| HIV and AIDS
http://www.thailandguru.com/health-hiv.html
AIDS (Acquired Immune Deficiency Syndrome) is caused by the
HIV-1 virus (Human Immunodeficiency Virus).
There are many sub-types of HIV virus, HIV subtype A, subtype
B, and on thru subtype F, plus a subtype O, much like hepatitus
has hep-A, hep-B, etc., and this may make HIV in Thailand
significantly different from HIV in the west.
In Thailand, the primary means of transmission of HIV is
by heterosexual sex, overwhelmingly HIV subtype E. A
second group is intravenous drug users (IDU's), most of whom are
infected with HIV subtype B, the subtype most common in western
homosexuals and IDU's, and which is apparently difficult to
transmit heterosexually.
In the west, the prevalent HIV subtype B has as its primary
means of transmission: anal sex (due to the abrasions of an
unlubricated and tight tract which give the virus access to the
blood), intravenous drug use (needle sharing between drug
users), blood transfusions, hemophilia (people who need blood
transfusions and who got donated blood with HIV before the
hospitals could detect HIV), and with heterosexual transmission
accounting for only about 10% of all cases. Subtype E is found
in only a tiny minority of cases in the west, and is often
traceable to travellers from Thailand.
For more than 20 years, Thailand has had HIV subtypes B and
E. However, it is subtype E which has taken off in the
heterosexual population. This has suggested that there are
significantly different degrees of contagiousness between the
two subtypes as regards heterosexual transmission.
It might be a common deadly mistake by western men to
have unprotected sex with prostitutes in Thailand based on a
lack of education and understanding of the difference between
HIV subtype B in the west and HIV subtype E in southeast Asia.
Southeast Asia predominantly has subtype E, whereas other
regions of the world have different predominant subtypes.
Thailand has a mix of two subtypes, subtype B and subtype E.
Subtype B is mainly found in northern Thailand among intravenous
drug users. Subtype E is what is predominantly found among
prostitutes and heterosexuals. For example, a Chulalongkorn
University clinic in Bangkok which had large numbers of HIV
enrolled patients for studies found that 92% of male
heterosexuals were infected with HIV subtype E, whereas 79% of
intravenous drug users (IDU's) were infected with subtype B. (In
both cases, practically all the rest were infected with the
other subtype of HIV.)
HIV infection is highest in northern Thailand near the Golden
Triangle, due to the opium and intravenous drug use in that
area. Northern Thailand is also where the highest concentration
of HIV subtype B can be found.
Prostitution is rampant in many countries in Asia and the
world, yet the percentage of the population in Thailand that are
HIV carriers (approximately 2%) appears much higher than in
other places with prostitution, after adjusting for per capita
infection rates.
A research report at the University of New South Wales in
Sydney, Australia, has an analysis that concludes: "it has
been estimated that the heterosexual HIV transmission rate in
Thailand (where subtype E predominates) is fifty-fold higher
than that observed in USA and Europe (where subtype B
predominates)."
One of the best medical web research sites (geared for
physicians) has an in-depth research report conducted in
Thailand, which reports: "One of the earliest studies suggesting
differences in efficiency of transmission among HIV-1 subtypes
was a cross-sectional seroprevalence study of HIV-1, presumed
subtype E, in Thai military conscripts infected by commercial
sex workers (CSWs).[52] Using mathematical modeling, researchers
estimated that the probability of female-to-male HIV-1
transmission per sexual contact was approximately 1 in 30 to 50
contacts; previous estimates for HIV-1 subtype B were estimated
at 1 in 500 to 1000 contacts. A second Thai study compared
serodiscordance in couples in which the index case was either
infected with subtype E from CSW contact or subtype B from
intravenous drug use (IVDU). After controlling for factors known
to affect transmissibility (eg, STDs, advanced disease), subtype
E was associated with a much higher rate of seroconcordance,
suggesting a difference in the intrinsic properties of the
subtypes, with enhanced heterosexual transmission in HIV-1
subtype E.[53] One recently published report suggested that this
apparent enhanced heterosexual transmission of subtype E may be
due to increased replication in Langerhans' cells, which are
located in the vaginal mucosa and may be the cell types that
first become infected during heterosexual transmission of
HIV-1.[54] The data from these studies, and the predominance of
HIV-1 subtype B in the Americas and Europe where
homosexuality/bisexuality is the major risk behavior, have led
some investigators to conclude that subtype B is less
efficiently transmitted heterosexually than the other subtypes,
particularly subtype E." Reference: http://www.medscape.com/SCP/IIM/1997/v14.n09/m3170.brodine/m3170.brodine.html
Reports that analyzed only HIV in general, without specifying
the subtype, are apparently not completely applicable to
situations in Thailand.
