Is Asia getting the message on HIV prevention?
Updated
Nearly thirty years since HIV-AIDS registered on the medical radar, scientists and researchers have been unsuccessful in finding a cure. There is no vaccine either, and experts agree, prevention holds the only hope of stopping the deadly disease. Since 1988, December 1st has been chosen as World AIDS Day, to fight the socially and economically destructive disease. Twenty years on, is the message getting through?
Presenter: Sen Lam
Speakers: Bill Bowtell, executive director of the Friends of the Global Fund Pacific, and director of the HIV-AIDS project at the Lowy Institute in Australia; Dr Nafsiah Mboi, secretary Indonesian National AIDS Commission
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DR NAFSIAH MBOI, SECRETARY, NATIONAL AIDS COMMISSION, INDONESIA: Although HIV is still low prevalence nationally, we only have 0.16 percent prevalence, which is low for the national, but actually we know that in some populations we already have high prevalence, so we are mostly concentrated epidemic level with prevalence of more than 5 percent among injecting drug users, sex workers, men who have sex with men, or high-risk men. And also in the two provinces east of Indonesia, which is Papua and West Papua, we already have proven low-level generalised epidemic, which means that the epidemic has reached the population. Identified at the moment, Papua plus West Papua is 5,000, more than 5,000. And we did the national estimate in 2006 and, at that time, we estimated for the whole island of Papua, of Papua and West Papua, 22,000.
SEN LAM, PRESENTER, CONNECT ASIA: How confident are you, though, that these figures are an accurate reflection, given that there are many parts of Papua that are quite remote?
DR NAFSIAH MBOI: Yeah. We have what's called the scientific methods. First of all, of course, we did check with the districts and they estimated how many sex workers, how many clients of sex workers and their spouses or partners, how many injecting drug user, how many men have sex with men - by district, OK? And that was then validated with scientific methods to say, OK the estimate for Papua is the - for the whole of Indonesia - for the whole of Indonesia it was estimated that we have about 200,000.
SEN LAM: So, Dr Nafsiah, are you saying then that Papua province does not have an inordinately or extraordinarily large incidence of HIV infections compared to the rest of Indonesia? That it's not is a special case?
DR NAFSIAH MBOI: It IS a special case. We are very much concerned because the population is small. The population of Papua is only 1 percent of the population of the whole Indonesia. Case rate is already 18 times higher because the population is so small and, anyway, wherever we are, whether inside Papua or outside of Papua, every single person is valuable.
SEN LAM: Indeed. We'll return to outlying areas in a moment but, Bill Bowtell, is that the problem? The tyranny of geography, if you like, to get the AIDS message through to the outer-lying regions in the area that you're familiar with?
BILL BOWTELL, DIRECTOR, HIV-AIDS PROJECT, LOWY INSTITUTE: This is always a very serious problem when you have remote populations, often small populations. When we look at the extent of the Pacific area, you know, even in south-western Pacific, it's perhaps a sixth of the earth's surface, and if we added up all the populations of all the 30 or 40 jurisdictions in that area, in the south-west Pacific, we might come to 20 million people. And they are small and vulnerable and remote. So, we have a problem in getting the message out to people about prevention. And in many cases, if there is a problem with HIV infection, we have a problem in getting the treatments to them. We have wonderful, excellent treatments now developed since the mid-'90s that, if they're applied, can really improve the lot of people with HIV, but we need a functioning health system to be able to deliver that treatment to them every day. So, the more remote, the more small these populations are, the bigger our problems in getting both a prevention message and, where necessary, effective care and treatment through the primary health care system.
SEN LAM: And, of course, even though the treatments might be available, they're not often accessible by these local populations who possibly can't afford them?
BILL BOWTELL: Well, I'm very happy to say that the global fund to fight AIDS, TB and malaria, since it has been established in 2002, it's deployed about US 20 billion dollars, collected US$20 billion, and, since then, distributed about $11.5 billion in grants, specifically to underwrite and to get these treatments - in the case of HIV and AIDS - to get these treatments into mouths of the people who need them. And when we ally that with the very generous donations that have been made by the Government of the United States, under their PEPFAR programme, the Bill & Melinda Gates Foundation, the Clinton Foundation, a whole range of bilateral donors, including Australia, and multi-lateral donors, I'm very happy to say that, after 20 years, the world is finally putting a lot of money and resources and effort into getting these treatments out. So, the cost to the individual is not really now so much a problem; it's the getting the network established, getting the treatment, getting the reporting, the regime - all of those things done that can make sure these treatments are delivered where they're most urgently needed.
