Sudirman Nasir
The link between intravenous drug use and HIV/AIDS is now attracting media attention and becoming a topic of everyday conversation. HIV/AIDS and the misuse of narkoba (narcotics, psychotropics and other addictive substances) are seen to be twin epidemics, as awareness grows that HIV can be easily spread by sharing needles. The story of Wina* is typical. ‘I was four months pregnant when my boyfriend proposed marriage. I didn’t know that he often injected putau (heroin). A year after we were married, my husband suffered a variety of illnesses and had to go to hospital. The doctor said he had contracted AIDS. He ordered me and my baby to be tested and we discovered we were both HIV positive.’ (Kompas, 4 October 2004)
Daeng Taba* from Makassar, who is addicted to putau, explains why so many people inject narcotics and share needles. ‘Putau and shabu-shabu (crystal methamphetamine) are increasingly expensive. We inject them, so we can be economical. If you smoke shabu-shabu using a bong, a lot needs to be thrown away. It’s a waste. It means that you get high much more slowly. It’s also very nice if injected. The first time, I was afraid of shooting up. But after a friend had injected me, and I was taught how to inject, I felt increasingly addicted. If you only smoke for a moment, the feeling quickly leaves you.’
After he was told about the danger of HIV and Hepatitis C, Daeng felt terrified. But when he suffered sakaw (withdrawal symptoms), he couldn’t resist. Sterile needles and syringes were difficult to come by, so he just re-used old ones. But he welcomed the needle and syringe exchange program initiated by the Metamorfosa Institute, one of the NGOs that carries out harm reduction programs in Makassar. He also admits that he frequently went to brothels in Makassar. He worked casually at the market both as an overseer and as preman (gangster), and there were a number of brothels nearby. He didn’t like to wear condoms because they lessened his pleasure. When he learned that HIV could infect his wife, and the baby too if she was pregnant, he was even more terrified. He never wore a condom when he had sex with his wife. His wife knew that he often injected narcotics and visited sex workers. She was angry, but couldn’t do anything because he found it difficult to stop his habitual drinking of ballo (fermented palm wine), smoking, injecting drugs and visiting brothels. He had been doing all that since he was a teenager. In the end Daeng and his wife suffered the same fate as Wina and her husband.
Twin epidemics
In South Sulawesi there have only been a few reported cases of HIV or AIDS. In June 2005 there were 7,098 confirmed cases in the whole of Indonesia, 44 per cent of which were in Jakarta. But this is only the tip of the iceberg. Official government figures estimate there are 130,000 HIV positive people in Indonesia, and probably 20 million are at risk of becoming infected. The spread of HIV has become more rapid in recent years as intravenous drug use increases. Cases of HIV resulting from drug use are now estimated to be about 26 per cent of all those infected. There are probably one to two million narcotics users in Indonesia, about half of whom inject drugs, and the number is still increasing. The UN now assesses Indonesia as an ‘area of concentrated prevalence of HIV’, increased from its former status as an ‘area of low prevalence’ in 1999. Recently, the misuse of drugs has overtaken heterosexual sex as the main means of transmission of new HIV cases in some provinces, although widespread poverty, a high frequency of prostitution, low rates of condom usage, and a high rate of inadequately treated sexually transmitted diseases all contribute to the spread of HIV.
Women at risk
These figures also include increasing numbers of women. Men are rarely aware that women are more susceptible to contracting HIV from heterosexual activity. Women are usually in a weak negotiating position, and find it difficult to refuse risky sexual activities or relationships. Many women know that their husbands engage in high-risk behaviour, such as having multiple sexual partners or injecting drugs, but are unable to force them to wear condoms. HIV/AIDS thus is a gender-related phenomenon. Large numbers of young, sexually active drug addicts die with the clinical symptoms of AIDS, but without being tested for HIV. Their sexual partners, especially women, are at high risk of contracting HIV.
An increasing number of women are also misusing narcotics. Dewi’s* story is typical. ‘I began using drugs in high school. My boyfriend and his friends invited me to smoke (tobacco), drink and smoke marijuana. After a short while we became bored and started to try stronger drugs – ecstasy, shabu-shabu and later putau. After that we tried injecting. My boyfriend injected more and more and finally died of an overdose. We often shared needles. My parents forced me to undergo detoxification a number of times. But I always relapsed. I often stole things from home to buy putau. In the end my family couldn’t take it any longer. They kicked me out of home, and I am staying with a friend who is also a drug addict. He invited me to become a sex worker, and I am still engaged in such work.’ (Suara Karya, 13 September 2003).
Preventing infection
The use of narcotics is condemned, both socially and legally, but Indonesian women experience a greater stigma than male drug users. Much of the research states that women drug users become involved in a vicious cycle of criminality, prostitution, stigma and discrimination. Their situation is exacerbated because it is more difficult for women drug users to obtain access to health services and HIV/AIDS prevention programs, including needle and syringe exchange programs. Sofyan, the head of Metamorfosa Institute says, ‘Drug users are a difficult group to reach, but it is even more difficult to reach women drug users.’ Far fewer female than male drug addicts come to the drop-in centres run by Metamorfosa. Women usually rely on their drug-addicted partner to obtain sterile needles and syringes.
More in-depth research is required to design HIV/AIDS prevention programs for women. Programs are also urgently needed to change the behaviour of drug addicts, especially men, to use sterile needles and syringes and condoms if they have more than one sexual partner. Without these changes it will be difficult to overcome women’s susceptibility to HIV/AIDS.
The stories of Wina, Daeng Taba and Dewi show the increasing threat of these twin epidemics. The government has developed a National Strategy for the Prevention of HIV/AIDS, which emphasises the narcotics problem as well as HIV itself, and recommends harm reduction programs amongst intravenous drug users. However this strategy is yet to be translated into clear and sustainable programs.
* Not their real names.
Sudirman Nasir (s.nasir@pgrad.unimelb.edu.au)is a postgraduate student in the Key Centre for Women’s Health in Society, School of Population Health, the University of Melbourne. He is a member of the South Sulawesi Commission for the Reduction of the Harmful Effects of Narcotics.