Abstract
COVID-19 pandemic known to affect health service deliveries including for HIV care support and treatment. In this retrospective study involving 2,780 people living with HIV (PLHIV), we evaluated impact of COVID-19 pandemic by comparing the proportion of PLHIV linked to care, started antiretroviral therapy (ART), retained in care (within the first 3 months of treatment), and adhered to ART (within the first 3 months of treatment) between the pre-pandemic period (2018–2019) and pandemic period (2020–2021) in Yogyakarta and Bandung, Indonesia. Our study showed that during the pandemic period the number of PLHIV linked to care was 18% lower (1,529 vs 1,251) and those retained in care was significantly lower (59.6% vs 53.3%, p = 0.0009) than the pre-pandemic period. Whereas, proportion in ART initiation (79.6% vs 78.3%, p = 0.3892) and ART adherence (50.0% vs 46.8%, p = 0.1010) were not statistically different. Multivariate analysis showed that ART initiation (aOR = 1.00, p = 0.996) nor retention in care (aOR = 0.90, p = 0.344) were not significantly different between two period cohorts. Adherence for the first three months of treatment, however, was significantly higher in the pandemic cohort (aOR = 1.53, p = 0.009). In the subgroup analysis, older PLHIV and those attending hospitals (tertiary versus primary care clinics) were significantly less likely to initiate ART, be retained in care, or adhere to ART. This study provides evidence of the impact of the COVID-19 pandemic on several characteristics of the HIV treatment cascade such as lower number of linkage to- and retention in care, lower number of older PLHIV, and attendance to tertiary care (hospital). General and HIV-specific mitigation strategies should be designed to minimise pandemic related disruptions and to support the continuity of HIV care to face possible future health crises.
Introduction
The COVID-19 pandemic has had a massive impact on public health services worldwide. In Indonesia, there were 6,829,221 cases of COVID-19, and 162,063 COVID-19 deaths recorded between 2020–2024 [1]. Most cases were on Java Island [2]. In 2024, Indonesia reported an estimated 570,000 people living with HIV (PLHIV), more than in any other country in Southeast Asia [3,4]. HIV/AIDS cases were most prevalent on Java Island, particularly in East Java, West Java, and Central Java [5]. In 2024, only 60% of PLHIV were aware of their status; among them, 67% were on antiretroviral therapy (ART), 59% of those on ART had undergone viral load testing, and just 56% achieved viral suppression [5].
Prior to the pandemic, HIV services in Indonesia routinely delivered through a network of Comprehensive Care and Support for Treatment (CST) facilities via monthly in-person visits, during which patients received one-month ART supplies, adherence counselling, and laboratory monitoring [6]. However, during the early stages of the COVID-19 pandemic, concerns were quickly raised about the potential disruptions to HIV treatment and care and the increased risk of PLHIV developing severe illness [7–11].
In an effort to control the pandemic, the Indonesian government imposed wide scale mobility restrictions and reprioritized health care funding towards COVID-19, resulting in reduced access to many other core health services [12,13]. Given that much of Indonesia’s HIV program is supported by international donors (28.8%), including the Global Fund, this heavy reliance on external funding may have further exacerbated the health system’s vulnerability during the COVID-19 crisis, particularly on key population outreach and peer support [14]. Evidence from a range of low- and middle-income countries (LMIC) showed that these types of restrictions had the potential to undermine access to HIV treatment, a central element of HIV control strategies globally, by disrupting medicine/diagnostic supplies, diverting staff from testing, counselling, and outreach services [15–17]. To mitigate these effects, the Ministry of Health issued pandemic-specific guidelines in 2020, including multi-month ART dispensing (2–3 months), triage, and COVID-19 symptom screening at clinics [18]. Despite these efforts, increased fear of COVID-19 in the community and rising levels of unemployment and poverty threatened access to HIV care [19], increasing the risk of HIV treatment failure, disease relapse/progression, and transmission of infection [20,21].
Several investigations reported on the impact of the COVID-19 pandemic on services for HIV-related key populations in Indonesia [22–24]. However, none of these directly measured the impact of the COVID-19 pandemic on the uptake and continuity of HIV treatment using well-characterised clinical cohorts, for Indonesia or any other South-East Asia country [25,26]. Our study sought to address this gap by assessing the impact of the pandemic on people enrolled in HIV treatment in two cities in Indonesia experiencing a high burden from COVID-19.
Methods
Ethics statement
The DOMINO study was approved by the ethics committees of Universitas Gadjah Mada Yogyakarta (No KE/FK/1410/EC/2021), the London School of Hygiene and Tropical Medicine (No 22829), and the University of New South Wales (No HC200989). All three ethics committees approved the waiving of consent for patient inclusion in our cohort study on the basis that health facilities contributed de-identified medical records data to protect privacy.
Study design
This study was part of the DOMINO study, which sought to measure the effects of the COVID-19 pandemic on tuberculosis and HIV care in Indonesia. Observational retrospective cohort data on PLHIV linked to care were collected from 2018 – 2021. For this analysis, we compare two datasets from 2018-2019 (representing the pre-COVID-19 pandemic period) and from 2020-2021 (representing the during COVID-19 pandemic period). Data collection was conducted from 01 December 2021 until 01 December 2022.
Study setting
The study was conducted in two major cities on Java Island, i.e., Bandung and Yogyakarta. These two cities were selected based on their high number of COVID-19 cases and heavy HIV burden [27,28]. Between 2020 and 2021, Bandung reported 99,324 COVID-19 cases and 1,423 COVID-19 deaths [29]. In 2021, there were 2,397 people known to be living with HIV [27]. For the same time period, Yogyakarta reported 35,763 COVID-19 cases, 1,164 COVID-19 deaths, and 1,421 HIV cases [28,30]. The sites of Bandung and Yogyakarta were selected to reflect conditions in larger Indonesian cities and the findings are expected to be applicable to other cities beyond just the most affected areas [31,32]. Feasibility factors also influenced site selection, including our ability to effectively engage with existing staff working in city health offices and health facilities.
