if you think you have been exposed, contact an infectious disease specialist as soon as possible.
Tips written with advice from Dr. On-Umar
Banpamai, a specialist in the field of infectious disease at Samitivej Sukhumvit Hospital
(see below).
Resources
Where to get tested and get help
The Anonymous Clinic
Thai Red Cross AIDS Research Center. 105 Rama 4 Rd., 02-256-4109. Open Mon-Fri 7:30am-6pm, Sat 7:30am-3pm.
www.trcarc.org
Test results are confidential and the clinic isn’t required to give an account of HIV-infected patients to the government. Free private consultation. Free testing for Thai nationals with their identification number. The organization also provides anti-viral drugs; however, this is not free.
Men’s Health Clinic
1/F, Bangrak Hospital. 189 South Sathorn Rd., 02-286-0431 ext 34. Open Mon-Fri 8:30-10:30am
Testing for HIV, syphilis, hepatitis B, and gonorrhea (B400 testing for all). Treatment also provided. Free condoms.
Silom Community Clinic
3/F, Bangkok Christian Hospital. 124 Silom Rd. Open Tue-Sat 5-10pm. 02-634-2917. www.silomclinic.in.th
A free clinic offering testing for sexually transmitted diseases (STD), including HIV.
Foundation for AIDS Rights
133/235 Mooban Ruan Rudee 3, Satairat Rd., 02-171-5135/6. Open Mon-Fri 9am-5pm. www.farthai.org
Free legal support and consultation.
Bumrungrad Hospital
22 Sukhumvit Soi 3. Direct line to HIV department: 02-667-2865 (daily 8am-8pm). www.bumrungrad.com
Antibody HIV testing, B750. PCR HIV testing (providing results for exposures a couple weeks old as opposed to three months for antibody testing), B2,900. Post-exposure phrophylaxis also available.
Rainbow Sky Association of Thailand (RSAT)
The Beach Residence Building,
159 Ratchadapisek Soi 19. Open Mon-Fri 9am-10pm. www.fasiroong.org
Free consultations on how to live with HIV and how to have safe sex.
Samitivej Sukhumvit Hospital
133 Sukhumvit Soi 49, 02-711-8000. www.samitivej.co.th
Antibody HIV testing, B620. PCR HIV testing (see Bumrungrad), B2,699. Infectious disease specialists for HIV treatment available for consultation.
