HIV Awal (Early) Testing & Treatment Indonesia Project Intervention Phase
Condition: HIV/AIDS
MeSH terms: Acquired Immunodeficiency Syndrome; HIV Infections
Study type: Interventional

Summary: 
      This study will be one of the first to systematically evaluate strategies to improve the
      implementation of a T&T strategy in a concentrated epidemic in Asia.

      HATI Project is an implementation research designed, of which consisted of phase I as
      observation of available standard practice and data collection and phase II implementation of
      intervention of intervention designed based on the results of phase I.

      The first year observation study showed that there are poor cascade of HIV care. The first is
      the low coverage of HIV test uptake. Along the HIV test and treatment cascade there are
      substantial reductions.

      Furthermore, In the qualitative analysis we found several reasons for the study population
      for not coming to the ARV sites after being diagnosed with HIV, e.g. social and
      administrative reasons such as not possessing ID card and unsuited hospital opening hours,
      etc. Another important finding was the requested laboratory testing by the physicians prior
      to ART initiation, such as Levels of Haemoglobin, serum transaminases, creatinine, and chest
      X-ray (manuscript in preparation).

      The aims of the proposed interventions are:

        1. Increase uptake of HIV testing

        2. Increase uptake of HIV treatment initiation

        3. Reduce time from testing to treatment initiation

        4. Increase percentage of treatment adherence

        5. Reducing loss to follow-up on ART

        6. Improve treatment outcomes (virological suppression)

      There are five interventions proposed:

        1. Oral fluid-based testing (self-testing) as a strategy to overcome barriers of testing

        2. Simplification of ART initiation

        3. CBOs and Brothel-based ART service

        4. SMS reminders to increase treatment adherence

        5. Motivational Interviewing Approach to increase treatment uptake & adherence

      Study sites of the intervention will be conducted in Denpasar (Bali), Yogyakarta (Special
      Region of Yogyakarta), Bandung (West Java), and Jakarta

      The study population for the intervention phase are the same with the first year
      observational study, i.e.: Female sex workers (FSW), Gay men and other men who have sex with
      men (MSM), Waria (or transgender) and People who inject drugs (PWID)
    

Detailed description: 
      Description of the Each Proposed Interventions After the qualitative research, literature
      reviews, thorough discussions, and based on practical/ logistic considerations, there are
      five specific interventions that have been chosen. Each of the intervention will be presented
      here in the same format, i.e. rationale of the intervention, aims of the intervention, study
      site and key population, description of the intervention, and evaluation of the intervention.

        1. ORAL FLUID BASED TESTING (SELF-TESTING) AS A STRATEGY TO OVERCOME BARRIERS OF TESTING
           AMONG MSM IN BALI, INDONESIA While in Indonesia facility-based HIV testing and
           counselling (HTC) has been available widely, studies including the HATI qualitative
           research found that people still worry about stigma, visibility, and social
           discrimination. Also some reports mentioned lack of privacy and lengthy waiting time for
           the result impede people to access facility based testing. Public health effort to
           increase testing coverage and treatment uptakes is urgently needed. Home based testing
           kit including oral saliva test for HIV has been available in the international market
           that could bring more control to the communities in finding out their HIV status. A
           number of studies have reported that the self-testing strategy is accepted and in many
           cases preferred, however there is still limited study to evaluate its effectiveness in
           increasing HTC and treatment uptake.

      The aim of intervention : To test whether oral fluid self-testing will increase the uptake
      HTC in MSM and increase the number of HIV+ve MSM who are aware of their status in Bali,
      Indonesia Description of intervention The current HIV testing practices in Indonesia is
      happen in two major settings: VCT clinic settingand Mobile testing; both procedure need the
      health provider team in minimum consist of a doctor, a nurse, a lab technician/analyst and
      outreach staffs.

      The intervention will be different to above practices as it will add or introduce a new
      option of HIV diagnosis using oral fluids rapid test that could be conducted by the clients
      themselves (self-testing).

