As dusk falls along the banks of the Tonle Sap River, opposite the Royal Palace in Phnom Penh, the Cambodian capital, Noun, 35, a married engineer, stops at his favourite vantage point on his route home each evening, a popular cruising site for Cambodian gays, where last month alone he met seven different partners.
Noun's world is a complex one, riddled with deception and hypocrisy in this otherwise conservative Khmer society. "I'm not gay," he said. "I just like having sex with men."
Such an assertion is not unusual in many South East Asian nations, including Cambodia. In less than an hour's time he will return to his wife and two children about a kilometre away - none of whom are any the wiser about his activities.
Men who have sex with men (MSM) could well prove a pivotal part of Cambodia's bid to mitigate the spread of HIV/AIDS. "This is the hidden MSM population, who not only have sex with men, but also have sex with female partners," Tony Lisle, Country Coordinator for the Joint United Nations Programme on HIV/AIDS (UNAIDS) in Cambodia, told IRIN.
Penetrating Noun's world, and others like it, could be the most difficult challenge, but failing to do so could accelerate the spread of the pandemic among the country's 14.5 million people.
CURRENT PREVALENCE RATES
Cambodia has the highest HIV/AIDS prevalence in South East Asia, but has also made significant inroads against the disease since it first appeared in 1991. According to UNAIDS, the estimated level of infection among adults has dropped from a high of 3 percent in 1997 to 1.6 percent in 2006, which can be partly attributed to increasing HIV mortality as those infected during the period of peak HIV incidence move into AIDS.
Current surveillance data also suggest that the epidemic, largely driven by the continued patronage of commercial sex workers by Cambodian men, is changing: behavioural data now show consistently higher rates of condom usage in the sex industry, largely the result of enhanced public information campaigns and an assertive effort to promote 100 percent condom usage.
HIV incidence among sex workers and their clients appears to have been dramatically reduced, as corroborated by a reduction in the prevalence of other sexually transmitted infections (STIs) among them, but sexual networking continues to shift towards casual sex, making MSM as a risk group all the more important.
MSM PREVALENCE RATES
Prevalence in the general population has also declined in recent years, but health workers warn there is little room for complacency. According to the latest survey by the Cambodian National Centre for HIV/AIDS Dermatology and STDs (sexually transmitted diseases), the HIV prevalence rate among MSM in Phnom Penh is 8.7 percent, and their networking behaviour has become a serious source of concern.
Of the 58 percent of men surveyed in three provinces - Phnom Penh, in the south, and Batdambang and Siem Riep in the northwest - who reported having sex with female partners in the past year, almost 25 percent also reported having sex with female sex workers, with 16.6 percent having had sex with casual female partners in the past month.
"When you have a very dense network, and when you have crossovers in the network between males and females, in the presence of high risk of STIs and in the presence of very low condom usage, then you have a potential for an explosive epidemic," Lisle warned.
"You're looking at multipartner behaviour," the UNAIDS official said, pointing out that not only were the men putting themselves at risk, but also the women they slept with.
MSM - A GLOBAL PHENENOMENON
Male-to-male sex is found in every culture and society, and is often defined as a social and behavioural phenomenon rather than a specific group of people. Although the description may include men who identify themselves as being homosexual or gay, bisexual or transgender, it can also include men who identify themselves as exclusively heterosexual and are often married, particularly where discriminatory laws or social stigma exist.
The manner in which Cambodian MSM define themselves blurs this distinction even more: according to a 2004 study of 1,306 MSM by Family Health International (FHI), 'Men Who Have Sex with Men in Phnom Penh, Cambodia: Population Size and Sex Trade', there are four times more of what are described locally as 'short-haired MSM' (masculine-acting MSM who have sex with each other) than 'long-haired MSM' (transgender MSM whose masculine sexual partners identify themselves as being from either group).
Relations between the two groups are not always cordial. Short-haired MSM enjoy a degree of privacy by being less visible than long-haired MSM, who tend to be more conspicuous, have a great deal of difficulty in securing employment and are often thrown out of their homes.
A recent report on 'MSM and HIV/AIDS Risk in Asia', by Therapeutics Research Education AIDS Training Asia (TREAT Asia), found that short-haired MSM were more likely to receive money for sex (20 percent regularly and 41 percent occasionally).
RISK AND AWARENESS
In terms of HIV risk, male-to-male intercourse is significant in that it can involve anal sex, which, when unprotected, carries a risk 10 times greater than unprotected vaginal intercourse does for the receptive partner. At least 5 percent to 10 percent of HIV infections worldwide are estimated to occur via MSM but, according to UNAIDS, this figure varies considerably between countries and regions.
