Laila Khondkar, from Thailand
Introduction
The HIV/AIDS epidemic is the single most important health and development issue facing many countries around the world (World Bank, 1997). Over the past two decades, AIDS has spread affecting the lives of men, women, and children, their families, and societies. Country data indicate that the number of people living with HIV/AIDS continues to increase in all parts of the world. According to UNAIDS, globally 39.4 million people are living with HIV. In 2004, an estimated 4.9 million acquired the virus and a total of 3.1 million AIDS deaths was recorded (UNAIDS, 2004).
The epidemic in Asia is catching up fast. According to the UNAIDS annual report, 8.2 million people in Asia, which excludes the Asian part of the Russian Federation, were living with HIV/AIDS at the end of 2004. Asia is the region with the second largest number of people living with HIV after sub-Saharan Africa with 25.4 million. Last year, there were 1.2 million new infections and 540,000 deaths in Asia (UNAIDS, 2004). In this continent, the HIV epidemic remains largely concentrated in injecting drug users (IDUs), men who have sex with men (MSM), sex workers, clients of sex workers and their immediate sexual partners. Effective prevention coverage among these populations is inadequate (UNAIDS, 2004a).
Thailand is one of the very few countries to have reversed a serious HIV/AIDS epidemic and met the Millennium Development Goal 6 (which targets to halt by 2015 and begin to reverse the incidence of major diseases including HIV/AIDS) well ahead of schedule (UNDP, 2004).In sharp contrast to other groups at risk of HIV such as sex workers and military recruits, HIV prevalence among Thai IDUs never dropped. Although there is extensive literature on the Thai success in addressing HIV/AIDS, very little is known about the response of some marginalized groups. The objective of this study is to examine Thai response to HIV/AIDS among IDUs. Presently injecting drug use is considered to be one of the major causes of spreading HIV/AIDS in Asia and so the lessons learned from Thailand could provide some useful understanding in this regard, which in turn could be used in addressing this challenge in different countries of the region. The research questions are: How did Thailand address HIV/AIDS among IDUs? What policies and practices in Thailand affect the human rights of IDUs? What are the lessons that other countries could learn from the Thai experience?
The first section of the paper deals with the conceptual framework of the study. Then Thai response to HIV/AIDS is described in the literature survey. The next section is about the link between drug use and HIV/AIDS, international guidelines regarding
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this and available interventions. Then the HIV/AIDS situation among IDUs and the Thai response in this regard is explored. Finally all the findings are discussed and conclusions drawn.
Existing literature including peer reviewed journals, policy documents, and grey literature were reviewed for the purpose of the study. Visits were made to government and non-government organization (NGO) intervention sites. Thirty in-depth interviews were conducted with People Living With HIV/AIDS (PLWHA) and other activist groups, government, United Nations (UN) agencies, international organizations, national NGOs, and academia. The snow-ball technique was used to select the interviewees in Bangkok and Chiang Mai. Interviews were semi-structured, and a questionnaire guide was prepared for this.
Linkages between health and human rights
The right to health is based on article 12 of the International Covenant on Economic, Social, and Cultural Rights (ICESCR). Rights which relate to autonomy, information, education, food and nutrition, association, equality, participation and non discrimination are integral parts of achieving the highest standard of health. On the other hand, enjoyment of the right to health is inseparable from civil or political, economic, social and cultural rights (Tarantola, 2000). There are two ways to analyze the relationship between health and human rights (Gruskin et al., 2000). The first focuses on the ways in which health policies can promote or violate human rights. The second approach examines how violations of human rights have direct or indirect health impacts. Human rights offer a powerful conceptual framework and a vocabulary with which to discuss marginalization, discrimination, and stigmatization and what must be done about these societal problems.
Human rights and HIV/AIDS
There are empirical and theoretical links between human rights abuses and vulnerability to HIV/AIDS. It has already been realized that populations who are already marginalized before AIDS (such as sex workers, homosexuals, IDUs etc) are at greater risk of HIV infection. Thus vulnerability to HIV was identified as resulting from lack of respect for human rights and dignity. Not only are human rights violations committed against people with AIDS, it is one of the root causes of disease.
