Positive Life NSW

Rob SutherlandRob Sutherland on HIV and men who have sex with men (MSM) in Thailand and progress at the United Nations

I’m not quite sure what it is, but something keeps drawing me back to Thailand. This is my fourth visit in as many years, and the most substantial consisting of 12 months of living and working in Bangkok. I shouldn’t be surprised however, why I keep finding myself here. It is a colourful and vibrant city, full of history, rich in culture and with food that is so good that it is sure to add a few kilos to even the most avid gym goer. It is also home to a beautiful and welcoming people that are resilient in the face of significant challenges, maintain a very refreshing sense of perspective and humour (essential in a city such as Bangkok) and with a smile that is never far away. In fact, many call it the land of smiles, and whilst some Bangkok taxi drivers may at times test the validity of that statement, for the people generally it holds true.

It is also a country of many contradictions and extremes. Bangkok particularly is a city renowned for its sex trade, its go-go bars, its ping pong shows and its ‘anything goes’ nightlife. It is also paradoxically a place of quiet conservatism when it comes to sex, influenced by a strong and devout Buddhist population and what are often coined as ‘traditional Thai values’ centering around the importance of family and social structure. Both coexist in an unusual dichotomy, complicated now by a more liberal and western approach to sex which is being fostered by a younger generation of Thais growing up in a society now heavily influenced by western-style media and advertising, and often flaunting the ideals of aesthetic beauty, status and consumerism as Thailand transitions to a middle income country.

My work here in Bangkok is on a placement through AusAID’s Australian Youth Ambassadors for Development (AYAD) Program. As a staff member of the AIDS Council of NSW (ACON), and with their ongoing support, I am working with the United Nations Joint Programme on HIV/AIDS (UNAIDS), in the Regional Support Team for Asia and the Pacific. Australia generally, and particularly community organisations like ACON, have a key role in showing leadership regionally in this area and sharing the lessons we have learnt. My placement is very much a reflection of this and of ACON’s expanding international work in the Asia Pacific region.

The focus of my assignment is on HIV relating to men who have sex with men (MSM). When it comes to MSM, whether gay, bisexual, transgender or straight men, Thai society is in many ways relatively more liberal than Australia. Generally society is quite accepting, at the least tolerant, and in any case lacking much of the overt homophobia that often flares up in Australian society.

There are many examples of this, one being the very fact that gay men appear to more openly express affection without a fear of violence or harassment, a situation that is not replicated even in most parts of Sydney, arguably Australia’s most liberal city. It is a common sight to see same sex partners holding hands or embracing in the streets. A high school in northeastern Thailand even recently introduced toilets specifically for transgender and transvestite students after a survey found that many students didn’t feel comfortable with the choice between male or female toilets. In fact the rights of sexual minorities are even protected in Thailand’s constitution adopted last year.

All of this is not to say that MSM don’t face many significant challenges. In fact, when one digs beneath the surface, they become glaringly obvious. Much of this acceptance is restricted to the larger cities of Thailand, with less tolerant attitudes often leading gay men to migrate to larger urban centers. HIV rates among MSM are also alarmingly high, according to a study by the Thai Ministry of Public Health around 30.7% in Bangkok with high rates in Thailand’s second largest city, Chiang Mai (16.9%) and the popular tourist destination Phuket (20%). Coupled with this is a high prevalence among young MSM, where in Bangkok 22% of under 22 year olds are HIV positive. Male sex workers and transgender also often experience higher rates of HIV as they report more sexual coercion and receptive anal sex. There is also generally a relatively low level of condom use, poor rates of HIV testing and access to services. International organizations estimate that there are 10 million MSM in Asia and less than 8% have access to any HIV prevention services and interventions.

The contrast to the situation in Sydney and NSW more generally is quite stark. Where condom use, HIV and STI testing and sexual health awareness is high among gay men and HIV treatment almost universally accessible and heavily subsidized, where strong community based organizations such as ACON, Positive Life, BGF and many others exist, where a gay press can effectively highlight issues of importance and provide access to specific information and where there is a clearly defined gay community with a number of events and venues where its members can socialize and come together.

Of course there are many issues of ongoing concern, such as violence and homophobia, the diffusion (or not) of the GLBT community, HIV rates and same sex relationship recognition to name a few, but it is clear that the GLBT community in NSW has come a long way. These are sophisticated considerations, compared to many of our regional neighbours - a region where male to male sex is still illegal in 12 countries, where gay men and people living with HIV have a weaker voice, where prejudice on the basis of HIV is still widespread and where access to treatment and health services is lacking. And while significant inroads are being made on most of these fronts, progress is often frustratingly slow. It is estimated that by 2020, 50% of all new infections in the Asia and Pacific region will be in men who have sex with men (Report on the Commission on AIDS in Asia).

Recently in June I was fortunate to be invited to be part of the Australian delegation to the High Level Meeting on HIV at the United Nations General Assembly in New York. This invite as Australia’s youth representative was extended by the Australian Government largely because of my work with ACON and my AYAD placement with UNAIDS. The meeting was to review the global progress on HIV since 2001 when the Declaration of Commitment was made to reach ‘Universal Access’ by 2010. This involved a target of access to treatment and prevention services for all. At the meeting all 147 member states reported on their progress in achieving these goals.

Unfortunately despite clear progress in some areas such as 3 million people being on antiretroviral treatment since 2001, the world is falling far short of its commitment. Even for this apparent step forward, we were reminded that for every 1 person who begins treatment, 2.5 become newly infected with HIV. In 2008 HIV must still be considered a crisis, with 6000 deaths due to AIDS everyday and the vast majority of the 30million people living with HIV without access to antiretroviral treatment. As has been the case for many years, the bulk of HIV infections occur in Sub-Saharan Africa with HIV playing out significantly but slightly different in our region. Whereas the African epidemic is a generalised one, having spread across the general population, the Asian and Pacific epidemic is largely concentrated among specific populations. Essentially these groups are sex workers and their clients, men who have sex with men (MSM) and people who inject drugs. Within these populations, HIV prevalence can reach an alarming 50%, exacting a devastating impact on these communities. The epidemic is outpacing the response and this was widely acknowledged.

In many aspects, Australia is regarded as a world leader when it comes to its HIV response. It has established harm reduction measures such as needle exchange programs and has legalised brothel based sex work. Largely due to progressive policies, HIV infection among both people who inject drugs and sex workers has remained extremely low. It has been estimated that providing people who inject drugs with clean needles and injecting equipment in Australia has averted tens of thousands of HIV infections.

This was the focus of Australia’s position at the meeting. We met with Australia’s Ambassador Robert Hill and hosted a session on injecting drug use at the Australian mission which was well attended. An additional focus was to urgently resource the scale up of interventions aimed at men who have sex with men, sex workers and other at risk populations, which are based on evidence rather than ideology. The fact that Australia’s delegation had half of its members from community organisations shows a commitment in itself and many other country delegations applauded this. However even Australia has improvements to be made in its domestic response and this is particularly clear at this time of increasing rates of HIV nationally.

It is clear that a lack of political will is one of the key barriers to improved progress in the fight against HIV, and there was much discussion on this issue at the meeting. Even in places where we do have clear data on the need to act and which populations to target, many governments and policy makers fail to act adequately. Even when resources are made available they are not always used most effectively by targeting the most at risk populations with best practice interventions. Meanwhile, 6000 people die from AIDS every single day. We were told by leading researchers that ‘the quest for a vaccine is proving more difficult than we could ever have imagined’ and a cure is rarely even mentioned.

For the foreseeable future prevention is the best vaccine available to us and so we are left to promote and advocate for better resourced and scaled up prevention based interventions for all people as a basic human right.

In the meantime back in Thailand, demonstrating their inspiring perspective on life, the Thais continue to smile.

Rob Sutherland is an ACON staff member currently on placement in Bangkok with the United Nations Joint Programme on HIV (UNAIDS), Regional Support Team for Asia and the Pacific. This is with support from ACON and AusAID’s Australian Youth Ambassadors for Development (AYAD) Program. sutherlandr@unaids.org