Rapidly Expanding Access to Care for hiv in Tanah Papua (reach) 2012 2016
Annex 1: Overview of the epidemiology of HIV in Indonesia
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Annex 1: Overview of the epidemiology of HIV in IndonesiaThis Annex provides a more detailed analysis of the epidemiology of HIV in Indonesia as a whole and in the two Papuan provinces. A1.1 The HIV epidemic in Indonesia Indonesia's extraordinary geographical and cultural diversity is reflected in the diversity of its HIV epidemic. Although concerns were raised as early as 1992 about the potential for an explosive HIV epidemic driven by commercial sex40, HIV prevalence among female sex workers remained low -- largely below one per cent -- across the majority of the country for the decade that followed. This was very probably because of a combination of the following: high rates of male circumcision, relatively low consumption of commercial sex (in population-based surveys in Java in the mid-1990s under five per cent of adult men in urban areas and one per cent of men in rural areas reported having ever bought sex) and low partner turnover among sex workers.41 It was not until HIV shot through drug injectors in urban areas in the late 1990s that the epidemic became firmly entrenched in Java, home to two thirds of Indonesia's population. Since then, significant rates of HIV have been recorded among transgender, male and female sex workers in many urban areas outside of Papua, as well as among men in prison and gay men. Table 9 shows HIV rates recorded in surveillance in 2011. The quality of these data, especially the sampling procedures and thus representativeness of the data, have not been independently verified. However they give the best available indication of the current status of the epidemic in Indonesia. Table 9: HIV prevalence rates recorded in cities outside of Tanah Papua in 2011
PPS: Probability proportional to size * The MSM sample appears to be a mixture of gay men and male sex workers: 49 per cent of the sample reports selling sex in the last year, mostly to other men. Source: Indonesia MoH 2011 While the sex partners of the sub-populations in Table 9 are clearly also at risk for HIV, there is no indication that the virus is circulating widely outside of these groups in most of the Indonesian archipelago. The mid-point estimate for the number of people living with HIV in Indonesia in 2009, the most recent national estimates, was 186,000, some 150,000 of them living in provinces west of Tanah Papua. This equates to adult HIV prevalence in Indonesia of 0.13 per cent, excluding the Papuan provinces. Including the Papuan provinces, national prevalence rises to 0.15 per cent. In other words, around one adult in 650 is infected with HIV.
In Indonesia as a whole, four out of five people estimated to be living with HIV are male. HIV is transmitted primarily during sex between two men or between men and transgenders, or through the sharing of needles during drug injection. The 2011 IBBS omitted to collect information on the gender of drug injectors, but ethnographic evidence suggests that the overwhelming majority of injectors are men. In heterosexual commercial sex, women are clearly at higher risk than men, because their partner turnover is higher and because they have very high rates of untreated STIs that increase the probability of acquiring HIV. In cities for which we have data for both sex workers and occupational groups in which an average of 23 per cent of men buy sex, direct sex workers are 20 times more likely to be infected with HIV than "high risk" men.42 Female sex workers account for an estimated 0.3 per cent of the adult female population, according to national estimates. Outside of Tanah Papua, the other 99.7 per cent of the female population is at risk largely to the extent that they have sex with men who inject drugs, men who have anal sex with other men, and men who regularly buy sex from sex workers -- the latter group by far the largest, but with the lowest HIV prevalence by an order of magnitude compared with other high risk male groups. The best estimate that can be derived from currently available data is that in Indonesia west of Tanah Papua, one woman in 1,000 is currently at high risk for HIV infection because of her sex partner's behaviour.
