By Tan Ee Lyn and Fitri Wulandari
JAKARTA | Tue Apr 12, 2011 10:28am EDT
Liana, who holds an economics degree, is one of 300,000 Indonesians in the world's most populous Muslim nation who have fallen victim to widespread ignorance about AIDS, and the government's inability to campaign effectively against it for fear of being accused by conservatives of promoting promiscuity.
Social taboos and strict laws that ban prostitution also work against those most vulnerable to the incurable disease, because police often use condoms -- one of the best protection against AIDS -- as evidence against sex workers.
Although HIV prevalence in Indonesia's population is low at 0.2 percent, the government and health experts are worried because the number of newly confirmed cases has more than doubled to 4,158 in the five years to 2010.
"When I started the job, I did not know anything about HIV/AIDS or that condoms can prevent you from getting infected with the disease", said Liana, who quit her job and turned to prostitution after her husband died in 2007 because she needed to pay off a mortgage and support their daughter.
A few months after she started sex work, Liana heard about HIV and tried getting tested. But was turned away two times by healthcare workers, who often do not understand the disease and are afraid of getting infected themselves.
Liana tested positive last year after falling ill and is now on AIDS drugs, which cost her 30,000 Indonesian rupiah ($3.5) a month as they are subsidized. Until today, she doesn't know how she became infected. Her 4-year-old daughter is uninfected.
"Thinking it over, I'm not lacking in education. But how is it that I never heard of this disease nor how to prevent it? Why does the government not spread the information," said Liana, a graduate of an East Java university who now insists all her clients use condoms.
"How can we prevent HIV/AIDS if we can't use the only protection that we have?
There is no cure for Acquired Immune Deficiency Syndrome (AIDS), which is caused by the Human Immunodeficiency Virus (HIV), but drugs can help to control the replication of the virus and prolong life.
While Liana uses condoms, she says many of her friends do not as they are tempted by offers of more cash from clients who don't want to practice safe sex. They are also afraid they may be thrown in jail if police find condoms on them.
Health Minister Endang Sedyaningsih told Reuters the government faced enormous opposition in the fight against AIDS in this country of 238 million people. "We cannot put ads for condoms openly on television or promote their use, or people will say the Ministry of Health promotes promiscuity," she said in a recent interview.
Islam is the dominant religion in Indonesia and society remains largely conservative. "We have a program for methadone substitution and clean needle exchange (for drug users) but it's very difficult to expand it as it is seen as legalizing narcotics use."
Indonesia's approach is in sharp contrast to the aggressive interventions taken in nearby Thailand, which implemented a high-profile "100 percent condom use campaign" in the early 1990s to rein in an explosive HIV epidemic.
That campaign was hugely successful and brought down drastically new HIV infection rates particularly in young men.
The disease, which has killed 4,539 people so far in Indonesia, used to be spread mainly by injecting drug users. Eight out of 10 addicts have HIV. But in 2010, 65 percent of newly confirmed HIV infections came through unsafe heterosexual sex between sex workers and clients, who went on to infect their wives or girlfriends. The government estimates there are 200,000 female sex workers in the country and a male clientele of up to 3 million. Only 10 to 15 percent of clients use condoms.
A sharp jump in mother-to-fetus HIV infections is one of the clearest signs that the AIDS epidemic may be moving from particularly vulnerable groups, such as injecting drug users and sex workers, into the general population. These perinatal infections made up 3 percent of all newly confirmed HIV cases in 2010, up from 0.2 percent in the 1990s. "This means that HIV transmission within the family is increasing ... If we have no new approach for HIV prevention within the family, it (the HIV epidemic) may become generalized. We should think out of the box to protect the family from AIDS," said Inang Winarso, assistant deputy secretary of the National AIDS Commission for program coordination.
When HIV/AIDS becomes generalized and widespread, as in many parts of Africa, it takes a huge toll on countries, draining them of resources and economic productivity.
FEW TOOLS LEFT
In many parts of Asia, HIV has made a comeback in recent years among vulnerable groups. Governments and concerned groups in China, Hong Kong, Australia and Cambodia are battling hard to contain the epidemic. Through the use of high-profile campaigns, sometimes even involving state leaders as in China, they push hard for the use of condoms and clean needles to prevent the disease from spreading into the general community. But such high-profile interventions cannot be adopted in conservative Indonesia.
Winarso, who was involved in a successful campaign against HIV transmission among gay and bisexual men, hopes to stop the virus from spreading among sex workers through empowering the women, quietly. "In every story that was told to me, nobody said they liked or that they trained to be sex workers. They all started because of trafficking or because of poverty, but they have no awareness that they are victims," he said.
Winarso and his colleagues plan to reach out to sex workers in a pilot project in Semarang in East Java.
"We will visit brothels, we will avoid the pimps. We will spread awareness, get them to tell us their stories, so that they realize they are victims, and continue to be victims under their pimps," said Winarso. "How do they fight? They need to fight their customers (for condom use) and they must fight the government to provide them with jobs."
The World Health Organization estimates there are 300,000 people in Indonesia living with HIV/AIDS, with the worst affected places being Jakarta and Papua province, where 2.3 percent of the population is infected. Some 50,000 HIV patients require drugs but only 20,000 are getting them. "There are several reasons: no access and shortage of drugs even though there are 200 (HIV drug distribution) sites all over the country," said Khanchit Limpakarnjanarat, the WHO's representative in Indonesia. The WHO has a 10-member team in Indonesia and one of its missions is to train medical personnel in treating HIV patients. "We need to strengthen the healthcare system in terms of human resources ... To provide HIV services requires human resources, like counseling and testing. Drug treatment is complicated. These remain a challenge," he said. ($1 = 8,677.5 Rupiah)
(Editing by Alan Raybould and Miral Fahmy)