Indonesia: tackling HIV in one of the world’s fastest-growing epidemics

A prospective study that recruited a significant proportion of people newly diagnosed with HIV in four locations in Indonesia and offered them immediate antiretroviral therapy (ART) found that only 35% of them were still on ART and virally suppressed at the end of the year.

The study, published in The Lancet HIV, draws attention to challenges with the HIV care cascade for men who have sex with men, sex workers, transgender women and people who inject drugs. It has now moved on to a second phase to find out what interventions will improve retention and viral suppression in these key populations most at risk of HIV.

The Indonesian epidemic

Indonesia, the world’s fourth most populous country, also has the fourth largest number of new HIV infections per year: the World Health Organization estimates that 73,000 people are infected per year, only behind China, India and Russia. It is also the only country in the Asia-Pacific region where HIV prevalence is still increasing, up from very few people with HIV in 2000 to an estimated 630,000 now. HIV prevalence is still low in the general population at 0.5% but is estimated to be 39% in people who inject drugs, 12.8% in men who have sex with men, 7.4% in transgender women and 7.2% in female sex workers.

It was estimated that only 10-20% of Indonesians with HIV were receiving ART at the end of 2016. So the investigators decided to prospectively evaluate strategies to improve the cascade of HIV care in members of key populations.

The study and its participants

The study was conducted in the two cities of Bandung and Yogyakarta and the island of Bali, each of which have high prevalence and clinical services with experience of working with key populations. The populations selected for the study were men who have sex with men (MSM), female sex workers (FSW), transgender women (known as waria in Indonesia), and people who inject drugs (PWID). Because the study failed to find many PWID, a fourth arm enrolling only PWID was added in the capital, Jakarta, and they could already be diagnosed as long as they had not previously taken ART.

The study was based in hospital centres, which then invited local clinics to participate. As a result, 77% of participants were diagnosed and 67% had their baseline ART assessment visit at primary care centres. Slightly over half of these were government-run local health clinics, known in Indonesia as Puskesmas, and the rest at NGO-run private clinics. Not all the Puskesmas and NGO clinics prescribed ART, and in these cases people were referred to clinics that did.

The study enrolled 831 participants. These formed a high proportion of people diagnosed at the study sites over the trial period.

Because of the Indonesian reporting system, it is impossible to say what proportion of newly diagnosed people this represents in the localities and whether that differs from population to population, but the researchers estimate that in Bali, they recruited 70% of members of key populations who had been diagnosed across the island in the study period. The Indonesian Health Ministry estimates that only 44% of people with HIV in the country have been diagnosed. 

Of the 831 enrolled, 77% were MSM, 14% were FSW, 6% were PWID and 3% were waria. There were some differences between the groups: for instance, MSM tended to be slightly younger than the median age of 27 years and waria and PWID were older (34 years). FSW and waria were more likely to lack secondary education, with only 26% and 44% having attended high school, compared with 86% of MSM.

One cause for concern was that a high proportion of those diagnosed had advanced HIV disease and had presumably been infected for several years. At diagnosis, 73% of participants had a CD4 count below 350 cells/mm³ and 15% had an HIV-related condition.

Results

The ‘cascade’ in the study looks like this. At the end of the first year:

• 85% had been linked to care;
• 73% (86% of those linked to care) started ART;
• 55% (75% of those starting ART) remained in care, which meant having at least one follow-up appointment in any three-month period;
• 39% (71% of those who remained in care) had the required viral load test between five and nine months after study initiation;
• 35% (48% of those who started ART, and 64% of those retained in care) were virally suppressed (below 200 copies/ml).

The researchers do not have data on undiagnosed infection. However, using the the health ministry's estimate that 44% of people with HIV are diagnosed, the proportion of all people living with HIV who are virally suppressed would be 15% – identical to the ministry’s own figure.

Viral suppression rates were lower in non-MSM: they were 26% in waria, 23% in FSW, and 20% in PWID, compared with 39% in MSM.

Education was a significant factor in achieving undetectability; 48% of study recruits with degree-level education achieved viral suppression compared with 17% with primary education or none.

Twenty-seven per cent of participants were diagnosed at clinics that did not prescribe ART. These people were considerably less likely to reach viral suppression.

While 87% of people tested in a clinic offering ART started it, only 35% started if they had to be referred to a different centre for treatment. The figures for viral suppression were respectively 47% and 13%. So people were more than three times more likely to become virally suppressed if they did not have to travel to another clinic to get ART.

‘Loss to follow-up’ (LTFU) over the course of the whole study was defined as failing to attend an appointment in a six-month period. LTFU was higher in FSW, PWID and waria than in MSM. It was 60% lower in the university educated.

Of note, although 83% of participants were given an efavirenz-containing single tablet, LTFU was 45% lower in people taking non-efavirenz-based regimens.

Where were the weak points in the cascade?

One thing cascades can do is to show where the weak points are in the care continuum. In the case of MSM and FSW, the biggest drop came between starting ART and being retained in care: 16% of MSM and 20% of FSW who started ART were not retained in care according to the definition of the study, i.e. attending three-monthly appointments.

However, while this patient factor was important, so was the provider factor of whether viral load testing was done, and this was the biggest failing in the care continuum for waria and PWID. Twenty-six per cent of waria and 33% of PWID who were retained in care failed to receive a viral load test, as did 18% of FSW and 14% of MSM.

For those who did stay in care, it was the absence of viral load testing rather than adherence that contributed to the low suppression levels in the final cascade step. This is underlined by the fact that the viral suppression rate was excellent in those who were tested: it was 96%, and this varied little between groups.

Although a qualitative analysis from this cohort has not yet been published, the researchers do mention that earlier qualitative research in Bali had uncovered that staff competency and workload, the inability to do all diagnostic tests recommended, and fear of stigma among patients attending local facilities all served as barriers to integrating ART into the Puskesma primary-care system.

The study offers an interesting insight into the barriers faced by some middle-income countries like Indonesia in tackling their HIV epidemics and it will be interesting to see if the interventions introduced in the second year of the study produce better viral suppression rates.