Deadly Denial

Barriers to HIV/AIDS Treatment for People Who Use Drugs in Thailand

Executive Summary and Recommendations

The doctor said if I use drugs, I can't have ART.

-Chai L., age 45, HIV-positive drug user

Thailand is one of the few developing countries to have successfully curbed a runaway HIV/AIDS epidemic, cutting the number of new infections by almost 80 percent since 1991. Among injection drug users, however, prevalence has not dropped, and remains at nearly 50 percent-virtually unchanged over the past two decades.

Thailand is also a global leader among developing countries in providing antiretroviral therapy (ART), with more than 180,000 people living with HIV/AIDS on ART by mid-October 2007. More than 80 percent of people in need of ART in Thailand are receiving it, making it one of three developing countries worldwideand the only one in Asiato achieve this level of coverage.[1]Thailand has also been hailed as a model with regard to its efforts to provide antiretroviral drugs to HIV-positive women to prevent mother-to-child transmission, reaching 89 percent of women who need it. Yet despite repeated proclamations to provide access to antiretroviral treatment to all who need it, the government of Thailand has failed to systematically extend treatment to drug users.

Thailand has refused to implement proven, evidence-based strategies to reduce HIV risk among drug users as promoted by the World Health Organization, UNAIDS, and the UN Office on Drugs and Crime. It has in the past systematically blocked access to HIV treatment for drug users. Most pointedly, in 2003 the Thai government launched a repressive and inhumane "war on drugs" that included thousands of extrajudicial killings of alleged drug users or dealers, and drove drug users further underground and away from effective HIV/AIDS prevention or treatment. The result of these policies is an HIV epidemic among drug users that mars Thailand's reputation as a success story in the global fight against AIDS.Indeed, the Thai government has publicly acknowledged that the HIV infection rate among people who use drugs "has sustained itself at an unacceptably high level in Thailand."

In response to advocacy by people who use drugs, the Thai government has taken steps to reduce some of the barriers to health services. In 2004, for example, the Thai government rescinded a national policy that explicitly permitted the exclusion of injection drug users from ART programs.

Thailand has repeatedly pledged to address its failures to prevent HIV infection or extend treatment to drug users. In its report to the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS in 2006, the Royal Thai Government acknowledged that "little has been done to address specific challenges" of providing HIV testing and counseling, care and support, and ART for injection drug users, and acknowledged that it should "act quickly" to scale up outreach, related harm reduction, ART, and other HIV/AIDS services for injection drug users. At the Special Session itself, the government pledged to promote and implement HIV prevention and harm reduction services for all those who need them, to increase access to methadone maintenance, and to enable and empower drug users to take measures to reduce unsafe injecting practices and to enter treatment programs.The government's 2007-2011 National AIDS Plan, introduced in June 2007, again recognized its failures to address HIV and AIDS among drug users and renewed its commitments to ensure HIV and AIDS services to them.

Research by Human Rights Watch and the Thai AIDS Treatment Action Group (TTAG) found, however, that drug users still face serious obstacles to obtaining needed care. Many healthcare providers either do not know or do not follow the revised HIV/AIDS treatment guidelines and therefore continue to deny antiretroviral treatment to people who need it based on their status as drug users, even if they are in methadone treatment programs. HIV and drug treatment care providers are grossly under-informed and untrained in issues central to the appropriate care and treatment of people who use drugs, and they continue to let their negative attitudes toward people who use drugs inhibit drug users' right to healthcare services. For example, some healthcare providers denied drug users access to ART because of an erroneous conviction that the treatment would be "wasted" on "unreliable" drug users who would fail to adhere to medication, develop resistance to it, or spread drug-resistant HIV strains.

HIV clinicians and drug treatment providers reported that they did not have the knowledge or training they needed concerning interactions between ART and methadone or illicit drugs and the associated consequences. Reflecting another dimension of the same problem, Human Rights Watch and TTAG also found that drug users who do receive ART are unlikely to tell their physicians about their drug use, or to seek information about drug dependence treatment from their ART provider, out of fear of reprisal. This fear is not unfounded: our research confirms that many public hospitals and clinics share information about drug use with law enforcement, both as a matter of policy and in practice. Some ART providers operated a "don't ask, don't tell" policy toward drug users, refusing to inquire about patients' drug use or drug treatment history, in some cases despite knowledge or suspicion of current drug use or methadone treatment.

In this setting, information sharing between drug users and clinicians is a dangerous "catch-22": in a context where police both formally and covertly gain access to hospitals' information about individual drug users, drug users as well as sympathetic healthcare workers have good reason not to disclose any information about drug use. However, failure to ensure conditions in which safe exchange of information is possible can compromise drug users' access to adequate HIV and other healthcare services, and can expose ART recipients to dangerous drug-drug interactions.

International experience has shown that, with adequate support, people who use drugs can adhere to ART regimens and benefit from other HIV care at rates comparable to non-drug users. The World Health Organization, UNAIDS, and the UN Office on Drugs and Crime have recommended that a comprehensive package of linked services-including general medical care, drug dependence treatment, and psychosocial support-is crucial in the treatment of drug users living with HIV/AIDS. Integrated services appropriate to people who use drugs are not provided to drug users in Thailand.

International agencies have also advocated strongly for strategies that reduce the harms associated with illicit drugs even for those unable or unwilling to stop using those drugs. Harm reduction strategies include targeted interventions, often through peer outreach and education, such as the provision of sterile injecting equipment, methadone maintenance therapy, and HIV testing and counseling. All of these actions have proved effective in preventing HIV transmission and other adverse consequences of drug use without increasing drug use or drug-related crimes. These approaches have also been internationally recognized as a key entry point to the healthcare system for people who use drugs.

The Thai government has provided minimal support for harm reduction services for people who use drugs, notwithstanding their proven effectiveness. Basic harm reduction programs for injection drug users such as syringe exchange remain a major point of contention, with government officials ignoring the calls of nongovernmental organizations for such services in favor of abstinence-based approaches to drug use.

Moreover, the limited harm reduction programs available in Thailand are seriously undermined by the government's ongoing, repressive anti-drug campaigns. Police regularly interfere with drug users' health-seeking efforts by harassing clients outside drug treatment centers and by using the possession of sterile syringes or presence at a methadone clinic as a basis for drug charges. A police superintendent in Chiang Mai acknowledged that his office maintained a blacklist of suspected drug users, and said that possession of clean needles, while legal, was a basis for questioning someone on the blacklist. Many government officials seem to be unaware of the fact that it is legal to possess syringes in Thailand. Ministry of Public Health representatives, physicians providing HIV/AIDS and drug treatment services at government clinics, and law enforcement officials told Human Rights Watch that syringe exchange was illegal or impracticable in Thailand, notwithstanding international guidance to the contrary. Many government authorities see needle and syringe exchange programs as "immoral," "foreign," "not Thai, or not appropriate for Thailand," or "encouraging drug use." As a result, peer outreach workers are forced to conduct sterile syringe exchanges underground and are routinely harassed by the police.

The harassment of peer outreach workers has a direct impact on the health and lives of drug users. Many identified their peers as the most important-if not sole-source of HIV-related information, counseling, and support for HIV testing and obtaining basic HIV-related health care and drug treatment. Likewise, the harassment of drug users directly impacts the effectiveness of peer outreach programs.

Many Thai drug users spend time in pretrial detention or prison, often repeatedly. But in custodial settings drug users have an even harder time obtaining needed HIV prevention, care, and treatment services. Thailand has no national guidelines on ensuring access to ART on entry to or exit from prison. Human Rights Watch and TTAG found that antiretroviral therapy was available only on an extremely limited basis to Thai prisoners. Further, we found that the Thai government has failed to take measures to ensure that fundamental services (medical care, harm reduction, drug dependence treatment, psychosocial support) are coordinated in the general community, or with services provided on entry to or exit from prison. All of these services are a critical part of comprehensive HIV care for drug users.

Thailand's failure to ensure equal access to antiretroviral treatment to drug users, and to ensure access to harm reduction services violate its constitutional obligations to provide "quality public health services" and protection "against dangerous infectious diseases" "free of charge and in a timely fashion."

