Injecting drug users in Thailand are among the highest risk groups for HIV transmission. According to the WHO, prevalence in this group has stayed consistently high over the last 15 years, ranging between 30 percent to 50 percent (WHO 2007).
Stigma and discrimination against this marginalised population are still widespread. Although the country has been lauded for its achievements in reversing the HIV epidemic, many drug users have found themselves unable to access free ARV treatment through the national health scheme.
In 2005 the Thai Drug-user Network (TDN), a local organisation offering support to drug users, asked Médecins Sans Frontières (MSF) to run weekly mobile clinics at their drop-in centre and organise workshops on HIV/AIDS. After three years working with drug users, MSF has recently begun scaling down its activities and is now helping them develop a health education curriculum to train their peer workers.
"Drugs have totally ruined my life," said Pailin, 48, who has been struggling with his addiction for 25 years and has been off heroin for a month. "Because of them, I've dropped out of college, I've lost jobs, failed in my relationships. I spent nearly three years in jail and I contracted HIV. And that's why I began working with TDN to help myself and people with the same problem." TDN was created in 2002 by a group of drug users who, tired of seeing their friends dying of HIV/AIDS related causes, decided to document the barriers they faced when trying to access healthcare.
The organisation provides counselling, helps those who wish to give up drugs join governmental clinics where methadone is prescribed to reduce withdrawal symptoms, and help control addiction. TND continues to lobby the public health authorities to fully include drug users in antiretroviral therapy.
Pailin is one of the TDN peer workers who regularly attended MSF's workshops. At the drop-in centre, he and other outreach workers split into groups to discuss prevention and infections linked to weak immune systems (opportunistic infections). He also raises awareness of high-risk behaviour such as sharing needles.
"Outreach workers have good networks in their community and it's crucial to train them to recognise the symptoms of opportunistic infections so that they can seek treatment on time," said MSF nurse Ratchaneekorn Krongnam who has been running workshops with drugs users for two years. "One of the issues is that they tend to hide for fear of arrest and they often wait too long before getting treatment when they develop opportunistic infections."
During the last three years, MSF has run fortnightly clinics in two drop-in centres in Bangkok, where drug users could come for basic healthcare. Most of those attending the clinic were suffering from upper respiratory infections and skin problems and around half of them were HIV positive. Syringe exchange programmes allowing drug users to exchange their used syringes for sterile ones, are not available in Thailand.
In the past, addiction was often seen as a scourge to be eradicated rather than treated. In 2003, a brutal crackdown on narcotics led to violent repression and the controversial killing of over 2000 people. Thousands more were arrested and many drug users went underground during what was called the "war on drugs".
Although Thai citizens have free health care and AIDS treatment, many drugs users seemed unable to access such services. "It was difficult to go to the clinic, the doctors had a negative attitude towards us. As soon as they saw on our record or guessed we were drug users, they treated us like third class citizens," said Pom who is currently on Methadone.
"If there was a queue we'd be the last one to be seen. We often had to wait for hours in vain." MSF staff often used to accompany drug users who needed to be referred to the hospital and talk to the staff to bridge the gap in communication with drug users and ensure they get proper medical attention. "Some of them couldn't access ARV treatment simply because they had lost or were unable to renew their identity card," said Krongnam.
"We helped them with this so they could be put back in the system." MSF also monitored them closely for treatment compliance. All those receiving ARVs through MSF have now been switched to the national health system. "Working with drug users can be difficult," said Krongram. "Their lives are often ruled by their addiction and their attention span is short, but we've learnt a lot about them and the results have been positive overall."
As the relationship with hospital staff improved throughout the years, drug users felt increasingly confident to seek treatment by themselves. For Pailin, the developing atmosphere of trust contributed significantly to the achievements in terms of knowledge and awareness. "Years ago, I used to inject heroin three times a day," he said. "We would share the needles among a little group of five people. We knew very little about the risk of HIV transmission.
Today, people know a lot more now about the risk and how to protect themselves." Yet the government's recent talk of reviving the "War on Drugs" has prompted fears that drug users' access to HIV/AIDS care could again be seriously disrupted. "During the 2003 'War on Drugs', I got arrested and sent to jail. Most of my friends were also sent to prison at that time," Pailin said.
"People were hiding, too scared to come to the centre as the police were raiding the place regularly. The situation was really bad at the time and it closed its doors to all those who were seeking healthcare. I hope these days are well and truly over."