RISK FACTORS OF GONORHEA INFECTION AMONG INDIRECT

FEMALE SEX WORKERS (IFSW) IN INDONESIA 2015

Frans Landi1
Nuning Maria Kiptiyah2
1
Master of Epidemiology Study Program, Faculty of Public Health, University of Indonesia, Depok
2
Department Epidemiology, Faculty of Public Health, University of Indonesia, Depok

ABSTRACT
Background: Chlamydia trachomatis is the most common cause of curable bacterial sexually transmitted infection
(STI) worldwide. Indirect Female sex workers (IFSWs) are the key population to be affected by sexually transmitted
infections (STIs). In indonesia, little is known about Chlamydia infection in most at risk population. This study
aimed to know the risk factors of gonorhea infection among IFSW in Indonesia 2015. Methods: This research uses
Cross Sectional study design. This study used secondary data based on the Integrated Biological and Behavioral
Survey ( IBBS) 2015. The study population was 3,153 IFSWs who registered in the IBBS 2015 in 13 districs and
cities Indonesia. The study sample was derived from an eligible population that met the inclusion criteria=813
responden. Results: The results show the prevalence of gonorrhea among IFSWs was 9,4%. Gonorhea infection is
associated to Chlamydial infection (OR=4.29 ; 95%CI=3.124–5.891) and age (OR=1.52 ; 95%CI=1.104-2.096).
Conclusion: IFSW who also suffer from chlamydial infection and are <28 years old are more at risk to gonorrhea
infection. For this reason, IFSW infected with chlamydia and young people must be treated thoroughly and prioritize
safe sex to avoid gonorrhea infection. Gonorrhea infections among IFSW warrant the need to strengthen
intervention efforts.

Keywords: gonorrhea, chlamydia, Indirect Female Sex Workers, Integrated Biological and Behavioral Survey

BACKGROUND
Sexually transmitted infections (STIs) are a major public health problem worldwide, affecting quality of
life and causing serious morbidity and mortality. STIs have a direct impact on reproductive and child health through
infertility, cancers and pregnancy complications, and they have an indirect impact through their role in facilitating
sexual transmission of human immunodeficiency virus (HIV) and thus they also have an impact on national and
individual economies. More than a million STIs are acquired every day. In 2012, an estimated 357 million new cases
of curable STIs (gonorrhoea, chlamydia, syphilis and trichomoniasis) occurred among 15–49 year-olds worldwide,
including 78 million cases of gonorrhoea 1
The prevalence of STIs in FSW in Indonesia has not been systematically observed and is only measured
sporadically. In Indonesia, based on research conducted in 9 provinces, prevalence is 28.6% 2, while based on 2013
STBP data the prevalence of gonorrhea in WPSTL is 17.7% 3. Gonorrhea is a bacterial exudative infection caused by
Neisseria gonorrhoeae, a fastidious gram-negative bacteria. N. gonorrhoeae was first described by Neisser in 1879,
and is a gram-negative, nonmotile, non-spore-forming diplococcus, belonging to the family Neisseriaceae 4.
Untreated gonorrhea can cause serious and permanent health problems in both women and men. In women,
gonorrhea can spread into the uterus or fallopian tubes and cause pelvic inflammatory disease (PID) 5. Some
epidemiological data have suggested that gonorrhea contributes to increased HIV transmission. (Puspitosari, et al.,
2014). More than that, increased resistance to most antibiotics used to treat gonococcal infections has been reported
worldwide, raising concerns about the eventual development of untreatable gonococcal infections with serious
sexual and reproductive health consequences 1.
Gonorrhea transmission is related to sexual behavior, such as having multiple sex partners, unsafe sex and
and lack of knowledge. Indirect Female Sex Worker (IFSW) are a population at high risk for STIs. In certain
geographical areas STIs is transmitted by IFSW which acts as a core group to customers as a bridging population
and will then transmit to their partners in the general population 7. Compared to Direct Female Sex Worker (DFSW)
who openly work as sex workers, IFSW generally covers their work as sex workers and this has an impact on
supervision and access to health services and which results in the vulnerability of IFSW to STI. Based on the
estimation of the key population of HIV in Indonesia in 2016, the number of key population of FSW was 226,791
people and the number of WPS customers was 5,254,065 people 8.
Sex work is usually classified as “direct” (open, formal) or “indirect” (hidden, clandestine, informal).
Direct FSW are typically women who do define themselves as sex workers and earn their living by selling sex.
Indirect FSW are women for whom sex work is not the first source of income. They may work as waitresses,
hairdressers, tailors, massage girls, street vendors, or beer promotion girls and supplement their income by selling
sex on a regular basis or occasionally 9.
To achieve target of Indonesia free prostitution in 2019, until the end of 2018 the Ministry of Social Affairs
and Regional Government has closed 151 of the total 168 prostitution localization in Indonesia and repatriated more
than 20.00 Female Sex Work. On the other hand, the closure of localization has resulted in the loss of income from
the FSW, since most of them are the backbone of the family, they also have difficulty finding other jobs, because
they get the stigma from the community. There are several facts found related to the situation after the closure of
places of localization. WPS do not change professions, but only move to new locations such as boarding houses,
massage places, streets or graves. Thus in the future it is predicted that the number of IFSW will increase due to the
possibility of DFSW turning into IFSW.
Several risk factors and indicators are associated with differing prevalence gonorrhea infections including
sex, age, geography, membership in a vulnerable group, high-risk sexual behaviors, and biological and
epidemiological factors10. Several previous studies have shown an associated between gonorrhea infection and
several factors including: age, marital status, education level, chlamydial infection, consistency of condom use, age
at first sexual intercourse, duration of sex work, number of client, use of drugs before sexual intercourse, dan STI
information11-16.
The aim of this study was to determine the prevalence of gonorrhea and identify factors associated with
gonorrhea infection in Indirect Famale sex worker in Indonesia 2015

