BOOK: Model Pencegahan HIV Melalui Transmisi Seksual di Tingkat Pelayanan Primer Puskesmas dan Jejaringnya

Reference

http://www.kebijakanaidsindonesia.net/id/hasil-penelitian/1562-model-pencegahan-hiv-melalui-transmisi-seksual-di-tingkat-pelayanan-primer-puskesmas-dan-jejaringnya

Model Pencegahan HIV Melalui Transmisi Seksual di Tingkat Pelayanan Primer Puskesmas dan Jejaringnya / Pande Putu Januraga; Aang Sutrisna; Vidia Darmawi; Ignatius Praptoraharjo; M. Suharni; Ignatius Hersumpana; Ita Perwira; Swasti Sempulur; Satiti R.P; & Eviana Hapsari Dewi / Yogyakarta: INSISTPress & Pusat Kebijakan dan Manajemen Kesehatan Fakultas Kedokteran Universitas Gadjah Mada (PKMK FK UGM). xvi+102 halaman/19 x 25 cm Cetakan pertama, September 2016 ISBN: 978-602-0857-19-0

Model Pencegahan HIV Melalui Transmisi Seksual di Tingkat Pelayanan Primer Puskesmas dan Jejaringnya HOT

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INDONESIA sedang mengalami potensi pergeseran epidemi, awalnya didominasi oleh penularan melalui jarum suntik pada kelompok pengguna narkoba suntik (penasun), kemudian penularan seksual pada populasi wanita penjaja seks (WPS); kini didominasi oleh penularan seksual pada WPS dan laki-laki seks dengan laki-laki (LSL) termasuk waria, yang mencapai 90% dari proyeksi infeksi baru HIV-AIDS 70,000 – 80,000/tahun sepanjang 2014-2019. Sebuah model intervensi spesifik pencegahan penularan seksual kepada populasi kunci, yakni program pencegahan melalui transmisi seksual (PMTS), telah dikembangkan sejak tahun 2010 sebagai respons terhadap perkembangan epidemi HIV di Indonesia. Sayangnya program tersebut lebih banyak mengandalkan dukungan finansial mitra internasional.

Penelitian hasil kerjasama PKMK FK UGM dengan Department of Foreign Affairs (DFAT) ini menghasilkan usulan model layanan yang terintegrasi agar PMTS dapat terus berlangsung di tingkat pelayanan kesehatan dasar (primary health care, PHC), serta model kebijakan operasional yang mendukung terlaksananya integrasi. Penelitian ini memilih layanan primer sebagai fokus pelayanan PMTS karena posisi, peran, dan kontribusinya dalam upaya penanggulangan HIV-AIDS di Indonesia telah teruji.

Metode yang digunakan merupakan kombinasi berbagai pendekatan. Utamanya adalah desk review, yang disusun menjadi kertas kerja model pelayanan PMTS, dan kuesioner yang digunakan untuk survei Delphi. Usulan model yang ditampilkan dalam laporan ini telah mendapatkan dukungan/konsensus dari responden survei Delphi yang terdiri dari para pakar dan praktisi penanggulangan HIV-AIDS di Indonesia.

Secara ringkas, hasil desk review terhadap berbagai dokumen ilmiah dan kebijakan terkait penanggulangan HIV-AIDS di tingkat nasional maupun internasional mendukung strategi pencegahan yang komprehensif, meliputi pencegahan dengan pendekatan biomedik seperti penyediaan kondom, sirkumsisi, testing, dan konseling HIV, yang dilanjutkan dengan pengobatan antiretroviral(ARV) jika positif, penanganan infeksi menular seksual (IMS), dan pencegahan berbasis ARV lainnya. Selain itu, pencegahan dengan pendekatan perilaku juga penting dilakukan melalui berbagai upaya promosi kesehatan, baik individual maupun masyarakat. Di sisi lain, diperlukan dukungan struktural berupa reformasi kebijakan dan peraturan yang menghambat pelayanan, serta gerakan pemberdayaan baik berbasis gender, ekonomi, dan pendidikan masyarakat. Disadari bahwa di tingkat layanan primer, pendekatanstruktural lebih bergantung pada upaya lintas sektor instansi atau organisasi terkait lainnya.

