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MONITORING THE INCLUSION OF VAW AT THE NATIONAL LEVEL OF THE AIDS RESPONSE AND THE IMPLEMENTATION OF THE UNAIDS AGENDA FOR WOMEN AND GIRLS

MONITORING THE INCLUSION OF VAW AT THE NATIONAL LEVEL OF THE AIDS RESPONSE AND THE IMPLEMENTATION OF THE UNAIDS AGENDA FOR WOMEN AND GIRLS

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    WWW Report   English - Final WWW Report English - Final Document Transcript

    • MONITORING THE INCLUSION OF VAW AT THE NATIONAL LEVEL OF THE AIDS RESPONSE AND THEIMPLEMENTATION OF THE UNAIDS AGENDA FOR WOMEN AND GIRLS Researchers (in alphabetical order): Aditya Wardhana, Nur Handayani, Oldri Sherli, Sari Aznur,IAC (Indonesia AIDS Coalition) – IPPI (National Women HIV Positive Network) - ARI (Indepentent Youth Alliance).IAC (Indonesia AIDS Coalition) - Women Won’t Wait, 2011. Indonesia  AIDS  Coalition  2011.   1  
    • A. 1. STATISTICAL DATA OF NATIONAL HIV & AIDS:1. HIV Epidemic Profile on National Scope Since its first case of HIV in Bali Province in 1987, the AIDS epidemic has been increasing significantly in Indonesia. The Asian AIDS Commission report in 2006 said that AIDS epidemic in Indonesia is considered as the fastest in whole Asia. From the most recent report of Ministry of Health, HIV infection has been found in 33 provinces in Indonnesia. Within 13 years, AIDS cases which have been reported by Ministry of Health number about 26.483 cases with 5056 death cases reported cumulatively from January 1, 1987 until June 30, 2011 (see Table 1). Table 1 Number of New HIV/AIDS Cases by Year Reported Year AIDS AIDS/IDU 1987 5 0 1988 2 0 1989 5 0 1990 5 0 1991 15 0 1992 13 0 1993 24 1 1994 20 0 1995 23 1 1996 42 1 1997 44 0 1998 60 0 1999 94 10 2000 255 65 2001 219 62 2002 345 97 Indonesia  AIDS  Coalition  2011.   2  
    • 2003 316 122 2004 1195 822 2005 2639 1420 2006 2873 1517 2007 2947 1437 2008 4969 1255 2009 3863 1156 2010 4158 1266 2011 s.d Juni/thru June 2352 365 Source: DirGen. Communicable Diseases & Environmental Health, MoH Indonesia (13 July 2011) If categorized according to age group, then the data will be: Table 21. Year 2006 Year 2011 < 1 year 37 265 1 - 4 year 70 318 5 - 14 year 22 212 15 - 19 year 222 821 20 - 29 year 4.487 12.288 30 - 39 year 2.226 8.342 40 - 49 year 647 2.595 50 - 59 year 176 742                                                                                                                        1 Quarterly report of Ministry of Health taken via website www.spiritia.or.id Indonesia  AIDS  Coalition  2011.   3  
    • > 60 year 38 106 If AIDS case number reported in 2006 is aggregated according to sex group, there are 6.604 cases on male and 1.529 on female. If this data is compared with AIDS case number reported on June 30, 2011 based on sex group, there are 19.139 cases on male and 7.255 cases on female. From this data, there is significant rise of HIV transmission prevalence on female within the last 5 years. There is a gap concerning on the long-neglected transgender group who are also prone to HIV infection. The data unavailability on transgender group creates some difficulties in assessing prevalence rate among transgender people and in establishing an accurate strategy and resource allocation needed to prevent AIDS epidemic among transgender group. AIDS epidemic in Indonesia is classified into two major groups, concentrated epidemic in 31 provinces whose concentration is on AIDS key population group and general epidemic in two provinces, namely, Papua and West Papua. Considering that the majority of Indonesian regions have concentrated epidemic, the surveillance data that is conducted regularly by Ministry of Health is limited to survey prevalence rate in key population level and has not encompassed general household group. For, particularly, Papua and West Papua, data shows that HIV prevalence occurs in 2,4% of population among 15-49 years2 age group, however the data is not aggregated by sex group. One of challenges is that we do not have HIV transmission prevalence data in municipal/town level. HIV transmission prevalence on key population according to HIV and Behavior Integrated Surveillance (STHP, key population) in 2007h, direct female sex worker 10,4%; and indirect WPS 4,6%; transgender 24,4%; WPS client 0,8%; male sex male (MSM) 5,2%; injection-drug user (IDU) 52,4%. STHP data on these key population groups is not aggregated by age group. Within 5 year period, vertical HIV transmission rate in 2006 were about 123 cases and raised significantly on June 30, 2011 period, numbering 742 cases. This is due to several factors, among them are lack of PMTCT service and centralized in provincial capitals, limited knowledge among female group especially women living with HIV on PMTCT service and PMTCT program that is not well-disseminated and synchronized with mother and infant health services.2. HIV on female/male According to the above data, it has been known that female groups are among the most vulnerable group to get contracted to HIV infection in Indonesia. National                                                                                                                        2 Integrated Surveillance on HIV and Behavior (STHP), 2007, Ministry of Health. Indonesia  AIDS  Coalition  2011.   4  
    • Commission on AIDS Prevention data shows that more than 90% of HIV infection among female occurs among housewife group. This situation implies a transmission trend shift (second wave of epidemic) so that, in order to overcome it, a special HIV prevention strategy is needed of which is formulated, addressed, and conducted by women. The Indonesian Ministry of Health report on HIV and AIDS cases in Indonesia, based on age group, is not aggregated by sex (male and female) group. This is a big challenge in measuring trend or situation tendency that female and female adolescent groups must undergo in the context of AIDS epidemic in Indonesia.3. Socioeconomic Profile of PLHIV According to National Development Planning Agency (BAPPENAS) data through the “Roadmap to Accelerate Achievement of The MDGs in Indonesia, 2010” report says that Progress has been achieved in increasing the proportion of females in primary, junior secondary schools, senior high schools and institutions of higher education. The ratio of NER for women to men at primary education and junior secondary education levels was 99.73 and 101.99 respectively, and literacy among females aged 15-24 years has already reached 99.35. As a result, Indonesia is on track to achieve the education-related targets for gender equality by 2015. In the workforce, the share of female wage employment in the nonagricultural sectors has increased. In politics, the number of women in the Indonesian parliament increased to 17.9 percent in 2009. Priorities for the future are to: (i) improve the role of women in development; (ii) improve protection for women against all forms of abuse; and (iii) mainstream gender equality in all policies and programs while building public awareness on issues of gender. Based on quick-assessment data conducted by Indonesia Positive Women Network (IPPI) to all its members in almost 10 provinces shows that among IPPI members who are women living with HIV and HIV-affected women (PLHIV spouse), 18,8 % have attained middle school/similar educational level, 59,4% attained high school/similar educational level, and 10,1% attained university/college level. Aggregated data based on gender identity in Indonesia is currently unavailable concerning on income and educational level.4. HIV-affected children and adolescents The number of orphaned children and adolescents categorized by sex group is not available. The data unavailability created a major challenge in establishing mitigation program that is needed by these orphaned children in order to maintain and improve their living condition. Indonesia  AIDS  Coalition  2011.   5  
    • Ministry of Social Affairs once had a pilot program by providing nutritional support for PLHIV children and HIV-infected children, but the program was limited to four provinces and discontinued.5. Other Sexual Transmitted Disease (STD) Prevalence Sexual Transmitted Infection (STI) has long been an indicator of AIDS epidemic within key population. STI prevalence among Female Sex Worker (FSW) population group from STHP 2007 shows a very high number of STI among direct FSW and moderately high among indirect FSW. There are few evidence on STI prevalence decrease among FSW. FSWs who are infected by STIs such as chlamydia, gonorrhea, and syphilis have higher risk to transmit or get transmitted by HIV. Chlamydia is the most frequent STI found within the two FSW groups. Chlamydia and gonorrhea prevalence is among the highest in Asia, and active syphilis prevalence is moderately high and dangerous. The 2007 STBP report shows a high STI and HIV prevalence among transgender group. HIV prevalence ranges from 14% to 34%, while rectal gonorrhea or chlamydia prevalence ranges from 42% to 55%. Syphilis prevalence ranges from 25% to 30%. Meanwhile, urethral STI prevalence is low (0-2%). STI prevalence data on male sex worker and pregnant mother groups is unavailable in Indonesia. The unavailability of STI data on pregnant mothers becomes a contributing factor in transmitting vertical HIV.6. ARV Treatment Access ARV provision has become an important intervention in the national strategy to prevent death and further HIV transmission. The available data shows that currently there are 15.422 PLHIV who receive and consume ARV among 50.510 clients with HIV that are currently in treatment process (see Table 2)3. To date, Indonesia is able to produce 3 ARV regiments that have been licensed according to Presidential Decree. However, productions of other ARV regiments are delayed due to ARV production patent policy. Another ARV production-related impediment in Indonesia is caused by the uncertified WHO pre-qualification production so that the ARV industrial development potential to reduce selling price is hampered. The data also shows that Indonesia is getting better in performing this service. Opportunistic-infection mortality that once reached 46% in 2006 could be reduced into 17% in 2008. AIDS-related mortality among patients who consume ARV in 2008 was 11,2% and decreased to 10,8% in 2009.                                                                                                                        3 Integrated Surveillance on HIV and Behavior (STHP), 2007, Ministry of Health. Indonesia  AIDS  Coalition  2011.   6  
