IDU AT ICAAP 9

SPECIAL REPORT - Bali, Indonesia: the 9^th International Congress on AIDS in Asia and the Pacific (ICAAP) was held here from 9-13 August 2009. APMG attended and followed streams related to most at risk populations (MARPs). The theme for this ICAAP was 'Empowering People, Strengthening Networks". The organizing committee wanted to highlight the need for sectors to work together to expand treatment and prevention to sustainable levels across the region. ICAAP 9 was attended by almost 3000 people from 65 countries including the Asia Pacific region, but also Africa, Europe and America. Information about the conference is available at www.icaap9.org.

This article reports on presentations related to Injecting Drug Use (IDU) at ICAAP 9 and has been developed by APMG Asia Pacific.

LIST OF PRESENTATIONS (click on titles for details of each session)

IDU prevention and education

Shooting Galleries as NSP Site Partners with CARE Myanmar
Preventing HIV transmission among female addicts in Kerobokan Prison, Denpasar
Behavior Change through targeted education in Xinjiang, China - International Red Cross
PANAZABA – HIV/AIDS Prevention among drug user using critical awareness
Empowering Teachers in Penabur, Jakarta to be the agents for HIV prevention
Drug Users community based HIV prevention and Care in West Java
Using Quality Improvement Processes to Improve Program Performance

Health and wellbeing of IDUs, their partners and families

Health Status at Baseline of a Cohort of Drug Injectors in New Delhi
Family support of Jakarta and Bali IDUs receiving antiretroviral (ARV)
Factors related to Hepatitis C (HCV) prevalence among sexual partners of HIV/HCV co-infected patients

Sex and IDU

Condom Use and Sexual Networks of IDU&s in Bandung, West Java, Indonesia, A Review
Night Outreach: Addressing Female Injecting Drug User Sex worker needs West Jakarta
Sexual Networks Study among IDUs in Indonesia
Injecting and sexual risk behavior among fishermen in Kuantan, Malaysia

IDU PREVENTION AND EDUCATION

Poster 116: Innovative Approaches to Harm Reduction: Shooting Galleries as NSP Site Partners with CARE Myanmar

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One of the most interesting posters at ICAAP reported on the co-opting of 'shooting galleries' and their proprietors as NSP site partners and participants in HIV prevention for IDU in Myanmar. Care Myanmar initiated the project in 2003 with support from UNODC. They found that many IDU in Yangon were not self injecting but instead buying drugs and using the service of a shooting gallery where a 'staff member' injected them – often with equipment that had been used previously. IDU reported that ' a clean fit for every hit' was not the norm and Care changed this community norm by providing clean fits and safe disposal bins in shooting galleries which were collected daily by outreach workers. They reported a significant change in community norms with IDU reporting that they go elsewhere now if shooting galleries are not able to guarantee a clean fit. When Care supplies ran low shooting gallery owners, on their own initiative, purchased new equipment to meet client demand.

Authors: Sarah (Sally) Moore, Dr Kyaw Hlaing, Tammy Hasselfeldt: CARE Intervention in Myanmar.

BACKROUND

Injecting drug use in Myanmar is a significant route of HIV infection with estimates of up to 37.5% IDU being HIV positive. The introduction of Needle and Syringe Programs (NSP) is challenged by the legal environment and socio-cultural factors. Strategic Direction Three in Myanmar National Strategic Plan on HIV AIDS 2008-2010 focuses on the reduction of HIV related risk, vulnerability and impact on IDU. Until the Care Harm Reduction Program began it was common for needles to be shared between users in shooting galleries allowing for rapid spread of HIV and other blood borne viruses (BBVs). Following project completion, new funding was secured through the 3DF to continue NSP activity, DIC, advocacy and harm reduction training with law enforcement officials (ref: National AIDS Program: MoH and WHO 2009; Myanmar HIV Sentinel Surveillance Survey 2008).

RESULTS

In 2003 Care began advocacy to shooting gallery proprietors, educating them on HIV and safe injecting practices. Free sterile needles and syringes were distributed to shooting galleries as part of the CARE outreach work. Basically the shooting gallery staff were supported to use a new needle each time they provided a hit for drug users. One of the conveniences of shooting galleries is that drug users who come to buy drugs and get an injection do not have to carry or share any injecting equipment. CARE provided safe needle collection bins for the shooting galleries and outreach workers collected these for safe disposal each day.

IDU reported that a clean fit for every hit was not the norm and, subsequent to the introduction of this program, they will go elsewhere if there is any risk of equipment being reused. Through discussions with shooting gallery owners, feedback from clients and in collecting used injecting equipment it was clear that shooting gallery owners were responding to clients' demands. When CARE NSP supplies ran low, shooting gallery owners on their own initiative, purchased new single-use needles and syringes from pharmacies to ensure clients continued to use their services. Over a twelve month period in 2007-2008, more than 100,000 sterile needles and syringes have been distributed through shooting galleries and outreach activity.

"Now many injecting drug users no longer want to use nor will they accept non sterile needles so shooting gallery owners have to buy needles and syringes when supplies from CARE run out. Many IDU choose to attend only shooting galleries where clean needles are available and provided. IDU recap and bend the tip of the needle because they do not want their needle to be reused by another IDU" A quote from a Care Project Staff Member.

