International Journal of Nursing Practice 2010; 16: 87–91

SCHOLARLY PAPER

The HIV/AIDS epidemic in Indonesia:

Does primary health care as a prevention
and intervention strategy work? ijn_1816 87..91

Kusman Ibrahim RN MNS PhD (Cand)

PhD Candidate, Faculty of Nursing, Prince of Songkla University, Hat Yai, Thailand, and Lecturer, Faculty of Nursing, Padjadjaran University,
Bandung, Indonesia

Praneed Songwathana RN PhD

Associate Professor, Faculty of Nursing, Prince of Songkla University, Hat Yai, Thailand

Umaporn Boonyasopun RN PhD

Assistant Professor, Faculty of Nursing, Prince of Songkla University, Hat Yai, Thailand

Karen Francis RN PhD Med MHlthScPHC GradCertUniTeachLearn BHlthScNsg DHlthSCNsg

Professor of Rural Nursing, School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Churchill,
Victoria, Australia

Accepted for publication December 2009

Ibrahim K, Songwathana P, Boonyasopun U, Francis K. International Journal of Nursing Practice 2010; 16: 87–91
The HIV/AIDS epidemic in Indonesia: Does primary health care as a prevention and intervention
strategy work?

The continuing increase in the number of people living with HIV/AIDS (PLWHA) in Indonesia is impacting on society.
Various policies and strategies have been adopted and implemented to tackle this epidemic including primary health-care
(PHC) initiatives. This paper describes the current HIV/AIDS epidemic in Indonesia and highlights a range of prevention
and intervention initiatives introduced to limit the spread and impact of this disease factors, such as the characteristics of
high-risk groups, the decentralization policy in the health sector, and the lack of skilled human resources and supplies in
health centres have been identified as influencing access to health-care services among high-risk groups. Revitalization of
a PHC approach coupled with adequate fiscal, infrastructure and human resources if addressed will increase of PLWHA
and other risk groups to health care.
Key words: HIV/AIDS, Indonesia, primary health care, prevention and intervention.

Correspondence: Kusman Ibrahim, Faculty of Nursing, Universitas
Padjadjaran, Jl. Raya Bandung Sumedang Km 21, Jatinangor, Sumed-
ang 45362, West Java, Indonesia. Email: k.ibrahim@unpad.ac.id
INTRODUCTION
The human immunodeficiency virus/acquired immune
deficiency syndrome (HIV/AIDS) epidemic has reached
pandemic proportions affecting millions of people around
the world. The HIV remains the most serious of infectious
disease challenges to public health due to the number of

doi:10.1111/j.1440-172X.2010.01816.x © 2010 Blackwell Publishing Asia Pty Ltd

88
reported cases of new infections that steadily increases
each year.1 The first case of a person diagnosed as having
HIV/AIDS in Indonesia was in 1987. Since this date, the
incidence rates of people living with HIV/AIDS
(PLWHA) have been escalating. Although other neigh-
bouring countries, such as Thailand, Cambodia and
Myanmar show a decline in HIV prevalence due to the
effectiveness of prevention efforts, Indonesia has an
increasing HIV prevalence rate, particularly in high-risk
groups. It has been noted that the number of HIV/AIDS
cases in Indonesia has risen 40 times within a decade
(1997–2007).2 Data indicate that Indonesia has the fastest
growing HIV epidemic in Asia.3
The continuing growth in the numbers of PLWHA
increases the health-care burden. Predictions suggest that
an estimated 27% of public hospital beds will be filled
with PLWHA by 2025. The treatment costs are predicted
to reach 3210 billion Indonesia Rupiah (about $321
million), which is equal to the current annual income and
expenditure budget of a major city in Indonesia.4 As an
outcome of this pandemic, life expectancy of Indonesians
is expected to reduce by 6 months and the crude death
rates will increase by 0.2% by 2015.5 Eventually, if this
epidemic is not addressed, HIV/AIDS might affect the
rate of the human development index that reflects the
development of the country.
There are several factors that contribute to the spread
of HIV/AIDS in Indonesia including high rates of popula-
tion mobility, urbanization, migrant workers, lack of
awareness among the population, the sharing of contami-
nated needles among drug users and unsafe sexual prac-
tices among high-risk groups such as commercial sex
workers (CSWs), men who have sex with men (MSM)
and injecting drug users (IDUs).6,7 Migration is one of
many social factors contributing to the spread of HIV/
AIDS. Movement of infected individuals to diverse geo-
graphic locations provides for dissemination. Indonesia
has the highest low-skilled migrant worker workforce in
the world thus by implication is potentially contributing
to the spread of HIV/AIDS.6
The Indonesian government has responded to this epi-
demic by developing and implementing a broad range of
policies and programmes including the establishment the
National AIDS Prevention and Control Commission
(NAC) as a central coordinating body responsible for
implementing AIDS prevention and control efforts and
increasing public awareness of HIV/AIDS.8 In the health-
care sector, programmes have been developed and imple-
© 2010 Blackwell Publishing Asia Pty Ltd
K Ibrahim et al.
mented that incorporate a primary health-care (PHC)
approach to improving health services access for PLWHA
as well as at-risk populations. Prevention, care including
palliative care, treatment and support have been put as
programme priority areas in control HIV/AIDS.
However, the results seem to be far from satisfactory.
This paper aims to examine and evaluate the implemen-
tation of PHC prevention and intervention initiatives
addressing the HIV/AIDS epidemic in Indonesia.
TRANSMISSION
In Indonesia, HIV transmission primarily occurs as a result
of sharing needles among IDUs, which constitutes 52.6%
of the population PLWHA, followed by heterosexual
37.2% and homosexual 4.5% intercourse.9 Many drug
users engage in unprotected sex, which increases the
chances of HIV infection. An even, greater risk for drug
users to transmit the virus is the sharing of contaminated
needles and other drug paraphernalia. A survey in four
major cities of Indonesia reported that 43–56% of IDUs
have infected by HIV; 38–59% have steady sex partner;
20–60% have casual sex partner; 9–54% have sex with
sex workers; and majority of them reported inconsistency
condom uses in the last 12 months.10 Drug users are also
vulnerable to HIV because of their social and legal status.
They often live on the periphery of society, away from
family and friends, and beyond the reach of health, edu-
cation or treatment programmes; many drug users simply
do not see themselves as vulnerable to HIV infection and
do not test for the virus. Being a drug user is considered
illegal worldwide, resulting in users being stigmatized and
living in the shadows of society as they are reluctant to
access HIV/AIDS prevention or treatment services. To
date, the epidemic among IDUs in Indonesia has spread to
their non-injecting sex partners, prisoners, sex workers
and their clients. Eventually, wives and children are also
infected.
PREVALENCE
The number of reported PLWHA in Indonesia had risen
from 93 000 in 2001 to 270 000 by the end of 2007.11
Although the aggregate national HIV prevalence is still
low (0.16%) for the general population, the rate of
increase is high.3 Recent data indicated that by the end of
March 2009 there were cumulatively 16 964 AIDS and
6668 HIV positive cases reported in Indonesia.12 If the
preventative measures implemented are not successful,
this figure is expected to rise to 500 000 by 2010.9
The HIV/AIDS epidemic in Indonesia
Data conclusively show that prevalence rates continue
to rise particularly among risk populations, although there
is wide variation between the provinces/states and major
cities. In Papua, the easternmost area of Indonesia, the
HIV epidemic has reached a generalized level with the
typical mode of transmission being heterosexual inter-
course. Although in provinces of Bali, Java, Sumatra,
West Kalimantan and South Sulawesi, needle-sharing
among IDUs is the predominant mode of HIV
transmission.
PREVENTION AND INTERVENTION
INITIATIVES
The Indonesian government has invested in several initia-
tives to address the growing HIV/AIDS epidemic. A
National AIDS Commission (NAC) was established
through the Presidential Decree no. 36/1994. This orga-
nization established AIDS Commissions at provincial,
residencies and municipality levels. The NAC developed
the first National AIDS Strategy and a Five-Year Program
Plan for AIDS Prevention and Control (1995–2000) as
part of the National Development Plan. Subsequently the
National AIDS Strategic Plan for 2003–2007 and 2007–
2010 has been formulated.13 In addition, Indonesia signed
the United Nations General Assembly Special Session
Declaration of Commitment on HIV/AIDS in June 2001,
reflected in the global consensus framework to reach the
Millennium Development Goals to reverse the epidemic
by the year 2015.14
Programmes to move towards achieving universal
access have been adopted. Universal access encompasses
the principles of equality, sustainability, comprehensive-
ness, accessibility and sustainability as guides in develop-
ing interventions of the comprehensive package.15 In
December 2005, in reference to the Sentani Commit-
ment, the NAC published a new policy, the accelerated
programme response to HIV/AIDS in 100 priority
districts/cities in 21 provinces. The policy mandated
these districts/cities to implement minimal services in the
following areas: (1) behavioural change communication
and 100% condom use programmes; (2) prevention of
HIV/AIDS through a response to sexually transmitted
infections; (3) prevention of HIV/AIDS among IDUs; (4)
voluntary counselling and testing services; (5) care,
support and treatment services; (6) prevention of mother-
to-child transmission services; (7) public communication
services about HIV/AIDS; (8) HIV/AIDS services in the
work place; (9) HIV/AIDS services in non-governmental
89
organizations (NGOs); (10) HIV/AIDS prevention in
young people; and (11) legal services, especially the pub-
lication of regional policies related to HIV/AIDS.14
In 2007, the NAC issued a policy to control the HIV
epidemic among drug users by adopting and implement-
ing the harm reduction strategy. The strategy covers 12
activities: (1) outreach and guidance; (2) communication,
information and education; (3) peer education; (4) behav-
ioural change counselling; (5) voluntary counselling and
testing; (6) bleaching; (7) sterile needle and syringe
service; (8) syringe used disposal; (9) rehabilitation for
drug addiction; (10) methadone substitution therapy; (11)
care, support and treatment; and (12) PHC.16
Although, the NAC has implemented many useful
strategies and initiatives to limit the spread of HIV in
Indonesia, these have not been effective. The decentrali-
zation policy adopted by the health sector was conceptu-
alized to improve access to local-level resources.
Although decentralization resulted in services being estab-
lished throughout the provinces, funding to support local
initiatives in responding to HIV including programmes
targeting IDUs and sex workers have been inadequate.4
Rangarajan et al. argued that the AIDS Commissions
either at provincial or districts/cities levels in Asian
lacked the political will and capacity to coordinate avail-
able resources to control the epidemics.17 Inconsistency
between policies at the top governmental level and the
implementation on the ground has also been highlighted as
another impediment limiting the impact of local initia-
tives.18 Outreach programmes targeting IDUs and CSWs
have been put forward as priority programmes for con-
trolling the epidemic. Unfortunately, government has not
appointed a director to manage this initiative. Community
health centres are the first- or primary-level health-care
facilities funded by government. These health centres
generally do not employ dedicated staff to manage out-
reach programmes. Currently, outreach programmes for
high-risk populations are offered primarily by NGOs
funded by foreign donors through work contracts that are
time-specific. Many NGOs cease offering services when
initial funding has been expanded.
Limited health-care facilities offering HIV test and anti-
retroviral therapy (ART) compared with the high demand
of PLWHA, and limited numbers and inequitable distri-
bution of skilled health-care providers have limited the
impact of prevention and early intervention strategies.
Irwanto and Moeliono reported that PLWHA complained
