N/A

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 07 - CIRC Biomedical Prevention: Male Circumcision

Total Planned Funding for Program Budget Code: $0

Program Budget Code: 08 - HBHC Care: Adult Care and Support

Total Planned Funding for Program Budget Code: $640,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

UNAIDS estimates there are 270,000 Indonesians infected with HIV (2008). The GOI recently reported that ART services were

available at approximately 237 health facilities, including 124 hospitals and a limited number of Community Health Centers. A

recent round of monitoring visits to ART sites, jointly undertaken by the MOH, WHO and the USG-supported Aksi Stop AIDS

(ASA) Program, implemented by FHI, suggests, however, that the number of sites actually providing services is much smaller and

is largely confined to the original 25 hospitals covered in the national scale-up scheme. The Minister of Health has proposed a

more rapid expansion of ART service sites, with a target of 482 facilities by the end of 2010. Sufficient resources needed to

accomplish this have yet to be identified, although Indonesia was recently awarded a GFATM Round 8 grant that may help

address some of the resource needs.

The MOH reports that by the end of April 2008, there were 28,086 people accessing some form of HIV care and/or treatment

services. The MOH estimates the number of HIV+ individuals who are or should be receiving ARV therapy services to be

approximately 17,095. Of these, only 13,737 persons have ever received ART - 11,142 males, 2,322 females, and 293 children

under 14. Additionally, 8145 (60%) were actively on ARV treatment in April 2008 (MOH report on the 2008 Indonesian HIV/AIDS

Situation Response Report). The MOH, with support from the GFATM, anticipates expanding the number of individuals receiving

ARV combination therapy to 15,000 by March 2010. There are limited data available on treatment adherence, treatment failure,

drug resistance, so assessing the quality of program efforts to date is difficult.

The first line ART regimen is AZT + 3TC + NVP, with the following alternative regimens: AZT + 3TC + EFV, d4T + 3TC + NVP,

and d4T + 3TC + EFV. The approved second line regimen, TDF + ddI + Lop/r, is problematic because TDF and ddI should not be

used in combination. The approved second line regime has been reviewed and is expected to be adjusted. According to MOH,

ART drugs and CD4 tests are provided free-of-charge by the GOI, supported by GFATM. In practice, barriers to free ART and

CD4 remain as local providers interpret the policy in different ways (e.g., only for registered residents of the district where they are

seeking services, only for the indigent, not for active IDU). All other treatment costs must be borne by patients.

The MOH is responsible for supply chain management of ARV drugs. Although there appears to be sufficient funding from

GFATM, concerns continue to be voiced from the field as to the reliability of supplies. This is particularly the case in Papua. A

USAID core-funded situational assessment of the commodities management system in Tanah Papua was conducted by SCMS in

October 2007. The resulting report stated that any strategic design for a supply chain management system must be constructed

so that it meets the needs of the local hospital and community health center (puskesmas) level. The assessment report serves as

a starting point in the development of a master plan to strengthen the supply chain system in parallel with a possible health

systems strengthening initiative which could be funded under the USG Compact.

The USG, through ASA, has supported the development of a Continuum of Prevention and Care (COPC) network which links,

coordinates and consolidates care, treatment, and support services for PLHIV. COPC services are provided to PLWHA in their

homes, in the communities where they live, and in the health facilities that serve them through a partnership between the

government (and other) supported hospital and health centers and civil society (NGO/CBO/FBO). While COPC services are

generally provided by a number of different organizations, the system that links and coordinates them is planned and managed by

the COPC-Coordination Committee whose members include government officials, service providers, non-governmental

organization (NGO) representatives, PLHIV, and other stakeholders operating at the district/municipal level.

The USG program prioritizes implementation of the MOH strategic plan to include Community Health Centers as ART sites,

starting as satellite sites to hospitals, in order to accelerate universal access to ART and through FHI/ASA has been a key MOH

partner in adapting the IMAAI (Integrated Management of Adult and Adolescence Illnesses) approach for HIV/AIDS case

management to provide clear implementation guidelines on initiation and management of ART patients at hospitals and

Community Health Centers, respectively. Case managers function as an integral part of CST teams, providing out-of-

hospital/clinic psycho-social support, advocacy, and follow-up, including adherence support. Case management is critical for

supporting treatment adherence which cannot be adequately addressed by hospital/clinic staff. The role of case managers in the

COPC is particularly critical with regard to ART and opportunistic infection (OI) drug supplies, which are frequently interrupted due

to weaknesses in the supply chain. Case managers have served as a vital link by locating alternative supplies and ensuring that

their clients can continue the therapy without interruption.

In FY07, the USG began to pilot the COPC network model focusing on MARPs in 3 sites in Java (DKI/Jakarta, West Java

(Bandung) and East Java (Malang). The COPC network model focuses on 2-3 health centers in each site. In Papua, the health

system strengthening effort focused on implementing the COPC in at least 1 health center in each of 5 (out of 10) priority districts.

USG FY08 funds were used to scale-up services in the MARPs COPC, continue efforts in the 5 initial Papua districts and initiate

the COPC in 5 additional districts. Integrated palliative care and treatment services for PLHWA were made available through

these selected community health centers. Services consist of chronic, acute, and palliative care, including OI prophylaxis, OI

treatment, ART, PMTCT, and TB screening and treatment.

