A COLLABORATION BETWEEN THE MINISTRY OF HEALTH AND THE NATIONAL AIDS COMMISSION INDONESIA 2014
TECHNICAL REPORT:
2013 SERO-SENTINEL SURVEILLANCE
AND
2013 RAPID BEHAVIORAL SURVEY
A COLLABORATION BETWEEN THE MINISTRY OF HEALTH AND THE NATIONAL AIDS COMMISSION
TECHNICAL REPORT: 2013 SERO-SENTINEL SURVEILLANCE AND 2013 RAPID BEHAVIORAL SURVEY
vey veillance And 2013 Rapid Behavioral Sur A COLLABORATION BETWEEN THE MINISTRY OF HEALTH AND THE NATIONAL AIDS COMMISSION Technical Report: 2013 Sero-Sentinel Sur vey Ind 616.91
Indonesia. Kementerian Kesehatan RI.
Katalog Dalam Terbitan. Kementerian Kesehatan RI veillance And 2013 Rapid Behavioral Sur Direktorat Jenderal Pengendalian Penyakit dan Kementerian Kesehatan RI. 2014 And 2013 rapid behavioral survey. - Jakarta: Technical report: 2013 sero - surveilance survey Penyehatan Lingkungan III. HEALTH SURVEYS II. ACQUIRED IMMUNO DEFICIENCY VIRUS 1. JudulISBN 978-602-235-796-4
I. HUMAN IMMUNODEFICIENCY SYNDROME
IV. BEHAVIORAL RISK FACTOR Technical Report: 2013 Sero-Sentinel Sur SURVEILLANCE SYSTEM V. BEHAVIORAL RESEARCH Summary
This report contains the results of the 2013 HIV Sero-Surveillance Survey and the Rapid Behavioral surveys. In its first part, the report describes the results of the 2013 HIV Sero-Surveillance Survey Survey (SSS) conducted by the Ministry of Health (MOH) and in its second part, it provides the results of the 2013 Rapid Behavioral survey (RBS) conducted by the National AIDS Commission (NAC).
The 2013 Sero-Surveillance Survey was conducted among direct female sex workers (DFSW), people who inject drugs (PWID), men who have sex with men (MSM) and transgenders in 22 cities while the 2013 Rapid Behavioral Survey included MSM, DFSW, and PWID in 8 cities.
The Sero-Surveillance Survey aimed to determine the magnitude of the HIV epidemic and syphilis among key populations and the Rapid Behavioral Survey studied the prevalence of associated risk factors. The results of these surveys will serve to set targets for the new national HIV/AIDS national strategic plan and for planning and/or modifying existing programs to prevent HIV in Indonesia. DFSW and transgender participants were sampled using a two stages probability proportional to size method while MSM and PWID were sampled using the respondent driven sampling method (RDS). The target sample sizes were 250 for each key population per site for the 2013 SSS and 240 per site for the 2013 Rapid Behavioral Survey.
A total of 6603 participants were recruited for the 2013 SSS. Of those, 3685 were DFSW, 985 were transgenders, 978 were PWID, and 985 were MSM. The total number of participants in the 2013 Rapid Behavioral Survey was 2829. Of vey these, 1120 were DFSW, 989 were PWID, and 720 were MSM.
Characteristics of Respondents
In the 2013 SSS, direct female sex workers represented 55.8% of participants, PWID and transgenders represented each 14.8%, and MSM represented 14.5% of participants. The distribution of all key populations by location was as followed: 14% were from veillance And 2013 Rapid Behavioral Sur Malang, 15% from Surabaya, 15% from Jakarta and 15% from Bandung. All the other locations had less than 7% of the participants. In the 2013 Rapid Behavioral Survey, 25% of the participants were MSM, 40% DFSW and 35% were PWID. By location, Jakarta, Bandung and Surabaya contributed each 17% of participants; Denpasar 14% and Malang, Medan and Banyuwangi contributed each 8%. Technical Report: 2013 Sero-Sentinel Sur Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey HIV and STI Prevalence
HIV prevalence was highest among the PWIDs with 44.5% and it was followed by transgenders with 19%, MSM with 17.3% and DFSW with 10%.
Malang and Surabaya did not register any case of syphilis among PWID in the 2013 Sero-Surveillance Survey
HIV prevalence among the MSM increased significantly from 10.6% to 17.3% [p< 0.000002, OR=0.56 (0.43-0.73)]
This comparison included only data from cities which participated to the two surveys. The results showed that:
The comparison of HIV and syphilis prevalence between 2013 Sero-Sentinel Survey and 2011 Integrated Biological and Behavioral Survey
The lowest prevalence of syphilis among DFSW was recorded in Batang (1.2%).
The prevalence of syphilis among DFSW was highest in Jayawijaya (33.3%), followed by Ambon (10.2%), Denpasar (7.3%) and Malang and Lampung (6.8% and 6.4% in respectively).
Among transgenders, Jakarta had the highest syphilis prevalence with 29.2%, followed by Surabaya with 17.1%, Bandung with 14% and Malang was last with 4,2%
The highest prevalence of syphilis among MSM was recorded in Bandung at 15.4%, followed by Surabaya and Jakarta with 14.6% and 14.2% respectively. In Malang, syphilis prevalence among MSM was 6.7%.
