Inmates With HIV Told to See the Shrink

Jakarta Globe, Basten Gokkon on 12:03 am Dec 01, 2014

Public health activists are attempting to persuade inmates living with HIV and
 AIDS to accept antiretroviral treatment through psychological counseling despite
 previously refusing. Meanwhile, Governor Basuki made bold pronouncements about
 HIV-positive inmates’ coverage under the national health insurance scheme,
. administered by BPJS, that strain credulity. (AFP Photo/Manpreet Romana)

Jakarta. Inmates at Salemba Penitentiary learned on Saturday morning that they may soon benefit from a service sorely needed by so many throughout Indonesia, yet actually available to vanishingly few: psychological counseling for people living with HIV and AIDS.

Inmates learned of the news during their observance of World AIDS Day, which was organized in cooperation with the Jakarta chapter of the National AIDS Commission (KPA) and the Justice and Human Rights Ministry’s Jakarta Office.

The Jakarta Globe visited the counseling center and saw three group sessions led by six psychologists from the Indonesian Psychological Association’s Jakarta branch (Himpsi Jaya).

“We’re here because the National AIDS Commission in Jakarta asked us about two months ago to help the inmates who are living with HIV and AIDS,” psychologist Seri Liani Ketaren said. “This is our first time ever helping inmates who are living with HIV and AIDS.”

Voluntary refusal: a psychopathology?

Rohanna Manggala, who heads the National AIDS Commission in Jakarta, said her office sought to involve psychologists in their prison program after finding cases in which inmates who tested positive for the virus, which attacks the immune system, declined to partake in voluntary antiretroviral (ARV) therapy because of what her organization sees as a psychological issue. “It’s got to be really difficult for them.

They must be very depressed for having been imprisoned and then tested positive for HIV,” Rohanna said. “That’s why they decline to join the therapy: Because they tend to think that there’s no hope any more, anyway.”

Rohanna said that such thinking would only further harm inmates’ health and could eventually lead to premature death.

Seri said she spoke with 14 inmates at the prison in Salemba who had tested positive for HIV but refused ARV therapy, because, as she tells it, “they feel ashamed to disclose their HIV-positive status.”

“Some of them also said that they had ‘poor knowledge about the treatment,’ ” she added, in what may be presumed was a clinically stilted ventriloquation of the prisoners’ actual words. Warden Abdul Karim said 105 of Salemba prison’s 1,812 total inmates have tested HIV-positive.

The prison’s capacity is just 587. “When they are admitted to the prison, they will be screened for HIV, they can’t say no to that,” Abdul said. “However, inmates who tested positive for HIV have the right to decline treatment.”

According to the UN World Health Organization’s guidelines on HIV infection and AIDS in prisons: “Compulsory testing of prisoners for HIV is unethical and ineffective, and should be prohibited.”

The Jakarta Globe was unable to speak with inmates who declined to undergo ARV treatment, but we spoke with Indra Agustiawan, a 24-year-old inmate living with HIV who has been on ARV treatment since April.

Indra told the Jakarta Globe that the fear of stigma by other inmates, particularly cell mates, was the biggest reason why some of his friends declined to partake in ARV therapy. “[Those who decline to be treated] are afraid of people insulting them and not accepting them,” Indra told the Jakarta Globe.

“But that’s not the truth. That’s not what happens here.” “Ever since I came out [as seropositive], my friends, including those who are negative, have fully supported me,” he said.

“They even sometimes remind to take my medicine when it’s time. We’re only people living with HIV and AIDS. We don’t spread our disease,” Indra said.

Changing minds

The group counseling session ranged from education about ARV treatment to a sharing session by inmates on ARV treatment who encouraged their peers to join them.

“We’ve trained the six psychologists from Himpsi about ARV treatment and other things,” Rohanna said. “Himpsi tried to encourage the inmates to think positively about ARV treatment,” Seri said. “We tell them that having HIV is not a death sentence, and what you need is treatment to stay healthy.”

