Tuberculosis care provided by private practitioners in an urban setting in Indonesia: Findings from a standardized patient study.

In Indonesia, government-owned Community Health Centers (CHCs) spearhead tuberculosis (TB) care at the primary level, but a substantial proportion of individuals with pulmonary TB also seek care from Private Practitioners (PPs). However, little is known about PPs' practice in managing patients with TB-associated symptoms. To avoid bias associated with self-administered surveys, we used standardized patients (SPs) to evaluate PPs' adherence to the national TB guidelines. Four clinical scenarios of individuals presenting complaints suggestive of TB, accompanied by different sputum smear results or TB treatment histories were developed. We assigned 12 trained SPs to PPs practicing in 30 CHC catchment areas in Bandung city, Indonesia. For comparison, two scenarios were also presented to the CHCs. A total of 341 successful SP visits were made to 225 private general practitioners (GPs), 29 private specialists, and 30 CHCs. When laboratory results were not available, adherence to the recommended course of action, i.e., sputum examination, was low among private GPs (31%) and private specialists (20%), while it was requested in 87% of visits to the CHCs. PPs preferred chest X-ray (CXR) in all scenarios, with requests made in 66% of visits to private GPs and 84% of visits to private specialists (vs. 8% CHCs). Prescriptions of incorrect TB drug regimens were reported from 7% and 13% of visits to private GPs and specialists, respectively, versus none of the CHCs. Indonesian PPs have a clear preference for CXR over microbiological testing for triaging presumptive TB patients, and inappropriate prescription of TB drugs is not uncommon. These findings warrant actions to increase awareness among PPs about the importance of microbiological testing and of administering appropriate TB drug regimens. SP studies can be used to assess the impact of these interventions on providers' adherence to guidelines.

Management of drug-resistant tuberculosis in Indonesia: a four-year cascade of care analysis.

Background: In Indonesia, drug resistance testing for TB largely relies on Xpert MTB/RIF, and it is unknown what proportion of drug-resistant (DR) TB is adequately diagnosed and treated. Methods: We conducted a cascade of care analysis on a cohort of presumptive rifampicin-resistant (RR) TB patients registered in 2015-2018 in a tertiary hospital in Indonesia. Estimated incidences of (presumptive) DR-TB cases were assumption-based using global reports. Data on diagnosis and consecutive cascades steps, including their timing were collected from national electronic registers, and medical records. We described a secondary cascade for patients receiving treatment not supported by phenotypic drug susceptibility testing (pDST). Factors associated with delay and loss between diagnosis and treatment were identified using logistic regression. Findings: Less than a third of estimated incident TB cases at risk of DR-TB were identified as presumptive DR-TB case and tested, and 9.8% (982/10,065) of estimated true DR-TB cases was diagnosed. Of those diagnosed, only 45.1% (443/982) had treatment regimens supported by pDST results, but this did not significantly influence treatment outcomes. Only 25.5% (250/982) of diagnosed patients completed all steps of the cascade including successful treatment. Delays between diagnosis and treatment were substantial, and more common among those referred from a primary healthcare facility, and among those who were employed, living outside of Bandung, and reporting engagement with the private sector. Interpretation: The DR-TB care cascade in this urban setting in Indonesia is characterized by substantial attrition and delays. Strategies to increase access to DR-TB diagnosis accompanied by optimisation of clinical care could substantially improve outcomes and reduce onward transmission. Funding: Radboud university medical center and University of Otago.

Assessing the impact of booster vaccination on diphtheria transmission: Mathematical modeling and risk zone mapping.

The COVID-19 pandemic caused significant disruptions in the healthcare system, affecting vaccinations and the management of diphtheria cases. As a consequence of these disruptions, numerous countries have experienced a resurgence or an increase in diphtheria cases. West Java province in Indonesia is identified as one of the high-risk areas for diphtheria, experiencing an upward trend in cases from 2021 to 2023. To analyze the situation, we developed an SIR model, which integrated DPT and booster vaccinations to determine the basic reproduction number, an essential parameter for infectious diseases. Through spatial analysis of geo-referenced data, we identified hotspots and explained diffusion in diphtheria case clusters. The calculation of R0 resulted in an R0 = 1.17, indicating the potential for a diphtheria outbreak in West Java. To control the increasing cases, one possible approach is to raise the booster vaccination coverage from the current 64.84% to 75.15%, as suggested by simulation results. Furthermore, the spatial analysis revealed that hot spot clusters were present in the western, central, and southern regions, posing a high risk not only in densely populated areas but also in rural regions. The diffusion pattern of diphtheria clusters displayed an expansion-contagious pattern. Understanding the rising trend of diphtheria cases and their geographic distribution can offer crucial insights for government and health authorities to manage the number of diphtheria cases and make informed decisions regarding the best prevention and intervention strategies.

