very 25 minutes in Indonesia, one person is newly infected by HIV. One out of
every five newly infected people is below the age of 25 years. Indonesia's.
Ministry ...
IssueBriefs UNICEF INDONESIA
OCTOBER 2012
Issue Brief: Responding to HIV and AIDS
Responding to HIV and AIDS Inequities
Inequities Every 25 minutes in Indonesia, one person is
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newly infected by HIV. One out of every five newly very 25 minutes in Indonesia, one person is newly infected people is below the age of 25 years. infected by HIV. One out of every five newly Indonesia’s Ministry of Health projections showinfected that people is below the age of 25 years. Indonesia’s without acceleration of HIV prevention programmes, Ministry of Health projections show that without acceleration over half a million people in Indonesia will be HIV ofpositive HIV prevention programmes, over half a million peopleby by 2014. The epidemic is fuelled primarily in sexual Indonesia will be HIV and positive by 2014. Theuse. epidemic transmission injecting drug Tanahis fuelled primarily by sexual transmission and injecting Papua (the two provinces of Papua and West drug use. Tanah Papua (the twoBali provinces Papua WestHIV Papua), Jakarta and lead inofthe rateand of new Papua), and Balipeople lead in (Figure the rate 1). of new HIV cases per casesJakarta per 100,000 Jakarta has the highest number of new cases has (4,012 in 2011). 100,000 people (Figure 1). Jakarta the highest number of new cases (4,012 in 2011).
The increasing feminization of the epidemic in the country inequities in status and power. is higher (2.8highlights per cent) than that amongst non-indigenous Women are more vulnerable due to their traditional population (1.5 per cent) and higher in men (2.9 per roles in society, which extend to marital relationships. cent) than in women (1.9 per cent). The proportion of women in new HIV infections in Indonesia has grown from 34 per cent in 2008 to 44 Theper epidemic in Tanah Papua cent in 2011 (Figure 2). is driven almost completely by unsafe sexual intercourse. The underlying and structural causes include grinding poverty amidst Figure 2. New HIV cases amongst women and men, 2008-2011. unequal patterns of rapid development and natural HIV data from Ministry of Health, Progress Report HIV & AIDS Situation in Indonesia up to December 2011 resources exploitation, ethnic and linguistic inequities, of low Number levels of education and knowledge about HIV, Male Female new cases gender discrimination, a young age of sexual debut and 25,000 other social and cultural norms.
Issue Brief: Responding toDHIV and AIDS
Inequities
Figure 1. The top ten provinces in new HIV cases per 100,000
Every 25 minutes inpopulation Indonesia, one person is in 2011. newly infected by HIV. One out of every five newly 131 Papua infected people is below the age of 25 years. 46 West Papua Indonesia’s Ministry of Health projections show that 43 Bali without acceleration of HIV prevention programmes, 43 over halfJakarta a million people in Indonesia will be HIV 41 positive by 2014. The epidemic is fuelled primarily by Riau Islands sexual transmission and injecting drug use. 2011 Tanah 32 Maluku Papua (the two provinces of Papua and West 13 East Kalimantan Papua), Jakarta and Bali lead in the rate 2010 of new HIV 11 West Kalimantan cases per 100,000 people (Figure 1). Jakarta has the North Sulawesi highest number of10new cases (4,012 in 2011).
