THE ROLE OF HEALTH PROTECTION INTERVENTIONS IN THE PUBLIC HEALTH

RESPONSE TO HIV IN INDONESIA

Your Name

Course Name and Number

Name of Professor

Institutional Affiliation

Date Submitted
 Outline

1. Introduction
• Prevalence or Incidence Proportion
• Mortality and Morbidity Ratio of HIV/AIDS cases in Indonesia
• Risk proportion and Case fatality of HIV:
2. Most vulnerable populations, social determinants and risk factor
3. Policy, Management and Control Responses
4. Critical assessment of the effectiveness of control responses
5. Critical appraisal of the HIV/AIDS status quo in Indonesia and conclusions
6. Reference list
THE ROLE OF HEALTH PROTECTION INTERVENTIONS IN THE PUBLIC HEALTH
RESPONSE TO HIV IN INDONESIA

Introduction

Indonesia, like some other underdeveloped Asian countries, is striving hard to reach

development. One of the main obstacles and public issues is the high prevalence of HIV/AIDS

among the Indonesian population since the 1990s. HIV (Human Immunodeficiency Virus) can

be transmitted by infected blood, vaginal fluids, or people with HIV. If proper treatment is not

taken, HIV can be modified into AIDS (Acquired Immunodeficiency Syndrome) which causes

severe damage to the immune system. It is quickly transmitting deadly viruses affecting people

from teenagers to adults. In 2015, the incidence of HIV/AIDs was 630,000 residents of

Indonesia. (2021). Behaviors of the Indonesian population promoting the transmission of

HIV/AIDS include sex workers, people who inject drugs (PWID), common gender sexual

activities, and the transgender community involved in such activities. An increase in

HIV/AIDS population in Indonesia has a great impact on society.

Prevalence or Incidence Proportion:

Indonesia has 34 provinces and a population of about 270.6 million is according to 2019

data. Most of its provinces are facing the obstacle of the HIV/AIDS epidemic. Jakarta, the

capital of Indonesia has an increased prevalence of HIV/AIDS among men who have sex with

men. On the contrary, the prevalence is decreasing among female sex workers. According to

research in 2018, Jakarta has 109,676 of the estimated population with HIV/AIDS. (SIHA,

2018). HIV risk groups have more prevalence as the data shows, homosexuals (25.8%),

transgender (24.8%), and people who inject drugs (PWID) (28.8%) (de Bresser et al., 2019).
Thus the PWID population is a great source of HIV transmission. Multiple usages of a single

syringe make it easier to transmit the deadly virus among the Indonesian population.

In recent years, Indonesia has faced the greater impact of the epidemic. The latest

UINAIDS report of the global HIV/AIDS epidemic shows the Injected drugs as the greater

source of HIV/AIDS expansion in Asia. In Indonesia, the first epidemic case of HIV/AIDS was

reported in 1987. In 1995, the first AIDS case among PWID was reported. Since then, the major

component of the epidemic in a country is PWIDS. (Mesquita et al., 2021)

A 2019 research shows that PWID has greater HIV incidence and prevalence also in some

settings they have the lowest access to antiretroviral therapy. (Palumbo et al., 2021) Many

regions of Indonesia have reported the great prevalence and incidence of HIV/AIDS in PWIDS.

Mortality and Morbidity Ratio of HIV/AIDS cases in Indonesia:

Indonesia, in the Asia Pacific, has the third rank in increasing the prevalence of HIV.

Between the era of 2005-2013, Indonesia has the greatest proportion of mortality rate due to

AIDS in Asia. As a global health problem, the rate of mortality and morbidity due to

communicable HIV/AIDS is still high among underdeveloped countries having Low-Middle

Salaries. According to a retrospective cohort study, the mortality rate between 2006- 2014 was

10% per year. The Census that occurred in 2019 tells that among 640,443 people with HIV the

prevalence of adults was 0.4%. The epidemic has expanded to 34 provinces and 61% of

Indonesia’s district.

Risk proportion and Case fatality of HIV:

 A report of 2006 conducted by the Ministry of Health and NAC on the estimation of

HIV risk in the adult population shows that 4-8 million people are at a higher risk of contracting

HIV. Among those 4-8 million people, 46% are people who injected drugs (PWID) and 14%

are sex worker’s clients. The greater complication arises because most PWID buys and sells

sex. According to the estimation, there will be an incidence of 1 million people with HIV and

350,000 deaths related to HIV. To clarification, the increase in HIV prevalence is because the

risk is not limited to a specific group of people. It can be transferred from high-risk behaviors

to their suppose as well as from mother to children.HIV has been transmitted from HIV-

positive mothers to more than 38,500 children. Most of these mothers have contracted HIV-

positive husbands. (2021).

To find out the case fatality ratio, the study was conducted and published in CDC’s

Morbidity and Mortality Weekly Report shows the result from 2010-2017, there is a decline of

48% as the death rate related to HIV death fell from 9.1 to 4.7.

Most vulnerable populations, social determinants, and risk factors

Indonesia’s highest concentration areas of HIV are Jakarta, Papua, East, and West Java,

Bali, and Riau. The data from 2016 from the Ministry of Health shows 47% of new HIV cases

are due to heterosexual sex, 25% due to homosexual sex, and 2% due to under 4 years old sex.

All these factors combined to form 75% of new HIV cases. The risk of HIV transmission can

be increased due to sexual activity with carriers during acute and late-stage of HIV infection.

According to national surveys, the most vulnerable and affected group is people who

injected drugs (PWID) reaching 48% in the capital of Indonesia, 53% in Denpasar as well as
24% in West Java. While in Merauke, Papua 26% prevalence is due to female sex workers.

However, According to 2002 national estimates, PWID has HIV prevalence ranging from 20%

to 47% while 2% to 5% among female sex workers. The other groups are 9% to 27%

transgender, 9% to 22% prisoners, and 0.4 to 1.3% homosexuals. (2021)

The incidence of HIV in Indonesia involves various societal factors including

unemployment, low education level, poverty, trafficking, unhygienic practice, lack of

resources, and involvement in illegal and unethical activities. According to the study, various

societal determinants are supporting the vulnerability to HIV. They also include the lack of

information and knowledge about the transmission of HIV and its prevention, easy accessibility

to brothels and female sex workers, and peer influence. (Fauk et al., 2021) Societal factors act

as assistance in the transmission of HIV in the general society. One of the greater factors is a

poor health system that fails in providing enough sources to meet the needs of the population

with the highest risk of HIV.

The most influenced vulnerability of female sex workers with HIV infection faces the

social determinant of poverty, economic pressure, personal life background, low education

level, women’s role, legal policies, violence, and trafficking. The other factors involving

environmental determinants are workplace environment and location, health care services,

peer’s company, and activities and mobility. Thus, social determinants have a greater impact

on the expansion of HIV due to several factors.

Most of the findings have shown that poverty, limited income sources, low education,

unemployment, the burden of responsibilities, and the need to support a family play a structural

factor role in optioning for sex work practice, a cause of unprotected sexual intercourse,

facilitation the HIV transmission. The individual needs fulfillment and personal savings desire

are also the factors that lead to greater involvement in sex working.
 According to the research in previous years, the study shows that a low level of

education is one of the social determinants in the transmission of HIV. Lack of knowledge and

information about sexually transmitted diseases like HIV/AIDS and its source of transmission

has led to unprotected sexual intercourse with multiple female sex workers who may be the

carrier of HIV infection.

The easy access to brothels, female sex workers, and friendships with sex workers in

the community proves as great support for HIV transmission among the different clients of the

same area. Also, lacking knowledge about condoms, the unavailability of condoms, use of

alcohol, PWIDs, the beliefs that condoms are not effective in preventing transmission of HIV

and inconsistent use of protective measure has made the transmission easy. (Fauk et al., 2021)

Stigma is experienced by some native groups based on caste and geographical

remoteness. Some religious minority-based stigma, as well as traditional belief-based stigma,

is other societal factors responsible for HIV transmission. Due to the discrimination, most of

them lack resources, employment, and proper access to education which means the spread of

viral infections due to lack of knowledge and preventive care.

Most of the studies showed that most people living with HIV (perceived or real person)

have experienced stigma and discrimination which led to unequal rights affecting the chances

to get employment. Limited knowledge about viral infection transmission leads to a lack of

understanding of HIV transmission and its prevention.

Policy, Management, and Control Responses

In Countries involved in promoting HIV/AIDS prevention programs, Indonesia is one

of them to promote HIV/AIDS prevention in the workplace. Jakarta, the capital of Indonesia is
promoting the prevention of HIV/AIDS by promoting HIV testing among pregnant females

and patients of HIV. (UNAIDS, 2016). To approach the target, Jakarta has to identify the HIV

carriers to connect them to care units. (2021). Since 2010, 68% of new HIV infections have

been increased while 22% of AIDS-related deaths have been decreased, due to the treatment.

