amfAR, The Foundation for AIDS Research

TREAT Asia Site Profile: Udayana University and Sanglah Hospital, Bali, Indonesia


October 2005—Bali has been called the jewel of the East, but beneath the surface of the island’s lush beauty lies an ever growing threat from AIDS. Drug use has fueled the spread of HIV across the Indonesian archipelago, which encompasses 6,000 inhabited islands scattered across 5,000 kilometers of sea. Bali alone has an estimated 3,000 people living with HIV/AIDS.

Official figures show Indonesia’s adult prevalence rate at a relatively low 0.1 percent, but many believe that the true figure is much higher. The country is home to 3.6 million drug users nationwide (1.5 percent of the total population), 31 percent of whom are classified as addicts. Indonesian IV drug users tend to be much younger than their Western counterparts, often starting drugs as young as 11 or 12. According to public health experts, the overwhelming concentration of HIV among young people and the sharp increases in HIV among injection drug users and sex workers suggest the potential for a dramatic rise in infections in the general population.

At the center of Bali’s fight against AIDS stands Sanglah Hospital and the School of Medicine at Udayana University, which established an AIDS program in 1991. It serves as a TREAT Asia site in Indonesia and it also fully participates in and contributes to the TREAT Asia Observational Database (TAHOD). The site provides testing as well as treatment and conducts research in areas such as attitudes and behaviors of high-risk groups.

According to Indonesia’s National Narcotic Agency, 53 percent of HIV-positive Balinese contracted the virus through IV drug use, and infection rates due to drug use follow close behind in other major provinces. (Only in Papua is the epidemic primarily driven by commercial sex.) Dr. Tuti Parwati Merati, head of tropical and infectious diseases at Udayana University and chair of Sanglah Hospital’s AIDS working group, notes that Bali’s HIV/AIDS statistics reflect in part what she calls the “higher mobility” of the Balinese—in many other parts of Indonesia the virus has spread more slowly because population movement and tourism are limited.

HIV was first diagnosed in Indonesia in 1987 by Dr. Tuti, and her commitment to fighting the disease remains steadfast. Because a Dutch tourist was the first case diagnosed, Indonesians initially shrugged off AIDS as a Western disease. And because the virus spread slowly compared with some neighboring nations—in part because of the isolation of many Indonesian islands—public health officials failed to grasp the seriousness of the unfolding epidemic for some time.

For many years very few HIV testing centers existed in Bali, and when Sanglah Hospital’s AIDS clinic first opened in 1991 its staff treated only one or two patients each month. A few years ago, however, the government launched a program at Sanglah offering free counseling and testing, free treatment for some opportunistic infections, and free antiretroviral drugs. The result has been a sharp rise in the number of cases seen at the hospital. From 1991 until 2003, around 200 people were treated at Sanglah, but from July 2004 to October 2005, 613 were tested and 136 were found to be HIV positive.

Before the introduction of free antiretrovirals, noted Dr. Tuti, survival rates for people with AIDS at Sanglah were low. “Medical students in their three-month rounds in our department were not able to meet with the same patients because the patients would have already died,” she recalled. Today, drugs are much more widely available in Indonesia, largely supplied by the government, although the Global Fund also provides some medications. The central government has also begun a program to train health-care workers to treat HIV/AIDS, Dr. Tuti said, with the goal of equipping 25 hospitals across the country with HIV expertise.

From the earliest years of the HIV/AIDS epidemic in Indonesia, stigma and discrimination have been widespread. At times, hospitals and health-care workers refused to provide care to HIV-positive patients, postponed treatment, charged additional fees for using health facilities, and revealed blood test results without permission, Dr. Tuti has reported. Perhaps most painfully, people have been shunned by their families and neighbors. Research performed at Sanglah Hospital shows that little has changed.

Recent behavioral surveillance data for Indonesia also indicate that condom use has not increased, the incidence of sexually transmitted diseases has not dropped, and the number of men buying commercial sex has increased. With public health education lagging and the virus spreading in certain communities, the challenge facing institutions such as Sanglah Hospital is significant. “It’s only a matter of time,” said Dr. Tuti, before Bali and Indonesia confront a full-scale HIV/AIDS crisis.