Focusing Injecting Drug Users as

The Main Root of HIV/AIDS

Transmission

Shelly,dr.,Msi

Picture from Bahtera Foundation, Bandung

Background

Indonesia faces Three HIV epidemics:

General population in Papuathrough sexual risk behaviour

Concentrated epidemic in IDU through shared needles

Concentrated epidemic in CSW through unprotected sex

* Source : Directorate General CDC & EH, Ministry of Health, Republic of Indonesia, 2007

Source : Sentinel Surveilance, Indonesia Health Department

IDUs

CSWs

HIV

(+

) p

erce

nta

ge

Illustration of HIV prevalence among Injecting Drug Users (IDUs) and Comercial Sex Workers (CSWs)

Source : MAP, 2005 (http://www.unaids.org/epi/2005/doc/EPIupdate2005_html_en/epi05_06_en.htm)

Prediction of HIV Infection

Estimation of IDUs population in each province in 2006

Estimation of adult person vulnerable to be infected with HIV in 2006 National report, Health Department & National AIDS commission

IDUs population

West Java (population : 40.000.000)

HIV Risk factors in West Java

Source UNAIDS 2006* Source chart: UNAIDS 2006 according to the risk factors form 1989-december 2004

• West Java is in the third highest (Jakarta, Papua)• 22,000 IDU’s in Province West Java*• 21% of IDU’s are in prison in West Java; • 71,9% of AIDS patients are IDUs

Characteristics of IDUs in Bandung

Compare with other countries :

The age are younger (19 y.o)

Higher education background (85% senior high school or )

Type of drug used : alcohol, marijuana, heroin, tranquilizer

(> 75%)

The most common drug used for injecting is heroin (close to 100%)

Increasing use of buprenorphine (Subutex ® = opioid agonist)

Wrong knowledge about cleaning needle (sterile water > 75%)

Source : Bahtera questionnaires, 2006 (345 respondents), FGD 2007

Needle sharing is 34-39% and sharing injecting equipments

Still able to use drug in control environment (14,8% in

prison, 3,5% in rehabilitation center)

High sexual risk behavior (no condom use 52%)

Sexual partner : partner (88%), CSW (42%), IDUs (25%),

casual (19%), spouse (15%)

Low number of HIV test (11%)

Low number of Hepatitis B or C test (10%)

Characteristics of IDUs in Bandung

Source : Bahtera questionnaires, 2006 (345 respondents), FGD 2007

Clients MSM

CSW

Low risk woman

Low risk man

CSW : commercial sex worker; MSM : men sex with men; IDUs : injecting drug users

Transmission HIV/AIDS in Bandung

37-5

2%

37-52%

IDUs(34-39%)

12 persons

Interventions to Control HIV

Increased HIV-testing for risk groups

Harm reduction for IDUs

HIV-treatment

Target group

IDUsHIV + AIDS

community

OutreachCase Finding

VCT

Harm Reduction :Methadone Program

Treatment & Care forHIV/AIDS ( including ART)

Prevention and care Treatment and care

Education

Framework for comprehensive measures to control the HIV epidemic in West Java.

Target group

IDUsHIV + AIDS

community

OutreachCase Finding

VCT

Harm Reduction :Methadone Program

Treatment & Care forHIV/AIDS ( including ART)

Prevention and care Treatment and care

Education

Harm Reduction Strategies To Control HIV Transmission

Safe Injection (Needle & Syringe Exchange Programs)

Heroin substitution Programs (methadone, buprenorphine)

Education and Outreach Programs

Condoms to reduce risk of sexual transmission

Best programs provide combination of preventive and therapeutic services (“comprehensive care”)

Heroin Substitution Program

• Methadone is a ‘synthetic opioid agonist’ prevents withdrawal symptoms • Long acting (15 to 32 hours)• Taken orally so reducing the injection of heroin• Reduces criminality*• Increases health status*• Reduces depression*• Decreases HIV transmission by reducing injecting ecreases HIV transmission by reducing injecting risk behavior and other skin penetrating risk behavior*risk behavior and other skin penetrating risk behavior*• Reduces the number of sexual partner*Reduces the number of sexual partner*

* Source : Study of methadone effectivity in Hasan Sadikin Hospital, September, 2006

CONCLUSION

Indonesia has an explosive HIV-problem driven by IDU

Need a comprehensive approach

Sustainability of effective interventions needs local capacity building

Academic partnerships work

This document has been produced with the financial assistance of the European Union. The contents of this document are the sole responsibility of IMPACT Bandung and can under no circumstances be regarded as reflecting the position of the European Union

Acknowledgement

Reinout van Crevel, Lucas Pinxten, Diba Basar (IMPACT Program (Integrated Management for Prevention And Control and Treatment of HIV/AIDS Bandung, West Java, Indonesia))

Teddy Hidayat, Bachti Alisjahbana (Medical Faculty, Universitas Padjadjaran & Hasan Sadikin Hospital, Bandung West Java Indonesia)

Jose Boom (Radboud University Nijmegen Department NUSI/ Internal Health)

Tamami A Zain (Yayasan Bahtera Community HIV Prevention Program)

Octavey Kamil (Family Health International / ASA, Jakarta)

Cor de Jong (Radboud University Nijmegen, Scientist Practioners in Addiction)

Universitas PadjadjaranBandung - Indonesia

Hasan Sadikin HospitalBandung - Indonesia

CORDAID The HaqueThe Netherlands

Maastricht UniversityThe Netherlands

Radboud UniversityNijmegen The Netherlands

Antwerp UniversityBelgium

• IEC / Health Promotion about HIV-related risk

behavior in adolescents • Scaling-up HIV-testing & VCT • Harm reduction (including methadone), for IDU’s

in community, prison & hospital• Scaling-up treatment & care for HIV/AIDS, incl.

antiretroviral treatment • Building Capacity, transfer of knowledge to local

professionals to conduct and up-scale the above activities

Working Groups for 5 Activity Areas:

Harm Reduction focuses on reducing the harms related to drug use rather than eliminating drug use itself. Harm Reduction aims to: prevent the spread of infections including HIV/AIDS, Hepatitis and other blood-borne infections; reduce the risk of overdose and other drug-related fatalities; and lessen the negative effects drug use may have on individuals and communities including poverty and crime.

Proportion of HIV new infection among subpopulation in Indonesia in 2020

Estimation of adult person vulnerable to be infected with HIV in 2006 National report, Health Department & National AIDS commission

CONCLUSION

Indonesia faces an explosive HIV-problem which is mostly driven by Intravenous Drug Use.

The nature of the epidemic requires a comprehensive approach: integrating prevention, harm reduction, addiction medicine and HIV/AIDS treatment and care and building on both behavioural and medical sciences

Use of local capacity and technical expertise will enable the establishment of effective and sustainable interventions in HIV/AIDS.

Academic partnerships and technical assistance from Europe will help local professional capacity in a pragmatic and effective response to the Indonesian HIV epidemic.