(UNAIDS, 2016). The prevalence among males remained the same between the years 2014-

2016 while for females it has increased by 10,000 from 2014-2015 and reamined the same

between 2015-2016. (2021)

To combat the epidemic of HIV, several strategies are available such as outreach

homosexuality, transgender, meeting for harm reduction of PWIDs, educational programs, and

Information. Civil society has played a crucial role in supporting HIV prevention programming

and the advancement of human rights through financial support. (Indonesia, 2021)

In 1994, the first national strategy for HIV/AIDS prevention was formed. Later, in 2006

National AIDS Commission was established. The National Strategy was a guideline for

government sectors, local government sectors, NGOs, and the private sector for the prevention

of HIV/AIDS. The recent strategic plan of the years between 2010-2014 focuses on prevention

of HIV/AIDs, support, care, and treatment, impact reducing programs, and improving

environmental programs. National AIDS Commission and Local AIDS Commission were

assigned to ensure the role of stakeholders. The responsibility was to lead, manage, control,

and keep check of the implementation of programs in various government sectors.

Furthermore, to determine the role and responsibilities of the government in implementing the

HIV/AIDS prevention programs (includes diagnosis of HIV, healthcare facilities), the Minister

of health promoted the laws. (2021)

 Also, the government of Indonesia strategized the 3-ZEROS plan to overcome the

HIV/AIDS epidemic. These 3-ZEROS refers to the following:

1. ZERO- New HIV Infection

2. ZERO- Stigma and Discrimination

3. ZERO- AIDS-related death

This zero strategized plan will be helpful by providing knowledge, testing HIV positives and

treating them, and by maintaining the preventive measures. By testing HIV, the positive ones

will be identified and treated before transmitting the virus. The government is providing Anti-

Retroviral (ARV) treatment which can be taken by HIV-positive workers so that they can

maintain a healthy lifestyle.

International Labour Organization developed a recommendation in the concern of

HIV/AIDS. It is the first international labor support for HIV/AIDS which provides effective

policies for the workplace as well as programs for HIV/AIDS prevention. ILO finds out the

priorities sectors that prioritize the prevention of HIV/AIDS to support HIV prevention.

To fill the gaps of HIV/ AIDS awareness and to mitigate the stigma and discrimination,

the programs like HIV/AIDS awareness, Non-stigmatized policies, and HIV/AIDS treatment

accessibility should be designed.

ILO has strategized the program which includes the following:

1. Training of trainers, peer education, skill development, development, and action

of plans within the organization to prevent HIV/AIDS

2. Development of a Non-Stigmatized and discriminate environment by arranging

seminars, campaigns, within the workplace and by engaging people living with HIV.
 3. Equal access for employment opportunities to HIV-positive people and extension

of HIV/AIDS services at the workplace.

4. Social protection for people living with HIV as well as coordination and

partnership improvement among stakeholders. (HIV/AIDS Program in the World of

Work in Indonesia, 2021)

Further interventions performed at Jakarta includes Anti-Retroviral Therapy, HIV

testing, Distribution of condom, etc. The aim of the Ministry of Health is to put 40% of HIV-

positive on ART by the end of 2020 while 90% by the year 2027. In May 2020, from 640,443

HIV-positive, 62% knew about it but only 21% were taking treatment.

Critical assessment of the effectiveness of control responses

Indonesia has witnessed the worse epidemic since the 1980s; the expansion of sexually

transmitted viral diseases such as HIV/AIDS has expanded to most of Indonesia provinces thus

causing it a common public disease in Indonesia. The measures formulated in the prevention

of HIV/AIDS have not helped in past years because of different factors stimulating the spread

of HIV. The easy access to brothels and lack of knowledge about HIV transmission played a

greater part in distributing the disease among various cities. According to recent studies, the

preventive strategizes of testing HIV and counseling can provide help in preventing the

expansion of HIV by referring the patients of HIV to health care centers and by providing them

with proper treatment for the disease. Another intervention with great impact is organizing the

informative workshop and organizing events for knowledge on the mode of transmission of

HIV, as the low level of education has become one of the reasons for the greater spread of HIV,

people with no-low knowledge involves in unprotected sexual activities with multiple sex
workers thus transmitting the HIV. The controlled practice of Stigma and discrimination

removal will lead to successful prevention of HIV, as the majority targeted people suffering

from inequality; unemployment finds ways to drug addiction which further led to HIV due to

the use of the same syringe multiple times or also due to unprotected sexual intercourse. HIV

transmission is not limited to sexual intercourse it can be transmitted by non-sexual means such

as donor blood or by vaginal fluid. To prevent the transmission through non-sexual means, the

preventive measures of healthcare practices have helped in decreasing the HIV incidence.

