Denpasar

After a short introduction, Adi Mantara,  director of Yakeba, presented a slide show about Yakeba and its experience and success with harm reduction for  injecting drug users. A couple of years ago Yakeba has gained a region-wide reputation for its successful harm reduction program directed at the local IDU community. Through Yakeba’s comprehensive harm reduction program IDUs were provided with accurate information regarding HIV and AIDS, information on using drugs safely, sterile injecting equipment (including new needles, alcohol swabs and bleaching kits), free condoms and referral information on Methadone and VCT clinics. Yakeba has also been actively engaged in promoting human rights for people affected by drug addiction and HIV and AIDS. Activism led to the establishment of a daughter organization named IKON Bali, an organization of former drug users fighting for equal rights and a more human treatment of drug addicts and people living with HIV and AIDS.

Another front of harm reduction work in Bali and other parts of Indonesia is the work in prisons. Some prisons have adopted harm reduction strategies and could successfully lower the spread of HIV among their inmates. Indonesia was the first country in Asia providing harm reduction inside the prison system.

In Thailand, harm reductionists and Human Rights activists are currently lobbying the Ministry of Public Health for greater leadership and cooperation concerning the nations harm reduction strategy. While Thailand has been successful in greatly reducing the spread of HIV among sex workers and their clients, HIV transmission among IDU’s has remained largely unrestricted. This is believed to be a result of the governments reluctance to seriously implement harm reduction for IDUs as well as the governments criminal justice approach when it comes to drugs. In the year 2003, under the former Prime Minister Thaksin Shinawatra, a bloody “war on drugs” was initiated, which cost the life of more than 2500 people thought to be associated with the drug trade. Thaksin’s “war on drug” was highly criticized by Human Rights activists from around the world. Today, activists call for a greater involvement of (former) IDUs in harm reduction policy development and programming and the abolition of repressive laws and policies which rather increase the negative impacts of drug use than minimizing it.

At the end of the presentation there was enough time for the visitors to ask questions and the Thai Media reporters seized the chance to interview Adi Mantara and some of the present staff of Yakeba.

Harm reduction programs like the one from Yakeba could successfully slow the spread of HIV among IDUs on the island of Bali and in other regions across Indonesia. Nevertheless, prevalence rates among IDUs are still unacceptably high. Thus harm reduction should still be a priority, not only for the sake of IDUs but also for the sake of society at large.

By Felix Neuenschwander

Gianyar,

The purpose of the students’ field work activities was to increase public awareness about the dangers of HIV and AIDS and tackle the widespread stigma and discrimination related to the disease. In order to maximize the impact of the awareness activities, the UGM students’ committee formed a partnership with Yakeba. But apart from Yakeba also other community organizations took part in the activities, such as Kita Sayang Remaja (Kisara) and Yayasan Kerti Praja (YKP).

Each awareness session was attended by around 40 to 60 residents from the local neighborhood. Amongst them were community leaders and elders as well as representatives of local women and youth organizations. Some sessions were also attended by children. Thus, the audience covered the whole age spectrum of the local community. Consequently, Yakeba made sure that the material presented was easily understandable for all parties and had a strong link to prevailing issues in the local community.

During the awareness sessions, Yakeba mainly focused on the issue of drug use and its link to HIV and AIDS. First, some basic information about the different types of drugs and their impact was given. This was followed by the delivery of basic knowledge about HIV and AIDS and its prevention. Then, the relationship between intravenous drug use and HIV and AIDS was highlighted.

Ubud’s community responded with great interest to the awareness activities. Moreover, the diverse questions asked by the audience testify to a quite diverse community. Many people still do not know how to deal with people living with HIV and AIDS (PLWHA) in their neighborhood and especially within their family. Also, many do not understand how the transmission of HIV from an infected mother to her child can be prevented or minimized. Yakeba also provided information on HIV testing sites in the area and conveyed information associated with the culturally important bathing of bodies of people deceased because of AIDS.

