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Original Article

Evaluating the impact of triple elimination

program for mother-to-child transmission of
HIV, syphilis, and hepatitis B in Indonesia
Buti A. Azhali1*, Djatnika Setiabudi2 and Anggraini Alam2
1Department of Child Health, Faculty of Medicine, Universitas Islam
Bandung, Bandung, Indonesia; 2Department of Child
Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia

*Corresponding author: [email protected]

Abstract
Indonesian government launched a triple elimination program to eliminate mother-to-
child transmission (MTCT) of human immunodeficiency virus (HIV), syphilis, and
hepatitis B in 2018, aiming to increase screening uptake among pregnant women during
antenatal visits and to reduce the rates of these infections in children less than 50 per
100,000 live births. Despite this initiative, a thorough assessment of its effectiveness,
particularly in Bandung, the capital city of West Java, as one of the most densely populated
cities in Indonesia with a high HIV incidence, has yet to be conducted. The aim of this
study was to analyze the impact of this triple elimination program in Bandung by assessing
the data between 2017 and 2020. Monthly data was obtained from the Health Office of
Bandung for four years, including number of screenings done for HIV, syphilis, and
hepatitis B, number of confirmed cases and number of pregnant women treated for those
infections. Additionally, data on children under 24 months old afflicted by these infections
were also collected. Our data indicated an increase in screening coverage for HIV, syphilis,
and HBV among pregnant women; however, it remained below the national set
benchmarks for screening coverage. Only 59.5% of HIV-positive pregnant women received
anti-retroviral therapy in 2020, while merely 25% of syphilis-positive cases were
administered benzathine penicillin G. Syphilis screening was correlated with an increase
in positive cases among children, suggesting missed opportunities in managing syphilis-
positive pregnant women. Furthermore, management of HIV- and syphilis-positive cases
had suboptimal outcomes. Data on hepatitis B was not evaluated since it was not available.
To achieve the triple elimination program goals, comprehensive coordination among all
relevant stakeholders is required, as is continuous monitoring and evaluation.

Keywords: HIV, syphilis, hepatitis B, mother-to-child transmission, triple elimination

Introduction
Human immunodeficiency virus (HIV), syphilis, and hepatitis B are among eight pathogens
linked to the most significant incidence of sexually transmitted infections (STIs) [1]. Individuals
may have more than one infection at the same time and often do not cause symptoms or may have
long asymptomatic period [1]. These infections can be vertically transmitted to newborns from
expectant mothers during pregnancy, labor, and breastfeeding. Infection in neonates can result
in morbidity, disability, and even mortality, reducing the child's quality of life [2]. Globally, 39
million (33.1–45.7 million) people were living with HIV at the end of 2022, half of them were
women and around 1.5 million were children under the age of 15 years-old [3]. The presence of
cases in children under the age of four suggests that mother-to-child transmission (MTCT)

Received: August 10, 2023 - Accepted: November 13, 2023 - Published online: November 17, 2023
 Azhali et al. Narra J 2023; 3 (3): e405 - http://doi.org/10.52225/narra.v3i3.405
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persists [3]. According to the World Health Organization (WHO) data, 7.1 million adults were
newly infected with syphilis in 2020 and an average of 3.2% of prenatal care participants tested
positive for syphilis in 2019 [4]. Pregnancy-related syphilis is the second greatest cause of
intrauterine fetal death worldwide, as well as causes of prematurity, low birth weight, neonatal
death, and infection in newborns [4]. In 2019, 296 million people were living with chronic
hepatitis B virus (HBV) infection with 1.5 million new infections each year [5]. Perinatal
transmission is the leading cause of new infections in newborns that progresses to chronic
hepatitis B [5].
In Indonesia, the rates of pregnant women with HIV, syphilis, and HBV infection were 0.3%,
1.7%, and 2.5%, respectively in 2017 [6]. Efforts to prevent infection are critical since vertical
transmission from pregnant women causes more than 90% of HIV, syphilis, and HBV infections
in children [6]. MTCT can be effectively prevented with simple interventions such as antenatal
screening, treatment for the child’s parents, birth planning, early management of newborns, and
infant immunization. In Indonesia, these preventive efforts are delivered through integrated
reproductive and health services for pregnant women, neonates, and children as part of a triple
elimination program that launched in 2018 [7]. This program targets to eliminate transmission
by 2022, with a target of ≤50 new pediatric HIV, syphilis, and HBV infections per 100,000 live
births [6,7]. However, a thorough assessment of the effectiveness of this program is not available.
The aim of this study was to analyze the impact of the triple elimination program in Bandung,
West Java as one of the most densely populated cities with a high HIV incidence in Indonesia.

Methods
Study design and variables
An ecological study was conducted to analyze the impact of triple elimination program in
Bandung, Indonesia, using four years data, from 2017 to 2020. Participation data and outcomes
of antenatal screening were collected from electronic databases: Information System of
HIV/AIDS and STIs (SIHA) and Information System of Hepatitis (SIHEPI). The study variables
included the triple elimination MTCT program coverage, number of pregnant women tested and
infected with HIV (diagnose with rapid HIV test), syphilis (diagnose with rapid treponema
pallidum (TP) test), and HBV (diagnosed by rapid HBsAg test), as well as children under 24
months old infected with HIV (diagnosed by early infant diagnosis and antibody HIV test),
syphilis (diagnosed by rapid plasma reagin (RPR) titer test), and HBV (diagnosed by HBsAg test)
in Bandung.

Data collections
Data from triple elimination was collected from each program. The data of HIV/AIDS and STIs
program were collected from Indonesian Ministry of Health web-based reporting system SIHA.
The data hepatitis B were collected from SIHEPI, a web-based reporting system of Ministry of
Health. The pooled data were collected form the program coordinator in monthly basis.
Evaluation was performed on the data, information on screening uptake and general
screening outcomes. Screening outcomes were reported based on laboratory-confirmed positive
tests. Screening coverage was calculated by dividing the number of women screened by the
number of pregnancies each year. Since the number of pregnancies each year was unavailable, an
estimation was made by the Bandung government by multiplying the crude birth rate with
number of population in the same year and 1.10 x; this estimation available in the database.

Statistical analysis
The Spearman’s rank correlation was used to assess the correlations between screening coverage
for HIV, syphilis, and HBV infection in pregnant women and number of children aged less than
24 months infected with HIV, syphilis, and HBV. This test selection was based on the data
normality tested using the Shapiro-Wilk test analysis. The correlation coefficients (r) were
classified as very low (0–<0.2), low (<0.4), moderate (<0.6), high (<0.8) and very high
correlation (0.8–1). A value of p<0.05 was considered significant. All analyses were conducted

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using SPSS version 28.0 (IBM SPSS, New York, United States). Data from triple elimination
program and its comparison on the national and program targets was analyzed descriptively.

Results
HIV, syphilis, and HBV screening coverages in pregnant women
Throughout the four-year period (2017–2020), the number of pregnant women participating in
HIV, syphilis, and hepatitis B screenings has increased significantly, with HIV from 11,988 in
2017 to 20,446 in 2020, syphilis from 279 to 2,919, and hepatitis B from 1,484 to 15,381 (Figure
1A). However, there was a decline trend in screening participation from year 2019 to 2020
(Figure 1A). HIV screening coverage doubled from 2017 (26.5%) to 2019 (54.2%), while syphilis
and HBV screening coverage increased more than tenfold from 3.3% in 2017 to 39.8% in 2019 for
HBV and 0.5% in 2017 to 6.4% in 2019 for syphilis. Despite the fact, screening coverage among
pregnant women in Bandung have not yet met the specified targets of 60% in 2018, 70% in 2019,
and 80% in 2020 (Figure 1B).

Figure 1. Number and coverage of pregnant women screened for HIV, syphilis, and hepatitis B
virus (HBV) during triple elimination program in Bandung, Indonesia, 2017−2020. (A) Number
of pregnant women screened for HIV, syphilis, and HBV. (B) Coverage of pregnant women
screened for HIV, syphilis, and HBV.

