Evolving ART crisis for people living with HIV in Indonesia.

Country lockdowns in response to the COVID-19 pandemic are causing drug shortages that are crippling health-care provision for people living with HIV in Indonesia. The supply chain of antiretroviral treatment (ART) has halted amid lockdowns and travel restrictions from India. Many Indonesian districts have completely run out of ART, with other districts running out within 2 weeks. This shortage will result in tens of thousands of people living with HIV stopping ART treatment.

All ART procurement and administration is handled via the Indonesian Ministry of Health, but drugs are procured from outside the country. First-line ART predominantly involves generic fixed-dosed tenofovir, lamivudine, and efavirenz via Mylan (Canonsburg, PA, USA); some supplies are stuck in procurement systems with no further supplies able to come in. Our clinic, a key population HIV/sexual health clinic in Bali, has made provisions to ration tenofovir, lamivudine, and efavirenz to 10 days' supply at once and made switches to zidovudine-based treatment; we have also stopped immediate ART start. At present, all our stocks of drugs will run out within 2 weeks. There has been disconnected local advice to supply patients with mono or dual ART using existing low stocks of nucleoside reverse transcriptase inhibitors (lamivudine and zidovudine) and non-nucleoside reverse transcriptase inhibitors (efavirenz or nevirapine) to keep people going, which would have terrible consequences in driving ART drug resistance. We have restricted, controlled supply of boosted lopinavir reserved for second-line and third-line treatment.

Many of our patients, who are mostly men who have sex with men, live far away but prefer to visit our service rather than government general community clinics, where greater levels of stigma might exist. Many of our patients have lost jobs because of the COVID-19 crisis, have moved back home to different islands, and will stop ART. High loss to follow-up and poor ART adherence already exist, as reflected in poor UNAIDS HIV testing and treatment outcomes. Such outcomes increase the vulnerability of these individuals to infections and ill health, potentially including COVID-19, when they are off ART and accelerate the existing fast-growing HIV epidemic.

The Indonesian Ministry of Health has recommended an operational programme for special populations, including people with HIV, and a sped up agreement to supply a maximum of 2–3 months ART (normally 1 month) if drugs are available in high-burden HIV districts and epicentres of the COVID-19 outbreak. These challenges have been brought to the attention of the Presidential Office in Indonesia and the Global Fund to Fight AIDS, Tuberculosis and Malaria, who are aiming to purchase and prioritise the procurement of a small number of tenofovir-based regimens from India via specially arranged shipping, which are expected to arrive in late April. Unfortunately, this will not be enough for the shortages throughout the country.