Bangkok Post - December 3, 2000
Patcharin Wongsatien

Campaigners against Aids, including the World Bank, point out that prostitution is also illegal but the provision of condoms has proved effective in curbing the spread of the virus.

In recent years, Thailand has been highly successful in reducing new HIV infections through public awareness campaigns and the distribution of free condoms. However, at the same time, the infection rate among intravenous drug users, already high, has risen to well above 40%. Regions of most serious concern, according to a report by the World Bank on Thailand's Response to Aids, are Bangkok, the Central Plains and the South. A multi-discipline study found that HIV infection among northern military conscripts due to intravenous drug use increased from less than 2% in 1991 to 27% in 1998.

The bank says there are an estimated 100,000-250,000 intravenous drug addicts nationwide. Infected addicts not only pass the virus on to other addicts but also to their sexual partners and children. Once a person becomes HIV-positive, they are vulnerable to a host of opportunist infections, such as tuberculosis, hepatitis B and C, which are highly contagious, and are driven from the mainstream of society into prostitution and theft to earn money to feed their addiction.

Since up to 33% of HIV cases directly or indirectly involve intravenous drug users, the bank says that if left untreated, the threat can spread to the rest of the population. But the government has yet to pay serious attention to what is considered an imminent danger. One of the authors of the report, Dr Chris Beyrer of the School of Public Health, Johns Hopkins University in Maryland, United States, says:

"The transmission cycle among intravenous drug users will not be broken unless the same effort that was given to commercial sex is given to this problem and if there is a serious effort to prevent HIV in prisons and improve the legal environment [to encourage] behaviour change among intravenous drug users.

"Ton Smits, executive director of the Asian Harm Reduction Network, says it is imperative for the authorities to change their attitude and apply a public health approach rather than treat the problem as a security issue. Addicts should not be regarded as criminals but as patients who need treatment.

To control the spread of the deadly virus, health workers must have access to addicts. Needle-exchange programmes have proved highly successful in the West. In addition, certain health programmes must be established, including drop-in centres that offer addicts information, help and counseling without fear of arrest. Also, long-term methadone treatment for heroin addicts-instead of short courses-to enable them to work and function in day-to-day life.

"Prostitution is illegal but that doesn't stop Thailand from providing condoms in all brothels," say Mr Smits. "Drug users are the same. You should not deprive them of clean needles or long-term methadone treatment.

"Methadone treatment is not at all expensive. In the United States, it costs only US$200 a year per person. Once you're hooked, you do anything to get the drug. Methadone takes care of the craving, so addicts can start to live a normal life. They can work to earn money because the body is not aching for drugs. There are thousands of addicts who are on methadone and can live a normal life," Mr Smits says.

CAPTIVE MARKET

Prisons are a major breeding ground for Aids. The report says the infection rate among intravenous drug users in Bangkok jails rose from 2% to 40% within six months in 1989. There are more than 1.2 million prisoners, or one sixtieth of the population, and more than 60% are serving time for drug-related crimes.

The sharp increase in the incarceration rate of drug users not only results in overcrowding but heightens the risk of HIV infection among drug users. In 1991, the median infection rate among newly admitted male prisoners was 12% in 20 provinces and 19% among those about to be discharged in 10 provinces. In 1987-88 when a substantial spread of HIV was observed, the infection rate among intravenous drug users in Bangkok surged from virtually nil to beyond 30%_a jump that was eventually seen in other countries in the region.

According to a report on Prisons and Aids by Unaids, general factors in prisons which facilitate HIV spread include overcrowding; a general climate of violence; tension and fear; lack of information about HIV; and lack of adequate facilities.

It is evident that banning drugs in jails has always failed. Therefore, it is important that addicts have access to preventive measures such as information, clean needles and healthcare, Mr Smits say.

But more importantly, addicts should not face criminal charges in the first place. According to PM's Office's Order 141/1998, addicts must not be treated as criminals but as patients who need treatment and rehabilitation. Also, under the Drug Addict Rehabilitation Act, drug suspects are required to have their urine tested and get treatment accordingly. The law was enacted in 1991 after several attempts to curb the spread of drugs had already failed.

But in reality, drug suspects are often charged with criminal offences and subsequently imprisoned. A case in point is when a third-year Chulalongkorn student was put in jail after policemen claimed they found an amphetamine tablet on him. He protested his innocence but remained behind bars for over a month before his lecturer bailed him out.

Anindya Chatterjee of Unaids says that putting more addicts behind bars puts more people at risk of infection and that it is cheaper and more cost-effective to treat them. "A significant number of young adult males are in jail. Most of them are users. You can treat them at a much cheaper rate," he says.

