Challenges to integrating programs for the elimination of mother-to-child transmission of HIV, syphilis, and hepatitis B into antenatal care: Experiences from Indonesia.

The WHO's Asia-Pacific framework for triple elimination recommends that countries evaluate their programs for the elimination of mother-to-child transmission of HIV, syphilis, and hepatitis B (EMTCT), including identifying gaps to improve program planning and the implementation of elimination strategies in antenatal care (ANC) services. In 2022, the Indonesian Ministry of Health reported that only 39% of pregnant women were tested for HIV, 14% for syphilis, and 28% for hepatitis B, respectively. We conducted a qualitative study involving a focus group discussion (FGD) and in-depth interviews with 25 key stakeholders in Bali and West Nusa Tenggara Provinces to identify specific challenges to testing for HIV, syphilis, and hepatitis B in ANC settings. Thematic analysis was used to identify the themes generated from the data. Health system bottlenecks experienced by stakeholders included supply chain management issues involving stock forecasting and stock monitoring, stock-outs of rapid test reagents which were particularly most frequent and for longer durations for syphilis and hepatitis B, high staff turnover, lack of staff training on how to perform the test, the complexity and time needed to record the data on women's characteristics, risk behaviours, and testing in both paper format and into the computer-based surveillance systems, discrepancies in program coverage data from different divisions of the district health office involved in the reporting system, high levels of stigma that prevented women from being followed up, challenges in notifying partners, and inadequate reporting and referral of women from private providers to public ones for testing. Interventions addressing the above challenges are worthy of consideration to improve the health system function and integrate EMTCT into the ANC settings.

Costs and scale-up costs of community-based Oral HIV Self-Testing for female sex workers and men who have sex with men in Jakarta and Bali, Indonesia.

BACKGROUND: The proportion of individuals who know their HIV status in Indonesia (66% in 2021) still remains far below the first 95% of UNAIDS 2030 target and were much lower in certain Key Populations (KPs) particularly Female Sex Workers (FSW) and Male having Sex with Male (MSM). Indonesia has implemented Oral HIV Self-testing (oral HIVST) through Community-based screening (HIV CBS) in addition to other testing modalities aimed at hard-to-reach KPs, but the implementation cost is still not analysed. This study provides the cost and scale up cost estimation of HIV CBS in Jakarta and Bali, Indonesia. METHODS: We estimated the societal cost of HIV CBS that was implemented through NGOs. The HIV CBS's total and unit cost were estimated from HIV CBS outcome, health care system cost and client costs. Cost data were presented by input, KPs and areas. Health care system cost inputs were categorized into capital and recurrent cost both in start-up and implementation phases. Client costs were categorized as direct medical, direct non-medical cost and indirect costs. Sensitivity and scenario analyses for scale up were performed. RESULTS: In total, 5350 and 1401 oral HIVST test kits were distributed for HIV CBS in Jakarta and Bali, respectively. Average total client cost for HIV CBS Self testing process ranged from US$1.9 to US$12.2 for 1 day and US$2.02 to US$33.61 for 2 days process. Average total client cost for HIV CBS confirmation test ranged from US$2.83 to US$18.01. From Societal Perspective, the cost per HIVST kit distributed were US$98.59 and US$40.37 for FSW and MSM in Jakarta andUS$35.26 and US$43.31 for FSW and MSM in Bali. CONCLUSIONS: CBS using oral HIVST approach varied widely along with characteristics of HIV CBS volume and cost. HIV CBS was most costly among FSW in Jakarta, attributed to the low HIV CBS volume, high personnel salary cost and client cost. Future approaches to minimize cost and/or maximize testing coverage could include unpaid community led distribution to reach end-users, integrating HIVST into routine clinical services via direct or secondary distribution and using social media network.

Intimate partner violence and factors influencing HIV status disclosure among women living with HIV in Indonesia: a cross-sectional study.

