Indonesian Policy on HIV/AIDS

15 Maret 2011

1. HIV infection in Indonesia

Indonesia has among the fastest growing prevalence of people infected with HIV in Asian regions.
Nonetheless, the prevalence in Indonesia itself is still low: according to the Data and Information
Centre from Indonesian Ministry of Health, around 0.2 percent from the total population. However,
since Indonesia is the world fourth most populous nation, this number means that currently there are a
total of about 200.000 people living with HIV in Indonesia (UNAIDS, 2007).

The first AIDS case was detected in Indonesia in 1987 in Denpasar, Bali, and then at the following
years the pattern followed the same pattern like other sexual transmitted disease just like in most other
countries. However, especially since 2001, injecting drug users are increasingly being reported with
HIV infection, and then there was a high annual increase of HIV infection reported from injecting drug
users in Indonesia: from 146 cases in 2003 to 1183 cases in 2004 (Ford, Wirawan, Sumantera, Sawitri,
& Stahre, 2004).

From the data in Indonesian Ministry of Health (2006), we can also see that 82% of known people
living with HIV/AIDS is men and are concentrated within specific groups with specific behaviour in
the population: about 50.3% of HIV infection cases are from injecting drug users, 40.3% from
unprotected heterosexual sex, while 4.2% from unprotected homosexual sex. There are also several
studies that show the HIV infections epidemic men who have sex with men communities in developing
Asian countries, including Indonesia (Pisani et al., 2004; Toole et al., 2006; Wong, Zhang, Wu, Kong,
& Ling, 2006).

2. Political will to curb HIV epidemic

To answer with the HIV infections pandemic, the government, with the presidential decree number
36/1994, established the National AIDS Commission. This commission were created to prevent and to
take integrated and coordinated, inter-sectoral actions against AIDS in Indonesia. This commission is
headed by the Ministry of Welfare and also with the coordination of other Ministries, such as Ministry
of Health and Ministry of Internal Affairs (Presiden Republik Indonesia, 1994).

It is aimed to prevent and to take actions against AIDS according to the current regulations, in
accordance with the global strategy set by the United Nations, and also to increase community
awareness for AIDS and improving the intersectoral, integrated and coordinated prevention and actions
against AIDS

In 2003, another presidential decree was set up to improve this commission. It stated that the
commission actions are coordinating measures in actions against AIDS, including prevention,
education, health service, surveillance, and control of AIDS, epidemiological observation on vulnerable
populations at risk of infecting HIV, health education, health campaign and regional and international
cooperation in preventing against AIDS (Presiden Republik Indonesia, 2006).

3. Is it improving the condition?

The program set up by the central government, regional government, non governmental organisation,
and the support received from foreign donors in the form of HIV awareness and prevention programs
throughout Indonesia have been improving some of the situation of HIV infection in Indonesia. A
survey on condom use in sex industry in Indonesia in 2004-2005 reported that 61% of sex workers in
brothels said that they had use a condom in the last time they sold sex. A prevalence of 57% was found
in sex workers who didn’t work in a brothel. (UNAIDS/WHO, 2008).

For injecting drug users, the program is focused on reducing the use of non-sterile injecting equipment.
In Jakarta and Medan, where programs such as these are reaching the injecting drug users, the survey
found out that more than 80% of injecting drug users said that they always used clean needles
(UNAIDS/WHO, 2008). The harm reduction method, which has been set up as a model for Indonesian
government to tackle the growing HIV infections from injecting drug users group in Indonesia, was
established by the Sentani Commitment (see Appendix), as an agreement between the National AIDS
Commission and regional governments (National AIDS Commission, 2004).

While programs to prevent HIV infections in female sex workers and injecting drug users have been
showing some degree of success, another vulnerable populations is still have lower priority in AIDS
prevention program. A report in 2004 mentioned HIV infection levels of 2.5% in men who have sex
with men, 3.6% among male sex workers, and 22% on waria (Indonesian term for transgender) sex
workers in Jakarta, the capital of Indonesia. Almost of them are practicing risky sexual behaviours. It is
stated that 65% of the male sex workers and 53% of men who have sex with men in Indonesia reported
having unsafe anal sex with male partners and also 54% of the male sex workers reported that they had
sex with women in the prior year (Pisani et al., 2004).

However, when we look at the trends in the following figure, we can clearly see the increasing number
of new cases of HIV infection found in Indonesia until 2006.

(Pusat Data dan Informasi Departemen Kesehatan Republik Indonesia, 2006)

Also we have another graph showing the model to predict the number of HIV infections in Jakarta, just
from the data taken from one population: the injecting drug users.
(UNAIDS/WHO, 2008)

From the above graph, we can see that the situation in Indonesia is still far from improving. In
addition, although the overall HIV infection prevalence in Indonesia is still low, if we look into the
regions of Indonesia, we have a number as high as 2.4% as the adult prevalence rate of HIV infection
in the Papua province (Pusat Data dan Informasi Departemen Kesehatan Republik Indonesia, 2006).
The Ministry of Health vision of Healthy Indonesia by the year 2010, which set a goal of 0.9 percent of
maximum prevalence in 2010(Menteri Kesehatan RI, 2003) in all regions of Indonesia, seems
farfetched. In the following section, we will discuss problems in the implementation of the policy for
HIV prevention in Indonesia.

