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Similar to Final - HIV & Custodial Settings 30_Jan_2008
Similar to Final - HIV & Custodial Settings 30_Jan_2008 (20)
Final - HIV & Custodial Settings 30_Jan_2008
- 1. HIV/AIDS and CustodialHIV/AIDS and Custodial Settings in South East AsiaSettings in South East Asia An exploratory country review in Cambodia, China,An exploratory country review in Cambodia, China, Lao PDR, Myanmar, Thailand and Viet NamLao PDR, Myanmar, Thailand and Viet Nam Lessons learned: Iran’s experienceLessons learned: Iran’s experience Sonia Bezziccheri, UNODC Regional Centre for East Asia and the Pacific Gino Vumbaca, Australian National Council on Drugs Asian Consultations on Drug Use, HIV/AIDS and Poverty Goa India 31 January 2008
- 2. 2 Purpose, methodologyPurpose, methodology - Purpose: Inform onPurpose: Inform on conditions of CDTCs inconditions of CDTCs in Greater Mekong Sub-Greater Mekong Sub- regionregion - Formal letter to UN andFormal letter to UN and other stakeholders inother stakeholders in the regionthe region - 19-item questionnaire19-item questionnaire - Literature regionalLiterature regional reviewreview - Limitations: dataLimitations: data
- 3. 3 ContentContent 1. Key Findings1. Key Findings 2. Discussion2. Discussion 3. Recommendations3. Recommendations
- 4. 4 Key FindingsKey Findings Incarceration of drug dependent people inIncarceration of drug dependent people in compulsory drug treatment centers iscompulsory drug treatment centers is commoncommon CDTCs Cambodia China Lao PDR Myanmar Thailand Viet Nam Number of CDTC Not Reported 516 (as report ed) 3 26 (major) and 40 (minor) 49 (adult) 17 (youth) 80 Population in CDTC Unknown 140,000 844 1,492 2,358 (adults) 3,500 (youth) Approx. 100,00 0
- 5. 5 Key Findings cont’Key Findings cont’ Number of compulsory drug treatmentNumber of compulsory drug treatment centrescentres is increasingis increasing CountriesCountries ThailandThailand CambodiaCambodia 20042004 35 CDTCs35 CDTCs 20052005 49 CDTCs49 CDTCs None reportedNone reported 20072007 > 10 CDTCs> 10 CDTCs
- 6. 6 Key Findings cont’Key Findings cont’ - Lack of data- Lack of data - Peer drug education in Myanmar,- Peer drug education in Myanmar, China and ThailandChina and Thailand - TC pilot in Hunan and RelapseTC pilot in Hunan and Relapse prevention in Shanghai, Chinaprevention in Shanghai, China - TC/relapse prevention in ThailandTC/relapse prevention in Thailand - No pharmacological oral substitutionNo pharmacological oral substitution treatment therapy in any countrytreatment therapy in any country
- 7. 7 Key findings – common issuesKey findings – common issues - OvercrowdingOvercrowding - Under and unqualified staffUnder and unqualified staff - Modest budget for HIV/AIDSModest budget for HIV/AIDS servicesservices - Acknowledgement of high riskAcknowledgement of high risk behaviors for HIV transmission asbehaviors for HIV transmission as major health concernsmajor health concerns
- 8. 8 Key findings: common issues cont’Key findings: common issues cont’ - Needs: HIV/AIDS educationNeeds: HIV/AIDS education material / Trainingmaterial / Training - Limited NGOs/civil societyLimited NGOs/civil society involvement in custodyinvolvement in custody Incarcerated youthIncarcerated youth Incarcerated womenIncarcerated women Remand detaineesRemand detainees
- 9. 9 Key Findings cont’Key Findings cont’ HIV/AIDS and ARVHIV/AIDS and ARV Provision of ARV : Myanmar and ThailandProvision of ARV : Myanmar and Thailand – free of charge– free of charge HIV/AIDS cases: Cambodia, Thailand andHIV/AIDS cases: Cambodia, Thailand and MyanmarMyanmar Major health threats: HIV/AIDS, TB, skinMajor health threats: HIV/AIDS, TB, skin infections, mental illness, gastroinfections, mental illness, gastro intestinal and other infectionsintestinal and other infections Main cause of death: TB and AIDSMain cause of death: TB and AIDS
- 10. 10 DiscussionDiscussion - Policy for the incarceration of drugPolicy for the incarceration of drug usersusers is normis norm in South East Asiain South East Asia - Compulsory drug treatment centresCompulsory drug treatment centres areare present in every countrypresent in every country underunder review, and number isreview, and number is increasingincreasing - Lack of researchLack of research onon effectiveness/consequences of policyeffectiveness/consequences of policy - Relapse is highRelapse is high - when reported- when reported
- 11. 11 Discussion cont’Discussion cont’ - No adequate provision of evidenceNo adequate provision of evidence based drug treatment, HIV/AIDSbased drug treatment, HIV/AIDS prevention, treatment, care andprevention, treatment, care and support for drug userssupport for drug users - No access to condomsNo access to condoms - Lack of evaluation on effectiveness ofLack of evaluation on effectiveness of the CDTCs in the regionthe CDTCs in the region - Youth and women at higher riskYouth and women at higher risk
