HIV AND INDONESIA: NATION SITS ON A VOLCANO

THEY are in many ways a throwback to their parents' era, often either
saving themselves until marriage or having few sexual partners.

But whereas Indonesia's teenagers may be shunning their Western
peers' interest in sex, they are taking up drug use with an
increasing passion, from Jakarta rich kids to those in the poorer
outlying areas across Java, Kalimantan and South Sulawesi.

It is injecting drug use that is fuelling Indonesia's HIV epidemic,
and new modelling obtained by the Herald suggests that if prevention
efforts are not stepped up, the country could be facing 2 million HIV
infections by 2025.

More than 145,000 of those would be in Papua, representing 7 per cent
of the 2.3 million residents of the troubled province, where HIV,
unlike in the rest of the vast Muslim nation, is transmitted by sex.

As Indonesia deals with the scale of the effects of the tsunami, the
recent Yogyakarta earthquake and the threat of terrorism, more and
more families are facing an added burden of caring for HIV-positive loved ones.

And as Indonesia attempts to quash the corruption endemic in its
government agencies and push through policies such as the abolition
of longstanding fuel subsidies and deal with the poor health of much
of its population, experts fear HIV could stop the nation's progress
in its tracks.

The United Nations AIDS Program estimates that there are at least
170,000 people living with HIV or AIDS across Indonesia, although the
recent Australian modelling indicates a much higher infection rate.

By 2025, HIV prevalence will have climbed to 40 per cent in injecting
drug users, and the flimsy barrier between users and the general
population will have been well and truly broken, according to figures
from Australia's National Centre in HIV Epidemiology and Clinical
Research, and the National Centre in HIV Social Research, produced for AusAID.

Over the same period, HIV infection among the country's 270,000
prostitutes will rise from 4 per cent to 23 per cent. Prevalence
among their 7-10 million clients will rise from 0.5 per cent to 3 per
cent, forming "a bridge to wives and girlfriends in the general
population", the researchers predicted.

The impact on Papua will be catastrophic, with an estimated 85,000
deaths expected by 2025, mostly among people aged 14-49.

In the rest of Indonesia, which has a population of about 245
million, more than 300,000 will have died by 2010 and 1.5 million by
2025, placing untold pressure on the health sector as large numbers
of people require treatment and hospital admission. Nearly a third of
all hospital beds will be filled by people with AIDS.

There is a growing awareness in Indonesia that HIV will have an
impact on the country's social and economic development, yet a mass
mobilisation of government resources remains a long way off.

It is also acknowledged that if a widespread, comprehensive
prevention and treatment program was enacted now, HIV prevalence
rates would drop immediately and a large-scale, generalised epidemic
could be averted.

"There are some needle and syringe programs but not nearly enough -
they are just a drop in the bucket in the face of these staggering
numbers," says Heather Worth, one of the researchers and deputy
director of the National Centre in HIV Social Research at the
University of NSW.

"Getting donor money into Indonesia is not the problem. It is
changing public and political opinion on the issue of injecting drug
use that is the challenge."

Added to that, she says, the severe social dislocation in Papua,
fuelled by feelings of dispossession among indigenous Papuans, was
feeding the HIV epidemic.

Australia is a large donor to Indonesia. A five-year, $37 million
project funded by AusAID is due to be completed next year, involving
work with Indonesia's National AIDS Commission.

Harm reduction - involving the provision of clean needles and
syringes to injecting drug users, as well as treatment and support
programs - is an urgent priority, says Tim Mackay, the Australian
team leader of the AusAID-funded Indonesia HIV/AIDS Prevention and
Care Project.

Despite small improvements, the number of people taking HIV
treatments is still scandalously low - there are only 5000 people on
antiretroviral treatment, including 80 in Papua.

The head of program and policy at Indonesia's National AIDS
Commission, Muhammed Nasser, says the Indonesian Government is not
moving quickly enough.

"Around 50 to 60 per cent of all new HIV cases are through injecting
drug use, mostly involving 22- to 27-year-olds, but the national
response is just too slow," Dr Nasser says.

"There is inadequate legislation - we need to reform the health and
narcotic laws so we can intensify our prevention efforts and improve
treatment and care." The commission aims to have needle and syringe
programs in 100 districts and cities by 2007, as well as an extensive
network of methadone programs in hospitals and health centres.

"Under current laws, drug users are arrested and then there is no
chance to give them access to clean needles or methadone treatment,"
Dr Nasser says.

That could change on September 1, when the National AIDS Commission,
the National Narcotics Control Board and the police are expected to
sign a memorandum of understanding regarding injecting drug use and
harm reduction - a step made easier by the fact that Indonesia's
police chief now reports directly to the President, Susilo Bambang
Yudhoyono, and not to the military.

Anak Agung Gede Hartawan is the director of the methadone program at
Bali's Kerobokan jail, where 56 per cent of prisoners who inject
drugs are HIV-positive and where sharing needles and tattooing are
common practices.

Dr Hartawan says Indonesia's tough drug laws mean prisons are filled
with young men charged with possession of a small amount of drugs.

He told the 16th International Conference on AIDS in Toronto this
week that the AIDS epidemic inside jails would soon move into the
general population. "Reports of deaths of prisoners are growing,
indicating growing numbers of HIV infections," he said, describing
jails as "AIDS factories".

But the methadone programs operate within a prison system that spends
less than 50 US cents per prisoner on health care annually, leaving
many without help.

Jane Wilson, the country co-ordinator for UNAIDS in Indonesia,
describes the population of injecting drug users as "very, very
young" and often from middle-class or wealthy families.

Dr Wilson says the current figures on HIV infection are "just the tip
of the iceberg", with cities such as Jakarta reporting rates of
infection up to eight times the national average.

"Drug use is prevalent across all social classes, it is very much the
norm, while behavioural surveillance surveys indicate the number of
sexually active teenagers is absolutely minuscule."

Frika Chia Iskander is the new face of the HIV epidemic - a young
Asian woman. She is 24, and has been HIV-positive for six years.

She is not hopeful the Government will act fast enough to avert an
African-style HIV catastrophe.

Instead, she laments, it will wait until it is a disaster.

"It is really important not just to see AIDS as a problem of Africa -
if we only see Africa and forget about Asia we will not learn from
the mistakes ... and the epidemic will remain hidden until it is too late."