For Indonesian Drug Users, HIV and Addiction Present a Double Burden

October 2008—Quietly and destructively, starting in the mid-1990s a low-grade form of heroin known as putaw found a thriving market in Indonesia's cities. The sharp increase in injection drug use led to a dramatic rise in HIV/AIDS among users. Today, Indonesia finds itself battling twin epidemics of drug addiction and HIV/AIDS.

For HIV/AIDS advocates and activists in this Southeast Asian archipelago, fighting HIV/AIDS among injection drug users (IDUs) takes place in a world of contradiction. "IDUs are the easiest people to work with—and the most difficult," says Samuel Nugraha, a longtime HIV counselor who is now with the UN Office of Drugs and Crime HIV/AIDS unit in Indonesia and who serves on TREAT Asia's steering committee. "Compared with other vulnerable groups, they have less shame, they're not hidden so it's relatively easy to reach them. But they are addicts, and the addiction itself is often too much to overcome. When it comes to adherence to medication or responsibility, their priority is their addiction."

Dhayan Dirgantara has worked closely with IDUs as an HIV treatment educator, first in Bali and now in Jakarta with the Spiritia Foundation, and like Sam he sees the double burden of his clients' lives. "For IDUs, dealing with HIV isn't just about HIV," he says. "To get healthy, they have to go to rehab, change their habits, change their environment, change their friends—it's so much harder than just taking ARVs [antiretrovirals]."

The number of IDUs in need of HIV treatment is daunting. In 1995, barely one percent of Indonesia's HIV cases were attributed to injection drug use; today, drug-related transmission accounts for almost half of its HIV caseload, according to the Ministry of Health.

For many years, ARV treatment for IDUs was withheld because of their drug dependence—IDUs who wanted medication had to have been clean for at least six months. In the minds of policy makers, Sam explains, "the issue was treatment adherence. If you're still using drugs, you'll never make ARV treatment a priority. But these people need to understand the concept of harm reduction: as long as you can be on treatment and access services, that will reduce the harm. A lot of people cannot accept that concept."

Harm reduction in Indonesia has gained support on the national level, but local governments often resist the idea. "Needle exchange programs can be shut down by police, and methadone clinics are under surveillance by police officers in certain areas," says Dhayan. "It happens quite a lot."

While addiction treatment efforts in Indonesia are also growing, they are often undermined by contradiction and confusion, according to Dhayan and Sam—both former members of TREAT Asia's Asian Community for AIDS Treatment and Advocacy (ACATA). These contradictions, they say, are fueled by the competing viewpoints of international donors who support a variety of clinics advancing different treatment modalities. "Different donors have different agendas," explains Sam, "so there is competition."

"For IDUs, the only effective way is to provide options," he continues. "You have methadone, you have clean syringes, you have ARV treatment, you have rehab, you have drop-in centers. "People have started losing faith in rehab over the past couple of years because they thought putting their kids into rehab would be like putting their cars into the garage—they wanted them to come out fixed. But the rate of relapse is really high regardless of the approach. A single methodology will be successful for only about eight percent of addicts. If one approach doesn't work, maybe they need something different, but many projects don't offer a comprehensive set of approaches."

Dhayan agrees, pointing out that different NGO-funded drug treatment projects "don't even share information or data with each other." The solution, they both agree, is strong central coordination. "But it's hard to get everyone on the same page," Dhayan notes. "The government cannot impose its ideas on funders because they need their help to save lives."

Even so, nationwide efforts to slow the spread of illegal drugs in Indonesia—and limit the spread of HIV among IDUs—have begun to bear fruit. Seven years ago there was little talk or action about drugs, says Dhayan, but between Indonesia's tough drug laws and the efforts of its AIDS control programs, current projections show the epidemic easing away from IDUs by 2010.

Still, the two advocates admit that they can be discouraged. They're both young, but they've been fighting HIV/AIDS for years and the progress can seem achingly slow. Nonetheless, they remain commited. "There's always hope that we can make a small advance," says Dhayan. "The willingness is there, the money is there, but the challenge is how we get it together. We must work together."