Indonesia’s health system comprises both public and private providers with decentralized administration. Private healthcare includes hospitals and clinics run by non-profit organizations, for-profit entities, and individual practitioners who may work both in public and private sectors. Public healthcare services are stratified between primary health care centres (also known as Pusat Kesehatan Masyarakat or Puskesmas), and hospitals [33]. Puskesmas serve as primary points of contact, offering a wide range of services including curative, rehabilitative, preventive, and promotive care both onsite and through community outreach programs. In contrast, hospitals provide specialised and tertiary care [33].
Services for PLHIV are administered through a network of Comprehensive Care and Support for Treatment (CST) facilities, which deliver antiretroviral therapy (ART). In Bandung, there are eleven government CST and five private CST facilities, the corresponding numbers for Yogyakarta being seven government CST and three private CST facilities [27,30]. However, there are no formal national criteria determining whether PLHIV receive care at hospitals or primary health centres. Service utilization depends on clinical condition of the patient, the availability and capacity of local facilities to provide CST services, including one-stop testing and treatment. Patients with HIV clinical stage 3 or 4 required specialized care and laboratory equipment [34].
At CST facilities, data on PLHIV who have been linked to care but have not yet initiated ART are recorded in the pre-ART register, while those who have started ART are recorded in the ART register. National guidelines recommend same-day or seven-days at the latest of ART initiation upon HIV diagnosis for asymptomatic patient. However, ART initiation also depends on clinical factors and/or patient readiness [35]. Health facilities upload their pre-ART and ART data every month to the national HIV/AIDS Information System (SIHA/Sistem Informasi HIV/AIDS) developed by the Indonesian Ministry of Health in 2012 [36]. This data collection process remained consistent during the entire study period.
Study procedures
Data was collected from the pre-ART and ART registers in fifteen public CST health facilities, including nine Puskesmas, four hospitals, and two private clinics, with four facilities located in Yogyakarta and eleven in Bandung. All PLHIV enrolled in care from January 2018 to December 2021 were included. Data were extracted from all participating facilities. Prior to analysis, all data were verified together with health facilities and the City Health Offices, and pre-ART and ART data were merged based on the national registration number of each PLHIV. We included all individuals recorded in the SIHA registry with no exclusion criteria applied. All research activities were undertaken with the permission from the City Health Offices.
Data analysis
Data were analysed using Stata 17 (StataCorp, College Station, TX, USA). For each study period (i.e., pre-COVID-19 and during COVID-19), we determined the number of PLHIV linked to care, started on ART, retained in care, and adherent to ART. Although viral suppression is the preferred indicator of treatment success, most PLHIV in Indonesia do not receive viral load (VL) testing due to the limited availability of testing devices [37]. Similarly, CD4 testing remains inconsistent, with only 53% of PLHIV receiving baseline CD4 testing [38]. As a result, we were unable to include viral suppression and CD4 count in our treatment cascade analysis. We have used the term ‘linked to care’ to define clients diagnosed with HIV who successfully commenced treatment. ‘Started ART’ includes any clients diagnosed with HIV who entered treatment services and began ART based on information in the SIHA registry for each time period (2018–2019 and 2020–2021). ‘Retained in care’ includes PLHIV that started ART and had at least two outpatient visits during the first 3 months of ART. ‘Adherent to ART’ includes PLHIV retained in care with a documented medication adherence rate of at least 95% during the first three months of treatment. Medication adherence is based on ART refill timeliness, defined as within 30 days of the scheduled date [39,40]. PLHIV linked to care in the last three months of the ‘pre-COVID-19’ study period (i.e., October-December 2019) or ‘during the COVID-19’ study period (i.e., October-December 2021) were excluded from our analyses as they could not meet our definition of ‘retained in care’ or ‘adherent to ART’. Binomial confidence intervals were calculated for the proportion of individuals starting ART, retained in care, and adherent to ART. Logistic regression was used to evaluate the impact of COVID-19 at each step in our HIV care cascade and when adjusting for demographic and health facility characteristics including: age; sex; education; employment status; marital status; HIV key populations (men who have sex with men, female sex workers, people who inject drugs, transgender women and non-key population); and facility type (Puskesmas and private clinic, and hospital). In our final multivariate model, all covariates were retained regardless of statistical significance. Individuals with missing covariate data were retained in all analyses by assigning them to a missing category for the covariate. We also performed interaction analyses to assess the impact of COVID-19 among study sub-populations defined by the above-mentioned demographic and health facility characteristics.
Results
HIV treatment cascade – whole study population
The study included 2,780 PLHIV enrolled in care. Of those, 1,529 were linked to care pre-COVID-19 pandemic and 1,251 were linked to care during the pandemic. Table 1 shows that each cohort’s demographic and clinical characteristics were broadly consistent.
Table 1. Characteristics of PLHIV linked to care pre-COVID-19 and during the COVID-19 pandemic.
