HIV in Japan: Epidemiologic puzzles and ethnographic explanations

Abstract

Japan is widely perceived to have a low level of HIV occurrence; however, its HIV epidemics also have been the subject of considerable misunderstanding globally. I used a ground truthing conceptual framework to meet two aims: first, to determine how accurately official surveillance data represented Japan's two largest epidemics (urban Kansai and Tokyo) as understood and experienced on the ground; and second, to identify explanations for why the HIV epidemics were unfolding as officially reported. I used primarily ethnographic methods while drawing upon epidemiology, and compared government surveillance data to observations at community and institutional sites (459 pages of field notes; 175 persons observed), qualitative interviews with stakeholders in local HIV epidemics (n = 32), and document research (n = 116). This revealed seven epidemiologic puzzles involving officially reported trends and conspicuously missing information. Ethnographically grounded explanations are presented for each. These included factors driving the epidemics, which ranged from waning government and public attention to HIV, to gaps in sex education and disruptive leadership changes in public institutions approximately every two years. Factors constraining the epidemics also contributed to explanations. These ranged from subsidized medical treatment for most people living with HIV, to strong partnerships between government and a well-developed, non-governmental sector of HIV interventionists, and protective norms and built environments in the sex industry. Local and regional HIV epidemics were experienced and understood as worse than government reports indicated, and ground-level data often contradicted official knowledge. Results thus call into question epidemiologic trends, including recent stabilization of the national epidemic, and suggest the need for revisions to the surveillance system and strategies that address factors driving and constraining the epidemics. Based upon its utility in the current study, ground truthing has value as a conceptual framework for research and shows promise for future theoretical development.

HIV’s Syndemic Links With Mental Health, Substance Use, and Violence in an Environment of Stigma and Disparities in Japan

“…The results called into question widely held beliefs about low HIV occurrence in Japan, and some of the officially reported epidemiologic trends—including current stabilization of the national epidemic. These findings are discussed elsewhere (DiStefano, 2016).…”

“…Thus, to effectively meet the challenge of HIV syndemics, probably the most urgent need in Japan is to aggressively reduce stigma toward HIV, mental health problems and care, homosexuality, transgender identity, and immigrant groups. In a separate article (DiStefano, 2016), I report my findings on problems in sex education curricula in Japanese schools, particularly in terms of limited content on HIV and sexual and gender minorities. Though detailed discussion of this issue is beyond the scope of this article, positive depictions of sexual and gender minorities and people with HIV in school curricula and learning materials would be one way to address entrenched cultural stigma attached to these groups.…”

Prevalence and correlates of lifetime and recent HIV testing among men who have sex with men (MSM) who use mobile geo-social networking applications in Greater Tokyo

“…Moreover, this figure is likely to be underreported as some small healthcare centers, where approximately 40% of Japanese HIV tests take place, do not differentiate between HIV and AIDS and report all cases as HIV [14]. Furthermore, the volume of HIV tests in Japan has reduced by 35% from their peak of 177,000 in 2008 to 118,000 in 2016 due to fewer advertising campaigns and redirection of resources from HIV prevention to AIDS care, and the subsequent closure of free testing centres [15]. Considering the network of health services providing free testing and access to treatment in Greater Tokyo, HIV testing is still infrequent compared to other countries with similar services.…”

Body/Selves and Beyond: Men’s Narratives of Sexual Behavior on PrEP

“…Ethnographic approaches in multiple contexts have documented widespread lack of awareness of PrEP (DiStefano 2016), and structural and sociocultural barriers to its uptake (e.g., Garcia et al 2015; Syvertsen et al 2014; van der Straten et al 2014). Other forms of qualitative inquiry have documented PrEP-related stigma and uncertainty existing alongside perceptions of valuable potential benefits (Collins, McMahan, and Stekler 2017; Jaspal, Daramilas, and Lee 2016; Schwartz and Grimm 2017; Koester et al 2017).…”