The disclosure of HIV status poses challenges, and women living with HIV often face intimate partner violence as a result of revealing their HIV status. This study aims to investigate the prevalence of intimate partner violence and HIV status disclosure among women living with HIV in Indonesia, as well as the factors associated with disclosure. A total of 283 women with HIV participated in an online survey, and descriptive and logistic regression analyses were performed. The findings revealed that women reported experiencing physical (9.54%), sexual (6.01%), mental (23.67%), and economic (14.49%) abuse. HIV status disclosure varied among different individuals, with higher rates observed for partners (71.2%), other family members (65.02%), close friends (37.10%), and lower rates for health workers (1.77%). Factors such as employment status and partner's HIV status influenced disclosure to partners, while the duration of knowing one's HIV status, experiences of intimate partner violence, and perceived barriers influenced disclosure to both family and non-family members. To mitigate the negative consequences of HIV status disclosure, targeted health promotion efforts should prioritize partners, family members, and non-family members, focusing on enhancing knowledge and awareness about HIV, including the impact of violence.

Lived Experience, Social Support, and Challenges to Health Service Use during the COVID-19 Pandemic among HIV Key Populations in Indonesia.

The COVID-19 has greatly affected the lives, health and social well-being of people globally including presenting special challenges in low to middle income countries for people living with HIV. This study investigates the pandemic experiences of the four key HIV-positive populations in Indonesia: men who have sex with men, transgender women, female sex workers, and people who use drugs. In-depth interviews were conducted with a convenience sample of 22 key population members recruited through 9 nongovernment HIV agencies in Jakarta and Bali, Indonesia. Indonesia's Large-scale Social Restrictions Policy mandating physical distancing and stay-at-home orders had been in effect for 7-10 months. The interviews were audio-recorded, transcribed, and coded using NVivo™ (R1.7) software A grounded theory approach identified key concepts along with similarities, differences, and reoccurring patterns of COVID-related lived experience among participants. Participants recounted the impact of both the pandemic and the Restriction Policy on their interpersonal, financial, medical, and psychosocial well-being. When in need, they turned to formal and informal sources of financial and social support plus their own resourcefulness. Along with other factors, HIV medication shortages, HIV and COVID-related stigma, and fear of acquiring COVID-19 negatively impacted antiretroviral adherence and the use of health services. The results point to the latent consequences of government attempts to curb a pandemic through public health lockdowns and enforced policies of physical separation. Its findings reveal the importance of ensuring that public safety nets for HIV key populations are available to supplement more informal personal sources of needed support.

Sociodemographic and Healthcare Factors Associated with Stunting in Children Aged 6-59 Months in the Urban Area of Bali Province, Indonesia 2018.

Stunting is a worldwide public health concern, including in Indonesia. Even when living in an urban area with urban characteristics, it is still possible for children to be at risk of stunting. The aim of this study was to determine the sociodemographic and healthcare factors associated with stunting in a province experiencing tourism growth, namely, Bali. Cross-sectional data on Bali Province from the Indonesian Basic Health Research Survey (Riskesdas, 2018) were used as the basis for the research analysis. A total of 846 respondents under five years of age were analyzed, indicating a stunting prevalence of 19.0%. Multivariate logistic regression demonstrated low maternal educational attainment (adjustedOR = 1.92; 95% Confidence Interval = 1.24-2.97), the inadequate consumption of iron tablets during pregnancy (adjustedOR = 1.56; 95% Confidence Interval = 1.08-2.24), and no extended family (adjustedOR = 1.55; 95% Confidence Interval = 1.07-2.26) as being significantly associated with stunting. According to these findings, sociodemographic and healthcare factors are associated with stunting in urban Bali. Improving women's education, ensuring sufficient iron tablets are consumed during pregnancy, and encouraging the involvement of the extended family in childcare are recommended.

An evaluation of global Chikungunya clinical management guidelines: A systematic review.

