RESEARCH Open Access

HIV prevalence and risk behaviours among

injecting drug users in six indonesian cities
implications for future HIV prevention programs
Guy Morineau
1,2*
, Liesbeth JM Bollen
2
, Rizky Ika Syafitri
2
, Nurjannah Nurjannah
3
, Dyah Erti Mustikawati
3
and Robert Magnani
2
Abstract
Background: The HIV prevalence among injecting drug users (IDUs) in Indonesia reached 50% in 2005. While drug
use remains illegal in Indonesia, a needle and syringe program (NSP) was implemented in 2006.
Methods: In 2007, an integrated behavioural and biological surveillance survey was conducted among IDUs in six
cities. IDUs were selected via time-location sampling and respondent-driven sampling. A questionnaire was
administered face-to-face. IDUs from four cities were tested for HIV, syphilis, gonorrhoea and chlamydia. Factors
associated with HIV were assessed using generalized estimating equations. Risk for sexual transmission of HIV was
assessed among HIV-positive IDUs.
Results: Among 1,404 IDUs, 70% were daily injectors and 31% reported sharing needles in the past week. Most
(76%) IDUs received injecting equipment from NSP in the prior week; 26% always carried a needle and those who
didnt, feared police arrest. STI prevalence was low (8%). HIV prevalence was 52%; 27% among IDUs injecting less
than 1 year, 35% among those injecting for 13 years compared to 61% in long term injectors (p <0.001). IDUs
injecting for less than 3 years were more likely to have used clean needles in the past week compared to long
term injectors (p < 0.001). HIV-positive status was associated with duration of injecting, ever been imprisoned and
injecting in public parks. Among HIV-infected IDUs, consistent condom use last week with steady, casual and
commercial sex partners was reported by 13%, 24% and 32%, respectively.
Conclusions: Although NSP uptake has possibly reduced HIV transmission among injectors with shorter injection
history, the prevalence of HIV among IDUs in Indonesia remains unacceptably high. Condom use is insufficient,
which advocates for strengthening prevention of sexual transmission alongside harm reduction programs.
Keywords: Injecting drug users, HIV, Indonesia, Harm reduction
Background
Injecting drug use drives HIV epidemics in several
regions of the world [1,2]. HIV can spread rapidly among
injecting drug users (IDUs) and can increase from virtu-
ally zero to HIV prevalence levels of 20-50% [3-5]. A
study among IDUs in Bangkok, Thailand, showed an
explosive spread of HIV with a prevalence of 1% in late
1987 to 43% in late 1988 [4].
Sharing of contaminated injecting equipment has
driven the HIV epidemic in Indonesia [6]. Sentinel
surveillance among IDUs in drug treatment programs in
Jakarta indicated a rise in HIV prevalence from near
zero in 1995 to over 50% in 2002 [7]. In 2006, the Minis-
try of Health (MOH) estimated that the 220,000 IDUs
living in Indonesia contributed for 63% of all HIV infec-
tions , including 55% acquired through injecting and 8%
sexually transmitted by infected IDUs [8].
The Indonesian government, including the National
AIDS Commission, National Narcotic Board and Minis-
try of Health collaborates with international partners
and local non-governmental organizations to implement
* Correspondence: [email protected]
1
FHI Asia Pacific Regional Office, 19th floor, Tower 3, Sindhorn Building;
130-132, Wireless Road, Lumpini, Phatumwan, Bangkok 10330, Thailand
2
FHI Indonesia, Menara Salemba, Lantai 3; Jalan Salemba Raya No. 5, Jakarta
10440, Indonesia
Full list of author information is available at the end of the article
2012 Morineau et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Morineau et al. Harm Reduction Journal 2012, 9:37
http://www.harmreductionjournal.com/content/9/1/37
harm reduction programs for IDUs since 2000 [8]. Com-
munity health centres (Puskesmas) and NGOs are pro-
viding harm reduction services, including distribution of
clean needles and syringes through the Needle and
Syringe Program (NSP) [9]. Peer educators provide
bleach and information regarding HIV prevention and
safe injecting practices. The methadone maintenance
treatment program was initiated in 2003 by the WHO
and the MOH at two pilot sites (Jakarta and Bali) and
was scaled up to seven clinics serving approximately
1,000 clients by the end of 2006 [9]. A national prisons
program was launched in 2005 by the Ministry of Justice
and Human Rights with the aim of providing inmates
with prevention, care and support services for tubercu-
losis and/or HIV [10]. However, drug use remains illegal
in Indonesia resulting in challenges to implement
the NSP.
