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.4Thailand 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 Thailands injection drug users has never shown significant decline.6 Injecting drug users were Thailands 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 Thailands failure to adopt harm reduction strategies immediately, despite the governments 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 17,0008 -- 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 Thailands 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 capacity23and 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 Thailands 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 baht28 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 Thailands 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 Thailands 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 patients 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 WHOs 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
2 United Nations Development Programme (UNDP), Thailand Human Development Report 2007 (Bangkok: United Nations Development Programme, 2007), p. 2.
3 Email communication from Dr. Sanchai Chasombat, Department of Disease Control, Ministry of Public Health, Thailand to TTAG, October 18, 2007.
4 World Health Organization, UNAIDS, UNICEF, Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector: Progress Report, April 2007 (Geneva: World Health Organization, 2007), p. 15. The other two countries are Botswana and Brazil.
5 Ministry of Public Health, Thailand, and World Health Organization Regional Office for South-East Asia (WHO-SEARO), External Review of the Health Sector Response to HIV/AIDS in Thailand (New Delhi: WHO Regional Office for South-East Asia, 2005), p. 35.
6 See, for example, Chris Beyrer et al., Drug Use, Increasing Incarceration Rates, and Prison-Associated HIV Risks in Thailand, AIDS and Behavior, vol. 7, no. 2, June 2003, p. 153, citing Ministry of Public Health, Thailand, HIV/AIDS Sentinel Surveillance Report (Bangkok, 2000).
7 World Bank, Thailand Social Monitor: Thailands Response to AIDS: Building on Success, Confronting the Future, November 30, 2000, http://wwwwds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2002/03/29/000094946_02031904060482/Rendered/PDF/multi0page.pdf (accessed November 5, 2007), p. 5. HIV spread rapidly among networks of injection drug users in Thailand in the late 1980s, with clear links to incarceration. Ibid.
8 Thai Working Group on AIDS Projections, Projections for HIV/AIDS in Thailand (Bangkok: Ministry of Public Health, Thailand, 2001), p. xvii.
9 The Thai Ministry of Public Health estimates the number of new HIV infections in 2006 to have been approximately 17,000. See Pongphon Sarnsamak, HIV Rate Rises in Married Couples, The Nation, October 11, 2007 (reporting 7000, 0r 40 percent of new infections, of new infections in 2006 among married couples, and thus about 17,500 total infections).
10 UNDP, Thailands Response to HIV/AIDS: Progress and Challenges (Bangkok: UNDP, 2004), p. 54.
11 Thailand Ministry of Public Health, Towards Universal Access by 2010: Thailand National HIV and AIDS Program, 2006.
12 Warunee Punpanich et al., Thailands Response to the HIV Epidemic: Yesterday, Today, and Tomorrow, AIDS Education and Prevention, Supplement A, June 2004, pp. 119-136.
13 UNAIDS, Epidemiological Fact Sheet on HIV/AIDS and Sexually Transmitted Infections: Thailand (2002). Sentinel surveillance for HIV/AIDS is the unlinked and anonymous testing of blood for the purpose of monitoring the prevalence and trends in HIV infection over time and place in a given population. WHO Regional Office for South-East Asia, Tuberculosis and HIV: Some Questions and Answers, http://www.searo.who.int/en/Section10/Section18/Section356/Section421_1623.htm (accessed November 2, 2007).
14 UNAIDS, AIDS Epidemic Update, 2006 , p. 33.
15 Submission by Royal Thai Government to UNAIDS, , Follow-up to the Declaration of Commitment on HIV/AIDS (UNGASS) Country Report, 2006, p. 19, http://www.unaids.org/en/Publications/2005ungassreporting/default.asp (accessed November 5, 2007).
16 Thailand Ministry of Public Health, Towards Universal Access by 2010: Thailand National HIV and AIDS Program, 2006.
17 Thailand Ministry of Public Health, Department of Disease Control, Book 1: National Plan for Strategic and Integrated HIV and AIDS Prevention and Alleviation 2007-2011: Key Contents (National Committee for HIV and AIDS Prevention and Alleviation, 2007), pp. 8, 11-15, 19, 28, 30.
