Globally, drug-related problems are increasing and becoming more intertwined with development issues [1]. To effectively combat drug problems, it requires “development-sensitive” drug control policies [1]. Research evidence presented in the World Drug Report 2016 indicates that “efforts to achieve the Sustainable Development Goals and to effectively address the world drug problems are complementary and mutually reinforcing” [1]. In other words, to address problems related to the use of illicit drugs, policies need to aim at “the overall social, economic and environmental development of communities” [1]. Many experts agree that punitive policies do not work to reduce health and socio-economic problems associated with drugs in the long run [2,3,4]. In Asia, for instance, evidence indicates that punitive policies and practices exacerbate drug use and consequent ills, and human rights-based approaches work better [5]. Suppressive policies and social discrimination could worsen the HIV epidemic among people who inject drugs (PWID) and people who use drugs (PWUD) since they are discouraged from carrying clean needles and syringes due to the fear of being arrested and may not seek health services due to stigmatization [4, 6]. Conversely, human rights-based and voluntary community-based approaches prove to be effective in preventing and treating drug use and related diseases [4, 6]. For example, in Malaysia, transforming compulsory detention centers into voluntary cure and care centers attracts more PWID/PWUD to receive health services [7].
In Cambodia, two major legal instruments have been enacted to combat drug trafficking and drug use, namely the Drug Control Law (DCL) [8] and the Village/Commune Safety Policy (VCSP) [9, 10]. The DCL, originally ratified in 1996 and periodically modified in 2005 and 2007, was lastly amended in 2012. This law essentially stipulates administrative and legal actions and punishment against illegal drug production, trafficking, and use. However, it embraces some harm reduction elements, including voluntary treatment, choice of treatment method, and sufficient treatment periods for PWID/PWUD. For instance, Article 105 allows the police to refer PWID/PWUD to a treatment program as an alternative to criminal prosecution.
Nonetheless, the DCL contains some ambiguities, inconsistencies, and controversies surrounding treatment of PWID/PWUD. While the police are entitled to send PWID/PWUD to a treatment program, the DCL does not provide clear guidance for prosecutors as to what treatment program and when to refer them to. Article 107 states that “forced treatment shall not be imposed unless there is a serious situation;” but it does not define the term “seriousness” or the level of “seriousness.” Articles 45 and 53 implicitly criminalize repeated use of drugs by PWID/PWUD by stating that “drug users who have already received forced treatment and rehabilitation and are caught using drugs again will face imprisonment from one to six months.” Further, Article 40 articulates that “a person in possession of drugs faces imprisonment from two to five years,” without specifying the amount of drugs carried. As a result, police officials have challenges in distinguishing between PWID/PWUD and drug dealers [11].
The VCSP, launched in 2010, aims to combat crimes such as robbery, drug trafficking, and other illegal activities such as prostitution and illegal gambling [9, 10]. This policy requests authorities to “cut off and eliminate production, dealing, and use of illegal drugs in villages and communes” as part of efforts to ensure “public security and order” [9]. However, it was classified as “red” legislation by human rights groups in 2012, meaning it violates the core principles of human rights [12]. Since the launch of the VCSP, law enforcement officers have extensively used the DCL as a legal basis to implement the VCSP with regards to crimes and violence in relation to drug trafficking and drug use [10]. Some articles of the VCSP (and the DCL) allow law enforcement officers to check PWID/PWUD for condoms, needles, and syringes and arrest them or force them to relocate. Violation of human rights and physical abuses of PWID/PWUD take place regularly [10], making PWID/PWUD live in fear of being arrested and/or removed from communities [10]. In many cases, PWID/PWUD were isolated from health, education, legal support, and other harm reduction services [10, 11]. Another repercussion of the VCSP was that besides the police’s suppressing approach, communities could report illegal activities, such as drug use, to local authorities [11, 13]. Also, parents could report and turn in their children who used illicit drugs to the police for rehabilitation.
When talking about and implementing the DCL and VCSP, law enforcement agencies, particularly local authorities in Cambodia, emphasize physical safety issues. This is reflected by the fact that treatment programs for PWID/PWUD are mostly conducted within compulsory rehabilitation centers, which are hardly different from prisons [14]. Also, this is reflected by a lack of community-based treatment approaches adopted by the government [14]. Moreover, the concepts of harm reduction and its implementation have not been well understood and accepted by the general public and law enforcement officers. The general public, and law enforcement officers, sometimes refer to harm reduction as needle and syringe program (NSP), while harm reduction embraces more aspects of health and human rights-related issues among PWID/PWUD [11]. In addition, in Cambodia, due to the perception that the risk of the transmission of HIV through injecting drug use is not as high as through unsafe sex, many law enforcement officers are not convinced that NSP is an effective means to prevent HIV transmission among PWID in Cambodia [11]. Their disbelief is exacerbated by a lack of evidence of the effectiveness of NSP in the Cambodian context [11].
The discrepancies in the understanding and application of drug-related legal instruments and harm reduction programs warrant further investigation into perspectives of concerned actors about these issues. Previous research mainly explored these issues from law enforcement perspectives, insufficiently addressing perspectives of PWID/PWUD and harm reduction practitioners [10, 11, 14, 15]. This study aimed to examine how the understanding and application of the DCL and VCSP affects harm reduction interventions in Cambodia from the standpoints of PWID/PWUD, harm reduction practitioners, law enforcement officials, and other key stakeholders.