Background: Chikungunya virus (CHIKV) has expanded its geographical reach in recent decades and is an emerging global health threat. CHIKV can cause significant morbidity and lead to chronic, debilitating arthritis/arthralgia in up to 40% of infected individuals. Prevention, early identification, and clinical management are key for improving outcomes. The aim of this review is to evaluate the quality, availability, inclusivity, and scope of evidence-based clinical management guidelines (CMG) for CHIKV globally. Methods: We conducted a systematic review. Six databases were searched from Jan 1, 1989, to 14 Oct 2021 and grey literature until Sept 16, 2021, for CHIKV guidelines providing supportive care and treatment recommendations. Quality was assessed using the appraisal of Guidelines for Research and Evaluation tool. Findings are presented in a narrative synthesis. PROSPERO registration: CRD42020167361. Findings: 28 CMGs were included; 54% (15/28) were produced more than 5 years ago, and most were of low-quality (median score 2 out of 7 (range 1-7)). There were variations in the CMGs' guidance on the management of different at-risk populations, long-term sequelae, and the prevention of disease transmission. While 54% (15/28) of CMGs recommended hospitalisation for severe cases, only 39% (11/28) provided guidance for severe disease management. Further, 46% (13/28) advocated for steroids in the chronic phase, but 18% (5/28) advised against its use. Interpretation: There was a lack of high-quality CMGs that provided supportive care and treatment guidance, which may impact patient care and outcomes. It is essential that existing guidelines are updated and adapted to provide detailed evidence-based treatment guidelines for different at-risk populations. This study also highlights a need for more research into the management of the acute and chronic phases of CHIKV infection to inform evidence-based care. Funding: The UK Foreign, Commonwealth and Development Office, Wellcome Trust [215091/Z/18/Z] and the Bill & Melinda Gates Foundation [OPP1209135].

Incidence and risk factors for syphilis infection among men who have sex with men: A cohort study from an urban sexual health clinic in Jakarta, Indonesia.

Objective: Syphilis infection remains a significant health issue among marginalised populations in Indonesia, in particular among men who have sex with men (MSM), in whom there are limited studies from Indonesia exploring risk factors associated with STI acquisition.Our study aimed to identify risk factors of syphilis infection among MSM attending large sexual health clinic in Jakarta. Methods: We conducted a retrospective cohort analysis using patient records (MSM aged 18 years or older) period Jan 2018-Dec 2019. We used Cox regression to identify risk factors associated with syphilis incidence. Results: Study population were 2912 MSM tested for syphilis, 473 (16.2%) were diagnosed with syphilis on their first visit; early syphilis (415; 14%) and latent syphilis (58, 2%). Among the cohort of 2439 MSM who tested negative at baseline, 40 MSM were identified with a new positive syphilis result during 2 years follow up. Risk factors remaining significantly associated with syphilis incidence included having STI symptom at 1st visit (aHR, 2.8; 95% CI, 1.38-5.65), and HIV-infection (aHR 4.53; 95% CI 2.24 - 9.17).Syphilis incidence rate was 8.19 (95% CI 6.01-11.16) per 100 PYFU. Conclusions: Syphilis infection at baseline and incidence was high among MSM attending this large clinic in Jakarta. Integrated and accessible syphilis prevention and detection coupled with HIV services are needed, with a special focus on high-risk individuals.

Open Communication About Reproductive Health Is Associated With Comprehensive HIV Knowledge and a Non-stigmatising Attitude Among Indonesian Youth: A Cross-sectional Study.