Thailand's failure to ensure comprehensive HIV/AIDS services to drug users according to international standards violates its obligations to respect and fulfill the right to health. Refusal to provide ART based on an individual's drug user status violates the right to non-discrimination. The failure to create conditions to promote open exchange of information about drug use, and to protect the confidentiality of information about drug use, compromises fundamental rights to information and to health, and may violate the right to privacy.

Thailand needs to take urgent steps to address the various failings identified in this report. Human Rights Watch and the Thai AIDS Treatment Action Group make the following key recommendations:

Recommendations

To the government of Thailand

Increase harm reduction services for drug users:

Develop a clear national harm reduction policy, consistent with international standards, in consultation with high-level officials from the Ministry of Public Health, the Office of the Narcotics Control Board, the Ministry of Interior, the Ministry of Justice, the National Police Office, the Prime Minister's office, Thai and regional non-governmental HIV/AIDS and harm reduction organizations, relevant United Nations officials and offices (such as the Joint United Nations Programme on HIV/AIDS (UNAIDS)), the U.N. Special Envoy for HIV/AIDS in Asia, and the United Nations Office on Drugs and Crime) and people who use drugs

Establish and integrate needle and syringe exchange, methadone maintenance therapy, and other evidence-based harm reduction interventions into the existing Continuum of Care Centers in Thailand.

Ensure that drug users have access to harm reduction services, including methadone and sterile syringes, and that cost or fees are not a barrier to such access. This would be consistent with the constitutional provision that all persons shall be protected "against dangerous infectious diseases" "free of charge and in a timely fashion."

Establish clear, time-bound targets for extending the provision of low-threshold harm reduction services to all parts of the country.

Take concrete steps to reduce drug users' fear of seeking health services:

Immediately and publicly declare that drug users seeking health services will not be penalized or forced into drug treatment based solely on their identification as drug users, and amend relevant laws and policies to ensure prompt compliance with this policy.

Provide basic training to police on HIV/AIDS prevention, care, and treatment, and the importance of harm reduction in the fight against HIV/AIDS.

Take active steps to address drug users' distrust of public health services. This should include concrete measures to ensure that information about patient drug use provided in the course of medical care is not shared with law enforcement officials and to establish and sustain active cooperation with harm reduction programs and outreach workers.

Train healthcare providers in the appropriate care and treatment of people who use drugs. This should include human rights training to reduce stigma and discrimination against people who use drugs.

Take concrete steps to ensure drug users' rights to information:

Ensure that drug users, healthcare providers, and law enforcement officers have complete, accurate information about ART, HIV/AIDS, and harm reduction services, and information about drug users' rights to these services.

Ensure that drug users can obtain ART, harm reduction, and other HIV/AIDS information and services without fear of punishment or discrimination.

Expand and enhance the scope of and support for ART, harm reduction, and other HIV/AIDS information and services including voluntary HIV testing and counseling for people in prison and other places of detention.

Provide information and training to healthcare providers about basic principles and practices of providing antiretroviral treatment to injection drug users, including about adherence support; drug-drug interactions; and co-infection, such as with tuberculosis and hepatitis C.

Provide information and training to drug users about HIV/AIDS-related services, including ART, drug interactions, tuberculosis, and hepatitis C.

Provide support for peer outreach and education workers, including as counselors for HIV testing, ART adherence support, and harm reduction.

Establish and strengthen communication among relevant ministries (including the Ministry of Public Health, the Office of the Narcotics Control Board, the Ministry of Interior, the Ministry of Justice, the National Police Office, and the Prime Minister's office).

Address structural barriers to care:

Adopt and disseminate a clear national policy to ensure coordination of basic services for drug users (HIV/AIDS services, harm reduction, drug treatment, psychosocial support) and ensure that such services are coordinated between those provided in the community and in custodial settings.

Develop effective referral systems between HIV, drug treatment, and other relevant services to link community and custodial settings.

Ensure that people who use drugs enjoy an equal right to receive public health and welfare services, and protection against disease. The Thai constitution provides that there should be guaranteed access to public health and social welfare services.

To the government of the United States

• Lift the ban on U.S. funding for syringe exchange program services.
• Officially recognize the importance of harm reduction in preventing HIV/AIDS and other infectious diseases, and encourage and support international efforts to implement harm reduction interventions, including measures to ensure access to sterile syringes.

To the United Nations and International Donors to Thailand

• Relevant United Nations agencies (including UNAIDS, WHO, UNODC, the U.N. Special Envoy for HIV/AIDS in Asia, and the U.N. Special Rapporteur on the Right to Health) and international donors to Thailand should take steps to ensure that Thailand promptly and immediately adopt concrete measures to address drug users' fear of seeking health services, and that Thailand promptly and immediately meet its public commitments to ensure harm reduction, ART, and other HIV/AIDS services for drug users.

Methods

This report is based on information collected during field investigations in Thailand in June-July and November-December 2006. Two Thai AIDS Treatment Action Group (TTAG) staff members and a Human Rights Watch staffer conducted detailed individual interviews with 43 current and former drug users and spoke more informally with two groups of drug users at drop-in centers for methadone patients and for people living with and at high risk of HIV/AIDS. The interviews took place in Chiang Mai, Bangkok, Samut Prakhan, Songkhla, and Satun provinces, five diverse provinces with high concentrations of injection drug users.Interviews were conducted either in Thai or with translation to and from English. Interviews with drug users were arranged through nongovernmental organizations (NGOs) providing services to drug users living with and at high risk of HIV/AIDS. These interviewees may therefore have had greater access to harm reduction and HIV/AIDS services than the general population of people affected by HIV/AIDS. The identity of these interviewees has been disguised with pseudonyms and in some cases certain other identifying information has been withheld to protect their privacy and safety.

Additional interviews were also conducted in Thai or with Thai-English translation with healthcare workers providing HIV/AIDS care and/or drug treatment services, including chief medical staff at Thailand's largest prison, and the directors and staff of the two largest government inpatient drug treatment centers and a major government inpatient compulsory drug treatment center; high-level officials in the Office of the Narcotics Control Board, the Ministry of Public Health at national and provincial levels; local police; representatives of domestic and international NGOs working with drug users and people living with HIV/AIDS; and United Nations (UN) officials. All documents cited in the report are either publicly available or are on file with Human Rights Watch and TTAG.

Background

Thailand as an HIV/AIDS "Success Story"

Thailand is one of the few developing countries to have successfully curbed a runaway HIV/AIDS epidemic, cutting the number of new infections by almost 80 percent since 1991.[2] It is a global leader among developing countries in providing antiretroviral therapy (ART), with more than 180,000 people living with HIV/AIDS on ART by mid-October 2007.[3] More than 80 percent of people in need of ART in Thailand are receiving it, making it one of three developing countries worldwideand the only one in Asiato achieve this level of coverage.[4]Thailand has also been hailed as a model with regard to its efforts to provide antiretroviral drugs to HIV-positive women to prevent mother-to-child transmission, reaching 89 percent of women who need it.[5]

HIV/AIDS and Injection Drug Use in Thailand

In stark contrast to other groups at risk of HIV, such as sex workers and military recruits, HIV prevalence among Thailand's injection drug users has never shown significant decline.[6] Injecting drug users were Thailand's "first wave" of HIV infection. HIV prevalence among this group skyrocketed from virtually nil to 40 percent in a single year when it was first identified in 1987-88.[7] The consequences of Thailand's failure to adopt harm reduction strategies immediately, despite the government's awareness of their effectiveness as determined by local studies (see below), can be measured in the sustained high HIV infection rates among injection drug users to date. The Thai Working Group on HIV/AIDS Projections estimated in 2001 that with a significant investment in programs that reduced needle-sharing among injection drug users, the number of new HIV infections in Thailand could drop from 29,000 in 2000 to 11,800 in 2006. Without such an investment, the number of new infections in 2006 would be 17,000[8] -- approximately the number of new infections reported in 2006.[9]

The UNDP reported in 2004 that one-quarter of all new infections occurred among injecting drug users.[10]At a high-level UN meeting on HIV/AIDS in 2006, the Thai government publicly expressed concern about the HIV infection rate among people who use drugs, acknowledging that it had "sustained itself at an unacceptably high level in Thailand since the very beginning of the epidemic."[11]

