HIV/AIDS in Indonesia

Situation in women and children at Cipto Mangunkusumo Hospital Jakarta

Estimation of HIV/AIDS in Indonesia: 2002 and 2006

2002: estimated 90.000-130.000 cases 2006: estimated 190.000-210.000 cases Rapid increased among pregnant women and children

7000 6000 5000 4000 3000 2000

RAPID INCREASED OF REPORTED CASES IN INDONESIA (until March 2006)

AIDS KUMULATIF
5823 5321

2683

1488

1000 0
96 19
155 199 259 353

1172 608 827

97

98

99

00

01

03

04

02

19

19

19

20

20

20

20

20

20

20

05

06

HIV/AIDS cases at Pokdisus AIDS Clinic 2004-june 2006

Total : 1922 PLWHAs

16.69% female male 1502 female 309

female male

Marital status
not married 17%

widow 15%

married widow not married

married 68%

Why female is more susceptible to HIV infection?

1. Biological vulnerability 2. Socioeconomic vulnerability 3. Sexual assault

 Mrs N, 20 yr old, came in her 9th month of pregnancy Her husband died 2 days ago due to severe CNS infection and HIV. She is also HIV positive, jobless, living in her mother in law home. She can not tell her own parents because they did not agree when she married her husband

Sexual assault
14 yr-old street girl was raped and came in her 7 months pregnancy HIV positive, lung tuberculosis, and sexually transmitted infections

1 0 0 p r e g n a n t H I V p o s it iv e w o m e n 35 babies will be infected

7 babies infected before labour

15 babies infected during labour

13 babies infected through breastfeeding

HIVT-E14

Prevention of mother to child HIV transmission

Could reduced transmission risk from 35% to 2%

Prevention of mother to child transmission

antenatal intrapartum After birth

Antiretrovirus

Cesarean surgery Formula feeding antiretrovirus Antiretrovirus for baby

PMTCT program in Jakarta

Started in 2004 Standard case need:
HIV testing Antiretroviral for mother Antiretroviral for babies Cesarean surgery Milk formula (for 1 year) 2 x PCR-RNA for babies Total cost Rp. 120.000 Rp. 550.000 Rp. 60.000 Rp. 5.000.000 Rp. 1.200.000 Rp. 1.700.000 Rp. 8.730.000

Supported cases
Pregnant women:
2006: 30 cases January to June 2007: 31 cases

Babies:
Until 2006 exposed babies: 300 cases Positive cases 180 cases

Source of financing
Self-finance (only small portion) Support by Pokdisus Personal donation: other patients, students, other participants Global fund: stop since July 2006

Expected cases 2007

January June 2007: 35 June December 2007: 50

Sample case
A 4 year old boy hospitalized for severe malnutrition. He has oral candidiasis, liver enlargement, pallor due to severe anemia and chronic diarrhea. We suspected HIV infection because he has no father (his mother denied any marriage) and she committed to have unsafe sex practice

 We asked for HIV test in patient and mother, which showed positive results on both patient and his mother. CD4 test performed of the patient showed 3%, less than 15% (lower limit) Management of this patient was nutrition intervention, followed by opportunistic infection diagnosis and treatment for 8 weeks, before we started antiretroviral

 During hospitalization, the mother (a 23 y.o mother, high school graduate) was not working. They were supported by Social Security set up by government. After discharging home, the mother started to work in a hotel as a room cleaner. The boy was taken care by the grandmother. He is now on ARV for 4 month and gradually gained weight.

Intra Uterine Insemination Following Sperm Washing in HIV Serodiscordant Couple

Outline
HIV/AIDS situation after ARV Willingness to have children among HIV Serodiscordant couple Our Preparation at Ciptomangunkusmo hospital Procedures and Result from other centers

New era of ARV

AIDS became controlled chronic Disease PLWA could enjoy good quality of life Rapid scaling up ARV in Indonesia 2004

Nicopoullos D.M. James ; Human Reproduction vol 19, No. 10 pp. 2289-2297, 2004

Process
1. Screening Male Partner : Healthy(relatively) On ARV,VL <1000 Sperm analysis: normal Female : HIV negative reproductive screening: normal 2. Sperm washing: HIV RNA in semen 3. Intrauterine insemination

Counselling
Objective of the method is risk reduction not eliminate the risk Discussing the process, successful rate, and the risk Discussion preparation of future parenting Discussion of sexual health screen and fertility screen
Nicopoullos D.M. James ; Human Reproduction vol 19, No. 10 pp. 2289-2297, 2004

Sperm washing process

Semen collection : masturbation after abstinence at least 3 days collected in sterile plastic container for analysis Universal precaution applied Separation ejaculate by density gradient Sperm pellet resuspended, wash for 3 times Allow the sample to swim up Washed sperm tested for HIV RNA

Ethical issue
Competence Clinical and laboratory resources (ultra sensitive PCR) Cost effectiveness Long term Support

When a woman is able to give birth, that is a gift. But when an HIV-positive woman is able to give birth, and the baby turns out to be negative, that is a miracle.

Empowerment
Healthy life style needs sufficient family income Most of HIV positive Indonesian family is not enough Empowerment progrmamme could make HIV positive family to be self sufficient Women have important role in increasing family income

Strategy
Life Skills training In job training Microcredite service If possible small scale bussiness at home

Life Skills
Personal vision Communication skill Managing time and resources skill Learning skills Identify and managing chances Organization skill

Specific Skills
Small trading (food ,clothe etc) Tailor Salon Mechanics Services (laundry etc)

How to Start ?
Life skill training Specific skill training (on the job training) Microcredit support Supervision and support

Starting Projects 2006-2007

Sanggar YPI 15 families (all women ), funding from personal donation Sandar 10 families all women (personal donation) Parung, rural economic development , YPI 75 families mostly youth (boys and girls) Cirebon 6 families , 5 men one woman (personal donation) Depok 10 families ,poor village development project Kelurahan Rawamangun 200 families, funding by Dana Kecamatan