A targeted combination intervention approach for acute HIV infections to curb the explosive epidemic among high-risk populations in Indonesia

在印度尼西亚，艾滋病毒感染风险最高的关键人群中艾滋病毒流行不受控制，包括男男性行为者(MSM)、变性人和性工作者。迫切需要创新的、针对具体情况的方法来遏制艾滋病毒传播。欧洲和美洲的研究表明，急性艾滋病毒感染(AHI)是男男性接触者继续传播的关键驱动因素。在急性期诊断艾滋病毒感染对于及早提供护理、通过立即治疗保护健康以及尽早防止进一步传播至关重要。然而，由于AHI的症状相当不特异，而且缺乏使用现有的标准血清学测试的适当测试，诊断AHI是具有挑战性的。高收入环境中的干预模式，包括基于风险分数的AHI筛查算法和护理点艾滋病毒病毒载量测试，已被证明可以改进AHI识别，使之能够与护理直接联系，并立即开始抗逆转录病毒治疗(ART)。此外，它们允许通过伙伴通知服务和社区暴露前预防教育(PrEP)与高危人群更密切地接触，以加强社区对何时在印度尼西亚引入PrEP的准备。我们的研究提案解决了一个关键问题：我们能否通过实施针对AHI患者的当天诊断和治疗路径，以及促进AHI筛查和合作伙伴通知服务的行为干预，来遏制印度尼西亚关键人群中迅速增长的艾滋病毒流行？我们的研究提案将调查一种基于证据的、量身定做的方法，以在雅加达和巴厘岛的三个社区性健康诊所实施基于症状和风险行为的筛查算法以及护理点病毒负载测试，并结合社区外联方法来加强AHI测试。所有新诊断的AHI患者将被联系到护理，并提供当天的抗逆转录病毒治疗开始。将使用定性和定量分析方法评估这一创新护理途径的摄取率、产量、可行性和可接受性。最终，将使用数学建模和成本效益分析来估计如果大规模推广这种干预措施可能对遏制印度尼西亚艾滋病毒流行产生的潜在人口影响。这一实施科学项目将为印度尼西亚卫生政策制定者提供关键证据。研究团队包括来自英国、肯尼亚和荷兰的国际研究人员，他们一直站在制定战略的前沿，以改善各种环境下的AHI筛查和管理，以及与临床实践、关键人口社区和印度尼西亚各地政府有密切联系的印度尼西亚领先的艾滋病毒研究人员。地方研究能力建设是该项目的一个重要方面；知识交流、地方领导和所有权、培训和会议将有助于建立地方在执行研究和创新艾滋病毒护理模式方面的专门知识。最终，我们预计这项工作将在印度尼西亚和其他中低收入国家对艾滋病毒流行产生重大影响，从而加强卫生服务的提供，减少新的艾滋病毒感染和死亡，并降低卫生成本。

There is an uncontrolled HIV epidemic among key populations at highest risk of HIV exposure in Indonesia, including men who have sex with men (MSM), transgender people and sex workers. Innovative, context-specific approaches are urgently needed to break HIV transmission. Studies in Europe and the Americas have shown that acute HIV infections (AHI) are a key driver of onward transmissions among MSM. Diagnosing HIV infection in the acute phase is crucial for early care engagement, preservation of health by immediate treatment, and prevention of onward transmission at the earliest possible moment. However, diagnosing AHI is challenging due to the rather nonspecific symptoms and lack of appropriate testing using the available standard serological tests. Intervention models in high-income settings including AHI screening algorithms based on risk scores and point-of-care HIV viral load testing have been shown to improve AHI identification, enabling direct linkage to care and immediate initiation of antiretroviral therapy (ART). Furthermore, they allow for closer engagement with high-risk populations through partner notification services, and community education on pre-exposure prophylaxis (PrEP), to enhance community preparedness for when PrEP will be introduced in Indonesia. Our research proposal addresses one overarching question: can we curb the rapidly growing HIV epidemic among key populations in Indonesia by implementing a same-day diagnosis and treatment pathway targeting persons with AHI, coupled with a behavioural intervention to promote AHI screening and partner notification services? Our research proposal will investigate an evidence-based, tailored approach to implementing a screening algorithm based on symptom and risk behaviour and point-of-care viral load testing in three community sexual health clinics in Jakarta and Bali, combined with community outreach approaches to enhance AHI testing. All newly diagnosed AHI patients will be linked to care and offered same-day ART initiation. The uptake, yield, feasibility and acceptability of this innovative care pathway will be evaluated using both qualitative and quantitative analytical methods. Ultimately, mathematical modelling and cost-effectiveness analysis will be used to estimate what potential population impact this intervention may have on curbing the HIV epidemic in Indonesia if rolled out at scale. This implementation science project will provide critical evidence to Indonesian health policy makers. The research team includes international researchers from UK, Kenya and The Netherlands who have been at the forefront of developing strategies to improve AHI screening and management in various settings, and the leading Indonesian HIV researchers, with strong linkages to clinical practice, key population communities and governments across Indonesia. Local research capacity building is an important aspect of the project; knowledge exchange, local leadership and ownership, training and conferences will help build local expertise on implementation research as well as innovative HIV care models. Ultimately, we anticipate the work will have substantial impacts within Indonesia and in other low-middle income countries (LMIC) on HIV epidemics, resulting in strengthened health service delivery, reduced new HIV infections and deaths, and health costs.