4. Problem in program of HIV prevention

Although the government already set up a commission accountable directly to the president, we can see
that the problem with HIV infections in Indonesia is still growing. In the following, I would like to
discuss several points why the policy against HIV in Indonesia is still unable to achieve its goal (such
as in the Healthy Indonesia by 2010). There are 4 main problems that I would discuss, two related to
the target of the program, in dealing with the sexual transmission of HIV infection, and also
transmission in injecting drug users. The others two related to the decentralisation process in Indonesia
and on funding.

4.1. Extensive sex network and geographical difference

Sex industry in Indonesia itself is extensive even though their legality is questioned. A survey on 1994-
1995 found that there were 71,281 sex workers in Indonesia (Endang, Ivan, Walter, Noni, & et al.,
2002), even though the actual number should be higher. Prostitution is not allowed in Indonesia, and
sex workers who were caught soliciting in the streets can be sent to a rehabilitation camp. Nonetheless,
brothels are somewhat accepted especially in the big cities: they are not illegal, there are no rules
regarding this, the illegality of prostitution only concern on those who sell sex on the street. Therefore
the local governments have regulated sex works in these brothels, providing health facilities and put
certain limitations. Nonetheless, this unclear status for brothels can pose a problem for maintaining
sustainable health program in preventing HIV infections.

The vast regions in Indonesia also made an obstacle in the program to prevent HIV infections. In most
Indonesian provinces, such as in Java, Bali, Sumatra, and others, the common transmission of HIV
infections is through injecting drug users. However, in Papua province, we have a different
transmission pattern.

Papua is rivalling Jakarta in terms of HIV infections prevalence: a prevalence of 2.4% for overall adult
HIV prevalence, and this could reach to as high as 3.2% in remote highlands of the Papua province
(UNAIDS/WHO, 2008). In this region, unprotected sex is the main mode of transmission. Based on
data from the UNAIDS/WHO, there’s a high proportion of men engaged in high-risk sex, with 25%
reported that they had sex with non regular partner (over half of it were paid sex) and 20% had more
than one sexual partner. From this report we can also see that the use of condom is uncommon. It is
reported that only 14% who said that they use condoms for paid sex, and even only 3% said that they
had use condom every time in previous month. Another problem with the Papua province is sexual
violence. It was mentioned that 12% of women has experience sexual violence, even from their
domestic partner. Therefore, to prevent increasing HIV infection in Papua, the main concern is to
provide better sex education and also to promote and to distribute condom throughout Papua region.
(UNAIDS, 2007)

4.2. Harm reduction policy for injecting drug user

Even though the term of harm reduction itself is still controversial, whether it is a broad term of
measures encompassing strategies of limiting supply and minimising harm, just like in Australia, or just
strictly only a part of the strategy to tackle drug abuse specifically to minimise the harm of using drug
(Ball, 2007).

According to Beyrer, Kumarasamy and Pizer (2005), the problems with the implementation of harm
reduction policy in Asia, including Indonesia, can be categorised into three categories. The first one is
this policy is considered as a way to say that it is all right to have people who abuse drugs and that this
behaviour is only an expression from several people that tend to take risks. The focus of the harm
reduction (at least in the narrow definition) then is to minimise the harm from using drugs regardless
whether the status of using drug is right or wrong or wherever the drug comes from, since it is the
health sector itself would bear the brunt if HIV infections (and also Hepatitis B and Hepatitis C
infections) spreads from injecting drug users. Whether drug addiction itself pose a serious health
problem to the community, where increasing drug user would also means increasing number of
neurologic disability and psychosocial problem, would be tackled by the limitation of supply of drugs,
not by the harm reduction system. I think that if Asian countries, especially Indonesia, want to fully
implement harm reduction policy, both minimising the supply and managing the harm of drug abuse
should put into practice. Therefore, the harm from bad practice of injecting drug users (for example
needle sharing) can be minimised while effects of drugs to individual and society itself can also be
minimised through controlling/ reducing supply of drugs in the black market.

Nevertheless, it is interesting to see in Iran, another Asian countries with high Muslim population, just
like Indonesia, that the head of Iranian Judiciary declare, regarding on this dilemma between public
health and drug control, after considering the Islamic principle of “doing no harm to oneself or others”
and “the worst harm is eliminated by a lesser harm”, that the public health is more important in
controlling the spread of HIV infections (as the worst harm) rather than control on drug abuse (which
considered as a lesser harm)(Ball, 2007).

