Sunday, 31 July 2011

Win us to our harm

Are we winning the 'war on drugs'? "New HIV infections among drug addicts [in Indonesia] have dropped significantly in recent years," Ibu Nafsiah (National AIDS Commission secretary) is quoted as saying in an article (Indonesia's Uphill Fight Against Aids) in the Jakarta Globe. Ibu Naf partly puts this down to the success of the authorities in cracking down on heroin use, as well as the distribution of sterile needles, and increased use of methadone.

Let's start by examining the evidence for Ibu Naf's statement. The data from the MoH seems to support it.

However, we should bear in mind that less than 20% of the almost 400,000 people thought to be living with HIV in Indonesia actually know that they are infected. And reasonably reliable data is available only for the 26,483 who have been reported as diagnosed with AIDS. Can this be considered a representative sample from which we can draw accurate conclusions?

On the other hand, there is anecdotal evidence to support the statement. At a recent meeting Ibu Naf noted that outreach workers were finding it very difficult to find additional injecting drug users.  Yes, it is a 'hidden epidemic', but there has been considerable success in reaching these users in many parts of Java.

Further. we frequently hear that drug users are abandoning injected heroin. Some may indeed be migrating to methadone, although only 2548 clients are accessing this service according to the latest MoH report, More are probably using buprenorphine, which is reported to be quite freely available in many places.

But there is fear that more are probably switching to sabu (as crystal meth is known here). This may reduce the risk of HIV infection, but greatly increases the risk of an addled brain, and there is of course no effective substitution therapy for meth addicts.

So, although the evidence base may be limited, it does seem reasonable to infer less people are injecting heroin. But our ill-fated war on drugs just may be causing more collateral damage.


Saturday, 30 July 2011

Good women standing shoulder to shoulder

Unusually, the Jakarta Post on Wednesday published an opinion article on its front page. Headlined "Taking charge in a transition", it was by Sri Mulyani Indrawati, Managing Director of the World Bank Group and a former finance minister of Indonesia. For some reason (probably copywrong), this article is not accessible on the Post's web site, but I managed to find it at its original location, under the headline "Winning the Transition."

Although having no direct connection with HIV, I commend this article to you for its clarity and simple language - and because I'm sure that Ibu Sri does have an indirect impact on HIV here, an impact which hopefully will increase.

Indonesia is lucky in having many women like Ibu Sri. Another closer to home is our Minister of Health, Ibu Endang R Sedyaningsih. An ex-AIDS activist, she's now attempting the Herculean task of sorting out the culture of her ministry, sullied as it is by alleged corruption by several of her predecessors (not all female leaders can be trusted!).

There's another women making an impact, Ibu Sri Pandam Pulungsih. This Ibu Sri was previously a very caring Medial Services Director at the Infectious Diseases Hospital in Jakarta, and is now a hugely respected WHO manager, working on their response to HIV in Jakarta.

We are lucky to have so many talented and dedicated women in Indonesia. Standing shoulder to shoulder, they give us hope for the future.


Monday, 25 July 2011

Woman, hard beset

Recent research among inmates in Indonesian prisons has raised a worrying red flag. While HIV prevalence among male inmates was a little over 1%, the figure was 6% among female inmates. The report does not attempt to explain this difference, although it should be noted that random selection of study prisons turned out not to include any of the narcotics prisons, where the rate among men would be expected to be much higher. A further study of these prisons is planned. But at least in theory. these results should reflect the situation in Indonesian prisons in general. Clearly we've got to strive to reduce this high rate of infection among women in prison. Ideas?

Once again, this study does not provide a picture of the incidence of HIV infection in prisons. The conventional wisdom is that HIV is spreading uncontrolled in Indonesian prisons. Redefining AIDS in Asia, the 2008 report by the Commission on AIDS in Asia, notes that "men who had recently arrived in jail were only a quarter as likely to be HIV-infected compared with other prisoners," citing a Health Ministry surveillance report as the source of this data. Perhaps this was the case then, but my gut tells me that it's not true today. Yes, there is still some drug injecting in prisons, and yes there's certainly some unprotected sex occurring.  But the study reports only 0.7% of male respondents and no female respondents had injected while in prison. And given that almost half of both sets of respondents had served less than one year of their current sentence, it does seem unlikely that a significant number had been infected after incarceration. What it does tell us is that we really do need a follow-up study to give us a better picture of the real risks for HIV infection in Indonesian prisons.

There is a good summary of the results available for download, together with the full report.