Adiatma Siregar

Cost-effectiveness of methadone maintenance therapy as HIV prevention in an Indonesian high-prevalence setting: A mathematical modeling study

BACKGROUND Indonesia faces an HIV epidemic that is in rapid transition. Injecting drug users (IDUs) are among the most heavily affected risk populations, with estimated prevalence of HIV reaching 50% or more in most parts of the country. Although Indonesia started opening methadone clinics in 2003, coverage remains low. METHODS We used the Asian Epidemic Model and Resource Needs Model to evaluate the long-term population-level preventive impact of expanding Methadone Maintenance Therapy (MMT) in West Java (43 million people). We compared intervention costs and the number of incident HIV cases in the intervention scenario with current practice to establish the cost per infection averted by expanding MMT. An extensive sensitivity analysis was performed on costs and epidemiological input, as well as on the cost-effectiveness calculation itself. RESULTS Our analysis shows that expanding MMT from 5% coverage now to 40% coverage in 2019 would avert approximately 2400 HIV infections, at a cost of approximately US

Costs and outcomes of VCT delivery models in the context of scaling up services in Indonesia

7000 per HIV infection averted. Sensitivity analyses demonstrate that the use of alternative assumptions does not change the study conclusions. CONCLUSION Our analyses suggest that expanding MMT is cost-effective, and support government policies to make MMT widely available as an integrated component of HIV/AIDS control in West Java.

Priority setting in HIV/AIDS control in West Java Indonesia: an evaluation based on the accountability for reasonableness framework

Objective  To evaluate costs and outcomes of voluntary counselling and testing (VCT) service delivery models in urban Indonesia.

Time to recognise countries' preferences in HIV control

BACKGROUND Indonesia has insufficient resources to adequately respond to the HIV/AIDS epidemic, and thus faces a great challenge in prioritizing interventions. In many countries, such priority setting processes are typically ad hoc and not transparent leading to unfair decisions. Here, we evaluated the priority setting process in HIV/AIDS control in West Java province against the four conditions of the accountability for reasonableness (A4R) framework: relevance, publicity, appeals and revision, and enforcement. METHODS We reviewed government documents and conducted semi-structured qualitative interviews based on the A4R framework with 22 participants of the 5-year HIV/AIDS strategy development for 2008-13 (West Java province) and 2007-11 (Bandung). RESULTS We found that criteria for priority setting were used implicitly and that the strategies included a wide range of programmes. Many stakeholders were involved in the process but their contribution could be improved and particularly the public and people living with HIV/AIDS could be better engaged. The use of appeal and publicity mechanisms could be more transparent and formally stated. Public regulations are not yet installed to ensure fair priority setting. CONCLUSIONS To increase fairness in HIV/AIDS priority setting, West Java should make improvements on all four conditions of the A4R framework.

IMPORTANCE of MULTIPLE CRITERIA for PRIORITY SETTING of HIV/AIDS INTERVENTIONS.

www.thelancet.com Vol 387 March 12, 2016 1053 thermonebulisation as an attempt to control the adult vector; despite serious concerns regarding Malathion. The Revolving Fund for Strategic Public Health Supplies in the Pan American Health Organization has prioritised the purchase of pesticides. The prescribed model of implementation is centralised, vertical, and does not consider the steep social gradient where clusters of microcephaly areis found in poor outskirts of cities, where sanitary conditions are bad. Although offi cial data point out that 92% of urban households in Brazil were connected to public water in 2010, there are 3 983 329 unserved households, and intermittent water supply, forcing the population to store water for everyday consumption, and favouring mosquito breeding. And only 28% of rural households are connected to public water. The approach applied so far by the Government uses large resources on inefficient or unsafe vector control methods, instead of improving urban infrastructure and environmental sanitation, with a stable supply of potable water. Relying on a chemical war against the vector tends to pacify the population with false security, while a broad programme for better sanitary urban conditions could generate social mobilisation and co-responsibility of the population. Improvement of sanitary conditions is a long-term investment in population health, while pesticide use will have to be repeated. The Brazilian Association of Collective Health calls to stop the use of chemical products against A aegypti, especially in household water reservoirs, and prioritise sanitary measures.

