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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 worldwide–and the only one in Asia–to 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 In 2004, for example, the Thai government rescinded a national policy that explicitly permitted the exclusion of injection drug users from ART programs.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.

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