By 2003 HIV prevalence among injection drug users at Thailand's addiction clinics stood at approximately 45 percent, exceeding the 1988 levels.[12] Prevalence among injection drug users may be as high as 60 percent in some regions, according to sentinel surveillance conducted in 39 sites in 2000.[13] An estimated 3 to 10 percent of injection drug users are newly infected each year, chiefly through contaminated injection equipment.[14]

Thailand has made a number of public commitments to address its failure to combat HIV/AIDS among drug users that have, to date, remained unfulfilled. In its 2006 report to the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS, the Royal Thai Government acknowledged that "little has been done to address specific challenges" of providing HIV testing and counseling, care and support, and ART for injection drug users, and acknowledged that it should "act quickly" to scale up outreach, related harm reduction, ART, and other HIV/AIDS services for injection drug users.[15] At the Special Session itself the government pledged to promote and implement HIV prevention and harm reduction services for all those who need them to increase access to methadone maintenance, and to enable and empower drug users to take measures to reduce unsafe injecting practices and to enter treatment programs.[16] And in its 2007-2011 National AIDS plan, introduced in June 2007, Thailand recognized its failures to address HIV/AIDS among people who use drugs, and renewed its pledge to scale up efforts to ensure access to HIV/AIDS prevention, care, and treatment services to them.[17]

An estimated 3 million people (5 percent of the population) use drugs in Thailand. While the majority of drug users take methamphetamines, an estimated 100,000 to 275,000 use heroin, 80 percent of whom inject. In 2003 the Thai government launched a "war on drugs" campaign, which is discussed below. Studies suggest that one unintended consequence of this war on drugs may have been increased injection of sedatives (particularly midazolam) among heroin injectors.[18] Injection of methamphetamines, opium and cocaine has also been reported.[19]

Narcotic Drug Law and Policy in Thailand

Thai law and policy regarding drug users has only recently begun to reflect the international consensus that drug dependence is an illness to be treated, and not a crime to be punished.

As far back as 1991 a Bangkok Metropolitan Administration study showed that patients on "methadone maintenance" (in this case, 180 days) were much less likely to return to heroin use than those on a "methadone detoxification" program (here, 45 days).[20] However, it was not until 2001 that the Ministry of Public Health changed its policy to allow for methadone maintenance, and even then limited treatment to a maximum of two years.[21]

The number of people incarcerated in Thailand more than tripled between 1992 and 2001, largely due to tough drug policies.[22] By February 2002, there were 25o,000 people incarcerated in correctional facilities throughout Thailand almost three times official capacity[23]-and nearly two-thirds of those in prison were drug offenders.[24] In 2002, to address serious problems associated with prison overcrowding, Thailand amended its Narcotic Addict Rehabilitation Act to provide alternatives to incarceration for some drug offenses.[25] The law, which considers "drug addicts" as "patients," and not "criminals," provides for up to six months compulsory treatment (in lieu of incarceration), renewable for up to three years, for "drug users" or "drug addicts" found to have used or been in possession of small quantities of illicit drugs. After rehabilitation, a committee appointed by government authorities considers whether a person has been "rehabilitated," or whether criminal proceedings should be instituted.[26]

But Thailand's harsh drug control laws have not been amended to accommodate the spirit of the 2002 Narcotic Addict Rehabilitation Act. Thai narcotics law criminalizes the possession of extremely small amounts of drugs for personal use and gives wide powers of search, seizure, and arrest to the police.[27]The Thai government provides significant financial resources to local communities to assist with identification and reporting of drug users and dealers. According to Pithaya Jinawat, deputy secretary general of the Office of the Narcotics Control Board (ONCB)(the coordinating and policy-making bureau for drug control efforts), the ONCB actively recruited villagers to assist ONCB with local-level surveillance of drug users and dealers and to share information about drug use and drug users with them. Jinawat said that 200 million baht[28] had been allocated to village committees to assist with local-level surveillance, and that more than 10,000 villages (out of 85,000) were involved this work.[29]

Since 2003 the government of Thailand has periodically declared successive rounds in its "war on drugs," which in its earliest stages involved arbitrary and brutal practices including at least 2,275 extrajudicial killings of alleged drug users or dealers.[30]In its investigation into killings in the first phase of the war on drugs, the National Human Rights Commission found that the victims were mostly innocent persons whose deaths in 2003 had never been properly investigated, and that some of the murders plainly had been set up by the police.[31] In its 2005 report on Thailand, the UN Human Rights Committee expressed concern over "the extraordinarily large number of killings during the 'war on drugs' which began in February 2003," and government failure adequately to investigate these killings, or prosecute and punish the alleged perpetrators.[32]

Four-and-a-half years after the first and most violent phase of the war on drugs, and more than two years after the Human Rights Committee issued its findings, the government has just begun to conduct full and impartial investigations into the killings, and institute proceedings against their perpetrators.In August 2007 Thailand's interim military government appointed six sub-panels to investigate the extrajudicial killings in the 2003 war on drugs and to analyze the impact of the drug suppression policies implemented during that regime, ostensibly to prevent violations from occurring again.[33]

Providing HIV Care and Treatment to People Who Use Drugs: General Principles

International experience has demonstrated that with adequate support, people who use drugs can adhere to antiretroviral treatment regimens and benefit from other HIV care at rates comparable to non-drug users.[34] Drawing on this experience, the World Health Organization (WHO), the United Nations Office on Drugs and Crime (UNODC), and UNAIDS have identified important principles governing the delivery of HIV care and treatment to people who use drugs to facilitate their optimal access and adherence to antiretroviral therapy, which are summarized below.[35]Thailand's constitution and its national HIV/AIDS policies recognize these principles and their importance toward reaching the national goal of universal ART access.[36]

Antiretroviral treatment should be provided on an equitable basis to all who need it, based on internationally accepted clinical criteria.Current or past drug use should not be a criterion for deciding who should receive antiretroviral treatment.

Healthcare services should be comprehensive, and integrated with general medical care, harm reduction services, drug dependence treatment, and psychosocial support.

People who use drugs have proved effective as peer counselors and educators in facilitating and supporting HIV care and treatment to their peers, and should be involved in the design and delivery of integrated treatment programs.

Open communication about drug interactions must be guaranteed. The

WHO specifically advises healthcare providers to "counsel every patient on all possible interactions of ARVs with other drugs administered, including substitution therapy drugs, illicit/recreational drugs, and medications for tuberculosis, hepatitis B, hepatitis C, and opportunistic infections. Awareness of interactions and reporting and management of symptoms is critical for the patient's well-being, treatment adherence and effectiveness, and management of drug interactions."[37]

Viral hepatitis and tuberculosis should be addressed as components of HIV treatment and care. Co-infection with hepatitis B, hepatitis C, and/or tuberculosis is common among HIV-positive injection drug users. Healthcare workers providing HIV/AIDS treatment to drug users must understand the dynamics of co-infection with HIV and hepatitis B, hepatitis C, and tuberculosis, and be trained to provide appropriate diagnostics, treatment, and monitoring for these conditions.

Healthcare services should be coordinated with harm reduction programs.Harm reduction programs can be a key entry point to the healthcare system for people who use drugs, and have proved effective in improving uptake and adherence to HIV care and treatment for HIV-positive drug users. The WHO's South-East Asia and Western Pacific regional offices have recognized the important role that harm reduction programs have played in facilitating drug users' access to HIV care and treatment in Indonesia, where by mid-2006 91 syringe exchange programs and seven methadone programs (including one in prison) had been set up by the government.[38]

HIV/AIDS treatment and care must be provided in prisons and custodial settings as in the general community. Many drug users spend time in prisons or other closed settings such as police detention, compulsory drug treatment centers, or "rehabilitation" centers. In many countries the rates of HIV infection among prisoners and people in state custody are significantly higher than those in the general population. Incarcerated drug users may have begun drug dependence and/or HIV treatment prior to incarceration and face abrupt withdrawal and/or ART interruption while in custody. Prisons and closed settings thus present a key opportunity to address HIV/AIDS and drug dependence. Prisoners must be ensured access to comprehensive drug dependence and HIV-related services, including harm reduction, opioid medication-assisted therapy, and antiretroviral therapy. Ensuring continuity of services both on entry to and on release from prison is also critical.