Up to now information about HIV transmission risk
among IDUs in Indonesia was limited to behavioural
data. Data allowing assessing factors that drive the HIV
epidemic are needed in order to inform programs and
target those at highest risk. This paper provides behav-
ioural and biological data about IDUs in Indonesia and
discusses possible implications for future harm reduction
programs.
Methods
Behavioural survey data were collected from samples of
1,404 IDUs in six cities between August and November
2007: Bandung (West Java), Jakarta, Malang (East Java),
Medan (North Sumatra), Semarang (Central Java) and
Surabaya (East Java). IDUs interviewed in Bandung,
Jakarta, Medan and Surabaya were asked to provide
biological samples and were tested for HIV and syphilis
(n =992), and chlamydia and gonorrhoea (n =728).
In Jakarta, Malang, Semarang and Medan, IDUs were
selected through two-stage, time-location sampling. Lists
of venues where IDUs congregated (streets, parks, pri-
vate houses and drop-in) were developed by non-
governmental organizations providing services to IDUs
and local health authorities. Samples of venues were
chosen via systematic-random sampling with probability
proportional to venue size. All IDUs present at the time
of data collection were selected for participation.
In Bandung and Surabaya, IDUs were recruited
through respondent-driven sampling (RDS) as access to
IDUs was insufficient to use time-location sampling.
Eight male IDUs seeds were recruited purposively in
each city, ensuring that they (1) lived in the city; (2) were
aged 1549; and (3) were part of an extended network
of IDUs. All seeds and subsequent recruits were each
given three coupons to recruit other IDUs. Recruiters
received 40,000 Indonesian Rupiah (equivalent to USD
4, depending on exchange rates) for each recruit who
could be verified to be an IDU and completed the survey
interview. The survey was terminated when the target
sample size of 250 was reached.
Survey field teams were drawn from staff of provincial
offices of the Central Statistics Bureau and Provincial
Health Offices; all received specialized training. Inter-
views were conducted in locations that offered visual
and auditory privacy.
Interviewers obtained witnessed verbal consent and
gathered behavioural data using a structured, pre-coded
questionnaire. In four cities, a nurse then collected
blood through finger prick, and in three cities partici-
pants provided self-collected, first-void urine. Behav-
ioural and biological data were gathered anonymously
and linked by identification numbers. Per MOH surveil-
lance guidelines, participants received a coupon for free
HIV counselling and testing at a nearby Community
Health Centre and were given their participant number
in order to access their STI test results and receive treat-
ment free of charge if needed.
Blood specimens were collected in EDTA tubes,
stored at 4-60C and transported to the nearest govern-
ment laboratory to be tested for HIV and syphilis. HIV
was tested using two parallel rapid tests: SD Bioline
W
HIV 1/2 3.0 (Standard Diagnostics, Suwon City, South
Korea) and Determine
W
HIV-1 (Abbott, Abbott Park,
IL, U.S.A.). Discrepant results were re-tested at the na-
tional research laboratory using two ELISA assays:
Murex
W
(Murex Biotech, Dartford, United Kingdom)
and Vironostika
W
(Biomrieux, Marcy lEtoile, France).
Syphilis was tested using a treponemal test Determine
Syphilis-TP
W
(Inverness Medical, Bedford, United King-
dom). Urine samples were tested for chlamydia and gon-
orrhoea by Cobas Amplicor
W
(Roche, Basel, Switzerland).
Behavioural data were double-entered using CSPro
2.6.007 (U. S. Census Bureau). Laboratory data were
entered using Microsoft Excel. Analysis was performed
using Stata 9.0 (Stata Corporation, College, Station, TX).
