Building partnerships to address the HIV epidemic

O r i g i n a l A r t i c l e
Singapore Med J 2008; 49(5) : 376
Building partnerships to address the HIV
epidemic
Chua A C, Leo Y S, Lee C C
ABSTRACT
InTRODuCTIOn
Introduction: Batam is one of the islands The Riau archipelago is one of the provinces in Indonesia
comprising the Riau Province in Indonesia, and and bordered by three countries: Malaysia, Singapore and
is closest to Singapore. It is a popular destination Vietnam. Geographically, the Riau islands are located
of many Singaporeans. Surveillance reports on the international trading route, and in Indonesia, this
among commercial sex workers conducted in province is the second largest tourism destination for
Batam showed the prevalence rate of human Singaporeans and Malaysians.(1) Batam, together with
immunodeficiency virus (HIV) is 16.2 percent. At Bintan, Karimun, Natuna, Lingga Regencies and Tanjung
the end of 2006, the total number of HIV-infected Pinang, make up the Riau Province in Indonesia; it is the
Singaporeans was 3,060, the majority being closest to Singapore, a mere 20 km away or 20 min by
infected via heterosexual transmission. The aim ferry. Batam has a land area of 415 km2, and its population
of the Indonesian government is to rapidly scale has risen during the last ten years from 106,667 in 1990
up HIV treatment to those needing it. One of the to 439,971 in 2000.(1,2) According to the 2006 UNAIDS
factors critical to the rapid scale-up is healthcare report on the global acquired immunodeficiency syndrome
worker training.
(AIDS) epidemic, there are currently 176,000 people
living with human immunodeficiency virus (HIV)/AIDS in
Methods : An intersectoral collaboration Indonesia. The prevalence rate among adults aged 15–49
addressing the issue of HIV care and treatment with years is 0.1%.(3) Surveillance reports among commercial
a hospital in Batam was created. The first activity sex workers conducted by the local department of health
of the collaboration was a two-day HIV training in Batam showed that in 2006, the prevalence rate of HIV
course conducted in February 2007. The aim of the is 16.2%, an increase from 3% in 2000.(4)
course was to provide a basic understanding of HIV,
Because of its proximity, the Riau Islands is a
as well as knowledge on common opportunistic popular destination among Singaporeans. A recent
infections that may present to a general hospital survey conducted by Action for AIDS, a Singapore non- Department of
Medicine,
or clinical setting.
governmental organisation involved in HIV prevention, Division of
revealed the demographics of Singaporean men who Infectious Diseases,
National University
Results: 34 doctors from 23 institutions in Batam engaged in high-risk sexual activities overseas, in Hospital,
5 Lower Kent Ridge
and three doctors from two hospitals in the Riau particular those in the nearby Riau Islands.(5) The survey Road,
Islands attended the two-day HIV training course. was conducted between July 2005 and September 2005 Singapore 119074
The participants found the training very useful and on a sample of 979 Singaporean male travellers at ferry Chua AC, MD
Consultant
highly relevant.
terminals and hotels in the Riau Islands, including Batam.
Results showed that about 40% of the survey participants Department of
Infectious Diseases,
Conclusion: This first HIV training provided a had travelled to the Riau Islands 1–2 times in the last six Communicable
foundation to build on further HIV education.
Disease Centre,
months, with a mean average stay of about two days. Tan Tock Seng
It is our belief that through the HIV training 70% of the respondents said they were in the Riau Islands Hospital,
Moulmein Road,
programme, there will be more awareness of HIV to have sexual intercourse with a girlfriend and/or with Singapore 308433
among the various medical institutions in Batam. commercial sex workers. Close to 70% of the respondents Leo YS, MRCP,
As the HIV epidemic knows no borders, working said they never or rarely use condoms when they have FRCP, FAMS
Clinical Director and
with neighbouring countries is one strategy that intercouse there. Sen et al noted in their review on the Associate Professor
deserves attention.
rising trend of sexually-transmitted infections (STI) and Lee CC, MRCP,
HIV infections in Singapore, that the Riau islands follows FRCP, FAMS
Senior Consultant
Key words : acquired immunodef iciency only Singapore as the source of primary contacts of
syndrome (AIDS), health education, human patients diagnosed with gonorrhoea.(6)
Correspondence to:
Dr Arlene C Chua
immunodeficiency virus (HIV), infectious disease,
At the end of 2006, the total number of HIV-infected Tel: (65) 6772 4033
sexually transmitted disease
Fax: (65) 6779 4112
Singaporeans was 3,060, with the majority being infected Email: arlene_chua@
Singapore Med J 2008; 49(5): 376-379
via heterosexual transmission.(7) As the HIV epidemic nuhs.edu.sg

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Singapore Med J 2008; 49(5) : 377
knows no borders, working with neighbouring countries is National Healthcare Group (CDC-TTSH and NUH) and
one strategy that deserves attention. The provision of HIV Budi Kemuliaan Hospital on December 15, 2006 in
care and treatment in resource-limited settings is rapidly Batam, Indonesia. The memorandum of understanding
expanding. In Indonesia, anti-retroviral treatment (ART) expresses the interest of both parties for collaboration
has been subsidised by its government since August in infectious disease training and education, provision
2004. There are 25 designated HIV referral hospitals of bilateral exchanges of information with the aim of
throughout Indonesia.(8) The aim of the Indonesian supporting and improving patient care delivery, as well
government is to rapidly scale up HIV treatment to those as exploring mutually beneficial collaboration in the area
needing it. One of the factors critical to the rapid scale-up of research. Focus group sessions were held with local
is healthcare-worker training. HIV training is required by general practitioners. One of the identified needs was the
healthcare workers who are faced with patients with HIV lack of awareness and training in HIV management among
infection. This is one of the objectives of this intersectoral the local general practitioners in Batam and surrounding
collaboration.
Riau Islands. The first activity of the collaboration was a
two-day HIV training course conducted in February 2007.
MeTHODS
The aim of the course was to provide a basic understanding
In May 2006, the National University Hospital (NUH), of HIV as well as knowledge on the common opportunistic
Singapore, was invited by the World Health Organisation infections that may present to a general hospital or clinical
team in charge of HIV monitoring and surveillance in setting.
Indonesia, to join them in a site visit to Budi Kemuliaan
Hospital in Batam, Indonesia. Since August 2004, ReSuLTS
the Indonesian government has provided subsidised 34 doctors from 23 institutions, including hospitals,
ART. There are an estimated 11,806 HIV patients being clinics, the local Ministry of Health office in Batam,
followed-up, as of September 2006. The total number of and three doctors from two hospitals in the surrounding
patients who have received ART in Indonesia is estimated Riau Islands, attended the two-day HIV training course.
to be 8,084.(8) Budi Kemuliaan Hospital is one of the 25 The list of the hospitals and clinics taking part in the
designated referral hospitals for HIV care and treatment course are listed in Table I. Topics in the HIV training
in Indonesia and serves the surrounding Riau Islands. were: epidemiology of HIV including local, regional
There are 118 patients being actively followed-up in the and international data; pathogenesis of HIV; voluntary
hospital, and as of July 2006, 52 patients were receiving counselling and testing for HIV in Batam, Indonesia;
ART.(4) One of the challenges of local doctors taking care introduction to the continuum of care for HIV patients
of HIV patients is the lack of experience and expertise in Batam; prevention of maternal to child transmission;
in HIV medicine, including management of opportunistic ART; tuberculosis and HIV; chest radiograph findings and
infections. After this initial visit, both Budi Kemuliaan pulmonary manifestations of HIV-related opportunistic
Hospital and the NUH mutually expressed their interest in infections; neurological manifestations of HIV-related
forming a collaboration that would be beneficial to both opportunistic infections; gastrointestinal opportunistic
parties.
infections; and dermatological manifestations of HIV-

Through the National University of Singapore (NUS) related infections. Speakers were consultants from CDC-
Leadership in Academic Medicine Mentoring Programme, TTSH, NUH and Budi Kemuliaan Hospital. Participants
a small fund was granted to support this initiative to build received six CME credits for the course, endorsed by the
and develop an intersectoral collaboration between the Indonesian Medical Association.
academic (NUH), public (Communicable Disease Centre
A pre-test was conducted to assess the baseline
[CDC]-Tan Tock Seng Hospital [TTSH], Singapore) and knowledge of HIV among the participants. After the
private non-governmental (Budi Kemuliaan Hospital) two-day training, a post-test was conducted to assess
organisations. This was co-funded by the Department of understanding of the lectures given. The test consisted of
Infectious Diseases, TTSH.
15 multiple-choice questions covering the topics presented

In June 2006, the medical team from Budi Kemuliaan on HIV as detailed above. Pre-test results showed a mean
Hospital visited Singapore for a site visit of both NUH and score of 4.10 (range 1–6) and post-test results revealed an
TTSH, where they were shown the care and management improved mean score of 7.04 (range 4–9). The participants
of HIV patients in Singapore. Subsequent meetings were found the training very useful and highly relevant, giving
held discussing details of collaboration and eventually an average score of 4.47 (5: excellent; 4: very good; 3:
a memorandum of understanding was signed by the good; 2: unsatisfactory; 1: poor).

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Singapore Med J 2008; 49(5) : 378
Table 1. List of institutions who participated in the HIV
the formal lectures and training, short-term postings for
training course
Indonesian doctors to CDC-TTSH or NUH as observers
Batam
RS Elizabeth

RS Harapan Bunda
were planned. Long-term plans also include possibilities

RS Otorita Batam
for medical research that are mutually beneficial to both

RS Budi Kemuliaan

RSUD Batu Aji
countries.