- 12. 12 Discussion cont’Discussion cont’ - HIV main transmission modes (sex, IDU,HIV main transmission modes (sex, IDU, sharing of injecting equipment, tattooing,sharing of injecting equipment, tattooing, violence)violence) not addressed but recognizednot addressed but recognized - ARV are generally not free/available inARV are generally not free/available in custodycustody - Little access to VCTLittle access to VCT - High number of people in remandHigh number of people in remand - HIV/AIDS and TB as recognized as urgentHIV/AIDS and TB as recognized as urgent public health riskspublic health risks
- 13. 13 Discussion cont’Discussion cont’ - NGOs/civil society/families/affectedNGOs/civil society/families/affected seldom seen as part of solutionseldom seen as part of solution - Aftercare services not in placeAftercare services not in place - Human rights of drug dependentHuman rights of drug dependent people at stakepeople at stake - No Oral Substitution Treatment forNo Oral Substitution Treatment for opioid dependenceopioid dependence
- 14. 14 Universal AccessUniversal Access oror Access: Denied?Access: Denied? What are the human, economic and socialWhat are the human, economic and social costs of the CDTCs approach forcosts of the CDTCs approach for individual, the community, the state?individual, the community, the state? What are the public health risks forWhat are the public health risks for incarcerated drug users and the widerincarcerated drug users and the wider society?society?
- 15. 15 RecommendationsRecommendations 1.1. ResearchResearch on health risks and vulnerability inon health risks and vulnerability in custodial settings is neededcustodial settings is needed 2.2. Evaluation on effectivenessEvaluation on effectiveness of compulsoryof compulsory drug treatment centres is necessarydrug treatment centres is necessary 3.3. Alternatives to imprisonmentAlternatives to imprisonment, including, including increased access toincreased access to low threshold,low threshold, voluntary,voluntary, evidence based drug treatment options;evidence based drug treatment options; and aand a comprehensive HIV/AIDS package ofcomprehensive HIV/AIDS package of interventions for injecting drug usersinterventions for injecting drug users need toneed to be considered especially for women, youthbe considered especially for women, youth
- 16. 16 Recommendations cont’Recommendations cont’ 4. Protect4. Protect human rights of drug usershuman rights of drug users 5.5. Cease long period of detention withoutCease long period of detention without trialtrial and without access to health careand without access to health care especially for drug dependent peopleespecially for drug dependent people 6.6. Involve NGOs/civilInvolve NGOs/civil society/families/affected communitysociety/families/affected community inin the research; design, andthe research; design, and implementation of responsesimplementation of responses
- 17. 17 We can do it!We can do it! Tools:Tools:
- 18. 18 Others did it: Iran’s experienceOthers did it: Iran’s experience 1980s CDTC approach under State Social1980s CDTC approach under State Social WelfareWelfare CDTC was experimental, not evidence basedCDTC was experimental, not evidence based 1983: plan to scale up CDTC in all 301983: plan to scale up CDTC in all 30 provinces; but reached only 13 centresprovinces; but reached only 13 centres Relapse rate: > 90%Relapse rate: > 90% Courtesy Dr Parviz Afshar, Senior Advisor for Minister of Welfare and Social InsuranceCourtesy Dr Parviz Afshar, Senior Advisor for Minister of Welfare and Social Insurance
- 19. 19 The comprehensive HIV/AIDSThe comprehensive HIV/AIDS package for injecting drug users inpackage for injecting drug users in the community and in prisonsthe community and in prisons 1996: HIV outbreak in CDTCs1996: HIV outbreak in CDTCs 2002: A comprehensive HIV/AIDS package for injecting2002: A comprehensive HIV/AIDS package for injecting drug users implemented with triangular clinic model indrug users implemented with triangular clinic model in community and in prisons, including comprehensivecommunity and in prisons, including comprehensive aftercareaftercare 2002-2006: rapid scale up; and decreased HIV2002-2006: rapid scale up; and decreased HIV infections, re-incarceration, relapse ratesinfections, re-incarceration, relapse rates 2007:2007: CDTC approach declared ineffective andCDTC approach declared ineffective and abandonedabandoned Courtesy Dr Parviz Afshar, Senior Advisor for Minister of Welfare and Social InsuranceCourtesy Dr Parviz Afshar, Senior Advisor for Minister of Welfare and Social Insurance
Editor's Notes
- Introduction: The data in the review presented in this study was gathered between October 2005 and March 2006.
