Operating Needle Exchange Programs in the Hills of Thailand

Abstract

Injecting drug use is increasingly markedly amongst the ethnically distinct Hilltribe peoples of northern Thailand in the notorious "Golden Triangle." This paper reports on the establishing of needle exchanges in three remote Hilltribe villages, examining the success and the failure. Up to 60% of adult males and a smaller percentage of adult females in these villages are habitual users of opium and/or heroin. Overcoming initial concern that needle distribution would encourage increased use, the villagers themselves have assumed responsibility for much of the needle exchange operation. Prior to the introduction of the needle exchanges all the injecting drug users were sharing needles. This behaviour changed significantly with the introduction of the exchanges. Reluctance on the part of locally-based government officials to participate fully in the programme created difficulties in maintaining needle supplies which saw some resumption in needle sharing. HIV seroprevalence rates amongst the tested injecting drug users remained fairly stable at 33% in February 1993 and 32% in February 1994. The conclusion can be drawn that needle exchange programmes are operable in the Hilltribe context and that they are the best means of limiting HIV/AIDS transmission amongst injecting drug users and the wider community. The success of needle exchange programmes, however, is dependent upon co-operation from various government agencies and non-government agencies, in addition to the local communities. To this end mechanisms ensuring co-operation, training, monitoring and evaluation need to be developed alongside the introduction of needle exchanges.

Introduction

The pandemic of acquired immune deficiency syndrome (AIDS) and the virus believed to cause it, human immunodeficiency virus (HIV), has spread through the Southeast Asian country of Thailand with a rapidity matched perhaps only by that of India. In the mid-1980s, when it became apparent in the United States of America, Western Europe, sub Saharan Africa and Australia that the world was in the grip of a deadly epidemic, the limited seroprevalence testing carried out in Thailand showed minimal rates of HIV seropositivity (Weniger et al., 1991). Within the space of seven years - from 1987 to 1994 - the HIV seroprevalence rate increased from a handful of cases to an estimated 780,000 HIV infections (Sittitrai, personal comment).

By the end of 1993 there were 5,596 cumulative AIDS cases reported. Data current to August 1993 show that of these AIDS cases, 67.3% were heterosexual males, 8.9% injecting drug users, 8.4% vertical transmission, 8% heterosexual females, 1.3% gay and bisexual men, 0.6% blood products and a further 5.5% unknown (Brown et al., 1994). Estimates of current HIV infection rates vary considerably and are influenced by the populations selected to determine HIV seroprevalence: typically data are abstracted from antenatal clinics, sexually transmitted diseases (STD) clinics, from amongst blood donors, military recruits and sex workers. Some estimates are as low as 250,000 to 370,000 HIV infections (to mid-1992). Others, notably those of Brown and Sittitrai, consider a figure between 556,000 and 696,000 (mid-1992) to be more accurate (Brown et al., 1994), now revised by Sittitrai to 780,000 (end of 1994). The Ministry of Public Health, having long denied the seriousness of the HIV epidemic in Thailand, has revised its figures. By their calculation, in 1989 there were 50,000 HIV infections in Thailand. This rose to 200,000 in 1990 and then to 450,000 HIV infections by the beginning of 1993 (Kumnuan, 1993), rates consistent with the estimates produced by the World Health Organization (Chin & Lwanga,1991).

These figures primarily represent the extent of HIV/AIDS infection amongst the lowland ethnic Thai population. The prevalence and incidence amongst the Hilltribe population - the ethnically diverse mountain dwellers living primarily along the north and western borders of the kingdom - is unknown. Isolated data coming from hospitals (Gray, unpublished) and drug treatment centres (Anop, 1990; Kunstadter, 1994) provide some evidence of a coming HIV/AIDS epidemic. One small-scale study conducted in Mae Chan district, Chiang Rai Province, found HIV/AIDS prevalent in each of the four villages covered, with rates varying from 1% to 6% of the total adult population. Significantly, all those who tested HIV seropositive were either injecting drug users (evidencing an HIV seroprevalence rate of 23% amongst the IDUs tested) or young women currently or formerly employed in the commercial sex industry (an HIV seroprevalence of 63%) (Thai-Australia Highland Agricultural and Social Development Project, 1993).