Altogether, the two Papuan provinces are home to just one per cent of adult Indonesians, but 26per cent of the Indonesians estimated to be living with HIV, according national estimates made in 2009 and revised with more complete data by the team that developed this proposal. There is no indication of significant levels of HIV infection outside the key affected populations in most of the Indonesian archipelago. The exceptions are Papua and West Papua, where a different pattern of HIV infection began to emerge in the late 1990s. It was among female sex workers (FSWs) in the port city of Sorong, West Papua, that HIV was first recorded as crossing the five per cent threshold considered by WHO to warn that a nation's HIV epidemic may be escalating. That was in 1990/2000. By 2004, HIV prevalence ranged between five and 16 per cent in FSWs in the five Papuan cities in which it was measured, while in most of the western part of Indonesia, HIV rates remained much lower. Ethnographic studies and systematic surveys among civil servants and teenagers suggested that patterns of sexual networking among Papuans may fuel a more widespread epidemic; young Papuans reported starting having sex earlier than non-Papuans in the same province, Papuan men were more likely than non-Papuans to report buying sex, multiple concurrent partnerships were more frequently reported, and alcohol consumption before sex was much more common. This raised concerns at both provincial and national levels that HIV might become established and begin to circulate widely among men and women in the general population in Papua. In 2006, a household based survey of HIV prevalence and related knowledge and risk behaviours was conducted in Tanah Papua. The results of this survey are discussed in the section on HIV in the general population, below. STI and HIV among female sex workers Since that time, ongoing surveillance among FSWs has shown that HIV has remained high, as Table 10 shows. One in four street-based sex workers in the highlands town of Wamena was found to be infected with HIV in surveillance in 2011 - the highest rate recorded among FSWs anywhere in Indonesia; of those with HIV, three quarters were currently infected with at least one other STI (syphilis, chlamydia or gonorrhoea). Among the HIV negative, two thirds had another STI. Three quarters of Wamena's FSWs said they did not use a condom with all of their clients in the past week. Among motorcycle taxi drivers who buy sex in Jayapura, just 15 per cent report using condoms consistently.43 Table 10: HIV, gonorrhoea and chlamydia data for Papua and West Papua, IBBS 2009 and 2011
Source: MoH AIDS Sub Directorate Gonorrhoea and chlamydia: Table 10 summarizes the HIV, gonorrhoea and chlamydia data for Papua and West Papua from the Integrated Biological-Behavioural Surveillance (IBBS) rounds in 2009 and 2011. On any one day, 35-60 per cent of FSWs in Tanah Papua will have either gonorrhoea or chlamydia. The data suggest that rates may have been lower in sites that had implemented periodic presumptive treatment (PPT) in the period before the surveillance, for example, in Jayapura. Syphilis: While we have syphilis data from multiple rounds of IBBS conducted in Tanah Papua the syphilis results have often been poorly interpreted with inclusion of all past syphilis infections, resulting in overestimates of the prevalence of active infection. This is a common problem in Indonesia but could be easily corrected by review of raw data using the MoH standardized case definition for active syphilis (TPHA positive, RPR greater than or equal to 1:8). Of the recent reported IBBS data the 2007 data are the most reliable and indicate that syphilis is concentrated among FSWs with less than 10 per cent prevalence of active infection among brothel-based FSWs in Jayapura and Sorong.44 Other STIs: There are a number of other STIs (that are known cofactors for HIV transmission) that are likely present in the Papuan provinces but are under-diagnosed, under-treated and under-reported, including chancroid, donovanosis, genital herpes and trichomonas (see Annex 7). With such high rates of HIV, STI infection and unprotected sex, it is certainly the case that commercial sex continues to contribute disproportionately to new infections throughout the Papuan provinces. In order to reduce the ongoing spread of HIV (and thus to contain the number of people who will ultimately be in need of treatment) stronger and more effective prevention among sex workers and their clients will be needed. Effective STI and HIV treatment for infected sex workers provided under REACH will contribute to preventing the ongoing spread of the virus. But HIV treatment services differ from prevention services in that they are harder to concentrate geographically; by the time people are symptomatic and/or in need of treatment they have often moved on from the high-risk settings in which they were exposed to the virus. Note, too, that few highland towns currently have the kind of structured, venue-based sex industries which are common in larger coastal cities such as Jayapura or Sorong. Women are more likely to regard the sale of sex as a