Download Tackling HIV/AIDS Among Injecting Drug Users: Lessons Learned

Tackling HIV/AIDS Among Injecting
Drug Users: Lessons Learned from
Thailand
Laila Khondkar
Asia Fellow (Cohort 6)
Bangladesh
Context
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Thailand achieved millennium development goal
on HIV/AIDS ahead of schedule
Thailand’s success in averting HIV/AIDS
epidemic has won international praise
In sharp contrast to other groups at risk, HIV
prevalence among injecting drug users (IDUs)
never dropped
Research questions
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How did Thailand address HIV/AIDS among
IDUs?
What policies and practices in Thailand affect
human rights of IDUs?
What are the lessons that other countries could
learn from Thai experience?
Methodology
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Literature review
Observation by visiting intervention sites
In-depth interviews with stakeholders from
activist groups, government, academia, NGOs,
international organizations
Snow-ball technique was used in selecting the
interviewees
Interviews were semi-structured
Study period: Sep 2004-May 2005
“Are we-is the world-now mature enough, now
wise enough-to accept that the deepest
meaning of solidarity requires that we
consider ourselves as we too were infected
with HIV-that we are all-on a human levelseropositive?”
(Jonathan Mann)
Conceptual framework: link between
human rights and health
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The right to health is based on article 12 of
International Covenant on Economic, Social,
and Cultural Rights (ICESCR)
Human rights offer a theoretical framework to
discuss marginalization, discrimination, and
stigmatization
There are theoretical and empirical links
between human rights abuses and vulnerability
to HIV/AIDS
Conceptual framework (contd.)
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Human rights violations not only occur to AIDS
affected people, it is one of the root causes of
disease
Populations who are already marginalized
before AIDS are at a greater risk of HIV infection
IDUs are usually criminalized, marginalized, and
discriminated against
Human rights abuses against IDUs are one of
the most important causes of HIV transmission
HIV/AIDS in Thailand
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1 million people have been infected with HIV
since the beginning of the epidemic
National adult HIV prevalence is estimated to
be 1.5%
600,000 people are living with the virus today
Present challenges
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HIV/AIDS burden is still high, and is a major
public health threat to the country
There is upward trend of HIV risk behaviors
among youth, homosexuals, and IDUs
Current prevention efforts are not adequate
Thailand needs to find effective ways for
implementation of anti-retroviral (ARV) treatment
Revised strategies are required to confront the
disease that has entered a new phase
Injecting drug use in Thailand
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The actual number of users who inject drugs
is not known
Estimates range from 100,000 to 250,000
addicts
Most of them are males (around 90 percent)
and mostly aged between 20-24 years
HIV/AIDS among IDUs
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About one quarter of all new infections is
occurring through unsafe injecting drug use
Median HIV prevalence among IDUs is as high
as 50%
HIV is a major killer of IDUs in Thailand
The situation has remained consistent for nearly
15 years
The high prevalence is due to the frequency of
injecting, widespread sharing of needles, and
imprisonment of IDUs
Limitations in addressing HIV/AIDS
among IDUs
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Little collaboration between drug control programs
and HIV/AIDS response
Narcotic Control legislation does not pay attention
to the prevention of HIV among IDUs
Lack of communication between AIDS control
authorities, Office of Narcotics Control Board, and
those working in drug treatment
Technical skills are not very high in addressing
HIV/AIDS among drug users
Challenges faced by drug
users
War on drugs
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War on drugs that started in 2003 has been a
serious blow to IDUs
The crackdown resulted in the unexplained
killings of more than 2000 persons and arbitrary
arrests or several thousands
The campaign drove numerous drug users into
hiding and away from the few existing services
War on drugs increased drug users’ risk of HIV
and other health complications
War on drugs (contd.)
“Government has lots of populist policies. War on drugs
is one of those.” (Activist)
“Society normally discriminate drug users, and so most
approved government’s war on drugs.” (NGO worker)
“In the short term some people are happy about the war
on drugs, but in the long run it is not going to be
effective. We have to address the root cause of the drug
problem.” (Academic)
Discrimination
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It is not only HIV positive IDUs, there are reports
of insult or harassment due to HIV status among
other People Living With HIV/AIDS
“The situation is improving, but discrimination is still
there.”
“People get discriminated in workplace, as employers
ask them to have HIV test before recruitment.”
“IDUs face double discrimination if they are HIV
positive.”
Discrimination
“Some health care workers behave in a way as if
they are owners of our lives.” (Former IDU)
“Sometimes service providers say: You are a
junkie and don’t care about your life. Why
should you get ARV?” (Former IDU)
Negative attitude of the government
“There is no consensus within government on how to
address HIV/AIDS among drug users. Some are
progressive, but some have quite rigid views.” (NGO
worker)
“Government does not like drug users.” (Researcher)
“Prime Minister’s personal attitude towards the IDUs
is partly responsible that Thailand has not managed
AIDS epidemic well among them.” (Activist)
Lack of participation
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There is no proper partnership between IDUs
affected by HIV/AIDS and the government
“There is token participation of IDUs in
committees dealing with HIV/AIDS.”
(Activist)
Summarizing the challenges
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Criminal justice approach taken by government
Non-availability of harm reduction programs
Limited prevention coverage
Ineffective treatment interventions
Discriminatory practices in society and health
care facilities
Lack of opportunity for IDUs to take part in
decision making process affecting them
Addressing the challenges
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Policy that emphasizes drug suppression only
needs to be changed
IDUs should be targeted actively to include them
in interventions
Stigma and discrimination that drive drug users
underground must be eliminated
Establishing needle and syringe exchange
programs should be considered
Better inter-sectoral collaboration needs to be
promoted
Addressing the challenges (contd.)
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Technical capacity on drug use and HIV/AIDS
should be improved
More research is needed regarding guidelines on
prevention and treatment of HIV positive IDUs
Adequate funding support is required to demand
reduction and HIV/AIDS prevention activities
Drug users should be given real alternatives such
as access to education, training, and employment
Addressing the challenges (contd.)
“Protecting rights, decrease in drug supply, and
improvement in drug treatment is required to address
the situation.” (Activist)
“Government needs to tackle drug problem in a
holistic way in stead of focusing on eradicating any
particular drug, which has happened many times
earlier.” (Academic)
Lessons learned
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Systematic discrimination and rights violations at
every level add to HIV/AIDS vulnerability of IDUs
Criminal justice approach towards illicit drug use
makes it even more difficult to prevent HIV
Lack of political will is a major barrier in
addressing HIV/AIDS among IDUs
Lessons learned (contd.)
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Repressive policies and existing ineffective
interventions contribute to the HIV crisis among
IDUs
Rights violations of IDUs are not acceptable from
human rights perspectives, and it does not make
sense from public health point of view
Conclusions
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Even a “best practice” model like Thailand does
not guarantee that HIV/AIDS response has
benefited all
Thailand has failed to implement scientifically
proven policies and international guidelines to
prevent HIV among IDUs
State imposed barriers to harm reduction
programs for IDUs violate their human right to
health
Conclusions (contd.)
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Sound public health rationale based on scientific
evidence should prevail against moralistic and
judgmental arguments
The challenge posed by drug use should be
addressed within broader socio-economic context
Protecting human rights of IDUs should be central
while addressing HIV/AIDS among them
“I would like those who are concerned about AIDS
to use the opportunity to develop a more
compassionate, a more comprehensive view of
human relationships-we should see the problem
of AIDS as an opportunity for us to deepen and
broaden our understanding of fellow human
beings. We should not stop simply at trying to
control the disease or caring for those who have
contracted it but as using it as an opportunity for
further developing our humanity.”
(Aung San Suu Kyi)
Acknowledgements
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Asian Scholarship Foundation, Bangkok
(www.asianscholarship.org)
Dr. Wassana Im-em, IPSR, Mahidol
University
Dr. Niyada Kiatying-Angsulee, Faculty of
Pharmaceutical Sciences, Chulalongkorn
University