Health in Action

HIV Prevention, Care, and Treatment
in Two Prisons in Thailand
David Wilson, Nathan Ford*, Verapun Ngammee, Arlene Chua, Moe Kyaw Kyaw

A

s scale-up of antiretroviral
therapy (ART) progresses in
less-developed countries, the
challenges of providing treatment to
marginalised populations become
of increasing concern. One such
marginalised group is prisoners. While
there is an emerging consensus that
prevention and treatment is feasible
and effective in prisons [1], experience
of implementing comprehensive
HIV/AIDS programmes that include
antiretroviral therapy in resourcelimited countries is limited. This article
describes our experience of providing
HIV prevention and treatment in two
prisons in Thailand.

HIV in Prisons in Thailand
Thailand is noted for its successful
response to the HIV epidemic.
Successful prevention efforts achieved
an 83% reduction in new infections
between 1990 and 2003, and the
country can be said to have achieved the
goal of universal access to antiretroviral
therapy, with about 76,000 people on
treatment out of a total of roughly
600,000 people with HIV [2]. However,
several groups have been unable to
access the government’s treatment
programme, in particular injecting drug
users, migrants, and prisoners (the first
two groups contributing significantly to
the third) [3].
A reported 168,264 people are
incarcerated in Thailand (point
prevalence), exceeding prison capacity
by over 50% [4]. Prison data on
HIV prevalence are sparse—testing
is not performed systematically
and no random surveys have been
done—but what data do exist indicate
that prevalence is much higher than
in the general population [5]. One
study in Klong Prem Central Prison,
Bangkok, found that 25% of prisoners
who agreed to be tested (n = 689;
convenience sample) were HIV positive
The Health in Action section is a forum for individuals
or organizations to highlight their innovative
approaches to a particular health problem.

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Box 1. Minburi and Bangkwang Prisons
Minburi Remand Prison is a medium-security prison with a capacity of 2,000 (1,700
males and 300 females). The duration of sentence is two to seven years. Health care staff
are one part-time doctor and three full-time nurses. Prisoners needing hospitalisation
are transferred to Klang Hospital, a 300-bed hospital in Klong Prem Central Prison,
Bangkok. MSF began working in Minburi Remand Prison in June 2003.
Bangkwang is a maximum-security prison. Its official capacity is 3,500 (males only),
but in March 2006 it held 4,922 prisoners, including 870 on death row. The minimum
sentence is 25 years. There is a 40-bed hospital and an outpatient clinic. Health services
are staffed by one full-time doctor (director of prison medical services) and another parttime doctor, six registered nurses, six technical nurses, two pharmacists, one laboratory
technician, and two x-ray technicians. MSF began working in Bangkwang in December
2004.
Both prisons are overcrowded. Prisoners occupy large communal rooms. In Minburi
there are about 400 prisoners per room in the male prison and 300 per room in the
female prison. In Bangkwang there are 20 to 40 prisoners per room, except on death
row, where there are about 100 per room. A small number of prisoners are held in
solitary confinement.
In both prisons, all inmates are locked in their cells from 4 pm to 7 am, during which
time health staff do not access the cells. In Bangkwang, “first aid” health care is provided
by designated prisoner volunteers during these hours.
[6], compared to a general prevalence
of 1.5% in the national population [2].
Thailand’s prisons suffer from lack
of health staff and severe budget
constraints. The health care workforce
in the 139 prisons across Thailand
comprises just 17 full-time and 16 parttime doctors and 307 nurses. In 2000,
Thailand spent over US$150 million
on prison health care (including
infrastructure-related costs), but less
than US$25,000 was spent on HIV/
AIDS care [7]. Until October 2005, the
total annual health budget per prisoner
was around US$3.5, disbursed through
the Department of Corrections. Since
then, the prison health budget has
come under the administration of
the National Health Security Office’s
health insurance scheme. This scheme
covers treatment for most health
conditions, including HIV/AIDS, thus
removing budgetary constraints for the
treatment of most patients. However,
health insurance is only available to
registered Thai nationals. Around
5% of the total prison population
are foreign nationals, mostly
from Myanmar, and an additional
0988

