Pubdate: Sat, 19 Aug 2006
Source: Sydney Morning Herald (Australia)
Copyright: 2006 The Sydney Morning Herald
Contact:  http://www.smh.com.au/
Details: http://www.mapinc.org/media/441
Author: Ruth Pollard, Health Reporter in Toronto
Bookmark: http://www.mapinc.org/hr.htm (Harm Reduction)
Bookmark: http://www.mapinc.org/find?136 (Methadone)
Bookmark: http://www.mapinc.org/rehab.htm (Treatment)

HIV AND INDONESIA: NATION SITS ON A VOLCANO

THEY are in many ways a throwback to their parents' era, often either 
saving themselves until marriage or having few sexual partners.

But whereas Indonesia's teenagers may be shunning their Western 
peers' interest in sex, they are taking up drug use with an 
increasing passion, from Jakarta rich kids to those in the poorer 
outlying areas across Java, Kalimantan and South Sulawesi.

It is injecting drug use that is fuelling Indonesia's HIV epidemic, 
and new modelling obtained by the Herald suggests that if prevention 
efforts are not stepped up, the country could be facing 2 million HIV 
infections by 2025.

More than 145,000 of those would be in Papua, representing 7 per cent 
of the 2.3 million residents of the troubled province, where HIV, 
unlike in the rest of the vast Muslim nation, is transmitted by sex.

As Indonesia deals with the scale of the effects of the tsunami, the 
recent Yogyakarta earthquake and the threat of terrorism, more and 
more families are facing an added burden of caring for HIV-positive loved ones.

And as Indonesia attempts to quash the corruption endemic in its 
government agencies and push through policies such as the abolition 
of longstanding fuel subsidies and deal with the poor health of much 
of its population, experts fear HIV could stop the nation's progress 
in its tracks.

The United Nations AIDS Program estimates that there are at least 
170,000 people living with HIV or AIDS across Indonesia, although the 
recent Australian modelling indicates a much higher infection rate.

By 2025, HIV prevalence will have climbed to 40 per cent in injecting 
drug users, and the flimsy barrier between users and the general 
population will have been well and truly broken, according to figures 
from Australia's National Centre in HIV Epidemiology and Clinical 
Research, and the National Centre in HIV Social Research, produced for AusAID.

Over the same period, HIV infection among the country's 270,000 
prostitutes will rise from 4 per cent to 23 per cent. Prevalence 
among their 7-10 million clients will rise from 0.5 per cent to 3 per 
cent, forming "a bridge to wives and girlfriends in the general 
population", the researchers predicted.

The impact on Papua will be catastrophic, with an estimated 85,000 
deaths expected by 2025, mostly among people aged 14-49.

In the rest of Indonesia, which has a population of about 245 
million, more than 300,000 will have died by 2010 and 1.5 million by 
2025, placing untold pressure on the health sector as large numbers 
of people require treatment and hospital admission. Nearly a third of 
all hospital beds will be filled by people with AIDS.

There is a growing awareness in Indonesia that HIV will have an 
impact on the country's social and economic development, yet a mass 
mobilisation of government resources remains a long way off.

It is also acknowledged that if a widespread, comprehensive 
prevention and treatment program was enacted now, HIV prevalence 
rates would drop immediately and a large-scale, generalised epidemic 
could be averted.

"There are some needle and syringe programs but not nearly enough - 
they are just a drop in the bucket in the face of these staggering 
numbers," says Heather Worth, one of the researchers and deputy 
director of the National Centre in HIV Social Research at the 
University of NSW.

"Getting donor money into Indonesia is not the problem. It is 
changing public and political opinion on the issue of injecting drug 
use that is the challenge."

Added to that, she says, the severe social dislocation in Papua, 
fuelled by feelings of dispossession among indigenous Papuans, was 
feeding the HIV epidemic.

Australia is a large donor to Indonesia. A five-year, $37 million 
project funded by AusAID is due to be completed next year, involving 
work with Indonesia's National AIDS Commission.

Harm reduction - involving the provision of clean needles and 
syringes to injecting drug users, as well as treatment and support 
programs - is an urgent priority, says Tim Mackay, the Australian 
team leader of the AusAID-funded Indonesia HIV/AIDS Prevention and 
Care Project.

Despite small improvements, the number of people taking HIV 
treatments is still scandalously low - there are only 5000 people on 
antiretroviral treatment, including 80 in Papua.

The head of program and policy at Indonesia's National AIDS 
Commission, Muhammed Nasser, says the Indonesian Government is not 
moving quickly enough.

"Around 50 to 60 per cent of all new HIV cases are through injecting 
drug use, mostly involving 22- to 27-year-olds, but the national 
response is just too slow," Dr Nasser says.

"There is inadequate legislation - we need to reform the health and 
narcotic laws so we can intensify our prevention efforts and improve 
treatment and care." The commission aims to have needle and syringe 
programs in 100 districts and cities by 2007, as well as an extensive 
network of methadone programs in hospitals and health centres.

"Under current laws, drug users are arrested and then there is no 
chance to give them access to clean needles or methadone treatment," 
Dr Nasser says.

That could change on September 1, when the National AIDS Commission, 
the National Narcotics Control Board and the police are expected to 
sign a memorandum of understanding regarding injecting drug use and 
harm reduction - a step made easier by the fact that Indonesia's 
police chief now reports directly to the President, Susilo Bambang 
Yudhoyono, and not to the military.

Anak Agung Gede Hartawan is the director of the methadone program at 
Bali's Kerobokan jail, where 56 per cent of prisoners who inject 
drugs are HIV-positive and where sharing needles and tattooing are 
common practices.

Dr Hartawan says Indonesia's tough drug laws mean prisons are filled 
with young men charged with possession of a small amount of drugs.

He told the 16th International Conference on AIDS in Toronto this 
week that the AIDS epidemic inside jails would soon move into the 
general population. "Reports of deaths of prisoners are growing, 
indicating growing numbers of HIV infections," he said, describing 
jails as "AIDS factories".

But the methadone programs operate within a prison system that spends 
less than 50 US cents per prisoner on health care annually, leaving 
many without help.

Jane Wilson, the country co-ordinator for UNAIDS in Indonesia, 
describes the population of injecting drug users as "very, very 
young" and often from middle-class or wealthy families.

Dr Wilson says the current figures on HIV infection are "just the tip 
of the iceberg", with cities such as Jakarta reporting rates of 
infection up to eight times the national average.

"Drug use is prevalent across all social classes, it is very much the 
norm, while behavioural surveillance surveys indicate the number of 
sexually active teenagers is absolutely minuscule."

Frika Chia Iskander is the new face of the HIV epidemic - a young 
Asian woman. She is 24, and has been HIV-positive for six years.

She is not hopeful the Government will act fast enough to avert an 
African-style HIV catastrophe.

Instead, she laments, it will wait until it is a disaster.

"It is really important not just to see AIDS as a problem of Africa - 
if we only see Africa and forget about Asia we will not learn from 
the mistakes ... and the epidemic will remain hidden until it is too late."
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MAP posted-by: Beth Wehrman