Krit spends weekdays in his office on Sathon Road and nights out at a gay club on Silom Soi 2. The 28-year-old is a gym fanatic, and can also be found at one of Bangkok’s most famous gay saunas twice a week.
Activist: Apcom director Midnight Poonkasetwattana wants all gay men to be able to access PrEP.
Krit loves sex as much as he loves working out, and the sauna on Sathon Soi 1 is a mecca for single and attractive men just like him.
“I meet guys for sex every time I go to the sauna,” Krit said. “Occasionally, if the guy is cute enough, I’ll do it without a condom. I’m sure it’s not that easy to catch HIV and there are not that many people with HIV here anyway.”
Krit does practise safe sex most of the time and remains HIV negative, but he’s at increasing risk of contracting the deadly virus.
According to research by UNAIDS, men who have sex with men in Asia are facing a creeping HIV epidemic.
In 2012, only 1% of the general population was living with HIV. But nationwide, 7% of men who have sex with men were infected, rising to 24% in Bangkok. Of those infected in Bangkok, 8% were 15- to 19-year-old men.
RISING INFECTION RATE
According to Tony Lisle, a regional adviser with UNAIDS, HIV infections are falling overall in Asia, yet rising among men who have sex with men.
“If we look at countries across the region, from China to Vietnam, HIV prevalence is declining in the general population, but among men who have sex with men there remains a very serious and concentrated epidemic. When we look at data for each city, we have an extraordinary rate of infection,” he said.
“The data gives us good reason to believe we are in a crisis. It also tells us that prevention measures alone are not adequate to avert new HIV infections, particularly among young men.”
HIV prevention programmes are based on one key principle: encouraging consistent condom use.
Unless 80% of men are committed to using condoms in all sexual encounters, it’s impossible to stem new HIV infections, Mr Lisle said. UNAIDS research suggests the proportion who consistently do in Bangkok is just 68%. In Ho Chi Min City that figure stands at 35%, while only 25% consistently use condoms in Jakarta and 15% in Chennai.
“Bangkok is doing well, but not well enough,” Mr Lisle said. “If you’re not consistently using condoms, the chances are that you will get infected with HIV. It’s very difficult to prevent when condom use is not consistent.”
One of the issues is that condoms are not always available at the right time, for example in gay saunas, he said, adding that Asian countries are failing to deliver effective combination prevention programmes, which fuse a range of initiatives to tackle HIV.
However, Thailand is trying to buck that trend, with a drug proven to reduce HIV transmission in gay men and other high-risk groups.
TRANSFORMING PREVENTION
Pre-exposure prophylaxis, or PrEP, is being hailed as one of the most innovative HIV prevention tools now on the market.
PrEP is starting to transform HIV prevention in the United States, and although most of Asia has yet to pick up on the approach, Thailand is already offering the treatment to men whose lifestyles put them at risk.
PrEP refers to the use of antiretroviral medication, taken as a daily pill, to prevent users acquiring HIV. The pill is sold under the brand name Truvada and is a combination of two drugs — tenofovir and emtricitabine — that can prevent HIV infection from taking hold when someone is exposed to the virus.
According to the Asia-Pacific Coalition on Male Sexual Health (Apcom), PrEP has shown up to 90% effectiveness in preventing transmission of HIV in people at substantial risk, including gay men and other men who have sex with men, HIV-negative people whose partners are living with HIV, transgender women and people who inject drugs.
Apcom executive director Midnight Poonkasetwattana said, “We know that insisting on >>
>> using condoms alone does not work for HIV prevention. PrEP can be an option for some men who have sex with men, but it needs to be integrated into the current prevention package.”
Mr Lisle said increasing access to PrEP is essential to stopping the rise of HIV in Thailand.
“With an epidemic like this, we need to be able to include PrEP if we are going to protect the youngest men who have sex with men, particularly 15- to 19-year-olds who are exposed to a pool of HIV infection with very few preventative options.
“This is one option that will make a big difference,” he said. “A tablet a day can block transmission of HIV effectively.”
