Posted by: Indonesian Children | June 14, 2009

Children and HIV/AIDS in Indonesia

A Situation Analysis

by  Laine Berman

AIDS in Indonesia is fed by a wide range of human rights abuses from sexual violence, the marginalization of sex workers and intravenous drug users, lack of education services, lack of access to testing and counselling, and specifically the violation of children’s right to protection, education, and information on HIV transmission and prevention. Among prison populations, HIV has risen drastically because of lack of access to condoms, and harm reduction measures for drug users. Prisoners eventually go home and infect their wives and girlfriends. Human rights violations are multiplied again via the stigma toward high risk persons, which further marginalizes them and exiles those who most need information, prevention services, and treatment. Then, there are the partners of ‘high-risk’ groups, who become infected with HIV/AIDS and are then branded as belonging to one of these stigmatized groups.

Research on AIDS in Indonesia (as elsewhere) is an investigation into multiple levels of rights violations, including silence, violence, rejection, fear, abandonment, social inequality, lack of privacy, poverty, ignorance, religious dogma, corruption, and the domination of international agendas. But it is also a vehicle for progress and change, focusing on building and strengthening protective measures and advocacy, legal and cultural protections for children, families, communities, and persons affected by or at risk of HIV/AIDS. The regulations, the funds, the networks, and the support are already in place. Real consolidated action must follow.  

While broadly recognized in Indonesia as a threat to specific high risk groups, HIV/AIDS is also a threat to child development. With such a heavy focus on commercial sex workers (CSWs) and intravenous drug users (IDUs), it is far too easy to overlook children and their rights, roles and our obligations to them in the HIV/AIDS picture. Compounded by poverty as a major cause and consequence of the AIDS epidemic, children loose their rights to:

  • survival, development and protection from abuse, neglect, sexual, and economic exploitation;
  • participate in decision making in matters concerning them;
  • have their best interests as the primary consideration;
  • be free from discrimination.

Responses to the epidemic thus must make sure that children are not omitted from participation in the planning and implementation of HIV/AIDS programmes and as part of their greater involvement in civil society. Youth representation in the development of national HIV/AIDS plans and poverty reduction initiatives is not an option but a necessity.

 

Role of Education

Case studies from Africa, India and Thailand show how children with HIV/AIDS or those who have lost one or both parents to HIV/AIDS, often experience discrimination and exclusion from the community. In Indonesia, where testing is still rare, prolonged illness and the inability to work for whatever reason translates into children leaving school and taking over the responsibilities of adult wage-earners. As street or working children, they are stigmatized as ‘children who produce social problems’. Just as poverty has done, once widespread testing and seroprevalence become known, the HIV/AIDS epidemic will have a critical direct and indirect impact on the education of children due to discrimination and exclusion, as well as loss of funds for schooling and the need for them to financially and emotionally make up for the breakdown of the family unit. Yet with no widespread testing, how will agencies know which of the thousands of street and working children are on the streets because of AIDS? With estimates as high as 18,000 AIDS orphans already in Indonesia, the government must act to ensure that no children are excluded from access to primary schools, health care, and basic protections.

The capacity of the education system to protect children is fundamental. But, the GoI has yet to make best use of available resources to achieve compulsory and free primary education. The regional autonomy (1999) movement has further undermined the full realization of this basic right, throwing this fundamental responsibility away from the central government and onto the shoulders of 30 regional, autonomous governments, each with its own problems. A truly compulsory and free primary education is not only an important right. It serves as a key towards the fulfilment of other children’s rights such as the right to free expression and the right to be protected from economic exploitation[1].

Reproductive health education is not offered in Indonesian schools because society and the authorities still believe that discussing sex only encourages promiscuity. Such concerns have been proven wrong. Yet the persistence of such avoidance results in confusion, fear, and anxiety among teenagers living in a more globalized, permissive society, with pressures from the media, peer groups and other people close to them[3]. For many children HIV/AIDS education starts too late, once they have become sexually active. It is essential to begin informing girls and boys about HIV at a younger age, so that when they do become sexually active, they are equipped with the knowledge and skills that will reduce their risks of early pregnancies, contracting STIs, and HIV. The UN Declaration of Commitment on HIV/AIDS aims to reduce the prevalence of HIV infection by 2005 in men and women aged 15–24. This translates into practice as providing today’s ten-year-olds effective life skills education.

