HARM REDUCTION -- PART I: COMBATING DRUG ABUSE

While drug abuse is a broad problem encompassing many potential
causes and consequences, both personal and societal, the problem of
associated HIV infection is becoming one of the primary concerns due
to the rapidly rising proportion of HIV/AIDS cases that are linked to
injecting drug use.

According to a 2005 study by the National Narcotics Board (BNN) and
the University of Indonesia, approximately 1.5 percent of Indonesia's
population (3.2 million people) abuse drugs; 25 percent of them by
injecting. Furthermore, 60 percent of these injecting drug users
(IDUs) are estimated to be infected with HIV.

In the same study, the Communication and Information Technology
Ministry estimated that 15,000 people die each year in Indonesia due
to drug abuse, either from overdose or from AIDS. In addition,
according to an article on the BNN website (www.bnn.go.id), 2006 saw
more than 15,000 cases of secondary school students who were "victims
of illegal drugs", with over 4,000 among junior hih school students
and over 11,000 among senior high school students.

The first case of HIV due to injecting drug use (IDU) was reported in
1993. According to the Health Ministry, only 1.1 percent of all known
HIV/AIDS cases by December 1995 were due to IDU, but by December 2000
this figure had risen to 6.4 percent; by December 2005, it reached
38.9 percent.

In 2006, IDU surpassed heterosexual transmission as the most common
mode of transmission among all cumulative reported cases of HIV/AIDS
in Indonesia. The latest data, compiled through September 2007,
indicates that 49.5 percent of the 10,384 known AIDS cases in
Indonesia (cumulative, not including HIV) are due to IDU.

Harm Reduction

Harm reduction has become quite a global buzzword in recent years. It
refers to interventions aimed at minimizing the medical and social
problems associated with drug use, such as methadone maintenance and
needle exchange programs. It is not exclusively concerned with IDUs
or with HIV, but with all kinds of drug use and all kinds of harmful
consequences.

In other parts of the world, HR has become a major thrust of
government and community efforts to combat the problems of drug
abuse, within the context of frustrated efforts at controlling drug
trafficking and dissuading people from using drugs.

Despite being recently embraced by the office of the Coordinating
Minister for People's Welfare, HR remains somewhat controversial in
Indonesia, mainly due to its different approach from the more popular
demand reduction and supply reduction programs (see Part II-sidebar).

Octavery "Very" Kamil is head of the Injecting Drug Users
Intervention Unit at the Aksi Stop AIDS! (ASA) project, run by the
Jakarta-based Family Health International (FHI). He has worked for
ASA since its inception in 2001.

ASA is funded mainly by the U.S. Agency for International Development
(USAID), but also by The Global Fund to fight AIDS, Tuberculosis and
Malaria and the HIV/AIDS Indonesian Partnership Fund (IPF) of the UK
Department for International Development (DFID). The IDUs
Intervention Unit was created in 2005, and it manages 22
non-governmental organizations (NGOs) and two Health Ministry
programs in six provinces -- the latter covering 40 districts and cities.

"The goal of ASA's IDUs unit is to reduce the spread of HIV among
IDUs," said Very, "thus all of the unit's work is concerned with harm
reduction (HR)."

The organizations and programs supported by ASA's IDUs Intervention
Unit work on preventing the spread of HIV and sexually transmitted
infections, assisting with health issues related to HIV infection,
and assisting on addiction problems through rehabilitation programs,
counseling and family intervention.

HR programs include outreach work, needle and syringe programs (NSP),
counseling and testing for HIV, case management and support groups.

Rise of Heroin in Indonesia

Although Very's unit deals mainly with HR among people already
injecting drugs, he and his team also make it their business, he
said, to learn about the drug problem in Indonesia from every angle.

As Very explained, Indonesia's response to the spread of HIV began in
1991, when the reported cases of HIV or AIDS began reaching the
double-digits, but before the emergence of cases linked to IDU.

"Around 1995 to 2000, the availability and use of heroin in Indonesia
increased greatly," he said.

The monetary crisis in 1998, with its attendant lawlessness and
loosening of social controls at the community level, exacerbated
these already growing problems.

During this period, Very estimates that about 70 percent of high
school students in major cities had access to heroin and other drugs,
regardless of social or economic status; at the same time, the number
of HIV/AIDS cases linked to IDU began to increase dramatically.

But by 2001, Very continued, the country saw a substantial
restoration of law and order.

"The socio-economic profile of IDUs in Indonesia varies from city to
city," noted Very, "and they come from widely varying backgrounds."

Initially, heroin users were from the upper classes, but during the
heroin boom throughout the 1990s, its use spread toward greater
variation among users.

According to Very, many users from affluent families were thrown out,
and some middle-class families were cast into poverty due to the
heroin addiction of a family member.

In major cities like Jakarta, Bandung and Surabaya, he said, many
IDUs were youth from middle- and lower-class families. According to a
survey in late 2006 among clients of the Kios Atmajaya IDU program in
Jakarta, 20 percent of the sample group were below the age of 23, and
38 percent had never reached high school.IDUs who drop out of school
due to drug use never complete their education," said Very.