Motivational Interviewing as an Intervention to Improve Antiretroviral Treatment Initiation among People who Inject Drugs (PWID): A Pilot Study in Jakarta and Bandung, Indonesia.

INTRODUCTION: Progress towards the 95-95-95 target among People Who Inject Drugs (PWID) with Human Immunodeficiency Virus (HIV) infection was considerably low. A behavioral approach, such as motivational interviewing (MI), has been recognized as an effective strategy for improving HIV treatment outcomes among PWID. OBJECTIVE: This study aimed at assessing the impact of MI counselling to improve ARV initiation among HIV-positive PWID. METHODS: A cohort design pilot study was performed, and participants were recruited using a convenience sampling technique. Participants were PWID with HIV who accessed healthcare facilities in two Indonesian cities. Selected participants were assigned to an intervention group and a control group. The intervention group followed MI counselling, while the control group received ART following the standard of care. The participants were assigned to each group based on their preferences. The data was collected between January 2018 and January 2019. RESULTS: In total, 115 PWID with HIV participated in this study in the intervention (n=30) and control (n=85) groups. All but one intervention group's participants started ART, while 68/85 in the control group did so. Receiving MI counselling significantly contributed to ART initiation. In addition, the participants were followed-up until 12 months after ARV initiation. During this period, we found that similar proportions of participants in both groups discontinued the treatment, and only a small number achieved HIV viral suppression. CONCLUSION: The positive effect of MI counselling on ART initiation provides insight into the possibility of its wider implementation. Further studies are needed to gain a deeper understanding of MI counselling and its effect on other outcomes of the HIV treatment cascade.

Cost of improved test and treat strategies in Indonesia.

OBJECTIVE: To estimate and compare the cost of improved test and treat strategies in Indonesia under HIV Awal (Early) Testing and Treatment Indonesia (HATI) implementation trial in community-based and hospital-based clinics. DESIGN: The cost and outcome [i.e. CD4 + cell count] and viral load (VL) at the beginning of interventions and their change overtime) analysis of Simplifying ART Initiation (SAI), Community-based Organization and community-based ART Service (CBO), Motivational Interviewing (MI), Oral Fluid-based Testing (OFT), and Short Message Service (SMS) reminder in community-based and hospital-based clinics in 2018-2019. METHOD: We estimated the total and unit costs per patient (under HATI implementation trial interventions) per year from societal perspective in various settings, including costs from patients' perspective for SAI and MI. We also analyzed the outcome variables (i.e. CD4 + cell count and VL at the beginning of each intervention, the change in CD4 + cell count and VL over time, and adherence rate). RESULT: The unit cost per patient per year of SAI and SMS were lower at the community-based clinics, and more patients visited community-based clinics. The cost per patient visit from patient perspective for SAI and MI was mostly lower than 10% of the patients' household monthly expenditure. Average CD4 + cell count was higher and average VL was lower at the start of interventions at the community-based clinics, while average CD4 + cell count and VL changes and adherence rate were similar between the two types of clinics. CONCLUSION: Community-based clinics hold the potential for scaling up the interventions as it costs less from societal perspective and showed better outcome improvement during the HATI implementation trial.

Behavioral Changes, Adaptation, and Supports among Indonesian Female Sex Workers Facing Dual Risk of COVID-19 and HIV in a Pandemic.

The objective of this study is to explore the impacts of COVID-19 and changes taking place among the Indonesian female sex worker (FSW) community during the COVID-19 pandemic and the predictors of these changes. We conducted a cross-sectional online survey and selected the participants using a purposive snowball sampling technique. Incentives were provided to participants in the form of a 5 USD e-wallet balance. Variables of interest included adaptation to online sex work, adherence to COVID-19 prevention measures during sex work, number of clients, income reduction, social support, condom access, and condom use frequency. Sociodemographic data and COVID-19 fear index values were also collected. Final analysis included 951 FSWs, of whom 36.4% of had adapted to online sex work and 48.6% had practiced COVID-19 prevention measures. Major reductions in client frequency and income were reported by 67.8% and 71.1% of respondents, respectively. However, only 36.3% of FSWs reported they had ever received any form of social support from any parties, public or private. Meanwhile, 16.7% encountered difficulties in accessing condoms and 12.5% reported less frequent condom use during the pandemic. Easy access to condoms was the main factor influencing the frequency of condom use. As expected, staying in employment protected FSWs from major income loss, while education and younger age predicted adaptive behavioral changes, such as taking up online sex work. The COVID-19 pandemic has disrupted access to socioeconomic support systems and HIV prevention services among FSWs and has further exposed them to the dual jeopardy of HIV and COVID-19 infections.

