HIV Epidemiological Update, Indonesia (2007)

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Indonesia, located between Asia and Australia, comprises more than 17 000 islands. With a population of over 220 million, it is the fourth most populous country in the world. The gross domestic product (GDP) per capita is estimated at US$ 1 280. In 2004, the World Bank estimated that 52% of the population lived on less than US$2 per day.

Life expectancy at birth is 67 years.[i] The Central Bureau of Statistics estimated the infant mortality rate at 35 per 1000 live birth in 2003. In 2002, the mortality rate in children under five (5) was at 46 per 1 000 live births. Maternal mortality, although in decline, remains high in Indonesia with WHO estimating it to be at 230 per 100 000 live births. Communicable diseases remain a large burden, even as the burden from non-communicable diseases is climbing. Indonesia, for example, ranks third in the world for the burden of tuberculosis (TB), with a prevalence of 262 per 100 000 (all cases), and TB mortality of 41 per 100 000 in 2005. Health spending per capita is estimated at US$ 33 in 2004, representing 2.8% of the gross domestic product (GDP). Government expenditure on health represents about 34% of total spending on health. The majority of private spending on health is out-of-pocket. Recent steps have been taken to ensure that the poor can access health facilities. With the implementation of a national social health insurance scheme, or Askeskin,the government will now pay the premiums for 60 million poor as of the beginning of 2005.

In 2001, Indonesia underwent a rapid process of decentralization, devolving budgetary and implementation authority for most health services, down to the district level. Previously it had been a vertical system, where the national level government set priorities and agendas, as well as determined funding. Now, the 440 districts in Indonesia have this authority. The 33 provinces coordinate districts and municipalities. While decentralization brings the opportunity for increased efficiency, flexibility and accountability, the ability of the central government to influence decisions about priority setting and funding is limited. The health system has been affected by the challenges of intergovernmental relationships in a decentralized system, with some functions, such as disease surveillance, becoming more difficult.

Although the aggregate national HIV prevalence is still low (0.16%), the rate increase in Indonesia is high, giving it one of the fastest growing HIV epidemics in Asia (Figure 1). What began as mainly an epidemic among IDU in Jakarta, West Java and Bali, has now spread from IDUs to their non-injecting sex partners, prisoners, SWs and their clients. About 70.8% of injecting drug users (IDUs) in Depok, Jakarta, and up to 23% of sex workers in Papua have being infected as of 2006.

Since the first AIDS case was reported in 1987 in Bali, HIV has affected all of Indonesia. Currently, 32 provinces and 169 districts out of a total of 33 provinces and 440 districts respectively have reported AIDS cases. Injecting drug use accounts 50% of AIDS cases reported out of a cumulative number of 8194 AIDS cases reported up to December 2006 (Figure 2).[ii]

In 2006, an estimated 193 000 (ranging from 169 000 to 216 000) people were living with HIV and AIDS (PLHA). In most parts of the country, the epidemic remains concentrated among groups at high risk characterized by sharing injecting equipment and engaging in unprotected sex. Data from behavioural surveillance show that there are two major categories of high-risk behaviours that account for the majority of HIV infections: sharing of contaminated injecting equipment among injecting drug users, and low condom use during sex among female, male and transgender sex workers and as well as men having sex with men. Also there are considerable overlapping risk behaviours between the groups. (See Figure 3: Reported AIDS cases in Indonesia, by district, 1993-2006)

There is a vast variation in the HIV burden by geographical area. In the provinces of Bali, Java, Sumatra, West Kalimantan and South Sulawesi needle sharing among injecting drug users is the predominant mode of HIV transmission. However, sex work is found across the country with an estimated 3.1 million male clients (Figure 4). While other provinces have concentrated epidemics, Papua seems to be experiencing an emerging generalized epidemic with HIV prevalence several times the national average. A first population-based integrated bio-behavioural surveillance (IBBS) conducted in 2006 in Papua found HIV prevalence several times the national average. The reported AIDS cases per 100 000 population in the Papua province is 20 times higher than that of the national average of two cases per 100 000 population. From 1998 to 2005, HIV prevalence among sex workers increased from approximately 1% to 23% in Sorong (Figure 5 HIV prevalence among populations at high risk.

The high rates of STIs among sex workers in Papua also enhance transmission of HIV.

The Minister of Health established the National AIDS Committee in 1987. A Short-Term Plan and a Medium-Term Plan were implemented from 1988 to 1994 with assistance from the WHO Global Programme on AIDS. Presidential Decree No. 36/1994 expedited the establishment of the National AIDS Commission (NAC), a multi-sectoral body. According to the decree, the NAC was chaired by the Coordinating Minister for People’s Welfare, with the Minister of Health as one of the Vice-Chairs. It also stipulated the formation of AIDS Commissions at provincial, district and municipality levels.

The NAC formulated the first National AIDS Strategy and a Five-Year Program Plan for AIDS Prevention and Control (1995-2000) as part of the 6th National Development Plan. Due to the economic crisis, the plan did not receive the necessary budget from the government but attracted foreign donors. The Minister of Health Indonesia signed the Declaration of Commitment of the UN General Assembly Special Session on HIV/AIDS in June 2001. Subsequently the National HIV/AIDS Strategy, National AIDS Commission (2003 – 2007)[iii] and the National Strategic Plan on HIV/AIDS Control, Ministry of Health (2003 – 2007) [iv] were developed. With the changing pattern of the HIV epidemic and increasing awareness on HIV many new activities have started during recent years.

[1] This is an extract of the Introduction from the WHO SEARO publication, Review of the Health Sector Response to HIV and AIDS in Indonesia, April 2007. This publication is available on the Internet at http://www.searo.who.int/hiv-aids publications

[i] Indonesia’s National Socio Economic Survey 2003. Central Bureau of Statistics.

[ii] Ministry of Health 2006.

[iii] National HIV/AIDS strategy 2003-2007 (2003). Jakarta. National AIDS commission.

[iv] National strategic plan for the prevention of HIV/AIDS in Indonesia (2003-2007).

Last update: 16 May 2008