Civil Society and Harm Reduction in Thailand – Lessons Not Learned

This essay is part of a series on harm reduction responses to drug use in the MENA and Asian regions—the actors and networks engaged in such activities, the contributions they have made, and the roadblocks they have met. Read more ...

“We are looking to learn from Thailand”[1] – Mark Dybul, Executive Director, Global Fund to Fight AIDS, Tuberculosis and Malaria, Global Fund board meeting, November 2014

The Thai government was acclaimed in the 1990s for the bold approaches it supported to reduce HIV transmission among sex workers. Later, the Thai government’s leadership was internationally praised for providing generic antiretroviral treatment (ART) to people living with HIV. Today, global leaders applaud the Thai government’s decision to provide ART to everyone in an effort to prevent transmission,[2] as well as for its decision to take full financial responsibility for HIV programming as of 2017, essentially weaning itself off external donor support.[3] Indeed, there is much to celebrate, and the Thai government’s contributions to leadership and innovation in the area of HIV prevention, treatment, care, and support must be acknowledged—but not blindly.

For more than two decades, HIV prevalence among people who inject drugs (PWID) in Thailand has remained alarmingly high—between 25 and 30 percent since 1989[4]—while PWID population size has declined from 100,000-250,000 in 1994 to 40,300 today, likely due to AIDS-related illnesses.[5] Recent studies indicate that as many as 90 percent of PWID are living with hepatitis C (HCV),[6] and that overdoses are common.[7]

The Thai government has relied almost exclusively on repressive policies that criminalize people who use drugs (PWUD), prioritizing public security at the expense of public health. For example, the 2002-2004 war on drugs led to the extrajudicial killing of over 2,700 drug dealers and users.[8] The focus on law enforcement and public security in addressing drug-related issues in Thailand has also led to the following:

• Mass incarcerations: With over 60 percent of the prison population incarcerated for drug-related crimes,[9] Thailand’s prisons are overcrowded. Operating at double the maximum capacity,[10] they offer few services that address HIV and drug dependence.[11]
• Forced detention: Hundreds of thousands of individuals are detained, without due process, legal support, or possibility of appeal,[12] in the name of drug treatment. Between October 1, 2011 and September 30, 2012, the Thai government recorded over 500,000 people entering so-called drug treatment centers,[13] more than three times the number sent to such centers during the 2003-2004 war on drugs.[14] Across Thailand, the government records over 1,200 such centers,[15] the vast majority being operated by military personnel who have little or no medical training.[16]
• Human rights violations: Physical, sexual, and psychological abuse at the hands of law enforcement officials has been documented in community[17] and closed[18] settings. The testimonies of PWUD indicate that extortion, entrapment, and exchange of sexual favors routinely take place, with few opportunities to hold law enforcement representatives accountable. 
• Public health barriers: Law enforcement approaches are now widely acknowledged to drive PWUD underground, further away from essential health services, fueling stigmatization and discrimination as well as the transmission of HIV and other blood-borne infections like HCV.

In this context, addressing HIV and public health among PWUD has been almost entirely left to civil society organizations (CSO). Over the past decade, CSOs have played an indispensible role in HIV prevention, bringing services to PWID with very little support from national government agencies. Dedicated workers—the majority of them PWUD—have continually placed themselves at personal risk to deliver essential services to PWUD across the Kingdom. This essay first reviews key milestones—successes and challenges—related to CSO-led initiatives, and then discusses the future of the national response to HIV, highlighting the need for continued meaningful involvement of CSOs.

CSO Engagement in Harm Reduction

The Thai Drug Users’ Network (TDN) was established in 2002 after community activists gathered with the objective of documenting human rights abuses against Thai PWUD.^[19] Shortly thereafter, the Thai government launched an intensive repression campaign to eliminate illicit drugs from the country, which resulted in the extrajudicial killing of over 2,700 PWUD. In the midst of the war on drugs, CSOs worked to submit a proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) to address HIV among PWID in Thailand. The proposal, submitted by TDN, the Thai AIDS Treatment Action Group (TTAG), Alden House, and the Raks Thai Foundation in April 2003, requested $1.3 million to support the delivery of peer-based health and social services targeting PWID, including the establishment of four harm reduction drop-in centers (DIC).