    • However, according to Civil Society Report for UNGASS AIDS 2010 says that, in their founding, the affordability of ARV access is still problematic. PLHIV who reside in municipal area or town still have to come to the provincial capital to get the ARV. Similarly, the ARV availability is sometimes understocked in provincial level causing a “drug-borrowing” culture among PLHIV. The availability of ARV syrup for children is still questioned because currently children with HIV still consume half of adult dosage via grinding. Recently, expired ARV is still distributed in almost all Indonesian provinces causing much worry and disappointment among PLHIV.4 “…obviously it won’t work because it matters. In that area, ARV can only be available in provincial capitals, and it is not convenient enough because they (PLHIV) who live in municipal towns 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) Data on patient number categorized by sex and age group who receive ARV treatment is currently not available in Indonesia. The available data does not aggregate by sex and age group, therefore we are unable to identify the number of female and female adolescents with HIV who consume ARV. Table 2 Juni  2011       December  2008             Number  of  patients  %   Number  of  patients   %   Receiving  HIV  Treatment   81.960       36628       Not   qualified   to   medical   treatment   26.444   32.3   13268   36.2   Eligible  to  receive  ARV   55.516   67.7   23360   63.8   Not  yet  eligible   16.388   29.5   5480   23.5   Received  ARV   39.128   70.5   17880   76.5   Deaths   8.005   20.5   3612   20.2   Drop  out   4.918   12.6   2005   11.2   Transfers  to  other  hospital   2.777   7.1   998   5.6                                                                                                                          4 Civil Society Report for UNGASS on AIDS 2010, UNGASS-AIDS Forum. Indonesia  AIDS  Coalition  2011.   7  
    • Quit   1.641   4.2   649   3.6   Still  receiving  ARV   21.775   55.7   10616   59.4   1st  line   17.630   81   8444   79.5   Substitute  1st  line   3.586   16.5   1994   18.8   Transfer  to  2nd  line   8.29   3.8   178   1.7   Numbers  of  hospital   276       150      7. National HIV/AIDS Observation Indonesia has accommodated the three-one principles and it has been strengthened with Presidential Act No. 75 on National Commission on AIDS Prevention (NAC). NAC becomes a coordinating agency of AIDS prevention program and is directly responsible to the president. The official observation system to record all HIV/AIDS and STD cases has been the task and responsibility of Ministry of Health, which is also a member of NAC, through data report on HIV/AIDS cases issued quarterly. Whereas official observation system to record STD and behavioral cases is conducted by HIV and Behavioral Integrated Surveillance (STHP) and Biological and Behavioral Integrated Surveillance (STBP) which are conducted in every four-year period under the supervision of Ministry of Health. Data on non-consensual sexual intercourse as a means of transmitting HIV is not available in Indonesia. This situation is worsened by the disaggregated data on transgender people in classifying them HIV transmission category. It has been criticized by civil society organizations that work on gender identity recognition or transgender organization.A. 2. NATIONAL STATISTICAL DATA ON VAW1. VAW Case Profile on National Scope Since 1997, Indonesia has National Commission on Elimination of Violence against Women (Komnas Perempuan), which issues the Yearly Report containing data on violence against women in Indonesia. According to Komnas Perempuan Yearly Report namely CATAHU data published in 2011, it reveals general overview on violence against women (VAW) cases during the year 2010. From documentations gathered by Komnas Perempuan, the women victims are numbered about 105.103. Indonesia  AIDS  Coalition  2011.   8  
    • From the data number above, it has been identified that violence pattern against women is still dominated by Domestic Violence (KDRT) and Courtship Violence (KRP) both numbering about 96% (equal to 101.128 victims). Community-level violence against women is numbered about 3.530 cases, and national-level 445 cases—an eight-fold increase from 2009 data. In 2010, sexual violence acts in domestic level (864 cases) and community level (1.781 cases) are recorded. Sexual violence recorded by organizational partner of Komnas Perempuan consists of sexual act, abuse, rape attempt, and rape. Komnas Perempuan also records some VAW cases based on religion and morality. The characteristics of violence perpetrator and victim against women, from the acquired data, shows that both victims and perpetrator of KDRT/RP mostly come from 25-40 years age group. Observing the data from organizational partner of Komnas Perempuan, the VAW victims encompass all range of ages (except for national-level VAW victims). The number shows an increasing number in 13-18 years age group (adolescent age) and shows the highest number in 25-40 years age group. The pattern shows that women in all age groups can be the VAW victims with female adults and adolescents being the most vulnerable groups. Location of violence, victim’s resident, educational level and wounds/trauma due to violent acts are not available in the Yearly Report of Komnas Perempuan. The Journal itself identifies VAW perpetrator: husband, ex-husband, boyfriend and ex- boyfriend. In the occupational profile of VAW perpetrator, many of them hold public service jobs (government officials, armed forces, policemen, members of parliament/house of representatives, schoolteachers, religious figures, ministers). Data on pregnant mothers who experience gender-based violence and female mortality due to violent acts is not available in the Yearly Report. Whereas VAW data based on special groups such as sex workers and drug users is also unavailable in the Yearly Report but it is shown in the “Review” section. Other data such as the number of VAW victims who have health access due to violent acts, VAW cases reported to police, VAW victims who receive legal assistance from government/non-government parties, and VAW victims who receive psychological counseling from government/non-government parties are not available. The Yearly Report is easily accessible and updated annually. The available data scope is sufficient to overview the scale of problem within urban and provincial levels to municipal/town and village levels. However, the available data does not list the detailed number of VAW cases in municipal/town and village levels.2. VAW Observation by the State In Indonesia, we have recording system in documenting VAW every year. The system is known as Yearly Report (CATAHU) issued by Komnas Perempuan in which is published yearly on March 7. The Journal gives a general overview on VAW Indonesia  AIDS  Coalition  2011.   9  
    • data in Indonesia during one-year period. The compiled data is derived from organizational partners that provide service to address VAW cases, including observational data from Komnas Perempuan itself, and encompass VAW case analysis which has been observed for one year. CATAHU has accommodated various VAW types such as physical, psychological and sexual violence and it has also been categorized by age groups. It should be noted that some forms of violence such as feminicide, violence against certain women groups (lesbians, sex workers, female drug users, women living with HIV/AIDS) have not been identified into the report. On the commitment level, VAW observation by the State has been sufficiently comprehensive, consisting of: complaint handling, referral assistance to medical service for the victims, social rehabilitation program, legal assistance, counseling service5 but one should note that, due to lack of monitoring and evaluation, these services are not carried out effectively.A. 3. NATIONAL STATISTICAL DATA RELATING HIV AND VAW (EDO)1. State Observation on HIV and VAW In Indonesia, integrating VAW problem as an influencing factor of AIDS epidemic has not been considered as a main factor that needs to be concerned and addressed. In government, and even AIDS-related NGOs, perspective, violence is a separated issue and disassociated to AIDS problems. In the AIDS prevention program policy, i.e. National Action Plan Strategy (SRAN) of AIDS Prevention 2010-2014, women, female adolescents and children issues have received minor concerns that when the SRAN is conducted in its implementation level a major gap occurs in addressing women issues, including VAW. In fact, Indonesia had AIDS Prevention Strategy for women and children in 2007. However, according to observation, the strategy was never realized in a concrete manner and there were no sufficient monitoring and evaluation.6                                                                                                                        5 Presentation of Ministry of Women Empowerment and Child Protection6 SRHR Report – Indonesia UNGASS-AIDS Forum, 2010. Indonesia  AIDS  Coalition  2011.   10  
    • A. 4. QUALITATIVE AND QUANTITATIVE RESEARCH ON HIV, VAW, AND THEIR RELATION (Sari)1. Qualitative and Quantitative Research on VAW and HIV/AIDS VAW is strongly related to the women’s vulnerability to HIV infection. There are several factors that contribute to the higher risk of women of getting contracted to HIV infection/transmission and disproportionally affected by HIV infection:7 • Culture-based sexual practice. For example: “gurah” (vaginal smoking) that is believed to increase sexual pleasure for men, actually tend to cause injury on vaginal lining during sexual intercourse because of lack of lubrication. Another example: female genital mutilation. • Social pressure to obey creates some difficulties for women to have their own negotiating ability and to be assertive whenever they encounter with things they dislike (for instance, to refuse sexual intercourse when she does not want it at that time or to negotiate condom usage). • Women subordination that makes harder for women to communicate their needs or to negotiate safe sexual practices such as using condom. • Economic and educational disadvantages force women to depend on their spouse and other family member in order to survive. This hampers them to communicate in an equal-level relationship, and it also becomes a major fear for women to get out from abusive/violent partner. In addition, access to information of health and HIV slows down because the unavailability of access to medical and educational services due to poverty. • Domestic and sexual violence; women often experience sexual violence both in and outside marital relationship. This sexual violence increases the occurrence of lesions around mucosal area of vagina due to the lack of vaginal lubrication. Domestic violence indirectly contributes to women’s vulnerability to HIV infection. Some studies shows that women who experience domestic violence by their spouse have higher risk of getting transmitted by STIs than those who do not. • Double standard imposed upon men and women. For example, young women are expected to remain virgin until marriage and they do not need to know about sexuality and reproductive health. Those who do want to know about sexuality and reproductive health or information on both things are considered as immoral. However, men are expected to know about sexuality and to have more experience on pre-marital sexual intercourse. • Social construct on gender role causing the transmission of HIV has more effect on women (i.e. gender role of woman as a caretaker if a family member have illness).                                                                                                                        7 Factsheet Burnet Institute, “Perempuan dan kerentanannya terhadap HIV", cited from website. Indonesia  AIDS  Coalition  2011.   11  