In Cambodia, illicit drug use is on the rise [1]. The estimated numbers of PWID/PWUD in the country vary, ranging from 20,000 in 2012 [16] to 46,000 in the same year [10]. However, government estimates put the numbers of PWID/PWUD at 10,000 in 2012 and 16,600 in 2015, respectively [17, 18]. Despite the different estimates, there is a common agreement that drug-related health and socio-economic problems are increasing [1, 18]. In 2015, the police escalated law enforcement on 3061 drug-related cases (up from 1339 cases in 2014), arresting 7008 suspects (up from 3138 suspects in 2014) and seizing nearly 2000 kg of drugs [18]. Cambodia has a much less serious opiate/heroin and injecting problem than other Southeast Asian countries, and amphetamine-type stimulants (ATS) are a major drug problem [1]. This contextual issue particularly affects “harm reduction,” which here (and elsewhere) is mostly focused on needles and methadone [5, 11].
There have been various efforts to address drug-related issues in Cambodia, including rehabilitation programs [18] and community-based treatment and reintegration programs [19]. The government recognized and accepted harm reduction programs in 2003, when the HIV epidemic declined from its peak from 2% in 1998 to 1.2% in 2003 [20]. At that time, the epidemic shifted from the general population to the key populations (KPs), which include female sex workers (FSW), men who have sex with men (MSM), transgender women (TG), and PWID/PWUD [20]. PWID, whose total population in the country was estimated at around 1300, had one of the highest HIV prevalence estimates (24.8% in 2012) [16]. Eventually, the government recognized drug use as social and health problems and acknowledged the need to take a harm reduction approach in response to HIV among PWID in 2003, and officially launched the NSP in 2005. However, this transitional solution was mainly from the perspective of public health and was driven by the HIV response and funding; no new laws and policies were approved to formally support NSP operations. It was only in 2013 that the National Authority for Combating Drugs (NACD) started to draft policy and guiding principle for the operation of NSP [21], which was finally completed in 2014. The approaches to addressing drug related issues in Cambodia, both in the law and practices, are punitive.
Non-governmental stakeholders have active engagement in harm-reduction-related activities [11, 13]. The engagement includes providing technical and financial support to harm reduction programs as well as service delivery and policy advocacy. The main features of harm reduction implementation for PWID in Cambodia include NSP, HIV education, HIV counseling and testing, healthcare referrals, and free methadone. However, as we will show, the NSP program is not widely accepted because of, among other barriers, conflicts with the VCSP and DCL, the norm and belief in the communities, and the law enforcement, and therefore not being widely used since its approval in 2005. Moreover, the NSP program is unable to reach all PWID in communities and reportedly is not well understood and welcomed by some police officers and community members [11].
Rehabilitation centers are the most common service that law enforcement officers can use to refer arrested PWID/PWUD to [22, 23]. There are several centers, which are run by NGOs, the private sector and the government. Based on the DCL, there should be no forced treatment unless necessary. However, in practice, the referrals of PWID/PWUD to the centers are usually based on an agreement with parents or guardians of the PWID/PWUD or sometimes without an agreement of the PWID/PWUD or their parents or guardians. Physical abuses of PWID and PWUD were reported occurring in many centers.
Community-based treatment program, a more comprehensive approach being strengthened and scaled-up by the Ministry of Health (MoH), is an alternative to compulsory rehabilitation centers [19, 24, 25]. This program has been integrated into the general public healthcare system under the MoH with the support from the United Nations Office on Drug and Crimes (UNODC) and World Health Organization (WHO). The community-based treatment program in Cambodia uses multi-stakeholder collaboration to refer PWID/PWUD to community-based drug dependence treatment services [19, 24, 25]. The program includes comprehensive health and psychosocial care services provided by health centers and referral hospitals as well as social reintegration and support services provided by NGOs. Other distinctive features of the program are effective collaboration from law enforcement officers who are sensitized and trained to support the program and peer educators who conduct outreach, home visits, and counseling. Notably, in the community-based treatment program, methadone maintenance therapy (MMT) is not a priority since the bulk of clients mainly consume ATS.
After piloting in a province in 2012, the community-based treatment program was planned to be expanded nationwide in 2016 thanks to its effectiveness in treatment, reintegration, and skills training of clients [19, 22, 23, 26]. The MoH planned to integrate NSP in the community-based treatment at health centers and referral hospitals [11]. An assessment of the community-based intervention program in three provinces in 2015 pinpointed that its success relied on strong leadership and national commitment, meaningful involvement of clients, community participation, NGO engagement, and multi-sectoral collaboration and coordination between public health, public security, and NGO sectors [26]. Notwithstanding, the community-based treatment program encountered a number of shortcomings, including non-functioning of some services, compromised quality of care, and limited access, due to decreasing financial and technical aid and overloaded staff. Further, provision of care through public health facilities made clients reluctant to access services due to fear of arrest, stigmatization, or discrimination. Also, the program depended on NGOs to provide social support services, including vocational training, family support, and social reintegration. Thus, to make the community-based treatment program more effective and sustainable, these challenges need to be addressed.
Given the unique context of drug use and the specific approaches to harm reduction in Cambodia, it is crucial to examine how the understanding and application of the DCL and VCSP among the various stakeholders affect these approaches. This paper is intended to provide this insight.