THE IMPLEMENTATION RESEARCH OF A TEST AND TREAT STRATEGY FOR HIV TREATMENT AND PREVENTION AMONG HIGH RISK MEN (HRM) GROUP IN BALI INDONESIA Assessment Study (year 1).
Code/Field of Science: 351/Public Health
RESEARCH REPORT
UDAYANA INTERNATIONAL RESEARCH
COLLABORATION
RESEARCH TITLE
THE IMPLEMENTATION RESEARCH OF A TEST AND TREAT STRATEGY FOR HIV TREATMENT AND
PREVENTION AMONG HIGH RISK MEN (HRM) GROUP IN BALI INDONESIA
Assessment Study (year 1)
RESEARCH TEAM
dr. Pande Putu Januraga, M.Kes, DrPH (0010017902)
Prof. dr. Dewa Nyoman Wirawan (0010104802)
dr. Luh Putu Lila Wulandari, MPH (0027067806)
dr. AAS Sawitri, MPH (0014096801)
Desak Widyanthini, SKM, M.Kes
Institution partner: Kirby Institute UNSW, Australia
FACULTY OF MEDICINE
UDAYANA UNIVERSITY
November 2015
Dibiayai oleh: DIPA PNBP Universitas Udayana
sesuai dengan Surat Perjanjian Penugasan Pelaksanaan Penelitian
Nomor: 246-371/UN14.2/PNL.01.03.00/2015, tanggal 21 April 2015
TABLE OF CONTENTS
TABLE OF CONTENTS ............................................................................................................................... 2
SUMMARY ............................................................................................................................................... 4
1 INTRODUCTION .................................................................................................................................... 5
1.1 Background and rationale ............................................................................................................. 5
1.2 Objectives ...................................................................................................................................... 6
2 METHODS ............................................................................................................................................. 6
2.1 Overview of study design .............................................................................................................. 6
2.2 Duration ........................................................................................................................................ 6
2.3 Study setting.................................................................................................................................. 6
2.4 Study population and sample ........................................................................................................ 7
2.5 Data collection and analysis .......................................................................................................... 8
2.6 International partner (Kirby Institute) roles .................................................................................. 9
2.7 Results dissemination and peer reviewed publications ................................................................. 9
2.8 Ethics consideration ...................................................................................................................... 9
3 STUDY BUDGET AND SCHEDULE ......................................................................................................... 11
3.1 Budget summary ......................................................................................................................... 11
3.2 Schedule of activities ................................................................................................................... 11
4 Survey Results .................................................................................................................................... 12
4.1 Respon rate ................................................................................................................................. 12
4.2 Sociodemographic characteristics of the participants ................................................................. 12
4.3 Number and type of sexual partners ........................................................................................... 13
4.4 The sexual practices with regular non commercial partners. ...................................................... 13
4.5 The sexual practices with casual non commercial partners. ....................................................... 13
4.6 The sexual practices with female sex workers partners .............................................................. 14
4.7 Social network ............................................................................................................................. 14
4.8 Knowledge about condom .......................................................................................................... 15
4.9 Knowledge and history of STI ...................................................................................................... 15
4.10 Knowledge on HIV ..................................................................................................................... 16
4.11 HIV testing ................................................................................................................................. 16
4.12 Exposure to health promotion activities ................................................................................... 17
2
4.13 Health seeking behaviour .......................................................................................................... 18
4.14 Predictors of HIV testing ............................................................................................................ 18
Discussion .............................................................................................................................................. 19
Conclusions ........................................................................................................................................... 21
Appendix 1 Test and treatment facility ............................................................................................. 22
Appendix 2 Study team ..................................................................................................................... 23
Appendix 3 Questionnaire ................................................................................................................. 24
Appendix 4 Observation form and In-depth interview questions ..................................................... 25
Appendix 5 Information card............................................................................................................. 26
Appendix 6 Information letters for in-depth and survey ................................................................... 27
Appendix 7 Verbal consent................................................................................................................ 28
REFERENCES .......................................................................................................................................... 29
3
SUMMARY
The primary objective of this study was to identify strategies of increasing HIV test and treatment
uptake, also known as the test and treat (T&T) strategy, among clients of female sex workers (FSWs)
i De pasa Bali. The stud ’s spe ifi o je ti es e e:
1. To investigate HIV related risk behaviours of clients of FSWs.
2. To investigate the barriers of HIV testing and treatment uptake among clients of FSWs
3. To quantify the cascade of HIV treatment during the time of study conducted.
Mixed research methods using quantitative and qualitative approaches were employed. The
quantitative phase applied a survey procedure in brothel based sites in Denpasar area. Survey
interviews were delivered by seven trained field workers of Yayasan Kerti Praja, Denpasar. They had
been trained to approach clients of sex workers to join the study, to complete questionnaire and to
provide survey respondents with information on HIV testing and treatment facilities at Yayasan Kerti
Praja, Denpasar. Furthermore, in-depth interviews were conducted to investigate the barriers of HIV
testing and treatment uptake among clients of FSWs. This report will only be describing the result of
the first objectives of this study. Other objectives will be described in other report formats which will
be published in international journals.
In the survey, 412 men were approached, however only 200 men were willing to participate in this
study. Only 15 (8.1%) of the participants have had an HIV test previously. Willingness to get tested
was the only factors associated with previous HIV testing, suggestive of the importance of
interventions to increase HIV testing among those who never been tested previously, to improve the
acceptance of repeat testing among high risk group. Future study needs to explore this association in
other settings. While the role of social network, exposure to HIV information from several types of
media were not associated with HIV testing, conforming the association in the future study is worth
considering.
4
1 INTRODUCTION
1.1 Background and rationale
While a number of national and local surveillances is still reporting the high burden of HIV epidemic
among injecting drug users (IDUs) in Indonesia, there is a growing evidence of an increasing trends of
sexual transmission of HIV, with female sex workers (FSWs) and man having sex with man (MSM) bear
a disproportionate burden of the epidemic.1-3 One of the province with continuing high prevalence of
HIV among FSWS is Bali. A number of surveys have indicated that relatively low rates of consistent
condom use and high numbers of clients made FSWs at risk of infection.3
To anticipate the problems and to curb the spread of the epidemic into more general population,
following the national policy, Bali Health Office (BHO), Bali AIDS Commission (BAC) and related
stakeholders including local NGOs have agreed that the interventions should be designed
comprehensively to facilitate health providers to be able to address the needs of affected populations
while also empower them to participate actively in the designing and implementing of interventions.4
This will only be possible through the effective implementation of Layanan Komprehensif
berkesinambungan (LKB) that consist of different strategies including health education, condoms
distribution, STIs test and treatment, as well as strategic use of antiretroviral (SUFA). The
implementation of this comprehensive package have been started gradually since 2009,5 with
intervention focusing on peer education, condom distribution and improvement of FSWs access to
STIs clinics. Since 2013 the comprehensive package has been equipped by the implementation of test
and treat strategy or SUFA.
While intervention to reduce the risk of HIV infection among FSWs in Bali have developed
progressively, limited is addressed to the other core group that link directly to FSWs group; their
clients. This group has important role on HIV transmission to the general population, linking high
prevalence of HIV infection among FSWs to the general population of women (wives, girlfriends).6,7
Traditionally, in Indonesia, this group is labelled as mobile man with money (3M), thus, within a
number of surveys, clients of sex workers were represented mostly by driver (truck or taxi).8-10 This
made the overall characteristics of clients is remain unknown. Some studies conclude that efforts to
reduce the risk of HIV infection among clients of FSWs might have a considerable impact in slowing
the spread of epidemic.11,12
Since the coverage of HIV prevention, treatment and care among clients of sex workers in Indonesia,
particularly in Bali remains inadequate, a novel approach to increase the coverage is needed. This
study will provide new information on how to reach clients of sex workers by investigating
5
characteristics of clients, their related risk behaviours as well as barriers to access testing and
treatment.
