Chasing targets in a pandemic: The impact of COVID-19 on HIV outreach workers for MSM (men who have sex with men) in Jakarta, Indonesia

ABSTRACT

The COVID-19 pandemic has had a significant impact on HIV services globally, including community-based outreach programmes. This article draws on a qualitative study of HIV outreach workers for men who have sex with men (MSM) in Jakarta, Indonesia undertaken between July and September 2020. The research documented the impact of the COVID-19 pandemic on HIV outreach programmes for MSM based on interviews, focus group discussions and video diaries collected from outreach workers. As a result of the pandemic, and in response to the guidelines issued by international donors and the Indonesian government, outreach workers shifted activities to ‘virtual outreach’ where possible. However, outreach workers consistently performed in-person work to address what they referred to as ‘urgent’ cases (e.g. required them to attend the clinic). Regardless of delivery mode, the steps comprising outreach work during the pandemic aligned with the ‘cascade of care’, which forms the dominant policy narrative for the management of HIV. Outreach work during the pandemic therefore continued to be based primarily on the objective of maintaining testing and treatment rates. Although outreach workers responded innovatively to the pandemic, including to the risk of COVID-19 infection, they were limited by the prevailing emphasis on targets in HIV programmes.

KEYWORDS:

• COVID-19
• outreach work
• men who have sex with men (MSM)
• Indonesia
• virtual outreach

Introduction

The onset of the COVID-19 pandemic has disrupted the provision of HIV services globally. There are growing concerns not only about the risks that COVID-19 infection poses to people living with HIV, but also the impacts of border closures and supply chain disruption on the delivery of essential medicines and testing.¹ These critical concerns notwithstanding, there is also the potential for the COVID-19 public health response to learn valuable lessons from the HIV response, particularly its emphasis on a dedicated role for community-based workers (Hargreaves et al., 2020). Community-based workers in many parts of the world play an important role in connecting communities to HIV prevention, testing and treatment, actively shaping the provision of healthcare services.²

The pandemic has further revealed intersecting vulnerabilities of ‘key populations’, which includes men who have sex with men (MSM), transgender women, sex workers and injecting drug users. Several accounts have highlighted how the pandemic has impacted the delivery of clinical services for key populations, including those that require the labour of community-based workers funded by international HIV programmes (Pinto & Park, 2020; Ponticiello et al., 2020). Other research has described how the pandemic presents an opportunity to scale up or initiate innovative forms of HIV service delivery, including the use of home-based testing services (Wilkinson & Grimsrud, 2020). Beyond these studies, which focus on the clinical and technical aspects of HIV service delivery, Kimani et al. (2020) demonstrate how community-based HIV programmes for sex workers in in Kenya continued throughout the COVID-19 pandemic and related public health orders. Similarly, Quilantang et al. (2020) have documented the role of MSM outreach workers in the Philippines in mapping the most vulnerable in their communities, through which they were able to coordinate the delivery of medication via courier services. In Indonesia, Mallay et al. (2021) describe the central role of transgender women in community mobilisation with respect to COVID-19, including through maintaining access to HIV services via community networks.

Although funding bodies encouraged community-based programmes to adopt new methods – such as shifting outreach work that involves communicating through online platforms (see UNAIDS, 2020) – the ways in which outreach workers continued to deliver essential HIV programmes remains little understood. As a result, the impact of the pandemic on community-based outreach workers, including the significant risk they face of contracting COVID-19 in the course of their work, remains largely undocumented. As well as describing the impact of the pandemic on community-based HIV workers, our research documented the innovative responses that our research participants adopted both with and without formal or institutional support. Attending to outreach workers’ knowledge and skills offers an important way to both understand and provide responsive support more relevant to the situation of the COVID-19 pandemic on the ground.

The research on which this article is based investigated the impact of the COVID-19 pandemic on community-based outreach workers for men who have sex with men (MSM) in Jakarta, the capital of Indonesia and a large city with a population of approximately ten million people.³ Our research aimed to understand the impact of the COVID-19 pandemic on a cohort of outreach workers with whom the researchers had a pre-existing relationship through earlier research projects (Hegarty et al., 2020). At the onset of the pandemic in early 2020, we rapidly reoriented our research to move to document the experiences of the community-based outreach workers involved in our previous research. To achieve this aim, we asked three main questions: What impact have COVID-19 and related public health measures in Indonesia had on HIV outreach programmes? How have these changes impacted the quality, quantity and type of work undertaken? What impact has the pandemic had on the ability to meet programme targets? We sought to answer these questions by collecting and analysing narratives collected from outreach workers for MSM ­about their work through three types of data: online interviews, focus group discussions and video diaries which were collected between July and September 2020.

