Feasibility, acceptability and impact of an innovative, tailored HIV prevention intervention for MSM at high-risk of HIV in Indonesia.

Despite significant progress in HIV management and prevention, 1.8 million new HIV infections were recorded worldwide in 2016, with many settings observing increasing numbers of new HIV infections, predominantly in key affected populations. Despite the development of revolutionary evidence-based HIV prevention interventions, combating the HIV/AIDS epidemic still remains a major global health challenge. Key populations groups, namely, men who have sex with men (MSM), transgender people, people who inject drugs, prisoners and sex workers, are at greatest risk of being affected by HIV and they frequently lack adequate access to appropriate services. Stigma and discrimination are among the primary barriers to HIV prevention, treatment and support; key populations in particular face significant stigma in many settings.
Indonesia has the third largest number of people living with HIV (PLWH) in Asia and the Pacific; with 620,000 PLWH and 48,000 new infections recorded in 2016. Key populations are most affected and at greatest risk of HIV. In 2016, HIV prevalence estimates were 25.8% in MSM (compared to 8.5% in 2011), new infections are increasing significantly and rapidly in MSM in Indonesia but more reportedly stable in other key populations. In major cities Denpasar in Bali and Jakarta, nearly one in three MSM are infected with HIV.

Indonesia is observing worsening stigma and discrimination against MSM, transgender people and PLWH which is significantly slowing the country's HIV response. This rise in anti- LGBT rhetoric adds great challenges of allowing a human rights-based approach to sexual health care and HIV prevention to hard-to-reach key populations and counteracting HIV prevention and treatment targets. Innovative and sensitive methods of engaging at risk communities to improve access and uptake to services, without increasing their vulnerability to abuse, are greatly needed. Tailored mobile phone, internet-based programs may be a critical way to engage key populations like MSM who are understood to be a technologically/mobile smartphone literate population.

We propose a tailored, innovative HIV prevention model to strengthen HIV prevention services and accelerate the response to a growing burden of HIV in MSM, in Indonesia. A model appropriately adapted through at-risk population engagement, from one that has demonstrated success in dramatically reducing new HIV infections in MSM in London.
We propose assessing the feasibility, acceptability and impact of;
(1) a mobile-phone text-message based digital-health HIV risk-reduction intervention, tailored to the MSM population at high risk of HIV in Indonesia; developed through at-risk population engagement and needs assessment.
(2) integrating point of care/rapid HIV and HIV monitoring diagnostics in an existing sexual-healthcare service, to also determine the proportion of very early HIV acquisition in new HIV diagnoses to further guide HIV treatment and prevention.
(3) integrating evidence-based prevention interventions - immediate antiretroviral treatment as prevention to all individuals recently diagnosed/living with HIV and oral Pre-Exposure Prophylaxis provision (a proven HIV preventative medicine) to MSM at risk of HIV in an existing sexual-healthcare service.

Can the prevention model have an impact on; increasing HIV testing coverage in MSM at risk of HIV; reduce undiagnosed and late diagnoses of HIV infection in this at-risk population; have an impact on reducing new HIV infections and improve retention in HIV care and antiretroviral treatment (ART) adherence in people diagnosed and living with HIV. Ultimately to contribute to the UNAIDS/WHO goals in ending AIDS as a global public health threat in this region, to aid disease prevention and improve health in this population and consequently have economic benefits for the country as a whole.

In Indonesia 620,000 people living with HIV (PLWH) and 48,000 new HIV infections were reported in 2016. Key populations are most greatly affected and at highest risk; HIV prevalence estimates were 25.8% in MSM (compared to 8.5% in 2011); new infections are increasing significantly and rapidly in MSM. Indonesia is observing worsening stigma and discrimination against MSM, transgender people and PLWH which is significantly slowing the country's HIV response. This adds great challenges of allowing a human rights-based approach to HIV prevention to these hard-to-reach populations. Innovative and sensitive methods of engaging at-risk communities to improve access and uptake to services, without increasing vulnerability, are greatly needed.
We propose a tailored, innovative HIV prevention model to strengthen HIV prevention services and accelerate the response to a growing burden of HIV in MSM.
We propose a mixed methods prospective observational cohort study to assess feasibility, acceptability and impact of;
(1) a HIV risk-reduction mobile-phone text-message based digital-health intervention, tailored to the MSM population at high risk of HIV in Indonesia; developed through at-risk population engagement and needs assessment.
(2) integrating & scaling up point of care (POC) HIV antibody/antigen testing; POC HIV viral load and RITA testing to detect diagnoses in primary infection in an existing sexual-healthcare service.
(3) integrating evidence-based prevention interventions-immediate ART as prevention to all individuals recently diagnosed/living with HIV and PrEP provision to at-risk individuals in an existing sexual-healthcare service.
Can the model have an impact on;(1) increasing HIV testing coverage in MSM at-risk of HIV; (2) reduce undiagnosed HIV infection and; (3) reduce late diagnoses of HIV in this at-risk population; (4) have an impact on reducing HIV incidence in this population, (5) improve retention in care and ART adherence in PLWH.

The proposed intervention is designed to promote health, prevent disease and enhance the quality of the target population's sexual health and well-being, particularly at a time when the target population experiencing increasing discrimination, abuse and are affected by increasing HIV infections.
We will use focus-group sessions to engage the at-risk target population to better understand high risk behavior in the current environment in Indonesia and what increases vulnerability, social exclusion and dis-empowerment, and what information and additional support can reduce this - to develop a innovative digital and mobile phone/web based method to provide tailored, accepted HIV risk- reduction information and integrate at greater scale evidence based HIV prevention methods to accelerate the HIV response in Indonesia.

In addition to the academic beneficiaries outlined, independent digital health companies may also benefit from this research with regards to whether digital methods can be tailored to different populations to improve disease prevention and promote health/well-being.
We are interested and keen to present data and outcomes to differing academic and relevant independent healthcare innovation forums including Digital Health and healthcare Innovation forums and non-infectious disease international conferences where appropriate.

Beneficiaries include all stakeholders, including the sexual health and HIV study clinic staff, and in general the local Balinese population, local ministry of health/Government, policy makers and Indonesian society as a whole and the national (Indonesian) HIV clinical community.

Translating an appropriately adapted and tailored model involving digital healthcare innovation by target population engagement, understanding risk behavior and complex drivers of risk behavior at this current challenging time of increasing HIV infections in MSM but within an increasingly stigmatized environment, can be used to inform local government and policy makers within Indonesia and Asia.

This research will in our opinion directly impact on Bali's and consequently Indonesia's health (accelerating the HIV response), wealth by creating health related savings (reduced HIV/AIDS mortality and morbidity/reduced late HIV diagnoses), and culture by empowering vulnerable at-risk groups to be better informed of their risk, access to HIV prevention, using innovative platforms they show existing high engagement in.
This research can also guide and inform researchers and industry on further developing tailored, digital health methods disease prevention.

We will also be training staff within the sexual health and HIV study site which will provide them with skills they can take forward when managing patients and offering HIV and sexual health prevention advice even after the end of the study. Having been a HIV clinician in diverse settings for over 10 years I believe the first consultation with a newly HIV diagnosed individual has paramount importance with regards to how they go on to perceive themselves, how empowered they are with information and hope for the future and how well they manage their condition, adhere to ART and to their general wellbeing.
Although working with an Indonesian team, I will myself be learning Indonesian as soon as I arrive in order to better and more effectively communicate with the target population subjects and with staff. We aim to share knowledge and skills that will benefit research teams from both countries after the end of the research project.