By Sara Schonhardt
Sunday, October 11, 2009
A tiny percent of Jakarta's nearly 33,000 female sex workers use condoms reliably, according to government data. But will a condom distribution plan succeed this time around? And will it really help stop the spread of HIV-AIDS?
JAKARTA, Indonesia (WOMENSENEWS)--Tiny wooden kiosks line a Jakarta street near Tanah Abang railway, a popular late-night site for drugs and sex.
The carts, which look like they belong in a magic act, sell packets of blue pills known as Indonesian Viagra and condoms in various sizes and flavors. It is a one-stop shop for those seeking sex and could be the Indonesian government's vision for the future.
On Oct. 1 the National AIDS Commission, known as KPA, Indonesia's coordinating body on AIDS policies and activities, submitted its strategy for tackling HIV to the incoming House of Representatives. Their goal is to install 22,000 condom outlets in four years in the 12 provinces with the highest HIV prevalence.
In a country with 240 million people, Indonesia's 270,000 recorded HIV cases account for only a sliver of the population. But high risk-taking behavior and rising HIV rates among female sex workers and their clients--often truck drivers, sailors and migrant workers--increase the odds of the disease spreading to the wives and long-term partners of those who buy and sell sex.
In July Indonesia starting disbursing the $120 million it received from the Global Fund to fight HIV and AIDS, its largest slice of HIV funding ever. Most of the money will go towards prevention, care support and treatment.
That means targeting the populations where the disease is most concentrated--among sex workers, injecting drug users and men who have sex with men.
KPA has a goal of providing preventive treatment to 80 percent of the people in so-called "hotspots," areas hit by the HIV epidemic, and effecting "behavior change" in 60 percent in these areas.
Whether or not the condom distribution program will get past historic political opposition here remains a big question.
Michael Buehler, a postdoctoral fellow in Modern Southeast Asian Studies at Columbia University in New York, said it's not a lack of money, foreign aid or condom marketing that has caused the rise in HIV infection.
"The Indonesian government just does not have the political will to address the issue," he said, referring to a Ministry of Health decision to stop issuing free condoms and the Family Planning Coordination Board, the government's national family planning program, caving to pressure from Islamic authorities to stop the installation of condom vending machines across the archipelago. Indonesia is the world's largest Muslim nation.
Dewi Ismajani Puradiredja, a researcher at the London School of Economics studying condom use in Indonesia, said previous attempts by the Indonesian government to eradicate commercial sex work activities, through raids and brothel closures, have also added to the risk of HIV spreading. These attempts drive female sex workers onto the streets or to rural areas where they have less access to treatment and prevention services.
Even if the government does go ahead with an aggressive condom distribution plan, Robert Magnani, country director of the nonprofit Family Health International, with an office in Jakarta, wonders whether easing access to condoms is so crucial. He says low condom use in this Muslim country results from social stigmas that associate condoms with immorality rather than a lack of access to the contraceptives.
"People don't want to be seen buying them or carrying them," Magnani said, referring to bylaws in some districts that allow a woman to be prosecuted for prostitution if she is caught carrying a condom.
KPA keeps a comprehensive database of HIV-AIDS-related statistics, but has no comprehensive data on how many condom outlets are currently operating. According to a KPA study they have conducted, less than half the women working in brothels and massage parlors report having access to condoms and only 15 percent of sex workers who sell on the street say condoms are available in their areas.
That poses a problem as the source of the transmission of new HIV infections in Indonesia shifts from drug use to sex, said UNAIDS country coordinator Nancy Fee, with an office in Jakarta. "We're at a danger point in the spread of the epidemic. A lot more people have sex than do drugs, so that's where we see the numbers growing," she said.
Unprotected sex between female sex workers and their clients is the second most common route of HIV transmission in Indonesia, after the sharing of contaminated needles among drug users, according to a joint study by Indonesia's Health Ministry, USAID and the KPA.
Meanwhile, Indonesia has one of the lowest rates of condom use in Asia--with commercial sex workers reporting 32 percent consistent use compared to more than 90 percent in Thailand.
Data from the KPA find that only 2 percent of Jakarta's nearly 33,000 female sex workers say they have used a condom with each of their clients during the previous week.
"Jakarta is the one city where condom use rates are actually falling," said Puradiredja, who has been studying condom use among female sex workers in rural and urban Indonesia since 2007.
Changing risky behavior among female sex workers also depends on the brothel owners and the men who seek their services, said Puradiredja, who is also researching the obstacles to consistent condom use among Indonesian prostitutes. "Mere awareness of the risk does not allow female sex workers to negotiate condom use when faced with pressure from paying clients."
KPA's goal is to provide male and female condoms to sex workers, install condom kiosks in places where sex is sold and train vendors on condom use and storage.
"Unless you involve the whole community you will not have a sustainable intervention," said KPA Secretary Nafsiah Mboi.
Some programs have shown success.
A Family Health International project in East Java encouraged condom use through a series of incentives and disincentives that required brothel-based sex workers to undergo monthly screenings for sexually transmitted infections.
And DKT, a social marketing company responsible for the bulk of Indonesia's commercial condom sales, reported a five-fold increase in revenue from 1996 to 2008.
But in a country of Indonesia's size, the sale of 110 million condoms a year is still far from where it should be, said Todd Callahan, DKT's country director.
A vast urban-rural divide is partly to blame for the lack of outreach, but Puradiredja said that even in cities like Jakarta many of the nongovernmental organizations working on HIV-AIDS have only one person responsible for outreach to an area with hundreds of sex workers.
Sara Schonhardt is a freelance writer based in Jakarta, Indonesia. She has lived and worked in Southeast Asia for six years and has a master's degree in international affairs from Columbia University.
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