MSM peer outreach workers in Jakarta play a crucial role in HIV programmes. In addition to providing harm reduction services, comprising the provision of safe sex information, condoms and lubricant to the community, outreach workers also play a role in referring and accompanying individuals to access HIV testing, counselling and treatment. This is the case in Jakarta, where several well-established peer outreach programmes for MSM employ outreach workers through non-governmental organisations funded by international programmes. Although some forms of online outreach have been a component of formal programmes for several years, the dominant model of outreach work has remained largely ‘hotspot’ based, meaning that programmes are based on specific physical locations in which significant numbers of people identified as MSM congregate or live (see Nugroho et al., 2019, for an ethnographic account see Hegarty, in press). The practice of outreach has been transformed by a dominant international policy shift towards the ‘cascade of care’ (also known as the care continuum) which has altered the role of outreach work as one step towards the facilitation of anti-retroviral therapy. This shift been further consolidated since 2019, when the Indonesian Ministry of Health introduced the requirement that local, government-funded healthcare clinics provide anti-retroviral therapy free of charge (Lazuardi, 2019, p. 2). As a result of this emphasis, community-based outreach workers therefore play an important role in mediating between MSM and healthcare workers, including providing assistance to newly diagnosed HIV positive individuals to navigate complex health bureaucracies (Hegarty et al., 2020; Nugroho et al., 2019). The role of community-based outreach workers thus extends beyond prevention alone, comprising the role of vital care workers.

This close relationship between community-based outreach work and the Indonesian healthcare system shaped outreach workers’ experience of the COVID-19 pandemic. Since the imposition of initial public health guidelines in April 2020, Indonesia experienced relatively high rates of infections and deaths from COVID-19 despite the imposition of limited public health measures.⁴ Although Indonesia’s response to the pandemic is coordinated by the national government, regional and local governments are responsible for the imposition of public health orders. In Jakarta, one immediate impact of the pandemic response was a reduction of HIV testing in primary healthcare centres to prioritise COVID-19 cases (Kementerian Kesehatan Republik Indonesia, 2020b). Despite this, HIV outreach programmes continued to operate throughout the length of our study, albeit according to the modified guidelines supplied by international donors (see, for example, Meeting Targets and Maintaining Epidemic Control (EpiC) Project, 2020). International donors also implemented other programmes to allow for uninterrupted access to HIV testing and treatment. For example, in response to the strain on public clinics, international agencies funded private clinics in Jakarta to offer free testing and treatment to clients as an exceptional measure. Another programme supported the home delivery of medication services for clients already enrolled in treatment. Although focused on maintaining rates of testing and treatment during the pandemic, the day-to-day delivery of these programmes relied on existing community-based outreach workers.

Despite the significant changes made to the delivery of HIV programmes during the COVID-19 pandemic, our research found that outreach workers largely narrated the steps undertaken for outreach as unchanged from those employed prior to the pandemic. In particular, HIV outreach workers framed the steps required to do their work as effectively unchanged. We speculate that this is because, even as international funders did introduce notable and welcome changes to programme requirements in response to the pandemic (including adjustments to targets), the role of community-based outreach workers overall remained positioned in relation to the goal of maintaining rates of HIV testing and treatment.

This is not to say that outreach workers did not adapt or innovate in their approaches to HIV outreach during the COVID-19 pandemic. Indeed, within each of the steps that they described outreach work as encompassing, participants made subtle adjustments to their everyday practices. Community organisations requested outreach workers to work from home in March 2020, ahead of clear public health guidance, and drew on their own funding and fundraising efforts to provide hand sanitiser, masks and support for suspected COVID-19 cases to self-isolate. Yet the strategies that participants enacted – and their vulnerability to infection from COVID-19 – were not easily legible to funders and programme directives, which largely stressed a shift to ‘virtual outreach’ and adjustments in the number and type of targets to be met. An emphasis on technical aspects of service delivery at the programme level meant that the altered, but not decreased, demands on the labour required of outreach workers was left unaddressed. That is, outreach workers continued to understand their task in terms of an overall goal of filling gaps left in technical processes: linking individual patients to information about HIV, testing and treatment, regardless of whether activities were undertaken virtual, in person or (as was more usually the case) movement between the two as required.

Materials and methods

Study design and data collection

This article is based on data collected from outreach workers for MSM in Jakarta, Indonesia. All research data was collected remotely via telephone, Zoom and encrypted messaging service regardless of the location of the researchers in Indonesia and Australia. The methods used for data collection were: (1) Interviews of approximately one hour with outreach workers and outreach NGO staff (groups 1 and 2); (2) Interviews with healthcare workers (group 3); (3) Focus group discussions with outreach workers (groups 1 and 2); (4) Weekly video diaries of approximately 5–30 minutes each sent by outreach workers for four weeks (group 1); and, (5) A survey from the outreach worker participants measuring the changes to outreach work as a result of the COVID-19 pandemic (group 1). These different forms of data collection facilitated different insights into the impact of the pandemic, with the interviews serving as a core component of the data. The focus group discussions served as an opportunity to introduce emerging findings to participants and to invite reflection on points of difference or contrast in a way that fostered interaction and exchange. The video diaries offered insights into the day-to-day life of doing outreach work during the pandemic, as well as an opportunity to collect data consistently from the same participants across the entire three-month period. The researchers both communicated research findings with participants and continued to measure the ongoing impacts of the pandemic after the data was collected. This article primarily draws on interviews and focus group discussions with outreach workers, with supporting and contextual data drawn from the other sources.

Data was gathered between July and September 2020, a period that covered the implementation, lifting and reimplementation of public health measures to address the pandemic in Indonesia. The data collected during this period – the early stages of the pandemic – provides insights into both the impact of COVID-19 and related public health and policy measures on outreach workers. On 10 April 2020, the capital of Indonesia, Jakarta was placed under a suite of restrictions referred to by the government as ‘large-scale social restrictions’ (Kementerian Kesehatan Republik Indonesia, 2020a).⁵ On 5 June 2020, the Jakarta government announced a shift in policy to what it called the ‘new normal’, a directive that aimed to sustain economic activity while maintaining measures to slow transmission of the virus (Kementerian Kesehatan Republik Indonesia, 2020b). On 14 September 2020, the regional government again imposed large-scale social restrictions over people resident in the city in response to the rising number of COVID-19 infections and hospitalisations from the virus.