| Pre-COVID-19 (n = 1,529), % | During-COVID-19 (n = 1,251), % | |
|---|---|---|
| Age (years) | ||
| Mean (SD) | 29.9 (8.6) | 29.5 (87) |
| Median (IQR) | 28 (23 - 34) | 27 (23 - 34) |
| Age group | ||
| <16 | 1 (0.1) | 2 (0.2) |
| 16-19 | 50 (3.3) | 60 (4.8) |
| 20-29 | 834 (54.5) | 687 (54.9) |
| 30-39 | 429 (28.1) | 339 (27.1) |
| 40-59 | 204 (13.3) | 150 (12.0) |
| >60 | 8 (0.5) | 10 (0.8) |
| Missing data | 3 (0.2) | 3 (0.2) |
| Sex | ||
| Male | 1343 (87.8) | 1122 (89.7) |
| Female | 186 (12.2) | 129 (10.3) |
| Highest level of education | ||
| Primary school or less | 67 (4.4) | 41 (3.3) |
| High school | 902 (59.0) | 736 (58.8) |
| University or diploma | 460 (30.1) | 260 (20.8) |
| Missing data | 100 (6.5) | 214 (17.1) |
| Employment | ||
| Employed or self-employed | 1,100 (71.9) | 806 (64.4) |
| Unemployed or student | 332 (21.7) | 231 (18.5) |
| Missing data | 97 (6.3) | 214 (17.1) |
| Marital status | ||
| Married | 312 (20.4) | 185 (14.8) |
| Not Married | 1,052 (68.8) | 656 (52.4) |
| Divorced | 84 (5.5) | 44 (3.5) |
| Missing Data | 81 (5.3) | 366 (29.3) |
| Population group | ||
| Men Who Have Sex with Men | 947 (61.9) | 756 (60.4) |
| Female Sex Workers | 159 (10.4) | 91 (7.3) |
| People Who Inject Drugs | 36 (2.4) | 32 (2.6) |
| Transgender Women | 7 (0.5) | 3 (0.2) |
| Non-Key Population | 358 (23.4) | 358 (28.6) |
| Missing Data | 22 (1.4) | 11 (0.9) |
| Pregnancy status (Female only; n = 315) | ||
| Pregnant | 8 (4.3) | 6 (4.7) |
| Not Pregnant | 114 (61.3) | 52 (40.3) |
| Missing Data | 64 (34.4) | 71 (55.0) |
| Clinical stage | ||
| Asymptomatic | 802 (52.5) | 664 (53.1) |
| Mild symptoms | 122 (8.0) | 63 (5.0) |
| Severe symptoms | 130 (8.5) | 64 (5.1) |
| AIDS | 23 (1.5) | 13 (1.0) |
| Missing Data | 452 (29.6) | 447 (35.7) |
| Health Facilities | ||
| Puskesmas and Private Clinic | 926 (60.6) | 911 (72.8) |
| Hospital | 603 (39.4) | 340 (27.2) |
Compared with the pre-COVID-19 period, a smaller proportion of individuals linked to care were started on ART (79.6% (95%CI 77.5-81.6) vs 78.3% (95%CI 75.9-80.5), p = 0.3892), retained in care (59.6% (95%CI 57.1-62.1) vs 53.3% (95%CI 50.5-56.1), p = 0.0009), and adherent to ART (50.0% (95%CI 47.4-52.5) vs 46.8% (95%CI 44.0-49.7), p = 0.1010) in the COVID-19 period (Fig 1). Results for Bandung and Yogyakarta individually were similar to our pooled results (see Supplementary material, S1 Fig and S2 Fig). Cascade results for Puskesmas, private clinic, and hospital can be seen in the Supplementary material file, S3 Fig and S4 Fig.
Fig 1. The cascade of HIV treatment in Bandung and Yogyakarta cities.
The multivariate analysis adjusted for PLHIV demographics and clinical characteristics shows that the likelihood of PLHIV being linked to care and starting ART was similar between pre-COVID-19 and during the COVID-19 pandemic (adjusted OR [aOR] = 1.00, 95%CI 0.81-1.23, p = 0.996). Likewise, among PLHIV starting ART, the probability of being retained in care during the pandemic was similar to that in the pre-COVID-19 period (aOR = 0.90, 95%CI 0.73-1.12, p = 0.344). Among those PLHIV on treatment and retained in care, there was a greater adjusted likelihood of being adherent to ART during the COVID-19 pandemic compared to pre-COVID-19 pandemic (aOR = 1.53, 95% CI 1.11 – 2.11, p = 0.009) (Table 2, Fig 1).
Table 2. Adjusted* odds of starting ART, being retained in care, and adhering to ART during COVID-19.
| COVID-19 era | Started ART (among 2780 linked to care) | Retained in care (among 2196 starting ART) | Adherent to ART (among 1578 retained in care) | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| n(%N) | Univariate OR | p | Multivariate OR* | p | n(%N) | Univariate OR | p | Multivariate OR* | p | n(%N) | Univariate OR | p | Multivariate OR* | p | |
| Pre COVID-19 | 1,217 (79.6) | 1.00 | 1.00 | 911 (74.9) | 1.00 | 1.00 | 764 (83.9) | 1.00 | 1.00 | ||||||
| During COVID-19 | 979 (78.3) | 0.92 (0.77, 1.11) | 0.389 | 1.00 (0.81, 1.23) | 0.996 | 667 (68.1) | 0.72 (0.60, 0.87) | 0.001 | 0.90 (0.73, 1.12) | 0.344 | 586 (87.9) | 1.39 (1.04, 1.86) | 0.026 | 1.53 (1.11, 2.11) | 0.009 |
*All odds ratios adjusted for age, sex, education, employment status, marital status, key HIV population, and treatment facility type.
HIV treatment cascade – subgroup analyses
Full details of our interaction analyses are shown in S1 Table. During the pandemic, those attending hospital facilities were significantly less likely to start ART (aOR = 0.67, 95% CI 0.49 – 0.90), be retained in care (aOR = 0.40, 95% CI 0.27 – 0.59), or remain adherent to ART (aOR = 0.55, 95% CI 0.41 – 0.73) as compared to the pre-COVID-19 period. On the other hand, those attending a Puskesmas during the COVID-19 period were significantly more likely to start ART (aOR = 1.41, 95% CI 1.06 – 1.87) and be adherent to ART (aOR = 1.25, 95% CI 1.01 – 1.54) compared to the pre-COVID-19 period. PLHIV aged >40 years were less likely to be retained in care (aOR = 0.47, 95% CI 0.26 – 0.82) or remain adherent to ART (OR = 0.62, 95% CI 0.39 – 0.99) during the COVID-19 pandemic compared with the pre-COVID-19 period. PLHIV aged 20–29 years (OR = 0.71, 95% CI 0.54 – 0.93), men (OR = 0.64, 95% CI 0.51 – 0.79), university or diploma graduates (OR = 0.62, 95% CI 0.41 – 0.93), those employed (OR = 0.72, 95% CI 0.56 – 0.92), those not married (OR = 0.65, 95% CI 0.51 – 0.84), and MSM (OR = 0.76, 95% CI 0.59 – 0.98) were all less likely to be retained in HIV care during the COVID-19 era compared to the pre-COVID-19 era.