Care pathways of individuals with tuberculosis before and during the COVID-19 pandemic in Bandung, Indonesia.

The COVID-19 pandemic is thought to have undone years' worth of progress in the fight against tuberculosis (TB). For instance, in Indonesia, a high TB burden country, TB case notifications decreased by 14% and treatment coverage decreased by 47% during COVID-19. We sought to better understand the impact of COVID-19 on TB case detection using two cross-sectional surveys conducted before (2018) and after the onset of the pandemic (2021). These surveys allowed us to quantify the delays that individuals with TB who eventually received treatment at private providers faced while trying to access care for their illness, their journey to obtain a diagnosis, the encounters individuals had with healthcare providers before a TB diagnosis, and the factors associated with patient delay and the total number of provider encounters. We found some worsening of care seeking pathways on multiple dimensions. Median patient delay increased from 28 days (IQR: 10, 31) to 32 days (IQR: 14, 90) and the median number of encounters increased from 5 (IQR: 4, 8) to 7 (IQR: 5, 10), but doctor and treatment delays remained relatively unchanged. Employed individuals experienced shorter delays compared to unemployed individuals (adjusted medians: -20.13, CI -39.14, -1.12) while individuals whose initial consult was in the private hospitals experienced less encounters compared to those visiting public providers, private primary care providers, and informal providers (-4.29 encounters, CI -6.76, -1.81). Patients who visited the healthcare providers >6 times experienced longer total delay compared to those with less than 6 visits (adjusted medians: 59.40, 95% CI: 35.04, 83.77). Our findings suggest the need to ramp up awareness programs to reduce patient delay and strengthen private provide engagement in the country, particularly in the primary care sector.

Impact of the COVID-19 pandemic on quality of tuberculosis care in private facilities in Bandung, Indonesia: a repeated cross-sectional standardized patients study.

BACKGROUND: Indonesia has the second highest incidence of tuberculosis in the world. While 74% of people with tuberculosis in Indonesia first accessed the private health sector when seeking care for their symptoms, only 18% of tuberculosis notifications originate in the private sector. Little is known about the impact of the COVID-19 pandemic on the private sector. Using unannounced standardized patient visits to private providers, we aimed to measure quality of tuberculosis care during the COVID-19 pandemic. METHODS: A cross-sectional study was conducted using standardized patients in Bandung City, West Java, Indonesia. Ten standardized patients completed 292 visits with private providers between 9 July 2021 and 21 January 2022, wherein standardized patients presented a presumptive tuberculosis case. Results were compared to standardized patients surveys conducted in the same geographical area before the onset of COVID-19. RESULTS: Overall, 35% (95% confidence interval (CI): 29.2-40.4%) of visits were managed correctly according to national tuberculosis guidelines. There were no significant differences in the clinical management of presumptive tuberculosis patients before and during the COVID-19 pandemic, apart from an increase in temperature checks (adjusted odds ratio (aOR): 8.05, 95% CI: 2.96-21.9, p < 0.001) and a decrease in throat examinations (aOR 0.16, 95% CI: 0.06-0.41, p = 0.002) conducted during the pandemic. CONCLUSIONS: Results indicate that providers successfully identify tuberculosis in their patients yet do not manage them according to national guidelines. There were no major changes found in quality of tuberculosis care due to the COVID-19 pandemic. As tuberculosis notifications have declined in Indonesia due to the COVID-19 pandemic, there remains an urgent need to increase private provider engagement in Indonesia and improve quality of care.

Assessing potential surge of COVID-19 cases and the need for booster vaccine amid emerging SARS-CoV-2 variants in Indonesia: A modelling study from West Java.

