Intimate Partner transmission of HIV

Indonesia
This summary is based on research undertaken by Plurpol Consulting (1) for UN Women. Updated statistics and references are cited as appropriate.

Indonesia, except in Papua province, has a concentrated epidemic; an epidemic concentrated among four most affected populations: sex workers, injecting drug users, men who have sex with men and waria (transgender population). HIV prevalence is estimated to be 0.30% [between 0.20% - 0.40%] among women and men aged 1549 (2). Two categories of women who are particularly affected by HIV are female sex workers and women who are married to or in relationships with both intravenous drug users and clients of sex workers. Surveys and epidemiological data are available for populations most at risk (sex workers and their male clients; men who have sex with men, injecting drug users; prison populations). However a major gap is the lack of sex disaggregated data and gender analysis of injecting drug users. This translates into a lack of gender sensitive policies and programs ultimately excluding female injecting drug users and the female partners of male injecting drug users. Policies recognize the increasing impact of HIV on women in partnerships but as yet there are no specific studies (quantitative or qualitative) on intimate partner transmission of HIV.

Womens status in legislation

While laws exist which protect women and promote their rights, a lag time persists between the introduction of legislation and changes in the judicial system and an increase in wider public consciousness. However, extremely important advances have been made which enshrine womens rights and therefore provide the legislative mandate for increasing prosecutions for violations of law. Ambiguities remain in various laws which have the potential to dilute the strength of those with more clarity. In Indonesia, for example, freedom of religion is promoted for all citizens; at the same time Religious Courts have jurisdiction over Muslims and are arguably biased because no women participate in the courts decision making. Indonesias laws and practical regulations seem to lag behind the changing realities of women, particularly those in business. The domestic violence laws allow for criminal action to be taken against perpetrators but it is not clear how awareness of the relatively new legislation has filtered into public awareness and whether there are many prosecutions. Punitive drug laws continue to criminalize drug users and female injecting drug users have little protection and many harm reduction programs overlook their needs.

Availability of treatment
Indonesias coverage of voluntary counselling and testing and has increased significantly. However, apart from among waria (transgender people), the percentage of key populations accessing the services has not surpassed 50%. Access by the male clients of female sex workers remains very low at 10% and this is an important group to reach in order to reduce intimate partner transmission among women. Almost half of people who need ART are

receiving it, but the researchers note that prevention programs are not consistently evident in all regions including the areas that were the focus of this research.

Vulnerability to HIV transmission among women in relationships

Some common themes emerged from the three-country study of Laos PDR, Indonesia and Thailand. Sex work is perceived very differently in the three countries despite its widespread prevalence: in Indonesia there seems to be considerable denial about the existence of both brothels and street based sex work. The acceptance/denial of sex work and the forms in which it takes place has implications for the effectiveness of a national HIV response. In Indonesia there is pronounced gender inequality which fuels the epidemic women seem to have little decision making power and are unaware of the potential for and reality of their husbands extramarital sex.

Unique to Bali in Indonesia is the social caste system which compounds gender inequality and adds another layer of complexity between strata of society which acts as a deterrent to disclosure of HIV status. Overall there was an expectation of married women to be less sexually experienced than men and to tolerate their husbands sexual relationships including commercial sex. However in Indonesia women seem less likely to know if such relationships take place. The taboo nature of sex between men means that some men get married to conform to societal expectations but continue clandestine sexual relationships with other men. The expectation (or acceptance) of men to have multiple partners creates a paradox if women are expected not to have sex, and therefore creates a demand for sex workers. However in Indonesia sex workers are criminalized and despite the existence of brothels there is little promotion or protection of the human rights of women who sell sex. Subsequently female sex workers are unable to protect themselves from violence or negotiate condom use. The lower level of condom use among couples is common throughout Indonesia, Lao PDR and Thailand. In all three countries the emphasis on condoms for sex workers has firmly associated them with infidelity and mistrust making it very difficult for both men and women to request using them in their intimate relationships.

Mens perception of their immunity to STIs and widespread misinformation about remedies to prevent infection override correct knowledge about sexual transmission of infections including HIV

Condom use among couples where both know their status is much more likely than among couples where one or both do not know their status. Condoms are associated with people who are unclean; a women (whether sex worker or non-commercial sex partner) who requests their male partner uses a condom risks insulting him, risks rejection and potentially risks violence

Stigma and societal structures prevent people seeking information and services. The stigma surrounding the behaviour of men who have sex with men deters many from seeking health care services. The complexities of the caste system and local social hierarchies can discourage people from disclosing their HIV status to their partners and families. People are deterred from seeking information and treatment lest their status is revealed or suspected through association with STI and HIV services.

Bibliography
1. Kaybryn, Jo. Responding to the Feminization of AIDS: Women and Intimate Partner Transmission of HIV, Indonesia, Laos PDR and Thailand. Bangkok : UN Women, 2009. 2. UNAIDS. Indonesia Profile. UNAIDS. [Online] 2011. [Cited: December 26, 2012.] http://www.unaids.org/en/regionscountries/countries/indonesia/.

Summary of womens vulnerabilities to HIV infection in Indonesia

Pronounced gender inequality results in womens low negotiation and decision making power within relationships The status of sex workers is low so many find their negotiation power in the use of condoms is low to none Commercial sex, injecting drug use, and sex between men are socially and religiously unacceptable behaviours making responses focused on these issues controversial and often accompanied by political opposition Female injecting drug users are particularly vulnerable to exploitation and violence. Harm reduction programs do not outreach sufficiently to female injecting drug users or the female partners of drug users Donor funding and program indicators do not require responses to target partners of injecting drug users or female injecting drug users

Plurpol Research Summaries 2012

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