The second obstacle of harm reduction policy, as in many Asian countries, is the legal system (Beyrer
et al., 2005). The current legal system in Indonesia still considers that the abuse of drugs is illegal and
can be punished. The problem arise with this is that the harm reduction policy is usually set up several
places for injecting drug user to access clean needles and also places to dispose them properly.
Injecting drug users also need place for them to get some treatment, education, and referral. If setting
up these places can pose a threat in the security of the community and also risking the injecting drug
users being caught by the police, there should be some compromise between the rights of injecting drug
users and also the rights of community for security. Therefore if we want to set up a safe haven for
injecting drug users so that they can safely gain access of clean needles, treatment, education and
referral, the provider of such place must be able to provide legal protection for their client from being
arrested in that places. Obviously we should just put safe domain for injecting drug users everywhere,
but we must understand first where injecting drug users needed mostly.

Another aspect of the legal system is related to the status of possessing injection equipment: eg syringe.
Although in Indonesia it is not illegal to carry needle syringe, however, it is regulated under
prescription only. In several countries, there are laws that prohibit people to possess injecting
equipment, but eventually experience from developed countries shows that if this regulation is
abolished, it really removes the practice of needle sharing between injecting drug users while does not
really have much effect on the prevalence of new user (Deany, 2000).

In addition to that, if the legal system can work to accommodate the harm reduction system, the police
can also act an important part in HIV prevention among injecting drug users. Police then should refers
drug users for treatment rather than incarcerate them.

Finally, the last obstacle is on financial support and coverage of harm reduction program. Other than
providing a safe place for injecting drug users, a program on harm reduction of drug abuse must
provide a continued supply of clean needles. They also need human resources to run the program such
as medicals and paramedics, counsellors, and others. Perhaps it is hard to put some money from the
budget just to “satisfy” the need (or rights?) of injecting drug users, however, this is needed to prevent
further problem in public health. And this problem in funding will be discussed in the next section.

From this we can see that the problem is much clear: whether the society accepts such behaviour and
deals with the harm caused by it and whether the government is willing to conduct such program.

4.3. Problem in regional implementation

In 2007, 23 provincial governments reduced their HIV budget by a total of 5.72 billion rupiahs, to be
put toward the expenditure of regional election, even though President Susilo Bambang Yudhoyono
called for an increase in the state’s budget for HIV/AIDS during a cabinet meeting in July. In Papua,
for example, the provincial government allocated Rp 10 billions for its regional AIDS commission in
2007, but only 1 percent of the budget was realised. The government did not consider HIV/AIDS a
priority because the number of infected people remained small compared to patients of other diseases.
In December 2007 the Ministry of Health recorded 6,066 people with HIV and 11,141 with AIDS. The
National AIDS Commission said it needs more than Rp 1.5 trillion in 2008 to deal with the virus,
which most of the budget would be spent on prevention programs, but the central government has
promised to provide Rp 1 trillion only. The commission estimated the number of people with
HIV/AIDS would reach 400,000 in 2010 and one million in 2015 across the country. (The Jakarta Post,
2008).

4.4. Problem on funding and sustainibility

In relation to the previous discussion on regional implementation of the policy, we can see that it was
expected for the regional government to increase their spending on promotions against HIV infections.
This is because Indonesia is still depending on foreign donors to tackle the issue of HIV infections.
Foreign donors provide up to 70 percent of funds to prevent HIV infections in Indonesia (Pathoni,
2008). However, donors such as the United States and Australia are expected to decrease AIDS-related
assistance partly because they now consider Indonesia a middle-income country. This means that
programs on HIV prevention in Indonesia should emphasize on sustainability. We shall look at one
example: the Aksi Stop AIDS program.

The Aksi Stop AIDS program is a program of HIV prevention where USAID, in cooperation with the
Family Health International and working together with the government of Indonesia through the
National Commission of AIDS (Family Health International, 2007). This program is aimed to reduced
incidence of STI/HIV/AIDS in most-at-risk groups (MARGs) thereby helping to prevent a generalize
epidemic and reduced incidence of STI/HIV/AIDS within the general population of Papua (Family
Health International, 2007, p. 5).

The program itself were recently came to an end in September 2008, where it was expected that we
have (Family Health International, 2007, p. 5) :

• Increased coverage of most-at-risk groups with tailored interventions and improved uses of risk
reduction behaviours, practices, and access to and use of services; and

• Increased ability of implementing agencies to regularly monitor, evaluate and improve program
performance, thus achieving expanded coverage.

We can see that from this example that sustainability of the program is very important. After the
program ended, and we have the output of improved implementing agencies in HIV prevention,
therefore we can expect the outcome is the continuity of the HIV prevention program.

5. Conclusion
In conclusion, we can see that although Indonesian policy on HIV prevention is already set, they have
to deal some of the issues which are different from other countries: the extensive sexual network, the
geographical difference in HIV infection prevalence and main method of transmission, problems in
implementing the harm reduction policy for injecting drug user, problems arose with decentralisation,
where regional governments don’t prioritise HIV preventions, and also the problem with funding and
sustainability. In dealing with the increasing number if HIV infections in Indonesia, therefore we need
to develop a better strategy which addressing these issues.

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