Legislation, policies, and standards that enable implementation of effective services for drug users are key to ensuring access to healthcare services. Drug users throughout the world face a wide range of human rights abuses that put them at risk of HIV and other diseases, and impede their access to HIV/AIDS and other health care services to address them. Supportive legislation, regulations, policies, and attitudes that prevent the marginalization, discrimination, and stigmatization of drug users, and protect their human rights and dignity, are critical to ensuring access to comprehensive HIV/AIDS-related services for drug users.[39]

Findings

Drug Control Policy and Policing Practices Impeding Access to ART

Although official policy in Thailand now emphasizes rehabilitation over punishment (treating low-level or first-time drug offenders as "patients" not "criminals"), drug users remain under surveillance by police and anti-drug agencies, and information about patient drug use is shared among public health and law enforcement agencies. As Human Rights Watch and others have documented, a lasting consequence of the war on drugs has been that drug users seeking protection from police violence, forced rehabilitation, and arrest were driven underground, away from critical health and support services, and put at increased risk of HIV.[41]Human Rights Watch and TTAG found that, as a result of these past and ongoing practices, many drug users avoid public healthcare services altogether, foregoing necessary health care or seeking treatment at private institutions where they are forced to pay for services that they are entitled to receive free of charge from the government.

Police Registration of Drug Users

Drug users and outreach workers said that the "war on drugs" has had a lasting detrimental effect on drug users' access to healthcare services, and that many drug uses would not seek treatment at public hospitals out of fear that information about their drug use (past or current) would be shared with the police. Indeed, public hospitals and drug treatment centers collect and share information about individuals' drug use with agencies including law enforcement as a matter of policy and practice.

When asked whether things had changed since a recent round in the war on drugs had been declared in May 2006, Lek L., a 28-year-old outreach worker in Chiang Mai, replied, "You can say it's better if you look at the number of people killed. What is worse is the number of people who fear and won't seek services." He continued that, as a peer outreach worker, he had learned that drug users' primary concern was that if they reported to any government office they would be "blacklisted," or registered as drug users, and their names would remain on the list.[42] At K., age 33, an HIV-positive peer educator in Chiang Mai, explained that HIV-positive drug users like him "would not go to the hospital unless we are dragged there." "The war on drugs has had an impact on me personally," At K. said, "The policy continues. HIV-positive injection drug users won't see the doctor because this policy has been there for too long and it's starting again now. My friends won't dare go to the hospital. My friends say it's a state unit, it's a government office."[43]

Drug users reported using private health clinics when seeking treatment for anything that might reveal their status as drug users (such as for treating abscesses or obtaining methadone.) Not only is this costly, but it also means that drug users are less likely to obtain information about government-funded HIV/AIDS services (including low-cost antiretroviral therapy) to which they are entitled.

It R., age 27, said that he was afraid to seek treatment at a public hospital for anything related to drug use, and that in mid-2006, when his friend had an injection-related injury, It R. took him to a private hospital for treatment. It R. explained that private hospitals did not ask for personal information and would not give it to police. "I am concerned that the state hospital would give information to the police. I feel more comfortable to pay more money than to risk my life."[44]

Ministry of Public Health and Office of the Narcotics Control Board officials explained that public hospitals registered information about active drug users on forms that were submitted via the internet to a central office at the Ministry of Public Health.[45]Rachanikorn Sarasiri, director of the ONCB's Foreign Affairs Bureau, explained that these forms were used "to monitor the drug use situation"; Sarasiri and her ONCB colleague further explained that this information was available to ONCB, to police involved with compulsory treatment, and in rehabilitation centers.[46] Gen. Bovorn Ngamkasem, consultant with the NationalCommandCenter for Combating Narcotic Drugs in the Ministry of Public Health, said that drug users' names also were shared with the local Ministry of Public Health and with members of the district committee, which included police. According to Ngamkasem, "If you come to the hospital with a broken leg and volunteer for [drug] treatment, they will put your name in the Ministry of Public Health network. This information is not given to police automatically, but if police ask for information about people who have been for drug treatment, they can get it."[47]

A police superintendent in Chiang Mai-the site of many extrajudicial executions during the 2003 "war on drugs"-acknowledged that his office maintained a blacklist of suspected drug users: "[W]ho was likely to be a user, an addict, or a dealer Each amphur [district] must send their list to the provincial headquarters, which will then chase us up on whether those on the list have been arrested or not. They monitor us and follow up." The police lieutenant explained how they collected information about drug users from both state and private hospitals. "State hospitals must send us the names of users who seek treatment at hospitals in our zone. In the case of private hospitals we have to use other methods, for example send a policeman or a spy to get close to a member of the hospital staff and then ask who their patients are and where they live." When asked whether these surveillance practices affected drug users' access to healthcare services, the police superintendent replied, "For sure! Sometimes they are not ready to disclose that they are a drug user because the police will be told and then they will have to have a urine test at the station. If the test is positive they will be charged. If it's negative we put them under observation."[48]

Healthcare officials differed on the question of information sharing with police. Some officials at public hospitals acknowledged that they would report any drug user to police, and that this kept drug users from seeking antiretroviral treatment at public hospitals. For example, Dr. Anchalee <<Avihingsanon, an HIV clinician in Bangkok, said that hospitals were required to report active drug users to state officials, adding that "active drug users are afraid that they are going to get caught and sent to police or to a drug treatment program."[49] However, Thinmanee Tippanya, the chief of the drug abuse section of Chiang Mai's provincial health authority commented, "Drug users have told me that if they disclose information to health officers, they don't trust that the information won't be leaked to police. We say as a public health officer, our emphasis is on health, not detection of drug use." According to Tippanya, information about drug users arrested and subject to the 2002 Narcotic Addict Rehabilitation Act was routinely shared with police, but that information disclosed about drug use during the course of voluntary health care or drug treatment would not be shared with police.[50]

In fact, pursuant to the 2002 Narcotic Addict Rehabilitation Act, the identity and other information about drug dependent persons referred for consideration under the Act is available to all persons assigned to enforce the Act, which includes representatives of the Ministry of Justice and the Department of Probation, as well as medical doctors, social workers, psychologists and in some cases, ex-drug users or people who work in Rehabilitation Centers.[51]

Tippanya added, "Personally, I think that drug users should disclose openly to health officers so they can get the right treatment and their health will improve. But they may have gotten the wrong information and fear that if they disclose to us, police will know. But as a public health officer, I tell people I do not disclose information about drug use to police." She acknowledged, however, that police nonetheless managed to get this information. "But of course, police have ways They have their spies to get information."[52]

Preserving the confidentiality of medical information is protected by international law[53] as well as Thai law.[54]While the right to privacy does not establish an absolute rule of confidentiality of medical information, interference with this rule must be strictly justified. While limited information about patient drug use may be permitted in certain circumstances (for example, to establish patient compliance with compulsory drug treatment programs mandated pursuant to the 2002 Narcotic Addict Rehabilitation Act), such broad sharing of information about drug use, especially in the context of harsh government crackdowns on drug users, is not justified.

Interference with Harm Reduction Services

The Thai government has made numerous public commitments to develop and implement harm reduction programs on a national scale for people who use drugs, and specifically recognized their importance as an entry point for HIV treatment for drug users.[55] But the government has provided minimal support for harm reduction services for people who use drugs, notwithstanding their proven effectiveness, and in some cases government agents have directly interfered with them. In February 2004 the United Nations Office on Drugs and Crime estimated that barely 1 percent of injection drug users in Thailand were receiving harm reduction services.[56] A July 2006 study by USAID found no improvement, reporting that harm reduction reached 1 percent of injection drug users in Bangkok.[57]

The possession and sale of needles and syringes is legal in Thailand, and they can be purchased from a pharmacy without a prescription. However, under Thai law the possession of paraphernalia can be used as evidence to establish "the commission of an offense related to narcotics."[58] The National Police Office has issued a memorandum instructing that possession of injecting equipment is not grounds for arrest.[59] In practice, however, police regularly interfere with drug users' efforts to take measures to prevent HIV, including using the possession of sterile syringes or presence at a methadone clinic, as a basis for drug charges.

