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Frerichs, R.R. HIV in Indonesia.

SEA-AIDS Network, November 7, 1996

R.R. Frerichs Posting

While few doubt that HIV is spreading in Indonesia, the extend of the epidemic remains unknown. In the floury of newspaper articles recently shared with sea-group members, Dr. Kartono, former chairman of the Indonesian Medical Association, summarizing the problem by stating, "It's not because doctors are unable to diagnose the virus, but that the virus is very good in disguising its symptoms." A similar point was made earlier by Dr. Meiwita B. Iskandar, Director of the Center for Health Research of the University of Indonesia, when she explained the discrepancy between the low number of HIV/AIDS cases reported by the government and the much better estimates of her institution: "There has been a low number of reported HIV-positive cases because they are detected after they develop into AIDS." A silent epidemic is hard to observe, and even harder to control.

At this point, Indonesia needs first to establish a comprehensive sentinel surveillance program that regularly samples groups at high risk of infection, likely at 6 month intervals. Sentinel sites should be distributed throughout the country, and at least in all of the larger cities. Included at minimum should be commercial sex workers, persons attending STD clinics, and intravenous drug users -- groups that are infected at the front end of the epidemic and serve as warning of the impending epidemic for the remaining society. Once these groups are found to be infected, the surveillance program should be expanded to such lower risk groups as women attending antenatal clinics, and military and police recruits. To test for HIV antibodies, the surveillance program should use serum from these groups that already collect blood for other purposes. Saliva is a more logical testing medium for street groups such as commercial sex workers and intravenous drug users, where non-medical personnel may be used to gather specimens. At the clinical level, physicians around the country should be equipped with rapid test kits that have reasonable shelf life, so that they can quickly screen for HIV those patients who they think might be infected. Finally, people in high risk areas should be permitted to screen themselves with home tests (termed HIV indicators) purchased in the private sector, and if found to be positive, encouraged to seek further confirmatory testing by their physician.

While surveillance for HIV is helpful, more information also needs to be gathered via rapid surveys to assess HIV/AIDS knowledge of the people, and the occurrence of endangering sexual and injection practices. Such surveys are essential for community based planning of intervention or prevention programs, and provide the basis for subsequent evaluation studies.

If HIV becomes more common in a region (as determined by the sentinel surveillance program), the local surveys could also gather saliva specimens to test for the prevalence of HIV infection, bringing sharper focus on the movement of the virus in the general population. Training for doing such surveys is currently being offered by the University of Indonesia at Depok, and should be extended nationwide, or at least to all of the larger municipalities. Once such aggressive, multifaceted testing and survey programs gets underway, the full extent of the epidemic and the susceptibility to the epidemic will be revealed and the hard work of preventing further transmission can progress at both the individual and community levels. Such awareness will also help generate support for broader health education campaigns, aimed at the general society, and specialized intervention campaigns focusing on high risk groups such intravenous drug users, commercial sex workers and people engaging in anal intercourse.

Indonesia need only look north at India, Thailand, Myanmar, and Cambodia to see the devastating effects of the epidemic. HIV/AIDS is not inevitable, especially for those countries willing to use all available means (including widespread testing and aggressive health education programs) to halt viral spread. Information, while not always easy to gather, is essential if the society is to be mobilized for action.