|Refocusing HIV/AIDS Interventions in Thailand (UNAIDS - Best Practice Digest, 2000, 3 p.)|
Extracted from 'Refocusing HIV/AIDS interventions in Thailand: the case for male sex workers and other homosexually active men'. Malcolm McCamish, Graeme Storer and Greg Carl. Published in Culture, health and sexuality. An international journal for research, intervention and care. Vol 2 No 2 April-June 2000.
Although seroprevalence studies have shown that Thai male sex workers are at heightened risk of HIV infection, no sustained preventive strategies have so far targeted homosexually active men in Thailand. There is a real difficulty in reaching these men whose risks and infection levels remain hidden, or worse, are closeted in the heterosexual statistics.
A number of research studies with Thai male sex workers and their clients, and with management and staff working in the male sex industry, map the sexual networks for homosexually active men. In addition to clients, male sex workers will have sexual encounters with regular and casual, free and commercial, male and female, Thai and foreign partners. There is also a ready mobility among male sex workers, and their clients, between different establishments. Some men temporarily move in and out of sex work, not uncommonly returning home for the planting and harvest season.
The mapping of the sexual networks for homosexually active men shows the interconnectedness of homosexual and heterosexual commercial and non-commercial networks. There is a complexity which indicates that bar-based interventions have the potential to access directly or diffuse to both organised and freelance male sex workers, as well as their clients and male and female casual sex partners. Focusing HIV-preventive interventions in bars makes good sense for others reasons as well.
First, bars are identified as sites of high HIV prevalence. They provide access to large, identifiable groups of homosexually active men with probably the greatest concentration of high risk behaviours. Focusing on bars also provides an opportunity to maximise resources.
Secondly, interventions in bars address not only the risk but also the vulnerability of workers. Workers in bars are subject to the policies of bars and to the dictates of management. The authors' research suggests that male sex workers in bars have fewer choices than do their freelance counterparts in terms of what they do and with whom they do it. They are less likely to be able to reject a client, even when they are pressured to engage in unprotected anal sex.
Third, the ease with which workers migrate among bars suggests that there are overriding similarities in bar culture. With managerial support, a neutral or hostile environment could be converted into a supportive one, so that new recruits would encounter worker-driven and management - endorsed strategies to reduce vulnerability and risk immediately, rather than be dependent on itinerant, non-continuous, externally driven interventions.
In order to reach these populations of homosexually active men, interventions need to provide detailed information relating to risk behaviours, and they should address both male-male and male-female sexual behaviours. They should also address issues relating to self-esteem, communication and sexual negotiation, and create a supportive environment through messages and services to all facets of the sexual network. They should address the development of decision making and problem solving skills.
Bar-based interventions will not succeed if they remain non-continuous and restricted to high-profile tourist areas; if they do not acknowledge the importance of recreational sex; and if they do not build on the resources and experiences within the group of male sex workers. Interventions need to have stable long-term funding to enable them to develop strategically to meet the changing needs of the workers. They must seek to build peer support mechanisms among the bar workers, while promoting managerial support for safe sex practices.