Trying to explain to an 18 year old sex worker that she must insist on using condoms is gruelling. She is in a powerless position. On the one hand she risks offending customers and therefore losing her job, a job that may well support her entire family. On the other, she risks contracting HIV. Witnessing a young girl grapple with this reality is perhaps the hardest part of working in HIV prevention.
The number of HIV/AIDS cases in Indonesia continues to increase. The government recorded the first case of HIV in 1987. As of June 2005, the number of reported cases of HIV in Indonesia had reached 7098, with nearly half of these in Jakarta. The Indonesian Department of Health, however, estimates the true number of cases to be close to 150,000 nationally. Independent experts estimate the number to be even higher.
The booming red light district of West Jakarta has the largest number of people at risk of contracting HIV. It is home to 160 listed ‘entertainment venues’ – karaoke bars and massage parlours – that serve as fronts for brothels. It is estimated that over 300,000 people there risk contracting HIV or other sexually transmitted infections (STI).
> The need for HIV prevention
These frightening statistics led Yayasan Kusuma Buana (YKB), a public health NGO, to establish a prevention program aimed at female sex workers. Between 2000 and 2005, YKB conducted prevention activities in 64 of West Jakarta’s entertainment venues. Yet since YKB is the only NGO working with female sex workers in the area, this means that fewer than half of the entertainment venues in the area have received any STI information.
Several factors slowed prevention work. With the exception of the West Jakarta Public Health Board, local government is largely unsupportive of this kind of HIV prevention effort. While local government officials and law enforcers are fully aware of the nature of entertainment venues, they maintain the pretence that massage parlors only provide massages and karaoke bars are only home to renditions of Frank Sinatra songs. To support an HIV prevention program would be an implicit acknowledgement of the sex industry operating in the area. This the government is unprepared to do.
Secondly, venue managers have little incentive to conduct STI prevention for their workers. Indonesia’s high unemployment rates mean there is always a ready supply of girls to replace those who become too sick to work.
In addition, doctors working in the red light district continue to administer antibiotic injections to sex workers as means of disease prevention. Whether this is out of ignorance or malpractice is unclear. As a result sex workers and their clients believe they are protected against viral STIs, including HIV.
Nowhere to turn
For the young women who become sex workers, there are few places to seek advice. There are nine hospitals in Jakarta that have been designated as referral centres for HIV cases. However, hospitals are often austere, intimidating places, and hardly conducive to revealing one’s problems and fears. As a result, the number of sex workers from West Jakarta’s red light district presenting to these hospitals remains low.
While YKB focuses its operations on female sex workers, several other NGOs work with the high risk communities of transsexual sex workers, male sex workers and intravenous drug users in West Jakarta. All these NGOs have experienced difficulties in referring cases of STIs and HIV to the appropriate institutions.
The Jelia Clinic
The lack of a suitable facility led YKB, together with the West Jakarta Public Health Board, to push for the establishment of a clinic dealing specifically with HIV and STIs. This clinic would be the first to assist female sex workers, male sex workers and intravenous drug users alike. In September 2004, the clinic was opened. Local sex workers who had provided input into the clinic’s design named it the ‘Jelia Clinic’ (a shortened form of the Indonesian ‘Jeli AIDS’, meaning ‘AIDS aware’).
The Jelia Clinic aims to prevent the continuing spread of HIV and STIs, increase awareness about HIV, and promote 100 per cent condom use. Services provided at Jelia Clinic include screening, counselling, sex education and health check-ups. During the first few months of the clinic’s operations, of the 213 patients that attended the clinic for STI screening, 94 per cent had some form of STI.
The clinic combines a mixture of health workers and outreach workers, some of whom have formerly worked in the sex industry. This combination marries expertise with compassion and personal experience of the pressures female sex workers face. This has enabled the clinic to form a strong relationship with many local sex workers.
Their growing faith in these services means sex workers are presenting earlier, and are therefore avoiding the complications of long-term infection. Equally importantly, HIV awareness has increased among workers, although this is yet to convert into practice change. Condom use remains low.
Jelia Clinic has been so successful that the Jakarta Provincial Health Board is now using YKB’s program as a model to replicate in all of Jakarta’s red light districts. While this move is encouraging, the ultimate aim, namely to empower Jakarta’s sex workers to protect their own sexual health, is still far off.