MONITORING THE INCLUSION OF VAW AT THE NATIONAL LEVEL OF THE AIDS RESPONSE AND THE IMPLEMENTATION OF THE UNAIDS AGENDA FOR WOMEN AND GIRLS

1. MONITORING THE INCLUSION OF VAW AT THE NATIONAL
LEVEL OF THE AIDS RESPONSE AND THE
IMPLEMENTATION OF THE UNAIDS AGENDA FOR WOMEN
AND GIRLS
Researchers (in alphabetical order):
Aditya Wardhana, Nur Handayani, Oldri Sherli, Sari Aznur,
IAC (Indonesia AIDS Coalition) – IPPI (National Women HIV Positive Network) -
ARI (Indepentent Youth Alliance).
IAC (Indonesia AIDS Coalition) - Women Won’t Wait, 2011.
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2. A. 1. STATISTICAL DATA OF NATIONAL HIV & AIDS:
1. HIV Epidemic Profile on National Scope
Since its first case of HIV in Bali Province in 1987, the AIDS epidemic has been
increasing significantly in Indonesia. The Asian AIDS Commission report in 2006 said
that AIDS epidemic in Indonesia is considered as the fastest in whole Asia. From the
most recent report of Ministry of Health, HIV infection has been found in 33 provinces
in Indonnesia.
Within 13 years, AIDS cases which have been reported by Ministry of Health number
about 26.483 cases with 5056 death cases reported cumulatively from January 1,
1987 until June 30, 2011 (see Table 1).
Table 1
Number of New HIV/AIDS Cases by Year Reported
Year AIDS AIDS/IDU
1987 5 0
1988 2 0
1989 5 0
1990 5 0
1991 15 0
1992 13 0
1993 24 1
1994 20 0
1995 23 1
1996 42 1
1997 44 0
1998 60 0
1999 94 10
2000 255 65
2001 219 62
2002 345 97
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3. 2003 316 122
2004 1195 822
2005 2639 1420
2006 2873 1517
2007 2947 1437
2008 4969 1255
2009 3863 1156
2010 4158 1266
2011 s.d
Juni/thru' June 2352 365
Source: DirGen. Communicable Diseases & Environmental Health, MoH Indonesia
(13 July 2011)
If categorized according to age group, then the data will be:
Table 21.
Year 2006 Year 2011
< 1 year 37 265
1 - 4 year 70 318
5 - 14 year 22 212
15 - 19 year 222 821
20 - 29 year 4.487 12.288
30 - 39 year 2.226 8.342
40 - 49 year 647 2.595
50 - 59 year 176 742
1
Quarterly report of Ministry of Health taken via website www.spiritia.or.id
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4. > 60 year 38 106
If AIDS case number reported in 2006 is aggregated according to sex group, there
are 6.604 cases on male and 1.529 on female. If this data is compared with AIDS
case number reported on June 30, 2011 based on sex group, there are 19.139 cases
on male and 7.255 cases on female.
From this data, there is significant rise of HIV transmission prevalence on female
within the last 5 years. There is a gap concerning on the long-neglected transgender
group who are also prone to HIV infection. The data unavailability on transgender
group creates some difficulties in assessing prevalence rate among transgender
people and in establishing an accurate strategy and resource allocation needed to
prevent AIDS epidemic among transgender group.
AIDS epidemic in Indonesia is classified into two major groups, concentrated
epidemic in 31 provinces whose concentration is on AIDS key population group and
general epidemic in two provinces, namely, Papua and West Papua. Considering that
the majority of Indonesian regions have concentrated epidemic, the surveillance data
that is conducted regularly by Ministry of Health is limited to survey prevalence rate in
key population level and has not encompassed general household group.
For, particularly, Papua and West Papua, data shows that HIV prevalence occurs in
2,4% of population among 15-49 years2 age group, however the data is not
aggregated by sex group. One of challenges is that we do not have HIV transmission
prevalence data in municipal/town level.
HIV transmission prevalence on key population according to HIV and Behavior
Integrated Surveillance (STHP, key population) in 2007h, direct female sex worker
10,4%; and indirect WPS 4,6%; transgender 24,4%; WPS client 0,8%; male sex male
(MSM) 5,2%; injection-drug user (IDU) 52,4%. STHP data on these key population
groups is not aggregated by age group.
Within 5 year period, vertical HIV transmission rate in 2006 were about 123 cases
and raised significantly on June 30, 2011 period, numbering 742 cases. This is due to
several factors, among them are lack of PMTCT service and centralized in provincial
capitals, limited knowledge among female group especially women living with HIV on
PMTCT service and PMTCT program that is not well-disseminated and synchronized
with mother and infant health services.
2. HIV on female/male
According to the above data, it has been known that female groups are among the
most vulnerable group to get contracted to HIV infection in Indonesia. National
2
Integrated Surveillance on HIV and Behavior (STHP), 2007, Ministry of Health.
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5. Commission on AIDS Prevention data shows that more than 90% of HIV infection
among female occurs among housewife group. This situation implies a transmission
trend shift (second wave of epidemic) so that, in order to overcome it, a special HIV
prevention strategy is needed of which is formulated, addressed, and conducted by
women.
The Indonesian Ministry of Health report on HIV and AIDS cases in Indonesia, based
on age group, is not aggregated by sex (male and female) group. This is a big
challenge in measuring trend or situation tendency that female and female
adolescent groups must undergo in the context of AIDS epidemic in Indonesia.
3. Socioeconomic Profile of PLHIV
According to National Development Planning Agency (BAPPENAS) data through the
“Roadmap to Accelerate Achievement of The MDGs in Indonesia, 2010” report says
that Progress has been achieved in increasing the proportion of females in primary,
junior secondary schools, senior high schools and institutions of higher education.
The ratio of NER for women to men at primary education and junior secondary
education levels was 99.73 and 101.99 respectively, and literacy among females
aged 15-24 years has already reached 99.35. As a result, Indonesia is on track to
achieve the education-related targets for gender equality by 2015. In the workforce,
the share of female wage employment in the nonagricultural sectors has increased.
In politics, the number of women in the Indonesian parliament increased to 17.9
percent in 2009. Priorities for the future are to: (i) improve the role of women in
development; (ii) improve protection for women against all forms of abuse; and (iii)
mainstream gender equality in all policies and programs while building public
awareness on issues of gender.
Based on quick-assessment data conducted by Indonesia Positive Women Network
(IPPI) to all its members in almost 10 provinces shows that among IPPI members
who are women living with HIV and HIV-affected women (PLHIV spouse), 18,8 %
have attained middle school/similar educational level, 59,4% attained high
school/similar educational level, and 10,1% attained university/college level.
Aggregated data based on gender identity in Indonesia is currently unavailable
concerning on income and educational level.
4. HIV-affected children and adolescents
The number of orphaned children and adolescents categorized by sex group is not
available. The data unavailability created a major challenge in establishing mitigation
program that is needed by these orphaned children in order to maintain and improve
their living condition.
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6. Ministry of Social Affairs once had a pilot program by providing nutritional support for
PLHIV children and HIV-infected children, but the program was limited to four
provinces and discontinued.
5. Other Sexual Transmitted Disease (STD) Prevalence
Sexual Transmitted Infection (STI) has long been an indicator of AIDS epidemic
within key population. STI prevalence among Female Sex Worker (FSW) population
group from STHP 2007 shows a very high number of STI among direct FSW and
moderately high among indirect FSW.
There are few evidence on STI prevalence decrease among FSW. FSWs who are
infected by STIs such as chlamydia, gonorrhea, and syphilis have higher risk to
transmit or get transmitted by HIV. Chlamydia is the most frequent STI found within
the two FSW groups. Chlamydia and gonorrhea prevalence is among the highest in
Asia, and active syphilis prevalence is moderately high and dangerous.