The highest prevalence of syphilis prevalence among PWID, was recorded in Medan (7.3%), followed by Jakarta (3.8%) and Bandung (1.3%).
The highest prevalence of syphilis was among transgenders (16.2%), followed by MSM (12.7%) and direct female sex workers (5.5%).
The prevalence of syphilis was 6.6% among all the participants in the 2013 SSS.
HIV prevalence among DFSW was 20.3% in Denpasar and Jayapura, Ambon, and Surabaya had HIV prevalence among DFSW above 10%
The highest prevalence among DFSW was found in Jayawijaya (32.5%) and the lowest was noted in Deli Serdang (1.6%)
Jakarta had the highest HIV prevalence among transgenders with 29.6% followed by Surabaya with 27.5%, Bandung and Malang with 9.6% and 9.2% respectively
HIV prevalence among MSM was highest in Surabaya with 22.1% followed by Bandung (21.3%), Jakarta (19.6%) and lastly by Malang (6.3% )
The highest HIV prevalence among PWID was found in Malang (59.1%) and the lowest in Bandung (27.1%). In Jakarta, Surabaya and Medan HIV prevalence among PWID was 49.2%, 48.8% and 27.3% respectively
HIV prevalence among transgenders decrease significantly from 23.8% to 19%
The prevalence of syphilis significantly declined from 27.5% to 16.2% among transgenders. [p<0.000001, OR=1.96 (1.57-2.44)] and from 8.8% to 5% among DFSW [p<0.000001, OR=1.82(1.48-2.24)]
HIV prevalence increased significantly in Malang from 36.4% to 59.1% [p<0.001, OR=0.4 (0.27-0.58)]
HIV prevalence among MSM increased in Bandung and in Surabaya from 10.4% to 21.3% [p=0.001, OR=0.43(0.26-0.72)] and from 10% to 17.3% [p<0.001, OR=0.53(0.4-0.69)]
HIV prevalence among transgenders significantly decline in Malang from 16.8% to 9.2% [p=0.017, OR=2.01(1.16-3.48)]
The prevalence of syphilis among transgenders declined significantly in Bandung from 26.4% to 14% [p<0.001, OR=2.19(1.39-3.46)] and in Malang from 20.8% to 4.2% [p<0.001, OR=6.07(3-12.26)]
HIV prevalence among DFSW significantly decreased in Jakarta and in Bandung from 10.5% to 3.8% [p=0.0046, OR=3 (1.38-6.56)] and from 20.7% to 9.4% [p=0.0013, OR=2.53(1.45-4.4) respectively
The overall syphilis prevalence among DFSW declined from 9.8% from the 2011 Integrated Biological and Behavioral Survey to 5.7% in the 2013 Sero-Surveillance Survey.
Syphilis prevalence among DFSW significantly decreased in five of the 15 locations surveyed. It decreased from 16.6% to 4.8% [p<0.05, OR 0.42(0.28-0.63)] in Deli Serdang. It also decreased from 11.6% to 3.3% [p=0.001, OR=3.3(1.5-6.75)] in Batam, from 10.4% to 2.8% [p<0.001, OR=4.03(1.7-9.72)] in Bandung; from 12.4% to 4.6% [p=0.003, OR=2.96(1.45-6.04)] in Surabaya and from 13.4% to 1.2% [p<0.0001, OR=13.1(3.88-44.2)] in Batang. Trends of HIV prevalence among Key Populations, 2007, 2011-2013 vey
Risk behaviors among key population from the 2013 Rapid Behavioral Survey
The highest number of clients per DFSW per week was noted in Denpasar (14 clients) followed by Malang (eight clients) and Banyuwangi (seven clients).
Condom use during the last commercial sexual intercourse among DFSW was 76.5% in Denpasar, 71.3% in Malang and Banyuwangi and 68.8% in Semarang. veillance And 2013 Rapid Behavioral Sur
Consistent condom use during the last week preceding the survey was 65.5% in Denpasar, 38.3% in Semarang, 35.1% in Banyuwangi and 24.2% in Malang.
More than two thirds (73%) of MSM in Jakarta used condoms during their last sexual intercourse, compared to 43% in Bandung and 53% in Surabaya.
In none of the three cities surveyed, MSM reported the use of injectable drugs.
The proportion of PWID who have tested for HIV was highest in Medan (66.2%); followed by Jakarta (64%), Surabaya (47.5%), Bandung (41%), and Semarang (25%). Technical Report: 2013 Sero-Sentinel Sur
Jakarta, Bandung, and Semarang had rates of PWIDs who shared needles at their last injection above 10%
The proportion of PWIDs sharing needles was lowest in Surabaya (0.8%) followed by Medan (3.1%).
Comparison between risk behaviors between 2013 Rapid Behavioral Survey and 2011 Integrated Biological and Behavioral Surveyin the some locations
The median number of clients per DFSW per week remained high
Significant declined of the proportion of DFSW who used condom during their last sexual encounter in Malang from 83.2 % to 71.3 % [P=0.0025, OR= 1.99 (1.29-3.07)] and was from 90 % to 76.5% [P=0.00003, OR=2.74(1.71-4.4) in Denpasar.
Significant decline of proportion of reported consistent condom use during the last week prior to the survey among DFSW from 35.1% to 12.5% [P<0.001, OR=3.78(2.38- 5.99)] in Bandung and from 44.9% to 24.2% [P<0.001, OR=2.57 (1.74-3.780] in Malang.
Significant increase in condom use during commercial sex among DFSW during the same period from 49.6% to 65.5% in Denpasar [P<001, OR=0.52 (0.38-0.72)].
The percentage of MSM injecting drugs dropped from 5% to 0% in Jakarta between 2011 and 2013 (p<001) but remained stable in the other cities.
The proportion of MSM who used condom during their last sexual encounter dropped significantly in Surabaya from 75.9% to 53% [P=00001, OR=2.79(1.9-4.1)].
The comparison of data from the 2011 Integrated Biological and Behavioral Survey and the 2013 Rapid Behavioral Survey revealed that there have been a significant drop vey in the proportion of PWIDs who ever tested for HIV from 59.6% to 41.3% in Bandung [P<0.001, OR=2.1(1.5-3)]. This was also noted in Denpasar from 77.6% to 47.5% [P<0.001, OR=3.83(2.59-5.66)] from 2011 Integrated Biological and Behavioral Survey to the 2013 Rapid Behavioral Survey
During the same period of time, proportion of PWIDs who shared needles during the last injection dropped significantly from 18 % to 10.8 % [P=0.033, OR=1.81(1.07-3.04)] veillance And 2013 Rapid Behavioral Sur in Bandung and from 8.4 % to 0.8 % [P=0.0002, OR=10.9(2.5-47.07)] in Surabaya.
The trends analysis from 2007 to 2013 showed that:
Statistically significant decline of HIV prevalence of about 15% among PWIDs in the locations surveyed from 52.3% to 44.5% between 2007 and 2013. [p=0.00036, OR=0.729].
HIV prevalence among MSM increased steadily between 2007 and 2013 from 5% to 17.3%. This represented an increase of more than 200% from 2007.
Technical Report: 2013 Sero-Sentinel Sur Syphilis prevalence increased significantly among MSM from 1% to 12.7% [p=00001,
HIV prevalence increased among MSM in Jakarta, Bandung and Surabaya from 8.1% to 19.6% [p=0.00031, OR=2.837], from 2% to 21.3% [p<0.00001, OR=13.22] and from 5.6% to 22.1% [p<0.00001, OR=4.778] respectively.
The prevalence of syphilis increased among MSM in Jakarta from 3.2% to 14.2% [p=0.00013, OR=5.055]; in Bandung from 5.6% to 15.4% [p=0.034, OR=2.129] and in Surabaya it increased from 4% to 14.6% [p=0.00008, OR=4.098].
The analysis revealed that HIV prevalence among transgenders decreased by 5% from its 24.4% level in 2007 to 19% in 2013. [p=0.00284, OR=0.726].
The prevalence of syphilis declined among transgenders from 24.4% to 16.2% [p=0.00001, OR=0.599] and among DSFW from 6.2% to 5% [p=0.0317, OR=0.796].
HIV prevalence among transgenders significantly declined in Malang 16.8% to 9.2% [p=0.00792, OR=0.497] from 2007 to 2013.
The prevalence of syphilis among transgenders significantly declined from 25.2% to 14% in Bandung [p=0.00204, OR=.0483]; from 28.8% to 17.1% in Surabaya [p=0.00198, OR=.509] and from 20.8% to 4.2% [p<0.00001, OR=0.165]in Malang between 2007 and 2013
HIV prevalence significantly declined among PWIDs by 50% in Medan and in by 37% in Bandung between 2007 and 2013 [p=0.00014, OR=0.496].
The prevalence of syphilis increases significantly among PWIDs in Jakarta and Bandung from 0.1% to 3.8% [p=0.03, OR=9.86] and from 0% to 1.3% [p=0.033, OR=9.818]
Between 2007 and 2013, HIV prevalence declined significantly among DFSW from 6.1% to 1.6% [p=0.00662, OR 0.254] in Deli Serdang; from 10.2% to 3.8% [p=0.00654, OR=0.337] in Jakarta and from 6.6% to 2.5% [p=0.0229, OR=0.36. in Semarang.
HIV prevalence among DFSW increased in Surabaya from 6.5% to 12.5% [p=0.02754, vey OR=2.089] and in Denpasar from 14.1% to 20.3% [p=0.04, OR=1.56] between 2007 and 2013
Syphilis prevalence declined among DFSW in Deli Serdang from 12.9% to 4.8% [p=0.0037, OR=0.342], in Batam from 16.8% to 3.8% [p<0.00001, OR=0.198] and in Jakarta from 9.2% to 2.5% [p=0.00084, OR=0.253] between 2007 and 2013
The prevalence of syphilis among DFSW also declined in Jayapura from 6% to 2.4% [p=0.027, OR=2.6(1.08-6.23)].
veillance And 2013 Rapid Behavioral Sur
The prevalence of syphilis among DFSW increased in Batang from 0.9% to 1.2% [p=0.00713, OR=1.488] and in Ambon from 5.2% to 10.2% [p=0.048, OR=0.47(0.22-1)]
The data showed a strong relation between HIV and syphilis prevalence among all the key populations (R-Squared=0.9656).
Technical Report: 2013 Sero-Sentinel Sur
CHAPTER I: INTRODUCTION 13
3.1.3. HIV prevalence
19
2.4. Analysis
19 CHAPTER III:RESULTS 21
3.1. Results of the 2013 HIV Sero-Surveillance Survey
21
3.1.1. Participation rate
21
3.1.2. Characteristics of the Population Groups
22
22
19
3.1.3.1. HIV prevalence among different key population
22
3.1.3.2. HIV prevalence among PWID
23
3.1.3.3. HIV Prevalence among MSM
23
3.1.3.4. HIV prevalence among transgenders
24
3.1.3.5. HIV prevalence among DFSW
25 Table of Contents
2.3. Implementation
Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey SUMMARY 1 TABLE OF CONTENTS
7 LIST OF TABLES
16
10 LIST OF FIGURES
11 LIST OF ABBREVIATIONS 12
1. Background
13
2. Scope
15
3. Outcomes
15 CHAPTER II: METHODOLOGY 16
2.1. Sero-Surveillance Survey
2.1.1. Selection criteria
19
16
2.1.1.1. Sampling
16
2.1.2. Biological testing and quality assurance
17
2.1.3. Locations
18
2.2. Rapid Behavioral Survey
19
2.2.1. Sample size
2.2.2. Tools
3.1.4. Prevalence of syphilis
27
3.1.4.1. Syphilis prevalence among different key population
27
3.1.4.2. Prevalence of Syphilis among PWID
27
3.1.4.3. Prevalence of syphilis among MSM
27
3.1.4.4. Prevalence of syphilis among transgenders
28
3.1.4.5. Prevalence of syphilis among DFSW
29
3.1.5. Comparison between HIV and syphilis prevalence between 2011 Integrated Biological and Behavioral Survey and 2013 Sero-Surveillance Survey
31
3.1.6. Trends analysis of HIV and syphilis prevalence among key populations between 2007 and 2013
33
3.1.6.1. Trends of HIV prevalence among Key Populations, 2007-2013
33
3.1.6.2. Trends of HIV Prevalence among Key Populations by Location, 2007-2013 34
3.1.6.3. Trends of HIV Prevalence among PWIDs by Locations, 2007-2013
34
3.1.6.4. Trends of Syphilis Prevalence among PWIDs by Locations, 2007-2013
35
3.1.6.5. Trends of HIV Prevalence among MSM by Locations, 2007-2013
35
3.1.6.6. Trends of Syphilis Prevalence among MSM by Locations, 2007-2013
36
3.1.6.7. Trends of HIV Prevalence among Transgenders by Locations, 2007-2013 36
3.1.6.8. Trends of Syphilis Prevalence among Transgenders by Locations, 2007-2013 37
3.1.6.9. Trends of HIV Prevalence among DFSW by Locations, 2007-2013
37
3.1.6.10. Trends of Syphilis Prevalence among DFSW by Locations, 2007-2013
38
3.1.6.11. Relationship between HIV Prevalence and Syphilis prevalence among Different Key Populations, Sero-Surveillance Survey 2013
39
3.2. Results of the 2013 HIV Rapid Behavioral survey
40 vey
3.2.1. Participation rate
40
3.2.2. Risk behaviors among key population
40
3.2.2.1. Direct female sex workers
40
3.2.2.2. Men who have sex with men
41
3.2.2.3. People who inject drugs
42
3.2.3. Comparison between risk behaviors between the 2011 Integrated Biological and Behavioral Survey and 2013 Rapid Behavioral Survey 45 veillance And 2013 Rapid Behavioral Sur
CHAPTER IV: CONCLUSION, DISCUSSION AND RECOMMENDATIONS
46
4.1. Conclusion
46
4.2. Discussion
48
4.3. Recommendations
50 Technical Report: 2013 Sero-Sentinel Sur REFERENCE
51 Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey
Table 1 : List of provinces, districts/cities and the number of the participating sites
31 Table 13 : Prevalence of Syphilis among PWID by Location, 2011-2013
43 Table 21 : Prevalence of risk Behavior among PWID in Semarang, 2010-2013
43 Table 20 : Prevalence of risk Behavior among PWID in Bandung, 2010-2013
43 Table 19 : Prevalence of Risk Behavior among PWID in Jakarta, 2010-2013
Table 18 : Prevalence of risk Behavior among PWID in Medan, 2010-2013
41 Table 17 : Prevalence of Risk Behaviors among MSM inJakarta, Bandung and Surabaya, 2011-2013 42
41 Table 16 : Prevalence of Risk Behaviors among DFSW in Malang and Denpasar, 2011-2013
40 Table 15 : Prevalence of Risk Behaviors among DFSW in Semarang and Banyuwangi, 2011-2013
32 Table 14 : Sample sizes by locations for the Rapid Behavioral Survey, 2013 Sero-Surveillance Survey
30 Table 12 : Comparing HIV prevalence among key population in the same locations for IBBS 2011 and Sero-Surveillance Survey 2013
18 Table 2 : Planned Sample Size and Sampling Method by Target Population and Location 21 Table 3 : Prevalence of HIV and Syphilis per Target Group of Key Affected Populations in the Sero-Surveillance Survey 2013
29 Table 11 : Prevalence of Syphilis among the DFSW by Location in IBBS 2011 and in Sero-Surveillance Survey (SS) 2013
28 Table 10 : Prevalence of Syphilis among the Transgenders by Location in IBBS 2011 and in Sero-Surveillance Survey (SS) 2013
27 Table 9 : Prevalence of Syphilis among the MSM per Location in IBBS 2011 and in Sero-Surveillance Survey (SS) 2013
26 Table 8 : Prevalence of Syphilis among PWID per Location in IBBS 2011 and Sero- Surveillance Survey 2013
25 Table 7 : HIV Prevalence of DFSW per location in IBBS 2011 and Sero-Surveillance Survey 2013
24 Table 6 : HIV Prevalence among the transgenders per location in IBBS 2011 and in Sero- Surveillance Survey (SS) 2013
23 Table 5 : HIV Prevalence among the MSM per Location in IBBS 2011 and in Sero- Surveillance Survey (SS) 2013
22 Table 4 : HIV Prevalence among PWID per Location in IBBS 2011 and Sero-Surveillance Survey 2013
44 List of Tables
Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey
Figure 1 : Trends of HIV Prevalence among Key Populations, 2007-2013
33 Figure 2 : Trends of HIV Prevalence among Key Population by Location, 2007-2013
34 Figure 3 : Trends of HIV Prevalence among PWIDs by Locations, 2007-2013
34 Figure 4 : Trends of Syphilis Prevalence among PWIDs by Locations, 2007-2013
35 Figure 5 : Trends of HIV Prevalence among MSM by Locations, 2007-2013
35 Figure 6 : Trends of Syphilis Prevalence among MSM by Locations, 2007-2013
36 Figure 7 : Trends of HIV Prevalence among Transgenders by Locations, 2007-2013
36 Figure 8 : Trends of Syphilis Prevalence among Transgenders by Locations, 2007-2013
37 Figure 9 : Trends of HIV Prevalence among DFSW by Locations, 2007-2013
38 Figure 10 : Trends of Syphilis Prevalence among DFSW by Locations, 2007-2013
38 Figure 11 : Correlation between HIV and Syphilis Prevalence among DFSW, MSM, and Transgenders, SSS 2013
39 List of Figures List of Abbreviations
AIDS : Acquired Immune Deficiency Syndrome CIS : Cluster Information System DFSW : Direct Female Sex Workers FSW : Female sex workers HIV : Human Immunodeficiency Virus HRM : High Risk Men
IBBS : Integrated Biological Behavioral Survey
IFSW : Indirect Female Sex Worker MOH : Ministry of Health MSM : Men who have sex with men NAC : National AIDS Commission NGO : Non-Governmental Organization PWID : People Who Inject Drugs RBS : Rapid Behavioral Survey RDS : Respondent Driven Sampling vey PPS : Probability Proportional to Size RPR : Rapid plasma reagin SSS : Sero-Surveillance Survey STI : Sexually Transmitted Infection TPHA : Treponema pallidum particule agglutination assay WHO : World Health Organization veillance And 2013 Rapid Behavioral Sur SRS : Simple Random Sampling
Technical Report: 2013 Sero-Sentinel Sur
Chapter I: Introduction
1. Background
Indonesia is facing one of the fast growing HIV epidemic in the Southeast Asia region. With an estimated half a million people believed to be infected by HIV in Indonesia[1]. Indonesia has both concentrated epidemic in the majority of its districts and a generalized epidemic in the Papua region[2]. Given the mortality and morbidity caused by the disease, it is very important to continuously monitor its burden in order to orient efficiently prevention and support programs and evaluate the response put in place to tackle the epidemic. Hence, the country has instituted HIV surveillance. This is a systematic data collection on HIV, followed by analysis, interpretation to collected data, and dissemination for utilization for HIV programs design, planning and for the evaluation of impacts in the community.
Since 1988, Indonesia conducted HIV Sero-Surveillance Survey and Syphilis in two provinces, Jakarta and East Java to measure the burden and the trend of HIV and Syphilis distribution among sex workers. For more representativeness of the HIV surveillance, the number of provinces and districts participating in HIV surveillance and the target groups increased over the years. Since then, HIV prevalence surveillance was conducted as sentinel surveillance or as ad hoc exercises. Other key populations including men who have sex with men (MSM), direct female commercial sex workers (DFSW), indirect female sex workers (IDFSW), people who inject drug (PWID), transgenders and other high risk populations who are at risk of getting HIV due to their occupations such as fishermen, truck drivers (called high risk men (HRM) were included.
From 1996, a surveillance of risky behaviors exposing individuals to HIV was instituted. vey This was followed by the adoption of the report on the second generation of HIV surveillance[3] and the HIV surveillance system in Indonesia included HIV prevalence, risky behaviors and knowledge about HIV prevention and HIV program coverages. In 2007, for the first time, Indonesia conducted its first integrated biological and behavioral survey(IBBS)[1], which was followed by two other rounds in 2011[2] in the same geographical areas. However, given the large size of the country and logistic challenges to conduct the integrated biological and behavioral survey across the country at once,
IBBS was conducted in two groups of provinces in two different waves of surveys. veillance And 2013 Rapid Behavioral Sur The survey also included the measurement of sexually transmitted infections (STIs) as STIs increases the transmission of HIV [4]. Therefore, an increase in STIs may indicate a potential risk of increased HIV prevalence.
HIV prevalence has been high in some key populations in most of the districts in Indonesia except in Papua region where the infection has reached the general population The 2000 Sentinel Surveillance showed that HIV prevalence among the Technical Report: 2013 Sero-Sentinel Sur female sex workers (FSW) was greater than 5% in several locations. It was even higher STIs prevalence remains high among sexual active and other adult key populations in Indonesia. The 2011 Integrated Biological and Behavior Survey indicated that prevalence of gonorrhea in several locations was between 19% and 38%, the prevalence of chlamydia ranged between 21% and 41%, syphilis was found among 2% and 10% of tested adults. It also showed that HIV prevalence was between 0.7% and 41% and both gonorrhea and or chlamydia were concomitantly found among 33% to 56% of tested adults[2]. STIs prevalence may also reflect condom use behavior. An increasing condom use will reduce STIs’ incidence and prevalence, and if sustained, it can also have an impact on the reduction of HIV prevalence with time. The STIs prevalence is also able to inform on the coverage and quality of the STI control program. Therefore, given the higher prevalence of STIs among key populations and the great concern that the prevalence of HIV in Indonesia is increasing following the pattern of STIs distribution, a periodical data monitoring of STI prevalence as part of HIV surveillance is needed, to see the trend of sexual behavior, and the potential of HIV transmission [4]. STI’ surveillance may serve as a tool for monitoring, evaluation, and planning of STI and HIV and AIDS control program.
With the introduction of the second generation of HIV surveillance approach, Indonesia started monitoring risky behaviors among key populations. In 2010, the national AIDS commission, in collaboration with different partners and local authorities, conducted the first rapid behavioral survey among PWID and female commercial sex workers. PWID were surveyed in 8 cities (Medan, Palembang, DKI Jakarta, Bandung, Semarang, Surabaya, Denpasar, Makassar) and were recruited from 10 cities (Bintan, Palembang, Jakarta Barat, Semarang City, Malang, Banyuwangi, Denpasar, Makassar, Jayapura and Sorong City) respectively. This survey showed that vey 73% PWID did not share needles at their last injection, 63% of them did not share needles in their last week injections, 61% of them did not share needles in the last moth injections and 35% did not share needles during injections in the past last year prior to the survey[5, 6]. To have a solid trend data on HIV, another IBBS in 2014 will be conducted in the same locations of IBBS 2011. A Sero-Surveillance Survey and Rapid Behavior Survey were conducted in 2013 in the same locations as the IBBS 2011 to provide data for the planning veillance And 2013 Rapid Behavioral Sur these activities did not measure the prevalence of gonorrhea and chlamydia. The 2013 of both the MOH and NAC HIV/AIDS strategic plans. However, unlike in the 2011 IBBS, SSS measured HIV and syphilis prevalence and the 2013 RBS assessed the prevalence of risk behavior among key populations. The 2013 was conducted in collaboration with the National AIDS Commission.
Technical Report: 2013 Sero-Sentinel Sur
2. Scope
This report aimed to provide data to assess the impact of the national response to the HIV epidemic. It aims at:
Determining the prevalence of HIV and syphilis among key affected populations in twenty-three districts/cities in Indonesia in 2013.
Determining the trends of the prevalence of HIV and syphilis among key affected populations in twenty-two districts/cities in Indonesia by comparing these results with the 2007 and 2011 IBBS, and 2013 Sero-Surveillance Survey.
Determine trends in the level of selected HIV related risk behaviors among key affected populations in twenty-two districts/cities in Indonesia and comparing them with the 2007 IBBS and 2011 IBBS.
3. Outcomes
The report provides information about the following indicators for the locations and cities surveyed:
1. Prevalence of HIV among PWIDs, MSM, transgenders and direct FSW
2. Prevalence of syphilis among PWIDs, MSM, transgenders and direct FSW
3. Number of DFSW’s clients per week
4. Proportion of DFSW who used condom during the last commercial sex
5. Proportion of DSFW who used condoms in commercial sex the last week
6. Proportion of MSM who ever injected drug vey
7. Proportion of MSM who used condom at their last commercial sex
8. Proportion of PWIDs who ever tested for HIV
9. Proportion of PWIDs sharing needle during injection last month
10. Proportion of PWIDs not sharing needle during the last injection veillance And 2013 Rapid Behavioral Sur
Technical Report: 2013 Sero-Sentinel Sur
Chapter II: Methodology
2.1. Sero-Surveillance Survey
The Sero-Surveillance Survey was a cross-sectional, using a two-stage sampling techniques. It was conducted from July to October 2013 in 22 cities/districts from 11 provinces. For the Sero-Surveillance Survey DFSW were recruited form 16 cites, PWID were recruited from five cities, transgenders were from four cities, and MSM were recruited from four cities (Table 2). The population for the Sero-Surveillance Survey included direct female sex workers, people who inject drugs, transgenders and men who have sex with men. The participants for the Sero-Surveillance Survey wererecruited from multiple sites, including community health centers, hotspots, support groups and community based organizations.
