Rapid spread of HIV among drug users calls for action

Joyce Djaelani Gordon, Chairperson, Kita Foundation, Addiction Treatment and Community, Recovery Center in West Java, Jakarta

The latest, most up-to-date report on the spread of HIV in Asia released by the Monitoring the AIDS Pandemic (MAP) Network shows how Indonesia, Iran, Japan, Nepal and Vietnam have registered a marked increases in HIV infection.

Two years ago, these countries reported a fairly slow spread of Human Immunodeficiency Virus (HIV).

The report, which was released on the eve of the 6th International Congress on AIDS in Asia and the Pacific (ICAAP) in Melbourne last month, highlights specific examples of the rapid HIV spread among specific sub-populations, such as among injecting drug users (IDUs) in Indonesia, where HIV levels have increased from around 15 percent in 1999 to 40 percent in 2000.

The increase of HIV prevalence among IDUs in Vietnam and Nepal have also been similarly dramatic in recent years.

According to the MAP Network, the interface between sexual and drug-using behavior indicates that the spread of HIV between population groups is more widespread than previously thought. "Most drug users are sexually active men. Many have steady partners, are sex work clients and some finance their drug habit by selling sex. A recent phenomenon is that many sex workers are turning to intravenous drugs." Translated into simple terms, reducing harm among IDUs will rapidly reduce HIV among the general population.

In a special session titled "Scaling Up Harm Reduction in Asia", which was co-sponsored by the World Health Organization (WHO) and the Asian Harm Reduction Network during the AIDS Congress in Melbourne, WHO's director Gundo Weiler emphasized the role of harm reduction as a crucial element of comprehensive HIV/AIDS strategies.

It is clear that WHO is now advocating harm reduction strategies in the region. Therefore, the Indonesian government is likely to follow future regional guidelines on this issue and prepare to undertake harm reduction work with IDUs. The drug-for- drug strategy the government is now slating is a simple beginning to more comprehensive harm reduction strategies.

The dramatic increase of HIV infection among IDUs in Indonesia is worrying. We are not fully prepared to face an epidemic when we are already burdened with various other issues. That is why effective and proven prevention strategies should be carried out immediately.

Yet, although support to move in this direction is beginning to increase, there are still some who are against these strategies, either because they are misinformed, do not understand addiction, or because they are even less aware about HIV, drug-related harm and how this affects the country on a national scale.

In confronting drug problems, there are groups who can be categorized as "supply reductionists" -- those who believe that focus should be given to finding ways to cut supplies of illicit drugs and using the full strength of law enforcement. Another group, "demand reductionists", are those who believe we should focus on finding ways to prevent drug use and to rehabilitate those with drug problems. With HIV in mind, we now have "harm reductionists" who are more concerned about cutting down the amount of harm that is related to drugs. There is a place for each of these approaches and there are places where supply reduction, demand reduction and harm reduction overlap.

Those focused on supply reduction strategies - feeling that demand reduction programs are a waste of money - often make calls for tougher laws as the panacea for drug problems in the country. Demand reductionists on the other hand, often think that we can cure every single case. The reality is, putting people in prison not only places a financial burden on the government but it is also not much of a solution because many prisons do not have programs to deal with drug abuse.

News of rampant drug dealing in prison is still fresh in our minds. IDUs, who have been through prison, report a very high incidence of needle sharing, leading to the rampant spread of HIV and Hepatitis C Virus (HCV) in prison, which in turn leads to an added health cost to be carried by the government in later years. Even countries with stringent laws continue to fail to keep their countries free of drugs.

On the other hand, demand reductionists who call for prevention and rehabilitation often forget that most are not going to listen to prevention messages, even if the messages are accurate, comprehensive and widespread, like what we find in developed countries. And those who do become addicted will only find themselves admitted to a rehabilitation center after years of use.

Imprisonment, death by overdose or driving accidents under the influence of alcohol and drugs, drug-induced mental damage and finally infection of incurable blood-borne viruses such as HIV and hepatitis, are just some of the costs we must look at. And if we are to rehabilitate all cases of drug abuse and addiction, we must remember that we are dealing with close to four million drug users. Indonesia simply does not have the resources, manpower and the finances necessary to do this on a national level. However, if we wait for more resources and manpower, many lives will already have been lost.

Demand reductionists hope that drug abusers will achieve sustained abstinence. There is nothing wrong with that, because sustained change or abstinence is ideal, so ideal that it is parallel to achieving a gold medal in sports. Yet, we know that winning a gold medal takes learning and practice. In other words it is a process.

From the perspective of harm reduction, would it be acceptable to teach a person how to swim if the conditions for learning puts them in real danger of losing their life? If a person cannot swim, do we take them to the deep end of a pool for their first lesson and leave them there? If we know that a person may relapse, as most addicts do, is it acceptable for us to risk their life by withholding lifesaving information and tools to protect them and others around them from ever getting infected by HIV and HCV? Would that not be parallel to shooting them on the spot, along with their sexual partners and those they have shared risky behavior with?

Tools to reduce harm can be applied in all situations, be it on the street level, where resources are low and hamper treatment-seeking behavior, in prison, or in counseling centers or any other service points where the drug abuser or addict may show up. Its simple objective, which is to reduce harm for anyone using drugs, decreases potential harm and cost to those around them. It has also been shown that harm reduction approaches often motivate people to ultimately stop using drugs.

Are you sure your loved ones are not using drugs? Or perhaps, that your child is not using drugs, or dating and having sex with an IDU? If you are a typical parent, like many parents of addicts who come to Yayasan Kita recovery center in Cipayung, you probably don't know. Most parents find out that their children use drugs only a year or so after they have first started. You cannot always tell an addict from their appearance and you cannot tell who has HIV or HCV from how they look. And if your loved ones are in fact using drugs, would it not be better if you could get them off drugs before they get HIV or HCV from needle sharing? Would it not be great if someone out there told them the facts and gave them lifesaving tools while you yourself were sleeping?