How understanding and application of drug-related legal instruments affects harm reduction interventions in Cambodia: a qualitative study

Factors contributing to ambiguities of DCL and VCSP

First, the formulation of the DCL and VCSP lacked sufficient consultation with civil society organizations and beneficiaries concerned. This may have caused inadequate or incorrect stipulation about treatment of PWID/PWUD. Law enforcement officials and the general public have a limited understanding of these legal instruments in relation to drug use. Subsequently, harm reduction efforts in Cambodia have resulted in limited success due to the improper understanding and implementation of these drug-related law and policy. Research shows that at-risk communities and community-based organizations (CBOs) perform critical roles in executing successful harm reduction interventions [5]. For instance, the government in Vietnam works with CBOs on harm reduction responses since they increasingly acknowledge that CBOs better understand and have greater access to PWID/PWUD [27]. Thus, the shortcoming in dialogs with target communities and CBOs may have rendered loopholes in understanding and addressing the needs of PWID/PWUD.

Second, the gap in understanding drug use and harm reduction by law enforcement officials stems from a very slow evolution of implementation—from policy to practice—of harm reduction in Cambodia. Harm reduction programs in the Kingdom had a long and difficult evolution [11]. Before a tardy acceptance of harm reduction by the government in 2003, all key players, including DPs and NGOs, had worked very hard to advocate for the need to implement harm reduction and to adopt policies and strategies that guide the responses of harm reduction [11]. Harm reduction activities, particularly NSP interventions, had been perceived by authorities as a motivating factor for PWID/PWUD to continue using drugs rather than an intervention to reduce harms, including risks of HIV and hepatitis C infections. Despite the existing mechanisms, such as the Police-Community Partnership Initiative (PCPI) and Provincial Drug Control Committees (PDCC), the national NSP policy remained in draft form until 2012 [11]. Law enforcement officers perceive harm reduction mainly as NSP, reflected in their lack of referring PWID/PWUD to MMT and social and health services [11, 15]. Therefore, there is an ongoing need to strengthen the adoption and enabling environment of harm reduction policies in Cambodia.

Third, the misunderstanding and malpractice of the DCL and VCSP in relation to harm reduction pertained to the lack of awareness and training of law enforcement officials about these instruments and harm reduction responses. This reinforces the need for enhancing capacity and behavioral change of law enforcement officials pinpointed by earlier research [11]. The paucity in knowledge about the legal instruments, coupled with stigmatization against PWID/PWUD, leads to abuses of PWID/PWUD by these agents. This is common in many Asian countries [5]. In Cambodia, the police perceive their role as the keeper of public order, security, and safety in communities, and they distance themselves from being a contributor to harm reduction or HIV prevention [11]. Their misconception about the correlation between crime and drug consumption stems their harsh treatment of PWID/PWUD [11].

A review on harm reduction responses in Asia and the Pacific concedes that a priority should be placed on convincing authorities that it is possible to contain, and is worth controlling, HIV epidemics by properly addressing drug use [5, 18]. It is vital to change an official standpoint that HIV among PWID cannot be prevented and reduced, and that the virus will be confined to this population, which the society despises [5]. Many of the police officers in our study did not believe in the benefits of harm reduction because they did not buy the idea that PWID are at a high risk of contracting HIV, and there has been no research suggesting that harm reduction techniques actually lower the risk of HIV transmission in Cambodia. In fact, there is global consensus that “combination prevention” harm reduction methods decrease HIV prevalence among key populations. However, the link is not a natural one, but one that is shaped by the availability and performance of harm reduction measures themselves. To exemplify, a Dutch study revealed that “full participation in harm reduction programs was associated with lower incidence of HIV infection” in PWID [28]. Participation in a NSP alone did not result in lower HIV infection, but instead multiple harm reduction strategies must be incorporated to lower HIV infection [28]. The criticality of diverse and integrated elements in harm reduction programs should be stressed because many participants in our study misconceived that harm reduction and NSP were the same, rather than NSP being just one component of harm reduction.