1.2 Objectives
1. To investigate HIV related risk behaviours of clients of FSWs.
2. To investigate the barriers of HIV testing and treatment uptake among clients of FSWs
3. To quantify the cascade of HIV treatment during the study time.
2 METHODS
2.1 Overview of study design
This was a cross sectional research study using quantitative and qualitative approaches that were
conducted over three months of duration. During this time, a cross-sectional sexual behaviour study
were conducted, 200 informants were recruited for interview. In addition to interviews, all survey
informants received information on the availability of free HIV testing and treatment facility at YKP
Clinic in Denpasar (details of the clinic is available in appendix 1). In order to have thorough
understanding on the barriers of HIV testing and treatment uptake among clients of FSWs, 20
participants were recruited for in-depth interviews.
2.2 Duration
The study was conducted within 6 months from preparation for the study (refining the study protocol,
obtain ethics approval, developing manual of operations, staff training et cetera) to the
commencement of participant recruitment (survey, HIV test, and in-depth interviews).
Analysis and evaluation, reporting and preparing publication outputs will continue beyond the study
period.
2.3 Study setting
The study were conducted in 7 complexes in Denpasar, each complex consist of a number of brothels
a aged
othel’s a age o pi p. A
othel ha a te ised
a udi e ta
uildi g ith oo s
for sexual transactions and or used for daily life by FSWs. In common, a small mini bar (warung) or
lounge available in each brothel for FSWs and clients socialising. This was an area where most of study
informants and participants would be recruited.
6
2.4 Study population and sample
The study population is the clients of FSWs working in the selected brothels. A client of FSWs was
defined as a male who is present in the brothel during the intensive outreach and who have a history
of sexual transaction at the brothel sites with a FSW working there.
Eligibility criteria for enrolment:
Participants had to meet all of the following inclusion criteria:
i.
Aged 18 years and over;
ii.
Self-reported sex with female sex workers in the last 12 months;
iii.
Providing consent to be enrolled in the study.
Exclusion criteria included:
i.
Unable to provide informed consent;
ii.
Participation in another study with a similar research focus;
iii.
Known to be HIV-i fe ted
the stud tea
a d stud ’s e u e ato s.
All men who fall into the client definition and fulfil the criteria are eligible to participate, thus will were
invited to join the study.
200 clients joined the survey and received information on free HIV testing and treatment at YKP clinic
in Denpasar. Since providing survey respondents with information on free HIV testing and treatment
facility is a normal practice in any outreach program among at risk populations, this activity was not
considered as a study intervention. Within this scenario the study was not targeting number of survey
respondents that would finally come to the clinic, however, based on regular reports provided by
outreach and VCT program of YKP.
For qualitative part of the study, there were 20 participants recruited under the same inclusion and
exclusion criteria as the survey phase. This number is quite representative to gain maximum variation
of participants as well as thorough information on clients sexual behaviours and barriers to HIV test
and treatment. There were 10 participants recruited from clients who come to the clinic for HIV test
a d
pa ti ipa ts f o
othels o ple es. The YKP’s field staff a ted as e uit e t tea , ho e e
all in-depth interviews were conducted by the study team.
7
2.5 Data collection and analysis
The survey phase of the study was delivered by 7 field workers (penjangkau) of Yayasan Kerti Praja.
These staffs have had experiences of working with hard to reach population including clients of sex
workers. They were trained in a workshop to recruit survey informants, to conduct survey interviews
using structured questionnaire (appendix 4) as well as to provide clients with information card on free
HIV testing and treatment facilit at YKP’s li i appe di
. The su e i te ie s e e o du ted
in sex workers rooms available in each location/brothel. Before the survey, the YKP field staffs
egotiated the a aila ilit of these oo s ith all
othels’
a age s of sele ted sites.
Meanwhile in-depth interviews in the qualitative phase of the study were delivered in a private room
available at YKP building by the principal investigator and a co-investigator using semi-structured open
ended questions (appendix 5). All potential parti ipa ts e e app oa hed a d e uited
YKP’s field
work staffs during the survey and clinic visits. For participants recruited during survey time, they will
be offered transport costs for travelling to YKP building.
The study were not provide or delive a
li i al i te e tio to the stud ’s pa ti ipa ts; ho e e ,
as explained before, it is anticipated that there were a number of study participants who have received
information on free HIV testing and treatment facility at YKP might come to the clinic for services. In
this case, the clinic staffs (doctors, nurses, analyst and counsellors) would conduct HIV test and
t eat e t as usi ess as usual usi g o
al “OP p a ti ed
the YKP’s li i . The “OP itself is alig ed
with the national guidelines on HIV test and treatment for high risk group people including clients of
sex workers. In order to prepare the clinic well, before the data collection begin, the study team held
a meeting with YKP clinic staffs to discuss the data management procedure. There were two important
procedures involved at this stage; first, the process of identifying clients who come to the clinic prior
to receiving information card from the survey. Second, the process of de-identifying VCT and ART data
from this group of clients to be used by the study.
Fo
those stud ’s a ti ities, th ee t pes of data e e de eloped:
a. Data from survey, this was a quantitative data useful for generating information on sexual
behaviours of clients of FSWs. A number of univariate and multivariate statistical procedures
were conducted in order to gain determinants of sexual behaviours including condom use;
b. Data from in-depth interviews, this was a qualitative data useful for theorising the underlying
context and mechanism of barriers of HIV testing and treatment uptake. To analyse the data,
thematic framework analysis will be applied to reach the study objective.
8
c. Results on HIV testing and treatment, this was a quantitative data useful for generating
summary on HIV testing and treatment uptake. Demographic characteristics of all subjects
being tested for HIV were summarized. The rates of HIV diagnosis, transfer to care, and
commencing ART, was also summarized.
2.6 International partner (Kirby Institute) roles
The Kirby Institute, formerly the National Centre in HIV Epidemiology and Clinical Research (NCHECR)
collaborated extensively in the international effort that ensured that HIV became one of the most
intensively studied diseases in the history of medical science. The Kirby Institute is directly affiliated
with the Faculty of Medicine at the University of New South Wales (UNSW), and receives funding
th ough the Aust alia Go e
e t Depa t e t of Health a d Agei g. The Ki
I stitute’s p i a
functions relate to the co-ordination of national surveillance programs, population health and
epidemiological research, clinical research and clinical trials. With these extensive experiences, Kirby
Institute provided active consultation for the development of study design including instruments
developments. The Kirby Institute also assisted local research team in developing and analysing the
stud ’s data.
2.7 Results dissemination and peer reviewed publications
A fi al epo t is su
itted to Uda a a U i e sit Resea h I stitutio
LPPM at the e d of the stud ’s
duration as per their requirements. This report describes the results of the survey, while the results
of interviews and observations will be reported in other format. The study results will also be
disseminated for relevant stakeholders in Bali and Jakarta (KPAN and Ministry of Health) through
policy briefs and series of seminars. Main study findings as well as sub-analyses and sub-studies will
be published in peer-reviewed journals.