The "first wave" of HIV infection in Thailand occurred amongst injecting drug users, and did so at an alarming rate (Weniger et al., 1991). When systematic monitoring of IDUs began in August 1987 at Thanyarak Hospital, Bangkok, the largest drug dependence treatment hospital, and at various of Bangkok Metropolitan Health Department's methadone clinics, seroprevalence rates were found to be less than 1%. Thirteen months later, by September 1988, HIV seroprevalence rates had rocketed to between 34% and 43% (Weniger, 1991; Kumnuan, 1993; Vichai, 1993; Wodak & Des Jarlais, unpublished). Similar rates of rapid transmission of HIV have occurred within other IDU populations around the world, most notably in New York City, Edinburgh and Burma (Vichai, 1993; Wodak et al., 1993; Lintner, 1994; Wodak & Des Jarlais, unpublished).

Infection levels are now said to have stabilized at around 35-40%, with a new incidence rate of 10% (Brown et al., 1994, Kumnuan, 1993), although Vichai (1993) reports prevalence rates as low as 14.1% at Thanyarak Hospital by August 1992. There are significant regional and provincial variations masked within the overall prevalence figures, with the northern province of Chiang Mai evidencing seroprevalence rates of 61% in 1991-1992 (Ministry of Public Health, 1994). The Chiang Mai rates are consistent with those from the methadone clinic operating at Mae Chan District Hospital in Chiang Rai Province, in the far north of the country. There the seroprevalence rates were found to be 41.4% in 1989, 45.2% in 1990, 58.6% in 1991, 69.5% in 1992, and 62.9% in 1993 (Mae Chan District Hospital, 1994). It should be noted that the northern provinces have the highest rates of HIV infection in the country - among sex workers, women attending antenatal clinics, and military recruits (Weniger et al., 1991). It seems likely that, unless there is rapid intervention, seroincidence rates amongst IDUs in the North will rise again as the long-time opium-using Hilltribe people are forced to switch from smoking opium to injecting heroin.

From Opium to Heroin

The countries of Southeast Asia during the 19th century tolerated the sale and smoking of opium in such a way that it became an "indigenous situation." In 1930 there were 830 opium shops in Thailand actively selling opium to local users, with yearly consumption amounting to 49.4 tons (Vichai, 1993). In Malaysia, Laos, Hong Kong, China, Vietnam and Burma the smoking of opium was commonplace (Westermeyer, 1976; Henman, 1993; Vichai, 1993). Heroin appears not to have been used at all. This situation changed with the introduction of anti-opium laws, beginning in China in the 1930s (Henman, 1993), and in country after country bans on opium use and sale were very quickly followed by the introduction of heroin (Westermeyer, 1976; Henman, 1993; Vichai, 1993). Westermeyer (1976) says there appears to be a causal relationship between anti-opium laws and the introduction of heroin use. He states that Hong Kong in the late 1940s and 1950s, Thailand in the 1960s and Laos in the 1970s all exhibited the same process at work - the banning of legally-produced opium, its replacement with illegal heroin, and a switch from smoking to injecting.

In Thailand the law prohibiting all opium production, transportation, sales and use was promulgated in December 1958. Nine months later, in September 1960, heroin-dependent users began presenting at drug treatment centres (Westermeyer, 1976; Vichai, 1993). Data from Thanyarak Hospital show that by 1961, 75.1% of the indigenous (Thai) opium-smoking population reported having switched to heroin smoking. By 1990, reports Vichai (1993), 86.9% of people presenting for drug treatment were dependent upon heroin (82% of them injecting Grade IV), and only 8% were using opium.

Hilltribe areas were not liable to effective Thai law and enforcement and the borders could not effectively be patrolled (Westermeyer, 1976): thus opium continued to be produced in the highlands. McCoy argues (1989) that opium production actually expanded in the Hills at the time of the Vietnam War under the auspices of the CIA, and that production remained high until massive opium-crop substitution programmes, funded by the United Nations and other international donors, took place (see also Taswell, 1985). That Hilltribe users have made the switch from opium to heroin and from smoking to injecting much later than the Thai users is evidenced by statistics of users entering the government-run Northern Drug Dependence Treatment Centre (NDTC) in Chiang Mai. The 1992 figures for NDTC admissions show:

• 40% (n = 944) were ethnic Thai heroin users (75.6% IDU, 24% smoking, 0.3% oral);
• 7% (n = 166) were ethnic Thai opium users (16% IDU, 74% smoking, 10% oral);
• 14% (n = 323) were Hilltribe heroin users (24% IDU, 76% smoking);
• 36% (n = 833) were Hilltribe opium users (1% IDU, 96% smoking, 3% oral);
• 4% other addictive substances (Northern Drug Dependence Treatment Centre, 1992).

