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Drug-related harm among people who inject drugs in Thailand: summary findings from the Mitsampan Community… Hayashi, Kanna; Ti, Lianping; Fairbairn, Nadia; Kaplan, Karyn; Suwannawong, Paisan; Wood, Evan; Kerr, Thomas Oct 7, 2013

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RESEARCH Open AccessDrug-related harm among people who injectdrugs in Thailand: summary findings from theMitsampan Community Research ProjectKanna Hayashi1,2, Lianping Ti1, Nadia Fairbairn1,3, Karyn Kaplan4, Paisan Suwannawong4, Evan Wood1,3and Thomas Kerr1,3*AbstractBackground: For decades, Thailand has experienced high rates of illicit drug use and related harms. In response,the Thai government has relied on drug law enforcement to address this problem. Despite these efforts, high ratesof drug use persist, and Thailand has been contending with an enduring epidemic of human immunodeficiencyvirus (HIV) among people who inject drugs (IDU).Methods: In response to concerns regarding drug-related harm in Thailand and a lack of research focused on theexperiences and needs of Thai IDU, the Mitsampan Community Research Project was launched in 2008. The projectinvolved administering surveys capturing a range of behavioral and other data to community-recruited IDU inBangkok in 2008 and 2009.Results: In total, 468 IDU in Bangkok were enrolled in the project. Results revealed high rates of midazolam injection,non-fatal overdose and incarceration. Syringe sharing remained widespread among this population, driven primarilyby problems with access to syringes and methamphetamine injection. As well, reports of police abuse were commonand found to be associated with high-risk behavior. Problems with access to evidence-based drug treatment and HIVprevention programs were also documented. Although compulsory drug detention centers are widely used inThailand, data suggested that these centers have little impact on drug use behaviors among IDU in Bangkok.Conclusions: The findings from this project highlight many ongoing health and social problems related to illicitdrug use and drug policies in Bangkok. They also suggest that the emphasis on criminal justice approaches hasresulted in human rights violations at the hands of police, and harms associated with compulsory drug detentionand incarceration. Collectively, the findings indicate the urgent need for the implementation of evidence-basedpolicies and programs in this setting.Keywords: Injection drug use, Drug law enforcement, Harm reduction, Community-based participatory research, ThailandBackgroundThailand has experienced longstanding epidemics ofillicit drug use and human immunodeficiency virus(HIV) among people who inject drugs (IDU). During the1970s, Thailand became the world’s largest opium refi-ning and distribution center, and accordingly, heroin usequickly became a major driver of drug-related harm inthis setting [1,2]. Since the late 1990s, there has been adramatic increase in the use of methamphetamine inThailand, which has become the most commonly usedillicit drug in the country today [3]. In response, the Thaigovernment has relied on criminal justice approaches inan effort to eradicate illicit drugs. However, the nationalhousehold survey indicates that illicit drug use remainswidespread, with an estimated over 5% of the populationhaving used illicit drugs in 2007 [4]. The prevalence ofHIV among Thai IDU remains strikingly high, with ap-proximately 30-40% of IDU living with HIV during the* Correspondence: uhritk@cfenet.ubc.ca1Urban Health Research Initiative, British Columbia Centre for Excellence inHIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6,Canada3Faculty of Medicine, University of British Columbia, 317-2194 HealthSciences Mall, Vancouver, BC V6T 1Z3, CanadaFull list of author information is available at the end of the article© 2013 Hayashi et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Hayashi et al. Harm Reduction Journal 2013, 10:21http://www.harmreductionjournal.com/content/10/1/21past two decades [5]. Although the Thai government of-fers a range of HIV prevention, care and treatment ser-vices for free (e.g., HIV testing and antiretroviraltherapy), past reports suggested that IDU faced manybarriers to access these services [6].In response, IDU in Thailand have organized them-selves and called for funding to institute evidence-basedharm reduction and treatment strategies for them. In2003, a drug user-driven harm reduction initiative waslaunched with funding from the Global Fund to Fight toAIDS, Tuberculosis and Malaria (GFATM) [7]. Althoughthis civil society-driven movement led to the inclusionof methadone treatment in the national health securityprogram in 2008 [5], needle and syringe programs(NSPs), which is recommended by the World HealthOrganization (WHO) and other United Nations (UN)agencies as an essential HIV prevention service for IDU[8], remain controversial: While public health authoritieshave endorsed NSPs, legal authorities regard it as illegal[9,10]. The legal uncertainty has created a challengingenvironment for some civil society organizations thatwere allowed to operate NSPs with funding from theGFATM, while their service providers were routinelyarrested by police [6,11]. To date, the coverage of NSPsremains as low as less than 1% among Thai IDU [12].In 2002, Thailand enacted the Narcotic Addict Re-habilitation Act B.E. 2545, which reclassified people whouse drugs as “patients” instead of “criminals.” Despitethis reclassification, in practice, Thailand continues tosupport large-scale police crackdowns and the expansionof compulsory drug detention centers (CDDCs) [13,14].Most notably, a “war on drugs” policy in 2003 led to theextrajudicial killings of over 2,800 people and sparkedcriticism both domestically and internationally [15,16].However, the intensive drug law enforcement-based ap-proach continues to be endorsed by successive Thai go-vernments [17,18], and the impact of this policy approachon the health and behavior of IDU remains unevaluated.As well, little is known about the coverage, quality, andeffectiveness of public health programs for IDU in thissetting.In light of persistent concerns regarding drug policy inThailand, the Mitsampan Community Research Project,an academic-community research partnership involvingpeople who use drugs in Bangkok, was launched in2008. This report briefly describes the project and sum-marizes the key peer-reviewed findings from the project.Mitsampan Community Research Project andresearch methodsThe Mitsampan Community Research Project is a col-laborative research effort involving the Mitsampan HarmReduction Center (MSHRC; Bangkok, Thailand), Thai AIDSTreatment Action Group (TTAG; Bangkok, Thailand),Chulalongkorn University (Bangkok, Thailand), and theUrban Health Research Initiative of the British ColumbiaCentre for Excellence in HIV/AIDS/University of BritishColumbia (Vancouver, Canada). The MSHRC is a druguser-run drop-in center opened in 2004 with funding fromthe GFATM. The center provides a range of programs andharm reduction services (e.g., NSPs, health education, coun-seling and assistance in accessing healthcare), and is alsoactive in advocating for the human rights of people whouse drugs. The overarching objectives of this researchwere to investigate patterns of drug use, health servicesuse, interactions with the criminal justice system, andhealth-related harms among IDU in Bangkok.The specific methods employed in this research havebeen described in detail elsewhere [19]. In brief, it em-ploys a serial cross-sectional study design, and the dataused for this report were collected over two cycles ofsurveying in August 2008 and June – July 2009. Thestudy participants were all active IDU residing inBangkok or in adjacent provinces and being ≥18 yearsold when they enrolled in the study. Active IDU weredefined as individuals who had injected drugs at leastonce in the six months prior to the interview. In 2008and 2009, potential study participants were contactedthrough peer outreach and word-of-mouth, and were in-vited to the MSHRC to participate in the study. Afterproviding oral informed consent, participants completedan interviewer-administered questionnaire covering arange of topics including demographics, drug use pat-terns, HIV risk behavior, health problems, access tohealthcare and harm reduction services, and experienceswith the criminal justice system. HIV seropositivity wasalso determined through self-reporting. Since the study’sfocus on vulnerable populations and collecting data onillegal activities raised ethical concerns, we employedoral consent to protect the participant’s anonymity andconfidentiality. Additionally, the data collected did notinclude any identifying information or permit identifica-tion of specific individuals. The study was approved bythe research ethics boards of Chulalongkorn Universityand the University of British Columbia.This report summarizes the results of twelve peer-reviewed studies conducted through the MitsampanCommunity Research Project. In keeping with the over-arching research objectives, four studies were conductedto investigate four different aspects of harms associatedwith drug use [20-23]. Similarly, four studies examinedexperiences of four different dimensions of drug law en-forcement [24-27], and four studies focused on access tovarious healthcare and harm reduction services amongIDU in Bangkok [28-31]. Because each study addressed adifferent research question, they employed different par-ticipant eligibility criteria, variables, sample sizes, andstatistical analyses. The analytical methods have beenHayashi et al. Harm Reduction Journal 2013, 10:21 Page 2 of 9http://www.harmreductionjournal.com/content/10/1/21described in detail in each published study. In most ofthe studies, conventional regression methods (i.e., multi-variable logistic regression) were used to address thestudy objective.Results: summary of findingsIDU recruitmentIn total, 252 IDU participated in the study in August2008, and 317 IDU participated in the study betweenJune and July 2009. Therefore, an accumulated total of569 IDU were enrolled in the study over the two years.Because 101 individuals participated in the study in bothyears, the study reached a total of 468 unique IDU (252individuals in 2008 and 216 individuals in 2009). Samplecharacteristics are shown in Table 1. As shown, 157(27.6%) were women, and the median age was 36 years(interquartile range [IQR]: 32 – 46 years). The threemost commonly injected drugs by the study participantsduring the previous six months were: heroin (91.3%),midazolam (65.9%), and methamphetamine (57.5%) in2008; and midazolam (80.4%), heroin (65.3%), and met-hamphetamine (65.3%) in 2009. The prevalence of self-reported HIV seropositivity was 17.4% over the twoyears. Of note, 362 IDU (77.4%) newly accessed theMSHRC as a result of their participation in the study,and an increase in the attendance rate at the MSHRChas been observed since the launch of the project [19].The effective involvement of MSHRC members in thestudy likely facilitated the observed high rates of IDUrecruitment [19].Drug-related harmIn order to better understand the health status of andrisks facing IDU in Bangkok, four studies wereconducted to examine the prevalence and correlates ofdrug-related harm commonly experienced among thestudy participants. Anecdotal reports suggested that anincreasing number of IDU in Bangkok were injectingmidazolam—a short-acting benzodiazepine that can beacquired through private clinics. In 2008, over two thirds(67.5%) of participants in our study reported a history ofmidazolam injection, and 57.1% reported daily injectionof midazolam in the previous six months. Midazolaminjection was independently associated with poly-substance use (adjusted odds ratio [AOR] = 5.86; 95%CI: 2.96 – 11.60) and binge drug use (AOR = 2.25;95% CI: 1.09 – 4.63), and was commonly used in com-bination with both opiates and methamphetamine [20].Our study involving 238 IDU in 2008 demonstratedthat 30.3% of participants reported syringe borrowing inthe past six months. Consistent with past research[32,33], syringe borrowing was defined as injecting witha syringe used by others. As shown in Figure 1, syringeborrowing was independently associated with difficultyaccessing sterile syringes (adjusted odds ratio [AOR] =2.46; 95% confidence interval [CI]: 1.08–5.60). Primaryreasons for experiencing difficulty accessing syringes in-cluded being too far from syringe outlets, pharmaciesbeing closed, and being refused syringes at pharmacies[21]. These findings suggest that poor access to sterilesyringes is driving the high rate of syringe borrowingTable 1 Characteristics of a community-recruited sample of IDUs in Bangkok, Thailand, participating in the MitsampanCommunity Research Project in 2008 and 2009 (n = 569)Characteristic Total n (%) Study enrolment2008 2009252 (44.3%) 317 (55.7%)n (column%) n (column%)Female gender 157 (27.6%) 66 (26.2%) 91 (28.7%)Age< 35 years 243 (42.7%) 111 (44.0%) 132 (41.6%)35-45 years 175 (30.8%) 74 (29.4%) 101 (31.9%)≥ 46 years 151 (26.5%) 67 (26.6%) 84 (26.5%)Drugs injected at least oncea:Heroin 437 (76.8%) 230 (91.3%) 207 (65.3%)Methamphetamine 352 (61.9%) 145 (57.5%) 207 (65.3%)Midazolam 421 (74.0%) 166 (65.9%) 255 (80.4%)Self-reported HIV seropositivity 99 (17.4%) 29 (11.5%) 70 (22.1%)Being on antiretroviral therapyb 54 (54.5%)c 21 (72.4%)c 33 (47.1%)cIDUs: injection drug users.a Denotes activities during the 6 months prior to the interview.b Denotes activities at the time of interview.c The number of HIV-infected individuals is used as a denominator.Hayashi et al. Harm Reduction Journal 2013, 10:21 Page 3 of 9http://www.harmreductionjournal.com/content/10/1/21observed in this study, and various lines of evidence cor-roborate this interpretation [34,35].Methamphetamine injection appeared to be increasingamong IDU in Bangkok, raising concerns about the as-sociated impacts on HIV risk behavior among this popu-lation. Among 311 study participants in 2009, 36.7%reported having injected methamphetamine pills, locallyreferred to as “yaba,” twice or more per week in the pre-vious six months. The prevalence of methamphetamineinjection observed in this study was much higher thanpreviously reported rates using data collected during1999 and 2004 [36,37]. In multivariate logistic regressionanalyses, after adjustment for potential social, demo-graphic and behavioral confounders, syringe sharing (i.e.,borrowing or lending used syringes from or to others)in the past six months remained independently associ-ated with injecting methamphetamine more than onceper week (AOR = 2.86; 95% CI: 1.59–5.15) [22].Although drug-related overdose is a leading cause ofdeath among people who use drugs globally [38-40], theoverdose experiences of Thai IDU have not been investi-gated. Our study conducted in 2008 found that 29.8% ofparticipants had a history of overdose, and reporting ahistory of overdose was independently associated with ahistory of incarceration (AOR = 3.83; 95% CI: 1.52 – 9.65).The majority of participants (67.9%) had also respondedat the scene of an overdose. While many reported re-sponses with resuscitative potential, almost half reportedengaging in responses with low life-saving potential,such as injecting the individual with salt water [23].Experiences with drug law enforcementGiven the ongoing emphasis on drug law enforcementin Thailand, we conducted a series of analyses to exa-mine experiences with drug law enforcement among 252IDU recruited in 2008. The first study exploring incar-ceration experiences demonstrated high rates of HIVrisk behavior among IDU who had been in prison. Themajority of participants (78.2%) reported a history ofincarceration, and approximately 30% reported usingdrugs while in prison; 81.4% of these individuals alsoshared used syringes while incarcerated. A history of im-prisonment was independently associated with a historyof syringe sharing (AOR = 2.20; 95% CI: 1.12 - 4.32) [24].Our examination of the prevalence and correlates ofexperiences with CDDCs revealed that 31.7% of partici-pants had been in a CDDC at some point. As shown inTable 2, the exposure to CDDCs was independentlyassociated with experiencing police abuse (i.e., havingillicit drugs planted on oneself by police) (AOR = 1.81;Figure 1 Multivariate logistic regression analysis of factors associated with syringe borrowing among Thai IDU (n = 238).Table 2 Multivariate logistic regression analysis of factors associated with compulsory drug detention exposure amongThai IDU (n = 252)Variable Adjusted Odds Ratio (AOR) 95% Confidence Interval (CI) p-valueEver used drugs in combination(yes vs. no) 1.78 (0.94 – 3.36) 0.078Ever had drugs planted by police(yes vs. no) 1.81 (1.04 – 3.15) 0.035Median daily expenses for purchasing drugs(≥ 300 THB vs. < 300 THB) 1.86 (1.07 – 3.22) 0.028Reproduced from Csete et al. [25].Hayashi et al. Harm Reduction Journal 2013, 10:21 Page 4 of 9http://www.harmreductionjournal.com/content/10/1/2195% CI: 1.04 – 3.15). Further, the intensity of recent in-jection drug use did not differ between those who wereand were not exposed to CDDCs (p > 0.14) [25]. Thesefindings suggest that CDDCs are associated with policeabuse and appear not to be helping to reduce drug useamong IDU in Bangkok.Previous studies have shown that intensive drug mar-ket policing can produce harmful impacts on publichealth [41]. In two separate studies, encounters with po-lice were operationalized into two variables: (1) experi-ences with evidence planting by police (in the form ofpolice placing illicit drugs on an individual) as an indica-tor of direct encounters with police; and (2) perceivingan increase in police presence where people obtained orused drugs in the previous six months as an indicator ofindirect encounters with police. The first study revealeda high rate of police abuse against IDU: 48.4% of partici-pants reported having illicit drugs planted on them bypolice. In multivariate analyses, this form of police mis-conduct was strongly associated with a history of over-dose (AOR = 2.56; 95% CI: 1.40 – 4.66), syringe lending(AOR = 2.08; 95% CI: 1.19 – 3.66) and having been in aCDDC (AOR = 1.88; 95% CI: 1.05 – 3.36). Moreover,among those who reported having drugs planted onthem by police, almost half (48.3%) paid police a bribe(median = 5,000 Thai Baht or approximately $140 USD)in order to avoid arrest [26].Among the same sample, 54.4% reported observing anincrease in police presence where they obtained or useddrugs in the previous six months. However, levels ofdrug use did not vary among those who did and did notreport observing an increase in police presence [27].Despite the continued use of police crackdowns, thefindings suggest that increasing police presence in drugmarkets appears to have had little effect in reducingdrug use among IDU in Bangkok.Access to health care and harm reduction servicesFour studies have been conducted to examine access toessential health and harm reduction services among IDUin Bangkok. The first study sought to investigate accessto methadone treatment, one of the core interventionsfor HIV prevention and care for IDU [8]. While metha-done treatment has been available in Bangkok for de-cades, concerns have been raised regarding inadequatedaily dosing and the provision of methadone as a shortdetoxification program [42]. To conduct an external as-sessment of methadone treatment programs in Bangkok,273 IDU who had a history of heroin or other opiate usewere recruited in 2009. In total, 52.4% opiate users hadaccessed methadone treatment in the previous sixmonths, but almost all (98.6%) of them relapsed into ac-tive drug use while on treatment. As shown in Figure 2,injecting midazolam twice or more per week was inde-pendently associated with being enrolled in methadonetreatment (AOR = 1.85; 95% CI: 1.04 – 3.29). High ratesof ongoing drug use among methadone patients is likelyindicative of the suboptimal system of methadoneprovision in Bangkok, consistent with previous reports[42]. Moreover, 72.7% reported having stopped metha-done treatment, and the most common reason for stop-ping methadone was incarceration [28].Figure 2 Multivariate logistic regression analysis of factors associated with accessing methadone treatment in the previous 6 monthsamong a community-recruited sample of people who inject drugs in Bangkok, Thailand (n = 273).Hayashi et al. Harm Reduction Journal 2013, 10:21 Page 5 of 9http://www.harmreductionjournal.com/content/10/1/21The second study described the prevalence of and fac-tors associated with HIV testing behavior and exploredthe willingness to access rapid HIV testing at theMSHRC among HIV-negative IDU or IDU of unknownHIV serostatus. Although 76.2% of the study sample re-ceived HIV testing in the previous six months, 56.9% ofthose who had not been tested in the previous sixmonths reported engaging in HIV risk behavior in theprevious six months. Also, it was unclear whether thehigh rate of testing observed in the study was partially areflection of the existence of the tenofovir trial (a pre-exposure prophylaxis trial conducted out of BangkokMetropolitan Administration methadone clinics) [43],as enrolment in the trial was strongly associated withreceiving HIV testing (odds ratio = 44.81; 95% CI:13.44 – 149.45). In total, 74.2% of participants expressedwillingness to receive rapid HIV testing at the MSHRCif it were made available [29].The