Introduction of The Strategic Use of ARVs For Treatment & Prevention in

Indonesia:From Policy Development to

Implementation

Dr. Siti Nadia Tarmizi M EpidNational AIDS Program Manager

Ministry of Health Indonesia

Outline

1. Epidemiological situation and Programme Progress

– Prevention outcomes– Treatment outcomes

2. Rational for Policy Formulation3. Policy Implementation 4. Programmatic Questions and Challenges

1. Epidemioliogical Background• Concentrated epidemic in most of country, but

low-level generalized epidemic in Papua

Source: Estimates & Projection of HIV/AIDS 2011-2016, MoH 2012

From Driven By Injection To Predominantly Sexual Transmission

Estimated Number of New Infections by Population Sub-Groups

Source: Estimates & Projection of HIV/AIDS 2011-2016, MoH 2012

Programme Progress

HIV Prevalence by Population Sub-group

WPSL WPSTL Pria Risti Waria LSL Penasun WBP0

20

40

60

80

100

9.8

4.00.1

24.3

5.3

52.4

9.3

3.10.7

23.2

12.4

42.4

6.52.6

0.4

9.17.0

27.0

7.4

1.5 0.2

7.4

12.8

39.5

1.2

2007 2011 Series3 2009 2013

%

Challenges remaining in controlling sexual transmission

Source: IBBS 2007 – 2011 and 2009 -2013 at the same location, MoH

DFSW IDFSW HRM TG MSM IDU Inmates

Remaining Sexual Risk BehaviorsCondom Use at last sex

DFSW IDFSW IDU MSM Waria0

20406080

100

68 6955

6978

61 6556

68 7064 62

29

54 5868

59 52

74 77

Source: IBBS 2007 & 2011 and IBBS 2009 & 2013, MoH

Always Condom Use

DFSW IDFSW IDU MSM Waria0

20

40

60

80

100

68 6955

6978

61 6556

68 70

4133

9

31 3445

36

13

46 42

2007 2011 2009 2013

TG

TG

Prevention Efforts PWIDs

• Perilaku penggunaan kondom konsisten masih rendah (STBP 2009: 31%, 2013:46%).

Source: Rapid Behavior Survey 2010 & 2013, NAC

1 July 2014

Great variability in access to ART in Asia

Indonesia

BangladeshNepal

Sri Lanka

Malaysia

Maldives

MyanmarIndia

ASIA

Viet Nam

Philippines

Thailand

Papua New Guinea

Cambodia0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Asia:51%

ART coverage in selected Asian countries, 2012

Coverage: number of people receiving ART in 2012 / number of individuals eligible for ART in 2012 according to 2010 guidelines

Source: WHO SEARO, 2013

Annual ART Scale Up

2005 2006 2007 2008 2009 2010 2011 2012 2013

2,3814,552

6,653

10,616

16,063

19,572

24,410

31,002

39,418

Source : MoH Indonesia, 2013

1 July 201412 months 24 months 60 months

0

10

20

30

40

50

60

70

80

90

100

84%80%

69%MalaysiaCambodiaChinaPapua New GuineaIndonesiaWeighted av-erage

Still too many people are lost from ART: Retention at 12, 24 and 60 months

%

Source: WHO/UNAIDS

Retention rates for ART at 12, 24 and 60 months in selected countries, 2011

Retention rates for ART at 6 & 12months in Indonesia, 2004-2012

2004 2005 2006 2007 2008 2009 2010 2011 20120

20

40

60

80

57.9 57.2 57.561.1 63 65.2 64 64.5

71.6

65.2 64.8 65.368.8 70.8

73.4 72.6 70.675.9

12 months 6 Months On ART

Perc

enta

ge

Source: MoH 2013

1 July 2014

HIV Treatment Cascade

0

100000

200000

300000

400000

500000

600000 590000

188284141360

42411

NA NA

Source: MoH 2014

2. Rationale for Policy Formulation• Evidence of further reducing new HIV infections through “Test and Treat”

or SUFA and global move towards earlier treatment• Implementing SUFA will help accelerating coverage of ART for those most

in need• Joint rapid assessment early 2013 in collaboration among MoH, NAC,

WHO, UNAIDS and UNICEF – to obtain information for developing a roadmap to accelerate

expansion of ARVs for HIV treatment and prevention in Indonesia – To assess barriers to diagnosis and treatment– to review and learn current existing good practices – to find opportunities to further accelerate expansion and coverage of