Differences in frequencies were assessed using the Wald
test, and means were tested with the Wilcoxon ranksum
test. All tests were double sided and p-values <0.05 were
considered significant. Background characteristics and
behaviours were presented in term of frequency, mean
and median. Associations between HIV and individual
characteristics and/or behaviours were assessed using
generalized estimating equations (GEE), which control
for correlations within sampling clusters. Histograms
representing the distribution of continuous variables that
were tested in GEE were examined to ensure that they
had a single mode and limited skewness. Independent
contributions of factors to predicting HIV infection were
assessed by fitting variables associated with HIV infec-
tion in bivariable analyses significant at the p 0.20 level
into multivariable GEE models. Backward stepwise
Morineau et al. Harm Reduction Journal 2012, 9:37 Page 2 of 7
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elimination was used and logits significant at the p < 0.05
level on Wald tests were retained in the final model. To
accommodate readers more familiar with logistic regres-
sion, the logit results were converted to odds-ratios by
taking their anti-logs.
Preliminary data analyses indicated that respondents
sampled via RDS differed from those sampled via TLS
with regard to key background characteristics they
were somewhat better educated and more likely to hold
salaried positions, have resided in their interview city
their entire life, and be somewhat longer-term drug
injectors (all p < 0.01). However, because such differences
can be controlled in multivariable analyses, we opted to
use the full set of data available irrespective of sampling
method. Analyses were performed on the multi-site
pooled data assuming stratified cluster sampling, with
drug injecting venues and RDS recruitment chains being
considered as clusters.
The study protocol was approved by the Ethics Com-
mittee of the Indonesian Centre for Biomedical and
Pharmaceutical Research, as well as the Protection of
Human Subject Committee of Family Health Inter-
national. Oral witnessed informed consent was obtained
from participants for publication of the survey results.
Results
Background characteristics
A total of 1,404 IDUs participated in the survey with a
median age of 27 years, 1350 (96.2%) were male. Most
IDUs (63.6%) had attended senior high school, and 12.8%
had attended college or university. Most (67.3%) had
never married, 27.4% were currently married, and the re-
mainder were separated, divorced or widowed. Most
IDUs lived with parents and/or siblings (66.8%) and some
lived with their spouse (20.1%). Forty percent of IDUs
were independent workers, 26.6% held salaried positions,
12.7% were unemployed, and 7.5% were students. The
Table 1 Reported behaviours among 1,404 Injecting Drug
Users (IDUs) in six cities in Indonesia, 2007
Behaviour N %
Duration of injecting drugs
< 1 year 33 2.4
1 - 3 years 481 34.5
3 years 879 63.1
Mean/Median 5.4/5.0
Age at first injection
< 20 years 536 38.5
20 - 29 years 778 55.9
30 years 79 5.7
Mean/Median 21.3/21.0
Number of injections yesterday
0 243 17.5
1 449 32.4
2 467 33.7
3 227 16.3
Mean/Median 1.6/2.0
Number of daily injections last month
Dont inject regularly 411 30.2
1 324 23.8
2 3 539 39.6
4 88 6.5
Number of people with whom shared last injection
None 167 11.9
1 161 11.5
2 488 34.8
3 4 532 37.9
5 55 3.9
Mean/Median 2.0/2.3
Shared needle (borrowed or lent) last week 436 31.1
Shared drugs after mixing with water last week 934 70.4
Always carried needle last week 371 26.4
Used public needle last week 175 12.8
Injected with used needle at last injection 164 11.7
Cleaned used needle before injecting, at last injection 160 97.0
Injected in park past week 241 17.2
Injected in other city past year 516 36.9
Received needles from NSP last week 1060 75.5
Number of needles received from NSP last week
Mean 4.8
Median 6.0
Had abscess at injecting site last year 904 66.3
Participated in rehabilitation program last year 680 48.6
Participated in methadone program last year 622 54.6
Oral methamphetamines last three months 863 61.5
Ever been in prison 417 29.7
Jailed for narcotic use last year 174 12.4
Table 1 Reported behaviours among 1,404 Injecting Drug
Users (IDUs) in six cities in Indonesia, 2007 (Continued)
Ever tested for HIV 680 48.5
Tested for HIV last year 547 39.3
Took action to reduce risk of HIV infection last year 1014 72.5
Stopped using drugs 851 60.6
Reduced needle sharing 835 59.5
Reduced water sharing 858 61.1
Reduced number of fixes per day 932 66.4
Used bleach/disinfectant 815 58.1
Participated in NSP 911 64.9
Reduced number of injecting friends 832 59.3
Note. NSP: Needle Syringe Program.
