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Wulandari LPL, Lubis DS, Kurniati DPY, Sumintang K, Ardrini DAM, Mariani P, Januraga PP, Camellia A, Laksmi NMDP, Mahmudah L, Ong JJ, Causer L, Liverani M, Guy R, Wiseman V. Challenges to integrating programs for the elimination of mother-to-child transmission of HIV, syphilis, and hepatitis B into antenatal care: Experiences from Indonesia. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002977. [PMID: 38446812 PMCID: PMC10917262 DOI: 10.1371/journal.pgph.0002977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 01/25/2024] [Indexed: 03/08/2024]
Abstract
The WHO's Asia-Pacific framework for triple elimination recommends that countries evaluate their programs for the elimination of mother-to-child transmission of HIV, syphilis, and hepatitis B (EMTCT), including identifying gaps to improve program planning and the implementation of elimination strategies in antenatal care (ANC) services. In 2022, the Indonesian Ministry of Health reported that only 39% of pregnant women were tested for HIV, 14% for syphilis, and 28% for hepatitis B, respectively. We conducted a qualitative study involving a focus group discussion (FGD) and in-depth interviews with 25 key stakeholders in Bali and West Nusa Tenggara Provinces to identify specific challenges to testing for HIV, syphilis, and hepatitis B in ANC settings. Thematic analysis was used to identify the themes generated from the data. Health system bottlenecks experienced by stakeholders included supply chain management issues involving stock forecasting and stock monitoring, stock-outs of rapid test reagents which were particularly most frequent and for longer durations for syphilis and hepatitis B, high staff turnover, lack of staff training on how to perform the test, the complexity and time needed to record the data on women's characteristics, risk behaviours, and testing in both paper format and into the computer-based surveillance systems, discrepancies in program coverage data from different divisions of the district health office involved in the reporting system, high levels of stigma that prevented women from being followed up, challenges in notifying partners, and inadequate reporting and referral of women from private providers to public ones for testing. Interventions addressing the above challenges are worthy of consideration to improve the health system function and integrate EMTCT into the ANC settings.
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Affiliation(s)
- Luh Putu Lila Wulandari
- The Kirby Institute, University of New South Wales, Sydney, Australia
- Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University, Bali, Indonesia
| | - Dinar Saurmauli Lubis
- Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University, Bali, Indonesia
| | - Desak Putu Yuli Kurniati
- Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University, Bali, Indonesia
| | - Karjono Sumintang
- Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University, Bali, Indonesia
| | - Dewa Ayu Mirah Ardrini
- Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University, Bali, Indonesia
| | | | - Pande Putu Januraga
- Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University, Bali, Indonesia
- Center for Public Health Innovation, Faculty of Medicine, Udayana University, Bali, Indonesia
| | | | | | | | - Jason J. Ong
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
- China-Australia Joint Research Center for Infectious Diseases, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Louise Causer
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Marco Liverani
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Faculty of Public Health, Mahidol University, Bangkok, Thailand
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - Rebecca Guy
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Virginia Wiseman
- The Kirby Institute, University of New South Wales, Sydney, Australia
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Ryan LM, Mahmood MA, Mufiddah I, Yulianti M, Laurence CO. Concomitant illnesses in pregnancy in Indonesia: A health systems analysis at a District level. PLoS One 2022; 17:e0279592. [PMID: 36584088 PMCID: PMC9803104 DOI: 10.1371/journal.pone.0279592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 12/10/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In LMICs, including Indonesia, there is a rising burden of non-communicable diseases (NCDs) with a prevailing burden of infectious diseases, including among pregnant women. The Indonesian health system faces significant challenges to provide effective care for infectious diseases, and even more so, NCDs. This is concerning due to the greater vulnerability of pregnant women to complications caused by concomitant illnesses (NCDs and infectious diseases), and the need for complex, integrated healthcare between maternal care and other health services. METHODS The objective of this study was to understand supporting factors and challenges of the health system to providing care for concomitant illnesses in pregnancy and how it may be improved. Semi-structured interviews were conducted with sixteen key stakeholders, including health providers and health service managers, involved in maternal healthcare for concomitant illnesses at a District level in Indonesia. The study was conducted in Kutai Kartanegara District of East Kalimantan. Analysis was conducted using framework analysis to identify themes from transcripts. RESULTS Supporting factors of the health system to provide care for concomitant illness in pregnancy included collaboration between health providers and health services, availability of screening and diagnostic tools, and access to universal healthcare coverage and financial subsidies. Common challenges included knowledge and awareness of concomitant illnesses among health providers, competency to diagnose and/or manage concomitant illnesses, and inappropriate referrals. Suggested improvements identified to address these gaps included increasing education and refresher training for healthcare providers and strengthening referrals between primary and hospital care. CONCLUSIONS The findings identified gaps in the health system to provide care for concomitant illnesses in pregnancy in Indonesia that need to be strengthened. More evidence-based research is needed to guide the implementation of policy and practice interventions for the health system to deal with a broader range of concomitant illnesses in pregnancy, particularly NCDs.
