The epidemic is spreading more slowly than once feared, but OCTAVERY KAMIL still wants better resources for prevention work.
'We need to have compassion for people with HIV, no matter how they were infected. The moral quality of those who say that some people deserve this bad fate needs to be questioned. For people infected with HIV, while fate has not been good to them, there should be no Muslim who gives thanks for their suffering. That goes against the values of our religion, Islam....'
The speaker is a Muslim student representing a traditional Islamic school. He opens the floor to questions, and a young man says: 'In my opinion, this sickness AIDS shouldn't be exaggerated. Our prophet Mohammad tells us that for every sickness there will be a cure. It must be so for AIDS, they will surely find a cure!'
The speaker answers: 'In another of Mohammad's words he says: "Honey is the cure for all sickness", but today we don't take his words literally. You have to know, when studying religion you cannot take everything at face value, you must think about Mohammad's words within a broader context...'
The dialogue between workshop participants continued into the late evening. By the end of the weekend they not only had a stronger understanding of AIDS and its prevention, they supported a range of prevention strategies.
For me, this workshop was especially meaningful. It broke down stereotypes of Muslims as being hostile towards AIDS prevention efforts. And it showed how much AIDS education programs can influence the attitudes of individuals.
Spread
Indonesia is the largest Muslim country in the world. It is struggling with its response to the AIDS epidemic. In a country with over 200 million people, the official number of HIV/AIDS cases is only 524 (April 1997), small compared to neighbouring epidemics in Thailand and India. In 1993, the Centre for Disease Control (CDC), a US government agency that monitors and responds to infectious disease around the world, predicted a rapid spread of HIV in Indonesia, with a potential for 2.5 million cases by the year 2000.
However, more recent surveillance shows infection rates are low even among high risk groups such as female sex workers. Both CDC and Indonesian epidemiologists have now revised their prediction to less than 750,000 cases by the year 2000.
They still predict that the epidemic will be spread mostly by heterosexual sex. Factors such as high rates of male migration, widespread prostitution, high rates of sexually transmitted disease infection, the absence of sex education for youth, the low status of women, and the absence of a national AIDS awareness campaign are still cited as reasons HIV could spread quickly.
Non-government organisations (NGOs) working on AIDS prevention understand the great risks of HIV. In Surabaya, a port city in East Java, the 20,000 sex workers average 5 clients per night. In Yogyakarta and Jakarta, studies show 25-40% of married women seeking family planning services are infected with a sexually transmitted disease. In Bali, the use of injection drugs is on the rise.
National strategy
Since the first case of HIV was reported in Indonesia in 1987, much has been done to anticipate the epidemic. A Presidential Statement outlined the National AIDS Prevention Strategy in 1994. Since then a variety of NGOs have sprung up to address the issue. AIDS has been a big issue in the media, with both positive and negative impacts.
While Indonesia has a strong national strategy, as well as AIDS prevention committees at every level of the government, the effect in the field has been minimal. Government officials and public figures are still frequently quoted in the mass media as saying things contrary to the official AIDS strategy, as well as giving misinformation about AIDS.
For instance, in 1995 several cases of HIV were detected in Irian Jaya. After the cases were announced in the media, a government official was quoted as saying: 'We have located some of those people infected and are keeping them under surveillance. I can assure you we will track and find the rest of them'. The National Strategy clearly outlines non-discrimination towards people with HIV. Yet no effort was made to reprimand this official.
Recently in Aceh, North Sumatra, the Department of Health announced the results of a mandatory surveillance effort. Several people - their identities known to the government - were said to be HIV+. Yet the National Strategy clearly states that HIV testing must be both voluntary and anonymous.
Map
Epidemiologists have struggled to map the epidemic, but with minimal resources for surveillance, the status of the epidemic remains unclear. The National Epidemiology Network, under the Department of Health, has identified some factors they believe will enable HIV to spread rapidly in Indonesia. These include: low use of condoms as a birth control method, a large sex industry, high rates of male migration and mobility, as well as a high incidence of sexually transmitted disease.
However, while these theories about the spread of HIV are helpful, they are generally not based on real research about sexual behavior among the public.
