1. TB/HIV: Public-Private Partnership for MARGs in Jakarta, Indonesia Dr Flora Tanujaya, MSc Senior Clinical Officer, FHI Indonesia Dr Halim Danusantoso*, Dr Wia Melia*, Dr Janto G Lingga **, Dr Chawalit Natpratan***, Robert J Magnani***, Julietty Leksono***, Kekek Apriana*** *Indonesian Tuberculosis Control Association, Jakarta Branch, Indonesia **Dr Sulianti Saroso Infectious Disease Hospital, Jakarta, Indonesia *** Family Health International – Indonesia, Aksi Stop AIDS Program

2. Outline of Presentation Context Partners Background Program Outcome Recommendation

3. Context Indonesia: 3 rd world rank re TB incidence HIV epidemic: concentrated in MARGs TB is observed: most common OI/co-infection reported in Indonesia (MoH), cause of 40% death among PLHA Routine TB screening among PLHA has not been emphasized in National CST Guideline. But more often done National TB-HIV coordination is stronger since 2007

4. Partners Indonesian Tuberculosis Control Association (PPTI) – private non profit. TB clinic serving urban poor; popular among MARGs Dr Sulianti Saroso Infectious Diseases Hospital (RSPI), Public Hospital in North Jakarta FHI and donors (governmental, personal, private company, community associations)

5. Background PPTI saw increasing non-specific PTB & EPTB and wondered ‘Could it be HIV?’ 2003: 10 TB-HIV (self reported by patients) Early ‘04: capacity building efforts (FHI- USAID, IHPCP-AusAID) 1 Sept 04: VCT service started at TB clinic, supported by FHI-USAID

6. Program – The 1 st of its kind in Indonesia New TB patients HIV Education Session TB screening Pre test counseling HIV test Post test counseling Follow up interventions: - TB DOTS & nutrition support at PPTI - HIV psychosocial support at PPTI - HIV care & treatment referred / at PPTI - Follow up for HIV (-) with HIV prevention referred

7. Program (2) All TB-HIV cases: 1.Pay ID card 0.5 USD + Chest X-Ray 3 USD (can be waived) 2.Food supplement from WFP 3.Free DOTS for 6 months from NTP. 4.Free additional 3 months OAT (personal donors / adopters) 5.Case management service (psychosocial support, home visit) 6.Mobile DOTS dispensing (radius 70 km) 7.Care & Treatment for HIV referred to nearby hospitals 2004. Starting February 2005, provided at PPTI 8.Secondary prophylaxis One-stop TB-HIV services for urban poor MARGs

8. Outcome Challenges: 1.Limited availability of HIV education session (daily: 8-9 and 9-10 am) 2.Selective referral to VCT, based on clinical criteria 3.No CST follow up on site, referral only

9. Program Modification & Outcome (1) Modification 1: 1.“Opt in” strategy applied 2.HIV care and treatment provided at PPTI as RSPI’s “satellite” Challenge: 1.Limited availability of HIV education session 2.Is it time for “opt out”?

10. Program Modification & Outcome (2) Modification 2: HIV education session using audiovisual tools (donation from private for profit company), more availability Free ketoconazole donation from a women’s association

11. Outcome (3) Proportion of Female PLHA: 2004: 8% 2005: 16% 2006: 20% 2007: 20% Proportion of Female New Patients 2006: 39% 2007: 42%

12. What’s next? National Policy, Framework, and Guidelines are needed. This model can become learning site for decision makers as well as other service providers It is time for “opt out” strategy at PPTI and others of its kind The model service should be brought to scale: serving patients’ best interest, comprehensiveness, responsiveness, multi-party collaboration under one roof and coordination mechanism