The Role of Health Protection Interventions in The Public Health Response to HIV in Indonesia

Introduction

Indonesia is one of the countries that experience the fastest-growing HIV epidemics globally. Since the country recorded its first HIV cases in the late 1980s, it has been experiencing a rapid expansion in the number of HIV victims and deaths, which has caused significant implications in the region’s social and political environments. By 2010, the country’s HIV infection rate had expanded to 11%, with more than 36.7 million cases among all ages (Rionoand Challacombe 2020, p. 28). Such a high disease prevalence forced the Indonesian government to develop strategies to curtail its spread and improve life expectancy among the infected people to reduce the social and economic implications of elevated death rates. Such strategies included improved access to antiretroviral therapy among HIV patients to help regulate the population’s transmission rate. Early testing and public sensitization methods were also established to keep track of HIV prevalence among key population groups, such as pregnant women, tuberculosis patients, and couples (World Health Organization 2017). Despite applying such control strategies, the country continued to experience elevated infection rates and ever-growing death rates, which necessitate the development of more effective health protection interventions to address HIV prevalence in Indonesia.

Presently, the country is still far from reaching the Joint United Nations Program on HIV/AIDS (UNAIDS) treatment cascade goals. HIV prevalence in the general population is currently at 0.5% among individuals aged 15 to 49 (Johnston et al. 2021, p. 1). While such a prevalence level may seem low, the disease is common among vulnerable members of society, such as drug users, prisoners, and sex workers. According to a study conducted by Suryana (2021), about 73,000 people are infected with HIV each year, among whom 39% are people who inject drugs, 7.2% are female sex workers, 12.8% are gay, and 7.4% are transgender women. Despite such a high disease prevalence among vulnerable groups, most infected people do not take antiretroviral therapy, which results in a high rate of infection and disease progression. It is estimated that only half of the total number of people living with HIV in Indonesia have been medically diagnosed with the virus, and only a small proportion of those who have been confirmed to have the disease receive antiretroviral therapy (Suryana, Suharsono, and Antara 2019, p. 307). Such statistics indicate that many people in Indonesia are unaware of their HIV status, which causes a high infection rate as many fail to heed public health guidelines regarding the disease.

The high prevalence of HIV and increased mortality rate in Indonesia have caused alarming implications for the economy and society. As the population’s infection rate continues to expand, the number of HIV-related deaths continues to last, causing serious economic and social effects. According to Kurniasari, Huruta, Tsai, and Lee (2021), the number of AIDS-related deaths in Indonesia has increased by 60% over the last ten years. Since a larger proportion of the infected people fall within the productive age bracket, the HIV pandemic has significantly affected the country’s productivity level. The increased infection and mortality rates imply that the economy is left with fewer workers, both in total and across different industries and occupations. Eventually, the country’s gross domestic product declines with reduced productivity, leading to economic strain when developing HIV management strategies. While the government is determined to develop methods to regulate the spread of the virus among its population and provide effective care to the affected people, it lacks the sufficient economic capacity to conduct such activities. Therefore, public health policies ought to be developed to control the prevalence of the virus and uphold the country’s economic potential to manage similar pandemics in the future.

Most vulnerable populations, social determinants, and risk factors

The most vulnerable groups of the Indonesian population include men who have sex with other men, people who inject drugs, individuals in prisons and other closed settings, adolescents, and transgender people. According to Fauk et al. (2017), men who engage in romantic relationships with other men are 25 times more likely to contract HIV. While the lesbian, gay, bisexual, and transgender (LGBT) community constitutes up to 3% of the Indonesian population, the high vulnerability of such individuals to contract HIV constitutes a factor for its high prevalence in the country (Fauk et al. 2019, p. e0221013). Moreover, as HIV remains common among the LGBT community, people who enter the societal group experience a high risk of contracting the virus from the people they romantically relate to. Similarly, drug users experience a high risk of contracting the virus. Since drugs affect a person’s cognitive efficiency and lead to improper judgment, drug users are likely to make poor decisions that put them at risk of contracting or transmitting HIV, particularly through unsafe sex. While it is estimated that about 1.2 million people in Indonesia use at least one drug, such people do not utilize safety guidelines provided by the public health department regarding HIV control, such as abstinence and the use of condoms (Fauk et al. 2019, p. e0221013). Eventually, the country records a high prevalence of HIV among drug users.

In addition to members of the LGBT community and drug users, adolescent youths have limited capacity to make informed health decisions, which contributes to their high vulnerability to HIV. Some societal factors also reduce adolescents’ ability to avoid risky behaviors, which include violence and abuse, lack of access to safety information and services, and lack of parental guidance and support. According to Rizkianti et al. (2020), the reported HIV infections in Indonesia increased annually by 13.1 percent among adolescents between 2011 and 2015. As such individuals grow up to be sexually active in their later life, the infection rate continues to expand among other age groups.