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North Sumatra INDONESIA
9 8.88
Figure 1. The top ten provinces in new HIV cases per 100,000 50 in 2011. 100 150 0 population New HIV cases per 100,000 population 131 Papua Calculated from: New HIV cases from Ministry of Health, Progress Report HIV & AIDS Situation in Indonesia up to December 2011. Population data from SUPAS 46 West Papua 2005 (Intercensal Survey) projection for 2011 population. 2010 census for 2010 population (2011 projects unavailable 43 at the time of this Report). Bali
Tanah Jakarta Papua illustrates 43a case of extreme inequity in Tanah Papua illustrates a case ofcent extreme Riau Islands infection patterns. With41only 1.5 per of Indonesia’s inequity in infection patterns. With only percent 32 population, accounted for 2011 over 1.5 15 per Maluku Tanah Papua cent of Indonesia’s population, Tanah Papua of Indonesia’s13new HIV cases in 2011. Papua alone Eastall Kalimantan 2010 accounted for over 15 per cent of all Indonesia’s new has a case rate nearly 15 times higher than the national 11 West Kalimantan HIV cases in 2011. Papua alone has a case rate average. Unlike the rest of Indonesia, Tanah Papua is 10 nearly 15 times higher than the national average. North Sulawesi experiencing a low level generalised HIV epidemic with Unlike the rest9 of Indonesia, Tanah Papua is North Sumatra a prevalence of 3 per cent in youth aged 15-24. HIV experiencing a8.88low level generalised HIV epidemic INDONESIA prevalence amongst of the3 indigenous Papuan population with a prevalence per cent in youth aged 15-24. 50 100 150 0 HIV prevalence amongst the indigenous Papuan New HIV cases per 100,000 population population is higher (2.8 per cent) than that amongst Calculated from: New HIV cases from Ministry of Health, Progress Report HIV & AIDS Situation in Indonesiapopulation up to December 2011. data from non-indigenous (1.5Population per cent) andSUPAS higher 2005 (Intercensal Survey) projection for 2011 population. 2010 census for 2010 in men(2011 (2.9 per unavailable cent) than women (1.9 per cent). population projects at thein time of this Report).
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unite for children The epidemic in Tanah Papua is driven almost
Tanah Papua illustrates a case of extreme completely by unsafe sexual intercourse. The inequity in infection patterns. With only 1.5 per underlying and structural causes include grinding cent of Indonesia’s population, Tanah Papua poverty amidst unequal patterns of rapid accounted for over 15 per cent of all Indonesia’s new
The increasing feminization of the epidemic in the 20,000 The increasing feminization of the epidemic in the 44% country highlights inequities39% in status and power. country highlights inequities in status and power. Women are more vulnerable due to their traditional 15,000 are more vulnerable due to their traditional Women roles in society, which extend to marital relationships. roles society, which extend to marital relationships. The in proportion of women in new HIV infections in The proportion of women in new HIV infections Indonesia has grown from 34 per cent in 2008 toin44 10,000 34% Indonesia has grown from 34 per cent in 2008 to 44 per per cent in 2011 (Figure 35% 2). 56% cent in 2011 (Figure 2). 61% 5,000
Figure 2. New HIV cases 65%amongst women and men, 2008-2011.
66% HIV data from Ministry of Health, Progress Report HIV & AIDS Situation in Indonesia up to December 2011 0
Number of new cases 25,000
2008
D2009
2010 Male
2011 Female
The Ministry of Health has projected a rise in infections among children, as new HIV infections 20,000 increase among women.39% Preliminary 44%findings of a recent study commissioned by UNICEF and the 15,000 National AIDS Commission highlight the difficulties faced by children affected and infected by HIV/AIDS. Their access to education and health services is 10,000 limited by discrimination, the family’s financial 34% 35% difficulties because of the 61% illness, the ill health of the 56% 5,000 child and the need to take care of the sick parent. 65% The estimated number of children infected each year 66% is projected to increase from 1,070 in 2008 to 1,590 0 2009 2010 2011 in 2014.2008
TheThe Ministry of Health projected a risefor in 18 per age group 15-24has years accounted The Ministry of Health has projected a rise in infections among children, as new HIV infections cent of reported new HIV cases in 2011. Young infections among children, as new HIV infections increase women. Preliminary of a peopleamong make up around 30 per centfindings of the most-atincrease among women. Preliminary findings of a recent study commissioned by UNICEF and the risk population, where HIV prevalence is higher. recent study commissioned by UNICEF and the Estimates in 2011 placed prevalence rates at 36 per National AIDS Commission highlight the difficulties cent amongst injecting drug users, 22 per cent faced by children affected and infected by HIV/AIDS. amongst transgender waria, 10 per cent amongst Their access to education and health services is female sex workers and 8.5 per cent amongst men limited by discrimination, the family’s financial who have sex with men. difficulties because of the illness, the ill health of the child and the need to take care of the sick parent. The estimated number of children infected each year Barriers is projected to increase from 1,070 in 2008 to 1,590 inYoung 2014. people have limited access to sexual and
ISSUE BRIEFS
OCTOBER 2012
National AIDS Commission highlight the difficulties faced by children affected and infected by HIV/AIDS. Their access to education and health services is limited by discrimination, the family’s financial difficulties because of the illness, the ill health of the child and the need to take care of the sick parent. The estimated number of children infected each year is projected to increase from 1,070 in 2008 to 1,590 in 2014. The age group 15-24 years accounted for 18 per cent of reported new HIV cases in 2011. Young people make up around 30 per cent of the most-at-risk population, where HIV prevalence is higher. Estimates in 2011 placed prevalence rates at 36 per cent amongst injecting drug users, 22 per cent amongst transgender waria, 10 per cent amongst female sex workers and 8.5 per cent amongst men who have sex with men.
