Integration of TB and HIV services urgently needed in Indonesia

Indonesia is second only to India and China in its number of active TB cases, being home to 6 percent of the global TB burden. Approximately 150,000 people die each year of TB in Indonesia. According to recent headline news in Indonesia, "Its HIV epidemic is among the fastest growing in Asia." The estimated number of people living with HIV (PLHIV) in Indonesia is 169,000 to 216,000 in the nation of 220 million. This is despite the considerable progress Indonesia has recently made in delivering TB and HIV services. Not surprisingly, the problem of drug resistant TB is also on the increase in the country.

"TB and HIV are often forgotten while the world's attention is now focussing on new emerging epidemics," according to the Health Minister of Indonesia, Dr Siti Fadilah Supari. Speaking on World AIDS Day last year, he added: "I strongly endorse the Call to Stop TB in Asia, and commit to ensuring that the recommendations within it are pursued with priority within Indonesia. The world is focusing on Indonesia for many competing health issues, with the danger that TB may be forgotten."

Now, with World TB Day fast-approaching, a re-examination of how to best respond to the dual epidemics of TB and HIV in Indonesia is timely.

Several factors in Indonesia could potentially spark a sudden and rapid spread of HIV: an extensive sex industry; limited clinical and laboratory services to detect and treat sexually-transmitted infections (STIs); highly mobile populations; rapidly expanding injection drug use; and the aftermath of major economic and natural crises.

Indonesia is committed to integrating HIV prevention efforts into the national family planning programme by promoting condom use for dual protection. The Government of Indonesia is providing free antiretroviral drugs for poor people on a case-by-case basis, developing harm-reduction activities for injection drug users, and devising programmes for high-risk populations to reduce HIV transmission.

Indonesia has also contributed significantly to efforts aimed at reaching global targets for TB programmes. Latest reported figures from the country's DOTS programme (directly-observed treatment short-course) include a 68% TB case detection rate and among those an 89% treatment success rate. This compares well with 2005 global targets for the same, set at 85% and 70% respectively.

The HIV and TB epidemics go hand-in-hand and according to World Health Organization (WHO), over half of PLHIV in Indonesia ultimately lose their lives to TB. Despite this, neglecting integration of AIDS and TB care is still a risk.

Among the challenges facing more integrated approaches to TB and HIV is the regional variation of TB rates and health care provision in different parts of the country. In Java and Bali, for example, which are home to 60% of the population and have among the lowest TB incidence, healthcare services are the most advanced. Meanwhile, Sumatra and the eastern parts of Indonesia - which have double and quadruple the national TB burden respectively - have many remote and hard-to-reach areas, and the numbers of healthcare workers areas are limited.

In terms of HIV care, there have been media reports in the past year not only indicating rising HIV resistance to antiretroviral drugs (ARVs), but also decreasing ARV adherence among PLHIV. According to The Jakarta Post (8 February 2007, Resistant virus threatens people with HIV/AIDS), there is no facility for conducting ARV resistance testing in Indonesia.

Yusuf Rey Noldy, a counsellor from the Hatihati Foundation, and organisation that supports people with HIV, said that some PLHIV send their blood to an Australian laboratory at a cost of around US$440 per test. ARV resistance threatens the lives of some 4,000 PLHIV in Bali, according to data from the Bali Province HIV/AIDS Commission.

"It [resistance] is the tip of the iceberg. There are many more people with HIV experiencing virus resistance who have gone undetected," Noldy said.

The commission said several people with HIV in Bali had deliberately stopped their ARV therapies for various reasons. Ariawan, 41, decided to stop taking ARV because he disliked its side-effects.

The numbers from Denpasar's Sanglah Hospital are discouraging. Through January 2007, some 23 people with HIV treated at the hospital have stopped their ARV therapies. There are 19 others who have failed to show up at the hospital.

In many settings in Indonesia, there is an urgent need to expand equitable access not only to quality TB diagnosis and treatment, but also to comprehensive HIV prevention, treatment, support and care services. But these two types of services are offered at different levels of the health system, adding another challenge to their integration. TB control is currently strong at the health centre level, while HIV programmes are mainly concentrated at the hospital level.

For adequate care and support to people living with HIV and active TB in Indonesia, two measures appear to be in need of urgent action: Voluntary HIV testing and counselling (VCT) needs to be more widely available, and TB services need to be fully integrated in the hospital programmes and programmes delivering ARVs.

Bobby Ramakant-CNS

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