1. Thailand is located at the Golden Triangle: Population: 65 millions Current Status of Drug Use and HIV in Thailand Apinun Aramrattana, MD, PhD Faculty of Medicine & Research Institute for Health Sciences Chiang Mai University, Chiang Mai Thailand International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

2. Methamphetamine epidemics has been predominated since 1996 Transitional patterns of drug users :10 years ago Vichai Poshyachinda: MOPH Drug treatment statistics 13946 21894 29167 18353 27995 27082 30129 38582 29403 19117 NUMBER 27155 International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

3. Understand young ATS users:- Majority were young males 99% Inhalation / take orally Multiple sex partners Age of first sex around 13-14 years Age at first use of methamphetamine 91% International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

4. Duration of MA use (yrs) and frequency of alcohol use in last 30 days), Chiang Mai, Thailand, 2005 P <.0001 Celentano D D, Aramrattana A, Sutcliffe CG, et.al. (2008) Journal of Adolescent Medicine. 2(2):66-73. High prevalence of depression (CES-D score >=22) Male = 31% Female = 45% International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

5. Prevalence rates C. trachomatis and N. gonorrhoeae infections, methamphetamine users, Chiangmai, Thailand, 2005 Chlamydia trachomatisNeisseria gonorrhea Substance abuse was associated with sexual behavioral risks but not with prevalent STI. Celentano D, Sirirojn B, Sutcliffe C, et.al. (2008) Sexually Transmitted Diseases 35,400-5. Youth drug related HIV/STD risk in Thailand International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

6. Alcohol and Substance Use Patients at OPD Suan Prung Psychiatric Hospital 1995-2006 War on drugs Rehabilitation law Short-term impacts of the ‘War on Drug’ 9% mortality in 5 years among MA psychotic patients. Main causes were suicide, accidents & AIDS Source: Kittiratanapaiboon, P.,Suan Prung Hospital, MOPH, Thailand International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

7. บุหรี่ Cigarettes YA Ba (Meth. tab.) Retrospective trends of new users ICE (MA crystal) Ecstacy Trends towards polydrugs use. Meth. tab. decreased. Ecstacy increased. Ice was introduced recently and increased. War on drug 2003 International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

8. War on drug effects: Overcrowded prisons In 2012, 141 prisons (1 hospital) in Thailand contains around 215,000 prisoners. About 60% related to drugs, use or trafficking 86% related to ATS Overcrowded Delay diagnosis and treatment International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

9. Marihuana is re-emerging. Ya Ba are increasing again with Ice emerges on top. Source: ACSAN, ONCB, 2012 Household Survey Trends: Ever users: 2001-2011 Estimated Numbers ( x 1,000) International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

10. Estimated number of ATS users in northern Thailand, 2011: 311,600 WHO-ASSIST Score among ATS ever users, Household Survey, 2011. >26 4-26 0-3 1.4 % 12.0 % 86.6 % Research Institute for Health Sciences, Chiang Mai University, 2011 International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

11. HIV prevalence among Injection Drug Users: Trends from HIV Sero-Sentinel Surveillance (HSS) Source: 1989-2011 HSS, Bureau of Epidemiology (BoE), Thailand (2012) International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

12. Source: 1989-2011 HIV Sero-Sentinel Surveillance, BOE (2012) International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

13. IDU size estimation: Background HIV prevalence among IDUs have been 30-50% since 1992. Little data was available on the size of the IDU population. The previous estimate of IDU population size for Bangkok in 1991, using capture-recapture method, were 36,600 (Mastro et al, 1994). This was divided by 0.224 (1980- 1999 Bangkok/Nationwide IDU-associated AIDS case ratio) to give a national estimate of 160,000 for 1980-1995 (Asian Epidemic Model, 2008). In 2004 Wattana et al., using RDS and multiplier methods to come up with Bangkok estimate. With the same method and additional assumptions, the national estimate was then calculated to be 38,380 IDUs (Asian Epidemic Model, 2008). International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

14. National Household Survey on Substance Abuse, 2011 Method: Ask direct question ‘Have you ever injected drug?’ Results: Ever injected any drugs = 29,300 IDUs Asian Epidemic Model based on RDS study in Bangkok, 2004 Method: Assumptions 1: 30% underestimation Assumption 2: Bangkok/National AIDS case ratio can be a multiplier. Results: Any injections in the past 6 months = 38,300 IDUs Nation-wide Network Scale-Up Survey, 2010 Methods: Known population scale-up & Summation Results: IDUs known in the past 2 years = 40,300 – 97,300 Consensus number (10 Jan. 2012) = 40,300 IDU size estimation: Current status International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

15. Injection trends among drug dependence patients, 2003-12 Number %injection among each drug type Most common was heroin Second most common were Ya-Ba and opium Opium Ya-Ba Ice Source: Office of Narcotics Control Board database, (2012) International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

16. Military conscripts 2 nd round, 2011 26,761 malesMilitary conscripts 2 nd round, 2011 26,761 males Ever used drug 14,596 (55%)Ever used drug 14,596 (55%) Non-injection 13,519 (50.6%) ; Injection 1,077 ( 4.0%) Majority of IDUs were Ya-Ba injectors! Source: Rangsin’s presentation, MOPH workshop, November 2012, Chiang Mai 81% of Non-IDUs used Ya-Ba. International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

17. IDUs in Bangkok and Chiang Mai were poly-drug users. ( RDS, 2009) Bongkok Chiang Mai Age < 25 years (%) 342 % Male8383 % Injection drug experience Heroin3434 Methamphetamine6332 Midazolam42 4 Methadone13 6 OpiumNA14 % Sharing needle at last injection 548 % HIV prevalence2411 Respondent-Driven Survey (RDS) 2009, Thailand International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

18. These are currently supported by the Global Fund round 8 through CHAMPION IDU program. - Outreach for education, counseling and engaging - Needle and syringe exchange program (NSP) - Expanding HIV voluntary counseling and testing - Scale-up methadone maintenance treatment - ARV and related programs - Prison programs Response of Thailand to drug use related HIV epidemic 1 st November 2010, Prime Minister approved National HIV prevention and care plans including NSP. However, current laws still allow polices to arrest people who carrying syringes. International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

19. Available services for drug users ( Rapid Assessment and Responses (RAR): Chiang Mai 2010) Peer group: Thai Drug User Network (TDN) Population Service International (PSI) - Drop-in centers and outreach activities by peers providing education, information and counseling, needle and syringe exchange GO: Drug Treatment Centers, Hospitals - HIV voluntary counseling and testing (VCT) - CD4 test (free) - Methadone maintenance treatment - ARV programs through universal coverage including prison settings :Prisons - HIV education program, VCT, Tbc - Methadone program is under planning. International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013

20. Thank you very much. Q & A Current Status of Drug Use and HIV in Thailand Apinun Aramrattana, MD, PhD Faculty of Medicine & Research Institute for Health Sciences Chiang Mai University, Chiang Mai Thailand International Conference on Global Health, National Health Research Institute, Taiwan, 17-9 April 2013