Investing in the Elimination of HIV/AIDS in Indonesia:

What’s the Impact on Epidemic After 10 Years of the

Investment?

Abstract
Indonesia has committed to respond to HIV and AIDS with significant domestic and

international funding has been secured to support a greatly expanded national response.

HIV transmission has stabilized and begun to decline among all Key Affected

Populations but excluded Men who have Sex with Men (MSM). However, reaching

Fast-Track objectives required fast and sustained scale-up of programs. This study

purposed to to determine the best way to proceed regarding the national “fast-track”

strategy, transition planning of the HIV/AIDS international financing to be reduced

significantly and making the case for increased HIV funding under the Universal Health

Coverage scheme which targeted to reach by 2019. AIDS Epidemic Model (AEM)

software was used to analyze the case investment on this study. The results showed that

the trend of investment was increasing together with decreasing of new cases. Thus, the

greater HIV funding invested will give greater impact on reducing HIV epidemic.

Keywords: HIV/AIDS, AIDS Epidemic Model, Investment Case Analysis,

Epidemiology, Health Economics.

What We Already Know

HIV and AIDS in Indonesia remains concentrated in sub-populations exposed to
elevated risk of HIV transmissions. Indonesia has committed to respons on HIV/AIDS
pandemic over the last 15 years with domestic and international grant fundings. There
are still 640,000 PLHIV lived in Indonesia and the Fast-Track progress needs to be
escalated quickly to achieve the targets by 2030.
Research Contribution to the Field
This research contributes to identify cost-effective methods, high-impact interventions
or program’ enablers followed by a prioritized scaled-up plan, identify the opportunities
of sustainable funding and decrease ineffeciency in a continuing program. The best
scenario to achieve the targets will be identified in this study, thus, can measure how the
country have to escalate their progress in order for achieving the targets by 2030.
Research’s implications toward theory, practice, or policy.
This research’s implication found that some actions needed to escalate the HIV/AIDS
control and prevention in Indonesia such as: decentralize and improve the integration of
health facilities at all levels; increasing of coverage and effectiveness of community-
based outreach to reduce the risk of sexual behaviors; involving private health sectors
for wider coverage services; create more enabling enviroment and improving the
advocacy strategy to increase funding support for HIV programming both at provincial
and district levels.

Introduction
In 2019, there were an estimated 640,000 persons living with HIV (PLHIV) in

Indonesia.1 As in other Asia-Pacific countries, HIV and AIDS in Indonesia remains

concentrated in sub-populations exposed to elevated risk of HIV transmission due to

their behaviors. These are commonly referred to as “Key Affected Populations” (KAPs)

which included sex workers and their clients, persons who inject drug (PWID), men

who have sex with men (MSM) and transgender. Papua is an exception to the regional

norm, with an estimated HIV prevalence 2.3% of general population in 2013.

The national HIV prevalence rate among people aged 15 years and above was

estimated to be 0.33% in 2019. Provincial estimates of HIV prevalence range from

0.1% to over 2.0%. In 2016, the absolute numbers of Persons Living with HIV

(PLHIV) were the highest in Jakarta and in the highly populated provinces of Java, as
well as in Papua and West Papua although driven in earlier years by needle sharing

among Persons who Injecting Drugs (PWID) and sexual transmission.2

The most recent bio-behavioral surveillance survey (IBBS) data available

suggested that progress has been made in stabilizing the sub-epidemics among most

KAPs and general population in Papua. It can be seen by comparing the estimated and

projected numbers of annual new HIV infections in the 2016 Ministry of Health

Epidemic Report shown below (see Figure 1).1 There were only 141 out of 502 cities

and districts in Indonesia which have been took HIV interventions to be prioritized. In

2012, Indonesia’s AIDS expenditure reached US$ 87.5 million which 27% was spent on

prevention and 36% on care and treatment. Around 75% of spending on care and

treatment was domestically funded while the most prevention spending were from

international sources.3

Figure 1: Comparison of New HIV Infections from 2016 HIV Mathematical

Modelling (1990-2030)

However, there remains to concern about the expanding of sub-epidemic

among MSM which continues to expand, although they grow with lower rate than what

it previously projected. The HIV testing coverage among KAP has increased from
33,577 in 2010 to 1,435,112 in 2016 but still remains low related to the numbers needed

for the Ministry of Health target on treatment as prevention (i.e., Scaling up the

Strategic Use of ART / SUFA) to be successful[2]. Anti-Retroviral Therapy (ART)

treatment coverage cannot be meaningfully expanded, unless the number of persons

being tested for HIV increased significantly. The number of persons who received ART

increased from 15,442 in 2009 to 63,000 at the end of 2016 but still being the lowest in

Asia.2 If the current pace of national HIV program implementation performance remains

low, they will not achieve 2019 National Strategic Plan or Fast-Track Target for

2020/2030 cannot be realized.