OBJECTIVES: Human immunodeficiency virus (HIV) prevention among youth seems under-prioritised compared to other key populations. HIV knowledge and stigma are important parts of HIV prevention. To inform HIV prevention among youths, this study quantitatively analysed the associations between open communication regarding sexuality and sexual health, comprehensive HIV knowledge, and non-stigmatising attitudes in Indonesia. METHODS: This study used data from the Indonesian Demographic and Health Survey (IDHS) 2017. The analysis included unmarried men and women aged 15-25 years old. Comprehensive HIV knowledge and a stigmatising attitude were defined according to the IDHS 2017. Open communication about sexuality and sexual health was defined as the number of people with whom participants could openly discuss these topics in their direct network of friends, family, and service providers, with a scale ranging from 0 to a maximum of 7. Primary analysis used binomial logistic regression with weighting adjustments. RESULTS: The final analysis included 22 864 respondents. Twenty-two percent of youth had no one in their direct network with whom to openly discuss sexual matters, only 14.1% had comprehensive HIV knowledge, and 85.9% showed stigmatising attitudes. Youth mostly discussed sex with their friends (55.2%), and were less likely to discuss it with family members, showing a predominant pattern of peer-to-peer communication. Multivariate analysis showed that having a larger network for communication about sexuality and sexual health was associated with more HIV knowledge and less stigmatising attitudes. CONCLUSIONS: Having more opportunities for open sex communication in one's direct social network is associated with more HIV knowledge and less stigmatising attitudes.

Comprehensive Travel Health Education for Tour Guides: Protocol for an Exploratory Sequential Mixed Methods Research.

BACKGROUND: Tourists are at risk of experiencing health problems during their travel. However, even though tour guides have the potential to become travel health promoters, their participation has not been optimal. OBJECTIVE: This study aims to develop a comprehensive travel health education model to help tour guides improve health information delivery to tourists. METHODS: This is an exploratory sequential mixed methods research. The first phase consisted of a qualitative study with an informed grounded theory design. In-depth interviews were carried out with tour guides from all language divisions and policymakers of the Indonesian Tour Guide Association Bali Branch or Himpunan Pramuwisata Indonesia Daerah Bali (HPI Bali). The interview guidelines were developed based on the theory of planned behavior and identity theory. Qualitative data were analyzed thematically. In the interim phase, a travel health education model and questionnaire were developed based on the qualitative findings. The initial model and its instruments were finetuned after consultation with travel medicine and health promotion experts. Furthermore, the validity and reliability of the questionnaire were tested on 30 tour guides. The second phase consisted of a quantitative study with a randomized pretest-posttest control group design. A total of 76 tour guides in the intervention group received comprehensive travel health education, while 76 in the control group received no specific intervention. Outcome variables (ie, attitudes, subjective norms, perceived behavioral control, actual behavioral control, role identity, and behavioral intention) were measured at baseline (T0), after the online training (T1), before information sharing via WhatsApp (T2), a month after the start of the WhatsApp intervention (T3), and at the end of the WhatsApp intervention (T4). The mean difference of each outcome variable before and after the intervention will be compared between the intervention and control groups. Thereafter, the quantitative and qualitative findings will be integrated into a joint display. RESULTS: The qualitative phase was conducted through in-depth interviews with 21 informants who included tour guides and policymakers from HPI Bali from May to June 2021. The education model, educational materials, and questionnaire were developed based on the qualitative findings and consultation with experts. The education model consists of online training and information sharing through WhatsApp and was trialed with tour guides from November 2021 to February 2022. As of April 2022, this study is in the quantitative data analysis stage. CONCLUSIONS: A travel health education model was developed based on qualitative findings and consultation with experts. The model was tested with tour guides, and a series of self-administered questionnaires were completed. This study is in the quantitative data analysis stage and will continue by integrating qualitative and quantitative findings into a joint display. TRIAL REGISTRATION: ClinicalTrials.gov NCT04961983; https://clinicaltrials.gov/ct2/show/NCT04961983.

Health Beliefs and Socioeconomic Determinants of COVID-19 Booster Vaccine Acceptance: An Indonesian Cross-Sectional Study.

