Preventing HIV/AIDS by Promoting Life for Indonesian Street Children

An HIV/AIDS prevention program in Indonesia has given hope to children living on the streets and helped put children on the national policy agenda.

Iwan beat up another student at school. Fearing his father's reaction, he fled his parents' home in the Indonesian city of Krawang and moved to Jakarta, the country's capital. Since then, he has lived on the streets, making his living shining shoes, stealing and trading sex for money. Another street youth introduced him to sex. Now 15 years old, Iwan has never used a condom. He has heard about syphilis, but not about HIV or AIDS.

Fourteen-year-old Siti left home because she could not tolerate her parents' anger. She earns money singing on the street with two friends. Siti thinks AIDS is "a skin disease that makes you feel itchy."

Dede is 15 years old. He dropped out of junior high school and began singing on the street to make a living. At night he sleeps in bus terminals with a group of friends. He patronizes sex workers regularly but won't use a condom. Once he experienced genital itching and treated it with a lotion he bought from a drug peddler. Dede has heard about AIDS and knows it has no cure.

Iwan, Siti and Dede live on Indonesian streets, but stories like theirs could be told by millions of other children in countries around the world. Their days are consumed with finding food and a place to sleep. In the struggle to survive, they live with violence and sexual exploitation. Many seek relief by drinking alcohol, sniffing glue or taking other harmful drugs.

Given these daily concerns, it is difficult to convince children and teenagers who live on the streets to focus on something as abstract as HIV/AIDS that may take years to manifest itself. The challenge is to give them a reason to change behaviors that help them survive today but increase their risk of developing HIV/AIDS in the future.

This challenge was taken on by RESCUE/AIDS, a 16-month pilot project targeting street children in Indonesia. Conducted by Pact Indonesia with support from the AIDS Control and Prevention (AIDSCAP) Project, RESCUE/AIDS grew out of Pact's previous work with Indonesian nongovernmental organizations (NGOs) to connect underserved street children with social services. The pilot project ended in September 1996, but its success led to continuation under the HIV/AIDS Prevention Program (HAPP), implemented by AIDSCAP and funded by the U.S. Agency for International Development (USAID) and the Government of Indonesia.

Surviving on the Streets

Some 4,000 to 20,000 children live on Jakarta's streets. According to Pact surveys conducted with Atma Jaya University, 25 percent are younger than 11, 15 percent are homeless and 40 percent live in slum rooms with other children. Understanding how these children live was fundamental to planning HIV/AIDS interventions.

"The street population is diverse," said Dr. Anne Scott, director of Indonesia programs for Pact. "You can have a 17-year-old who follows his cousin to the city for a job. It doesn't work out, he doesn't get a job, but he doesn't want to go back home until he's 'successful.' You can also have children fleeing from a violent family, where a 15-year-old and his 6-year-old brother came together."

Many street children left home after getting into trouble -- doing poorly at school, fighting or committing a crime. Some were sent away by parents who could not care for them. Others were orphaned. Still others have parents who maintain street-based businesses. About nine out of ten street children are boys, but the number of girls is increasing.

Once on the street, marginalized by and from society, street children are driven by the economics of survival. Some earn a living by singing, shining shoes, cleaning car windows, carrying packages or selling items such as candy, cigarettes, newspapers and magazines. Others become pickpockets or commit more serious crimes.

Facing Sexual Threats

Street culture often encourages and reinforces risky behaviors. Street children reported that being forced to have sexual intercourse was one of the greatest problems they faced in living on the streets.

Many street children seek out the physical protection of an older youth, but that kind of partnership can be dangerous. "There are relationships on the street much like in a prison culture," Dr. Scott said. "The younger boys need the protection of an older boy for survival, but it puts them at risk sexually."

A 1995 assessment conducted by Pact and the Atma Jaya Research Center suggested that older youths often use anal intercourse as a rite of initiation with younger street children they are "protecting."

