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The invisibility of the HIV epidemic among men who have sex with men in Bangkok, Thailand

Thanprasertsuk, Sombata; Sirivongrangson, Pacharaa; Ungchusak, Kumnuana; Jommaroeng, Rapeepunb; Siriprapasiri, Taweesapa,c; Phanuphak, Praphand; Tappero, Jordan Wc,e; van Griensven, Fritsc,f

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aDepartment of Disease Control, Thailand Ministry of Public Health, Nonthaburi, Thailand

bRainbow Sky Association of Thailand, Bangkok, Thailand

cThailand Ministry of Public Health, US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand

dAIDS Research Center, Thai Red Cross Society, Bangkok, Thailand

eGlobal AIDS Program

fDivisions of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, Atlanta, GA, USA.

Received 26 May, 2005

Accepted 20 July, 2005

Recently, we reported in this journal an HIV prevalence of 17.3% found in our first assessment of HIV infection among men who have sex with men (MSM) in Bangkok [1]. In an editorial, Dr Celentano [2] wrote that the timing of our assessment is ‘ironic since the first case of AIDS in Thailand reported in 1984 occurred in a Thai male with a male partner’ and that the HIV epidemic among MSM in Thailand has been ‘ignored' because of ‘stigma and discrimination’. In this letter we provide some additional information and highlight some of the steps taken by the Royal Thai Government to address this previously undocumented epidemic of HIV infection in MSM.

That the first case of AIDS in Thailand was reported in a homosexual man may well have been the result of active case-finding. At the time, HIV/AIDS was almost exclusively reported in western homosexual men, and, indeed, Thailand's first AIDS case was diagnosed in a man who had returned from the United States where he had had multiple male sex partners [3]. In response to the threat of an HIV epidemic, in 1985 the Thailand Ministry of Public Health (MOPH) opened a male sexual health clinic in Bangkok, initiated several small-scale prevention activities, and started sentinel HIV surveillance in male sex workers (MSW) [3–5]. Subsequent AIDS case reports and other epidemiological information did not provide any evidence for substantial male-to-male HIV transmission [6,7], and eventually the prevention focus shifted towards the exploding HIV epidemic among heterosexual populations. This epidemic was largely controlled a decade later [8]. As in many other countries, evolving HIV epidemics pose new challenges, which the MOPH has addressed, for example by taking the initiative to conduct the MSM assessment in 2003 [1].

Regarding stigma and discrimination against MSM, we would like to point out that in Thailand no legal or religious sanctions exist against same-sex behaviour. In addition, the Thai language does not contain any indigenous words for homosexuality and does not differentiate between sex and gender. Therefore, epidemiological population categories commonly used to depict HIV epidemics in the west, such as homosexual or bisexual men, are difficult to apply. This is not to say that Thai MSM do not experience stigma and discrimination, but much of their experience comes from the enforcement of Thai cultural norms about what is considered appropriate for public display. If ignorance, stigma, and discrimination were the reasons to not address the HIV epidemic in Thai MSM, how could it be that the MOPH has conducted HIV sentinel surveillance in MSW, a subcategory of MSM, since 1989? [9] The explanation is simple. Unlike MSM, MSW were an identifiable HIV epidemiological population category that could be located and targeted for HIV surveillance and prevention activities.

Only fairly recently, Thai MSM have started to adopt homosexual identities and gay lifestyles similar to those seen in the West [10]. They have also begun to organize themselves around issues such as equal rights, healthcare, and education about same-sex relationships. At the same time there has been a strong increase in the number of venues for Thai MSM to socialize and seek sex partners [1,7]. The MOPH identified these developments as an opportunity to engage MSM in addressing the spread of HIV in their community. As part of the 2003 assessment, several community meetings were organized to solicit input and support from stakeholders, venue owners, and members of the MSM community. The assessment itself was conducted in close collaboration with Rainbow Sky, a volunteer group performing HIV prevention outreach for MSM. Shortly after the HIV prevalence of 17.3% became known, the MOPH established an MSM task force with representatives of the MSM community and other governmental and non-governmental organizations. A national strategic plan for the prevention of HIV and sexually transmitted infections among MSM was developed and is being implemented [11]. As part of the process, Rainbow Sky developed into an officially recognized community-based organization providing legal representation for MSM.

At the time of this writing, a second assessment of HIV infection and risk behaviour among MSM is under way. The current assessment covers not only the capital city of Bangkok, but also the northern and southern urban areas of Chiang Mai and Phuket. Further increases in geographical coverage are planned for 2007; full national coverage is foreseen for 2009. These periodic assessments will help to gauge whether increased preventive interventions and services for MSM, as outlined in the strategic plan, will result in increased protective behaviour and decreased HIV prevalence.

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© 2005 Lippincott Williams & Wilkins, Inc.