A National Assessment for Preventing HIV in Mother and … · DKI Jakarta Bandung, West Java Malang, East Java Denpasar, Bali Jayapura, Papua Provincial HIV referral hospital located

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A National Assessment for Preventing A National Assessment for Preventing HIV in Mother and Children : HIV in Mother and Children :

An Indonesian StoryAn Indonesian Story

Dr. Lukman Hendro Laksmono, MBADr. Lukman Hendro Laksmono, MBADr. Muh. Ilhamy Setyahadi, SpOGDr. Muh. Ilhamy Setyahadi, SpOG

Directorate of Maternal Health, MOH, Republic of Indonesia

Joint Forum Incorporating theConsultation on Integrating Prevention and Management of STI/HIV/AIDS into Reproductive, Maternal and

Newborn Health Servicesand the

6th Asia-Pacific UN PMTCT Task Force Meeting

Sheraton Subang Hotel, Kuala Lumpur, Malaysia, 6-10 November 2006

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IntroductionIntroduction• By 2007, we are working towards the implementation of the

integrated PMTCT. On the process of the implementation, we based our recent PMTCT programmes on the 3 by 5 policy.

• The programmes towards the integrated PMTCT next year include: Rapid assessment, capacity building workshops, training of medical health professional, etc.

# #

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Overview: HIV/AIDS situation in IndonesiaOverview: HIV/AIDS situation in Indonesia

316

1195

2638

1756

44 60 94 255 219 345

6987

198 258 352 607 826 11711487

2682

5321

0

1000

2000

3000

4000

5000

6000

7000

8000

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

AIDS Kumulatif

Figure 1 : Number of Figure 1 : Number of AIDS CasesAIDS Cases in Last 10 Years up to September 30,2006 in Last 10 Years up to September 30,2006

Figure 2 : Number of Figure 2 : Number of HIV PositiveHIV Positive in Last 10 Years up to September 30, 2006in Last 10 Years up to September 30, 2006

403732 648

168649

875373

83 126 178

2552

3368

46174244

27201904

1172769

591465

0500

100015002000250030003500400045005000

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

HIV Kumulatif

AIDS-MOH monthly report up to Sept 30, 2006

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Overview: HIV/AIDS situation in IndonesiaOverview: HIV/AIDS situation in IndonesiaFigure 3Figure 3 : Cumulative Percentage on : Cumulative Percentage on AIDS Cases by Age GroupAIDS Cases by Age Group

Figure 4 : Percentage of Figure 4 : Percentage of AIDS CasesAIDS Cases by Sexby SexUnknown

2%Female

16%

Male82%

0,46 0,76 0,273,02

54,77

26,56

8,04

2,18 0,493,45

0

10

20

30

40

50

60

< 1 yr 1-4 yr 5-14 yr 15-19 yr 20-29 yr 30-39 yr 40-49 yr 50-59 yr > 60 yr Unknown

Age groups

Percen

tage


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Overview: HIV/AIDS situation in IndonesiaOverview: HIV/AIDS situation in IndonesiaFigure 4 : Cumulative Percentage on Figure 4 : Cumulative Percentage on AIDS Cases byAIDS Cases by Mode of TransmissionMode of Transmission

4,5

37,2

52,6

0,1 1,44,2

0

10

20

30

40

50

60

Homosex Heterosex IDU Trasfusion Perinatal Unknown

Mode of transmission

Percen

tage

64,7

43,2

17,6

53,7

72,5

36,630,3

17,6

64,9

11,8

1,32,7

7,73,4

02,1

53,3

2,21,05 2,2

0,0

5,5

5,90 00

10

20

30

40

50

60

70

80

90

100

87-90 91-95 96-2000 2001- 2005 2006 -sekarang

Tahun

Pers

en

Homoseks Heteroseks IDU Lain-lain Tak diketahui

Figure 5 Figure 5 : Trend : Trend Mode of TransmissionMode of Transmission of AIDS Casesof AIDS Cases per Periodper Period


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PMTCT Rapid Assessment 2006PMTCT Rapid Assessment 2006

Directorate of Maternal Health, DG of Community Health, MOH Republic of Indonesia

in collaboration with

Unicef RO Indonesia 2005-2006

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To identify the conditions which support or inhibit the delivery of interventions for the prevention of HIV from mother to child.

