hiv prevention through sexual transmission model at the primary health care level

HIV Prevention through Sexual Transmission Model at the Primary
Health Care Level
Pande Putu Januraga; Aang Sutrisna; Vidia Darmawi; Ignatius
Praptoraharjo; M. Suharni; Ignatius Hersumpana; Ita Perwira; Swasti
Sempulur; Satiti Retno Pudjiati; Eviana Hapsari Dewi
National Library: Catalog under Issuance
HIV Prevention through Sexual Transmission Model at the Primary
Health Care Level/ Pande Putu Januraga; Aang Sutrisna; Vidia Darmawi;
Ignatius Praptoraharjo; M. Suharni; Ignatius Hersumpana; Ita Perwira;
Swasti Sempulur; Satiti Retno Pudjiati; Eviana Hapsari Dewi

Yogyakarta: Center for Health Policy and Management (CHPM) Faculty
of Medicine Universitas Gadjah Mada
xiv + 96 pages / 25 x 17 cm
First edition, September 2016

1. Sexual Transmission 2.HIV Prevention Model 3. Primary Health Care
I. HIV Prevention through Sexual Transmission Model at the Primary
Health Care Level

Written with the support of the Australian government through a grant

from the Department of Foreign Affairs and Trade (DFAT) to the Center for
Policy and Health Management (CHPM), Faculty of Medicine, Universitas
Gadjah Mada. This publication does not represent the views of either the
Government of Australia or the Government of Indonesia.
All rights reserved.
Any part of the report may be used, reprinted, reproduced, quoted,
or cited in any manner through proper citation and for the purpose of
community education, not for commercial interests.
For more information please contact the Center for Policy and Health
Management (CHPM), Faculty of Medicine, Universitas Gadjah Mada.
Suggested citation:
CHPM. 2016. HIV Prevention through Sexual Transmission Model at the
Primary Health Care Level. Yogyakarta: CHPM GMU
Copyright © 2016 by
Center for Policy and Health Management (CHPM), Faculty of Medicine,
Universitas Gadjah Mada

H IV P re ve nt ion Throu g h Se xu a l Tra nsmission M od e l a t The P rima ry H e a l th Ca re Le v e l

Executive Summary

Indonesia is experiencing a shift in epidemic
population trends in HIV transmission from
injecting drug users (IDUs), followed by
direct female sex workers (DFSW), and is
now dominated by sexual transmission
among indirect female sex workers (IFSW)
and men who have sex with men (MSM),
including waria. Projections indicate that
these key populations will constitute 90%
of new infections, that is, 70,000 to 80,000
individuals/per year during the 2014-2019
period. The model-specific intervention to
prevent sexual transmission among key
populations (PMTS initiative) was developed
in 2010 in response to the growing HIV
epidemic in Indonesia, unfortunately
however, the continuity of the PMTS program
has been heavily reliant on financial support
from international donors.

This study is a collaboration between the
Center for Health Policy and Management
(CHPM) Faculty of Medicine, Universitas
Gadjah Mada and the Department of Foreign
Affairs (DFAT), Australia. Researchers
explored the applicability of an integrated
services model that would ensure
sustainability of the PMTS program at primary
health care level. The study also looked into
models of operational policies that would
support the implementation of integration.
Primary health care level was chosen as the
locus of the study considering its function and
proven contribution in responding to the HIV
epidemic in Indonesia.
The study used a mixed methods approach.
A desk review was conducted by compiling
references related to HIV prevention
through sexual transmission and analyzing

iv

them to subsequently develop a PMTS
service delivery model. A questionnaire
was developed and was administered by
Delphi participants during the meeting.
The proposed model shown in this report is
the agreement among Delphi participants
who are experts and practitioners on HIV in
Indonesia.
The results of the desk review of various
scientific documents and related policy briefs
on HIV-AIDS at national and international
levels stipulated a number of comprehensive
prevention strategies including biomedical
approaches such as condom use,
circumcision, HIV testing and counseling
followed by antiretroviral therapy (ARV) if
positive, treatment of sexually transmitted
infections (STIs), and other ARV-based

preventions. In addition to this, behavior
change interventions are also important at
both individual and societal level. However,
a paucity in necessary structural support in
the form of policy reforms and regulations
serve to hamper services, as well as work
against the empowerment of marginalized
communities, and the improvement
of economic and social concerns. It is
recognized that at the primary health care
level the structural approach relies more on
cross-cutting efforts coordinated with other
agencies or other related organizations.
From exploration into the various policy
documents at international and national
levels, it can be concluded that almost
all components are implementable at
the level of primary health care, however
this is dependent on structural support
across sectors. Public health centres are

the provision of condoms, distribution
of condoms, diagnosis and treatment of
STIs at the individual level, screening and
periodic presumptive treatment (PPT) with
sex workers, circumcision of adult males, HIV
testing in public health centre facilities, either
through VCT clinics or provider-initiated
counseling and testing (PITC) and mobile
VCT as an extension of public health efforts
targeting high-risk groups, ART services,
the promotion of reproductive health and
HIV-AIDS to the general population and the
continuation of prevailing health promotion
activities related to HIV-AIDS high-risk
groups.

The two rounds of Delphi survey and
post-Delphi discussion conducted with
practitioners and experts associated with

PMTS concluded that the PMTS model must
involve all groups of high-risk populations
outside the FSW community and its clients,
namely MSM and waria. Further activities
should be prepared by considering the
differences in epidemic conditions, ability
of providers as well as population mapping.
In the short term, the role of international
donors in funding the activities of PMTS
especially the provision of condoms, condom
distribution, outreach and education of highrisk groups remains predominant. Integration
should be iterated gradually considering
the financial capability and commitment of
service providers. Furthermore, the results of
the survey and post-Delphi discussion also
concluded there are 11 specific issues related
to the implementation of PMTS activities/
components, especially at the level of current
and future service integration which includes

Consequently, a proposed level of services
integration is as follows: (1) a partly
integrated service carried out by others in full
coordination with public health centres which
provide the bulk of facilities/infrastructure for
condom distribution and health promotion
services in high-risk groups; (2) integrated
services should be coordinated by public
health centres along with other parties,
with a clear division of tasks and authority
particularly in the provision of condoms;
(3) integrated services in which financial
support and human resources from other
parties come from outside the regular funding
mechanisms specifically mobile VCT and
ART services; and (4) fully integrated services
which is routinely carried out by public health
centres including the diagnosis and treatment
of STIs in individual health efforts, screening
and treatment of STIs for FSW, adult male

circumcision and finally, health promotion
services to the general public.

E xe c u tiv e Su mma ry

successfully providing services to high-risk
groups, however, this work continues to be
informed by global policies and financial
support from international donors. The role
of public health centres is critical, especially,
in the distribution of condoms to high-risk
populations, and health promotion targeted
to high-risk population groups, as well as
the service of antiretroviral therapy (ART)
which remains a necessity. Even though this
is being carried out, there is still a need for
strengthening the capacity of public health
centres in the distribution of condoms, in
managing STIs, as well as in carrying out
voluntary counseling and testing.

v

Table of Contents

H IV P re ve nt ion Throu g h Se xu a l Tra nsmission M od e l a t The P rima ry H e a l th Ca re Le v e l

Executive Summary - iv
Table of Contents - vi
List of Figures - vii
List of Tables - vii
List of Abbrevations - viii
Preface - x

Introduction - 1
Background and Rationale - 10
Objectives - 11

Integration Frameworks at
The Primary Health Care

Level - 12
Model Development
Approach - 18
Study Design - 18

Generating Consensus
about a PMTS Model
through a Delphi Study - 40
Practitioner Consensus about PMTS
Concepts and Strategies - 41
Consensus on the PMTS concepts and
strategies from experts - 55
Conclusion on consensus and model
development - 61

Proposed PMTS Model for
Indonesia - 63

Desk Review Strategy - 18

Final Remarks - 69
Desk Review of PMTS
Integration Models at the
Primary Health Care Level
- 20
HIV transmission through unsafe sexual
practices in Indonesia - 20
PMTS Model Integrated into Mainstream
Services in other Countries - 23
Literature Review of PMTS Policy - 26
Findings from exploration into the
practical application of current PMTS
program - 33
Desk review conclusions - 38

vi

Conclusion - 69
Recommendations - 70

Appendix - 74

List of Figures

/ List of Tables

Figure 1. PMTS Service Integration
Framework at the Primary Health Care
Level - 17

Tabel 1. Sub-System Service Integration
Categories According to the Continuum
of Integration - 15

Figure 2. Reliability of the PMTS
Definition - 42

Table 2. New HIV Infections in Indonesia
- 21

Figure 3. Reliability of condom
procurement and distribution strategy
- 44

Table 3. Comparative Analysis of PMTS,
LKB and WHO Recommendations - 28
Table 4. PMTS LKB Related Services - 29

Figure 4. Desirability and feasibility on
condom procurement and distribution 46

Table 5. Current and Proposed SubSystem Integration Efforts for PMTS
Health Services - 68
Ta b l e of C onte nts

Figure 5. Reliability of STI management
- 48
Figure 6. Desirability and feasibility of
STI management - 49
Figure 7. Reliability of HIV Testing and
Treatment - 50
Figure 8. Desirability and feasibility HIV
Testing and Treatment - 51
Figure 9. Reliability on sexual and
reproductive health for the community
- 52
Figure 10. Desirability and feasibility of
STI-HIV prevention education - 53
Figure 11. Desirability and feasibility of
the role of implicated stakeholders - 54
Figure 12. Reliability of the PMTS model
according to expert cohort - 56
Figure 13. Desirability of the PMTS model
according to expert cohort - 59
Figure 14. Feasibility of the PMTS model
according to expert cohort - 60

vii

H IV P re ve nt ion Throu g h Se xu a l Tra nsmission M od e l a t The P rima ry H e a l th Ca re Le v e l

List of Abbrevations

viii

ABAT

Aku Bangga Aku Tahu/I’m
Proud I Know

AIDS

Acquired
Immunodeficiency
Syndrome

ANC

Ante Natal Care

ARV

Antiretroviral Drugs

KDPA

Kader Desa Peduli AIDS/
Village cadres concerned
with AIDS

KDS

Kelompok Dukungan
Sebaya/Peer Support
Group

KSPAN

Kelompok Siswa Peduli
AIDS dan Narkoba/A cadre
of students that care about
AIDS and drugs

ART

Antiretrovirals

BCC

Behaviour Change
Communication

KISS

BKKBN

Badan Kependudukan
dan Keluarga Berencana
Nasional/National
Population and Family
Planning Board

Koordinasi, Integrasi,
Sinkronisasi dan Sinergi/
Coordination, Integration,
Synchronization, and
Synergism

LKB

CBO

Community Based
Organisation

Layanan Komprehensif
Berkesinambungan/ HIV
Continuum of Care

CSO

Civil Society Organisations

LGBT

DFAT

Department of Foreign
Affairs and Trade

Lesbian, Gay, Bisexual and
Transgender

MOH

Ministry of Health

DFSW

Direct Female Sex Worker

MSM

Men Who Have Sex with
Men

DOH

Department of Health

FP

Family Planning

NAC

National AIDS Commission

FSW

Female Sex Worker

P/DAC

GF

Global Fund

Provincial/District AIDS
Commission

GFATM

Global Fund to fight AIDS,
Tuberculosis, Malaria

NGO

Non-government
Organisation

GFNFM

Global Fund New Funding
Model

NHS

National Health System

OI

Opportunistic Infections
Orphans and Vulnerable
Children
Post-exposure prophylaxis

HIV

Human Immunodeficiency
Virus

OVC

IBBS

Integrated Biological and
Behavioural Surveillance

PEP

IDP

International Development
Partner

PERMENKES Peraturan Menteri
Kesehatan/ Ministry of
Health’s Regulation

IDU

Injecting Drug User

PMK

IEC

Information, Education,
Communication

Peraturan Menteri
Kesehatan/ Ministry of
Health’s Regulation

IFSW

Indirect Female Sex Worker

PHC

Primary Health Care or
Public Health Centre

List of Abbrevations

PICT

Provider Initiated
Counseling and Testing
Primary Personal Health
Services

PKMK

Pusat Kebijakan dan
Manajemen Kesehatan/
Center for Health Policy
and Management

PLWHA

People Living with HIVAIDS

PMTCT

Prevention of Mother to
Child Transmission

PMTS

Pencegahan Melalui
Transmisi Seksual/
Prevention of HIV through
Sexual Transmission

PPT

Periodic Presumptive
Treatment

PR

Principal Recipient

PrEP

Pre-exposure prophylaxis

RTI

Reproductive Tract
Infections

SIHA

Sistem Informasi HIV-AIDS/
HIV-AIDS Information
System

SIP/SIMPUS Sistem Informasi
Puskesmas/ HIV-AIDS
Information System in
Public Health Centre
SKPD

Satuan Kerja Perangkat
Daerah/ Local Government
Component Working Unit

SPM

Standar Pelayanan
Minimal/ Minimum Service
Standards

SOP

Standard Operating
Procedures

STI

Sexually Transmitted
Infection

SUFA

Strategic Use for
Antiretrovirals

Tuberculosis

UKBM

Upaya Kesehatan Berbasis
Masyarakat/Communitybased Health Effort

UKM

Upaya Kesehatan
Masyarakat/Public Health
Effort

UKP

Upaya Kesehatan
Perorangan/Individual
Health Effort

UNAIDS

Joint United Nations
Programme on HIV and
AIDS

UNAIR

Universitas Airlangga/
Airlangga University (East
Java)

UNCEN

Universitas Cenderawasih/
Cenderawasih University
(Papua)

UNDANA

Universitas Nusa Cendana/
Nusa Cendana University
(East Nusa Tenggara)

UN

United Nations

UNUD

Universitas Udayana/
Udayana University (Bali)

USU

Universitas Sumatera
Utara/North Sumatera
University

VCT

Voluntary Counseling and
Testing

WG

Working Group

WHO

World Health Organisation

List of A b b re v a tions

PKPP

TB

ix

H IV P r eve ntion Throu g h Se xu a l Tra nsmission M od e l a t The P rima ry H e a l th C a re Le v e l

x

Preface

I

ntegration of HIV and AIDS response into existing health services has gained
significant attention from program administrators, donor organisations and
researchers as a feasible concept and strategy to strengthen effectiveness,
efficiency, client satisfaction, and sustainability of the response. However, at
the implementation level, integration may not be implemented as expected
because integration basically demands for negotiation of interests and power owned
by various actors. The prevention of HIV through sexual transmission (PMTS)
Program is one of programs designed to integrate different actors with different
interest and power in a multi sectoral program. Therefore, the implementation of
PMTS remains facing obstacles such as establishing a conducive environment,
ensuring provision of condoms, encouraging behavioural change, and conducting
testing and treatment of STIs and HIV. Due to this dynamics of interaction among
the actors in PMTS, assessment and evaluation of the PMTS implementation shall be
conducted constantly in order to achieve better result or outcome.

P re fa c e

The Indonesian National AIDS Commission (NAC) would like to express our
appreciation for publication of the PMTS program modelling at primary health
service and its networks. Focus in the integration at primary health services is a
strategic choice since, historically, the role of primary health services in Indonesia
has strong evidence in involving both the community and non-health sectors, and
it has also been successful in promoting inter-sectoral collaborations and service
integration. It should be aware that the recommended model has considered
principles of decentralisation in health sector and regional capacity in providing
basic services. Orientation on regional characteristics of the model makes PMTS
integration would vary at the sub-national level due to variations of the need
of the beneficiaries, capacity of the service providers, epidemic situation, and
implementation of main functions of the health system at sub-national level.
This model also emphasizes that integration is not the ends of the service, but as
the means to provide a service that are accessible, fair, fulfil the basic needs of the
population, and sustainable. by defining integration as such, efforts in strengthening
PMTS at the primary service level could strategically contribute to achieve better
result and outcome in preventing the HIV transmission through sexual transmission
in terms of effectiveness, efficiency and continuity. At the sub-national level,
recommendations of the study could be utilized as the guidance for policy makers to
enhance the implementation of the PMTS program in their areas.