For example, the cost of putting somebody in prison in the United States is US$80,000 a year. Several studies show that for every $1 spent on treating a person, the return is more than $25 in terms of gains through the person's productivity and savings on health and criminal justice costs, Mr Chatterjee says.

"All over the world in every country we find only poor people in jail. Middle class kids who get into drugs will bribe their way out or fight their way out with lawyers. It is only the poor scum boys who land in trouble because of drug use," he says.

In many countries, the control of HIV infection among intravenous drug users has proved one of the most effective among all methods of prevention and treatment. Better results are achieved if vigorous action is taken early.

But the major problem is that policy makers are reluctant to adopt a public health approach because of the belief that drug addiction is evil and illegal. "The lack of policy to support the scheme means that the project cannot be applied by government staff who have most access to addicts. We are not in a position to make those policy changes but to present facts, discuss options and make recommendations for changes. It is up to Thai policy- makers to make the final decision," Mr Smits says.

OFFICIAL INFLEXIBILITY

And yet, even in the face of these compelling arguments from health professionals, the authorities still refuse to do anything other than go strictly by the book.

According to the Office of Narcotics Control Board, the distribution of free needles is out of question. It is not only illegal but can be counter-productive and send the wrong message to the population, particularly the younger generation.

"We have been preaching that drug abuse is bad and have applied tough measures to stop people taking drugs. If we give out free needles, kids will get confused. How can we say drugs are bad when we give free needles to people to take them?" an official at the Drug Dependence Treatment Coordination reasoned.

But she admits that the government's get-tough-on-drugs approach, including imposing death sentences on amphetamine traffickers, have so far failed miserably. The number of addicts has skyrocketed and the Corrections Department is faced with at least 95,000 drug addicted inmates even though they have space to treat only 7,900.

The rehabilitation programme has also had little success. As many as 95% of the rehabilitated addicts return to their habit after completion of the programme. There are 247 treatment centres and six therapeutic community clinics run by government agencies and the private sector.

But the official is positive that once the rehabilitation law is implemented, the number of addicts will decline. "Although we have the law to treat addicts rather than sending them to jail, it still cannot be implemented because there are still a lot of problems. I agree that prevention is the best way to control the spread of Aids but we cannot give away free needles. For one thing, people's attitude towards addicts may improve but many still view them as trouble makers. They might ask why we have to spend on needles to help addicts while most people in the country are still poor," she says.

Bundit Rachatanand, deputy permanent secretary of the Justice Ministry, says Aids prevention measures, such as needle exchange programmes, may work in some countries but under no circumstances can it be applied in Thailand. "We have been running a campaign against drugs. We don't want addicts. To give them syringes is to encourage them to use drugs even more.

"The law says drug use is illegal. Distributing syringes is like encouraging people to break the law. Even if you give them free needles, they can still share them," he says.

In the case of long-term methadone treatment, Mr Bundit says the use of drugs to cure drug addicts has never worked.

"The programme has existed for the past 10 years but has hardly been successful. It is more important that addicts are willing to give up the habit themselves," he says. Mr Bundit says Thailand has already had the effective prevention laws in place-the 1991 Drug Addict Rehabilitation Act-and as soon as it can be implemented, drug and Aids problems will improve.

"Gen Chatichai (the then prime minister) got this concept from Singapore where addicts are given two choices: treatment or jail. Here, suspects will be tested and sent to rehab centres for six months to three years if they are addicts. If they can kick the habit, they will get off the criminal charges."At present, drug addicts can either seek treatment voluntarily at public or private clinics, or face arrest and criminal charges.

If found guilty, they will be forced to get treatment in rehabilitation centres within prison compounds.

But the authorities have yet to make clear when the law will be put into practice.

Mr Bundit says many obstacles, especially lack of budget, supporting systems and manpower, have yet to be overcome.

"The system needs a lot of co-operation from many government departments but there is not enough manpower. For example, the law requires the formation of a committee to take charge of the process. We need someone from the Justice Department, the Medical Services Department, the Communicable Disease Control and the Police Office. We also need doctors, psychiatrists and social workers," Mr Bundit says.

But he says the best prevention method and the only way to solve the drug problem is to create a healthy community and social environment.

"Drug addiction results in many ills, including the collapse of the family institution and social degradation. The only way to get addicts out of the vicious circle and prevent new addicts from falling in is to build up a strong community," says Mr Bundit.

"Addicts need a complete cycle of help_that is: treatment, rehabilitation, training, work and a healthy environment to return to_not free needles."
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