Needle exchanges for injecting drug users and the decriminalization of people who use drugs are the most effective ways of preventing HIV and hepatitis C infections in Thailand, say experts.

“When users do not have access to sterile injecting equipment they will share needles, [and] that will lead to HIV transmission as well as to hepatitis C,” said Pascal Tanguay, programme director in the Thailand office of the international NGO, Population Services International (PSI).

Providing free clean needles and syringes has proven to be the safest and most effective way to prevent new infections among injecting drug users (IDUs). But the Council of State, Thailand’s central legal advisory body, has interpreted any needle distribution programme as promoting drug use, Petsri Siriniran, Director of the National AIDS Management Centre in the Public Health Ministry’s Department of Disease Control, told IRIN.

Nevertheless, the ministry is collaborating on a pilot project, run by PSI since 2009, in which counselling and sterile syringes are provided through drop-in centres and outreach services in 19 of Thailand’s 76 provinces.

PSI has partnered with various local NGOs and support groups for people living with HIV to distribute clean needles to the country’s estimated 40,000 IDUs, 20 percent of whom share needles, according to 2010 government figures.

The Urban Health Research Initiative of the British Columbia Centre for Excellence in HIV/AIDS and the local Thai AIDS Treatment Action Group released a survey of 468 injecting drug users from a community in Bangkok, the capital, in 2012.

The study found that 30 percent of participants borrowed needles from other drug users, largely because there was nowhere to buy new ones or because pharmacies refused to sell them syringes.

A 2011 World Bank review of HIV prevention among IDUs in Thailand indicated that needle exchange programmes could be one of the key factors in decreasing HIV infections among them.

HIV prevalence among Thai IDUs dropped from 49 percent in 2008-2009 to 22 percent the following year. However, this is still among the highest in the Southeast Asia region, according to the Global AIDS Response progress report by the UN Joint HIV/AIDS Programme (UNAIDS).

Anne Bergenstrom, regional adviser on HIV/AIDS at the UN Office on Drugs and Crime (UNODC), questions the apparent drop. “Some of this reduction may be due to deaths in this population. There is no recent national survey on drugs, so we do not know how many initiate drugs and how many are HIV positive,” she said.

In Bangkok, Sak Aim Kien, 47, said, “When I am with friends and I have money, I still inject heroin, although I try hard to quit.” He has attended government drug rehabilitation programmes for the past eight years with faltering success. “My family does not know about my addiction and I tell my children I have a lung disease to hide it.”

Another man at the same local drop-in centre who went by the name of Aun, 37, went from injecting heroin to midazolam - a legally available psychotropic drug that alters brain function by affecting the central nervous system - after completing a methadone treatment programme five years ago.

Daily doses of methadone, a pain reliever, have been shown to help wean injecting drug users off heroin by blocking drug-induced euphoria and blunting their withdrawal symptoms, but in some cases, users have simply substituted one addiction for another.

Government “ambivalence”

Since 2009, PSI has distributed more than 300,000 needles and syringes, reaching up to 8,000 drug users, but workers say they operate on the margins of the law. “We currently run the only needle and syringe distribution project in Thailand, but the Thai government refuses to implement needle and syringes distribution, proclaiming falsely that such projects would encourage drug use,” said Tanguay.

“Sometimes the police are waiting outside our premises, arresting people who come here,” Piyabutr Nakaphiw, the manager of O-Zone, a drop-in centre for drug users in Bangkok, told IRIN. The centre employs drug users as outreach workers to distribute clean needles to other users in their communities. “They stop our outreach community workers, and if they are tested positive for drugs, the police either ask for money or arrest them,” said Nakaphiw.

UNODC’s Bergenstrom noted that “The government always had an ambivalent attitude towards the needle exchange. If we try to achieve HIV reduction, then coverage to needle exchange, access to rehabilitation programmes and to counselling services should be increased.”

The 2012-2016 national AIDS strategy calls for a review and amendment of current legislation that prohibits needle exchange and criminalizes drug users. A past effort to change the relevant laws failed.

Although the Drug Addict Rehabilitation Act passed in 2002 promotes the treatment of people who use drugs as patients, under the 1979 Narcotics Act drug addicts can still be arrested.

“It will be virtually impossible to halt HIV transmission as long as the national legal and policy framework around drug issues focuses on punishment and deterrence at the expense of the health and human rights of citizens,” said Tanguay.

Hepatitis C infection is another concern. A recent study published by the UK medical journal, The Lancet,  reported that almost 90 percent of IDUs in Thailand are living with hepatitis C, which is transmitted through needle sharing, and can lead to liver failure and cancer.

Tanguay said although needle exchange programmes alone will not halt the spread of HIV and hepatitis C, it can be a major part of the solution if combined with the decriminalization of drugs and drug users.

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