Yakeba is grateful to have been involved in the above mentioned awareness activities together with the students of Gajah Mada University. As most staff members of Yakeba have a history of drug abuse themselves, they managed to bestow the provided information with a human face. This will hopefully help to reduce the stigma and discrimination against drug users and PLWHA. To sum it up, the message of the activities would be to avoid the virus and its negative consequences instead of avoiding the affected people. Because stigma and discrimination cannot stop the transmission of HIV and the problem of drug use, rather it will make it bigger.

Tabanan,

Yakeba’s Tabanan office is located in the sub-district of Kediri, in eastern Tabanan regency. The Global Fund supported outreach and peer support program covers the entire regency of Tabanan, which is further divided into 10 sub-districts (kacamatan). With a population of almost half a Million people Tabanan is densely populated (as most parts of Bali) but has maintained a predominantly rural character. To reach all corners of the regency the outreach workers have to cover considerable distances, with road conditions being poor in many areas.

Currently Yakeba employs six outreach workers, who reach out to people living with HIV and AIDS as well as populations at high risk of contracting HIV (mostly sex workers, clients of sex workers, men who have sex with men (MSM) and transgender). The outreach workers are all from vulnerable communities themselves.  Some are ex-drug users, others were involved in some form of sex work or are MSM. Some are living with HIV and AIDS themselves. Having similar backgrounds as many of the people they reach out to facilitates their work in several ways. They can not only relate better to the problems and obstacles faced by their clients, but are also more easily trusted by them. As many clients are marginalized by society as a result of their occupation or sexuality and the issues of HIV and AIDS are surrounded by secrecy and stigma, gaining the trust of their clients is crucial to successful outreach and support.

The duties and responsibilities of the outreach workers are manifold. Educating high risk populations and to a lesser degree the general public, about issues surrounding HIV and AIDS, stands at the core of their work. They regularly frequent so called HIV hotspots, such as kafe (local bars), lokalisasi (red-light districts), massage parlors and places where MSM and transgender congregate. There, the outreach workers distribute free condoms and water-based lubricant sachets along with information leaflets about its correct usage and HIV and STI prevention. During individual or group counseling the importance of regular STI check-ups and their treatment at a cost free STI clinic are stressed. Clients are actively encouraged and referred to one of the VCT (Voluntary Counseling and Testing) sites in the region to know their HIV status. Mobile VCT and STI testing on the spot (mostly at kafe) was organized a number of times, in conjunction with the local health department and AIDS commission. Apart from the prevention work the outreach workers help to fight the widespread discrimination and stigma related to HIV and AIDS within the community by organizing educational gatherings with local community leaders and the local population. Issues such as drug and alcohol abuse are also raised during outreach activities.

Some of the outreach workers also serve as  buddies for clients living with HIV and AIDS. The buddies themselves are living with HIV and AIDS. That way clients get the chance to talk to another person with the same disease, get first-hand information about the buddies experiences as well as general information about HIV and AIDS. They have someone who listens to their own stories, problems and worries. Thus the buddies provide emotional and psychological support, provide social support and friendship and connect their clients with other PLWHA. They also provide practical support like home visits, accompany clients to hospital and help them access financial assistance from the relevant authorities. Clients also have the possibility to discretely contact their buddies through text messages. For some of them that is the main mode of interaction with the outreach workers, as they keep their HIV positive status a secret and are afraid that visits from Yakeba buddies would make family members or neighbors suspicious.

Yakeba’s outreach workers also attend to  AIDS patience at the hospital. They regularly visit their clients at the AIDS ward in Tabanan Hospital. Especially for patients who have no family or friends to look after them, these visits are of great importance. Recently for example one of the outreach workers helped to feed and wash a terminally ill woman, who was dropped there a couple of days before by some family members who rejected her (her husband and child already passed away because of AIDS). Nothing but skin and bone, she lay there dying alone. The medical personal neither washed her nor assisted in feeding her, things which are supposed to be done by family members. In such situations, an assisting hand and some supportive words by an outreach worker can restore the dignity of a patient.

