HIV incidence and adherence after pre-exposure prophylaxis initiation in key populations in Indonesia: Findings from a real-world pilot program 2021-2023.

OBJECTIVES

To provide important data for the national rollout, Indonesia launched a pre-exposure prophylaxis (PrEP) pilot program. In this study, we determined the HIV incidence and adherence among key populations, PrEP initiation, sexually transmitted infection incidence, and changes in sexual behaviors.

METHODS

The Indonesian PrEP pilot program (December 2021 to December 2023, rolled out in 21 districts in 10 provinces) was a longitudinal, non-randomized implementation study among men who have sex with men, female sex workers, transgender women, people who inject drugs, and serodiscordant partners of people with HIV. Eligible participants were offered same-day oral PrEP and completed the baseline, 1-monthly, and 3-monthly follow-up visits.

RESULTS

A total of 9124 individuals initiated PrEP between December 2021 and December 2023; 4220 had at least one follow-up visit. Of the 4220, 31 seroconverted over 2817.5 person-years; overall incidence rate (IR) 1.10 (95% confidence interval 0.75-1.56) per 100 person-years. All seroconversions occurred during poor adherence or PrEP discontinuation (IR 7.8; 5.34-11.16 vs 0; 0-0.4 for adequate adherence). Event-driven PrEP users showed poorer adherence than daily PrEP users (0.001). In men who have sex with men, HIV incidence was higher in those who lived outside Java and Bali (adjusted IR ratio 5.56; 1.68-18.38, = 0.005).

CONCLUSION

Insufficient adherence leads to decreased efficacy of PrEP. Improving adherence and access to PrEP is a public health priority in Indonesia.