Heterogeneous Risk Profiles and Discrimination against Men Who Have Sex with Men and Transgenders in Thailand: Implications for HIV Prevention

Background and Purpose: Thailand's internationally acclaimed prevention efforts have contained HIV-prevalence at 1.4%; yet a burgeoning epidemic persists among MSM (30% HIV-prevalence) and transgenders (14%). Although MSM constitute over 20% of new infections, MSM-specific spending represents 1% of Thailand's HIV/AIDS budget. Nevertheless, MSM and transgender women in Thailand are heterogeneous populations. We examined demographics and HIV risk profiles among diverse men and transgenders to support tailored prevention efforts.

Methods: Participants were recruited using purposive, venue-based sampling in Bangkok and Chiang Mai. Nine of 13 sites approached (gay entertainment venues [GEV]: gay bars, strip clubs, massage parlors, cinemas; and community-based organizations [CBO] providing services to gay men, male sex workers and transgenders) granted approval. We designed a structured questionnaire in English, which was translated into Thai, back-translated, revised and pilot tested. The questionnaire was programmed on laptop computers and administered by trained community interviewers to GEV staff and CBO clients and volunteers. Items included demographics, HIV risk factors and perceived discrimination; sexual behavior items were self-administered to mitigate social desirability.

Results: Among 260 participants, 57% identified as gay, 27% heterosexual/bisexual and 16% transgender (Thai-specific assessment), median age=27 years. One-third had < high-school education. In the past 3 months, one-fifth (19%) reported unprotected anal sex (UAS), 10% unprotected vaginal sex, with mean=11 male partners; 83% had sex with men, 28% sex with women, 21% sex with both men and women. One-fifth reported sexually transmitted infection (STI) diagnosis by a medical provider (past year). Half reported sex in exchange for money, nearly two-thirds (63%) visiting gay bathhouses, and one-fifth (19%) using illicit drugs (past 3 months). Nearly one-third (31%) reported receiving less attention than other patients and 43% hostility from healthcare providers. In bivariate logistic regression, GEV staff were more likely to be heterosexually-identified, less likely to have high school-degree education, and had higher income vs. CBO participants. GEV staff were more likely to: exchange sex for money (Odds ratio [OR]=2.73, 95% confidence interval [CI] 1.60-4.63), go to gay bathhouses (OR=3.40, 95% CI 1.99-5.80), have > 4 sex partners (OR=1.99, 95% CI 1.15-3.45), have sex with women (OR=3.80, 95% CI 1.91-7.52), unprotected vaginal sex (OR=3.49, 95% CI 1.16-10.42) and use illicit drugs (OR=2.56, 95% CI 1.26-5.40); and less likely to engage in UAS (OR=.42, 95% CI .22-.80) than CBO participants. In multivariate analysis, identifying as heterosexual or gay (vs. transgender), < high-school education, exchanging sex for money, and lower odds of UAS were significantly and independently associated with GEV staff.

Conclusions and Implications: MSM, male sex workers and transgenders in Thailand are diverse populations at high risk for HIV infection. Targeted, venue-based HIV prevention efforts should highlight the need for consistent condom use with male partners among gay men and transgenders at CBOs; and risks of drug use and unprotected vaginal (as well as anal) sex among GEV staff, many of whom do not identify as gay. The importance of STI diagnosis and treatment should be emphasized overall; however, structural interventions should target healthcare institutions to build respect and competence in working with gay men, male sex workers and transgenders.