N/A

New/Continuing Activity: New Activity

Continuing Activity:

Program Budget Code: 13 - HKID Care: OVC

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

N/A

Program Budget Code: 14 - HVCT Prevention: Counseling and Testing

Total Planned Funding for Program Budget Code: $350,000

Total Planned Funding for Program Budget Code: $0

Program Area Narrative:

Until recently, Indonesians had limited access to HIV Counseling and Testing (CT) services, with services being available

primarily through NGOs. However, in line with the GOI intention to provide universal access to HIV/AIDS-related services, the

number of CT sites is being scaled up rapidly. At present, the MOH is offering CT services at 218 hospitals that are capable of

implementing comprehensive HIV/AIDS services, including CT and ARV. The MOH has plans to increase the number of sites

providing CT, currently MOH has established 482 VCT units in Indonesia (204 in hospitals; 14 in mental hospitals, and 119 in

health centers, 115 in NGO clinics, and 30 in prisons) and more than 28,000 individuals have received complete CT services. In

addition, CT has been introduced at 63 Community Health Centers in Jakarta and West Java in connection with IDU efforts

supported by the respective provincial health offices, the Indonesian Partnership Fund, and AusAID.

The current MOH policy uses triple, serial rapid tests with immediate feedback of results. The MOH minimum standards for HIV

diagnostic tests are: (1) registered at MOH Indonesia; (2) sensitivity first reagent should be > 99%; (3) specificity second reagent

should be = 98% and > first reagent; (4) specificity third reagent should be = 99% and > first reagent; (5) antigen preparation and

or principle of test from each reagent should be different; and (6) indeterminate result should be < 5%.

The first-line combination of HIV tests currently recommended by the MOH is SD HIV 1/2 Bioline (Multi) - Determine HIV 1/2

(Abbott) - HIV Tridot. To date, this combination has yielded good results - over 99% joint sensitivity and specificity, with

specificity of the second and third reagents being 100%. The primary concern using this combination is maintaining cold chain

during transport, as the HIV Tridot test needs to be kept at 2-8 °C. Some resistance to the use of the triple rapid test without

confirmation by ELISA has been reported at the field level. This appears to reflect mistrust of rapid testing in the provinces and

possibly vested interests in labs doing ELISA. The MOH is responsible for supply chain management, and with the recent Round

8 proposal success, GFATM funding appears to be sufficient. However, concerns continue to be voiced from the field as to the

reliability of supply.

Since CT services are a key entry point into the full range of interventions that make up the continuum of prevention and care

(COPC) and provide an opportunity to reach both HIV+ and HIV- individuals with prevention messages and information, the USG

has supported the national roll-out of CT services through the USG-funded Aksi Stop AIDS (ASA) program, implemented by FHI.

Through FY07, support focused on developing national policy, service guidelines and SOPs, as well as facilitating ASA staff

participation as national trainers in efforts to develop a cadre of skilled service providers. ASA assisted the MOH with evaluating

new HIV test kits for possible adoption by the national program and quality assurance of HIV testing being undertaken under the

national program. Additionally, USG funded the reprinting of national CT service guidelines and SOP manuals to support the

ongoing accelerated scale-up of CT services.

In 2007, the number of USG directly supported sites offering complete CT services was 8. An additional 39 sites were supported

through joint funding with the Indonesian Partnership Fund. With the drop in IPF funding, a transition from direct services to

technical assistance is taking place and this is no longer the case. The emphasis is now shifting to supporting district level

facilities providing the services with limited technical support by USG. USG funding fills gaps in GOI efforts by supporting CT

services at locations where HIV is transmitted sexually and via contaminated needles (by IDU). USG-supported CT services are

located nearby in sexual transmission "hotspots". CT sites are linked with NGOs providing outreach, behavior change

communication, condoms and lubricants, and CT referral services to MARPs (IDU, FSW, MSM, transvestites). GOI clinics, in

USG-supported "hot spots" are open extra hours each day in order to increase access by MARP. Although the official GOI policy

for CT is "opt-in," USG programs are advocating an "opt-out" policy for MARP and have pilot-tested this in CT sites. The MOH

triple rapid test policy is followed at all USG-supported sites in order to maximize the likelihood of individuals tested receiving their

test results. As the ASA program moves away from funding individual CT sites to supporting networks of provincial and district

health facilities and strengthening the COPC model in specific sites, support for CT services will be transitioned to local and

provincial governments. Items such as incentives and the purchase of reagents will have to be covered by MOH and the local

government health budgets. USG FY09 funding will continue to provide support in the form of mentoring programs, quality

assurance, and other technical assistance.

In FY08 the USG supported unmet need and filling gaps in CT by supporting 3 COPC MARP sites in Java. In Tanah Papua, CT

services are extremely limited (large hospitals in a few large cities). USG has been the primary supporter of the Papua Provincial

Health Office's Health System Strengthening scheme, which entails developing a functioning network of health facilities in

Jayapura with capacity to provide comprehensive services, including CT. With FY 08 funds, CT services have been expanded so

that in each of the 10 USG priority districts in Tanah Papua there should be at least one Community Health Center providing

comprehensive services (OI management, ART), including quality CT.

Additionally, in FY08, a major thrust of all CT efforts is to continue supporting the improvement of the quality of counseling and

ensuring confidentiality of CT clients. Lack of privacy and confidentiality remains an issue at GOI facilities. USG continues to

support capacity building within NGOs to improve their outreach skills to increase demand and use of CT services.

In FY09, USG funding will focus on providing support in the form of mentoring programs, quality assurance, and other technical

assistance. The USG will support the Provincial Health Office and other partners to roll-out provider-initiated HIV testing and

counseling in Tanah Papua. The Provincial Health Offise is using a "Could it be HIV" campaign for all patients who come to the

public health centers, regardless of the service sought, including those receiving TB treatment. If risk factors are present or HIV is

suspected, the patient will be offered CT and followed up with case management and CST for positive patients or post-test

counseling on prevention, STI screening and treatment for negative patients.

In addition in FY09, the USG will work with companies, industry associations and the local health services to promote STI and CT

services for high-risk men by strengthening referral systems and in particular by identifying a wider network of public and private

health care providers (clinics and/or doctors) that are prepared to provide services to high-risk men.

USG will continue support to the Indonesian military to scale-up the capacity of additional military clinics to provide CT services

and surveillance. With FY07 funds, Defense Forces (TNI) Center for Health (PUSKES) coordinated, planned, and executed TOT

counseling workshops for CT clinics. This allowed the PUSKES medical staff to reach Indonesian TNI units posted throughout

Indonesia. With FY 08 funds HIV tests kits will also be procured to support CT, screening, and surveillance activities. Distribution

of supplies will also be targeted to facilities in high prevalence areas. Test kits may include, but are not limited to HIV Rapid test

kits (2-3 brands to satisfy testing algorithm) as well as consumables to augment testing (gloves, vacutainers, pipettes, etc).

With FY09 funds, DOD will expand and provide support to VCT activities and will be used to fund much needed HIV/AIDS rapid

test kits and to build upon training provided with FY07 and FY08 funding. HIV test kits will be procured to support testing and

surveillance activities. Distribution of supplies will be targeted to facilities designed by the TNI as high prevalence areas. Test kits

will be those approved for use by the MOH so that they may be used both for military personnel and civilians accessing military

health facilities. In addition, funds will support technical assistance and travel as required.

Table 3.3.14: