Ethical approval for this research was granted by Mahidol University [ref: 2020/254] and the London School of Hygiene and Tropical Medicine [ref: 22861]. All participants provided verbal recorded consent in line with Mahidol University policies.

In order to inform future research and gather a broad range of perspectives, we conducted a qualitative scoping study exploring key informants’ perspectives on the range of forces shaping hi-fun, as well as current provider responses.

Fieldwork occurred in Bangkok, Thailand between January and April 2021. Bangkok was selected as it is the social and economic hub of the country, and because of its status as the most important centre for gay life in Southeast Asia [14,18,19].

Eligible participants worked in policy, development, clinical and community-based organisations serving MSM. We aimed to recruit a cross-section of professionals working in a variety of organisations targeting different segments of the MSM population, and to include staff from a range of roles (e.g. peer-workers, clinicians, managers).

Key informants were recruited through the personal and professional networks of the authors. In line with scoping research approaches (which can include smaller numbers of participants) and because of budgetary considerations, we initially sought a sample size of 12 key informants from a range of organisations. Ultimately 13 were included, spread across policy, development, clinical and community-based organisations. Given that this research sought to identify a broad range complimentary and divergent avenues for further research with multiple stakeholders, we did not attempt to reach thematic saturation.

A topic guide was developed by the study team and used to guide interviews. This covered contextual factors relevant to hi-fun (e.g. observed changes in sexual behaviour, technology and drug use), harms identified during service provision as well as barriers and facilitators to service development and implementation. Some discussed their own experiences of hi-fun and harms they had observed in their personal lives.

Interviews were conducted by the first and second author in English (n = 7) and Thai (n = 3) respectively and lasted between 45 minutes and 1.5 hours. Nine interviews were online (conducted through Zoom), and 1 interview was in-person. Three participants requested a group interview which was in both languages, conducted in-person and attended by the first, second and fourth author.

All interviews were transcribed verbatim and Thai transcripts were translated into English. Transcripts were checked by the interviewers for accuracy. Analysis fused thematic and framework approaches: themes were identified through reading the transcripts and comparison with extant data, these were organised hierarchically, piloted on two interview transcripts (one English and one Thai) and then refined. Analysis was conducted by the first author with input from the study team. QSR Nvivo 12 was used for data organisation.

Clinical and community responses to hi-fun need to understand and acknowledge the practice in its social and cultural context. This first meta-theme explores the unique cultures and environments which shape hi-fun practices and experiences. Three primary themes were identified in analysis: technology use, innovation and norms; cultures of power and influence and drugs, tension and change.

This theme focuses on the faciliatory role of technology in hi-fun organisation, exploring the role of both ‘open’ (e.g. Twitter, Facebook) and ‘closed’ (e.g. instant messaging groups) online spaces.

Key informants felt hi-fun was increasingly visible in online spaces frequented by MSM; their perception was that this SDU is primarily organised online. However, in comparison with high-income Western settings, in Bangkok this included not just geo-location social networking applications (apps) catering to MSM, but also public facing social media such as Twitter and closed discussion groups on generic online messaging applications (e.g. LINE, WhatsApp).

In addition to facilitating organisation, some participants expressed a belief that these sites normalised SDU practices, thereby providing an entry point to hi-fun for uninitiated MSM. This was felt especially the case through Twitter, where content frequently appeared alongside other MSM sexual material.

Indeed, several key informants discussed the increasing role of ‘influencers’ in disseminating norms around drug use online. These included individuals uploading videos of injecting methamphetamine and combining different drugs, often in highly stylised settings. However, the online context was not limited to sexualised imagery and discussion but also featured the sharing of information about harm reduction. This included advice on ways to inject safely and how to find SDU competent healthcare providers.

Key informants identified strong links between hi-fun and perceptions of high socioeconomic status. These associations were also seen to contribute to complex power dynamics between those with greater and lesser financial means and/or social capital.

