Indonesia / Epidemic: The feminization of the HIV epidemic

10 Feb, 2010
By: Inga Ting

The overlap between injecting drug use and sex work is a driving force in the so-called “feminization” of Asia’s HIV/AIDS epidemic.

Between 70 and 80 percent of women injecting drug users (IDUs) are involved in some kind of sex work, according to Ratna Mardiati, a former director of the Drug Dependence Hospital (RSKO) in East Jakarta with 14 years’ experience dealing with injecting drug users.

“They are not formal sex workers but they sell their bodies when they need money,” she says.

Other sources of structural inequality, such as the gender wage gap — which sees Indonesian women earning on average 75 percent of what their male counterparts earn, according to the International Labor Organization — and health insurance policies that force women to depend on their husbands for medical cover, effectively trap women in unhappy or destructive relationships.

“That is why most [women IDUs] cannot bring themselves to make a choice,” Ratna says. “They are dependent on people — on partners, firstly, and then anyone who can give them money, shelter, and whatever else they need.”

Although there is a conspicuous lack of data due to gross under-reporting, it is widely believed that sexual and other forms of abuse are common in relationships that involve drug dependence in one or both partners. In many cases, such abuse involves the male IDU selling the woman’s body for drugs or money.

Economic disadvantage combined with the social stigma also means women IDUs tend to be dependent on their partners for drugs and needles.

“It’s not good for the woman to be seen buying drugs; it’s better that she stays at home,” says Sekar Wulan Sari, director of the Stigma Foundation, a community-based organization for drug users and former users.

“The exception is when finances are stretched or supply is low. Then the responsibility shifts to the woman, probably because she can get drugs more easily by selling sex.”

However, as Asmin Fransiska — a lecturer in law and human rights at Atma Jaya University and co-founder of the Indonesian Coalition for Drug Policy Reform — points out, the problems faced by women IDUs are inseparable from the wider issue of discrimination against women. It is extremely difficult, for example, to defend the sexual rights of women IDUs in a society that in many corners still denies the existence of marital rape, she says.

“There are laws against domestic violence but… if you are the wife and you say that you are being raped by the husband, society will think: ‘What? It’s your duty to serve your body to your husband.’

You cannot just say no. It’s taboo to say no to the husband,” Asmin says.

According to researchers and health workers, this makes women IDUs exponentially more vulnerable to infection by HIV and AIDS because they are far more likely to share both drugs and injecting equipment.

“Mostly, if the woman IDU has a partner who is also a drug user, she is treated as a second class person… Even when she is the one who gets the drugs, she will give the drugs to him and he will use first. This is partly why HIV rates among women are rising – because usually, if the male IDU partner has HIV, the woman will have it too,” Asmin says.

Furthermore, given the intersection between injecting drug use, sexual violence and sex work, women IDUs are not often in a position where they can negotiate for safer sex.

Finally, compounding the economic and social factors is women’s biological susceptibility to HIV infection. According to UNAIDS, women are almost twice as likely as men to acquire HIV from an infected partner during unprotected