HIV scourge spreads from red lights to white collars
A recent report says that the spread of the virus in Bangkok has become an 'explosive epidemic' and that an increasing number of sufferers are not sex workers, but ordinary people whose lifestyles expose them to risk
Thirty-four-year-old Ball met his partner Sonchai at high school and the pair started living openly as a gay couple when they roomed together at university.
YOU’LL BE SAFE HERE: The reception area at the Silom Community Clinic. Both the reception area and the examination rooms are well decorated to help patients feel more comfortable.
But eight years ago, Ball, who had been monogamous and loving in the relationship, was shocked to learn his partner had not been. Sonchai had infected Ball with HIV.
"I have only had one sexual partner for 10 years. I was with my boyfriend for more than 10 years," he said.
"I thought we had a really healthy relationship until one day I became very ill. I went to see the doctor and he found that I had TB and oral thrush.
"Then the doctor asked me to test for HIV. I was shocked when I found out I had tested positive.
"I told my partner and he confessed that he was fooling around and having unprotected sex with other people. He told me that he attended many group sex parties and sometimes he did not use a condom. So I took him to see the doctor to get tested and he also tested positive."
Ball's case is typical of a worrying trend of increasing HIV infections in the MSM (Men who have Sex with Men) category described by a 2012 paper as an "explosive epidemic" in Bangkok.
The report _ a joint effort by the Public Health Ministry and the US Centres for Disease Control and Prevention Collaboration _ based its findings on at-risk men visiting the Silom Community Clinic near Bangkok's red light district for gay and bisexual men.
Despite the perception that those visiting the clinic were restricted to sex workers and their cruising clients, Timothy Holtz, director of the Health Ministry's HIV/STD Research Programme, said many of them were regular men. "From 2005 to 2012, we had 6,526 clients who made 23,600 visits to our clinic," Dr Holtz said. "This group of MSM people, who are regular white collar people ... come to the clinic for free HIV testing as well as other kinds of sexually transmitted diseases, counselling and treatment support."
Long-term statistics from the centre show a steady increase in HIV in the MSM group from 2005 to 2011. In 2005 the prevalence of HIV among the group was 24.6% (51 out of 207 men) increasing to 29.4% in 2011 (301 of 1,023 men).
LEADING THE FIGHT: Dr Timothy Holtz, Thailand Ministry of Public Health - US CDC Collaboration HIV/STD Research Programme.
An emerging risk factor was the use of methamphetamine, or crystal ice, to prolong sexual intercourse.
This was a growing problem across Asia, according to the 2012 report "Evidence of an explosive epidemic of HIV infection in a cohort of men who have sex with men in Bangkok, Thailand". The drug was not injected, as reported in MSM communities in the US and Australia, but smoked and taken along with stimulants.
"Drug impairment may lead to inconsistent condom use and ultimately HIV transmission," the report said.
While the clinic's findings are not intended to be a comprehensive study of the estimated 300,000-400,000 strong MSM group in Thailand, they are representative of the situation, Dr Holtz said.
"We open the clinic and we invite them to come in," Dr Holtz said. "We feel that it is as representative as it's going to get. We can't say that it is the truth with a capital 'T', but I think we can say that it is consistent with the other research that there is a high rate of HIV in [the] MSM population."
What makes the clinic valuable to medical researchers is that the men are asked to join a "cohort" group where they agree to be tested every four months over a five-year period for HIV and other sexually transmitted diseases.
THE YOUNG AND THE RECKLESS
Dr Holtz said that as part of the follow-up tests they are asked questions about "their behaviour, what kind of sex are they having and where, with who, and are they using drugs?"
"The biggest risk for HIV infection we found is from receiving anal intercourse without a condom," Dr Holtz said. "That is by far, the biggest factor. Another factor is drug use associated with HIV infection."
QUICK ANSWERS: The clinic is fully equipped with laboratory equipment enabling it to provide accurate HIV test results within 30 minutes.
The highest risk group for new infections are men aged under 24. Dr Holtz said this was due to factors such as living away from a family home, having more sex than older men, drug taking for sexual pleasure and inconsistent condom use.
Lack of education about safe sex is another problem.
"We worry about the young MSMs," Dr Holtz said. "Another problem is that they have multiple sexual partners. In the research, we found that having more than five sexual partners puts you at a higher risk.
"I'm personally concerned about drug use in this population, especially crystal methamphetamine. When you are under the influence of drugs, you are not thinking straight. You may forget to put on a condom, you may forget to ask your partner to wear the condom, you may put yourself in the situation with multiple sexual partners that you wouldn't normally do."
Ball, now living with HIV, knows he learned the safe sex message the hard way. Ball and Sonchai both have new partners, but some old habits are hard for Sonchai to break.
"We are still living together, but not as boyfriends," Ball said. "We still support each other emotionally. Now I have my own partner while he also has his.
"I am honest with everyone by telling them my status before having sex and I never forget to use a condom. But my ex-boyfriend does not always tell people about his status and he still attends group sex parties. I want everyone to always use a condom. It's not safe to have sex without it, and you can't really trust anyone."