Jakarta, 30th of August, 2016

Dr. Kemal N. Siregar
Secretary of the National AIDS Commission

xi

H IV P r eve ntion Throu g h Se xu a l Tra nsmission M od e l a t The P rima ry H e a l th C a re Le v e l

xii

Introduction

Background and Rationale
The Continuation of PMTS is the key to
halting the HIV epidemic in Indonesia
The HIV epidemic that has lasted for more
than two decades in Indonesia is indicating a significant shift in epidemic trends,
after initially growing quite rapidly among
injecting drug users (IDUs), the epidemic
exploded among female sex workers (FSW),
which was then feared as an epidemic
bridge to the general population (Riono and
Jazant, 2004; NAC of Indonesia, 2012). The
reality of a full shift in the epidemic to becoming generalised through unsafe sexual
practices of FSW and their male clients
have come into question owing to a variety

of surveillance data and mathematical
modeling which have showed a significant
increase in incidence among MSM (MOH of
Indonesia, 2008; MOH of Indonesia, 2013).
By observing the accumulated number of
HIV-AIDS cases and risky behaviours carried out by FSW and MSM groups including
waria, it is apparent that continued focus on
these populations are key to tackling the
HIV epidemic in Indonesia.
HIV prevention efforts among FSW,
MSM and waria have predominantly been
facilitated through the global initiative in the
form of donor funding assistance which has
impacted upon the dynamic development
of policies and programs among these
populations (Yu et al., 2008; CHPM, 2015). In
Indonesia, this influence is clearly visible in
the national program design which aligned
greatly with donor program modeling. In
the 90s, prevention programs focused on
strengthening the role of civil society and it
was characterized by the growth of various
NGOs working in HIV-AIDS response. Then,
in the 2000s, strengthening of government
institutions was promoted so that these
bodies would play a greater role in HIVAIDS prevention activities, especially in the
provision of preventive services at primary
and secondary levels, such as STI clinics,
VCT and ART service providers. Later, the
concept of sustainable and comprehensive
services, including the test and treat
approach, became a major campaign in
alignment with the “90-90-90” UNAIDS
campaign (CHPM, 2015).
Irrespective of the approach and
dynamics of the HIV-AIDS work among
the FSW, MSM and waria populations,
interventions have largely focused on
preventing sexual transmission of HIV
through positive behaviour change
activities, including condom promotion and
early access to diagnosis and treatment of
STIs and HIV. Although health interventions
specifically focused on key populations

1

Introd u c tion

In order to achieve the common
goal of globally ending the HIV
epidemic, the strengthening
of health systems, specifically
in the planning capacities,
implementation abilities, and
evaluation approaches is
imperative (Yu et al., 2008;
WHO, 2007; UNAIDS, 2015).
Large scale reductions in
donor funding have made
this approach even more
relevant, and in order to ensure
sustainability of programs
and services, the successful
integration of specific HIV
interventions into mainstream
health care systems becomes a
necessity (UNAIDS, 2015).

H IV P re ve nt ion Throu g h Se xu a l Tra nsmission M od e l a t The P rima ry H e a l th Ca re Le v e l

have proven to be more efficient to
implement, especially in countries with
limited resources, several weaknesses
persist, among others: 1) the development
of multiple systems or parallel systems
within the broader health system, 2)
funding diversity affecting programming
approaches, and 3) the lack of incentives
and proper adoption of endorsed health
systems, which is considered a particular
threat to sustainability (Atun et al.,
2010; Suharni et al., 2015). Therefore, a
focus on the integration of specific HIV
prevention initiatives, especially in highrisk populations, in order to ensure the
continuity of services at the grassroots
level is increasingly being recommended
(Suharni et al., 2015; CHPM, 2015; Atun et
al., 2010).

The Need for the Development of a
National PMTS Service Model and
Associated Policies
How to bring about such integration, and
determine what models are appropriate
to encourage integration are questions
that still need to be addressed (Atun et
al., 2010; Frenk, 2009). Based on the
results of a series of studies on HIV Policies
and Programs within the Health System
Framework in Indonesia (which is a joint
program between the CHPM and DFAT), it
is evident that there are variations in levels
of integration and levels of effectiveness
of health care coverage. In the context of
regional differences, this inconsistency
is tangible in the ability and capacity of
human resources, including disparities in
funding, as well as the magnitude of the
problem or differences in the level of the
epidemic. The results of study I and II also
show that the policies to combat HIV-AIDS,
including prevention programs for sexual
transmission of HIV (PMTS), were comprised
of national and local level policies,
however, the execution of said policies was

2

problematic (CHPM, 2015; Suharni et al.,
2015). Systematic effort is needed within
the framework of scientific research to
create a model for services, policies and
programs that correspond to differences
in local capacities and epidemic situations
of various provinces in Indonesia. This
study is the third activity (III) in a series of
collaborative research between CHPM and
DFAT regarding policies and programs on
HIV-AIDS in the Health System Framework
in Indonesia.

Objectives
This study aims to explore two lines of
query:
1.

What kind of integration model would
be able to guarantee the continuation
of the PMTS program in Indonesia at the
primary health care level?

2. What policies would be necessary in
order to ensure the effective integration
and operationalization of the PMTS
program at the primary health care
level?

3

H IV P r eve ntion Throu g h Se xu a l Tra nsmission M od e l a t The P rima ry H e a l th C a re Le v e l

4

Integration
Frameworks at
The Primary Health
Care Level

T

More specifically, there are 6 main
reasons underlying the importance of
developing the PMTS program’s integration
model at the level of basic services:

1) Peraturan Presiden No.72, 2012, or national legislation
endorses an integrated approach.