Translating international HIV treatment guidelines into local priorities in Indonesia

Objectives: This study describes the views of various stakeholders on the importance of different criteria for priority setting of HIV/AIDS interventions in Indonesia. Methods: Based on a general list of criteria and a focus group discussion with stakeholders (n = 6), a list was developed of thirty-two criteria that play a role in priority setting in HIV/AIDS control in West-Java province. Criteria were categorized according to the World Health Organizations health system goals and building block frameworks. People living with HIV/AIDS (n = 49), healthcare workers (HCW) (n = 41), the general population (n = 43), and policy makers (n = 22) rated the importance of thirty-two criteria on a 5-point Likert-scale. Thereafter, respondents ranked the highest rated criteria to express more detailed preferences. Results: Stakeholders valued the following criteria as most important for the priority setting of HIV/AIDS interventions: an interventions impact on the HIV/AIDS epidemic, reduction of stigma, quality of care, effectiveness on individual level, and feasibility in terms of current capacity of the health system (i.e., HCW, product, information, and service requirements), financial sustainability, and acceptance by donors. Overall, stakeholders’ preferences for the importance of criteria are similar. Conclusions: Our study design outlines an approach for other settings to identify which criteria are important for priority setting of health interventions. For Indonesia, these study results may be used in priority setting processes for HIV/AIDS control and may contribute to more transparent and systematic allocation of resources.

The annual cost of not breastfeeding in Indonesia: the economic burden of treating diarrhea and respiratory disease among children (< 24mo) due to not breastfeeding according to recommendation

International guidelines recommend countries to expand antiretroviral therapy (ART) to all HIV‐infected individuals and establish local‐level priorities in relation to other treatment, prevention and mitigation interventions through fair processes. However, no practical guidance is provided for such priority‐setting processes. Evidence‐informed deliberative processes (EDPs) fill this gap and combine stakeholder deliberation to incorporate relevant social values with rational decision‐making informed by evidence on these values. This study reports on the first‐time implementation and evaluation of an EDP in HIV control, organised to support the AIDS Commission in West Java province, Indonesia, in the development of its strategic plan for 2014–2018.

Feasibility study of strengthening the public–private partnership for tuberculosis case detection in Bandung City, Indonesia

BackgroundIn Indonesia, 96% of children (< 24mo) are breastfed. However, only 42% of children (< 6mo) are exclusively breastfed, as per World Health Organization recommendations. Breastfeeding provides protective benefits such as reducing the risk of morbidity and mortality associated with diarrhea and pneumonia/respiratory disease (PRD). This study estimates the potential economic impact of not breastfeeding according to recommendation in Indonesia based on infants suffering from attributable diarrhea and PRD.MethodsA cost analysis examined both the healthcare system costs and non-medical costs for children (< 24mo) with diarrhea and PRD. Data collection took place between 2015 and 2016 and healthcare expenditures were assessed in 13 facilities, in five sites including Bandung and Tomohon City. Costs from a provider perspective were estimated using healthcare records and 26 interviews with healthcare workers. A discount rate of 3% was used. A cross-sectional survey with caregiver-child pairs (n = 615) collected data related to out of pocket costs such transportation and opportunity costs such as wage loss. These figures were combined with the national disease prevalence rates from Indonesia Demographic and Health Survey 2012, and the relative risk of disease of not breastfeeding according to recommendation from literatures to extrapolate the financial burden of treatment.ResultsThe healthcare system cost due to not breastfeeding according to recommendation was estimated at US

Cost-effectiveness of scaling up voluntary counselling and testing in West-Java, Indonesia

118 million annually. The mean healthcare system cost and out of pocket costs was US

Costs of HIV/AIDS treatment in Indonesia by time of treatment and stage of disease

11.37 and US