HIV/AIDS Activist Fighting for Care

and Justice in Indonesia

By webadmin  on 11:28 am January 13, 2013.
Category Archive

http://www.thejakartaglobe.com/archive/hivaids-activist-fighting-for-care-and-justice-in-indonesia/

Charlotte Greenfield 

Baby Rivona is a 45-year-old mother of two who lives in Jakarta. She is

a busy woman. As well as caring for her 3-year-old son, her role as the
head of a nationwide advocacy group requires her to communicate
with members from around Indonesia, meet with government
departments and travel around the world to consult with international
organizations such as the United Nations.

Ten years ago, Baby was diagnosed with HIV during a routine test
required by her Malaysia visa. Her work permit was revoked and Baby
returned to Jakarta with little money and no job. As she sat in a
hospital waiting room for treatment, Baby looked around at fellow HIV
and AIDS patients. Observing that many of them looked sick and gaunt,
Baby told herself, “I don’t want to be like them.”

After reading every piece of information she could find on her condition
and ensuring she received adequate medical care, Baby is now able to
manage her condition so that she can lead a healthy life. As the
national coordinator of the Indonesian Positive Women Network (IPPI),
she is painfully aware that not all HIV-positive women in Indonesia are
as informed and empowered to fight the disease as she is.

“We’re talking about people like me who can read the documents in
English on ARV [antiretroviral] treatment and everything, but what
about people who don’t know a word of English? The counsellors and
the doctors do not always update their skills. How can they give their
patients the current information?” Baby says.

She adds, “So people living with HIV think treatment is useless, they
think you will die. The demand [for ARVs] is still not strong enough,
because the information is not there.”
Around 24,000 people are taking antiretroviral drugs in Indonesia,
which help to keep people with HIV healthy and reduce the risk of
transmitting the disease. The Ministry of Health estimates this figure
accounts for only 40 percent of those who need the medication.

Baby says that in spite of the government’s policy of providing ARV

medication free of charge, “fees” or bribes are regularly charged for
patients trying to access treatment. “If you want the services, you
pay,” she says.

Aditya Wardhana, the coordinator of the Indonesian AIDS Coalition,

adds that receiving any kind of medical treatment is made more
difficult for people who are HIV positive because of discrimination
within the health care system.

“We have 250 AIDS hospitals in Indonesia. And that’s sometimes an

obstacle because when people [with HIV/AIDS] try to access treatment
outside the AIDS hospital they get refused. The provider will say, ‘You
should go to the other hospital,’ but maybe they don’t need any specific
treatment,” Aditya says. “We need to tell our government that every
hospital should be ready to treat people with HIV. Because besides the
ART [antiretroviral therapy] and diagnostic tests, they don’t need any
specific treatment.”

General hospitals that do treat those with AIDS often require HIV-
positive patients to wait in special “isolation rooms” where they often
have to wait longer than other patients to see a doctor, according to
complaints received by the Indonesian AIDS Coalition and the IPPI.

Over the past few years examples of human rights abuses in the health
care system have come to light with reports of the forced sterilization
of HIV positive women.

“We began to hear of the situations in 2006,” Baby says, “but we did
not really understand yet. Then in 2008 we started to understand why:
some women living with HIV were saying when they were using the
health services they had to undergo sterilization. We did a study. We
talked to the then minister of health and we protested at the National
AIDS Summit in Yogyakarta.”

Any medical procedure conducted without consent is considered a

violation of human rights conventions that Indonesia has ratified,
including the International Covenant on Civil and Political Rights.
Guidelines from the World Health Organization (WHO) that have been
adopted in Indonesia recommend ARV treatment and, in some cases, a
caesarean delivery as the best practices to prevent the likelihood of
transmission of HIV from mothers to their babies. Such methods
reduce the chance of a baby contracting HIV from its mother to below
5 percent, according to the WHO.

A report released last year by the Women of the Asia Pacific Network
of People Living with HIV/AIDS surveyed 109 HIV-positive Indonesian
women in 2011. Just over 40 percent had been asked, usually by a
medical professional, to undergo sterilization and five women reported
they did not have the option to decline the procedure.

Baby says improvements have been made, with the help of the current
health minister, Nafsiah Mboi, who discouraged sterilization and
reminds health workers of the WHO guidelines.

“We know they don’t force sterilization anymore,” Baby says, “but they
still ask women many, many times to do the procedure.”