Jika dilihat dari berbagai dokumen kebijakan program penanggulangan dari tingkat internasional maupun nasional, dapat disimpulkan bahwa hampir seluruh komponen layanan di atas dimaksudkan untuk dapat dilakukan di tingkat primer, yaitu puskesmas dan jejaringnya, kecuali, sebagaimana yang disampaikan sebelumnya, khusus untuk dukungan struktural diperlukan peran lebih aktif lintas sektor. Secara praktis, model pelayanan yang ada saat ini juga telah menunjukkan peran puskesmas yang penting dan bermakna dalam pelayanan PMTS kepada kelompok berisiko tinggi, meski kemudian masih dominan didorong oleh kebijakan global dalam bentuk dukungan finansial donor internasional. Peran penting puskesmas terutama dalam pendistribusian kondom pada populasi berisiko tinggi, promosi kesehatan terarah kepada kelompok populasi berisiko tinggi, serta pelayanan antiretroviral therapy (ART) masih harus ditingkatkan. Sementara peran lainnya, kendati sudah berjalan, namun masih memerlukan penguatan kapasitas dalam distribusi kondom dalam gedung, penatalaksanaan IMS, dan juga konseling dan testing sukarela (KTS/VCT).

Selanjutnya dari kedua tahapan survei Delphi dan diskusi pasca Delphi yang dilakukan pada praktisi dan pakar terkait PMTS terhadap pendefinisian PMTS, dapat disimpulkan bahwa dalam model PMTS yang dikembangkan harus memperhatikan pendefinisian program yang komprehensif, melibatkan seluruh kelompok populasi berisiko tinggi di luar WPS dan pelanggannya, yaitu LSL dan waria. Lebih lanjut kegiatan PMTS harus disusun dengan memperhatikan perbedaan kondisi epidemi, kemampuan pemberi layanan, dan setting daerah kelompok berisiko. Dalam jangka pendek, peran donor internasional dalam pendanaan kegiatan PMTS, terutama pengadaan kondom, distribusi kondom, kegiatan penjangkauan dan edukasi kelompok berisiko tinggi masih cukup besar. Pengintegrasian harus dilakukan bertahap dengan melihat kemampuan finansial dan komitmen penyelenggara layanan. Selanjutnya, dari hasil survei dan diskusi pasca Delphi juga dapat disimpulkan, terdapat 11 isu spesifik terkait pelaksanaan kegiatan atau komponen PMTS yang dijadikan pertimbangan dalam penentuan model, terutama dalam tingkatan integrasi layanan yang terjadi saat ini, dan bagaimana harapan tingkat integrasi layanan di masa depan, meliputi: pengadaan kondom, distribusi kondom, diagnosis dan pengobatan IMS pada pelayanan perorangan, skrining dan pengobatan presumtif berkala (PPB) pada penjaja seks, sirkumsisi lelaki dewasa sebagai layanan kesehatan perorangan dan masyarakat, kegiatan tes HIV di dalam gedung puskesmas, baik melalui klinik KTS maupun provider-initiated counseling and testing (PITC) serta mobile KTS sebagai perwujudan upaya kesehatan masyarakat (UKM) menyasar kelompok risiko tinggi, layanan ART, promosi kesehatan reproduksi dan HIV-AIDS pada masyarakat umum, dan, terakhir, promosi kesehatan terkait HIV-AIDS pada kelompok berisiko tinggi sebagai UKM.

Dari keseluruhan rangkaian kegiatan desk review dan juga survei Delphi serta diskusi pasca Delphi dapat diusulkan tingkatan integrasi layanan, sebagai berikut: (1) layanan terintegrasi yang sebagian dilakukan pihak lain di dalam koordinasi penuh puskesmas, dengan menyediakan sebagian sarana/prasarana adalah distribusi kondom dan layanan promosi kesehatan pada kelompok risiko tinggi; (2) layanan terintegrasi yang sebagian dilakukan puskesmas bersama pihak lain, dengan pembagian tugas dan kewenangan yang jelas, adalah penyediaan kondom; (3) layanan terintegrasi yang sudah menjadi layanan rutin puskesmas, dengan bantuan SDM dan pendanaan dari pihak lain di luar mekanisme pendanaan regulernya, adalah mobile KTS dan layanan ART; dan (4) layanan terintegrasi penuh yang merupakan layanan rutin puskesmas dengan perencanaan, pendanaan, dan layanan yang terintegrasi penuh dengan mekanisme yang ada di dalamnya, adalah diagnosis dan pengobatan IMS dalam upaya kesehatan perorangan (UPK), penapisan dan pengobatan IMS pada WPS sebagai UKM, sirkumsisi lelaki dewasa dalam UKP serta terakhir, layanan promosi kesehatan pada masyarakat umum.

ENGLISH SUMMARY

Objective of this research is to propose an integrated service model of HIV prevention through sexual transmission (PMTS). The proposed model is consisted of 10 different services that can be organized by public health center and its alliances. The model also indicates level of integration for each service into the public services in puskesmas. The level of integration could vary from partially integrated to fully integrated with the existing public health services at puskesmas. Partially integrated services where public health centers provide condom distribution and health promotion services for high-risk groups. The same integration level also can be seen where services are coordinated by public health center along with other parties, with the division of tasks and authority that is clear particularly in the provision of condoms. While fully integrated can be observed where the financial support and human resources from other parties come from outside the regular funding mechanisms specifically mobile VCT and ART services. This also works for services where PMTS related services are routine and mainstreamed including the diagnosis and treatment of STIs in individual health efforts, screening and treatment of STIs for FSW, adult male circumcision in individual health efforts and finally, health promotion services to the general public.

