The hidden epidemic

From: Bangkok Post

Writer: Tanyatorn Tongwaranan

Despite impressive progress in the global fight against HIV, infection rates are still rising among high-risk groups including adolescents.

Kavee was 15 years old and experiencing all the joys and challenges of teenage life, but his heart sank when he saw his HIV test result.

Now 19, he recalls the time when his sexual preferences were beginning to emerge. He knew his family regarded such choices as a stigma, and confronting them with the news that he was HIV-positive would only strain the already fragile relationship they had. His fear of being ostracised grew.

“My mother started to separate things in the house, fearing that she would get the virus,” he tells Asia Focus, flashing a gentle smile. “Now it’s getting better because it’s been over three years, but we still don’t talk that much.”

Kavee (not his real name) admits he had multiple sex partners at the time, mostly without protection, and he only went for a test after his symptoms became noticeable.

The infection, however, has not stopped him from being sexually active. He still meets people regularly through dating applications and social networks. “If they prefer not to use condoms, I have to go with it because I don’t want to tell them about my condition,” he said.

While remarkable progress has been made in the battle against HIV across the globe, Kavee’s story underlines an uncomfortable truth: Infection rates are rising among pockets of high-risk and vulnerable people, especially in societies where some of the contributing factors are criminalised and diagnosis is perceived as a disgrace.

The tendency toward risky behaviour and multiple sex partners has been further enabled by the emergence of online and mobile dating applications that have transformed the global sexual network. Men who have sex with men (MSM), sex workers, transgenders and drug users are among the high-risk groups that usually are not aware of their status and become active sources of a continuing spread.

“The problem with our society is that we still see HIV as a stigma rather than a disease that can be treated. People are ashamed to get diagnosed and sex is still a taboo topic,” said Kulkanya Chokephaibulkit, head of infectious diseases with the Department of Paediatrics in the Faculty of Medicine at Siriraj Hospital and Mahidol University.

“Condoms should be considered as protection rather than an object of stigmatisation,” she told Asia Focus recently on the sidelines of 18th Bangkok International Symposium on HIV medicine, organised by HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT).

For instance, she says, girls should be able to obtain condoms in private, such as from vending machines in restrooms.

In her view, society should be aware that anyone who has sexual intercourse is considered as having risk. A monogamous person is also at risk given that his or her partner might not behave the same way.

An infected person could display no symptoms for eight to 10 years and assuming that a person does not get tested, imagine how many more sexual partners he or she would encounter, she said.

“The only way to stop the epidemic is to normalise and destigmatise HIV tests with options for anonymity,” said Dr Kulkanya. “HIV testing is something everyone who is sexually active needs to get, and the infected (HIV-positive) person must get treatment as soon as possible to stop the chance of further transmission.”

Statistics from the Joint United Nations Programme on HIV/Aids (UNAIDS) show that MSM are 19 times more likely to be living with HIV than the general population. Stigma, prejudice and discrimination make this a huge problem in heavily populated Asia where beliefs and cultural norms surrounding sexuality and gender roles tend to be conservative.

Sex between men is against the law in 19 of the 48 countries in Asia Pacific, and those who engage in it are frequently subject to police abuse, extortion, harassment, assault, detention and human rights violations.

Midnight Poonkasetwattana, executive director of the Asia-Pacific Coalition on Male Sexual Health (Apcom), said punitive laws and criminalisation have discouraged high-risk people from taking HIV tests.

“A huge portion of gay men, other MSM and transgender people may not yet be aware of their HIV status given various barriers that inhibit them from seeking services,” he said, adding that obtaining an HIV test is the cornerstone of all modern prevention strategies.

The HIV infection rate among the MSM population has been reported between 15% and 31% in large urban areas including Bangkok, Hanoi, Jakarta and Manila.

The Thai National Aids Committee reported that 41% of total new Aids infections in 2012-13 were among MSM, male sex workers and transgenders. This group, however, usually receives little attention despite being the key priority for prevention work.

“The Thai government invested a large amount of resources to battle the HIV epidemic among female sex workers in Thailand in the 1990s, but we still do not see a similar effort among MSM and transgenders that would halt and then reverse the prevalence of the spread of HIV,” said Mr Midnight.

Prevention programmes and services for MSM have improved, but are till not sufficient. In addition, younger MSM in particular appear not to have a comprehensive understanding of their risks, fuelled by multiple sex partners and drugs.

