A targeted combination intervention approach for acute HIV infections to curb the explosive epidemic among high-risk populations in Indonesia

There is an uncontrolled HIV epidemic among key populations at highest risk of HIV exposure in Indonesia, including men who have sex with men (MSM), transgender people and sex workers. Innovative, context-specific approaches are urgently needed to break HIV transmission. Studies in Europe and the Americas have shown that acute HIV infections (AHI) are a key driver of onward transmissions among MSM. Diagnosing HIV infection in the acute phase is crucial for early care engagement, preservation of health by immediate treatment, and prevention of onward transmission at the earliest possible moment. However, diagnosing AHI is challenging due to the rather nonspecific symptoms and lack of appropriate testing using the available standard serological tests. Intervention models in high-income settings including AHI screening algorithms based on risk scores and point-of-care HIV viral load testing have been shown to improve AHI identification, enabling direct linkage to care and immediate initiation of antiretroviral therapy (ART). Furthermore, they allow for closer engagement with high-risk populations through partner notification services, and community education on pre-exposure prophylaxis (PrEP), to enhance community preparedness for when PrEP will be introduced in Indonesia.

Our research proposal addresses one overarching question: can we curb the rapidly growing HIV epidemic among key populations in Indonesia by implementing a same-day diagnosis and treatment pathway targeting persons with AHI, coupled with a behavioural intervention to promote AHI screening and partner notification services?

Our research proposal will investigate an evidence-based, tailored approach to implementing a screening algorithm based on symptom and risk behaviour and point-of-care viral load testing in three community sexual health clinics in Jakarta and Bali, combined with community outreach approaches to enhance AHI testing. All newly diagnosed AHI patients will be linked to care and offered same-day ART initiation. The uptake, yield, feasibility and acceptability of this innovative care pathway will be evaluated using both qualitative and quantitative analytical methods. Ultimately, mathematical modelling and cost-effectiveness analysis will be used to estimate what potential population impact this intervention may have on curbing the HIV epidemic in Indonesia if rolled out at scale. This implementation science project will provide critical evidence to Indonesian health policy makers.

The research team includes international researchers from UK, Kenya and The Netherlands who have been at the forefront of developing strategies to improve AHI screening and management in various settings, and the leading Indonesian HIV researchers, with strong linkages to clinical practice, key population communities and governments across Indonesia. Local research capacity building is an important aspect of the project; knowledge exchange, local leadership and ownership, training and conferences will help build local expertise on implementation research as well as innovative HIV care models. Ultimately, we anticipate the work will have substantial impacts within Indonesia and in other low-middle income countries (LMIC) on HIV epidemics, resulting in strengthened health service delivery, reduced new HIV infections and deaths, and health costs.

There is an uncontrolled HIV epidemic among key populations at highest risk of HIV exposure in Indonesia, including men who have sex with men (MSM), transgender people and sex workers. Innovative, context-specific approaches are urgently needed to break HIV transmission. In high-income countries, multifaceted intervention models based on detection of individuals with acute HIV infection (AHI), using symptom and behaviour risk scores and point-of-care HIV viral load testing, have been successful in curbing local HIV epidemics, by enabling direct linkage to care and immediate initiation of antiretroviral therapy (ART). There is a thus a strong impetus to tailor those successful models to explosive epidemics in low- and middle-income countries (LMIC).

Our research proposal will address one overarching question: can we curb the rapidly growing HIV epidemic among key populations in Indonesia by implementing a person-centered AHI diagnosis and treatment pathway?

The proposed research will adopt these successful evidence-based intervention models to the Indonesia context. We will implement an AHI care pathway in three community sexual health clinics serving key populations in Jakarta and Bali, combined with innovative community outreach to promote AHI screening and partner notification services. The uptake, yield, feasibility and acceptability will be evaluated using qualitative and quantitative analytical methods. Ultimately, mathematical modelling and cost-effectiveness analysis will be used to estimate the population impact of this intervention strategy if rolled out at scale.

The proposed research will strengthen local capacities to adopt implementation science approaches to improve HIV service delivery, reduce new HIV infections, death and health costs, and provide critical evidence to health policy makers in Indonesia and in other LMIC.