    • These contributing factors can be categorized into three major groups:1. Biological factor – Physiological • Female body is more “receptive” to HIV through sexual intercourse because of its genital form. • As declared by the UNAIDS, “heterosexual women are more vulnerable to be infected because female genitalia is more exposed to sexual fluid.” Female vagina has larger mucous lining and can take more sexual fluid than male penis. Moreover, laboratory research shows that virus concentration is largely found on seminal fluid rather than vaginal fluid. This increases the risk of HIV transmission on women because bodily fluid exchange is the main cause of HIV transmission. • During sexual intercourse, micro-lesion may occur. Micro-lesion is a tearing that allows body fluid to enter the blood vessel. This tearing is typically found in female children and adolescents, making them more vulnerable. • Women who had sexual violence are more vulnerable to HIV. During a forced sexual intercourse, HIV transmission risk is much higher because of vaginal fluid. Particularly if the violence occurs on female adolescent whose vaginal tract is not fully matured. According to a UNAIDS study in Rwanda, South Africa, and Tanzania, the risk of women who had sexual violence is higher three-times more than those who do not experience sexual violence. WHO estimates that almost a quarter to a third of women in the world have physical or sexual violence by their spouse during their lifetime. • Childbirth complication that causes bleeding makes a higher possibility for blood transfusion to women during this critical stage.2. Socioeconomic factor • Economic violence, coercion, and dependency on the majority of women makes them difficult to negotiate sexual intercourse or to avoid highly risked sexual intercourse. • Women do not have control on sexual behavior and medical drugs with their male spouse. • Inequal economic growth that erodes social support has made some women to become sex workers in order to make their living. • Women often do not take test to see their health status because they are afraid of violence, stigma, being abandoned by their male spouse of whom they are so dependent. • Unequal property and inheritance rights increase the vulnerability of women. In South Asia and Africa, men usually have full control over property and asset. In some countries, if a husband dies, property rights are not controlled by the widow. • In the situation of limited income resources in a family, education for male children are more prioritized. Indonesia  AIDS  Coalition  2011.   12  
    • 3. Sociocultural factor • Bride-price and dowry practices often mean that men have larger control over the life and property of women. • In some countries, a married woman has higher status from legal perspective, for example; she needs to get her husband’s permission to do many things. • Women are often taught to give sexual decision to men; therefore women do not need to know about sexuality and reproductive health. • Some of social norms encourage men to have several female spouses. Men who have many sexual spouses are regarded as masculine, while on the contrary, women who have similar situation are regarded immoral and dirty. • Female genital mutilation (FGM) or female circumcision is usually carried out during children or adolescent age in several cultures. Some forms of FGM increase higher risk of HIV transmission if unsterilized apparatus are used or if there is a serious genital wound. Furthermore, FGM whose purpose is to inflict wound on female sexual organ are usually carried out to reduce (or “to control”) the ability for women to enjoy sexual intercourse. • Child marriage is another form of practice that increases women vulnerability. In major parts of the world, daughters usually get married sooner than sons. There are some causes of child marriage: lack of self-protection awareness, lack of power within relationship, family pressure forcing women to obey their husbands. • Some cultural views that women are confined to domestic affairs, therefore they do not need education and access to other information, especially on health. Ministry of Women Empowerment is aware on the relation between VAW and HIV. They note that in dealing with HIV problems, there are at least four contributing aspects:8 1. Women often do not know the HIV status of their spouse and, certainly, do not know their own. 2. Even if they already know about their HIV status, women are often afraid to tell their family due to stigma and discrimination that would probably be imposed by their own family. 3. In health service, women (and their spouse) tend to be ignored on their high-risk behaviors so that the majority of HIV cases found are in their late stage— unchecked in the early stage. 4. Promotion and health service program in preventing and alleviating AIDS often place women as the objects of intervention. This is due to lack of gender comprehension from health service workers and lack of dissemination of a gender-sensitive AIDS prevention strategy.                                                                                                                        8 Adapted from Pemberdayaan Perempuan dalam Pencegahan Penyebaran HIV-AIDS – KementerianNegara Pemberdayaan Perempuan RI, 2008 Indonesia  AIDS  Coalition  2011.   13  
    • In the level of civil society organization, VAW is not yet understood as a relevant factor of AIDS epidemic. The programs that are currently being implemented are mostly masculinized and, furthermore, the absence of gender-based HIV program achievement indicator makes the issue oversighted. Several civil society organizations had created qualitative review to overview violence cases and pattern and State’s response in dealing with VAW from AIDS key population groups. The recorded studies were conducted by IPPI, Intuisi, and Yayasan Stigma. The survey report of VAW on female PLHIV and female PLHIV partner conducted by IPPI shows that the majority of respondents do not have any understanding on violence, particularly domestic-level violence. From this survey, data shows that the majority of victims do not know what they are supposed to do whenever they have domestic violence. Economic-factor dependency makes this phenomenon as a naturally-accepted experience by women living with AIDS. Cultural factor in Indonesia in which patriarchy still dominates social structure of society always creates women-insensitive policies, negligent to the protection of weakened class in male-dominated world, even the potency of violence—both verbal and non-verbal. The increasing rate of women who get transmitted by HIV from their spouse, even to their babies, during the last five years is very relevant to VAW.9 Study conducted by Yayasan Stigma shows that VAW on female IDU are usually done by law enforcements officers who are supposed to eradicate VAW.10 Female IDUs have more complex problems than male IDUs, such as their vulnerability to sexual and physical violence conducted by drug dealers, sexual partners or law enforcement officers. Violence often happens if their spouse is also an IDU. Law- related violence is typically experienced by respondents, ranging from verbal abuse, snapped when the policemen interrogate them, even to shoe-throwing. Verbal and physical violence that humiliates their dignity as a woman is often experienced. Sexual abuse has also been encountered either from the drug dealers and their rehab sponsor who are supposed to help and assist respondents in rehabilitation.11 In some areas, study conducted by Yayasan Intuisi underlines that cultural norms are often relevant to the VAW pattern. In Timika, for instance, a region where HIV prevalence has reached generalized epidemic, domestic relationship is heavily influenced by the “women-purchasing” tradition. The offering of material things such as goods, money, or farm animals to the bride from the bridegroom or husband becomes a main requirement to hold a wedding. Even this “dowry” influences sexual relation between husband and wife. Husband who has not paid off the “dowry” will be regarded as an indebted person to his wife and is obliged to pay it off even with several installments. And if it is not paid off, then the protection of wife’s family will remain rigid. On the contrary, if the husband can pay off the dowry then he will have                                                                                                                        9 “Discordant couple research in 5 cities, Intuisi Research, 2009.10 “Pengalaman Perempuan Penasun dalam mengakses layanan Harm Reduction”, Yayasan Stigma201011 Women in the drug circle, IHPCP Ausaid, 2007. Indonesia  AIDS  Coalition  2011.   14  
    • full ownership upon his wife and the wife’s family will no longer protect her. Even if the husband conducts violence against his wife, the wife’s family can no longer have a strong bargaining position. The Muslim-majority population of Indonesia also becomes a contributing factor to VAW. The female genital mutilation is still being carried out in Indonesian society. Ironically, the Ministry of Health issued Ministry of Health Decree that regulates female genital mutilation procedure. From the studies that we have reviewed, none of them is encouraged, conducted, nor financially supported by local/national government. Most of them are financed by international donors. Research studies conducted in Indonesia do not describe the relevance between VAW and HIV/AIDS transmission. None of these studies explicitly states about the impact of VAW on HIV. The studies are conducted separately, of which violence is regarded as a part of female PLHIV experience. Only very few research studies involve the community as researchers, whereas the vast majority of studies involves the community as respondents for data gathering.A. 5. STATE REGULATORY LAW ON VAW AND HIV1. National regulatory law on HIV and VAW Indonesia has signed the CEDAW (Convention on the Elimination of All Forms of Discrimination Against Women) and ratified the Law No. 7 Year 1984. During the era of post-ratification of CEDAW into Law No. 7 Year 1984 that has been going for the last 27 years, there are still found some of regulatory laws and others regulations contrary to the CEDAW so that it creates ambiguity in implementation level. An example of regional law contrary to the CEDAW can be found in Regional Law (Perda) of some parts of Indonesia. Komnas Perempuan data shows that discriminatory Perda against women in early 2009 are 154 laws. This number keeps increasing. To the end of September 2010, there were 35 additions of this kind of Perda. Discrimination against women is found in the form of freedom of expression restriction upon women through clothing regulation and reduced legal protection. Aceh sharia bylaws abuse women and the poor: Report12 The Jakarta Post | Thu, 12/02/2010 11:05 AM “God will punish us by sending another great earthquake and tsunami if we don’t uphold and enforce sharia [Islamic law] in this land,” says a resident of Banda Aceh. This well-educated man, who prefers to remain anonymous, was referring to a series                                                                                                                        12 Cited from http://www.thejakartapost.com/news/2010/12/02/aceh-sharia-bylaws-abuse-women-and-poor-report.html Indonesia  AIDS  Coalition  2011.   15  