The human rights approach helps to identify the commonalities between the HIV prevention status of gay men in Eastern Europe and married women in East Africa, or between adolescents in Latin America and drug users in Asia (Gruskin et al., 2000). Human rights abuses against IDUs are one of the most important causes of HIV transmission around the world today. IDUs face unparalleled health and human rights crisis that shows no sign of declining (Open Society Institute, 2004). In this study, response to HIV/AIDS among IDUs in Thailand is examined using a human rights framework.
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Thai response to HIV/AIDS
HIV/AIDS in Thailand
More than one million people have been infected with HIV/AIDS in Thailand since the beginning of the epidemic, which is a country of approximately 63.5 million people. The latest estimate shows the national adult HIV prevalence to be 1.5% at the end of 2003 (UNAIDS, 2004). 600,000 people are living with the virus today, and it is estimated that 50,000 people will die from the disease in each year of the Ninth National Economic and Social Development Plan (2002-2006). So it is now the leading cause of death among young adults.
Elements of success
In Thailand, the number of new infections has fallen from around 140,000 a year in 1991 to around 21,000 in 2003 (UNAIDS, 2004a). Thai response to AIDS has been well documented. Existing literature suggests that the following factors contributed to the successful response (Ainsworth et al 2000, Family Health International 2004, Punpanich et al 2004, UNDP 2004a): 1) strong political leadership and commitment were achieved at the national level, and this generated similar commitment at the provincial and local levels; 2) a multisectoral approach was used in all structures and mechanisms; 3) a wide range of actors and institutions were involved in the broad based response; 4) patients, Buddhist monks, the medical community, teachers, sex workers, NGOs have worked with the national government to plan and implement the AIDS program; 5) an essential component of the Thai response was the “100% condom program” which aimed to enforce consistent condom use in all commercial sex establishments; 6) a massive public education and information campaign, activism and mobilization by civil society, a relatively strong healthcare infrastructure, the provision of reliable epidemiologic information and analysis, and the feedback channels between programming experiences and policy making contributed to the success.
Present challenges
HIV/AIDS in Thailand is continuing to evolve. A new phase has begun in which the epidemic becomes endemic. Commercial sex work is still an important factor in HIV spread, but there is a disturbing upward trend of HIV risk behaviors in certain sub populations, especially among young women, MSM, and IDUs. Current prevention efforts are not adequate. Public information and education campaigns are not sufficient either (UNDP, 2004a).
The executive summary prepared by Ministry of Public Health (MoPH) emphasizes that the HIV/AIDS burden is high, and that it is a major public health threat to the country (Bureau of AIDS, TB, and STIs, 2004). Present challenges include reviving
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intensive HIV prevention efforts, providing care and support to PLWHA and maintaining political commitment at the highest level.
Drug Use and HIV/AIDS: Global Context
Extent of the crisis
Sharing or use of contaminated needles is a very efficient way of spreading HIV. So HIV prevalence can rise rapidly among IDUs who share needles. Very few countries have reliable information on the number of people who inject drugs, but there is information on risk behavior who inject, which shows that in many settings, needle and syringe sharing are very common. In Indonesia, around nine out of every ten injectors said they had used a needle that had been previously used by someone else (MAP, 2004). Injecting drug use is emerging as a key determinant of the epidemic in Asia and Eastern Europe. It also continues to be a key driver of the epidemic in other regions, except Africa. There are estimated to be 500,000 IDUs in Central Asia, and 3.5 million in China (Open Society Institute, 2004). Worryingly large pockets of HIV infected IDUs exist in other populous countries like India and Pakistan (Wodak et al, 2004). Even where the numbers of people injecting drugs are relatively small, their contribution to the overall epidemic can be significant. Drug users in Asia are highly vulnerable to HIV transmission because of legal, political, socio-economic, and cultural reasons (UNAIDS, 2001).
