Things you do not hope happen

Yesterday, I mentioned that the second half of my week was taken up with prisons. Actually, I was lucky enough to attend a workshop on scaling up the response to HIV in prisons in Java and Bali. The workshop was organized by the Department of Justice and Human Rights (Depkumham in its Indonesian acronym; a combination which often causes a snigger, but in my experience makes good sense). Invited were some 50 prison governors plus the heads of the provincial offices in charge of prisons in each of the seven provinces of Java and Bali.

The meeting started with a review of the Master Plan for Strengthening and Providing Clinical Services Related to HIV and AIDS in Prisons 2007-2010. This provides for 22 prisons in Java and Bali to offer basic HIV counselling and treatment, while a further seven will provide comprehensive HIV services, including provision of antiretroviral therapy, effectively to become provincial centres of excellence on treatment of HIV-infected detainees. And a further eight prisons will also provide methadone, adding to the existing eight, with intention to further increase this number.

I find the provision of methadone in prisons interesting. It seems to me that the only justification for this 'harm reduction' activity is to reduce the risk of HIV infection from sharing needles. Thus it is an implicit admission that this continues to occur in the prisons - a remarkably refreshing fact in my view.

On the other hand, as I pointed out (to deathly silence!), there has been little if any progress on provision of condoms in the prisons, even though this is 'blessed' by the national strategy. At one prison I visited some time back, the warden (with a very straight face) responded to a question on condoms by saying that there were no women detainees, so there was no need for condoms (I really can't believe he was really that naive!).

Nevertheless, I find it amazing and cause from hope that the prison governors are clearly convinced of the need to respond to HIV, including providing methadone (I wonder how many countries have moved that far?).

The dark side of all this is the admitted high rate of mortality in the prisons, rising to 893 deaths in custody in 2007. It seems there has been a slight improvement in 2008, but perhaps what was heartening was that everyone seemed to accept that this rate was totally unacceptable, and must be addressed - hence the Master Plan.

Adding to this is the chronic overcrowding in these prisons. We were told that nationally, occupancy in the prisons is 30-40% over the 88,000 capacity. But this average figure conceals the reality in Java. For example, the juvenile prison in Tangerang has around 950 kids aged 15-18 years incarcerated (almost all for drug offences), against a capacity of less than 250. I heard similar stories about many other prisons, including those for women. Prisoners sleeping eight to a room intended for three. People sleeping in front of the bathroom door. One can only imagine what will happen when TB hits them.

And there also lies a challenge. Sadly this AusAID-supported scaling-up is limited to HIV; there was little talk of integration of TB services. A number of prisons have apparently been provided with lab equipment (including microscopes) by the Global Fund, but there has been no authorization of lab technicians, so the equipment remains in the boxes. Some have tried to make arrangements for technicians from the local community health centre to moonlight in the prison clinic, but this doesn't seem to be a feasible solution.

But I came away heartened. The prison governors are beginning to understand the challenges and seemed determined to come to grips with them. The perplexity that we met even a year ago, the feeling of helplessness in the face of all the problems of HIV and drugs, seems to be clearing. And although the prisons directorate must take much of the kudos, there is no doubt that Dr. Nurlan's team in the AusAID-funded HIV Cooperation Program for Indonesia have quietly stimulated and nurtured this response, and also deserve to take a good part of the credit.

Babé