The current and evolving epidemiology of the HIV and AIDS in Indonesia

Aang Sutrisna
Indonesia is the worlds largest archipelago with 17,508 islands, some 6,000 of which are inhabited,
and an estimated population of 255 million in 20151,2 The country is assembled into 34 provinces or
states which subdivide into 416 districts and 98 municipalities. A policy of decentralization of
government was put in place in 2001.3 Life expectancy at birth in 2012 was 68 years for men and 72
for women. Adult literacy is 88% and infant mortality 31/1000 births. The World Bank classifies
Indonesia as a lower middle income country. The GDP per head in 2013 was $3,475. 4 While the
economy grew 5.1% in 20145, the rate of growth has been slowing since 2011. However, the World
Bank projects 5.6% GDP growth in 2015 and 2016, an increase from 2014, but still lower than 2011
2013. Half of all households remain clustered around national poverty line set at IDR 200,262/month
($17). The Gini coefficient has increased from 0.30 in 2000, to approximately 0.41 in 2013.
Indonesia is a republic, with a delicate balance between the central government authority, the provinces
and the districts, which receive funds directly from the central government, but also finance themselves
a significant proportion of programs and operations. The health system is decentralized, with ultimate
responsibility for the provision of health services being vested in governors and mayors. There is a
high degree of disparity in health services between remote, underserved areas and urban areas
(especially Java). With its large population and vast geographical spread, Indonesia is critical to the
global HIV/AIDS. The WHO classifies Indonesia as a high TB/ HIV priority country. The HIV
epidemiology is concentrated in specific provinces and specific risk groups, with an overall population
prevalence of around 0.3%.
In 2012, UNAIDS listed Indonesia as one of nine countries where HIV continued to rise, with new
infections increasing by more than 25% between 2001 and 2011.6 With the exception of Papua and
West Papua, provinces, which have a low-level generalized epidemic (estimated general population
HIV prevalence of 2.3% in 2013,)7 Indonesia continues to experience a concentrated HIV epidemic
composed of multiple intertwined epidemics in different key affected populations (KAPs). HIV KAPs
in the Indonesian context include female sex workers and their clients, Transgendered Women (Waria)
and their clients, persons who inject drugs (PWID), men who have sex with men (MSM) and prison
inmates.
There were an estimated 638,537 persons living with HIV in Indonesia in 2014.Error! Bookmark not defined. The
national HIV prevalence rate was estimated at 0.41% among people aged 15-49 years of age in 2014.
Estimated HIV prevalence by province ranges from 0.1% or less to over 3% (see Figure 4).8 Cumulative

http://www.indonesia.go.id/in/sekilas-indonesia/geografi-indonesia
Indonesia Statistics. http://www.bps.go.id/linkTabelStatis/view/id/1274
3 TB NSP 2015-2019
4 World Bank Country Data - Indonesia
5 World Bank projected
6 HIV in Asia and the Pacific, UNAIDS Report, 2013
7 IBBS Tanah Papua Report, 2013
8 Estimation and Projection of HIV AIDS in Indonesia 2011 2016, MoH Report 2012
2

AIDS cases reported by September 2014 ranged from 0.5 per 100,000 population in West Sulawesi to
359 per 100,000 persons in Papua.9
Estimated HIV Prevalence by Province, 2012

Although it was initially anticipated that Indonesia would follow Thailand in having a HIV epidemic driven
by heterosexual commercial sex, instead an injecting drug-led epidemic exploded in the early 2000s,
with HIV prevalence among PWID reaching over 50% in several large cities by 2005-2007. The HIV
epidemic in the country has since shifted to being sexual transmission-led. The Asian Epidemic Model
(AEM) estimates indicate that 97% of new HIV infections in 2014 occurred through unsafe sex vs. only
3% attributed to unsafe injecting drug use.10 Of the new infections due to unsafe sex, as many as 29%
occur in men who have sex with men (MSM) and Waria (Transgender or TG). 32% arise from female
sex workers (FSW) and their clients; and 34% from discordant couples, who are mostly partners of Key
Affected Populations (KAPs). KAPs include persons who became infected due to engaging in high risk
behaviors earlier in life but whose HIV infections were not detected until after they had discontinued
such behaviors for example, former female sex workers and men who had engaged sex workers
when younger.
New HIV infections among adults by mode of transmission11

