Antenatal testing for anaemia, HIV and syphilis in Indonesia - a health systems analysis of low coverage

Factors influencing the implementation of integrated screening for HIV, syphilis, and hepatitis B for pregnant women in Nepal: A qualitative study

In Nepal, national guidelines recommend free HIV and syphilis screening for pregnant women at their first antenatal visit, using an opt-out approach. However, screening uptake is low and the guidelines do not include hepatitis B screening. It is essential to understand the factors influencing the implementation of integrated screening for HIV, syphilis, and hepatitis B, as recommended by WHO, to improve uptake and prevent vertical transmission. This study explored the knowledge, attitudes, and perceptions of pregnant women, their families, healthcare providers and policymakers on integrated prenatal screening. We conducted 12 in-depth interviews with pregnant women, 10 with their husbands and 4 with mothers-in-law in Kapilvastu and Kathmandu. In addition, we interviewed 7 health workers and 4 decision-makers. These interviews were sufficient to reach saturation. Data were analysed using a thematic content analysis. A combination of the social-ecological model and the WHO building blocks provided a theoretical framework for interpreting data. The analysis showed that antenatal screening in Nepal involved many stakeholders and was influenced by various factors. Implementation issues were found in the building blocks service delivery, health workforce and medical products. Husbands and in-laws play an important role in the acceptance of screening by pregnant women, especially in rural areas. High levels of stigma and discrimination against people with sexually transmitted diseases were reported, and knowledge of hepatitis B and syphilis was low. Access and uptake of screening could be improved through rapid testing, by strengthening the health system and by integrating hepatitis B screening through an opt-out approach like that for HIV and syphilis. Effective community involvement through awareness campaigns and investment in lower-level health facilities is essential to improve screening rates. This study provides information for decision-makers about challenges in implementing integrated screening to guide the design of targeted interventions to reduce vertical transmission.

Patient perspective on the elimination mother-to-child transmission of HIV, syphilis, and hepatitis B in Bali, Indonesia: a qualitative study

BACKGROUND

This study aimed to explore the facilitators and barriers to the elimination of human immunodeficiency virus (HIV), syphilis, and hepatitis B transmission based on the perspectives of mothers living with HIV, syphilis, and hepatitis B.

METHODS

This study employed a descriptive, qualitative design. Semi-structured interviews were conducted with mothers living with HIV, syphilis, and/or hepatitis B virus. A total of 25 participants were included in the study. This study used a triangulation method conducted by members to enhance the validity and dependability of the findings. The study was conducted at referral hospitals and community health centers between September 2022 and February 2023. Data analysis utilized deductive content analysis and categorized themes based on a socio-ecological framework.

RESULTS

The findings revealed facilitators and barriers across five levels of the socio-ecological framework and 21 subcategories. The findings included the following: (1) At the policy level, facilitators were mandatory testing programs, and barriers were separating testing services from antenatal care facilities. (2) At the community level, facilitators included the involvement of non-governmental organizations (NGOs) and cross-sector support. Barriers included challenges faced by non-residents and fear of stigma and discrimination. (3) At the healthcare system level, facilitators included tracking and follow-up by midwives, positive relationships with healthcare providers, and satisfaction with healthcare services. Barriers included prolonged waiting times, insufficient information from healthcare providers, and administrative limitations. (4) At the interpersonal level, facilitators included partner and family support, open communication, and absence of stigma. Barriers included the reluctance of sexual partners to undergo screening. (5) At the individual level, facilitators included the desire for a healthy baby, adequate knowledge, self-acceptance, and commitment to a healthy lifestyle; barriers included the lack of administrative discipline.

CONCLUSION

Mothers living with HIV, syphilis, or hepatitis B require tailored healthcare approaches. Healthcare professionals must understand and meet the needs of mothers within a comprehensive care continuum. The findings of this study advocate for the development and implementation of integrated care models that are responsive to the specific challenges and preferences of affected mothers, aiming to improve health outcomes for both mothers and their children.