Aside from IDUs, other drug users are also vulnerable to HIV/AIDS, as they do engage in high-risk sexual behavior under the influence of drugs. A high prevalence of sexually transmitted infections among drug users reflects their unsafe sexual practices (UNAIDS, 2001). They and their partners often act as a bridge in transmitting HIV to others such as commercial sex workers, clients of commercial sex workers, and to the general population. Drug injecting may also contribute to an increased incidence of HIV infection through HIV transmission to the children of drug injecting mothers (UN, 2001a).
International mandate
After years of denial and discrimination, the international community has acknowledged the need to reach out to IDUs in a world with AIDS. In June 2001, The United Nations General Assembly Special Session on AIDS adopted the Declaration of Commitment on HIV/AIDS (UN, 2001). All 184 member states committed themselves to specific targets and objectives without reservation. These include:
…..establishing by 2003 national prevention targets to reduce the incidence of HIV infection among key populations, including injecting drug users, with high or increasing rates of infection or at highest risk of new infection; and by 2005 expanding access to condoms and sterile injecting equipment and
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ensuring the availability of harm reduction efforts related to drug use. (UN, 2001)
In 2001, a joint United Nations paper was approved, which recommends a comprehensive package of measures for countries to address HIV and injecting drug use (UN, 2001a).
Evidence of successful interventions
HIV prevention services for drug injectors remain controversial politically, but there are good examples that include Bangladesh and parts of China and Vietnam to suggest that these programs can be effective in Asian settings (MAP, 2004).The best responses are based on three pillars: supply reduction, demand reduction, and harm reduction (UNAIDS, 2004a). Harm reduction for IDUs aims to help them avoid the negative health consequences of drug injection, improve their health and social status, and often reduce social crime and cost of imprisonments.
Programs such as syringe exchange and methadone maintenance are among the most well-researched HIV prevention strategies in the world. The aim of the syringe exchange program is to ensure that IDUs have access to clean injection paraphernalia, which provides a bridge to drug treatment programs by providing clients with information, counseling, and referrals. A review comparing HIV prevalence in cities across the world with and without needle and syringe programs found that cities which introduced such programs showed a mean annual 19% decrease in HIV prevalence, while there is an 8% increase in cities that failed to implement prevention measures (UNAIDS, 2004a).
Drug substitution treatment maintenance involves the medically supervised treatment of individuals with opioid dependency based on the prescription of opioid agonists such as methadone. The primary goal of drug substitution is abstinence from illicit drug use, but many patients are unable to achieve that. However, there is clear evidence that methadone maintenance significantly reduces unsafe injection practices of those who are in treatment, and so the risk of HIV infection.
Drug Use and HIV/AIDS in Thailand
History and types of drug use
There is lack of reliable data and documentation on the drug situation in Thailand. In 2001, the estimated figure is two to three million drug users, about five percent of the population (Reid et al, 2002). Thailand is located at the center of what is known as the “Golden Triangle”, which has contributed to the increase in drug use. Due to the government’s extensive development and crop substitution efforts beginning in 1973, there has been substantial reductions in the total area under cultivation in Thailand. But Thailand is still one of the major trade routes for opium and heroin from Laos and Myanmar (Phongpaichit et al, 1998).
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The main drugs of abuse are heroin, methamphetamine, marihuana and volatile substances. Cocaine and ecstasy are gaining popularity among foreign visitors and youth from wealthy families in Thailand. Methamphetamines, popularly known as yabba, have overtaken heroin as the prime drug of choice. Yabba is generally taken orally or vapor inhaled. There are reports that yabba increases sexual risk taking behavior, and could facilitate HIV infection (Reid et al., 2002). It is widely used by people from different occupations such as truck drivers, public transport operators, fishermen, and agricultural users (UNAIDS, 2001a).The actual number of users who inject drugs is not known. Estimates range from 100,000 to 250,000 addicts. Most of them are males (around 90 percent) and mostly aged between 20-24 years (UNDP, 2004a).
HIV/AIDS among IDUs
Between 1987 and 1988, surveillance among IDUs at Tanyarak hospital in Bangkok and in the Bangkok Metropolitan Administration clinics revealed the explosive increase in HIV among drug users. Presently in Northern Thailand, 30% of drug users are infected with HIV, while median HIV prevalence as high as 51% has been found in other parts of the country (UNAIDS, 2004).The high prevalence of HIV/AIDS among IDUs is due to the frequency of injecting, the widespread sharing of needles, and imprisonment of drug users (Reid et al, 2002). In Thailand, about one quarter of all new infections is through unsafe injecting drug use (UNDP, 2004a).
