In June 2003, the Department of Corrections of Thailand asked Médecins Sans Frontières (MSF) to help treat prisoners suffering from HIV and AIDS in Minburi prison, in Bangkok. Although the country was lauded for its fight against the disease and for its universal access to antiretroviral (ARV) therapy, prisoners remained excluded from the scheme at the time.

As a result, those affected by HIV/AIDS suffered and died in prison, while life saving drugs were widely available outside. Five years of collaboration between MSF and the Department of Corrections have yielded great results in improving the care and treatment of prisoners. In 2005 and 2007, the project was extended to two other prisons in the Bangkok area: Bangkwang, Asia's highest security prison and Pathum Thani prison. Today, MSF is handing over its project and has finalised a curriculum to help develop this model in other prisons nationwide.

Minburi becomes the example

From the outside, Minburi jail, in the east of Bangkok, looks like an ordinary prison. Around 2,100 men and 400 women are serving sentences of less than seven years there, the majority for drug-related crimes. Despite the relatively short sentences, in 2003 Minburi set a precedent by becoming the first Thai prison to provide free ARV to prisoners suffering from AIDS.

Treatment of opportunistic infections and HIV/AIDS

Shuffling in a chair in the prison's clinic, Patchara, 43, contracted HIV after sharing needles while injecting drugs. She is eager to share her experience. After shorter sentences in various prisons around the country, she is now serving the last year of a three and a half year sentence in Minburi.

"I tested positive in another prison," she explained. "The stigma there was so widespread at the time that we were separated from the rest of the prisoners. We had different work shifts and we also had to shower at different times. It was like a prison within the prison."

Being segregated also meant she was able to witness the fate of those who had developed AIDS and the memory still brings tears in her eyes.

"There were no drugs inside and it was horrible. I really saw all the stages of the disease when left untreated, from opportunistic infections to death. Women were dying one after the other falling like the leaves of a tree."

Patchara was not sick at the time but the memories were graphic enough to still haunt her when, a few years later, she developed her first opportunistic infection.

"I was already in Minburi by then. My lymph got swollen, I knew my status and thought I would end up like those women I had seen dying in prison. I went straight to the prison's clinic. But in Minburi, the atmosphere was very different than what I had known before. The staff encouraged me to take a blood test, provided moral support and I began ARVs in March 2006."

For Patchara, along with the availability of treatment, access to information played a critical role in changing the environment in the prison.

"I disclose my status, there's no discrimination here since we know about transmission and that HIV doesn't mean death. PHA (people living with HIV/AIDS) groups in the prison are very supportive and I can consult them whenever I need to."

Today there are three women and 13 men who, like Patchara, are under ARVs in Minburi. MSF worked with the Department of Corrections not only to provide ARVs but also treat opportunistic infections, raise awareness and organise training on prevention. MSF set up a peer support system for adherence and ran attitude change and health promotion workshops with the prisoners and prison staff. This helped create a significant improvement in care as well as in the trust and relationship between prisoners and staff.

"Before 2003, there was no compulsory testing and no treatment available for HIV/AIDS patients in Minburi," said Phi Toon Suchada, a prison nurse who played a key role in pushing for changes and became the first nurse to be trained by MSF.

At the time only prisoners working in the kitchen had to undergo a test, and as many were found positive, Toon turned to MSF for support.

"We knew very little about HIV. Even I, as a qualified nurse, had many misconceptions. The staff was scared of the disease. We didn't know how to treat it, we thought we could catch it, and most of all we thought they were condemned and this meant there was nothing we could do."

The lack of knowledge and fear of discrimination also prevented prisoners from seeking care before they reached an advanced stage of the disease.

When ARV therapy was introduced by MSF for the first time in Minburi in 2003, it seemed simply too good to be true. Everyone was so used to see those suffering from AIDS eventually dying that no one believed there could be a miraculous recovery from such a ruthless killer.

"I will never forget the first woman who was put on ARVs," said Toon. "She was so thin and sick, I was convinced she would die quickly. Only when I saw how treatment transformed her, did I truly believe in ARVs," Toon says still looking a bit stunned."

The impact it had on the first patient was simply incredible."

This sudden glimpse of hope instilled the will and energy to learn more and more. It boosted prison staff to get trained and train others, including guards, prisoner leaders, voluntary helpers and PHA.

It also led to more understanding, more solidarity, more prevention and tests and finally more lives saved. As trust built and treatment became available, prisoners became less reluctant to get tested and seek earlier treatment.

"None of this would have been possible without will at government level," stressed Toon. "Before 2003, I was often asked, 'Why do you want to help HIV positive prisoners? They are bad people.' But with information, there was less stigma and more awareness of prisoners' rights."

In 2004, MSF was authorised to distribute condoms to inmates, which helps reduce the transmission of HIV/AIDS. At the end of 2006, MSF and the prison staff launched a VCT (Voluntary Counseling and Testing) campaign to push prisoners to get tested as early as possible.

The project was then extended to two other prisons; in 2005 in Bangkwang maximum-security prison, with inmates serving life sentences, and Pathum Thani in September 2007.

In October 2005, the prison health budget came under the National Health Security Office's health insurance scheme. This health insurance covers for HIV/AIDS treatment including ARVs but was available for registered Thai nationals only.

MSF helped Thai patients to be put back into the national scheme, while focusing on the prisoners who had no Thai identity papers, whether foreigners or Thais from minority groups who therefore were not eligible. Today the budget has been extended for a year to incarcerated migrants as well, so that all prisoners can get their drugs from the local hospital.

MSF has now handed over its project to the Ministry of Health in both Minburi and Bangkwang and is finalising its work in Pathum Thani. The organisation developed a curriculum to help the Department of Corrections apply this model to other prisons.

"We feel Minburi has really been a successful project and we hope the Department of Corrections will use this to improve access to HIV/AIDS care in other prisons throughout Thailand because the situation remains very different in other prisons," Toon said.