Project overview There is an uncontrolled HIV epidemic among key affected populations in Indonesia, including men who have sex with men (MSM), transgender communities and sex workers. Innovative, context-specific interventions are urgently needed to break HIV transmission. Acute HIV infections (AHI) are key to driving new HIV infections and sustaining HIV epidemics, particularly among MSM. Diagnosing acute HIV enables early engagement in care, immediate antiretroviral treatment (ART), and prevention of onward transmission. However, diagnosing AHI is challenging due to nonspecific symptoms and the lack of sensitivity of routine diagnostics. Combination intervention models incorporating diagnosis of acute HIV, using symptom and behaviour risk scores and point-of-care HIV viral load diagnostics, and encouraging frequent testing, immediate ART, enhanced partner notification and HIV prevention, have been pivotal to reducing HIV transmission in urban high-income settings. There is a need to tailor successful intervention models to growing epidemics in low- and middle-income countries (LMIC). INTERACT (Indonesia Intervention Study to Test & Treat people with Acute HIV infection) is an ongoing implementation research project, funded by the UK Medical Research Council, that aims to demonstrate the proof-of-concept that a context-specific combination intervention focused on test and treat clinical pathways for acute HIV infection can curb the growing HIV epidemic in key populations in Indonesia. Study aim The overall aim of this implementation study is to demonstrate the proof-of-concept that context-specific implementation of AHI diagnostic screening, as part of a clinical pathway for same-day diagnosis and treatment of AHI, can optimize current HIV care delivery and strengthen the HIV care cascade, and thereby curb the HIV epidemic in key affected populations in Jakarta and Bali, Indonesia. The specific objectives of the project are: 1. To evaluate the effectiveness/yield of an AHI test and treat clinical pathway, and establish an optimized AHI risk assessment algorithm; 2. To evaluate the uptake, acceptance and feasibility of an AHI test and treat clinical pathway; 3. To estimate the potential impact of an AHI test and treat clinical pathway on HIV care cascades and the HIV epidemic in the Indonesian context Experimental approach: INTERACT core activities comprise: • Implementing an optimally sensitive AHI screening approach through a client self-completed risk assessment, coupled with AHI diagnostic testing; • Strengthening HIV care cascades by same-day delivery of test results, immediate offer of ART in those newly diagnosed with HIV, and monitoring HIV viral load at 3 and 6 months after ART initiation to ensure response and adherence to treatment; • Implementing a digital behavioural intervention tool, tailored to the wider target population at high risk of HIV, to promote uptake/adoption of HIV prevention, testing and the AHI clinical pathway. Data collection methods include: literature and policy review, clinical and laboratory patient data, Consolidate Framework for Implementation Research (CFIR) evaluation, and key informant and stakeholder interviews (with patients, local staff, policy makers and other stakeholders). AHI screening and testing is ongoing in three sexual health clinics serving high-risk populations in Jakarta and Bali. Based on existing implementation research frameworks, several inter-related quantitative outcome measures will be measured, related to the effectiveness/yield, uptake/adoption, acceptability, feasibility and potential impact of the AHI clinical pathway. A qualitative implementation evaluation, based on semi-structured interviews with clinic and study staff, will help identify barriers and enablers associated with implementing the AHI clinical pathway. Although not the topic of the DPhil project, the study data will be used to perform a cost-effectiveness analysis and predict the impact (mathematical modelling) of scalable intervention scenarios on the Indonesian HIV epidemic, and inform the development of further research topics and potential interventions, if applicable. Collaboration institutions in Indonesia include: Oxford University Clinical Research Unit (OUCRU) Indonesia at the Faculty of Medicine Universitas Indonesia, Atma Jaya Catholic University and Globalindo Clinic in Jakarta; Udayana University in Denpasar, and Bali Peduli in Ubud and Denpasar, Bali. International partners include: 56 Dean Street, Chelsea & Westminster Trust and Imperial College, UK; Amsterdam University Medical Centers, The Netherlands; Big Data Institute at Oxford University, UK. Research questions: The INTERACT project aims to answer the following key scientific questions: 1. What is the effectiveness/yield of implementing an AHI clinical pathway? • Is a risk/symptom screening score an effective method for detecting AHI among MSM and other key affected populations in Jakarta and Bali? Can the score be locally optimized? • Do same-visit delivery of diagnosis and immediate initiation of ART shorten the time to reaching an undetectable viral load? • What are factors associated with AHI diagnosis and immediate ART failure/success? 