Overview of Sexually Transmitted Diseases in Indonesia

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Prevalence and Incidence of STDs

Sexually transmitted diseases are a serious medical, social and cultural problem in Indonesia, but it is difficult to obtain population-based data on the their prevalence and incidence. Limited reports from some teaching and other hospitals are available. These reports do not represent the population epidemiologically, however, and cannot give a precise picture of STD prevalence for the country as a whole.

Available data show that gonorrhea is the most common sexually transmitted disease, representing from 16 to 57.7 percent of all STDs (Hamzah et al 1991; Mitaart et al 1991; Ramsi et al 1991). Non-gonococcal urethritis is the next most common, varying between 24 and 54 percent, followed by candidiasis (23 percent), trichomoniasis, syphilis and genital herpes (Daili et al 1994; Hamzah et al 1991; Mitaart et al 1991).

The numbers and types of STDs found in eight general hospitals (Medan, Jakarta, Bandung, Semarang, Surabaya, Malang, Despasar and Ujung Pandang) in Indonesia in 1986–1988 are presented in Table 1. The data show that the most common STD in the general hospitals is nonspecific urethritis/nonspecific genital infection (NSU/NSGI) (36.6 percent), followed by candidiasis (22 percent) and trichomoniasis (10.3 percent). Data from nine teaching hospitals show that the prevalence of gonorrhea and NSU/NSGI is higher than in general hospitals (Daili et al 1994).

Table 1. The Number and Type of STDs in Eight General Hospitals in Indonesia: 1986–88

Sexually Transmitted Diseases 1986 1987 1988 Total F % F M F M F M F NSU/NSGI 1455 1098 1473 1027 1284 980 3105 36.66 Gonorrhea 1877 229 1770 191 1805 173 593 7.00 Candidiasis 78 608 84 677 85 578 1863 22.00 Condyloma acuminata 320 347 369 250 312 205 802 9.47 Trichomoniasis 3 289 6 319 7 284 872 10.3 Herpes genitalis 211 63 232 85 170 62 210 2.48 Ulcus molle 131 25 112 8 177 18 51 0.6 Syphilis 100 45 91 72 80 80 197 2.33 Lymphogran, venereum 79 12 109 9 81 7 28 0.33 Others 240 341 277 190 467 217 748 8.83 TOTAL 4504 3057 4523 2828 4448 2828 8469 - % 59.6 40.4 61.5 38.5 61.5 38.5 - 100.0

The Department of Health has not been able to monitor actively all STDs until recently. Through the System of Registration and Reporting in Health Centers (SP2TP), the System of Registration in Hospitals (until 1987), and the Integrated System of Surveillance on Contagious Diseases (since 1988), syphilis and gonorrhea have been used as indicators of STDs. In 1988, these systems reported an adjusted incidence rate of between 0 and 17 for syphilis and between 0 and 316 for gonorrhea for every 100,000 population in 27 provinces (Wibisono 1990).

HIV/AIDS

The first case of HIV/AIDS was identified in Indonesia in April 1987 when a Dutch tourist died in a Bali hospital. It was assumed that he had been in a sexual relationship with one or more Indonesians during his visit. In the same year a field observation found two cases of AIDS and six other cases of HIV infection. As of January 1995, only 69 AIDS cases and 280 cases of HIV infection had been reported in Indonesia, primarily in Jakarta, West Irian and Bali, with 50 percent of cases in the age group 20–29 (Table 2). It is estimated, however, that currently there are between 35,000 and 50,000 cases of HIV infection in Indonesia (Djoerban 1995), and the number is expected to rise. It is projected that, with no intervention program, the number of HIV infections will be 2.5 million by the year 2000. If an intensive prevention program is put into place, however, the number of cases by the year 2000 can be leveled off to 500,000.

Table 2. Cumulative AIDS/HIV Cases in Indonesia (through January 31, 1995)

Year AIDS HIV-Infected Total 1987 2 4 6 1988 2 5 7 1989 3 4 7 1990 5 4 9 1991 12 6 18 1992 10 18 28 1993 17 96 113 1994 16 71 87 January 1995 2 3 5 TOTAL 69 211 280

Programs to Manage STDs

The overall goal of the Indonesian STD program is to decrease the prevalence of STDs to a level that is not dangerous to the community. The following policies have been determined:

• Activities to prevent and eliminate STDs should be integrated across programs, as well as across both public and private sectors.
• Priority should be given to high-risk population groups.
• Priority should be given to geographical areas where high-risk groups are found, for example, large cities, shopping areas, industrial areas, harbors and tourist areas.

