Interview with MSF doctor Mo about the HIV/AIDS care in prison in Thailand

Progress and challenges in HIV/AIDS care in prison in Thailand. – Is Minburi a model to develop nationwide?

MSF's project in Minburi demonstrates that complex and life-long therapies can be implemented in prisons despite tight budget and human resource constraints.  The experiment in Minburi proved successful and was extended to two other prisons: the high security prison Bangkwang and later Pathum Thani.

Thanks to a network of health leaders, health volunteers, peers and the collaboration of both prison staff and the prison staff273 prisoners have been able to receive HIV/AIDS treatment and care through MSF since the beginning of the project in the three prisons.

HIV/AIDS treatment and care has now been taken over by the Department of Corrections in Minburi. In Bangkwang and Pathum Thani prisons, it will be done in December 2008. MSF developed a curriculum to help the Department of Corrections use this model in other prisons nationwide. MSF doctor Mo describes the challenges and success in providing HIV/AIDS treatment and care in in three prisons in Bangkok 

Why were prisoners denied access to treatment before MSF began its project, when the country was at the same time aiming to provide free ARVs to all those who needed it?

Thailand had been very successful in its national campaign for prevention and treatment and offered free first-line AIDS treatment to all those who needed it, under the national health scheme. But marginalised populations such as injecting drug users (IDUs), prisoners or all those who didn't have Thai identity papers were excluded. There were also problems of budget constraints and a lack of health staff in the prisons. For example, there was on average one nurse for 1,250 prisoners in Minburi.

The general feeling was that providing ARVs in prison was too expensive and too complex. Finally the bureaucracy meant it was long and difficult for those who wanted to change things and to have an impact and there was a lack of political will to change things. Also there was a general lack of knowledge and information about HIV/AIDS, even among the medical staff working in the prisons.

How did things begin to change?

MSF provided treatment as well as information about the disease and trained the staff and prisoners. The result was positive and it was key in changing attitudes in the prisons.

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. Prisoners can get their drugs from the local hospital and we have been able to hand over our project to the Department of Corrections in two prisons.

What were the biggest challenges you met?

The Corrections Department suffers from budget constraints and a lack of health staff, but many patients were successfully put on treatment. The national health coverage has now been extended and covers prisoners who don't have the Thai citizenship, which is real progress. But despite these efforts, there are many. Referral to the hospital, especially in a high security prison like Bangkwang, is problematic for security reasons. MSF tries to follow up on referred  patients.  In Pathum Thani prison we have still many hidden cases. People will not come forward for treatment early enough and tend to wait until they have reached an advanced stage for fear of disclosing their status. 

Diagnosis can also be challenging. CD4 tests are expensive and the patient has to go to the local hospital. Because of the workload and human resource constraints there often are delays there too.

MSF will soon hand over its last project in Pathum Thani prison. What do you hope to see in the future?

Overall the project has been very successful and has really made a difference. We hope that this model can be developed in other prisons nationwide and that the Ministry of Public Health (MOPH) will show a real political will to provide access to HIV/AIDS treatment and care in all prisons. Despite the challenges of budget and human resource constraints our experience shows that with the political will, it is possible to change things and achieve great results. In many prisons, it's not seen as a priority and many people are dying because they can't be diagnosed fast enough, or cant access drugs and be treated.
 
HIV/AIDS care in prison in Thailand

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.