Policy Brief 1 : Indonesia – HIV epidemic, response and challenges

HIV Epidemic in Indonesia
Indonesia is one of a few countries in the world who has reported an increase in the number of new HIV infection in recent years.1 Like other countries in Asia, the epidemics in Indonesia is concentrated in the key population groups for HIV transmission. According to several national-scale surveys, HIV prevalence in key population groups keeps increasing, i.e. 8-10% in men who have sex with men (MSM), >40% in transgenders, 8-20% in female sex workers (particularly transmitted directly from their clients), and 36-40% in injection drug users.1-6 West Java, Jakarta and Bali are areas with the highest concentration of HIV cases.3

The latest modelling results showed that HIV infection would keep increasing cumulatively up to 67,217 people live with HIV (PLHIV) in 2015, with prevention activities in this current level. Sexual transmission is predicted to be the most dominant pathway in the future. MSM group will have a considerable contribution (around 23.6%) in new HIV infection case proportion, while syringe transmission will be relatively low. Sex worker clients, a risk group with the highest proportion, are also expected to contribute significantly to new HIV infection cases, and eventually this will be followed by an increase in the transmission risk to their permanent partners.7

Indonesian Response to HIV
Currently, Indonesia is making an effort to accelerate the increase in prevention of HIV infection transmission and in HIV treatment. Structured approach with community empowerment, extended involvement of stakeholders with networking, and health care provision have been conducted and kept being expanded. Health care provider facilities are continuously developed and added each year. Until the end of 2013, there were 899 HIV testing and counselling care units in districts/cities in Indonesia.8 This number increased rapidly from only 500 units in 2011.4 The increase in availability of these service units led to an increase of access (12.8%) to HIV testing and counselling care to adult (15+) men and women in 2013 compared to that in the previous year.8 An increasing trend was also occurred in at-risk population groups, such as indirect sex workers (from 53% to 57%), transgenders (64% to 72%), and injection drug users (50% to 63%).9 Potentially high-risk men is the group with the lowest HIV test conducted, showing a decreasing trend compared to the previous survey (10% to 7%).9

HIV Health Care and Treatment Services and the Development of the Strategic Use of Antiretroviral (SUFA)
HIV testing and counselling care is believed to have an impact on HIV transmission prevention by encouraging people, either those who were infected or those who were not, to conduct safe behaviour, so that they will not transmit the infection or get infected by others. Currently Indonesia encourages “Test and Treat” effort as a strategy to decrease the mortality rate caused by AIDS and to decrease the incidence rate of HIV infection. This effort, known as Strategic Use of ARV (SUFA), is a response to global recommendation published by WHO based on findings that ARV is effective in controlling HIV in the body, keeps the patients with HIV infection healthy.10 Scientific evidence showed that people with HIV infection with ideal level of compliance to ARV treatment had similar average life expectancy with the general population.11 Clinical trials have also shown that early initiation of high-quality ARV treatment given to people with HIV infection would reduce up to 96% potential HIV transmission to their partners.12 A study in South Africa found that each 10% increase in proportion of people with HIV infection who received ARV treatment would decrease 17% occurrence of new HIV infection cases.13 Furthermore, analysis of a cohort population in China showed that the occurrence of new HIV infection in sero-discordant partner who had a partner with ARV treatment was 50% lower compared to a couple with partner who had not started his/her ARV treatment.14

The Health Ministry published a circular letter, No 129, 2013, on the access to HIV prevention in Indonesia, to support the recommendation of SUFA implementation in Indonesia. Recommendations particularly include the initiation of ARV regardless of CD4 level, offered to people with HIV infection with:

  • Pregnancy
  • Sero-discordant partners,
  • Key populations (injection drug users, MSM, transgenders, sex workers and their clients), and
  • Co-infection with TB, hepatitis B and C.

This circular letter also recommends to healthcare providers to focus the HIV-AIDS care on providing HIV testing and prevention to reach the community who needs them and those at risk to HIV infection. Providers of local health service are requested to guarantee the cost of HIV test, CD4 and viral load examinations.

Challenges to SUFA Implementation
Despite the strong global and government recommendations on SUFA implementation, the success of this strategy implementation is confronted by various challenges. Based on treatment cascade, HIV care includes these steps: 1) diagnosis of HIV infection, 2) refer the people who are tested to treatment or prevention, 3) refer and maintain patients in ARV pre-initiation care, 4) initiate ARV treatment, and 5) ensure treatment compliance, and finally achieve and maintain undetected level of viral load.15

Treatment cascade shows that HIV testing for diagnosis of HIV infection is very critical as the first step to the success of HIV care. SUFA will not achieve its aim if the HIV program can not encourage people to access HIV test.15 Comprehension of determinant factors associated with people who had HIV test, along with factors that inhibit this behaviour, is decisively needed.

