IssueBriefs

UNICEF INDONESIA

OCTOBER 2012

Issue Brief: Responding to HIV and AIDS

Responding to HIV and AIDS

Inequities

Inequities
Every 25 minutes in Indonesia, one person is

newly infected by HIV. One out of every five newly

very 25 minutes in Indonesia, one person is newly
infected people is below the age of 25 years.
infected by
HIV. One
out of every
five newly
Indonesias
Ministry
of Health
projections
showinfected
that
people
is
below
the
age
of
25
years.
Indonesias
without acceleration of HIV prevention programmes,
Ministry
of Health
projections
show
that without
acceleration
over half
a million
people in
Indonesia
will be
HIV
ofpositive
HIV prevention
programmes,
over
half
a
million
peopleby
by 2014. The epidemic is fuelled primarily
in sexual
Indonesia
will be HIV and
positive
by 2014.
Theuse.
epidemic
transmission
injecting
drug
Tanahis
fuelled
primarily
by
sexual
transmission
and
injecting
Papua (the two provinces of Papua and West drug
use.
Tanah Papua
(the
twoBali
provinces
Papua
WestHIV
Papua),
Jakarta
and
lead inofthe
rateand
of new
Papua),
and Balipeople
lead in (Figure
the rate 1).
of new
HIV cases
per
casesJakarta
per 100,000
Jakarta
has the
highest
number
of new
cases has
(4,012
in 2011).
100,000
people
(Figure
1). Jakarta
the highest
number of
new cases (4,012 in 2011).

The increasing feminization of the epidemic in the

country
inequities
in status
and power.
is higher
(2.8highlights
per cent) than
that amongst
non-indigenous
Women
are
more
vulnerable
due
to
their
traditional
population (1.5 per cent) and higher in men (2.9 per
roles in society, which extend to marital relationships.
cent) than in women (1.9 per cent).
The proportion of women in new HIV infections in
Indonesia has grown from 34 per cent in 2008 to 44
Theper
epidemic
in Tanah
Papua
cent in 2011
(Figure
2). is driven almost
completely by unsafe sexual intercourse. The underlying
and structural causes include grinding poverty amidst
Figure 2. New HIV cases amongst women and men, 2008-2011.
unequal
patterns of rapid development and natural
HIV data from Ministry of Health, Progress Report HIV & AIDS Situation in
Indonesia up to
December 2011
resources exploitation, ethnic and linguistic
inequities,
of
low Number
levels
of
education
and
knowledge
about
HIV,
Male
Female
new cases
gender
discrimination, a young age of sexual debut and
25,000
other social and cultural norms.

Issue Brief: Responding toDHIV and AIDS

Inequities

Figure 1. The top ten provinces in new HIV cases per 100,000

Every 25 minutes inpopulation

Indonesia,
one person is
in 2011.
newly infected
by
HIV.
One
out
of
every five newly
131
Papua
infected people is below the
age
of
25
years.
46
West Papua
Indonesias
Ministry of Health projections show that
43
Bali
without acceleration
of HIV prevention programmes,
43
over halfJakarta
a million people in Indonesia will be HIV
41
positive
by 2014. The epidemic
is fuelled primarily by
Riau Islands
sexual transmission
and
injecting
drug use.
2011 Tanah
32
Maluku
Papua (the two provinces
of
Papua
and
West
13
East Kalimantan
Papua), Jakarta and Bali lead in the rate 2010
of new HIV
11
West Kalimantan
cases
per 100,000 people (Figure 1). Jakarta has the
North Sulawesi
highest
number of10new cases (4,012 in 2011).

North Sumatra
INDONESIA

9
8.88

Figure 1. The top ten provinces in new HIV cases per 100,000
50 in 2011.
100
150
0
population
New HIV cases per 100,000 population
131
Papua
Calculated from: New HIV cases from Ministry of Health, Progress Report HIV &
AIDS Situation in Indonesia up to December
2011. Population data from SUPAS
46
West Papua
2005 (Intercensal Survey) projection for 2011 population. 2010 census for 2010
population (2011 projects unavailable
43 at the time of this Report).
Bali

