Care Disengagement Prevention in Treatment Naive Indonesian Living with HIV - Summary Indonesia is facing a looming HIV crisis. In Asia, the population size of people living with HIV (PLH) in Indonesia is second only to that in India and China. Currently, HIV epidemics disproportionally impact a handful of key populations marginalized within its society. One of the most critical reasons for the increasing mortality among people living with HIV (PLH) in Indonesia is their dismal engagement in HIV treatment. According to recent estimates from UNAIDS, while there were an estimated 540,000 PLH in Indonesia in 2022, only 179,659 (33.27%) were reportedly on antiretroviral therapy (ART), 36,821 (6.82%) were regularly tested for viral load, and 33,395 (6.18%) achieved viral suppression. The majority of Indonesian PLHs are lost across the HIV care continuum, even after the government's Strategic Use of Antiretroviral Therapy (SUFA) program launched in 2013. The reasons for this failure to retain PLH in care include insufficient knowledge and limited accessibility and affordability of care, but the most prominent barrier is fear of stigma. Stigma not only deters PLH from seeking care but also strains patient-provider relationships. Indeed, stigma is considered the greatest barrier to ending HIV in Indonesia. As the world’s largest Muslim-majority country, accounting for 13% of the global Muslim population, Indonesia's cultural meanings surrounding HIV, especially with respect to gender, sexuality, and substance use, are rooted in the local “religious-familial” complex. As such, there is an urgent call for culturally adapted interventions to help curb HIV related stigma among PLH to promote their treatment engagement. The purpose of this study is to culturally adapt an intervention to reduce stigma and prevent treatment disengagement among Indonesian PLH, and evaluate its feasibility, acceptability, and primary efficacy. The scientific premise is that HIV stigma remains rampant in Indonesia and has severe negative impacts on treatment engagement among Indonesian PLH. This study addresses the critical need to increase treatment engagement among Indonesian PLH and retain PLH in care by addressing the stigma surrounding HIV. Study aims are: 1. Utilize the ADAPT-ITT model to culturally adapt an evidence-based stigma reduction intervention using in-depth interviews with 30 Indonesian PLHs and two focus groups with stakeholders (n=12) while gathering data on stigma experiences and HIV care engagement. 2. Test the feasibility, acceptability, and preliminary efficacy of the adapted intervention for stigma reduction and care engagement, through use of a stratified, waitlisted randomized-controlled design with 80 Indonesian PLHs with a follow-up of 26 weeks. HIV related stigma can have profound negative impacts on PLH’s engagement across the care continuum, especially in resource-limited settings with tenacious religious-familial cultural norms. This study would be one of the first studies to promote treatment engagement by addressing HIV related stigma linked to the local religious-familial complex in a Muslim-majority country.