    • of bylaws known as qanun that effectively have been applied in the province since2005. According to the Asia chapter of the Human Rights Watch (HRW), whichannounced the results of its most recent survey on Wednesday, the enforcement of abylaw on clothing requirements and another on relationship between genders robspeople, especially women and those of the lower and middle classes of their rights.The research, conducted from April to September this year, involved more than 80respondents, including rights abuse victims, such as women, as well as locals andgovernment officials throughout the province widely known as the Mecca’s Terrace.HRW deputy director for Asia, Elaine Pearson, said, “[The two bylaws] deny people’srights to make their own decisions about who they can meet and what they can wear.The bylaw and their selective enforcement are an invitation to abuse.”Since 2002, Aceh’s legislature has issued five qanun including the two. The otherthree are on alcohol consumption, alms and gambling.Pearson added that the bylaws did not seem to apply to the military and people whohad high social status.The HRW cited several cases of abuse, including the rape of a young woman bysharia police officers during her detention and aggressive interrogations.There are currently 6,300 official sharia police officers in Aceh, who have stronggrassroots support.According to the HRW, officers often act on their own as vigilantes.“These officers easily arrest men and women who are simply eating in food stalls,riding on motorcycles or carrying out routine activities for the smallest perceivedinfractions. Although the bylaws do not differ between genders, most of the peoplearrested are women,” Pearson said.She added that many of the women were arrested for wearing jeans or otherrelatively tight clothing. Last year, sharia police arrested more than 800 people underthe bylaw regulating proper conduct between genders and more than 2,600 under thebylaw regulating Islamic clothing.HRW coordinator for research Christen Broecker went into detail on the report ofNita, the 20-year-old college student detained and raped by sharia officers.Nita, not her real name, told the HRW that sharia police arrested her and herboyfriend in January 2010 while they were taking a shortcut through a coconutplantation in Langsa, East Aceh, to pick up Nita’s younger sister after school.“When my mom came to get me [from the sharia police office] at 7 a.m., I was crying.The head lecturer at my campus, Doni, was there to scold me. A sharia police officertold him that I had been caught [on an isolated road on a motorcycle] with my Indonesia  AIDS  Coalition  2011.   16  
    • boyfriend. He told my mom and me that I should be stoned to death. I said, ‘Sir, I wasonly trying to look for a shortcut and why should I be stoned for that? What about theofficers who raped me last night,” she said.Two of the three accused officers were convicted and sentenced to eight years inprison in July 2010, while one remains free.Broecker said that it was hard to learn who victims were and to find those willing totestify on abuse.“Our report cites four cases of abuse under the bylaws but we are certain there aremany more. They are afraid to testify and there isn’t any official institution for thesevictims to report cases,” she said, adding that people who had enough money couldhire lawyers.She said that the HRW recommended in the report that the government shouldsupport local NGOs and establish legal aid institutions so that abuse victims fromlower- and middle-class households could come forward and receive help.The HRW is urging the Aceh Council to revoke both of the bylaws and the Acehgovernor to stop violent acts by sharia police officers.The report also shows that most government officials do not agree with the twobylaws. However, the sharia bylaws are heated issues that could have a directpolitical impact. The HRW report can be found on its website, www.hrw.org. (rch)Based on our observation, there are some improvements in the response of statepolicy in addressing VAW-related problems. There are seven regulatory laws relatedto the elimination of violence against women and children, among them are: Law No.3 Year 1997 on Juvenile Court; Law No. 23 Year 2002 on Child Protection; Law No.23 Year 2004 on Elimination of Domestic Violence; Law No. 13 Year 2006 onWitness/Victim Protection; Law No. 21 Year 2007 on Combating Human Trafficking;Law No. 44 Year 2008 on Pornography; and Law No. 36 Year 2009 on Health.State Ministry of Women Empowerment then issued State Ministry of WomenEmpowerment and Child Protection Law (Kemeneg PP) No. 1 Year 2010 onMinimum Service Standard (SPM) in Integrated Service Sector for Women andChildren Victims of Violence on January 28, 2010 and this is a breakthrough incomplying women and children victims of violence. The birth of SPM is a positiveresponse from the government following the ratification of those seven regulatorylaws.For the implementation of these laws, Ministry of Women Empowerment and ChildProtection regulates minimum standard service and standard operational procedure(SOP) that will become a guideline in implementing integrated services for women Indonesia  AIDS  Coalition  2011.   17  
    • and children victims of violence by relevant ministries and institution and IntegratedService Center (PPT).In relation to comprehensive sexual education, Indonesia still faces many challengesin its implementation. In the Law on Health No. 36 article 72 states that “every personhas right to obtain accurate and reliable information, education, and counseling onreproductive health.” But in reality, due to the rigid social, cultural, and religiousnorms, this kind of education is only reserved for married couple and not for school-age teenagers.Indonesia has regulatory law on HIV and AIDS in workplace that has been includedin Ministry of Labor Decree No. 64 Year 2004. However, there are still many PLHIVwho are fired from workplace because of their HIV status. The implementation of thisdecree has not been effective yet because it needs technical regulation as aguideline of implementation.Indonesia still does not have specific regulation on the confidentiality of voluntary HIVdiagnosis. This confidentiality is regulated in the general confidentiality rule of theMedical Code of Ethics and Health Law. For the provision of free medical drugs,Minister of Health issues List of Essential Drugs Decree subsidized by the State andfor ARV since the issue of Minister of Health Decree No. 1190/Menkes/SK/X/2004 onfree provision for tuberculosis and ARV drugs.In Law No. 52/2009 on Population Growth and Family Development article 23 – 26states that contraception can be accessed by married couple only, and sexuallyactive adolescents cannot get contraception service.Independent Youth Alliance (ARI) documentation in Jakarta shows that pap smeartest form still contains “Ms.” and “Mrs.”. In addition, there is a regulation thatunmarried female adolescents should be accompanied by parents and marriedfemale adolescents should be accompanied by husband. The reason behind thisMinistry of Health regulation is that women are regarded as powerless and should beprotected by others. This situation put many female adolescents to avoid the servicerather than stigmatized and discriminated. In this context, the government hasviolated female adolescents rights to access sexual and reproductive health services.In Health Law No. 36/2009 article 75 – 77 on abortion, abortion is generallyprohibited by the law and the government is obliged to protect and prevent women tohave abortion with the exception of those who have certain uteral problem or thosewho have fatal risk or rape victims. These articles state, several times, that theabortive regulation refers to religious values and norms, whose relativity is debatable,and do not refer to universal human rights values.Article 76 explains about abortion access procedure, i.e. abortion can be done at sixmonths gestational age at maximum and must obtain permission from husband,unless the abortee is a rape victim, and health service provider according toministerial decree. This regulation makes women rightless to their own bodies Indonesia  AIDS  Coalition  2011.   18  
    • because they need permission from husband to have an abortion and, thus, unmarried women cannot access this service. The regulation on abortion is not well-disseminated to general public. The bill draft on regulatory law and ministry of health regulation that regulate safe abortion as the operational mandate of Health Law is being initiated by Indonesian Obstetrics and Gynecology Development (POGI) and women organization network of which this legislation is assisted by Yayasan Kesehatan Perempuan.B. HIV/AIDS AND VAW: PROGRAM AND SERVICE IMPROVEMENTS.1. HIV/AIDS policy and government norms in health service According to the policy issued by Ministry of Women Empowerment and Child Protection via State Ministry Law PP No. 2/2008 on Women Protection Implementation Guideline shows that this ministerial law has comprehensively accommodated services that should be provided to female victims of violence. As for five services that should be provided to female victims of violence according to the regulation are: 1. Complaint handling 2. Health service 3. Social rehabilitation 4. Legal assistance 5. Repatriation and reintegration These services are provided referring to the minimum service standard (SPM) in which female victims of violence may access assistance and support according to Ministry of Women Empowerment and Child Protection Act No. 1/2010 on Minimum Service Standard Integrated Service Sector for Female and Children Victims of Violence. In its implementation, this regulation still faces challenges regarding its qualities. Female victims of violence often encounter some difficulties to access legal assistance and health services. Implementation of this regulation is weakened by the absence of monitoring efforts and sanctions to the parties who ought to carry out the regulation. In the health service components for female victims of violence according to Ministry of Women Empowerment and Child Protection Act No. 1/2010 on Minimum Service Standard Integrated Service Sector for Female and Children Victims of Violence, the health service refers to all efforts that includes promotive, preventive, curative, and rehabilitative aspects. Whereas in its implementation, the health service only encompasses investigative findings and physical wound treatment and counseling for traumatic victims. Indonesia  AIDS  Coalition  2011.   19  
