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Having a decentralized form of government and being the largest archipelago in the world may have greatly affected the HIV care delivery in the country. According to the Asia-Pacific Observatory on Health Systems and Policy Review (Mahendradhata, et. al., 2017), little progress have been made in Indonesia’s fight against HIV & AIDS, Tuberculosis, Malaria and other communicable diseases. At the national level, the Ministry of Health (MOH) is the lead agency in the structural and policy development to fight against infectious and communicable diseases (ICD) yet the programmes are delivered by the network of public health facilities at the district and community levels. In addition, foreign health investments are acknowledged but limited to hospital levels only. Telemedicine and telehealth programs, and ICT utilization in healthcare delivery are uncommon despite ranking as eighth-largest internet users in the world.
Five years after the implementation of the government of its national health insurance program, Jaminan Kasehatan Nasional (JKN), 84% health coverage have been achieved. However, HIV services such as ART delivery remains low. Several commentaries and articles have been. In a prospective study conducted in 4 locations in Indonesia (Januraga, et. al., 2018), there were 85% people diagnosed with HIV who were linked to care across Bali, Bandung, Jakarta, and Yogyakarta, 73% have started ART. From those who started ART, only 55% retained in HIV care, only 39% had the required viral load test 5-9 months after the research initiation, only 35% have been virally suppressed.
The high risk for abuse, violence, discrimination, and stigma remain palpable across Indonesia as the social norm and culture consider transgender women as “human deviation” and “public disturbance” (Alam, 2020). Because of such discriminating attitude towards transwomen, access to basic human rights becomes difficult even before, and especially during, the COVID-19 pandemic. Aside from the transwomen, sex workers also face socioeconomic disparity and human rights abuses that need to be addressed by policymakers (Riswanda, et. al., 2016). Socioeconomic disparity and human rights abuses, among others, are significant driving factors of inaccessible HIV prevention, treatment, care, and support pre-pandemic and may intensify because of the layers of arduous impacts of the COVID-19 pandemic. A significant number of transgender women suffer job loss and residential displacement, and these socioeconomic conditions are further aggravated by local policies—weaponizing conservative religious beliefs leading to punitive laws that condemn the LGBT members, especially among transgender women. These discriminative culture and punitive laws may have been significant driving forces of the continuous increase in HIV infection in the country.
Indonesia is one of the countries in the world that still has an increasing number of the HIV infections. Access HIV testing and treatment remains low, resulting to poor retention to ART and viral suppression. The treatment suggests an urgent need to develop and implement effectively to support patients in achieving viral suppression among all people with HIV. In the UNAIDS has set ambitious 90-90-90 targets for the proportions of people with HIV who are aware of their status, referred to care, and have effective viral suppression. The result of between 2015 and 2016 the people who infected with HIV are 73% participants started ART, resulting hundreds of persons year follow up. In the perspective of the study the HIV care cascade among key populations in Indonesia found high proportion of those diagnosed with HIV but saw a substantial decrease in the proportion of referred participants who initiated treatment and were subsequently retained in care with viral suppression.
To this date, community-based organizations are currently developing several emergency response programs to overcome the impact of COVID-19 among key populations in close collaboration with the Global Fund, UNAIDS, and the Ministry of Health (MOH). One CBO also received financial support from the Australian government and reported that the funding received is currently allocated for socioeconomic relief of key populations. Another CBO has been documenting incidents of discrimination against MSM and transgender women, and providing legal assistance at the grassroot and community level.
Despite the on-going financial adversities in program implementation, CBO members and legal aid centers have been responsive in protecting the rights of key population. However, there are still a lot to do in terms of legal and socioeconomic support for sex workers across many provinces in Indonesia.
Lessons learned from, and good practices on,
continuity of community-based HIV service delivery
despite the COVID-19 pandemic
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