Developing a Culturally Informed Peer Support Model for Men Who Have Sex With Men Living With HIV: A Qualitative Study in Indonesia

Abstract

Background

Men who have sex with men (MSM) living with HIV in Indonesia experience intersecting stigma affecting psychosocial wellbeing and healthcare engagement. Existing peer support models often lack cultural and spiritual relevance.

Aim

This study aimed to develop a culturally informed peer support model based on the experiences of MSM living with HIV and key stakeholders.

Methods

A qualitative study was conducted in Central Java, Indonesia, using in-depth interviews, a focus group discussion, and field observations. Data were analysed using reflexive thematic analysis.

Results

Three themes emerged: stigma and internalised stigma, barriers to healthcare access, and the need for holistic peer support integrating psychosocial, spiritual, and cultural aspects. These informed a culturally grounded peer support model integrating the Information-Motivation-Behavioural Skills framework with the Javanese philosophy of Sangkan Paraning Dumadi.

Conclusion

This model may support HIV care engagement and improve the relevance of peer support interventions among MSM living with HIV.

Introduction

The global HIV epidemic continues to disproportionately affect men who have sex with men, who face acquisition risks twenty-six times higher than the general population. In the Asia-Pacific region, men who have sex with men accounted for forty-four percent of new HIV infections in 2019. ¹ In Indonesia, the epidemic among MSM has intensified in recent years, driven by a complex interplay of behavioural, structural, and socio-cultural factors. ² The province of Central Java, including culturally rich urban settings, has experienced a steady rise in HIV cases among MSM, highlighting the urgent need for tailored interventions that are both evidence-based and culturally congruent. ³ A growing body of literature demonstrates that MSM living with HIV experience intersecting stigma related to both HIV status and sexual orientation, often described as “double stigma”, which negatively affects mental health, healthcare access, and treatment engagement. ⁴ In Indonesia’s sociocultural context, where same-sex relations remain highly stigmatized, such challenges are further amplified by cultural norms, moral judgments, and limited public discourse on sexual diversity. ⁵ This pervasive stigma not only affects psychosocial wellbeing but also undermines engagement with HIV services, including testing, treatment adherence and retention in care. ⁶

Peer support interventions have been shown to improve psychosocial wellbeing and healthcare engagement among people living with HIV. ⁷ However, most existing models are designed without adequate consideration of local cultural frameworks or spiritual dimensions, which are crucial determinants of acceptability and effectiveness in collectivist, faith-oriented societies. ⁸ In the Indonesian context, culturally adapted interventions remain scarce, and empirical evidence on their development, validation, and implementation is limited. This represents a clear research gap that hampers the optimization of HIV care strategies for MSM populations.

The importance of cultural and social dimensions in HIV prevention extends beyond the Indonesian context. The effective HIV prevention in diverse settings including Australia, Uganda, and Zimbabwe was achieved through genuine partnerships among government, affected communities, and public health stakeholders, emphasizing what they termed “social public health”. Their analysis revealed that prevention successes arose from community mobilization and social transformation rather than solely biomedical interventions, with cultural norms, social relations, and collective responses playing central roles in reducing HIV transmission. This global evidence underscores that culturally grounded approaches are not merely contextual adaptations but fundamental requirements for effective HIV prevention across diverse populations. The challenge is particularly acute in collectivist societies where spiritual and cultural identity significantly influence health behaviors, coping mechanisms, and treatment adherence, making culturally adapted interventions essential rather than optional. ⁹ Integrating cultural and spiritual perspectives into peer support interventions is essential to ensure their relevance and effectiveness in local contexts. Cultural values influence how individuals cope with stigma and engage with healthcare services. Therefore, incorporating culturally grounded approaches may strengthen peer support interventions for MSM living with HIV. ¹⁰

The study contexts offers a unique foundation for culturally grounded intervention design. Embedded within Javanese cultural traditions, the local philosophy of ‘Sangkan Paraning Dumadi’ which emphasizes existential reflection on origin, purpose, and moral responsibility presents an opportunity to integrate spiritual and cultural meaning-making into peer support frameworks. This philosophical concept teaches humans to live life in the best possible way, guiding individuals toward purposeful existence. The philosophy posits that life has a good origin (Sangkan), can achieve a good direction or purpose (Paran), and ultimately reach perfection (Dumadi). Sangkan Paraning Dumadi serves as a guiding principle to prevent humans from living ‘sak paran-paran’ (without direction), emphasizing that all actions must have clear objectives aimed at achieving perfection both for oneself and others.1 ¹¹

While ‘Sangkan Paraning Dumadi’ is rooted in Javanese culture, its underlying principles of existential reflection, purposeful living, and moral responsibility resonate with universal human values found across collectivist societies. The philosophy’s emphasis on understanding one’s origin, purpose, and ultimate destination aligns with existential frameworks in other cultural contexts, particularly in Asian societies that prioritize harmony, collective welfare, and spiritual meaning-making. This conceptual alignment suggests potential transferability to populations with similar characteristics: collectivist value orientation, strong emphasis on family and community relationships, integration of spirituality in daily life, and experience of intersectional stigma. Therefore, while the specific cultural expressions may vary, the core intervention principles can be adapted to other Southeast Asian contexts, Muslim-majority societies, or communities where spiritual and cultural identity significantly influence health behaviors and coping mechanisms. While theoretical models such as the Information Motivation Behavioural Skills (IMB) model have been applied successfully to guide behavioural interventions for PLHIV. Their integration with indigenous philosophical constructs in HIV care for MSM remains underexplored. ¹²

Addressing this gap is both scientifically and practically important. Developing a culturally adapted, biopsychosocial–spiritual peer support model may enhance understanding of how cultural and behavioural factors influence HIV care engagement among men who have sex with men (MSM) living with HIV. Therefore, this study aimed to develop and validate a culturally adapted peer support model for MSM living with HIV in an urban Indonesian setting, integrating the Information-Motivation-Behavioural Skills (IMB) framework with the Javanese philosophy of Sangkan Paraning Dumadi. The study further seeks to provide a contextually relevant framework to inform peer support interventions and strengthen engagement in HIV care. ¹³

Methods

Study Design

This study employed an exploratory qualitative design to inform the development of a peer support model grounded in the lived experiences of MSM living with HIV. Data were collected by the primary researcher, a doctoral candidate with prior experience in HIV-related research and qualitative methods, including conducting in-depth interviews and community-based studies. To minimize potential bias, reflexivity was maintained through regular reflective journaling and team discussions throughout the research process.This approach was considered appropriate to capture the complex psychosocial, spiritual, and cultural dimensions of peer support within the Indonesian context. The study constituted the first phase of a model development process, in which empirically derived qualitative findings formed the foundation of the proposed model. The process of developing and validating the model is illustrated in Figure 1.

Figure 1.

Developing and validating peer support model

Participants and Setting

Participants were recruited using a purposive sampling strategy to ensure the inclusion of information-rich cases relevant to the study objectives. Recruitment was conducted in Central Java, Indonesia, between March and August 2024, in collaboration with local HIV-related services and community-based organizations. Participants were recruited from multiple settings to capture diverse perspective across clinical, community, and policy level. No prior relationship was established between the researchers and participants before data collection, except for initial contact facilitated through community networks. A total of 15 participants were recruited and grouped into four categories: MSM living with HIV (n = 6), peer supporters providing support to people living with HIV (n = 5), healthcare professionals involved in HIV services (n = 2) and policymakers (n = 2). The sample size was determined based on the principle of data saturation. Data saturation was achieved across data sources, as no new themes emerged from in-depth interviews, focus group discussion, and field observations during the later stages of analysis.

To ensure a comprehensive understanding of peer support within the local HIV context, participants were purposively selected to represent key stakeholder groups involved at multiple levels of peer support delivery and utilization. MSM living with HIV were included to capture lived experiences, perceived needs, and the impact of stigma on help-seeking behaviours. Peer supporters were selected to provide insights into the practical implementation of peer support within community-based settings. Healthcare professionals contributed clinical and service-level perspectives on HIV care delivery, while policymakers offered insights into programmatic and policy contexts shaping peer support initiatives. This multi-level sampling approach supported the development of a culturally adapted peer support model grounded in both experiential and structural perspectives. Eligibility criteria were defined for each participant category to ensure that participants possessed relevant experience and contextual knowledge aligned with the study objectives. The inclusion criteria for each group are detailed as follows.

MSM living with HIV:

• 1. Aged 18 years or older

• 2. Diagnosed with HIV for at least one year

• 3. Reported a history of sexual relations with same-sex partners within the past three months

• 4. Residing in Surakarta or surrounding areas

Peer supporters:

• 1. Actively involved in providing peer support services to people living with HIV

• 2. Having a minimum of one year of experience as a peer supporter

• 3. Delivering peer support activities

Healthcare professionals:

• 1. Medical doctors and nurses

• 2. Having at least three years of experience in providing HIV-related services

• 3. Working in healthcare facilities with a high volume of HIV cases

Policymakers:

• 1. Holding leadership roles directly related to HIV program coordination or policy implementation at the local level (Peer support leader)

• 2. Including the chairperson of the Peer Support Group Network and the chairperson of AIDS Commission (local AIDS Commission)

Data Collection

Multiple qualitative methods were used, including in-depth interviews (IDIs), focus group discussions (FGDs), and structured field observations. Multiple qualitative methods were employed to ensure comprehensive data collection. A total of 10 individual in-depth interviews (IDIs) were conducted: six with MSM living with HIV, two with healthcare providers, and two with policymakers (Local AIDS Commission and peer support group leader). Each IDI lasted 45–90 minutes and was conducted at private, participant-selected locations to ensure confidentiality and comfort. In-depth interviews were conducted to explore personal experiences of living with HIV, perceived benefits and challenges of peer support, experiences of stigma, and meanings attached to psychosocial and spiritual support. Additionally, one focus group discussion (FGD) was conducted with five peer support workers, lasting 90–120 minutes, to facilitate peer-to-peer dialogue and collective reflection on program experiences.

Field observations were conducted independently over three months, separate from interview and FGD sessions. Observations included: (1) eight weekly peer support group meetings to document social dynamics, support mechanisms, and cultural practices; (2) five visits to HIV clinic settings to observe healthcare service interactions and identify potential barriers to care; and (3) three community gathering events organized by MSM support networks to understand broader social contexts and community mobilization efforts. Field notes were recorded using a structured observation protocol focusing on social interactions, stigma manifestations, communication patterns, and cultural expressions relevant to HIV care and prevention. Field observations were conducted over three months in peer-support group meetings, healthcare facilities, and community gatherings. All sessions were audio-recorded with informed consent, conducted in Bahasa Indonesia, and accommodated local dialects.

Data Analysis

Audio recordings were transcribed verbatim and translated into English, with accuracy verified through back-translation. A reflexive thematic analysis, following Braun, V., & Clarke, (2019) six-phase framework was applied: familiarization, coding, theme generation, theme review, theme definition, and report production. NVivo 12 software was used to manage and organize the data. Two analysts independently coded the transcripts and mapped the findings onto the constructs of the IMB model and the overarching conceptual framework.

Rigour and Trustworthiness

Methodological rigour was ensured through multiple strategies. Credibility was strengthened by six months of sustained researcher engagement in the field, methodological and data source triangulation, participant validation of findings (member checking), scheduled weekly reflective discussions within the research team (peer debriefing), and in-depth case analysis. Dependability was supported by maintaining a comprehensive audit trail, applying a two-week interval code–recode procedure, and conducting independent reviews by an experienced qualitative researcher not directly involved in the study. Confirmability was promoted through reflective journaling, bracketing, and the inclusion of a research team diverse in gender, discipline, and cultural background. Transferability was facilitated by providing rich contextual descriptions, employing maximum variation sampling, and documenting detailed demographic characteristics of participants. This study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines to ensure transparency and rigor in qualitative reporting.

Development of the Peer Support Model

The initial model was developed by integrating key themes and their interrelationships identified during thematic analysis. The model aimed to represent core components of peer support and the processes through which peer interactions contributed to participants’ quality of life and coping with HIV-related stigma. The model was conceptual rather than procedural, emphasising meaning, relational processes, and contextual influences. The development of the peer support model followed a sequential process. First, qualitative data were collected from MSM living with HIV and relevant stakeholders. Second, thematic analysis was conducted to identify key needs and challenges. Third, an initial model was developed based on these findings. Finally, the model underwent iterative validation by an expert panel.

Expert Consultation and Model Refinement

Following the development of the initial model, expert consultation was conducted to refine its conceptual clarity and contextual relevance. A purposive panel of four experts was involved, including two HIV experts (one of whom was a healthcare provider who had previously participated in the qualitative phase), one cultural expert, and one psychologist. The remaining experts were not part of the initial participant group and were involved specifically during the model validation phase. Experts were provided with a visual representation of the model along with a narrative explanation of its components and underlying qualitative themes. They were invited to offer feedback on conceptual coherence, cultural and spiritual relevance, feasibility in community settings, and alignment with peer support practices in HIV care. The consultation process was conducted iteratively over several rounds. The HIV and cultural experts reviewed the model twice, while the psychological expert provided feedback across three rounds of evaluation. Input from all experts was analyzed qualitatively and used to guide successive refinements of the model. Feedback from experts was analysed qualitatively and used in an iterative refinement process. Revisions focused on clarifying relationships between model components, refining terminology to better reflect local cultural meanings, and strengthening the integration of psychosocial, spiritual, and cultural elements. This process was intended to enhance the robustness and contextual appropriateness of the model rather than to establish quantitative validity.

Ethical Considerations

This study was approved by the Ethics Committee of Universitas Sebelas Maret (Approval No. 75/UN27.06.11/KEP/EC/2024). The study was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants prior to data collection. Participation was voluntary, and confidentiality and anonymity were assured. Participants were informed of their right to withdraw at any time without consequences.

Results

Participant Characteristics

A total of 15 participants were recruited across four stakeholder groups to provide comprehensive perspectives on peer support needs for MSM living with HIV in an urban setting in Indonesia. Participants in this study included men who have sex with men living with HIV (n=6) and a diverse group of stakeholders (n=9), including peer support workers, a peer support group leader, a representative from the local AIDS Commission, and healthcare providers (a physician and a nurse). These groups contributed distinct but complementary perspectives. Participants living with HIV shared their lived experiences and personal needs, while stakeholders provided insights based on their roles in supporting, delivering, and managing HIV care and peer support services. The sample included six MSM living with HIV (ages 23-38 years), five peer support workers (ages 32-45 years), two healthcare providers (physician and nurse, ages 30-35 years), and two policy stakeholders (Local AIDS Commission representative and peer support group leader, ages 50-53 years). Most participants (n=9, 60%) were married, while single participants were predominantly MSM living with HIV (n=5, 83% of MSM participants). Educational backgrounds varied from high school (n=9) to graduate level (n=6), with HIV diagnosis duration ranging from 2-17 years among affected participants (Table 1).

Table 1.

Participant Demographics and Characteristics

Participant	Age	Sex	Role	Education	Experience/HIV duration (years)	Marital status
P1	53	Male	Local AIDS Commission	Graduate	9	Married
P2	35	Male	Physician	Graduate	5	Married
P3	30	Female	Nurse	Graduate	3	Married
P4	50	Male	Peer Support Group Leader	High school	17	Married
P5	32	Male	Peer Support Worker	High school	3	Married
P6	35	Male	Peer Support Worker	High school	2	Single
P7	37	Male	Peer Support Worker	High school	4	Single
P8	42	Female	Peer Support Worker	High school	5	Married
P9	45	Female	Peer Support Worker	High school	3	Married
P10	23	Male	MSM with HIV	High school	2	Single
P11	25	Male	MSM with HIV	High school	3	Single
P12	32	Male	MSM with HIV	Graduate	3	Single
P13	38	Male	MSM with HIV	Graduate	8	Single
P14	35	Male	MSM with HIV	High school	5	Single
P15	34	Male	MSM with HIV	Graduate	4	Single

Note. MSM = Men who have sex with men; Experience refers to years working in HIV care/peer support for healthcare providers and peer workers.

Qualitative Findings

Data were analysed using Braun and Clarke’s reflexive thematic analysis. All interviews and focus group discussions were transcribed verbatim and read repeatedly alongside field observation notes to achieve data familiarisation. Initial codes were generated inductively to capture meaningful features related to stigma experiences, engagement with healthcare services, peer support, and cultural spiritual meanings.

Codes were then examined and grouped into broader patterns of shared meaning, resulting in three themes: stigma and internalization, barriers to accessing services, and the need for holistic support. Themes were reviewed and refined through iterative comparison across data sources to ensure coherence and analytic distinctiveness.

In the final analytic phase, the interrelationships among themes were interpreted to move beyond description toward conceptual integration. This analytic synthesis informed the development of a conceptual peer support model that translates thematic findings into three intervention domains: (1) identity rediscovery through psychoeducation and self-reflection, (2) sense of purpose and meaning through spiritual and cultural integration, and (3) strengthening existence through peer support and social integration. These domains are visually represented in the conceptual model (Figure 2).

Figure 2.

Thematic analysis results

Thematic Analysis Results

Through systematic thematic analysis, three major themes emerged that characterized the complex challenges faced by MSM living with HIV and informed the development of the culturally adapted peer support model.

Theme 1: Double Stigma and Internalization

The most prominent finding, primarily reported by participants living with HIV and supported by observations from stakeholders, was the pervasive experience of double stigma related to both HIV status and sexual orientation, which became deeply internalized among participants. This stigma manifested as shame, guilt, and social withdrawal, significantly impacting mental health and healthcare engagement.

Shame and Self-Blame: Participants living with HIV consistently described their HIV status and sexual orientation as sources of profound shame and moral failure:

“I feel this is truly shameful, really embarrassing if people found out. So I still very much limit myself with this status.” (P11)

“I feel like this is my fault, like I'm being punished for my lifestyle. It's hard not to blame myself.” (P14)

This perspective was also highlighted by stakeholders, who observed similar patterns of self-stigmatization among individuals living with HIV:

“Sometimes the person stigmatizes themselves too, feeling dirty, having shame, sin, so they don't deserve to live normally.” (P1).

Social Isolation and Fear of Rejection: The fear of discrimination led to deliberate social isolation and selective disclosure, even to close family members:

“I'm only open to certain people, afraid it will spread everywhere, become more stigmatized. I'm afraid of being rejected in social relationships, problems at work.” (P13)

“I've felt negative before, making me afraid to meet people. Afraid of being avoided because of my condition.” (P10)

“I'm more closed off now, don't let many people know that I have HIV. Especially since my sexual orientation is also different, I'm even more closed off.” (P15)

Stakeholders further noted that fear of stigma often led individuals to limit social interactions and selectively disclose their status:

“They also expressed fear of being rejected by society due to their status. As a result, they preferred to conceal their HIV status and sexual identity.” (P2)

Psychological Impact: Internalized stigma resulted in significant mental health challenges, including depression, anxiety, and diminished self-worth:

“Sometimes I accept it, sometimes it's still hard to accept… I also sometimes experience anxiety… mood drops, can't accept and all sorts of things.” (P15)

“What affects me most is the social and psychological aspects, sometimes I feel down, and feel that I'm different from other men, becoming more insecure.” (P14)

In addition to personal accounts, stakeholders also emphasized the psychological burden associated with internalized stigma:

“This group appears to be at increased risk of depression as a result of compounded stigma. They frequently report feelings of being different from others.” (P1)

Theme 2: Healthcare Access Barriers

These barriers led to treatment delays, discontinuation, and reliance on peer intermediaries.

Discriminatory Healthcare Experiences: Participants reported judgmental attitudes and discriminatory treatment from healthcare providers:

“I also feel stigma from healthcare workers. They like to… judge… asking 'why are you like that, you should be a leader,' and making snide remarks. So I feel like they're actually judging me. Eventually, I became reluctant to get medication myself, sometimes asking a peer support to get it for me.” (P12)

“I had an experience of discrimination from healthcare workers. They made snide remarks about my sexual orientation, not everyone, but there are still one or two. So I minimize going to healthcare services that do that. Just find another place to be comfortable.” (P13)

Significant barriers to healthcare access were primarily reported by participants living with HIV, while stakeholders provided additional insights into how these barriers influenced care-seeking behavior:

“One of my patients reported experiencing difficulties and being neglected during hospital care, which ultimately led them to seek services at another healthcare facility.”(P3)

Treatment Avoidance and Discontinuation: Stakeholders further observed that fear of disclosure and stigma contributed to treatment discontinuation among some individuals.Fear of stigma led to complete avoidance of healthcare services:

“There are also those who don't want to go to healthcare services, afraid of being more stigmatized. Eventually, they don't take ARV.” (P1)

“Some also don't want to take medication, don't take pills, rather than have their status known.” (P3)

Seeking Alternative Healthcare Sources: Participants living with HIV often sought healthcare from different facilities or relied entirely on peer support networks:

“Healthcare feels judgmental because of sexual behaviour. They look cynical, we feel when we're judged differently than others. Eventually, our response is to check somewhere else, not go there anymore.” (P14)

Peer support workers highlighted their role in helping individuals navigate and access more supportive healthcare environments:

“We consistently provide information about free viral load testing and also offer support to clients who wish to transfer to another healthcare facility.” (P7)

Theme 3: Need for Holistic Support

Both participants living with HIV and stakeholders emphasized the importance of holistic, culturally sensitive support, although from different perspectives, culturally sensitive support that addressed not only medical needs but also psychological, social, spiritual, and cultural dimensions of living with HIV.

Emotional Support Through Peer Connection: Participants living with HIV highlighted that peer support provided emotional understanding and a sense of shared experience

“When there are peers, I feel like I have friends who understand what it feels like, so we're more enthusiastic. It's different with outsiders; they sometimes just tell us what to do.” (P12)

“Peer support can at least listen to our complaints. And we also don't feel alone.” (P10)

“Having someone who's been through the same thing makes all the difference. They don't just give advice, they understand.” (P11)

Stakeholders emphasized the importance of providing empathetic and structured support:

“We share our feelings and experiences, including how we have gone through difficult situations. This helps the clients feel more motivated, as they realize they are not alone.”(P9)

Spiritual and Religious Dimensions: Spiritual practices and religious support provided strength and coping mechanisms. MSM living with HIV described spirituality as a personal coping mechanism:

“Spirituality is personal… but reminding each other is also needed. For example, just do obligatory worship, like prayer.” (P11)

“When we're down, we remind each other to stay strong, obey taking medication and pray to be strong.” (P12)

“Faith gives me strength when everything else feels hopeless. It's not about judgment, it's about finding peace.” (P13)

Stakeholders emphasized its role in strengthening resilience and adherence:

“We consistently motivate them by emphasizing that there is always hope, as we are spiritual beings who believe in God. We encourage them to keep praying and to involve God in their lives.”(P1)

Cultural Philosophy Integration: The Javanese philosophy of Sangkan Paraning Dumadi emerged as a significant cultural resource. Participants living with HIV viewed this philosophy as a source of personal meaning:

“That philosophy teaches continuous goodness, from birth to death.” (P14)

“Understanding where we come from and where we're going helps me accept my situation and find meaning in it.” (P12)

Stakeholders considered it a culturally appropriate framework for guiding peer support interventions:

“According to me, it will influence PLHIV. At least how to not infect friends.” (P1)

Participants living with HIV perceived peer support as a trusted source of information, while stakeholders emphasized the importance of experiential knowledge in building trust.:

“Information from peer support is more accepted, because they experienced it themselves. So when they tell us about taking medication, the effects, I believe them.” (P13)

“They tend to trust and feel more open with peers who are also living with HIV, which makes them more receptive to advice.” (P2)

Conceptual Framework Integration

The qualitative findings revealed the complex interplay between cultural stigma, healthcare discrimination, and the need for holistic support among MSM living with HIV in Surakarta. The integration of the IMB model with Javanese cultural philosophy provided a framework for understanding how culturally adapted interventions could address the multifaceted challenges faced by this population (Table 2).

Table 2.

Comprehensive Framework of Qualitative Findings

Theme	Sub-themes & key manifestations	IMB component affected	Sangkan paraning dumadi integration	Intervention needs	Intervention activities (individual & group phase)
Theme 1:	1. Shame and Self-Blame	MOTIVATION	SANGKAN (Origin)	• Identity rediscovery	Individual Phase (Weeks 1-2):
Stigma and Internalization	Shame about HIV status and sexual orientation	Reduced by anticipated stigma and internalized shame	Understanding inherent self-worth and human dignity regardless of HIV status or sexual orientation	• Self-acceptance support	• Session 1: Self-concept exploration
	2. Social Isolation			• Psychoeducation on HIV and stigma	• One-on-one counselling
	• Fear of rejection and disclosure			• Self-reflection activities	• Strengths identification
	• Selective social withdrawal				Group Phase (Weeks 3-4):
	3. Psychological Impact				• Session 4: Stigma management training
	• Depression and anxiety				• Resilience building
	• Diminished self-worth
Theme 2:	1. Discriminatory Experiences	INFORMATION + BEHAVIORAL SKILLS	PARANING (Purpose)	• Healthcare navigation support	Individual Phase (Weeks 1-2):
Healthcare Access Barriers	• Judgmental provider attitudes	Impeded by healthcare discrimination and mistrust	Finding meaning in healthcare engagement and treatment adherence as purposeful living	• Peer advocacy	• Sessions 2-3: Physical & psychological needs assessment
	• Stigmatizing remarks			• Provider-patient communication skills	• Personalized care planning
	2. Treatment Avoidance			• Accompaniment services	Group Phase (Weeks 3-4):
	• Fear of disclosure in clinics				• Sessions 1-2: HIV knowledge & ART education
	• ART discontinuation				• Adherence strategies
	3. Alternative Sources
	• Seeking different facilities
	• Reliance on peer intermediaries
Theme 3:	1. Emotional Peer Connection	ALL IMB COMPONENTS	DUMADI (Perfection)	• Structured peer support groups	Individual Phase (Weeks 1-2):
Need for Holistic Support	• Shared understanding	Enhanced through comprehensive biopsychosocial-spiritual approach	Achieving wholeness and optimal well-being through integrated biopsychosocial-spiritual support	• Spiritual counselling	• Sessions 4-5: Social & spiritual needs
	• Solidarity and belonging			• Cultural philosophy integration	• Holistic needs assessment
	2. Spiritual Dimensions			• Meaning-making activities	Group Phase (Weeks 3-4):
	• Religious practices as strength			• Community building	• Session 3: Quality of life enhancement
	• Collective spiritual support				• Session 5: Sangkan Paraning Dumadi philosophy
	3. Cultural Integration				• Meaning-making & spiritual reflection
	• Cultural philosophy as resource				• Peer sharing & support
	• Trusted peer information
	4. Social Integration
	• Community building
	• Network strengthening
EXPECTED OUTCOMES: • ↑ ART Adherence • ↑ Quality of Life • ↓ Internalized Stigma• ↑ Healthcare Engagement

IMB = Information-Motivation-Behavioral Skills model.

Model Development Process

Based on qualitative findings, we developed a comprehensive peer support model through four iterative design cycles involving stakeholder consultation and co-creation workshops. The model integrated the IMB framework with ‘Sangkan Paraning Dumadi’ philosophy to address identified needs culturally and systematically. The preliminary model was subsequently reviewed through an expert consultation process involving an HIV practitioner from a community-based organization, a healthcare worker engaged in HIV services, a clinical psychologist, and a cultural expert. Experts assessed the model’s conceptual clarity, methodological coherence, content relevance, cultural congruence, and alignment with holistic HIV care principles.

Expert feedback supported the conceptual soundness and cultural appropriateness of the model. Overall mean scores across experts ranged from 3.50 to 3.78, indicating good to very good appropriateness across evaluation domains. The biopsychosocial–spiritual coverage of the model received consistently high ratings, reflecting strong alignment with holistic and culturally grounded care approaches. Minor variations in expert ratings were observed, particularly regarding content detail and methodological clarity. These insights informed targeted refinements to the model, including clarification of objectives, enhancement of culturally meaningful components, and strengthening of implementation guidance. Following refinement, the model was considered acceptable and feasible for application within community-based HIV peer support settings. A summary of expert assessments across evaluation criteria is presented in Table 3.

Table 3.

Expert Validation Scores for Peer Support Model

Assessment criteria	HIV practitioner (CoPS)	HIV practitioner (HCW)	Psychologist	Cultural expert	Mean score
Introduction
Background appropriateness	3.5	3.5	3.0	4.0	3.5
Needs analysis adequacy	3.5	3.5	3.0	4.0	3.5
Theoretical Foundation	3.5	3.0	4.0	4.0	3.63
Objective Clarity	4.0	3.0	4.0	4.0	3.75
Model Structure
Method clarity	3.5	3.5	4.0	3.0	3.5
Content appropriateness	3.0	4.0	3.0	4.0	3.5
Evaluation clarity	3.5	3.5	4.0	3.0	3.5
Biopsychosocial-spiritual coverage	4.0	4.0	4.0	4.0	4.0
HIV/AIDS program support	4.0	3.5	4.0	4.0	3.86
Overall Expert Mean	3.61	3.50	3.67	3.78	3.64

Rating scale: 1=Very Poor, 2=Poor, 3=Good, 4=Very Good; CoPS=Coordinator of Peer Support; HCW=Healthcare Worker.

Final Model Framework

The validated peer support model integrates biopsychosocial-spiritual care principles with Javanese cultural philosophy, specifically incorporating ‘Sangkan Paraning Dumadi’ as a framework for existential meaning-making and spiritual grounding. The model addresses the three major themes identified through structured peer support interventions that combine individual counselling, group support sessions, cultural integration activities, and spiritual reflection practices. The peer support model follows a sequential implementation approach, beginning with individual sessions followed by group sessions. The individual phase consists of five topics covering understanding of self-concept, fulfilment of physical, psychological, social, and spiritual needs. The group phase comprises five topics addressing HIV/AIDS knowledge, antiretroviral therapy (ARV) concepts, quality of life, stigma management, and the philosophy of ‘Sangkan Paraning Dumadi’. Each session is designed to complete one topic, with the individual phase completed over two weeks and the group phase implemented over an additional two weeks, resulting in a comprehensive four-week intervention program (Figure 3).

Figure 3.

Culturally adapted peer support model for MSM living with HIV

This structured approach ensures progressive skill-building and peer connection, starting with personal reflection and self-awareness in the individual sessions, then advancing to shared learning and community support in the group sessions. The integration of cultural philosophy throughout both phases provides participants with culturally resonant coping mechanisms and meaning-making frameworks. The peer support model is expected to enhance HIV/AIDS knowledge, increase motivation for health-promoting behaviours, improve prevention behaviours, strengthen therapy adherence, and enhance quality of life while reducing internalized stigma among MSM living with HIV. Through its culturally adapted approach, the model aims to address both the clinical and psychosocial needs of this vulnerable population within their cultural context.

Discussion

This study developed a culturally adapted peer support model for men who have sex with men (MSM) living with HIV in urban setting, Central Java, Indonesia, grounded in qualitative inquiry and refined through expert consultation. By centring the lived experiences of MSM living with HIV, the study ensured that social, cultural, and spiritual dimensions were embedded throughout the model development process. Consistent with previous evidence, culturally adapted interventions are more likely to be acceptable, relevant, and responsive to the needs of key populations, including MSM living with HIV. A central finding of the qualitative analysis was the persistence of intersectional or “double stigma,” arising from both HIV status and sexual orientation. This stigma was frequently internalized, manifesting as shame, guilt, fear, and social withdrawal, which in turn negatively affected mental health and engagement in HIV care. In high-stigma environments, internalized stigma often functions as a survival strategy, reinforcing concealment and avoidance of disclosure, with significant implications for wellbeing and treatment continuity. ¹⁴ These findings align with broader literature documenting the profound psychosocial burden of intersecting stigmas among MSM living with HIV.

MSM living with HIV experience complex problems encompassing biological, psychological, social, and spiritual aspects. These challenges are related to opportunistic infections, physical changes, disruptions in meeting daily needs, and the presence of double stigma that creates pressure, anxiety, depression, and fear of facing family or death. Feelings of shame, guilt, and low self-esteem are experienced as forms of internalized stigma in this population, leading to disruptions in social relationships, causing them to tend to withdraw and feel isolated. Spiritual problems are experienced when MSM living with HIV feel that God does not love them, leading them to blame God for their destiny.^15-18 These findings reinforce the need for holistic interventions that address the full spectrum of lived experience among MSM living with HIV. This perspective reinforces the understanding that sexual minorities living with HIV face a complex, multidimensional burden, where stigma and discrimination significantly influence health behaviors and care engagement. In line with patient-centered and consumer advocacy traditions, peer support interventions aim to mitigate stigma that may deter individuals from accessing services due to fear of discrimination. Importantly, shared lived experiences within peer relationships have been associated with improved treatment adherence. This emphasizes the value of empowerment-oriented, integrated approaches that address both personal and structural dimensions of stigma. ¹⁹

MSM living with HIV articulated their needs through lived experiences shaped by stigma, isolation, and psychological challenges, whereas stakeholders provided complementary insights into how these needs can be addressed within care systems. Consistent with prior research, stigma within healthcare settings remains a key barrier that requires structured and system-level interventions. Stakeholders emphasized the importance of culturally responsive and contextually grounded approaches, particularly in strengthening peer support delivery. Furthermore, peer-based interventions grounded in shared lived experiences have been shown to improve engagement in care and treatment adherence.^19,20 This convergence between lived experience and implementation-oriented perspectives supports the application of behavioral frameworks, such as the IMB model, in designing effective peer support interventions. The findings are consistent with the Information–Motivation–Behavioural Skills (IMB) model, which explains how anticipated stigma and fear of rejection can reduce motivation and impede health-promoting behaviours. Recent applications of the IMB model in HIV care have shown its utility in identifying behavioural barriers among MSM. ²¹ In the present study, this theoretical lens informed the development of peer support components designed to strengthen motivation and behavioural skills through culturally resonant and supportive social interactions.

These findings were also echoed by stakeholders, who observed that stigma within healthcare settings often leads to delayed care-seeking and treatment discontinuation among individuals living with HIV. Participants also reported significant barriers to healthcare access, often stemming from discriminatory attitudes or fear of mistreatment by providers. Similar findings have been reported in other settings, where healthcare-based stigma discouraged timely care-seeking and ART adherence. ²² Mistrust of healthcare providers also led some participants to rely on peer intermediaries to collect ART medication, a strategy that carries risks for continuity of care. A study confirms that discriminatory provider–patient interactions are linked to lower ART adherence and worse clinical outcomes, reinforcing the need for stigma-reduction and cultural humility training in HIV care. ²³

Participants MSM living with HIV emphasized their need for empathetic, non-judgmental, and culturally sensitive support, reflecting their lived experiences of stigma and isolation. In contrast, stakeholders highlighted the importance of delivering structured, consistent, and contextually appropriate peer support interventions. The convergence of these perspectives underscores the need for a holistic peer support model that is both experience-informed and implementation-oriented. The integration of perspectives from both individuals living with HIV and stakeholders enhances the credibility and applicability of the findings, providing a more comprehensive understanding of peer support needs in this context. Beyond clinical barriers, participants emphasized the importance of psychosocial, cultural, and spiritual support. Peer networks provided spaces for shared understanding, emotional connection, and solidarity, benefits that are well-documented in previous studies. ²⁴ Beyond biological and psychosocial approaches, spiritual approaches are necessary for PLHIV. Spiritual health is obtained when there is balance in other dimensions, namely physiological, psychological, social, and cultural. Strengthening spiritual aspects can be done through the belief that everything comes from God, awareness to purify the heart by drawing closer to God, and efforts to take wisdom from every event. ²⁵

Strategies for fulfilling biological needs include HIV transmission prevention, ARV adherence, and balanced nutrition fulfilment. Consistent condom use and medication adherence are key to HIV transmission prevention. ARV works by suppressing viral development, enhancing immunity, and reducing opportunistic infections. Balanced nutritional status reduces ARV side effects, helps increase weight gain, and supports physical recovery in PLHIV. ²⁶ Meanwhile, strategies for fulfilling psychological aspects include confidence in the therapy being undertaken, optimism, enthusiasm, and acceptance in life. Healthy psychology encourages good social interaction. ²⁷ A distinctive feature of the model was the integration of the Javanese philosophy ‘Sangkan Paraning Dumadi’, which offers a culturally grounded existential framework for resilience. Spiritual meaning-making has been shown to be a valuable coping mechanism in HIV care, and its inclusion in the model enhanced cultural relevance and participant engagement.^28,29

The operational design of the model followed a sequential mentoring process, beginning with individual sessions and progressing to group sessions, as presented in Figure 3.1. The two-week individual phase offered a private and secure space for participants to discuss sensitive issues, particularly for MSM living with HIV who had not yet disclosed their status. This setting facilitated trust-building and enabled tailored support to individual needs. The following two-week group phase emphasized peer-to-peer experience sharing, collective motivation, and exposure to role models who demonstrated effective coping and ART adherence. Cultural adaptation in the developed peer support model aligns with HIV case management policies. Continuous mentoring models can influence attitudes and behaviours to better understand, address, and reduce stigma and discrimination against PLHIV. ³⁰ Both phases were delivered using a structured curriculum that addressed biological, psychological, social, spiritual, and cultural dimensions, ensuring holistic coverage. This staged structure aligns with evidence that combining individualized counselling with group-based interaction strengthens empowerment, social connectedness, and intervention uptake.^31,32 Individual sessions are conducted at the beginning of mentoring as a means of self-acceptance with HIV-positive status. Self-acceptance is influenced by having a positive self-concept. Someone with a positive self-concept has high self-acceptance and self-esteem. A good understanding of self-concept can provide motivation to be more optimistic in living life. ³³

Expert consultation and validation further supported the acceptability, cultural congruence, and practical feasibility of the model. The highest ratings were observed for biopsychosocial–spiritual coverage, indicating strong alignment with holistic HIV care principles. Consistent with previous studies, multidisciplinary expert involvement enhances intervention fidelity and community uptake by ensuring relevance across clinical, psychological, and cultural domains. ³⁴ Evidence from recent trials reinforces the role of peer support in improving ART adherence, psychosocial outcomes, and healthcare engagement among MSM living with HIV. A systematic review and meta-analysis found that social support interventions yield moderate, statistically significant improvements in ART adherence across multiple controlled trials. ³⁵ Peer navigation and other peer-led models have been shown to increase retention in care and engagement along the HIV care cascade in diverse settings. Moreover, peer-support interventions have demonstrated positive effects on psychosocial outcomes, patient-reported outcomes, and quality of life among PLHIV, including MSM populations. ³⁶ These findings underscore the need for culturally responsive, community-driven models to advance HIV care equity. Rooted in the Javanese philosophy of ‘Sangkan Paraning Dumadi’, the model capture fundamental human values, such as self-awareness, purpose, and interconnectedness that resonate beyond cultural boundaries and align with global health framework.

Although the model was developed within the Javanese cultural context of Central Java, its potential transferability lies in its structured and principle-based design. Adaptation to other settings may be achieved by identifying locally relevant cultural or philosophical frameworks that emphasize meaning-making and purpose, engaging community stakeholders in co-design, and maintaining fidelity to the core biopsychosocial–spiritual structure. The model is most transferable to collectivist contexts characterized by strong spiritual influences on health behaviour and intersecting HIV- and sexuality-related stigma. Future research should examine implementation processes and outcomes across diverse settings to generate empirical evidence on scalability and transferability.

Strengths and Limitations of the Study

This study has several limitations that should be considered when interpreting the findings. The number of participants was relatively limited and drawn from a specific area in Central Java, which may restrict the broader applicability of the results to other regions or populations. Although data saturation was reached, the perspectives obtained may not capture the full diversity of experiences among men who have sex with men (MSM) living with HIV in different sociocultural settings. In addition, as the data relied on self-reported experiences, there is a possibility of recall bias or responses influenced by social desirability. The model was not re-evaluated by participants living with HIV after expert validation, which may limit the extent to which the final model reflects participant perspectives. However, future implementation studies will incorporate ongoing participant feedback, process evaluation, and iterative refinement to identify and address any barriers, concerns, or contextual challenges encountered during implementation. This adaptive approach will enable the model to be modified in response to local sociocultural needs and participant experiences, thereby enhancing its acceptability and feasibility in real-world settings. In addition, one of the experts involved in the validation phase had previously participated in the qualitative data collection as a healthcare provider. While this may introduce potential bias, the individual contributed in a different capacity during the validation process, focusing on model refinement rather than data generation.

Despite these limitations, the study offers several strengths. The inclusion of multiple participant groups, such as MSM living with HIV, healthcare providers, policymakers, and peer support workers, enabled a more comprehensive and nuanced understanding through data triangulation. The use of various data collection methods, including interviews, focus group discussions, and field observations, contributed to the depth and credibility of the findings. Furthermore, the involvement of expert consultation enhanced the refinement, cultural relevance, and practical value of the developed peer support model. The detailed description of the research context also supports the potential transferability of the findings to similar settings.

Conclusion

This study highlights the importance of culturally grounded peer support approaches for men who have sex with men (MSM) living with HIV in Indonesia. The findings indicate that intersecting stigma influences psychosocial wellbeing and engagement with HIV care services. The peer support model developed in this study integrates biopsychosocial, spiritual, and cultural dimensions, reflecting the lived experiences and contextual needs of MSM living with HIV. By combining the Information-Motivation-Behavioural Skills framework with the Javanese philosophy of Sangkan Paraning Dumadi, the model provides a contextually relevant framework for peer support interventions. This model may strengthen peer support interventions and support engagement in HIV care by offering a culturally sensitive approach for MSM living with HIV. Incorporating cultural and spiritual components may improve the acceptability and relevance of interventions in collectivist settings. Further research is needed to evaluate the effectiveness and implementation of the model in HIV care settings.

ORCID iDs

Endah Sri Wahyuni https://orcid.org/0009-0002-2662-2409

Vitri Widyaningsih https://orcid.org/0000-0003-0116-7120

Ethical Considerations

This study was approved by the Ethics Committee of Universitas Sebelas Maret (Approval No. 75/UN27.06.11/KEP/EC/2024). The study was conducted in accordance with the principles of the Declaration of Helsinki.

Consent to Participate

Written informed consent was obtained from all participants prior to data collection. Participation was voluntary, and confidentiality and anonymity were assured. Participants were informed of their right to withdraw at any time without consequences.

Data Availability Statement

Subject to appropriate ethical and legal considerations, the qualitative data supporting the findings of this study are not publicly available due to the sensitive nature of the research and the need to protect participant confidentiality. Anonymized data excerpts may be available from the corresponding author upon reasonable request.*