Mode of Transmission

2012

2013

Commercial sex

21,524 21,030 20,606 20,576 20,559 20,562 20,588

Discordant couples

21,971 21,885 21,702 21,527 21,427 21,428 21,520

Casual sex

3,048

MSM

15,800 17,155 18,595 20,173 21,819 23,532 25,308

Needle sharing

2,777

2,913

2,459

2014

2,754

2,101

2015

2,831

2,109

2016

2,893

2,160

2017

2,947

2,208

2018

2,994

2,252

National AIDS Program Quarter IV 2014, MoH Report 2015

AEM estimates undertaken in conjunction with the 2014 Investment Case Analysis (ICA) and SRAN 2015-2019
11 Source: Investment Case Analysis Report, NAC 2014
10

Historical and projected future trends in HIV prevalence among KAPs are displayed in figure below.
Recent data suggest that the rate of epidemic growth may have slowed and perhaps stabilized among
some KAPs.
Estimated and Projected Trends in HIV Prevalence for KAPs

However, AEM modelling undertaken in 2014 indicates that the number of annual new HIV infections
will continue to grow unless further efforts are made to consolidate the gains made and expand program
coverage and intervention effectiveness, especially among men-who-have-sex-with men (MSM) and to
a lesser extent Transgendered Women Women (TG), among whom HIV transmission continues to
expand rapidly.12
Estimated & Projected Number of Annual New HIV Infections (2014)13

Persistently high STI prevalence continues to fuel several of the sub-epidemics, despite some
aggressive control efforts. For example, periodic presumptive treatment (PPT) of female sex workers
was implemented in major cities during 2009-2011. No clear trend emerges during the 2003-11 period
12
13

AEM estimates undertaken in conjunction with the 2014 Investment Case Analysis (ICA) and SRAN 2015-2019
Investment Case Analysis Report, NAC 2014

with regard to prevalence of Chlamydia or Gonorrhea in Category A Provinces (i.e. the 12 provinces
with the largest numbers of PLHIV and KAPs), although prevalence of both STIs appears to have
declined slightly by 2013 in all KAPs except MSM. Comparable data for Category B Provinces (i.e. the
next nine provinces in terms of PLHIV and KAP size) indicates declining rates for some KAPs (Indirect
FSWs and Waria), but rising rates for clients of sex workers and MSM. Data for Tanah Papua, where
STI control services have only recently been introduced on a significant scale, indicate declining rates
in some of the larger cities, but from very high prevalence levels. The trend in syphilis prevalence has
been flat to gradually declining among all groups, again with the exception of MSM (see Figure below).
These data suggest the possibility of improved results in STI control efforts from 2011 on, but further
data will be needed to confirm this.
Trends of Syphilis prevalence among KAPs

The HIV epidemic situation has evolved differently in Tanah Papua, consisting of the two eastern most
provinces of Papua and West Papua. Tanah Papua, which comprises 1.5% of the total population of
Indonesia, accounts for 13% of recorded AIDS cases. The first IBBS ever conducted in Tanah Papua
in 2006 revealed a general population prevalence of 2.4% -- 2.9% among men and 1.9% among
women. A second general population IBBS undertaken in 2013 indicated general population
prevalence of 2.3%. HIV in Tanah Papua is concentrated among the indigenous Papuan population,
with estimated 2013 HIV prevalence of 2.9% vs 0.4% among non-Papuans. A recent study points to a
number of factors that contribute to these differences, among them lower levels of education and HIV
awareness, lower proportions of circumcised males, more limited health infrastructure in the central
highlands where most indigenous Papuans live, lower rates of service utilization and lower condom use
rates during commercial sex.14 IBBS among KAPs have consistently shown FSWs in Tanah Papua to
have among the highest HIV and STI rates among FSWs nationally.

