The Dichotomy of Progress: A Look at PrEP in Indonesia

Indonesia faces a significant and sustained HIV epidemic. According to 2024 estimates, over 500,000 people are living with HIV, and the nation grapples with approximately 35,000 new infections annually. The epidemic is not uniformly distributed; it is concentrated within specific "key populations" who are disproportionately affected due to a confluence of social, legal, and behavioral factors. Among these groups, gay, bisexual, and other men who have sex with men (GBMSM)—referred to locally as LSL (Lelaki Seks dengan Lelaki)—represent a primary focus for public health interventions due to the high prevalence and incidence of HIV within this community.

In response, Indonesia has begun to adopt modern biomedical prevention tools. One of the most promising is Pre-Exposure Prophylaxis (PrEP), a strategy with the potential to dramatically alter the trajectory of the epidemic if implemented effectively. This article provides a scientific analysis of the introduction of PrEP in Indonesia, drawing on recent research to examine its successes, the significant research gaps, and the multi-level barriers that challenge its widespread adoption.

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PrEP: A Biomedical Prevention Modality

Pre-Exposure Prophylaxis is a biomedical intervention where individuals who are HIV-negative take antiretroviral (ARV) medication to prevent contracting the virus. It is a powerful tool for individuals at substantial risk of HIV infection. Globally, PrEP is available in several forms, including:

• Oral PrEP: A tablet taken on a scheduled basis. This is the most common form and the only type currently available in Indonesia, offered in two approved regimens: a daily dose, and an on-demand or "event-driven" schedule taken before and after potential sexual exposure.

• Dapivirine Vaginal Ring: A flexible ring inserted into the vagina that releases an ARV drug over a month.

• Long-Acting Injectable PrEP: An injection administered every two months (Cabotegravir) or even every six months (Lenacapavir), offering a more convenient alternative to daily pills.

The fundamental mechanism of PrEP involves maintaining a concentration of antiretroviral drugs in the bloodstream and mucosal tissues, which is sufficient to block the HIV virus from establishing a permanent infection after exposure. It is, in essence, a lower-dose application of the same class of drugs used for curative HIV treatment.

The Trajectory of PrEP Implementation in Indonesia

The pathway to PrEP availability in Indonesia has been protracted. Although the World Health Organization (WHO) issued its first guidelines on PrEP in 2014, and Indonesia's food and drug agency (BPOM) registered an oral PrEP medication as early as 2015, it was not authorized for widespread sale or public programming. This created a period where access was limited to informal channels, such as personal importation from countries like Thailand, available only to those with the necessary resources and knowledge.

A pivotal moment came in 2022 with the launch of a national PrEP pilot program, supported financially by the Global Fund. This program was introduced in 60 designated health facilities—a mix of public health centers (Puskesmas), hospitals, and community-friendly private clinics—primarily located in major cities. Following the pilot phase, PrEP was officially integrated into Indonesia's national HIV program in 2024, theoretically expanding its availability to all facilities that provide ARV treatment.

However, a critical challenge in evaluating this rollout has been a lack of systematically published data. Much of the operational knowledge remains as "corporate knowledge"—held by program implementers but not formally documented or published. This creates a significant research gap, particularly the absence of baseline data to measure the program's true impact from its inception.

Quantitative Analysis: Findings from the APMIS and PrEP APPEAL Surveys

Recent academic work has sought to fill this data void through an opportunistic analysis comparing two large-scale online surveys. The 2020 Asia Pacific MSM Internet Survey (APMIS) provided a de facto baseline of the pre-pilot environment, while the 2022 PrEP APPEAL survey offered a snapshot during the pilot program's implementation. The combined dataset, comprising nearly 2,400 GBMSM respondents, yielded several crucial insights:

1. Increased Awareness and Uptake: The pilot program appears to have been highly successful in building awareness. The proportion of GBMSM who had heard of PrEP surged from 21% in 2020 to 72% in 2022. This translated into a significant, more than four-fold increase in current PrEP usage, rising from 1.7% to 7.6%.

2. Net Prevention Coverage: A key concern with PrEP is "risk compensation," where users might feel protected and thus reduce other protective behaviors like condom use. The data suggests this is not the case in Indonesia. Condom use remained stable (24% in 2020 vs. 25% in 2022), while the proportion of men engaging in condomless anal intercourse decreased substantially from 67.7% to 50.5%. This indicates that PrEP is expanding the "net prevention coverage," reaching individuals at high risk who were previously using no form of protection, rather than simply substituting for condoms. This is vital for preventing "super spreader" events, where an individual with a high frequency of unprotected sex can rapidly transmit the virus.

3. Targeting and Equity: The program is successfully reaching its intended audience. Analysis shows that individuals engaging in higher-risk behaviors, such as chemsex (sexual activity under the influence of narcotics), were more likely to use PrEP. However, a major equity issue emerged: access is heavily skewed geographically. GBMSM living outside of major metropolitan areas were significantly less likely to use PrEP, highlighting a critical barrier in service delivery.

Multi-Level Barriers to Effective Implementation

Despite these promising quantitative outcomes, the long-term success of PrEP is threatened by deep-seated, multi-level barriers that fall within the domains of implementation science.

1. Socio-Cultural and Healthcare System Barriers: Beyond geographical access, the quality of care is a major determinant of uptake. Stigma remains pervasive within the healthcare system. Patients frequently report facing judgment, microaggressions, and the "moralization" of their health from providers. Some healthcare workers express personal reluctance to prescribe PrEP, viewing it as enabling perceived "immoral" behavior. This erodes trust and discourages individuals from seeking care. In response, community-based clinics—often run by community members—have proven more effective at creating safe, non-judgmental spaces, but their limited number and location restrict their reach.

2. Policy and Structural Stigma: These provider-level attitudes are reflected in and reinforced by national policy. A recent Ministry of Health regulation (Permenkes) on reproductive health contains deeply problematic language, classifying "disfunction and disorders of sexual orientation" as a condition to be prevented and rehabilitated. This codification of sexual orientation as a pathology represents a form of structural stigma. It creates a hostile policy environment that directly contradicts global public health standards and the declassification of homosexuality as a disorder, undermining the very foundation of providing affirming and equitable healthcare to the LGBTQ+ community.

3. Financial and Geopolitical Instability: The sustainability of Indonesia's HIV response is precarious. The program is heavily reliant on international donors, principally the Global Fund. This dependency makes it vulnerable to shifts in global politics and funding priorities, as was seen when the U.S. government under a previous administration cut programs like PEPFAR and USAID, causing the abrupt closure of HIV projects in Jakarta. Securing domestic funding to offset this risk is politically fraught. Pervasive homophobia and social conservatism make politicians unwilling to champion funding for programs targeting the GBMSM community, creating a critical financial sustainability gap.

Conclusion and Future Directions

The story of PrEP in Indonesia is a dichotomy. On one hand, it is a public health success story, demonstrating that a well-designed biomedical intervention can rapidly increase awareness and uptake within a key population without negative behavioral consequences. On the other hand, its potential is severely constrained by formidable structural forces: systemic stigma, discriminatory policies, geographical inequity, and financial instability.

Moving forward, a purely biomedical approach is insufficient. An effective, sustainable HIV response requires an integrated strategy that marries health technology with profound social and political reform. This includes advocating for comprehensive anti-discrimination laws, securing stable domestic health financing, and training healthcare providers to deliver culturally competent, non-judgmental care. Ultimately, the success of targeted programs like PrEP depends on the broader societal adoption of principles of Gender Equality, Diversity, and Social Inclusion (GEDSI). Only by addressing the root causes of vulnerability can Indonesia hope to fully leverage scientific advancements to end its HIV epidemic.