1.

The HIV-AIDS burden is tremendous. It
does not only impact on the patient’s
health but also on the social and
economic welfare of the family.
Negative social and economic impacts
can be minimized if the transmission
of HIV can be addressed, or when
transmission has occurred, treatment
can be provided as early as possible
at the most basic or primary level of
service provision or care.

2. The problems of STIs and HIV-AIDS are
undoubtedly connected to various other
health issues that are often reported in
mainstream services, eg. TB and ANC
services.
3. Gaps found within the service coverage
or within the HIV and STI cascade
remain an issue. Surveillance data
and results of the study indicated that
one of the barriers in the continuity of
HIV patient care is access difficulty
and convoluted referral systems. The
coordinated approach of an integrated
PMTS program will help reduce such
gaps.
4. Public health centres are found
throughout all of Indonesia, therefore,
an integrated PMTS approach will help
improve access to services.
5. The provision of services at the most
basic level would reduce stigma and
discrimination. Preliminary evidence
suggests that the specialization of
services specifically targeting certain
populations can actually increase
stigma and discrimination towards
affected groups.
6. Integration of services at the primary
health care level could increase costeffectiveness.
Although these assumptions and strong
rationale argue for the integration of PMTS
services at the primary health care level,

5

Inte g ra tion F ra me w ork s a t The P rima ry H e a l th C a re Le v e l

here are two main assumptions
in determining the development
model of PMTS at the primary
care level. The first is the
position and important role of
primary health care in the national health
system, where primary services are placed
at the forefront of health care and able
to provide comprehensive and essential
services, including personal health
services and community health promotion,
prevention, treatment and rehabilitative
activities.1 With such vital position and role,
the strengthening of PMTS at the primary
health care level will contribute greatly
towards efforts to control the HIV epidemic.
The second assumption is that owing to
the history of the role of public health
centres in Indonesia, especially in providing
services that involve the community and
non-health sectors, and the arguably well
executed and managed services provided,
they are in an excellent position to lead
in the efforts towards integration. Based
on the two major assumptions above, the
development of the integrated PMTS model
at the primary health care level will lead to
an increase in the effectiveness of services
described within the framework shown
in Figure 1, where the integration into the
national health system will encourage the
implementation of PMTS in order to achieve
the desired output of increased access to
services, increased coverage and improved
quality of service. The output will include
positive behaviour change to reduce the
risk of STIs and HIV transmissions which
will inevitably lead to a decrease in new
infections of STIs and HIV.

H IV P re ve nt ion Throu g h Se xu a l Tra nsmission M od e l a t The P rima ry H e a l th Ca re Le v e l

there are some major hurdles that must
considered to ensure that the proposed
model has an adequately strong foundation
prior to implementation. The main obstacle
in developing an integrated service model
is the dominance of donor funding or
support from international development
partners (IDP), such as the Global Fund (GF),
in financing PMTS services and activities.
One of the largest components of the
funding model from the GF is the financing
of human resources. There are two types of
health related human resources supported
by the grants: firstly, those who work in the
government health care system but later
received an additional honorarium or salary
for conducting HIV-related activities; and
secondly, non-civil servant staff recruited
by CSOs or NGOs. Therefore, behaviour
change efforts at the primary health care
level work under separate systems in
conjunction with the mainstream health
education program (Suharni et al., 2015).
Not only are there differences in the
provision of services at the primary health
care level, but support services, such as
logistical use of medical equipment, and
procurement of condoms and lubricants as
medical devices for HIV prevention, are also
controlled predominantly by the NAC, which
functions as a coordinating body outside
of official government structures. In other
words, the procurement and distribution of
condoms is beyond the official procurement
system of medical equipment in general
(Suharni et al., 2015). Another example is
the separation of information/data systems
for outreach services and the mainstream
national and regional health information

6

systems. The previous GFATM program
was an abundance of health information
collated from activities involving outreach
programs and the distribution of condoms
and lubricants, but this was not reported
beyond being used as validation for
financial liability and was not used to feed
into the planning of health programs. In
general, management of the information
was not well coordinated and efficient
utilization of shared information between
the sectors was infrequent (Suharni et al.,
2015).
It is vital, therefore, to develop a model
capable of addressing these constraints.
The approach able to support sustainability
of the health system, the epidemic
situation, service providers and the effective
implementation of primary care is known
as the continuum of integration approach
(Blount, 2003; Doherty et al., 1996). The
main focus of this framework is to map the
integration level of services and activities at
the public health centres and among their
networks. This approach was appropriated
not because it is deemed successful in
improving services but rather as a method
to provide services that are accessible,
equitable and also meet the basic needs of
all parties.
The operational definition of the term
continuum of integration in this model
has been adapted from Doherty et al.
(1996) and Blount (2003) by categorizing
the levels of integration into coordinated
services, co-located services and integrated
services. These are detailed in the box
below:

Minimal collaboration

1
Coordinated
Services

Services or activities performed in a separate facility
using systems different to those of the public health
services delivery system. Communication with the
public health centre is minimal and dependant on the
service needs of individuals and groups.

Basic collaboration at a distance

2

Inte g ra tion F ra me w ork s a t The P rima ry H e a l th C a re Le v e l

Services or activities performed in a separate facility
from the public health centre and using different
systems, but the service providers view each other
as mutual sources so as to communicate periodically
about the groups or individuals being served.