2. What is the uptake/adoption, acceptability and feasibility of an AHI clinical pathway? • Does the clinical pathway lead to an increased number of individuals and their sexual partners being tested for and diagnosed with AHI, and starting immediate ART during AHI, compared to standard of care? • Are AHI patients willing to start ART on the day of diagnosis and adhere to immediate ART? And what are barriers and facilitators to immediate ART start? • Can we identify HIV-negative, high-risk populations for enhanced sexual health counselling, and preparation for future PrEP introduction? 3. What is the potential impact of implementing an AHI clinical pathway on curbing the HIV epidemic in Indonesia? • How many infections and deaths would be averted, and quality-adjusted life-years (QALYs) gained in various intervention scale-up scenarios? • What are incremental costs or cost savings of those possible scenarios? Supervisors (indicate areas of expertise and role in the project): 1. Primary supervisor: Prof. Raph Hamers, infectious disease and HIV physician with expertise in HIV medicine, clinical and implementation research, based at the Oxford University Clinical Research Unit Indonesia in Jakarta, and will serve as the daily supervisor. 2. Co-supervisor(s): Dr. Keerti Gedala, HIV physician with expertise in HIV medicine and prevention and social science research methodologies, at Dean Street and Imperial College, UK, and will be the co-supervisor with focus on community engagement and implementation research. Prof Pande Putu Januraga, public health researcher at Udayana University, Bali, Indonesia, with expertise in developing innovative public health programs and policies for underserved, stigmatized and marginalized groups in Indonesia using multi methods approaches, including qualitative studies, policy analysis, and participatory approaches. Additional co-supervisor(s) will be added as appropriate. Location(s) of studies: The study is planned to take place in Jakarta and Bali, and potentially other settings. The candidate will be based at OUCRU-Indonesia in Jakarta with occasional short visits to Denpasar, and Oxford and London, UK. Start date and duration of studies: Start date: April or October 2024 Duration of studies: 4 years (April/October 2024 until April/October 2027) Training opportunities: The PhD student will be part of the OUCRU-MORU PhD Student Network and the student will work closely with the research team at OUCRU Indonesia in Jakarta. Other specific trainings include: - Quantitative and qualitative research methods, including clinical epidemiology and advanced biostatistics - Implementation research and health system approaches - Data visualization, thematic coding and qualitative analysis, and statistical analysis (e.g. regression) for all aforementioned data collection methods - Specific topics on HIV, STIs and sexual health - There are also opportunities to receive basic training and be involved in cost-effectiveness analysis and mathematical modelling, as guided by the student’s interests, although these are not the core focus of the DPhil project - Short training visit(s) to Chelsea & Westminster and Dean Street in London to gain experience with state-of-the art models of HIV/sexual health care, with opportunities for London and Oxford based courses where applicable. - Teaching opportunities to wider clinical and academic community for knowledge sharing and teaching experience. Skills required in the candidate: - Experience with both quantitative and qualitative data collection and analysis for research studies. - A Master’s degree in a medical, public health/epidemiology, pharmacy, nursing, and/or social sciences or related field. - Experience working on health-related research studies, preferably interdisciplinary and implementation research - Experience or affinity with HIV and sexual health and the key affected populations - Excellent spoken and written English and Bahasa Indonesia - Experience working with government and non-government stakeholders - Strong interpersonal and communication skills - Willingness to travel, interact with, and conduct field work in a range of settings and communities - Experience with statistical software (e.g. Nvivo, STATA, R, SPSS) NOTE: OUCRU DPhil projects are tightly coupled to funding for students ordinarily resident in Vietnam/Indonesia. For further information related to this project you may contact training@oucru.org.