Many Cambodian men are unaware of these obvious risks. "It can be very difficult to reach MSM," Lisle said, particularly those who might be classified as short-haired MSM and therefore do not necessarily identify themselves as homosexual.
A government report, 'Turning the Tide - Cambodia's Response to HIV/AIDS 1991-2005', identified the need to promote better understanding of risks and behaviour change, encourage consistent condom use among MSM, and to consider them not only a high-risk target group, but to involve them in the planning and implementation of prevention interventions.
A study of sexual behaviours, STIs and HIV among MSM in Phnom Penh, undertaken by FHI in 2000, documented an alarming HIV prevalence rate of 14.4 percent - approximately equivalent to the rate among informal sex workers at the time - aggravated by drug use among 24 percent of the sample population.
Although the government has begun to acknowledge MSM in its intervention efforts, the researchers found that NGOs and community-based organisations had only recently started implementing programmes to reach this group.
ACCESS TO HEALTH CARE
Men's Health Cambodia (MHC) in Phnom Penh, established in 2002 and funded by FHI, was the first NGO dedicated to addressing the health needs of short-haired MSM in its drop-in centre and outreach programme.
According to UNAIDS, fewer than one in 20 MSM have access to the HIV prevention and care services they need - a figure largely in line with global indicators.
Of the 30 men visiting the MHC centre weekly, most are concerned about STIs and HIV testing, while others seek counselling to deal with their sexual identity in a country that frowns on homosexuality.
After successful awareness interventions, condom usage overall appears to be increasing, but the Executive Director of MHC, Mao Kimrun, 32, said much more needed to be done. "Not everyone understands the risks - there are still misconceptions that MSM are not at risk," he asserted. "Condom usage is still not widespread, and many men cannot afford them."
MHC runs a daily outreach programme in parks and other locations that MSM might frequent. "They usually ask me about HIV/AIDS or STIs, and they want to know about safe sex practices," Thavro Dum, an MHC outreach member, told IRIN/PlusNews as he readied his motorcycle to make his evening rounds.
He said MSM were often aware of HIV transmission and prevention, but did not always know how to apply this knowledge to their own behaviour to avoid risking infection.
As confirmed by the TREAT Asia report, condoms are imported and expensive, which limits access, except when offered in social marketing programmes; secrecy exacerbated the situation - some MSM even based their HIV-risk assessment on whether a potential partner appeared to have good personal hygiene or not; male sex workers were often unable to negotiate condom use and generally did not use lubricant, because clients "would know for sure that they are non-female".
"I'm afraid of HIV/AIDS," said Eam Vanndy, 27, a male sex worker who arrived in the capital three years ago in search of a job. He told IRIN/PlusNews his customers paid between $5 and $10, and he always used a condom. "Many of my friends are pretty boys [long-haired MSM]. Some use condoms; many do not."
Such stories are not unusual in a country where poverty is rife and drives a growing number of people to work in the sex trade.
Sou Sothevy, 67, who has been a transgender sex worker since she was 14 and still works occasionally, commented, "Although MSM are aware of the risks, they don't always use condoms with their partners. Some male sex workers forego the usage of the condom for more money."
She spends most of her time as a local team leader in a network of some 5,000 sex workers - the Women's Network for Unity - and also serves on the national steering committee as an elected representative. Sothevy, who has been living with HIV for over 10 years, believes most people have some awareness of the risk factors, but remain careless. "Many use drugs, including heroin," she said.
"Cambodia is a very conservative country and there is discrimination towards MSM, not just from the family, but society as a whole," she pointed out. As a team leader, she monitors members' needs and keeps an eye out for new sex workers in her local area. Nationally, the network advocates for access to medicines and undertakes research for NGOs, United Nations agencies and the government by sex workers and the HIV-positive community.
Changing people's perceptions would not be easy said Sear Young Tan, 39, of the recently established National MSM Network, which aims to eliminate stigma and discrimination against MSM, and promote equal access to HIV- and MSM-related information and services. "Discrimination against MSM is very much part of Cambodian life, both in the family and society at large," the clothes-maker and makeup artist noted.
"This makes the fight against HIV/AIDS all the more difficult," he said, reiterating the fact that many MSM do not think of themselves as MSM - even when they have sex with men. "It's just for pleasure and means nothing."
But with many short-haired MSM engaging in more sexual encounters than long-haired MSM - some having up to five different partners a week - he said, getting the message out to this group should be an integral part of the country's intervention efforts.
Most Cambodians are unaware of how many masculine-acting - and often married - men are sexually active with other men, heightening the risk of spreading the virus among the general population.
One MSM focus group participant in rural Cambodia cited in the TREAT Asia report remarked: "I had a lot of friends, but my friends who have sex with the same gender ... are all dead. Now it is only me here."