As behaviour studies reveal, reproductive health and HIV/AIDS prevention are not reaching the majority of the Indonesian population[4], and young people in particular find it very difficult to gain access to HIV prevention messages and sexual health services[5] even more so as they become increasingly ‘out of reach’ after leaving school. Outreach through peer educators and clinic-based structures is essential in order to provide sexual and reproductive health information and services to young people if any response to HIV/AIDS is to be sustained. Orphans and vulnerable children are not just those already personally impacted by HIV/AIDS – all Indonesian children are at risk as long as open discussion of sexual health and honest reflection and acceptance of the issues of economic, political, and social poverty remain clouded in silence. Key programming principles must provide a framework for the development of a broader holistic response to the problems. The main aspects of these principles are;

_ to expand coverage to include all children and communities;

_ to give particular attention to the gender-specific needs of boys and girls;

_ to involve children and adolescents as part of the solution;

_ to strengthen the role of schools and education systems – both formal and informal;

_ to strengthen the role of health care and monitoring systems – both formal and informal;

_ to reduce stigma and discrimination;

_ to ensure that external support does not undermine community initiative and motivation.

These programme principles are based on the respect of basic human rights and are fundamental to effective care and support and the development of a broadly united cultural coping capacity. 

HIV/AIDS needs to be mainstreamed into the general national debate for both the education and health sectors, as this is the key to a sustained commitment that is perfectly in line with Indonesia’s national development plan. Attention cannot focus on HIV/AIDS in isolation without also rebuilding the community public health care systems and strengthening educational access and quality. Then, there is the intolerable increase in poverty and the compounding effects this has on HIV/AIDS and specifically children. Further problematic to both the development program and HIV/AIDS prevention initiatives is the general neglect for people living in rural areas, as evidenced by the almost total absence of state services available to them. The promise of financial gain lures young women into cities in search of jobs in factories, as overseas labourers, and in domestic service, where family support and protection is gone. No government agencies protect these vulnerable women, many of whom are well under 18 years old and have dubious agencies ‘assist’ them by creating false identity papers. Where ever children are not in schools, they are often on the streets, in the fields, in domestic labour in private homes, in market stalls, earning money for their families or just to survive. With no monitoring facility and no legal defences, these children are not enjoying their rights to education, health, and safety from exploitation. Where ever weaknesses in state services exist, HIV enters to make things worse.

Yet while it is easy to criticize Indonesia’s malaise in responding, and recognize the bitter naiveté of the popular perception of the disease as ‘someone else’s problem, worldwide initiatives are also largely ineffectual, not living up to their commitments, and falling short of the principles of civil society participation. HIV/AIDS requires an integrated community-owned response, a comprehensive package of strategies in response to a combination of problems, by recognizing the interconnectivity of all sectors and populations to act collectively and with a common purpose. Integrated community care involving HIV/AIDS knowledge and prevention, care and treatment, the rebuilding of community health services, the strengthening of a truly compulsory and quality education system, and the promotion of economic self-reliance are needed. All must recognize their own vulnerability if a truly successful program is to revert this major disaster.

 

Focus on Indonesia

Ten years after founding a National AIDS Control Commission (KPA) to prevent and control the spread of HIV/AIDS in 1994, real political will on the part of the Indonesian government has begun to emerge. The trigger came as recently as 2001, when results of limited surveillance testing revealed concentrations as high as 53% among specific high risk groups. Worst case scenarios on Indonesia were now becoming reality, and in the wake of the UN Special Session on AIDS in 2001, a cabinet level session on HIV/AIDS was convened to revise the role of the National AIDS Commission.

Yet advancement in facing Indonesia’s pressing realities are severely hampered by four factors:

1) lack of information: cultural and religious obstacles prevent open discussion of sexual, and high risk behaviours.

2) economic hardship: issues of personal health and the health of one’s children are subordinate to issues of economic need.

3) HIV: the disease itself is largely invisible and what is not directly impacting a family or a community is not seen as a pressing problem.

4) information systems: information provided is veiled in euphemisms, medical terms, foreign loan words, threatening terminology, and focused on the negative activities of specific groups.

News media and human rights reports show high occurrences of harassment, violence, and terror by organized gangs, police, communities, and families toward high risk groups and people with HIV/AIDS (PWA)[7]. By 2004, religious groups have yet to be fully convinced that AIDS, condoms, and plain talk about sexual health are not just “Western” issues but that they can be appropriate in an “Asian” society[8]. The majority of information released to the public is still based more on scare tactics that create and maintain irrational fears against HIV/AIDS. The emphasis on intravenous drug users (IDUs), sex workers (CSWs), and transgendered men (waria) as the main risk population, has fomented a huge gap between who is at risk and who is safe in the minds of the general public. Thus, stigma and discrimination are increased as myths of ‘no cure’ and personal fault prevail.  While Indonesia has failed to meet most of the prevention and care goals established at the 2001 special session on AIDS (UNGASS), this failure is most prominent in contexts where children are concerned[9].

Numbers of children in sectors vulnerable to HIV/AIDS[10]

Sector

Child sex workers (under 18 years of age and assuming 30% of the total number of sex workers)

Child domestic workers (under 15 and based on 25% of the total number of domestic workers) 

Children living or working in the streets

Total Number of Children           

Number of Children

   129,000

 

    350,000

 1,700,000

 2,179,000

 

The Indonesian Study

The study sought primarily to identify situations relevant to HIV, and the factors favouring or impeding its spread. This meant an analysis of the current level of HIV/AIDS concerns, awareness, and activities in the nation and specifically in several regions. Research focused on the following questions:  What are the most serious obstacles to reducing the spread and impacts of HIV/AIDS? Who is at risk? Where are they? Why are they are at risk? What factors protect against HIV infection? How has HIV/AIDS affected males and females differently? Attention was given to children, young people and their experiences which were a key source of data collected. In general, the study emphasizes that the most serious obstacle is ignorance and that all are at risk because of it.

Firstly, does Indonesia have an HIV/AIDS epidemic?

  • It is apparent that in Indonesia reported cases are only a fraction of actual cases.  (The UN has estimated that in China, in a similar situation, only 5 percent of all HIV/AIDS cases are reported[11]).
  • There has been a steady increase in reported cases each year – due to increased testing.
  • The conditions in Indonesia are favourable to a rapid spread of the disease in a similar way as to what has occurred in Thailand (ibid.).

Numbers and statistics presented here need to be recognized as limited and limiting. Many studies cited here have already shown how Indonesia has a very high rate of STIs and that the majority of people with symptoms do not seek treatment. Unable to face STIs, it is not surprising most Indonesians remain in denial as to the existence of HIV/AIDS in their own lives. Meanwhile, HIV/AIDS has forced Indonesians to face up to other social and cultural problems that have long been denied, such as injecting drug use. The IDU issue has helped disclose the fact of ineffective national and regional governments and corruption, while it also shows how Indonesians turn to vigilante groups and attack drug users as accepted policy[12]. As Berman (2003) writes:

None of the dilemmas inherent in drug prevention – abstinence versus responsible use, drug education versus skills training, treatment versus incarceration, education versus legalization, tradition versus globalization, and especially the various methods of harm reduction – have been given serious thought in Indonesia. Instead, the lack of political will and the general state of social breakdown lead to such a proliferation of excesses: emotional responses and violence on the one hand and helplessness, silence, and prayer on the other. Public dialogues emphasize the problems, never the solutions. Powerlessness prevails and no sane response to the issue is under consideration.

Through comparison to these drug issues, we can grasp a clearer picture of what the problems and fears are in relation to HIV/AIDS. To start, there are the problems of acceptance of the issue in general and acknowledging the extent of risk behaviour in society.  Then there is the hierarchical control over access to information and care: only those few who are supported rather than abandoned by caring families and can afford treatment are tested and helped. The vast majority on the other hand, are pushed to the margins and into situations where transmission of HIV is more likely. Like the drug issue, where police arrest users only to collect the money they pay to be released with no charges (between 3 – 15 million rp.), CSWs frequently report that they are picked up, forced to ‘serve’ the officers, then released after paying bribe money. The government policy of raiding prostitution centres (lokalisasi – which are run by different branches of the government in competition with one another, i.e., different branches of the military), only forces women into the streets and further distances them from the protection, care, training, and treatment so badly needed. Anti-discrimination and harm-reduction campaigns, needle exchanges, condom promotion and sex education, information and user-friendly services, enlightened government, medical and protection services are not just essential but life-saving measures that have no history in Indonesia.