In October 2004, the proposal was approved and GFATM resources were disbursed to support the “HIV Prevention, Care and Support for Injecting Drug Users" (CASIDU) project, representing the first large-scale investment in harm reduction in Thailand.[20] In particular, the CASIDU project was revolutionary in that approval bypassed Thailand’s Country Coordinating Mechanism (CCM), where CCM is usually the exclusive mechanism for national engagement with GFATM and provides oversight over all national GFATM commitments.[21] Indeed, TDN and its partners made compelling arguments—highlighting the lack of support for harm reduction among Thai government officials as well as the ongoing war on drugs—to convince the GFATM to invest in CSOs providing services to PWID in Thailand. In that process, TDN helped the GFATM review and refine its criteria for disbursing funds to non-CCM applicants globally.[22]

TDN mobilized members, partners, and other allies to call attention—through coordinated activism—to the spread of HIV and the gross disregard for the health and human rights of PWUD.[23] TDN demonstrated national leadership and initiative in pushing the national response forward despite strong political and social opposition. In 2004, TDN’s critical role in successfully mobilizing global support for Thai PWUD and bringing attention to the wide range of human rights violations suffered by this group was recognized with the Award for Action on HIV/AIDS and Human Rights, conferred by the Canadian HIV/AIDS Legal Network and Human Rights Watch.[24]

Unfortunately, the CASIDU project came to a close in 2007; the investment was not continued and the infrastructure developed under CASIDU was largely dismantled.[25] While CSOs were once more under financial pressure, TTAG was invited by TDN to manage the Bangkok drop-in center—the Mitsampan Harm Reduction Center (MSHRC), established under CASIDU—in order to continue and expand service delivery. Fortunately, in January 2008, TTAG partnered with the British Columbia Center for Excellence in HIV/AIDS and Chulalongkorn University to begin a community-based peer-led research project in June 2008.

This community-based research initiative ensured that PWID retained access to health and social care services. The new coalition was able to generate significant results within a short period of time, including an increasing number of client visits to the harm reduction drop-in center in Bangkok (MSHRC), the strengthening of stakeholder capacity, and the dissemination of information through publications and presentations in key national and international forums.[26] These successes soon attracted interest from other donors.

In parallel with the participatory research project led by TTAG, Population Services International (PSI) Thailand was able to attract support from USAID in late 2007 to operate a network of drop-in centers branded as “Ozone”[27] in Bangkok, Chiang Mai, and Chiang Rai. The Ozone DIC also delivered a range of interventions for PWID, focusing on “behavior change” interventions.[28] Unfortunately, budgetary and programmatic constraints led to the discontinuation of USAID support in early 2008, once again placing the results of previous investments at risk, including infrastructure and human resource capacity.

As the services targeting PWID were being suspended across Thailand, several CSOs met between early 2007 and late 2008 to strategize and develop an emergency response. Over the course of the meetings, a consensus emerged around the need for concerted harm reduction advocacy. The groups agreed on the urgent need to mobilize funds from national and international sources and collaborate with key government agencies. These consultations culminated in the establishment of a formal CSO coalition, called 12D, whose mission is to promote sustainable harm reduction policies and quality health and social care services to meet the needs of PWUD in Thailand.[29]  

12D became a vehicle for coordinated advocacy supporting the empowerment of CSOs in the national response to drug-related issues. At the UNAIDS Program coordinating board meeting in Chiang Mai in 2008, 12D members called attention to the reemergence of the war on drugs. In 2009, 12D called for the inclusion of methadone in the National Health Security Scheme, and in 2010, the coalition was acknowledged as a key partner in the success of the International Harm Reduction Conference in Bangkok. In 2012, 12D received its first grant, from the Open Society Foundations (OSF).