MATERIALS AND METHODS

The design of this research was cross sectional study by using secondary data sources
from the 2015 IBBS. The independent variables in this study were age, marital status, chlamydial infection, vaginal
douching, duration of sex work, number of customers, drugs use before sexual intercourse in the last 3 months, and
STI information, while the dependent variable is the incidence of gonorrhae infection. The target population in this
study were all IFSW in 13 districs dan cities in Indonesia.
The inclusion criteria in this study were IFSW who were 15 years of age or older who had commercial sex
with at least one customer in the last month and were at the survey site at the time of the survey team's visit , while
the exclusion criteria in this study namely incomplete or missing data. The minimum sample size is 508 respondents,
after the exclusion criteria were carried out, the total sample in this study was 1.955 respondents. Statistics data
analysis using computer software included univariate, bivariate (chi square) and multivariate (regression logistics
prediction factor model)

RESULTS
Table. 1 Bivariate Analisis Associations of Dependen Variable with Gonorrhea Infection Among IFSW
Gonorrhea Infection
Variable Positive Negative OR 95%CI p value
n=184 9.4% n=1771 90.6%
Age (in year)
<28 113 61.4% 828 46.8% 1,81 1.328-2.474 0.000
≥28 71 38.6% 943 53.2%
Marital status
Single 66 35.9% 436 24.6% 1,71 1.244-2.359 0.001
Married 118 64.1% 1335 75.4%
Education level
Low 105 57.1% 1082 61.1% 0,85 0.623-1.151 0.324
 Hight 79 42.9% 689 38.9%
Chlamidia Infection
Positive 111 60.3% 448 25.3% 4.49 3.280-6.148 0.000
Negative 73 39.7% 1323 74.7%
Consistency Condom
Unconsistent 134 72.8% 1.172 66.2% 1.370 0.976-1.923 0.082
Consistent 50 27.2% 599 33.8%
Vaginal Douching
Yes 134 72.8% 1172 66.2% 1.37 0.976-1.923 0,068
No 50 27.2% 599 33.8%
Age of first sexual
intercourse
< 18 years 79 42.9% 742 41.9% 1.04 0.768-1.418 0.847
≥ 18 years 105 57.1% 1029 58.1%
Duration of sex work
≥ 2 years 94 51.1% 1064 60.1% 0.69 0.512-0,941 0.022
< 2 years 90 48.9% 707 39.9%
Number of Customers
≥ 4 people 81 44% 998 56.4% 0.99 0.725-1.337 0.985
< 4 people 103 56% 773 43.6%
Drugs before sexual
intercourse
Yes 46 25% 456 25.7% 0.96 0.677-1.364 0.895
No 138 75% 1315 74.3%
STI information
Unexposed 138 75% 1218 68.8% 1.36 0.961-1.930 0.097
Exposed 46 25% 553 31.2%
Based on table 1 above, it is known that the prevalence of gonorrhea in IFSW in 13 districts and cities
Indonesia is 9.4%. Bivariate analysis was conducted to assess the correlation between independent varibales and
gonorrhea infection as independen variable. From the results of chi-square test, the correlation among both variables
can be examined by looking at the p value and Odd Ratio (OR). If the value of p < 0.05 and OR > 1 or <1, then both
variables have a significant correlation. Based on Chi-square test results, there is a significant correlation between
age (p value= 0,000 ; OR=1,81 ; 95%CI=1.328-2.474), marital status (p value= 0,001 ; OR=1,71 ; 95%CI=1.244-
2.359), chlamydial infection (p value=0.000 ; OR=4.49 ; 95%CI=3.280-6.148), duration of sex work (p=0.022).
Whereas the variables that did not have a significant relationship with the incidence of gonorrhea (p> 0.005 ;
OR=0.69 ; 95%CI=0.512-0,941).
Bivariate analysis is also used for variable selection that enters to multivariate analysis. variables that have
p value <0.25 are included in multivariate analysis. As for the variables entered into multivariate analysis were : age,
marital status, chlamydial infection, condom consistency, vaginal rinse, length of work, and STI information. Then
multivariate analysis was carried out using logistic regression with the backward analysis method, then eliminating
one by one variables that were not significant (p value <0.05) until the final model was obtained. The final model in
this study can be seen in table 3 below:

Table 3 Final Model of Risk Factors for Gonorrhae Infection

 Variabel Independen P value OR CI 95%
Age 0.010 1.52 1.104 – 2.096
Chlamydial Infection 0.000 4.29 3.124 – 5.891
From the final result of multivariate analysis using logistic regression by removing one by one the variable
with p>0.05, it is known the variables that having correlation with gonorrhea infection in Indonesia are age (p
value=0,010 ; OR=1.52 ; 95%CI=1.104-2.096) and chlamydial infection (p value=0,010 ; OR=4.29 ; 95%CI=3.124-
5.891). Chlamydial infection variable is the most significant factor since it has the largest OR value.

DISCUSSIONS
Based on the results of the study, it is found that gonorrhea prevalence among IFSW in Indonesia is 9,4%.
Multivariate analysis showed a significant predictor of gonorrhea infection in IFSW are age and chlamydial
infection. IFSW <28 years old had a risk of 1.53 times for gonorrhea infection compared to those aged ≥ 28 years.
IFSW with chlamydial infection were 4.29 times at risk of gonorrhea compared to those who did not suffer from
chlamydial infection. The results of statistical tests it is known that the age variable has a relationship with the
incidence of gonorrhea in the IFSW, the results of this study are in line with the research conducted by Afriani on
Female Sex Workers in 16 City and Districts in Indonesia in 2011, where IFSW aged <29 years had a risk of 1.53
times being infected with gonorrhea compared to those aged ≥29 years ( OR: 1.53; 95% CI: 1.30-1.79)11
Young people are a critical target group for sexually transmitted infections (STI) surveillance due to their
particular behavioural and social related vulnerability. Gonorrhea is the most common sexually transmitted infection
in young people ages 15-24 years 5. One explanation for the observed age disparity in STI is immature reproductive
and immune systems in younger adolescents 19. Young age is related to changes in sexual hormones for the maturity
of sexual organs, sexual hormones can increase sexual drive so that it affects sexual behavior at a young age. Young
IFSWs are susceptible to gonorrhea because they are more sexually active and usually the younger IFSWs are more
attractive so that they get more buffets, this is related to the higher number of sex partners which is a risk factor for
gonorrhea
Based on the results of the study, chlamydial infection variable is the most significant factor for gonorrhea
infection among IFSW in Indonesia. Similar results were reported in other studies conducted among FSWs
Yangzhou and Changzhou, China, was known that female sex workers who suffer from chlamydia are a risk factor
for gonorrhea infection (p value=<0.01 ; OR=1.99 ; 95%CI=1.43–2.79) 15. Sexual transmission is the primary route
of gonorrhea infection and chlamydial infection, As all these infections share the similar mechanisms of
transmission, infection by one organism offers more potential opportunities for others. Chlamydia trachomatis is an
obligate intracellular parasite, this parasite causes infection in columnar epithelium. Symptoms that arise are caused
by inflammation in endocervical gland, which produces mucopurulenta or endoservical secretions. If infected,
endocervical tissue will usually swollen and reddish17. The presence of inflammation in the reproductive tract is the
entry point for other sexually transmitted infections, including being the entry point for neissceria gonorrhea
bacteria.

CONCLUSION
Gonorrhoea is the second most common bacterial STI after chlamydia and results in substantial morbidity
and economic cost. Because and gonorrhea and chlamydia are usually asymptomatic, screening is necessary to
identify most infections. Screening of all sexually active women younger than 28 years old and women with risk
factors such as multiple partners. STI screening and treatment in high-risk groups is a form of intervention to
prevent further complications and spread of the diseases. Screening and treatment of chlamydial and gonorrhea
infections in female sex workers aims to prevent complications, spread the disease further and co-infection,
especially at the young IFSW.

LIMITATION OF STUDY
This study used a cross sectional study design so that there was no clear temporal time relationship. In
addition, not all variables were examined so that they were still unable to explain thoroughly about other risk factors
related to the association of chlamydia infection among IFSW. Bias information that might occur in this study are
questions that explore information that has long happened (retrospective)

CONFLICT OF INTEREST
 The authors declare that they have no conflict of interest.

ACKNOWLEDGEMENT
We thank the Sub Directorate HIV/AIDS and PIMS, Mininistry of Health of Indonesia for providing survey
data.

ETHICAL CLEARANCE
The formal permission was also obtained from Sub Directorate HIV/AIDS and PIMS, Ministry of Health of
Indonesia

SOURCE OF FUNDING
Self funding.

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