A nation must rely on itself

Taking responsibility for the national AIDS response means empowering governments to synergize internally and allocate more local resources instead of relying on foreign help, Indonesia National AIDS Commission Secretary Nafsiah Mboi said on Wednesday.

“[The AIDS response] is not the responsibility of the Australians, it’s not the responsibility of the Americans, but it is our responsibility,” she said during the plenary titled Power Dynamics and AIDS Governance during the 9th International Congress on AIDS in Asia and the Pacific (ICAAP).

Nafsiah, who is also one of the Co-Chairs of the 9th ICAAP said that part of the responsibility includes taking leadership of the response by staffing the national AIDS commission secretariat with professionals instead of simply assigning civil servants to do the task.

It also means synergizing with other government agencies to secure domestic funding.

“By coordinating with the National Development Planning Board (Bappenas) and the Finance Ministry, we successfully included HIV into the planning for the state budget, as HIV response should be seen as part of national development,” she said.

Actively participating in international funding allocation bids such as the Global Fund for AIDS, Tuberculosis and Malaria (GFATM) is another form of responsibility.

“With technical assistance from Australia and the U.S. we were able to have a very good proposal for the GFATM funding round 8,” Nafsiah said, adding that the proposal development process was a good example of various institutions – governmental and non-governmental – coming together for a common purpose.

As result, Indonesia has seen growth on state budget allocation for the AIDS response, to US$70,642,541 in 2009 from only $11,383,676 in 2006, she said, explaining that there have been drastic increases in budget allocation for AIDS from the Health Ministry in the last three years.

“This trend of increasing the contribution from domestic sources is also visible down to the district level,” Nafsiah said.

The allocated provincial budget for AIDS grew to Rp 38.3 billion (about $3.8 million) in 2009 from Rp 16.99 billion in 2005, while district budget allocation grew to Rp 35.2 billion this year compared to Rp 3.7 billion in 2005.

“With the Indonesian Partnership Fund, the National AIDS Commission has managed to strengthen capacity of local AIDS commissions,” she said.

With this approach, Indonesia has seen a shift in the funding landscape for its AIDS response.

In 2006, despite the growing threat of HIV and AIDS in the country, the government failed to allocate a budget for the National AIDS Commission. This changed in the last two years, with national budget allocation growing to $2.4 million this year, Nafsiah said.

On the other hand, funding from international donors managed through the Indonesian Partnership Fund (IPF) decreased to $2.9 million this year, from $4 million the year before. And the GFATM awarded Indonesia with $2 million for the AIDS response, compared to $192,800 the year before, and $242,222 in 2007.

“We ourselves have to improve governance and find resources within ourselves in commitment to our responsibility,”
Nafsiah said.

Plenary rejects double standards

The third plenary session at the 9th International AIDS Congress on AIDS in Asia and the Pacific (ICAAP) on Tuesday highlighted the double standards governments around the region are employing in their response to the AIDS epidemic.

“What achievements can we hope for in empowering MSM while sex between consenting adult males remains illegal and subject to police harassment in at least 11 countries of the region?” asks chairman of the AIDS Access Foundation in Thailand Jon Ungphakorn in his presentation.

“How can harm reduction be fully achieved in Thailand, Indonesia and many other countries, when injecting drug users are still regularly sent to prison while the financiers of the drug trade remain free and powerful?”

In a session titled Inequality, Vulnerability and AIDS, Ungphakorn outlined that populations in society considered “vulnerable” to HIV infection were thus because they have been denied the basic human rights accorded to mainstream society, and are in fact victims of social prejudices and structural inequities.

These include the prison population, people who use drugs, sex workers, men who have sex with men, transgender communities, ethnic minorities, migrant workers, refugees and stateless people, the homeless and street people, as well as women who have sex with men.

“Because of their vulnerability, they are regarded as ‘high-risk groups’ and as ‘threats to society’, which often result in them becoming even more stigmatized and criminalized,” Ungphakorn said, adding that the situation becomes worse when the groups overlap, such as when sex workers are also migrants.

Further, stigmatization aggravated by inequalities around class, gender, and sexual orientation becomes the underlying condition in which population groups are lacking access to care and treatment, medical anthropologist from the University of the Philippines Michael L. Tan said in his presentation.

“People who are vulnerable and socially disadvantaged have less access to health resources, get sicker, and die earlier than people in more privileged social positions,” Tan said, citing a study published in PLoS Medicine.

He compared a Filipino living in Germany who received proper treatment and care when he discovered he was infected with HIV in the 1990s, while during the same period another Filipino living in the Philippines succumbed because he had no access to antiretrovirals, essential medicines and health care.

“Even with antiretrovirals subsidized by the government, the majority still have inadequate access to treatment and care because they could not afford the diagnostics, transportation and other expenses associated with such treatment and care,” Tan said.

“While we have learned of many praiseworthy efforts to direct financial resources and program interventions towards vulnerable groups in the region, unless the fundamental injustices which shape their circumstances are fully redressed, such efforts cannot lead to sustainable results,” Ungphakorn said in conclusion.

AIDS behind bars

The Kerobokan area in Denpasar, Bali, used to be a sleepy little hamlet with rows upon rows of rice paddies turning golden during harvest time, but in 1983, following new city planning, the government constructed a prison to replace the old Dutch-built penitentiary in Pekambingan.

