1. 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

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

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

4. 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 , MoH 2012

5. 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 at the same location, MoH

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

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

8. 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

9. Annual ART Scale Up
Source : MoH Indonesia, 2013

10. 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

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

12. HIV Treatment Cascade NA NA
Source: MoH 2014

13. 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

14. 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 )

15. 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

16. 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)

17. 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

18. 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

19. 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)

20. Increasing HIV test coverage
Source : MoH Indonesia, 2013

21. 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.

22. 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

23. THANK YOU
TERIMA KASIH