To reduce the harm of drugs in people who injected drugs 133 meetings were designed

from which 11 were held in community health centers and one in clinics of HIV/AIDS. This

approach to people living with HIV was successful as it resulted in 8 visits of patients on

monthly basis and 22 people on average. (de Bresser et al., 2021).

Thus showing that the approach to affected ones helping them to get support and treatment in

an effective manner. The role of stakeholders has proved a remarkable reduction in the

prevalence of mortality rate in recent years.

For timely and proper prevention, the government should have take steps to ban local

and community brothels, an easy approach to female sex workers, and the use of drugs. The

injecting drug approach should be minimized by making it illegal to use syringes in drug

addiction. Also, the preventive measures should have increased the resources of information

and education to minimize the rate of illiteracy due to which the viral infection takes no time

in becoming epidemic. Furthermore, if the Implementation of strategizing designed by ILO

and Indonesian government efforts will remain consistent for years, it can help Indonesia to

come out of the HIV epidemic from most of its cities.

 Since 2010, 68% of new HIV infections have been increased while 22% of AIDS-

related deaths have been decreased, due to the treatment. (UNAIDS, 2016). The preventions

used during these years have been proved helpful in preventing HIV spread. The prevalence

among males remained the same between the years 2014-2016 while for females it has

increased by 10,000 from 2014-2015 and reami9ned the same between 2015-2016. (2021)

Critical appraisal of the HIV/AIDS status quo in Indonesia and conclusions

Indonesia is a country with one of the fastest HIV epidemics. Since 2010, AIDS-related

deaths have been increased by 60% in 2018 which means the conditions are getting worse

despite preventive measures. The reason behind this crisis is that the prevalence of HIV/AIDS

patients is greater while only a few are receiving treatment and ART willingly. People living

with HIV making have made it impossible for the country to decrease the incidence rate of

HIV because of transmission. The most vulnerable population with HIV high risk is mothers

transmitting it to newborns. According to studies done in 2020, 51% population with HIV

tested positive while only 17% are on ART. that means the rest are the primary source of

transmission of HIV making the situation worst in Indonesia.

The current situation of Indonesia is falling again with the increased deaths due to

AIDS. The current cases include various HIV-positive cases under the age of 15. People who

injected drugs (PWID) have increased the prevalence of HIV, as well as homosexuality, have

developed new germs transmitting different infections among HIV patients. With the great

preventive strategize Indonesia has still failed to overcome the epidemic because of irregular

regulation of treatment protocols. With HIV testing and counseling, it’s the core responsibility
of government and stakeholders to look after the progression of improvement in cases and their

treatments.

To deal with the current situation, along with HIV/AIDS preventive measures, the anti-

pornography law can help in decreasing the prevalence by decreasing the desire for enjoyable

sexual activity. The current policies for Preventive measures in Indonesia of using the drug are

labeled as criminalization. These can prevent the situation from further worsening.

References List:

Apps.who.int. 2021. [online] Available at:

<https://apps.who.int/iris/bitstream/handle/10665/254716/9789290225164-eng.pdf>
[Accessed 20 September 2021].
Asiafoundation.org. 2021. [online] Available at: <https://asiafoundation.org/wp-
content/uploads/2016/10/Understanding-Social-Exclusion-in-Indonesia.pdf>
[Accessed 21 September 2021].

de Bresser, I., Remers, T., Wieland, M., Prawiranegara, R., Siregar, A. and Baltussen,
R., 2019. Prioritizing HIV/AIDS prevention strategies in Bandung, Indonesia: A
cost analysis of three different HIV/AIDS interventions. PLOS ONE, 14(8),
p.e0221078.

de Bresser, I., Remers, T., Wieland, M., Prawiranegara, R., Siregar, A. and Baltussen,
R., 2021. Prioritizing HIV/AIDS prevention strategies in Bandung, Indonesia: A
cost analysis of three different HIV/AIDS interventions.

