“living a life less ordinary”: risk perspectives of men acquiring hiv while travelling and...

“Living a life less ordinary”Risk perspectives of men acquiringHIV while travelling and working overseas

Dr Graham BrownDr Jeanne Ellard, A/Prof Garrett

Prestage Dr Julie Mooney-Somers,

HIV Epidemiology Trends in WA 1993 - 2008

Total HIV Diagnoses By Exposure in WA

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20

40

60

80

100

120

93-96 97-00 01-04 05-08

Years

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MSM

Hetero Male

Hetero Female

IDU Male & Female

Unknown

HIV Epidemiology Trends in WA 1996 - 2008

0

20

40

60

80

100

120

93-96 97-00 01-04 05-08

Years

No

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MSM / IDUHetero MaleHetero FemaleIDU Male & FemaleUnknown

Only those acquired overseas by exposure

ABS,2007

O/S Acquired HIV Social Research

Funding: Sexual Health and BBV, WA Dept of Health

Collaboration of WA Centre for Health Promotion Research,

Curtin Health Innovation Research Institute National Centre in HIV Social Research (UNSW) National Centre in HIV Epidemiology and Clinical

Research (UNSW) Australian Research Centre in Sex, Health and Society

(La Trobe)


Increase in men acquiring HIV while overseas

Only one aspect of the issue of HIV and mobility that WA is experiencing

Some insight into what, but little on why or what we could do to about it.


Qualitative in depth interviews – about 2 hours each

About identifying the range of experiences and the common underlying themes rather than a representative sample of behaviour

Who have we interviewed?

14 Men (12 in WA, 2 in NT)

Sexuality identity

9 heterosexual, 5 gay

Believed location of transmission 11 Asia (6 in Thailand) 1 North America 2 Africa

Age 20+ 1 30+ 3 40+ 4 50+ 3 60+ 3

1 born in Asia 3 born in Europe 10 born in Australia

Role of networks

Friendship groups and networks were substantially other Australian or western expats or they were regular travellers who linked in with expat networks.

Some had strong friendship networks which

included locals, but generally was mostly western

Role of networks

Fly in Fly out mining context, spending most breaks in Thailand

30+, Heterosexual, Asia

Well there’s a hotel in Phuket called the Expat Hotel and that’s owned by a guy that used to work in the seismic industry, so you’d always see guys there that you’d worked with or knew… … But there’s always people I knew up there and that sort of centred around that hotel…. …vast majority of any information like that I ever got was from workmates and guys that I’d have a beer with in Thailand. Either at work, during a quiet period, or sitting around the bar somewhere in Thailand.

Role of networks

There was a clear theme of mentoring and advising other westerners, and in particular fellow Australians, creating an experience of support and camaraderie between expats and longer term travellers.

In the context of bars – advice would include which bars to go to and which bars “treat the girls well”, how to choose “a nice girl”, and how much to get involved.

Advice came from other guys in Australia who travelled frequently, or were based / living in the destination country.

Role of networks

50+, Heterosexual, Asia, Expat A good friend of mine who had a marriage

breakdown many years ago … I had a phone call from him saying ‘mate, come to Thailand, it’s paradise. I’m married, I got a lovely little daughter. Book for a month, stay at my place, I’ll show you the ropes and then your on your own”… When I get there for a holiday for a month it was fantastic like he said and when I got back I booked for another six months and….within 3 years I sold I was over there….He taught me right from wrong right from the word go. ..showed me, what to do, how to go about it, what’s this, who’s this… …There’s lady men, the men that have changed to ladies and all this, and how do you pick em. … I tried to do that for guys who first come across when I was in the bar.

Social norms and assumptions

The men saw themselves first and foremost as an expat or as a seasoned traveller, and not a short term or naïve tourist

Active distancing themselves from a tourist identity

None of the men saw themselves going overseas exclusively for sex (including those involved in bar girl/sex work contexts).

Their understanding of the situation, context and culture seemed to be more driven by interactions with other foreigners than with locals

Experience and Perspective Typology

The men and their experiences could be grouped into four groups which helps to understand their perspectives about risk Going native…but not local Escaping and Finding Fantasy realised Living a life less ordinary

Still working on the labels

Going native, …but not a local

Felt they had found a place with which they had more connection with than Australia

Preferred to, planned to or had already decided to live permanently in their new country. could come back to Australia if things went wrong and

their Australian citizenship was maintained. However this was not always the case - some

descriptions of changes to religion and (prior to HIV diagnosis) had investigated changing citizenship.

Considered themselves to be actively and confidently engaging in local language and customs.

There was a sense of becoming local but not a local - there was still an underlying sense of difference.

Going native, …but not a Local

(R2, 30+, Heterosexual, Asia, FIFO). It was more the people and just the place and just the

whole attitude of the place is nice……, you sort of, you know you go native a bit, I think, is the expression…. you start picking up some more language and when you just walk down the street, if you’ve been there for a couple of years, you’ll see people you know, like locals and that. So it’s more like home I always used to feel as though I had a lot more freedom up there to do what I felt like doing, basically. I was happier being up there, basically, than down here…. Although you’re definitely separate, you know?... you sort of feel like you’re at home or it’s getting that way, but you’re also an outsider to them, mostly.


(G1, 50+, Heterosexual, Asia, Expat). It's like people say, how come you know so much

about Indonesia? I said I studied the Koran for two years, if I can understand the Koran I can understand what the people are doing and I need to know what the people are doing because I'm a (profession) and I'm in the villages and I gotta know my danger areas you know. Which there isn’t really any, so it doesn’t matter, but at least if you can say some Islamic phrases, you'll get more fried rice you know. Or you know if you can say a good Islamic phrase, you might get a root for half price


Often forming a relationship with a local partner was an important part of feeling connected, and was characterised by managing trust in relationship terms rather than risk in sexual health terms.