Unfortunately, despite encouragement by our outreach workers, many people at high risk of HIV infection are still reluctant to test for HIV. Consequently late diagnosis of HIV remains a serious problem, with a majority of people already having developed AIDS at the time of HIV diagnosis. Many patients are diagnosed only after having been hospitalized as a consequence of one or several opportunistic infections. This not only reduces the chances of survival but also reinforces the image of HIV and AIDS as something untreatable and inevitably deadly. Routine VCT of people at high risk of HIV could not only prevent the further spread of the disease, but also reduce the morbidity and mortality of people infected with HIV. But as free antiretroviral treatment is only available for people who have already reached the stage of AIDS, early diagnosis could not safe the vast majority of people who have no means to pay for their medication themselves.

Being confronted with tragic destinies, disease and death on a regular basis, outreach workers need to have a thick skin. But asking my colleagues how they deal with their often difficult work, they emphasize the many success stories. Helping to prevent people from becoming infected with HIV, reducing discrimination and stigma against PLWHA and seeing people literally rising from deathbed to become strong and active members of society again is rewarding indeed.

By Felix Neuenschwander

Denpasar,

Activities started with a short introduction of each participant. After this, Adi Mantara, director of Yakeba, held a short introduction statement. He explained that the purpose of this training was to equip the outreach workers, activists and members of high risk groups with new skills and knowledge related to writing. He emphasized that writing should be considered an important tool for outreach workers, as they are the ones who can best describe the situation in the field. This would not only improve their work performance but by writing they could also pass their experiences and knowledge on to the wider public. But also members of high risk groups should be able to voice their issues and concerns through writing as a way to empower themselves.

After a short break, Luh Deh Suriyani started by providing some basic information on writing. She explained that there are many types of writings and that through writing any issue could be addressed. She then went on to say that, most importantly, a text should be interesting to read and be easily understood by its readership. Participants then had to do a small writing exercise. After the exercise she equipped the participants with  a technique called “5 w 1 h” which should help writers to start writing a text. This was very useful, as many people find it difficult as how to begin writing a text.

After the lunch break Anton Muhajir regained the participants attention with a short and amusing activity called “ice breaker”. Thereafter he encouraged the participants to create a short writing about personal change. Subsequently Anton discussed one of the created texts and gave inputs on how to improve it. Participants were then asked to revise and finish their article.

For many of the participants it was their first encounter with the world of writing and they were quite enthusiastic to gain more knowledge and improve their skills. “The workshop was very interesting and I hope it will help me to write better field reports in the future, so it will benefit my work. Even though one day is not enough to learn how to write better, it is a good start,” said Desak, an outreach worker of Yakeba in Tabanan. Harli, a client of Yakeba, added that “if we improve our writing we can also write better e-mails and this is very important these days.”

At the end of the workshop Yakeba handed over two symbolic awards. One to Anton Muhajir, facilitator and  representative of Sloka Institute and another one to Nyoman Budaya, representative of the vulnerable communities.

As Desak said, the art of good writing cannot be learned within one day, it needs a lot of practice. But the workshop was a successful introduction and will hopefully stimulate the participants’ interest in becoming better and more creative writers. Especially when it comes to topics which are surrounded by secrecy and stigma, like HIV and AIDS, writing can be a useful tool to change public perceptions and is good for education more generally.

By Felix Neuenschwander

When reading about HIV and AIDS all too often we are confronted with statistics. We learn about the number of people newly infected, about prevalence rates within certain populations, regions or countries and how many people have died from AIDS. While such statistics are necessary, they tell us little about the realities behind these numbers. Thus the idea of “notes from the field” is to tell the stories of real people and give a human face and voice to the epidemic.

This week, we will tell the story of a woman living with AIDS in the regency of Tabanan, lets call her Komang. Komang is in her mid twenties, widow and mother of a HIV positive three year old child. Komang’s husband passed away two years ago because of AIDS.

