“My husband never told me the truth, that he was HIV positive. Within four years of marriage, his condition worsened and as it happened, I was diagnosed HIV positive.” – Woman living with HIV, Makassar
“I beat him once … the man who infected me with HIV. I feel that I am a good woman, I did not deserve to end up like this. I knew it would be very painful for me. I could not accept it, so I beat him. Some time after all this happened, he died.” – Woman living with HIV, Bandung
An estimated 65 per cent of people living with HIV in Indonesia now come from outside the key affected populations typically considered more vulnerable to HIV transmission, that is, sex workers, injecting drug users, transgender people, prisoners, and men who have sex with men. In fact, heterosexual transmission accounted for 70.3 per cent of new cases from 1987 to 2018. Yet most Indonesian government interventions still only directly target the key affected populations.
The complicated dynamics of sexual interaction among heterosexual couples are posing a barrier to efforts to counter the spread of HIV in Indonesia. The government has pledged to meet UN 90-90-90 targets by 2020 and eliminate HIV by 2030. But stigma surrounding HIV status and high-risk sexual behaviour continues to put populations at risk, including those not previously considered to be key affected populations.
Expanding prevention programs to reach the general population will be crucial if Indonesia is to meet its targets for achieving treatment for all, and eliminating HIV for good.
Populations at risk
Knowledge about HIV and AIDS has improved dramatically over the last decade among the general population in Indonesia. By 2012, 77 per cent of women had heard of HIV and AIDS, and 85 per cent of men were aware of the HIV epidemic.
However, awareness of the nature and spread of HIV does not necessarily trigger behavioural change in practice. Most people still do not know where to get an HIV test, and concerns about stigma and discrimination are still very real.
The risk factors for heterosexual transmission of HIV are well known – high numbers of sex partners, sex with sex workers, being a sex worker, being a sex partner of an infected person, and having a history of other sexually transmitted diseases can put individuals at risk. Heterosexual transmission can also occur among men who have sex with men who also have female partners.
Among heterosexual couples, transmission is also spurred by the complex dynamics of sexual interaction in Indonesia, according to a study conducted in 2016 by the Atma Jaya HIV/AIDS Research Centre (PPH). For example, many heterosexual men are reluctant to disclose their HIV status to their partner, but continue to engage in high-risk behaviours, such as injecting drugs or having unprotected sex with other partners.
Condoms are the most effective tool for preventing sexual transmission of HIV. But stigma surrounding the use of condoms is fuelling Indonesia’s HIV epidemic. Only 40 per cent of women know that condoms can protect them from HIV infection, and the level of condom use among young women engaging in premarital sex is very low.
Power inequalities between men and women within the structures of a patriarchal culture also complicate women’s agency in asking their partner to use a condom. Some married people are resistant to using condoms because it may be seen as an admission or accusation of unfaithfulness.
The stigma surrounding condoms is further provoked by their use by police as evidence of sex work. The mere possession of condoms is sometimes used against sex workers and their clients. This effective criminalisation of condoms forces sex workers and high-risk men to choose between protecting their health and protecting themselves from police arrest.
Finally, there is strong resistance from some conservative groups to any initiative to promote condom use, which they say encourages free sex.
Knowledge is power
Now that most people living with HIV come from outside the typical key affected populations, it’s time to expand strategies to target not only individuals, but also couples. Old paradigms need to be upgraded to mainstream prevention of heterosexual transmission of HIV through all available programs.
Couple-friendly approaches could include services for partner notification, partner referral, couples’ counseling, testing for intimate partners of people living with HIV, and support groups for couples.
As the testimonies at the beginning of this article demonstrated, transmission often occurs unexpectedly because of a lack of knowledge of the disease. Understanding the importance of safe sex is an essential element in preventing heterosexual transmission of HIV. And with 70 per cent of infection cases reported among people aged 25-49 years, education efforts should be targeted toward this group.
Pushing for progress
To achieve the 2030 target for elimination of HIV in Indonesia the country needs to work hard and pick up the pace.
A 2006 presidential decree (No. 75/2006) started the ball rolling on preventing HIV transmission by establishing the National AIDS Commission. In 2013, the Ministry of Health released a regulation on the prevention of HIV and AIDS transmission (No. 21/2013), focusing on health promotion, prevention, diagnosis, treatment and rehabilitation for individuals, families and communities.
At the local level, governments have implemented a range of piecemeal policies to reduce rates of transmission. In Papua, for example, circumcision has become mandatory for newborn boys, following evidence to suggest this can reduce rates of HIV acquisition among heterosexual men. In Jakarta, all brides- and grooms-to-be are now required to undergo premarital HIV tests. Results are confidential but if they are positive, health providers encourage affected people to share the result their partners and begin treatment immediately. The impact of these initiatives on national targets is uncertain.
National programs to reduce HIV transmission, meanwhile, focus on diagnosis and treatment for HIV, such as free HIV testing and antiretroviral therapy, provider-initiated testing and counseling, prevention of mother-to-child transmission, and early infant diagnosis, among other basic services. But these initiatives are skewed towards testing and treatment. Health promotion efforts are significantly underdone. Further, they still only reach key affected populations, with no programs targeted toward the general population.
The government has set up integrated health posts (Posbindu) for non-communicable diseases, which promote community involvement in early detection, monitoring and follow-up of risk factors for non-communicable diseases, such as high-blood pressure, obesity, cancer, and heart disease. A similar approach could be applied for communicable diseases, including HIV. An approach like this could not only help to spread knowledge and awareness but could also include necessary prevention activities to lower risk factors of HIV transmission within the community.
The Ministry of Health could also make much better use of social media to help more people understand patterns of transmission.
With the right approach, deeper understanding can develop into safer behaviours for the prevention of HIV, ultimately contributing to its eradication in Indonesia.