Wednesday, 3 August 2011

Released the prisoned spirit

Who should be responsible for prisoners with HIV and/or TB, or with drug use problems, after their release from prison? That question has resulted in some heated discussions among my colleagues. One makes the reasonable point that released prisoners are no longer the concern of the corrections service. After release, they are the same as any other members of the community, and should therefore be served by community health centres, hospitals, social welfare services and support groups in the same way as anyone else,

But released prisoners surely do have some special needs. One of my colleagues who spent two drug-use terms in the Kerobokan prison ten years or so back recounts his experience. Before release, he knew exactly what he would do after he got out. But once he actually stood outside the prison gate, his mind became blank. Absent any real alternative, he wandered back to his old haunts, and immediately picked up where he left off - except that he had now lost his tolerance for heroin, and was lucky not to overdose. It wasn't long before he was back in his cell.

There have been a number of studies worldwide showing that adherence to antiretroviral therapy (ART) falls drastically among prisoners after release - if indeed they don't drop out. The same is true for those still taking anti-TB therapy. This is not surprising. Therapy in prison is often effectively directly observed, and adherence is better than that among almost any other group of people taking medications. Enforced discipline is developed. But once outside, they lose this support; the discipline is lost. They have to find a referral clinic, visit it regularly and develop their own ways to ensure that they take their medications on time. Most don't.

Those with a drug problem face even greater challenges. If they've been on methadone in prison, they must find the nearest clinic - surely much more difficult to access than the service in the prison. Chances are that without support they won't bother; just like my colleague, they'll return to their old friends, and the sugesti (craving) will immediately take over. And what about the increasing number addicted to meth?

The parole service in the prison does have the task of attempting to identify such needs before release, and referring the prisoner to appropriate services after they get out. Everybody seems to agree that responsibility after release passes to the Social Welfare Service and/or to NGOs. But the former seems to have very limited if any resources for this, while there are few NGOs working in this field, and fewer still are funded for the work. And it is rare for either to actually work with prisoners before release to ensure continuity.

I'm told that recidivism is low in Indonesia, although probably higher among drug offenders. So this may (or may not) counter the argument that more should be done to reduce re-offense. But surely there is a human rights imperative to help ex-prisoners reintegrate into the community, including ensuring their continued access to appropriate health care. Whose job is it?


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.


Sunday, 20 December 2009

Health and wealth have missed me

Some good news for those in prison. The Jakarta Post reports on the signing of a memorandum of understanding (MoU) by the Minister of Justice/Human Rights and the Minister of Health. This makes prison inmates eligible for the government-run health insurance scheme for poor people, known as Jamkesmas.

In the past, it has frequently been difficult for prison staff to arrange free health care for inmates, since they often do not have valid identity cards and have difficulty proving that they are poor (within the meaning of the act). Now, all that will be needed to access hospital services is a recommendation from the prison warden.

Except for "inmates assumed to be rich, like drug abusers," the Post reports the Minister of Justice/Human Rights as saying. Since something like half of prisoners are there for drug offences, this would seem to place a severe limit on eligibility. A similar limitation previously in place in Jakarta excluded the inmates of the Cipinang Narcotics Penitentiary from accessing the free health care which at least in theory was available to other inmates.

The Director-general of Prisons appears to be unaware of this. He is quoted as noting that 90% of prisoners will be included in the scheme. Let's hope the wardens ignore the oft-held assumption that all drug users must be rich to afford their habit.


Saturday, 12 December 2009

Isolated with no before or after

A disturbing interview on NPR yesterday (Questions On Public-Private Prisons For Immigrants) confirmed my impression that the prison system in Indonesia could teach some others a thing or two. We heard about inhumane treatment in a prison in Texas (A Death in Texas). This prison in a remote part of the USA, with 3,700 inmates, has no infirmary! An epileptic prisoner was denied his medication, and locked up in an isolation cell (the "hole"} when he fell sick, because there was nowhere else to put him. He died in the cell.

Read the article. Listen to the program. And thank God that Indonesia is more enlightened.


Friday, 11 December 2009

All the little birds go tweet, tweet, tweet

Although I've been using the internet since 1995, I'm really not into social networking. Perhaps because I'm basically anti-social? I've never been good at old-fashioned chatting, let alone chatting on the internet. I've on occasion set up both Yahoo Messenger and Facebook accounts, but shut them down within minutes. And tweeting? They're all just not me!

But there's no doubt that Indonesians are really into these forms of social networking. It seems that almost everyone now has a Blackberry. A recent report on the Kompas Daily web site (Penetrasi Internet di Indonesia Naik Dua Kali Lipat) says that 17% of Indonesians are accessing the internet, with a rise of 700% in numbers of Facebook users and 3,700% in Twitter users over the last year. And it notes that most of the users are in the 15-39 year age range.

So what? Well, that age range is clearly that most affected by HIV. But many of those involved with AIDS planning are a bit (or in some cases, more than a bit!) older than that, and probably feel less than comfortable with these new developments.

Some examples: the Spiritia web site hot line received 109 anonymous questions last month. Since we started it in May last year, the Spiritia web site forum has attracted 427 members, who have posted close to 7000 messages. I guess Spiritia staff respond to an average of 3 SMS questions every day. And Spiritia is clearly not alone. An increasing number of NGOs are employing cyber-outreach, particularly for difficult-to-reach gays. Yet it sometimes seems that few program managers are aware of all this activity.

There is an increasing literature regarding AIDS outreach via SMS in Africa. Of course, internet coverage in Africa is currently much lower than in Indonesia. I would suspect there is a great opportunity for develop some cutting-edge ideas using these new tools. Perhaps it's time I re-established my Facebook page...