Barrier
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oung people have limited access to sexual and reproductive health information and services. Sex remains a taboo subject that is not openly discussed with parents, teachers, and even with health providers. Legal restrictions make it difficult for unmarried unmarried young people to access sexual and young people tohealth accessservices. sexual and reproductive health reproductive Other legal provisions services. Other legal provisions criminalize the dissemination criminalize the dissemination of information on sex 1 The promotion of of information education. education.1 on Thesex promotion of condom use is still condom use is still problematic in Indonesia; certain this problematic in Indonesia; certain regions oppose regions opposeor this on religious on religious moral grounds.or moral grounds. TheThe ageage of of sexual debut in in Indonesia is quite young, sexual debut Indonesia is quite young, for especially for girls. Across Indonesia, especially girls. Across Indonesia, some 1 persome cent 1 per and cent4ofper boys and per cent girls havehad of boys cent of4girls have of reportedly reportedly had sexual the some age ofas sexual intercourse beforeintercourse the age ofbefore 13 years, 13 years, some as young as before 10 years (Figure young as before 10 years (Figure 3). By the time they 3). By the time they are 17 years of age, about a third are 17 years of age, about a third of young people will of young people will have had at least one sexual have had at least one sexual encounter. In of Tanah Papua, encounter. In Tanah Papua, 13 per cent in-school 13 and per cent of in-school and 19 per cent of out-of-school 19 per cent of out-of-school adolescents (aged adolescents (aged 16-18 years)towere reportedactive. to be Of 16-18 years) were reported be sexually sexually active.active Of this sexually active group, this sexually group, about half of thoseabout who halfwere of those were out ofhaving schooltwo reported having out ofwho school reported or more proportion to 15 per cent they twopartners. or moreThe partners. The drops proportion drops toif15 per are school. cent if still theyinare still in school. Figure 3. Percentage of unmarried young people aged 10-24 years by age of first sex. Source: Riskesdas 2010
20% 18% 16% 14%
Male
Female
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12% 10% 8% 6% 4% 2% 0%
Age at first sex
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Amongst young people, knowledge about HIV has increased but is still limited. A study in five provinces by the Ministry of Health showed an increase in comprehensive knowledge about HIV and
Amongst young people, knowledge about HIV has increased but is still limited. A study in five provinces by the Ministry of Health showed an increase in comprehensive knowledge about HIV and AIDS amongst youth (age 15-24 years) in the general population, from 11.4 per cent in 2010 to 20.6 per cent in 2011, with similar proportions for men and women. Over half the youth knew that AIDS could not be transmitted by sharing food, and two-thirds responded correctly that a healthy-looking person could be infected with HIV. In another 2011 study, only 22 per cent of grade 11 secondary school students had comprehensive knowledge of HIV transmission, and 64 per cent had misconceptions about HIV. However, knowledge amongst young people is not sufficient to guarantee safe behaviour. Surveys of high school students in six cities over the period 2007-2009 showed low rates of consistent condom use (below 20 per cent), although over half the respondents were able to identify condoms as a means of preventing HIV. In 2011, of the senior secondary school students who admitted to having had sex, 49 per cent reported that they did not use condoms during their last sexual intercourse. the respondents were able to identify condoms as a means of preventing HIV. In 2011, of the senior
Knowledge levels are low amongst the general secondary school students who admitted to having population aged 15 years and older. The had sex, 49 per cent reported that they didRiskesdas not use 2010 surveyduring foundtheir thatlast some 42 per cent of the total condoms sexual intercourse. population older than 15 years had never heard about Knowledge levels are low amongst the general HIV/AIDS. Only 10 and 13 per cent respectively of population aged 15 years and older. The women and men had comprehensive knowledge of HIV Riskesdas 2010 survey that some 42 higher per centfor prevention, although thefound proportions were of the total population older than 15 years had never specific questions. heard about HIV/AIDS. Only 10 and 13 per cent respectively of women and men had comprehensive Fear, stigmaofand againstthe people living knowledge HIVdiscrimination prevention, although with HIV still pose formidable barriers. Families and proportions were higher for specific questions.