        1. The second year intervention will introduce provider supervised and unsupervised
           self-testing as an option for early HIV diagnosis among MSM community in Denpasar Bali
           Indonesia.

        2. The intervention will be delivered by outreach workers of Kerti Praja Foundation (YKP)
           in Denpasar Bali. Currently there are 8 outreach workers for MSM in Denpasar. The main
           task of the outreach staff would be delivering health communication and education around
           self-testing procedures, distribute the kits to participants who received the test,
           supervised the test when participants choose to have supervised test, collect the used
           kits, conduct follow up counselling procedure of the test results including for
           participants who choose to have unsupervised or home-based test, and conduct referral of
           reactive result participants to the VCT clinics for confirmatory test and ART services.

        3. Potential subjects will be approached in the outreach setting conducted by outreach
           workers during a standard outreach works. Every MSM will be offered HTC at VCT clinics
           or mobile VCT available near to their living or working areas. If the client refuse,
           outreach worker will offer self-testing option.

        4. Steps that will take place if potential subject received the intervention i. Subjects
           will be given detailed information on how to use the test kit in a standardised
           information (brochure or video) and counselling session for the use of self-testing kit.

      ii. Subjects will be offered a supervised self-testing procedure first and if refused
      unsupervised self-testing procedure will be offered as second option.

      iii. All Reactive Subject during OFT intervention will be referred to Clinic for further
      confirmatory testing.

      Evaluation of the impact of the intervention

        1. Primary outcome: The number of MSM tested for HIV during the intervention and the number
           of MSM testing positive for HIV during the intervention

        2. Secondary outcomes:

             1. Proportion of those who refuse regular HTC.

             2. Proportion of taking an HIV self-testing kit (regardless of whether used)

             3. Proportion of reporting a positive HIV self-test result to counsellors

             4. Proportion of confirming the result to VCT clinics

             5. CD4 count at enrolment into HATI before and during intervention (may give an
                indication if people testing earlier i.e.less late presenters)

        3. Data collection:

           As per phase one HATI screening, baseline, ARV and follow-up forms will be completed for
           all participants enrolled into HATI. An additional flag will be added to identify those
           who had initially tested positive using self-testing-supervised or unsupervised.

        4. Impact of other interventions This intervention will be conducted in Bali in parallel
           with two other intervention; the 'Simplification of ART initiation' and the 'SMS
           reminders to increase treatment adherence'. However these two interventions target at
           people already aware of their HIV status and attending a HATI site for treatment.
           Whereas oral-self testing will be offered in the outreach setting in MSM unaware of
           their HIV status. Therefore it should be possible to evaluate this intervention
           independently of these two other interventions. MSM who subsequently attend a HATI
           clinic for confirmatory testing and receive a positive results will then be eligible for
           the other intervention packages.

        5. The impact of intervention on the improvement of HIV test coverage in MSM population in
           Bali will be measured using before and after approach.

           2. SIMPLIFICATION OF ART INITIATION TO INCREASE ART UPTAKE AND REDUCE TIME TO ART
           INITIATION The observational result at the first year of HATI project in the four sites
           showed that there is a big number of HIV positive clients did not initiate ART in the
           corresponding HATI sites. There is also lag time between HIV testing and initiation of
           ARV treatment among study participants. The first year result also showed difference of
           this average lag time between different types of test and treatment linkage, i.e.
           hospital to hospital, puskesmas to hospital, CBO (Vesta) to hospital. This time lag
           between diagnosed as HIV (or testing HIV positive) and ARV initiation putting risk of
           transmission to their partner and population. In addition, HATI qualitative study stated
           that MSM, FSW, and transgender did not really like to be referred. They have limited
           time to move from one place to another place and it will reduce confidentiality.