The Akha of Mae Chan and Injecting Drug Use

The Hilltribe people living in the area in which the needle and syringe exchanges were established are the Akha; they are the largest Hilltribe group living in Chiang Rai Province, numbering approximately 36,000 people (Chiang Rai Provincial Hilltribe Development and Welfare Centre, 1992). Coming originally from Yunnan Province in south-west China and the mountainous region of Burma, the Akha have settled in the Hills of Mae Chan District, Chiang Rai Province for more than 50 years. Located 30 kilometres south of the Thai-Burma border, the Akha from this area continue to cross the border at will.

The villagers from Anamai Village 1, 2 & 3 have smoked opium for a number of generations, using it for ritual and for medicinal purposes. Many of those now dependent upon opium became so through using opium as a herbal remedy for coughs, diarrhoea, fevers, and to mask the symptoms of hunger. Never having grown opium, they have always been reliant upon opium supplies from across the border in Burma and from the hills farther south, in Chiang Mai Province. With opium crop eradication to the south and the opening up of new laboratories producing heroin along the border to the north, the Akha villagers find themselves locked into a supply-demand for opium and heroin that they cannot control. Whereas 5 years ago only a couple of villagers had had experience with heroin, and in these cases they had begun using heroin in Bangkok when serving time in prison (cf. Westermeyer, 1976) or when working as pimps in low-class brothels, now heroin use is commonplace, with only the old men and the old women finding enough opium to meet their modest needs.

Not only is opium becoming less and less available, but the type of heroin being produced by the laboratories is a new grade, more suitable for injecting than for smoking (fieldwork notes; Wodak et al., 1993). The villagers initially smoke the heroin in cigarette form but find it an expensive and inefficient method of using the drug. Injecting, on the other hand, is quick, effective, satisfying and highly portable. This ease of use makes it attractive in the face of police harassment. Injecting takes little time, can be done anywhere and needles and syringes are easily disposed of and easily hidden. The villagers in the Hills are well experienced with police and border patrols carrying out raids on their villages and hauling off to prison anyone found to be using illicit drugs. Either a prohibitive bribe must be paid or the offender is likely to spend 6 months incarcerated. Another great appeal of injecting over smoking, apart from its much more effective and euphoric absorption in the body, is that it is initially cheaper. An average user from Anamai Village 1, 2 & 3 may consume 80 baht (A$4.70) of opium per day. Upon switching to injecting the cost for heroin falls to as little as 10-20 baht (A$0.58-$1.17) per day, for the first month or two of using. The fact that some users are now injecting between 120 and 300 baht (A$7.05-A$17.65) per day is not a deterrent.

The situation, then, that led to the need for this intervention was one where traditional opium smoking was being rapidly replaced with heroin injecting: a lack of availability of opium, fear of being caught up in police raids, a dissatisfaction with heroin in a smoked form, and the initial cost effectiveness of injecting over smoking, were the main reasons for this change. Injecting heroin, in and of itself, presents the user with certain dangers, but it is the transmission of blood- borne viruses, notably HIV, through shared injecting equipment that poses the greatest risk of all to the user and the community and underpins this intervention.

Organization of the Intervention

The needle and syringe exchanges were established in three villages - Anamai Village 1, 2 & 3. All are within a two kilometre walking distance from each other and some seven kilometres up the mountain from the main road linking Mae Chan town with the former Kuomingtang-held Mae Salong mountain, which forms part of the border with Burma.

The villages have an average of 47 households, with 5-6 people per household. The villages were selected on the basis of evident drug use and a clear indication that injecting drug use was not only prevalent but increasing: there is scarcely a household in these three villages without at least one member of the household habitually using opium or heroin.