Strategies to implement these policies include:

• dissemination of information about STDs to high-risk groups
• epidemiological surveillance
• early detection of disease and prompt treatment of those infected
• technical training of a variety of types of health workers
• research on ways to eliminate STDs

Based on these policies and strategies, the main target of the STD program is commercial sex workers. Active case finding of gonorrhea and syphilis is carried out through screening surveys, while passive case finding is done at the health center level. Through the “Regular Mass Treatment” (RMT) program, commercial sex workers receive weekly prophylactic treatments for syphilis in the form of 0.9 million IU penicillin aluminum monostearate (PAM). With this dose, the level of penicillin in the blood reaches 0.3 unit/ml or higher, thus preventing treponema infection. Although the target group is only CSWs at this time, additional groups such as students, soldiers and other types of workers may also be included in the program if funding permits.

All STD activities are carried out under the supervision of the Regional Health Office which regularly reports to the Communicable Disease Control (CDC) in Jakarta. In 1980, a new regulation simplified the process of reporting and recording in the health centers by prohibiting the reporting of a specific disease unless it was classified as a “reportable disease.” Sexually transmitted diseases, which formerly were reported directly to the CDC, now must be reported to the Directorate of Health Services along with other data from the health centers (Daili et al 1994).

The RMT program has proven effective in decreasing the prevalence of syphilis. Because of the reduction of available funds in the Ministry of Health, the program was transferred to the regional offices in 1986. Some of the local areas instituted a “Self Supporting Program on RMT” whereby the cost of the injections is borne jointly by the CSWs and their employers. In 1990, the Directorate of the CDC developed a “Sentinel Areas for STDs” program in nine provinces: Riau, North Sumatra, Jakarta, West Java, Yogyakarta, East Java, Bali, East Nusa Tenggara and West Irian. Program activities include a regular serologic survey for syphilis and cross-sectional studies on STDs in CSWs in 27 provinces (Wibisono 1990). In the last few years, the program has been extended to include HIV/AIDS infection and the target population has been expanded to include high risk workers such as night club hostesses and massage girls.

Program to Manage HIV/AIDS

In 1988 the Government established a National Committee for AIDS under the Ministry of Health. This committee has produced a short-term program and has carried out a number of activities, including improving AIDS surveillance; improving laboratory testing for HIV infection (ELISA test) in six provinces; establishing a reference laboratory for the Western Blot test; training health workers in handling HIV/AIDS cases; and providing information, education and communication (IEC) on HIV/AIDS (Titi 1991). The Committee was upgraded in 1994 to become a Joint Committee to Control AIDS, under the Coordinating Minister of Public Welfare. Tuberculosis and STDs were added to the Joint Committee’s area of responsibility.

The National Family Planning Coordinating Board (BKKBN) is another government institution that plays an important role in the effort to eradicate STDs and HIV/AIDS. The success of the Indonesian National Family Planning Movement is recognized worldwide. Unfortunately, it is now known that some contraceptive methods are related to STDs. The use of IUDs, for example, may increase the risk of PID in those clients who acquire STDs. Although in many countries condom use is promoted to prevent HIV/AIDS infection, the BKKBN and the Indonesian government do not actively promote their use due to their low efficacy in preventing pregnancy. The National Family Planning Movement is dedicated to promoting more effective contraceptive methods.

A new approach has been developed to overcome HIV/AIDS infection through the Gerakan Keluarga Sejahtera (Family Welfare Movement). Through this movement, a national policy on HIV/AIDS is being formulated encompassing prevention, treatment, monitoring, control and dissemination of information.

The basic strategy is to empower the family as the basic unit in protecting family members from HIV/AIDS infection (Kantor menteri Negara Kependudukan/BKKBN 1995).

Short-term objectives of the new approach (Sumbung 1994) are:

• to increase awareness, commitment and participation of government agencies, nongovernmental organizations (NGOs) and the community at large in the prevention of HIV/AIDS infection
• to increase knowledge of family planning managers and officials about STDs/HIV/AIDS and the effort to prevent disease through family education

Strategies to reach these objectives include:

• establishing family resilience as the focus of the program by integrating family welfare
• development with other development initiatives
• ensuring that prevention efforts involve related government agencies, NGOs and community leaders
• improving the understanding of the eight family functions critical to developing family resilience

Nongovernmental organizations have also been involved in the effort to overcome HIV/AIDS (Table 3). Yayasan Kusuma Buana in Jakarta and Yayasan Lentera, affiliated with PKMI (Indonesian Planned Parenthood Association) Bali, in collaboration with the Program for Appropriate Technology in Health (PATH), have organized a refresher course for midwives. They also have developed information packages covering RTIs, STD services at clinics, RTI and STD counseling and other topics (Daili et al 1994). Through the PATH/Indonesia AIDS Initiatives Program, PATH has also developed and introduced Rapid STDs Diagnostics, including the Rapid Test System for HIV-1 and HIV-2, the Rapid Test Strip for N. gonorrhoeae in men and the Simple Culture System for N. gonorrhoeae in women (Daili et al 1994).