14

HIV-AIDS Impact Assessment on National Responses in Indonesia, NAC 2015

Key populations that may have disproportionately low access to prevention,

treatment, care and support services
As noted earlier, HIV KAPs in the Indonesian context include female sex workers and their clients, 15
transgendered women, (Waria) and their sexual partners, persons who inject drugs (PWID), men who
have sex with men (MSM) and prison inmates. Most of these KAPs have low access to HIV prevention,
treatment, care and support services due to several factors, the main one being social discrimination.
Some groups are considered as illegal such as drug users, sex workers (female, male and
transgender). Mere possession of a condom/needle/syringe can be construed as a sign of sex work
and/or illicit drug use. Attending services of Methadone Maintenance Therapy (MMT) puts key
populations at risk of arrest.
In addition, in many cities, recently, the sex service locations were abolished and sex workers were
driven underground so that they are difficult to localize. Accordingly, a revised approach to outreach
will be needed in the NFM. Some groups such as MSM and high-risk men (clients of sex workers)
remain hidden and are thus hard to reach with TB and/or HIV interventions and services. Condoms
are highly stigmatized in Indonesia, and open promotion is prone to be attacked by conservative groups.
Recent data and analyses have called attention to the fate of the youngest KAPs; that is, those under
25 years of age. Data presented in a UNICEF Concept Note on Programming for Young KAPs (YKAPs)
suggest that within these key populations there are young people aged 1524, who are experimenting
with sexuality or drugs. IBBS 2011 data show that they are getting infected with HIV in worrying levels
while still adolescents or young adults.16
HIV Prevalence Rates among KAPs by Age Group

Young people in the key affected populations (YKAP) have high rates of infection and are at the center
of the HIV epidemic in Indonesia, but have the least access to accurate information and services. These

15.Previous

documents have alternately referred to clients of sex workers, high-risk men (HRM) and particular subpopulations of men falling within these headings. In order to simplify, the CN only refers to clients of sex workers as a subpopulation of epidemic interest. As explained in Section 3, however, only selected segments of this population will be
targeted for intervention
16

UNICEF. Concept Note on Programming for Young KAPs (YKAPs)

sub-populations have been targeted for special attention in the HIV Strategic Plan, the SRAN 20152019
Prison inmates are a key population with lower access to both TB and HIV services. Among the
inmates, HIV and TB were the leading causes of death in year 2011. There is overcrowding - 464
prisons and detention centers with a capacity of 100,000, usually host more than 150,000 inmates.
Among them, 26 prisons/ detention centers host around 60,000 drug-related inmates with a higher HIV
prevalence (6.5% in 2012). There are high chances for HIV transmission in the prisons via drug use or
sexual transmission. The inmates with TB, either with or without HIV can easily spread the disease to
their peers due to poor ventilation.
The following observations emerged from a National Review on Policy and Legal Barriers to Universal
Access to HIV Services undertaken in September 2013:17
1. PLHIV, Indonesia does not have a specific national law protecting the rights of people living with
HIV; however it does have an overarching constitution where specific human rights guarantees are
implied such as the right to non-discrimination. However, due to their HIV-positive status, PLHIV
still face difficulty in accessing the national health insurance schemes (JKN/BPJS) even though in
terms of their economic status, they are eligible beneficiaries. Some of the HIV-related tests and
medication are not covered under JKN/BPJS. Similarly, even though the Ministry of Health Decree
already stated that all of the insurance must covered HIV on their plan. However, in practice, none
of the private insurers accepts PLHIV as beneficiaries yet.
2. People Who Inject Drugs (PWID), PWID still face difficulties in accessing clean needles. With only
the Health Ministerial Decree as the legal foundation for NSP, there is limited protection for PWIDs
accessing services. Possession of needles is often utilized as evidence of drug use which may lead
to criminal arrest and legal prosecution.
Despite having adopted a policy to divert drug users, including for PWID, from prison sentences to
rehabilitation, many who are arrested on drug charges are still being sent to prison. To date
Indonesia still has no policy that deals with therapy under diversion policy. It is therefore not clear
what steps should therefore be taken if a diversion to rehabilitation is deemed necessary given the
absence of a comprehensive set of directives on therapy. The decision to grant therapy
/rehabilitation ultimately rests with judges, and earlier rulings in favor of rehabilitation do not appear
to have set a precedent for subsequent sentencing.
Due to their drug using status, PWID still face difficulty in accessing national health insurance
scheme (JKN/BPJS) even though in terms of their economic status, they are eligible beneficiaries.
In the health insurance regulation, drug using is considered as a self-inflected condition that does
not merit access to health insurance.
3. Female Sex Workers, Female Sex Workers in Indonesia work in an uncertain environment in which
local regulations on the HIV/AIDS response can be in contradiction with other local regulations that,
for example, allow possession of condoms as admissible evidence of criminal act. The majority of
FSW have never felt safe or protected in their profession, leading to negligible bargaining power
and heightened vulnerability towards STIs and HIV. FSW have no right to resist or defy the wishes
of the procurer, with no objection whatsoever, including with regard to condom use. FSW are often
left out from social protection schemes including national health insurance (JKN/BPJS).
17

National Consultation on Legal and Policy Barriers to HIV In Indonesia, National AIDS Commission 2013.