      A One-stop service (same day, same place) and streamlining ARV initiation either in hospital,
      puskesmas, or in the NGO and hotspots (brothel) may reduce waiting time to ARV initiation and
      time of appointments of patients to access HIV treatment in hospital.

      One of the main (medical) reasons for "delayed" ART initiation is that clients have to
      conduct pre-ART laboratory examinations, such as Levels of Haemoglobin, serum transaminases,
      creatinine, and chest X-ray, of which may be very costly (for those who do not have health
      insurance scheme) and hamper ART initiation. There is a need to streamline pre-ART laboratory
      testing.

      Based on the low incidence rate of nephrotoxicity due to Tenofovir, the intervention will
      explore the possibility to initiate ART independent of laboratory tests results and
      creatinine levels will be tested 2 weeks after ART initiation. If result is normal, patients
      can continue monthly ART. But if there is an (marked) increased of the creatinine level, we
      will consider as side effect of Tenofovir, and regiment will be changed accordingly.

      The aims of the intervention would be:

        1. To increase uptake of ART initiation.

        2. To reduce time between testing positive and starting treatment Description of the
           intervention In this intervention, there will be a change in the clinical practice of
           ART initiation. In the current practice, clients are asked to perform full pre-ART
           laboratory examination (complete blood count, liver and renal function tests) before
           decision of ART initiation. In this intervention, the study participants who are already
           confirmed as HIV positive and meet specific clinical criteria (see below) will initiate
           ART (antiretroviral therapy) immediately (after clients' approval) without having to
           perform full pre-ART laboratory examination. Here, laboratory criteria for initiating
           ART will be simplified and specific laboratory examination, I.e. creatinine test will be
           delayed in two weeks after ART initiation.

      To attract potential clients, the sites will publicise this intervention to the public. If a
      client from key population come to HATI hospital and or puskesmas site, they will receive
      pre-HIV test counselling, HIV test, receive results and immediately initiate ART (if it is
      HIV positive).

      All patients newly found to have HIV, or referred with HIV, will be offered recruitment in
      HATI, regardless of whether or not they meet the criteria for simplified initiation.

      Steps to the intervention are as follow:

        1. HIV positive patients will be screened for inclusion criteria and clinical symptoms of
           Tuberculosis (TB). Those meeting the inclusion criteria and does not have symptoms of TB
           will immediately given ARV regiment for 14 days. The ART regiment consist of Tenofovir +
           Lamivudine / Emtricitabine + Efavirens. Tenovofir may occasionally causing renal
           function disturbance. Patients will be checked for Creatinine level on day 14 (two weeks
           after ART initiation) to monitor Tenofovir sie-effect. The argument to move the
           examination of laboratory test (from baseline to two weeks after ART initiation) is that
           patient will already exposed to the drug (tenovofir) so increased creatinine level may
           be caused by the Tenofovir.

        2. One-two days before their next visit, patient will go for creatinine level laboratory
           testing

        3. On the day of the next visit, patient will present their laboratory finding.

             1. If creatinine level is within normal limit, patient can continue their ARV. They
                will receive ARV for one month and continue as standard HIV care

             2. If creatinine level is slightly increased, they will be closely observed. They will
                be advised to drink fluid

             3. If creatinine level is > 1.5 gr/dL, ARV regiment will changed. Patients will be
                referred to hospital for further evaluation.

        4. All patients newly found to have HIV, or referred with HIV, will be offered recruitment
           in HATI, regardless of whether or not they meet the criteria for simplified initiation

        5. All patients will be registered in SIHA HIV test and SIHA ARV

      Evaluation of the intervention

        1. Primary outcome: The increased number of key population tested for HIV and reduction of
           time lag between diagnosed with HIV and initiation pf ART.

        2. Data collection:

           As per phase one HATI screening, baseline, ARV and follow-up forms will be completed for
           all participants enrolled into HATI. A flag will be added to the follow-up forms to
           identify those who qualified for 'Simplification of ARV initiation' and those who did
           not.

        3. Intervention has worked if there is increased number of key population doing HIV testing
           and there is decreased time between testing and treatment in the second years is shorter
           than in the first year of this study These intervention outcomes will be compared with
           result in the first year

        4. Impact of other interventions:

      This intervention is aimed at increasing the uptake of ARV. The other interventions are
      addressing different aspects of the HIV cascade (testing and adherence) and therefore should
      not impact on the main variables used to measure the impact of this intervention.

      3. COMMUNITY BASED ORGANIZATION (CBO) AND BROTHEL-BASED ART SERVICE Based on the first year
      result, there is an urgent need to minimize barrier between HIV testing and ART service
      sites, one of which is One-Stop Service in CBO and or brothel.

      Many HIV NGOs and CBOs in Indonesia already conduct mobile VCT where they facilitate HIV
      testing in their place or else, in collaboration with a puskesmas. There is, however, no
      known existing ART initiation conducted at CBO and or brothels, on top of the HIV testing
      service.

      In Yogyakarta, there are two CBOs involved in many HIV programs, i.e. Kebaya and Vesta.
      Kebaya is an organization for transgenders that collaborate with Puskesmas conducting mobile
      VCT at its place once a month, whereas Vesta, organisation for men who have sex with men
      (MSM) conducts mobile VCT every week in collaboration with several Puskesmases depending on
      schedule availability. Out of the 13 puskesmases, 5 Puskesmas have HIV-trained doctors and
      provide ART (continuation) in Puskesmas.

      The Pasar Kembang (abbreviated as Sarkem) brothel collaborated with a Puskesmas conducting
      HIV testing every three months and STI testing and treatment every two weeks, held at the
      multi-function hall of the kampung.

      Based on the existing activities in Kebaya, Vesta, and Sarkem brothel, it is thought that it
      would be feasible and beneficial to develop CBO and brothel as One-stop (same day, same
      place) HIV diagnosis and ARV treatment site, particularly for key populations.

      Aims of the intervention

        1. To increase uptake of HIV treatment initiation.

        2. To Reduce time between testing positive and starting treatment Description of the
           intervention In Indonesia, there are numerous numbers of NGO (Non Government
           Organization) and CBO (Community Based Organization) working on HIV issues but are
           mostly limited to only providing buddies and or outreach workers. Yet, NGOs and CBOs are
           very close to the key populations. It is rationale to collaborate with HIV NGO and CBO
           to provide HIV medical services for key populations in the community. This can be done
           in the condition that NGO/CBO work together with Puskesmas, and that all medical
           services are provided by health care personnel of Puskesmas.

      The CBOs involved in this intervention are Kebaya and Vesta. Kebaya is an CBO working for
      Transgender (TG) community. It serves as community gathering place for TG and others, as HIV
      testing site on regular bases, and also as shelter for homeless HIV patients. For this
      intervention, Kebaya and Vesta will collaborate with HITI Puskesmas to provide medical
      service to key populations: MSM, FSW, and Transgenders.

      The Pasar Kembang brothel has, for many years, work together with PKBI (Perkumpulan Keluarga
      Berencana Indonesia / Indonesia Planned Parenthood) providing STI and HIV test in situ. For
      STI service, it is conducted every two weeks, but HIV testing is only every 1 - 3 months. The
      proposed intervention Is that HATI Project will provide HIV testing and treatment in the
      community, CBO and brothel in collaboration with nearby Puskesmas. Several steps and training
      will be taken before commencing the intervention,

      Steps to the intervention in the CBO and Brothel are as follow:

        1. Key populations are already informed about the service and are invited to participate.

        2. They will go for pre-HIV test counseilng and tested for HIV.

        3. All patients newly found to have HIV, or referred with HIV, will be offered recruitment
           in HATI, regardless of whether or not they meet the criteria for simplified initiation

        4. All patients will be registered in SIHA HIV test and SIHA ARV

           Delivery and place of the intervention a. The intervention will be delivered by and in
           CBO and brothel in collaboration with health care workers from the assigned Puskesmas.

           b. Counseling will be conducted by counselor from Puskesmas and CBO. Analyst, nurse and
           doctor for HIV testing and ART initiation from Puskesmas.

           c. The intervention will be conducted at Vesta and Kebaya office and at a hall of RW
           (Balai RW) in brothel area.

             1. Vesta and Kebaya CBOs and Pasar Kembang (Sarkem) brothel.

             2. In CBO office, there were rooms which was provided for every phase of this
                intervention (e.g. room for HIV testing, Counselling, diagnose/treatment). In the
                brothel, it will be conducted at Hall of RW's and there were small rooms, which was
                provided for every phase of this intervention.

                Evaluation of the intervention

             1. Primary outcome: The increased number of key population tested for HIV and
                reduction of time lag between diagnosed with HIV and initiation pf ART.

             2. Data collection:

                As per phase one HATI screening, baseline, ARV and follow-up forms will be
                completed for all participants enrolled into HATI. A flag will be added to the
                follow-up forms to identify those who qualified for 'Simplification of ARV
                initiation' and those who did not.

             3. Intervention has worked if there is increased number of key population doing HIV
                testing and there is decreased time between testing and treatment in the second
                years is shorter than in the first year of this study. These intervention outcomes
                will be compared with result in the first year

           Impact of other interventions:

           This intervention is aimed at increasing the uptake of ARV. The other interventions are
           addressing different aspects of the HIV cascade (testing and adherence) and therefore
           should not impact on the main variables used to measure the impact of this intervention.

      4. SMS REMINDERS TO INCREASE TREATMENT ADHERENCE ARV treatment failure caused by poor
      adherence, which also lead to AIDS, development of resistant strains of HIV, and death. HATI
      qualitative study in 2016 showed that the reasons for non-adherence in patients are occurence
      of ARV side effects, lack of support from family and service provider, or simply forgetting
      to take the medication.

      Several reviews suggest that behavioral intervention could improve ART adherence even though
      the effects is rarely durable (Sabine et al, 2015). With substantial growth in the number of
      mobile phone users, researchers and health practitioners have become increasingly interested
      in the field of mobile health, or m-health, broadly defined as the use of mobile phone
      technology to improve the delivery of health services. Usage of short message services (SMS)
      to promote ART adherence could be a good strategy to maintain patients adherence in
      Indonesia, since data from World Bank in 2015 showed that there were 132 mobile cellular
      subscriptions per 100 Indonesian people. From anecdotal observation, majority of HATI
      patients own mobile phones. HATI project in the intervention phase intends to develop a SMS
      reminder system that effective to promote good ART adherence in Indonesia setting.

      Aims of the intervention : SMS Reminder is aimed to improve patient's adherence.

      Description of the intervention

        1. All HIV positive client in the study sites are offered to join the SMS reminder
           intervention.

        2. For those who refuse to join SMS intervention will receive standard clinic reminder
           practice

        3. For those who agree to join this intervention will protocol below. HATI SMS reminder:
           short message services as reminders to inform ART patients when to take medication,
           visit the clinics (1 week before the next visit) and remind if they miss clinic
           appointment.

      The system will automatically flag when patient visits are due, allow automatic SMS reminders
      for taking medication and flag patients who miss a visit.

      HATI Tracing System:

      Tracing for patients whom their SMS status were "not delivered" within a month and who do not
      come on schedule. The list of patients whom their SMS status were "not delivered" within a
      month and who missed a visit will be forwarded to the peer support/buddy from CBO previously
      approved to contact them from the informed consent for them to trace. Tracing management will
      follow regular practice in every ARV sites.

