Drug abuse spurs spread of AIDS in Indonesia

Widespread drug abuse has spurred not only social ills in Indonesia, but also has escalated the spread of AIDS in the country. AIDS activist Chris W. Green has written the following three articles in conjunction with World AIDS Day on Dec. 1.

JAKARTA (JP): The future of AIDS in Indonesia is tied up with drug use. That was the headline of my World AIDS Day article in The Jakarta Post this time last year. Sadly, the last few months have proved this prophecy correct. Almost 80 percent of new cases of HIV/AIDS identified over the last few months have resulted from injecting drug use.

The theme for World AIDS Day 2000 is men. This is recognized in the slogan AIDS: Men Make a Difference. Some may ask what has this to do with drugs?

Sharing needles while injecting drugs is the most efficient way of transmitting HIV, the virus which causes AIDS. If one person in a needle-sharing group of injecting drug users (IDUs) becomes infected with HIV, the rest will likely become infected within weeks. And once the HIV prevalence among any population of IDUs exceeds 10 percent, experience in many parts of the world has shown that this can rise to 50 percent, 70 percent or even higher within one to two years -- unless very effective action is taken to stem this.

Not only does the virus spread among IDUs who share needles, but it will spread from them to their sexual partners (including sex workers) and onward to their children during birth or breastfeeding. Thus an epidemic of HIV among IDUs can also quickly spread into the general population.

We can only guess at the current situation regarding HIV among IDUs in Indonesia. One recent estimate is that there are 3.1 million drug users in the country, but probably a large proportion of these are using "soft" drugs such as marijuana.

Perhaps half are using the two main injected drugs, heroin (putauw) or methamphetamine (shabu-shabu). Surveys around the country have shown that 70 percent of such "hard" drug users are injecting -- and the vast majority of these are sharing needles, at least occasionally.

Thus a conservative estimate would suggest perhaps as many as one million drug users in Indonesia are currently at risk of HIV infection -- and at even greater risk of infection with hepatitis C, which is almost as nasty as HIV.

What little data we have on HIV infection rates among IDUs in Indonesia suggest that the 10 percent threshold has been breached, certainly in Jakarta.

Here, at least two surveys have indicated HIV infection rates among IDUs of 15 percent or more. If this reflects a wider situation, that could mean that at least 10 percent of the one million IDUs are infected with HIV -- a total of 100,000. And not only is prevalence rising; so is the number of IDUs. It is not unlikely that by this time next year, we will be looking at 30 percent HIV prevalence among 1.5 million IDUs, i.e. close to half a million infections. That is more than a disaster; it is a threat to the whole future of the country.

What other data do we have to support this dire estimate? The reports of HIV infection submitted to the Department of Health are known to represent the very tip of the iceberg -- the total number of cases reported at the end of October was 1,521 -- against an official UN estimate of 52,000 cases. Thus a rise in reported cases of HIV infection due to injecting drug use from six in June 1999 to 212 this October, while not appearing to be too large, represents a very frightening situation.

In this case, do men make a difference, as the slogan says? Indeed they do, in a number of ways. First, although we know that the number of women injecting drugs is consistently underestimated -- they are a hidden group within an already hidden population -- there is little doubt that in general many more men inject drugs than women.

It is often men who introduce women to injecting. And as with many activities in life, women are served after the men are satisfied -- which in the case of injecting drug use means that women get to use the syringe after the men have had their fill, increasing the risk that it will be contaminated with dangerous viruses. In this way, it is men who are putting women at greater risk. Further, male drug users are much more likely to have noninjecting sexual partners -- and are even less likely than other men to use condoms.

If the threat is becoming clearer, the solution has long been clear. We need to bring the problem into the open, not drive it underground through law enforcement activities. If the result of such activities is to put drug users in jail, the result is even worse, since drugs are widely available in prison and HIV prevalence is probably even higher, while a lack of clean needles increases the risk. We need to find effective approaches to reducing the harmful effects of drug use, being aware that few drug users are willing or able to stop their habit in the short term.

We need to involve current and former drug users in the solution -- they understand the problem much better than most of us who talk knowledgeably about drug use.

We have a very brief window of opportunity to start taking real action. If we neglect this, the AIDS-related problems resulting from drug use will take years and huge sums of money to address.