Objectives: Primary and booster vaccinations are crucial in COVID-19 control. This study aimed to assess the minimum booster coverage to hamper potential surge of COVID-19 cases in 2023 in Indonesia, a low-resource setting country. Methods: We used a modified SEIR compartment model to assess different scenarios in booster coverage across West Java population: 35%, 50%, and 70%. We fitted the model, then we calculated the potential active cases in 2023 if each scenario was met before 2022 ends. A heat map of predicted cases from various booster coverages and time frames was produced and matched with vaccination rate's function to determine feasible time frames. Results: A minimum of 70% booster coverage in West Java is needed to reduce 90% of potential COVID-19 cases and avert possible surge in 2023. The booster doses should be distributed before February 2023 to achieve its optimum preventive effect. Delays in achieving minimum booster coverage is acceptable, but higher booster coverage will be required. Conclusions: For better COVID-19 control in Indonesia, booster vaccination is warranted, as presented by a case study in West Java. Sufficient vaccine supplies, infrastructure, and healthcare workers should be ensured to support a successful booster vaccination program.

Breast Self-Examination Practice and Its Determinants among Women in Indonesia: A Systematic Review, Meta-Analysis, and Meta-Regression.

Breast cancer (BC) is a heavy burden for Indonesian healthcare, but there is still no thorough evaluation for Breast self-examination (BSE) practice as routine BC screening. In this study, we aimed to synthesize the pooled prevalence data of BSE practice, compare BSE practice prevalence between Java Island and non-Java Islands in Indonesia, and identify the determinants that we thought could affect the BSE practice in the Indonesian population. Intensive searches were conducted in Cochrane Library, PubMed, Google Scholar, and SINTA (Indonesian Web of Science and Technology Index) from September 2017-2022. We utilized Review Manager 5.4 for conducting the meta-analysis. We found the overall national prevalence of BSE practice was 43.14% (95% CI: 36.08, 50.20, p < 0.00001). BSE practice in Java Island was higher compared to non-Java Island (44.58% vs. 41.62%). The highest prevalence of BSE practice was found among university students, with a 49.90% prevalence. Good knowledge, good attitude toward BSE, family history of BC, family support, and BC information exposure were all statistically associated with a higher determinant of BSE practice. We concluded that BSE practice in Indonesia is still low, especially in non-Java Islands. Integrative and collaborative programs should be established to promote BSE as routine screening for BC.

Adaptation of health systems to climate change-related infectious disease outbreaks in the ASEAN: Protocol for a scoping review of national and regional policies.

BACKGROUND: The Association of South-East Asian Nations (ASEAN) member states (AMS) are among the countries most at risk to the impacts of climate change on health and outbreaks being a major hotspot of emerging infectious diseases. OBJECTIVE: To map the current policies and programs on the climate change adaptation in the ASEAN health systems, with particular focus on policies related to infectious diseases control. METHODS: This is a scoping review following the Joanna Briggs Institute (JBI) methodology. Literature search will be conducted on the ASEAN Secretariat website, government websites, Google, and six research databases (PubMed, ScienceDirect, Web of Science, Embase, World Health Organization (WHO) Institutional Repository Information Sharing (IRIS), and Google Scholar). The article screening will be based on specified inclusion and exclusion criteria. Policy analysis will be conducted in accordance with the WHO operational framework on climate-resilient health systems. Findings will be analyzed in the form of narrative report. The reporting of this scoping review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). ETHICS AND DISSEMINATION: Ethical approval is not required for this study as this is a scoping review protocol. Findings from this study will be disseminated through electronic channels.

The Impact of COVID-19 Quarantine on Tuberculosis and Diabetes Mellitus Cases: A Modelling Study.

COVID-19 has currently become a global pandemic and caused a high number of infected people and deaths. To restrain the coronavirus spread, many countries have implemented restrictions on people's movement and outdoor activities. The enforcement of health emergencies such as quarantine has a positive impact on reducing the COVID-19 infection risk, but it also has unwanted influences on health, social, and economic sectors. Here, we developed a compartmental mathematical model for COVID-19 transmission dynamic accommodating quarantine process and including tuberculosis and diabetic people compartments. We highlighted the potential negative impact induced by quarantine implementation on the increasing number of people with tuberculosis and diabetes. The actual COVID-19 data recorded in Indonesia during the Delta and Omicron variant attacks were well-approximated by the model's output. A positive relationship was indicated by a high value of Pearson correlation coefficient, r=0.9344 for Delta and r=0.8961 for Omicron with a significance level of p<0.05. By varying the value of the quarantine parameter, this study obtained that quarantine effectively reduces the number of COVID-19 but induces an increasing number of tuberculosis and diabetic people. In order to minimize these negative impacts, increasing public awareness about the dangers of TB transmission and implementing a healthy lifestyle were considered the most effective strategies based on the simulation. The insights and results presented in this study are potentially useful for relevant authorities to increase public awareness of the potential risk of TB transmission and to promote a healthy lifestyle during the implementation of quarantine.

