“POMPa HIV/AIDS” Optimal Care to Mothers with HIV / AIDS Patients in Kardinah Hospital
Kardinah Hospitals Tegal City (RSUD KARDINAH TEGAL)

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Tegal city, Central Java, Indonesia, is an area located in the central part of the Java island under Central Java Province, consists of 4 districts with a population of 250,000 people, most of this city is coastal areas, and be the main crossing of traffic in Java and in the city center is the center of commerce and entertainment activities. The citizens livelihood are fishermen, traders and moving workers for a long time and also the high number of nightclubs caused a high risk factor for HIV transmission, especially through sexual transmission. The number of HIV / AIDS sufferer founded in Kardinah Hospital Tegal has increased significantly by 56.5% at the last 3 years (from 69 people in year 2012 to 108 people in 2014). Pregnant women who are HIV sufferer also increased significantly by 75% (from 4 people in 2013, to 7 people in 2014). Similarly, for the group of infants under 1 year, always found HIV-positive, in 2012 as many as four babies, and in 2013 found 3 babies. HIV transmission in women of childbearing age group will bring further consequences, especially if the end of pregnancy in women because of possible infectious fetus. This coupled with the fact that the issue of HIV / AIDS is not only a health issue alone but also has social and psychological impact for patients, families and the surrounding community. On the other hand the public's understanding of HIV / AIDS is still not optimal, ranging from the modes of transmission, prevention and how to treat patients. HIV / AIDS transmission could be happened by a various ways, through sexual contact, blood contact, from mother to child through pregnancy and childbirth and breastfeeding. So as people with HIV / AIDS especially for pregnant women have problems more unique, because they will bear the double burden that is apart because of the pregnancy itself, also the potential transmission of the HIV virus to the fetus as well as the stigma and discrimination of people, the environment, family and health professionals own. Double burden of HIV-positive pregnant women is compounded by the unavailability of health facilities in Tegal and its surrounding area are not ready and unwilling to handle the pregnant women with HIV / AIDS, and prefer to refer them to the Provincial or National hospital. Community health workers are also afraid of HIV / AIDS sufferer, they do stigma and discrimination against HIV-positive sufferer, because they also do not fully understand how the virus is transmitted and how to prevent transmission of the virus

B. Strategic Approach

 2. What was the solution?
sustainable comprehensive services for mothers hiv / aids

 3. How did the initiative solve the problem and improve people’s lives?
Service initiative in groups for high risk HIV AIDS sufferer, both men and women are carried out with the following strategies: • Prevention Effort: through communication, information, education, and checking the HIV status in society, such as : a) Women of fertile age: Prospective brides and Women's Organization. b) Workers: Community driver, fisherman, military / police, civil servants, and Private. c) Citizens Patronage: Prisons, Social Institutions. d) Students: junior & senior high school and university students e) Transgender Association Tegal. • Treatments: a) General, - The treatment was started since the patients were detected as HIV sufferrer, followed by physical checking and its supplement, the provision of antiretroviral drugs (Anti Retro Viral), periodic health monitoring, and nutritional care. b) Pregnant women and babies Maternal care initiative on HIV-positive pregnant women is integrated and collaborative services starting from: 1. Before pregnancy: Early detection before pregnancy through an effective communication, education and information for women of childbearing age, either unmarried / bride or married, about HIV / AIDS and conduct a further action by a series of HIV tests through the mechanism of VCT (Voluntary Counseling and Test) and PITC (Provider Initiative Test and Counseling) in both the public and health care facilities. In cooperation with the Ministry of Religious / Kementerian Agama Tegal and mass organizations / Fatayat NU, HIV test are conducted wider, for the bride and groom; and Puskesmas and Posyandu for couples who are married / pregnant women, including all pregnant women in Tegal, particularly those allegedly high risk of HIV virus. 2. Pregnancy period: When the pregnant HIV sufferer are found, the team conducted an education process to the sufferer and their families (including to involve their husbands or partners for the education and conducted the HIV test to ascertain the direction of transmission and the further treatment). Individual or peer assistance, administration of drugs ARV, baby birth planning process in the hospital until the implementation of a series test to the baby to ensure the infants conditions of HIV infection and the empowerment of community groups around the patient / client through WPA (Citizens AIDS Care) and the Forum of LKB (Services Comprehensive Sustainable) HIV / AIDS to provide support for the sufferer to avoid stigma and discrimination. 3. After the delivery process: Further treatment for postnatal is determined by the results of HIV tests on infants who are born. A positive /HIV sufferer will be given ARV treatment and facilitation of nutrients for remaining the baby in a stable health, whereas if the test is negative, still conduct a health monitoring through Posyandu (Integrated Service Post) including immunization and nutritional supplements (PMT = Feeding).

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Maternal care initiative for pregnant women- HIV sufferer in Kardinah Hospital is unique and different program with many other hospitals. Maternal care for pregnant women-HIV sufferer are handling earlier, comprehensive, sustainable to strengthen mental and spiritual in personal treatment. Initiation of this actions have been started before the pregnancy process, especially for the bride and groom, conducted a Voluntary HIV testing and Provider Initiative for women and men and his/her partners, and also providing the education about HIV / AIDS. The assistance efforts / case managers, both individual and Peer Support Group undertaken to strengthen patient’s mental and spiritual, and also the supervision of Medication. VCT and CST teams Kardinah Hospital monitor the general health of patients through periodic pregnancy controls, advise the nutrients supply, including delivery planning process and identify the condition of the baby and its postpartum. Strengthening the society through community forum to accept the conditions of HIV-AIDS sufferers in their neighborhood, psychosocial support to patients and families in order to survive naturally. This is a special concern of Kardinah Hospital direct handling for HIV – AIDS sufferer that is still frightening and have a negative stigma and social discrimination in the family and the surrounding community

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
In accordance to implement the initiative, an action plan has developed to support the successful handling of HIV-positive pregnant women by a series of main activities as follows: 1. The establishment of Polyclinic VCT in Kardinah Hospital that can provide integrated services (counseling to mentoring) in handling the HIV-Sufferer 2. Mobile screening and screening of HIV cases through the implementation of a series of tests VCT for the HIV potential high risk community (Worker Night / PSK, Homosexual/Gay, Transgender and people who are living in the prostitution area) 3. Screening and filtering of HIV through methods PITC (Provider Initiative Test and Counseling) to each patient who potentially HIV transmission, such as in case of surgery in Kardinah Hospital 4. Optimally the STI (Sexually Transmitted Infections) clinic satellites in each Primary health center (Puskesmas=Pusat Kesehatan Masyarakat) to prevent cases of transmission through sexual transmission 5. Establishment of community support groups, namely Aids Concerned Citizens Forum (WPA) in all 27 villages, establishment of Continuous Comprehensive Services (LKB=Layanan Komprehensif Berkesinambungan) in every area of the primary health center (Puskesmas), strengthening the networking with NGOs and women religious group - Fatayat NU (Nahdatul Ulama) 6. Cooperation with the PMI (Indonesian Red Cross) to follow up on reactive donor blood through the mechanism of Informed Consent 7. Health education and conselling to the public about HIV / AIDS through a pregnant women class, IHC/ Integrated Health Care in Community, socialization of school children, workers and the environment 8. Treatment of patients through the establishment of clinics CST (Care Support and Treatment) in Kardinah Hospital 9. Management of Integrated Ante Natal Care (ANC) for pregnant women, Delivery and Post Natal Care (PNC) for HIV-sufferer - pregnant women 10. Monitoring and health care for mothers and babies after treatment from the hospital
 6. How was the strategy implemented and what resources were mobilized?
Program initiatives maternal HIV services in Kardinah Hospital is part of the referral health services in Kardinah Hospital supported with funds derived from: Tegal local budget of Rp.100,000,000 in 2013 and Rp.150,000,000 in 2014; Medical devices sourced from National & Provincial Budget (DAK, TK APBD I (Bangub). Human resources involved in maternal care for pregnant women with HIV / AIDS are: • Health Cadre • Reach Fatayat NU • Companion KDS (Peer Support Groups) • Commissioner KPA (AIDS Commission) • Social Fund PKPU (Pos Keadilan Peduli Umat) to PMT for patients • Kardinah Hospital team consists of: - Councelor And Doctor VCT (Voluntary Counselling and Test) - Radiologist - Health analyst - Medical Records - Pharmacist - Midwife - Nurse - Nutrisionist - CST doctor (Care Support and Treatment) - HIV Program Manager HIV All resources play their roles according their function, ranging from the education and outreach initiator in the community, outreach the potentially infected with the HIV virus especially from the women group of childbearing age, including pregnant women, carry out a blood test on the client, accompany if detected positive HIV, manage pregnant women before until after birth, babies born to handle and ensure to get appropriate follow-up of post-natal examination.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
1. Kardinah Hospital both team leaders and health care team as the key stakeholders of maternal care for pregnant women with HIV / AIDS, 2. Community Group / Forum: Health care, Pregnant Class, and Sub District Kelurahan Siaga), be an important contributor in implementating of these services. 3. a) Active involvement of Peer Support Groups (KDS), namely 'Bahari Plus': in assisting clients, b) NGO Fatayat NU I: doing outreach, c) Citizens Concerned Aids (WPA) for each village: eliciting community participation tackling the spread of HIV / AIDS, d) Association of Transvestites Tegal (IPWT): reaching the transgender and special community, 4. AIDS Commission (KPA) Tegal: coordinating the relevant stakeholders in HIV / AIDS, 5. Tegal District Health Office and Bappeda (regional planning agency) Tegal: in collaboration and funding programs, 6. The Indonesian Red Cross (PMI): in a screening and outreach.

 8. What were the most successful outputs and why was the initiative effective?
The output of the initiative program management services for maternal HIV sufferer are as follows: 1. The establishment of Polyclinic VCT and CST in Kardinah Hospital supported by Medical Physician Specialists and Midwifery, Pediatrician, Specialist, Doctors Nursing and Medical Support staff who are trained and willing to treat patients of HIV / AIDS sufferer 2. Management of Ante Natal Care (ANC) integrated to detect women of childbearing age as soon as possible of their HIV status, Delivery and Post Natal Care (PNC) by Tim HIV in Kardinah Hospital to deal with HIV-positive pregnant women and infants 3. The establishment of Citizens AIDS Care (WPA) in villages in Tegal as a community forum to disseminate the information and to participate in the handling of preventing transmission of the HIV virus in the community 4. Establishment of Sustainability Comprehensive Services (LKB) in all primary health care (Puskesmas) in Tegal to assist HIV-positive clients while in the community and make sure to get psychosocial support

 9. What were the main obstacles encountered and how were they overcome?
The main problems encountered and solutions to overcome these problems during the implementation of the program initiatives maternal care of pregnant women with HIV positive indication is as follows: 1. The increasing number of cases of HIV-positive findings on housewives, it needs the additional reagent for HIV testing to test of all groups in society, not only in high-risk groups. Today there is an increasing number of reagent through local budget funds and Global Fund. 2. There is still a stigma that the health workers who are unwilling to serve patients with HIV-positive, and then Kardinah Hospital increase the workshops and meetings on the medical officer / paramedic and related units to discuss about HIV AIDS and conducted the staff capacity building in the prevention of transmission of infection. 3. Pregnant women with HIV usually still willing to have their maternity with the midwife near her domicile , so that created networks between hospitals with health centers and midwives Kardinah Independent Practice, in order to facilitate the patient while handling needs. 4. The high stigma and discrimination against HIV-positive patients, so hospitals Kardinah together Tegal City Health Department multiply step socialization and counseling to the public health and family about HIV AIDS.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The real impact of successful implementation of the maternal HIV sufferer services, are: 1. Increasing public awareness for their health and families, indicated by the increasing number of people, including housewives to check their condition in Kardinah Hospital about their health status or pregnancy related to HIV / AIDS. The visitors tripled from 500 women in 2012 become 1.594 people in 2013. 2. The handled number of HIV sufferer pregnant women cases in RSUD Kardinah were increasing about 25% at last three years, which is the number of pregnant women increased twice. From 69 people in year 2012, increased to be 82 people (4 pregnant) in year 2013, and 108 people 97 pregnant) in year 2014 3. The increased handle babies from HIV sufferer mother (from 25% in year 2012 became 50% in year 2014) 4. Increased number and more active of the WPA village group (Warga Peduli Aids - concerned Citizens Aids), from 10 villages in year 2014 became 27 villages in mid of year 2015. The positive impacts of this program are: 1. Cost and time efficiencies for HIV-sufferer pregnant women, because they could test at the nearby the hospital, without be referred to the Provincial or National hospitals. 2. Improving the safety of mothers and babies through early treatment of pregnancy and the process of education for families and communities to reduce the impact of patient environments such social stigma and poor mental psychology that are bad for the mother and baby to be born. 3. Reduce the risk of transmission of HIV positive virus from pregnant mothers to babies through health education and a series of tests and treatment to HIV-positive pregnant women.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
An effort to improve the safety of pregnant women and babies indicated of HIV-positive, Kardinah Hospital increase the number of HIV test for pregnant women in Tegal, who check her pregnancy at hospital Kardinah or Posyandu, health centers and other primary health care, in collaboration with NGOs Fatayat NU Forum WPA (Citizens Care Aids), LKB and KPA (AIDS Commission) in order to prepare a suspected pregnant women have an early treatment in her young pregnancy and will be able to plan a safe pregnancy. The initiator of this innovation is VCT Kardinah Hospital team in collaboration with the District Health Office and National AIDS Commission (KPA=Komisi Penanggulangan Aids).

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
The initiative is expected to solve the problems of pregnant women with the condition of HIV / AIDS, as follows : 1. Reduce the risk of transmission of HIV virus from pregnant mothers to babies through health education, a series of tests and treatment, as well as the assistance by the Supervisory Drinking Drugs (PMO), Peer Support Groups (KDS) and the health workers. 2. Improve the safety of mother and baby through early pregnancy treatment and education process for the family and their environment in order to reduce the bad impact of such social and psychological stigma of mothers and babies. 3. Cost and time efficiency, because the HIV-positive pregnant women will able to check her condition at the nearest regional hospital at Kardinah Hospital Tegal without be referred to the hospital provincial and even national level in Jakarta. 4. Raise the community togetherness in supporting and fighting the spread out of the HIV virus in the environment through community groups such as WPA, LKB and other forums.

Contact Information

Institution Name:   Kardinah Hospitals Tegal City (RSUD KARDINAH TEGAL)
Institution Type:   Local Government  
Contact Person:   Agus Dwi Sulistyantono
Title:   deputy director of services in Kardinah hospital  
Telephone/ Fax:   0283356067, 0816640582
Institution's / Project's Website:  
E-mail:   agoes.dwee@yahoo.com  
Postal Code:   52124
City:   Tegal
State/Province:   Center of Java

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