WHITE COLLAR NO PROTECTION
Another interesting finding from the clinic was the rise in HIV and STD infection rates among non-sex workers.
In fact, the study found white collar workers made up the majority of new infections, according to clinic manager Supaporn Chaikummao.
"The majority of our clients are general MSM _ they are not sex workers," said Ms Supaporn. "They are all white collar people, professionals and well-educated people. I would say that less than 5% are sex workers. Injecting drug use is not common and it is not a preferred type of drug in this group. There are drug users in the MSM group, but they use other kinds of drugs."
Dr Holtz said that transgender people are also included in the MSM group.
"People can classify themselves however they want, but we classify them by their behaviour," he said.
"In medical terms we call them TGW [transgender women]. Sometimes they want to classify themselves differently, but we include them in the MSM group according to their sexual behaviour. People who have sexual intercourse through their rectum are considered at risk, and we want them to protect themselves from HIV."
Dr Holtz said some men consider themselves "straight" and only have casual sex with a male partner, however, for the clinic's purpose they are classified as MSM.
BEING POSITIVE ON BEING POSITIVE
Rak is 48 year-old transgender person who has been living with HIV since 1997. She did not start using antiretroviral drugs until 2004. "I was waiting for the day I would die. I couldn't work, I couldn't eat," said Rak. "I was without hope for five years, then I realised I am still healthy and alive. It was the most confusing time of my life but I got through it. So I started to apply for jobs and to try and get my life back on track."
ON THE FRONT LINES: Supaporn Chaikummao, the site coordinator and clinic manager of Silom Community Clinic, which has been actively involved in research on the spread of HIV among the MSM community.
Rak, who now helps newly diagnosed HIV sufferers come to terms with the virus, was a singer before she tested positive.
She said she practised safe sex on a regular basis, but not all the time.
''One wrong decision I made affected the rest of my life,'' she said. ''One time a man I slept with removed the condom he wore without me knowing it. By the time I realised, he had already finished.
''I was scared at first and I didn't get a blood test for HIV until I needed one prior to surgery. That's when I was tested and found out I had HIV.''
Rak says nowadays she has no sexual relations and feels no need to do so. ''What I did earlier was just to please the guy I liked,'' she said. ''Sexual pleasure has never been what I've looked for.''
Dee, a 34-year-old gay man who works as an executive for a private company, has been HIV positive for almost 10 years.
He says he was tested for the disease after he began to feel weak and started to fall ill easily.
''The result came back positive. It wasn't a shock to me at all. I kind of knew from my sexual behaviour,'' he said.
''My sexual behavior totally changed from the moment I know I was infected. I have practised 100% safe sex ever since knowing the result.''
Still Dee has regrets about his reckless sexual history which resulted in his infection.
''I feel like my life has become worse,'' he said. ''I have no-one to talk to about my health problem. I feel like no one can support me. Actually, the only person who gives me support is my sister.''
Dee says he is greatly concerned about younger MSMs and warns that public health campaigns should also focus on gay youngsters.
''I know many schools think sexual issues are taboo to talk about with young students,'' he says. ''Even if they do have proper lessons, they are about safe sex practices among heterosexuals. What about homosexual kids? The sexual activity among this group is different and they need to learn how to practise safe sex too.''
A TESTING TIME
Alex Duke, programme manager for Population Services International's Thailand Foundation, said health organisations had to come up with new strategies to get their safe sex message across.
PSI is is funded by USAID and works with MSM and transgender women in Bangkok, Pattaya and Chiang Mai.
Mr Duke said in the past the message was largely disseminated in bars and clubs. However, nowadays many like-minded MSMs are meeting on the internet.
''Now meeting up is not only limited to bars, it's also online,'' he said. ''There is a lot of online networking happening now. People are meeting in less traditional venues than in the past.''
There was also no guarantee a condom would be used every time, despite the safe sex message getting across.
''Within this population you cannot guarantee that [condoms are] used every time. There's always going to be some occasions where HIV transmission may be possible,'' he said.
Mr Duke said the new emphasis was getting people to test for HIV, and if positive, move them into government and community health services for treatment.
''If you are HIV infected and on antiretroviral drugs, your viral load is significantly reduced and this vastly reduces the chance of being able to transmit HIV to the other people,'' he said.
Dr Holtz agreed testing for HIV and other STDs was crucial for at-risk people.
''One important tool in terms of prevention is to get tested,'' he said. ''Our research shows, that 43% have been tested before and that is not enough. Our goal is to get more and more people tested. We are encouraging them to come here to get tested for free. We have anonymous confidential service.''
Siroat Jittjang, assistant programme manager at PSI, explained the organisation's ''Test and Treat'' strategy.
''We cannot make everyone use a condom with their partners every time, so those people may be living with HIV already,'' he said.
''People already living with HIV and who aren't aware of it can get to know their status and get proper treatment as soon as possible. If the viral load is very low to the undetectable level, it will be difficult for the transmission to happen.''
IT’S BETTER TO KNOW: Clinic staff provide free blood testing and counselling services for the MSM (Men who have Sex with Men) population. Those visiting the clinic can do so anonymously without having to register with their identification cards.