Health and HIV Situation

Overall, the HIV prevalence rate of Indonesia remains low at 0.16%, but the HIV epidemic in the country has been among the fastest growing in Asia. Indonesia now faces a concentrated epidemic mainly fuelled by injecting drug use and the sharing of contaminated equipment, unprotected paid sex and, to a lesser degree, unprotected sex between men.

HIV infection rates vary in Indonesian provinces. The two provinces of Papua (Papua and West Papua) face a generalized epidemic. In Papua province, the number of AIDS cases is 15 times higher than the national average and HIV prevalence is estimated at approximately 2.4%. Even higher infection rates have been recorded in remote highlands (3.2%) and less accessible lowland areas (2.9%). In West Papua, the number of AIDS cases is twice the national average.

Currently, an estimated 193,000 people live with HIV in Indonesia, up from 170,000 in 2005, and 110,000 at the end of 2003. It is estimated that 46% of people living with HIV are injecting drug users (IDUs) and 14% are clients of sex workers. AIDS-related deaths have also drastically increased from 2,300 at the end of 2003 to 5,500 in 2005.

In 2006, 2,873 AIDS cases were recorded, 82% of them men. Every year, an estimated 3,000 to 5,000 lose their lives to AIDS in the country, or 8-14 people per day.

As of December 2006, out of the estimated 20,577 people who had an advanced HIV infection, 5,100 of them (24.78%) were receiving ART. 50 In Papua, which presents a generalized epidemic, only 3% of people living with HIV had received ARV treatment.

The number of women infected by HIV has almost doubled from 15,000 in 2003 to 29,000 in 2005. As of December 2006, an estimated 2,563 pregnant women were HIV-positive in Indonesia. Women in stable relationships are increasingly becoming infected by their partners who are either injecting drugs or having multiple unprotected sexual relationships. HIV transmission between female sex workers and their partners is a cause of concern with 6.37% of female sex workers living with HIV in Jakarta (2003).

In 2006-2007, the percentage of most-at-risk populations tested for HIV and informed of the results doubled compared to 2004-2005.

National HIV Program and Response

In 2007, the National AIDS Commission launched the HIV/AIDS Response Strategies 2007-2010. Key objectives include HIV prevention by targeting high-risk behaviour and vulnerable populations, and providing medical treatment, care, and support services to people living with HIV. The Strategy encourages greater stakeholder involvement in the HIV/AIDS response; more partnerships between the government, professional organizations, civil society, NGOs, the private sector, as well as strengthened policy coordination in HIV/AIDS efforts at national and local levels.

In January 2004, the Sentani Commitment was signed by Indonesian central and provincial governments to reach the following goals: promoting condom use in every high-risk sexual activity; promoting harm reduction practices among IDUs; providing ART to at least 5,000 PLWHA by end 2004; reducing discrimination against PLWHA; establishing active provincial and district AIDS committees; developing laws and regulations conducive to HIV/AIDS prevention, care and support programmes; and expanding information, education and communication efforts, including religious instruction, to reduce the spread of HIV/AIDS. The Commitment was re-endorsed in July 2005 by 14 provinces.

To increase and improve access to ART for PLWHA, the Ministry of Health developed national guidelines for ART and case management, as well as policy initiatives, which are currently being undertaken. Indonesia has 296 VCT clinics and 153 hospitals that provide free ART, 19 of which run PMTCT programmes. In addition, there are 20 referral networks for Integrated Management Adult Illnesses.

Weak institutional and human resource capacities however, hinder national efforts to extend ART among PLHWA. National AIDS programmes reach a limited number of injecting drug users and sex workers with their HIV prevention, care and treatment strategies. Stigma and discrimination limit the successful delivery of any HIV intervention. Implementation programmes face other challenges such as weak HIV programme management, uncoordinated interventions between partners and the limited capacity of the HIV surveillance system.

Internal and cross-border migrants are recognized as a vulnerable and sometimes at risk group, but limited national capacity exists to address their HIV issues.

The Ministry of Manpower and Transmigration and the Ministry of Health have developed policies on medical testing for migrants that prohibit using HIV test results in recruitment. However, because in most cases destination countries require HIV testing as part of the recruitment process, migrant workers undergo thorough mandatory medical tests, including an HIV test, under the responsibility of recruitment agencies before employment.

In 2006, the Government accredited 119 clinics to perform HIV testing. Prospective migrants are not always informed of test procedures or their purpose, and pre- or post-test counseling and HIV prevention and information services are not given to migrant workers. There is also no standardised referral system to provide care, support and treatment services to those found HIV positive, although there are currently several institutions in Indonesia that provide those services to PLWHA and that can be accessed by migrant workers.

Recruitment agencies are responsible for providing health and reintegration services to repatriated migrant workers under the 2004 Placement and Protection of Indonesian Migrant Workers in a Foreign Country. Undocumented migrants or trafficked persons do not benefit from this decree. Migrant workers found HIV positive in destination countries receive no treatment or referral services before being repatriated.

The Medical Service Centre (Pusat Pelayanan Medis, or PPM) of Raden Soekanto Hospital in Jakarta provides medical services to migrant workers and trafficked persons in cooperation with IOM and assists their reintegration to their villages with the help of a local non-profit organization.

Migration Patterns

Indonesia is a major sending country of migrant workers to the Middle East and to neighbouring Hong Kong, Malaysia, Singapore and Taiwan. In 2006, 680,000 Indonesian migrant workers - 80% (541,708) of them female - were deployed by the government; 502,432 migrants (73.9%) worked in the non formal sector including domestic work, and the rest in the formal sector. Government estimates of the total annual number of Indonesian migrants abroad was 1 million in 2007.

However, because migrants are often deployed overseas for more than one year with not all of them going through official channels, the number of Indonesian migrants overseas at any point in time is much larger than annual numbers. It is currently estimated that 3.5 million Indonesians work overseas. Undocumented migration remains an issue with an estimated annual 150,000-200,000 undocumented migrants working abroad. In 2006, remittances amounted to USD 4.4 billion.

Indonesia is a source, transit, and destination country for women, children, and men trafficked for sexual exploitation and forced labour. In 2006, Indonesia and Malaysia signed an MOU ceding basic worker rights to employers; this may increase the incidence of exploitative forms of labour among migrant workers.

An estimated 150,000-250,000 people are displaced in Indonesia. In 2006, UNHCR reported 301 refugees and 265 asylum seekers in the country.

Limited information is available on HIV infection rates and risk behaviours among migrant and mobile populations from Indonesia.

No surveillance systems are in place to monitor and evaluate HIV infections among this vulnerable group.

HIV Response for Migrant Populations: Gaps and Opportunities

Indonesia has shown commitment to address HIV vulnerability among migrants and mobile populations with their inclusion in national HIV prevention, care and treatment strategies. Policies have been developed to provide migrants with health and reintegration services and to prohibit HIV mandatory testing during the recruitment process.

However, HIV testing is mandatory in most destination countries as part of recruitment procedures and onsite medical exams often take place upon arrival. This raises concerns about the availability of care, treatment and referral services for potential and returning migrants found HIV positive.

Strengthening national capacities to provide migrant and mobile populations with quality prevention, care and treatment services throughout the migration cycle is needed. In addition, gender-based data collection and surveillance systems that target vulnerable migrant and mobile populations with strategic HIV interventions remain to be developed.