Following the imprisonment of Schapelle Corby and the Bali Nine for drug trafficking in 2004 and 2005, the Kerobokan State Penitentiary gained a notorious reputation exacerbated by hundreds of websites detailing life behind bars.

“A nightmare destination not featured in any travel brochure,” Queensland-based newspaper The Courier Mail was quoted as saying in one website.

Faced with overcrowding, the prison became a breeding place for infectious diseases, including HIV. In 2000, a sero-survey of Kerobokan prison’s inmates found 35 people tested positive for HIV. It does not help that about 60 percent of the prison’s inmates were convicted for drug-related cases – the sharing of contaminated needles and syringes is identified as one of the main modes of HIV transmission.

Happily, conditions have improved since then, and a report in March 2009 said that based on sero-surveys conducted in the last three years, the number of inmates testing positive each year has steadied to between 12 and 14 people.

Attributed to the success of this is the establishment of an HIV and AIDS mitigation task force in 2004, and the implementation of harm reduction programs in Kerobokan.

Focusing on reducing the harm caused by needle and syringe sharing between people who use drugs, the inmates were taught that this behavior increases the probability of someone being infected with HIV.

“The program being implemented here has made them aware that needle and syringe sharing is a very risky practice because it makes them vulnerable to HIV infection,” task force head Anak Agung Gde Hartawan said in an earlier report.

A breakthrough in HIV mitigation efforts is the establishment of a methadone maintenance therapy (MMT) clinic in the prison. MMT is considered the most effective intervention available for the treatment of opiate dependence, and has been shown to be effective in improving the physical and social wellbeing of the patient. It has been associated with reductions in risk behavior, illegal drug use, criminal behavior, participation in sex work, unemployment, mortality and HIV transmission.

In Indonesia, MMT is available in only four prisons, namely Kerobokan, Cipinang and Pondok Bambu in Jakarta, and Banceuy in Bandung. Providing inmates with a regular supply of orally taken methadone, the program aims at weaning inmates off the habit of injecting drugs.

[This article was published in the 9th ICAAP congress newspaper, The 9th ICAAP Post]

Navigating the corridors of life

Contemplation: Two high school children visit part of an interactive exhibition that illustrates the life experiences of HIV-positive people. The exhibition, held in Discovery Mall, Kuta, runs through to Aug. 13.
(photo by R. Berto Wedhatama)

She’s called Tasya, she’s three years old, and she is living with HIV. Born of a former injecting drug user father and an HIV-positive mother, Tasya has never known a life without antiretrovirals (ARV), but her story does not end on a sad note. Tasya is now living with her mother and attends the Sekolah Ceria pre-school where she receives support from her teachers and is accepted by her peers.

“This just shows that people should never give up, no matter the circumstances,” Ari, a 15-year-old student from State Senior High School No. 1 in North Kuta, said Monday, commenting on Tasya’s mother’s struggle to get support and treatment for herself and her daughter.

The story of Tasya is one of five real life stories that visitors could experience at the One Life, Do Something interactive exhibition held at the Discovery Mall in Kuta, Bali, between Aug. 9 and 13, 2009. The other stories relate the life of Retno and Ahmad from Indonesia, Srey Mom from Cambodia, and Anjali from India.

While located a little far from the main plenary hall of the 9th International Congress on AIDS in Asia and the Pacific (ICAAP), the exhibition is well placed at where youths between the ages of 15 and 25 years old – an important key population in the AIDS response – mostly frequent.

“We want to educate the general public, bringing the life experiences of HIV positive people to light in the hope of reducing some of the stigma and discrimination that are usually associated with them,” Sari Estikarini, exhibition organizer World Vision Indonesia’s media relations, told The 9th ICAAP Post.

“Because very often discrimination is practiced by people closest to them – family members, friends, health service
providers,” she added.

Visitors are provided with MP3 players to guide them through the exhibition. Upon entering Tasya’s life corridor exhibition, you are greeted with the usual things related to babies – talcum powder and cotton balls, baby clothes and a makeshift batik cloth swing. But continue on through the corridor, you will discover bottles of pills and doctor’s prescriptions – things one would not usually associate with babies.

The corridor then opens up to a mock voluntary counseling and testing (VCT) clinic, where visitors can get sample results of an HIV test – “reactive” for a positive result, meaning you are infected with HIV, and “non-reactive” for a negative result.

Writings on the wall and the MP3 recording set the mood for people to contemplate getting these lab test results – teaching them how to avoid transmitting the virus to other people, as well as how to stay safe from being infected.

“This is where people can really feel how it is for people with HIV finding out for the first time they are infected, and in the next room, we provide a mirror for people to reflect on this experience, and make a life resolution” Sari said, explaining that the whole exhibition can be seen in 20-minutes, with a three-minute interval between each visitor.

They are then invited to write these life resolutions on a piece of cloth in the “Yard of Hope” section of the exhibition. They leave with a World Vision Indonesia bracelet to remind them of the experience, and a chance to browse through more information on HIV and AIDS on one of the laptops provided at the exhibition.

“We also provide a special room in case visitors are really interested in getting an HIV test,” Sari said.

The One Life, Do Something exhibition will also open in Surabaya on Oct. 9 to 11, and in Jakarta on Nov. 13 to 15, Nov. 20 to 22, and Nov. 27 and Dec. 1. For more information on the exhibition, visit www.onelifeevolution.com.

[This story was published in the 9th ICAAP congress newspaper, The 9th ICAAP Post]