Trend of HIV, syphilis, and HBV positive in pregnant women

HIV positive rates in pregnant women were steady, ranging from 0.1% to 0.3% (Figure 2A).
Considering syphilis screening in pregnant women was limited to specific populations in 2017,
the positivity rate was relatively high, reaching 14.3% (Figure 2B). Following all pregnant
women were obligated to be screened for syphilis, it declined to 1.2% by 2020 (Figure 2B). The
positive rates of hepatitis B in pregnant women has increased from 0.7% in 2017 to 1.5% in 2020
(Figure 2C) since the implementation of triple elimination program.

HIV, syphilis, and HBV treatment in pregnant women

In 2020, the percentage of pregnant women receiving treatment decreased to 59.5%, from 87.5%
in 2019 (Figure 3A). Treatment for pregnant women with syphilis has increased significantly at
16.1% from 2018 to 2020 (Figure 3B). There was no data on treatment for HBV positive
pregnant women because they were all referred to an internal medicine specialist for further
evaluation.

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Figure 2. Number pregnant women screened and positive rate for (A) HIV, (B) syphilis, and (C)
hepatitis B virus (HBV) during triple elimination program in Bandung, Indonesia, 2017−2020.

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Figure 3. Number and percentage of HIV (A) and syphilis (B) positive pregnant women that were
treated during triple elimination program in Bandung, Indonesia, 2017−2020.

Children under 24 months old infected with HIV, syphilis, and HBV
Records on children tested for HBV surface antigen (HBsAg) and had positive results begun in
2020 and were only included in the reporting format (Table 1). There were 90 children tested
for HBsAg and, one was positive. The number of HIV-infected child under 24 months old detected
per year was one in 2017, five in 2019, and one in 2020. There were no HIV-positive children
reported in 2018. Since the start of triple elimination initiative, number of children diagnosed
with syphilis has increased by one each year (Table 1).

Table 1. Incidence rate of HIV, syphilis, and hepatitis B in children under 24 months old
Year Live birth rate HIV Syphilis Hepatitis B
Frequency % Frequency % Frequency %
2017 No data 1 - 2 - No data No data
2018 41,001 0 0% 3 0.005% No data No data
2019 41,834 5 0.012% 4 0.010% No data No data
2020 34,366 1 0.003% 5 0.015% 1 0.003%

The Spearman correlation test results found that there was no correlation between the number of
pregnant women who had screened for HIV and the number of HIV infected children (p=0.074)
(Table 2). However, there was a positive correlation between the number of pregnant women
who had screened for syphilis and the number of syphilis infected children (r=0.293, p=0.043)
(Table 2). Data on HBV infection was not evaluated since it was not available in the database.

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Table 2. Spearman correlation test assessing the correlation between the pregnant women
screened and number of infected children for HIV and syphilis
Coefficient correlation (r) p-value
HIV 0.261 0.074
Syphilis 0.293 0.043

Discussion
Vertical transmissions are responsible for more than 90% of HIV, syphilis, and HBV infections in
children [6]. Antenatal screening and proper treatment of pregnant women, together with early
neonatal management, can prevent MTCT of the diseases [7]. In 2018, WHO launched the
regional framework for the triple elimination of MTCT of HIV, hepatitis B, and syphilis in Asia
and the Pacific 2018–2030 [2]. The goal of this triple elimination program was to reach MTCT
rates of <2% for HIV, <0.1% for hepatitis B, and <0.05% for syphilis [2]. Thailand, Malaysia, and
Sri Lanka are among the Asian countries that have validated prevention of HIV and syphilis
MTCT. To date, no country has achieved the target numbers of the triple elimination program
[8]. One of the possible reasons was coronavirus disease 2019 (COVID-19) pandemic, which
began in 2019 has disrupted global health systems and access to care [9]. Services associated to
triple elimination program, such as prenatal care and routine immunization, have been
compromised in several countries. A report also claimed that access to HIV care and antiretroviral
(ARV) medications has been affected [10]. These disruptions were likely to impair the success of
the triple elimination initiatives around the world, particularly in Indonesia.
Since 2007, Indonesia has implemented vertical programs to prevent MCTC of HIV. In 2010,
syphilis testing for pregnant women was included in the national prevention of MTCT program,
however, the target is more focused on key populations (community groups at risk of HIV/AIDS
and other STIs) [11]. Hepatitis B screening and treatment has been included in the prenatal care
programs since 2016 [12]. The Indonesian Ministry of Health began a national triple elimination
initiative in 2018 to attain universal health coverage (UHC), zero elimination by 2030 [7]. With
the program implementation, it is expected that HIV, syphilis, and hepatitis B screening tests for
pregnant women will be performed concurrently during the first antenatal visit in early pregnancy
(first trimester), as opposed to the previous MTCT program, which did not integrate these three
diseases. However, the program has not been successfully implemented, as evidenced by data
acquired in this study, which demonstrated that number of pregnant women getting tested for
HIV, syphilis, and HBV infections were not even.
The screening goal for the triple elimination program was 60% of all pregnant women served
by integrated antenatal care (ANC) in 2018, 70% in 2019, 80% in 2020, 90% in 2021, and 100%
in 2022 [7]. The results of this study demonstrated that pregnant women in Bandung had not met
these goals. A study revealed similar findings in 2018 at a tertiary hospital in Eastern Indonesia,
particularly that only 14.1% of pregnant women were tested for HIV, syphilis, and HBV infections
[13]. When the triple elimination program began in 2018, screening coverage for pregnant women
in Bandung increased compared to previous years. These findings fell short of Vietnam’s
successes, which increased coverage from 50.2% to 98% following the trial adoption of an HIV,
syphilis and HPV infection screening program during ANC [14].
The positivity rate is determined by number of pregnant women tested for HIV, syphilis, and
HBV infections. According to this study, HIV-positive rates among pregnant women in Bandung
ranged between 0.1% and 0.3%, similar to the 0.3% prevalence of HIV infections in Indonesia
[15]. According to the Indonesian Health Profile in 2020, 0.25% of pregnant women in West Java
were HIV positive [16]. Prior to the initiation of the triple elimination program, syphilis screening
in pregnant women was typically limited to a target demographic, mainly female commercial sex
workers [11]. WHO classifies Indonesia as having a medium to high endemicity for hepatitis B,
with a prevalence of roughly 2.5% [15]. According to Indonesia Health Profile, as many as 1.68%
of pregnant women were found to be HBsAg reactive in 2020, with West Java accounting for 1.3%
[16], similar to this study’s results in Bandung with 1.5% in the same year.
The aim of the triple elimination MTCT program to screen pregnant women in their first
trimester was to provide adequate therapy promptly therefore cutting the risk of infection to their
infants. This is especially crucial in preventing MTCT of HIV and syphilis. This study found not