INTRODUCTION: The threat of new SARS-CoV-2 variants indicates the need to implement COVID-19 vaccine booster programs. The aim of this study was to identify the level of booster acceptance and its determinants. METHODS: A cross-sectional online survey was conducted in Jakarta and Bali, Indonesia. Booster acceptance was divided into three categories: non-acceptor, planned acceptor, and actual acceptor. The primary independent variables were health beliefs, media influence, and trust in authoritative sources. Other covariates included demographics, socioeconomic status, and COVID-19 history. A primary analysis was conducted through multinomial logistic regression. The effects of the hypothetical situations on booster acceptance were tested using the Wilcoxon signed-rank test. RESULTS: The final analysis included 2674 respondents with a booster acceptance rate of 56.3% (41.2% planned acceptors, 15.1% actual acceptors). Health beliefs, social media influence, and trust in authoritative information sources were identified as determinants for planned and actual booster acceptance. Socioeconomic status indicators were also identified as determinants for actual booster acceptance. Booster acceptance was increased in hypothetical scenarios involving booster requirements for work, travel, and accessing public places. CONCLUSIONS: Booster acceptance was found to be lower than the predicted primary vaccine acceptance prior to its launch. The acceleration of booster coverage requires strategies that leverage health beliefs and focus on people with a lower socioeconomic status.

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.

The short-term effects of COVID-19 on HIV and AIDS control efforts among female sex workers in Indonesia.

BACKGROUND: The COVID-19 pandemic has raised concerns as to its impact on other health programs. One program that appears particularly vulnerable is HIV and AIDS. We undertook an assessment of COVID-19 impact on HIV control efforts in Indonesia for a sub-population that has received little attention in the global literature-female sex workers (FSW). METHODS: The study was undertaken in 23 National AIDS program priority districts. Four sources of monthly data during January-July 2020 were considered. COVID-19 infection data were extracted from national and district surveillance systems. Combination prevention program outputs were reported by civil society organizations (CSOs) providing community support services to FSW. These organizations also undertook monthly scans of levels of commercial sex activity and HIV testing availability. We also considered data from an ongoing HIV community screening trial. The primary mode of analysis entailed comparisons of levels and trends of indicators from the four data series. RESULTS: Commercial sex activity was severely curtailed in April-May in many districts. While recovering to pre-COVID-19 levels in "Localization" areas, the number of active FSW in July was one-third below that in February. HIV testing service availability declined by 50% at health facilities before recovering slowly, while mobile clinic services largely ceased during April-June. Numbers of FSW reached, condoms distributed, FSW tested for HIV, HIV cases detected, and FSW starting treatment all declined precipitously in April/May but had largely recovered to pre-COVID-19 levels by July. We found only a temporary dip in treatment initiation rates among HIV positive FSW and no discernible impact on treatment retention. The HIV community screening trial data revealed significant demand for HIV testing among FSW that was not being met even before the onset of COVID-19. CONCLUSIONS: COVID-19 has had at least short-run economic effects on FSW and the national response to HIV and AIDS targeting FSW. However, the effects appear to have been cushioned by community-based services and support in study districts. The findings make a compelling case for the expansion of community-based services irrespective of the future trajectory of COVID-19. As COVID-19 has not yet been contained, the trajectory of economic activity and service delivery is uncertain.

HIV self-testing for men who have sex with men: an implementation trial in Indonesia.

We investigated oral fluid testing (OFT) among men who have sex with men (MSM) to increase HIV testing in Bali, Indonesia. We distributed OFT in January-December 2018 to 813 MSM in Bali. Supervised testing was offered first, and unsupervised was only offered to an individual who declined supervised testing. Included participants were MSM who did not have a HIV test result in the last 6 months and declined referral to facility-based testing. Of 813 participants, 93% (765/813) chose supervised testing and 7% (57/813) unsupervised. The OFT result was reactive for 83 (10%), of whom 52/83 (63%) underwent confirmatory testing with 47/52 (90%) found HIV positive. Among confirmed positives, 43/47 (92%) were enrolled in HATI study cohort, of whom 39 (91%) started treatment. At six months follow up, 25/39 (64%) of those initiating treatment were still receiving it, and all had a suppressed viral load. There was an increase in the mean number of MSM tested for HIV by HATI study Bali sites per month, from 100 (95%CI: 85-112) before the intervention to 152 (95% CI: 130-172) during the intervention. Our findings show the potential utility of offering HIV oral fluid self-test kits to scale-up HIV testing in MSM.Trial registration: ClinicalTrials.gov identifier: NCT03429842.