Tanah Jakarta
Papua illustrates 43a case of extreme inequity in
Tanah
Papua
illustrates
a case
ofcent
extreme
Riau Islands
infection
patterns.
With41only
1.5 per
of Indonesias
inequity
in
infection
patterns.
With
only 1.5 per
2011
32
population,
Maluku Tanah Papua accounted for over 15 per cent
cent of Indonesias population, Tanah Papua
of
Indonesias13new HIV cases in 2011.
Papua alone
Eastall
Kalimantan
2010
accounted
for over 15 per cent of all Indonesias
new
has
a
case
rate
nearly
15
times
higher
than
the national
11
West
Kalimantan
HIV
cases in 2011. Papua alone has a case rate
average.
Unlike
the
rest of
Indonesia,
Tanah
Papua is
10
nearly
15 times
higher
than
the national
average.
North
Sulawesi
experiencing
a
low
level
generalised
HIV
epidemic
with
Unlike
the rest9 of Indonesia, Tanah Papua is
North
Sumatra
a prevalence
of
3
per
cent
in
youth
aged
15-24.
HIV
experiencing
a8.88low level generalised HIV epidemic
INDONESIA
prevalence
amongst of
the3 indigenous
Papuan
population
with a prevalence
per cent in youth
aged
15-24.
50
100
150
0
HIV prevalence
amongst
the indigenous
Papuan
New HIV cases per 100,000 population
population is higher (2.8 per cent) than that amongst
Calculated from: New HIV cases from Ministry of Health, Progress Report HIV &
AIDS
Situation in Indonesiapopulation
up to December 2011.
data from
non-indigenous
(1.5Population
per cent)
andSUPAS
higher
2005 (Intercensal Survey) projection for 2011 population. 2010 census for 2010
in
men
(2.9
per
cent)
than
in
women
(1.9
per
cent).
population (2011 projects unavailable at the time of this Report).

unite
for children
The epidemic
in Tanah Papua is driven almost
Tanah Papua illustrates a case of extreme
completely by unsafe sexual intercourse. The
inequity in infection patterns. With only 1.5 per

The
increasing feminization of the epidemic in the
20,000
The
increasing feminization of the
epidemic
in the
44%
country highlights inequities39%
in status
and power.
country
highlights
inequities
in
status
and
power.
Women are more vulnerable due to their traditional
15,000 are more vulnerable due to their traditional
Women
roles
in society, which extend to marital relationships.
roles
society, which
extend
to marital
relationships.
The in
proportion
of women
in new
HIV infections
in
The
proportion
of
women
in
new
HIV
infections
Indonesia
has grown from 34 per cent in 2008 toin44
10,000
34%
Indonesia
has
grown
from
34 per cent in 2008 to 44 per
per cent in
2011
(Figure
35% 2).
56%
cent in 2011 (Figure 2).
61%
5,000

Figure 2. New HIV cases

65%amongst women and men, 2008-2011.

66%
HIV data from
Ministry of Health, Progress Report HIV & AIDS Situation in
Indonesia up to December 2011
0

Number of
new cases
25,000

2008

D2009

2010
Male

2011
Female

The Ministry of Health has projected a rise in

infections among children, as new HIV infections
20,000
increase among women.39%
Preliminary
44%findings of a
recent study commissioned by UNICEF and the
15,000
National AIDS Commission highlight the difficulties
faced by children affected and infected by HIV/AIDS.
Their access to education and health services is
10,000
limited by
discrimination,
the familys financial
34%
35%
difficulties because of the 61%
illness, the
ill health of the
56%
5,000
child and the need to take care of the sick parent.
65%
The estimated
number
of children infected each year
66%
is projected
to
increase
from 1,070 in 2008 to 1,590
0
2009
2010
2011
in 2014.2008

TheThe
Ministry
of Health
projected
a risefor
in 18 per
age group
15-24has
years
accounted
The Ministry
of Health
has
projected
a rise in
infections
among
children,
as
new
HIV
infections
cent of reported new HIV cases in 2011. Young
infections
among
children,
as new HIV infections
increase
women.
Preliminary
of a
peopleamong
make up
around
30 per centfindings
of the most-atincrease
among
women.
Preliminary
findings
of a
recent
study
commissioned
by
UNICEF
and
the
risk population, where HIV prevalence is higher.
recent study commissioned by UNICEF and the
Estimates in 2011 placed prevalence rates at 36 per
National AIDS Commission highlight the difficulties
cent amongst injecting drug users, 22 per cent
faced by children affected and infected by HIV/AIDS.
amongst transgender waria, 10 per cent amongst
Their access to education and health services is
female sex workers and 8.5 per cent amongst men
limited by discrimination, the familys financial
who have sex with men.
difficulties because of the illness, the ill health of the
child and the need to take care of the sick parent.
The estimated number of children infected each year