Sample and recruitment

Research participants were recruited from three groups: (1) MSM outreach workers (n = 10); (2) Outreach NGO staff (n = 4); (3) Healthcare workers in HIV clinics (n = 6). The researchers recruited participants based on individuals’ employment status as a community-based outreach worker or healthcare worker at the time of the study. MSM outreach workers and NGO staff were recruited from an existing relationship with an organisation developed through our previous study. At the onset of the COVID-19 pandemic, in line with ethnographic approaches, the authors followed up with one community-based organisation with which we had an established relationship to seek voluntary participation. Healthcare workers were invited to participate through direct contact made with clinics. Although outreach workers that formed the participant group all worked for one organisation, outreach activities within that organisation were funded by two international funding bodies, which differed in the targets set and types of work performed.⁶

We invited participation in the research via a call for participation made through direct contact made with the relevant organisation (the outreach organisation in the case of groups 1 and 2, and health clinics for group 3). Individuals’ participation in the study was voluntary, and consent was sought prior to the commencement of each form of data collection, including through the distribution of a participant information sheet and a consent form. All participants were given pseudonyms to ensure confidentiality, with any identifying information excluded from the study. The demographic profile of the outreach workers ranged in age from 24 to 39 years of age, and all had greater than six months of experience in their current role.

Analysis

All data collected, encompassing interviews, focus group discussions and video diaries was recorded and transcribed in Indonesian. All members of the team read the transcripts and came up with a list of relevant codes that was further refined in a collaborative way. These preliminary codes were then applied to the transcripts using the Dedoose software package. After the initial coding process, members of the team examined transcripts for recurring themes, which included the five steps of outreach presented here. The researchers identified similarities between the five steps described by outreach workers and the dominant policy narrative of the ‘cascade of care.’ As a result, this article is presented in subheadings that correspond with the five steps of outreach contained in participants’ narratives, drawing out and describing various thematic threads that emerged through the coding process within each step.

Ethics

The project received ethics clearance from University of Melbourne (2057173.1) and Atma Jaya University (FR-UAJ-26-13). Participant information sheets and consent forms were prepared and translated into Indonesian and shared with those who expressed interest in participating. Interview participants received 50,000 Indonesian Rupiah (approximately US$5) as compensation for mobile phone credit used. Outreach workers who participated in focus groups and video diaries were offered 100,000 Indonesian Rupiah (US$10) and 250,000 Indonesian Rupiah (US$25) respectively.

The methods used reflected the need to undertake all data collection remotely due to the pandemic. This posed various ethical challenges for a team comprising Indonesian and non-Indonesian members. One reason why the researchers were able to gain the trust necessary to conduct the study at short notice was due to the ongoing relationship between the researchers and the community-based organisation. This relationship had been established since members of the team undertook research with the organisation in 2018, and maintained frequent contact since this time. The research team also hired Amalia Handayani as a Jakarta-based research assistant to coordinate all data collection, although Handayani too worked remotely. After we communicated the research to the management team of the community-based organisation, the director circulated our call for participants. Interested participants were invited to contact Handayani to express their interest, following which they were provided with the participant information sheet and consent form. In response to the challenge of communicating with outreach workers remotely, the research team set up a mobile phone application chat group to communicate organisational components (focus group timing and reminders about video diaries). No information shared in the chat group was used as data in the study. Taking advantage of increased engagement with online communication during the pandemic, we presented our preliminary research findings to participants during focus groups and an Indonesian audience comprising policy-makers and academics. We also sought the input of participants into the analysis and presentation of data findings.

Results

An important component of conducting outreach work during the pandemic as described by outreach workers involved the shift to virtual or online forms of outreach (i.e. programmes that use digital platforms, ranging from dating applications to social media platforms). The two programmes that fund most outreach programmes in Indonesia instructed recipients to rapidly shift all of their programme delivery to virtual methods. This was possible because virtual outreach programmes have been in place in Indonesia for several years (Burrows et al., 2019). International funding agencies have placed a greater emphasis on virtual outreach over the past few years, given declining numbers of physical hotspots for MSM. This shift is reflected in a virtual outreach framework launched in 2019 called Going Online, which advanced the use of online and mobile platforms to accelerate meeting HIV education, prevention, testing and treatment objectives (FHI 360, 2021). Outreach workers in Indonesia are therefore adept users of virtual outreach methods (Wilcher & Akolo, 2020). This knowledge was valuable during the COVID-19 pandemic, when HIV funding agencies instructed outreach workers to pivot to online platforms for the majority of their activities.

Although international programmes showed flexibility towards community-based outreach work in the context of the pandemic, the demand to meet targets nevertheless remained in place (FHI 360, 2020). Targets in pursuit of indicators related to outreach, testing and treatment, are a key means through which community-based organisations are evaluated and funded in line with the ‘cascade of care.’ At the onset of the pandemic, international donors adjusted targets to align with the shift to virtual modes of delivering outreach. For example, rather than having to successfully ‘make contact’ with five people in person and provide them with information about HIV per month, each outreach worker was instead required to contact at least 60 people online per month. This target was designed to better reflect the fact that outreach work was not taking place in person.

