As many people from around the region head to Bangkok to be on time for the opening of the ICAAP 11, those from Indonesia carry a special piece of news with them. Quietly, The Ministry of Health is encouraging the practice of Test and Treat.
Indonesia has an epidemic largely concentrated among the key populations of female sex workers, men who have sex with men (MSM), injecting drug users (IDUs) and transgendered (TG) women who call themselves waria. About one in ten female sex workers and MSM are infected with HIV. The prevalence among IDUs and waria is much higher. There is a more complex sexually transmitted epidemic among ethnic Papuans on the island of New Guinea. Adult prevalence in general population there is under 3% while the prevalence among sex workers there is the highest in the country.
Almost a fifth of the men who have sex with men (MSM) in Jakarta are living with HIV. This must be considered a public health emergency.
Access to HIV testing of any kind has been low among key populations in the country. Between a third of female sex workers and three quarters of waria have been tested at least once. Some reports note that testing rates are higher and increasing. But testing is just the first barrier in a long line of hurdles to getting HIV treatment in Indonesia. Getting a CD4 cell test has always been a major barrier. This test is not available in many places, tests are not run daily, and the cost has been prohibitive for those who have a low income. The next hurdle has long been getting access to a health provider who will initiate treatment. Only hospital staff can initiate treatment and most people living with HIV are extremely wary of going to a hospital. Only about a quarter of the people who are eligible for treatment actually receive it. Then after starting treatment, retention in care is dismally low.
Earlier this year, the Minister of Health signed a circular distributed to health departments in all provinces and districts in the country, as well to the directors of every hospital--https://tinyurl.com/qbhht3t .
The circular recommended that female sex workers, MSM, and IDUs who are found to be living with HIV be started on antiretroviral treatment without/ regardless of the results of a CD4 cell count test. The circular did not use the word waria. This is Test and Treat for key populations-- a major step forward in increasing access to treatment.
Even the most conservative population estimate for the four key populations is 800,000 people. A major barrier to them exercising their right to health was removed with the stroke of the Minister’s pen. Or was it? Neither members of key populations nor the Health Sector personnel are rushing forward to begin Test and Treat.
Armed with copies of the circular, members of key populations who have just tested seropositive could present themselves at hospitals and health centres and demand to be treated. But many of them are unaware of the circular. It has not been widely circulated to the public or to members of key populations and many of them have never read it. Organisations representing these key populations have not printed copies of the circular for their constituents and held sessions to explain it.
The health sector is, predictably, in no rush to start Test and Treat in Indonesia. There is a roll out plan that is being slowly promulgated. Based on the glacial response of the health sector to the Three by Five initiative a decade ago, progress towards Test and Treat for the thousands of newly-diagnosed people with HIV will be slow. Decentralisation has given districts the power to decide whether to heed the advice of the circular or not. They are not bound to it. If the Ministry of Health cannot prescribe a high standard of practice and create a self-regulating work force of health care providers who provide care to the new Test and Treat standard, who can?
Is anyone in a rush to scale up Test and Treat in Indonesia? If you are, write to SEA-AIDS to say so.
Jamie Uhrig, Citizen News Service - CNS
November 2013
Note: This article was first published in 11th ICAAP INSIGHT, the official daily conference newspaper of 11th International Congress on AIDS in Asia and the Pacific (11th ICAAP) in Bangkok, Thailand. This newspaper was managed by Inis Communication and CNS.