ISSUE BRIEFS

OCTOBER 2012

National AIDS Commission highlight the difficulties

faced by children affected and infected by HIV/AIDS.
Their access to education and health services is limited
by discrimination, the familys financial difficulties
because of the illness, the ill health of the child and
the need to take care of the sick parent. The estimated
number of children infected each year is projected to
increase from 1,070 in 2008 to 1,590 in 2014.
The age group 15-24 years accounted for 18 per cent
of reported new HIV cases in 2011. Young people make
up around 30 per cent of the most-at-risk population,
where HIV prevalence is higher. Estimates in 2011
placed prevalence rates at 36 per cent amongst injecting
drug users, 22 per cent amongst transgender waria, 10
per cent amongst female sex workers and 8.5 per cent
amongst men who have sex with men.

Barriers

oung people have limited access to sexual and

reproductive health information and services.
Sex remains a taboo subject that is not openly
discussed with parents, teachers, and even with health
providers. Legal restrictions make it difficult for unmarried
unmarried young people to access sexual and
young
people tohealth
accessservices.
sexual and
reproductive
health
reproductive
Other
legal provisions
services.
Other
legal
provisions
criminalize
the
dissemination
criminalize the dissemination of information on sex
1 The promotion of
of information
education.
education.1 on
Thesex
promotion
of condom
use is still
condom
use is still
problematic
in Indonesia;
certain this
problematic
in Indonesia;
certain
regions oppose
regions
oppose
this
on
religious
or
moral
grounds.
on religious or moral grounds.
TheThe
ageage
of of
sexual
debut
in in
Indonesia
is quite
young,
sexual
debut
Indonesia
is quite
young, for
especially
for girls.
Across Indonesia,
especially
girls. Across
Indonesia,
some 1 persome
cent
1 per and
cent4ofper
boys
and
per cent
girls havehad
of boys
cent
of4girls
have of
reportedly
reportedly
had sexual
the some
age ofas
sexual
intercourse
beforeintercourse
the age ofbefore
13 years,
13
years,
some
as
young
as
before
10
years
(Figure
young as before 10 years (Figure 3). By the time
they
3). By the time they are 17 years of age, about a third
are 17 years of age, about a third of young people will
of young people will have had at least one sexual
have
had at least
one sexual
encounter.
In of
Tanah
Papua,
encounter.
In Tanah
Papua,
13 per cent
in-school
13 and
per cent
of cent
in-school
and 19 peradolescents
cent of out-of-school
19 per
of out-of-school
(aged
adolescents
(aged
16-18
years)towere
reportedactive.
to be Of
16-18 years)
were
reported
be sexually
sexually
active.active
Of this
sexually
active
group,
this sexually
group,
about
half of
thoseabout
who
halfwere
of those
were
out ofhaving
schooltwo
reported
having
out ofwho
school
reported
or more
proportion
to 15 per
cent
they
twopartners.
or moreThe
partners.
The drops
proportion
drops
toif15
per
are
school.
cent
if still
theyinare
still in school.
Figure 3. Percentage of unmarried young people aged 10-24 years by
age of first sex. Source: Riskesdas 2010

20%
18%
16%
14%

Male

Female

12%
10%
8%
6%
4%
2%
0%

Age at first sex

Amongst young people, knowledge about HIV has

increased but is still limited. A study in five

Amongst young people, knowledge about HIV has

increased but is still limited. A study in five provinces by
the Ministry of Health showed an increase in
comprehensive knowledge about HIV and AIDS
amongst youth (age 15-24 years) in the general
population, from 11.4 per cent in 2010 to 20.6 per cent
in 2011, with similar proportions for men and women.
Over half the youth knew that AIDS could not be
transmitted by sharing food, and two-thirds responded
correctly that a healthy-looking person could be
infected with HIV. In another 2011 study, only 22 per
cent of grade 11 secondary school students had
comprehensive knowledge of HIV transmission, and
64 per cent had misconceptions about HIV.
However, knowledge amongst young people is not
sufficient to guarantee safe behaviour. Surveys of high
school students in six cities over the period 2007-2009
showed low rates of consistent condom use (below
20 per cent), although over half the respondents were
able to identify condoms as a means of preventing
HIV. In 2011, of the senior secondary school students
who admitted to having had sex, 49 per cent reported
that they did not use condoms during their last sexual
intercourse.
the respondents were able to identify condoms as a
means of preventing HIV. In 2011, of the senior