      Evaluation of the intervention

        1. Evaluation of the intervention will use 3 relevant indicators from the Early Warning
           Indicators (EWIs) HIV Drug Resistance from WHO, which have been implemented at almost
           all hospitals providing ART in Indonesia since 2012.

             1. Indicator 1. On-time pill pickup (EWI 1)

             2. Indicator 2. Retention in care (EWI 2)

             3. Indicator 3. Viral load suppression at 12 months (EWI 3)

        2. Outcomes a. Primary outcome: 12 months retention in care b. Viral load suppresion
           (percentage of viral suppresion within 12 months divided by total study participants) c.
           Secondary outcome: Self-reported adherence d. Process outcomes: i. Proportion of study
           participants receive SMS reminders Proportion of study participants requesting to stop
           receiving SMS reminders ii. Proportion of study participants who come to clinic for
           on-time pill pick-up iii. self-reported adherence

        3. Measurements from current HATI data:

             1. Viral load data in 12 months

             2. Self-reported adherence

             3. Proportion of 12 months retention in care

      Impact of other interventions: This intervention is aimed at increasing adherence to ARV. The
      other interventions are addressing different aspects of the HIV cascade (testing and
      treatment uptake) and therefore should not impact on the main variables used to measure the
      impact of this intervention.

      5. MOTIVATIONAL INTERVIEWING APPROACH TO INCREASE TREATMENT UPTAKE & ADHERENCE

      The first year of HATI project data for PWID in Jakarta shows 72% of PWID who enrolled the
      study wants to start treatment and only 58% of all PWID enrolling the study still continue
      the treatment currently. In Bandung, only 55% of PWID who enrolled the study wants to start
      treatment and only 33% of PWID enrolling the study still continuing treatment. From
      qualitative data, we see an obvious need for mental health services. People are not
      initiating treatment for fear of side effects, misguided beliefs on the effects of ART, and
      fear of stigma and discrimination from immediate family members and the community. Of those
      that have started treatment and stopped, we saw that they suffered from treatment
      fatigue/burnout, have some issues related to mental health. For example, especially for the
      PWID, they often find it difficult to manage drug use and manage ART with different harm
      reduction programs. These issues are rooted in lack of psychosocial assistance, which need to
      be addressed.

      This particular intervention is designed to improve ART uptake and to increase adherence to
      ART for PWID, by providing better support for psychosocial issues that may affect ART uptake
      and adherence. there is no existing study, which showed how this model works in enhancing ART
      adherence among PWID in Indonesia. Therefore, this study will be the first study to provide a
      MI intervention and also to train health care provider to deliver the MI for enhancing ARV
      uptake and adherence.

      Aims of the intervention :

      MI Intervention aims to increase uptakes of HIV treatment initiation and adherence among PWID
      using motivational intervention approach Description of the intervention: Motivational
      Interviewing intervention is a client-centered approach for enhancing motivation to change
      behaviors or maintain healthy behaviors. In the MI intervention, the providers will guide the
      clients toward change, but the clients are the center of the intervention, the clients are
      encouraged and empowered to share their barriers of doing something and therefore to find
      solutions and make a decision for their situations. In other words, the MI counselors will
      emphasize the clients' autonomy and freedom in making their decisions. In sum, the aim of MI
      approach is to raise clients' confidence in voicing their arguments by their self.

      The approach used in this intervention is an individual counselling with a MI approach, as it
      is considered a brief form of therapy have been known to be effective in improving HIV
      treatment adherence. The sites that will be chosen as intervention sites are Puskesmas Grogol
      Petamburan and Puskesmas Senin.

      The sessions will be held from 3 to up to 10 MI counselling over 6-month period of
      intervention. The goal of this intervention is to help PWID gain an understanding of their
      medication-taking behaviors and the actions necessary to successfully maintain a high level
      of adherence.