Nafsiah, who used to be the head of the National AIDS Commission, is

described by those in the AIDS advocacy community as a strong leader
willing to take action on HIV and AIDS. The minister believes a holistic
approach is needed to combat the disease

“We are working on very comprehensive efforts to tackle all the

problems,” Nafsiah says. “But first we must educate the youth about
religion, morals, reproductive health and how to avoid drug addiction.
We have too many young people engaging in risky behaviors, especially
unsafe sex. The number of abortions is increasing.”

This can be made difficult by concerns among some religious

communities over sex education. While last year’s National AIDS
Commission report says that the Nahdlatul Ulama have assisted with
outreach services to treat those with HIV and AIDS, another Islamic
group, the Indonesian Council of Ulema (MUI), is less supportive of
some efforts to prevent HIV.

The chairman of MUI, Amidhan Shaberah, told the Jakarta Globe, “We
reject the use of condoms outside of marriage.” He explained that until
now the MUI had not supported sex education but that its members
were now trying to agree on requirements to decide whether a
curriculum that met its guidelines would be permissible.
Aditya says that while views such as the MUI’s do make HIV prevention
more difficult, organizations targeted toward specific communities
affected by HIV and AIDS are able to operate effectively.

More difficult, he says, is reaching out to members of the general

population.

“The problem is, the epidemic is already broader than we thought.

Right now, we know that many housewives are infected. As the
numbers increase, we don’t have any programs for them.”

Nafsiah agrees, saying, “What’s terrifying is the fact that more and
more housewives are getting infected, mostly from their husbands, and
these women could transmit their disease to their babies. We can save
the babies from being infected if we can catch the infection early and
put the mother on antiretroviral treatment immediately. Next year we
plan to perform HIV tests on all pregnant women.”

Over 8,000 pregnant women are estimated to be infected with

HIV/AIDS, based on 2011 Ministry of Health figures. The number of
Indonesians living with HIV was around 370,000 in 2011, according to
UNAIDS.

Around $69 million was spent in 2010 to prevent and treat AIDS,
according to the National AIDS Commission, an increase of around 13
million since 2006. More than half of that comes from international
funds.

Baby says that while more funding is always helpful, addressing HIV
and AIDS in Indonesia is as much about attitude as it is about money.

“This is still a patriarchal culture. There’s discrimination, stigma,

financial issues and a lack of knowledge that are causing this. The
discrimination in the health system has gotten better over the past few
years, but we want more. We want people with HIV to be treated like
any other people. I used to wonder why God gave me HIV, but I think
maybe it is so I can be a role model and fight for women on these
issues.”
'Give me some place to work - anywhere other
than the streets'
Transgender sex workers in Indonesia know that condom use can help
prevent HIV infection – but clients' refusal is fuelling Asia's fastest-growing
rates of HIV infection
http://www.theguardian.com/global-development/2010/dec/01/world-aids-day-transgender-sex-
workers

Purple Romero for Panos, part of the Guardian Development Network

theguardian.com, Wednesday 1 December 2010 17.32 GMT

When Bea became a sex worker in the red light district of Jakarta, Indonesia, she knew she needed
to use condoms to protect herself from HIV but her clients refused to use them.

Bea, 30, is a waria – a man who has assumed a female identity. The word is derived from wanita,
which means woman in Indonesian, and pria, meaning man. Whether they wear women's clothes or
have undergone a full sex change operation, waria view themselves women.
"I knew the big risks that having this job would bring," she says matter-of-factly, although her voice
betrays emotion.

She needed the money so she stayed quiet. Meanwhile her clients continued to insist on sex without
condoms, believing anal sex could not lead to HIV.

Nightfall in Taman Lawang, a street in the Menteng subdistrict of central Jakarta, signals the start of
Bea's day. Dressed in fishnet stockings, her short hair dyed burgundy, pale skin exposed in her short
T-shirt, Bea takes her place. Groups of waria sex workers, clad in tight dresses and flawless make-up,
line the streets, sauntering in vertiginous heels and calling out to strangers in melodic, teasing
voices.

"Some clients believe [anal sex] is not real penetration," explains Tono Permana, a national
coordinator of the Jaringan GWL-INA Network, an Indonesian NGO supporting the gay,
transgendered and MSM – men who have sex with men – community.

This ignorance of the fact that HIV and AIDS can be transmitted through anal sex has made waria sex
workers vulnerable to contracting HIV.

Since discovering she was HIV positive, Bea has insisted on using condoms. If a customer does not
want to use one, she rejects them. But many waria, relying on sex work as their only income,
continue not to use condoms.