 Table 3. Activities of Nongovernmental Organizations in Combatting AIDS/STDs

			Diseases Targeted in Main Activities
Location	Total	STD	AIDS
			IEC	Couns	Treat	Surveill	Study	Public
Jakarta	18	3	16	10	4	3	11	15
Bandung	3	-	2	2	1	-	2	1
Surabaya	6	1	5	6	2	1	3	4
Yogyakarta	2	-	1	1	1	1	-	1
Bali/Denpasar	3	2	2	2	-	1	2	1
Ujung Pandang	2	-	2	2	-	-	-	-
West Nusa Tenggara	1	1	-	-	-	-	-	-
East Nusa Tenggara	2	-	-	2	-	1	-	1
TOTAL	32	6	31	25	8	7	18	23

Source: Directory of Non-Government Organizations in the Control of HIV/AIDS 1994.
Note:  IEC = Information, Education and Communication
           Couns = Counseling
           Treat = Treatment and other services
           Surveill = Surveillance
           Study = Studies
           Public = Publications

Of 32 NGOs mentioned in the 1993–1994 Directory of organizations involved in combatting HIV/AIDS in Indonesia, published by Private Agencies Collaborating Together (PACT), only six included prevention of HIV/AIDS, including IEC activities, counseling and publication of materials, as their primary activities. Some NGOs limit their activities to specific groups, such as adolescents or religious leaders. Surveillance and treatment are the activities reported least (Directory of Non-Government Organizations in the Control of HIV/AIDS 1994).

 

Conclusion

The basic data on STDs in Indonesia, including HIV/AIDS infection, are limited. From the data available from teaching hospitals and surveys it can be concluded that STDs, including HIV/AIDS, represent a tremendous challenge for the country. Sexually transmitted diseases, and in particular HIV/AIDS, have a huge impact on individuals, families, communities and the nation as a whole. It is clear that further studies of the consequences of these diseases, such as infertility, transmission of infection to the fetus during pregnancy and the perinatal period, and the many other associated health problems are urgently needed.

Recommendations for Indonesia

• An information center for STDs/HIV/AIDS should be created. This center would establish and facilitate communication among all parties working to prevent STDs/HIV/AIDS. 
• Comprehensive STD/HIV/AIDS services should be integrated with maternal and child health and family planning services.
• The impact of STDs on pregnancy outcomes in particular and women’s health in general should be studied.
• Nongovernmental organizations working on the STD/HIV/AIDS problem should coordinate their activities.

References

Basuki B, MA Rossing and JR Daling. 1994. Intrauterine device and risk of tubal pregnancy: an Indonesian case-control study. International Journal of Epidemiology 23: 1000–1005.

Daili SF et al. 1994. Literature Review on Reproductive Tract Infection in Women Associated with STDs in Indonesia.FKUI, FKMUI, Perinasia: Jakarta.

Directory of Non-Government Organizations in the Control of HIV/AIDS. 1994. PACT: Jakarta.

Djoerban Z. 1995. Penatalaksanaan Penderita AIDS di Jakarta. Seminar AIDS: Jakarta.

Hamzah MS et al. 1991. Penyakit Kelamin di Unit Penyakit Kulit dan Kelamin RSU Palembang 1986–1988. Kumpulan Artikel Kongres Nasional VII Perdoski: Bukittinggi.

Kantor Menteri Negara Kependudukan/BKKBN. 1995. Buku Pegangan tentang Pembangunan

Keluarga Sejahtera Sadar HIV/Penyakit AIDS: Jakarta.

Mitaart A et al. 1991. Pola PHS di RSUP Gunung Wenang, Manado. Kumpulan Artikel Kongres Nasional VII Perdoski: Bukittinggi.

Ramsi RR et al. 1991. Gambaran Prevalensi PMS di RS Dr. Pirngadi, Medan. Kumpulan Artikel Kongres Nasional VII Perdoski: Bukittinggi.

Sumbung PP. 1994. Prevention of STD/HIV/AIDS in the Indonesian Family Welfare Movement. International Symposium on Prevention and Therapy of Perinatal Injection for Mother and Child Health: Mataram.

Titi IS. 1991. Kebijaksanaan Departemen Kesehatan menghadapi masalah AIDS. Depkes: Jakarta.

Wibisono B. 1990. Situasi PMS dan penanggulangannya saat ini di Indonesia. Dalam: Daili SF et al (eds). Standardisasi Diagnostik dan Penatalaksanaan Beberapa PMS. FKUI: Jakarta.

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