Escaping and Finding

Focus on the experience of being far from home and the familiar.

Travel was part of a personal journey of distancing themselves from their previous life, or to start again.

However it was never envisaged as a long term home – more in common with a working holiday or lengthy but eventually limited travel.


(B1, 20+, Gay, Asia, Expat) I didn’t plan to stay there that long. I stayed in Tokyo

all the time. I was only planning 1 year in Tokyo and 1 year somewhere else in Japan but I got stuck in Tokyo for 3 years. …I got away from a lot of stuff from Perth. So I was also trying to get away and avoid stuff and trying to find myself as well. So that was another reason why I went over. But yeah I settled in really quickly. Wasn’t really home sick. Made lots of knew friends. It was good…….I guess in some ways kind of a fresh start and I didn’t have family to worry about. I didn’t have all my old friends to worry about… It was kind of like I could go over, be myself. No preconceptions and stuff like that.

Escaping and Finding (B2, 30+, Heterosexual, Asia, Traveller). It was a bit strange, I was a virgin until I was thirty and

was intensely romantic and stuff like that … Life’s going by and you are missing out and you might be hit by a bus tomorrow. … But then on top of that you have ‘You should wear condoms, you should be sensible and that. But overriding that you have got ‘it’s human nature’. … I had lost a fair bit of self esteem … It was the aura of doing something that was forbidden and different.


For these men, the focus was on managing a new or change in life than managing risk.

A Fantasy Realised

For these men – the location was a fantasy land, an outlet from their life in Australia or at work.

Where they could partake in activities they would not normally see themselves doing or have the opportunity in Australia.

Experiences they would normally consider indulgent were normalised around them, and while in country became normalised for them personally.

The experiencing of this fantasy became a regular event – risk was acknowledged but actively distanced.

A Fantasy Realised

(C3, 40+, Gay, Asia, Traveller) You know, I’m not A list, but I’d scrape by as a B

list…. So, yeah, it was a real indulgence being around happy confident sexy people who were enjoying their lives and were quite happy to have you enjoying your life in the same spot that they’re enjoying their life. You know, it was all, everything was good. Its one big aura of ecstasy that permeates the culture …… you’re so in demand, knowing that you never have to go home alone. It’s a big attraction, of course it is.

A Fantasy Realised

(R2, 30+, Heterosexual, FIFO, Asia) It’s a mind set like working five weeks away and one

week off or whatever- you do get that sense that you are being a robot and not having a life. ..So the minute you get a chance to live your life, like you become hedonistic and stuff. …You are not having a holistic balanced life that you would have down here.

I mean it amazes me now that I ever would have thought like that.…But really speaking you were there to experience what you wouldn’t be able to do back here. Big difference between your options, I guess you’d say. And I mean it’s pretty weird to me now, because it surprises me that I was ever into something like that, you know?

A Fantasy Realised

These men found themselves in an environment where risk was normalised, and being risk averse was the antithesis of what they were experiencing. It was more about managing a fantasy than managing risk.

Living a life less ordinary

Travel was very much a work related or life experience but had less long term connection with any particular country.

For these men it was more a sense of living life as an adventure, of actively seeking experiences, and considered themselves confident, resilient and had experienced many countries and occupations.

For these men risk was very much a relative concept.


(G1, 50+, Asia, Heterosexual) I'm a [sport and leisure industries and photographer]

I lived in Indonesia for 15+ years and anyway in '99 had an opportunity to …go to Phuket…I went, gee this isn’t a bad place for a single male, an Australian and had a really good six months. And then after that came back to Australia, went over and saw [doctor] and told him my story and he said you still have a good time mate, you're a lucky man you know, but he said it's getting dangerous to be playing games in those countries you know


I was working for a drilling company over there in Africa, troubleshooting and it’s [after] about 8 years of war, so I had to go over there, sort out all their problems and stuff with them, tax, well all sorts of things, you don’t want to know… …Three months on, one month off… …The owner of the company is an old friend of mine….I saw people robbing four guys who tried to rob a house down the road were executed just down by my house just shot, interrogated and shot on the spot, so yes you think you can’t be shocked or whatever and then something like that happens you think woo you know (A1, 40+, Africa, Gay)


They saw themselves living and working within risky contexts and situations, and risk was something to be managed, accepted and for some pursued, but certainly not avoided.

Other aspects of study

Meanings of risk, safety and adventure Meanings of condom use and HIV testing Interaction with bar based sex work Sex, romance, love and money – the

Girlfriend / Boyfriend experience Aussie bars / dodgy bars How not to be a butterfly• Report under consultation• Expected release June/July

Early Recommendations

Develop a deeper understanding of Australian expatriate networks in higher prevalence countries

Develop effective ways to engage with this shared epidemic that does not stigmatise either side of the borders, and supports host country efforts

Determine health promotion role in Australia and in host countries

Strategies that challenge assumptions about who is at risk and why

Next steps…

Expat Social Network Research Dept of Health has funded the first stage of a study to

look at the social networks which exist amongst Australian expatriates in South East Asia (particularly Thailand) to guide potential interventions, social marketing and peer network based.

Aim To determine whether Australian expatriate social networks

have the qualities that can support peer education and social influence interventions to reduce sexual health harms including HIV/STIs.

CI: Gemma Crawford Study Began in January 2010 - ongoing

Overseas Acquired HIV Social Research Study

Acknowledgements

WAAC, RPH, Fremantle, NTAHC and Darwin Clinic

Men who participated in the interviews

WA Centre for Health Promotion Research, Curtin University

National Centre in HIV Social Research

National Centre in HIV Epidemiological and Clinical Research

Sexual Health and Blood Born Virus Program, WA Department of Health

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