In-depth: Asia: Facing the HIV/AIDS challenge

LAOS: Keeping the lid on HIV

Photo: David Swanson/IRIN

Armed with mobile phones and motorcycles, young people in Laos have adopted more liberal attitudes towards sex

Vientiane, 1 February 2007 (PlusNews) - Being sexually active couldn't be more natural for Wath Jommanevong, 27, who hopes to marry one day when he has enough money. "I like sex. Sex is good," he said with a grin, standing beside his three-wheeled taxi or 'samlor' on the streets of the Laotian capital, Vientiane. "Sometimes the sex is free. Sometimes you pay."

Such candour was not always possible. Since the collapse of the former Soviet Union in 1991, when commercial sex, and to a certain degree pre-marital or non-marital sex, was suppressed by the threat of arrest or fines, Laos has experienced a barrage of change.

The country is opening up economically and socially, altering the lifestyles of its six million inhabitants and, increasingly, their attitudes to and perceptions of sex.

How the government addresses those challenges will have a direct effect on the spread of HIV.

LOW PREVALENCE

Laos is surrounded by countries with higher infection rates, but the nation enjoys low prevalence, estimated by the government's Centre for HIV/AIDS/STIs (CHAS) at less than 0.1 percent of the adult population.

Between the first reported case of HIV in 1990 and the end of 2005, 1,827 cases of HIV infection were officially recorded, with 1,190 people still living with the virus.

Almost 95 percent of infections occurred through heterosexual sexual transmission, 3.9 percent from mother to child, 0.7 percent in men who have sex with men (MSM), 0.3 percent from blood products and 0.2 percent by unsterilised needles.

While the number of cases among the general population remains low - although unofficial estimates assume a much higher figure - the same studies indicate that there is little room for complacency. In 2004, prevalence rates among commercial sex workers in the country rose to 2.02 percent, compared to 0.9 percent in 2001.

"This has increased because the knowledge of HIV among certain high-risk groups remains low," Dr Phouthone Southalack, deputy director of CHAS, told IRIN/PlusNews. "Moreover, we have a much more mobile population than before, making the risk of spreading the virus higher."

According to CHAS, the main propellant of HIV in Laos is the so called mobile populations, comprising sex workers, their clients, and migrant labourers, many of whom travel outside the country or make regular trips between rural and urban areas.

"Our government is fully aware of this and is committed to containing the problem at this level," Southalack said. But that may be easier said than done: low levels of awareness, limited access to prevention and protection, including condoms, increase the likelihood of infection rates rising in the impoverished, landlocked nation.

KEY CHALLENGES

Laos, a largely Buddhist country, was isolated until fairly recently, but there are now more than 180,000 Lao nationals living as registered migrants in neighbouring Thailand, where prevalence rates among the general population stand at 1.4 percent.

Many mobile men are potential clients of sex workers, but fail to consider themselves as being at risk of HIV/AIDS and sexually transmitted infections (STIs). According to UNAIDS, other factors, such as the low socioeconomic status of women, high levels of poverty and a widening generation gap, are contributing to the spread of HIV.

There is also a growing use of recreational drugs, particularly amphetamines. An alarming number of sex workers are also thought to be injecting drugs, which could substantially deepen the HIV problem. Alcohol plays a significant role in the spread of the virus, particularly in relation to commercial sex and condom use, while behaviour patterns among young people are changing.

"More young people in Laos are having pre-marital sex at a younger age," said Sythong Nouansengsy, executive director of Population Services International, which has been advocating for safer sex and condom use since 1998. "This puts the country's prevalence rates in danger."

"Urban society is loosening up," Tony Bennett of Family Health International (FHI) agreed.

Such changing perceptions can be seen at popular meeting places and restaurants along the banks of the Mekong River, where young patrons may pair off for more romantic interludes afterwards - a sign of more liberal attitudes towards sex in this otherwise conservative society.

MSM

Xay Boulommavong, peer education supervisor at the Peuan Mai or New Friend Centre, the only facility of its kind dedicated to supporting members of the MSM community, warned that young people, including gay men, were not only having more sex, but more partners as well.

"There is a lot more freedom in terms of sexual behaviour in Laos than before," Boulommavong said. "Nowadays, everyone has a mobile phone and motorbike, meaning everyone seems to have a network of people they can tap into, any time, any place, for sex."

MSM is a particularly high-risk group in need of further awareness, with condom usage perhaps even lower than among the general population. "Some MSM have limited understanding of HIV, and feel that if they are having sex with a man they aren't at risk of becoming infected. That's problematic, and that's why we are here," said the activist.

Photo: David Swanson/IRIN

Wath Jommanevong, a local driver in the capital Vientiane, admits he sometimes pays for sex

PROSTITUTION ON THE RISE

Paramount to any successful intervention effort, however, is how to do deal with the growing number of sex workers - an estimated 8,000 women - much to the chagrin of the authorities. Although they work hard to keep the sex industry under wraps, a short stroll down Setthathirat Road, in the heart of Vientiane, reveals that this is proving all but impossible.

"I work here every night," Ning, 22, giggled in broken English. Most of her clients are Thai businessmen who come across the Mekong River for the weekend. She occasionally has run-ins with the law, but she and her friends are generally back on the street next day.

One reason cited for the increase in sex work is the upsurge in large-scale infrastructure projects being undertaken by the government, which is eager to open the country up for further development.

Hundreds of men, separated from their wives and families, now work for extended periods on a variety of bridge and road projects in areas like Champasak, in the far south, and Vientiane, in the northwest near the border with Thailand, resulting in innumerable informal brothels sprouting up to cater to the demand.

Sex work in Laos generally takes a more subtle approach than in neighbouring Thailand and Cambodia. It is often conducted behind the closed doors of massage parlours or guesthouses catering for Laotian men with money, and makes access for outreach programmes particularly difficult.

Clients in these establishments, many of whom are married, might share a drink and food with one of the working women before retiring upstairs for sex, which can set patrons back anywhere from US$25 to $30, a price largely out of reach to the average man.

"If the price of sex - which is currently quite high - gets down to a level below $5 per act, then you'll have a situation where client volume will probably increase and you'll have the ingredients for an HIV outbreak," Bennett said. "The lower the price, the higher the number of partners."

Once you start having more than two partners a night, and you have a less than 50 percent condom usage, you have a serious problem, and it is "time to ring the alarm bell", he commented.

At one such popular venue in Vientiane, upwards of 30 girls could be working on any night. But, unlike their Thai counterparts across the river, they appeared to have more control over who they went with, providing a greater capacity to negotiate safer sex: if they did not like the customer, they were free to get up and leave.

"I always insist on the man wearing a condom and if he refuses, I don't go with him," said one demure 20-year-old, who dreams of one day opening up her own beauty parlor with the money she earns. "Sometimes I find a customer. Sometimes I don't." She hesitated when asked how many customers she might have in a night.

Many of the women are finding a growing number of customers. The latest round of surveillance, undertaken in the country in 2004, showed an accelerated transmission of HIV among sex workers in Bokeo Province in the north, bordering Thailand, and the central, highly populated province of Savanakhet.

Bokeo has reached an HIV prevalence of 3.9 percent, while rates in Savanakhet had risen to 3.3 percent, compared to 1 percent in 2001. Data collected in six provinces revealed an overall increase of HIV among sex workers from 0.9 percent in 2001 to 2.02 percent in 2004.

Equally worrying was the number of STIs reported among sex workers - ranging from 19.9 percent to 46 percent for chlamydia and/or gonorrhoea - suggesting that consistent condom usage remained a key challenge.

A WAY FORWARD

Pushing for consistent condom usage will require sustained interventions, according to CHAS director Southalack. "The government is committed at the highest level to these efforts and - given similar campaigns now taking place in neighbouring countries - properly assisted by the international community, we can do it."

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ASIA
Facing the HIV/AIDS challenge

January 2007
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