Simplified clinical algorithm for immediate antiretroviral therapy initiation: The HATI [HIV awal (early) Test & Treat in Indonesia] implementation research in Indonesia.

Background & objectives: Although the World Health Organization recommends same day or rapid (< seven days) antiretroviral therapy (ART) initiation, delays in ART initiation remain common due to waiting for laboratory test results. This study employed a simplified clinical algorithm the HATI [HIV Awal (Early) Test & Treat Indonesia]-SAI (Simple ART Initiation) aimed to increase the proportion of ART uptake and decrease the time to ART initiation that can be used in various care settings. Methods: This study compared the percentage of ART uptake and retention, viral load (VL) suppression and time to ART initiation between the observation and intervention phases among newly diagnosed HIV patients from key populations. As part of the intervention, the newly diagnosed patients underwent screening using a simple form [consisting of data on age, height and weight (for body mass index calculation), questions on the presence of symptoms of HIV stages 1 and 2, tuberculosis, history of diabetes, hypertension and kidney disease], to determine eligibility for immediate ART initiation. Those who met the pre-defined criteria immediately received a combination of tenofovir lamivudine and efavirenz for two weeks. The baseline laboratory examination due to this was moved up to two weeks post ART. Factors significantly associated with ART uptake were also determined and their odds ratios were measured using logistic regression analysis. Results: A total of 2173 people newly diagnosed with HIV were recruited, with 1579 and 594 in the observation and intervention phases, respectively. In both phases, the majority were men who have sex with men, who were young (<30 yr old) and employed, with high levels of education. The intervention phase significantly increased the proportion of ART initiation [91%, 95% confidence interval (CI): 89-93% vs. 78%, 95% CI: 76-80%] but did not have any impact on the proportion of six months retention and VL suppression. The intervention also significantly decreased the time to ART initiation from median ± interquartile range: 9±20 days to 2±10 days. Interpretation & conclusions: The findings of this study suggest that the HATI-SAI intervention increased the uptake and decreased the time for immediate ART initiation. The HATI-SAI provides a simple and safe clinical approach that can readily be adopted in different settings without a costly investment in technology.

Alarmingly High HIV Prevalence Among Adolescent and Young Men Who have Sex with Men (MSM) in Urban Indonesia.

Indonesia's HIV epidemic is concentrated among key populations. While prevalence among men who have sex with men (MSM) is high, transmission among young MSM (15-24-years-old) remains poorly understood. We conducted a respondent driven sampling survey of 211 young MSM in urban Bandung, Indonesia in 2018-2019 to estimate HIV prevalence and associated risk factors. Thirty percent of young MSM were HIV antibody positive. This is nearly 100-fold greater than Indonesia's population prevalence and sevenfold higher than average estimates for young MSM across Asia and the Pacific Region. Individual risk factors associated with HIV infection were being 20-24 years old, having a steady partner and preferring the receptive position during sex. Issues of stigma, discrimination and social exclusion were common. Few young MSM who were open with friends and family members about their sexual identity. Among those that were, close to half reported experiencing feelings of aversion from these groups. Wider structural factors that reduce social tolerance, restrict the rights of young MSM and compel concealment of sexual identity are likely to fuel high-risk behaviors and limit access to essential testing care and support services including pre-exposure prophylaxis which is not yet widely available. Urgent health, social, legal and political actions are required to respond to these factors and reduce the disproportionate contribution of young MSM to Indonesia's HIV epidemic.