Overall, in Bangkok, at a hospital which has the subtype
statistics for more than 2000 HIV infected patients,
approximately 82% have subtype E (95% of subtype E infections
contracted heterosexually), and approximately 13% have subtype B
(70% of subtype B infections contracted by intravenous drug
use). (Reference: RetroConference 99.) Stated
differently, non-IDU's (i.e., heterosexuals, homosexuals and
hemophiliacs who do not inject drugs) accounted for approx. 30%
(85/284) of subtype B infections, but approx. 95% (1723/1820) of
subtype E infections.
It has been determined in general that HIV is more easily
transmitted when another sexually transmitted disease is
present. How much this applies to subtype B vs. subtype E is
not clear to me at this point, since subtype B appears to need
access to the blood more than subtype E, and thus may need to
take advantage of herpes lesions, inflammation of the urethra
due to other STD's such as chlamydia, NSU, or gonorrhea,
scratches due to teeth during oral sex, etc.
In any case, to compare the chances of getting HIV by
unprotected sex in the west vs. the chances in Thailand are not
comparable due to factors including the following:
-
HIV
subtype E vs. HIV subtype B
-
The
higher percentage of HIV carriers in Thailand
-
The
preponderance of other STD's such as NSU which increase
transmissibility
The rate of spread of HIV in Thailand levelled off in the
early 1990's, apparently due to diligent campaigns on condom use
by the Thai government and certain NGO's. However, many ex-pats
continue to "bareback" (i.e., have sex without a condom) with
prostitutes, with more ex-pats doing so after consumption of
alcohol.
Some studies estimate that the percentage of prostitutes
infected with HIV is approximately 10% in the ex-pat areas of
Bangkok. However, these studies have uncertainties due to the
biases of their samplings.
A Chulalongkorn study found that "disguised prostitutes",
that is, ladies who freelance in shopping malls and the like
posing as non-prostitutes but who extract presents
(fashion items, mobile phones, etc.) and spending money from
quasi-boyfriends in an extrinsically motivated relationship, had
HIV infection rates of around 30%. The Chulalongkorn study
speculated that the higher rates may be due to lower condom use
in these relationships. However, the Chulalongkorn study notes
that this was an unexpected finding and based on a statistically
small and arguably insignificant sampling.
The best protection against HIV, besides abstinence, is
condom use. Condoms are a highly effective protection against
HIV.
The most often recommended condom is Durex, especially those
with the N-11 spermicidal lubricant which may also help protect
against some sexually transmitted diseases. However, some of the
very thin and polyurethane ones have been reported by associates
to break, including a Durex non-mainstream variety. A larger
condom for ex-pats has recently arrived on the local market,
often in the form of vending machines in ex-pat areas, and it is
called BodyGuard. More information is on the ThailandGuru page
on condoms.
Update in December 2006:
One thing I find interesting is that the more contagious
subtypes found in Thailand and Africa don't seem to be spreading
around the world as quickly as I would expect from travellers.
Therefore, I wonder if there is more than one factor here.
Contrary to popular belief among many laymen, subtype E does
NOT require blood-to-blood contact to transmit itself. Based on
research studies, scientists have found that subtype E attacks
the Langerhans cells (LC) at the skin surface, particularly
those located in the penis foreskin and on the surfaces of oral
and genital mucosa, with HIV subtype E infecting and reproducing
itself multiple times more quickly than other strains of HIV.
