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Tackling HIV/AIDS Among Injecting Drug Users: Lessons Learned from Thailand Laila Khondkar Asia Fellow (Cohort 6) Bangladesh Context 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 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 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 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.) 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 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 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 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 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 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 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 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 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 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 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.) 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 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.) 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 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.) 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 Asian Scholarship Foundation, Bangkok (www.asianscholarship.org) Dr. Wassana Im-em, IPSR, Mahidol University Dr. Niyada Kiatying-Angsulee, Faculty of Pharmaceutical Sciences, Chulalongkorn University