HIV/AIDS Policy Direction
It must be admitted that much progress has been made in development across various fields under the leadership of President Joko “Jokowi” Widodo.
However, it should also be acknowledged that in 2014-2019, development in human rights, especially concerning minority groups, has been worsening instead. This is seen in the performance of health programs closely related to marginalized communities, particularly in HIV/AIDS prevention programs.
Since the first local HIV/AIDS case involving a Dutch tourist in 1987 at Bali’s Sanglah Hospital, the government has shown much progress in its response. The uneasy start to dealing with the issues of commercial sex, homosexuality and injecting drug use prompted the government to take the special step of establishing the National AIDS Commission (KPAN) through Presidential Decree No. 36/1994.
KPAN is an infrastructure and response mechanism that was established outside the healthcare system, as HIV/AIDS is more than a health issue. Since its management required a specific mechanism and minimal domestic investment was available and due to weak policy support (for example in providing condoms and sterile needles), HIV/AIDS in Papua turned into a generalized epidemic in 2003.
Most of the initiatives to manage the spread of HIV came from the affected communities (key populations) with the assistance of medical, social and human rights activists, as well as the international community. Public investment in these programs remained less than those from private donors until 2013 (NASA Indonesia, 2016), or 26 years after the first recorded case.
Progress and setbacks
Comprehensive policies emerged in 2006 when all stakeholders – including both key populations and the government – agreed to form a joint national strategy (Stranas). KPAN, which was given a new mandate under Presidential Regulation (Perpres) No. 75/2006, has successfully implemented a one-door policy and to command a variety of solutions-based innovative programs. It has carried out its activities consistently, despite criticism from various circles. The Stranas programs have been implemented with measurable results, and empirical data was gathered to determine the success of the program. Various reports pointed to a decline in transmission among key populations, especially among injecting drug users. Transmission in other key populations has been controlled.
Nonetheless, heterosexual HIV transmission continues to increase. One of the milestones of the national program was 2014, when the implementation of the BPJS program enabled the reintegration of HIV/AIDS with the mainstream National Health System (SKN) directly under the Health Ministry. This dissolution was planned for 2015 and was implemented on 31 Dec. 2017 through Perpres No. 124/2016. While the plan was being discussed, research was carried out to monitor symptoms that might not be directly related, but could potentially have negative impacts. An government initiative to dissolve localized prostitution was also proposed internally, but without any plans to prevent sexually transmitted diseases (STDs).
Initiatives emerged in various educated circles to expand the criminalization of extramarital sex. The lives and lifestyles of the LGBT community were exposed in the public spotlight and acts of violence that targeted the community gained space in several national media. At the same time, primal and identity politics and communism were often linked to LGBT.
All this caused fear and concern among public officials who work with marginalized groups. Participants in methadone and buprenorphine substitution programs to prevent HIV withdrew one after the other, because of a general decline in numbers and because people became afraid to reach out. HIV prevention education programs disappeared due to fear and audience loss. Thousands of boxes of condoms accumulated in government offices because of a fear in distributing them. Programs referring to case findings and early treatment became half-hearted. Indonesia again emerged in the international spotlight in the context of its HIV/AIDS prevention and mitigation programs.
In 2017, UNAIDS Indonesia published a surprising fact sheet. Using mathematical formulas with existing data, 630,000 Indonesians are currently living with HIV, and 49,000 new infections occur every year, particularly among youth aged 15-24 years. Of all cases, an estimated 39,000 people have died. Even worse, only 18 percent of newly infected people have access to the antiretroviral drugs (ARVs) that can help prolong the lives of patients, while only 1 percent of patients receiving ARV treatment (3,541 people) showed s reduced HIV count in the body.
Indonesia\'s ARV coverage is one of the worst in the world, only slightly better than Sudan (13 percent), Pakistan (8 percent) and Madagascar (7 percent). Indonesia is among 20 countries in the world that have the largest number of HIV-positive people. If efforts at HIV/AIDS management remain poor, this epidemic will soon become a huge burden on national development.
For more than 31 years, the country and its people have struggled with potentially fatal infections that could disrupt national development. We are not without achievements in HIV prevention, but why has it grown worse since the program was returned to the National Health System (SKN)? Is there something wrong?
Looking for root causes
We need to consider many things in order to find the root of the problem, and its solution. Is the government’s political will in addressing HIV/AIDS truly disrupted by discriminatory discourse that has reappeared on the political scene? Has the program succeeded in ensuring that the lowest level of human resources (services) is ready in terms of attitude and skills? Has the program lost leadership so it no longer has the support and motivation to implement the new strategies that have been agreed? Are there any changes in the structure and nature of the partnership between the public and the government that hinder the program’s implementation?
