MSF's work with Injecting Drug Users in Thailand.

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% to 50% (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 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. Because of them, I've dropped out of college, I've lost jobs, failed in my relationships. I spent nearly 3 years in jail and I contracted HIV," says 48-year old Pailin, who has been struggling with his addiction for 25 years and has been off heroin for a month. "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 on HIV/AIDS, 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," explains 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," explains Pom who's 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." explains 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. 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," stresses Krongram. 

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. 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," explains Pailin, "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."

Drug User & Outreach Worker

48-year old Pailin is eager to share his experience as an outreach worker and doesn't hide his enthusiasm about the Thai Drug-user Network (TDN). "I could have done some other work, but I really enjoy helping my friends," he says

Pailin has been taking drugs for 25 years, switching between heroin and methadone. He started injecting heroin at 17 years old and contracted HIV while sharing needles. "My life was totally controlled by heroin. I used to inject once in the morning and would go to work in a shipping company in a daze until my next shot in the evening. Nothing else mattered," he explains. "Drugs have totally ruined my life."

Like many drug users in Bangkok, Pailin has been arrested several times. He was detained three times, the longest sentence being two and a half years, when he was found in possession of heroin.  "While in prison I had neither heroin nor methadone. It was horrendous. I became violently sick. I kept vomiting and had terrible cramps. I was in so much pain I couldn't do anything but it was very hard to see the doctor." However, immediately after his release from prison, Pailin began injecting heroin again, spending up to 80% of his salary on drugs.

Today Pailin has been off heroin for a month. He's on a methadone substitution therapy provided by a governmental clinic to reduce withdrawal symptoms but admits it's too early to say what will happen next. He has been trying to quit for ten years but his addiction has always defeated him in the end. "It' so hard to quit, it's truly awful. I tried so many times but you're always back on it and it totally alienates you from society." Yet he firmly believes drug users should not be discriminated against but helped.  Two years ago he became an outreach worker when a peer visited him and introduced him to TDN. "It really made me want to help myself and others, raise awareness about harm reduction and prevent more people from getting infected with HIV in my neighbourhood. I really think drop-in centres like TDN can make a difference."

TDN is a network of Thais formed in 2002 by current and former drug users to promote basic human rights and improve access to HIV/AIDS care. The organisation works in partnership with other NGOs and aims to increase awareness of health issues among drug users and to disseminate Harm Reduction information. It provides counselling and information on HIV/AIDS, and lobbies the public health authorities to fully include drug users in ARV therapy and help improve attitudes and understanding towards them in the hope of better social inclusion.