This essay is part of a series on harm reduction responses to drug use in the MENA and Asian regions—the actors and networks engaged in such activities, the contributions they have made, and the roadblocks they have met. Read more ...
Harm reduction started in Asia about two decades ago, as a response to both the increase in injecting drug use and the spread of HIV/AIDS in the region. Most of these programs were spearheaded by community organizations and NGOs, often in conflict with the more moralistic approaches of their respective governments. Indonesia began moving toward the adoption of harm reduction policies in 1999, when various stakeholders gathered to discuss the state of AIDS and injecting drug use in the country. At the time, there were no statistics available, but by the end of the year, YAKITA—a drug recovery center in Bogor, West Java—presented its first findings. Of the 50 injecting drug users (IDUs) who were tested at the recovery center, 14 percent were found to be HIV positive and an astounding 80 percent tested positive for hepatitis C. This test was followed by another, conducted by Fatmawati Hospital, which cited a 15 percent HIV infection rate among drug users in their care. They did not test for hepatitis C. While these test results showed the gravity of the problem, it took years of lobbying and advocacy before harm reduction was accepted as a plausible way to stop the AIDS epidemic driven by injecting drug use.
By 2002, harm reduction was supported by the Indonesian government. No longer do communities and NGOs have to hide from law enforcement officials because they are carrying needles and syringes for distribution. Identity cards have been issued to outreach workers. Needle-syringe programs are widely available in local community clinics. Furthermore, some NGOs continue to help injecting drug users access the range of available services, including HIV testing and antiretroviral therapy. Although drug consumption rooms have not been provided, Indonesia has implemented a basic harm reduction policy that includes needle-syringe programs and opioid substitution treatment (or drug replacement therapy). In addition, government-supported, community-based rehabilitation programs lasting one to two months have been established for drug users who wish to “get clean.” These are located in priority areas that are considered at-risk based on HIV infection rates and the high number of IDUs reported in the vicinity.
Started by communities and NGOs, harm reduction programs are now being implemented by the Indonesian government. However, lack of funding is seriously undermining the gains achieved so far. External funding began plummeting in 2006. At that time, most foreign funding was redirected toward national programs and was thus provided directly to host governments. As a result, many NGOs found their promised program funding suddenly taken away. When in 2012 Indonesia was declared a middle-income country, funding was further reduced and redirected to low-income countries. Shifts in bilateral aid priorities and narrowing international budgets have added to the problem. Even at its height, the funding was barely sufficient to provide basic harm reduction services. Due to these issues, some community services and NGOs that focused exclusively on harm reduction programs have begun to close down, and outreach in some areas has come to a full stop. In other areas, prevention and outreach services have been cut back.
While those working in harm reduction can see and prove that harm reduction significantly decreases the rate of HIV infection and other blood-borne infections among injecting drug users, this is often not so obvious to the wider public. The number of those served under harm reduction programs has risen, but this increase is often misconstrued by the public as proof that the number of people with drug problems has grown. The lack of funding, coupled with inadequate training of workers in the harm reduction field and their increased work load, has in some places reduced harm reduction programming to needle shuffling and substitute therapy pushing without meaningful client engagement. This approach undermines the effectiveness of harm reduction interventions.
Meanwhile, increasing drug trafficking “busts” have raised public awareness and indeed anger over the state of affairs regarding drug abuse. It is no wonder that in 2015 Indonesia declared a national state of emergency over drugs and drug use and launched a “war on drugs.” Law enforcement efforts have targeted traffickers, but those apprehended and/or executed are soon replaced by others. Poor people in need of cash are more likely to hope that they will not be caught than be deterred, while the most powerful actors within the trafficking networks arguably would prefer that these “mules” be executed to cover their tracks.
The downward spiral in funding over the last decade to support AIDS programming in general and harm reduction specifically has undoubtedly decreased the effectiveness of services. According to the Ministry of Health, Global Fund has come to view Indonesian HIV/AIDS prevention as less than effective. The conclusion was based on low rates of condom use, which amounted to three percent among married couples, 41 percent among injecting drug users, 35 percent among sex workers, 24 percent among homosexuals, and 41 percent among transgender people, according to a 2011 survey by the ministry. The criticism did not take into account that condom use was highest among IDUs and the transgender community. The same survey recorded a 10 percent decrease in new HIV cases among IDUs compared to the 2007 survey, but these encouraging results were also apparently disregarded. In the face of its severe funding shortfall, the AIDS program in Indonesia must now find a way to obtain the $220 million needed for programming to continue into 2020. Yet even if this funding target is reached, only an estimated three percent will be allocated for harm reduction, and there remains a real threat that funding for antiretroviral therapy will be cut to zero.
