Only 35% of key populations in Indonesia are on effective HIV treatment
Landmark research from Indonesia reveals a missed opportunity to immediately link key affected populations living with HIV to treatment services.
Just 35% of key affected populations living with HIV in an Indonesian cohort were virally suppressed – that is, where HIV treatment reduces the amount of virus in the body to very low levels, which is the ultimate goal of HIV treatment programmes.
The findings were revealed in the first-ever study to measure the cascade of HIV care among female sex workers, gay and other men who have sex with men, people who inject drugs and transgender women (known locally as waria) in the Asia Pacific region.
The ‘treatment cascade’ measures the journey of a person living with HIV from diagnosis through to viral suppression and records the percentage of people living with HIV who are diagnosed, starting antiretroviral treatment (ART), retained in care, receiving a viral load test after six months, and are virally suppressed.
According to UNAIDS, Indonesia accounts for nearly a quarter (23%) of AIDS-related deaths and 18% of new infections in the Asia-Pacific region. HIV prevalence is also very high in key populations compared to the general population – 5.3% of sex workers, 25.8% of men who have sex with men, 28.8% of people who inject drugs, and 24.8% of transgender people are thought to be living with HIV.
A lack of reaching out to these groups with HIV prevention services is driving new infections in the country where 630,000 people were living with HIV in 2017.
In a study published in the Lancet this week, researchers enrolled 831 people newly infected with HIV belonging to these groups in four locations: Bali, Bandung, Jakarta, and Yogyakarta. Each location was serviced with a mix of primary care sites, hospitals and non-governmental organisation programmes, and each provider was selected because they already had HIV prevention and treatment programmes in place, as well as experience working with key affected populations.
Three-quarters (77%) of the participants were gay men, followed by sex workers (14%), people who inject drugs (6%) and waria (3%).
At every step along the treatment cascade people were lost – revealing very poor rates of retention and viral suppression. 85% of the participants attended an ART site after diagnosis and 73% of the participants started treatment. Just over half (55%) of the original participants were retained in care (i.e. had two visits to the health centre 90 days apart after ART initiation), while 39% had a viral load test at six months. But those who did remain in care and those who did have a viral load test had high rates of viral load suppression.
The data revealed that care retention rates were much better in places where participants could get tested and then immediately linked to treatment services, as opposed to locations where only testing was available . The researchers note that this is important evidence for integrating HIV testing and treatment into primary care services – which has been happening slowly.
They also found that having a higher education, i.e. those who had completed junior or senior year of high school or university-level education, had significantly higher rates of care retention. Interestingly, however, most of the study participants had good levels of education, with over half attending at least high school. In their discussion, the authors note that perhaps the study was, unknowingly, preferentially set up to appeal to those with more education, and more research may need to be completed to reach those who are not educated or do not come forward for testing.
Broken down, female sex workers were the least likely to start and remain in care – an alarming 43% of female sex workers did not return to care after they initiated ART, compared to 32% of waria, 24% of people who inject drugs, and 20% of gay men lost to care. The overwhelming majority of sex workers recruited were living in Bali, where an active civil society and outreach network exists for this group, so generalising outcomes from these may be more difficult for the rest of the country – particularly as the sex industry is characterised by stigma, mobility issues, andpoor education.
Older participants were also more likely to be virally suppressed than their younger counterparts – which suggests innovative technology solutions may be needed to reach this group.
In their discussion, the authors note, “With cascade of care parameters far worse than those needed to reach the global 90-90-90 commitment, much remains to be done. The participating sites in our study were overseen by highly experienced HIV clinical teams; as such, ART programme sites in other parts of the country where staff might be less experienced could be even further from reaching the target commitments.”
In the second phase of the study, which is underway now, researchers will explore different interventions to improve testing and ART adherence. The pilot will provide vital evidence to suggest interventions which can be brought to scale across the country to improve the HIV treatment cascade for key affected populations.