Our research found that, even though outreach workers did adopt virtual methods for undertaking outreach during the pandemic, they often combined it with in-person activities as well. This was described as particularly necessary for the delicate work of assisting clients to navigate access to testing and treatment. Although in-person work was in theory limited to ‘urgent cases’, in reality this was a broad category; defined as clients with any symptoms, including symptoms of sexually transmitted infections. Moreover, outreach workers described that successfully meeting targets required them to connect clients to HIV testing and treatment, which was difficult to achieve through virtual methods alone. In the absence of alternatives, outreach workers creatively combined forms of virtual and in-person methods throughout the COVID-19 pandemic despite the risks to their own health.

Despite these changes, the fundamental expectations placed on outreach from workers did not shift. Thus, the steps involved in outreach work during the pandemic as narrated by outreach workers remained largely unchanged. At the preliminary stage of analysis, we identified the pattern that outreach workers narrated their role as a series of steps aimed at the objective of meeting targets, measured ultimately as the successful enrollment of a client in anti-retroviral therapy. We therefore coded the data into five steps, which we identified as: (1) gain visibility; (2) build and maintain relationships; (3) provide HIV and safe-sex information; (4) follow up with clients; (5) refer to healthcare providers for testing/treatment. One key finding from this analysis was that the mode of delivery of outreach, that is as virtual or as in-person, was not understood as fundamentally important to the outcome. Regardless of the mode of delivery, the labour of outreach work – which often requires in-person contact and close communication with healthcare workers – is essential to the successful delivery of HIV programmes.

Gain visibility

The first step of outreach described by participants was to obtain the attention of potential clients. The aim of this step was to encourage initial interest in further participation in HIV programmes, whether through receiving information, getting tested, and/or getting treated (i.e. enrolling in anti-retroviral therapy). As this step was successfully undertaken online (as well as in person) prior to the pandemic, in light of the advent of popular online applications for sex between men, this aspect of outreach work was perhaps the least affected. Nevertheless, the need to adopt an online format of delivery almost entirely in the context of the pandemic – given that in-person locations were either closed or largely unoccupied – posed several challenges.

Participants used three main platform types to gain visibility, encompassing: (1) dating applications, (2) social media applications (Instagram, Facebook), and (3) mobile phone applications, such as WhatsApp. Obtaining a clients’ mobile phone application number was therefore seen as a critical step which would enable outreach workers to more readily communicate with them in future and as evidence to demonstrate that they had met their monthly targets.⁷ Participants described employing a wide range of strategies to obtain a mobile phone application number, including engaging with dating applications on terms appropriate to the medium. This included altering their appearances to make themselves more attractive to clients:

We edit our photos for use on dating applications, but not too much. Afterwards if we actually meet in person, it won’t be good. What I mean is, the photo that we think is the best on social media, that is the kind of photo we should use on dating applications. (OW01, focus group, 21 August 2020)

Participants described the step of gaining visibility as requiring a great amount of time spent online. Generally, they described a process of scrolling through profiles, liking photographs and contacting people in the hope of entering into a conversation. In addition to posing ethical challenges, the anonymity of online communications and specific profiles of platforms meant that outreach workers found it difficult to verify that those who they were speaking to formed part of their target population:

Tinder can be accessed by the general public. (OW07)

Yes, Tinder is a general platform, like Badoo. You keep working through it, liking photographs of people, and eventually you match. Then once you match with someone, you can chat. (OW10)

The problem is that it isn’t certain that he is an MSM, unfortunately. (OW07, focus group, 4 September 2020)

Most dating applications make use of geographical location data provided by cell phones. During the pandemic, participants described one challenge as reaching areas that were more densely populated by MSM when they were working from home. To address this challenge, participants described making use of technologies including VPNs (virtual private networks) and fake GPS (global positioning system) applications through which they could target or appear to be in a specific location even if they were not in fact nearby.

The application is free, but it comes with a risk that we can be hacked more easily. For example, if we are at home and we open a dating application, it will only show the same people who are close to me. So, whether I wanted to or not, I installed the fake GPS application, then targeted a specific spot where I know a lot of MSM meet or live. (OW09, interview, 13 July 2020)

Participants described using social media sites such as Facebook and Instagram to increase their visibility to a much wider audience during the pandemic. Participants described the information that they provided as dependent on their own interests and used strategies that they found worked best for them. Some participants described directly communicating scientific facts about HIV, which facilitated an opportunity for people to ask them about testing:

The social media that I am passionate about in outreach efforts are live broadcasts via Bigo Live, Instagram, or Facebook … my goal is to include education about HIV/AIDS in these [applications]. (OW5, video diary, 20 July 2020)

Others used standard methods of obtaining more visibility and followers on social media. For example, some participants described a strategy of tagging ‘influencers’ or people with many tens of thousands of followers, whose engagement could act as a signal booster to attract further interest and visibility. Participants also described making use of captions and hashtags to draw attention to their content:

I tag influencers or celebrities or actors who have a lot of followers. Usually, our content will then be seen with the influencer’s tag. (OW07, focus group, 4 September 2020)

First, Instagram will not be stale when we reach out or create promotional content because if we edit the caption, the content won’t be lost. Once a person clicks on a hashtag, it will come up with the information that we want to show them. (OW07, focus group, 4 September 2020)

Build and maintain relationships

Once visible to their target audience, the next step in successful outreach was building and maintaining a relationship with potential clients, which required obtaining a client’s mobile phone application or phone number. Even after obtaining a number, participants described falling out of contact as a frequent occurrence. Participants shared accounts of being blocked by users or ignored when they asked for the personal information needed to facilitate access to HIV programmes.

