While on my way to the office (a journey of an hour at best), I (try to) do the Sudoko and crossword puzzles in the Jakarta Post. On the rare occasions that I finish both, I often turn to the Classifieds. The section headed Massage; it rarely has less than 20 small ads, offering massage by females and males in about equal quantities.
There used to be one or two that are offering a 'real' massage, but these clearly didn't do much business. The females now are almost all 'models', offering 'fantasy special massage for expats.' with 'sensational females to your hotel' - 'One Look & You're Hooked' - sounds like a real hooker!
The males increasingly describe themselves as 'boys' (although I'm sure the Post would not abet under-age sex - not so difficult since the definition of 'under-age' here is anything but clear!). Several have taken to adding 'See website Utopia' - you don't have to look very long at the result of Googling that keyword to find that it refers to a gay and lesbian site - I doubt it's referring to the Utopia Bathroom Furniture Group.
All good clean fun, I'm sure. But having worked for a large Mid-Western multinational company (Caterpillar), I know how frequently 'wet-behind-the-ears' visiting 'firemen' are sent by such companies on brief visits to this part of the world. What would not play in Peoria can easily happen in Jakarta. First night in the hotel, there's a knock, and they are offered service by someone who looks a lot more attractive than their spouse. But most of these 'kids' (and they're not only men) have never even seen a condom and would have no idea where to find one in Jakarta even if they had. I often wonder how many take back an 'oleh-oleh (souvenir).'
Before they leave the US, they are provided with a medicine box, including meds for diarrhoea and the like. I once asked my boss here (who is now the top man in Caterpillar) if the box included condoms. 'No,' he said. 'Should it?' I asked. 'Probably.' 'Could it?' 'No way' was his answer.
Babé
Saturday, 14 March 2009
Wednesday, 11 March 2009
God screens us evermore
There's been much uninformed discussion regarding Provider-Initiated Testing and Counselling (PITC - or is it PICT?) here. Nobody seems willing to come up with a clear definition of what we mean by this, let alone achieving a consensus on how it might be implemented. But it is abundantly clear (as I have written before) that the current practice of VCT will take more than 25 years to identify those who are infected today.
It's clear as well that most of the HIV testing taking place in hospitals in effectively provider-initiated. A sick patient is admitted; the doctor (finally) suspects an opportunistic infection, the patient admits previous risk behaviour, so the patient gets referred for VCT, perhaps getting counselling, perhaps just having blood taken in the same way as for other tests. So effectively we wait until the person falls sick, often with a badly damaged immune system, before we diagnose the underlying condition.
Several WHO experts have proposed annual universal testing of all people over the age of 15 years for HIV. This is clearly not yet feasible, and thus has often been rejected. But the fact is that we must find a better way to identify the 95% of people infected with HIV here before they fall sick with very nasty conditions.
The military have it easier, A report on the Indonesian armed forces web site recently described mass testing of a Marine unit. Unfortunately the article is peppered with so many military acronyms, it's a little difficult to understand, but this photo helps. The article refers to 'early detection through Blood Screening Tests', but it does appear that it is not 'unlinked-anonymous' - as if that would be possible in the military! It also reports that the 'marines welcomed the blood-letting enthusiastically, proved by the attendance of all ranks of the unit.' Does that mean it was not in fact compulsory? Only obligatory, perhaps.
Let's hope that those diagnosed with HIV remain enthusiastic. The military is now trying to come to grips with HIV, and total isolation inflicted on 16 members of the peacekeeping force returning Cambodia with HIV in the 90's is hopefully a thing of the past. But HIV-positive soldiers are still often removed from active service, generally posted to the medical corps, where they while away their days. But at least they now get treatment.
The Marines say their top brass now give great attention to HIV, including with 'Peer Leader HIV Training'. So far no reports of formation of peer support groups for marines known to be HIV-positive. Maybe we need to take more initiative...
