Undocumented epidemics of HIV continue to persist in the twenty-first century

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Abstract
It may seem inconceivable that the basic epidemiology of HIV infection remains undocumented in many parts of the world at the close of 2004. Indeed, while descriptions of HIV prevalence and associated risk factors may not be readily available for low-risk, possibly obscure settings, noticeable gaps today of basic information in societies with well-documented high prevalence epidemics strains credulity. Yet, that is exactly the case of HIV epidemiology among men who have sex with men (MSM) in Thailand [1]. This is particularly ironic since the first case of AIDS reported in Thailand in 1984 occurred in a Thai male with a male partner [2]. The voluminous Thai record of its explosive and high prevalence HIV epidemic has been extremely well documented and published widely in international scientific journals [3–6]. However, the focus was primarily centered on demonstrating the escalating rates of HIV/AIDS among heterosexuals and, more recently, injection drug user populations. How is it that the MSM epidemic was ignored in Thailand? In two words – stigma and discrimination! van Griensven and colleagues in Thailand [1], who attended locations where significant numbers of Thai MSM were found, report on the first, large-scale epidemiologic study of HIV prevalence and associated risk behaviours in MSM in the capital city of Bangkok in 2003. Although the reported HIV prevalence of 17.3% may be considered to be relatively low or high in relation to other settings, what is of greatest importance is that a figure now exists that allows for domestic and international comparison. Because homosexuality is widely stigmatized in Thailand, as in most of the world, little local political or social movement exists to advocate for the health and human rights of MSM. Without empirical data to suggest the presence of a widespread epidemic, MSM were not included in the Thai national HIV sentinel surveillance system that has been underway since 1989 [7], despite the fact that MSM comprised the majority of HIV/AIDS cases in many other parts of the world. Without systematic data collection, ignorance continued. Data from the Bangkok report [1] demonstrate that without active surveillance, an ‘unknown’ epidemic may flourish. Indeed, of the 491 men who reported having received an HIV test before participating in this survey, none reported themselves to be HIV infected; the data presented strongly suggests otherwise. The behavioural risk factors identified by van Griesven et al. [1] are all well known: low education, high-risk anonymous partners of unknown HIV status, larger number of male sex partners, and duration (years) of anal intercourse (both receptive and insertive). The epidemiology is not new, but its lack of existence in the literature and to the Thai public health community is significant. The finding that 22.3% of MSM reported a female sex partner in the past 6 months should be a major alarm. Thailand has rightfully been proud of its internationally renowned prevention campaign (‘100 Percent Condom Use in Commercial Sex’) [8,9], which focused on condom promotion in brothels to reduce HIV acquisition among men in the general population. This intervention has been documented to have reduced both brothel visits and to have led to a dramatic decline in prevalent infection among young men [9] and pregnant women [7]; it is further substantiated by a seven-fold decline in the estimated number of new infections nationally over the past decade [10]. Nevertheless, the gains from this exemplary public health program may be undermined by a lack of attention to the HIV problem faced by MSM, many of whom have female partners with no awareness of their partners’ sexual practices.