The counseling session, Seri said, also informed inmates about possible side effects from taking ARV medication, which include nausea, headache and itchiness, lasting up to three months. “But, we tell them that once their body tunes in with the medicines, the side effects will be gone,” Seri said.

Psychologists also told inmates that ARV treatment’s benefits include the chance of having a family without needing to worry about infecting their partner or children, as long as they adhere to treatment. Indra said he decided to adhere to ARV therapy because he “wanted to be healthy” so that he “could help his family” once he’s out of prison sometime next year.

“We then tell them, ‘You have a disease, the medicines are free and you have doctors to help you. Why not do treatment?’ ” Seri said. Saturday’s counseling session reportedly worked out well, especially for the inmates, according to Seri.

“[The 14 inmates] agreed to join ARV treatment,” she said. The central government, she added, should involve psychologists in handling HIV and AIDS-related issues within prisons across Indonesia.

Needle-sharing by intravenous drug users, a more common practice among inmates before the adoption of harm-reduction as a national strategy in 2007, was previously accounted for the majority of new AIDS cases. (Sexual transmission has since surpassed intravenous drug use as the leading means of transmission in Indonesia.) Still, the effects on the prison population remain a grave concern for many: An estimated 25 percent of Jakarta’s prisoners are HIV-positive, but do not know their status, according to a presentation by former United Nations Joint Programme for HIV and AIDS country coordinator for Indonesia, Nancy Fee.

“As of now, the ARV therapy has been conducted by doctors provided by the Justice and Human Rights Ministry,” Seri said. “But I think psychologists should also be involved in their mental health.”

BPJS promised, but what will it deliver?

Jakarta Governor Basuki “Ahok” Tjahaja Purnama announced during Saturday’s 2014 World AIDS Day ceremony that the Health Care and Social Security Agency (BPJS), would administer health care for all inmates, including those living with HIV and AIDS, next year.

Basuki’s announcement appears to contradict BPJS and Ministry of Health officials’ long-repeated policy that the national health insurance scheme will not cover HIV or other infections contracted through intravenous drug use, citing moral hazard.

According to the current division of responsibility between BPJS and the Health Ministry, ARV treatment is the sole responsibility of the ministry’s existing infectious disease programs.

“Starting Jan. 1, we will issue a decree that BPJS will cover all treatment costs [for prisoners living with HIV and AIDS],” Basuki said. “If there isn’t any component in the BPJS program for that, then the Jakarta office will cover the costs.”

Since Governor Basuki holds no official authority to make such a decree on BPJS’s behalf and there is not, in fact, a BPJS component to cover all treatment costs for prisoners, it is fair to assume Basuki’s administration will be left holding the bag.

“All inmates here in the prisons are citizens of Jakarta and we’re preparing a letter to BPJS allowing the inmates to be covered by their program just by submitting a letter from the head of the prison,” Basuki said.

The capital’s six detention centers have a combined official capacity of 5,810 inmates. According to January-November 2014 data from Mardjoeki, who heads the Justice and Human Rights Ministry’s Jakarta office, these six detention centers currently hold 15,536 inmates, 744 of whom have tested positive for HIV.

During the same period, 115 Jakartans  died from AIDS-related illnesses. “Death from [AIDS-related illness] still takes the second place after tuberculosis,” Mardjoeki added.

It should be noted that Mardjoeki has no background in public health and his ministry is not responsible for HIV and AIDS surveillance, which is the province of the Health Ministry’s research arm.

Mardjoeki added that HIV transmission in Jakarta’s prisons has narrowed to nearly zero because the inmates condemn any homosexual activities and have ceased using drugs intravenously.

The Jakarta Globe was unable to independently verify any of Mardjoeki’s claims at press time; however, background discussions with health officials have suggested post-2007 acceptance of harm reduction measures have had an impact on the rate of increase in new AIDS cases in prisons.

“Prison conditions are often ideal breeding grounds for onward transmission of HIV infection. Tensions abound, including sexual tensions. Release from these tensions, and from the boredom of prison life, is often found in the consumption of drugs or in sex,” according to a UNAIDS report.