Abstract
Dear Editor-in-Chief,
I am particularly interested in the research conducted by Mbotwa et al. 1 on the use of the Jichunge mHealth application in Dar es Salaam, Tanzania, as it provides preliminary evidence that digital interventions can enhance retention in PrEP services among female sex workers, a group that is epidemiologically at high risk of HIV infection. These findings highlight the complex interplay between health technology, individual behaviour, social stigma, and legal regulation. Only approximately 27.7% of participants remained engaged in the PrEP programme after one month, yet optimal users of the application exhibited twice the retention rate of sub-optimal users, indicating that effective adoption of technology can strengthen engagement in critical health services.
When contextualised within Indonesia, the situation of sex workers differs significantly in legal terms. Commercial sex work is largely criminalised under the 2023 Penal Code and related regulations, exposing sex workers to legal threats and discrimination.2,3 This contrasts with regulatory models such as that in Senegal, where sex workers can engage legally with health systems, facilitating higher retention. Within the Indonesian legal framework, the risk of criminalisation creates a chilling effect that limits access to HIV prevention services, including PrEP, and increases the need for alternative pathways that are safe, anonymous, and non-discriminatory. Digital interventions, such as mHealth, can act as a mitigating mechanism against these legal barriers, offering a virtual space where sex workers can access information and health services without social or legal exposure.
Foucault’s4,5 perspective provides a theoretical framework for understanding this phenomenon through the concepts of bio-power and social discipline. Stigma surrounding sex work and PrEP use is not merely a moral issue but a form of surveillance that constrains individuals’ control over their bodies and health. In this context, stigma functions as a disciplinary mechanism that normalises exclusion and limits retention in health services. The study demonstrates a significant relationship between stigma and retention: those experiencing lower stigma exhibited higher retention. Thus, mHealth can be seen as a means to renegotiate power relations, granting individuals greater autonomy in managing their health amidst normative and legal pressures.
From a human rights perspective, retention in health services is integral to the right to health, the right to privacy, and the right to be free from discrimination. In Indonesia, despite the 2023 Health Law guaranteeing health services for all, sex workers frequently encounter barriers due to social stigma and legal threats. 3 The implementation of mHealth offers an innovative model that can enhance equitable access, strengthen individual capacity to maintain health, and mitigate the effects of marginalisation. Applications such as Jichunge provide medication reminders, easily accessible health information, online consultations, and anonymous discussion forums, effectively reducing the risk of identity disclosure and potential discrimination. Consequently, digital technology becomes an instrument for realising human rights principles within complex social and legal contexts.
Further analysis indicates that the effectiveness of digital interventions is highly dependent on local social and economic conditions. Factors such as age, educational level, experiences of stigma, and awareness of PrEP influence retention. This underscores that digital intervention design cannot be universal but must be sensitive to the specific conditions of the target population and existing legal risks. In Indonesia, this presents an additional challenge as sex workers face structural criminalisation that may affect their motivation to participate in health programmes, even when technology offers a safe pathway.
Moreover, Foucault’s perspective reminds us that digital technology, while potentially enhancing individual autonomy, also carries the possibility of new forms of surveillance.6,7 Usage data collected anonymously can still constitute information gathering that may be misused if implemented in countries with strict regulations. Therefore, the deployment of mHealth in Indonesia must prioritise privacy and data security to avoid exacerbating the marginalisation of vulnerable groups. Legal protection of users’ personal data becomes relevant as an extension of human rights into the digital sphere.
The study also emphasises the relationship between stigma and retention in health services. Social and internalised stigma regarding sex work and PrEP reduces user engagement in programmes. In Indonesia, similar stigma manifests through moral narratives, social media, and cultural pressures, reinforcing the marginalisation of sex workers. 8 From a Foucauldian viewpoint, this exemplifies bio-power operating through norms and social surveillance, influencing individuals’ behaviour in accessing health services. By providing decentralised and anonymous access via digital technology, mHealth applications can disrupt cycles of social surveillance and stigma, while simultaneously strengthening individual autonomy.
Legally and from a policy perspective, implementing mHealth in Indonesia may require regulatory reform to ensure access to health services for sex workers without the risk of criminalisation, alongside the protection of personal data. This digital strategy, in addition to enhancing service retention, aligns with human rights principles: non-discrimination, equitable access, and individual privacy. Thus, mHealth is not merely a health tool but also an instrument of social transformation that can expand spaces of freedom for marginalised groups, reduce the impact of stigma, and support the achievement of public health goals.
By integrating legal, human rights, social stigma, and Foucauldian perspectives, this study demonstrates that digital interventions such as mHealth have the potential to serve as innovative, effective, and equitable health strategies. In Indonesia, such a strategy could help bridge disparities in health service access caused by legal pressures and social stigma, enhance the autonomy of sex workers in managing their health, and reinforce the implementation of the right to health as a fundamental human right. In this context, mHealth emerges not merely as a technological tool, but as a socio-political negotiation space that enables individuals to maintain control over their bodies and health amidst normative and legal constraints.
