Elsevier

Drug and Alcohol Dependence

Volume 149, 1 April 2015, Pages 71-79
Drug and Alcohol Dependence

Within-prison drug injection among HIV-infected male prisoners in Indonesia: A highly constrained choice

https://doi.org/10.1016/j.drugalcdep.2015.01.018Get rights and content

Highlights

  • We examined within-prison drug injection (WP-DI) among HIV-infected prisoners in Indonesia.

  • Over half (56%) reported WP-DI, and 93% of those shared injection equipment in jail or prison.

  • Multivariate analysis associated WP-DI with prison type and daily drug injection before arrest.

  • Socio-environmental factors further influenced decisions to inject drugs or share needles while incarcerated.

Abstract

Background

In Indonesia, incarceration of people who inject drugs (PWID) and access to drugs in prison potentiate within-prison drug injection (WP-DI), a preventable and extremely high-risk behavior that may contribute substantially to HIV transmission in prison and communities to which prisoners are released.

Aims

This mixed method study examined the prevalence, correlates, and social context of WP-DI among HIV-infected male prisoners in Indonesia.

Methods

102 randomly selected HIV-infected male prisoners completed semi-structured voice-recorded interviews about drug use changes after arrest, drug use cues within prison, and impact of WP-DI on HIV and addiction treatment. Logistic regression identified multivariate correlates of WP-DI and thematic analysis of interview transcripts used grounded-theory.

Results

Over half (56%) of participants reported previous WP-DI. Of those, 93% shared injection equipment in prison, and 78.6% estimated sharing needles with ≥10 other prisoners. Multivariate analyses independently correlated WP-DI with being incarcerated for drug offenses (AOR = 3.29, 95%CI = 1.30–8.31, p = 0.011) and daily drug injection before arrest (AOR = 5.23, 95%CI = 1.42–19.25, p = 0.013). Drug availability and proximity to drug users while incarcerated were associated with frequent drug craving and escalating drug use risk behaviors after arrest. Energetic heroin marketing and stigmatizing attitudes toward methadone contribute to WP-DI and impede addiction and HIV treatment.

Conclusions

Frequent WP-DI and needle sharing among these HIV-infected Indonesian prison inmates indicate the need for structural interventions that reduce overcrowding, drug supply, and needle sharing, and improve detection and treatment of substance use disorders upon incarceration to minimize WP-DI and associated harm.

Introduction

Indonesia's HIV epidemic is expanding rapidly. Annual new infections rose 48% from 51,300 to 76,000 between 2008 and 2013, a period when HIV incidence decreased or stabilized in most other Asia-Pacific countries (Joint United Nations Programme on HIV/AIDS, 2013, Ministry of Health, 2008). Despite recent evidence of a transitioning epidemic (National AIDS Commission, 2012), people who inject drugs (PWID) comprise the largest proportion of people living with HIV (PLWH) in Indonesia (Ministry of Health, 2009) and provide a bridge to other high risk groups and the general population (National AIDS Commission, 2012).

HIV prevalence among the estimated 73,000–200,000 PWID in Indonesia ranges from 31.4% to 67.9% (Joint United Nations Programme on HIV/AIDS, 2013, Ministry of Health, 2009, United Nations Office on Drugs and Crime, 2013). Indonesia's response to the HIV epidemic among PWID, which includes universal access to methadone maintenance therapy (MMT), needle–syringe programs (NSPs), and primary care through non-governmental organizations and community health centers (Afriandi et al., 2009, Mesquita et al., 2007, National AIDS Commission, 2012), has contributed to decreasing HIV prevalence among PWID (National AIDS Commission, 2012, United Nations Office on Drugs and Crime, 2013); although HIV prevalence rose sharply in subgroups of PWID, notably new injectors in Jakarta (National AIDS Commission, 2012).

Drug policies, including new laws (Law No. 27/2009), make little distinction between drug users and traffickers (Nasir, 2011), and have generally proved counterproductive to HIV control (Joint United Nations Programme on HIV/AIDS, 2013). Drug enforcement has spawned police brutality against PWID (Davis et al., 2009), itself a social determinant of unsafe injection among PWID in the community (Hayashi et al., 2013, Ti et al., 2014), and increased criminal convictions and incarceration rates among PWID (HIV Cooperation Program for Indonesia, 2013, Morineau et al., 2012). Conservatively, 8–13% of Indonesian prisoners are PWID and official estimates of HIV prevalence among prisoners range from 1.1% to 13.9% (Directorate of Corrections, 2010a, Directorate of Corrections, 2012, Nelwan et al., 2010), with the highest prevalence being in specialized narcotics prisons which house inmates sentenced for drug-related crimes (including drug possession), although prisoners with substance use disorders (SUDs) are detained throughout the prison system (National AIDS Commission, 2010).