Knowledge
levels are
low amongst
the general
secondary school
students
who admitted
to having
population
aged
15
years
and
older.
The
had sex, 49 per cent reported that they
didRiskesdas
not use
2010
surveyduring
foundtheir
thatlast
some
42 per
cent of the total
condoms
sexual
intercourse.
population older than 15 years had never heard about
Knowledge
levels
are low
amongst
the general
HIV/AIDS.
Only
10 and
13 per
cent respectively
of
population
aged
15
years
and
older.
The
women and men had comprehensive knowledge
of HIV
Riskesdas 2010
survey
that some
42 higher
per centfor
prevention,
although
thefound
proportions
were
of the total population older than 15 years had never
specific questions.
heard about HIV/AIDS. Only 10 and 13 per cent
respectively of women and men had comprehensive
Fear,
stigmaofand
againstthe
people living
knowledge
HIVdiscrimination
prevention, although
with
HIV
still
pose
formidable
barriers.
Families and
proportions were higher for specific questions.

children living with HIV/AIDS are subject to stigma

Fear,
stigma and discrimination
against
people
and
discrimination,
which translates
to reduced
acliving
HIV still
formidable
barriers.
cess
to with
services,
loss pose
of dignity
and a greater
degree of
Familiesand
anddeprivation.
children living
with HIV/AIDS
are 20.2
subject
poverty
In Tanah
Papua, only
per
to
stigma
and
discrimination,
which
translates
to
cent of young people in school and 15 per cent of outreduced access
to services,
loss of dignity
and atowards
of-school
young people
had accepting
attitudes
greater degree of poverty and deprivation. In Tanah
people living with HIV. The fear amongst people creates
Papua, only 20.2 per cent of young people in school
resistance
HIVoftesting,
embarrassment
abouthad
seeking
and 15 pertocent
out-of-school
young people
treatment,
in some
cases,people
a reluctance
to be
educated.
accepting and
attitudes
towards
living with
HIV.
All
these
it difficult
control
the epidemic.
The
fear make
amongst
people to
creates
resistance
to HIV
testing, embarrassment about seeking treatment, and

in some cases,
reluctance
to be of
educated.
these
High-risk
groupsaare
more aware
HIV, butAllstill
make itindifficult
to control the
engage
risky behaviour.
In epidemic.
2011, one-third of female
sex workers reported not using a condom with their most
High-risk
groups
are more
of HIV,drug
but still
recent
client.
Less than
half ofaware
all injecting
users (41
engage in risky behaviour. In 2011, one-third of
female sex workers reported not using a condom with
1 their
most recent
client.
thanlegal
halfprovisions
of all injecting
Indonesias
Criminal
CodeLess
contains
that
drug users
(41 perinformation
cent) consistently
use condoms
criminalize
supplying
to people relating
to the
prevention
andpartners.
interruption
of pregnancy
(Articles
283, 534, 535).
with casual
Some
39 per cent
of male
The
Pornography
Law
(No.
44/2008)
prevent
people from
clients
of female
sex
workers
didcould
not use
a condom
at
disseminating
information
on sex education.
their last paid
sexual encounter.
Around 40 per cent
of reproductive-aged men who had sex with more
than one partner reported not having used a condom
at their last sexual encounter.

OCTOBER 2012

per cent) consistently use condoms with casual partners.