Temporal trend and spatial clustering of the dengue fever prevalence in West Java, Indonesia.

Dengue fever is a notable vector-borne viral disease, currently becoming the most dreaded worldwide health problem in terms of the number of people affected. A data set of confirmed dengue incidences collected in the province of West Java has allowed us to explore dengue's temporal trends and spatial distributions to obtain more obvious insights into its spatial-temporal evolution. We utilized the Richards model to estimate the growth rate and detect the peak (or turning point) of the dengue infection wave by identifying the temporal progression at each location. Using spatial analysis of geo-referenced data from a local perspective, we investigated the changes in the spatial clusters of dengue cases and detected hot spots and cold spots in each weekly cycle. We found that the trend of confirmed dengue incidences significantly increases from January to March. More than two-third (70.4%) of the regions in West Java had their dengue infection turning point ranging from the first week of January to the second week of March. This trend clearly coincides with the peak of precipitation level during the rainy season. Further, the spatial analysis identified the hot spots distributed across central, northern, northeastern, and southeastern regions in West Java. The densely populated areas were likewise seen to be associated with the high-risk areas of dengue exposure. Recognizing the peak of epidemic and geographical distribution of dengue cases might provide important insights that may help local authorities optimize their dengue prevention and intervention programs.

Factors associated with treatment outcome of MDR/RR-TB patients treated with shorter injectable based regimen in West Java Indonesia.

BACKGROUND AND AIMS: Multi drug or rifampicin resistant tuberculosis (MDR/RR-TB) is a major burden to TB prevention and eradication globally. Since 2016, WHO guidelines have included options for treating MDR/RR-TB with a standard regimen of 9 to 11 months duration (the 'shorter regimen') rather than an individual regimen of at least 20 months. This regimen has been introduced in Indonesia since September 2017. Therefore, we aimed to determine the success rate and factors associated with the treatment outcome of shorter injectable based regimen in West Java province, Indonesia. METHODS: This was a retrospective cohort study of MDR/RR-TB patients aged over 18 years old who received the shorter injectable based regimen between September 2017 and December 2020. We defined successful outcomes as the combined proportion of patients who were cured or had complete treatment. While, unsuccessful outcomes were defined as the combined proportion of patients who died from any causes, failure, and loss to follow-up (LTFU). RESULTS: A total of 315 patients were included in this study. The success rate was 64.5%. Multivariate analysis showed male gender (aRR = 1.18, 95% CI 1.04 to 1.34) increased the chance of successful outcome, while malnutrition (aRR = 0.78, 95% CI 0.68 to 0.89), history of previous TB treatment (aRR = 0.80%CI 0.68 to 0.94), and time of culture conversion >2 months (aRR = 0.72 (95% CI 0.59 to 0.87) decreased the chance of successful outcome. CONCLUSION: History of previous TB treatment, time of culture conversion >2 months, and malnutrition were independent factors that decrease the chance for success rate, while male gender increase the likelihood for success rate of patients treated by the shorter injectable based regimen.

Are neighbourhoods of tuberculosis cases a high-risk population for active intervention? A protocol for tuberculosis active case finding.

BACKGROUND: Indonesia has the second largest tuberculosis (TB) burden globally. Attempts to scale-up TB control efforts have focused on TB households. However, in most high burden settings, considerable Mycobacterium tuberculosis (Mtb) transmission occurs outside TB households. A better understanding of transmission dynamics in an urban setting in Indonesia will be crucial for the TB Control Program in scaling up efforts towards elimination of TB in a more targeted way. Therefore, the study aims to measure TB prevalence and incidence in household contacts and neighbourhoods in the vicinity of known TB cases and to assess their genomic and epidemiological relatedness. METHODS AND ANALYSIS: Individuals (~1000) living in the same household as a case diagnosed with pulmonary TB (n = 250) or in a neighbouring household (~4500 individuals) will be screened for TB symptoms and by chest x-ray. Two sputum samples will be collected for microbiological analysis from anyone with a productive cough. Any person found to have TB will be treated by the National TB Control Program. All those with no evidence of TB disease will have a repeat screen at 12 months. Whole-genome sequencing (WGS) and social network analysis (SNA) will be conducted on Index cases and contacts diagnosed with TB.

