BUILDING CRITICAL AWARENESS THROUGH HIV AND AIDS MANAGEMENT POLICY AT SUBDISTRICT AND VILLAGE LEVEL

The number of PLWHA in Jember Regency has been increasing every year from 2004 to 2016 always, hence HIV/AIDS prevention must involve the community, not just relying on programs from the Department of Health or KPAD. Jember Regent’s policy on HIV/ AIDS Management Team at Subdistrict and Village Level strategically involve all components of the society. Society’s participation was not limited to physical participation but extended to critical awareness. This is a descriptive analytic study about logical thinking on fostering critical awareness on HIV/AIDS through subdistrict and village HIV/AIDS team regulated by Jember’s Regent. Policy analysis was done through Triangle of Policy Analysis theory which includes: context, content, process and actors. The result showed that Jember Regent’s policy on HIV/AIDS prevention teams at subdistrict and village level was very effective to foster community’s critical awareness in HIV/AIDS preventive programs at Jember Regency.


Introduction
 Correspondence Address: Jl. Kalimantan I/93 Jember.Email : dewiirokhmah@unej.ac.id pISSN 1858-1196 eISSN  HIV is a virus spread through certain body fluids that attacks the body's immune system, specifically the CD4 cells, often called T cells.Over time, HIV can destroy so many of these cells that the body can't fight off infections and disease.These special cells help the immune system fight off infections.Untreated, HIV reduces the number of CD4 cells (T cells) in the body (Akinsola, 2017;Chinyama, 2017).
This damage to the immune system makes it harder and harder for the body to fight off infections and some other diseases.Opportunistic infections or cancers take advantage of a very weak immune system and signal that the person has AIDS (Kaur, 2017;McRobie, 2017).
The Ministry of Health of the Republic of Indonesia reported that the cumulative incidence of HIV/AIDS from the early investigation in April 1987 until June 2014 was 55,623 cases.There was 29,882 male and 16,092 female while the remainder's sex is unknown.
According to the risk factors, the highest case was found among heterosexual (34,187 cases), followed by IDU (8,451 cases), and the third highest was homosexual and bisexual (1,298 cases).National AIDS Management Commission (KPAN) believed that in the next decade, new transmissions would be dominated by sexual transmission, contributing 70% of new transmissions.Due to this epidemiologic trend, high risk sexual behavior leading to HIV/AIDS transmission must be recognized in order to improve case management efficiency and to control the impact of HIV/ AIDS on other sectors.The National Strategy and Action Plan on HIV/AIDS Management 2010-2014 emphasized that for HIV/AIDS, civilians must support AIDS management by the government.Organized community groups, including people living with HIV/AIDS (PLWHA) and key populations, NGO, social institution, professional workers, professional organizations, and higher education institutions, could act as the major initiators and actively aid AIDS prevention in Indonesia, in the form of policy-making, planning and implementation of each program, monitoring and evaluation (Demartoto, 2013).
The number of PLWHA in Jember Regency has always been increasing every year since 2004 to 2014.Based on the report by Jember Regency Public Health Office, the number of HIV/AIDS cases has reached 1,589 until December 2014.This number was the third highest in East Java after Surabaya City and Malang Regency.
Pertaining to the situation above, an effort to manage the HIV/AIDS in Jember Regency needs to involve various parties and sectors.Strong legal protection in the form of local government policy is needed.The policy mentioned was managing HIV/AIDS at the level of Subdistrict and Village area.The policy is hoped to be able to optimize community's potentials and resources at Subdistrict and Village level.
Healthcare policies include several efforts and decision making which include medical technical aspects and healthcare services, as well as the involvement of actors at individual, government's organization or institution, private, NGO, and other community representative scale that could affect health (Gani, 2015).Policies related to sexually transmitted disease and HIV/AIDS prevention must be implemented at Province, Regency/ City, Subdistrict, and Village level (Sulaeman, 2015).
Due to the high incidence of HIV/ AIDS in Jember, HIV/AIDS management must involve the community, not relying solely in Public Health Office's programs or Jember KPAD.In Subdistricts and Villages potential for HIV transmission, a task force for HIV/AIDS prevention and control was formed and led by head of the Subdistrict and the Village.The main duty was to encourage the community to contribute in HIV/AIDS prevention and control designed by Regency/ City KPA.Therefore, Jember Regent's policy, as stated in Jember Regent's Decree number 188.45/131.1/012/2014 on HIV and AIDS Management at Subdistrict and Village level in Jember, strategically involved the participation of all community's components.