2.8 Ethics consideration
During the data collections, all potential subject in survey and in-depth interviews were handed an
information letter explaining the purpose of the study (appendix 7). Those willing to participate in the
study were asked to give verbal informed consent. For survey respondents responding to the
questionnaire in the survey phase after receiving information on the survey procedure is considered
as implying consent to participate in the study.13 For in-depth i te ie s, pa ti ipa ts’ o se t to e
interviewed was recorded to replace written consent. Verbal informed consent (Appendix 8) is
preferred to obtaining a signed form, which could be intimidating for clients of sex workers as
currently the social and political situation is circulating issues around criminalisation of clients of sex
9
workers. Also, verbal agreement is an alternative to signed consent forms in cross-cultural research
and research in marginalised or oppressed groups or hard to reach population including clients of sex
workers.13,14 By doing this, the study ensured that all subjects participate voluntarily. In addition,
during data collection all study subjects had right to withdraw their involvement at any time they
want, this right has been clearly written in the information letters and verbal consent documents.
Meanwhile for both HIV testing and ART initiation, the study will rely on the standard clinical
procedu e of YKP’s li i , the stud
ill o l gai de-ide tified data f o
lie ts’ e o ds.
Furthermore, the study subjects were offered funds for their times spend in survey (Rp. 50,000.-) and
in in-depth interviews (Rp. 75,000.-) to recognise their valuable contribution to this research.
Participants also received information card on free HIV testing and treatment facility available at YKP
in Denpasar. These practices are common for HIV research in Indonesia and particularly in Bali.
For those who come to the clinic after receiving information from the survey, HIV test were performed
based on normal procedure conducted at the clinic with adequate pre- and post-test counselling by
trained personnel to minimize risk which might arise from learning of HIV diagnosis. There were no
reward for clients who come to the clinic for testing and treatment as normal or usual procedure were
applied to them. Irrespective of no direct financial reward for their participation in the test, knowing
HIV status earlier and joining the ART earlier in case they are found to be positive will benefit the
health of clients.
All stud i fo
a ts, pa ti ipa ts a d patie ts’ o fide tialit
e e ai tai ed th oughout the stud .
“u je ts’ ha d op data e e sto ed i a lo ked a i et i P“IKM FK UNUD, while softcopy data were
stored in a password protected laptop. These data were kept for the duration five years after the study
fi ish, o l the stud ’s tea
had a ess to it. Fu the
o e, o l de-identified data will be used in all
reports and publications related to the study. All patients starting ART in the study will be continuing
the treatment after the conclusion of the study as there is no current evidence supporting treatment
interruption. Also, this treatment will be provided through the national ART policy and program
(Strategic use of ART – Layanan Komprehensif Berkesinambungan or SUFA-LKB).
Ethics approval were sought at Komisi Etika Penelitian Fakultas Kedokteran UNUD-RSUP Sanglah
Denpasar.
10
3 STUDY BUDGET AND SCHEDULE
3.1 Budget summary
The stud is fu ded th ough i te atio al esea h olla o atio
g a t, U i e sitas Uda a a’s
research unit. The overall budget for 6 months study is one hundred million rupiah. There is no funds
support from the international partner.
3.2 Schedule of activities
The study will be conducted from May 2015 and should be concluded in November 2015 as outline in
table below
2015
Activities
1
2
3
4
5
6
7
Preparatory activities and study setup
Apply for Ethics Committee approval
Intensive outreach training and workshop
Survey
In-depth interviews
Analysis and Reporting
Dissemination seminar
11
4 Survey Results
4.1 Respon rate
Among 412 participants who were approached during the data collection, 200 of them agreed to
participate in the survey, giving the response rate of 48.5%. Among these, 200 questionnaires were
included in the analysis
4.2 Sociodemographic characteristics of the participants
The mean age of participants were 39 years old, with the majority of them (46%) enjoyed the highest
education in the senior high school. Islam and Hindu comprised the two main religions among
participants, 58% and 36% respectively. The majority of the respondents came from Java (49%) and
Bali(36%). 65% of respondents admitted that they consume alcohols at least less than once a week.
Only 2 respondents had a history of drug use, and none of these were on injecting drug.
In terms of marital status, more than half (131 or 65,5%) of them have ever been married and currently
remain married, with almost 70% of them married at the first time at the age between 23-30 years
old. Those who reported that they currently married, 58% of them living with their spouse. On the
other hand, those who reported that they do not married, 7% of them admitted they livewith their
sexual partners.
While the majority of respondents (70.5%) of them reported that their age when they first married
were between 23-30 years, surprisingly the majority of the respondents begin their sexual debut long
before that age. More than 80% of the respondents reported that the first time they had sex were at
the age between 14 to 22.
Table 4.1 Sociodemographic Characteristics of the Participants
Sociodemographic characteristics
N
%
137
46
74.9
25.1
42
59
91
6
21.2
29.8
46.0
3.0
116
72
2
10
58.0
36.0
1.0
5.0
Age
Mean±SD (39±19)
≤40 years old
>40 years old
Education
Primary
Secondary junior
Secondary senior
Higher
Religion
Islam
Hindu
Catholic
Protestant
Marital status
12
Ever been married/currently remain married
Never married
Age first married
14-22 years old
23-30 years old
Age first married
14-22 years old
23-30 years old
131
69
65.5
34.5
38
91
29.5
70.5
167
31
84.3
15.7
4.3 Number and type of sexual partners
The number of commercial sexual partners the participants had within the last 12 months ranging
from 1- 24, with 80% of the participants admitted they had sex with 1-5 female sex workers within the
last 12 months. In addition to female sex workers, 18% of the respondents also admitted that they
had other occasional non-commercial sexual partners, with the number of this type of partners
ranging from 1-2. None of the respondents in this study reported the history of having sexual
relationship with men.
4.4 The sexual practices with regular non commercial partners.
128 (64%) of the respondents reported that they had this regular non commercial sex partners
(including wife). When they were asked about how many times they had sex with this partners in the
last month, the answer was ranging from 0 to 20 times, with around 40% of them had sex 2-4 times
within a month. Only 4 of the respondents reported the use of condom with this type of partners in
the last sex. While the respondents who reported to use condom mentioned that it was the join
decision with their partner, those who reported of not using condom mentions various reasons of not
using it. The three most common reasons for not using condom were that because they already use
other contraception methods (65%), because they thought it as ot e essa
% a d the did ’t
like it (35%). When the question on the time period of condom use was expanded to the period of
ithi the last ea , still the
ajo it
% of the espo de ts ad itted the
e e use it.
4.5 The sexual practices with casual non commercial partners.
As noted above, 37 ( 18.50%) of the respondents admitted that they have this type of sexual partners,
i.e casual non-commercial. Among these, the number of sexual intercourse ranging from 1-8 times
within the last month, with only 14(37%) of the respondents reported the use of condom within the
last sexual engagement. Those who reported to use condom mentioned that it was the decision made
jointly 8 or 57%) or from himself ( 6 or 42%). Those reported not to use condom, the three most
o
o
easo s e tio ed e e e ause the did ’t like it
% , o do is ot a aila le
% a d
13
condom was not necessary ( 12%). When they were asked about the use of condom within last year,
the majority answer given was sometime ( 43%).
4.6 The sexual practices with female sex workers partners
While all of the respondents reported to have sex with brothel based sex workers within the last year,
only 5(2.5%) of them reported to have sex with non-brothel based sex workers within the same period,
with the number of non-brothel based sex workers they had sex with were 1, and admitted that they
have sex with this type of sexual partners 1-3 times in the last year.
The number of brothel based commercial sex partners the respondents had within the last year
ranging from 1 to 24. The number of sexual engagement with FSW within the last month were ranging
from 0-8, with the majority of respondents (76.5%) reported the number of sexual activity with this
type of partner in the last month between 1-3 times.
The majority of the respondents (88.5%) said they use condom when the last time they had sex with
the brothel based sex workers. Those who used condom, mentioned the decision maker process of
using condom that that it was the decision of their sexual partners to use it (43.3%), it was the join
decision (37.8%), and his decision ( 18.3%). Those who reported not to use condom mentioned despite
they aware of the availability of condoms in the brothels, the three most common reasons for not
usi g o do
e e as follo : e ause the did ot like it
. % , e ause it as ’t e essa
to use
condom ( 27.3%), and because they did not think of it ( 13.6%). When the time period of condom use
uestio
e e e pa ded as
ithi the last
o th , 61% of the respondents reported the use of
condom every time they have sex with sex workers.
4.7 Social network
It is interesting to note that more than half (54%) of the respondents mentioned that they come to
the brothels with their friends; followed by coming alone by himself (45%). Almost all (98.5%)
admitted that this is not the first time they go to the brothels; with almost all of them ( 90%)
mentioned that they found out the existence of brothels location from their friends. Other than the
brothels area they had visited during the interview sessions, 125 (63%) participants reported that they
also visited other brothels within the last year, with number of brothels visited ranging from 1-4
brothels; and they mentioned that in most often case, they visited the brothels with their friends
(55%).
14
4.8 Knowledge about condom
192(96%) of the respondents reported that they have ever used condom previously. Almost all ( 199
or 99.50%) have heard about male condoms, however only 4% of the respondents have heard about
female condoms. 97% of the respondents know where to find condoms, with sexual partners
(56.41%), pharmacy (56.41%) and friends (21.5%) were three most quoted sources where they can
find condoms.
4.9 Knowledge and history of STI
Regarding knowledge on STI, 95.5% of the respondents have heard about STIs. Foul smelling discharge
(50.3%), itching (35.1%), and genital ulcers (13.1%) were three most perceived common symptoms for
STIs among female; while the three most quoted STIs symptoms among male were burning pain on
urination (60.73%), genital discharge (48.7%), and genital ulcers (36.7%). Among the respondents,
11,50% admitted that they have had a genital ulcers within the last year, while 9% also reports the
history of genital discharge.
Table 4.2 Knowledge and history of HIV among participants
Knowledge and history of STI
Heard about STIs
Have heard
Do ’t ha e hea d
Common symptoms for STIs
among female
Foul smelling discharge
Itching
Genital ulcers
Common symptoms for STIs
among male
Burning pain on urination
Genital discharge
Genital ulcers
Have had a genital ulcers within
the last year
Yes
No
Reports the history of genital
discharge.
Yes
No
N
%
191
9
95.5
4.5
96
67
25
50.3
35.1
13.1
116
93
70
60.7
48.7
36.7
23
177
11.5
88.5
18
182
9.0
91.0
15
4.10 Knowledge on HIV
Almost all (185 or 92.50%) of the respondents have heard about HIV. However only 43% perceived
themselves at high risk of HIV, while 40% others perceived that they may be at risk, and 7.6% of them
perceived that they were not at risk at all of HIV.
Although more than half (59%) of the respondents did not know someone who are infected with HIV,
and no relatives were infected with the virus (91.3%), the majority of the respondents (61.62%)
perceived HIV as very severe.
Although most two third (77%) answered yes when they were asked of whether we can protect
ourselves by consistently using condom during sexual act, 71% said yes when asked whether having
faithful partner can protect them from HIV, and 72% answered yes when asked about whether
abstinentia can protect them from HIV infection, and 91% said yes when asked whether sharing
needles can be a means of HIV transmission; misconception about HIV transmission is still common.
Only 44% of the respondents said that HIV cannot be transmitted by mosquito bites nor by sharing
food and drink with HIV infected persons. Additionally, around 67% do not or not sure if person
infected with HIV might look as other healthy people.
4.11 HIV testing
With regards to HIV testing, only 41.6% of the respondents aware that they can receive a confidential
HIV testing. Only 15 people (8.1%) had ever been tested before, and most of them ( 14 persons) seek
the test voluntarily, and only 13 people got the results of the test. Among those who got the results.
6(40%) of them mentioned that the test was conducted within a year, 4(26.67%) of them did the test
1-2 years before, and 2 of them did the test 2-4 years ago.
Only 39.50% of the respondents know where to get tested, and 76% of these who knew where to get
tested, 76% perceived that those places were convenient.
66.5% of the participants answered yes when they were asked whether they would willing to receive
an HIV test offer in the future.
Table 4.3 HIV testing awareness and experiences
HIV testing
Aware that they can receive a
confidential HIV testing
Yes
No
Do ’t k o
No answer
N
%
77
23
83
2
41.6
12.4
44.9
1.1
16
Had ever been tested before
Yes
No
Voluntary or mandatory
Voluntary
Mandatory
Know the result
Yes
No
When was the received result test
conducted
Within a year
1-2 years before
2-4 years before
Do ’t k o
15
170
8.1
91.9
14
1
93.3
6.7
13
2
86.7
13.3
6
4
2
3
40.0
26.7
13.3
20.0
4.12 Exposure to health promotion activities
The exposure of health promotion activities were explored in this survey. When exposure to everyday
social media was asked, the rank of media used every day by the participants rank from television (
91.50%), radio ( 25%), online social media ( 11%), and newspaper ( 6.5%). However, the rank is
different, when they were asked about whether they have heard about HIV information from those
media, i.e newspaper (84.50%), social media (77.8%), tv (71.50%), and radio ( 61.3%).
When they were asked about health education session they had ever attended, only 19% of said that
they have attended health education session, with almost all of these mentioned that they received
HIV information on that session.
Table 4.4 Exposure to HIV Promotion Activities
Experiences on health promotion
activities
The rank of media used every day
Television
Radio
Online social media
newspaper
Have heard about HIV information
Newspaper
Social media
Television
Radio
Attended health education session
Yes
No
No answer
N
%
183
50
22
13
91.5
25.0
11.0
16.5
109
42
143
87
84.5
77.8
71.5
61.3
38
161
1
19.0
80.5
0.5
17
4.13 Health seeking behaviour
Among those who had a history of STI symptoms, the first thing they did when they had the symptoms
were seek medicine at the chemist. This was the answer mostly expressed by the participants
(35.71%).
Analysis was conducted to identify predictors of history of HIV testing among this group. Several
variables were selected based on that they suggested as factors that more likely to influence HIV
testing. These factors include age, age at the first married, age at first sexual intercourse, number of
wife and regular partners, number of female sex workers they have had sex with, and number of
occasional sexual partners; the highest education level, history of alcohol, and drugs, history of
marriage, the use of condom, knowledge that HIV can be transmitted through sexual act, history of
genital ulcer within a year, history of genital discharge within a year, have heard about AIDS, perceived
risk, and the history of HIV information exposure through several media; history of having attended
education session on HIV, and know the place to get tested, and perception whether those place were
convenient.
4.14 Predictors of HIV testing
Analysis was conducted to identify factors associated with HIV testing. Several variables, which were
considered as factors that might predict HIV testing behaviours were selected. These includes the level
of education, the number of female sex workers that have been visited in the last 12 months, the
importance of sexual network (such as, who took them to the brothels, and who provide information
about this brothels); HIV information exposure from tv, radio, and education session, history of STI
symptoms, and willingness to get tested in the future.