The Global Fund’s New Funding Model emphasized on increasing the

domestic share of investment in HIV/AIDS program to maintain sustainable funding.

By strengthen the mobilization and increasing effectiveness use of domestic resources,

countries can reduce their dependency on external funding which help them pass

through sustainable development.4 In 2012, UNAIDS have launched the HIV strategic

investment framework guidelines for countries in order to get maximum impacts in

allocating limited resources. This framework focused on development of an investment

case which based on a robust analysis of the epidemiology, the current response and

recent science evidence-based. The investment tool was made to guide countries

developing strong investment cases by identifying cost-effective methods, high-impact

interventions or program’ enablers followed by a prioritized scale-up plan that will put

them to reach the target by 2030. Investment cases also help countries to identify the

opportunities of sustainable funding and decrease inefficiency.3,5

This study analyzed the case investment on decreasing of HIV impact of high-

risk populations by scenario-based approach. The scenario-based approach included

many items of AIDS budgets to determine which item can give impact on reducing

incidence or death such as critical enablers, mitigation, program support and synergy of

development (education, health and social services). Formal optimization is not used

because the unit data costs are weak, and cost-effectiveness is not the only one we

consider on resources allocation. This kind of approach needs to integrate through larger

health system costs and effects.6

Method
This study was used the secondary data from Population Census and Integrated

Bio-Behavioral Survey (IBBS) for HIV prevalence and the data from program

monitoring to measure the program coverage. The Investment Case Analysis (ICA) 5 was

used mathematical modelling methodology by the AIDS Epidemic Model (AEM)7

software to generate the results. Four scenarios leading to near elimination of HIV and

AIDS in Indonesia were evaluated in the ICA along with a “Business-as-Usual”

scenario. These scenarios vary in terms of the rate and timing of scale up. They come

from the recent HIV Epidemic Update. In these scenarios, it is assumed that

intervention coverage and effectiveness would remain constant until 2030 at observed

2015 levels.

The first is Fast-Track Scenario by 2020 through all populations. The scenario

have targeted that 90% of all HIV-infected persons will know their HIV status, 90% of

HIV positive persons will be on treatment, and 90% of persons on treatment having

suppressed viral loads (i.e., 90-90-90) by 2020 and 95% will be achieved all these

criterias by 2030. The second is Fast-Track Scenario by 2027, also through all

populations which assume that the “90-90-90” target will be reached by 2027 instead of

2020. Next, there is Fast-Track Scenario by 2027 through the KAPs. It is also the same
with previous scenario but will achieve the KAPs as the population target by the end of

2020. Moreover, there is also National Strategic and Action Plan Scenario which

assumes that all 2019 goals from the Indonesia Long and Medium Range Development

Plan 2015-2019 Program by The National AIDS Commission will be reached at 2020.

After 2020, it was expected to slightly increase to reach the Fast Track 95-95-95%

target by 2030.8

The population study were Female Sex workers, Injecting Drug Users (IDU),

Transgender, Men who have Sex with Men (MSM), low risk female and low risk male.

This study used data from Population Census and Integrated Bio Behavioral Survey

(IBBS) for HIV prevalence and behavior data, while others were data from program

monitoring to measure the program coverage.

Results
The key data inputs of this AEM investment case analysis were HIV estimates

and projections; KAPs size estimates; results from the behavior sentinel surveillance,

HIV sentinel surveillance and HIV-integrated bio-behavioral surveillance. Figures 2 and

3 showed the projected impact on the number of annual new HIV infections and HIV-

related deaths from 2016 to 2030. Both were reduced more rapidly in scenarios that

featured early and aggressive scale up. Without any further actions, the annual number

of new HIV infections will decline very slowly, and will still be around 44,000 per year

in 2030 while the number of annual HIV-related deaths will continue to increase until

2025 or so, before stable at around 45,000 per year.

