Four recommendations can move Indonesia toward achieving HIV epidemic control

The following is a guest post by Cathy Cantelmo, Rebecca Ross, Shree Prabhakaran and Arin Dutta.

Indonesia has not yet achieved UNAIDS 90-90-90 HIV treatment targets or epidemic control. Of the people living with HIV as of June 2020, only 63 percent knew their status, just a quarter were on antiretroviral therapy, and a mere 4% were confirmed as virally suppressed. To accelerate progress, the government of Indonesia released revised minimum service standards for health and an ART Acceleration Plan, both establishing ambitious targets to rapidly scale up access to HIV services.

Yet, the country still faces constraints in tackling its HIV epidemic. As a middle-income country facing declines in external financing support, higher-than-average HIV commodity prices, and a growing demand for HIV services, Indonesia is challenged in its ability to mobilize sufficient domestic resources for HIV prevention, testing, and treatment. But there is a path forward. By focusing on changes to service delivery models, populations targeted, payment mechanisms, and more sustainable HIV financing, Indonesia could boost its HIV response and accelerate epidemic control.

A path forward

How should Indonesia proceed from here to achieve epidemic control on a more accelerated timeline? From 2018 to 2020, Health Policy Plus (HP+) — a project funded by USAID and the U.S. President’s Emergency Plan for AIDS Relief — supported the government of Indonesia to secure more sustainable financing for HIV, conduct analyses, and strengthen the capacity of national and local governments and civil society organizations in HIV resource mobilization strategies, efficiency measures, budgeting, and planning. Key findings and takeaways from HP+ technical assistance suggest that:

1. Indonesia needs a more strategic approach to scaling up HIV testing. Indonesia’s current testing strategy aims to test all populations at risk of HIV, even though most Indonesian provinces face concentrated epidemics. This untargeted approach and lack of guidance to districts on how to use limited resources for HIV testing likely will result in declining testing yields and higher costs over time. In fact, HP+ estimates that the costs of HIV testing could surpass that of HIV treatment in the next few years. An evidence-based, epidemiologically and yield-driven testing strategy is needed to allow more people living with HIV to know their status and offer them a linkage to care. If the country sets more ambitious HIV testing targets for high-yield populations, such as men who have sex with men, and scales up new testing modalities, such as self-testing and index testing, the country could identify more people living with HIV for a lower overall cost.
2. Localized evidence on the cost efficiency of civil society organization services should inform government contracting, target setting, and performance-based payments for HIV. Indonesia’s civil society organizations provide essential HIV services, particularly to key populations. However, HP+-led cost analyses in Jakarta and Papua revealed that the organizations often have high management and indirect costs, and that the cost efficiency of their services varied significantly by service delivery model and population served. For example, the costs of traditional hotspot outreach per person tested for HIV are much higher for female sex workers than any other population. Further, support group meetings for key populations and people living with HIV are among the highest-cost interventions provided by civil society organizations, yet their impact on ART retention and adherence remain unknown.
3. Epidemic control requires targeted prevention and treatment response. HP+-led mathematical modelling in Jakarta and Papua was used to characterize the epidemic in each province, using detailed programmatic, epidemiological, and anthropological data. The project analyzed the local epidemic using sexual network mapping and highlighting key risk groups and local geographic factors. The nature of the epidemic (generalized, mixed, concentrated) differed by province, and therefore targeted responses would be more impactful and cost-effective in reducing HIV prevalence and incidence.
4. Revised payment mechanisms can promote more efficient HIV service provision. Evidence from Indonesia and globally suggests that routine ART services can be efficiently and effectively delivered at the primary care level. HP+ found that there is an excessive proportion of ART services being delivered at the hospital level in Indonesia, resulting in higher costs and reduced capacity to scale up access to ART. By revising payment mechanisms at both the primary care level and at hospitals, primary care providers can be incentivized to retain routine antiretroviral treatment patients at their clinics and limit referrals to hospitals for severe HIV cases. At the same time, hospital-based providers can be incentivized to refer patients who do not require hospitalization to lower-level facilities. Adding performance elements to payment reforms could also incentivize providers to promote viral suppression among their antiretroviral treatment patients.

Overall, HP+ found that changes to service delivery models, populations targeted, and payment mechanisms can reduce costs while improving HIV-related outcomes. There are other opportunities for more sustainable HIV financing, as well, such as redirecting cost savings from lower antiretroviral prices into HIV prevention. With HP+ technical assistance, local civil society organizations in Jakarta and Papua have generated outcome-linked budgets for government grant applications, allowing more such organizations to be funded by the government for HIV prevention and support activities. For example, the Kusuma Buana Foundation, a Jakarta-based civil society organization, received technical assistance from HP+ when submitting a proposal for local government funding for the first time in 2020. Foundation staff feel more confident in preparing proposal budgets now and plan to submit another proposal in 2021 on their own.

HP+ technical assistance filled evidence gaps and developed capacity of the Ministry of Health’s Subdirectorate for HIV, provincial health offices, and civil society organization staff to use evidence in decision making. Indonesia will only achieve its HIV goals, however, if there is political will to prioritize HIV in government budgeting and decision making. The government is currently considering a proposal that would change the payment terms for HIV services under JKN, the national health insurance scheme, significantly and exclude certain services from reimbursement at the hospital level. If enacted, this proposal could introduce uncertainty for providers, affect access and quality, and potentially hinder availability of affordable HIV services. The government should conduct further due diligence of such proposals. Further, the central government needs to hold districts accountable for achieving HIV targets under the revised minimum service standards. As the government of Indonesia mobilizes resources to contain the COVID-19 pandemic and obtain vaccine stocks, it should also recall and honor its ambitious internal HIV commitments and act on recommendations to improve the HIV program’s efficiency and effectiveness.