One in 10 gay and bisexual men aged 18 to 21 became infected with HIV during their first year of enrollment in a cohort study in Bangkok. The rate of new infections slows down a bit after that, in part because those most likely to become infected already are. Fully 1 in 3 of them carry the virus by the time they reach 30.
“From 18 to 21 it has been a slaughterhouse,” says Frits van Griensven, shaking his head in dismay. “They are getting the best prevention information possible, counselling every four months, condoms and lubricants. They know the facts of incidence of new infections.” And yet the infections continue to occur, “It is something that we cannot control with behavioural interventions.”
Van Griensven runs what is believed to be the only HIV prevention clinic in all of Asia that was created to serve men who have sex with men. This is despite the fact that in Asia, that group is 18.7 times more likely to become infected with HIV than the general population.
“It’s my opinion that the epidemic in young men is driven by methamphetamines – crystal ice. I don’t know what to do about it,” he says.
He is not alone. The drug has been a major factor in the spread of HIV among gay men in the US and Europe, though its use seems to be receding because of educational campaigns and because other drugs have become more chic to use.
Rather than adopt a harm reduction approach, the Thai government has taken the approach favoured by most governments, namely a “war on drugs,” and it is having the same lack of success.
The day after our conversation the Bangkok Post reported a billion baht drug bust near the city of Chaing Rai when police stopped a pickup truck for a routine inspection and the driver fled. Left behind were 2.46 million pills of speed (methamphetamine), 95 kilograms of “ya ice,” a form of crystal methamphetamine, and 3.4 kg of heroin.
Ya ice is the drug of choice of most addicts, half of whom are between 15 and 24, said Naramon Chuangrungsi, director of the Narcotics Control Strategy Bureau. It is a purer form of meth, can be absorbed by the body more quickly, and many users mistakenly believe that it is safer than methamphetamine.
Thailand is not a particularly young country – the median age is about 34 compared with 25 for India and 40 for the UK – but the popular culture and street life is very youth oriented. Sexuality is not fettered by restrictions of the monotheist religions of the west, and translational sex – a kind of monetary equivalent of the sexual “friends with benefits” of the west, rather than prostitution where sex work is a principle source of income – is a broadly accepted part of life.
Young people are the early adaptors of western fashion, music, and electronics and they have shaped a Thai twist to what has become a global youth culture.
Sex has driven the broad popular adoption of many technologies in the post-World War II period, including use of the internet. The Thai government has tried to control this but has had the same limited success as most of the other governments that have tried the same task.
Much of the drug use and risky behaviour “is being arranged online and practised offline,” says van Griensven. That can range from one-on-one sexual encounters to large dance and/or sex parties.
“At any time there are probably 40-50 video channels online with thousands of young Thai gay men” talking about sex, ya ice, and other drugs like Viagra. The focus is on action “and there is no talk of HIV prevention or risks. Five years ago you wouldn’t see anything about crystal or having sex while high but now it is everywhere. They are soliciting sex with people high on drugs.”
The DJs on those channels keep the conversation going but they haven’t been recruited to help the task of HIV prevention. Nor have the owners of these sites, who profit from the advertising.
Van Griensven started the Bangkok gay men’s HIV clinic and cohort study in 2005 to prepare a clinical research infrastructure that would meet the criteria of studies accepted by the US FDA. Funding has come from the US CDC’s Division of HIV/AIDS Prevention.
“At first I didn’t know if people would show up,” he says, but they did. So much so that the initial staff of 5 has grown to 30. The clinic is housed at the Bangkok Christian Hospital. The old hospital ward has been tastefully and minimally decorated around the colour purple. There are comfortable overstuffed chairs and a nook with three Internet connections in the lobby area. A constant stream of young Thai men came through the doors while I was waiting.
The prevention study cohort has grown to 1800 and van Griensven is hoping to add treatment services so that he no longer has to refer those clients elsewhere. The unfortunate fact is that his clientele is likely to continue to grow.
Bob Roehr is a biomedical journalist based in Washington, DC, and a regular contributor to the BMJ.