Strict Indonesia backs free needles for drug users

The atmosphere at the clinic seems jovial. But Budi, a visitor, is in no mood to linger. Having gotten what he needed, he slips out onto the busy street, on the move again.

His immediate plan: find a safe place to shoot up with his new syringe.

Budi's age - 28 - and heroin drug habit make him a prime target for needle-exchange projects like this one, run out of a nondescript house in Bali's capital, Denpasar. Using donor funds with a quiet nod from local authorities, Yayasan Hati-Hati (Take Care Foundation) hands out hundreds of needles a month to local drug users.

For Indonesia, whose strict drug laws include penalties for carrying a needle without a doctor's prescription, helping addicts to inject safely would have been unthinkable in the past. What has forced a sea change in attitudes, at least in some government circles, is an alarming rise in needle-borne infections from HIV and hepatitis.

"There's no ambiguity. Indonesia's youth are injecting in large numbers...." says Jane Wilson, country director of the United Nations program for HIV/AIDS in Jakarta. "If we want to do something about HIV in the drug community, we only have a limited window open to act."

A similar shift is under way in other countries in Asia, where traditional law-and-order responses to illegal drugs are mixing, often uneasily, with efforts to reach out to drug users. In doing so, they are following a lead set by European countries that have long recognized the limits of law enforcement efforts against drug addiction.

China recently approved needle exchanges in six provinces, while India already has similar projects running in Manipur state, a prime heroin-smuggling route. In the Middle East, state-sanctioned needle exchanges and methadone projects are up and running in Iran, with support from the World Health Organization.

Advocates of "harm reduction" say Asian leaders must be pragmatic if they want to stem the transmission of HIV both among drug users who share needles, and into the wider population through unsafe sex.

"What we're doing is protecting young people who use drugs, and ultimately that helps everyone," says Patrick O'Hare, executive director of the International Harm Reduction Association, a campaign group in Melbourne, Australia.

That includes Budi, who so far has escaped the virus. But 24 of 35 drug users at the same center have tested positive, an infection rate mirrored at other drug clinics. Indonesia has 200,000 to 1 million injecting drug users (IDU).

Experts say high-risk groups like Bali's needle users, who are young and sexually active, often act as a reservoir for the virus. Surveys show that few use condoms and sometimes visit prostitutes, another high-risk group.

"The data for IDUs is not encouraging. We're continuing to see higher and higher rates of HIV in drug users," says Ms. Wilson.

Budi, whose smooth skin belies a 12-year habit, says he knows the dangers of using dirty equipment. "Clean needles don't help me to stop [using drugs], but at least it's less risky," he says.

The Bali project is one of two needle exchanges in Indonesia that, while already quietly operating, has received government backing, if not explicit legal approval, within the past 6 months. Six more plan to open around the country by year's end using Australian and US funds earmarked for anti-AIDS programs.

Staff workers in Bali say that police are so far taking a hands-off approach and have recently issued identity cards for workers who distribute needles. But the notion that drug addicts should be helped, not hindered, remains controversial here, as it does in many countries.

"This [harm reduction] is a new approach in Asia, so of course it can be hard for police to accept ... because in the meantime the [drug] laws haven't been changed, so it requires some pragmatism," says Dr. Sandro Calvani, regional director of the UN's Office on Drugs and Crime.

Thailand earlier this year launched a bloody war against drug dealers that has sent many addicts into hiding. After a period of relative tolerance, Vietnam recently cracked down on private outreach programs for addicts in Hanoi and Ho Chi Minh City.

Across Asia, police and antinarcotics officials worry that harm reduction sends the wrong message to young people, undermining years of stern antidrug campaigns. Many continue to insist that medical treatment and abstinence is the answer to addiction.

"A lot of police grow to hate and despise drug users. They don't understand why they don't just give up the drugs," says Drew Morgan, an Australian policeman based in Hanoi for an AIDS-awareness training program for Asian security officials.

The result is often a clash between public health officials, who tend to support harm reduction - even if it breaks the law - and security officials who dislike bending rules. "Even if high-ranking police say, 'OK, go ahead [with harm reduction],' the lower ranks are still resisting and trying to arrest people," says Djoko Suharno, a member of the National AIDS Commission.

Advocates of harm reduction insist that they aren't promoting drug use, rather accepting that, until users can break their habit, safer behavior is paramount.

"Rehabilitation is the best way, sure. But if addicts then relapse, what do we do?" asks Dr. Dewa Wirawan, who runs a health clinic for prostitutes in Bali and sits on the provincial AIDS commission.

"Five years ago, we couldn't talk about needle exchanges. Now it's easier to advocate this policy to the people, but when you've got 50 percent infection rates, it's too late," says Dr. Wirawan. "This is our dilemma."