Bali's dramatic increase of HIV prevalence among sex workers has changed the face of the epidemic on this famed tourist destination of 3.9 million local residents, NGOs say.
In 2010, 25.9 percent of Bali’s 3,945 sex workers - those working in brothels or on the streets mostly in the inner-island town centre known as Denpasar - were living with HIV, up from 1.6 percent in 2000, according to the provincial health department.
The HIV prevalence rate among sex workers nationwide in 2007 was 10.4 percent and 4.6 percent among “indirect” sex workers, such as those in massage parlours, karaoke bars and places not known primarily for selling sex, according to a UNAIDS report on Indonesia.
The virus is taking hold of the general population in Bali as some 100,000 clients - mostly heterosexual Indonesian men - have sex with an estimated 6,000 sex workers and then go home to their 70,000-odd partners.
"I want Jakarta [capital and seat of national government] to look at the problem," said Dewa Wirawan, director of the Kerti Praja Foundation (KPF) and one of Bali’s leading HIV experts, "They have to know this is our situation and maybe it's not just in Bali."
Paying for sex
The secretary and head of the government’s National AIDS Commission, Nafsiah Mboi, said tackling HIV is a high priority of the government, and the biggest “headache” she faces nationwide is HIV prevention due to the current biggest vehicle for HIV transmission - sex.
“One out of nine Indonesian men uses sex services. Those men have partners - male and female - who face risk of infection.”
Nationwide in 2009, the government estimated 3-5 million people, mostly men, paid for sex.
“There is not one [inhabited] harbour where people are not having sex, not one [inhabited] island without commercial sex,” she said. The geographical spread of Indonesia, with its 17,000 islands, makes it a challenge to get out both contraception and safe sex messages, she added.
"Those we reach we see progress, but there are so many sex workers we cannot reach."
A Jakarta-based contractor currently distributes condoms to 137 districts nationwide. The goal is to reach 20,000 outlets. Of the country’s 480 districts, 300 have reported HIV infections and 90 percent of HIV infections are concentrated in the 137 targeted districts, Mboi reported.
A decade ago, Bali's HIV problem - as was the entire country’s - was concentrated among intravenous drug users (IDUs). HIV in heterosexual men and women began its steady upward climb in 2005 in Bali, as the number of new infections of IDUs living with HIV steadily declined.
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Needle exchange programmes as part of an overall “harm reduction” initiative targeting drug users since 2007 helped to bring down new drug-related infections, said Mboi.
Bali currently has close to 700 reported HIV cases in the general population, up from a little more than 100 five years ago, according to health department figures. But actual cases that go unreported may be in the thousands, NGOs and health workers say.
Safe sex hard sell
The shifting needs of HIV outreach have troubled aid workers and officials struggling to convince people to choose safe sex.
A 2010 KPF survey showed that 57 percent of sex workers in Bali had not consistently used a condom in the previous week.
“Drug users were easier to deal with - to tell them to use clean needles,” said Adi Mantara, director of Yakeba, a local HIV NGO.
Mantara, 29, contracted HIV in 2003 and now works with people at high risk of being infected. “But it’s difficult to get people who use sex workers to use condoms.”
Bali’s numbers fall below the average condom use among sex workers nationwide, almost 68 percent, as reported in 2007 by the government.
The feeling that HIV is an illness people “buy” is a persistent undertone at government meetings, Wirawan said.
“The commitment [by the government and local communities] to HIV prevention is very low,” said Wirawan, who has been working on HIV almost since Bali’s first reported case in 1987. “Efforts are increasing, but not enough to prevent an increase in cases like this [the current situation].”
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The support for IDUs by local communities contrasts with the shunning of sex workers, Wirawan said, possibly in part because only 1 percent of the workers are Balinese and the rest mostly come from Eastern Java.
As the focus has shifted from IDUs to prevention among sex workers, gaining local support has not been easy, said Mboi of the National AIDS Commission.
"We still have a lot of opposition because of the image of the model woman in Indonesia," she said. "The central government is placing a high priority on the HIV/AIDS issue, but with local governments support is very, very uneven. Local governments say they have other more important priorities such as tuberculosis and diarrhoea."