The 2007 STBP report shows a high STI and HIV prevalence among transgender
group. HIV prevalence ranges from 14% to 34%, while rectal gonorrhea or chlamydia
prevalence ranges from 42% to 55%. Syphilis prevalence ranges from 25% to 30%.
Meanwhile, urethral STI prevalence is low (0-2%).
STI prevalence data on male sex worker and pregnant mother groups is unavailable
in Indonesia. The unavailability of STI data on pregnant mothers becomes a
contributing factor in transmitting vertical HIV.
6. ARV Treatment Access
ARV provision has become an important intervention in the national strategy to
prevent death and further HIV transmission. The available data shows that currently
there are 15.422 PLHIV who receive and consume ARV among 50.510 clients with
HIV that are currently in treatment process (see Table 2)3.
To date, Indonesia is able to produce 3 ARV regiments that have been licensed
according to Presidential Decree. However, productions of other ARV regiments are
delayed due to ARV production patent policy. Another ARV production-related
impediment in Indonesia is caused by the uncertified WHO pre-qualification
production so that the ARV industrial development potential to reduce selling price is
hampered.
The data also shows that Indonesia is getting better in performing this service.
Opportunistic-infection mortality that once reached 46% in 2006 could be reduced
into 17% in 2008. AIDS-related mortality among patients who consume ARV in 2008
was 11,2% and decreased to 10,8% in 2009.
3
Integrated Surveillance on HIV and Behavior (STHP), 2007, Ministry of Health.
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7. However, according to Civil Society Report for UNGASS AIDS 2010 says that, in
their founding, the affordability of ARV access is still problematic. PLHIV who reside
in municipal area or town still have to come to the provincial capital to get the ARV.
Similarly, the ARV availability is sometimes understocked in provincial level causing a
“drug-borrowing” culture among PLHIV. The availability of ARV syrup for children is
still questioned because currently children with HIV still consume half of adult dosage
via grinding. Recently, expired ARV is still distributed in almost all Indonesian
provinces causing much worry and disappointment among PLHIV.4
“…obviously it won’t work because it matters. In that area, ARV can only be available
in provincial capitals, and it is not convenient enough because they (PLHIV) who live
in municipal towns cannot access it and they need it so much…So, it is useless when
ARV is available but we cannot access it, death rate and prevalence are still high
because of transportation problem…” (FGD key population network, Jakarta)
Data on patient number categorized by sex and age group who receive ARV
treatment is currently not available in Indonesia. The available data does not
aggregate by sex and age group, therefore we are unable to identify the number of
female and female adolescents with HIV who consume ARV.
Table 2
Juni
2011
December
2008
Number
of
patients
%
Number
of
patients
%
Receiving
HIV
Treatment
81.960
36628
Not
qualified
to
medical
treatment
26.444
32.3
13268
36.2
Eligible
to
receive
ARV
55.516
67.7
23360
63.8
Not
yet
eligible
16.388
29.5
5480
23.5
Received
ARV
39.128
70.5
17880
76.5
Deaths
8.005
20.5
3612
20.2
Drop
out
4.918
12.6
2005
11.2
Transfers
to
other
hospital
2.777
7.1
998
5.6
4
Civil Society Report for UNGASS on AIDS 2010, UNGASS-AIDS Forum.
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8. Quit
1.641
4.2
649
3.6
Still
receiving
ARV
21.775
55.7
10616
59.4
1st
line
17.630
81
8444
79.5
Substitute
1st
line
3.586
16.5
1994
18.8
Transfer
to
2nd
line
8.29
3.8
178
1.7
Numbers
of
hospital
276
150
7. National HIV/AIDS Observation
Indonesia has accommodated the three-one principles and it has been strengthened
with Presidential Act No. 75 on National Commission on AIDS Prevention (NAC).
NAC becomes a coordinating agency of AIDS prevention program and is directly
responsible to the president.
The official observation system to record all HIV/AIDS and STD cases has been the
task and responsibility of Ministry of Health, which is also a member of NAC, through
data report on HIV/AIDS cases issued quarterly. Whereas official observation system
to record STD and behavioral cases is conducted by HIV and Behavioral Integrated
Surveillance (STHP) and Biological and Behavioral Integrated Surveillance (STBP)
which are conducted in every four-year period under the supervision of Ministry of
Health.
Data on non-consensual sexual intercourse as a means of transmitting HIV is not
available in Indonesia. This situation is worsened by the disaggregated data on
transgender people in classifying them HIV transmission category. It has been
criticized by civil society organizations that work on gender identity recognition or
transgender organization.
A. 2. NATIONAL STATISTICAL DATA ON VAW
1. VAW Case Profile on National Scope
Since 1997, Indonesia has National Commission on Elimination of Violence against
Women (Komnas Perempuan), which issues the Yearly Report containing data on
violence against women in Indonesia. According to Komnas Perempuan Yearly
Report namely CATAHU data published in 2011, it reveals general overview on
violence against women (VAW) cases during the year 2010. From documentations
gathered by Komnas Perempuan, the women victims are numbered about 105.103.
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9. From the data number above, it has been identified that violence pattern against
women is still dominated by Domestic Violence (KDRT) and Courtship Violence
(KRP) both numbering about 96% (equal to 101.128 victims). Community-level
violence against women is numbered about 3.530 cases, and national-level 445
cases—an eight-fold increase from 2009 data.
In 2010, sexual violence acts in domestic level (864 cases) and community level
(1.781 cases) are recorded. Sexual violence recorded by organizational partner of
Komnas Perempuan consists of sexual act, abuse, rape attempt, and rape. Komnas
Perempuan also records some VAW cases based on religion and morality.
The characteristics of violence perpetrator and victim against women, from the
acquired data, shows that both victims and perpetrator of KDRT/RP mostly come
from 25-40 years age group. Observing the data from organizational partner of
Komnas Perempuan, the VAW victims encompass all range of ages (except for
national-level VAW victims). The number shows an increasing number in 13-18 years
age group (adolescent age) and shows the highest number in 25-40 years age group.
The pattern shows that women in all age groups can be the VAW victims with female
adults and adolescents being the most vulnerable groups.
Location of violence, victim’s resident, educational level and wounds/trauma due to
violent acts are not available in the Yearly Report of Komnas Perempuan. The
Journal itself identifies VAW perpetrator: husband, ex-husband, boyfriend and ex-
boyfriend. In the occupational profile of VAW perpetrator, many of them hold public
service jobs (government officials, armed forces, policemen, members of
parliament/house of representatives, schoolteachers, religious figures, ministers).
Data on pregnant mothers who experience gender-based violence and female
mortality due to violent acts is not available in the Yearly Report. Whereas VAW data
based on special groups such as sex workers and drug users is also unavailable in
the Yearly Report but it is shown in the “Review” section.
Other data such as the number of VAW victims who have health access due to
violent acts, VAW cases reported to police, VAW victims who receive legal
assistance from government/non-government parties, and VAW victims who receive
psychological counseling from government/non-government parties are not available.
The Yearly Report is easily accessible and updated annually. The available data
scope is sufficient to overview the scale of problem within urban and provincial levels
to municipal/town and village levels. However, the available data does not list the
detailed number of VAW cases in municipal/town and village levels.
2. VAW Observation by the State
In Indonesia, we have recording system in documenting VAW every year. The
system is known as Yearly Report (CATAHU) issued by Komnas Perempuan in
which is published yearly on March 7. The Journal gives a general overview on VAW
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10. data in Indonesia during one-year period. The compiled data is derived from
organizational partners that provide service to address VAW cases, including
observational data from Komnas Perempuan itself, and encompass VAW case
analysis which has been observed for one year.