Over the life of this project IDU have been trained by CARE in peer approaches. Peer-to-peer information sharing has been conducted in shooting galleries on harm reduction topics ranging from safer injecting practice, injecting site rotation, to HIV, Hepatitis B and C risk reduction and management. Recruitment to participate in drop in centre activities such as primary health care, home based care for HIV positive drug users, referral for VCCT and information sharing on treatment options including MMT, ART and home based care for HIV positive IDU has occurred with IDU using shooting galleries.

LESSONS LEARNED

• Partnerships between shooting gallery and NSP programs offer innovative opportunities to promote harm reduction site and reduce the risks of HIV and blood borne virus transmission to IDU.
  
• Access to these sites through peer approaches can ensure that marginalized groups such as IDU are able to obtain correct information, clean equipment and referral to appropriate and client friendly primary health care services.
  
• Continued advocacy with law enforcement agencies is required to ensure programs can build sustainable demand for safer practices. Involvement of shooting galleries represents a pragmatic approach to harm reduction along with opportunities to promote supportive services for IDU.
  

POSTER 111: Preventing HIV transmission among female addicts in Kerobokan Prison, Denpasar Indonesia, Bali.

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This poster reported on IDU prevention initiatives in Kerobokan Prison for women in Denpasar, Indonesia. It presents lessons learned from a series of education sessions and support/focus groups undertaken with female IDU in this prison and it used a twelve step approach. The overall aim of the project appears to be to reduce or stop drug use among participants. The poster concludes that life skills education and support programs are good methods for female IDU especially where these programs can include recovery, reproductive health and PMTCT to reduce transmission of HIV in prison.

Authors: Ni Luh Putu Ariaqstuti, Yayasan Kasih Kita, Jalan Tukad Pancoran Gang IIIA no 11, Panjer. Denpasar, Baili Indonesia.

ISSUES AND BACKGROUND

Like many other prisons in Indonesia and throughout the world, Kerobokan Prison in Bali faces the issues of drug addiction and HIV/AIDS. In 2003, an estimated 50% of all inmates were entering prison because of drug related offenses. Female addicts are considered more vulnerable to HIV. This risk seems to be higher in prison related to increased risk behavior in prisons and detention center settings.

ABOUT THE PROJECT

The project is part of "Building the capacity of prison in working with substance abusers and addicts and HIV in Bali" project involving prison staff and inmates in Kerobokan Prison. The projects aim is to increase knowledge and practical skills to prevent substance abuse and HIV transmission among female addicts in prisons.

METHODS

• Prison staff and peer educators training on drugs, HIV and Hepatitis C.
  
• Life skills education and support group program to increase knowledge and awareness about addiction, Hepatitis C, HIV and reproductive health female inmates every week
  
• Distribution of IEC materials on addiction, HIV and harm reduction to inmates.
  
• Life skills education
  
• Life skill education activities takes place every Thursday from 9am until 11am. Life skill education conducted in the form of lectures and focused group discussions facilitated by YAKITA staff.
  

Topics discussed during the lectures and/or focus group discussions were adapted from the Yayasan KITA 6 month basic residential treatment program and six month peer training program.

SUPPORT GROUP PROGRAM

This support group program used self help and self supported groups based on twelve step programs for 'substance abusers' [reporters' quotation marks]. The meetings are held every Friday at nine to ten thirty am. In the meetings inmates share their experiences, strengths and hopes in efforts to achieve harm reduction, abstinence from drugs and to share problems relating with their life and coping with the prison environment. The meeting is facilitated and chaired by inmates themselves and also guided by other recovering addicts and NA (Narcotics Anonymous) members.

LESSONS LEARNED

Life skill education and support programs in Kerobokan Prison are a good media to give intervention to female addicts related to their behavior in prison. Comprehensive approach programs include recovery, reproductive health and PMTCT will remarkably reduce transmission of HIV in prison.

ORAL PRESENTATION: Behavior Changes through Comprehensive program approach of targeted education in Xinjiang Red Cross.

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This oral presentation delivered results achieved through a program targeting IDU in Xinjiang by the International Red Cross. Methods included workshops, outreach and referral related to HIV and IDU, relapse prevention, wound care and other basic health issues related to injecting and life skills training. While more outcome data was delivered than the reporter could record at the time the data provided here show significant improvement in general HIV awareness, access to service knowledge and reduction in sharing of equipment. The presenter attributes the success of the program to a non-judgmental approach by the team and the active involvement of affected communities and their families in the design, delivery and evaluation of services.

At the time of posting, Chinese separatists have been blamed for syringe attack violence in Urumqi, the capital of Xinjiang province. Chinese authorities dispatched riot police to the city after more than 10,000 ethnic Han Chinese marched to protest what they consider government failure to protect public safety after attacks in which hundreds of people were stabbed with syringes. Authorities said the Uighur separatists are also blamed for violent riots in July in which syringes were also used and caused over 500 injuries [Source: UNWire].

Author: Ms Hai Liman.

BACKGROUND

Xinjiang is situated in the north eastern border areas of China. It is the biggest province by area but lesser for population (19.2 million). There are 47 ethnic groups. There were 256,940 reported cases of HIV in 2008 - the fourth highest ranking in China in terms of HIV prevalence. Ethnic groups are hit hardest by the epidemic - 85% of all cases in 2003 are among ethnic minorities. The sharing of injecting equipment among drug users is the major HIV transmission mode - 79% in 2007. Double stigma of IDUs and as PLHIV is reported as a significant barrier to better health seeking behavior in HIV positive IDU.