GoalGoal

1. Collect baseline dataSpecific objectivesSpecific objectives

• Existing programs, policies and intervention• Selected health care, VCT facilities, ARV availability, Support mechanism• KAP providers, policy makers, community, youth regarding PMTCT issues• Gaps• Key person/ institution for influencing youth and women

2. To gather data to inform the development of comprehensive PMTCT intervention in Indonesia

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Assessment TeamAssessment TeamGovernmentGovernment CommunityCommunity

1. Yayasan Pelita Ilmu2. Yayasan Spiritia

1. Ministry of Health•Maternal Health•CDC•Hospital & Medical Services

2. National Family Planning Board3. Provincial and District/City Health

Office

AcademiaAcademia ConsultantConsultantStudy Center for Social Health,

University of Indonesia1. Unicef2. National Health Research

Institute, MOH3. University of Indonesia4. University of Atmajaya

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MethodsMethods

Review of secondary data from:Review of secondary data from:• Assessment results of pilot PMTCT programs • Government and health facility records

Qualitative data gathering:Qualitative data gathering:• In-depth individual and group interviews• Questionnaires (respondent=651)• Focus group discussions

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Assessment siteAssessment site

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Batam, Batam, Riau IslandsRiau Islands

North Jakarta, North Jakarta, DKI JakartaDKI Jakarta

Bandung, Bandung, West JavaWest Java

Malang, Malang, East JavaEast Java

Denpasar, Denpasar, BaliBali

Jayapura, Jayapura, PapuaPapua

Provincial HIV referral hospital locatedProvincial HIV referral hospital located

District Level Hospital onlyDistrict Level Hospital only

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Respondent InstitutionsRespondent Institutions

1. Government HIV Referral Hospitals

2. Private and Public District Level Hospitals

3. Community Health Centers – Puskesmas

4. Community-based Integrated Health Posts – Posyandu

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Key InformantsKey InformantsHospitalsHospitals StakeholdersStakeholders

Chairpersons of Health Officials, Chairpersons of FP Board, Parliament Members, Managers of AIDS NGOs, Chairpersons of Women’s Org.

GP, Obstetricians, Pediatricians, Nurses, Midwifes, Hospital Directors, Chairpersons AIDS working groups, Pharmacy staff, Lab technicians, Blood bank techniciansManager ANC units, VCT Counselors, Pregnant women & Partners

Primary Health CentersPrimary Health Centers CommunityCommunityCommunity leaders, Unmarried Youth Males & Females, Females LWHA

Administrators, Nurses,Community/village midwives, Cadre (Integrated Health Volunteers)

Number of respondent = 1008 personsNumber of respondent = 1008 persons

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What was learned about currentknowledge of HIV / PMTCT ?

WhatWhat was learned about was learned about currentcurrentknowledge knowledge of HIVof HIV / / PMTCT ?PMTCT ?

• In general; respondents were knowledgeable knowledgeable about HIV including mother to child transmission.

• Health Care Workers were less informedless informed as to specific ways to prevent MTCT

• Mass media was a cross cutting influencer for all respondents for knowledge about the size of the HIV epidemic in Indonesia as well as basic information about HIV and new AIDS related technology

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What are the current attitudes and practices related to HIV/PMTCT ?

What are the current attitudes and practices What are the current attitudes and practices related to related to HIV/PMTCT ?HIV/PMTCT ?

•• Health Care Workers expressedHealth Care Workers expressed fear of HIV infection fear of HIV infection in the work place due to lack of resourcesin the work place due to lack of resources such as disposable gloves, other protective equipment, and PEP.

• In both hospital and community health care settings, pregnant women and new mothers arepregnant women and new mothers are seldom seldom provided basic informationprovided basic information on HIV and MTCT.

•• OnlyOnly women with women with ““suspicioussuspicious”” behaviors or family behaviors or family histories arehistories are provided informationprovided information about HIV and/or referred to VCT

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What are the current attitudes and practices related to HIV/PMTCT ?

What are the current attitudes and practices What are the current attitudes and practices related to related to HIV/PMTCT ?HIV/PMTCT ?

•• VCTVCT isis only available in hospital settingsonly available in hospital settings and referral mechanisms within hospital units and from community health centers is not yet optimal.

•• Most Most health care workers support public health health care workers support public health messagesmessages to reduce HIV infection including condom promotion and sexual health education to sexually active youth

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What problems or obstacles do people identify in relationship to HIV / PMTCT ?What problems or obstacles do What problems or obstacles do people people

identifyidentify in relationship to HIV / in relationship to HIV / PMTCT ?PMTCT ?

•• The existing health care system is burdened with The existing health care system is burdened with only only a few HIV trained staffa few HIV trained staff who are overworked.

•• Health Care WorkerHealth Care Worker’’ss are not in the practice of are not in the practice of initiating discussionsinitiating discussions about healthy sexual marital about healthy sexual marital relationshipsrelationships with pregnant women or their partners even though there are many beliefs and practices related to sex during and after pregnancy which may increase couples risk for HIV.

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What problems or obstacles do people identify in relationship to HIV / PMTCT ?What problems or obstacles do What problems or obstacles do people people

identifyidentify in relationship to HIV / in relationship to HIV / PMTCT ?PMTCT ?

•• ManyMany youth are youth are sexually activesexually active yet there are few health facilities who provide reproductive health services to unmarried youth.

•• Exclusive Breast Feeding and itExclusive Breast Feeding and it’’s benefits s benefits are not are not uniformly promoteduniformly promoted among pregnant womenamong pregnant women. There is much confusion about infant feeding recommendations for women infected with HIV.

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What exists in terms of potential support systems, infrastructure, strategies

for the support of PMTCT initiatives ?

