Apcaso UA Indonesia

UNIVERSAL ACCESS COUNTRY REPORT ASIA PACIFIC ACHIEVING UNIVERSAL ACCESS : SUPPORTING COMMUNITY SECTOR INVOLVEMENT & ADVOCACY 2011Indonesia A collaboration between With funding support from: Our Voice Canadian International Development Agency Asia Pacific Council on AIDS Service Organizations International Council of AIDS Service Organizations

AcknowledgementsWe would like to thank the many community advocates and keyinformants who gave their time to participate in the research andshare their expertise and insights on Universal Access in Indonesia.Their contributions were invaluable resources for this country reportas well as the APCASO Universal Access regional analysisThis country report is part of a global initiative by the InternationalCouncil of AIDS Service Organizations (ICASO), together with theregional secretariats, on Universal Access and civil societyparticipation in 15 core participating countries. Special thanks to thedonors that supported this project: the Canadian InternationalDevelopment Agency of the Government of Canada and the FordFoundation.The contents are the responsibility of APCASO and Our Voice, anddo not necessarily reflect the views of any of the aforementioneddonors.@ 2011 Asia Pacific Council of AIDS Service Organizations and Our VoiceInformation contained in this publication may be freely reproduced,published or otherwise used for non-profit purposes as long asAPCASO and Our Voice are credited as the source of the information.Authors of report Aditya Wardhana, Anton Sugiri,(UA Team) in Hartoyo, Iman Rachman, Irwandyalphabetical order: Widjaja, Laura Nevendorff and Oldri SherliProject coordinators Aditya Wardhana and HartoyoCopyeditor Shalina AzharCover design Politeia KodyOur Voice Asia Pacific Council of AIDS Service OrganizationsJl. Mampang Prapatan XV Gang HR No. 21D 16-3 Jalan 13/48A, Sentul Boulevard, off Jalan SentulJakarta Selatan 12740, Jakarta, Indonesia 51000 Kuala Lumpur, MalaysiaTel: +6221-92138925 ; Fax: -- Tel: +603-40449666 ; Fax: +603-40449615Email: gawardhana@gmail.com Email: admin@apcaso.org ; www.apcaso.org 1

CONTENTSForeword 3Section A: Situation in Indonesia 4Section B: Universal Access review and target setting 7Section C: Analysis of approved targets of Universal Access 9Section D: Analysis of Universal Access approved target achievement rate 11Section E: Lessons learned and recommendations to attain Universal 19Access by 2015Annex 1:Informant list; reference list; participants at validation meeting 21Annex 2: 23Project execution reportAnnex 3: 26Recommendations to ICASO to implement projectAbbreviations 27 2

Foreword 30 YEARS OF HIV, 11 YEARS OF UNGASS-AIDS, 5 YEARS OF UNIVERSAL ACCESSI n 2006, leaders from all over the world committed to reach Universal Access in 2010. The commitment encouraged every nation to increase the scale of AIDS program in order to attain targets that have been seton a national level. This effort generates some real improvements in which we can see that HIV transmission,disease, and death rate of AIDS are gradually decreasing. Several countries have made some accomplishmentsin controlling the epidemic within their countries, even though it must be admitted that we still cannot reachUniversal Target on a global scale.One of interesting point from Universal Access achievement review in Indonesia is that although manyIndonesian civil societies contribute so much in implementing the program to reach Universal Access, they stilldo not know that their efforts produce significant contribution in attaining a global commitment, i.e. UniversalAccess.This “ignorance” in turn generates a low sense of belonging to the Universal Access from civil society thusdiscouraging them to comply the Commitment that has been made by the government. This creates a gap inattaining Universal Access commitment process where civil society involvement will then transform into only akind of “symbolic” involvement.Through this review, we would like to contribute some thoughts and ideas so that what have not beenattained by now could be manifested in the future. Universal Access can only be fully realized if there is astrong, comprehensive and meaningful involvement from one of the most important components in AIDSalleviation program, the civil society.We would like to send our gratitude to all parties who helped us in implementing this review includingNational AIDS Commission for their partnership, APCASO and ICASO for their support and all members ofIndonesia UNGASS-AIDS Forum among others for their cooperation in materializing impossible things tobecome possible.For a better world,OurVoiceOn behalf of Indonesia UNGASS-AIDS Forum 3

Section ASituation in IndonesiaA. HIV & AIDS EPIDEMIC SITUATION IN INDONESIAI ndonesia is an archipelago in Southeast Asia that consists of more than 18.000 islands, with population of 237.556.363 (BPS Statistics Indonesia, 2010) and dispersed among its 33 provinces. The majority ofIndonesians are Muslims (88%) with Bahasa Indonesia as the official language. The economic condition of 1Indonesia has improved from low-income country to low-middle income country. The capital of Indonesia isJakarta, located in Java Island. There are five large islands in Indonesia, with Java as the most economicallydeveloped region in Indonesia, compared to Sumatera, Kalimantan, Sulawesi, and Papua.The HIV epidemic development in Indonesia has been increasing significantly since its first case in Bali in 1987.According to Global AIDS report (2008), HIV prevalence in Indonesia is among the fastest in Asia. According toAIDS case report in Indonesia, by September 2010 there are 22.726 people living with AIDS. From this number,the ratio between male and female is 3:1, most of the transmission are through heterosexual intercourse(51,3%) and drug injection (39,6%) and widely distributed in 32 provinces. Most of AIDS cases are reported(based on absolute number) in DKI Jakarta, West Java, East Java, Papua, Bali, West Kalimantan, Central Java,South Sulawesi, North Sumatera, and Riau, while the highest AIDS case rate are reported in Papua, Bali, DKIJakarta, West Kalimantan, Riau Islands, Maluku, DIY, Bangka-Belitung. According to the Estimated HIV-PronePopulation in 2009, there were 186.000 people living with HIV (PLHIV) in Indonesia.Based on prevalence distribution, HIV epidemic in Indonesia is classified into three types; low epidemic,concentrated epidemic, and spreading epidemic. Low epidemic occurs in general population of Indonesiaexcept in Papua and West Papua, concentrated epidemic occurs in risk population such as sex workers,transgender, MSM, IDUs, who are living in almost every part of Indonesia, and spreading epidemic that occurs>1% among general population (both in Papua and West Papua). According to Integrated HIV and Behavior 2Survey in 2006, the average HIV prevalence in both provinces were 2.4% among general population.Based on mathematical modeling—Asia Epidemic Model (2008), HIV epidemic trend in Indonesia will bedominated by sexual transmission with estimated percentage of 58% in 2014. HIV epidemic trend in Indonesiais being on the development stage if we refer to AIDS Commission on Asia report.3 Table 1 Estimated and HIV prevalence on high risk population in Indonesia Estimated key HIV Prevalence Estimated PLHIV Key Population population Average Average Average Injection Drug User 73.885 53,47 39,51 Female sex workers 149.472 5,46 8,16 Transgender 30.348 19,47 5,91 Gay 254.190 4,00 10,16 Sex worker clients 2.150.349 1,22 26,23 Drug User spouse 19.746 26,06 5,15 Sex worker customer spouse 1.276.764 0,59 7,52 Convicted 140.559 3,63 5,11Source: Kemenkes RI (2009)1 Global report on AIDS 20102 Country Progress Report for UNGASS – AIDS 2010.3 AIDS Commission on Asia report, 2008. 4

B. AIDS RESPONSE IN INDONESIAGovernment commitment to AIDS epidemic is obviously seen by the enactment of Presidential Act (Perpres) no.75/2006 on National AIDS Commission (NAC) that coordinate the implementation of counseling, prevention,care, monitoring, controlling, and alleviating AIDS. This policy establishes the point that AIDS alleviation is undercoordination of NAC secretariat, with commission members consisting of 15 Ministerial Sectors and 8government agencies. This act helped make the design of AIDS alleviation spread evenly in every ministerialsector.NAC itself already has had AIDS alleviation strategy since 2003 and recently for 2010-2014 periods. The maincomponents of SRAN 2010-2014 include prevention, treatment, support and treatment, mitigation of impactand creating conducive environment.Department of Health/Health Ministry as the 1st Head of NAC, and in their HIV/AIDS Controlling Efforts has hadfive-year Strategic/Action Plan. In order to harmonize and coordinate programs within Kemenkes, the ministryhas decreed Minister of Health Law no. 1197/Menkes/SK/XI/2007 on HIV & AIDS alleviation working groups(pokja) by which they are responsible directly to Minister of Health.The roles of AIDS alleviation are generally divided between National AIDS Commission and Ministry of Healthwhere NAC has coordinating and harmonizing roles while Ministry of Health has prevention service, treatment,support and treatment, and surveillance roles.a. Budget AllocationIn addition to listing the role and responsibility of every government sector, the policy of AIDS AlleviationNational Strategy that had been made by the government stimulates local funding in response to AIDSproblems throughout Indonesia. In SRAN 2010-2014, there is a clear gap between funding until 2014, 300billion rupiahs in 2010 and 1306 billion rupiahs in 2014. Chart 1. AIDS fund underwriting support in IndonesiaSource: UNGASS on AIDS achievement presentation (NAC, 2010)As we can see from the chart above, in 2006 Indonesian domestic funding that came from APBN and APBD onlycontribute 26% for the overall AIDS alleviation funding (the rest 74% came from international donations).However, in 2009, domestic funding had rocketed to 55%. The total of budget also increased significantly from2006 fund requirement of US$ 56.576.587 to US$ 143.294.516 in 2009.b. TreatmentTreatment access for PLHIV was already started from the very first HIV and AIDS case in Indonesia, although theavailability of ARV drugs still depended on private doctors. We must note that the breakthrough in 2000 whenspecial polyclinic for AIDS in Cipto Mangunkusumo General Hospital (Pokdisus AIDS RSCM) in cooperation witha private pharmaceutical company to provide generic ARV drugs in Indonesia. This effort was then followed-upwith a series of advocacy resulting in Presidential Law no. 083/2004 on mandatory license of Lamivudine-typeARV. Year 2004 became a milestone enabling Indonesia to produce its own generic ARV drugs along with 100-percent subsidy from the government in order to distribute ARV drugs freely to PLHIV. 5

Treatment service for PLHIV in Indonesia is under coordinating hand of Ministry of Health. Treatment accessservice provision in Indonesia was based on Minister of Health Law no. 760/2007 mentioning 237 referencedhospitals for AIDS throughout Indonesia. ARV provision itself is based on Minister of Health Law no. 1190/2004on full subsidization of ARV by government in order to distribute freely to PLHIV.Several challenges in extending the service access include; the extent of geographical areas in Indonesianarchipelago; lack of funding allocation for general public health sector, comprising only 3% of APBN in total; lackof funding (14.41%) from total expenditure AIDS program for AIDS treatment, and; the need for improvingnumber and quality of health care workers in AIDS program in light of vast geographical areas of Indonesia.c. PreventionPreventive program intervention is categorized on the basis of target group by creating several preventivestrategies for high risk population. The strategy is implemented through the National Strategy for PreventingHIV and AIDS among female and children, sex worker group, injection drug users, and gay, transgender andmale sex male groups. By September 2010, the number of methadone site around 61 clinics, NSP service 119locations, VCT 357, ART 193, PMTCT 73, STI 158, TB-HIV 145 (Kemenkes, 2010).Positive Prevention has not yet been accommodated as a government program, even though it must beadmitted that some NGOs has been undertaking this kind of intervention towards service beneficiaries. There isstill confusion regarding the Positive Prevention program causing resistance among certain groups. There aresome people who resist positive prevention conception if it considers PLHIV as the most responsible party inAIDS epidemic, to change their behavior, so that it will bias the notion of government responsibility to handleAIDS epidemic in line with Constitution of Indonesia which entrusts government/state to guarantee a highhealth standard for every citizen.d. Human RightsAlthough it is obviously stated in SRAN 2010-2014 that establishing conducive environment where human rightsprotection is one of the components, in reality the implementation of AIDS alleviation program cannot be yetfully realized in Indonesia. None of the legal product has been made to regulate protection for vulnerablegroups in relation to AIDS epidemic from discrimination. The only legal product concerning protection is the lawof anti-violence against female.Ironically, some public policies in Indonesia are still discriminative toward PLHIV and other key populations.Reports show that it is forbidden for PLHIV to become civil servants, Narcotics Law that still discriminates drugusers, and some 137 regional laws discriminating against female by which 36 of these laws criminalizeprostitutes and homosexuals.4 There are regional laws regulating death penalty and lashes for homosexuals andmarried female who conduct sexual intercourse outside marriage.4 Komnas Perempuan, monitoring report, 2010 “Atas nama otonomi daerah: Pelembagaan diskriminasi dalamtataran Negara-Bangsa Indonesia 6

Section BUniversal Access Review and Target SettingT he president of Republik Indonesia—Susilo Bambang Yudhoyono—through Presidential Decree no. 75/2006 on the establishment of National AIDS Commission has decreed that the commission membership consistsof representatives from PLHIV organizations. In 2009, there was additional commission membership fromrepresentatives and key population networks such as Ikatan Perempuan Positif Indonesia (IPPI), Gay-Waria-Lelaki seks lelaki lainnya Indonesia (GWL-INA), Organisasi Perubahan Sosial Indonesia (OPSI)—as therepresentative organization of Indonesian sex workers. Persaudaraan Korban Napza Indonesia (PKNI) as therepresentative organization of drug users has not yet joined into NAC. Several funding policy makers for AIDSsector such as Partnership Coordinating Committee Aus-AID, Indonesia Partnership Fund Steering Committeeand Management Committee along with Country Coordinating Mechanism GF-ATM have involved PLHIVnetworks, key population networks and other civil society networks as the member. This recognitioncontributed to the involvement of civil society and HIV&AIDS-affected people into many forms of AIDSalleviation program in Indonesia.On November 8, 2005, WHO SEARO, collaborated with UNAIDS, invited its country members to carry out JointRegional Technical Briefing on Universal Access with the theme of Scaling-up Towards Universal Access to HIVPrevention, Treatment and Care that was attended from representatives of HIV/AIDS alleviation program inhealth department.The meeting discussed about the framework concept to attain Universal Access by integrating “three ones”principle, especially the framework of Universal Access for HIV prevention, treatment and care within healthsectors. All country members were urged to determine a set of main interventions to HIV prevention,treatment and care. The framework was subsequently processed in domestic level through nationalconsultation to prepare work plan with key indicators from main intervention in order to reach UniversalAccess, and also identified obstacles that might arise and their solutions.Unfortunately, since UNGASS-AIDS meeting in 2006, there wasmissing documentation archives causing the development ofUniversal Access in Indonesia could not be well-monitored by civil “..Can’t really recall when and where, and we don’tsociety. The high turnover rate of staff within government have any recording filesagencies, UN organizations, international development and civil because KPA was leadingsociety partners, makes the indicator setting process difficult and at that time.” (In-depthnot well-documented. In general, only few people know exactly interview WHO)about Universal Access and its role to AIDS alleviation program inIndonesia. Some of civil society components generally knownothing that what they are doing in the work field contribute tothe government achievement on Universal Access.In early 2009, National AIDS Commission held a consultative “…UA in Indonesia ismeeting to determine national indicators of AIDS program managed by Depkesachievement. According to its minutes, civil society involvement and in cooperation withtheir problem were recognized. WHO. Most of UA information is inSo far, there is no mechanism and open selection within civil society English so it is difficult for us to understandin national consultative meeting for AIDS program indicators. and we don’t knowParticipant selection is conducted by the government initiative where to find…” (FGDmostly. On the other hand, limited capacity improvement regarding key populationthe target and indicator of AIDS programs, nationally and network)internationally, have made civil society involvement a façadewithout giving significant contributions into the process ofdetermining indicator and target of Universal Access. 7