Xingjiang Red Cross HIV Program – provides prevention, Care and Support, Advocacy, Capacity Building – peer education, targeted education, PLHIV Centre, PE Outreach Program, Drama performances, community lectures, staff capacity building.

Targeted education approach and activities:

Methods, approaches and content of targeted education are workshops, outreach, referral of which the content for these interventions includes:

• Major content: understanding drugs and drug use, and introducing relapse prevention
  
• Basic HIV information
  
• Understanding dependence, and types of drugs
  
• Basic skills: how to deal with overdose, basic wound dressing and syringe cleaning
  
• Life skills for behavior change – revisiting peer pressure
  

PROGRAM EVALUATION 2008

Evaluation utilized UNAIDS Global AIDS Monitoring and Evaluation Framework. Knowledge and attitudes of injecting drug users: comparisons between the respondents who were beneficiaries of XRC project activities and those who were not. Evaluation Findings: 100% know where to get clean NSP 100% (n=54); 83% know where to go to get condoms (n=45); Any sharing in the last 6 months outside the program was 8% while inside the program was 12%. The presenter reported that the knowledge increase ranged from 15-32% in participants and the overall affect of the program on supporting an enabling environment was significant in terms of reducing incidents of stigma and discrimination in the province.

KEY ELEMENTS OF SUCCESS

• Red Cross: non judgment, respect, empathy, equal/working together.
  
• Close involvement of target people, IDU families, friends and their community
  
• Provided wide information and skills which previously IDU were unable to access
  
• Information upgraded on a continual basis.
  
• Facilitated access to available services
  
• Building supportive environment for family and community.
  

POSTER 156: PANAZABA – HIV/AIDS Prevention among drug user using critical awareness

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This poster presented on a program called PANAZABA "Drug Victims Community Bandung". (Note that some aspects of this poster were not clear as the English capacity of the author or translator was not high and some language would be considered inappropriate by IDU advocacy groups).

Name: Febby Cahaya. K. Website: www.panazaba.org.id

Government health services data from 1989 to Sept 2008 shown about 4,051 HIV cases reported in West Java. There are 132 cases in Bandung (according to this poster). This means HIV/AIDS is growing over the years. "HIV/AIDS preventions method happens not to touch the drug 'victims' [reporters' quotation marks] who became social movement subjects. Critical Education is a way that oppressive in thinking process and drug victim involvement in making avoidance in HIV spreads to themselves and their environments." (I think this means that HIV prevention doesn't reach IDUs or engage them and involve them in prevention of HIV to themselves and others).

The drug victims' community in Bandung (PANAZABA) is an organization that fights for the drug victims right through reorganizations, advocacy, and campaigns that aim to change social paradigms. Critical Education is a way to treat and to prevent HIV/AIDS because it involves key populations as Transformation Agents.

RESULTS

Results of PANAZABA are reported in the poster in a number of ways: the program has more than 100 members that have connections in their territories and provide ongoing critical education through discussions that put the PLWHA IDU point of view. They appear to engage IDU and PLHIV in critical discussions involve them in HIV/AIDS prevention interventions.

LESSONS LEARNED

• PLHWHA IDU gains health access without stigma and discrimination
  
• Treatment and preventions of HIV/AIDS can more effectively be undertaken with Key Populations involvement
  
• ODHA IDU basic needs are more understandable by doing critical discussions (I'm not exactly sure what this means)
  
• "Respect Drug User Right as a Human Right"
  

POSTER 153: Empowering Teachers of Penabur, Jakarta to be the agent of change on drug abuse and HIV prevention.

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This poster presented a teacher training pilot aimed to raise awareness of "drug abuse" [reporters' quotation marks] and HIV prevention. It argued that "the wrong paradigm on AIDS and drugs abuse in school will lead to misperception."

Author: Andreas Sigit Pamungkas

The program was a Live-In-Program for senior high school teachers (60 teachers involved). The curriculum involved mainly sharing experiences with "drug abusers" and PLHIV. It included information on how to prevent the transmission of HIV, how to get access to VCT, how to "deal with" PLHIV and "how to control the drug abuse problem." [Again, quotation marks are the reporters].

RESULTS

Results reported included increased knowledge and changed behavior towards PLHIV and drug abusers (not exactly sure how this was evaluated as information about this was not provided). The author suggests that the program empowers the teachers to be the agent of change, changing students' paradigm.

POSTER 152: Drug Users community based HIV prevention and Care in West Java

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This poster presented field analysis from community-based HIV prevention and care programs to drug users in West Java. As an introduction it presented that the number of reported cases of HIV continues to increase significantly in West Java. All districts have reported HIV infections. It reported that IDUs contribute 68% of HIV infections in West Java through needle sharing practices and are thus a high priority for intervention.

