A social context perspective to the increasing HIV epidemic in MSM in Indonesia

Understanding current HIV epidemics requires understanding the impact of the wider global and local environment including political rhetoric, health systems, geographical diversity and instability, institutional stigma, changes in how people from differing socio-economic backgrounds in all corners of the globe live, and the rise in digital technology. These apply particularly in Indonesia, that is observing one of the fastest growing HIV epidemics.^1,2

In Indonesia there have been alarming increases in the number of HIV infections in men who have sex with men (MSM). In 2018, HIV prevalence estimates were 25.8% in MSM nationally, compared to 8.5% in 2011. ¹ In major cities Jakarta and Denpasar in Bali, one in three MSM are infected with HIV. ³

Indonesia is the fourth most populous country in the world with an estimated 267 million people in an archipelago of over 17,000 islands. In recent times there has been a growing populist right-wing political rhetoric and the country is observing worsening stigma and active discrimination against lesbian, gay, bisexual and transgender (LGBT) people which is significantly slowing the country’s HIV response. For example, proposed laws that aim to criminalize sexual relations outside marriage ⁴ and impose legal requirements for individuals and their families to report to the Government for rehabilitation if they have same sex relationships. ⁵ The impact this has on public health outreach and driving health inequality to MSM populations, directly contributing to increasing HIV rates has been highlighted by Human Rights Watch. ⁶

Indonesia has a highly diverse cultural and traditional identity, home to over 600 ethnicities and languages in a geographically complex environment. It is also a digitally literate nation: Jakarta tweets more than any city on Earth and in 2018 there were 130 million Facebook accounts, placing Indonesia as having the fourth-highest number of Facebook users in the world. ⁷ In 2018, there were an estimated 83.5 million smartphone users. ⁸

In addition to a number of ways technology acts to enable today’s world it has also ‘disrupted’ how people can meet to have sex. Accessing sex through dating apps, social media and messaging groups is a global phenomenon. In London, apps are one of the most relied-upon sources of sex by MSM; ⁹ data from Australia suggest MSM accessing sex through websites and apps were likely to have more sexual partners than MSM not using these forums. ¹⁰

High numbers of MSM in Indonesia are using secretive methods, in particular mobile apps and web applications, to meet other men for sex.^11,12 In Indonesia, MSM reportedly have female partners and may marry to conform to cultural and religious norms.^13,14 These men may not identify as ‘gay’, MSM or bisexual and are a particularly hard-to-reach population. Mobile and web forums provide a perceived safe place for MSM to find sexual partners without being targeted.

The use of recreational drugs, specifically crystal meth, mephedrone and gamma-hydroxybutyrate (GHB) to facilitate sex (known as chemsex) in MSM has been well described in Europe and the US, associated with high risk sexual behaviour and an increased risk of HIV.^15,16 Crystal meth is becoming an increasing problem in Indonesia and is understood to be the second most widely used illicit drug after cannabis. ¹⁷ Data from Bangkok report the use of ‘club drugs’ (includes crystal meth, ecstasy, amphetamine, ketamine, cocaine, GHB) often used with erectile dysfunction drugs in MSM, to be significantly associated with HIV incidence. ¹⁸

The combination of a hostile environment to at-risk populations alongside greater access to risk and the globalisation of changing cultures of risk behavior (e.g. chemsex), is a dangerous one that exists in our time. Whilst there are a number of diverse challenges that contribute to the poorly-controlled HIV epidemic in Indonesia that deserve a more comprehensive and co-ordinated response, ² effective HIV prevention cannot be achieved without considering the social-behavioural, cultural and political context. Tailored, innovative and sensitive methods of engaging MSM populations involving digitally-led behavioural approaches alongside comprehensive biomedical HIV prevention, that avoid increasing vulnerability, are greatly needed.

We need to advance the agenda on understanding the impact that evolving risk behaviour, social and political dynamics have on HIV epidemics in young people and key populations and proactively integrate this knowledge into tailored behavioral interventions. Such interventions should be curated and/or championed by key population representatives and updated to manage changing modern times and cultures of risk behavior.

There is no doubt that a political landscape that exacerbates discrimination against LGBT populations, encouraging anti-human rights activities that greatly hinder public health outreach, should be challenged; however, caution and a moderate and culturally sensitive approach involving key stakeholders must be applied if interventions are to be acceptable, effective and sustainable.