unknown but significant number are
unregistered Thais (ethnic minorities,
nationals without birth registration, or
those who have lost their identity cards)
[8]. In addition, the health insurance
Funding: The programmes described in this article
are funded by private donations to Médecins Sans
Frontières. Medication is supplied by Thai Ministry
of Public Health programmes or purchased with
Médecins Sans Frontières private funds, using locally
produced generics where possible.
Competing Interests: The authors have declared
that no competing interests exist.
Citation: Wilson D, Ford N, Ngammee V, Chua A,
Kyaw MK (2007) HIV prevention, care, and treatment
in two prisons in Thailand. PLoS Med 4(6): e204.
doi:10.1371/journal.pmed.0040204
Copyright: © 2007 Wilson et al. This is an openaccess article distributed under the terms of
the Creative Commons Attribution License,
which permits unrestricted use, distribution,
and reproduction in any medium, provided the
original author and source are credited.
Abbreviations: ART, antiretroviral therapy; MSF,
Médecins Sans Frontières; WHO, World Health
Organization
The authors are at Médecins Sans Frontières,
Bangkapi, Bangkok, Thailand.
* To whom correspondence should be addressed.
E-mail: msfb-bangkok@brussels.msf.org

June 2007 | Volume 4 | Issue 6 | e204

Box 2. Sex in Prisons
What kinds of sex occur in all-male prisons?
• Sex in the prisons is frequently related to power.
• Consensual sex between men includes partner sex, paid sex, and sex in exchange for
protection.
• Non-consensual sex includes rape, sometimes used as an intimidation tactic, and
coerced sex as repayment of debt. New prisoners are particularly vulnerable as they
can be subjected to sex as an initiation to the power relations in the prison.
Why may the attitude of prison staff prevent safer sex practices?
• Some prison staff try to forbid all sexual activities in order to prevent non-consensual
sex; others believe that forbidding sex is the most effective form of prevention,
though in practice this is unrealistic.
Why do prisoners fail to use condoms?
• Condoms are not banned in prison, but in practice it is difficult to gain acceptance
from prison guards for condom distribution.
• Some prisoners are unaware of the risk of HIV transmission by anal sex. Others
are aware, but are unable to access condoms or to negotiate their use in coercive
situations.
• Being known to have sex or to possess condoms may lead to criticism by prison
guards or ostracism by other prisoners. Prisoners may prefer to risk becoming HIV
positive than to try to access condoms.
• Prisoners may believe that having sex with another man is against nature. This leads
them to be secretive and have clandestine, unprotected sex.
• Someone who insists on condom use can give the impression that they are HIV
positive or have a sexually transmitted infection.
scheme does not fund prevention,
education, or other non-curative
activities.

HIV/AIDS Care in Two Prisons in
Bangkok
Médecins Sans Frontières (MSF) has
supported HIV/AIDS programmes
in Thailand since 1995. In June
2003, at the invitation of the prison
health services, we began providing
clinical support in two prisons in
Bangkok—Minburi, a remand prison,
and Bangkwang, a maximum-security
prison (Box 1). The initial focus was on
treatment, but once a level of trust was
built between MSF and prison health
authorities, we were invited to expand
our work to prevention activities. The
following observations are derived from
these programmes.