The police superintendent in Chiang Mai who acknowledged that his office maintained a blacklist of suspected drug users (see above) said that possession of clean needles, while legal, was a basis for questioning someone on the blacklist. The Office of the Narcotics Control Board confirmed that in practice even clean syringes would sometimes be taken by police officers as evidence of drug use.[60]

Government officials-including Ministry of Public Health representatives, physicians providing HIV/AIDS and drug treatment services, and law enforcement officials-said that syringe exchange was either illegal or impracticable in Thailand, notwithstanding international guidance to the contrary, and many government authorities see it as "immoral," "foreign," "not Thai, or not appropriate for Thailand," or "encouraging drug use." US government policy banning the use of US funding for syringe exchange services also undermines harm reduction work.[61] Peer outreach workers with US-funded organizations said that their employers instructed that syringe provision was prohibited by the terms of their organizations' agreements with USAID, which are governed by US law.[62] Though US-funding recipients could choose to use other funding for syringe exchange, outreach workers to drug users throughout Thailand said that their employers did not do so. Lek L., an outreach worker with a US-funded organization in Chiang Mai, said, "It's not [my employer's] policy to provide needles. [My employer] gets USAID money, and USAID doesn't support needle exchange."[63]

Peer outreach workers promoting syringe exchange face harassment and abuse by police, who recognize them as drug users, and risk arrest for carrying syringes or suspected distribution. As Prem C., an outreach worker to drug users in Bangkok, explained, "We cannot provide needles because it is against the law. It is considered to be promotion. If we carry needles, we can be arrested and have our urine tested."[64]

Outreach workers also reported being targeted for police harassment at the Bangkok methadone clinic where they worked and facing repeated harassment and arrest, including having been arrested outside the methadone clinic two days before meeting with Human Rights Watch and TTAG. Prem said, "At the time [of the arrest], we had just had an outreach activity in the members' room at the clinic, and we were taking a lunch break, smoking outside the clinic."[65] Daeng P., an outreach worker with Prem C., told researchers, "I was in front of the clinic, near a public phone. The police said, 'Don't move! We've been looking for you.'Three or four police came; they were aware we are former drug users. They searched us in front of the clinic and made us lose face in front of our peers. They took six of us down to the police station, where we stayed for two hours. The police said if we didn't want to be arrested, we should help them find dealers."[66]

Obstacles to ART in Healthcare Settings

Denial of Antiretroviral Treatment to Drug Users

In 2004 Thailand amended national guidelines that had until then excluded active drug users from eligibility for antiretroviral treatment.[67] This policy change has apparently benefited some drug users, who are now receiving ART under the government program.[68] But the government did not follow its policy change with awareness raising and training, and therefore many healthcare providers do not know or do not follow the revised guidelines. HIV clinicians variously reported that hospital policy was to deny drug users ART, notwithstanding what they knew to be government policy to the contrary, or contended that government policy excluded drug users from government ART programs and therefore drug users were not eligible for ART. In both circumstances the denial extended to drug users on methadone treatment (see below).

HIV clinicians in two of the provinces visited openly stated that they would not provide ART to active drug users. Dr. Somsak Wasuwithitkul, deputy director of a district hospital in Satun province, said that hospital policy was to exclude active drug users from antiretroviral treatment, despite government policy to the contrary. "It's not the Ministry of Public Health regulation, but if a patient is still using drugs, they will not start antiretroviral therapy."[69] A nurse at a provincial hospital in the south who provided HIV counseling for people living with HIV, including patients on ART, said that at her hospital, "We ensure that the patient has stopped using drugs, or the doctor won't provide antiretroviral treatment to them."[70] This nurse understood abstinence from methadone or drug use as a condition of eligibility under the national ART program. She said that "according to the [the government-funded program], a patient has to stop using drugs to be entitled to enroll in the program."[71]

Health care providers justified denial of ART to drug users based on concerns that drug users would not adhere to antiretroviral regimens, and that drug or methadone use would undermine the effectiveness of ART.[72]

Drug users throughout Thailand reported having been told that they could not get ART if they used drugs. The comments of NoiI., a Bangkok drug user, were typical. She told researchers, "I went to the doctor [at a Bangkok hospital] and said that I have HIV, how do I get treatment? He said that I have to give up drugs. The doctor is afraid that the medicine would go against the drugs. The social worker talked to me personally and said that the medicines would not work well if I was still on drugs. I never returned. I moved to a different health center. I never got ART, just drug treatment."[73]

Not surprisingly, drug users reported that they would not disclose drug use to an HIV clinician out of fear that they would be forced to leave the ART program (if they were receiving ART) or considered ineligible to receive ART. Thien C., age 44, a peer outreach worker in Bangkok who was on ART, said that he would not disclose his drug use to his doctor, "because I think I would get kicked out of the program."[74] Lek L., an outreach worker in Chiang Mai, said that alongside fear of being "blacklisted," a chief preoccupation among drug users was that physicians would refuse to provide them with treatment. "Most doctors require that people quit drugs before they get ART. Drug users may lie to the doctor if they have no record. Some can't get substitution [medication-assisted] therapy and some people die."[75]

Bias against drug users among PWA outreach workers

People living with HIV play an important role in facilitating access to antiretroviral therapy for their peers. This is particularly true for hospitals that are "comprehensive continuum of care" centers (CCCs), where people living with HIV/AIDS are included as part of the CCC team. In addition to providing adherence and other counseling to people living with HIV, they often function as gatekeepers to antiretroviral treatment by assisting HIV clinicians in identifying people living with HIV who might be in need of ART.

Outreach workers to drug users said that leaders of people living with HIV/AIDS groups were biased against drug users, whom they presumed were incapable of responsibly taking ART, and that they blocked drug users from obtaining ART by refusing to refer them to physicians for treatment. An outreach worker to drug users in Samut Prakhan said that the leader of a hospital-based group of people living with HIV had refused to assist him in obtaining referrals to ART for drug users with AIDS, and had made plain that he did not think drug users deserved treatment.

They think that if they only have one pill [limited ART], they would prefer to give it to a non-drug user, because a drug user won't take ART responsibly and will continue to get high.

I was told this by a peer counselor to people with HIV This is from one of the PWA leaders. This guy is in charge of giving counseling to people who test positive. He's a leading PWA with the new friends club. He is an employee of the CCC. He said this when [name withheld] was taken there and his CD4 was three.[76] I asked why he didn't give [name withheld] ART. He said he was going to die anyway; better to save the ART. Another friend who was seriously ill tried to get advice from this guy about why his friend was not referred to Bamrasnaradura hospital [in Nonthaburi province]. He said it doesn't matter where he's referred, because he will die anyway.[77]

Problematic Approaches to Methadone Patients

Methadone maintenance therapy has been shown to improve uptake and adherence to ART for HIV-positive opiate users.[78]Its integration into HIV/AIDS care and treatment programs has thus been recommended by international drug and health organizations.[79] Coordination between methadone and HIV/AIDS treatment programs is critical because interactions between antiretroviral drugs and methadone (as well as other drugs) have a range of consequences for people using antiretroviral drugs together with other drugs. This includes the need for increases in methadone when given, for example, with certain common first- and second-line HIV therapies provided in Thailand, such as nevirapine, efavirenz, nelfinavir, and lopinavir.[80] Both efavirenz and nevirapine interact with methadone, decreasing concentrations of methadone, and causing withdrawal symptoms (interactions with heroin and other opiates are similar). The WHO notes that methadone withdrawal is common, and that "significant methadone dose increase" is usually necessary for patients receiving efavirenz or nevirapine.[105]