Hi-fun was firmly linked to Westernisation and wealth; key informants identified that MSM engaged in hi-fun typically understood their drug use as ‘high-class’ in relation to other drugs which they stereotypically associated with low socioeconomic status.

Given the financial resources required to engage in hi-fun, and the impact of wider group dynamics, some key informants described power imbalances affecting those with less resources and/or less cultural capital. Those impacted were typically (but not exclusively) younger MSM, who often had less power and autonomy in SDU settings.

This key informant linked imbalances in financial and cultural capital in hi-fun settings with uneven power dynamics leading to specific harms, including potential increases in reports of sexual assault.

This theme explores the types of drugs and administration modes most closely linked with hi-fun in Bangkok, focusing on tensions between accounts of key informants.

Methamphetamine was the drug most commonly linked with hi-fun. However, there was substantial disagreement amongst key informants about the boundaries between hi-fun drugs and differing administration modes.

Several key informants felt that the introductory route to hi-fun in Bangkok was primarily through smoking methamphetamine. This was in comparison with those who felt that hi-fun in Bangkok almost exclusively involved injecting methamphetamine.

A further group took a wider view on drugs associated, and linked polydrug use including MDMA, novel psychoactive substances and ketamine with hi-fun. This suggests a contested landscape where hi-fun was viewed and defined differently by various key informants.

There was substantial agreement, however, that injection of methamphetamine was common, likely more so than in other contexts. In comparison, GHB/GBL was felt to be used only by a minority. There is, as yet, insufficient population-level data pertaining to these practices to provide clarity as to the relative frequency of each, or the boundaries between hi-fun and other types of SDU in this context.

This meta-theme details the most pressing harms identified by key informants. Harms clustered in three main areas: police, coercion and enforcement; acquisition and transmission risks and emergencies, overdose and psychosis.

The police, and the legislative environment more broadly, were linked to harm for MSM involved hi-fun. This was the most pressing concern for key informants who themselves were engaged in hi-fun, but was identified nearly universally as a significant issue.

Key informants described potential police entrapment taking place through a number of means. Most commonly, police officers would use apps, pose as someone hosting a hi-fun party and lure men before fining or potentially prosecuting them for drug use.

Some key informants reported hearing that police coerced men into luring their sexual contacts to parties, before extorting them for financial gain. This contributed to trust issues between men engaged in hi-fun men because of the potential for someone to be ‘turned’ by the police and begin acting as an informant.

There was substantial concern among key informants on the potential of SDU to lead to increases in STIs, HIV and hepatitis C (HCV).

As in many settings, most concern focused on the potential for increases in HIV and HCV acquisitions linked to hi-fun because of potentially low condom use and high partner numbers in these environments. This was further compounded by the sense that significant proportions inject methamphetamine, leading to increased opportunity for transmission of bloodborne viruses.

While increasing provision of HIV pre-exposure prophylaxis (PrEP) was felt to lessen the risks of HIV transmission, concerns around bacterial STIs were substantial. Indeed, many key informants identified that Thailand specifically did not have a sexual healthcare system that could respond to the range of STIs faced by MSM engaged in hi-fun. This was primarily because of resource constraints around expensive diagnostic tests.

The risk from STIs was felt by key informants to affect most MSM engaged in hi-fun, as condom use in these settings was perceived to be inconsistent.

This theme explores the most acute, physical and mental health harms faced by MSM engaged in SDU, notably the potential for overdoses and psychosis from extended methamphetamine use.

Key informants who identified polydrug use as being part of hi-fun were more likely to describe concerns about deaths resulting from overdose. This was felt to be especially pressing amongst those who injected mixed substances as part of their SDU practices.

Indeed, some key informants felt that a lack of understanding of the range of drugs being used in hi-fun settings made providing harm reduction advice challenging.

Alongside general concerns about depression and anxiety being exacerbated by stimulant drugs, several key informants identified psychotic episodes caused by extended methamphetamine use without breaks for sleep.

Some key informants felt that episodes of psychosis had the potential to lead to vulnerability to physical harm, or enforcement action by the police.