4. MSM and Transgender, The terminology LGBT is still not formally recognized by the state and this
robs this community of the right to freedom of association and assembly. In society, the transgender
and gay community are often faced with social, moral and religious persecution. Under the Social
Affairs Ministry, the transgender and gay community are given status of people with social problems
(PMKS) which makes them vulnerable to violence and to being charged with minor offences. On
Dec. 31, 2014, Majelis Ulama Indonesia issued a fatwa (No. 57/2014 on lesbians, gays, sodomy
and immoral behavior) that stigmatizes same-sex behavior. They recommend punishment up to the
death penalty and have urged the government not to allow lesbians, gays and bisexuals to organize.
Transgender people often face obstacles in arranging for their identity which denies them access
to various services (health, government aid, legal process, etc.). Transgender people are also
marginalized by society from an early age which denies them of the opportunity to develop their
work skills. As a consequence, any opportunity that they may have in entering formal employment
is obstructed by social norms that refuse to acknowledge their presence, in addition to
administrative issues that fail to recognize their identity, and their lack of proper work skills.
5. Other HIV/ AIDS patients, Some HIV/AIDS and TB/MDR-TB patients also experience
discrimination from health care providers. While Indonesia has made progress in reducing stigma
and discrimination for KAPs and PLHIV in the health system and in society at large, these issues
are by no means resolved. The country has policies that prohibit gender discrimination, but the
extent to which policies are able to overcome individual provider bias is uncertain. Some health
service providers consider PLHIV with co-characteristics of drug use and/or links to sex work as
less deserving of their sympathy and professional/ private support. Although assessments of the
magnitude of discrimination being faced by PLHIV and KAPs vary substantially across the limited
number of studies that have been undertaken to date, the most recent study on community access
to HIV treatment services undertaken in seven provinces indicated that 59% of male PLHIV
respondents and 53% of female PLHIV respondents reported experiencing some form of
discrimination in health care facilities18. This was in spite of explicit guidance prohibiting differential
treatment of PLHIV in health facilities. Fear of disclosure, mistrust in health care staff and concerns
regarding patient confidentiality are often a source of apprehensions for HIV/ AIDS and TB patients.
These factors continue to reduce demand for HIV testing and promote late initiation into ART
(despite near universal access to first and second line treatments). Personal shame associated
with HIV, prevents patients themselves, even those at highest risk, the most vulnerable and most
affected, from accessing health and other social services.

The Socioeconomic Impact of HIV at the Individual and Household Levels in Indonesia A Study in Seven Provinces
Report, NAC 2010
18

The health systems and community systems context in the country, including
any constraints relevant to effective implementation of the national HIV
programs
The organization of health services is the responsibility of Ministry of Health officials at district, province
and national level. The network of public health services follows the political structure of the country.
Administrative and financial responsibility has been decentralized to province and district level
according to the reforms of 200119, 20.
There are 10,455 health facilities in the country. These include 8,792 clinics of which 8,764 are district
public health centers (termed Pusat Kesehatan Masyarakat or puskesmas). There are 1,653 hospitals,
of which 533 are public hospitals, 867 private hospitals, 181 military/ police facilities, 63 other general
hospitals and 9 are chest hospitals.21 More peripheral than the district level are satellite and mobile
health centers with 94% of the population living within 5 kilometers of a facility. There are approximately
90,000 licensed practitioners of medicine and an unknown number of licensed traditional practitioners.22
Licensing is coordinated by the Indonesian Medical Association and the national association of
traditional healers and is granted by government at local level.
Services for HIV patients are included under various Ministries and Directorates. Training and capacity
building for HCWs are the responsibility of the Human Resources Board. Accreditation, licensing,
laboratory services and infection control rest with the Directorate of Medical Services. Responsibility
for the health information system resides with the Secretariat General. The Ministry of Internal Affairs
coordinates management of local services. Coordination of financing of activities is through the
Planning Bureau at each of these levels to which programs submit budgets up to a fixed ceiling.
The availability of HIV-related services has increased significantly over the past five or so years. The
number of public sector health facilities offering sexually transmitted infection (STI) diagnostic and
treatment services increased nearly eightfold from 92 in 2010 to 801 in 2014; HIV counselling and
testing (HCT) services from 385 to 1,391, methadone maintenance therapy (MMT) from 65 to 87,
Needle Syringe Exchange services from 180 in 2010 to 194 in 2013, ART services from 195 to 455,
and PMTCT services from 29 to 116 during the same timeframe. However the majority of these
services are still provided as vertical interventions (vs. part of an integrated package of services), and
providing a mandatory minimum standard of service everywhere has proven challenging.
The MoH has issued regulation No. 21/2013 which updated roles and responsibilities of all key
stakeholders as well as activities for the HIV AIDS continuum of care program in Indonesia (LKB).
The regulation clearly emphasizes GoI responsibility to provide key medicines and medical supplies,
while district government has the authority to assess the status of the epidemic as well as having the
responsibility to fund and implement prevention, care, support and treatment programs.
The MoH also issued Regulation No. 5/ 2014 allowing PHCs to provide HCT and ART for simple cases
of HIV. Utilizing primary healthcare supported by adequate fiscal, infrastructural and human resources

19

Law No. 22/1999 on local government

Law No. 25/1999 on balance of financial authority between central and local governments.
21 Directorate of Medical Services MoH data, 2014
22 Agency for Development and Empowerment of Human Resources for Health MoH data, 2013
20

may increase the access of PLHIV and other key population at risk to healthcare.23 Indeed the scaleup of HIV testing and treatment is primarily related to improving access to as well as integrating HIV
services and adherence programs with primary healthcare.24 From the patients point of view, a survey
among 57 HIV patients has revealed that most of them (74%) feel the need for ART at the
primary/community healthcare centers (puskesmas). The research also indicates that communitybased ART may ensure better adherence, although several conditions such as the guarantee of
confidentiality need to be fulfilled to encourage the patients to take ART in puskesmas.25 The more
recent study in 7 provinces indicates a lower likelihood of PLHIV who are MSM, Sex Workers or having
personal income to visit government hospitals after an HIV diagnosis.26
Financing: Provincial and district contributions to HIV control budgets remain minimal in most areas.
Local government (provincial and district) budgets for HIV control have been difficult to calculate as
financing of local services is spread across 500+ local governments and budgets are not systematically
reported to the central level. Although increasing local funding for HIV was a priority of the HIV SRAN
2010-2014, the rate of increase in provincial and district funding fell far below that targeted.
The charges for services such as registration, laboratory examination (baseline chemistry, CD4 count,
etc.), likely act as a disincentive to further treatment even though the drugs for treatment are provided
free of charge from the government. At present, there is no mechanism to protect HIV patients or their
families from catastrophic costs. Information on the availability of free treatment for HIV is not freely
available. (It may not be easily available for all conditions.)
Regulation: Notification to the proper public authorities of HIV cases from private providers and other
service providers outside MoH authority is not mandatory. In public hospitals, it may be mandatory, but
is not always implemented, which indicates that making case reporting mandatory may only solve a
part of the problem.
Human resource management: Staff shortages are currently reported in several areas, such as
laboratories and remote health facilities. It is difficult to obtain data on staffing, vacancies and staff
turnover on a regular basis to assist in planning. A zero-growth policy for public sector health staff is
currently in effect. There is a lack of HIV management skills among staff. Staff with managerial and
technical skills for HIV care and prevention are often not in place or in a position to take on the required
additional tasks due to already heavy workload.
Partnership: Community mobilization for HIV is strong and Civil Society Organizations (CSOs), Faith
Based Organizations (FBOs) and other community groups include HIV patient groups. They are
actively involved in HIV activities and advocacy, with many of them focusing on particular risk
groups.The HIV CSOs can be more involved to support the HIV control, including areas of prevention,
case finding and case holding.