Healthcare providers have an important opportunity to provide counseling as well as referral to appropriate care, treatment, and prevention services when individuals return for test results. But healthcare providers failed to take advantage of this opportunity when reporting HIV test results to drug users. When asked how he was informed of his test results, Pong H.said, "The officer just said you are positive. He didn't tell me the difference between HIV and AIDS. There was no information about how to take care of yourself. They just said, "You're positive.""[106] When Wat V. returned for his test results, the social worker told him "You have to be able to bear with it. Can you take it?'" When he said yes, she called him and told him, "You have HIV, and you have to look after your health. But it's not at the level where you have to take drugs. You also have hepatitis C."[107]

Hepatitis C

Hepatitis C virus (HCV) is endemic among injection drug users in Thailand.Government health officials were forced to acknowledge the HCV epidemic after a series of studies reported that HCV prevalence among Thai injection drug users was greater than 90 percent.[108] Due to overlapping modes of transmission, HCV is highly prevalent among HIV-positive injection drug users. Studies by Thai researchers have found extremely high HIV/HCV co-infection prevalence among injection drug users, including coinfection levels as high as 99 percent among injection drug users in prison. [109]

HIV treatment is especially important for co-infected persons. ART may delay hepatitis C progression and decrease liver-related mortality in co-infected persons, but HIV drugs must be selected carefully, since some-including those provided in Thailand through the government treatment program-are particularly liver-toxic.[110]

Hepatitis C is treatable regardless of HIV status. Indeed, the strain of hepatitis C common in Thailand (genotype three) has one of the best prospects for successful treatment.[111] HCV can be eradicated in approximately 50 percent of mono-infected persons, and up to 44 percent of co-infected individuals. HCV treatment has additional benefits, even for non-responders: it has been associated with decreased liver inflammation and a lower risk of liver-related mortality.[112]

Given the prevalence of hepatitis C among Thai injection drug users, it is astonishing that many drug users have little or no information about hepatitis C transmission, prevention, natural history, or treatment. Healthcare workers and service providers-including HIV clinicians and drug treatment providers-also lack this crucial information.

HCV is preventable if drug users are given the knowledge and the means to protect themselves and each other. There is ample opportunity to prevent new HCV infections among Thai injectors since most become infected with hepatitis C within two to three years of initiating drug use.[113] Unfortunately, there is no organized hepatitis C prevention program in Thailand. The majority of Thailand's injection drug users are unaware of their HCV status and cannot get tested or treated. Neung P., 47, a longtime peer educator, ran a drug treatment center for 22 years where he worked with scores of injection drug users. He told researchers,

There's almost no information about hepatitis. If it's HIV, they know. But almost no doctors have information about hepatitis C. If I hadn't come into contact with the Thai Drug Users Network, I wouldn't know about hepatitis C. [114]

In Thailand, hepatitis C treatment costs well over US$10,000 per person and is therefore unattainable for most drug users. The government does not provide a comprehensive care package; diagnostics and monitoring, such as hepatitis C viral load and liver enzyme testing are not available to persons who cannot afford them. Neung P. told researchers, "I went to a private hospital and said, 'I've got hepatitis C and I want to be treated.' [The doctor] said, 'That's impossible. It's nearly impossible to find hepatitis C treatment in Thailand.'"[115]

Hepatitis C treatment is available in Thailand, however. The major barrier is its prohibitive cost. According to Dr. Anchalee Avihingsanon, an HIV clinician in Bangkok, "99 percent of people with hepatitis C can't get treatment. You can only get treatment if you have the money."[116]Dr. John Lewitworapong, director of medical services at Klong Prem Central Prison explained, "We don't check for hepatitis C because it's expensive."[117]

The lack of information about hepatitis C and hepatitis C/HIV co-infection keeps drug users from getting appropriate treatment for both conditions. Thien C., who is co-infected, did not start antiretroviral therapy until more than a year after learning that his CD4 count had dropped to less than 200 cells/mL , when he therefore qualified clinically for ART, thus putting him at needless risk in the meantime for opportunistic infections and serious liver damage. Although Thien's physicians knew that he had been an injection drug user, he never received any information about hepatitis C from them. After learning from his peers that he was at risk for hepatitis C, he got tested and diagnosed with HCV. He had to switch hospitals twice before he was he able to enroll in an ART program. Thien told researchers that after learning that his CD4 count was less than 200, "I asked when I would get ART I kept asking them because I knew the CD4 criteria. This was in 2004. They told me to take care of my liver first. I was not given any treatment for my liver. They asked me how I got HIV. I told the doctor it was from drugs. [The doctor] said your liver is not good. . . It was about a year before I got ART."[118]

Access to HIV-related Services in Custodial Settings

Many Thai drug users are incarcerated at some point in their lives, including in prisons, remand or pretrial centers, juvenile detention centers, and compulsory drug treatment centers.[119] Incarceration, in turn, is strongly associated with HIV infection for Thai drug users.[120] Official statistics reported 869 known cases of HIV/AIDS and 331 deaths from AIDS-related causes in Thai prisons in 2004 (within a prison population of 167,000)[121], but in 2006 the Ministry of Public Health estimated actual numbers at about 4,800 cases (within a prison population of 160,000).[122] Data from studies in Thai prisons and among injection drug users who had been in pre- or post-trial detention suggest that the actual numbers may be much higher. Studies by Thai researchers have documented HIV prevalence rates as high as 40 percent among injectors who had been jailed, and documented significant risks of HIV infection related to syringe sharing both in pretrial detention and in prison.[123] The high rates of incarceration for drug-related offenses-more than 90,000 people in 2006-coupled with high HIV prevalence rates among drug users (especially among injection drug users) suggest that HIV/AIDS cases in prison may well exceed 4800.[124] People in custody also face a risk of exposure to other infectious diseases such as tuberculosis and Hepatitis C, which exacerbate HIV-infection and complicate medical treatment.[125]

Until mid-2007 Thailand had no clear national policy on providing ART in pretrial detention facilities and prisons.[126] Inmates who do receive antiretroviral treatment in prison faced barriers to continuing care on release. Methadone (available in the community) or other medication-assisted treatment for opioid dependence are not provided in prison.

Access to Antiretroviral Therapy

HIV testing in prison is done at the prisoner's request, and antiretroviral treatment provided according to the same clinical guidelines as outside prison.[127] Dr. John Lewitworapong, director of medical services at Klong Prem Central Prison, said that there were "no barriers to HIV treatment in prison," as antiretroviral treatment was available free of charge to all Bangkok prisoners and prison officials made an effort to provide information about antiretroviral treatment and other HIV-related services to prisoners.[128] Dr. Lewitworrapong conceded, however, that prison officials were not reaching all prisoners in need of care, as some HIV-positive inmates did not want to disclose their status or submit to a test that would reveal their status.[129] Nipa Ngamtrairai, a public health officer with the Department of Corrections specializing in HIV/AIDS, confirmed that "very few [prisoners] ask for an HIV test."[130] As a result, prisoners may be identified as in need of antiretroviral therapy only after presenting with signs and symptoms of the disease.

An estimated 300 prisoners were receiving antiretroviral therapy nationwide in 2006, approximately 200 of whom were in Bangkok prisons.[131] Outside Bangkok, access to antiretroviral therapy depends on arrangements made with local Ministry of Public Health officials and local provincial hospitals or with prisoners' family members.[132] According to Nipa Ngamtrairai, the government of Thailand had no clear national policy on providing antiretroviral therapy in prison and prisoners' access to antiretroviral therapy therefore "really depends on the local situation."[133] Ngamtrairai noted that "some hospitals are very strict," and therefore required prisoners to come to the hospital for treatment, which presented a significant burden for prison staff as well as a challenge to ensuring appropriate health care to prisoners: "You need two guards per person and so in Chiang Rai prison where 30 prisoners are on ART, it is impossible from a personnel standpoint to provide that service. You can't take a lot of people at once to the hospital."[134] In some provinces, healthcare workers are charged with providing HIV-related services in prison. According to Ngamtrairai, this situation also presented problems with access to care, not least because in some provinces a single doctor was charged with healthcare provision for several prisons or detention centers.