Prevention
Drug users in Thailand are the highest
risk group for HIV infection. Around
one-fifth of all new HIV infections
occur through injecting drug use; in
some parts of the country this figure
rises to above 50% [3]. Up to twothirds of prisoners are incarcerated for
drug-related offences [2]; some, but
not all, are injecting drug users, and

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this contributes to the high prison HIV
prevalence. Injecting drug use in the
prisons has decreased in recent years,
partly because of reduced availability
of heroin (inside and outside). Where
it does occur, injecting equipment is
scarce and almost always shared. Some
prisoners tell us that they used to
belong to an “injecting group” but this
stopped when other drug users started
to die from AIDS.
Tattooing is another risk factor
for HIV infection. In Thai prisons,
tattooing equipment is prohibited and
therefore it is often shared. Sharpened
pens or sewing needles may be used for
tattooing and there are no means for
sterilisation.
But by far the greatest risk factor
for HIV transmission within Thai
prisons is unprotected sex between
men. Sex, consensual or otherwise, is
part of prison life (Box 2). Condoms
are not banned from prisons, but the
attitude of prison staff towards sex
between prisoners influences condom
distribution.
The governors of both prisons
where we work gave approval for
condom distribution during 2006,
but distributing them widely depends
on changing attitudes of prison

0989

staff. While health staff are generally
supportive, the engagement of other
staff is essential to move distribution
beyond the clinics. Prison guards want
to see HIV transmission reduced,
but often find it hard to accept that
for this to occur they must play an
active role in condom distribution.
Progress has been made in both prisons
through workshops in which prison
staff are encouraged to question their
own attitudes and behaviour towards
prisoners, through activities such as
role-plays. In Bangkwang condoms
are available through prisoner
representatives (prisoners designated
by the Director of Medical Services and
trained by MSF). In Minburi, where
there is a rapid turnover of prisoners,
prisoner representatives are less easy
to establish and the focus is on prison
guards, many of whom now agree to
distribute condoms.
Workshops for prisoners give
information about HIV transmission
and prevention. These workshops also
provide an opportunity for participants
to share their experiences and learn
from each other about how to solve
the difficulties of establishing safer
sexual practices in the prison. Such a
participatory approach is also part of
the development of mutual support
amongst the prisoners.

HIV Testing and Counselling
In the past, prisoners generally received
no pre- or post-test counselling. Health
care staff may have avoided informing
prisoners of their status because
treatment was unavailable. We have
seen several patients whose medical
record showed that an HIV diagnosis
had been made several years ago but
the patients had not been informed
of their status. Counselling is now
implemented in both prisons, but not
all prison staff believe it is necessary
and more work is needed to explain
its benefits. Confidentiality is a major
challenge and we have attempted to
address this issue during workshops for
both staff and prisoners. Nevertheless,
during the first 18 months of the
programme, 20 prisoners failed to
attend any follow-up counselling after
receiving a positive HIV diagnosis.
Most patients we have seen to
date (112 from a total of 165) were
diagnosed with HIV infection while
in prison, with diagnosis most often
prompted by an opportunistic infection

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Table 1. Characteristics and Outcomes of Patients with HIV Receiving ART in Two Prisons
Characteristics and Outcomes

Indicators

Characteristics of patients receiving ART (n = 88)

Male, n (%)
Female, n (%)
Mean age, y (min–max)
Median follow up in months (IQR)
WHO staging at the time of initiating ART
Stage I, n (%)
Stage II, n (%)
Stage III, n (%)
Stage IV, n (%)
Median CD4 at the time of initiating ART, cells/mm3 (IQR)
After 6 months ART, cells/mm3 (standard error)
After 12 months ART, cells/mm3 (standard error)
After 18 months ART, cells/mm3 (standard error)
Intolerance to stavudine (switch to zidovudine), n
Intolerance to nevirapine (switch to efavirenz), n
Switch to 2nd line (failure confirmed by viral load), n

Mean CD4 cell increase in patients receiving ART (n = 14)a

Switch of ART regimen (n = 11)

Values
72 (82)
16 (18)
34 (21–49)
18 (9–23)
7 (8)
10 (11)
41 (47)
30 (34)
119 (23–205)
73.5 (14.1)
134 (24.6)
161 (35.9)
4
6
1

a

Cases with any missing values were excluded.
IQR, interquartile range
doi:10.1371/journal.pmed.0040204.t001

(81 patients) such as pulmonary
tuberculosis (45 patients). Some
former injecting drug users sought
testing when other drug users died.

Care and Treatment for HIV/AIDS
Clinical support began with the
treatment of opportunistic infections.
During this phase—lasting six months
in both prisons—prison medical staff
and MSF jointly set up a peer support
system for adherence to antiretroviral
treatment.
Of 165 HIV-infected prisoners
identified since the program began,
122 (74%) were in disease stage
3 or 4 as defined by the World
Health Organization (WHO). Most
opportunistic infections have been
manageable within the prison,
including pulmonary tuberculosis
(43 cases) and extra-pulmonary
tuberculosis (28 cases). Two patients
with multidrug-resistant tuberculosis,
two with cryptococcal meningitis, and
two with cytomegalovirus retinitis have
been referred to an infectious diseases
hospital for diagnosis and treatment.
Two patients with pneumonia have
died after referral and hospital
admission. There is no access to
treatment for hepatitis B and C in the
prisons and we do not routinely test
for these conditions. Even outside the
prison availability of such treatment is
extremely limited.
Medical criteria to initiate
antiretroviral therapy follow Thai
national guidelines: CD4 count below
250 cells/mm3 for patients with WHO

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stage 2, 3, or 4 disease, or below 200
in asymptomatic cases. Patients are
provided with basic knowledge about
HIV, opportunistic infections, ART,
and the importance of adherence so
that they can make informed decisions
regarding whether and when to start
treatment. If patients proceed to
treatment, antiretroviral therapy is
administered by a nurse helper—a
volunteer prisoner who helps medical
staff with tasks such as dispensing
medications and checking temperature,
weight, and blood pressure. The firstline regimen for 87 patients (75%) is
a fixed-dose combination of stavudine,
lamivudine, and nevirapine [9]. Patients
with tuberculosis co-infection who
are taking rifampicin are prescribed
stavudine, lamivudine, and efavirenz.
We have enrolled 88 patients on
antiretrovirals, of whom 12 (15%) had
previously taken ART but discontinued
it when they were imprisoned (Table
1). The median follow-up time on
treatment is 18 months and CD4 cell
gain is comparable with treatment
programmes in other settings [9].
Currently we follow 63 patients on
ART (72%) within the prisons. Of the
remaining patients, 18 (20%) have
been released from prison and five
(6%) were transferred to other prisons;
two patients (2%) have died.
Peer support from people living
with HIV/AIDS is part of Thailand’s
treatment strategy [10], and peer
support systems have been established
in both prisons. In addition to this
group support, patients are assigned

0990

a buddy to support adherence to
medication (the buddy is normally
someone who has HIV and who may
also be on ART).
Prisons have been said to be the
ideal environment for ensuring high
compliance to treatment [11], but
in our experience there are many
important barriers to overcome that
require constant re-evaluation. These
include fear of stigma associated with
HIV, which discourages prisoners
from taking medicines in a crowded
environment; mistrust of prison staff,
including hospital staff; transfer
to another facility; and poor social
support upon release.
The attitude of the prison health
care staff towards the rights of prisoners
to access ART is very positive. Staff are
committed to working through difficult
problems and referring people to
other hospitals in cases where specialist
care is needed. The fact that none
have questioned that three prisoners
facing the death sentence receive
antiretroviral treatment is a clear
indication of the staff’s commitment to
treatment as a basic human right.
This positive attitude is crucial
to success in a setting where the
traditional relationship between
prisoners and prison staff is
antagonistic: in the past prisoners
distrusted staff and were unwilling to
come forward for care. According to
the medical director in Bangkwang,
it took two years to gain the trust of
patients before they were willing to
seek treatment.

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Patient Transfer and Release
Bangkok prisons are overcrowded
and transfers to less crowded prisons
elsewhere in the country are common.
Such transfers create problems for
ensuring continuity of treatment
because most prisons outside Bangkok
have limited health staff and no access
to HIV treatment. While efforts are
made to communicate the particular
health needs of people with HIV/AIDS
within the prison system, the reality
is that we do not know what care is
provided for the five patients from our
cohort who have been transferred to
other prisons.
Continuity of care upon release
is also challenged by substance use,
homelessness, joblessness, poverty,
and difficulties in accessing the health
insurance scheme, especially for exprisoners without an ID card (Box 3).
Before being released from prison,
patients meet with a social worker
employed by MSF to develop a plan for
continuing treatment. In both prisons,
MSF provides a medication supply
for three months—the average time
taken for people with a correct Thai ID
card to enrol in the government ART
program. Of 18 prisoners released since
the start of the treatment programme,
seven receive treatment through the
public health system, while six receive
treatment from MSF because they lack
a Thai ID card. Despite considerable
efforts, five have been lost to follow up.

Ethical Considerations
Surrounding This Article
Ethical questions inevitably arise
during any intervention amongst
incarcerated populations. In this paper
we have described our experience
of implementing proven HIV
prevention strategies and delivering
standard treatment to a difficultto-reach population requiring an
innovative approach. The main
ethical challenges we have faced,
together with our partners, have been
the implementation of practices of
confidentiality and informed consent;
we have done our best to rise to these
challenges.
During the peer review process for
this article, a number of questions
related to ethics were raised, specifically
concerns about patient anonymity and
the need for ethical approval for such a
publication. The matter was referred to
the PLoS Medicine Advisory Group on
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Box 3. Ensuring Continuity of Care after Release from Prison: Case
Studies
The first patient is a 33-year-old Thai man who lost his ID card many years ago. He
was found to be HIV positive whilst in Minburi Remand Prison and began antiretroviral
therapy in May 2004. He contacted MSF many times for reassurance that he could
continue treatment after his release.
He was released in October 2005, stayed with friends to whom he did not disclose
his HIV status, and worked as a welder. MSF supplied his medication and arranged
lab monitoring. Documentation he needed in order to apply for an ID card included
his birth certificate, his father’s death certificate, a certificate of release from prison,
proof of residence—which required the house owner to add his name to a household
registration document—and two certificates of good character signed by state
employees. MSF helped him through the necessary bureaucratic procedures and he
received his ID card in February 2007—16 months after release. This enabled him to
register with the National Health Insurance scheme and, after a further three months,
receive treatment through the government program.
The second patient is a 30-year-old man diagnosed with HIV in 2002 in Minburi
Remand Prison. He did not attend the clinic while in prison but asked MSF to visit him
upon his release in May 2004. Subsequently he was diagnosed with miliary tuberculosis
and then commenced ART in May 2005 after MSF helped link him to the government
ART program. He had previously injected drugs and started again in June 2005.
However, his adherence to ART remains good.
Publication Ethics, who were divided
on the matter [12]. We referred the
issue to an independent institutional
review board, whose judgement was
that there was minimal risk of harming
individuals or the community by
publishing this paper. The board also
felt that as a descriptive paper in which
no research hypothesis was being tested
and no analytic statistics were used,
there was no requirement for formal
ethics committee review and approval.

Discussion
There are few examples of HIV/AIDS
treatment programmes in prisons
in the developing world. Emerging
outcomes from pilot programmes
support the effectiveness of treatment
in prisons [13–15], but poor or nonavailability of antiretrovirals is still
frequently reported [16–18]. This lack
of availability has become a growing
concern for treatment activists: in
South Africa, civil society groups have
recently taken the government to
court to fight for prisoners’ rights to
treatment [19].
In our experience, satisfactory
outcomes can be achieved in underresourced prison settings. MSF’s initial
input was to provide treatment for
opportunistic infections, antiretroviral
drugs, and technical support. Thailand
is not a “least-developed” country,
but the approach taken follows
WHO guidelines for treatment in
0991