ART • Mathematical modelling to look at the impact and effectiveness of

program that is expected from rapidly scaling-up ART in Indonesia• Followed by national consultation meeting in March 2013

Mathematical Modeling on Impact of ART coverage on numbers of new HIV infection

• The impact on numbers of new HIV infection would be modest at current levels of ART coverage (the dark blue, red lines and purple)

• Impact will be significantly observed by increasing coverage of those treatment-eligible persons of 80%. (The green and light blue lines )

3. Policy ImplementationContinuum of Comprehensive HIV Services Framework (LKB)

• Indonesia is intensifying the response by strengthening the continuum of HIV-STI comprehensive care, a service delivery model was on going

• Addressing the prevention, care and treatment comprehensively by increased participation of all related stakeholders especially the community members at district level & HIV service available at PHC

Introduction of Strategic Use of ARVs (SUFA) through “LKB”

• Objectives:– To significantly increase HIV testing and ART coverage – To optimize the prevention impact of ARVs by offering ART

regardless of CD4 level to key affected populations and sero-discordant couples

– To strengthen the involvement and ownership by CSO groups.• Strategies

– 1. Expanding HIV diagnosis– 2. Effective enrollment and retention in HIV care– 3. Build on effective efforts that already exist, including the

LKB (CoC)

Phased Approach• Roadmap of “Rapid Scale Up of ART and Strategic Use

of ARVs (SUFA) through LKB” – 75 priority districts– phased implementation and scale-up approach

• started in 13 districts (3 from Tanah Papua and 8 from the remainder of Indonesia) in October 2013.

• rolled-out in 63 additional districts during April till December 2014.

• Minister of Health Regulation No. 21/2013– PITC approach to increase HIV test and counseling– ART regardless CD4 count to KAPs (CSW, MSM,

transgender IDUs), TB-HIV patients, Hep-HIV patients, and HIV infected pregnant women

Initiate ART when the CD4 under 350

Start ART regardless of the

CD4

Key Affected Populations: IDU, MSM, TG, SW Prisoners

Accelerating getting to Zero New Infections (and reduce mortality)

Population PN ART 2012 WHO Consolidated

ARV Guidelines 2013

SUFA

HIV+ ARV-Naïve AZT/TDF + 3TC (FTC) + EFV/NVP

TDF + 3TC (or FTC) + EFV

Priority for new patients TDF + 3TC (or FTC) +

EFV

HIV+ ARV-Naïve Pregnant Women

AZT/TDF + 3TC (FTC) + NVP/EFV

HIV/TB Co-infectionAZT/TDF + 3TC (FTC) + EFV

HIV/HBV Co-infection

TDF + 3TC (FTC) + EFV

Serodiscordant

KAPs (FSW, PWID, MSM, Transgender)

20

Increasing HIV test coverage

56,784 48,13087,651

162,040

300,577

579,185

884,905

1,080,000

7,1846,048

10,362 9,793

21,591 21,031 21,511

29,037

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

2006 2007 2008 2009 2010 2011 2012 2013

Test HIV +

Source : MoH Indonesia, 2013

4. Programmatic Questions - Challenges• For T&T as part of LKB/SUFA to have an impact in Indonesia it would

need to be accessible/acceptable and reach all key affected groups.• T&T/SUFA as in the Permenkes 21 raises programmatic questions

specially about how to improve the HIV treatment cascade:– How best to control STI ?– How best to expand HIV testing and reach those KAPs?– How bes decentralization of HIV services implemented– How best to retain them on treatment– How SUFA will affect adherence and risk behaviors?

• Effective community-based interventions involving KAPs are fundamental in the success of LKB/SUFA

• In a decentralized context local ownership by policy/decision makers is key for adoption of policy and financial sustainability

Acknowledgments

• Ms Wenita I – NAC Indonesia• Dr Oscar Barreneche – WHO Indonesia• Mr Cho Kah Sin – UNAIDS Indonesia• Dr Sri Pandam – WHO Indonesia• Dr Janto Lingga –WHO Indonesia • Ms Fetty Wijayanti –WHO Indonesia• Mr Daniel – Spiritia Foundation• USAID, DFAT, FHI 360, CHAI

TERIMA KASIH

THANK YOU