Adults wishing to purchase sex are also a threat to street children. Some believe that youngsters are less likely to be infected with HIV than older persons and take advantage of their desperation and gullibility, promising special gifts in exchange for sexual services.

In addition, many of the older street children maintain relationships with sex workers. "It's more of a comforting relationship with an older female figure, like a mother they didn't have," Dr. Scott said. "But that's a direct bridge for the transmission of sexually transmitted infections."

Most street children are poorly equipped to combat such sexual threats. In Indonesia, Pact found that few had accurate information about HIV/AIDS or other sexually transmitted diseases (STDs) and many held misperceptions about effective cures and prevention.

In general, street children had received little education, and compounding that lack of knowledge was a fatalistic world view. "We designed the pilot project because we saw that there is a link between basic health issues -- what we call 'perception of life' -- and AIDS," said Yustina Sari, Pact's RESCUE/AIDS project director. "'Why should I care about life; what's the difference between life and death?' was the attitude of many street children."

Instilling in street children a sense that life is worth preserving would be the first step in reducing their risk of HIV/AIDS. First, however, the messengers had to be clear about the message.

Educating the Educators

A group of 10 Indonesian NGOs that had been involved in Pact's earlier work with street children were chosen for the RESCUE/AIDS project. As in the earlier projects, street educators formed the link between street children and the NGOs. They were a diverse group: some were graduate students in social work, some came from religious backgrounds and some were former street children. Most were in their early twenties.

"They were very dedicated," Dr. Scott said. "They became like big brothers or big sisters to the street children."

These close relationships made it possible for the educators to talk to street children about sensitive issues. However, Pact found that many street educators themselves needed to know more about STDs, including HIV/AIDS. Before the project started, less than half of the street educators knew how HIV/AIDS was transmitted.

"In general, the street educators needed more basic knowledge of the human body and health, sexual reproduction, STDs/HIV/AIDS and condoms -- what they are, how to talk about them and how to use them," Sari said. "Communication techniques, basic counseling and referral systems also needed improvement."

None of the educational media available at the time targeted street educators or street children. So Pact developed its own training materials and manuals that covered basic facts about HIV/AIDS, STDs and other reproductive health issues, as well as communication, outreach and counseling.

Another challenge was the street educators' attitudes and emotions concerning sexuality. Because of Indonesia's social traditions, women are expected to be more conservative than men in their views regarding sex, posing a dilemma for some of the female street educators.

Even when individuals felt comfortable discussing sexual issues with street children, not all of their NGOs fully backed them. Some groups believed other issues were more important than HIV/AIDS in improving the children's lives. Other NGOs opposed condom promotion, favoring moral education. "What we learned is that attitudes on moral issues determine the commitment of NGO management, and this determines the success of the field work," Sari said.

Two of the original ten NGOs chosen for RESCUE/AIDS were not able to continue work in HIV/AIDS prevention, even though their street educators were strongly committed to the issue. "The board of directors and project management did not agree, so they could not consistently support their street educators," Sari said.

Other NGOs, however, became more supportive as they continued to work with Pact, enabling their street educators to have frank discussion with street children about HIV/AIDS and sex and to promote condom use.

According to Joyce Djaelani, who served as an outside evaluator, the impact of the RESCUE/AIDS project extended beyond the street children to the NGOs and the community. "RESCUE/AIDS increased awareness of sexual abuse happening among street kids and substance abuse," said Djaelani, who is an Indonesia program officer for the Program for Appropriate Technology in Health (PATH). "And it also encouraged creativity among the NGOs in developing information, education and communication (IEC) materials for AIDS education purposes."

Participating NGOs gained skills in project and financial management, human resources and time management and learned about model HIV/AIDS intervention strategies. "Part of Pact's achievement is building the capacity of indigenous community-based organizations and NGOs to learn the management and technical skills necessary to implement programs such as this one," said Kari Hartwig, program officer in AIDSCAP's Asia Regional Office in Thailand.

