Paper: Implementation of Program for the Prevention of Mother-to-Child Transmission of HIV in South Jakarta

Implementation of Program for the Prevention of Mother-to-Child Transmission of HIV in South Jakarta

Badriah, F., Tahangnacca, M., Alkaff, R., Abe, T., & Hanifah, L. (2018). Implementation of Prevention of Mother to Child Transmission of HIV Program in South Jakarta. Kesmas: National Public Health Journal, 12(4), 159-164.

Abstract

Even though the Prevention of Mother to Child Transmission (PMTCT) program has been running in Indonesia since 2006, the proportion of human immu- nodeficiency virus (HIV)-infected pregnant women remains high in several districts in Indonesia. The aim of this study was to observe the overall four-pronged strategy of PMTCT programs in South Jakarta. The study was a qualitative study on PMTCT program implementation in South Jakarta, Indonesia, whereas the proportion of children with HIV positive in the area was quite high. The analysis used domain analysis by looking the implementation of PMTCT as a system consisting of input, process and output. PMTCT strategy is based on a comprehensive four-pronged strategy. This study found that scaling-up com- munication and education about PMTCT program from health provider to community was needed. In the first prong, there was no specific health provider for PMTCT program, it was still integrated with the Medical Center Health staff. In the second prong, implementation of HIV testing and counseling for couples of women living with HIV remained a bottleneck because women living with HIV felt fear to inform their HIV status to their partners. Thus, counseling and HIV testing for couples have not benefited at all. This study found the low coverage and less responsiveness of PMTCT program to build a network of partners with various elements of government.

Keywords: HIV, prevention of mother to child transmission program, prong program, system analysis

Abstrak

Meskipun program Pencegahan Penularan Ibu ke Anak (PPIA) telah berjalan di Indonesia sejak 2006, proporsi wanita hamil yang terinfeksi virus (HIV) tetap tinggi di beberapa kebupaten di Indonesia. Tujuan penelitian ini adalah mengobservasi seluruh empat prong strategi PPIA program di Jakarta Selatan. Penelitian ini merupakan studi kualitatif tentang pelaksanaan program PPIA di Jakarta Selatan, Indonesia, yang memiliki proporsi anak dengan HIV positif di daerah itu cukup tinggi. Analisis menggunakan analisis domain untuk mengobservasi implementas sistem PPIA yang terdiri dari input, proses, dan output. Strategi PPIA didasarkan pada strategi empat cabang yang komprehensif. Studi ini menemukan bahwa perlunya peningkatan komunikasi dan pendidikan tentang program PPIA dari penyedia layanan kesehatan kepada masyarakat. Berdasarkan Prong pertama ditemukan tidak adanya penyedia layanan kese- hatan khusus untuk program PPIA, masih terintegrasi dengan staf Kesehatan Ibu dan Anak di puskesmas. Pada Prong kedua, implementasi tes dan konseling HIV untuk pasangan perempuan yang hidup dengan HIV tetap menjadi penghambat karena perempuan yang hidup dengan HIV merasa takut untuk meng- informasikan status HIV mereka kepada pasangan mereka. Studi ini menemukan cakupan yang rendah dan kurang responsif program PPIA untuk memban- gun jaringan mitra dengan berbagai elemen pemerintah.

Kata kunci: HIV, program pencegahan transmisi HIV ibu ke anak, prong program, analisis sistem

Qualitative research: interview from health care policy, health workers, ngo workers, hiv-positive women, cadres, HIV-negative couples

Methods

This study was a qualitative study by using in-depth interviews. Data were collected in 2015. The methods used in this study included literature review and key in- formant interviews. The informant in this study was a staff of infectious diseases unit at the district health of- fice, three heads of primary health care, three staffs ma- ternal and child health care from three primary health care, three cadres of community-based integrated health care, two health staff from one non-governmental organ- ization (NGO) and eight HIV positive-infected women with PMTCT records and six couples (women and men) with HIV negative and living in the area of primary health care.

The analysis used domain analysis by looking the im- plementation of PMTCT as a system consisting of input, process and output.8 PMTCT strategy is based on a com- prehensive four-pronged strategy.9-11 The strategy aimed at integrating key interventions into essential maternal, newborn and child health services. The first prong em- phasizes on the importance of preventing HIV amon

Women of childbearing age before they become sexually active or get pregnant. The second prong focuses on the prevention of unintended pregnancies among women li- ving with HIV by voluntary counseling and testing (VCT) and contraceptive services. The third prong focuses on pregnant women who are already infected, which in- cludes comprehensive maternal and child care, VCT, Antiretroviral treatment, HIV and baby feeding counsel- ing as well as safe delivery. Since breastfeeding is prohib- ited, the milk given to the baby should fulfill WHO stan- dard known as AFASS that is Acceptable, Feasible, Affordable, Sustainable, and Safe. The fourth prong calls for better integration of HIV care, treatment, psycholo- gical and social support for HIV positive-infected women and their families.11 There were two stages of analysis in this study. The first was system analysis based on input- process and output, then analysis on the four-pronged strategy of PMTCT program