resource-poor settings, and could
be implemented by any government
providing treatment in the general
population. Ultimately, barriers that
prevent the provision of treatment in
prisons when it is available outside are
not technical or financial, but political.
The effectiveness of any prison
programme depends on the attitude
of staff. We have found the attitude of
prison health staff to be very positive
towards the rights of prisoners, but
this is not yet the case for all staff.
Treatment provision was an important
first step towards building sufficient
trust that then allowed us to bring up
the more sensitive issue of prevention.
We believe the programme will have
a sustained impact. The prevention
component includes strategies to
change the attitudes and behaviour of
both prison guards and prisoners, and
the Department of Corrections has
asked us to develop training curricula
to be used in other prisons. In terms
of treatment, drug supply has been
handed over to the government and
training and mentoring has provided
prison medical staff with the skills to
manage most problems. Sustainability
also comes from the fact that part of
the budget for health care for Thai
prisoners, including antiretroviral
medicines, now comes under the
health insurance scheme. However,
Thai ethnic minorities and foreigners
are not eligible for this support and
June 2007 | Volume 4 | Issue 6 | e204

their access to care is a pressing
concern.
Most prisoners come from
marginalised groups such as drug users,
sex workers, or unregistered migrants.
These groups are at high risk of HIV
with limited access to health care in
general, and this is reflected in the
high number of HIV-positive cases
diagnosed in the prison. Implementing
treatment and prevention programmes
in prisons provides an opportunity to
work with particular groups who would
not normally seek, or be given, care.
An effective response must therefore
confront barriers to care outside of
prisons, in order to ensure continuity
of care for those who are released.

Supporting Information
Alternative Language Text S1.
Thai translation of the article by K.
Kijitiwatchakul
Found at doi: doi:10.1371/journal.
pmed.0040204.sd001 (201 KB DOC).

Acknowledgments
We are very grateful to Ms. Nipa Ngamtrirai
(Department of Corrections), Dr. Manop
Srisuphanthavorn and Mr. Boonyang
Chayatub (Bangkwang Prison), and Ms.
Suchacha Poking, Ms. Nittaya Inka, and Mr.
Kunakorn Viriyarumpa (Minburi Remand
Prison) for their support and suggestions
about this paper. We especially thank key
informants from amongst the prisoners who
necessarily remain anonymous. Additional
thanks to Philippe Cavailler for advice on
data collection and to Dr. France Roblain.
Finally we would like to thank the peer
reviewers who devoted considerable time
to suggesting improvements to our initial
submission.
Author contributions. DW and AC designed
the study. NF, VN, and AC contributed to
writing the paper. AC and MKK analysed
data. DW and AC enrolled patients. DW,
VN, AC, and MKK collected data for the
study. DW and AC carried out medical
consultations with the patients, prescribed
treatment and recorded the findings, and

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supervised other doctors doing the same.
DW made a formal review of the collection
of data at three monthly intervals. DW is
medical coordinator of MSF projects in
Thailand and as part of this role contributed
substantially to the conception and design
of the project described in the paper, and
also to the interpretation of data. Two other
authors drafted the first (internal MSF)
version of the paper and DW discussed
it with them and then revised it critically
for intellectual content and wrote the
final version to be published. VN is field
coordinator for the project described in
the paper and participated substantially
(with others) in project design, evaluation,
and monitoring. AC was the doctor
treating patients in the project described
in the paper from June 2003 to December
2005. AC participated substantially (with
others) in project design, evaluation, and
monitoring. MKK analysed the data with
“FUCHIA” software, which MSF uses for
monitoring and evaluation of antiretroviral
treatment programmes.
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19. [No authors listed] (2006 August 26) SA could
face constitutional crisis: Judge. South African
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June 2007 | Volume 4 | Issue 6 | e204