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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 National Command Center 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 law⁵³ 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 Noi I., 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.⁷⁸Its 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.⁸¹

Thailand has no national policy or guidance on providing ART to methadone patients, nor on coordinating drug dependence treatment with HIV treatment and care. As a result, practice varies among provinces. Some healthcare providers either refused to treat methadone patients, or they admitted drug users to ART programs without inquiring about their methadone use and thus depriving them of essential health information and compromising their medical care. The denial of ART based on methadone use is contrary to international health standards and inconsistent with obligations under the right to health. The failure to coordinate methadone and ART treatment compromises patient access to information and to medically and scientifically appropriate care.

Denial of ART treatment to methadone patients

The Bangkok Metropolitan Administration (BMA) policy is to integrate methadone with HIV treatment.⁸² As of the end of 2006, the BMA provided methadone at 19 sites (17 clinics and 2 hospitals) to 2,000 patients.⁸³ Dr. Sitthisat Chiamwongpaet, director general of the BMA’s health department, said that BMA clinics and hospitals coordinated methadone, ART, and TB services. Dr. Chiamwongpaet estimated that there were 600 to 700 people on ART and methadone in Bangkok at the end of 2006. When asked whether the BMA required people to stop methadone as a condition of receiving ART, Dr. Chiamwongpaet replied, “No. I think that methadone is attractive to induce treatment. If you don’t have methadone, they don’t come to see you.”⁸⁴

However, drug users in Bangkok reported that, in practice, ART and methadone treatment were not always coordinated. Thien C., the peer outreach worker in Bangkok who is on ART, acknowledged that staff at methadone clinics were well situated to provide information and facilitate access to ART for drug users, but said that in his experience some Bangkok health care workers refused to provide ART to methadone patients. Thien used to get methadone at a Bangkok clinic that also provided ART. But after hearing staff members chastise drug users on methadone and state publicly that they would not provide them with ART because it would be “a waste of medicine,” Thien stopped getting methadone there. Thien said that when he used methadone he bought it privately.⁸⁵

Moreover, the Bangkok Metropolitan Administration’s policy appears to be the exception. Dr. Sittichai Kulpornsirikul, an HIV clinician in nearby Samut Prakhan province, said that Samut Prakhan provincial hospital policy was to require that patients quit methadone before they would provide them with ART.⁸⁶ Human Rights Watch and TTAG noted that there was a methadone clinic at the hospital, which would have enabled HIV clinicians and methadone providers to coordinate drug treatment and ART for patients who needed both services, were they so inclined. As a practical matter, they did not coordinate patient care. Dr. Kulpornsirikul acknowledged, “Usually smart patients don’t come here to take methadone. We have their case portfolio, so the hospital can monitor this…. Drugs are treated elsewhere. They don’t tell us directly if they take methadone. If they take methadone here at Samut Prakhan hospital, we would know.”⁸⁷

A methadone provider at a public hospital in Satun province that also provided ART named two factors contributing to the steep decline of patients at her methadone clinic (from 43 to 3 since 2002): the government’s recent crackdown on drug users and the requirement that patients stop methadone as a condition of taking ART. “[We have so few patients]” because this year [2006] the government announced a drug war,” she said. In her seven years at the methadone clinic, she “never had a patient on antiretroviral therapy and methadone, because patients are not allowed to have both. They have to choose one.”⁸⁸

Clinicians’ failure to coordinate ART and methadone use

Dr. Somsak Wasuwithitkul, deputy director at Langhu hospital in Satun province (which had an on-site methadone clinic), reported what amounts to a policy of willful ignorance at his hospital about ART patients’ drug or methadone use: “The hospital doesn’t get information about current drug use. Even old cases used to get ART and go home and use drugs and go elsewhere for methadone…. But if they are on ART and start using drugs, they find methadone elsewhere. The methadone clinic informs me and it alarms me because I didn’t have this information before.”⁸⁹ Several other HIV clinicians reported 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. The comments of a doctor providing ART at a major hospital in Chiang Mai were typical of responses by many providers interviewed: “Most of the people I’m treating here—I don’t know if someone is a drug user or not. I don’t ask about drug use history, whether they use or not, how they got HIV. I don’t want to interfere with their personal rights. Mostly I don’t ask about HIV transmission route. I don’t ask about a patient’s methadone use.⁹⁰

