By Caroline Francis, EpiC Indonesia, Michael Cassell, EpiC, and the team at EpiC Indonesia: Irvin Romyco, Riska Apriliyanti, Imam Ahmadi, Erlian Aditya, Aulia Human
On the path to HIV epidemic control, the best-laid plans anticipate and pave strategic detours. This is perhaps no more evident than in the megacity of Jakarta, Indonesia. In Jakarta, decades of innovations to navigate traffic may have helped the national HIV programme to sustain HIV service connections despite severe COVID-19-related movement restrictions.
With the expansion of mobile connectivity, residents of Jakarta have increasingly turned to private ride-share-based delivery services to maintain connections to everything, including healthcare. When COVID-19 restrictions introduced threats to access to HIV treatment, the city turned to ride-share delivery as a differentiated pathway to overcome obstacles and reduce the frequency of clinical visits.
The Jakarta Government introduced social restrictions in response to the COVID-19 pandemic in March 2020. Health facility staff were required to work alternating shifts, reducing facilities’ ability to deliver care. Efforts to scale up and differentiate HIV treatment services were further compromised through challenges in securing the supply chain for antiretroviral therapy (ART) and laboratory supplies for viral load testing. These supply chain concerns undermined confidence in the expansion of multi-month dispensing of ART and constrained access to viral load testing.
Anticipating that the private sector might have some insights that could help overcome these obstacles, the LINKAGES Project – with support from the U.S. Agency for International Development through the U.S. President’s Emergency Plan for AIDS Relief – convened local health officials, people living with HIV, private sector representatives and community and clinical service providers to brainstorm solutions. Ride-share-based home delivery of ART emerged immediately as a priority and the team collaborated to develop the Jak-Anter system (Anter means “send” in Bahasa Indonesian). The system follows a five-step process to ensure safe and secure delivery of ART from facility to client.
In March 2020, the Jakarta Public Health Office (PHO) officially authorized ART home delivery on an emergency basis. Since then, 8,214 people living with HIV – almost half of about 17,000 people living with HIV accessing services across 55 facilities where home-based delivery options have been prioritized – have used Jak-Anter services at least once (Figure 1). While more detailed analyses are ongoing, an initial assessment suggests that Jak-Anter is saving costs for clients by reducing transportation and time away from work associated with clinical visits. The system may also reduce administration and consultation time and costs for providers, affording them more capacity to serve priority clients with greater needs. Based on these results, the Jakarta PHO recently made home delivery a lasting component of Jakarta’s differentiated response to HIV beyond COVID-19.
Ride-share-based services have also been mobilized to create a dedicated viral load specimen transport system called Jak Transporter. In Jakarta, eight Jak Transporters provide daily specimen transport services for viral load sample collection and delivery to geographic clusters of health facilities and private laboratories, unlocking systems barriers – like lack of point-of-care testing options – that had stymied viral load testing coverage and associated progress towards HIV epidemic control goals. The transporters have moved an average of more than 1,500 specimens monthly since early 2020, helping 74% of people living with HIV at 60 of Jakarta’s HIV facilities test their viral loads and move towards viral load suppression during the COVID-19 lockdown.
Jak-Anter and similar programmes in Southeast Asia show that context-specific, differentiated “detours” to overcome HIV service barriers can provide essential HIV programme resilience in the face of emergent challenges. While the science on what works to prevent and treat HIV has placed control of the HIV epidemic within reach, there remains an outstanding need for differentiated innovations to deliver. As we work towards an effective HIV response, the straightest path paradoxically may be one that provides clients with an expanding set of convenient detours around evolving barriers they may face. Ultimately, more inclusive engagement of the private sector and other actors is likely key to unlocking these alternative pathways and accelerating progress.