Basic collaboration onsite

3

The service is in the same location as mainstream services, but they either share or do not share the same
space. The systems used are still separate but the
communication may be frequent. Mutual reconciliation of services or activities are very likely to occur because they are in the same location. Service providers
feel as part of a team although its working mechanism
is unclear so that decisions regarding the groups or
individuals served is still implemented independently
by the respective service providers.

Co-located
Services

4
5
Integrated
Services

6

Close collaboration with some system integration
Low level mainstreaming or integration occurs at this
level and task delegation and spheres of influence
are clearly demarcated.

Close collaboration approaching an integrated
practice
The level of collaboration and open communication is
high . Effectiveness and efficacy of service provision
is established, although some aspects of reporting
and referral systems remain low.

Full collaboration in a transformed/merged practice
The highest level of integration and a transformedmerged approach applied for the community as a
whole. These services are provided to all.

7

H IV P re ve nt ion Throu g h Se xu a l Tra nsmission M od e l a t The P rima ry H e a l th Ca re Le v e l

The operational definition of integrated
services above can be translated into the
definition of a PMTS service model. The
results of previous CHPM research on
the integration level of HIV-AIDS within
sub-system health measures (Financing,
Human Resources, Services, Facilities,
Management, Regulation, and Information
Systems) were categorized into 3 groups:
integrated in full (), in part (), and
not integrated at all (), subsequently
definitions regarding the category of PMTS
services integration model with the public
health centre was drafted, as shown in the
table 1.
The definitions of the practical service
integration model can be summarized as
follows:
• Level 1: When the service is carried out
by others, outside the coordination of
public health centres which only receive
information sporadically. This level of
service, which includes the regulation,
management, human resources and
financing, functions separately and
is not integrated at all within the
system at the public health centre,
little communication is carried out
horizontally on an ad-hoc basis so that
it can be categorized as an integrated
part.
• Level 2: When the service is carried
out in coordination with other parties
in public health centres where
the regulation and management
of public health centres are also
actively engaged. This level of
service is conducted in a separate
area with facilities, human resources
and financing not integrated at all
with the system at the public health
centre. However, the regulation and
management of public health centres
play a role in the implementation of
services, and information is regularly
exchanged in writing so that at least the

8

elements of management, regulation
and information are integrated in part.
• Level 3: When the service is carried
out in full coordination with public
health centres which provide most of
the facilities/infrastructure. This level of
service is provided simultaneously or in
coordination with public health centres
although financial and human resources
for these services are not at all
integrated with the system at the public
health centre. Therefore, there is a
need for more intensive communication
and information exchange as well as
management, facilities, and technical
regulations that are partly integrated
within the system of public health
centres.
• Level 4: When the service is performed
by public health centres along with
other parties, with clearly defined
division of tasks. This level of service
is provided jointly by the public health
centre in conjunction with other parties
both inside and outside the public
health centre, though financing is still
not integrated with the service financing
mechanism of the public health centre.
Therefore, at least all the major
elements in the sub-system except
financing, has been partly integrated
with the system at the public health
centre.
• Level 5: When the service functions
through the help of financial and human
resources from other parties outside
the regular funding mechanisms. At
this level, the technical elements of the
service, regulation and management are
fully integrated with the system in public
health centre excluding elements of
human resources and finance.
• Level 6: When the service has become
mainstreamed, including aspects
of planning, financing and service,

HR

Services

Equipment

Management

Regulation

Information

Level 1: Minimal
collaboration















Level 2: Basic
collaboration at a
distance















Level 3: Basic
collaboration onsite















Level 4: Closed
collaboration with some
system integration















Level 5: Closed
collaboration
approaching an
integrated practice















Level 6: Full
collaboration in a
transformed/merged
practice















Level of Integration

Inte g ra tion F ra me w ork s a t The P rima ry H e a l th C a re Le v e l

Financing

Table 1. Sub-System Service Integration Categories
According to the Continuum of Integration

9

H IV P re ve nt ion Throu g h Se xu a l Tra nsmission M od e l a t The P rima ry H e a l th Ca re Le v e l

and is fully integrated with existing
mechanisms within the public health
centre. At this level, the service has
become part of the mandatory services
provided by the public health centre
and all the main elements in the subsystem level are fully integrated with
the system at the public health centre.
Models designed need to consider
how these levels of integration can be
implemented in public health centres. The
first issue is how to integrate both national
and regional health systems in support
of service delivery, such as in sub health
financing system and how financing policy
differs at the national and regional levels to
ensure financial capability when providing

10

support for human resources and health
facilities. The second issue is the level
of support from local stakeholders in the
implementation of the PMTS programs.
Stakeholder mapping will determine who
will be the executor. For example, ideally,
outreach work with high-risk populations
should be undertaken by professionals
who are trained in social work and funded
by the state, but in reality this is rarely the
case. The depiction of the health system
linkage, the epidemic situation, the service
organization and forms of services in the
PMTS model can be seen in Figure 1.

O

er

3.

an

ic

Human resources

3.

Pharmacy and
logistical supplies

4.

Health systems
information
management

5.

Community
empowerment

1.

Concentration of epidemic

2.

Stigma and discrimination

3.

Structure of key pops

1.

Human resources
1.1. Composition of healthcare
professionals
1.2. Training

2.

PHC Infrastructure
2.1. IT
2.2. Technology
2.3. Layout

3.

Organisational structure
3.1. Duties and authority
3.2. SOP
3.3. Organisation culture

4.