If they were able to maintain contact with clients, participants described that they used it as an opportunity to provide information from official health sources about HIV and COVID-19. Participants reported conveying accurate information about opening hours and the availability of doctor’s appointments. Participants described the importance of keeping up consistent contact via mobile phone application as especially important during the pandemic. Participants described that this required being in communication in a similar manner as with friends or as a salesperson:

Usually, if we are in communication via a dating application or social media, we can ask for their mobile phone application number … if we switch to the application, then it is like we are friends. For example, a client has free time, and the clinic is open during the week, I offer them that option. Outreach work is like sales. If the clients keep giving excuses, I approach it even more urgently. That said, people can get annoyed [with my persistence], and block me. (OW03, interview, 9 July 2020)

Although participants generally saw obtaining mobile phone application numbers as important for verifying they had met their targets, they also used client’s phone numbers to add them to mobile phone application groups which they facilitated. Such groups were a useful way to be able to provide information privately while also facilitating a sense of shared community:

Mobile phone applications are a product for the general public, meaning that those who are not MSM can use it. However, I have mobile phone application groups specifically for MSM, which have more than 60 members, some even have 300 or 400 members. (OW07, focus group, 4 September 2020)

During the pandemic, participants described that it remained difficult to maintain a balance between getting suitably close and respecting boundaries. Many described how it was more difficult to gain trust online compared to in person. Some participants described that they did meet in-person with clients at their homes due to limited access to public space during the closures resulting from the pandemic:

Many clients were afraid to go out during the pandemic, but strangely, they wanted to meet up at my place. Before the pandemic, we would avoid that, so we would meet out. Then if we got along, I would invite them to my place. (OW09, interview, 13 July 2020)

During the pandemic, many people worked from home. If they were working from home with the same salary, it meant that they had more time to be active on dating apps … But if we invited them to the clinic, they didn’t want to go. If we invited them to our house though, then they wanted to. (OW01, focus group, 28 August 2020)

Provide HIV and safe-sex information

Once outreach workers had established rapport with clients, they could then provide them with safe-sex information and facilitate access to HIV testing and treatment where required. Prior to the pandemic, outreach workers would normally undertake location-based outreach in person, when they would be able to directly provide their clients with condoms and lubricants. However, during the pandemic, outreach workers reported an overall drop in the number of condoms and lubricant that they provided to clients. This was partially the result of the shift to virtual outreach and no reported programmatic focus on the continuation of condom and lubricant provision.

The move to virtual outreach had a significant impact on the provision of HIV and safe-sex information. The difference appeared to stem from the ambiguous meanings of ‘providing information’ as understood among outreach workers. Several described virtual outreach methods as making it more difficult to ascertain whether the information provided had been received or not. This was of concern given that funding was tied to whether they could ascertain whether clients had ‘received’ basic information. Another challenge described by outreach workers came in the form of fielding requests from clients for information about COVID-19. Although trained to provide information about HIV, outreach workers found and conveyed relevant Indonesian-language information about COVID-19 in an ad-hoc nature, largely by keeping up to date on the pandemic in Jakarta and sourcing information about it online. Given their significant experience addressing misinformation about HIV, outreach workers reflected on their role providing information about COVID-19 on parallel terms. Nevertheless, outreach workers described the proliferation of sources of information made it challenging to locate accurate information about COVID-19:

We have to screen information and news stories … for example, is this story true or not? If I read something and it isn’t clear, or if I read it but we don’t know the source … but in the end, we get confused ourselves. (OW05, interview, 10 July 2020)

Thus, outreach workers found themselves taking on an expanded role during the pandemic, beyond that related to HIV alone. During the pandemic, they found themselves in a position where they were seen as trusted sources of information about COVID-19 within their communities. Yet at the same time, the organisation of HIV programmes as distinct from a broader understanding of health, and the continued emphasis on meeting targets in the former, meant that outreach workers were restricted in their focus. This structural separation meant that outreach workers described it as challenging to integrate information about COVID-19, or to explain its impact on HIV services to clients, in a meaningful way:

For example, a few requests [to clients to test] were rejected. And I’d already explained to them: yes, this is PSBB [restrictions], and the pandemic, but your health is also important … if you don’t [have COVID-19] symptoms, you’ll be able to get tested [for HIV]. But the response is that he is still afraid because of media reporting about COVID-19. So, the client says, ‘let’s just wait’ … that happened a lot. (OW03, interview, 9 July 2020)

Despite these challenges, outreach workers played a role in fielding questions about COVID-19 and linking people to information and health services. Despite tending to stress their primary role as related to HIV, outreach workers hinted at the possibility that they were capable of providing information and services beyond it. Outreach workers also welcomed small changes to reporting requirements, including the addition of new fields on forms, that extended information that they collected to include that about COVID-19. This suggests that outreach workers have the skills and relationships to play an expanded function beyond that of supporting technical aspects of HIV testing and treatment:

Even though it is really different now, it doesn’t mean I can relax … I have to fight more for my clients. I’m not a COVID-19 expert, I’m not an all-round medical expert … but during the pandemic I was required, indirectly, to know about COVID-19. During the pandemic, when we did HIV outreach, we included information about COVID-19, meaning we needed additional skills … Outreach workers don’t only think about VCT [voluntary counselling and testing] and STIs [sexually transmitted infections] but about COVID-19 as well. (OW07, interview, 13 July 2020)

We are now in a phase where we no longer talk only about HIV or AIDS, but about COVID-19 too. Like it or not we have to be keeping up with the virus. Also, our clients need information about it, about how it spreads, what the situation is in the field. (OW07, focus group, 14 August 2020)

Follow up with clients

The practice of following up with clients was, in many respects, a similar step to that of ‘building and maintaining relationships’. It required consistent communication, involving extensive engagement via mobile phone applications and in person. Moreover, requirements from funders to follow up with existing clients every three to six months to undergo a repeat test meant that this step was repeated consistently (together with step five, referring clients to healthcare providers). This included responding to questions about HIV, and providing other up-to-date public health information, including about COVID-19.

A particular concern expressed related to this step related to connecting clients with healthcare workers in order to undertake an HIV test and commence treatment where required. Outreach workers also supported clients in taking regular tests for sexually transmitted infections (STIs). Outreach worker’s capacity to connect clients to health services in both instances was one aspect of targets tied to funding. Sudden shifts in targets placed significant pressure on outreach workers.

Despite adjustments to targets made during the pandemic, outreach workers continued to engage a mix of offline and online elements to follow up with clients. In some instances, they would engage with their clients by engaging in social activities. In others, they would use mobile phone application groups and individual messaging. Outreach workers described how, during the pandemic, they adjusted from directly asking clients whether they wanted to take a test, to whether clients had symptoms of STIs. This was because, at the height of restrictions, only those clients with symptoms and who were therefore classed as ‘urgent cases’ were able to access HIV testing:

After we met, he told me that he had suspicions that he had HIV … Because on his skin he had symptoms like an STI. That evening, that client underwent counselling and the next day took a test. This kind of experience made me happy this week. (OW03, video diary, 20 July 2020)

Completing this step during the pandemic presented other difficulties, predominantly because outreach workers were at times not permitted to attend clinics due to public health regulations. Although one aspect of outreach workers’ role was communicating information about HIV and STIs, and directing clients to present to healthcare services, they described it as more effective if they accompanied them to the clinic directly. The continued need to meet targets despite limitations on attending clinics in person was described as a challenge by one outreach worker, who continued to field requests from clients:

We are still chasing the targets … but during the pandemic in April, a policy was introduced that we were not allowed to present at healthcare service. But in fact, there were many urgent cases that needed to present at clinics. (OW10, interview, 14 July 2020)

Despite the challenges that the pandemic presented in undertaking this step, given its overall reliance on meeting in person, outreach workers also demonstrated significant flexibility. In particular, they readily incorporated official information about COVID-19 into their engagement with clients:

In fact, when we are working from home, clients were more intense in contacting us about COVID-19. They’d ask ‘I want a COVID-19 test,’ or ‘It’s difficult to go anywhere.’ I’d find information for them, I got information on HIV and COVID-19 from the Ministry of Health and shared it with them … our communication with clients was more intense, actually, because they were asking about COVID-19. (OW05, interview, 10 July 2020)

Nevertheless, outreach workers described that it was not always easy to follow up with clients during the pandemic. Even when some clients expressed that they had symptoms of STIs, not all clients were able to or wanted to undertake a test, and some would suddenly drop out of contact. Outreach workers were required to negotiate carefully with clients during the pandemic, given that they might provide various reasons for not attending health facilities, including conditions in the city or that they were afraid of contracting COVID-19. Although this unpredictability was an existing condition of outreach, outreach workers had to constantly adjust their methods, both in light of the changing conditions of the pandemic and shifting demands in the form of targets from funders.

Refer to healthcare providers

The final step in conducting outreach was to refer clients to healthcare providers for testing and treatment. During the pandemic this step was difficult to achieve due to the imposition of various restrictions, including limitations in the opening hours of clinics and density requirements. Outreach workers described being unable to enter clinics in order to interact with healthcare workers and clients. This shifted the form that their work took. At various stages of the pandemic, funders requested that outreach workers focus on maintaining clients to ensure treatment adherence. Other directives, issued by both funders and clinics, requested that outreach workers only accompany ‘urgent’ cases for testing and treatment. As one outreach worker explained:

During the pandemic, we are afraid of going to health facilities. We only take clients who have STI or other symptoms. And, during the pandemic, there are a lot of [HIV] positive cases. Is it caused by fewer condoms being distributed? (OW10, focus group, 14 August 2020)

In this context, outreach workers employed diverse strategies to refer clients to healthcare providers for testing and treatment. Officially, funders instructed outreach workers to work virtually while adjusting targets to reflect this altered form of work. This was supported by several programmes funded by international donors in addition to outreach activities; including funding to send medication by courier known as JakAntar, the granting of small emergency cash grants for travel and other costs associated with attending clinics for testing and treatment known as JakSupport, and the provision of testing and treatment at private clinics. These were described as positive innovations by outreach workers:

There is an additional program called JakSupport. We have to ask the clients whether they are affected by COVID-19 situation. We are screening them. So, when they need money for their treatment or had lost their job, we needed to report this. (OW10, focus group, 14 August 2020)

When we are implementing these innovations, such as JakSupport and JakAntar, it raises our confidence because there is something that we can offer and support [to the clients during the pandemic]. (OW07, focus group, 4 August 2020)

Nevertheless, outreach workers described working both in person and virtually throughout the pandemic in ways that exceeded the support made available through these programmes. Several informants described consistently accompanying clients in person to obtain access to testing and treatment, helping them to navigate intermittent closures. One factor which contributed to this discrepancy was that public health regulations issued by provincial and national governments to address COVID-19 were, as outlined, in constant flux. Outreach workers described how the situation was further complicated by an inconsistent application of regulations by individual clinics:

The health facilities applied the policy differently. I asked one health facility … to conduct a mobile health centre with limited patients and follow health protocol. But, it couldn’t be done yet. Another facility … did that. It is confusing. We just hope that the clients have free time and really do need to have the test, and then we can refer one or two to that particular health facility [which was willing to do so]. (OW03, interview, 9 July 2020)

One implication of the inconsistent application of regulations and outreach worker’s attempts to navigate them was clients ended up needing to travel far from their own homes to access testing and treatment. In some cases, the demands of targets for outreach workers (linked to the geographical location of clinics) meant that they were required to meet with clients at clinics far from either the outreach workers or the client's home. This became difficult in the context of intermittent restrictions on physical movement in the city. Some outreach workers explained that, despite the considerable restrictions on movement imposed in the city, they would still travel to the clinic. This was the case even where they did not go inside the clinic:

We used to be inside the clinic. When the pandemic hits, we are requested to hang out outside. We were told by the health workers not to come if there is no urgent case. But, we are still going to the Puskemas [clinic], but we don’t enter. (OW10, interview, 14 July 2020)

Other outreach workers described how, despite their reduced capacity to enter clinics, they continued to coordinate closely with healthcare workers. This was especially important given shifting processes and the need to ascertain which cases would be classed as ‘urgent’. One outreach worker described coordinating on a range of issues with a doctor at a clinic:

We are suggested to coordinate with the doctor when there is a client who wants to take the test. For example, how many clients can we take on that day? What are the health protocols? We need to make sure that clients can receive service needed before taking them to the local health clinic … I sent a text to the doctor, ‘How is the situation at the clinic? Can I take clients there? What is the protocol?’ Because I haven't seen it myself [the situation at the health clinic]. (OW03, interview, 9 July 2020)

Overall, the step of referring clients to healthcare providers appeared the most transformed by the pandemic, given that it relied on close relationships with healthcare providers and access to clinics. The provision of extended support schemes granted an extended capacity for outreach workers to play a role in supporting both HIV but public health efforts more broadly. Yet these schemes, while largely seen as beneficial, were focused on supporting clients. They did not appear to incorporate additional support for outreach workers, who were largely expected to adjust their activities (whether to online, or modified forms of in person work at clinics) without substantial additional support.

Discussion

The narratives offered by outreach workers in our study reveals how the subtle yet important impacts on HIV outreach work resulting from the COVID-19 pandemic. In particular, outreach workers spent more time conducting outreach work virtually. A shift away from location-based programmes did not, however, mean that outreach workers stopped meeting clients in person. Indeed, several participants in the study reported meeting with clients at their own home or the client’s home to facilitate easier provision of information. In other cases, outreach workers described accompanying clients in person, whether because they presented as urgent cases or because they felt it would simply be more efficient if they did so. These changes notwithstanding, many aspects of outreach work as viewed by participants remained the same as prior to the pandemic. This appears to be one result of structural aspects of HIV programmes, and in particular the influence of targets that emphasise pharmaceutical or technical interventions such as testing and treatment.

The impact of the COVID-19 pandemic on outreach workers was thus most acutely felt in the form of an ongoing stress on targets, which seemed to make the needs of outreach workers subservient to the dominant policy narrative of the ‘cascade of care’. Targets were indeed adjusted by funders at the onset of the pandemic to reflect altered conditions for conducting outreach work. Yet the steps which we analysed based on outreach worker’s narratives reflects the considerable role that even altered targets play in shaping the focus and direction of HIV outreach. The assumption of a relatively linear ‘cascade’ through which people receive information and undertake HIV testing and treatment remained a common preoccupation in the narratives of outreach workers. For example, one outreach worker explained the contradictory pull between the work that they undertook ‘from the heart’ and the need to meet monthly targets:

In NGOs, we do our work based on targets. It causes a conflict. Our work is a calling from our heart, but we also need to think about meeting targets. It means that we lessen our focus on clients … . (OW04, interview, 9 July 2020)

In addition to feeding such dilemmas, an emphasis on meeting targets during the COVID-19 pandemic heightened a sense of stress for outreach workers at a challenging time. For example, in a video diary, one outreach worker explained the effects of alterations to targets:

I have been thinking a lot within this week, ‘Can I reach the target at the end of this program? Does my organization achieve the target? Will our program be extended?’ There was a rumour saying that if our targets are not achieved, this program won’t be extended. I am thinking a lot about this. If it is not extended, I need to start over from zero, and look for another job. I am confused, and meanwhile I am getting old. I also have personal problems, so I am overthinking things more and more. (OW09, video diary, 10 August 2020)

Beyond this pressure, a focus on targets based on programme outcomes concealed other important information gathered by outreach workers. For example, outreach workers expressed concern that the number of people receiving a positive HIV diagnosis increased and speculated that this might be linked to the reduced number of condoms and lubricants provided. Yet even though outreach workers did meet with clients in person (both officially and unofficially), the focus on targets concerned with measuring the efficacy of virtual outreach at the programme level meant that they did not receive guidance to respond to such a situation in the field. This attention to virtual outreach – while important – overshadowed the fact that outreach workers required ongoing support to provide condoms and lubricants during the pandemic.

