TB/HIV: Public-Private Partnership for MARGs in Jakarta, Indonesia

Dr Flora Tanujaya, MScSenior Clinical Officer, FHI Indonesia

Dr Halim Danusantoso*, Dr Wia Melia*, Dr Janto G Lingga **,Dr Chawalit Natpratan***, Robert J Magnani***, Julietty Leksono***,

Kekek Apriana***

* Indonesian Tuberculosis Control Association, Jakarta Branch, Indonesia ** Dr Sulianti Saroso Infectious Disease Hospital, Jakarta, Indonesia*** Family Health International – Indonesia, Aksi Stop AIDS Program

Outline of Presentation

• Context• Partners• Background• Program• Outcome• Recommendation

Context

• Indonesia: 3rd world rank re TB incidence

• HIV epidemic: concentrated in MARGs

• TB is observed: most common OI/co-infection reported in Indonesia (MoH), cause of 40% death among PLHA

• Routine TB screening among PLHA has not been emphasized in National CST Guideline. But more often done

• National TB-HIV coordination is stronger since 2007

Partners

• Indonesian Tuberculosis Control Association (PPTI) – private non profit. TB clinic serving urban poor; popular among MARGs

• Dr Sulianti Saroso Infectious Diseases Hospital (RSPI), Public Hospital in North Jakarta

• FHI and donors (governmental, personal, private company, community associations)

Background• PPTI saw increasing non-specific PTB & EPTB and

wondered ‘Could it be HIV?’

• 2003: 10 TB-HIV (self reported by patients)

• Early ‘04: capacity building efforts (FHI-USAID, IHPCP-AusAID)

• 1 Sept 04: VCT service started at TB clinic, supported by FHI-USAID

Program – The 1st of its kind in Indonesia

New TB patients

HIV Education Session

TB screening

Pre test counseling

HIV test

Post testcounseling

Follow up interventions:

- TB DOTS & nutrition support at PPTI- HIV psychosocial support at PPTI- HIV care & treatment referred / at PPTI- Follow up for HIV (-) with HIV prevention referred

Program (2)All TB-HIV cases:1. Pay ID card 0.5 USD + Chest X-Ray 3 USD (can be waived)2. Food supplement from WFP3. Free DOTS for 6 months from NTP. 4. Free additional 3 months OAT (personal donors / adopters)5. Case management service (psychosocial support, home visit)6. Mobile DOTS dispensing (radius 70 km)7. Care & Treatment for HIV referred to nearby hospitals 2004.

Starting February 2005, provided at PPTI8. Secondary prophylaxis

One-stop TB-HIV services for urban poor MARGs

Outcome

Challenges:

1. Limited availability of HIV education session(daily: 8-9 and 9-10 am)

2. Selective referral to VCT, based on clinical criteria

3. No CST follow up on site, referral only

VCT at PPTI Jakarta, Sept-Dec 2004

196

39

196

206

1371

749

0 200 400 600 800 1000 1200 1400 1600

Reactive Result

Post Test Counseling

Tested

Pre Test Counseling

HIV Education Session

New Patient

Program Modification & Outcome (1)

Modification 1:

1. “Opt in” strategy applied

2. HIV care and treatment provided at PPTI as RSPI’s “satellite”

Challenge:1. Limited availability of

HIV education session2. Is it time for “opt out”?

VCT at PPTI Jakarta, Jan-Dec 2005

168

640

681

692

2177

4106

0 500 1000 1500 2000 2500 3000 3500 4000 4500

Reactive Result

Post Test Counseling

Tested

Pre Test Counseling

HIV Education Session

New Patient

Program Modification & Outcome (2)

Modification 2:

HIV education session using audiovisual tools (donation from private for profit company), more availability

Free ketoconazole donation from a women’s association

VCT at PPTI J akarta, J an-Dec 2006

245

1332

1401

1431

4658

4658

0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000

Reactive Result

Post Test Counseling

Tested

Pre Test Counseling

HIV Education Session

New Patient

Outcome (3)VCT at PPTI Jakarta, Jan-May 2007

143

675

747

755

1826

1826

0 200 400 600 800 1000 1200 1400 1600 1800 2000

Reactive Result

Post Test Counseling

Tested

Pre Test Counseling

HIV EducationSession

New Patient

Proportion of Female PLHA:

2004: 8% 2005: 16%2006: 20%2007: 20%

Proportion of Female New Patients

2006: 39%2007: 42%

What’s next?

• National Policy, Framework, and Guidelines are needed.

• This model can become learning site for decision makers as well as other service providers

• It is time for “opt out” strategy at PPTI and others of its kind

• The model service should be brought to scale: serving patients’ best interest, comprehensiveness, responsiveness, multi-party collaboration under one roof and coordination mechanism