Targets that have been determined by thegovernment to become a national indicator “…speaking about involvement, it is done inare still far from real involvement of civil every key population meeting. It is true that we are involved and invited along with 13society. This was sensed from early indicator executive ministerial because we haveplanning that had not been known by civil representatives as NAC members. As for UA,society until the meeting was held. There we don’t have understanding about whatwere early processes of target and indicator UA is, suddenly we received TOR and that’sdiscussion that were not known. National it. We weren’t told about things, workingconsultative meeting is conducted to reach with whom, etc…” (FGD key populationceremonial purpose only through consultative network, Jakarta)process with civil society Indonesia. This mustbe avoided as much as possible.Another problem that we are facing is that Indonesia has not established a mechanism enabling every civilsociety in Indonesia to give inputs on many processes undertaken within a national scope.Civil society involvement in Universal Access indicator and target determination tends to accommodate civilsociety involvement in capital region only. Whereas there are geographical and limited budget problems, thereis high gap of understanding from civil society concerning Universal Access causing lack of sense of belongingfrom civil society to the UA indicator and target. International development partnerships and UN agenciessupporting AIDS program in Indonesia are not sufficient enough to contribute capacity and information to theirpartners and civil society in particular, so that otherwise civil society can be more connected to this globalcommitment.References for Universal Access are still difficult to find in Indonesia. Some existing materials are constrained bylanguage barrier causing limited involvement of civil society in the process of achieving target and monitoringefforts. Universal Access target seems to be a utopia concept and incomprehensible by many of civil society inIndonesia, particularly for key population community.A major flaw from target determination process of Universal Access is that civil society does not have muchsense of belonging to the target achievement of Universal Access. Hence, there are not many efforts to ensurethat the government can achieve this target and lack of role sensitivity from civil society to measure how farUniversal Access has been reached in Indonesia. 8

Section CAnalysis of Approved Targets of Universal AccessG lobal indicators such as MDGs, UNGASS on AIDS and Universal Access implemented as national indicator generally have major disadvantages encompassing the general nature of these indicators, no distinctionbetween a country’s epidemic contexts and considering its resources to achieve the target. This often makesglobal indicators tend to be inapplicable for certain countries.In implementing AIDS alleviation efforts with low cost – high impact strategy, Universal Access is not equippedwith sufficient guidance for Indonesia in order to determine which indicators that must be prioritized regardingcontextual situation in Indonesia, especially epidemiological context.National consultative meeting for this indicator agreed to achieve 28 main targets in AIDS alleviation program inIndonesia consisting of collaborated targets from Millennium Development Goals, Universal Access andUNGASS on AIDS. Several indicators from Universal Access are shown in Table 2. Table 2. Universal Access indicator comparison No Main Indicators of Universal Access UNAIDS Targets of UA Indonesia (National Indicator Consensus) 1 Percentage of HIV-infected female, male, and Percentage of adults and children with children receiving ARV therapy advanced HIV infection who receive ART 2 Percentage of male and female OVC under 18 yrs N/A of age receiving “basic support package” 3 Scope of program preventing HIV transmission Percentage of pregnant HIV-positive female from mother to infant receiving ART to reduce transmission from mother to infant 4 Scope of counseling and HIV test Percentage of female and men within 15-49 age receiving HIV test in the last 12 months and know the result Percentage of high risk population receiving HIV test in the last 12 months and know the result 5 The number of condoms distributed in a year, N/A both from the government and private companies 6 Percentage of female and male adolescents Percentage of female and male adolescents under 15 years of age conducting sexual under 15 years of age conducting sexual intercourse intercourse 7 National budget used by the government Domestic and international fund expenditure based on funding source category Indicators recommended by UNAIDS 1 Percentage of male and female adolescents from Percentage of male and female adolescents 15-24 yrs or age, both groups can identify HIV from 15-24 yrs or age, both groups can transmission and resist wrong conception about identify HIV transmission and resist wrong HIV transmission conception about HIV transmission. 2 Prevention program scope is focused on Percentage of high risk population that has countries with low prevalence and concentrated just been reached by prevention program. prevalence With targets of 80% population reached and 60% behavior change. 9

Note that there is no synchronous output among approved indicator results; M&E tools indicators and SRAN-based implementation program. In other words, programs that are being undertaken seldom built oncommitment platform that has been agreed and M&E indicator that has been set such as access for orphansand vulnerable groups. Seen from core indicator manual of Universal Access, this type of access should notbeen included in main indicators. In fact, this indicator is not considered as indicators that were agreed onnational consultative meeting for indicators. Nevertheless, on M&E mechanism regarding UNGASS AIDS, workachievement for the indicator was included.This is because of weak coordination among parties conducting AIDS alleviation program in Indonesia so thatevery sector or intervention seems working individually without synchronized work and unified reports of workresult.The ambitious target setting is not conjoined with binding policy. Concerning the ambiguity whether thisindicator would be implemented for country with concentrated epidemic or general epidemic, it important toconsider countries with large population that require massive resources to achieve the target.For instance, the needed fund for prevention and support, treatment and medication for Indonesia must beconjoined with public policy making that bind the government in budget allocation in order to reducedependency from donor countries and to ensure its sustainability.Officially, Indonesia has just set Universal Access achievement target on national consultative meeting forindicators in early 2009. In mid-2009, NAC made a mid-term review concerning AIDS program in order tobecome a basis for 2010-2014 National Strategy. Unfortunately, the documentation of this mid-term reviewcannot be accessed easily.Regarding age-scale indicator, it is important to consider age group outside the scale. For instance, populationfewer than 15 and above 50 years of age seem to be excluded from 15-49 age scale focus in AIDS alleviationprogram.The indicators, set in Universal Access, have not yet supported efforts to give a greater autonomy for everycountry in managing AIDS problems. Indicators that have and/or do not have general quality will encouragecountries to give a greater autonomy for their domestic industries in order to support AIDS alleviation programmore independently (ARV for instance). It would be better if ARV-service indicators emphasize domestic ARVproducts so that every country would be stimulated to strengthen its domestic industry that support AIDSalleviation program and to work more independently.Likewise, indicators that contribute to domestic funding allocation for AIDS program are needed. Expenditurefor AIDS sector that is not selected according to its funding resource will jeopardize Indonesia. The rapideconomy development of Indonesia, making it to become middle-income country, has made it not feasibleenough to receive some foreign aids thus threatening AIDS alleviation program that depends on this foreignaids. Target achievement based on foreign aids will make a sense of “comfort zone” for the government, thushindering them to allocate their own budget for AIDS program.Target achievement can only be done if there is a good coordination among NAC sectors along with a formalmonitoring and evaluation tools in order to measure performance and affectivity of every sector in AIDSalleviation program. Indonesia also needs a strong budget policy to decrease its dependency on foreign aid. 10

Section DAnalysis of Universal Access Approved Target Achievement RateT he government of Indonesia realized that Universal Access achievement which should be reached at the end of 2010 while in fact is still far away from expectation. In SRAN 2010-2014 document, it is stated thatIndonesia will try to achieve the target in line with MDGs targets, given that all targets can be done in 2014.The main challenge in achieving this target is the inconsistency of implementation and commitment fulfillmentfrom the government in its effort to alleviate AIDS so that it can be implemented in a concrete program andalso lack of civil society initiative to involve significantly in implementing the program and their monitoringefforts.For comparison, from all key population targets that are serviced by Prevention, Treatment and Medicationprogram in 2009, sex workers (51%) have a broader scope than injection drug users and MSM (9%) Chart 1 Program Scope and target comparison of Universal Access in 2010 Source: Rencana Aksi Nasional NAC 2010-2014Targets that have been set by the government seem sufficient from Indonesia’s situation where the epidemic isa concentrated one. Its large and widely distributed population plus a lack of resources, both human andfinancial resources, have made focused intervention a main choice. Unfortunately, target achievement efforttends to be undertaken with instant ways instead of preparing a strong foundation. The government concernsonly with quantitative target achievement and often neglects some points regarding qualitative issues in 5implementing the program. Table 3 Universal Access target and achievement comparison in IndonesiaUA Targets that have been approved in IndonesiaArea of Intervention Target Achievement until 2008 (% and numbers)Scope of Prevention ProgramInjection drug users 80% 29%Sex workers 80% 51%MSM (gay) 80% 9%Change of behavior in key population 60% N/A5 Indonesia UNGASS-AIDS Forum Shadow Report for UNGASS on AIDS 2010. 11