CATAHU has accommodated various VAW types such as physical, psychological
and sexual violence and it has also been categorized by age groups. It should be
noted that some forms of violence such as feminicide, violence against certain
women groups (lesbians, sex workers, female drug users, women living with
HIV/AIDS) have not been identified into the report.
On the commitment level, VAW observation by the State has been sufficiently
comprehensive, consisting of: complaint handling, referral assistance to medical
service for the victims, social rehabilitation program, legal assistance, counseling
service5 but one should note that, due to lack of monitoring and evaluation, these
services are not carried out effectively.
A. 3. NATIONAL STATISTICAL DATA RELATING HIV AND VAW (EDO)
1. State Observation on HIV and VAW
In Indonesia, integrating VAW problem as an influencing factor of AIDS epidemic has
not been considered as a main factor that needs to be concerned and addressed. In
government, and even AIDS-related NGOs, perspective, violence is a separated
issue and disassociated to AIDS problems. In the AIDS prevention program policy,
i.e. National Action Plan Strategy (SRAN) of AIDS Prevention 2010-2014, women,
female adolescents and children issues have received minor concerns that when the
SRAN is conducted in its implementation level a major gap occurs in addressing
women issues, including VAW.
In fact, Indonesia had AIDS Prevention Strategy for women and children in 2007.
However, according to observation, the strategy was never realized in a concrete
manner and there were no sufficient monitoring and evaluation.6
5
Presentation of Ministry of Women Empowerment and Child Protection
6
SRHR Report – Indonesia UNGASS-AIDS Forum, 2010.
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11. A. 4. QUALITATIVE AND QUANTITATIVE RESEARCH ON HIV, VAW, AND THEIR
RELATION (Sari)
1. Qualitative and Quantitative Research on VAW and HIV/AIDS
VAW is strongly related to the women’s vulnerability to HIV infection. There are
several factors that contribute to the higher risk of women of getting contracted to HIV
infection/transmission and disproportionally affected by HIV infection:7
• Culture-based sexual practice. For example: “gurah” (vaginal smoking) that is
believed to increase sexual pleasure for men, actually tend to cause injury on
vaginal lining during sexual intercourse because of lack of lubrication. Another
example: female genital mutilation.
• Social pressure to obey creates some difficulties for women to have their own
negotiating ability and to be assertive whenever they encounter with things they
dislike (for instance, to refuse sexual intercourse when she does not want it at
that time or to negotiate condom usage).
• Women subordination that makes harder for women to communicate their needs
or to negotiate safe sexual practices such as using condom.
• Economic and educational disadvantages force women to depend on their
spouse and other family member in order to survive. This hampers them to
communicate in an equal-level relationship, and it also becomes a major fear for
women to get out from abusive/violent partner. In addition, access to information
of health and HIV slows down because the unavailability of access to medical
and educational services due to poverty.
• Domestic and sexual violence; women often experience sexual violence both in
and outside marital relationship. This sexual violence increases the occurrence of
lesions around mucosal area of vagina due to the lack of vaginal lubrication.
Domestic violence indirectly contributes to women’s vulnerability to HIV infection.
Some studies shows that women who experience domestic violence by their
spouse have higher risk of getting transmitted by STIs than those who do not.
• Double standard imposed upon men and women. For example, young women
are expected to remain virgin until marriage and they do not need to know about
sexuality and reproductive health. Those who do want to know about sexuality
and reproductive health or information on both things are considered as immoral.
However, men are expected to know about sexuality and to have more
experience on pre-marital sexual intercourse.
• Social construct on gender role causing the transmission of HIV has more effect
on women (i.e. gender role of woman as a caretaker if a family member have
illness).
7
Factsheet Burnet Institute, “Perempuan dan kerentanannya terhadap HIV", cited from website.
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12. These contributing factors can be categorized into three major groups:
1. Biological factor – Physiological
• Female body is more “receptive” to HIV through sexual intercourse because of its
genital form.
• As declared by the UNAIDS, “heterosexual women are more vulnerable to be
infected because female genitalia is more exposed to sexual fluid.” Female
vagina has larger mucous lining and can take more sexual fluid than male penis.
Moreover, laboratory research shows that virus concentration is largely found on
seminal fluid rather than vaginal fluid. This increases the risk of HIV transmission
on women because bodily fluid exchange is the main cause of HIV transmission.
• During sexual intercourse, micro-lesion may occur. Micro-lesion is a tearing that
allows body fluid to enter the blood vessel. This tearing is typically found in
female children and adolescents, making them more vulnerable.
• Women who had sexual violence are more vulnerable to HIV. During a forced
sexual intercourse, HIV transmission risk is much higher because of vaginal
fluid. Particularly if the violence occurs on female adolescent whose vaginal tract
is not fully matured. According to a UNAIDS study in Rwanda, South Africa, and
Tanzania, the risk of women who had sexual violence is higher three-times more
than those who do not experience sexual violence. WHO estimates that almost a
quarter to a third of women in the world have physical or sexual violence by their
spouse during their lifetime.
• Childbirth complication that causes bleeding makes a higher possibility for blood
transfusion to women during this critical stage.
2. Socioeconomic factor
• Economic violence, coercion, and dependency on the majority of women makes
them difficult to negotiate sexual intercourse or to avoid highly risked sexual
intercourse.
• Women do not have control on sexual behavior and medical drugs with their
male spouse.
• Inequal economic growth that erodes social support has made some women to
become sex workers in order to make their living.
• Women often do not take test to see their health status because they are afraid
of violence, stigma, being abandoned by their male spouse of whom they are so
dependent.
• Unequal property and inheritance rights increase the vulnerability of women. In
South Asia and Africa, men usually have full control over property and asset. In
some countries, if a husband dies, property rights are not controlled by the
widow.
• In the situation of limited income resources in a family, education for male
children are more prioritized.
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13. 3. Sociocultural factor
• Bride-price and dowry practices often mean that men have larger control over the
life and property of women.
• In some countries, a married woman has higher status from legal perspective, for
example; she needs to get her husband’s permission to do many things.
• Women are often taught to give sexual decision to men; therefore women do not
need to know about sexuality and reproductive health.
• Some of social norms encourage men to have several female spouses. Men who
have many sexual spouses are regarded as masculine, while on the contrary,
women who have similar situation are regarded immoral and dirty.
• Female genital mutilation (FGM) or female circumcision is usually carried out
during children or adolescent age in several cultures. Some forms of FGM
increase higher risk of HIV transmission if unsterilized apparatus are used or if
there is a serious genital wound. Furthermore, FGM whose purpose is to inflict
wound on female sexual organ are usually carried out to reduce (or “to control”)
the ability for women to enjoy sexual intercourse.
• Child marriage is another form of practice that increases women vulnerability. In
major parts of the world, daughters usually get married sooner than sons. There
are some causes of child marriage: lack of self-protection awareness, lack of
power within relationship, family pressure forcing women to obey their husbands.
• Some cultural views that women are confined to domestic affairs, therefore they
do not need education and access to other information, especially on health.
Ministry of Women Empowerment is aware on the relation between VAW and HIV.
They note that in dealing with HIV problems, there are at least four contributing
aspects:8
1. Women often do not know the HIV status of their spouse and, certainly, do not
know their own.
2. Even if they already know about their HIV status, women are often afraid to tell
their family due to stigma and discrimination that would probably be imposed by
their own family.
3. In health service, women (and their spouse) tend to be ignored on their high-risk
behaviors so that the majority of HIV cases found are in their late stage—
unchecked in the early stage.