Capacity building for law enforcement officials should go beyond improving the comprehension and implementation of the DCL and VCSP and should embody harm reduction methods. There have been many efforts to train police officers in harm reduction. For instance, a National Harm Reduction Curriculum for the Cambodian Police Training Academy has been implemented since 2011 [29]. This initiative has yielded some positive results, such as increase in knowledge about law enforcement approaches and support of harm reduction programs. Moreover, some NGOs have provided short training courses on harm reduction to police officers, which have changed their attitudes toward harm reduction approaches and rendered a better environment for service delivery [11]. However, police officers in our study depicted a limited understanding about harm reduction approaches. Thus, more attention should be devoted to training methods and follow-up on enforcement. A study in the USA disclosed that training police officers in HIV transmission, harm reduction strategies (including NSP), and occupational safety (including the risk of contracting HIV from needle-stick injuries) enhanced their proper understanding and practices of drug-related laws [30]. Prior to the training, 51% of police officers believed NSP promoted drug use, 38% thought NSP failed to reduce HIV spread, and only 7% accurately understood the syringe possession law [30]. In the wake of the training, they were more likely to state proper interpretations of laws pertaining to PWID and understand information about occupational safety related to HIV transmission [30]. This suggests that police officers may be more inclined to learn from training that offers information about their personal health and safety and replicate it in law enforcement with PWID. The study concluded that “using occupational safety content as a vehicle to deliver a broader set of public health content” can ensure that implementing officers are knowledgeable about harm reduction methods and benefits and apply them in law enforcement [30].

Fourth, the emphasis on the physical dimension of harm reduction by seconding its social and health tenets by the DCL and VCSP and the relevant authorities exacerbated the wrong understanding and implementation by enforcement officers. This inadequate focus on social and health aspects of harm reduction implies a lack of “combination prevention” embrace of safety and security. The VCSP defines “safe communities” as those with no thefts, gambling, drug use, prostitution, or other crimes [9]. This policy presses local law enforcement officers to regard drug use as an issue of social security or safety indicated by an absence of physical crimes [11]. Not only authorities but also local communities prioritize physical security of their neighborhood over HIV prevention, which is deemed as more a matter of individuals [11]. Nonetheless, harm reduction encompasses mitigation of both physical and mental harms by providing health and social services to at-risk individuals, notably PWID/PWUD. Prioritizing the state of security over harm reduction, which is strongly associated with HIV prevention in general, may yield a short-term physical order and peace, but a long-term socio-economic repercussion in communities.

As aforementioned, to ensure “safe communities,” people could report such illicit activity as drug use to local authorities or parents could turn in their drug-using children to the police for rehabilitation. This sort of “community policing” could create fear and suspicion among villagers, which could exacerbate the post-trauma lack of mutual trust culminating from the genocidal regime (1975–1979) in the recent history of Cambodia [31].

Finally, the lack of harm reduction facilities and services and insufficient knowledge about these facilities and services made it difficult for law enforcement officials to refer PWID/PWUD for help and support. Further, the available facilities were difficult for PWID/PWUD to access, and experiences of being treated badly in the rehabilitation facilities scared them away. Also, comprehensive rehabilitation services, usually private ones, are not affordable for PWID/PWUD or their families. Services at the government rehabilitation centers were not user-friendly, and the centers were filled with physical abuses [22, 23]. A Vietnamese study has found that negative attitudes toward drug use and compulsory detention of PWID/PWUD failed to reduce HIV infections among PWID. Harm reduction strategies were not effective because the country viewed drug use as a social danger and jailed PWID/PWUD in rehabilitation centers. Many Vietnamese felt that NSP, particularly methadone treatment, supported drug use. Mandatory detention centers were plagued with abuses and unsuccessful rehabilitation. PWID/PWUD undertook many risky behaviors to avoid law enforcement out of fear of detainment [6]. Vietnam later shifted to a local harm reduction approach by changing the negative public opinion about drug use within communities and became successful in lessening HIV infections among PWID [6]. This type of strategy is likely to be successful in Cambodia as well because changing the government officials’ mindset is more challenging than focusing on community opinion.

Malaysia represents a success story in terms friendly service delivery for PWID/PWUD by moving away from a punitive approach to a voluntary, rights-based approach to drug treatment [32]. The country has transformed eight compulsory detention centers into voluntary cure and care centers or clinics [33]. Opioid substitution therapy provision in prisons increased from one site in 2008 to 18 in 2013 [34], and NSP site provision increased by 431 between 2012 and 2014 [32, 35]. It was expected that this increasing implementation of services would reduce the prevalence of PWID living with HIV [34]. It is of note that in both Vietnam and Malaysia, heroin and opiates are more prevalent, whereas in Cambodia, they are not, and this makes drug treatment and harm reduction more challenging because of a lack of evidence for approaches to helping people with dependence on ATS drugs. Contingency management and financial incentives (such as conditional cash management) are possibly the only approach for which there is evidence of success [36, 37]. Thus, Cambodia needs to consider adopting this evidence-based approach to harm reduction.

