Client-centered enablers and persistent bottlenecks across Indonesia's HIV cascade: a multi-stakeholder qualitative...

Area of Science:

• Public Health
• Epidemiology
• Qualitative Research

Background:

• Indonesia's HIV epidemic disproportionately affects key populations.
• Existing policies and programs have not fully curbed HIV transmission.
• Understanding service delivery mechanisms is crucial for improving HIV care cascades.

Purpose of the Study:

• To examine how service design and implementation influence HIV cascade performance in Indonesia.
• To identify facilitators and barriers to effective HIV service delivery.
• To inform strategies for enhancing HIV prevention and treatment outcomes.

Main Methods:

• Qualitative study employing focus groups and interviews across four Indonesian provinces.
• Involved 64 participants from diverse stakeholder groups, including policymakers, healthcare providers, and beneficiaries.
• Reflexive thematic analysis of transcribed data to identify key themes.

Main Results:

• Client-centered models (free testing, same-day ART, CBO partnerships) improved linkage and retention.
• Quality counseling, confidentiality, and trust boosted testing uptake; workflow pressures and resource limitations hindered engagement.
• Prevention efforts were limited by commodity gaps, poor coordination, and suboptimal pre-exposure prophylaxis (PrEP) and partner services.
• Workforce capacity and system reliability (stock management, referrals, integrated services) were vital for retention and viral suppression.
• Donor dependence, outdated routines, and coordination issues exacerbated urban-rural disparities.

Conclusions:

• Consistent execution of HIV services is more critical than policy alone for improving cascade performance.
• Recommendations include formalizing enablers, upgrading HIV testing services, simplifying PrEP access, and implementing retention strategies.
• Addressing systemic issues and ensuring reliable service delivery are essential for reducing HIV disparities.