Prevention tools and logistics

Inte g ra tion F ra me w ork s a t The P rima ry H e a l th C a re Le v e l

Health services
funding

2.

xt
nt e

rg

ization of S

rv

Co

pid

g

ce

2. E

lo

vi

1.

io

alth System
1. He
l S i t u at i o n & S
e
ica

e

em

Figure 1. PMTS Service Integration Framework at the
Primary Health Care Level

Health Service Delivery Model
Continuum of integration*
PMTS Domain

Co-ordinated

Co-located

Integrated

Domain of Service Efficacy
Access
1. Availability
2. Coverage
3. Sustainability

Relationship with
key populations
1. Interpersonal
communication
2. Respectfulness
3. Trust
4. Cultural
competence

Continuity
1. Relational
continuity
2. Communication

Service
satisfaction
1. Satisfaction score
from patients
2. Satisfaction score
from stakeholders

11

H IV P r eve ntion Throu g h Se xu a l Tra nsmission M od e l a t The P rima ry H e a l th C a re Le v e l

12

Model Development
Approach

Study Design

T

Desk Review Strategy
A literature review of the PMTS integration
model was conducted to obtain information
on three major points: the first is related
to the role of sexual transmission in the
development of the HIV-AIDS epidemic in
Indonesia as well as the various attempts
that have been made to mitigate the
impact of the HIV-AIDS epidemic. The
second literature review was intended to
obtain an overview of the various models
of prevention of sexual transmission that
have been carried out in various countries
around the world and to examine how the
integration model was instrumental in the
success of their implementation. Thirdly, on
PMTS policy developments in Indonesia,
and on policy that may support and
obstruct the implementation of the PMTS
integration model.

Literature research strategy
In order to assess the extent and distribution of the implementation of prevention
programs in Indonesia, a review on peer reviewed publications in international journals
was conducted.
A search for peer reviewed literature
was conducted through the PubMed
database using a number of search words:
((HIV[MeSH Terms]) OR (STDs[MeSH
Terms])) AND ((care[Title/Abstract]) OR
(program*[Title/Abstract]) OR (service*[Title/
Abstract]) OR (prevent*[Title/Abstract]))
AND (Indonesia[Title/Abstract]) Filters:
Humans. The search unearthed 108
articles which were then screened to see
whether they fit the desired criteria. The
first stage of screening was performed on
the article title and produced 58 articles.
This phase resulted in 36 articles available
for download in which 33 articles were
then analysed. In general, there were two
groups of articles: one that discussed the
magnitude of the problem and the risk of
sexual transmission of HIV through both
quantitative and qualitative approaches.
The second category of articles discussed
specific interventions in reducing the risk
of HIV transmission through sexual activity
in key populations in Indonesia. The scope
of the study in both groups of literature
included:

13

M od e l D e v e l opme nt A pproa c h

his study used a mixedmethods approach (Johnson
and Onwuegbuzie, 2004;
Creswell, 2008) in order to
collect in-depth and varied
information from a variety of sources. A
desk review of the issues and strategies
of sexual transmission prevention services
within the context of the problem, policy,
structure and organization of health
services in Indonesia was conducted. The
desk review results were then compiled into
a working paper supported by information
gathered from a Delphi study which was
conducted to explore the support or
consensus of practitioners and experts on
the proposed PMTS models. The approach
to data collection was a sequential design
(Creswell, 2008) wherein the desk review
was a major part of the data collection
method.

To provide understanding on the four
main topics of review above, the search
and analysis was directed to literature
on the application and impact of PMTS
in Indonesia, PMTS models used in other
countries and the factors that influenced
the outcomes, as seen from the service
organizations, including the role of
integration in the system of health provision,
as well as the research strategies implicit in
the policy document on PMTS in Indonesia.

• The epidemic level reported in key
populations;
• The magnitude of the problem and an
illustration of the risk of transmission
through sexual activity;

H IV P re ve nt ion Throu g h Se xu a l Tra nsmission M od e l a t The P rima ry H e a l th Ca re Le v e l

• The social, political, economic, and
policy conditions affecting the issue
and descriptions of the risk of HIV
transmission through sexual activity;
• If there are intervention settings to
reduce or prevent the risk of HIV
transmission through sexual activity
including specific interventions
undertaken, description, duration,
comparison, and the presence of cointerventions;
• Characteristics of the study, such as
design and duration;
• Participatory study including unit of
analysis, number of participants in the
intervention group and comparison;
• The impact or outcomes of the studies
and interventions;

To complement the results of the
study of peer reviewed literature, reports
on case studies of activities in several
cities in Indonesia were used to add the
latest information on the application and
outcomes of the impact of PMTS activities
in Indonesia. PMTS case studies were
conducted in Medan, Surabaya, Bali, East
Nusa Tenggara and Papua. These case
studies were conducted in different key
population groups, including MSM and FSW.

