Government policy on former foreign migrant workers who are at risk of infecting HIV/AIDS in East Lombok District, Indonesia

Purpose: This study aims to determine government policies for former migrant workers at risk of transmitting HIV/AIDS and find solutions to improve the effectiveness of these policies. The Province of West Nusa Tenggara is ranked fourth in Indonesia due to the increasing transmission of sexually transmitted diseases (STDs) and HIV/AIDS among migrant workers from Lombok. The main factor causing the high number of Indonesian workers going abroad is the economic factor. This sending of workers has a negative impact on their return to the district, for example the spread of HIV/AIDS and STDs. Design/Methodology/Approach: This study used a qualitative-descriptive approach to understand the behavior, views and attitudes of migrant workers towards government policies and the risk of HIV/AIDS transmission. Determination of informants in this study using a purposive sampling technique. Finding: The results of this study explain the risk of HIV/AIDS transmission and the lack of information about transmitting HIV/AIDS among migrant workers. Conclusion: Migrant workers are marginalized and lack sufficient knowledge about HIV/AIDS transmission and its prevention. Their perception of risk is generally low, services and access to information about HIV/AIDS and its impacts are limited and there are cultural misunderstandings and the high cost of treatment for foreigners among illegal migrant workers. Research Limitations: The study’s focus is limited to the East Lombok District. Other provinces have not been addressed. Practical Implications: The results of this study can be used as a reference for local governments to make or reformulate health policies. Contribution to Literature: This case can be used as a reference for developing health policies especially for Indonesian migrants.