Authors: Suharni, Siswanto, Suwartini, Bayu, Mochammad

The authors reported on a project initiated in 2003. It was a community-based intervention which incorporated sensitization of local community, IDU socio-cultural norms and practices. It was established in 10 districts/cities managed by six NGOs. Project staff were trained on technical and social-cultural aspects of the interventions in which outreach was a program key component and education on safe injecting practices, use of clean needles and effective use of condoms were key interventions. IDU and their partners were "motivated" to have HIV counseling and testing (HCT) - case management for HIV IDUs was reported as part of the program of services.

RESULTS

• By December 2008 7,598 IDUs were reached.
  
• 1,308 (17.2%) IDUs received HIV counseling and testing (HCT).
  
• Case managers assisted 1,813 HIV and drug addiction-related cases.
  
• Over 500 volunteers with drug injecting backgrounds were involved.
  
• 291,795 clean needles and 87,267 condoms were also distributed.
  

Authors argue that outreach is a key component in working effectively with IDUs. Participation of IDUs and local people in the program is essential. Support from local authorities and community leaders, provision of essential and accessible services are the key to program success.

ORAL PRESENTATION: Using Quality Improvement Processes to Improve Program Performance

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Presenter: Rizky Ika Syafitri (FHI Indonesia)

This oral presentation reported on an FHI program to deliver clean syringes and HIV prevention information to IDU in Indonesia. It was particularly concerned to analyze the ways that data was used to improve programming and quality of service delivery.

It found that the program reached inadequate numbers of IDU and distributed inadequate numbers of syringes. For example the frequency of contact was only 1-2 times per month in which a total of 1-15 needles were delivered to individual IDU through outreach. The key finding here was that minimum level of contact frequency needed to be at least 3-4 times per month in which 20-25 needles were delivered to individual IDU.

A concern for IDU in Indonesia is the law that prohibits the carrying of needles and makes arrest highly likely if stopped by police. However, the need to provide adequate numbers of needles is highlighted and was noted by the speaker as an essential strategy for increasing health and decreasing risk of HIV transmission. Legal change is required.

• The speaker recommended that an evidence based model, guidelines and procedures and minimum standard of interventions should be in place before QI processes are undertaken.
  
• Database systems and routine monitoring are needed to continuously monitor program performance
  
• Technical support and encouragement are crucial.
  

HEALTH AND WELLBEING OF IDUs, THEIR PARTNERS AND FAMILIES

ORAL PRESENTATION: Health Status at Baseline of a Cohort of Drug Injectors in New Delhi

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An oral presentation by Luke Samson et al reported on a cohort of IDU in New Delhi, India and reported the health profile of this group with a view to better understanding the impacts of ill health and poverty on consistent use of clean injecting equipment and safe sex. The research focused on 449 IDU in New Delhi over 18 months beginning in 2004. All participants were men, mainly single (74%) although 29% reported having children. 60% of the cohort was employed as scavengers in which their daily income was around US$2.4, the majority were homeless and 62% had no access to toilet facilities. 38% of the cohort were underweight at baseline and the average BMA was 19.2. Only 66% had ever heard of AIDS and of these 65% had low functional knowledge. 45% believed they were already HIV positive. 46% believed they would eventually acquire HIV and 19% knew someone who had died of AIDS. 22% were HIV positive at baseline while 10% were Hep C positive and 50% Hepatitis C positive. 13.6% had syphilis at baseline and systemic infections affected were experienced by a third of the cohort. 85.5% initiated drug use after the age of 17 and the two drugs reported as most regular included cannabis (57%), heroin (18%). Half the cohort reported injecting for less than 5 years while 59% used injecting and non injecting drug together. The authors conclude that integrated welfare and health programs are essential to NSP success in resource poor settings.

Authors: Luke Samson, Enisha Sarin, Jimmy Dorabjee, Basant Singh, Mike Weat

BACKGROUND

The program followed a cohort of 449 IDU in New Delhi India for up to 18 months beginning in 2004 to assess the effectiveness of sequential interventions: NSP, condom access, health education, case management, nutrition, VCT, medical care, buprenorphine. The
study area and recruitment was New Delhi population. Study Site Yamuna Bazaar and this is the earliest hub of IDU in New Delhi. Eligibility – self reported injecting over 18 years; resident in area. Examine the impact of a sequential set of interventions for IDU e.g. NSP, substitution, nutrition, residential care programs. Measures included baseline survey questionnaire assessing demographics, knowledge and attitudes, sexual history, drug use history, medical history, voluntary screening for HIV, syphilis, Hepatitis B and C.

RESULTS

All participants were males from 18-64 years mainly single (74%). 29% reported having children. 66% had less than 5 years of formal schooling. 60% employed as scavengers. Average daily reported income $2.4. 92% were homeless and 62% had access to a toilet. 66% had heard of AIDS of these 65% had low functional knowledge, 46% believed they would get AIDS, 49% believed they had AIDS, 19% knew someone who had died of AIDS.88% reported having had sex in their life time but current rates were low (71% not engaged in sexual activity). 17% reported unprotected sex in the past six months. 18% reported having paid for sex in last six months. 4% reported anal sex in the last 6 months.85.5% initiated drug use after age 17. 57% were using cannabis; 18% heroin. 54% reported injecting for less than 5 years. 59% used injecting and non injecting drugs together. 22% of participants were HIV positive at baseline. 10% were Hepatitis B positive. 60% were Hepatitis C positive. 13.6% had syphilis at baseline. Systemic infections totaled 30% of the cohort. The average BMA was 19.2 with 38% clinically underweight at baseline. Mental health is abysmal (presented in another paper in this conference). Psychiatric co-morbidity not captured as it was beyond the scope of the study.