The prioritisation of curable sexually transmitted infections among pregnant women in Zambia and Papua New Guinea: Qualitative insights

Curable sexually transmitted infections (STIs) are neglected in public health policy, services and society at large. Effective interventions are available for some STI but seem not to be prioritised at global, regional or local levels. Zambia and Papua New Guinea (PNG) have a high burden of STIs among pregnant women but little is known about the prioritisation of STI treatment and care among this group. We undertook a qualitative study to explore how STIs are prioritised among pregnant women in local health systems in Zambia and PNG. Semi-structured interviews were conducted with 19 key informants-health care workers providing antenatal care, and policy and programme advisers across the two countries. Audio recordings were transcribed and translated into English and stored, managed, and coded in NVivo v12. Analysis used deductive and inductive thematic analysis. Findings were coded against the World Health Organization health system building blocks. Participants spoke about the stigma of STIs at the community level. They described a broad understanding of morbidity associated with undiagnosed and untreated STIs in pregnant women. The importance of testing and treating STIs in pregnancy was well recognised but many spoke of constraints in providing these services due to stock outs of test kits for HIV and syphilis and antibiotics. In both settings, syndromic management remains the mainstay for treating curable STIs. Clinical practice and treatment were not in alignment with current STI guidelines in either country, with participants recognising the need for mentorship and in-service training, as well as the availability of commodities to support their clinical practice. Local disruptions to screening and management of syphilis, HIV and other curable STIs were widely reported in both countries. There is a need to galvanise priority at national and regional levels to ensure ongoing access to supplies needed to undertake STI testing and treatment.

Challenges to integrating programs for the elimination of mother-to-child transmission of HIV, syphilis, and hepatitis B into antenatal care: Experiences from Indonesia

The WHO's Asia-Pacific framework for triple elimination recommends that countries evaluate their programs for the elimination of mother-to-child transmission of HIV, syphilis, and hepatitis B (EMTCT), including identifying gaps to improve program planning and the implementation of elimination strategies in antenatal care (ANC) services. In 2022, the Indonesian Ministry of Health reported that only 39% of pregnant women were tested for HIV, 14% for syphilis, and 28% for hepatitis B, respectively. We conducted a qualitative study involving a focus group discussion (FGD) and in-depth interviews with 25 key stakeholders in Bali and West Nusa Tenggara Provinces to identify specific challenges to testing for HIV, syphilis, and hepatitis B in ANC settings. Thematic analysis was used to identify the themes generated from the data. Health system bottlenecks experienced by stakeholders included supply chain management issues involving stock forecasting and stock monitoring, stock-outs of rapid test reagents which were particularly most frequent and for longer durations for syphilis and hepatitis B, high staff turnover, lack of staff training on how to perform the test, the complexity and time needed to record the data on women's characteristics, risk behaviours, and testing in both paper format and into the computer-based surveillance systems, discrepancies in program coverage data from different divisions of the district health office involved in the reporting system, high levels of stigma that prevented women from being followed up, challenges in notifying partners, and inadequate reporting and referral of women from private providers to public ones for testing. Interventions addressing the above challenges are worthy of consideration to improve the health system function and integrate EMTCT into the ANC settings.

Concomitant illnesses in pregnancy in Indonesia: A health systems analysis at a District level

BACKGROUND

In LMICs, including Indonesia, there is a rising burden of non-communicable diseases (NCDs) with a prevailing burden of infectious diseases, including among pregnant women. The Indonesian health system faces significant challenges to provide effective care for infectious diseases, and even more so, NCDs. This is concerning due to the greater vulnerability of pregnant women to complications caused by concomitant illnesses (NCDs and infectious diseases), and the need for complex, integrated healthcare between maternal care and other health services.

METHODS

The objective of this study was to understand supporting factors and challenges of the health system to providing care for concomitant illnesses in pregnancy and how it may be improved. Semi-structured interviews were conducted with sixteen key stakeholders, including health providers and health service managers, involved in maternal healthcare for concomitant illnesses at a District level in Indonesia. The study was conducted in Kutai Kartanegara District of East Kalimantan. Analysis was conducted using framework analysis to identify themes from transcripts.

RESULTS

Supporting factors of the health system to provide care for concomitant illness in pregnancy included collaboration between health providers and health services, availability of screening and diagnostic tools, and access to universal healthcare coverage and financial subsidies. Common challenges included knowledge and awareness of concomitant illnesses among health providers, competency to diagnose and/or manage concomitant illnesses, and inappropriate referrals. Suggested improvements identified to address these gaps included increasing education and refresher training for healthcare providers and strengthening referrals between primary and hospital care.

