Tackling HIVAIDS Among Injecting Drug Users: Lessons Learned from Thailand

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Tackling HIV/AIDS Among Injecting Drug Users
Lessons Learned from Thailand

• Laila Khondkar
• Asia Fellow (Cohort 6)
• Bangladesh

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Context

• Thailand achieved millennium development goal on
  HIV/AIDS ahead of schedule
• Thailands success in averting HIV/AIDS epidemic
  has won international praise
• In sharp contrast to other groups at risk, HIV
  prevalence among injecting drug users (IDUs)
  never dropped

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Research questions

• How did Thailand address HIV/AIDS among IDUs?
• What policies and practices in Thailand affect
  human rights of IDUs?
• What are the lessons that other countries could
  learn from Thai experience?

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Methodology

• Literature review
• Observation by visiting intervention sites
• In-depth interviews with stakeholders from
  activist groups, government, academia, NGOs,
  international organizations
• Snow-ball technique was used in selecting the
  interviewees
• Interviews were semi-structured
• Study period Sep 2004-May 2005

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• Are we-is the world-now mature enough, now
  wise enough-to accept that the deepest meaning of
  solidarity requires that we consider ourselves as
  we too were infected with HIV-that we are all-on
  a human level-seropositive?
• (Jonathan Mann)

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Conceptual framework link between human rights
and health

• The right to health is based on article 12 of
  International Covenant on Economic, Social, and
  Cultural Rights (ICESCR)
• Human rights offer a theoretical framework to
  discuss marginalization, discrimination, and
  stigmatization
• There are theoretical and empirical links between
  human rights abuses and vulnerability to HIV/AIDS

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Conceptual framework (contd.)

• Human rights violations not only occur to AIDS
  affected people, it is one of the root causes of
  disease
• Populations who are already marginalized before
  AIDS are at a greater risk of HIV infection
• IDUs are usually criminalized, marginalized, and
  discriminated against
• Human rights abuses against IDUs are one of the
  most important causes of HIV transmission

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HIV/AIDS in Thailand

• 1 million people have been infected with HIV
  since the beginning of the epidemic
• National adult HIV prevalence is estimated to be
  1.5
• 600,000 people are living with the virus today

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Present challenges

• HIV/AIDS burden is still high, and is a major
  public health threat to the country
• There is upward trend of HIV risk behaviors among
  youth, homosexuals, and IDUs
• Current prevention efforts are not adequate
• Thailand needs to find effective ways for
  implementation of anti-retroviral (ARV) treatment
• Revised strategies are required to confront the
  disease that has entered a new phase

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Injecting drug use in Thailand

• The actual number of users who inject drugs is
  not known
• Estimates range from 100,000 to 250,000 addicts
• Most of them are males (around 90 percent) and
  mostly aged between 20-24 years

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HIV/AIDS among IDUs

• About one quarter of all new infections is
  occurring through unsafe injecting drug use
• Median HIV prevalence among IDUs is as high as
  50
• HIV is a major killer of IDUs in Thailand
• The situation has remained consistent for nearly
  15 years
• The high prevalence is due to the frequency of
  injecting, widespread sharing of needles, and
  imprisonment of IDUs

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Limitations in addressing HIV/AIDS among IDUs

• Little collaboration between drug control
  programs and HIV/AIDS response
• Narcotic Control legislation does not pay
  attention to the prevention of HIV among IDUs
• Lack of communication between AIDS control
  authorities, Office of Narcotics Control Board,
  and those working in drug treatment
• Technical skills are not very high in addressing
  HIV/AIDS among drug users

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Challenges faced by drug users
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War on drugs

• War on drugs that started in 2003 has been a
  serious blow to IDUs
• The crackdown resulted in the unexplained
  killings of more than 2000 persons and arbitrary
  arrests or several thousands
• The campaign drove numerous drug users into
  hiding and away from the few existing services
• War on drugs increased drug users risk of HIV
  and other health complications

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War on drugs (contd.)