TreatmentPLHIV needs 80% 46% (18.982 people)MitigationMitigation of Impacts 80% N/ASource: Rencana Akses Nasional NAC 2009 & Laporan Negara UNGASS on AIDSA. AIDS POLICY AND PROGRAMNote that there are some policies in global and regional scopes that influence to the achievement of UniversalAccess commitment in Indonesia. For example, International Competitive Bidding (ICT) policy undertaken byGlobal Fund often becomes an obstacle to domestic industry independency in giving a greater autonomy forAIDS alleviation program in Indonesia. Another example is the policies of World Trade Organization that oftenmake developing countries to become dependent on developed countries thus affecting AIDS alleviationprogram in the developing countries.Presidential Act no. 75/2006 that becomes a legal foundation for AIDS alleviation program in Indonesia cannotaccommodate coordination requirements for every sector in NAC. This law unclearly regulates the role andresponsibility of governmental sectors in NAC. The weak monitoring and evaluation tools from this presidentialact also become a major concern in relation to the highest policy within AIDS program in Indonesia.There is still disproportional program funding in accommodating PLHIV needs in Indonesia. Nearly half ofHIV/AIDS expenditures are served for prevention (47.5%), while expenditure for program management andhuman resources cost reaches 29.06% and cost of treatment and medication just 14.41%B. TREATMENTAlthough Indonesia has undertaken breakthrough steps by enacting Presidential Decree that enable it toproduce generic antiretroviral (ARV) drugs, there are still some challenges ahead. One of the main challenges isthat the price of domestic ARV drugs is still higher than ARV price from outside Indonesia. This becomes aburden for national budget. It is imperative that sustainability issues are concerned; especially when morepeople are doing HIV tests and ARV needs is increasing. Table 4. ARV price comparison in Indonesia and overseas PRICE KIMIA FARMA CHAI PRODUCT PACKAGING USD Rupiah USD Rupiah (1$ = Rp 9.000) (1$ = Rp 9000)LAMIVUDINE (3TC) 60 tablets/bottle 132.000 14,67 25.470 2.83tablet 150mgNEVIRAPINE (NVP) 60 tablets/bottle 195.938 21,77 29.970 3.33tablet 200mgZIDOVUDINE (AZT) 60 tablets/bottle300mg + LAMIVUDINE 268.125 29,79 86.220 9.58(3TC) 150mg tabletZIDOVUDINE (AZT) 60 tablets/bottle 70.208 9,75 45.000 5tablet 100mgSource: SK MENKES no. HK.03.01/Menkes/146/I/2010 on generic drugs price & the Clinton Health AccessInitiative (CHAI), 2010This condition is because Indonesia has not pass WHO pre-qualification because the local producers cannot yetincrease their production to reach a maximum production rate therefore they still use ARV producing machine 12

alternately with production of other drug types. ARV purchasing scheme that is being undertaken by GlobalFund (in which disabling to buy ARV products that have not been approved by WHO pre-qualification) becomesa challenge in increasing productivity in order to reduce domestic ARV price in Indonesia. This issue expresseslack of commitment from governmental sector and lack of support for Universal Access achievement.ARV drugs are distributed for free by the government to PLHIV who undergo therapy. According to PresidentialAct, there are two types of first-line ARV that can be produced domestically: Lamivudine and Nevirapine. Whileother types and second-line ARV such as Efevirenz, Tenovoir, and Aluvia must be imported.There are few ARV types distributed in Indonesia thus making it is unsupportive for PLHIV women who want tobear children. NNRTI-type regiment is only available in two types: Efevirenz and Nevirapine/Neviral, so if thereis a PLHIV woman unsuitable to consume Nevirapine then she has to switch to Efevirenz disabling her toproduce a child or she voluntarily change to second-line ARV regiment.In addition to ARV availability, the government tries to meet the needs of health monitoring instruments. Theseinstruments for PLHIV are registered only 29 CD4 test instruments and five viral load instruments throughoutIndonesia. “…the trial of decentralizing ARV is considered good, which means that it can be replicated in other provinces...Reporting stock is important…Our partners in remote areas often forget to report health care facilities that have ARV shortage…But when decentralization system have been undertaken, when there will be one party (state-owned company) to be distributor, this will ease the problem because there’s a good management system and storage. There will be no problem anymore with ARV…” (In-depth interview with P2PL directorate general of health ministry, Jakarta)Aside from ARV availability that receives full subsidization from the government, according to ARV monitoringresult conducted by Kemenkes in 2010 founds that only 195 referral hospitals which send reports regularly. Thisaffects the availability of HIV drugs which regularly consumed by PLHIV. To overcome this problem, Kemenkesconducted tests in four provinces, namely; East Java, Bali (Denpasar), South Sulawesi, and Central Java, tomaintain drug reserve and distribution to city/municipal. The expected result can be replicated into otherprovinces, providing that reporting is maintained regularly. “…which means giving educations to new centers such as how to carry out VCT, PMTCT, ARV, etc. Kemenkes certainly supports on providing tools and laboratory facilities, from the needing regency, even to drugs, operational and human resource development. If these tasks are going to be undertaken, with advocacy from Kemenes, I’m sure that our purpose for those facilities in 2014 could be realized in all cities/municipals…” (In-depth interview with P2PL directorate-general of health ministry, Jakarta)Free ARV does not necessarily mean it will ease the burden of PLHIV in accessing this drug because there arestill additional test costs like CD4 (price: Rp 110.000) and Viral Load (price: Rp 850.000) that must be paid byPLHIV. The case is elaborated with research from Riyarto, et.al (2009, p. 280) on “Financial Burden of HIV Carein Three Sites in Indonesia” stating that PLHIV in Jogjakarta, validated with PLHIV in Jakarta, consider thatadditional HIV treatments cost around 50% of their total monthly expenditures. Another conclusion from thisresearch is that the majority of PLHIV experienced financial limitation or problem. “…obviously it won’t work because it matters. In that area, ARV can only be available in provincial capital, and it is not convenient enough because they (PLHIV) who live in municipal cities cannot access it and they need it so much…So, it is useless when ARV is available but we cannot access it, death rate and prevalence are still high because of transportation problem…” (FGD key population network, Jakarta) 13

The vast geographical areas of Indonesia become a major problem because until now, the number of ARV-referral hospitals is not proportional with the number of cities/municipals (546 cities). Distance becomes one ofobstacles for PLHIV who live in remote areas. Table 4. PKM : Reaching those in need.We serve everyone indiscriminately on the basis of key and general population, said Dr. Fadhlina (MentalHealth and NAPZA Department of Community Health Centre/Puskesmas, Tebet South Jakarta)She re-confirmed that if still done discriminately then it is a discrimination against key population group.Sometimes I’m confused, some of the gay groups do not want to be discriminated but they want a specialservice such as special appointment hour. There was a case of a gay patient, for instance. Every time he wantedto come here, he would make an appointment with me, said Fadhlina while in fact this only added moredifficult for him. Let alone that if he still wanted to be treated differently than the service cost would increasetoo. So Puskesmas Tebet decided to treat all patients equally just as Puskesmas Pasar Minggu, South Jakarta.Puskesmas Tebet has given treatment service to key population since 1998. First, we visited directly to theserisk groups, because there was still difficult to access these people. So we decided to “pick up the ball” to thekey population group, said dr. Fadhlina in a meeting with the neighborhood counseling workers in Tebet aboutHIV when she was interviewed. Another strategy is to use focal point from every group.Since 2006, Puskesmas Tebet has given treatment service, including: VCT, LISS, Methadone, IMAI, PMTCT, ARV,and sterile injection until 2007 when it was categorized on the basis of structure, such as individual VCT andPMTCT. Now that we have sufficient facilities, eventually we can do all VCT tests here. Puskesmas Tebet isknown as the one-stop health care service, means that all treatments and cares for PLHIV can be accessed here,said her, so that patients do not have to come back-and-forth anymore.Puskesmas Tebet still collaborates with Yayasan Pelita Ilmu (YPI) in term of ARV access. They (YPI) send ARVs toPuskesmas Tebet. Up to now there are 25 persons who are served by ARV. Because we’re afraid that there isARV stock concern from YPI, we do not accept additional PLHIV patients who need ARV, let alone otherdiseases. In this case, we refer them to hospitals, said dr. Fadhlina. That is the main concern in Puskesmas Tebetregarding ARV availability.Another challenge of HIV service is that the lack of information to community about HIV thus there is still astrong stigma against PLHIV. She asserts that constant information is urgently needed. All this time, we spreadthe information about HIV to women who belong to the community recitation group, without using any kind ofbudget. I am not sure if we can make it when there is a budget allocation for this action, she said.C. PREVENTIONAvailable HIV preventive tools in Indonesia include KIE, condoms and lubricants (for both male and female),circumcision (done by the majority of male population in Indonesia), PMTCT program, sterile injection andmethadone home-therapy. HIV preventive measures in Indonesia are in accordance with the general principles,although the program and strategy still cannot accommodate HIV prevention requirement, particularly inrelation to the situational context in Indonesia.The numerous terms and abbreviations in AIDS alleviation program can create confusion especially amonglower-income population who tend to be undereducated. Foreign terms without Bahasa Indonesia equivalentsoften make the messages ineffective.Individual strategy sometimes make HIV and AIDS problem to become an exclusive matter, not integrated tohealth care service system from the government, thus it creates problem regarding to the sustainability ofservice. Prevention strategy targeting on indicators and appointed targets, in turn, neglects the componentsoutside the indicators and targets within HIV and AIDS prevention program such as housewives. This eventuallycreates feminization in AIDS epidemic. 14

