Indonesia continues to face a high HIV burden, with an estimated 564,000 people living with HIV/AIDS (PLWHA) by 2025. Jombang Regency has recorded 2,013 HIV/AIDS cases as of 2024; however, support services remain fragmented and lack systematic integration across health, psychosocial, and social sectors. Objective: To formulate a community-based integrated support model for key populations living with HIV/AIDS in Jombang Regency. A descriptive qualitative study with a model-development orientation was conducted in Jombang Regency from Mei to Juli 2026. Participants were purposively selected, comprising 20 PLWHA from key populations, 7 community support workers from the Jombang Care Center (JCC), and 3 health workers. Data were collected through in-depth interviews, Focus Group Discussions (FGDs), and field observations, then analyzed thematically using source and method triangulation. Three support needs were identified: (1) medical (24-hour ARV access, treatment adherence, and management of treatment interruption), (2) psychosocial (status acceptance, safe spaces, and self-empowerment), and (3) social (social support, children's education, and stigma reduction). The support mechanism follows this flow: case finding, JCC referral, outreach, assessment, collaborative solution-finding, and monitoring. Program sustainability depends on program commitment, safe spaces, confidentiality, multisectoral partnerships, human resources, and technical guidelines. The formulated integrated model comprises input, process, output, and outcome components aimed at achieving the "3 Zeros" target by 2030. Technical guidelines, safe spaces, and human resources require strengthening.
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