In part II of our Bangkok special, Gus Cairns meets the Thai Aids activists who fought to get HIV treatment for all
Thailand has 750,000 people with HIV, 150,000 who need urgent
treatment; just 10,000 are on anti-retroviral drugs. A government, conscious
of its repressive image, has mounted a bold plan to get 70,000 people on HIV
drugs by the end of the year. But Prime Minister Thaksin’s treatment
campaign may never have got off the ground without the courageous work of ordinary
Thai people with HIV.
Paisan Tan-Ud, a skinny, intense 37-year-old, was diagnosed 12 years ago at a drug addicts’ recovery centre. He was first chair of the TNP+ (the Thai network of people living with HIV and Aids) and now heads his own organisation, the Thai drug users’ network.
 Paisan Tan-Ud with Gus Cairns photo: karyn Kaplan |
“ I was part of the group that set up the Wednesday friends’ club at Chulalongkorn hospital, Thailand’s first support group for people with HIV, in 1991. I saw so many friends dying or living in fear; I felt we had to become more active, a force for change instead of just for support. In about 1999, shortly after TNP+ started, we saw what was happening in the west and decided to focus on treatment. Without treatment, there is nothing for us.”
Paisan says doctors regarded them as bad people for catching HIV and had no means of treating them. “We told them we would die without information. We started training people to train their doctors. Now things are moving fast. The government wants an HIV comprehensive care centre in each of the 800 public hospitals, each with two people living with HIV on staff. They have already set up 100 centres.”
But Paisan thinks the biggest battle is yet to come. “It’s going to be complex getting people on to anti-retrovirals. I haven’t heard much about how they are going to encourage people to come forward for treatment.”
Seventy-five per cent of the drugs will be GPOvir (3TC/d4T/nevirapine combination made by the Government Pharmaceutical Organisation costing 1,250 baht or £17.58 a month). But second line regimes, efavirenz for people who can’t tolerate nevirapine, and boosted indinavir for people with NNRTI resistance, will cost far more. The government is funding just one CD4 count every six months and a viral load test every two years. Paisan asks: “How will we know if people fail? We will really fuck this up if we don’t plan it properly.”
A recent crackdown on drug users has made it harder for patients to come forward; treatment centres are empty and drug users do not want to identify themselves. But Paisan has never feared exposure or bowed to stigma. The drug users’ network was born at the Chiang Mai 14th International Harm Reduction Conference in April 2003. At the height of the government-sanctioned murders of drug users, the network mounted a continuous vigil outside the conference, silent witnesses to the terror around.
“Other organisations said we should call ourselves the former drug users’ network. We said ‘No. We are who we are’.”
On 4 December 2003, the network demonstrated outside the royal palace during the King’s birthday celebrations to attract the attention of His Majesty, King Bhumibol Adulyadej, and ensure Thaksin kept his word.
Any visitor to Thailand knows how the King is revered. He never makes his views public but what the King says goes. Word is, he told Thaksin to curb his addiction for killing drug users, and to concentrate on treating them instead.
 Kamon Uppakaen: part of a group which forced Bristol-Myers Squibb to relax its patent. |
Former engineer Kamon Uppakaen caught HIV, he thinks, from a sex worker in 1994. He turned activist after he was diagnosed in 1996 when he applied to work at a truck factory in Taiwan. Now chair of TNP+, he was part of a group which forced Bristol-Myers Squibb (BMS) and the Thai government, to free up their patent right for ddI (didanosine).
Kamon says: “According to section 51 of the Public Health Act there is room for the government to issue a compulsory licence to manufacture a patented drug in ‘emergency conditions’. The GPO was going to manufacture ddI but BMS threatened to sue. So they made it as a powder, since the patent BMS was enforcing was for the buffered tablets. But the powder was difficult to tolerate.
“ It was clear they didn’t invoke section 51 because they feared being shut out of the World Trade Organisation. So we decided we couldn’t rely on the government and formed our own team of people with HIV.
The group learned that BMS didn’t have the right to enforce the patent
because the drug was developed with grants from the US National Institute of
Health. This argument is currently being used in the US against Abbott to force
it to reverse the price rise of ritonavir.
Kamon and Paisan helped organise the first ever public demonstration by people
with HIV in December 2000, when 500 people stood for three days outside the
health ministry to demand an end to the ddI patent. In December 2001, the
crowd came back, double in size, this time to demand HIV treatment be included
in
Thaksin’s 30-baht health scheme, the first move to introduce free primary
healthcare in Thailand.
Activist Paul Cawthorne, of Médecins sans Frontières, originally a nurse from Lancashire, has worked in Bangkok for seven years. He said the demo forced the Minister of Health, to pledge to include anti-retroviral drugs in the scheme if the price of combination therapy fell below 2000 baht - inconceivable at that time.
“ Drugs were produced for less than 2,000 baht within three months of her announcement,” said Paul.
Now the PM wants to show Thailand in the best light at the international Aids conference.
“ Thaksin wants Thailand to become Brazil number two; to be the second developing country to treat all its citizens with HIV, and to do it better. Brazil is slightly richer than Thailand and we have something like three times its HIV prevalence. But now, things are moving fast, and there’s only one barrier to getting the drugs to the people: stigma.”
Kamon says the typical person living with HIV in Thailand is now young, married and has caught it from her husband.
“ She will be shunned by her family and ostracised from her village if she presents for treatment.” To combat the stigma, TNP+ has a 30-strong group that attends 600 support groups educating people on anti-retrovirals use.
“ But people do not come forward until they are very ill, and then you find you are trying to treat someone who needs treatment for multi-drug resistant TB, meningitis, or KS. It’s going to be very complicated over the next few years.
“ There’s no CD4 criterion for getting anti-retrovirals because people won’t test. It’s all based on symptoms. We are considering a campaign to encourage testing but we’re honestly not sure if the public would support it. It would bee seen as a campaign to expose people. All we can do is raise awareness in people who suspect they might have HIV.”
Sujima ‘Luknoo’ Viravaidya, daughter of Senator Mechai, is running
youth activities at the Bangkok Aids conference. She says the battle is not
over. “There’s no culture of voluntary counselling and testing.
Testing is seen as part of the process of becoming a victim with Aids and a
tool of government to keep tabs on you.”
Luknoo and her father have already started thinking about the onward survival
of people with HIV. “There will be a whole group of people trying to
make a living often in the face of stigma.” Their solution is simple:
funding business.
“Positive Partners Programme involves us basically bribing HIV negative
people by giving outcast positive people money. The positive person chooses an
HIV negative business partner. It’s got to be one positive, one negative
- but the positive person has the cash.
“This HIV positive lady wanted to set up a village laundry service. The washing machines and irons were in her house and people wouldn’t come. But when they put them in her partner’s house they started coming. Once established, the business laundry moved back into the positive lady’s house, and they still came. In fact she got even more customers. And so the village learned that you can’t catch HIV from clean clothes.”
Positive Partners is, so far, low-key: 10 projects set up in 18 months (and only one business failure). It is a typically Thai solution: a refreshing, pragmatic way of empowering people with HIV in a country that has never had a social security safety net, but where everyone is a business person.
The Thais also have a refreshing and pragmatic attitude to sex. Luknoo is helping to set up a Global Village at the conference, including a worker-run bar run handing out condoms and “useful advice” on striptease. I wondered what the Americans would say. “I don’t care,” says Luknoo. “It’s our way of doing things.”
