In his November 7 posting, Dr. Ivan Wolffers of the Free University
of Amsterdam reported on HIV among studied commercial sex workers (CSWs)
in Indonesia (message not available). He wrote that the prevalence was "a little over 1% HIV-infection
in Jakarta and 0% in ... Bandung and Surabaya."
He also offered words of caution:
"These data are not immediately enough to reassure Indonesians that
the pandemic will not hit their country, because we are still looking into
important details like: Have we sampled the right groups of sex workers? How is their mobility and what are the reasons for their high mobility?"
I agree with his call for caution.
In June, 1989 when the Ministry of Public Health in Thailand started
their then biannual sentinel surveillance program, the prevalence of HIV
among non-brothel based CSWs (perhaps similar to those working in Indonesia)
was 0.7%. One year later, the prevalence was 2.7%, and one year thereafter
in June, 1991 the prevalence was 6.7%. The rise was even more dramatic
among brothel-based CSWs, going from 4.8% in June 1989, to 14.0% in June
1990, and to 22.1% in June 1991. Was this rapid rise unique to Thailand,
or could it occur in among CSWs in Indonesia as well?
Based on comparable patterns among CSWs in Myanmar, Cambodia and areas
of India, it seems prudent for government officials in Indonesia to plan
for the worst. HIV has the power and ability to gain hold in most societies,
spreading as it does through sexual transmission and via contaminated blood.
A quality sentinel surveillance program that searches for infection in
likely spots will do much to help prepare Indonesia for the coming epidemic.
To gain support and compliance, the risk groups being approached should
be sampled anonymously, getting specimens for analysis in streets, bars
and shady places where sex is exchanged for money or drugs. The importance
for surveillance is not to get names or addresses of those included in
the sample, but rather to find the reservoir of infection, so as to warn
the general society of the impending epidemic. In this regard, sentinel
surveillance is different from personal screening, where individual identification
is important so that individual action can be taken.
Indonesia would do well to hire older former addicts or prostitutes
to serve as bridges to current addicts and CSWs, giving them the opportunity
to assist the government in finding the source of the epidemic.
Such "bridge" workers could use non-invasive saliva collection devices
to gather samples from street workers, bar girls, and drug addicts, using
only numbers to identify the sample, the risk group, and the general location
where the specimen was collected. Many studies have documented the accuracy
of saliva tests. A listing of all published studies to date can be found
at the UCLA Department of Epidemiology website (http://www.ph.ucla.edu/epi/saliva.html).
Likely after casting a wider net into darker corners, public health officials
in Indonesia will have a clearer idea as to where the epidemic is and where
it is going.