The results is summarised in table 4.5
18
Table 4.5 Predictors of previous HIV testing
Predictors
Level of education
The number of female sex workers that
have been visited in the last 12 months
Who took them to the brothels
Provide information about this brothels
from friends
HIV information exposure from from
television
HIV information exposure from radio
Education session
Know where to get HIV test
Have had genital ulcers or sores for
the last
year
Have had genital discharge for the last
year
Willingness to get tested in the future
OR
0.51
5.51
Univariate analysis
pV
95%CI
0.233
0.17-1.56
0.015
1.21-25.17
0.06
0.26
RESEARCH REPORT
UDAYANA INTERNATIONAL RESEARCH
COLLABORATION
RESEARCH TITLE
THE IMPLEMENTATION RESEARCH OF A TEST AND TREAT STRATEGY FOR HIV TREATMENT AND
PREVENTION AMONG HIGH RISK MEN (HRM) GROUP IN BALI INDONESIA
Assessment Study (year 1)
RESEARCH TEAM
dr. Pande Putu Januraga, M.Kes, DrPH (0010017902)
Prof. dr. Dewa Nyoman Wirawan (0010104802)
dr. Luh Putu Lila Wulandari, MPH (0027067806)
dr. AAS Sawitri, MPH (0014096801)
Desak Widyanthini, SKM, M.Kes
Institution partner: Kirby Institute UNSW, Australia
FACULTY OF MEDICINE
UDAYANA UNIVERSITY
November 2015
Dibiayai oleh: DIPA PNBP Universitas Udayana
sesuai dengan Surat Perjanjian Penugasan Pelaksanaan Penelitian
Nomor: 246-371/UN14.2/PNL.01.03.00/2015, tanggal 21 April 2015
TABLE OF CONTENTS
TABLE OF CONTENTS ............................................................................................................................... 2
SUMMARY ............................................................................................................................................... 4
1 INTRODUCTION .................................................................................................................................... 5
1.1 Background and rationale ............................................................................................................. 5
1.2 Objectives ...................................................................................................................................... 6
2 METHODS ............................................................................................................................................. 6
2.1 Overview of study design .............................................................................................................. 6
2.2 Duration ........................................................................................................................................ 6
2.3 Study setting.................................................................................................................................. 6
2.4 Study population and sample ........................................................................................................ 7
2.5 Data collection and analysis .......................................................................................................... 8
2.6 International partner (Kirby Institute) roles .................................................................................. 9
2.7 Results dissemination and peer reviewed publications ................................................................. 9
2.8 Ethics consideration ...................................................................................................................... 9
3 STUDY BUDGET AND SCHEDULE ......................................................................................................... 11
3.1 Budget summary ......................................................................................................................... 11
3.2 Schedule of activities ................................................................................................................... 11
4 Survey Results .................................................................................................................................... 12
4.1 Respon rate ................................................................................................................................. 12
4.2 Sociodemographic characteristics of the participants ................................................................. 12
4.3 Number and type of sexual partners ........................................................................................... 13
4.4 The sexual practices with regular non commercial partners. ...................................................... 13
4.5 The sexual practices with casual non commercial partners. ....................................................... 13
4.6 The sexual practices with female sex workers partners .............................................................. 14
4.7 Social network ............................................................................................................................. 14
4.8 Knowledge about condom .......................................................................................................... 15
4.9 Knowledge and history of STI ...................................................................................................... 15
4.10 Knowledge on HIV ..................................................................................................................... 16
4.11 HIV testing ................................................................................................................................. 16
4.12 Exposure to health promotion activities ................................................................................... 17
2
4.13 Health seeking behaviour .......................................................................................................... 18
4.14 Predictors of HIV testing ............................................................................................................ 18
Discussion .............................................................................................................................................. 19
Conclusions ........................................................................................................................................... 21
Appendix 1 Test and treatment facility ............................................................................................. 22
Appendix 2 Study team ..................................................................................................................... 23
Appendix 3 Questionnaire ................................................................................................................. 24
Appendix 4 Observation form and In-depth interview questions ..................................................... 25
Appendix 5 Information card............................................................................................................. 26
Appendix 6 Information letters for in-depth and survey ................................................................... 27
Appendix 7 Verbal consent................................................................................................................ 28
REFERENCES .......................................................................................................................................... 29
3
SUMMARY
The primary objective of this study was to identify strategies of increasing HIV test and treatment
uptake, also known as the test and treat (T&T) strategy, among clients of female sex workers (FSWs)
i De pasa Bali. The stud ’s spe ifi o je ti es e e:
1. To investigate HIV related risk behaviours of clients of FSWs.
2. To investigate the barriers of HIV testing and treatment uptake among clients of FSWs
3. To quantify the cascade of HIV treatment during the time of study conducted.
Mixed research methods using quantitative and qualitative approaches were employed. The
quantitative phase applied a survey procedure in brothel based sites in Denpasar area. Survey
interviews were delivered by seven trained field workers of Yayasan Kerti Praja, Denpasar. They had
been trained to approach clients of sex workers to join the study, to complete questionnaire and to
provide survey respondents with information on HIV testing and treatment facilities at Yayasan Kerti
Praja, Denpasar. Furthermore, in-depth interviews were conducted to investigate the barriers of HIV
testing and treatment uptake among clients of FSWs. This report will only be describing the result of
the first objectives of this study. Other objectives will be described in other report formats which will
be published in international journals.
In the survey, 412 men were approached, however only 200 men were willing to participate in this
study. Only 15 (8.1%) of the participants have had an HIV test previously. Willingness to get tested
was the only factors associated with previous HIV testing, suggestive of the importance of
interventions to increase HIV testing among those who never been tested previously, to improve the
acceptance of repeat testing among high risk group. Future study needs to explore this association in
other settings. While the role of social network, exposure to HIV information from several types of
media were not associated with HIV testing, conforming the association in the future study is worth
considering.
4
1 INTRODUCTION
1.1 Background and rationale
While a number of national and local surveillances is still reporting the high burden of HIV epidemic
among injecting drug users (IDUs) in Indonesia, there is a growing evidence of an increasing trends of
sexual transmission of HIV, with female sex workers (FSWs) and man having sex with man (MSM) bear
a disproportionate burden of the epidemic.1-3 One of the province with continuing high prevalence of
HIV among FSWS is Bali. A number of surveys have indicated that relatively low rates of consistent
condom use and high numbers of clients made FSWs at risk of infection.3
To anticipate the problems and to curb the spread of the epidemic into more general population,
following the national policy, Bali Health Office (BHO), Bali AIDS Commission (BAC) and related
stakeholders including local NGOs have agreed that the interventions should be designed
comprehensively to facilitate health providers to be able to address the needs of affected populations
while also empower them to participate actively in the designing and implementing of interventions.4
This will only be possible through the effective implementation of Layanan Komprehensif
berkesinambungan (LKB) that consist of different strategies including health education, condoms
distribution, STIs test and treatment, as well as strategic use of antiretroviral (SUFA). The
implementation of this comprehensive package have been started gradually since 2009,5 with
intervention focusing on peer education, condom distribution and improvement of FSWs access to
STIs clinics. Since 2013 the comprehensive package has been equipped by the implementation of test
and treat strategy or SUFA.
While intervention to reduce the risk of HIV infection among FSWs in Bali have developed
progressively, limited is addressed to the other core group that link directly to FSWs group; their
clients. This group has important role on HIV transmission to the general population, linking high
prevalence of HIV infection among FSWs to the general population of women (wives, girlfriends).6,7
Traditionally, in Indonesia, this group is labelled as mobile man with money (3M), thus, within a
number of surveys, clients of sex workers were represented mostly by driver (truck or taxi).8-10 This
made the overall characteristics of clients is remain unknown. Some studies conclude that efforts to
reduce the risk of HIV infection among clients of FSWs might have a considerable impact in slowing
the spread of epidemic.11,12
Since the coverage of HIV prevention, treatment and care among clients of sex workers in Indonesia,
particularly in Bali remains inadequate, a novel approach to increase the coverage is needed. This
study will provide new information on how to reach clients of sex workers by investigating
5
characteristics of clients, their related risk behaviours as well as barriers to access testing and
treatment.
