Rapidly Expanding Access to Care for hiv in Tanah Papua (reach) 2012 2016
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- Bu səhifədəki naviqasiya:
- 1.4.1 HIV care, support and treatment in Papua and West Papua
- 1.4.2 Supply chain management for HIV-related commodities
- 1.4.3 HIV care, support and treatment policy support to the Ministry of Health
- 1.4.4 Lessons learnt from other programs
1.4 Programmatic needsThis sub-section gives an overview of programmatic needs and the Clinton Health Access Initiative’s (CHAI) current work under Phase II in three areas:
1.4.1 HIV care, support and treatment in Papua and West PapuaIssues and current situationHIV Since testing began in Tanah Papua in the mid-1980s, approximately 13,305 people are recorded as having been diagnosed as HIV-infected21 (Table 3). Most are either known to be dead, (1,235) or been lost to follow-up and presumed dead (>8,000) by the medical centres where they were diagnosed. Of the current 38,000 plus individuals thought to be living with HIV in the Papuan provinces, 1,879 are currently on ARVs and another 1,300 in Papua are taking antibiotic prophylaxis for pneumocystis pneumonia and diarrhoea. Of those diagnosed with HIV, an unknown number are awaiting CD4 testing or clinical signs of AIDS before initiating treatment. Table 3: Key HIV indicators, Papua and West Papua
* May include some patients followed but no CD4 results or clinical signs ^ Unknown number on cotrimoxazole and may not be LTFU Direct and indirect sex workers in Jayapura included in the 2011 IBBS reported the highest level of HIV testing in Indonesia (89% and 74% respectively). Motor-bike taxi drivers in the same city also topped the charts for male groups: nearly one in four reported an HIV test, over three times the national average for men in mobile occupations. Less encouragingly, just a third of the street-based sex workers in the highland town of Wamena had ever been tested for HIV. In 2006, before any significant efforts had been made to scale up testing, just 2.4 per cent of adults in Tanah Papua reported ever having been tested for HIV and less than one per cent said they had received their test result. Few people who are at risk for HIV, or know they have been HIV exposed, come in for an HIV test of their own accord, a necessary first step in the VCT model. If a patient does get tested at a site other than an ART satellite clinic, they will often have to travel to a distant HIV referral centre for clinical staging and initiation of treatment. If a patient is diagnosed HIV positive and asymptomatic, laboratory testing to establish immune status (CD4) is often not available in rural areas. Patients are eligible to start on treatment if their CD4 count drops below 350 cells/mm. In the absence of CD4 testing, ART is postponed until symptoms appear or an AIDS defining opportunistic infection (OI) is diagnosed as a result of a damaged immune system. Wider access to HIV and CD4 testing would allow early initiation of treatment before significant immune system damage occurs. Most symptomatic HIV positive individuals present with pulmonary or extra-pulmonary tuberculosis or diarrhoea and wasting, stage three or four HIV disease, and nearly all are eligible for beginning ART. Unfortunately, ART is often not initiated because of adherence concerns by care providers and the possibility of the development of antiretroviral drug resistance due to irregular dosing of medications. In addition, the distance between home and the limited number of treatment sites are simply too far for patients to return for all the necessary follow-up visits and monthly collection of medications. Decreasing distance from home to treatment sites would ease patient burden. Improved training for health care providers and community support could improve adherence. Tanah Papua is vast covering 415,000 square kilometres, over three times the size of Java. Transportation infrastructure is underdeveloped and the cost of transport is expensive. Of 38 public, private and military hospitals in Tanah Papua, only 16 are designated ART sites (Table 4). Of the 460 puskesmas, only 50 are registered as ART site satellites. Most of these are in large coastal cities. In West Papua there is only one satellite in Fak Fak, one in Manokwari and four in Sorong. All these satellites are in the respective West Papuan cities and do not serve more isolated populations. In the Papuan highlands, home to nearly 60 per cent of the Papuan population and an estimated 15,000 HIV-infected people in potential need of treatment, there are three hospital ART sties and only two puskesmas satellite ART sites. Tanah Papua accounts for over 25 per cent of the total national estimate of PLHA, but, with only 1,879 people on treatment, accounts for only 6% of the total number on ARV within Indonesia (5% in Papua and 1% in West Papua). Table 4: Health services in Papua and West Papua
