The epidemiology of HIV infection and AIDS in Thailand

Concurrent partnerships could cause AIDS epidemics

There is a need for new hypotheses to supplement existing explanations for the observed differences in HIV prevalence between countries and within countries. Due to high levels of viraemia during the initial phase of HIV infection, networks of concurrent regular partnerships in a community could be the determining factor in the development of an AIDS epidemic. If this hypothesis is true, projections of the future development of the epidemic could be altered. Simple health education messages based on the hypothesis might make a major contribution to the prevention and control of AIDS epidemics.

Sexual activity among never-married men in northern Thailand

We use data collected in 1991 to investigate sexual activity among never-married men in Thailand, with a focus on age at first intercourse, characteristics of sexual partners, and conditions under which men visit prostitutes. We sampled men from a broad spectrum of northern Thai society, including university undergraduates, soldiers, and semiskilled/unskilled workers. We found that except for the students, the majority of each subsample is sexually experienced; prostitutes are the most common type of sexual partner for all groups. Alcohol consumption is associated with several measures of sexual activity. Condom use with prostitutes varies among the subsamples. Among men who have both prostitute and nonprostitute partners, the majority of those who do not use condoms with prostitutes also do not use condoms with their nonprostitute partners. We consider the implications of these results for the AIDS epidemic in Thailand.

HIV infection among injecting drug users in north-east Malaysia, 1992

Human immunodeficiency virus (HIV) has spread widely among injecting drug users (IDUs) in countries to the north and west of the 'Golden Triangle' region of South-East Asia; it is likely to have spread southwards to Malaysia as well. In order to assess HIV seroprevalence among IDUs in north-east Malaysia and describe risk factors for HIV infection in this population, we performed a cross-sectional seroepidemiological study among 210 IDUs recruited at the detoxification ward of the General Hospital in the capital city of the north-eastern Malaysian state, Kelantan. Subjects were sequential entrants to the detoxification ward, interviewed about HIV risk behaviour, and tested for antibody to HIV and to syphilis. Nearly a third (62/210, 30%) of these IDUs were HIV seropositive. Three-quarters (159/210) had travelled to Thailand in the preceding 5 years, of whom 32% (51/159) were HIV seropositive; this was associated with injecting in Thailand, but not with sexual contact there. Of those who had not left Malaysia in the preceding 5 years, 26% (11/43) were HIV seropositive, a rate not significantly different from those who had travelled. Travel within Malaysia was common (144/210, 69%) among IDUs interviewed, as was unsafe injecting and unsafe sexual behaviour (20% had shared injecting equipment and 21% had had unprotected intercourse) in other states. In every locale, rates of unsafe injecting behaviour were high (55% sharing in last month), even among those who knew they were HIV infected, and rates of condom usage were low (93% of 160 sexually active IDUs had never used a condom). Syphilis was not associated with HIV infection, but with contact with Thai prostitutes.(ABSTRACT TRUNCATED AT 250 WORDS)

Levels of HIV risk behaviour and AIDS knowledge in Thai men having sex with men

Although many of the earliest cases of AIDS and HIV infection in Thailand were men who had sex with other men (MHSWM), transmission by heterosexual intercourse and needle sharing rapidly became dominant. This resulted in comparatively little attention being given to studies of risk behaviour and seroprevalence in groups of MHSWM with a consequent lack of information about these populations relevant to designing effective interventions. In the Partner Relations Survey, 3.3% of male Thais described their orientation as bisexual or homosexual, most probably an underestimate of the occurrence of same sex behaviour in Thai males. This paper briefly reviews the situation and presents results from a survey in the northeast of Thailand among men who have sex with men. Substantial levels of risk behaviour were found in MHSWM in the Northeast, with high rates of partner exchange and low levels of consistent condom use in insertive and receptive anal intercourse. Significant defects in AIDS knowledge existed implying a strong need for enhanced and expanded interventions in this community. Factors relevant to the design of interventions are highlighted and recommendations for further studies of MHSWM in Thailand are presented.

HIV infection among injecting drug users in Asia: an evolving public health crisis

Injecting drug use is being reported from an increasing number of Asian and other Third World countries. HIV continues to spread globally among and from populations of injecting drug users (IDUs), although the rate of spread appears to have slowed down recently in some industrialized countries. Asia produces two-thirds of the world's supply of opium. In recent years the rapid development of new illicit drug trade routes in efforts to evade detection by law enforcement authorities has exposed new populations in Asia to drug injecting and, thus, the risk of HIV infection. Epidemic spread of HIV has recently commenced in some Asian countries among injecting drug users, and others are at substantial risk of an HIV epidemic among their IDU populations. The speed of spread and the consequences of HIV infection among IDUs in Asian and other Third World countries are even more profound than in western countries. Asian countries attempting to control this component of the epidemic often have greater difficulty than industrialized countries because of their proximity to drug producing areas, scarcity of resources and a greater likelihood of pragmatic policies conflicting with traditional values. Vigorous efforts are urgently required at both a national and international level to raise awareness of the consequences of an uncontrolled epidemic of HIV among IDUs in Asian and other countries, and to support the implementation of policies which are likely to reduce the spread of HIV.