Subtype B prevalent in the US and Europe doesn't seem to have
ever had (or possibly lost) the same viral sequences as subtype
E for transmission this way.
However, this may not entirely account for increased spread
of subtype E in Thailand in view of the slow spread of subtype E
to the outside of Thailand, similar to African HIV.
In Africa, there are widespread trends for ladies to dry
their vagina before intercourse in order to create more friction
for the man and presumably pleasure, rather than a well
lubricated vagina. In fact, the ladies often insert powders and
herbs and other things. These things can cause irritation and
even bleeding, which could account for the increased
transmission in Africa, not the particular strains of HIV there
(which, again, differ from western countries).
Is there some custom in Thailand which could serve a similar
role? I think maybe so, for reasons similar to those in Africa.
("Same-same but different" as is joked here.)
HIV seems to be transmitted mainly thru the prostitution
community, not the mainstream Thai community nearly as much,
even though many young Thais are promiscuous in their multiple
romantic and casual relationships. What do prostitutes do which
is different from mainstream Thai ladies? Talk to any guy who
goes with prostitutes, whether they are picking up the lady from
a bar, going to a massage place, or just a knocking shop. It's
all the same -- the lady takes a shower and cleans herself
first, and requires the man to do likewise. Unfortunately, this
removes natural lubrication.
Of course, prostitutes having mercenary sex are generally not
as naturally lubricated as a girlfriend with sincere sexual or
emotional attraction to you. However, the cleaning just
exacerbates this.
Never, not once, have I ever been with a mainstream Thai lady
who stopped the action to go take a shower first, or require
that I do so. Same thing with foreign ladies. I don't want to
brag here, but for the sake of research and statistics, I've had
sex with many foreign ladies and many mainstream Thai ladies,
and none -- not one -- ever stopped to take a shower first or
required me to do the same. I've rarely had any significant
lubrication issues in these encounters.
I've also never had a broken condom, but I've heard of many
cases of broken condoms in Thailand. I have spoken with these
guys, including brand of condom, and one of the clear answers is
that there wasn't enough lubrication for complete penetration
before the condom broke. If there wasn't enough lubrication on
the condom, then imagine penetration without a condom with the
same lady and circumstances! That must be creating irritation,
not only in the lady's vagina which makes her more susceptible
to infection (and whereby she passes it on), but also to the man
by pulling the sides of the front end of the penis so that its
inner urethra & mucous membrane are not only exposed but
seriously contacted in a way which just doesn't happen with well
lubricated sex. That exposes any HIV viruses to the LC targets
in the man.
That may be a major part of the answer.
Therefore, pack both condoms and a water based lubricant.
Durex sells the lubricant all over Bangkok. There's also K-Y jel
available at pharmacies and department stores all over, and it's
water based.
Another thing I've found out from talking with guys is that a
lot of them who don't like to use condoms (and try not to) will
take an antibiotic prior to visiting prostitutes and immediately
after, in order to prevent infection by gonorrhea, chlamydia,
and other things -- the same broad spectrum antibiotic that is
given to cure these diseases, with the theory being that just a
little bit will prevent infection by a small number of bacteria,
rather than curing a full blown infection several days later.
They take these antibiotics shortly before and immediately after
sex, but don't need to take them for long, and apparently that
works from their reports.
Besides the unrelated issue of developing antibiotic
resistant strains due to not completing an antibiotic regimen, I
also wonder if attempts to decrease bacterial infection may
increase HIV infection.
In the West, heterosexual HIV transmission tends to occur
much more frequently when another sexually transmitted disease
(STD) is present in the recipient. This infection could result
in more LC's being available as part of the body's natural
defense against the bacterial STD.
If someone takes antibiotics, they artificially raise the
number of infection-fighting T-Cells. This creates more targets
for the HIV virus to find in the same places that other STDs
come in. Does this cause a significant increase in one's chances
of contracting HIV somehow? I don't know, and I've never seen
this "prophylactic antibiotic usage" issue researched.
