Rapidly Expanding Access to Care for hiv in Tanah Papua (reach) 2012 2016

1.3 HIV in Indonesia and the response

1.3.1 National overview of epidemiology and the national response

Estimated adult HIV prevalence in Indonesia in 2009 was 0.15 per cent¹⁴. If the Papuan provinces are excluded, prevalence drops to 0.13 per cent. In the non-Papuan parts of Indonesia, HIV infection is concentrated primarily in drug injectors, female and transgender sex workers, men who have sex with men, prisoners and men in mobile occupations. An overview of the epidemiology of HIV in Indonesia is in Annex 1. A description of the HIV epidemic in Papua and West Papua is in section 1.3.2.

The goal of the National AIDS Strategy and Action Plan 2010-2014 is “to prevent and reduce transmission of HIV infection; improve the quality of life for people living with HIV; and to reduce the socio-economic impact of the AIDS epidemic on individuals, families and society.”¹⁵ The CST objective is to “provide quality care, support and treatment services that are accessible, affordable and client friendly for all people living with HIV who need services.”¹⁶

The access target for antiretroviral (ARV) drugs is for all eligible people living with HIV/AIDS (PLHA) to be on treatment. Strategies to reach this target are increased HIV testing as an entry point to treatment, increasing the number and quality of hospitals and community health centres providing CST, increasing the number and quality of health care providers; strengthening supply chain management (SCM) of essential medicines; and strengthening the role of community based health services. The target for prevention of mother to child transmission (PMTCT) is for all HIV positive pregnant women and their children to receive ARV prophylaxis as appropriate. For PMTCT the strategies are to significantly increase the number of pregnant women and their partners who test for HIV and expanded availability of PMTCT through existing maternal and child health (MCH) services. The national strategy proposes integration of HIV into sexually transmitted infection (STI), MCH and tuberculosis (TB) services.

There has been significant scale up of access to antiretroviral therapy (ART) over the last six years, but coverage is low by global standards. At June 2011, a total of 21,775 people were receiving ART which is estimated to be around one-third of those eligible. ART is primarily available from hospitals, although the MoH is starting to decentralise ART to puskesmas satellite sites. The model of decentralised CST adopted by the MoH’s AIDS Sub Directorate is outlined in Annex 2. Continued scale up is planned along with a focus on patient retention, adherence and service quality. Coordination and supervision at the provincial and district levels needs to be improved, including better training and mentoring.

Indonesia is currently not on track to meet the Millennium Development Goals (MDG) targets for HIV. However, improvement of performance in relation to the MDG targets is a high priority for the GoI. The Government’s Road Map to Accelerate Achievement of the MDGs in Indonesia has explicit targets through to 2014 to increase HIV testing and the percentage of PLHA who receive ART. Strategies identified to meet those targets include improving the number and quality of health care facilities providing diagnosis and treatment and care; mobilising additional financial resources through integrating HIV into development programs financed at both the national and local levels; and defining the respective roles of national provincial and district health authorities.

Many of the key building blocks for STI control programming are in place. There are National STI Guidelines, a National STI Control Strategy (2008-2012) and a national Essential Drug List (EDL). Unfortunately, the current National EDL does not include a number of STI drugs that are listed in the National STI Guidelines including cefixime, azithromycin and metronidazole.

1.3.2 Papua and West Papua

Epidemiology

Altogether, the two Papuan provinces are home to just one per cent of adult Indonesians, but 26 per cent of the Indonesians estimated to be living with HIV, according to national estimates made in 2009 and revised with more complete data by the design team.

Ethnographic studies and other surveys have suggested that patterns of sexual networking among Papuans have fuelled a more widespread epidemic; young Papuans report starting to have sex earlier than non-Papuans in the same province, Papuan men are more likely than non-Papuans to report buying sex, multiple concurrent partnerships are more frequently reported, and alcohol consumption before sex is much more common.

STIs and HIV among female sex workers

The 2011 national Integrated Biological-Behavioural Surveillance survey among key affected populations found HIV prevalence rates among FSW varied from 3.2 per cent to 25 per cent, depending on geographic location and type of sex worker. The highest prevalence rate was among street-based FSW in the highlands town of Wamena. 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. (See Table 10 in Annex 1 for more data on HIV and STI prevalence among FSWs.)

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 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.

HIV in the general population

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 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. 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).¹⁷ 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%). (See Table 11 in Annex 1 for more data on HIV prevalence in the general population.)

It is plausible, at the levels of HIV prevalence found in the 2006 IBBS 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 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 4 in the section on gender for more details).¹⁸ 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. ¹⁹

No data on behaviour among the general population have been collected since 2006. It seems unlikely 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 above 38,000, but it is not possible to make a meaningful estimate of the number of people currently living with HIV.

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.

HIV and gender

In Indonesia as a whole it is estimated that four out of five people living with HIV are male. In the Papuan provinces, both sex workers and other women are at higher risk for HIV than their counterparts elsewhere in Indonesia, in part because HIV prevalence among the men they have sex with is higher. Representative household surveys on extramarital sex among women are not available for other areas of Indonesia, but Papuan women are almost three times more likely to report multiple sex partners compared with non-Papuan women living in the Papuan provinces (see Table 2). However Papuan and non-Papuan women alike are still far less likely to report multiple partners than men are - a common feature of historically polygamous societies. Women are also much less likely to report selling sex than men are to report buying it, though the proportions reporting selling sex are remarkably high for a household survey, particularly among ethnic Papuan women.

Table 2: Sexual behaviour in Tanah Papua, by gender and ethnicity, 2006

Sexual behaviour	Men		Women
Papuan	Non-Papuan	Papuan	Non-Papuan
Two or more sex partners in last year	21.2	10.3	8.2	3.2
Men who bought sex in last year	11.3	5.5
Women who sold sex in last year			2.7	1.4

Source: IBBS, 2006

In the 2006 IBBS survey, men in Papua province were 30 per cent more likely to be infected with HIV than women. This sex ratio is identical to that in the Papuan case report data, suggesting that there are no major biases in case detection by gender, at least when aggregated over time. However it is also interesting to note that late detection (cases reported once they had already progressed to AIDS) is more common for men than for women. Some 63 per cent of cases ever reported among men in Papua were detected when the person already met the case definition for AIDS, compared with 53 per cent among women. There are two likely reasons for this: proactive HIV testing of female sex workers, and the fact that women are more likely to come into contact with the health system than men are (and therefore potentially to get tested earlier in the course of their infection). The differential is likely to grow over time as more sites begin provider-initiated testing in settings such as ante-natal clinics.

In West Papua, the sex ratio of HIV infection recorded in the 2006 IBBS was far higher than in Papua province: men were nearly three times as likely as women to be infected. If women's extramarital sexual relations do indeed support the spread of HIV through heterosexual networks independent of commercial sex in West Papua, this differential will be eroded over time.

Papuan women suffer from gender inequality which can take multiple forms, including rape and other forms of gender based violence and generally lesser access to social services such as education and justice. While women are more frequent users of health services than men, their access to health services can be reliant on male permission. There is a need for health services to have a strong gender sensitivity and to develop strategies to deal with gender inequality.

The HIV response

Papua and West Papua provinces have developed strategic plans for HIV which are consistent with the National AIDS Strategy. The Provincial AIDS Commissions have developed a joint Communications Plan for HIV and AIDS Prevention and Management in Tanah Papua and more recently a draft communications plan for the highlands. While both plans refer to the need to increase HIV testing and utilisation of CST services, the plans and implementation have been criticised for a lack of specificity and efficacy in their strategic approach on these issues.

HIV awareness and prevention programming in the Papuan provinces is conducted by the Provincial AIDS Commissions and local civil society organisations, some of which are donor funded, and consists of general awareness raising and communication campaigns around themes such as HIV testing for the general population and targeted interventions for most-at-risk populations (MARPs). Overall, HIV prevention work lacks sufficient coverage and intensity, with vague messages about the need to test and an insufficient focus on key populations such as FSWs and their clients.

A description of the current state of HIV CST in Papua and West Papua is in section 1.4.1.