AIDS: global disease, local action

AIDS is one of the main concerns of international health problems. Therefore, a lot of NGOs’ resources have been invested for this theme. AIDS is accepted as a global disease. However, each people groups understand it differently and it affects them also differently. Then, clear understanding of how people in specific circumstance perceive this disease is needed. The following description explains the importance of medical anthropology in the AIDS era.

In Papua, the most East province of Indonesia, AIDS situation uniquely has a different portrait compare to other provinces. Although HIV and AIDS cases are increasing significantly in the last 10 years in Indonesia, its prevalence is still moderately low. However, the epidemic is already happened in Papua. While in most part of Indonesia, HIV and AIDS is concentrated within high-risk populations, in Papua the epidemic has already spread into the general population[1]. (KPA 2006, Priohutomo 2006)

With total population of only less than 3 million, Papua has the second highest HIV and AIDS cases in Indonesia. However proportionally, Papua has the highest prevalence compare to other provinces. The latest statistic from Ministry of Health mentions that the AIDS prevalence in Papua is 51.42 (/100,000 population), while Indonesia in total is only 3.61. (Depkes RI 2007)

The HIV and AIDS statistic in Papua does not only differ in case number but also in its characteristic. The MOH reports that 94% of the mode of transmission in Papua is heterosexual, while in Indonesia generally IDU is the most frequent mode (50.3%). Women in Papua are at greater risk of being infected by HIV than women in the rest of Indonesia. In Papua, 45% of HIV and AIDS cases are female, while in Indonesia only 19%[2].
The Papua HIV and AIDS statistic also reveals that the many of AIDS patients are predicted to be infected while they were aged below 20 years old. It is concluded from the fact that there are 43% of AIDS patients ranged in 20-29 years old interval as seen in the following chart.[3]

The first AIDS case in Papua was found in October 1992. HIV may have been introduced to Papua by commercial fishermen. Fifteen years after the initial case, 883 people have been infected, 104 among them have died. HIV and AIDS have feared many people in Papua especially people living in towns. Stigma and discrimination to the people living with HIV and AIDS are happened followed the rising case number of the disease. In this small town where gossip is easily spreading, discrimination is also simply following the gossip. At the end, it makes the livelihood of PLHIV is threaten.

A controversy explanation on how the figure of HIV and AIDS in Papua differs from the rest of Indonesia was raised few years ago. It was an opinion that the epidemic is happened for an ethnic cleansing (Butt 2005). However, Butt (2005) explains a more realistic explanation. She utters that poverty, lack of education, poor access to health services and rapid changing in social and cultural conditions are the main causes of the epidemic in Papua. Many other contemporary explanations in discussions about the spread of HIV and AIDS in Papua rest upon stereotypes about a sexually non-conformist way of life such as ritual semen exchange, trading of wives. Because of those practices do not conform to the ideals of normal sex, which is monogamous, the sex practices of Papuan are often highlighted as being deviant, dangerous and associated to the epidemic. However, Butt et al. (2002) offers a balanced explanation. She says that rapid modernization is the critical factor in the fast spreading of HIV and AIDS. Hundreds of years, with geographical isolation, Papuan practiced their rituals of marriage with values and ideas of sexual life underneath it. Now many Papuans have left their ideals of reproductive norms and the kinship rules. New values have been intruding their indigenous norms. Access to new potential sex partners outside their cultural groups has led more Papuans to seek money or goods in exchange for sex.

Butt et al. (2002) also report that the rates of domestic violence, forced sex, and commercial sex have increased significantly as a lot of money pour into this province. Because of that women are at greater risk of abuse than before. The study also reports that young generation has less interest in the elderly norms of sex and marriage. The study found that social change has negatively influenced the youth sexual behavior. Extra-marital sex is frequently practiced among them. The age of first sex encounter is also lowering.

The description made by Butt (2002) explains why young generation in Papua at the highest risk to be infected by the virus. Young people in very young age involve in sex practices. Porn movies are easily found, sex for money is also practiced among the female youth. Many of the youth are also involved in the glue sniffing, smoking and alcoholism. Towns are magnets for young people living in countryside. They come to the town to get better education or employment. Here, they live with a very minimum support and supervision from their families.

Role of medical anthropology at HIV and AIDS policy making
The above description shows that the epidemiology (and its sub-field, social epidemiology) has revealed that heterosexual intercourse is the main measure for HIV transmission. It also has found that multi-partners and early sex correspond to it. Outsiders opinion may arise because of this finding, therefore stereotyping is frequently uttered by the immigrant or even the humanitarian health worker that the native’s sexual practices do not conform to the ideals of normal sex. Papuan are often highlighted as being deviant, dangerous and associated to the epidemic. Thanks to the ethnographies made in Papua that has contributed to a comprehensible explanation for the underlying causes which lay at the fast modernization and social change, poor education for the native, insufficient access to health care, limitation to access to new economic resources etc (Butt 2003 and 2005). Therefore, HIV and AIDS prevention should be designed not only to address the visible causal of HIV spreading, but also tackle the bottom casual.

Medical anthropology makes a different on the ground
The role of medical anthropology in HIV and AIDS intervention is not only located at macro or policy making level, but also valuable at the program implementation. The following is a simple example of it. Children’s friendship among youth is widely used to carry out health promotion especially HIV and AIDS. This is defined as peer education. This approach is designed firstly to increase young people’s knowledge about sexual health and drug use in the context of HIV and AIDS, provide them good personal development and enable them to become effective educators of their own peers (Backett-Milburn, K. & Wilson, S. 2000).
World Vision Indonesia has been implementing the peer education approach since 2001 at its HIV and AIDS projects in Jakarta and Papua. The organization found that recruitment process is an important issue to be considered to contribute to a successful peer education project. During previous projects implementation, most of the participants were selected by their teachers. As a result, most of them are classified as good students, diligent and smart. Focus group discussions with youth conducted by WVI found that friendships among the student are not homogeneous. The youth are grouped by several principles. The smart and ‘nerd’ pupils hang around together. The junkies make friendship among them. If a peer education project only selects one group of students instead of various kinds of them, the HIV and AIDS prevention messages will not be reached by all students. Therefore, recruitment of youth has to be done to all groups of students not only the smart ones. The simple finding that was produced from a series of FGDs was a straightforward contribution of medical anthropology to the humanitarian health work.
[1] See chart 1
[2] See chart 2 & 3
[3] See chart 4