There is enough availability of preventive tools in Indonesia although these preventive tools are more readilyavailable in main islands and big cities. Condoms, as one of HIV preventive tools, have been known in Indonesiasince their introduction as one of Family Planning (KB) measures.In some places, HIV preventive tools are distributed for free on account of government and foreign aid. Table 5. HIV preventive tools availability in three cities of Indonesia Availability Drugstore Bar/discotheque Store NGO KioskMEDAN, North Sumatera (Urban Area)Male condom [ √ ] YES [ √ ] YES [ √ ] YES [ √ ] YES [ √ ] YES Price range: Price range: Price range: Price range: Price range: Rp.3000-6000 Free Rp.3000-6000 Free Rp 4000-8000Female [ √ ] YES [ √ ] YES [ √ ] NO [ √ ] YES [ √ ] NOcondom Price range: Price range: Price range: Rp. 16.000 – Free Free 25.000Water-based [ √ ] YES [ √ ] NO [ √ ] YES [ √ ] YES [ √ ] NOlubricant Price range: Price range: Price range: Rp. 25.000 – Rp. 25.000 – Free 35.000 35.000NSP [ √ ] YES [ √ ] NO [ √ ] NO [ √ ] YES [ √ ] NO Price range: Price range: Rp. 1.500-2000 FreeJAKARTA (Capital City)Male condom [ √ ] YES [ √ ] YES [ √ ] NO [ √ ] YES [ √ ] YES Price range: Price range: Price range: Price range: Rp. 2500-5000 Free Free Rp. 5000Female [ √ ] YES [ √ ] NO [ √ ] NO [ √ ] YES [ √ ] NOcondom Price range: Price range: Rp. 15.000- Free 25.000Water-based [ √ ] YES [ √ ] NO [ √ ] YES [ √ ] YES [ √ ] YESlubricant Price range: Price range: Price range: Price range: Sachet: Sachet: Free Rp. 13.000- Rp 2500-3000 Rp 2500-3000 25.000 Bottle: Bottle: Rp 70.000 Rp 70.000NSP [ √ ] YES [ √ ] NO [ √ ] NO [ √ ] YES [ √ ] YES Price range: Price range: Price range: Rp. 3000-5000 Free Rp. 4000-6000 15

Availability Drugstore Bar/discotheque Store NGO KioskPAPUA (rural area)Male condom [ √ ] YES [ √ ] YES [ √ ] YES [ √ ] YES [ √ ] YES Price range: Price range: Price range: Price range: Price range: Rp. 12.000- Free Rp. 12.000- Free Rp. 5.000-Rp 22.000 (isi 3) 22.000 7.000Female [ √ ] YES [ √ ] NO [ √ ] NO [ √ ] YES [ √ ] NOcondom Price range: Price range: Rp. 15.000 FreeWater-based [ √ ] NO [ √ ] NO [ √ ] NO [ √ ] NO [ √ ] NOlubricantNSP [ √ ] NO [ √ ] NO [ √ ] NO [ √ ] NO [ √ ] NORegarding government budget allocation for condom purchasing, there is an interesting fact that some regionsconceal the purchase by giving an excuse of Family Planning program given the strong stigma on condom as ameans of promoting sexual intercourse.a. HIV prevention message2010 basic health research conducted by Ministry of Health reports a shocking data on HIV & AIDS information.Based on this research, the general information of HIV&AIDS on population above 15 years of age covers only57.5%, while the rest (42.5%) have never heard about HIV at all. From this numbers, 88.6% are still lack ofcomprehensive understanding about HIV. “…Now, KIE always tends to be combined and generalized, whereas we, from GWL, have our own special KIE for gay and transgender. It has not been realized up until now… DKT had made that but its continuity cannot be guaranteed. When shortages come, they say it’s unavailable and have no idea when to print it whatsoever…” (FGD key population network, Jakarta) “…just like KIE for drug users, the given information is only about hypodermic needle, without any information on condom. They too have sexual behavior and partner…” (FGD key population network, Jakarta) There are some problems concerning on Positive Prevention. The general understanding tends to be biased thus creating signals that the “…usually the HIV responsibility of positive prevention is on PLHIV individuals. In a infection is associated with his past behavior. national scope, positive prevention has not yet been recognized as a The problem is that national program although several NGOs have recognized it. when the information is given to the public, it There are still some challenges for communication media. All this time, seems to be some kind the communication media has never been evaluated for its of black campaign effectiveness so that it cannot be measured how far the preventive …more than messages have been conveyed to the public. The minimum use of IT like shock therapy and media is also one of the problems because this type of media is a very scaring messages…” strategic tool, especially when we look at social networking usage in (FGD key population network, Jakarta) Indonesia (ranking the world’s top five). 16

“…ABCD is a good message, but I think we have to improve the way it’s conveyed. Perhaps we can associate that with the lifestyle of key population group; I think they may receive the message…” (FGD key population network, Jakarta)b. HIV prevention from mother to infantPMTCT program has undergone limitedly in regions with high HIV prevalence since 2007. The numbers offemale population who need the service in 2010 are 5.730 people, with estimated number of 8.170 in 2014(NAC, 2009). Although the need for this program increases steadily, unfortunately by September 2010 therewere only new 73 PMTCT service centers throughout Indonesia (MOH, 2010). The number of people who 6accessed this PMTCT service in 2009 was numbering only 196 people. “…so the woman should have known her condition before her pregnancy, what are the preparations, including her condition. What is happening now is that the woman came when she was entering 6-7 pregnancy month, because she didn’t get the information, because of the discontinued prongs…” (FGD key population network, Jakarta)There are still many tasks to be done regarding the PMTCT program. An ideal PMTCT consists of four mainstrategies known as four PMTCT prongs, but in actual only two strategies that have been done. These fourPMTCT strategies are (according to the Ministry of Health 2006 manual): • Prong 1: Preventing HIV transmission among productive age female population • Prong 2: Preventing unplanned pregnancy among HIV-infected mothers. • Prong 3: Preventing HIV transmission from HIV-infected mothers to their infants. • Prong 4: Giving psychological, social, and treatment supports to HIV-infected mothers along with their babies and families.c. Voluntary HIV testVCT is a test method to reveal our health condition in terms of HIV infection and preceded by counselingmechanism conducted by VCT counselor to his/her client. The test is voluntary in nature and the decision to gettested lies in client’s discretion. If someone wants to have HIV test then he will be asked to sign an agreement. “…There are 5 priorities to attain universal access. First one is to increase testing and counseling, and within a year we can facilitate 222 from total of 379…” (In-depth interview with MoH, Jakarta) “…the next strategy of Universal Access is to develop PITC (Provider Initiative Testing and Counseling) which targets general physicians with the total number around 70.000 throughout Indonesia that have not been reached all this time…so, general physicians need to be provided with the program and we will prioritize this program in the early year (of 2011)…Also, there is Mentoring Clinic which is undertaken not only by doctors but also midwives, nurses, and laboratory staff members in service areas who not only work in clinics but also work in recording and reporting tasks…” (In-depth interview with MoH, Jakarta)6 Global report on AIDS, 2010. 17

