RESEARCH PROPOSAL

EVALUATION OF PROGRESS TOWARD THE UNAIDS TARGET

RELATED HIV CARE CASCADE AND FACTOR INFLUENCING IN
BANDUNG CITY, WEST JAVA, INDONESIA
Sidik Maulana
Student ID. 220120230029
Supervisor team
Prof. Kusman Ibrahim, BSN., RN. MNs., PhD. (FoN UNPAD, Indonesia)
Iqbal Pramukti, BSN., RN., MSc., PhD. (FoN UNPAD, Indonesia)
Wei-Ti Chen, RN., CNM., PhD. FAAN. (School of Nursing UCLA, USA)
Reviewer
Rudy Wicaksana, MD., Sp.PD., KPTI., PhD., (1) Laili Rahayuwati, Dra., MHSc., MPH., DrPH., (2) Chandra Isabella
Purba, BSN., RN., MNs., PhD, (2) Yen Chin Chen, RN., MNS., PhD. (3)
(1) Faculty of Medicine, UNPAD – RSHS, Indonesia (2) FoN, UNPAD, Indonesia (3) School of Nursing, NCKU, Taiwan
BACKGROUND
Background: High prevalence of HIV and Challenge of
Progress toward HIV Care Cascade
Despite. HIV mortality are decrease. The HIV
prevalence/transmission are increase across the
globe, over the year.
Since 2010, the mortality rate has decreased by 51%.
Since the peak of the HIV epidemic in 2004, also
decreased by 69% in 2022 (WHO, 2023).
The widespread of ART effect on HIV-
related morbidity and mortality has
significantly decreased, turning HIV into a
manageable chronic condition (Januraga et
al., 2018).
ART has been reduced the risk of HIV
transmission to sexual partners(Chou et al.,
2019; Lundgren et al., 2015).
Therefore, ART has to be strategy as a
primary method in prevention and treatment

However, despite significant efforts, global ART

coverage only reached 76% by 2022, falling short of
the 95% target. In Southeast Asian countries,
coverage reached only 63%.

Various studies have identified gaps in the HIV care cascade

(continuum of care).
Factors

Progress towards achieving coverage in the HIV care

cascade has shown suboptimal performance in various
WHO regions (WHO, 2023).
According to the 2022 annual report on HIV/AIDS by the
Indonesian Ministry of Health: 81% screening and diagnosis,
41% linkage to care, and 17% viral suppression
Background: Evaluation on Progress Toward HIV Care
Cascade in Indonesia

Linkage to Care:
89% Yogyakarta, 80% Bali, 62% Bandung.
Specifically in Kediri:
6.4% testing, 74.9% on ART, and 9,9% viral suppressed.
(Januraga et al., 2018; Ssekalembe et al., 2020)

ART initiation:
75% female commercial sex
73% Man Sex with Man
Limited source of
70% Transgender
evaluation on
67% Needle drug users
The HIV Care Cascade in Indonesia per progress toward
Viral suppression:
Key Population: UNAIDS 2030 by
47% Man Sex with Man
MSM group more favorable than other group
30% Transgender
group. However, the progress toward
25% Female sex worker
UNAIDS target showed sub-optimal.
22% Needle drug users

The continuing evaluation of progress toward UNAIDS target and analysis by key population are needed
To enhance the strategy in achieving UNAIDS target 2030
Background: Multilevel factors may influencing the
Progress toward UNAIDS target related HIV Care cascade
Studies conducted in the Southeast Asian region have
shown multiple factors related to the success of each Further exploration is needed that explore
WHO Southeast Asian Region

element of the HIV care cascade. The progress in the
cascade largely correlates with demographic factors (such
as education, employment, marital status) and clinical factors
(such as CD4 count, coinfections, and clinical stage) (Eng et
al., 2021; Januraga et al., 2018; Musumari et al., 2020; Ovari
et al., 2022).
The Progress of the care cascade is also determined by
social and community support factors, easy access to
services (both in terms of distance and cost), and policies
(Fauk et al., 2018; Hendricks et al., 2021; Manurung et al.,
2020; Sujianto & Aisyiyah, 2021).
barrier and facilitator factors related the
HIV care cascade in Indonesia using the
socio-ecological model framework (Mcleroy
et al., 1988). The socio-ecological model
provides a comprehensive framework for
understanding the factors influencing the
HIV care cascade, taking into account
various levels of influence that interact from
individual to broader system levels.

However, most studies evaluating the success of the care cascade

mainly assess its relationship with demographic and clinical factors.

In Indonesia, there is still insufficient evidence that identify the

factors associated with the HIV care cascade across all levels of
Individu

the system (Januraga et al., 2018; Manurung et al., 2020;

Megasari & Wijaksana, 2023; Nepomuceno et al., 2023; Ovari et
al., 2022; Pradnyani et al., 2020; Setiyawati & Meilani, 2021;
Suryana et al., 2019; Yunita et al., 2023).
Objective and benefit Benefit

• Enhancing HIV care strategies in Indonesia, particularly by

Objectives strengthening the coverage and effectiveness of the care

Practice
cascade.
• Providing a framework for nurses in care strategies to
1. Analyze the coverage of the HIV care improve access and adherence to care and treatment for
cascade PLHIV who have been screened.
2. Analyze the coverage of the HIV care • Providing evidence-based policy recommendations to assist
cascade per key population group policymakers in developing more effective strategies for
3. Analyze the relationship between managing HIV.

Policy
• Providing a foundation for policy stakeholders or program
demographic and clinical factors with
implementers in designing and implementing more
the coverage of the HIV care cascade effective HIV care and treatment programs.
4. Explore barriers to the HIV care • Enhancing healthcare services for HIV patients by ensuring
cascade that these services are responsive to their needs.
5. Explore facilitators of the HIV care
• Provides theoretical benefits on the dynamics of the HIV
cascade care cascade
6. Explore the needs of people living with • Enhances understanding of how the socio-ecological model

theory
HIV (PLHIV) and healthcare providers can be applied in the HIV context, offering data to strengthen
regarding HIV care cascade this model in public health research
• Offers a multidimensional view of HIV care, incorporating
medical, psychosocial, and healthcare system perspectives,
contributing to the academic literature on this disease.
 Conceptual framework
Facilitator factors
• Clinical (History of risky • Demographic (Age,
behaviors, Having multiple,
Occupation
sexual partners) • Clinical (Cholesterol levels,
• Demographic (Occupation,
Type of ART, Smoking status,
Education, Gender, Age)
• Clinical (Clinical stage, History of amphetamine use,
• Knowledge
Co-infections, CD4 count, CD4 count)
• Perceptions of vulnerability
Mode of transmission, • Open disclosure • Demographic (Age,
• Self-efficacy • Involvement in prevention
Body weight, Service • Self-efficacy
• Motivation programs Education)
location) • Psychological health • Clinical (Clinical stage)
• Dependence on services • Clinical (Use of
Stage

• Demographic (Education, • Quality of life • Time of ART initiation.

• Family support amphetamines)
Gender, Age) • Health function
2

• Healthcare provider support

• Counseling • Family support
• Attending physician • Stigma-free environment
• Peer support • Having a provider in primary
• Support from significant others
care
• Education and information • Access to services
• Ease of access to services
• Telecounseling
Evaluation

coverage
Stage

Screen and
Linkage to care
of

diagnosis Retention in care Adherence Viral suppression

1

• Demographic (Occupation)
• Clinical (Mode of • Clinical (Risky sexual behavior,
• Demographic
transmission, Having Time of diagnosis, Healthcare
• Clinical (Late diagnosis, (Gender, Age,
multiple sexual partners, facility where diagnosed, Smoking,
History of needle drug use) Erectile dysfunction, Alcohol Income)
Low practice of safe sex, Co-
Stage

• Demographic (Education, • Clinical (CD4 count,

infections, Location of consumption, CD4 count)
Age, Marital status) Not available • Open status Co-infections, Drug
detection)
2

• Differences in screening • Low information availability resistance, BMI,

• Demographic (Age,
and treatment services • Self-care issues Comorbidities)
Education, Ethnicity, Income
• Interpersonal conflict • Psychosocial problems • Time of ART
below minimum wage
• Service distance • Partner not taking ART initiation when CD4
standards, Unemployment)
• Low social relationships is low
• Low participation in services
• Barriers to accessing services
Barrier factors
RESEARCH
METHODS
 A Sequential Explanatory Mixed Method
Design
Paradigm Post-positivism
Paradigm
a

Quantitative Qualitative
Sampling Convenience sampling Purposive sampling
technique

Sample People living with HIV and Healthcare providers in HIV care service in Bandung City

Research Quantitative Qualitative data Qualitative

procedure data analysis collecting data analysis

Data cleaning Transcription

Coding Reduction
Analysis
procedure Tabulation
Coding and categorizing

Descriptive
analysis Developing into themes

Evaluation HIV Care Cascade Barrier and facilitator

Coverage and correlation analysis of factors in a level
Output
demographic and clinical factors system