Discussion
Our study shows that, while fewer PLHIV presented for care during the pandemic, HIV treatment cascades in Bandung and Yogyakarta were shown not to be negatively impacted by the COVID-19 pandemic, and that early adherence to HIV treatment actually improved during the pandemic after being adjusted to demographic and clinical characteristics. However, the cascade of care was not consistent across all subgroups evaluated. In particular, the cascade for PLHIV attending hospital services and older PLHIV were negatively impacted by the pandemic.
A reduction in the number of new patients being enrolled in care during the COVID-19 pandemic has been reported in several studies outside of Indonesia [16,17,26]. While some of these reductions may be attributed to decreased risk behaviours such as reduced sexual activity or needle sharing [41,42], in Indonesia, the decline appears to be more strongly linked to structural and socioeconomic barriers. These included fear of contracting COVID-19, mobility restrictions, limited information on ART service availability, requirements for vaccination certificates to travel, and financial hardship [8]. In Yogyakarta and Bandung, city surveillance data and our analysis show that there was an upward trend in HIV cases from 2016 until 2019, followed by a decline in 2020 and 2021, coinciding with the onset of the COVID-19 pandemic [27,30]. In Bandung, new HIV diagnoses dropped from 357 in 2019–82 in 2020 and 43 in 2021, while AIDS diagnoses showed a relatively smaller decrease [43]. Similarly, in Yogyakarta, the number of reported HIV diagnoses decreased from 123 in 2019–36 in 2020, before rising again to 93 in 2023 [44]. A sharp increase in both HIV and AIDS diagnoses in 2023–2024, particularly in Bandung (1,400 new HIV diagnoses and 1,284 AIDS diagnoses in 2024) [43], suggests a rebound in diagnoses as health services resumed and surveillance activities intensified. It is possible that COVID-19 delayed HIV diagnosis in some individuals which reduced transmission rates and led to more PLHIV seeking care at an advanced stage of disease [45,46].
This is the first study to assess the impact of the COVID-19 pandemic on HIV treatment using clinical cohort data from South-East Asia. Previous research has highlighted the pandemic’s effects on HIV retention in care and treatment adherence across various settings. For instance, in Uganda, clinic visits dropped by over 50% after national lockdowns [47]. Similarly, studies from ten countries in Asia [25], the United States [48,49], and Ethiopia [50] recorded a decrease in clinic visits and retention in care, and an increase in lost-to-follow-up cases due to the pandemic. Interruptions to in-person visits and medical follow-up services have also led to lower treatment adherence among PLHIV in several settings [51]. Our unadjusted findings concur with these earlier studies. However, after adjusting for patient and facility characteristics, which these earlier studies did not do, we found that the COVID-19 period was not associated with significant changes to the proportion of PLHIV starting ART or retained in care. Moreover, HIV treatment adherence was actually enhanced in the COVID-19 period in both Bandung and Yogyakarta. This could be attributed to the implementation of various mitigation strategies aimed at managing healthcare services amid the pandemic including multi-month ART dispensing and telemedicine [10]. Additionally, during the pandemic outreach workers pivoted their activities towards virtual outreach while peer support workers delivered medication to the homes of PLHIV [10,23].
It is important to note however that for certain groups, such as those attending hospital services and older PLHIV, the cascade of care was negatively impacted by the pandemic. One possible explanation is that the preparedness of hospitals for delivering services during the pandemic was highly variable, with a national survey showing that preparedness ranged from ‘adequate’ (highest) in 73% of hospitals to ‘not ready’ (lowest) in 9% of hospitals [52]. The Special Region of Yogyakarta demonstrated ‘adequate’ hospital preparedness, whereas in West Java, preparedness ranged from ‘adequate’ to ‘moderate’, with one hospital being classified as ‘not ready’ [52]. Additionally, PLHIV accessing treatment at a one-stop testing and treatment facility has a higher likelihoodin ART commencement and retention following an HIV diagnosis [35,40]. Loss to follow-up was also found to be higher in hospitals than in Puskesmas [53].
Furthermore, PLHIV aged ≥55 years were found to be significant predictors for missed appointments during the COVID-19 pandemic [54], suggesting that age-related concerns about infection risk may have adversely affected treatment continuity [55]. In our study, several other subgroups (e.g., men, university or diploma graduates) also had a low likelihood of being retained in HIV care during the COVID-19 era. Retention in HIV care is known to be worse among men than women in Indonesia [56]. In our study, university or diploma graduates were less likely to be retained in HIV care, a finding that contrasts with pre-pandemic research [40]. Many students who come from outside Bandung or Yogyakarta choose to return to their hometowns, of which potentially disrupting their HIV care. While there is limited direct evidence on student migration and its effect on HIV care, widespread internal migration during the pandemic has been reported across Indonesia [57]. This discrepancy underscores the need for further investigation to better understand why HIV care was negatively impacted by the pandemic in each of the subpopulations highlighted in our analysis.
These findings highlight the importance of targeted interventions to address the unique challenges facing the delivery and uptake of HIV services during public health crises and emergencies. Measures employed in Indonesia included testing clients for COVID-19 before providing medical care, enforcing physical distancing at healthcare facilities, revising medicine dispensing schedules, and involving community health workers, community pharmacies, and peer support workers in outreach activities like the home delivery of medicines [23,58,59]. Additionally, telemedicine was utilised for consultations [10]. Many of these mitigation strategies are shown to have improved adherence to ART treatment across a range of LMIC during the pandemic [59–63]. While multi-month ART dispensing has continued in many LMIC [64], it was only a temporary measure in Indonesia and is yet to be widely implemented [65] largely due to weak supply chain systems for ARTs [66,67]. Other strategies such as adjusting the national insurance policy to cover telemedicine and policy support to minimise disruptions in the ARV supply chain should also be explored. Further research is needed to assess the feasibility, effectiveness, and cost-effectiveness of these different strategies, considering the specific needs of PLHIV in Indonesia.