Babé
It's clear as well that most of the HIV testing taking place in hospitals in effectively provider-initiated. A sick patient is admitted; the doctor (finally) suspects an opportunistic infection, the patient admits previous risk behaviour, so the patient gets referred for VCT, perhaps getting counselling, perhaps just having blood taken in the same way as for other tests. So effectively we wait until the person falls sick, often with a badly damaged immune system, before we diagnose the underlying condition.
Several WHO experts have proposed annual universal testing of all people over the age of 15 years for HIV. This is clearly not yet feasible, and thus has often been rejected. But the fact is that we must find a better way to identify the 95% of people infected with HIV here before they fall sick with very nasty conditions.
The military have it easier, A report on the Indonesian armed forces web site recently described mass testing of a Marine unit. Unfortunately the article is peppered with so many military acronyms, it's a little difficult to understand, but this photo helps. The article refers to 'early detection through Blood Screening Tests', but it does appear that it is not 'unlinked-anonymous' - as if that would be possible in the military! It also reports that the 'marines welcomed the blood-letting enthusiastically, proved by the attendance of all ranks of the unit.' Does that mean it was not in fact compulsory? Only obligatory, perhaps.Let's hope that those diagnosed with HIV remain enthusiastic. The military is now trying to come to grips with HIV, and total isolation inflicted on 16 members of the peacekeeping force returning Cambodia with HIV in the 90's is hopefully a thing of the past. But HIV-positive soldiers are still often removed from active service, generally posted to the medical corps, where they while away their days. But at least they now get treatment.
The Marines say their top brass now give great attention to HIV, including with 'Peer Leader HIV Training'. So far no reports of formation of peer support groups for marines known to be HIV-positive. Maybe we need to take more initiative...
Babé
Tuesday, 10 March 2009
First do no harm
There's been a lot of traffic among the chattering classes here as a result of the news that Indonesia was among 13 countries that voted against the inclusion of the words 'harm reduction' in a footnote to the draft Political Declaration from the 52nd Session of the Commission on Narcotics Drugs (CND) in Vienna. As a result, apparently harm reduction is not mentioned in the draft political declaration, not even in a footnote.
This has confused everyone, because as I noted in my recent prisons report, the policy of the Indonesian government (as usual, whoever that is?) strongly supports harm reduction. Indeed, Michel Sidibe, the new Executive Director of UNAIDS in a speech to a donor conference on harm reduction on 28th January, praised Indonesia for its support: "It is extremely heartening that countries with huge populations like Indonesia and China are seriously embracing the harm reduction challenge, at the full scale. Indonesia for example is aiming to ensure that needle and syringe exchange covers 70% of injecting drug users by 2010, up from the baseline of only 10%, and that methadone treatment reaches 30% of users." He must be feeling like the rug has been pulled out from under him!
Ibu Naf, the AIDS Commission Secretary quickly confirmed that this does not reflect a change in policy: "Don't worry. We're still working in accordance with the ruling of the Coordinating Minister of Peoples' Welfare [he's also the chair of the AIDS Commission]. We can continue to use the term, and continue, indeed increase, our efforts as laid out in the national work plan for AIDS."
But activists are wondering if they may still use the term 'harm reduction.' Of course, that raises the question why we use an English term for this. When we translated the Asia Harm Reduction Manual ten years ago, we went to great efforts to achieve a consensus on the Indonesian translation of 'harm reduction'. A very late final agreement meant we had to make many last moment changes only a couple of days before we went to the printers.
Pandu Riono notes that the Coordinating Minister's ruling clearly has not reached all those concerned, particularly in Vienna. We need to do a much better job of communicating, he says. Prof. Wirawan wondered if the Indonesian delegation in Vienna was aware of this ruling, but Ibu Naf confirmed that they knew. But she notes that the CND is primarily made up of law enforcers and diplomats. They would refer to the narcotics law, which does not mention harm reduction.