Factors affecting outcome of longer regimen multidrug-resistant tuberculosis treatment in West Java Indonesia: A retrospective cohort study.

BACKGROUND: Multidrug-resistant tuberculosis had high treatment failure and mortality. Success rate of treatment currently 56% at global level, 48% in Indonesia and 36% in West Java province, the most populated province and surround Jakarta, the capitol of Indonesia. OBJECTIVE: This study aimed to evaluate factors affecting success of multidrug-resistant tuberculosis treatment in patients using longer treatment regimen in West Java Indonesia. METHODS: This was a retrospective cohort study of multidrug-resistant tuberculosis patients treated with longer regimen at Hasan Sadikin General Hospital from January 2015 to December 2017. Potential risk factors associated with the treatment outcome were analyzed using multiple logistic regression. RESULTS: A total of 492 patients were enrolled during the study period. Fifty percents multidrug-resistant tuberculosis patients had successful treatment outcome. Age ≤45 years, male, normal body mass index, no previous tuberculosis treatment, culture conversion ≤2 months, acid fast bacilli sputum smear ≤+1 were independent factors associated with increased treatment success. Sputum culture conversion ≤2 months was the major factor affecting successful outcome (RR 2.79; 95% CI: 1.61-4.84; p-value<0.001). Human Immunodeficiency Virus infection, chronic kidney disease, and cavitary lesion were independent risk factors for unfavourable outcome. CONCLUSION: Age, gender, body mass index, tuberculosis treatment history, time of sputum conversion, acid fast bacilli sputum smear, HIV infection, chronic kidney disease, and cavitary lesion can be used as predictors for longer multidrug-resistant tuberculosis treatment regimen outcome.

A public health intervention package for increasing tuberculosis notifications from private practitioners in Bandung, Indonesia (INSTEP2): A cluster-randomised controlled trial protocol.

Background. A significant proportion of tuberculosis (TB) patients globally make their initial visit for medical care to either an informal provider or a private practitioner, and many are not formally notified. Involvement of private practitioners (PPs) in a public-private mix for TB (TB-PPM) provides an opportunity for improving TB control. However, context-specific interventions beyond public-private agreements and mandatory notification are needed. In this study we will evaluate whether a tailored intervention package can increase TB notifications from PPs in Indonesia. Methods. This is a cluster-randomized trial of a multi-component public health intervention. 36 community health centre (CHC) areas will be selected as study locations and randomly allocated to intervention and control arms (1:1). PPs in the intervention areas will be identified using a mapping exercise and recruited into the study if they are eligible and consent. They will receive a tailored intervention package including in-person education about TB management along with bimonthly electronic refreshers, context-specific selection of referral pathways, and access to a TB-reporting app developed in collaboration with the National TB programme. The primary hypothesis is that the intervention package will increase the TB notification rate. The primary outcome will be measured by collecting notification data from the CHCs in intervention and control arms at the end of a 1-year observation period and comparing with the 1-year pre-intervention. The primary analysis will be intention-to-treat at the cluster level, using a generalised mixed model with repeated measures of TB notifications for 1 year pre- and 1 year post-intervention. Discussion. The results from this study will provide evidence on whether a tailored intervention package is effective in increasing the number of TB notifications, and whether the PPs refer presumptive TB cases correctly. The study results will guide policy in the development of TB-PPM in Indonesia and similar settings.

Patient pathways and delays to diagnosis and treatment of tuberculosis in an urban setting in Indonesia.

