Evaluation of Process Indicators and Challenges of the Elimination of Mother-to-Child Transmission of HIV, Syphilis, and Hepatitis B in Bali Province, Indonesia (2019–2022): A Mixed Methods Study
Abstract
:1. Introduction
2. Methods
2.1. Study Design
2.2. Study Setting
2.3. Participants and Recruitment
2.4. Process Indicator and Measurement
2.5. Data Collection
2.6. Data Analysis
2.7. Ethical Clearance
3. Results
3.1. Distribution of Triple Infection
3.2. EMTCT Process (Coverage)
3.3. Challenges of Triple EMTCT
3.3.1. Monitoring and Evaluation
3.3.2. Information Systems
3.3.3. Data Sources
3.3.4. Resources
3.3.5. Laboratory Availability
3.3.6. Availability of Reagents and Drugs
3.3.7. Policies
3.3.8. Involvement of the Private Sector
3.3.9. Human Rights
4. Discussion
4.1. Principal Findings
4.2. Implications for Practice
4.3. Study Limitations
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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No. | Process Indicator | Measurement |
---|---|---|
1. | Coverage of prenatal examinations during the first visit. | The number of pregnant women who undergo their first antenatal examination at healthcare facilities, regardless of gestational age, divided by the total number of pregnant women in the target population for the reporting year, multiplied by 100. |
2. | Coverage of HIV testing in pregnant women. | The number of pregnant women tested for HIV divided by the total number of women in the target population who attended ANC visits, multiplied by 100%. |
3. | The proportion of pregnant women who test positive for HIV. | The number of pregnant women who test positive for HIV among the total number of pregnant women tested for HIV during ANC visits multiplied by 100%. |
4. | The number of pregnant women with HIV who receive/initiate antiretroviral therapy (ARV). | The number of pregnant women living with HIV who receive ARV divided by the number of newly diagnosed pregnant women living with HIV who enter care, multiplied by 100. |
5. | Coverage of syphilis testing in pregnant women. | The number of pregnant women tested for syphilis divided by the total number of pregnant women in the target population who attended ANC visits, multiplied by 100%. Screening was conducted using Treponema pallidum (TP) rapid and Treponema pallidum hemagglutination (TPHA). |
6. | The proportion of pregnant women who test positive for syphilis. | The number of pregnant women diagnosed with syphilis, divided by the total number of pregnant women tested for syphilis, multiplied by 100%. |
7. | Coverage of pregnant women with syphilis receiving adequate treatment. | The number of pregnant women with syphilis treated with benzathine penicillin divided by the total number of pregnant women with syphilis, multiplied by 100%. |
8. | Coverage of early detection of hepatitis B in pregnant women. | The number of pregnant women tested for hepatitis B divided by the total number of pregnant women in the target population who attended ANC visits, multiplied by 100%. |
9. | Coverage of treatment for pregnant women with hepatitis B. | The number of pregnant women with hepatitis B and high viral load treated with tenofovir divided by the total number of pregnant women with hepatitis B, multiplied by 100%. |
10. | The proportion of pregnant women who test positive for hepatitis B. | The number of pregnant women who test positive for hepatitis B divided by the total number of pregnant women tested for hepatitis B during ANC visits, multiplied by 100%. |
11. | Coverage of newborns from hepatitis B-positive mothers receiving HBV vaccination (HB0) and hepatitis B immunoglobulin (HBIG) within 24 h of birth. | The number of newborns from hepatitis B-positive mothers who received HB0 and HBIg < 24 h after birth divided by the number of babies born to hepatitis B-positive mothers in the same time period, multiplied by 100% |
12. | Coverage of infants who receive complete three-dose hepatitis B immunization (HB0–HB3). | The number of infants who receive complete hepatitis B immunization divided by the target number of infants during a specific period, multiplied by 100%. |
Location/Year | HIV | Syphilis | Hepatitis B | |||
---|---|---|---|---|---|---|