SEN LAM: Dr Nafsiah, in Jakarta, I understand that you can't hear us very well... certainly not Bill.
DR NAFSIAH MBOI: I can hear YOU very well.
SEN LAM: That's good. Well, Bill was just telling me about some of the international funds that are available, such as the Bill & Melinda Gates Foundation. How much access to Indonesians have to these funds? Are some of these international funds filtering through to Indonesia anti-AIDS effort?
DR NAFSIAH MBOI: No. We have funds from the Bill & Melinda Gates Foundation. We have, from outside funding, it's mostly the largest was the global fund - that's the largest - for AIDS, TB, as well as malaria. And for AIDS, starting from now, AIDS is now the largest. We are the Partnership Fund, which was established with very generous donation from the DFID or UK. Then we might have some lateral which is from Australia. From Australia, actually already - this is the eighth year.
SEN LAM: But, Dr Nafsiah, is funding the key obstacle to the prevention of HIV infection in Indonesia, or might there be cultural problems, as well?
DR NAFSIAH MBOI: Well, funding is one of the problems but, indeed, I heard your voice to Bill, about "How do you reach the people?" Like in Papua, of course, it is very, very difficult. Our surveillance showed that only 48% of Papuans have ever heard about HIV and AIDS, so, we have just launched our communications strategy which is working with faith-based organisations other than tribal leaders or networks, but also using modern communication. Indeed, it is not easy. Communication is also key, besides resources.
SEN LAM: And in Papua, you also have, for instance, local sex-cultures, such as partner-swapping, the lack of condoms. Is the message of safe sex getting through to the remote parts of Indonesia?
DR NAFSIAH MBOI: We're trying. We're trying very hard. It's not yet going through to the most remotest areas, but at least those that can be reached by radio, TV, printed and the faith-based organisations, tribal leaders, etc., I hope will be able to reach even them. We have done the surveillance in 2006 and although we thought that most of the infections would occur in the urban areas where we have the quote/unquote 'bad environment' - a lot of sex workers, et cetera - but it seems that we found out that even in the remote highlands and the difficult-to-reach coastal areas that we do have HIV.
SEN LAM: You're listening to Connect Asia on Radio Australia and we're speaking this morning to Dr Nafsiah Mboi, whom you've just heard. Nafsiah Mboi of course, is the Secretary of Indonesia's National AIDS Commission. And joining her this morning is Bill Bowtell. He's director of the HIV/AIDS project at the Lowy Institute here in Australia.
SEN LAM: Bill Bowtell, if I may come to you now. Is the task ahead grappling with treatments, dealing with HIV patients, rather than getting the message through? Or does education still pose a huge challenge in the region?
BILL BOWTELL: Education and prevention is the greatest single challenge. There is no doubt that if we are ever to get on top of HIV spread in the world, we must only not stop education and prevention, we must double and redouble our efforts to educate young people about how HIV is spread and how easily and simply it can be stopped. And this is what I know the National AIDS Commission in Indonesia and many other national commissions are coming to terms with. It is difficult to talk to young people about sexual matters or about providing clean needles and syringes for those who use injecting drugs. These are terribly difficult problems to tackle in any society, much less sometimes remote and often conservative and socially introspective communities. But the lesson of the last 25 years is clear - there is no vaccine at the moment and unlikely to be so, there is no cure. Prevention is the only effective response we have to make sure that young people do not get this very difficult and very unfortunate disease, HIV.
SEN LAM: Well, we talk of prevention but, yet, you know, where say malaria is concerned, you can go around distributing mosquito nets to villagers and that's proven to be quite an effective preventative tool. But in places like Papua, for instance, access to condoms is very hard and people frequently don't have condoms or can't afford to buy condoms. Isn't there anything we can do about that? Because that seems to me a rather simple problem to solve?
BILL BOWTELL: Yes, well...
DR NAFSIAH MBOI: I don't know... I'm very sorry, I can't hear.
SEN LAM: Nafsiah Mboi, yes, go ahead.
DR NAFSIAH MBOI: Sorry, I can't hear Bill's wise words but because you're mentioning Papua, yes, indeed one of the problems is all the challenges actually - how to get condoms to the remotest areas. We are trying, but at least where we know there is sexual transmission that is where we focus our attention and have available - condoms available. Indeed, I'm very much more optimistic with the global fund around AIDS having been approved, that at least we have reliable source to buy condoms.
SEN LAM: So, are condoms freely available in say Jayapura, the capital of Papua?
DR NAFSIAH MBOI: Yes, both male and female condom in Jayapura, yes.
SEN LAM: If I may come to you, Bill Bowtell. How do we solve this problem of access to condoms?
BILL BOWTELL: Well, first of all, we have to have the information so that young people themselves know what condoms are, how they're used, how they can be used effectively to stop transmission of the virus. Of course, then we have to talk to faith-based organisations, or the people, the more senior people, the older people who have a lot of influence about the culture of these societies, and we must explain patiently to them that this is a problem, one that can be prevented. And that it will require some new and imaginative and maybe bold thinking, but, in the interests of protecting their young people, we must contemplate these things. So a large part of prevention is education and that simply means talking, talking and showing the evidence and talking and talking again in smaller and smaller communities. I'm happy to say that around the world, there have been great advances in local communities in the most improbable places where, because leaders of the community, faith-based people, parents and so on, have become aware of the problem and want to do something about it, they've brought about these simple behavioural changes with young people. So, we know what works but we have to have the commitment and the effort to keep talking and talking and talking because that's the key to effective prevention.
SEN LAM: Dr Nafsiah Mboi, in Jakarta, men, I understand, are still the ones most likely to engage in high-risk behaviour.
DR NAFSIAH MBOI: Yes.
SEN LAM: Do gender issues play a part in the spread of HIV? For example, how easily can a woman say no to unprotected sex with her husband or boyfriend or possibly even her client in Indonesia?
DR NAFSIAH MBOI: Oh yes, men are still this the most - in Indonesia, gender, definitely, plays a very important role because women, especially married women, have basically no bargaining power to safe sex with their husbands. That is why we are concentrating on where the sex workers are and, first of all tried to, as we always say, there is not one simple solution. But in the sex establishments what we do is, first of all, empower the sex workers, support the pimps so that they can talk and provide condoms all the time.
SEN LAM: How much support do you get from the authorities, though? Say from the police, for instance?
DR NAFSIAH MBOI: Still very uneven, very uneven. Some police will have vested interest, of course, will not agree. But in some areas, where we were able to include them in saying "OK, we will provide the condoms there and they will have because this is for the general health, for the public health," in the places where we have succeeded, the police and the local - the local government should be informed and saying, "OK, this is something that we have to do." But what will impact the epidemic immediately is in these quote/unquote 'high-risk' locations. That is where we focus our attention for treatment of STIs, condom use and education for everybody, all the stakeholders in that location.
SEN LAM: And finally, Bill Bowtell, what's your feeling about HIV/AIDS in the Asia Pacific region? Are you optimistic that it's become or could become a manageable disease in the future, like malaria and tuberculosis?
BILL BOWTELL: I think we're at a very critical point. The Asia-Pacific region, of course, is huge in geography but very, very large populations in India and China: 2 billion and 3 billion people. Now if we don't apply the lessons of prevention that we've learnt elsewhere in the world in the last 20 years, the very great risk is that we will have a very big expansion, increase in the number of HIV cases in the Asia-Pacific region, and every 0.1% in the Asia-Pacific region is hundreds of thousands, if not millions of young people getting this preventable disease. So I'm confident that we have the lessons. I would like to be confident that these will be applied by governments around the region. Some governments are doing very well. Other governments, I think, are a little complacent because they don't have the problem. But the money is there, I think increasingly, globally, the commitment is there, but it's up to the governments and the communities to apply the lessons and the money now so that we avoid the problems that have so crippled the rest of the world. And, as Nafsiah said, every life is precious and particularly of our young people. And it would be a very great shame if governments didn't become very active now and really take every step necessary to protect the greatest capital we have, which is our young people.
SEN LAM: Very well put, Bill Bowtell. And I'll give you the last word, Dr Nafsiah Mboi. Bill Bowtell was just talking about the political will, which is so necessary to translate into success in fighting HIV/AIDS. What's your view? Since the advent of democracy in Indonesia - I mean, it's been almost 10 years - do you think that that bodes well for fighting HIV/AIDS in Indonesia?
DR NAFSIAH MBOI: Yes and no. (Laughs) I fully agree that political commitment and political support is very, very important. The fact that we now - the government in Indonesia is now decentralised - we have to deal with 548 districts and district heads and 33 provinces and governors - it's a huge task. But, indeed, I have to say, since the commitment of the President, the current President and his cabinet is so big, we have been able to achieve much more in the last two years than in the 18 years before that.
