The diversity of the country is also reflected in the distribution of  reported AIDS cases. For instance, Papua in the east of the country reports a prevalence 26 times the national average, while the capital city of Jakarta reports a prevalence almost 10 times the national average. Similarly, prevalence in certain vulnerable groups, particularly injecting drug users and transvestites, has reached epidemic levels. On the other hand, heterosexual transmission appears to be at a lower level, other than in Papua and one or two other locations. It is becoming more common to describe Indonesia as having several "concentrated HIV epidemics". This term is probably appropriate for most large countries with low prevalence.

Those in government responsible for the response are aware of the possibility of an AIDS epidemic in Indonesia, and they are taking steps to prevent it. Although relying on faith and piety is often seen as dangerous, the relatively strong adherence to religious norms probably does mean that much of the population is at relatively low risk of infection. Pre- and extra-marital affairs are not unusual, but such behaviour is frowned upon, and promiscuity is relatively rare, particularly in rural populations.

As elsewhere, prevention programmes have emphasised that "anybody can catch AIDS." Although it is difficult to argue against this, the disease will not affect the vast majority of the population. Thus, scarce prevention resources must be focused where they can prevent epidemics, rather than towards preventing infection among those who are an "epidemiological dead end", i.e. unlikely to spread infection to more than one additional person. Surveys show that although most urban youth are aware of AIDS, they have little depth of knowledge. This is not surprising and additional resources should be spent only on those youth whose behaviour puts them at higher risk. The challenge is how to identify and target such individuals without stigmatising certain vulnerable groups.

A bigger challenge is responding to those who do become infected. Nowhere in the country is there a large enough population of people living with HIV/AIDS (PLWHAs) to encourage provision of dedicated services, be they medical, social or peer support. Doctors are reluctant to learn about AIDS, maintaining that the chances they will have a patient with the disease are small. Even those who take up the challenge (there are only two AIDS specialists in the whole country) cannot make a living from AIDS – they have insufficient AIDS patients and many of those can ill afford to pay for their services. Thus, doctors can neither justify the effort needed to keep up to date on the complex treatments, nor can they hope to gain the experience crucial in improving quality of life and survival of PLWHAs. In addition, few are fully competent in English and because of the small size of the market, little information is available in the vernacular.

Peer support organisations face even greater challenges. The lack of role models and the fear of negative consequences for themselves or their family, have contributed to the fact that very few PLWHAs are willing to identify themselves in any forum, let alone in public. The Spiritia Foundation, the national peer support network for people infected with, or affected by AIDS, is in contact with only about 100 PLWHAs nation-wide. Even the Pelita Ilmu Foundation, an NGO offering services to PLWHAs in Jakarta, has only reached a couple of hundred people. This is mainly because of its close connection with the two national AIDS specialists. There has probably been no occasion in which more than 30 PLWHAs have come together to meet.

It is tempting to assume that people with similar risk behaviours will have much in common. But with such small numbers, those who do meet often find the only thing they share is the virus; they come from a wide range of social, educational, religious and professional backgrounds and were infected by all routes of transmission. Gays, especially professionals who are gay, often find it difficult to establish rapport with transvestites. Sex workers have little in common with housewives. As more injecting drug users are becoming diagnosed HIV-positive through entry testing, the situation is beginning to change, at least for this group. A Bali support group, Bali Plus, however, is dominated by drug users in recovery and this risks alienating other members who feel uncomfortable with their response to the infection.

Perhaps one can be almost forgiven for feeling at times that "if only there were more people infected...." Certainly one essential element of the response must be to increase case identification through improved access to client-friendly, affordable and confidential voluntary counselling and testing. Other solutions are also being identified. If PLWHAs do not wish to meet, they may be willing to network by mail, telephone or e-mail. This can provide support and may lead to individual friendships that are more important than group meetings.

Advocacy on behalf of PLWHAs is difficult when the number of those known to be infected is not much higher than deaths and injuries resulting from a train crash and where treatable epidemics of dengue fever, TB and malaria claim many more lives than AIDS. One solution is to form coalitions with organisations responding to other conditions, including consumer groups, with the objective of improving overall health care. Indeed, many believe that this approach is appropriate globally as an effective response to the challenges of AIDS and other infectious diseases. Such responses must include informing and empowering patients.

Even with 90% of HIV infections in the developing world, overall the epidemic here is low prevalence, but "concentrated". The same will be true of epidemics that are sure to follow AIDS, given the new-found mobility of infected people and of pathogens. We must develop responses to HIV/AIDS that will be appropriate for these epidemics, both for prevention and for care and treatment. We must resist dependence upon a yet-to-be-developed vaccine, which may provide relatively low levels of protection and may even bring risks of infection, adding to numbers infected in low-prevalence situations.

Some donor representatives have been heard to comment "Call us when you have an epidemic." Clearly, such a response is inappropriate. Not only is prevention better than a cure, but we need a much better understanding of what low-prevalence communities are doing right, or what set of conditions contribute to local low prevalence, so that we can replicate these elsewhere. The pity is that this appears to generate such little interest.