about the long waiting lists to access health-care clinics as
© 2010 Blackwell Publishing Asia Pty Ltd
90
a result of limited numbers of medical doctors working in
these services.19 Respondents in this study identified the
negative attitudes of health-care providers’ towards
PLWHA as impacting adversely on the quality of care
provided. They also highlighted that many services were
provided by staff with limited skills, which they believed
effected the care that they received.19
Being stigmatized and discriminated against for having
HIV/AIDS and/or using IDUs are factors that impact
adversely on populations seeking assistance from public
health-care services.19,20 Restricting access to health ser-
vices on the basis of populations at risk is a strategy that
many governments adopt when services are limited.
Research suggests this strategy can increase stigmatization
resulting in decreased use by the ‘at-risk’ groups identi-
fied. Further, if access to health-care services is restricted
to normal office hours, stigmatized groups are less likely
to use them.19
THE FUTURE
Health systems founded on a PHC approach that values
equity, accessibility and collaboration. Models of health
care that use a PHC framework characteristically have
distributed services that ensure all people have access to a
level of health care that is affordable. In Indonesia, com-
munity health centres are widely distributed throughout
the nation and offer primary-level health services. These
services are in a strategic position to play a much more
significant role in addressing the HIV epidemic. It is
argued, however, that they must be revitalized if the HIV
epidemic is to be arrested. Specific funding initiatives to
raise awareness and early intervention programmes tar-
geting high-risk groups must be a priority. Well-educated
and skilled health-care providers need be recruited. A
diverse range of strategies formulated to disseminate
information to the community about HIV/AIDS and early
intervention measures including access to diagnostic and
ART should be funded appropriately. In additional,
enhanced access to acute and palliative care service when
end of life is approaching is required as HIV prevalence
becomes high. The advancement of ART that is widely
available and affordable in developing countries has
improved survival rate of PLWHA. HIV/AIDS recently
has become a chronic manageable disease. Furthermore,
innovative strategies to implement PHC in this population
are needed in line with the Millennium Development
Goals of WHO to reduce chronic disease death rates by
2% per year in present decade.21 The activities of PHC
© 2010 Blackwell Publishing Asia Pty Ltd
K Ibrahim et al.
that incorporate health promotion, illness prevention,
care for the sick, advocacy and community development,
with interconnecting principles of equity, access, empow-
erment, community self-determination and intersectoral
collaboration, are appropriate measures to prevent the
spread of HIV/AIDS and limit the impact on the individu-
als, families and communities.22
CONCLUSION
The spread of HIV/AIDS in Indonesia has not been
arrested. HIV/AIDS that was initially thought to be trans-
mitted among IDUs and sex workers, is now being trans-
mitted to the general population including women and
children. The continuing increase in the number of HIV-
infected people imposes significant burdens on the social
life of individuals, families and communities, health-care
services, and the overall development of the country.
Primary prevention and intervention strategies have been
developed but are largely underfunded and are currently
offered by staff with limited skills and understanding of
the disease. Revitalization of PHC approach by incorpo-
rating innovative strategies to the health-care services is
needed to increase health-care access of PLWHA and
related risk groups.
Strengthening the operations of community health
centres as the front line to manage the HIV epidemic is a
priority. Therefore, equipping the community health
centres with an appropriate level of staff, and supplies is
extremely important. Empowering the community
through greater engagement is necessary precursor to
arresting the spread of HIV/AIDS. Health-care staff must
identify and work in partnership with key community
stakeholders who have the potential to influence others
such as religious leaders, managers and staff of NGOs,
business sector, government officials if this epidemic is be
halted. Finally, sufficient funding needs to be allocated by
government to initiatives targeting HIV/AIDS prevention
and intervention.
ACKNOWLEDGEMENTS
The authors would like to thank Monash University, Aus-
tralia, for accepting the first author as visiting academic;
and gratefully acknowledge the grant provided by the
Faculty of Nursing, Prince of Songkla University and the
Directorate General of Higher Education, Ministry of
National Education, Indonesia.
The HIV/AIDS epidemic in Indonesia
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© 2010 Blackwell Publishing Asia Pty Ltd