Introduction of The Strategic Use of ARVs For Treatment & Prevention in Indonesia: From Policy Development to Implementation Dr. Siti Nadia Tarmizi M Epid National AIDS Program Manager Ministry of Health Indonesia

Outline Epidemiological situation and Programme Progress Prevention outcomes Treatment outcomes Rational for Policy Formulation Policy Implementation Programmatic Questions and Challenges

1. Epidemioliogical Background Concentrated epidemic in most of country, but low-level generalized epidemic in Papua Source: Estimates & Projection of HIV/AIDS 2011-2016, MoH 2012

From Driven By Injection To Predominantly Sexual Transmission Estimated Number of New Infections by Population Sub-Groups From Driven By Injection To Predominantly Sexual Transmission The mathematical modeling done in 2012 showed there’s a change of new infection pattern from driven by injection to sexual transmission, particularly among MSMs 2012 Epidemiologic Modeling Update indicates continuing growth in number of annual new HIV infections unless efforts are expanded and effectiveness is increased Source: Estimates & Projection of HIV/AIDS 2011-2016, MoH 2012

Programme Progress HIV Prevalence by Population Sub-group Challenges remaining in controlling sexual transmission Substantial progress made in recent years, but results are mixed: Declining epidemic among PWID Stable epidemics among FSW and Waria Growing epidemics among MSM and HRM DFSW IDFSW HRM TG MSM IDU Inmates Source: IBBS 2007 – 2011 and 2009 -2013 at the same location, MoH

Remaining Sexual Risk Behaviors Condom Use at last sex TG Always Condom Use Source: IBBS 2007 & 2011 and IBBS 2009 & 2013, MoH

Prevention Efforts PWIDs Perilaku penggunaan kondom konsisten masih rendah (STBP 2009: 31%, 2013:46%). Source: Rapid Behavior Survey 2010 & 2013, NAC

Great variability in access to ART in Asia ART coverage in selected Asian countries, 2012 Coverage: number of people receiving ART in 2012 / number of individuals eligible for ART in 2012 according to 2010 guidelines Source: WHO SEARO, 2013

Annual ART Scale Up Source : MoH Indonesia, 2013

Retention rates for ART at 12, 24 and 60 months in selected countries, 2011 Still too many people are lost from ART: Retention at 12, 24 and 60 months % Source: WHO/UNAIDS

Retention rates for ART at 6 & 12months in Indonesia, 2004-2012 Source: MoH 2013

HIV Treatment Cascade NA NA Source: MoH 2014

2. Rationale for Policy Formulation Evidence of further reducing new HIV infections through “Test and Treat” or SUFA and global move towards earlier treatment Implementing SUFA will help accelerating coverage of ART for those most in need Joint rapid assessment early 2013 in collaboration among MoH, NAC, WHO, UNAIDS and UNICEF to obtain information for developing a roadmap to accelerate expansion of ARVs for HIV treatment and prevention in Indonesia To assess barriers to diagnosis and treatment to review and learn current existing good practices to find opportunities to further accelerate expansion and coverage of ART Mathematical modelling to look at the impact and effectiveness of program that is expected from rapidly scaling-up ART in Indonesia Followed by national consultation meeting in March 2013 Mathematical modeling with various scenarios of ART coverage and effectiveness to look for the impact and effectiveness of program that is expected from rapidly scaling-up ART in Indonesia

Mathematical Modeling on Impact of ART coverage on numbers of new HIV infection The impact on numbers of new HIV infection would be modest at current levels of ART coverage (the dark blue, red lines and purple) Impact will be significantly observed by increasing coverage of those treatment-eligible persons of 80%. (The green and light blue lines )

3. Policy Implementation Continuum of Comprehensive HIV Services Framework (LKB) Indonesia is intensifying the response by strengthening the continuum of HIV-STI comprehensive care, a service delivery model was on going Addressing the prevention, care and treatment comprehensively by increased participation of all related stakeholders especially the community members at district level & HIV service available at PHC

Introduction of Strategic Use of ARVs (SUFA) through “LKB” Objectives: To significantly increase HIV testing and ART coverage To optimize the prevention impact of ARVs by offering ART regardless of CD4 level to key affected populations and sero-discordant couples To strengthen the involvement and ownership by CSO groups. Strategies 1. Expanding HIV diagnosis 2. Effective enrollment and retention in HIV care 3. Build on effective efforts that already exist, including the LKB (CoC)

Phased Approach Roadmap of “Rapid Scale Up of ART and Strategic Use of ARVs (SUFA) through LKB” 75 priority districts phased implementation and scale-up approach started in 13 districts (3 from Tanah Papua and 8 from the remainder of Indonesia) in October 2013. rolled-out in 63 additional districts during April till December 2014. Minister of Health Regulation No. 21/2013 PITC approach to increase HIV test and counseling ART regardless CD4 count to KAPs (CSW, MSM, transgender IDUs), TB-HIV patients, Hep-HIV patients, and HIV infected pregnant women