Adeeba Kamarulzaman, dean of the Faculty of Medicine at the University of Malaya in Malaysia, added that a lot of unsafe sex today is driven by drug use. In the past, HIV tended to be spread through contaminated needles, now it’s “party pills” that encourage promiscuous sexual behaviour.

Societal restrictions and repressive legislation surrounding high-risk groups are major barriers to treatment. “Criminalising these individuals prevents them from coming forward, getting tested and receiving treatment,” said Dr Adeeba.

For example, putting drug users into prisons is expensive and ultimately results in more harm than good for most of them, their families and society. “Millions and millions of people do drugs. I don’t see a reason why they need to be put in prison if they are not doing harm to anyone else apart from themselves,” she said.

Prisons are never 100% free of drugs, she noted, and unclean needles contribute to yet more infections. “There are no treatments offered and after they leave, we know they will relapse within a week if they do not get treatment. They get other diseases from prison and pass them to their families.”

In Dr Adeeba’s view, addiction is partly a medical condition and people need to receive treatment rather than punishment.

“Society needs to rethink how it should approach this issue. We should encourage the diagnosis of HIV, opt-out testing, referral to HIV care facilities and peer-driven interventions,” she said.

“Opt-out testing” refers to HIV tests that are performed after notifying the patient that the test is a norm but that he or she may elect to decline or defer testing. Assent is then assumed unless the patient declines testing.


While HIV infection rates globally have gone down, there has been rising concern about pockets of high-risk adolescents (aged 10-19) in Asia Pacific, home to more than half of the world’s 1.2 billion adolescents.

Data reveal that the total number of adolescents living with HIV in the region surpassed 220,000 last year; however, more data are required in order to successfully battle the spread.

“HIV is a very hidden epidemic among this age group,” said Wing-Sie Cheng, regional adviser on HIV and Aids with the United Nations Children’s Fund (Unicef). “Those for whom we don’t know the status are a big blank space and they are the source of new transmissions that will continue to go on infecting others.”

In 2014, an estimated 50,000 adolescents aged 15-19 in the region became HIV-positive, accounting for almost 15% of all new cases in Asia Pacific, according to a Unicef report.

The HIV burden among adolescents is heaviest in 10 countries: India, Indonesia, Thailand, Myanmar, Vietnam, China, Cambodia, the Philippines, Papua New Guinea and Pakistan. Together they account for 98% of adolescents living with HIV in the region, it noted.

Thailand, Indonesia, Pakistan and the Philippines are among the countries where the concern is greatest. In the Philippines, new HIV infections among those aged 15-19 rose from an estimated 800 in 2010 to 1,210 in 2014 and 1,403 last year.

Ms Cheng explained that many adolescents experiment with sex and drugs, which puts them at potentially grave risk. “They need confidence and want to look cool to get approval from society. They feel invincible and are willing to take any risks, thinking that illness is far away,” she said.

“Stigma and discrimination surrounding sex and HIV infection discourages a lot of them from seeking services,” she said, adding that many who know their status may choose not to take medication regularly as they don’t want to be seen as being sick.

The World Health Organization (WHO) has recommended that health authorities revisit policies on age consent for independent HIV testing. Currently, only 11 countries in Asia Pacific have policies that allow those under 18 to make independent decisions to be tested without parental permission.

“Thailand recently removed the age restriction in 2014 but it has not been well implemented and publicised,” added Ms Cheng.

Beena Kuttiparambil, chief of HIV/Aids (adolescent development) with Unicef, observed that there is also a lack of youth-friendly clinics that recognise the sensitive issues facing high-risk adolescents.

“Confidentiality has always been the issue that discourages them from getting tested. Adolescent-sensitive services will promote early testing and treatment,” she said.

In Thailand, she said, there are about 800 youth-friendly clinics, but most specialise in teenage pregnancy or reproductive health issues, and lack comprehensive service with social support to encourage young people to get tested and receive treatment.

“HIV is a very complex problem. There is a strong relationship between condom use and being in love and trusting their partners. Disclosing their status to partners and peers is usually very rare,” she said. “At this age, they don’t want to lose love and friendship. They find that losing friends is a major issue among them.”

Society still lacks the social support mechanisms and counseling that would help infected adolescents to gain more confidence through proper communication. “We need to promote greater understanding of the diseases and encourage them to take responsibility and not spread the virus to others,” added Ms Kuttiparambil.