4. Promotion and health service program in preventing and alleviating AIDS often
place women as the objects of intervention. This is due to lack of gender
comprehension from health service workers and lack of dissemination of a
gender-sensitive AIDS prevention strategy.
8
Adapted from Pemberdayaan Perempuan dalam Pencegahan Penyebaran HIV-AIDS – Kementerian
Negara Pemberdayaan Perempuan RI, 2008
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14. In the level of civil society organization, VAW is not yet understood as a relevant
factor of AIDS epidemic. The programs that are currently being implemented are
mostly masculinized and, furthermore, the absence of gender-based HIV program
achievement indicator makes the issue oversighted.
Several civil society organizations had created qualitative review to overview violence
cases and pattern and State’s response in dealing with VAW from AIDS key
population groups. The recorded studies were conducted by IPPI, Intuisi, and
Yayasan Stigma.
The survey report of VAW on female PLHIV and female PLHIV partner conducted by
IPPI shows that the majority of respondents do not have any understanding on
violence, particularly domestic-level violence. From this survey, data shows that the
majority of victims do not know what they are supposed to do whenever they have
domestic violence. Economic-factor dependency makes this phenomenon as a
naturally-accepted experience by women living with AIDS.
Cultural factor in Indonesia in which patriarchy still dominates social structure of
society always creates women-insensitive policies, negligent to the protection of
weakened class in male-dominated world, even the potency of violence—both verbal
and non-verbal. The increasing rate of women who get transmitted by HIV from their
spouse, even to their babies, during the last five years is very relevant to VAW.9
Study conducted by Yayasan Stigma shows that VAW on female IDU are usually
done by law enforcements officers who are supposed to eradicate VAW.10 Female
IDUs have more complex problems than male IDUs, such as their vulnerability to
sexual and physical violence conducted by drug dealers, sexual partners or law
enforcement officers. Violence often happens if their spouse is also an IDU. Law-
related violence is typically experienced by respondents, ranging from verbal abuse,
snapped when the policemen interrogate them, even to shoe-throwing. Verbal and
physical violence that humiliates their dignity as a woman is often experienced.
Sexual abuse has also been encountered either from the drug dealers and their
rehab sponsor who are supposed to help and assist respondents in rehabilitation.11
In some areas, study conducted by Yayasan Intuisi underlines that cultural norms are
often relevant to the VAW pattern. In Timika, for instance, a region where HIV
prevalence has reached generalized epidemic, domestic relationship is heavily
influenced by the “women-purchasing” tradition. The offering of material things such
as goods, money, or farm animals to the bride from the bridegroom or husband
becomes a main requirement to hold a wedding. Even this “dowry” influences sexual
relation between husband and wife. Husband who has not paid off the “dowry” will be
regarded as an indebted person to his wife and is obliged to pay it off even with
several installments. And if it is not paid off, then the protection of wife’s family will
remain rigid. On the contrary, if the husband can pay off the dowry then he will have
9
“Discordant couple research in 5 cities, Intuisi Research, 2009.
10
“Pengalaman Perempuan Penasun dalam mengakses layanan Harm Reduction”, Yayasan Stigma
2010
11
Women in the drug circle, IHPCP Ausaid, 2007.
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15. full ownership upon his wife and the wife’s family will no longer protect her. Even if
the husband conducts violence against his wife, the wife’s family can no longer have
a strong bargaining position.
The Muslim-majority population of Indonesia also becomes a contributing factor to
VAW. The female genital mutilation is still being carried out in Indonesian society.
Ironically, the Ministry of Health issued Ministry of Health Decree that regulates
female genital mutilation procedure.
From the studies that we have reviewed, none of them is encouraged, conducted, nor
financially supported by local/national government. Most of them are financed by
international donors.
Research studies conducted in Indonesia do not describe the relevance between
VAW and HIV/AIDS transmission. None of these studies explicitly states about the
impact of VAW on HIV. The studies are conducted separately, of which violence is
regarded as a part of female PLHIV experience.
Only very few research studies involve the community as researchers, whereas the
vast majority of studies involves the community as respondents for data gathering.
A. 5. STATE REGULATORY LAW ON VAW AND HIV
1. National regulatory law on HIV and VAW
Indonesia has signed the CEDAW (Convention on the Elimination of All Forms of
Discrimination Against Women) and ratified the Law No. 7 Year 1984. During the era
of post-ratification of CEDAW into Law No. 7 Year 1984 that has been going for the
last 27 years, there are still found some of regulatory laws and others regulations
contrary to the CEDAW so that it creates ambiguity in implementation level.
An example of regional law contrary to the CEDAW can be found in Regional Law
(Perda) of some parts of Indonesia. Komnas Perempuan data shows that
discriminatory Perda against women in early 2009 are 154 laws. This number keeps
increasing. To the end of September 2010, there were 35 additions of this kind of
Perda. Discrimination against women is found in the form of freedom of expression
restriction upon women through clothing regulation and reduced legal protection.
Aceh sharia bylaws abuse women and the poor: Report12
The Jakarta Post | Thu, 12/02/2010 11:05 AM
“God will punish us by sending another great earthquake and tsunami if we don’t
uphold and enforce sharia [Islamic law] in this land,” says a resident of Banda Aceh.
This well-educated man, who prefers to remain anonymous, was referring to a series
12
Cited from http://www.thejakartapost.com/news/2010/12/02/aceh-sharia-bylaws-abuse-women-and-
poor-report.html
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16. of bylaws known as qanun that effectively have been applied in the province since
2005. According to the Asia chapter of the Human Rights Watch (HRW), which
announced the results of its most recent survey on Wednesday, the enforcement of a
bylaw on clothing requirements and another on relationship between genders robs
people, especially women and those of the lower and middle classes of their rights.
The research, conducted from April to September this year, involved more than 80
respondents, including rights abuse victims, such as women, as well as locals and
government officials throughout the province widely known as the Mecca’s Terrace.
HRW deputy director for Asia, Elaine Pearson, said, “[The two bylaws] deny people’s
rights to make their own decisions about who they can meet and what they can wear.
The bylaw and their selective enforcement are an invitation to abuse.”
Since 2002, Aceh’s legislature has issued five qanun including the two. The other
three are on alcohol consumption, alms and gambling.
Pearson added that the bylaws did not seem to apply to the military and people who
had high social status.
The HRW cited several cases of abuse, including the rape of a young woman by
sharia police officers during her detention and aggressive interrogations.
There are currently 6,300 official sharia police officers in Aceh, who have strong
grassroots support.
According to the HRW, officers often act on their own as vigilantes.
“These officers easily arrest men and women who are simply eating in food stalls,
riding on motorcycles or carrying out routine activities for the smallest perceived
infractions. Although the bylaws do not differ between genders, most of the people
arrested are women,” Pearson said.
She added that many of the women were arrested for wearing jeans or other
relatively tight clothing. Last year, sharia police arrested more than 800 people under
the bylaw regulating proper conduct between genders and more than 2,600 under the
bylaw regulating Islamic clothing.
HRW coordinator for research Christen Broecker went into detail on the report of
Nita, the 20-year-old college student detained and raped by sharia officers.
Nita, not her real name, told the HRW that sharia police arrested her and her
boyfriend in January 2010 while they were taking a shortcut through a coconut
plantation in Langsa, East Aceh, to pick up Nita’s younger sister after school.
“When my mom came to get me [from the sharia police office] at 7 a.m., I was crying.
The head lecturer at my campus, Doni, was there to scold me. A sharia police officer
told him that I had been caught [on an isolated road on a motorcycle] with my
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17. boyfriend. He told my mom and me that I should be stoned to death. I said, ‘Sir, I was
only trying to look for a shortcut and why should I be stoned for that? What about the
officers who raped me last night,” she said.