A major initiative undertaken with FY08 funds provided leadership and technical support to the MOH in shifting care, support and

treatment efforts from a limited, facility-based "case management" model to a "community and home-based care" approach; and

continued expansion of coverage and improvement in the quality of community-based ART adherence counseling and support

through ASA's network of NGO community-based case managers. Using FY09 funds, USG will pilot palliative and home and

community based care (HCBC) initiatives to be implemented in Jakarta and Papua as a first step in developing long-term care

services for PLWHA. Based on this experience, a model program will be defined and appropriate training curriculum and

management systems will be developed for use in future expansion in East and West Java. Key components of the program will

include proactive linkages among PLWHA, improve access and quality of care, treatment and support for PLWHA with a focus on

increasing VCT, treatment for OI and community-based care and support, case managers, clinical service providers and HCBC

service providers, and home visit teams to provide direct care and adherence support in the community. Efforts focused on

refresher training in adherence monitoring and counseling for NGO and health facility staff, as well as improving linkages between

community-based support staff and health facilities that provide ART clinical services through regular case and program review

meetings. In addition, USG funds supported testing special palliative care service configurations to meet the needs of IDU.

Several clinics that received special training in the management of HIV/AIDS for IDU received additional training in FY08 to

undertake detailed health assessments for newly diagnosed IDU HIV+ individuals. The results of the health assessments will

provide a basis for developing treatment and referral plans, including TB screening and treatment, and management of Hepatitis

C for the above initiatives.

The concept of HIV palliative care is not well established in the Indonesian public health system; the most common perception is

that it entails end of life care and an emphasis on OI prophylaxis and treatment. The MOH has developed a national policy and

established targets for "PLWA care and support services," but guidelines lack a comprehensive description of the standards and

services to be included in the service package. The WHO, along with the USG-supported Aksi Stop AIDS (ASA) Program,

implemented by FHI, and the AusAID-funded Indonesian HIV/AIDS Prevention and Care Program, are currently working with the

MOH to develop national service guidelines and Standard Operating Procedures (SOP) for palliative care. National service

guidelines were piloted in three service sites in 2007 and will expand to Papua in 2008. The goal is to adopt these as national

guidelines and SOPs in 2009.

In FY 07, the USG program began to provide support to a limited number of provincial hospitals (Soetomo in Surabaya, Hasan

Sadikin in Bandung, Dok II in Jayapura, Selebesolu in Sorong, and Gatot Subroto Army Hospital in Jakarta) with an eye towards

creating a "center of excellence" in each province to lead the national scale-up effort. Efforts here focused on additional mentoring

of hospital staff, introducing quality assurance mechanisms, and developing stronger linkages between the different HIV-related

service components in order to strengthen the COPC model. Several of these sites now function as referral hospitals for the

district-level COPC sites that was initiated with FY07 and scaled up with FY08 funds. USG funding now provide on-going

technical assistance for the 3 model COPC district sites in Java and for the COPC district sites in Papua mentioned above. ASA

provides mentoring, quality assurance training and adherence counseling training as part of ART services. DoD funds will provide

support for the creation of a Center of Excellence at the Gatot Subroto Army Hospital, through a capacity development workshop

related to care and treatment.

With FY08 funds, USG also supported clinical staff to continue to serve as front-line trainers for the planned expansion of sites

offering ART under the national roll-out plan (for which primary funding comes from the Global Fund). The FHI/ASA Country Office

Clinical Services Unit and Clinical Services Officers, located in each of the 8 USG priority provinces, are active participants in all

national program scale-up activities. The USG, through ASA, supports partner organizations to provide technical assistance and

collaborate with the Ministry of Social Welfare on capacity building and developing a core of case management trainers and

supervisors to coordinate training, mentoring, and supervision from central to district levels. Particular emphasis is placed on

"positive prevention," communicated through the "HIV stops with me" message. Through USG support, ASA also provides

assistance to the MOH and indigenous PLWHA support groups on developing a standard format for medical records and a "health

passport" to be carried by patients to assist with referrals and care. ASA also provides home care kits for use by Case Managers.

Finally, ARV services in Papua are linked to the expansion and strengthening of the network model. USG is the primary supporter

of the ASA Papua Provincial Health Office's Health System Strengthening scheme, which will entail the development of a

functioning network of health facilities (i.e., hospitals linked with several Community Health Centers) in Jayapura and one

Community Health Center in each of the 29 districts in Tanah Papua. FHI/ASA staff played a lead role in assisting the Papua

Provincial Health Office in developing the plan and in the early stages of capacity building. These efforts, which leverage both GOI

and Global Funds, as well as USG funds, are geared to rapidly expanding the availability of ART and supporting services.

In Tanah Papua increased focuses on strengthening reporting and recording systems to bring these in line with the national

system. In FY09, USG will focus on improving record-keeping systems to manage individual patient care, and monitor the scale-

up of ART services and developing referral systems and other mechanisms to enable a functioning network model. Given

physical distances involved and the limited transportation infrastructure in many parts of Papua, it is essential that community

health centers are capable of managing at least non-complicated HIV/AIDS cases as quickly as possible, though it may be

necessary for ART to continue to be prescribed at higher-level facilities. In order to accomplish this, USG FY07 funds were used

to strengthen and standardize recordkeeping and reporting formats at Provincial Health Offices and initiate regular monitoring and

mentoring visits at "network" facilities offering ART in Jayapura, the capital of Papua Province. In FY08, these efforts were

expanded to 10 priority districts in Tanah Papua.

In FY09, USG funds will continue to be used to provide technical assistance to support the scale-up clinic and palliative care

aspects of the COPC system as well as for on-going support to MOH in rolling out comprehensive services.

Table 3.3.08: