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Outrage over U=U messaging in Thailand: An example of pervasive stigma and discrimination in 2020

Tue 25 Feb 2020 Hilight
Tanat Chinbunchorn, MD
Reshmie Ramautarsing, MD, PhD

In January 2019, a Thai influencer, who is open on social media about living with HIV, his sex work, and use of stimulant drugs, offered to teach the public how to have safe bareback sex, using U=U as a back-up theory. He posted the offer on Twitter and Facebook, but did not receive much interest. More than a year later, in February 2020, this particular post was shared on Facebook by a student nurse with an angry caption, calling the influencer several names. The influencer then responded that he would take a legal action against her, which sparked a large public outrage with hundreds of thousands of profiles on Facebook and Twitter condemning him, and accusing him of being a public threat. Self-proclaimed "HIV-experts" without any demonstrable HIV experience, began blaming the influencer for spreading lies, and for instigating fear of HIV-transmission in the Thai community. This outcry took social media by storm, and the U=U message kindled national-level interest and scrutiny.

In response, several television interviews took place with a renowned HIV doctor - Dr. Nittaya Phanuphak, and a highly experienced HIV professor - Professor Praphan Phanuphak, both from the same organization, both with decades of experience in clinical HIV care, and HIV related research and advocacy. Dr. Nittaya Phanuphak endorsed the U=U message during her interviews, and carefully explained the science behind it. She mentioned that for people living with HIV and with undetectable viral load, it is safe to stop using condoms if the reason for condoms use was preventing HIV transmission, stressing that although condoms still play a role in prevention of other sexually transmitted diseases, it is everyone's own right to decide whether or not to continue using condoms for this purpose. Doctors should not blame their clients for deciding one way or the other, but rather educate them so that clients are equipped with the knowledge to make an informed decision. She also explained that although condoms are an effective HIV prevention option, in the real world it would be impossible for everyone to use condoms consistently due to a variety of personal or occupational reasons. She then thanked the influencer for bringing up U=U to discuss in a wider public.

Professor Praphan Phanuphak was also invited for a televised interview to discuss the legitimacy of the message, together with the influencer and an HIV advocate. Instead of condemning the influencer as the audiences would like to see, Professor Praphan Phanuphak and the HIV advocate endorsed U=U.

All instantly received intensely negative feedback from the public, and were attacked for allegedly being unethical. Both Dr. Nittaya Phanuphak and Professor Praphan Phanuphak received death threats, and threats from fellow doctors that their medical licenses and the professor’s emeritus position would be removed – much like a modern day Galileo Affair. Several other doctors took the stage to insert themselves into this national debate, criticizing the evidence generated by PARTNER, PARTNER2, and Opposites Attract, calling it inapplicable to Thailand’s setting. Both Dr. Nittaya Phanuphak and Professor Praphan Phanuphak had their professional credibility as doctors undermined, their ethical obligations questioned, and were publicly shamed as endorsing condomless sex, which was labelled by the public as "an evil act".

Professor Praphan Phanuphak subsequently issued a very clear, evidence-based, recommendation- oriented statement hoping to educate doctors and the public, increase knowledge and improve attitudes, which was met with responses that highlighted once again negative attitudes towards PLHIV and their life-long ART and condom use responsibilities.

This week-long public outrage against the scientifically backed U=U message implies that after years of advocating, this message has not reached the larger population. Most people do not know anything about it, and are not willing to listen, rather using social media to question and even attack those who carefully explain it. The magnitude of this fury as a response to a person living with HIV with undetectable viral load speaking out about condomless sex accurately illustrates the overarching and encompassing fear of HIV in Thailand, both among the general public and medical professionals. We propose the following call-to-action items.

  • Doctors need to be formally educated on U=U and how to apply it in clinical practice.
  • In Thailand, medical authorities such as The Ministry of Public Health, Thai AIDS Society, and Thai Medical Council, as well as Thai People Living with HIV Network, must publicly endorse U=U.
  • International HIV communities, researchers, clinicians, people living with HIV, and policy makers should seriously strategize dissemination of this evidence-based U=U message to educate wider global communities.
  • In Thailand and worldwide, the existence of condomless sex must be seen and accepted regardless of HIV status. Other preventive methods must be made accessible to people who choose to practice condomless sex with no judgement.

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