Field Note

Sidelined, But Not Silent

The Thai Drug Users’ Network (TDN) Fights Government Neglect and Abuse

By Karyn Kaplan, Director, Policy and Development, Thai AIDS Treatment Action Group (TTAG)

“How can we protect ourselves from HIV if we don’t have access to clean needles? How can we stay alive if we don’t have access to HIV treatment? Hepatitis C and overdose are also destroying our community: Access to healthcare is our right, but our right is being denied.”
- Paisan Suwannawong, co-founder, Thai Drug Users’ Network (TDN)

Paisan Suwannawong is one of about 50 HIV-positive former injecting drug users (IDUs) who came together in Bangkok on International Human Rights Day, Dec. 10, 2002, to develop a plan to stop the high rates of HIV and incarceration among injecting and other drug users. On that day, heroin and amphetamine users from all over the country, many of whom had cycled through ineffective drug treatment programs and overcrowded prisons throughout their adult lives, formed the first advocacy network of people who use drugs in Southeast Asia, the Thai Drug Users’ Network (TDN). The Network, whose mission is to promote the basic rights of people who use drugs, has worked to increase access to harm reduction services - but five years later still faces huge barriers.

History of Thailand Drug Use and HIV Infection
Thailand’s stunning reductions in new HIV infections over the past two decades, (a six-fold decrease in projected estimates to approximately new 18,000 cases in 2005) has garnered international attention and praise from UN agencies, donor organizations and government leaders the world over. Thailand’s “condom king,” Mechai Veravaidya, was recently awarded $1 million from the Bill & Melinda Gates Foundation in recognition of his role in promoting popular HIV prevention campaigns focusing on sexual transmission. Contradicting this success story, however, are many of the country’s most vulnerable groups who have enjoyed none of the benefits of Thailand’s prevention or treatment access programs. Injecting drug users, experiencing two decades of a 50 percent increase in HIV prevalence, have perhaps suffered the most.

Thailand, whose northern borders form part of the “Golden Triangle” (which also covers parts of Burma and Laos), first experienced a significant heroin injecting epidemic in the 1960s. Successful poppy crop eradication strategies and other drug control policies contributed to the shift from opium smoking to injecting heroin and other synthetic and processed drugs. Ongoing drug wars, resulting in scarcity and increased prices of heroin, led to a dramatic shift in drug consumption practices and more people taking other kinds of drugs. Today, an estimated 5 percent of the Thai population - more than 3 million people - use drugs, the majority of whom smoke the cheap and easy-to-produce-and-hide methamphetamine pills. TDN and others working with drug users note that heroin injectors are now forced to inject more toxic and harmful substances such as methamphetamine or the easily-accessible sedative, Midazolam (Dormicum). Researchers note that increased sexual risk among methamphetamine users may be an emerging factor in Thailand’s drug user HIV epidemic.

In the late 1980s, the ministry of public health documented a sudden spike in HIV infections among IDUs from 2 to 43 percent in only six months, figures supported by a 2006 World Bank report. This “first wave” of HIV infection quickly spread to commercial sex workers, their clients and the general population, and for the next two decades, an estimated one in two injectors was infected with HIV. Yet despite a well-documented epidemic among this group, the government ignored international advice to implement comprehensive, targeted HIV prevention (namely, the “harm reduction” approach).

International Advice Ignored
WHO and World Bank recommendations to provide aggressive prevention interventions with wide coverage including access to clean injecting equipment were eschewed in favor of a “just say no” abstinence-based drug treatment policy that did nothing to address the urgent problem of HIV and Hepatitis C transmission (Hepatitis C is even more prevalent than HIV among Thai IDU, with estimates upwards of 90 percent). Methadone, where provided, was not only prohibitively expensive, but provided as a quickly-tapering detox dose that was not in accordance with international standards. The government’s program of compulsory rehabilitation or incarceration of people who use drugs has only served to increase stigma and HIV risk among IDUs, who still suffer disproportionate rates of HIV infection: approximately 25 percent of all new infections in 2005. On the situation of IDU, Paisan said: “We’re all in prison, or in heaven.”