Two of the three accused officers were convicted and sentenced to eight years in
prison in July 2010, while one remains free.
Broecker said that it was hard to learn who victims were and to find those willing to
testify on abuse.
“Our report cites four cases of abuse under the bylaws but we are certain there are
many more. They are afraid to testify and there isn’t any official institution for these
victims to report cases,” she said, adding that people who had enough money could
hire lawyers.
She said that the HRW recommended in the report that the government should
support local NGOs and establish legal aid institutions so that abuse victims from
lower- and middle-class households could come forward and receive help.
The HRW is urging the Aceh Council to revoke both of the bylaws and the Aceh
governor to stop violent acts by sharia police officers.
The report also shows that most government officials do not agree with the two
bylaws. However, the sharia bylaws are heated issues that could have a direct
political impact. The HRW report can be found on its website, www.hrw.org. (rch)
Based on our observation, there are some improvements in the response of state
policy in addressing VAW-related problems. There are seven regulatory laws related
to the elimination of violence against women and children, among them are: Law No.
3 Year 1997 on Juvenile Court; Law No. 23 Year 2002 on Child Protection; Law No.
23 Year 2004 on Elimination of Domestic Violence; Law No. 13 Year 2006 on
Witness/Victim Protection; Law No. 21 Year 2007 on Combating Human Trafficking;
Law No. 44 Year 2008 on Pornography; and Law No. 36 Year 2009 on Health.
State Ministry of Women Empowerment then issued State Ministry of Women
Empowerment and Child Protection Law (Kemeneg PP) No. 1 Year 2010 on
Minimum Service Standard (SPM) in Integrated Service Sector for Women and
Children Victims of Violence on January 28, 2010 and this is a breakthrough in
complying women and children victims of violence. The birth of SPM is a positive
response from the government following the ratification of those seven regulatory
laws.
For the implementation of these laws, Ministry of Women Empowerment and Child
Protection regulates minimum standard service and standard operational procedure
(SOP) that will become a guideline in implementing integrated services for women
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18. and children victims of violence by relevant ministries and institution and Integrated
Service Center (PPT).
In relation to comprehensive sexual education, Indonesia still faces many challenges
in its implementation. In the Law on Health No. 36 article 72 states that “every person
has right to obtain accurate and reliable information, education, and counseling on
reproductive health.” But in reality, due to the rigid social, cultural, and religious
norms, this kind of education is only reserved for married couple and not for school-
age teenagers.
Indonesia has regulatory law on HIV and AIDS in workplace that has been included
in Ministry of Labor Decree No. 64 Year 2004. However, there are still many PLHIV
who are fired from workplace because of their HIV status. The implementation of this
decree has not been effective yet because it needs technical regulation as a
guideline of implementation.
Indonesia still does not have specific regulation on the confidentiality of voluntary HIV
diagnosis. This confidentiality is regulated in the general confidentiality rule of the
Medical Code of Ethics and Health Law. For the provision of free medical drugs,
Minister of Health issues List of Essential Drugs Decree subsidized by the State and
for ARV since the issue of Minister of Health Decree No. 1190/Menkes/SK/X/2004 on
free provision for tuberculosis and ARV drugs.
In Law No. 52/2009 on Population Growth and Family Development article 23 – 26
states that contraception can be accessed by married couple only, and sexually
active adolescents cannot get contraception service.
Independent Youth Alliance (ARI) documentation in Jakarta shows that pap smear
test form still contains “Ms.” and “Mrs.”. In addition, there is a regulation that
unmarried female adolescents should be accompanied by parents and married
female adolescents should be accompanied by husband. The reason behind this
Ministry of Health regulation is that women are regarded as powerless and should be
protected by others. This situation put many female adolescents to avoid the service
rather than stigmatized and discriminated. In this context, the government has
violated female adolescents rights to access sexual and reproductive health services.
In Health Law No. 36/2009 article 75 – 77 on abortion, abortion is generally
prohibited by the law and the government is obliged to protect and prevent women to
have abortion with the exception of those who have certain uteral problem or those
who have fatal risk or rape victims. These articles state, several times, that the
abortive regulation refers to religious values and norms, whose relativity is debatable,
and do not refer to universal human rights values.
Article 76 explains about abortion access procedure, i.e. abortion can be done at six
months gestational age at maximum and must obtain permission from husband,
unless the abortee is a rape victim, and health service provider according to
ministerial decree. This regulation makes women rightless to their own bodies
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19. because they need permission from husband to have an abortion and, thus,
unmarried women cannot access this service.
The regulation on abortion is not well-disseminated to general public. The bill draft on
regulatory law and ministry of health regulation that regulate safe abortion as the
operational mandate of Health Law is being initiated by Indonesian Obstetrics and
Gynecology Development (POGI) and women organization network of which this
legislation is assisted by Yayasan Kesehatan Perempuan.
B. HIV/AIDS AND VAW: PROGRAM AND SERVICE IMPROVEMENTS.
1. HIV/AIDS policy and government norms in health service
According to the policy issued by Ministry of Women Empowerment and Child
Protection via State Ministry Law PP No. 2/2008 on Women Protection
Implementation Guideline shows that this ministerial law has comprehensively
accommodated services that should be provided to female victims of violence.
As for five services that should be provided to female victims of violence according to
the regulation are:
1. Complaint handling
2. Health service
3. Social rehabilitation
4. Legal assistance
5. Repatriation and reintegration
These services are provided referring to the minimum service standard (SPM) in
which female victims of violence may access assistance and support according to
Ministry of Women Empowerment and Child Protection Act No. 1/2010 on Minimum
Service Standard Integrated Service Sector for Female and Children Victims of
Violence. In its implementation, this regulation still faces challenges regarding its
qualities. Female victims of violence often encounter some difficulties to access legal
assistance and health services. Implementation of this regulation is weakened by the
absence of monitoring efforts and sanctions to the parties who ought to carry out the
regulation.
In the health service components for female victims of violence according to Ministry
of Women Empowerment and Child Protection Act No. 1/2010 on Minimum Service
Standard Integrated Service Sector for Female and Children Victims of Violence, the
health service refers to all efforts that includes promotive, preventive, curative, and
rehabilitative aspects. Whereas in its implementation, the health service only
encompasses investigative findings and physical wound treatment and counseling for
traumatic victims.
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20. PEP, EC, and IMS services are not integrated with health service for female victims
of violence. According to State Ministry Law PP No. 1/2010 on SPM for Female and
Children Victims of Violence, the major difficulty of health service is the lack of
medical staff for mental health specialists, forensic experts, psychologists, and well-
trained counseling personnel. Abortion is another service that can be accessed by
female victims of violence, such as rape, only if the victims become pregnant (Health
Law No. 36/2009).
In Health Law No. 36/2009 article 75 – 77 on abortion, abortion is generally
prohibited by the law and the government is obliged to protect and prevent women to
have abortion with the exception of those who have certain uteral problem or those
who have fatal risk or rape victims. These articles state, several times, that the
abortive regulation refers to religious values and norms, whose relativity is debatable,
and do not refer to universal human rights values. Article 76 explains about abortion
access procedure, i.e. abortion can be done at six months gestational age at
maximum and must obtain permission from husband, unless the abortee is a rape
victim, and health service provider according to ministerial decree. This regulation
makes women rightless to their own bodies because they need permission from
husband to have an abortion and, thus, unmarried women cannot access this
service.
