Indonesian women face growing threat of lethal AIDS
By Harry Purnama
JAKARTA (JP): Indonesia's safe motherhood plan was still struggling when the country was confronted with a new public health problem -- Acquired Immune Deficiency Syndrome. HIV and AIDS spread into Indonesian households just as the government was trying to lower the maternal mortality rate, which now stands at 425:100,000. The high rate, coupled with the high infant mortality rate (three to six times higher than that of other ASEAN countries) has only helped the HIV and AIDS move from a nightmare to reality.
Dr. Michael Merson of the World Health Organization's Global Program on AIDS estimates that the spread of AIDS in Asia, especially in South and East Asia, is the fastest in the world. In 1994, of the 15 million HIV-positive people in the world, 14 million were teenagers and adults. One million were infants whose mothers had been infected with the virus. The worldwide ratio of women infected with HIV to men was even at 1:1.
Infected women carry the risk of dying during pregnancy but the abortion of an infected fetus involves complicated humane and moral considerations. The more so if the husband has been infected because of his relationship with an HIV-contaminated spouse. A whole family may die from this fatal disease, or leave the children orphaned. If this happened in Indonesia, there would be an uproar.
Until June 30, 1995, records show that HIV-positive women and AIDS cases are rising in Indonesia. In 1993, the female proportion compared to HIV positive males stood at 1 to 3, while those with AIDS stood at 1 to 13. On June 30, 1995, the ratio of HIV positive females to males was close to 1 to 2, while those with AIDS stood at 1 to 10. This means that the HIV/AIDS threat is not exclusively restricted to males, it also threatens Indonesian women. Every province has AIDS infected inhabitants.
Why has the HIV/AIDS threat to women become a public health concern? Firstly, because the infection is preventable, even though the ill effects are unsurmountable.
Secondly, children have the right to a healthy life. The HIV and AIDS threat is a threat against the realization of this blessing and the right to live a secure and happy life. Unfortunately, HIV-infected children tend to be publicly ostracized, as happened to thousands of children in Rumania.
Thirdly, only women can lower the infection rate in future generations.
Fourth, women's contributions to household economies have earned more recognition. The loss of a female spouse would obviously be felt by the husband and children.
Greater risk
Why do we fear that women carry greater risk of being infected with HIV/AIDS than men?
Dr. Nafsiah Mboi, a member of the House of Representatives, brought up the following reasons. The first one is "biological vulnerability". Contamination passed on by a male to a female appears two to four times more efficient than when it happens the other way round. From a biological view point, women carry greater risks than men. Girls are even more vulnerable to the disease because an undeveloped cervix produces little vaginal mucus, which in adult females acts as a natural preventive agent against HIV infection. There is the possibility that women do not seek treatment of sexual ailments since these afflictions are generally asymptomatic in nature.
Other factors are ignorance of symptoms, embarrassment and an aversion for medical checkups out of fear for public stigmatization.
The socio-cultural economic reason fits in the gender of stereotypes. It is generally assumed in Indonesia that knowledge, pleasure and initiative are men's prerogatives while innocence, acceptance and duty are characteristics normally attributed to women. From this weak position, women find it difficult to negotiate safe sex, even though they realize the risk of AIDS.
Research has disclosed that most married females give in to sexual relationships with their husbands as if their lives depended on it, out of fear of loosing their breadwinners. Some women are also involved in unwanted sexual relationships for reasons of survival, as trying to keep a job. Tourists also enter the country to enjoy sex.
The ignorance of prostitutes also adds to the risks. With beauty as their only earning power, these girls are placed in a difficult position. These women face rape, unwanted relationships and customers who corner them into an unprotected sexual relationships.
At the edge of Jatinegara in East Jakarta, for instance, conditions are extremely poor. No party has ever guided the girls in the prevention of HIV and AIDS. Yety, 17, explained that she had heard of AIDS, but, didn't know how contagious it is. Most customers don't use condoms.
When asked if she accepts customers who refuse to wear a condom, she answered, "What do you expect... I can't do anything about it."
Her answer can be blamed directly on poor access to information and social services. Women are regarded as second class citizens in Indonesia which restricts their access to information and services. Geographic, intellectual, social and economical isolation of women worsen the plight of these women. Research conducted in Thailand, India and Indonesia by Geeta-Rao Gupta (1993), an Indian expert on AIDS, have found that some women do not know the anatomy of their own bodies, let alone the process of pregnancy and birth. The constraints women feel about discussing sex with their husbands isn't helped by the misconception many doctors have about AIDS.
Added to this, parents and children also find it difficult to discuss sex.
Santi (not real name), an attractive 18-year-old girl working at a singing hall in Mangga Besar in downtown Jakarta, has never been informed about sex, let alone AIDS, by her mother.
"No one has ever talked about AIDS with me, my mother wouldn't know, although she should be the one to inform me," the young woman explained.
If sex workers were as enlightened as Mona, a prostitute in Kramat Tunggak, North Jakarta, the threat of HIV/AIDS could be slowed.
"I dare to suggest that customers use condoms which I keep at hand. And, amazingly, they use them. The poster in my room makes customers ask, 'What's that Mona?' Then I start explaining and suggest that they use a condom," the 40-year-old sex worker said, pointing to a poster which reads "Enjoy as long as you stay Healthy". The poster was produced by Hotline Surya, Surabaya.
Several sex workers supported by the Kusuma Buana Foundation have been educated, but there are many more Indonesian prostitutes and women who have never been informed or educated about HIV and AIDS.
The foundation's peer education approach follows the activities of the WHO Global Program on AIDS. But, of the 1,800 to 2,000 sex workers and 300 pimps in Kramat Tunggak, only 80 peer educators have been motivated by this NGO program. Even if the program draws satisfactory results, extension of the program faces funding restrictions.
The peer education program, which helps the women of Kramat Tunggak to becoming more aware and self assured when talking about safe sex, is still extended free of charge. The program therefore fails to recover its costs, which in turn makes extension to other women difficult. Large scale intervention to halt HIV and AIDS threatening women and children faces the constraints of sustainability.
Dr. Nafsiah Mboi outlined her endeavors to fight HIV and AIDS on National Children's Day last July 23.
"Millions of children in the world have been adversely affected because their parents died of AIDS. We have to act now, if we want to prevent Indonesian children suffering the same fate."
Only two Indonesian children have been registered as suffering from HIV/AIDS so far. This was done outside official government registration. The potential for more children to be infected rises with the number of HIV infected women.
This fact opened Dr. Nafsiah Mboi's eyes and forced her direct her plea for adults and youngsters to adopt a responsible and healthy life style. Her plea doesn't only extend to sex, it includes proper blood transfusions, safe and hygienic childbirth and utilizing proper equipment during operations. This is necessary because the HIV virus has been found to withstand disinfectants.
Harry Purnama holds a Master's degree in of Public Health. He is a graduate of Monash University, Australia.