Figure 1: Cascade of HIV Care in Indonesia during 2011-2012 (Source: AIDS data hub, UNAIDS). This figure highlights the “leak” in cascade of care.

Note: PLHIV = people live with HIV infection, ART= antiretroviral therapy

Factors Associated with utilization of HIV Testing care units

Worldwide, the proportion of people who are delayed to be diagnosed with HIV infection due to the delay in taking HIV test is significant. Since the diagnosis is delayed, the patients start the treatment after suffering from more advanced symptoms, like opportunistic infection or severe condition. This will reduce the benefit of ARV treatment for PLHIV, and the patients will be more susceptible to adverse effects of ARV treatment.15

Several factors associated with the delay in access or with never had access to HIV testing in various countries, including Indonesia, are :16-22

  • Demographic characteristics, such as age, education, dwelling, income and marital status,
  • Knowledge on the risk of HIV and HIV test,
  • Fear of the results, fear of family reaction to HIV status (if reactive), and fear of treatment maintenance,
  • Knowledge on ARV treatment,
  • Test cost and health insurance ownership,
  • Access to the test site (distance, travel duration),
  • Stigma from internal and external sources, and
  • Support/influence from family, friends, and community.

Results of CAT-S study on the Delay in HIV Testing in indonesia
The Community Access to HIV Treatment Services Study (CAT-S), conducted in 7 provinces in Indonesia, involving 1,655 PLHIV from December 2012 until February 2013, identified a behavioural trend to postpone HIV testing. Forty-one percent male respondents admitted that they took HIV test because they were sick with HIV-related symptoms. Meanwhile, 21% female respondents took HIV test because of their sick partners, 28% because of HIV-related symptoms found by health providers, and 31% because their partners admitted that they were HIV-positive.23

Further, this study also found that 68% PLHIV showed that their first CD4 examination results were ≤ 350 cells/mm3. PLHIV who took HIV test because of HIV-related symptoms or because of knowing their partner’s HIV status had a higher probability to have ≤ 350 cells/mm3 results for their CD4 examination.

Generally, government-owned hospitals and clinics, including mobile clinics facilitated by civil society organization (CSO) or community-based organizations (CBO), were the most popular HIV test sites (31% and 21%, respectively). However, in key population groups, such as sex workers, MSM, and transgenders, HIV test sites facilitated by community/CBO were those where they received diagnosis (42%, 39% and 34%, respectively).23

Reflecting on various factors considered to be the inhibitors of utilization of HIV testing, and based on the findings from CAT-S, testing and counselling care in community level can be an alternative or complementary strategy. This approach may increase the access to testing by reducing stigma and discrimination, which often are the issues in clinical-based testing.

In several areas/countries, community-based HIV testing and counselling targeted to key populations has been demonstrated very acceptable and effective to reach the community, particularly those who have never had a previous HIV test.24 A review on 21 studies in several African countries showed that 83% people offered home-based HIV testing and counseling care agreed to have their HIV status tested.25 These facts prompted WHO to recommend Community-based Testing and Counselling in 2013 WHO ARV Guideline, which associated with treatment, healthcare, and prevention service in managing HIV.26

From the perspective of program, the concept of community-based HIV testing has advantage in making an approach to the key populations, because it can be adapted to social values and specific preferences of the key populations. Simplifying the test may also lead to flexibility of implementation and funding.26

Availability of Community-based Testing and Counselling as a complement to conventional test (testing and counselling in the clinics) is considered to empower the community to contribute in solving the problems associated with the acceptance of HIV care. Community-based Testing and Counselling may bring the testing closer to home environment, or integrate it with other community services to expand the scope by increasing the total number of populations who are tested, increasing PLHIV who are appropriate to receive ARV treatment, and decreasing PLHIV who are lost-to-follow-up.27

Community-Based HIV Testing for Indonesia
In Indonesian context, the development of the concept of Continuous HIV-STD Comprehensive Care (Layanan Komprehensif HIV–IMS Berkesinambungan/LKB) as an approach in HIV program in Indonesia has accommodated the critical role of community involvement. This is specifically mentioned in Pillar 2, the active role of community, including PLHIV and their families.28 Principally, this concept has admitted that HIV comprehensive care should be started from home or community, to healthcare providers (primary community healthcare centers, hospitals, etc.), and then back to home or community. Based on this concept, community-based testing and counselling should be given a space in HIV program, given that community can reach other community with peer-to-peer strategy.

Community-based Testing and Counselling care in itself is not a completely new issue in HIV program implementation in Indonesia. One of Community-based Testing and Counselling care currently implemented is CSO, along with local health care providers, conducting mobile HIV testing in community gathering sites or locations which are comfortable for the community. Several results of evaluation survey showed that mobile testing tended to be more effective to reach the community, particularly in at-risk groups who were susceptible to stigma and discrimination, such as sex workers, MSM, and transgenders.

Policy Recommendation
Implementation of Continuous HIV-STD Comprehensive Care, followed with SUFA, has shown that community involvement was absolutely required and needed to be continuously optimized. With the WHO recommendation on Community-based Testing and Counselling, the future Indonesian response towards HIV needs to consider the following:

  1. To identify optimized model of Community-based Testing and Counselling suitable for Indonesian context.

Aside from the previous implemented Community-based Testing and Counselling model, it is necessary to explore several alternative Community-based Testing and Counselling models considered to be effective to increase the acceptance and utilization of HIV testing in Indonesia. One example is community/CSO, who has a role in conducting a simple, user-friendly test, which need no medical licence to use, yet fulfilling the standard criteria of sensitivity and specificity. Several HIV tests fulfilling the criteria, such as saliva test or finger-prick test, have been used in several countries.29-32

This concept allows to conduct the test at home environment, which has been proven effective to increase the acceptance of HIV testing in several countries with stigma and discrimination issues. Debates on whether non-medics are allowed to conduct the test will certainly always emerge. However, based on WHO guideline that all tests that can ensure the implementation of “five Cs” (consent – voluntary & informed, confidentiality, counselling, correct test results, and connection to care and treatment) are recommended26, Community-based Testing and Counselling needs to be given space.

  1. To identify and allocate resources needed and develop the proper workflow.

Implementation of optimal Community-based Testing and Counselling will need an allocation of resources, including funding, power, and equipments. Strengthening the coordination between all relevant parties is needed, as well as the workflow and accommodative role distribution. Learning from Continuous HIV-STD Comprehensive Care implementation, which apparently not followed by the strengthening of network of available component functions in CSO, such as case manager, buddies, cadres, peer educators, and field staff, this often leads to loss-to-follow-up and treatment discontinuation.

  1. To ensure a proper referral system.

No feedback from service to local CSO has also contributed in the long list of lost-to-follow-up patients. To anticipate this, mechanism standard for adequate referral system from community/CSO to the service unit, and from service unit back to community/CSO, is needed.

Figure 2: Referral mechanism from community to the service unit and from service unit back to community (Source: Design by Iman Abdurakhman, GWL-INA network)


  1. To plan a trial/pilot study on Community-based Testing and Counselling.

Whether the concept of Community-based Testing and Counselling appropriate for Indonesian context will continue to be a question and become a discourse only, as long as no trial is conducted. A pilot trial in a certain scale (several cities/districts) is needed, and it should be followed with an operational study as a tool for evaluation and documentation.


  1. World Health Organization (WHO): HIV/AIDS in the South-East Asia Region: Progress Report 2011. In.; 2012.
  2. MoH Republic of Indonesia: Mathematical model of the HIV epidemic in Indonesia 2008–2014. In. Jakarta, Indonesia; 2008.
  3. AIDS Hub: Evidence to action: Indonesia country profile at a glance. In. Jakarta, Indonesia; 2011.
  4. Indonesian National AIDS Commission: Republic of Indonesia Country Report on the follow-up to the Declaration of Commitment On HIV/AIDS. In. Indonesian National AIDS Commission; 2012.
  5. UNAIDS: UNAIDS Report on the global AIDS epidemic. In.; 2012.
  6. UNAIDS: HIV in Asia and the Pacific:Getting to zero. In.; 2011.
  7. MoH Republic of Indonesia: Estimates and Projections of HIV and AIDS in Indonesia (Draft). In.: Ministry of Health of the Republic of Indonesia; 2014.
  8. Indonesian National AIDS Commission: Global AIDS Response Progress Reporting Indonesia Country Progress Report 2014 (Draft). In.: Indonesian National AIDS Commission; 2014.
  9. MoH Republic of Indonesia: IBBS 2011: Integrated Biological and Behavioural Survey. In. Jakarta: Directorate General of Disease Control and Environmental Health Ministry of Health Republic Indonesia; 2011.
  10. World Health Organization (WHO): The Strategic Use of Antiretrovirals to help end the HIV epidemic. In. Geneva: World Health Organization; 2012.
  11. World Health Organization (WHO): Scaling up antiretroviral therapy in resource-limited settings. Guidelines for a public health approach. In. Geneva: World Health Organization; 2002.
  12. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, Hakim JG, Kumwenda J, Grinsztejn B, Pilotto JH et al: Prevention of HIV-1 infection with early antiretroviral therapy. The New England journal of medicine 2011, 365(6):493-505.
  13. Tanser F, Barnighausen T, Grapsa E, Zaidi J, Newell ML: High coverage of ART associated with decline in risk of HIV acquisition in rural KwaZulu-Natal, South Africa. Science (New York, NY) 2013, 339(6122):966-971.
  14. Jia Z, Mao Y, Zhang F, Ruan Y, Ma Y, Li J, Guo W, Liu E, Dou Z, Zhao Y et al: Antiretroviral therapy to prevent HIV transmission in serodiscordant couples in China (2003-11): a national observational cohort study. Lancet 2013, 382(9899):1195-1203.
  15. World Health Organization (WHO): Global Update on HIV Treatment 2013: Results, Impact, and Opportunities – WHO report in partnership with UNICEF and UNAIDS. In. Geneva: World Health Organization; 2013.
  16. Golub SA, Gamarel KE: The impact of anticipated HIV stigma on delays in HIV testing behaviors: findings from a community-based sample of men who have sex with men and transgender women in New York City. AIDS patient care and STDs 2013, 27(11):621-627.
  17. Mall S, Middelkoop K, Mark D, Wood R, Bekker LG: Changing patterns in HIV/AIDS stigma and uptake of voluntary counselling and testing services: the results of two consecutive community surveys conducted in the Western Cape, South Africa. AIDS care 2013, 25(2):194-201.
  18. Smolak A, El-Bassel N: Multilevel stigma as a barrier to HIV testing in Central Asia: a context quantified. AIDS and behavior 2013, 17(8):2742-2755.
  19. Stephenson R, Miriam Elfstrom K, Winter A: Community influences on married men’s uptake of HIV testing in eight African countries. AIDS and behavior 2013, 17(7):2352-2366.
  20. Pyun T, Santos GM, Arreola S, Do T, Hebert P, Beck J, Makofane K, Wilson PA, Ayala G: Internalized homophobia and reduced HIV testing among men who have sex with men in China. Asia-Pacific journal of public health / Asia-Pacific Academic Consortium for Public Health 2014, 26(2):118-125.
  21. Schwarcz S, Richards TA, Frank H, Wenzel C, Hsu LC, Chin CS, Murphy J, Dilley J: Identifying barriers to HIV testing: personal and contextual factors associated with late HIV testing. AIDS care 2011, 23(7):892-900.
  22. Tenkorang EY, Owusu GA: Correlates of HIV testing among women in Ghana: some evidence from the Demographic and Health Surveys. AIDS care 2010, 22(3):296-307.
  23. Asia Pacific Network of PLHIV (APN+): Community Access to HIV Treatment Services Study in Indonesia. In. Jakarta: GWL-INA Network 2013.
  24. Suthar AB, Ford N, Bachanas PJ, Wong VJ, Rajan JS, Saltzman AK, Ajose O, Fakoya AO, Granich RM, Negussie EK et al: Towards universal voluntary HIV testing and counselling: a systematic review and meta-analysis of community-based approaches. PLoS medicine 2013, 10(8):e1001496.
  25. Sabapathy K, Van den Bergh R, Fidler S, Hayes R, Ford N: Uptake of home-based voluntary HIV testing in sub-Saharan Africa: a systematic review and meta-analysis. PLoS medicine 2012, 9(12):e1001351.
  26. World Health Organization (WHO): Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. In. Geneva; 2013.
  27. (GNP+) GNoPLwH: A Community-Based Service Delivery Model to Expand HIV Prevention and Treatment. In. Edited by HIV GNoPLw; 2014.
  28. Kementerian Kesehatan RI: Pedoman Penerapan Layanan Komprehensif HIV – IMS Berkesinambungan. In.: Kementerian Kesehatan RI; 2012.
  29. Belza MJ, Rosales-Statkus ME, Hoyos J, Segura P, Ferreras E, Sanchez R, Molist G, de la Fuente L: Supervised blood-based self-sample collection and rapid test performance: a valuable alternative to the use of saliva by HIV testing programmes with no medical or nursing staff. Sexually transmitted infections 2012, 88(3):218-221.
  30. Jaspard M, Le Moal G, Saberan-Roncato M, Plainchamp D, Langlois A, Camps P, Guigon A, Hocqueloux L, Prazuck T: Finger-stick whole blood HIV-1/-2 home-use tests are more sensitive than oral fluid-based in-home HIV tests. PloS one 2014, 9(6):e101148.
  31. Pavie J, Rachline A, Loze B, Niedbalski L, Delaugerre C, Laforgerie E, Plantier JC, Rozenbaum W, Chevret S, Molina JM et al: Sensitivity of five rapid HIV tests on oral fluid or finger-stick whole blood: a real-time comparison in a healthcare setting. PloS one 2010, 5(7):e11581.
  32. Zachary D, Mwenge L, Muyoyeta M, Shanaube K, Schaap A, Bond V, Kosloff B, de Haas P, Ayles H: Field comparison of OraQuick ADVANCE Rapid HIV-1/2 antibody test and two blood-based rapid HIV antibody tests in Zambia. BMC infectious diseases 2012, 12:183.