Some 39 per cent of male clients of female sex workers
did not use a condom at their last paid sexual encounter.
Around 40 per cent of reproductive-aged men who had
sex with more than one partner reported not having used
a condom at their last sexual encounter.
The availability of and access to condoms is still an
issue, although the use of condoms in Indonesia has
more than doubled from 2006. Both the Population and
Family Development Law (No. 52/2009) and the Health
Law (No. 36/2009) stipulate that only legally married
couples can access sexual and reproductive health
services.2 This makes it difficult for young people and
unmarried adults to access contraception or family
planning services from government clinics. However,
condoms can easily be obtained from nearby markets,
except in remote areas.
Although voluntary and confidential testing (VCT)
services have increased throughout the country,
knowledge about their existence is limited. In 2010, only 6
per cent of the population older than 15 years knew about
VCT services. This proportion, the same for women and
men, was only 4 per cent in rural areas. The higher wealth
quintiles were better informed on both VCT services and
HIV prevention. In December 2011, the Ministry of Health
reported 500 active VCT sites in 33 provinces, up from 156
in 27 provinces in 2009. Confidentiality issues and fear of
stigma and discrimination hamper efforts to increase the
uptake of testing.
Capacity, attitudinal and cultural constraints affect
measures to prevent parent to child transmission and
promote follow up care for mother-baby pairs.
Services to prevent parent to child transmission (PPTCT)
are limited and the implementation at provincial and
district levels is variable. The disparities in availability and
usage are probably a reflection of the variation in local
capacities, follow-up mechanisms (or lack thereof) and the
local cultural norms and attitudes towards HIV. Thus, the
numbers of pregnant women tested and the proportion of
HIV-positive women receiving antiretroviral drugs vary
widely from year to year. Less than one per cent of
pregnant women were tested for HIV in 2008. In 2011,
only 15.7 per cent of pregnant women living with AIDS
received ARV to reduce mother to child transmission.
The knowledge and uptake of VCT remains low
amongst young people in Tanah Papua. In 2006, less
than 20 per cent of youth aged 15-24 in Tanah Papua
knew an HIV testing site. The percentage of youth who
reported having had a test was also low (2-3 per cent).
The proportion having had a test and knowing the
result was even lower (0.3-1.6 per cent).
Articles 72 and 78 of the Health Law, and Articles 21.1, 24.1
and 25.2 of the Law on Population and Family Development.
2

ISSUE BRIEFS

Opportunities for action

HIV/AIDS education amongst decision makers and
opinion makers should focus on removing complacency
and on the need to allocate sufficient resources to
fighting HIV. In many low-prevalence countries, where
the HIV/AIDS epidemic is concentrated amongst highrisk groups, the attitude is one of complacency and
dismissal that HIV only happens because these
groups have questionable morals. Indonesia is not an
exception to this division between them and us.
Indeed, as in some other Asian cultures, one term used
for a female sex worker is wanita tunasusila or woman
without morals. People need to be made aware that the
epidemic is also spreading amongst those who are not
in high-risk groups, and that people are sexually active
from a young age, yet lack the knowledge and services
to protect themselves from HIV/AIDS.
Young people who are affected or at risk have special
needs. Specific strategies and programmes for such
young people need to be tailored to these needs.
Advocacy on HIV/AIDS will require credible data,
especially on the nations young people, and not just
on high-risk groups. So far, HIV information systems
have emphasized high-risk groups. Yet the trends
show that increasingly, more information is needed
on HIV prevalence and epidemiology, risk behaviour
and knowledge amongst the general population. For
instance, the National AIDS Commission (2012) in its
UNGASS report mentioned the lack of data on some
indicators considered by the government to be relevant
for Indonesia, but on which data are not available.
Similarly, there is a crucial need to obtain more
disaggregated data amongst youth (age 15-24 years) in
order to tailor programmes to their particular needs.
Support is thus needed for district teams to build strong
information systems disaggregated by age, gender,
location and ethnicity. Having levels of different access
to information can meet the need for confidentiality on
HIV testing.
Legal and policy barriers that limit young peoples
access to information and services need to be lifted
across districts and regions. The efforts should
emphasize access to VCT services and condoms. Most
young people do not normally use health services.
Overcoming this inherent resistance will require the
expansion and promotion of the Adolescent Friendly
Health Services (AFHS) approach, launched by the
Ministry of Health in 2003. In 2012, some 61 per cent of
all districts had at least four health centres implementing
the AFHS approach. Nonetheless, the approach remains
limited. Better coordination will be needed with other
relevant services, such as those relating to sexually
transmitted infections, methadone maintenance therapy,
and needle and syringe programmes.