It was noted that, for the majority, these types of harms were uncommon and that when they occurred, they were often among further marginalised MSM and reinforced by pre-existing vulnerabilities.

This meta-theme explores the broader political, social and organisational contexts that help and hinder MSM SDU service development and delivery. These include the themes politics, macro-economics and wider culture; organisational contexts and cultures and approaches, aims and philosophy.

This theme relates to the political, economic and cultural considerations in hi-fun and other SDU service delivery. Specifically, we explore the role of political economy in the distribution of development funding and its impact on service provision for MSM in Bangkok. Following this, we outline cultural considerations in developing hi-fun/SDU support.

It was recognised that an important source of funding for sexual health programming was from overseas development aid, largely from the United States. Funding from these sources was often focused solely on HIV prevention or treatment and could not be used for broader services. When funding was less restrictive, substantial barriers existed surrounding what harm reduction services or messages could be provided.

These barriers meant that some approaches which were valued by MSM engaged in hi-fun were not acceptable to funders. This was compounded by a sense of reluctance on the national level in Thailand for stakeholders to engage with issues of hi-fun because of multiple stigmas surrounding homosexuality, condomless sex and drug use.

Negative attitudes towards drug use within wider Thai culture were frequently cited as a further barrier to developing comprehensive services. This was most pronounced if said services were targeted towards younger MSM because of cultural imperatives against discussing sex and/or drugs with this group. Despite these barriers, MSM culture was felt to be faciliatory, with men engaged in hi-fun keen to engage in service development activities:

Despite substantial wider macro-economic, political and cultural barriers, MSM hi-fun culture facilitates service development and engagement, especially with trusted organisations. This underscores the fact that despite widespread cultural and political barriers, there are highly motivated MSM engaged in hi-fun who wish to shape service provision.

This theme describes the organisational contexts relevant when considering support strategies for hi-fun engaged MSM in Bangkok. We explore the willingness of organisations to adapt and support MSM engaged in hi-fun, as well as barriers surrounding provider stigma towards this type of SDU.

Most organisations began working on issues related to hi-fun incidentally; SDU became an organisational concern through individuals presenting to services with acute needs. For some, there was a feeling that hi-fun was not within their purview, and they should only focus on areas directly related to their organisational objectives.

Although key informants were very keen to engage with issues surrounding SDU and a series of regional meetings had been held to explore emerging issues, several felt there was reluctance from the sexual health sector to make hi-fun a visible issue because it did not align with donor priorities. This was further compounded because of stigma from some service providers towards those who use drugs. It was also felt that explicitly providing hi-fun support may also act as a barrier for MSM in accessing services because of stigma related to drug use. Promoting or delivering services online only was a way to circumvent issues of visibility but could, of course, complicate awareness and accessibility of services.

It was felt to be important that skills were developed within the sector to improve the success of these initiatives, and that organisations responding to hi-fun sometimes lacked capacity in this area. This also includes addressing stigma towards people who use drugs, which was often dealt with effectively by collaborating with drug use organisations to providing enhanced training around the needs and experiences of MSM engaged in hi-fun.

This theme explores the approaches to support provided by organisations, as well as the underlying philosophy of their interventions.

Support for MSM engaged in hi-fun was often, but not always, informally developed in response to the needs that emerged during routine provision of other services. In many cases, this involved using peers to deliver support in response to individual need. Organisations also relied on collaborative working, referring MSM with specific issues arising from hi-fun to the services of collaborators.

Service providers frequently used peers when delivering HIV, HCV and STI specific services, both in clinical and community-based settings. These sometimes also included additional psychosocial interventions such as motivational interviewing aimed at supporting behaviour change.

Services were usually client centred and focused on supporting people in meeting their own goals and aspirations. Delivering them by peers and/or in community settings increased intervention acceptability, relevance and impact.