LIMITATIONS

TB status not considered in health status although the same population was treated for TB , data captured was of poor quality due to lack of resources.

OVERALL CONCLUSIONS

Ill health, poverty and homelessness present a significant challenge to the notion of a comprehensive package services to IDU. The abysmal BMI shows the need for nutritional interventions. The reality of 92% of the population being homeless exacerbates vulnerability to multiple infections (22% HIV infected = low resistance). Poor literacy and the reality that over 90% of the reported income was spent on drug use indicated little or no resources for nutrition or health related expenditure. The reality that 60% that Hepatitis C positive complicated access to ARV treatment and currently no interventions are available. 31% reported prior participation in buprenorphine substitution program that was run by Sharan. The substitution program closed two years prior to the study and only NSP was available to this population. Clients recruited were from Sharan's NSP program supported by Delhi Government of which 87% reported sharing needles accessed through the needle exchange program. This population represents the average clientele covered AIDS Control Targeted Interventions the bulk of whom are only being provided with needles and syringe.

Targeted interventions appear to be severely compromised unless they take cognizance of the need to build linkages with IDU/HIV interventions, general health interventions including Hepatitis C and poverty alleviation measure including access to food and shelter.

FLOOR DISCUSSION AND QUESTIONS

This session stimulated some questions and debate from the floor which was particularly interested and so the discussion is provided here for the reader.

Q; 87% still sharing needles is stunningly high. Are you saying that if you just give out needles and syringes, needle sharing will continue unless accompanied by a number of other services? Do you need nutrition and counseling programs to modify behavior?

A: not sure there's a clear answer. We count reduction in sharing episodes –but what is in that? Were they sharing every day? How was it happening? There's been a large amount of NSP – it's not that it doesn't work it's just that it isn't enough unless it is complemented with additional services to sustain it – simple factors, if you are spending 100 rupees a day on heroin-use then what's happening? You might have borrowed money, people will be looking for you. You may also have engaged in petty crime and so you won't go to the same NSP because people will get to know that you go there.

Q: sharing equipment 84% - what's in it? The model you're proposing includes dealing with suicidal issues, homelessness, nutrition and shelter and family counseling - are there any good examples that you know of in South Asia, in a resource poor setting, that provide a more comprehensive program?

A: We would like to think that we've spent a huge amount of time and energy on local messages and in terms of cleaning needles and syringes. I think there is hopefully a little more education. The problem is that it's a moving line – money and funding change and services change so it's difficult. I haven't found an international model that is completely acceptable. We have no integrated residential care with substitution or one stop shop concept.

POSTER 170: Family support of Jakarta and Bali IDUs receiving antiretroviral (ARV)

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This report notes that many studies support the effectiveness of ARV therapy in resource poor areas but data are sparse from areas like Indonesia where IDU is a key risk factor. Social isolation, ongoing substance use, unstable housing, depression and absence of outreach, drug treatment and other support services are potential obstacles to effective ARV use in IDUs. This report focused on analyzing the ARV and care needs IDU with HIV in Jakarta and Bali who live with their families. The authors conclude that the family context represents a useful one for promoting ARV adherence and appropriate levels of care to IDUs with HIV. In particular, they propose using family support as a key component of ARV support to IDUs and continuity of overall care.

Authors: RC Hershow, S Lenggogeni, O Kamil, M Setiawan, R Tambunan, Irwanto. Institutions: UIC School of Public Health, University of Illinois at Chicago, Chicago, USA; Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia; Keri Praja Foundation, Bali, Indonesia. Funding for this project was provided by the National Institute of Child and Health Development NIH.

OBJECTIVES

Objectives of the study were to assess and compare the availability of family and friend support, substance use treatment, other support services satisfaction with HIV care and self reported ARV adherence among IDUs receiving ARVs in Jakarta and Bali. Also the study aimed to assess the prevalence of potential obstacles to successful ARV use such as ongoing substance use, depression and social isolation.

METHODS

Included cross sectional survey of 130 HIV infected adult patients who have been receiving ARVs for at least 3 months in Jakarta (n=60) and Bali (n-70). Also participants interviewed using a structured questionnaire regarding 1. Demographics, 2. Family and friend support, 3. Use of support services including drug treatment 4. HIV care satisfaction 5. Current substance use, 6. Depression screen using CES-D instrument and 7. ARV adherence. Also 36 randomly selected Jakarta participants underwent serum HIV RNA viral load testing at enrolment.

CONCLUSIONS – HIV care and adherence

• Among IDUs receiving ARVs in Jakarta and Bali, ARV adherence and satisfaction with care are reasonably high.
  
• Although ARVs are free, nearly half of participants claimed that associated HIV clinical costs were problematic
  

CONCLUSIONS – Family and Friend Support of ARV Use

• In Jakarta and Bali, most HIV infected IDUs live with family. For the great majority of participants, relatives are aware of their IDU and HIV status.
  
• For married persons, spouses are the family members who offer most assistance with ARV use. For unmarried participants, mothers are considered "most helpful".
  
• Reminding participants to take ARVs is common, but family-supervised directly observed ARV therapy is uncommon.
  
