The most recent Integrated Biological and Behavioral Surveillance (IBBS) survey in Indonesia shows high levels of HIV prevalence among men who have sex with men (MSM) and transgender women (TG or transgender) nationwide, but particularly in the national capital city of Jakarta (17.2% and 30.8%, respectively). These are also the only populations among which the rate of new HIV infections has continued to grow since 2007, and recent mathematic modeling has projected that, in the absence of effective interventions to prevent HIV transmission, MSM will be a very significant contributor of new HIV cases in Indonesia over the next decade.
Despite widespread condom availability in Indonesia, the HIV epidemic among MSM and transgender continues to grow. Consistent condom use remains low and It is by now generally understood that ending the AIDS epidemic among these key populations will require a combination of HIV prevention strategies that expands beyond existing measures. Indeed, analysis in recent years suggests that even were behavior change interventions widely adopted and successful this would still be insufficient to curb the epidemic among these populations given the unique biological factors (including a high per-act transmission probability, sex role versatility and sexual network clustering) that drive HIV transmission.
While condom programming is and will remain a cornerstone of HIV programming, it is at this point well accepted that this strategy must be paired with interventions at a community level to reduce the biological infectiousness of HIV. Pre-exposure prophylaxis (PrEP) for HIV prevention among MSM and transgender represents an important new tool with an efficacy as high as 92% among individuals who use the drug as directed. PrEP has been approved by the US FDA and endorsed as part of comprehensive HIV prevention programming for MSM by both the US CDC and the World Health Organization.
However, there are critical questions regarding how PrEP is to be best integrated into existing HIV programming – not the least of which is that evidence to date suggests PrEP’s success hinges not only on access but also on uptake and consistent use. Effective behavioral strategies around promotion and adherence support will therefore be crucial to any attempt to introduce PrEP into MSM populations.
Additional anticipated complications include questions regarding policy support in settings where basic HIV services are difficult to obtain, healthcare provider readiness, and questions regarding side effects and community acceptability. To explore these questions, Atma Jaya HIV-AIDS Research Center funded by FHI360 has conducted a qualitative assessment of barriers and facilitators to uptake of PrEP among MSM and transgender in Jakarta.
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