Harm reduction was provided in two primary forms. Firstly, some organisations engaged with MSM online, either on Twitter or in closed messaging groups, and provided harm reduction advice. Secondly, organisations also provided physical materials to support risk reduction, including condoms, lubricant and (sometimes) safe injection packs. These initiatives, rather than being informally developed, were usually adapted from approaches observed in high-income settings.

While some appreciated easy access to injection equipment, distributing syringes was sometimes contentious; key informants reported that a substantial proportion of MSM felt that it might encourage drug use.

Our scoping study confirms earlier research in Thailand exploring the role of Twitter in hi-fun organisation and in developing norms [14]. Although apps are central in chemsex organisation in other settings, and user generated pornography in establishing norms [22], the centrality of Twitter (an open social media platform) and of closed discussion groups appears to be unique to Thailand, or possibly the region more broadly [28]. This remains under-theorised.

Bangkok is characterised by stark wealth inequality. Indeed, Thailand is among the most unequal countries in the world [29]. Wealth inequalities have impacts on many facets of life, including in hi-fun organisation where unique power dynamics seem to emerge based on imbalances in financial and cultural capital. The impacts of these dynamics on the lives of MSM engaged in hi-fun are largely unknown, however, and require further attention.

Key informants in our sample felt injecting methamphetamine was very common, this is in comparison to a study in Malaysia which showed smoking was a more common route of administration [10]. In addition, the risks from extended methamphetamine use is an issue of concern noted in other contexts [30–32]. Further research is required to establish the patterns of drug consumption, their administration modes and impacts to prioritise effective supportive strategies.

Harms related to police entrapment and coercion as well as transmission of HIV, HCV and STIs were felt likely to be distributed evenly throughout the hi-fun engaged population; their frequency and severity of impact were unclear, however. While potential for HIV/HCV transmission through sharing injecting equipment during SDU was raised, research in other settings does not show this to be a substantial issue, at least in part due to the supportive role more experienced MSM provide in teaching others safe injection techniques [5,33]. However, MSM engaging in hi-fun and other SDU have pronounced utility for innovative sexual health interventions including new prevention technologies for HIV prevention, such as HIV self-testing and PrEP [34–36]. Given some service providers in Thailand are reluctant to engage with people who use drugs, and that peer-delivered interventions were highly acceptable, key-population led models of care should be central in supporting this group [37–39]. Research on the values and preferences of MSM engaged in hi-fun and other SDU is required to inform peer-led service design and delivery.

Harms related to overdose and impacts on mental health were felt to impact more marginalised MSM with greater frequency, and, potentially, severity. This remains under-theorised and evidence from Thailand, and other settings, is lacking.

The global political economy of development funding and the centrality of the United States as a donor in Thailand provides a substantial barrier to developing holistic services for MSM engaged in hi-fun. These issues are not unique to Thailand, and the form funding takes has long shaped the priorities of the HIV response [40–42]. This research, however, provides yet another example that urgent action is required to re-shape funding remits so the health and well-being needs of MSM, which extend far beyond HIV, can be addressed by services.

Finally, despite substantial political, economic and social barriers, organisations were successful in developing services which respond to many of the needs of MSM engaged in hi-fun. Because these were largely informally developed or adapted from high-income settings, developing a theoretical basis for further interventions is a priority.

This study provides a thorough overview of key hi-fun domains in Bangkok relevant for further research and service provision. Never-the-less some limitations are noted. Consistent with scoping research, our sample size is relatively modest. To counter concerns, we aimed to recruit as diverse a sample as possible. Unfortunately, we were unable to recruit representatives from organisations supporting MSM sex workers who will have distinct experiences of transactional SDU. Future research should prioritise including this group.

All key informants worked in services which address the health needs of MSM in Bangkok. As such it is likely that accounts will overestimate the severity of harms experienced as these individuals will have more contact with those experiencing the worst outcomes. Countering this, our sample includes key informants who were or had been engaged in hi-fun themselves, adding richness and nuance to our data. This was not the result of focussed recruitment effort but rather is a reflection of how peers often form a valued part of the workforce in organisations that serve MSM, further underlining the value of peer-led programs [43].