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.

A Health Belief Model-Based Motivational Interviewing for Medication Adherence and Treatment Success in Pulmonary Tuberculosis Patients.

Medication adherence behavior plays a central role in the success of tuberculosis (TB) treatment. Conventional motivation is not optimal in strengthening long-term medication adherence. A motivational interviewing (MI) communication motivation model based on the Health Belief Model (HBM) was designed with the main objective of improving medication adherence and treatment success. This study used an experimental design with a randomized posttest-only control group design. The intervention and control groups consisted of 107 TB patients each, who were selected by random cluster sampling. The study was conducted from November 2020 to June 2021 at 38 public health centers in Bali Province. The HBM-based MI model intervention was given in seven counseling sessions, pill count percentages were used to measure medication adherence, and treatment success was based on sputum examination results. Logistic regression was used to assess the effect of the intervention on medication adherence and treatment success. Logistic regression analysis showed that MI-based HBM and knowledge were the most influential variables for increasing medication adherence and treatment success. Medication adherence was 4.5 times greater (ARR = 4.51, p = 0.018) and treatment success was 3.8 times greater (ARR = 3.81, p < 0.038) in the intervention group compared to the control group, while the secondary outcome of knowledge of other factors together influenced medication adherence and treatment success. The conclusion is that the HBM-based MI communication motivation model creates a patient-centered relationship by overcoming the triggers of treatment barriers originating from the HBM construct, effectively increasing medication adherence and treatment success for TB patients, and it needs further development by involving families in counseling for consistent self-efficacy of patients in long-term treatment.

Estimation of Potential HIV Transmission Risk in Recent Anal Intercourse Events among Men Who Have Sex with Men and Transgender Women in Bali, Indonesia.

In recent years, prevalence of Human Immunodeficiency Virus (HIV) has increased substantially in Bali, Indonesia, in men who have sex with men (MSM) and transgender women, known locally as 'waria'. There are limited behavioural data in this population. We conducted a behavioural survey of MSM/waria in Bali in March-April 2018. Respondents were primarily recruited by HIV outreach workers. Respondents reported details about anal intercourse events with their last male/waria romantic partner and/or last male/waria casual partner (respondents could report on both if relevant). Statistical significance was tested with generalised estimating equations. Among 709 participants, median age was 27 (interquartile range = 24-31), and 92.1% were male and 7.9% were waria. One-third were born in Bali. Overall, 85.9% had ever had an HIV test; 55.1% reported being HIV-negative, 15.0% HIV-positive, and 30.0% had unknown serostatus. Most (86.5%) reported sex with men, 9.5% with waria, and 20.0% with women in the previous 6 months. Respondents described 703 anal intercourse events (397/306 with romantic/casual partners, respectively; 191 reported on both). Over half (56.5%) of the events were protected by condoms and 7.3% by biomedical prevention (2.6% by PrEP in either partner, 4.7% by HIV treatments in either partner). Thus, 36.3% of events involved unprotected condomless anal intercourse (40.8%/30.4% in romantic/casual partners, respectively). In multivariate analysis, unprotected condomless anal intercourse events were associated with romantic partners (p < 0.001), being born in Bali (p = 0.002), lower education (p = 0.013), believing that withdrawal before ejaculation is effective (p < 0.001), liking to use withdrawal (p = 0.021), and not liking condoms (p < 0.001). One-quarter of events had potentially reduced HIV transmission risk through non-condom-based risk reduction strategies, while 11.1% had no potential risk reduction. Events presenting the highest potential risk of HIV transmission were more commonly reported by respondents born in Bali.

