In-depth: Asia: Facing the HIV/AIDS challenge

INDONESIA: On a razor's edge - HIV vulnerability in Aceh

Photo: David Swanson/IRIN
Women and children were left particularly vulnerable in tsuanami-affected Aceh
Banda Aceh, 1 February 2007 (PlusNews) - Ratnawati Zulkifli, 32, will always remember the morning of the tsunami, a day still etched in her mind nearly two years after this century's greatest natural disaster to date.

"I lost everything that day, and everyone I love," she said, sitting on the steps of the crowded barracks-like structure she shares with her sister and two children in one of the ramshackle wooden shelters where many of the displaced still live on the outskirts of Banda Aceh, capital of Indonesia's devastated Nanggroe Aceh Darussalam (NAD) Province, more commonly known as Aceh.

More than 130,000 people died and over 500,000 were left homeless when the tsunami struck on 26 December 2004. Living conditions in the barracks, meant to be temporary, are poor. Most residents are women, many of whom lost their husbands and have no choice but to care for their children alone, often without a source of income or support.

Billions of dollars in international assistance have enabled thousands of survivors to be relocated to permanent housing, and signs of reconstruction are everywhere, but the plight of many displaced women is still dire. Isolated and alone, they face social instability, poverty and powerlessness - conditions that could heighten their vulnerability to another possible tsunami that could sweep the nation - HIV/AIDS.


Indonesia's National AIDS Commission estimates that between 90,000 and 120,000 people are living with HIV, with 13 million to 20 million at risk of contracting the virus, including mobile populations and commercial sex workers.

Although there is low prevalence in the general population, there is a concentrated epidemic among certain population groups, with injecting drug users and the sex industry fuelling the epidemic.

More than 80 percent of all cases involve men, and there has been an upsurge in needle-related HIV infections in the last six years. According to Ministry of Health figures for 2005, current infection rates among injecting drug users constitute 48 percent of all reported cases, and more than 60 percent to 90 percent in many provinces.

Intravenous drug use, previously rare in Indonesia, has become widespread, with drug-related HIV now being reported in nearly all of the country's 33 provinces, but programmes are actually reaching fewer than 10,000 of the country's estimated 160,000 injecting drug users.

"The amount of unsafe injecting going on without adequate information to educate them, is huge," Jane Wilson, country representative for the Joint United Nations Programme on HIV/AIDS (UNAIDS), told IRIN in the Indonesian capital, Jakarta. "About one in two drug users in Indonesia appear to be living with HIV," she said, describing needle sharing as the main vehicle for transmitting the virus.

The epidemic in Indonesia, a nation of over 225 million, appears to be concentrated mainly in Riau, on the island of Sumatra, Papua, Jakarta and East Jawa on the island of Java, and the island of Bali. In Papua alone, the prevalence rate is already well above 5 percent, Wilson commented.

According to the NAD Province AIDS Commission, as of March 2006, all provinces had reported cases of HIV/AIDS, including Aceh, a particularly conservative part of the country.


Indonesia, an archipelago of some 17,000 islands, was worst affected by the tsunami, with Aceh at the western end of the country's northernmost island, Sumatra, taking the hardest hit.

Already reeling from decades of strife between Indonesian military forces and the Acehnese rebel movement, GAM, the tsunami unleashed a wave of new problems, intensifying vulnerability among marginalised populations in what was previously an isolated region.

The United Nations Development Fund for Women (UNIFEM) noted that women accounted for about 55 percent to 70 percent of tsunami casualty figures, and had suffered physical, social, economic and psychological harm and deprivation.

Years of conflict had multiplied the roles of many women, obliging them to head households, sustain subsistence economies, raise children, care for the sick, wounded and elderly; they were described as the lifelines of Acehnese communities.

After the disaster many women, like Ratnawati, found themselves living in camps for displaced persons or barracks where they were alone, powerlessness and subject to increased domestic violence and other forms of abuse - all conditions that could enhance the risk of HIV/AIDS.

"Women and children are particularly vulnerable after a disaster such as this. Many had lost their husbands and were forced to be the breadwinners," said Herawati Daud, assistant project officer for HIV/AIDS with the United Nations Children's Fund (UNICEF) in Banda Aceh.


Aceh had no facilities for HIV testing and treatment before the tsunami, forcing those seeking such services to travel south for 12 hours to Medan, the provincial capital of North Sumatra Province.

Photo: David Swanson/IRIN
Thousands of people found themselves living in barrack-style temporary living centres following the 26 December 2004 tsunami in Aceh. Over 130,000 people were killed and more than half a million made homeless in the disaster
Sex and contraception are largely taboo subjects in Aceh's staunchly conservative Islamic society. According to Baby Rivona, programme director of the recently established Media Aceh Partnerships (MAP), a nongovernmental organisation (NGO), and one of the few people in Aceh Province working with HIV-positive people, even the government was hesitant in referring to women as being vulnerable, given religious restrictions on such discussions, while promoting condom usage might be misconstrued as condoning premarital sex.

Indeed, many Acehnese believe the tsunami was a punishment for insufficient piety, resulting in an even stronger emphasis on religion and its traditional views on family values.

Despite efforts by the NAD Province AIDS Commission prior to the tsunami to address HIV/AIDS, the sensitive nature of the subject meant there was little or no data on HIV prevalence.

"Our concern in a tragedy like this is to see a province like NAD from being a province with almost no HIV prevalence, or perhaps hidden incidence, to a being a place where, due to increased drug usage, vulnerability among women and sexual exploitation, more and more people becoming infected," Wilson warned.


Describing Acehnese as a high-risk population as a result of the disaster, particularly women and children, the HIV prevention coordinator for UNAIDS in Banda Aceh, Nicholas Peissel, commented, "IDP [internally displaced person] camps breed high-risk behaviour." People in such environments were introduced to those they would not normally associate or live with, and there was always the potential risk of sexual exploitation, rape, or sex for food.

David Gordon, programme director for a local NGO, Yakita, which has done extensive work with young people and injecting drug users, agreed, pointing out that in the confined quarters of barracks for the displaced, sex became either a vehicle or a commodity. "There is more potential for young people to have sex under the circumstances of living in these camps, as people looking to express ... [themselves], or getting what they want in return."


Besides interaction between groups that normally would not mix socially, the potential increase in sexual activity, and a large military presence as a result of the conflict, thousands of people, foreign as well as local, poured into the area to provide emergency and reconstruction assistance, bringing the unique impact of the heightened humanitarian response.

Of particular importance, said Peissel, was the arrival of tens of thousands of migrant workers from other parts of the country, such as Medan and Jakarta - mostly mobile men with money - some of whom might be infected with HIV and other sexually transmitted infections (STIs).

After extended periods of separation from their families, engaging in sexual activity with the local population was inevitable. It was not uncommon for construction camps to be set up alongside barrack housing for the displaced, often sharing facilities such as showers and toilets.

Uniformed personnel, who had been on conflict-related duty for upwards of two years at a stretch in the area, were also deployed in emergency and reconstruction efforts. "We all know that there is always a higher rate of STIs and HIV among the armed forces," Peissel said, because they were also men with money and therefore contributed to the expansion of sex work.


Access to groups at high risk of HIV was particularly difficult because the sex industry, already rising to meet the demand, has largely been driven underground by the conservative attitude towards sex in Aceh.

There are no organised brothels in the traditional sense, but it is not uncommon for some hairdressers and other establishments to act as fronts for such activity, making access and intervention all but impossible.


Although the primary risk of HIV infection now is reportedly via unprotected sex, given the steady rise in needle-related infection rates throughout the country, coupled with the acute lack of health services in Aceh - health infrastructure was destroyed by the disaster - experts are more than concerned.

In 1990, drug-related crimes in Indonesia accounted for between 5 percent and 10 percent of all incarcerations - but this has risen steadily ever since. "The increase of incarcerations directly due to drugs in one form or another has gone up 400 percent in a decade," Gordon commented, and in some prisons in Jakarta today it was closer to 60 percent.

There are no accurate assessments to determine the extent of drug usage, but a visit to Aceh's Rutan Kelas IIB prison in the town of Jantho, 42km outside Banda Aceh, is revealing. Of the 201 inmates in the facility, 150 - or 75 percent - were jailed for drug-related offences.

"If you are talking about high risk, you're not going to find a better indicator than that," said Gordon, a reformed addict whose NGO now oversees seven recovery centres and one drop-in centre.

Equally troubling is that marijuana, cheap and plentiful in the area, is now being used in exchange for 'Shaba Shaba', or amphetamines, which can also be injected. "Amphetamines were largely unheard of in this part of Indonesia two years ago. The fact that people are using them now points to a much deeper problem, and a huge risk factor," Gordon warned.

Three young local men serving sentences for either possession or dealing at the Rutan Kelas prison IIB were interviewed by IRIN/PlusNews. "We felt lonely after the tsunami," said one 24-year-old serving an eight-month sentence for possession of marijuana. "We lost our families; we lost everything."

All three said they knew someone who was injecting drugs - something that would have been almost impossible two years ago. Another young man who shared his cell with up to 15 inmates nodded in agreement. "More and more people are using drugs - it's a way of escaping the stress."


Despite some progress, there is much work to be done, but the taboo on discussing sex or condom usage is making the task all but impossible.

"It's a matter of reaching a critical mass," said Ip Daroesman, programme manager with the Aceh Partnership in Health, a local NGO, which runs a facility for the Burnett Institute, the Australian International Health Institute and World Vision Australia. "There is a lot of misconception about how the virus is transmitted; there is still a lot of fear."

"Some people have such low levels of awareness that they believed whatever HIV was actually in the area was brought in by the international community," Rivona added.

Ensuring that interventions are sustainable after members of the international community have gone home is critical.

"Aceh ... is sitting on a razor's edge, because ... the number of HIV-positive people that have been identified is relatively low," Daroesman said. "Aceh is in a position where its tradition can actually save it but ... you're not going to get very far in stopping that if you can't talk about things openly and begin educating people."

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