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all HIV-positive pregnant women in Bandung received ARV medications. Only 59.5% of pregnant
women received ARV therapy in 2020, which was comparable to the Quarterly Report of
HIV/AIDS and STIs in 2021, which showed that only 36.5% of HIV-positive pregnant women
received ARV therapy [17]. It was also revealed that the number of HIV-positive cases among
children under the age of 24 months increased in 2019 but dropped in 2020. Children born to
HIV-positive mothers are often diagnosed over the age of one year using widely available anti-
HIV serological tests [18]. Increment in 2019 could be attributed to the previous year's surge in
HIV-positive rates, which was 0.3% in 2018, and coverage of ARV administration to pregnant
women was likewise only 76.1%.
Preventing MCTC of HIV requires ongoing intervention, starting with screening and therapy
for HIV-positive pregnant women and continuing ARV prophylaxis in neonates. Gaps in any
phase may significantly decrease the intervention's effectiveness [19]. WHO recommends starting
anti-retroviral therapy (ART) as soon as feasible in HIV-positive pregnant women as an effective
strategy in minimizing MTCT of HIV, and evidence revealed that at least 4–13 weeks of ART is
needed to achieve viral suppression at the time of delivery [20]. According to one study, the rate
of HIV transmission in non-breastfed infants reached 5.7% in utero and 4.8% during intrapartum
even though the infant had been given ARV prophylaxis for 6 weeks if the mother did not receive
ARV therapy during pregnancy, demonstrating the critical role of providing ART to HIV positive
pregnant women in reducing vertical transmission [21].
Since the introduction of the triple elimination program, there has been an increase in the
number of maternal syphilis diagnoses, but this has not been followed up with adequate therapy,
benzathine penicillin G administration. According to the Quarterly Report of HIV/AIDS and STIs
in 2021, 44.3% of syphilis-positive pregnant women received treatment, which was higher than
the findings obtained in this study which was 25% in 2020. A study conducted at a tertiary
hospital in Surabaya revealed that only 66.7% of pregnant women with syphilis received
benzathine penicillin G injections [13]. In high-income developed countries such as the United
States Centers for Disease Control (CDC) reported a 30.7% delay in treating syphilis in pregnant
women even though it was diagnosed during the first antenatal screening, leading to a 261%
increase in the number of congenital syphilis cases between 2013 and 2018, from 362 to 1,306
[22]. This study also discovered an increase in syphilis cases in children under the age of 24
months, which can be attributed to inadequate treatment of pregnant mothers who tested positive
for syphilis in Bandung.
In this study, a weak positive correlation was identified between the number of pregnant
women screened for syphilis and the incidence of congenital syphilis. Many pregnant women have
tested positive for HIV, syphilis, and HBV infection but have not received adequate treatment by
program standards, resulting in numerous missed opportunities. The situation may contribute to
a rise in cases among children later in life.
Effective triple-elimination programs demand a collaborative, interdisciplinary approach,
yet in practice, programs were frequently administered independently. Inequitable funding for
these three diseases, with less investment in syphilis and hepatitis B compared to HIV, impedes
efficient integrated treatment [23]. Differences in finance and political support have resulted a
greater progress in HIV infection control than in syphilis and hepatitis B [23]. This problem was
also discovered in this study, which revealed that screening for each disease was done
individually, as seen by disparities in number of pregnant women who received HIV, syphilis, and
hepatitis B screening. HIV screening was performed more frequently in pregnant women than
hepatitis B screening. Screening for syphilis lags substantially behind HIV and hepatitis B. The
main cause for the low coverage of syphilis interventions for pregnant women was said to be a
lack of political and monetary funding. Shortage of rapid diagnostic tests and benzathine
penicillin G therapy limits pregnant women's access to treatment [24].
Some limitations of this present study need to be discussed. The use of tertiary data was one
of the limitations of this study. Several factors may influence data quality, such as from registry
accuracy until reporting. Data availability was highly dependent on the report fulfillment and
certain data were still incomplete.

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Conclusion
The triple elimination program of MTCT for HIV, syphilis, and hepatitis B has the primary
objective of minimizing vertical transmission from infected mothers to their infants through
antenatal screening, treatment of infected pregnant women, follow-up, and vaccination of infants
born to infected mothers. Since the implementation in 2018, there has been an increase in HIV,
syphilis, and hepatitis B screening coverage for pregnant women in Bandung, although the target
has yet to be met. To achieve the triple elimination program goals, comprehensive coordination
among all relevant stakeholders is required, as is continuous monitoring and evaluation.

Ethics approval
This study was approval by the Research Ethics Commission of Universitas Padjadjaran,
Bandung, Indonesia number: 151/UN6.KEP/EC/2022 and authorized by the National Unity and
Political Agency of the Bandung City Government listed in the Research Certificate Number:
PP.09.01/212-kesbangpol/II/2022.

Competing interests
The authors declare that there is no conflict of interest.

Acknowledgments
The authors would like to acknowledge and appreciate the Health Office of Bandung staff who
supported the implementation of this study.

Funding
This study received no external funding.

Underlying data
Derived data supporting the findings of this study are available from the corresponding author
on request.

How to cite
Azhali BA, Setiabudi D, Alam A. Evaluating the impact of triple elimination program for mother-
to-child transmission of HIV, syphilis, and hepatitis B in Indonesia. Narra J 2023; 3 (3): e405 -
http://doi.org/10.52225/narra.v3i3.405.

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