- The purpose of the review was to inform UNODC on health conditions on custodial settings in South East Asia, including compulsory drug treatment centres (CDTCs). The review covers the Greater Mekong Sub-Region Countries (Cambodia, China, Lao PDR, Myanmar, Thailand and Viet Nam). Findings of the review were published in the publication: 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. A note on methodology: The review was initiated by formal letter sent to all UNODC field offices in the countries under review specifying the objectives of the project and requesting information on HIV/AIDS in custodial settings. The letter was also sent to UNAIDS, WHO and UNICEF offices, and to the wider regional UNODC RC networks and counterparts. However, a very limited amount of information was received in response to the letter, hence reflecting the scarce attention given to such issues in the Greater Mekong Sub-Region. In response to this gap and with the assistance of experts, a 19-item questionnaire on HIV/AIDS and drug use in custodial settings was compiled and distributed to the six countries. Discrete results were gathered: Cambodia and Myanmar filled the questionnaire as requested. Thailand, reflecting an enhanced data collection capacity, was the only country that completed separate questionnaires for prisons, juvenile detention centres and compulsory drug treatment centres. Lao PDR and China filled the questionnaire only with regard to compulsory drug treatment centres; no information was received on prisons. No response to the questionnaire was received from Viet Nam. In addition to the questionnaire results, the project team reviewed the literature on existing assessments, projects and other information as provided by national and international organisations on conditions, health and management in custodial settings. The limitations of this review are many, first and foremost, data gathered is only based on received questionnaires from governments, and literature review. None of the centres were formally evaluated, and no studies on high risk behaviours/vulnerabilities and quality of drug treatment were found at the time. Lack of data on HIV/AIDS in custodial settings will be a major finding of this work. I would also like to acknowledge the principle peer reviewers of this work: Mr Gino Vumbaca, Executive Director of Australian National Council on Drugs.
- The presentation is organized in 3 sections: Key findings: what we understand on health and custodial settings in South East Asia Discussion points: what we can overall conclude from the findings and what remain unanswered Recommendations: what we recommend as the ‘way forward’ as based on the gaps identified
- KEY FINDINGS: Incarceration of drug dependent people in compulsory drug treatment centres (CDTC) is common trend; this was reported by 5 out of the 6 countries that were surveyed: Cambodia is the only surveyed country that at the time of the questionnaire did not report on any such centres. 2. China reported on 140,000 clients and 516 CDTC in 2005 . ( However, according to the ‘Standing Committee of the National People’s Congress, there are 746 DTCs and 168 Rehabilitation Through Labour (RTL) centres. According to 1999 data, every year around 220,000 drug users are treated at compulsory rehab centres, and around 120,000 at RTL camps around the country. (HIV/AIDS and Custodial Settings in South East Asia p. 28) 3. Lao PDR reported 1,319 clients in 2004, and 844 clients in 2005; and a total of three CDTCs. 4. Myanmar reported 1,492 (2005); and 26 major and 40 minor CDTCs. 5. Thailand reported 9,781 (2004) and 2,358 (2005) people in compulsory drug treatment centres, with 35 centres in 2004, and 49 in 2005. Additionally, Thailand reported on 17 ‘youth training centres’ with 3,500 young inmates in 2004 and 2005. 6. Viet Nam did not report. It is reported elsewhere, however, that CDTCs may house around 100,000 in 80 so-called ‘05-06’ CDTCs around the country – hence outpacing population in prisons proper at 55,000 people.
- In two countries, the number of CDTCs is growing as response to increased drug use and overcrowding in prison proper. The policy of viewing a drug user as ‘patient’ rather than criminal, has resolved in the increasing the number CDTCs - rather than more availability of voluntary, evidence based drug treatment in the community. In fact: 1. In Thailand, CDTCs increased from 35 in 2004, and 49 in 2005. 2. In Cambodia, while the country did not report on any such centres at time of questionnaire, by 2007 there were more then 10 CDTCs.
