RI needs 'harm reduction' approach to cut HIV/AIDS

I Wayan Juniartha, The Jakarta Post, Jakarta

With the rate of HIV infections increasing at alarming levels among injecting drug users (IDUs) in the country, Indonesia is moving toward adopting the controversial "harm reduction" approach to contain the epidemic.

The harm reduction approach is a range of measures and strategies focused on reducing the adverse health consequences caused by drug abuse, particularly intravenous drugs.

The most common harm reduction measures include primary health care programs, peer education, community outreach, counseling and HIV testing, drug abuse therapy, and substitution (using Methadone or Buprenorphine pills) and sterile needle exchange.

The measures, especially the sterile needle exchange program, have especially drawn criticism from religious leaders as well as police for what they claim advocating drug use.

Despite the opposition, the Ministry of Health has actually adopted the term "harm reduction" in a ministerial decree, but it has not yet been implemented.

According to Director of Communicable Disease Eradication Haikin Rachmat at the Ministry of Health, the term "harm reduction" is incorporated in health ministry decree No. 1285/Menkes/SK/X/2002 on the Guidelines for the Prevention of HIV/AIDS and Sexually Transmitted Diseases.

"For the first time, the term 'harm reduction' has been incorporated in an official decree," he said during a national workshop on HIV/AIDS strategic advocacy here earlier this week.

The two-day workshop was organized by the Melbourne-based Center for Harm Reduction, the Bangkok-based Asian Harm Reduction Network, and the Jakarta-based Aksi Stop AIDS.

Rachmat said HIV transmission through contaminated syringes and needles used by the IDUs had multiplied over ten-fold since 1999, when there were only 16 new cases of HIV-infected IDUs. In 2002, however, there were 203 new cases, he said.

He warned that the cases would continue to rise drastically in the near future unless effective and comprehensive intervention was carried out immediately.

Djoko Suharno of the Commission for AIDS Eradication (KPA) supported the ministry's move to introduce the harm reduction approach to address the soaring cases of HIV infection resulting from intravenous drug use.

He commented further that the incorporation of the term "harm reduction" into a ministerial decree was indeed a brave move on the part of the Ministry of Health, considering that many were still reluctant to accept the term.

"I think that, without the brave initiative and incessant push from Pak Sujudi (the minister of health), we would not have been able to reach the level of acceptance for harm reduction that we currently enjoy," he said.

"We have already adopted this strategy, although on a much smaller scale. Since it is still a new concept, we are developing the strategy through pilot projects. In these pilot projects, the distribution of sterile syringes and needles is carried out under strict supervision and control," Haikin said.

The pilot projects of providing easier access to sterile syringes and needles, and the hospital-based substitution therapy of Methadone Maintenance Therapy have been established in several places in Jakarta and on Bali.

Similar pilot projects will be carried out in Bandung in West Java, Surabaya in East Java, Medan in North Sumatra, Manado in North Sulawesi, Makassar in South Sulawesi, and Kupang in East Nusa Tenggara.

The next challenge would be in formulating and advocating a harm reduction policy and program that would be accepted by law enforcement agencies, religious leaders and educators, Haikin said.

For years, harm reduction methods, particularly the sterile needle exchange program, had drawn strong criticism mainly from police and religious leaders, who claimed that the program not only condoned illegal drug-use, but that it also contributed to increasing the number of new IDUs.

Nevertheless, former religious affairs minister Tarmizi Taher is one who has apparently been converted into a supporter of the harm reduction approach.

Tarmizi promised to help lobby leaders of the country's two largest Muslim organizations, the Nahdlatul Ulama (NU) and Muhammadiyah, to support the approach.

"We will move the dinosaurs to support this program," Tarmizi said, referring to the NU and Muhammadiyah.

He further claimed that he had asked several important figures from both organizations to form JOINT -- the acronym for Indonesians' Jihad Against Narcotics and AIDS.

Separately, Steve Wignall of Family Health International (FHI)/Aksi Stop AIDS (ASA), revealed that the organization had finalized plans to invite the country's top religious figures to a special meeting, during which the rationale of the harm reduction campaign and needs for quick action against the epidemic would be outlined before them.

Tim Moore of the World Health Organization (WHO) warned that time was the essence in this matter and furthermore, that speedy implementation of the harm reduction approach must also be paired with the widest possible media coverage.

He also stressed that the spread of HIV in Indonesia was driven primarily by IDUs, and predicted that over 80 percent of new HIV infections in 2003 nationwide would be due to intravenous drug use.

"Most importantly, harm reduction is a safe approach. Various reviews have reported that there was no evidence of increase in the number of IDUs, neither in frequency of injecting drug use, nor in discarded, used injecting equipment," he said.