2.1.1. Selection criteria
To be included in the study, participants should have been identified to one of the key population definitions below:
Direct female sex worker (DFSW) - a woman who operates openly as a commercial sex worker;
Transgenders are biologically males but behave and feel like women. Transgenders in this 2013 Sero-Surveillance Survey are not only sex workers but also include those who work in salons;
vey Men who have sex with men includes men who consider themselves as gay or those who do not but have sex with men and includes men who are bisexual as well as
homosexual;
People who inject drugs are people who inject drugs or have a history of injecting drugs in the last 1 year. veillance And 2013 Rapid Behavioral Sur
2.1.1.1. Sampling
During the sampling of DFSW and transgenders, the first stage consisted into selecting sample at the survey sites by using the Cluster Information Sheet (CIS) application according to the decided sampling framework. The CIS application was used to perform the sample selection at the survey sites using Probability Proportional to Size (PPS), with the ‘size’ being the size of the population group in each location. During the second stage, the sample (respondents) was used to meet the planned sample Technical Report: 2013 Sero-Sentinel Sur selection at the survey sites using Probability Proportional to Size (PPS), with the size being the size of the population group in each location.
The respondents driven sampling was used for mobile and hard to find key populations such as MSM and PWID. This sampling method was used because behavior in which these subpopulations engaged in is illegal or stigmatized. A total of eight participants were selected by the surveyors and recruited as seeds. These seeds recruited the next wave of participants who also went on to recruit each three (3) other participants using the snowball technique until the end of the recruiting period.
For the Sero-Surveillance Survey, the sample size for each key population was 250 per surveyed site. The total sample size planned for DFSW, PWID, MSM and transgenders was eight thousand participants.
2.1.2. Biological testing and quality assurance Blood was collected by venipuncture from consenting key population participants.
All surveyors were trained to collect and handle specimen accordingly to the national standard procedures. Laboratory technicians were also trained in performing correctly HIV and syphilis tests. All collected specimens were sent to the provincial laboratories designated by the Ministry of Health. HIV tests were performed using Focus (R1) and Oncoprobe (R2) HIV 1 & 2 Antibody Rapid Test reagents following the MOH national HIV testing algorithm for HIV surveillance. Syphilis test used Rapid SD (TPHA) and RPR Shield (RPR).
All laboratories had an internal and external quality assurance system in place to ensure the validity of the test result.
2.1.3. Locations
Both the 2013 Sero-surveillance Survey and Rapid Behavioral Survey (RBS) recruited vey participants from the 22 cities/districts in 11 provinces listed below:
Table 1: List of provinces, districts/cities and the number of the participating sites Number of Provinces Cities and districts Locations
1
2 Sumatera Utara City of Medan, district of Deli Serdang veillance And 2013 Rapid Behavioral Sur
2
1 Kepulauan Riau City of Batam City of Bandar Lampung, district of Lampung
3
2 Lampung
1 Selatan City of Jakarta Barat, Jakarta Timur, Jakarta
5 Utara, Jakarta Selatan, Jakarta Pusat
4 DKI Jakarta
11
5 Jawa Barat City of Bandung Technical Report: 2013 Sero-Sentinel Sur
Number of Provinces Cities and districts Locations 2,3
2
6 Jawa Tengah City of Semarang, district of Batang
City of Surabaya,2,3 Malang, 2district of3
7 Jawa Timur
2
Banyuwangi1
8 Bali City of Denpasar
9
1 Nusa Tenggara Timur City of Kupang
10
1 Maluku City of Ambon City of Jayapura, district of Jayapura, and
11
3 Papua Jayawijaya.
2.2. Rapid Behavioral Survey
2.2.1. Sample size
The sample size for each risk sub population was determined accordingly to the WHO recommendation and the National Guideline of Second Generation HIV Surveillance of 2013. These recommend a selection of 30 clusters of seven respondents in each location. To account for data quality and none response, the sample size was fixed at 240 respondents per each risk group in each selected location (city or district). This is generally sufficient enough to be fairly a uniform distribution of the key population of interest as per WHO recommendation. The total sample size key population and location is provided below (Table 2). vey
2.2.2. Tools
A structured questionnaire was used to collect behavioral data on injecting and sexual behaviors between MSM and DFSW. Surveyors were trained to conduct interview and record participants ‘responses in the questionnaire. PWID were not included in the 2013 Rapid Behavioral Survey.
2.3. Implementation
veillance And 2013 Rapid Behavioral Sur Surveyors were from MOH (Sub directorate AIDS & STI), Provincial Health Offices, District and City Health Offices, provincial laboratories units and Health Centers in different survey locations. Supervision was ensured by staffs from the national level.
In Denpasar, the survey was additionally supported by, a local non-governmental organization (NGO) and by WHO. The Clinton Foundation supported the implementation in Jayapura and Jayawijaya Papua. 1 Technical Report: 2013 Sero-Sentinel Sur 2 PWID and MSM were recruited form for both 2013 SS and 2013 Rapid Behavioral survey 3 DFSW were recruited from here for both 2013 SS and 2013 Rapid Behavioral survey
2.4. Analysis
Univariate analysis was conducted at location level only for both biological and behavioral data to determine prevalence of HIV and syphilis among different key populations and the frequency of risk behaviors among DFSW, PWID, and MSM. A chi square test was used to compare observed data in 2013 Sero-Surveillance Survey to the 2011 Integrated Biological and Behavioral Survey results. This test was also used to determine the trends within same locations having data for 2007-2013. These analyses concerned only DFSW, PWID, MSM, and transgenders.