At its nadir, Thailand’s approach led to some of the worst human rights violations in drug war history. Documented by a 2004 Human Rights report, “Not Enough Graves: The War on Drugs, HIV/AIDS and Violations of Human Rights,” in February 2003, then-Prime Minister Thaksin Shinawatra announced the launching of a drug war in the name of the king and a “drug-free” Thailand. He said that suspects would be treated in a “ruthless” and “severe” manner, including a “shoot-to-kill” policy toward alleged traffickers. Thailand’s minister of the interior stated that people suspected of involvement with drugs would “be put behind bars or even vanish without a trace. Who cares? They are destroying our country.”

More than 2,500 people were estimated to be extra-judicially executed, in that drug war, said the National Human Rights Commission of Thailand, the Asian Human Rights Commission and many international groups. Police abuse and the forced participation of tens of thousands of drug suspects in specially-designed military boot camps created a climate of terror driving many drug users underground and farther from the few HIV/AIDS services that existed. Increased needle sharing was reported during this period, and peer outreach workers trying to contact IDUs found it nearly impossible. In some cases, research projects among IDUs had to be shut down or postponed.

Birth and Growth of the TDN
TDN was born just months before this violent drug war. Often the only voice publicly criticizing the government for its policies, TDN relied on a wide range of tactics to bring national and international attention to the abuses. The Network held street demonstrations, including a mock funeral at the Government House to deplore those killed in the drug war or by HIV/AIDS; they marched on the king’s birthday to the Grand Palace imploring him to end the violence. TDN met with senators and national human rights commissioners to raise awareness around IDU human rights issues and to enjoin them in the fight. In June 2003, TDN held an “International Day of Solidarity Against the Thai Drug War,” in which activists across the globe from Nepal to South Africa, UK to Australia rallied at Thai embassies in their cities to request TDN’s demands for justice be met.

TDN received impressive validation when the Global Fund to Fight AIDS, TB and Malaria (GFATM) granted them $1.3 million dollars for their proposal, submitted outside the traditional “CCM” or country-participants) to implement a three-year project for peer-driven HIV prevention, care and support for injecting drug users in Thailand with its two community-based partners, Thai AIDS Treatment Action Group (TTAG) and Alden House, as well as its principal recipient, Raks Thai Foundation. Coinciding with Thaksin’s violent war on drugs, the TDN project was Thailand’s first drug user-run service and advocacy project. It centered around the drop-in centers where TDN provided information, education, advocacy and support services to people who use drugs in four regions of Thailand, and in prisons. The project partners also conducted harm reduction policy advocacy work. While they have achieved small steps forward, they still face many obstacles, including within the AIDS NGO community itself, where there is little understanding of drug user issues and little commitment to addressing the legal and political barriers.

Today, TDN continues to meet with highlevel government officials like the minister of public health and works at the provincial government level as well, to ensure, for example, that the government’s national health insurance plan covers methadone and that needle exchange programs are high on the agenda of the discussion around integrated and comprehensive care and support for drug users.

ARVS for HIV-Infected Drug Users
Access to ARVs is a major point of contention. One of the few developing countries in the world to provide free antiretroviral therapy to the majority of PWLHA who need it, (more than 100,000 as of 2007), Thailand has no guidelines for ensuring access for drug users, a practice that belies its policy of “universal access.” Police interference with drug treatment programs, lack of access to appropriate information, and virtually no comprehensive harm reduction programs or needle exchange means that people who use drugs continue to suffer neglect and ongoing HIV infection that ultimately bridges to the general population.

But TDN will not stay silent until the government recognizes the basic dignity and rights of drug users, including the rights to health and life. As a founding member of TDN said in the midst of the 2003 war on drugs, “I am not afraid to stand up for my rights in the midst of this drug war. What is there to lose? I couldn’t live with the shame of doing nothing, knowing every day my peers are dying and no one is doing anything.” Bravery like this should not be necessary. But it is - and Thai drug users are modeling this courage and AIDS activism for drug users and all marginalized groups, on a global scale.

For more information contact karyn.kaplan@gmail.com.

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