INDONESIA. Decree No. 9/KEP/MENKO/KESRA/VI/1994 of 6 June 1994 concerning the National Strategy of Combating AIDS in Indonesia.

National Strategy of Combating AIDS in Indonesia

I. Preface

A. Background

Acquired Immuno Deficiency Syndrome (AIDS) is an aggregate of symptoms of diseases caused by the HIV Viruses (Human Immunodeficiency Viruses) which is very easy to spread and deadly. The virus damages the immunity system of the human body causing deterioration/loss of bodily resistance which results in vulnerability to infection and death because of infectious diseases, cancer and so forth.

Until this time there has [not been] found any vaccine for prevention or medicine for cure. The period between the time of becoming infected and the appearance of the disease symptoms in adults ranges from 6 to 10 years on the average. During such a period, despite being outwardly healthy, either consciously or not, the sufferer may spread the HIV viruses to other people. The HIV viruses are spread to healthy people particularly through sexual relations; also, it could happen through blood/blood products (such as transfusion, injection, medical treatment, and so forth) and from an infected mother to her fetus/baby.

Nowadays, HIV/AIDS has become a pandemic, attacking millions of the world population, men, women, even children. The World Health Organization (WHO) estimates the number infected by HIV to be 15 million people and among these 14 million are juveniles and adults, 1 million babies born to infected mothers. Every day as many as 5,000 people are infected by HIV viruses. It is estimated that in [the year] 2000 around 30-40 million people would be infected by HIV viruses, 12-18 [million] people would show the symptoms of AIDS and each year as many as 1.8 [million] people would die of AIDS. At that time, the infection rate in women would be much faster than in men. Out of all cases of HIV infection, 90% would take place in the developing countries, particularly in Asia. The most severely hit countries include Thailand, India, Myanmar and the southern part of China. In the meantime, the more advanced industrial countries have succeeded in repressing the HIV infection rate in their countries.

B. HIV/AIDS threat in Indonesia

AIDS has been factually present in Indonesia. Through very limited blood tests, its presence has been found in 14 provinces. The first case was found in 1987, and 7 years later (March 1994) there was a report on 55 people suffering from AIDS, with the cumulative number of positive HIV cases being 213, but according to WHO the actual number is estimated to come closer to a number of 35,000-50,000 people which would imply a very unusual increase.

Like the spread pattern in other countries, it also came to the surface among homosexuals; it then appeared in the small group of people with high-risk behavior, such as the drug addicts, prostitutes and their clients. However, this fatal disease has impartially spread over all walks of life, men and women; there has even been a pregnant woman contracting AIDS though she is not a prostitute. But the largest percentage has been found in the productive age group (15-49): 82.9%, while the infection has been mostly taking place through sexual intercourse (95.7%), being 62.6% among heterosexuals, and 33.1% among homo/bisexual men.

In terms of the number of cases, the problem of HIV/AIDS infection in Indonesia is still comparatively insignificant. However, the things to be concerned about are: the rapid increase in the number of infected people, the wide spread (14 provinces, all socioeconomic groups and the more speedy increase in the number of women being infected compared with men). This is a threat to the development and life of Indonesian people. The rough rate of death (particularly among the productive age group) will increase, life expectancy will drop. The number and productivity of labor will decrease drastically which will indirectly affect the national productivity and income. Health expenses (direct and indirect), and the budget required for social welfare (families [deprived] of living, fatherless and motherless children) as some of the impacts of AIDS will greatly increase. It will affect the outcome of development accomplished in the first Long-Term Development and the State budget will become very enormous if it is to overcome the problems of HIV/AIDS. So the poverty alleviation effort and other development programs will encounter a big obstacle. The rate of infection in the countries around Indonesia, such as Australia, the Philippines and Singapore at this time has been very high. The high rate of human traffic and mobility between Indonesia and those countries is a threat and allows for increasing rate of HIV/AIDS infection in Indonesia.

Political, economic, social and cultural reactions of a negative nature in the forms of: deportation, stigmatization, discrimination, isolation and violence against HIV carriers/AIDS sufferers in Indonesia, should also be anticipated and suppressed as early as possible.