BACKGROUND: Understanding patient pathways can help align patient preferences and tuberculosis (TB) related services. We investigated patient pathways, and diagnostic and treatment delays among TB patients in Indonesia, which has one of the highest proportions of non-notified TB cases globally. METHODS: We conducted a study of TB patients recruited from Community Health Centers (CHCs), public and private hospitals, and private practitioners from 2017 to 2019 in Bandung City, regarding general characteristics and symptoms, and health-seeking, diagnostic and treatment pathways. FINDINGS: We recruited 414 TB patients: 138 (33%) in CHCs, 210 (51%) in hospitals, 66 (20%) in private practitioners. Most patients (74·6%) first sought care at an informal or private provider and experienced a complex pathway visiting both public and private providers to obtain a diagnosis. The median number of health provider visits pre-diagnosis was 6 (IQR 4-8). From start of symptoms, it took a median 30 days (IQR 14-61) to present to a health provider, 62 days (IQR 35-113) to reach a TB diagnosis, and 65 days (IQR 37-119) to start treatment. Patient delay was longer among male, lowly-educated and uninsured individuals. There were longer diagnostic delays among uninsured individuals, those who initially visited private providers, and those with multiple visits prior to diagnosis. Longer treatment delays were found in those with multiple pre-diagnosis visits or diagnosed by private practitioners. INTERPRETATION: Patient pathways in Indonesia are complex, involving the public and private sector, with multiple visits and long delays, especially to diagnosis. A widely available accurate diagnostic test for TB could have a dramatic effect on reducing delays, onward transmission and mortality. FUNDING: This project was funded by the Partnership for Enhanced Engagement in Research (PEER) grant under Prime Agreement Number AID-OAA-A-11-00,012 by National Academy of Sciences (NAS); the United States Agency for International Development (USAID); University of Otago, New Zealand, and the Indonesian Endowment Fund for Education (LPDP).

Evaluation of Xpert MTB-RIF guided diagnosis and treatment of rifampicin-resistant tuberculosis in Indonesia: A retrospective cohort study.

BACKGROUND: Rifampicin-resistant tuberculosis (RR-TB) is largely underdetected in Indonesia. Xpert MTB/RIF (Xpert) has recently been introduced, prioritizing patients at risk of RR-TB, followed by phenotypic drug-susceptibility (DST) if rifampicin resistance is detected. OBJECTIVE: This study investigated Xpert-based management of presumptive RR-TB cases under routine practice in West Java, Indonesia. METHODS: We examined all records of patients tested with Xpert in the referral hospital for West Java in 2015-2016. We measured loss across a limited cascade of care, time to Xpert diagnosis and the commencement of initial second-line treatment, and identified factors associated with diagnostic and treatment delay. Additionally, we analyzed the appropriateness of treatment according to DST results. RESULTS: Of 3415 patients with presumptive RR-TB, 3215 (94%) were tested by Xpert, of whom 339 (10.5%) were diagnosed as RR-TB. 288 (85%) of 339 RR-TB patients started initial second-line TB treatment, with 48 (14%) patients being lost between diagnosis and pre-treatment assessment. Second-line treatment was commenced at a median of 41 days (IQR 29-70) after RR-TB diagnosis. Delays in both diagnosis and treatment initiation were observed in 104 (52%) of 201 RR-TB patients with identifiable referral date. Rural residence was associated with delay to diagnosis (adjusted OR 2.7; 95%CI 1.5-5.2) and treatment initiation (adjusted OR 2.0; 1.2-3.4). Of 162 patients with available DST result, 107 (66%) had multidrug-resistant tuberculosis (MDR-TB) and 32 (20%) had either pre-extensively drug resistant (pre-XDR) or extensively drug resistant tuberculosis (XDR-TB). We estimated that with the current algorithm 41% of pre-XDR or XDR-TB patients are diagnosed, and 33% of them started on an appropriate treatment regimen. CONCLUSIONS: Many patients with Xpert-diagnosed RR-TB either do not start MDR-TB treatment or encountered diagnostic and treatment delays under programmatic conditions in Indonesia, and most pre-XDR and XDR-TB cases remain undiagnosed. Further expansion and ongoing quality improvement of RR-TB services are urgently needed.

The cascade of HIV care among key populations in Indonesia: a prospective cohort study.