What exists in terms of potential support What exists in terms of potential support systems, infrastructure, strategies systems, infrastructure, strategies

for the support of PMTCT for the support of PMTCT initiatives ?initiatives ?

Human ResourcesHuman Resources•• HIV referral hospitals have functioning HIV referral hospitals have functioning

interdisciplinary AIDS working groups whichinterdisciplinary AIDS working groups whichcoordinate continuum of care servicescoordinate continuum of care services from VCT to CS&T.

•• There areThere are many health facilities and NGOs with many health facilities and NGOs with experienceexperience of providing services to PLWHA

•• There are There are community based health volunteerscommunity based health volunteers who who support breast feeding education and followsupport breast feeding education and follow--up up supportsupport to new mothers.

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for the support of PMTCT initiatives ?for the support of PMTCT initiatives ?

Reaching Populations at riskReaching Populations at risk• Large populations of women with potential risk of MTCT

are more apt to be reached apt to be reached at community health care at community health care centerscenters via maternal child health clinicsvia maternal child health clinics

NetworkingNetworking•• There is There is evidence of referral networkingevidence of referral networking between

community health centers (Puskesmas) – integrated health posts (Posyandu) – hospitals – NGOs

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for the support of PMTCT for the support of PMTCT initiatives ?initiatives ?

RoleRole of men in maternal and child healthof men in maternal and child health• Male partners are accompanying accompanying women to established

antenatal care services but are not involved in health but are not involved in health education or consultationeducation or consultation with the health teamwith the health team.

•• Men are viewed as Men are viewed as influential decision makersinfluential decision makers in the family.

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Who has the most influence on young people especially women of reproductive age?

Who has the most influence on young people Who has the most influence on young people especially women of reproductive age?especially women of reproductive age?

1. Parents or older family members *2. Men (fathers, older brothers, husbands, and boyfriends*)3. Health care workers (doctors and midwives)4. Teachers5. Religious organizations and religious leaders6. Peers*7. Woman’s organizations 8. Youth groups (district youth groups, faith-based youth

groups, scouts, student government)9. Department of Women Empowerment

* responses by youth

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What community support mechanisms exist to support breastfeeding and or

infant feeding programs ?

What community support mechanisms What community support mechanisms exist to support breastfeeding and or exist to support breastfeeding and or

infant feeding programs ?infant feeding programs ?

• ANC and MCH clinics in both the Puskesmas and hospital have health educators experienced with supporting mothers with infant feeding. There are There are few health few health educators specifically trainededucators specifically trained in breastfeeding in breastfeeding counseling and recommended feeding protocols to counseling and recommended feeding protocols to prevent MTCTprevent MTCT

•• Health Cadres volunteering with the integrated health Health Cadres volunteering with the integrated health posts (Posyandu) are posts (Posyandu) are very effective in community very effective in community based followbased follow--upup with new mothers including home visits

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What community support mechanisms exist to support breastfeeding and or

infant feeding programs ?

What community support mechanisms What community support mechanisms exist to support breastfeeding and or exist to support breastfeeding and or

infant feeding infant feeding programs ?programs ?

•• ReferralReferral hospitals engage hospitals engage HIV social case managersHIV social case managerswho have the potential to provide advocacy and community follow-up to new mothers in support of infant feeding choices.

•• Local women's organizations Local women's organizations have potential in have potential in community advocacy for changing attitudes and community advocacy for changing attitudes and responsesresponses of communityof community towards HIV infected women and children.

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LESSONS LEARNEDLESSONS LEARNEDLESSONS LEARNED

1.1. Developing capacityDeveloping capacity among Health Care Workers as Rapid Assessment Team is is possiblepossible

2.2. Assessment tools/processes are replicableAssessment tools/processes are replicable and can can assist as monitoring/evaluation assist as monitoring/evaluation methodsmethods

3.3. Potential entry pointsPotential entry points for PMTCT messages; community based maternal child health clinics; community based maternal child health clinics; immunization clinics, and workplaceimmunization clinics, and workplace

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LESSONS LEARNEDLESSONS LEARNEDLESSONS LEARNED

4.4. MaleMale partnerspartners, as important decision makers for women, were uniformed about were uniformed about PMTCTPMTCT

5.5. There is evidence of changing attitudes and There is evidence of changing attitudes and improved understanding of HIVimproved understanding of HIV among health care workers

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Nurses completing Questionnaire, Wangaya General Hospital, Denpasar

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FGD with Pregnant Women

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In-depth interview with a Husband of a Pregnant Woman

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FGD with Health Cadres, Integrated Health Post (Posyandu)

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In-depth interview with Local Health Official

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FGD with Female Youth

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FGD with Male Youth

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TThank Youhank You

Indonesian PMTCT Indonesian PMTCT ProgramProgram logologo’’ss

Documents

A National Assessment for Preventing HIV in Mother and … · DKI Jakarta Bandung, West Java Malang, East Java Denpasar, Bali Jayapura, Papua Provincial HIV referral hospital located