Cho Kah Sin: Indonesia's HIV prevention should be an example  

TEMPO.CO, Jakarta - There has been discordant voices following the launch of the UNAIDS Gap Report on July 16, which details the prevalence of this deadly disease, and how governments attempt to prevent its spread. It was not particularly well received by Indonesian Health Minister, Nafsiah Mboi. "In the press release (about the report), they (UNAIDS) said that we are left behind. I ask, just how we have been left behind?" she told Tempo, at a press conference about Indonesia's HIV/AIDS program, 20 days after the report was launched

UNAIDS Country Director for Indonesia, Cho Kah Sin, agrees that the report could well lead to misinterpretations. "The GAP report is not meant to invalidate what countries are doing," explained Cho, who took office in Jakarta two years ago. He is impressed at the close cooperation between different community groups and the central as well as local governments in preventing the spread of the disease. "Other countries can learn from Indonesia," said Cho, who is Malaysian.

Cho, a public health policy expert, has been extensively involved with managing all aspects of this deadly disease. His first contact with HIV/AIDS epidemic was in the US, where he conducted his doctoral research on the topic of drug control policies. As a drug treatment specialist working at a major teaching hospital in Boston, he also had experience treating heroin drug users and it was through them that he became familiar with the HIV problem. In 2004, Cho joined UNAIDS and was posted at its headquarters in Geneva, Switzerland and Bangkok, Thailand prior to his appointment to Indonesia. 

Tempo English reporters Sadika Hamid and Seulki Lee met Cho at his office last week, during which he discussed the report and the Indonesia's battle against HIV/AIDS. 

According to the UNAIDS GAP report, Indonesia has the third largest number of people living with HIV/AIDS in Asia-Pacific. How did you come to that conclusion?

Prevalence rate is basically the percentage of people in the population who are infected by HIV. Indonesia now has 0.43 percent prevalence which means 0.43 percent of the population is estimated, not reported to have HIV. This may appear to be a small percentage. But because Indonesia is a big country, that translates into a total of about 640,000 people. We should be careful that these are not actual numbers we are counting, but estimates obtained through modeling. So of course, after China and India, it is Indonesia. But the percentage is still much lower than countries with generalized epidemic, where the prevalence rate is above one percent among adults.

But the report categorizes Indonesia as a country of concern.

It is a concern because new infections, according to this report, are continuing to rise. Indonesia as of 2012 and 2013 is one of three countries with a rising epidemic. It is because the epidemics started rather late, maybe sometime towards the end of the 1990s. The number of infections in many other countries have started to come down, because the epidemic (follows) a curve, like in Thailand, Cambodia, which started way back in the 80s. Indonesia is probably almost at the peak. We do not know what will happen in the next couple of years but we will want to do whatever we can to ensure that the drivers of the epidemic do not contribute to new infections.

Which groups do we have to watch out for? 

We know that new infections primarily come from people of certain population groups: man who have sex with men (MSM), sex workers and to a very much less extent, injecting drug users (IDUs). Our report is based on a 2012 modeling. But what we can see from the modeling that was done in 2013 and this is still not completely launched yet by the Ministry of Health and the National AIDS Commission is that there is a certain leveling of the epidemic. It is not official yet, and we understand that this is preliminary, but it is encouraging. The epidemic among sex workers and transgenders, for example, is stabilizing. The epidemic among IDU is declining while MSM is actually rising. Now that is the one we have to watch out for.

Why do you think cause the rise of new infections among MSM?

Men who have sex with men, more than any other group, experience a lot more stigma and discrimination. It is much more difficult for them to come out in the open and seek help. They often feel that the services tend to be discriminated against them and they are not welcome.

How should we reach out to them? 

We are starting to see some efforts from private sector-led services and some initiatives in Ministry of Health to make their services more friendly to the MSM community. One of the things is not being judged, not being told that something is wrong about MSM. Number two, make sure that the services are open when the people are able to come. Many people in the MSM community work. To open the clinic from 9AM to 3PM makes no sense. Confidentiality is important. I visited the Bali Medika Clinic and I could not believe the detail they went to make it safe. When people find out their HIV tests are positive, some break down emotionally. They have a special room where people wait for their results. If they cannot handle it they can go out through a back door.

Health Minister Nafsiah Mboi voiced objections to the UNAIDS Gap Report during the AIDS Conference in Melbourne last month. Which were the points of disagreement?

If I recall correctly, she was generally not disputing the numbers but how the numbers are being interpreted. For example, she said that if Indonesia is able to reach out to more people and bring them to take tests, of course the numbers (of infected people) will increase. Meanwhile, she also objected to specific issues like the way in which prevention coverage for sex workers and MSM are reported each year, suggesting that the indicators are not reflecting the level of achievement. There is a piece of information in the report that says Indonesia's prevention coverage for sex worker as 18.5 percent. This is based on two questions, whether sex workers were given free condoms and whether they know where to get a HIV test. But in Indonesia (survey data in 2011), condom use 'at last sex' among sex workers reached 58 percent and the percentage of sex workers tested was 67 percent. She has a good point. In Indonesia, you do not need to know where the test is, because it comes to you. They have mobile testing that goes to sex work complexes on a regular basis. Minister Nafsiah has forwarded a request for that indicator to be reviewed. (*)

Read the full interview in this week's edition of Tempo English Magazine