18 Vichai Poshyachinda et al, Illicit substance supply and abuse in 2000-2004: an approach to assess the outcome of the war on drug operation, Drug and Alcohol Review , September 2005, p. 465.
19 United Nations Office on Drugs and Crime, Regional Centre for East Asia and the Pacific (UNODC-SEARO), Patterns and Trends of Amphetamine-Type Stimulants and Other Drugs of Abuse in East Asia and the Pacific 2005, June 2006, http://www.apaic.org/dc/Patterns_and_Trends_2005.pdf (accessed November 5, 2007), p. 103.
20 Ainsworth et al., Thailands Response to AIDS, p. 45.
21 UNODC-SEARO, Drugs and HIV/AIDS in South East Asia: A Review of Critical Geographic Areas of HIV/AIDS Infection among Injecting Drug Users and of National Programme Responses in Cambodia, China, Lao PDR, Myanmar, Thailand and Viet Nam, February 2004, http://www.unodc.un.or.th/drugsandhiv/publications/2004/5_hivaids.pdf (accessed November 5, 2007), p. 38.
22 R. Walmsley, World Prison Brief. Prison Population for Thailand, 2005, http://www.kcl.ac.uk/depsta/rel/icps/worldbrief/continental_asia_records.php?code=114Population List (6th ed.) (accessed August 26, 2007).
23 Kanokpun Kalyanasuta and Atchara Suriyawong, The Criminal Justice System and Community-Based Treatment of Offenders in Thailand, Paper presented at the 121st International Training Course. Resource Material Series No. 61, pp. 265-293. Tokyo: United Nations Asia and Far East Institute For the Prevention of Crime and the Treatment of Offenders (2002), pp. 273-274.
24 Ibid., p. 273.
25 Narcotic Addict Rehabilitation Act, B.E. 2545 (2002). See also Mikinao Kitada, director, United Nations Asia and Far East Institute for the Prevention of Crime and the Treatment of Offenders, Prison Population in Asian Countries: Facts, Trends and Solutions, paper presented at UN Programme Network Institutes Technical Assistance Workshop, Vienna, Austria, May 10, 2001, p. 8; and Ampa Santimetanedol,Faster executions, but amnesties for minor crimes, Bangkok Post, March 15, 2001.
26 Human Rights Watch is concerned that the powers granted to sub-committees authorized under the Narcotic Addict Rehabilitation Act to may violate guarantees under the International Covenant on Civil and Political Rights with respect to right to liberty (Article 9) and the right to a fair hearing before a competent, independent and impartial tribunal (Article 14) as the committees include non-judicial officials and individuals who may not be independent, and yet exercise authority to determine the eligibility of a defendant for rehabilitation and release under the law.
27 See, e.g., Narcotics Control Act of B.E. 2519 (1976), section 14, as amended by the Narcotics Control Act (No. 3), B.E. 2543 (2000) and the Narcotics Control Act (No. 4), B.E. 254g 5 (2002); Narcotics Act of B.E. 2522 (1979), chapters 2, 8, 10, 12 (as amended by the Narcotics Act (No. 5), B.E. 2545 (2002).
28 On July 1, 2006, 200 million baht was US $5,236,530.
29 Human Rights Watch and TTAG interview with Pithaya Jinawat, Bangkok, July 25, 2006.
30 See Order of the Prime Ministers Office No. 29/B.E. 2546 (2003), A Fight to Overcome Drugs; Y. Tunyasiri and W. Ngamkham, Thaksin orders new round of suppression, Bangkok Post, February 29, 2004; Order of the National Command Center for Combating Drugs (NCCD) No. 6/B.E. 2547 (2004), Kingdoms Unity for Victory Over Drugs, NCCD Order No. 24/B.E. 2547 (2004), Second Kingdoms Unity for Victory Over Drugs; Anti-Narcotics Campaign: PM Launches New Round In War On Drugs, The Nation, April 12, 2005; ONCB, Roadmap of Drug Surveillance and Establishment of Sustainable Victory over Drugs 2006-2008, March 24, 2006, http://en.oncb.go.th/document/Roadmap06-08.pdf (accessed November 12, 2007). Human rights abuses in the war on drugs are documented in Human Rights Watch, Not Enough Graves: The War on drugs, HIV/AIDS, and Violations of Human Rights, vol. 16, no. 8(c), June 2004, http://hrw.org/reports/2004/thailand0704/thailand0704.pdf.