    • PEP, EC, and IMS services are not integrated with health service for female victimsof violence. According to State Ministry Law PP No. 1/2010 on SPM for Female andChildren Victims of Violence, the major difficulty of health service is the lack ofmedical staff for mental health specialists, forensic experts, psychologists, and well-trained counseling personnel. Abortion is another service that can be accessed byfemale victims of violence, such as rape, only if the victims become pregnant (HealthLaw No. 36/2009).In Health Law No. 36/2009 article 75 – 77 on abortion, abortion is generallyprohibited by the law and the government is obliged to protect and prevent women tohave abortion with the exception of those who have certain uteral problem or thosewho have fatal risk or rape victims. These articles state, several times, that theabortive regulation refers to religious values and norms, whose relativity is debatable,and do not refer to universal human rights values. Article 76 explains about abortionaccess procedure, i.e. abortion can be done at six months gestational age atmaximum and must obtain permission from husband, unless the abortee is a rapevictim, and health service provider according to ministerial decree. This regulationmakes women rightless to their own bodies because they need permission fromhusband to have an abortion and, thus, unmarried women cannot access thisservice.“A female, 27 years old, having gestational age of 4 months. She’s unmarried, andtherefore must take abortion in Bekasi area. Its price is relatively higher Rp1,5 millionthan the official price under Rp1 million (in 2008). This price depends on gestationalage, if it is under 3 months you pay less than Rp1 million.” (In-depth interview with afemale PLHIV, Jakarta)“Abortion is considered illegal and prohibited. If there’s anyone who have abortion,then she’ll be accused of criminal act.” (In-depth interview with a female sex worker,Jakarta)“The regulation prohibits teens to have abortion.” (In-depth interview with a femaleteenager, Bogor)“No (information) at all. When you come, abortion is taken place. You just take thedrugs and are explained how to use them.” (In-depth interview with a female sexworker, Jakarta)The regulation on abortion is not well-disseminated to general public. Legal abortionservice can be accessed in communities although it is deliberately concealed by thelocal government and communities. Unmarried pregnant women gets the illegalabortion services with much higher price than the legal one (it also depends ongestational age). The absence of legal abortion service leads to unsafe abortionprocedure.“One of the victim wanted to access Raden Saleh clinic, but because there weremany procurers ask her to visit cheaper clinics. Eventually, she got bleeding for 3weeks and she was hospitalized. It happened when I was in the 3rd class of high Indonesia  AIDS  Coalition  2011.   20  
    • school and the price was 2 millions, let alone transportation cost to Jakarta fromBogor.” (In-depth interview with a female teenager, Bogor)“I have no idea about the law, but I’ve heard about abortion stuff. It usually happensamong my PLHIV friends, when they want to have abortion they usually cover it upand have the abortion in illegal clinics.” (In-depth interview with a female PLHIV,Jakarta)Even though abortion service is illegal in Indonesia, there are some NGOs andhospitals that provide safe abortion service. In several hospitals, the abortion serviceis conducted by an expert medical surgeon, but they only cover the abortion service.Whereas in some NGOs, this service includes pre-abortion counseling, abortion, andpost-abortion assistance (if necessary).“In PKBI DKI there’s a clinic for counselling and the doctor is well trained, but it’s onlynon-medical abortion. If you want to have abortion by taking pills, you can have it inSamsara Jogjakarta, and a counselor there helps you through the process.” (In-depthinterview with a female teenager, Bogor).According to Minister of Women Empowerment and Child Protection Act No. 2/2008on protection to female victims of violence also includes the victims of domesticviolence. One of the subjects of this act is the household group, comprising around40.000.000 – 50.000.000 households in Indonesia.Services or treatments provided are: Complaint handling, health service, socialrehabilitation, legal assistance, and repatriation or reintegration. In theimplementation level, female victims of domestic violence receive psychologicalcounseling, consultation, and legal assistance. Some civil society organizationsprovide shelters or reservation house for the victims if necessary.The protocol for HIV prevention to infants is the national guideline of mother-to-infanttransmission prevention issued by Indonesian ministry of health in 2011, in whichencompasses sexual and reproductive health treatment. Prong 1 states about HIVtransmission prevention for reproductive women through primary prevention of whichit gives awareness to them and health service providers, builds communityinvolvement, and creates an HIV-friendly mother and infant treatment so that thespouse can involve too. Prong 2 consists of prevention on unplanned pregnancy forHIV-positive reproductive women who need counseling, HIV test, and safe andeffective contraception services. In Prong 3, prevention method emphasizes onmother-to-infant transmission prevention through several steps: comprehensivetreatment for mother and infant, counseling and HIV test, antiretroviral drugs,counseling on HIV and baby food and safe childbirth method. Prong 4 explains onhow to provide psychological and social supports and health treatment to HIV-positive mother, infant, and the family.Overall, the protocol has encompassed sexual and reproductive health treatment forHIV-positive women in which consists of recommendation on double protection and Indonesia  AIDS  Coalition  2011.   21  
    • parenting method. However, the protocol does not mention or give information onVAW prevention and treatment.Based on in-depth interviews with HIV-positive women and sex workers ontreatments for WLHIV, only PMTCT and pap-smear services that are available andeasily accessed. Comprehensive information on PMTCT is still difficult to find byrespondents. The awareness of WLHIV and female sex workers in accessing theservice is still low due to the severe stigma on WLHIV.Stigma and discrimination still happens whenever health service workers know theHIV status of WLHIV. They are placed into the last number during examinationprocess and they are asked about their HIV status (which can be seen from medicalrecord) with a judgmental tone. To this day, HIV-positive women are often confusedafter taking health test. For example, if they encounter financial problem, they areusually unwilling to continue into the next step. In one case, they received free pap-smear test service, but the providing organization does not inform the result.Regarding PMTCT service, WLHIV reproductive rights are often violated in whichthey are forced, or without their consent, to get sterilized. According to thedocumentation of limited cases gathered by IPPI in 2009, there are 4 provinces inIndonesia that report sterilization cases. In 2010 – 2011, additional 2 provinces reportthe similar case.“In state hospitals, PMTCT information service is not given to PLHIV who have justrealized their HIV status. Even I don’t know at all on PMTCT steps, and it is notdetailed.” (In-depth interview with an HIV-positive female sex worker, Jakarta)“There was a woman who take pap-smear test and she’s unmarried, then she’sasked whether she is married or not. ‘You’re unmarried but you want to have pap-smear test?’ Then, she got the last number, it was a discrimination.” (In-depthinterview with an HIV+ female, Jakarta)One of the subject of Ministry of Women Empowerment and Child Protection Act No.2/2008 is the female victims of violence during armed conflict and disaster whichaccommodates 33 provinces and 485 municipalities/towns in Indonesia. This act alsotargets female adolescents with estimated number of 15.000.000.In the State report for UNGASS AIDS in 2010 shows the availability of Post ExposureProphylaxis (PEP) of 10.621 health services, only 1,41% of them provide PEPservice. The lack of information on PEP creates difficulty to receive comprehensiveexplanation on the service. However, no data found whether this service hasaccommodated treatment for sexual violence victims.Post exposure prophylaxis in HIV-related jobs, particularly in harm reductionprogram, is sufficiently informative in which the workers are provided with the ability,skill, and care on themselves in performing exposure prevention by using tools thatmay prevent HIV exposure such as gloves or clasps and the post-exposureprocedure including the prophylaxis. However, the institutions or employers do not Indonesia  AIDS  Coalition  2011.   22  
    • give further guarantee to their workers, even if there is a worker who gets contracted,it is usually considered as occupational risk.Informational access or contraception service for unmarried youths is not facilitatedby the government. Law No. 52/2009 on Population Growth and Family Developmentarticle 23 – 26 states that contraception can only be accessed by married couples,thus sexually active teenagers cannot access the contraception service.To this day, the most frequent service is consultation service prior to choosingcontraception, which are mostly used by women, not counseling service.Contraception promotion all this time is emphasized on women, especially permanentcontraception (besides condoms). Contraception drug (to weaken the sperm) wasdeveloped in around 2008 – 2009 for male. The government and foreign donorsspent huge fund for its development. The high gender bias in Indonesia makes thiskind of contraception unpopular and it is never heard since.Contraception use for WLHIV is suggested when accessing PMTCT service onpregnancy planning. In the implementation level, sterilization is also offered toprevent later pregnancies for WLHIV.The recommendation of using emergency contraception (EC) such as KB pills iswidely available in Indonesia. KB pills and other contraception programs can only beaccessed by married women. Information on EC is very limited.Consuming pills such as postinor cannot be distributed in supermarkets or publiccommercial stores. Legalization process of EC is against the Health Law No. 36/2009from which religious leaders oppose the wide distribution of EC, including postinor.National recommendation or guideline on HIV infection treatment is basically ageneral information and there is no classification based on age groups. The contentitself does not describe requirements on certain groups. Sexual and reproductivehealth issues are not explicitly discussed, only information on types of sexualtransmitted disease without referral system nor treatment recommendation.HIV infection treatment guideline for adults, adolescents, and children remainsunknown to general public. All HIV-related treatment services can only be accessedby PLHIV after getting referral from clinics. In hospitals, inpatient children of 11 yearsold above are considered adult treatment service because there is no specialtreatment for adolescents. Lack of information and HIV-related treatment methodmakes doctors assume the right dose of ARV for children, and this situation isworsened with the absence of ARV syrup or powder. HIV-related information serviceprovided to PLHIV on opportunistic infection is only basic-based service withmaximum time of 5 minutes because state public hospitals handle too many patientsso that they only have very limited time allocation. In addition, PLHIV are stigmatized “In hospital, children care is different. No service for adolescents, they are treated like adults. Twelve year-old children are categorized as adults. There are hospitalized men, women, and children, children of 12 – 15 years of age are treated in adult room.” (In-depth interview with a WLHIV, Jakarta) Indonesia  AIDS  Coalition  2011.   23   “In fact, medical knowledge among nurses is different to each other, so the patients are often confused when they want to access the servie.” (In-depth interview with a female sex worker, Jakarta)
    • whenever healthcare workers know their HIV status, usually around questions on how and where they got transmitted.2. HIV Test, Treatment, Care, and Supporting Services The State’s integrated service package for HIV, tuberculosis, and sexual & reproductive health, including harm reduction service is widely available. However, accessing reproductive health-related service is confusing for women, whether they should take mother and infant health service or IMS examination, lack of comprehensive service on female-related problems especially in addressing and responsing VAW and vertical transmission prevention and treatment. The services are not integrated enough that create difficulty to access them. Free, confidential, and voluntary VCT and HIV counseling are available in Indonesia, but they still lack of women-friendly services so that many women are not comfortable to access them, especially when they reveal their HIV status or violence that they had. The HIV counseling service never discusses on violence, neither information on harm reduction strategy for female victims, post-violence strategy or measures, nor referral system because the HIV counseling protocol does not integrate VAW. According to HIV/AIDS Counseling and Testing Service Guideline issued by Ministry of Health in 2006, VCT service can facilitate and provide relevant referral on behavior change, PMTCT intervention, early management on opportunistic infection & IMS including ARV introduction, prevention and treatment therapy on reproductive infection, social and peer support referral, HIV/AIDS normalization, future planning, orphan care, inheritance, serostatus acceptance and self-treatment coping. The protocol does not explicitly mention and actively persuade to fight discrimination and violence against all groups of women and female adolescents. The protocol does mention about confidentiality of client as a part of patient or client rights, but does not clearly explain on sanction and impact of status disclosure. HIV/AIDS Counseling and Testing Service Guideline issued by Ministry of Health in 2006 does not establish a system that can filter violence that has been experience by a female client. Lack of counselor knowledge on violence issue makes this system underdeveloped. Counselors in HIV/AIDS VCT service are trained to give information on HIV/AIDS, IMS, and high-risk behavior. The pre- and post-counseling protocol explains the typical requirements for women in situation of violence, among them are: - Information on harm reduction strategy for female victims of violence. - Alternative models on HIV status disclosure, including disclosure method through mediation of friend or counselor. - Information on HIV risk in marital relationship. - Information on strategy in negotiating condom (which is much safer). Indonesia  AIDS  Coalition  2011.   24  
    • - Referral to gender-based violence service or peer groups working on this issue.- Referral to social or psychological support center.According to HIV/AIDS Counseling and Testing Service Guideline issued by Ministryof Health in 2006, pre-counseling activities encompass HIV-based information,reasons of VCT, and communication on behavioral change. Whereas post-testcounseling helps client to understand and adapt to the test result. Counselor alsopersuades client to discuss strategy to prevent HIV transmission.Female clients do not obtain sufficient information on harm reduction program,referral to gender-based violence service, and condom-using strategy. The positiveside is that the service helps them in providing alternative information in HIV statusdisclosure by giving a proper information on HIV/AIDS to the family members andgives referral to PLHIV peer-support groups.Healthcare service for pregnant mothers in Indonesia are not automatically integratedwith PMTCT service. Due to this unintegrated service, many pregnant mothers do notknow about HIV/AIDS-related information and the importance of HIV testing duringpregnancy. Violence-based information is still technically medical, in which pregnantmothers are suggested to avoid things that may cause miscarriage.In the government-based PMTCT program in several referral hospitals, the hospitalworkers do not prevent the violence itself. Instead, violence occurs in the form offorced sterilization on HIV-positive women. Counseling for HIV-positive pregnantmothers is seen as uncomfortable because of the stigma and prejudice fromhealthcare service workers that HIV-positive women should have not have babies orHIV disease is correlated with immoral acts.Treatment and medication service that encompass sexual and reproductive needsare available and can be accessed by general public including WLHIV such asMother and Infant Clinic and IMS Clinic. In the AIDS issue, IMS clinic is activelydisseminated to the key population group including WLHIV. The challenge for WLHIVis how to access the service. Sexual and reproductive health service is stillsegmented in Indonesia, therefore when a woman has problems with herreproductive health, she does not know whether should visit mother and infant clinicor IMS clinic. Whereas in IMS clinic, the service is only in the form of detection ofillness and Reproductive Tract Infection (ISR) is not the main focus in this service.Another challenge is the difficulty to access healthcare service when women havesexual dysfunction problems. Healthcare service that can accommodate this kind ofservice is rare in Indonesia.Healthcare service that accommodates WLHIV to have children and to choosecontraception methods can be accessed in PMTCT service. Cervical cancerexamination can be obtained in IMS clinics. With the lack of information on sexualand reproductive health for WLHIV found in the Need Assessment Survey 2010(conducted by IPPI) and segmented healthcare services put some difficulties forWLHIV in maintaining, improving, and treating their sexual and reproductive health. Indonesia  AIDS  Coalition  2011.   25  
    • PEP availability of 10.621 healthcare services within all Indonesian regions can only be able to be distributed in 1,41% of all the total number.13 The lack of information on PEP provision is still a major challenge. We are not sure whether PEP provision for victims of sexual violence has been given or not. Healthcare centers that provide free HIV & syphilis test and counseling are mostly operated by social organizations even though there are some local healthcare service provide the service in their IMS program. State report for UNGASS AIDS in 2010 shows that the number of healthcare facilities providing HIV test and counseling increased from 290 units in 2007 to 547 units in 2008. Meanwhile, the number of clients above 15 years of age increased from 53.929 persons in 2007 to 109.544 persons in 2008.14 There are many hospitals and clinics, both private and public, that provide HIV test service, but not all of them have pre- and post-test HIV counseling. Particularly for private hospitals and clinics, they usually do not have counseling service. Unfortunately, for hospitals and clinics that do have the service, specific service for adolescents is still absent as they are still considered as adults. Prior to counseling, the officer asks several questions that make adolescents uncomfortable because the registration desk is placed in the same room with the waiting patients and they can hear the questions. Counseling service in some clinics and hospitals is conducted by adolescent-friendly counselors but there are also counselors who asks as if it were an interrogation and unfriendly to adolescents. Confidentiality is guaranteed and the information given is still around IMS and basic knowledge of HIV and AIDS, and not includes SRHR. Some of the clinics are not strategically located. The average working hour is at 9 am to 5 pm. Several NGOs conducted research visit to take HIV test. Counseling was given during the visit even though it was not quite comfortable (there was no special room for counseling, only separated by partition). The medical staff workers who provide HIV/AIDS services have been trained in sexual and reproductive health through IMS clinics and VCT clinics. However, the sexual and reproductive health service is focused on IMS only, thus it is difficult for those who want to consult about ISR. Gender and violence knowledge is still limited among the staff workers in HIV/AIDS service so that clients will not receive this kind of information from them.3. VAW Service The type of service in addressing VAW consists of complaint and situation handling, healthcare service of which the victims are provided with treatment service, trauma                                                                                                                        13 UNGASS Country Progress Report – National AIDS Commission, 2010.14 Presentation of Ministry of Health for UNGASS on AIDS Report, 2010. Indonesia  AIDS  Coalition  2011.   26  