children living with HIV/AIDS are subject to stigma Fear, stigma and discrimination against people and discrimination, which translates to reduced acliving HIV still formidable barriers. cess to with services, loss pose of dignity and a greater degree of Familiesand anddeprivation. children living with HIV/AIDS are 20.2 subject poverty In Tanah Papua, only per to stigma and discrimination, which translates to cent of young people in school and 15 per cent of outreduced access to services, loss of dignity and atowards of-school young people had accepting attitudes greater degree of poverty and deprivation. In Tanah people living with HIV. The fear amongst people creates Papua, only 20.2 per cent of young people in school resistance HIVoftesting, embarrassment abouthad seeking and 15 pertocent out-of-school young people treatment, and in some cases, a reluctance to be educated. accepting attitudes towards people living with HIV. All these it difficult control the epidemic. The fear make amongst people to creates resistance to HIV testing, embarrassment about seeking treatment, and
in some cases, reluctance to be of educated. these High-risk groupsaare more aware HIV, butAllstill make itindifficult to control the engage risky behaviour. In epidemic. 2011, one-third of female sex workers reported not using a condom with their most High-risk groups are more of HIV,drug but still recent client. Less than half ofaware all injecting users (41 engage in risky behaviour. In 2011, one-third of female sex workers reported not using a condom with 1 their most recent client. thanlegal halfprovisions of all injecting Indonesia’s Criminal CodeLess contains that drug users (41 perinformation cent) consistently use condoms criminalize supplying to people relating to the prevention andpartners. interruption of pregnancy (Articles 283, 534, 535). with casual Some 39 per cent of male The Pornography Law (No. 44/2008) prevent people from clients of female sex workers didcould not use a condom at disseminating information on sex education. their last paid sexual encounter. Around 40 per cent of reproductive-aged men who had sex with more than one partner reported not having used a condom at their last sexual encounter. The availability of and access to condoms is still an issue, although the use of condoms in
OCTOBER 2012
per cent) consistently use condoms with casual partners. Some 39 per cent of male clients of female sex workers did not use a condom at their last paid sexual encounter. Around 40 per cent of reproductive-aged men who had sex with more than one partner reported not having used a condom at their last sexual encounter. The availability of and access to condoms is still an issue, although the use of condoms in Indonesia has more than doubled from 2006. Both the Population and Family Development Law (No. 52/2009) and the Health Law (No. 36/2009) stipulate that only legally married couples can access sexual and reproductive health services.2 This makes it difficult for young people and unmarried adults to access contraception or family planning services from government clinics. However, condoms can easily be obtained from nearby markets, except in remote areas. Although voluntary and confidential testing (VCT) services have increased throughout the country, knowledge about their existence is limited. In 2010, only 6 per cent of the population older than 15 years knew about VCT services. This proportion, the same for women and men, was only 4 per cent in rural areas. The higher wealth quintiles were better informed on both VCT services and HIV prevention. In December 2011, the Ministry of Health reported 500 active VCT sites in 33 provinces, up from 156 in 27 provinces in 2009. Confidentiality issues and fear of stigma and discrimination hamper efforts to increase the uptake of testing. Capacity, attitudinal and cultural constraints affect measures to prevent parent to child transmission and promote follow up care for mother-baby pairs. Services to prevent parent to child transmission (PPTCT) are limited and the implementation at provincial and district levels is variable. The disparities in availability and usage are probably a reflection of the variation in local capacities, follow-up mechanisms (or lack thereof) and the local cultural norms and attitudes towards HIV. Thus, the numbers of pregnant women tested and the proportion of HIV-positive women receiving antiretroviral drugs vary widely from year to year. Less than one per cent of pregnant women were tested for HIV in 2008. In 2011, only 15.7 per cent of pregnant women living with AIDS received ARV to reduce mother to child transmission. The knowledge and uptake of VCT remains low amongst young people in Tanah Papua. In 2006, less than 20 per cent of youth aged 15-24 in Tanah Papua knew an HIV testing site. The percentage of youth who reported having had a test was also low (2-3 per cent). The proportion having had a test and knowing the result was even lower (0.3-1.6 per cent). Articles 72 and 78 of the Health Law, and Articles 21.1, 24.1 and 25.2 of the Law on Population and Family Development. 2