Back in 2008, as the small investments in harm reduction were being reduced or completely terminated, a group of CSOs―PSI Thailand, RTF, TTAG, TDN, TRC, and Alden House―developed a proposal for the GFATM’s consideration. With an approved budget of approximately $18 million, the Comprehensive HIV Prevention among Most At-Risk Populations by Promoting Integrated Outreach and Networking (CHAMPION-IDU) project was initiated in July 2009. The project was designed to deliver and strengthen a range of essential health services for PWID through peer-based drop-in centers and outreach services across 19 provinces. The services included distribution of sterile needles and syringes, provision of condoms, “behavior change” interventions, diagnosis and treatment of sexually transmitted infections (STI), voluntary HIV counseling and testing, and methadone and antiretroviral treatment. In January 2013, an overdose prevention component was also initiated under CHAMPION-IDU with incremental funding from the OSF.[30] Several Thai government agencies did simultaneously receive GFATM support for HIV prevention among PWID,[31] but despite several requests from CHAMPION-IDU partners to improve coordination and collaboration with government recipients, CSO partners implemented the project with limited official support up until its close-out on December 31, 2014.[32]

With government agencies focused on prohibition, punishment, and forced rehabilitation, and CSOs focused on health and social care, project partners had to develop a range of solutions to overcome conflicts between these two agendas.  For example, CSOs took measures to reduce the risks and consequences of interference with law enforcement operations.[33] Given the extraordinary challenges in scaling up harm reduction in a hostile environment, the project could not reach the challenging quantitative targets set forth in the performance framework and was rated at an overall B2 (inadequate but potential demonstrated) based on GFATM measurements.[34] However, CSO partners were able to generate important successes. They reached approximately 14,000 PWID during the project’s life cycle, while advocacy efforts led to the official ratification of the national harm reduction policy in February 2014.[35]

Discussion

For over a decade, external donors have invested approximately $20 million in CSO-led harm reduction projects in Thailand, footing the bill for the country’s response to HIV among PWID. However, this funding has covered only a fraction of the need. This essay has shown that the positive results from those investments have systematically been at risk as CSOs have struggled to find sufficient national and external support.

Under the New Funding Mechanism (NFM), GFATM’s new national financing framework set up in 2014, Thailand will receive only approximately $762,525 of new funding for two years.[36] (in addition to funding already committed under existing grants) across all key populations to cover HIV and tuberculosis.[37] This accelerated transition towards national funding and the consequent drop in the funding provided under the NFM represents a stark break from the past for which the majority of harm reduction CSOs were not ready. Indeed, this drop in funding has already led to a measurable scale-down in the response to HIV among PWID. While the Thai government is using the NFM to front-load the transition to fully funding its national response to HIV by 2017, it has made no effort to change its repressive approaches or to invest national resources in evidence-based health services that improve the quality of life of PWUD. Instead, the government continues to invest in drug control efforts proven to have negative effects on health-seeking behaviors.[38]

The history of Thailand’s response to HIV among PWID demonstrates the invaluable leadership and accomplishments of CSOs.[39] For more than a decade, CSO-driven projects like CASIDU and CHAMPION-IDU have represented almost the entirety of the response to HIV among people who use and inject drugs in Thailand, while organizations like TDN, TTAG, and 12D have provided critical leadership in moving the advocacy agenda forward. Without the dedicated involvement of CSOs and their partners, the health and quality of life of PWUD would likely be much worse today.

Unfortunately, the future of Thailand’s national response to HIV is far from clear at the present time, and allocations for harm reduction programming beyond 2016 remain undefined. As the next steps are implemented under the NFM, the Thai government should demonstrate support for CSO-led initiatives, allocate significant resources to ensure scale-up and expansion of harm reduction, and work to harmonize public health and public security strategies. Otherwise, its response to HIV will no longer be recognized as a global standard. International agencies like UNAIDS and the GFATM will need to keep a close eye on progress made in Thailand in the coming years and temper their praise with caution and technical support to ensure that key populations like PWUD and PWID are not left behind. Meanwhile, it is clear that CSOs will continue to bear a large proportion of the risks associated with sustaining harm reduction service delivery in Thailand.

[1] The Global Fund, “Transitioning in Thailand,” Global Fund News Flash, November 28, 2014, http://www.theglobalfund.org/en/blog/2014-11-28_Global_Fund_News_Flash/.