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vast majority of IDUs (81.2%) had lived their entire life in
the city where they were interviewed.
Injection experience and practices
Respondents began injecting drugs an average of 5.4 years
prior to the survey interview (median =5.0 years) at a
mean age of 21.3 years (Table 1). Based upon self-
reported injecting practices during the month prior to
the survey, 70% of IDUs were considered regular injec-
tors (at least one injection per day) and 30% were inter-
mittent injectors.
Sixteen percent of IDUs reported sharing a needle
(borrowed or lent) at last injection with a median of 2
persons. Twelve percent of IDUs injected with a previ-
ously used needle at last injection and thirteen percent
used a public needle. The mean number of persons with
whom respondents shared needles in the last week was
3.5 (95% CI 2.8 - 3.1) among IDUs injecting in parks
compared with 2.9 (95% CI 3.2 - 4.1) among those
injecting in other locations (p =0.002). Nearly all injec-
tors using previously used needles at last injection
reported having cleaned the needle before injecting.
Over 75% of respondents reported having obtained clean
needles and syringes from an NSP in the prior week, re-
ceiving an average of five needles (median=6.0).
Twenty-six percent of IDUs always carried a needle in
the last week; 907 (87.8%) of the 1,033 who did not carry
a needle were afraid of being arrested by the police. Of
the 1,404 IDUs, the majority (1,292) injected heroin in
the last year, few injected amphetamines (74), metha-
done (15) and opium (22); 59.8% had used oral metham-
phetamines in the year prior to the survey. Around 50%
of respondents reported having participated in detoxifi-
cation programs in the last year and 55% in methadone
programs.
One third (29.7%) of IDUs reported having ever been
in prison and 8.3% of them injected for the first time
while in prison. Of all survey respondents, 12.4%
reported having been jailed for narcotic use last year. Of
the 269 IDUs who were in prison last year, 139 (51.7%)
received information on HIV and 26 (9.7%) received
condoms while in prison.
HIV and STI prevalence
Estimated prevalence of HIV and STIs among IDUs in
four cities are shown in Table 2. The prevalence of HIV
was 52.4% (range 42.8- 56.0%). Prevalence of syphilis,
gonorrhoea and chlamydia was low across cities. HIV
prevalence was 27.0% among the 33 IDUs injecting for
less than one year, 35.4% among those (n =303) injecting
for one to three years and 61.0% among those (n =670)
injecting for longer than three years (p < 0.001) (Figure 1).
In addition, a higher proportion of injectors with shorter
injection history accessed NSP in the last week com-
pared with those injecting for longer duration (76.5%,
79.5% and 71.9%, respectively; p =0.003) (Figure 1).
Factors associated with HIV infection
Duration of injecting was associated with a higher likeli-
hood of HIV infection, with the odds of infection in-
creasing by 12% for each year of injecting (Table 3).
Respondents who injected in a park in the previous
month were significantly more likely to have tested HIV-
positive (AOR=1.64), as were those who had been jailed
(AOR=1.58). IDUs who tested positive for gonorrhea
or chlamydia were less likely to have been infected
Table 2 Prevalence of HIV and Sexually Transmitted Infections (STIs) among Intravenous Drug Users (IDUs) in four
cities in Indonesia, 2007
City HIV % (n/N) Syphilis % (n/N) Chlamydia % (n/N) Gonorrhoea % (n/N) Chlamydia/
gonorrhoea % (n/N)
Any STI % (n/N)
Medan 55.6% (139/250) 2.4% (6/250) 5.3% (13/246) 0.0% (0/249) 5.3% (13/249) 7.2% (18/249)
Jakarta 55.0% (137/249) 0.8% (2/242) 6.0% (14/234) 1.3% (3/234) 7.3% (17/234) 8.1% (19/234)
Bandung 42.8% (107/250) 0.0% (0/250) NA NA NA NA
Surabaya 56.0% (140/250) 1.6% (4/250) 5.72% (14/249) (1.2%) (3/249) 6.8% (17/249) 8.4% (21/249)
All cities 52.4% (523/999) 1.2% (12/992) 5.6% (41/729) 0.8% (6/732) 6.4% (47/732) 7.9% (58/732)
NA=Not available.
