A study has found that 17% of a sample of men who have sex with men in Bangkok, Thailand are HIV-positive. The study, which is published in the April 1st edition of AIDS is accompanied by an editorial which highlights that although Thailand had been praised for its response to HIV, there were no sentinel data on HIV prevalence amongst men who have sex with men prior to this study due to stigma and discrimination.
Thailand has been recognised as an example of effective HIV control. After HIV prevalence was found to be increasing rapidly amongst commercial sex workers, the government introduced a “100% condom use in commercial sex progamme” which is widely credited with reducing the country’s HIV prevalence. In 1991 there were an estimated 143,000 new HIV infections in Thailand, but by 2003 this had fallen to 19,000.
However, there is concern that HIV is spreading amongst Thai men who have sex with men. Research has estimated the HIV prevalence amongst this population to be between 3% - 16%, however, because of prejudice, there has been no sentinel study of HIV prevalence amongst men reporting sex with other men. Official figures are thought to grossly under-estimate the prevalence of HIV amongst men who have sex with other men. For example, of the 236,000 AIDS cases reported in Thailand to the end of March 2004, only 1% (2280) are said to involve men who have sex with men.
Accordingly, investigators aimed to assess HIV prevalence and associated risk behaviours in a community-based sample of Thai men.
Men were recruited by peer-educators at 14 venues, comprising six saunas, four parks and four bars. Participants had to be over 18 years old, Thai citizens and resident in Bangkok and were asked by the peer-educators about their demographic background and HIV risk behaviours. They then provided an oral sample for HIV testing. A total of 1121 men participated in the study.
A total of 194 men (17%) were HIV-positive. The mean age of the sample was 25 years, 42% had completed university, and 49% lived with their family.
In the previous six months, 22% of men said that they had had sex with both men and women, 46% said they had a steady male partner in previous three months, during which period 65% reported having a casual male partner. In addition, 9% said that they had had a steady female partner and 9% a casual female partner.
Unprotected sex in the previous three months was reported by 36% of men.
Although alcohol consumption was widespread (74%), only 4% reported illicit drug use in the previous three months, and 12% reported ever using drugs.
A previous HIV test was reported by 43% of men but none of these men said that the result was positive.
In multivariate analysis, the investigators found that lower education (p = 0.03), recruitment to the study in a park (p = 0.007), engaging in both insertive and receptive anal sex (p = 0.007), identifying as gay or bisexual (p = 0.02), the number of years of anal sex (p = 0.001), and the number of male anal sex partners (p = 0.02) were all significantly and independently associated with increased HIV prevalence.
“Despite Thailand’s remarkable success in controlling the HIV epidemic among the general population, the HIV prevalence amongst MSM was found to be surprisingly high”, write the investigators. They add that the risk factors for HIV amongst men who have sex with men in Bangkok were “consistent” with those for gay men in western countries: anal intercourse and increased sexual activity. The investigators therefore recommend that “prevention activities should therefore focus on sexual behaviour, such as reduction of sex partners, increased condom use, and increasing awareness of risk associated with specific practices."
The investigators note with concern that a significant proportion of men having sex with other men also reported sex with women, and that although a large number of men had had a previous HIV test, none reported being HIV-positive. They recommend that the importance of condom use be emphasised to men engaging in bisexual behaviour and that efforts to encourage HIV voluntary testing and counselling amongst men having sex with other men should be increased.
An editorial accompanying the study says that it “strains credulity” that basic epidemiological data about the prevalence of HIV amongst Thai men having sex with other men was lacking until 2004. The author notes that this is particularly ironic as the first case of AIDS in Thailand involved a man with a male partner. Despite successful, and internationally praised HIV prevention work with the general population, the HIV epidemic amongst Thai men who have sex with men was ignored, says the editorial, due to stigma and discrimination.
“The stigma and discrimination faced by MSM and drug users in Thailand cannot be underestimated. However, public health officials must continuously deal with unpopular causes. With these new findings, hopefully preventive interventions will now begin to address the lingering HIV/AIDS problem amongst MSM in Thailand”, concludes the editorial.
van Griesven F et al. Evidence of a previously undocumented epidemic of HIV infection among men who have sex with men in Bangkok, Thailand. AIDS 19: 521 – 526, 2005.
Celentano DD et al. Undocumented epidemics of HIV continue to persist in the twenty-first century. AIDS 19: 527 – 528, 2005.