Regulations, implementation instructions, and technical guidelines governing the duties and responsibilities of public health centers in  PMTS are urgently needed. The regulations should cover mechanisms necessary for the implementation of the integrated services such as procurement and distribution of condoms; national pharmaceutical list of essential medicines for public health centers so that the treatment of STIs can be provided by the public health center efficiently; standard operational procedures for reporting systems, reporting lines, and data flow from the district/city health office; and financing structures for the provision of STI screening/treatment and VCT.

IMPORTANT QUOTATION:

More specifically, there are 6 main reasons underlying the importance of developing the PMTS program’s integration model at the level of basic services: (pp 5)

1. The HIV-AIDS burden is tremendous. It does not only impact on the patient’s health but also on the social and economic welfare of the family. Negative social and economic impacts can be minimized if the transmission of HIV can be addressed, or when transmission has occurred, treatment can be provided as early as possible at the most basic or primary level of service provision or care. 

2. The problems of STIs and HIV-AIDS are undoubtedly connected to various other health issues that are often reported in mainstream services, eg. TB and ANC services. 

3. Gaps found within the service coverage or within the HIV and STI cascade remain an issue. Surveillance data and results of the study indicated that one of the barriers in the continuity of HIV patient care is access difficulty and convoluted referral systems. The coordinated approach of an integrated PMTS program will help reduce such gaps. 

4. Public health centres are found throughout all of Indonesia, therefore, an integrated PMTS approach will help improve access to services.

5. The provision of services at the most basic level would reduce stigma and discrimination. Preliminary evidence suggests that the specialization of services specifically targeting certain populations can actually increase stigma and discrimination towards affected groups. 

6. Integration of services at the primary health care level could increase cost

effectiveness.

The definitions of the practical service integration model can be summarized as follows: (pp 8)

• Level 1: When the service is carried out by others, outside the coordination of public health centres which only receive information sporadically. This level of service, which includes the regulation, management, human resources and financing, functions separately and is not integrated at all within the system at the public health centre, little communication is carried out horizontally on an ad-hoc basis so that it can be categorized as an integrated part. 
• Level 2: When the service is carried out in coordination with other parties in public health centres where the regulation and management of public health centres are also actively engaged. This level of service is conducted in a separate area with facilities, human resources and financing not integrated at all with the system at the public health centre. However, the regulation and management of public health centres play a role in the implementation of services, and information is regularly exchanged in writing so that at least the

elements of management, regulation and information are integrated in part. 

• Level 3: When the service is carried out in full coordination with public health centres which provide most of the facilities/infrastructure. This level of service is provided simultaneously or in coordination with public health centres although financial and human resources for these services are not at all integrated with the system at the public health centre. Therefore, there is a need for more intensive communication and information exchange as well as management, facilities, and technical regulations that are partly integrated within the system of public health centres. 
• Level 4: When the service is performed by public health centres along with other parties, with clearly defined division of tasks. This level of service is provided jointly by the public health centre in conjunction with other parties both inside and outside the public health centre, though financing is still not integrated with the service financing mechanism of the public health centre. Therefore, at least all the major elements in the sub-system except financing, has been partly integrated with the system at the public health centre
• Level 5: When the service functions through the help of financial and human resources from other parties outside the regular funding mechanisms. At this level, the technical elements of the service, regulation and management are fully integrated with the system in public health centre excluding elements of human resources and finance. 
• Level 6: When the service has become mainstreamed, including aspects of planning, financing and service, 

and is fully integrated with existing mechanisms within the public health centre. At this level, the service has become part of the mandatory services provided by the public health centre and all the main elements in the subsystem level are fully integrated with the system at the public health centre.

Models designed need to consider how these levels of integration can be implemented in public health centres. The first issue is how to integrate both national and regional health systems in support of service delivery, such as in sub health financing system and how financing policy differs at the national and regional levels to ensure financial capability when providing support for human resources and health facilities. The second issue is the level of support from local stakeholders in the implementation of the PMTS programs. Stakeholder mapping will determine who will be the executor. For example, ideally, outreach work with high-risk populations should be undertaken by professionals who are trained in social work and funded by the state, but in reality this is rarely the case. The depiction of the health system linkage, the epidemic situation, the service organization and forms of services in the PMTS model can be seen in Figure 1.