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Affiliation(s)
- Lareesa M. Ryan
- School of Public Health, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
- * E-mail:
| | - Mohammad Afzal Mahmood
- School of Public Health, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
- Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia
| | - Ismi Mufiddah
- Kutai Kartanegara District Department of Health, Tenggarong, Kutai Kartanegara District, East Kalimantan, Indonesia
| | - Martina Yulianti
- Kutai Kartanegara District Department of Health, Tenggarong, Kutai Kartanegara District, East Kalimantan, Indonesia
| | - Caroline O. Laurence
- School of Public Health, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
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Zhang Y, Guy R, Camara H, Applegate TL, Wiseman V, Treloar C, Lafferty L. Barriers and facilitators to HIV and syphilis rapid diagnostic testing in antenatal care settings in low-income and middle-income countries: a systematic review. BMJ Glob Health 2022; 7:bmjgh-2022-009408. [PMID: 36319030 PMCID: PMC9628546 DOI: 10.1136/bmjgh-2022-009408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 09/24/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Testing and treatment during pregnancy is a well-established and cost-effective prevention strategy, which relies largely on use of rapid diagnostic tests (RDTs). Yet, in many low-income and-middle-income countries, the uptake of RDTs is suboptimal. A qualitative meta-synthesis was conducted to identify the barriers and enablers to use of HIV and syphilis RDTs among pregnant women in low-income and middle-income countries. METHODS This review was conducted using PRISMA guidelines. Eligible studies included peer-reviewed publications, which used qualitative methods to explore HIV and syphilis RDT in antenatal care clinics in low-income and middle-income countries. Studies focusing on perspectives of pregnant women, healthcare workers and/or stakeholders were included. We used an inductive approach informed by a modified socioecological model to synthesise the data. RESULTS 62 manuscripts met the eligibility criteria. For pregnant women, initial acceptance of the RDT and continuation in antenatal care depends on the perception that engaging in testing will be a beneficial experience for their baby and themselves, often influenced by the provision of services that are gender-sensitive, confidential, respectful, flexible and considers their well-being into the future. Local sociocultural beliefs about pregnancy and diseases, awareness of diseases and gender roles in society also influenced RDT acceptability among pregnant women. For healthcare workers, the ability to provide high-quality RDT care required ongoing training, accurate and easy to use tests, support from supervisors and communities, sufficient resources and staffing to provide services, and reliable salary. At the stakeholder level, well-developed guidelines and health system infrastructures were imperative to the delivery of RDT in antenatal clinics. CONCLUSION Our findings highlight clear gaps to the provision of sustainable and culturally acceptable maternal HIV and/or syphilis screening using RDTs. In addition, greater attention needs to be paid to community stakeholders in promoting the uptake of RDT in antenatal clinics. PROSPERO REGISTRATION NUMBER CRD42018112190.
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Affiliation(s)
- Ye Zhang
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Rebecca Guy
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Hawa Camara
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Tanya L Applegate
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Virginia Wiseman
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Carla Treloar
- Centre for Social Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Lise Lafferty
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Centre for Social Research in Health, University of New South Wales, Sydney, New South Wales, Australia
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Adawiyah RA, Boettiger D, Applegate TL, Probandari A, Marthias T, Guy R, Wiseman V. Supply-side readiness to deliver HIV testing and treatment services in Indonesia: Going the last mile to eliminate mother-to-child transmission of HIV. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000845. [PMID: 36962570 PMCID: PMC10021386 DOI: 10.1371/journal.pgph.0000845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 07/06/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Despite national efforts to integrate Prevention of Mother-to-Child Transmission (PMTCT) of HIV services into antenatal care in Indonesia, the rate of mother-to-child transmission of HIV remains the highest in the world. A range of barriers to uptake and long-term engagement in care have been identified, but far less is known about health system preparedness to deliver PMTCT of HIV services. This study explored supply-side barriers to the delivery of PMTCT services in Indonesia and whether these factors are associated with the uptake of antenatal HIV testing. MATERIALS AND METHODS An ecological analysis was undertaken, linking data from the World Bank Quality Service and Delivery Survey (2016) with routine data from Indonesia's HIV and AIDS case surveillance system and district health profile reports (2016). Supply-side readiness scores-generated from a readiness index that measures overall structural capacity and is often used as proxy for quality of care-were adapted from the WHO Service Availability and Readiness Assessment and presented by sector and geographic area. Univariate and multivariate regression analysis was used to explore factors associated with the uptake of antenatal HIV testing in public facilities. RESULTS In general, public facilities scored more highly in most inputs compared to private facilities. Facilities located in urban areas also scored more highly in the majority of inputs compared to ones in rural areas. Readiness scores were lowest for PMTCT services compared to Antenatal Care and HIV Care and Support services, especially for the availability of medicines such as zidovudine and nevirapine. The national composite readiness score for PMTCT was only 0.13 (based on a maximum score of 1) with a composite score of 0.21 for public facilities and 0.06 for private facilities. The multivariate analysis shows that the proportion of pregnant women tested for HIV was more likely to be greater than or equal to 10% in facilities with a higher readiness score and a higher number of trained counsellors available, and less likely in facilities located outside of Java-Bali and in facilities supporting a higher number of village midwives. DISCUSSION Despite targeted efforts by the Indonesian government and multinational agencies, significant gaps exist in the delivery of PMTCT that compromise the standard of care delivered in Indonesia. Future strategies should focus on improving the availability of tests and treatment, especially in the private sector and in rural areas.
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Affiliation(s)
| | - David Boettiger
- The Kirby Institute, University New South Wales, Sydney, Australia
| | | | - Ari Probandari
- The Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Indonesia
| | - Tiara Marthias
- Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
| | - Rebecca Guy
- The Kirby Institute, University New South Wales, Sydney, Australia
| | - Virginia Wiseman
- The Kirby Institute, University New South Wales, Sydney, Australia
- The London School of Hygiene and Tropical Medicine, London, United Kingdom
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