    • counseling, reproductive organs trauma treatment, legal assistance, socialrehabilitation, and repatriation.The service encompasses all kinds of violence against women and children. Itincludes domestic violence, sexual violence, and violence during armed conflict anddisaster. The availability of service can be accessed in provincial capitals and due tothe vast geographical areas of Indonesia, the service still faces a major challenge inorder to be accessed by women who live in the remote villages. The service ismanaged by the government and civil society. For example, social rehabilitationprogram, in the form of shelter house, is managed by both the government and civilsociety. Unfortunately, the violence service does not provide HIV-related information,counseling, and test.There is no HIV risk examination on violence victims. The only available service isonly confined to special treatment on the violence itself.The service cannot be accessed comprehensively as some forms of service areunavailable such as minimum information on PEP. We are not sure whether PEP forsexual violence victims has been given or not. Legalization process of EC is againstthe Health Law No. 36/2009 from which religious leaders oppose the wide distributionof EC, including postinor. The only available services are medical and psychological(through counseling) treatments. However, counseling for PEP and HIV service usersis not yet carried out due to the lack of information on PEP and HIV of which thetreatment is carried out separately and exclusively so that it is not integrated with anyother issues. Therefore, ARV treatment cannot be given immediately.Training for healthcare service workers is still not optimum causing slowimplementation process. The service cannot be performed in just one place or by asingle person.Healthcare service workers, civil society organizations, and shelter houses have notyet been trained on the relation between HIV and VAW. Ministry of WomenEmpowerment has published a manual on HIV/AIDS and women, but theimplementation of this manual is still questioned.Concerning HIV/AIDS service, healthcare service workers have received informationon key population groups such as LGBTIQ, IDU, sex workers, etc. which is giventhrough training or workshop. But to this day, these key population groups still facediscrimination from healthcare service workers.Healthcare service workers only specifically give treatment to women and children.The lack of information on managing women groups with various backgrounds makesit difficult to measure sensitivity of healthcare service workers in this issue.There are shelter-houses managed by either the government or civil societyorganizations, in which post-trauma counseling programs and activities such assewing can be seen. However, these shelter-houses still lack of information orcapacity building to help the treatment process when violence case occurs. Indonesia  AIDS  Coalition  2011.   27  
    • Police department, through public service unit, also provides a service focusing on women and children served by female police officers. The legal assistance is also provided by the government or civil society.4. Supply Availability Male and female condoms and lubricants can be accessed for free through AIDS program under the “condom outlet” strategy in which the field officers and NGOs working on HIV/AIDS prevention and outreach to the key population groups actively promote condom and distribute it to the key population group. Female and male condoms and lubricants are available in drugstores and supermarkets so that it can be easily accessed. EC availability still faces major challenges, however, in Indonesia due to the lack of information and strong opposition from religious leaders. According to research conducted by UNGASS Forum Indonesia for Sexual Reproductive Health & Rights (SRHR) in 2010 explains that Social Department in several provinces distributes powdered milk for HIV-infected women who have children. However, this nutritional support is not widely distributed in Indonesia with vast and remote geographical areas. Free distribution of modified milk for WLHIV children is not well-distributed and is not provided regularly. The program is implemented if there is budget allocation for it and in provinces where the program enlisted in regional revenue and expenditure budget (APBD). Sometimes, disorganized distribution occurs causing some difficulties for HIV-positive women to access the modified milk. It can be concluded that free distribution of modified milk depends on the budget and the involvement of social department workers. Free ART provision and drugs for opportunistic infection treatment and prevention, including vertical HIV transmission treatment, can be accessed in referral hospital or selected private hospitals. Although the drugs are free, we still have to pay administration fee and doctor consultation (sometimes the doctor does not perform examination, only makes the prescription). In UNGASS state report in 2010 on ART treatment, opportunistic infection treatment (particularly for TBC) and ARV prophylaxis provision, it shows that there is an increasing number of PLHIV who receive ARV treatment. The increasing number of HIV-positive adults and children who receive ARV reaches 3,2%. The report also shows that in 2006 – 2008 period, female group receives more ARV drugs than male group. There is an increasing number in ART provision to pregnant mothers; 3,8% in 2008, compared to 3,5% in 2006. Meanwhile, HIV transmission was doubled from 2006 to 2009 in all 33 provinces. This situation is not balanced by the wide availability of comprehensive PMTCT that have been only available in 9 provinces with additional challenge such as lack of well-trained PMTCT medical staff workers. Concerning opportunistic infection, particularly TBC, Ministry of Health through state report for UNGASS 2010 explains that there is an increasing number of PLHIV with Indonesia  AIDS  Coalition  2011.   28  
    • TBC incident in 2008 with 115.202 infected persons. In addition, the limited healthcare service centers that provide ART and TBC drugs are still a major constraint because there is no one-stop policy in dealing with the issue. Referring to SPM issued by Ministry of Women Empowerment, victims of sexual violence receive healthcare service particularly reproductive tract infection treatment if they have trauma or reproductive problems. But the SPM does not mention PEP provision for victims. According to the state report for UNGASS AIDS 2009, 81% of high schools in Papua teach HIV education as a life skill education/LSE in the final academic year. In 2008, 41% of high school teaches it throughout Indonesia. The LSE continuity is heavily needed. HIV-based LSE is the first step to prevent HIV among youths. LSE dissemination is very important, not only in formal schools but also in civil and community groups. Among teenagers within 15 – 24 years of age, 14,3% of them have comprehensive knowledge on HIV/AIDS prevention. Girls tend to have more comprehensive knowledge on HIV than boys. The percentage of comprehensive knowledge on HIV/AIDS has increased from 11,5% in 2002 – 2003 to 14,4% in 2007. However, the major obstacle is that there is no definite measurement to see the scope and impact of this important knowledge. Also, different level of knowledge may occur between urban and rural populations. KIE materials do not encompass HIV, VAW, and SRHR intended for various women and young women groups. Information on HIV, VAW, and SRHR is usually segmented and is not specifically intended for women group.5. HIV and VAW prevention efforts Comprehensive sexual education (according to the providing organization) has been available in some schools in Indonesia. However, sex education that includes gender and power relation is not yet available; the main cause of VAW and violence against young women and how to avoid it; contraception method, and regulatory laws on SRHR, VAW, and HIV, are all absent. Most of sex education materials consist of basic information, and very few of them consist of skill training, let alone information on regulatory law in Indonesia. There are several programs that introduce basic human rights such as rights to information. But these too are not comprehensive enough to encompass legal aspects on SRHR, VAW, and HIV. Many organizations claim that they have given comprehensive sex education, but the fact tells that the information given is only confined to reproductive health education. So far, there is no training for school staff to recognize highly risk and HIV-positive teenagers and/or who experience violence and to respond and refer them in a proper way. The training only encompasses basic HIV and AIDS information (transmission way, preventive measures, and a hint of stigma and discrimination). HIV is generally seen as a fatal and destructive to nation’s future and this slogan is often used as a Indonesia  AIDS  Coalition  2011.   29  
    • “NAC now is preparing for women and HIV/AIDSrisk behavior.that would create have very few threat to students so that they avoid action plan Lots of schools gender-perspective AIDS HIV, and many do not know it comprehensively. AIDS knowledge on prevention program.” (Baby, IPPI) FGD with organization National media campaign to reach parents, school dropouts, and general public on   comprehensive sexuality education and gender equality is completely absent. HIV campaigns only show about the preventive measures or how to avoid risk behavior. The Indonesian government has the program but it only consists of slogans and there is no monitoring effort on its implementation and continuity. Instead, regular campaigns are conducted by NGOs and communities. The ODHA Berhak Sehat community specifically works on disseminating efforts in AIDS issue, including VAW through social media network they manage. The network is able to consistently connect into more than 7000 individuals via several social media accounts. Indonesia has national campaign on VAW called “16 days forever” which was initiated by Komnas Perempuan and its network in 22 provinces and 43 municipalities to commemorate 16 days without violence. The theme of 2010 – 2011 campaign is: “Sexual violence: identify and handle it.” To this day, there is no national campaign that integrates between VAW and HIV risk. Small-scale activities to integrate VAW and AIDS have been conducted by IAC and IPPI during the last two years. Participation in the 16 days without VAW is carried out through campaigns via social media, public discussion, radio campaign, and other activities. C. WOMEN EMPOWERMENT AND LEADERSHIP IN THE CONTEXT OF HIV EPIDEMIC 1. Civil Society Organizations in HIV and VAW Response *. Women network, including WLHIV and VAW victims, involves in planning and monitoring of national HIV response. According to Presidential Act No. 75 that becomes the legal basis of AIDS prevention program in Indonesia, the involvement of civil society organizations particularly key population group has been regulated. The key population network and civil society organization representatives are the members of National AIDS Commission/NAC. According to NAC mandate, the commission acts as coordinating organization on AIDS prevention program based on the Three-One Principle. From the national AIDS response planning aspect, the majority of key population groups have been involved, including sex worker and WLHIV network groups. Based on FGD result with these groups, they answered that NAC as the coordinating organization on AIDS issues has involved them in the program planning process. Indonesia  AIDS  Coalition  2011.   30  
    • “The planning started to be involved last week in creating SRANAS for HIV-positive adolescents.” (Handa, ARI) FGD with AIDS organization their involvement in AIDS issue Organizations working on youth issue answered that has just begun in the last few weeks. Their involvement consists of creating AIDS prevention national action plan for adolescents. In the FGD, a gap can be seen when the involvement process does not affect organizations in regional level. The regional-level organizations feel that the involvement is only opened for national-level and capital-based organizations. WLHIV who join in these organizations and reside in non-capital cities still focus on PMTC service access issue and their limitations to access the service because it is only available in the provincial capitals. “Provincial-level organizations is not involved, let alone us who reside in municipal towns.” (Aris, SOLIDARITAS) FGD with AIDS organization Concerning monitoring efforts, IPPI as the network organization working in national level said that they are involved in the national-level monitoring process. However, in its implementation, their involvement is not accompanied by capacity building and they feel that their involvement is only symbolic. The annual monitoring result is considered as weak because there is no follow-up effort. “The result of this process (monitoring and evaluation) is always the same from year to year, nothing changes.” (Baby, IPPI), FGD with AIDS organization From the total respondents who took online-based survey of whom they came from organizations working on women issue said that they are not involved in the planning and monitoring process of AIDS issue. This is highly correlated with the unintegrated policy and service availability between VAW and HIV/AIDS issues, making the involvement of women organization in AIDS issue insignificant. Based on in-depth interview with gender and human rights expert staff in NAC secretariat office, she said that there is an improvement with the re-activation of Gender and Human Rights Working Group consisting of ministries, international development organization partner, and civil society organizations as an opportunity for civil society to address suggestions and data that may raise VAW and HIV/AIDS issue to be followed up in NAC. “The working group consists of ministries and HIV and women NGOs.” (Syafira, NAC) In-depth interview with NAC The head of gender and human rights working group that is being held by partner of Komnas Perempuan also gives a good opportunity to raise women issue and integrates it into AIDS prevention program. Indonesia  AIDS  Coalition  2011.   31  
    • *. Women organization network, including WLHIV and violence victims, is involved inthe monitoring and planning process in national VAW response.IPPI as the WLHIV network in Indonesia has raised VAW issue since itsestablishment in 2007. During its progress, the organization has involved Ministry ofWomen Empowerment and Child Protection through several activities, but until nowthe follow-up process is still considered weak. The involvement of civil societyorganization often encounter obstacles especially for communities which are highlystigmatized.“It is difficult for sex workers to enter the ministry because of the stigma anddiscrimination against them.” (Dea, OPSI) FGD with AIDS organizationAIDS-related organizations said that they are never involved in the planning andmonitoring process in violence issue. Whereas women-related organizations said thatthey are only involved in the monitoring and documentation process on VAW cases.NAC has partnered with Ministry of Women Empowerment and Child Protection. Thepartnership is mutual in nature; NAC through its gender and human rights worktaskforceConducts capacity building activities for KPAP/K in provincial and municipal level ongender mainstreaming which involves Ministry of Women Empowerment in providingPUG materials (modules). This partnership is reciprocal; Ministry of WomenEmpowerment works with NAC to provide HIV/AIDS information to the ministryofficers. Commitment and partnership on integrating VAW and HIV/AIDS issue havenot yet been made.“So, we always consult and ask them to give channelling to organizations thatalready conduct PPRG and vice versa.” (Syafira, NAC) In-depth interview with NAC*. Training/workshop that is financially supported by the national government forwomen organization and network on HIV and VAW response monitoring.Based on FGD with AIDS-related organizations, some of them said that they receivegovernment fund to strengthen organizational structure. Youth organizations said thatthey never have financial support in creating capacity building for their members.Meanwhile, some organizations said about the low commitment of the government tofinancially support regional organizations.“We had support in the form of training or workshop, but this too was only limited inJakarta region.” (Baby, IPPI) FGD with AIDS organization Indonesia  AIDS  Coalition  2011.   32  
    • *. National action plan to facilitate coalition among women organizations, WLHIVnetwork, organizations working on gender equality, AIDS activists and human rightsgroups to create a social movement in order to reduce stigma and discrimination andto advocate and improve gender equality and women rights and empowerment in theHIV context.All the respondents in FGD said that they have cooperated with various organizationsto carry out the national action. Not only HIV/AIDS issue that have been raised, butalso other important issues such as human rights, pluralism, VAW, migrant workersto environmental issue.“We have done it as partner in Komnas Perempuan, for instance in the VAW issue…”(Baby, IPPI) FGD with AIDS organization“There was a group initiated to encourage people who live in Salatiga as to not onlyconcern with AIDS issue, but also other major issues in that town. Its members areHIV, environment, and various organizations.” (Aris, SOLIDARITAS) FGD with AIDSorganizationHowever, these programs are usually conducted inconsistently and they worktogether if a major issue is raised or if there is a nationwide ceremonial agenda.*. Women rights groups and WLHIV networks cooperate to monitor the reinforcementof CEDAW by the government.For women-issue organizations, their involvement in monitoring and reinforcingCEDAW has been seen and they have a special group called CEDAW WorkingGroup Indonesia (CWGI). CWGI membership consists of organizations working onwomen issues. IPPI and IAC have involved as CWGI members to integrate violenceagainst WLHIV and other AIDS-related women issues. UNWOMEN and IPPIpartnership has been going on capacity building and documentation on violenceagainst WLHIV by using CEDAW framework.“This year we are involved in the CEDAW working group of UNWOMEN. IPPI isalready supported by UNWOMEN to conduct CEDAW workshop. Therefore, besidesAIDS, violence is also a major concern of IPPI.” (Baby, IPPI) FGD with AIDSorganizationIPPI partnership with UNWOMEN in CEDAW issue is a very good opportunity toincrease the role of AIDS-related organizations so that they can be more involved inmonitoring VAW.*. WLHIV networks and women rights groups represented by Country CoordinatingMechanisms of the Global Fund to Fight AIDS, Tuberculosis, and Malaria ensure thatthe needs and perspectives of women and young women groups are reflected in the Indonesia  AIDS  Coalition  2011.   33  
    • national program. The AIDS national planning has special arranged budget tosupport women CBO capacity, particularly WLHIV.The role of CCM is still questioned by most of AIDS-related organizations. Manyorganizations do not understand the mechanism of CCM and process of Global Fundprogram in Indonesia. The representation of WLHIV through IPPI as the alternateCCM member that does not have right to vote and to give suggestions to PLHIVrepresentative members is not so strong. Furthermore, this representation is notaccompanied with information dissemination and capacity building on CCMmechanism.“As an alternate member, we only have right to whisper. We are quite disappointedwhen deciding to join because we can only be the whisperer.” (Baby, IPPI) FGD withAIDS organizationThe presence of social security mechanism (for example, fund transfer,microfinancing, free transportation, shelter, food provision) that applies for WLHIV.The social protection program in Indonesia is under the Ministry of Social Affairs.Among the aid programs to the community are micro business, rehabilitation house,nutritional aid for PLHIV children, and many others. Almost all women organizationsand AIDS-related organizations have heard and received this program. The majorchallenge of this program is the indicator in measuring quality and effectiveness ofthis aid.“In the province, access for the fund is easily obtained and not only in the form ofmoney but also modified milk.” (Aris, SOLIDARITAS) FGD with AIDS organization Indonesia  AIDS  Coalition  2011.   34  
    • Recommendation:1. Encouraging that the creation of National Strategic Action Plan AIDS response forwomen can be realized with sufficient budget allocation in order to implement programsand civil society involvement particularly women groups in its each process.2. Encouraging more commitment from the government by issuing joint decree amongNAC, Minister of Women Empowerment and National Commission on Elimination ofViolence against Women in order to address the relation between VAW and HIV/AIDS.3. Encouraging the government, international development partner and UN agencies toprovide funding scheme for women-related organizations in order to enhance publicawareness on the relation between VAW and HIV/AIDS.4. Establishing capacity building for women organizations and communities in exploringthe relation between VAW and HIV/AIDS carefully planned and measured effectiveness.5. Creating a joint campaign among women-related organizations to increase publicawareness on the relation between VAW and HIV/AIDS.6. Conducting yearly monitoring on progress of VAW prevention effort as an integralpart of AIDS prevention program in Indonesia. Indonesia  AIDS  Coalition  2011.   35  
    • BIBLIOGRAPHYBurnet Institute, “Perempuan dan kerentanannya terhadap HIV"BPS (2009). A socio-economic impact study of HIV and AIDS on Households. Draftreport.FHI-ARC (2010). Perilaku dan jaringan seksual pengguna napza suntik. Jakarta: ARC-FHI.Indonesia UNGASS-AIDS Forum. (2010). Monitoring UNGASS-AIDS Goals on Sexualand Reproductive Health.Indonesia UNGASS-AIDS Forum (2010), Civil Society Report for UNGASS on AIDS.KOMNAS Perempuan (March, 2009). Atas Nama Otonomi Daerah; PelembagaanDiskriminasi dalam Tatanan Negara-Bangsa Indonesia.NAC (2008). Strategi Nasional Penanggulangan HIV dan AIDS pada Anak dan Remaja2007-2010. Jakarta: NAC.Ministry of Health (2007), Integrated Surveillance on HIV and Behavior (STHP).Solidaritas Perempuan (2009). Mandatory testing on Indonesian migrant workers: 2007report. Jakarta: Solidaritas perempuan, CARAM Asia, UNIFEM.STIGMA (2010). Pengalaman Perempuan Penasun dalam Mengakses Pelayanan harmReduction: Sebuah kajian cepat. Draft report. Indonesia  AIDS  Coalition  2011.   36  
    • Table of respondents:No Name Organization Focusing work1 Dhea OPSI (Indonesia Sex Worker Network) Women, Sex Workers IPPI (Indonesia Women living with HIV2 Baby Rivona Network) Women, WLWHIV Aris3 Setyawan Solidaritas PLHIV Minority Right, Aditya Transparency,4 Wardhana IAC (Indonesia AIDS Coalition) Accountability5 Handa ARI (Independent Youth Alliance) Women, Youth Syafira6 Hardani National AIDS Commission NAC Mike7 Verawatil KPI (Indonesia Women Coalition0) Women Coalition OPSI (Indonesia Sex Worker Network)8 Liana Jakarta Chapter Women, Sex Workers9 Loveria ARI (Independent Youth Alliance) Youth IPPI (Indonesia Women living with HIV10 Sunarsih Network) WLHIV11 Martha Kios Atmajaya Women, Drug user Valentine12 Merrita Sari Ardhanary Institute Women, LQBTIQ13 Roni Rifka Annisa Women Crisis Center14 Hartoyo Our Vice LGBTIQ Women and15 Farhanah Yayasan Jurnal Perempuan publication Indonesia  AIDS  Coalition  2011.   37  
    • Indonesia  AIDS  Coalition  2011.   38