• Government has lots of populist policies. War
  on drugs is one of those. (Activist)
• Society normally discriminate drug users, and so
  most approved governments war on drugs. (NGO
  worker)
• In the short term some people are happy about
  the war on drugs, but in the long run it is not
  going to be effective. We have to address the
  root cause of the drug problem. (Academic)

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Discrimination

• It is not only HIV positive IDUs, there are
  reports of insult or harassment due to HIV status
  among other People Living With HIV/AIDS
• The situation is improving, but discrimination
  is still there.
• People get discriminated in workplace, as
  employers ask them to have HIV test before
  recruitment.
• IDUs face double discrimination if they are
  HIV positive.

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Discrimination

• Some health care workers behave in a way as if
  they are owners of our lives. (Former IDU)
• Sometimes service providers say You are a
  junkie and dont care about your life. Why should
  you get ARV? (Former IDU)

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Negative attitude of the government

• There is no consensus within government on how
  to address HIV/AIDS among drug users. Some are
  progressive, but some have quite rigid views.
  (NGO worker)
• Government does not like drug users.
  (Researcher)
• Prime Ministers personal attitude towards the
  IDUs is partly responsible that Thailand has not
  managed AIDS epidemic well among them. (Activist)

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Lack of participation

• There is no proper partnership between IDUs
  affected by HIV/AIDS and the government
• There is token participation of IDUs in
  committees dealing with HIV/AIDS. (Activist)

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Summarizing the challenges

• Criminal justice approach taken by government
• Non-availability of harm reduction programs
• Limited prevention coverage
• Ineffective treatment interventions
• Discriminatory practices in society and health
  care facilities
• Lack of opportunity for IDUs to take part in
  decision making process affecting them

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Addressing the challenges

• Policy that emphasizes drug suppression only
  needs to be changed
• IDUs should be targeted actively to include them
  in interventions
• Stigma and discrimination that drive drug users
  underground must be eliminated
• Establishing needle and syringe exchange programs
  should be considered
• Better inter-sectoral collaboration needs to be
  promoted

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Addressing the challenges (contd.)

• Technical capacity on drug use and HIV/AIDS
  should be improved
• More research is needed regarding guidelines on
  prevention and treatment of HIV positive IDUs
• Adequate funding support is required to demand
  reduction and HIV/AIDS prevention activities
• Drug users should be given real alternatives such
  as access to education, training, and employment

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Addressing the challenges (contd.)

• Protecting rights, decrease in drug supply,
  and improvement in drug treatment is required to
  address the situation. (Activist)
• Government needs to tackle drug problem in a
  holistic way in stead of focusing on eradicating
  any particular drug, which has happened many
  times earlier. (Academic)

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Lessons learned

• Systematic discrimination and rights violations
  at every level add to HIV/AIDS vulnerability of
  IDUs
• Criminal justice approach towards illicit drug
  use makes it even more difficult to prevent HIV
• Lack of political will is a major barrier in
  addressing HIV/AIDS among IDUs

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Lessons learned (contd.)

• Repressive policies and existing ineffective
  interventions contribute to the HIV crisis among
  IDUs
• Rights violations of IDUs are not acceptable from
  human rights perspectives, and it does not make
  sense from public health point of view

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Conclusions

• Even a best practice model like Thailand does
  not guarantee that HIV/AIDS response has
  benefited all
• Thailand has failed to implement scientifically
  proven policies and international guidelines to
  prevent HIV among IDUs
• State imposed barriers to harm reduction programs
  for IDUs violate their human right to health

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Conclusions (contd.)

• Sound public health rationale based on scientific
  evidence should prevail against moralistic and
  judgmental arguments
• The challenge posed by drug use should be
  addressed within broader socio-economic context
• Protecting human rights of IDUs should be central
  while addressing HIV/AIDS among them

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• I would like those who are concerned about AIDS
  to use the opportunity to develop a more
  compassionate, a more comprehensive view of human
  relationships-we should see the problem of AIDS
  as an opportunity for us to deepen and broaden
  our understanding of fellow human beings. We
  should not stop simply at trying to control the
  disease or caring for those who have contracted
  it but as using it as an opportunity for further
  developing our humanity.
• (Aung San Suu Kyi)

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Acknowledgements

• Asian Scholarship Foundation, Bangkok
• (www.asianscholarship.org)
• Dr. Wassana Im-em, IPSR, Mahidol University
• Dr. Niyada Kiatying-Angsulee, Faculty of
  Pharmaceutical Sciences, Chulalongkorn University