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Tackling Indonesia's HIV spread

By Lucy Williamson
BBC News, Jakarta

Dendy Hikmah
Former heroin addict Dendy is now getting treatment for his HIV

It is 0400 at Jakarta's main HIV hospital and Dendy Hikmah is waiting for the doctor.

Appointments are running late. Dendy sits in the overcrowded waiting room and flicks through his medicine file - anti-retroviral treatment, methadone, anti-depressants.

A few years ago, Dendy would never have imagined himself here.

Most likely he would have been injecting himself with heroin or looking for money to buy it - unaware that he was HIV-positive, clueless about the complex anti-retroviral treatment he is receiving now.

"I remember the first time I came here," he said. "I was so scared."

"Back then, it was all about the drugs. I'd already lost my car, my girlfriend, everything that mattered to me. No-one trusted me. I was like a criminal in my own house."

But the fact that Dendy is here talking to doctors and not shooting up on the street is very interesting to Indonesia.

It has just been given $130m (95m) by the Global Fund to fight HIV and Aids - the largest slice of HIV funding the country has ever had.

It wants to use the money to tackle the epidemic across the 12 worst-hit provinces. But to do it, it needs to get marginalised groups like drug users and sex workers into clinics like this one.

Community outreach

The man who got Dendy off heroin and into the health system is Putra.

He works for an outreach project called Kios Atmajaya, funded mainly by the US government. Once a week, he goes to a small community called Kampung Boncos - known to his colleagues as "The Bronx".

In some outlying provinces there are very few NGOs - much less with experience and skills to be effective in the short run
Bob Magnani,
Family Health International

It is a slum of several thousand people clustered around a rubbish dump.

Job prospects are not good - salvaging rubbish, selling sex. The crime rate is sky-high and around half the young people are thought to use drugs. It is an HIV crucible.

Putra arrives on schedule and puts a few empty pots on the ground by his motorbike.

A small crowd lines up to fill them with used needles. In return, they get a box of clean, sterile ones, some condoms and a chat about HIV.

"It is quite hard in the beginning," said Putra. "It takes almost a year to make people understand what I'm doing. Like Dendy - he was a hardcore addict, injecting at least three times a day."

"But I also used to buy drugs here, so it's easier for people to trust me - we speak the same language, there are no barriers."

Ambitious plans

This is the model Indonesia wants to adopt. And the fact that it does is a big step forward.

Drug user takes a blood test for HIV virus on 28 January 2009, in Kampung Boncos, west Jakarta
Those carrying the virus are hard to reach
The epidemic here is concentrated in hard-to-reach populations - sex workers, drug users, men who have sex with men.

Those groups have not always been well-targeted in the past. In fact, most people here - even in government - would prefer not to see or talk about them.

That is something the head of Indonesia's National Aids Commission, Nafsiyah Mboi, is acutely aware of.

"When I got this appointment everyone said 'Congratulations, this is not an easy job', so I was prepared," she said.

It is now her job to co-ordinate the new programme across three national agencies and 72 districts, in a hugely populated and decentralised country. And that, she says, is not easy.

"I'm from the old order, right? So if we say 'A' in Jakarta, 'A' goes down all the way to the family level. That's not possible anymore; we have to do advocacy with each and every one."

To reach 72 districts across such a diverse and enormous country is ambitious.

'Spread thinly'

Bob Magnani is country head of Family Health International, the organisation that runs the project in Kampung Boncos.

Training government workers in the health sector is one thing, he says, but when you are trying to mobilise local community NGOs to access these high-risk groups, that is quite another.

"Indonesia does not have a history of NGOS," he said. "In some outlying provinces there are very few NGOs - much less with experience and skills to be effective in the short run."

"One of the big dangers with Global Fund - with its vast amounts of money and ambitions to cover many, many provinces - is that you spread the resources very thinly.

"And we know from the history of dealing with infectious diseases that you have to have to attack the point of transmission very aggressively, concentrate your resources at those key hotspots."

In some ways, Indonesia needs to think big. This is a vast country of 240 million people; hotspots are by their nature much bigger than they are elsewhere.

The country aims to reach 80% of people in those hotspots, and effect what it calls "behaviour change" in 60%. But what does "reaching" a person, or "behaviour change" actually mean?

Changing habits

One of the women lining up in Kampung Boncos to swap needles with Putra is Lia. She is a sex worker who injects heroin. Free needles and free condoms are great, she says, but she does not always use them.

"I'm trying hard, but there have been two or three times recently when I shared," she said.

"We're frightened of the police," she explained. "They know we're drug users and if they search us and find a needle - even a sterile one - they can arrest us."

Recent data suggests that more than half of all injecting drug users in Indonesia are HIV-positive.

But it also suggests that the epidemic may have peaked, and the virus is now spreading faster through sexual contact. So, does Lia use a condom every time she sleeps with a client?

"For me, yes, but my guests don't always want to. And I need money," she answers.

Indonesia has made big changes over the past few years.

It has got better data on the spread of HIV and is starting to plan programmes that target the hidden communities where the epidemic is based.

But a lot of the new energy is coming from Jakarta, and in Indonesia's decentralised system, it will be local leaders, local networks and local stigmas that decide what happens on the ground.

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SEE ALSO
Progress made in HIV prevention
29 Jul 08 |  Health
Indonesia's Aids alert
02 Jul 02 |  Asia-Pacific
Country profile: Indonesia
07 Aug 08 |  Country profiles

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