HIV Transmission Through Unsafe Sexual Practices in Indonesia, pp17-18

HIV-AIDS through sexual transmission in Indonesia was to begin with widely reported to have developed among FSW, particularly from the 90s until the 2000s and this is detailed in a report on Surabaya (Joesoef et al., 1997). The rate was reported as an approximate of merely 0.2% (Ford et al. 2000a), but was reported to be much higher in the study by Januraga et al. (2013) with a prevalence of over 15% among direct FSW and 6% among indirect FSW in Bali in 2010. Although in the early development of the epidemic HIV prevalence among female sex workers was reported to be very low, several studies reported a potential epidemic outbreak among this group, due mainly to the high incidence of STIs such as syphilis and gonorrhoea (Joesoef et al., 1997; Joesoef et al., 1998; Ford et al., 2000a). In addition to the high incidence of STIs, studies in the 90s and early 2000s also reported risky behaviours especially in the DFSW population, such as the high number of clients per day and low use of condoms (Wirawan et al., 1993; Fajans et al., 1995; Ford et al., 1995; Ford et al., 1998; Sedyaningsih-Mamahit, 1999; Ford et al., 2000a; Basuki et al., 2002). 

Surprisingly enough, more recent publications reported a high incidence of STIs in nine provinces in Indonesia as well as 70% inconsistent use of condom (Tanudyaya et al. 2010). In the same year, Majid et al. (2010) reported an increase in the incidence of syphilis in DFSW in nine cities in Indonesia from 2005 to 2007 (8% -14%). Although the focus of reporting or publications were initially concerned with the potential of an HIV epidemic outbreak among DFSW, the role of male customers of sex workers started to emerge in the early 90s as presented by Fajans et al. (1994, 1995) and Setyaningsih-Mamahit (1997). Another study reported a lack of customers’ knowledge on STIs and HIV, a high number of sexual partners, low rates of condom use and a high number of respondents reporting symptoms and signs of STIs. Interestingly, not much was found on the client’s role in sexual transmission of HIV affecting the development of the HIV epidemic in Indonesia after the 90s. Searches related to this only found one study by Davies et al. (2007) that reported fairly high positive antibody findings of HSV-2 in men who visited STI clinics in Indonesia. In early 2000, publications began reporting on the progress of the epidemic among MSM and waria. For example, that of Joesoef et al. (2003), which showed a high incidence of sexually transmitted infections among waria in Jakarta, which was subsequently supported by the Pisani et al. study (2004). 

Recent studies have reported a high incidence of HIV among waria and the emergence of an HIV epidemic among MSM in Indonesia, especially Jakarta. The study by Prabawanti et al. (2011) reported a high prevalence of HIV (24%), syphilis (27%) and rectal gonorrhoea or chlamydia (47%) in Java. More recent studies related to the increased incidence of HIV associated with the development of sexual transmission in MSM and waria in Bali have been published by Januraga et al. (2013), and subsequently in Jakarta by Safika et al. (2014). In Bali, the research reported an increase in HIV prevalence among MSM and waria, while the research in Jakarta which reported on patterns of risk behaviours of MSM and waria showed that condom use among MSM and waria was high – between 66% and 84% respectively. The study concluded that the density of sexual networks is of serious concern. Sexual transmission continues to dominate the pattern of HIV transmission in Indonesia with an indication of increase in HIV prevalence in MSM populations and sero-discordant couples. Transmission of HIV through sexual activity is the main cause of HIV in Indonesia. 

Estimates and projections of the HIV epidemic shows that 90% of 70,000 to 80,000 new HIV infections per year in 2014 -2019 occur through sex,whereas transmission through the exchange of non-sterile injecting equipment is only 3%, and 7% through transmission from mother to baby.2 This estimate is consistent with the percentage of the risk factors of reported AIDS cases at the end of 2015, namely 80% heterosexual, 8% homosexual (MSM), 4% of HIV-positive mother to child, and 3% IDU.3 Therefore, the current PMTS program model has been developed for high-risk and vulnerable groups (PMTs guidelines NAC, Permenkes No. 21 of 2013, as well as LKB guidelines for 2014).


see pp 18

Table 2. New HIV Infections in Indonesia


pp 20
In general, search results in international publications reinforce the researchers’ basic assumption that sexual transmission play a major role in the development of the HIV epidemic in Indonesia, and that effectively handled evidence-based strategies and interventions are a given necessity. The various interventions reported on and evaluated also support the assumption that it is necessary to increase the capacity and quality of public health centres in HIV programming in Indonesia. The success of educational programs through outreach, diagnosis and treatment of STIs and condom distribution at the grassroots level shows the importance of strengthening public health centres in carrying out PMTS activities.