 Figure 2. Projected Annual Number of New HIV Infections, by Scenario (2016-

2030)

Figure 3. Projected Annual Number of HIV-Related Deaths, by Scenario (2016-

2030)

The projected annual total resource needs are shown in Figure 4. In the case of

the most aggressive scenario which is the Fast Track 2020 through-all scenario, annual

total resource increases up to 607 million USD in 2029 before it began to decrease. The

growth line of resource needs in the other scenarios reflected the slower, less aggressive

scale up. While aggressive scale-up stabilizes resource needs by 2030, the annual
resource needs of the less aggressive scenarios continue to rise and were projected to

continue doing so until peaking in the mid-2030s before it become stable and begin to

decrease.

Figure 4: Projected Total Resource Needs by Scenario (2015-2030)

What is the potential magnitude of investment returns if Indonesia were to

invest more heavily in HIV elimination? Relevant data were provided in Table 1 below

for each of the scenarios. All scenarios produce returns on investment in the USD 2.65-

3.00 range per USD. However, the scenarios differ widely regarding to the absolute

level of investment returns. The largest returns on an absolute basis come from

scenarios that feature earlier, more aggressive scale up which is the Fast-Track by 2020

through all populations and the National Action Strategist scenarios. Analysis of the cost

per Daily Adjusted Life Years (DALYs) which ranged from USD 561 to USD 747 in

these four scenarios, indicates that investment in HIV elimination is highly cost-

effective given a nominal Gross National Product (GDP) per capita of 3,345 in 2015.
 Table 1. Projected Return on Investment by Scenario through 2016 – 2030

(Assume 3% Annual Discount Rate)

National
Fast-Track Fast Track Fast Track Action
Parameters 2020 (All) 2027 (All) 2027 (KAPs) Strategies
Non-ART prevention 1,409,083 1,189,162 1,189,162 1,294,330
Treatment 4,379,956 2,247,550 3,250,587 2,971,374
Total 5,789,039 3,436,712 4,439,749 4,265,704
Lives saved 423,117 271,143 333,126 347,027
Life-years gained from averted deaths 2,768,970 1,418,034 1,969,402 2,119,694
Contribution to GDP (‘000s USD) –
9,267,744 4,746,159 6,591,588 7,094,614
persons whose deaths were averted
Total HIV infections averted 436,158 346,932 359,420 394,245
Future treatment costs saved (‘000s USD) 6,260,145 4,976,582 5,154,832 5,656,820
Future treatment costs saved plus
15,527,889 9,722,742 11,746,420 12,751,434
contribution to GDP (‘000s USD)
Return on investment to 2030 –
9,738,850 6,286,029 7,306,671 8,485,730
absolute (‘000s USD)
Total return per USD 1 of investment in
2.68 2.83 2.65 2.99
HIV programming to 2030

Discussion

The investment case analysis (ICA) was designed to assist countries by using

investment approach which essentially focused for effectiveness and efficiency,

estimating or projecting the response impact, mapping the resource requirements and

preparing for financial sustainability.5

Based on the results, potential impacts of the main strategic priorities of the

response (such as health continually services and SUFA) at different coverage levels

and the effectiveness of implementation were assessed. Significant impact is projected

for the current initiatives at a “high” level of implementation performance. The priority

should be made immediately to increase number of people tested and get the treatment.
The results from this investment case analysis have found on five main things to be

prioritized: focusing approach towards high risk population, providing ART for people

living with HIV and treating the opportunistic infections (not only receive ART but to

maintain the therapy continually), prevention treatment (such as HIV testing and

provide pre-exposure prophylaxis towards people with high risk and pregnant women),

behavioral change (include condom use) and male circumcision (in Indonesia, this is

reliable because there is a low-level generalized epidemic in Papua and West-Papua,

even though it has not yet being recommended as priority).4

The following actions and achievements are needed in order to end HIV and

AIDS in Indonesia such as: decentralize and improve the integration of services within

health facilities or between health facilities, social organizations and other groups

working with KAPs in community settings; getting key interventions implemented in an

integrated; efficient manner on wider geographic scale to increase service access and

aggressively implement Strategic Use For ARV (SUFA). 8 The Ministry of Health has

prioritized taking greater advantage of the preventive benefits of ART. However, as this

approach to be effective, significant improvements are required to cover HIV testing

among KAPs and other priority sub-group population (e.g., TB patient, Hepatitis B & C

patient, discordant couples) by strengthen the linkages between testing and Care,

