Rapidly Expanding Access to Care for hiv in Tanah Papua (reach) 2012 2016
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Figures, tables and boxesAcronymsAIDS Acquired Immunodeficiency Syndrome AIP Australia Indonesia Partnership AIPD Australia Indonesia Partnership for Decentralisation AIPH Australia Indonesia Partnership for HIV AIPHSS Australia Indonesia Partnership for Health System Strengthening ANC Antenatal care ART Antiretroviral Therapy ARV Antiretroviral ASHM Australasian Society for HIV Medicine AusAID Australian International Development Agency BAPPEDA Regional Development Planning Agency CEPAT Community Empowerment of People against Tuberculosis CHAI Clinton Health Access Initiative CoE Centre of Excellence CSO Civil Society Organisation CST Care, Support and Treatment DFO District Finance Office DHO District Health Office DOTS Directly Observed Therapy Short (course) EDL Essential Drugs List EQA External Quality Assurance FSW Female Sex Worker GIPA Greater Involvement of People Living with HIV/AIDS GoI Government of Indonesia HCPI HIV Cooperation Program for Indonesia HCW Health Care Worker HIV Human Immunodeficiency Virus IBBS Integrated Biological-Behavioural Surveillance IHPCP Indonesia HIV/AIDS Prevention and Care Project IMAI Integrated Management of Adult Illness IPR Independent Progress Review IT Information Technology MARPs Most-at-Risk Populations M&E Monitoring and Evaluation MCH Maternal and Child Health MDG Millennium Development Goals MoH Ministry of Health MOU Memorandum of Understanding MSM Men who have sex with men MWM Medical waste management NIH National Institutes of Health (US) NIHRD National Institute of Health Research and Development NTP National Tuberculosis Program PCC Partnership Coordination Committee (AIPH) PCR Polymerase Chain Reaction PFO Provincial Finance Office PHO Provincial Health Office PHL Provincial Health Laboratory PITC Provider Initiated Testing and Counselling PKM Puskesmas (primary health care centre) PLHA People Living with HIV/AIDS PMTCT Prevention of Mother to Child Transmission PNG Papua New Guinea PPT Periodic Presumptive Treatment PSC Provincial Steering Committee (REACH) QC Quality Control RDT Rapid Diagnostic Test RPR Rapid Plasma Reagin SCM Supply Chain Management SOP Standard Operating Procedures STI Sexually Transmitted Infection SUM Scaling Up for Most-at-Risk Populations TB Tuberculosis TPHA Treponema Pallidum Haemagglutination Assay UNICEF United Nations Fund for Children USAID United States Agency for International Development VCT Voluntary Testing and Counselling WHO World Health Organisation
The most effective way of increasing access to HIV treatment in Tanah Papua is to make quality treatment available closer to where infected people live. REACH will provide technical assistance to Indonesian government health services so that they can decentralise and expand quality care. To maximise the impact of service delivery, it is necessary to simultaneously ensure the supply chain for key commodities, and central government policies around HIV-related treatment and care, are evidence based. REACH will be directed by data about what works best in a challenging setting. Technical support for service provision will be underpinned by a substantial investment in solid monitoring systems and operational research. REACH will have four program components. These components and their objectives are:
The most recent population prevalence survey (2006) found that 2.4 per cent of adults in Tanah Papua were infected with HIV. This is over 18 times the HIV prevalence for the rest of Indonesia. It is estimated that in 2009, 38,000 adults were living with HIV: 9,000 in West Papua and 24,000 in Papua. Of those, some 24,000 live in districts that have not previously had access to HIV testing and treatment but that will be covered by REACH. Although poor access to treatment will have resulted in many HIV-related deaths since 2006, the limited coverage, intensity and efficacy of prevention programs means it almost inevitable that new infections have outstripped deaths and that the number of people living with HIV has risen since 2006 and is now greater than 38,000. Although HIV has spread among men and women in the general population, commercial sex continues to contribute disproportionately to the epidemic in all areas. In 2011, HIV prevalence rates among sex workers ranged from 3.2 to 25 per cent, with 35 to 60 per cent of sex workers being infected with at least one sexually transmitted infection (STI)3. However, given the already elevated levels of HIV in the general population, coupled with high levels of multiple sex partners, especially in the highlands, it is very plausible that the HIV epidemic is now self-sustaining even without the contribution of commercial sex. HIV testing rates are low, with a cumulative total of only 13,305 people having been diagnosed with HIV, many of whom have already died. Access to HIV treatment is particularly low with only 1,897 people currently on antiretroviral therapy (ART) in Tanah Papua. This represents only 15 per cent of an estimated 12,540 people in need of treatment. Though Tanah Papua accounts for over a quarter of estimated HIV infections in Indonesia, it accounts for only 6per cent of Indonesians on HIV treatment. Most present with late stage disease making effective treatment more difficult, increasing stigma and increasing dependency as they are unable to work. REACH will expand and promote access to HIV testing and treatment before the onset of symptoms. The current AusAID supported CHAI Phase II program has shown that decentralisation of HIV CST to primary care through puskesmas4 is effective, with a rapid increase in the number of patients on treatment, improved treatment adherence and a significant decrease in patients lost to follow up. Under REACH, the program will be rapidly scaled up, expanding from three to 21 districts (15 in Papua and 6 in West Papua). CHAI will support Provincial Health Offices (PHOs) to establish nine Centres of Excellence (CoE). The CoE will serve as both regional referral centres for complicated cases and as base for expert teams that will facilitate the decentralization process through training, mentoring and monitoring in puskesmas. They will support the expansion of HIV CST services in 17 hospitals in Papua and three in West Papua and an additional 120 satellite puskesmas. CoE will come on-line progressively over 18 months and the 120 puskesmas over four years. CHAI’s role will be technical assistance rather than direct service delivery. Key indicators and targets will be set in the first quarter of the program. Initial numbers of people that will benefit from REACH over the four years of the program include:
The model takes an integrated approach to service delivery which will include HIV, tuberculosis (TB) and STI testing and treatment and prevention of mother to child transmission (PMTCT). Other sub-components will include strengthening of laboratory capacity and puskesmas infrastructure and medical waste management. The assessment of the team developing this proposal is that there is more than adequate fiscal space in provincial and district budgets to significantly increase funding for health services. The two key issues that need to be addressed are the priority accorded to health and efficient and effective use of funds. As districts will be responsible for health service delivery costs, REACH will work actively with all levels of government to advocate for increased funding for health services and assist in improving planning, resource allocation and ensuring adequate staffing of health facilities. AusAID funding will support the CoE for the first three years, with PHOs being responsible for funding from year four. Success in achieving the end of program goal (“increased access to and increased number of people on HIV-related care and treatment in Tanah Papua”) will contribute to the long term goal of reduced HIV-related morbidity and mortality in the two provinces. In addition to strengthened HIV, TB, STI services and PMTCT through maternal and child health services, the benefits of REACH will have a broader effect through enhanced management, planning, budgetary and supervisory capacity for PHOs and District Health Offices (DHOs); improved communication and linkages with Regional Development Planning Agencies (BAPPEDA) and Provincial and District Finance Offices (PFOs, DFOs); strengthened links and referral pathways between district hospitals and puskesmas; strengthened laboratory capacity and puskesmas infrastructure; potential demand creation for HIV and a broader range of services at the primary health care level; and potential application of findings from operational research to other areas of health care in Indonesia. Effective SCM of HIV-related drugs and commodities is a prerequisite for adherence and the provision of clinical services. Under REACH, CHAI’s technical support to the MoH will focus on four areas: 1) strengthening of SCM systems for HIV-related commodities, including reagents and medications for tuberculosis and STIs in Papua and West Papua; 2) extending the decentralised model of ARV SCM to 12 provinces, including West Papua; 3) further strengthening of the MoH’s national HIV SCM system; and 4) undertaking work with the MoH’s Pharmaceutical Directorate to promote realisation of the One Gate policy for integration of all SCM systems in Indonesia in the medium to long term. CHAI will also develop a transition plan that will result in progressive hand-over of SCM functions and technical assistance to the MoH’s AIDS Sub Directorate, with a full exit by the end of REACH in mid-2016. Under REACH, CHAI will strengthen its technical support to the AIDS Sub Directorate for development, dissemination and implementation of evidence based national policies relevant to HIV CST. This will be done through establishment of a small Policy Secretariat within the Sub Directorate to assist policy review and development by expert panels. The Secretariat will work to ensure that MoH and partner training curricula are consistent with national policy, and to establish a distribution system for policies to the health sector and professional associations. CHAI, through its technical assistance, will promote implementation of national policies in the Papuan provinces and bring lessons from the field to the national level to inform policy development. REACH includes a strong operational research component, linked to a robust program monitoring system, that will focus on what works and what does not when trying to increase provision and access to HIV-related services through routine health systems in a challenging context. Findings are likely to have application to both HIV and non-HIV services in the Papuan provinces and other parts of Indonesia. The research agenda will be developed using inclusive processes which seek to ensure that research questions are program-relevant and that research results are likely to be used. Research will be undertaken in partnership with GoI and other partners such as the Australia Indonesia Partnership for Decentralisation (AIPD). There will be a strong focus on both provincial level dissemination and rapid use of findings in program implementation and sharing findings with a broad range of partners at the national level to inform HIV and other health programming. REACH is an ambitious project that faces multiple programmatic and external risks in a challenging environment. This proposal has placed a strong emphasis on identification of risks and controls to mitigate impact. CHAI will implement a cascading issues management framework that regularly monitors issues and risks from site level upwards. The management and staffing of CHAI has been enhanced and restructured to support the significant effort required for this program scale up. A proactive approach will be taken to staff recruitment through networking, with a focus on maximising recruitment of Papuan staff. In the course of designing this proposal the team identified multiple areas where strong synergies exist between REACH, other AusAID programs, and other donor programs where outcomes for all programs could be enhanced through a collaborative approach. Key areas where consistency or synergies exists are: 1) facilitation of decentralisation processes; 2) health system strengthening; 3) demand creation for HIV testing and treatment, and prevention; 4) policy support for the MoH; 5) technical assistance for health programs; and 6) operational research. Key features of this proposal are:
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