To our knowledge, this is the first retrospective cohort study using clinical cohort data to investigate the impact of the COVID-19 pandemic on the continuity of HIV care in Indonesia and South-East Asia more widely. What sets this research apart is the use of a large four-year cohort data set that focuses on newly diagnosed PLHIV (linked to care) as the starting point for evaluating treatment progression, instead of the more common approach of focussing on PLHIV who are already receiving treatment. However, our study also has some limitations. Mostly public HIV treatment centres in two cities were included, thereby limiting the generalizability of our findings in Indonesia. Our analysis was also based on secondary data generated during the routine clinical management of HIV-positive individuals at participating facilities and was therefore subject to incompleteness. Nonetheless, we were able to address many of the missing data points through extensive consultation and data confirmation with the City Health Office and participating health facilities. Our study did not differentiate between the various waves of the pandemic and their impact on the cascade of care, potentially overlooking useful lessons for policy-making including the timing and design of mitigation strategies.
Conclusion
The COVID-19 period was associated with a reduction in the number of PLHIV linked to care and disruptions to the HIV treatment cascade among various subpopulations in Bandung and Yogyakarta. These associations may delay progress by the Indonesian government towards ending AIDS by 2030. Implementing general and targeted mitigation strategies such as multi-month dispensing, telemedicine, and health worker task shifting and training could help alleviate these disruptions and support the continuity of HIV care in the face of possible future health crises.
Supporting information
This figure presents the number and percentage of PLHIV at each step of the HIV treatment cascade in Yogyakarta, including linkage to care, ART initiation, retention, and adherence.
(TIF)
This figure shows the number and percentage of PLHIV at each step of the HIV treatment cascade in Bandung, from diagnosis and linkage to ART initiation, retention, and adherence.
(TIF)
This figure displays the number of PLHIV at each cascade stage, stratified by type of treatment facility.
(TIF)
This figure presents the percentage distribution of PLHIV at each cascade stage, stratified by health facilities.
(TIF)
This table provides adjusted* odds ratios comparing the COVID-19 period with the pre-COVID-19 period for ART initiation, retention, and adherence. Sub-group analyses include age, sex, education level, employment status, marital status, key population category, and type of treatment facility. *Adjusted for age, sex, education, employment status, marital status, key population category, and treatment facility type. ^Pre-COVID-19 period is the reference group.
(DOCX)
Acknowledgments
We would like to thank the Ministry of Health of Indonesia, Yogyakarta City and Bandung City Health Offices, and all health facilities involved in this study. We also thank Professor Matthew Law for his statistical advice throughout this study.
Data Availability
The dataset analysed in this study contains sensitive health information on people living with HIV. Public data sharing is restricted under the data sharing agreement with the Indonesian Ministry of Health and in accordance with Peraturan Menteri Kesehatan Republik Indonesia Nomor 23 Tahun 2022 (Regulation of the Minister of Health No. 23/2022). De-identified data may be made available upon reasonable request to the Center for Tropical Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada (contact via pusatkedokterantropis@ugm.ac.id), subject to review and approval to ensure compliance with national regulations and institutional ethics requirements.
Funding Statement
This work was supported by the National Institute for Health and Care Research (NIHR) and the Medical Research Council [grant number MR/V030825/1 to VW] using UK aid from the UK Government to support global health research. The funders do not play any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. No authors received salary support from this funder. The views expressed in this publication are those of the authors and not necessarily those of the MRC, NIHR or the UK government.
References
- 1.Worldmeter. Indonesia COVID - Coronavirus Statistics. 2024 [cited 9 Oct 2024]. Available: https://www.worldometers.info/coronavirus/country/indonesia/
- 2.Antara News Indonesian News Agency. COVID-19 Development Data in Indonesia by Province (Data Perkembangan COVID-19 di Indonesia per Provinsi). 2023 [cited 26 Oct 2023]. Available: https://www.antaranews.com/covid-19
- 3.UNAIDS, UNICEF, WHO. HIV/AIDS Data Hub for the Asia Pacific 2023. 2023 [cited 9 Oct 2024]. Available: https://www.aidsdatahub.org/
- 4.UNAIDS. Indonesia Country Factsheet 2024. 2024 [cited 23 Jul 2025]. Available: https://www.unaids.org/en/regionscountries/countries/indonesia
- 5.Directorate General of Disease Prevention and Control Ministry of Health Republic of Indonesia. HIV/AIDS and Sexually Transmitted Infectious Diseases (STIs) Executive Report for January - December 2024 Period/Laporan Eksekutif Perkembangan HIV/AIDS dan PIMS Periode Januari-Desember 2024. 2024.
- 6.Kementerian Kesehatan Republik Indonesia. Indonesian National Clinical Guidelines for HIV Management/ Pedoman Nasional Pelayanan Kedokteran Tata Laksana HIV. 2019.
- 7.Yunihastuti E, Karjadi TH, Widhani A, Mahdi HIS, Sundari S, Hapsari AF, et al. Incidence and severity prediction score of COVID-19 in people living with HIV (SCOVHIV): experience from the first and second waves of the pandemic in Indonesia. AIDS Res Ther. 2022;19(1):47. doi: 10.1186/s12981-022-00472-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Fauk NK, Gesesew HA, Seran AL, Ward PR. Barriers to access to antiretroviral therapy by people living with HIV in an indonesian remote district during the COVID-19 pandemic: a qualitative study. BMC Infect Dis. 2023;23(1):296. doi: 10.1186/s12879-023-08221-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Wirawan GBS, Wardhani BDK, Pradnyani PE, Nurhalina A, Sulaiman N, Sukmaningrum E, et al. Behavioral Changes, Adaptation, and Supports among Indonesian Female Sex Workers Facing Dual Risk of COVID-19 and HIV in a Pandemic. Int J Environ Res Public Health. 2022;19(3):1361. doi: 10.3390/ijerph19031361 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Wulandari LPL, Negara SNS, Wahyuningtias SD, Mashuri YA, Putra IWCSD, Fardousi N, et al. Delivering HIV and TB services amidst the COVID-19 pandemic in Indonesia: a qualitative study of challenges and mitigation strategies. Journal of Global Health Reports. 2024;8. doi: 10.29392/001c.117620 [DOI] [Google Scholar]
- 11.Wulandari LPL, Negara SNS, Mashuri YA, Wahyuningtias SD, Putra IWCSD, Subronto YW, et al. A Systematic Review and Meta-analysis of the Impact of the COVID-19 Pandemic on Access to HIV Pre-exposure Prophylaxis: Lessons for Future Public Health Crises. J Acquir Immune Defic Syndr. 2024;97(3):208–15. doi: 10.1097/QAI.0000000000003488 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.The Global Fund. The Global Fund Results Report 2022. 2022.
- 13.Downey LE, Gadsden T, Del V, Vilas R, Peiris D, Jan S. The impact of COVID-19 on essential health service provision for endemic infectious diseases in the South-East Asia region: A systematic review. 2022. 10.1016/j [DOI] [PMC free article] [PubMed]
- 14.UNAIDS Evaluation Office. An Evaluation of the contribution of the UNAIDS Joint Programme to strengthening HIV and Primary Health Care outcomes | Indonesia report. 2023. Available: http://www.unaids.org/en/whoweare/evaluation
- 15.Prabhu S, Poongulali S, Kumarasamy N. Impact of COVID-19 on people living with HIV: A review. J Virus Erad. 2020;6(4):100019. doi: 10.1016/j.jve.2020.100019 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.McFall AM, Menezes NP, Srikrishnan AK, Solomon SS, Anand S, Baishya JJ, et al. Impact of the COVID-19 pandemic on HIV prevention and care services among key populations across 15 cities in India: a longitudinal assessment of clinic-based data. J Int AIDS Soc. 2022;25(7):e25960. doi: 10.1002/jia2.25960 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Harkness A, Morales V, Defreitas W, Atuluru P, Jaramillo J, Weinstein ER, et al. Impact of COVID-19 on HIV service delivery in Miami-Dade County: a mixed methods study. BMC Health Serv Res. 2022;22(1):1476. doi: 10.1186/s12913-022-08849-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Ministry of Health of the Republic of Indonesia. Protocol for Implementing HIV/AIDS Services During the COVID-19 Pandemic (Protokol Pelaksanaan Layanan HIV AIDS selama Pandemi COVID-19). PM.02.02/3/2022/2020 Indonesia: Kementerian Kesehatan Direktorat Jenderal Pencegahan dan Pengendalian Penyakit; Apr, 2020.
- 19.Winwood JJ, Fitzgerald L, Gardiner B, Hannan K, Howard C, Mutch A. Exploring the Social Impacts of the COVID-19 Pandemic on People Living with HIV (PLHIV): A Scoping Review. AIDS Behav. 2021;25(12):4125–40. doi: 10.1007/s10461-021-03300-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Adepoju P. Tuberculosis and HIV responses threatened by COVID-19. Lancet HIV. 2020;7(5):e319–20. doi: 10.1016/S2352-3018(20)30109-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Hogan AB, Jewell BL, Sherrard-Smith E, Vesga JF, Watson OJ, Whittaker C, et al. Potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria in low-income and middle-income countries: a modelling study. Lancet Glob Health. 2020;8(9):e1132–41. doi: 10.1016/S2214-109X(20)30288-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Magnani RJ, Wirawan DN, Sawitri AAS, Mahendra IGAA, Susanti D, Utami Ds NKAD, et al. The short-term effects of COVID-19 on HIV and AIDS control efforts among female sex workers in Indonesia. BMC Womens Health. 2022;22(1):21. doi: 10.1186/s12905-021-01583-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Hegarty B, Handayani A, Nanwani S, Praptoraharjo I. Chasing targets in a pandemic: The impact of COVID-19 on HIV outreach workers for MSM (men who have sex with men) in Jakarta, Indonesia. Glob Public Health. 2021;16(11):1681–95. doi: 10.1080/17441692.2021.1980599 [DOI] [PubMed] [Google Scholar]
- 24.Sukmaningrum E, Levy J, Negara MD, Devika D, Wardhani BDK, Wulandari LPL, et al. Lived experience, social support, and challenges to health service use during the COVID-19 pandemic among HIV key populations in Indonesia. BMC Health Serv Res. 2024;24(1):774. doi: 10.1186/s12913-024-11227-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Hung C-C, Banerjee S, Gilada I, Green K, Inoue Y, Kamarulzaman A, et al. Impact of COVID-19 on the HIV care continuum in Asia: Insights from people living with HIV, key populations, and HIV healthcare providers. PLoS One. 2022;17(7):e0270831. doi: 10.1371/journal.pone.0270831 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Shi L, Tang W, Hu H, Qiu T, Marley G, Liu X, et al. The impact of COVID-19 pandemic on HIV care continuum in Jiangsu, China. BMC Infect Dis. 2021;21(1):768. doi: 10.1186/s12879-021-06490-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Bandung City Health Office. Health Profile of the City of Bandung in the Year 2021 (Profil Kesehatan Kota Bandung Tahun 2021). 2021.
- 28.Government of Yogyakarta City. Information on the Development of COVID-19 in Yogyakarta City (Informasi Perkembangan COVID-19 di Kota Yogyakarta). 2022 [cited 26 Oct 2023]. Available: https://corona.jogjakota.go.id/
- 29.Government of Bandung City. Details of COVID-19 Cases in Bandung City (Detail Kasus COVID-19 Kota Bandung). 2022 [cited 26 Oct 2023]. Available: https://covid19.bandung.go.id/detail-kasus
- 30.Yogyakarta City Health Office. Health Profile of Yogyakarta City for the Year 2022 (Data from 2021) (Profil Kesehatan Tahun 2022 Kota Yogyakarta (Data Tahun 2021)). Yogyakarta; 2022.
- 31.AIDS Data Hub. HIV and AIDS Data Hub for Asia-Pacific Review in slides Indonesia. 2023. Available: www.aidsdatahub.org
- 32.Data and Information Center Ministry of Health Republic of Indonesia. Daily COVID-19 Case Developments (Perkembangan Kasus Harian COVID-19). 2022 [cited 8 Jul 2024]. Available: https://dashboardcovid19.kemkes.go.id/tabel_konfirmasi
- 33.Mahendradhata Y, Trisnantoro L, Listyadewi S, Soewondo P, Marthias T, Harimurti P, et al. The Republic of Indonesia Health System Review. Health Systems in Transition. World Health Organization 2017 (on behalf of the Asia Pacific Observatory on Health Systems and Policies); 2017.
- 34.Menteri Kesehatan Republik Indonesia. Keputusan Menteri Kesehatan Republik Indonesia Nomor HK.01.07/Menkes/90/2019 Tentang Pedoman Nasional Pelayanan Kedoktera Tata Laksana HIV (Decree of the Minister of Health of the Republic of Indonesia Number HK.01.07/Menkes/90/2019 concerning the National Guidelines for Medical Services on HIV Management). 2019.
- 35.Subronto YW, Kusmayanti NA, Januraga PP, Dewa Wirawan LN, Wisaksana R, Sukmaningrum E, et al. Simplified clinical algorithm for immediate antiretroviral therapy initiation: The HATI [HIV awal (early) Test & Treat in Indonesia] implementation research in Indonesia. Indian J Med Res. 2022;156(6):729–41. doi: 10.4103/ijmr.ijmr_239_23 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Indonesian Ministry of Health Directorate General of Disease Prevention and Control. Manual Book of HIV-AIDS and STIs Information System Application (SIHA) Version 1.7. (Buku Manual Aplikasi Sistem Informasi HIV-AIDS dan IMS (SIHA) Versi 1.7). 2016.
- 37.Ssekalembe G, Isfandiari MA, Suprianto H. Current Status Towards 90-90-90 UNAIDS Target and Factors Associated with HIV Viral Load Suppression in Kediri City, Indonesia. HIV AIDS (Auckl). 2020;12:47–57. doi: 10.2147/HIV.S231173 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Meeting targets and maintaining epidemic control (EpiC) project. EpiC advanced HIV disease (AHD) program in Jakarta, Indonesia. N Engl J Med. 2022. [Google Scholar]
- 39.Umeokonkwo CD, Onoka CA, Agu PA, Ossai EN, Balogun MS, Ogbonnaya LU. Retention in care and adherence to HIV and AIDS treatment in Anambra State Nigeria. BMC Infect Dis. 2019;19(1):654. doi: 10.1186/s12879-019-4293-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Januraga PP, Reekie J, Mulyani T, Lestari BW, Iskandar S, Wisaksana R, et al. The cascade of HIV care among key populations in Indonesia: a prospective cohort study. Lancet HIV. 2018;5(10):e560–8. 10.1016/S2352-3018(18)30148-6 30143455 [DOI] [PubMed]
- 41.Mitchell KR, Willis M, Dema E, Baxter AJ, Connolly A, Riddell J, et al. Sexual and reproductive health in Britain during the first year of the COVID-19 pandemic: cross-sectional population survey (Natsal-COVID-Wave 2) and national surveillance data. Sex Transm Infect. 2023;99(6):386–97. doi: 10.1136/sextrans-2022-055680 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Whitfield M, Reed H, Webster J, Hope V. The impact of COVID-19 restrictions on needle and syringe programme provision and coverage in England. Int J Drug Policy. 2020;83:102851. doi: 10.1016/j.drugpo.2020.102851 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43.Bandung City Health Office. Bandung City Health Profile Year 2024/Profil Kesehatan Kota Bandung Tahun 2024. 2024.
- 44.Yogyakarta City Health Office. Yogyakarta City Health Profile Year 2024/Profil Kesehatan Kota Yogyakarta Tahun 2024. 2024.
- 45.Waterfield KC, Shah GH, Etheredge GD, Ikhile O. Consequences of COVID-19 crisis for persons with HIV: the impact of social determinants of health. BMC Public Health. 2021;21(1):299. doi: 10.1186/s12889-021-10296-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Mirzaei H, Moradi Y, Abbaszadeh S, Nasiri N, Mehmandoost S, Khezri M, et al. The Impact of COVID-19 on Disruptions of HIV-related Services: A Rapid Review. Med J Islam Repub Iran. 2022;36:98. doi: 10.47176/mjiri.36.98 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47.Wagner Z, Mukasa B, Nakakande J, Stecher C, Saya U, Linnemayr S. Impact of the COVID-19 Pandemic on Use of HIV Care, Antiretroviral Therapy Adherence, and Viral Suppression: An Observational Cohort Study From Uganda. J Acquir Immune Defic Syndr. 2021;88(5):448–56. doi: 10.1097/QAI.0000000000002811 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48.Sohail M, Mugavero M, Long D, Levitan EB, Batey DS, Reed-Pickens H, et al. Assessing the Impact of COVID-19 on Retention in HIV Primary Care: A Longitudinal Multisite Analysis. AIDS Behav. 2022;27(5):1514–22. doi: 10.1007/s10461-022-03886-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.Meyer D, Slone SE, Ogungbe O, Duroseau B, Farley JE. Impact of the COVID-19 Pandemic on HIV Healthcare Service Engagement, Treatment Adherence, and Viral Suppression in the United States: A Systematic Literature Review. AIDS Behav. 2023;27(1):344–57. doi: 10.1007/s10461-022-03771-w [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Adugna A, Azanaw J, Sharew Melaku M. The Effect of COVID-19 on Routine HIV Care Services from Health Facilities in Northwest Ethiopia. HIV AIDS (Auckl). 2021;13:1159–68. doi: 10.2147/HIV.S341012 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 51.SeyedAlinaghi S, Mirzapour P, Pashaei Z, Afzalian A, Tantuoyir MM, Salmani R, et al. The impacts of COVID-19 pandemic on service delivery and treatment outcomes in people living with HIV: a systematic review. AIDS Res Ther. 2023;20(1):4. doi: 10.1186/s12981-022-00496-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 52.Lestari F, Kadir A, Puspitasari A, Suparni, Wijaya O, El-Matury HJ, et al. Hospital preparedness for COVID-19 in Indonesia. Front Public Health. 2023;11:1187698. doi: 10.3389/fpubh.2023.1187698 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 53.Teshome W, Belayneh M, Moges M, Mekonnen E, Endrias M, Ayele S, et al. Do loss to follow-up and death rates from ART care vary across primary health care facilities and hospitals in south Ethiopia? A retrospective follow-up study. HIV AIDS (Auckl). 2015;7:167–74. doi: 10.2147/HIV.S85440 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 54.Chilot D, Woldeamanuel Y, Manyazewal T. COVID-19 Burden on HIV Patients Attending Antiretroviral Therapy in Addis Ababa, Ethiopia: A Multicenter Cross-Sectional Study. Res Sq. 2021;:rs.3.rs-699963. doi: 10.21203/rs.3.rs-699963/v1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 55.Şentürk S, Yıldırım Keskin A, Sarızayim Ş. The Relationship Between the Fear of COVID-19 in the Elderly Aged 65 Years and Over and Their Levels of Adaptation to the “New Normal”: A Cross-Sectional Study. Omega (Westport). 2021;87: 684. 10.1177/00302228211054315 [DOI] [PMC free article] [PubMed]