Comparison of saliva and serum for HIV surveillance in developing countries

Saliva has been proposed as a non-invasive alternative to serum for HIV antibody testing. In a field study in Myanmar (formerly Burma), we evaluated such an alternative to identify the frequency of HIV infection in a surveillance programme of high-risk and low-risk sentinel groups. Duplicate vials of saliva and serum were collected from 479 high-risk and 1039 low-risk subjects. One vial of each pair was analysed blind in two laboratories, one in the USA and the other in Myanmar. The US laboratory followed WHO confirmatory strategy III with three different enzyme-linked immunosorbent assays (ELISAs), while the laboratory in Myanmar followed strategy I with one ELISA. Serum testing in the US was the gold standard. The Cambridge ELISA with saliva was a more effective surveillance tool (sensitivity 90.5%, specificity 99.5-100%) for describing the frequency of subjects with HIV antibodies than the serum ELISA supplied to Myanmar by WHO (95.9% and 98.3%, respectively). Saliva is recommended as a safe and effective alternative to serum for HIV antibody testing with ELISA in surveillance programmes in developing countries.

Risk factors of HIV-1 infection among female prostitutes in Khon Kaen, Northeast Thailand

HIV infection has increased to epidemic proportions in Thailand since 1987. There have been separate epidemics among population groups at high risk of infection and significant increases in different localities. The northeast region of Thailand has been affected by the epidemic since early 1989. The purpose of this study was to identify factors associated with HIV transmission among prostitutes during an early phase of the epidemic in the regional center of Khon Kaen. Three hundred and fifty-six prostitutes known to work in the urban area of Khon Kaen (Ampur Muang) in November 1990 were included in the study. Prostitutes were divided into two groups according to the type of place where they worked: direct prostitutes (in brothels, n = 217) and indirect prostitutes (in massage parlors, n = 139). The prevalence of HIV infection was found to be 12% among direct prostitutes and 2% among indirect prostitutes. Four variables were significantly associated with HIV infection after adjusting for confounders by logistic regression analysis: previous work in an area of high HIV prevalence, working in Khon Kaen less than one month, a low price charged for sex and using injectable contraceptives. Follow-up investigations are currently being carried out to explore in detail the association between the use of injectable contraceptives and HIV infection.

AIDS acquired by drug consumption and other noncontagious risk factors

The hypothesis that human immunodeficiency virus (HIV) is a new, sexually transmitted virus that causes AIDS has been entirely unproductive in terms of public health benefits. Moreover, it fails to predict the epidemiology of AIDS, the annual AIDS risk and the very heterogeneous AIDS diseases of infected persons. The correct hypothesis must explain why: (1) AIDS includes 25 previously known diseases and two clinically and epidemiologically very different epidemics, one in America and Europe, the other in Africa; (2) almost all American (90%) and European (86%) AIDS patients are males over the age of 20, while African AIDS affects both sexes equally; (3) the annual AIDS risks of infected babies, intravenous drug users, homosexuals who use aphrodisiacs, hemophiliacs and Africans vary over 100-fold; (4) many AIDS patients have diseases that do not depend on immunodeficiency, such as Kaposi's sarcoma, lymphoma, dementia and wasting; (5) the AIDS diseases of Americans (97%) and Europeans (87%) are predetermined by prior health risks, including long-term consumption of illicit recreational drugs, the antiviral drug AZT and congenital deficiencies like hemophilia, and those of Africans are Africa-specific. Both negative and positive evidence shows that AIDS is not infectious: (1) the virus hypothesis fails all conventional criteria of causation; (2) over 100-fold different AIDS risks in different risk groups show that HIV is not sufficient for AIDS; (3) AIDS is only 'acquired,' if at all, years after HIV is neutralized by antibodies; (4) AIDS is new but HIV is a long-established, perinatally transmitted retrovirus; (5) alternative explanations disprove all assumptions and anecdotal cases cited in support of the virus hypothesis; (6) all AIDS-defining diseases occur in matched risk groups, at the same rate, in the absence of HIV; (7) there is no common, active microbe in all AIDS patients; (8) AIDS manifests in unpredictable and unrelated diseases; and (9) it does not spread randomly between the sexes in America and Europe. Based on numerous data documenting that drugs are necessary for HIV-positives and sufficient for HIV-negatives to develop AIDS diseases, it is proposed that all American/European AIDS diseases, that exceed their normal background, result from recreational and anti-HIV drugs. African AIDS is proposed to result from protein malnutrition, poor sanitation and subsequent parasitic infections. This hypothesis resolves all paradoxes of the virus-AIDS hypothesis. It is epidemiologically and experimentally testable and provides a rational basis for AIDS control.