Policies related to drug use and HIV/AIDS
Thailand has well-developed drug control programs and huge amount of experience in HIV/AIDS response. But there is little collaboration between the two sectors. There are no conceptual and operational linkages between drug control and HIV prevention and intervention policy, decision making, and planning (UNAIDS, 2001a). Although Thailand was successful in opium and cannabis crop eradication, drug problems continue to increase. Interviews revealed that technical skills are not very high among those who deal with HIV/AIDS among drug users.
There is a working group on drug use and HIV/AIDS which is under the leadership of the National AIDS Bureau. The working group includes participation from civil society and has produced a seven point plan on harm reduction. But interviews with activists made it clear that not much progress has been made so far.
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Available Interventions for Thai Drug Users
HIV/AIDS prevention and treatment activities
In Thailand, outreach and peer approaches are widely used in HIV/AIDS prevention, but not in the drug field. There is limited HIV prevention activity with IDUs across the country (Reid et al, 2002). Very limited resources are available in this area. Various NGOs are trying to educate and support IDUs to avoid HIV infection. Generally, the government has not been supportive of the initiatives. A climate of fear makes it very difficult to conduct outreach activities, as drug users are afraid of being reported to the police. As one NGO worker said, “Lack of trust is the main barrier in reaching IDUs for HIV prevention.”
Until recently the national treatment guidelines on anti-retrovirals (ARVs) stated that the current users had to quit using in order to receive ARVs. It is said that this is no longer applicable, but users face major barriers, as the health system lacks any additional support that could help them access ARV treatment (Open Society Institute,
2004).
Drug treatment
Drug treatment is provided through a variety of public and private treatment centers. The treatment provided by the Ministry of Public Health consists of pre-admission, detoxification, rehabilitation, and after care stage. But most of the drug users do not complete all four stages of the program, and so treatment outcomes are disappointing and relapse is at least 75% or even higher (Reid et al, 2002). Drug issue is not being addressed within proper socio-economic context, and so there is not much success. One activist opined, “We cannot ignore the socio-economic problems in which drug users live if we want to tackle the challenges of drug use.”
Methadone maintenance therapy
Methadone is now available in Bangkok clinics as the principal method of drug withdrawal. Methadone therapy is so constrained that it is largely ineffective (Reid et al, 2002). One academic said, “Some methadone clinics deal with the issue of drug use in a holistic way, but most do not.” Thai law allows for long-term methadone maintenance therapy, but most clinics offer only twenty-one days of methadone detoxification. One academic mentioned that policies regarding methadone are “scattered”. One drug user made the following remark during an interview,
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“Methadone clinics have been around for a long time, but operating in the same old style.” Drug users mentioned “lack of respect” from the providers. One of them said, “The providers treat the drug users very badly in the clinic. It is like a punishment.”
Needle and syringe exchange program
Since 1989, several narcotic clinics in Bangkok have been providing free bleach and providing instructions to IDUs on how to clean injecting equipments. But such programs are not available outside the capital. Despite numerous scientific evidence in favor of the needle and syringe exchange program, the government has not supported this approach. There is no major legal barrier in implementing this, but there is not much interest in pursuing the approach (Reid et al., 2002). Needles and syringes can be purchased easily, but drug users are reluctant to carry injecting equipment to avoid police scrutiny and arrest.
Challenges Faced by Drug Users
War on drugs
The war on drugs that started in 2003, and the third phase of which is presently going on, has been a serious blow to Thai response to HIV/AIDS. Drug users along with drug traffickers became the targets of state-sponsored killings and ill-treatment. The government claimed that the killings were done by drug dealers in order to silence potential witnesses. But many public and media critics believe the killings were extra
judicial murders, which were carried out by the police and other security officials. The government’s crackdown has resulted in the unexplained killings of more than 2000 persons and the arbitrary arrest or blacklisting of several thousands (Human Rights Watch, 2004).