      Steps of the intervention The MI intervention will be done in four stages as described in the
      flow chart and narration below Stage 1: Pre-ART Initiation Stage 2: ART Initiation Stage 3:
      ART adherence maintenance Stage 4: Termination Sessions (in the 6th month of intervention)
      Evaluation of the intervention We will conduct a baseline and end-line survey or comparison
      between groups, mainly between first-year/baseline cohort and second-year/intervention
      cohort. Should this intervention be done initially as a pilot, the comparison group might
      consist of people not receiving intervention in other HATI sites (non-consent or purposively
      not provided). We will also plan to conduct a small qualitative study to gather clients and
      providers' satisfaction and feedback of MI approach by in-depth interviews and focused group
      discussions. This qualitative study will be conducted and documented separately from this
      intervention protocol.

      In the first year, a thorough evaluation will be done after 6 months of the intervention. The
      evaluation will use data collected from the previous 6 months, as well as collecting new data
      to assess the acceptability and appropriateness of the topics in the intervention.

      Outcomes of the intervention:

      • Primary outcome: Clinical outcome: self-reported ARV adherence, CD4 count, VL result of
      HATI participants on intervention compared with those not receiving the intervention.

      • Secondary outcome: Psychological outcome (Self-efficacy & psychological wellbeing).

      Output indicators:

        -  The number of clients receiving intervention and maintained on treatment in 6 months
           (retention rate),

        -  Impact indicators: ARV adherence, lost to follow up, come on time to the ARV
           appointment, VL and CD4 levels, as well as evaluation of psychological well-being.

        -  Retention rate of people maintained in the intervention

        -  Number lost to follow up cases after ARV initiation

        -  Proportion of cascade stage of intervention

      Measurements:

        -  From current HATI Data: CD 4 count, VL result, 6 month follow up

        -  Questionnaire to assess self-efficacy and psychological well-being by using DASS.

        -  Self-reported adherence for PWID using ACTG Adherence Baseline and Follow up
           Questionnaire
    

Intervention name(s): Oral Fluid Based Self Testing; Simplified ART Initiation; CBO AND BROTHEL-BASED ART SERVICE; SMS REMINDER; MOTIVATIONAL INTERVIEWING
Intervention type(s): Diagnostic Test; Procedure; Procedure; Behavioral; Procedure
Intervention description(s): The intervention will introduce provider supervised and unsupervised self-testing as an option for early HIV diagnosis among MSM community in Denpasar Bali Indonesia.; In this intervention, there will be a change in the clinical practice of ART initiation. In the current practice, clients are asked to perform full pre-ART laboratory examination (complete blood count, liver and renal function tests) before decision of ART initiation. In this intervention, the study participants who are already confirmed as HIV positive and meet specific clinical criteria (see below) will initiate ART (antiretroviral therapy) immediately (after clients' approval) without having to perform full pre-ART laboratory examination. Here, laboratory criteria for initiating ART will be simplified and specific laboratory examination, I.e. creatinine test will be delayed in two weeks after ART initiation.; The CBOs involved in this intervention are Kebaya and Vesta. Kebaya is an CBO working for Transgender (TG) community. It serves as community gathering place for TG and others, as HIV testing site on regular bases, and also as shelter for homeless HIV patients. The proposed intervention Is that HATI Project will provide HIV testing and treatment in the community, CBO and brothel in collaboration with nearby Puskesmas.; HATI SMS reminder: short message services as reminders to inform ART patients when to take medication, visit the clinics (1 week before the next visit) and remind if they miss clinic appointment.; The approach used in this intervention is an individual counselling with a MI approach, as it is considered a brief form of therapy have been known to be effective in improving HIV treatment adherence.
The sessions will be held from 3 to up to 10 MI counselling over 6-month period of intervention. The goal of this intervention is to help PWID gain an understanding of their medication-taking behaviors and the actions necessary to successfully maintain a high level of adherence
Other intervention name(s): OFT; SAI; CBO ART SERVICE; MI
Allocation: Non-Randomized
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Health Services Research