Harsh Drugs Laws, Rising HIV Rates, and Indonesia's Battle Over Both

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Mira Febriyanti shoulders a backpack stuffed with needles as she steps onto the soft ground of a trash-strewn lot. In the distance, white smoke rises from a garbage fire smoldering in the afternoon rain.

The Indonesian capital of Jakarta is full of self-contained slum communities cut off from the walled mansions, Western-style apartments, and cavernous shopping malls built for the city's moneyed upper class. In some, homegrown industries are so pervasive that the slum takes on the air of a factory town. In Muara Angke, it's mussels harvested from the polluted waters of Jakarta Bay. In Mayestik, it's reams of colorful fabric sold at the local market.

Here in Kampung Boncos, it's heroin.

"I've met people from everywhere," Febriyanti says of those lured to the slum by the drug trade. "The dealers do not only sell drugs during the day; this lasts until night, even until dawn sometimes. There is always someone here who is ready to serve you."

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Febriyanti began working here more than a decade ago, handing out clean needles for Kios Atma Jaya, an HIV/AIDS prevention organization. But she first arrived in Kampung Boncos for the same reason most outsiders visit the cramped West Jakarta slum — to buy heroin. That was in the late nineties, when, Febriyanti explains, used needles sold for less than 10 cents and the bodies of addicts were abandoned in the dump.

"The situation in Boncos was not like it is today," she says.

She approaches a small crowd of heroin users waiting out the rain beneath a sagging blue tarp. A young man holds an energetic but dirty kitten in his lap, while a woman named Anastasya listens to Febriyanti speak.

"It was really bad," Anastasya says after Febriyanti describes the slum in years past. "Needles used to be available for rent."

Febriyanti opens her backpack and begins handing out fresh packages of sterile needles and rubbing alcohol. Anastasya takes a seat next to an older woman struggling to find a usable vein in her neck with the help of a circular pocket mirror decorated with glittery blue hearts.

Anastasya leans over and takes the needle.

"Right here?" she asks, gently tapping the woman's neck before sticking the needle in. The woman flinches as Anastasya moves the syringe, but she eventually pulls the needle out without pushing the plunger, unable to find a vein.

Neighborhoods like Kampung Boncos form the front lines of Indonesia's fight to curb the spread of HIV in a country where new infections continue to grow at an alarming rate. An estimated 54.4 percent of Jakarta's injecting drug users are HIV positive, according to figures released by the country's National AIDS Commission.

Nationwide, that figure drops to 36.4 percent, and for years it's remained stable — one of Indonesia's few successes in its battle to curb HIV's spread. But the results of an unpublished 2013 survey revealed an apparent spike in new infections among drug users in three of the country's provincial cities — Tangerang, Pontianak, and Yogyakarta — raising concerns that Indonesia's HIV prevention programs are starting to crack under the pressure of the country's increasingly harsh drug laws.

"This is a worrying trend," says Kah Sin Cho, Indonesia country director for UNAIDS. "For a long time, we have thought that the prevalence of HIV among drug users had started to decline, so this came as a bit of a surprise."

Experts cite a variety of factors to explain the spike, including the central government's decision sometime around 2007 to begin centralizing the distribution of clean needles at public health centers known as puskesmas. It was an attempt to reduce the nation's dependence on foreign funding for harm reduction programs, but drug users want little to do with the health centers.

"[They have] very good intentions," Cho says. "But part of the problem with distributing needles in the puskesmas is that drug users have to go to puskesmas… and health personnel are not necessarily seen as very friendly or very sympathetic toward drug users."

Organizations like Kios are attempting to fill the gap by collecting clean needles from the centers and distributing them. But in some cities, that can get you thrown in jail.

"Here we have a really effective tool for reducing HIV transmission among drug users," Cho says, "but at the same time, people hesitate to carry them around because they know they will be subject to arrest if they are found with needles."

Indonesia suffered a 427 percent increase in reported AIDS-related deaths between 2005 and 2013, according to UNAIDS. (For comparison, during the same years, AIDS-related deaths dropped 56 percent in Thailand.) In 2014, UNAIDS warned the Indonesian government that the country was being "left behind" in the fight to contain the virus after researchers discovered a 48 percent increase in new infections. Indonesia's then–health minister Nafsiah Mboi responded by saying UNAIDS lacked an understanding of the country.