New guidelines on PrEP from the World Health Organisation say any group where the HIV incidence rate is more than 3% should be eligible for the treatment, meaning all men who have sex with men in Thailand should have access to the drugs.
RIGHT ON TARGET
PrEP is still not widely recognised as an HIV prevention option in Thailand, but is already available to anyone in the high-risk group for infection.
Nittaya Phanuphak, who runs the HIV prevention centre at the Thai Red Cross, said the clinic started offering PrEP to HIV-negative people in recent months, though the antiretroviral medications have long been used with HIV-positive patients.
The centre is targeting men who have sex with men and transgender people as part of its efforts to widen the use of PrEP, since half of all new HIV infections affect these groups.
People can start taking it when they know they are going to be engaging in risky sex and stop whenever they are no longer facing potential exposure to HIV.
“If we can prevent people in our target groups from contracting HIV, it will make more of a difference than if we focused on the general population,” Dr Nittaya said.
Once men start taking PrEP, it takes seven days for the protection to kick in. The presence of the drug in their bloodstream can then stop HIV from taking hold, by blocking the replication of the virus. For women, such as those working in the sex industry, it takes three weeks to build up the same protection as men, since anal tissue retains the drugs more efficiently than vaginal tissue.
SAFETY FIRST
The United States was the first country to sanction the use of tenofovir and emtricitabine to prevent HIV infection in 2012. But in other countries, the official approval process has dragged on.
The main reason PrEP hasn’t been approved widely as a preventative drug is that it is only registered for use in those who already have HIV, or as a post-exposure prophylaxis, to be administered immediately after a person is exposed to the virus.
At the end of last year, a Thai drug company tried to register the combination of tenofovir and emtricitabine for HIV prevention with the Thai FDA. It is yet to be approved but should be given the green light by the end of this year.
Michael Cassell, an HIV adviser at USAID, said the US has been conducting research on prescribing antiretroviral medications to prevent HIV infection for almost a decade.
“Researchers knew these medications were safe and effective in treating HIV-infected individuals, and thought they might be effective in preventing at-risk individuals from becoming infected,” Mr Cassell said.
“We are starting to see promising signs that access to PrEP is reducing infection rates in communities in the US. A clinic in San Francisco that began to offer PrEP to men who have sex with men in 2012 recently published a paper reporting no new HIV infections over more than two and a half years among patients prescribed PrEP.”
As news spreads that PrEP works, the hope is that more people at risk will undergo HIV testing, Mr Cassell said. People who are not infected will then be able to access PrEP as part of an effective prevention strategy, while those who have the virus can access life-saving treatment that also prevents any further spread.
PREP IN THE CITY
Although the drug is not yet officially approved for preventative use in Thailand, private hospitals have been offering it to a handful of patients who request it for the past couple of years, in addition to the initiative at the Thai Red Cross.
Dr Nittaya believes PrEP should be available under the government’s universal healthcare scheme, since it could reduce the cost of HIV treatment in the long term.
“Our PrEP 30 service, which includes medication, consultation, and testing at an affordable rate, costs 30 baht a day or 900 baht a month,” she said.
That package comes with a complete blood check, HIV and kidney function tests, and a month’s supply of tenofovir and emtricitabine. Truvada from America costs about 50 baht per tablet, but a generic version made by the Government Pharmaceutical Organisation costs 600 baht for 30 tablets, or 20 baht each.
Private hospitals in Thailand charge up to 10,000 baht per month for PrEP, which has fuelled the perception it is expensive, Dr Nittaya said, despite the fact it’s accessible at an affordable price.
About 100 people now use the Red Cross PrEP service, most of whom are men who have sex with men.
Of the patients, 10% are foreigners from Singapore, Malaysia, Austria and the Philippines. Dr Nittaya said they come to use the service since the drugs are unavailable for preventative use or are prohibitively expensive in their countries. The medication can cost more than the round trip to Bangkok, she said.
First-time PrEP users are given a one-month supply and required to come back within 30 days. Once they return and test negative, doctors will give them a 90-day supply and ask them to come back for health checks every three months.