HIV prevalence and access to Needle Syringe Program (NSP)
among injecting drug users (IDUs) in Indonesia according to
duration of injecting drugs, 2007
%
Figure 1 HIV prevalence and access to Needle Syringe Program
(NSP) among injecting drug users (IDUs) in Indonesia according
to duration of injecting drugs, 2007.
Morineau et al. Harm Reduction Journal 2012, 9:37 Page 4 of 7
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(AOR=0.51). However, infection with chlamydia and/or
gonorrhoea was neither associated with variables on
types and numbers of sexual partners in the past month,
nor with reported condom use. Unprotected commercial
sex in the last month was not associated with higher risk
for HIV infection.
Indicators for HIV transmission
Of the 523 HIV-positive IDUs, 373 (71.3%) had sex in
the year prior to the survey (Table 4). Half of the HIV-
positive IDUs had a female steady partner and 14.8%
reported to use condoms consistently. Also, consistent
condom use was rare among the 185 HIV-positive IDUs
who had female casual partners (21.6%) and among the
105 who had commercial partners (27.9%). Twenty-two
percent of the 523 HIV-positive IDUs reported to have
given their used needle to another IDU in the last week.
Discussion
HIV prevalence among community-based IDUs in four
major Indonesian cities was high (53%) in November
2007. The HIV epidemic may have slowed down some-
what as injectors with shorter injection history had a
lower HIV prevalence and a higher proportion were
accessing clean needles from the NSP than those inject-
ing for a longer duration. Overall, 70% of IDUs reported
having taken some action to reduce HIV transmission
risk.
Implementation of NSP should be highly successful in
controlling the HIV epidemic among IDUs as demon-
strated in a recent publication from Australia [11]. How-
ever, drug use remains illegal in Indonesia and
subsequent law enforcement is conflicting with imple-
mentation and support for NSP. Indeed, a quarter of
IDUs in our survey reported to have been imprisoned
because of drug use. Although most received needles
from NSP, the main reason reported for not always car-
rying a needle was the fear of police arrest. The distribu-
tion of needles and syringes is currently shifting from
local NGOs to community health centres (Puskesmas),
which may affect the uptake of services.
Imprisonment was an independent risk factor for HIV
infection. New inmates could be HIV-positive at the
time of incarceration or they may get infected while in
prison as injecting drugs seems to continue in prison
under unsafe conditions. Although Indonesia implemen-
ted a national strategy for HIV prevention in prisons
[10], challenges remain to implement appropriate HIV
prevention and care services in this setting.
Injecting in a park was another risk factor for HIV in-
fection. It is well established that the size and density of
social and injecting networks are key factors in the
transmission of HIV among IDUs [12,13]. Indeed, a
Table 3 Bivariate and multivariate associations between selected factors and HIV Infection among 729 Injecting Drug
Users (IDUs) in four cities in Indonesia, 2007
Factors Bivariate Analysis Multivariate Analysis
Odds Ratio 95% CI p-value Adjusted
Odds Ratio
95% CI p- value
Age (continuous) 1.07 1.04 - 1.11 <0.001
Duration injecting drugs (continuous) 1.16 1.12 - 1.21 <0.001 1.14 1.09 - 1.20 <0.001
No. injections past week (continuous) 1.02 0.89 - 1.18 0.300
No. people who shared injection with last week 0.97 0.93 - 1.02 0.254
Shared needles in last week * 1.16 0.82 - 1.47 0.537
Shared drugs after mixing with water last week * 1.16 0.72 - 1.29 0.803
Injected in park last week * 1.19 1.24 - 2.44 0.001 1.64 1.11 - 2.42 0.012
Received needles from NSP last week * 0.86 0.60 - 1.24 0.426
Participated in methadone program last year * 1.43 1.05 - 1.94 0.022
Participated in rehabilitation program last year * 1.41 1.09 - 1.82 0.009
Used oral methamphetamines last 3 months* 0.93 0.76 - 1.13 0.457
Ever reached by outreach worker * 1.44 1.05 - 1.96 0.023
Ever been jailed * 1.86 1.43 - 2.42 <0.001 1.58 1.13 - 2.21 0.007
Had unprotected commercial sex past month 0.82 0.59 - 1.14 0.233
Ever tested for HIV * 1.57 1.20 - 2.01 0.001
Tested positive for gonorrhoea and/or chlamydia* 0.53 0.29 - 0.96 0.036 0.51 0.27 - 0.94 0.032
Tested positive for syphilis* 1.51 0.48 - 4.70 0.477
* For indicated variables, no is reference category with OR =1.0 (not shown).