Pregnant Women Screening Coverage (%) | The Proportion of Pregnant Women Who Test Positive | Pregnant Women Screening Coverage (%) | The Proportion of Pregnant Women Who Test Positive | Pregnant Women Screening Coverage (%) | The Proportion of Pregnant Women Who Test Positive | |
Denpasar | ||||||
2019 (n = 17,290) | 93.12 | 0.30 | 82.88 | 0.32 | 86.39 | 1.32 |
2020 (n = 12,493) | 86.74 | 0.13 | 77.17 | 0.79 | 94.84 | 1.48 |
2021(n = 17,306) | 69.48 | 0.33 | 75.17 | 0.73 | 70.39 | 0.88 |
2022 (n = 18,161) | 68.09 | 0.22 | 75.67 | 0.74 | 73.77 | 0.53 |
Average | 79.36 | 0.24 | 77.72 | 0.64 | 81.36 | 1.05 |
Badung | ||||||
2019 (n = 12,358) | 95.53 | 0.31 | 85.90 | 1.10 | 88.33 | 1.39 |
2020 (n = 11,199) | 85.73 | 0.34 | 72.25 | 0.75 | 84.32 | 1.03 |
2021 (n = 10,997) | 97.82 | 0.27 | 87.24 | 0.61 | 88.00 | 1.09 |
2022 (n = 10,084) | 94 | 0.16 | 89 | 0.36 | 89.00 | 0.65 |
Average | 93.27 | 0.27 | 85.37 | 0.70 | 87.41 | 1.04 |
Buleleng | ||||||
2019 (n = 11,375) | 87.92 | 0.37 | 60.44 | 0.52 | 29.03 | 2.88 |
2020 (n = 12,259) | 86.74 | 0.42 | 83.31 | 0.68 | 82.84 | 1.19 |
2021 (n = 10,962) | 92.00 | 0.31 | 93.99 | 0.64 | 94.28 | 1.07 |
2022 (n = 10,676) | 96.00 | 0.24 | 86.98 | 0.37 | 95.35 | 1.03 |
Average | 90.66 | 0.33 | 81.18 | 0.55 | 75.37 | 1.54 |
Indicators | Denpasar | Badung | Buleleng | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
2019 | 2020 | 2021 | 2022 | 2019 | 2020 | 2021 | 2022 | 2019 | 2020 | 2021 | 2022 | |
EMTCT Process Targets | ||||||||||||
≥95% ANC coverage (at least one visit(ANC-1)) | 99.90 | 72.18 | 96.89 | 99.89 | 115.56 | 104.72 | 88.16 | 84.05 | 104.10 | 112.19 | 102.02 | 97.07 |
≥95% coverage of HIV testing for pregnant women | 93.12 | 76.58 | 77.17 | 94.84 | 96.53 | 85.73 | 84.93 | 90.59 | 87.92 | 86.74 | 92.35 | 96.46 |
≥95% coverage of syphilis testing of pregnant women in ANC | 82.88 | 69.48 | 75.67 | 70.39 | 85.90 | 72.25 | 87.24 | 89.47 | 60.44 | 83.31 | 93.99 | 86.98 |
≥90% coverage of HBsAg antenatal testing among pregnant women | 86.39 | 68.09 | 77.07 | 73.73 | 88.33 | 84.32 | 87.66 | 89.47 | 29.03 | 82.84 | 94.28 | 95.35 |
Maternal Treatment | ||||||||||||
≥95% ART coverage of pregnant women living with HIV | 100 | 100 | 100 | 81.08 | 100 | 100 | 100 | 100 | 72.97 | 97.78 | 83.87 | 100 |
Adequate syphilis treatment of syphilis-seropositive-pregnant women of ≥95% | 100 | 68.12 | 95.79 | 71.28 | 62.39 | 93.36 | 100 | 69.69 | 83.33 | 71.01 | 78.79 | 100 |
≥90% coverage with antivirals for eligible HBsAgG-positive pregnant women with high viral loads | n.a | n.a | n.a | n.a | n.a | n.a | n.a | n.a | n.a | n.a | n.a | n.a |
Infant HBV Vaccination | ||||||||||||
≥90% coverage with three doses of HBV infant vaccinations (HepB3) | 97.78 | 95.5 | 98.2 | 98.3 | 105.5 | 85.64 | 94.1 | 103.25 | 105 | 114.01 | 92.63 | 96.07 |
≥90% coverage of HBV-exposed babies with hepatitis B immune globulin (HBIg) | 96 | 97.18 | 100 | 100 | 100 | 100 | 100 | 100 | 95 | 100 | 100 | 100 |
≥90% HepB timely birth dose coverage (with the universal program) or infants at-risk (with targeted timely HepB-BD) | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 101.5 | 121.45 | 119.63 | 103.34 |
Aspect | Theme | Quotations |
---|---|---|
Data | Monitoring and evaluation | Q1: “We conduct monitoring and evaluation every three months at the district and provincial levels, as well as validate data against reports from each healthcare facility, including both primary health centers and hospitals.” (R1, in-depth interview) Q2: “Every month, specialist obstetricians and gynecologists visit the community health centers (Puskesmas), and the program holders conduct internal monitoring and evaluation at each Puskesmas.” (R12, FGD) |
Information system | Q3: “...we haven’t been consistent with using the e-cohort because not everyone is actively using it, and the e-cohort was only introduced in 2022, so we still rely on manual reporting using Excel spreadsheets and recording in other books, using different systems, which leads to duplication of work.” (R2, FGD) Q4: “The existing information system, SIHA, has been in place for a long time, but it is only used for recording purposes and is not capable of case tracking.” (R6, in-depth interview) | |
Data resources | Q5: “The data we receive is comprehensive. Midwives, specialist doctors, and general practitioners who provide maternal and child healthcare are required to report to us and input data into the e-cohort. This applies to both public and private sector.” (R3, in-depth interview) Q6: “All midwives and doctors in our primary healthcare area are required to submit service data to us every month, as well as private hospitals.” (R22, FGD) | |