The Results of Prong Program and System Analysis of Prevention of Mother-to-Child Transmission Program Approach

Program	Target Four-Pronged program	Input	Process	Output
Community	First prong	No specific health staff for PMTCT program in primary health care, it was still integrated with the MCH staff of primary health care	The dissemination of information and education on PMTCT program had not been carried out to the community	Low coverage and utilized program
HIV-positive	Second prong	No. specific health staff for PMTCT program or primary health care staff who have skill to communicate educate about HIV	*Communication-education about HIV/AIDS program and safe sex effort had been running with the counselling by text or communication by phone, but the information provided was limited to what was being asked by the service recepients *Implementation of HIV testing and counselling for couples of women with the HIV remains a bottleneck; due to women living with HIV felt fear to inform their HIV status to their partners *Implementation of integrated ANC service, including offers of HIV testing had been done at all primary healty care and report to DHO	Less responsiveness Less coordination among stakeholders
HIV positive	Third prong	The number of PMTCT staff and the budget for HIV testing were limited	*There were some pregnant women who had not received HIV testing and counseling services because they did not visit the primary health care *HIV testing and counselling services had been done at the primary health care, however, it was still limited to the visitors of primary health care. Almost all progams had been implemented *Most of pregnant women who were already infected demanded that HIV testing	HIV positive-infected women lost of follow –up
HIV-positive		Speficif health staff of cadres had communication skill for empathy on HIV	*There was perception of HIV positive-infected mother who stated that the primary health care was not the right place to carry out PMTCT services. This was due her HIV status known by the local community *Several HIV positive-infected mothers went to the primary health care to check up their health status, and midwives that served them were different for each visit *HIV positive-infected women did not feel comfortable withthe PMTCT program at the primary health care *There was a challenge to establish primary health care to become comfortable for mothers living with HIV	Less responsiveness There were reports of loss to follow up related the incidence of HIV positive-infected mothers

Result

Health care-based-oriented services

Fears of hiv patients in health setting

Non-disclosure of hiv status to husbands

Lack of HIV notification for health workers of hiv status of their client

Less universal precaution, mothers, babies and health workers under threat of HIV

Not comfortable to access PMTCT service at primary level

No information about PMTCT in population

Not optimal implementation of PMTCT service

Limited number of cadres and NGO workers to support HIV-positive clients

Perception that it is still small number of HIV-positive pregnant women

Not integrated ANC and PMTCT service: loss-of-follow up HIV pregnant clients

Discussion

This study found that scale up of communication and education about PMTCT program from health staff to community is needed. The staff only concerned to inform PMTCT to patients who came to primary health care as patients of maternal and children care. This PMTCT arrangement needs more client-oriented system in Indonesia, like the one in the routine provider-initiated approach in Vietnam.12 In the fourth prong, the need for better integration of HIV care, treatment and support for women and their families was found to be positive. There were reports of loss to follow up related incidence of HIV positive-infected mothers.

Less responsiveness and fear of the HIV patients to use PMTCT services at health centre

HIV-positive pregnant women are not comfortamble getting service at the primary healty care, so that the role of cadres or voluntary officers to motivate mothers living with HIV was substantial

The situation was worsen if the mother gave birth when she was HIV positive infected, that also put health workers at risk to be infected too if they did not practice universal precation.

Postnatal transmission through breastfeeding also remains a significant concern andi s often a result of confusing infant feeding messages and good infant nutrition as well as low postnatal ARV coverage for both mothers and infants.

Community empowerment in PMTCT and other health services have been done by the primary health care and NGOs, although the number of NGOs involved in HIV programs is limited. Health workers, traditional leaders, and religious groups were also involved in the program. Nevertheless, socialization for HIV prevention programs, especially PMTCT, needs improvement.

Conclusion PMTCT program has not been optimally implemented. It is important to support the scale-up access to PMTCT for all women since the PMTCT program still concerns on informing PMTCT to persons that visited CHC only. The increasing number of HIV-infected mothers who lost follow-up indicates that it needs a better integration of HIV care, treatment and support for HIV positive-infected women and their families. The study finds that PMTCT program is not integrated with ANC at primary health care due to the high loss of follow-up among the HIV-infected mothers, and they do not feel comfortable getting services at the primary health care, so that the role of cadres or voluntary officers of NGO staff to motivate mothers living with HIV is substantial.