Drug users were penalized for possession of sterile syringes, which resulted in an increased risk of syringe sharing and infection with blood-borne viruses. Many drug users were forced into treatment at military style “boot camps.” Existing literature (Human Rights Watch, 2004) and interviews conducted for this study made it evident that the campaign drove numerous drug users into hiding and away from the few existing services that help protect them from HIV. Almost all who were interviewed said that the campaign made things “worse.” A recent study of Thailand’s February
April 2003 crackdown on drugs found that although 70 percent of IDUs reported ceasing heroin use in the campaign’s wake, nearly a third of quitters had switched to smoking methamphetamine or opium. The unintentional outcomes could include an elevated risk of HIV infection among former IDUs (Vongchak et al, 2005).
Discrimination
A study by the Asia Pacific Network of People Living with HIV/AIDS (APN+) found that a quarter of people living with HIV/AIDS in Thailand have reported insult or
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harassment due to their HIV status (APN+, 2004). One activist working with PLWHA groups said, “The situation is improving, but discrimination is still there.” The following remarks by an activist made during the International AIDS Conference in 2004 reflect the level of discrimination faced by drug users (Suwannawong, 2004): “Drug users are still seen as morally weak and bad people. We face stigma and discrimination in society and in health care setting. We experience constant police harassment and ineffective services.”
During interviews some drug users mentioned the discriminatory attitude faced by them even in the health care facilities. One of them said, “The service providers behave as if they are owner of our lives.” “The service providers say, ‘you are a junkie and don’t care about your life. Why should you get ARV?’ ” added another.
Negative attitude of government
During the interviews lack of political will was frequently cited as one of the major challenges that Thailand has to address since it has not responded to HIV/AIDS among IDUs successfully. One NGO activist said, “The Prime Minister’s attitude towards the drug users is one of the reasons why Thailand has not managed the epidemic well.” Another NGO worker confirmed this, “Government does not like drug users.” There is lack of shared understanding within the government and a person from an advocacy organization emphasizes this: “There is no consensus within government on how to address HIV/AIDS among drug users. Some are progressive, but some have quite rigid views.”
Lack of participation
There is no proper partnership between IDUs affected by HIV/AIDS and government. This is despite the fact that the PLWHA groups continue to contribute significantly to Thai response to HIV/AIDS. Even when they are in committees the activists are not able to participate meaningfully in decision making process. According to a former drug user activist, “There is token participation of IDUs in committees dealing with HIV/AIDS.”
Thai Drug Users Network (TDN) was formed in protest against the war on drugs, and they have been very vocal in protecting the rights of drug users. They organized publicly to promote HIV and harm reduction knowledge among their peers. TDN achieved huge success in building alliances and doing advocacy work at national and international levels for drug users’ rights (Nacapiew et al, 2004). But a lot more needs to be achieved.
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Addressing the Challenges
The Ministry of Public Health needs to review the current approaches to methadone treatment and make changes as appropriate. The ministry should also consider the establishment of needle and syringe exchange programs. Peer education approaches should be encouraged. Those working in the drug field need better training. More research is required regarding guidelines on prevention and treatment of HIV positive IDUs. Adequate funding support is needed to demand reduction and HIV/AIDS prevention activities.
According to an activist, “protecting rights, decrease in drug supply, and improvement in drug treatment is required to address the situation.” One researcher recommended that “more effort (is) needed to reach marginalized groups.” An academic mentioned that “government needs to tackle the drug problem in a holistic way, instead of focusing on eradicating any particular drug, which has happened many times before.”
Discussion
Discrimination against people with HIV/AIDS should be condemned because it is a form of cruelty. But it is not just the ethically unacceptable direct impacts that make it cruel. Systematic discrimination against people living with HIV/AIDS undermines prevention and care efforts. In a Caribbean nation, women detected as HIV positive at an antenatal clinic risked deportation, which ultimately led to a dramatic decline in attendance at antenatal clinics. Where laws require pre-marital HIV testing, requests for marriage licenses have declined. (WHO, 1988).
