Within-prison drug injection among HIV-infected male prisoners in Indonesia: A highly constrained choice
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
References (77)
- et al.
Treatment of medical, psychiatric, and substance-use comorbidities in people infected with HIV who use drugs
Lancet
(2010) - et al.
Attitudes toward opioid substitution therapy and pre-incarceration HIV transmission behaviors among HIV-infected prisoners in Malaysia: implications for secondary prevention
Drug Alcohol Depend.
(2011) - et al.
HIV in prison in low-income and middle-income countries
Lancet Infect. Dis.
(2007) - et al.
Within-prison drug injection among HIV-infected Ukrainian prisoners: prevalence and correlates of an extremely high-risk behaviour
Int. J. Drug Policy
(2014) - et al.
Assessment of attitudes towards methadone maintenance treatment between heroin users at a compulsory detoxification centre and methadone maintenance clinic in Ningbo, China
Subst. Abuse Treat. Prev. Policy
(2013) - et al.
Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review
Lancet
(2008) - et al.
The harm inside: injection during incarceration among male injection drug users in Tijuana, Mexico
Drug Alcohol Depend.
(2009) - et al.
The social structural production of HIV risk among injecting drug users
Soc. Sci. Med.
(2005) - et al.
The impact of substitution treatment in prisons—a literature review
Int. J. Drug Policy
(2007) - et al.
Cost-effectiveness of methadone maintenance therapy as HIV prevention in an Indonesian high-prevalence setting: a mathematical modeling study
Int. J. Drug Policy
(2012)