Have we failed to build data and information systems and thus hindered program planning and implementation? Have we failed to build an inclusive SKN? Does the proposed strategy lack elements that may be small but have large leverage in terms of their roles, such as mental health services programs that require notifying their partners?
There are still many questions to ask. Each question cannot be answered simply "No" or "Yes". Many bottlenecks still remain here and there, such as data on funds absorption that has been less than optimal (less than 80 percent), testing and treatment programs that do not meet their targets, the per-child unavailability of single-dose ARVs, lower allocation for prevention programs than those for testing
and treatment. Meanwhile, institutional stigma and discrimination are still found at schools, in workplaces and public service, and others.
All these indicate that many fundamental problems still need to be addressed.
Overcoming backwardness
To overcome backwardness, UNAIDS (2019) as well as national and international stakeholders have come up with an acceleration plan comprising three strategies to: (1) accelerate the implementation of strategic intervention to reach and test people who are at greatest risk; (2) encourage HIV-positive people to immediately start ARV treatment to reduce their HIV count; (3) Sustain as many treated patients as possible and maintain medication compliance.
Attention must be made to the geographical characteristics of the epidemic to achieve the above goals. If the UNAIDS strategy is followed consistently, it is expected that ARV therapy (ART) services will reach 119,567 people living with HIV/AIDS (PLWHA) in 112 districts/cities by 2020. Coupled with the results of the Health Ministry’s regular programs, ART services could reach 258,342 PLWHA, or 40 percent of the program target. This is not enough, but it meets the agreed targets.
The strategy has some very interesting aspects. First, in determining the targets of the program, extensive calculation and outreach of key populations is necessary. This is vital. Although the assumption that the HIV epidemic is concentrated in key populations still exists, a variety of evidence points to increased heterosexual infection. Second, HIV testing services must be promoted, including for couples, as a mechanism for preventing HIV transmission to children. Third is the need to revise treatment standards and protocols according to international experience to increase the effectiveness of the program. All require diversification in content or communication modalities to reach as many potential beneficiaries as possible.
The government’s role
The government must be responsible for achieving the targets of the national strategy. The implementation of the national strategy cannot be postponed yet again. To achieve all stated objectives, the government must be consistent with the existing policy frameworks of the 1945 Constitution, the Health Law and various presidential and ministerial decrees concerning the general application of a non-discriminatory approach in integrating HIV services with healthcare services. This is important because people living with HIV/AIDS are seeking inclusion in the BPJS’ universal health insurance scheme. The government’s partisanship against social stigma and discriminatory services will support the achievement of targets.
Third, the government must continue to open opportunities for new intervention measures that have proven effective. Most recently, it has been found that taking PrEP (pre-exposure prophylaxis) regularly can prevent HIV transmission. The drug has been clinically tested with convincing results and is used in the Philippines, Malaysia and Thailand. In fact, the Thai government has supported the use of PrEP under the state health insurance scheme. Indonesia has already registered PrEP for medicinal purposes, but the government is undecided on whether to support the distribution of PrEP for treatment as prevention.
If we do not want to be left behind, the initiatives needed from the government are: (1) Be careful and keep seeking information; (2) Provide room for research and verification that various negative implications can be overcome, at the same time lobby for PrEP as a means of prevention in addition to condoms and harm reduction programs; (3) Support experts who work with community groups to test the feasibility of PrEP.
We cannot play around with an epidemic. All parties will bear the impacts of negligence. HIV/AIDS is a non-communicable disease, like influenza. HIV infections should be more easily preventable. Failure to prevent transmission not only affects the costs of health and death, but also social harmony.
Of course, HIV transmission has aspects that intersect morality, even religion. However, HIV prevention and mitigation clearly cannot be resolved by moral and religious intervention alone. There are many inexpensive ways to prevent HIV, for example through the use of condoms and sterile syringes. ARVs have allowed long-term postponement of AIDS-related deaths and have restored quality of life for PLWHA.
PrEP and PEP (post-exposure prophylaxis) are presently available to prevent transmission. The national strategy must be based on optimizing intervention methods and technologies that have proven effective and on preserving the dignity of every human being. Therefore, do not allow long-held doubts over implementing the policy or the negligence of stigma and discrimination to ultimately cause more deaths.
Irwanto, Psychology Professor, Atma Jaya Catholic University, Jakarta