Other STDs may be another
Maybe I'm wrong about all of this, but I've never seen these
two issues really analyzed and addressed. If I'm right, then a
few lives could be saved here. I welcome comments and critiques.
(However, please don't send emails about HIV not being the
cause of AIDS, a common sort of feedback I receive. I'm aware of
that small minority school of thought at www.virusmyth.net/aids,
and I have read those hypotheses and find them full of one-sided
arguments which totally ignore the overwhelming evidence
otherwise. These people say HIV doesn't cause AIDS, and many of
their believers in Thailand don't use condoms as a result, using
this as a rationalization. Let natural selection takes its
course. Google the keywords [AIDS HIV myth] and you'll find
further discussion as well as thorough refutation of these
claims.)
HIV Blood Tests
If you are going to have a protracted relationship with an
individual, it is advisable that you perform an HIV test.
There are two different kinds of tests readily available in
Thailand. Both take a sample of blood, usually drawn from a vein
in the arm, and not very painful to most people. They are:
-
Antibody
tests like the "ELISA" or the "Western Blot"
These check for antibodies to the
HIV virus in the blood. The advantages of this test are that you
can get results in about an hour if the hospital or clinic is
suitably equipped, and the price is low, typically a few hundred
baht. A "negative" result means no detection of antibodies, a
"positive" means a detection of antibodies. The disadvantage is
that recently infected people may not show antibodies. It takes
approximately three months after infection for the body's
natural immune system to detect the invading virus, characterize
it, and produce sufficient levels of antibodies for the test to
detect the antibodies ... for more than 90% of infected people.
To get up over 99%, you may have a period of 6 months.
Unfortunately, the virus is most far more contagious shortly
after infection, before the body starts producing antibodies in
sufficient quantities to combat the virus (or be detected by the
test), as will be discussed below.
Notably, false positive results
occur in a small percentage of tests. If you get a positive
result, it does not mean the person is HIV+. A second, more
reliable test must be conducted to ascertain whether or not the
person is HIV+. The "ELISA" test is commonly used to check for
antibodies because it's cheap and quick, but it sometimes gives
a "false positive" in that a positive result of the ELISA test
is refuted by a more expensive and more accurate test such as
the "Western Blot" test. The ELISA test is often called a
"screening test" because it will identify HIV+ people just about
as accurately as any antibody test, and its main drawback is
that it will cause some extra people to be identified as HIV+
even though they aren't. As one doctor overseas put it, you're
more likely to get an ELISA positive than a real HIV positive.
It Thailand, it may be different. In any case, an ELISA HIV+
result must be confirmed by a Western Blot or other more
accurate test before any HIV+ conclusion can be called accurate.
-
Antigen
tests, which detect the virus directly, not the antibodies
This test can detect the virus in
the blood in the period before antibodies are produced. However,
it is more expensive (from 800 baht to more than 2,000 baht,
depending upon the particular test used and the institution),
and usually takes one to three days for a result. It can also
fail to detect the virus if an infected person's immune system
has strongly suppressed to virus to very low levels in the
bloodstream.
It's best to do both antibody and antigen tests. In general,
the antibody tests commonly used are more reliable because the
antibodies are more easily detectable in the blood stream once
the body has started producing them, and continue to be easily
detectable for the rest of the life of the infected person,
whereas some of the common antigen tests may not detect the
little virus in longterm carriers because the antibodies have
already reduced the levels of the virus in the blood stream to
very low levels. The antibody test works best when the antigen
test fails, which is from a few months after infection until
death of the infected person. The antigen test works well when
the antibody test fails, which is during the first few months of
infection when antibodies are low and the virus is replicating
without significant suppression by antibodies and usually easily
detected by antigen test. If you do only one test or the other,
not both, then you are playing with statistical probabilities
that may not be as good as you want.
The figure below shows the concentration of HIV vs.
antibodies in the blood stream in a typical carrier from the
time of infection to the time of the onset of AIDS symptoms
years later.