BACKGROUND: Indonesia has had low uptake of HIV testing and treatment. We did a study to estimate the cascade of HIV care in key populations and identify predictors of outcomes at key cascade steps. METHODS: We used an observational cohort study design to recruit and follow up men who have sex with men (MSM), female sex workers, transgender women (known as waria in Indonesia), and people who inject drugs (PWID) diagnosed with HIV in four locations in Indonesia: Bali, Bandung, Jakarta, and Yogyakarta. Recruitment, baseline, and follow-up visits were done at collaborating clinical services, including both primary care sites and hospitals. Inclusion criteria for participants included identifying as a member of a key population, age 16 years or older, not previously tested positive for HIV, and HIV positivity at baseline. All participants were offered treatment as per national guidelines, with the addition of viral load testing and completion of study-specific forms. Estimates were calculated of proportions of participants linked to care, commencing treatment, adherent to treatment, and who achieved virological suppression. We used logistic regression to investigate characteristics associated with antiretroviral therapy (ART) initiation and viral suppression and Cox regression to identify factors associated with loss to follow-up. This study is registered with ClinicalTrials.gov, NCT03429842. FINDINGS: Between Sept 15, 2015, and Sept 30, 2016, 831 individuals were enrolled in the study, comprising 637 (77%) MSM, 116 (14%) female sex workers, 27 (3%) waria, and 51 (6%) PWID. Of those enrolled, 703 (84·6%, 95% CI 82·1-87·1) were linked to HIV care and 606 (86·2%, 83·7-88·8) who were linked with care started ART. Among participants who started treatment, 457 (75·4%, 71·8-78·9) were retained in care, of whom 325 (71·1%, 66·7-75·2) had a viral load test about 6 months after enrolment, with 294 (90·5%, 86·7-93·4) of those tested (294 [35%, 32·1-38·7] of the original cohort) virally suppressed. 146 (24%) of 606 who started treatment were lost to follow-up. People who enrolled at sites that offered both testing and treatment had a higher likelihood of treatment initiation than those who enrolled at sites offering testing only (p<0·0001 by multivariate analysis), and participants who had been linked to care and had a high school or university education were significantly more likely to achieve viral suppression than those with a primary school or lower level of education (p≤0·029 by mulivariate analysis). INTERPRETATION: HIV cascade data among key populations in Indonesia show very poor rates of retention in treatment and viral suppression. Site and individual characteristics associated with initiating and continuing treatment suggest an urgent need to develop and implement effective interventions to support patients in achieving viral suppression among all people with HIV. FUNDING: Australian Government Department of Foreign Affairs and Trade, WHO, and Indonesian Government.

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

OBJECTIVE: Private practitioner's (PPs) collaboration for detection, diagnosis and treatment of tuberculosis (TB) is recommended by the World Health Organization and encouraged by the Indonesian National TB control programme. TB case management by PPs, however, are mostly not in line with current guidelines. Therefore, we developed an intervention package for PPs comprising of TB training, implementation of a mobile phone application for notification of TB cases and a 6-month regular follow-up with PPs. This study aimed to evaluate the feasibility of the intervention package to increase TB case detection and notification rates among PPs in five community health centre areas in Bandung City, Indonesia. RESULTS: A total of 87 PPs were registered within the study area of whom 17 attended the training and 12 had the mobile phone application successfully installed. The remaining five PPs had phones that did not support the application. During the follow-up period, five PPs registered patients with TB symptoms and cases into the application. A total of 36 patients with TB symptoms were identified and 17 were confirmed TB positive.

Quality and reporting of publications by Indonesian researchers: a literature survey.

OBJECTIVES: To evaluate the quality of reporting of the risk of bias of the Indonesian medical research. METHODS: Publications from PubMed and non-PubMed indexed Indonesian medical journals between January 2008 to December 2010 were assessed for risk of bias based on criterion combination from Hedges-criteria and the Oxford Center for Evidence-Based Medicine. We assessed whether the publications addressed the risk of bias adequately (quality of reporting) and whether the risk of bias criterion was fulfilled (quality of methods). The quality (both of reporting and of methods) of a study was classified as "high" if, for at least two-thirds of the criteria were adequately reported and fulfilled. It was classified as "low" when only one-third of the criteria were reported and or fulfilled. RESULTS: Of the 1753 publications, 29% (n = 507) were original medical research. For 21% (109/507) the quality of reporting was high; for 15% (77/507) the quality of methods was high. The proportion of high quality was significantly higher among PubMed than non-PubMed, with difference between proportions: (95%CI of difference: 3 to 23). CONCLUSION: A small proportion of Indonesian studies have high quality of reporting or methods. When international reporting guidelines are endorsed and followed, the quality of future studies may improve.