Fastest growing rate of HIV infection

According to a 2007 integrated biological-behavioural surveillance (IBBS) study of high-risk groups

there are around 35,000 waria in Indonesia. Eighty per cent of the waria interviewed in the cities of
Jakarta, Bandung, Semarang and Surabaya, had sold sex to male customers in the last year.

The study, carried out by Indonesia's National Aids Prevention and Control Commission (Komisi
Penanggulan AIDS, or KPA), the ministry for health and USAID, among others, suggests HIV
prevalence rate among waria sex workers had reached 34% in Jakarta, 28% in Surabaya and 16% in
Bandung. Less than 50% were using condoms.
Indonesia has the fastest-growing rates of HIV/AIDS infection in Asia, with more than 300,000 HIV
cases, according to UNAIDS. Meanwhile, condom use is extremely low, partly due to opposition from
Islamic groups that argue condoms encourage people to have sex outside marriage.

The KPA has been forced to address the issue, breaking the taboo against condoms to announce the
country's first national condom week in 2007. In 2008, the KPA announced it had distributed 20
million condoms to targeted high-risk groups across the country. The commission now aims to install
22,000 condom outlets by 2013 in the 12 provinces with the highest HIV prevalence.

Permana says that the KPA has tried to improve its communication strategy this year. Where
previously they focused solely on why condoms are necessary to avoid contracting HIV, they now
spread the message within the context of eliminating discrimination. "They are trying to tell them
that you should be proud of who you are, and that you should therefore take care of yourself and
take the necessary precautions," he said.

Accessibility to condoms is only one battle

Ienes Angela is an HIV programme manager at the Srikandi Sejati Foundation, helping Bea and other
waria get subsidised HIV treatment. A waria herself, she says that greater accessibility to condoms is
only one battle.

The bigger fight, she believes, is against prejudice. What the waria need from the government is the
recognition of their identity in order to help them find jobs beyond the sex trade.

Under Indonesia's "cacat law" (legislation defining mental disabilities) the department for social
affairs classifies the waria as mentally handicapped, hindering the chances of the waria gaining
mainstream employment.

Ienes says another problem is that official documents define waria as men. If a waria arrives at a job
interview dressed as a woman her chances of getting hired are virtually nil. "They don't think of our
capability, only our sexual identity," she says.
The waria also have difficulties securing national ID cards (Kartu Tanda Penduduk, commonly known
as a KTP), which are needed to get free HIV treatment. Rejection by their families is a root cause of
this problem. To get a KTP, you need a family card – a document that contains the identity of family
members and the order and relationships in the family. But many waria have been kicked out by
their families, says Tono Permana, of the Jaringan GWL-INA Network.

Across Indonesia, the obstacles are similar. The International Gay and Lesbian Human Rights
Commission notes that regulations in West Sumatra and West Java equate being a waria or being
homosexual to prostitution. Meanwhile, Aceh, an autonomous province that operates under Sharia
law, passed a by-law last year punishing homosexual acts with up to eight years in prison, 100 lashes
and a fine of up to one kilo of gold.

As a result of this discrimination, the majority of waria are confined to working in beauty salons or as
sex workers.

Bea has worked as both. She was an assistant at a beauty parlour when she was 17 but left after
three years. As a hairdresser she earned Rp 30,000 (£2.13) a day. As a sex worker she earns a little
over three times as much – although some nights she goes home empty handed. While Bea was
aware of the dangers of sex work she said that at the time it seemed to be the "right choice" - she
needed the money and there were no other options.

When asked how the government could help her, Bea says without hesitation: "Give me some place
to work - anywhere other than the streets." But for now she continues to stand on Taman Lawang
waiting for the cars to stop.
Living with HIV (2005)*: 170,000 (0.1% pop.)
Receiving Drugs (2005): 3,000-4,000 (30% of those who need them)
Est. AIDS Deaths (2005): 5,500

http://www.pbs.org/wgbh/pages/frontline/aids/countries/id.html

Indonesia is confronting a rapidly worsening HIV epidemic among its large populations of drug
injectors and commercial sex workers. Experts fear it's "just a matter of time" before the disease
spreads further in this country of 242 million, and reaches even the most remote of the archipelago's
13,000 inhabited islands.

Already one-third of the country's drug injectors have HIV, and in the capital city of Jakarta nearly
half of the injection drug users are infected. Despite the religious conservatism of this predominantly
Muslim country, drug abuse is on the rise and commercial sex is widespread -- an estimated 10
million men visit sex workers every year.