Altogether there were 46 injecting drug users participating in the programme: 16 from Anamai Village 1; 12 from Anamai Village 2; and 18 from Anamai Village 3. They represented 47%, 50% and 31% of the known drug users in each village, respectively. The injecting drug users were almost exclusively men. There was only one woman known to inject and she did so only occasionally and always with her husband; she did not participate in the needle and syringe exchange, and continued to share injecting equipment with her husband throughout. The men involved in the needle and syringe exchange were commonly over the age of 25 and frequently married with a number of young children.

As has been discussed already, injecting heroin rather than smoking opium/heroin was a fairly new behaviour at the time of this intervention, and it was one that the overall village populations felt unsure about. The villagers as a whole were rather afraid of the needles and syringes and displeased that this new behaviour had entered village life. These communities have watched their social and economic life disintegrate as a result of ever increasing drug use: young women have entered the sex industry, women have become beggars on the streets of the city, and habitual users are increasingly unable to take part in farming and other productive activities, thus impoverishing their families. Villager reaction was one of concern and of misgiving; needle and syringe exchanges, they felt, would only encourage use by making it easy and convenient.

Drug use is in many ways an important part of the daily social activity of these men; they like to sit around in groups of three or four and spend the day using, talking and sleeping. When smoking opium they shared the pipe and often their opium. This has changed little with the switch to injecting heroin. Prior to this intervention, one needle and syringe was shared, occasionally rinsed with water but most often not. Given their extreme poverty a needle was used until it could no longer be sharpened with the family carving knife. There had been no suggestion that sharing needles and syringes could be harmful and therefore no need to go to the expense and effort of always having your own personal supply of needles and syringes.

Through a series of meetings in each of the villages, involving all the villagers, including the users, the village committee, male elders, and local representatives of the Thai government, various methodologies available to prevent the transmission of HIV/AIDS in an injecting drug using context were discussed. Alternatives such as boiling needles and syringes for reuse were considered, but rejected on the basis of incompatibility with lifestyle: these villages have no electricity or gas, and boiling water over a slow-burning charcoal pit in between injections was deemed not feasible. In addition, the plastic syringes would melt after three such treatments.

The villagers similarly rejected the suggestion that they each buy their own supply of needles and syringes from the pharmacy shop in the nearby lowland town. The trip to the lowlands to buy the needles and syringes would cost them 40 baht (A$2.50), or one day's heroin for the lighter users. Only one vehicle per day does the trip, leaving in the morning and returning in the afternoon, meaning it would take the IDUs the better part of a day to purchase needles and syringes.

After much discussion over a period of 6 weeks the villagers in each village agreed that needle and syringe exchanges would be useful. The death of a 16 year old IDU from needle-related tetanus poison in one village brought home to the villagers the risks associated with dirty needle use.

Process of the Intervention

The needle and syringe exchanges commenced operation in November 1992, with a supply of 5,000 1cc needle and syringe fits, an amount considered adequate for one year's supply. In each of the three villages a register was drawn up of all the IDUs, recording the number of times a day they injected, how much they spent on average, in what circumstances they injected - alone or with friends - and where, and how many times they could use one needle before it was no longer sharp.

Each user had to be shown how to clean the needles and syringes effectively between use and educated about the risks associated with continuing to share needles. The IDUs had no knowledge of safe using practice, nor of safe disposal of needles. Very little HIV/AIDS education had reached these villages and the information that had reached them failed to address injecting drug use. The approach implemented for cleaning needles and syringes between injections was modeled on the 2 x 2 x 2 method successfully used amongst IDUs in Australia. This approach calls for flushing the needle and syringe twice in cold water, twice in bleach, and twice again in cold water (see also Des Jarlais, 1992; Wodak, 1993; Wodak & Des Jarlais, unpublished.). The use of bleach was discontinued very early on, despite knowledge of its efficacy in decontaminating HIV (Wodak & Des Jarlais, unpublished). The villagers had never previously encountered bleach and were afraid of accidentally injecting it into their bodies. For some, too, it was regarded as a troublesome extra step in the cleaning process.

In the initial phases records were kept. Each week a tick would be made alongside the person's name indicating they had come, handed in their old needles and syringes and received new needles. The heavy users - those injecting three or more times a day - received three new needles per week whilst the lighter users received two needles per week. At the end of each week one of the IDUs and one member from the village committee from each village burned and buried the used needles and syringes, ensuring their safe disposal.

