N/A

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 02 - HVAB Sexual Prevention: AB

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Indonesia is comprised of over 220 million people and is at a critical crossroad in the transmission of HIV/AIDS. While the national

HIV prevalence among the adult population is estimated to be 0.01%, the low prevalence rate among the general population

masks HIV sub-epidemics within Most At Risk Populations (MARPSs), including Injecting Drug Users (IDU), Female Sex Workers

(FSW), clients of sex workers/high risk men (HRM) and men who have sex with men (MSM), including transgenders/waria.

In 2006, the National AIDS Program (KPA) with technical assistance from the USG-funded Aksi Stop AIDS program (ASA)

conducted a size estimation exercise for MARP groups. The media population sizes were determined to be 219,200 for IDU,

221,120 for FSW, 766,800 for MSM, 28,130 for transgenders/waria, and 3,161,920 for high risk men (HRM)/clients of sex

workers. The figures represent varying degrees of accuracy with some estimates being more evidence-based than others. In

2007, an Integrated Bio-Behavioral Survey (IBBS) was conducted among selected high risk populations, again with support from

ASA.

Direct (brothel-based) and indirect (karaoke bar) female sex workers (DFSW and IDFSW) were sampled in 16 sites across the

country. In seven cities, the HIV prevalence rates among DFSW were greater than 10% with the highest rates occurring in the

Papuan cities of Sorong (16.9%) and Jayapura (14.4%). Several cities also had rates over 5% among IDFSW (Batam - 8.8% and

Sorong - 8.3%). STI rates were also very high among DFSW with the highest rates of STI reported in the following sites - active

syphilis in North Sumatra (12.9%), gonorrhea in Jakarta (41.2%) and Chlamydia in West Java (55%).

While condom use at last sex increased between 2002 and 2007, the percentage of DFSW and IDFSW who reported that they

always used condoms in the last week remains insufficient (32% and 36%, respectively). On the other hand, FSW report that

when they do propose condom use to their clients, condoms often do get used - 77% acceptance by clients of DFSW and 84% by

clients of IDFSW. Among FSW who report having had multiple contacts with prevention outreach workers, the rate of condom

proposal increases to 90%, demonstrating the effectiveness of outreach efforts. A major challenge is that a large proportion of

FSW are infected with HIV within the first six months of initiating sex work, before they are exposed to prevention interventions.

Younger sex workers (< 25 years) are more likely to be HIV+ - 12.8% versus 9.4% for DFSW and 5.8% versus 3.9% for IDFSW.

Most transgender/waria report selling sex (95.6% in Bandung, 90% in Surabaya and 82.4% in Jakarta) and about half report

having regular male partners. HIV prevalence among waria is high - 34% in Jakarta, 25.2% in Surabaya and 14% in Bandung -

and continues to rise (21.7% in 2002 to 34% in 2007 in Jakarta). HIV prevention intervention coverage among waria is high with

80-90% of waria reporting contact with a worker in the past 3 months; STI referrals are also high and significant numbers of waria

reported receiving HIV test results. Injecting drug use is virtually non-existent and non-injecting drug use is modest, but alcohol

use is high with over 50% of waria reporting drinking. Consistent condom use in anal sex is insufficient ranging from less than

50% in Bandung to about 10% in Jakarta; and despite high STI referral rates, most waria do not follow-up on attendance at STI

clinics.

Prevalence rates among MSM are comparable to IDFSW - 8.1% in Jakarta, 5.6% in Surabaya, 2.0% in Bandung). Among MSM

who participated in the IBBS, rectal STI rates are high at around one-third of MSM testing positive for a rectal STI. The majority of

MSM who engaged in insertive and receptive anal sex reported not always using a condom in the past month. Ten to twenty

percent of MSM reported that they had never used a condom, and most MSM have never purchased condoms. Some MSM cite a

lack of condom and lube availability. Like the waria, MSM have a high degree of knowledge about male-to-male transmission and

HIV prevention. Several cities report high rates of coverage by outreach workers with multiple contacts, but limited condom use

and only modest numbers of MSM (~30%) follow-up on referrals for HIV testing underscore the need to insure not only coverage,

but also to develop and implement effective of behavior change interventions among MSM (and waria).