Source: Bangkok Nursing Home hospital/clinic, soi Convent
(between Silom and Sathorn)
After infection by the HIV virus, the infected person usually
experiences flu-like symptoms from 2 to 12 weeks after
infection. These symptoms are generally:
·
fever
·
headache
·
fatigue
·
malaise
·
decreased appetite and nausea
·
swollen lymph glands
·
muscular stiffness or aching (myalgia)
·
a skin rash, usually flat to slightly raised (maculopapular)
These symptoms may last from a few days to two weeks, and
then subside.
After the above symptoms, antibodies to the virus can be
detected in the blood. This is called "seroconversion". HIV
seroconversion (converting from HIV negative to HIV positive)
usually occurs within 3 months of exposure, but on rare
occasions may occur up to a year after exposure.
Known good places to go for an HIV test:
-
On
Sukhumvit, Bumrungrad Hospital off Sukhumvit soi 3 (Nana Nua)
about halfway between Petchburi and Sukhmvit Roads, to the
west, look for the top of the building. Has in-house lab for
both antibody and antigen tests (i.e., they don't send the
blood to an outside lab as many clinics do), but some people
have questioned the quality control in this high class
hospital (except as regards accounts receivable)... You can
go just about any time of day or night.
-
In the
Silom-Sathorn area, the Thai Red Cross, located by the Snake
Farm on Rama 4 road, diagnonally across from Suriwongse Road
(and the Galaxy No-Hands restaurant) is a reputable clinic.
-
In the
Silom-Sathorn area, the Bangkok Nursing Home clinic/hospital
on soi Convent between Silom and Sathorn Roads, but some
people have not been satisfied with some of the doctors here
-
In the
Silom-Sathorn area, Chulalongkorn Hospital, on the corner of
Rama 4 Rd and Rajdamri Rd., opposite Lumpini Park and
opposite Silom Rd., sometimes a little bit difficult for an
English speaking person to get things lined up, but the
doctors seem good
-
On
Petchburi Rd. between Ekkamai (Suk. 63) and Klong Tan (Suk.
71) is Klong Tan Hospital, near where the overpass comes
down on Petchburi Rd. There is an excellent female doctor
there who understands the research issues of HIV extremely
well. Small hospital, clinic-like atmosphere.
-
One
reader reports that for quality control of HIV tests, he
thinks "the HIV reference laboratory for Thailand is at
Siriraj hospital. That is they take part in international
quality-control programs etc ...." This is one of the few
major Thai research and teaching hospitals in the Bangkok
area, located in Thonburi at Phran Nok Rd., Tel: 411-0241,
411-3192, 411-4230
-
A reader
suggests Paolo Hospital at Saphan Kwai skytrain station.
"You can come back any time after 2 hours for your result.
Again, you must see the doctor for your result. They will
not give it out by telephone to anyone (even you). Only the
doctor is authorized to give you the result face to face...
The cost is about 500 baht."
You should be able to get an HIV test at
nearly any hospital and many STD clinics, but the above are
tried and known good places. You should ask first how long it
will take to get the results, which is determined by whether
they have the testing kits in stock at the hospital, versus
sending your blood sample to an outside lab. Test kits for
antibody tests are more commonly in stock. Antigen tests take
longer even if they have the kits in stock. The particular
antigen tests used may differ from site to site, but the
antibody tests are usually the ELISA or the Western Blot.
However, many other tests have been coming out of R&D and
hitting the market.
To make you and your partner more comfortable, you may want
to insist on an anonymous test. Usually, this is done by making
up a name before you go in, and filling out all the forms using
this name. If they want to see an ID card or passport, just
don't bring it with you so that you can say you don't have it.
They will usually take your money and do the test using your
assumed name, as they should, and I've never heard of a case
otherwise.
In some places in the world, there are home testing kits,
e.g., saliva tests. One saliva test is done with the OraSure
product, and is claimed to be 99+% accurate. I don't know if
this is available in Thailand. The results take 1 - 2 days.
This website does not address the issue of HIV treatment, a
very large and broad topic. There is no cure for an HIV
infection at the time of this writing, though there are many
interesting treatments to prolong health against the onset of
AIDS.
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