23

Ibrahim, K., Songwathana, P., Boonyasopun, U., Francis, K. The HIV/AIDS Epidemic in Indonesia: Does Primary Health
Care as a Prevention and Intervention Strategy Work? International Journal of Nursing Practice, 2013; 16: 87-91
24 Mukherjee, J.S., Ivers, L., Leandre, F., Farmer, P., Behforouz, H. Antiretroviral Therapy in Resource-Poor Settings:
Decreasing Barriers to Access and Promoting Adherence. Journal of Acquired Immune Deficiency Syndromes 2006:
43:1:123-6
25 Handayani, M., Prawiranegara, P., Siregar, A.Y.M., Wisaksana, R., Pinxten, L., van der Ven, A. Need, Opinion, and
Expectation of PLHIV toward Establishment of ART at Community Health Center (Puskesmas) in Bandung, Indonesia.
Presented in the 42nd Asian Pacific Academic Consortium for Public Health Conference (APACPH), 2010.
26 Community Access to Treatment Study in Seven Cities in Indonesia Report, GWL INA APN 2013

There are efficiency gains to be made by having CSOs and communities actively involved on HIV.
Community based initiatives, including from private sectors, need to be explored and engaged more in
HIV control, and existing initiatives such as Posyandu27 need to be revitalized. Posyandu is a
community-based healthcare center where basic maternal and child health problems, including family
planning, antenatal care, immunization, simple diarrhea intervention and nutritional problems, are
identified and tackled at the community level. The main Posyandu activity is the conduct of monthly
child growth monitoring events supported by volunteers from the surrounding hamlet and supervised
by village midwives.
Information system: the Sistem Informasi HIV/AIDS (SIHA) has not linked with information systems
outside the HIV, such as the Sistem Informasi Kesehatan Daerah (SIKDA), the generic health
information system at MoH.
Urban migration: Migrants increasingly come to the cities, living in urban slums and have difficulties
in accessing public sector health care in cities because they do not have city-based insurance. They
are therefore driven towards the private sector and out of pocket payment (OOP). If they have
insurance from their place of origin, they may return home for treatment, or just because they are sick.
Poor urban migrants may receive some small-scale support from CSOs but nothing systematic.
Conditions in prisons, While HIV are more common in prisons than in the general population, the
provision of HIV services is still limited due to resource constraints. Moreover, the prisons are
overcrowded and contain many more prisoners (about 163,000) than they were designed for. There
are 26 narcotic prisons and detention centers where around 60,000 inmates are incarcerated. Violent
social hierarchies can exist in prisons, and condoms are not freely available, predisposing to HIV
transmission.

27

Integrated community health post at village level for preventive services

The key goals, objectives and priority program areas

The National AIDS Strategic and Action Plan (NASAP) 2015-2019 was developed within the framework
of the National Mid-Term Development Plan, in coordination with Health Sector Strategy development,
following the conceptual framework from BAPPENAS for sectoral strategies and action plans. NASAP
2015-2019 builds on the previous NASAPs, which established many of the required coordination and
management structures and built relevant capacities at the national, provincial and district levels.
NASAP planning was closely coordinated with the simultaneous health sector strategy planning.
NASAP 2015-2019 development took place beginning in late 2013 under the leadership of the
Executive Secretary of National AIDS Commission, with overall supervision by the NAC Board, and
with technical support by UNAIDS. The extensive consultations in 2012-2013 within the Mid-Term
Review (MTR) process identified the achievements and the challenges to the HIV and AIDS response.
The Asia Epidemic Model (AEM) modelling results presented in the Investment Case Analysis (ICA)
were an integral part of the NASAP development process, suggesting options for accelerating the HIV
response. The ICA analyses and recommendations were based upon all data available as of February
2014.
The goal of the HIV control program is achieving The Three Zeros (zero new infections - zero
stigma and discrimination - zero AIDS-related deaths) by:

Preventing and reducing the transmission of HIV,

Rapidly expanding access to treatment for HIV and increasing retention among those on treatment;
Improving the quality of life for people living with HIV; and
Reducing the socio-economic impact of the AIDS epidemic on individuals, families, and society
(HIV SRAN (NSP) 2015-2019). Detailed objectives may be found in the SRAN document28.