INTRODUCTION
The HIV/AIDS epidemic is a disease that threatens social and economic development and national security. The Indonesian government is trying to control it by making various programs that are carried out in the long term and implemented in a coordinated manner by involving multiple agencies as well as by mobilizing intensive resources from all levels of society to accelerate and expand the reach of the program. Policy on HIV/AIDS includes a series of decisions and actions that affect institutions, organizations and service providers' systems and funding related to HIV/AIDS. The international, regional, national and local levels are all included in AIDS policy (Ministry of Health-Indonesia, 2023b). Human Immunodeficiency Virus (HIV) is a global health problem. According to WHO, HIV/AIDS affects every country worldwide. The risk of death caused by HIV is still high. HIV has claimed 40.1 million (33.6-48.6 million) lives. According to data from the Joint United Nations Program on HIV and AIDS (UNAIDS), 33.9-43.8 million people will have HIV in 2021. According to the reports of the Directorate General of P2P, Ministry of Health of the Republic of Indonesia, the cumulative number of HIV/AIDS cases until June 2022 reached 549,291 consisting of 419,551 HIV and 129,740 AIDS, with an estimated death rate of 38,000. During the COVID-19 pandemic in 2020, 50,626 cases of HIV/AIDS were detected consisting of 41,987 HIV and 8,639 AIDS. In contrast, the estimated number of cases of HIV/AIDS is 640,000. This means that 90,709 cases of HIV/AIDS in the community were undetected (Ministry of Health, 2021). The rejection of condoms and myths are additional problems Indonesia faces in tackling the HIV/AIDS epidemic. The first problem is related to legends that have occurred since the beginning of the HIV/AIDS epidemic in Indonesia. HIV/AIDS is a cursed disease that only affects those who have risky behavior which leads to discrimination against people living with HIV/AIDS. Most people still think HIV is transmitted through shaking hands (Kayaert, Van den Eynde, & Deschamps, 2013), hugging, kissing (Rawat, Saxena, Sharma, & Adhikari, 2012), sharing cutlery, swimming together, mosquito bites (Jerome, 2000), using public toilets and other things (Al-Rabeei, Dallak, & Al-Awadi, 2012). HIV transmission is only possible through genital fluids, blood fluids and breast milk from HIV-positive mothers without routine antiretroviral therapy (Kordy, Tobin, & Aldrovandi, 2019). According to a study from the Spiritia Indonesia Foundation, this stigma and discrimination prevent PLHIV from seeking treatment up to 2-3 years after being diagnosed with HIV (Munthe et al., 2022). The government has also advocated for increased family and community responsibility towards people with HIV/AIDS. On the other hand, efforts have been made to make HIV positive people more responsible for keeping their families and communities from infection. The Indonesian government is committed to implement international agreements for AIDS control, promoting multilateral and bilateral cooperation and expanding cooperation with neighboring countries in the AIDS Control Program as HIV epidemic has become a global problem (Ministry of Health, 2021). The impact of the COVID-19 pandemic has become the basis for changes in Indonesian government policies especially in the health sector. One of these policies is the formation of the Task Force for the Acceleration of Handling COVID-19 through Presidential Decree Number 7 of 2020, dated March 13, 2020. The government's steps in handling COVID-19 are considered good but it would be better if they were balanced with HIV/AIDS prevention efforts which are also an important global issue. Digital technology can also assist in HIV AIDS prevention programs. For example, for education and self-screening for the detection of HIV/ AIDS symptoms as well as developing a mobile-based application for mapping cases that will make it easier for field workers or NGOs to carry out communication and assistance for antiretroviral therapy (ART) during the COVID-19 pandemic (Ministry of Health-Indonesia, 2017a). The World Minister of Health and Family Welfare reaffirmed the countries' commitment at the UN High-Level meeting to eradicate the AIDS epidemic as a health threat by 2030 including ensuring commitment to the Joint United Nations program. The nation on HIV/AIDS has a target to provide more effective, sustainable and comprehensive AIDS coverage (NACO, 2018). The Province of West Nusa Tenggara ranks fourth for the most significant number of Indonesian Migrant Workers (IMW) in Indonesia. National data explains the spread of HIV/AIDS, namely in the provinces of East Java, West Java, and Central Java. East Lombok Regency has the second largest number of sending migrant workers after Indramayu Regency, West Java. Working abroad can solve various family economic problems. On the other hand, sending of Indonesian workers had a negative impact that happen IMW from pre and post-placement. During pre-placement, some did not have an exit permit but were employed illegally or while working, their salary was deducted by 10-25% by private Indonesian migrant worker recruitment companies. After finishing work and returning to the district, some of them carry STDs and HIV/AIDS. East Lombok regency is the sender of the highest number of IMWs in the province namely 235,821 people followed by Central Lombok with 147,611 people, West Lombok with 66,977 people, North Lombok with 10,158 people, Mataram with 12,621 people, Sumbawa with 34,474 people, KSB 5,384 people, Bima Regency 17,101 people, Bima City 1,045 people and Dompu 6,305 people. This makes East Lombok District vulnerable to HIV/AIDS transmission (Yasmin et al., 2020).East Lombok Regency is one of the areas that are entirely at risk of HIV/AIDS transmission because the population is quite dense, the mobility of the population and transportation are relatively smooth and it is a tourist area. There are drug cases and a very dynamic population especially with the increasing number of IMW working abroad, which can become a potential transmission source if not adequately supervised. The number of workers departing in 2021 will be 11,000 people. For 2022, from January to December, there will be 15,931 people (Santia, 2022). A medical check-up is necessary for those who work abroad. Meanwhile, for workers who have come to Indonesia or returned, their medical check-up is not evaluated. This needs to be a concern because being abroad has been a risk to his health for many years if he has deviant sexual behavior (Moyce & Schenker, 2018). The IMW who have just returned from abroad are likely to be infected with HIV/AIDS as they have been abroad for years, so when they returned to their hometowns. There was an increase in HIV and AIDS cases in West Nusa Tenggara Barat Province. In several districts, the HIV/AIDS prevalence rate has increased. According to the data for 2022, there are 37 new HIV/AIDS sufferers, 96% of whom are productive age (17-45 years), 2% over 60 years, 2% are children, 92% are men while 8% are women. For sufferers, homosexuals are dominated by 75%, households are at risk at 13%, customers of sex workers are 10% and babies are 2%, 91% of sufferers are former migrant workers and 2% of children are from marriages of former migrant workers 7% are female customers of commercial sex workers. For 2023, new sufferers were traced until March 2023; there were 15 sufferers, all of them were former migrant workers (Central Bureau of Statistics East Lombok, 2023). This study aims to understand government policies on former overseas migrant workers at risk of transmitting HIV/AIDS in the East Lombok District and find solutions for policy effectiveness.