In Cambodia, it was estimated that in 2010 only 1% of PWID/PWUD in drug detention centers were admitted on a voluntary basis [22]. Methadone was not available at these centers since the majority of those admitted used ATS. These centers were essentially just prisons for detaining PWID/PWUD or people with psychiatric problems [22]. Having more harm reduction strategies implemented in prisons will mitigate the risks of the target population as many PWID are jailed for drug and non-drug related crimes.

Improving these aspects would better address the major needs of PWID/PWUD concerning safety, security, stigmatization, discrimination, and access to and affordability of harm reduction services. PWUD were more hopeful than PWID about their future regarding jobs or family. Although PWID/PWUD in our study expressed similar needs and concerns, their risks occur based on the situation or context they are in. Therefore, they might face different challenges depending on their risks [38]. “Social context, comprising interactions between individuals and environments” induces different types and levels of harm and risks [29]. Put another way, “social situations and environments” perform an integral role in determining what and how PWID/PWUD encounter risks [38].

How punitive policies hamper harm reduction responses

The mistreatment of PWID/PWUD by arresting and detaining them mirrors a punitive practice of tackling drug use, which contradicts a rights-based approach effective in dealing with drug-related issues worldwide. Evidence depicts that punitive policies and practices exacerbate drug use and consequent ills [2–4]. For instance, a study in India revealed that negative social perceptions about and harsh treatment of PWID/PWUD increased the risk of HIV transmission [14]. This occurred since PWID/PWUD engaged in more risky behaviors, such as not carrying clean syringes/needles from NSP out of fear of getting caught with them and then punished by law enforcement officers [14]. This is also true in Cambodia because our study and an earlier study in Cambodia [15] unveil that PWID/PWUD were fearful of sanctions from law enforcement, thus not accessing harm reduction and health services.

Moreover, if PWID/PWUD in Cambodia continue to be ill-treated by law enforcement officers and rehabilitation facilities, there will be more adverse ramifications, such as more drug use and subsequent health and social problems, for the society as a whole. Cracking-down policies and measures are not effective to ensure drug control and the safety of communities. Mistreated PWID/PWUD are unlikely to openly seek safe and sterile equipment for drug injection and other support, which will amplify HIV spates. Conversely, voluntary, right-respected services will contain drug use and its consequent effects, particularly risks of contracting and spreading HIV.

Limitations of the study

There were some limitations in this study. The first limitation concerned the limited geographic coverage that confined to three Khans/districts of Phnom Penh. Secondly, the PWID/PWUD participants were limited to those with connections to the NGO participants, meaning those without these linkages were not able to participate. PWID/PWUD in Cambodia are “sensitive” people since they are perceived as “criminals” [39]. Thus, it was difficult to recruit PWID/PWUD into the study. Sensing the difficulty, we went straight to our partner NGOs working on harm reduction to recruit the participants. The fact that they were beneficiaries of the NGOs enabled them to feel confident in partaking in the study although their views might be different from those of non-beneficiaries of the NGOs. Thirdly, given 14 of the 18 PWID/PWUD participants were males, the findings of their perceptions and experiences might have been shaped by their gender. These findings thus should be interpreted in the context of gender imbalance since drug use among women is highly prevalent.

Fourthly, the NGO staff were field staff working directly with PWID/PWUD; although, they were assigned to the study by their superiors. They were chosen because they had more knowledge on the ground than program managers; we did not know if they were chosen in a biased way by their superiors. Fifthly, we could not conduct the planned FGDs with PWID/PWUD in rehabilitation centers due to the restriction and assumption by the center management that they were not conscious enough to provide accurate responses while taking drug treatment. Moreover, it would have posed ethical challenges. Thus, their views were not presented in this study. Finally, the data collection tools (the FGD and KII guides) were not pre-tested or validated in the Cambodian context. Thus, the findings of this study should be read in lieu of these shortcomings.