[2] Michel Sidibé, “Thailand Leads Way to Ending Aids,” Bangkok Post, October 27, 2014, http://www.bangkokpost.com/opinion/opinion/439819/thailand-leads-way-to-ending-aids.  

[3] The Global Fund, “Transitioning in Thailand.”

[4] Canadian HIV/AIDS Legal Network, “Drug Use and HIV/AIDS in Thailand,” 2009; “UNGASS Country Progress Report Thailand: Reporting Period: January 2008–December 2009;” National AIDS Prevention and Alleviation Committee, Thailand, 2010; Bureau of Epidemiology, “Integrated Biobehavioral Survey,” 2012 (unpublished); HIV/AIDS Data Hub, Thailand Country Profile: HIV Prevalence and Epidemiological Status, 2013, https://skydrive.live.com/view.aspx?resid=AFD9EDEA3DDFB75C!936&app=Excel.

[5] World Bank, “Thailand Social Monitor: Thailand's Response to AIDS -- Building on Success, Confronting the Future,” 2000.

[6] K. Hayashi, “Low Uptake of Hepatitis C Testing and High Prevalence of Risk Behavior among HIV Positive Injection Drug Users in Bangkok, Thailand,” Journal of Acquired Immune Deficiency Syndromes 56 (2011): 5.

[7] M.J. Milloy et al., “Overdose Experiences among Injection Drug Users in Bangkok, Thailand,” Harm Reduction Journal 7 (2010): 9.

[8] Human Rights Watch, “Not Enough Graves: The War on Drugs, HIV/AIDS, and Violations of Human Rights,” July 2004, http://www.hrw.org/reports/2004/07/07/not-enough-graves-0.

[9] United Nations Office on Drugs and Crime, Regional Center for East Asia and the Pacific, “HIV/AIDS and Custodial Settings in South East Asia: An Exploratory Review into the Issue of HIV/AIDS and Custodial Settings in Cambodia, China, Lao PDR, Myanmar, Thailand and Viet Nam,” 2007. 

[10] International Center for Prison Studies, “World Prison Brief: Thailand,” http://www.prisonstudies.org/country/thailand.

[11] K. Kaplan, “HIV and Prison in Thailand,” HIV Australia 8 (2011): 4.

[12] Kaplan, “HIV and Prison in Thailand.”

[13] Office of the Narcotics Control Board, “Press Release,” September 12, 2012.

[14] K. Kaplan and P. Tanguay, “One Step Forward, Two Steps Back: Consequences of Thailand’s Failure to Adopt Evidence-based Drug Policy,” eds. Fifa Rahman and Nick Crofts, Drug Law Reform in East and Southeast Asia (Lanham, MD: Lexington Books, 2013).

[15] Wassayos Ngamkham, “Govt War on Drugs Hailed a Success,” Bangkok Post, August 17, 2012.

[16] Canadian HIV/AIDS Legal Network, “Compulsory Drug Treatment in Thailand: Observations on the Narcotic Addict Rehabilitation Act B.E. 2545 (2002),” 2009.

[17] Thai AIDS Treatment Action Group, “Reducing Drug-Related Harm in Thailand: Evidence and Recommendations from the Mitsampan Community Research Project,” 2012.

[18] Open Society Institute, “Detention as Treatment: Detention of Methamphetamine Users in Cambodia, Laos, and Thailand,” 2010.

[19] K. Hayashi et al., “Collective Empowerment while Creating Knowledge: A Description of a Community-Based Participatory Research Project with Drug Users in Bangkok, Thailand,” Substance Use and Misuse 47 (2012): 502-510.

[20] GFATM, “Thailand Grant Scorecard (THA-304-G06-H),” undated.

[21] For more information on the decision to circumvent the Thai CCM, see T. Kerr et al., “Getting Global Funds to Those Most in Need: The Thai Drug Users’ Network,” Health and Human Rights 8, 2 (2005): 170-186.

[22] T. Kerr et al., “The Global Fund to Fight AIDS, Tuberculosis, and Malaria: Funding for Unpopular Public Health Programmes,” The Lancet 364, 9428 (2004): 11-12.

[23] Kerr et al., “Getting Global Funds to Those Most in Need.”