Prisons and other closed settings are high-risk environments for unhealthy behaviors such as drug abuse, needle sharing, and tattooing with unsterile equipment. As prisoners share piercing objects, their possibility of transmitting or contracting HIV is high. Such unhealthy factors also compound the implications of drug abuse to increase prisoners’ vulnerability to the virus. Transgender people in Indonesia also experience a high risk of contracting HIV. Such people are often stigmatized in society, which limits their access to tailored HIV prevention and management programs. They also face social and legal exclusion, economic vulnerability, and violence that result in disempowerment and low self-esteem, which makes them less likely to negotiate for safety strategies such as condom use in romantic relationships. Transphobia also creates barriers to access to HIV testing and treatment services by transgender people, which intensifies their vulnerability.

Some social determinants and risk factors for HIV prevalence in Indonesia include income and wealth disparities, the social stigmatization of infected people, and migratory behavior. Indonesia is one of the countries with the greatest wealth inequality globally. According to Panjawa, Samudra, and Soesilo (2018), four of the richest men in the country hold more wealth than the combined total of the poorest 100 million people. With such a high wealth disparity in the country, many people live in extreme poverty and have limited capacity to practice healthy living and consume healthy foods. As a result, immunity among such people is weakened by malnutrition and unhealthy lifestyles, which leads to a greater risk of HIV transmission in any unprotected sexual encounter. Also, as individuals who are confirmed to have the virus face social stigmatization, many people in society avoid taking HIV tests due to the fear of being socially condemned. As such individuals fail to check their HIV status, they do not practice control strategies leading to the expansion of the infection rate. Moreover, a large proportion of the country’s population engages in migratory activities in search of employment to better their lives. As a result, the rate of dispersion and infection increases in many parts of the country, which leads to a significant increase in the prevalence of the disease.

Policy, Management, and Control Responses

To control the prevalence of HIV in the country, the Indonesian government adopted a national strategy to increase access to antiretroviral therapy. The government launched awareness campaigns that sensitized members of the public concerning the importance of taking antiretroviral therapy among individuals who had already contracted the virus. Opportunities for early testing and initiation of antiretroviral therapy among the most vulnerable and people with chronic diseases were widely applied under the regulation of the ministry of health (Sawitri et al. 2021, p. 136). The strategy involved multiple stakeholders who played specific roles throughout the implementation process. The Badan Pusat statistic bureau conducted a demographic analysis of the population to present information regarding the level of prevalence, most vulnerable populations, social determinants, and estimates of financial resources that would be needed throughout the implementation process. The public health department was critical in distributing the material and equipment required for antiretroviral therapy in most healthcare centers across the nation. Eventually, many cities across Indonesia recorded increased access to antiretroviral therapy among HIV patients and a lowered prevalence of sexually transmitted infections such as Syphilis in Indonesia.

The Indonesian government also established the regulation for mandatory HIV screening at the time of admission to prison. As assessment reports revealed the most vulnerable groups in society, the Indonesian government found the need to develop policies tailored towards controlling infection rates among such groups. One of the most vulnerable groups identified by the government was prisoners, who constituted a significant proportion of the national prevalence rate. The government stipulated that each person should be tested for HIV during admission, conviction, and before release from prison without informed consent. Each prison was equipped with a screening, testing, and counseling unit to allow inmates who had already contracted the virus to access antiretroviral therapy, while those who had not been exposed to HIV received counseling on how to maintain their health. The application of the strategy led to a significantly lower number of HIV cases among tested prisoners. According to Culbert et al. (2017), introducing mandatory screening during admission and before exiting prison led to a 1.3% decrease in HIV prevalence in Indonesian prisons between 2014 and 2017. However, there was a question as to whether the government should have introduced condom distribution units in prisons places to allow inmates to have safe sex and limit the spread of the virus.

Mobile HIV testing and religious-based information, education, and communication (IEC) services were also introduced to aid in the fight against the virus. Community HIV screening services were introduced in non-clinical settings to encourage members of the public to check their HIV status and adopt preventive and management practices. Such programs, combined with education and outreach events such as HIV awareness campaigns and health fairs, enhanced public sensitization strategies. Healthcare organizations also partnered with community-based organizations to provide testing resources such as test kits and antiretroviral drugs and trained staff members who specialized in providing care to HIV patients and guidance to non-infected members. Conducting mobile HIV testing helped in reaching a broad set of people who were at risk of contracting the virus but could not access institution-based screening services. Religion-based IEC services also provided a cost-effective measure in the fight against the virus. In collaboration with local administrative structures, the public health department organized campaigns in religious centers to inform believers about the need for screening and HIV prevention and management strategies. As a result, the country recorded an increased number of tests which helped formulate further control strategies.