Many of those HIV infected in the highlands live far from the four hospitals that serve the region. Many of the 180 highlands puskesmas are either non-functional or unable to provide testing, provision of ARV, medications for OIs and monitoring of health status for those HIV infected because of staffing, training or facilities issues. HIV positive highlands residents with the will, financial means and deteriorating health often seek care in coastal cities like Jayapura, Sentani, Timika, and Nabire. Healthcare providers in these areas indicate that many of their HIV patients originate from the highlands (Table 5). Many of those that are able to go to other distant coastal health centres for treatment stay as long as resources last, only to return and die because continuity of care cannot be sustained. Table 5: Source of HIV patients in Jayapura hospitals
Tuberculosis TB is the primary opportunistic infection of HIV individuals. Most HIV-related deaths are from TB. Given widespread prior TB infection, pulmonary and extra pulmonary TB have emerged as the primary opportunistic infections among HIV infected individuals in Papua. Only half the hospitals and a third of puskesmas are able to diagnose and treat active TB infections and not all match sites providing ART, (Table 6, above). Sexually transmitted infections22 Managing STIs is a problem at a village level where diagnostic and treatment facilities in puskesmas are limited or non-existent. Shame, and/or lack of access to care drive many to pharmacies where ‘syndromic’ management by non-clinicians is inappropriate and may only mask symptoms and not result in cure. STI laboratory capacity: Most district hospital laboratories and puskesmas have limited existing capacity to provide simple diagnostic tests for gonorrhoea, syphilis and trichomonas.23 Other weaknesses include SCM for laboratory reagents and supplies, inappropriate testing practices, weak laboratory quality assurance systems and standard operating procedures (SOPs), and poor infection control. Laboratory capacity appears weaker in West Papua than in Papua. While there are many areas of STI laboratory capacity that need strengthening at hospital and puskesmas level in Tanah Papua, the required level of capacity is within reach. The more sophisticated STI diagnostic tests (polymerase chain reaction, gonococcal culture) are carried out at the Provincial Health Laboratory and, at this stage, are not planned to be provided at district hospital or puskesmas level. Syphilis: There is quite a large amount of testing going on in Tanah Papua – often on the wrong people, with the wrong combination of test kits, wrong diagnoses, overtreatment among sex workers, reluctance to use the first line drug (Penicillin) and patient non-compliance with the alternative (Doxycycline). Routine use of rapid plasma reagin (RPR) testing with confirmatory Treponema Pallidum Haemagglutination Assay (TPHA) for syphilis diagnosis appears low. Key policies and experience: STIs are not reportable illnesses making data collection difficult outside of MARP surveys. Clinics do not always have the latest version of the national guidelines and there are standard STI drugs that are not on the EDL. On the positive side, there is valuable experience in Papua in the use of enhanced syndromic management and periodic presumptive treatment in FSWs. Medical waste management Medical waste is poorly managed in Papua and West Papua with inadequate separation of infectious waste (sharps, rapid diagnostic tests (RDTs), surgical waste) and non-infectious waste (drink containers, plastic bags, paper), open burning at both puskesmas and hospital levels, inappropriate and poorly performing incineration technology, disposal of infectious waste through the municipal waste stream and untrained staff without personal protective equipment or vaccination. There also appears to be little awareness of new non-incineration technologies which avoid dioxin and furan production. What has CHAI done?Overview Addressing the systemic weaknesses in the HIV care delivery systems for those in remote, underserved areas is essential to the health and well-being of many. CHAI’s Phase II approach has provided a framework for scale up that could reach and serve those underserved populations. In Phase II of its AusAID contract, CHAI’s Papua CST program initially reviewed the treatment situation in Jayawijaya District in the highlands and Jayapura District and City on the northern coast, its two current sites, and developed plans of action to:
CHAI established support teams, based in the Yowari Hospital, Jayapura District, and Wamena Hospital, Jayawijaya District. Teams analysed data to confirm the actual number of HIV cases detected, their current status, and where they were being followed if alive and under care. Data management plans were put in place to ensure patients could be tracked, referred and followed up without violating confidentiality. Staff refresher training was held with an emphasis on early testing, treatment benefits, and early initiation of treatment. HIV positive individuals who had not yet initiated ART were encouraged to come for CD4 testing. Training on PITC was conducted and staff encouraged to offer HIV testing to all new TB and STI patients, all pregnant mothers and all hospitalized patients and outpatient