Actually they are in good company. As the international activists have only just noticed, back last November, Antonio Costa, the head of UN body concerned with drugs (and a UNAIDS co-sponsor), claimed harm reduction has been appropriated by "a vocal minority. This kind of harm reduction can prevent the spread of blood-borne diseases. But it does not solve the underlying problem, and can even perpetuate drug use."
It seems we all need to do a better job of communicating...
Babé
This has confused everyone, because as I noted in my recent prisons report, the policy of the Indonesian government (as usual, whoever that is?) strongly supports harm reduction. Indeed, Michel Sidibe, the new Executive Director of UNAIDS in a speech to a donor conference on harm reduction on 28th January, praised Indonesia for its support: "It is extremely heartening that countries with huge populations like Indonesia and China are seriously embracing the harm reduction challenge, at the full scale. Indonesia for example is aiming to ensure that needle and syringe exchange covers 70% of injecting drug users by 2010, up from the baseline of only 10%, and that methadone treatment reaches 30% of users." He must be feeling like the rug has been pulled out from under him!
Ibu Naf, the AIDS Commission Secretary quickly confirmed that this does not reflect a change in policy: "Don't worry. We're still working in accordance with the ruling of the Coordinating Minister of Peoples' Welfare [he's also the chair of the AIDS Commission]. We can continue to use the term, and continue, indeed increase, our efforts as laid out in the national work plan for AIDS."
But activists are wondering if they may still use the term 'harm reduction.' Of course, that raises the question why we use an English term for this. When we translated the Asia Harm Reduction Manual ten years ago, we went to great efforts to achieve a consensus on the Indonesian translation of 'harm reduction'. A very late final agreement meant we had to make many last moment changes only a couple of days before we went to the printers.
Pandu Riono notes that the Coordinating Minister's ruling clearly has not reached all those concerned, particularly in Vienna. We need to do a much better job of communicating, he says. Prof. Wirawan wondered if the Indonesian delegation in Vienna was aware of this ruling, but Ibu Naf confirmed that they knew. But she notes that the CND is primarily made up of law enforcers and diplomats. They would refer to the narcotics law, which does not mention harm reduction.
Actually they are in good company. As the international activists have only just noticed, back last November, Antonio Costa, the head of UN body concerned with drugs (and a UNAIDS co-sponsor), claimed harm reduction has been appropriated by "a vocal minority. This kind of harm reduction can prevent the spread of blood-borne diseases. But it does not solve the underlying problem, and can even perpetuate drug use."
It seems we all need to do a better job of communicating...
Babé
Monday, 9 March 2009
Truth suppressed by friends is the enemy's readiest weapon
The younger members of the community, or perhaps those with shorter memories, tend to forget the AIDS is only the latest spectre affecting the sex scene. Although the cure for syphilis emerged in the 1940's, at the time I was coming out in the 50's, there was still a huge fear of this venereal disease (VD as we all knew it then). And rightly so. Prior to the arrival of penicillin, syphilis infection was just as much a death sentence as HIV used to be. And in a nasty way. Death from neurosyphilis was said to be pretty awful - I recall a description of someone dying of the pox in one of James Clavell's early books - Tai Pan, I think it was.
Penicillin - and Stonewall (although I was not aware of it then) changed all that, as Gabriel Rotello recounts in Sexual Ecology. But wait! There was another one before AIDS. Yes, herpes. When I was living in Singapore in the early 80's. we heard rumours of this incurable disease. Of course it soon became apparent that it was by no means like the pox, but incurable and recurring really worried us.
I'm reminded of this by the fact that the most common search term on our web site every month is herpes. It ain't gone away, and many think it's often the entry point for HIV infection. We thought we could lick that; treat herpes and we'd reduce HIV incidence. Seemed too easy only a couple of years back when I listened to Connie Celum propose it. So go our dreams!