• Participants less commonly disclose their HIV status to friends and tend to distance themselves from drug using acquaintances after starting ARVs.
  

CONCLUSIONS – Use of Support Services

• Outreach services and case management are available in Jakarta and Bali, but only a minority report contact in the last month; HIV+ support group attendance was more common in Bali. Narcotics and Alcoholics Anonymous were only available in Bali.
  
• Methadone and other drug treatment modalities are available in Jakarta and Bali and current heroin use is reportedly uncommon in this population.
  
• Although 29% of participants are depressed by CES-D screening, less than 5% report recent use of mental health services.
  

IMPLICATIONS AND FUTURE STUDY

• It may be reasonable to enlist family to play a more direct role in facilitating successful ARV use, relieving some of the burden on outreach and case management support services.
  
• Analyses are planned to compare the clinical course of patients after initiation of ARVs to examine the effects of drug substitution therapy, depression, and ongoing substance use on clinical response to ARV therapy.
  
• This is a highly select group of patients who have managed to enter HIV care and sustain ARV use over time. Even in this select group, almost half report that HIV care costs are problematic. More research is needed to explore cost and other factors that may impede or facilitate successful entry and retention in HIV care.
  

POSTER 290: Factors related to Hepatitis C (HCV) prevalence among sexual partners of HIV/HCV co-infected patients

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This poster reported upon the prevalence of Hepatitis C among a cohort of sexual partners of HIV/HCV co-infected IDU in Jakarta, Indonesia. 118 participants were enrolled in the study and the majority were female. As well as baseline health status investigation and analysis of medical histories, the research used structured individual interviews to seek information from participants. HCV prevalence was 9.3% among subjects at baseline. Non vaginal sexual contacts and HIV positive status increased the risk of acquiring HCV infection up to 8 times. The poster concludes that screening and prevention program for HCV transmission upon high risk groups should be integrated in to HIV service centers.

Authors: Sri Agustini Kurniawaqti, Teguh H. Karijadi, Rino A. Gani. Institutions involved: International Medicine Dept, Medical School, University of Indonesia; Allergy Immunology Division Internal Medicine Dept, University of Indonesia; Hepatology Division International Medicine Department, University of Indonesia.

BACKGROUND

Management of hepatitis C virus co-infection in Indonesia has become an emerging issue due to improved life expectancy of HIV patients because of the availability of free ARV by government. Prevention of HCV is an important part of management of HCV infection. Various factors related to transmission of HCV among sexual partners of HIV/HCV co-infected patients were not previously investigated in Indonesia. Thus, the research was conducted with the purpose of evaluating the prevalence of HCV infection and identifying factors related to HCV prevalence among sexual partners of HIV/HCV co-infected patients, as an important part to the better quality of health service in HIV/HCV co-infected patients.

METHODS

This was a cross sectional study among non-intravenous-drug-using sexual partners of HIV/HCV co-infected patients in the outpatient clinic Pokdisus Ciptomangunkusumo Hospital, Jakarta. Index patients were taken from medical records. Evaluated risk factors included blood transfusion, HIV status, condom use, numbers of sexual contacts, numbers of sexual partners, types of sexual contacts, and CD4+ count of HIV/HCV co-infected patients. Data was collected using structured interviews with individuals for each group. Blood samples were taken for examination of anti-HCV third generation and anti-HIV ELISA. Statistical analyses were performed using CHI square or Fisher Test and logical regression with CI 95%.

RESULTS

During May-Aug 2008, 118 eligible subjects participated in this study. The median age was 26 years (range 19-39) 96.1% were female. HCV seroprevalence was 9.3%. In univariate analysis, higher HCV prevalence was evident in subjects with HIV positive results or in subjects with non-vaginal sexual contact even though in multiple logistic regression analysis showed that only subjects with non-vaginal sexual contacts correlated with HCV prevalence.

CONCLUSIONS

HCV prevalence was 9.3% among subjects. Non vaginal sexual contacts and HIV positive status increased the risk of acquiring HCV infection up to 8 times. Based on these, screening and prevention program for HCV transmission upon high risk groups should be integrated in to HIV service centers. Total larger samples and genotype examination of HCV in both spouses were needed to evaluate HCV sexual transmission.

SEX AND IDU

Poster 169:
Condom Use and Sexual Networks of IDU&s in Bandung, West Java, Indonesia, A Review (On behalf of IMPACT Project Indonesia).

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This poster presented a literature review undertaken to report on available data related to condom use within sexual networks of IDUs in Bandung. Its importance is highlighted because the numbers of IDU is estimated at around 22,000 in West Java while numbers of IDU reported as living with HIV is 60% (UNAIDS, 2006). The literature review reports that, while risky injecting drug use is reducing from 33% in 2004 to 24% in 2007 across the six big cities of Indonesia, in Bandung 82% do not use condoms consistently with their regular partners while 72% do not use condoms consistently with their casual partners and 45% don't use condoms consistently with sex workers (IBBS, 2007).

Authors: Basar, Indriasari, Prawiranegara, Pinxten, Martodirdjo.