d. Human rights for key population groupsIndonesia has ratified several human rights convention such as CIPOL, EKOSOB, CEDAW, children rights andother human rights convention. Law no. 39/1999 on human rights, Law no. 23/2002 on child protection, Lawno. 23/2004 on domestic violence elimination are the examples, but until today Indonesia has not yet ratifiedlegal products concerning HIV and AIDS.For policies that hinder human rights compliance, the research recorded some legal products in Indonesia thatmay deter service access such as; Law no. 35/2009 on Narcotics that limit access for injection drug-user, Lawno. 36/2009 that limit access SRH service for unmarried people and several regional laws criminalizing sexworkers, homosexuals, transgender, and even PLHIV themselves. Weak understanding from service provider onhuman rights concepts sometimes creates this case: Table 6 Case study 2 “Nuraida, the wasted womb”Nuraida (pseudonym) – 25 years old, a woman who are infected by HIV from Jakarta, is a victim of sterilizationthat was done by a doctor in a state-owned hospital in Jakarta. At that time, according to a female doctor, Iwould not get a proper medical treatment if I refuse to be sterilized, said Nuraida.Nuraida is one of the victims who lost their chance to get pregnant because of the sterilization process.When she got married, Nuraida did not know her husband’s disease. This woman was diagnosed with HIV aftera doctor suggested her to have a HIV test, after her husband’s severe illness in 2007. Four months later, she losther first child, in his 9 months ago because of HIV. In her second pregnancy she got the information ofPrevention Mother to Child Transmission (PMTCT) program. And thank God my daughter survived the HIV.“But I am really disappointed, why should I get sterilized? I did not know at all about this information. Thedoctor did not give me any kind of explanation before sterilization” Nuraida said. At that time she had 9-monthspregnancy. It was her husband who signed sterilization agreement upon the contraction in giving birth to hersecond child. The doctor suggested, “One child is enough.” But Nuraida wanted to have more children. “Whywomen with HIV do not have freedom to choose? This is unfair!” said her.Her husband, who happened to be a drug user, eventually died in 2010. His second child was only 1.5 years old.After her husband’s death, Nuraida does not want to get married again. She worried that the next husbandwould insist her to get pregnant. From information given by her friends, sterilized women need 10 years to getpregnant again. “Maybe I would have a husband someday, but how if he wants me to bear a child? If only Ialready knew that in PMTCT program a mother should be sterilized I would not have to join the program!” criesNuraida. After underwent sterilization, she knew that not all HIV-infected women have to get sterilized. Sheconsiders not to get married again.Until now, her family does not know about her HIV status. She will tell this to her daughter when she has grownup. Nuraida hopes that the government will not force HIV-infected women to sterilize themselves. “Womenhave rights to conceive!” she said expressively. - told to the research team on November 3, 2010 –Only a few Indonesians who intervene into promoting and building human rights on AIDS alleviation program inIndonesia. The lack of monitoring documentation and human rights abuse data in AIDS alleviation programhave complicated the problems and made these issues difficult to handle by human rights institution inIndonesia such as National Commission for Human Rights (Komnas HAM) and National Commission for Women(Komnas Perempuan). 18

Section ELessons Learned and Recommendations to Attain UA by 2015A. LESSONS LEARNEDF rom the findings, we can conclude that there are much work to be done if we want to attain Universal Access target. Government statement saying that we will fail to attain Universal Access target in 2010should be learning for anyone who involves in the AIDS alleviation program, whether it is government, civilsociety, international development partner and UN agencies.In response system of AIDS alleviation program in Indonesia, where interventional responsibility lies inseparated sectors, a strong coordination is needed among the participating parties. Indicators and targets thathave been agreed upon must be explained in details so that they can be used to measure performance andachievement of each sector.There is a missing documentation process related to turnover process from the government, UN and civilsociety let alone a weak documentation mechanism from the three parties resulting in a partial programimplementation. It is important to consider making a responsive and updated data portal so that thedevelopment of AIDS alleviation program can be monitored year by year.Civil society involvement to bring out sense of belonging “…perhaps we can make re-toward indicators and targets of AIDS alleviation socialization, giveprogram must be managed seriously. introduction to the key population and involveExpanding civil society involvement must conjoin with a them in every step towardcomprehensive capacity building (information UA. Because we were not involved directly…“dissemination, training, mentoring, coaching, monitoring (FGD key population,and evaluation). In fact, capacity building only occurs on Jakarta)monitoring and output thus discouraging outcome andimpact.The need to promote the country’s targets and Indicators on AIDS to civil society will consequently serve theinterest of society. Universal Access understanding is limited only to those who are in top management level. Itis important to expand involvement not only in dissemination level but also policy making process level.Ambitious target setting must be accompanied with a strong budget policy in order to reduce dependency onforeign aid in attaining the targets.B. RECOMMENDATIONSThese are recommendation based on researches and findings in attaining Universal Access targets in Indonesia:Government 1. Re-socialization of things that is associated to Universal Access to increase sense of belonging to UA indicators and targets. 2. Reviewing appointed indicators with full involvement from civil society in agreeing on indicators and setting the targets. 3. Putting conducive-environment indicators (to abolish discriminating and criminalizing public policies) as a foundation in AIDS alleviation program efforts. 4. Creating a data portal that enables all parties to monitor AIDS alleviation program annually. 5. Creating a responsive budget policy in order to attain the appointed targets. 6. Evaluating the effectiveness of KIE in AIDS alleviation program that have been used all this time. 7. Integrating AIDS care service with the existing government service structures such as Posyandu and Puskesmas in order to ensure its continuity instead of making a new service track. 19

UNAIDS Indonesia 1. Controlling and setting AIDS policy globally, regionally, and nationally in a fair and supportive manner in every country 2. Providing KIE materials concerning UA by eliminating language barrier 3. Creating a contextual KIE content so that it can be applied to encourage civil society involvement 4. Mobilizing financial resources that are needed to encourage a larger involvement of civil society in attaining the targets and its monitoring effortsWHO 1. Encouraging and giving technical aids to domestic industries in order to get WHO pre-qualification on their products so that the price can be lowered significantly.Civil Society 1. Redefining the mechanism of involvement and a more meaningful of civil society representation by observing the number and quality for a better civil society involvement 2. Expanding civil society involvement access regarding the preparation process and indicators achievement 3. Monitoring the achievement and overcoming the challenges in attaining UA targets, including documenting human rights violation that may ariseInternational Partners and Donors 1. Creating a more comprehensive program, particularly in capacity building to attain UA, that is interest- oriented and benefactor-oriented, paying attention to quality beside quantity achievement. 2. Encouraging and supporting civil society efforts in monitoring targets achievement together. 20

Annex 1Informant List, Reference List, Participants at MeetingA. INFORMANT LISTName Sex Age Sub-key population OrganizationFocus Group DiscussionOldri Mukuan Female 24 HIV-affected female IPPISunarsih Female 32 HIV-affected Female IPPIAndreas Pundung Male JOTHIElvina Harapap Female JOTHIIenes Angela Transgender 36 Transgender GWL-INASumedi Rian H Male 37 Gay GWL-INASuhendro Sugiharto Male 33 Penasun PKNIYudha Wahid Male Penasun PKNIPardamean Napitu Male Sex worker OPSISusi Female Sex worker OPSIIn-depth interviewHarry Prabowo Male 41 Gay GWL-INADr. Subuh Male 48 Government agency Ministry of HealthDr. Fadlina Female 53 Puskesmas doctor Puskesmas Tebet, JakartaNorma Female 25 HIV-affected Female Housewife, JakartaDr. Sri Pangdam Female 59 Badan PBB WHO IndonesiaSupporting interviewJoan Gracia Female 27 NGO EmployeeLiung Naga Male 25 NGO YakitaB. REFERENCE LIST• Riyarto, S. et al., 2009. ‘The financial burden of HIV care, includingantiretroviral therapy, on patients in three sitesin Indonesia’, Health Policy and Planning, 2010, vol.25, p.272–282, Oxford University Press in th association with The London School of Hygiene and Tropical Medicine, retrieved on October 19 2010.• Kementrian Kesehatan Republik Indonesia (Ministry of Health Republic Indonesia – MOH RI). 2010, laporan Triwulan III Kasus AIDS 2010 (Quarterly III AIDS case report), retrieved on October 21st 2010, <http://spiritia.or.id/Stats/StatCurr.php?lang=id >• Komisi Penanggulangan AIDS Nasional (National AIDS Commission of Indonesia). 2009, Strategi Nasional AIDS 2010-2014 (National AIDS Commission 2010-2014 responses strategies), Komisi Penanggulangan AIDS Nasional, Jakarta.• UNGASS AIDS Forum Indonesia. 2009, UNGASS on AIDS Civil Society Shadow report, reporting period 2010, Jakarta: UNGASS AIDS Forum Indonesia.• Komnas Perempuan (National Women Coalition), 2010. Atas nama otonomi daerah: Pelembagaan diskriminasi dalam tataran Negara-Bangsa Indonesia (in the name of decentralization: Institutionalized of discrimination in the Indonesian state of Indonesia), Laporan pemantauan kondisi pemenuhan hak-hak konstitusional perempuan di 16 kabupaten/kota pada 7 provinsi (Report of women’s constitutional rights in 16 cities in 7 province), Jakarta: Komnas Perempuan th• Clinton Health Access Initiatives (CHAI), 2010. Antiretroviral (ARV) Price List, retrieved on October 19 2010, <http://www.clintonfoundation.org/files/chai_arv_priceList_april2010_english.pdf> 21

• UNAIDS (The Joint United Nations Programme on HIV/AIDS), 2010. UNAIDS Global report on The global AIDS Epidemic 2010, Geneva: UNAIDS• Redefining AIDS in Asia: crafting and effective response 2008, Report of the commission on AIDS in Asia. Oxford university press, New Delhi.• Kementrian Kesehatan Republik Indonesia (Ministry of Health republic Indonesia – MOH RI). 2010. Surat Keputusan Menteri Kesehatan tentangHarga obat generic (Command paper on Generic medicines price), (HK.03.01/Menkes/146/I/2010), Jakarta: KEMENKES• National AIDS Commission of Indonesia, 2010. Republic of Indonesia country report on the follow up to the declaration of Commitment on HIV/AIDS (UNGASS), reporting period 2008-2009. Jakarta: National AIDS Commission• Subuh, M., 2010. Situasi terkini epidemic HIV/AIDS dan respon kementrian kesehatan. In: Direktorat P2ML Direktorat Jenderal PP&PL Kementrian Kesehatan RI, Pertemuan UNGASS Forum Indonesia, Hotel Cemara, 28 Oktober 2010, Jakarta.• Mboi, N., 2010. Strategi dan rencana aksi nasional penanggulangan HIV dan AIDS 2010-2014. In: Komisi Penanggulangan AIDS Nasional, Rapat pleno KPA Nasional. Kantor Kemenko Kesra, 13 januari 2010, Jakarta.• Tim Estimasi 2009, 2010. Estimasi populasi rawan tertular HIV dan ODHA 2009. In: 8 Februari 2010, Jakarta.C. LIST OF PARTICIPANTS AT VALIDATION MEETINGNAME SEX Email Sub-Population OrganizationLely Wahyuniar F wahyuniarl@unaids.org PBB UNAIDSHerru Pribadi M Herru.stigma@yahoo.co.id Komunitas Napza FORKONWisnu Prasadja M wprasadja@yahoo.co.id NGO YKBRikky M sidosidestory@gmail.com NGO OurvoiceInang Winarso M Inang.winarso@aidsindonesia.or.id Government NACSusi F Ri3_nai@yahoo.com Populasi kunci OPSINaomi F Esteria_naomi@yahoo.com NGO StigmaSunarsih F Aci_ippi@yahoo.com Populasi kunci IPPIHari Rusli M Komunitas.utanpanjang@gmail.com Komunitas HIV KUTANGHartoyo M Hartoyo_mdn@gmail.com NGO OurvoiceAndreas M Beware_andreas@yahoo.com Populasi kunci JOTHIDeni A.F M fauzid@unaids.org PBB UNAIDSZaenal M orstoxix@yahoo.com Komunitas KUTANGIrwan M Widjaja27@yahoo.com LSMOldri Sherli F alldree@yahoo.com Populasi kunci IPPIIman A M Iman.gwl.ina@yahoo.com Populasi kunci GWL-INASekar Wulan F Our_stigma@yahoo.com LSM StigmaLaura N F milette@cbn.net.id Komunitas UFIThrough emailSri Pandam F PulungsihS@SEARO.WHO.INT UN WHO 22

Annex 2Project Execution ReportI. BACKGROUNDOn June 2, 2006, member countries of UN General Assembly adopted a Political Declaration in which everycountry had committed to set ambitious targets at the end of 2006 to expand the program scope in order toattain Universal Access in 2010. The process to set these targets needs a transparent and inclusive process forcivil society and other policy makers. UNAIDS had facilitated multi sector review in relation to Universal Accessto determine a country’s position within national target achievement.“ICASO has defined that Universal Access can be reached when everyone has equal access to quality serviceand/or product that they require to meet the needs of Prevention, Support, Care and Treatment of HIV.”II. PURPOSEThe project will support community in terms of: 1. Measuring how far their involvement in Universal Access process. 2. Reviewing data and analysis of AIDS epidemic and associated needs (especially for key population, prevention, human rights and gender equality). 3. Identifying the gap between the set targets and targets that have been reached. 4. Advocating comprehensive targets and approaches and reflecting the fact of epidemic in a country, and to ensure a well-organized, inclusive, and transparent monitoring process and reporting process in the future. 5. Monitoring and documenting achievements in attaining the targets.III. METHOD AND EXPECTED RESULTSBased on past experience in similar projects created by ICASO networks, the methodology will be based onParticipatory Action Research, where members of community get involved fully and meaningful in the processof data accumulation and interpreting it, disseminating and using the research findings.Partners on a national level will gather and analyze data during the last quarter of 2010 according to manualand questionnaire that have been set. Partners and policy makers will then share the research results andvalidate findings and recommendations to agree upon their advocacy planning.Regional secretariat of ICASO and partners will then combine and analyze reports from each country and tocomplement findings and recommendations by doing some interviews with key informants, activists, andinstitutional leaders to show a glimpse of Universal Access on regional level.ICASO will compile all reports and create a global report that will be launched in 2011 Summit reviewing theprogress of Universal Access achievement. The report will present actual analysis regarding the challenges andobstacles and learning in attaining Universal Access and will propose recommendation package so thatUniversal Access can be reached in 2015.IV. PROCESS1. ManagementPrior to research, research team recruitment was conducted. The process itself was not carried out openlybecause UFI already had research team consisting of various communities from PLHIV, PLHIV women, injectiondrug users, and gays, each of them had experience in doing research.In this project, one of the researchers acted as financial administrator, because of limited fund. Nevertheless,the researcher who manage financial affairs had some experience in financial planning thus it was notproblematic in executing the project. 23

Team that had been recruited consisted of 1 Project Coordinator, 1 Consultant, 3 Researchers, and 2 Co-Researchers. All team members received written contract.2. Research Pre-operational MeetingPreoperational meeting was held to discuss things that were associated with planning and researchimplementation, including primary and secondary data sources that would be used in the report, specifyinginterviewee for FGD and in-depth interview, research method and discussing report making manual that hadbeen provided by APCASO.Preoperational meeting was held six times, attended by all team members in the research.3. Team CoordinationAs a means of discussing research progress, coordination was implemented, followed by all team members. Inaddition to meetings, coordination was done by utilizing media such as phone, email, messenger device andsome meeting involving research team. The media utilization was a kind of efficiency effort.4. Executing the Research • Research Instrument Development This included data gathering protocols, key respondents list, questionnaire, and track record of activities based on the manual from APCASO. • Secondary Data Gathering This served as a complement for making the report, because most of the secondary data had been readily available from previous UFI researches and from other researches in order to facilitate team in making the analysis. • Focus Group Discussion FGD served as a means of gathering qualitative data, involving key affected population as many as 10 people. FGD was conducted to reveal their understanding about Universal Access, what UA is, what the challenges are, and how the progress of UA in reality is, how fast Indonesia in reaching these goals is, and what kind of recommendation to reach these goals until 2015. Key population that were involved in this FGD included IDUs, gays, transgender, PLHIV, and HIV-infected women. Prior to discussion (data gathering), participants already knew that the purpose of this research was to increase and strengthen understanding from NGOs, CBO, and key population to get involved in decision making process on the national level regarding the AIDS policies and programs. • In-depth Interview The interview was conducted as a means of verifying data on setting the UA targets in Indonesia, how far CSO and NGO understanding and their involvement in setting the targets of Universal Access. Respondents in this interview were from WHO, Kemenkes, NAC, and NGO that were involved in “Target Setting Agreement on Universal Access Indonesia” meeting.5. Data analysis meetingThe meeting was conducted to analyze the gathered data before preparing the report. The meeting wasattended by the team plus several persons as complimentary. There was a changed schedule on this meeting,previously planned for 1 day only, but because of the abundant needs then the analysis meeting was held forthree days involving 10 participants.6. Validation Meeting.This meeting has a purpose to get a feedback from relevant AIDS stakeholder according to data being gathered.The participants consists of representative of National AIDS Commission, UNAIDS Country Office and CivilSociety Organization. We also seek input from other key relevant informants through email basis.7. Financial administrationFinancial management was done according to SOP in UNGASS-AIDS Forum Indonesia. Expenditure procedureswere based on demand and needs in line with items of the planning. Expenditure report would be presentedalong with research report. 24

8. Challenges and obstacles In implementing a project, there are always obstacles ahead. The challenges faced by Universal Access project were: - Schedule change of informant data gathering The difficulties of adjusting interview schedules particularly with government and UNAIDS cannot be avoided due to their end-of-year meetings. Whereas lots of domestic funds that had just been consumed at the end of year resulting in the difficulties to meet with respondents and lagged schedules. - The activities of each team members Due to the changing of interview schedules, the work routines of team members were also disturbed. This lead all team members to reschedule their activities outside the project. - Lots of UNGASS Forum work agenda There are many advocacy works in UNGASS Forum agenda thus the scheduled activities could not be realized in a timely manner.9. ConclusionWe hope this project report could contribute to all parties, especially for us, APCASO, and those who areinvolved in the AIDS alleviation program in Indonesia. 25

Annex 3Recommendations for ICASO to Implement Project 1. The timeline was too tight. It is difficult to get a comprehensive data to make a national picture since Indonesia has a huge demography and two different kind of epidemic. 2. ICASO should have an advocacy agenda following this research because many CSO doesn’t get the message that what they did for a long time was a roadmap to reach UA and MDGs. We need to build a bridge so their message would politically stronger. 3. It would be better if the research tools could accommodate the local context best practice according to country effort to make a sustainability response. 26

Abbreviations AIDS Acquired Immunodeficiency Syndrom APBN Anggaran Perencanaan dan Belanja Negara (national planning and expenditure budget) APBD Anggaran Perencanaan dan Belanja Daerah (regional planning and expenditure budget) AusAID Australian Agency for International Development ARV Anti Retroviral ART Anti Retroviral Treatment APCASO Asia Pacific Council of AIDS Service Organizations CHAI Clinton Health Access Initiatives CPR Country Progress Report CBO Community Based Organisation CSO Civil Society Organisation Depkes Departemen Kesehatan (department of health) FGD Focus Group Discussion GWL-INA Gay Waria Lesbian – Indonesia (Indonesian gay-transgender-lesbian) Organisasi jaringan nasional populasi kunci; gay, waria dan lesbian seluruh indonesia (national organizational network of key population: gays, transgenders, and lesbians within Indonesia) GF Global Fund HR Harm Reduction HIV Human Immunodeficiency Virus HAM Hak Asasi Manusia (human rights) IPPI Ikatan Perempuan Positif Indonesia(Female Living with HIV organization) ICASO International Council AIDS Service Organisation IDU Injecting Drug User IT Information Technology JOTHI Jaringan Orang Terinfeksi HIV Indonesia (Indonesian network of HIV-infected people) NAC Komisi Penanggulangan AIDS Nasional (National AIDS commission) Kemenkes Kementrian Kesehatan (health ministry) KIE Komunikasi Informasi Edukasi (communication information education) LSM Lembaga Swadaya Masyarakat (NGO) LSL Lelaki seks dengan Lelaki Lainnya (male sex male, MSM) LJSS Layanan Jarum Suntik Steril (Sterile Injection Services) Menkes Mentri Kesehatan (health minister) MDG Millenium Development Goals Monev Monitoring Evaluasi (evaluation monitoring) NAC National AIDS Commission NSP Needle Syringe Program NAPZA Narkotika, Psikotropika dan Zat adiktif lainnya (narcotics, psychotropics, other addictive substances) MOH Ministry Of Health ODHA Orang dengan HIV dan AIDS (people living with HIV & AIDS) OPSI Organisasi Perubahan Sosial Indonesia (Social change organization in Indonesia) OVC Orphans Vulnerable Children PKNI Persaudaraan Korban Napza Indonesia(Drug victims network) Pepres Peraturan Presiden (Presidential Act) PMTCT Prevention Mother To Child Transmission Pokja Kelompok Kerja (working group) PBB Perserikatan Bangsa-Bangsa (United Nations) Penasun Pengguna NAPZA suntik (drug-injection users/IDU) Puskesmas Pusat Kesehatan Masyarakat (community health centre) RW Rukun Warga (neighborhood) SRAN Strategi Rencana Aksi Nasional (National Action Planning Strategy) SDM Sumber Daya Manusia (human resources) SOP Standard Operational Procedure TOR Term Of Reference UNGASS AIDS United Nation General Assembly Special Session on AIDS UNAIDS Joint United Nations Programme on AIDS UU Undang-Undang (Law) UA Universal Accses VCT Voluntary Testing and Counseling WHO World Health Organization WPS Wanita Pekerja Seks (female sex workers) WTO World Trade Organization 27

Universal Access 2010 Review by the ICASO NetworkThe ICASO international and regional secretariats are working with national partners in 15 countries to supportthe community sector to document, provide critical analysis, and undertake policy dialogue for accountabilityon achieving universal Access commitments. The project is supported by the Canadian InternationalDevelopment Agency (CIDA) and the Ford Foundation (with some support from UNAIDS Regional Support TeamAsia Pacific for Nepal and Sri Lanka only).The objectives of the project are to support community sector advocates to: 1. assess their involvement in the Universal Access process 2. review data and analysis of the AIDS epidemic and related needs (especially of key populations, prevention, human rights and gender equality) 3. identify the gaps in the targets set and in the associated achievements 4. advocate for targets and approaches that are comprehensive and that reflect the reality of their country’s epidemic, and for transparent and inclusive periodic monitoring and reporting process in the future 5. monitor and document progress in achieving those targetsParticipating countries:Africa: Ghana, Kenya, Morocco, Senegal, TanzaniaAsia Pacific: China, India, Indonesia, Vietnam (+ Nepal and Sri Lanka)Eastern Europe/Central Asia: Romania, Ukraine, UzbekistanLatin America – Andean region: Bolivia, Colombia, PeruThe project methodology is based around participatory action research where members of the communityparticipate meaningfully in the data collection process and the interpretation, dissemination and use ofresearch results.Country partners collected and analyzed data based on a set of common guidelines and questionnaire in thelast quarter of 2010. The results were then shared and findings and recommendations validated; an advocacyplan was also developed. These reports have been collated into regional analyses which are now available.ICASO is currently developing a global report which will be launched at the 2011 UN High-Level Meeting in June2011. The global report will provide a frank analysis of the challenges and barriers as well as lessons inachieving Universal Access, and will propose a set of recommendations for Universal Access to be trulyachieved by 2015.COMMUNITY ACTIONS: • Initiate your own community-led review using the ICASO UA methodology tools (www.icaso.org or contact country partners) • Get involved in the official country review process • Contact ICASO at universalaccess2010@icaso.org International Council of AIDS Service Organizations 65 Wellesley Street East, Suite 403, Toronto, Ontario M4Y 1G7, Canada Tel: +1-416 9210018 ; Fax: +1-416 9219979 ; icaso@icaso.org ; www.icaso.orgOur Voice Asia Pacific Council of AIDS Service OrganizationsJl. Mampang Prapatan XV Gang HR No. 21D 16-3 Jalan 13/48A, Sentul Boulevard, off Jalan SentulJakarta Selatan 12740, Jakarta, Indonesia 51000 Kuala Lumpur, MalaysiaTel: +6221-92138925 ; Fax: -- Tel: +603-40449666 ; Fax: +603-40449615Email: gawardhana@gmail.com Email: admin@apcaso.org ; www.apcaso.org 28

Apcaso UA Indonesia

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