HIV/AIDS in Indonesia: A Pathway Towards Three Zero
By: Annisya Diva Shafira
Tags: Health, Indonesia, HIV AIDS

In December 2006, there were 39.5 million people worldwide living with HIV. Among those, approximately 4.3 million were newly infected patients, while 19 million people did not know that they had been exposed to HIV. Asia’s highest rate of national HIV infection is centered in Southeast Asia. Based on the data published by the Ministry of Health in 2013, Indonesia is fifth at most risk of HIV/AIDS in Asia because of its dramatic annual increase in HIV cases. High-risk behaviors, such as unprotected intercourse and illegal injected drug use, are especially evident in Indonesia. In many present-day cases, infections are heavily contracted among the young (15–24 years old). Despite progress made to increase the overall survival rate and possibly find a cure for HIV/AIDS, the number of cases and death due to this disease continues to grow.

Antiretroviral therapy (ART) is given to HIV-positive patients to lessen the viral load and increase the CD4+ T cell count. The combination of at least three effective drugs has been proven to decrease viral replication below the detected rate. After the viral growth is restrained, peripheral CD4+ count slowly increases to a normal level. For many years, ART has improved the lives of many HIV-positives. HIV+ compliant patients who adhere to the therapy also reduce transmission rate, even enabling HIV+ women to give birth to HIV-negative newborns. ART is given to halt persistent inflammation and improve T cell function so that the possibility of HIV-positives contracting life-threatening opportunistic infections is minimized. Overall, the number of annual HIV/AIDS-related death rates worldwide has decreased due to the utilization of ART.

At present, the production of protective vaccines is incredibly intricate due to the persistent mutation of the virus. Consequently, prevention and antiretroviral drugs remain the cornerstone in battling the HIV/AIDS epidemic. In Indonesia, the regions dealing with the higher HIV/AIDS prevalence are obligated to supply ART at first-rate healthcare facilities (FKTP). Nevertheless, sustaining the availability of these drugs remains a hurdle, especially in rural areas.

Despite the subsidized ART, making it cost-free for HIV+ patients, barriers in the distribution process continue to prevail. Stuart Watson, UNAIDS Country Director for Indonesia, explained that 23% or more than 500.000 HIV-positives in Indonesia do not take antiretroviral drugs. Furthermore, there are over 60.000 patients that stopped taking ART, which can cause the virus to become drug-resistant. Unsuppressed viral loads of HIV-positives that do not take medication cause a higher chance of opportunistic infections and transmission in high-risk behaviors.

Amid the pandemic, the situation worsens, especially for marginalized communities. Before the pandemic, HIV+ patients used to obtain medication monthly; now, as hospitals restrict visiting access, a multi-month dispensing (MMD) approach for ART is taken. HIV-positives are provided with either three or six months of medications. However, in reality, many hospitals have not been able to meet this need. Aditia Taslim, Executive Director of Rumah Cemara (an organization working on HIV/AIDS community support), explained that his medications are only supplied for two weeks to one month during the Covid-19 pandemic.

Moreover, in December 2020, The Minister of Health held Monitoring and Evaluation of HIV/AIDS and STI (Sexually Transmitted Infections). Reflecting on the nation’s achievement in battling the epidemic, it disclosed that HIV screening in pregnant women is only 45%, denoting that Indonesia still has a long way to achieve the aimed 85% percentage. Furthermore, uninformed of their HIV+ status, these women are not on ARV medication. Unsuppressed viral load increases the likelihood of HIV transmission to newborns. The discrimination and stigma faced by HIV-positives are also long-standing issues that render them from reaching out to obtain supports and start medications early. All of these problems contribute to the hurdles in sustaining nationwide access to antiretroviral drugs.

Objective to attain three zero (zero transmission, zero HIV-related death, and zero discrimination and stigma towards HIV-positives) by 2030, acceleration in resolving principal issues must be made. In this pandemic, as the sole provider for antiretroviral drugs, the government must react rapidly in increasing the availability and accessibility of multi-month dispensing of ART as suppressing the viral load in HIV+ patients is especially crucial during this time. Limited pharmaceutical laboratories producing ARV and imported second-line regimens are the root causes of the shortage of HIV medication. Thus, the Minister of Health must emphasize and escalate the national focus and budget allocated to increase pharmaceutical laboratory development.

Furthermore, involvement and collaboration between the Minister of Health and HIV+ communities in forming regulations and carrying out HIV/AIDS-related programs need to be intensified. Aditya Wardhana, Indonesia AIDS Coalition (IAC) staff, highlighted the lack of public access in the process of forming the National Action Plan for HIV/AIDS. This condition limits HIV-positives, the impacted community, to give response and evaluation on the proposal. Thus, transparency, responsibility, accountability, and community participation must be emphasized to create a favorable environment for HIV-positives.

On top of the government’s role in ending the epidemic, we also need to take our part as citizens. Based on research regarding the stigma towards HIV-positives carried out in Indonesia, approximately 72% of the adolescent respondents have a particular stigma regarding HIV patients. The study also concluded that lacking HIV/AIDS knowledge contributes to the social stigma towards HIV-positives. The alarming rate of people, especially adolescents, that still stigmatized HIV/AIDS patients manifests inadequate education and public awareness regarding their roles in ending the epidemic.

As a future doctor, I believe that continuous socialization debunking common myths regarding HIV/AIDS is able to give rise to public understanding and perception. This emphasizes the importance of community organizations, including medical student associations, in utilizing as many platforms to attain people’s attention and spread awareness, especially within the youths, beneficial to create a supportive climate for HIV/AIDS-positives. An encouraging environment is able to motivate compliance in ARV medication and promote testing, especially for high-risk communities. Hence, in the hope that by 2030, Indonesia will succeed in achieving the three zero, the Minister of Health and citizens must be committed to more collaboration as a unity to end the HIV/AIDS epidemic.

References :

Joint United Nations Programme on HIV/AIDS., & World Health Organization. (2006). AIDS epidemic update, December 2006. World Health Organization.

Ford, N., Wilson, D., Chaves, G. C., Lotrowska, M., & Kijtiwatchakul, K. (2007). Sustaining access to antiretroviral therapy in the less-developed world: lessons from Brazil and Thailand. Aids, 21, S21-S29.

Insight Start Study Group. (2015). Initiation of antiretroviral therapy in early asymptomatic HIV infection. New England Journal of Medicine, 373(9), 795–807.

Situmeang, B., Syarif, S., & Mahkota, R. (2017). Hubungan Pengetahuan HIV/AIDS dengan Stigma terhadap Orang dengan HIV/AIDS di Kalangan Remaja 15–19 Tahun di Indonesia (Analisis Data SDKI Tahun 2012). Jurnal Epidemiologi Kesehatan Indonesia, 1(2).

Traub AM, Ifafore-Calfee T, Phelps B. Multimonth dispensing of antiretroviral therapy protects the most vulnerable from 2 pandemics at once. Glob Health Sci Pract. 2020;8(2):176–177.

Humas Direktorat Jenderal Pencegahan dan Pengendalian Penyakit Kementerian Kesehatan RI. (2020, December 2). Monitoring dan Evaluasi Nasional Program Pengendalian HIV AIDS dan IMS Tahun 2020 dan Dukungan Global Fund AIDS Tahun 2021. http://p2p.kemkes.go.id/monitoring-dan-evaluasi-nasional-program-pengendalian-hiv-aids-dan-ims-tahun-2020-dan-dukungan-global-fund-aids-tahun-2021/.