Initiate ART when the CD4 under 350 Start ART regardless of the CD4 Accelerating getting to Zero New Infections (and reduce mortality) Initiate ART when the CD4 under 350 Start ART regardless of the CD4 Added to strengthening quality of structural interventions for the prevention of sexual transmission or PMTS- the recent biomedical innovation indicates that treatment is not only effective in reducing morbidity and mortality due to AIDS but also very effective in preventing new infections. This slide sumarises Indonesia’s new policy to introduce Strategic Use of ARV or SUFA. We would like to encourage PLHIV to start treatment as early as possible. With the strategic use of ART, providing ART to those who have CD4<350 will reduce mortality, and providing ART regardless of CD4 to certain groups will reduce new infections The current existing treatment guidelines set the criteria for starting HIV treatment at a threshold of 350 CD4 or less. With the new policy, we are expanding eligibility to include some special population whre such as sero-discordant couples, pregnant women, and key affected groups such as people who inject drugs, men who have sex with men, female sex workers, the transgender regardless of their CD4. This ambitious policy opens the door for eligibility to treatment to many PLHIV in Indonesia. Its implementation has started in phased manner in selected priority districts and includes strategies to substantially scale up HIV testing and improving the HIV treatment cascade, from HIV testing to retention in treatment and viral suppression. The SUFA strategy is also included and to be delivered through the CoC at disctrict level Key Affected Populations: IDU, MSM, TG, SW Prisoners 18

WHO Consolidated ARV Guidelines 2013 Population PN ART 2012 WHO Consolidated ARV Guidelines 2013 SUFA HIV+ ARV-Naïve AZT/TDF + 3TC (FTC) + EFV/NVP TDF + 3TC (or FTC) + EFV Priority for new patients TDF + 3TC (or FTC) + EFV HIV+ ARV-Naïve Pregnant Women AZT/TDF + 3TC (FTC) + NVP/EFV HIV/TB Co-infection AZT/TDF + 3TC (FTC) + EFV HIV/HBV Co-infection TDF + 3TC (FTC) + EFV Serodiscordant KAPs (FSW, PWID, MSM, Transgender)

Increasing HIV test coverage Source : MoH Indonesia, 2013

4. Programmatic Questions - Challenges For T&T as part of LKB/SUFA to have an impact in Indonesia it would need to be accessible/acceptable and reach all key affected groups. T&T/SUFA as in the Permenkes 21 raises programmatic questions specially about how to improve the HIV treatment cascade: How best to control STI ? How best to expand HIV testing and reach those KAPs? How bes decentralization of HIV services implemented How best to retain them on treatment How SUFA will affect adherence and risk behaviors? Effective community-based interventions involving KAPs are fundamental in the success of LKB/SUFA In a decentralized context local ownership by policy/decision makers is key for adoption of policy and financial sustainability The use of ART in HIV-positive individuals has been proposed as an effective tool in prevention of HIV transmission.8 In a clinical trial, early initiation of ART in HIV-positive partners of sero-discordant couples resulted in 96% protection from HIV acquisition in HIV-negative partner over the observation period.9 Modeling and observational studies support that the ‘Test and Treat’ (T&T) strategy of expanded voluntary HIV testing and immediate initiation of ART on HIV diagnosis is likely to result in a decline in rates of HIV transmission. Early ART is likely to provide clinical benefits to the individual in terms of reduction in AIDS, mortality and tuberculosis and to burden of disease at the population level. Although definitive evidence for benefit at CD4 counts>500/mm3 is awaited, none of the observational studies have shown any harm and all suggest potential benefits. In addition to these clinical benefits, it is plausible that direct linkage to treatment at time of diagnosis may reduce the loss in the early steps of cascade of care (i.e. from diagnosis to retention in care). Wider implementation of T&T is thus a promising tool for HIV prevention and is generating global interest. For this strategy to successfully impact upon the epidemic in Indonesia T& T would need to accessible to and effectively reach all key affected groups as the part of the broader HIV prevention package.

Acknowledgments Ms Wenita I – NAC Indonesia Dr Oscar Barreneche – WHO Indonesia Mr Cho Kah Sin – UNAIDS Indonesia Dr Sri Pandam – WHO Indonesia Dr Janto Lingga –WHO Indonesia Ms Fetty Wijayanti –WHO Indonesia Mr Daniel – Spiritia Foundation USAID, DFAT, FHI 360, CHAI

THANK YOU TERIMA KASIH