Rapidly Expanding Access to Care for hiv in Tanah Papua (reach) 2012 2016

2. Program description

2.1 Overview

There is now a wealth of international evidence that demonstrates that ART, when provided effectively, both restores and maintains the health of PLHA, resulting in a significant extension of life. These benefits will be maximised if PLHA commence treatment at a clinically appropriate time rather than waiting till they become ill ³¹. This emphasises the importance of early diagnosis through HIV testing of people at risk and ongoing monitoring of their health. There is also a solid body of evidence that demonstrates that it is cost-effective to provide quality HIV-related treatment in resource poor settings, including through a primary health care model linked to hospitals.

There is also strong evidence that effective HIV treatment reduces viral load to undetectable levels which significantly reduces the risk of sexual transmission, as long as the HIV-infected partner does not have another STI ³².

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.

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:

• 
  An estimated 640,800 people will be tested for HIV. Of those tested, an estimated 25,200 people will be found to be HIV positive and provided with ongoing monitoring and care, with 20,160 people commencing on antiretroviral (ARV) drugs. The 615,600 people found to be negative will have access to prevention counselling, condoms, STI services and repeat HIV testing in the future.
  
• 
  An estimated 2,600 people will be diagnosed with TB and receive treatment.
  
• 
  An estimated 80 per cent of sex workers at target sites will receive routine STI and HIV examinations and related treatment every three months.
  
• 
  An estimated 80 per cent of pregnant women attending antenatal care at target sites will receive HIV and syphilis screening and treatment as needed.
  

REACH aims to help people infected with HIV in the Papuan provinces to live longer and healthier lives, and to reduce the likelihood that they will pass on their infection. REACH will do this by supporting improved HIV and related health services that are available in more sites that people can reach more easily. Better access to quality services should lead to:

• 
  earlier diagnosis of HIV infection
  
• 
  earlier initiation of treatment
  
• 
  more frequent monitoring of patients, with less treatment drop-out.
  

Supported by work to ensure a strong supply chain and community engagement to increase adherence to ARVs, these achievements will lead to less HIV-related illness, less HIV transmission, and fewer deaths.

REACH will work through government health systems. It will provide intensive technical support through nine Centres of Excellence based in district hospitals. The expert teams in these CoE will cascade knowledge and competence in practice through the hospitals and puskesmas they support, in large part through hands-on, in-service training and active mentoring of health staff. They will support health workers to provide friendly, high-quality services for the diagnosis of HIV, TB and STIs, and for case management and treatment. Services to reduce HIV transmissions from infected women to their infants will also be supported.

In addition to strengthening of capacity to provide these services, the benefits of REACH will have a broader effect through strengthening of:

• 
  the management, planning, budgetary and supervisory capacity of PHOs and DHOs;
  
• 
  links and referral pathways between district hospitals and puskesmas;
  
• 
  links between puskesmas and community organisations;
  
• 
  laboratory capacity;
  
• 
  puskesmas infrastructure, (including staff housing that should increase staff retention);
  
• 
  waste management; and
  
• 
  information management.
  

All of these activities will strengthen provision of primary health care services across the board. Although the focus of REACH is on the supply side, the strengthening of services may result in demand creation for HIV and a broader range of services. REACH will also leverage off the work of partners in relation to demand creation for HIV testing and HIV treatment.

The implementation of REACH will be guided by strong monitoring systems, with built in analysis and feed-back loops. Monitoring information will be supplemented by operational research which will seek to generate and publish knowledge about expanding HIV treatment in difficult contexts that will be of value in other areas of health service provision in areas outside of Papua.

An underlying objective of REACH is to further test the model of decentralised HIV CST through primary care, supported by CoE, which can be replicated by the MoH in other parts of the Papuan provinces and other parts of Indonesia. Analysis of data from the monitoring system and operational research will be fed back by CHAI to the MoH to promote broader replication.

2.2 Goal and objectives

The REACH end of program goal is increased access to, and increased number of people on HIV-related care and treatment in Tanah Papua. The overarching program outcome will be 17 hospitals and some 120 puskesmas with trained staff providing HIV-related clinical services. The long term goal is reduced HIV-related morbidity and mortality in Tanah Papua.

More specifically, REACH will have four program components. These components and their objectives are:

Component 1: Care, support and treatment

To increase the number of GoI supported health facilities that are well staffed and equipped and providing quality HIV-related clinical services in Tanah Papua.

There are seven sub-components, each with a specific objective:

• 
  1.1 Antiretroviral therapy: To increase access to ART at puskesmas and hospitals in Tanah Papua, and adherence to ART among patients treated.
  
• 
  1.2 Tuberculosis: To improve the quality of TB diagnosis and treatment in Tanah Papua.
  
• 
  1.3 Sexually Transmitted Infections: To reduce STI prevalence in high prevalence populations in Tanah Papua.
  
• 
  1.4 Laboratories: To strengthen laboratory capacity to provide HIV, TB and STI related diagnostic testing and monitoring.
  
• 
  1.5 Infrastructure: To strengthen health infrastructure at puskesmas level to support provision of primary health services including HIV-related care, support and treatment.
  
• 
  1.6 Support for effective decentralised systems: To support policies that increase the efficiency, transparency and sustainability of service delivery in a decentralised health system.
  
• 
  1.7 Medical Waste Management: To strengthen safe management of infectious medical waste in Tanah Papua.
  

Component 2: Supply chain management for HIV-related commodities

To decrease stock outs and increase efficiency of strengthened supply chain management of HIV-related commodities.

There are three sub-components:

• 
  2.1 Provincial level: To strengthen supply chain management systems for HIV-related commodities in Tanah Papua.
  
• 
  2.2 National level: To strengthen national and decentralised supply chain management systems for HIV-related commodities.
  
• 
  2.3 One gate: To support the medium to long-term shift towards a national one gate policy in supply chain management of HIV-related commodities in Indonesia.
  

Component 3: Policy support to the Ministry of Health

To develop, disseminate and implement an evidence-based MoH national policy framework relevant to HIV-related care, support and treatment.

There is one sub-component:

• 
  3.1 National level policy: To strengthen the national policy framework relevant to HIV-related care, support and treatment.
  

Component 4: Operational research

To generate and apply knowledge that contributes to achieving the program goal of increasing access to high quality HIV-related treatment in Tanah Papua.

There are two sub-components:

• 
  4.1 Operational research: To undertake research that generates reliable knowledge with the potential to contribute to the program goal.
  
• 
  4.2 Local engagement: To increase the use of operational research data to achieve program goals
  

A diagram outlining the programmatic structure of REACH appears in Annex 5.