Komang first met her husband in high school. Back then she became his girlfriend, but they did not yet have a sexual relationship. After finishing high school in Tabanan and working for a year in East Java’s capital city Surabaya, Komang return to her native Bali and caught up with her high school sweetheart. They started a romantic relationship and soon after, got married. Komang soon realized that her husband had an alcohol problem, as he often went drinking with male friends at so called kafe (local bars, where sexual transactions with the waitresses take place) and came home drunk. She also suspected him of having affairs with women working at these kafe, but she felt she could do nothing about it. When Komang was three month pregnant her husband fell ill for the first time. He had to spend a couple of weeks in hospital. After that, he started getting sick all the time. At the hospital they recommended a blood test and he was diagnosed HIV positive, already having reached the stage of AIDS. Even though he was given medication, he passed away soon after. Just a couple of weeks before he passed away, Komang gave birth to a son. The doctors then suggested Komang take a test as well and that is how Komang found out about her own HIV infection.

Komang then started antiretroviral therapy (ART), but stopped taking her medication after a couple of months. Having seen her husband pass away from AIDS despite taking medication, she lost hope and did not believe that the drugs would prolong her life. Moreover, she felt discriminated against by her family and the neighbors, which made her feel miserable. Luckily, after being repeatedly counseled by an outreach worker of Yakeba, Komang resumed her treatment. When Komang’s son was one year old, they tested him as well and sadly the result turned out to be positive. Nevertheless, now three years old, he is still strong and healthy and not yet in immediate need of medication.

Apart from the emotional struggle of losing her husband and being diagnosed with a life threatening disease herself, Komang had to endure another struggle – that of discrimination. It manifested itself for the first time when her husband passed away and nobody wanted to wash his dead body, even though the ritual washing of the dead body is an essential part of Balinese custom when somebody passes away. It was only when an outreach worker of Yakeba gave accurate information to the family and villagers and demonstrated the washing himself, that people would join and perform the ritual washing. But discrimination did not end there. Once Komang disclosed her own HIV status to her parents-in-law (where she lived) they started avoiding her. They would not eat what she cooked, did not share plates and avoided touching her. Furthermore, the neighbors did not let their children play with Komang’s son. As a result of this, Yakeba’s outreach workers held various small gatherings in Komang’s village, talked to her in-laws and the local community leaders. Slowly but surely people started to understand more about HIV and AIDS and realized that there is absolutely no reason to be afraid of someone who is infected. Rather they learned, that embracing people suffering from HIV and AIDS is not only essential for the physical and emotional well-being of the affected but also for the sake of the community at large.

Komang’s experience of discrimination is anything but unusual. As ignorance and misconceptions about HIV and AIDS are still widespread within the community, people tend to discriminate against the ones who disclose their status or people perceived to be suffering from the stigmatized disease. Discrimination comes in many forms and is widespread in all sectors of society. Often society’s negative and discriminatory views are internalized by the affected, leading to low self esteem and negatively impacting their physical and psychical well-being. As a result people are reluctant to seek information or test and the interaction between people living with HIV and AIDS (PLWHA) and the health care system is hampered. This not only fuels the epidemic and enhances its socially damaging effects but is also highly concerning from a Human Rights perspective. Thus, Yakeba is trying hard to bring about a change and reduce discrimination and stigma against PLWHA .

Although most people with HIV and AIDS in the Province of Bali are still from “high risk groups”, an increasing number of “low risk women”, that is mostly married women who have had only one or very few sexual partners, are becoming infected. Komang is one of them. Like her, in most cases these women were infected by their husbands or boyfriends, who patronized sex workers. In epidemiological terms this could be an indication of a shift from a concentrated (within some risk groups) to a more generalized epidemic.

Our aim here is not to blame anyone, but rather to promote a more responsible sexual (and otherwise) lifestyle – taking into account all the complexities of sexuality and its embeddedness in local culture and religion. The community and its leaders have to open their eyes to what is really going on. Drastic times call for drastic measures, so we have to be willing to talk about things that many would rather not talk about. This alone will not halt the epidemic, but it is an essential step towards reducing its devastating impact.

Komang’s story is a story of hope. Having gone through very difficult times, she is now strong enough to help others who are only at the beginning of their tough journey. Encouraged by our outreach workers Komang has become a role model for other people living with HIV and AIDS. Her advice and example is of great value for them.