Nongovernmental organizations play an important role in providing HIV/AIDS-related services to prisoners, a fact that both international organizations and government officials have acknowledged.[135]Since 2003, Mdicins Sans Frontires-Belgium/Thailand (MSF) has been providing HIV/AIDS services in two Bangkok prisons, and as of June 2007 had enrolled 88 patients in antiretroviral therapy.[136] Jai W., age 24, received antiretroviral therapy as well as medical treatment from MSF both while she was in prison and after release, until she was successfully transferred to the public health system.[137]

Access to Medication-assisted Treatment for Opioid Dependence

The United Nations office on Drugs and Crime, the World Health Organization, and the Joint United Nations Program on HIV/AIDS all recommend that methadone maintenance and other opioid substitution treatments be provided free of charge to prisoners in jurisdictions where medication-assisted treatment is available outside of prisons.[138] They specifically recommend that anyone receiving medication-assisted therapy before incarceration should be able to continue receiving treatment, and anyone else who qualifies should be able to start substitution therapy while incarcerated.[139] Although prisons must provide at least the standard of care to prisoners that is available in the general population, methadone and other medication-assisted treatment for opioid dependence are unavailable in prison.

Some prisoners can still obtain drugs inside the prison system.[140] Studies in prisons in Thailand have shown that many opioid dependent prisoners continue to inject while incarcerated, often sharing syringes with their fellow inmates, thus risking HIV and other bloodborne diseases.[141] Thai researchers have found that injection drug users in Bangkok "are at significantly increased risk of HIV infection through sharing needles with multiple partners while in holding cells before incarceration."[142] Human Rights Watch and TTAG interviews with outreach workers to prisoners and ex-inmates documented both injection drug use in prison, as well as prison authorities' failure to address HIV-related risk among incarcerated drug users.

The provision of methadone maintenance therapy has been shown to reduce the incidence of injection in prison.[143] Likewise, stopping methadone on incarceration is associated with the likelihood of sharing injection equipment.[144]

Department of Corrections officials and HIV/AIDS clinicians providing care both inside and outside prisons offered several reasons for failure to provide access to methadone in prison. Nipa Ngamtrairai said that it was "against the law" to provide methadone in prison and that it was not needed as the number of injection drug users in prison was very low.[145] However, the government's own estimates-nearly 80 percent of inmates incarcerated for drug offences, with 60-80 percent of inmates having a drug use history[146]-and recent studies suggest that the number of injection drug users in prison is not insignificant.[147] Dr. Werakit Hanparipan

from Klong Prem Central Prison, Bangkok's main prison, acknowledged that injection drug use was a persistent problem there but said that it was against hospital policy to provide methadone in prison and, further, that he believed that there was no medical reason to provide methadone in prison: "There's no significant difference between using methadone and having them go cold turkey, in terms of morbidity and mortality."[148]

Dr. Hanparipan expressed concern about methadone diversion within prison. He explained, "We treat withdrawal symptoms but we don't have substitution [medication-assisted] therapy. We don't use methadone because it's not good inside prison." Citing Australia as an example he added, "We have learned from other countries that it's not good inside prison because of the methadone black market."[149]

Methadone programs have been successfully created in prisons throughout the world including Indonesia, Iran, Puerto Rico, and Canada.[150] The World Health Organization advises that prison-based opioid substitution programs are relatively simple to carry out.[151] In the face of this evidence, state failure to provide available and necessary medical attention to opioid dependent prisoners, thus increasing their vulnerability to HIV and other blood borne diseases, could amount in certain cases to exposing prisoners to inhuman and degrading treatment. Such treatment would be a violation of the state's obligation to prevent such occurrence and to ensure that all detainees are treated with humanity.[152]

For those opioid-dependent prisoners unable or unwilling to access drugs in prison, many are forced to undergo abrupt opioid withdrawal (both from legally obtained methadone, as well as illicit opioids). Forced or abrupt opioid withdrawal can cause profound mental and physical pain, and can have serious medical consequences for pregnant women and their fetuses, immune-compromised people, and people suffering from comorbid medical disorders.[153] The trauma of imprisonment, coupled with severe opioid withdrawal, can also increase the risk of suicide in opioid-dependent individuals with co-occurring disorders.[154] It may also undermine antiretroviral therapy for opioid-dependent drug users, for whom opioid substitution therapy is important to support adherence to ART.[155]

Continuity of Care in and between Custodial Settings

Maintaining a high level of adherence to antiretroviral medications is critical for HIV therapy to be successful, since incomplete adherence may lead to virological failure, resistance to antiretroviral medications, and therefore a reduction in available antiretroviral therapies, as well as the potential for transmission of drug resistant virus.[156] Incomplete adherence also has been associated with clinical progression of HIV disease and mortality.[157]

The government has no guidance or policy to ensure continuity of antiretroviral therapy on entry to or exit from custodial settings (pretrial detention, prisons, or inpatient drug treatment centers). Government failure to coordinate HIV/AIDS services on entry to and exit from custodial settings threatens the lives and health of people living with HIV/AIDS both within and outside custodial walls, as well as those of their sex partners and of others with whom they may use drugs.[158]

Human Rights Watch and TTAG's research found that people on antiretroviral treatment risk interruptions in treatment when they transition between prison and the community, with potential harmful effects on their health.

Difficulty with ensuring continuity of antiretroviral treatment on entry to and on release from prison was identified as a major concern by physicians providing antiretroviral therapy both in and outside prison, a Department of Corrections official working on HIV/AIDS in prison, NGOs working with drug users inside prison and after release, and drug users. HIV clinicians in Satun, Chiang Mai, Bangkok, and Samut Prakhan provinces reported that it was difficult to monitor ART for patients who were incarcerated or entered drug treatment programs, and that many pre- and post-trial detention facilities had no one to monitor ART for prisoners.[159] Several clinicians said that family members sometimes brought ART to incarcerated relatives, but that they did not monitor their care because the prisons were outside of the respective hospital coverage areas.[160] Dr. Praphan Phanuphak, director of the Thai Red Cross AIDS Research Centre and co-director of HIV-Netherlands Australia Thailand Research Collaboration, described the ad hoc nature of these referrals. He said that, if a patient were incarcerated, they would not know unless informed by their families. He added, "Whether people get ART in prison depends on where the prison is and whether their families are taking care of them. Usually in prison people don't want to tell anyone about their HIV status or that they're taking antiretroviral drugs."[161]

Nipa Ngamtrairai said that antiretroviral treatment was sometimes interrupted for people who were receiving antiretroviral treatment in one province and imprisoned in another. According to Ngamtrairai, "If a person is on ART in one province, and arrested in a second province, the second won't provide ART. I have to fight for prisoners to get access to ART, or get help from MSF." She added, "We try not to transfer prisoners within the prison system because that creates problems with continuity of care. This policy applies to all diagnoses, not just HIV. It's not a written policy, but something we discuss in staff meetings. There are no written guidelines on this There is an official order that you can't move prisoners on ART.[162]

Inmates who received antiretroviral therapy while incarcerated faced barriers to continuing care on release. Health care workers in Klong Prem prison hospital in Bangkok reported that prisoners frequently could not obtain ART outside prison and that many former inmates continued to receive ART from the prisoner pharmacy for months following discharge because they could not successfully transfer their cases to hospitals outside of prison.[163] NGOs working with prisoners and ex-prisoners reported that many ex-prisoners did not have identity cards; without these they could not establish eligibility for ART and other healthcare services under the national health insurance scheme.[164] When asked how a person might seek services if he or she had no identity card, Ngamtrairai replied that in Bangkok, "They can contact MSF or Alden House [a Bangkok-based NGO] with the problem."[165] In some cases (as in the case of Jai W., described above), NGOs like MSF can help fill these gaps, but this is not always the case.