In the discussion of the conceptual framework of this study it was mentioned that the violation of human rights of any population adds to their HIV/AIDS vulnerability, and human rights are being violated due to one’s HIV status as well. The rising incidence of HIV/AIDS among IDUs in Thailand is an example of that. Drug addiction poses unique clinical challenges, which includes the high risk of HIV infection. This obliges governments to tailor their health services to drug users’ needs instead of restricting safe and effective programs in the name of drug prohibition. In Thailand, state imposed barriers to harm reduction programs for IDUs violate their human right to health. A criminal justice approach towards illicit drug use drives the problem underground and makes it even more difficult to treat and prevent practices that spread HIV infection among drug users and their sexual partners. The interviews conducted for this project clearly demonstrate how Thai drug users have been driven away from services available to them. Thailand’s drug policies emphasize criminalization over humane treatment and harm reduction. The Thai government’s use of fear tactics to deter drug use and its failure to take any effective steps to mitigate the health consequences of its war on drugs could be viewed as a failure to protect drug users’ right to highest attainable standard of health, which is in violation of its obligations under the ICESCR (Human Rights Watch, 2004).
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Although Thailand is known as a “best practice” model in the fight against HIV/AIDS, it has failed to implement scientifically proven policies as well as international guidelines to prevent HIV/AIDS among IDUs. Lack of respect for the human rights of IDUs could explain why they are the most underserved group when it comes to AIDS in Thailand. They are discriminated in all aspects of drug control, HIV/AIDS prevention and treatment. IDUs are not viewed as people with rights who have to be treated properly. Moreover, they are blamed, criminalized and victimized. The interviews revealed that drug users face “double discrimination” when they are diagnosed with HIV.
Interviews conducted for the study confirm the discrimination and systematic rights violations faced by IDUs at every level. It also reveals how this is increasing their vulnerability to HIV/AIDS. The policies are repressive, and existing interventions are almost ineffective. Rights violations range from limited prevention budget to the discrimination faced by drug users at health care facilities. They are deprived of human dignity and face stigma in society. The politicians at the top level endorse brutal suppression of drug users. This attitude of the government was repeatedly mentioned as a contributory factor to Thailand’s lag in addressing HIV/AIDS among IDUs. The war on drugs is a clear example of how government wants to apply the punitive approach to deal with the challenge. Rights violations of drug users are not acceptable from the human rights perspective. Moreover, it also does not make sense from the public health point of view. Draconian drug laws, discriminatory policies, and stigmatization of drug users are not compatible with containing the HIV/AIDS epidemic (Open Society Institute, 2004).
Policy that emphasizes drug suppression only needs to be changed. Societal attitudes towards drug users need to be altered, and a more compassionate view should be promoted. It is essential to treat IDUs as “patients” who need support, not as “criminals” who deserve punishment. The challenge of drug use must be analyzed within a broader socio-economic context, and a holistic approach should be taken. It is essential to change laws and policies that prevent drug users from accessing services. Stigma and discrimination that drive drug users underground and undermine prevention efforts must be eliminated. Government should ensure the equal involvement of drug users in developing national AIDS plans and policies and implementing HIV prevention and treatment programs. Better inter-sectoral collaboration should be promoted between drug control on the one hand, and HIV/AIDS prevention and treatment agencies on the other.
Conclusion
The Thai experience shows that even when a country has been successful in controlling HIV/AIDS, this does not guarantee that the interventions have benefited all. There could be inconsistencies in reaching certain groups regarding prevention and treatment efforts.
Economic, social, and political constraints are fuelling injecting drug use in Asia as they also do in other parts of the world. Lessons learned from Thailand are
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particularly important, as injecting drug use is playing a significant role in spreading HIV across Asia. The Thai example shows that HIV prevention efforts need to expand focus beyond commercial sex and address politically challenging risk behaviors like drug use. This study confirms that it is very important to have a non-judgmental attitude while working with IDUs. Sound public health rationale based on scientific evidence should prevail against moralistic arguments. The attitude towards IDUs must not be one of victimization, criminalization or marginalization. Protecting the human rights of IDUs should be central while addressing the HIV/AIDS in their midst.
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