third study examined access to testing for hepa-titis C virus (HCV) among IDU who were living withHIV. Although HIV and HCV co-infection is highlyprevalent among Thai IDU [44], and WHO recommendsthat all people living with HIV be screened for HCV[45], only half (52.2%) of the HIV-infected IDU who en-rolled in the study had ever been tested for HCV. Thisappeared to be related to a lack of awareness of HCV, asprimary reasons given for not getting tested for HCV in-cluded “never heard of HCV” (65.6%) and “not aware ofHCV risks” (37.5%). Further, rates of HCV risk behavior(i.e., syringe sharing) were high (38.2%) among HIV-positive IDU who did not know their HCV status [30].The deficit in HCV case finding uncovered in thisstudy is significant, given the high rates of HCV riskbehavior observed among the study sample and the in-dependent contribution of HCV to morbidity and mor-tality among HIV-infected IDU [46].Lastly, an evaluation of the MSHRC was conductedby examining factors associated with access to theMSHRC. In 2008, 29.3% of participants surveyed hadaccessed the MSHRC, and these individuals were fourtimes more likely to have had difficulty accessing ste-rile syringes than those who had not previouslyaccessed the MSHRC (AOR = 4.05; 95% CI: 1.67 –9.80). Forms of support most commonly accessed atthe MSHRC included sterile syringes (100%), food anda place to rest (83.8%), and information about HIV(75.7%) and safer injecting (66.2%) [31]. Consistentwith a large body of research indicating the benefits ofpeer-based approaches in providing public health edu-cation and services to IDU [47-50], the results of thisstudy demonstrated that the peer-run MSHRC is helpingto expand harm reduction programming in Bangkok byreaching a sub-population of IDU at heightened risk ofHIV infection.DiscussionThe results of the Mitsampan Community Research Pro-ject reveal that IDU in Bangkok continue to engage inhigh rates of HIV risk behavior (i.e., syringe sharing) andsuffer from high rates of drug-related harm, includingoverdose. The findings also indicate a lack of appropriatehealthcare service provision and problems with subopti-mal service delivery among this population, as low ratesof sterile syringe access, HCV testing and awareness,and poor outcomes from methadone treatment persist.A number of social and structural factors appear to bedriving these problems, including the limited availabi-lity of evidence-based interventions targeting IDU, anoverreliance on drug law enforcement and incarce-ration, and a failure to adhere to international guide-lines on HIV prevention and care, and drug treatmentfor IDU. Although Thailand has continued to rely onintensive drug law enforcement, the evidence derivedfrom this study suggest that this approach is failing toproduce reductions in drug use, and is associated withhuman rights violations and the perpetuation of a sys-tem of compulsory drug detention that appears to havelittle impact on the drug use behaviors of IDU inBangkok. On the other hand, a promising means to re-duce drug-related harm among this population wasidentified at the drug user-run harm reduction centerwhere IDU experiencing difficulty in accessing sterilesyringes obtain sterile syringes and other supports.Many of our findings are congruent with previousstudies identifying various pathways through which in-tensified drug law enforcement produces harmful im-pacts on the health of IDU and public health [41,51-54].For example, in previous studies from other countries,increasing policing in drug markets has been shown tohave had no effect in reducing injection drug use [54]but instead have resulted in shifts in local drug use pat-terns and greater harm [51,55]. Our research also de-monstrated that perceived increases in police presencein drug markets did not seem to reduce injecting beha-vior among IDU in Bangkok [27]. As well, data from thisproject suggested that midazolam and methampheta-mine injection is increasing despite ongoing intensivepolice crackdowns, and injection of these substances wasshown to be associated with risk factors of HIV infectionand overdose [20,22]. In particular, the finding that theobserved prevalence of methamphetamine injectionappeared to be higher than the previously reported ratesmay reflect the concurrent growth of the