BACKGROUND

This poster presented some initial facts on Indonesia, HIV and IDU. Indonesia has the fastest growing HIV epidemic in Asia more than 1,000,000 HIV infected by 2005. IDU are believed to make up 52.4% of HIV-infected populations in Indonesia. There has previously been reported HIV transmission from IDUs to the general population due to high rates of unprotected sex by IDUs and their partners (including regular, casual partners or female sex workers (Pisani 2003). Condoms have a poorer reputation in both the Indonesian general population and among HIV risk groups and no improvement in consistent condom use in this group with spouses, casual partners and SWs is reported.

This poster reported on a literature review of available data on condom use within the sexual networks of injecting drug users in Bandung. Its method was to first literature search for studies on IDU and collect all statistical data related to condom use among IDU in Bandung. It then analyzed and reviewed studies on condom use among IDUs in Bandung.

RESULTS

Results included findings that analyzed the current HIV situation among IDUs. Numbers of IDU estimated at 22,000 in West Java with 60% of IDUs infected with HIV (UNAIDS 2006). Latest official data stated that 46% are already infected by HIV are IDUs (KPA, 2006). In terms of IDU Risk Behavior the study looked at injecting behavior in Bandung and said there is a positive tendency of reduce d needle sharing from 33% in 2004 to24% in 2007. In terms of sex, data from 6 big cities in Indonesia (Jakarta, Medan, Bandung, Surabaya, Semarang and Malang) show that 38-39% of IDUs have regular partners and 20-60% have casual partners. Between 9 and 54% of IDUs buy sex (IBBS, 2007). In Bandung, 60% of IDUs have multiple partners with 59% have regular partners, 59% have casual partners and 46% buy sex, 10% sold sex (IBBS, 2007) In terms of condom use – In Bandung 82% of IDU do not use condoms consistently with their regular partner, 72% do not use condom consistently with casual partners and 45% do not use condoms consistently with sex workers (IBBS, 2007). Reasons for not using condoms with regular partner included that IDUs were afraid of suspicion from their regular partners. In casual partners and female sex worker there was no plan for having any sexual relationship before (I think this means these were fairly spontaneous encounters with no pre-planning) and that they had not been in the habit of using a condom. Among female sex workers the decision to use condoms was seen as dependent upon the client's attitude and preference for condom use. There were also reported some attitudes and myths about condom use – in particular that they lessen the experience and satisfaction of having sexual relationships.

CONCLUSION

Conclusions from this study are that inconsistent condom use by IDUs having sex with multiple partners results in the "spill over" to FSWs and subsequently to the general population. Gender inequalities affected the decision to use condoms. 100% condom use enforcement is the first step to fight the spreading of the HIV. More in depths research s needed.

ORAL PRESENTATION: Night Outreach: Addressing Female Injecting Drug User Sex worker needs West Jakarta, INDONESIA.

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An oral presentation from West Jakarta reported upon night outreach to female IDU sex workers through the organization Kios Atma Jaya. They reported on the activities and results of the project which included night outreach that promoted attending to the reproductive health of the target group, educated on negotiating condoms in sex transactions, provided advice on keeping safe during police raids and referrals to STI clinics. The numbers female IDU sex workers reached were particularly small but numbers female IDU (who were not sex workers) was higher. The approach was noted as innovative for Indonesia.

Authors: Nazaruddin latief. Atma Jaya University Jakarta, Indonesia.

KIOS ATMA JAYA PROFILE

Started 2002, outreach is used as a platform for the intervention, outreach carried out in three municipality spread over in 12 sub district in west, north and center of Jakarta, Kios program focus is to prevent HIV infection among IDU and their sexual partners.

PROGRAM ACTIVITIES

The range of program activities for this particular project included outreach NSP, VCT, case management, basic health services, HIV and drug dependence counseling, peer education, advocacy, support group, vocational training.

TARGETING FEMALE, DRUG INJECTING SEX WORKERS (FISW)

KIOS identified female IDU who worked as sex workers as at particular risk of HIV infection through sex and injecting. However, no specific program and intervention was available for FISW, there is limited understanding of HIV and STI among this group, low access to condoms and a weak bargaining position with sex client regarding condom use.

The best time to reach FISW is at night time but this puts a particular stress on CBOs in terms of attracting staff to work at those hours. In the BCC intervention itself there is usually limited time to communicate and provide information education due to the work and activities in the street. The streets in which FISW work are often crowded and education occurs in a hectic environment. Police raids make it difficult to work. Kios has twelve outreach workers who carry the main responsibility for reaching IDU and IDU sexual partner generally. To meet the need to target FISW seven out of twelve outreach workers were used for this project.

STRATEGIES

A set of strategies were used to make this work most effective and they included:

• Rearrange schedule for outreach team to be able to do outreach at night
  
• The best time to reach FISW is before 'peak hour (around 2-3 am)
  
• Approaching FISW through the pimp
  
• Involving local people associated with FISW activities to deliver prevention material and promoting health services
  

The particular outreach activities engaged for this project included:

• Promoting of reproductive health services
  
• Condom negotiation techniques
  
• Referral to STI clinics
  
• Safety procedures on police raid situation
  

PROGRAM OUTCOMES

• 5,570 total IDU reached by Dec 2008 in which 349 were female IDU and 53 were FISW
  
• Needles distributed to FIDU and FISW 21,986 while Condoms distributed to them totaled 13,366
  
• FISW accessing VCT totaled 21 and IEC materials distributed to FISW totaled 2,471
  
• Night outreach only twice per week
  
• 341 FISW were reached in the current life of the project
  

LESSONS LEARNED

• Female IDUs who also work as sex workers are the hardest group to reach. Different approaches and strategies were needed to reach them.
  