supplement to other income-generating activities than as a full-time job, and are less likely to be consistently reachable in locations where they prospect for partners. HIV in the general population The WHO makes a distinction between HIV epidemics in which HIV transmission is concentrated primarily among sub-populations with significantly higher than average partner turnover such as sex workers and their regular clients, and those in which HIV is "generalised". In a generalised epidemic, HIV would continue to spread in a sustained way among heterosexual adults even in the absence of highly exposed sub-populations. It is clear that Indonesia west of Tanah Papua falls into the first group. The status of the Papuan epidemic is less clear. In 2006, 2.4 per cent of the 6,217 adults in Tanah Papua aged 15-49 tested for HIV in the population prevalence survey were infected with the virus. That is over 18 times the population prevalence of 0.13 per cent estimated in 2009 for the rest of Indonesia. In the area that is now Papua province prevalence was 2.5 per cent, and in West Papua, 2.1 per cent. As Table 11 shows, HIV prevalence was significantly higher among men than among women, (2.9% vs. 1.9%) and higher among ethnic Papuans than among non-Papuans in West Papua (4.1% for male Papuans and 1.8% for female Papuans vs. 1.8% for male non-Papuans and 0.4% for female non-Papuans).45 Among men, the recorded prevalence of HIV was slightly greater in the highlands than in the rest of Tanah Papua. Among women, the reverse was true. The differences between highland and lowland areas were not, however, statistically significant. HIV prevalence was nearly twice as high in areas classified as "rural" than in urban areas (2.9% vs. 1.5%). So is the Papuan epidemic "generalised"? We cannot say for certain. Embedded research potentially undertaken under Component 4 of REACH might help clarify the contribution that commercial sex makes to the epidemic. But it is plausible, at the levels of HIV prevalence outlined in Table 11 and given what is known about sexual networking, that HIV could continue to circulate among the general population in Tanah Papua even in the absence of especially high risk behaviours such as Table 11: HIV prevalence in the general population, Papua and West Papua, 2006
* Virtually all the non-Papuans in the sample were in lowland areas Source: IBBS, 2006 commercial sex. This is especially true in the highlands; 27 per cent of men and 11 per cent of women in the highlands reported multiple sex partners in the previous year in the 2006 IBBS survey compared with 18 per cent of men and four per cent of women in non-highland areas (see Table 2 on gender in section 1.3.2 for more details46.) Applying the district-level prevalence measured in 2006 to the 2009 population projections from the Central Bureau of Statistics and adding the number of brothel-based sex workers estimated to be infected with HIV (since these women, unlike other higher risk groups such as men who buy sex or women who sell sex on the streets, would not be captured in a household survey) gives an estimated 38,000 adults living with HIV in Tanah Papua: 9,000 in West Papua and 29,000 in Papua. Of those, some 24,000 live in districts that will be covered by REACH. 47 No data on behaviour among the general population have been collected since 2006. It seems unlikely that that prevention campaigns using non-specific slogans such as "HIV is important", which appear to form the bulk of prevention messages currently reaching the general population in Papua, will lead people to have sex with fewer partners, or to use condoms more frequently. Although access to treatment has been poor and many of those who were already HIV infected in 2006 will have died, it is almost inevitable that new infections have outstripped deaths and that the number of people living with HIV has risen since 2006, but it is not possible to make an estimate of the number of people currently living with HIV. Other sources of data, including the results of testing of pregnant women in CHAI-supported clinics in highland areas, suggest that among those who currently access health services routinely, HIV prevalence remains well below five per cent. These data do not, of course, reflect prevalence rates in those who do not access health services, including many at-risk men. In the 2007 Demographic and Health Survey, some 69 per cent of married women in Papua reported some antenatal care by a skilled provider, the lowest rate in Indonesia (the national average was 93%). Of those who did report any skilled care, a relatively high 40 per cent reported having a blood sample taken during antenatal care (compared with a national average of 29%). The Ministry of Health is planning another round of household-based HIV and behavioural surveillance in Papua and West Papua in 2012. The survey will include an oversampling in the highland areas where REACH will concentrate its activities, and should provide more reliable information on the number of people likely to be in need of HIV and STI treatment and related services in program areas.
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