“A female, 27 years old, having gestational age of 4 months. She’s unmarried, and
therefore must take abortion in Bekasi area. Its price is relatively higher Rp1,5 million
than the official price under Rp1 million (in 2008). This price depends on gestational
age, if it is under 3 months you pay less than Rp1 million.” (In-depth interview with a
female PLHIV, Jakarta)
“Abortion is considered illegal and prohibited. If there’s anyone who have abortion,
then she’ll be accused of criminal act.” (In-depth interview with a female sex worker,
Jakarta)
“The regulation prohibits teens to have abortion.” (In-depth interview with a female
teenager, Bogor)
“No (information) at all. When you come, abortion is taken place. You just take the
drugs and are explained how to use them.” (In-depth interview with a female sex
worker, Jakarta)
The regulation on abortion is not well-disseminated to general public. Legal abortion
service can be accessed in communities although it is deliberately concealed by the
local government and communities. Unmarried pregnant women gets the illegal
abortion services with much higher price than the legal one (it also depends on
gestational age). The absence of legal abortion service leads to unsafe abortion
procedure.
“One of the victim wanted to access Raden Saleh clinic, but because there were
many procurers ask her to visit cheaper clinics. Eventually, she got bleeding for 3
weeks and she was hospitalized. It happened when I was in the 3rd class of high
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21. school and the price was 2 millions, let alone transportation cost to Jakarta from
Bogor.” (In-depth interview with a female teenager, Bogor)
“I have no idea about the law, but I’ve heard about abortion stuff. It usually happens
among my PLHIV friends, when they want to have abortion they usually cover it up
and have the abortion in illegal clinics.” (In-depth interview with a female PLHIV,
Jakarta)
Even though abortion service is illegal in Indonesia, there are some NGOs and
hospitals that provide safe abortion service. In several hospitals, the abortion service
is conducted by an expert medical surgeon, but they only cover the abortion service.
Whereas in some NGOs, this service includes pre-abortion counseling, abortion, and
post-abortion assistance (if necessary).
“In PKBI DKI there’s a clinic for counselling and the doctor is well trained, but it’s only
non-medical abortion. If you want to have abortion by taking pills, you can have it in
Samsara Jogjakarta, and a counselor there helps you through the process.” (In-depth
interview with a female teenager, Bogor).
According to Minister of Women Empowerment and Child Protection Act No. 2/2008
on protection to female victims of violence also includes the victims of domestic
violence. One of the subjects of this act is the household group, comprising around
40.000.000 – 50.000.000 households in Indonesia.
Services or treatments provided are: Complaint handling, health service, social
rehabilitation, legal assistance, and repatriation or reintegration. In the
implementation level, female victims of domestic violence receive psychological
counseling, consultation, and legal assistance. Some civil society organizations
provide shelters or reservation house for the victims if necessary.
The protocol for HIV prevention to infants is the national guideline of mother-to-infant
transmission prevention issued by Indonesian ministry of health in 2011, in which
encompasses sexual and reproductive health treatment. Prong 1 states about HIV
transmission prevention for reproductive women through primary prevention of which
it gives awareness to them and health service providers, builds community
involvement, and creates an HIV-friendly mother and infant treatment so that the
spouse can involve too. Prong 2 consists of prevention on unplanned pregnancy for
HIV-positive reproductive women who need counseling, HIV test, and safe and
effective contraception services. In Prong 3, prevention method emphasizes on
mother-to-infant transmission prevention through several steps: comprehensive
treatment for mother and infant, counseling and HIV test, antiretroviral drugs,
counseling on HIV and baby food and safe childbirth method. Prong 4 explains on
how to provide psychological and social supports and health treatment to HIV-
positive mother, infant, and the family.
Overall, the protocol has encompassed sexual and reproductive health treatment for
HIV-positive women in which consists of recommendation on double protection and
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22. parenting method. However, the protocol does not mention or give information on
VAW prevention and treatment.
Based on in-depth interviews with HIV-positive women and sex workers on
treatments for WLHIV, only PMTCT and pap-smear services that are available and
easily accessed. Comprehensive information on PMTCT is still difficult to find by
respondents. The awareness of WLHIV and female sex workers in accessing the
service is still low due to the severe stigma on WLHIV.
Stigma and discrimination still happens whenever health service workers know the
HIV status of WLHIV. They are placed into the last number during examination
process and they are asked about their HIV status (which can be seen from medical
record) with a judgmental tone. To this day, HIV-positive women are often confused
after taking health test. For example, if they encounter financial problem, they are
usually unwilling to continue into the next step. In one case, they received free pap-
smear test service, but the providing organization does not inform the result.
Regarding PMTCT service, WLHIV reproductive rights are often violated in which
they are forced, or without their consent, to get sterilized. According to the
documentation of limited cases gathered by IPPI in 2009, there are 4 provinces in
Indonesia that report sterilization cases. In 2010 – 2011, additional 2 provinces report
the similar case.
“In state hospitals, PMTCT information service is not given to PLHIV who have just
realized their HIV status. Even I don’t know at all on PMTCT steps, and it is not
detailed.” (In-depth interview with an HIV-positive female sex worker, Jakarta)
“There was a woman who take pap-smear test and she’s unmarried, then she’s
asked whether she is married or not. ‘You’re unmarried but you want to have pap-
smear test?’ Then, she got the last number, it was a discrimination.” (In-depth
interview with an HIV+ female, Jakarta)
One of the subject of Ministry of Women Empowerment and Child Protection Act No.
2/2008 is the female victims of violence during armed conflict and disaster which
accommodates 33 provinces and 485 municipalities/towns in Indonesia. This act also
targets female adolescents with estimated number of 15.000.000.
In the State report for UNGASS AIDS in 2010 shows the availability of Post Exposure
Prophylaxis (PEP) of 10.621 health services, only 1,41% of them provide PEP
service. The lack of information on PEP creates difficulty to receive comprehensive
explanation on the service. However, no data found whether this service has
accommodated treatment for sexual violence victims.
Post exposure prophylaxis in HIV-related jobs, particularly in harm reduction
program, is sufficiently informative in which the workers are provided with the ability,
skill, and care on themselves in performing exposure prevention by using tools that
may prevent HIV exposure such as gloves or clasps and the post-exposure
procedure including the prophylaxis. However, the institutions or employers do not
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23. give further guarantee to their workers, even if there is a worker who gets contracted,
it is usually considered as occupational risk.
Informational access or contraception service for unmarried youths is not facilitated
by the government. Law No. 52/2009 on Population Growth and Family Development
article 23 – 26 states that contraception can only be accessed by married couples,
thus sexually active teenagers cannot access the contraception service.
To this day, the most frequent service is consultation service prior to choosing
contraception, which are mostly used by women, not counseling service.
Contraception promotion all this time is emphasized on women, especially permanent
contraception (besides condoms). Contraception drug (to weaken the sperm) was
developed in around 2008 – 2009 for male. The government and foreign donors
spent huge fund for its development. The high gender bias in Indonesia makes this
kind of contraception unpopular and it is never heard since.
Contraception use for WLHIV is suggested when accessing PMTCT service on
pregnancy planning. In the implementation level, sterilization is also offered to
prevent later pregnancies for WLHIV.
The recommendation of using emergency contraception (EC) such as KB pills is
widely available in Indonesia. KB pills and other contraception programs can only be
accessed by married women. Information on EC is very limited.
Consuming pills such as postinor cannot be distributed in supermarkets or public
commercial stores. Legalization process of EC is against the Health Law No. 36/2009
from which religious leaders oppose the wide distribution of EC, including postinor.
National recommendation or guideline on HIV infection treatment is basically a
general information and there is no classification based on age groups. The content
itself does not describe requirements on certain groups. Sexual and reproductive
health issues are not explicitly discussed, only information on types of sexual
transmitted disease without referral system nor treatment recommendation.