- 56.Rahmalia A, Price MH, Hartantri Y, Alisjahbana B, Wisaksana R, van Crevel R, et al. Are there differences in HIV retention in care between female and male patients in Indonesia? A multi-state analysis of a retrospective cohort study. PLoS One. 2019;14(6):e0218781. doi: 10.1371/journal.pone.0218781 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 57.Mashuri YA, Boettiger D, Wahyuningtias SD, Negara SNS, Subronto YW, Liverani M, et al. “I pity the TB patient”: a mixed methods study assessing the impact of the COVID-19 pandemic on TB services in two major Indonesian cities and distilling lessons for the future. BMJ Glob Health. 2024;9(5):e014943. doi: 10.1136/bmjgh-2023-014943 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 58.Mashuri YA, Wulandari LPL, Khan M, Ferdiana A, Probandari A, Wibawa T, et al. The response to COVID-19 among drug retail outlets in Indonesia: A cross-sectional survey of knowledge, attitudes, and practices. Lancet Reg Health West Pac. 2022;22:100420. doi: 10.1016/j.lanwpc.2022.100420 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 59.Hoke T, Bateganya M, Toyo O, Francis C, Shrestha B, Philakone P, et al. How home delivery of antiretroviral drugs ensured uninterrupted HIV treatment during COVID-19: experiences from Indonesia, Laos, Nepal, and Nigeria. Glob Health Sci Pract. 2021;9:978–89. doi: 10.9745/GHSP-D-21-00168/-/DCSUPPLEMENTAL [DOI] [PMC free article] [PubMed] [Google Scholar]
- 60.The Global Fund. Mitigating the Impact of COVID-19 on Countries Affected by HIV, Tuberculosis and Malaria. 2020. 2020.
- 61.Gatechompol S, Avihingsanon A, Putcharoen O, Ruxrungtham K, Kuritzkes DR. COVID-19 and HIV infection co-pandemics and their impact: a review of the literature. AIDS Res Ther. 2021;18(1):28. doi: 10.1186/s12981-021-00335-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 62.Harsono D, Deng Y, Chung S, Barakat LA, Friedland G, Meyer JP, et al. Experiences with Telemedicine for HIV Care During the COVID-19 Pandemic: A Mixed-Methods Study. AIDS Behav. 2022;26(6):2099–111. doi: 10.1007/s10461-021-03556-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 63.Pry JM, Sikombe K, Mody A, Iyer S, Mutale J, Vlahakis N, et al. Mitigating the effects of COVID-19 on HIV treatment and care in Lusaka, Zambia: a before-after cohort study using mixed effects regression. BMJ Glob Health. 2022;7(1):e007312. doi: 10.1136/bmjgh-2021-007312 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 64.Bailey LE, Siberry GK, Agaba P, Douglas M, Clinkscales JR, Godfrey C. The impact of COVID-19 on multi-month dispensing (MMD) policies for antiretroviral therapy (ART) and MMD uptake in 21 PEPFAR-supported countries: a multi-country analysis. J Int AIDS Soc. 2021;24 Suppl 6(Suppl 6):e25794. doi: 10.1002/jia2.25794 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 65.UNAIDS Regional Office for Asia and The Pacific. A rapid assessment of multi-month dispensing of antiretroviral treatment and pre-exposure prophylaxis the Asia-Pacific region Final Report. 2020.
- 66.Luis H, Fridayantara WD, Mahariski P, Wignall FS, Irwanto I, Gedela K. Evolving ART crisis for people living with HIV in Indonesia. Lancet HIV. 2020;7(6):e384–5. doi: 10.1016/S2352-3018(20)30138-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 67.Gedela K, Rajus N, Luis H, Fridayantara WD, Irwanto I, Sukmaningrum E, et al. Antiretroviral drug switches to zidovudine-based regimens and loss to follow-up during the first COVID-19 lockdown in Bali, Indonesia. HIV Med. 2022;23(9):1025–30. doi: 10.1111/hiv.13298 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
This figure presents the number and percentage of PLHIV at each step of the HIV treatment cascade in Yogyakarta, including linkage to care, ART initiation, retention, and adherence.
(TIF)
This figure shows the number and percentage of PLHIV at each step of the HIV treatment cascade in Bandung, from diagnosis and linkage to ART initiation, retention, and adherence.
(TIF)
This figure displays the number of PLHIV at each cascade stage, stratified by type of treatment facility.
(TIF)
This figure presents the percentage distribution of PLHIV at each cascade stage, stratified by health facilities.
(TIF)
This table provides adjusted* odds ratios comparing the COVID-19 period with the pre-COVID-19 period for ART initiation, retention, and adherence. Sub-group analyses include age, sex, education level, employment status, marital status, key population category, and type of treatment facility. *Adjusted for age, sex, education, employment status, marital status, key population category, and treatment facility type. ^Pre-COVID-19 period is the reference group.
(DOCX)
Data Availability Statement
The dataset analysed in this study contains sensitive health information on people living with HIV. Public data sharing is restricted under the data sharing agreement with the Indonesian Ministry of Health and in accordance with Peraturan Menteri Kesehatan Republik Indonesia Nomor 23 Tahun 2022 (Regulation of the Minister of Health No. 23/2022). De-identified data may be made available upon reasonable request to the Center for Tropical Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada (contact via pusatkedokterantropis@ugm.ac.id), subject to review and approval to ensure compliance with national regulations and institutional ethics requirements.