The participation was not limited to physical participation, but also the critical awareness because community participation would improve the policy's efficiency and effectiveness.Through community participation, a collective action could be founded which would be a potent aid in policy implementation and resolving health problems.Moreover, the health policy was expected to cater to community's belief and trust on the community's self-reliance on health issues.

Method
This was a qualitative case study aimed to analyze the policy of Jember Regent Number: 188.45/131.1/012/2014 on HIV/AIDS management team at Subdistrict and Village level, in building community's critical awareness toward HIV/AIDS prevention program.In this study, the "case" selected was Jember Regent's Decree Number: 188.45/131.1/012/2014 on HIV and AIDS management team at Subdistrict and Village level that was considered as a specific intervention in HIV/AIDS prevention in Jember Regency.
The activities in this study could be divided into several phases.The phases included research concept development and case determination, data collection, data analysis and case writing until the conclusion was reached.This study utilized primary and secondary data.
The data was analyzed using framework approach which is a method commonly used in social and healthcare policy researches.This framework is appropriate to analyze large amount of data in a limited amount of time.The research steps using this framework was: (1) mapping thematic framework -identifying key issues, concept, and theme from existing data; (2) developing index -developing sequence of codes to be applied to text/data available to ease interpretation; (3) charting -organizing data according to thematic framework to elaborate on the relationship between themes and to be developed into a diagram; (4) mapping and interpreting -using the diagram to define the concept, to map the variation of determined themes, and to find the relationship between themes in order to provide explanation on the research findings concerning development of critical awareness on HIV/AIDS through Jember Regent's policy on HIV/AIDS management team at Subdistrict and Village level, through Triangle of Policy Analysis theory by Buse (2005) in Akinsola ( 2017) which includes: context, content, process, and actor.
Healthcare policy triangle is the simplest approach for complex association arrangement.This triangle assumes that the four factors could be considered separately.In actuallity, the actors could be influenced (as an individual or member of a group/organization) in the context where they lived and worked; the context could be influenced by several factors such as instability or ideology, history and culture; as well as the policy formulation process, how issues became a policy agenda and how issues became valuable and influenced by the actors, their position in the power structure, and their own norms and expectations.The content of a policy reflect parts or all of these components.

Results and Discussion
According to Buse (2005) in Akinsola (2017), context is systematic factors -politic, economy, social or culture, at national or international level, which affect health policy.There are several methods to classify those factors, but Leichter presented that there were 4 factors in the context of health policy.The first is situational factor, a non-permanent or special state that could affect policies.These are known as focusing event.
This study found that the context classified as situational factor or focusing event was the high incidence of HIV/AIDS cases in Jember Regency that placed this Regency to be one of 78 Regencies/Cities receiving intensive attention from KPAN.According to the Office of Population and Civil Registration in 2014, Jember Regency consisted of 32 subdistricts with an area of 3,293.34km2; 86.9% of the area consisted of forest, farms/rice fields and plantations areas, while the remaining 13.1% were villages, swamp ponds, shrubs, and badlands.The real population of Jember Regency in 2014 was 2,590,516 people.High population density was found among subdistricts located in cities.The report from Health Office in 2014 on HIV/AIDS Management Programs in Jember Regency stated that the first case was reported in 2004, and the number increased annually until 1,433 cumulative cases in August 2014.
The main transmission route among all reported PLWA was from heterosexual transmission, 1,232 cases (85.97%).This shows that transmission occurred through sexual intercourse between male and female, including between commercial sex workers and their customers.It was predicted that more than 3 million males in Indonesia were regular customers of female sexual workers (approximately 2,324,660-3,981,180).The situation was most likely caused by illegal prostitutions in the community.The possibility of men to buy sex was high because there was no special localization label, hence they had no fear of stigmatized as sexual workers' customer.A study by Rokhmah (2015) found that the policy of safe-sex approach through PMTS program was ineffective in reducing sexuallytransmitted disease (STD) and HIV/AIDS prevalence among homosexual community in Jember.The evidence showed that new cases from homosexual community is rising in number and the age tend to be younger.This condition is worsened by the result of indepth interview which found that there were various obstacles in socialization of safe sex program to the homosexual community, such as pleasure and comfort issues.Therefore, highrisk behavior such as multiple sexual partners without condoms was still frequent.
Vertical and horizontal mobility of Jember's population, supported by the increasing use of transportation and communication technologies, led to an increase of high-risk sexual behavior which facilitate HIV/AIDS transmission.The closure of Puger localization inadvertently resulted in new 15 illegal localizations, resulting in an increase of HIV/AIDS transmission through unsafe sexual contact with illegal sexual workers.
