The DOMINO Study: Measuring and mitigating the indirect effects of COVID-19 on TB and HIV care in Indonesia

The disruption to TB and HIV health services brought about by the COVID-19 pandemic, if sustained over six-months, has been predicted to result in 1.4 million extra deaths from TB-related illnesses and over 500,000 from HIV (5,6). If correct, these predictions correspond to deaths rates for HIV and TB last seen globally more than a decade ago. Indonesia, the fourth most populous country in the world, has the highest number of COVID-19 infection cases in Southeast Asia (2). The country is also ranked third for TB burden globally (3) and one of few countries with an increasing number of new HIV infections (4). While Indonesia has recently strengthened efforts to control these diseases, the diversion of resources to the pandemic combined with social distancing policies is creating new vulnerabilities and exacerbating existing ones for people who rely on TB and HIV services. The country urgently needs to understand the wider impact of the pandemic on TB and HIV care to inform mitigation strategies. We will build on strong, existing collaborative research relationships to rapidly assess the impact of the COVID-19 outbreak (and policy responses to it) on the delivery of and access to TB and HIV care in Indonesia, with a particular emphasis on highly vulnerable sub populations. Our findings will be used to design strategies to safeguard the continuity of care for TB and HIV patients in the near and medium term, thereby ensuring the country does not lose ground on the major advances it has made towards the control of these diseases.

The global health community has made urgent calls for countries to find solutions to minimising the impact of COVID-19 on programs targeting long-standing health problems such as TB and HIV (1). Indonesia, with a population of around a quarter of a billion people, currently has the highest number of COVID-19 infection cases in Southeast Asia, averaging 1000-1300 new infections each day since the 15th June and a case fatality rate of around 6.6% (2). It is also ranked third in TB burden globally (3) and one of a few countries where the number of new HIV infections is rising (4). In recent years Indonesia has strengthened its commitment to controlling these two important diseases. However, the diversion of health resources to the pandemic along with social distancing policies is creating new vulnerabilities and exacerbating existing ones for TB and HIV programs and affected populations. Our team is partnering with the Indonesian government and community organisations to conduct an observational cohort study across all TB and HIV facilities in the major cities of Bandung (N=62) and Yogyakarta (N=30) to assess clinical outcomes before and during the pandemic. We will analyse routinely collected data to measure linkage to care, retention in care and treatment outcomes along TB and HIV cascades of care. Qualitative methods will be used to explore the experiences of TB and HIV patients and their health care providers during the pandemic, including changes to treatment seeking and actions to minimise disruptions. Out-of-pocket health spending by TB and HIV patients and their families during the pandemic will be measured using structured diaries. Wider health system impacts of COVID-19 on stocks of medicines/tests and health facility funding levels will be assessed using facility records and interviews with health authorities and facility staff. Our findings will generate recommendations on how to minimise disruptions to HIV and TB services in the face of the pandemic.