Ecoi.net. 2021. [online] Available at:

<https://www.ecoi.net/en/file/local/1030169/1329_1212589636_indonesia-2008-
country-progress-report-en.pdf> [Accessed 19 September 2021].

En.wikipedia.org. 2021. HIV/AIDS in Indonesia - Wikipedia. [online] Available at:

<https://en.wikipedia.org/wiki/National_AIDS_Commission_(Indonesia)>
[Accessed 19 September 2021].

En.wikipedia.org. 2021. HIV/AIDS in Indonesia - Wikipedia. [online] Available at:

<https://en.wikipedia.org/wiki/HIV/AIDS_in_Indonesia#cite_note-depkes.go.id-7>
[Accessed 19 September 2021].

En.wikipedia.org. 2021. ProQuest - Wikipedia. [online] Available at:

<https://en.wikipedia.org/wiki/ProQuest_(identifier)> [Accessed 19 September
2021].

En.wikipedia.org. 2021. United States Agency for International Development -

Wikipedia. [online] Available at:
<https://en.wikipedia.org/wiki/United_States_Agency_for_International_Developm
ent> [Accessed 19 September 2021].

Fauk, N., Kustanti, C., Wulandari, R., Damayani, A. and Mwanri, L., 2021. Societal
determinants of HIV vulnerability among clients of female commercial sex workers
in Indonesia.

Healthpolicyplus.com. 2021. [online] Available at:

<http://www.healthpolicyplus.com/ns/pubs/16340-17656_JakartaLEAPBrief.pdf>
[Accessed 19 September 2021].

Healthpolicyplus.com. 2021. [online] Available at:

<http://www.healthpolicyplus.com/ns/pubs/18446-
18809_IndoHIVLegalReviewBrief.pdf> [Accessed 20 September 2021].

Ilo.org. 2021. [online] Available at: <https://www.ilo.org/wcmsp5/groups/public/---

asia/---ro-bangkok/---ilo-
 jakarta/documents/projectdocumentation/wcms_742623.pdf> [Accessed 19
September 2021].

Ilo.org. 2021. HIV/AIDS Programme in the World of Work in Indonesia. [online]

Available at: <https://www.ilo.org/jakarta/whatwedo/projects/WCMS_737618/lang-
-en/index.htm> [Accessed 20 September 2021].

Mesquita, F., Winarso, I., Atmosukarto, I., Eka, B., Nevendorff, L., Rahmah, A.,
Handoyo, P., Anastasia, P. and Angela, R., 2021. .

Palumbo, P., Zhang, Y., Fogel, J., Guo, X., Clarke, W., Breaud, A., Richardson, P.,
Piwowar-Manning, E., Hart, S., Hamilton, E., Hoa, N., Liulchuk, M., Anandari, L.,
Ha, T., Dumchev, K., Djoerban, Z., Hoffman, I., Hanscom, B., Miller, W. and
Eshleman, S., 2021. HIV drug resistance in persons who inject drugs enrolled in an
HIV prevention trial in Indonesia, Ukraine, and Vietnam: HPTN 074.

Septarini, N., 2021. THE SOCIAL AND ENVIRONMENTAL DETERMINANTS OF HIV

INFECTION IN FEMALE SEX WORKERS IN INDONESIA. [online]
Jikm.unsri.ac.id. Available at:
<http://www.jikm.unsri.ac.id/index.php/jikm/article/view/209> [Accessed 19
September 2021].

Theglobalfund.org. 2021. [online] Available at:

<https://www.theglobalfund.org/media/8721/crg_humanrightsbaselineassessmentin
donesia_report_en.pdf> [Accessed 20 September 2021].

Unaids.org. 2021. Indonesia. [online] Available at:

<https://www.unaids.org/en/regionscountries/countries/indonesia> [Accessed 19
September 2021].

Unaids.org. 2021. Indonesia. [online] Available at:

<https://www.unaids.org/en/keywords/indonesia> [Accessed 19 September 2021].

Who.int. 2021. [online] Available at: <https://www.who.int/docs/default-

source/searo/indonesia/non-who-publications/2017-hiv-country-review-indonesia-
eng.pdf?sfvrsn=90a4c49f_2> [Accessed 19 September 2021].

Who.int. 2021. [online] Available at: <https://www.who.int/hiv/HIVCP_IDN.pdf>

[Accessed 19 September 2021].