While the strict code of morality doesn't stop people from engaging in these behaviors, it does play a
role in preventing Indonesians from adopting safer practices that could halt the transmission of HIV.
Most drug injectors know where to get sterile needles, say researchers, yet 88 percent still use non-
sterile equipment because they fear that if they are caught in possession of needles, the police will
view that as indication of IV drug abuse, a serious criminal offence in Indonesia.

Similarly, 85 percent of the country's sex workers reported that they had not used a condom with
any client in the previous week, in part because the police still arrest women for being in possession
of a condom, which they view as proof of prostitution. If Indonesia can't control the growing
epidemic among these groups, experts argue that it may need to change its conservative stance.

The good news, says Peter Piot, executive director of UNAIDS, is that in Indonesia, "the opportunities
are enormous to really stop the epidemic, to nip it in the bud." Already the Indonesian government
provides antiretroviral drugs at no cost to anyone who needs them and "aggressive" AIDS training
for health care workers. Yet there are still barriers to treatment. Fear and discrimination against
those who have the disease lingers, even among health care workers. And ever since the massive
decentralization of government following the corrupt regime of General Suharto, the country's
former dictator, the provinces are responsible for most public services, including health care. But in
poorer provinces, where government struggles to provide basic health care and education, HIV
treatment and prevention isn't a top priority.

However, there is cause for hope. In 2005, the remote province of Papau, where 1 percent of the
population is already infected with HIV, passed a law that fines clients of commercial sex workers up
to $500 for refusing to wear a condom. The local health department has begun giving sex workers
monthly check-ups and requires that those who test positive for a sexually transmitted disease must
stop working until they are given a clean bill of health.

* Note: Figures reflect most recent statistics from UNAIDS and the World Health Organization.
AMERIKA

New WHO guidelines to better prevent HIV in

sex workers
Feature story 
12 December 2012
http://www.who.int/hiv/mediacentre/feature_story/sti_guidelines/en/index.html

New guidance from the World Health Organization (WHO) aims to better protect sex workers from
HIV and other sexually transmitted infections (STIs).

The WHO, in partnership with UNFPA, UNAIDS, and the Global Network of Sex Work Projects,
developed new guidelines following consultations with a wide range of stakeholders, including
national programme managers, researchers, sex workers’ representatives, international
organizations and development partners.
“The risk of a sex worker becoming infected with HIV and STIs is far higher than for other people,”
said Dr Gottfried Hirnschall, Director of the WHO Department of HIV/AIDS.

According to global data reported between 2007 and 2011, HIV infections among sex workers were
highest in sub-Saharan Africa, where more than a third (36.9%) of female sex workers were HIV-
positive, followed by Eastern Europe where the figure was one in ten (10.9%), and around half that
number in Latin America and the Caribbean (6.1%) and Asia (5.2%). The lowest rate, 1.7%, was
reported in the Middle East and North Africa.

Sex workers often find it difficult to access HIV and STI prevention and treatment services, even
though many countries have effective programmes in place. Many sex workers fear the stigma,
discrimination and, in some cases, violence they may encounter.

Some national AIDS programmes specifically support implementation of HIV prevention programmes
for sex workers. Many do not. The WHO guidelines are intended to be tailored and implemented
according to local situations and needs. The aim is to help countries establish national programmes
that work.

The new WHO guidelines recommend that countries work towards decriminalization of sex work and
urge countries to improve sex workers’ access health services. They also outline a set of
interventions to empower sex workers and emphasize that correct and consistent condom use can
reduce transmission between female, male and transgender sex workers and their clients.

Evidence indicates that where sex workers are able to negotiate safer sex, HIV risk and vulnerability
can be sharply reduced. The guidelines call for voluntary periodic screening and treatment of STIs for
sex workers to both improve their health and control the spread of HIV and STIs.

“There are some excellent examples of community-run HIV prevention schemes among sex workers.
More national programmes need to support this kind of approach,” says Dr Hirnschall.

WHO’s evidence-based guidelines are designed for use by national public health officials, managers
of HIV and STI programmes, civil society and health workers in low- and middle-income countries.
para perawat mampu melakukan penyuluhan kesehatan, screaning masalah kesehatan di
Posyandu, melatih kader dan memberi pelayanan langsung berhubungan dengan
kesehatan ibu dan anak. "Uji Kompetensi di Posyandu ini terutama dilakukan oleh perawat
komunitas yang memiliki salah satu bidang ilmu di keperawatan," ujar Prayetni seraya
menambahkan, "kami juga punya program melatih Posyandu."