The general aim of 2nd Long-Term Development (PJP II) as set forth in the Broad Outlines of the State Policy is "The creation of quality of Indonesian people and society being progressive and independent within a physically and spiritually calm and peaceful atmosphere, in the life system of society, nation and State based on Pancasila philosophy and in the life atmosphere of Indonesian people with balance and harmony among fellow men, between man and society, man and nature along with his environment, man and the Only One God." The spread of HIV/AIDS, the presence of HIV/AIDS carriers, are not merely a matter of health, but it has political, economic, social, ethical, religious and legal implications, and the real impacts will, sooner or later, touch all the aspects of life of the nation and State. This will threaten the nation's effort to enhance the quality of human resources.

In order to secure the national development, realization of the expected quality of men, it is necessary to enhance the HIV/AIDS combating effort which should involve all the national sectors through a well directed, integrated and comprehensive program. So, a comprehensive and multisectoral National Strategy of Combating AIDS has been formulated as follows:

II. Aim

The combating of HIV/AIDS is aimed at:

1. preventing the spread of HIV/AIDS

2. reducing as much individual suffering and social as well as economic impacts of HIV/AIDS as possible all over Indonesia

3. consolidating and unifying the national efforts to combat HIV/AIDS.

III. National Strategy of Combating AIDS

This National Strategy constitutes the frame of reference and guide to any HIV/AIDS combating effort in Indonesia by the Government, society, community self-resilience institutes (LSM), families, individuals, universities and research institutes, international donors and bodies that should be able to work as partners and be complementary to one another within the scope of their own expertise and concern.

This National Strategy has been formulated with the following systematics:

Basic principles of combating HIV/AIDS, the Scope of program, Role and Responsibility, International Cooperation and Finance.

A. Basic principles of combating HIV/AIDS

1. The effort to combat HIV/AIDS shall be carried out by society and the Government. Society is the main performer and the Government should give direction, guidelines and create a conducive atmosphere.

2. Any combating effort shall reflect the religious and cultural values existing in Indonesia.

3. Each activity shall be aimed at maintaining and strengthening the family resilience and well-being, as well as the social support system having its root in society.

4. Prevention of HIV/AIDS shall be aimed at educational and enlightening effort to stabilize behavior which will give no chance to infection and will change high-risk behavior.

5. Anybody shall have the right to obtain the right information to protect himself and others against HIV/AIDS infection.

6. Any policy, program, service and activity must consistently respect the self-esteem and dignity of HIV carriers/AIDS sufferers and their families.

7. Any check-up for diagnosing HIV/AIDS shall be preceded by correct explanation and shall have prior informed consent from the person concerned. Adequate counseling shall be given before and after the check-up and result of the check-up shall be kept confidential.

8. It shall be endeavored to make legislation in support of and in harmony with the National Strategy of Combating AIDS at any level.

9. Any provider of service shall provide service without discrimination against HIV carriers/AIDS sufferers.

B. Scope of program

The National Strategy of Combating AIDS has three main concerns inseparable from and complementary to one another:

1. protecting the human resources enhancement effort from the negative impacts of HIV/AIDS;

2. motivating individual, family and social activities all over Indonesia to prevent the wide spread of HIV/AIDS viruses; and

3. guaranteeing medication, treatment and support services which are technically justifiable, humane, fair and not discriminative against those living with and dying of AIDS as well as their immediate surroundings (family, workmates and friends).

This necessitates a series of activities that can be implemented by the Government, non-governmental institutions and groups including the social organizations and community self-reliance institutes, with consideration of the local people's needs and social and cultural conditions. The course of sickness from the time of pre-infection until death involves various interventions. Hence, the scope of [the] main program shall be as follows:

1. Communications, information and education (CIE)

This activity is aimed at:

a. carrying out education and giving the accurate and right information about HIV/AIDS to the general public so as to develop positive attitude and behavior for protecting oneself and others against HIV infection;

b. promoting a mutually assisting and non-discriminating spirit against HIV carriers/AIDS sufferers, as well as [for their] immediate surroundings: wife/husband, family, workmates and friends.

c. giving broad explanation of the National Policy and Strategy of Combating HIV/AIDS in Indonesia as well as the implementation in accordance with local situation and conditions.

