Paper : Women with HIV in Indonesia: are they bridging a concentrated epidemic to the wider community?



Reference:
Rahmalia, A., Wisaksana, R., Meijerink, H., Indrati, A. R., Alisjahbana, B., Roeleveld, N., ... & Crevel, R. (2015). Women with HIV in Indonesia: are they bridging a concentrated epidemic to the wider community?. BMC research notes, 8(1), 757.

https://bmcresnotes.biomedcentral.com/articles/10.1186/s13104-015-1748-x

Women with HIV in Indonesia: are they bridging a concentrated epidemic to the wider community?

  • Annisa RahmaliaEmail author,
  • Rudi Wisaksana,
  • Hinta Meijerink,
  • Agnes R. Indrati,
  • Bachti Alisjahbana,
  • Nel Roeleveld,
  • Andre J. A. M. van der Ven,
  • Marie Laga and
  • Reinout van Crevel
BMC Research Notes20158:757
https://doi.org/10.1186/s13104-015-1748-x
©  Rahmalia et al. 2015
Received: 4 June 2015
Accepted: 25 November 2015
Published: 9 December 2015

My summary.....................


Abstract

Background

Male injecting drug users drove the onset of the HIV epidemic in Indonesia but over time more women have been diagnosed. We examined the relative proportion of female patients in an HIV cohort and characterized their probable transmission route and reproductive profile.

Designs

Prospective cohort study in a referral hospital in West Java.

Methods

Interviews with standardized questionnaires, physical and laboratory examinations were done for 2622 individuals enrolled in HIV care between 2007 and 2012. The proportion of women in this cohort was compared with national estimates. The general characteristics of HIV-infected women and men as well as the sexual and reproductive health of HIV-infected women were described.

Results

The proportion of female patients enrolled in HIV care increased from 22.2 % in 2007 to 38.3 % in 2012, in line with national estimates. Women were younger than men, fewer reported a history of IDU (16.1 vs. 73.8 %, p < 0.001) and more were tested for HIV because of a positive partner (25.5 vs. 4.0 %, p < 0.001). The majority of women were in their reproductive age, had children, and were not using contraceptives at the time of enrolment.

Conclusion

HIV-infected women in Indonesia have specific characteristics that differ them from women in the general population. Further research to elucidate the characteristics of women exposed to HIV, their access to testing and care and sexual and reproductive needs can help reduce transmission to women and children in the context of concentrated HIV epidemic in Indonesia.

Keywords

HIVWomenReproductive healthConcentrated epidemicIndonesia


Methods

Setting and study population

The study was performed at Hasan Sadikin hospital, the main referral hospital in Bandung, the capital of West Java, a province of 43 million [18] in Indonesia, which has one of the highest HIV rates in Indonesia. Since August 2007 all subjects enrolled in HIV care have been included in a prospective cohort [19]. The Health Research Ethics Committee of the Faculty of Medicine Padjadjaran University in Bandung, Indonesia approved the study, and all patients provided written informed consent. As one of the first 25 hospitals selected by the government to provide HIV care, this hospital has delivered free antiretroviral therapy (ART) since December 2004. CD4 testing became available in Hasan Sadikin hospital in September 2007 while measurement of HIV-RNA can be done since January 2008.
HIV testing was done through voluntary counselling and testing (VCT) or, when patients were referred from other departments within the hospital, through provider-initiated testing and counselling (PITC). HIV-infected patients were enrolled in care and given cART according to the national guidelines. Women who were found pregnant when entering HIV care were given prophylactic ARV and referred to the obstetrics department. HIV screening in antenatal clinics is no routine in West Java, including in the main referral hospital.
RESULT

Characteristics of HIV-infected men and women

Women in this cohort were younger, fewer of them had a job and more were divorced or widowed compared to men (Table 1). More women than men reported that their partners have had an HIV test (53.8 vs. 32.6 %, p < 0.001) and this was also true for the subgroup of married women and men (73.8 vs 64.6 %, p = 0.001). Men and women differed in their probable transmission route (Table 1): significantly fewer women than men (16.1 vs. 73.8 %, p < 0.001) reported a history of IDU, and more women had been involved in sex work (6.6 % vs. 0 %, p < 0.001) and tested for HIV because of an HIV-positive partner (25.5 vs. 4.0 %, p < 0.001)—the two latter numbers were obtained from a subgroup analysis of 212 women and 348 men. Women also presented earlier with less advanced disease, fewer HCV co-infections and a higher CD4 cell count (median: 207 vs. 81 cells/µl; p < 0.0001) (Table 1). Among the ART-naïve population, including 499 women and 904 men, CD4 cell counts were much higher in women compared to men (median: 176 vs. 41 cells/µl; p < 0.0001). Fewer women than men had received ART prior to enrolment (18.1 vs. 28.4 %, p < 0.001). Seventeen women (2.4 %) took ART as PMTCT, two of whom were pregnant when entering care.
Table 1
Baseline characteristics of HIV-infected men and women (n = 2662)
 
Female* (n = 881)
Male* (n = 1781)
Sociodemographics
 Median age, years (IQR)
28 (25–32)
30 (28–34)
 Education, n (%)
No education
2 (0.3)
2 (0.2)
Up to 6 years
83 (11.3)
44 (2.9)
>6 to 9 years
110 (14.9)
136 (9.0)
>9 to 12 years
356 (48.3)
799 (53.1)
>12 years
186 (25.2)
524 (34.8)
 Occupation, n (%)
None
163 (22.1)
340 (22.5)
Housewife
299 (40.5)
3 (0.2)
Job in the past month
277 (37.5)
1166 (77.3)
 Marital status, n (%)
Single
85 (11.6)
669 (44.5)
Married
439 (59.7)
709 (47.1)
Divorced/widowed
211 (28.7)
126 (8.3)
 Smoking, n (%)
 
188 (35.7)
776 (76.0)
Probable transmission route
 History of IDU, n (%)
 
112 (16.1)
1081 (73.8)
 History of sex work, n (%)
 
14 (6.6)
0
 HIV test because of partner notification, n (%)
54 (25.5)
14 (4.0)
Risk behaviour
 Condom use, n (%)
Never
337 (67.8)
427 (56.1)
Rarely
33 (6.8)
48 (6.4)
Sometimes
41 (8.3)
66 (8.8)
Often
14 (2.8)
51 (6.6)
Always
71 (14.3)
170 (22.1)
Clinical status
 WHO clinical stage,  %
I
258 (39.6)
179 (13.5)
II
58 (8.9)
83 (6.3)
III
133 (20.4)
399 (30.1)
IV
203 (31.1)
663 (50.1)
Laboratory parameters
 Median CD4, cells/µl (IQR)
207 (51–370)
81 (18–270)
 Positive anti-HCV Antibody, n (%)
122 (22.8)
868 (74.9)
 Positive Hepatitis B, n (%)
 
17 (2.9)
96 (7.7)
Reproductive health
  
N/A
 Pregnant, n (%)
 
43 (8.6)
 Contraceptive use other than condom, n (%)
120 (22.5)
 Number of children, n (%)
0
179 (25.6)
1
320 (45.9)
2
142 (20.3)
≥3
57 (8.2)
Data were missing for smoking (40.2 % in women and 42.7 % in men), pregnant (43.1 % in women), condom use (43.6 % in women and 56.8 % in men), history of sex work (75.9 % in women and 80.5 % in men) and HIV test because partner is HIV positive (75.9 % in women and 80.5 % in men)
IQR interquartile range, IDU injecting drug use, HCV hepatitis C virus
* Chi square or Mann–Whitney tests p value <0.01 for all variables presented


Sexual and reproductive health

More than half of the women (56.1 %) never used condoms, less than a quarter of them reported other contraceptive use and some were pregnant at time of enrolment (Table 1). The majority of women had had a steady partner; only 11.6 % were single while the rest were either married or divorced/widowed. Almost all women were in their reproductive age with one quarter of them aged between 16 and 25 years old and less than 1 % older than 49.
The proportion of HIV-infected married women who had disclosed their HIV status to their husbands was higher than disclosure from men to their spouses (75.8 vs. 70.5 %, p = 0.057). Likewise, more women indicated that their husbands had been tested for HIV than men indicating their wives had been tested (73.8 vs. 64.6 %, p = 0.001).
Forty-three women (8.6 %) were pregnant when entering HIV care (Table 1), but only one was referred to the HIV clinic from an antenatal service. A high proportion of women had at least one child (74.4 %). There were no data of HIV status of these children; but 79 HIV positive children had been enrolled in the cohort with a median age of 3.1 years old and median CD4 cell count of 221 cells/µl.

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