Dr. Sittichai Kulpornsirikul, the primary HIV doctor in Samut Prakhan hospital, and Bang-orn Jaemrukjaeng, a nurse who worked in HIV care at the hospital, said they did not inquire about patients’ drug use nor were patients likely to disclose this information. They also denied ART, as a matter of policy, to patients on methadone (as noted above). Both acknowledged, however, that some of their patients may have been using drugs or taking methadone. The nurse recalled that they had had two patients on ART who had been on methadone. “They said they quit. Actually, we can’t know for sure. We don’t know, we can’t follow them around.”⁹¹ Similarly, a methadone provider at Samut Prakhan hospital told Human Rights Watch and TTAG, “Yes, there are ART takers on methadone... The methadone provider won’t know—unless the user tells us they are on ART, we don’t investigate.”⁹²

This kind of failure to coordinate HIV/AIDS and drug treatment services may be undermining both HIV/AIDS care for drug users, and drug treatment for people living with HIV/AIDS. Given that drug treatment services are often provided at or near hospitals and clinics that provide HIV/AIDS services, the failure to ensure such coordination represents a missed opportunity to ensure access to healthcare services as well as lifesaving information to drug users living with or at risk of HIV/AIDS.

Lack of Knowledge on Drug-Drug Interactions

As noted above, interactions with antiretroviral drugs have a range of consequences for people using them together with methadone or other drugs. Several HIV clinicians we spoke to acknowledged that they lacked sufficient information about drug-drug interactions, and said that they would like more training on this issue.⁹³

Similarly, several drug users said that they would like more information about ART and drug use, but that they were afraid that they would be denied ART if they disclosed their drug use. As a result, drug users on ART are forced to conduct what essentially amount to daily, individual experiments on themselves, with dangerous potential consequences for their health and, ultimately, their lives.

Bang In T., a 40-year-old injection drug-user on ART, told us that he occasionally injected amphetamines. Since starting ART, he sometimes had difficulty breathing. He said that he would like to know more about drug use, HIV, and ART, but was afraid to speak with his doctor, who had said that he would stop providing ART to anyone who used drugs. “I feel uncomfortable speaking with the doctor about drug use. I’m afraid the doctor wouldn’t give me ART and wouldn’t take care of me. The doctor hasn’t told me that directly, but he has said that if he knows if anyone uses drugs, he would stop providing ART to them. I would feel really good if I could speak with the doctor about occasional drug use and not worry about losing ART. I have not received information about the relationship between drug use, HIV, and ART. I assume there’s a bad interaction, but I would like to know. I don’t know where I would get this information.”⁹⁴

Some drug users reported receiving limited information about methadone and ART interactions from their peers. However, apart from the warning that taking antiretrovirals with drugs could be lethal, none of the drug users interviewed reported receiving any information about either methadone or illicit drug use and ART from healthcare providers. 

When asked whether he had been told anything about the effect of methadone on ART, Thien C., an HIV-positive methadone patient on ART, replied, “I went to the harm reduction group. They said that some antiretrovirals can’t be used with methadone because they make methadone less effective.” But Thien had never received information about methadone/ARV interactions from his healthcare providers. He said, “I have never gotten any information from a doctor or nurse about the effect of methadone on ARV.”⁹⁵  Mee U., 33, said that he had been told by a doctor, “If you are on ART, you have to stop using drugs because if you take ART with drugs, you could die. I believe this is true, because I know the situation of someone who was on ART [who died] and his friend said that he used drugs heavily.”⁹⁶

Inadequate Voluntary Counseling and Testing Services

Drug users living with HIV need to know their HIV status in order to seek antiretroviral treatment and other health services. Voluntary HIV testing and counseling (VCT) is the process by which an individual undergoes confidential counseling to enable an informed choice to be made about whether to take an HIV test and learn one’s HIV status.  The voluntary nature of VCT is critical to ensure that HIV testing is not coerced, and that an individual has made an informed choice about whether or not to take an HIV test. 