The target group for CIE comprises:

a. General Public

The general public should be equipped with basic information about HIV/AIDS which is essentially the same for any people, including the infection process[and] possible (on individuals, family and the nation) methods of prevention for protecting oneself and others. The basic information should be made varied in regard to the method and specific emphasis so as to be suitable for Indonesian people, who are varied in their social and cultural conditions. The social groups and community self-resilience institutes play a specific and important role in the effort to fulfill the needs of general public for the accurate and right education and information.

b. Health personnel (Government, private and society)

Health personnel shall have multiple and decisive role[s] in the HIV/AIDS combating program which includes: the provision of basic information on the infection and spread of HIV as well as . . . prevention, check-up for early detection, motivating the patient to have voluntary HIV check-up and giving the right counseling. Also, they shall exercise universal precautions in treating sufferers to protect themselves and other sufferers. So, they have to specifically receive training and be equipped with the right information.

c. Individuals and Institutions

Individuals/institutions with specific and important role[s] in the HIV/AIDS combating educational movement are, for example, teachers and religious and social leaders, religious institutions and mass media.

d. Women and youths

Women and youths have an important position as members of society being vulnerable in their daily lives to HIV/AIDS infection but they also have potential for becoming very effective educators and motivators.

e. People with high risk

People whose a job or lifestyle makes them face the possibility/run a higher risk of being infected and of causing HIV infection in others such as: prostitutes, other sexual partners of husband/wife, injected drug addicts and certain people that, due to their job, have to be separated from their family for a long period and get involved in sexual relations with [a] "temporary partner."

f. HIV carriers and AIDS sufferers

It is important to supply HIV carriers and AIDS sufferers with knowledge about how to live with their sickness and the methods of preventing it from spread to others.

2. Preventive Measures

a. The chief aim of these preventive measures in the program shall be: to ensure the availability of equipment, service, information and support for everybody who wish to protect himself and others against HIV infection. The activity in this part shall be a follow-up to the Communication, Information and Education i.e., to assist people to take a forward step from "understanding" to "taking action." Close cooperation between the related Government, community self-resilience institutes, social organizations and international bodies is absolutely needed.

b. The close relation between the other sexually transmitted diseases and vulnerability to HIV infection has been proved all over the world. Hence, identification and medication of the sexually transmitted diseases [are] important aspects in the National Strategy of Combating HIV/AIDS.

c. An important step to prevent the infection of HIV viruses is the blood check-up of each donor to ensure that the blood to be transfused is free of "HIV." In the event of positive HIV being present, the donor concerned shall have the right to being informed and having the right counseling.

Various problems such as the enhancement of women's ability and skill in discussing and "negotiating" for matters related to sexual intercourse, child protection against sexual exploitation, provision and utilization of condoms and so forth, shall constitute important elements in effectively implementing this policy.

Due to the complexity and sensitivity of the matter, research and combating activities have to go hand in hand in support of each other.

3. Testing and counseling

This part of [the] program is aimed at:

a. determining if someone has had an HIV infection;

b. helping [to] give information and practical advice as well as moral support to people in need, those being afraid of getting infected, those having been infected as well as to their immediate family and surroundings.

In principle, the testing for HIV diagnosis must always be carried out:

-- voluntarily

-- with confidential result

-- with counseling before and after the testing. Counseling plays a very important role in assisting those afraid of getting infected (either with good reason or not), those already infected (positive HIV), wife's/husband's sexual partner, and if necessary, the immediate family and friends. In principle, the counseling must be done at the first time of testing for diagnosis and each time needed during the course of the sickness to help the sufferer and his/her family to live with HIV/AIDS until the end of his/her life.

The quality of counseling is very important to achieve a success in the effort to combat HIV/AIDS in a humane manner in Indonesia. Therefore, it is necessary to ensure that the method and content of counseling is efficient, consistent, with good quality, confidential and carried out in a conducive environment and atmosphere.

The testing and counseling program shall be carried out by the Government, private sector and community self-reliance institutes. In a selective manner, the community self-reliance institutes are encouraged to set up public clinics as effective testing and counseling facilities. Supervision for quality assurance in the implementation and the testing results as well as the coordination of information on the results shall be in the hands of an independent institution specifically assigned for that purpose.

Both counseling and testing constitute a part of program in need of a staff, skill and special equipment. Hence, a need for adequate training, funds and facilities in accordance with the needs.