Getting the Message Across

Three different approaches were used to reach more than 1,000 street children with integrated messages on HIV/AIDS, self-care and life skills. Some of the NGO street educators approached young people where they congregated in public parks, bus terminals, markets, street corners and shopping centers. Others met them at community centers or in school classrooms. A third group allowed street children to come and live temporarily at small residential facilities that provided shelter, along with education and skills development.

All the children received basic literacy and health education. For younger children, general information about HIV/AIDS and other STDs was conveyed through simple messages. Older street youth received more complete information about HIV transmission and prevention and assistance in assessing their own personal risk and developing prevention strategies.

Since many of the children had dropped out of school and had limited reading skills, several NGOs used games to hold their attention and convey HIV/AIDS prevention messages. Comic books, stickers, posters and booklets with lots of illustrations and simple text were also created for the same purpose, with advice and training from Pact. Some of the children made batiks or T-shirts bearing HIV/AIDS prevention messages. Street children also helped develop some of the educational materials.

In the community centers, street children worked closely with the street educators. They decided together how to maintain the center and schedule the activities. "It was a bottom-up participatory activity," Sari said. "Most of them felt like this was their home."

"We built a sense of friendship and solidarity in this sense, hoping they would protect themselves and each other," she added. For example, one group of street children drew up a list of concerns and solutions. Sleeping on the street at night where they felt vulnerable to sexual abuse was considered a main concern. Their solutions included trying to find a mosque to sleep in, sleeping with a group of friends or coming to the nearest RESCUE/AIDS center.

Whenever possible, the NGO staff members mentioned HIV/AIDS in counseling sessions and informal discussions with individual street children. HIV/AIDS was discussed with other health issues, such as eating the right kinds of food, avoiding illegal drugs and watching out for traffic in the streets.

"The focus of the project was more broadly on risk behavior, about saying 'no' to risks and about why they were sometimes doing dangerous things," Dr. Scott said. "For example, when one child was hit by a car after sniffing glue, street educators took the opportunity to raise safety and self-care issues with the children who wanted to know what had happened to the injured child."

One of the major accomplishments of the project was getting street kids to take better care of themselves. "RESCUE/AIDS touched their lives through a basic message that matters most -- that someone cares," Djaelani said. "When you feel that someone cares, you are less fatalistic in life. Any kindness makes a whole lot of difference to these kids."

Making a Difference

During the past few years, Pact and other Indonesian NGOs have helped the government develop a national strategy on children that addresses the plight of street children.

"The project has certainly raised the issue of the vulnerability of youth and street children to policymakers," Hartwig said. "Reaching policymakers is key to long-term strategic change."

Public awareness of the vulnerability of street children has also grown. In 1996, media coverage of the rape, mutilation and killing of nine street children drew widespread public concern. And in September of that year, government agencies, NGOs and other organizations sponsored a three-day national conference on street children. "The government is developing an agenda with an infrastructure for street children," Dr. Scott said.

Changes in attitudes and behavior are also beginning to appear among street children. "Local organizations are saying that there is a group of younger kids who are aware of the danger they face," Dr. Scott said. "There is progress."

The importance of reaching Jakarta's street children with STD/HIV/AIDS prevention messages has been recognized in the expanded activities of HAPP, which continued work started by RESCUE/AIDS under a new Underserved Youth (USY) Project in Northern Jakarta. The HAPP-USY Project also reaches youth who are informal dock workers, fishermen, factory workers, drivers and school dropouts.

Such work is increasingly important, Djaelani noted, as urbanization continues, and more and more homeless, friendless young people arrive each day in Jakarta. "The social gap is getting wider, slum areas are getting bigger, drug abuse is becoming more extensive," she said. "Children are our future: We can still make a difference in their lives, but if we turn our backs on them now when they are in need, in later years they will turn their backs on us."

-- Bill Black and Arin P. Farrington