The following are the Key Strategic Elements proposed in the 2015-2019 SRAN:

28

Target priority geographic areas containing large numbers of KAPs and PLHIV (141 cities/districts),
with further prioritization of the 75 cities/districts in which the Strategic Use of ARVs (SUFA) will be
rolled out, over the next three (3) years (2015-2017)
Focus on combination prevention, with an emphasis on SUFA
Strengthen the comprehensive continuum of care (LKB - Layanan Komprehensif
Berkesinambungan and PMTS - Pencegahan Melalui Transmisi Seksual) models, with emphasis
on strengthened linkages between health facility- and community-based activities
Decentralize and improve integration of HIV with other health services, notably the NTP and TB
services
Expand disease impact mitigation initiatives
Create and sustain a supportive environment for PLHIV and KAPs
Undertake process evaluations and monitor quality standards to strengthen the quality of
interventions
Provide greater support to community system strengthening initiatives
Improve knowledge management and skills at all levels, including at the city/district level
Encourage the allocation of funds for tackling AIDS by the city/district level
HIV SRAN 2015-2019, page 108

Strengthen research as well as data quality, accelerate use of innovations and new technologies
Strengthen international partnerships, both bilateral and multilateral

One of the highest priorities of the SRAN 2015-2019 is the strengthening of the existing continuum of
care model Layanan Komprehensif Berkesinambungan (LKB) for HIV/STI-related health promotion,
prevention and treatment in primary health care facilities and hospitals. In the continuum of care, the
role of CSOs will be reinforced including for advocacy, prevention,, outreach and treatment
adherence29. Under the approach of continuum of care, integrated TB-HIV services and program
components and the community mobilization approach being implemented under the complimentary
Pencegahan Melalui Transmisi Seksual (PMTS) at primary health care level. This approach is expected
to be an effective strategy to deliver comprehensive care for key populations, particularly PLHIV,
pregnant women and patients with HIV-TB co-infection linkages between health services under MoH
and other ministries will be strengthened, most notably with the Ministry of Law and Human Rights
(MoLHR) with respect to the delivery of HIV and TB coordinated services in prisons. The role of the
National AIDS Commission in facilitating this coordination is critical and should be strengthened.
Implementation to date of HIV program
Program efforts have been focusing on 141 priority districts covering approximately 60% of the total
KAP populations nationally since 2012
Priority attention has been focused in strengthening the implementation of LKB and PMTS
continuum of care model that decentralizes treatment to the district level and integrates health
facility- and community-based activities within targeted districts
Indonesia initiated a test and treat strategy among KAPs, pregnant women, TB patients, and serodiscordant couples in 2014. The cut-off for treatment initiation for others is CD4 350
The Strategic Use of ARTs (SUFA) initiative was begun in 2014, with an initial target of reaching
high coverage of persons eligible for ARTs in 75 high priority districts (that is, those with the largest
numbers of KAPS and PLHIV). SUFA is currently being implemented in 50 districts
HIV prevalence is declining or stable among FSW and PWID in some area, but increasing among
MSM and TG
STI prevalence among KAPs has been declining slowly in the past 2-3 years, but remain very high
and fuel the HIV epidemic
Program efforts to promote consistent condom use and STI screening among KAPs continue to
progress slowly, but results to date fail to reach national targets
ART increased from 15,442 in 2009 to 50,400 in 2014, but is still the lowest in the region with only
19% by end of 2013 (24% at the end of 2014)
From January 2013 to December 2014, the median CD4 count at treatment initiation rose from 90
to 166
PMTCT program coverage remains very low both in terms of testing (5.6%) and treatment (9% in
2014)
HIV testing coverage among KAP has increased from 33,577 in 2010 to 1,095,148 in 2014, but
remains very low

29

HIV SRAN 2015-2019, page 110

Limitations and lessons learnt from HIV activities:

Recent reviews and analyses suggest that the strategies being employed to contain HIV in Indonesia
are by and large appropriate given the stage of the HIV epidemic, but are not seeing their full impact
for a variety of reasons, mainly having to do with program implementation and management:
Insufficient utilization of services: while the supply of prophylactics and the services needed to
control HIV are generally (but not always) in place, demand has not been generated sufficiently among
target sub-populations to utilize them Recent experience with MSM clinics in Bali and Jakarta
demonstrate that a combination of high-quality health facility-based service with flexible hours,
recruitment using KAP networks and strong community support can dramatically increase rates of
service uptake. Evaluation data indicate a direct relationship between the presence of community
health workers/CBOs and HIV testing rates among MSM. There are also examples of successful
implementation with FSWs and PWID, but not on a sufficiently large scale.30 More effective outreach
and stronger linkages between KAP communities and the health sector are key requirements for
increased success. Although improving outreach was a priority for SSF Phase 2, the results to date
have been disappointing. New thinking and approaches are needed for work under the NFM. Stigma
and discrimination constitute important barriers to service utilization, and although efforts have been
made to address these in a number of ways, a general societal drift toward reduced tolerance for
religious minorities and alternative lifestyles may have hindered progress. Pressure from conservative
religious groups has limited the policy space of recent governments. Questionable program strategies
have also resulted in additional barriers to service use for example in the past the decision to restrict
distribution of clean needles and syringes only from public health facilities has decreased the number
of PWID accessing needle and syringes. Efforts have been made to address this problem by mobilizing
NGO outreach worker to distribute and promote needles from Puskesmas, and increasing coordination
between NGO and Puskesmas for the distribution of needle and syringes.
Slow decentralization of HIV treatment services from large hospitals to Primary Health Care
LKB was designed to address this very issue, with ART services being decentralized from hospitals to
at least five (5) Primary Health Centers (Puskesmas) per district. Several positive lesson-learns have
been generated from the LKB/SUFA roll-out experience. In cities/districts when primary health centers
have closer partnerships and routine coordination meetings with community-based services, the uptake
of HIV related services by community clients has increased. In cities/districts where community-based
services are offered as part of the primary health-center service, the uptake of client referrals to
community-based support and services such as PLHIV support group is higher. Participation of new
PLHIV in support groups is a key to receiving psychosocial support needed to continue maintaining
their treatment.
Lack of international standards of intervention quality -- Based upon fairly consistent data
indicating that impact in terms of behavior change and reduced infection rates do not necessarily follow
from increased program coverage, SRAN 2015-2019 assigns high priority to concrete steps to
improving service quality. Further attention will be directed to deviations from international good
practices in terms of quality and standard, of intervention. Examples include (1) increasing dose and
frequency of peer outreach contact and education, (2) eliminating unnecessary steps in service
delivery, (3) increasing use of information technology (e.g., internet, SMS and social media) to reach
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hard to reach population sub-groups, (4) expanding use of task shifting to extend the public health
workforce, and (5) strengthened health facility and community support mechanisms for patients on
ART.
Insufficient integration of health facility-based services and coordination of facility- and
community-based services - Continuum of care (i.e. LKB) guidelines were adopted in 2014 and used
for TB/HIV activities explicitly to address this issue This complements the PMTS, which focuses on
mobilizing and coordinating community-based activities and connecting these with health facilities with
the goals of reducing transmission of HIV and other STIs among KAPs. Partnership meetings occur
monthly in districts and quarterly at provincial level, and since January 2015 the minutes are available
on the web. Community Outreach Workers / Counsellors including from community / Case Managers
for HIV care have been supported to work in health facilities as part of the team delivering services
(routine scheduled) where services are providers.
Limited attention and resource allocation for programming to key population sub-groups
among whom epidemic growth is currently the most robust, MSM in particular Increased focus
on MSM is a high priority per the NASAP 2015-2019. Funding to achieve ambitious targets for MSM
will be included in the within allocation request in the CN. Prioritization in the SRAN is broadly
consistent with the results of an Optima analysis, the results of which have just been made available.
Limited in-depth review and mid-course correction both in overall response and in specific
programmatic areas, including interventions among different sub-populations Earlier efforts to
address these issues have not produced adequate results. During SSF Phase 2, efforts were made in
monitoring and evaluating implementation through six monthly and annual evaluation meetings
involving all PRs and SRs. This has led to recommendations and adjustments within the limitations of
the GF rules and regulations. More can be done; for example, the conduct of process evaluations for
key interventions and strengthening of QA/QI systems by PRs and SRs as called for in SRAN 20152019. More frequent impact data would also be useful in assessing end results more frequently. This
will be addressed via a restructuring of the HIV surveillance system.
Weak data management The impact of weak of limited data for program management is recognized,
and a number of steps have already been taken. For example, data analysis and data use training for
district managers have been conducted; coordination of the HIV sentinel surveillance survey and the
rapid behavior survey was implemented (albeit only once); an online system reporting from district AIDS
commission level to the provincial and national levels was established; and since 2014 all PRs have
agreed to have an integrated dashboard of all PRs. In April 2015, an HIV portal for data transparency
will be launched; expansion of SIHA to more health facilities for the monitoring of SUFA and
strengthening collaboration with other programs such as TB at district and provincial levels.