Turning strategy into concrete action

Drug use, including drugs that are injected, is rampant among youths in Bali, Bali Provincial Narcotics Agency Rehabilitation and Treatment Center head Dr Made Molin Yudiasa says.

"A study in late 2002 showed that 35 percent of the Injecting Drug Users in Bali were HIV positive," Molin said.

The harm reduction approach incorporates a number of activities, the first of which is counseling.

Dr Satya said people were basically advised not to start using, but "if they have to, we tell them not to inject but to use a substitute, namely methadone, which is taken orally so it reduces the risk of HIV, Hepatitis A and B".

Dr Hanati of the methadone clinic at Sanglah Hospital said that of all the treatments he had used "this is the one that clients say is the most effective".

"What we are seeking is behavioral change," she said. "We want them to be disciplined enough to come to the clinic for their daily supply of methadone everyday, to refrain from injecting and to eventually stop using drugs altogether."

So far, the results appear promising. Some clients who worked in the past have returned to work because they no longer have to think, "what can I steal this morning in order to get my fix?" Dr Hanati said.

Dr Amaya Maw-Naing of WHO Indonesia agreed the methadone projects aimed to provide stability for addicts so they had time for behavioral changes.

Addicts became stable, less restless, could think better, could return to school or work, did not need to commit crime for drug money and family relations usually improved, she said.

Molin said recent commitments by the local government to support the HRT did not yet include financial assistance. "What financial support there is is usually given to the preventative approaches. It is not enough for rehabilitation," he said.

He said a rehabilitation program for one drug user cost Rp 6 million a month whereas the government had decided this year to allocate only Rp 180 million to support the work of 5 addict support organizations, namely Kesehatan Bali Foundation, Hati- hati Foundation, Trijata Polri Hospital, Bangli Mental Hospital and the Putra Kusuma Foundation.

Two weeks after the introduction of a methadone treatment project in March, 14 drug users have enrolled in Denpasar, and 30 in Jakarta, lending a cause for optimism on the part of the experts and health workers. But the question of funding remains critical, for both the health workers and the clients.

"What happens after this pilot project ends?" said a client. "What if I became dependent on Methadone, the way I was once dependent on heroin, and the project is then finished?"

Maw-Naing said the project was a shared responsibility for many parties, most notably the central and local governments.

UNAIDS assisted in the funding of the methadone project in Bali and Jakarta, which started three years ago and is expected to involve some 500 patients before it ends in two years.

"Funds will end eventually," she conceded. "WHO can assist in the purchase of cheap methadone but WHO wishes to see that (the government) allocates funds for that purpose."

However, "we'll find ways to continue our support in technical capacity building."

How long do addicts take to wean themselves off substitute heroin? "Until they finally decide they have enough strength to let go of the drug -- this can take two to six months or two years or even longer," Maw-Naing said.

Dr Wirawan of Udayana University said: "It is our hope that within 6 months, clients will have the discipline to quit. They must not think that methadone will always be provided for them. They have to think when and how they can stop using drugs."

There are criticisms of the programs, including resistance from some community leaders in Bali who thought the health workers were basically pushing drugs on the clients, and those who believed the project was a waste of good money because it "spoon-fed" drugs to the addicts.

Dr Georg Petersen of WHO Indonesia, however, insisted that "the cost of methadone is much smaller than the price we'd have to pay to allow heroin dependence to continue, the social costs as well because drug abusers steal and do other things to support their habit."

How necessary is it in Indonesia where the HIV/AIDS prevalence, at 0.1 percent, is relatively low?

Joint U.N. Program on HIV/AIDS Director Peter Piot recently warned in Jakarta that the low rate of the disease could also mask the growing risk of HIV spreading in the country.

Speaking recently at the launch of Indonesia's National HIV/AIDS Strategy through 2007, Piot said urgent action was needed to slow the spread of the disease.

"The current low levels of condom use and widespread sharing of unsterilized needles among injecting drug users can be a lethal mix for the spread of HIV in the country," Piot said.

According to UNAIDS, the majority of the estimated 90,000 to 130,000 HIV/AIDS cases in the country were concentrated in high- risk groups, including drug users and sex workers.

"Indonesia must urgently scale up prevention interventions targeting sex workers and their clients, and injecting drug users, if it is going to succeed in slowing the spread of the epidemic," Piot said. "Young people must also be given the life skills to protect themselves from HIV infection."

Indonesia's National AIDS Commission decided to revise the National HIV/AIDS Strategy because of an increase in HIV infections in recent years and to respond to commitments made at the 2001 U.N. General Assembly Special Session on HIV/AIDS. The new national strategy outlines six priority areas -- surveillance of the epidemic; prevention; treatment, care and support of people living with HIV/AIDS; human rights of people living with HIV/AIDS; research; and government coordination at all levels.

"AIDS cannot be fought by one sector alone, every part of the government and every force in society must be harnessed in a common fight," Piot said. "The challenge now is to implement the national strategy and to ensure that resources and capacity are in place so that it can be translated into action." -- Santi W.E. Soekanto