Focusing Injecting Drug Users as The Main Root of HIV/AIDS Transmission.
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 Papua
through 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
Illustration of HIV prevalence among Injecting
Drug Users (IDUs) and Comercial Sex Workers
(CSWs)
HIV (+) percentage
IDUs
CSWs
Source : Sentinel Surveilance, Indonesia Health Department
Prediction of HIV Infection
Source : MAP, 2005 (http://www.unaids.org/epi/2005/doc/EPIupdate2005_html_en/epi05_06_en.htm)
Estimation of IDUs population in each province in
2006
IDUs population
West Java (population : 40.000.000)
Estimation of adult person vulnerable to be infected with HIV in 2006
National report, Health Department & National AIDS commission
HIV Risk factors in West Java
•
•
•
•
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
Source UNAIDS 2006* Source chart: UNAIDS 2006 according to the risk factors form 1989-december 2004
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
Characteristics of IDUs in Bandung
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%)
Source : Bahtera questionnaires, 2006 (345 respondents), FGD 2007
Transmission HIV/AIDS in Bandung
37
-52
%
CSW
Clients
Low risk man
IDUs
(34-39%)
s
12 person
37
-5
2
MSM
%
Low risk woman
CSW : commercial sex worker; MSM : men sex with men; IDUs : injecting drug users
Interventions to Control HIV
Increased HIV-testing for risk groups
Harm reduction for IDUs
HIV-treatment
community
Target group
IDUs
Education
Outreach
Case Finding
VCT
Prevention and care
AIDS
HIV +
Harm Reduction :
Methadone Program
Treatment & Care for
HIV/AIDS ( including ART)
Treatment and care
Framework for comprehensive measures to control the HIV epidemic in West Java.
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
risk behavior and other skin penetrating risk behavior*
• 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 Padjadjaran
Bandung - Indonesia
Hasan Sadikin Hospital
Bandung - Indonesia
CORDAID The Haque
The Netherlands
Radboud University
Nijmegen The Netherlands
Antwerp University
Belgium
Maastricht University
The Netherlands
Working Groups for
5 Activity Areas:
•
•
•
•
•
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
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 drugrelated 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.
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 Papua
through 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
Illustration of HIV prevalence among Injecting
Drug Users (IDUs) and Comercial Sex Workers
(CSWs)
HIV (+) percentage
IDUs
CSWs
Source : Sentinel Surveilance, Indonesia Health Department
Prediction of HIV Infection
Source : MAP, 2005 (http://www.unaids.org/epi/2005/doc/EPIupdate2005_html_en/epi05_06_en.htm)
Estimation of IDUs population in each province in
2006
IDUs population
West Java (population : 40.000.000)
Estimation of adult person vulnerable to be infected with HIV in 2006
National report, Health Department & National AIDS commission
HIV Risk factors in West Java
•
•
•
•
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
Source UNAIDS 2006* Source chart: UNAIDS 2006 according to the risk factors form 1989-december 2004
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
Characteristics of IDUs in Bandung
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%)
Source : Bahtera questionnaires, 2006 (345 respondents), FGD 2007
Transmission HIV/AIDS in Bandung
37
-52
%
CSW
Clients
Low risk man
IDUs
(34-39%)
s
12 person
37
-5
2
MSM
%
Low risk woman
CSW : commercial sex worker; MSM : men sex with men; IDUs : injecting drug users
Interventions to Control HIV
Increased HIV-testing for risk groups
Harm reduction for IDUs
HIV-treatment
community
Target group
IDUs
Education
Outreach
Case Finding
VCT
Prevention and care
AIDS
HIV +
Harm Reduction :
Methadone Program
Treatment & Care for
HIV/AIDS ( including ART)
Treatment and care
Framework for comprehensive measures to control the HIV epidemic in West Java.
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
risk behavior and other skin penetrating risk behavior*
• 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 Padjadjaran
Bandung - Indonesia
Hasan Sadikin Hospital
Bandung - Indonesia
CORDAID The Haque
The Netherlands
Radboud University
Nijmegen The Netherlands
Antwerp University
Belgium
Maastricht University
The Netherlands
Working Groups for
5 Activity Areas:
•
•
•
•
•
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
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 drugrelated 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.