31 See Statement by Asian Human Rights Commission, Thailand: Investigate institutions that kill, not just killers, November 23, 2006.
32 UN Human Rights Committee, Consideration of Reports Submitted by States Parties under Article 40 of the Covenant, Concluding Observations, Thailand, CCPR/CO/84/THA, July 8, 2005, http://www.unhchr.ch/tbs/doc.nsf/898586b1dc7b4043c1256a450044f331/e860ca7730edc51ec125706900453a28/$FILE/G0543504.pdf, para. 10.
33 Supawadee Inthawong, Drug War Inquiry Chiefs Named, Bangkok Post, August 30, 2007.
34 See Matt Curtis, ed., Delivering HIV Care and Treatment for People Who Use Drugs: Lessons from Research and Practice (New York: Open Society Institute, 2006), pp. 25-35.
35 This section draws on the following sources: WHO, UNAIDS, UNODC, Evidence for action on HIV/AIDS and Injecting Drug Use. Policy Brief: Antiretroviral Therapy and Injecting Drug Users, WHO/HIV/2005.06; WHO Regional Offices for South-East Asia and the Western Pacific, HIV/AIDS Care and Treatment for People Who Inject Drugs In Asia. A Guide to Essential Practice (draft), December 2006; Matt Curtis, ed., Delivering HIV Care and Treatment for People Who Use Drugs; WHO, UNODC, UNAIDS, Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention: Position paper, 2004; World Health Organization Regional Office for Europe, HIV/AIDS Treatment and Care for Injecting Drug Users. Clinical Protocol for the WHO European Region.2006, pp. 5-24.
36 Constitution of Thailand, sections 51, 55; National Committee for Prevention and Solutions to AIDS Problems, "National Strategic Plan to Integrate Prevention and Solutions to AIDS Problems (2007-2011), Main Content (Book 1), 2007; National Committee for Prevention and Solutions to AIDS Problems, "National Strategic Plan to Integrate Prevention and Solutions to AIDS Problems (2007-2011): Details on Strategy, Standards, Approaches and Indicators and Responsible Agencies, 2007.
37 World Health Organization Regional Office for Europe, HIV/AIDS Treatment and Care for Injecting Drug Users. Clinical Protocol for the WHO European Region, pp. 5-24; see also WHO Regional Offices for South-East Asia and the Western Pacific, HIV/AIDS Care and Treatment for People Who Inject Drugs In Asia, pp. 29-30. Human Rights Watch prefers the term medication-assisted treatment in place of substitution therapy. Medication-assisted treatment (MAT) involves the administration of a substance like methadone or buprenorphine that is pharmacologically effective in treating the one causing dependence, usually provided in oral form, and under medical supervision. MAT prevents opiate withdrawal, decreases opiate craving, and diminishes the effects of illicit opiate use. Medicines used in medication-assisted treatment can be prescribed for short or long periods of time. MAT for opioid dependence (often called opioid substitution therapy or substitution maintenance therapy), through which patients receive a stable dose of methadone or buprenorphine over a long period of time, is one of the most effective and best-researched treatments for opiate dependence. Once a patient is stabilized on an adequate dose, he or she can function normally.
39 WHO Regional Offices for South-East Asia and the Western Pacific, HIV/AIDS Care and Treatment for People Who Inject Drugs In Asia, pp. 7, 9,-10; UNAIDS, Joint UNAIDS Statement on HIV Prevention and Care Strategies for Drug Users, June 2005, http://data.unaids.org/UNA-docs/cco_idupolicy_en.pdf (accessed November 2, 2007).