Among Indonesian PWID, incarceration, SUDs, and HIV are syndemic (Morineau et al., 2012, Nelwan et al., 2010, Singer and Clair, 2003). Studies outside Asia suggest that needle sharing during incarceration contributes greatly to this syndemic (Calzavara et al., 2003, Pollini et al., 2009, Small et al., 2005, Werb et al., 2008, Wood et al., 2005), particularly needle sharing among HIV-infected prisoners (Izenberg et al., 2014). Environmental factors like overcrowding of PWID, access to drugs, and limited access to NSPs and MMT, facilitate within-prison drug injection (WP-DI) and transmission of blood-borne pathogens (Dolan et al., 2007, Dolan et al., 2014). In Indonesia, prisons therefore may serve as amplifying reservoirs, contributing to HIV transmission in prisons and in communities where prisoners are released (Mathers et al., 2008, Prasetyo et al., 2013). Limited data about WP-DI in Indonesia are available. Existing studies suggest that WP-DI is generally a rare occurrence (0.07–1.3% of male prisoners), but that it occurs more frequently in narcotics prisons and is associated with high levels of injection equipment sharing, drug injection initiation, and HIV infection (Directorate of Corrections, 2010a, Directorate of Corrections, 2012, National AIDS Commission, 2012). No studies, however, have specifically examined WP-DI among PLWH – the only people who can transmit virus to others – nor have they examined barriers to evidence-based MMT strategies that could thwart HIV prevention and treatment efforts among prisoners. To address this unmet need, we undertook a mixed methods study to understand better why HIV-infected prisoners engage in WP-DI, how they weigh the potential risks, and gain insight into how MMT expansion might benefit this especially vulnerable and high-risk group.

Section snippets

Ethics statement

This study was conducted in accordance with international standards for research with prisoners (Lazzarini and Altice, 2000). Participation resulted in neither benefit nor punishment. Ethics review boards at Yale University and University of Indonesia approved the study. This study was authorized by The Ministry of Research and Technology, and the Directorate General of Corrections, Ministry of Law and Human Rights, Republic of Indonesia. For their contributed time, participants received a

Sample characteristics

WP-DI was highly correlated with recruitment from Jakarta Narcotics Prison where about half (53%) of study participants were incarcerated. Table 2 describes bivariate correlations for the 100 participants who provided responses about WP-DI. A majority (68%) was diagnosed with HIV during the current incarceration. Pre-incarceration health service utilization was low among those already aware of their status. Participants recruited from Jakarta Narcotics Prison were more likely to meet CD4

Discussion

This mixed-method study provides empirical and contextual insights into WP-DI among incarcerated PLWH in Indonesia. Our findings document an extraordinarily high prevalence of WP-DI (56%) among PLWH—the only ones capable of transmitting HIV. WP-DI reported by PLWH in the narcotics prison (66%) was nearly twice as high (37%) as previously reported (Directorate of Corrections, 2012), and vastly higher compared to the general Indonesian male prison population (Directorate of Corrections, 2010a).

Role of funding source

Nothing declared.

Contributors

G.J.C. conceived and designed the study, analyzed data, and wrote the paper. M.I. and A.P.M. conducted, transcribed, and translated interviews and assisted with analysis. R.L.A. analyzed data and assisted with conceptualization and writing of the paper. A.W. provided technical support at all stages of the research and extensive input on initial manuscript drafts. A.K. provided commentary on the final draft. All authors discussed the results and implications and approved the final draft.

Conflict of interest

No conflict declared.

Acknowledgements

Thanks to study participants for generously sharing their time. We thank Swasti Wulan, Budhi Mulyadi and Herlia Yuliantini for research assistance. We gratefully acknowledge operational support provided by the Directorate General of Corrections, Republic of Indonesia, especially Akbar Hadi Prabowo, Finnahari, Astia Murni, and Hetty Widiastuti. We also thank Nurlan Silitonga, Cindy Hidayati, Alia Hartanti, David Shenman, Suzanne Blogg (HIV Cooperation Programme for Indonesia); Judith Levy and

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