Indonesian HIV care cascade scheme has mixed results

Early results from a government-run initiative to improve Indonesia’s HIV treatment cascade suggests it has increased the number of people diagnosed with HIV who enrol in HIV care and stay in it. But it has not increased the proportion of people who begin treatment, nor has it reduced deaths among people living with HIV.

The Indonesian government introduced the Strategic Use of Antiretroviral Therapy (SUFA) initiative in 2013 to improve the impact and reach of HIV treatment. According to UNAIDS, HIV infections have fallen by 27% in Indonesia in the last decade, but AIDS-related deaths have increased by 60%. This is due to a lack of testing and treatment, with only 51% of people living with HIV aware of their status and only 33% receiving antiretroviral treatment (ART) as of 2018.

Before SUFA, pregnant women, people with tuberculosis (TB), key populations, people with a sexually transmitted infection and their partners, and people displaying symptoms of undiagnosed HIV were offered HIV testing. SUFA has expanded this to include people with hepatitis, prisoners, men in high-risk groups, such as truck drivers, and the partners of people living with HIV.

SUFA has also changed its treatment criteria. Now, female sex workers, men who have sex with men, transgender people, people who inject drugs, mixed-status couples, pregnant women, and people with TB can start treatment immediately, regardless of their CD4 count. Previously, only people at an advanced stage of HIV could start treatment straight away.

SUFA has also changed the type of ART regimen offered, from a twice-daily to a once-daily pill.

To assess SUFA’s impact, researchers analysed data from HIV clinics in the cities of Medan and Batam, where SUFA was implemented in 2013 and 2015, respectively. 

Around 2,300 adults were followed through the HIV treatment cascade, roughly half in the year before SUFA was introduced and half the year after.  

SUFA significantly increased retention in care by 27%, most likely because of the switch to a simpler ART regimen. It also increased the linkage to care rate by 11%. This is because, under SUFA, people can now enrol in HIV care at the same health facility where they are diagnosed.

But SUFA failed to reduce deaths among people living with HIV, which remained at around 12% in both periods, or the proportion of those eligible for treatment who went on to receive it - around 70% started ART in both periods.

Although SUFA expanded ART eligibility by 13%, most people accessing ART under SUFA would have also been eligible under the old policy. This is because, in both periods, the vast majority of people began treatment at an advanced stage of HIV (96% before SUFA and 89% post-SUFA). SUFA’s main testing strategy, which targets people already in hospital and clinical settings, is a major reason for this as it tends to miss people living with HIV who are in earlier, potentially asymptomatic, stages. This suggests community-based testing and self-testing are needed alongside facility-based testing in order for key populations to fully benefit from the new test and treat criteria.

Late diagnosis could also explain why SUFA has not improved the death rate among people living with HIV.

The reasons as to why around 30% of those eligible for treatment are still not receiving it were not explored. But it is likely that issues such as transportation costs and stigma remain persistent barriers.

The study suggests scaling up SUFA across Indonesia is justified. But diagnosing people living with HIV much earlier through significantly improved testing strategies and addressing the social and economic barriers to beginning treatment will be crucial to further improvement.