AIDS in Indonesia

AIDS was first identified in 1981, following outbreaks of Kaposi’s sarcoma and Pneumocystis carinii (now jiroveci) pneumonia (PCP) in several US cities. These were previously viewed as very rare illnesses, and were always linked to failure of the body’s immune system, usually following therapy connected with organ transplants. Since many of the people concerned were homosexual, the illness was first called Gay-Related Immune Deficiency (GRID), but later when it became clear that it was affecting the whole population, the name was changed to Acquired Immune Deficiency Syndrome.

The virus which is the cause of AIDS was identified in 1983 and was originally called HTLV-III or LAV, but later renamed Human Immunodeficency Virus (HIV).

AIDS spread rapidly and there are now more than 30 million cases worldwide. Countries in sub-Saharan Africa were first badly hit, and in some of these countries more than 30% of people in the 15-30 age group are infected.

It was not until the late 1980’s that AIDS began to make an impact in Asia, initially being seen in Thailand and later spreading in epidemic numbers to Myanmar and Cambodia. It is now building up to be a very major threat in India, which is now seen as the world epicentre of the disease. But it has not reached epidemic stage in other countries of the region and prevalence in Indonesia and the Philippines is still relatively low. The reasons for this is not clear, but many suggest that the rate of partner exchange is much lower in these countries; research shows, for example, that the average prostitute ‘entertains’ many fewer client per day in Indonesia than in Thailand.

Early History

In Indonesia, the first case was officially identified in 1987, a foreign tourist who died of AIDS in Bali on 5 April 1987, with cases shortly thereafter identified in the local population. However, Dr. (now Prof.) Zubairi Djoerban, in his book “Membidik AIDS: Ikhtiar memahami HIV dan Odha”, published in 1999, recounts that he encountered a 25 year-old married female haemophiliac with PCP in Jakarta in early 1986. Infection was confirmed three positive ELISA results and the clinical signs. However, for a variety of reasons, this case was not officially reported.

The early days of the epidemic in Indonesia were dominated by infections among homosexuals. However, by the mid 1990’s, more cases were being reported as a result of heterosexual relationships. But it is clear that by that time, a hidden epidemic of injecting drug use had started to develop in Indonesia. This only began to become apparent in the reported cases in 1999, and serious responses only started to be discussed in around 2002.

Following these increases in reported cases, the epidemic in Indonesia is now designated as ‘concentrated’.

Esimates and Statistics

The latest official estimate of infections was carried in late 2002. This puts the total number at 90,000–130,000, with around half of these resulting from injecting drug use. A new estimation exercise is planned for mid-2006. However, in the meantime, several informed people have ‘guessed’ that the figure is now approaching 500,000, with more than two-thirds of these as a result of injecting drug use. Indeed, there is evidence of extremely high levels of prevalence among injecting drug users (IDUs), in places exceeding 90 per cent! Responses are still few and far between, with only two methadone clinics (Jakarta and Bali), and needle and syringe exchange programs (NSPs) few and far between and reaching very few clients.

With this in mind, we should be very cautious over reading too much into the official statistics, which report only a total of 10,156 cases as at March 2006, with 1,430 reported deaths. These clearly do not provide a representative picture of the overall situation. Nontheless, it is clear that the epidemic is primarily hitting the young, and most cases are now among IDUs. Women are significantly under-represented in the figures (less than 20 per cent of reported AIDS cases), but this probably at least in part to the IDU epidemic among women still being to a great extent hidden. However, increasing numbers of faithful women are being infected by their partners, who may have injected drugs in the past, but are now ‘clean’.

Papua

The epidemic in Papua has a pattern of its own. Injecting drug use is reported to be rare among the indigenous population, although excessive alcohol use is common. This may in part explain why prevalence among this population may be approaching sub-Saharan African proportions, although there are other cultural factors together (probably) with the effect of low rates of circumcision among males. Greater efforts are being directed to responses, both by government (national and local) and by donor agencies, but it is not clear that these have yet to start to bear fruit.

National AIDS Response

A National AIDS Commission (KPA in Indonesian) was set up by Presidential Decree in 1994. This was followed by the establishment (at least in theory) or AIDS Commissions at provincial and district/municipal levels; however, many of these have only recently started to become effective, while others still exist in name only. The KPA published the first national five-year AIDS strategy in 2004, while the second was released in 2003 covering the period to 2007. While the first strategy tended to place the load of the response on government agencies, the second strategy provided a clearer role for the community, as well as strongly supporting the GIPA principle for greater involvement of people with AIDS.

In Januari 2004, representatives of six provincial governments met together with KPA leaders to discuss the exploding number of AIDS cases in their provinces. The outcome of this was the Sentani Commitment to make an “effort to ensure that the epidemic does not become more widespread [in the six priority provinces] and spread to the general population and become a national threat”. The list of priority provinces was subsequently increased to nine, and later so almost 20.

Community Response

There are a large number of NGOs and community-based organizations working in the response to HIV/AIDS in Indonesia. However, apart from Spiritia, none has national scope, and few even have a province-wide program. Most work in the field of prevention, many focussing on specific target groups, such as sex workers, transsexuals, IDUs, etc.

Voluntary Counselling and Testing

Provision of voluntary counselling and testing (VCT) services has not kept pace with needs, rarely being easily acessible, or friendly to vulnerable groups. A Ministry of Health report of 2005 noted that VCT services in the AIDS Referral Hospitals (see below) were largely passive, and serving in-patient clients. Services are rarely well-promoted, and few of those who should be tested know where to go. This list of almost 130 places offering VCT dates from September 2006.

Care, Support and Treatment

In early 2004, Indonesia committed to join the WHO’s “3 by 5” initiative to provide antiretroviral therapy (ART) to 50 per cent of those who needed it in the developing world. The target number of people to receive ART by 2005 in Indonesia was set at 10,000. However it soon became clear that identifying this number of people requiring ART would be a major challenge without a major scale up on voluntary counselling and testing (VCT) services. This has not occured. However, currently around 5,000 people (said to be all those identified who fulfil the WHO criteria for starting ART) are now receiving it free-of-charge. Provision of drugs is partly funded by the national government and partly by the Global Fund to fight AIDS, TB and Malaria (GF-ATM).

To manage provision of ART, 25 hospitals were designated as AIDS Referral Hospitals in October 2004, and training of professional staff from these hospitals was started. It was planned that the number of AIDS Referral Hospitals should be increased to 75 (including at least one in every province) by 2005, but although training has started, the official designation has yet to be promulgated.

Facilities for CD4 and viral load testing are still quite limited, although it is understood that a number of CD4 testing machines are in process of being purchased. Viral load testing remains unaffordable for most who need it in Indonesia.

Last update: 16 May 2008