• Flexibility to different times (shifting)
  

POSTER 386: Sexual Networks Study among IDUs in Indonesia

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This poster reported on the sexual networks of IDUs in Indonesia. It began with a background on HIV in Indonesia explaining that by year 2004, it was estimated almost 50% of IDU in Indonesia have been infected with HIV/AIDS. Potential sexual transmission of HIV IN injecting drug users is increasing. Understanding IDU sexual networks, the nature of sexual relationships and sex risk is still limited. This investigation, initiated by FHI aimed to address gaps in knowledge.

Author: Octavery Kamil, AIDS Research Center, University of Atmajaya; Ignatius PraptoRaharjo, University of Illinois at Chicago, USA; Wayne Wiebel PhD, University of Illinois at Chicago; Alfred PachIII PhD, Consultant.

METHODS

The study was conducted in 4 big cities in Indonesia (Jakarta, Surabaya, Medan, Bandung and Denpasar, Bali). The study used purposive sampling design to include IDU representing various characteristics at each location. Inductive analyses revealed common themes and exceptional cases.

FINDINGS

Findings include:

• Sexual relationships among IDUs in the study covered an array of relationships based on different levels of emotional intensity, social involvement, sexual activities and risk behavior. They also varied in their age, social group membership and risk profile, which reflected patterns of sexual mixing and a bridge of HIV transmission.
  
• IDU informants found to commonly have regular casual and commercial sex partners. "Serious relationships" included emotional ties and mutual expectations and obligations. Those with regular sex partners had concurrent relations with casual and/or commercial partners. Male IDU also reported sex with transvestite and other males. Condoms were rarely used during sexual activities.
  

The result demonstrate that with the sharp increase in HIV infection among IDUs the substantial proportion of IDUs who buy sex, lack regular condom use and are involved with multiple partners, will lead to an increase in HIV prevalence among their different sexual partners and partners of their sexual partners. Effective and high coverage interventions aimed at simultaneously reducing injecting and sexual risk behavior among IDUs and their different sexual partners are urgently required.

ORAL PRESENTATION: INJECTING AND SEXUAL RISK BEHAVIOR AMONG FISHERMEN IN KUANTAN, MALAYSIA

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One of the most significant statements by the presenter of this paper was that, previously, alcohol use in Muslims at risk of HIV has not been a factor considered in research or education. However, given the high rates of alcohol use by participants in this study, there is a need to reconsider alcohol consumption in those at risk of HIV residing in Muslim countries.

Authors: Sumathi Govindasamy, University of Malaysia: Centre of Excellence for Research in AIDS

BACKGROUND

Fishermen account for 4% of all HIV cases in Malaysia. IDU behavioral survey findings from Kuntan Feb 2007 found 69 out of 100 were fishermen whose first IDU experience was at 23 years of age. HIV prevalence among fisherman in this survey was 42%. Port doctor use (a service that provides 'black market' assisted injecting) was 25% by participants in the sample. Polysubstance drug use is high (BPN 65%; heroin 42%; stimulants 26%). Sex with sex workers was 6%. SEP began July 2007.

OBJECTIVE

This study aimed to describe the injecting and sexual risk behavior of fisherman in Kuantan 1 year after SEP implementation.

METHOD

Sample size was 69 fisherman. Modified snowball recruitment was used in which drug use was not an eligibility requirement. Method included a 30 minute questionnaire that gathered information on demographics, IDU, sexual behavior, general health, HIV awareness from individual participants. There were also qualitative interviews using open ended questions with some individuals (n=15).

RESULTS

• mean age of respondents was 42 (between 21-70).
  
• The majority of respondents were Malay Muslims = 91%.
  
• Those having less than secondary school education = 54%.
  
• Those married = 51%.
  
• Those who earned below poverty level = 44%.
  
• Those who spent more than 6 months at sea per year = 84%.
  
• Among these fisherman 38% had injected drugs, 30% were recent injectors, 66% of IDUs had not shared, heroin was most common drug used = 78%.
  
• 25% continues to use port doctors despite having access to new needles
  
• 4 reported visiting sex workers in previous month: 3 were HIV+ and only one used condoms.
  
• IDU correlated with 1. Occupational role as crew. 2. Being unmarried 3. Time spent at sea. 4.
  
• Consumption of alcohol was high.
  
• Drugs and Fisherman: fisherman and drugs cannot be separated.
  

SUMMARY

HIV prevention remains a challenge with this population because they are often away from HIV prevention activities, drug use is culturally embedded within fisherman's lives; ii is as yet unclear the role of alcohol and IDU; HIV and drug treatment will similarly pose a challenge due to logistical constraints.

LIMITATIONS

Relatively small convenient sample; limited to one geographical area.

BROADER IMPLICATIONS

• fisherman appear to contribute greatly to the economy of SEA;
  
• fisherman are at increased injection and sexual risk in Thailand, Vietnam, Cambodia and Indonesia;
  
• no clear and effective model for reducing HIV transmission and providing treatment in this logistically challenging population.
  

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