An implementation trial of continuous quality improvement for antenatal syphilis and HIV detection and treatment in Indonesia: The MENJAGA study

通过对孕妇进行筛查和治疗，双重消除艾滋病毒和梅毒的母婴传播（EMTCT）已被确定为全球公共卫生优先事项。印度尼西亚制定了到2030年的雄心勃勃的EMTCT目标。目前，尽管98%的孕妇在怀孕期间至少接受一次产前保健，但只有27%的孕妇接受艾滋病毒检测，1%接受梅毒检测（使用快速检测和实验室检测的混合方法）。此外，只有48%的艾滋病毒检测呈阳性和30%的梅毒检测呈阳性的人接受了治疗。这构成了一个巨大的挑战，并被认为是印度尼西亚产前保健方面最重大的差距之一。产前艾滋病毒/梅毒筛查的持续障碍包括（但不限于）：卫生工作者对普遍筛查必要性的认识有限；一些女性害怕这项测试；诊所层面缺乏当地标准操作程序；检测和治疗方面的供应链缺口；转介程序的问题；以及在卫生系统中追踪女性的困难。印度尼西亚迫切需要针对具体情况的干预措施，以更好地支持将艾滋病毒和梅毒检测和治疗纳入产前保健平台。在撒哈拉以南非洲的一些国家，持续质量改进（CQI）已被有效地用于加强非洲人国民大会的服务，它涉及当地的非洲人国民大会小组系统地收集和反思当地数据，以便为服务提供的设计和实施提供信息。这种方法对印度尼西亚具有相当大的前景，印度尼西亚是一个人口众多、多样化的国家，在那里，“一刀切”的方法很少适用于提供高质量的非国大。采用整群随机设计，我们将评估多方面CQI干预的有效性、成本效益、可接受性、保真度和覆盖范围，以改善3个省（西爪哇、南苏门答腊和南加里曼丹）6个地区的公立和私立ANC诊所的产前检测和艾滋病毒和梅毒治疗。这项为期3年的多学科研究将涉及来自印度尼西亚卫生部（研究伙伴）、伦敦卫生与热带医学学院、Gadjah Mada大学、Sebelas Maret大学和Kirby研究所的临床医生、流行病学家、经济学家、社会科学家、卫生服务研究人员和决策者。在整个研究过程中，将涉及一系列其他利益攸关方（例如，患者倡导团体、执行机构、专业专业协会、诊所和ANC服务），以评估干预措施的适当性和可接受性，以及扩大干预的障碍和促进因素。这项研究有可能为改善印度尼西亚的孕产妇和儿童健康做出重大贡献，同时也加强了基础卫生系统。

The dual elimination of mother-to-child transmission (EMTCT) of HIV and syphilis through screening and treatment of pregnant women has been identified as a global public health priority. Indonesia has set an ambitious EMTCT target of 2030. Currently, only 27% of pregnant women are tested for HIV and 1% for syphilis (using a mixture of rapid tests and laboratory-based testing), this is despite 98% of pregnant women attending antenatal care at least once during pregnancy. Moreover, only 48% of those testing positive for HIV and 30% for syphilis receive treatment. This poses a formidable challenge and is recognised as one of the most significant gaps in antenatal care in Indonesia. Persistent barriers to antenatal screening for HIV/syphilis include (but are not restricted to): limited awareness among health workers of the need for universal screening; some women are fearful of the test; lack of local standard operating procedures at the clinic level; supply chain gaps in tests and treatments; problems with the referral processes; and difficulties tracking women as they move across the health system. Context-specific interventions to better support the integration of HIV and syphilis testing and treatment into the Antenatal care (ANC) platform are urgently needed in Indonesia. Continuous Quality Improvement (CQI), which involves local ANC teams systematically collecting and reflecting on local data to inform the design and implementation of service delivery, has been effectively used to strengthen ANC services in a number of Sub-Saharan African countries. This approach holds considerable promise for Indonesia, a highly populous and diverse country where a 'one size fits all' approach to the delivery of quality ANC rarely applies. Using a cluster-randomised design, we will evaluate the effectiveness, cost-effectiveness, acceptability, fidelity and reach of a multi-faceted CQI intervention to improve antenatal testing and treatment of HIV and syphilis in public and private ANC clinics in 6 districts across 3 Provinces (West Java, South Sumatra and South Kalimantan). This 3-year multi-disciplinary study will involve clinicians, epidemiologists, economists, social scientists, health services researchers and policy-makers from the Indonesian Ministry of Health (research partner), the London School of Hygiene & Tropical Medicine, the Universitas of Gadjah Mada, the University of Sebelas Maret and the Kirby Institute. A range of other stakeholders will be involved throughout the study (e.g. patient advocacy groups; implementing agencies; specialist professional associations; clinics and ANC services) to assess the appropriateness and acceptability of the intervention and barriers and facilitators to scale up. This research has the potential to contribute significantly to improved maternal and child health in Indonesia while also strengthening the underlying health system.