Web-Based Multifaceted Approach for Community-Based HIV Self-Testing Among Female Sex Workers in Indonesia: Protocol for a Randomized Community Trial.

BACKGROUND: New HIV infections in Indonesia continue to be concentrated among key populations, including female sex workers (FSWs). However, increasing HIV testing among this subpopulation remains a challenge, necessitating exploration into alternative testing modalities. OBJECTIVE: This study aims to assess whether the addition of an oral fluid testing option in community settings would increase the rate of HIV case identification among FSWs. Because the study was implemented early in the outbreak of COVID-19 in Indonesia, a secondary objective is to assess approaches and tools for implementing both community outreach and community HIV screening for FSWs during pandemic conditions. METHODS: We undertook a community-based randomized trial in 23 national priority districts in which community outreach services were being provided. Community-based screening using an oral fluid-based rapid test was added to the community outreach standard of care in intervention districts with clients having the option of performing the test themselves or being assisted by outreach workers. A web-based system was created to screen for eligibility and collect participant data and test results, facilitating the process for both unassisted and assisted participants. Participants with reactive screening results were encouraged to undergo HIV testing at a health facility to confirm their diagnosis and initiate antiretroviral treatment as needed. Multiple means of recruitment were deployed including through outreach workers and social media campaigns. RESULTS: Of the 1907 FSWs who registered, met the eligibility criteria, and gave consent to participate, 1545 undertook community oral fluid test (OFT) screening. Most (1516/1545, 98.1%) opted for assisted screening. Recruitment via social media fell far short of expectations as many who registered independently for the OFT because of the social media campaign did not identify as FSWs. They were eventually not eligible to participate, but their interest points to the possibility of implementing HIV self-testing in the general population. The successful recruitment through outreach workers, facilitated by social media, indicates that their roles remain crucial in accessing FSW networks and improving HIV testing uptake. CONCLUSIONS: The addition of HIV self-testing to the standard of care supported by a web-based data collection system was able to increase HIV case identification among FSWs in intervention districts. The high satisfaction of OFT users and the interest of the general population toward this alternative testing modality are promising for scaling up community HIV screening nationally. TRIAL REGISTRATION: ClinicalTrials.gov NCT04578145; https://clinicaltrials.gov/ct2/show/NCT04578145. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/27168.

Prevalence of Depression, Anxiety, and Stress Among Repatriated Indonesian Migrant Workers During the COVID-19 Pandemic.

Introduction: Repatriated Indonesian migrant workers are vulnerable to developing serious mental health problems during the COVID-19 pandemic. This study aimed to assess the prevalence and associated factors of depression, anxiety, and stress among these populations during the COVID-19 pandemic. Methods: Guided by the health belief model, a cross-sectional study design was employed among 335 participants, and primary data were collected through an online survey. Measured using DASS-21, anxiety, depression, and stress were the dependent variables. We performed descriptive and inferential statistical analyses-logistic regression was used to predict independently associated variables. STATA was used to execute all data analyses. Results: The prevalence of depression, anxiety, and stress among repatriated Indonesian migrant workers were 10.15, 9.25, and 2.39%, respectively. The risk of anxiety and depression was low among those aged 21-30 years old, who had completed a university degree, were married, and had quarantined for 14 days. Conversely, the risk of anxiety and depression was high among those who had bad perceived health status, high perceived susceptibility, and negative stigma perception. Conclusion: The prevalence of depression, anxiety, and stress among repatriated Indonesian migrant workers was relatively low compared to the general population. The risk of anxiety and depression was low among young people, educated people, and those under effective quarantine, but the risk was high among those who had negative perceptions about their health, stigma, and susceptibility to the disease.