Literature research strategy
and analysis of PMTS in other
countries
In order to obtain information on the
delivery of care, a literature review was

14

conducted on peer reviewed articles from
the PubMed database with the key words:
((vertical[Title/Abstract]) OR (horizontal[Title/
Abstract]) OR (integrat*[Title/Abstract])
OR (coordinat*[Title/Abstract]) OR (coordinat*[Title/Abstract]) OR (link*[Title/
Abstract])) AND ((program*[Title/Abstract])
OR (care[Title/Abstract]) OR (service*[Title/
Abstract]) OR (delivery of health care,
integrated[MeSH Terms])) AND ((HIV[MeSH
Terms]) OR (STDs[MeSH Terms])). The search
resulted in 3524 articles which were refined
and resulted in 861 identified abstracts.
Ultimately, 28 full text articles were
downloaded and 22 were reviewed.
Scope of the literature covers three
main topics, namely:
• Regional settings or areas of
intervention, care delivery system
settings and population or target
groups;
• Specific interventions into the
health system, description, duration,
comparison, and the presence of cointerventions;
• The impact or outcomes of studies and
interventions;
• The level and quality of integration
including leadership and governance,
financing, planning, service delivery,
monitoring and evaluation;
• The policy setting or contextual factors:
continuity or sustainability, prospect or
opportunities, and the willingness for
integration or desirability.

Indonesian PMTS policy
research strategy
To find the appropriate policy documents
various sites were perused. In contrast
to the peer reviewed article search that
uses a systematic approach, the search
for document on policies and programs

were unstructured with more emphasis on
knowledge of documents available to the
public.
The study mainly focused on attempts
to analyse the development of PMTS
policy in Indonesia, and the presence of
sustainability policies or regulations within
the capacity of service organizations,
including on issues of financing, human
resources and logistics.

M od e l D e v e l opme nt A pproa c h

15

H IV P r eve ntion Throu g h Se xu a l Tra nsmission M od e l a t The P rima ry H e a l th C a re Le v e l

16

Desk Review of PMTS
Integration Models at
the Primary Health
Care Level

HIV Transmission Through
Unsafe Sexual Practices in
Indonesia

H

Although in the early development
of the epidemic HIV prevalence among
female sex workers was reported to be very
low, several studies reported a potential
epidemic outbreak among this group, due
mainly to the high incidence of STIs such
as syphilis and gonorrhoea (Joesoef et
al., 1997; Joesoef et al., 1998; Ford et al.,
2000a). In addition to the high incidence
of STIs, studies in the 90s and early 2000s
also reported risky behaviours especially
in the DFSW population, such as the high
number of clients per day and low use of
condoms (Wirawan et al., 1993; Fajans et
al., 1995; Ford et al., 1995; Ford et al., 1998;
Sedyaningsih-Mamahit, 1999; Ford et al.,
2000a; Basuki et al., 2002). Surprisingly
enough, more recent publications reported
a high incidence of STIs in nine provinces
in Indonesia as well as 70% inconsistent
use of condom (Tanudyaya et al. 2010). In
the same year, Majid et al. (2010) reported
an increase in the incidence of syphilis in
DFSW in nine cities in Indonesia from 2005
to 2007 (8% -14%).
Although the focus of reporting or
publications were initially concerned with
the potential of an HIV epidemic outbreak
among DFSW, the role of male customers of

In early 2000, publications began
reporting on the progress of the epidemic
among MSM and waria. For example, that of
Joesoef et al. (2003), which showed a high
incidence of sexually transmitted infections
among waria in Jakarta, which was
subsequently supported by the Pisani et al.
study (2004). Recent studies have reported
a high incidence of HIV among waria and
the emergence of an HIV epidemic among
MSM in Indonesia, especially Jakarta. The
study by Prabawanti et al. (2011) reported a
high prevalence of HIV (24%), syphilis (27%)
and rectal gonorrhoea or chlamydia (47%)
in Java. More recent studies related to the
increased incidence of HIV associated with
the development of sexual transmission in
MSM and waria in Bali have been published
by Januraga et al. (2013), and subsequently
in Jakarta by Safika et al. (2014). In Bali,
the research reported an increase in HIV
prevalence among MSM and waria, while
the research in Jakarta which reported on
patterns of risk behaviours of MSM and
waria showed that condom use among MSM
and waria was high – between 66% and
84% respectively. The study concluded that

17

D e sk Re v ie w of P M TS Inte g ra tion M od e l s a t the P rima ry H e a l th C a re Le v el

IV-AIDS through sexual
transmission in Indonesia
was to begin with widely
reported to have developed
among FSW, particularly
from the 90s until the 2000s and this is
detailed in a report on Surabaya (Joesoef
et al., 1997). The rate was reported as an
approximate of merely 0.2% (Ford et al.
2000a), but was reported to be much higher
in the study by Januraga et al. (2013) with a
prevalence of over 15% among direct FSW
and 6% among indirect FSW in Bali in 2010.

sex workers started to emerge in the early
90s as presented by Fajans et al. (1994,
1995) and Setyaningsih-Mamahit (1997).
Another study reported a lack of customers’
knowledge on STIs and HIV, a high number
of sexual partners, low rates of condom use
and a high number of respondents reporting
symptoms and signs of STIs. Interestingly,
not much was found on the client’s role
in sexual transmission of HIV affecting
the development of the HIV epidemic in
Indonesia after the 90s. Searches related
to this only found one study by Davies et
al. (2007) that reported fairly high positive
antibody findings of HSV-2 in men who
visited STI clinics in Indonesia.

H IV P re ve nt ion Throu g h Se xu a l Tra nsmission M od e l a t The P rima ry H e a l th Ca re Le v e l

Table 2. New HIV Infections in Indonesia

Number of new HIV infections
Population
2014

2015

2016

2017

2018

2019

Direct Female Sex Workers

3,854

3,853

3,850

3,851

3,858

3,869

Indirect Female Sex Workers

897

898

899

901

904

909

Male Sex Workers

1,327

1,449

1,576

1,708

1,844

1,983

Client of Sex Workers

16,056

16,040

16,038

16,051

16,079

16,123