1 Quantitative
Retrospective cohort (2020-2023)
Setting
Secondary data by Sistem
Informasi HIV/AIDS (SIHA)/
Information Health System
for HIV/AIDS
Population
Adult people living with HIV
that receiving care and
treatment in Bandung
according SIHA data
Sample
Non-probability (Convenece
sampling) of PLHIV who
reported by SIHA data
No Variable Definition Measurement Output Scale
Dependent variable
1 Screen and PLHIV known their The number of PLHIV screened for Percentage Numeric
diagnosis status diagnosis divided by the estimated
number of PLHIV, multiplied by 100.
2 Linkage to care PLHIV referred to The number of PLHIV referred to services Percentage Numeric
services with CD4 or with CD4 or VL examination at least once
VL examination at within 12 months of knowing their status,
least once within 12 divided by the estimated number of PLHIV,
months of knowing multiplied by 100.
their status.
3 Retention in care PLHIV who attend The number of PLHIV who attend routine Percentage Numeric
routine visits to 2 or visits to 2 or more HIV services within a
more HIV services 12-month period, divided by the estimated
within a 12-month number of PLHIV, multiplied by 100.
period.
4 Treatment/ PLHIV on ART The number of PLHIV on ART treatment Percentage Numeric
Adherence treatment. divided by the estimated number of PLHIV,
multiplied by 100.
5 Viral suppression PLHIV with an PLHIV on ART treatment divided by the Percentage Numeric
undetectable viral estimated number of PLHIV, multiplied by
load. 100.
Independent variable: (1) HIV care service location (2) Age (3) Key population (4) Education (5)
Employment (6) Marital status (7) Clinical stadium/stage (8) CD4 count (9) ART
Instrument Data analysis
SIHA data, accessed Univariate using descriptive analysis, Bivariate using
through Bandung City spearmen correlation, and Multivariate using logistic
Health Office regression. Also, sub-analysis by group.
1 Qualitative
No
1
Variable Definition
Barrier factors related HIV Participants' opinions on factors hindering
Source
PLHIV and
Method
Semi-structure
care cascade HIV prevention and treatment efforts at the healthcare interview
individual, interpersonal, community, and professional who
Setting healthcare service and policy levels, from had experienced in
the perspective of individuals at risk of HIV providing HIV care
HIV health service across the and PLHIV. service in Bandung
level healthcare setting (primary,
secondary, tertiary). Pasundan 2 Facilitator factors related Participants' opinions on factors supporting PLHIV and Semi-structure
PHC, Teratai OPD – Hasan HIV care cascade HIV prevention and treatment efforts at the healthcare interview
Sadikin Hospital, Bandung individual, interpersonal, community, and professional who
healthcare service and policy levels, from had experienced in
General Hospital
the perspective of individuals at risk of HIV providing HIV care
and PLHIV. service in Bandung
Participant
3 HIV care cascade need Participants' opinions on hopes and needs PLHIV and Semi-structure
Purposive sampling. Include
assessment for HIV care at the individual, interpersonal, healthcare interview
PLHIV > 17 y.o. has been community, healthcare service, and policy professional who
received at least 1 year across levels, from the perspective of individuals at had experienced in
key population. Exclude PLHIV risk of HIV and PLHIV. providing HIV care
with 4th clinical stage, EoLC, and service in Bandung
severe mental health problem
Credibility Member checking
Data analysis
Instrumen
Transferability Thick description
Trust
Human instrument Thematic analysis worthi
Additional: tape record, field (Braun & Clarke, 2006) ness Dependability Triangulation
note
Confirmability Reflexivity
Collecting data procedure Ethical clearance

Respect for human dignity

Literature review and Inform consent directly to participant
research proposal

Review and curation of Respect for privacy and confidentiality

research proposal Anonnymeous; SIHA data will removed in our folder until data was
analyzed and published in form as academic article; Thesis document only
saved in Bandung Health Office and UNPAD library

Ethical clearence
Respect for Justice and inclusiveness
Selected participant will choice with justice and without any discrimination;
Quantitative collecting Every participants have equal rights to voice their perspective.
data
Beneficence and non-maleficence
This study will benefit and inform a better understanding in the progress
Qualitative collecting toward UNAIDS target related HIV care cascade and factor influencing;
data there is no potential harm in this study, all of the activity in this study will
adhere to the agreement between researcher and participant
Thank you very much 