Resources | Q7: “...for laboratory examinations, I conduct them as a laboratory analyst using RDT (Rapid Diagnostic Test), and the results are available in less than 30 min.” (R10, FGD) Q8: “We are required to have laboratory analysis, and all our counselors have received counseling training.” (R2, in-depth interview) | |
Laboratory | The availability of the laboratory | Q9: “The HBV DNA testing has not been conducted as not all healthcare facilities have the equipment, and even if we can, the cost is very high and not covered by the national health insurance (BPJS).” (R4, in-depth interview) Q10: “In our primary health centers, we only conduct serological tests. For CD4 testing and titer checks, patients need to go to general hospitals...” (R23, FGD) |
The availability of reagents and drugs | Q11: “Our coverage is not the same for HIV, Syphilis, and Hepatitis B screening because we often experience a shortage of Syphilis and Hepatitis B reagents, as is the case this month, where the Syphilis reagent is unavailable. The availability of Benzathine Penicillin is also often insufficient from the central supply.” (R1, FGD) Q12: “The procurement of reagents is done centrally using funds from the national budget (APBN), and at the provincial level, there has been a shortage of reagents for syphilis and hepatitis B for the past three months...” (R25, FGD) | |
Program | Policy | Q13: “Pregnant women with asymptomatic Hepatitis B, such as jaundice, are referred to obstetricians/gynecologists. However, if they exhibit symptoms of jaundice, we refer them to specialist doctors in internal medicine...” (R6, in-depth interview) Q14: “We always adhere to the policies set by the Ministry of Health, but the district health office regulates the treatment flow and referrals for infected individuals...” (R15, FGD) |
Involvement of the non-public sector | Q15: “...for the screening of these three diseases, we conduct them at the primary health centers, and if a person tests positive, we refer them to the hospital.” (R5, FGD) Q16: “All screening procedures are conducted at the primary health centers (puskesmas), so midwives and village midwives must refer their patients to the nearest puskesmas.” (R17, FGD) | |
Human rights | Human rights | Q17: “...for the initial information, we provide it verbally and obtain informed consent. If someone tests positive, we conduct counseling and make a referral. If they disagree, a refusal form needs to be filled out.” (R12, FGD) Q18: “We provide counseling to all pregnant women who test positive before their referral or treatment. Almost all of them accept the treatment, especially when they are pregnant...” (R19, FGD) |
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Armini, L.N.; Setiawati, E.P.; Arisanti, N.; Hilmanto, D. Evaluation of Process Indicators and Challenges of the Elimination of Mother-to-Child Transmission of HIV, Syphilis, and Hepatitis B in Bali Province, Indonesia (2019–2022): A Mixed Methods Study. Trop. Med. Infect. Dis. 2023, 8, 492. https://doi.org/10.3390/tropicalmed8110492
Armini LN, Setiawati EP, Arisanti N, Hilmanto D. Evaluation of Process Indicators and Challenges of the Elimination of Mother-to-Child Transmission of HIV, Syphilis, and Hepatitis B in Bali Province, Indonesia (2019–2022): A Mixed Methods Study. Tropical Medicine and Infectious Disease. 2023; 8(11):492. https://doi.org/10.3390/tropicalmed8110492
Chicago/Turabian StyleArmini, Luh Nik, Elsa Pudji Setiawati, Nita Arisanti, and Dany Hilmanto. 2023. "Evaluation of Process Indicators and Challenges of the Elimination of Mother-to-Child Transmission of HIV, Syphilis, and Hepatitis B in Bali Province, Indonesia (2019–2022): A Mixed Methods Study" Tropical Medicine and Infectious Disease 8, no. 11: 492. https://doi.org/10.3390/tropicalmed8110492
APA StyleArmini, L. N., Setiawati, E. P., Arisanti, N., & Hilmanto, D. (2023). Evaluation of Process Indicators and Challenges of the Elimination of Mother-to-Child Transmission of HIV, Syphilis, and Hepatitis B in Bali Province, Indonesia (2019–2022): A Mixed Methods Study. Tropical Medicine and Infectious Disease, 8(11), 492. https://doi.org/10.3390/tropicalmed8110492