The 2007 IBBS also focused on 4 groups of HRM - dockworkers, moto-taxi drivers, truckers and seafarers. HIV prevalence

among these groups revealed differing patterns between the groups according to geography. In Papua, 3.0% of dockworkers and

1.0% of moto-taxi drivers were HIV+ - rates that are in line with the 2.9% prevalence rate among general population men in

Papua. In the rest of Indonesia, HIV was not detected among dockworkers and moto-taxi drivers; HIV prevalence among truckers

(0.2%) and seafarers (0.5%) was higher than in general population males. The majority of seafarers and truckers had multiple

partners (64% and 60%, respectively) and reported sex with FSW (45% and 60%, respectively). They also reported using

condoms with FSW less than 50% of the time in the past 3 months. Less than 50% of HRM demonstrated adequate knowledge

regarding HIV prevention.

In Papua, where the epidemic is generalized, the data from the recent Papua general population IBBS conducted in 2006

coupled with the 2007 MARP IBBS data for Papua, reveal that the low prevalence, generalized epidemic in Papua is still driven by

commercial and transactional sex. Data showed that HIV was higher among men (2.9%) than women (1.9%); among persons who

had more than 2 sexual partners in 1 year (4.0%); those who engaged in sex for payment (5.1%). The HIV prevalence among

men who had a history of STI in Papua was 5.9%. More than 20% of male residents reported more than one sex partner in the

past year compared to 8% of female residents. The 2007 FSW data from Papua combined with the general population data show

that high risk men and commercial/transactional sex workers continue to be the main drivers of the epidemic in Papua. The World

Bank is currently supporting an ethnographic study with Cendrawasih University to understand the dynamics of commercial and

transactional sex work in Papua.

In most of Indonesia, the level of sexual activity among non-MARP youth is fairly low and conservative social norms are effective

in discouraging pre-marital sexual activity. While data on the age of sexual debut is limited, it is believed that age at first marriage

closely corresponds to the age of sexual debut. The median age at first marriage for women is 19.5 years.

The primary focus of the GOI national prevention efforts is, appropriately given the data, on preventing HIV transmission between

FSW and clients, harm reduction among IDU and sexual transmission among MSM and IDU and their partners, with minimal

prevention efforts directed at the general population and youth.

The KPA and the MOH are fully supportive of comprehensive prevention efforts. However, full implementation of an effective

response to prevent new HIV infections has been hindered by a variety of issues, including: (1) lack of consensus among key GOI

bodies and conservative groups; (2) regulatory barriers; (3) budgetary constraints related to a general economic downturn; and (4)

reluctance of the GOI to formally acknowledge the magnitude of the commercial sex industry in the country. The condom supply

has been problematic. According to the IBBS condoms are not readily accessible where many FSW work. Only 45% of DFSW can

obtain condoms at the localisasi (brothel area) and only 15% of IDFSW can get condoms at their place of employment. Recently,

the MOH has stopped procuring condoms using GOI funding. This has led to shortages in free condoms to NGOs working with

MARPs. While DKT offers several brands of socially marketed condoms, there is limited national condom advertising and

distribution.

Given the nature of the epidemic in Indonesia, there are few AB programs, including those supported by other international

organizations. The development of a national communications strategy featuring comprehensive HIV/AIDS prevention messages,

including AB, is in process through the KPA, but has been slow in coming to fruition. AusAid has, as a focus for their HIV

program, a comprehensive behavioral communication program in Papua targeting the general population, including youth. In

addition, UNICEF will be expanding its efforts to general population youth in Papua, incorporating AB messages.

USG-supported program efforts targeted 80 districts, located in 8 USG priority provinces. These districts were chosen, in

consultation with the KPA because they are sexual and IDU transmission "hotspots," which means that they have considerable

MARPs populations engaged in high risk behavior, and need additional resources to mount a prevention effort to impact the

epidemic. USG support for NGOs targeting MARP is designed to contribute to the national objective of reaching 81% of MARPs

in each of these priority provinces by 2010. The targeted MARPs for the USG-supported program include FSW, MSM, and other

high risk men which include both actual clients at sexual transmission "hotspots" and potential clients (as more information defines

who those clients actually are).