The other consequence of heterosexual HIV/AIDS cases is the increased transmission to housewives and from mother to their infants.Mothers infected with HIV could transmit HIV to their offspring during pregnancy or during labor (Elisa et al, 2012).The data on HIV/AIDS cases in Jember, based on the profession, showed that the first rank was housewives, totaling 342 cases (23.87%), followed by entrepreneurs, totaling 283 cases (19.75%), and sexual workers, totalling194 cases (13.53%).Pregnancy would accelerate the onset of AIDS symptoms in seropositive women.It is estimated that 50% of infants born to HIV seropositive mothers would acquire HIV infection before, during, and shortly after childbirth.This happened because housewives with minimal knowledge on HIV/AIDS and were not sexual workers and did not misuse drugs, were infected by husbands who were illegal sexual workers' customers.This is was consistent with Octaviany (2015), who found that there was a significant association between general knowledge on HIV/AIDS among housewives with husbands who work as intercities drivers and the HIV/AIDS prevention program at Tanah Bumbu Regency.The second factor was structural factor, the part of society which is relatively unchanged.This factor involves the political system, system's openness and opportunities for citizens to participate in discussions and policy making.Structural factor also involves economic system, labor base, demographic conditions or technology advances (Buse, 2005in Akinsola, 2017).In this case, the structural factor was the existence of an environment that supports the implementation of policies on HIV/AIDS prevention teams at subdistrict and village levels.The policy's environment is regency-city areas throughout Indonesia with local government authority in accordance to the Law No. 32/2007 on Regional Government which is subject to the applicable laws and regulations.In accordance to the Law No. 32/2007, local governments have developed regional mid-term development plans (RJPMD), Plans and Strategies (Renstra) and Regional Government Work Plans (RKPD) for each Local Government Work Unit (SKPD), especially on health issues, such as local regulations on free medical treatment for local residents, regional financial management, and others.HIV and AIDS control is included there (Helmizar, 2014).
The The content of a policy is the substance detailing parts of the policy.The content of a policy responds to public issues from defense, security, energy, healthcare, education, welfare, etc.The content of regent's decree on HIV/AIDS Mitigation Team at subdistrict and village level consists of team structure, team assignment, follow-up through decision of the subdistrict's and village's head, funding source from regional income and expenditure budgets (APBD) and other legal sources, as well as decision enactment.The basis for this policy was to optimize government function at subdistrict level in HIV/AIDS mitigation programs.The tasks of the HIV/AIDS mitigation team at Subdistrict, Village and Village Levels consists of: 1) Coordinating the necessary actions to mitigate HIV and AIDS established by KPAD.
2) Leading, managing, controlling, monitoring and evaluating the implementation of HIV and AIDS mitigation at subdistrict and village level.
3) Collecting, mobilizing, providing/raising fund and optimizing resources from central, regional, community and overseas aids.4) Coordinating the implementation of duties and functions of each agencies incorporated in team membership.5) Disseminating information on HIV and AIDS prevention efforts.6) Encouraging the formation of citizens/ community groups concerned about HIV and AIDS.7) Monitoring, evaluating and submitting reports periodically to KPAD.
It is hoped that problems at subdistrict level would be forwarded to urban or village level in the form of ADD support.Thus, critical awareness would pay more attention to system and structure aspects as the source of problem.Structural approach avoids victim blaming and further analyze and recognize critically about social, political, economic and cultural structures and systems and their impact on the society related to HIV/AIDS programs.
Critical awareness would create a movement that is based on a complete understanding so that intervention programs would have high sustainability.
Critical awareness is the basis to build collective awareness into group mobilization.People need to understand that they are responsible for their future and they can learn to take control of its direction.Therefore, the issuance of Jember Regent's Decree Number: 188.45/131.1/012/2014 on HIV/AIDS mitigation team at subdistrict and village levels could be used as a basis for the government at the subdistrict and village level to mobilize communities for HIV/AIDS prevention programs.Strong community participation is a key for the program's success.This concept was deemed to be a way to achieve equitable health care.This is in accordance to the study by Kasmini (2014), which revealed that social elements that affect nutritional status of infants in rural areas at Indonesia and Thailand, were 1) citizenship, in the form of active and creative participation, especially from cadres or volunteers 2) social organization such as Posyandu and Toddler Development Center that help government's healthcare programs, social organizations that were very influential on development of nutritional status of children under five.
In addition, according to this policy, the team's task provide opportunities for communities at subdistrict and village levels to engage in HIV/AIDS prevention and mitigation programs in the form of preventive and promotive actions.Community involvement in healthcare program was more focused on the prevention aspect.Therefore, preventive and promotive efforts play important role in healthcare programs in addition to curative and rehabilitative efforts.This was supported by Simbolon (2014), who revealed that the existence of Public Health Insurance (for poor families) could overcome the problems of Maternal and Child Health and nutrition problems (stunting); it is thus expected that healthcare services focus more on promotive and preventive efforts.