As I say, AIDS is only the latest in this series. There's a successor girding its loins right now. Is it one of the HTLV family? Sexual and particularly Injecting Ecology mean viruses that previously only mutated once a generation when transmitted from mother-to-child now get the opportunity to mutate and combine continuously as they move directly from bloodstream to bloodstream by shared needles.
Rotello's 1997 book deserves a re-read...
Babé
Penicillin - and Stonewall (although I was not aware of it then) changed all that, as Gabriel Rotello recounts in Sexual Ecology. But wait! There was another one before AIDS. Yes, herpes. When I was living in Singapore in the early 80's. we heard rumours of this incurable disease. Of course it soon became apparent that it was by no means like the pox, but incurable and recurring really worried us.
I'm reminded of this by the fact that the most common search term on our web site every month is herpes. It ain't gone away, and many think it's often the entry point for HIV infection. We thought we could lick that; treat herpes and we'd reduce HIV incidence. Seemed too easy only a couple of years back when I listened to Connie Celum propose it. So go our dreams!
As I say, AIDS is only the latest in this series. There's a successor girding its loins right now. Is it one of the HTLV family? Sexual and particularly Injecting Ecology mean viruses that previously only mutated once a generation when transmitted from mother-to-child now get the opportunity to mutate and combine continuously as they move directly from bloodstream to bloodstream by shared needles.
Rotello's 1997 book deserves a re-read...
Babé
Sunday, 8 March 2009
Law embodies the story of a nation's development
My brain (that box that sits beside my keyboard) reminds me that I planned to write more about laws addressing HIV in Indonesia. As I mentioned, there is no national law on HIV, and this in theory presents a challenge for provincial legislators. This is because a local by-law must refer to a higher level law (those paragraphs starting 'Mindful of' and 'Paying attention to'). Without that higher authority (so I'm informed) they are not fully valid.
It's not only by-laws on HIV that are of questionable validity. But since the central government seems to have no wish to take on the local administrations. and perhaps because many of the national laws appear to be just as unconstituional, nothing is done. Of course, few laws are actually implemented - or even have the required implementing regulations, so everyone is 'fat, dumb and happy,' as one of my mid-West colleagues used to say.
Back to the topic. Another of my more recent colleagues, Bang Syaiful, has carried out a review of 21 of the 22 provincial by-laws on HIV that have so far been enacted. He reports that without exception they place their main emphasis on morals. In doing so, as he says, they encourage stigma and discrimination.
For example, he notes, several prioritise the role of 'faith and piety' in HIV prevention. This despite the mountains of evidence that it is no more effective now than it was almost 25 years ago, when in 1985 the then Minister of Health replied to a journalist's question that "with faith in God, we don't need to worry about contracting AIDS." So much for pious hopes!
The by-laws also refer to 'healthy living' (the NGO I first worked for here in support of people living with the virus had the slogan "healthy living prevents AIDS"; I had quite a job explaining that to my 'clients', for whom this suggested that they had been living unhealthily. But then, who can claim to live a healthy life now?).
The other favourite cliche in the by-laws is 'family solidarity'. As Bang Syaiful notes, they are effectively saying that HIV-infected people are not pious, have no faith (in God), live unhealthy lives and come from broken families. Good excuses?
And as a result, Bang Syaiful notes, a member of the staff of the provincial AIDS Commission in Aceh told him and other journalists firmly and repeatedly that AIDS control in Aceh would in no way include reference to condoms. As he says, surely use of a condom is part of healthy living?
Babé
It's not only by-laws on HIV that are of questionable validity. But since the central government seems to have no wish to take on the local administrations. and perhaps because many of the national laws appear to be just as unconstituional, nothing is done. Of course, few laws are actually implemented - or even have the required implementing regulations, so everyone is 'fat, dumb and happy,' as one of my mid-West colleagues used to say.
Back to the topic. Another of my more recent colleagues, Bang Syaiful, has carried out a review of 21 of the 22 provincial by-laws on HIV that have so far been enacted. He reports that without exception they place their main emphasis on morals. In doing so, as he says, they encourage stigma and discrimination.