1.2 Objectives
1. To investigate HIV related risk behaviours of clients of FSWs.
2. To investigate the barriers of HIV testing and treatment uptake among clients of FSWs
3. To quantify the cascade of HIV treatment during the study time.
2 METHODS
2.1 Overview of study design
This was a cross sectional research study using quantitative and qualitative approaches that were
conducted over three months of duration. During this time, a cross-sectional sexual behaviour study
were conducted, 200 informants were recruited for interview. In addition to interviews, all survey
informants received information on the availability of free HIV testing and treatment facility at YKP
Clinic in Denpasar (details of the clinic is available in appendix 1). In order to have thorough
understanding on the barriers of HIV testing and treatment uptake among clients of FSWs, 20
participants were recruited for in-depth interviews.
2.2 Duration
The study was conducted within 6 months from preparation for the study (refining the study protocol,
obtain ethics approval, developing manual of operations, staff training et cetera) to the
commencement of participant recruitment (survey, HIV test, and in-depth interviews).
Analysis and evaluation, reporting and preparing publication outputs will continue beyond the study
period.
2.3 Study setting
The study were conducted in 7 complexes in Denpasar, each complex consist of a number of brothels
a aged
othel’s a age o pi p. A
othel ha a te ised
a udi e ta
uildi g ith oo s
for sexual transactions and or used for daily life by FSWs. In common, a small mini bar (warung) or
lounge available in each brothel for FSWs and clients socialising. This was an area where most of study
informants and participants would be recruited.
6
2.4 Study population and sample
The study population is the clients of FSWs working in the selected brothels. A client of FSWs was
defined as a male who is present in the brothel during the intensive outreach and who have a history
of sexual transaction at the brothel sites with a FSW working there.
Eligibility criteria for enrolment:
Participants had to meet all of the following inclusion criteria:
i.
Aged 18 years and over;
ii.
Self-reported sex with female sex workers in the last 12 months;
iii.
Providing consent to be enrolled in the study.
Exclusion criteria included:
i.
Unable to provide informed consent;
ii.
Participation in another study with a similar research focus;
iii.
Known to be HIV-i fe ted
the stud tea
a d stud ’s e u e ato s.
All men who fall into the client definition and fulfil the criteria are eligible to participate, thus will were
invited to join the study.
200 clients joined the survey and received information on free HIV testing and treatment at YKP clinic
in Denpasar. Since providing survey respondents with information on free HIV testing and treatment
facility is a normal practice in any outreach program among at risk populations, this activity was not
considered as a study intervention. Within this scenario the study was not targeting number of survey
respondents that would finally come to the clinic, however, based on regular reports provided by
outreach and VCT program of YKP.
For qualitative part of the study, there were 20 participants recruited under the same inclusion and
exclusion criteria as the survey phase. This number is quite representative to gain maximum variation
of participants as well as thorough information on clients sexual behaviours and barriers to HIV test
and treatment. There were 10 participants recruited from clients who come to the clinic for HIV test
a d
pa ti ipa ts f o
othels o ple es. The YKP’s field staff a ted as e uit e t tea , ho e e
all in-depth interviews were conducted by the study team.
7
2.5 Data collection and analysis
The survey phase of the study was delivered by 7 field workers (penjangkau) of Yayasan Kerti Praja.
These staffs have had experiences of working with hard to reach population including clients of sex
workers. They were trained in a workshop to recruit survey informants, to conduct survey interviews
using structured questionnaire (appendix 4) as well as to provide clients with information card on free
HIV testing and treatment facilit at YKP’s li i appe di
. The su e i te ie s e e o du ted
in sex workers rooms available in each location/brothel. Before the survey, the YKP field staffs
egotiated the a aila ilit of these oo s ith all
othels’
a age s of sele ted sites.
Meanwhile in-depth interviews in the qualitative phase of the study were delivered in a private room
available at YKP building by the principal investigator and a co-investigator using semi-structured open
ended questions (appendix 5). All potential parti ipa ts e e app oa hed a d e uited
YKP’s field
work staffs during the survey and clinic visits. For participants recruited during survey time, they will
be offered transport costs for travelling to YKP building.
The study were not provide or delive a
li i al i te e tio to the stud ’s pa ti ipa ts; ho e e ,
as explained before, it is anticipated that there were a number of study participants who have received
information on free HIV testing and treatment facility at YKP might come to the clinic for services. In
this case, the clinic staffs (doctors, nurses, analyst and counsellors) would conduct HIV test and
t eat e t as usi ess as usual usi g o
al “OP p a ti ed
the YKP’s li i . The “OP itself is alig ed
with the national guidelines on HIV test and treatment for high risk group people including clients of
sex workers. In order to prepare the clinic well, before the data collection begin, the study team held
a meeting with YKP clinic staffs to discuss the data management procedure. There were two important
procedures involved at this stage; first, the process of identifying clients who come to the clinic prior
to receiving information card from the survey. Second, the process of de-identifying VCT and ART data
from this group of clients to be used by the study.
Fo
those stud ’s a ti ities, th ee t pes of data e e de eloped:
a. Data from survey, this was a quantitative data useful for generating information on sexual
behaviours of clients of FSWs. A number of univariate and multivariate statistical procedures
were conducted in order to gain determinants of sexual behaviours including condom use;
b. Data from in-depth interviews, this was a qualitative data useful for theorising the underlying
context and mechanism of barriers of HIV testing and treatment uptake. To analyse the data,
thematic framework analysis will be applied to reach the study objective.
8
c. Results on HIV testing and treatment, this was a quantitative data useful for generating
summary on HIV testing and treatment uptake. Demographic characteristics of all subjects
being tested for HIV were summarized. The rates of HIV diagnosis, transfer to care, and
commencing ART, was also summarized.
2.6 International partner (Kirby Institute) roles
The Kirby Institute, formerly the National Centre in HIV Epidemiology and Clinical Research (NCHECR)
collaborated extensively in the international effort that ensured that HIV became one of the most
intensively studied diseases in the history of medical science. The Kirby Institute is directly affiliated
with the Faculty of Medicine at the University of New South Wales (UNSW), and receives funding
th ough the Aust alia Go e
e t Depa t e t of Health a d Agei g. The Ki
I stitute’s p i a
functions relate to the co-ordination of national surveillance programs, population health and
epidemiological research, clinical research and clinical trials. With these extensive experiences, Kirby
Institute provided active consultation for the development of study design including instruments
developments. The Kirby Institute also assisted local research team in developing and analysing the
stud ’s data.
2.7 Results dissemination and peer reviewed publications
A fi al epo t is su
itted to Uda a a U i e sit Resea h I stitutio
LPPM at the e d of the stud ’s
duration as per their requirements. This report describes the results of the survey, while the results
of interviews and observations will be reported in other format. The study results will also be
disseminated for relevant stakeholders in Bali and Jakarta (KPAN and Ministry of Health) through
policy briefs and series of seminars. Main study findings as well as sub-analyses and sub-studies will
be published in peer-reviewed journals.