HIV infection treatment guideline for adults, adolescents, and children remains
unknown to general public. All HIV-related treatment services can only be accessed
by PLHIV after getting referral from clinics. In hospitals, inpatient children of 11 years
old above are considered adult treatment service because there is no special
treatment for adolescents. Lack of information and HIV-related treatment method
makes doctors assume the right dose of ARV for children, and this situation is
worsened with the absence of ARV syrup or powder. HIV-related information service
provided to PLHIV on opportunistic infection is only basic-based service with
maximum time of 5 minutes because state public hospitals handle too many patients
so that they only have very limited time allocation. In addition, PLHIV are stigmatized
“In hospital, children care is different. No service for adolescents, they are treated
like adults. Twelve year-old children are categorized as adults. There are
hospitalized men, women, and children, children of 12 – 15 years of age are
treated in adult room.” (In-depth interview with a WLHIV, Jakarta)
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“In fact, medical knowledge among nurses is different to each other, so the
patients are often confused when they want to access the servie.” (In-depth
interview with a female sex worker, Jakarta)

24. whenever healthcare workers know their HIV status, usually around questions on
how and where they got transmitted.
2. HIV Test, Treatment, Care, and Supporting Services
The State’s integrated service package for HIV, tuberculosis, and sexual &
reproductive health, including harm reduction service is widely available. However,
accessing reproductive health-related service is confusing for women, whether they
should take mother and infant health service or IMS examination, lack of
comprehensive service on female-related problems especially in addressing and
responsing VAW and vertical transmission prevention and treatment. The services
are not integrated enough that create difficulty to access them.
Free, confidential, and voluntary VCT and HIV counseling are available in Indonesia,
but they still lack of women-friendly services so that many women are not
comfortable to access them, especially when they reveal their HIV status or violence
that they had. The HIV counseling service never discusses on violence, neither
information on harm reduction strategy for female victims, post-violence strategy or
measures, nor referral system because the HIV counseling protocol does not
integrate VAW.
According to HIV/AIDS Counseling and Testing Service Guideline issued by Ministry
of Health in 2006, VCT service can facilitate and provide relevant referral on behavior
change, PMTCT intervention, early management on opportunistic infection & IMS
including ARV introduction, prevention and treatment therapy on reproductive
infection, social and peer support referral, HIV/AIDS normalization, future planning,
orphan care, inheritance, serostatus acceptance and self-treatment coping.
The protocol does not explicitly mention and actively persuade to fight discrimination
and violence against all groups of women and female adolescents. The protocol does
mention about confidentiality of client as a part of patient or client rights, but does not
clearly explain on sanction and impact of status disclosure.
HIV/AIDS Counseling and Testing Service Guideline issued by Ministry of Health in
2006 does not establish a system that can filter violence that has been experience by
a female client. Lack of counselor knowledge on violence issue makes this system
underdeveloped. Counselors in HIV/AIDS VCT service are trained to give information
on HIV/AIDS, IMS, and high-risk behavior.
The pre- and post-counseling protocol explains the typical requirements for women in
situation of violence, among them are:
- Information on harm reduction strategy for female victims of violence.
- Alternative models on HIV status disclosure, including disclosure method through
mediation of friend or counselor.
- Information on HIV risk in marital relationship.
- Information on strategy in negotiating condom (which is much safer).
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25. - Referral to gender-based violence service or peer groups working on this issue.
- Referral to social or psychological support center.
According to HIV/AIDS Counseling and Testing Service Guideline issued by Ministry
of Health in 2006, pre-counseling activities encompass HIV-based information,
reasons of VCT, and communication on behavioral change. Whereas post-test
counseling helps client to understand and adapt to the test result. Counselor also
persuades client to discuss strategy to prevent HIV transmission.
Female clients do not obtain sufficient information on harm reduction program,
referral to gender-based violence service, and condom-using strategy. The positive
side is that the service helps them in providing alternative information in HIV status
disclosure by giving a proper information on HIV/AIDS to the family members and
gives referral to PLHIV peer-support groups.
Healthcare service for pregnant mothers in Indonesia are not automatically integrated
with PMTCT service. Due to this unintegrated service, many pregnant mothers do not
know about HIV/AIDS-related information and the importance of HIV testing during
pregnancy. Violence-based information is still technically medical, in which pregnant
mothers are suggested to avoid things that may cause miscarriage.
In the government-based PMTCT program in several referral hospitals, the hospital
workers do not prevent the violence itself. Instead, violence occurs in the form of
forced sterilization on HIV-positive women. Counseling for HIV-positive pregnant
mothers is seen as uncomfortable because of the stigma and prejudice from
healthcare service workers that HIV-positive women should have not have babies or
HIV disease is correlated with immoral acts.
Treatment and medication service that encompass sexual and reproductive needs
are available and can be accessed by general public including WLHIV such as
Mother and Infant Clinic and IMS Clinic. In the AIDS issue, IMS clinic is actively
disseminated to the key population group including WLHIV. The challenge for WLHIV
is how to access the service. Sexual and reproductive health service is still
segmented in Indonesia, therefore when a woman has problems with her
reproductive health, she does not know whether should visit mother and infant clinic
or IMS clinic. Whereas in IMS clinic, the service is only in the form of detection of
illness and Reproductive Tract Infection (ISR) is not the main focus in this service.
Another challenge is the difficulty to access healthcare service when women have
sexual dysfunction problems. Healthcare service that can accommodate this kind of
service is rare in Indonesia.
Healthcare service that accommodates WLHIV to have children and to choose
contraception methods can be accessed in PMTCT service. Cervical cancer
examination can be obtained in IMS clinics. With the lack of information on sexual
and reproductive health for WLHIV found in the Need Assessment Survey 2010
(conducted by IPPI) and segmented healthcare services put some difficulties for
WLHIV in maintaining, improving, and treating their sexual and reproductive health.
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26. PEP availability of 10.621 healthcare services within all Indonesian regions can only
be able to be distributed in 1,41% of all the total number.13 The lack of information on
PEP provision is still a major challenge. We are not sure whether PEP provision for
victims of sexual violence has been given or not.
Healthcare centers that provide free HIV & syphilis test and counseling are mostly
operated by social organizations even though there are some local healthcare
service provide the service in their IMS program.
State report for UNGASS AIDS in 2010 shows that the number of healthcare facilities
providing HIV test and counseling increased from 290 units in 2007 to 547 units in
2008. Meanwhile, the number of clients above 15 years of age increased from 53.929
persons in 2007 to 109.544 persons in 2008.14
There are many hospitals and clinics, both private and public, that provide HIV test
service, but not all of them have pre- and post-test HIV counseling. Particularly for
private hospitals and clinics, they usually do not have counseling service.
Unfortunately, for hospitals and clinics that do have the service, specific service for
adolescents is still absent as they are still considered as adults. Prior to counseling,
the officer asks several questions that make adolescents uncomfortable because the
registration desk is placed in the same room with the waiting patients and they can
hear the questions.
Counseling service in some clinics and hospitals is conducted by adolescent-friendly
counselors but there are also counselors who asks as if it were an interrogation and
unfriendly to adolescents. Confidentiality is guaranteed and the information given is
still around IMS and basic knowledge of HIV and AIDS, and not includes SRHR.
Some of the clinics are not strategically located. The average working hour is at 9 am
to 5 pm. Several NGOs conducted research visit to take HIV test. Counseling was
given during the visit even though it was not quite comfortable (there was no special
room for counseling, only separated by partition).
