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

Abstract

Background: Adverse pregnancy outcomes can be prevented through the early detection and treatment of anaemia, HIV and syphilis during the antenatal period. Rates of testing for anaemia, HIV and syphilis among women attending antenatal services in Indonesia are low, despite its mandate in national guidelines and international policy. Methods: Midwife-held antenatal care records for 2015 from 8 villages in 2 sub-districts within Cianjur district were reviewed, alongside the available sub-district Puskesmas (Community Health Centre) maternity and laboratory records. We conducted four focus group discussions with kaders (community health workers) (n = 16) and midwives (n = 9), and 13 semi-structured interviews with laboratory and counselling, public sector maternity and HIV management and relevant non-governmental organisation staff. Participants were recruited from village, subdistrict, district and national level as relevant to role. Results: We were unable to find a single recorded result of antenatal testing for HIV, syphilis or anaemia in the village (566 women) or Puskesmas records (2816 women) for 2015. Laboratory records did not specifically identify antenatal women. Participants described conducting and reporting testing in a largely ad hoc manner; relying on referral to health facilities based on clinical suspicion or separate non-maternity voluntary counselling and testing programs. Participants recognized significant systematic challenges with key differences between the more acceptable (and reportedly more often implemented) haemoglobin testing and the less acceptable (and barely implemented) HIV and syphilis testing. However, a clear need for leadership and accountability emerged as an important factor for prioritizing antenatal testing and addressing these testing gaps. Conclusions: Practical solutions such as revised registers, availability of point-of-care tests and capacity building of field staff will therefore need to be accompanied by both funding and political will to coordinate, prioritize and be accountable for testing in pregnancy.

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

“…For example, healthcare workers from Indonesia thought their local ‘policy recommended HIV testing to pregnant women at risk, such as pregnant women with tattoo or whose husband work as driver’. 49 …”

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

“…There is a dearth of research on supply-side determinants of the uptake of antenatal HIV testing in LMICs [25,60]. Our analysis begins to address this gap by firstly demonstrating that pregnant women attending public facilities with higher service readiness scores are more likely to be tested for HIV.…”

“…Systematic reviews show that these variables are commonly associated with the effective delivery and uptake of HIV testing and treatment in ANC in resource-constrained settings [20,25,46]. The full list of variables and their definitions are provided in S1 Table . Since this is an ecological study using data collected at the health facility level, supply-side readiness will from hereon be referred to as 'health facility readiness'.…”

“…Far fewer studies have examined the influence of supply-side factors on the delivery of PMTCT services, especially in the Asia-Pacific region [22]. Service availability and readiness, which reflects the system level willingness and preparedness to provide quality services [23], has been shown to be lacking in several key areas of ANC delivery in Indonesia including diagnostic capacity and medicine supply [15,24,25]. This study will be the first in Indonesia to assess the readiness and availability of both public and private health services to deliver PMTCT services, a key element of ANC, and to examine the role of supply-side factors in the uptake of antenatal testing for HIV.…”

Literature Review: Sensitivity and Specificity of VDRL and RPR as Screening Tests of Syphilis in Pregnant Women

“…4 However, in terms of availability of test kits and affordability for the community, ELISA is not yet potential as a screening test that can be applied in Indonesia for triple elimination screening in pregnancy. Indonesia also relies on small, distributed community health centers ("Puskesmas") which can perform 79 simple screening tests for syphilis, 10 and not large-volume laboratories, so that from the comparison between RPR and VDRL, RPR is the better option for screening tests.…”