Critical assessment of the effectiveness of control responses

The awareness campaigns developed by the government effectively sensitized members of the public concerning the importance of taking antiretroviral therapy and brought about a significant decrease in the prevalence of HIV and other sexually transmitted diseases. However, the strategy mainly focused on improving immune resilience among individuals who had already contracted the virus. In so doing, the strategy failed to propose ways through which members of the public could avoid getting infected with HIV. As a result, the infection rate continued to increase despite the government’s application of such a management method. According to Rico and Challacombe (2020), the number of people living with HIV in Indonesia rose from 630,000 in 2015 to 640 000 in 2018. Although the level of prevalence per 100,000 people significantly decreased throughout the period, the statistics indicate that members of the public continued to contract the virus despite having access to information regarding the effectiveness of antiretroviral therapy. The strategy, therefore, ought to have advocated for a preventive measure that could inform members of the public about practices that could help them avoid contracting the virus. Also, the strategy should have established alternative ways to help infected community members avoid transmitting the disease to other people. For example, the government ought to have established ways through which pregnant women could ensure the safety of their babies from the virus outside the care setting to control the infection rate.

The government’s decision to regulate mandatory HIV screening during admission to prison also failed to conduct follow-up assessments for infected individuals. The mandatory HIV screening helped ensure that each prisoner’s HIV status was established before they got admitted to prisons and before joining the public after completing their jail terms. The strategy also provided policymakers with information regarding the number of positive cases in prisons, which helped in determining the overall prevalence of the disease among different groups of people in society. However, no follow-up was conducted once a prisoner was confirmed to be infected with the virus. As a result, the infected prisoners continued infecting other inmates despite being tested before admission. Similarly, no follow-up was conducted for individuals who left prisons, which indicates a possibility that they transmitted the virus to other people. Moreover, since the mandatory HIV screening was conducted without informed consent, prisoners were unaware of their status. As a result, individuals who were confirmed to have the disease could not make the necessary life changes to improve their immune resilience to the virus leading to an increase in the mortality rate among HIV victims. Moreover, people who tested negative for the virus were not informed on methods they could use to avoid contracting the virus while in prison. As a result, the infection rate continued to increase despite the application of the mandatory HIV screening regulation.

Mobile HIV testing facilities allow members of the public to identify their HIV status for the easier establishment of management or preventive strategies. However, the strategy failed to include follow-up and coping strategies for individuals who tested positive for the virus. While a positive test result can come as a great shock and difficult for a person to cope with, the government ought to establish ways through which people who tested positive would receive physical and emotional support to avoid developing complications that could lead to disease progression. According to Jackson-Best and Edwards (2018), people who test positive for HIV experience a greater risk of developing emotional deprivations that affect their cognitive and psychological health. Since HIV attacks the body’s immune system, emotional complications among victims can weaken their body’s resilience to the virus leading to rapid progression. To ensure minimal HIV deaths, the government ought to have established ways through which local health professionals could provide long-term care to HIV patients. Also, the government could consider providing such individuals with basic needs, such as quality food, to ensure that they have the required nutrients to support immune resilience to disease progression.

Critical appraisal of the HIV/AIDS status quo in Indonesia and conclusions

As the Indonesian government continues to utilize different strategies to curtail the spread of HIV, various ways could be used to improve the efficiency and effectiveness of the interventions. The government ought to promote non-stigma and discriminatory policies related to HIV/AIDS to encourage members of the public to embrace the existing control strategies. Individuals who are confirmed to have contracted HIV experience different forms of internal stigma, including feeling ashamed of their status, self-guilt, and fear of having children (Irmayati, Yona, and Waluyo 2019, p. 546). They also experience diverse forms of prejudice in society due to their health status. As a result, many people in the country fail to utilize screening services provided by the government due to fear of stigmatization. People who already have the disease also fail to seek antiretroviral therapy and other interventions as they fear being associated with the virus by other community members. The government, therefore, needs to develop anti-stigmatization policies to ensure that people living with HIV are treated with dignity in society to encourage them to embrace various control and management methods and minimize the prevalence of the disease in the long run.

Moreover, policies need to be developed to extend HIV/AIDS services at the workplace and equal access for vulnerable groups to employment. In addition to stigmatization, people living with HIV often face challenges when seeking employment. Many employers perceive them as incapable of delivering quality services due to their health conditions (Desyani, Waluyo, and Yona 2019, p. 510). As a result, such people experience financial strain, which limits their ability to adopt healthy lifestyles and maintain a strong immune system despite having the disease. While the number of HIV deaths recorded by the nation every year is alarming, the government ought to consider developing strategies that could improve the quality of life for people living with HIV to promote their longevity and reduce the economic and social implications that the community experiences due to an elevated mortality rate. To achieve this goal, the public health department could develop policies that encourage the introduction of VCT services at workplaces. Such an intervention could encourage companies to take the lead in the involvement of preventing new HIV infections among their employees and providing access to HIV treatment and support for employees who live with HIV.

An opportunity also exists for the improvement and partnership among stakeholders on the progress, evidence-based data, and advocacy. Studies need to be conducted to review societal and workplace issues that arise to threaten social protection among people living with HIV. Such studies would provide insight into the best way to serve HIV victims to promote quality of life and reduce risk factors that increase their predisposition to disease progression. Findings from such studies should be shared by the ministry of health and other stakeholders to illuminate strategies that could improve their ability to monitor the progress of the initiatives put in place and identify defects to improve efficiency.

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