METHODS
This research uses a descriptive qualitative approach to get quality and valid data for analysis which will later be poured into the form of descriptive words to find out what phenomena occur in research subjects such as behavior, views and attitudes. Thus, in-depth discussions are being held regarding policies to overcome the risk of HIV/AIDS transmission to former migrant workers in East Lombok District. Determination of informants in this study using a purposive sampling technique. The selected informants were the Head of the East Lombok District Health Office, the Secretary of the East Lombok District Health Office, the East Lombok District AIDS Commission, the Pelita Ilmu Foundation and Migrant Workers with HIV/AIDS. Data collection techniques were carried out through observation and interviews using interview guides and documents. Data analysis and interpretation techniques used techniques from Miles and Huberman (Onwuegbuzie & Weinbaum, 2016) which included data collection, data reduction, data validity testing, data presentation and conclusion. Triangulation techniques were used to test the validity of the data (Hartono & Saputro, 2018;Heale & Forbes, 2013).

Migrant Worker Knowledge
The knowledge of illegal migrants is minimal compared to that of official (legal) migrants (Dias, Aldina, Margaret, & Maria, 2004). The number of unofficial migrants is much larger. These include migrants who enter illegally without going through official inspections and migrants who enter legally but remain even though they have a visa (Ne'Matullah, Pek, & Roslan, 2021). Migration is increasing in several ASEAN countries primarily Malaysia. Twentythree percent of Malaysia's labor force is Indonesian dominated by men and associated with low wages and lowstatus work that Malaysians seek to avoid (Rakkapao, Kiattisaksiri, & Samakkekarom, 2019). Research conducted in 1999, 300 migrant workers who worked in the construction sector and entered through unofficial channels, 49.63% fulfilled their sexual desires with commercial sex workers who were specially brought to their homes far from the crowds by pimps (Arpangi, 2018). Sexual workers are brought in once a month for one week because they cannot go to prostitution brothels for fear of arrest (Fick, 2006). Meanwhile, according to a study conducted in Kabul in 2000, the frequency of sexual intercourse in one month was 4-5 times as high as 48.49%, 2-3 times as high as 37.23% and only once per month as high as 14.28%. Shabana's case study found that 87.5% of IMW had sexual intercourse and 97.3% had sexual intercourse while working abroad (Shabana, Muksin, Tohari, & Jamiati, 2023). The relationship between the spread of HIV/AIDS and population mobility is authentic and complex regarding the spread of infectious diseases (Camlin & Charlebois, 2019). Three essential components in the relationship between population mobility and HIV/AIDS are the presence of high-risk behavior (unprotected sex), risk groups (conventional and non-permanent immigrants) and mobility places a person in a permanent situation. Population mobility is one of the essential factors in accelerating HIV transmission in an area. HIV/AIDS will spread among people who move into risky situations so that they are involved in unsafe sexual behavior (Agarwal et al., 2016). Research conducted by Viriyathorn in Thailand related to the unemployed who suffer from illness and return to their place of origin, usually located in villages, shows a high rate of return among people with AIDS (Viriyathorn, Sachdev, Wanwong, Patcharanarumol, & Tangcharoensathien, 2021). Based on an interview with the East Lombok District AIDS Commission, it was explained that the factors causing migrant workers to be at risk of contracting STDs mainly HIV/AIDS are caused by: Most of these migrant workers go to other countries unaccompanied by their families and are still young. Migrant workers work long hours and most contracts are longer than two years. Interestingly, some are illegal workers, paid to work in brothels and have unprotected sex. Overseas workers are a special group that faces the problem of being vulnerable to HIV/AIDS transmission. Moreover, male migrant workers are more at risk because they tend to have sex in the destination country (Sukartini, Eka Mishbahatul M Has, Candra Panji Asmoro, & Misutarno, 2016). When asked about migrant workers who had worked in Malaysia, they explained as follows: We work in the construction sector in Malaysia and to fulfill our sexual needs we engage in relationships with other female immigrants from Indonesia who are in the same area or partnership, often provide sexual services in return. This practice provides additional income for women migrants. Many Indonesian migrants fulfill their sexual needs in prostitution places around the city with frequent visits at least once a month. When asked which prostitutes IMW is most interested in, they say: Prostitutes of interest are prostitutes with low pay, around RM 20-25 who come from Indonesia, the Philippines, Thailand and India. They are treated differentially by the arrival of prostitutes from cities in the states of Malaysia. According to the Pelita Ilmu Foundation: Some IMW in Malaysia admit that every week several prostitutes are brought to the plantations where they work. Some of their colleagues cannot help themselves which is one reason they cannot send money to their families because their income is spent on prostitution. Free sexual behavior in Malaysia will make IMW vulnerable to the transmission of sexually transmitted diseases (STDs) and HIV. It is undeniable that their low average education also increases this risk. Their knowledge about STDs and HIV/AIDS is minimal (Voyiatzaki et al., 2021). The most dangerous impact is when IMW infected with or carrying STIs and other viruses return to visit their families in their place of origin (Anaf, Fitranita, Haning, & Mita, 2022). They can transmit STDs, HIV or other reproductive diseases to their wives. If they return home and remarry with women in their place of origin, they will have a high risk of infecting their partners (Van Gerwen, Muzny, & Marrazzo, 2022; Yadav, Mann, & Balyan, 2022).

HIV/AIDS Control Policy
The Head of the East Lombok District Health Office explained in his interview that: Government policies on HIV/AIDS control aim to increase advocacy, outreach, capacity building, management capability, professionalism, accessibility, quality and outreach for HIV/AIDS services. Another goal is to drive community-based programs, work networks, partnerships and cooperation while striving to meet resource needs. In order to achieve this goal, integrated services were formed in hospitals, health centers, Non-Governmental Organizations and detention centers or prisons. The transmission of HIV/AIDS mainly occurs due to risky behavior such as unprotected sexual practices, using unsterile and multiple needles and the transmission of HIV-positive mothers to their babies. So, HIV/AIDS control policies must be carried out comprehensively including preventive, curative and rehabilitative efforts. It must involve all sectors, civil society organizations, the private sector and community leaders. In Dye's opinion, government policies respond to public issues to overcome their problems (Howlett & Cashore, 2014). A public policy has preventive, curative and developmental functions (Deusdad, Comas-d'Argemir, & Dziegielewski, 2016) to prevent social problems (preventive function), address social problems (curative function) and promote social welfare (development function) as a form of state obligation to fulfill the social rights of its citizens (Kuppen, de Leede, Lindenberg, & van Bodegom, 2023 The preventive function in this context is preventing HIV-AIDS transmission which is carried out through several efforts (Choudhry & Choudhry, 2004). Sexually, it can be prevented by abstinence from sex, monogamous sex with an uninfected partner, non-penetrative sex behavior and consistent and correct use of male or female condoms. In addition to these positive sex features, drug users are injected using new needles that are certain to be sterile (Krienert, Walsh, & Lech, 2014;Rodrigues, Lopes, & Conley, 2019). The Secretary of the East Lombok District Health Office explained that: Prevention efforts can also be carried out by ensuring the safety standards of blood and blood products through an HIV test. Policies are realized in three categories: legislation, social service programs and taxation. Based on this category, it can be stated that every legislation, law or regional regulation concerning social problems and life is a form of social policy but not all social policies are legislation.

Government Program to Hinder the Spread of HIV/AIDS
The HIV/AIDS prevention program based on Regulation of the Minister of Health Number 21 of 2013 is carried out practically by the government with the participation of the wider community. Government policy requires comprehensive and sustainable management of HIV/AIDS for all levels of society (Noviana, Suwitri, Supriyono, & Jati, 2019).
To understand government programs tackling the spread of HIV/AIDS among migrant workers, the Head of the East Lombok District Health Office explained that: Implementing HIV/AIDS management programs includes: a) Promotion and promotional activities are carried out through the regional government and the community by increasing communication, education and information. b) HIV diagnostic tests are carried out to prevent as early as possible the occurrence of transmission or an increase in the incidence of HIV infection. This HIV diagnostic examination is carried out based on the principle of confidentiality, namely that the results of the examination must be kept confidential and can only be disclosed to the person concerned, the health worker in charge, the next of kin, sexual partners and other parties by statutory regulations and HIV counseling and testing by medical personnel who are trained and understand HIV disease. c) Activities are carried out to care for, support, treat and assist people with HIV/AIDS based on a clinical approach, family, peer support categories, professional organizations and the community. d) Social rehabilitation activities involve mental, physical, social, intellectual and skill guidance. Social guidance includes exchanging opinions, providing motivation and support and providing counseling. Mental and spiritual guidance including religious lectures, spiritual guidance and manners. Guidance on abilities or skills including work training and work practices. It is necessary to explain that IMW are Indonesian citizens who work abroad in an employment relationship for a certain period by receiving wages (Martyn, 2018). However, the term IMW is often connoted with manual workers. Women migrant workers are often called women workers (Koh, 2020). According to law, the IMW is defined as every Indonesian citizen who fulfills the requirements to work abroad in an employment relationship for a certain period by receiving wages (Indonesia Republic, 2004). According to the law on the 18/2017 about the protection of Indonesian migrant workers, former migrant workers return to their country of origin due to the expiration of the work agreement period, the termination of employment before the end of the work agreement period, a war, natural disaster or disease outbreak in the destination country, a work accident death in the destination country or paid leave or deportation by the local government (Supli, Sari, & Retno, 2019 Migrant workers are not only at risk of getting HIV/AIDS but also of receiving sadistic treatment because of being abused or raped by their employers. Many male migrant workers work in the field for example, in the construction sector. Meanwhile, women usually work as housekeepers or housemaids. Migrant workers working abroad are vulnerable to HIV/AIDS transmission because this infectious disease is deadly. Migrant workers still have biological needs that must be met. They work abroad in various regions of the country. They mingle with all kinds of people and if they reach the stage of having sex, it will make these migrant workers vulnerable to contracting HIV/AIDS. According to the East Lombok District AIDS Commission: Risk factors for HIV/AIDS transmission among migrant workers include not being open to their husbands or partners mainly related to fear of marital conflict and loss of social and financial support. Female migrant workers are unable to discuss the use of condoms with their partners due to secrecy. The reasons for not disclosing to friends, family and other community members are mostly fear of rejection and discrimination in society because of the stigma associated with HIV. Explanations about unprotected sex in the context of disclosing HIV status show that male sex is predominant over female sex influencing decision-making to practice safe sex. According to some female migrant workers, being obedient and good can reduce the risk of HIV transmission (Ayuttacorn et al., 2019). This is called the iceberg phenomenon where the number of reported HIV/AIDS cases does not reflect the number of cases in the community (Hardisman, 2009). These undetected cases represent a link in the spreading of HIV/AIDS in society, primarily through unprotected sexual intercourse (Moyce & Schenker, 2018). This is due to the absence of screening for migrant workers returning to their regions and the existing cases will be identified if the patient complains and goes to a health facility so that new officers can trace cases and contacts that sufferers have made (Porru & Baldo, 2022). Officers experienced difficulties because more sufferers believed that it was inappropriate to discuss their sexual activity. Koesrianti (2016) is mostly concerned with Lombok culture especially what is known as a thousand mosques. This made it difficult for officers to cut the risk chain for HIV/AIDS transmission.

CONCLUSION
The increase in HIV transmission and its prevention among migrant workers from Lombok does not have sufficient knowledge. Similarly, services that provide HIV/AIDS information and their impact are relatively limited. Various reasons include the inability to speak the local language, cultural misunderstandings and the high cost of treatment for foreigners and their immigration status, especially illegal migrant workers. These factors make migrant workers vulnerable to STDs and HIV/AIDS. Most cases of HIV and AIDS occur in high-risk groups that are marginalized. Government policies through HIV and AIDS prevention and control programs require consideration of religion, customs, prevailing societal norms and health considerations. The transmission and spread of HIV and AIDS are closely related to risky behavior. Factors for HIV/AIDS transmission among migrant workers include risky sexual relations, sexual violence and sexual relations with people who are infected with HIV without protection such as visiting commercial sex workers' premises or companies. Lower-class society does not stigmatize or treat people with HIV/AIDS.

RECOMMENDATIONS
a) It is suggested that in the future, government policies will become a necessity to address the problems of migrant workers by developing health and sexual reproduction programs for them. b) Therefore, the control policy must consider the factors influencing this behavior: religious considerations, customs, prevailing community norms and health considerations. These factors must be included in HIV and AIDS prevention and control programs. c) The government must implement a policy to increase communication, information and outreach about reproductive health and HIV/AIDS outreach to first-time workers mainly migrant workers.

FUNDING
This research is supported by the Faculty of Social and Political Sciences, Universitas Muhammadiyah Jakarta, Indonesia with the total value of the fund standing at IDR15,000,000 (Grant number: 261/UMJ/FISIP/N16.2/2022).