4. Medication, service and treatment

The activities in this part of program are aimed at:

a. ensuring continual medication, service and treatment at the time of need characterized by: humaneness, non-discrimination, promptness and accuracy;

b. ensuring personal security for those giving service to HIV carriers and AIDS sufferers.

The concerns in this program are:

a. HIV carriers and AIDS sufferers from the beginning of their becoming sick until their demise, including the service handling their corpses and funeral;

b. their immediate environment, i.e., family, workmates and friends;

c. provider of service/treatment, either the professionals or family caring for them at home; those in health, economic, social, psychological sectors and so forth. The counseling given at the time of testing should be continued and done in accordance with the need of the sufferer and his family. As far as possible, the activities in this part of program should also develop the skill and commitment of the family and community members in providing home and community base care.

The formulation of legislation and the standard for treatment and case management which are ethical, technically accurate, non-discriminative and humane should be endeavored soon in accordance with basic principles of the National Strategy of Combating HIV/AIDS.

5. Research and study

The aim of activities in this part of [the] program is to carry out researches and study of good quality (objective, accountable and reliable) and to endeavor the spread and monitoring of the results in the right and accountable manner, in support of the National Strategy of Combating HIV/AIDS and the implementation at the local, national and international levels. The research and study in this national strategy are aimed at:

a. development/improvement of the policy, strategy and program; this calls for researches/studies in order to understand the cause and course of the sickness, find out the effective and efficient combating methods, discover new breakthroughs, as well as means of solving the technical problems in the operation;

b. monitoring the development of epidemic all over the territory of Indonesia;

c. understanding and developing the methods of solving various technical problems in medical, social, legal, religious, ecological and other terms.

The researches and studies are needed on a national, regional and international scale as well as in a smaller scope such as a group of people or in a territory with a certain lifestyle, behavior and belief. This will call for involvement and concern on the part of the Governmental and private sectors.

Coordination of the spread and efficient utilization of the results of research at the local, national, regional and international levels [are] very important in order to avoid high cost and duplication of activities. Various research institutions in Indonesia shall play an important role in this effort.

6. Monitoring and evaluation

The monitoring and evaluation activities are aimed at:

a. monitoring the development of HIV/AIDS' spread and implementation of the efforts/activities in the scope of this strategy all over Indonesia;

b. doing evaluation and analysis of the epidemic situation and the implementation of National Strategy of Combating HIV/AIDS to be utilized in perfecting further plans and activities. "Sentinel seroprevalence surveillance" is a selective testing program in a certain group to find information on the scale, distribution and "trend" of the development of HIV infection in society. This is needed for planning and developing an effective policy and program, in the effort to combat HIV/AIDS at the national and local levels.

Due to the importance of monitoring activity and evaluation in this strategy, in laying out any plan for activity in each organization and group, there must be a budget of time, funds and energy for the monitoring and evaluation.

C. Role and responsibility of the Government and society

The effectiveness of [the] national effort to combat the threat of HIV/AIDS in Indonesia will depend on cooperation between all parties. Detailed plan and operational responsibility will be developed for each activity, but broadly speaking, the distribution of task[s] and responsibility will be as follows:

1. Government

a. Central Level

The Minister Coordinator for People's Welfare as Chairman of the Commission, assisted by several Ministers as Vice Chairmen and Members, shall coordinate the formulation of [a] plan for the national policy on the prevention and combating of HIV/AIDS in Indonesia giving emphasis on the family resiliency. The task and responsibility of the Commission for Combating AIDS are specified as follows:

1) fostering and providing the technical and social services needed by the HIV/AIDS combating program beyond the reach of society;

2) cooperating with partners in the HIV/AIDS combating effort, by developing the right directives to ensure equitable and quality case management and direct service in accordance with the needs;

3) developing and maintaining an environment and working procedures which motivate, facilitate and support a creative and responsible HIV/AIDS combating activity of various social groups and non-governmental institutions.

b. Provincial and Regency/Municipal

The HIV/AIDS combating effort in the region shall be headed by the Governor as Head of 1st Level Region, Regent/Mayor as Head of 2nd Level Region, with [the] active role of governmental officials in related sectors, representatives of non-Government institutions and organizations as well as universities/higher education institutions in the region. The task and responsibility of the Commission for Combating AIDS in the Region shall be:

1) to lead, manage and coordinate the HIV/AIDS combating activity in the region;

2) to identify the location/territory potential for more rapid spread of HIV/AIDS;

3) to effectively collect, mobilize and utilize resources;

4) to ensure the allocation of funds for HIV/AIDS combating from local resources;

5) to effectively and efficiently utilize resources and funds from the Central Government, region, society and overseas;

6) to assist and facilitate the effort made by society, non-Governmental institutions and organizations in mobilizing resources and funds for HIV/AIDS combating activity.

c. District Level

The HIV/AIDS combating effort at the District Level shall be headed by the District Head in cooperation with operators in related sectors, representatives of the local social institutions and Non-Government Organization[s].

The task and responsibility of [the] District Head in the HIV/AIDS combating effort at the District level shall be:

1) to lead, manage and coordinate the HIV/AIDS combating activity in his district;

2) to identify the location/territory potential for more rapid spread of HIV/AIDS;

3) to effectively collect, mobilize and utilize resources and assist to facilitate the effort made by society and non-Governmental institutions in the HIV/AIDS combating activity;

d. Sub-district and village levels:

The Sub-district/Village Head shall play the key role in leading the implementation of HIV/AIDS prevention/combating in [his] respective territory. His task and function shall be:

1) to motivate the people's effort and provide facilities for the activity of social groups in accordance with the spirit of [the] National Strategy;

2) to cooperate with the Government apparatus for effective and efficient implementation of the HIV/AIDS combating program at the Sub-district and Village level.

2. Society

a. Household and family

Family is a very important social unit in the development of [a] healthy and accountable pattern of behavior which provides the first and fundamental service and support for those living with HIV/AIDS.

Family as the smallest social unit should be strengthened in its resiliency by enhancing and stabilizing the family role and functions so as to share the responsibility of fostering its members in preventing HIV/AIDS infection and not to discriminate against HIV carriers and AIDS sufferers.

b. Social self-resilience institutes and non-Governmental organizations/institutions. Social self-resilience institutes and non-Governmental organizations/institutions play an important role and are recognized as equal partners in the national effort to combat HIV/AIDS in Indonesia. To reach people and their group[s] with specific needs, such as the groups of youths, religions, women, professions which are usually not difficult to be reached by the Government workers.

In support of the activity of social self-resilience institutes and non-Governmental organizations/institutions in an optimal manner, a data and information center as well as an effective cooperation network should be developed.

3. Business world/private sector

The role of [the] business world/private sector as equal partners in the national effort to combat HIV/AIDS in Indonesia is very important in order to speed up and extend the scope of [the] HIV/AIDS combating effort in their respective environments and in providing support of funds, facilities, experts and other efforts in the national combating of HIV/AIDS.

D. International Cooperation

Indonesia is in full support of the global effort to combat HIV/AIDS. As a WHO member country, Indonesia has developed its national AIDS policy in accordance and harmony with the "WHO Global AIDS Strategy."

The experience of Indonesia's neighbors, the ASEAN countries and Australia in combating HIV/AIDS is quite extensive and important so that it will be very beneficial for Indonesia to learn from this. Due to the high rate of human traffic and mobility, it is very important to have cooperation in the effort to combat HIV/AIDS at the regional and international levels. International bodies, donors and NGOs (Non-Governmental Organizations) play an important role as partners in the effort to combat HIV/AIDS in Indonesia. Coordination of international cooperation shall be carried out by the Commission for Combating HIV/AIDS in collaboration with Bappenas (National Development Planning Board).

E. Finance

The finance of activities to be developed in this National Strategy shall come from the State Budget, 1st Level Regional Budget, 2nd Level Regional Budget, communities contributions, business world and foreign cooperation.

IV. Conclusion

This National Strategy is the actualized resolve of the Nation of Indonesia to cope with the increasingly enormous threat of HIV/AIDS to secure the outcome and progress of national development. The Nation of Indonesia as a State in the world shares the responsibility for the global HIV/AIDS combating effort in the world.

The task ahead is not easy, but Indonesia has had a variety of experience which has successfully motivated the Nation for mutual benefits.

With concern on the part of everybody among the Indonesian people, it is believed that the Nation of Indonesia will be able to combat HIV/AIDS in the interest of the present generation and those to come.