Limitations
The behavioral data and the biological data from the 2013 Sero-Surveillance Survey could not be linked at individual level due to some technical reasons, making any association between HIV and syphilis prevalence and risk behaviors difficult. Only indirect inference can be made from the data in this report.
Comparison of data of HIV and syphilis prevalence at location level should be interpreted with caution as the disaggregation at that level yielded small numbers. Limitations inherent to sampling methods are not excluded from this study. The multi- stage sampling method used for transgenders and direct female sex workers may not reflect the diversity of the community from where the sample came. It may provide less information per observation than a simple random sampling (SRS) of the same size (redundant information: similar information from the others in the cluster) and the standard errors of the estimates may be high, compared to other sampling designs with same sample size. On the other hand, the respondent driven sampling used for MSM and PWID may not vey overcome the coverage and non-response error which it is intended to avoid.
veillance And 2013 Rapid Behavioral Sur Technical Report: 2013 Sero-Sentinel Sur
Chapter III: Results
3.1. Results of the 2013 HIV Sero-Surveillance Survey
Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey
240
Malang 250 249 203 240 SurabayaSample size attained Total
3685
4 985 978 960Jayapura
114
Jayawijaya331
East NT Kupang
110
Maluku Ambon 225 Papua240 244 240 240 Bali Denpasar
400
Semarang
244
East Java Banyuwangi3.1.1. Participation rate Table 2: Planned Sample Size and Sampling Method by Target Population and Location
240 240 West Java Bandung 250 247 240 240 Central Java Batang 255
55 Lampung Lampung 250 Riau Island Batam 286 DKI Jakarta Jakarta Utara 240 245
Deli Serdang 250 Medan
1250 1000 % Participation Rate 92% 99% 78% 96% North Sumatra
Respondents driven sampling Target Sample (n) 4000 1000
Province City DFSW Transgenders PWID MSM Multistage sampling proportional to size
Of the planned sample sizes, the survey participation rate was 92% for DFSW, 78% for PWID, 99% for transgenders and 96% for MSM.
4 Specimens from Kupang were not tested for syphilis
3.1.2. Characteristics of the Population Groups
A total of 6603 participants were recruited for the 2013 SSS. Of those, 3685 were DFSW, 985 were transgenders, 978 were PWID, and 985 were MSM. In the 2013 SSS, direct female sex workers represented 55.8%of participants, PWID and transgenders represented each 14.8%, and MSM represented 14.5% of participants. The distribution of all key populations by location was as followed: 14% were from Malang, 15% from Surabaya, 15% from Jakarta and 15% from Bandung. All the other locations had less than 7% of the participants.
3.1.3. HIV prevalence
3.1.3.1. HIV prevalence among different key population Table 3: Prevalence of HIV and Syphilis per Target Group of Key Affected Populations in the Sero-Surveillance Survey 2013 HIV Prevalence Syphilis Prevalence Target Syphilis N HIV +(n) N % HIV (95% CI) Group
Positive (n) %Syphilis (95% CI) PWID 978 435 44.5 (41.4-47.6) 978 16 1.6 (0.8-2.4) 122 MSM 960 166 17.3 (14.9-19.7) 960 12.7 (10.6-14.8) Transgender 980 186 19 (16.5-21.5) 980 159 16.2 (13.9-18.5)
10 (9-11) 202 Direct FSW 3685 367 3575 5.7 (4.9-6.5) Total 6603 499 7.7 (7-8.3) 1154 17.5 (16.6-18.4) 6493 vey
From the key populations surveyed in the 2013 Sero-Surveillance Survey, HIV prevalence was highest among the PWIDs with 44.5%. They were followed by transgenders with 19%, MSM with 17.3% and DFSW with 10% (Table 3).
3.1.3.2. HIV prevalence among PWID Among PWID, HIV prevalence ranged between 27.1% in Bandung to 59.1% in Malang.
veillance And 2013 Rapid Behavioral Sur This prevalence was 27.3% in Medan, 48.8% in Surabaya and 49.2% in Jakarta (Table 4).
Technical Report: 2013 Sero-Sentinel Sur Technical Report: 2013 Sero-Sentinel Sur veillance And 2013 Rapid Behavioral Sur vey Table 4: HIV Prevalence among PWID per Location in IBBS 2011 and Sero-Surveillance Survey 2013
The Sero-Surveillance Survey results showed, in table 5, that HIV prevalence among MSM was highest in Surabaya with 22.1% followed by Bandung (21.3%), Jakarta (19.6%) and lastly by Malang (6.3%).
PWID HIV Prevalence (%) of IBBS 2011 in all location HIV Prevalence (%) of IBBS 2011 in same locations as for SSS 2013 HIV Prevalence (%) of SSS 2013 Comparison Location N % HIV (95% CI) N % HIV (95% CI) N % HIV (95% CI) P-value comparing same location IBBS 2011 and SS 2013 OR (CI 95%)
HIV Prevalence in same locations IBBS 2011 vs. SS 2013