San Francisco Chronicle - Sunday, June 1, 2003
Simon Montlake, Chronicle Foreign Service

As recently as 1999, Indonesia idled in the AIDS slow lane.

In a nation of 210 million inhabitants, fewer than 1,000 of them were known to be HIV-positive. At the time, health officials attempted to curb the spread of the disease by concentrating on the nation's premier high-risk group -- sex workers and their clients.

But soon after the collapse of the authoritarian regime of Gen. Suharto in 1998, illegal drug trafficking rose dramatically. As a result, AIDS workers are now targeting the latest group most apt to acquire the virus -- heroin addicts who share infected needles.

"HIV snuck up on Indonesia and whacked it on the back of the head before anyone knew what was going on," said Wayne Wiebel, regional adviser to Family Health International, a nonprofit group based in Durham, N.C. "We have to stop it from spreading from drug injectors to the wider community."

The Indonesian government estimates there are between 124,000 and 196,000 intravenous drug users, although some health experts say the actual figure is nearly 1 million. The Indonesian AIDS Commission says HIV infection rates among drug addicts have soared from nearly zero in 1998 to more than 50 percent in cities such as Jakarta and Denpasar, the capital of Bali.

LOW HIV RATE

Yet by Southeast Asian standards, Indonesia remains a nation with a low HIV rate.

According to UNAIDS, a United Nations program that monitors the spread of the disease, 130,000 Indonesians have HIV, which is less than 0.1 percent of the population. The U.S. Agency for International Development reports that 43, 000 of those who are HIV-positive are intravenous drug users.

Most health workers agree that the HIV rate is increasing sharply -- not only among drug users, but among the estimated 190,000 to 270,000 female and male sex workers and 1 million migrant workers who frequent prostitutes while looking for jobs in construction, mining and forestry throughout the far-flung country.

A National AIDS Commission report shows that between 6 percent and 26 percent of sex workers are HIV-positive. In Jakarta, a study by the University of Indonesia found that the infection rate among transsexual prostitutes known as waria, or "half-man, half-woman," increased from 6 percent in 1997 to 21 percent in 2002. About 10 percent of migrant workers have tested HIV-positive.

FEW USE CONDOMS

Condom sales have doubled since 1998, to 60 million a year, but use remains low. Fewer than 10 percent of all men say they use them, according to UNAIDS. "Our distribution is pretty good now, so it's a behavioral issue. The condoms are there -- but will they buy in?" asked Christopher Purdy, country director of DKT International, a Washington-based charity organization that specializes in family planning.

Purdy and others say condom promotion has been hampered by conservative Islamic groups -- about 90 percent of Indonesia's population is Muslim -- whose members believe condoms sanction premarital sex.

Many AIDS activists play down the threat of a religious backlash, pointing to Indonesia's generally moderate form of Islam and the prominent role played by Christian and Muslim groups in successful family-planning programs of the 1970s.

"We must do these campaigns gradually if we want to change the attitudes of the people," said Tarmizi Taher, the former minister of religious affairs who now advises Islamic leaders on AIDS-related issues.

The government's battle to contain AIDS has also been jeopardized by scant resources. Only 1.2 percent of the nation's gross domestic product is spent on all health care, one of the lowest rates in Asia. A 1999 law also complicates a national anti-AIDS campaign by giving local districts responsibility over health care matters.

Until now, most resources have been spent on prevention programs and AIDS education, since many Indonesians have little understanding of the disease. A recent UNICEF survey of 1,000 youths between 14 and 17 showed that 84 percent "knew only a little or nothing about HIV/AIDS," while 73 percent didn't know what a condom was.

But as more cases emerge, AIDS activists say, the government will have to expand care and treatment because most Indonesians cannot afford costly anti- retroviral drugs. In February, the government signed an agreement with a local pharmaceutical company called PT Indofarma and the University of Indonesia's medical school to supply generic AIDS drugs for $6.74 a daily dose, a small fraction of the cost of branded versions.

Meanwhile, the government is trying to stem infection rates among drug users by introducing needle exchange and free methadone pilot programs in Bali and Jakarta.

"We try to get them to inject less, say twice a day and not three times a day," said Bambang Eka, a staff physician for the needle exchange program in Jakarta.

"Five years ago, we couldn't talk about needle exchanges," said Dewa Wirawan, a member of the Bali AIDS Commission. "But when you have a 50 percent infection rate, it may be too late."

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