2.8 Ethics consideration
During the data collections, all potential subject in survey and in-depth interviews were handed an
information letter explaining the purpose of the study (appendix 7). Those willing to participate in the
study were asked to give verbal informed consent. For survey respondents responding to the
questionnaire in the survey phase after receiving information on the survey procedure is considered
as implying consent to participate in the study.13 For in-depth i te ie s, pa ti ipa ts’ o se t to e
interviewed was recorded to replace written consent. Verbal informed consent (Appendix 8) is
preferred to obtaining a signed form, which could be intimidating for clients of sex workers as
currently the social and political situation is circulating issues around criminalisation of clients of sex
9
workers. Also, verbal agreement is an alternative to signed consent forms in cross-cultural research
and research in marginalised or oppressed groups or hard to reach population including clients of sex
workers.13,14 By doing this, the study ensured that all subjects participate voluntarily. In addition,
during data collection all study subjects had right to withdraw their involvement at any time they
want, this right has been clearly written in the information letters and verbal consent documents.
Meanwhile for both HIV testing and ART initiation, the study will rely on the standard clinical
procedu e of YKP’s li i , the stud
ill o l gai de-ide tified data f o
lie ts’ e o ds.
Furthermore, the study subjects were offered funds for their times spend in survey (Rp. 50,000.-) and
in in-depth interviews (Rp. 75,000.-) to recognise their valuable contribution to this research.
Participants also received information card on free HIV testing and treatment facility available at YKP
in Denpasar. These practices are common for HIV research in Indonesia and particularly in Bali.
For those who come to the clinic after receiving information from the survey, HIV test were performed
based on normal procedure conducted at the clinic with adequate pre- and post-test counselling by
trained personnel to minimize risk which might arise from learning of HIV diagnosis. There were no
reward for clients who come to the clinic for testing and treatment as normal or usual procedure were
applied to them. Irrespective of no direct financial reward for their participation in the test, knowing
HIV status earlier and joining the ART earlier in case they are found to be positive will benefit the
health of clients.
All stud i fo
a ts, pa ti ipa ts a d patie ts’ o fide tialit
e e ai tai ed th oughout the stud .
“u je ts’ ha d op data e e sto ed i a lo ked a i et i P“IKM FK UNUD, while softcopy data were
stored in a password protected laptop. These data were kept for the duration five years after the study
fi ish, o l the stud ’s tea
had a ess to it. Fu the
o e, o l de-identified data will be used in all
reports and publications related to the study. All patients starting ART in the study will be continuing
the treatment after the conclusion of the study as there is no current evidence supporting treatment
interruption. Also, this treatment will be provided through the national ART policy and program
(Strategic use of ART – Layanan Komprehensif Berkesinambungan or SUFA-LKB).
Ethics approval were sought at Komisi Etika Penelitian Fakultas Kedokteran UNUD-RSUP Sanglah
Denpasar.
10
3 STUDY BUDGET AND SCHEDULE
3.1 Budget summary
The stud is fu ded th ough i te atio al esea h olla o atio
g a t, U i e sitas Uda a a’s
research unit. The overall budget for 6 months study is one hundred million rupiah. There is no funds
support from the international partner.
3.2 Schedule of activities
The study will be conducted from May 2015 and should be concluded in November 2015 as outline in
table below
2015
Activities
1
2
3
4
5
6
7
Preparatory activities and study setup
Apply for Ethics Committee approval
Intensive outreach training and workshop
Survey
In-depth interviews
Analysis and Reporting
Dissemination seminar
11
4 Survey Results
4.1 Respon rate
Among 412 participants who were approached during the data collection, 200 of them agreed to
participate in the survey, giving the response rate of 48.5%. Among these, 200 questionnaires were
included in the analysis
4.2 Sociodemographic characteristics of the participants
The mean age of participants were 39 years old, with the majority of them (46%) enjoyed the highest
education in the senior high school. Islam and Hindu comprised the two main religions among
participants, 58% and 36% respectively. The majority of the respondents came from Java (49%) and
Bali(36%). 65% of respondents admitted that they consume alcohols at least less than once a week.
Only 2 respondents had a history of drug use, and none of these were on injecting drug.
In terms of marital status, more than half (131 or 65,5%) of them have ever been married and currently
remain married, with almost 70% of them married at the first time at the age between 23-30 years
old. Those who reported that they currently married, 58% of them living with their spouse. On the
other hand, those who reported that they do not married, 7% of them admitted they livewith their
sexual partners.
While the majority of respondents (70.5%) of them reported that their age when they first married
were between 23-30 years, surprisingly the majority of the respondents begin their sexual debut long
before that age. More than 80% of the respondents reported that the first time they had sex were at
the age between 14 to 22.
Table 4.1 Sociodemographic Characteristics of the Participants
Sociodemographic characteristics
N
%
137
46
74.9
25.1
42
59
91
6
21.2
29.8
46.0
3.0
116
72
2
10
58.0
36.0
1.0
5.0
Age
Mean±SD (39±19)
≤40 years old
>40 years old
Education
Primary
Secondary junior
Secondary senior
Higher
Religion
Islam
Hindu
Catholic
Protestant
Marital status
12
Ever been married/currently remain married
Never married
Age first married
14-22 years old
23-30 years old
Age first married
14-22 years old
23-30 years old
131
69
65.5
34.5
38
91
29.5
70.5
167
31
84.3
15.7
4.3 Number and type of sexual partners
The number of commercial sexual partners the participants had within the last 12 months ranging
from 1- 24, with 80% of the participants admitted they had sex with 1-5 female sex workers within the
last 12 months. In addition to female sex workers, 18% of the respondents also admitted that they
had other occasional non-commercial sexual partners, with the number of this type of partners
ranging from 1-2. None of the respondents in this study reported the history of having sexual
relationship with men.
4.4 The sexual practices with regular non commercial partners.
128 (64%) of the respondents reported that they had this regular non commercial sex partners
(including wife). When they were asked about how many times they had sex with this partners in the
last month, the answer was ranging from 0 to 20 times, with around 40% of them had sex 2-4 times
within a month. Only 4 of the respondents reported the use of condom with this type of partners in
the last sex. While the respondents who reported to use condom mentioned that it was the join
decision with their partner, those who reported of not using condom mentions various reasons of not
using it. The three most common reasons for not using condom were that because they already use
other contraception methods (65%), because they thought it as ot e essa
% a d the did ’t
like it (35%). When the question on the time period of condom use was expanded to the period of
ithi the last ea , still the
ajo it
% of the espo de ts ad itted the
e e use it.
4.5 The sexual practices with casual non commercial partners.
As noted above, 37 ( 18.50%) of the respondents admitted that they have this type of sexual partners,
i.e casual non-commercial. Among these, the number of sexual intercourse ranging from 1-8 times
within the last month, with only 14(37%) of the respondents reported the use of condom within the
last sexual engagement. Those who reported to use condom mentioned that it was the decision made
jointly 8 or 57%) or from himself ( 6 or 42%). Those reported not to use condom, the three most
o
o
easo s e tio ed e e e ause the did ’t like it
% , o do is ot a aila le
% a d
13
condom was not necessary ( 12%). When they were asked about the use of condom within last year,
the majority answer given was sometime ( 43%).
4.6 The sexual practices with female sex workers partners
While all of the respondents reported to have sex with brothel based sex workers within the last year,
only 5(2.5%) of them reported to have sex with non-brothel based sex workers within the same period,
with the number of non-brothel based sex workers they had sex with were 1, and admitted that they
have sex with this type of sexual partners 1-3 times in the last year.
The number of brothel based commercial sex partners the respondents had within the last year
ranging from 1 to 24. The number of sexual engagement with FSW within the last month were ranging
from 0-8, with the majority of respondents (76.5%) reported the number of sexual activity with this
type of partner in the last month between 1-3 times.