In previous years, ASA provided technical assistance through direct funding mechanisms to FBOs and other community groups

for organizational capacity building to work with youth and high risk groups including developing AB messages for FBOs and

themes for political leaders, FBOs and religious groups. Future USG programs will continue to advocate for a more active role of

religious organizations, FBOs, and community groups in the fight against HIV/AIDS. USG programs continue to support groups

such as the Catholic Dioceses in Papua, the Gereja Protestan Indonesia di Papua (GPI Papua), and Mohammadiya - the 2nd

largest Muslim group in the country, to assist them in mainstreaming HIV/AIDS prevention, care and treatment and stigma and

discrimination messages into their general programs.

In FY08, USG funding supported 66 selected NGOs and CBOs to implement the basic prevention intervention package for MSM,

waria, FSW and HRM, including clients of sex workers. The basic MARP prevention intervention package consisted of peer

outreach with IEC materials, including "B" messages for HRM; condoms, lubricants and safe sex kits; targeted multi-media

campaigns, including innovative internet campaigns for MSM; peer support groups; negotiation skills training; and policy

interventions, including 100% condom policies and STI testing for brothel-based FSW. As part of the Continuum of Prevention and

Care (COPC), each community-based NGO is linked with and provides referrals to either a GOI or NGO clinic for case

management, CT, and STI screening and treatment. ASA also supported the KPA's efforts to make female condoms more widely

accessible throughout Indonesia, especially to FSW and women who may be engaged in commercial/transactional sex in Papua.

In FY08, USG supported 5 NGOs who work exclusively with private sector businesses and government ministries on ABC

workplace programs for HRM, including clients and potential clients of sex workers. Other NGOs targeted port workers, truck

stops and other points along major highways where CSW services are available with aBC messages. Gender-based violence and

inter-generational sex continued to be addressed through messages stressing that these practices are socially unacceptable,

particularly among HRM in Papua. These messages as well as VCT and case management were incorporated into all IEC

materials and training curricula provided to individuals in outreach areas including hotspots and workplace programs.

Alcohol and/or gender-based violence (GBV) issues among certain groups such as HRM in Papua and waria need to be

addressed as part of effective HIV prevention behavior change interventions, USG/Indonesia is interested in strengthening these

themes in future interventions and has initiated consultations with the MARPs TWG to undertake an assessment/programmatic

design visit exploring such programming in among relevant populations.

In 2007 USG funds were used to support specific health clinics to conduct STI services. The emphasis in FY08 funding shifted

the approach from funding specific clinics to helping the provincial and district health services develop systems to serve MARPs --

- including expansion of local STI services to other clinics (NGOs) and strengthening the system (training, mentoring, quality

assurance, reporting). Pilot studies conducted by ASA in 2008 showed that a move away from enhanced syndromic management

for FSW and toward the introduction of periodic presumptive therapy (PPT) with a package of standard medication which can

effectively treat STI with easier adherence requirements, can successfully address STI rates among FSW and may be able to

reduce HIV transmission.

In FY07 DOD funding for peer education sessions was conducted in selected locations in South Sulawesi and East Kalimantan in

support of the TNI overall peer education program. In FY08 USG funding was allocated to coordinate, plan and support ‘traveling'

peer leader workshops to Indonesian Defense Forces (TNI) throughout the country. PUSKES medical staff and TNI officers were

trained as peer leaders. These activities will be re-energized in FY09 with a greater number and geographic distribution of peer

education activities. Increased funding for peer education activities will allow for an additional training of trainers (TOT), bringing

the total up to three peer leader workshops for non-medical military troops and new recruits. These workshops will further provide

the opportunity for the TNI/PUSKES to develop its own peer leader TOT workshop using and adapting the training and material

resources from the FHI-organized, national TOT workshops. Training materials will include behavior change tools that address

gender through male norms and behavior that lead to risk for infection. Condoms will be procured and funds will also support

technical support and travel as required.

With FY 09 funds, USG programming will build on existing successes in support of the integration of NGOs and GOI partners to

scale-up and improve the quality of the outreach-, clinic- and institution-based interventions for MARPs described above in the 80

priority districts, with an emphasis on developing, implementing and evaluating more innovative and effective behavior change

interventions.

Program Budget Code: 03 - HVOP Sexual Prevention: Other sexual prevention

Total Planned Funding for Program Budget Code: $5,500,000

Total Planned Funding for Program Budget Code: $0

Table 3.3.03: