Date Published: June 26, 2007
Publisher: Public Library of Science
Author(s): David Wilson, Nathan Ford, Verapun Ngammee, Arlene Chua, Moe Kyaw Kyaw
Abstract: The authors discuss the challenges of providing HIV treatment to a marginalized population: prisoners in Thailand.
Partial Text: As scale-up of antiretroviral therapy (ART) progresses in less-developed countries, the challenges of providing treatment to marginalised populations become of increasing concern. One such marginalised group is prisoners. While there is an emerging consensus that prevention and treatment is feasible and effective in prisons , experience of implementing comprehensive HIV/AIDS programmes that include antiretroviral therapy in resource-limited countries is limited. This article describes our experience of providing HIV prevention and treatment in two prisons in Thailand.
Thailand is noted for its successful response to the HIV epidemic. Successful prevention efforts achieved an 83% reduction in new infections between 1990 and 2003, and the country can be said to have achieved the goal of universal access to antiretroviral therapy, with about 76,000 people on treatment out of a total of roughly 600,000 people with HIV . However, several groups have been unable to access the government’s treatment programme, in particular injecting drug users, migrants, and prisoners (the first two groups contributing significantly to the third) .
Médecins Sans Frontières (MSF) has supported HIV/AIDS programmes in Thailand since 1995. In June 2003, at the invitation of the prison health services, we began providing clinical support in two prisons in Bangkok—Minburi, a remand prison, and Bangkwang, a maximum-security prison (Box 1). The initial focus was on treatment, but once a level of trust was built between MSF and prison health authorities, we were invited to expand our work to prevention activities. The following observations are derived from these programmes.
Drug users in Thailand are the highest risk group for HIV infection. Around one-fifth of all new HIV infections occur through injecting drug use; in some parts of the country this figure rises to above 50% . Up to two-thirds of prisoners are incarcerated for drug-related offences ; some, but not all, are injecting drug users, and this contributes to the high prison HIV prevalence. Injecting drug use in the prisons has decreased in recent years, partly because of reduced availability of heroin (inside and outside). Where it does occur, injecting equipment is scarce and almost always shared. Some prisoners tell us that they used to belong to an “injecting group” but this stopped when other drug users started to die from AIDS.
In the past, prisoners generally received no pre- or post-test counselling. Health care staff may have avoided informing prisoners of their status because treatment was unavailable. We have seen several patients whose medical record showed that an HIV diagnosis had been made several years ago but the patients had not been informed of their status. Counselling is now implemented in both prisons, but not all prison staff believe it is necessary and more work is needed to explain its benefits. Confidentiality is a major challenge and we have attempted to address this issue during workshops for both staff and prisoners. Nevertheless, during the first 18 months of the programme, 20 prisoners failed to attend any follow-up counselling after receiving a positive HIV diagnosis.
Clinical support began with the treatment of opportunistic infections. During this phase—lasting six months in both prisons—prison medical staff and MSF jointly set up a peer support system for adherence to antiretroviral treatment.
Bangkok prisons are overcrowded and transfers to less crowded prisons elsewhere in the country are common. Such transfers create problems for ensuring continuity of treatment because most prisons outside Bangkok have limited health staff and no access to HIV treatment. While efforts are made to communicate the particular health needs of people with HIV/AIDS within the prison system, the reality is that we do not know what care is provided for the five patients from our cohort who have been transferred to other prisons.
Ethical questions inevitably arise during any intervention amongst incarcerated populations. In this paper we have described our experience of implementing proven HIV prevention strategies and delivering standard treatment to a difficult-to-reach population requiring an innovative approach. The main ethical challenges we have faced, together with our partners, have been the implementation of practices of confidentiality and informed consent; we have done our best to rise to these challenges.
There are few examples of HIV/AIDS treatment programmes in prisons in the developing world. Emerging outcomes from pilot programmes support the effectiveness of treatment in prisons [13–15], but poor or non-availability of antiretrovirals is still frequently reported [16–18]. This lack of availability has become a growing concern for treatment activists: in South Africa, civil society groups have recently taken the government to court to fight for prisoners’ rights to treatment .