The medical staff workers who provide HIV/AIDS services have been trained in
sexual and reproductive health through IMS clinics and VCT clinics. However, the
sexual and reproductive health service is focused on IMS only, thus it is difficult for
those who want to consult about ISR. Gender and violence knowledge is still limited
among the staff workers in HIV/AIDS service so that clients will not receive this kind
of information from them.
3. VAW Service
The type of service in addressing VAW consists of complaint and situation handling,
healthcare service of which the victims are provided with treatment service, trauma
13
UNGASS Country Progress Report – National AIDS Commission, 2010.
14
Presentation of Ministry of Health for UNGASS on AIDS Report, 2010.
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27. counseling, reproductive organs trauma treatment, legal assistance, social
rehabilitation, and repatriation.
The service encompasses all kinds of violence against women and children. It
includes domestic violence, sexual violence, and violence during armed conflict and
disaster. The availability of service can be accessed in provincial capitals and due to
the vast geographical areas of Indonesia, the service still faces a major challenge in
order to be accessed by women who live in the remote villages. The service is
managed by the government and civil society. For example, social rehabilitation
program, in the form of shelter house, is managed by both the government and civil
society. Unfortunately, the violence service does not provide HIV-related information,
counseling, and test.
There is no HIV risk examination on violence victims. The only available service is
only confined to special treatment on the violence itself.
The service cannot be accessed comprehensively as some forms of service are
unavailable such as minimum information on PEP. We are not sure whether PEP for
sexual violence victims has been given or not. Legalization process of EC is against
the Health Law No. 36/2009 from which religious leaders oppose the wide distribution
of EC, including postinor. The only available services are medical and psychological
(through counseling) treatments. However, counseling for PEP and HIV service users
is not yet carried out due to the lack of information on PEP and HIV of which the
treatment is carried out separately and exclusively so that it is not integrated with any
other issues. Therefore, ARV treatment cannot be given immediately.
Training for healthcare service workers is still not optimum causing slow
implementation process. The service cannot be performed in just one place or by a
single person.
Healthcare service workers, civil society organizations, and shelter houses have not
yet been trained on the relation between HIV and VAW. Ministry of Women
Empowerment has published a manual on HIV/AIDS and women, but the
implementation of this manual is still questioned.
Concerning HIV/AIDS service, healthcare service workers have received information
on key population groups such as LGBTIQ, IDU, sex workers, etc. which is given
through training or workshop. But to this day, these key population groups still face
discrimination from healthcare service workers.
Healthcare service workers only specifically give treatment to women and children.
The lack of information on managing women groups with various backgrounds makes
it difficult to measure sensitivity of healthcare service workers in this issue.
There are shelter-houses managed by either the government or civil society
organizations, in which post-trauma counseling programs and activities such as
sewing can be seen. However, these shelter-houses still lack of information or
capacity building to help the treatment process when violence case occurs.
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28. Police department, through public service unit, also provides a service focusing on
women and children served by female police officers. The legal assistance is also
provided by the government or civil society.
4. Supply Availability
Male and female condoms and lubricants can be accessed for free through AIDS
program under the “condom outlet” strategy in which the field officers and NGOs
working on HIV/AIDS prevention and outreach to the key population groups actively
promote condom and distribute it to the key population group. Female and male
condoms and lubricants are available in drugstores and supermarkets so that it can
be easily accessed. EC availability still faces major challenges, however, in Indonesia
due to the lack of information and strong opposition from religious leaders.
According to research conducted by UNGASS Forum Indonesia for Sexual
Reproductive Health & Rights (SRHR) in 2010 explains that Social Department in
several provinces distributes powdered milk for HIV-infected women who have
children. However, this nutritional support is not widely distributed in Indonesia with
vast and remote geographical areas.
Free distribution of modified milk for WLHIV children is not well-distributed and is not
provided regularly. The program is implemented if there is budget allocation for it and
in provinces where the program enlisted in regional revenue and expenditure budget
(APBD). Sometimes, disorganized distribution occurs causing some difficulties for
HIV-positive women to access the modified milk. It can be concluded that free
distribution of modified milk depends on the budget and the involvement of social
department workers.
Free ART provision and drugs for opportunistic infection treatment and prevention,
including vertical HIV transmission treatment, can be accessed in referral hospital or
selected private hospitals. Although the drugs are free, we still have to pay
administration fee and doctor consultation (sometimes the doctor does not perform
examination, only makes the prescription).
In UNGASS state report in 2010 on ART treatment, opportunistic infection treatment
(particularly for TBC) and ARV prophylaxis provision, it shows that there is an
increasing number of PLHIV who receive ARV treatment. The increasing number of
HIV-positive adults and children who receive ARV reaches 3,2%. The report also
shows that in 2006 – 2008 period, female group receives more ARV drugs than male
group. There is an increasing number in ART provision to pregnant mothers; 3,8% in
2008, compared to 3,5% in 2006. Meanwhile, HIV transmission was doubled from
2006 to 2009 in all 33 provinces. This situation is not balanced by the wide availability
of comprehensive PMTCT that have been only available in 9 provinces with
additional challenge such as lack of well-trained PMTCT medical staff workers.
Concerning opportunistic infection, particularly TBC, Ministry of Health through state
report for UNGASS 2010 explains that there is an increasing number of PLHIV with
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29. TBC incident in 2008 with 115.202 infected persons. In addition, the limited
healthcare service centers that provide ART and TBC drugs are still a major
constraint because there is no one-stop policy in dealing with the issue.
Referring to SPM issued by Ministry of Women Empowerment, victims of sexual
violence receive healthcare service particularly reproductive tract infection treatment
if they have trauma or reproductive problems. But the SPM does not mention PEP
provision for victims.
According to the state report for UNGASS AIDS 2009, 81% of high schools in Papua
teach HIV education as a life skill education/LSE in the final academic year. In 2008,
41% of high school teaches it throughout Indonesia. The LSE continuity is heavily
needed. HIV-based LSE is the first step to prevent HIV among youths. LSE
dissemination is very important, not only in formal schools but also in civil and
community groups. Among teenagers within 15 – 24 years of age, 14,3% of them
have comprehensive knowledge on HIV/AIDS prevention. Girls tend to have more
comprehensive knowledge on HIV than boys. The percentage of comprehensive
knowledge on HIV/AIDS has increased from 11,5% in 2002 – 2003 to 14,4% in 2007.
However, the major obstacle is that there is no definite measurement to see the
scope and impact of this important knowledge. Also, different level of knowledge may
occur between urban and rural populations.
KIE materials do not encompass HIV, VAW, and SRHR intended for various women
and young women groups. Information on HIV, VAW, and SRHR is usually
segmented and is not specifically intended for women group.
5. HIV and VAW prevention efforts
Comprehensive sexual education (according to the providing organization) has been
available in some schools in Indonesia. However, sex education that includes gender
and power relation is not yet available; the main cause of VAW and violence against
young women and how to avoid it; contraception method, and regulatory laws on
SRHR, VAW, and HIV, are all absent. Most of sex education materials consist of
basic information, and very few of them consist of skill training, let alone information
on regulatory law in Indonesia. There are several programs that introduce basic
human rights such as rights to information. But these too are not comprehensive
enough to encompass legal aspects on SRHR, VAW, and HIV. Many organizations
claim that they have given comprehensive sex education, but the fact tells that the
information given is only confined to reproductive health education.
So far, there is no training for school staff to recognize highly risk and HIV-positive
teenagers and/or who experience violence and to respond and refer them in a proper
way. The training only encompasses basic HIV and AIDS information (transmission
way, preventive measures, and a hint of stigma and discrimination). HIV is generally
seen as a fatal and destructive to nation’s future and this slogan is often used as a
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