Support and Treatment (CST) services; and the retention of patients on ART. To

increase HIV testing, Strategic Use for ARV (SUFA) cannot be successful unless the

number of persons tested for HIV in Indonesia increases significantly. 9 Thus, increasing

of coverage and effectiveness of community-based outreach is important. Several

studies said that community-based and behavioral interventions can reduce risky sexual

behavior and the incidence of sexually transmitted diseases among high-risk

populations; increasing contraceptive use and the knowledge of HIV transmission; also

introduce infected-people to anti-retroviral therapy.10 The community-based approach

should be focused on social behavioral interventions which is important to help people

living with HIV (PLHIV) receive adequate anti-retroviral therapy continually and

prevent about the social stigma.11 Recent program reviews have highlighted the

weaknesses in community outreach in the national HIV and AIDS program. The data

showed limited differences in risk-taking and health-seeking behaviors among those

reached and not reached.7 Indonesia also has identified an opportunity to include private

health sector for greater roles. Many KAPs (such as female sex workers and their

clients) were part of Indonesia’s rapidly growing middle class and can access HIV

services through private health facilities. Addressing HIV test-kit and drugs through the

private health facilities might be cost-effective and can increase the coverage.3

During several years, Indonesia National AIDS Commission has pursued

strategy to increase funding at province and district-levels. The cities or district-level

investment takes important role in resource mobilization and provides an assessment of

what they need to do for implementing the programs.3 The new outreach approaches

being implemented must be tested, refined and scaled up. Besides, the program should

create more enabling environment for effectively addressing HIV and AIDS, release the

stigma and discrimination which can pressure the efforts to effectively engage KAPS

with behavioral and health service interventions. An advocacy strategy needed to

increasing funding support on HIV programming and recommend for doing provincial

and district-level investment analysis.3

This study has limitations such as, there is the need to differ program coverage

and intensity for sub-populations with any risk different levels. However, not every data
disaggregated into sub-populations. Also, this study was not consider about reducing

social stigma/discrimination and policy barriers to effective service delivery which

happened mostly among PWID.

Conclusion
Indonesia was a bit slow to respond to the HIV/AIDS epidemic, so it was expanded

among Key-Affected Populations (KAPs) and the general population in Papua. The

efforts by the last 10 years or so seemed to have stabilized the situation, with continued

sub-epidemic growth only happened among men who have sex with men (MSM).

However, unless further action is taken, the National Strategic Plan and all Fast-Track

scenarios are unlikely to be reached and the prospects for ending HIV and AIDS in

Indonesia by 2030 may not good. The roadmap for achieving the main goals is clear that

Indonesia is already doing most of the right things but needs to more rapidly scale-up

and improve intervention effectiveness. Ending HIV and AIDS in Indonesia will require

significant investment far higher than what has been previously made. However, the

results showed that the returns to investing early and aggressively are substantial

indeed.

References
1. Ministry of Health Republic of Indonesia. HIV Projection 2015-2019. 2017.
2. Ministry of Health Republic of Indonesia. HIV Three Monthly Report [Internet].
Available from: www.SIHA.gov.id
3. UNESCAP. A Comparative Analysis of Selected National AIDS Investment
Cases from the Asia-Pacific Region. 2016.
4. UNAIDS. The case for Increased and More Strategic Investment in HIV in
Indonesia [Internet]. 2015. Available from:
www.aidsdatahub.org/sites/default/files/publication/The_Case_for_Increased_an
 d_More_Strategic_Investment_in_HIV_in_Indonesia.pdf
5. UNAIDS. Investment Case Analysis. In 2017.
6. Stover J. HIV Resource Allocation using the Goals Model. 2016;(February).
7. The East West Center. The Asian Epidemic Model: A Process Model for
Exploring HIV Policy and Program Alternatives in Asia. 2017.
8. The National AIDS Commission. National Strategic and Action Plan 2015-2019.
2015.
9. Brown T, Peerapatanopokin W. Collaboration on HIV/AIDS Modelling, Analysis
and Policy. East West Center/Thai Red Cross Soc. 2015;
10. LaCroix J, Synder L, et al. Effectiveness of Mass Media Interventions for HIV
Prevention, 1986–2013. J Acquir Immunodefic. 2014;66:329–40.
11. Kulkarni SP, Shah K, et al. Clinical uncertainties, health service challenges, and
ethical complexities of hiv “test-and-treat”: A systematic review. Am J Public
Health. 2013;103(6).