The majority of the respondents (88.5%) said they use condom when the last time they had sex with
the brothel based sex workers. Those who used condom, mentioned the decision maker process of
using condom that that it was the decision of their sexual partners to use it (43.3%), it was the join
decision (37.8%), and his decision ( 18.3%). Those who reported not to use condom mentioned despite
they aware of the availability of condoms in the brothels, the three most common reasons for not
usi g o do
e e as follo : e ause the did ot like it
. % , e ause it as ’t e essa
to use
condom ( 27.3%), and because they did not think of it ( 13.6%). When the time period of condom use
uestio
e e e pa ded as
ithi the last
o th , 61% of the respondents reported the use of
condom every time they have sex with sex workers.
4.7 Social network
It is interesting to note that more than half (54%) of the respondents mentioned that they come to
the brothels with their friends; followed by coming alone by himself (45%). Almost all (98.5%)
admitted that this is not the first time they go to the brothels; with almost all of them ( 90%)
mentioned that they found out the existence of brothels location from their friends. Other than the
brothels area they had visited during the interview sessions, 125 (63%) participants reported that they
also visited other brothels within the last year, with number of brothels visited ranging from 1-4
brothels; and they mentioned that in most often case, they visited the brothels with their friends
(55%).
14
4.8 Knowledge about condom
192(96%) of the respondents reported that they have ever used condom previously. Almost all ( 199
or 99.50%) have heard about male condoms, however only 4% of the respondents have heard about
female condoms. 97% of the respondents know where to find condoms, with sexual partners
(56.41%), pharmacy (56.41%) and friends (21.5%) were three most quoted sources where they can
find condoms.
4.9 Knowledge and history of STI
Regarding knowledge on STI, 95.5% of the respondents have heard about STIs. Foul smelling discharge
(50.3%), itching (35.1%), and genital ulcers (13.1%) were three most perceived common symptoms for
STIs among female; while the three most quoted STIs symptoms among male were burning pain on
urination (60.73%), genital discharge (48.7%), and genital ulcers (36.7%). Among the respondents,
11,50% admitted that they have had a genital ulcers within the last year, while 9% also reports the
history of genital discharge.
Table 4.2 Knowledge and history of HIV among participants
Knowledge and history of STI
Heard about STIs
Have heard
Do ’t ha e hea d
Common symptoms for STIs
among female
Foul smelling discharge
Itching
Genital ulcers
Common symptoms for STIs
among male
Burning pain on urination
Genital discharge
Genital ulcers
Have had a genital ulcers within
the last year
Yes
No
Reports the history of genital
discharge.
Yes
No
N
%
191
9
95.5
4.5
96
67
25
50.3
35.1
13.1
116
93
70
60.7
48.7
36.7
23
177
11.5
88.5
18
182
9.0
91.0
15
4.10 Knowledge on HIV
Almost all (185 or 92.50%) of the respondents have heard about HIV. However only 43% perceived
themselves at high risk of HIV, while 40% others perceived that they may be at risk, and 7.6% of them
perceived that they were not at risk at all of HIV.
Although more than half (59%) of the respondents did not know someone who are infected with HIV,
and no relatives were infected with the virus (91.3%), the majority of the respondents (61.62%)
perceived HIV as very severe.
Although most two third (77%) answered yes when they were asked of whether we can protect
ourselves by consistently using condom during sexual act, 71% said yes when asked whether having
faithful partner can protect them from HIV, and 72% answered yes when asked about whether
abstinentia can protect them from HIV infection, and 91% said yes when asked whether sharing
needles can be a means of HIV transmission; misconception about HIV transmission is still common.
Only 44% of the respondents said that HIV cannot be transmitted by mosquito bites nor by sharing
food and drink with HIV infected persons. Additionally, around 67% do not or not sure if person
infected with HIV might look as other healthy people.
4.11 HIV testing
With regards to HIV testing, only 41.6% of the respondents aware that they can receive a confidential
HIV testing. Only 15 people (8.1%) had ever been tested before, and most of them ( 14 persons) seek
the test voluntarily, and only 13 people got the results of the test. Among those who got the results.
6(40%) of them mentioned that the test was conducted within a year, 4(26.67%) of them did the test
1-2 years before, and 2 of them did the test 2-4 years ago.
Only 39.50% of the respondents know where to get tested, and 76% of these who knew where to get
tested, 76% perceived that those places were convenient.
66.5% of the participants answered yes when they were asked whether they would willing to receive
an HIV test offer in the future.
Table 4.3 HIV testing awareness and experiences
HIV testing
Aware that they can receive a
confidential HIV testing
Yes
No
Do ’t k o
No answer
N
%
77
23
83
2
41.6
12.4
44.9
1.1
16
Had ever been tested before
Yes
No
Voluntary or mandatory
Voluntary
Mandatory
Know the result
Yes
No
When was the received result test
conducted
Within a year
1-2 years before
2-4 years before
Do ’t k o
15
170
8.1
91.9
14
1
93.3
6.7
13
2
86.7
13.3
6
4
2
3
40.0
26.7
13.3
20.0
4.12 Exposure to health promotion activities
The exposure of health promotion activities were explored in this survey. When exposure to everyday
social media was asked, the rank of media used every day by the participants rank from television (
91.50%), radio ( 25%), online social media ( 11%), and newspaper ( 6.5%). However, the rank is
different, when they were asked about whether they have heard about HIV information from those
media, i.e newspaper (84.50%), social media (77.8%), tv (71.50%), and radio ( 61.3%).
When they were asked about health education session they had ever attended, only 19% of said that
they have attended health education session, with almost all of these mentioned that they received
HIV information on that session.
Table 4.4 Exposure to HIV Promotion Activities
Experiences on health promotion
activities
The rank of media used every day
Television
Radio
Online social media
newspaper
Have heard about HIV information
Newspaper
Social media
Television
Radio
Attended health education session
Yes
No
No answer
N
%
183
50
22
13
91.5
25.0
11.0
16.5
109
42
143
87
84.5
77.8
71.5
61.3
38
161
1
19.0
80.5
0.5
17
4.13 Health seeking behaviour
Among those who had a history of STI symptoms, the first thing they did when they had the symptoms
were seek medicine at the chemist. This was the answer mostly expressed by the participants
(35.71%).
Analysis was conducted to identify predictors of history of HIV testing among this group. Several
variables were selected based on that they suggested as factors that more likely to influence HIV
testing. These factors include age, age at the first married, age at first sexual intercourse, number of
wife and regular partners, number of female sex workers they have had sex with, and number of
occasional sexual partners; the highest education level, history of alcohol, and drugs, history of
marriage, the use of condom, knowledge that HIV can be transmitted through sexual act, history of
genital ulcer within a year, history of genital discharge within a year, have heard about AIDS, perceived
risk, and the history of HIV information exposure through several media; history of having attended
education session on HIV, and know the place to get tested, and perception whether those place were
convenient.
4.14 Predictors of HIV testing
Analysis was conducted to identify factors associated with HIV testing. Several variables, which were
considered as factors that might predict HIV testing behaviours were selected. These includes the level
of education, the number of female sex workers that have been visited in the last 12 months, the
importance of sexual network (such as, who took them to the brothels, and who provide information
about this brothels); HIV information exposure from tv, radio, and education session, history of STI
symptoms, and willingness to get tested in the future.
The results is summarised in table 4.5
18
Table 4.5 Predictors of previous HIV testing
Predictors
Level of education
The number of female sex workers that
have been visited in the last 12 months
Who took them to the brothels
Provide information about this brothels
from friends
HIV information exposure from from
television
HIV information exposure from radio
Education session
Know where to get HIV test
Have had genital ulcers or sores for
the last
year
Have had genital discharge for the last
year
Willingness to get tested in the future
OR
0.51
5.51
Univariate analysis
pV
95%CI
0.233
0.17-1.56
0.015
1.21-25.17
0.06
0.26