Klong Prem healthcare workers said that it was not enough to simply provide ART, and that more needed to be done to improve the entire continuum of care throughout the cycle of incarceration, including pre-entry and upon release.[166]

Compulsory Drug Treatment Centers

As of March 2005, Thailand had 49 compulsory drug treatment centers, to which drug users were placed pursuant to the 2002 Narcotic Drug Rehabilitation Act. At the end of 2004, nearly 10,000 drug users were in treatment at these centers. [167]

Staff at compulsory drug treatment facilities also identified access to ART for HIV-positive patients and continuity of care for patients receiving ART as problems.[168] Montol Kaewkaw, director of the LadlumkaewTreatmentCenter, a secure compulsory drug treatment center run by the Ministry of Justice, recognized the importance of ensuring continuity of HIV and other medical care on exit from the treatment facility. Kaewkaw had taken the initiative to try to incorporate patient follow up after release, but said that his center lacked the capacity to ensure patient referrals in all cases, and that they needed support from other agencies to do so. Kaewkaw suggested that there be a national policy to assist with continuity of care for patients in need of HIV services on release. "We should have a role to cooperate with the hospitals," Kaewkaw said, "For example, one former patient lives in [name of town withheld], and we should sent a letter [to the hospital], because that person needs ART in [town]." But, he added, "We counsel and help as much as we can. It's a national problem, which we cannot resolve at our level. We need cooperation from all agencies."[169]

Human Rights Standards

Thailand is a party to both the International Covenant on Economic, Social and Cultural Rights (ICESCR) and the International Covenant on Civil and Political Rights (ICCPR).[170] As such it has obligations to respect, protect, and fulfill the rights protected under both treaties for all those within its jurisdiction, including HIV-positive drug users. In particular it must respect the right of everyone to "the enjoyment of the highest attainable standard of physical and mental health,"[171] the right to privacy,[172] and the right of all detainees to be treated with dignity.[173]Thailand also recognizes in its constitution that everyone has "equal rights to receive quality public health services."[174]Thailand has obligations to ensure drug users can enjoy the right to health without fear of punishment and discrimination, including in prison, and can access voluntary, affordable, and quality medical treatment.[175] It also has obligations to take positive measures to ensure equal access to HIV/AIDS-related information and prevention, care, and treatment services for all people living with and at risk of the disease.[176]

The Right to Health

The right to health includes both freedoms and entitlements: freedom from unjustified interference by the State directly or indirectly with an individual's health; and entitlements to a particular, nondiscriminatory health care.[177] Respect for the right to health also incorporates respect for other rights such as the right to privacy and the right to seek, receive, and impart information. In fulfilling the right to health, states are specifically obliged to take those steps necessary for "the prevention, treatment and control of epidemic diseases."[178] This includes "the establishment of prevention and education programmes for behaviour-related health concerns such as sexually-transmitted diseases, in particular HIV/AIDS."[179] Laws and policies that "are likely to result in ... unnecessary morbidity and preventable mortality" may violate the obligation to respect the right to health.[180]

The UN Committee on Economic, Social and Cultural Rights has identified four essential elements of the right to health:availability; accessibility; acceptability; and quality.[181] The availability requirement means that states must make available "[f]unctioning public health and health-care facilities, goods and services, as well as programmes." The accessibility requirement has four overlapping dimensions: non-discrimination, physical accessibility, economic accessibility, and information accessibility (people have the opportunity to seek, receive, and impart information about health issues). Acceptability means that health services are medically and culturally appropriate. Finally, health services must be scientifically and medically appropriate and of good quality.

The right to the highest attainable standard of health outlined in the ICESCR is subject to "progressive realization," under which states parties have a "specific and continuing obligation to move as expeditiously and effectively as possible towards the full realization of [the right]."[182] States must guarantee certain core obligations as part of the right to health. These include ensuring non-discriminatory access to health facilities, especially for vulnerable or marginalized groups; providing essential drugs; ensuring equitable distribution of all health facilities, goods and services; adopting and implementing a national public health strategy and plan of action with clear benchmarks and deadlines; ensuring reproductive, maternal, and child care; taking measures to prevent, treat, and control epidemic and endemic diseases; providing education and access to information for important health problems; and providing appropriate training for health personnel, including education on health and human rights.[183] To justify the failure to meet at least minimum core obligations as based on a lack of available resources, a state party "must demonstrate that every effort has been made to use all resources that are at its disposition in an effort to satisfy, as a matter of priority, those minimum obligations."[184]

Rights of Detainees to Health Care

International human rights law clearly affirms that prisoners retain fundamental rights and freedoms guaranteed under human rights law, except the right to liberty, although they may be subject to restrictions that are commensurate with a closed environment.[185] However, the conditions of confinement should not aggravate the suffering inherent in imprisonment.[186] Prisoners, therefore, like all other persons, enjoy the right to the highest attainable standard of health and in particular the right to be treated with dignity and protection against torture and cruel, inhuman, or degrading treatment or punishment.[187]

International law requires states to take measures to ensure that conditions of incarceration conform to international human rights norms and standards. The prohibition on inhuman or degrading treatment specifically "compels authorities not only to refrain from provoking such treatment, but also to take the practical preventive measures to protect the physical integrity and the health of persons who have been deprived of their liberty."[188] It has been recognized that failure to provide adequate health care or medical treatment to a detainee in prison may contribute to conditions amounting to "inhuman or degrading treatment."[189]

Key international instruments establish the general consensus that prisoners are entitled to a standard of health care equivalent to that available in the general community, without discrimination based on their legal status.[190] The UN Committee on Economic, Social and Cultural Rights, in its commentary on the right to health, repeatedly stresses the importance of states' obligations to ensure access to health facilities, goods, and services to all persons, "especially the most vulnerable or marginalized sections of the population" without discrimination on the basis of (inter alia) "health status including HIV/AIDS" or "political, social or other status" that "has the intention or effect of nullifying or impairing equal enjoyment of the right to health." The Committee notes in particular government obligations to "refrain from denying or limiting equal access for all persons, including prisoners or detainees to preventive, curative, and palliative health services," and to abstain from "enforcing discriminatory practices as State policy."[191]

Conclusion

In June 2007, Thailand introduced its 2007-2011 National AIDS Plan which recognizes its failures in combating HIV and AIDS among drug users and prisoners, and proposes to scale up efforts to ensure access to HIV and AIDS prevention, care, and treatment services to them.

Thailand's success in addressing HIV/AIDS in the broader population is due in large part to its decision to engage people living with and at high risk of HIV/AIDS and their networks as equal partners in its response. If Thailand is to make progress in its efforts to fight HIV and AIDS among drug users, it must engage people who use drugs as equal partners in its plans and in the same spirit as it has other people living with and at high risk of HIV/AIDS. Open communication about methadone and about drug use, without fear of negative consequences, is critical to receiving good care. Thailand must therefore follow its commitments with prompt and forceful action to address the violations of human rights against drug users and prisoners by law enforcement and healthcare providers, and the widespread prejudices by government and civil society against them.

If Thailand takes such steps, it could reach its goal of ensuring universal access to HIV/AIDS services to all those who need them. Otherwise, it will miss an opportunity to reverse the course of its epidemic, and at the cost of thousands of drug users' lives.

Acknowledgments

This report was researched by Karyn Kaplan, director of policy and advocacy, and Paisan Suwannawong, director, of the Thai AIDS Treatment Action Group, and Rebecca Schleifer, advocate with Human Rights Watch's HIV/AIDS and Human Rights Program, and written by Karyn Kaplan and Rebecca Schleifer. The report was reviewed by Joseph Amon, director of the HIV/AIDS and Human Rights Program; staff of Human Rights Watch's Asia Division; Aisling Reidy, legal advisor; and Ian Gorvin, consultant to the Program Office of Human Rights Watch. Clara Presler, Andrea Holley, Veronica Matushaj, Anna Lopriore, Grace Choi, and Fitzroy Hepkins provided production assistance.Rafael Jimenez designed the cover.The report was translated into Thai by Pipob Udomittipong and Anusorn Quamman.

A number of experts and nongovernmental organizations in Thailand and elsewhere assisted with this research. Human Rights Watch and TTAG gratefully acknowledge the Thai Drug Users' Network, and staff members and peer outreach workers with Raks Thai Foundation in Bangkok and Samut Prakhan, Population Services International in Chiang Mai, Alden House in Bangkok, Thai AIDS Treatment Action Group in Bangkok, Tracy Swan, hepatitis C/HIV coinfection project director, Treatment Action Group, and Madeleine O'Hare, consultant to TTAG, for their assistance in this work.

Most of all, we thank the drug users and people living with HIV/AIDS who were courageous enough to share their experiences with us.