VCT is essential to identify drug users living with HIV and AIDS for prompt entry into HIV care and support services, as well as referral to drug treatment and other health and social services for those testing positive for HIV. VCT also provides an important opportunity to counsel drug users about harm reduction. It has proved effective in reducing HIV risk behaviors among drug users, and is therefore an integral part of HIV prevention strategies for drug users.⁹⁷  A recent review in Thailand showed that injection drug users who were already confirmed to be HIV-positive had a better understanding of HIV prevention than injection drug users who were unaware of their status (97-100 percent HIV-positive compared with 48–70 percent HIV-unknown status knew sharing needles could transmit HIV infection).⁹⁸

HIV voluntary testing and counseling has been available in government hospitals since 1992. Thailand’s Ministry of Public Health and international organizations have found, however, that VCT services in hospitals are constrained by inadequate staff training and staff shortages, lack of confidentiality, the cost of VCT, and the lack of anonymous testing.⁹⁹ The Ministry of Public Health and the World Health Organization have also observed that little has been done to address the specific challenge of providing VCT services to drug users, notwithstanding sustained high HIV prevalence rates among them.¹⁰⁰ A 2006 study by Thai researchers concerning VCT to drug users found that counseling is either not provided or ineffective, and that new HIV infections among drug users remain high, despite having had VCT.¹⁰¹

Human Rights Watch and TTAG interviews revealed a number of problems with VCT services to drug users. Drug users reported that they had been tested for HIV without their informed consent at drug treatment clinics or while in prison; that they had received little (if any) HIV-related information or counseling prior to the test (including that they were being tested for HIV), and little or no post-test counseling; and that they received no referral to medical or social services if they tested positive, or on HIV prevention specific to drug use.

The administration of inadequate pre- and post-HIV test counseling constitutes a severe limitation on the human right to receive essential information on health. It also compromises opportunities to link drug users living with HIV to adequate care and treatment services, impeding the states’ fulfillment of its positive obligation under the right to health to take steps necessary for the “prevention, treatment and control of epidemic … diseases.” The United Nations International Guidelines on HIV/AIDS and Human Rights (UN Guidelines), which provide guidance in interpreting international legal norms as they relate to HIV and AIDS, has advised that “public health legislation should ensure, whenever possible, that pre- and post-test counseling be provided in all cases” because counseling ensures the voluntary nature of HIV testing and contributes to the effectiveness of subsequent care or HIV prevention. ¹⁰² The research of Human Rights Watch and TTAG indicates that counseling provided to people who use drugs in the public health system is insufficient on both counts: it fails to equip people who use drugs with the information necessary for them to give informed consent to testing, and fails to give them the information they need to pursue HIV care or treatment.

Pong H., age 29, was tested for HIV in Samut Prakhan. He told researchers, “My [pre-test] counseling was: ‘If you have HIV, will you be able to accept it?...There was no discussion. The official just asked, ‘Is there any possibility that you might have HIV?’’’¹⁰³

Staff and patients at outpatient drug treatment clinics reported that HIV tests were administered on a regular basis to methadone patients.¹⁰⁴  Drug users reported that they felt coerced into taking an HIV test as a condition of receiving methadone or participating in a clinical trial. Wat V., age 31, found out that he was HIV-positive at a methadone clinic where he was an outpatient. He told researchers, “The nurse at the clinic said that they wanted to test everyone, and they did it.” When asked if he had been given any information about the test, Wat replied, “No. That’s why I didn’t know what the blood test was for. It was like they forced me to do it. I was taking methadone with them [the clinic], so I had to cooperate. They didn’t say it was an HIV test. They just said it was a blood sample test, but they didn’t say what it was for. I thought it might be HIV but they didn’t explain. They just said, ‘Today before you take methadone, you have to take a test.’”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, Médicins Sans Frontières-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 history¹⁴⁶—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 Ladlumkaew Treatment Center, 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