For example, he notes, several prioritise the role of 'faith and piety' in HIV prevention. This despite the mountains of evidence that it is no more effective now than it was almost 25 years ago, when in 1985 the then Minister of Health replied to a journalist's question that "with faith in God, we don't need to worry about contracting AIDS." So much for pious hopes!
The by-laws also refer to 'healthy living' (the NGO I first worked for here in support of people living with the virus had the slogan "healthy living prevents AIDS"; I had quite a job explaining that to my 'clients', for whom this suggested that they had been living unhealthily. But then, who can claim to live a healthy life now?).
The other favourite cliche in the by-laws is 'family solidarity'. As Bang Syaiful notes, they are effectively saying that HIV-infected people are not pious, have no faith (in God), live unhealthy lives and come from broken families. Good excuses?
And as a result, Bang Syaiful notes, a member of the staff of the provincial AIDS Commission in Aceh told him and other journalists firmly and repeatedly that AIDS control in Aceh would in no way include reference to condoms. As he says, surely use of a condom is part of healthy living?
Babé
Saturday, 7 March 2009
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
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
Friday, 6 March 2009
Everyone confesses in the abstract
It's been a hectic week! We were asked by UNAIDS here to run three courses on preparing and submitting abstracts to the 9th International Congress on AIDS in Asia and the Pacific (ICAAP). Actually, UNAIDS is only funding; the ICAAP Local Organising Committee (LOC) is responsible for selection of the 150 participants, drawn from seven key groups: drug users; gay, lesbian, bisex and transex (LGBT); women; inter-faith; PLHIV; youth; and sex workers.
Monday and Tuesday we ran the first course. Unfortunately, it quickly became clear that the selection had not been over successful in eliminating candidates who had really had very little of interest or value to present at the Congress. With only four mentors, it was quite a task to help and encourage all the participants to think of an interesting topic and commit it to paper. And of course, few were capable finally to translate the result into English, even more within the 200 word limitation. Google Translate came to our rescue for that; although the result is far from perfect (and sometimes quite amusing!), several of us found it did save time in preparing a first draft.
We heard a lot of stories, some of which I may report here later. Some were indeed only confessions or sharing. But in the end, the majority were able to submit their abstracts on-line (what a change this has made!), and although I suspect some will confuse the reviewers, others will definitely offer a broader community view. I guess if perhaps three quarters of the participants benefit, and half of those have abstracts accepted, it'll have been useful.
The next course, also in Jakarta, is planned for next week, although we still don't have a final list of participants. I'm always amazed at our ability to arrange flights for a large number of people from all over the country at very short notice; pity our poor travel agent!
The rest of the week was spent on prisons; more on that tomorrow...
Babé
Monday and Tuesday we ran the first course. Unfortunately, it quickly became clear that the selection had not been over successful in eliminating candidates who had really had very little of interest or value to present at the Congress. With only four mentors, it was quite a task to help and encourage all the participants to think of an interesting topic and commit it to paper. And of course, few were capable finally to translate the result into English, even more within the 200 word limitation. Google Translate came to our rescue for that; although the result is far from perfect (and sometimes quite amusing!), several of us found it did save time in preparing a first draft.
We heard a lot of stories, some of which I may report here later. Some were indeed only confessions or sharing. But in the end, the majority were able to submit their abstracts on-line (what a change this has made!), and although I suspect some will confuse the reviewers, others will definitely offer a broader community view. I guess if perhaps three quarters of the participants benefit, and half of those have abstracts accepted, it'll have been useful.
The next course, also in Jakarta, is planned for next week, although we still don't have a final list of participants. I'm always amazed at our ability to arrange flights for a large number of people from all over the country at very short notice; pity our poor travel agent!
The rest of the week was spent on prisons; more on that tomorrow...
Babé
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