The 100 Percent Solution?

Thailand's radical and effective HIV strategy is struggling to get off the ground in Indonesia, writes Trish Anderton.

When Esthi Susanti Hudiono took up HIV prevention more than 10 years ago, she figured she could not fail.

"I thought this would be an easy job: just promote condoms," she recalls in her small, cluttered office in Surabaya. "Promote condoms face-to-face. Easy! Because people will be told about the risks, about sexually transmitted diseases like HIV and the others.

"It turns out we still haven't succeeded."

Esthi's organization, Hotline Surabaya, provides HIV testing and education and runs programs to combat trafficking of women. It has experimented with various ways to empower prostitutes to insist that their customers use condoms. They have achieved some success, she says, but not enough. Ultimately she reached an unwelcome conclusion: empowerment alone will not work.

"Sex workers do not have bargaining power," she says. "The bargaining power is in the hands of their customers." In Indonesia, she continues, "behavioral change can't be only on an individual level, because the influence of community is very strong. Because of that, behavioral change has to be tied closely with social change."

With that in mind, Esthi worked with other organizations to pass a law requiring condom use for risky sexual activities. The measure went on the books in East Java in 2004.

And there it sits -- in the law books, but rarely observed in Surabaya's many lokalisasi, or red-light districts.

An education and enforcement system is needed, Esthi says, "but there's no funding."

The idea of 100 percent condom use, as it is often called, has a striking record of success in some of Indonesia's neighboring countries. Pioneered by activist and politician Mechai Viravaidya in Thailand in the early 1990s, it was credited with slashing the rate of new HIV infections there by more than 80 percent. Cambodia has had similar success in recent years.

The Thai campaign was unusual for its high spirits. Mechai, who became known as "Mr. Condom", persuaded Buddhist monks to sprinkle condoms with holy water to counter the sense that they were innately immoral. He led condom-blowing contests in villages, and got police to hand the contraceptive devices out through a program called "Cops and Rubbers". 

Anyone who did not get the message through public service announcements got it loud and clear at brothels, where signs declared "No condom, no sex, no refund".

While it was humorous, the campaign was backed up by serious enforcement. If sex workers tested positive for new sexually transmitted infections -- meaning they weren't using condoms -- their brothels received a warning. A second warning meant a one-day closure. After the third, the brothel would be shut for a week.

Indonesia has endorsed the 100 percent condom idea, stating in its national strategy that the approach "needs to be prioritized". But progress has been painfully slow. Where condom promotion is involved, Dr. Nafsiah Mboi says, "the sensitivities and the resistance are still huge".

"This is hard work," the secretary of the National AIDS Commission said by phone. "We have to keep saying, ‘no, no, no, no, no, promoting condoms is not promoting promiscuity’."

Mboi encourages local governments to pass 100 percent condom laws, but says selling the idea nationwide is "too difficult at the moment." Instead she promotes condom use in tandem with messages discouraging fornication and adultery. She says this approach has won over some religious leaders.

"They said OK, we will promote A and B -- Abstinence and Be faithful --  but we will not go against the C, Condoms. For me, for the moment, that's fine."

Mboi says attitudes toward condoms are changing.  "I've been in this work for 20 years. It's better now. It's more accepted."

Encouraging condom use remains a sensitive topic in much of the world. While studies of U.S. teens have found that condom promotion does not increase sexual activity, some social and religious organizations dispute those results and insist abstinence education is the only acceptable method.

Even Thailand's efforts have been inconsistent. In recent years, the Thai government shifted money away from prevention and into treatment. The result has been a decrease in condom use, and what the UN calls signs of a resurgent HIV problem.

"Mr. Condom" is back in the fray with a renewed public education campaign. He hopes to see results by the end of next year.

"Lack of information doesn't save lives," says Mechai on the phone from Bangkok. "It's only knowledge. If you don't provide knowledge, somebody will provide it in the black market for you."

What advice does he have for countries trying to promote condom use?

"There will be some people arguing out of ignorance," he says. "Don't worry about it. Continue."

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