To make matters worse, previous studies emphasize population mobility as the key to understanding the HIV/AIDS epidemic and its containment[13]. It is apparent that much of the high risk behaviour as well as the early introduction of the disease is among migrant populations, tourists and workers, both within and outside of Indonesia.  Not just the migrant workers are exposed to higher risk but also it is in the workplace that the worker is often introduced to new norms of sexual behaviour by fellow workers. Sex industries are concentrated in areas with a migrant workforce, such as near harbours, factories, mines, plantations, bus and train stations, and various transport depots.

As economic growth improves roads and access to international and domestic transport, economic integration of regions is changing the map as we know it. Millions of people are seeking access to opportunity through migration – some with families in tow, others leaving them behind. This demographic shift exposes communities and households to forces that overwhelm traditional resilience systems and create new vulnerabilities that increase exposure to HIV/AIDS. Loss of land or crops often translates into out-migration or sex work. HIV/AIDS strategies need to work in combination with development strategies, that increase resiliencies, increase access to education, health care, and jobs. It also shows how prevention programmes need to target these shifts in population at both work and home regions.

What stands out most is that the knowledge bases we have access to, in the areas of behaviour, mobility, and in the prevalence of HIV/AIDS, are all limited and the information which we have relating to the incidence of infection is restricted.  Was it the sex or the shared  tattoo needle, the transfusion or the shared toothbrush?  With close to half of all cases in Indonesia as unknown sources[14], the best way to go from here is in a general, all-encompassing programme that will not only cover a comprehensive sex education for all, but also promote life skills and 100% condom use.  The epidemic needs to be contained immediately, but this will not happen as long as it is not understood in realistic terms.
 


[1] Comments on the First Periodic Report of the Government of Indonesia to the Committee on the Rights of the Child (Covering the period from 1993 to June 2000).

[2] Assessment of the Epidemiological Situation & Demographics (Dec 2003) FHI: Jakarta.

[3] Safe sex facts vital protector for teens. The Jakarta Post. 7 April 2002

[4] The HIV/AIDS Survey Indicators Database: Indonesia. http://www.measuredhs.com/hivdata

[5] It remains illegal in Indonesia for unmarried women to access family planning or STI services. PKBI youth centres are the only sources of youth-friendly counselling and assistance, but these exist only in some cities.

[6] HIV/AIDS is unusual business: the need for an integrated community-level response. Statement by Dr. Massimo Barra, President of the Red Cross European Regional Network on AIDS (ERNA), to the ECOSOC Substantive Session 2003, Humanitarian Segment, Geneva. 14 July 2003

[7] Documentation of Human Rights Violations against People Living with HIV/AIDS in Indonesia. (2001) Jakarta: Spiritia Foundation; Diskriminasi terhadap Pengidap HIV (2003) Pontianak Post,  Dec. 2

[8] Personal communication from Arist Merdeka Sirait, (2004), Secretary General of the National Commission for the Protection of Children, Jakarta.

[9] Low Mark for Indonesia in Fight against AIDS. (2003) The Jakarta Post, 2 October . See too the full study for SC UK.

[10] Source: Rosenberg, R., ed. (2003) Trafficking of Women and Children in Indonesia. ICMC: Jakarta; Updated with Komnas PA reports; DepKes 2003 reports.

[11] http://www.hiv-development.org/text/publications/Chapter2.doc

[12] See Berman (2003) on drug culture at http://www.geocities.com/laineberman/drugs2003.htm

[13] http://www.hiv-development.org; Hsu, L. & de Guerny, J. Crossing national and sectoral boundaries in HIV/AIDS strategies – experiences from Southeast Asia. at http://www.hiv-development.org/publications

[14] They could likely be sentinel surveillance results that the individual knew nothing about, and thus could not add to the general picture of the epidemic.

 

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https://childrenhivaids.wordpress.com/

 

Editor in Chief :

DR WIDODO JUDARWANTO

email : judarwanto@gmail.com,

 

Copyright © 2009,  FIGHT AGAINST  AIDS, SAVE  INDONESIAN CHILDREN  Information Education Network. All rights reserved.


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