clinic clients. In house training programs were developed and all hospital staff trained on HIV issues with special attention to stigma reduction, occupational health, early testing and treatment. Laboratory procedures were reviewed in hospitals and puskesmas. The Provincial Health Laboratory was contracted to assist in setting up standard operating procedures in Jayawijaya and to provide training and external quality control for HIV testing. Staff at 14 puskesmas were trained in HIV testing, counselling and comprehensive ART and these puskesmas were established as satellite ART sites of Jayawijaya and Yowari Hospitals. Where there was no doctor, nurses were trained and can now initiate ART under the direction of the hospital. These activities have formed the basis of the Centres of Excellence (CoE) concept where additional personnel, not current hospital staff, will form support teams that focus first on establishing high quality referral HIV-related services at their base hospital and then will extend that support in the form of training, mentoring and monitoring to puskesmas in the surrounding region. These are technical assistance teams who do not provide services but rather support those who are providing services at the different facilities. Key achievements In an 18 month period, CHAI- supported sites dramatically eclipsed HIV screening and treatment rates achieved in the previous five-year period at the same sites. There was a 10-fold increase in the number of cases on treatment, (Table 6). No similar increases were seen in sites not supported by CHAI over the same 18 month period. Table 6: Comparison of key outcomes following commencement of CHAI Phase II
* includes 499 patients on cotrimoxasole antibiotics Additional achievements include:
Key challenges
Lessons learned
Future need
1.4.2 Supply chain management for HIV-related commoditiesIssue and current situationCHAI Indonesia has been involved in supply chain management since 2007. Working together with the AIDS Sub Directorate and GFATM, CHAI’s goal in SCM is to assist the government to improve access to HIV commodities by ensuring stock availability. Specifically, the AIDS Sub Directorate has prioritized the reduction of ARV stock outs at treatment sites. CHAI has used a two-track strategy to strengthen the centralised national SCM system managed by the MoH’s AIDS Sub Directorate and a decentralised SCM pilot in four provinces. This work has resulted in significant reductions in ARV stock outs at treatment sites, increased timeliness and accuracy of treatment site reporting, and increased coordination among stakeholders at the national, province and district levels in managing HIV commodities. What has CHAI done?Overview CHAI has worked with the AIDS Sub Directorate on the following initiatives:
Key achievements CHAI’s work has resulted in a dramatic and sustained reduction of ARV stock outs, with less than two per cent of the 315 treatment sites nationwide experiencing stock outs during Phase II. A key contributing factor is increased timeliness and accuracy of ARV ordering by sites, with 57 per cent of sites now reporting on time and accurately, up from 25 per cent at the beginning of Phase II. Key challenges The key remaining challenges that REACH will seek to address are: Staff capacity: Of the 13 staff who work on SCM in the AIDS Sub Directorate, only two are civil servants—the remaining 11 are donor-funded, mostly by the Global Fund. Moreover, the two civil servants also have other responsibilities apart from SCM. There is a need for government funded staff to progressively take over SCM work. Procurement policy and funding: Seventy per cent of funding for ARVs is provided by the GoI and 30 per cent by the Global Fund. In 2012, the GoI plans to fund 100 per cent of ARV purchases; however, this may not be realistic. Coordination and communication: Program roles and responsibilities at the national, provincial, and district levels are not clearly defined. Without clear processes, there is significant confusion and misunderstanding, which can lead to stock outs. Monitoring and evaluation: The AIDS Sub Directorate performs regular monitoring and evaluation of treatment sites. While SCM problems have been identified, sites are often not given guidance and support in how to improve performance. Parallel system: The SCM system, which has been established specifically for ARVs, is not sustainable in the long term. Options for how to effectively integrate HIV SCM with mainstream MoH systems need to be explored. Lessons learned Policies and procedures: In terms of policy, the HIV treatment guidelines set by the AIDS Sub Directorate have the most impact on SCM. Changes to the guidelines have major supply chain consequences that are not often considered when policy changes are recommended. Infrastructure: The physical infrastructure (provincial and district warehouses) has been established but needs strengthening at the provincial and district levels in the areas of management, human resource skills and capacity and systems. Decentralisation: The decentralisation of SCM has been successful, with these provinces achieving better performance on key indicators compared to provinces in the centralised system. Although decentralisation is only feasible for provinces with higher HIV caseloads, there is scope for further decentralisation to additional provinces. Future needThere are still a number of challenges that remain to be addressed in REACH in order to ensure that the investment to date results in lasting and sustainable outcomes, with a particular focus in Tanah Papua. REACH’s work in SCM will seek to ensure that:
1.4.3 HIV care, support and treatment policy support to the Ministry of HealthIssue and current situationThe AIDS Sub Directorate in the MoH is responsible for setting national policies and guidelines in relation to HIV CST. Health services provided by DHOs are meant to follow national policies and guidelines. There is a need to institutionalise a MoH led process for evidence based policy review and development in support of the MoH’s national HIV CST program, aimed at increasing access to treatment, including decentralisation of ART to puskesmas. What has CHAI done?Overview and key achievements CHAI Phase II has provided assistance to the AIDS Sub Directorate in the development of policies on ARV, PITC, STIs and PMTCT. In Papua, CHAI has collaborated with MoH, PHO and health services to support a task shifting policy where trained nurses and midwives at puskesmas and posyandu levels provide HIV testing and treatment initiation for pregnant women in order to increase PMTCT uptake. CHAI and the Australasian Society for HIV Medicine (ASHM) have developed a concept for a MoH led process for evidence based policy review and development which has been endorsed by the AIDS Sub Directorate. That concept forms the basis for CHAI’s policy support for the Sub Directorate under REACH, (see section 2.7).
The ad hoc approach to policy development through a MoH-convened large expert panel has been irregular and slow. Decision making processes have not been clear nor sufficiently evidence-based. There has been advocacy by some senior clinicians for policies not based on evidence; training and clinical practice are not always consistent with policies; some health services follow different guidelines (for example, MoH, World Health Organisation (WHO) or FHI guidelines); and dissemination has been poor. Due to limited resources, the AIDS Sub Directorate lacks capacity to more effectively lead policy development. Lessons learned Even within Indonesia’s highly decentralised health system, national policies and guidelines can be an important vehicle for driving change in how services are provided. For example, after PITC was adopted as national policy, CHAI was able to use the new national policy to successfully advocate for the adoption of PITC in the health services it is supporting in Papua. This has resulted in all patients in these services being offered an HIV test and a significant increase in earlier diagnosis of HIV and initiation of treatment as clinically appropriate. It is unlikely that these health services would have commenced PITC if it was not national policy. This also points to the important roles of dissemination and technical assistance in adoption of national policies in clinical practice. Future needThere is a need for a MoH led system for regular, evidence based review and revision of HIV policies and guidelines, coupled with a greater emphasis on application through training, mentoring and dissemination. In addition, the operations research and monitoring aspects of REACH will provide a mechanism to bring lessons learned from implementation in the Papuan provinces to the national level for consideration in policy, guidelines and program development. A summary of key achievements by CHAI Phase II is in Annex 3. 1.4.4 Lessons learnt from other programsCHAI is implementing an AusAID funded HIV program in Papua New Guinea which has some similarities to REACH. A list of lessons learned from CHAI’s AusAID supported Papua New Guinea (PNG) program of relevance to REACH is in Annex 4. These include, to give just some examples, the potential of orienting services towards patient retention vs. clinician convenience, use of clinical job-aides in improving quality and the involvement of PLHA in peer counselling. A lesson learned from the Australia Indonesia Partnership for Maternal and Neonatal Health is that weak capacity at district and puskesmas level can be addressed by using donor funding and technical assistance to improve health care delivery through a focus on planning, budgeting and workforce quality and availability.25 Lessons from international health systems strengthening programs which can be applied to REACH are that quality, accessible primary health care is cost effective and appropriate for a program that aims to improve the health of the poor; and that programming in a decentralised system requires interventions at the policy level (national) as well as the service delivery level (district), with strong linkages between national policy work and district implementation.26
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