Note. NSP; Needle Syringe Program.
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recent study in Pakistan pointed out large sharing net-
works as a key factor for explosive HIV prevalence
growth among IDUs [14]. Assuming that IDUs who re-
cently injected in parks did so in the past as well, the
high prevalence of HIV found among those injecting in
parks plausibly reflects their exposure to larger and
more diverse needle sharing networks than those not
injecting in parks.
Sexual risk behaviour, such as unprotected commercial
sex, was not associated with HIV, indicating that the
main route for HIV acquisition among IDUs is unsafe
injections rather than sexual intercourse. Surprisingly,
infection with gonorrhoea or chlamydia (NG/CT) was
associated with lower likelihood of HIV infection, but
our data could not identify any behaviours associated
with both HIV infection and NG/CT.
Around half of IDUs were HIV-positive with high po-
tential of onward HIV transmission. Sharing used nee-
dles by HIV-positive IDUs was common as well as
unprotected sex with steady, casual and commercial
partners. Condom use was especially rare with steady
partners, which is concerning as steady partners will
have multiple exposures to unprotected sex. It was
pointed out earlier that sexual behaviour among IDUs in
Indonesia has the potential for HIV spread to non-
injectors [15]. Condom use promotion and provision
should be strengthened alongside NSP programs to-
gether with disclosure counselling, reaching out and
promotion of HIV-testing for partners. The high preva-
lence of HIV also emphasizes the need to assess and en-
sure access to antiretroviral treatment (ART).
This survey presents several limitations. As it is the
case for all cross-sectional studies, it is not possible to
know if the risk factors associated with HIV pre-existed
the time of infection. The pooling of population sampled
with different methodologies threatens the validity of the
statistical tests in bivariable analysis. However, this het-
erogeneity was somehow addressed in the regression
analysis using GEE. Syphilis testing did not include a
quantitative RPR test; hence syphilis test results included
both active syphilis and serologic scars.
Although the uptake of NSP has possibly reduced HIV
transmission among injectors with shorter injection his-
tory, the prevalence of HIV among IDUs in four Indo-
nesian cities remains unacceptably high. Sharing of
injecting equipment is sustained by the fear of police
arrests when carrying needles. Shifting emphasis from a
security approach to a public health approach would
contribute to reducing HIV transmission among IDUs in
Indonesia. Sexual partners of IDUs are at high risk for
getting infected with HIV and programmes should in-
clude strategies to this vulnerable population.
Competing interests
The authors declare that they have no competing interest.
Authors contribution
GM, LB and RM drafted the paper. GM conducted data analysis. GM, RM and
DEM designed the survey and overviewed its implementation. RIS and NN
provided technical review for survey design and reviewed the paper. All
authors read and approved the final manuscript.
Acknowledgements
Primary financial support for this research was provided by the US Agency
for International Development (USAID).
We would like to thank Octavery Kamil for providing comments for this
manuscript.
Author details
1
FHI Asia Pacific Regional Office, 19th floor, Tower 3, Sindhorn Building;
130-132, Wireless Road, Lumpini, Phatumwan, Bangkok 10330, Thailand.
2
FHI
Indonesia, Menara Salemba, Lantai 3; Jalan Salemba Raya No. 5, Jakarta
10440, Indonesia.
3
Ministry of Health, Republic of Indonesia; Sub-Directorate
for HIV/AIDS & STIs; Komplek Ditjen PP & PL Depkes RI, Jalan Percetakan
Negara No. 29, Jakarta 10560, Indonesia.
Received: 8 June 2011 Accepted: 10 August 2012
Published: 3 September 2012
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doi:10.1186/1477-7517-9-37
Cite this article as: Morineau et al.: HIV prevalence and risk behaviours
among injecting drug users in six indonesian cities implications for
future HIV prevention programs. Harm Reduction Journal 2012 9:37.
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