By Felix Neuenschwander

Tabanan

On July 8th, 2011, Yakeba did an awareness session at Banjar Ole Delod Puri at Petiga village in the regency of Tabanan. The event was held at the request of local community leaders and is part of Yakeba’s effort to fight the HIV epidemic in Tabanan and Bali as a whole.

The event was attended by approximately 70 people consisting of community representatives, women and youth. Among the participants were also the head of Petiga village, representative of the local Police and local representatives of the Indonesian National Army (TNI). The spokesman of the event was Adi Mantara, director of Yakeba.

Yakeba also used this activity as a way to introduce itself to and strengthen its ties with the local community. Almost the entire staff of Yakeba participated at the event. Among the ones present were Fais, field coordinator of Yakeba, Artini, Care-Support-Treatment (CST) coordinator, Gusdek and Desak both outreach workers as well as Alvin, data officier.

Activities started at 7.30pm with local community leaders opening the event, followed by an introduction of the village head of Petiga village. After that Yakeba started a presentation about its journey as an organization and its HIV & AIDS prevention activities in Bali. This was mainly done in order to illustrate the changing approaches and techniques of HIV & AIDS prevention, due to the evolving nature of the epidemic and prevailing myths about the disease among the population.

During the evening, many questions were raised by members of the local community, such as how it was possible for infected people to have children, how to provide first aid to infected people after a traffic accident, how to wash the body of people suffering from AIDS, how to prevent children from contracting HIV from their mothers, how to know their HIV status and many more.

At the end of the event the local community leaders conveyed their thankfulness to Yakeba. Thanks to awareness activities like this, misconceptions and fears about the stigmatized disease can be reduced.

By:

Yakeba Team

Tabanan

On June 29^th, 2011, for the umpteenth time, Yakeba carried out awareness activities in the district of Tabanan. Activities took place at Banjar Pengembungan at a village called Tegaljadi and were organized by the Student AIDS Care Community (KMPA) of Bali Province and the regional branch of the National AIDS Commission (NAC). The KPA Tabanan delegated the matter to Yakeba and it was run by its director Adi Mantara.

Apart from Yakeba the event was also attended by Dr. I Gede Wiryana Putra Jaya, representative of the Indonesian Red Cross (PMI) Tabanan. Dr. I Gede Wiryana Putra Jaya is also the head of the Tabanan Hospital. Furthermore representatives from the local community were present.

The event started at 7.30 pm with the opening of the committee, followed by the introduction of local community leaders. Dr. Putra Jaya started the session giving some general information on HIV and the dynamics of the epidemic as well as how to respond to people among us who are infected with HIV. This was followed by information associated with the bathing of bodies of people deceased because of AIDS. Such information is important, as bathing the dead body before cremation is an important element of Balinese culture.

Then, Adi Mantara spoke about policies and activities done by various Non Governmental Organizations (NGO’s) associated with HIV and AIDS in the regency of Tabanan and more generally in Bali. Adi Mantara also informed the participants on the number of HIV cases in the regency.

The event lasted until 9.30 pm and was concluded with the assignment of an award by KMPA Bali to Yakeba and PMI. Events like these are very necessary, as stigma and discrimination is still very widespread in the community. We believe that fears and misconceptions resulting in discrimination are rooted in ignorance; therefore, providing accurate information about HIV & AIDS will reduce these fears and the stigmatization of people living with HIV & AIDS.

By :

Yakeba Team

Recently, two staff members of Yakeba (Alvin and Ruben) took part in a training session for addiction counselors in Bogor, West Java. Yakeba as an organization has a long history providing rehabilitation services, especially in the Province of Bali.

On June 23^rd 2011, Yakeba received a visit from Sam Nugraha and Erry, two members of the Indonesian Association of Addiction Counselors (IKAI). The main purpose of their visit was to see Yakeba’s efforts regarding the planned implementation of PABM. Additionally, the two visitors from IKAI provided information on capacity building, particularly the capacity of addiction counseling.

