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 IndonesiaNew 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

applied2. 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