“I pity the TB patient”: a mixed methods study assessing the impact of the COVID-19 pandemic on TB services in two major Indonesian cities and distilling lessons for the future

Abstract

IntroductionIn Indonesia, a country with around 280 million people and the second-highest tuberculosis (TB) incidence rate in the world, the impact of the COVID-19 pandemic on TB care needs careful assessment so that future response strategies can be strengthened. We conducted a study comparing TB testing and treatment rates before and during the first 2 years of the COVID-19 pandemic in Indonesia, and the reasons for any disruptions to care.MethodsWe conducted retrospective secondary data analysis and qualitative interviews in Yogyakarta and Bandung, Indonesia. Routine data on TB testing and treatment were sourced from the national TB information system operated by the Indonesian Ministry of Health. TB testing and treatment outcomes were compared between two time periods: pre-COVID (2018–19); and during COVID-19 (2020–21). In-depth interviews were conducted with patients and health workers to explore their experiences in accessing and providing TB services during the pandemic.ResultsThere was a 45% (21 937/39 962) reduction in the number of patients tested for TB during the pandemic compared with pre-COVID-19, while the proportion of TB tests returning a positive result increased from 12% (4733/39 962) to 50% (10 945/21 937). The proportion of TB patients completing treatment increased by 2.6% during the pandemic, yet the proportion cured and the number of patients successfully treated both decreased (by 7% and 4.4%, respectively). Our qualitative interviews highlighted several factors influencing TB service access and delivery, including fear of being diagnosed with COVID-19 during TB-related clinic visits, fear of COVID-19 exposure among patients and health workers, healthcare facilities prioritising COVID-19 over other services, and mandatory mobility restrictions affecting both patients and health workers.ConclusionThe COVID-19 pandemic impacted TB testing and treatment outcomes in Bandung and Yogyakarta. Policymakers should consider these findings in designing strategies to ensure TB services are maintained and supported during future health crises.

Delivering HIV and TB services amidst the COVID-19 pandemic in Indonesia: a qualitative study of challenges and mitigation strategies

“…12 Estimates from UNAIDS in 2023 revealed an alarmingly high HIV prevalence among key population groups at higher risk of HIV infection: 13.7% of people who inject drugs; 17.9% of men who have sex with men; 11.9% of transgender individuals; and 2.1% of sex workers. 11 Our study 6 and several other studies [13][14][15][16] have documented the impact of the COVID-19 pandemic on HIV programs and services in Indonesia. In our study, we noted that compared to the pre-pandemic period, individuals living with HIV who visited hospitals had a lower likelihood of starting anti-retroviral treatment (ART), staying in care, and adhering to ART during the pandemic. 17 These disruptions were due, among other things, to social distancing orders, lockdown, and healthcare workers being redeployed to work on COVID-19 testing, contact tracing, and surveillance activities.…”

“…2 It was also among the top 10 countries that contributed to a global decrease of more than 90% in TB case notifications among people newly diagnosed with TB since 2020, compared with 2019. 2 Further impact of the COVID-19 pandemic on TB services in Indonesia has been documented by our team 6 and others. [7][8][9] We have previously shown that the rates of tuberculosis testing, treatment completion rates, and successful treatment rates decreased in two Indonesian cities (Yogyakarta and Bandung) during the COVID-19 pandemic.…”

“…We utilized routinely collected clinic data to measure various metrics along the TB and HIV cascades of care, such as testing, linkage to care, retention in care, and treatment outcomes. 6,17 Additionally, we employed qualitative methods to explore the perspectives and experiences of both patients and healthcare providers regarding TB and HIV services during the pandemic. This in-Delivering HIV and TB services amidst the COVID-19 pandemic in Indonesia: a qualitative study of challen… Journal of Global Health Reports cluded examining changes in treatment seeking behavior and identifying actions taken to mitigate service disruptions.…”

“…[7][8][9] We have previously shown that the rates of tuberculosis testing, treatment completion rates, and successful treatment rates decreased in two Indonesian cities (Yogyakarta and Bandung) during the COVID-19 pandemic. 6 A modelling study estimated the impact of the disruptions on TB-related outcomes in Indonesia: one of the key predictions being that the worst-case scenario for cumulative TB-related mortality during the five-year period from 2020 to 2024 is 10% to 12% higher than it was prior to the pandemic. 9 The HIV epidemic is also a concern in Indonesia.…”