ISSUE BRIEFS
Opportunities for action HIV/AIDS education amongst decision makers and opinion makers should focus on removing complacency and on the need to allocate sufficient resources to fighting HIV. In many low-prevalence countries, where the HIV/AIDS epidemic is concentrated amongst highrisk groups, the attitude is one of complacency and dismissal that HIV only “happens” because these groups have questionable morals. Indonesia is not an exception to this division between “them” and “us.” Indeed, as in some other Asian cultures, one term used for a female sex worker is wanita tunasusila or woman without morals. People need to be made aware that the epidemic is also spreading amongst those who are not in high-risk groups, and that people are sexually active from a young age, yet lack the knowledge and services to protect themselves from HIV/AIDS. Young people who are affected or at risk have special needs. Specific strategies and programmes for such young people need to be tailored to these needs. Advocacy on HIV/AIDS will require credible data, especially on the nation’s young people, and not just on high-risk groups. So far, HIV information systems have emphasized high-risk groups. Yet the trends show that increasingly, more information is needed on HIV prevalence and epidemiology, risk behaviour and knowledge amongst the general population. For instance, the National AIDS Commission (2012) in its UNGASS report mentioned the lack of data on some indicators considered by the government to be relevant for Indonesia, but on which data are not available. Similarly, there is a crucial need to obtain more disaggregated data amongst youth (age 15-24 years) in order to tailor programmes to their particular needs. Support is thus needed for district teams to build strong information systems disaggregated by age, gender, location and ethnicity. Having levels of different access to information can meet the need for confidentiality on HIV testing. Legal and policy barriers that limit young people’s access to information and services need to be lifted across districts and regions. The efforts should emphasize access to VCT services and condoms. Most young people do not normally use health services. Overcoming this inherent resistance will require the expansion and promotion of the Adolescent Friendly Health Services (AFHS) approach, launched by the Ministry of Health in 2003. In 2012, some 61 per cent of all districts had at least four health centres implementing the AFHS approach. Nonetheless, the approach remains limited. Better coordination will be needed with other relevant services, such as those relating to sexually transmitted infections, methadone maintenance therapy, and needle and syringe programmes.
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ISSUE BRIEFS The high HIV prevalence amongst Tanah Papua’s youth needs special education and prevention efforts. Public education campaigns are urgently needed in Tanah Papua. The AFHS approach, with VCT and condoms as the key element, should also be accelerated. Peer education activities in communities and schools need to consider the extremely high proportion of out-of-school youth. Amongst 33 provinces, Papua has the highest proportion (38 per cent) of out-of-school children in the age group 7 to 15 years. To eliminate HIV transmission to children, Indonesia will need to implement provider-initiated HIV testing and counselling for all pregnant women. HIV testing and treatment should be offered routinely by antenatal care services. This would require changing the existing minimum service standards on antenatal care. More rigorous follow-up and public education are also needed on PPTCT services. It is still unclear why the majority of pregnant women testing positive for HIV do not receive treatment. Most likely, the reasons include fear of stigma and leakage of confidentiality; lack of support from the husband, family and community; the poor quality of services received at initial contact and unsympathetic health staff. District assessments may be needed to determine why the majority of pregnant women diagnosed with HIV do not come back to undertake antiretroviral therapy. Fighting HIV/AIDS will require better coordination between sectors on youth-related policy and programming. Most of the issues confronting young people are inter-related. National policy promotes cross-sectoral approaches to fighting HIV/AIDS, but the coordination and collaboration has to come at district and province level. Developing youth-related policies and programmes will also require greater levels of participation from youth and other stakeholders. Social protection and social assistance programmes need to be HIV-sensitive. This means strengthening measures to protect and enhance the access to social services by HIV-affected families. Efforts are underway to include PPTCT services under Jamkesmas, the Government’s health insurance programme for the poor. More needs to be done to support the education, protection, health and nutrition of children and young people affected by HIV/AIDS.