As all funding from Global Fund will come to a full stop this year, the funds needed to sustain AIDS programming in Indonesia will have to be sourced and covered by the central, provincial, and city governments, as well as by local enterprises and donors. In countries such as Indonesia, where attracting a sizeable corporate social responsibility (CSR) contribution remains a challenge and has to compete with other social issues, harm reduction may not receive the attention and therefore the funding it deserves.
Lack of funding for harm reduction services is a major problem for countries still grappling with domestic economic challenges, including poverty and an unequal distribution of wealth. In Asian countries, funding—both domestic and international—earmarked for harm reduction ranges from a mere one percent in Thailand to 29 percent in Pakistan. Therefore, focused advocacy for harm reduction programs and other efforts to increase the political will to support such programs must continue.
In Asia, the priority has shifted to treatment of diseases. This in itself will further cut back prevention programs. And even if diseases are to be prioritized, hepatitis C will remain untouched―though there are an estimated 170-200 million HCV infected individuals worldwide―because of the prohibitive cost of treatment. The latest treatment for hepatitis C, sofosbuvir, costs about US$100,000 per course, or US$1,000 a day, a sum that far exceeds what the average Asian can afford.
The shift from prevention to treatment is mainly due to the new funding model under Global Fund, which uses country income status and disease burden to determine allocations. Catherine Cooke, from the International Harm Reduction Association, explains the likely impact of this formula on harm reduction programs:
Funding allocations based on country income and population-level disease burden could prove disastrous for investments in harm reduction programming—which predominantly relates to concentrated epidemics, and to middle-income countries in Eastern Europe and Asia that are often not politically prepared to replace donor funding for harm reduction with national funding.
In countries where HIV, tuberculosis, and hepatitis C are still driven by injecting drug use, harm reduction programming still plays a critical preventive role, and several studies have proven this. In the absence of harm reduction programming, the disease burden will likely increase unabated and the number of HIV infections is likely to rise again. Nations will have to later foot a larger bill for treatment of diseases than they would for investment in prevention now. This is especially true in Indonesia, where a resurgence in drug injecting can already be observed. A 2013 World Bank report titled “The Global HIV Epidemics among People Who Inject Drugs” said harm reduction should be scaled up rather than scaled down in Asia:
The scientific evidence…the public health rationale, and the human rights imperatives are all in accord: we can and must do better for PWID [people who inject drugs]. The available tools are evidence-based, right affirming, and cost effective. What is required now is political will and a global consensus that this critical component of global HIV can no longer be ignored and under-resourced.
Harm reduction proponents in Asia must continue to call attention to the role that harm reduction can play in containing concentrated epidemics, even those that are not considered a priority by the Global Fund. Advocates will need to raise funds in their local communities while continuing to lobby for increased funding and the scaling up of harm reduction programs. Developing business ventures to help communities and NGOs working in harm reduction become self-supporting is another strategy for maintaining funding and closing the gaps in services.
A mother once said to me, “I found out last year that my son has been on substitution therapy without my knowledge for three years. But even until now, he is still lazy and unemployed. He goes to the local health clinic at 9:00, dozes off until 3:00 pm, and is incorrigible when he speaks. When will this ‘thing’ begin to work? When will his life get better?” Her question required a complex set of answers, and it highlighted the continued need to work harder to engage with the public in order to mobilize support for harm reduction as a way of not only stopping the spread of AIDS but also providing support to drug users and their families.
 YAKITA Rapid Assessment, Yayasan Harapan Permata Hati Kita, 2000
 Harm Reduction International, “The Global State of Harm Reduction: Towards an Integrated Response,” 2012.
 Surveilans Terpadu Biologis dan Perilaku (STBP) (Comprehensive Biological and Behavioral Surveillance), Ministry of Health, 2011.
 Catherine Cook et al., “The Funding Crisis for Harm Reduction: Donor Retreat, Government Neglect, and the Way Forward,” Funding Report 2014, International Harm Reduction Association, http://www.ihra.net/files/2014/09/22/Funding_report_2014.pdf.
 Catherine Cook et al., “The Funding Crisis for Harm Reduction,” 17.
 Arin Dutta et al., “The Global HIV Epidemics among People who Inject Drugs,” World Bank, 2013.
 Private communications.