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Injecting more than drugs

Recovering drug addict, Jakarta Indonesia.
Off the needle - recovering IDU enrolled on methadone programme (Obinna Anyadike/IRIN)

For heroin addicts in the Indonesian capital, Jakarta, the cheapest way to get a "fix" is entirely legal and provided by the government.

Five public clinics in the city supply methadone, a synthetic opiate recommended by the World Health Organisation, which recovering drug users take daily to help wean them off "putau" - cheap, readily available low-grade heroin. The government also provides free needles and syringes in 30 health centres as the other leg of its "harm-reduction" strategy.

It has taken political bravery for the government to embrace the new drug policy; local communities generally regard addicts as street criminals and conservative politicians complain that the strategy encourages narcotics use, which has exploded over the past decade.

But the reality is that the authorities may be responding too late and too haphazardly. According to a sentinel survey, half of all injecting drug users (IDUs) in Jakarta are HIV-positive, and modelling suggests that by the end of the decade they will account for over 100,000 infections in the city of eight million.

Sex and needles

IDUs sharing needles rapidly spreads infection, which then slips into the wider population via unprotected sex. "Even where the numbers of people injecting drugs are relatively small, their contribution to the overall HIV epidemic in a country can be considerable," said a 2005 report by the Monitoring AIDS Pandemic Network (MAP), a group of internationally recognised experts.

Putau took hold in Indonesia in the late 1990s, coinciding with the shock of the Asian financial crisis and the political upheaval when the autocratic regime of Suharto fell. Typically, putau is injected, the most cost-effective way of getting high; but when needles are shared, it is also an extremely efficient way of transmitting HIV.

"The truth is that it is very easy to buy putau; what's difficult is to find needles," explained Ade Suryana, of the Indonesian Drug Users Solidarity Association (IDUSA). It is common for IDUs to hide their injecting equipment from the police, usually in parks or public toilets, but in a spot known to other users in the neighbourhood.

IDUs are well aware of the risk of using contaminated needles; but "HIV is just one of the many potential problems facing drug injectors, and it is by no means the most immediate," the MAP report noted. In the daily struggle to stay high, overdosing, suicide and gangrene are far more pressing concerns.

A new life

A two-storey community clinic in Pusat, central Jakarta, provides a daily dose of methadone to roughly 115 recovering addicts who trickle in throughout the day. It's a straightforward procedure: pay a standard charge of 50 US cents at one window; take the receipt to another, collect a plastic beaker with a bright red, bitter-tasting solution, and wash it down with water.

By comparison, putau costs US$5 a fix, and the average addict has to shoot up three times a day. "You spend a lot of time looking for the money to get high," commented one young man in a baseball cap, relaxed and waiting his turn to go to the window. He said he first started using putau when he was 15 years old.

Indonesia's HIV epidemic is highly concentrated. The national prevalence among adults is 0.2 percent, but at the Pusat clinic over 80 percent of the IDUs who took HIV tests this year were positive; IDUSA found similar rates among the groups it works with. Indonesia could have as many as three million drug users, or that figure could be just the tip of the problem, according to a report by the National Narcotics Board.

Most of the men and women visiting the Pusat clinic are unemployed or petty traders in their early 20s, who started shooting up at high school. On the other hand, Roy, 29, is a part-time data programme manager. He was hooked on putau for 13 years, and acknowledged that sharing needles for that length of time almost guaranteed his HIV-positive status. What he does not yet know is whether his wife is also infected.


Photo: Obinna Anyadike/IRIN
Roy, 29, used putau for 13 years

"Harm-reduction programmes have multiplied since 2003, but we are late by several years," said IDUSA's Suryana. Progress is also being frustrated by a chronic lack of cooperation by the police: although the ministry of health endorses free needles, the police regard carrying injecting equipment as sufficient pretext for arrest.

"The top brass all know about harm-reduction programmes, but when you get down to the cops in the field, it's corruption. None of the police who work in the narcotics division are poor," said Suryana, a former putau dealer and user, now clean for seven years.

"We don't want to be treated like criminals, because we are actually the victims of the drug policy of the government, which criminalises the use of drugs," complained the young man in the baseball cap.

Harassing drug users on the streets inevitably limits the reach of needle exchange programmes, while jailing addicts merely quickens the spread of HIV infection. After IDUs and sex workers, prisoners are the group at highest risk in Indonesia.

Prison blues

The new wing of Cipinang prison, built in 2003, is supposedly a model facility. The vast majority of its 2,000 inmates are drug users and, in theory, the prison authorities provide both methadone and antiretroviral (ARV) drugs, which can help prolong the lives of people living with the HI virus. In reality, the officials promote "D5" - a Chinese herbal remedy they claim is far more efficacious.

"This medicine is not only good for HIV, but for other types of diseases," said Frans Elias Nico, head of the methadone and ARV therapy programmes. Since the beginning of the year D5 has been tested on 10 volunteer inmates, all formerly IDUs, who told IRIN/PlusNews they felt much better. Nico said prison management would soon be approaching the government with the results.

According to the National AIDS Commission (NAC), 56 percent of prisoners in one Indonesian jail were found to be HIV-positive. In Cipinang, 38 inmates died in the first six months of this year, said Nico, mostly due to AIDS-related illnesses. In the tiny prison clinic, all five beds were occupied by emaciated men, yet only a total of eight prisoners are on ARVs.

''You spend a lot of time looking for the money to get high''

A crackdown on drug crimes in Indonesia in the late 90s led to a five-fold increase in the number of drug-related cases in prison, according to the MAP report. "Subsequently, in the capital's overcrowded jails, HIV prevalence started to rise two years later, from zero in 1999 to 25 percent in 2002."

The prison authorities refuse to provide clean needles or condoms on the grounds that this would encourage illegal behaviour, detrimental to discipline. Nico even insisted there were no drugs in his jail, despite the fact that all analysts stress the ease of access to narcotics on the inside, and the life-threatening risks of needle sharing.

"Drug use is much more relevant to the spread of AIDS in Asia than in Africa," said NAC secretary Nafsiah Mboi. "But treatment for drug dependency is very weak and very limited in Indonesia. We have to scale up very fast ... 52 percent of IDUs are young, and drug use is increasing."

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This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions

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