During their visit, IKAI asked the Yakeba administration to scale-up their preparations for PABM. Some of the areas of focus were the Standard Operating Procedures (SOP) used by Yakeba. All SOP (for instance the SOP assessment, the SOP of daily activities, the SOP Discharge (release of the client) and others) were reviewed by IKAI and some inputs were given to improve the quality of service.

IKAI also trained Yakeba in conducting a new assessment method called Addiction Severity Index (ASI). Moreover they trained some staff members of Yakeba (Alvin, Ruben and Adi Mantara) on how to perform better with the client. Such activities are conducted regularly by IKAI as a form of cooperation with the National AIDS Commission so as to improve the quality of PABM.

By:

Yakeba Team

In order to expand and improve HIV and AIDS services in the regency, a local regulation was introduced. It was high time for Tabanan, as most other regencies in Bali have already introduced such regulations at an earlier stage. The new regulation is also needed so as to better implement the provincial regulation no 3 of 2006 which deals with the problem of HIV and AIDS.

On Wednesday 22^nd June 2011, the Tabanan AIDS Commission (KPAK Tabanan) held a meeting to discuss the draft of the planned regulation with local stake holders and NGO’s. The regional government was represented by the Tabanan Department of Law, the Tabanan Health Department, the Tabanan Social Welfare Department, the regency’s Social Department, the Police, representatives from “Desa Pekraman” as well as by Tabanan Hospital and other local public health services. Nongovernmental Organizations were represented by Yayasan Kesehatan Bali (Yakeba) and Yayasan Dua Hati. Mr Yahya Anshori and Mr Ketut Sukanata from the Bali AIDS Commission (KPAP Bali) were present at the meeting and gave some insights on the draft of the local regulation. Currently the draft is being checked by the Tabanan Law Department and will soon be submitted to the local parliament for approval.

“This regulation is important because the regency of Tabanan is seeing more and more HIV and AIDS cases. We can push it if all parts of society are involved; the public community, the government and people living with HIV. And such a regulation will regulate the collaboration of all these different elements“, said Adi Mantara, director of Yakeba, decidedly. And he went on to say with a warning tone that “even the best government services will not achieve a maximal outcome, if HIV infected people have difficulties accessing these services. And as high as the awareness among people infected with HIV might be, as long as there is still stigma and discrimination from society and the government, interventions will not tap the full potential. Therefore a regulation is needed in order to ensure that all elements of society are involved in the response to HIV and AIDS”.

Ketut Randem, daily coordinator of the Tabanan AIDS Commission, said that he will push the release and implementation of Tabanan’s new HIV regulation but underlined that the combined effort of all parties – stake holders as well as the local community – are necessary.

By : Yakeba Team

The goal of the workshop was to improve the implementation of Community-Based Drug Dependency Treatment (PABM in Indonesian). The first phase of Community-Based Drug Dependency Treatment started in 2009 and Yakeba was involved from November 2009 until August 2010.

PABM brings a new alternative solution to drug users in Indonesia who want to free themselves from their addiction. In Bali, addicts (drug users) who want to stop using already have a number of options when it comes to choosing a way how to stop: there are Needle Syringe Programs (NSP), there is the possibility of Heroin substitution (Methadone or Buphrenorpine), as well as regular rehabilitation programs run by local NGO’s. And now there is also PABM as a new and alternative solution for drug addicts who desire to stop using.

PABM uses similar methods as conventional rehabilitation, with the main difference being the duration of the program. Standard rehabilitation usually lasts between three months and one year, with the clients staying at the service facility fulltime. By contrast the PABM program lasts six months, with the clients staying at the service facility only one month and the remaining five months staying at home but attending regular counseling sessions. The aim of PABM is to increase the quality of life of people suffering from drug addiction. Thus PABM is also linked to Care, Support and Treatment (CST) programs addressing the issue of HIV/AIDS.

Yakeba was involved in the training because of its experience applying PABM in the first phase. But the workshop also served as an evaluation tool in order to improve the services of PABM in the next phase. Representatives from Bali were Mr. Yahya from the Bali AIDS Commission, Mr. Adi Mantara from Yakeba and Mr. Nanol Prasetya from Yakita Bali.