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来消除艾滋病毒和梅毒的母婴传播已被确定为全球公共卫生优先事项。印度尼西亚制定了一个雄心勃勃的EMTCT目标，即2030年。目前，只有27%的孕妇接受了艾滋病毒检测，1%的孕妇接受了梅毒检测(使用快速检测和基于实验室的检测)，尽管98%的孕妇在怀孕期间至少接受了一次产前护理。此外，只有48%的艾滋病毒检测呈阳性的人和30%的梅毒患者接受了治疗。这构成了一项艰巨的挑战，并被认为是印度尼西亚产前保健方面最重大的差距之一。产前筛查艾滋病毒/梅毒的持续障碍包括(但不限于)：保健工作者对普遍筛查必要性的认识有限；一些妇女害怕这种检查；诊所一级缺乏当地标准的操作程序；检查和治疗方面的供应链差距；转诊过程中的问题；以及难以跟踪妇女在保健系统中流动的情况。印度尼西亚迫切需要针对具体情况的干预措施，以便更好地支持将艾滋病毒和梅毒检测和治疗纳入产前护理平台。持续质量改进(CQI)涉及当地非国大团队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，在一些撒哈拉以南非洲国家有效地用于加强非国大的服务。对于印度尼西亚来说，这种方法有着很大的希望。印尼是一个人口众多、多元化的国家，“一刀切”的方法很少应用于优质非国大的交付。采用整群随机设计，我们将评估在3个省(西爪哇、南苏门答腊岛和南加里曼丹)的6个地区的公立和私立非国大诊所实施的多方面CQI干预措施的有效性、成本效益、可接受性、保真度和覆盖面，以改善艾滋病毒和梅毒的产前检测和治疗。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政策制定者。一系列其他利益相关者将参与整个研究过程(例如，患者权益倡导团体、执行机构、专家专业协会、诊所和非国大服务)，以评估干预措施的适当性和可接受性，以及扩大规模的障碍和促进者。这项研究有可能对改善印度尼西亚的妇幼保健作出重大贡献，同时也加强基本的卫生系统。

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.