While studies around the world have shown the side effects of PrEP are minimal, the drug can damage bone mineral density and kidney function. Users can also build up a resistance to the medication over time. That’s why regular HIV testing and health checks are vital for anyone on PrEP.
“Testing every three months is important to ensure that people are remaining negative,” Mr Lisle said.
Dr Nittaya stressed that PrEP is a temporary prevention measure, so people don’t need to be on it for the rest of their lives, like those infected with HIV.
“People can start and stop PrEP anytime, depending on their risk,” Dr Nittaya said.
PEACE OF MIND
Em Tibamrung has always been mindful about his sexual health. The 25-year-old gay man uses protection and has not had many sexual partners, but knows something could go wrong at any time.
Mr Em referred himself to the Red Cross “test and treat” HIV prevention programme after a condom broke while he was having sex. He attended the clinic for one year, before seeing an advertisement for the PrEP service.
After doing his own research into the drug, Mr Em was convinced the PrEP service was right for him, and has been using the drug for the past two months.
“I feel much safer and more confident that I won’t get HIV now,” Mr Em said. “Being on PrEP offers double protection. Condoms and lubrication are still the most important things. PrEP also can’t prevent other sexual transmitted infections.”
Jonas Bagas, a 37-year-old gay man from the Philippines, travelled to Thailand as soon as he found out that PrEP was available.
Mr Bagas first learned about PrEP in 2012, at an HIV/Aids conference where he was living in the US.
He was interested, but couldn’t afford to pay for it. He later moved back to Philippines and tried to find PrEP there, but it was unavailable.
“We don’t have gay or sexual health support groups in the Philippines,” Mr Bagas explained.
“The government promotes safe sex but they seem to focus more on heterosexuals.
“Is it convenient to come to Bangkok every three months? No. But it is necessary for my health.
“I would like my government to look seriously at the issue. Free condoms are not even readily available in the Philippines. Everyone should have access to safe sex and HIV testing."
SEXUAL NETWORKING
Gay saunas and night clubs are the traditional venues for many sexual liaisons, but these places are less of a concern to HIV prevention workers than the new route to finding sex: mobile phone applications.
Many young gay men now hook up through phone apps, but sexual health organisations are still using old-fashioned approaches to fight HIV. They send peer outreach workers to the physical places where young gay men are known to meet, but this overlooks a large portion who no longer frequent such places.
Mr Lisle said sexual networking is now largely conducted over mobile devices.
“Most HIV prevention programmes are not using social media or mobile applications to reach young men,” he said.
“I think we need to ensure that applications provide responsible prevention messages.
“We need to work with communication companies and app providers to ensure we deliver a sound evidence-based prevention message. We can also use that platform to refer to sexual health services.”
The most popular gay social networking application in China, called Blued, has started providing HIV prevention messages to all users, including information on how to practise safe sex.
COMMUNITY APPROACH
Most people in Thailand go to a hospital when they need a health check. But the Red Cross is trialling a community-based approach to improving sexual health which it hopes will make it easier for people to protect themselves.
The scheme is training community members to act as health ambassadors, who can refer others to a clinic for testing and PrEP treatment if they are at high risk of contracting HIV.
The Red Cross is also providing free PrEP at drop-in clinics for men who have sex with men and sex workers at community centres in Bangkok and Pattaya, while the Ministry of Public Health has launched PrEP schemes in Thammasat University Hospital and Lerdsin Hospital.
“PrEP is new to us, so no one knows which is the best way to provide the service yet,” Dr Nittaya said. “Some people might find it too much hassle to go to a doctor and prefer to visit a drop-in centre in their community.
“We have to do something to stop the problem getting any worse while we are waiting for the government to include PrEP in the universal healthcare scheme. For some, especially young people, they may not be able to afford 30 baht a day to pay for their protection.”
Mr Lisle warned that access to PrEP is only one element of improving the lives of those most at risk of contracting HIV.
“Men who have sex with men can be alienated from their families. They can be suffering depression, and often take recreational drugs to escape from the discrimination and alienation,” Mr Lisle said.
“If we can get more young men to access services such as PrEP then we can better address all of those things.”