Figures don't lie...

The HIV epidemic seems to be built upon figures. Funding, prevalence, case reports, ages, as well as CD4 counts and viral loads. And too often we make crucial decisions based upon less than accurate figures.

Case in point: the decision to start antiretroviral therapy is often dependent upon the CD4 count. We meet the criteria if our CD4 count is less than 200. Nice and simple. But as John Bartlett and Joel Gallant of Johns Hopkins note in 'The Medical Management of HIV Infection', if our measured CD4 count is 200 we can be 95% confident that the actual value is between 118 and 337! This is never discussed in the current hot debate over changing the criteria to allow starting at 350, but it does seem quite relevant. Of course, we are advised never to take any decision based on only one test, but given that many in Indonesia find difficulty in affording one CD4 test a year, few people are able to follow that advice.

How about bigger decisions, such as by the national policy makers? The national estimates are based on a rigorous build up from each of more than 450 districts and municipalities in Indonesia. They all (we are told) estimated the number of sex workers, their clients and their partners, the number of gays and waria, the number of drug users and so on, then estimated the prevalence in each 'risk group'. Difficult to argue with the figures. Trouble is, the total (around 270,000), seems rather low. Malaysia, with around one tenth of the population of Indonesia, but in many other ways surely quite similar, has diagnosed around 70,000 cases of HIV infection, and they estimate this as half of the total. Thus it does not seem to be unreasonable to guess that Indonesia would have at least five times the number of cases as Malaysia. That would be 350,000. So far, no one seems to have found the flaw in this logic.

Of course, at least we can rely on the reported figures, no? Trouble is, as Dr Adi Sasongko (a long-term AIDS activist) recently pointed out, no cases have been reported from Indramayu in West Java. Indramayu is notorious as the source of many women reputedly sold by their families for sex work in Batam. But when they are found to be HIV-positive during raids there, they are returned back to their homes in Indramayu. Everyone 'knows' they are there; but they are not officially counted.

Similarly, while the number of reported cases in Papua province has increased 2.5 times to 2,382 since it split from West Papua in 2006, the number of cases reported from West Papua has not changed by even one case; it remains at 58! Perhaps congratulations due to the West Papua administration for totally controlling the epidemic?

Finally, the Indonesian CDC publishes the total reported cases every quarter. The total at December 2008 was 16,110. Around only 5% of the estimated total. But wait! The same CDC also occasionally reports the number of people with HIV on treatment. The total reported as 'followed in HIV care' as at December 2008 was 36,628! There seems to be a discrepancy, but no one seems to notice it.

The figures clearly don't always tell the truth...

Babé