ISSUE BRIEFS
The high HIV prevalence amongst Tanah Papuas youth
needs special education and prevention efforts. Public
education campaigns are urgently needed in Tanah
Papua. The AFHS approach, with VCT and condoms
as the key element, should also be accelerated. Peer
education activities in communities and schools need to
consider the extremely high proportion of out-of-school
youth. Amongst 33 provinces, Papua has the highest
proportion (38 per cent) of out-of-school children in the
age group 7 to 15 years.
To eliminate HIV transmission to children, Indonesia
will need to implement provider-initiated HIV testing
and counselling for all pregnant women. HIV testing
and treatment should be offered routinely by antenatal
care services. This would require changing the existing
minimum service standards on antenatal care. More
rigorous follow-up and public education are also needed
on PPTCT services. It is still unclear why the majority of
pregnant women testing positive for HIV do not receive
treatment. Most likely, the reasons include fear of stigma
and leakage of confidentiality; lack of support from the
husband, family and community; the poor quality of
services received at initial contact and unsympathetic
health staff. District assessments may be needed to
determine why the majority of pregnant women
diagnosed with HIV do not come back to undertake
antiretroviral therapy.
Fighting HIV/AIDS will require better coordination
between sectors on youth-related policy and
programming. Most of the issues confronting young
people are inter-related. National policy promotes
cross-sectoral approaches to fighting HIV/AIDS, but the
coordination and collaboration has to come at district
and province level. Developing youth-related policies
and programmes will also require greater levels of
participation from youth and other stakeholders.
Social protection and social assistance programmes
need to be HIV-sensitive. This means strengthening
measures to protect and enhance the access to social
services by HIV-affected families. Efforts are underway to
include PPTCT services under Jamkesmas, the
Governments health insurance programme for the
poor. More needs to be done to support the education,
protection, health and nutrition of children and young
people affected by HIV/AIDS.

Resources
Beadle, S. and Temongmere, G.A. (2012): A Brief Review of
Youth Policy & Programs in Papua & West Papua, Indonesia.
Indonesia, Jayapura: UNICEF
Ministry of Health (2005): Decree of the Minister of Health of the
Republic of Indonesia No 1507/ MENKES/ SK/X/2005 Regarding

OCTOBER 2012
Guidelines for Voluntary HIV/AIDS Counselling and Testing, Jakarta:
Ministry of Health.
Ministry of Health (2008): Mathematic Model of HIV Epidemic
in Indonesia, 2008-2014. Jakarta: Ministry of Health. Cited in
Indonesian National AIDS Commission (2012)
Ministry of Health (2011): Rapid Study on HIV comprehensive
knowledge in 5 cities in 5 provinces. Jakarta: Ministry of Health,
Directorate General of/Centre for Communicable Disease
Control
Ministry of Health (2011): Integrated Biological and Behavioural
Survey (IBBS) 2011. Jakarta: Ministry of Health, Directorate
General of Disease Control and Environmental Health. Available at the Data Hub for Asia-Pacific (supported by UNAIDS,
UNICEF, WHO, ADB HIV and AIDS):
http://aidsdatahub.org/en/country-profiles/indonesia Accessed 9 August 2012
Ministry of Health (2011): Laporan Nasional: Riset Kesehatan
Dasar (Riskesdas) 2010, Jakarta: Ministry of Health, National
Institute of Health Research and Development.
Ministry of Health (2011): Progress Report HIV & AIDS Situation
in Indonesia up to December 2010 (Laporan Situasi Perkembangan HIV & AIDS di Indonesia Sampai dengan Desember
2010, Kementerian Kesehatan RI). Jakarta: Ministry of Health,
Directorate General of Disease Control and Environmental
Health. Available at the Data Hub for Asia-Pacific (supported
by UNAIDS, UNICEF, WHO, ADB HIV and AIDS): http://aidsdatahub.org/en/country-profiles/indonesia Accessed 9 August
2012
Ministry of Health (2012): Progress Report HIV & AIDS Situation
in Indonesia up to December 2011 (Laporan Situasi Perkembangan HIV & AIDS di Indonesia Sampai dengan Desember
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This is one of a series of Issue Briefs developed by UNICEF Indonesia. For more information, contact jakarta@unicef.org or go to www.unicef.or.id