Outreach workers also had to contend with fast-changing public health guidance from local and national authorities. This impacted how outreach work could take place but also exposed the gap between donor’s programme requirements during the pandemic versus the reality on the ground. For example, as result of the shift to virtual outreach, outreach workers no longer received transportation fees for travel to the clinic. However, conditions in the city and loosened public health restrictions sometimes meant that participants saw in-person outreach work as possible or favourable. This meant that outreach workers were doing in person outreach but with reduced funds and with targets that were inappropriate or not suited to the work they were doing in the field. It also placed them at risk of contracting COVID-19 in the absence of adequate resources for testing, contact tracing and personal protective equipment.

The assumption that outreach work could be separated into ‘virtual’ and ‘in-person’ formats was challenged in many participant’s narratives. The focus among outreach workers was largely on the client, and they shifted their mode of communication and engagement in line with what was required of each particular case. As a result, funded HIV programmes should focus less on defining targets and funding relative to the type of delivery, and more on offering support and engagement that reflects outreach worker’s role as an essential component of delivering HIV testing, treatment and care. Furthermore, the emphasis on separating 'virtual' from 'in-person' work, as well as the delineation between healthcare services and HIV programmes failed to account for the crucial role that outreach workers played in moving clients across these artificial boundaries. The provision of new programmes that supported clients, while welcomed, resulted in additional labour for outreach workers. Some of this work could not be undertaken virtually and so needed to take place in person to be effective. What an emphasis on targets for testing and treatment misses is that much of outreach work is comprised of negotiating relationships­ with healthcare workers, other outreach workers and clients. Attending to the innovative ways that outreach workers use these relationships to deliver healthcare highlights both the need for ongoing support for their role in HIV programmes as well as the essential role that they play as part of Indonesia’s public health response more broadly.

Acknowledgements

We would like to acknowledge the participants in the study for their time and engagement in the research project, in addition to the tireless dedication that they show to their community through their work. We would like to dedicate this article to one participant who passed away after contracting the COVID-19 virus following the completion of the study. We thank the Indonesian Democracy and Human Rights Hallmark Initiative administered by the Melbourne Law School for funding the project, and to Dr Helen Pausacker for her administrative support. Helpful comments and questions from two anonymous reviewers sharpened the analysis contained in this article.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by Indonesia Democracy Hallmark Research Initiative (IDeHaRI) Collaborative Research Grant, The University of Melbourne [grant number: n/a].

Notes

1 In addition to broad interruptions globally, HIV/AIDS organisations and activists in Indonesia reported shortages in antiretroviral medications, with only two weeks supply available in some areas as of April 2020 (Luis et al., 2020).

2 The COVID-19 pandemic takes place after at least a decade of concerted calls for and investment in community-based responses as a critical component of part of global HIV programs.

3 National health data has documented significant increases in new HIV infections found among MSM in Jakarta and several other Indonesian cities (HIV and AIDS Data Hub for Asia Pacific, 2017).

4 Rates of COVID-19 transmission and hospitalisation were high during the period of data collection for this research, with a seven-day average of 2817 new infections reported on 1 September 2020. From late June until mid-July in 2021 there was a significant surge in new COVID-19 infections, with a seven-day average of 48,821 on 17 July 2021 (World Health Organization, 2021). The Indonesian government imposed its most widespread public health measures since the beginning of the pandemic on 3 July 2021, which encompassed the whole of the most populous island of Java and international tourist destination Bali (Indonesian Government COVID-19 Website, n.d.). The widespread closure of clinics and hospitals in 2021 had a severe impact on outreach workers in this study. Since the data for this article was collected, one participant has sadly passed away from COVID-19 and several dozen have tested positive to the virus. Although access to adequate testing services remains a challenge, vaccination rates among outreach workers are high.

5 The Jakarta government imposed measures at the regional level during the period that the data for this study was collected in 2020, ranging from mask mandates and restrictions on access to public spaces (e.g. a 50% cap on entry to malls and other buildings). More localized neighbourhood closures both with and without official endorsement represented another feature of the public health response at this time (Kuno, 2020).

6 The two main programs that funded outreach activities at the time of the study were the Global Fund (GF) and the USAID-funded Linkages program. Despite some differences, both programs focus on increasing access to HIV testing and anti-retroviral therapy uptake and adherence (Sustainable HIV Financing in Transition (SHIFT) Programme, 2017, p. 12). These were adjusted at various points during the pandemic to accommodate changes in modes of outreach.

7 During the pandemic, the information that outreach workers used to verify targets was adjusted to reflect the increased reliance on online outreach. Participants described needing to provide five variables in reports for new contacts (name, age or birth year, and a number to verify identity; either a phone number or the name given in a dating application).