Low condom use hampering HIV prevention in Indonesia

Ben Harkness, Jakarta

As of July, 2004 the official number of HIV/AIDS infections in Indonesia recorded by the Indonesian Department of Health was 4,389. However, a widely accepted estimate of the true number of cases is between 100 000 and 150 000. The most common means of transmission (around 49 percent) is heterosexual contact but intra-venous drug use is rapidly becoming an equally common way for the virus to spread. The highest number of cases is found in Jakarta followed by Papua, East Java, Bali and Riau. HIV infections are also beginning to spread into non-high risk groups within the community.

This problem is not going unchecked. A number of government bodies, international and local NGOs, health centres, and religious organisations are working to address this problem, particularly in the sex industry and injecting drug user (IDU) community. However, their efforts are still being hampered by ignorance, apathy and taboo. Generally low levels of sexual health knowledge within the community, for example, have resulted in widespread myths and misinformation about condoms and sexually transmitted infection (STI) prevention.

Many people still believe condoms have pores and are therefore useless, condoms are difficult to put on or reduce the enjoyment of sex, STIs including HIV can be prevented by taking antibiotics before or after sex, and someone's HIV status can be determined from their physical appearance, if they seem outwardly healthy condoms are not necessary. As a result, condom use both for protection in commercial sex transactions and as a means of contraception remains very low.

Unlike many other large cities, prostitution in Jakarta is through indirect sex with brothels themselves being a relatively rare phenomenon. Instead, various karaoke bars, health spas and massage parlors, in addition to offering the advertised services, will often facilitate sexual transactions between clients and workers.

This scenario of indirect sex, however, has implications for HIV/AIDS prevention. While many local government officials and law enforcers are fully aware of the true nature of such venues, they officially uphold the pretense that a massage parlor only provides massages and a karaoke bar is home only to off-key renditions of Rod Stewart and Frank Sinatra.

When public outcry becomes too loud, law enforcers will conduct raids on various venues, looking for evidence that sexual transactions are taking place. While these raids are usually just a means of extracting payment from managers rather than any genuine attempt to uphold moral standards, the fear of being fined or shut down means such venues will rarely stock condoms for their clients.

Both the reluctance for clients to use condoms and for venues to stock them has dramatic implications. Condoms are the only way to prevent the spread of STIs and HIV through sexual contact. With the estimated number of Indonesian males visiting female sex workers each year ranging from 6.9 million to 9.6 million, Indonesia runs the risk of widespread STI infection.

There have, however, been some positive developments in the fight against HIV. Police are beginning to show increased levels of tolerance, no longer arresting venue workers for simply stocking condoms. Arrests are now only made if direct evidence of prostitution is found. This increased level of tolerance has also meant managers are beginning to provide condoms for their clients and staff.

Several managers have even taken more active steps in the fight against HIV and formed the Communication Forum for Entertainment Venues Concerned with HIV/AIDS, abbreviated in Indonesian to the slightly catchier name of Forkihpa. This forum actively approaches other venue managers not involved in HIV prevention education to explain the social and financial impacts HIV can have. This forum is also providing input to relevant government bodies in designing more effective HIV/AIDS prevention legislation.

In addition, research by Yayasan Kusuma Buana, a Jakarta-based public health NGO, has shown that the percentage of sex workers in the "always use condoms" category has increased from 10 percent to 39 percent with similar improvements in the "usually use condoms" category. These results have been attributed largely to the HIV/AIDS education activities being conducted by NGOs like Yayasan Kusuma Buana in Jakarta's red-light districts. However, for the spread of HIV through the sex industry to be prevented, there needs to be 100 percent condom use.

Government policy on prostitution in Indonesia has always been confusing. There are laws prohibiting the facilitation of commercial sex transactions (acting as a pimp) and the trade of women and children but there is no law in Indonesia that prohibits prostitution itself. Despite this, it is usually sex workers rather than managers or clients who attract the condemnation of society or the attention of police. Often referred to in Indonesian as "women without morals", female sex workers are often targeted as needing social rehabilitation. The role of clients in perpetuating the cycle of prostitution, in comparison, largely escapes public criticism.

At present the West Jakarta district government is drafting a decree that would enforce compulsory condom use in entertainment venues throughout West Jakarta. The decree represents an enormous opportunity for the government to take effective and meaningful steps towards curbing Indonesia's growing HIV/AIDS infection rates.

If the decree allows for increased discussion on condom use, encourages a multi-sectoral approach to HIV/AIDS prevention in the sex industry, and introduces penalties for establishments not enforcing condom use with their clients then significant behavioural change is possible. However, if the decree contains ambiguity and rhetoric or lacks the means for effective enforcement then HIV infection rates will continue to climb.

The writer is currently working in Jakarta through Australian Volunteers International (AVI).