For instance, several research reports on adolescent sexuality, which many AIDS activists still felt underestimated the incidence of sexual activity among teenagers, were protested by government officials, who said the methodology was invalid. The researcher himself was dismissed from his position as a doctor at a hospital in Central Java, making other researchers and organisations hesitant to attempt their own studies.
Without real information about sexual behavior, it is even more difficult to plan effective AIDS prevention strategies for both the government and NGOs.
Meanwhile, the majority of Indonesians in rural areas don't have any access to HIV information or services. Most of the current prevention campaigns are funded by only a few international donors, who limit their funds geographically. Human resources also remain limited and undertrained - in the government as well as among NGOs.
Moreover, there has been little effort to document what strategies are working, nor to adapt programs from one area to other parts of the country. Something as simple as what kind of information will be given about HIV/AIDS is still debated.
Confusion
Different types of information about AIDS from various sources has caused confusion among the public. For example, during World AIDS Day events in Jakarta in 1996, the wife of the Minister of Youth and Sports gave the confusing prevention message: 'Don't commit adultery or you will make your innocent babies AIDS victims'.
While condoms are discussed as one way of preventing the spread of HIV within the National Strategy, discussing access to condoms for teenagers is still taboo. The public either has trouble accepting that young people are sexually active, or they believe that access to condoms will encourage them to become sexually active.
Response to the potential epidemic continues to be slow, and for those doing AIDS work the barriers are many. There have been indications that the National Family Planning Board (BKKBN), one of the largest and most well-funded government departments, will start an AIDS prevention campaign with the theme of 'Strengthening Family Values.' The Department of Education is planning a peer education program for high school and university students. But it is likely that abstinence promotion will be stressed, despite global findings that abstinence promotion alone does little to change risky sexual behaviour.
NGOs
Target groups such as female and transvestite sex workers will be left to the NGOs, while funding for their efforts is uncertain. Funds from the United States Agency for International Development (USAID) are limited to three 'demonstration areas' over the next three years: North Jakarta, East Java and Menado. Funds from the Australian Agency for International Development (AusAID) are limited to Eastern Indonesia, where less than 15% of the population lives. Other NGOs will be in fierce competition for small grants from donors such as the Program for Appropriate Technology in Health (PATH), the Ford Foundation and various embassies.
Gay organisations providing HIV education have been frozen out of the national dialogue, and it is rumoured that funders have been forbidden by the government from providing grants to gay prevention education efforts. The only support group for people with AIDS, an organisation called Spiritia based in Jakarta, has received little support from donors, the government or other NGOs.
Move fast
I believe several things need to occur for AIDS prevention in Indonesia to work:
1) The National Strategy needs to be put into law and enforced. Addressing the common violations of the strategy is the key to an ethical and legal platform to dealing with AIDS. Chief among them are protecting confidentiality, and promoting non-discrimination towards people with HIV/AIDS.
2) Training on AIDS should be prioritised for government officials, public figures such as religious leaders, and the mass media. They should be encouraged to actively support AIDS prevention campaigns in their regions, for example by allowing access to public schools. They should also be prepared to give correct, clear information about HIV/AIDS so that it is not blown out of proportion by the public.
3) The HIV surveillance system needs to be strengthened, as should studies about sexual behaviour. This will strengthen the ability of program planners to make effective, targeted HIV prevention programs.
4) Men of productive age need to be more aggressively targeted with HIV prevention programs. A patriarchal culture shapes men as the likely key to the spread of an HIV epidemic in Indonesia.
The Muslim students discussing AIDS prevention illustrate that Indonesians of every age, ethnicity, religion, class and sex are ready to learn about HIV and are open to supporting HIV prevention programs. However, because of an unclear National AIDS Strategy, a lack of human and funding resources, frequent misleading information about AIDS by public figures and government officials in the mass media, and a lack of understanding about the shape and size of the epidemic, Indonesia is missing its chance to put in place effective AIDS prevention programs. Indonesia needs to move fast, before it is too late.
Octavery Kamil has worked in AIDS prevention since 1993 as a street outreach worker, workshop leader, trainer and program manager. He co-founded Lentera, the AIDS prevention program of the Indonesia Planned Parenthood Association in Yogyakarta, one of the first and largest AIDS service organisations in the country.