methampheta-mine market suggested in the government’s reports [3],although this explanation warrants a further examin-ation. Further, the observed high rates of police abuseand the strong association with risk taking among IDUin this setting [26] is consistent with previous researchindicating that aggressive policing practices not onlyHayashi et al. Harm Reduction Journal 2013, 10:21 Page 6 of 9http://www.harmreductionjournal.com/content/10/1/21produce direct harm to IDU but also function as path-ways to more distal forms of drug-related harm[41,52,56,57].Our findings also point to the urgent need for theimplementation of harm reduction measures withinprisons. According to the latest official report, 56.4% ofall incarceration events in Thailand are attributable todrug-related charges [58]. Consistent with previous stu-dies [59-61], our study demonstrated alarmingly highrates of HIV risk behavior among IDU in Bangkok whoreported a history of incarceration [24]. Moreover, incar-ceration was also associated with overdose [23] and wasreported to be the most common reason for the discon-tinuation of methadone treatment [28]. The independentassociation between overdose and incarceration is con-sistent with evidence from Western settings indicatingthat incarceration exacerbates the risk of heroin over-dose upon release from prisons as a result of reducedtolerance [62]. These findings suggest that incarcerationis contributing to the production of a variety of drug-related harms in this setting. Given the ongoing highrates of incarceration of Thai IDU, our findings reinforcethe recommendations by WHO and other UN agenciesto implement essential harm reduction programs withinprisons, including NSPs [53].The findings of this research also highlight the need toscale up HIV prevention, care and treatment servicestargeted for IDU in Bangkok. The HIV prevalenceamong our study sample (17.4%) was high and similar tothe 2010 Integrated Biological and Behavioral Surveysdata showing that the HIV prevalence was 21.3% (CI:15.2-26.5) among a sample of 412 IDU in Bangkok [63].The observed rate of syringe borrowing (30%) [21] washigher than the rates of syringe sharing among IDU inBangkok reported by two other studies in 2003–2004(17%) [37] and 2009 (14%) [64], although the potentialdifferences in sample characteristics make the compari-son difficult. The finding that frequent methampheta-mine injection had an independent relationship withsyringe sharing [22] builds on previous studies showingheightened risk of HIV seroconversion among metham-phetamine injectors [36,61] and calls for the scale-up ofNSPs for this sub-population of IDU. Although the Thaigovernment supports some harm reduction programs,the illegality of NSPs is still debated [10]. Given thedemonstrated strengths of the MSHRC in reaching asub-population of IDU at heightened risk of HIV infec-tion due to difficulty accessing sterile syringes [31] andthe fact that the MSHRC, like many other drop-in cen-ters implementing NSPs that are operated by civil soci-ety organizations, relies on the GFATM grant [11], suchpeer-run interventions should be supported and scaledup by the government. Also, given the substantial levelof willingness to access rapid HIV testing at the MSHRCamong HIV-negative IDU or IDU of unknown HIVserostatus [29], it may worth exploring the expansion ofpeer-led harm reduction interventions in this setting,such as the provision of HIV testing and counselingby peers.The work described in this report has limitations, andthe limitations of each individual study are described indetail in the published versions of the studies. First, as inany research that is based on surveying methods, our re-search cannot prove causal relationships. Second, as thestudy sample was not randomly recruited, our findingsmay not be generalizable to the IDU populations inBangkok or other parts of Thailand. Third, the self-reported data may be affected by response biases, in-cluding socially desirable reporting and recall bias.Therefore, we may have over- or underestimated thetrue prevalence of drug use or HIV risk behaviorsamong IDU in Bangkok. However, we also note that thistype of data has been commonly utilized in other studiesexamining drug use patterns and found to be valid[65,66]. Finally, building on