RS Awal Bross

It is our belief that through the HIV training

RS Harapan Bunda

PKM Sei Panas
programme, there is more awareness of HIV among the

PKM Bulang
various medical institutions in Batam. Aside from the

PKM Baloi Permai
medical management of the HIV infection, there is also

PKM Sei Pancur

PKM Sekupang
more awareness and understanding of the social aspects

PKM Sungai Panas
of the infection. Fear and stigma remain one of the main

PKM Sei Lekop

PKM Sei Pancr
barriers to HIV care and treatment from society as well as

Klinik Ginjal RA Habibibie
from medical personnel. Knowledge that treatment for HIV

Klinik McDermott

Klinik Prima Dati
is available can help transform public attitudes about HIV.

Klinik Kimia Farma
As a follow-up from the first module, participants were

KF Kampung Utama

IDI Batam/Sagulung Clinic
asked to bring medical cases and non-medical problems

Din Kes Kota Batam (government)
that they encounter in their institution to be discussed at

Yonif 134 (military hospital)
Tanjung Balai Karimun
RS Umum Daerah
the next module. Another advantage of this collaboration
Tanjung Pinang
RS Angkatan Laut (navy hospital)
is the establishment of a means to refer patients for ART
in Indonesia. Most non-Singaporeans do not have access
RS: rumah sakit or hospital; PKM: pusat khumat medis or poly-
clinic/general clinic; Din Kes: dinas kesahatan or Ministry of to subsidised medical care, and thus, the cost of medical
Health; Yonif: military unit
care and treatment in Singapore can be quite expensive.
Likewise, immigration laws in Singapore do not allow
non-resident non-Singaporeans with HIV infection to
DISCuSSIOn
remain in Singapore. Through our relationship with
This first HIV training provided a foundation to build on Budi Kemuliaan Hospital, our Indonesian patients can be
further HIV education. All participants expressed their followed-up for their HIV infection. Moreover, we are
interest in additional training and follow-up. Discussions able to follow-up on their care as well as provide advice
during the first HIV training included how to ensure patient an complicated medical cases when needed.
confidentiality in settings where this could be difficult;
Ultimately, better care and treatment of HIV patients
e.g. in the military, where military doctors may be forced benefit the whole population. It has been well accepted
by more senior officers to disclose the HIV status of their that in order to control the HIV epidemic, there should
patients. Several doctors expressed concern regarding be a concerted effort on both prevention and treatment.(9)
occupational risk while managing HIV patients, and these Indeed, it is important to emphasise that with effective
were addressed and clarified. In general, the training treatment, there is indirect benefit to the sexual partners.
provided a better understanding and awareness on various According to clinical studies, ART suppresses HIV
HIV issues of concern to the local practitioners.
viral levels in body fluids and has been shown not only

Two more modules of HIV training were planned to increase survival in HIV patients, but also to reduce
for 2007, following the successful first HIV training. The rates of mother-to-child transmission and heterosexual
goal was to have the same participants in modules two transmission.(10) Therefore, ART should be seen as a
and three. Module two covered other topics, such as ART means for both reducing morbidity and mortality among
and its principles; side effects and drug interactions; ART HIV patients, and also for lowering rates of transmission
monitoring; infection control, occupational post-exposure within populations.(11) Data supporting and verifying
prophylaxis, prevention of maternal to child transmission this argument was reported by Fang et al, who showed
and women’s issues; and children and HIV. Module three decreased transmission of HIV after a policy of providing
included topics such as counselling and support to people free ART.(10) HIV infection does not recognise any borders;
living with HIV/AIDS. The first HIV training module was and when we speak of populations at risk, we need to see
conducted in English as most of the participants are familiar beyond populations within countries. It is important to
with the English language. However, based on feedback reiterate the proximity of Singapore and Indonesia, and
received, a Bahasa Indonesia speaker was included in the the number of travellers that cross these two countries on a
subsequent modules to enhance the understanding of the daily basis. We hope that this initiative will be recognised
lectures. In addition, subsequent training modules also as a strategy to address the HIV epidemic and that support
included nurses and other paramedical staff. Aside from in developing this partnership will be maintained.

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Singapore Med J 2008; 49(5) : 379
ACKnOwLeDgeMenTS
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We are grateful for the enthusiasm and collaboration of
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our partners Ms Ibu Sri Soedarsono (Chairman of Batam
2006.
HIV/AIDS Foundation), Dr Dindin Nadim, Dr Danang 5. Lee L. High risk in heterosexual men. 5th Singapore AIDS
Legowo, Dr Fransisca Tanzil, Dr Yamin and Dr Willy
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7. Ministry of Health, Singapore. Update on the HIV/AIDS situation
for the support of A/Prof Paul Tambyah and A/Prof Wong
in Singapore 2006. Available at: www.moh.gov.sg/mohcorp/
Mee Lian through the NUS Leadership in the Academic
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naïve and experienced patients: Indonesian situation. 2nd HIV
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