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Visiting Jakarta in the early 1990s, when health officials in Asia were just beginning to wake up to the challenge posed by a global HIV/Aids epidemic, I had occasion to discuss the subject with a foreign businessman.

At the time, barely a handful of HIV infections had been confirmed in Indonesia. But the businessman was very worried.

'Imagine what would happen if it (the virus) gets into the general population,' he warned, pointing to the devastating economic effect the disease was already having in parts of Africa.

Indeed, the threat looked very real. There was little attempt at monitoring or testing in Indonesia, and only those admitted to local hospitals with full-blown Aids seemed to be showing up in official statistics. With hundreds - or perhaps thousands - presumably already infected, the businessman insisted, it was only a matter of time before the nation's rudimentary health system was overwhelmed.

HIV infections in Indonesia were rare until the mid-1990s. As recently as 2000, only half of the country's 33 provinces had reported an HIV or Aids case. A few years later, however, it appeared that the businessman's fear was about to be realised. The number of HIV infections had ballooned, and the National Aids Commission (NAC) established in 1994 remained poorly funded.

According to a report published by the NAC in 2009, almost half the people living with HIV in Indonesia were infected through sharing contaminated needles. Most drug injectors were also sexually active, but only a small minority consistently used condoms. They passed the virus on to others, creating what the report described as a 'critical mass' of sexually transmitted infections that have since spread into the general population.

Battling HIV/Aids in a Muslim country like Indonesia was never going to be easy. But after a slow start, the NAC is now making real progress. The turning point came in 2006 when newly elected President Susilo Bambang Yudhoyono issued a decree requiring the commission to report directly to him. Additional funds were also forthcoming from the British, United States and Australian governments.

From a mere 25 voluntary counseling and testing (VCT) sites in 2004, the NAC now maintains 388. Anti-retroviral drugs are also distributed without charge at government hospitals and clinics.

As of March this year, 746,000 people have visited the NAC's voluntary testing sites, with 84,423 testing positive. And most of those are young. Even so, experts believe that many more infections remain undetected. The estimated prevalence of HIV among Indonesians 15 to 49 years old is 0.2 per cent, about the same level as in Singapore. However, infection rates are not uniform. Some provinces report much higher rates, particularly in Java and Papua.

African countries face far more difficult circumstances. There are also countries in Asia that are worse off. Examples include Cambodia (8 per cent) and Thailand (1.4 per cent). But with a huge, widely scattered population and only rudimentary health services available in some areas, the situation in Indonesia remains potentially serious.

According to NAC secretary Natsiah Mboj, new HIV infections among drug addicts have dropped significantly in recent years, partly due to the distribution of sterile needles, increased use of methadone (a heroin substitute taken orally), and the success of the authorities in cracking down on heroin use.

Sexual transmission, however, remains a problem. 'There are thousands of harbours in the archipelago, and each one has prostitution,' says Natsiah. 'Indonesia is too big. We have 17,000 islands. And our population is young and mobile, traveling from island to island and city to city.'

Mining areas in Kalimantan and elsewhere also have large numbers of unregulated sex workers servicing young workers from all over the country. The increased use of stimulants such as methamphetamine, which also increases the sex drive, is yet another issue.

Further progress may well depend on the willingness of the nation's Muslim religious authorities to cooperate.

'In many areas, I am not allowed to talk about condoms,' Natsiah tells me.

Local government crackdowns on red-light districts, many in response to pressure from religious militants, also slow progress. Before a red-light district at a local bus station in Bali's Tabanan Regency was closed down in April, for example, anti-Aids volunteers worked with local prostitutes, arranging regular medical check-ups for them at local community health centers, and encouraging the use of condoms. Since the crackdown, however, many of these sex workers have begun to ply their trade in local villages, making it difficult for health workers to contact them.

Despite this, Natsiah believes Indonesia's anti-Aids efforts will eventually be successful.

'I am always optimistic. But that doesn't mean I think it will be easy,' she says.

The businessman I spoke to back in the early 1990s would no doubt agree.




Reprinted courtesy of Straits Times Indonesia. To subscribe to Straits Times Indonesia and/or the Jakarta Globe call 021 2553 5055.