the present research fin-dings, future research should further examine observedassociations between various health and social prob-lems and injection drug use, including the relationshipbetween midazolam injection and dosages of methadone.ConclusionsThe findings from this research project highlight manyongoing health and social problems related to illicit druguse among IDU in Bangkok. They indicate a lack ofappropriate healthcare and harm reduction serviceprovision to this population, problems which are likelycontributing to ongoing HIV risk-taking and other drug-related harms within this population. These findings alsosuggest that the emphasis on criminal justice approacheshas resulted in human rights violations at the hands ofpolice, and harms associated with compulsory drug de-tention and incarceration. Collectively, the findings indi-cate the need for urgent government endorsement,funding and independent evaluation of a comprehensiveset of IDU-specific harm reduction and addiction treat-ment programs in Bangkok.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsKH drafted the manuscript and incorporated all suggestions from co-authors.All authors made significant contributions to the conception of the analyses,interpretation of the data, and drafting of the manuscript. All authors readand approved the final manuscript.AcknowledgementsWe would particularly like to thank the staff and volunteers at theMitsampan Harm Reduction Center for their support. We also thankDr. Niyada Kiatying-Angsulee, Director of Social Research Institute,Chulalongkorn University, for her assistance with developing this project.We gratefully acknowledge a number of graduate students and staff for theirHayashi et al. Harm Reduction Journal 2013, 10:21 Page 7 of 9http://www.harmreductionjournal.com/content/10/1/21assistance with data collection and management: Prempreeda Pramoj NaAyutthaya, Amnat Chamchern, Wiwat Chotichatmala, Tricia Collingham, EricFu, Deborah Graham, Donlachai Hawangchu, Caitlin Johnston, PrapatsaraKaewkoon, Daniel Miles Kane, Calvin Lai, Puripakorn Pakdirat, Cristy Power,Jiezhi Qi, Jirasak Sripramong, Vipawan Suwannawong, Kamon Uppakaew,Peter Vann, Tanyaporn Wansom, and Ruth Zhang. We also thank JoanneCsete, M-J Milloy, Julio Montaner, and Dan Werb for their invaluablecontribution to the development of the manuscripts. Particular thanks go tothe participants in the project who were courageous enough to share theirexperiences with us. The project was originally funded by the Michael SmithFoundation for Health Research. Its knowledge translation activities weresupported by the Public Health Program and Global Drug Policy Program ofthe Open Society Foundations. TK is supported by the Michael SmithFoundation for Health Research. KH is supported by the University of BritishColumbia Doctoral Fellowship.Author details1Urban Health Research Initiative, British Columbia Centre for Excellence inHIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6,Canada. 2Interdisciplinary Studies Graduate Program, University of BritishColumbia, Green College, Green Commons, Room 153A, 6201 Cecil GreenPark Rd, Vancouver, BC V6T 1Z1, Canada. 3Faculty of Medicine, University ofBritish Columbia, 317-2194 Health Sciences Mall, Vancouver, BC V6T 1Z3,Canada. 4Mitsampan Harm Reduction Center / Thai AIDS Treatment ActionGroup, 18/89 Vipawadee Rd., soi 40 Chatuchak, Bangkok 10900, Thailand.Received: 9 July 2012 Accepted: 24 September 2013Published: 7 October 2013References1. Reid G, Costigan G: Revisiting the hidden epidemic: a situation assessment ofdrug use in Asia in the context of HIV/AIDS. Fairfield: The Center for HarmReduction, The Burnet Institute; 2002.2. 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Darke S: Self-report among injecting drug users: a review. Drug AlcoholDepend 1998, 51(3):253–263. discussion 267–258.doi:10.1186/1477-7517-10-21Cite this article as: Hayashi et al.: Drug-related harm among people whoinject drugs in Thailand: summary findings from the MitsampanCommunity Research Project. Harm Reduction Journal 2013 10:21.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitHayashi et al. Harm Reduction Journal 2013, 10:21 Page 9 of 9http://www.harmreductionjournal.com/content/10/1/21

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