In the first 6 months the users were given extra needles and syringes to supply fellow users who might come to inject with them. Collecting user histories had made it possible to map out drug using networks and to identify key distribution points. To safeguard against the possibility of sharing equipment with IDUs from outside these villages, these key persons were given an additional supply of needles. News soon spread around the Hills that needles were being handed out for free in these three villages. There followed an inundation of requests for needles and syringes and for needle and syringe exchanges to be established in other villages. The situation was a potentially difficult one and was resolved by the IDUs themselves; they took the decision at a village meeting to provide needles and syringes only for those people on the list for Anamai Village 1, 2 &3. They were adamant that their villages were not to be turned into an IDU playground and equally firm that they would be able to negotiate non-sharing of their injecting equipment. Their decision also freed them from the need to provide unaffordable hospitality to other IDUs, who may also be kin.

Results of the Intervention

The needle and syringe exchange programmes established in the three villages have worked quite well. Support from the village committees in terms of needle and syringe distribution and disposal has been good and the wider community is happy for the exchanges to continue until effective drug dependence treatment programmes are implemented: both the villages and the village committee have always regarded the exchanges as a short-term measure until such programmes are put in place.

In each of the three villages the needle and syringe exchanges have operated independently, following their own system. The successful involvement of the IDUs in the exchanges was seen clearly by a distinct decrease in the number of infected injecting sites, and the steady exchange and disposal of new and old fits. Certain modifications were made to the operation of the exchanges to suit the needs of the IDUs and the villagers. Two of these have already been mentioned, namely the discontinuation of the use of bleach, and the discontinuation of the supply of fits to people from outside Anamai Village 1, 2 & 3. A third modification was the ceasing to keep written records of weekly exchanges once the village committees took over distribution: the villagers are functionally illiterate, and written records are not a part of normal cultural practice. This lack of recording, however, was of no real consequence and it was left up to the users to come and ask for new needles.

The needle and syringe exchanges did face several major problems, however. The first of these involved the denial of access of new IDUs to the programme. Village politics prevented a group of new, young IDUs from receiving new needles and syringes free of charge. Instead, if they were given access to needles and syringes at all, they had to pay for them. The situation was resolved, but very probably only temporarily. A second problem that arose was the resentment the village committees came to feel towards the IDUs, who would insist on exchanging their needles and syringes at any time of the day or night.

Results of HIV serostatus testing amongst the IDU population

Apart from the obvious and regular depletion of the needle and syringe stocks, and the absence of infected injecting sites in most of the users, it is possible to evaluate, to a certain extent, the effectiveness of the intervention by comparing two sets of HIV serum testing carried out amongst the IDU population.

The first of these tests was conducted in February 1993 as part of a village-level health survey in one of the three villages (for details see the Thai-Australia Highland Agricultural and Social Development Project, 1993). In this survey, 13 of the injecting drug users were tested for the presence of HIV antibodies, and three were found to be HIV seropositive. Two other IDUs from this village were tested at the local hospital and also found to be HIV seropositive, bringing the total to five cases of HIV infection from the 15 IDUs tested, or 33% testing HIV seropositive.

Twelve months later, in February 1994, 25 IDUs from the three villages were tested for HIV at the Northern Drug Treatment Centre. Eight of the 25 IDUs were found to be HIV seropositive (a rate of 32%), five of whom had tested HIV seropositive in the first survey of February 1993 (including three diagnosed as having AIDS). Of the remaining three who were found to be HIV seropositive, only one was known to have definitely seroconverted during the operation of the needle and syringe exchanges. This 43 year old father of five had commenced injecting only two months prior to the commencement of the intervention. He was introduced to injecting by his brothers, one of whom has AIDS, the other of whom was first tested for HIV antibodies in February 1994, and found to be positive.

The 17 men found to be HIV negative in February 1994 despite their injecting behaviour would seem to indicate that the needle and syringe exchanges are being effective in limiting the transmission of HIV/AIDS amongst the IDU population. These figures only provide an indication of possible rates of HIV infection amongst the IDU population. There are, as was stated earlier, IDUs who have not been able to get access to the needles and syringes. Commonly they are the new 'recruits' to IDU - those who are forced to switch to heroin in the absence of opium, and from there from smoking to injecting.

Discussion

A variety of "harm reduction," or "safer injecting" strategies have been developed or extended for use amongst injecting drug users in response to the rapid transmission of HIV/AIDS around the world. These include over-the-counter sales of injection equipment to illicit users, needle and syringe-exchange programmes, bleach distribution (Des Jarlais, 1992), drug treatment programmes and the establishments of clinics for methadone maintenance. Each has its advantages and disadvantages.

Drug abuse treatment, states Des Jarlais (I 992), has the major advantage of not only preventing HIV, if it is successful, but also of immediately improving the social and economic circumstances of the ex-user. The chief problems with this strategy are, he says, that many IDUs do not want to enter treatment, others leave the treatment before they are ready to do so, and still others relapse. Drug abuse treatment, or attendance at drug dependency centres, as this treatment is referred to in Thailand, has the additional drawback of being very costly. Prior to the HIV/AIDS epidemic, the chief policy of the Thai government towards treating illicit drug users, particularly Hilltribe people, was detoxification at drug treatment centres. The United Nations, through its drug control agency, backed the expansion of drug treatment centres as a central part of the war against opium (Northern Drug Dependence Treatment Centre, 1992).

The rapid transmission of HIV amongst injecting drug users in Bangkok, however, required the Thai government to consider another method that could more quickly contain the epidemic. Their response was to establish methadone maintenance programmes throughout the country, operating out of local district hospitals (Des Jarlais, 1992; Mae Chan District Hospital, 1994). Methadone maintenance had proved to be a successful strategy in many countries and has retained drug users in treatment longer than other modalities (Wodak & Des Jarlais, unpublished). Methadone treatment is also associated with substantially lower rates of HIV infection (Des Jarlais, 1992).

There are problems with both these modalities as strategies for containing HIV transmission amongst Hilltribe injecting drug users. There are only a limited number of places available in drug treatment centres and waiting lists are long. The very high rates of recidivism (fieldnotes, personal comments Thai government officials and Hilltribe villagers) have resulted in a situation where Thai government officials working in the field are reluctant to refer villagers to the drug treatment centres and even more reluctant to provide follow-up after treatment. Officials within the Hilltribe Division, the sub-department responsible for Hilltribe welfare, are concerned about the possibility of rapid HIV infection in the Hills but seem unable to act. With more than 6,000 current opium/heroin users in Hilltribe villages in Chiang Rai Province alone, a strategy relying on detoxification at drug treatment centres seems unlikely to succeed.

If the strategy of methadone maintenance is to have any success in limiting the transmission of HIV/AIDS amongst Hilltribe IDUs major alterations to its operation will need to be made. Currently for the villagers of Anamai Village 1, 2 & 3, the nearest methadone maintenance clinic is located at Mae Chan Hospital (the clinic has been in operation since August 1989). The clinic requires the users to attend every day, Monday to Friday, and allows them to take sufficient methadone home with them to cover Saturday and Sunday. For the lowland Thai IDUs this poses little or no problem as the majority live a short bus ride away (cost 60 baht per week = A$3.50). For the IDUs from Anamai Village 1, 2 & 3 attendance at the clinic would take them the better part of each day and at a cost of 200 baht per week for transport (A$11.60). Located close to all Hilltribe villages is a sub-district health station. Staffed by a public health worker and with the necessary facilities to store methadone they could very easily become outreach methadone clinics. This would require a change in policy on the part of the Ministry of Public Health.

Despite the obvious success of needle and syringe exchanges in helping to limit the transmission of HIV/AIDS amongst injecting drug users in many parts of the world (Wodak, 1993), the Thai government has been unwilling to adopt such an approach for Thailand. In countries where the drug policy has been one emphasizing the primacy of supply reduction, the introduction or subsequent expansion of the provision of sterile needles and syringes is difficult, point out Wodak and Des Jarlais (unpublished). The reluctance on the part of the Thai government seems also to stem from a perception that to provide sterile injecting equipment is to actually encourage illicit drug use (fieldnotes). To the contrary, states Des Jarlais, "None of the programs studied have found increases in rates of injection, ... increases in the numbers of new injections, or decreases in the number of drug injectors entering drug abuse treatment" (1992).

In the absence of accessible methadone maintenance programmes and the likelihood that it will be a long time yet before sufficient places in drug treatment centres become available, the establishment of needle and syringe exchanges in Hilltribe villages with injecting drug use may well be the best way forward. This paper has illustrated that it is possible to establish and operate needle and syringe exchange programmes in the Hills and that the community as a whole participates and is supportive of the process. It is possible, also, to operate such programmes on a larger scale but only with interagency co-operation - ensuring continuing needle and syringe supply, monitoring the access of all IDUs to the programme, and encouraging referral to drug treatment centres and participation in methadone maintenance programmes, where feasible.

There needs first to be considerable and sensitive training of the Thai government officials with responsibility for Hilltribe villages (see also Wodak, 1993), with clear policy directives from the top: one of the problems with this intervention was that it required local government officials to participate in a programme that was contrary to Thai law. A consequence of this was the sometimes haphazard and intermittent supplies of needles and syringes: on one occasion there were no needles or syringes made available to the village committee for distribution for two months.

The result of the unavailability of needles and syringes in these villages was the immediate resumption of sharing behaviour amongst some of the IDUS. Controlling injecting behaviour in any setting is difficult and the three 'unsolved problems' associated with safer injecting programmes/needle exchange programmes spoken of by Des Jarlais (1992) all featured in this intervention. The first of these is the problem of reaching all the IDUS: as stated earlier there were a number of new users who were not known to be injecting. The second is that of providing sufficient coverage so that injectors have access to clean needles and syringes every time they inject. This speaks firstly to a guaranteed supply of sterile needles and syringes, and secondly to using networks. The extensiveness of the using networks in the Hills makes it impossible to provide sufficient coverage ensuring safe injecting for everyone. IDUs from these three villages come under pressure from kins folk and friends from other villages to extend appropriate hospitality, which includes lending needles and syringes. Not infrequently they will allow the visitor, especially if a relative, to use one of their soon-to-be-discarded needles and syringes. In this sense they regard themselves as 'not sharing' and at the same time being able to maintain important social relations. The third problem Des jarlais sets out is the propensity to relapse into unsafe injecting after a period of safe injecting. The villagers from Anamai Village 1, 2 & 3 did not lapse back into 'bad' habits; their resumption of equipment sharing was related only to the unavailability of clean equipment.

The final point to be made here is the rather mixed perceptions the injecting drug users had of HIV/AIDS. They expressed sufficient fear and concern about the threat of HIV/AIDS to participate willingly in the needle and syringe exchanges, yet at the same time as soon as there were no needles and syringes roughly half of them immediately began sharing (cf. Singh & Crofts, 1993). Even when they had changed their behaviour so that they only used their own, clean, equipment, they lent their used needles to their relatives. In addition, each of the married IDUs found to be HIV infected took the decision not to tell their wives: their rationale was that if she had already become HIV infected there would be no point in telling her, and if she wasn't already HIV seropositive then it was unlikely she would become so.

In conclusion, injecting drug use amongst previous opium smokers in Hilltribe villages will increase over the next few years. With injecting drug use will come HIV infection: periods of incarceration and the efficient "mixing" of populations that occurs in prisons will be significant points of transmission (Des Jarlais, 1992). Once there- is significant HIV seroprevalence in Hilltribe communities, culturally approved partner exchange will make HIV transmission almost uncontainable (Gray, 1993). With poor access to water, food, health facilities, education and a lack of sanitation, opportunistic infections such as tuberculosis will spread rapidly and the fatality rate will be high. Needle and syringe exchanges are but one approach to preventing the transmission of HIV/AIDS. Ideally they should be part of an overall strategy that provides the assistance necessary to break the cycle of chronic habitual drug use in the Hills - a cycle related to issues of unemployment, lack of identity cards, marginal status within Thailand, inadequate access to appropriate health care, and lack of education.

Acknowledgements

The research undertaken concurrently with the establishment of these exchanges has been funded by the Commonwealth AIDS Research Grant scheme (CARG), Department of Human Services and Health, Australia; by the National Centre for HIV Social Research, School of Behavioural Sciences, Sydney, Australia; Australia's International Development Assistance Bureau; and the Thai-Australia Northern AIDS Prevention and Care Program.

Thanks go also to the Royal Thai Government's Hilltribe Welfare Division, Department of Public Welfare, Ministry of Interior and staff of the Chiang Rai Provincial Hilltribe Development and Welfare Centre. Special thanks are due to Dr Chaowalit Natpratan, Chief of Communicable Diseases Control, Region 10, Ministry of Public Health, Thailand.

References

Anop Wisutthimak (1990) AIDS virus incidence among tribal addicts seeking rehabilitation therapy at the Northern Region Drug Rehabilitation Centre (Roneo) (in Thai).

Brown, T., Sittitrai, W., Suphak Vanichseni & USA Thisyakorn (1994) The recent epidemiology of HIV/AIDS in Thailand (forthcoming).

Chiang Rai Hill Tribe Development and Welfare Centre (1993) Statistical Report B.E. 2536 (in Thai).

Chin, J. & Lwanga, S.K. (1991) Estimation and projection of adult AIDS cases: a simple non- mathematical, epidemiology based model, Bulletin of the World Health Organization, 69, pp. 399-406.

Des Jarlais, D.C. (1992) The first and second decades of AIDS among injecting drug users, British Journal of Addiction, 87, pp. 347-353.

Gray, J.A. (1992) The HIV/AIDS situation in Hilltribe Villages in Northern Thailand, paper presented to the Thai-Australia Highland and Social Development Project.

Gray ,J.A. (1993) A crisis just waiting to happen: HIV/AIDS in the Hills, paper presented at the 5th International Thai Studies Conference, University of London, U.K.

Henman, A. (1993) Harm reduction or harm aggravation? The impact of the developed countries' drug Policies in the developing world, in: N. Heather, A. Wodak, E. Nadelmann & P. O'Hare (Eds) Psychoactive Drugs and Harm Reduction: from Faith to Science (London, Whurr Publishers).

Kumnuan Uuchusak (1993) The present state of the spread of HIV in Thailand, paper presented at the 5th International Conference on Thai Studies, University of London, UK.

Kunstadter, P. (1994) Cultural factors related to transmission and control of HIV infection: Highland minorities of Northern Thailand, paper presented at the International Workshop on Sociocultural Dimensions of HIV/AIDS Control and Care in Thailand, Chiang Mai, Thailand.

Lintner, B. (1994) Plague without borders, Far Eastern Economic Review, July 21:26.

McCoy, A.W., Read, C.B. & Adams, L.P. (1989) The Politics of Heroin in Southeast Asia (New York, Harper and Row).

Mae Chan District Hospital (1994) Mae Chan District Hospital NCA and AIDS activities 1991- 1993.

Northern Drug Dependence Treatment Centre (1992) Statistical Report for 1992, Northern Drug Dependence Treatment Centre, Department of Medical Services, Ministry of Public Health, Bangkok.

Ministry of Public Health (1994) Sentinel Surveillance for HIV Infection (Bangkok, Ministry of Public Health).

Singh, S. & Crofts, N. (1993) HIV infection among injecting drug users in north-east Malaysia, 1992, AIDS Care, 5, pp. 273-281.

Taswell, R. (1985) Heroin - an overview, Cultural Survival Quarterly, 9, (4), pp. 6-8.

Thai-Australia Highland Agricultural and Social Development Project (1993) Improving Hilltribe Village Health Status (Chiang Mai, AIDAB, Public Welfare Department, Royal Thai Government).

Vichai Poshyachinda, (1993) Drugs and AIDS in Southeast Asia, Forensic Science International, 62, pp. 15-28.

Weniger, B.G., Khanchit Limpakarnjanarat, Kumnuan Ungchusak, Sombat Thanprasertsuk, Kachit Choopanya, Suphak Vanichseni, Thongchai Uneklabh, Prasert Thongcharoen & Chantopong Wasi (1991) The epidemiology of HIV infection and AIDS in Thailand, AIDS, 5 pp. S71-S85.

Westermeyer, J. (1976) The pro-heroin effects of anti-opium laws in Asia, Archives of General Psychiatry, 33, pp.1135-1139.

Wodak, A. (1993) Policy issues relating to drug abuse and the human immunodeficiency virus (HIV), Bulletin on Narcotics, XLV, pp. 48-60, United Nations Drug Control Programme.

Wodak, A., Cofts, N. & Fisher, R. (1993) HIV infection among injecting drug users in Asia: an evolving public health crisis, AIDS Care, 5, pp. 313-320.

Wodak, A. & Des Jarlais, D.C. (unpublished) The prevention of further spread of HIV infection among and from injecting drug users: an outline for national approaches (Global programme on AIDS, World Health Organization, Geneva, Switzerland).