[24] Canadian HIV/AIDS Legal Network. “Press Release: Thailand - Drug Users Honored for Courage in the Face of Crackdown,” July 14, 2004; T. Kerr et al., “Health and Human Rights in the Midst of a Drug War: The Thai Drug Users’ Network,” in Public Health and Human Rights: Evidence-Based Approaches, eds. Chris Beyrer and H. F. Pizer (Baltimore: Johns Hopkins University Press, 2007).

[25] Hayashi et al., “Collective Empowerment while Creating Knowledge.”

[26] Hayashi et al., “Collective Empowerment while Creating Knowledge.”

[27] “Ozone” was first established in 2003, at the time when Population Services International (PSI) officially registered its office in Thailand as a local Thai CSO under the name PSI Thailand Foundation, with DICs operating in Bangkok and Chiang Mai and with financial support from Britain’s Department for International Development (DFID). Ozone was the initial brand name for the PSI Thailand service delivery sites targeting PWID. Since January 2015, Ozone is a fully registered local organization, operating independently of the PSI Thailand Foundation.

[28] USAID, “End of Project Review of ‘Social Marketing and Targeted Communications for HIV and AIDS Prevention Among Most–at–Risk Populations in Burma, China, Lao, and Thailand’ October 2007–September 2010,” 2010.

[29] Originally, 12D was composed of AIDS Access Foundation, Alden House, AHRN, Foundation for AIDS Rights (FAR), PSI Thailand Foundation, RTF, TTAG, TDN, Thai NGO Coalition on AIDS (TNCA), Thai Network of People Living with HIV/AIDS (TNP+), and Thai Red Cross (TRC). Today, 12D members include AIDS Access Foundation, Foundation for AIDS Rights (FAR), PSI Thailand Foundation, TTAG, Thai NGO Coalition on AIDS (TNCA), and Thai Network of People Living with HIV/AIDS (TNP+).

[30] PSI Thailand, “Servicing Communities with Opioid Overdose Prevention – Lessons Learned from Thailand,” 2010.

[31] These government agencies included the Bangkok Metropolitan Administration (BMA), the Department of Disease Control (DDC), the Department of Medical Services (DMS), and the Bureau of AIDS, Tuberculosis & STI (BATS) under the Ministry of Health, the Office of Narcotics Control Board (ONCB), the Department of Corrections (DoC), and the Princess Mother Institute on Drug Abuse Treatment (formerly known as the Thanyarak Institute).

[32] It is worth noting that unofficial support from a handful of key government officials has led to significant improvements in the collaboration with several government agencies since 2013. For example, CHAMPION-IDU partners were intimately involved in the revision of national methadone guidelines in collaboration with the Bangkok Metropolitan Administration and the Princess Mother Institute on Drug Abuse Treatment. They also conducted trainings and curriculum development with the Department of Corrections and were invited by the Thai Royal family to present options to imprisonment. 

[33] See upcoming UNODC practical guidelines for civil society HIV services providers on improving working relationships and collaboration with police services.

[34] See an analysis of CHAMPION-IDU performance and implications in P. Tanguay, “Harm Reduction at the Crossroads: Case Example on Scale and Sustainability,” 2012. For a detailed overview of CHAMPION-IDU performance results, see http://portfolio.theglobalfund.org/en/Grant/Index/THA-809-G11-H (Phase 1) and http://portfolio.theglobalfund.org/en/Grant/Index/THA-H-PSI (Phase 2).

[35] Transnational Institute, “Bouncing Back - Relapse in the Golden Triangle: Harm Reduction and Drug Policy,” 2014.

[36] M. Eldon-Eddington, Official communication to Thailand regarding country allocation under the NFM, 12 March 2014.

[37] The Global Fund to Fight AIDS, Tuberculosis and Malaria, T"Transitioning to Thailand."  

[38] P. Tibke, “Thailand Steps Up Its Dubious War on Drugs,” Asian Correspondent, September 15, 2014.

[39] P. Panitchpakdi, “The Imbalance between Government and Civil Society in Global Fund Processes: A View from Thailand,” Global Fund Observer (2006): 65.