Today, the Ministry of Health is expanding HIV testing programs, a herculean task in a country of 250 million people living on 13,000 islands spread across an area roughly as wide as the United States. As HIV testing facilities open their doors, health officials routinely discover new populations beset by the virus. In the remote region of Papua, for instance, the government has struggled to contain an isolated epidemic where infection rates have climbed to 200 times the national average, affecting an estimated 86,000, according to UNAIDS.

The country's current health minister, Nila Moeloek, is now promoting abstinence and condom use as effective barriers to HIV transmission — but she has yet to directly address the rise in new infections among drug users. President Joko Widodo has doubled down on the country's already harsh drug laws since taking office last year, declaring that the nation was facing a "drug emergency" before resuming executions for convicted drug traffickers. In his first year in office, Widodo ordered the execution of 14 people, most of them foreigners, over drug trafficking offenses. The country's drug executions have now been put on hold as the government focuses on boosting Indonesia's sluggish economic growth.

Widodo claims about 50 people die of drug use in Indonesia every day and has warned that as many as 18,000 people may die by the year's end. Those figures have been repeatedly reported as fact by domestic media, despite evidence presented by academics that Widodo's numbers are exaggerations.

The president also ordered the National Narcotics Agency (BNN) to dramatically increase the number of users in the country's rehabilitation programs. The agency wants to be placing 400,000 drug users a year into rehab by 2017, and ultimately, in effect, the BNN wants to force every drug user in Indonesia, from recreational marijuana smokers to long-term heroin addicts, into treatment.

"In Indonesia, there are 4 million drug addicts," the BNN's spokesman said earlier this year. "So if we rehabilitate 400,000 addicts a year, then in 10 years our work will be done."

The BNN has been conducting sweeps in open-air drug markets, private homes, hotel rooms, and even entire apartment buildings, forcing residents to submit urine samples in a push to meet a presidential quota of 100,000 new patients in drug treatment facilities by the end of 2015. Meanwhile, the BNN's new chief continues to float controversial ideas, like a plan to build an island prison for drug traffickers that is surrounded by crocodiles, tigers, and piranha.

Harm reduction organizations warn that the kind of aggressive policing that's become the norm under Widodo may further undermine the country's fight against HIV — something already happening in the city of Tangerang.

The Greater Jakarta area is a geographical grouping of five cities and their associated districts that is home to some 30 million people. Indonesians call the metro area "Jabodetabek," a portmanteau of city names that grows longer as the capital's suburbs expand. Tangerang, one of those cities, is the manufacturing hub of Java, home to more than 1,000 factories that make everything from yarn to Toyotas.

About 2 million people live in Tangerang, where HIV rates among intravenous drug users are on the rise. The city lacks the open-air drug markets of Jakarta because, locals say, the city's conservative residents and strict police force won't allow it. So heroin users cop in neighborhoods like Kampung Boncos, a 30-minute bus ride away.

Kios runs a branch office in Tangerang in a quiet residential neighborhood off one of the main roads. A white sign hangs above the front gate, informing visitors in pink letters that the modest stucco house is an "HIV-AIDS Information and Service Center." A man named Afriano greets visitors in jeans and a dark gray t-shirt. In his office, I ask if it's safe for the drug users who seek access to clean needles.

"Is it safe? Of course it's not — they still have to deal with the police," Afriano says. "Even at the several clinics that offer methadone, drug users are still detained by the police to be interrogated."

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Law enforcement in Tangerang is less tolerant than police in the capital, he says, so the fear of getting caught with drugs or a needle is quite high. Still, in Tangerang, the government allows Kios to operate in the open. A few miles away, in the city of South Tangerang, the needle exchange program is banned outright.

"These policies are one of the reasons why HIV increased here," Afriano says. "If there are difficulties finding needles, [heroin users] will share the needles instead. They don't care what type of disease they might catch. What they know is, 'I need to get high. I have the package. I want to inject drugs.'"

Follow Jonathan Vit on Twitter: @JonathanGVit