Client-centered enablers and persistent bottlenecks across Indonesia’s HIV cascade: a multi-stakeholder qualitative study

Indonesia's HIV epidemic remains concentrated among key populations despite policy development and program expansion. This qualitative study examined how service design and implementation mechanisms shape cascade performance. Across four provinces, we conducted nine focus groups and 22 interviews with 64 participants, including policymakers, program managers, providers, community-based organization (CBO) staff and peers, academics, and beneficiaries. Transcripts were analyzed using reflexive thematic analysis. Four themes emerged. First, client-centered service models including free testing, one-stop touchpoints, same-day antiretroviral therapy, TB-HIV collaboration, self-testing, extended hours, CBO-facility partnerships, enabled faster linkage and early retention. Second, counseling quality, confidentiality, and trust influenced testing uptake and linkage, while workflow pressure, limited privacy, and fragile resources weakened early engagement. Third, prevention impact was constrained by gaps in commodity readiness, multisector coordination, and user-friendly pre-exposure prophylaxis (PrEP) and partner services. Four, workforce capability and system reliability including stock management, referral continuity, integrated services, psychosocial support, shaped retention and viral suppression. Cross-cutting factors like donor dependence, legacy clinic routines, and coordination gaps increase disparities between urban and rural areas. Outcomes rely more on consistent execution than on policies. Programs should formalize key enablers, upgrade HIV testing services, simplify PrEP and partner services, and implement a retention bundle.