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A consummate insider pushes ideas from outside Indonesia

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Science  11 Jul 2014:
Vol. 345, Issue 6193, pp. 162-163
DOI: 10.1126/science.345.6193.162

Sex and drugs rock Health Minister Mboi's reign.

On 14 June 2012, Nafsiah Mboi's first day on the job as this country's minister of health, she announced a new campaign to distribute condoms to people at high risk of HIV infection. A loud uproar followed, leading Mboi—more commonly known by the honorific Ibu Naf—to post a YouTube video to explain that she was not advocating distributing condoms in high schools, as rumors had it.

Video

Interview with Nafsiah Mboi, http://scim.ag/hiv2014.

Indonesia's HIV/AIDS politics are fiery—and Ibu Naf seems to like the heat. A pediatrician by training, Ibu Naf has had a prominent political life, first as the wife of the governor of East Nusa Tenggara province and then as a member of parliament for 5 years in the 1990s. She went on to do a stint in Geneva, Switzerland, at the World Health Organization as the director of gender and women's health, and in 2006, she was appointed secretary of Indonesia's National AIDS Commission. She held the job for 6 years before being tapped to serve as minister of health. In June 2013, the Global Fund to Fight AIDS, Tuberculosis and Malaria appointed her chair of its board.

Indonesia has a serious epidemic: New infections jumped 2.6-fold between 2001 and 2012, according to the Joint United Nations Programme on HIV/AIDS. The epidemic began mainly in injecting drug users, but today the highest spread occurs in men who have sex with men (MSM), sex workers and their clients, and transgenders. One exception is the two Indonesian provinces on New Guinea, which have a largely heterosexual epidemic that mirrors the one on the other side of the island in Papua New Guinea (see p. 158).

Islamic concerns complicate HIV/AIDS prevention efforts.

PHOTO: MALCOLM LINTON

Ibu Naf has successfully lobbied for expanded access to antiretroviral drugs for HIV-infected people. She pushed through legislation that decriminalized drug use and allows government-run clinics to provide methadone and clean needles and syringes. Tuti Parwati Merati, a clinician who heads a nongovernmental organization (NGO) devoted to HIV/AIDS in Bali and also works at Udayana University in Denpasar there, says Ibu Naf “can pick the most difficult and make it happen.”

Yet Ibu Naf acknowledges that serious problems remain. Police harassment of drug users continues, and the epidemic in MSM is largely ignored. Science spoke with Ibu Naf at her office in Jakarta about the country's response to HIV/AIDS and the challenges it faces. This interview has been edited for clarity and brevity.

Q:Reports long warned that HIV/AIDS would become a huge problem if you didn't ramp up harm reduction for people who inject drugs. Did this take too long?

A:For my taste, yes, but indeed the fight was not easy. When I became the secretary of the National AIDS Commission in 2006, we already knew that we had prevalence rates of more than 60% in several areas because of people who inject drugs. The first thing I did was invite everybody: the legal beagles, as well as people from the health sector, several ministries, the police, the narcotics boards, welfare, and said, “OK, what do we do? It is estimated that we have 330,000 kids injecting. Do we want to kill them or save them? If we don't do anything, if we keep fighting, they will die. They will die of AIDS. They will die of overdose. They will die of hepatitis. They will die in prison because they'll beat them in there. If we want to save them, we have to work together.” There was silence. Total silence. But then I was very happy because it was the police who said, “Ibu, you're right. We have to save our kids. Actually, my son is a drug user and I don't know what to do.”

Nafsiah Mboi pushed through harm reduction efforts.

PHOTO: SUTANTA ADITYA/AFP/GETTY IMAGES

Q:What happened?

A:First of all, I said, “The law says they're criminals and we should decriminalize them.” We put a new regulation together, but it was very hard to convince the different ministers. So I invited our colleagues from Australia to do a cost analysis and presented that in front of all the ministers and said, “This is what it will cost us if they all get HIV infected and hepatitis.” That was the thing that changed it.

Q:Did you have needle and syringe exchange right away or was that a battle also?

A:I knew that the NGOs had started it, but they were hiding under cover. It was illegal and if they were caught, they went to prison. But I'm very proud to say we have very courageous NGOs. These NGOs got together with the networks of people who inject drugs. And then the Global Fund provided the resources.

Q:The government accepted it?

A:Not always very happy, but we did it.

Q:When you became minister, you had to very quickly fight over condoms.

A:We've been fighting about condoms since the minute I came back from Geneva when I was secretary of the National AIDS Commission. As the minister it was different, you see. Here was an amoral minister of health who is promiscuous who wanted to distribute condoms to schoolchildren. So they demonstrated. I said, “OK, come in.” So we talked and I gave them the data of sexual transmission, of housewives being infected and babies born. I said, “Look, what else can we do? You're religious leaders, and you have been telling them that they are not allowed to go to brothels or whatever, but I cannot do that. I'm just the minister of health. All I can do is prevent the transmission of the disease and I can only do that with condoms.” Then they said, “Yeah but it's wrong if the government does it.” And they said, “You have to beat them in public. Beat them to death. It's the Islamic Shariah.” And I said, “But it's not in our law.” So I said, “Let's agree to disagree. You do your work so that no man will ever go to brothels and no young person will ever have sex before marriage. I will do my work with those who engage in risky sex and tell them to wear condoms.”

Q:You came from a Muslim background and converted to Catholicism. How do you view the Islamic community that challenges prevention interventions because they violate their moral tenets?

A:It has changed a lot actually. From the beginning, there was only a small group who were really aggressively looking at [HIV/AIDS] from the moral point of view. A lot of people actually knew that yes, what we were doing was the right thing to do. All they needed was somebody to be the—how do you call that?—the one to get the stones thrown at.

Q:They're still throwing stones at you. Muslim leaders attacked National Condom Week in December 2013, and the Health Ministry halted the annual event.

A:Yes, yes. But not as fiercely as before.

Q:One criticism is that the government hasn't spent enough on the MSM community. What do you think?

A:Yeah. It is because we believe that MSM can only be reached by their peers. It's not that I don't want to spend money. Unfortunately, there are still a lot of districts or provinces where this cannot be done by our local government. Once I had to basically fire the secretary of the local AIDS commission because he said, “Ibu, I will do anything you say, but don't ask me to work with men who have sex with men. It's against my conscience.” And I said, “Then you cannot be the secretary of the local AIDS commission.” MSM is still much hated in many areas in Indonesia, I'm sorry to say.

Q:Your supporters are worried about you getting kicked out of office with the elections coming up.

A:Most probably so, yes.

Q:Are you worried about whether there will be continuity?

A:I am, but the only thing I can do is strengthen my colleagues who will still be here, empowering them, as well as the NGO community. We have a strong NGO community, and they need a stronger voice in the government. And I can still do things from outside, I think. I may not be as powerful as the minister, but I can always say what I want.

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