CONCLUSIONS

The findings identified gaps in the health system to provide care for concomitant illnesses in pregnancy in Indonesia that need to be strengthened. More evidence-based research is needed to guide the implementation of policy and practice interventions for the health system to deal with a broader range of concomitant illnesses in pregnancy, particularly NCDs.

Barriers and facilitators to HIV and syphilis rapid diagnostic testing in antenatal care settings in low-income and middle-income countries: a systematic review

BACKGROUND

Testing and treatment during pregnancy is a well-established and cost-effective prevention strategy, which relies largely on use of rapid diagnostic tests (RDTs). Yet, in many low-income and-middle-income countries, the uptake of RDTs is suboptimal. A qualitative meta-synthesis was conducted to identify the barriers and enablers to use of HIV and syphilis RDTs among pregnant women in low-income and middle-income countries.

METHODS

This review was conducted using PRISMA guidelines. Eligible studies included peer-reviewed publications, which used qualitative methods to explore HIV and syphilis RDT in antenatal care clinics in low-income and middle-income countries. Studies focusing on perspectives of pregnant women, healthcare workers and/or stakeholders were included. We used an inductive approach informed by a modified socioecological model to synthesise the data.

RESULTS

62 manuscripts met the eligibility criteria. For pregnant women, initial acceptance of the RDT and continuation in antenatal care depends on the perception that engaging in testing will be a beneficial experience for their baby and themselves, often influenced by the provision of services that are gender-sensitive, confidential, respectful, flexible and considers their well-being into the future. Local sociocultural beliefs about pregnancy and diseases, awareness of diseases and gender roles in society also influenced RDT acceptability among pregnant women. For healthcare workers, the ability to provide high-quality RDT care required ongoing training, accurate and easy to use tests, support from supervisors and communities, sufficient resources and staffing to provide services, and reliable salary. At the stakeholder level, well-developed guidelines and health system infrastructures were imperative to the delivery of RDT in antenatal clinics.

CONCLUSION

Our findings highlight clear gaps to the provision of sustainable and culturally acceptable maternal HIV and/or syphilis screening using RDTs. In addition, greater attention needs to be paid to community stakeholders in promoting the uptake of RDT in antenatal clinics.

PROSPERO REGISTRATION NUMBER

CRD42018112190.

Supply-side readiness to deliver HIV testing and treatment services in Indonesia: Going the last mile to eliminate mother-to-child transmission of HIV

INTRODUCTION

Despite national efforts to integrate Prevention of Mother-to-Child Transmission (PMTCT) of HIV services into antenatal care in Indonesia, the rate of mother-to-child transmission of HIV remains the highest in the world. A range of barriers to uptake and long-term engagement in care have been identified, but far less is known about health system preparedness to deliver PMTCT of HIV services. This study explored supply-side barriers to the delivery of PMTCT services in Indonesia and whether these factors are associated with the uptake of antenatal HIV testing.

MATERIALS AND METHODS

An ecological analysis was undertaken, linking data from the World Bank Quality Service and Delivery Survey (2016) with routine data from Indonesia's HIV and AIDS case surveillance system and district health profile reports (2016). Supply-side readiness scores-generated from a readiness index that measures overall structural capacity and is often used as proxy for quality of care-were adapted from the WHO Service Availability and Readiness Assessment and presented by sector and geographic area. Univariate and multivariate regression analysis was used to explore factors associated with the uptake of antenatal HIV testing in public facilities.

RESULTS

In general, public facilities scored more highly in most inputs compared to private facilities. Facilities located in urban areas also scored more highly in the majority of inputs compared to ones in rural areas. Readiness scores were lowest for PMTCT services compared to Antenatal Care and HIV Care and Support services, especially for the availability of medicines such as zidovudine and nevirapine. The national composite readiness score for PMTCT was only 0.13 (based on a maximum score of 1) with a composite score of 0.21 for public facilities and 0.06 for private facilities. The multivariate analysis shows that the proportion of pregnant women tested for HIV was more likely to be greater than or equal to 10% in facilities with a higher readiness score and a higher number of trained counsellors available, and less likely in facilities located outside of Java-Bali and in facilities supporting a higher number of village midwives.

DISCUSSION

Despite targeted efforts by the Indonesian government and multinational agencies, significant gaps exist in the delivery of PMTCT that compromise the standard of care delivered in Indonesia. Future strategies should focus on improving the availability of tests and treatment, especially in the private sector and in rural areas.