- KEY FINDINGS: The first and most important finding of this review is the lack of data on health conditions in compulsory drug treatment centres and prisons in the region. As for the quality of drug treatment provided, we understand that: Evidence based drug dependence treatment and after care services are seldom offered: China and Myanmar reported on the provision of peer drug education in custody. Particularly, China also implements counselling on limited scale as provided by trained security staff rather than health professionals. A pilot relapse prevention program is available to small number of inmates at Shanghai Rehabilitation Labour Camp; The first Therapeutic Community (TC) was established at a labour camp in Hunan and was favourably evaluated against standard re-education through labour approach. A six month follow up TC inmates and standard inmates found that TC inmates has significantly lower score on the Addiction Severity Index (ASI). (M. Zhao et., 2002). Thailand provided a greater range of options including TC, relapse prevention, family therapy. Compulsory drug treatment are abstinence oriented; hence pharmacological interventions such as oral substitution maintenance therapy for opioid dependence – are not available in any countries under the review, whether in prison proper or compulsory drug treatment centres.
- KEY FINDINGS: Common problems in custody were reported as follows: Overcrowding in prison and compulsory drug treatment centres: Reported especially with regard to prison proper in Cambodia: capacity 5,700 v. current population of 7,484 And Thailand: capacity 110,900 v. current population of 174,542. Thailand, with a current population of 3,500 in its youth “training centres” and an official capacity of 500, has a serious overcrowded incarcerated youth population too. Also large population in compulsory drug treatment centres was reported but standard capacity versus current population was not reported. Lack of capacity for the provision of HIV/AIDS prevention, care and treatment: Under- or unqualified staff and a meagre HIV/AIDS budget for prison settings, when reported at all, was identified by four out of six countries (Cambodia, China, Myanmar and Thailand) as the main obstacle for the provision of HIV/AIDS prevention, care and treatment among all inmates and prison guards. Acknowledgement of occurrence of high risk behaviors for HIV transmission were reported as major health concern: 3 out of 6 countries (Lao PDR, Myanmar and Thailand) identified AIDS and the transmission of HIV as a major health concern in prison settings due to MSM, IDU and sharing of injecting equipment, tattooing, and blood splatters (rape and violence). Penis modification was also reported in Thailand.
- KEY FINDINGS: Common problems in custody continues and were reported as follows: HIV/AIDS education material Posters, booklets and audio visual material and tailored training programmes for staff and inmates were identified by all countries as the most useful HIV prevention and awareness raising tools, and for contributing to attitudinal change aimed at decreasing stigma and discrimination of AIDS patients among inmates and prison staff. Little cross sectoral collaboration/Civil society involvement in prison settings: NGO collaboration with prison authorities for health related service provision was reported by Cambodia, Myanmar and Thailand only. Incarcerated youth: Data for youth in detention was provided by Myanmar, 529 (0.8 per cent), and Thailand with 1,800 young detainees awaiting trial and 3,500 youth in training centres (3%). Women in prison settings: Women populations were reported by Myanmar with 8,638 (13.3 per cent) and Thailand with 40,520 for 2004 (18.5 per cent) and 30,207 for 2005 (17.3 per cent). Remand prisoners: Cambodia reported 2,351 remand prisoners (31 per cent), and Myanmar with 4,741 in 2004 (7.3 per cent) and 5,867 (nine per cent) in 2005.
- Furthermore, data from the questionnaire also indicated: ARV provision in prisons settings: ARV provision was reported only in Thailand and Myanmar, but the extent of coverage for prison or compulsory drug treatment inmates was not made clear. HIV and AIDS cases in prison settings: HIV cases among inmates were reported in Cambodia (28 cases, 0.37 per cent), Myanmar (610, including 351 women, 0.94 per cent) and Thailand (869, 0.49 per cent). However, data from vulnerability assessment in China and Viet Nam: National HIV prevalence in the Rehabilitation through Labour Camps in China is estimated at 5% (Bureau of RE-education Administration 2006) HIV prevalence among IDUs in drug treatment centre in Cai Yuan City, China, was estimated at 42% (Dolan et al., 2004) From a study in Viet Nam of 48 state prisons, HIV prevention was estimated at 20% (Dolan et al., 2004) AIDS related deaths were reported also by Cambodia (ten, 0.13 per cent), Myanmar (184, including 19 women, 0.28 per cent) and Thailand (331, 0.18 per cent). Major health threat in prison settings: Cambodia reported skin infections, contagious diseases, respiratory and gastro intestinal infections; Myanmar reported infectious diseases; and Thailand reported HIV/AIDS and TB as well as general high risk behaviour and mental illness. Main cause of death in prison settings: Cambodia and Thailand reported these as TB and AIDS; Myanmar only reported TB (accounting for 33 per cent of deaths).
- In conclusion, A policy of incarceration of drug users is norm in South East Asia. 2. CDTCs are common and increasing in number as response to increased drug use and overcrowding in prison proper; 3. Lack of research on effectiveness and the extent of the consequences of this policy on public health are unknown. None of the compulsory drug treatment centres were reported as being evaluated. 4. Relapse rates are high, when reported: 62% of clients relapse after 3 days after complying with detoxification at China’s Compulsory Drug Rehabilitation Centres 20% relapse after within 30 days. (From National Surveillance Centre on Drug Abuse, 2005)
- Further we can conclude that: Compulsory drug treatment centres are not equipped to provide up to standard drug treatment; TC, relapse prevention therapy are small scale only. CDTCs do not provide ready access to HIV prevention commodities e.g condoms. CDTCs do not link to community aftercare service where clients can continue their therapy; and do not provide a continuum of care in case clients are previously on treatment (e.g. MMT). Youth and women are higher risk. Young people comprise the majority of drug related apprehensions and national house surveys in the region indicate that they also comprise the majority of drug dependent people. Youth specific approaches to drug treatment and rehabilitation in custodial facilities are critical; the UN Convention on the Rights of the Child needs to be considered: ‘imprisonment of a child shall be used only as a measure of last resort and for the shortest appropriate period of time’. For example: From a study conducted in 5 juvenile justice centres in Thailand by Save the Children UK in 2003, it found that: Median age 17 92% reported having used one or more types of drugs, of whom 28% reported continued drug use while in detention 85% had ever had sex, of whom 17% reported sex with a sex worker in the previous year 37% rarely/never used a condom with sex worker (Save the Children UK. Study on Children at Risk of HIV/AIDS and Drugs in Five Detention Facilities in Thailand. 2003) High rates of women in prison settings with no appropriate services or alternatives – while women are at much higher risks of being HIV infected; they are usually imprisoned for drug use/petty dealing and sex work
- We also conclude that: Sex, injecting drug use, and sharing of injecting equipment, low or no access to condoms, violence, sexual abuse and rape, low protection for youngest and weakest, and tattooing are reported but not addressed. Other source: In one study, 31% (107/347) of IDUs surveyed had injected in prison in Bangkok, Thailand (Buavirat et al. 2003). There is very limited access to ARV treatment (lack of resources) Little access to VCT (lack of resources) Further: We found that there are: High number of people in remand – slowness of judiciary and high prevalence of inmates in pre-trial detention facilities with no access to health care/drug treatment (if they were on Methadone while a withdrawal experience from Methadone can be much worse that heroin) HIV/AIDS and TB are urgent public health risks and well acknowledged by authorities
- Furthermore, drug users are not seen as part of society: NGOs and civil society are not collaborating partners neither inside institutions or outside; three countries allow NGOs to work in prisons (Cambodia, Myanmar and Thailand) Aftercare services are not in place: no country reported on sound aftercare system that links custodial institutions with community based treatment services. Human rights of drug dependent people are at stake. Drug dependence is NOT seen as chronic and relapsing health condition, and CDTCs are not equipped to provide necessary health care. Important considerations apply on the experience of withdrawal from Methadone when oral substitution maintenance therapy is offered in the community but not in custody.
- A question is asked: Universal Access or Access: Denied? What is the human, economic and social costs of the CDTCs approach? What are the health risks for incarcerated drug users and the wider community?
- Recommendations: Research on risks and vulnerability in custodial settings is needed; Evaluations on the effectiveness of CDTCs are needed; Alternatives to imprisonment of drug users should be considered: Alternatives to imprisonment aim at substituting incarceration with opportunity for access to community based treatment, including oral substituion treatment for opiod dependence, education, and social reintegration. Alternatives to imprisonment are advantageous from a human, economic and social perspective; Such approach has been proven to decrease crime and recidivism; Recommended by International Narcotics Control Board
- Recommendations: 4. Human rights consideration for drug users must be addressed: especially access to quality drug treatment options; access to HIV/AIDS prevention, treatment, care and support specific for drug users; access to HIV prevention commodities; access to VCT, and appropriate counselling Principle of equivalence: what is available in the community should be available in custody also. 5. Cease long period of detention without trial and without access to health care especially for drug dependent people 6. Involve NGOs/civil society/families in the research; and design, implementation of responses; 7. Involve international policy community in the development and implementation of culturally appropriate evidence based interventions.
- To assist countries in the development of evidence based interventions for drug users, including injecting drug users, the United Nations Office on Drugs and Crime has developed the following tools: UNODC Criminal Justice Assessment Toolkit Handbook on Alternatives to Imprisonment A ‘Step by Step Algorithm of the Procurement of Controlled Substances for Drug Substitution Treatment’