The policy process is a way to initiate, expanding, strategizing, negotiating, communicating, implementing and evaluating policies.The most commonly used approach to understand policy process is using ' heuristic stage' .In this method, the policy process is divided into a series of stages as a theoretical tool, a model that does not necessarily show what actually happens in the real world.
National HIV/AIDS Strategy and Action 2010-2014 stated that decentralization and regional autonomy aim to improve the community's condition, including the healthcare sector.Regional Autonomy provides an opportunity for local governments to plan and implement programs needed by the region.It also provides the flexibility to respond to HIV and AIDS.For example, in 2007, with the aim of controlling the number of cases of HIV/AIDS, Jember Actors or policy stakeholders are individuals or groups directly related to a policy that may influence or be influenced by the decision or policy.These policy stakeholders may consist of a group of citizens, labor organizations, street vendors, journalist communities, political parties, government agencies, and others.The actors in Jember Regent's Decree Number: 188.45/131.1 012/2014 on HIV/AIDS mitigation team at the subdistrict and village levels were HIV/AIDS mitigation teams at subdistrict and village level which consisted of community leaders, government and society.HIV/AIDS mitigation teams at the subdistrict level included head of the subdistrict, head of stakeholders, religious leaders and community leaders, NGOs, PIKM cadres and PIK-R cadres, religious instructors, family planning officials and subdistrict social workers.At village level the team consisted of village chief, and social and community empowerment chief, chief of Village Working Group, chief of Environment, Family Planning cadres, religious figures, community leaders, WPA representatives and LKB cadres.
Active participation of these community components was hoped to enable communities to independently access the healthcare services necessary and available in their areas (related to HIV and AIDS prevention).Public participation in the implementation of HIV/ AIDS policies and programs cannot be separated from the understanding that healthcare is the right of citizens that must be fulfilled by the state regardless of social and economic status (Praptorahardjo et al, 2014).This was in accordance to the results by Umayana & Cahyati (2015) which revealed that there was a relationship between family & community leaders' support and the active participation of the population in activities of Posbindu PTM (Integrated Non Communicable Disease Development Post) at Semarang City.
The most important thing to understand was that in the implementation of Regent's Decree No.188.45/131.1/012/2014 on HIV and AIDS mitigation teams at subdistrict and village levels was that KPAD is the team leader who play an important role from the policy making process, implementation until monitoring and evaluation.Therefore, KPAD of Jember Regency should have adequate capacity and resources to implement this policy.Advocacy to local governments should be increased to ensure that the AIDS Commission (KPA) in the area can be strengthened and provided with adequate funding and other forms of assistance (National AIDS Commission, 2008).At least Jember Regency can learn from Sorong regency in advocating HIV and AIDS programs.KPAD Sorong Regency did not conduct formal advocacy with key stakeholders (BAPPEDA and DPRD), thus there was a difficulty in receiving adequate budget allocation to implement HIV/ AIDS prevention and mitigation efforts in Sorong Regency (Mitsel et al, 2015).This was in accordance to a study by Choirunisa (2014), which revealed that health financing remains an important factor although increasing financing alone is not enough to improve health status.

Conclusion
The policy of Jember Regency Government in Jember's Regent Decree No. 188.45/131.1/012/2014 on HIV and AIDS mitigation teams at subdistrict and village level could have a positive impact on the quality of life of Jember people, especially in HIV and AIDS prevention.Reviewed from the context, this policy is an evidence that the government understands that the spread of HIV and AIDS in Jember Regency is a serious problem, and supports the Regent's Decree No. 2 of 2014 on HIV/AIDS Prevention and Mitigation in Jember Regency, Regent's Decree No. 188.45/131/012/2014 on Jember Regency AIDS Commission and Regent's Decree No. 188.45/141/012/2014 on PAKJANIS KPA Jember Regency.The content aspect includes team structure, team tasks, follow-up through Decree of the Subdistrict Head and decision of the Village Head, source of funding from APBD and other legitimate sources and enactment of the decree.In the process aspect, the issuance of Jember's Regent Decree on HIV and AIDS Response Team at Subdistrict and Village Level cannot be separated from advocacy that has been done by KPAD Jember to local government and support from related institutions.From the actor aspect, in the appendix of the decree, there were HIV and AIDS mitigation teams at subdistrict and village levels which included community leaders, government and community.