Resources Beadle, S. and Temongmere, G.A. (2012): A Brief Review of Youth Policy & Programs in Papua & West Papua, Indonesia. Indonesia, Jayapura: UNICEF Ministry of Health (2005): Decree of the Minister of Health of the Republic of Indonesia No 1507/ MENKES/ SK/X/2005 Regarding
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OCTOBER 2012 Guidelines for Voluntary HIV/AIDS Counselling and Testing, Jakarta: Ministry of Health. Ministry of Health (2008): Mathematic Model of HIV Epidemic in Indonesia, 2008-2014. Jakarta: Ministry of Health. Cited in Indonesian National AIDS Commission (2012) Ministry of Health (2011): Rapid Study on HIV comprehensive knowledge in 5 cities in 5 provinces. Jakarta: Ministry of Health, Directorate General of/Centre for Communicable Disease Control Ministry of Health (2011): Integrated Biological and Behavioural Survey (IBBS) 2011. Jakarta: Ministry of Health, Directorate General of Disease Control and Environmental Health. Available at the Data Hub for Asia-Pacific (supported by UNAIDS, UNICEF, WHO, ADB HIV and AIDS): http://aidsdatahub.org/en/country-profiles/indonesia Accessed 9 August 2012 Ministry of Health (2011): Laporan Nasional: Riset Kesehatan Dasar (Riskesdas) 2010, Jakarta: Ministry of Health, National Institute of Health Research and Development. Ministry of Health (2011): Progress Report HIV & AIDS Situation in Indonesia up to December 2010 (Laporan Situasi Perkembangan HIV & AIDS di Indonesia Sampai dengan Desember 2010, Kementerian Kesehatan RI). Jakarta: Ministry of Health, Directorate General of Disease Control and Environmental Health. Available at the Data Hub for Asia-Pacific (supported by UNAIDS, UNICEF, WHO, ADB HIV and AIDS): http://aidsdatahub.org/en/country-profiles/indonesia Accessed 9 August 2012 Ministry of Health (2012): Progress Report HIV & AIDS Situation in Indonesia up to December 2011 (Laporan Situasi Perkembangan HIV & AIDS di Indonesia Sampai dengan Desember 2011, Kementerian Kesehatan RI). Jakarta: Ministry of Health, Directorate General of Disease Control and Environmental Health. Available at the Data Hub for Asia-Pacific (supported by UNAIDS, UNICEF, WHO, ADB HIV and AIDS): http://aidsdatahub.org/en/country-profiles/indonesia Accessed 9 August 2012 Ministry of Health (2012): Provincial Routine Report Year 2011. Jakarta: Ministry of Health, Directorate of Child Health Development Ministry of Health and BPS-Statistics Indonesia (2006): Risk behaviour and HIV prevalence in Tanah Papua: Result of the IBBS 2006 in Tanah Papua. Jakarta: National Ministry of Health and Statistics National AIDS Commission (2009): Age Group Disaggregation of Survey and Research Data. Jakarta: National AIDS Commission. National AIDS Commission (2009): Republic of Indonesia Country Report on the Follow up to the Declaration of Commitment on HIV/AIDS (UNGASS): Reporting Period 2008 – 2009. Jakarta: National AIDS Commission. National AIDS Commission (2012): Republic of Indonesia Country Report on the Follow-Up to the Declaration of Commitment on HIV/AIDS (UNGASS): Reporting Period 2010-2011. Jakarta: National AIDS Commission.
This is one of a series of Issue Briefs developed by UNICEF Indonesia. For more information, contact
[email protected] or go to www.unicef.or.id
